Anterior Knee Pain- A Test for Fat Pad Irritation

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We as physical therapists are constantly seeing patients with anterior knee pain with a very vague history. Often times, there’s not a specific onset or mechanism of injury. With that, it seems as if the retro patellar fat pad is a common source of pain in many people and is commonly overlooked.

What actually hurts in the knee?

Whenever I am evaluating someone with knee pain, I always keep in mind the Dye et al AJSM article from 1998. In my opinion, this is a keeper for all PT’s and future PT’s to have in their arsenal of top literature papers.

For those that are not familiar, let me explain it a bit.

Basically, San Francisco orthopaedic surgeon Dr. Scott Dye had his knee scoped without any anesthesia. That’s right, classic beast mode!

He did have local anesthesia (for the record), so they could make the incisions…otherwise, he was awake and alert for the whole procedure.

This allowed him to report back to his colleagues (one being his brother) an actual pain response as they were poking away at the different structures within the knee. He ranked the pain on a 0-4 scale with 0 being pain-free (patella cartilage) and 4 being a severe pain (fat pad, anterior synovium, joint capsule.)

You can read the article to get the full gist (and I HIGHLY RECOMMEND this!) but my point is to let you realize that there are only certain structures capable of causing severe pain in the anterior knee.

Their Findings

Cartilage is avascular and aneural. It has no blood supply or nerves that innervate it. None! So the whole chondromalacia patella diagnosis attempting to implicate a maltracking patella is often hogwash.

But the fat pad, anterior synovium, and anterior capsule are extremely painful and are often involved, I believe, in patients that we see on a daily basis.

In my opinion, this is a diagnosis that sees us more than we see it. Like thoracic outlet syndrome… we can talk about that a different day though.

Back to the point of the blog.

1 Test for Fat Pad Assessment

Assessing the knee and asking the right questions is critical. Besides a tremendously great subjective, there’s one test that I use to rule in or out a fat pad irritation. Check out the video below:

I promise you this test is a great way to establish a pretty clear diagnosis and reassure the patient that a specific structure may be the issue.

When it’s painful, its pretty obvious and the patient can immediately report back to you their symptoms. I test for this a bunch in a given week and it’s not always present. But when someone presents with a positive finding, it’s pretty relieving to them (believe it or not.)

Differential Diagnosis

Keep in mind, my differential diagnosis is all over the place at times.  With knee pain you need to consider:

  1. Meniscus (see my previous blog post)
  2. ITB
  3. Osteochondral lesion
  4. Patella tendonitis
  5. Pes anserine bursitis
  6. MPFL sprain
  7. Hamstring strain
  8. Plica syndrome
  9. MCL/LCL
  10. Tumor

That’s a bunch to consider for someone who can’t really explain why or when their injury occurred. That’s why I still believe this overuse injury sees us more than we see it.

Treatment of Fat Pad Irritation

This one can get a bit tricky. Again, it’s often due to an overuse injury. In others, it’s attributed to kneeling on it for too long or banging it against something. In those more acute cases, the answer is pretty straightforward. Ice, motion and progressive return to their function.

In the overuse group, which is more prevalent in my opinion, we need to figure out which stimulus is causing the issue. It’s often due to starting a new program or ramping up too quickly during some training event.

In these people, I need to modify their volume of training or destress the area by giving them new activities that they can do pain-free…but only for a short period of time.

Along with activity modification, a course of some form of modality (yup, the M-word was used) can help expedite the pain control. I still have a special place in my heart for iontophoresis with dexamethasone. I’ve had tremendous results in patients with fat pad irritation.

I also like to use a low-level laser to help with the healing process (future blog post alert!) I’ve used it on my self for various ailments and even my dog after her ACL surgery. I’m definitely a believer in the healing power of the laser when applied in the correct situation.

Besides all of that, I would also want to assess the person’s movements and attempt to adjust any motions or movements that I thought could contribute to the knee pain. Often times, there’s an underlying weakness or misconception of a weakness that needs to be explained to the patient.

These things run their course for a few weeks but should improve pretty quickly if handled correctly. Patient gratification is pretty obvious because their pain diminishes after a session or 2 and they buy into the program pretty quickly.

Fat Pad Conclusions

Infrapatellar fat pad irritation can be functionally debilitating. I believe it presents itself pretty often in the clinic, more than most PT’s realize. Use my test above to see if it truly is a fat pad issue. Here’s a nice open-access article that you can read to learn more about the fat pad.

Remember, the test should be pretty obvious and locally oriented. If pain-free, then move on. If not, then try some of my above recommendations. It’s usually an overuse issue so you need to adjust their volumes and maybe some form of mechanics.

Mike Reinold and I discuss this and much more about how we treat the knee conservatively. Check it out in our acclaimed all online knee course www.onlinekneeseminar.com.

Looking back at 2017 & beyond to 2018

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It’s that time of year to reflect on what we’ve done and a game plan on what’s to come. I’ve taken a moment to look back at some changes I made in 2017 and share it with you.

New website- LennyMacrina.com

I had been thinking about building my website for a while. Being surrounded by some of the guru’s in our field, who have used their website to share their thoughts, I had no choice but to take the leap.

Mike (mikereinold.com), Dave (shiftmovementscience.com), and Dan (Fitnesspainfree.com) are constantly talking about WordPress, funnels, and calls to action than most. As much as it’s gibberish, it made me think about why I don’t have my own calling card, so to speak, to be able to capture my opinions on rehabilitation and physical therapy.

I fumbled a bunch and had to redo the whole site from scratch after hiring someone to do it for me.  In the meantime, I had to develop knowledgeable content that people may find interesting.

