Physical therapy can span a wide spectrum, ranging from injury rehabilitation, to injury prevention, and even performance enhancement. To truly help people get the most out of their bodies, we need to focus on all three of those.
But many of us don’t, and if you’re one of them, I think you may be really missing the boat.
I’m not completely sure why this happens, but if I had to guess, I think there may be two main thoughts holding us back:
The vast majority of the physical therapy profession is focused on injury rehabilitation, this includes both our college curriculums and most workplace settings, which is really limiting our potential to help people maximize their function and performance.
We spend the majority of time focusing on “function” and not “performance.”
Perhaps this is just terminology, but I know when I was in school and early in my career, “function” was people’s activities of daily living, and “performance” was sports. Would you agree? That was my perception at least.
I couldn’t disagree with these definitions more. Here is how I would define them now:
Function is an activity. Sure, this could include things like bathing and getting dressed, but I would also say running, jumping, throwing, and just playing a sport, in general, is also a function.
Performance is how well you perform that function.
Performance is not something that only athletes do. We all need to perform at whatever function we want with our bodies. This is probably the most important concept to understand, and one of the main things that people have said have helped them most after going through my Champion Performance Specialist course.
The Need for a Shift Towards Performance Physical Therapy
Here’s what I suspect is the most common vision of the performance spectrum to most physical therapists. At any point in time, you have your baseline. Most people then focus on either restoring or enhancing performance based on that baseline.
We sit back and wait for someone to get injured, then help them restore themselves back to baseline.
Well, what if their baseline was part of the reason why they got injured in the first place?
If we just focus on restoring their function back to their baseline, we’re completely missing the boat on helping them optimize and enhance their performance.
I can’t help but think that this is one of the reasons why so many people have recurring injuries, chronic pain, and failed surgeries. Restoring people back to their baseline isn’t enough, we need to build their capacity and enhance their baseline.
As we all know, many things can predispose a person to injury, including weakness, mobility concerns, and imbalances.
There has been a recent uptick in criticism on social media that too many physical therapy interventions are either ineffective, transient in nature, or both. Rightfully so.
But maybe it’s not the physical therapy treatments that are the concern, but rather the overall strategy? Maybe we are focusing too much on just restoring function, and not enough on optimizing and enhancing performance?
If you have limited shoulder range of motion overhead, and you have pain in your shoulder every time you overhead press in the gym, then we can do a great job reducing that pain with physical therapy. But don’t you think that pain will likely just come back when they get back to overhead pressing? We reduced their pain, restored them to their previous baseline (which wasn’t optimal), but we didn’t optimize their mobility.
Their long term outlook can’t be great, right?
The Goal of Performance Physical Therapy
The goal of performance physical therapy is to raise the capacity of the body, not just restore their function. If you haven’t seen it yet, you should watch our podcast episode discussing our vision of performance based physical therapy.
It’s not enough to simply try to restore someone to their previous baseline. That’s “traditional” physical therapy if you ask me. Performance physical therapy not only restores function, but also works on optimizing and enhancing performance. That’s the key difference to me.
If you add optimizing performance to the spectrum, it could look like this:
But I still don’t think that’s enough, we can do better.
If you are working on restoring or enhancing performance, you should also be working on optimizing performance. Realistically, there is an overlap between these concepts.
This changes our focus in a couple of ways:
It shows that these concepts all overlap. We can restore and optimize performance, and we can optimize and enhance their performance. Thinking of them as independent factors, is not ideal
It shifts our thought process from retrospective, to prospective. When you know the endpoint isn’t just to simply restore their baseline, but also to optimize and hopefully even enhance their performance, it changes your entire outlook on the injury rehabilitation process from day 1.
Our Profession Needs Performance Physical Therapy
I have good news for you.
Physical therapists are really good at diagnosis and treating injuries. All of the assessment and diagnostic skills that allow physical therapists to evaluate and treat an injury can easily be adapted to also assess someone’s function and level of performance.
Think about it, what’s the difference between an evaluation of someone with an injury and someone that is healthy that wants to enhance their performance?
Special tests. That’s kinda it, right?
Special tests were designed to help diagnose a specific injury. If this special test, or cluster of tests, is positive, then you may have this injury.
But everything else other than special tests essentially evaluate someone’s level of function, right? Strength, mobility, balance, movement. These are all things that we can evaluate to help develop a complete performance therapy and training program for a person. We can then work on optimizing and enhancing each of those qualities.
How do you blend all this together? Treat the injury and optimize the body.
When we started our facility at Champion PT and Performance, one of our biggest goals was to develop a simple system for our physical therapists and strength coaches to help people move and perform better.
My Introduction to Performance Therapy and Training program will teach you our 4-step system at Champion to assure you have everything you need to start helping people move and perform better.
Shoulder impingement is a really broad term that is used too often. It has become such a commonly used junk term, such as “patellofemoral pain,” especially with physicians.
Other common variations include subacromial impingement or rotator cuff impingement, but it seems as if any pain originated from around the shoulder is often labeled as “shoulder impingement.”
Unfortunately, the use of such a broad term as a diagnosis is not helpful to determine the treatment process. There is no magical “shoulder impingement protocol” that you can pull out of your pocket and apply to a specific person.
Luckily, a thorough examination can be used to determine the best treatment plan. Each person will likely present differently, which will require variations on how you approach their shoulder rehabilitation.
Most of the clinical examination for shoulder impingement involves provocative tests. Those are great, but the real challenge when working with someone with shoulder impingement isn’t figuring out that they have shoulder pain, that’s fairly obvious. That’s why they are there.
It’s figuring out WHY they have shoulder pain, and what to do about it.
