Tag Archive for: rehabilitation

Looking back at 2017 & beyond to 2018

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It’s that time of year to reflect on what we’ve done and a game plan on what’s to come. I’ve taken a moment to look back at some changes I made in 2017 and share it with you.

New website- LennyMacrina.com

I had been thinking about building my website for a while. Being surrounded by some of the guru’s in our field, who have used their website to share their thoughts, I had no choice but to take the leap.

Mike (mikereinold.com), Dave (shiftmovementscience.com), and Dan (Fitnesspainfree.com) are constantly talking about WordPress, funnels, and calls to action than most. As much as it’s gibberish, it made me think about why I don’t have my own calling card, so to speak, to be able to capture my opinions on rehabilitation and physical therapy.

I fumbled a bunch and had to redo the whole site from scratch after hiring someone to do it for me.  In the meantime, I had to develop knowledgeable content that people may find interesting.

Instead of just using my Twitter (@lenmacpt), Facebook (Lenny Macrina MSPT, SCS, CSCS) or Instagram (@lenmacpt) accounts to share content, I decided to centralize the process. I figured this would be my home base for content that I can control forever and not be stuck in a social media platform.

I feel like I’m winging it but the early feedback has been pretty positive.

Improve my Listening Skills

I’ve said over and over again that listening to your clients is the most important aspect of any examination.

I feel as if I do a pretty good job at listening to my clients (despite what my wife says about my listening skills.) I try to ask the right questions and let the client state their story. Too often we get ideas in our head and jump to conclusions. We try to diagnose an injury too quickly and may miss an important detail that could sway the story in a different direction.

I’ve had this happen numerous times and completely blame myself for not giving the client the platform to reveal the pertinent details. I alluded to this is in a previous post if you’re interested. The client comes first…no questions asked!

Remember, they don’t know what may be contributing to their injury. To them, the injury is often a result of a specific action. They don’t consider the other contributing factors in their lives that seem insignificant.

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I always ask them “What do YOU think is going on?” This allows me to hear their thoughts, impressions and any details that they think may be adding to their current presentation

For example, I recently had a client present with shooting and burning pain down her arm. To many, it would seem like a cervical herniated disk. Pretty clear cut, right?

Well, she had a clavicle fracture that required an ORIF 10 years ago. She didn’ think it was significant but every time I palpated at the surgical site, especially the lateral aspect, we could replicate her symptoms…Every time! Two previous medical professionals missed this detail and just brushed it off.

To me, it seemed pretty clear that some component of her ORIF or clavicle had been rubbing a portion of her brachial plexus during a specific movement. It just did not seem like a cervical spine issue and the detail of her clavicle fracture, that she thought was insignificant, seemed to be the clue we needed to hone in on the culprit.

Listen up…they may just tell you what you need to hear!

Systemize Everything

Life gets crazy. Responsibilities grow so we need a way to manage all of the chaos. What helped me to better manage my time was contained in the book “15 Secrets Successful People Know About Time Management: The Productivity Habits of 7 Billionaires, 13 Olympic Athletes, 29 Straight-A Students, and 239 Entrepreneurs“

I’ve had to block time out of my calendar to get tasks done. Like specific times to do specific tasks. Whether it’s a dentist appointment, a powerpoint or running payroll, I have reminders in my calendar for everything.

More importantly, I have to prioritize tasks, what Kevin refers to as my MIT’s or Most Important Tasks.

I have done my best to stick with this plan but he recommends working on your MIT 1st thing in the morning when he thinks you are the sharpest. As of now, I have carved this time out to be with my daughter before the day begins. I guess as of writing this, she is my most important task. Can’t argue that!

At work, including client evaluation and treatment sessions, we have begun to systemize everything we do at Champion PT and Performance. We feel as if most people present with very similar presentations.

We’ve developed internal treatment progressions that we utilize daily. It makes it a lot easier for PT’s to see each other’s clients on the rare occasion we need to cover for someone. It takes any questions out of the client’s head. They don’t need to worry why their regular PT may or may not be doing a specific treatment.

