Tag Archive for: pain

Testing the elbow for a UCL sprain in baseball players

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I have assessed hundreds if not thousands of elbows for various injuries. One of the most common ailments that I see in my practice is a UCL (ulnar collateral ligament) sprain, aka ‘Tommy John ligament’, especially in a baseball player. This post discusses the typical presentation of a UCL sprain, testing the elbow for a UCL sprain and how I rule in/out with a few simple tests.

Factors contributing to UCL sprains

Injuries to the elbow UCL continue to grow due to many factors. Some think it may be due to:

  • current training regimens,
  • sports specialization,
  • overuse/fatigue,
  • weighted ball training or
  • increased velocity.

(Seems like a great outline for future blog posts!)

Whatever the thought, the clinician needs to be able to differentially diagnose the issue and come up with a game plan that meets the goals and desires of the athlete. No algorithm is going to fit perfectly into each individual’s current/future baseball plans.

That’s why I carefully consider each factor and review it with my baseball players so we can come up with a good game plan in case they get diagnosed with the dreaded UCL sprain!

The Typical UCL Story

Most of the pitchers that come to me with elbow pain have a similar story… and it’s probably not what you would think. Often times, it’s not a dramatic blowout where the ball goes flying into the stands while the pitcher is writhing in pain. Most commonly, it’s a slow onset of elbow soreness, loss of velocity and/or location, or tingling into their fingertips.

The epidemic of Tommy John injuries has freaked out most pitchers. They automatically think they’ve blown their elbow out if they even feel a slight hint of pain or soreness.

It’s up to the clinician to determine what structures may be involved and to have a firm plan in place that allows for a gradual return to throwing or to refer out to a surgeon that you trust.

Unfortunately, it’s not always clear-cut. We need to be able to sift through the stories and recognize that there are many potential causes for elbow pain in a baseball player.

Differential Diagnosis

There are many structures that could become injured in a baseball pitcher. Let’s quickly run through the most common injuries and give my thoughts on each:

  • Flexor-pronator strain– often accompanies a UCL sprain because static stability compromised; painful resisted wrist flexion and sometimes extension. Palpable tenderness in muscle belly not close to the UCL insertion (sublime tubercle.) Often pain-free UCL special tests.
  • Loose bodies: pain-free UCL special tests, pain with late follow-through phase of throwing; significant posterior elbow pain with bounce home test that replicates their symptoms
  • Ulnar neuritis: tingling in the 4th-5th fingers (ring and pinkie fingers); often accompanies a UCL sprain due to increased medial elbow laxity; rarely an isolated event in my opinion.
  • Little Leaguer’s elbow: younger pitcher/player less than 14 years of age; may have painful UCL tests; pain at similar location but often closer to epicondyle; MRI to confirm; rest for at least 3 months; don’t mess with these (would’ve been a UCL if a couple years older and has a higher propensity for a UCL issue later in life.)
  • Thoracic Outlet Syndrome: pain-free UCL tests; loss of control (some call it the yips); vague heaviness and weakness with loss of velocity and location; TOS sees us more than we see it
  • Cervical spine: negative UCL tests; need to consider myotomes and dermatomes; not as common in younger-aged baseball players but may be seen in older pitchers

My go-to UCL tests

There are many tests out there but after many years of playing around with lots them, I have narrowed it down to 4 tests that I feel are the best to help diagnose a UCL sprain. Check out the video below.

 UCL Treatment Options

The treatment options will vary case by case and highly dependent on many variables. The clinician and client need to consider:

  • How much rest, if any has occurred- should try AT LEAST 4-6 weeks of no throwing and rehab to restore ROM (GH flexion, external rotation, and horizontal adduction) then attempt an ITP if pain-free on the clinical exam.
  • Time of year- If it’s the end of the baseball season, may shut it down to give the athlete plenty of time to rest. If clearly needs surgery, plan surgery and rehab, including throwing programs, to last 12-18 months before return to competition.
  • Previous injury history- previous history of elbow issues, especially Little Leaguer’s elbow sets off many bells and whistles; had tingling into fingers a previous time but it went away with some rest; Rest may help but usually leans toward surgery.
  • Tommy John Surgery- reconstruct the ligament; need at least 9-12 months if a pitcher…the longer the better it seems
  • Internal brace UCL repair- a new procedure that repairs the ligament then braces it with a collage-dipped fiber sewn into the joint; currently a quicker rehab but no long-term outcomes and not for all.