Instead of just using my Twitter (@lenmacpt), Facebook (Lenny Macrina MSPT, SCS, CSCS) or Instagram (@lenmacpt) accounts to share content, I decided to centralize the process. I figured this would be my home base for content that I can control forever and not be stuck in a social media platform.

I feel like I’m winging it but the early feedback has been pretty positive.

Improve my Listening Skills

I’ve said over and over again that listening to your clients is the most important aspect of any examination.

I feel as if I do a pretty good job at listening to my clients (despite what my wife says about my listening skills.) I try to ask the right questions and let the client state their story. Too often we get ideas in our head and jump to conclusions. We try to diagnose an injury too quickly and may miss an important detail that could sway the story in a different direction.

I’ve had this happen numerous times and completely blame myself for not giving the client the platform to reveal the pertinent details. I alluded to this is in a previous post if you’re interested. The client comes first…no questions asked!

Remember, they don’t know what may be contributing to their injury. To them, the injury is often a result of a specific action. They don’t consider the other contributing factors in their lives that seem insignificant.

via GIPHY

 

I always ask them “What do YOU think is going on?” This allows me to hear their thoughts, impressions and any details that they think may be adding to their current presentation

For example, I recently had a client present with shooting and burning pain down her arm. To many, it would seem like a cervical herniated disk. Pretty clear cut, right?

Well, she had a clavicle fracture that required an ORIF 10 years ago. She didn’ think it was significant but every time I palpated at the surgical site, especially the lateral aspect, we could replicate her symptoms…Every time! Two previous medical professionals missed this detail and just brushed it off.

To me, it seemed pretty clear that some component of her ORIF or clavicle had been rubbing a portion of her brachial plexus during a specific movement. It just did not seem like a cervical spine issue and the detail of her clavicle fracture, that she thought was insignificant, seemed to be the clue we needed to hone in on the culprit.

Listen up…they may just tell you what you need to hear!

Systemize Everything

Life gets crazy. Responsibilities grow so we need a way to manage all of the chaos. What helped me to better manage my time was contained in the book “15 Secrets Successful People Know About Time Management: The Productivity Habits of 7 Billionaires, 13 Olympic Athletes, 29 Straight-A Students, and 239 Entrepreneurs“

I’ve had to block time out of my calendar to get tasks done. Like specific times to do specific tasks. Whether it’s a dentist appointment, a powerpoint or running payroll, I have reminders in my calendar for everything.

More importantly, I have to prioritize tasks, what Kevin refers to as my MIT’s or Most Important Tasks.

I have done my best to stick with this plan but he recommends working on your MIT 1st thing in the morning when he thinks you are the sharpest. As of now, I have carved this time out to be with my daughter before the day begins. I guess as of writing this, she is my most important task. Can’t argue that!

At work, including client evaluation and treatment sessions, we have begun to systemize everything we do at Champion PT and Performance. We feel as if most people present with very similar presentations.

We’ve developed internal treatment progressions that we utilize daily. It makes it a lot easier for PT’s to see each other’s clients on the rare occasion we need to cover for someone. It takes any questions out of the client’s head. They don’t need to worry why their regular PT may or may not be doing a specific treatment.

Even more than that, we MAY have a new system coming out in 2018 that will help many with their evaluation skills. I can’t say much more than that but look for a big announcement mid-2018!

Preview of 2018

Wow, 2018 is right around the corner. I feel good about it because it’s an even number. Yeah, I’m a bit weird with stuff like that. Maybe it’s my baseball background and superstitions.

  • In 2018 I hope to accomplish more vlogs…or video blogs as the kids say. I feel like a 3-5 minute snippet of my thoughts is a very effective way of communicating with the masses. Look for more vlogs as we roll into luck 2018.

I also plan on booking more speaking engagements worldwide. As of now, my calendar has me in:

I have other courses that just need to be finalized but it seems like there may be 1-2 more dates that are in the works.

2018 is shaping up to be a very exciting and productive year. It’s important that I have these plans in place to keep me on my toes and on top of the literature.

Hope you have looked back at your past year and can continue to build into 2018. What goals do you have for 2018? Hit me up in the comments below so we can discuss.

Happy New Year!!

Kids and Sports Injuries: What are we doing wrong?

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I recently had a conversation with a parent who reached out to me slightly concerned for her 12-year-old child. He’s stressed out, hurt again and she didn’t know if I could help. It made me think about kids and sports injuries… and how we could make a difference.

Real Life Story

I had seen this kid for an overuse elbow injury within the past year, a growth plate fracture of his medial epicondyle. He’s a catcher for his team, one of many teams that he plays on. He had considered converting to pitcher but I believe he was going to rethink that decision.

He also wrestles, has multiple hours of homework each night, has hitting lessons and practices with his teams…even in the dead of Winter in December. If he’s late to practice, he gets yelled at by the coaches. Not just a casual “why are you late” kinda question but a scolding that would make any 12 year old (or adult for that matter) think twice about what they’re doing. At least this is what Mom tells me.

So Mom called me recently to discuss her son’s predicament. He’s not feeling good about himself and worried about making the AAU team. He’s a decent sized kid, big for a 12-year-old, so he tends to stick out. He can throw harder than the other kids and can probably wrestle slightly better. I’m just guessing here…I’ve never seen him wrestle.

Mom is worried that he’s too stressed with all of the sports and schoolwork. I think she may be right!

I recall a 12-year-old Lenny playing my last year of Little League baseball but that didn’t start until May or June (Yup, that’s me below on the right with my brother Brian).

During the months of November and December, I was playing basketball, hockey and tackle football in the snow. There’s nothing like tackle football in the snow…trust me all of you warm-climate readers!

What does the research say & do kids need to specialize to play college or pro?

