Tag Archive for: shoulder pain

Risk Factors for Recurrent Instability After a Bankart Repair Surgery

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Recurrent instability after a Bankart repair surgery is unfortunately very common. This paper looks to highlight the most common risk factors associated with recurrent instability.

I thnk it’s valuable to understand these various risk factors so you can better educate your patients. It may also help clinicians be mindful of the people that may need to have their rehab modified appropriately.

I see a lot of high school and college students that have had a shoulder injury. In this population, they’ll specifically have a dislocation event.

If there is one factor that you should consider in educating a patient about surgery or not, it is their age.

I’ll review this paper from The Bone and Joint Journal and let you know what you need to consider when a patient presents to you with an acute shoulder dislocation.

Age Influences Recurrence Rates

A patient’s age is a huge factor in determining whether or not they will have a recurrent instability episode. And people younger than 25 years of age, I typically recommend a surgery to stabilize the shoulder joint and prevent future issues.

Hovelius et al has shown that patients in their 20’s exhibited a recurrence rate of 60%, whereas patients in their 30’s to 40’s had a recurrence rate of less than 20%. 

Unfortunatley the long term prognosis in these people does not seem promising. They often develop some form of a shoulder arthropathy, as seen in this study by Hovelius in 2016.

That’s not to say that surgery is 100% required. In this study, they showed that ‘after 25 years, half of the primary anterior shoulder dislocations had been treated nonoperatively. And in these patients with an age of 12-25 years, many had not had any recurrences and had become stable over time.

What are the risk factors for recurrent instability or revision surgery following arthroscopic Bankart repair?

This paper ‘sought to determine the rate and risk factors associated with ongoing instability in patients undergoing arthroscopic Bankart repair for instability of the shoulder.’

They looked at 5719 patients with a mean age was 24.9 years, which is pretty much what we see in the clinic.

Nearly 10% of patients (8.1%) in this study had to undergo a 2nd surgery at a mean of 31 months post-operative. So, the 1st 2 years after a surgery is critical, just like in the ACL literature.

Patients between the ages of 10 and 19 had the highest rate of subsequent procedures (11.0%), and comprised over half the patients (53.8%) undergoing a revision procedure or closed reduction.

They also went to conclude that:

  • Younger age,
  • Caucasian race,
  • bilateral instability,
  • and closed reduction prior to the initial repair were independent risk factors for recurrent instability.

They also showed that a 2nd arthroscopic surgery had significantly higher rates of persistent instability than subsequent open revision procedures.

Treatment for shoulder instability

In this post that I wrote for Medbridge Education, an online continuing education company, I discuss my progression for a rotator cuff related issue.

You can use this progression when developing a plan for these patients that have had an instability episode. These progressions are used to treat both non-operative or post-surgery patients.

There are so many different variables to consider when trying to initiate physical thrapy. I tried to outline them below.

This table outlines some of the variables that Kevin Wilk and I came up with in a recent paper in Clinics in Sports Medicine journal in 2013.

Key factors to consider in the unstable shoulder

Conclusions from this paper

This paper should help you to better understand the populations at risk for recurrent instability. I try to use these papers to educate my future patients that are considering a surgey.

Keep in mind, surgery should be saved for only those that truly need it. Physical therapy can often be employed in most patient populations.

Be mindful of the patients that wuld most benefoit from surgery. Confidently educate them that their decision will be the best for them to return to their function.

An Update on Diagnosing SLAP tears

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Diagnosing a SLAP tear is not easy

We hear a lot about trying to diagnose shoulder pain and to be as specific as possible. It’s often difficult to differentiate SLAP (superior labrum anterior to posterior) tears from other soft tissue injuries of the shoulder.

For a review of the different types of SLAP tears, check out this old blog post that classifies the 10 different types of tears.

from https://commons.wikimedia.org/wiki/File:SLAP-Lesion-front-2.jpg

This paper in IJSPT by Clark et al 2019 attempts to help out the process and recommend a few special tests that MAY aid in diagnosing a SLAP tear.

What do they Recommend to diagnose a slap tear?

They recommend that a combination of at least 3 positive SLAP lesion tests may be clinically useful in diagnosing a shoulder SLAP lesion with greater diagnostic accuracy.

Combo of Tests

The combination of the Biceps Load I/II and O’Brien’s showed the highest sensitivity and specificity.

I have found similar results with this set of special tests so maybe this paper just hits my biases correctly.

In this video at my YouTube channel, I wanted to let you hear my thoughts and small tweaks to the evaluation process.

It’s not easy to diagnose a SLAP tear.

Differential Diagnosis is Critical

Furthermore, does it really matter and will it change the treatment plan much at all? I think it may a little but overall it will remain a pretty similar treatment approach to other similar pathologies like:

  • rotator cuff tendonopathy
  • Biceps strain
  • Latissimus strain
  • Subscapularis strain
  • internal impingement
  • pectoralis major strain

I think one also needs to consider the cervical spine and to make sure the pain is not referred from the neck.

