Simplifying ACL Rehab

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ACL surgery continues to be a huge focus in the literature and in our outpatient rehabilitation settings. Numerous studies focus on return to play guidelines and retear rates. Social media is all over the place, most times. Let’s try to make things simple and set the stage early.

Paralysis by Analysis- What ACL tests are best for return to play

I previously wrote about return to play guidelines here  and even the neurocognitive challenges that are associated with ACL rehabilitation.

As troubling as it all seems, I almost feel as if the recent research is confusing and often unattainable in a traditional outpatient PT setting. I’m worried about the paralysis by analysis mindset that seems to have overtaken my recent discussions on social media.

Most don’t have an isokinetic device to test.

Hop tests, vertical jump, strength…what really matters?

Do hop tests really give us a complete picture of an athlete’s return to play readiness?

What combinations of tests are appropriate?

Is it more than just quadriceps strength?

What about a vertical jump test to determine lower extremity strength and function for an LSI?

Lots of questions!

Timeframes have shifted from a 4-6 month return to play goal to a more realistic 9+ months before we return people. Studies continue to show that a slower rehab may be better.

ACL retear rates still too high

Yet, our retear rates still remain very high and we’re still missing the boat for many.

I get it. It’s not just the timelines and rehab. Many are limited by equipment, insurance limitations, differing MD protocols, and so much more. It’s easy to blame one concept when it truly is multifactorial. 

That’s why I employ a very simple approach to my ACL rehab programs that seems to work for most and hope this concept can help you too.

It all really occurs at the beginning of rehab when you set the stage for the rest of your planning. If you can establish full motion, remove most of the swelling and restore a pretty normal gait, then you have achieved your goals.

From here, it gets fun and we’ll talk about that later…

An easier approach to ACL rehab

Immediately Post-op Phase

During the earlier stages of rehab, we’ll call it 6 weeks post-op, my main focus is calming the knee down and establishing a normal range of motion.

Range of Motion

It is critical to get the knee as straight as possible and as quickly as possible. For example, most people naturally have some 3-5 degrees of hyperextension. For these individuals, I like to get 0-3 degrees of hyperextension immediately and allow the rest to come through normal functional stresses.

For hypermobile patients, say 10-15 degrees of knee hyperextension, I will only get about 5-7 degrees of hyperextension because I know their underlying tissue mobility will allow the motion to return very easily. 

These individuals will not struggle with ROM and it often comes too easily. I don’t want to put unneeded stress on the graft.

Before you yell at me that knee extension will affect retear rates, a study in AJSM showed that the degree of hyperextension did not affect graft laxity and retear rates.

For flexion ROM, I like to have them seated at the edge of the table as I have shown in this video.

I just feel as if it’s easier on the patient and their knee instead of supine or prone, as I’ve described in the video.

I’m a bit obsessive with measuring ROM early, especially extension. It’s critical to stay on top of it and monitor for subtle changes in the motion and end-feel. Here’s an example of an ACL patient of mine who I recently saw and her post-session ROM.

measuring knee extension after an ACL surgery

Normalize Patella Mobility

You must also normalize patella mobility, especially in a patella tendon autograft. It is critical to regain this mobility in order for the normal motions to occur in the knee and to restore normal arthrokinematics.

I don’t push things too quickly and think this sets the stage for the rest of the rehab. In my hands, slow and steady is the best approach. A spike in volume can slow things down.

When I say a spike in volume, it could simply be a long walk or an extra bike session. The patients are often feeling good and looking for some independence and normalcy. They want to push it and we need to let them know that an increase in swelling or pain can create an issue.

Strengthening

I tend to go pretty slow with this concept as well. I tend to stay conservative for 4-6 weeks and stay with mainly table exercises like leg raises and mini squats.

I do love to use electrical stimulation (I prefer the DJO Global Continuum 2 unit!) for the first 2 weeks then add blood flow restriction training to compliment the NMES.

Not sure the research backs up my thoughts besides this 2015 paper or this one from 2018 but it definitely shows promise and makes sense in my head.

I’ll stay with these particular exercises for 4-6 weeks to ensure that the knee is calming down and my exercise progressions are not causing more pain or swelling.

