Tag Archive for: knee surgery

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 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 12-17-18

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Not a lot this week…sorry folks. Focusing a bit more on other projects. The Week in Research Review, etc 12-10-18 included only 3 posts but they definitely made some waves. Especially my latest Instagram post on burn-out in the PT field. Check it out and chime in…it’s never too late to like a post and comment on SoMe.

When is it Safe to Drive after Orthopaedic Surgery?

💥OPEN ACCESS! 💥⠀

This study looked to comb the research to see the available data regarding when patients are safe to resume driving after common orthopedic surgeries and injuries affecting the ability to drive.


This is always the age old question as a PT or ATC (amongst the other disciplines) and this study may help to shed light and give a bit more concrete evidence.

Often times, our answer is ‘it depends’ and that is definitely true. Or we pass the ball to the doctor who did the surgery and try to buy time by waiting until that 1st post-op visit.

Or we just say you can’t drive because you’re still on pain meds…and that is definitely true! All of these factors may play a role but it seems as if the literature can help guide our answers a little better so I invite you to take a look to this OPEN ACCESS paper and keep it in your patient database.

It may help to guide a future patient’s independence after an injury.

Posterior Shoulder Stretching after a Surgery

The efficacy of stretching exercises to reduce posterior shoulder tightness acutely in the postoperative population: a single-blinded randomized controlled trial. Salamh et al Physiother Theory Pract. 2018.


This paper looked at acutely post-op shoulder patients (no repairs, just debridements) and followed their ROM horizontal adduction and internal rotation after the surgery.


Group 1 was assigned the supine sleeper stretch and shoulder pendulum exercises. Group 2 was assigned the standing horizontal adduction (cross-body) stretch and shoulder pendulum exercises. Group 3 (control group) was assigned and performed shoulder pendulum exercises only and asked to perform 10 clockwise or counter-clockwise pendulum exercises twice a day.

The study noted that ‘the horizontal adduction stretch is more effective 
at reducing acute posterior shoulder tightness in the postoperative shoulder population when compared to the supine sleeper stretch and no stretch at all.

Not surprised but wanted to share the information and maybe help someone use this for their clinical practice.
Not sure why they chose supine sleeper stretch versus sidelying sleeper stretch but most likely because of pain tolerance.

Traditionally, the sleeper stretch is performed in supine. It’s modified by having the patient rollback to potentially put the shoulder in a more comfortable position. We wrote a paper about this in JOSPT 2013 with @wilk_kevin and @toddrhooks

I’m still more of a fan of the horizontal adduction stretch and use it clinically every day for my shoulder patients.

Burn Out in Physical Therapy

Just said yesterday that I don’t post my tweets to IG but get like this one should be posted here too.

Not going to say much more than I already have.. maybe a future blog post or something.

Curious to hear the comments below too. Throw it all at me and I’ll try to write something up in the future.

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

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

Surgery vs Physical Therapy for Carpal Tunnel Syndrome

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

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

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

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

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

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

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

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

Return to Sport Criteria and Reinjury Rates

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

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

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

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

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

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


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

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

Physical Therapy vs Knee Scope for Meniscus Tears

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

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

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

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

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

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

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

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

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

Shoulder Health Accessory Exercises

by @kieferlammi

Want strong and healthy shoulders!?

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

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

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

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

Give these two exercises a try:

✅ Band Front Raise Pull-Apart

✅ Band Overhead Y Raise

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

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

Should we Brace after an ACL Surgery?

  
 
 
 
 
 
 View this post on Instagram
 
 
 
 
 
 
 
 
 
 
 [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
 
A post shared by  Lenny Macrina MSPT, SCS, CSCS (@lenmacpt) on

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

 

Documenting Knee Extension Range of Motion

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I’ve talked a lot about the importance of regaining knee extension range of motion (ROM) after a knee injury or surgery. In this post, I want to talk about how exactly I believe we should be documenting knee extension range of motion.

I think it’s important because I hear many other medical professionals and students document differently. Hope this post clears the air and gets everyone on the same page.

Knee Extension after ACL

I’ve written about getting knee extension back after an ACL and how to figure out if it was a cyclops lesion or not. You can read this recent post if you like..it should help you gather more information on diagnosis and treatment of a cyclops lesion.

Therefore, I can’t stress the importance of obtaining not just knee extension, but symmetrical hyperextension after a knee injury or surgery.

With that, I feel as if many practitioners are all over the place with their documentation. This makes it difficult to communicate with each other and with the patients.

Documenting Knee Extension Range of Motion

In this video, I discuss the rationale for how I document knee hyperextension. I think it;’s important that we’re all on the same page to avoid confusion.

 

Does this make sense to you? Is this how you document knee hyperextension?

Let’s discuss in the comments section or on social media. You can find me on Twitter or Instagram @lenmacPT.

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.