Otherwise, a well thought out program should be implemented that addresses the strain on the shoulder and any strength issues.

I talked about this in an article that I wrote for Medbridge a while back so check out that post here:

You can also check out a snippet of one of my courses at this YouTube video where I discuss rotator cuff and labral issues. Hope it helps too!

Will this Change your Practice?

How ever you look at it, I wanted to use this paper to let you know that there MAY be a cluster of tests that better diagnose a suspected SLAP tear in your next patient’s shoulder.

Check out the paper and comment so we can talk it through. Are these tests similar to what you use in your clinical practice? Will this paper change what you do in your clinical practice?

The Week in Research Review, etc 12-17-18

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

When is it Safe to Drive after Orthopaedic Surgery?

💥OPEN ACCESS! 💥⠀

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


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

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

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

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

Posterior Shoulder Stretching after a Surgery

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


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


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

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

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

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

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

Burn Out in Physical Therapy

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

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

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

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

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

Surgery vs Physical Therapy for Carpal Tunnel Syndrome

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

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

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

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

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

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

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

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

Return to Sport Criteria and Reinjury Rates

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

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

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

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

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

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


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

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

Physical Therapy vs Knee Scope for Meniscus Tears

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

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

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

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

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

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

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

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

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

Shoulder Health Accessory Exercises

by @kieferlammi

Want strong and healthy shoulders!?

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

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

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

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

Give these two exercises a try:

✅ Band Front Raise Pull-Apart

✅ Band Overhead Y Raise

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

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

Should we Brace after an ACL Surgery?

  
 
 
 
 
 
 View this post on Instagram
 
 
 
 
 
 
 
 
 
 
 [NEW BLOG POST]⠀ 💥Knee Bracing Immediately After an ACL Reconstruction 💥⠀ In this post, I review some recent Twitter, Facebook and Instagram discussions about the usage of a hinged knee brace after an ACL surgery.⠀ .⠀ You'd be surprised what I found in the literature and the differences that exist throughout the US and the world.⠀ .⠀ Go to my website <LINK in my BIO> and read/share with your friends/colleagues.⠀ .⠀ It was a bit eye-opening and I'm curious to hear what others have to say.⠀ .⠀ I still like to recommend a brace for my clients because it seems to give them an added security after a pretty painful surgery.⠀ .⠀ I typically keep them braced 4-6 weeks, depending on their quadriceps activity and if they can do an active straight leg raise without a lag.⠀ .⠀ Many others don't even bother bracing at anytime post-op, which was surprising.⠀ .⠀ What do you think? Read the blog post and let me know. Let's try to educate and come to a better consensus...thanks!⠀ .⠀ #kneerehab #knee #kneepain #kneesurgery #acl #aclsurgery #ROM #physio #physiotherapist #crossfit #exercise #deadlift #physiotherapy #physicaltherapy #physicaltherapist #athletictraining #athletictrainer #ATC #PT #teamchampion #dptstudent #lenmacpt #instagram
 
A post shared by  Lenny Macrina MSPT, SCS, CSCS (@lenmacpt) on

You can also get to the blog post by clicking this link

Let me know what you think about this new blog post or any of my social media posts…thanks!

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.

If you’re already a Medbridge subscriber, then you have immediate access today.

If you’re not a Medbridge member, then you can use my promo code “Lenny2018” to save up to 40% off a yearly membership.

This gets you unlimited CEU’s for 1 year and potential access to their online HEP and a lot more!

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⁣⠀

Save 25% off our OnLine Knee Seminar Course…all this week!

Expires Sunday, November 25th at midnight ET

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⠀⠀
-⠀⠀
🧠 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 10-29-18

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This week we started the week off with a couple shoulder posts, specifically the rotator cuff and SLAP tears. As usual, I can’t resist a good ACL paper so included that NM control program that should be in all knee patients’ programs. We ended the week with a recorded knee scope as the surgeon was mobilizing the patella. It was a very informative and fun way to see the patella. We closed the week off with an old school video of myself performing a proprioception drill for the shoulder. I recommend you read these posts and like them on Instagram. Take a look at The Week in Research Review, etc 10-29-18

 

  1. Topics on the Rotator Cuff including post-op
  2. Classifying SLAP tears
  3. Essential Components of a neuromuscular control program
  4. Live Patellar scope during mobilization
  5. Shoulder Proprioception Drill

 

 

Topics on the Rotator Cuff including post-op

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff- Jancuska et al OJSM 2018

Nice summary of systematic reviews for you guys if you treat patients after a rotator cuff surgery. I’ve been doing a pretty good literature on the topic and wanted to share some of the articles that I have found helpful.