Let the ACL rehab fun begin

If you’ve made it this far, then the important concepts have been met. No really!

The first 6 weeks set the tone and it can only go up from here.

For my patients, I basically turn into a strength coach and progress them based on muscle capacity and progress their programs based on movements and muscle groups.

I like to really hammer single leg work early but only after I’ve given them a good bout of 2-legged work to establish a base of movement.

Some do it the other way but I want to build confidence with 2-legged squats and/or deadlifts to reinforce a movement then use single leg work to take it to the next level.

When to run after an ACL

As I’ve gotten older in my career, I’ve gotten slower with my progressions. I typically don’t like to start running until at least 4 months after surgery and that’s if their quadriceps muscle is strong enough.

I look to this paper that shows a quadriceps strength to bodyweight ratio (QS/BW) of 1.45 Nm/Kg as a rough estimate to initiate running.

Some may argue that this paper only considers ACL patients that utilized a hamstring autograft and that’s a fair argument. But there’s limited information out there and I wanted something more objective.

So, until they can establish a good quadriceps contraction and their ROM/gait are normalized, I will hold off running.

ACL rehab is mainly about strengthening

The cat’s out of the bag…don’t tell anyone!

It’s pretty simple, once you get through that 6 week interval that we talked about earlier.

If you’re not proficient in this, find someone who is in your area.

Otherwise, program using simple strength training principles that incorporate power, velocity, full ROM and tempo. Work on their aerobic capacity while building strength, power and endurance.

I could write another full blog post on this but we touch upon these concepts in our all online knee course.

Hope this helps!

ACL tears and bone bruises

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Research Review

Not sure if you saw my recent post on social media about bone bruises after an ACL tear so I wanted to discuss it further here.

In this study, the authors looked at the incidence of radiographic chondral changes (without correlation with clinical and functional outcomes) on MRI 5 years after the ACL tear.

Bone bruises often coincide with an acute ACL tear and can be seen on an MRI. Basically, a larger bone bruise was shown to have a significant influence on chondral changes 5 years post-surgery.

In most of the cases, the lateral side of the knee (both the tibia and the femur) were involved. Whereas the medial side had fewer incidences of a bone bruise after the injury.

Outline of a bone bruise on the distal femur and proximal tibia after an ACL injury

This is very typical after an ACL injury and previously cited by numerous authors.

I’ve always said that these bone bruises need to be communicated throughout the rehab team. These bone bruises should influence the progression back to sport.

Delay impact activities after ACL surgery

It is for this reason that I have delayed most of my athletes’ return to impact activities until 4-5 months after the surgery. I often don’t initiate running and plyometrics until 4-5 months after the surgery.

We need to respect the bone bruise healing times (which are still not truly known). They seem to take months to achieve homeostasis, which means no pain or swelling.

Only another MRI would truly confirm full healing so we need to rely on symptoms, most of the time.

I think this may allow the athlete to achieve better long-term success. But we need to understand these bruises more before we can fully determine the correct rehab process.

I think the long term life of the athlete’s knee can be influenced by our rate of rehab progressions. To me, slower seems to be better in these situations.

Gone are the days of trying to return our athletes back to their sport as quickly as possible.

Take the time to get their motion back, especially knee extension.

We are beginning to better understand the implications of these bone bruises on the long-term health of the athlete’s knee.

Educate the patient fully and build confidence! Rehab after an ACL surgery is never easy so don’t take anything for granted!

ACL Volume Changes over a Women’s Soccer Season

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I’m a bit interested, confused and looking to seek more on this open access paper that just came out in March of 2019 looking at the effects of season-long participation on ACL volume in female intercollegiate soccer athletes. The title of the paper is: “Effects of season-long participation on ACL volume in female intercollegiate soccer athletes” by Myrick et al.

ACL Growth influenced by soccer Activity?

Basically, they did MRI scans (only using a 1.5 Tesla machine) of the bilateral knees of the Quinnipiac University women’s soccer team before and after their soccer season.

The researchers wanted to look at the ACL structure and size in the 17 participants to see what, if any, changed in the size of the ligament and if there were any noticeable changes that occurred.

