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Is Early Physical Therapy Safe After a Rotator Cuff Repair?

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Physical therapy is vital after a rotator cuff repair and continues to be common in an outpatient setting. Unfortunately, there’s no true consensus on when to actually begin PT.  Is early physical therapy safe after a rotator cuff repair or should we delay PT to protect the healing tendons?

Let’s dive into this and see what the research is saying…

Why I’m writing this post on rotator cuff rehabilitation

It seems as if we’re all over the place despite the research, which is pretty typical. Some docs prefer early passive range of motion (PROM) while others wait 6-8 weeks (and even up to 12+ weeks for a revision repair) before they allow any form of PT.

For the record, I’m going into this blog post as a firm believer of early PROM. It’s what we’d been doing for years in Birmingham at Champion Sports Medicine.

It’s what I only knew until I moved to Boston in 2014. Now I’ve seen a nearly 180-degree turn in rehab thoughts. Much more conservative!

I recently got in a Twitter discussion (debate) about this same topic with some very respected and prominent PT’s in the field.

It made me think about things so I decided to do a little research to see what the literature says. You can check out the discussion here.

Twitter can be confusing and tough to follow but just trust me, it goes on for a while!

Rotator Cuff Anatomy

The tendon most commonly torn is the supraspinatus tendon. Don’t get me wrong, you can tear the other rotator cuff tendons (infraspinatus, teres minor, subscapularis).

Keep in mind a medium, large or massive rotator cuff tear often will involve the infraspinatus tendon. If it does, then you need to consider modifying your progression appropriately.

But for the sake of this post, I’m going to stick to an isolated supraspinatus tendon for now.

Rotator Cuff Tendon Size and Location

Look at the size of the tendons as they insert on the greater tuberosity. You’ll see it differentiated by antero-posterior and medial-lateral directions.

According to my colleague and friend Jeff Dugas out of Birmingham, he showed in 2002 that the mean dimensions of the supraspinatus insertion were 1.27 cm in the medial-to-lateral direction. For the anterior-to-posterior direction, the supraspinatus dimension was 1.63 cm.

It helps to know this information because you may need to read an operative report and see the size of the tear. The docs will usually mention a 2 cm tear or something like that.

That means that the supraspinatus tendon and a small portion of the infraspinatus tendon were involved (and repaired.)

This is critical information to have when you’re trying to plot the post-op rehab progressions and determine the prognosis. The more tendons involved, then the higher the chance of repair failure.

There are many other factors that influence retear rates but tendon repair size is definitely one to consider.

Rotator Cuff Repair Surgery Types

I’m not going to bore you with the details of a repaired rotator cuff. There are numerous surgical techniques being used by orthopaedic surgeons.

Techniques such as a single row, double row, suture bridge or transosseous repairs are commonly performed. The picture below shows the difference between a single row and a double row repair, for example.

As you can see below, the double row tends to repair more of the tissue back to the humeral insertion point, which in theory has led to better tendon healing. This has been shown in numerous research studies and has become the best technique available.

So you had shoulder surgery…when to start physical therapy?

That seems to be the million dollar question! The research is all over the place. This means that doctors’ opinions are all over the place too, right?

Keep in mind that I’ve written about this in the past. Rotator cuff repair surgery is not always warranted and can be avoided!

Since I joined the group in Birmingham in 2002 (as a PT student), we had our post-op rotator cuff repair patients starting PT post-op day 1. They started PT early regardless of the tear size. This means a small tear of 1 cm in length started PT the same time a massive, 5 cm repair would start PT.

Some may disagree with this start time but it worked…it just worked. At least I think!

Why Early PT after a Rotator Cuff Repair

This is Key!!

There were several reasons why I think it worked:

  • They could chat with a professional.
  • Patients better understand their pain and get reassurance that what they were feeling was normal.
  • Someone could monitor their incisions and answer any and all questions.
  • Begin early, gentle ROM which often helps with pain control, too.

But, that was our ‘protocol’ and it continues to be that way many years later. Most other doctors that I have dealt with outside of Birmingham have taken a far more conservative approach to post-op rehab.

Agree to Disagree

Here in Boston, most docs wait at least 2-3 weeks and even up to 8-12 weeks to begin PT. Talk about eye-opening!

I don’t agree with this premise and wanted to dive a bit deeper into the literature to see if early physical therapy had a detrimental effect on short-term, mid-term and long-term outcomes.

Structure vs Function

The problem that continues to plague the research is the measurement of outcomes. Doctors care about the structural integrity of their rotator cuff repair. They see the research and are concerned with retear rates that hover in the 25-70%+ stratosphere. Of course I’d be concerned with retear rates that high!

Can you imagine if ACL re-tear rates were that high? Well, guess what they still hover in the 6-40% range even with our tremendous rehab skills and return to play testing.

But fortunately, we have other parameters to consider with our patients after a rotator cuff repair. We can look at the pain-free function!

Huh, what a novel idea. Regardless of the integrity of the repair, many patients can still live their lives to the fullest and in most cases without any pain.

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Start PT Early after a Rotator Cuff Repair? What does the literature say…

I’m going to do my best and unbiased research to figure out if early PT after a rotator cuff repair is safe and effective compared to a delayed protocol. Let’s take a look…

There are a bunch of studies out there that you need to sift through. You can tell when the lead authors are MD’s or PT’s because the docs want to make sure their repair integrity is intact and the PT’s are concerned with restoring ROM, strength, and function.

With that, I’ve done my best to pull out some studies that have helped guide my practice and continue to influence me today.

Literature Review Findings

Age a BIG Factor!

Mind you, Cho et al showed that healing rates after a rotator cuff repair drastically change for older patients compared to younger patients.

The slide below was taken from my rotator cuff lecture that I’ve done in the past and helps to put things in perspective.

In no particular order…

Parsons et al JSES 2010 looked at 43 full thickness RTC repairs who were in a sling for 6 weeks. All were without PT for that time then evaluated for stiffness in PROM. They defined stiffness as 100° flexion/ 30° ER.

Overall, of the 43 surgeries, 23% (n=10) became stiff after that 1st evaluation session. The whole cohort displayed a 56% retear rate overall at 1 year, which to me seems crazy high!

To break it down further there was:

  • 30% retear in stiff group
  • 64% retear in non-stiff group
  • There was no significant difference in ROM or functional scores.

In my opinion, there were some pretty big limitations to the study that should be exposed, like:

  • Single row repair
  • No consideration for Diabetes or smoking
  • MRI without contrast to re-evaluate the repair status
  • What is “ER by the side???”- need to better define what degree of abduction.