Their conclusions:

❇️There is substantial evidence indicating that the most accurate physical examinations for diagnosing RC tears are a positive painful arc and positive ER lag test

❇️Considerable evidence showing that rehabilitation is better than no rehabilitation for non-op management of RC tears, although RC repair was shown to be superior to rehabilitation alone.⠀

❇️No evidence to support the use of injections for nonoperative management of RC tears.

❇️Double Row repair results in better outcomes and fewer re-tears than Single Row repairs, especially for tears >3 cm.

❇️Predictors of re-tears and poor postoperative outcomes:⠀

✔️older age⠀

✔️female sex⠀

✔️smoking⠀

✔️increased tear size⠀

✔️preoperative fatty infiltration⠀

✔️preoperative shoulder stiffness⠀

✔️diabetes⠀

✔️workers’ compensation claim⠀

✔️decreased preoperative muscle strength⠀

✔️concomitant procedures.

Overall, a good review of the literature on rotator cuffs and anything associated.⠀

 

Classification of SLAP Tears

If you treat patients with shoulder pain, then you may run into different labral tears of the shoulder.

This post hopes to summarize the 10 different types of #SLAP tears that are currently known.

Type 1️⃣: Fraying but intact biceps

Type 2️⃣: Superior Labrum and biceps detached from the glenoid rim

Type 3️⃣: Bucket handle tear of the superior labrum but biceps anchor attached

Type 4️⃣: Bucket handle tear of the superior labrum that extends up into the biceps tendon

Type 5️⃣: BankartTear and also a detached biceps anchor

Type 6️⃣: an unstable flap of the superior labrum with a detached biceps anchor

Type 7️⃣: Anterior superior labral tear that extends to the middle Glenohumeral ligament; Biceps anchor detached

Type 8️⃣: Superior and posterior labral tear along with detached biceps anchor

Type 9️⃣: 360° labral tear

Type 🔟: Superior labral tear along with reverse Bankart tear and a detached biceps anchor.

That’s a lot and some are pretty rare but it helps to be able to communicate effectively with the medical team or to read an operative report.⠀

 

Neuromuscular training to reduce ACL injuries in female athletes

Critical components of neuromuscular training to reduce ACL injury risk in female athletes: meta-regression analysis. Sugimoto et al BJSM 2016.

This meta-regression analysis looked at the effects of combining key components in neuromuscular training (NMT) that optimize ACL injury reduction in female athletes.

They looked at a total of 14 studies that met the inclusion criteria of the current analyses. A total of 23 544 athletes were included.

They showed that there are 4 Key components

✅14-18 years old better than other age groups

✅2x/week for 30 minutes/session

✅Balance, planks, ‘posterior chain’ and plyometrics

✅Verbal cues like ‘Land softly’ or ‘Don’t let knees cave in’

Furthermore, inclusion of 1 of the 4 components in NMT could reduce ACL injury risk by 17.2–17.7% in female athletes. A great look that really specifics what age groups would best benefit from a NMT program. Do you incorporate any of these key concepts into your programs, even 1-2 of them?

I know I try to with most of my clients, whether or not they’re returning from an ACL or not.

 

Patella mobility during a knee scope

Great video by @physionetwork looking at the patella during a knee scope. This stuff is just exciting to see (in my opinion) because it gives us a little bit of insight into what is exactly going on during a patella mobilization.

In my opinion, the PF joint is often overlooked when it comes to knee surgery and it can affect joint mechanics, quadriceps activation and patient function. You need to mobilize the patella and normalize the motion…can’t stress this enough!

Check out the post below…good stuff!

Patellar mobilization is important to avoid stiffness after surgery. In this video, you can see from an arthroscopic view that little motion outside the knee, translates into a significant motion inside the knee. Mobilization may help prevent the formation of scar tissue and allow for better biomechanics of the knee joint.

We review the latest and most clinically relevant research in physiotherapy. Click link in bio to learn more and boost your knowledge 🔗

Video by Jorge Chahla, MD, PhD – Orthopaedic Surgeon -Sports Medicine Specialist

 

 

Active Reposition Drill after a Passive Motion

Loss of proprioception after a shoulder injury has been documented numerous times in the literature and can affect long-term function.

This drill may help the rehab specialist to test proprioception by measuring the exact active position difference that the patient attains.

You can also use this drill as a treatment reproduce the exact position that you passively brought them into.

Give it a shot and see what you think…you can use this drill for any joint in which you have assessed proprioception loss.

 

The Week in Research Review, etc 10-22-18

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That was a milestone week as my Instagram account finally hit 10k followers, whatever that means! I’ve really been pushing a daily post to help other rehab professionals better simplify the research. One milestone hit but I still want to keep publishing good quality research reviews. The Week in Research Review, etc 10-22-18 included:

  1. Do baseball Pitchers really have a tight posterior capsule?
  2. ACL strain curve during the squat
  3. Does the pec minor length influence shoulder pain?
  4. What does the literature say about the EMG activity of the rotator cuff, particularly of the supraspinatus, with ROM
  5. Classification of Meniscus Tears and Osteoarthritis

Do baseball Pitchers really have a tight posterior capsule?

