Infraspinatus atrophy due to a spinoglenoid notch cyst
This was an incidental finding of mine in a collegiate baseball pitcher. He presented with a UCL sprain during his senior year and was struggling.
He came in looking to salvage his senior year and attempt to pitch at some point. UCL surgery would’ve been warranted if he was anything but a senior.
UCL Evaluation
We evaluated his elbow and he presented with typical findings of painful valgus stress tests. I’ve discussed my UCL exam previously in a post that you can find here.
UCL Tommy John Assessment
His shoulder PROM was slightly limited compared to what we normally see in our overhead throwers, which may have contributed to his elbow issues.
He only had 120 degrees of external rotation compared to 110 degrees on the right side. If you’re wondering how I measure external rotation, then this video below may be a good one to review.
External rotation passive range of motion (PROM)
We use these concepts for our research studies that we have published on weighted ball usage the past few years.
For those that will ask about GIRD, he had 60 degrees of IR on the L side and 50 degrees on the R side. I’m not a big GIRD guy like has been written by others. I still think GIRD is pretty normal and our research has shown that too.
I had him remove his shirt and noticed a large defect in the infraspinatus area that showed obvious atrophy (see picture below).
Infraspinatus atrophy due to a spinoglenoid notch cyst
The cyst was compressing the suprascapular nerve as it coursed along the spine of the scapula.
His external rotation strength was significantly weaker on his throwing side compared to his right side. This would make complete sense considering the amount of atrophy present.
Often times surgery is warranted to decompress the nerve. There’s often an underlying labral tear that has resulted in a cyst to form. The surgery would remove the cyst and repair the labrum to prevent future issues.
Quick Literature Review on Surgical Outcomes
Reports of improved outcomes are in the literature, here and here and here.
Obviously, this may have contributed to his elbow issues as the posterior cuff muscles are tremendous stabilizers of the arm, especially during the deceleration phase of throwing.
Treatment for infraspinatus muscle atrophy
Our goal was to calm the elbow down through active rest and focus on strengthening of his forearm and shoulder musculature.
We used neuromuscular electrical stimulation (NMES) to the infraspinatus. We felt as if the electrical stimulation would allow for a better muscle contraction than what he could do actively. This is a similar concept to using NMES to the quads after a knee surgery.
NMES to the infraspinatus to help with muscle recruitment
Believe it or not, we were able to salvage his senior year despite all of the issues that presented.
He made numerous pitching outings and was pretty successful for his team.
The lesson here: Don’t take anything for granted, observe and test.
Make sure you look distal and proximal. It could’ve been very easy to just treat the elbow with some exercises and massage. Don’t get me wrong, we did a bunch of strengthening exercises to his forearm.
His secondary finding was most likely a leading cause for his elbow dysfunction.
This isn’t the 1st time that I’ve run across an issue like this. I’ve found numerous scapula dysfunctions like this involving the infraspinatus. But also a winging issue due to a long thoracic nerve palsy.
You must look at the whole picture… shirts off for a guy and a sports bra for a female to make sure we’re not missing anything obvious!
https://lennymacrina.com/wp-content/uploads/2020/07/Infra-Atrophy-IG.001.jpeg10801080Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2020-07-13 06:00:002021-02-17 14:34:07Infraspinatus atrophy in a baseball pitcher with a UCL sprain
Physical therapy is vital after a rotator cuff repair and continues to be common in an outpatient setting. Unfortunately, there’s no true consensus on when to actually begin PT. Is early physical therapy safe after a rotator cuff repair or should we delay PT to protect the healing tendons?
Let’s dive into this and see what the research is saying…
Why I’m writing this post on rotator cuff rehabilitation
It seems as if we’re all over the place despite the research, which is pretty typical. Some docs prefer early passive range of motion (PROM) while others wait 6-8 weeks (and even up to 12+ weeks for a revision repair) before they allow any form of PT.
For the record, I’m going into this blog post as a firm believer of early PROM. It’s what we’d been doing for years in Birmingham at Champion Sports Medicine.
It’s what I only knew until I moved to Boston in 2014. Now I’ve seen a nearly 180-degree turn in rehab thoughts. Much more conservative!
I recently got in a Twitter discussion (debate) about this same topic with some very respected and prominent PT’s in the field.
It made me think about things so I decided to do a little research to see what the literature says. You can check out the discussion here.
Twitter can be confusing and tough to follow but just trust me, it goes on for a while!
Rotator Cuff Anatomy
The tendon most commonly torn is the supraspinatus tendon. Don’t get me wrong, you can tear the other rotator cuff tendons (infraspinatus, teres minor, subscapularis).
Keep in mind a medium, large or massive rotator cuff tear often will involve the infraspinatus tendon. If it does, then you need to consider modifying your progression appropriately.
But for the sake of this post, I’m going to stick to an isolated supraspinatus tendon for now.
Rotator Cuff Tendon Size and Location
Look at the size of the tendons as they insert on the greater tuberosity. You’ll see it differentiated by antero-posterior and medial-lateral directions.
According to my colleague and friend Jeff Dugas out of Birmingham, he showed in 2002 that the mean dimensions of the supraspinatus insertion were 1.27 cm in the medial-to-lateral direction. For the anterior-to-posterior direction, the supraspinatus dimension was 1.63 cm.
