Retlouping a new clinical technique for regaining knee extension in post surgical patients

Retlouping is a new simple to perform clinical technique for regaining knee extension in post surgical patients. It can be used on ACL reconstruction , PCL reconstruction, through to total knee arthroplasties.

A second feature of Retlouping is that it will increase apparent hamstring flexibility.

This can be a safe and effective way of regaining flexibility, without stretching. In numerous studies traditional stretching has been shown to be ineffective in increaseing flexibility, preventing delayed muscle onset pain, providing protection from injury, and stretching will actually decrease strength if performed before balsitic activities. (1,2,3,,4)

In a recent small sample randomized trail (5) Retlouping was shown to be superior to traditional hamstring stretching on improving flexibility in a group of professional Gaelic Football players.

What is Retlouping?

Excerpt from a recent paper on Retlouping (5)

"Retlouping has evolved from a series of chance observations by American Physical Therapist David Poulter.

In personal communication in 2007, Poulter explained the origin of Retlouping and its possible mechanism of action.

As a therapist, Poulter used the long sitting position to differentiate between neural tension and muscle tightness causing restriction of forward bend. He reports that while his patients were in the long sitting position with their feet dorsiflexed against the wall, he would instruct them to flex and extend their neck whilst assessing if this had any effect on the tension in their legs. He reports that he experimented with allowing the clients to relax back and support themselves on their hands to release the tension in their legs before moving their head, to see if this would produce neural tension. By chance on reassessment, he observed that those who performed this second manoeuvre, now known as retlouping, had an increased ability to forward bend after the procedure. After further observation it became apparent that if the feet remain dorsiflexed and supported against the wall, the eyes kept open and all tension removed from the legs by leaning back and supporting the upper body on the hands, the procedure was even more effective. Neck rotation was then introduced as a component to the procedure, with better results.

So what is the possible cause and effect of Retlouping?

Poulter hypothesizes that the procedure is not simply one of altering neural tension, as the patients often reported no adverse feeling of tension in their legs. Nor has the effect anything to do with stretching tight muscles, as the patients did not feel any stretch or tension in their legs during the procedure. He therefore hypothesizes that the logical explanation for the effect seems to be one of neural inhibition, “Simply put the theory according to Poulter is as follows: it appears to reboot your neurological computer and lessen the tone to the hamstrings”.

The key to the neural involvement is the open eyes and the rapid movements of the neck. The eyes, the ears and the neck are all intimately involved in sending neural input to the cerebellum to tell our body about positions in space and control balance.

The hamstrings are strong postural-gravity muscles, which prevent us from falling forward when we bend at the hips to touch our toes. The balance mechanisms inform the cerebellum that we are going to fall and hence the tone in the hamstring increases to prevent us.

Poulter continues by saying that some people may have lost the ability to lessen the tone or switch it off; they have essentially patterned themselves in to this restriction of the forward bend position. Retlouping recreates the forward bend position but in a stable supported position. There is increased neural input informing the cerebellum that even though the neck, ears and eyes are moving rapidly, everything is stable and hence the tone of the hamstrings is reduced. Poulter also hypothesizes that this is a primitive pattern that is recognized by the brain and when you stand up the effect lasts. Poulter proposes that Retlouping is an alternative to hamstring stretching, allowing athletes to increase the flexibility of the hamstrings without stretching. Until now, there was no experimental evidence to support this clinical observation.

The results of this study show that Retlouping is statistically significantly better than stretching when using the forward bend or toe touch test only. This test according to Devlin (6) is inaccurate in the measurement of the hamstring muscle length as there is no stabilization at the hip and the lumbar spine. However retrospectively the inclusion of this test adds support to Poulter’s theory about the mechanism of Retlouping.

The toe touch test or forward bend as it is referred to in this study assesses general lumbar spine and hamstring muscle flexibility by allowing movement at the spine, pelvis and the hip (Bennell 2000) as the subject bends forward. Therefore it may be safe to say that many structures are involved during the procedure. The Active Knee Extension Test is thought by many authors (Devlin (6)and Rolls and George (7)) to be more selective than other tests at measuring hamstring muscle length alone, because the hip and pelvis are stabilized in set positions. With regards to the SLR both Rolls and George (7) and Devlin (6) support each others work by saying that movement occurs in many structures during the performance of a SLR, namely neural mobility. The results of this study show that retlouping had a direct and significant effect on the general lumbar spine and hamstring muscle flexibility test, i.e. the forward bend or toe touch test.

This result adds support to Poulter’s theory that Retlouping works by decreasing the tone in the hamstrings as the subject bends forward, allowing further flexibility gains to be achieved. Retlouping had no significant effect on hamstring muscle length alone i.e. the active knee extension test and on the SLR which predominantly involves neural mobility. It is clear that the retlouping process is very different from stretching and an important area for future research would involve the ability to understand fully and prove what its mechanism might be. "

Retlouping case studies:

Case study 1

64 year old female.