I cannot recall a previous study like this, which is pretty surprising. I feel like this may give us some insight into why injuries may or may not happen at a given time during the season or in a given population (like women!).

They found that mean ACL volume significantly increased from preseason to the postseason (p = .006).

There was also greater volume increase in the right knee than the left and the difference between knees was significant (p = .047).

Figure 1 of Myrick et al. Journal of Experimental Orthopaedics

I’m just a bit flabbergasted, for lack of a better term, because I was completely unaware that the ACL would undergo such changes over a season.

The authors’ rationale was “repetitive subacute trauma occurring over the course of the competitive soccer season leads to microscopic tears in the ligament inducing an inflammatory response and subsequent remodeling of the ACL which results in increased volume.”

Sounds plausible… but does this stuff really happen like that?

from: https://gph.is/1sEKHQ2

I will say that their study was not blinded and the doctors’ assessment of edema volume seemed a bit too subjective.

The authors also reported that the plant leg (left leg) had more edema in the joint than the kicking leg (right leg) which seemed a bit odd to me. They were pretty vague with their methods when it came to this section and not everyone showed these changes.

I did want to mention it because they did as well but it certainly wasn’t the meat of the paper.

Future Implications

Maybe the open chain action of kicking a soccer ball aided in hypertrophy of the ACL and maybe this would help to create a stronger and more robust ligament.

On the flip side, a larger than normal ACL for that person may create a situation where the ligament is too large for that person’s condylar notch and create impingement. Taking it one step further, this ligament impingement may put the athletes in a greater risk of injury (ACL tear).

What else do we know?

Weightlifting linked to ACL Hypertrophy too

In another study from 2012, they found that weightlifters had a more hypertrophied ACL and PCL than age-matched controls. This paper also showed that weightlifters who started lifting earlier in their life span (mean 10 years old) and at least 10 years of training duration had a higher change in the size of their cruciate ligaments.

from Grzelak et al https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535026/

So, maybe the weight lifting creates a proliferation of the ligament that results in further growth compared to untrained athletes. Does puberty play a role when hormones are raging and growth spurts are running rampant?

Patella Ligament Influence

This same group published a paper in 2012 that showed the area of the patella ligament (patella tendon in our world) mid-substance and the onset of training were very strongly, reversely correlated. Beginning training during the onset of puberty highly influenced the growth of the patella ligament (tendon).

Maybe this is not as surprising as the ACL papers because of the direct stresses from weight training, especially in those that squat heavy weights.

We already know that tendon tissue remodels to the stresses placed upon it, even though one could call the patella tendon a ligament, right? it is contained between two bones!

I did want to show that there is precedent out there for such influences on our soft tissue but was extremely surprised by the ACL study.

Wrapping it up

I’m very curious to see if the research can be replicated by another group.

Some of my questions to ponder:

  1. Do other sports like football show similar effects?
  2. What if the women’s soccer team was followed long term to see injury rates over the course of their careers?
  3. Is there a particular time where the hypertrophied ligament returns to its baseline level? How long does it take?
  4. Does the open chain aspect of the soccer kick truly influence the ACL’s volume (or is it some other aspect of the soccer kick)?

Just so interested in this phenomenon and hope to better define its implications to all sports, including this women’s soccer team.

What do you think? Have you seen anything similar in your experiences? What am I missing?

An Update on Diagnosing SLAP tears

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Diagnosing a SLAP tear is not easy

We hear a lot about trying to diagnose shoulder pain and to be as specific as possible. It’s often difficult to differentiate SLAP (superior labrum anterior to posterior) tears from other soft tissue injuries of the shoulder.

For a review of the different types of SLAP tears, check out this old blog post that classifies the 10 different types of tears.

from https://commons.wikimedia.org/wiki/File:SLAP-Lesion-front-2.jpg

This paper in IJSPT by Clark et al 2019 attempts to help out the process and recommend a few special tests that MAY aid in diagnosing a SLAP tear.

What do they Recommend to diagnose a slap tear?

They recommend that a combination of at least 3 positive SLAP lesion tests may be clinically useful in diagnosing a shoulder SLAP lesion with greater diagnostic accuracy.