So getting stiff may be a good thing but the repairs were done as single row repairs. We know these did not heal as well as they do with double row repairs.

More Literature Reviews

Moving on to a 2014 Level II systematic review and Meta-analysis, the authors said “the results contradicted our hypothesis that immobilization would increase tendon healing compared with an early-motion rehabilitation protocol, as structural outcomes were similar in the two groups 1 year after the arthroscopic repair of rotator cuff tears.

From the paper: “We speculate that rehabilitation is not the sole factor affecting tendon–bone recovery; the effects of other factors, such as older age, fatty degeneration, larger tears, and surgical technique, may outweigh those of the rehabilitation protocol.”

Kim et al AJSM 2012 looked at small to medium sized RTC repairs. They compared immediate PROM (0-120 degrees) to 4 weeks of absolute immobilization. They eventually showed no difference in ROM, pain or tendon healing. So seems like a smaller tear of less than 3 cm may be appropriate for immediate ROM, albeit it was limited to 120 degrees for some reason.

Not sure why they limited to 120 degrees because it seems as if the tendon would shorten as the humerus is placed in further flexion. Maybe they were concerned with subacromial impingement or something but the limitation is a bit confusing to me.

Healing Affected?

Another study by Lee et al AJSM 2012 wanted to compare ROM and healing rates between 2 different rehabilitation protocols after arthroscopic single-row repair (use caution) for full-thickness rotator cuff tear.

They showed pain, ROM, muscle strength, and function all significantly improved after arthroscopic rotator cuff repair, regardless of early postoperative rehabilitation protocols.

They also looked at the repair integrity with postoperative MRI scans, 7 of 30 cases (23.3%) in the immediate ROM group and 3 of 34 cases (8.8%) in the delayed group had re-tears, but the difference was not statistically significant (P = .106).

Well then, only a trend and all had similar functional outcomes regardless of when they started ROM…I’d say that helps the case to start early.

But again, these repairs were done via a single row repair and they allowed manual therapy 2 times per day and unlimited self-passive stretching exercise, which seems a bit aggressive anyway.

Do we even need a sling for 6 weeks?

No Functional Difference Between Three and Six Weeks of Immobilization After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Non-Inferiority Trial Arthroscopy 2018

This study looked to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff repair in a prospective randomized controlled non-inferiority trial.

They concluded that “3 weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace.” For the structurally concerned people out there, MRI indicated similar degrees of healing between the groups. 

Well then, that throws a wrench in things for the docs!

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Does Early vs Delayed PT Affect Outcomes?

A systematic review by Gallagher et al 2015 looked to determine if there are differences between early and delayed rehabilitation after arthroscopic rotator cuff repair in terms of clinical outcomes and healing.  Six articles matched their criteria and reported significantly increased functional scores within the first 3-6 months with early rehabilitation compared to the delayed group.

To me, this is huge! Put yourself in their position. Imagine feeling better and being able to get back to work a little quicker. That’s my major argument for starting rehab sooner. Earlier pain relief, improved function and a feeling of being normal again.

Furthermore, none of the included studies reported any significant difference in rates of rotator cuff re-tear.

Medium-Large Tears use Caution

However, two studies noted a trend towards increased re-tear with early rehabilitation that did not reach significance. This was more pronounced in studies including medium-large tears. A similar trend that I’ve seen in the literature.

Here’s a nice table from that Gallagher study that summarized their findings for each research paper they included:

I want my patients to feel good as quick as possible and get back to some semblance of a normal life. But of course I want the long-term integrity of the repair to remain intact. And it seems as if this study helps that argument.

Then you look at a group of PT’s from Turkey (Duzgun et al Acta Orthop Traumatol Turc. 2011) that looked to compare the effects of the slow and accelerated protocols on pain and functional activity level after arthroscopic rotator cuff repair. Patients were randomized in two groups: the accelerated protocol group (n=13) and slow protocol group (n=16).

There was no significant difference between the slow and accelerated protocols with regard to pain at rest.

The accelerated protocol was superior to the slow protocol in terms of functional activity level, as determined by DASH at weeks 8, 12, and 16 after surgery.

I’ll take that!

Function over Structure (at times!)

Told you that the PT groups tend to favor function over structure, haha!

Early passive Motion ok- The French Version

This next study out of France that included French Society for Shoulder & Elbow ( 2012) looked to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks.

They concluded that their results suggested that early passive motion should be authorized: the functional results were better with no significant difference in healing. Functional results were statistically better after immediate passive motion and a lower rate of adhesive capsulitis and complex regional pain syndrome.

Seems as if there may be a trend but certainly not an overwhelming conclusion that early ROM is guaranteed to lead to inferior structural results. But, it seems pretty conclusive that ROM, pain, and function are improved after early ROM.

Let’s continue to look at the research

This group from China (Shen et al Arch Orthop Trauma Surg. 2014 Sep) performed a systematic review and meta-analysis to determine whether immobilization after arthroscopic rotator cuff repair improved tendon healing compared with early passive motion. Three RCTs examining 265 patients were included but we need to be cautious because of the limited number of studies included and the heterogeneity of the samples.

They found that there ‘no evidence that immobilization after arthroscopic rotator cuff repair was superior to early-motion rehabilitation in terms of tendon healing or clinical outcome. Patients in the early motion group may recover ROM more rapidly.’

This recent 2017 study in the Journal of Shoulder and Elbow Surgery included 9 meta-analyses in its review. They basically noted, “No clear superiority was noted in clinical outcome scores for early-motion or delayed-motion rehabilitation.”

They also concluded that “Whereas early motion and delayed motion after cuff repair may lead to comparable functional outcomes and retear rates, concern exists that early motion may result in greater retear rates, particularly with larger tear sizes.”

So, it seems as if function and healing the same after a RTC repair but there may be a discrepancy once we start looking at a larger repair size.

Immediate PT after a Revision Rotator Cuff Surgery

This study in AJSM 2018 looked to evaluate the clinical and radiological outcomes after revision rotator cuff repair surgery. They were able to track 31 of 40 patients (77.5%) for the final assessment at a mean follow-up of mean 50.3 months.

Interestingly enough, physical therapy started on the first postoperative day with passive flexion and abduction.

Revision rotator cuff repair improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing.

And they started PT 1 day after the surgery and got PT 2-3 times per week.

Retear Rates and Long-term function

This study in JBJS 2006 looked to determine the clinical and structural outcomes of re-ruptures in twenty patients after a longer period of follow-up. Nineteen of the twenty patients continued to be either very satisfied or satisfied with the outcome.

At an average of 7.6 years, the clinical outcomes after structural failure of rotator cuff repairs remained significantly improved over the preoperative state in terms of pain, function, strength, and patient satisfaction.