3 weeks s/p Right total knee replacement.

Having daily CPM at home prior to attending first appointment.

Walking with one cane and noticeable limp.

Scar well healed. Moderate swelling of the knee.

Day one range of motion Flexion 93 degree
Extension 24 degree lag.

Daughter reported that it was difficult to get knee straight with the CPM. Patient reported having increased pain with attempts to extend knee.

RETLOUPING procedure initiated on bed using board at end of bed.
During procedure patient reported decrease in knee pain, and a feeling like the knee was relaxing.
The Retloup procedure was carried out through 3 cycles.

After knee flexion was still 93 degrees, extension was now a 3 degree lag.

The patient was excited by the result and said she would continue to perform the procedure at home.


Second visit ( two days later)

The patient reported that she could now walk without a limp and that the knee felt more stable and less painful. She had performed the Retloup procedure sitting on a long coffee table with her feet against the wall, due to the fact she couldn’t get down to the floor.

Her knee was able to fully extend on the second visit.
Knee flexion was now 97 degrees.

Her extension remained full over the next two visits.


Case study 2

37 year old male

11 days s/p right arthroscopic ACL reconstruction with allo graft. Staples still in situ.

Reporting constant dull ache in knee , pain weight bearing. Walking full weight bearing with limp. (No brace, removed due to discomfort at MD orders)

Patient reported a fear of moving the knee, he had not bee doing any exercises prior to attending the clinic as he thought it was too early to move his knee.

On examination: Good scar healing staples in situ. Minimal swelling.

Range of motion: Flexion 80 degrees
Extension 20 degree lag with guarding when attempting
further motion, due to pain.

RETLOUPING procedure initiated on floor. Procedure carried out three time through.

Range of motion after Retlouping: Flexion 80 degrees
Extension full and patient able to contract
quads and perform SLR.

Patient reported decreased knee pain. Able to attain slight hyper extension with heel on towel roll.

Patient said he would perform the Retloup procedure for the next to days as part of his rehab program.

Second visit (two days later)

Patient walking with less visible limp. Reporting decreased knee pain, with increased feeling of stability.

Range of motion: Flexion 90 degrees
Extension 5 degree lag

Patient demonstrated Retloup procedure and attained full knee extension again. The patient reported he hadn’t had time to do the procedure this morning prior to his appointment time at 8am.

Case study 3

19 year old female college basket ball player.

Injured left knee in training. Tore ACL and medial meniscus.

12 weeks s/p ACL repair patella tendon graft with meniscal repair.

Received traditional ACL post op rehab. Unable to attain full knee extension over the 12 week rehab period.

Father attended a course I was teaching and saw a demonstration of Retloup procedure.

On returning home demonstrated the procedure to his daughter and her therapist. The daughter carried out the procedure and attained full extension in 4 minutes.
Prior to Retlouping , extension mobilization and passive stretching of knee and hamstrings had been performed daily for the whole rehab period.

She continued the procedure as a home exercise and stopped all other extension stretches, (which had been causing pain). She is now 18 weeks post op and has full extension and slight hyper extension with full quads control.


We have used the RETLOUP procedure on over 30 post op knees in our clinic with similar results.

Common patient reports.

· Feeling of knee relaxing and sagging in to extension.
· Decease in knee pain whilst performing the Retloup procedure.
· Strange tingle/ twitching in the quads.
· A feeling on standing that the knee will hyperextend.
· Temporary feeling on not knowing where the knee is in space.

References:

1. Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ. Aug 31;325(7362):468.,2002

2. Ingraham SJ. The role of flexibility in injury prevention and athletic performance: have we stretched the truth? Minn Med. 2003 May;86(5):58-61.

3.Shrier I; Gossal K. Myths and Truths of Stretching Individualized Recommendations for Healthy Muscles. THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 8 - AUGUST 2000

4. Shreir I . Stretching before exercises: An evidence based approach. Br J sports Med 34: 324-25, 2000

5. Durack K. Retlouping : Is it an alternative to hamstring stretching? Masters Thesis, University of Galway , Ireland, 2007

6. Devlin L. Recurrent posterior thigh symptoms detrimental to performance in rugby union. Predisposing factors. Sports Medicine 29(4) pp. 273-287, 2000.

7. Rolls A, George K. The relationship between hamstring muscle injuries and hamstring muscle length in young elite footballers. Physical Therapy in Sport 5 , pp. 179-187, 2004.

To receive a patient handout on Retlouping please e-mail DCPOULT@aol.com