My guess is emphatically no based on what I see on a daily basis, the general anatomy of the glenohumeral joint and some research studies.

Anatomy
1️⃣When I stretch a baseball pitcher’s shoulder, it is usually very mobile. I find this in both symptomatic and asymptomatic individuals.

If I try to assess their posterior capsule with a joint play technique, I can often translate the humeral head pretty far over the glenoid rim. Sometimes, I can even sublux the humerus!

2️⃣Anatomically, the posterior capsule is relatively thin compared to the anterior and inferior capsule (see the post).

In general, that capsule is thinner probably because of the glenoid position that is not strictly in the frontal plane.
Because of that, it is theorized that the capsule evolved to have less of a role in stabilizing the humerus.

3️⃣There are a couple of research studies that have specifically looked at baseball pitchers to determine their humeral head translation.

Borsa et al AJSM 2005 reported that posterior translation was actually greater than anterior translation in both the dominant and non-dominant shoulders of professional baseball pitchers.

Crawford et al J Ath Train 2006 found no significant differences in posterior glenohumeral laxity and stiffness between the throwing and non-throwing shoulders.

I understand why the theory exists and think it could be plausible but just don’t think it’s truly responsible for what we think.

We just don’t think we can stretch the posterior capsule with any joint mobilization or contract-relax procedure, including a sleeper stretch. I often giggle at all of those MD prescriptions that say ‘#GIRD, posterior capsule tightness’. I just treat what I find on my examination and ignore the script.

ACL strain curve during the squat

As you can see, the strain curve from the Beynnon et al study is very similar to the strain curve during resisted knee extension in a full ROM (90-0).

We argue all of the time about anterior tibial translation during the open chain exercises but often ignore the other side of the story.

The strain on the ligament is barely 4%, which is in line with many functional activities like walking, descending steps, etc. The argument that we’re going to stretch the ligament out just has not been proven in the literature.

I wanted to show the closed chain strain curve so you could compare it to the open chain strain curve. I know the n=8 argument is present but we really don’t have much more data on the ligament in vivo that shows the true effects of open vs closed chain exercises on the ACL.

Again, as @barbhoogie mentioned, you need to monitor the PF joint, especially after a patella tendon autograft but as long as we’re not aggravating that joint, then I begin early 90-0’s and mini squats as tolerated.

Do you agree with this? Do you prevent squats early on during the ACL rehab process? If you don’t, then why do you hold back on full active knee extension exercises?

Does the pec minor length influence shoulder pain

Does the pectoralis minor length influence acromiohumeral distance, shoulder pain-function, and range of movement? Navarro-Ledesma et al Phys Ther Sport Aug 2018.

Their conclusion: Pectoralis minor length is not a distinguishing factor in shoulder⠀
assessment when a chronic condition exists, and it seems not to play a key role in pain perception and ROM.

54 participants with chronic shoulder pain in their dominant arm were recruited, as well as fifty-four participants with a pain-free shoulder.

The resting muscle length is measured between the caudal edge of the 4th rib to the inferomedial aspect of the coracoid process with a sliding caliper.

The acromiohumeral distance (AHD) was defined as the shortest linear distance between the most inferior aspect of the acromion and the adjacent humeral head, measured by ultrasound.

An interesting study that used an asymptomatic control group along with the contralateral shoulder of the symptomatic subject. A pretty clean study that is very interesting. I’m not going to say that the pec minor doesn’t play a role in shoulder pain but maybe its role is not as prominent as we think.

What do you think? Do you find pec minor length has a substantial role in your patients with shoulder pain?⠀

EMG of the rotator cuff during rehab exercises

What does the literature say about the EMG activity of the rotator cuff, particularly of the supraspinatus, with ROM?

Many PT’s and doctors are uncertain when to safely begin physical therapy after a shoulder surgery, particularly after a rotator cuff repair. In my 15+ years as a PT, I’ve seen docs begin PT post-op day 1 or wait as long as 6 weeks (which drives me bonkers!!)

In this snippet that I’ve taken from an upcoming blog post at LennyMacrina.com. I discuss the research that’s helping to guide best practice, in particular, the research that looks at PROM and AAROM and how much EMG activity is actually going on in the supraspinatus with each movement.

As you can see in the video, there’s minimal supraspinatus activity (<20% is considered minimal) for all motions. Keep in mind, many of these studies are done on healthy individuals but who in their right mind would volunteer their newly repaired RTC repair to have fine-wire EMG done on them?

