Episode 288 | Should You Let Your PT Crank On Your Knee In ACL Rehab?

I want to open this episode with a real-life case. And I’m just going to warn you guys, I’m coming in super hot right now. I’m actually recording this at a not normal time because I just felt so fired up about this call and this case. I was like, “You know what? I’m just going to go straight to recording a podcast.”

This is the raw, real stuff right after talking to someone. And I’mgoing to call her “Maria.” That’s not her real name, but everything else about her story is true. And it’s something I hear quite often, but it’s just one that sometimes it just really sets me off, and this is one of those. And I know people are listening to this that are going to relate to this, so let’s just get into it.

Maria is about four and a half months post-op from her ACL reconstruction. She had an allograft plus a meniscus repair. She got hurt doing a burpee and she felt a twist in her knee and she felt the pop, and that was it. From day one, her range of motion was her problem, and her PT was extremely aggressive with it. She could get motion, but only with someone else forcing that range of motion, and it never really seemed to budge much on her own.

Nobody caught the pattern early. She had scar tissue building up and a cyclops lesion forming, but instead of that being flagged, she kept getting pushed into these walls session after session, with her knee being forced into certain positions. Eventually it got bad enough that she needed a second surgery, an MUA (manipulation under anesthesia) along with a lysis of adhesions, essentially a scar tissue clean-out. The surgeon manipulated and forced the knee into range of motion while she was under anesthesia because that cannot be done the same way while someone is awake.

They found a cyclops lesion in the knee. A cyclops lesion can sit in front of the ACL and typically block extension, although scar tissue can influence flexion as well. Scar tissue can also form in other areas of the knee joint, and there are likely multiple factors that influence why someone develops it, including genetics, the surgery itself, and the injury. Maria had surgery very quickly, about three weeks after the injury, without much prehab, so her knee had not really calmed down before surgery. That is another variable that can matter, although none of this was necessarily her fault because patients are often simply told to get the surgery done.

What was important in her case was recognizing that her range of motion was not progressing and that continuing to crank on the knee was not solving the problem. In our experience, scar tissue and cyclops lesions are underestimated, and I have a hunch that what we currently see in the research does not fully capture how common or significant they are. I also think they may be more prominent with quad tendon grafts, although Maria had an allograft and these problems can occur with other procedures as well. People are walking around with smaller amounts of scar tissue where their range of motion is only slightly limited, creating a gray area where it may not be obvious enough to immediately pursue another surgery.

The bigger issue in Maria’s case was that the pattern should have been identified earlier. She could have been referred back to her surgeon and potentially had an MRI to investigate why the range of motion was not progressing. Instead, she was repeatedly pushed harder. After the second surgery, she had already accumulated 40 physical therapy sessions, and during the last three she finally told her PT that she would not let them bend her knee anymore because she could not take it.

Right after the second surgery, she had a nerve block. For a couple of sessions, the PTs were able to bend her knee almost all the way toward her glute without her feeling pain because the nerve block was masking the pain signal. It probably felt like a win in the moment because there was pressure to get her range of motion back quickly. But when the nerve block wore off, the pain came back intensely, and her body started guarding again.

She told them, “You guys are traumatizing me.” Her partner was on the call and described watching the sessions, saying they would push on her legs, tell her she was going to cry, and hold her down. She would scream, curse, and cry, and eventually looked at the PT during one session and said, “I can’t do this anymore. This is bigger than me.” This is someone who does not quit, and she lasted through almost 40 sessions of this before finally reaching a point where she could not continue.

That is not rehab. It is not normal, and it should not be normalized as part of ACL recovery. There is a pattern where people talk about being tortured by their physical therapist almost like it is a rite of passage or a badge of honor. People sometimes accept that being manipulated into painful ranges is simply what has to happen to get their motion back. Similar practices can also occur in the total knee replacement population, where people are sometimes subjected to aggressive manipulation because of range-of-motion limitations.

