Complications are possible with any surgery that involves repairing a torn tendon. Most commonly, this involves loss of movement.

Depending on the activity, some discomfort is expected. But you also don’t want to overload the healing tissue.

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#AskMikeReinold Episode 318: Improving range of motion after patellar tendon repair

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Transcript

Corey:
Yes, so Dan from Kentucky asked, “What are some strategies for restoring knee flexion beyond 90 degrees after patellar tendon repair, especially when athletes report a lot of pain or discomfort?”

Mike Reynolds:
This is a good one. And I have to always admit that when we do these big tendon repairs, even I get a little anxious when they come back, especially when they start doing a lot of new things like running, jumping, stuff like that.

Dave Tilly:
The first hop of every Achilles tendon repair I’ve had, I’m like, ah, I know this is good, but I’m still nervous.

Mike Reynolds:
I don’t know it’s good. You’re like, man, I can’t believe this is going to last.surgery is amazing

Dave Tilly:
There is no literature on this either. There’s no literature on what to start with or where to start, and you say, well, let’s see how it goes.

Mike Reynolds:
Yes, we’re just taking it slowly, gradually. Any muscle tendon repairs still give me anxiety as they heal, but it goes back to the slow, gradual process we’ve been talking about, and as long as you do that, I think you’ll be fine gradually applying the load. I like this question about range of motion because I do think it’s something that early career professionals sometimes have where they get nervous about range of motion. Let’s start with that. Maybe I can even ask Len that question as well. You’ve probably seen most of these guys on the phone, but how common is discomfort after patellar or quadriceps tendon repair range of motion? is that normal?

Lenny McLeaner:
Yes, I mean it’s normal. Then you can assess why. What are we doing? Are we trying to advance them prematurely? What were their movements before surgery? Hope it’s normal, they suddenly fell and tore the tendon, but I think it’s normal, you have to evaluate, are we trying to progress too fast, we’re trying to do something they’re just, their bodies just aren’t ready for Well, that means you have to go back to your basics: do they have good baseline strength, do they have the passive movement to get there, and do they have the relative symmetry to squat to 90, never mind below 90, then Assess if you have force plates etc. What is their concentricity, what is their eccentricity, or are they partial to one side?

But I think that’s normal, I think you might step back a little bit and do the basics, more of the basics of getting the patella to move, getting the soft tissues, making sure it feels good and not irritating because they can be tight. The whole knee is probably still tight. You see a lot of these and they scar and the patella doesn’t move. All the tissue around the kneecap is… kind of stuck, maybe the quads aren’t stretched very well, and the quads aren’t moving well. You can move through the soft tissue material and the patella, and then do a lot of movement on the bike and slowly bring them down to more flexion.

Mike Reynolds:
You know, it’s funny… I think we’ve all heard the question, I thought they were talking about passive range of motion on the table, but I kind of like your idea there Len, maybe they’re talking about functionality Sexual movement. I think you’re actually right. I didn’t even think about it that way. So that’s actually a good point.

Lenny McLeaner:
I mean if they only have 90 on the table, but either…that’s not normal. But yes…

Mike Reynolds:
I’m thinking, yes, no, I think you’re right. I think you read the question correctly. For me, that’s progressive apps on load. I like this, but Mike, would you like to join in?

Mike Scaduto:
Well, my point is about restoring passive range of motion on the table, and just playing around with where the patient is. So if you’re doing supine or even prone knee flexion or quad extension, I can see how maybe that would cause more irritation to the patella insertion there… the patellar tendon insertion. So maybe classic Lenny… when he sits on the edge of the table, make sure they nail that first, if they can get over 90 in some positions, but some positions are more painful, it’s just something to play with and tweak.

Mike Reynolds:
It’s a great way to do this because when you’re doing passive movements on your stomach, yes, you’re pulling the quads from both ends, right? So if you’re sitting up, that takes some tension off the proximal end. I think it’s very helpful. correct. Dan, what do you think?

