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Measuring the Position and Mobility of the Patella

Measuring the position and mobility of the patella is still a very important component of my clinical examination of the knee.  It gives me a great sense of soft tissue restrictions that may be present when patellar hypomobility is noted.  This is especially common after knee surgery.  But measuring patella mobility is also important to assess generalized laxity when patellar hypermobility is observed.

The first time you feel either of these during your clinical exam, you’ll know what I mean.

But if you read through the literature, you may find conflicting results regarding the validity and reliability of assessing patella position and mobility.

The Reliability of Measuring Patella Mobility

One study that I reference often is a systematic review by Smith, who looked at the reliability of assessing patella position, specifically in the medial-lateral position.  Like any examination technique that is commonly performed, it is necessary to establish that the test has adequate intra-rater and inter-rater reliability. The test needs to be easily replicated and produce accurate results both between two different clinicians but also when repeated during re-evaluation with the same clinician.

Otherwise, the test may have limited use and not be able to provide helpful information.

The authors conclude the intra-tester reliability is good to assess medial-lateral patellar position, but inter-tester reliability was variable.  The variability is interesting to me and makes me wonder if we just aren’t standardizing how we look at patella mobility.

Another study by Herrington demonstrated that a group of 20 experienced therapists could reliably measure patellar position.  This tells me that a group of similar trained or skilled clinicians will show greater inter-tester reliability than a randomized selection of clinicians.  When I see that a test has good intra-tester and worse inter-tester reliability, I think one of two things:
The test is difficult to perform and/or is more accurate with more experience.

Reliability can be enhanced if we all use the same examination techniques. There may be subtle differences in techniques that may produce poor inter-tester reliability. This is what came to my mind when the Herrington study showed good inter-tester reliability with a group of experienced clinicians.

The Validity of Measuring Patella Mobility

In regard to validity of the measurements, the authors conclude that the criterion validity of this test is at worse moderate, based on limited evidence.  However, a couple of interesting studies were referenced.  A study by McEwan demonstrated that a lateral tilt of the patella greater than 5 degrees can be detected.  This was confirmed with MRI measurements.  The previously reported study by Herrington also reported that medial-lateral patellar position could accurately be measured as confirmed by MRI measurements.

A Simple Way to Measure Patella Mobility

It appears that clinical measurements of patellar positions can be both reliable and valid.  While intra-tester reliability, or your own ability to accurately repeat a test, appears to be more accurate, inter-tester reliability may be enhanced with a standardized examination technique.

Taking all this into consideration, I honestly do not try to “measure” patellar position.

I will assess the position but I do not try to place a label, such as millimeters or degrees, on the exact position.  If I want or need this information, I would much rather obtain this from a MRI.  I focus more on assessing the amount of hypomobility or hypermobility.

And there is a really simple way that we can do this that I think will great enhance our reliability.

To simplify this measurement, I try to just use a percentage of the patella that I feel can displace.  Here is how I do it:

  1. I break the patella down into 4 equal segments representing 25% of the width of the patella each.
  2. I visually try to establish where I believe the midline of the trochlea is located when I am measuring position.  If I am measuring displacement, I will visualize the edge of the lateral trochlea.
  3. I then measure the percentage of the patella that is positioned beyond the midline of the trochlea and then displace the patella and attempt to determine if 25%, 50%, 75%, or 100% of the patella can displace beyond the lateral edge of the trochlea, as in the image below:

Measuring the Position and Mobility of the Patella

I’ve learned over the years that knee experts, such as Dr. Frank Noyes, consider 50% displacement to be “normal.”  I use that as a frame of reference, but comparing side-to-side is probably even more important.

I feel that this provides me with plenty of information to compare to the other extremity and simplifies the process, which I hope would enhance intra- and inter-tester reliability.  If we all do it this way, I think we’ll be far more accurate.

What do you think? Is this too simple? How do you measure patellar mobility?

 

Return to Play Testing After ACL Reconstruction

This week’s article is a guest post from Lenny Macrina.  Lenny discusses a really important topic right now regarding the safe return to sport after ACL reconstruction.  Are we returning people too fast? If you want to learn exactly how Lenny and I return people after ACL reconstruction be sure to check out our acclaimed online program on the Evaluation and Treatment of the Knee.

 

ACL reconstruction surgery continues to dominate the sports medicine and orthopaedic world. Research surrounding ACL surgery is abundant and I have written about it in previous posts on LennyMacrina.com and for Mike on his website. It’s an important topic because of the lack of general consensus on what’s the best way to assess return to play testing, never mind the relatively high failure rates.

For this post, I wanted to discuss the return to play testing after an ACL reconstruction to see what the literature says. I’m not going to lie, I don’t have a formal algorithm like some. I have people hop, skip and jump but don’t necessarily do a formal hop test.

I believe in slowly returning my athletes to their sport in a time that is safe. I carefully watch them move, advance their strength and power exercises and chat about how they feel about their knee.

With that, I wanted to do an extensive literature search to figure out what was the best way to truly test our athletes to determine their readiness.

Is there a best algorithm that will decrease retear rates? If so, why are we not using it for injury reduction programs…or are we?

 

Risks for ACL Reconstruction Failure

The risk of a second ACL injury in a young, active individual is high after a previous ACL reconstruction and return to sport.

