ACL Post Surgery

[SIR CUSTAC CANT]

Hi All,

Has anyone worked with a client with excessive scar tissue following ACL surgery?

I have a client I am seeing in a couple of days and this is her case in one of her knees that she had ACL surgery on...her other one which also needed the ACL repair is fine.

She is two years post surgery and I let her know that I doubt at this point that massage is going to be able to break up the collagen that has already been laid down in the new tendons of her new makeshift ACL band. That it is really a few months out after surgery after recovery from the acute seforum.xxxes after surgery that massage can affect scar tissue. Although I do believe massage can effectively support the muscles around the knee and only benefit her.

I also let her know that I do not specialize in Sports Medicine Massage or Physical therapy and I may refer her out.

Ideas?

Thanks!

 

[PaoloPH]

I haven't worked with a case like this, but I would say that although you are right that the most help can be given soon after surgery, I don't think your efforts will be futile even this far out. It make take longer, and be slower, but I do think scar tissue can be reduced using slow deep structural bodywork techniques, melting the connective tissue, especially if she is motivated to make change through bodywork. However, if you're not familiar with techniques like these you may want to refer her out, though they're not hard to apply.

 

[Pompal 09.]

Thank you Shivashiva for your reply.

My deep tissue work is much like myofascial release - I am not certified but the school I went to taught a deep tissue work steeped in the myofascial release tradition.

As well, I have taken one structural integration class however it dealt mostly with the spine so yes, referral may be in order.

We shall see.

I get the feeling she mostly was scheduling a relaxation massage at present and then called with the ACL issue as an afterthought.

Thanks for your insight and I agree that any work we can do to surrounding muscles and tendon as well as work with ACL can only help. Maybe some PNF too.

 

[Ardnaid Janus]

I would think that MFR would be a good fit. As you mentioned going very slow.

WaltFritz might have some suggestions, being a P.T. and a background in JFB MFR, that might be different than what those of us with a massage background might recommend. You could PM him and direct him to this thread perhaps...

Either way, if you work on her yourself or refer out, will you keep us posted on the situation? Thanks!

 

[Techwing]

Here's a quick anatomy review on AMTCs myspce of the knee in 3D for fun.

http://vids.myspace.com/index.cfm?fuseaction=vids.individual&VideoID=34236651

Since the ACL is deep in the joint your limited on how much you can address a 2 year old scar. MF Unwinding may get some but if it were me I would mainly concentrate on all the muscle that cross the knee joint. Hamstrings, Quads, Adductors and IT Band, calfs, Achellis tendon and planter fascia. Make sure the fascia around the knee slides on the bone so to speak as well. There are some specialized moves but I won't get into them by text on the web.


Heat the tissue around the knee well. Work the anterior fascia superiorly and the posterior fascia inferiorly. As well the lateral fascia superiorly and the adductors inferiorly. Include Gluteals, especially Glut Max as it has a common attachment with the IT Band.

I agree with maetra as well, good PT work might do more than massage but massage has it's place here. Keep in mind the body didn't lay down a pretty and neat scar. A lot of the surrounding tissue around the knee is glued I am sure. If just from lack of movement. If the client has had PT, I would suggest they start back on some of their exercises and stretches. There is a good chance they had minimal PT after surgery these days and this might not apply.

Hope that helps. These can be rewarding sessions if you stick with it. ~peter

 

[Angry:(]

Thanks Nola and Maestra! Such helpful advice and resources.

I will keep you posted on how it goes.

She did have extensive PT in both cases of surgery the first time she said it hurt so badly to do her extension exercises that she didn't do them as much as she could while with the second surgery on the other knee she was told to take pain medication then do the extension exercises so she did and she feels this cut down on the scar tissue.

I told her to not beat herself up that it may not be an issue with lack of work on her part but it could be as simple as a compensatory pattern in her body that created a different tension on one of her knees than the other...

It should be interesting. I want her to get the treatment that she needs so I will access and see if I feel my work will benefit her specifically as she would like otherwise we will find the appropriate therapist and work.