They also found that re-ruptures of the supraspinatus that had been smaller than 400 mm(2) had the potential to heal….wow!

Failure Rates too High!

Another study in JBJS 2013 looked at 18 patients who had undergone arthroscopic repair of massive rotator cuff tears.  At two years of follow-up, 94% had a failed repair. This current study wanted to evaluate the 10-year results for these patients with known structural failures of rotator cuff repairs.

Despite a high rate of progression of radiographic signs associated with large rotator cuff tears (proximal humeral migration or cuff tear arthropathy), most did well.

Clinical improvements and pain relief after arthroscopic rotator cuff repair of large and massive tears are durable at the time of long-term (10 years) follow-up. They went on to say:

“These results demonstrate that healing of large rotator cuff tears is not critical for long-term satisfactory clinical results in older patients.”

So our obsession with healing rates still appears to be overblown, even in older patients with a known cuff tear.

Pendulum Exercises Effects on Muscle Activity

Activation of the Shoulder Musculature During Pendulum Exercises and Light Activities JOSPT 2010

Look at that Paper in JOSPT 2010 (I’ve pulled out the Results Table for you below).

If there’s one exercise that doctors allow after a rotator cuff repair then it’s a pendulum or Codman exercise. How often does our patient do them correctly and make it a completely passive motion? I’d say rarely if seldom, right?

Most often, the patient is just bent over and actively moving their shoulder. They have no body movement or sway. Most of the movement is shoulder based and are not completely relaxing their shoulders.

Furthermore, they were instructed in the doctor’s office that 1st week or 2 after surgery.

They’ve been doing them incorrectly for weeks on end because they have no one to help them (cough cough!)

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EMG of common Rehab ExerciSES

A study in JOSPT 2016 looked at EMG activity in healthy individuals. They wanted to quantify muscular activity during daily tasks and common PT motions. They showed that “of all the tasks assessed, ambulation without a sling and donning and doffing a sling and a shirt consistently showed the highest activity.”

EMG results table is found below.

Pretty helpful to see it listed by muscle and EMG activity and specific movement.

EMG of contralateral movements

A pretty neat EMG paper from 2004 (small n=6 and healthy individuals) were assessed using fine wire and surface EMG during common functional activities of the contralateral extremity while immobilized.

They found high supraspinatus EMG activity of the immobilized shoulder for all fast pulling activities of the contralateral shoulder (25-32%)!

Furthermore, they found high infraspinatus activity (56%) of the immobilized shoulder when the contralateral extremity performed straight forward reaching activities.

So even if they are immobilized and using their non-operative shoulder for daily activities, the rotator cuff is still sustaining a higher amount of activity than anything that we would do in the early phases (PROM, dowel self-ROM, rope and pulleys, properly performed pendulums).

How about revision rotator cuff repairs, you ask?

This study from AJSM in 2018 looked at outcomes after a revision rotator cuff repair. They showed revision rotator cuff repair improved outcomes regardless of tendon integrity (MRI confirmed).

Oh boy, what is going on??

Dig deeper into the study and they started PT the 1st day post-op with passive flexion and abduction. Sounds familiar, no? And this was in revision surgeries.

We used a very similar approach in Birmingham as they did in this study, so I may be a bit biased.

My Closing Thoughts on Physical Therapy after Rotator cuff repair surgery

I think it just shows you that rehab can begin early, will not affect long-term outcomes and that tendon integrity is not correlated to function.

I honestly don’t think our 15-30 minutes of passive motion early on in the rehab process is significantly affecting outcomes and retear rates.

It seems as if the repair technique, contralateral arm daily use, compliance with proper exercises (like pendulums, for example).

Let’s not blame early PT. There are so many more variables that are more likely to affect rotator cuff repair outcomes than anything that we could do in PT.

So I say let’s get people into PT early, educate them, guide them and help them get over this painful surgery.

I’ve been doing this for years and have seen the benefits of early PT. I say the literature agrees with me!

Treating Patients with Low Back Pain

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My thoughts on treating low back pain

As many of you may know, I have been practicing physical therapy since 2003. Throughout that time, the clear majority of my patients have had injuries to their extremities. Yet, I somehow was able to ‘avoid’ treating patients with low back pain (LBP). As has been with most of my career, I wanted to share my thoughts on treating low back pain and how I went from completely confused, to utterly intimidated and finally to embracing a common injury.

My early years of LBP rehab and confusion

When I first graduated from PT school, I worked in an outpatient sports medicine practice in North Carolina. I saw a little of everything. There, I was mentored by a very senior PT who specialized in low back pain.

She tried to introduce me to the rotated innominate (didn’t even know what that meant at the time) and how she could fix people with those issues. I looked at the charts of her patients and they had been coming for years.

To me, that seemed like they trusted her and she was helping them. Then I realized quickly that maybe there was more to the story. Maybe she was or wasn’t helping them, but I could never say anything. Something was working so this new grad just went with it.

She would spend hours of her time explaining the pelvis and how we could influence its position. My mind just couldn’t grasp the biomechanics. To this day, I think I’ve blocked out many of the concepts because they just didn’t make sense to me.

They even sent me to an Institute of Physical Art class out in western NC. Again, I couldn’t grasp it which is ironic because I’m very much a biomechanics type guy when it comes to the extremities.

The back was just a mystery to me!

Nothing against the IPA course, but it didn’t jive with me. I just couldn’t apply it to my patients when I didn’t understand it in the 1st place.

Going back to my rotated innominate… I just faked it that I could feel the sacral torsion or the elevated ASIS.

As a new grad, I didn’t want to seem like my palpation skills sucked so I went along with the process. I just never applied it to my patients. I just did exercise with them, because that’s all I knew.

The Evolution of my LBP Fear

When I moved to HealthSouth in Birmingham, AL we had a separate spine department that was run by 2 PT’s. You know what that meant, I didn’t treat any spine patients!! Not sure why they did that, but I wasn’t going to complain.

This trend continued on when HealthSouth had a little accounting issue and Champion Sports Medicine was founded in late 2004.

Again, no spine patients on my schedule for ~ 10 years. Rarely, a patient would be on my schedule for more than a visit or 2 before I’d move them to the “Spine PT.”

Spine Scaries

I just didn’t have an interest in the spine and from what I had seen and heard, I didn’t agree with many of the ‘theories’ out there. I watched other PT’s look for limitations in individual spinal segments from the cervical spine to the sacrum…and even the coccyx (mind blown!).

