Late Stage ACL Rehab - Narrow ISA - BillHartmanPT.com Q&A for The 16%

ACL Rehabilitation: Addressing Graft Site Pain

Introduction to ACL Rehabilitation

• The discussion begins with a focus on managing graft site pain in ACL rehabilitation, specifically addressing a late-stage revision case.

• The patient is experiencing symptoms at the contralateral patellar tendon graft site, which is central to the conversation.

Key Concepts in ACL Rehabilitation

• The speaker emphasizes the importance of understanding load influences on the knee and strategies for alleviating symptoms during rehab.

• A specific case is introduced where pelvic diaphragm orientation affects tissue behavior, leading to stiffness due to constant downward force.

Patient Assessment and Range of Motion Measurements

• The patient's shoulder flexion measurements are noted: 115° on the left (affected side) and 130° on the right.

• Internal rotation (IR) measures are 70° on the left and 60° on the right; external rotation (ER) is symmetrical at about 115° for both sides.

Analyzing Pelvic Orientation and Load Distribution

• Discussion reveals that the patient has an anteriorly oriented pelvis, contributing to magnified range of motion measures, particularly in ER.

• It’s highlighted that this anterior orientation leads to continuous loading on the anterior knee, necessitating adjustments in treatment strategy.

Treatment Strategies for Alleviating Knee Pain

• The first step involves reducing anterior pelvic orientation to relieve pressure from posterior left forces affecting knee function.

• Emphasis is placed on restoring relative motion within the pelvis to allow yielding actions necessary for offloading tension from tendons.

• As part of recovery strategies, early propulsive movements should be encouraged while monitoring knee flexion capabilities as she progresses through rehabilitation.

Restoring Yielding Action in Movement

Understanding Left Yielding Action

• The discussion begins with the concept of restoring yielding action, particularly focusing on a left shifter's movement pattern during squats. This involves an orientation to the right while sitting back and to the left.

• A short staggered chopping action is suggested for initiating movement, emphasizing the importance of maintaining a left yielding action posteriorly while reducing body weight through unweighting techniques.

Load Management Techniques

• The speaker explains how using an overhead pulley can create a lighter load, allowing for anterior muscle activity necessary for pelvic orientation and promoting yielding action on the left side.

• Progression from lazy bear position to upright squatting is discussed, stressing that pelvic orientation should be prioritized before increasing load on the anterior knee.

Testing Knee Tolerance

• An important test involves assessing knee pain when transitioning into all fours; if discomfort arises, it indicates a lack of available yielding action.

• Clarification is needed regarding any sensations in the knee during this position since individuals may normalize discomfort without recognizing it as abnormal.

Monitoring Progression and Retesting

• The necessity of retesting after each intervention is highlighted to ensure that progress in pelvic diaphragm positioning is maintained throughout activity progression.

• Emphasis is placed on using extremity range of motion measurements as indicators for evaluating ongoing improvements.

Foot Positioning and Joint Functionality

• When placing someone in a split stance with their left foot forward, heel elevation is recommended to support proper foot alignment and prevent toe extension which could hinder yielding actions.

• The speaker notes that knees are not inherently good decision-makers; thus, creating conditions where they do not need to compensate for other joints' movements is crucial.

Addressing Muscle Weaknesses

• There’s a misconception about needing quad strengthening; instead, understanding how quads function as hip rotators when grounded can inform better rehabilitation strategies.

• It’s essential to restore relative motion within the pelvis and hip joint to alleviate undue stress on quadriceps during movement patterns.

Exploring Range of Motion Dynamics

• A request for clarification regarding narrow versus wide archetypes leads into discussions about how certain ranges of motion might be magnified or diminished based on compensatory patterns.

• The conversation touches upon maintaining center of gravity while considering diaphragmatic compensation effects related to narrow stances affecting external rotation capabilities.

Understanding Anterior and Posterior Compression Strategies

Mechanisms of Compression

• The body experiences anterior compression, leading to a backward push in the thorax and pelvis. This is easier to visualize in the thorax.

• When individuals fall backward due to anterior compression, they instinctively push forward, creating posterior compression that helps them regain balance.

Exercise Strategies for Recovery

• Engaging in quadruped activities is beneficial as it promotes posterior lower expansion and targets pump handle units effectively.

• In rehabilitation contexts, addressing superficial strategies layered on top of the axial skeleton is crucial for effective recovery.

Range of Motion Considerations

• The range of motion measurements can vary significantly based on lumbar spine orientation; this variability must be considered during assessments.

• Hip external rotation (ER) can be magnified when the lumbar spine turns towards that hip, affecting measurements like straight leg raises or hip flexion.

Impact of Lumbar Spine Positioning

• A counter-mutated spine with associated lumbar flexion will influence how movements are measured; certain positions may lead to diminished hip flexion.

• Understanding how different orientations affect movement is essential for accurate assessment and treatment planning.

Importance of Upper vs. Lower Extremity Comparisons

• Comparing upper extremity movements with lower extremity movements provides insights into overall body mechanics since legs have more mass and drive significant movement.

• Recognizing these differences aids practitioners in diagnosing issues related to mobility and function effectively.