I have a great guest post on neurocognitive training after ACL surgery by Lenny Macrina. This is an emerging field of research that is starting to show some promise in helping us with our ACL rehabilitation programs, as well as return to play decision making.
Return to play after ACL reconstruction surgery is often a complicated decision-making process. As we have written in the past, numerous studies have shown that return to play testing after ACL reconstruction is not straightforward. With ACL re-tear rates so high, our physical therapy research is still lacking definitive guidelines on the best return-to-play criteria.
I’m consistently trying to figure out the best methods to allow our patients to return to their sport as safely and effectively as possible.
In this post, I wanted to look at the research on the neurocognitive effects of an ACL tear. This is definitely an emerging field of research that has blossomed the past few years. There are not many studies published on this topic so I hope to better understand and explain what this field is proposing, and how it may impact our return to sport decision making after ACL reconstruction surgery.
Neurocognitive Changes After an ACL Tear
From what I can see, Grooms et al first talked about this phenomenon in 2015 in a paper in the Journal of Athletic Training. They looked at functional MRI’s of the brain for one ACL-injured participant versus a single matched control participant. Small sample size, of course, and a pilot study of some sort.
They determined that the ‘ACL-injured participant exhibited increased activation of motor-planning, sensory-processing, and visual-motor control areas. A similar activation pattern was present for the contralateral knee that sustained a subsequent injury.”
The brain activity was absolutely different than the control matched patient that did not have a previous ACL tear.
Based on this one patient, they concluded that “Neuromuscular training that incorporates visual or neurocognitive processing, such as ball tracking or engaging other players, task complexity (reaction and decision making), anticipatory aspects, and cognitive load (dual-task), can address the possible sensory reweighting of visual feedback for motor control.”
Interventions that integrate sensorimotor feedback with injury reduction programs have the potential to enhance brain functional connectivity to improve ACL injury risk reduction biomechanics.
Interesting findings… but how can we apply this concept to our ACL physical therapy programs and return to sport testing to make them even better?
Combining ACL Neuromuscular and Neurocognitive Training
Reactive control and athletic decision making needs to become a subconscious response based on sensory and visual input. An external focus of control is needed to optimize neuromuscular control.
In an even more simple term, we as rehabilitation specialists need to create rehab programs that integrate the surrounding environment into each program.
This concept is very different from what we traditionally use in many of our cues during an exercise. We often tell people to prevent their knees from collapsing inward. Sometimes we even use an external force to pull the knee into more valgus to facilitate a neuromuscular response to prevent that movement.
Instead, maybe we need to use a neurocognitive cue and have our patients to perform drills like a RDL toward an external prop like a cone based on randomized cueing.
It seems similar but using the visual and external input, the brain wiring will be different and potentially allow the athlete to perform this movement subconsciously as their training progresses.
As the person progresses, we can start to combine a visual cue to react prior to beginning a movement. Here’s an example of a simple 3-way hop. But rather than knowing and anticipating the movement, we are cueing the person as to which direction to hop. They subsequently need to react based on the visual stimulus.
We often focus on strength and even neuromuscular control, but by adding an element of visual input and reaction to the direction of the hop, we further challenge the neurocognitive input as well as the neuromuscular output. As you can see here, this professional athlete struggles by trying to anticipate, but then adjusts and improves his reaction. This takes a lot of effort!
This could easily be progressed to include randomized and more complicated cues.
Combing neuromuscular and a neurocognitive training approach may allow a transfer of motor control to subcortical regions and free cortical resources for programming more complex motor actions. This would help to screen out incorrect motor responses by the athlete.
Return to Sport Testing after ACL surgery
By better understanding this information, we can develop return to sport testing guidelines that can better determine readiness and hopefully reduce future injuries even more.
I’m not going to lie, I struggle to have a formal test that solely determines my athlete’s return to sport.
With that, I wanted to seek out this new research that may help to better determine an athlete’s readiness, both neuromuscularly and neurocognitively.
