ACL surgery continues to be a huge focus in the literature and in our outpatient rehabilitation settings. Numerous studies focus on return to play guidelines and retear rates. Social media is all over the place, most times. Let’s try to make things simple and set the stage early.
Paralysis by Analysis- What ACL tests are best for return to play
I previously wrote about return to play guidelines here and even the neurocognitive challenges that are associated with ACL rehabilitation.
As troubling as it all seems, I almost feel as if the recent research is confusing and often unattainable in a traditional outpatient PT setting. I’m worried about the paralysis by analysis mindset that seems to have overtaken my recent discussions on social media.
Most don’t have an isokinetic device to test.
Hop tests, vertical jump, strength…what really matters?
Do hop tests really give us a complete picture of an athlete’s return to play readiness?
What combinations of tests are appropriate?
Is it more than just quadriceps strength?
What about a vertical jump test to determine lower extremity strength and function for an LSI?
Lots of questions!
Timeframes have shifted from a 4-6 month return to play goal to a more realistic 9+ months before we return people. Studies continue to show that a slower rehab may be better.
ACL retear rates still too high
Yet, our retear rates still remain very high and we’re still missing the boat for many.
I get it. It’s not just the timelines and rehab. Many are limited by equipment, insurance limitations, differing MD protocols, and so much more. It’s easy to blame one concept when it truly is multifactorial.
That’s why I employ a very simple approach to my ACL rehab programs that seems to work for most and hope this concept can help you too.
It all really occurs at the beginning of rehab when you set the stage for the rest of your planning. If you can establish full motion, remove most of the swelling and restore a pretty normal gait, then you have achieved your goals.
From here, it gets fun and we’ll talk about that later…
An easier approach to ACL rehab
Immediately Post-op Phase
During the earlier stages of rehab, we’ll call it 6 weeks post-op, my main focus is calming the knee down and establishing a normal range of motion.
Range of Motion
It is critical to get the knee as straight as possible and as quickly as possible. For example, most people naturally have some 3-5 degrees of hyperextension. For these individuals, I like to get 0-3 degrees of hyperextension immediately and allow the rest to come through normal functional stresses.
For hypermobile patients, say 10-15 degrees of knee hyperextension, I will only get about 5-7 degrees of hyperextension because I know their underlying tissue mobility will allow the motion to return very easily.
These individuals will not struggle with ROM and it often comes too easily. I don’t want to put unneeded stress on the graft.
Before you yell at me that knee extension will affect retear rates, a study in AJSM showed that the degree of hyperextension did not affect graft laxity and retear rates.
For flexion ROM, I like to have them seated at the edge of the table as I have shown in this video.
I just feel as if it’s easier on the patient and their knee instead of supine or prone, as I’ve described in the video.
I’m a bit obsessive with measuring ROM early, especially extension. It’s critical to stay on top of it and monitor for subtle changes in the motion and end-feel. Here’s an example of an ACL patient of mine who I recently saw and her post-session ROM.
measuring knee extension after an ACL surgery
Normalize Patella Mobility
You must also normalize patella mobility, especially in a patella tendon autograft. It is critical to regain this mobility in order for the normal motions to occur in the knee and to restore normal arthrokinematics.
I don’t push things too quickly and think this sets the stage for the rest of the rehab. In my hands, slow and steady is the best approach. A spike in volume can slow things down.
When I say a spike in volume, it could simply be a long walk or an extra bike session. The patients are often feeling good and looking for some independence and normalcy. They want to push it and we need to let them know that an increase in swelling or pain can create an issue.
Strengthening
I tend to go pretty slow with this concept as well. I tend to stay conservative for 4-6 weeks and stay with mainly table exercises like leg raises and mini squats.
I do love to use electrical stimulation (I prefer the DJO Global Continuum 2 unit!) for the first 2 weeks then add blood flow restriction training to compliment the NMES.
Not sure the research backs up my thoughts besides this 2015 paper or this one from 2018 but it definitely shows promise and makes sense in my head.
I’ll stay with these particular exercises for 4-6 weeks to ensure that the knee is calming down and my exercise progressions are not causing more pain or swelling.
