Tag Archive for: ACL

Simplifying ACL Rehab

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

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

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

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

Most don’t have an isokinetic device to test.

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

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

What combinations of tests are appropriate?

Is it more than just quadriceps strength?

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

Lots of questions!

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

ACL retear rates still too high

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

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

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

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

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

An easier approach to ACL rehab

Immediately Post-op Phase

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

Range of Motion

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

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

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

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

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

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

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

measuring knee extension after an ACL surgery

Normalize Patella Mobility

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

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

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

Strengthening

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

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

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

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

Let the ACL rehab fun begin

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

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

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

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

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

When to run after an ACL

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

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

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

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

ACL rehab is mainly about strengthening

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

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

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

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

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

Hope this helps!

ACL tears and bone bruises

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Research Review

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

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

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

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

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

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

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

Delay impact activities after ACL surgery

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

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

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

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

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

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

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

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

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

ACL Volume Changes over a Women’s Soccer Season

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

ACL Growth influenced by soccer Activity?

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

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

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

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

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

Figure 1 of Myrick et al. Journal of Experimental Orthopaedics

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

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

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

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

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

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

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

Future Implications

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

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

What else do we know?

Weightlifting linked to ACL Hypertrophy too

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

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

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

Patella Ligament Influence

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

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

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

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

Wrapping it up

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

Some of my questions to ponder:

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

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

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

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

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This week we’re still playing with formats and learning these Instagram changes. With that, in the week in research review 12-10-18, we discussed many topics that I wanted to share!

Surgery vs Physical Therapy for Carpal Tunnel Syndrome

Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial Fernández-de-las-Peñas et al JOSPT 2018.

This Level 1b study looked to evaluate cost-effectiveness differences of manual physical therapy versus surgery in women with carpal tunnel syndrome (CTS).

Performed in Spain, 120 women with a clinical and electromyographic diagnosis of CTS were randomized through concealed allocation to either manual physical therapy or surgery.

They concluded that manual PT including desensitization maneuvers of the central nervous system has found to be equally effective but less costly, i.e., more cost-effective than surgery for women with CTS.

From a cost-benefit perspective, the proposed manual PT intervention of CTS can be considered.

Interesting results but 2 obvious limitations to this study:
1️⃣No control group. What if the symptoms could spontaneously improve over time
2️⃣ They only looked at 1-year improvement and not short-term improvements. I would’ve liked to have seen 3 months and 6 months results as well to see the acute effects.

Not sure what to make of this study but it does seem as if a population of Spanish women may respond to Rx of CTS without surgical intervention.

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

Return to Sport Criteria and Reinjury Rates

The Association Between Passing Return-to-Sport Criteria and Second ACL Injury Risk: A Systematic Review With Meta-Analysis  Losciale et al JOSPT 2018.

Not going to lie, this study caught my attention because the results match my confirmation bias.⠀

I’ve been saying for years that hop tests, even combined with other tests, just don’t cut it.⠀

I wrote a blog post about this too for @mikereinold. This study, although with its limitations, did show that passing RTS criteria did not show a statistically significant association with risk of a second ACL injury. 

This review also determined that 12% of those who failed RTS testing suffered a graft injury, compared to 5.9% of patients who passed. 

It seems as if quadriceps strength measured via isokinetic testing or isometric testing may be an important factor to consider for RTS decision making.


Also, hamstring-quadriceps strength ratio symmetry should also be considered.

So with this review demonstrating that current objective criteria-based RTS decisions did not show an association with the risk of a second ACLI, how does this affect your practice?

Physical Therapy vs Knee Scope for Meniscus Tears

💥PT vs Scope for Meniscus Tear 💥
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Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Non-obstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial. van de Graaf VA et al JAMA Oct. 2018

Among patients with non-obstructive meniscal tears, PT was equal to arthroscopy for improving patient-reported knee function over a 24-month follow-up period. 

They went on to say that “Based on these results, PT may be considered an alternative to surgery for patients with non-obstructive meniscal tears.”

So basically, if there’s no bucket handle tear present that may be blocking joint range of motion, then it is highly encouraged that the patient #GetPT1st and not do surgery.

Without going out on a limb, I’d say this is a much more cheaper treatment option as well and would save society many costs associated with the surgery and lost time from work.

I do note a couple limitations: the surgical group did not get PT after surgery if they did ‘as expected’ but they could get PT to help improve their symptoms.

The PT group did pretty basic exercises although leg press, lunges, and balance type exercises were included.

Have you read this paper? It was a multi-center, randomized controlled trial performed in 9 hospitals in the Netherlands.

So, are we encouraged or surprised? Let me know by commenting below…thanks!

Shoulder Health Accessory Exercises

by @kieferlammi

Want strong and healthy shoulders!?

Shoulder strength is about more than pushing big lifts like strict pressing, push pressing, etc.

If you want a robust, healthy, well moving shoulder you should be including lower level drills that more specifically address scapular and RTC strength and control. –

I will always be a fan of traditional exercises like side like ERs, Prone Ys, Ts, etc.

Lately, I’ve thrown in more band work because it’s easy for me to do for higher volumes on a frequent basis and I enjoy the constant tension that the band provides. 

Give these two exercises a try:

✅ Band Front Raise Pull-Apart

✅ Band Overhead Y Raise

I find that these two do a great job of targeting my mid back and posterior shoulder without much compensation through a big range of motion.

Give them a try either in a warm-up for 1-3 sets of 10-15 reps or at the end of a training session for 2-4 sets of 10-25 reps depending on the difficulty of your band and your capacity. 

Should we Brace after an ACL Surgery?

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

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

Knee Bracing Immediately After an ACL Reconstruction

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

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

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

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

What does the Research Say about Bracing after an ACL?

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

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

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

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

More studies!

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

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

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

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

Instagram Story Poll will Decide It!

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

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

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

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

Twitter Discussion

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

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

Regional Differences with Bracing

Midwest

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

West Coast

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

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

Europe

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

Guess that topic will be for a different day!

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

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

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

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

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

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

Closing Thoughts

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

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

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

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

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

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

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

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

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

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

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Hey everyone,  The Week in Research Review, etc for this week has a new look, compliments of Instagram’s new algorithm. Hope the new format doesn’t throw you too big of a curveball (maybe you’ll like it better), so here goes…

 

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

Preventing low back pain by @joegambinodpt

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

Anatomy of the Proximal Humerus

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

 

View this post on Instagram

 

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Preventing low back pain by @joegambinodpt

 

View this post on Instagram

 

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

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

 

View this post on Instagram

 

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

Anatomy of the Proximal Humerus

 

View this post on Instagram

 

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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 11-5-18

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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.