Neurocognitive Hop Tests to Determine Return to Play after ACL Surgery
I stumbled upon this recent Tweet by Ohio University PT and researcher Dusty Grooms (@Dusty_Grooms) so I clicked on his 2 links to read the articles.
The articles really made me think about what we are doing with our patients and the role of the brain. I have always thought that the brain plays a much larger role than what we ever imagined.
This Grooms paper sought to compare the relationship between four foundational single-leg hop tests and their respective neurocognitive single-leg hop test. These hop tests have been shown to be reliable in a previous study from 2019.
Nine males and 13 females were recruited for this study. They performed the traditional hop test which included a single leg hop, single a crossover hop, single-leg triple hop, and single-leg 6m hop.
They also performed these tests separately in which neurocognitive conditions were altered in order to compare the two groups.
The hop test for the neurocognitive group utilized a Fit-Light System that signaled when each hop trial was initiated. Signals changed color and were randomly activated to force the athlete to anticipate each hop then respond as quickly as possible.
The hop tests consisted of:
Single leg hop – When the correct color flashed, green the participant jumped as far as possible with a single hop
Single leg triple hop – the fit light flashed one of six colors at random each trial, a random color was selected as the Hop color while the remaining five or assigned as do not hop the participant would perform a single leg hop full within three consecutive hops when the correct color flashed.
Single leg crossover hop – the participant stood on a centerline in either hop. Based on if the right or left light flashed in their periphery, the sequence of hops was determined by which light was first seen by the participant.
Single leg 6-meter hop at a random time – the fit light would blink either red or green and hop 6m as quickly as possible.
Here is an example of the crossover hop test performed in the study, big thanks to Dusty Grooms for allowing us to use this video:
Neurocognitive Tasks Decreased Hop Test Performance
The addition of the neurocognitive task decreased the performance for each crossover hop, triple hop, and 6-meter hop test when compared to the traditional hop test.
The only hop test that was not affected was the single-leg hop test when compared to the traditional manner.
Adding a cognitive challenge resulted in the athletes’ inability to jump as far and as quickly, relative to the traditional hop test.
These results may have implications for our rehab programs to help us better design a more mentally challenging environment for our athletes.
As they described in the study, “the more complex hop tests were devised to challenge different aspects of visuomotor and cognitive-motor function, as well as increase the complexity.”
Performance declines were affected by environmental stimuli, which may be extrapolated to real-life performances on the field when actions are less rehearsed and more reactive.
Neurocognitive Training for ACL Rehabilitation
I find the topic of neurocognitive training interesting and fascinating. I’m hopeful that what Dusty and others are doing in this field will help future patients’ recoveries. I also think that it will help clinicians to better understand the complexities of post-surgical ACL rehabilitation.
With our ACL outcomes being far from perfect, I feel as if this new field of research could offer potentially promising outcomes once we better understand and implement these research findings into a comprehensive ACL reconstruction physical therapy program.
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Returning to golf after an injury can sometimes be tricky. One of the more common mistakes we see golfers make when trying to gelt back to golf after an injury is simply jumping right back in, resulting in doing too much too soon.
When you take a step back and think about the type of injuries that occur to golfers, you tend to see a pattern.
Some of the most common golf injuries we see are:
Low back pain
Elbow tendonitis
Wrist pain
Neck pain
All of these golf injuries predominantly occur from overuse or poor workload management, rather than an acute injury.
Anyone that golfs knows how easy it is to go to the driving range and just swing away. It’s very easy to take 75+ swings in a really short amount of time with no warm-up. Just get out of the car and start hacking. Golf is also a sport that many recreational golfers play occasionally. It’s not uncommon for someone to go weeks without swinging a golf club, and then play several rounds in one weekend.
Many golfers think trying to get back to golf after an injury is like turning on a lightbulb. Even though poor workload management was likely a key factor in sustaining their golf injury, once they start to feel better they return to golf at the same workload and overload the healing tissue again.
How to Return to Golf After an Injury
The key to returning to golf after an injury is building a gradual plan to return that slowly applies load. You want to avoid needing to speed up and slow down the process.
Many golfers think this means they need to do less. But remember, quantity is just one part of the workload equation for golfers. Frequency and intensity are also important.