It helps to know this information because you may need to read an operative report and see the size of the tear. The docs will usually mention a 2 cm tear or something like that.
That means that the supraspinatus tendon and a small portion of the infraspinatus tendon were involved (and repaired.)
This is critical information to have when you’re trying to plot the post-op rehab progressions and determine the prognosis. The more tendons involved, then the higher the chance of repair failure.
There are many other factors that influence retear rates but tendon repair size is definitely one to consider.
Rotator Cuff Repair Surgery Types
I’m not going to bore you with the details of a repaired rotator cuff. There are numerous surgical techniques being used by orthopaedic surgeons.
Techniques such as a single row, double row, suture bridge or transosseous repairs are commonly performed. The picture below shows the difference between a single row and a double row repair, for example.
As you can see below, the double row tends to repair more of the tissue back to the humeral insertion point, which in theory has led to better tendon healing. This has been shown in numerous research studies and has become the best technique available.
So you had shoulder surgery…when to start physical therapy?
That seems to be the million dollar question! The research is all over the place. This means that doctors’ opinions are all over the place too, right?
Since I joined the group in Birmingham in 2002 (as a PT student), we had our post-op rotator cuff repair patients starting PT post-op day 1. They started PT early regardless of the tear size. This means a small tear of 1 cm in length started PT the same time a massive, 5 cm repair would start PT.
Some may disagree with this start time but it worked…it just worked. At least I think!
Why Early PT after a Rotator Cuff Repair
This is Key!!
There were several reasons why I think it worked:
They could chat with a professional.
Patients better understand their pain and get reassurance that what they were feeling was normal.
Someone could monitor their incisions and answer any and all questions.
Begin early, gentle ROM which often helps with pain control, too.
But, that was our ‘protocol’ and it continues to be that way many years later. Most other doctors that I have dealt with outside of Birmingham have taken a far more conservative approach to post-op rehab.
Agree to Disagree
Here in Boston, most docs wait at least 2-3 weeks and even up to 8-12 weeks to begin PT. Talk about eye-opening!
I don’t agree with this premise and wanted to dive a bit deeper into the literature to see if early physical therapy had a detrimental effect on short-term, mid-term and long-term outcomes.
Structure vs Function
The problem that continues to plague the research is the measurement of outcomes. Doctors care about the structural integrity of their rotator cuff repair. They see the research and are concerned with retear rates that hover in the 25-70%+ stratosphere. Of course I’d be concerned with retear rates that high!
Can you imagine if ACL re-tear rates were that high? Well, guess what they still hover in the 6-40% range even with our tremendous rehab skills and return to play testing.
But fortunately, we have other parameters to consider with our patients after a rotator cuff repair. We can look at the pain-free function!
Huh, what a novel idea. Regardless of the integrity of the repair, many patients can still live their lives to the fullest and in most cases without any pain.
Start PT Early after a Rotator Cuff Repair? What does the literature say…
I’m going to do my best and unbiased research to figure out if early PT after a rotator cuff repair is safe and effective compared to a delayed protocol. Let’s take a look…
There are a bunch of studies out there that you need to sift through. You can tell when the lead authors are MD’s or PT’s because the docs want to make sure their repair integrity is intact and the PT’s are concerned with restoring ROM, strength, and function.
With that, I’ve done my best to pull out some studies that have helped guide my practice and continue to influence me today.
Literature Review Findings
Age a BIG Factor!
Mind you, Cho et al showed that healing rates after a rotator cuff repair drastically change for older patients compared to younger patients.
The slide below was taken from my rotator cuff lecture that I’ve done in the past and helps to put things in perspective.
In no particular order…
Parsons et al JSES 2010 looked at 43 full thickness RTC repairs who were in a sling for 6 weeks. All were without PT for that time then evaluated for stiffness in PROM. They defined stiffness as 100° flexion/ 30° ER.
Overall, of the 43 surgeries, 23% (n=10) became stiff after that 1st evaluation session. The whole cohort displayed a 56% retear rate overall at 1 year, which to me seems crazy high!
To break it down further there was:
30% retear in stiff group
64% retear in non-stiff group
There was no significant difference in ROM or functional scores.
In my opinion, there were some pretty big limitations to the study that should be exposed, like:
Single row repair
No consideration for Diabetes or smoking
MRI without contrast to re-evaluate the repair status
What is “ER by the side???”- need to better define what degree of abduction.
So getting stiff may be a good thing but the repairs were done as single row repairs. We know these did not heal as well as they do with double row repairs.
More Literature Reviews
Moving on to a 2014 Level II systematic review and Meta-analysis, the authors said “the results contradicted our hypothesis that immobilization would increase tendon healing compared with an early-motion rehabilitation protocol, as structural outcomes were similar in the two groups 1 year after the arthroscopic repair of rotator cuff tears.
From the paper: “We speculate that rehabilitation is not the sole factor affecting tendon–bone recovery; the effects of other factors, such as older age, fatty degeneration, larger tears, and surgical technique, may outweigh those of the rehabilitation protocol.”
Kim et al AJSM 2012 looked at small to medium sized RTC repairs. They compared immediate PROM (0-120 degrees) to 4 weeks of absolute immobilization. They eventually showed no difference in ROM, pain or tendon healing. So seems like a smaller tear of less than 3 cm may be appropriate for immediate ROM, albeit it was limited to 120 degrees for some reason.