 

[northernredneck65]

Just a couple of thoughts. While the overall effecacy of the work may largelly be determined by the extent of the fascial build up/scar tissue, I think it's important that you communicate and believe the possibility of the work working without advancing any promises. By you doing this, you and your client remain open to possibilities.

Whether you work on her or you refer her out, the chances of an overnight success is not likely. If she and you are committed (spelling) to the work, the progress may be slow but it will likely hold as fascial release techniques tend to 'last' longer.

I agree with nolalmt in that you've been given the opportunity to work on a number of areas that may have strain/counterstrain functional problems.

Have fun! Keep us posted.

 

[CheyGirl]

Thanks for the input Gaspen - will keep you posted.

She is very concerned about the scar tissue and was considering a second surgery which I let her know could create even more scar tissue possibly...so what I need to ask her when she comes in is how is the scar tissue affecting her? Is it causing pain, loss of ROM, etc...and then go from there.

And yes, you are right I need to realize the power of myofascial work and how just easing the muscle tension in surrounding muscles and fascia, even those elsewhere could have an extremely powerful effect.

 

[gansta432]

One of my clients has had successful knee repair surgery, BUT, was extremely lax in the follow-up exercises for extension and as a result, much more difficulty with walking, "locking" the knee when standing, etc. We tried upteen thousand different techniques [or at least it seemed like it] to ease some of the internal issues with the joint.....

Very long story very short......... one day I got fed up with the whining and bellyaching and said, "Look, when I put my hand on your shin, move it like you are straightening your leg out to raise it [sitting on side of table at the time].... he obeyed and gained a bit more flexion / extension in the joint..... so, we kept at it for about 15 mins using varying positions to use as much ROM as possible with the strain /counterstrain. With the very first millimeter of improvement the client said, "Guess I should have listened to the doctor, hulh?!" :banghead: About that time a good "thunk" like in the V8 commercials would have come in handy..... LOL

Don't know if strain / counterstrain would help your client, but, it sure helped mine.... his extension is now w/in .25 mm of the "healthy" knee.

 

[Atheist.]

Thank you all for all of your advice and input.

The appointment went really well last Saturday and I can thank you all for the resources you provided as a brush up on my anatomy.

The scar tissue was minimal and really was mostly in the patellar tendon which I think was resulting from where the surgeon had removed tendon there to repair the ACL although I will say it was not on the left knee.

There were definite restrictions and/or adhesions in the fascial compartments between Peroneus Longus and Brevis on the side of the ACL repair and some issues in the Adductors, and Gracilis.

So I think the work was very effective and brought some awareness around for the client around the muscles surrounding the knee, not just the knee.

I really enjoyed working with this client and pushing myself to delve into detail in regards to an injury which is not something I do a lot of with my practice since I am giving a lot of massages focusing on stress relief and tension patterns, not sports massage yet.

I am going to be taking some CEUs in just specific injuries and how to most effectively work with the clients who have them. As well, I think I am going to just start making it part of my weekly study to produce a pretend client with a specific injury and research how exactly I would work with it to get myself on a new level in practice. Some I know already but I really want to delve into what happens with specific surgeries for instance like this ACL example where a tendon is repaired by using the tissue of a different one and how that ultimately can effect not just the repaired one but everything around it.

I love this forum and all of the great members that contribute.

Thanks again!

 

[Jenuine]

I am going to be taking some CEUs in just specific injuries and how to most effectively work with the clients who have them. As well, I think I am going to just start making it part of my weekly study to produce a pretend client with a specific injury and research how exactly I would work with it to get myself on a new level in practice. Some I know already but I really want to delve into what happens with specific surgeries for instance like this ACL example where a tendon is repaired by using the tissue of a different one and how that ultimately can effect not just the repaired one but everything around it.

Glad it went well for you. This type of work can be career saving as it stimulates your thought processes for years and I personally don't get as burnt out.
I highly recommend Whitney Lowes "Functional Assessment in Massage Therapy". The book was written for LMTs as a quick reference and we use it as our curriculum book. We study it extensively. Too bad you aren't in our part of the country. What you want to learn is a big part of our program. 8)