Dry Needling Combined with Spinal & Extremity Manipulation to Quickly Achieve Post-Operative Terminal Knee Extension

Terminal knee extension deficits, getting the knee fully extended, can be a difficult and frustrating impairment to treat. Terminal knee extension deficits are most frequently observed following some type of knee surgery. Post-ACL repair, for example, since the body is being sliced open by a scalpel, all of the muscles surrounding and crossing the knee get tight. Tight muscles crossing any joint is one of the most detrimental things you can do to your joints. It leads to hypoxia, pain, collagen degeneration, and a lot of joint compression.

When joints are compressed, the joint capsule does not move normally. To stimulate production of new synovial fluid (joint oil) and to replace the old fluid in the knee joint, which is produced by the synovial tissue on the inside of the joint capsule, the joint needs to move through normal range of motion (ROM). Poor synovial fluid production leads to a situation similar to driving a car with old, gritty, sludgy oil. If the knee joint lacks ROM following surgery, it leads to all sorts of problems. Slow / incomplete healing, hyperalgesia, nutritional deficiencies in the menisci secondary to lack of clean synovial fluid, and low back pain, to name a few.

I typically find the popliteus to be the main culprit limiting full knee extension following surgery. The popliteus is the deepest muscle in the back of the knee and its function is to unlock the screw-home mechanism, internally rotating the tibia on the femur. Remember, the screw-home mechanism involves external rotation of the tibia on the femur during the last 10 or so degrees of extension. This approximates the tibial plateau and the femoral condyles, essentially locking the knee into stable extension. Unfortunately, if you are not using needles and manipulation, it can be next to impossible to properly treat the popliteus and the knee joint. You have to get through the thick gastroc, and potentially the soleus as well.

Remember, most of the popliteus sits below the knee joint. The tendon is really the only thing crossing the joint, which attaches underneath the LCL and lateral hamstring tendons. Without needles, the only popliteus treatment one can perform is indirect. With needles, it is super easy to directly treat just about the entirety of the muscle; origin, belly (mid-belly is covered by neurovasculature) and insertion. Needling allows us to directly touch / treat most muscles in the body, popliteus included. The deeper the muscle, the harder it is to treat without needles. The multifidus, piriformis, psoas, and popliteus are all deep muscles that, oftentimes, simply do not respond to typical, indirect treatment. Once needles are added to the equation, direct treatment becomes possible and life gets way easier for the patient and practitioner, with rapid, easy improvements in ROM.

The knee consists of a few different joints. Tibia-fibula, tibia-femoral & patellar-femoral. All three of these joints need to move normally to allow for normal knee ROM. To achieve normal, full knee extension, the patella has to slide cephalic in the femoral groove, the tibial plateau needs to tilt posterior, the entire tibia needs to externally rotate, and the fibula needs to be freely moving against the tibia. The tib-fib joint does not move much, but it is vital that it move normally if your goal is achieving full, fluid knee ROM. For example, most people dorsiflex the ankle when extending the knee. To dorsiflex the ankle, the fibular head needs to move cephalic on the tibia. Regardless of how an individual may extend their knee, all those joints need to move normally to allow for normal overall knee motion.

I always needle first, then manipulate. Needling improves muscle length, induces significant increases in blood perfusion and has an overall relaxing effect on the joint. This makes for an easier, more comfortable and lasting manipulation. If only needling or only manipulation is performed, half of the problem still remains. Any deviation in one will lead to a deviation in the other, and treating only one is asking for the impairment to return and become chronic. Manipulation and needling have synergistic effects on depressing sympathetics and elevating parasympathetics, pushing the ANS / CNS towards homeostasis. Remember, any post-surgical patient, and just about all PT patients in general, present with sympathetic hyperactivity. I won’t go into detail about how to specifically manipulate the knee. Suffice it to say, you will never achieve maximal patient outcome potential without combining needling with manipulation. This holds true for the entire body.

Aside from pathology of the knee joint itself, the ankle, hip and pelvic joints are probably the next most common causers of knee pathology and lack of terminal knee extension. For this reason, the knee, just like every other joint or structure in the body, should never be treated alone. The entire body must always be addressed to achieve your patients’ potential.

Think about anterior and or medial ilial rotation, the most common SIJ deviations. Let’s assume we have a patient with anteromedial ilial rotation on one side, which is super common. If the ilium is in anterior rotation on one side, that leg is going to be “longer.”

Related: Check out this video on Leg Length Discrepancy

If the ilium is also medially rotated, the femur is likely going to be in either internal or external rotation, depending on specific compensatory patterns. The compensation for this conversation doesn’t matter. Any deviation in any joint, especially from the low back down, is going to cause abnormal knee position and deficits in ROM.

Consider how deep a lot of the low back, hip and knee musculature is. Again, the deeper the muscle, the harder it is to treat, without needles. It is basically impossible to treat many of the deep muscles in the body without needling. This makes affecting a successful, lasting manipulation, or any other treatment, seriously difficult to achieve. If both the muscles and the joints are not properly addressed, arriving at maximum patient potential is simply not possible.

Thanks for reading everyone. Let me know if anyone has any questions about anything or if you would like to sign up for one of our four needling or three manipulation courses. Talk to you soon.

Jason

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