6 Keys to Shoulder Instability Rehabilitation

Shoulder instability is a common pathology encountered in the orthopedic and sports medicine setting.

But “shoulder instability” itself isn’t that simple to understand.

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’re both “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.

I’ve had great success rehabilitating dislocated shoulders and helping people return back to full activities without surgery.  But to truly understand shoulder instability, there are several key factors that you must consider.

 

Key Factors When Designing Rehabilitation Programs for Shoulder Instability

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 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 – Chronicity of Shoulder Instability

The first factor to consider in the rehabilitation of a patient with shoulder instability is the onset of the pathology.

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.

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.

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 et al 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 et al 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.

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.

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

Bankart LesionThe 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 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.

Speer et al have 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.

Thus, in the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid (this is called a Bankart lesion – see pictures to the right) and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”

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

Hill Sachs LesionThe 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 anterior 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.

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

Shoulder Multidirectional InstabilityThe 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 et al 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.

Shoulder Sulcus SignOne 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 to the right, the sulcus is clearly larger than my finger width.

Due to the atraumatic mechanism and lack of acute tissue damage with MDI, ROM 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 ROM.

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

neuromuscular controlThe 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 et al 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 et al reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.

Zuckerman et al 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 ROM 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 do.  I hope these factors help you too.  What other factors do you consider when designing rehabilitation programs for shoulder instability?

 

Learn How I Evaluate and Treat the Shoulder

shoulder seminarWant 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 at ShoulderSeminar.com.  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!

 

 

 

 

What is the Best Graft Choice for ACL Reconstruction?

Today’s article is from my co-owner of Champion PT and Performance and co-author of OnlineKneeSeminar.com, Lenny Macrina.  Lenny does a great job discussing and comparing the different options when it comes to graft choice for ACL reconstruction.

Tearing an ACL can be a devastating experience.  Fortunately you are not alone as more than 250,000 people will tear their ACL in the United States and over 80% of people will have that tear reconstructed.

When the injury does occur, the person has some serious decisions to make including which graft to choose for the reconstruction. Often times, the person will leave that decision up to the orthopedic surgeon and blindly go with that decision.

All too often, the graft choice for that person may not be the best option for their age, goals and for their lifestyle, amongst many other things.  Consideration for the current research should play a big role in this decision-making process on which graft to use for ACL reconstruction.

So, what graft choices are out there and why may one be better than another one?

Well, as I normally say ‘it often depends,’ but I usually coach my clients and start with the gold standard, consider the pros and cons, then move onto the next best option.

ACL Reconstruction Graft Choices

What are the options and why choose one over the other?  First, I want to clarify the difference between “autograft” and “allograft.”  Autograft means using your own tissue.  Allograft means using tissue from a cadaver.

The most common choices available are:

  • Patellar tendon autograft
  • Hamstring autograft
  • Quadriceps tendon autograft
  • Patella tendon allograft

Let’s look at some of the research behind each ACL graft choice.

 

Patella Tendon Autograft

To me, the gold standard of ACL reconstruction is the patella tendon autograft and should be considered for most people in their teens, 20’s and for many in their 30’s or 40’s.

It is believed that the bone-patella tendon-bone graft has a stronger fixation because of the bone plugs that can incorporate into the femoral and tibial tunnels by 6-8 weeks after surgery.

Better graft fixation may prevent stretching or excessive laxity that is often seen with hamstring autografts and allografts. A strong and stable graft is key when considering the long term stability of the knee joint, as seen in this video showing the harvesting of the graft and the reconstruction.

Numerous studies have shown that re-tear rates are also significantly lower in patients undergoing a reconstruction with a patella tendon versus a hamstring tendon autograft.

A Scandinavian study looking at nearly 46,000 reconstructions showed this as well as a Norwegian study looking at greater than 12,000 reconstructions.  Furthermore a Danish study of nearly 14,000 reconstructions showed similar results.

Here in the US, a similar trend has been identified when looking at revision rates amongst the different graft choices. In this study out of over 21,000 reconstructions in California, patients under 21 years old with hamstring autografts had a 1.61 times higher risk of revision than did patients with patella tendon autografts. In patients less than 40 years old, those with allografts had a higher risk of revision than those with patellar tendon autografts.

A couple of disadvantages that are often reported after the surgery are an increase in general knee pain because of the soft tissue and bony dissection and anterior knee pain. This anterior knee pain may be more of a long term issue for some, especially while trying to kneel, because of the graft harvesting and scar that remains. To me, this is a small inconvenience but I always let my clients know of the potential long term kneeling limits. Usually not a big deal for most but you never know.

Some often say that it is more difficult to get a patient’s range of motion back, especially their hyperextension, if a patella tendon graft was used. I, personally have not seen this and have addressed this in a past article on 3 Ways to Avoid Loss of Motion After ACL Reconstruction.