Not sure why they limited to 120 degrees because it seems as if the tendon would shorten as the humerus is placed in further flexion. Maybe they were concerned with subacromial impingement or something but the limitation is a bit confusing to me.
Healing Affected?
Another study by Lee et al AJSM 2012 wanted to compare ROM and healing rates between 2 different rehabilitation protocols after arthroscopic single-row repair (use caution) for full-thickness rotator cuff tear.
They showed pain, ROM, muscle strength, and function all significantly improved after arthroscopic rotator cuff repair, regardless of early postoperative rehabilitation protocols.
They also looked at the repair integrity with postoperative MRI scans, 7 of 30 cases (23.3%) in the immediate ROM group and 3 of 34 cases (8.8%) in the delayed group had re-tears, but the difference was not statistically significant (P = .106).
Well then, only a trend and all had similar functional outcomes regardless of when they started ROM…I’d say that helps the case to start early.
But again, these repairs were done via a single row repair and they allowed manual therapy 2 times per day and unlimited self-passive stretching exercise, which seems a bit aggressive anyway.
Do we even need a sling for 6 weeks?
No Functional Difference Between Three and Six Weeks of Immobilization After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Non-Inferiority Trial Arthroscopy 2018
This study looked to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff repair in a prospective randomized controlled non-inferiority trial.
They concluded that “3 weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace.” For the structurally concerned people out there, MRI indicated similar degrees of healing between the groups.
Well then, that throws a wrench in things for the docs!
Does Early vs Delayed PT Affect Outcomes?
A systematic review by Gallagher et al 2015 looked to determine if there are differences between early and delayed rehabilitation after arthroscopic rotator cuff repair in terms of clinical outcomes and healing. Six articles matched their criteria and reported significantly increased functional scores within the first 3-6 months with early rehabilitation compared to the delayed group.
To me, this is huge! Put yourself in their position. Imagine feeling better and being able to get back to work a little quicker. That’s my major argument for starting rehab sooner. Earlier pain relief, improved function and a feeling of being normal again.
Furthermore, none of the included studies reported any significant difference in rates of rotator cuff re-tear.
Medium-Large Tears use Caution
However, two studies noted a trend towards increased re-tear with early rehabilitation that did not reach significance. This was more pronounced in studies including medium-large tears. A similar trend that I’ve seen in the literature.
Here’s a nice table from that Gallagher study that summarized their findings for each research paper they included:
I want my patients to feel good as quick as possible and get back to some semblance of a normal life. But of course I want the long-term integrity of the repair to remain intact. And it seems as if this study helps that argument.
Then you look at a group of PT’s from Turkey (Duzgun et al Acta Orthop Traumatol Turc. 2011) that looked to compare the effects of the slow and accelerated protocols on pain and functional activity level after arthroscopic rotator cuff repair. Patients were randomized in two groups: the accelerated protocol group (n=13) and slow protocol group (n=16).
There was no significant difference between the slow and accelerated protocols with regard to pain at rest.
The accelerated protocol was superior to the slow protocol in terms of functional activity level, as determined by DASH at weeks 8, 12, and 16 after surgery.
I’ll take that!
Function over Structure (at times!)
Told you that the PT groups tend to favor function over structure, haha!
Early passive Motion ok- The French Version
This next study out of France that included French Society for Shoulder & Elbow (Orthop Traumatol Surg Res. 2012) looked to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks.
They concluded that their results suggested that early passive motion should be authorized: the functional results were better with no significant difference in healing. Functional results were statistically better after immediate passive motion and a lower rate of adhesive capsulitis and complex regional pain syndrome.
Seems as if there may be a trend but certainly not an overwhelming conclusion that early ROM is guaranteed to lead to inferior structural results. But, it seems pretty conclusive that ROM, pain, and function are improved after early ROM.
Let’s continue to look at the research
This group from China (Shen et al Arch Orthop Trauma Surg. 2014 Sep) performed a systematic review and meta-analysis to determine whether immobilization after arthroscopic rotator cuff repair improved tendon healing compared with early passive motion. Three RCTs examining 265 patients were included but we need to be cautious because of the limited number of studies included and the heterogeneity of the samples.
They found that there ‘no evidence that immobilization after arthroscopic rotator cuff repair was superior to early-motion rehabilitation in terms of tendon healing or clinical outcome. Patients in the early motion group may recover ROM more rapidly.’
This recent 2017 study in the Journal of Shoulder and Elbow Surgery included 9 meta-analyses in its review. They basically noted, “No clear superiority was noted in clinical outcome scores for early-motion or delayed-motion rehabilitation.”
They also concluded that “Whereas early motion and delayed motion after cuff repair may lead to comparable functional outcomes and retear rates, concern exists that early motion may result in greater retear rates, particularly with larger tear sizes.”
So, it seems as if function and healing the same after a RTC repair but there may be a discrepancy once we start looking at a larger repair size.
Immediate PT after a Revision Rotator Cuff Surgery
This study in AJSM 2018 looked to evaluate the clinical and radiological outcomes after revision rotator cuff repair surgery. They were able to track 31 of 40 patients (77.5%) for the final assessment at a mean follow-up of mean 50.3 months.
Interestingly enough, physical therapy started on the first postoperative day with passive flexion and abduction.
Revision rotator cuff repair improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing.
