The Week in Research Review, etc 8-19-18

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We posted a lot of information this week to review so hopefully you were able to keep up with it all. If not, here’s a bunch of it from the week. Check it out and comment as you want. Lots of good information on:

  1. Advanced Rhythmic Stabilization Drills
  2. Our ACL rehab paper from 2012
  3. PT usage for Frozen Shoulder
  4. Comparison of posterior shoulder stretching techniques
  5. Increased Sweating after an ACL surgery? Seems pretty common in the comments section
  6. @theprehabguys show how to do a posterior shoulder stretch

 

Advanced stabilization drills

These advanced stabilization drills are a great way to progress the patient once they’ve shown improved neuromuscular control with the basic drills from the other day.

I use these for most of my clients that need improved dynamic stability, especially those hypermobile athletes that play baseball, swim, or do gymnastics.

You can modify the speed and amount of force that I give during the drill based on how they are responding that day and how they have progressed overall. You can also increase the time of the drill to bring in an endurance component, as well.

The goal is to use these to prep the shoulder for higher level activities such as plyometrics, throwing, etc.

I want the shoulder joint to be as strong as possible. And most importantly, I want the client to perceive that their shoulder is stronger so that they are more confident!

Do you use these rhythmic stabilization drills with your patients?

Tag a friend who may benefit from these drills and try them on your patients the next time they’re ready to progress their dynamic stability drills!

Recent advances in the rehabilitation of anterior cruciate ligament injuries. @wilk_kevin et al JOSPT 2012 @drlylecain @dugasmd1

We wrote this paper in JOSPT to help clinicians better understand the rehab involved after their patient undergoes an ACL reconstruction.

The paper discussed the principles of ACL rehab, including:
✅obtaining full symmetrical extension
✅restoring patella mobility
✅ROM goals
✅Decrease inflammation/swelling
✅voluntary quadriceps control
✅restore neuromuscular control
✅Gradually apply loads

We also discuss special rehab implications for:
✅The Female Athlete
✅Concomitant injuries (MCL, meniscus, LCL, cartilage lesions)
✅Implications of Graft type

Our Accelerated ACL-PTG protocol is included to help guide the rehab process and give the rehab specialist some goals to achieve.

Again, a protocol is just a guide and by no means meant to place aggressive limitations on a patient.

Hope this paper helps you to better understand ACL rehab. Tag a friend or colleague who may benefit from this post.

 

Outcomes From Conservative Treatment of Shoulder Idiopathic Adhesive Capsulitis and Factors Associated With Developing Contralateral Disease Lamplot et al 2018 OJSM 2018

A minimum 2-year follow-up of patients diagnosed with idiopathic adhesive capsulitis.

They were treated with a single intra-articular glenohumeral injection of local anesthetic and corticosteroid as well as 4 weeks of supervised PT.

Physical therapy reduced the use of a second injection as part of treatment. Contralateral disease was more likely in patients with diabetes and those younger than 50 years.

PT is an important component of a conservative treatment protocol, as PT decreased the likelihood of receiving a second injection from 100% to 27.3%.

In my opinion, a cortisone injection + PT is the best treatment ‘cocktail’ for someone with frozen shoulder, particularly in the freezing phase.

Do you guys agree? Let’s discuss this very debilitating pathology. Tag a friend who may want to discuss this further.

A Randomized Controlled Comparison of Stretching Procedures for Posterior Shoulder Tightness McClure et al JOSPT 2007

This study looked to compare changes in shoulder internal rotation range of motion (ROM), for 2 stretching exercises, the “cross-body stretch” and the “sleeper stretch,” in individuals with posterior shoulder tightness.

From their results, “The improvements in IR ROM for the subjects in the ✅cross-body stretch group (mean ± SD, 20.0° ± 12.9°) were significantly greater than for the subjects in the control group (5.9° ± 9.4°, P = .009). The gains in the ❌sleeper stretch group (12.4° ± 10.4°) were not significant compared to those of the control group (P = .586) and those of the cross-body stretch group (P = .148).”

Just be aware of the large standard deviations and low number of subjects…plus the subjects were all asymptomatic.
With that, I still believe clinically that the cross-body stretch is one of the better stretches for the shoulder. I have gotten away from the sleeper stretch because I don’t believe the risk/reward presents favorably.

✅✅I personally prefer the supine horizontal adduction stretch with the scapula stabilized. I feel like this best isolates the posterior soft tissue (mainly muscle, in my opinion) and that’s my target tissue.

Do you use the sleeper stretch with your patients or do you prefer the cross-body stretch?

Comment below and let’s talk about it. Also, tag a friend who may benefit from this post…thanks!