I’ve actually had more difficult times getting hyperextension back in my hamstring autografts for some reason. They often feel that residual medial knee pain where the tendon was harvested and are reluctant to allow me to stretch them out into hyperextension.

Regardless, while anterior knee pain and range of motion restrictions are often cited as concerns, in my experience I feel these can be overcome with good postoperative rehabilitation.

 

Hamstring Tendon Autograft

The hamstring tendon autograft is another graft option for someone about to undergo an ACL reconstruction, as you can see in this video by Dr. Khalfayan:

I think it is too widely used currently and we need to further assess the outcomes and high risk of re-tear rate studies that I just presented.

Yeah, it may hurt less, and I stress MAY, but in my experience it is a graft that often presents a pretty big pain challenge. I’ve seen people in very comparable pain to a patella tendon graft because of the soft tissue dissection involved in the harvesting.

Think about a tendon shaver being poked under your skin high enough to clip the tendon from the muscle belly. No wonder hamstring grafts have a pretty significant bruising effect on the posterior aspect of their knees.

Ok, what about the famous: “But you can come back faster and progress rehab faster?”

I often hear this from patients who have done some research or have spoken to other health care practitioners but I completely disagree and actually progress people SLOWER with a hamstring autograft.

And here’s why…

The healing capacity for a hamstring autograft is believe to be inferior to the patella tendon graft.  Remember the Ekdahl study from 2008 but there are others too.

I know many are in sheep, goats and dogs but that’s all we have to guide us right now. Until humans will volunteer their knees periodically through a study to get histological samples, then we have to rely on animal studies to guide our thoughts and progressions.

And don’t forget there is an increased risk of infection with a hamstring graft compared to a patella tendon autograft or allograft.

But good news, many say the hamstring will regenerate after being taken out although the strength deficits into knee flexion persist.

Because of this, I often progress my patients that have ACL reconstruction using a hamstring autograft much slower than those with patellar tendon autografts.

A slower healing potential that may lead to graft stretching and eventual failure, never mind the potential strength deficits that may persist and affect jumping/landing biomechanics due to the use of the hamstring.

Remember, the hamstrings line of pull will help limit anterior translation of the tibia and dynamically stabilize during running, jumping and cutting tasks. If we take 1-2 of those tendons out, how will that affect the athlete short term and long term as they return to their function/sport.

Maybe that’ another reason why re-tear rates are statistically higher in ACL’s reconstructed with a hamstring graft?

I definitely go slower with my female clients, as well, who are much more likely to tear their ACL’s, in general.

Remember, numerous studies like this, this, this, and this have shown females to land in a quadriceps dominant and valgus position, which may predispose them ACL rupture, amongst many other reasons.

So, why would we even consider a hamstring graft in an active female population and take away one for their main stabilizers. It’s almost like we’re promoting the quadriceps dominant position by “robbing Peter to pay Paul.”

For this reason, I almost always tell my female clients to highly consider a patella tendon autograft. Furthermore, I very rarely recommend a hamstring graft for most of my patients that ask.

I just feel like the risk of re-tear outweighs the POTENTIAL for increased anterior knee pain after surgery. They tend to agree, quite often.

 

Quadriceps Tendon Autograft

Another autologous graft option, which I feel is underutilized, is harvesting a quadriceps tendon autograft to reconstruct the ACL. Honestly, the more I researched this graft option, the more I consider this a truly viable choice.

This video give a great overview of graft harvesting for the quadriceps tendon:

Numerous studies have shown very good outcome compared to hamstring and patellar tendon autografts. I could make a pretty good sized list but have picked just a few to make my point. Like this one, this one,  or this one.

Because of the size comparison and increased collagen present within the graft, the quadriceps tendon graft is definitely a graft with comparable strength qualities compared to the previous grafts mentioned.

This table, taken from the lectures at from my online course with Mike Reinold at OnlineKneeSeminar.com, summarized strength and strength to failure of the various graft choices.

What is the Best Graft Choice for ACL Reconstruction

Biomechanically, the cross-sectional area of the quadriceps tendon was nearly twice that of the patellar tendon. Ultimate load to failure and stiffness were also significantly higher for the quadriceps tendon graft.

Well, maybe we consider a hamstring graft if the primary revision failed and we need a new graft option?

I still say maybe consider an ipsilateral quadriceps tendon before thinking about a hamstring tendon. This study showed revision ACL reconstruction using the quadriceps tendon graft showed clinical outcomes similar to those of the contralateral hamstrings graft in terms of knee stability and function.

But we said pain was less in hamstring grafts, right?

We’d rather have less pain so I can progress ROM and function quicker, no?

Well, maybe not, as this study showed comparing quadriceps to hamstring autografts. Supplementary analgesic drug was 38% higher in the hamstring group compared with the quadriceps tendon group.

Guess the hamstring option isn’t so painless!

 

Allograft Tissue

What about the ‘other’ graft choice that seems to be utilized a decent amount in the sports medicine and orthopedic world, the allograft.