There is no reason to treat extreme pain as proof that rehabilitation is working. If you have ever bitten onto a towel, screamed, cursed, or dreaded walking into your PT session because you know your knee is going to be cranked on, that is not what good rehab looks like. The problem is not that the patient is weak or unwilling to work. The problem is that the rehabilitation approach is creating an environment where the knee and nervous system are continually being threatened.

The same thing has even been visible with elite athletes. Neymar, for example, has been shown on camera in agony while medical staff held him down and forced his knee into further flexion. If something like that can happen to a professional athlete with supposedly elite resources, then it is easy to understand how the same thing can happen in outpatient clinics without a camera or anyone questioning it. When a physical therapist tells a patient that this is simply what needs to happen, the patient is likely to accept it because they assume the provider knows what they are doing.

The problem is that forcing the knee past what it can tolerate can backfire. Think of pain in terms of green, yellow, and red light: green is low-level, tolerable discomfort; yellow is moderate; and red is high-level pain. When we talk about what the knee can tolerate, that does not mean we should deliberately drive it into the red zone. Pain is a noxious stimulus and an alarm from the body, so the goal is not to repeatedly trigger the alarm and then assume the body will simply ignore it.

When the knee is pushed beyond its threshold, the body can respond with more swelling, more pain, and more guarding. The nervous system starts treating the movement as a threat, and the muscles around the knee can become increasingly protective. The quads, hamstrings, and calves can all become rigid and guarded. Instead of teaching the knee that the movement is safe, aggressive manipulation can teach the nervous system that the range of motion being forced on it is dangerous.

That is essentially what happened with Maria after the nerve block. The block did not make the tissue capable of tolerating the movement; it simply blocked the pain signal. Once the block wore off, the nervous system came back online, and the pain and guarding returned. Repeating this process over and over can create a cycle where the patient becomes increasingly anxious about movement, the knee becomes more reactive, and the exact range of motion the PT is trying to restore becomes harder to obtain.

I have had my own moments early in my career where I thought pushing harder into range of motion was the answer, but I learned that it does not work. You may sometimes gain a few degrees temporarily, but if the knee becomes swollen, angry, and guarded afterward, the cost is not worth it. You are creating an environment where the knee is less capable of moving rather than more capable. A knee that is already reactive does not need a giant dose of stress added to it.

The framework we have used with hundreds of ACL athletes is very different. We have worked remotely with people across the country and in other countries, meaning we physically cannot put our hands on their knees. Yet people have still been able to regain their range of motion. Passive range of motion can have a role as an assessment and a proxy, but active range of motion needs to be prioritized because lasting movement comes from the patient producing the movement themselves.

This is why devices such as CPM machines do not magically restore range of motion. They can move the knee and have a role in the process, but the patient still has to actively develop the ability to move the knee. Passive work has its place when appropriately dosed, but active movement is what drives the lasting change. The goal is not to have someone else repeatedly force the knee farther and farther while the patient’s body is telling them that it does not feel safe.

The dosing of range-of-motion work matters tremendously. Instead of one brutal 20- or 30-minute session of aggressive stretching, it can be much more productive to spread short, low-intensity bouts throughout the day. Think higher frequency and lower intensity, particularly early after surgery. Undercook it first, see how the knee responds, and then titrate the dosage rather than trying to win the entire range-of-motion battle in one or two days.

That is the idea behind microdosing rather than delivering one large bolus of stress. You start below what you think the knee can handle, observe the response, and adjust. Every small bout gives you information about how the knee reacts to that particular stimulus. If you go all in during one aggressive session and flare the knee up, you lose that useful feedback because now you are dealing with the aftermath of an unnecessarily large stress response.

The same approach applies to both extension and flexion. You can gradually nudge the knee toward the range it needs instead of trying to force it there. We have seen this work in hundreds of ACL athletes, including people who were months or even years out from surgery and had never regained their end-range motion. Some people had been told that 70 or 80 percent of their range of motion was good enough, when what they really needed was a better prescription, better dosing, and the right movements.