So, I can only draw my conclusions from a limited body of evidence and my own anecdotal evidence (which consists of 12+ years of immediate PROM POD 1). Many still think it’s safe to get a RTC repair patient’s shoulder moving early for many reasons that I will describe in this blog post.

I just wanted to get this early point out there to get another discussion going. I think our patients can do much better after a RTC repair and this is one of the reasons.

Do you agree? Do you advocate for early PROM after a RTC repair, especially a small-medium repair?

Classification of Meniscus Tears and Osteoarthritis

Great post by @physicaltherapyresearch talking about the various types of meniscus tears. Nice visual & description of each type and the incidence of OA. Take a look! 👇🏼
_______________
Meniscus Tears and Osteoarthritis

💡

Prevalence of meniscal tears is estimated as ~24-31% of some populations, increasing with age and ranging from 19% in women aged 50–59 years to 56% among men between 70 and 90 years and is markedly higher in established OA subjects.
💡

Medial meniscus and/or the posterior horn tears make up 66% of cases, with horizontal and complex tears being the most common.
💡

Most subjects with a meniscal tear are asymptomatic.
💡

Regardless of morphologic type, meniscal tears are strongly associated with OA cross-sectionally and predict OA longitudinally and are considered to be part of the spectrum of early or pre-radiographic disease

📝📝📝

TEAR TYPES INFO:

Often enough, meniscal tear types are categorized into varying groups for comparison rather than separately compared to each other.
📝

There is a striking lack of data on the relevance of different morphologic types of meniscal tears in OA.

📝

Horizontal and complex tears are common findings in knees with OA

📝

Posterior radial tears of the medial meniscus are associated with a high degree of cartilage loss and meniscal extrusion, and appear to be a highly relevant event in the progression of OA in the knee. 📝

Lateral meniscus radial tears affect younger individuals and are considered post-traumatic.

📝
Despite their suggested high relevance, radial tears are more commonly misdiagnosed on MRI than any other type of tear.

📝

While medial meniscus posterior root tears are of “radial” morphology, there is growing interest in regarding them as a separate entity.
📝

Longitudinal and bucket handle tears affect younger individuals and are highly associated with ACL injuries, favoring a traumatic etiology.
📝

MRI is important to detect and locate a possible displaced tear.
📝

Further epidemiologic studies should focus on the morphology of specific meniscal tears to better understand their relevance in the genesis and progression of knee OA.
📚📚📚
SOURCE:
Jarraya et al. 2017 Semin Arthritis Rheum

The Week in Research Review, etc 10-15-18

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This week I posted a lot of research and thoughts on shoulder and knee rehab, particularly after an ACL injury. I also shared some others posts that really complimented my posts so there’s some bonus reading to do too. Hope The Physical Therapy Week in Research Review helps your Monday patients and beyond! Take a read and share with your friends!

  1. Co-morbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse, and cardiometabolic conditions. Rhon et al BJSM 2018.⠀
  2. Range of Extension Correlates with Posterior Capsule Length after Knee Remobilization Zhou et al Med Sci Sports Exerc 2018⠀
  3. Sidelying External Rotation- The 1 exercise in all upper body programs
  4. @dr.jacob.harden talking Infraspinatus release.
  5. Do you account for Bone Bruises after an ACL
  6.  @cbutlersportspton bone bruises and the specifics
  7. When is it safe to initiate full AROM knee extension after an ACL-PTG autograft
  8. @mickhughes.physio on when it MAY be safe to initiate full knee extension from 90-0 after an ACL reconstruction.

 

 

Comorbidities after Hip Arthroscopy

Co-morbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions. Rhon et al BJSM 2018.

This is an interesting study on 1870 mainly US Military personnel between 2004-13 (~33% were not active duty).

Relative to baseline, cases of:

❇️mental health disorders rose 84%

❇️chronic pain diagnoses increased by 166%

❇️substance abuse disorders rose 57%

❇️cardiovascular disorders rose by 71%

❇️metabolic syndrome cases rose by 85.9%

❇️systemic arthropathy rose 132%

❇️sleep disorders rose 111%

The comorbidity with the greatest increase of new cases was that of mental health disorders (26% of the entire cohort). Age and socioeconomic status had significant associations on outcomes as well.

Just an eye-opening study that followed each subject 2 years after their respective surgeries. One giant variable that jumped out at me was that they used mainly military personnel only as the subjects.

We certainly can’t extrapolate on non-military personnel but need to keep this study in mind for others treating a similar cohort. Did the surgery cause these disorders? Absolutely not! No causation can be associated and that is very important!

What do you think about this study and how mainly military personnel and civilians that were tracked ending up developing many chronic disorders? I say it is very troubling! Let’s chat…and remember, this is not a causation study but just a reminder to educate and monitor your patients’ well-being after a surgery.