And they started PT 1 day after the surgery and got PT 2-3 times per week.
Retear Rates and Long-term function
This study in JBJS 2006 looked to determine the clinical and structural outcomes of re-ruptures in twenty patients after a longer period of follow-up. Nineteen of the twenty patients continued to be either very satisfied or satisfied with the outcome.
At an average of 7.6 years, the clinical outcomes after structural failure of rotator cuff repairs remained significantly improved over the preoperative state in terms of pain, function, strength, and patient satisfaction.
They also found that re-ruptures of the supraspinatus that had been smaller than 400 mm(2) had the potential to heal….wow!
Failure Rates too High!
Another study in JBJS 2013 looked at 18 patients who had undergone arthroscopic repair of massive rotator cuff tears. At two years of follow-up, 94% had a failed repair. This current study wanted to evaluate the 10-year results for these patients with known structural failures of rotator cuff repairs.
Despite a high rate of progression of radiographic signs associated with large rotator cuff tears (proximal humeral migration or cuff tear arthropathy), most did well.
Clinical improvements and pain relief after arthroscopic rotator cuff repair of large and massive tears are durable at the time of long-term (10 years) follow-up. They went on to say:
“These results demonstrate that healing of large rotator cuff tears is not critical for long-term satisfactory clinical results in older patients.”
So our obsession with healing rates still appears to be overblown, even in older patients with a known cuff tear.
Pendulum Exercises Effects on Muscle Activity
Activation of the Shoulder Musculature During Pendulum Exercises and Light Activities JOSPT 2010
Look at that Paper in JOSPT 2010 (I’ve pulled out the Results Table for you below).
If there’s one exercise that doctors allow after a rotator cuff repair then it’s a pendulum or Codman exercise. How often does our patient do them correctly and make it a completely passive motion? I’d say rarely if seldom, right?
Most often, the patient is just bent over and actively moving their shoulder. They have no body movement or sway. Most of the movement is shoulder based and are not completely relaxing their shoulders.
Furthermore, they were instructed in the doctor’s office that 1st week or 2 after surgery.
They’ve been doing them incorrectly for weeks on end because they have no one to help them (cough cough!)
EMG of common Rehab ExerciSES
A study in JOSPT 2016 looked at EMG activity in healthy individuals. They wanted to quantify muscular activity during daily tasks and common PT motions. They showed that “of all the tasks assessed, ambulation without a sling and donning and doffing a sling and a shirt consistently showed the highest activity.”
EMG results table is found below.
Pretty helpful to see it listed by muscle and EMG activity and specific movement.
EMG of contralateral movements
A pretty neat EMG paper from 2004 (small n=6 and healthy individuals) were assessed using fine wire and surface EMG during common functional activities of the contralateral extremity while immobilized.
They found high supraspinatus EMG activity of the immobilized shoulder for all fast pulling activities of the contralateral shoulder (25-32%)!
Furthermore, they found high infraspinatus activity (56%) of the immobilized shoulder when the contralateral extremity performed straight forward reaching activities.
So even if they are immobilized and using their non-operative shoulder for daily activities, the rotator cuff is still sustaining a higher amount of activity than anything that we would do in the early phases (PROM, dowel self-ROM, rope and pulleys, properly performed pendulums).
How about revision rotator cuff repairs, you ask?
This study from AJSM in 2018 looked at outcomes after a revision rotator cuff repair. They showed revision rotator cuff repair improved outcomes regardless of tendon integrity (MRI confirmed).
Oh boy, what is going on??
Dig deeper into the study and they started PT the 1st day post-op with passive flexion and abduction. Sounds familiar, no? And this was in revision surgeries.
We used a very similar approach in Birmingham as they did in this study, so I may be a bit biased.
My Closing Thoughts on Physical Therapy after Rotator cuff repair surgery
I think it just shows you that rehab can begin early, will not affect long-term outcomes and that tendon integrity is not correlated to function.
I honestly don’t think our 15-30 minutes of passive motion early on in the rehab process is significantly affecting outcomes and retear rates.
It seems as if the repair technique, contralateral arm daily use, compliance with proper exercises (like pendulums, for example).
Let’s not blame early PT. There are so many more variables that are more likely to affect rotator cuff repair outcomes than anything that we could do in PT.
So I say let’s get people into PT early, educate them, guide them and help them get over this painful surgery.
I’ve been doing this for years and have seen the benefits of early PT. I say the literature agrees with me!
https://lennymacrina.com/wp-content/uploads/2019/06/RTC-Blog.001.jpeg10801080Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2019-06-04 06:00:052019-06-03 13:56:23Is Early Physical Therapy Safe After a Rotator Cuff Repair?
Not a lot this week…sorry folks. Focusing a bit more on other projects. The Week in Research Review, etc 12-10-18 included only 3 posts but they definitely made some waves. Especially my latest Instagram post on burn-out in the PT field. Check it out and chime in…it’s never too late to like a post and comment on SoMe.
When is it Safe to Drive after Orthopaedic Surgery?
💥OPEN ACCESS! 💥⠀
This study looked to comb the research to see the available data regarding when patients are safe to resume driving after common orthopedic surgeries and injuries affecting the ability to drive.
This is always the age old question as a PT or ATC (amongst the other disciplines) and this study may help to shed light and give a bit more concrete evidence.