Paterno and his group reported 23.5% of young, active patients suffered a second ACL injury in the first 12 months after RTS following ACLR.

Another study by Paterno and his colleagues showed 37.5% suffered a non-contact retear within 24 months after the initial reconstruction.

Surprisingly enough, this group also reported that 29.5% of young, active athletes who returned to cutting and pivoting sports after an ACL reconstruction suffered a second ACL injury 24 months after return to their sport.

A recent review by Wiggins et al showed that young, active athletes are at greater risk to suffer another ACL injury after ACL reconstruction and return to sport compared with uninjured adolescents.

With retear rates so high, there has to be a better strategy to get our athletes back to their sport safely.

 

ACL and Kinesiophobia

We know the mental component involving fear of movement/reinjury, or kinesiophobia, is often the last to come back for the athlete. A good majority of patients have some form of kinesiophobia after an ACL reconstruction and we need to be able to address that too. Numerous studies have shown this and it definitely needs to be understood and addressed as the program is progressed. Here’s another one for you to check out.

Those are just a couple of articles that discuss the self-reported fear that is involved in an athlete’s head. My pubmed search gave me 36 total articles that you may want to check out here.

There’s no denying the power of the mind when a return to play decision has to be made. I want them feeling as strong and confident as possible. It takes time and the days of trying to return someone back in 4-6 months seems to be a thing of the past. I did it.

Some self-reported outcome measurements that are commonly used are the TSK-11, known as the Tampa Scale for KInesiophobia. This is a shortened version of the original TSK-17 that was published previously.

 

 

Another questionnaire that can be use is the ACL-RSI or the Return to Sport after Injury Scale. It is used to assess psychological impact that may be in the athlete’s head. The goal of the questionnaire is to the athlete’s emotion, confidence and self-risk appraisal.

There are many other tools out there that can gauge a patient’s knee function such as the IKDC, KOOS, VAS scale, Lysholm, Tegner, and the Cincinnati Knee Scoring scale. I just wanted to add those in as an informational thing but they don’t necessarily measure the psychological component ad readiness for return to play.

 

Slow and Steady ACL Rehabilitation

I’ve gotten high school seniors back to their sport quickly and bragged about it. Despite their isokinetic test being marginally ok, the docs would clear them because of other circumstances. It’s the last game of the season or it’s their senior year or they made the playoffs and the team ‘needs them.’

It seems as if the literature supports some form of formal testing but there is no clear answer, in my opinion.

The tests that many currently utilize in the clinic have just never felt right to me. I’m not sure we can simply do some hop tests or a step down test and have enough information to decide on whether an athlete is ready to return to their sport. Both tests are in the sagittal plane and don’t account for fatigue or other planes of movements such as the frontal plane (side to side) or transverse plane (rotational motions.)

Never mind that when we are comparing the involved leg to the uninvolved leg during functional testing to determine limb symmetry index (LSI), are we inherently flawed? Does the strength and proprioception of the uninvolved leg diminish months after the ACL reconstruction which makes our battery of tests invalid by inflating the LSI?

 

Rethinking the Way We Determine Return to Play After ACL Surgery

Delaware researchers seem to think that the LSI can overestimate knee function after an ACL surgery. They have shown that doing baseline functional tests soon after the ACL tear gives a better estimate of the body’s strength and functional output.

So if we’re using the uninvolved leg as the comparison leg and it has undergone strength and proprioceptive changes during the 6-12 months of rehab, are we flawed from the start and our LSI testing is invalid and over-estimates an athlete’s return to play?

Maybe that’s one reason why our retear rates are so high.

 

Physical Therapy Is Not Good at Advanced Stage Rehab

Never mind the pink elephant in the room…  many PT’s are poor at prescribing higher level exercises. We just don’t see people past 8-12 weeks after surgery because of insurance visit limitations. We don’t have experience or the access to these patients once they’re discharged from PT.

It’s at this point that the real strength, power, endurance and agility activities really take shape. Unfortunately, most patients are on their own or working with other professionals. It is key that we maintain our relationships with other fitness professionals so we can influence and guide the later-stage rehab process.

But we often don’t, sadly.

It’s a long process, longer than we think and longer than the patient wants it to be.

 

Should We Delay Return to Sport Longer Than 12 Months?

This article talks about how the rehab is multifactorial and can often take 1-2 years to feel comfortable enough.

Even renowned ACL researcher Tim Hewett, known for his injury reduction programs, has advocated for a 2 year return to sport in one of his latest papers.

Most are not functionally ready to return to their sport even though they are cleared by their surgeon. It seems as if time is the number one decision maker and not necessarily functional tests of strength power and endurance.

This paper showed that at 6 months, 2 patients (3.2%) passed all criteria. At 9 months, seven patients (11.3%) passed all RTS criteria. Patients improved in all RTS criteria over time except for the IKDC score. Twenty-nine patients (46.8%) did not pass the strength criterion at 60°/s at 9 months after ACL reconstruction.