Any time someone tried to teach me their assessments, I could never feel what they were feeling. No one felt limited or rotated unless I pushed a little harder with one thumb, then all of them were ‘rotated.’ I’m right handed so everyone seemed left rotated because I could push harder into the patient’s anatomy with my right hand.

So again, my faith in spine rehab dwindled and I built my practice around sports medicine and post-op injuries. That’s my niche but I knew that when I moved to Boston to help open Champion PT and Performance that I would have to make my skills better.

My current Approach to low back rehab

My career has been about simplifying my approach to physical therapy. In my earlier days, people were trying to help me (definitely grateful) but conceptually I just couldn’t grasp it.

I knew that there were very small the joints in the spine, but I just couldn’t ‘feel’ the millimeter or 2 of motion that was present. My palpation skills were dismal, but it turns out we may not be able to palpate what we think we’re palpating. (research) (More research) (even more research)

With that, I needed a game plan for my big return to my hometown, Boston.

My Macro Views

In my head, I could conceptualize watching someone move and trying to figure out if a movement dysfunction was the culprit. More of a macro view of the person instead of a micro view, like looking at individual joint segments.

My macro approach often came back to a strength issue or a simple overuse issue that led to back pain. We often blow this off and don’t account for it in our education and treatment.

Don’t Overcomplicate it!

In PT, we try too hard to complicate things.

Let’s think about it, if someone has pushed their tissues beyond their physiological limits (whatever that means), then something has to give.

In my opinion, most people that I see have overuse injuries as a result of overactivity or inactivity. It’s that simple. They’ve either pushed their muscles/joints beyond their capacity and the body is giving a warning.

Or they just don’t do enough to maintain, and the body is pissed off.

Answer in the details

For example, I see many people with non-specific low back pain that are active. Either playing baseball or working out. But, when you dive a bit deeper into their lives, they may have just started a new program that had more volume (weight training volume, more swings of the bat, more deadlifts).

It’s often stories of their (in)activities that are directly contributing to their current state. Never mind if you dive even deeper, then they reveal a stressor in their lives that MAY also be adding to their pain.

I am certainly not a pain science expert, but I can add up 1+1 and realize that life stress + physical stress can play a HUGE role in someone’s experiences of pain.

How I treat Low back pain

So what I do is pretty simple.

I assure my patients with lots of education and encourage early motions. Like any other joint, our body needs to move. Our joints need to move.

The last thing I want to do is discourage someone from moving.

I need to create an environment that is relatively pain-free and creates confidence in their ability to move. Trust me, I’ve been there!

What helped me, you ask?

I had an acute low back spasm a few years ago that was awful!

Advil, foam rolling my low back (what seemed to be my quadratus lumborum), soft tissue work to my low back (again, maybe my QL) and general low back/hip muscles and exercises. No one told me that I had a rotated innominate or that I had too much motion at L5/S1.

I don’t even know what that means.

All I did was try to move each day with a little less pain. I did things like Cat-Cow and dead bugs. I also did clams and bridging. I stretched my hip flexors and tried to squat a bit. I just did anything to promote a safe and pain-free movement.

It built confidence and it built function.

Most people need that after they hurt their back. I know we’re always looking for the reason why the pain occurs. We try to blame the anatomy or the biomechanics because we’re ‘movement experts’.

Keep it Simple

But I say we need to take a step back and realize that it can be even simpler than that. If we sit 8 hours a day, then we’re stagnant and our tissue capacity dwindles. Imagine sitting all day then randomly try to go play 18 holes of golf!

The muscles, tendons, ligaments and anything else in that area are not conditioned for the 90+ strokes it will take to finish the frustrating round.

You wouldn’t try to run a 10K without training for it 1st. Your legs and the cardiovascular system just wouldn’t allow it.

It’s the same thing with the concept of sitting all day then trying to be active. It often won’t work. You need to train the tissue!

Final Thoughts on Low Back Pain

If anything comes out of this blog, I hope it takes some of the scary thoughts that are out there and simplifies them a bit. The human anatomy is so much more complicated than we think. We can’t just blame a rotated innominate or left rotated lumbar spine segment for the dysfunction.

All of the systems seem to play a role but as PT’s we think we can control a couple of them.

I say build tissue capacity by a general strength training program that builds confidence in the client. Let them leave feeling super positive about themselves and I guarantee that your outcomes will be so much better.

No worrying about fake palpation, popping backs and charts that are years deep of short term relief. Hope I didn’t offend anyone but sometimes the truth hurts and I want my readers to hear my simple perspectives.

Now get out there and embrace your next low back pain patient (but don’t worry about the cavitation!)

Why you need “Feel” as a Physical Therapist

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I haven’t written a post in a while but wanted get back into the swing of things. In this post, I wanted to talk about having ‘Feel’ as a PT.

When I say feel, I’m talking about being able to read people and adjust the situation based on their response to things. So, what does that mean? Not really sure… but wanted to give a few examples that I have heard recently that I think happen pretty commonly in our profession.

Exercise Progression (or lack of)

This one happens a bunch in our profession and I was guilty of this early on in my career. It’s much easier to have someone come in 2-3 times per week and give them the same exercises, right? But to do this for multiple weeks, if not months, is a travesty!

Listen, I don’t think we need to progress someone’s program every session. Adding a new exercise each visit can be a bit much. know we want to make people feel as if they are moving forward in their rehab but there are other ways we can progress people besides giving them 17 different exercises that keeps them in PT for 2+ hours.

Again, I was guilty!

There are so many variables that we can manipulate for each session, it’s silly! Think about each move that someone does and break it down.

Exercise Variables to Manipulate

We can play with:

  • Tempo
  • Single leg versus double leg
  • Reps/sets scheme
  • Upper body or lower body
  • Time under tension
  • External resistance (bands, chains)
  • Rest periods between exercises
  • Perceived RPE (stole that one from Kiefer!)
  • Volume

So as you can see, even if you don’t have heavy weights as we do here at Champion PT and Performance, then you can still get creative with progressions.

The training facility at Champion PT and Performance in Waltham, MA
The training facility at Champion PT and Performance in Waltham, MA

Personally, my clients have the same program for 4 weeks and then we write them a new program. That means that they can focus on the aforementioned variables as needed even though they are doing the same exercises for 4 weeks.

The client likes it because they get really good at that movement plus they can see their progression in their weights, which is a huge mental gain!

Besides the obvious weight progressions, there’s a ton that can be manipulated but I don’t see or hear it enough from the patients that come through here. I rarely hear a client tell me that their previous PT experiences involved any type of variable manipulation but maybe that’s why they find us in the 1st place. Who knows…

My advice, let the patient feel as if they are moving forward in their exercise prescription because they are a smarter consumer than you would think. As PT’s we must do better with this stuff and the above bullet points are a good starting point for you.