Allograft tissue, or cadaver grafts, have recently become very popular in the United States for some reason, despite the numerous studies like this or this that show higher revision rates and graft stretching never mind the often under-reported cases of allografts being degraded by the body’s immune response.

I will say there is some research out there that is showing similar outcomes in allografts not chemically processed or irradiated when compared to autografts.  But we are still learning.

This study looked at outcomes and revision rate after bone-patellar tendon-bone allograft versus autograft ACL reconstruction in patients aged 18 years or younger with closed physes. They determined there was no significant differences in function, activity, or satisfaction were found between allograft and autograft reconstructions BUT the allograft group had a failure rate 15 times greater than that in the autograft group, with all failures occurring within the first year after reconstruction.

I’ve spoken to surgeons who have  reported almost no remnants of the previous allograft at the time of the revision surgery. It’s like the patient’s body completely rejected the graft.

That’s just a risk I almost never want to take.

I’d maybe consider an allograft for an older but active patient, say in their 50’s or 60’s but very rarely for an active person. I’d definitely not recommend an allograft to an athlete in their teens and 20’s although I have personally seen many kids present to me post- primary or revision surgery with an allograft reconstruction.

When I asked them why they chose it, they most often say: “it was recommended by the physician because I may be able to return to sports sooner and less pain.”

I could not disagree anymore and usually have to give them my dissertation on graft healing and the potential for graft rejection (as I mentioned previously).

Again, we think it takes several months longer for allograft tissue to incorporate itself compared to autograft tissue. There are very few reasons why someone should return their sport any quicker when the tissue is not fully incorporated, so why even consider it?

I very RARELY recommend an allograft for an ACL reconstruction. I frequently have to talk clients out of this option because the 1st thing they see or hear is there’s less pain. When they hear the whole story, they quickly realize an autograft seems to be the right choice.

 

Choosing the Right ACL Graft

Which autograft will depend on many factors but it seems like a patella tendon or quadriceps tendon may be the grafts of choice.

If you tore your ACL and are considering ACL reconstruction surgery, consider these factors when deciding which graft may be the most appropriate for you.

 

Learn How I Evaluate and Treat the Knee

If you want to learn even more about ACL rehabilitation, we discuss all of this this and much more in our online knee course at OnlineKneeSeminar.com where we teach you exactly how we evaluate and treat the knee.

 

2 Things PT Students Do That Drive Me Crazy

Over the years I have worked with countless physical therapy students, who have all been outstanding.  We have a pretty strict process to accept students at Champion PT and Performance now, as we want to assure that each student is a perfect fit.

There are two main points I try to drive home with all of our students over the course of their clinical rotation that I want to discuss.  I have been getting emails and seeing a lot of PT students on social media that are doing these two things…

And they are driving me crazy!

Once these two concepts “click” for our students, you can literally see them take off with their effectiveness.

 

1. Don’t Get Caught Up in Specific Systems

As a physical therapy student, I get it, the road ahead is a bit daunting.  You’ve learned so much in school, how do you apply it all?  And I would bet most still lack confidence in their skills.

The internet has really been sensationalizing systems.  However, you really need to be careful and avoiding selling your soul to one specific system.

I love systems.

In fact, we are working on making an educational program teaching you our systems at champion. But…

I’ve yet to find a system that is perfect and works 100% of the time for 100% of the people.

It’s easy to be influenced by the sensationalism, but realistically, you don’t have the clinical experience to know if a specific system is appropriate for you patient.

I see so many students going deep into a complex theoretical system, and then blindly defending it without the knowledge or experience to justify.

Take this as an example, imagine we have an athlete that strains their hamstring. I’ve heard people discuss all of this for treatment suggestions:

  • Educate them that it’s a perceived threat when elongating tissue
  • Work on improper breathing pattern and diaphragmatic function
  • Give exercises to help with asymmetrical pelvic orientation and rib cage position
  • Use corrective drills for lack of thoracic rotation

All of these things may have some merit, but you know what?

You forgot about the hamstring!

The athlete was rounding first base and considered going for a double when the outfielder made a great play, so they had to change direction quickly and accelerate back to the base.  They overloaded their tissue.

Want to know my system?

  1. Fix what’s broke
  2. Fix what’s suboptimal

Too many times we jump to the suboptimal and think working on the hamstring is ridiculous, as it’s not the true “cause” of the injury.  Well, it’s still injured, and that player wants to get back on the field ASAP.  Your job is to help them accomplish their goal.  If you spend more time on diaphragmatic breathing than facilitating healing of the injured tissue, you have this all backwards.

Realize I mentioned the athlete, as I work in the sport medicine and orthopedic world.  A general population orthopedic patient with chronic hamstring pain may benefit from working on the suboptimal first.

But I am seeing people literally mocking others for working on facilitating healing of the hamstring.

Keep an open mind and don’t sell your soul to one system.  You still have a lot to learn by experience what does and does not work for your patients.  Every patient population is different.