Dan Pope:
Yes, I think the quads are a little weird, but in deeper knee flexion the quads actually start to share a little bit of the surface area available to the patellofemoral joint. So I think at the very end of the movement, let’s say the squat, two things are going on. So the deeper you squat, the more the quads and knees have to work, so the more stress the whole mechanism puts on the tendons and the tendons can wind up in the trochlear groove, sort of like the patellofemoral joint. So it’s just, the tendon is under a lot of stress and a deep bend. So in response to everyone’s point, get back the passive range of motion, but if your tendons aren’t handling the forces well, then you might just want to do a really good set of exercises where you can start loading those end ranges of motion.
So maybe it’s like a TRX assisted squat where you go into the full range and you try to utilize the whole joint and put some stress through the tendons in a way that’s less tense at first and then gradually increases the time throughout. Yes, I think what does happen is that squats just stiffen the knees, so that’s the extreme range of motion. It’s just that the knee is hard. Before you can send someone into the bottom of a squat, you must have a library or catalog of exercises available to train that position. It makes sense that it still hurts.

Mike Reynolds:
If you’re trying to do movements over 90 degrees in a functional movement, like squats or similar, and they have a fair amount of pain and discomfort, then it’s definitely not something you want to do. We often talk about pain. We’ve talked about it a few episodes ago that exercise here causes pain, but when you’re talking about tendon repair, you’re exercising to repair the tendon and you get pain, that’s not what you’re trying to solve, right? Is that either a little bit, or are you getting too nervous about the structural integrity of the restoration? That’s really bad, right? So I think it makes sense that they must have passive range of motion. Then you have to slowly load the weights through a shallow to deep range of motion, with light to moderate to heavy loads. That makes sense. Just in case Dan asks the question from this angle, let’s jump back to Lenny. Lenny, two weeks after the patellar tendon repair, you’re doing passive range of motion on their knee. Is that painless?

Lenny McLeaner:
correct? No, no, usually not. If your doctor allows you to do so at this time.

Mike Reynolds:
good idea.

Lenny McLeaner:
We’ve dropped everything, everything so much that they’ve become very rigid. Because they want to stiffen the tendons, right? Unfortunately, it’s like a cup and they’re slowing down the recovery, but no, they’re going to be miserable. So it’s slowly building capacity in that tissue, which means slowly returning to motion, slowly moving the patellar tendon, the patella, and even the tissue around the patellar tendon. It has to be removable, and if everything is scrunched up and scarred, you’re going to have pain in that area. Just for the legs to need to flex, especially in the weight bearing position, things have to move if that’s what we’re talking about. So it’s going to be a pain. Do it slowly and not too painfully, especially if they are carrying heavy weights. And then these things take weeks or even months, unfortunately, longer than the visits our insurance companies give us. You must distribute these accesses appropriately. correct?

Mike Reynolds:
I think that brings up a good point here too, because let’s say someone has 7/10 pain, that’s on their way, I don’t know, three or four months from now, and you’re trying to do squats number one times or something like that, they have a 7/10 pain. Well, now let’s say they have 7/10 pain and it’s week two and you just let gravity tilt their knee down to about 30, 40 degrees. For me, I think the two are different because I know that within my passive range of motion, the stress on the tendon, especially that kind of mild stress, isn’t enough to hurt the repair. I just know this because it’s not a stressful sport. So if they have discomfort, I mean it has a lot to do with surgery, they’re recovering from trauma, things like that.

That’s the kind of thing I think, look, if we don’t do that, you’re stuck, it’s going to be more painful. It will be harder to pass it. I think as a clinician you also have to think about, what is the activity that I’m doing, what is the inherent stress that I’m doing on the tissue? Is there pain, does it make sense? So I think the pain of squatting after three months is much different than when you just do some gentle exercise. It would be easier for me to tolerate a little bit of pain. Note now that I said “let gravity bring the knee down”, not that I was pushing and forcing it. Now you can say it’s stressful, right? Now I’m putting pressure on it, but there’s only a little gravity there. I think this is where you have to start using some clinical judgment, right?

So I would say think about it by activity. Is the activity I’m asking them to do really so stressful that it should be causing this pain? Or is this more due to the trauma of the surgery, and something we should be working on? When you’re later on and you start doing it through practice and you get pain during practice, that’s probably not good. I think that’s a great way to think about it. great. Good question, Dan. Hope this helps. If you have such questions, head over to mikereinold.com. Click on the podcast link and you can fill out the form to ask us questions. Go to Apple, Spotify and subscribe so you can continue to receive notifications when we have new episodes. Thank you so much.