Tag Archive for: research

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 11-19-18

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Great ‘Week in Research Review, etc 11-19-18’ that I hope you find helpful to your practice.

I’ve always touted the importance of the subjective portion of the exam so I wanted to share a slide from a recent talk I gave to a group in Canandaigua, NY. Obviously, the squat is a fundamental movement and I wanted to give some basic positions that I use to help assess. So excited that I’ve launched a brand new Medbridge course that helps the rehab specialist better eval and treat the baseball pitcher. On my YouTube channel, I discussed my thoughts on setting the scapula with various upper and lower body exercises. And finally, my co-worker Kiefer Lammi discusses the landmine with exercise.

 

Importance of the Subjective Exam

Assessing the Squat

My New Baseball Medbridge Course

Set the Scapula with Shoulder Exercises?

6 Ways to use the Landmine by @kieferlammi

 

💥Subjective the most important aspect of the Evaluation💥

This slide, taken from this past weekend’s course in Canandaigua, NY is always a favorite of mine.

I try to keep a slide like this in all of my lectures because I have found that this portion of the examination can give the rehab specialist a huge look into what is going on with the person in front of them.

Don’t get me wrong, I still consider the biomechanical aspect of what may be causing their symptoms.

It often comes down to a tissue capacity issue but it’s up to me to determine the appropriate course of treatment.

These questions will help build confidence in your client and guide the early stages of rehab.

Do you have any specific questions that you like to ask your clients during their 1st few sessions? Remember, these questions are just not for the evaluation. You should be asking these questions periodically to gauge progress and help guide the next phases of rehab, too!

 

🔅Assessing the Squat 🔅

Squatting is a fundamental movement that all of us have to do on a daily basis.

Utilizing several different positions can help the rehab specialist better assess the squat and develop a treatment plan that enables their client the ability to improve their squat pattern.

In the above videos, I have utilized 3 different squat patterns and will outline them by the degree of difficulty.

✅The Overhead Squat- by far the most challenging version which challenges the shoulders, thoracic spine, lumbar spine, pelvis, knee and ankles.

A movement limitation at any of these joints will most likely cause the squat pattern to break down. Using overhead resistance would further challenge the system and potentially cause the squat to further breakdown.

✅Arms Crossed Chest Squat- alters the challenge by taking most of the shoulder and thoracic spine out of the equation and isolates the motions to the lumbar spine, hips, knees and ankles.

I often use this position as my fundamental motion because most people don’t have to squat with any weights over their head. This position, in my opinion, should be the most informational and utilized.

✅Counter-weight Squat

This position changes the center of mass by moving some of the weight distribution more anteriorly (front) and making the squat motion slightly easier. I use this position as a regression, for some, which allows them to squat with less stress and potential difficulty.

There are many other variations to the squat that you can make but I wanted to highlight a few of the major changes that you cause successfully. Assessing the squat is essential and can give the rehab specialist a nice picture of the function of multiple joints during a common movement.

 

My BRAND NEW course on Medbridge’s platform

…that helps the sports and ortho rehab specialist (PT, OT, ATC) better understand the anatomy and biomechanics involved in the baseball pitching motion.

Advanced Rehab for the Baseball Pitcher to Improve ROM & Strength@medbridge_education

The goal of this course was to allow the clinician to be able to evaluate and treat the baseball pitcher using evidence-based guidelines that I use on a daily basis.

Numerous research studies discuss the adaptive changes that occur with the pitching motion followed by numerous videos to help guide the treatment process.

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Students can also get 1 year of unlimited courses (no CEU’s) by using promo code LennySTUDENT2018 and pay only $100.

Check out my other shoulder courses as well by using the Medbridge platform…along with many other great speakers!

Hope you enjoy and good luck!

 

💥Should you Set the Scapula with your Shoulder Exercise?💥

In this video excerpt from my YouTube channel, I wanted to discuss my opinion on setting the scapula during common exercises.

I think there’s an obvious role for setting the scapula during a heavier lower body lift like a deadlift.

