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| SLR stretching with ACL brace (Ref: https://www.choc.org/orthopaedics/) |
In my physiotherapy experience, I have a special stretching pose for specific conditions. The posterior knee tightness from swelling is a specific condition which can be found in knee joint injury. It is common in ACL injury, PCL injury, meniscus injury, knee degenerative, and postoperative all of them.
“The remarkable feature is slightly knee flexion with normal SLR range”.
So, I never achieve full knee extension by SLR stretching. Physiotherapists and doctors have used the low - load long duration techniques including “Knee lag stretch” and “Prone knee hanging stretch” to improve full knee extension. Many patients do like the knee lag stretch because they feel more comfortable than the prone knee hanging stretch. I prefer the prone knee hanging stretch because I feel more effective. Do not sleep during stretching, you will get strong suffering at knee fold and hamstring tendon because of too long stretching.
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| Left side of picture illustrates knee swelling (Ref: https://www.bjchealth.com.au/) |
The prone hanging is a stretch pose which hangs the target lower leg away from the edge of support for a while. The lower leg is pulled downward by gravity that will move away from the upper leg which is stationary with support. The result of this mechanic makes the soft tissue at the knee fold expand.
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| Knee swelling with slightly knee flexion (Ref: https://www.bjchealth.com.au/) |
Exercise #1: The prone knee hanging stretch: Prone on the table with a towel as cushion at the table edge. Put the distal thigh or knee cap on the towel and relax the hamstring muscle that means do not go against the gravity. Try to keep the pelvic on the table. You can apply some weight at the ankle to increase stretch. I have selected weights between 3 - 10 kilograms that depend on the patient's body size.
Hold 1 - 5 minutes with rest 30 - 60 seconds. Make 3 - 5 reps/set and repeat 3 - 5 sets during the day.
This exercise should not be done if the surgery was performed with a hamstring graft.
Exercise #2: The knee lag stretch: Sit or supine with a roll towel supports the heel that has space under the knee fold. Put some weight on the knee cap and let the knee straight as much as possible, that means do not bend the knee against the weight. I have selected weights between 5 - 10 kilograms that depend on the patient's body size.
Hold 1 - 5 minutes with rest 30 - 60 seconds. Make 3 - 5 reps/set and repeat 3 - 5 sets during the day.
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| 3 options to do the knee lag stretch (1) by bag (2) by free weight equipment (3) by sand weight (Ref: https://www.pogophysio.com.au/blog/) |
It has been stretched by standard hamstring stretching that cannot straight that area. I have given SLR to some athletes that was normal range but the knee fold still was not straight. This is the reason which doctor and physiotherapist gave the knee lag stretch and the prone knee hanging stretch to solve the problem.
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| Normal range of motion of knee (Ref: https://favpng.com/) |
In many textbooks, knee range of motion is described as 0 degree of extension and 135 or 140 degrees of flexion. However, 96% of the population has some degree of hyperextension. They found normal knee extension to be a mean of 5 degrees of hyperextension in males and 6 degrees of hyperextension in females. In my physiotherapy experience, I have seen slightly knee flexion between 5 - 30 degrees.
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| Knee hyperextension in standing (Ref: https://www.knee-pain-explained.com/) |
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| Knee hyperextension in supine (Ref: https://championptandperformance.com/) |
Knee articular injury or injury into the knee joint, including knee surgery take many chain conditions. The most common is pain and joint effusion because there is some intra - articular fluid or blood. Pain can be caused by structure damage and intra - articular pressure from effusion. The intra - articular pressure can be a trigger of the pain impulse to the brain.
Slightly knee flexion needs to be done to release pain from effusion. The strategy of releasing pain is to decrease pressure by increasing joint space so that the fluid will be distributed to that space. The trigger of the pain impulse gets less pressure that the pain intensity will decrease afterward.