While this research paper looked at younger athletes cleared for sports participation After an ACL Reconstruction.  Only 13.9% of the participants passed all of the criteria (IKDC, quadriceps and hamstring strength limb symmetry index (LSI), and single-leg hop test) 1 year after surgery

This study looked to assess the changes over time in patients tested at 6 months and 9 months after ACL reconstruction.  At 6 months, only 2 patients (3.2%) passed all criteria. At 9 months, 7 patients (11.3%) passed all criteria.

What if they had a previous ACL tear and then they subsequently tear the contralateral side? What does the PT use for an index?

A study by the Zwolski group that the use of LSI’s during strength and performance tests may not be an appropriate means of identifying residual deficits in female patients after bilateral ACL reconstruction. They also concluded that “a better indicator of strength performance in this population may need to include a comparison of strength performance values to the normative values of healthy controls.”

There seems to be a persistent issue with getting the quadriceps muscle to return in our athletes. Despite our efforts, there seems to be a neuromuscular component that requires time and persistence.

This study showed that in patients an average of 7.5 months out of surgery demonstrated nearly a 30% weakness. They said diminished motor neuron recruitment or decreased motor-unit–firing frequency was likely contributing to reduced isometric quadriceps strength and interlimb asymmetries.

Another study looked to compare adolescent athletes ages 15-20 years old with adults ages of 21-30 years old. At the 8-month follow-up, 29% of the patients, in both age groups, who had returned to sport had recovered their muscle function in all 5 tests of muscle function (unilateral vertical hop; unilateral hop for distance; and unilateral side hop, isometric quad at 60° and knee flexion at 30°.) At the 12-month follow-up, the results were 20% for the adolescents and 28% for the adult patients.

Again, a large strength deficit at 12 months post-surgery despite our objective testing.

Never mind that most of these studies lum everyone together and don’t account for graft differences. In my opinion, we need to consider graft type as another variable that could contribute to retear rates and return to sport testing. I talked about graft selection in this blog post.

 

How Do We Determine When Safe to Return to Sports?

That’s the million dollar question. There are a few common ways that we can determine when it is safe to return to sports after ACL reconstruction.

 

Isokinetic Testing 

Isokinetic testing has been used for many years and seems to be valid and reliable. Although ths recent systematic review in BJSM stated that  isokinetic strength measures have not been validated as useful predictors of successful RTS.

Oh great, now what?

Don’t forget, back in 1994 Kevin Wilk and his group looked to determine if a correlation exists between three commonly performed clinical tests: isokinetic isolated knee concentric muscular testing, the single-leg hop test, and the subjective knee score in anterior cruciate ligament reconstructed knees. They noted a positive correlation was noted between isokinetic knee extension peak torque (180, 300 degrees/sec) and subjective knee scores, and the three hop tests (p < 0.001).

The problem lies with many clinics having limited access or just don’t use them anymore.

Because of that, we’ve had to adjust our thinking and use ground based testing such as hop tests, isometric strength testing and agility tests.

The research says that “athletes who did not meet the discharge criteria before returning to professional sport had a 4x greater risk of sustaining an ACL graft rupture compared with those who met all 6 RTS criteria (isokinetic strength testing at 60°, 180° and 300°/s, a running t-test, single hop, triple hop and triple crossover hop tests.) In addition, hamstring to quadriceps strength ratio deficits were associated with an increased risk of an ACL graft rupture.

This study says that the single hop for distance and ACL-RSI were found to be the strongest predictive parameters, assessing both the objective functional and the subjective psychological aspects of returning to sport. Both tests may help to identify patients at risk of not returning to pre-injury sport.

 

Hand-Held Isometric Strength Testing

This is another test that is commonly used in return to sport testing after an ACL. I think it could be used but it gives limited information and can be painful if not done correctly. The painful response has been shown to statistically influence outcomes and needs to be modified to prevent alterations in true quadriceps force generation.

Also, the measurements using a hand held dynamometer are often lower than what can be obtained with an isokinetic device, as seen in this study.

I know many use hand-held dynamometry but I just can’t see its value as a return to sport test that is valid.

There are just too many questions about where to put the device to minimize pain while kicking. Also, at what angle do we place the knee to best isolate the quadriceps? Ninety degrees or 60 degrees of flexion? Research seems to look at both methods.

Plus, does a concentric, isometric contraction REALLY give us the information that we truly need to make an informed decision or have we sought a cheaper alternative to isokinetics and embraced it. We PT’s are suckers for the easiest way to diagnose, treat and test and often miss the big picture.

Research can guide us but common sense and experience must play some role as well.  

 

Hop Tests to Determine Return to Play

Hope tests are often utilized by rehabilitation specialists to determine an athlete’s ability to generate and dissipate a force when compared to their contralateral knee. As far as I can see, Noyes was one of the 1st to talk about hop tests in the literature in 1991.

Four common tests are utilized and reported in the literature. They include single leg hop for distance, triple hop for distance, crossover hop for distance and 6-meter time hop. The general rule is to obtain an LSI ≥ 90% compared to the reference limb.

 

As usual, both limbs are tested and the uninvolved limb is used as the reference, which we mentioned previously as an inherent potential flaw (the Delaware study.)

Using these tests can help the rehab specialist reduce ACL re-tears as noted in this study from BJSM in 2016. They showed reinjury rates were “significantly reduced by 51% for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed.”