But for a classic upper body exercise like the Full Can (Scaption Raises) or prone T (horizontal abduction), prone Y (Prone full can), etc then I definitely want the scapula to freely move along the rib cage.

I did a quick literature search and didn’t see anything obvious that helped to guide my thoughts so most of this is anecdotal. Check out the video and comment below.

Do you coach your clients to set their scapulae before a rotator cuff workout? If so, why? If not, do you think we should reconsider?

 

6 WAYS TO USE THE LANDMINE!⁣

Great post from our own @kieferlammi at @championptp on various ways to use the landmine in your client’s workout routine.

If you don’t have one, then I’d highly recommend you try to obtain one because they are highly versatile and can be used in many stages of rehab. See Kiefer’s original post below 👏🏼

_____________

6 WAYS TO USE THE LANDMINE!⁣

The landmine attachment is a super versatile tool for loading that is traditionally known for being used for angled pressing variations. While that’s probably my most programmed use for it, it also provides benefit to a ton of other movements by placing the load and direction of force at a bit of an angle, which can help to promote a particular path of movement, like sitting back more in a squat or lunge. Here are 6 of my favorite ways to use the landmine:⁣

1️⃣1-Leg RDL⁣

2️⃣Split Stance Row⁣

3️⃣Reverse Lunge⁣

4️⃣Deadlift⁣

5️⃣Squat⁣

6️⃣Russian Twist⁣⠀

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The Week in Research Review, etc 7-29-18

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Last week was the 1st of my research review that summarized my social media posts from the previous week. It seemed to be well received so I figured I’d continue it. My goal is to help summarize some of the research that I found interesting and package it nicely for my readers.

Each photo contains a link back to a social media feed where you can see the conversation that ensued and maybe chime in…or just be a passive reader and see where the conversation went. You never know where the conversation may go on social media…so be ready! haha!

Socioeconomic Factors for Sports Specialization and Injury in Youth Athletes Jayanthi et al Sports Health Journal 2018.

This study looked at the effect of socioeconomic status (SES) on rates of sports specialization and injury among youth athletes.

They looked at injured athletes between the ages of 7 to 18 years that were recruited from 2 hospital-based sports medicine clinics. They compared these with uninjured athletes presenting for sports physicals at primary care clinics between 2010 and 2013.

They concluded that:
✅High-SES athletes reported more serious overuse injuries than low-SES athletes
✅More hours/wk playing organized sports
✅Higher ratio of weekly hours in organized sports to free play
✅Greater participation in individual sports

I applaud the authors for attempting to bring this very difficult collection of data into a formal research paper. I will say some of the statistics and standard deviations may not make the conclusions as powerful.

I do think this is a good paper to help educate our athletes on injury rates, especially in those that specialize in 1 sport.

What do you think? Tag a friend that may benefit from this article!

From #Twitter’s @retlouping that perfectly sums up what I’ve observed recently on social media with many PT’s.

For some reason, pain science has overtaken most diagnosis and treatment conversations.

It’s as if you get bullied into talking pain science and ignoring our clinical judgment and diagnosis skills. I understand there’s a constant tug-of-war between the biomechanical PT’s and the pain science PTs.

But as usual, the answer usually lies somewhere in between and both groups are correct. The biomechanics of an injury are often important as well as the language we use to explain these tissue biomechanics.

To my fellow clinicians, especially the newer grads and #dptstudent, remember this little cartoon for every future encounter.

Yeah, speak to people in non-threatening tones (in my world it’s just being respectful) but trust me, they WANT to hear what could be going wrong or what may be causing their pain.

Don’t blow off their symptoms and don’t go into depth about pain science because they won’t understand.

Trust me, the clinicians that try to do that often end up losing their patients in the long run.

I hear these stories day after day of people coming to me because the last PT either only talks to them or made them ONLY do strength exercises and it didn’t help their pain.

The PT didn’t listen to them and was so blinded by their pain science background that they ignored the person sitting right in front of them. Remember, the person sitting there will tell you what is going on and what treatment will most help them feel/move better.