2. Learn How to Connect with People

The second thing that drives me crazy with physical therapy students is when they have no ability to connect with people.  Again, I get it.  You just had your nose in textbooks and practical exams for several years.

We’re all dorks.  Me too.

But you can’t talk over the heads of people.  If your primary focus is showing how smart you are, you are going to be in trouble.

You aren’t in a practical exam anymore, you can’t talk like a robot or scientist and expect to connect with people.  If you’ve ever worked with me, you know I fool around a lot.  I’m rarely serious.  But I know when I need to be serious and I know how to educate effectively.

You need to speak in a language that the patient can understand and relate.  I talk to my baseball pitchers about “throwing pens” and “pain in layback.”  I don’t ask if they have pain when they externally rotate their glenohumeral joint to end range of motion.

Remember the classic quote:

“Nobody cares how much you know until they know how much you care.”

That really applies to the field of physical therapy.  If you don’t connect with your patients, you won’t be as effective.

Read these books and think the whole time, “how can I apply this to working with a patient:”

 

Start Your Career in the Right Direction

PT students, read all the above one more time and let it sink in.

I promise, if you work on both, you will become a much more effective physical therapist.

I have an Inner Circle webinar that dives deeper into this topic, “5 Ways to Start Your Career in the Right Direction.”  These are the points I try to drive home with our students, and honestly, are things I wish I knew 20 years ago.

 

ACL Reconstruction Rehabilitation Protocol

 

Meniscus Repair RehabilitationRehabilitation following Anterior Cruciate Ligament Reconstruction (ACL) continues to be a exciting and popular topic in orthopedics and sports medicine.  Just pick up any journal and you are bound to find at least one article on the ACL in each issue!

Over the past decade, Kevin Wilk, James Andrews, and I have continuously adapted and expanded our preferred treatment guidelines following ACL reconstruction.  Kevin has published many classic manuscripts on the topic and we collectively have presented our treatment program several times in journal articles the last decade.

Since these publications, Kevin and I have continued to advance our rehabilitation protocol.

I am pleased to announce that we have officially just released our latest protocol for Accelerated Rehabilitation Following ACL Reconstruction with our latest protocols at RehabilitationProtocols.com.

But because our ACL reconstruction rehabilitation protocol is one of our most popular, we simple want to give it away for free!

But first, take a quick look at this video to see the building our our ACL protocols.  I share an inside look at our Rehabilitation Protocols:

 

 

 

 

Clinical Examination of Superior Labral Tears – What is the Best Special Test for a SLAP Tear?

**Updated in 2017**

What is the best test for a SLAP tear?  That is a pretty common question that I hear at meetings.

Clinical examination to detect SLAP lesions is often difficult because of the common presence of concomitant pathology in patients presenting with this type of condition. Andrews has shown that 45% of patients (and 73% of baseball pitchers) with superior labral lesions have concomitant partial thickness tears of the supraspinatus portion of the rotator cuff.  Mileski and Snyder reported that 29% of their patients with SLAP lesions exhibited partial thickness rotator cuff tears, 11% complete rotator cuff tears, and 22% Bankart lesions of the anterior glenoid.

The clinician should keep in mind that while labral pathologies frequently present as repetitive overuse conditions, such as those commonly seen in overhead athletics, the patient may also describe a single traumatic event such as a fall onto the outstretched arm or an episode of sudden traction, or a blow to the shoulder.  This is an extremely important differentiation you need to make when selecting which tests you should perform.

A wide variety of potentially useful special test maneuvers have been described to help determine the presence of labral pathology.  Lets review some of them now.

This article is part of a 4-part series on SLAP Lesions

Special Tests for a SLAP Tear

There are literally dozens of special tests for SLAP tears of the shoulder.  I am going to share some of the most popular SLAP tests.

 

Active Compression Test

active compression SLAP testThe active compression test is used to evaluate labral lesions and acromioclavicular joint injuries. This could be the most commonly performed test, especially in orthopedic surgeons.  I am not sure why, though, I do not think it is the best.

The shoulder is placed into approximately 90 degrees of elevation and 30 degrees of horizontal adduction across the midline of the body. Resistance is applied, using an isometric hold, in this position with both full shoulder internal and external rotation (altering humeral rotation
against the glenoid in the process). A positive test for labral involvement is when pain is elicited when testing with the shoulder in internal rotation and forearm in pronation (thumb pointing toward the floor). Symptoms are typically decreased when tested in the externally rotated position or the pain is localized at the acromioclavicular (AC) joint.

O’Brien et al found this maneuver to be 100% sensitive and 95% specific as it relates to assessing the presence of labral pathology.  These results are outstanding, maybe too outstanding. Pain provocation using this test is common, challenging the validity of the results. In my experience, the presence of deep and diffuse glenohumeral joint pain is most indicative of the presence of a SLAP lesion. Pain localized in the AC joint or in the posterior rotator cuff is not specific for the presence of a SLAP lesion. The posterior shoulder symptoms are indicative of provocative strain on the rotator cuff musculature when the shoulder is placed in this position.