Let the ACL rehab fun begin
If you’ve made it this far, then the important concepts have been met. No really!
The first 6 weeks set the tone and it can only go up from here.
For my patients, I basically turn into a strength coach and progress them based on muscle capacity and progress their programs based on movements and muscle groups.
I like to really hammer single leg work early but only after I’ve given them a good bout of 2-legged work to establish a base of movement.
Some do it the other way but I want to build confidence with 2-legged squats and/or deadlifts to reinforce a movement then use single leg work to take it to the next level.
When to run after an ACL
As I’ve gotten older in my career, I’ve gotten slower with my progressions. I typically don’t like to start running until at least 4 months after surgery and that’s if their quadriceps muscle is strong enough.
I look to this paper that shows a quadriceps strength to bodyweight ratio (QS/BW) of 1.45 Nm/Kg as a rough estimate to initiate running.
Some may argue that this paper only considers ACL patients that utilized a hamstring autograft and that’s a fair argument. But there’s limited information out there and I wanted something more objective.
So, until they can establish a good quadriceps contraction and their ROM/gait are normalized, I will hold off running.
ACL rehab is mainly about strengthening
The cat’s out of the bag…don’t tell anyone!
It’s pretty simple, once you get through that 6 week interval that we talked about earlier.
If you’re not proficient in this, find someone who is in your area.
Otherwise, program using simple strength training principles that incorporate power, velocity, full ROM and tempo. Work on their aerobic capacity while building strength, power and endurance.
I could write another full blog post on this but we touch upon these concepts in our all online knee course.
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.
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.
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 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.
https://lennymacrina.com/wp-content/uploads/2019/11/Instagram-feed-2019-11-03-20-46-53.jpg16021090Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2019-11-04 06:00:282019-11-03 20:50:23Risk Factors for Recurrent Instability After a Bankart Repair Surgery
I’m a bit interested, confused and looking to seek more on this open access paper that just came out in March of 2019 looking at the effects of season-long participation on ACL volume in female intercollegiate soccer athletes. The title of the paper is: “Effects of season-long participation on ACL volume in female intercollegiate soccer athletes” by Myrick et al.
ACL Growth influenced by soccer Activity?
Basically, they did MRI scans (only using a 1.5 Tesla machine) of the bilateral knees of the Quinnipiac University women’s soccer team before and after their soccer season.
The researchers wanted to look at the ACL structure and size in the 17 participants to see what, if any, changed in the size of the ligament and if there were any noticeable changes that occurred.
I cannot recall a previous study like this, which is pretty surprising. I feel like this may give us some insight into why injuries may or may not happen at a given time during the season or in a given population (like women!).
They found that mean ACL volume significantly increased from preseason to the postseason (p = .006).
There was also greater volume increase in the right knee than the left and the difference between knees was significant (p = .047).
Figure 1 of Myrick et al. Journal of Experimental Orthopaedics
I’m just a bit flabbergasted, for lack of a better term, because I was completely unaware that the ACL would undergo such changes over a season.
The authors’ rationale was “repetitive subacute trauma occurring over the course of the competitive soccer season leads to microscopic tears in the ligament inducing an inflammatory response and subsequent remodeling of the ACL which results in increased volume.”
Sounds plausible… but does this stuff really happen like that?
from: https://gph.is/1sEKHQ2
I will say that their study was not blinded and the doctors’ assessment of edema volume seemed a bit too subjective.
The authors also reported that the plant leg (left leg) had more edema in the joint than the kicking leg (right leg) which seemed a bit odd to me. They were pretty vague with their methods when it came to this section and not everyone showed these changes.
I did want to mention it because they did as well but it certainly wasn’t the meat of the paper.
Future Implications
Maybe the open chain action of kicking a soccer ball aided in hypertrophy of the ACL and maybe this would help to create a stronger and more robust ligament.
On the flip side, a larger than normal ACL for that person may create a situation where the ligament is too large for that person’s condylar notch and create impingement. Taking it one step further, this ligament impingement may put the athletes in a greater risk of injury (ACL tear).
What else do we know?