With that, I decided to dive into the literature and see what it says…

Most recently, a 2017  study in AJSM looked a 1st round draft picks from 2008 to 2015 in the NBA. They concluded that “those who were multisport athletes participated in more games, experienced fewer major injuries, and had longer careers than those who participated in a single sport. ”

Interestingly, of the 237 athletes included, 36 (15%) were multisport athletes and 201 (85%) were single-sport athletes in high school. Yikes!

This 2017 study from The Sports Health Journal looked at division 1 college athletes. They asked them to complete a previously utilized sports specialization questionnaire regarding sport participation patterns for each grade of high school.

Specialization increased throughout high school and ~ 41% had eventually specialized in a sport b their senior year. Conversely, only 17% of the freshman had specialized in a sport. Also, football athletes were less likely to be highly specialized than non-football athletes for each year of high school.

Do football players just need time off because of the nature of the sport? Makes you wonder…

A similar finding was seen in this study from 2017 in AJSM. They basically showed that 2011 young athletes between the ages of 12-18 that became specialized in a sport had higher injury rates by nearly 2 fold.

Nearly triple the rate of injuries

In another study out of Wisconsin looked at high school athletes between the ages of 13 and 18 years from 2 local high schools. Athletes in the high specialization group were more likely to report a history of overuse knee injuries.

Athletes who trained in one sport for more than 8 months out of the year were more likely to report a history of knee injuries (more than 2.3x more likely), overuse knee injuries ( 2.9x more likely), and hip injuries (2.7x more likely.) School size matters too. Kids that go to a smaller high school report playing in more sports than kids that go to larger schools. I see this daily in my own practice.

This descriptive level 3 epidemiology study in Sports Health Journal surveyed 235 athletes between the ages of 7-18 years. They showed that athletes started to specialize at the age of 8 years old, which is crazy!

They also showed that 60% played their primary sport for 9 or more months per year (which we know is already an increased risk of an overuse injury.) Nearly 1/3 of players ‘reported being told by a coach not to participate in other sports, with specialized athletes reporting this significantly more often.’ This kind of fits my kid above…an over-bearing coach that is pressuring the kids to practice all year round.

My Solution for him

So, my conversation with Mom ended by me telling her that I completely understood. I felt as if he needed more positivity in his life. That he was being pulled in way too many directions and needs a more positive role model (besides his parents, of course) to help him.

I had these studies in my head but I didn’t want to bore the Mom with statistics gibberish and big terminology. I told her that I loved that he played 2 sports although I didn’t like that he was speeding from school to wrestling practice, to baseball practice then to a hitting lesson. It just seemed like a lot…nevermind that he still had to get home to do all of his homework.

By the way, homework nowadays is a lot more than anything that I ever experienced as a child. It takes hours for these kids to complete. Maybe that’s why Massachusetts ranks as #1 in education in the US. A great feat for the teachers and students of this state!

But what does it mean to the youth athlete trying to play multiple sports or on multiple teams? How do they juggle all of this and get their hours of homework done?

It’s not just an isolated story…I hear this daily from our student/athletes of all ages. Kids in middle school and high school have more work to do than our college athletes. Or maybe the college kids are better at time management. I imagine it’s a little of both.

What Should we Recommend?

It’s becoming evident that specializing too early in one’s athletic career may not benefit the child in the long run. Remember, they are children that are skeletally immature. The stresses that they can handle are not the same as what an older, more developed and a mature kid can tolerate.

I’m always telling kids to take time off from their sport. I usually recommend 3-4 months of active rest. This means they can still work out that may include some baseball activities such as tossing/hitting but it can’t be the priority during their off-season.

They really need to go play another unrelated sport, like soccer or basketball to get stronger in their lower body. We all know the importance of a strong lower half…see pitchers like Roger Clemens below.

What better way to get stronger than to run and jump for hours at a time (and not have to throw anything with maximal velocity.)

I hope my advice helps my young friend and his Mom figure out his dilemma.  Unfortunately, this won’t be the last time I’ll be reciting the literature to a family looking for advice. We can do our part by keeping these findings in our treatment educational components as we help get our athletes back on the field.

Last Call- Kids & Sports Injuries

Because we’re beginning to see some interesting (crazy) injuries in our youth, it seems as if the literature is beginning to paint the picture for us.  Intuitively, one would think that playing multiple sports, getting enough rest and doing a little homework each night would be sufficient to allow a kid to get through high school or college (the few that do that.) Maybe this would allow the athlete to not sustain a significant injury. When I say significant, I mean an injury that requires months of rest, multiple doctor visits and rethinking if the kid should still be playing that sport.

Note: The Mom gave me permission to talk about our conversation and was excited to know that I was writing this post. In case anyone was worried…

 

Operative versus non-operative treatment for the management of full-thickness rotator cuff tears

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Rotator cuff tears can be a functionally debilitating injury for many. Surgery is often recommended to help decrease pain and return the patient back to their baseline function. But is surgery definitely needed in someone with a known rotator cuff tear? I originally discussed this for an article at Champion’s blog here and here

Photo by Piron Guillaume

Here’s my review and thought process for this paper…

Recent Systematic Review & Meta-analysis

A recent paper published in the Journal of Shoulder and Elbow Surgery attempted to clarify whether surgery or conservative treatment could deliver the best results 1 year after a diagnosis.

This group, from George Washington University Hospital’s Department of orthopaedic surgery, looked at level I and II studies to compare operative versus non-operative management of atraumatic rotator cuff tears through a meta-analysis.

After the initial search, 1013 articles remained for review. Of that, only 3 studies involving 269 subjects met the inclusion criteria and were included.