The challenging part of this test is that many patients will be symptomatic from overloading their rotator cuff in this disadvantageous position.

  • Sensitivity: 47-100%, Specificity: 31-99%, PPV: 10-94%, NPV: 45-100% (a lot of variability between various authors)

 

Biceps Load Test

The biceps load testBiceps Load SLAP Test involves placing the shoulder in 90 degrees of abduction and maximally externally rotated. At maximal external rotation and with the forearm in a supinated position, the patient is instructed to perform a biceps contraction
against resistance. Deep pain within the shoulder during this contraction is indicative of a SLAP lesion.
The original authors further refined this test with the description of the biceps load II maneuver. The examination technique is similar, although the shoulder is placed into a position of 120 degrees of abduction rather than the originally described 90 degrees.  The biceps load II test was noted to have greater sensitivity than the original test.  I like both of these tests and usually perform them both.
  • Sensitivity: 91%, Specificity: 97%, PPV: 83%, NPV: 98% for Biceps Load I; Sensitivity: 90%, Specificity: 97%, PPV: 92%, NPV: 96% for Biceps Load II

 

Compression Rotation Test

Compression Rotation SLAP TestThe compression-rotation test is performed with the patient in the supine position. The glenohumeral joint is manually compressed through the long axis of the humerus while, the humerus is passively rotated back and forth in an attempt to trap the labrum within the joint. This is typically performed in a variety of small and large circles while providing joint compression when performing this maneuver, in an attempt to grind the labrum between the glenoid and the humeral head. Furthermore, the examiner may attempt to detect anterosuperior labral lesions by placing the arm in a horizontally abducted position while providing an anterosuperior directed force. In contrast, the examiner may also horizontally adduct the humerus and provide a posterosuperiorly directed force when performing this test.  I think of this test as “exploring” the joint for a torn labrum.  It is hit or miss for me.

  • Sensitivity: 24%, Specificity: 76%, PPV: 90%, NPV: 9%

 

Dynamic Speed’s Test

dynamic speeds SLAP testThe Speed’s biceps tension test has been found to accurately reproduce pain in instances of SLAP lesions.  I have personally not seen this to be true very often.

It is performed by resisting downwardly applied pressure to the arm when the shoulder is positioned in 90 degrees of forward elevation with the elbow extended and forearm supinated. Clinically, we also perform a new test for SLAP lesions.

Kevin Wilk and I developed a variation of the original Speed’s test, which we refer to as the “Dynamic Speed’s Test.”  (I came up with the name, what do you think?)  During this maneuver, the examiner provides resistance against both shoulder elevation and elbow flexion simultaneously as the patient  elevates the arm overhead. Deep pain within the shoulder is typically produced with shoulder elevation above 90 degrees if this test is positive for labral pathology.

Anecdotally, we have found this maneuver to be more sensitive than the originally described static Speed’s test in detecting SLAP lesions, particularly in the overhead athlete.  To me, it seems like you only get symptoms with greater degrees of elevation, making the original Speed’s Test less sensitive in my hands.

  • Sensitivity: 90%, Specificity: 14%, PPV: 23%, NPV: 83% for the Speed’s test

 

Clunk and Crank Tests

clunk crank slap testThe clunk test is performed with the patient supine. The examiner places one hand on the posterior aspect of the glenohumeral joint while the other grasps the bicondylar aspect of the humerus at the elbow. The examiner’s proximal hand provides an anterior translation of the humeral head while simultaneously rotating the humerus externally with the hand holding the elbow.  The mechanism of this test is similar to that of a McMurray’s test of the knee menisci, where the examiner is attempting to trap the torn labrum between the glenoid and the humeral head. A positive test is produced by the presence of a clunk or grinding sound and is indicative of a labral tear.

The crank test can be performed with the patient either sitting or supine. The shoulder is elevated to 160 degrees in the plane of the scapula. An axial load is then applied by the examiner while the humerus is internally and externally rotated in this position. A positive test typically elicits pain with external rotation. Symptomatic clicking or grinding may also be present during this maneuver.  These tests seem to do well with finding a bucket-handle tear of from a Type III or Type IV SLAP lesion more than anything else for me.

  • Sensitivity: 39-91%, Specificity: 56-93%, PPV: 41-94%, NPV: 29-90%

 

 

2 New(er) Special Tests for SLAP Lesions

In addition to the classic SLAP tests that have been described, there are two additional tests that gained popularity more recently.

I wanted share a video that I have on YouTube that demonstrates these two tests. These were actually published in a paper I wrote in JOSPT a few years ago, but I have modified them a little and wanted to share. These two tests are both excellent at detecting peel-back SLAP lesions, specifically in overhead throwing athletes, but are useful for any population. I share these two tests because I know that there is a lot of confusion regarding the “best” test. These may not be them, but in my hands, both have been extremely helpful and, more importantly, accurate.

