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5 of the most common problems plaguing post ACL surgical rehab…PLUS a case on how it can lead to Plantar Fasciitis

June 11, 2013

1.  Extension, Extension, Extension – Contrary to your gut instinct that wants you to work on knee flexion, the most important movement to restore post surgery is FULL knee extension.  Flexion, while important can often be attained months after the fact.  I know this as I have had several cases referred to me after having had sub-par rehabilitation efforts where ROM was not fully restored months after surgery.  Even for these unfortunate individuals, flexion can be regained….however extension…less likely with every passing day.

2.  Patellofemoral Joint – Restoration of knee motion must involve assessment, treatment, and rehabilitation of patellar glide in every direction.  This articulation is just as important as that of the tibio-femoral for proper knee mechanics.

3.  Rotation, Rotation, Rotation – Although often thought of as a ‘hinge joint,’ proper knee mechanics requires a certain amount of tibial rotation allowance for pivoting/turning motions.  Failing to restore this vital role of the articulation can very quickly lead to re-rupture of the donor tendon.

4.  Scar/Portal mobility – This concept is one that is stressed in all of the Functional Anatomy Seminars….if an external scar is adhered to underlying tissue, the biomechanics/bioflow of the articulation will be hindered.  Many forget that cutaneous receptors, as well as those found in EACH fascial layer affected by an incision, contribute afferent information to the central nervous system regarding the status of articular motion.  Such information is utilized in the formation of motor patterns.  Fibrosis, leading to impaired tissue sliding and relative tissue motion leads to faulty movement information…and thus in turn, faulty movement output.

5.  Mobility vs. Flexibility – So you have restored normal passive motion…now what.  The general assumption that gains in flexibility will lead to articular control during active motion within those ranges is, well….wrong.  One can never assume that the nervous system will be able to control any newly acquired ranges…nor can one assume that ranges that are restored back to pre-surgical status will automatically be ‘remembered’ by the nervous system.  Thus restoring ‘flexibility’ is not enough.  The re-establishment of mobility is key.


In this case we discuss how failing to restore proper knee extension can lead to problems both in the knee, as well as other areas which are affected by aberrant knee function.

A 37-year-old competitive rec hockey goalie presented with plantar fasciosis/opathy/algia/itis/heel foot pain/whatever of 2 months duration.  The presentation was typical with pain upon first step in the morning, reproduction with palpation of the medial calcaneal tubercle, etc.  Upon further questioning of the patients health history it was revealed that 8 months prior to the onset of the symptoms, he had underwent ACL reconstructive surgery of the ipsilateral knee (using a hamstring graft).  Following surgery, the patient had under gone a course of manual therapy and post-surgical rehabilitation after which the patient describes the results as ‘fair’ noting a constant, generalized ‘stiffness’ in the joint.  Pertinent to this case, with physical examination I discovered that the knee was able to achieve approximately 90% of flexion (not acceptable after 8 months of care – especially since treatment of this patient thus far by me has restored full flexion in few visits), yet it lacked terminal extension.  In fact, when observing gait, a lack of total knee extension was noted at the cessation of the swing phase.  Examination of the hamstring demonstrated palpable fibrosis and decreased extensibility.

Thought Process:

We do know from literature that tightness/shortening of the hamstrings group is linked to Plantar Fasciitis – References:  1, 2, 3, 4

The mechanism behind this relationship is believed to be related to the fact that lack of terminal knee extension at the end of the swing phase leads to prolonged forefoot loading which in tern increased the windlass effect.  This then causes increased stress on the plantar fascia leading to degenerative tissue changes.

Thus in this case we see that the lack of proper terminal knee extension lead to the onset of another debilitating symptom.

From my personal experience in dealing with post surgical ACL cases, Plantar Fasciitis is only one possible result of a failure to restore terminal knee extension.  Others include:

–       Ipsilateral chronic Dorsal Sacral Ligament sprain

–       Metatarsalgia

–       Degeneration of the first ray of the foot

–       Patellar tendonopathy

On can also make the logical deduction that lack of proper knee movement would induce the onset of premature degenerative arthritis of the knee joint, and or any other joints affected by aberrant knee mechanics.




5 Comments leave one →
  1. Ali Rubie permalink
    June 11, 2013 12:42 pm

    Hi Dr Spina,
    Thank you for your posts making this information accessible.

    I would appreciate your thoughts/experience regarding return to elite level middle distance running following semitendinosus proximal tendon avulsion injury (26 yr old male, injury misdiagnosed – had injury 5 to 6 weeks now) The tendon is retracted 2 cm.
    He also had experienced ITB friction syndrome prior to rupture for a period of 3 to 4 months.

    Thanks for your help

    Kind regards,
    Ali Rubie

    Sent from my iPad

    • June 11, 2013 5:36 pm

      Hello Ali

      I am not sure I understand your question. You said a proximal tendon avulsion of the Semi-tendinosus? Do you mean the proximal common hamstrings tendon, or the distal insertion of the semi-tendinosus. Also…you mentioned the diagnosis but with no question. Are you wanting management advise?

  2. August 20, 2013 12:01 pm

    I had acl reconstruction the middle third patellar tendon used in2004, I never regained feeling in the tendon, feels numb like novacaine during dental visits. My knee sometimes get swollen just below my kneecap to the left(outside). It doesn’t happen when I run, just when I start playing tennis. Is this normal? Is it more prevalent with using my own patellar tendon?

    • August 20, 2013 12:23 pm

      Hello Nahid

      Although I cannot provide you with medical advice over the internet…I can say that that ‘numbing’ feeling under the patella is very common with patellar grafts as the infra-patellar nerve is severed during the procedure. In some of my patients the feeling returns very slowly…in others it never does. Regarding the swelling, you should consult a therapist/doctor regarding this. In my experience this is not a common finding.

  3. Victor permalink
    October 23, 2013 4:19 am

    So how do you treat the scars?

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