Shoulder Impingement: 3 Keys to Assessment and Treatment
To make the treatment process for shoulder impingement a little more simple, there are 3 things that I typically consider to classify and differentiate shoulder impingement.
The location of shoulder impingement
The structures involved
The underlying cause of shoulder impingement
Each of these can significantly vary the treatment approach and how successful you are treating each person.
If you approach each patient with these 3 things in mind, you are going to do a much better job developing an effective treatment plan, versus just trying things and hoping they work.
I’ve called this the corrective exercise bell curve in the past. If you just throw the same treatments at every person with shoulder pain, you’ll probably get lucky 20% of the time, make them worse 20% of the time, and simply waste your time the rest.
Let’s dig in…
Location of Shoulder Impingement
The first thing to consider when evaluating someone with shoulder impingement is the location of impingement. This is generally in reference to the side of the rotator cuff that the impingement is located, either the outside of the rotator cuff or the undersurface of the rotator cuff.
These are broken down into either:
Bursal sided shoulder impingement – this is your traditional subacromial impingement
Articular sided shoulder impingement – this is called internal impingement
Bursal Sided Shoulder Impingement
See the photo of a shoulder MRI above (photo credit). The bursal side is the outside of the rotator cuff, shown with the red arrow. This is probably your “standard” subacromial impingement that most people refer to when simply stating “shoulder impingement.”
This is often called subacromial impingement because of the location of impingement occurs between the rotator cuff and the undersurface of the acromion, hence the term “subacromial.” This is also called the bursal side of the rotator cuff because there is a bursa located between the rotator cuff and the acromion, which acts as a shock absorber.
Articular Sided Shoulder Impingement
The green arrow shows the undersurface, or articular surface, of the rotator cuff. This Impingement on this side is often termed “internal impingement” because the impingement occurs on the inside, or joint side, of the rotator cuff. If you look closely in the image above, the yellow arrow shows an articular sided partial thickness rotator cuff tear. Note the irregularity of white at the bottom of the dark line of the rotator cuff.
This often involves the supraspinatus and infraspinatus rotator cuff muscles as the undersurface impinges against the glenoid joint rim. I’ll go over this in more detail below.
The two types of impingement are completely different and occur for different reasons, so this first distinction is important.
Because the cause of shoulder impingement is so different, the evaluation and treatment of subacromial and internal impingement will also be completely different. More about these later when we get into the evaluation and treatment.
Impinging Structures Involved
The next factor to discuss is which structures are involved in the shoulder impingement. This is more for the bursal sided, or subacromial impingement, and refers to what structure the rotator cuff is impinging against.
Take a look at the shoulder from the side view, with the front of the shoulder to the right and the back of the shoulder to the left. You can see the acromion is superior and the coracoid is a little more anterior. The coracoacromial ligament runs between these two areas.
As you can see in the image, your subacromial space is pretty small (the red areas). It’s pretty easy to impinge on the acromion, coracoid, or coracoacromial arch. There isn’t a lot of room for error. In fact, this really isn’t a blank “space”, there are actually many structures running in this area including your rotator cuff and subacromial bursa.
Get ready… I’m about to blow your mind…
You actually “impinge” every time you move your arm. We all do.
That’s right, impingement of these structures itself is normal and happens in all of us every time we use our arms. It’s when this becomes abnormal, excessive, or too frequent that shoulder pain and pathology occurs.
This is why it is very shortsighted to say “impingement” is normal and that people should work through their discomfort. Yes, some impingement is normal, but excessive impingement is what may cause pain and pathology down the road.
So when it comes to the structures involved in impingement, I try to differentiate between subacromial and coracoacromial arch impingement. These can happen in combination or isolation and typically involve the supraspinatus rotator cuff muscle.
Another area that has received more attention lately is the subcoracoid space or the area below the coracoid. You can also have subcoracoid impingement. Because this is located more anteriorly, the subscapularis rotator cuff muscle can be involved with subcoracoid impingement.
The three types of bursal sided impingement are fairly similar in regard to assessment and treatment, but I would make a couple of mild modifications for coracoacromial and subcoracoid impingement, which we will discuss below.
So if we were to get very specific, you can break shoulder impingement down into four different types based on the location and structures involved:
Bursal sided impingement:
Subacromial impingement – Involves the supraspinatus and acromion
Coracoacromial impingement – Involves the supraspinatus and coracoacromial arch
Subcoracoid impingement – Involves the subscapularis and coracoid
Articular Sided:
Internal impingement – Involves the supraspinatus and infraspinatus and glenoid rim
See what I mean? How can all of these be “shoulder impingement?” They all involved different muscles, different impinging structures, different locations, and different mechanisms!
OK, great, we now have differentiated and know “what” is impinging, we still don’t know “why” the person has impingement.
Cause of Shoulder Impingement
The next thing to look at is the actual reason why the person is experiencing shoulder impingement.
There are two main classifications of causes that I refer to as “primary” or “secondary” shoulder impingement.
Primary Shoulder Impingement
Primary impingement means that the impingement is the main problem with the person.
A good example of this is someone that has impingement due to anatomical considerations, with a hooked tip of the acromion like this in the picture below. Many acromions are flat or curved, but some have a hook or even a spur attached to the tip (drawn in red):
This also happens with the coracoid and subcoracoid impingement. An anatomical variation of the coracoid or bone spur can be present.
This is referred to as primary impingement because improving things like mobility, strength, and dynamic stability may be ineffective as there is a primary cause of impingement causing the symptoms.
Sure we may improve the symptoms and often times are successful with rehabilitation, but sometimes we aren’t. It’s not because a certain treatment “isn’t effective for shoulder impingement.” It’s because there is a primary reason why impingement is occurring that we can’t change.