Combo of Tests

The combination of the Biceps Load I/II and O’Brien’s showed the highest sensitivity and specificity.

I have found similar results with this set of special tests so maybe this paper just hits my biases correctly.

In this video at my YouTube channel, I wanted to let you hear my thoughts and small tweaks to the evaluation process.

It’s not easy to diagnose a SLAP tear.

Differential Diagnosis is Critical

Furthermore, does it really matter and will it change the treatment plan much at all? I think it may a little but overall it will remain a pretty similar treatment approach to other similar pathologies like:

  • rotator cuff tendonopathy
  • Biceps strain
  • Latissimus strain
  • Subscapularis strain
  • internal impingement
  • pectoralis major strain

I think one also needs to consider the cervical spine and to make sure the pain is not referred from the neck.

Otherwise, a well thought out program should be implemented that addresses the strain on the shoulder and any strength issues.

I talked about this in an article that I wrote for Medbridge a while back so check out that post here:

You can also check out a snippet of one of my courses at this YouTube video where I discuss rotator cuff and labral issues. Hope it helps too!

Will this Change your Practice?

How ever you look at it, I wanted to use this paper to let you know that there MAY be a cluster of tests that better diagnose a suspected SLAP tear in your next patient’s shoulder.

Check out the paper and comment so we can talk it through. Are these tests similar to what you use in your clinical practice? Will this paper change what you do in your clinical practice?

Why you need “Feel” as a Physical Therapist

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I haven’t written a post in a while but wanted get back into the swing of things. In this post, I wanted to talk about having ‘Feel’ as a PT.

When I say feel, I’m talking about being able to read people and adjust the situation based on their response to things. So, what does that mean? Not really sure… but wanted to give a few examples that I have heard recently that I think happen pretty commonly in our profession.

Exercise Progression (or lack of)

This one happens a bunch in our profession and I was guilty of this early on in my career. It’s much easier to have someone come in 2-3 times per week and give them the same exercises, right? But to do this for multiple weeks, if not months, is a travesty!

Listen, I don’t think we need to progress someone’s program every session. Adding a new exercise each visit can be a bit much. know we want to make people feel as if they are moving forward in their rehab but there are other ways we can progress people besides giving them 17 different exercises that keeps them in PT for 2+ hours.

Again, I was guilty!

There are so many variables that we can manipulate for each session, it’s silly! Think about each move that someone does and break it down.

Exercise Variables to Manipulate

We can play with:

  • Tempo
  • Single leg versus double leg
  • Reps/sets scheme
  • Upper body or lower body
  • Time under tension
  • External resistance (bands, chains)
  • Rest periods between exercises
  • Perceived RPE (stole that one from Kiefer!)
  • Volume

So as you can see, even if you don’t have heavy weights as we do here at Champion PT and Performance, then you can still get creative with progressions.

The training facility at Champion PT and Performance in Waltham, MA
The training facility at Champion PT and Performance in Waltham, MA

Personally, my clients have the same program for 4 weeks and then we write them a new program. That means that they can focus on the aforementioned variables as needed even though they are doing the same exercises for 4 weeks.

The client likes it because they get really good at that movement plus they can see their progression in their weights, which is a huge mental gain!

Besides the obvious weight progressions, there’s a ton that can be manipulated but I don’t see or hear it enough from the patients that come through here. I rarely hear a client tell me that their previous PT experiences involved any type of variable manipulation but maybe that’s why they find us in the 1st place. Who knows…

My advice, let the patient feel as if they are moving forward in their exercise prescription because they are a smarter consumer than you would think. As PT’s we must do better with this stuff and the above bullet points are a good starting point for you.

Running on Empty

On another note, I recently started treating someone for a knee injury she sustained while skiing. Fortunately, she didn’t require surgery but the fracture needed time to heal. I don’t want to reveal too many details of the case for privacy reasons but just know she could’ve easily done more damage to her knee from the mechanism of injury.

She was given a brace and a prescription for PT to begin immediately for ROM and strengthening. She was limited in weight bearing for a period of time (I don’t remember the exact amount) so she had those effects that she had to deal with too.