Moreover, knee joint effusion arises from joint injury, ACL tear, PCL tear, knee osteoarthritis (OA), and after knee surgery. One effect of knee joint effusion on quadriceps muscle is quadriceps arthrogenic muscle inhibition (AMI). On the other hand, I have never seen AMI in patients with MCL injury, LCL injury, or patellar tendinitis which are extra - articular structure.
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| Ice compression to control swelling 20 minutes often. (Ref: https://www.active.com/running/articles/) |
Arthrogenic muscle inhibition (AMI) impedes the recovery of muscle function following joint injury, and in a broader sense, acts as a limiting factor in rehabilitation if left untreated.
This common clinical scenario reflects an underlying neurophysiological phenomenon known as arthrogenic muscle inhibition (AMI) in which otherwise healthy muscle becomes reflexively inhibited following an injury to the joint. The AMI contributes to the characteristic muscle weakness, activation failure, and atrophy observed in patients recovering from joint injuries. The restoration of muscle function is not only essential to short-term recovery but also poses a threat to long term joint health and patient well-being if left unresolved. Therefore, AMI impedes the recovery of muscle function following joint injury, and in a broader sense, acts as a limiting factor in rehabilitation if left untreated.
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| Knee cap mobilization (Ref: https://thenakedphysio.com/) |
AMI has been linked to articular swelling, inflammation, pain, joint laxity, and structural damage. The relative importance of these factors is not clearly understood but it is generally accepted that AMI is caused by a change in the discharge of sensory receptors from the damaged knee joint. To understand this phenomenon from a neurophysiological perspective, we must consider motor neuron behavior as muscle function is dependent on both the availability of motor neurons and the ability to voluntarily recruit them.
As early as 1965, we learned that capsular stretching in response to an experimental knee effusion causes a reflexive inhibition of the quadriceps. The resulting change in sensory information arising from joint mechanoreceptors was presumed to play an important role in this process. This observation was later repeated and confirmed in the early 1980s as we understood that the magnitude of inhibition was related to the amount of effusion present. Although pain was identified as an independent cause of AMI at that time, subsequent investigations confirmed it was not required to inhibit the surrounding musculature.
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| Neuromuscular Electrical Stimulation to restore VMO muscle function (Ref: https://mikereinold.com/) |
By theory, the treatment approach is simple by attempting to resolve (1) minimize pain, effusion, and inflammation of the injured joint; (2) improve muscle activation; and (3) minimize atrophy of the involved musculature.
My own protocol includes ice to control inflammation and swelling at the same time with the knee lag stretch or the prone knee hanging stretch, mobilize knee cap, facilitate quadriceps that focus on VMO by neuromuscular electrical stimulation, and activate quadriceps that focus on VMO by neuromuscular facilitation. Then, I have maintained all of them until effusion and muscle function are improved.
In conclusion, the factor of slightly knee bending consists of knee joint posture adaptation for more comfortable position and decrease pain, and quadriceps dysfunction with AMI. They affect knee fold shortening including hamstring tendon. The low - load long duration techniques are needed to be a part of treatment.
In ACL reconstruction, has could been started the low - load long duration techniques since the first day after operation for achieve knee ROM 0 - 90 degree in the first two week. The protocol recommends static 1 - 5 minutes with rest 30 - 60 seconds. Make 3 - 5 reps/set and repeat 3 - 5 sets during the day.
In PCL reconstruction, has could been started the low - load long duration techniques since the first day after operation for achieve full knee extension in the first three months, and not allow to be hyperextension by three months. The protocol recommends holding 15 minutes for 4 reputation or 60 minutes of stretch time total per day.
I cannot find a paper about recommendations for knee replacement patients. I have always selected the details following ACL reconstruction. 
Sand weight at ankle in the prone knee hanging
(Ref: https://www.researchgate.net/figure/Prone-Hang-Begin-without-weight-for-10-minutes-and-progress-to-increased-weight_fig1_22168841)
Reference:
https://www.jospt.org/doi/pdf/10.2519/jospt.2012.3871
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953293/
https://www.uwhealth.org/files/uwhealth/docs/sportsmed/SM-35549_ACL_Protocol.pdf
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