Luckily, a workload progression is easy to do if you break down the different components of the game of golf. You can easily break golf down into both “distance” and “finesse” shots. Distance shots are obviously full effort, but finesse shots are often partial effort. You can also do the same with different club lengths.
Here’s a great video of an interview I did with Mike Scaduto. Mike’s our golf specialist at Champion PT and Performance. He and I got together for a big presentation on golf injury rehabilitation and performance training for my Inner Circle. We talked about the different types of golf injuries, evaluation process, performance enhancement, and how to collaborate with local golf pros and swing coaches. Inner Circle members can check out the entire presentation.
I wanted to share this portion of the presentation on how we build a return to golf program after an injury. I thought it was really helpful.
Here’s Mike and I talking about how to get back to golf after an injury:
How to Build a Return to Golf Program After an Injury
So, remember, when trying to get back to golf after an injury, there are a lot more things you can do to build up to your full golf swing. The key is making sure that you understand how to manage the workload progression.
Here are a couple of options of return to golf programs as an example of how we would build up the volume and intensity, while controlling the frequency:
Day 1 – 20 full swings
Day 2 – 20 finesse swings
Day 3 – off
Day 4 – 30 full swings
Day 5 – 30 finesse swings
Or another option could be:
Day 1 – 20 finesse swings, 10 full swings
Day 2 – off
Day 3 – 15 finesse swings, 15 full swings
Day 4 – off
Day 5 – 15 finesse swings, 20 full swings
Those are not specific to a certain injury, but I think you can see how we manipulate the workload to get back to golf after an injury and use that as a baseline to build your own return to golf program.
The only other thing I would add is that it is always a good idea to collaborate with a PGA professional or golf swing coach. Check out our podcast episode we did with Adam Kolloff and the golf professionals at Pure Drive Golf about how we collaborate on golf rehabilitation and performance programs.
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Limitations in ankle dorsiflexion can cause quite a few functional and athletic limitations, leading to the desire to perform ankle mobility exercises.
These types of ankle mobility drills have become popular over the last several years and are often important components of corrective exercise and movement prep programming.
In this article, I’m going to cover everything you need to know about improving ankle dorsiflexion, including:
What causes poor ankle dorsiflexion?
Why limited ankle dorsiflexion can be a problem
What is normal range of motion for ankle dorsiflexion?
How much dorsiflexion range of motion do you need?
How to assess your ankle mobility
My 3-step approach to ankle dorsiflexion exercises to optimize mobility
What Causes Poor Ankle Dorsiflexion?
Before we get too deep into discussing how to fix poor ankle dorsiflexion, it helps to understand what could cause poor ankle mobility.
In my experience, the most common reason people may have poor dorsiflexion is a past surgery or injury.
This makes sense when dealing with big injuries, such as fractures, Achilles tendon ruptures, and ligament tears from acute sprains. Anything that requires a period of immobilization of the foot can obviously lead to a loss of ankle mobility.
But you don’t need to have a major injury or surgery, even mild injuries can lead to a loss of ankle mobility.
Ankle sprains, even mild degrees, seem to be an injury that frequently leads to a loss of dorsiflexion range of motion.
If you look at the anatomy of the anterior talofibular ligament, otherwise known as the ATFL, you can see that it attaches to both the fibula and the talus:
Any disruption of the ATFL ligament will lead to increased translation of the ankle, and even a more anteriorly positioned fibula. A 2006 study in JOSPT and a 2014 Study in JOSPT have both confirmed that subjects with chronic ankle instability had an altered position of the fibula.
But even if you haven’t sprained your ankle, activities with repetition dorsiflexion, such as sports that involve a lot of running and jumping, can also lead to adaptive changes and anterior ankle impingement.
As always, another factor can be our postural adaptations and terrible shoe wear habits, especially if high heels. Remember the body adapts to stress applied and stress NOT applied. It’s no wonder that so many people have ankle mobility issues. So the concept of “use it or lose it” can be a factor for those that don’t perform a lot of daily activities that need dorsiflexion.
