6 Hip Mobility Drills Everyone Should Perform

Recently, I have seen dozens of social media posts with “advanced” hip mobility drills that made me stop and think…

Should we actually be seeking to perform these advanced variations?

I would argue most people still need the basics, and should incorporate just a handful of more simple drills as the foundation of their mobility drills.

The internet is famous for sensationalizing the drills that look “fancy” rather than the ones that are likely the most effective.  It’s probably another case of the Pareto Principle, where 80% of the drills seen online should only be performed 20% of the time, and conversely, 20% of the drills seen online should be performed 80% of the time!  Heck it may be even less than that when it comes to hip mobility.

To make matters worse, the more advanced hip mobility drills are probably inappropriate for most people.  In my experience, limitations in hip mobility seem to be more related to the individuals unique anatomy, boney adaptations, and alignment rather than simple soft tissue limitations.  So, forcing hip mobility drills through anatomical limitations is just going to cause more impingement and issues with the hips, rather than helping.

Sometimes less is more.

 

My Favorite Hip Mobility Drills

I wanted to share my favorite hip mobility that I use with most of my clients.  I think you should really focus on these hip mobility drills before proceeding to more advanced variations.  If these don’t do the trick, it’s probably best that you seek out a qualified movement specialist to assess the reason behind you hip mobility limitations, rather than forcing more drills.

 

Quadruped Rockbacks

The first drill is a quadruped rockback.  This is one of my favorite drills for the hips, and feels great to loosen up the adductors and hip joint into flexion.  Plus, I do these barefoot to get more dorsiflexion and great toe extension.

 

Adductor Quadruped Rockbacks

The adductor quadruped rockback is a variation of the rockback that involves straightening out one hip.  This takes away a little bit of the hip flexion benefit, but enhances the effect on the adductors.  Performing this on both sides is the best of both worlds.

 

True Hip Flexor Stretch

The true hip flexor stretch is probably the most fundamental hip mobility drill we should all be performing.  I started calling it the “true” hip flexor stretch because the more common versions of this do not lock in the posterior pelvic tilt and just end up torquing the anterior capsule.

 

Posterior Hip Stretch

The posterior hip stretch feels great on the glutes and hits the posterior hip area, which is often tight.  Many people feel like the can get into a hip hinge much better after this drill.

 

Figure 4 Stretch

The posterior hip is a complicated area of muscles, I often pair the figure 4 stretch with the posterior hip stretch above to get different areas.  For me, I simple go by the feedback from my client on what feels more effective for them.

 

Spiderman

The Spiderman hip mobility drill is likely the most advanced of this list, which is why I have it last.  This is something I don’t always perform right away, but is a goal of mine to integrate with everyone eventually.  This requires more hip mobility that the others, so acts as a nice progression to put these all together.

 

How to Get Started with Hip Mobility Drills?

So wondering how to get started?  Start with the quadruped rockbacks and hip flexor stretch.  Those two are very foundational and will be the most impactful for most people.  Once you get those down, progress to the posterior hip stretch and figure 4 to hit more of the posterior aspect of the hip.  Lastly, progress to the Spiderman drill.

I honestly don’t think you need much more than that, and if you seek to get too aggressive with hip mobility drills, you often make things worse.

 

 

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.