Even more than that, we MAY have a new system coming out in 2018 that will help many with their evaluation skills. I can’t say much more than that but look for a big announcement mid-2018!

Preview of 2018

Wow, 2018 is right around the corner. I feel good about it because it’s an even number. Yeah, I’m a bit weird with stuff like that. Maybe it’s my baseball background and superstitions.

  • In 2018 I hope to accomplish more vlogs…or video blogs as the kids say. I feel like a 3-5 minute snippet of my thoughts is a very effective way of communicating with the masses. Look for more vlogs as we roll into luck 2018.

I also plan on booking more speaking engagements worldwide. As of now, my calendar has me in:

I have other courses that just need to be finalized but it seems like there may be 1-2 more dates that are in the works.

2018 is shaping up to be a very exciting and productive year. It’s important that I have these plans in place to keep me on my toes and on top of the literature.

Hope you have looked back at your past year and can continue to build into 2018. What goals do you have for 2018? Hit me up in the comments below so we can discuss.

Happy New Year!!

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.

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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/

 

The Challenges of ACL Rehab- It’s Never Easy!

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It seems like I always have someone on my schedule that is post-op ACL reconstruction (or anything post-op, for that matter!). Although I thoroughly enjoy progressing ACL rehab because this population is very motivated to get back to their sport or activity.

Knowing that it scares the bejeezus out of me at times!

There are so many variables, almost too numerous to count, that can affect the outcomes. Some are modifiable and some are not. I wanted to take a moment and step back from the boring “just need to get knee hyperextension posts” that I’ve done in the past and take a more holistic approach.

The Little Details

For those that know me, this may be a bit of a stretch. But I honestly think that the little details of the process are just as important as the big picture. It’s like anything else, you need to focus on the little details in order for the final goal to be achieved.  The same is true for ACL rehab but I feel like this is something that is missed by many and can make or break a good outcome (which we know can be hard to find).

There’s a reason why nearly 25% of ACL reconstruction patients have a retear event and need a revision surgery. I’m not saying this is the only reason but I will say the mental aspect of the process can help the athlete during he process, and that begins post-op day 1 when they present to me in the clinic!

So, what’s going through my mind when I’m rehabbing someone after an ACL reconstruction?

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Human Soul, Mind, Spirit

From the get go, I’m trying to figure out the psyche of the person in front of me. Look up the word psyche in the dictionary and it means ‘human soul, mind or spirit’. This exactly sums up what I’m trying to define early on.

The tricky part is connecting with this person (and their family) so they can gain the utmost trust in you. You see, their future is in your hands so there’s a lot of blind trust that is going on early in the rehab process. They’re in pain, clueless to the process and hoping you know what the heck you’re doing.

I know the basic principles of ACL rehabilitation- calm the knee down, get their ROM back and get them walking/running/jumping. There’s a lot more to do but I’m being wicked brief, I know. And it does go way beyond that, trust me! It’s much easier said than done for most.

Some Factors to Consider

Each case involves a gazillion variable to consider when I’m trying to outline a logical rehab program. Often it can consist of:

  • pre-op status
  • graft choice
  • meniscal involvement
  • other joint issues (bone bruise)
  • revision surgery
  • surgeon
  • pain status
  • previous surgery (if so, how did that go?)
  • ultimate goal
  • school status
  • home situation
  • good support
  • insurance (not as much for me due to OON)

It goes on and on, trust me! If you don’t believe me, then read this paper that I found AFTER writing this blog post. Basically sums up my nearly 15 years of experiences very well. Check it out, if you want… Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review.

So my mind races as I’m trying to figure this stuff out. I’m also trying to sound half educated as I progress their program and observe their response to each new exercise, cue and bad joke I make.

Some people freak out with anyone touching their knee cap while others just sit there and chat it up. If I see the freaked out person begin to squirm, I need to anticipate that the next few steps may equally be a challenge for the client. Knowing that (and assuming that), I go into show mode and make every attempt to turn the focus from their knee and each and every painful bend or leg raise, to something very obscure. To me, it’s all about mind games.