Sweating Leg after an #ACL

Had this in my story and posted to Twitter and got some pretty good discussion going. Is this some altered autonomic nervous system response after #ACLsurgery? I’ve seen it a bunch, where the area inferior to the incision sweats significantly more than the contralateral leg. Anyone else see this phenomenon and have an opinion? Have had people say that maybe it was compartment syndrome or CRPS but it happens with many many ACL patients so it seems very normal. What do you think? #ACL #ACLrehab

Horizontal Adduction Stretching

Perfect timing by @theprehabguys with their horizontal adduction post from the other day. Blends perfectly with the McClure 2007 et al study I posted the other day that showed horizontal adduction is the best way to obtain internal rotation mobility at the shoulder. I often tell people to wedge their lateral scapula against a wall to help stabilize but this way may also benefit them. Check out their post below!⠀
👇🏻⠀
Are You Performing The Arm Across Body Stretch Correctly⁉️⠀
[How to Stretch Your Posterior Cuff]

A tight posterior cuff is associated with a handful of shoulder dysfunctions like subacrominal impingement syndrome, posterior impingement, anterior instability, etc. And thus, ⬇️ tone/increasing extensibility of the posterior cuff is part of the treatment protocol for many with shoulder pain. The cross-body stretch is a fantastic way to target the posterior cuff but far too often it is done INCORRECTLY.

‼️In order to effectively stretch the posterior cuff, you need to keep your SCAPULA STABILIZED ie your scapula CANNOT MOVE!‼️

❌If you pull your arm across your body and your scapula comes with it into horizontal abduction, the only stretch your getting is of your mid-scapular muscles like your rhomboids or traps. Furthermore, in this position there’s more of a distraction force on the glenohumeral joint than a true stretch of the posterior cuff – aka not as specific as it can be.

✅First pull your shoulder blades back. This will keep your scapula in a retracted position. Only WHILE MAINTAINING THE POSITION OF YOUR SHOULDER BLADES BACK can you effectively target the posterior cuff. Pay attention to WHERE you feel the stretch, as you should feel a “deep stretch” in the back of your shoulder in the highlighted area on the video. If you feel a stretch or anything else not in the back of the shoulder, you’re either doing the stretch incorrectly or abutting other structures in your shoulder due to pathology (ie don’t do the stretch anymore and seek out a physio if you’re in pain).

Try it out and let us know how it feels! Tag a friend who NEEDS this stretch! #shoulderstretch #posteriorcuff#posteriorcapsule

 

The Week in Research Review, etc 8-12-18

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This week’s articles discuss a wide variety of research topics. We discussed:

  1. Risk Factors for ACL tears
  2. Injury after a concussion
  3. EMG of the hip to minimize TFL activity
  4. We made of our posture and applied it to daily tasks
  5. Rhythmic Stabilization drills for the shoulder

Hope you enjoy and make sure to share with your friends and colleagues!

Factors Associated with Non-Contact Anterior Cruciate Ligament Injury: A Systematic Review. Pfeiffer et al IJSPT Aug 2018

This study looks to examine the existing literature for risk factors associated with non-contact anterior cruciate ligament (ACL) injury in both sexes.

A total of 79 full-text articles were reviewed, 55 of which met criteria for inclusion.
✔️Degrading weather conditions⠀
✔️Narrow inter-condylar notch index or width⠀
✔️Increased lateral or posterior tibial plateau slope⠀
✔️Decreased core and hip strength⠀
✔️Potential genetic influence

Individuals with previous ACL injury are at a higher likelihood for injury in the same knee (9.1x risk).

Take a look at this study because they do a good job of breaking down the literature and pointing out some of the common risk factors, both extrinsic and intrinsic.
✅Anatomic factors⠀
✅Neuromuscular Factors⠀
✅Physiologic Factors⠀
✅Biomechanical Factors⠀
✅Genetic Factors

Check out this paper and tag a friend or colleague that may benefit from reading this paper.

 

 

Musculoskeletal Injury Risk After Sport-Related Concussion: A Systematic Review and Meta-analysis – McPherson et al AJSM 2018

This systematic review & meta-analysis looked to determine the odds that athletes will sustain a musculoskeletal injury after a concussion. It was hypothesized that a concussion would increase the risk for MSK injury.

Eight studies met inclusion criteria for meta-analysis reporting 860 male and 163 female athletes with concussion compared with 3719 male and 507 female control athletes without a concussion.

✅Athletes with concussion had 2.11 times greater odds of sustaining a MSK injury compared with control groups and 1.67 times more likely to experience a lower extremity injury.

