Objective strength testing is always important to document progress and ensure that patients are ready for the next phase of rehabilitation.
But, when do you start testing strength with a hand-held dynamometer after rotator cuff repair surgery?
We discuss on this episode of the podcast.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 369: When to Test Strength
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Show Notes
• Evaluation and Treatment of the Shoulder Online Course
Transcript
Mike Reinold:
Welcome back, everybody, to the latest episode of The Ask Mike Reinold Show. I’m here with the crew from Champion PT and Performance. PTs only today, right? Diwesh has been busy, hasn’t been able to join us lately, but here with a great crew, Mike Scaduto, Anthony Videtto, Lenny Macrina, Dave Tilley, Kevin Coughlin, and the introduction, not your first episode, right? Because five… I don’t know how many years ago, Brendan, were you a student? And you probably read a question at one point in time, right, Brendan?
Brendan Gates:
Yeah. I think about four years ago. I was sweating, shaking in my boots, reading a question on here. But it’s been awesome. This is probably three years now that we’ve worked together, and I’ve learned a ton from you guys. So, really cool opportunity to be on here and share some of the things that I’ve learned with a listener. So thanks again for having me.
Mike Reinold:
Awesome, man.
Dave Tilley:
Not to jump in, but I just realized that Kevin wasn’t working with us during COVID, and that shook me completely. The other day, he was like, “I was not even here.” And I was like, “Dude, there’s no way that’s possible.”
Mike Reinold:
I agree. It seems like Kevin has been here forever. But excited to have Brendan Gates here, though. He’s been a big asset to Champion, and I know he’s got a lot to offer for education, for everybody. So we get to learn from Brendan, too. I know we’re excited as the staff to learn from Brendan’s mind a little bit, too, so I’m sure you guys will. And Lisa Lowe, I didn’t go out of order. Lisa just joined late, so we got Lisa in there. So, it was awesome.
Anyway, we’re back at you. We got a question from a listener today that we’re going to start with. Question’s from Holly, from Portland, Oregon. She says, “When do you test rotator cuff strength with a handheld dynamometer after a repair?” So after rotator cuff repair surgery. I don’t know. I wouldn’t say at Champion we have this standardized where we say, “Do this at a certain week.” Who wants to start? What do you think? When do you test rotator cuff strength with a dynamometer? Dave?
Dave Tilley:
I’ll say what I’m pretty sure I think Dan would’ve said, because he’s on vacation. But I think a lot of these things depend heavily on the factors of how the repair was, small, medium, large, tissue quality, how did it happen, Traumatic versus generative? It makes a huge indication on what surgery they’re getting, how involved the surgery is. Is that person healthy and strong and working out before versus after? Of course, there’s tissue timelines, but in my opinion, somebody with a slow degenerative tear that has a small repair… It’s not this massive blowout surgery, versus somebody who… I literally treated one person who fell, tried to grab her husband’s bike, and the bike just ripped her cuff in half.
She had a huge surgery with a massive repair. Completely different story. So, to bucket people into like, “We strength test everybody at X month with a rotator cuff repair,” I think is really, really short-sighted. And I think a lot of the factors for when you test… There’s a lot of feel to the tissue timelines as well as the surgical timelines. But I just think that Dan probably would’ve said that earlier after he read 300 papers on this recently.
Mike Reinold:
I’m glad you said that, and that’s a great way to start. There’s so many variables. Is there a surgical procedure that is anything like rotator cuff repair? When you say rotator cuff repair, that’s the name of the surgery, but has such a large variation on what that means. A small tear and a 35-year-old versus a massive tear and a 75-year-old, and everywhere in between, is so different. It’s so different. Every part of the rehab process is different. Is there any procedure like that, like rotator cuff tear?
Dave Tilley:
I don’t think so, unless you say meniscus repair and you include every type of meniscus in everything.
Mike Reinold:
It’s crazy. I mean, you just tear your ACL in half, like boring. But anyway, who else? Who wants to jump in? What other variables do you look at? And then, Holly, we will answer your question, but I like going over some of the variables. Who else wants to jump in? Lenny?
Lenny Macrina:
I think Dave summed it up well. There’s so many different variables. So get the op report is number one, communicate with your surgeon, and obviously, if the patient is doing well, they got full motion, no pain, you’ve been working on strengthening… I would probably say no sooner than three months out of surgery, and I would probably even push it to four months out of surgery easily, because you’re going to get a max effort, isometric contract. You do not want to pop an anchor, and you probably haven’t done anything close to max effort up to three, four months out of surgery, doing kind of isotonic-related functional basic stuff.
So if you’re going to have them give a max effort, isometric contraction, probably four to six months, depending on the size of the tear. Let the tissue heal. We think tendons take about three-ish months to heal. So if you can get them beyond that… And again, younger person could probably do it faster than… In the orthopedic world, 50-plus, even 40-plus is old. But I would say in the typical 45, 50-year-old, you’re looking at least four months before you would consider it. And prior to that, you’ve done a good job pushing them to see if they can handle some good stresses.