Often times, our answer is ‘it depends’ and that is definitely true. Or we pass the ball to the doctor who did the surgery and try to buy time by waiting until that 1st post-op visit.
Or we just say you can’t drive because you’re still on pain meds…and that is definitely true! All of these factors may play a role but it seems as if the literature can help guide our answers a little better so I invite you to take a look to this OPEN ACCESS paper and keep it in your patient database.
It may help to guide a future patient’s independence after an injury.
Posterior Shoulder Stretching after a Surgery
The efficacy of stretching exercises to reduce posterior shoulder tightness acutely in the postoperative population: a single-blinded randomized controlled trial. Salamh et al Physiother Theory Pract. 2018.
This paper looked at acutely post-op shoulder patients (no repairs, just debridements) and followed their ROM horizontal adduction and internal rotation after the surgery.
Group 1 was assigned the supine sleeper stretch and shoulder pendulum exercises. Group 2 was assigned the standing horizontal adduction (cross-body) stretch and shoulder pendulum exercises. Group 3 (control group) was assigned and performed shoulder pendulum exercises only and asked to perform 10 clockwise or counter-clockwise pendulum exercises twice a day.
The study noted that ‘the horizontal adduction stretch is more effective at reducing acute posterior shoulder tightness in the postoperative shoulder population when compared to the supine sleeper stretch and no stretch at all.
Not surprised but wanted to share the information and maybe help someone use this for their clinical practice. Not sure why they chose supine sleeper stretch versus sidelying sleeper stretch but most likely because of pain tolerance.
Traditionally, the sleeper stretch is performed in supine. It’s modified by having the patient rollback to potentially put the shoulder in a more comfortable position. We wrote a paper about this in JOSPT 2013 with @wilk_kevin and @toddrhooks
I’m still more of a fan of the horizontal adduction stretch and use it clinically every day for my shoulder patients.
Burn Out in Physical Therapy
Just said yesterday that I don’t post my tweets to IG but get like this one should be posted here too.
Not going to say much more than I already have.. maybe a future blog post or something.
Curious to hear the comments below too. Throw it all at me and I’ll try to write something up in the future.
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This week we’re still playing with formats and learning these Instagram changes. With that, in the week in research review 12-10-18, we discussed many topics that I wanted to share!
Surgery vs Physical Therapy for Carpal Tunnel Syndrome
Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial Fernández-de-las-Peñas et al JOSPT 2018.
This Level 1b study looked to evaluate cost-effectiveness differences of manual physical therapy versus surgery in women with carpal tunnel syndrome (CTS).
Performed in Spain, 120 women with a clinical and electromyographic diagnosis of CTS were randomized through concealed allocation to either manual physical therapy or surgery.
They concluded that manual PT including desensitization maneuvers of the central nervous system has found to be equally effective but less costly, i.e., more cost-effective than surgery for women with CTS.
From a cost-benefit perspective, the proposed manual PT intervention of CTS can be considered.
Interesting results but 2 obvious limitations to this study: 1️⃣No control group. What if the symptoms could spontaneously improve over time 2️⃣ They only looked at 1-year improvement and not short-term improvements. I would’ve liked to have seen 3 months and 6 months results as well to see the acute effects.
Not sure what to make of this study but it does seem as if a population of Spanish women may respond to Rx of CTS without surgical intervention.
The Association Between Passing Return-to-Sport Criteria and Second ACL Injury Risk: A Systematic Review With Meta-Analysis Losciale et al JOSPT 2018.
Not going to lie, this study caught my attention because the results match my confirmation bias.⠀
I’ve been saying for years that hop tests, even combined with other tests, just don’t cut it.⠀
I wrote a blog post about this too for @mikereinold. This study, although with its limitations, did show that passing RTS criteria did not show a statistically significant association with risk of a second ACL injury.
This review also determined that 12% of those who failed RTS testing suffered a graft injury, compared to 5.9% of patients who passed.
It seems as if quadriceps strength measured via isokinetic testing or isometric testing may be an important factor to consider for RTS decision making.
Also, hamstring-quadriceps strength ratio symmetry should also be considered.
So with this review demonstrating that current objective criteria-based RTS decisions did not show an association with the risk of a second ACLI, how does this affect your practice?
💥PT vs Scope for Meniscus Tear 💥 . Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Non-obstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial. van de Graaf VA et al JAMA Oct. 2018
Among patients with non-obstructive meniscal tears, PT was equal to arthroscopy for improving patient-reported knee function over a 24-month follow-up period.
They went on to say that “Based on these results, PT may be considered an alternative to surgery for patients with non-obstructive meniscal tears.”
So basically, if there’s no bucket handle tear present that may be blocking joint range of motion, then it is highly encouraged that the patient #GetPT1st and not do surgery.
Without going out on a limb, I’d say this is a much more cheaper treatment option as well and would save society many costs associated with the surgery and lost time from work.
I do note a couple limitations: the surgical group did not get PT after surgery if they did ‘as expected’ but they could get PT to help improve their symptoms.
The PT group did pretty basic exercises although leg press, lunges, and balance type exercises were included.
Have you read this paper? It was a multi-center, randomized controlled trial performed in 9 hospitals in the Netherlands.
So, are we encouraged or surprised? Let me know by commenting below…thanks!
Shoulder strength is about more than pushing big lifts like strict pressing, push pressing, etc.