✅Female athletes with concussion had 2 times greater odds to sustain injury compared with non-concussed female control athletes.

✅Male athletes with concussion similarly demonstrated an increased odds of 2.1x risk for injury compared with non-concussed male control athletes.

Of course, they say further studies are needed to determine the physiological reasoning behind the increased risk for injury after a concussion.

Kinda makes sense, right? Anecdotally I feel like we see this a lot but good to be able to see it in the literature and educate our clients prior to a return to their sport.

 

 

Electromyographic Analysis of Gluteus Maximus, Gluteus Medius, and Tensor Fascia Latae During Therapeutic Exercises With and Without Elastic Resistance. Bishop et al IJSPT 2018

This study looked to determine the gluteal-to-tensor fascia latae muscle activation (GTA index) and to compare electromyographic muscle activation of the GMax, GMed, and TFL while performing 13 commonly prescribed exercises designed to target the GMax and GMed.

Clams with and without resistance, running man gluteus maximus exercise on the stability trainer, and bridge with resistance, generated the highest GTA index respectively.

It seems as if these 3 exercises may give you the biggest bang for your buck when trying to maximize gluteal activity and minimize TFL activity.

Knowing previous research, it seems as if most single-leg-stance exercises are going to give the patient the best gluteal activity per EMG.

Do you guys use any of these exercises? Maybe you need to use them more for your patients looking to improve their hip strength.

Tag a friend who may need bigger 🍑 and may benefit from this research by the esteemed Barton Bishop and his research team! TThanks, carlokoo for modeling!⠀

 

Loss of knee extension after a surgery can greatly impact a patient’s function in the long term.

Although opinions vary greatly in the orthopaedic world, I am a firm believer that regaining symmetrical knee extension is critical for a surgery to be successful.

Shelbourne et al showed that the number one factor in determining long-term satisfaction after a knee surgery was symmetrical knee hyperextension.

Per Benner et al 2016, obtaining full hyperextension that is anatomically normal for most patients does not affect objective stability, ACL graft tear/failure rates, or subjective scores after ACL reconstruction with patellar tendon autograft.

So why do some docs and PT’s still think you only need 0 degrees of knee extension? 🤔⠀

I’m not sure but I’ll tell you it is safe to get hyperextension and here are 3 tools that I use to help regain that last bit of motion.

1. Low load long duration in supine: in my opinion a better position to regain extension and more comfortable than hanging a patient’s leg off of a table. You try doing that and see how you like it!

2. Retro treadmill walking: walking at ~ 1.0 mph on the treadmill has been a great way to get that last bit of motion back and is something they can do at their gym when they’re not with you in PT.

3. Retro cone walking: Again, the goal is to accentuate the end range into hyperextension and it will also challenge their dynamic balance.

So, do you use these techniques with your patients? If not, tag a friend or colleague that may benefit from seeing this post!

 

I love when we can make fun of ourselves & this post nails it! Give @beardthebestyoucanbe a follow!

There is no such thing as good or bad form or posture. There is no right or wrong “exercise”. What does “functional exercise” even mean, & what is this “core” thing everyone keeps talking about whilst planking or crunching?! My newsfeed is blowing up with these so-called “fitness coaches” and “rehab experts” putting all type of crap out there. For 1 of 2 reasons, maybe both⠀
1. Pure ignorance⠀
2. Trying to grow their following by giving people what they think they want⠀
_⠀
The only bad posture is the posture we spend too much time in (shout-out Andreo Spina). Life is not perfect posture & neither is sports⠀
As human beings, our movement capacity should be vast. If we only stay in a small handful of postures we aren’t fulfilling our movement potential and we’re creating more dysfunctions and weaknesses because of it. Your body will devolve rapidly⠀
If you always hammer down the same posture, even if it’s “good posture”, you’re only creating strength and neurological control in that specific posture. So when your body slips out of that particular shape, weakness and injury is the outcome – and that’s not a good sign⠀

There is no such thing as a functional exercise, just functional (or non-functional) joints that can fulfill movement potential. If your joints can’t successfully control a range of motion that is necessary for your daily life, you should probably make that a priority for your training practice⠀

So in conclusion, is it that you need to practice good form (and never lose it, ever)…or practice multiple forms⠀

How do we practice in those ways? Well, it’s going to take a philosophical change first and foremost. Understanding our biology and neurology is important⠀

If you do not know how to train in such ways, find those who do.

 

I use Rhythmic Stabilization drills daily in my practice for most of my upper body patients.

I think they are critical to use to help the patient regain neuromuscular control, a sense of their joint and it’s a great way for the PT to get a sense of how the patient is doing overall.

