The Week in Research Review, etc 11-26-18

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This week, I discussed the progression of someone after a knee surgery. I tried to highlight the key stages and some techniques that I like to use to advance the patient’s mobility and comfort. Take a look at The Week in Research Review, etc 11-26-18 and share with your friends. Hope it helps you improve your patient care tomorrow and beyond!

 

ACL Reconstruction in a Pediatric and Adolescent Population

1st Day of #PT after an ACL Surgery

Patella Mobilization after Knee Surgery

Knee Flexion PROM after Surgery- Seated or Supine?

Stretching the Quads after Knee Surgery

Assessing for a Cyclops Lesion after an ACL

Assessing for Fat Pad Irritation of the Knee

 

 

ACL Reconstruction in a Pediatric and Adolescent Population

17 Year Follow-up After Meniscal Repair With Concomitant ACL Reconstruction in a Pediatric and Adolescent Population. Tagliero et al AJSM 2018

Results: 28% failed meniscal repair and required repeat surgery at the time of final follow-up. They also showed that outcomes and failures rates were comparable across tear complexity.

Guess that means that no matter the tear type, there was no difference in outcomes or retear rates. Although the repair techniques are now outdated and no longer used.

Their study also showed a 30% failure rate for meniscal tear repaired in the medial compartment at index surgery and 7% in the lateral compartment.

Interesting long-term outcomes that may help to guide your rehab and client advancement (and prognosis). Keep these in mind when you treat a future adolescent or pediatric ACL patient.

 

 

💥1st Day of #PT after an ACL Surgery 💥

If you have never treated a post-op ACL, then this video should interest you!

This is what the knee looks like that 1st day after surgery and can often set the stage for what’s to come over the next 6-12 months.

Often, the patient is both very curious and ultra-grossed out by the 1st unveiling. It can be stressful for them to see their knee in this condition so you really have to confidently reassure them that it is very normal.

The blood-soaked gauze is mainly saline that was used to irrigate the knee during the reconstruction. Some still leaks out of the incisions the 1st few days and can often be confused with true blood.

Understand that this is quite normal and happens to most every ACL patient’s knee that I’ve seen…nothing to worry about!

From here, I’d work on patella mobility (see the post later today) and then work on flexion ROM at the end of the table.

Again, it’s very important to get the knee moving after surgery. This will help with pain, swelling and gain confidence that the rehab process is moving forward.

 

Patella Mobilization after Knee Surgery

Get the patella moving early with #patella mobilizations immediately after surgery. One major reason (amongst many others) why we need to get our clients into #PT early.

I am certainly a very loud advocate for early PT and getting the patella moving can help to prevent excessive scarring, which can affect ROM and quadriceps force output.

Glove up and get that patella moving in all directions… medial, lateral, superior, inferior!

 

 

🤔Knee Flexion PROM after Surgery- Seated or Supine? 🤔

I’ve treated many patients after an ACL I can honestly say that this may be a huge influence on the early ROM outcomes that you may see.

I’ve tried to bend the knee in both supine or seated, as the video shows, and there’s no doubt that most people tolerate the seated version so much better after a knee surgery. In particular, a big surgery like an ACL, TKA or MPFL reconstruction.

It just seems to be more comfortable and with less stress on the anterior knee because of the position of the tibia (at least I think so!).

My theory, it seems as if the supine position may cause a slight posterior sag which may cause more pain and guarding than when they’re seated at the edge of the table.

I use a similar concept later on in the rehab process when I’m initiating my prone quad stretching. You can see a definitive improvement when I wedge my hand in the popliteal fossa and create a slight anterior translation on the tibia.

Most people say that the anterior knee pain that they were feeling (and not a quad stretch) was replaced by a stretch feeling only and no more anterior knee pain.

Try it out with your ACL patients and see what position they like best…I’ll bet I can covert you over if you still bend your knee patients in supine!

 

💥Stretching the Quads after Knee Surgery 💥

Continuing my sequence of videos after a knee surgery, I discussed my technique for progressing knee flexion PROM once they hit 120 degrees or so of flexion.

At this point, they’ve probably maxed out how much ROM they can achieve at the edge of the table. They’re ready to get that end range of motion and even some quadriceps flexibility.

In prone, most people will often feel a pain or pressure in the front of their knee when you try to bend it.

To overcome this, I like to wedge my hand into the back of the knee and give an anteriorly directed force through the gastrocnemius (calf) soft tissue and into the tibia.

This seems to create just enough movement of the tibia on the femur to take the pressure off the front of the knee. This may redirect the forces more onto the quadriceps muscle.

You’ll need to play with the amount and direction of force but most often they’ll begin to feel a better quad stretch.

Try this technique out on your next knee surgery client and see if it helps them. I usually initiate this ~4 weeks after an ACL but timeframes will vary person to person.⠀

 

💥Assessing for a Cyclops Lesion after an ACL 💥

In this video snippet from my YouTube Channel, I discuss how to assess for a Cyclops lesion in a knee. In particular, after knee surgery.

A patient with a potential cyclops lesion, they often present with loss of normal knee extension compared to the other side. They’ll often have anterior knee pain and poor patella mobility. Sometimes a tight feeling in their hamstrings and calves, too.

No matter how they try to regain their extension ROM, the knee just never feels right. Often times, surgical intervention is needed to remove that scar tissue.

Immediate rehab should continue to work on knee extension ROM using low load long duration stretching and aggressive patella mob’s.

No one’s to blame if this occurs. We don’t know exactly why it occurs in some people but we believe a remnant of the ACL stump may be a source of the frustrating issue.

 

💥Assessing for Fat Pad Irritation of the Knee 💥

Anterior knee pain is very common in the outpatient #PhysicalTherapy setting.

One of my go-to tests to assess for fat pad irritation is simply trying to capture the fatty tissue in the anterior aspect of the knee joint during active and/or passive ROM.

In this snippet from my YouTube channel, you can see that I pinch the fat pads on either side of the patella tendon as @corrine_evelyn is actively extending her knee. I’ll also do it in a relaxed state to assess passive irritability.

I 1st learned this test from @wilk_kevin and it continues to be a mainstay in my knee examination algorithm.

As for a treatment, it usually comes down to a volume issue and/or strength issue or both.

I’ll usually have to address the volume of the activity by relatively easing off of the activity while simultaneously adding in exercises to address an underlying weakness.

Remember the Dye et al study in AJSM 1998 when he talked about the fat pads being super painful during his arthroscopic surgery without anesthesia. Makes sense why they can be so painful if the knee stresses fall upon this tissue.

We talk about this study, fat pad irritability and much much more in our online knee seminar course.

If you want to learn more about how I treat ACL’s or the knee in general, then you can check out our all online knee seminar at www.onlinekneeseminar.com and let me know what you think.

We cover the anatomy, rehab prescription, ACL, meniscal injuries knee replacements and patellofemoral issues. Furthermore, the course covers both the non-operative and post-operative treatment.t

This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

The Week in Research Review, etc 11-19-18

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Great ‘Week in Research Review, etc 11-19-18’ that I hope you find helpful to your practice.

I’ve always touted the importance of the subjective portion of the exam so I wanted to share a slide from a recent talk I gave to a group in Canandaigua, NY. Obviously, the squat is a fundamental movement and I wanted to give some basic positions that I use to help assess. So excited that I’ve launched a brand new Medbridge course that helps the rehab specialist better eval and treat the baseball pitcher. On my YouTube channel, I discussed my thoughts on setting the scapula with various upper and lower body exercises. And finally, my co-worker Kiefer Lammi discusses the landmine with exercise.

 

Importance of the Subjective Exam

Assessing the Squat

My New Baseball Medbridge Course

Set the Scapula with Shoulder Exercises?

6 Ways to use the Landmine by @kieferlammi

 

💥Subjective the most important aspect of the Evaluation💥

This slide, taken from this past weekend’s course in Canandaigua, NY is always a favorite of mine.

I try to keep a slide like this in all of my lectures because I have found that this portion of the examination can give the rehab specialist a huge look into what is going on with the person in front of them.

Don’t get me wrong, I still consider the biomechanical aspect of what may be causing their symptoms.

It often comes down to a tissue capacity issue but it’s up to me to determine the appropriate course of treatment.

These questions will help build confidence in your client and guide the early stages of rehab.

Do you have any specific questions that you like to ask your clients during their 1st few sessions? Remember, these questions are just not for the evaluation. You should be asking these questions periodically to gauge progress and help guide the next phases of rehab, too!

 

🔅Assessing the Squat 🔅

Squatting is a fundamental movement that all of us have to do on a daily basis.

Utilizing several different positions can help the rehab specialist better assess the squat and develop a treatment plan that enables their client the ability to improve their squat pattern.