Furthermore, 38.2% of those who failed RTS criteria involving hop tests and quad strength symmetry within 10% suffered re-injuries versus 5.6% of those who passed all of the testing criteria.

 

Closing Thoughts on ACL Return to Sport Testing

My research has confounded my thoughts even more and added to the questions. It seems as if there is no clear way to determine readiness to return to sport after an ACL. Our testing seems somewhat flawed and despite our efforts, ACL retear rates are too high.

To simply say it comes down to strength is not enough. We’re so focused on quadriceps strength that we’re missing the big picture. Of course the quadriceps are highly important, bt don’t forget about hamstring:quadriceps ratios, gluteus strength, force attenuation, and fatigue-state rehab.

Never mind there’s the mental component and the ability to attenuate forces in game situations. These are things we cannot truly test.

We’re missing something but it does seem that the time-based scenario may be an option to consider, meaning they need to stay out of their sport for at least 9 months, and ideally 12-24 months, or as long as they are continually doing their progressive strength training.

I think therein lies the answer. As physical therapists, we don’t do a very good job at advanced strength training and periodization. We can learn a lot from our fellow strength coaches. Plus the fact that the athlete is all too eager to return to their sport without fully understanding the consequences.

Despite all of our testing, we continue to show poor outcomes even 12+ months after reconstruction. I can’t blame the tests, right? It’s the preparation for the tests that seems to be lacking.

What do you do to test your athletes when they’re considering a return to their sport?

 

Learn Exactly How We Evaluate and Treat the Knee

online knee seminarIn our online course at OnlineKneeSeminar.com we discuss the many pathologies of the knee, including ACL reconstruction. We outline a progressive program that starts preoperative and goes until the athlete is ready to return to their sport.  If you are interested in learning are full approach, our course has a lot to offer. You’ll learning exactly how we evaluate and treat the knee and become an expert at knee rehabilitation.

 

 

4 Things I Learned in 2017

Each year I try to always look back and reflect on what I have learned and changed in my life, both personally and professionally. We really put a priority on personal development at Champion. This helps me to grow and evolve as I learn each year, plus, helps me set goals for the upcoming new year.

If you don’t also reflect back on what you have learned and changed, I think you are missing out on a huge opportunity to grow.  Too many people in our fields spend all their energy defending their beliefs instead of keeping an open mind and evolving.

I’ll share some of the things I learned in 2017, but if you are interested, I’d love to read in the comments what you have learned that has changed your approach this year. By sharing, we can all grow.

Ego is the Enemy

Early in the year I read a great book called Ego is the Enemy, by Ryan Holliday. I thought it was great and had a big impact on my year.

Usually when we think of ego, we think of it in a bad way. But that’s not always the case and not what I took from the book.

Being egotistical all the time can be bad, but often times we just do things for the wrong reasons, that I believe often limit us and inhibit our growth.

I actually used this mindset a lot this year, and said “no” more than any past year in my career. I am a big fan of establishing goals. If a project wasn’t right and didn’t ultimately lead to my goals, I said “no.” In the past I have felt like I have always said “yes” to everything for the fear of missing out. That to me was saying “yes” for my ego.

From a business perspective, think of it this way, rather than building a new service for your facility to make money or gain notoriety, or essentially to boost your ego, build a new service to actually help people achieve their goals.

It’s surprising to me when I clearly see people advertise things that are clearly just for them, not for the consumer. If your motivation behind the program is sincere, things will always work out better for you, and you’ll make that money and gain that notoriety organically.

EliteBaseballPerformance.com is a great example of this concept for me. I started the website because I was sick of all the garbage and marketing around baseball development that I saw online. We needed a trustworthy place for information for players, parents, coaches, and rehab/fitness specialist.

I didn’t start it to make money, in fact I’m well in the hole financially, I did it to help the game of baseball, which I’m passionate about. Will we offer products on it in the future and make money, sure, but we won’t offer these products with the goal of making money, that will be the side benefit. We’ll offer them to help our mission and the game of baseball.

We also did this when we launched our new Elite Pitching Performance Program at Champion this winter. We could have charged triple what we did, but it wasn’t about the money, it was about giving back to the local teams in the area and building what I believe is the best and more comprehensive pitching development program in the country. It wasn’t about my ego, it was about helping these kids achieve their goals, heck their dreams, by taking their baseball career to the next level.

This year I really reflected on my decisions and said, am I doing this for the right reasons, or for my own ego?

Simple is Still Better

Man, are we getting carried away in the rehab and fitness fields with the latest trends and fads. It seems like every day there is a new post on social media that blows my mind by taking such huge leaps in rationale.

I’ve always been complimented on my presentations for one main reason – people have told me I make the complicated more simple.

As social media continues to become a contest of who can make simple things more complicated, I’ve been doing the exact opposite.

Students are graduating school right now with set mindsets and opinions that complicated systems are the definitive answer. Wow, I wish everyone realized there are no definitive answers.

But more alarming to me is that they haven’t learned how to actually treat a shoulder, yet think the first thing they must tackle is diaphragmatic breathing. Sure, that may be important but is that your primary focus? Is that how you want to spend your VERY limited time with your client?

At Champion, we always focus on the low hanging fruit first. You’ll hear us say that a lot.