Without addressing the primary issue, like a large bone spur, working on secondary issues may not be effective.
Secondary Shoulder Impingement
Secondary impingement means that something else is causing impingement, perhaps their activities, posture, lack of dynamic stability, or muscle imbalances are causing the humeral head to shift in its center of rotation and cause impingement.
The most simple example of this is weakness of the rotator cuff.
The rotator cuff and larger muscle groups, like the deltoid, work together to move your arm in space.
The rotator cuff works to steer the ship by keeping the humeral head centered within the glenoid. The deltoid and larger muscles power the ship and move the arm.
Both muscles groups need to work together.
If rotator cuff weakness is present, the cuff may lose its ability to keep the humeral head centered. In this scenario, the deltoid will overpower the cuff and cause the humeral head to migrate superiorly, thus impinging the cuff between the humeral head and the acromion:
This is just a simple example, but as you can see is very impactful for shoulder function. It’s not just weakness of the rotator cuff, it’s also imbalanced strength ratios and improper timing of dynamic stabilization.
Other common reasons for secondary impingement include mobility restrictions and poor dynamic stability of the shoulder, scapula, and even thoracic spine.
All of these areas need to work together to produce optimal shoulder function.
I see this a lot in my patients.
In the person below, you can see that they do not have full overhead mobility, yet they are trying to overhead press and other activities in the gym, flaring up their shoulder.
If all we did with this person was treat the location of the pain in his anterior shoulder, our success will be limited. He’ll return to the gym and start the process all over if we don’t restore this mobility restriction.
The funny thing about this is that people are rarely aware that they even have this limitation until you show them.
Also, keep in mind that this is not “chronic pain.” Sure this person has had shoulder pain for 8 months, but it’s because they keep irritating the area. This is more like recurring acute pain.
Differentiating Between the Types of Shoulder Impingement
In my online shoulder program on the Evidence Based Evaluation and Treatment of the Shoulder, I talk about different ways to assess shoulder impingement that may impact your rehab or training. There are specific tests to assess each type of impingement we discussed above.
The two most popular special tests for shoulder impingement are the Neer test and the Hawkins test.
In the Neer test, the examiner stabilizes the scapula while passively elevating the shoulder, in effect impinging the humeral head into the acromion.
In the Hawkins test, the examiner elevates the arm to 90 degrees of abduction and forces the shoulder into internal rotation, impinging the cuff under the subacromial arch.
As I mentioned earlier, these special tests for shoulder impingement are provocative in nature, meaning that we are looking for reproduction of pain.
Both of them will cause the structures to impinge in all of us, but they shouldn’t produce pain. But if the area is sensitive and irritable, they will cause pain.
You can alter these tests slightly to see if they elicit different symptoms that would be more indicative to the coracoacromial arch or subcoracoid types of subacromial impingement.
Because these structures are more anterior, we can alter the tests to better assess this area.
The Neer test can be performed in the sagittal plane, and the Hawkins test can be modified and performed in a more horizontally adducted position. Both of these positions will impinge more anteriorly.
There is a good chance that many patients with subacromial impingement may be symptomatic with all of the above tests, but you may be able to detect the location of subacromial impingement (acromial versus coracoacromial arch) by watching for subtle changes in symptoms with the above four tests.
Now, before we go any further, let’s talk briefly about the reported accuracy of these tests in the literature.
Just like we’ve talked about with the studies looking at the treatment effectiveness in people with shoulder impingement, most studies published vaguely look at how accurate a test may be at detecting “impingement.” Hopefully, if you’ve gotten this far in the article, you see how flawed this approach is, as this is simply too broad.
How can we evaluate how “specific” a special test is for such a “non-specific” diagnosis?
Internal impingement is a different beast.
This type of impingement, which is most commonly seen in overhead athletes, is typically the result of some hyperlaxity of the shoulder in the anterior direction.
As the athlete comes into full external rotation, such as the position of a baseball pitch, tennis serve, volleyball serve, and others, the humeral head slides anterior slightly causing the undersurface of the cuff to impingement on the inside against the posterior-superior glenoid rim and labrum.
This is what you hear of when baseball players have “partial thickness rotator cuff tears” the majority of the time. They aren’t the same partial thickness tears your grandmother has.
The best special test for internal impingement is simple and is exactly the same as an anterior apprehension test.
The examiner externally rotates the arm at 90 degrees abduction and watches for symptoms. Unlike the shoulder instability patient, someone with internal impingement will not feel apprehension or anterior symptoms. Rather, they will have a very specific point of tenderness in the posterosuperior aspect of the shoulder (below left). When the examiner relocates the shoulder by giving a slight posterior glide of the humeral head, the posterosuperior pain diminishes (below right).
3 Keys to Treating Shoulder Impingement – How Does Treatment Vary?
Using the three main keys from the above information, you can alter your treatment and training programs based on the specific of impingement exhibited:
The location of shoulder impingement – bursal or articular sided impingement
The structures involved – Subacromial, coracoacromial arch, subcoracoid, or internal impingement
The underlying cause of shoulder impingement – primary or secondary.
I promise you are going to have much more success in designing a physical therapy or training program if you factor in these keys.
Treating Different Types of Impingement
As I hope you can now see, to properly treat shoulder impingement you should differentiate between subacromial, coracoacromial, subcoracoid, and internal impingement.
Treatment is similar between these types of impingement. There is a bunch of overlap.
However, there are some differences:
With subacromial impingement, you should be cautious with overhead activities that produce discomfort
With the more anterior-based coracoacromial arch and subcoracoid impingement, you need to be cautious with elevation in more of a sagittal plane and horizontal adduction movements that produce discomfort
With internal impingement, you should be cautious with excessive external rotation at 90 degrees abduction (like the throwing position) that produce discomfort
Notice that I said “that produce discomfort” for all three? The key here for me is that you should not work through discomfort or a “pinch” with impingement.