The hands-on strength training (trying not to trigger dependency by the patient, so relax!) is a great way to gauge a patient’s progress.

Various tools can be used to progress and regress these exercises. I hope these few basic RS drills can give you a basic understanding of what we do @championptp

I hope to get more of these videos out in the future.

Share with your friends and colleagues so they can see these valuable drills for the shoulder joint!

 

 

 

The Week in Research Review, etc 7-29-18

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Last week was the 1st of my research review that summarized my social media posts from the previous week. It seemed to be well received so I figured I’d continue it. My goal is to help summarize some of the research that I found interesting and package it nicely for my readers.

Each photo contains a link back to a social media feed where you can see the conversation that ensued and maybe chime in…or just be a passive reader and see where the conversation went. You never know where the conversation may go on social media…so be ready! haha!

Socioeconomic Factors for Sports Specialization and Injury in Youth Athletes Jayanthi et al Sports Health Journal 2018.

This study looked at the effect of socioeconomic status (SES) on rates of sports specialization and injury among youth athletes.

They looked at injured athletes between the ages of 7 to 18 years that were recruited from 2 hospital-based sports medicine clinics. They compared these with uninjured athletes presenting for sports physicals at primary care clinics between 2010 and 2013.

They concluded that:
✅High-SES athletes reported more serious overuse injuries than low-SES athletes
✅More hours/wk playing organized sports
✅Higher ratio of weekly hours in organized sports to free play
✅Greater participation in individual sports

I applaud the authors for attempting to bring this very difficult collection of data into a formal research paper. I will say some of the statistics and standard deviations may not make the conclusions as powerful.

I do think this is a good paper to help educate our athletes on injury rates, especially in those that specialize in 1 sport.

What do you think? Tag a friend that may benefit from this article!

From #Twitter’s @retlouping that perfectly sums up what I’ve observed recently on social media with many PT’s.

For some reason, pain science has overtaken most diagnosis and treatment conversations.

It’s as if you get bullied into talking pain science and ignoring our clinical judgment and diagnosis skills. I understand there’s a constant tug-of-war between the biomechanical PT’s and the pain science PTs.

But as usual, the answer usually lies somewhere in between and both groups are correct. The biomechanics of an injury are often important as well as the language we use to explain these tissue biomechanics.

To my fellow clinicians, especially the newer grads and #dptstudent, remember this little cartoon for every future encounter.

Yeah, speak to people in non-threatening tones (in my world it’s just being respectful) but trust me, they WANT to hear what could be going wrong or what may be causing their pain.

Don’t blow off their symptoms and don’t go into depth about pain science because they won’t understand.

Trust me, the clinicians that try to do that often end up losing their patients in the long run.

I hear these stories day after day of people coming to me because the last PT either only talks to them or made them ONLY do strength exercises and it didn’t help their pain.

The PT didn’t listen to them and was so blinded by their pain science background that they ignored the person sitting right in front of them. Remember, the person sitting there will tell you what is going on and what treatment will most help them feel/move better.

Influence of Body Position on Shoulder and Trunk Muscle Activation During Resisted Isometric Shoulder External Rotation Krause et al Sports Health 2018.

The purpose of this study was to examine ER torque and electromyographic (EMG) activation of shoulder and trunk muscles while performing resisted isometric shoulder ER in 3 positions:
✔️Standing
✔️Side-lying
✔️Side plank

Using surface EMG and a hand-held dynamometer, the researchers tried to determine EMG activity of the:
✔️infraspinatus
✔️Posterior Deltoids
✔️Mid traps
✔️Multifidi
✔️External/internal obliques (dominant side)
✔️External/internal obliques (non-dominant side)

EMG values for the infraspinatus were greatest in the side plank position. In general, EMG values for the trunk muscles were also greatest in the side plank position.

✅Their Conclusions: If the purpose of a rehabilitation program is to strengthen the rotator cuff, in particular, the infraspinatus, the side plank is preferred over standing or side lying. If the goal is to simultaneously strengthen both the rotator cuff and trunk muscles, the side plank position again is preferred.

Makes sense but good to see the research and have concrete evidence to back up what we think actually goes on.

Tag a friend who may be interested in this research paper!

Reliability of heel-height measurement for documenting knee extension deficits. Schlegel et al AJSM 2002

Prone heel-height difference of 1cm equates to 1.2 degree difference in knee extension ROM.

Do you use this method to assess knee ROM? I still measure knee extension ROM is supine but find this method helpful as well.

I know my friend and colleague @wilk_kevin has measured this way for many years. i originally saw his use this technique at @ChampionSportsM

I don’t want people to confuse this with prone hangs for knee extension ROM. I am not a fan of that method as I’ve stated in the past.