In the above videos, I have utilized 3 different squat patterns and will outline them by the degree of difficulty.

✅The Overhead Squat- by far the most challenging version which challenges the shoulders, thoracic spine, lumbar spine, pelvis, knee and ankles.

A movement limitation at any of these joints will most likely cause the squat pattern to break down. Using overhead resistance would further challenge the system and potentially cause the squat to further breakdown.

✅Arms Crossed Chest Squat- alters the challenge by taking most of the shoulder and thoracic spine out of the equation and isolates the motions to the lumbar spine, hips, knees and ankles.

I often use this position as my fundamental motion because most people don’t have to squat with any weights over their head. This position, in my opinion, should be the most informational and utilized.

✅Counter-weight Squat

This position changes the center of mass by moving some of the weight distribution more anteriorly (front) and making the squat motion slightly easier. I use this position as a regression, for some, which allows them to squat with less stress and potential difficulty.

There are many other variations to the squat that you can make but I wanted to highlight a few of the major changes that you cause successfully. Assessing the squat is essential and can give the rehab specialist a nice picture of the function of multiple joints during a common movement.

 

My BRAND NEW course on Medbridge’s platform

…that helps the sports and ortho rehab specialist (PT, OT, ATC) better understand the anatomy and biomechanics involved in the baseball pitching motion.

Advanced Rehab for the Baseball Pitcher to Improve ROM & Strength@medbridge_education

The goal of this course was to allow the clinician to be able to evaluate and treat the baseball pitcher using evidence-based guidelines that I use on a daily basis.

Numerous research studies discuss the adaptive changes that occur with the pitching motion followed by numerous videos to help guide the treatment process.

If you’re already a Medbridge subscriber, then you have immediate access today.

If you’re not a Medbridge member, then you can use my promo code “Lenny2018” to save up to 40% off a yearly membership.

This gets you unlimited CEU’s for 1 year and potential access to their online HEP and a lot more!

Students can also get 1 year of unlimited courses (no CEU’s) by using promo code LennySTUDENT2018 and pay only $100.

Check out my other shoulder courses as well by using the Medbridge platform…along with many other great speakers!

Hope you enjoy and good luck!

 

💥Should you Set the Scapula with your Shoulder Exercise?💥

In this video excerpt from my YouTube channel, I wanted to discuss my opinion on setting the scapula during common exercises.

I think there’s an obvious role for setting the scapula during a heavier lower body lift like a deadlift.

But for a classic upper body exercise like the Full Can (Scaption Raises) or prone T (horizontal abduction), prone Y (Prone full can), etc then I definitely want the scapula to freely move along the rib cage.

I did a quick literature search and didn’t see anything obvious that helped to guide my thoughts so most of this is anecdotal. Check out the video and comment below.

Do you coach your clients to set their scapulae before a rotator cuff workout? If so, why? If not, do you think we should reconsider?

 

6 WAYS TO USE THE LANDMINE!⁣

Great post from our own @kieferlammi at @championptp on various ways to use the landmine in your client’s workout routine.

If you don’t have one, then I’d highly recommend you try to obtain one because they are highly versatile and can be used in many stages of rehab. See Kiefer’s original post below 👏🏼

_____________

6 WAYS TO USE THE LANDMINE!⁣

The landmine attachment is a super versatile tool for loading that is traditionally known for being used for angled pressing variations. While that’s probably my most programmed use for it, it also provides benefit to a ton of other movements by placing the load and direction of force at a bit of an angle, which can help to promote a particular path of movement, like sitting back more in a squat or lunge. Here are 6 of my favorite ways to use the landmine:⁣

1️⃣1-Leg RDL⁣

2️⃣Split Stance Row⁣

3️⃣Reverse Lunge⁣

4️⃣Deadlift⁣

5️⃣Squat⁣

6️⃣Russian Twist⁣⠀

Save 25% off our OnLine Knee Seminar Course…all this week!

Expires Sunday, November 25th at midnight ET

If you want to learn more about how I treat ACL’s or the knee in general, then you can check out our all online knee seminar at www.onlinekneeseminar.com and let me know what you think.

We cover the anatomy, rehab prescription, ACL, meniscal injuries knee replacements and patellofemoral issues. Furthermore, the course covers both the non-operative and post-operative treatment.t

This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

The Week in Research Review, etc 11-12-18

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This week in research review for 11-12-18 we focused a bit more on assessment and also dabbled in some basic treatment strategies for the back and shoulder. Check out the topics below and like them or comment on Instagram to keep the conversation going…thanks all!

 

  • A quick fix for a sore low back?
  • Knee Fat Pad Testing and Diagnosis
  • How to Assess the Elbow for a Tommy John (UCL) Sprain
  • Lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers
  • Full Can or Empty Can? – by @mikereinold

 

Looking for a quick fix for a sore low back?

I’m speaking from personal experiences when I post a few of the common exercises that have helped me tremendously in the past.

I’m not saying that this is all you have to do but I do think that new onset of low back soreness, you know that tightness that you feel on either side of your spine, can be somewhat alleviated with some foam rolling and active range of motion.

I would definitely include more focal strengthening of the core like deadbugs and bird dogs, squats, deadlifts (when they’re ready), etc.

But for the purpose of this post, I think some foam rolling and motion to the area can take the edge off of someone’s soreness and get them feeling a little better. That’s my goal for many and hopefully those small gins can add up to big gains in the long run!

Do you utilize these techniques as well? If you don’t, then I suggest that you try! They’ve helped me numerous times and continue to help me when my soreness gets a bit out of control.

Tag a friend who may want to check out this post…thanks!

Thanks @corrine_evelyn for the demos!

 

Knee Fat Pad Testing and Diagnosis

Here’s an excerpt from a previous blog post where I talked about anterior knee pain fat pad irritation. Link in bio!

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

Meniscus (see my previous blog post)⠀

ITB

Osteochondral lesion

Patella tendonitis

Pes anserine bursitis

MPFL sprain

Hamstring strain

Plica syndrome

MCL/LCL

Tumor

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 this test to see if it truly is a fat pad issue.

 

How to Assess the Elbow for a Tommy John (UCL) Sprain

In this excerpt from my YouTube channel, I discuss the tests that I use to help identify an elbow sprain, typically seen in the baseball players that I treat.

In the full video, I discuss:

✅Joint Palpation

✅Seated Milking Sign

✅Prone Valgus Test (maybe a new one for you!)

✅Supine end range External Rotation with Valgus Extension Overload (VEO)

I also wrote a blog post about this topic so hopefully you’ll go to my site and read a bit more about this.

If you treat baseball players of all ages, then you should know how to diagnose a UCL sprain.

 

The influence of lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers

Laudner et al JSES 2018.

This study looked at 43 asymptomatic, #NCAA Division I and professional minor league baseball pitchers. They measured the bilateral amount of anterior-posterior lumbopelvic tilt during a single-leg stance trunk stability test.

The Level Belt Pro (Perfect Practice, Columbus, OH, USA) was used to assess anterior-posterior lumbopelvic control. The LevelBelt Pro consists of an iPod–based digital level secured to a belt using hook-and-loop fasteners.

This test has been used and studied previously by Chaudhari et al (JSCR 2011) and he showed that pitchers with less lumbopelvic control produced more walks and hits per inning than those with more control.

Also, pitchers with less lumbopelvic control have been shown to have an increased likelihood of spending more days on the disabled list than those with more control (Chaudhari et al AJSM 2014).

“The results of our study show that as lumbopelvic control of the drive leg decreases, shoulder horizontal abduction torque and elbow valgus torque increase.”

Have you tried this simple test? I will say that having the ability to detect millimeters of motion is clinically difficult.

It is good to see such a simple test utilized clinically can help aid in determining the need for more core/hip exercises for our pitchers. In all, I think it’s a safe bet to incorporate these exercises in all pitchers’ programs.

 

Full Can or Empty Can?

– by @mikereinold 

Great Post by @mikereinold on which motion is BEST to isolate the supraspinatus during arm elevation. I know you can’t isolate the supraspinatus but numerous studies have (Kelly et al 1996, Reinold et al 2004) shown that the full can (or thumb up position) is better than the empty can position.

Check it out below! 👇🏼

Full Can or Empty Can? – by @mikereinold⠀⠀
-⠀⠀
🧠 WANT TO LEARN MORE FROM ME? Head to my website MikeReinold.com, link in bio.⠀⠀
-⠀⠀
I’m still surprised after all these years that I still see the empty can exercise kicking around. I analyzed these two movements many years ago in an article in JOSPT and showed that the full can exercise (thumbs up 👍) had similar EMG of the supraspinatus with lower levels of deltoid EMG, while the empty can (thumbs down 👎) had higher levels of deltoid EMG.