A “pinch” is impingement of a sensitive structure!
I’m not a fan of working through pain with shoulder impingement. That to me shows me that you either have a primary or secondary cause of impingement that hasn’t been addressed. Trying to work through this could actually just irritate it more.
Treating Primary Versus Secondary Shoulder Impingement
This is an important one and often a source of frustration in young clinicians.
If you are dealing with secondary impingement, you can treat the person’s symptoms all you want, but they will come back if you do not address the underlying reason why they have symptoms.
But please remember, I do treat their symptoms, that is why they have come to see me.
I want to reduce discomfort and inflammation. This is going to allow me to do more in the long term. However, this should not be the primary focus if you want long term success.
This is where a more global look at the patient, their posture, muscle imbalances, and movement patterns all come into play. Breakthrough and see patients in this light and you will see much better outcomes.
You should have a systemized way of assessing movement and building programs to optimize and enhance their function. If you don’t you really should check out my system in my free online Introduction to Performance Therapy and Training course.
A good discussion of the activities that are causing their symptoms may also shed some light on why they are having shoulder pain.
Again, using the example above, if you don’t have full mobility and try to force the shoulder through this motion restriction you are going to likely cause some irritation.
This is especially true if you add speed, loading, and repetition, such as during many exercises in the gym.
I spend a great deal of time discussing what “zones” of motion the person should be working in. Essentially, I try to develop a “green zone” and a “red zone” depending on when they have symptoms.
It’s important to continue working within their green zone and not simply say “take a few weeks off.” And slowly over time, our goal is to expand their green zone and reduce their red zone.
Treating Internal Impingement
Internal impingement involves a little more discussion. The main thing to realize with internal impingement is that this is pretty much a secondary issue. It is going to occur with any cuff weakness, fatigue, or loss of the ability to dynamically stabilize.
The overhead athlete will show some hyperlaxity in the “lay back” shoulder position of external rotation. Most overhead athletes have underlying laxity, what tends to happen is they lose strength or have an excessive workload that causes fatigue and then the structures impingement more and become irritable.
Treat the cuff weakness and its ability to dynamically stabilize to relieve the impingement. This often includes an initial period of rest and then building back their strength and dynamic stability.
Learn Exactly How I Evaluate and Treat the Shoulder
If you are interested in mastering your understanding of the shoulder, I have my acclaiming online program teaching you exactly how I evaluate and treat the shoulder.
The online program takes you through everything you need to become a shoulder expert. You can learn at your own pace in the comfort of your own home. In addition to shoulder impingement, you’ll learn about:
The evaluation of the shoulder
Selecting exercises for the shoulder
Manual resistance and dynamic stabilization drills for the shoulder
Nonoperative and postoperative rehabilitation
Rotator cuff injuries
Shoulder instability
SLAP lesions
The stiff shoulder
Manual therapy for the shoulder
The program offers CEU hours for physical therapists and athletic trainers. Click below to learn more:
https://mikereinold.com/wp-content/uploads/shoulder-impingement-3-keys-to-assessment-and-treatment.jpg6281200Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2019-07-29 06:15:402019-07-29 06:15:42Shoulder Impingement – 3 Keys to Assessment and Treatment
Today’s article is a guest post from Lenny Macrina, my co-owner of Champion and co-author of my online knee course. Meniscal tears are common, and some interesting new studies are coming out showing that surgery may not be the best option, at least for some people. Social media is quick to shun meniscus tear surgery, however there are likely still some people that will benefit from this more than physical therapy alone. Lenny discusses more in the article below. But I also wanted to make sure you knew that Lenny and I’s online course on the Evaluation and Treatment of the Knee is on sale this week for 50% off. More info below!
Meniscus tears are very commonly diagnosed by physical therapists and doctors. The question remains, what is the best treatment for someone with a meniscus tear…surgery or physical therapy?
I may be a bit biased because I am a physical therapist. Let me get that out there right now. I’d almost always advocate for physical therapy over surgery for most of the cases that I deal with. But I do believe we are trying to be too black and white at times and need to keep an open mind.
There are many factors that need to be considered when deciding between physical therapy or surgery for a meniscus tear. Some people may do better with physical therapy, while others may do better with meniscal tear surgery.
It depends.
With that, I decided to do a literature to see what the latest research is telling us. There’s lots out there and it seems as if the recent studies push for physical therapy as the first line of defense for someone with a mensical tear.
Intuitively, that makes sense but I wanted to dig deeper and see if this was true for everyone, or are there certain people that may benefit more from surgery.
Do You Need Surgery After a Meniscus Tear?
Of course, I went to PubMed because that’s my go to website for the latest in research topics. My search for knee meniscus physical therapy pulled up hundreds of papers, so of course I read them all…ok, maybe not.
I did my best so here goes…
In summary, it seems like there’s pretty good evidence to support that physical therapy should be used early after a meniscus tear in most of the common cases that we see.
There’s a growing body of evidence to try physical therapy first, especially for chronic degenerative meniscus tears. When I say a degenerative meniscus tear, I mean a tear that is probably a bit older and has been chewed up, well beyond repair.
These degenerative meniscus tears are also often associated with knee arthritis, to some extent. Because of this, surgery to help with the associated pain is often limited due to the arthritis, and may not help the patient as much.
A period of active rest to calm the knee down and determine the course of treatment (surgery or more physical therapy) is often employed.
Very rarely is there a case where we should rush in to a surgery unless there’s a gross loss of motion, as in a bucket-handle meniscus tear that is obvious and leading to a disability.