This is a method to assess knee extension differences, particularly after an ACL reconstruction. I have gone back to using this method for some people that have subtle ROM differences side-to-side.

The patella position (on the plinth or off) did not matter in the study and thigh girth did not appear to make a difference.

I would recommend stabilizing the pelvis to prevent excess ROM from occurring at that region and to better isolate the knee joint.

Have you tried this method? Tag a friend who may benefit from using this ROM method…thanks!

Evidence-Based Best-Practice Guidelines for Preventing #ACL Injuries in Young Female Athletes: A Systematic Review and Meta-analysis Petushek et al AJSM 2018.

Injury prevention neuromuscular training (NMT) programs reduce the risk for anterior cruciate ligament (ACL) injury.

Eighteen studies were included in the meta-analyses, with a total of 27,231 participants, 347 sustaining an ACL injury.

The overall mean training amount was 57 sessions totaling 18.17 hours (roughly 24 minutes per session, 2.5 times per week).

They concluded:

✔️Interventions targeting middle school or high school–aged athletes reduced injury risk to a greater degree than did interventions for college or professional-aged athletes.

✔️Continued exposure to neuromuscular training throughout the sport season seems to enhance prophylactic effects of NMT.

✔️NMT interventions were effective for female basketball, and handball athletes and interventions including various athletes were potentially effective (eg, soccer, basketball, and volleyball).

✔️ Interventions included some form of implementer training (eg, instructional workshop, video, or brochure) on proper program implementation.

✔️Programs including more landing stabilization and lower body strength exercises during each session were most effective.

🤔Programs including balance, core-strengthening, stretching, or agility exercises were no more effective than programs that did not incorporate these components.

✔️ Specifically, programs that included more landing stabilization exercises (eg, drop landings, jump/hop and holds), hamstring strength (eg, Nordic hamstring), lunges, and heel-calf raises reduced the risk for ACL injury to a greater degree than did programs without these exercises.

✅ Wow, lots of great information here. Please share this with a friend or colleague who may benefit from knowing this information.

Hope that helped to catch you up on my posts from this week.

Do you like these weekly updates? Let me know if I should continue…love your feedback!

Thanks for reading!

The Week in Research Review, etc 7-22-18

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The Week in Research Review, etc 7-22-18

I’m trying out this new concept of publishing my social media posts into a nice package for a weekly delivery to my subscribers.

  1. Knee Case Study
  2. Contralateral ACL Strengthening
  3. Shoulder Static Stabilizers
  4. Weighted Ball Research
  5. Glute Activation


This kid came to me the other day with L knee swelling after sliding headfirst into 2nd base during a baseball game.⠀

Continued to play in the game and even pitched the next day, all without pain or loss of motion.⠀

As you can see from the video, he has a bunch of fluid in his knee, medial ecchymosis (bruising) but full pain-free ROM.

Ligamentous tests appear negative and he has absolutely no pain or stiffness with anything.

I took this video to show what appears to be a bursal sac disruption from the impact of his knee into the ground as he was sliding.

The mechanism fits the presentation and clinical exam.

I advised him to monitor his swelling, wear a knee sleeve and continue his activities per his tolerance.

He is going to touch base with me next week to make sure the fluid is dissipating (and not worsening) and he remains asymptomatic.

What do you think? Am I missing anything? What’s your diagnosis? Tag a friend who may be interested in this case.

Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial. Harput et al Knee Surg Sports Traumatol Arthrosc. 2018

This study looked at a group of ACL reconstructed patients that were divided into 3 groups.

All 3 groups performed the same standardized ACL rehab, but one group was the control group that performed the standardized rehab only.

The other 2 groups did either 3x per week extra concentric knee extensions on their uninjured leg for 2 months (beginning at 1-month post-op through 3-months post-op) or additional eccentric knee extensions on their uninjured leg 3x per week for 2 months between months 1-3 post-op.
💪🏼
They found that the quads strength for the concentric group was 28% greater compared to the control group. 💪🏼
The eccentric group was 31% greater when compared to the control group.

Conclusion: Concentric and eccentric quadriceps strengthening of healthy limbs in early phases of ACL rehabilitation improved post-surgical quadriceps strength recovery of the reconstructed limb.

Pretty crazy stuff and one more reason to work on bilateral strengthening with most of our patients, especially when they’re post-op ACL reconstruction.

Do you work on bilateral strengthening? if not, why? If you do, what other studies have you seen that show similar results?
Tag a friend who may benefit from this study or let’s discuss in the comments section!