For extension, a heel-pop test can be a useful proxy. Lying on the ground, you can perform a quad set and compare how high the heel comes off the surface on the involved side versus the uninvolved side. For flexion, a tall-kneeling rock-back can be a useful way to assess how the knee feels as you sit back toward your heels. People may shift toward the uninvolved side, feel pressure in the involved knee, or hike the hip when there is a meaningful difference.

These tests do not replace a complete assessment, but they can help identify whether there is a meaningful difference that needs attention. Typically, we want to nudge people toward around 120 degrees of flexion, while still considering how the knee feels and what the rest of the assessment shows. Some people regain motion quickly, while others need more time. That is why the person guiding the rehabilitation needs to understand how to assess the knee rather than simply cranking harder whenever the range is not where they want it to be.

It is important to be fair about this because manipulation being bad and active work being good is not a universal rule for every single case. There can be a real mechanical block. Scar tissue, a cyclops lesion, or another problem inside the knee can create a physical wall that the patient cannot simply move through with more effort. When that happens, no amount of active range-of-motion work or microdosing is going to magically remove the obstruction.

That is exactly why Maria’s pattern should have been caught earlier. If there is a mechanical block, repeatedly forcing the knee does not solve the underlying problem. Instead, it can reinforce the cycle of swelling, pain, guarding, and frustration while the actual mechanical issue remains. The correct response to a knee that is not progressing is not automatically to push harder; it is to figure out why it is not progressing.

There is also a psychological consequence to repeatedly experiencing painful manipulation. Maria described feeling traumatized, and that response should not be dismissed. When someone repeatedly associates physical therapy with being held down, screaming, crying, and having their knee forced into painful positions, it is understandable that they begin to develop anxiety or fear around the next appointment. The nervous system is learning from those experiences just as much as the muscles and joints are.

This is where the environment around the knee becomes important. Consistent swelling, pain, muscle guarding, and an inflammatory cycle create a poor environment for recovery. The knee is trying to heal and calm down, while repeated aggressive treatment can continue to irritate it. I cannot prove that aggressive manipulation directly causes additional scar tissue, but it is reasonable to question whether repeatedly provoking swelling and inflammation could contribute to an environment that is not favorable for a knee already susceptible to scar tissue formation.

Instead, the goal should be to listen to the knee and titrate the loading and range-of-motion work appropriately. Let the knee become quieter. Allow the patient to gradually increase the stimulus while monitoring the response. The objective is to make the knee less reactive and less guarded, not to repeatedly provoke the exact responses that make movement harder.

This is why “no pain, no gain” is not an appropriate philosophy for ACL range-of-motion rehabilitation. If you are being cranked on session after session and you are not making progress, that is a signal that something needs to be looked at. It is not automatically a signal to push harder. If the same approach keeps producing the same negative response, the answer is to reassess the approach and the underlying problem.

If you are experiencing agony during range-of-motion work, anxiety before every session, or something that feels close to PTSD around physical therapy visits, that should not be accepted as the price of recovery. You should not need to be terrified of your PT appointment because you know your knee is going to be forced into painful positions. Whether that advice came from a surgeon or a physical therapist, the idea that someone has to crank on your knee to restore range of motion should be questioned.

And it is not necessarily too late. We have worked with people years after surgery who had persistent range-of-motion limitations and were able to make meaningful improvements without being manipulated. If your knee has been repeatedly forced into painful positions and the process is creating more swelling, pain, and guarding rather than progress, that is information. It may be time to find a different physical therapist who understands ACL rehabilitation, load management, the nervous system, and how to progress range of motion without relying on pain and force.

One of the things I would look for in a PT is objective strength testing. That could include a dynamometer or referral to someone with access to an isokinetic machine. Strength testing gives you objective information about where you are and provides a much better foundation for decision-making than simply looking at how many months it has been since surgery.