Why does this matter?

Well, think about it. If you are performing this exercise you probably are trying to strengthen the rotator cuff. And if you are weak and performing an exercise with more deltoid, the ratio of cuff to deltoid will be lower and you’ll have more potential for superior humeral head migration.

Plus, let’s be honest, the empty can just hurts… It’s also a provocative test, and I don’t like to use provocative tests as exercises. 😂😂😂⠀

 

The Week in Research Review, etc 11-5-18

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The Week in Research Review, etc 11-5-18 was filled with more informative and eye-opening posts! Lots of visually stimulating posts to help clarify what exactly is going on in the hip joint with PROM. Another post that shows the suction effect from an intact hip labrum… amongst other great posts.  Just some great stuff..hope you enjoy!

 

  1. Manual Forearm Resistance Drills
  2. ACL Graft Healing Times to Maturation
  3. Hip Capsule Stress with PROM External Rotation
  4. Muscle Activation Affected by Hip Thrust Variation
  5. Hip Thrust Form by Bret Contreras
  6. Hip Joint Suction Affected by labral Status

 

 

Manual Resistance Forearm Exercises

In this post, I wanted to show you guys some of the manual resistance drills we use @championptp on our shoulder and elbow clients, especially our baseball players. We love to use these drills because we can control so many variables with each athlete and tailor it for their specific needs.

We can control the speed and tempo, the direction of forces (eccentric, concentric), and the magnitude of the forces. Plus it’s a great way to interact with our clients. It’s also a great way to feel how well they’re progressing in their programs instead of just giving them dumbbells.

I have found these manual resistance drills to be very helpful with my overhead athletes and hope you give them a try on your clients soon! Let me know what you think or tag a friend below who may like to use these drills too.

In my course that I teach around the US, I try to include these concepts so you can practice and be able to utilize these drills for your clients…thanks!

 

ACL Graft Harvesting and Healing times

In this post, I wanted to show some research studies on graft healing times and why we need to respect tissue biology.

The systematic review from AJSM 2011 looked at ‘The ‘‘Ligamentization’’ Process in Anterior Cruciate Ligament Reconstruction.’

They essentially looked at 4 different biopsy studies on BPTB and Hamstring autograft reconstructions. They concluded that maturation of the graft, as determined by mainly vascularity and cellularity, was not complete until 12 months at the earliest. The healing time even extended to 24+ months as well.

The ligamentization endpoint is defined as the time point from which no further changes are witnessed in the remodeled grafts. The surgical procedure is quite involved, as you can see in the video that I took from @drlylecain on #YouTube.

As I’m rehabbing my clients, my decision making and post-op progressions often take into account:

✔️Healing biology

✔️Graft harvesting

✔️Graft Type

✔️Bone bruise presence (often!)

✔️Other concomitant issues (meniscus, articular cartilage).

So, respect the tissue and allow natural healing to occur before you add more exercises or are concerned that they’re not making the gains you’d expect.⠀

 

 

Hip Capsular Closure: A Biomechanical Analysis of Failure Torque

Chahla et al AJSM 2016

Interesting look at tissue failure, albeit in a cadaver graft, that should help to guide the physical therapist or ATC early in the rehab process after a hip scope.

The purpose of this study was to determine the failure torques of 1-, 2-, and 3-suture constructs for hip capsular closure to resist external rotation and extension.

The 3-suture construct withstood a significantly higher torque (91.7 Nm) than the 1-suture construct (67.4 Nm) but no significant difference was found between the 2- and 3- suture construct.

The hip external rotation degree in which the capsule failed was:

✅1-suture construct: 34 degrees

✅2-suture construct: 44.3 degrees

✅3-sutures: 30.3 degrees (yes, smaller than 2-suture construct)

I think as a #PT, we need to keep this study in mind and respect the healing tissues after a hip scope.

Love when we can get this information and put it into practice, similar to RTC repairs, ACL, etc.

Obviously, this was on a cadaver where there’s no guarding, pain or muscle contraction. We still need to know that there MAY be enough tension on the capsule to create potential issues (like tissue failure).

If you treat patients after hip scopes, then I recommend you read this cadaveric study.

 

 

Barbell Hip Thrust Variations Affect Muscle Activation

COLLAZO GARCIA et al JSCR 2018

This study looked at the EMG activity of various lower body muscles while performing the hip thrust in various positions.

Their results showed that by varying the foot position into more external rotation, you can recruit the glute max and medius more than by the traditional hip thrust.⠀ …”the activity of the gluteus maximus increases significantly reaching up to 90% MVIC with only 40% of 1RM” with this hip ER variation.

Also, ‘when the distance between the feet is increased, the activity of knee flexors increases. Therefore, this is a very recommendable option to increase hamstring: quadriceps co-activation ratio.’

I like this study because it helps guide our rehab if we’re targeting a specific muscle group a bit more because of an injury or surgery.

It’s one of my go exercises for anyone with a lower body injury, especially after an ACL reconstruction. But I do use this exercise for most of my clients rehabbing from any injury, including the upper body.

It’s a great way to recruit the gluteus maximus and medius, which we know are hugely? (is that a word?) important to help produce and dissipate forces during athletic movements.

The exercise was widely researched by @bretcontreras1 and should be a staple in your rehab programs.

Check it out and add this to your go-to exercise list…thanks!

 

Hip Thrust Form

[REPOST] and a great one from @bretcontreras1 talking hip thrust form, which is perfectly coinciding with my post earlier today on variations to the hip thrust and how they affect muscle activation. Check out his original post below…highly recommended!

Teaching optimal hip thrust form is complicated. While the occasional lifter prefers and functions better staying fairly neutral in the head, neck, and spine, the vast majority of lifters do best maintaining a forward head position, which leads to ribs down and a posterior pelvic tilt.

It’s not just the forward eye gaze; the whole head has to maintain its forward position. You’re not hinging around the bench; the body mass above the bench stays relatively put, while the body mass below the bench is where the movement occurs.

The astute science geeks out there will rightfully point out that posterior pelvic tilt is associated with some lumbar flexion, and that lumbar flexion under load can be problematic. However, lumbar flexion is only dangerous when the discs are simultaneously subjected to compressive forces. With this style of hip thrust, the glutes are driving hip extension and posterior pelvic tilt, and erector spinae activation is greatly diminished. Core activation is what creates the bulk of the compressive forces, so with the erectors more “silenced,” the discs aren’t as compressed. This makes the exercise very safe. In fact, it’s safer than the “neutral” technique because as you rep to failure or go a bit too heavy, you will inevitably arch the chest and hyperextend the spine, which can lead to lower back pain. ⁣

We have 200 members at Glute Lab hip thrusting day in and day out, and there have been zero injuries to date. Considering how heavy we go, this is astounding.⠀
⁣⠀
#gluteguy #glutelab #thethrustisamust⠀

 

Hip Joint Suction and Stability

[REPOST] From @chicagosportsdoc and a very cool look at the suction within the hip joint that contributes to its stability. As the video progresses, they have simulated a labral tear that shows how easily the joint can dislocate. Once the labrum is repaired, the suction effect is recreated, and joint stability is re-established.

That’s 2 posts this week on the hip…if you want to see some awesome posts, then follow him. He just got on Instagram but his visual posts really aid in learning the mechanics of the various joints…see below!

An impressive demonstration of the powerful hip suction seal. When the hip labrum is injured, the seal is disrupted which can potentially produce microinstability. A labral reconstruction can restore the suction seal #labrum #sportsmedicine #hip #anatomy#orthopedicsurgery #medicine

 

The Week in Research Review, etc 10-29-18

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This week we started the week off with a couple shoulder posts, specifically the rotator cuff and SLAP tears. As usual, I can’t resist a good ACL paper so included that NM control program that should be in all knee patients’ programs. We ended the week with a recorded knee scope as the surgeon was mobilizing the patella. It was a very informative and fun way to see the patella. We closed the week off with an old school video of myself performing a proprioception drill for the shoulder. I recommend you read these posts and like them on Instagram. Take a look at The Week in Research Review, etc 10-29-18

 

  1. Topics on the Rotator Cuff including post-op
  2. Classifying SLAP tears
  3. Essential Components of a neuromuscular control program
  4. Live Patellar scope during mobilization
  5. Shoulder Proprioception Drill

 

 

Topics on the Rotator Cuff including post-op

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff- Jancuska et al OJSM 2018

Nice summary of systematic reviews for you guys if you treat patients after a rotator cuff surgery. I’ve been doing a pretty good literature on the topic and wanted to share some of the articles that I have found helpful.

