My client has bad atrophy of her left quad due to a past knee injury and lack of use. Currently, I have her on the bike and doing some light leg presses. Can you recommend what I can do to increase her ROM?
Using the exercise bike with light resistance and the leg press with light weight are two of the best ways to increase one’s range of motion at the knee. Another great strategy is to incorporate some pool workouts. The buoyancy of the water produces less stress on the joints since one does not have to support her entire body weight. A pool with warm water would be ideal if it is possible since this would help the muscles relax more.
I would start with doing leg extension and flexion one leg at a time. Have your client stand by the edge of the pool in waist deep water. Keeping the leg straight, extend it forward for 15 repetitions and backward for 15 repetitions. Next, perform abduction and adduction, bringing the leg away from the body and then across the body 15 times. One can also perform leg curls and squats in the water. Add sets as your client gets stronger and utilize water weights around the ankle if they are available.
The exercises mentioned above can also be performed in the gym or at home. Leg extension, flexion, abduction and adduction can be done on cable crossover machines with the lightest weight or with light resistance bands. (One end of the band is closed in a door and the other end is tied around the ankle.) Only do these if the client is strong enough to maintain proper form throughout the movements. Leg curls can be performed on the cable crossover, with a band or with a leg curl machine. Use one leg at a time if possible to isolate the affected leg. Squats can be performed over a chair or using a Total Gym machine if one is available. The Total Gym works great because you can start on the lowest setting (almost horizontal to the floor) so the client uses little of her body weight. Progress to the higher settings as she gets stronger. When performing squats, it is important to instruct your client to squeeze the inner thigh and glute muscles to push the body up. Holding a small ball between the knees will cue the client to do this correctly.
Speaking from personal experience following two knee surgeries, the following exercises worked well to help me regain full range of motion. The first one is VMO flexes. This involves sitting with your legs straight and flexing the vastus medialis muscle, which is located on the inner third of the quadriceps muscles. Your client should be able to isolate this muscle by visualizing it during the exercise. I was instructed by my physical therapist to do two sets of 10, twice per day for this exercise. Bridge is the second exercise. This is performed by lying on your back with legs at 45 degrees, drawing the belly button in and raising the hips all the way off the ground. Hold two seconds, then lower and do two sets of 15, twice per day. Progress to five second holds and then perform the exercise with the legs straight on an exercise ball. This will strengthen the stabilizing muscles around the knee. The third exercise is chair pulls. Have your client sit on the edge of a chair with wheels. Instruct her to pull herself across the floor by extending the leg and digging the heel into the ground. Start with a hard floor and progress to a carpet floor, doing two sets of 10 twice per day.
Finally, stretching as often as possible is crucial to increasing range of motion. This should be a combination of static leg stretches and assisted stretches. For the static stretches, use standard leg stretches such as reaching toward the toes, butterflies, and quad stretches. Perform two to three sets of 30 second holds. Assisted stretches are usually done with the client lying on her back or stomach. First, have the client supine with the leg straight. Push the leg gently as far as tolerated while keeping the other leg straight on the floor and hold at least 30 seconds. Next, have the client bend at the knee and push the foot toward the chest. Following this stretch, bring the leg across the body at a 45 degree angle. Finally, have the client assume a prone position, place one hand under the thigh just above the knee and use your other hand to push the leg toward the client’s backside. Do three sets of the assisted stretches, and only stretch when the muscles are warm. Heat can be applied for 10 minutes prior to stretching to help the muscles relax more.
Further instruction on these types of stretches can be found by looking up articles under keyword "PNF Stretching."