Laminectomy, Atrophy, and Posterior Knee Pain

Recently had a question from a reader regarding a patient who had a previous Laminectomy with residual atrophy to R calf musculature (Unable to perform a single leg heel raise). Subsequently this patient was also experiencing hamstring pain as well. A couple of the exercises that were trialed was isometric hamstring contractions in the supine 90-90 position which were performed without increased symptoms. However when the knee was extended and a bridge was performed with a long lever arm it caused a flare up in the clients symptoms.

When looking at this case, there would be a couple assessments that I would do to try and help differentiate what may be the issue.

1. Achilles Tendon Reflex - routine neuro exam to determine how much atrophy is neuro related.
2. Modified Obers Test and Sternal angle - To help determine how much extension and compression strategies may be present in lumbosacral region.
3. Hamstring MMT at 90 degree knee flexion
4. Hamstring MMT in supine with hip flexed to 90 degree and knee near full extension ~ 15-20 degree from full extension

The purpose of the MMT would be to help determine how much hamstrings truly playing a role in the issue. If no pain with these tests then we may want to consider ruling out hamstring injury in favor of more of a general diagnosis such as posterior knee pain.

With atrophy of the calf, it may be beneficial to start performing resisted heel raises in the seated position for soleus hypertrophy if feasible. Another consideration would be if cannot perform single leg heel raise, then before bilateral concentric and unilateral isometric hold at the top position or eccentric lowering or combination.  That may be your entry point for strengthening.

Furthermore if we assume there is a lot of compression at the low back then an exercise such as the 90 90 hip lift with exhalation emphasis and addressing rib position as we have talked about on the site before may be of benefit to reduce some of the extension bias. If this is a chronic case, I doubt manual therapy to S1-S2 area via dry needling or manual therapy of choice would help improve the standing heel raise. However, it certainly could be worth a shot and retest to see if single leg heel raise is any better.

Considering the knee pain further, remember the hamstrings function to stabilize or posterior glide of tibia. When the hip and knee is extended this may be too long of a lever arm for the hamstrings to effectively control. Also if the hip does not currently have enough strength and control, or presents with a significant anterior pelvic tilt (extension based strategy) then the hamstrings or quad may start to try and function in the transverse plane to assist with stabilization. So the solution may be to monitor hip position (posterior pelvic tilt and ribs down) then perform glute activities such as bridges in hooklying while maintaining this position and calling upon the adductors to help stabilize the pelvis.

Also, don't forget the use of closed chain exercises! So split squat, lateral lunges, single leg RDLs, and step ups may all be simple solutions to avoid a provocative position.

These are all considerations to stimulate potential ideas for your clients. Feel free to ask questions to elaborate further on the case inside the members discussion forum!