Their conclusions:

❇️There is substantial evidence indicating that the most accurate physical examinations for diagnosing RC tears are a positive painful arc and positive ER lag test

❇️Considerable evidence showing that rehabilitation is better than no rehabilitation for non-op management of RC tears, although RC repair was shown to be superior to rehabilitation alone.⠀

❇️No evidence to support the use of injections for nonoperative management of RC tears.

❇️Double Row repair results in better outcomes and fewer re-tears than Single Row repairs, especially for tears >3 cm.

❇️Predictors of re-tears and poor postoperative outcomes:⠀

✔️older age⠀

✔️female sex⠀

✔️smoking⠀

✔️increased tear size⠀

✔️preoperative fatty infiltration⠀

✔️preoperative shoulder stiffness⠀

✔️diabetes⠀

✔️workers’ compensation claim⠀

✔️decreased preoperative muscle strength⠀

✔️concomitant procedures.

Overall, a good review of the literature on rotator cuffs and anything associated.⠀

 

Classification of SLAP Tears

If you treat patients with shoulder pain, then you may run into different labral tears of the shoulder.

This post hopes to summarize the 10 different types of #SLAP tears that are currently known.

Type 1️⃣: Fraying but intact biceps

Type 2️⃣: Superior Labrum and biceps detached from the glenoid rim

Type 3️⃣: Bucket handle tear of the superior labrum but biceps anchor attached

Type 4️⃣: Bucket handle tear of the superior labrum that extends up into the biceps tendon

Type 5️⃣: BankartTear and also a detached biceps anchor

Type 6️⃣: an unstable flap of the superior labrum with a detached biceps anchor

Type 7️⃣: Anterior superior labral tear that extends to the middle Glenohumeral ligament; Biceps anchor detached

Type 8️⃣: Superior and posterior labral tear along with detached biceps anchor

Type 9️⃣: 360° labral tear

Type 🔟: Superior labral tear along with reverse Bankart tear and a detached biceps anchor.

That’s a lot and some are pretty rare but it helps to be able to communicate effectively with the medical team or to read an operative report.⠀

 

Neuromuscular training to reduce ACL injuries in female athletes

Critical components of neuromuscular training to reduce ACL injury risk in female athletes: meta-regression analysis. Sugimoto et al BJSM 2016.

This meta-regression analysis looked at the effects of combining key components in neuromuscular training (NMT) that optimize ACL injury reduction in female athletes.

They looked at a total of 14 studies that met the inclusion criteria of the current analyses. A total of 23 544 athletes were included.

They showed that there are 4 Key components

✅14-18 years old better than other age groups

✅2x/week for 30 minutes/session

✅Balance, planks, ‘posterior chain’ and plyometrics

✅Verbal cues like ‘Land softly’ or ‘Don’t let knees cave in’

Furthermore, inclusion of 1 of the 4 components in NMT could reduce ACL injury risk by 17.2–17.7% in female athletes. A great look that really specifics what age groups would best benefit from a NMT program. Do you incorporate any of these key concepts into your programs, even 1-2 of them?

I know I try to with most of my clients, whether or not they’re returning from an ACL or not.

 

Patella mobility during a knee scope

Great video by @physionetwork looking at the patella during a knee scope. This stuff is just exciting to see (in my opinion) because it gives us a little bit of insight into what is exactly going on during a patella mobilization.

In my opinion, the PF joint is often overlooked when it comes to knee surgery and it can affect joint mechanics, quadriceps activation and patient function. You need to mobilize the patella and normalize the motion…can’t stress this enough!

Check out the post below…good stuff!

Patellar mobilization is important to avoid stiffness after surgery. In this video, you can see from an arthroscopic view that little motion outside the knee, translates into a significant motion inside the knee. Mobilization may help prevent the formation of scar tissue and allow for better biomechanics of the knee joint.

We review the latest and most clinically relevant research in physiotherapy. Click link in bio to learn more and boost your knowledge 🔗

Video by Jorge Chahla, MD, PhD – Orthopaedic Surgeon -Sports Medicine Specialist

 

 

Active Reposition Drill after a Passive Motion

Loss of proprioception after a shoulder injury has been documented numerous times in the literature and can affect long-term function.

This drill may help the rehab specialist to test proprioception by measuring the exact active position difference that the patient attains.

You can also use this drill as a treatment reproduce the exact position that you passively brought them into.

Give it a shot and see what you think…you can use this drill for any joint in which you have assessed proprioception loss.

 

The Week in Research Review, etc 10-22-18

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That was a milestone week as my Instagram account finally hit 10k followers, whatever that means! I’ve really been pushing a daily post to help other rehab professionals better simplify the research. One milestone hit but I still want to keep publishing good quality research reviews. The Week in Research Review, etc 10-22-18 included:

  1. Do baseball Pitchers really have a tight posterior capsule?
  2. ACL strain curve during the squat
  3. Does the pec minor length influence shoulder pain?
  4. What does the literature say about the EMG activity of the rotator cuff, particularly of the supraspinatus, with ROM
  5. Classification of Meniscus Tears and Osteoarthritis

Do baseball Pitchers really have a tight posterior capsule?

My guess is emphatically no based on what I see on a daily basis, the general anatomy of the glenohumeral joint and some research studies.

Anatomy
1️⃣When I stretch a baseball pitcher’s shoulder, it is usually very mobile. I find this in both symptomatic and asymptomatic individuals.

If I try to assess their posterior capsule with a joint play technique, I can often translate the humeral head pretty far over the glenoid rim. Sometimes, I can even sublux the humerus!

2️⃣Anatomically, the posterior capsule is relatively thin compared to the anterior and inferior capsule (see the post).

In general, that capsule is thinner probably because of the glenoid position that is not strictly in the frontal plane.
Because of that, it is theorized that the capsule evolved to have less of a role in stabilizing the humerus.

3️⃣There are a couple of research studies that have specifically looked at baseball pitchers to determine their humeral head translation.

Borsa et al AJSM 2005 reported that posterior translation was actually greater than anterior translation in both the dominant and non-dominant shoulders of professional baseball pitchers.

Crawford et al J Ath Train 2006 found no significant differences in posterior glenohumeral laxity and stiffness between the throwing and non-throwing shoulders.

I understand why the theory exists and think it could be plausible but just don’t think it’s truly responsible for what we think.

We just don’t think we can stretch the posterior capsule with any joint mobilization or contract-relax procedure, including a sleeper stretch. I often giggle at all of those MD prescriptions that say ‘#GIRD, posterior capsule tightness’. I just treat what I find on my examination and ignore the script.

ACL strain curve during the squat

As you can see, the strain curve from the Beynnon et al study is very similar to the strain curve during resisted knee extension in a full ROM (90-0).

We argue all of the time about anterior tibial translation during the open chain exercises but often ignore the other side of the story.

The strain on the ligament is barely 4%, which is in line with many functional activities like walking, descending steps, etc. The argument that we’re going to stretch the ligament out just has not been proven in the literature.

I wanted to show the closed chain strain curve so you could compare it to the open chain strain curve. I know the n=8 argument is present but we really don’t have much more data on the ligament in vivo that shows the true effects of open vs closed chain exercises on the ACL.

Again, as @barbhoogie mentioned, you need to monitor the PF joint, especially after a patella tendon autograft but as long as we’re not aggravating that joint, then I begin early 90-0’s and mini squats as tolerated.

Do you agree with this? Do you prevent squats early on during the ACL rehab process? If you don’t, then why do you hold back on full active knee extension exercises?

Does the pec minor length influence shoulder pain

Does the pectoralis minor length influence acromiohumeral distance, shoulder pain-function, and range of movement? Navarro-Ledesma et al Phys Ther Sport Aug 2018.

Their conclusion: Pectoralis minor length is not a distinguishing factor in shoulder⠀
assessment when a chronic condition exists, and it seems not to play a key role in pain perception and ROM.

54 participants with chronic shoulder pain in their dominant arm were recruited, as well as fifty-four participants with a pain-free shoulder.

The resting muscle length is measured between the caudal edge of the 4th rib to the inferomedial aspect of the coracoid process with a sliding caliper.

The acromiohumeral distance (AHD) was defined as the shortest linear distance between the most inferior aspect of the acromion and the adjacent humeral head, measured by ultrasound.

An interesting study that used an asymptomatic control group along with the contralateral shoulder of the symptomatic subject. A pretty clean study that is very interesting. I’m not going to say that the pec minor doesn’t play a role in shoulder pain but maybe its role is not as prominent as we think.

What do you think? Do you find pec minor length has a substantial role in your patients with shoulder pain?⠀

EMG of the rotator cuff during rehab exercises

What does the literature say about the EMG activity of the rotator cuff, particularly of the supraspinatus, with ROM?