Running on Empty

On another note, I recently started treating someone for a knee injury she sustained while skiing. Fortunately, she didn’t require surgery but the fracture needed time to heal. I don’t want to reveal too many details of the case for privacy reasons but just know she could’ve easily done more damage to her knee from the mechanism of injury.

She was given a brace and a prescription for PT to begin immediately for ROM and strengthening. She was limited in weight bearing for a period of time (I don’t remember the exact amount) so she had those effects that she had to deal with too.

At the beginning of the 6th week after the injury, her doc said she was fine to begin running even though no new x-rays were done on her knee. Guess they were just going off of time and that she was a healthy female without any co-morbidities.

Back at PT, she was told to start a running program that she thought was a bit early but she was excited to progress to more aggressive exercises.

According to her, she had been doing straight leg raises, clams, bridging and other low-level exercises for the whole duration of the rehab…see above rant!

Upon beginning her running program, she felt immediate pain and had to stop. She said she felt bad because the PT was surprised that the pain was still present but she wanted to work through it a bit. Despite trying to push through it, she still felt pain and had to stop again. She felt a big sense of failure because the pain persisted and she just couldn’t get over this hump.

Think Mode

Let’s think about this scenario for a second. Six weeks after a joint fracture, little strength training after a decent period of immobilization and the patient was expected to run?

As it turns out, the patient was frustrated enough with the scenario that she sought a second opinion and found us. I’ll never put down another PT’s plan of care but it was obvious that the plan was rushed and the patient’s opinions and communications were not fully observed.

She was frustrated and felt defeated but why? Why would someone be expected to run 6 weeks after a fracture without loading the joint and going through a progressive program?

I’m not sure but I wanted to use this case as a teaching moment for other clinicians, especially the younger crowd that may struggle with rehab progressions.

Listen Up!

Listen to the client and have a good understanding of basic soft tissue healing. I told the client that she needed a good 6-8 weeks of strength training before even talking about running. She was relieved that I wanted to take it slow and we now have a very happy client who has completely bought into my system.

Again, listen to your clients. They’ll tell you what’s wrong with themselves if you listen closely!

My Dad’s Knee Replacement

Switching gears, my Dad has his knee replaced a few weeks ago. Despite having treated a gazillion knee patients in my career, my Dad has yet to step foot in our facility. I’ve given him advice from a distance and have tried to keep an eye on things as they came up.

I’m not a home health PT and respect their jobs. I was surprised that no one ever tried to bend his knee during the home visits he had for nearly 6 weeks. Fortunately, he had about 80-90 degrees of flexion but the home health PT kept telling him he didn’t need more than 90 degrees of motion.

You try to get up from a chair with only 90 degrees of knee flexion! I’ll bet it’s much more difficult than 110+ degrees of motion. For the record, I shoot for 120 degrees of knee flexion ROM for all.

After home health, my Dad started outpatient PT and he sounded confident and happy. Yet again, no one felt the need to bend his knee (he did get some patella mob’s) and just showed him basic exercises like straight leg raises and squats.

Obviously an important component to PT but I still think getting more ROM is critical. I’ve talked about how I like to bend the knee after surgery at my YouTube channel that you can access here. As you can see, I prefer the seated position at the edge of the table for its comfort and isolation of the knee joint without hip compensation.

However, no one is bending his knee and he was feeling stiff. He did get a new PT for one of his sessions and they did bend his knee but only 2 times…and each time they cranked on it to the point he had to tell them to stop because of the pain.

Not how I would’ve initiated ROM!

Bad Ass Arya wouldn’t have been so aggressive either!

He’s now 3 days after the PT session and frustrated. He told me he can’t do anything around the house anymore and has considered taking pain medication to help get over the hump. This is the ‘feel’ that I’m talking about.

Why on Earth would any PT think this technique would be beneficial? I’ve heard this way too often in the past and am frustrated by it.

If that were you 🤔

My advice…as always, put yourself in their position and consider the risk/reward. Is this the best we can do and will the patient absolutely benefit from this?

In my Dad’s situation(s) I say he has received mediocre care so far. Fortunately, I have guided his home program and have tried to keep him positive and realistic.

He’s frustrated and vows to never consider his other knee even if he can’t walk. I hope he changes his mind once he gets stronger and more functional.

My lesson in this post- listen to the client and do what’s in their best interest. Have some FEEL and progress people more appropriately.

We can do better!

The Week in Research Review, etc 12-24-18

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The Week in Research Review, etc 12-24-18 only had two posts to social media this week but hopefully two very helpful posts for your practice.

The back pain post was a repost from a previous time but I thought it was very important to share it again. I also put a new post from my YouTube channel where I discussed patellar mobility assessment for instability. Check the post out at the link here or below to see the full version.

Physical Therapy First to Treat Low Back Pain

[ICYMI} Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs. Frogner et al Health Serv. Res. 2018

The Week in Research Review, etc 12-24-18This study compared the differences in opioid prescription, health care utilization, and costs among patients with low back pain (LBP) who saw a physical therapist as the first point of care, at any time during the episode, or not at all.

Patients aged 18-64 years with a new primary diagnosis of LBP, living in the northwest United States, were observed over a 1-year period.

Patients who saw a PT first had:

  • a lower probability of having an opioid prescription (89.4 percent),
  • any advanced imaging services (27.9 percent),
  • and an Emergency Department visit (14.7 percent), yet 19.3 percent higher probability of hospitalization.

Interestingly enough, 80% of the patients in the sample had no PT at all. Furthermore, 8.7% saw a PT first and 11.5% saw a PT later (avg 38 days). The most common provider seen 1st was a chiropractor.

Assessing for Patella Instability

Assessing Patella Mobility

💥Assessing for Patella Hypermobility💥

This Instagram snippet shows how I assess a patient with suspected patella hypermobility who may have sustained a subluxation, dislocation or instability episode.

To see the full video at my YouTube Channel, click the link here!

Basically, we’re looking at how mobile the patella is when the knee is locked at full extension compared to when the knee is flexed to about 25 degrees.

Normally, the patella should become relatively stable when the knee is flexed to 25 degrees because it engages the trochlea groove.

In patients with underlying patella hyper-mobility, the amount of mobility with the knee slightly flexed will be similar to when the knee is in full extension (and not locked into the trochlea groove).

This is often the case when the patient’s trochlea groove is too shallow to offer bony stability.

The test should help the clinician gain a better understanding of the patient’s anatomical make-up and prognosis for the long term.

Check out the full video at my YouTube Channel.

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.

