The goals after a knee injury & knee surgery are very similar. In both cases, clinicians & patients want to achieve a full & symmetrical range of motion; full & symmetrical quadriceps strength, normalized & symmetrical movement patterns, and a quiet knee. This is particularly true in the case of ACL, meniscal and other surgeries that take place inside of the joint. Much attention is given to the fact that many patients who undergo ACL reconstruction surgery simply never achieve symmetrical quadriceps strength, even years later, and the role this plays in the high risk of re-tear & re-injury. However, the goal of a quiet knee & the role it plays in success after knee surgery is often overlooked by clinicians & patients alike. This article will examine what a quiet knee is & how patients can reduce knee swelling after surgery.

 

So what is a Quiet knee? 

A quiet knee is simply a knee that has little to no joint effusion. Effusion is essentially another name for swelling that is inside of a joint, in this case, the knee. The knee, like a majority of joints in the body, is a synovial joint. A synovial joint is one in which two bones come together but leave a joint space. These joints are surrounded by a thin capsule that contains a liquid called synovial fluid which lubricates the joints during movement. While that synovial fluid is always present and important to the function of the knee, joint effusion represents an increase in the amount of fluid present inside of that joint capsule and indicates joint inflammation. 

While inflammation & effusion are an expected result of the trauma of an ACL injury, as well as the trauma of the surgery, this effusion should subside within the first 6-8 weeks after injury or surgery.

READ: WHAT TO KNOW ABOUT TISSUE HEALING

 

Why does Joint Effusion persist in some people months after surgery?  

The short answer: load management. Or, more accurately, load mismanagement. Joint effusion indicates that the knee is not prepared for the load that is being placed on it.  While any type of weight-bearing activity puts a force through your knee joint, your muscles, in particular, your quad serve to absorb & attenuate that force. However, the trauma of an ACL injury & the trauma of ACL surgery both decreases your quadriceps’ strength & capacity to support your joint through a process called neuromuscular inhibition. Re-training the quadriceps to support your knee joint requires significant focus during rehabilitation and isolated strengthening. Without appropriately rebuilding your quadriceps, something as simple as walking too many steps or standing for too long can create excessive force through your knee joint and lead to excess effusion. 

 

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So how do I know if I have a quiet knee? 

Fortunately, there is a quick and easy way to test if you have knee joint effusion as well as how much. This test is called the modified stroke test or sweep test and is best performed by a partner. Instructions for performing the test are included in the video & graphic below: 

When using this test, we are looking for the presence of fluid along the sulcus or indent on the inner portion of your knee. This is used simply because it is the easiest place to view the presence of effusion that is inside your knee joint and contained by that joint capsule. 

 

The test is graded as follows :

 

Zero indicates no wave of fluid produced after the downstrokes on the outside of the knee

 

Trace indicates a small wave of fluid after the downstrokes that do not completely fill that indent  

 

1+ indicates a larger wave of fluid after the downstrokes that completely fill that indent.

 

2+  indicates a larger wave of fluid that returns to completely fill that indent prior to performing the downstrokes 

 

3+ indicates so much fluid filling that indent that it is not possible to move it over to the outside of the knee even with the upstrokes 

 

A quiet knee is one that has a trace or zero effusion indicating that the joint is not being overloaded. 

 

Having Surgery? Make Sure To Do These Things Before!

 

What do I do if I have a 1+ or above?

A grade of 1+ or above on the modified stroke test indicates that there is a mismatch between the preparation your muscles are undergoing and the loads that are being placed on your joint during exercise and everyday activity. Thus, to address joint effusion you must close the gap between these two. In essence, you must increase the strengthening you are doing for your muscles, particularly for your quadriceps, while temporarily decreasing the weight-bearing loads that you are placing on your knee joint. So the question is: how do you train your quadriceps without overloading your joint? The answer is non-weight-bearing open chain exercises. Open chain exercises allow us to directly train the quadriceps without putting weight through the joint. Thus increasing the preparedness of our muscles to handle weight-bearing activities while resting them from overloading. 