Many PT’s and doctors are uncertain when to safely begin physical therapy after a shoulder surgery, particularly after a rotator cuff repair. In my 15+ years as a PT, I’ve seen docs begin PT post-op day 1 or wait as long as 6 weeks (which drives me bonkers!!)

In this snippet that I’ve taken from an upcoming blog post at LennyMacrina.com. I discuss the research that’s helping to guide best practice, in particular, the research that looks at PROM and AAROM and how much EMG activity is actually going on in the supraspinatus with each movement.

As you can see in the video, there’s minimal supraspinatus activity (<20% is considered minimal) for all motions. Keep in mind, many of these studies are done on healthy individuals but who in their right mind would volunteer their newly repaired RTC repair to have fine-wire EMG done on them?

So, I can only draw my conclusions from a limited body of evidence and my own anecdotal evidence (which consists of 12+ years of immediate PROM POD 1). Many still think it’s safe to get a RTC repair patient’s shoulder moving early for many reasons that I will describe in this blog post.

I just wanted to get this early point out there to get another discussion going. I think our patients can do much better after a RTC repair and this is one of the reasons.

Do you agree? Do you advocate for early PROM after a RTC repair, especially a small-medium repair?

Classification of Meniscus Tears and Osteoarthritis

Great post by @physicaltherapyresearch talking about the various types of meniscus tears. Nice visual & description of each type and the incidence of OA. Take a look! 👇🏼
_______________
Meniscus Tears and Osteoarthritis

💡

Prevalence of meniscal tears is estimated as ~24-31% of some populations, increasing with age and ranging from 19% in women aged 50–59 years to 56% among men between 70 and 90 years and is markedly higher in established OA subjects.
💡

Medial meniscus and/or the posterior horn tears make up 66% of cases, with horizontal and complex tears being the most common.
💡

Most subjects with a meniscal tear are asymptomatic.
💡

Regardless of morphologic type, meniscal tears are strongly associated with OA cross-sectionally and predict OA longitudinally and are considered to be part of the spectrum of early or pre-radiographic disease

📝📝📝

TEAR TYPES INFO:

Often enough, meniscal tear types are categorized into varying groups for comparison rather than separately compared to each other.
📝

There is a striking lack of data on the relevance of different morphologic types of meniscal tears in OA.

📝

Horizontal and complex tears are common findings in knees with OA

📝

Posterior radial tears of the medial meniscus are associated with a high degree of cartilage loss and meniscal extrusion, and appear to be a highly relevant event in the progression of OA in the knee. 📝

Lateral meniscus radial tears affect younger individuals and are considered post-traumatic.

📝
Despite their suggested high relevance, radial tears are more commonly misdiagnosed on MRI than any other type of tear.

📝

While medial meniscus posterior root tears are of “radial” morphology, there is growing interest in regarding them as a separate entity.
📝

Longitudinal and bucket handle tears affect younger individuals and are highly associated with ACL injuries, favoring a traumatic etiology.
📝

MRI is important to detect and locate a possible displaced tear.
📝

Further epidemiologic studies should focus on the morphology of specific meniscal tears to better understand their relevance in the genesis and progression of knee OA.
📚📚📚
SOURCE:
Jarraya et al. 2017 Semin Arthritis Rheum

The Week in Research Review, etc 10-15-18

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This week I posted a lot of research and thoughts on shoulder and knee rehab, particularly after an ACL injury. I also shared some others posts that really complimented my posts so there’s some bonus reading to do too. Hope The Physical Therapy Week in Research Review helps your Monday patients and beyond! Take a read and share with your friends!

  1. Co-morbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse, and cardiometabolic conditions. Rhon et al BJSM 2018.⠀
  2. Range of Extension Correlates with Posterior Capsule Length after Knee Remobilization Zhou et al Med Sci Sports Exerc 2018⠀
  3. Sidelying External Rotation- The 1 exercise in all upper body programs
  4. @dr.jacob.harden talking Infraspinatus release.
  5. Do you account for Bone Bruises after an ACL
  6.  @cbutlersportspton bone bruises and the specifics
  7. When is it safe to initiate full AROM knee extension after an ACL-PTG autograft
  8. @mickhughes.physio on when it MAY be safe to initiate full knee extension from 90-0 after an ACL reconstruction.

 

 

Comorbidities after Hip Arthroscopy

Co-morbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions. Rhon et al BJSM 2018.

This is an interesting study on 1870 mainly US Military personnel between 2004-13 (~33% were not active duty).

Relative to baseline, cases of:

❇️mental health disorders rose 84%

❇️chronic pain diagnoses increased by 166%

❇️substance abuse disorders rose 57%

❇️cardiovascular disorders rose by 71%

❇️metabolic syndrome cases rose by 85.9%

❇️systemic arthropathy rose 132%

❇️sleep disorders rose 111%

The comorbidity with the greatest increase of new cases was that of mental health disorders (26% of the entire cohort). Age and socioeconomic status had significant associations on outcomes as well.

Just an eye-opening study that followed each subject 2 years after their respective surgeries. One giant variable that jumped out at me was that they used mainly military personnel only as the subjects.

We certainly can’t extrapolate on non-military personnel but need to keep this study in mind for others treating a similar cohort. Did the surgery cause these disorders? Absolutely not! No causation can be associated and that is very important!

What do you think about this study and how mainly military personnel and civilians that were tracked ending up developing many chronic disorders? I say it is very troubling! Let’s chat…and remember, this is not a causation study but just a reminder to educate and monitor your patients’ well-being after a surgery.

 

Posterior Capsule Limits Knee Extension after an ACL

Range of Extension Correlates with Posterior Capsule Length after Knee Remobilization Zhou et al Med Sci Sports Exerc 2018

This study is a confirmation bias for me because it showed that the knee’s posterior capsule limits extension after immobilization (in rats!) This is why I’m a huge proponent of low load long duration stretching of most joints when they begin to get stiff.

It seems as if the prolonged stretching is needed to regain collagen length and return the ROM. I know it’s in rats so calm down…but we need to get the data from somewhere.

Take it with a grain of salt but know that LLLD is going to be the best mode to return ROM (and not just hamstring stretching).⠀
.⠀
Do you agree? Do you treat rats with stiff knees? Then this study was created for you!

 

The Best Exercise for the Rotator Cuff

❗️Sidelying External Rotation- The 1 exercise in all upper body programs❗️

I really think this exercise should be in everyone’s program, whether going through rehab for a painful shoulder or a high level, healthy powerlifter. The role of the infraspinatus and other rotator cuff muscles is crucial to maintaining humeral head stability.

Sidelying external rotation has been shown to elicit the highest amount of EMG activity for the infraspinatus so I give this exercise to everyone, once there are no precautions for tissue healing. The infraspinatus and subscapularis (front rotator cuff muscle) are force couples that help to stabilize the humerus within the glenoid. Weakness of the infraspinatus may affect this force couple and create an inefficient movement within the joint.

My goal for all of my clients is to create an efficient movement that allows them to work at their highest level. The infraspinatus is a critical muscle of the shoulder complex so MOST of my programs include this exercise.

 

Myofascial Release of the Infraspinatus

Great post by @dr.jacob.harden talking Infraspinatus release. Perfect timing for my earlier post today looking at my go to exercise for the shoulder joint. Check his post out below!👉🏻 🔴 𝙃𝙊𝙒 𝙏𝙊 𝙍𝙀𝙇𝙀𝘼𝙎𝙀 𝙄𝙉𝙁𝙍𝘼𝙎𝙋𝙄𝙉𝘼𝙏𝙐𝙎

Coming at ya with a little #throwbackthursday since I’m about to jump on a plane across the pond to London. So we’re looking at how to do a pin and stretch for the rotator cuff, specifically the infraspinatus. The infraspinatus is the main external rotator of your shoulder, so it’s that muscle we see everyone working when they swing there 5 pound plates side to side in their warm-ups. (Side note: if you do that, please use a band or do it sidelying. Standing with plates does nothing but work the bicep.👍)

This can also help with some those little hypersensitive areas in the back of the shoulder. If you’re feeling those spots or having shoulder pain or just want to improve your internal rotation a bit, this release can help.

𝗛𝗲𝗿𝗲’𝘀 𝗵𝗼𝘄 𝘁𝗼 𝗱𝗼 𝗶𝘁:

🔹️Ball placement is below the spine of the scapula.

🔹️Internally rotate, flex, and adduct the shoulder

🔹️Work back and forth for a minute or so

 

Bone Bruises after an ACL

Do you even consider a bone bruise after an ACL when progressing your patients? I know I certainly do and one of the major reasons why I have gone a bit slower with my latter stage progression, especially to impact activities like plyometrics and running.