Knee Bracing Immediately After an ACL Reconstruction

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

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

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

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

What does the Research Say about Bracing after an ACL?

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

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

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

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

More studies!

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

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

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

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

Instagram Story Poll will Decide It!

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

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

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

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

Twitter Discussion

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

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

Regional Differences with Bracing

Midwest

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

West Coast

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

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

Europe

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

Guess that topic will be for a different day!

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

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

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

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

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

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

Closing Thoughts

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

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

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

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

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

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

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

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

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

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

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

 

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

Preventing low back pain by @joegambinodpt

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

Anatomy of the Proximal Humerus

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

 

View this post on Instagram

 

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

Preventing low back pain by @joegambinodpt

 

View this post on Instagram

 

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

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

 

View this post on Instagram

 

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

Anatomy of the Proximal Humerus

 

View this post on Instagram

 

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

The Week in Research Review, etc 11-26-18

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This week, I discussed the progression of someone after a knee surgery. I tried to highlight the key stages and some techniques that I like to use to advance the patient’s mobility and comfort. Take a look at The Week in Research Review, etc 11-26-18 and share with your friends. Hope it helps you improve your patient care tomorrow and beyond!

 

ACL Reconstruction in a Pediatric and Adolescent Population

1st Day of #PT after an ACL Surgery

Patella Mobilization after Knee Surgery

Knee Flexion PROM after Surgery- Seated or Supine?

Stretching the Quads after Knee Surgery

Assessing for a Cyclops Lesion after an ACL

Assessing for Fat Pad Irritation of the Knee

 

 

ACL Reconstruction in a Pediatric and Adolescent Population

17 Year Follow-up After Meniscal Repair With Concomitant ACL Reconstruction in a Pediatric and Adolescent Population. Tagliero et al AJSM 2018

Results: 28% failed meniscal repair and required repeat surgery at the time of final follow-up. They also showed that outcomes and failures rates were comparable across tear complexity.

Guess that means that no matter the tear type, there was no difference in outcomes or retear rates. Although the repair techniques are now outdated and no longer used.

Their study also showed a 30% failure rate for meniscal tear repaired in the medial compartment at index surgery and 7% in the lateral compartment.

Interesting long-term outcomes that may help to guide your rehab and client advancement (and prognosis). Keep these in mind when you treat a future adolescent or pediatric ACL patient.

 

 

💥1st Day of #PT after an ACL Surgery 💥

If you have never treated a post-op ACL, then this video should interest you!

This is what the knee looks like that 1st day after surgery and can often set the stage for what’s to come over the next 6-12 months.

Often, the patient is both very curious and ultra-grossed out by the 1st unveiling. It can be stressful for them to see their knee in this condition so you really have to confidently reassure them that it is very normal.

The blood-soaked gauze is mainly saline that was used to irrigate the knee during the reconstruction. Some still leaks out of the incisions the 1st few days and can often be confused with true blood.

Understand that this is quite normal and happens to most every ACL patient’s knee that I’ve seen…nothing to worry about!

From here, I’d work on patella mobility (see the post later today) and then work on flexion ROM at the end of the table.

Again, it’s very important to get the knee moving after surgery. This will help with pain, swelling and gain confidence that the rehab process is moving forward.

 

Patella Mobilization after Knee Surgery

Get the patella moving early with #patella mobilizations immediately after surgery. One major reason (amongst many others) why we need to get our clients into #PT early.

I am certainly a very loud advocate for early PT and getting the patella moving can help to prevent excessive scarring, which can affect ROM and quadriceps force output.

Glove up and get that patella moving in all directions… medial, lateral, superior, inferior!

 

 

🤔Knee Flexion PROM after Surgery- Seated or Supine? 🤔

I’ve treated many patients after an ACL I can honestly say that this may be a huge influence on the early ROM outcomes that you may see.

I’ve tried to bend the knee in both supine or seated, as the video shows, and there’s no doubt that most people tolerate the seated version so much better after a knee surgery. In particular, a big surgery like an ACL, TKA or MPFL reconstruction.

It just seems to be more comfortable and with less stress on the anterior knee because of the position of the tibia (at least I think so!).

My theory, it seems as if the supine position may cause a slight posterior sag which may cause more pain and guarding than when they’re seated at the edge of the table.

I use a similar concept later on in the rehab process when I’m initiating my prone quad stretching. You can see a definitive improvement when I wedge my hand in the popliteal fossa and create a slight anterior translation on the tibia.

Most people say that the anterior knee pain that they were feeling (and not a quad stretch) was replaced by a stretch feeling only and no more anterior knee pain.

Try it out with your ACL patients and see what position they like best…I’ll bet I can covert you over if you still bend your knee patients in supine!

 

💥Stretching the Quads after Knee Surgery 💥

Continuing my sequence of videos after a knee surgery, I discussed my technique for progressing knee flexion PROM once they hit 120 degrees or so of flexion.

At this point, they’ve probably maxed out how much ROM they can achieve at the edge of the table. They’re ready to get that end range of motion and even some quadriceps flexibility.

In prone, most people will often feel a pain or pressure in the front of their knee when you try to bend it.

To overcome this, I like to wedge my hand into the back of the knee and give an anteriorly directed force through the gastrocnemius (calf) soft tissue and into the tibia.

This seems to create just enough movement of the tibia on the femur to take the pressure off the front of the knee. This may redirect the forces more onto the quadriceps muscle.

You’ll need to play with the amount and direction of force but most often they’ll begin to feel a better quad stretch.

Try this technique out on your next knee surgery client and see if it helps them. I usually initiate this ~4 weeks after an ACL but timeframes will vary person to person.⠀

 

💥Assessing for a Cyclops Lesion after an ACL 💥

In this video snippet from my YouTube Channel, I discuss how to assess for a Cyclops lesion in a knee. In particular, after knee surgery.

A patient with a potential cyclops lesion, they often present with loss of normal knee extension compared to the other side. They’ll often have anterior knee pain and poor patella mobility. Sometimes a tight feeling in their hamstrings and calves, too.

No matter how they try to regain their extension ROM, the knee just never feels right. Often times, surgical intervention is needed to remove that scar tissue.

Immediate rehab should continue to work on knee extension ROM using low load long duration stretching and aggressive patella mob’s.

No one’s to blame if this occurs. We don’t know exactly why it occurs in some people but we believe a remnant of the ACL stump may be a source of the frustrating issue.

 

💥Assessing for Fat Pad Irritation of the Knee 💥

Anterior knee pain is very common in the outpatient #PhysicalTherapy setting.

One of my go-to tests to assess for fat pad irritation is simply trying to capture the fatty tissue in the anterior aspect of the knee joint during active and/or passive ROM.