Pronated Load SLAP Test

The first test is the “Pronated Load Test,” it is performed in the supine position with the shoulder abducted to 90° and externally rotated. However, the forearm is in a fully pronated position to increase tension on the biceps and subsequently the labral attachment. When maximal external rotation is achieved, the patient is instructed to perform a resisted isometric contraction of the biceps to simulate the peel-back mechanism. This test combines the active bicipital contraction of the biceps load test with the passive external rotation in the pronated position, which elongates the biceps. A positive test is indicated by discomfort within the shoulder.

 

Resisted Supination External Rotation SLAP Test

The second test was described by Myers in AJSM, called the “Resisted Supination External Rotation Test.” Dr. Myers was a fellow at ASMI and a good friend of mine, he really wanted to call this the SUPER test (for SUPination ER) but I was one of many that advised him against this for obvious reasons!

During this test, the patient is positioned in 90° of shoulder abduction, and 65-70° of elbow flexion and the forearm in neutral position. The examiner resists against a maximal supination effort while passively externally rotating the shoulder. Myers noted that this test simulates the peel-back mechanism of SLAP injuries by placing maximal tension on the long head of the biceps by supinating.

Myers’ study of 40 patients revealed that this test had better sensitivity (82.8%), specificity (81.8%), positive predictive value (PPV) (92.3%), negative predictive value (NPV) (64.3%), and diagnostic accuracy (82.5%) compared to the crank test and extremely popular O’Brien’s or active compression test. A positive test is indicated by discomfort within the shoulder.

 

When Do You Perform These Tests?

Now that you know a bunch of special tests for SLAP tears, the real key is understanding “when” to pick each test.  In my mind, they all are slightly different and may even be better at detecting different types of SLAP lesions.  I have an Inner Circle webinar that discusses this and shows you my clinical algorithm on how and why I perform special tests to diagnose a SLAP tear:

 

 

Learn Exactly How I Evaluate and Treat the Shoulder

shoulder seminarIf you want to learn even more about the shoulder, my online course at ShoulderSeminar.com will teach you exactly how I evaluate and treat the shoulder.  It is packed with tons of educational content that will help you master the shoulder, including detailed information on the clinical examination and treatment of SLAP tears.

 

 

 

Special Tests to Diagnose SLAP Tears

The latest Inner Circle webinar recording on Special Tests to Diagnose SLAP Tears is now available.

 

 

Special Tests to Diagnose SLAP Tears

This month’s Inner Circle webinar is on Special Tests to Diagnose SLAP Tears.  In this presentation, I review the many, many different SLAP special tests that exist and explain when and why you would choose certain ones for different people.

This webinar will cover:

  • Why there are so many different SLAP special tests
  • The common mechanisms of injury for SLAP tears
  • Why a good subjective history should lead your clinical examination
  • How to choose specific special tests for specific people
  • How to perform my most commonly used SLAP tests

To access this webinar:

 

 

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

There continues to be great debate over the most appropriate rehabilitation progression following rotator cuff repair. Although our surgical techniques have gradually progressed from full open repairs, to smaller mini-open repairs, to the current standard all-arthroscopic repairs, many clinicians continue to utilize the same rehabilitation guidelines from past invasive procedures.

And more confusing is the lack of consensus among surgeons regarding the optimal postoperative rehabilitation protocol following arthroscopic rotator cuff repair.  Protocols can vary as drastically as beginning gentle passive range of motion and isometric exercises post-operative week 1 to delaying 12 weeks for the initiation of similar exercises.

I want to share the postoperative protocol that I have developed with Kevin Wilk and James Andrews.

It details the postoperative guidelines that we have used since the shift to arthroscopic rotator cuff repairs several years ago. While there is still a lack of efficacy studies, these guidelines have proven to us to be both safe and effective in the rehab of 1000’s of patients at our clinics.

Before downloading the protocol, I want to explain the goals of rehabilitation and what I believe are the 3 keys to rehabilitation. These principles are the cornerstone behind the protocol you are about to download.

 

Goals of Rehabilitation Following Rotator Cuff Repair

When rehabilitating after an arthroscopic rotator cuff repair surgery, the main goals of the rehabilitation protocol should be:

  • Protect the integrity of the rotator cuff repair
  • Minimize postoperative pain and inflammation
  • Restore passive range of motion
  • Restore strength and dynamic stability of the shoulder
  • Restore active range of motion
  • Return to functional activities

Pretty simple, right?  When you lay it out like that, we simply combine those goals with what we know about the basic science of healing tissue and you can fill in the gaps and individualize a program based on the patient and your treatment preferences.