There are a few studies that have shown the presence of a bone bruise after an ACL injury but we are not 100% certain this eventually leads to joint degradation.

Hanypsiak et al included 44 patients (82%) who underwent unilateral ACLR without multi-ligament involvement. Thirty-six (82%) patients had a bone bruise on index MRI. Potter et al reported all patients in their cohort sustained chondral damage at the time of injury.

Faber et al examined 23 patients with occult osteochondral lesion (bone bruise) who underwent ACLR. They found that at 6-year follow-up, a significant number of patients had evidence of cartilage thinning adjacent to the site of the initial osteochondral lesion (13/23 patients).

So as you can see, bone bruises are more common than most people think. This may be one reason why osteoarthritis rates are much higher in ACL reconstructed knees.

Additional factors, such as cartilage and meniscus injury, associated with ACL rupture may play an important role in subsequent outcomes following surgical reconstruction independent of a bone bruise.

Do you consider a bone bruise when progressing your patients back from a knee injury like an ACL reconstruction?

 

Types of Bone Bruises after an ACL Injury

@cbutlersportspton bone bruises, which fits perfectly with my post earlier today. He talks about the 3 different types of common bone bruises…check it out below!

❗️What is a Bone Bruise❗️We often hear that one of our Fantasy Football players has a Bone Bruise and may be out for a few weeks.

It sounds like something that an NFL athlete should be able to tough out, right?

Here’s why you may need to put in a backup for a few games.

A bone bruise occurs when several trabeculae in the bone are broken, whereas a fracture occurs when all the trabeculae in one area have broken. Trabecular bone is also known as spongy bone.

—-Three Types of Bone Bruises—-⠀
1️⃣Subperiosteal hematoma: A bruise that occurs due to an impact on the periosteum that leads to pooling of blood in the region.⠀
2️⃣Intraosseous Bruising: The bruise occurs in the bone marrow and is due to high impact stress on the bone.⠀
3️⃣Subchondral Bruise: This bruise is bleeding between cartilage and bone such as in a joint.

—-Symptoms of Bone Bruises—-

•Pain and tenderness in the region of injury

•Swelling in the region of injury

•Skin discoloration in the region of injury

Bone bruises often occur with joint injuries, such as ankle sprains and ACL tears, therefore a bone bruise can also coincide with stiffness and swelling in the joint.⠀

 

When is it safe to initiate full AROM knee extension after an ACL-PTG autograft?

I posted this video in my the other day and had a ton of people message me about the exercise.

Most people wanted to know how far out of surgery the patient was and when I felt it was safe to begin full, active knee extension after an ACL.

I’ve always been relatively conservative with my rehab (at least I think so) but I wanted to dig a little deeper. I recently saw a post by @mickhughes.physio and he was talking about the Fukuda et al study from 2013.

The study looked at 90-40 knee extensions and ‘ACLR patients can perform 3×10 at a 70% 1RM load through a restricted 45-90deg ROM between weeks 4-12 post-op, and then the same load full ROM from 12 weeks post-op. ‘

It made me dive a bit deeper and I went to my trusty Beynnon et al AJSM studies from the late 90’s. You can see the strain on the ACL decreases as we approach 40 degrees and stays low out to 90 degrees…but is 3-4% strain on the ligament significant?

If you look at the study (yes, it’s only on 8 subjects) you’ll see a similar strain curve for closed chain exercises as well…but we do mini squats immediately after surgery without 2nd guessing!

In 2011, Beynnon et al AJSM showed that an accelerated program that initiated full resisted knee extension (90-0) at 4 weeks showed similar knee laxity throughout the study. The other group initiated full resisted knee extension at 12 weeks. Also, those who underwent accelerated rehabilitation experienced a significant improvement in thigh muscle strength at the 3-month follow-up.

So, what do we do with this data? I have begun to do full, resisted knee extensions with my patients between 4-6 weeks post-op, as long as it’s a patella tendon autograft. For allografts or HS autografts, I tend to delay it a bit longer because of the soft tissue healing that is delayed.

What do you think? When do you initiate full AROM after an ACL? Do you know of a study that definitively says the strain on the ACL graft is detrimental to the healing ligament?

 

How much Resistance Should we Recommend Open Chain Exercises After an ACL

This is the post from @mickhughes.physio that made me dive a bit deeper into the research on when it MAY be safe to initiate full knee extension from 90-0 after an ACL reconstruction. Check out his post below! ⠀
____________________

So if we can safely perform OKC exercises (knee extensions) as part of ACLR rehab; how heavy can lift?⠀
*⠀
*

This is a question I often get asked. Based on the work by Fukuda et al (2013), ACLR patients can perform 3×10 at a 70% 1RM load through a restricted 45-90deg ROM between weeks 4-12 post-op, and then the same load full ROM from 12 weeks post-op. *⠀
*⠀

From then you can progressively load as per what can be tolerated. Usually the first sign that the knee is unhappy with the load is that the underneath the kneecap will be sore/painful. That’s a sign you need to back the load off a little so the exercise is felt in the quads only. *

If you’re still unsure about OKC exercises (knee extensions) during ACLR rehab read my blog by clicking on the link in my bio ⠀
#ACL #Physio #Knee #Rehab

 

The Week in Research Review, etc 10-8-18

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Hey all, the Week in Research Review, etc 10-8-18 has some great articles that really got some good discussion going. I highly recommend reading each post and chiming in. Looking forward to the new comments and discussions!

  1. PT Continuity of care
  2. Fatigue effects on ACL tears
  3. Measuring IR in a baseball pitcher
  4. Lever sign to diagnose an ACL tear
  5. Immediate or delayed ROM after a rotator cuff repair

 

Longitudinal continuity of care is associated with high patient satisfaction with physical therapy. Beattie et al Phys Ther 2005.

I saw a FB post the other day and it reminded me of a study that I had seen about continuity of care and physical therapy.⠀

This study looked to provide ‘preliminary information regarding the association between longitudinal continuity and reports of patient satisfaction with physical therapy outpatient care.’

What they showed was “Subjects who received their entire course of outpatient physical therapy from only 1 provider were approximately 3x more likely to report complete satisfaction with care than those who received care from more than 1 provider.”

All too often, I hear my current clients talk about their past PT sessions and often complain about seeing a tech/aide or a different PT for each session.

I always thought that was such a wrong concept for the client. Throughout my career, I have strived to connect with each client in an attempt to help them overcome an injury.

We did this at @championsportsm in Birmingham and we do it now in Boston at @championptp.

It is such a game changer for the client when they have complete faith in their treatment, can connect with their PT and their PT can connect with them.

Just my little soapbox rant on continuity of care. Are you able to maintain a good continuity of care with your patients or are you constantly sharing and/or just doing evals?

Tag a friend or colleague who may benefit from this post…thanks!⠀

 

Fatigue affects quality of movement more in ACL-reconstructed soccer players than in healthy soccer players. van Melick et al Knee Surgery, Sports Traumatology, Arthroscopy 2018.

This study looked at the influence of neuromuscular fatigue on both movement quantity and quality in fully-rehabilitated soccer players after ACLR and to compare them with healthy soccer players.

They showed ACL-reconstructed soccer players had a significantly decreased performance when comparing the non-fatigued with the fatigued state.

For movement quantity, they used a single-leg vertical jump, a single-leg hop for distance, and a single-leg side hop.

For movement quality, they used a double-leg countermovement jump with frontal and sagittal plane video analyses. The Borg Rating of Perceived Exertion (RPE) scale was used to measure fatigue after a soccer-specific field training session. In addition to soccer-specific drills, exercises focussing on speed, stability, and coordination were included in this session.

Seems like a pretty neat study that may help to show us that the fatigued state influences quality of movements and not the quantity of movements. I know Tim Hewett has said that there’s no evidence that fatigue influences ACL tears but maybe this study is the 1st step.

Do you agree with this study? Anecdotally it makes sense but there’s little evidence to support the notions.⠀

⠀

Measuring internal rotation in the baseball player

If you treat baseball pitchers, then you should have a good understanding of how to measure internal rotation of the shoulder joint.

Measuring internal rotation of the shoulder is one part of the equation when obtaining total rotational range of motion (TROM). Total rotational range motion is the sum of external rotation plus internal rotation. I use this equation weekly, if not daily when assessing my baseball players’ shoulders.

In a study in 2009 Sports Health Journal titled “Glenohumeral internal rotation measurements differ depending on stabilization techniques”, we looked at 3 different ways to measure IR. We determined that the scapula stabilized method had the best intra-rater reliability.

We also felt this was the best method to measure pure internal rotation of the glenohumeral joint.

Is this how you measure IR in your baseball pitchers? Do you consider TROM when making treatment recommendations?

Let’s talk it out and discuss the concept of TROM and how to measure it.