I’ve talked about this in the past with things like the concept Kinetic Chain Ripple Effect and my post on The Problem with the Kinetic Chain Concept. Sure, it stinks that your left big toes doesn’t extend. But there are about 50 other things I would work on first that will be more impactful for someone with shoulder pain.

Students and new grads – Master the basics first, then expand your approach to focus on the more complicated. You’ll get much better results.

As I look back on the year, I’m focusing on the basics and keeping it simple more than ever, and I believe my outcomes just keep getting better.

Our Assessments Must Have 2 Components

When I first started physical therapy school more than 20 years ago, we were a very “joint-based” profession. We weren’t thinking globally and we were very focused on the person’s symptoms.

Over the last couple of decades, the “functional” approach has taken priority with a focus on movement quality, which is great.

At Champion this year, we took a big step back and assessed our own evaluation process. We essentially said, each of our evaluations must have two components:

  1. A structural examination
  2. A movement assessment

Our treatment sessions and our performance programs all focus on both. If you are still focused on only one of these, you are really missing the boat.

As with anything, pendulums shift and we are probably starting to lean more towards the movement side of the assessment on our profession.  But, I think this will come back to the middle at some point.

You must look both structurally and functionally.

The Right Way to Use Social Media

I’m really proud of so many young professionals getting themselves out there on social media. I believe that sharing our knowledge is a key component of our own personal growth.

But, I’m not sure most are doing it right, or least what I would consider “right.”

I’m not sure we need another post on the plank, and I’m not sure we need to be making our own “quotes” as if we are all brilliant prophets.

I want to see more people educating and making posts for their clients.

This year I tried to keep it simple and not about my ego, make it more about helping people (see the recurring themes from above?). Remember, we are in a service industry.

Want some examples of people I think doing it right?

Here are some links to Instagram profiles you should follow and model yourself after, like I have:

  • @achievefitnessboston – My friends Jason and Lauren Pak may have the best IG account going right now, with excellent quality content.  Their approach to things like making strength training less intimidating to the masses is a great example of people doing it right through education and focusing their posts on helping people, not themselves.
  • @shiftmovementscience – Dave Tilley shares his passion about improving gymnastics.  Not 1 ounce of what he does is about his ego, it’s about the athletes he helps and the sport he loves.  
  • @fitnesspainfree – Dan Pope has been sharing his knowledge and walks the walk about high level fitness athletes.
  • @syattfitness – It’s been fun to watch Jordan build his online presence, sharing a TON of simple but impactful content
  • More of our crew at Champion, and some newbies to the online world are @lenmacpt, @kieferlammi, and @mikescadutodpt, who are building their online presence the right way with great educational content from the start.

What Have You Learned?

Now’s a great time to reflect on what you have learned this year. Again, I would love to hear about it in the comments below, but even if you don’t share I encourage you to reflect on the past year on your own.

Good luck in 2018!

 

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.

 

5 Ways to Decrease the Risk for an ACL Injury

Injuries to the Anterior Cruciate Ligament (ACL) are some of the most common injuries in the active population. As incidence of other injuries have decreased, injuries involving the ACL have rose astronomically over the years.  There have been numerous studies done looking at what causes the ACL to tear. More specifically, female athletes are 4-5x more likely to tear their ACL as compared to their male counterparts.

Like with any injury, it cannot be blamed on one thing. Injuries are multi-factorial as well as non-preventable.  Injuries will always happen.  The only thing that we can do is to decrease the frequency or incidence of them. Luckily, as we continue to learn more about the mechanism of injury, we have developed some strategies to reduce your chance of ACL injuries.

 

5 Ways to Decrease the Risk for an ACL Injury

Here are 5 things to focus on when designing programs to reduce ACL injuries.

 

Optimize Mobility

If you look at the human body, there are many joints. Some of those joints require mobility and some of those joints require stability. Depending on which plane of motion you are in, mobility or stability is usually more imperative than the other.

When it comes to mobility, there are certain joints in the body that we need to have optimal mobility in order to decrease the risk for an injury to the ACL. The two joints that come to mind are the talocrural joint of the ankle, and the femoroacetabular joint of the hip.

For the ankle, specifically dorsiflexion range of motion is imperative to decrease strain at the knee. If the ankle doesn’t have the ability to dorsiflex and absorb force during a land from a jump or cutting maneuver, the mid foot or knee are the two joints that will have to have increased mobility to accommodate the athletic endeavor.

 

Ankle Mobility

To assess for adequate ankle mobility, use the Knee to Wall Ankle Mobility Test.

Key Points:

  • Place your foot 4 inches away.
  • Keeping your foot flat on the floor, attempt to touch your knee to the wall.
  • Don’t allow for valgus or varus collapse.

If you can reach the wall from 4 inches, then you have sufficient ankle mobility to run, squat, and perform without playing increased stress through the knee due to poor ankle mobility.

The other joint in the body that needs to have optimal mobility is the hip.  The motions at the hip that need adequate mobility are hip flexion, hip extension, hip abduction, hip internal and external rotation.

Now, you may be saying, “Wow, that’s a lot of areas that need mobility.”  Well, let’s break it down!