Mind Games

Wait, I’m playing mind games with my clients? You better believe it. This is basically how I test my clients’ response to me, my personality, my rehab style and how the next 6-9 months will go. If I see a stoic, scared response, then I need to step up my game and find a common connection, QUICKLY!

The rehab especially at the beginning, is not about their flexion ROM or their swelling control but it’s about them gaining trust in me as their PT. Do they want to come to PT and put their complete future in my hands? Do they trust that I know what I’m doing and can lead them to their eventual goals? I hope so and it starts from that 1st joke I make or that 1st outcome study that I have to quote.

I don’t know which one will win them over but I have to be ready to offer either (or both). The last thing I need to happen is to have them show up for the next session and completely lose faith. If for some reason their swelling is up or their pain is worse (which happens in nearly 100% of the cases that I see) then I need to be able to talk them off the ledge and let them understand that it’s completely normal.

N=1 mindset

They have no comparisons to make. They also think their experience is worse than all others and that no one else has had swelling 2 weeks out of surgery. Or that all people can walk without crutches 7 days out of surgery, but they still have their crutches 14 days out. They have an n=1 mind and have no other experiences to compare it to but I have a database of cases to rummage through in my head.

Hope my mind can come up with a similar situation, make it real for them and get them back to reality…and get their faith back!

Trust me, no surgery is a guaranteed success and we know ACL surgery is a long ways a way from being perfect but we can truly make a difference by our confidence and personality.

I’ve made a career of this and can’t stress it enough!

Like the post? We have more to offer…

I hit upon all of this a little bit more in my online knee course that I have with Mike Reinold. If you’re interested in learning more about how we treat the knee, then go to our all online knee course that covers all topics including post-op ACL, TKA, PF surgeries. Also non-op treatment of the knee and a great overview of treatment progressions. The discussion boards are a great way to interact with other professionals and chat about the course and your own personal cases/experiences. Check it out soon!

1 question to ask when applying to PT school

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Applying to PT school can be an overwhelming and daunting process. With the move to doctorate programs, the competitive landscape can lead many to apply to a bunch of schools in hopes of getting into at least one.

The pressure mounts as prospective students try to figure out what program best fits their needs, demands and personality…and pocket book too (often the most important).

Many look at the US News and World Reports to see if their top school is in the top 10. Congrats to my colleagues at the U. of Delaware for taking the trophy this year! My alma mater, Boston University, keeps its post in the top 15!

Time after time I need to listen to the students gripe and worry but it always comes down to 1 major point that I always tell students…

Make sure the school is willing to take on new clinical rotations and make the effort to secure a rotation that YOU want

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The Actual Process

Listen, I’ve been the CCCE (or whatever the title is) for a few years now and the steps are very simple.

  1. Student or school reaches out to clinic in question
  2. Clinic says we have an opening, let’s get the student in
  3. School sends stock contract to CCCE
  4. CCCE signs it and returns it
  5. ACCE and school sign it

There may be some behind the scenes things that have to happen at each school but overall, the process should take a fews days to a week at the most.

Generally, this is a non-issue and most schools are great with this. But every once in awhile I’ll come across a student who wants to do a rotation with us but the school doesn’t want to fulfill the contract, for some reason. And I never understood why that was!

The process seems simple enough. If the student really wants that clinical site and it would help them with their educational goals, then why would any school deny that?

That’s why I ALWAYS tell students that are shadowing our facility, to get their required hours, and to definitely ask the schools about their policy on obtaining contracts with new clinical facilities.

The didactic information during lectures and labs is so important but the first hand experience and relationships that you create at a clinical site will equally help you for your long term goals.

Yes, PT school rankings are important but I also think the clinical sites you choose will help YOU take your knowledge to the next level.

Final Lesson

So, future DPT students, if you’re reading this, make sure the school you’re applying to will reach out to me for my contractual signature. If not, I’d highly consider moving on and finding a school willing to take on new sites!