 

Accuracy of the Lever Sign to Diagnose Anterior Cruciate Ligament Tear: A Systematic Review with Meta-Analysis. Reiman et al IJSPT Oct 2018

This study was a systematic review with meta-analysis that hoped to summarize the diagnostic accuracy of the Lever sign for use during assessment of the knee for an ACL tear.

They showed that based on limited evidence, the Lever sign can moderately change posttest probability to rule in an ACL tear.

I’m a bit surprised by the limited studies because I’ve had a more difficult time getting consistent results compared to the Lachmans test (definitely my go-to!).

For those not familiar with the Lever test, it was 1st published by Dr Lelli in Knee Surg Sports Traumatol Arthrosc. 2016.

From the review, ‘The test requires the evaluator to place their fist under the calf muscle to create a “fulcrum” extending the knee while applying a moderate downward force to the distal part of the femur.

In an intact knee, the ACL completes a lever mechanism, making the heel rise in response to the force applied to the femur. In an ACL-deficient knee, the heel does not rise indicating a positive Lever sign.’ I have personally struggled to get consistent accuracy using the test. My results have been inconsistent with MRI results.

I’ve also struggled to do the test on a plinth that has padding and often have patients lie on a firm surface like the floor (which is very weird) in order to get a better test result.

Some people are freaked out by the method of the test. The clinician has to apply force to the knee in order to create the fulcrum. Many have not liked that force applied to the knee.

In general, this is not my go-to for a suspicious ACL tear. I have tried and still ty to use it but my results have been less than stellar.

Have you used this test for an ACL tear? Do you like it to supplement your Lachmans?

 

Should we delay PROM after a rotator cuff repair?

It seems as if we’re all over the place, which usually says the research is not cut and dry. There are so many factors that are considered when trying to figure out the best time to initiate motion.

I’m not talking active ROM or strengthening…I”m talking about passive ROM by a rehab specialist like a #PT, #OTor #ATC. Obviously, the docs weigh in heavily with this decision. I feel as if patients are restricted for the wrong reasons and could potentially begin PT earlier than we often see.

This is going to be a beast of a blog post and may alter my thinking, we’ll see.

As of now, I fully embrace immediate PROM for most post-op rotator cuff repairs, including Large and Massive repairs.

For revisions, we may need to think it through but I still feel as if most benefit from early PROM. We did it for years and with very good results during my time in Birmingham but feel as if maybe the pendulum is swinging in the conservative direction (for the wrong reasons).

What do you guys do? Do you have any input with your docs and can influence their rehab decisions? Let’s talk it out now and get prepped for my blog release in the coming days, weeks, months…whenever I can make it the best!⠀

 

The Week in Research Review, etc 10-1-18

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Another week of some great discussions and learning opportunities. The Week in Research Review included:

  • Risk Factors for Patellofemoral pain
  • Shoulder ROM and elbow injuries
  • Rotator Cuff Exercises
  • Eccentric or Concentric exercise for Tendinopathy
  • Hamstrings Protect the ACL
  • Stretching the Shoulder in the Overhead Athlete

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Risk factors for patellofemoral pain: a systematic review and meta-analysis Neal et al BJSM 2018.

This systematic review and meta-analysis of 18 studies involved 4818 participants, of whom 483 developed patellofemoral pain syndrome (PFPS).

First off, PFPS is a wastebasket term that basically tells the client that they have knee pain…that’s it.

My 1st job is to educate the client about this fancy term because they often come in confused and wanting more information.

I use a good subjective exam to have the patient help me narrow in on a potential cause so I can answer the question ‘why’.

My clinical exam will attempt to diagnose the particular culprit…whether it’s mechanical, overuse or something else.

Back to the study…it showed that in patients with PFPS, quadriceps weakness in military recruits and higher hip strength in adolescents were risk factors for PFP.

Not surprised by the quadriceps weakness but kinda surprised by the hip weakness!

The same authors showed this in JOSPT 2012 Lankhorst et al that weaker knee extension strength, expressed by peak torque, appears to be a risk factor for PFPS.

Not sure what to do with the hip strength as a risk factor in adolescents but maybe it becomes a biomechanical issue if the hips are stronger than the quadriceps, relatively.

Do you guys see this out there as well? The key, as usual, is to strengthen the quadriceps!

I would also say activity modification that is causing the quad weakness (overuse) and a progressive return to their activity.

Chime in and let’s talk this out…thanks!⠀

 

Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: a prospective study. @wilk_Kevin, Macrina et al AJSM 2014.

In this paper, we looked to determine whether decreased ROM of the throwing shoulder is correlated with the onset of elbow injuries in professional baseball pitchers.

This one took years to get all of the data collected through multiple spring training trips to the @raysbaseball facilities.

In the end, we were able to show that: ⚾️pitchers with deficits of >5° in total rotation in their throwing shoulders had a 2.6x greater risk for injury.

⚾️Pitchers with deficit of ≥ 5° in flexion of the throwing shoulder had a 2.8x greater risk for injury.

These findings have guided our evaluation and treatment strategies at @championptp.

We hypothesize that loss of flexion may be a result of some soft tissue limitation of the lats, teres, pecs and other muscles.

We focus much of our attention on these muscle groups during our arm care to help regain the flexion and may even help gain back some of the ER in those that are tighter than normal…whatever that means.

After soft tissue work, we look to work on dynamic stability and strength in the newly gained ROM.
Do you use these similar concepts with your baseball pitchers too? Tag a friend who may be interested in this study…thanks!⠀

 

Rotator Cuff Exercises

In this post, I wanted to discuss my go-to exercises for the shoulder when someone presents with an injury or pain.

Of course, my exam TRIES to determine the tissue involved but most of our clinical exam tests cannot pinpoint the exact pain generator and pathological tissue.

With that, I have certain exercises that I think, through the available EMG data, are the best to help regain strength and confidence prior to beginning their return to sport (or life) activities.

Numerous studies have looked at the EMG during these specific motions and have determined that the supraspinatus and infraspinatus have higher relative levels compared to other positions, say the full can vs empty can debate, for example.

Take a look at these classic studies to help guide your programs:⠀

❇️Blackburn et al JAT 1990

❇️Townsend et al AJSM 1991

❇️Reinold et al JOSPT 2002

❇️Reinold et al JAT 2007

❇️Kelly et al AJSM 1996

❇️Worrell et al Med Sci Sports Exerc 1992

❇️Jobe et al 1982

❇️Decker et al AJSM 2003

These papers have provided the foundation for today’s shoulder programs and are some that I discuss during my Biomechanics lectures that I give when teaching my course.

Are you familiar with these papers and do you keep them in mind when building your shoulder programs for your clients?

Tag a colleague or friend that may want to see this post…thanks!⠀

 

Eccentric or Concentric Exercises for the Treatment of Tendinopathies? Couppe et al JOSPT Nov 2015

Interesting clinical commentary from a few years ago talking about tendinopathy treatments.

Most PT’s and ATC’s generally talk about eccentric loading of tendons to help treat suspected tendon pain.

In this review, they discuss the potential mechanisms that may aid in helping people suffering from tendon pain.

I found this statement very interesting:

👉🏼”There is little evidence for isolating the eccentric component of a loading-based regime.

👉🏼The basic mechanisms that are likely to influence tendon adaptations appear to be related mainly to tendon load/strain magnitude and duration, and there is no theoretical basis for greater tendon loads in eccentric exercises at a given force (body weight or external load).” 🤯

As always, it makes me think that as specific as we think we are with some of our exercises, maybe just putting any strain through the muscle-tendon unit is good enough.

Have you guys read this review? What do you think? is this similar to what you see in your practice?

Tag a friend who may want to read or comment on this post…thanks!⠀

 

𝐇𝐚𝐦𝐬𝐭𝐫𝐢𝐧𝐠𝐬 & 𝐓𝐡𝐞 𝐀𝐂𝐋

Great post by @rehabscience talking about the influence of the hamstrings on the #ACL. A big focus of my rehab for my patients that have had an ACL reconstruction involves building hamstring strength.

Check out his original post below!

💥𝐇𝐚𝐦𝐬𝐭𝐫𝐢𝐧𝐠𝐬 & 𝐓𝐡𝐞 𝐀𝐂𝐋💥
———–
📌The anterior cruciate ligament (ACL) is an extremely important ligament in terms of overall knee integrity and stability. Specifically, the ACL connects the femur (thigh bone) to the tibia (shin bone) and runs at an oblique angle from the posterior aspect of the femur to the anterior aspect of the tibia. Due to this arrangement, the ACL is responsible for preventing anterior translation of the tibia or posterior translation of the femur.
–
🔎Now, many of us are aware of the importance of the quadriceps to knee health, but, often times, the hamstrings get neglected. The hamstrings run along the posterior (backside) of the thigh and insert onto the posterior surfaces of the tibia and fibula (shin bones).