If you want a robust, healthy, well moving shoulder you should be including lower level drills that more specifically address scapular and RTC strength and control. –
I will always be a fan of traditional exercises like side like ERs, Prone Ys, Ts, etc.
Lately, I’ve thrown in more band work because it’s easy for me to do for higher volumes on a frequent basis and I enjoy the constant tension that the band provides.
Give these two exercises a try:
✅ Band Front Raise Pull-Apart
✅ Band Overhead Y Raise
I find that these two do a great job of targeting my mid back and posterior shoulder without much compensation through a big range of motion.
Give them a try either in a warm-up for 1-3 sets of 10-15 reps or at the end of a training session for 2-4 sets of 10-25 reps depending on the difficulty of your band and your capacity.
Let me know what you think about this new blog post or any of my social media posts…thanks!
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Hey everyone, The Week in Research Review, etc for this week has a new look, compliments of Instagram’s new algorithm. Hope the new format doesn’t throw you too big of a curveball (maybe you’ll like it better), so here goes…
ACL Injury Rates Higher on Synthetic Turf than Natural Grass in the NFL
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The Week in Research Review, etc 11-5-18 was filled with more informative and eye-opening posts! Lots of visually stimulating posts to help clarify what exactly is going on in the hip joint with PROM. Another post that shows the suction effect from an intact hip labrum… amongst other great posts. Just some great stuff..hope you enjoy!
Manual Forearm Resistance Drills
ACL Graft Healing Times to Maturation
Hip Capsule Stress with PROM External Rotation
Muscle Activation Affected by Hip Thrust Variation
Hip Thrust Form by Bret Contreras
Hip Joint Suction Affected by labral Status
Manual Resistance Forearm Exercises
In this post, I wanted to show you guys some of the manual resistance drills we use @championptp on our shoulder and elbow clients, especially our baseball players. We love to use these drills because we can control so many variables with each athlete and tailor it for their specific needs.
We can control the speed and tempo, the direction of forces (eccentric, concentric), and the magnitude of the forces. Plus it’s a great way to interact with our clients. It’s also a great way to feel how well they’re progressing in their programs instead of just giving them dumbbells.
I have found these manual resistance drills to be very helpful with my overhead athletes and hope you give them a try on your clients soon! Let me know what you think or tag a friend below who may like to use these drills too.
In my course that I teach around the US, I try to include these concepts so you can practice and be able to utilize these drills for your clients…thanks!
ACL Graft Harvesting and Healing times
In this post, I wanted to show some research studies on graft healing times and why we need to respect tissue biology.
The systematic review from AJSM 2011 looked at ‘The ‘‘Ligamentization’’ Process in Anterior Cruciate Ligament Reconstruction.’
They essentially looked at 4 different biopsy studies on BPTB and Hamstring autograft reconstructions. They concluded that maturation of the graft, as determined by mainly vascularity and cellularity, was not complete until 12 months at the earliest. The healing time even extended to 24+ months as well.
The ligamentization endpoint is defined as the time point from which no further changes are witnessed in the remodeled grafts. The surgical procedure is quite involved, as you can see in the video that I took from @drlylecain on #YouTube.
As I’m rehabbing my clients, my decision making and post-op progressions often take into account:
So, respect the tissue and allow natural healing to occur before you add more exercises or are concerned that they’re not making the gains you’d expect.⠀
Hip Capsular Closure: A Biomechanical Analysis of Failure Torque
Chahla et al AJSM 2016
Interesting look at tissue failure, albeit in a cadaver graft, that should help to guide the physical therapist or ATC early in the rehab process after a hip scope.
The purpose of this study was to determine the failure torques of 1-, 2-, and 3-suture constructs for hip capsular closure to resist external rotation and extension.
The 3-suture construct withstood a significantly higher torque (91.7 Nm) than the 1-suture construct (67.4 Nm) but no significant difference was found between the 2- and 3- suture construct.
The hip external rotation degree in which the capsule failed was:
✅1-suture construct: 34 degrees
✅2-suture construct: 44.3 degrees
✅3-sutures: 30.3 degrees (yes, smaller than 2-suture construct)
I think as a #PT, we need to keep this study in mind and respect the healing tissues after a hip scope.
Love when we can get this information and put it into practice, similar to RTC repairs, ACL, etc.
Obviously, this was on a cadaver where there’s no guarding, pain or muscle contraction. We still need to know that there MAY be enough tension on the capsule to create potential issues (like tissue failure).
If you treat patients after hip scopes, then I recommend you read this cadaveric study.
Barbell Hip Thrust Variations Affect Muscle Activation
COLLAZO GARCIA et al JSCR 2018
This study looked at the EMG activity of various lower body muscles while performing the hip thrust in various positions.
Their results showed that by varying the foot position into more external rotation, you can recruit the glute max and medius more than by the traditional hip thrust.⠀ …”the activity of the gluteus maximus increases significantly reaching up to 90% MVIC with only 40% of 1RM” with this hip ER variation.
Also, ‘when the distance between the feet is increased, the activity of knee flexors increases. Therefore, this is a very recommendable option to increase hamstring: quadriceps co-activation ratio.’
I like this study because it helps guide our rehab if we’re targeting a specific muscle group a bit more because of an injury or surgery.