Weightlifting linked to ACL Hypertrophy too
In another study from 2012, they found that weightlifters had a more hypertrophied ACL and PCL than age-matched controls. This paper also showed that weightlifters who started lifting earlier in their life span (mean 10 years old) and at least 10 years of training duration had a higher change in the size of their cruciate ligaments.
So, maybe the weight lifting creates a proliferation of the ligament that results in further growth compared to untrained athletes. Does puberty play a role when hormones are raging and growth spurts are running rampant?
Patella Ligament Influence
This same group published a paper in 2012 that showed the area of the patella ligament (patella tendon in our world) mid-substance and the onset of training were very strongly, reversely correlated. Beginning training during the onset of puberty highly influenced the growth of the patella ligament (tendon).
Maybe this is not as surprising as the ACL papers because of the direct stresses from weight training, especially in those that squat heavy weights.
We already know that tendon tissue remodels to the stresses placed upon it, even though one could call the patella tendon a ligament, right? it is contained between two bones!
I did want to show that there is precedent out there for such influences on our soft tissue but was extremely surprised by the ACL study.
Wrapping it up
I’m very curious to see if the research can be replicated by another group.
Some of my questions to ponder:
Do other sports like football show similar effects?
What if the women’s soccer team was followed long term to see injury rates over the course of their careers?
Is there a particular time where the hypertrophied ligament returns to its baseline level? How long does it take?
Does the open chain aspect of the soccer kick truly influence the ACL’s volume (or is it some other aspect of the soccer kick)?
Just so interested in this phenomenon and hope to better define its implications to all sports, including this women’s soccer team.
What do you think? Have you seen anything similar in your experiences? What am I missing?
https://lennymacrina.com/wp-content/uploads/2019/06/girl-soccer-kick-people.jpg-2019-06-20-08-19-47.jpg12611500Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2019-06-24 06:00:182019-06-20 21:13:22ACL Volume Changes over a Women’s Soccer Season
Physical therapy is vital after a rotator cuff repair and continues to be common in an outpatient setting. Unfortunately, there’s no true consensus on when to actually begin PT. Is early physical therapy safe after a rotator cuff repair or should we delay PT to protect the healing tendons?
Let’s dive into this and see what the research is saying…
Why I’m writing this post on rotator cuff rehabilitation
It seems as if we’re all over the place despite the research, which is pretty typical. Some docs prefer early passive range of motion (PROM) while others wait 6-8 weeks (and even up to 12+ weeks for a revision repair) before they allow any form of PT.
For the record, I’m going into this blog post as a firm believer of early PROM. It’s what we’d been doing for years in Birmingham at Champion Sports Medicine.
It’s what I only knew until I moved to Boston in 2014. Now I’ve seen a nearly 180-degree turn in rehab thoughts. Much more conservative!
I recently got in a Twitter discussion (debate) about this same topic with some very respected and prominent PT’s in the field.
It made me think about things so I decided to do a little research to see what the literature says. You can check out the discussion here.
Twitter can be confusing and tough to follow but just trust me, it goes on for a while!
Rotator Cuff Anatomy
The tendon most commonly torn is the supraspinatus tendon. Don’t get me wrong, you can tear the other rotator cuff tendons (infraspinatus, teres minor, subscapularis).
Keep in mind a medium, large or massive rotator cuff tear often will involve the infraspinatus tendon. If it does, then you need to consider modifying your progression appropriately.
But for the sake of this post, I’m going to stick to an isolated supraspinatus tendon for now.
Rotator Cuff Tendon Size and Location
Look at the size of the tendons as they insert on the greater tuberosity. You’ll see it differentiated by antero-posterior and medial-lateral directions.
According to my colleague and friend Jeff Dugas out of Birmingham, he showed in 2002 that the mean dimensions of the supraspinatus insertion were 1.27 cm in the medial-to-lateral direction. For the anterior-to-posterior direction, the supraspinatus dimension was 1.63 cm.
It helps to know this information because you may need to read an operative report and see the size of the tear. The docs will usually mention a 2 cm tear or something like that.
That means that the supraspinatus tendon and a small portion of the infraspinatus tendon were involved (and repaired.)