I also think there’s a population of people who will benefit from surgery because they MAY be expecting to have surgery. I know, it’s complicated but that’s why we practice this stuff daily.
It’s not always cut and dry. People are human, and have emotions and opinions.
We can do all of the educating that we want but if they expect to have surgery and WANT surgery then just maybe they may benefit from having surgery. And that group of people may just do well.
Part of my treatment plan early on would be to educate them regarding the surgery, potential complications, some of the research and the post-op course.
All too often people are told that they’ll be back in 4-6 weeks after meniscus tear surgery and we all know that is NOT true. I usually tell people that it will take 4-6 months and even then, they still may not feel right until a year later. Sure, they may be doing some of their activities in 4-6 weeks, but that doesn’t mean they are completely back to normal.
The key is to recognize and find that person during your examination. I previously wrote a blog post on meniscus examination that goes over this in more detail.
Once diagnosed, can you separate out the meniscus tears that truly could benefit surgery from the ones that would do just as good without surgery?
Unfortunately, that’s the complicated part!
In a recent study from 2016, this group found that shorter symptom duration and greater baseline pain may be a predictor of who would qualify for earlier surgical intervention rather than physical therapy. They also suggested that an initial course of rigorous treatment prior to a knee scope may not compromise surgical outcome.
When in doubt, take it to Twitter.
In a recent Twitter discussion with some doctor colleagues of mine, we talked about this same and it was refreshing to hear that many are recognizing the fact that physical therapy may be the better option for most meniscal injuries.
What is the Best Treatment Option for a Meniscus Tear?
Like I said earlier, there’s a bunch of research, so I tried to pick out some that I thought were the best and from highly reputable journals.
This study from the Journal of the American Medical Association showed that among patients with non-obstructive meniscal tears, physical therapy 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, physical therapy may be considered an alternative to surgery for patients with non-obstructive meniscal tears.”
So, basically if there is not a bucket handle meniscus tear present that may be blocking joint range of motion, then it is highly encouraged that the treatment and exercise, and not undergo surgery.
Without going out on a limb, I’d say this is a much cheaper treatment option as well and would greatly reduce health care costs associated with the surgery and lost time from work.
This study from the British Medical Journal looked at the cost-effectiveness of meniscus tear surgery versus nonoperative treatment and showed that surgery was not economically effective and should be reconsidered.
I did note a couple limitations: the surgical group did not get treatment after surgery if they did ‘as expected’ but they could get treatment to help improve their symptoms.
The physical therapy group did pretty basic exercises although leg press, lunges and balance type exercises were included. I would’ve liked to have seen a more robust attempt at treatment that involved more strength training and true progressions for the quads, hip and complete lower body.
Another study that I wanted to discuss was a systematic review that looked at the best treatment options for someone greater than 40 years of age diagnosed with a degenerative meniscus tear.
They showed that ‘the results of this systematic review strongly suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy for a meniscus tear.’
There was an issue with the quality of the studies involved in the study, including a high risk of bias, weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics.
Furthermore, they said that no conclusion could be drawn as to which treatment was the best option for this patient population. Which I tend to agree, right?
Intuitively, one would say that physical therapy, as the cheaper option, would be the best but I think it goes to my above statements that “it depends” on the person, type of mensicus tear, chronicity of the tear, their symptoms, AND their beliefs.
I think this study from The New England Journal of Medicine basically says the same thing. A course of physical therapy may be good for some but often times surgery may be needed for a select group of people.
This study from the British Medical Journal looked at exercise versus surgery for degenerative meniscal tears in Norway. The mean age was 49.5 years, which is pretty typical, right?
This study also controlled for degenerative tears only and most everyone had no signs of radiographic knee osteoarthritis (96% of the cohort had no definitive radiographic evidence of osteoarthritis).
They showed that middle aged patients with degenerative meniscal tear and no definitive radiographic evidence of osteoarthritis should consider supervised meniscus tear physical therapy as a treatment option over surgery.
What to Recommend to Your Patient, Physical Therapy or Surgery for a Meniscus Tear?
Remember, about 1/3 of the meniscus has blood supply that can help it to potentially heal on its own. We got that information from a paper way back in 1982 and it still seems to apply today.
I don’t think there’s any doubt that physical therapy (swelling control, range of motion, strengthening, education) should be one of the first treatment options in someone that has been recently diagnosed with a meniscus tear.
This seems to definitely be true in the groups of people with a degenerative meniscus tear. They seem to do just as well with early treatment than a more expensive surgical option.
For someone with an acute meniscus tear that is blocking range of motion, such as with a bucket handle tear, then surgery may be indicated right away.
For the younger athlete with an acute meniscus tear, I would potentially consider a surgery a bit earlier but still gives them a course of treatment for 4-6 weeks to see if the symptoms subside and the person can resume their normal function.
So, try meniscus tear physical therapy and hope to see significant changes in the patient’s symptoms and function in the first 4-6 weeks. If no true changes or if they are getting worse (and frustrated), then consider surgery.
After meniscus tear surgery, pick up the therapy where you left off and hopefully get them back to their ultimate goals.
Learn How We Evaluate and Treat the Knee
For those interested in learning more about how Lenny and I evaluate and treat the knee, we have an amazingly comprehensive course that covers everything you need to know to master the knee. Our detailed examination process, all our treatment progressions, and detailed information on nonoperative and postoperative treatment of ACL, patellofemoral, meniscus, articular cartilage, osteoarthritis injuries, and so much more.
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The latest Inner Circle webinar recording on 5 Keys to Returning to Sport After a Knee Surgery is now available.
