Loss of extension after ACL surgery: How to assess for a cyclops lesion
This was originally posted on Lenny Macrina’s blog and shared here with permission – enjoy!
Loss of extension after an ACL reconstruction can be debilitating for the patient. It’s not as common as you would think but I see it enough in the clinic from people that are months out from surgery. Usually, this loss of knee extension after an ACL reconstruction is caused by a cyclops lesion. Let’s dive deeper into this!
Often times, they’ll present with anterior knee pain, posterior knee soreness and a relatively weakened quadriceps muscle that just won’t return. No matter what they do to get the motion back, the knee just never feels normal.
I’ve written about the loss of extension after an ACL reconstruction in the past. In this post, I discussed how I like to work on knee extension immediately after an ACL surgery. There are a few ways that I think are most effective and with minimal patient efforts.
What is a Cyclops Lesion?
For those not familiar, a cyclops lesion is a wad of scar tissue in the anterior aspect of the knee joint. It is believed to be a remnant of the previous ACL stump that had remained during the reconstruction surgery. At least that’s one theory. Another theory states that it may be fibrocartilage as a result of drilling the tibial tunnels.
Whatever the case, this arthrofibrosis (scar tissue) physically blocks the knee joint from locking out into full extension. Check out this MRI that shows the scar tissue in the anterior knee.
Cyclops lesion in the anterior knee blocking full (hyper) extension
How do I assess for a cyclops lesion after ACL surgery?
In this video, I describe why and how I assess for a cyclops lesion. Check it out.
Is it a Cyclops lesion or just a tight knee?
From the video, you can clearly note that anterior pain, in my experiences, is most often related to a cyclops lesion. Other factors to consider include:
- temporary/transient gains in extension
- anterior knee pain after increasing activity
- poor patella mobility
- quads just won’t come back
- continued hamstring/calf soreness
These are tell-tale signs that there’s more going on and you should refer back to the doctor so they can order an MRI to rule in/out the anterior scarring. If diagnosed, the best (and only) option is to have a knee scope and remove that scar tissue.
There’s nothing else that can be done. No PT, injections or manual therapy can restore full symmetrical knee extension.
The scar tissue needs to be removed by surgical excision. Aggressive PT should commence immediately after surgery to restore the extension range of motion.
The Best and Easiest Way to Restore Knee Extension after an ACL
Rehab after an ACL is never easy. There are many things that could affect a patient’s outcome. I’ve treated hundreds of patients after an ACL reconstruction and each one is a unique challenge. I wrote about this in a previous post here..check it out and let me know what you think.
I put this video together for Mike Reinold’s website so you could see what I exactly do to gain knee extension back….and why I’m not a fan of prone hangs. Hope it helps with some of your knee patients.
Final Cyclops Thoughts
As a PT or athletic trainer, don’t blame yourself if the patient needs another surgery to remove the scarring. It seems as if it was inevitable and was going to occur no matter the efforts to work on knee extension. I think the lesson here is:
- work on extension early and often
- maintain good compliance at home
- assess/measure each visit to determine gains or losses
- early patella mobility and knee PROM
- get the pain and swelling out as quickly as possible
- refer back to the doctor if the ROM not improving despite your best efforts
Hope this post helps you get better outcomes for your ACL patients!
If you want to learn more about how I treat ACL’s, then you can check out our all online knee seminar. If interested, check it out at www.onlinekneeseminar.com and let me know what you think. We cover the anatomy, rehab prescription, ACL, knee replacements and patellofemoral issues both non-operative treatment and post-operative treatment. This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.
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