 

The 3 Most Important Keys to Rotator Cuff Repair Rehabilitation

Now that you understand the goals, I want to share what I consider the 3 most important keys to rotator cuff repair rehabilitation.  Follow the goals above and focus on these 3 keys and you’ll be well on your way to full functional recovery:

  1. shoulder-shrug-signRestore full passive ROM quickly. It is extremely easy to lose motion following surgery. In my opinion this is caused by scarring in the subacromial space as well as loss of the redundancy of the glenohumeral capsule with immobilization. This is one of the common “rookie mistakes” I see with students and new graduates. Passive range of motion should be initiated immediately following surgery in a gradual and cautious fashion. Studies have shown that passive range of motion into flexion and external rotation actually decreases strain in the rotator cuff repair (still need to be cautious with adduction, extension, and internal rotation).
  2. Restore dynamic humeral head control. This is likely the most important goal of postoperative rehabilitation, other than maintaining the integrity of the repair. What this means is to restore the rotator cuff’s ability to center the humeral head within the glenoid fossa. Have you ever seen a patient following repair that had a shoulder “shrug” sign? That is caused by the inability of the cuff to compress the humeral head and the resultant superior humeral head migration. This is why it is imperative to begin gentle isometrics, rhythmic stabilization drills, and other drills to re-educate the rotator cuff.
  3. Maximize external rotation strength. I often refer to external rotation as the key to the shoulder. Weakness of ER is common in almost every pathology and strengthening of the area is extremely important to balance the anterior and posterior balance of cuff. Several studies have shown that ER strength takes the longest amount of time to restore after rotator cuff repair. The longer this area is weak, the more difficult it will be to stabilize the joint.

 

 

Rehabilitation Protocol Following Arthroscopic Rotator Cuff Repair

physical therapy rehabilitation protocolsIf you are interested in using the protocols that I have helped develop with Kevin Wilk and Dr. James Andrews, we have recently revised and expanded all of our protocols and made them completely online and downloadable.  Our physical therapy rehabilitation protocols have been published in several journals over the years and based on our decades of research, scientific evidence, and experience.

They are the most widely used and respected rehabilitation protocols today.

Want to see what our protocols include?  You can download our 3 most popular protocols for FREE:

  • Accelerated rehabilitation following ACL reconstruction using a patellar tendon autograft
  • Rehabilitation following arthroscopic rotator cuff repair for a type II medium-large sized tear
  • Thrower’s ten exercise program

 

physical therapy rehabilitation protocols online accessOur entire collection includes over 175 nonoperative, preoperative, postoperative protocols for shoulder, elbow, hip, knee, foot, and ankle.  There are several variations of many protocols to account for many specific procedures and concomitant surgeries.  Plus, we have several of our exercise handouts and interval return to sport programs.

If you work in an outpatient orthopedic or sports medicine clinic, these protocols are an invaluable resource to help guide your treatment approach.

 

 

 

Is it Time to Finally Ditch Using Rehabilitation Protocols?

The use of rehabilitation protocols in physical therapy continues to be common practice.  I recently performed a quick survey of my readers and they mostly agree.  The majority still follow protocols:

do you still use rehabilitation protocols

 

However, a recent trend on social media has been to criticize these guidelines and those that follow them.  Students are even coming out of college shunning the use of protocols.  I’ve heard so many complaints over the years, like:

  • We need to use our brains, not follow a piece of paper
  • Physical therapists shouldn’t follow a cookbook
  • Physical therapy isn’t black and white
  • We need individualize our treatment approach

I completely understand and agree, to an extent at least.  As a physical therapist (or other rehabilitation specialist), we’ve spent a lot of time and energy learning how the human body functions.  We’ve spent countless hours (and dollars…) becoming a physical therapist and mastering our craft.  We’ve spent years refining our skills based on our experiences and patient outcomes.

We should be using our brains and individualizing programs based on each person.

But rehabilitation protocols can help us do this better if used properly.  To highlight this, it helps to break down exactly what rehabilitation protocols are, and are not, in physical therapy to best understand how we should be using them in our practices.

 

Rehabilitation Protocols Are Not Cookbooks

physical therapy cookbookLet’s get this point out of the way first – rehabilitation protocols are not designed to be complete cookbooks.  This is where a physical therapist can often become paralyzed by the protocols, thinking that they can’t do anything that isn’t specifically listed in the protocol.

Realistically, the purpose of a good rehabilitation protocol is to clearly define the goals, precautions, and timelines to gradually apply load to healing tissue.  These are designed based on our understanding of the basic science of the healing process.

There is a still a huge gray area between what you definitely SHOULD be doing and what you definitely SHOULD NOT be doing.

Think of this as your opportunity to customize your recipe and make your own sandwich.  You need to put bread on both sides, but what meat, cheese, and condiments you put between the slices of bread will depend on the patient, your training, and your experience.  You may have your own preferences, as will I.

I often do things that are not specifically listed in a protocol with my patients that I know are in alignment with the goals and precautions of the protocol.  A good example is working the soft tissue of the traps after rotator cuff repair or including core training in the early phases of ACL rehabilitation.  Just because they are not specifically included in the protocol, doesn’t mean you can’t perform them.