To Tommy John or not…that is the question

Wrapping it up, I’d just like to add that there are probably many more scenarios that could play out. My goal was to give you some sort of framework and guidelines for someone presenting with a medial elbow issue and looking for answers.

The cluster of tests seems to be pretty straightforward and simple to understand, hopefully! There are a bunch of possibilities but Tommy John issues should be diagnosed with a good history and careful examination…good luck!

Anterior Knee Pain- A Test for Fat Pad Irritation

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We as physical therapists are constantly seeing patients with anterior knee pain with a very vague history. Often times, there’s not a specific onset or mechanism of injury. With that, it seems as if the retro patellar fat pad is a common source of pain in many people and is commonly overlooked.

What actually hurts in the knee?

Whenever I am evaluating someone with knee pain, I always keep in mind the Dye et al AJSM article from 1998. In my opinion, this is a keeper for all PT’s and future PT’s to have in their arsenal of top literature papers.

For those that are not familiar, let me explain it a bit.

Basically, San Francisco orthopaedic surgeon Dr. Scott Dye had his knee scoped without any anesthesia. That’s right, classic beast mode!

He did have local anesthesia (for the record), so they could make the incisions…otherwise, he was awake and alert for the whole procedure.

This allowed him to report back to his colleagues (one being his brother) an actual pain response as they were poking away at the different structures within the knee. He ranked the pain on a 0-4 scale with 0 being pain-free (patella cartilage) and 4 being a severe pain (fat pad, anterior synovium, joint capsule.)

You can read the article to get the full gist (and I HIGHLY RECOMMEND this!) but my point is to let you realize that there are only certain structures capable of causing severe pain in the anterior knee.

Their Findings

Cartilage is avascular and aneural. It has no blood supply or nerves that innervate it. None! So the whole chondromalacia patella diagnosis attempting to implicate a maltracking patella is often hogwash.

But the fat pad, anterior synovium, and anterior capsule are extremely painful and are often involved, I believe, in patients that we see on a daily basis.

In my opinion, this is a diagnosis that sees us more than we see it. Like thoracic outlet syndrome… we can talk about that a different day though.

Back to the point of the blog.

1 Test for Fat Pad Assessment

Assessing the knee and asking the right questions is critical. Besides a tremendously great subjective, there’s one test that I use to rule in or out a fat pad irritation. Check out the video below:

I promise you this test is a great way to establish a pretty clear diagnosis and reassure the patient that a specific structure may be the issue.

When it’s painful, its pretty obvious and the patient can immediately report back to you their symptoms. I test for this a bunch in a given week and it’s not always present. But when someone presents with a positive finding, it’s pretty relieving to them (believe it or not.)

Differential Diagnosis

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

  1. Meniscus (see my previous blog post)
  2. ITB
  3. Osteochondral lesion
  4. Patella tendonitis
  5. Pes anserine bursitis
  6. MPFL sprain
  7. Hamstring strain
  8. Plica syndrome
  9. MCL/LCL
  10. Tumor

That’s a bunch to consider for someone who can’t really explain why or when their injury occurred. That’s why I still believe this overuse injury sees us more than we see it.

Treatment of Fat Pad Irritation

This one can get a bit tricky. Again, it’s often due to an overuse injury. In others, it’s attributed to kneeling on it for too long or banging it against something. In those more acute cases, the answer is pretty straightforward. Ice, motion and progressive return to their function.

In the overuse group, which is more prevalent in my opinion, we need to figure out which stimulus is causing the issue. It’s often due to starting a new program or ramping up too quickly during some training event.

In these people, I need to modify their volume of training or destress the area by giving them new activities that they can do pain-free…but only for a short period of time.

Along with activity modification, a course of some form of modality (yup, the M-word was used) can help expedite the pain control. I still have a special place in my heart for iontophoresis with dexamethasone. I’ve had tremendous results in patients with fat pad irritation.

I also like to use a low-level laser to help with the healing process (future blog post alert!) I’ve used it on my self for various ailments and even my dog after her ACL surgery. I’m definitely a believer in the healing power of the laser when applied in the correct situation.

Besides all of that, I would also want to assess the person’s movements and attempt to adjust any motions or movements that I thought could contribute to the knee pain. Often times, there’s an underlying weakness or misconception of a weakness that needs to be explained to the patient.

These things run their course for a few weeks but should improve pretty quickly if handled correctly. Patient gratification is pretty obvious because their pain diminishes after a session or 2 and they buy into the program pretty quickly.

Fat Pad Conclusions

Infrapatellar fat pad irritation can be functionally debilitating. I believe it presents itself pretty often in the clinic, more than most PT’s realize. Use my test above to see if it truly is a fat pad issue. Here’s a nice open-access article that you can read to learn more about the fat pad.