This is critical information to have when you’re trying to plot the post-op rehab progressions and determine the prognosis. The more tendons involved, then the higher the chance of repair failure.
There are many other factors that influence retear rates but tendon repair size is definitely one to consider.
Rotator Cuff Repair Surgery Types
I’m not going to bore you with the details of a repaired rotator cuff. There are numerous surgical techniques being used by orthopaedic surgeons.
Techniques such as a single row, double row, suture bridge or transosseous repairs are commonly performed. The picture below shows the difference between a single row and a double row repair, for example.
As you can see below, the double row tends to repair more of the tissue back to the humeral insertion point, which in theory has led to better tendon healing. This has been shown in numerous research studies and has become the best technique available.
So you had shoulder surgery…when to start physical therapy?
That seems to be the million dollar question! The research is all over the place. This means that doctors’ opinions are all over the place too, right?
Since I joined the group in Birmingham in 2002 (as a PT student), we had our post-op rotator cuff repair patients starting PT post-op day 1. They started PT early regardless of the tear size. This means a small tear of 1 cm in length started PT the same time a massive, 5 cm repair would start PT.
Some may disagree with this start time but it worked…it just worked. At least I think!
Why Early PT after a Rotator Cuff Repair
This is Key!!
There were several reasons why I think it worked:
They could chat with a professional.
Patients better understand their pain and get reassurance that what they were feeling was normal.
Someone could monitor their incisions and answer any and all questions.
Begin early, gentle ROM which often helps with pain control, too.
But, that was our ‘protocol’ and it continues to be that way many years later. Most other doctors that I have dealt with outside of Birmingham have taken a far more conservative approach to post-op rehab.
Agree to Disagree
Here in Boston, most docs wait at least 2-3 weeks and even up to 8-12 weeks to begin PT. Talk about eye-opening!
I don’t agree with this premise and wanted to dive a bit deeper into the literature to see if early physical therapy had a detrimental effect on short-term, mid-term and long-term outcomes.
Structure vs Function
The problem that continues to plague the research is the measurement of outcomes. Doctors care about the structural integrity of their rotator cuff repair. They see the research and are concerned with retear rates that hover in the 25-70%+ stratosphere. Of course I’d be concerned with retear rates that high!
Can you imagine if ACL re-tear rates were that high? Well, guess what they still hover in the 6-40% range even with our tremendous rehab skills and return to play testing.
But fortunately, we have other parameters to consider with our patients after a rotator cuff repair. We can look at the pain-free function!
Huh, what a novel idea. Regardless of the integrity of the repair, many patients can still live their lives to the fullest and in most cases without any pain.
Start PT Early after a Rotator Cuff Repair? What does the literature say…
I’m going to do my best and unbiased research to figure out if early PT after a rotator cuff repair is safe and effective compared to a delayed protocol. Let’s take a look…
There are a bunch of studies out there that you need to sift through. You can tell when the lead authors are MD’s or PT’s because the docs want to make sure their repair integrity is intact and the PT’s are concerned with restoring ROM, strength, and function.
With that, I’ve done my best to pull out some studies that have helped guide my practice and continue to influence me today.
Literature Review Findings
Age a BIG Factor!
Mind you, Cho et al showed that healing rates after a rotator cuff repair drastically change for older patients compared to younger patients.
The slide below was taken from my rotator cuff lecture that I’ve done in the past and helps to put things in perspective.
In no particular order…
Parsons et al JSES 2010 looked at 43 full thickness RTC repairs who were in a sling for 6 weeks. All were without PT for that time then evaluated for stiffness in PROM. They defined stiffness as 100° flexion/ 30° ER.
Overall, of the 43 surgeries, 23% (n=10) became stiff after that 1st evaluation session. The whole cohort displayed a 56% retear rate overall at 1 year, which to me seems crazy high!
To break it down further there was:
30% retear in stiff group
64% retear in non-stiff group
There was no significant difference in ROM or functional scores.
In my opinion, there were some pretty big limitations to the study that should be exposed, like:
Single row repair
No consideration for Diabetes or smoking
MRI without contrast to re-evaluate the repair status
What is “ER by the side???”- need to better define what degree of abduction.