At the beginning of the 6th week after the injury, her doc said she was fine to begin running even though no new x-rays were done on her knee. Guess they were just going off of time and that she was a healthy female without any co-morbidities.

Back at PT, she was told to start a running program that she thought was a bit early but she was excited to progress to more aggressive exercises.

According to her, she had been doing straight leg raises, clams, bridging and other low-level exercises for the whole duration of the rehab…see above rant!

Upon beginning her running program, she felt immediate pain and had to stop. She said she felt bad because the PT was surprised that the pain was still present but she wanted to work through it a bit. Despite trying to push through it, she still felt pain and had to stop again. She felt a big sense of failure because the pain persisted and she just couldn’t get over this hump.

Think Mode

Let’s think about this scenario for a second. Six weeks after a joint fracture, little strength training after a decent period of immobilization and the patient was expected to run?

As it turns out, the patient was frustrated enough with the scenario that she sought a second opinion and found us. I’ll never put down another PT’s plan of care but it was obvious that the plan was rushed and the patient’s opinions and communications were not fully observed.

She was frustrated and felt defeated but why? Why would someone be expected to run 6 weeks after a fracture without loading the joint and going through a progressive program?

I’m not sure but I wanted to use this case as a teaching moment for other clinicians, especially the younger crowd that may struggle with rehab progressions.

Listen Up!

Listen to the client and have a good understanding of basic soft tissue healing. I told the client that she needed a good 6-8 weeks of strength training before even talking about running. She was relieved that I wanted to take it slow and we now have a very happy client who has completely bought into my system.

Again, listen to your clients. They’ll tell you what’s wrong with themselves if you listen closely!

My Dad’s Knee Replacement

Switching gears, my Dad has his knee replaced a few weeks ago. Despite having treated a gazillion knee patients in my career, my Dad has yet to step foot in our facility. I’ve given him advice from a distance and have tried to keep an eye on things as they came up.

I’m not a home health PT and respect their jobs. I was surprised that no one ever tried to bend his knee during the home visits he had for nearly 6 weeks. Fortunately, he had about 80-90 degrees of flexion but the home health PT kept telling him he didn’t need more than 90 degrees of motion.

You try to get up from a chair with only 90 degrees of knee flexion! I’ll bet it’s much more difficult than 110+ degrees of motion. For the record, I shoot for 120 degrees of knee flexion ROM for all.

After home health, my Dad started outpatient PT and he sounded confident and happy. Yet again, no one felt the need to bend his knee (he did get some patella mob’s) and just showed him basic exercises like straight leg raises and squats.

Obviously an important component to PT but I still think getting more ROM is critical. I’ve talked about how I like to bend the knee after surgery at my YouTube channel that you can access here. As you can see, I prefer the seated position at the edge of the table for its comfort and isolation of the knee joint without hip compensation.

However, no one is bending his knee and he was feeling stiff. He did get a new PT for one of his sessions and they did bend his knee but only 2 times…and each time they cranked on it to the point he had to tell them to stop because of the pain.

Not how I would’ve initiated ROM!

Bad Ass Arya wouldn’t have been so aggressive either!

He’s now 3 days after the PT session and frustrated. He told me he can’t do anything around the house anymore and has considered taking pain medication to help get over the hump. This is the ‘feel’ that I’m talking about.

Why on Earth would any PT think this technique would be beneficial? I’ve heard this way too often in the past and am frustrated by it.

If that were you 🤔

My advice…as always, put yourself in their position and consider the risk/reward. Is this the best we can do and will the patient absolutely benefit from this?

In my Dad’s situation(s) I say he has received mediocre care so far. Fortunately, I have guided his home program and have tried to keep him positive and realistic.

He’s frustrated and vows to never consider his other knee even if he can’t walk. I hope he changes his mind once he gets stronger and more functional.

My lesson in this post- listen to the client and do what’s in their best interest. Have some FEEL and progress people more appropriately.

We can do better!

The Week in Research Review, etc 12-24-18

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The Week in Research Review, etc 12-24-18 only had two posts to social media this week but hopefully two very helpful posts for your practice.

The back pain post was a repost from a previous time but I thought it was very important to share it again. I also put a new post from my YouTube channel where I discussed patellar mobility assessment for instability. Check the post out at the link here or below to see the full version.

