How do you manage anterior knee pain after ACL reconstruction?

Hey, everyone. I had a reader submitted question here about ACL reconstruction.

“Hello, I'm a PT and I've been really enjoying going through your med bridge courses. They've been super insightful, particularly with ACL reconstruction."

Thank you so much. I appreciate it. I love doing them. They're super fun. Obviously, I'm passionate about it.

"I've got a question about a current patient that I'm seeing. He's about 10 weeks post-op and has a hamstring graft. He's been complaining on and off of anterior knee pain for the past few weeks. Recently, he's been saying that the only time he really feels it was when he "forces hyperextensions" such as when I'm queuing him to really get full knee extension during gait and if he's walking like that for longer periods of time. It definitely seems correlated to the active terminal knee extension, not passive. I'm wondering if we may have loaded him a bit too quickly and should I go back and work on more fundamental quad strengthening or if there's anything else I should check out so we can clear this up. Happy to give you more details. If you need, I really appreciate your time. Thank you so much."

Well, thank you for the question.  Thank you that you take care of your patients and are passionate enough to ask questions and reach out.  So I love that.  So there are two things to consider. And certainly the too much load too soon can be can be a thing.  But I'm going to put that actually probably third on the list.  And here's what I would put before that.  Number one, do they truly have a full knee hyperextension equal to the other knee?  Meaning when you prop them up, prop their heels up and they do a quad set on their uninvolved leg and try to straighten it out as much as they can, and you just leave a little space there, do they get equal on both sides?  Is it truly equal hyperextension?  Because if it's not truly equal, they will have pain with terminal knee activities.  That's exactly why it's so important.  Sounds like you're emphasizing that.  So that may not be the case, but I'm always double-checking myself on that because sometimes they have it and then lose it and we don't even quite realize it.  And when I say lose it, we're losing two or three degrees and, you know, maybe not noticeable, but it can be a big deal. 

The other thing that I'm going to think about before I'm thinking my load is too great is do they have trigger points in the rectus femoris? I frequently see rectus femoris leading to anterior knee pain.  As that person starts walking more, getting more activity, they start compensating a little bit. They don't have the strength in the quad.  They overuse the rectus femoris or sometimes it could be the hamstring or gastrocs as well. I checked all throughout there and make sure all of that tissue is nice and doesn't have those major trigger points in it, is functioning really well.  I'm also going to flip them over into a prone hip mobility position where their lumbar spine is locked out with their other knee kind of up in their armpit and working on knee flexion there. 

Can they get beyond that 90 degrees in that prone Thomas Test position? And so really looking at do they have the the tissue quality that they need and sometimes that tissue can be the pain generating source.

And then finally, yes, indeed, you know, loading it too much can be a problem and sometimes it's because of those number one and number two, what I just said. But it sometimes can be the load in and of itself.  You'll know it's the load if when you back off, it really decreases. But again, I wouldn't just back off without the absence of correcting, making sure that they have full knee extension range of motion, make sure their tissue quality is good.  And like you said in your in your question, they're some fundamental quad strengthening.  Yes, absolutely.  Make sure they can do that straight leg raise without a quad lag. 

Make sure that that quad is functioning really particularly well, has good endurance and see . . . test it out a little bit.  You know, truly when we are doing resisted open chain type of activities, do they have pain with doing that?  And if I've corrected their range of motion and corrected all the tissue quality throughout then that tells me it is a little bit more of a load problem.  Let's back it off a little bit and go back to non aggravating activities, loaded non aggravating activities, but loaded nonetheless. 

So great question.  I hope that helps.  Really can kind of consider those three points.  Just like everything, it is probably a combination of those three and let me know how this works for them and if you have any more questions, don't hesitate to reach out.  Thanks so much.

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