The inclusion criteria were as follows:

  • randomized controlled trial
  • full-thickness rotator cuff tear
  • age 18 years or old

The exclusion criteria included:

  • any history of rotator cuff surgery
  • follow-up period of less than 1 year.

A good beginning but I’m always curious to know the percentage of people included in any study that:

  • have diabetes
  • smoke
  • worker’s comp

…and we don’t have that information so I’m a bit skeptical already.

via GIPHY

So moving on and am curious about the variables they’re looking at in this study. Coincidentally, they’re only looking at VAS pain rating and Constant scores. Furthermore, 1 study’s data is not valid because they used a different version of the Constant score rating instead of a VAS pain rating.

So, we now only have 2 studies looking at VAS pain rating. And for the record, I am not a huge fan of pain scales anyway. Feel like patients are not always accurate and accountable when self-reporting their pain. I would imagine a study may somewhat bias someone when reporting how they feel.

Moving on…

Surgery better than Rehab

The study’s results concluded:

“A greater improvement in Constant score was found in operative patients relative to patients treated nonoperatively, and this was statistically significant. The mean difference between operatively treated patients and nonoperatively treated patients was 5.64 (95% confidence interval, 2.06-9.21; P = .002).”

“Patients treated operatively had significantly decreased pain scores at 1-year follow-up as compared with the nonoperative cohort, with a mean difference in VAS score of − 1.08 (95% confidence interval, − 1.56 to − 0.59; P < .0001).”

So what does this mean?

Well, they went on to say and this is the key: “However, both values were below the minimal clinically important differences of 10.4 and 1.4 for the Constant and VAS scores, respectively.”

Surprising to many, including myself, because I have made a career in rehabbing patients after rotator cuff repairs.  Surgery may just not be the obvious treatment choice for patients with atraumatic rotator cuff tears.

One must be concerned with the tear progressing and symptoms possibly worsening. Fortunately for the patient (unfortunate for the surgeon), the tear size does not correlate with pain and function. Surgery, although often successful, is no guarantee to restore function and pain better than physical therapy.

Study Limitations

Of course we must look at the self-proclaimed study limitations that are discussed and they definitely affect the study conclusions, in my opinion. The 3 studies included did not have a uniform grouping of rotator cuff tear types. One of the studies included supraspinatus only, while another included supraspinatus, infraspinatus, and subscapularis. Yikes!

One study also had a subset that included traumatic rotator cuff tears, which may have influenced the positive surgical outcomes reported.

Post-operative and non-operative physical therapy did not follow a standard protocol. This may affect the outcomes significantly!

Finally, the type of surgery performed varied in each study. Two of the 3 studies utilized an open or mini-open approach which is pretty outdated at this point. The other study used an arthroscopic approach to fix the rotator cuff tear.

My Conclusions

Although many had advocated for early surgical intervention for a rotator cuff tear, the literature continues to display an alternative treatment approach. Physical therapy may offer an equivalent, albeit a cheaper strategy, to atraumatic rotator cuff tears.

This paper tries to present a case for surgical intervention as a key to success but I am still not convinced. A patient with a diagnosis of a rotator cuff tear should definitely have a trial of physical therapy to see if they can get improvements in their pain and function.

I have outlined a typical rotator cuff rehabilitation progression in a previous blog post. Check it out and let me know what you think!

https://lennymacrina.com/simple-steps-rotator-cuff-rehabilitation/

 

Diagnosing meniscus tears: What’s the literature telling us now?

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Meniscal tears are commonly observed in an outpatient physical therapy setting. The ability of a PT to evaluate a patient’s knee and diagnose a meniscus tear can help guide the treatment plan for that patient. Having specific tests that can accurately and quickly pick up a meniscal tear are valuable.

Lots of test options but stick with the subjective

There are many theories, tests, and exam techniques that are reported in the literature. I definitely don’t know all of them but have been exposed to a bunch of common ones that I have found to be helpful.

Before I get bogged down with these tests and try to sound intelligent, I’d be remiss to not state the obvious… the subjective portion of the exam is by far the most important aspect and needs to be thoroughly utilized.  In many cases, ok maybe most cases, the client will tell you what’s going on…as long as you ask the questions correctly and listen to their responses.

This will most likely be a blog post at some point in the near future but as a collective profession known as medicine, we suck at listening and utilizing the information correctly. But I digress…

What Tests are out there?

There are many tests reported in the literature, commonly including:

  • McMurray’s
  • Apley’s compression
  • Joint line tenderness
  • Thessaly’s
  • End range flexion/extension overpressure

Unfortunately, the literature does not support using these tests to diagnose and may add to the fear avoidance a patient may exhibit after such a diagnosis. This systematic review and meta-analysis in the British Medical Journal stated:

“The results of this systematic review indicate that the accuracy of McMurray’s, Apley’s, JLT and Thessaly to diagnose meniscal tears remains poor. This conclusion must be taken with caution since frequent methodological design flaws exist within the included studies, most studies suffered from various biases, and between-study heterogeneity makes pooled data unreliable.”

To tell you the truth, I don’t even do the Apley’s compression test. I probably haven’t done the test since PT school sometime in 2001. Never saw a value, kinda like the Thessaly Test. Nice in theory but just not good enough when tried in a clinical setting. Unfortunately, most research and the associated methods are lacking so the results are pretty poor when trying to diagnose a meniscus tear.

Oh boy, now what do we do? Do we even need to diagnose the tear in the 1st place and add more fear to the patient’s hurting knee?

Even need to Diagnose Meniscus Tears?

I say yes… but with a caveat!

We must accurately diagnose and explain to the patient that many people have meniscal tears in their knee. The recent literature builds a strong case for a very good recovery without surgery. That’s right, surgery is often not needed for many people diagnosed with a meniscus tear.