 

Hip Flexion

5 ways to reduce ACL injuriesAnecdotally, I like to see clients present with full hip flexion. If there is decreased mobility into hip flexion, this can send a signal to the brain to alter movement and muscle firing patterns and in turn, can affect how someone lands or moves.

A quick and easy test is to test passive hip flexion range of motion.  

This involves bringing your knee towards your chest. Ideally, your thigh should reach the inferior aspect of your rib cage. Now, everyone is made differently and depending upon what sport you play, hip structure can vary from person to person.

If you cannot reach your thigh to your rib cage, slightly abduct your thigh and see if you can go further. If you can, then your hips are structured a little differently.

 

Hip Extension

Key Points:

  • Thigh should be able to reach parallel to ground.
  • Knee should be at 90 degrees to thigh.
  • Thigh should drop straight down and not flare out towards side of body.

Hip extension mobility is necessary to be able to activate the gluteus maximus and hamstrings in order to decrease incidence of a valgus collapse. If adequate hip extension mobility is not present, then muscular compensation will occur and in turn, possible injury.

 

Hip Internal Rotation (IR)

Even though hip internal rotation is part of the combination of movements that contribute to an ACL injury, not having the requisite mobility is a risk factor. If the body doesn’t have certain available ranges of motion, then the brain and central nervous system are not able to prevent going into those said ranges of motion. Therefore, if someone doesn’t have adequate hip internal rotation, then the body has no way to prevent that motion from occurring.

VandenBerg et al. in Arthroscopy: The Journal of Arthroscopic & Related Surgery that “risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases.”

 

Hip External Rotation

Hip external rotation is important because avoidance of a knee valgus position is necessary to avoid injury to the ACL. Having adequate hip external range of motion will allow the athlete to be able to get into an athletic position to avoid that valgus position.

 

Learn How to Land

You watch any NFL or NBA game and guys are jumping to catch a ball to to tap in a rebound for 2 points. Most injuries to the ACL don’t occur on the jumping portion as it does on the landing portion.

When athletes have to land from a jump, the body has to absorb 7-10x their body-weight in forces from the ground.  If joints aren’t in an ideal position to absorb and adapt to stress, injuries can happen.

landing mechanics ACL injury

Photo credit

Therefore, we need to assess athletes in their landing patterns and mechanics to make sure their body is resilient and capable to land properly.

 

Step Down Test

 

The Step Down Test is a simple way to determine an athlete’s predisposition to absorbing eccentric stress. Ideally, we like to see the pelvis, hip, knee, and ankle remain in a line during descent.

 

If someone steps down and the femur internally rotates and the knee goes into valgus collapse,  this is something that needs to be rectified.

If you want to use a more quantitative analysis of landing mechanics and skill as compared to the contralateral limb, then here are 3 tests that can help with that.

 

Single Leg Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as then can and land on 1 leg.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average of the 2 trials, then repeat on the opposite leg.

 

Triple Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, take the average, then repeat on the opposite leg.

 

Crossover Hop for Distance

Key Points:

  • Instruct the athlete to jump as far as they can, land on 1 leg, and continue for 2 more hops, sticking the 3rd landing while crossing over a tape line on the floor with each jump.
  • They must stick the landing without hopping around or using their leg/arm for balance.
  • Perform 2 trials.  Measure each jump, find the average, then repeat on the opposite leg.

Now that you have the average for all 3 jumps, we need to determine if the difference between the two limbs is significant. According to Adams in the Journal of Orthopaedic and Sports Physical Therapy, limb symmetry indexes of 90% have previously been suggested as the milestone for determining normal limb symmetry in quadriceps strength and functional testing.

According to Phil Plisky, one of the developers of the Y-Balance Test, he advocates that the athlete’s reconstructed lower extremity be within 95% on the non-involved leg.

To determine if distances hopped are significant, the involved limb must be within 90-95% of the non-involved side. If it is less than 90%, then that athlete is at risk for future knee injury.

Using a regimen consisting of single leg plyometrics in the sagittal, frontal, and transverse planes as well as single leg exercises that focus on power development can help to improve any major deficits.

 

Achieve Symmetry

If an athlete presents with a gross asymmetry, their risk for injury can increase 3-17x. Besides using the Hop Tests, one way to assess gross asymmetry is also using the Y-Balance Test.

The Y-Balance Test consists of 3 lower and upper body movements. For the sake of this post, we will be focusing on the lower body. The movements consist of:

y balance test ACL injuries

Photo credit

If there is greater than a 4 cm difference right vs left on the anterior reach (1st picture), this is considered a risk factor for a lower extremity injury.

Smith, Chimera, and Warren found in Medicine and Science in Sports & Exercise that “ANT (anterior)  asymmetry >4 cm was associated with increased risk of noncontact injury.”

If there is greater than a 6 cm difference right vs left on the posteromedial or posterolateral reaches, pictures 2 and 3, then this is considered a risk factor for a lower extremity injury.

Asymmetry is a normal thing.  Everyone from elite level athletes to the average joe has natural asymmetries right vs left. Some asymmetries may not change and some asymmetries may make someone the elite level athlete that they are. Having a relative asymmetry right vs left is ok, but having a gross asymmetry is not.