Remember, the test should be pretty obvious and locally oriented. If pain-free, then move on. If not, then try some of my above recommendations. It’s usually an overuse issue so you need to adjust their volumes and maybe some form of mechanics.

Mike Reinold and I discuss this and much more about how we treat the knee conservatively. Check it out in our acclaimed all online knee course www.onlinekneeseminar.com.

Kids and Sports Injuries: What are we doing wrong?

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I recently had a conversation with a parent who reached out to me slightly concerned for her 12-year-old child. He’s stressed out, hurt again and she didn’t know if I could help. It made me think about kids and sports injuries… and how we could make a difference.

Real Life Story

I had seen this kid for an overuse elbow injury within the past year, a growth plate fracture of his medial epicondyle. He’s a catcher for his team, one of many teams that he plays on. He had considered converting to pitcher but I believe he was going to rethink that decision.

He also wrestles, has multiple hours of homework each night, has hitting lessons and practices with his teams…even in the dead of Winter in December. If he’s late to practice, he gets yelled at by the coaches. Not just a casual “why are you late” kinda question but a scolding that would make any 12 year old (or adult for that matter) think twice about what they’re doing. At least this is what Mom tells me.

So Mom called me recently to discuss her son’s predicament. He’s not feeling good about himself and worried about making the AAU team. He’s a decent sized kid, big for a 12-year-old, so he tends to stick out. He can throw harder than the other kids and can probably wrestle slightly better. I’m just guessing here…I’ve never seen him wrestle.

Mom is worried that he’s too stressed with all of the sports and schoolwork. I think she may be right!

I recall a 12-year-old Lenny playing my last year of Little League baseball but that didn’t start until May or June (Yup, that’s me below on the right with my brother Brian).

During the months of November and December, I was playing basketball, hockey and tackle football in the snow. There’s nothing like tackle football in the snow…trust me all of you warm-climate readers!

What does the research say & do kids need to specialize to play college or pro?

With that, I decided to dive into the literature and see what it says…

Most recently, a 2017  study in AJSM looked a 1st round draft picks from 2008 to 2015 in the NBA. They concluded that “those who were multisport athletes participated in more games, experienced fewer major injuries, and had longer careers than those who participated in a single sport. ”

Interestingly, of the 237 athletes included, 36 (15%) were multisport athletes and 201 (85%) were single-sport athletes in high school. Yikes!

This 2017 study from The Sports Health Journal looked at division 1 college athletes. They asked them to complete a previously utilized sports specialization questionnaire regarding sport participation patterns for each grade of high school.

Specialization increased throughout high school and ~ 41% had eventually specialized in a sport b their senior year. Conversely, only 17% of the freshman had specialized in a sport. Also, football athletes were less likely to be highly specialized than non-football athletes for each year of high school.

Do football players just need time off because of the nature of the sport? Makes you wonder…

A similar finding was seen in this study from 2017 in AJSM. They basically showed that 2011 young athletes between the ages of 12-18 that became specialized in a sport had higher injury rates by nearly 2 fold.

Nearly triple the rate of injuries

In another study out of Wisconsin looked at high school athletes between the ages of 13 and 18 years from 2 local high schools. Athletes in the high specialization group were more likely to report a history of overuse knee injuries.

Athletes who trained in one sport for more than 8 months out of the year were more likely to report a history of knee injuries (more than 2.3x more likely), overuse knee injuries ( 2.9x more likely), and hip injuries (2.7x more likely.) School size matters too. Kids that go to a smaller high school report playing in more sports than kids that go to larger schools. I see this daily in my own practice.

This descriptive level 3 epidemiology study in Sports Health Journal surveyed 235 athletes between the ages of 7-18 years. They showed that athletes started to specialize at the age of 8 years old, which is crazy!

They also showed that 60% played their primary sport for 9 or more months per year (which we know is already an increased risk of an overuse injury.) Nearly 1/3 of players ‘reported being told by a coach not to participate in other sports, with specialized athletes reporting this significantly more often.’ This kind of fits my kid above…an over-bearing coach that is pressuring the kids to practice all year round.

My Solution for him

So, my conversation with Mom ended by me telling her that I completely understood. I felt as if he needed more positivity in his life. That he was being pulled in way too many directions and needs a more positive role model (besides his parents, of course) to help him.

