welcome guys tony maritado here physical therapist and in this video i'm going to answer a question
straight from the facebook total knee replacement support group so kathy was asking and i'm
going to read a little bit because it's a long question but it's got a lot of great information
kathy was asking if there are other positions she can work on stretching her knee into knee flexion
beside what's going on right now so right now just to give you guys watching some context kathy
gave us some history she had a left total knee replacement november 22nd 2020.
she had a manipulation under anesthesia on the 13th of january today is january 22nd
so not too long ago what is the seven nine days her flexion was 60 degrees
at the six week mark so definitely needed the manipulation um she had been up in the early
90s but guessing there was some scar tissue started to build up my rain started to drop
my first appointment after the mua was 95 degrees of flexion and three degrees of extension so
that's a huge improvement that's awesome in the or i was at 130. that is a really important kind of
understanding realization that has to happen here so i've had patients and i've shared this story
where in the or they get a hundred and you know 25 130 degrees of flexion
the day after they're back down in the 90s there is no physical way your body can produce scar
tissue that's going to restrict that much range of motion almost 35 degrees of range of motion
in 24 hours it's just not gonna happen so you have to ask yourself you have to to stop for a second
forget everything we think we know about the human body and anatomy and physiology and all that stuff
just stop and say does this make sense is this scar tissue what else is going on what is
causing the limited range of motion and so absolutely there's going to be a guarding
response because of pain there's going to be other influencing factors that are going on
so we always blame inactivity and scar tissue but maybe it's not maybe there's more to the
story that we just don't know we're not aware of so anyway back to this she's been going
to pt every day which is incredible and doing home exercises every hour i mean this is what
i see like the person who does so much does everything right pushes themselves like crazy
and they don't get the range of motion that they expect they tend to blame themselves
they think they did something wrong and then right next to him there's somebody god love them
who does none of the home exercises doesn't follow any of the therapy instructions
and they're walking around at 125 degrees of flexion zero extension two weeks after surgery
it is beyond the scope of what makes sense so just take it for what it is don't try to rationalize
the irrational we don't know enough to fully understand why some people gain their range and
some people don't it's definitely not something you're doing wrong it's definitely not something
that you need to do more of um if anything i think people do better when they do a little bit
less if they've been doing too much already but let's keep going through the story so she's saying
i'm currently at 105 which is amazing 13 days after the manipulation you're at 105
that is awesome uh i had two freak to something but significant knee injuries oh
freak knee injuries 10 days apart in august that's okay pt indicated that these knee injuries could
make the recovery slow the issue i never had manual massage for the first six weeks that's
okay i i do it i do a lot of hands-on but not every therapist does and i wouldn't say the
clinical research supports that you need it that it's beneficial i think it just feels nice i think
it helps to relax the tissue i think it's it's a benefit not a requirement so she goes on to say um
where are we here so she didn't have any in the first six weeks this past week the pt started
stretching me out in prone pushing my knee toward my butt so it's a very common condition
the patient lays on their stomach the therapist is typically behind the patient
one hand at the ankle maybe one hand down kind of at where the knee is at the top of the tibia
and you're assisting the patient moving the knee into flexion usually this position starts when the
patient has more than 90 degrees of flexion i've shared videos showing you how to do this yourself
with the strap how to do it yourself putting your toes up against the headboard or a wall
so it's not an uncommon position but certainly it's a vulnerable position and that's one of the
things that i learned as a therapist is that if i put patients in a vulnerable position
immediately the fear kicks in the guarding kicks in immediately just reflexively even
if they know me trust me like me the patient is still going to be fearful and resistant
so i find that in this position in particular there are some strategies that reduce some of that
now i can't demonstrate it for you kathy right now but i can tell you that if i get a chance in the
clinic next week i'll do it but if the therapist has one hand at the ankle and the other hand
behind the calf muscle so not on the shin bone but on the calf muscle what i have found is that if i
pull against the calf muscle while i move the leg into knee flexion it's a little more comfortable
whereas if i'm just pushing that tends to get that guarding response and of course pain so anyway
i got distracted let's see here so she was saying that you know put her in tears
she was sobbing she finds herself scooting forward on the table trying to escape the pain
i see that a lot certainly you don't see it in my clinic but i see it a lot in other clinics
i got the impression that i needed to do this kind of massage if i was going to increase flexion i
wouldn't necessarily necessarily call it a massage it's a stretch it's a manual stretch but anyway um
i cannot do this anymore and you are the person in charge that's your decision if it is at that
point it's not helping if i did something to the point of pain and i felt resistance
in the patient i'm done there is nothing more i can do i cannot overcome the pain response
that's why they do a manipulation under anesthesia that's why it's not just a manipulation because
you cannot have that pain response once that kicks in the benefit is done there you're not going to
get any more benefit so you don't need to do it you shouldn't do it i said there must be other
patients that can't tolerate this position what do you do the patient didn't or the therapist didn't
really answer the question he wants to keep moving um and not allowing him to do the the manipulation
it's impeding this so basically what you're saying is you're going to talk to the surgeon on tuesday
we agreed you and the therapist that the treatment plan for the weekend
