Loss of the last few degrees of knee extension after ligament surgery is easy to record and easy to postpone. It should not be. A knee that cannot fully straighten at six weeks is substantially harder to fix than one caught at two, and extension deficit is the single commonest reason a reconstructed knee comes back to theatre for something other than graft failure.
So make it a measured number at every early visit rather than an impression. Compare against the other side with the patient supine and the heel propped, and write the deficit in degrees. Any loss that is not improving between two consecutive visits in the first six weeks is the trigger for escalation: more frequent physiotherapy, a heel-prop programme with a stated daily duration, and a review of whether pain or effusion is the actual obstacle.
Two things make it worse and are worth checking first. An unresolved effusion inhibits quadriceps activation, so a knee that will not extend often has a knee that will not settle underneath it. And a cyclops lesion declares itself as a hard block with a springy end feel, not as stiffness that yields - if that is what you find, the answer is arthroscopy and the sooner the better.
- Measure and record extension deficit in degrees at every early postoperative visit, against the contralateral side.
- Escalate if the deficit has not improved across two consecutive visits in the first six weeks.
- Treat the effusion first - quadriceps inhibition from a swollen knee is the commonest reversible cause.
- Distinguish a springy hard block from soft stiffness; a cyclops lesion needs arthroscopy, not more physiotherapy.
- Give the heel-prop or prone-hang programme a stated daily duration, not an instruction to 'work on extension'.
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