This is likely due to the kinetic chain effect on the body. Here’s an example of some of the compensations with see with the lateral step down portion of the Champion Performance Specialist movement assessment:
When assessing a wide variety of studies in a systematic review, Lima found that limited ankle dorsiflexion is correlated with dynamic knee valgus angles during functional movements.
This can have obvious implications as a lack of dynamic knee valgus is associated with a variety of injuries, including ACL tears and patellofemoral pain. In fact, in one study, patients with patellofemoral osteoarthritis had less ankle dorsiflexion than those without arthritis.
What is Normal Range of Motion for Ankle Dorsiflexion?
The generally accepted normal range of motion for ankle dorsiflexion is 20 degrees as defined by both the American Academy of Orthopaedic Surgeons and the American Medical Association.
However, there is a lot of variability if you search the literature.
Benhamu showed between 13-21 degrees, Rome showed between 8-26 degrees, and Weir showed between 12 and 23 degrees of dorsiflexion their respective studies.
Baggett compared normal dorsiflexion range of motion in a non-weight bearing and weightbearing position, showing 0-17 in non-weightbearing and 7-35 degrees in weightbearing. Rabin also reported a large difference in dorsiflexion when comparing these two positions, however, they also noted a moderate correlation, meaning that a limitation in either position will likely show up in both.
With such a wide variety of methods of measuring and reported values, the bigger question may be how much dorsiflexion mobility do you need?
How Much Dorsiflexion Range of Motion Do You Need?
The ability to have a proper amount of dorsiflexion isn’t something that is only needed in sports, it’s actually a vital movement to allow normal functional activities.
Walking has been shown to require approximately 10 degrees of ankle dorsiflexion by Dr. Jacqueline Perry in her gait research. As the body advances, the trail leg needs to dorsiflex as the hip extends right before push off.
More recent research has reported that up to 20 degrees of dorsiflexion has been shown in subjects during gait analysis.
More dynamic movements, such as the squat, require even more ankle dorsiflexion range of motion. A 2006 study by Hemmerich in the J Orthop Res showed that the further you go into the squat position, the more dorsiflexion motion is needed. Maximal squat depth to just past parallel requires almost 35 degrees of dorsiflexion.
As you can see in the images above, once you get deeper than 20-30 degrees of squat depth, the amount of dorsiflexion needed goes up considerably. The first image is depicting someone with a restriction with ankle dorsiflexion, and how that will impact the depth of the squat. In the second image, you can see how having more dorsiflexion will improve the depth of the squat. The third photo shows an example of modifying the squat by elevating the heels. This take some of the dorsiflexion needs out of the squat to allow her to go deeper.
Check out this video demonstration on how to improve the squat with limited ankle dorsiflexion to see how we would coach this:
Ever wonder why weightlifting shows have a large heel lift? Well, it’s to squat deeper by taking out the need for so much dorsiflexion. In my experience, a lack of dorsiflexion is one of the biggest reasons why people often squat poorly.
How to Assess Your Ankle Mobility
So based on everything we’ve covered so far, you can see, dorsiflexion range of motion can be variable. That’s why when assessing ankle dorsiflexion mobility, I like to measure the specific degree, but also include a simple self-assessment that people can do themselves. This is simply a pass-fail type test.
I’m also a big fan of standardizing a test that can provide reliable results.
One test that is popular and part of our integrated movement assessment in the Champion Performance Specialist program is the half-kneeling dorsiflexion test. Here’s a video from the program demonstrating:
In this test, you kneel on the ground and assume a position similar to stretching your hip flexors, with your knee on the floor. Your lead foot that you are testing should be lined up 5″ from the wall. This is important and the key to standardizing the test.
From this position you lean in, keeping your heel on the ground. You can measure the actual tibial angle in relationship to the ground with a goniometer, or simply measure the distance of the knee cap from the wall when the heel starts to come up.
An alternate method would be to perform the same movement and measure how many inches forward your knee passes your toes. If I am looking to quantify this movement to be able to assess progress, I’ll use this method.
