An independent case study just performed at Great Moves PT by myself. How many patients have you seen struggling to get back their terminal knee extension following a total knee arthroplasty because they also have a pre-existing low back pain issue? One of my recent interns discussed this exact topic for her inservice. Bottom line: neurodynamics. So, I focused on lower quarter nerve glides for this lady who was still lacking 22 degrees extension following her total knee arthroplasty and had a history of low back pain. I rested her surgical leg over my shoulder, in supine, and adjusted the amount of hamstring stretch while she actively pumped her ankle (glided her sciatic nerve). I then had her in prone and worked hip posterior anterior mobility on the surgical side (SI and hip posterior anterior mobility on the non-surgical side that was being beaten up for compensated gait patterns) followed by passive prone knee bend (femoral nerve glide) or quad stretch on the surgical side within tolerance. Following treatment, that was not directed at the knee itself, she had no back pain and was able to obtain knee extension lacking only 6 degrees, and demonstrated significant improvement of gait. She and I were pretty happy with the results. It's nice to hear a patient say, "I feel like a new person after treatment today and it didn't even hurt".
Try it on your next total knee arthroplasty with back pain patient and let me know how it goes. If you are contemplating having a total knee arthroplasty and have back or hip pain, consider pre-surgical PT to address any core issues and ask your PT how he/she may address regaining your motion after your surgery considering you have a back issue. More research on neurodynamic treatment of total knee arthroplasty with low back pain is needed...and may just save a lot of pain and improve function sooner for those trying to regain their motion in this particular situation.
Here's what I sent my patient home with to reproduce the nerve glides we did in the clinic:
Can't seem to rotate this picture. You'll have to rotate it to your R 90' for proper orientation. Cue your patient to bring his/her legs up the wall as far as his/her hamstrings allow and then pump the ankles up and down to glide the nerve. I told my patient to lay in bed with her feet up on the wall to tolerance and then pump her ankles to glide the nerve to avoid difficulty getting up and down from the floor. I also told her not to hold the nerve stretch, just on and off!
My patient is actually doing this exercise simply laying on her stomach in bed or on the floor with a pillow under her thigh to encourage mild hip extension while actively bending and straightening her knee to tolerance to stretch her femoral nerve. Again, do not hold the stretch; just on and off. To incorporate core control and shoulder stability, you could certainly have a patient do this exercise as picted if it's an appropriate level for your patient. If the patient experiences low back pain with this exercise, try using a pillow under his/her stomach as well.
