[headline style=”1″ align=”center” headline_tag=”h2″]Introduction to Knee Extension Part 2
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A few weeks ago I had written a blog post on the importance of increasing knee extension after trauma, injury, or after surgery. In case you missed it, you can find it by clicking here.
I wanted to build upon this last post with some other strategies that I have found to work clinically if the ones prior didn’t work. I am going to disclose how I work on the soft tissue, where to ice the knee when swelling or effusion is present, functional mobilizations that work when all else fails, and other exercise strategies.
[headline style=”1″ align=”center” headline_tag=”h2″]Where Do You Ice the Knee?
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No matter how hard you try to extend the knee, it will not extend if swelling and effusion is present. This is usually common knowledge but I have seen many physios and patients try cranking away to ultimately inflict more swelling, pain, and guarding. Hint,hint,hint- don’t do this.
The second common mistake that I see amongst others is icing in the WRONG place of the knee. This is something I learned from anatomist, Dr. Gary Gorniak. In short, don’t ice the front or top of the knee. Rather, you need to be icing the back side of the knee. This makes sense because all the blood vessels run posteriorly, not anteriorly. If you ice the top you get a cold knee cap.
[headline style=”1″ align=”center” headline_tag=”h2″]Manual Strategies
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Sometimes doing a joint glide is not enough to get the knee to extend– you have to work on the surrounding soft tissue. For instance, I have found after surgery the calf becomes guarded and tight. This will restrict knee extension functionally and in the open kinetic chain.
Below you can find some strategies that I use to work the calf and some other functional mobilizations that I use.
Similar to ART, you can use Thomas Myers fascial release. The premise behind these techniques is to move the fascia with active movement from your patient. Tom performs it primarily for structural integration which I do as well. However, when the calf is swollen and guarded I like to have the patient pump their ankle while I drive the fluid more proximal back to the heart. Basically it is STM with movement.
Another great resource forms the basis of the majority of soft tissue technique that I prove to my patients is Myofascial Manipulation. I like this better than ART because it doesn’t hurt my hands as much, isn’t as discomforting for patients, and works really well if their is guarding and swelling in the posterior calf.
You can check out these techniques and order yourself a copy by Clicking Here.
Another great way to increase knee extension if you’re running out ideas is to use Brian Mulligan’s MWM for the knee. You can find this information by watching the video below.
[headline style=”1″ align=”center” headline_tag=”h2″]Exercise Strategies
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I have a few strategies that I like to use in my repertoire. One of them is using bands to facilitate the normal arthokinematic motion of the knee during exercise. This works great because you are working on NM control and the knee is integrated with the rest of the kinetic chain (this is usually how it works).
Do you remember from last post what the normal glides for the femur and tibia were respectively?
You can see how I use these glides with functional exercise by watching below.
You need to try and “time” the pull of the band by the therapist when doing the glide. For instance, apply tension when the bone should be gliding in that direction.
Another strategy that I like to use is mass and momentum. This is something that I learned form my friends over at the Gray Institute. You can apply this with your patients by simply adding load (weight) and/or velocity to an exercise.
In the case of increasing knee extension, I could have my patient supine and perform a leg extension on a swiss ball. However, I can increase the velocity at which the patient performs the activity to help add more momentum to extend the knee. What are some other ways you can apply this concept in your practice? What about functionally?
Personally, I like this strategy. I can assist the knee manually but also impose more force to the joint to help it extend. This is better than me cranking away at the joint and ruining my hands 🙂
One more strategy that I have found to increase knee extension is to work on a different plane of motion. For instance, during walking and anterior lunging the trail leg should extend which is driven primarily with the contralateral leg in the sagittal plane. This is how the knee extends during ambulation.
Instead of repeatedly trying to work this motion in the sagittal plane you can try a different plane. In this regard, you could do a lunge in a different plane and still get knee extension. Sometimes it improves, sometimes it doesn’t. You really just need to try it out and fix it. You can see me perform a lunge matrix to work on knee extension. Once it improves, go back to the sagittal plane and re-test.
Last but not least, don’t forget the importance of just using the stationary bike to get motion in the knee. As PT’s sometimes we have a tendency to overthink things. The bike is a great strategy, especially acutely because it pumps out swelling and effusion, increases movement of synovial fluid, works on getting the quadriceps muscles pumping again and, finally, you can do 1000’s of repetitions without usually flaring up your patient.
[headline style=”1″ align=”center” headline_tag=”h2″]Concluding Remarks On Knee Extension
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Knee extension is important to the majority of human function. It is needed to squat, walk, run, go up and down stairs, and many other functional tasks. When this motion is limited whether it be from surgery, trauma, or other injury it can lead to OA or other injuries up and down the kinetic chain. Try these simple exercise and manual progression but be sure to start simple and progress towards these if your patient is still not improving.