This landmark paper in the New England Journal of Medicine (neighbors of Champion PT and Performance in Waltham, MA) really created waves when it was released in 2013. They stated that “outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.” Now, these people did have a diagnosis of knee arthritis as well, but so do many of the people we see on a daily basis.

Hopefully, many clinicians have changed their treatment algorithms and have opted for conservative treatment first.

Don’t get me wrong, surgery may be needed, especially for the people sustaining an acute meniscus tear.  But that may only be a small portion of the people presenting to us in the clinic.  In these people, I still say give it a bout of conservative treatment to calm the knee down, restore ROM and strength and see how they do. Maybe a 6 week PT course is all they need, you never know. I have definitely seen it work, no doubt!

What meniscus tests do I do?

With all of that being said, I still believe your clinical examination is ultra-important to help guide the treatment plan.

As usual, keep it simple and don’t over-search. It needs to be pretty straightforward and it often is. The exam NEEDS to match the clinical history…let me say that again….the exam NEEDS to match the clinical history.

The client is going to tell me their issue and I just need to make sure my tests and measures solidify my working theory. I promise you that if you ask the right questions the right way, then you will have that much more information to at your disposal.

So, my go-to tests are:

  1. Joint line palpation
  2. End range flexion/extension pain/locking
  3. McMurray’s (but often not very valuable)

…in that order. I’d say joint line palpation and end range of motion are my 2 most valuable tests. I still do the McMurray’s test to see if it can add to the story. It often gives me very little information so I don’t rely on it too much.

Many of you are going to ask why I didn’t even mention the Thessaly test. I see it talked about a lot on social media. I just don’t understand why we’d want to put our client in a weight-bearing position, slightly bend their knee, and have them twist on a painful knee.

Never mind the research telling us that the test is not very valid which goes completely against early research that said it was a valid test.

The more (tests) the Merrier

Maybe we need to combine this test with others to help improve our accuracy as this paper showed in 2009.

Either way, there seems to be a case to cluster tests to help us draw better conclusions, as was stated in this paper in 2006.  “Five positive findings on composite examination yielded a positive predictive value of 92.3%. Positive predictive values remained greater than 75% with composite scores of at least 3 in the absence of ACL and DJD pathologies.”

This paper nearly matches my thought process. Obtain a good history, assess the joint line for tenderness, then put the joint at end range flexion/extension. If the symptoms match, then we will OFTEN have a meniscus tear.

Keep in mind that the particular side of the meniscus tear may influence the ability to detect a pathology. Lateral meniscal tears may be easier to distinguish than medial meniscal tears if we’re talking about joint line tenderness alone and was even the case in this 2009 article too.

Final Word on Diagnosing Meniscus Tears

Meniscus tears are pretty prevalent in the outpatient setting. Rehab specialists, including PT’s and athletic trainers need to understand what tests are best to deploy. I’m sticking with my in-depth history, joint line tenderness, and painful end-range as my go-to cluster of tests.

I’m pretty sure it has done me well over the years…and the research seems to match my thoughts too.

Online Knee Seminar Course

We discuss this and much much more in my online knee course that I have with Mike Reinold. If interested, check it out at www.onlinekneeseminar.com and let me know what you think. We cover the anatomy, rehab prescription, ACL, knee replacements and patellofemoral issues both non-operative treatment and post-operative treatment. This is an awesome course if you’re interested in learning more about rehabilitating the knee joint.

 

 

 

The one change I made that significantly improved my patient’s outcomes

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As a physical therapist, athletic trainer or any other rehabilitation specialist, we are always looking to improve our client’s outcomes. Without question, that is the single most important thing we can do to help others.

How do we do improve outcomes?

I can honestly say that you don’t always need to take every continuing education course under the sun and build all of your manual therapy skills in order to achieve better outcomes.

That’s not to say that it can’t help…but I’d say the one thing that helped improve my outcomes with my clients was a philosophical change I made with them and myself.

Too much of a softy

You see, I was too easy on them. I spent hours upon hours working with them in the clinic. I used all of my knowledge acquired from going to CEU courses, teaching me how to improve my manual therapy skills or how to assess their movement even better than I thought I was already doing.

All of this is great, I suppose, but only a very small fraction of what is truly needed to succeed as a PT (or any other clinician).

Empower the Client

To me, the greatest change that I made was to empower my clients (translation: hold them accountable!)

When I first started practicing PT in 2003, I would assign homework, so to speak, in the form of a home exercise program, like most of us do. The problem was, I didn’t always follow through in making sure the client was accountable.

I remember people telling me that they just didn’t have the time to do the work or forgot to do it. I tried to blame them and  wasn’t pro-active enough. In retrospect, I was always reacting to each situation instead of setting the tone for the treatment plan.

Philosophical Change

I had to change my philosophy, my delivery, my rapport and my interactions. It was me, not them. It’s this mindset that many need to utilize when they’re dealing with others, in general. If something doesn’t go as expected, one needs to look at their own actions and emotions and figure out how to make the situation better in the future.

It’s easy to blame others when things don’t go right.

In the PT-client relationship, you are dictating the situation therefore the outcomes will rely on your ability to take the lead. The client has no idea what to expect or what to do. Often times, they’ve never been to PT before or have never had to deal with an injury or surgery.

Understand the WHY

The PT needs to step up and ensure that the client fully understands the home program and WHY the program will help them in their recovery.  It’s easy to slip a pre-made sheet of exercises at someone and tell them to do it daily (which I very rarely tell people to do anyway) or to do them every other day (yeah, that’s more my style!)