5 Keys to Returning to Sport After a Knee Surgery
This month’s Inner Circle webinar is on 5 Keys to Returning to Sport After a Knee Surgery. In this presentation, I’m going to review some of the statistics regarding return to play rates and discuss some of the clinical implications. Based on this, we’ll review the 5 keys that I think you need to follow to maximize your outcomes and return to sports, while minimizing your chance of reinjury.
This is an updated version of a past presentation on the keys to ACL rehabilitation, but with some newer research and some broader implications that just ACL. I wanted to provide some updated concepts. The ACL talk still has more specific information, so be sure to check that out too
This webinar series will cover:
What the latest research is showing about return to play statistics follow knee surgery
The two keys you should focus on during the first couple of weeks following any knee surgery
How to structure more advanced strengthening into your rehabilitation programs
How blood flow restriction training fits into the postoperative rehabilitation process
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Subacromial decompression surgery is a very common procedure performed for people with shoulder pain. The procedure is often recommended for people with “shoulder impingement” and was originally theorized to open up the subacromial space and help reduce biomechanical impingement.
But recent research has challenged the effectiveness of the procedure, and even the diagnosis of “subacromial impingement” itself.
Subacromial Decompression Surgery for Adults with Shoulder Pain: A Systematic Review with Meta-Analysis
A recent article in the British Journal of Sports Medicine reviewed the results of 9 clinical trials in over 1000 patients with shoulder pain. The authors includes studies that compared subacromial decompression surgery with placebo surgery and exercise therapy.
The study noted that subacromial decompression surgery provided no important benefit compared with placebo surgery or exercise therapy.
In particular, they found that surgery did not provide any additional benefit for pain, function, and quality of life at the 6- and 12-month mark after surgery.
As you can see, there does not appear to be a significant benefit in undergoing subacromial decompression surgery for shoulder pain or function.
What’s All This Mean?
Based on the results of several studies recently, it sure looks like we’re going to be seeing less subacromial decompression surgeries in the future.
It seems like the benefit of undergoing surgery may be related to the postoperative rehabilitation and application of graded exercise postoperatively.
This is another one of those surgical procedures that seems like it was missing the boat anyway.
Thinking purely biomechanically, rather than addressing the underlying concern that may be causing “impingement,” such as stiffness or loss of dynamic stability, we simply just make more space?
Seems overly simplistic, right?
We probably haven’t address the underlying cause.
But based on all this, perhaps we shouldn’t even be using the term “impingement” anyway.
From a non-biomechanical perspective, I’m not even sure we truly understand the etiology of shoulder pain at times and always seem to rush towards a biomechanical “impingement” approach. There could be numerous reasons why graded exercise can help reduce shoulder pain other than purely biomechanical factors.
But let’s not forget one main point here from this study. At 5 years down the road, these patients still had shoulder pain between a 1.5 and 3 out of 10 on a visual analog scale.
So advising people to ignore the biomechanics and simply work through some pain may not be an ideal approach as well.
I’d hate to see us go down that road.
These patients had shoulder pain for greater than 3 months to be included in this study. It’s difficult to quantify the degree of rotator cuff pathology present in these people, how this impacted their shoulder function, and what their long term prognosis will be going forward. There is still underlying inflammation of the rotator cuff.
As research like this continues to be published, we’re probably going to be seeing less of these procedures.
Maximizing the function of the shoulder is going to become even more important, regardless of whether or not something is causing “impingement.”
I’ve had a lot of success with people by keeping it simple. Rather than worry about the exact specifics of the pain, just simply focus on normalizing motion, increasing strength of the rotator cuff and scapular muscles, enhancing dynamic stability, and then gradually building tissue capacity through loading.
This is a great example of when focusing on the functional deficits is more impactful than the structural diagnosis.
Optimize the person, don’t just treat the pain.
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I’m really excited to be launching my brand new course for rehabilitation and fitness professionals looking to help people restore, optimize, and enhance performance. It’s my Introduction to Performance Therapy Training course.
And you know what the best part is???
It’s absolutely FREE!
Check out the information and video below, and click the link below to enroll today!
Introduction to Performance Therapy and Training
If you’re anything like me, I’m sure you’d love to work with more highly motivated people, and even athletes, that want to focus on improving their performance.
But I remember not really feeling prepared for this or knowing how to get started, I really felt overwhelmed. We all learned the basics, but no one really teaches you how to optimize movement and enhance performance.
Over these years, I’ve learned a ton. Good and bad! But everything I have learned has shaped what I do, and it took some time and experience to realize this.
There so much info out there, but people tell me all the time they’re still confused and that they feel like they just start treatments and training programs and aren’t even confident that they choosing the right ones!
Check out this video for more of what I mean:
Enroll in My Course for FREE
I want to help. When we started our facility at Champion PT and Performance, one of our biggest goals was to develop a simple system for our physical therapists and strength coaches to help people move and perform better.
My Introduction to Performance Therapy and Training program will teach you our 4-step system at Champion to assure you have everything you need to start helping people move and perform better.
Best of all, it’s absolutely free to anyone that signs up for my Newsletter. You’ll get all my best articles straight to your email, and immediate free access to the course.
Thank so much, hope you enjoy!
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This week’s article is an excellent guest post from my friend Russ Paine, PT, discussing why and how we should be using biofeedback in our rehabilitation patients. Russ and I are both big fans of biofeedback but unfortunately it’s fallen out of favor because insurance companies don’t reimburse it. But that doesn’t mean it’s not effective. And now, there’s a new biofeedback device, the mTrigger, that uses an app on your phone that is amazingly easy to use and affordable. I think this is going to be a real game changer. And mTrigger was nice enough to offer my readers 10% off! More details below, but check out the article and our video first!