So getting stiff may be a good thing but the repairs were done as single row repairs. We know these did not heal as well as they do with double row repairs.
More Literature Reviews
Moving on to a 2014 Level II systematic review and Meta-analysis, the authors said “the results contradicted our hypothesis that immobilization would increase tendon healing compared with an early-motion rehabilitation protocol, as structural outcomes were similar in the two groups 1 year after the arthroscopic repair of rotator cuff tears.
From the paper: “We speculate that rehabilitation is not the sole factor affecting tendon–bone recovery; the effects of other factors, such as older age, fatty degeneration, larger tears, and surgical technique, may outweigh those of the rehabilitation protocol.”
Kim et al AJSM 2012 looked at small to medium sized RTC repairs. They compared immediate PROM (0-120 degrees) to 4 weeks of absolute immobilization. They eventually showed no difference in ROM, pain or tendon healing. So seems like a smaller tear of less than 3 cm may be appropriate for immediate ROM, albeit it was limited to 120 degrees for some reason.
Not sure why they limited to 120 degrees because it seems as if the tendon would shorten as the humerus is placed in further flexion. Maybe they were concerned with subacromial impingement or something but the limitation is a bit confusing to me.
Healing Affected?
Another study by Lee et al AJSM 2012 wanted to compare ROM and healing rates between 2 different rehabilitation protocols after arthroscopic single-row repair (use caution) for full-thickness rotator cuff tear.
They showed pain, ROM, muscle strength, and function all significantly improved after arthroscopic rotator cuff repair, regardless of early postoperative rehabilitation protocols.
They also looked at the repair integrity with postoperative MRI scans, 7 of 30 cases (23.3%) in the immediate ROM group and 3 of 34 cases (8.8%) in the delayed group had re-tears, but the difference was not statistically significant (P = .106).
Well then, only a trend and all had similar functional outcomes regardless of when they started ROM…I’d say that helps the case to start early.
But again, these repairs were done via a single row repair and they allowed manual therapy 2 times per day and unlimited self-passive stretching exercise, which seems a bit aggressive anyway.
Do we even need a sling for 6 weeks?
No Functional Difference Between Three and Six Weeks of Immobilization After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Non-Inferiority Trial Arthroscopy 2018
This study looked to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff repair in a prospective randomized controlled non-inferiority trial.
They concluded that “3 weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace.” For the structurally concerned people out there, MRI indicated similar degrees of healing between the groups.
Well then, that throws a wrench in things for the docs!
Does Early vs Delayed PT Affect Outcomes?
A systematic review by Gallagher et al 2015 looked to determine if there are differences between early and delayed rehabilitation after arthroscopic rotator cuff repair in terms of clinical outcomes and healing. Six articles matched their criteria and reported significantly increased functional scores within the first 3-6 months with early rehabilitation compared to the delayed group.
To me, this is huge! Put yourself in their position. Imagine feeling better and being able to get back to work a little quicker. That’s my major argument for starting rehab sooner. Earlier pain relief, improved function and a feeling of being normal again.
Furthermore, none of the included studies reported any significant difference in rates of rotator cuff re-tear.
Medium-Large Tears use Caution
However, two studies noted a trend towards increased re-tear with early rehabilitation that did not reach significance. This was more pronounced in studies including medium-large tears. A similar trend that I’ve seen in the literature.
Here’s a nice table from that Gallagher study that summarized their findings for each research paper they included:
I want my patients to feel good as quick as possible and get back to some semblance of a normal life. But of course I want the long-term integrity of the repair to remain intact. And it seems as if this study helps that argument.
Then you look at a group of PT’s from Turkey (Duzgun et al Acta Orthop Traumatol Turc. 2011) that looked to compare the effects of the slow and accelerated protocols on pain and functional activity level after arthroscopic rotator cuff repair. Patients were randomized in two groups: the accelerated protocol group (n=13) and slow protocol group (n=16).
There was no significant difference between the slow and accelerated protocols with regard to pain at rest.
The accelerated protocol was superior to the slow protocol in terms of functional activity level, as determined by DASH at weeks 8, 12, and 16 after surgery.