If I’m missing something, please comment below. But it seems pretty straight forward to me, despite what I hear from prospective students!

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.

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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

Welcome to LennyMacrina.com!

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Welcome to my new website, LennyMacrina.com

I hope to share some of my insight into the field of physical therapy, rehabilitation, and performance.

My goal is very simple: Take a huge step back from the complexities of all of the information on the web and make it more intelligible and applicable to your daily practice.

I plan on periodically reviewing the newest orthopaedic and sports medicine research that is cutting edge. But at the same instance, I want to convey some of the classics that still remain pertinent in my physical therapy practice today. I truly believe that rehabilitation can take a very simplistic approach and still get tremendous outcomes for your patients.

The logo was created to combine my initials with the depiction of someone performing an overhead movement. You see, I treat many overhead athletes, particularly baseball players, and this has helped shape my career into what it is today. But this is a small piece of what I do on a daily basis.

My passion lies in returning people to their highest function after most orthopaedic injuries. My goal is to build upon my daily experiences and report what I believe is the most succinct PT out there.

I have been practicing therapy physical since 2003 and have made it a point to keep things simple, for both mine and my patient’s well being.

Let’s be candid…they’re not looking for complicated solutions that are confusing. They want a simplistic approach that is understandable and easily adapted into their lives.

I will help to navigate the PT intricacies that are currently out there and make rehab a lot more straightforward and fun too!

Again, welcome to my website…I hope you enjoy the new journey I’m about to undertake.

If you want to learn more and stay up to date with my posts, you can join my team and get my tips to regaining knee extension after surgery AND a promo code to save money off of a Medbridge Education subscription:

Thanks!!

2 Tips to Improve Your Post-op Rehabilitation Outcomes

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I’ve treated hundreds, if not thousands of postoperative patients in my career. I’m always surprised to hear from others how they progress their patients. When I first got into physical therapy, I was all about protocols. I didn’t have much experience.

I would literally follow it word for word and do my best to match the person to that little piece of paper. Little did I know that I was gravely mistaking! This post will hopefully improve your post-op rehabilitation outcomes.

As I became more comfortable, let’s say 1-2 years in, I got cocky and progressed people based off of their presentation. I almost wanted to show off to THEM that they were doing better than the protocol. This made them want to go faster through the process and all was good…kinda.

Wake up call

Then I began to see people get sore, stiff and regress. So much for being the guru of post-op rehabilitation. I had to reassess my approach.

Fortunately, we had a steady flow of post-op patients at our disposal in Birmingham, AL.  Each day, week and month I would get 1, 2 3, 4 new post-op patients a day. I would look for the protocol and fight the temptation to progress too quickly.

Trial and Error

Through experience and chatting with Kevin Wilk (and Mike until he left for the Red Sox in 2005), I began to take a more conservative approach, especially during the 1st 6 weeks after surgery. I realized the protocols were intentionally broken down into phases of rehab for a reason.

Those initial weeks after surgery are all about calming the joint down. Whether it is a knee replacement, an ACL or a rotator cuff repair, they all cause pain and swelling. We truly need to address each circumstance on a case-by-case basis.

There are always the outliers, and you know who they are. The guy that walks in with no crutches 1 day out of surgery and says “I’m here for PT, let’s do this”.

Then you have the guy who gets rolled into PT with a wheelchair and can’t do anything because he’s puking, constipated and cranky. Completely different approaches to rehab for these 2 folks.

The cocky guys need to be held back a bit because you know he’s going to keep pushing it and make his knee swollen. The guy in a ton of pain needs reassurance that you will take good care of him. You just need him to be a big part of the process and get over his fear.  You’re almost playing mind games on a daily basis and need to adjust to each individual’s personalities.

Regression to the Mean

The majority of people present somewhere in the middle- can function but in some pain. They know they need to do the PT and you know they need more pain meds, quickly!!

They’ll unwillingly participate in the early process because the doc said so but often not like you for it. Then they’ll thank you later on when they’re moving well and feeling great!