Why You Should Be Using Biofeedback in Rehabilitation
I have been involved in the evaluation and treatment of sports medicine injuries for 33 years. I have been very fortunate to have a “true” sports medicine practice that predominantly includes professional, college, high school, amateur, and aging athletes. Having this type of clientele has forced me to explore and pursue restoring full function in the timeliest manner, being very careful to not cause harm using an aggressive approach.
I believe that one of the secrets to having successful return to sports with minimal adverse effects is fully restoring muscle function.
Although many aspects of our field have seen excellent advancements and growth, we continue to combat one of the most difficult challenges following injury and surgery, muscle atrophy and weakness.
Restoration of muscle function should not only be measured by muscle force output and scores obtained on functional tests, but neurological function. In my practice, establishing normal neurological function following knee surgery is goal number one for our patients’ initial step on the path toward successful return to function.
The Use of Biofeedback in Rehabilitation
So how do I do this? The use of biofeedback is my preferential method of attacking the neurological deficit following surgery or injury.
New advances in biofeedback devices have recently allowed the ability to provide a general assessment of the patients’ EMG neurological status. The subjects’ ability to fire the inhibited muscle may now be conveniently measured by recording EMG activity of the involved extremity and comparing this to the opposite normally functioning muscle group.
The primary rationale for use of biofeedback is the belief that the patient should begin use their own “electrical system” as soon as possible through volitional contraction.
The concept known as order of recruitment lends support to the use of biofeedback to enhance volitional contraction. This order is based on the size principle. Heinemann’s size principle states that under load, motor units are recruited from smallest to largest. In practice, this means that slow-twitch, low-force, fatigue-resistant muscle fibers are activated before fast-twitch, high-force, less fatigue-resistant muscle fibers.
When using a biofeedback device, the clinician sets the goal for the inhibited muscle so that a strong voluntary effort is required by the patent for each contraction. This is visible to the patient and forces a strong contraction to reach the pre-set goal. I believe that voluntary contraction using biofeedback produces the greatest results in restoring muscle function early.
Biofeedback or Neuromuscular Stimulation?
Neuromuscular electrical muscle stimulation (NMES) is often used to stimulate muscle contraction. There is a vast amount of literature supporting NMES for use during rehabilitation. Until recently, NMES has been a reimbursable modality, thus there was much financial support to research its’ effectiveness.
Biofeedback has not been reimbursable and that may have had an effect on the comparative lack of literature. One article from Draper and Ballard supports the use of biofeedback over NMES. This article compared the two modalities during ACL rehabilitation. After 6 weeks, the biofeedback group was shown to provide greater quadriceps isometric muscle strength than NMES treated group.
I believe in the use of NMES if a patient is unable to make any voluntary contraction, which sometimes happens following ACL reconstruction surgery. But, once a patient is able to produce a voluntary contraction, detected by the biofeedback, we immediately switch the patient to biofeedback.
When using NMES, all nerve fibers are stimulated simultaneously. This, in my opinion, is not as effective as biofeedback because the order of recruitment from small to large diameter nerve fibers is not sequential as is the case with voluntary contraction. NMES actually recruits the large diameter nerve fibers first because they are more excitable, as large diameter axons have less resistance to firing. Atrophy of muscles has predominate effects on the slow twitch smaller diameter Type I fibers, so recruiting these muscle fibers is critical to reverse the effects of muscle inhibition and atrophy.
How to Use Biofeedback in Rehabilitation
I use biofeedback on virtually every knee patient that has decreased neurological EMG output. As previously mentioned, we are able to use a new device to provide a side to side assessment of EMG activity.
This information as also very educational and motivational to the patient as they can see the actual deficit via visual EMG numbers between normal and involved.
Cycles of 10 seconds on and 10 seconds off are utilized during the 10 minute biofeedback session. My instructions to the patient for quadriceps re-education are to “tighten your muscle and force your knee straight”. Progress is continued to be monitored on a weekly basis to measure the change in EMG activity, as shown using the biofeedback application.
The mTrigger Biofeedback device that we use utilize has an amplifier that sends the measured EMG activity via a Bluetooth signal to an android or IOS device with the appropriately downloaded software application.
This mTrigger is available for home use as well as clinical use. Patient reported motivation using this type of biofeedback product is very high as they can actually visualize their intensity of muscle contraction when performing home exercise programs. There seems to be an interesting psychological connection between the use of one’s personal smartphone or computer pad and their muscle activity.
Lack of extension of the knee has been shown to have an adverse effect of knee function. Loss of extension alters the gait pattern and can produce abnormal stresses to the patellofemoral joint. Due to a lack of quadriceps control many quad inhibited patients will ambulate with a flexed knee gait pattern.
The use of biofeedback can be used to combat this common malady often associated with post-op care of the knee. Lacking quad control, patients’ are unable to eccentrically control the knee flexion moment that occurs during single limb balance. A quad inhibited patient will assume this flexed knee position because they “know” the position of the knee during single limb balance.
This sets up the knee for a co-contracted state and presents as muscle splinting until normal muscle tone and function are restored. This muscle splinting will continue to exacerbate the lack of extension in the knee. Biofeedback can be very effective at addressing this issue.
With muscle splinting, we want to teach the patient to relax the hamstring muscle during knee extension stretching, thus negating the effect of a contracting hamstring muscle. The patient is placed in a prone position, with both patella over the edge of the table. Electrodes are placed over the hamstring muscle. Unlike the inhibited quadriceps muscle where we are trying to elicit a more perfect contraction, the biofeedback unit is now used for relaxation purposes. As the patient uses the relaxation mode of the unit, and learns to control the overly active hamstring contraction immediate increase in passive knee extension is observed.
