Do No Harm.

This week on the social media interwebs, I saw a startling video of a rehab session of WNBA Player Angel McCoughtry. Angel is a two-time Olympic Gold Medalist and five-time WNBA All-Star who plays for the Atlanta Dream. She's a star on the basketball court.   The first time I saw her play in person was when her Louisville Cardinals lost to UConn in the 2009 NCAA Women's Basketball Championship in St. Louis but I've easily been watching her play since 2005 when Louisville entered the Big East Conference... she's a really fun player to watch, very dynamic and energetic.  I saw Kevin Garnett play in Boston for the first time after I had seen Angel play and thought he reminded me of her.  Unfortunately, Angel hurt her knee towards the end of this past WNBA Season and required surgery - information she posted on her social media pages.

Last week, Angel posted this video of her recent rehab session on her twitter and instagram accounts:

It’s easy to see the glits and glam of success , but this is what it looks like behind closed doors! pic.twitter.com/dtjy28QRmU

— Angel McCoughtry (@angel_35) February 14, 2019

I'm speechless watching this. It takes a lot to make me speechless... but this did the trick.

I'm not treating Angel's knee condition so I don't know what she's gone through to this point - or what the goal of this particular moment is - but I can make some educated guesses based on my work as a physical therapist and with women's basketball players.

Trying to bend a joint past what it is able to do is incredibly painful. The mobility is necessary, so it's possible that this rehab team has tried numerous other options before using this technique to try to get her knee to bend sufficiently. I'd have no way of knowing, but I do know that even if I had tried everything I could think of - this would not be in my list of treatment options.

There are many studies that show the need to have symmetrical knee mobility (both sides bend and straighten the same amount) to have normal walking pattern which would translate to normal running pattern.  However, this paper also examined the number of post-op ACL patients who don't get back their full mobility and found it to be 11% in a sample of 244 patients. This paper discusses the way that scar tissue build-up in a knee is classified and what is generally done if physical therapy intervention is insufficient.  Asymmetrical mobility increases risk of injury - and nobody wants that.  While I agree that she should have matching mobility on both knees, the method being used to achieve this seems inappropriate.  I have never done this in over four years as a physical therapist and, when I saw the video, I distributed it to several other physical therapists and athletic trainers, all of which agreed that there are numerous better ways to achieve the goal they're trying to achieve in the video.

It looks like someone is trying to make Angel's knee bend more than it currently does.  Knee flexion (bending) is a challenging thing to achieve sometimes, particularly after surgery, and sometimes it even requires an additional surgical treatment called a manipulation under anesthesia, in which a person is medicated so that they won't feel it when their knee is forcefully bent all the way to restore full motion.  These can be incredibly painful procedures and with the WNBA season starting in just about two months, nobody would want her to have another surgery when she;s starting to get back onto the basketball court to prepare for the season.

This research article from 2008 uses a similar position to try to get knee flexion but describes the need to hold the position for extended periods of time - at least 10 minutes - and notes that having a physical therapist apply this type of sustained hold is incredibly fatiguing to the therapist so it recommends using belts on a table to achieve long duration, low load stretching.  However, it also specifically states that the hold should be to the tolerance of the patient and may be a little uncomfortable.  I would argue that the session in this video is not to the patient's tolerance and is therefore harmful.

These papers: 1, 2, 3, 4, 5, are just a few which suggest alternative ways to achieve the same goal - or the last one talks about the lack of evidence to support what's going on in the video. A brief summary of each:
1) An alternative technique to use to try to gain knee flexion range of motion
2) Another alternative technique to use to try to gain knee range of motion
3) A list of manual therapy options with photos from a University of Kentucky physical therapist - none of which are what is used in this video.
4) This is from the PhysioPedia which includes videos that even include knee flexion in the prone (face down) position like the one in Angel's video, however you will notice joint mobilization is being used rather than just a cranking technique, and, if your sound is on, you will also notice an absence of apparent pain.
5) This is a much older paper from 1992 that looks at ways to change the length of connective tissue (like the ACL or capsule around the knee joint) which is composed primarily of collagen.  It describes that there is not sufficient understanding of how much force would need to be applied to make change in length of these tissues - but that if that force were measureable, it would require some amount of damage to the tissue.

So, if you're receiving physical therapy treatment and you're experiencing pain during the session that feels like it is harmful to you, tell your provider to STOP.  Sometimes treatment may be uncomfortable - and that's ok - but if you're yelling out, that's not ok.  You should ALWAYS feel like the treatments you are receiving are helpful.  You should ALWAYS know that you have the say of what is being done to your body.  And you should know that you ALWAYS have the right to ask why something is being done to you - and if there is another way it can be done.  Because in this case, I strongly believe there are alternative ways that are safer, more effective, and that do not look like torture.  Physical therapy gets a bad reputation because the abbreviation, PT, also is jokingly referred to as Pain and Torture.  This is wrong.  And if you feel like your PT session is more like pain and torture, please get another physical therapist.  We take an oath to Do No Harm.  The Hippocratic Oath of healthcare providers.  We should be living up to our oath.

Wishing a very speedy recovery to Angel McCoughtry.  I can't wait to see her back on the basketball court. And I hope her rehab is not painful in the future.