 

Posterior Capsule Limits Knee Extension after an ACL

Range of Extension Correlates with Posterior Capsule Length after Knee Remobilization Zhou et al Med Sci Sports Exerc 2018

This study is a confirmation bias for me because it showed that the knee’s posterior capsule limits extension after immobilization (in rats!) This is why I’m a huge proponent of low load long duration stretching of most joints when they begin to get stiff.

It seems as if the prolonged stretching is needed to regain collagen length and return the ROM. I know it’s in rats so calm down…but we need to get the data from somewhere.

Take it with a grain of salt but know that LLLD is going to be the best mode to return ROM (and not just hamstring stretching).⠀
.⠀
Do you agree? Do you treat rats with stiff knees? Then this study was created for you!

 

The Best Exercise for the Rotator Cuff

❗️Sidelying External Rotation- The 1 exercise in all upper body programs❗️

I really think this exercise should be in everyone’s program, whether going through rehab for a painful shoulder or a high level, healthy powerlifter. The role of the infraspinatus and other rotator cuff muscles is crucial to maintaining humeral head stability.

Sidelying external rotation has been shown to elicit the highest amount of EMG activity for the infraspinatus so I give this exercise to everyone, once there are no precautions for tissue healing. The infraspinatus and subscapularis (front rotator cuff muscle) are force couples that help to stabilize the humerus within the glenoid. Weakness of the infraspinatus may affect this force couple and create an inefficient movement within the joint.

My goal for all of my clients is to create an efficient movement that allows them to work at their highest level. The infraspinatus is a critical muscle of the shoulder complex so MOST of my programs include this exercise.

 

Myofascial Release of the Infraspinatus

Great post by @dr.jacob.harden talking Infraspinatus release. Perfect timing for my earlier post today looking at my go to exercise for the shoulder joint. Check his post out below!👉🏻 🔴 𝙃𝙊𝙒 𝙏𝙊 𝙍𝙀𝙇𝙀𝘼𝙎𝙀 𝙄𝙉𝙁𝙍𝘼𝙎𝙋𝙄𝙉𝘼𝙏𝙐𝙎

Coming at ya with a little #throwbackthursday since I’m about to jump on a plane across the pond to London. So we’re looking at how to do a pin and stretch for the rotator cuff, specifically the infraspinatus. The infraspinatus is the main external rotator of your shoulder, so it’s that muscle we see everyone working when they swing there 5 pound plates side to side in their warm-ups. (Side note: if you do that, please use a band or do it sidelying. Standing with plates does nothing but work the bicep.👍)

This can also help with some those little hypersensitive areas in the back of the shoulder. If you’re feeling those spots or having shoulder pain or just want to improve your internal rotation a bit, this release can help.

𝗛𝗲𝗿𝗲’𝘀 𝗵𝗼𝘄 𝘁𝗼 𝗱𝗼 𝗶𝘁:

🔹️Ball placement is below the spine of the scapula.

🔹️Internally rotate, flex, and adduct the shoulder

🔹️Work back and forth for a minute or so

 

Bone Bruises after an ACL

Do you even consider a bone bruise after an ACL when progressing your patients? I know I certainly do and one of the major reasons why I have gone a bit slower with my latter stage progression, especially to impact activities like plyometrics and running.

There are a few studies that have shown the presence of a bone bruise after an ACL injury but we are not 100% certain this eventually leads to joint degradation.

Hanypsiak et al included 44 patients (82%) who underwent unilateral ACLR without multi-ligament involvement. Thirty-six (82%) patients had a bone bruise on index MRI. Potter et al reported all patients in their cohort sustained chondral damage at the time of injury.

Faber et al examined 23 patients with occult osteochondral lesion (bone bruise) who underwent ACLR. They found that at 6-year follow-up, a significant number of patients had evidence of cartilage thinning adjacent to the site of the initial osteochondral lesion (13/23 patients).

So as you can see, bone bruises are more common than most people think. This may be one reason why osteoarthritis rates are much higher in ACL reconstructed knees.

Additional factors, such as cartilage and meniscus injury, associated with ACL rupture may play an important role in subsequent outcomes following surgical reconstruction independent of a bone bruise.

Do you consider a bone bruise when progressing your patients back from a knee injury like an ACL reconstruction?

 

Types of Bone Bruises after an ACL Injury

@cbutlersportspton bone bruises, which fits perfectly with my post earlier today. He talks about the 3 different types of common bone bruises…check it out below!

❗️What is a Bone Bruise❗️We often hear that one of our Fantasy Football players has a Bone Bruise and may be out for a few weeks.

It sounds like something that an NFL athlete should be able to tough out, right?

Here’s why you may need to put in a backup for a few games.

A bone bruise occurs when several trabeculae in the bone are broken, whereas a fracture occurs when all the trabeculae in one area have broken. Trabecular bone is also known as spongy bone.