 

Enhance Core Stability

The core musculature is responsible for providing a stable base for the pelvis, hips, knees, ankles, etc. to function off of in life and in sport. If a stable base is not provided, then it can create instability and injury further down or up the kinetic chain.

Decreased core stability can cause:

  • Pelvic Drop
  • Femoral Internal Rotation
  • Knee Valgus
  • Tibial External Rotation
  • Subtalar Excessive Pronation

All these movements are associated with injuries of the ACL. By stabilizing proximally and providing a stable base for all of the aforementioned areas to work off of, this can decrease the risk for injury.

In order to test for core stability, the Trunk Stability Push-Up (TSPU) by Functional Movement is a good test.

This is a great test to determine if someone can maintain a neutral spine while performing a push-up, but also to determine if they have a base level of core stability to maintain a certain trunk position during life/sport.

If someone cannot maintain a specific trunk position, this doesn’t mean that they have a “weak core.” or weak upper extremities. It means that the athlete doesn’t have the capability to stabilize their core proximally in order to exude force distally.

 

Learn How to Decelerate

Most athletes are fast or at least quick on their feet. The great athletes can speed up and slow down better than anyone. One common risk factor we see with ACL injuries is the inability or subpar ability to be able to decelerate.

What this means is that if someone is going to stop or change direction, they need to have the necessary skills to control their body in space when going from accelerating, to decelerating, and then back to accelerating again.

All fast cars are fast! All really fast cars have great brakes!

In order to assess an athlete’s ability to decelerate, observe how the do with change of direction drills.  For example, movements such as:

 

Sprint/Backpedal w/ Redirection

Lateral Shuffles w/ Redirection

Sprint with 45 Degree Cut

Sprint with 90 Degree Cut

Backpedal, Stop, to 90 Degree Sprint

Backpedal, Stop, to 45 Degree Sprint

All of these various movements test an athlete’s ability to accelerate, decelerate and change directions in all planes of movement. A coach, personal trainer, or physical therapist should be present to provide the athlete with the redirection component. This makes it more random and unpredictable to make sure the athlete can react and move appropriately.

While observing these various change of direction movements, observe the mechanics of the pelvis and lower extremity.

Does the pelvis and hip/knee stay in a relative stable and neutral position when decelerating and stopping?

Does the pelvis and hip/knee go into a valgus collapse during decelerating, stopping, and accelerating phases of movement? Compare these right versus left lower extremities.

If you are having trouble observing these things with the naked eye, film it!  There are apps such as DartFish or Hudl that you can download to film athletes and then you can watch it in slow motion to observe any differences side to side.

If differences are seen in right and left comparison, then work on change of direction drills. When first starting off, start the athlete at ½ or ¼ speed so that they can work on their deceleration, stopping, and accelerating mechanics.

We don’t necessarily want to bombard the athlete with too much information about biomechanics of the lower extremity, but having a basic discussion with them and showing them how they currently move and how you would want them to move safely and more efficiently is ideal.

Then once, then can master ¼ or ½ speed, then increase the speed of the drills until you are working at full speed on both sides. There are a multitude of drills out there to work on acceleration, deceleration, stopping, and change of direction. Make sure start with the sagittal plane, and then progress into the frontal and transverse planes.  

If you can’t master the sagittal plane, then the frontal and transverse planes will be much more challenging.

Assessing mobility, landing mechanics, relative lower extremity symmetry, core stability, and acceleration/deceleration can all help to improve an athlete’s performance as well as decrease their risk for an ACL injury.

 

About the Author

Andrew Millett is a Boston-based physical therapist in the field of orthopedic and sports medicine physical therapy.  He helps to bridge the gap between physical therapy and strength and conditioning.  Visit his website at AndrewMillettPT.com.

 

 

 

Meniscus Repair Rehabilitation: Why Are We Still Stuck in the 90’s?

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 some of the controversies surrounding postoperative progressions, specifically weight-bearing and range of motion, follow meniscus repair surgery.

 

Meniscus injuries within the knee are a common occurrence.  In fact, the National Center for Health Statistics reports that meniscus surgery is the most frequent surgical procedure performed by orthopedic surgeons in the United States, with more than 50% of the procedures performed in patients 45 years of age or older.

Despite this high occurrence, many inconsistencies continue to exist in the rehabilitation of a patient following meniscus repair surgery, particularly involving the rate of weightbearing and range of motion.

I’m still shocked by this and wanted to discuss the recent research that is lending to a more progressive approach to return people safely back to their prior level of function.

Rehabilitation Follow Meniscus Repair

meniscus repair surgery weightbearingRehabilitation after surgical debridement of the meniscus is pretty straightforward. We return the patient’s range of motion, strength and function per their symptoms and let pain and swelling guide the rehab process (a very general guide but one often employed by many rehabilitation specialists).

However, when the meniscus is actually repaired and not just debrided, there are other factors to consider.  When a meniscus is repaired, the tear is approximated using stitches to allow the tear to heal.  

Rehabilitation following a meniscus repair has to be more conservative, however, despite research saying otherwise, there are still many rehabilitation protocols floating around the orthopaedic and sports medicine world that recommend limiting weight-bearing and range of motion after a meniscal repair.  We continue to ignore the literature because of fear that the ‘stress’ on the meniscus with walking and range of motion may be too high.