This picture shows a simplified view of the static stabilizers of the shoulder joint. I highly recommend reading a classic paper by Wilk et al 1997 JOSPT that talks about this and cites a paper from Bowen et al Clin Sports Med 1991 @wilk_kevin

When one is picturing these stabilizers, the superior glenohumeral ligament (SGHL) is most taut when the shoulder is externally rotated at 0 degrees of abduction.

As we progress to 45 degrees of GH abduction, we stress the middle glenohumeral ligament (MGHL) as we externally rotate the humerus.

Finally, at 90 degrees of GH abduction, we stress the inferior glenohumeral ligament (IGHL) as we externally rotate. More specifically, the anterior band of the IGHL.

As we internally rotate at 90 degrees of abduction, we stress the posterior band of the IGHL.

These concepts have rehab implications and should be kept in mind when we’re rehabbing people after an injury or surgery.

For example, if someone has an anterior Bankart lesion (front labral repair), then we need to progress them slowly into external rotation, especially at 45 and 90 degrees of abduction.

Another example would be a rotator cuff repair, like the supraspinatus. We would want to progress them slowly at lower degrees of abduction 0-45 degrees but maybe we can progress them a bit quicker at 90 degrees of abduction.

Hope these concepts make sense because they are very important to understand for many patients with shoulder injuries.

Does this make sense? Have you heard this info before? Tag a friend who may benefit from this post!

Effect of a 6-Week Weighted Baseball Throwing Program on Pitch Velocity, Pitching Arm Biomechanics, Passive Range of Motion, and Injury Rates. Reinold et al Sports Health Jul-Aug 2018. @mikereinold⠀

Our 1st of potentially 3 research articles looking at the effects of weighted balls on youth baseball pitchers.

High school baseball pitchers performed a 6-week weighted ball training program.

Players gradually ramped up over the 6 weeks to include kneeling, rocker, and run-and-gun throws with balls ranging from 2oz to 32 oz.

🤔After 6 weeks, the weighted ball group did increase velocity by 3.3%, 8% showed no change, and 12% demonstrated a decrease in pitch velocity. Also of note, 67% of the control group also showed an increase in pitch velocity.⠀

The weighted ball group had a 24% injury rate although half of the injuries occurred during the study, and the other half occurred the next season. There were no injuries observed in the control group during the study period or in the following season.

The weighted ball group showed almost a 5-degree increase in passive shoulder external rotation, also known biomechanically as the late cocking position or layback position.

There were no statistically significant differences between pre- and post-testing valgus stress or angular velocity in either group.

✅Our conclusion: Although weighted-ball training may increase pitch velocity, caution is warranted because of the notable increase in injuries and physical changes observed in this cohort.

Some great Glute 🍑thoughts buy the @theprehabguys. Check out their videos and content for some great ideas that you can add to your practice!⠀
👇🏼⠀
___________________________________________________________________⠀
Episode 705: “Hip Prep for Glute Activation”⠀
.⠀
Tag a friend looking for a glute🍑 killer!⠀
Hip prep is a series of 6 exercises I’ve adopted from my girlfriend @smenzz and her clinic @eliteorthosport. I use it with my patients to prime the glutes and lower body in general before getting into more dynamic and plyometric activities. I will make the statement right now: if done RIGHT, it’s an absolute glute killer & I promise you that you will feel your glutes!⠀
.⠀
I like these 6 exercises in particular for a variety of reasons.⠀
✅They challenge the glutes in all 3 planes of motion.⠀
✅They hit all types of muscle contractions: isometric, concentric, and eccentric⠀
✅They are performed upright in a functional position⠀
✅There is a variety of double leg, single leg, and split stance variations⠀
✅They train proper lower extremity alignment in a variety of hip and trunk flexed/neutral/extended positions⠀
.⠀
The 6 exercises are:⠀
1️⃣3 way clams: 5 per leg per position⠀
2️⃣Side steps: Alternating steps to the left and right starting with 1 step all the way to 5 steps⠀
3️⃣Monster Walks: 10 steps forward, 10 steps backwards⠀
4️⃣W’s: 10 steps to the left, 10 steps to the right⠀
5️⃣Squats: 10 squats⠀
6️⃣Single leg fire hydrants: 30s per side⠀
.⠀
💡Understand that you first need to teach these exercises in isolation first, before throwing someone all 6 at once⠀
.⠀
Have fun!⠀

Hope this helps you keep up to date and fulfill my goal of this website…simplify the literature and bring great content to you so you can apply it 1st thing Monday morning! Happy Reading! 👊🏼

Follow me on Social Media here:

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The Evolution of a Physical Therapist

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I’ve been a practicing Physical Therapist since 2003. I’ve observed a lot, talked to a bunch and read a lot. By all means, I am no expert! The evolution and growth of a physical therapist can take many roads.