—-Three Types of Bone Bruises—-⠀
1️⃣Subperiosteal hematoma: A bruise that occurs due to an impact on the periosteum that leads to pooling of blood in the region.⠀
2️⃣Intraosseous Bruising: The bruise occurs in the bone marrow and is due to high impact stress on the bone.⠀
3️⃣Subchondral Bruise: This bruise is bleeding between cartilage and bone such as in a joint.

—-Symptoms of Bone Bruises—-

•Pain and tenderness in the region of injury

•Swelling in the region of injury

•Skin discoloration in the region of injury

Bone bruises often occur with joint injuries, such as ankle sprains and ACL tears, therefore a bone bruise can also coincide with stiffness and swelling in the joint.⠀

 

When is it safe to initiate full AROM knee extension after an ACL-PTG autograft?

I posted this video in my the other day and had a ton of people message me about the exercise.

Most people wanted to know how far out of surgery the patient was and when I felt it was safe to begin full, active knee extension after an ACL.

I’ve always been relatively conservative with my rehab (at least I think so) but I wanted to dig a little deeper. I recently saw a post by @mickhughes.physio and he was talking about the Fukuda et al study from 2013.

The study looked at 90-40 knee extensions and ‘ACLR patients can perform 3×10 at a 70% 1RM load through a restricted 45-90deg ROM between weeks 4-12 post-op, and then the same load full ROM from 12 weeks post-op. ‘

It made me dive a bit deeper and I went to my trusty Beynnon et al AJSM studies from the late 90’s. You can see the strain on the ACL decreases as we approach 40 degrees and stays low out to 90 degrees…but is 3-4% strain on the ligament significant?

If you look at the study (yes, it’s only on 8 subjects) you’ll see a similar strain curve for closed chain exercises as well…but we do mini squats immediately after surgery without 2nd guessing!

In 2011, Beynnon et al AJSM showed that an accelerated program that initiated full resisted knee extension (90-0) at 4 weeks showed similar knee laxity throughout the study. The other group initiated full resisted knee extension at 12 weeks. Also, those who underwent accelerated rehabilitation experienced a significant improvement in thigh muscle strength at the 3-month follow-up.

So, what do we do with this data? I have begun to do full, resisted knee extensions with my patients between 4-6 weeks post-op, as long as it’s a patella tendon autograft. For allografts or HS autografts, I tend to delay it a bit longer because of the soft tissue healing that is delayed.

What do you think? When do you initiate full AROM after an ACL? Do you know of a study that definitively says the strain on the ACL graft is detrimental to the healing ligament?

 

How much Resistance Should we Recommend Open Chain Exercises After an ACL

This is the post from @mickhughes.physio that made me dive a bit deeper into the research on when it MAY be safe to initiate full knee extension from 90-0 after an ACL reconstruction. Check out his post below! ⠀
____________________

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

This is a question I often get asked. Based on the work by Fukuda et al (2013), ACLR patients can perform 3×10 at a 70% 1RM load through a restricted 45-90deg ROM between weeks 4-12 post-op, and then the same load full ROM from 12 weeks post-op. *⠀
*⠀

From then you can progressively load as per what can be tolerated. Usually the first sign that the knee is unhappy with the load is that the underneath the kneecap will be sore/painful. That’s a sign you need to back the load off a little so the exercise is felt in the quads only. *

If you’re still unsure about OKC exercises (knee extensions) during ACLR rehab read my blog by clicking on the link in my bio ⠀
#ACL #Physio #Knee #Rehab

 

The Week in Research Review, etc 9-17-18

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Another week of some great discussions looking at the week in research review. Check it out below and let you friends know they need to subscribe to my blog! Thanks, everyone!

 

 

Gluteal Tendinopathy: A Review of Mechanisms, Assessment and Management. Grimaldi et al Sports Med 2015.

Great review of gluteal tendonopathy, which I think is more prevalent than we once thought.

It was often confused as greater trochanteric bursitis which was completely misleading, and treated with injections.

Non-inflammatory insertional tendonopathy of the gluteus medius and/or gluteus minimus is now considered the primary pathology underpinning lateral hip pain.

This paper does a nice job of outlining the pathomechanics, assessment, and management of patients diagnosed with gluteal tendonopathy.

In their conclusions they mention “The evidence for the best management is poor, and the underlying mechanisms of the condition are only beginning to be understood. Interventions reported in the literature do little to address potential underlying mechanisms.”

Found this pretty eye-opening but refreshing because as much as we think we know, we really don’t know.

Check it out and share with your colleagues and friends that may be interested…thanks!

 

 

 

The squat and deadlift definitely my go to exercises for most of my patients with a lower body injury. @kieferlammi@fitnesspainfree

Obviously, there’s a progression to get to heavy weights but the goal for MOST of my clients is to load their joints and muscles to be able to withstand the demands of their life and to meet their goals.