When I asked Maria whether her knee had been strength-tested, whether her PT had talked about strength testing, or whether she had even seen anyone else being objectively tested in the clinic, the answer was no. That was not surprising given the rest of the situation. A rehabilitation process should not be built around simply forcing movement and hoping the knee responds. It should involve assessment, objective measures, load management, progression, and an understanding of how the knee and nervous system respond to stress.

The larger lesson is that rehabilitation should not be measured by how much pain a patient can withstand. A patient should not have to prove their toughness by allowing someone to force their knee into an intolerable range. The goal is to build capacity, restore movement, reduce fear, and progressively expose the knee to the demands it needs to handle. There is a difference between appropriately challenging a knee and repeatedly overwhelming it.

Maria’s story is a reminder that patients are not supposed to know all of this themselves. They are trusting their providers to understand the process and guide them appropriately. If a patient is continually failing to make progress, the provider needs to investigate why rather than simply repeating the same intervention with more force. A lack of progress is information, and the right response is curiosity and reassessment.

The most important thing is to stop normalizing suffering as a requirement for ACL rehabilitation. There is no badge of honor for being able to survive 40 sessions of painful manipulation. There is no prize for biting down on a towel and getting through another session. The objective is not to make rehabilitation hurt as much as possible; it is to create the conditions that allow the knee to progressively move, strengthen, and recover.

If you are in a situation where every appointment creates dread, your knee repeatedly becomes more swollen after treatment, and you are being forced into painful ranges despite not making progress, pay attention to that pattern. You deserve a rehabilitation plan that takes your symptoms seriously and adjusts based on how your knee responds. You deserve objective testing and someone who understands how to manage load and progression. You should never have to believe that agony is the only path to getting your range of motion back.

If you are getting cranked on in these sessions and session after session, and especially if it is not making progress, that is a signal that something needs to be looked at. It is not a signal to push harder. You do not have to accept “no pain, no gain” as the standard for your ACL recovery, and you do not have to stay with a provider whose approach is making you afraid of rehabilitation.

If you are in agony during range of motion work, if you feel anxious before every session, if you’re having something close to PTSD around your physical therapy visits, I need you to hear this very, very clearly just ’cause I’m balling up my fist and I’m just like, “Argh.” Y- that is… That was never supposed to be the deal in this case, and you should never be feeling this. I don’t care who told you what needs to happen, whether it’s your surgeon or your physical therapist; you do not need someone cranking on your knee to get your range of motion back. And it is not too late.

We have worked with people, as I had shared, years out with range of motion loss who got it back without ever being manipulated. And if your PT is cranking on your knee and you’re in pain, if you’re biting a towel, screaming, you’re cursing, that’s your sign. You need to get rid of them. You need to fire them. You need to change PTs, someone who knows this process. And I would almost bet you, I would put money on it, that if you found a physical therapist who accurately and does objective strength testing, like they use a dynamometer or they refer out or they know someone who has a isokinetic machine, and they objectively test your strength, and if you looked at those PTs, and you looked at the PTs who cranked on your knee, there would be an inverse relationship.

Meaning there will be a strong relationship between those who truly strength-tested and the people who cranked on your knee would be very low, AKA nonexistent. Because usually those people who are strength testing are also keeping up with the literature. And guess what? I asked this person, “Has your knee been strength tested at all? Has your PT talked about it? Have you seen anyone else doing it in the clinic?” And she said, no. I was like, “Oh, go figure.” This is something that you need to make sure that if this is happening, get rid of them, find a different one, and I’m going to be pretty strong on this.

Find someone who understands load management, how to be able to get you there without being in this pain and agony, and how the nervous system actually responds to stress, and not someone who is just forcing these things or trying to be macho because they’re a PT. It’s just not going to work, y’all. You should never have to be in agony to get your range of motion back, ever. If someone tells you otherwise, they do not understand what they are doing, and that’s going to be my episode for today. 

If you feel that this is who you’re working with, please make a change. I promise you it will be worth it. Whatever growing pains come from it, it will be worth it, especially in the long run. And if you need any help, we are here to help. This is your host, Ravi Patel, signing off.