I am always learning and listening but at times I do become complacent (that’s human nature). I’d be the 1st to admit that. I sometimes get stuck in my ways despite what others are saying in the literature or on social media.

I think that’s the great thing about social media…it keeps me listening. It has helped me to evolve and keep me on my game.

Ultimately, what has kept me on my game has been my desire to give my patients the best care that I can give them. I would expect the same from my own personal healthcare provider (I have a PCP, dermatologist, and a rheumatologist).

We have a responsibility to be the best for our patients. There are a lot of people chirping their opinions all over the place s I wanted to take this time to reflect on how I’ve seen many PT’s grow.

I’ve always wanted to write this post but I was inspired by my friend and co-owner of Champion Physical Therapy Mike Reinold when he posted this graphic on his Instagram feed.

I’d like to briefly chat about the evolution of a physical therapist through my eyes.

There seems to be a general development that occurs in the PT world- most are good but I’m beginning to see a side that is a bit disheartening. Maybe it’s a social media thing but I think we need to take a step back and re-evaluate for a second.

We’re always looking for a protocol to guide our patients. Here’s my attempt at the phases of a PT…Hope you enjoy (some of it is tongue-in-cheek so don’t get all crazy on me!)

The New Grad DPT student

This is the hungry, newly crowned physical therapist looking to break into the profession. Their eyes finally on the prize but probably scared to death (I hyperbolize). No more clinical instructors to guide you. No more reliance on someone else to lead the way. The plan of care is all yours!

Looking at your schedule for the next day or week, you may see that eval that worries you. Someone on the schedule with a diagnosis of “LBP” or a post-op ACL.

It was easier to treat these when your CI called the shots and you could observe, help and chime in with your thoughts and treatments. Accountability was minimal but the rewards seemed grandiose when the patient emerged with better function.

  • When is it safe to push an ACL?
  • How fast should one start strengthening after a rotator cuff repair?
  • When is it safe to start a throwing program after a Tommy John surgery?
  • What do you tell the patient when they come in with their 1st episode of acute low back pain and how do you treat it?

These are just a few of the challenges a new grad has to face.

Insurances are daunting. People can be daunting. You greatly influence the functional outcomes of that person sitting in front of you. Your words and actions matter but you don’t know that yet.

I often compare this stage to a new NFL quarterback who struggles to read defenses and rushes the ball when he throws…oftentimes to a defensive back waiting for an easy interception. He wasn’t anticipating that defense and got nervous. The game was moving too quickly and he can’t keep up with the schemes.

This is the new grad, a simplified version, but one that tries to do a lot but has minimal experiences and abilities to “read the defense.” The game is moving quickly and your decisions often come with little confidence.

But don’t worry, the game will slow down a bit.

2-5 years out and Feeling Confident

At this point, you’ve seen a bunch. You better understand the complexities of people, the medical system and how to kinda manipulate your way through. You realize that you can do it but your school studying was only a small prep for reality.

You’re motivated, finding your groove and beginning to get comfortable. There are still some questions but you don’t have to rely on the other PT’s in your group to help with progressions.

Pubmed has hopefully become your greatest ally, hopefully.

Although I do run into many that rely on Facebook and Twitter for their ‘research’. There’s always a post looking for advice on progressing a meniscus repair or return to a sport after an ACL.

I’ll often direct them to PubMed because just feeding people research is not helping them in the long run. They need to know where to find the information and learn how to interpret it.

The game is slowing down and your confidence is growing. Some even think they’re super-confident and try to ‘take on the world’. They are the ones out on social media leading the charge for change. A revolution of sorts…that their way is better than what has been done the past 5, 10, 20, 40 years!

They’re seeing their practice through rosy glasses with blinders. Blind to the fact that there are many before them who equally tried to champion a cause only to find out there’s more to it. The journey, although it seems triumphant and vigilant, falls short.

There will always be a new treatment technique, new modality a new system that is promising better outcomes. Your words, although seemingly loud, fall on so many deaf ears because the ship is going to steer itself. You’ve tried to lead the charge only to learn that the profession of PT is bigger than you.

You can only control what happens within your practice, or the few people that follow you on Instagram.  Although those ‘followers’ are often bots of some sort, pretending to like your content.

It’s a strange world out there, your words are seemingly wise, but there are so many out there shouting similar words that it gets drowned out. You think your experiences, although limited in the grand scheme of things, should guide your practice and the people that ‘follow’ you.

