So what do you do about the graph site pain in an ACL rehab situation? Good morning. Happy Monday. I have neuro coffee in hand and it is perfect. Okay, man, it was a quick weekend. Got a busy week coming up. So let's dig straight into today's Q&A. Today's Q&A is a discussion with Zach and Zach is currently managing a late stage ACL reconstruction situation. It's a revision so they took a contralateral patellar tendon graft and that is actually the site of the current symptoms that they're working to resolve and so this covers a lot of things like the influence of the archetype why there would be ongoing load on the knee and then we talk about strategies to alleviate these symptoms. So it's a really good discussion. Zach is on point. He's a regular on the coffee and coach's conference calls. So I've gotten to talk to him on several occasions. But I think you'll find this very, very useful. If you would like to participate in a 15 minute consult, please go to askbillhartman at gmail.com. Put 15 minute consult in the subject line so I don't delete it. And I would be happy to talk with you. And you get to get your base up on social media. So there you go. Have an outstanding Monday. Have a great week. And I will see you guys tomorrow. All right. Clock has started. Go ahead.

So I was hoping to follow up on that ACL graft site pain conversation. And I have a specific patient with some range of motion measurements. I'm kind of working through that. The person I want to clarify is talking about how the pelvic diaphragm is pushing down and she's unable to concentrically orient, which is causing those tissues to behave more stiffly.

Let's do it.

You want to clarify really quick, you're talking about how the pelvic diaphragm is kind of just like pushing down and she's unable to concentrically orient, which is like causing those tissues to behave more stiffly.

Right, so if there is a constant downward force, such as what occurs when we talk about people with narrow intercostal spaces and limited breathing excursion, they're going to have an eccentrically oriented anterior pelvic outlet, which pushes pressure down and forward. So it is a perpetual load, meaning the rate of loading is instantaneous. Under those circumstances, the connected tissues will behave in a stiffer manner. That's just the normal viscoelastic behaviors.

It's kind of analogous to what you talked about, just like the back squat, how it seems slower than some movements, but it's actually a series of instantaneous loads.

One thousand percent.

Perfect. Can I throw some of her range of motion measurements at you and see?

Yeah. Let me hear them.

So I'm more confident in my upper extremity measurements. I'll start with shoulder flexion. She had 15 degrees on the left and 30 degrees on the right.

What's the affected side of the knee?

So she's a revision case. She tore the right side both times, but they took a contralateral patellar tendon graft for the revision case.

She's having the knee pain on the left side.

Yeah. It's on the left side. The right side's fine at this point.

Perfect.

Got it. So left shoulder flexion is at 30 degrees, and right shoulder flexion is at 30 degrees. Her shoulder internal rotation is 70 on the left and 60 on the right. Then shoulder external rotation, though it's pretty symmetrical, is about 115 degrees on both left and right. At the hip, hip flexion on the left was a bit more than the right. About 100 on the left and 95 on the right.

Atcha.

And then at the hip, hip flexion, left was a little bit more than right. So about a hundred on the left and 95 on the right. IR.

Yup.

IR.

I already know where she's at, dude. We're good up there. So here's what you're looking at, okay? She's narrow, right? Okay, so she is anteriorly oriented, so she's narrow, she's anteriorly oriented, and she's getting pushed really, really hard from posterior left, okay? So your flexion measures and your ER measures are magnified, right? So your external rotation on the table is the dead giveaway because she measures in a magnified manner, right? So we would consider that to be on average 90 degrees, she's 115. Okay, she's laying back on the table, which means you've got a pretty significant amount of anti-orientation that you're dealing with. So let's take the concept that we talked about at the very beginning of the call. And we talk about this anterior downward force. So her internal rotation right now is coming from this anterior orientation of the pelvis and the thorax. So she is way forward. So she's got a lot of load on the anterior knee all the time, okay?

Yup.

Okay, so she is anteriorly oriented, anteriorly oriented, and getting pushed really hard from posterior left. Therefore, flexion measures and external rotation measures are magnified. The external rotation on the table is the dead giveaway because she measures in a magnified manner; on average, it would be 90 degrees, but she's at 115. She is laying back on the table, which means you've got a pretty significant amount of anterior orientation that you're dealing with. Let's apply the concept we discussed at the beginning of the call: the anterior downward force. Her internal rotation is coming from the anterior orientation of the pelvis and the thorax. She is way forward, so she has a lot of load on the anterior knee all the time. First, you must reduce the anterior orientation. She is getting pushed from posterior left and is anteriorly oriented. If you try to bring her back or turn her too soon, it will be a block kind of movement, like when we talked about moving the refrigerator and everything turns together. What we want to restore is relative motion within the pelvis so she can create the yielding action posteriorly to take the load off the tendon and allow everything to yield. She cannot yield right now. You must posteriorly orient the pelvis first and foremost. You will not get any relative movement back until you do that. Once you do, she becomes your typical kind of left roller. You have to get her to turn, so you must create the yielding action. You will have to bring her back to early propulsive strategies, most likely on both sides, but to alleviate the load on the left knee, you will have to bring her back on that left side for sure. Depending on how much range she has, how far she is into her recovery, and how much knee flexion you can load her in, you can proceed.

Oh, okay.

Good, so anything that we have talked about in the past in regards to restoring that yielding action. So even as far as going, so she's going to be somebody that looks like the left shifter in a squat. You know where they're oriented to the right and as they sit down they sit back into the left, so you can use that kind of a thing all of your left rolling patterns around the table. She's gonna be probably gonna start her in like a short stagger kind of a chopping action to the left. Again, we're trying to perpetuate the left yielding action posteriorly, but you can unweight her. So again, she is constantly under load based on her physical structure. And so the chopping activities reduce body weight. So think about it, it's like, if I'm pulling a weight downward from an overhead pulley, that pulley is pulling me up. She's actually lighter under those circumstances. That's gonna be the way that you can sort of reduce the load. So we get the anterior muscle activity that she's gonna need to help maintain pelvic orientation. You get the yielding action on the left posterior side, and then you start to turn her into that left side.

Gotcha.

Does that make sense?

That does make sense. Um, and then I think you talked about, and I guess maybe. if it still applies, but can you have all the information on the zoom call the like starter and that like lazy bear position and then just like gradually progressing her to upright squatting.

Yeah.

And then I think you talked about, and I guess maybe if it still applies, but can you have all the information on the Zoom call, like the starter and that lazy bear position, and then just like gradually progressing her to upright squatting.