I’ll take that!
Function over Structure (at times!)
Told you that the PT groups tend to favor function over structure, haha!
Early passive Motion ok- The French Version
This next study out of France that included French Society for Shoulder & Elbow (Orthop Traumatol Surg Res. 2012) looked to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks.
They concluded that their results suggested that early passive motion should be authorized: the functional results were better with no significant difference in healing. Functional results were statistically better after immediate passive motion and a lower rate of adhesive capsulitis and complex regional pain syndrome.
Seems as if there may be a trend but certainly not an overwhelming conclusion that early ROM is guaranteed to lead to inferior structural results. But, it seems pretty conclusive that ROM, pain, and function are improved after early ROM.
Let’s continue to look at the research
This group from China (Shen et al Arch Orthop Trauma Surg. 2014 Sep) performed a systematic review and meta-analysis to determine whether immobilization after arthroscopic rotator cuff repair improved tendon healing compared with early passive motion. Three RCTs examining 265 patients were included but we need to be cautious because of the limited number of studies included and the heterogeneity of the samples.
They found that there ‘no evidence that immobilization after arthroscopic rotator cuff repair was superior to early-motion rehabilitation in terms of tendon healing or clinical outcome. Patients in the early motion group may recover ROM more rapidly.’
This recent 2017 study in the Journal of Shoulder and Elbow Surgery included 9 meta-analyses in its review. They basically noted, “No clear superiority was noted in clinical outcome scores for early-motion or delayed-motion rehabilitation.”
They also concluded that “Whereas early motion and delayed motion after cuff repair may lead to comparable functional outcomes and retear rates, concern exists that early motion may result in greater retear rates, particularly with larger tear sizes.”
So, it seems as if function and healing the same after a RTC repair but there may be a discrepancy once we start looking at a larger repair size.
Immediate PT after a Revision Rotator Cuff Surgery
This study in AJSM 2018 looked to evaluate the clinical and radiological outcomes after revision rotator cuff repair surgery. They were able to track 31 of 40 patients (77.5%) for the final assessment at a mean follow-up of mean 50.3 months.
Interestingly enough, physical therapy started on the first postoperative day with passive flexion and abduction.
Revision rotator cuff repair improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing.
And they started PT 1 day after the surgery and got PT 2-3 times per week.
Retear Rates and Long-term function
This study in JBJS 2006 looked to determine the clinical and structural outcomes of re-ruptures in twenty patients after a longer period of follow-up. Nineteen of the twenty patients continued to be either very satisfied or satisfied with the outcome.
At an average of 7.6 years, the clinical outcomes after structural failure of rotator cuff repairs remained significantly improved over the preoperative state in terms of pain, function, strength, and patient satisfaction.
They also found that re-ruptures of the supraspinatus that had been smaller than 400 mm(2) had the potential to heal….wow!
Failure Rates too High!
Another study in JBJS 2013 looked at 18 patients who had undergone arthroscopic repair of massive rotator cuff tears. At two years of follow-up, 94% had a failed repair. This current study wanted to evaluate the 10-year results for these patients with known structural failures of rotator cuff repairs.
Despite a high rate of progression of radiographic signs associated with large rotator cuff tears (proximal humeral migration or cuff tear arthropathy), most did well.
Clinical improvements and pain relief after arthroscopic rotator cuff repair of large and massive tears are durable at the time of long-term (10 years) follow-up. They went on to say:
“These results demonstrate that healing of large rotator cuff tears is not critical for long-term satisfactory clinical results in older patients.”
So our obsession with healing rates still appears to be overblown, even in older patients with a known cuff tear.
Pendulum Exercises Effects on Muscle Activity
Activation of the Shoulder Musculature During Pendulum Exercises and Light Activities JOSPT 2010
Look at that Paper in JOSPT 2010 (I’ve pulled out the Results Table for you below).
If there’s one exercise that doctors allow after a rotator cuff repair then it’s a pendulum or Codman exercise. How often does our patient do them correctly and make it a completely passive motion? I’d say rarely if seldom, right?
