Straight Leg Raise after ACL surgery

[tyson73]

We are discussing these days the effects of the straight leg raise during the first 2 weeks after an A.C.L surgery, some of our fellows think that it's harmful for the graft because of the gravity, I don't share that opinion, first the ligt needs to be stabilized and the fact that we are working in an open kinetic chain both sides of the thigh, quadriceps and hamstrings, are working in co-contraction whish 'secure' the graft against any kind of load, 2nd we had good results with the S.L.R patients, players or private, feel 'the movement in the upper leg including the hip...anyway it was a good subject that i wanted to share with you so any remarks just let me know.thx

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[physiobob]

Firstly some of your English words don't make sense in your post, which make it hard to get what you are saying.

Secondly, why would you choose to do a SLR exercise for an ACL (or for any problem really). Is the psoas dysfunctional? When does any body perform the action of an SLR? Maybe a dancer or Australia football player but that would be in standing.

The SLR is an over-used and mostly inappropriate exercise for just about anything I can think of. Always ask your self why you are doing an exercise. Then ask is that a problem the person has? Then ask are you doing it in a functional way that is relevant to that joint or in the way that synergy of muscles is used. The SLR is basically a waste of time!

[xplando]

I dont agree with the latter! I find the SLR (30 degrees of hip flexion) to work in a wonderful manner. that's because ur emphasizing the quadriceps to work in that range (not more than 30 degrees because u'll be recruting the hip flexors then) thus strengthening them in that range which is a good thing to do since we all know that during heel strike of gait , there is around 30 degrees of hip flexion with the knee locked. So, yes its a functional exercise in a way!

[vaibhav yadav]

SLR!!!& ACL!!!! big names bt cannot understnd y so much small to discuss abt it!!!!

after acl........... xercises depend upon the progresss n stage of tear............u want to strengthen quads....y don't u try it passively thrugh isometrics.........

SLR prevent adhesions during immobilization.............bt only do it in a cast..........if u r fond of it...............

[Physio Dace]

Personally I think there is a time and a place for SLR as an exercise - I find it a very useful technique (with progressions of eccentric; active assist etc) to restore post-op or painful quadriceps inhibition when the patient is NWB or even PWB.

However as soon as the patient can complete it without pain and with activation patterns similar to that of the contralateral leg the exercise should be discarded as it is mostly a non-functional exercise (with the exception being transfers in/out of bed/cars etc). The same goes for inner range quads post-op and post-injury - regain the lost recruitment patterns and move on immediately.

[physiobob]

I dont agree with the latter! I find the SLR (30 degrees of hip flexion) to work in a wonderful manner. that's because ur emphasizing the quadriceps to work in that range (not more than 30 degrees because you'll be recruiting the hip flexors then) thus strengthening them in that range which is a good thing to do since we all know that during heel strike of gait , there is around 30 degrees of hip flexion with the knee locked. So, yes its a functional exercise in a way!

Don't really agree and perhaps there are better exercises than a SLR that don't have a much of an impact on the lumbar spine.

Firstly the actual Straight Leg Raise (SLR) is not a functional movement, especially in supine lying. As the primary focus on that exercise is hip flexion are we saying that post of ACL patients have weak hip flexors? Didn't we just operate on their knees?

By locking the knee in extension and lifting the leg you are using the psoas, iliacus, perhaps sartorius (balanced by some adductors to stop external rotation), and the rectus femoris. Hopefully some abdominals are working as well. Of course the other quads are working to keep the knee at zero extension. Are the quads weak? If so why? or is there an extension lag? If so is that due to weak quads? Unlikely. Is it due to inhibition? Maybe. For some reason perhaps there is a lack of connection to switch the inner range quads on, perhaps for good reason.

Importantly does the knee passively make it to full extension? Maybe hamstrings are blocking that. Prone knee flexion with eccentric lowering back int extension is useful to assist with that in the early period post op.

Activity wise standing up to a straight knee position would be more functional than a SLR exercise. In fact I though we did away with open chain exercise a long time ago for functional rehabilitation. (That's not to say they don't have a place some of the time).

Why not put them on an exercise bike to get the quads firing up. Yes this in in a certain range but then if they are inhibited rather than weak then that's fine. I'd really like to hear from someone who has a clear rationale for the SLR in relation to what there are trying to achieve with it. For my mind I'd rather than walk a few lengths of the corridor than doing 2-3 sets of SLR's on the plinth or in bed.

p.s The swing phase of gait to heel strike is a largely a passive activity and does not require a strong hip flexor. As the yield of the keen is what happens on that heel strike the hip flexor isn't going to be much us. The quads of course are but surely walking again would be the solution there.

[Physio Dace]

I wholeheartedly agree that in the majority of cases the SLR as an exercise is pointless (e.g. in the case of ACL post-op) and the regaining of quadriceps function can be achieved much more efficiently with closed kinetic chain/functional positional/cycling/pool exercises etc etc; however this does not mean that it doesn't have a place in the rehab of some patients and conditions.

Sometimes physio's strive to be too original and innovative with exercise prescription and the simplest exercises can often get the fastest results (yes that includes walking, cycling etc). I think that if a person cannot actively complete a SLR (as an assessment) there is a major flaw in the quads mechanism and hence lower limb kinetic chain (even though its not a functional assessment)- if we consider specificity of training then perhaps the SLR as an exercise may be a means of regaining this quickly and effectively - perhaps faster than certain closed chain exercises despite being more functional.

In my experience I only use the SLR where there is an obvious post-op motor recruitment dysfunction (not weakness due to atrophy) and the patient is strict NWB and has restricted ROM (e.g. complicated patella dislocation). But again, as soon as the patient can complete the SLR to the same degree as the contralateral leg then it is discarded immediately as I don't think it offers any functional strengthening.

However getting back to the original post - using SLR as an exercise post ACL although not being harmful (the graft if incredibly strong initially) may not be the most effective way of restoring quads recruitment and promoting progression in ROM - WB or closed chain exercises such as cycling/walking/fitball extensions etc are much more indicated. In saying this, if after 2 weeks (make that 1 week) of this approach the patient still cannot perform an active SLR to the degree of the contralateral leg then maybe its worth doing - just don't tell other physio's as you may be excommunicated

[naveenedin]

i agree with physio dace. Lets r/v the orginal question, is SLR is anyway harmful in an 1-2 week post acl injury period. My understanding is that, check the SLR to identify the extensor mechanism, if there is an extensor lag- never do an SLR with an extensor lag, with compromised acl patients. Cos, tat puts too much stress on the acl, and may be potential harms. Going back to intial period, reduce swelling and get the range of flexion back upto 90degrees. I dont think any orthopaedic surgeon, would be operate an ACL, wth restricted knee ROM. Hence lets not glorify or underglorify SLR, treat as it goes. Any thoughts????????????