I had these studies in my head but I didn’t want to bore the Mom with statistics gibberish and big terminology. I told her that I loved that he played 2 sports although I didn’t like that he was speeding from school to wrestling practice, to baseball practice then to a hitting lesson. It just seemed like a lot…nevermind that he still had to get home to do all of his homework.

By the way, homework nowadays is a lot more than anything that I ever experienced as a child. It takes hours for these kids to complete. Maybe that’s why Massachusetts ranks as #1 in education in the US. A great feat for the teachers and students of this state!

But what does it mean to the youth athlete trying to play multiple sports or on multiple teams? How do they juggle all of this and get their hours of homework done?

It’s not just an isolated story…I hear this daily from our student/athletes of all ages. Kids in middle school and high school have more work to do than our college athletes. Or maybe the college kids are better at time management. I imagine it’s a little of both.

What Should we Recommend?

It’s becoming evident that specializing too early in one’s athletic career may not benefit the child in the long run. Remember, they are children that are skeletally immature. The stresses that they can handle are not the same as what an older, more developed and a mature kid can tolerate.

I’m always telling kids to take time off from their sport. I usually recommend 3-4 months of active rest. This means they can still work out that may include some baseball activities such as tossing/hitting but it can’t be the priority during their off-season.

They really need to go play another unrelated sport, like soccer or basketball to get stronger in their lower body. We all know the importance of a strong lower half…see pitchers like Roger Clemens below.

What better way to get stronger than to run and jump for hours at a time (and not have to throw anything with maximal velocity.)

I hope my advice helps my young friend and his Mom figure out his dilemma.  Unfortunately, this won’t be the last time I’ll be reciting the literature to a family looking for advice. We can do our part by keeping these findings in our treatment educational components as we help get our athletes back on the field.

Last Call- Kids & Sports Injuries

Because we’re beginning to see some interesting (crazy) injuries in our youth, it seems as if the literature is beginning to paint the picture for us.  Intuitively, one would think that playing multiple sports, getting enough rest and doing a little homework each night would be sufficient to allow a kid to get through high school or college (the few that do that.) Maybe this would allow the athlete to not sustain a significant injury. When I say significant, I mean an injury that requires months of rest, multiple doctor visits and rethinking if the kid should still be playing that sport.

Note: The Mom gave me permission to talk about our conversation and was excited to know that I was writing this post. In case anyone was worried…

 

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

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

Photo by Piron Guillaume

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

Recent Systematic Review & Meta-analysis

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

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

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

The inclusion criteria were as follows:

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

The exclusion criteria included:

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

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

  • have diabetes
  • smoke
  • worker’s comp

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

via GIPHY

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

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

Moving on…

Surgery better than Rehab

The study’s results concluded:

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

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

So what does this mean?

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

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

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

Study Limitations

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

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

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

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

My Conclusions

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

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

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

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

 

Diagnosing meniscus tears: What’s the literature telling us now?

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Meniscal tears are commonly observed in an outpatient physical therapy setting. The ability of a PT to evaluate a patient’s knee and diagnose a meniscus tear can help guide the treatment plan for that patient. Having specific tests that can accurately and quickly pick up a meniscal tear are valuable.

Lots of test options but stick with the subjective

There are many theories, tests, and exam techniques that are reported in the literature. I definitely don’t know all of them but have been exposed to a bunch of common ones that I have found to be helpful.

Before I get bogged down with these tests and try to sound intelligent, I’d be remiss to not state the obvious… the subjective portion of the exam is by far the most important aspect and needs to be thoroughly utilized.  In many cases, ok maybe most cases, the client will tell you what’s going on…as long as you ask the questions correctly and listen to their responses.

This will most likely be a blog post at some point in the near future but as a collective profession known as medicine, we suck at listening and utilizing the information correctly. But I digress…

What Tests are out there?

There are many tests reported in the literature, commonly including:

  • McMurray’s
  • Apley’s compression
  • Joint line tenderness
  • Thessaly’s
  • End range flexion/extension overpressure

Unfortunately, the literature does not support using these tests to diagnose and may add to the fear avoidance a patient may exhibit after such a diagnosis. This systematic review and meta-analysis in the British Medical Journal stated:

“The results of this systematic review indicate that the accuracy of McMurray’s, Apley’s, JLT and Thessaly to diagnose meniscal tears remains poor. This conclusion must be taken with caution since frequent methodological design flaws exist within the included studies, most studies suffered from various biases, and between-study heterogeneity makes pooled data unreliable.”