Influence of Body Position on Shoulder and Trunk Muscle Activation During Resisted Isometric Shoulder External Rotation Krause et al Sports Health 2018.

The purpose of this study was to examine ER torque and electromyographic (EMG) activation of shoulder and trunk muscles while performing resisted isometric shoulder ER in 3 positions:
✔️Standing
✔️Side-lying
✔️Side plank

Using surface EMG and a hand-held dynamometer, the researchers tried to determine EMG activity of the:
✔️infraspinatus
✔️Posterior Deltoids
✔️Mid traps
✔️Multifidi
✔️External/internal obliques (dominant side)
✔️External/internal obliques (non-dominant side)

EMG values for the infraspinatus were greatest in the side plank position. In general, EMG values for the trunk muscles were also greatest in the side plank position.

✅Their Conclusions: If the purpose of a rehabilitation program is to strengthen the rotator cuff, in particular, the infraspinatus, the side plank is preferred over standing or side lying. If the goal is to simultaneously strengthen both the rotator cuff and trunk muscles, the side plank position again is preferred.

Makes sense but good to see the research and have concrete evidence to back up what we think actually goes on.

Tag a friend who may be interested in this research paper!

Reliability of heel-height measurement for documenting knee extension deficits. Schlegel et al AJSM 2002

Prone heel-height difference of 1cm equates to 1.2 degree difference in knee extension ROM.

Do you use this method to assess knee ROM? I still measure knee extension ROM is supine but find this method helpful as well.

I know my friend and colleague @wilk_kevin has measured this way for many years. i originally saw his use this technique at @ChampionSportsM

I don’t want people to confuse this with prone hangs for knee extension ROM. I am not a fan of that method as I’ve stated in the past.

This is a method to assess knee extension differences, particularly after an ACL reconstruction. I have gone back to using this method for some people that have subtle ROM differences side-to-side.

The patella position (on the plinth or off) did not matter in the study and thigh girth did not appear to make a difference.

I would recommend stabilizing the pelvis to prevent excess ROM from occurring at that region and to better isolate the knee joint.

Have you tried this method? Tag a friend who may benefit from using this ROM method…thanks!

Evidence-Based Best-Practice Guidelines for Preventing #ACL Injuries in Young Female Athletes: A Systematic Review and Meta-analysis Petushek et al AJSM 2018.

Injury prevention neuromuscular training (NMT) programs reduce the risk for anterior cruciate ligament (ACL) injury.

Eighteen studies were included in the meta-analyses, with a total of 27,231 participants, 347 sustaining an ACL injury.

The overall mean training amount was 57 sessions totaling 18.17 hours (roughly 24 minutes per session, 2.5 times per week).

They concluded:

✔️Interventions targeting middle school or high school–aged athletes reduced injury risk to a greater degree than did interventions for college or professional-aged athletes.

✔️Continued exposure to neuromuscular training throughout the sport season seems to enhance prophylactic effects of NMT.

✔️NMT interventions were effective for female basketball, and handball athletes and interventions including various athletes were potentially effective (eg, soccer, basketball, and volleyball).

✔️ Interventions included some form of implementer training (eg, instructional workshop, video, or brochure) on proper program implementation.

✔️Programs including more landing stabilization and lower body strength exercises during each session were most effective.

🤔Programs including balance, core-strengthening, stretching, or agility exercises were no more effective than programs that did not incorporate these components.

✔️ Specifically, programs that included more landing stabilization exercises (eg, drop landings, jump/hop and holds), hamstring strength (eg, Nordic hamstring), lunges, and heel-calf raises reduced the risk for ACL injury to a greater degree than did programs without these exercises.

✅ Wow, lots of great information here. Please share this with a friend or colleague who may benefit from knowing this information.

Hope that helped to catch you up on my posts from this week.

Do you like these weekly updates? Let me know if I should continue…love your feedback!

Thanks for reading!

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!!