Rehabilitation protocols are the foundation of your program, which should be adjusted based on:

  • The unique goals of each person
  • The specific injury or surgery
  • Any concomitant injuries, which are common

 

Rehabilitation Protocols Are Guidelines Following Injury

A common misconception regarding protocols is that they are concrete rules, instead of guidelines.  All of the nonoperative rehabilitation protocols that we have produced over the years are intended to be a way of guiding you through the steps of returning a patient from an injury.

In fact, many don’t even have strict timelines associated with them, but rather phases with criteria to progress.  For example, here’s what some of the goals of each phases would be when rehabilitating a baseball player that has a Tommy John injury:

  • Phase 1: Facilitate healing, restore range of motion, develop baseline strength and proprioception
  • Phase 2: Maintain range of motion, maximize strength a dynamic stability
  • Phase 3: Gradually apply load to tissue, progress to sport-specific dynamic activities
  • Phase 4: Return to sport progression

Looking at the above phases, you can use these guidelines to determine what is and what is not appropriate for each phase.  This is where your personal preferences can come into play.  I like spicy mustard on my ham and cheese, you like yellow mustard.  I won’t judge.  They are both appropriate.

Postoperative is different, and we’ll discuss that more below, but for nonoperative this is how you should use a protocol.  For nonoperative injuries there are times that you may want to limit an exercise or activity for a certain amount of time, however more often than not, nonoperative rehabilitation protocols are used to divide the rehab sequence into manageable chunks.

 

Rehabilitation Protocols Are Needed Following Surgery

knee rehabilitation protocolOne area that I feel strongly about is the definitive need for rehabilitation protocols after surgery.  Rehabilitation protocols are very important components of postoperative physical therapy.  Certain standards of care following a surgery must be set and communicated to assure patients progress appropriately after surgery.

Many of these may be surgeon specific, meaning that certain doctors will want you to go faster or slower based on their experience.  As physical therapists, we must respect these guidelines from the operating surgeon.  They know their surgery and the inside of your patient better than you do.

After surgery, protocols are used to assure we protect, facilitate healing, and gradually applied load to the injured tissues.

Simply winging it and not following a protocol will give you the least likely chance that you return the person as quickly and safely as possible.  For example, you don’t want too much or too little shoulder range of motion at 6 weeks follow an anterior labral repair, both can be disadvantageous.  A well designed postoperative rehabilitation protocol will put the patient in the best position to succeed.

As a young clinician, it’s also hard to prioritize the precautions and restrictions of complicated patients.  For example, our rehabilitation protocols have 13 variations of rotator cuff repair protocols and 16 variations of ACL reconstruction protocols.  We change the guidelines based on several factors and concomitant injuries.  This is a must.

 

 

Is it Time to Finally Ditch Using Rehabilitation Protocols?

I really don’t think so, in fact, I am a huge believer in rehab protocols when used correctly.  I think it’s very shortsighted to dismiss protocols as being bad for our profession or something that we are above using.

However, a protocol simply gives you guidelines as to what you can and can NOT do.  What you “can” do is not restricted to what is within the protocol.  Think of them as guidelines to assure that you are not going too slow or too fast.  Realistically, a protocol does not list every treatment and exercise that should be included.  This is where your skill and experience comes into play.  You must determine what other interventions you can safely perform to help the patient, while assessing if that chosen intervention fits safely within the protocol restrictions.

We should not follow a rehabilitation protocol without thought, that is not “skilled” physical therapy.  However, we must appreciate the timelines often associated with the protocols and healing tissues.

The true expert clinician realizes this and combines the guidelines of a rehabilitation protocol with their vast experience and treatment preferences.

 

Want to Use My Protocols?

physical therapy rehabilitation protocolsIf you are interested in using the protocols that I have helped develop with Kevin Wilk and Dr. James Andrews, we have recently revised and expanded all of our protocols and made them completely online and downloadable.  Our protocols have been published in several journals over the years and based on our decades of research, scientific evidence, and experience.

They are the most widely used and respected rehabilitation protocols today.

Want to see what our protocols include?  You can download our 3 most popular protocols for FREE:

  • Accelerated rehabilitation following ACL reconstruction using a patellar tendon autograft
  • Rehabilitation following arthroscopic rotator cuff repair for a type II medium-large sized tear
  • Thrower’s ten exercise program

 

physical therapy rehabilitation protocols online accessThe entire collect of Wilk, Reinold, and Andrews physical therapy rehabilitation protocols includes over 175 nonoperative, preoperative, postoperative protocols for shoulder, elbow, hip, knee, foot, and ankle.  There are several variations of many protocols to account for many specific procedures and concomitant surgeries.  Plus, we have several of our exercise handouts and interval return to sport programs.

If you work in an outpatient orthopedic or sports medicine clinic, these protocols are an invaluable resource to help guide your treatment approach.