So with that, what 2 things do I think people need to consider when rehabbing a post-op patient?

via GIPHY

The 2 most important factors to progress a post-op patient

  1. Don’t overdo it- less is more
  2. End feel assessment

Don’t Over Do It- Less is More

As tempting as it is to progress someone quickly through the rehab process, fight the temptation in the early phase of PT. That 1st 4-6 weeks after surgery are critical to regaining homeostasis in the joint.

Dr. Scott Dye talks about this perspective in regards to patients that have patellofemoral pain or anterior knee pain: The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. His research has really shaped how I treat and progress people.

The quicker you can get the joint to ‘calm down’, the better they’ll be able to progress. I utilize range of motion and some modalities such as ice. I can’t overstate it enough that we can make or break an outcome in the first 4-6 weeks.

There’s no need to crank on someone’s knee because the protocol says you must have a certain ROM by a certain time. I’ve found great success with simple passive range of motion seated at the edge of the table at least 2x each visit.

It’s a lot more of a comfortable position for the patient than the dreaded prone ROM. Keep in mind, this puts a stretch through the quadriceps. It becomes an extra barrier that you must get through in order to achieve your motion goals. Plus, the patient feels like a WWE wrestler and may reflexively tighten up in anticipation of pain.

Each patient would get 5-10 minutes of PROM at the beginning and end of each session. No matter how busy I was or how many people were staring at me ‘waiting for their ‘next exercise, they all got 2 ROM sessions.

They looked forward to the range of motion and patiently watched me go from table to table (this was back a couple years ago) knowing they were next up.

This hands-on interaction is very important to develop the PT-patient relationship. This will hopefully blossom in the coming weeks and months as the patient progresses through the process.

I wrote about this previously for our Champion PT blog and I’m sticking to it Power of Touch. I truly believe that this is often missing and a huge complaint from people who end up coming to Champion PT in pursuit of reclaiming their functional goals.

End-feel Assessment

In my opinion, end feel is the single most important aspect of rehab progression a therapist needs to consider.  Being able to assess end-feel may be one of those skills that come with experience.

If a post-op rotator cuff is having painful guarding, then the therapist must adjust the process. Maybe it’s the frequency of the HEP, or the actual HEP content, or the patient’s pain control. There are so many factors to consider but the fun part is adjusting and reassessing. It’s a constant game of give and take!!

Commonly, the PT has to dive deeper into the patient’s life to figure out why this end-feel has changed. Often times a past medical history of diabetes can cause increased stiffness.

Also, you’ll find that they stop taking their pain meds because ‘they make me feel funny’ or ‘I have to drive to PT, don’t I?’ Everyone’s response to a surgery is different and it is very important to understand what could affect a patient’s presentation, as complicated as it may seem.

Ultimately, the goal is to get a nice capsular-like end-feel that has the potential to slowly stretch out as you progress the intensity of the ROM.

Assess and adjust each visit

I usually have them increase the frequency of their home exercises or adjust the daily frequency to easy bouts of motion 3-4 times per day. Most people think doing it 1x per day (if you’re lucky) is all they need so they can get credit for doing their ‘homework.’

I’m not afraid to lay the guilt-trip on them and remind them that their outcomes will only be as good as the effort they put into their rehab.  This usually gets the point across and we can progress on with the rehab process. This will allow us to quickly gain back the ROM and usually make that end-point not so hard or painful.

Conversely, a Bankart repair in a young athlete should be progressed at a slow speed so the tissue is not ‘stretched’ out. This often results in a nice, capsular endpoint. Should they begin to feel tight, don’t panic! Young adults, say up to 25-30 years old, very rarely get too tight.

Let the process happen, progress appropriately. The excessive ROM gains may cause the patient to have further issues down the road if their instability returns.

Take Home Point…

As much as we think we know about rehab progression after surgery, the only true feedback is from the patient.  Listen to them, monitor their response to the rehab and you will be well on your way to getting superb outcomes.