This position is maintained for a 10 minute period. Once the patient has “learned” to control the hamstring over activity, a light weight may be applied for the 10-minute period to produce a low-load long-duration stretch. Change in knee extension can be measured using heel height difference measurement technique. Dale Daniel described this measurement and showed that 1cm of HHD = 1 degree of flexion contracture.
Note from Mike: That’s a great example of how you would use biofeedback to work reducing muscle activity. It’s not always used to increase activity. Another way we use it is to use both channels together on 2 different muscle groups. Imagine doing a bird dog or glute bridge with the pads on the glutes and low back. You would focus on performing the drill with high glute activity and low back activity. It’s pretty neat.
Return to Play
Return to play is a hot topic in rehab right now. It’s difficult to determine if the athlete is ready to return to sport. There are many obstacles when assisting your athlete to the ultimate goal of returning to sport with pre-injury level of performance.
Too often, a shift is made during the rehabilitation process to more functional activities and reduced emphasis on strengthening. If your patient continues to possess a decreased EMG signal compared to normal side, it will be highly unlikely that they will be able to resume the pre-injury level of function.
With biofeedback, we have a tool that makes certain that we have completed one of the early critical steps in the process of rehabilitation – restoring and measuring normal neurological function of the inhibited muscle group. Don’t allow decreased EMG function be one of the obstacles to continue to linger.
The mTrigger Biofeedback Device
I thought that was a great article from Russ. Many don’t even realize how impactful biofeedback can be as it has fallen out of favor. Here’s a great video from Russ and I demonstrating the mTrigger device and talking about how and why we use biofeedback:
As you can see, the new mTrigger device is so simple to use and completely affordable. That has always been a limitation in biofeedback devices, they were just to clunky and expensive.
If you want to get started using biofeedback, mTrigger was nice enough to offer my readers 10% off their purchase, making this even more affordable. Click the link below and be sure to use coupon code REINOLD to get your 10% off
Russ Paine, PT, is known for his experience in sports medicine with special interests in injuries to the knee and shoulder, as well as golfing injuries and conditioning. His client list includes many professional athletes who have sought his expertise to help them recover to their prior level of function. Russ has a long career in sports medicine, having served as rehabilitation consultant to the Houston Astros, Houston Rockets, and NASA. Currently the Director of Sports Medicine Rehabilitation at UT Physicians in Houston, TX, Russ continues to devote his time to research and education while maintaining a busy sports medicine clinical practice. Russ was inducted into the Sports Physical Therapy Hall of Fame in 2018. As a well-established author and lecturer on topics related to sports medicine, he has lectured at over 500 meetings in the US and abroad. He has published 25 chapters in textbooks and over thirty research articles in peer review journals.
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We’ve come along way over the last decade when it comes to training the core. Not too long ago, training the core consisted of mainly exercises like sit ups, with no specific attention to how the core functions.
One of the key areas of core training that I focus on to enhance movement quality and performance is stabilizing the core while the arms and legs move. Essentially proximal stability, with underlying distal mobility of the extremities.
However, don’t forget that the body is amazing at compensating to get the job done.
Any lack of mobility or motor control will often result in compensatory movements. Many people want to fly through their core program, but often times don’t focus on the quality of the movement.
A common error I see when people perform a front plank is over relying on the hip flexors to hold the position. You sometimes see them tighten their core but also come up into a bit of hip flexion.
If you hold planks for too long, you may also notice that you slowly creep up into this position as your core fatigues and your hip flexors take over.
There are two easy ways to improve this:
1. Focus on tightening your core AND your glutes. This should help hold the neutral pelvic position. 2. Perform sets of planks with each rep being ~8-10 seconds, with no break, just a quick reset, instead of sustained holds.⠀This will keep the focus on the core before the hip flexors take over.
Similar to the front plank, the side plank is easy to use larger muscle groups to compensate. One easy way to ruin a good side plank is simply to lift the body too high off the table. You’ll see too much side bend and will make this a lateral bend motion instead of a core stability exercise.
To fix this, try performing with a mirror so you can see your form. Your body should be in a straight line with a nice neutral spine.
One of the common faults we see with the dead bug core exercises is a loss of neutral spine when the arms or the legs are full extended. ⠀The person tends to focus on getting there hands and feet extended, rather than keeping their core stable.
Remember the goal of the exercise is to brace and stabilize the core while moving the extremities.
Be sure to keep that brace, but also realize that it’s often better to reduce your arm and leg motion a bit if you are struggling and arching your back.⠀I’d rather you make the exercise less challenging, but performed well, then slowly progress over time.
I’m a big fan of the bird dog exercise for two main reasons:
1) It’s great exercise to work on driving hip extension with proper core stability. A lot of people hyperextend their back instead of extending their hip. 2) Because you use alternate arm and leg for advanced variations, it also provides some rotational stability through the core.
But people LOVE to perform this exercise poorly by compensating and arching their back. Many people struggle to extend their hip while keeping their spine stable. Be sure to keep your core stable and just work on reaching with arms and legs.⠀Similar to the dead bug, I’d rather you reduce the quantity of your motion, and focus on the quality of the motion.
A common flaw with the glute bridge exercise (and hip thrusts) is thinking that you need to go as far as possible, as far as your body will go. ⠀ But keep in mind, the goal here is the glutes, not the low back. So the exercise should really be performed to extend you hips and NOT your back. ⠀ To help with this, really tighten your anterior core during the exercise and focus on squeezing your glutes. Then, simply stop the motion when the glutes are done squeezing. Many people want to keep going. They tighten their glutes, but then keep pushing the body higher over the ground. Resist the urge to continue by hyperextending at your back.
Check out Eric Cressey and I’s Functional Stability Training of the Core program. We discuss the core in detail and how we rehabilitate and train the core.