To tell you the truth, I don’t even do the Apley’s compression test. I probably haven’t done the test since PT school sometime in 2001. Never saw a value, kinda like the Thessaly Test. Nice in theory but just not good enough when tried in a clinical setting. Unfortunately, most research and the associated methods are lacking so the results are pretty poor when trying to diagnose a meniscus tear.

Oh boy, now what do we do? Do we even need to diagnose the tear in the 1st place and add more fear to the patient’s hurting knee?

Even need to Diagnose Meniscus Tears?

I say yes… but with a caveat!

We must accurately diagnose and explain to the patient that many people have meniscal tears in their knee. The recent literature builds a strong case for a very good recovery without surgery. That’s right, surgery is often not needed for many people diagnosed with a meniscus tear.

This landmark paper in the New England Journal of Medicine (neighbors of Champion PT and Performance in Waltham, MA) really created waves when it was released in 2013. They stated that “outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.” Now, these people did have a diagnosis of knee arthritis as well, but so do many of the people we see on a daily basis.

Hopefully, many clinicians have changed their treatment algorithms and have opted for conservative treatment first.

Don’t get me wrong, surgery may be needed, especially for the people sustaining an acute meniscus tear.  But that may only be a small portion of the people presenting to us in the clinic.  In these people, I still say give it a bout of conservative treatment to calm the knee down, restore ROM and strength and see how they do. Maybe a 6 week PT course is all they need, you never know. I have definitely seen it work, no doubt!

What meniscus tests do I do?

With all of that being said, I still believe your clinical examination is ultra-important to help guide the treatment plan.

As usual, keep it simple and don’t over-search. It needs to be pretty straightforward and it often is. The exam NEEDS to match the clinical history…let me say that again….the exam NEEDS to match the clinical history.

The client is going to tell me their issue and I just need to make sure my tests and measures solidify my working theory. I promise you that if you ask the right questions the right way, then you will have that much more information to at your disposal.

So, my go-to tests are:

  1. Joint line palpation
  2. End range flexion/extension pain/locking
  3. McMurray’s (but often not very valuable)

…in that order. I’d say joint line palpation and end range of motion are my 2 most valuable tests. I still do the McMurray’s test to see if it can add to the story. It often gives me very little information so I don’t rely on it too much.

Many of you are going to ask why I didn’t even mention the Thessaly test. I see it talked about a lot on social media. I just don’t understand why we’d want to put our client in a weight-bearing position, slightly bend their knee, and have them twist on a painful knee.

Never mind the research telling us that the test is not very valid which goes completely against early research that said it was a valid test.

The more (tests) the Merrier

Maybe we need to combine this test with others to help improve our accuracy as this paper showed in 2009.

Either way, there seems to be a case to cluster tests to help us draw better conclusions, as was stated in this paper in 2006.  “Five positive findings on composite examination yielded a positive predictive value of 92.3%. Positive predictive values remained greater than 75% with composite scores of at least 3 in the absence of ACL and DJD pathologies.”

This paper nearly matches my thought process. Obtain a good history, assess the joint line for tenderness, then put the joint at end range flexion/extension. If the symptoms match, then we will OFTEN have a meniscus tear.

Keep in mind that the particular side of the meniscus tear may influence the ability to detect a pathology. Lateral meniscal tears may be easier to distinguish than medial meniscal tears if we’re talking about joint line tenderness alone and was even the case in this 2009 article too.

Final Word on Diagnosing Meniscus Tears

Meniscus tears are pretty prevalent in the outpatient setting. Rehab specialists, including PT’s and athletic trainers need to understand what tests are best to deploy. I’m sticking with my in-depth history, joint line tenderness, and painful end-range as my go-to cluster of tests.

I’m pretty sure it has done me well over the years…and the research seems to match my thoughts too.

Online Knee Seminar Course

We discuss this and much much more in my online knee course that I have with Mike Reinold. If interested, check it out at www.onlinekneeseminar.com and let me know what you think. We cover the anatomy, rehab prescription, ACL, knee replacements and patellofemoral issues both non-operative treatment and post-operative treatment. This is an awesome course if you’re interested in learning more about rehabilitating the knee joint.

 

 

 

Simple steps to Rotator Cuff Rehabilitation

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

 

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

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

via GIPHY

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

10 Key factors in Rotator Cuff Rehab

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

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

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

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

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

What’s the plan?

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

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

Calm down the shoulder pain

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

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

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

Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.

Initiate higher level strengthening

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

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

Advanced strengthening

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

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

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

Well, maybe not this aggressive!

Return to Sport Program

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

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

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

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

Final Rotator Cuff Thoughts

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

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

References for above paragraph:

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

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

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

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