Physical Therapy First to Treat Low Back Pain

[ICYMI} Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Frogner et al Health Serv. Res. 2018

The Week in Research Review, etc 12-24-18This study compared the differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist as the first point of care, at any time during the episode, or not at all.

Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period.

Patients who saw a PT first had:

  • a lower probability of having an opioid prescription (89.4 percent),
  • any advanced imaging services (27.9 percent),
  • and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization.

Interestingly enough, 80% of the patients in the sample had no PT at all. Furthermore, 8.7% saw a PT first and 11.5% saw a PT later (avg 38 days). The most common provider seen 1st was a chiropractor.

Assessing for Patella Instability

Assessing Patella Mobility

💥Assessing for Patella Hypermobility💥

This Instagram snippet shows how I assess a patient with suspected patella hypermobility who may have sustained a subluxation, dislocation or instability episode.

To see the full video at my YouTube Channel, click the link here!

Basically, we’re looking at how mobile the patella is when the knee is locked at full extension compared to when the knee is flexed to about 25 degrees.

Normally, the patella should become relatively stable when the knee is flexed to 25 degrees because it engages the trochlea groove.

In patients with underlying patella hyper-mobility, the amount of mobility with the knee slightly flexed will be similar to when the knee is in full extension (and not locked into the trochlea groove).

This is often the case when the patient’s trochlea groove is too shallow to offer bony stability.

The test should help the clinician gain a better understanding of the patient’s anatomical make-up and prognosis for the long term.

Check out the full video at my YouTube Channel.

The Week in Research Review, etc 12-17-18

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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.

The Week in Research Review, etc 12-10-18

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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.

This could be a huge cost/time saver for society!

Return to Sport Criteria and Reinjury Rates

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?

Physical Therapy vs Knee Scope for Meniscus Tears

💥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 Health Accessory Exercises

by @kieferlammi

Want strong and healthy shoulders!?

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. 

Should we Brace after an ACL Surgery?

  
 
 
 
 
 
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 [NEW BLOG POST]⠀ 💥Knee Bracing Immediately After an ACL Reconstruction 💥⠀ In this post, I review some recent Twitter, Facebook and Instagram discussions about the usage of a hinged knee brace after an ACL surgery.⠀ .⠀ You'd be surprised what I found in the literature and the differences that exist throughout the US and the world.⠀ .⠀ Go to my website <LINK in my BIO> and read/share with your friends/colleagues.⠀ .⠀ It was a bit eye-opening and I'm curious to hear what others have to say.⠀ .⠀ I still like to recommend a brace for my clients because it seems to give them an added security after a pretty painful surgery.⠀ .⠀ I typically keep them braced 4-6 weeks, depending on their quadriceps activity and if they can do an active straight leg raise without a lag.⠀ .⠀ Many others don't even bother bracing at anytime post-op, which was surprising.⠀ .⠀ What do you think? Read the blog post and let me know. Let's try to educate and come to a better consensus...thanks!⠀ .⠀ #kneerehab #knee #kneepain #kneesurgery #acl #aclsurgery #ROM #physio #physiotherapist #crossfit #exercise #deadlift #physiotherapy #physicaltherapy #physicaltherapist #athletictraining #athletictrainer #ATC #PT #teamchampion #dptstudent #lenmacpt #instagram
 
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You can also get to the blog post by clicking this link

Let me know what you think about this new blog post or any of my social media posts…thanks!

Knee Bracing Immediately After an ACL Reconstruction

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I recently came across a Facebook post that discussed bracing immediately after an ACL reconstruction and I was intrigued. I read some of the comments and chimed in with my observations and opinions.

In turn, a multi-platform discussion revealed many new details. I wanted to briefly share some of the research and the discussions that came up.

I was very impressed with the discussions by the way. They were very professional, grounded and level-minded.

No one got too emotional (typical of social media) and they really helped to educate and see both sides of the discussion.

What does the Research Say about Bracing after an ACL?

Again, I’m talking about post-op day 1 or as we like to say POD1 as clinicians.

Many people posted a 2007 systematic review that showed ‘no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use, thus supporting our hypothesis.’