It’s one of my go exercises for anyone with a lower body injury, especially after an ACL reconstruction. But I do use this exercise for most of my clients rehabbing from any injury, including the upper body.
It’s a great way to recruit the gluteus maximus and medius, which we know are hugely? (is that a word?) important to help produce and dissipate forces during athletic movements.
The exercise was widely researched by @bretcontreras1 and should be a staple in your rehab programs.
Check it out and add this to your go-to exercise list…thanks!
Hip Thrust Form
[REPOST] and a great one from @bretcontreras1 talking hip thrust form, which is perfectly coinciding with my post earlier today on variations to the hip thrust and how they affect muscle activation. Check out his original post below…highly recommended!
Teaching optimal hip thrust form is complicated. While the occasional lifter prefers and functions better staying fairly neutral in the head, neck, and spine, the vast majority of lifters do best maintaining a forward head position, which leads to ribs down and a posterior pelvic tilt.
It’s not just the forward eye gaze; the whole head has to maintain its forward position. You’re not hinging around the bench; the body mass above the bench stays relatively put, while the body mass below the bench is where the movement occurs.
The astute science geeks out there will rightfully point out that posterior pelvic tilt is associated with some lumbar flexion, and that lumbar flexion under load can be problematic. However, lumbar flexion is only dangerous when the discs are simultaneously subjected to compressive forces. With this style of hip thrust, the glutes are driving hip extension and posterior pelvic tilt, and erector spinae activation is greatly diminished. Core activation is what creates the bulk of the compressive forces, so with the erectors more “silenced,” the discs aren’t as compressed. This makes the exercise very safe. In fact, it’s safer than the “neutral” technique because as you rep to failure or go a bit too heavy, you will inevitably arch the chest and hyperextend the spine, which can lead to lower back pain.
We have 200 members at Glute Lab hip thrusting day in and day out, and there have been zero injuries to date. Considering how heavy we go, this is astounding.⠀
⠀ #gluteguy#glutelab#thethrustisamust⠀
Hip Joint Suction and Stability
[REPOST] From @chicagosportsdoc and a very cool look at the suction within the hip joint that contributes to its stability. As the video progresses, they have simulated a labral tear that shows how easily the joint can dislocate. Once the labrum is repaired, the suction effect is recreated, and joint stability is re-established.
That’s 2 posts this week on the hip…if you want to see some awesome posts, then follow him. He just got on Instagram but his visual posts really aid in learning the mechanics of the various joints…see below!
An impressive demonstration of the powerful hip suction seal. When the hip labrum is injured, the seal is disrupted which can potentially produce microinstability. A labral reconstruction can restore the suction seal #labrum#sportsmedicine#hip#anatomy#orthopedicsurgery#medicine
https://lennymacrina.com/wp-content/uploads/2018/11/TWIR-11-5-18.001.jpeg10801080Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2018-11-05 05:30:562018-11-04 21:43:41The Week in Research Review, etc 11-5-18
That was a milestone week as my Instagram account finally hit 10k followers, whatever that means! I’ve really been pushing a daily post to help other rehab professionals better simplify the research. One milestone hit but I still want to keep publishing good quality research reviews. The Week in Research Review, etc 10-22-18 included:
Do baseball Pitchers really have a tight posterior capsule?
ACL strain curve during the squat
Does the pec minor length influence shoulder pain?
What does the literature say about the EMG activity of the rotator cuff, particularly of the supraspinatus, with ROM
Classification of Meniscus Tears and Osteoarthritis
Do baseball Pitchers really have a tight posterior capsule?
My guess is emphatically no based on what I see on a daily basis, the general anatomy of the glenohumeral joint and some research studies.
Anatomy
1️⃣When I stretch a baseball pitcher’s shoulder, it is usually very mobile. I find this in both symptomatic and asymptomatic individuals.
If I try to assess their posterior capsule with a joint play technique, I can often translate the humeral head pretty far over the glenoid rim. Sometimes, I can even sublux the humerus!
2️⃣Anatomically, the posterior capsule is relatively thin compared to the anterior and inferior capsule (see the post).
In general, that capsule is thinner probably because of the glenoid position that is not strictly in the frontal plane.
Because of that, it is theorized that the capsule evolved to have less of a role in stabilizing the humerus.
3️⃣There are a couple of research studies that have specifically looked at baseball pitchers to determine their humeral head translation.
Borsa et al AJSM 2005 reported that posterior translation was actually greater than anterior translation in both the dominant and non-dominant shoulders of professional baseball pitchers.
Crawford et al J Ath Train 2006 found no significant differences in posterior glenohumeral laxity and stiffness between the throwing and non-throwing shoulders.
I understand why the theory exists and think it could be plausible but just don’t think it’s truly responsible for what we think.
We just don’t think we can stretch the posterior capsule with any joint mobilization or contract-relax procedure, including a sleeper stretch. I often giggle at all of those MD prescriptions that say ‘#GIRD, posterior capsule tightness’. I just treat what I find on my examination and ignore the script.
ACL strain curve during the squat
As you can see, the strain curve from the Beynnon et al study is very similar to the strain curve during resisted knee extension in a full ROM (90-0).
We argue all of the time about anterior tibial translation during the open chain exercises but often ignore the other side of the story.
The strain on the ligament is barely 4%, which is in line with many functional activities like walking, descending steps, etc. The argument that we’re going to stretch the ligament out just has not been proven in the literature.