Unfortunately, many of these commonly used protocols are from the 1990’s. (The current protocols we use can be found at RehabilitationProtocols.com)

So if we’re going to talk 90’s protocols, take a look at these studies from way back when from Shelbourne  and Barber  that showed excellent results in patients undergoing a combined ACL-meniscus repair procedure and utilizing no limitations in weightbearing or range of motion, similar to a protocol for an isolated ACL reconstruction.

Recent studies from VanderHave and Lind on isolated meniscus repairs have shown similar results using an “aggressive” program of immediate weightbearing compared to a more conservative approach.

I certainly wouldn’t consider these “aggressive” programs, they simply used immediate weightbearing and range of motion.

Again, these studies show meniscal repair outcomes are no different while using restricted weightbearing and range of motion versus an “aggressive” protocol of immediate weight-bearing and unlimited range of motion.

Early Weightbearing After Meniscus Repair

meniscus repair surgery range of motionBut what about the exact mechanisms that many are still fearful of allowing early in the process, like early walking and range of motion? Won’t that put the repair in a position to fail?

We typically immobilize people in full extension during weightbearing, locked in a brace for 4-6 weeks after meniscal repair surgery.

So, if immobilized in extension, why do we limit weightbearing?

During weightbearing, compressive forces are loaded across the menisci. These tensile forces create ‘hoop stresses’, which expand the menisci in extension. These hoop stresses are thought to be helping the healing process in many tears by approximating the tissue.

Furthermore, the compressive loads applied while weightbearing in full extension following a vertical, longitudinal repair or bucket-handle repair have been shown to reduce the meniscus and stabilize the tear, as noted by Rodeo  and more recently by McCulloch.

Early Range of Motion After Meniscus Repair

What about early range of motion?

There is very limited literature on the influences of range of motion on meniscal movement. Thompson showed that during flexion, the posterior excursion of the medial meniscus was 5.1 mm, while that of the lateral meniscus was 11.2 mm.

Looking at meniscal movement as the knee flexes in weightbearing and non-weightbearing you can see there’s less motion, although I really don’t think we know how much motion is detrimental. The motion has been shown to help improve blood flow to the area. This is huge and may aid in the healing process!meniscus biomechanics

What Do We Recommend?

Anecdotally, I can say we have handled meniscal repairs to allow weightbearing and range of motion to tolerance for many years.  Some of the top orthopedic surgeons in the world that I have worked with currently handle a meniscal repair the same as an ACL reconstruction with a meniscal repair .

For an isolated meniscal repair, I prefer the knee continue to be immobilized in full extension for 4-6 weeks but allowed full weightbearing immediately (if a longitudinal repair). For complex repairs, I would recommend limiting weightbearing to partial but understand that the hoop stresses could aid in healing and are arguably helpful and necessary.  For both cases, I would recommend passive range of motion to tolerance.

Trust me, I respect the healing meniscus and continually monitor patients as I progress their range of motion and weight-bearing activities. Things like new joint line pain along the site of the repair, new swelling or a change in pain patterns, and even clicking (although most people have this) are all signs that I may want to further assess and modify my progression.

Based off of this, I continue to stand by my rehab guidelines of full, pain free passive range of motion and immediate weightbearing after a vertical longitudinal meniscal repair. The literature is screaming this same thing at us but we continue to ignore their calls and revert to the 90’s!

What do the surgeons that you work with recommend?  Are any of them still recommending rehab guidelines based on outdated research?  Comment below and let me know, I want to hear what the rest of the country is seeing!

 

Learn How I Evaluate and Treat the Knee

If you want to learn even more about meniscus 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.  Click below to learn more.

OnlineKneeSeminar.com Bloopers!

I thought it would be funny to share some bloopers from OnlineKneeSeminar.com, our program teaching you exactly how Lenny Macrina and I evaluate and treat the knee.  

It’s not as easy as everyone thinks to film these programs so Lenny and I wanted to share some quick bloopers from the filming!

Enjoy!

Learn Exactly How I Evaluate and Treat the Knee

Want to learn even more about how I evaluate and treat the knee?  You still can!  My online program on the Recent Advances in the Evidence-Based Evaluation and Treatment of the Knee is now available.  I’ll show you everything you need to master the knee.  Click the button below for more information and to sign up now!
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The Best and Easiest Way to Restore Knee Extension

One of the most common complications following a knee injury or surgery is not restoring full knee extension.  Losing knee extension causes a lot of issues, ranging from anterior knee pain, to altered movement patterns, to even difficulty when walking.

It’s super important to assure you restore full knee extension.

In this video below, Lenny Macrina, my co-owner of Champion and co-author of OnlineKneeSeminar.com, shares what he considers the best way to restore full knee extension.  Luckily, it’s not only the best in our minds but also the easiest to perform!  More importantly, he discusses why he doesn’t like one of the most common exercises that people tend to use.

 

 

Learn Exactly How I Evaluate and Treat the Knee

Want to learn even more about how Lenny Macrina and I evaluate and treat the knee?  Our online program on the Recent Advances in the Evidence-Based Evaluation and Treatment of the Knee is now available.  I’ll show you everything you need to master the knee.  Click the button below for more information and to sign up now!

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