Q: I am a 24 years old girl. I met with a road accident on a two wheeler last year. I fractured my right tibial spine with an ACL (anterior cruciate ligament) avulsion. I underwent an arthroscopic fixation of the knee. My orthopedic surgeon also opened my knee at the time of the surgery and put a wire inside my leg which he suggested should be removed after 1 and half years to 2 years. I had a plaster on my leg for one and a half months after removal of stitches. Its been eight months now that I have been regularly doing physiotherapy after removal of plaster. I have attained complete knee flexion, but I still cannot extend my leg completely. My doctor says that the bone has healed completely from inside. I am trying a lot to straighten my leg, but somehow I feel it doesn't extend beyond a point. He assured me that physiotherapy would help me attain the complete knee extension. I am also doing gym for strengthening my quadriceps. The limp has almost disappeared, but you know the complete knee extension is so essential even for normal gait. I am worried as the time is passing by. I know it might be difficult for you to comment without actually looking at the range of movements and all, but I would be really glad if you could answer my query.

A:I wish you had written the nature of surgery done. This is because there are several methods described to reconstruct an avulsed cruciate ligament. The fact that there are several procedures indicates that there must be some drawback with each one of them. Otherwise, only one procedure would have been sufficient. Normally after repair a set of graded exercises are started off which basically aim at improving the quadriceps function and back of thigh muscles which are important for full flexion of knee. The condition you have is described as an extension lag (which means an inability to extend your knee fully). This can occur after ACL repair. This could be related to the inadequate recovery of quadriceps function or an abnormal tension in the reconstructed ligament. Either way regular exercises should improve your function. It is easier to recover quadriceps function extension lag as opposed to tension problems in the reconstructed ACL. You can only hope that your stretching exercises will stretch the tissues sufficiently to permit full extension. In a patient with inadequate quadriceps power, passive extension will be good while there will be an extension lag on active extension. In case, the extension lag is because of abnormal tension then passive extension will also be restricted. You must remember that a reconstructed ACL is never the same as the original ACL. This is partly because of the way the original ACL is made and partly because of the absence of proprioceptive nerve fibers (those that are important for the sense of position) in the reconstructive ligament. I do hope that you improve with your regular quadriceps exercises.