LISTEN: ARE OPEN EXTENSION KNEE EXERCISES SAFE?

 

Long Arc Quad – AROM

Sample Knee Rehab Program Exercise Video

 

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Long Arc Quad – Band

Sample Knee Rehab Program Exercise Video

 

Why is this important?

Joint effusion itself negatively impacts joint kinematics, is associated with poorer patient-reported outcomes, and can indirectly contribute to joint degeneration. Furthermore, joint effusion is a vicious cycle in which the presence of joint effusion further contributes to neuromuscular inhibition of the quadriceps, thus leading to further loads through the joint which in turn leads to further joint effusion and so on. 

Thus addressing joint effusion and managing loads early in knee rehab should be a priority for every patient and clinician.  

 

Closing thoughts

Establishing a quiet knee after surgery is one of the principle goals identified as crucial to a positive outcome. Yet this is often overlooked. Clinicians and patients alike often inappropriately prioritize “functional exercises” too early in rehab and fail to address lifestyle factors that contribute to swelling outside of rehab including walking & standing for prolonged periods. This can lead to a vicious cycle in which quad weakness & overloading of the joint lead to swelling that leads to further quad weakness and overloading of the joint. In order to have success after a knee injury patients and clinicians alike should focus on load management & progression to establish a quiet knee as early as possible and maintain that throughout the recovery process. 

 

Take Control of Your Knee Health

Knee discomfort is one of the reasons why people end up sitting out but that’s about to change through the tag team champs of the world: education and movement. The knee must be strong enough to create its own muscular forces and be the traffic director for force passing through. Therefore, to have a successful outcome your program must include not just the knee but the core, hip, and ankle. Teamwork makes the dream work, ready to be part of the team?

 

References

1. Failla MJ, Arundale AJ, Logerstedt DS, Snyder-Mackler L. Controversies in knee rehabilitation: anterior cruciate ligament injury. Clin Sports Med. 2015;34(2):301-312. doi:10.1016/j.csm.2014.12.008
2.  Lynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for defining ‘successful outcome’ after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. 2015;49(5):335-342. doi:10.1136/bjsports-2013-092299
3. Sturgill LP, Snyder-Mackler L, Manal TJ, Axe MJ. Interrater reliability of a clinical scale to assess knee joint effusion. J Orthop Sports Phys Ther. 2009;39(12):845-849. doi:10.2519/jospt.2009.3143
4. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2010;40(11):705-721. doi:10.2519/jospt.2010.3345

 

About The Author

Tommy Mandala, PT, DPT, CSCS, SCS, OCS

[P]rehab Writer & Content Creator

Tommy Mandala is a Doctor of Physical Therapy, Board Certified Clinical Specialist in Sports & Orthopedics, and Certified Strength and Conditioning Specialist in New York City. He is the founder of ALL IN ACL, a digital coaching platform dedicated exclusively to helping ACLers return to the life they had before their injury with full confidence in their knee. Prior to that, he worked in the sports clinic at Hospital for Special Surgery, the #1 Orthopedic Hospital in the country. While there, he had the opportunity to hone his skills as an ACL specialist working closely with world renowned surgeons and evaluating patients from all over the world. He completed his sports residency training at the University of Delaware where he had opportunities to work with many of their Division I sports teams as well as the Philadelphia 76’ers NBA G-league affiliate, the Delaware Blue Coats. He also trained at Champion Sports Medicine in Birmingham, Alabama where he had the opportunity to learn from researchers in the American Sports Medicine Institute. Currently, Tommy works exclusively with ACLers through his digital coaching model. While many of these clients are athletes, Tommy works with ACLers of all different abilities helping them to build the strength they need to overcome this unique injury. One of his favorite aspects of his job is taking active clients who have never been a “gym person” before and showing them the amazing things that happen when they learn to strength train.

 

 

 

 

 

 

Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.