Most often, the patient is just bent over and actively moving their shoulder. They have no body movement or sway. Most of the movement is shoulder based and are not completely relaxing their shoulders.
Furthermore, they were instructed in the doctor’s office that 1st week or 2 after surgery.
They’ve been doing them incorrectly for weeks on end because they have no one to help them (cough cough!)
EMG of common Rehab ExerciSES
A study in JOSPT 2016 looked at EMG activity in healthy individuals. They wanted to quantify muscular activity during daily tasks and common PT motions. They showed that “of all the tasks assessed, ambulation without a sling and donning and doffing a sling and a shirt consistently showed the highest activity.”
EMG results table is found below.
Pretty helpful to see it listed by muscle and EMG activity and specific movement.
EMG of contralateral movements
A pretty neat EMG paper from 2004 (small n=6 and healthy individuals) were assessed using fine wire and surface EMG during common functional activities of the contralateral extremity while immobilized.
They found high supraspinatus EMG activity of the immobilized shoulder for all fast pulling activities of the contralateral shoulder (25-32%)!
Furthermore, they found high infraspinatus activity (56%) of the immobilized shoulder when the contralateral extremity performed straight forward reaching activities.
So even if they are immobilized and using their non-operative shoulder for daily activities, the rotator cuff is still sustaining a higher amount of activity than anything that we would do in the early phases (PROM, dowel self-ROM, rope and pulleys, properly performed pendulums).
How about revision rotator cuff repairs, you ask?
This study from AJSM in 2018 looked at outcomes after a revision rotator cuff repair. They showed revision rotator cuff repair improved outcomes regardless of tendon integrity (MRI confirmed).
Oh boy, what is going on??
Dig deeper into the study and they started PT the 1st day post-op with passive flexion and abduction. Sounds familiar, no? And this was in revision surgeries.
We used a very similar approach in Birmingham as they did in this study, so I may be a bit biased.
My Closing Thoughts on Physical Therapy after Rotator cuff repair surgery
I think it just shows you that rehab can begin early, will not affect long-term outcomes and that tendon integrity is not correlated to function.
I honestly don’t think our 15-30 minutes of passive motion early on in the rehab process is significantly affecting outcomes and retear rates.
It seems as if the repair technique, contralateral arm daily use, compliance with proper exercises (like pendulums, for example).
Let’s not blame early PT. There are so many more variables that are more likely to affect rotator cuff repair outcomes than anything that we could do in PT.
So I say let’s get people into PT early, educate them, guide them and help them get over this painful surgery.
I’ve been doing this for years and have seen the benefits of early PT. I say the literature agrees with me!
https://lennymacrina.com/wp-content/uploads/2019/06/RTC-Blog.001.jpeg10801080Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2019-06-04 06:00:052019-06-03 13:56:23Is Early Physical Therapy Safe After a Rotator Cuff Repair?
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.
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.
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.
https://lennymacrina.com/wp-content/uploads/2018/12/ACL-TROM.jpg480480Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2018-12-09 07:00:322018-12-08 23:21:06Knee Bracing Immediately After an ACL Reconstruction
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
Topics on the Rotator Cuff including post-op
Classifying SLAP tears
Essential Components of a neuromuscular control program
Live Patellar scope during mobilization
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.
https://lennymacrina.com/wp-content/uploads/2018/10/TWIR-10-29-18.001.jpeg10801080Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2018-10-29 05:30:202018-10-28 16:27:25The Week in Research Review, etc 10-29-18
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!
https://lennymacrina.com/wp-content/uploads/2018/07/TWIR.001.jpeg10801080Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2018-07-29 07:20:082018-07-29 07:18:15The Week in Research Review, etc 7-29-18
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?
The 2 most important factors to progress a post-op patient
Don’t overdo it- less is more
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.
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.
https://lennymacrina.com/wp-content/uploads/2017/10/Picture-016.jpg18511631Lennyhttps://lennymacrina.com/wp-content/uploads/2021/04/LM-Logo-169x156-1.jpgLenny2017-10-02 09:45:222018-03-03 23:08:272 Tips to Improve Your Post-op Rehabilitation Outcomes
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