The key is for the client to feel excited by their new home program because it will be the key to their success, the key to their recovery and the key to returning to whatever they’re looking to do. I somehow missed that point when I was first practicing as a PT.

My key, now, is to connect with the client as quickly as possible so they have the utmost trust in all I say and do. They trust that I’m not going to waste their time and efforts. They fully understand the exercise, why it will help them and a potential mechanism of why it is the best for them right now.

I’m not afraid to tell them “I don’t know” but I will tell them that a particular movement or exercise has helped others in the past and believe the same is true for them too. Take each experience and interaction and file it away…you’ll need it for the future.

Take it to the house

So, if you’re looking to improve your outcomes, make sure the client is held accountable and they fully buy in to your plan. That edge will be the game changer in your practice, trust me!

 

 

1 question to ask when applying to PT school

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Applying to PT school can be an overwhelming and daunting process. With the move to doctorate programs, the competitive landscape can lead many to apply to a bunch of schools in hopes of getting into at least one.

The pressure mounts as prospective students try to figure out what program best fits their needs, demands and personality…and pocket book too (often the most important).

Many look at the US News and World Reports to see if their top school is in the top 10. Congrats to my colleagues at the U. of Delaware for taking the trophy this year! My alma mater, Boston University, keeps its post in the top 15!

Time after time I need to listen to the students gripe and worry but it always comes down to 1 major point that I always tell students…

Make sure the school is willing to take on new clinical rotations and make the effort to secure a rotation that YOU want

via GIPHY

The Actual Process

Listen, I’ve been the CCCE (or whatever the title is) for a few years now and the steps are very simple.

  1. Student or school reaches out to clinic in question
  2. Clinic says we have an opening, let’s get the student in
  3. School sends stock contract to CCCE
  4. CCCE signs it and returns it
  5. ACCE and school sign it

There may be some behind the scenes things that have to happen at each school but overall, the process should take a fews days to a week at the most.

Generally, this is a non-issue and most schools are great with this. But every once in awhile I’ll come across a student who wants to do a rotation with us but the school doesn’t want to fulfill the contract, for some reason. And I never understood why that was!

The process seems simple enough. If the student really wants that clinical site and it would help them with their educational goals, then why would any school deny that?

That’s why I ALWAYS tell students that are shadowing our facility, to get their required hours, and to definitely ask the schools about their policy on obtaining contracts with new clinical facilities.

The didactic information during lectures and labs is so important but the first hand experience and relationships that you create at a clinical site will equally help you for your long term goals.

Yes, PT school rankings are important but I also think the clinical sites you choose will help YOU take your knowledge to the next level.

Final Lesson

So, future DPT students, if you’re reading this, make sure the school you’re applying to will reach out to me for my contractual signature. If not, I’d highly consider moving on and finding a school willing to take on new sites!

If I’m missing something, please comment below. But it seems pretty straight forward to me, despite what I hear from prospective students!

Simple steps to Rotator Cuff Rehabilitation

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I recently wrote this post for Medbridge Education when they asked me how I would tackle a general shoulder pain patient with a suspected rotator cuff injury. I hope to outline a simple rotator cuff rehabilitation program that you can use for most shoulder patients that you see in the clinic

 

You can sign up for my website to get a Medbridge promo code to save up to $175 off of a yearly subscription that gets you unlimited CEU’s! You can see the full article here:

Each day I practice physical therapy, I am reminded that certain structures of the shoulder tend to play just a wee bit more of a critical role than others. That’s not to say that some structures are useless or less important. Because of this, my life can feel like Groundhog’s Day (remember that movie?!) All day, every day I am educating on and improving the integrity of the rotator cuff.

via GIPHY

In assessing the rotator cuff in that person standing in front of me, I need to fully understand how it is affecting their ability to lead their normal life. When I say ‘lead a normal life’ I mean: grab a dish, lift their coffee, brush their hair, throw a baseball or any other function.

10 Key factors in Rotator Cuff Rehab

There are so many factors that I need to consider that are almost too numerous to list out….but here’s my attempt:

  1. age of the patient,
  2. activity level,
  3. injury to that shoulder,
  4. response to previous treatment,
  5. what the person felt helped them the most,
  6. imaging and what were the findings,
  7. past medical history,
  8. joint status (hypermobile or hypomobile),
  9. what they think is going on in their shoulder,
  10. most importantly is the ultimate goal of the client.

As I’m taking a history, all of this is going through my head. As we continue to chat, I have a mental checklist that helps to guide the conversation. This can give me the answers that I need to hone in on a particular diagnosis and a treatment plan.

Once I have formulated a theory about the potential issue and proper treatment strategy, I need to outline the plan that will safely and effectively return the client back to their prior level of function.  A critical aspect of my care is to educate on what I think MAY be going on. Then I can give them a home exercise program that won’t overwhelm them.

In my practice at Champion PT and Performance in Boston (www.champ.pt), I only see most of my clients 1x per week or once every other week so the HEP is critical!

What’s the plan?

So what do I do for people presenting with some form of shoulder pain? So many different answers but for the purpose of this blog post, I will keep it simple.

I will outline a generic program that will help restore pain-free ROM, strength, and slowly return them back to their function. In reality, I am constantly tweaking the program based on response to the exercises. Most people certainly don’t take a linear recovery process.

Calm down the shoulder pain

In my acute series, I want to get the shoulder joint moving through self-ROM activities. I like to have the client foam roll their thoracic spine and Lat muscles to help aid overhead mobility. I’ll then have them use a golf club to work on external rotation ROM at 45 degrees and 90 degrees of abduction. Following this, I’ll have them work on shoulder flexion AAROM while supine to get them comfortable with some form of active motion.