When contracting, the hamstrings work to bend the knee, but also pull the tibia posteriorly. In this way, the hamstrings can serve as a dynamic protector of the ACL by limiting excessive anterior displacement of the tibia and strain on the ligament.
–
✅If you are looking to reduce your risk of ACL injury or recovering from an ACL reconstruction, don’t forget to include hamstring work in your strength training program as this group has an instrumental role in protecting the ACL.
–
⬅️Swipe left to see several exercises from myself, @jasonbombard, @zerenpt and @strengthcoachtherapy that can be incorporated to increase hamstring strength.

 

⚾️Stretching the Overhead Athlete ⚾️

In this post, I wanted to give a glimpse into the stretching routine I use on some of my OH athletes before and after a workout, bullpen or a game.

I like to stretch the shoulder into external rotation to make sure the athlete can maintain that important ROM, especially to keep that layback or late cocking position.

I also like to work on horizontal adduction with the lateral border of the scapula stabilized. It’s important that the athlete feels the stretch in the back of the shoulder and nowhere close to the front of the shoulder.

This is the lone reason why I have gone away from the sleeper stretch and focus on horizontal adduction.

I also stretch out the forearm flexors by extending the elbow/wrist and all of the fingers, including the thumb (don’t forget about the thumb!)

I also like to stretch the shoulder joint into flexion by pinning down the scapula and hope I’m somewhere on the lats and/or subscapularis to be able to stretch these muscles out and improve that overhead position.

Remember, in 2014 we showed a loss of flexion increased the risk of medial elbow injuries by almost 3x.
I like to repeat the process a few times until I feel like we maximized the amount of new ROM.⠀
.⠀
At the same time, we’re chatting about the session, how it went, what’s to come, how their fantasy football team is doing, etc.

It’s my way to connect with each client before and after they have a session with me. I feel this is very important and often overlooked by other PT’s.

Do you have any other stretches you like to do? Tag a friend who may want to check out this video…thanks!⠀

 

The Week in Research Review, etc 9-24-18

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Hey everyone, another great week of rehab-related posts that brought a lot of topics together. The week in research review for 9-24-18 involved:

  • Blood Flow Restricted Resistance study
  • RTP following an ACL
  • Prevalence of knee osteoarthritis in pain-free people
  • Training your core
  • Dosing Low load Long Duration
  • Using Boditrak during the deadlift

 

Blood Flow Restricted Resistance Exercise as a Post-Orthopedic Surgery Rehabilitation Modality: A Review of Venous Thromboembolism Risk JOSPT Bond et al 2018.

This paper is more of a review of the literature (so be cautious) but raises some important questions and thoughts about #BFR usage in our typical orthopaedic setting.

They talk about important decisions and concepts to be made including precautions, contraindications, and dosage.

They also admit that there are no universally agreed upon standards indicating which post-surgical orthopedic patients may perform BFR safely.

They also list close to 40 different precautions or contraindications including:⠀
❇️Age >40 yr⠀

❇️Creatine Supplement Use ⠀

❇️Diabetes⠀

❇️General/Local Infection ⠀

❇️Hypertension⠀

❇️Immobility >48 hr in the Past Month⠀

❇️Open or Unhealed Soft Tissue Injuries ⠀

❇️Amongst many others

Seems like a pretty strict list but curious to hear what others are using to determine if their client is appropriate for BFR resistance training.

💪🏼Thanks @kieferlammi for the swole session!

Let’s discuss below… tag a colleague who may be interested in discussing…thanks!

 

Return to Play after ACL

I posted this the other day on #Twitter because I keep hearing people talk about the failure rates after an ACL.

I feel like 1 major reason why people are failing within the 1st 1-2 years after returning is that they get back on the field with residual weakness.

When the patient’s insurance runs out, they workout on their own or often seek out a personal trainer to help them.

I feel we as PT’s can do a much better job at showing our value to our patients by keeping them under our care an progressing them back to their sport.

If we don’t have the facilities to do this, then we must work with others in our region to help our clients get the best care possible.

At @championptp, we often get referrals from area clinicians asking to take over their client’s care and advance them back to their sport. I definitely respect that clinician for recognizing their care may not be the best for the client at that time in the rehab process.

Do you utilize clinicians in your area in these situations? Do you think we could improve our ACL outcomes if we did this more?

Let’s discuss this below and make sure we have a plan in place when that 2-3 month rehab phase approaches. Tag a friend who may benefit from this post…thanks!⠀⠀

 

Prevalence of knee osteoarthritis features on MRI in asymptomatic uninjured adults: a systematic review and meta-analysis Culvenor BJSM 2018

This paper ‘performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees.

They basically looked to determine the normal changes in the knee that may be diagnosed on an MRI in people less than and greater than 40 years of age.

The information may help clinicians educate their patients prior to getting an MRI.

Overall pooled date included:⠀
Cartilage defects was 24%⠀
Meniscal tears was 10%⠀
Bone marrow lesions 18% ⠀
Osteophytes 25%⠀

Cartilage defect <40 years 11%⠀
Cartilage defect ≥40 years 43%⠀
Meniscal tear <40 years 4% (seems low to me)⠀
Meniscal tear ≥40 years 19%⠀

Interesting stuff that you need to store in our mental database for future clients.

What do you think of this data? Will it help you in your decisions with your clients?

Tag a friend or colleague who may benefit from this information…thanks!⠀

 

4 WAYS YOU SHOULD BE TRAINING YOUR CORE

Great post by our strength coach @kieferlammi discussing the 4 ways to train your ‘core’. Simple yet a great view of the concepts needed to best address a client’s weaknesses. Give him a follow and see his original post below. @championptp

There are a million different exercises to train your abs/core/trunk/whateveryouwanttocallit. Regardless of which you choose, in my mind there are 4 staple ways that I think belong in every training program:

⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀
1️⃣Anti-Extension – These consist mainly of plank variations, Rollouts, Fallouts, etc.

2️⃣Anti-Rotation – The anti-rotation press or “Pallof Press” is the most popular of this category and can be done from a variety of stances with a variety of tools.

3️⃣Anti-Lateral Flexion – Side planks and unilateral load carries are king here, but this would include anything resisting side bend.

4️⃣Anti-Flexion – Loaded carries and Deadlifts are the top two in my mind, but anything where you have to work to avoid rounding forward, will do.

What are your staples? Anything I’m missing? Disagree? Comment below!

 

LLLD DOSING

What dosing should you prescribe your patient with a stiff joint when using low load long duration stretching? 🤔

That’s the million dollar question and very little is known.

The one paper that I’m aware of is more of a concepts paper but has been the guidance for my LLLD dosing.

McClure et al talk about 60 minutes per day of total end range of motion time or TERT.

Basically, I tell my clients to apply some form of over-pressure 4x per day for 15 minutes each session. I’ll sometimes do 3x 20 minutes/day if they don’t have the time at work or school.

It allows them to moderately stress the tissue but not take up too much of their time during the day.

The key to this form of stretching (we think) is to elongate the tightened collagen that is limiting the posterior capsule of the knee… see Zhou et al 2018 MSSE ‘Range of Extension Correlates with Posterior Capsule Length after Knee Remobilization.’

Check out this paper and consider this dosing as the basis for your future clients. Do you have any dosing schedules that you use or any research that specifically talk about this?

Let’s talk it out and hopefully help you dose your patients who are tight after knee or elbow surgery…thanks!⠀

 

 

Using Boditrak during the deadlift

This video was recently taken of my #ACL patient who is ~ 12 weeks s/p L ACL reconstruction with a patella tendon autograft and a medial meniscus repair.

I took this video (it’s a mirror image so don’t get confused) to analyze her weight distribution between the involved leg (Left) and the uninvolved leg (right).

As you can see, she spends a lot of time on the front part of her foot throughout much of the deadlift and has her weight shifted to the uninvolved side during her initial pull.

As she ascends up and reaches the max pull position, she is able to redistribute her weight more evenly between each side but continues to keep her weight more toward her toes on that involved side.

To me, I would like to see her weight distribution more equal side to side but also more towards the mid-portion of her foot during the pulling phases.

She self-admits that she is shifting her weight and can’t help it. Through the naked eye, you may be able to see the shift but not necessarily see the anterior/posterior weight distribution (toes/heels).

I like to use the @boditraksports to pick up little nuances and help give feedback to the client.

Did you notice anything else with this video? What would you critique (be nice!!)?

Tag a friend or colleague who may want to see this video and help @lms651 get back to her fencing competitions…thanks!

⠀