you're gonna do your stuff at home change see what happens on monday every hour i'll be
doing prone stretches prone stretches or chair stretch exercise i'm not sure what those are
but i'll be holding that stretch position uh four to five minutes for prone few stretches
in the chair feel like this may help stretch out the muscle it's really not a muscle problem
you know and that's important to understand let's talk about the structures of the knee for a second
you have muscle no doubt but muscle is more like a rubber band this kind of limited range of motion
is not typically a muscular problem you've got the connective tissue generally speaking this could be
considered the fascia the white thick connective tissue that surrounds the muscle the joint capsule
which is kind of the ligament ligament attaches bone to bone the tendon tendon attaches muscle
to bone you've got multiple soft tissue structures that are not muscle but that are very dense very
very fibrous certainly you can consider some of that scar tissue but this stuff is tough
and remember we need it to be to be tough we don't want your knee to be so mobile that you take a
step and your body collapses right your knee has to be strong enough to support you jumping off a
park bench this is a lot of force and so we're always trying to find this balance between how
do i gain range of motion but how do i maintain the integrity of the knee and and you've heard
me say before a loose knee is much worse than a tight knee i would take a tight knee for myself
every single day of the week over a loose unstable knee because a loose unstable knee will buckle
you will fall you can break a bone a tight knee you're just tight it's a much better scenario
than a loose knee but but the point being this is not really a muscular problem you're dealing with
it's a connective tissue problem potentially it's a guarding like a nervous system just a reflex
right i tap a reflex and your body responds you don't have voluntary control over that that's the
stuff that we're dealing with here so so you're saying you're so afraid that's going to develop
more scar tissue and i might have problems with the manipulation your goal is to get to 120. so
here's the deal again i'm going to ask everybody watching who's dealing with this these kinds of
challenges take a moment step back for a second forget everything that you've been told forget
everything that we think we know and let's try to look at this problem with fresh eyes
and so when i look at this i say okay what's what's my objective i need my knee and i always
use my finger as the example i need my knee to bend right and if i can't bend like as i try to
bend my finger it tightens up as i get to the end range of motion now how do i get that tightness
to improve how do i get more range of motion well we know repeated exposure for prolonged duration
at a low enough intensity that we stimulate that we can maintain the position but at a
high enough intensity that we stimulate changes in the tissue the position can be repeated lots
of different ways so if you imagine yourself laying on your stomach with your knee bent
and your heel coming back toward your body that is no different than you kneeling on your bed
right imagine hands and knees you're kneeling on your bed the bed's a nice soft cushion
you're rocking your hips back toward your heels so in the one position your heel is going toward
your hip toward your butt in the position i'm describing and i've got videos and i'll post them
your butt is going toward your heels the benefit of the the hands and knees position
over the laying on your stomach position is your hip is flexed so by flexing the hip
we're we're allowing the musculature to relax a little bit while we try to bend the knee
you can get into any number of these positions so i'll record and share other videos about
laying on your stomach your toes against the headboard of your bed you're sliding your body
back toward your headboard if you can visualize this it's the same as the therapist pushing
i really think kneeling for me kneeling on a cushion kneeling on a couch kneeling on the bed
is the absolute best scenario and then getting into a deep squat so one of my favorite ways
to work on knee flexion i ask my patients to buy a six inch step stool little plastic
rubbermaid step i ask them to put it in the bathroom next to the commode next to the toilet
and every time you go to the bathroom you're going to the bathroom multiple times a day
you're you're going to sit to go to the bathroom right you're going to put your foot
up on that step and so that's providing multiple exposures to that knee in the flexed position
for a brief period of time minute two minutes you're working it back it's absolutely doable
finally the i mean there's thousands of ideas that could be shared here but another option if you
haven't seen it i just saw in the total knee group somebody posted that they're using the jazz device
jas joint active systems this device is a device that lots of patients use after manipulation
you can put it on you can set the level of resistance you can use it up to three times a
day 30 minutes an episode you can rent the device buy the device sometimes insurance will cover the
cost of the device but if you remember i did the interview with russ from russ's right that channel
rested this device he had the manipulation he did great with it it's slow it takes time but at the
end of the day it's not the kind of thing that you can push through the pain more pain does not
provide more gain there are times where we push through the pain this is not the time for that
more pain does not provide more gain we need to be smart we need to understand that it's not
about doing more you're already doing more than most it's about doing things properly kind of
resetting what we're doing asking some hard questions and then figuring out okay what does my
body respond best to i hope i gave you some useful advice i'm sorry i can't do demonstrations i'm at
the home office so i'm not in the clinic but if i get a chance next week i'm back in the clinic
i'll record some new videos share some new ideas there's tons of videos on the channel already
but anyway guys thank you so much for watching if you are watching this and dealing with the
same challenges post your challenges in the comments so other people can see
what you're dealing with what solutions you found to the problems you're dealing with and just
air your frustrations sometimes it just feels good to vent right just get it off your chest
and in the process like the video subscribe to the channel help me grow so i can reach more people
and answer more questions like this i will catch you guys all on the next video thanks so much