I personally prefer to standardize the distance to 5″ from the wall and simply perform it as a pass-fail test. If they can touch the wall from 5″, they have pretty good mobility.
I should note that my photo below has my client wearing minimal heel drop shoes, but barefoot is ideal
This is a great position to assess your progress, and as you’ll see, I’ll recommend some specific drills you can perform from this position so you can immediately assess and reassess.
Ankle Mobility Exercises to Improve Dorsiflexion
There are many great ideas on the internet on how to improve dorsiflexion with ankle mobility exercise, but I wanted to accumulate some of my favorites in one place. Below, I will share my system for assessing ankle mobility and then addressing limitations. I use a combined approach including self-myofascial exercises, stretching, and ankle mobility drills.
As I mentioned previously, I like to use a 3-step process to maximize my gains when trying to enhance ankle dorsiflexion:
Self-myofascial release for the calf and plantar fascia
Stretching of the calf
Ankle mobility drills
I prefer this order to neuromodulate tone, loosen the soft tissue and maximize pliability before working on specific ankle joint mobility.
When looking at the efficacy, a recent study showed that combining self-myofascial release and static stretching had a greater increase in ankle dorsiflexion range of motion than either on their own.
Self Myofascial Drills for Ankle Dorsiflexion Mobility
One of the more simple self-myofascial release techniques for ankle mobility is foam rolling the calf.
Anytime I perform self-myofascial release exercises, I follow a 3-step plan:
Roll up and down the entire length of the muscle for ~10 reps or up to 30 seconds
If they hit a tender spot or trigger point, pause at the spot for ~8-10 seconds
Add active ankle range of motion movements during rolling, such as actively dorsiflexing the foot or performing ankle circles:
A foam roller does a really good job of helping to improve ankle dorsiflexion. This has benefits as you can turn your body side to side and get the medial and lateral aspect of your calf along the full length.
Here’s a clip of someone performing this in real-time. Notice how they hit all aspects of the calf follow my 3-step self-myofascial release system. Don’t forget to roll the bottom of your foot with a ball, as well, to lengthen the posterior chain tissue even further. There is a direct connection between the plantar fascia and Achilles tendon.
Some people do not feel that the foam roller gives them enough of a release as it is hard to place a lot of bodyweight through the foam roller in this position. That is why I often use one of the massage sticks to work the area in addition. You can use a massage stick in a similar fashion to roll the length of the area and pause at tender spots. I often add mobility in the half-kneeling position as well, which gives this technique an added bonus.
Stretches for Ankle Dorsiflexion Mobility
Once you are done foam rolling, I like to stretch the muscle. A systematic review by Radford has shown that static ankle dorsiflexion stretching can lead to a statistically significant improvement in motion. A more recent meta-analysis revealed a 5-degree increase in mobility after ankle dorsiflexion stretches.
If moderate to severe restrictions exist, I will hold the stretch for about 30 seconds, but often just do a few reps of 10 seconds for most people.
The classic wall lean stretch is shown below. This is a decent basic exercise, however, I have found that you need to be pretty tight to get a decent stretch in this position.
I usually prefer placing your foot up on a wall or step instead, as seen in the second part of my video below. The added benefit here is that you can control the intensity of the stretch by how close you are to the wall and how much you lean your body in. I also like that it extends my toes, which gives a stretch of the plantar fascia as well. For both of these stretches, be sure to not turn your foot outward. You should be neutral to point your toe in slightly (no more than an hour on a clock).
Simple Ankle Mobility Exercises
I like to break down my ankle mobility exercises into basic and advanced, depending on the extent of your motion restriction. There are several basic drills that you can incorporate into your movement prep or corrective exercise strategies.
Half-Kneeling Dorsiflexion Wall Mobilization
The first drill involves a simple half-kneeling dorsiflexion movement, which is essentially just a dynamic warmup version of the ankle mobility test we described above:
This tends to be the first dorsiflexion mobility exercises that I tend to give people, as it is super easy to perform, and also easy to gauge progress by your distance from the wall.