Mike Reinold:
You know what, Len? I think with handheld dynamometry, if you’re just getting started with it and maybe you’ve gone to some courses or something like that, you might see there are some things, like let’s say hamstring strains, and stay tuned for the next episode if you want to hear more, but hamstring strains… We will do handheld dynamometry while they’re injured within their tolerance. And that’s part of the assessment procedure for a hamstring strain, is just to see what they can tolerate.
But man, you don’t want to do that with a rotator cuff repair. That’s completely different. Let that tissue heal. I don’t even want to challenge it. So, good. Who else wants to jump in here? I’m waiting for Mike because we had a good conversation about this yesterday.
Mike Scaduto:
Yeah, I think I’m right on board with Lenny in terms of the timeline. Four months even feels a little bit early for me. What are we testing at that point? They haven’t really strength trained enough to really have a meaningful test. That was kind of Lenny’s point. So, I think having an objective for the test… How is that going to guide the rest of your treatment? What’s the point of testing? I think any earlier than four months, the risk doesn’t outweigh the reward. We know that they’re going to do a progressive loading scheme. They’re probably getting back in the gym at that point. Why not give it a little extra time, get a little further down the line? I’d say at least five months to six months. That can give them a good idea of return to sport, whether they’re trying to get back into golf or whatever.
Then you can get some serious buy-in and be like, “Hey, you still have a 10% strength deficit in X rotator cuff muscle. Let’s wait a little bit.” Or maybe they look great, and it’s like then you start to push them, “Hey, you’re ready to get back into the sport or the activity that you want to do.” So, I think waiting has a lot of benefits.
Mike Reinold:
I don’t think I could have said that any better. Mike really nailed that. Sometimes you got to take a step back and say, “Why are we testing and why test at three, four months?” If you follow us at Champion, which you probably do if you’re listening to this podcast, and you understand our treatment style, we’re doing manual resistance exercises on these patients through their strengthening program for months.
I don’t want to say we know how strong they are, because sure, we value objective testing, but you know if somebody is behind or doing well with strength. Take a big step back, to Mike’s point, and say, “Why are you testing?” And Mike nailed it. I think you’re testing with a rotator cuff repair to see if they’re ready for that last push to return to their activities right there. Maybe the doctor cleared them to start golfing or playing tennis, or something like that.
You want to say like, “All right. Let’s see if we are ready for that.” So, I think Mike really said that well. To me, it’s about making sure you have a reason why you’re testing too. I think that’s important. So I know… Yeah, again, Mike.
Mike Scaduto:
I would just add, if you go and test too early, especially with a rotator cuff, and we’re trying to assume what they looked like before surgery, but they obviously had some kind of strength deficit… You strength test too early, and they get really bad numbers. That can have a psychological effect as well. So you want to build the person up throughout the course of their rehab and not give them a strength test too early, and then they flunk it, and then they feel really crummy about their rehab, or they think that they re-injured their shoulder.
Mike Reinold:
Right. That’s a solid point. Just resist that urge, I think. The other thing Mike said yesterday, too, which you didn’t bring up, which I thought was awesome, is like some doctors don’t even let you start strengthening until week 12. So you’re not going to test it week 12. You haven’t even started strengthening yet. And then you could argue week, month four, is that’s only a month of strengthening. It’s too early to start testing. There’s going to be no benefit. So, I don’t know. Anybody else before we wrap it up? I think to me, I don’t want to say an easy question, but I like a simple question like that. Anybody else have any more input on that?
Awesome. All right, sweet. So I think to summarize, Holly, a little bit here, I think we all think three months is too early. I think the earliest, maybe in a small, healthy person, very small tear, maybe four months. But I’d take a step back and say, “Why are you testing?” And kind of reverse hack that thought process a little bit and say, “Well, if I’m testing for that late phase thing, then, okay, maybe it’s closer to five, six months,” that sort of thing.
It’s not one of those things that we’re using this objective testing necessarily to dictate our rehab. I think we know how the rehab is going to go. It’s probably just more like are they ready for that progression they need to get to at that late stage phase? So I think that’s what we’d say, probably four or five months down the road, I would say, would probably be the earliest we would do that, Holly.
So if you have a question like that, please head to mikereinold.com, click on that podcast link, and you can fill out the link to ask us more questions. Holly, thanks for that one.
If you’re liking this stuff, just let us know. Write some reviews. We do read the reviews on Apple and Spotify, and be sure to subscribe so you can see us on that. I’m saying the same thing for 10… It’s been 10 years we’ve been doing this podcast. If you haven’t subscribed by now, you’re probably not going to. So thank you. See you on the next episode.