For strengthening, I like to begin with isometric activities to help with pain control because numerous studies have shown the analgesic effects (yup in patella tendon patients but let’s extrapolate for now).

Isometric Contractions Are More Analgesic Than Isotonic Contractions for Patellar Tendon Pain: An In-Season Randomized Clinical Trial.

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.

Initiate higher level strengthening

Once we get the client feeling better and believe they can progress onto strengthening activities, I like to add isotonic strength training such as band work, full can, sidelying external rotation, prone horizontal abduction, prone extension and prone full can. Numerous studies have shown the EMG activity of the rotator cuff and scapula stabilizers to be relatively high with most of these activities.

Because of that, I like to add all of these to a program. I will change the weights, sets and rep schemes for each exercise based on their tolerance while I see them performing. A periodized approach is critical and more details may be in a future blog post so stay tuned but always keep this concept in mind. I will very rarely have my clients perform 3 sets of 10 repetitions. The goal of the exercise needs to be fully understood in order to prescribe it correctly.

Advanced strengthening

Once an adequate base of strength is achieved and the exercises are constantly being progressed, I will add higher level strength training for the shoulder and surrounding muscles. Depending on the situation and the athlete presenting in front of me, I will focus on higher level strength training to maximize strength and underlying power production.

Plyometric strength training is incorporated to allow the athlete to produce and dissipate a force. This may include medicine ball chest passes, overhead throws, and rotational throws, amongst many others.

Pull-ups, push-ups, bench pressing and overhead pressing are also added. This is to make sure the athlete is strong in multiple planes and can withstand the forces that will be generated when they get back to their normal function.

Well, maybe not this aggressive!

Return to Sport Program

Finally, I like to outline a gradual return to sports program. To me, the key is knowing the ultimate goal of the athlete and working backward so I can come up with a program that is time-based and highlights important milestones in the process.

For example, in my baseball niche, I begin by having the athlete toss from 30 feet then progress them out to approximately 150 feet. I tend to avoid throwing from further than 220 feet at this point because of the stresses on the shoulder and elbow that ASMI published recently here.

If they can get out that far, then I begin doing pulldowns. A pulldown is when they throw more on a line and with full effort to continually work on arm strength.

If this goes well, then I will begin a mound program and slowly add fastball effort and increase the number of throws over a period of weeks. Gradual mound progressions can take weeks to months, depending on the situation and the goal of the athlete (and the timing of the season!).

Final Rotator Cuff Thoughts

There are many variables that need to be considered when returning a patient back to their highest functional level when they have a rotator cuff injury. It starts with a well thought out and thorough subjective. I can’t stress how important it is to connect with the patient from the 1st visit. We must continually assess and adjust as they report back to you.

This post was my attempt at outlining a very general program for an athlete with a rotator cuff issue. It is by no means the only way to rehab a patient with a shoulder injury. It may be a good starting point to begin to build that program for that person standing in front of you someday. Remember, listen to their issues…they may just tell you what program is best for them!

References for above paragraph:

Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises. J Athl Train. 2007;42:464-469); (Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004;34:385-394

Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder musculature activation during upper extremity weight-bearing exercise. J Orthop Sports Phys Ther. 2003;33:109-117

Uhl TL, Muir TA, Lawson L. Electromyographical Assessment of Passive, Active Assistive, and Active Shoulder Rehabilitation Exercises. PM R. 2010;2:132-141

Hintermeister RA, Lange GW, Schultheis JM, Bey MJ, Hawkins RJ. Electromyographic activity and applied load during shoulder rehabilitation exercises using elastic resistance. Am J Sports Med. 1998;26:210-220

Welcome to LennyMacrina.com!

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Welcome to my new website, LennyMacrina.com

I hope to share some of my insight into the field of physical therapy, rehabilitation, and performance.

My goal is very simple: Take a huge step back from the complexities of all of the information on the web and make it more intelligible and applicable to your daily practice.

I plan on periodically reviewing the newest orthopaedic and sports medicine research that is cutting edge. But at the same instance, I want to convey some of the classics that still remain pertinent in my physical therapy practice today. I truly believe that rehabilitation can take a very simplistic approach and still get tremendous outcomes for your patients.

The logo was created to combine my initials with the depiction of someone performing an overhead movement. You see, I treat many overhead athletes, particularly baseball players, and this has helped shape my career into what it is today. But this is a small piece of what I do on a daily basis.

My passion lies in returning people to their highest function after most orthopaedic injuries. My goal is to build upon my daily experiences and report what I believe is the most succinct PT out there.

I have been practicing therapy physical since 2003 and have made it a point to keep things simple, for both mine and my patient’s well being.

Let’s be candid…they’re not looking for complicated solutions that are confusing. They want a simplistic approach that is understandable and easily adapted into their lives.

I will help to navigate the PT intricacies that are currently out there and make rehab a lot more straightforward and fun too!

Again, welcome to my website…I hope you enjoy the new journey I’m about to undertake.

If you want to learn more and stay up to date with my posts, you can join my team and get my tips to regaining knee extension after surgery AND a promo code to save money off of a Medbridge Education subscription:

Thanks!!

2 Tips to Improve Your Post-op Rehabilitation Outcomes

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I’ve treated hundreds, if not thousands of postoperative patients in my career. I’m always surprised to hear from others how they progress their patients. When I first got into physical therapy, I was all about protocols. I didn’t have much experience.

I would literally follow it word for word and do my best to match the person to that little piece of paper. Little did I know that I was gravely mistaking! This post will hopefully improve your post-op rehabilitation outcomes.

As I became more comfortable, let’s say 1-2 years in, I got cocky and progressed people based off of their presentation. I almost wanted to show off to THEM that they were doing better than the protocol. This made them want to go faster through the process and all was good…kinda.