Half-Kneeling Ankle Dorsiflexion with a Dowel
A progression from the wall mobilization is to use a dowel. The dowel is an important part of the ankle mobility drill. You begin by half kneeling, then placing a dowel in front of your 2nd or 3rd toe. Now, when you lean into dorsiflexion, make sure your knee goes outside of the dowel. This will help maintain a neutral arch position and avoid compensating by pronating your foot and internally rotating your hip. You can add the dowel to many of the variations of drills we are discussing.
Half-Kneeling Ankle Dorsiflexion with Your Hand
A slightly more advanced variation of the dowel is to use your hand. Your arm will act like the dowel, and require your knee to go to the outside. This movement requires more hip mobility to perform but can be really useful for those that may be struggling to keep a neutral arch during the movement.
Half-Kneeling Lateral Ankle Glides
For some people, especially those with a past injury like an ankle sprain, lateral mobility of the ankle can become limited. This mobility drill is very popular with my clients, they really like the feeling and ability to move afterward/
Advanced Ankle Mobility Exercises
When the person is ready to progress to more advanced ankle mobility drills, I often like to progress the drills by including multiple planes of motion, making the positions more dynamic, or progressing to drills that require more dorsiflexion to accomplish.
Half-Kneeling Dorsiflexion with Voodoo Floss
Chris Johnson shared a nice video using a Voodoo Floss band to assist with the myofascial release and position the tibia into internal rotation. Restoring ankle dorsiflexion at the level of the talocrural joint is critical and should be established with the knee flexed to mimic the midstance demands of walking and running. The performer will grasp the distal tibia and fibula region and wind into internal or external rotation and then lunge forward and backward.
Half-Kneeling Dorsiflexion with a Mobility Band
For those that have a “pinch” in the front of the ankle of tight joint restrictions of the ankle in general, Erson Religioso shows us some Mulligan mobilizations with movement (MWM) using a band. In this video, he has his patient put the band under his opposite knee, however you could easily tie this around something behind you. In this position you step out to create tension on the band, which will move your talus posteriorly as you move forward into dorsiflexion:
Standing Dorsiflexion Wall Mobilization
The standing dorsiflexion wall mobilization is an advanced version of the half-kneeling position. But rather than simply leaning in and touching your knee to the wall, we change the start position to that your toes up on the wall and extended. This essentially combines an ankle mobility drill with a stretch to the calf, Achilles tendon, and even the plantar fascia due to the toes being extended.
This isn’t one of the first drills I use because it’s advanced, but it’s one of my favorites.
Standing 3-Way Dorsiflexion Wall Mobilization
Kevin Neeld shows a great progression of this exercise that incorporates both the toes up on the wall, essentially making it more of a mobility challenge and stretch. If you look closely, you’ll see that he is also mobilizing in three planes, straight neutral, inward, and outward:
Standing Lateral Ankle Glides
Similar to the above progression from half-kneeling to standing dorsiflexion drills, I like to perform a more advanced version of the lateral ankle glides by performing standing:
Push Up Position Ankle Rocks
As you can see, we’re really progressing to positions that require more and more ankle dorsiflexion range of motion, so you can see the potential progressions.
The push up position ankle rocks drill is a great one, that involves a great stretch of the calf and Achilles tendon. Most of my athletes will use this ankle dynamic mobility drill at some point in their warm-up.
Functional Dorsiflexion Dynamic Mobility Drills
So far, we’ve covered a variety of mobility drills to perform to enhance ankle dorsiflexion. As mobility increases, it’s super important that we try to functionally incorporate dorsiflexion into our programming.
Here are some examples that I like to use.
Seated Dorsiflexion Ankle Raises
Once you’ve established dorsiflexion mobility, it’s a good idea to strengthen the muscles that dorsiflex within the new range of motion. A nice easy drill to start with is seated dorsiflexion ankle raises. Because you start in the neutral position, any lift of the ground is moving towards more dorsiflexion
Standing Deficit Dorsiflexion Toe Raises
A variation of the seated position, standing up on a weight plate or similar low height box will allow you to need to dorsiflex against any tightness of the gastrocnemius. By adding the box, you will allow strengthening into a great range of motion.
