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Case Study: Tammy’s ACL rehab

This client came to me because she was off work after a knee injury. She came into the clinic wearing a knee brace and was cautious climbing the stairs into the treatment room. She is an active mom who enjoys hiking, biking and playing outdoors with her family. But her knee injury was holding her back from fully participating in her active life. She had previously fractured her right fibula. More recently she sprained her left MCL and then later tore her left ACL. She also had a history of right shoulder pain attributed to poor ergonomics.

When I first assessed her, she had a number of movement patterns that revealed her injury history. When she flexed her knees I could see an indirect journey of her right knee that reflected that old fibula fracture and she felt unstable her flexed right knee. Her right foot was supinated, again reflecting that fibula fracture. Her ribcage was rotated to the right and she had disorganized ribcage movement in all planes along with a tight feeling in her right scapula.

My hunch was that all of her issues in her left knee stemmed from her nervous system’s avoidance of bearing weight through her fractured right fibula and her poor ergonomic setup’s affect on her torso. We chuckled about how she came to me to work on her left knee and I was more interested in her right leg. As Ida Rolf famously said ‘where you think it is, it ain’t’.

We began by teaching her right foot to supinate. But it was clear that the foot wouldn’t supinate until I could get her right fibula to articulate against her calcaneus. When the distal fibula is stuck and can’t articulate against the calcaneus, the foot has trouble supinating. A stuck distal fibula is blocking the external rotation and inversion of the calcaneus that is required to create a supination of the foot. By freeing up the fibula we were able to restore this articulation. I was able to restore supination in her right foot and then ask all the joints superior to the foot to participate in allowing the foot to supinate.

Once we got the right foot supinating I could begin to work on the phase of gait that was important to her left knee. This is the point in time where one leg is pushing the body weight forward from behind as the body is load bearing on the opposite side. The back leg is in a supination while the front leg is in a pronation. To get her back leg into a supination we needed to do the work during her previous visits to get her body familiar with supination. Now that it was supinating we placed her right leg to the back and created the supination shape to push her forward. This is the point in time where the work gets redistributed away from the injured left leg. Restoring the mechanics throughout the right side to create supination meant that the distribution of effort was being shared by the two sides, rather than her avoiding putting weight into that fractured fibula. We taught the nervous system that it was safe to put weight into that right leg and create supination shapes that likely caused pain during the recovery phase.

Why is it that her left knee was vulnerable when it was her right leg that had the fracture? What likely happened is the nervous system was avoiding putting pressure into the formerly fractured right fibula and while she walked she quickly got her weight off the right leg and over onto her ‘safer’ left leg. The outcome was a pattern where weight was being put onto her left leg too soon and with more force than it was meant to endure causing her left knee over time to get the brunt of all her steps. It was just a matter of time before the left knee was caught in a vulnerable situation and couldn’t handle the load any more. By keeping herself off the formerly injured right leg, her left leg was taking on more work than it was prepared to do. It was inevitable that it would eventually give in.

Once we restored the movement on her right side and taught her leg knee to bend and rotate at the appropriate time, we got her firing muscles that hadn’t fired in a long time. The turning point was the day where we finally got her hamstring loading on a flexed knee.

Video 2019-08-13, 11 13 12 AM

hamstring having a bit of a wakeup call from the nervous system.

I mentioned that her shoulder was contributing to this pattern so I want to elaborate. Her not-so-ergonomic issue had her torso rotated to the right and her resting posture showed the same pattern. When we had her move her torso, her right scapula showed restrictions that created sticky points as she moved. We rebuilt her scapular movements by reteaching her shoulder joint and ribcage how to move in three planes, one plane at a time. The most beneficial movement retraining for her body was in the sagittal plane. I taught her ribcage to posterior tilt on axis stacked above her pelvis while getting her shoulder joints to externally rotate at the gleno-humeral joint. This allowed the scapulae to fully retract towards the spine. Over a matter of weeks, mastering this movement cleaned up the movements in the frontal and transverse planes. Sometimes cleaning up one plane of movement can clean up the remaining two planes. It’s all a matter of finding out which plane is the best entry point.

When I last saw my client her movements had cleaned up, she had stopped wearing her knee brace, she was hiking, biking and playing with her kids. She was able to return to work. Plus she had a toolkit to keep herself well. I got a message from her a few months ago telling me that she had some knee pain return but by doing the exercises we had developed together she had completely cleared it up, all on her own! She told me in one of our early sessions she wished she’d come to see me 5 years earlier.