This, my friend, is where you’ve gone wrong. You have a ways to go. In fact, you’ll never get there. You’ll realize that each day presents a new challenge that doesn’t fall into a predefined mental algorithm.

When you have this revelation, then I think you’re ready to explore the next phase of your growth curve.

5+ years- beyond

The chart above calls you an expert but I’m not 100% a fan of this. No one in our field is truly an expert because there are challenges way above anything we could ever control.

Each personality that enters into our facilities presents with life stories that have shaped their pain, their expectations, and their outcomes.

But you know what, it’s at this stage that you realize that you are only a small piece of the puzzle. You can only help guide the process based on your plethora of experiences.

You’ve stayed on top of the literature and have altered how you practice. You no longer think that your way is the best but have dabbled in many other systems and taken a bit from all of them. Your way is NOT the best way.

You also have come to realize that there are always outliers out there. You know the ones that think the extreme positions are the best for all patients.

For example, there’s a huge social media push that says “manual therapy sucks”. No one should use manual therapy and you’re only wasting your time.

The flip side arguments say that there are many people that have a shifted inominate (whatever the hell that means) or a rib that is out of place. That therapist has been pounding on that pelvis or relocating that rib 1x per week for 52 weeks and has that patient convinced that they need more visits.

These are the outlier PT’s (I’m not speaking for other professions so don’t try to sucker me in) that are loud on social media but don’t necessarily represent the majority.

You see, the majority are trying to do it correctly (at least I think they are). The young PT that is 2-5 years out only sees those outliers as a challenge to his/her practice and is trying to yell at them. When in reality, you’re speaking to the minority, the group that barely exists.

You should be speaking to everyone else. The ones on social media that have taken a middle-of-the-road approach. They are doing their best, are on facebook looking for advice and busting their butts in the clinic.

They are limited by resources, time and updated knowledge. These are the people hungry to learn but are stuck somewhere in the 3 categories above.

These therapists are the ones you should be trying to chat with. You recognize that your vast experiences can help them.

It’s when you have this breakthrough that I think you’re ready to enter that last growth phase. You’re confident in your practice and willing to share. You speak to other groups, you publish clinical research, and you review research papers for journals.

To me, this is the utmost level and should be where most of the PT’s strive to get. Your knowledge continues to grow as you read. Each patient experience and interaction is another mental data point that sharpens your practice. These data points will blend in with your research readings and produce a so-called ‘expert’.

I invite you to challenge yourself by aligning with a clinician or group that produces clinical research, reviews journals and stays on top of the literature. Until then, don’t talk the talk unless you can walk the walk.

Some will think I’m being harsh, but I think you’ll have the realization, like I did back in the day, that our PT profession is bigger than us. Control what you can control and keep the ultimate goal in mind- THE PRIORITY IS TO GIVE THE BEST CARE FOR OUR PATIENTS, ALWAYS!

I’ve written about this before…about empowering the patient and keeping them in the driver’s seat. Check it out here.

I’d love to hear your comments. Please share with your friends, new grads and experienced PT’s. Social media has given many a voice but the loudest voices are not always the wisest voices!

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

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

Photo by Piron Guillaume

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

Recent Systematic Review & Meta-analysis

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

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

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

The inclusion criteria were as follows:

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

The exclusion criteria included:

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

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

  • have diabetes
  • smoke
  • worker’s comp

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

via GIPHY

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

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

Moving on…

Surgery better than Rehab

The study’s results concluded:

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

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

So what does this mean?

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

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

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

Study Limitations

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

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

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

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

My Conclusions

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

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

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

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

 

Simple steps to Rotator Cuff Rehabilitation

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

 

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

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

via GIPHY

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

10 Key factors in Rotator Cuff Rehab

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

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

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

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

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

What’s the plan?

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

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

Calm down the shoulder pain

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

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

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

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.

Initiate higher level strengthening

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

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

Advanced strengthening

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

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

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

Well, maybe not this aggressive!

Return to Sport Program

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

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

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

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

Final Rotator Cuff Thoughts

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

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

References for above paragraph:

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

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

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

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

Welcome to LennyMacrina.com!

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Welcome to my new website, LennyMacrina.com

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

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

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

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

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

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

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

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

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

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

Thanks!!

2 Tips to Improve Your Post-op Rehabilitation Outcomes

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

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

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

Wake up call

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

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

Trial and Error

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

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

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

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

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

Regression to the Mean

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

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

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

via GIPHY

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

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

Don’t Over Do It- Less is More

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

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

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

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

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

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

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

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

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

End-feel Assessment

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

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

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

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

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

Assess and adjust each visit

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

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

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

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

Take Home Point…

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