Knee Extension with Dorsiflexion
In addition to strengthening into dorsiflexion, I also like to work on the endurance of maintaining the position. An easy way to do this is with a kettlebell around the toes of the foot. You will need to dorsiflex to hold the kettlebell, and can easily progress to heavier weights. I often incorporate this with a knee extension movement to include a lengthening of the gastrocnemius.
Toes Elevated Squats
As we’ve previously discussed, the squatting motion requires a lot of dorsiflexion to go deep into the motion.
One drill I like to do for a dynamic warm-up prior to squatting in someone that is working to increase their dorsiflexion is simple toes elevated squats. You can slide a small weight plate, or something about 1-1.5”, under the toes and slowly perform some bodyweight squats.
Reverse Bear Crawls
The reverse bear crawl is an amazing exercise for ankle dorsiflexion. When crawling backward, you’ll need a decent amount of ankle mobility. The movement includes a dynamic movement into dorsiflexion with the knee bent and toes extended, so acts as a good drill for the soleus and plantar fascia.
Improving Dorsiflexion Mobility
As you can see, there are many different variations of drills you can perform based on what is specifically tight or limited. You may have to play around a little bit to find what works best for each person. However, these are a bunch of great examples of ankle mobility exercises you can choose to perform when trying to improve your dorsiflexion.
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Shoulder instability is a common injury encountered in physical therapy. But there are many different types of shoulder instability.
Would you treat a high school baseball player that feels like their shoulder is loose when throwing the same as a 35 year old that fell on ice onto an outstretched arm and dislocated their shoulder? They both have “shoulder instability,” right?
There exists a wide range of symptomatic shoulder instabilities from subtle recurrent subluxations to traumatic dislocations. Nonoperative rehabilitation is commonly utilized for shoulder instability to regain previous functional activities through specific strengthening exercises, dynamic stabilization drills, neuromuscular training, proprioception drills, scapular muscle strengthening program and a gradual return to their desired activities.
But to truly understand how to successfully treat shoulder instability, there are several key factors that you must consider.
Key Factors When Designing Shoulder Instability Rehabilitation Programs
Because there are so many different variations of shoulder instability, it is extremely important to understand several factors that will impact the rehabilitation program. This will allow us to individualize shoulder instability rehabilitation programs and enhance recovery.
There are 6 main factors that I consider when designing my rehabilitation programs for nonoperative shoulder instability rehabilitation. I’m going to cover each in detail.
Factor #1 – Mechanism and Chronicity of Shoulder Instability
The first factor to consider in the rehabilitation of a patient with shoulder instability is the mechanism and chronicity of the injury. There are two different types of instability that can be classified as:
Acute, traumatic instability
Chronic, atraumatic instability
Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.
Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain and apprehension. The patient who has sustained a dislocation often exhibits more pain due to muscle spasm than a patient who has subluxed their shoulder. Furthermore, a first time episode of dislocation is generally more painful than the repeat event.
Here’s a great example of a traumatic dislocation. Note the amount of pain the athlete is in as they walk off the field with the shoulder still dislocated.
Rehabilitation will be progressed based on the patient’s symptoms with emphasis on early controlled range of motion, reduction of muscle spasms and guarding and relief of pain. But the main goal is to allow the shoulder capsule to heal.
The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive range of motion (ROM) exercises especially with first time dislocations.
The incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Therefore, the rehabilitation program should progress cautiously in young athletic individuals. It should be noted that Hovelius has demonstrated that the rate of recurrent dislocations is based on the patient’s age and not affected by the length of post-injury immobilization. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius also noted patients in their 20’s exhibited a recurrence rate of 60% whereas patients in their 30’s to 40’s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92% and 100% with an open physes.
Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.
They often times also have the ability to move their shoulder into excessive motion.
Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.
Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.
Remember, in these patients, the primary need is stability, not mobility.
The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control especially in the specific points of motion or direction which results in instability complaints.
Factor #2 – Degree of Shoulder Instability
The second factor is the degree of instability present in the patient and its effect on their function.
Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term shoulder subluxation refers to the complete separation of the articular surfaces with spontaneous reduction.
Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. This will result in underlying capsular tissue trauma. Thus, with shoulder dislocations the degree of trauma to the glenohumeral joint’s soft tissue is much more extensive.
In the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid. This is called a Bankart lesion, and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”
Speer has reported that in order for a shoulder dislocation to occur, a Bankart lesion must be present and also soft tissue trauma must be present on both sides of the glenohumeral joint capsule.
The rate of progression will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.
Factor #3 – Concomitant Pathology
The third factor involves considering other tissues that may have been affected and the premorbid status of the tissue.
As we previously discussed, disruption of the capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. But other tissues may also be involved.
Often osseous lesions may be present such as a concomitant Hill Sach’s lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation.
This has been reported in up to 80% of dislocations. Conversely, a reverse Hill Sach’s lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation. Similarly, the glenoid can also sustain a boney lesion.
The more boney involvement, the greater amount of instability that is often present.
Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation as well as pathology to the rotator cuff. In rare cases of extreme trauma, the brachial plexus may become involved as well. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum. These concomitant lesions will affect the rehabilitation significantly in order to protect the healing tissue.
Factor # 4 – Direction of Shoulder Instability
The next factor to consider is the direction of shoulder instability present. The three most common forms include anterior, posterior and multidirectional.
Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 95% of all traumatic shoulder instabilities. However, the incidence of posterior instabilities appears to be dependent on the patient population. For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Often, these posterior instability patients require surgery as Mair reported 75% required surgical stabilization.
Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability, or a Bankart lesion as discussed above.
Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. These individuals are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim.
Posterior shoulder instability occurs less frequently, only accounting for less than 5% of traumatic shoulder dislocations.
This type of instability is often seen following a traumatic event such as falling onto an outstretched hand or from a pushing mechanism. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.
Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.
One of the most simple tests you can perform to assess MDI is the sulcus sign.
I would consider an inferior displacement of greater than 8-10mm during the sulcus maneuver with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity. You can see this pretty good in this photo, the sulcus is clearly larger than my finger width.
Due to the atraumatic mechanism and lack of acute tissue damage with MDI, range of motion is often normal to excessive.
Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers. Initially, the focus is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control in mid range of motion.
Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization and neuromuscular control drills. Isotonic strengthening exercises for the rotator cuff, deltoid and scapular muscles are also emphasized to enhance dynamic stability.
Factor #5 – Neuromuscular Control
The fifth factor to consider is the patient’s level of neuromuscular control, particularly at end range.
Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.
Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability.
Lephart compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.
Smith and Brunoli reported a significant decrease in proprioception following a shoulder dislocation.
Blasier reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.
Zuckerman noted that proprioception is affected by the patient’s age with older subjects exhibiting diminished proprioception than a comparably younger population.
Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control that must be addressed.
Factor # 6 – Pre-injury Activity Level
The final factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient.
If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free motion and adequate strength has been achieved.
Patients whose functional demands involve below shoulder level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are often low, but possible.
Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86-94%.
Keys to Shoulder Instability Rehabilitation
To summarize, nonoperative rehabilitation of shoulder instability has many subtle variations. To simplify my thought process, I always think of these 6 key factors before I decide what I want to focus on for each person.
Learn How I Evaluate and Treat the Shoulder
Want to learn exactly how I rehabilitate shoulder instability?
I have a whole lesson on this as part of my comprehensive online program on the Evidence Based Evaluation and Treatment of the Shoulder. If you want to learn exactly how I evaluate and treat the shoulder, including shoulder instability, this course is for you. You’ll be an expert on shoulders!
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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:
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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
https://mikereinold.com/wp-content/uploads/MikeReinold.com-Blog-Featured-Image-14.png6281200Mike Reinoldhttps://mikereinold.com/wp-content/uploads/MikeReinold-Small-Signature-Logo-2017-red.pngMike Reinold2019-04-29 06:00:202020-04-22 12:58:385 Keys to Returning to Sport After a Knee Surgery
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