Another study that kept showing up was a 2012 study in AJSM that said ‘Bracing following ACL reconstruction remains neither necessary nor beneficial and adds to the cost of the procedure.’

Wow! Two pretty high level studies that completely went against my 15+ years of experience.

More studies!

Another study in the Scandinavia Journal of Medicine and Science in Sports looked at brace versus no brace after an autologous patella tendon graft reconstruction. 

There were no differences either pre‐operatively or 5 years post‐operatively  between the groups in terms of the knee score (Lysholm), activity level (Tegner), degree of laxity or isokinetic peak muscle torque.

Keep in mind there are a ton of studies out there. This study in the Journal of American Academy of Orthopaedic Surgeons suggests ‘that functional bracing may have some benefit with regard to in vivo knee kinematics and may offer increased protection of the implanted graft after ACL reconstruction without sacrificing function, range of motion, or proprioception.’

I have NEVER seen a post-operative ACL patient without a brace immediately after surgery.

Instagram Story Poll will Decide It!

So, what’s the next obvious thing to do? Take it to instagram and see what they have to say?

So I did a poll in my story and the results favored immediately bracing after surgery which goes completely against the literature.

Poll Results- 63% say they use a brace after an ACL surgery
Instagram Poll Results for ACL Bracing

Pretty interesting and I’d say overwhelmingly confirmed my biases!

Twitter Discussion

I’m a big Twitter guy so it was only natural to hit up my peeps there to see what they had to say.

I started the Twitter discussion here and an awesome conversation continued between PT’s and MD’s that was so beneficial.

Regional Differences with Bracing

Midwest

It definitely seems that geography plays a huge role! Midwest PT’s and MD’s in St Louis, Minnesota (near Mayo) and Indianapolis (near Dr. Shelborne) were all opinionated. They advocated for NO BRACE.

West Coast

The no-brace crowd extended to the west coast a bit too but we took a curious stop in Colorado. One person said their doctors all brace their patients and limit weight-bearing to 25% for a period of time.

It surprised me to read this! I can maybe understand limiting WB after an ACL-meniscus repair but not for an isolated ACL reconstruction. 

Europe

Of note, it seems as if no one in Europe uses a brace immediately after an ACL surgery. Are we that far behind or naive to the literature?

Guess that topic will be for a different day!

For now, I wanted to share this discussion with people and hope to learn a bit more by it.

I know the docs ultimately have the final say. It really was interesting to see the regional differences.

For example, Sylvia Czuppon, a respected professor and researcher from Wash U. in St. Louis, had a 180-degree response from me!

She has basically only seen post-op patients without a brace.

Pretty funny, but it basically sums up our current medical practices.

This should be a lesson for all, especially the students and new grads.

Closing Thoughts

Keep an open mind, learn from the research and do what’s best for your patient!

I worked 11+ years in Birmingham, Alabama with some of the top sports medicine docs in the world. We always braced after an ACL reconstruction.

Same thing here in Boston where I get patients from Children’s Hospital, Mass. General Hospital and other top-notch hospitals.

Every single patient that I have ever seen has won a brace after surgery

With that, it was very interesting to see the results and the literature. It was equally interesting to see the responses.

People were stunned when they heard the other side of the story.

ACL rehabilitation is not easy…trust me. I’ve written bout this before right here. Check it out before you move on!

What do you see in your practice? Do your docs brace immediately after an ACL?

Let’s talk it out in try to come to a consensus. Again, education is the key and we can always do better.

The Week in Research Review, etc 12-3-18

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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

Preventing low back pain by @joegambinodpt

Female Soccer Players have a 5x Increased Risk of a Second ACL injury

Anatomy of the Proximal Humerus

ACL Injury Rates Higher on Synthetic Turf than Natural Grass in the NFL

 

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Preventing low back pain by @joegambinodpt

 

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A post shared by Lenny Macrina MSPT, SCS, CSCS (@lenmacpt) on

Female Soccer Players have a 5x Increased Risk of a Second ACL injury

 

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A post shared by Lenny Macrina MSPT, SCS, CSCS (@lenmacpt) on

Anatomy of the Proximal Humerus

 

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