In this snippet from my YouTube channel, you can see that I pinch the fat pads on either side of the patella tendon as @corrine_evelyn is actively extending her knee. I’ll also do it in a relaxed state to assess passive irritability.

I 1st learned this test from @wilk_kevin and it continues to be a mainstay in my knee examination algorithm.

As for a treatment, it usually comes down to a volume issue and/or strength issue or both.

I’ll usually have to address the volume of the activity by relatively easing off of the activity while simultaneously adding in exercises to address an underlying weakness.

Remember the Dye et al study in AJSM 1998 when he talked about the fat pads being super painful during his arthroscopic surgery without anesthesia. Makes sense why they can be so painful if the knee stresses fall upon this tissue.

We talk about this study, fat pad irritability and much much more in our online knee seminar course.

If you want to learn more about how I treat ACL’s or the knee in general, then you can check out our all online knee seminar at www.onlinekneeseminar.com and let me know what you think.

We cover the anatomy, rehab prescription, ACL, meniscal injuries knee replacements and patellofemoral issues. Furthermore, the course covers both the non-operative and post-operative treatment.t

This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

The Week in Research Review, etc 11-12-18

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This week in research review for 11-12-18 we focused a bit more on assessment and also dabbled in some basic treatment strategies for the back and shoulder. Check out the topics below and like them or comment on Instagram to keep the conversation going…thanks all!

 

  • A quick fix for a sore low back?
  • Knee Fat Pad Testing and Diagnosis
  • How to Assess the Elbow for a Tommy John (UCL) Sprain
  • Lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers
  • Full Can or Empty Can? – by @mikereinold

 

Looking for a quick fix for a sore low back?

I’m speaking from personal experiences when I post a few of the common exercises that have helped me tremendously in the past.

I’m not saying that this is all you have to do but I do think that new onset of low back soreness, you know that tightness that you feel on either side of your spine, can be somewhat alleviated with some foam rolling and active range of motion.

I would definitely include more focal strengthening of the core like deadbugs and bird dogs, squats, deadlifts (when they’re ready), etc.

But for the purpose of this post, I think some foam rolling and motion to the area can take the edge off of someone’s soreness and get them feeling a little better. That’s my goal for many and hopefully those small gins can add up to big gains in the long run!

Do you utilize these techniques as well? If you don’t, then I suggest that you try! They’ve helped me numerous times and continue to help me when my soreness gets a bit out of control.

Tag a friend who may want to check out this post…thanks!

Thanks @corrine_evelyn for the demos!

 

Knee Fat Pad Testing and Diagnosis

Here’s an excerpt from a previous blog post where I talked about anterior knee pain fat pad irritation. Link in bio!

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

Meniscus (see my previous blog post)⠀

ITB

Osteochondral lesion

Patella tendonitis

Pes anserine bursitis

MPFL sprain

Hamstring strain

Plica syndrome

MCL/LCL

Tumor

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 this test to see if it truly is a fat pad issue.

 

How to Assess the Elbow for a Tommy John (UCL) Sprain

In this excerpt from my YouTube channel, I discuss the tests that I use to help identify an elbow sprain, typically seen in the baseball players that I treat.

In the full video, I discuss:

✅Joint Palpation

✅Seated Milking Sign

✅Prone Valgus Test (maybe a new one for you!)

✅Supine end range External Rotation with Valgus Extension Overload (VEO)

I also wrote a blog post about this topic so hopefully you’ll go to my site and read a bit more about this.

If you treat baseball players of all ages, then you should know how to diagnose a UCL sprain.

 

The influence of lumbopelvic control on shoulder and elbow kinetics in elite baseball pitchers

Laudner et al JSES 2018.

This study looked at 43 asymptomatic, #NCAA Division I and professional minor league baseball pitchers. They measured the bilateral amount of anterior-posterior lumbopelvic tilt during a single-leg stance trunk stability test.

The Level Belt Pro (Perfect Practice, Columbus, OH, USA) was used to assess anterior-posterior lumbopelvic control. The LevelBelt Pro consists of an iPod–based digital level secured to a belt using hook-and-loop fasteners.

This test has been used and studied previously by Chaudhari et al (JSCR 2011) and he showed that pitchers with less lumbopelvic control produced more walks and hits per inning than those with more control.

Also, pitchers with less lumbopelvic control have been shown to have an increased likelihood of spending more days on the disabled list than those with more control (Chaudhari et al AJSM 2014).

“The results of our study show that as lumbopelvic control of the drive leg decreases, shoulder horizontal abduction torque and elbow valgus torque increase.”

Have you tried this simple test? I will say that having the ability to detect millimeters of motion is clinically difficult.

It is good to see such a simple test utilized clinically can help aid in determining the need for more core/hip exercises for our pitchers. In all, I think it’s a safe bet to incorporate these exercises in all pitchers’ programs.

 

Full Can or Empty Can?

– by @mikereinold 

Great Post by @mikereinold on which motion is BEST to isolate the supraspinatus during arm elevation. I know you can’t isolate the supraspinatus but numerous studies have (Kelly et al 1996, Reinold et al 2004) shown that the full can (or thumb up position) is better than the empty can position.

Check it out below! 👇🏼

Full Can or Empty Can? – by @mikereinold⠀⠀
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🧠 WANT TO LEARN MORE FROM ME? Head to my website MikeReinold.com, link in bio.⠀⠀
-⠀⠀
I’m still surprised after all these years that I still see the empty can exercise kicking around. I analyzed these two movements many years ago in an article in JOSPT and showed that the full can exercise (thumbs up 👍) had similar EMG of the supraspinatus with lower levels of deltoid EMG, while the empty can (thumbs down 👎) had higher levels of deltoid EMG.

Why does this matter?

Well, think about it. If you are performing this exercise you probably are trying to strengthen the rotator cuff. And if you are weak and performing an exercise with more deltoid, the ratio of cuff to deltoid will be lower and you’ll have more potential for superior humeral head migration.

Plus, let’s be honest, the empty can just hurts… It’s also a provocative test, and I don’t like to use provocative tests as exercises. 😂😂😂⠀

 

The Week in Research Review, etc 11-5-18

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The Week in Research Review, etc 11-5-18 was filled with more informative and eye-opening posts! Lots of visually stimulating posts to help clarify what exactly is going on in the hip joint with PROM. Another post that shows the suction effect from an intact hip labrum… amongst other great posts.  Just some great stuff..hope you enjoy!