I wanted to show the closed chain strain curve so you could compare it to the open chain strain curve. I know the n=8 argument is present but we really don’t have much more data on the ligament in vivo that shows the true effects of open vs closed chain exercises on the ACL.
Again, as @barbhoogie mentioned, you need to monitor the PF joint, especially after a patella tendon autograft but as long as we’re not aggravating that joint, then I begin early 90-0’s and mini squats as tolerated.
Do you agree with this? Do you prevent squats early on during the ACL rehab process? If you don’t, then why do you hold back on full active knee extension exercises?
Does the pec minor length influence shoulder pain
Does the pectoralis minor length influence acromiohumeral distance, shoulder pain-function, and range of movement? Navarro-Ledesma et al Phys Ther Sport Aug 2018.
Their conclusion: Pectoralis minor length is not a distinguishing factor in shoulder⠀
assessment when a chronic condition exists, and it seems not to play a key role in pain perception and ROM.
54 participants with chronic shoulder pain in their dominant arm were recruited, as well as fifty-four participants with a pain-free shoulder.
The resting muscle length is measured between the caudal edge of the 4th rib to the inferomedial aspect of the coracoid process with a sliding caliper.
The acromiohumeral distance (AHD) was defined as the shortest linear distance between the most inferior aspect of the acromion and the adjacent humeral head, measured by ultrasound.
An interesting study that used an asymptomatic control group along with the contralateral shoulder of the symptomatic subject. A pretty clean study that is very interesting. I’m not going to say that the pec minor doesn’t play a role in shoulder pain but maybe its role is not as prominent as we think.
What do you think? Do you find pec minor length has a substantial role in your patients with shoulder pain?⠀
EMG of the rotator cuff during rehab exercises
What does the literature say about the EMG activity of the rotator cuff, particularly of the supraspinatus, with ROM?
Many PT’s and doctors are uncertain when to safely begin physical therapy after a shoulder surgery, particularly after a rotator cuff repair. In my 15+ years as a PT, I’ve seen docs begin PT post-op day 1 or wait as long as 6 weeks (which drives me bonkers!!)
In this snippet that I’ve taken from an upcoming blog post at LennyMacrina.com. I discuss the research that’s helping to guide best practice, in particular, the research that looks at PROM and AAROM and how much EMG activity is actually going on in the supraspinatus with each movement.
As you can see in the video, there’s minimal supraspinatus activity (<20% is considered minimal) for all motions. Keep in mind, many of these studies are done on healthy individuals but who in their right mind would volunteer their newly repaired RTC repair to have fine-wire EMG done on them?
So, I can only draw my conclusions from a limited body of evidence and my own anecdotal evidence (which consists of 12+ years of immediate PROM POD 1). Many still think it’s safe to get a RTC repair patient’s shoulder moving early for many reasons that I will describe in this blog post.
I just wanted to get this early point out there to get another discussion going. I think our patients can do much better after a RTC repair and this is one of the reasons.
Do you agree? Do you advocate for early PROM after a RTC repair, especially a small-medium repair?
Classification of Meniscus Tears and Osteoarthritis
Great post by @physicaltherapyresearch talking about the various types of meniscus tears. Nice visual & description of each type and the incidence of OA. Take a look! 👇🏼
_______________
Meniscus Tears and Osteoarthritis
💡
Prevalence of meniscal tears is estimated as ~24-31% of some populations, increasing with age and ranging from 19% in women aged 50–59 years to 56% among men between 70 and 90 years and is markedly higher in established OA subjects.
💡
Medial meniscus and/or the posterior horn tears make up 66% of cases, with horizontal and complex tears being the most common.
💡
Most subjects with a meniscal tear are asymptomatic.
💡
Regardless of morphologic type, meniscal tears are strongly associated with OA cross-sectionally and predict OA longitudinally and are considered to be part of the spectrum of early or pre-radiographic disease
📝📝📝
TEAR TYPES INFO:
Often enough, meniscal tear types are categorized into varying groups for comparison rather than separately compared to each other.
📝
There is a striking lack of data on the relevance of different morphologic types of meniscal tears in OA.
📝
Horizontal and complex tears are common findings in knees with OA
📝
Posterior radial tears of the medial meniscus are associated with a high degree of cartilage loss and meniscal extrusion, and appear to be a highly relevant event in the progression of OA in the knee. 📝
Lateral meniscus radial tears affect younger individuals and are considered post-traumatic.
📝
Despite their suggested high relevance, radial tears are more commonly misdiagnosed on MRI than any other type of tear.
📝
While medial meniscus posterior root tears are of “radial” morphology, there is growing interest in regarding them as a separate entity.
📝
Longitudinal and bucket handle tears affect younger individuals and are highly associated with ACL injuries, favoring a traumatic etiology.
📝
MRI is important to detect and locate a possible displaced tear.
📝
Further epidemiologic studies should focus on the morphology of specific meniscal tears to better understand their relevance in the genesis and progression of knee OA.
📚📚📚
SOURCE:
Jarraya et al. 2017 Semin Arthritis Rheum
https://lennymacrina.com/wp-content/uploads/2018/10/TWIR-10-22.001.jpeg10801080Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2018-10-22 05:00:232021-02-17 15:10:38The Week in Research Review, etc 10-22-18
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