I also like to make sure their accessory movements and stabilizing structures can maintain good stability, as in the glute tendonopathy I posted yesterday.

My focus is typically on improving hip,. ankle and knee mobility and stability through hip flexor stretching and maximizing ankle dorsiflexion. These principles apply to many but not all (so calm down!).⠀

I’ll also focus on glute/Hamstring work through clams, bridging, band walks, etc. Again, my go-to exercises for the lower half, kinda like my go-to rotator cuff exercises.

Our lives can be repetitive but that’s because many people fall into similar buckets in their presentations.

What do you think❓Do you use these similar principles when treating your clients?

Share or tag a friend who may benefit from this post…thanks!⠀

 

 

 

Arthrogenic muscle inhibition after #ACL reconstruction: a scoping review of the efficacy of interventions Sonnery-Cottet et al BJSM Sept 2018.

This paper looked to ‘determine whether reported therapeutic interventions for arthrogenic muscle inhibition (AMI) in patients with ACL injuries, following ACL reconstruction or in laboratory studies of AMI, are effective in improving quadriceps activation failure when compared with standard therapy in control groups.’

780 potential articles were identified. 20 met the inclusion criteria.

Using the GRADE approach, there was moderate-quality evidence for the efficacy of cryotherapy in the treatment of AMI.

Moderate-quality evidence for the efficacy of exercise in the treatment of AMI.

Surprisingly, there was low-quality evidence for the efficacy of NMES, which seems to be pretty accepted treatment but vibration, ultrasound, and TENS also demonstrated low-quality evidence.

The available evidence does not support taping or bracing in AMI. They mentioned active release or local anesthetics as other modalities that have no effect on quadriceps inhibition.

No mention of blood flow restriction training, which would’ve been interesting. #BFR

What do you think? Does this study match what you do in your clinical practice? Tag a friend or colleague who may be interested in this open access paper…thanks!⠀

 

 

Is There a Pathological Gait Associated With Common Soft Tissue Running Injuries? – Bramah et al AJSM 2018.

I took an interest in this study because they actually used people that had been diagnosed with an injury, which is pretty unusual.

They wanted to look to see if Injured runners would demonstrate differences in running kinematics when compared with injury-free controls. They looked at 72 injured runners and 36 healthy controls.

The injured runners demonstrated greater contralateral pelvic drop (CPD) and forward trunk lean at mid-stance and a more extended knee and dorsiflexed ankle at initial contact.

Contralateral pelvic drop was found to be the most important variable in predicting the classification of participants as healthy or injured.

Importantly, for every 1° increase in pelvic drop, there was an 80% increase in the odds of being classified as injured.

Curious to hear my running PT/Physios chime in and drop some knowledge like @zerenpt and @running.physio
Share with your running friends and colleagues who may benefit from reading this post…thanks!⠀

 

 

 

[REPOST] Thought this was a great post showing some advanced hamstring exercises by @scottlogan_nz(twitter) @scottlogan03 (Instagram). Check it out and give him a follow!

Can be used in rehab after an #ACLsurgeryor any lower body injury. can also be used in injury reduction programs, especially for those struggling with chronic strains.

Loved the addition of explosive power production while trying to dissipate the forces.

See his post below. 👇🏻

Higher speed, fast eccentric and rapid isometric hamstring exercises are an important part of any performance or injury risk reduction program. Here are a few variations I have used recently. There are plenty more out there, this is not an extensive video database. Add one or two of these to your next cycle and let me know how you get on. Remember to be smart adding new exercises and stimulus to training. do it gradually and progressively.⠀

 

 

 

Power of positive words. We use these on a daily basis at @championptp. Like @drewbrees talks about during a recent interview.

Dr. Andrews said “If I did that surgery 100 times, I couldn’t do it as good as I did it this time.” I wanted to plant that positive seed…

Wow, powerful stuff by the doctor who I know completely gets it when he’s dealing with all of his patients…from the youth athlete to the highest paid players ever to play professional sports.

There’s a kinda game we play at times to make sure our clients can buy into what we have done or are about to do with them.

Whenever someone tells me that they couldn’t have done it without me, I always tell them that they did all of the work and I was just there to help guide the process.

Dr. Andrews alluded to this and knew the mental challenges that Drew and his family were going through right after the surgery. He was able to set the tone for the rest of the rehab that @wilk_kevin did over the many months following the surgery.

I was able to watch across the room at @championsportsm (and at times work with Drew when KW would hit the road) and see the tremendous progress that was being made.

I distinctly remember Drew’s 1st day of throwing a football and the relief that day. It was such a great moment to witness and one in my personal career that I’ll never forget.

With that, I just wanted to share this video because the interactions and confidence that we can exude can make or break a rehab session, so choose your words and actions carefully.

Tag a friend who may like to read this or may just be a @saints fan!

 

Lots of good stuff…Thanks for reading!