 

  1. Manual Forearm Resistance Drills
  2. ACL Graft Healing Times to Maturation
  3. Hip Capsule Stress with PROM External Rotation
  4. Muscle Activation Affected by Hip Thrust Variation
  5. Hip Thrust Form by Bret Contreras
  6. Hip Joint Suction Affected by labral Status

 

 

Manual Resistance Forearm Exercises

In this post, I wanted to show you guys some of the manual resistance drills we use @championptp on our shoulder and elbow clients, especially our baseball players. We love to use these drills because we can control so many variables with each athlete and tailor it for their specific needs.

We can control the speed and tempo, the direction of forces (eccentric, concentric), and the magnitude of the forces. Plus it’s a great way to interact with our clients. It’s also a great way to feel how well they’re progressing in their programs instead of just giving them dumbbells.

I have found these manual resistance drills to be very helpful with my overhead athletes and hope you give them a try on your clients soon! Let me know what you think or tag a friend below who may like to use these drills too.

In my course that I teach around the US, I try to include these concepts so you can practice and be able to utilize these drills for your clients…thanks!

 

ACL Graft Harvesting and Healing times

In this post, I wanted to show some research studies on graft healing times and why we need to respect tissue biology.

The systematic review from AJSM 2011 looked at ‘The ‘‘Ligamentization’’ Process in Anterior Cruciate Ligament Reconstruction.’

They essentially looked at 4 different biopsy studies on BPTB and Hamstring autograft reconstructions. They concluded that maturation of the graft, as determined by mainly vascularity and cellularity, was not complete until 12 months at the earliest. The healing time even extended to 24+ months as well.

The ligamentization endpoint is defined as the time point from which no further changes are witnessed in the remodeled grafts. The surgical procedure is quite involved, as you can see in the video that I took from @drlylecain on #YouTube.

As I’m rehabbing my clients, my decision making and post-op progressions often take into account:

✔️Healing biology

✔️Graft harvesting

✔️Graft Type

✔️Bone bruise presence (often!)

✔️Other concomitant issues (meniscus, articular cartilage).

So, respect the tissue and allow natural healing to occur before you add more exercises or are concerned that they’re not making the gains you’d expect.⠀

 

 

Hip Capsular Closure: A Biomechanical Analysis of Failure Torque

Chahla et al AJSM 2016

Interesting look at tissue failure, albeit in a cadaver graft, that should help to guide the physical therapist or ATC early in the rehab process after a hip scope.

The purpose of this study was to determine the failure torques of 1-, 2-, and 3-suture constructs for hip capsular closure to resist external rotation and extension.

The 3-suture construct withstood a significantly higher torque (91.7 Nm) than the 1-suture construct (67.4 Nm) but no significant difference was found between the 2- and 3- suture construct.

The hip external rotation degree in which the capsule failed was:

✅1-suture construct: 34 degrees

✅2-suture construct: 44.3 degrees

✅3-sutures: 30.3 degrees (yes, smaller than 2-suture construct)

I think as a #PT, we need to keep this study in mind and respect the healing tissues after a hip scope.

Love when we can get this information and put it into practice, similar to RTC repairs, ACL, etc.

Obviously, this was on a cadaver where there’s no guarding, pain or muscle contraction. We still need to know that there MAY be enough tension on the capsule to create potential issues (like tissue failure).

If you treat patients after hip scopes, then I recommend you read this cadaveric study.

 

 

Barbell Hip Thrust Variations Affect Muscle Activation

COLLAZO GARCIA et al JSCR 2018

This study looked at the EMG activity of various lower body muscles while performing the hip thrust in various positions.

Their results showed that by varying the foot position into more external rotation, you can recruit the glute max and medius more than by the traditional hip thrust.⠀ …”the activity of the gluteus maximus increases significantly reaching up to 90% MVIC with only 40% of 1RM” with this hip ER variation.

Also, ‘when the distance between the feet is increased, the activity of knee flexors increases. Therefore, this is a very recommendable option to increase hamstring: quadriceps co-activation ratio.’

I like this study because it helps guide our rehab if we’re targeting a specific muscle group a bit more because of an injury or surgery.

It’s one of my go exercises for anyone with a lower body injury, especially after an ACL reconstruction. But I do use this exercise for most of my clients rehabbing from any injury, including the upper body.

It’s a great way to recruit the gluteus maximus and medius, which we know are hugely? (is that a word?) important to help produce and dissipate forces during athletic movements.

The exercise was widely researched by @bretcontreras1 and should be a staple in your rehab programs.

Check it out and add this to your go-to exercise list…thanks!

 

Hip Thrust Form

[REPOST] and a great one from @bretcontreras1 talking hip thrust form, which is perfectly coinciding with my post earlier today on variations to the hip thrust and how they affect muscle activation. Check out his original post below…highly recommended!

Teaching optimal hip thrust form is complicated. While the occasional lifter prefers and functions better staying fairly neutral in the head, neck, and spine, the vast majority of lifters do best maintaining a forward head position, which leads to ribs down and a posterior pelvic tilt.

It’s not just the forward eye gaze; the whole head has to maintain its forward position. You’re not hinging around the bench; the body mass above the bench stays relatively put, while the body mass below the bench is where the movement occurs.

The astute science geeks out there will rightfully point out that posterior pelvic tilt is associated with some lumbar flexion, and that lumbar flexion under load can be problematic. However, lumbar flexion is only dangerous when the discs are simultaneously subjected to compressive forces. With this style of hip thrust, the glutes are driving hip extension and posterior pelvic tilt, and erector spinae activation is greatly diminished. Core activation is what creates the bulk of the compressive forces, so with the erectors more “silenced,” the discs aren’t as compressed. This makes the exercise very safe. In fact, it’s safer than the “neutral” technique because as you rep to failure or go a bit too heavy, you will inevitably arch the chest and hyperextend the spine, which can lead to lower back pain. ⁣

We have 200 members at Glute Lab hip thrusting day in and day out, and there have been zero injuries to date. Considering how heavy we go, this is astounding.⠀
⁣⠀
#gluteguy #glutelab #thethrustisamust⠀

 

Hip Joint Suction and Stability

[REPOST] From @chicagosportsdoc and a very cool look at the suction within the hip joint that contributes to its stability. As the video progresses, they have simulated a labral tear that shows how easily the joint can dislocate. Once the labrum is repaired, the suction effect is recreated, and joint stability is re-established.

That’s 2 posts this week on the hip…if you want to see some awesome posts, then follow him. He just got on Instagram but his visual posts really aid in learning the mechanics of the various joints…see below!

An impressive demonstration of the powerful hip suction seal. When the hip labrum is injured, the seal is disrupted which can potentially produce microinstability. A labral reconstruction can restore the suction seal #labrum #sportsmedicine #hip #anatomy#orthopedicsurgery #medicine