Tag Archive for: hip

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

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

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

 

 

Comorbidities after Hip Arthroscopy

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

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

Relative to baseline, cases of:

❇️mental health disorders rose 84%

❇️chronic pain diagnoses increased by 166%

❇️substance abuse disorders rose 57%

❇️cardiovascular disorders rose by 71%

❇️metabolic syndrome cases rose by 85.9%

❇️systemic arthropathy rose 132%

❇️sleep disorders rose 111%

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

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

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

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

 

Posterior Capsule Limits Knee Extension after an ACL

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

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

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

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

 

The Best Exercise for the Rotator Cuff

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

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

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

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

 

Myofascial Release of the Infraspinatus

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

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

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

𝗛𝗲𝗿𝗲’𝘀 𝗵𝗼𝘄 𝘁𝗼 𝗱𝗼 𝗶𝘁:

🔹️Ball placement is below the spine of the scapula.

🔹️Internally rotate, flex, and adduct the shoulder

🔹️Work back and forth for a minute or so

 

Bone Bruises after an ACL

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

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

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

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

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

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

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

 

Types of Bone Bruises after an ACL Injury

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

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

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

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

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

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

—-Symptoms of Bone Bruises—-

•Pain and tenderness in the region of injury

•Swelling in the region of injury

•Skin discoloration in the region of injury

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

 

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

 

The Week in Research Review, etc 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!