Wake up call

Then I began to see people get sore, stiff and regress. So much for being the guru of post-op rehabilitation. I had to reassess my approach.

Fortunately, we had a steady flow of post-op patients at our disposal in Birmingham, AL.  Each day, week and month I would get 1, 2 3, 4 new post-op patients a day. I would look for the protocol and fight the temptation to progress too quickly.

Trial and Error

Through experience and chatting with Kevin Wilk (and Mike until he left for the Red Sox in 2005), I began to take a more conservative approach, especially during the 1st 6 weeks after surgery. I realized the protocols were intentionally broken down into phases of rehab for a reason.

Those initial weeks after surgery are all about calming the joint down. Whether it is a knee replacement, an ACL or a rotator cuff repair, they all cause pain and swelling. We truly need to address each circumstance on a case-by-case basis.

There are always the outliers, and you know who they are. The guy that walks in with no crutches 1 day out of surgery and says “I’m here for PT, let’s do this”.

Then you have the guy who gets rolled into PT with a wheelchair and can’t do anything because he’s puking, constipated and cranky. Completely different approaches to rehab for these 2 folks.

The cocky guys need to be held back a bit because you know he’s going to keep pushing it and make his knee swollen. The guy in a ton of pain needs reassurance that you will take good care of him. You just need him to be a big part of the process and get over his fear.  You’re almost playing mind games on a daily basis and need to adjust to each individual’s personalities.

Regression to the Mean

The majority of people present somewhere in the middle- can function but in some pain. They know they need to do the PT and you know they need more pain meds, quickly!!

They’ll unwillingly participate in the early process because the doc said so but often not like you for it. Then they’ll thank you later on when they’re moving well and feeling great!

So with that, what 2 things do I think people need to consider when rehabbing a post-op patient?

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The 2 most important factors to progress a post-op patient

  1. Don’t overdo it- less is more
  2. End feel assessment

Don’t Over Do It- Less is More

As tempting as it is to progress someone quickly through the rehab process, fight the temptation in the early phase of PT. That 1st 4-6 weeks after surgery are critical to regaining homeostasis in the joint.

Dr. Scott Dye talks about this perspective in regards to patients that have patellofemoral pain or anterior knee pain: The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. His research has really shaped how I treat and progress people.

The quicker you can get the joint to ‘calm down’, the better they’ll be able to progress. I utilize range of motion and some modalities such as ice. I can’t overstate it enough that we can make or break an outcome in the first 4-6 weeks.

There’s no need to crank on someone’s knee because the protocol says you must have a certain ROM by a certain time. I’ve found great success with simple passive range of motion seated at the edge of the table at least 2x each visit.

It’s a lot more of a comfortable position for the patient than the dreaded prone ROM. Keep in mind, this puts a stretch through the quadriceps. It becomes an extra barrier that you must get through in order to achieve your motion goals. Plus, the patient feels like a WWE wrestler and may reflexively tighten up in anticipation of pain.

Each patient would get 5-10 minutes of PROM at the beginning and end of each session. No matter how busy I was or how many people were staring at me ‘waiting for their ‘next exercise, they all got 2 ROM sessions.

They looked forward to the range of motion and patiently watched me go from table to table (this was back a couple years ago) knowing they were next up.

This hands-on interaction is very important to develop the PT-patient relationship. This will hopefully blossom in the coming weeks and months as the patient progresses through the process.

I wrote about this previously for our Champion PT blog and I’m sticking to it Power of Touch. I truly believe that this is often missing and a huge complaint from people who end up coming to Champion PT in pursuit of reclaiming their functional goals.

End-feel Assessment

In my opinion, end feel is the single most important aspect of rehab progression a therapist needs to consider.  Being able to assess end-feel may be one of those skills that come with experience.

If a post-op rotator cuff is having painful guarding, then the therapist must adjust the process. Maybe it’s the frequency of the HEP, or the actual HEP content, or the patient’s pain control. There are so many factors to consider but the fun part is adjusting and reassessing. It’s a constant game of give and take!!

Commonly, the PT has to dive deeper into the patient’s life to figure out why this end-feel has changed. Often times a past medical history of diabetes can cause increased stiffness.

Also, you’ll find that they stop taking their pain meds because ‘they make me feel funny’ or ‘I have to drive to PT, don’t I?’ Everyone’s response to a surgery is different and it is very important to understand what could affect a patient’s presentation, as complicated as it may seem.

Ultimately, the goal is to get a nice capsular-like end-feel that has the potential to slowly stretch out as you progress the intensity of the ROM.

Assess and adjust each visit

I usually have them increase the frequency of their home exercises or adjust the daily frequency to easy bouts of motion 3-4 times per day. Most people think doing it 1x per day (if you’re lucky) is all they need so they can get credit for doing their ‘homework.’

I’m not afraid to lay the guilt-trip on them and remind them that their outcomes will only be as good as the effort they put into their rehab.  This usually gets the point across and we can progress on with the rehab process. This will allow us to quickly gain back the ROM and usually make that end-point not so hard or painful.

Conversely, a Bankart repair in a young athlete should be progressed at a slow speed so the tissue is not ‘stretched’ out. This often results in a nice, capsular endpoint. Should they begin to feel tight, don’t panic! Young adults, say up to 25-30 years old, very rarely get too tight.

Let the process happen, progress appropriately. The excessive ROM gains may cause the patient to have further issues down the road if their instability returns.

Take Home Point…

As much as we think we know about rehab progression after surgery, the only true feedback is from the patient.  Listen to them, monitor their response to the rehab and you will be well on your way to getting superb outcomes.