[Katie Long]

Tim Uhl’s shoulder rehab and EMG presentation was very helpful for me! I have a couple of patients right now that this is incredibly helpful for considering progression (and regression) as necessary. I had never really thought to consider lever arm when performing scapular strengthening (physics was not my strong suit), but I thought the way he broke down progressions regarding load and lever arm was very helpful and made a lot of sense.

I was also encouraged by how much consensus there was between surgeons and PTs regarding SLAP repairs. I had a patient a month or so ago, who was considering getting his repaired and he ended up not undergoing surgical intervention due to his positive outcomes in therapy. His surgeon here in Woodstock was pushing the surgical route more than I thought was necessary, and it was nice to hear the opinions this weekend regarding surgical repair of SLAP tears.

[Katie Long]

I can’t gain access to the article that references 100% LSI for cutting/pivoting sports, but its “Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward” by Dingenen et al., Sports Medicine, August 2017. It was an article cited in the VCU course for good return to sport criteria.

[Katie Long]

Hi Justin, good case, certainly relevant following the Running Medicine conference from last month. I agree with Tyler about wanting more information on her L hamstring and bilateral quad strength for consideration in a limb symmetry index. I also agree with Tyler on liking a single-limb RDL for this patient or a resisted runner’s ready at the pulleys or with a band.

As for her hop testing, I am willing to bet she still has lingering impairments in her hop testing. However, something that was emphasized quite heavily in the VCU return to sport course was the endurance component. I am a little more interested in what her hop testing would look like after she has been fatigued, as she would be at the end of an ROTC run over uneven ground. I am wondering if maybe assessing something like the VAIL Sport Test might be valuable, as it objectively assesses power, endurance, strength and movement quality? This article addresses the question of 90% being the cut off, from what I gathered from the VCU course, some are recommending 100% LSI in those participating in pivoting/cutting/competitive sports.

I have not yet had to make the “return to sport” decision in a patient s/p ACLr yet, but I think I would consider what LSI I would aim for and why (>90% in recreational athletes, 100% in competitive/cutting/pivoting sports). I would also consider the demands of their sport and consider the fatigue/endurance component when performing my objective assessments, as that is when their deficits are going to be the most pronounced.

Lastly, with patient compliance, I wonder about getting her more involved in her specific rehab goals. For example: when you can perform x-number of reps of this weight, you can progress to this functional task. Or when you can perform this hop testing distance, then you can return to running this milage. It might help her motivate herself to keep up with her exercises and take some of the decision making off of you.

[Katie Long]

I agree with the points brought up above. A lot of this information was new to me in regards to which types of tears increased contact pressures and which did not. I thought the point made about root tears being the functional equivalent of a meniscectomy was very interesting. It makes sense in regards to the hoop stresses. It also reminded me of Dr. Gawathmy’s point regarding alterations in labral suction in hip surgeries gone bad. Those contact points for these connective tissues are essential and once that “seal” is lost, it obviously has very significant effects on contact pressures and function of the tissue. I also thought the information on the relationships between meniscal tears and resections in regards to ACL strain was interesting, but makes complete sense. As soon as intra-articular structures are altered, that stress and strain is going to have to go somewhere. I think keeping that in mind in these patients is a good treatment consideration. Maybe addressing an increased emphasis on hamstring strength and control to assist in anterior tibial translation control could be a good adjunct to care for these patients.

I am excited to see this published in the JBJS. I hope some of the MDs that refer to me see it! I tend to see a lot of patients after the surgical decision has been made, but I fully intend on using this article as an education tool if I get the chance!

[Katie Long]

Hi Everyone,

I don’t know if there is anyone still emotionally invested in this case or not, but I wanted to post an update. I have now successfully treated this gentleman for his shoulder pain and today was his first session back for his groin/pelvic floor pain. He continues to have (+) Adductor squeeze test for reproduction of his groin, testicular and adductor pain. He also continues to have sx provocation with L spine ROM testing, although considerably better. He no longer has groin pain provoked with CPA spinal accessory motion testing. He no longer has sx provocation into his testicles or groin with palpation to his adductors, although continues to demonstrate significant tone upon palpation. His hip flexors and TA are very hypertonic and produce his anterior groin pain with palpation. We needled his right adductor magnus and provided some STM to his left and with re-assessment of his adductor squeeze, he denied ANY testicular pain!! The rest of the session was focused on flexibility (butterfly, happy baby, quad stretching) and he reported reduction of his sx from a 10/10 to a 4/10 following the session!

Katie

[Katie Long]

Hey Sarah,

I looked into some articles on gait with PAO. PICO: “In patients with PAO, what parameters of gait are most affected at >1 year post-op?”. I found the two articles you posted while doing my literature search and read over them a little. Additionally, I found an article by Pederson et al. (“Walking pattern in 9 women with hip dysplasia 18 months after periacetabular osteotomy”) talking about gait mechanics pre- vs. post- operatively. They discuss the improvements in upright gait pattern following PAO as evidenced by increased knee extension throughout stance phase of gait and increased hip extension torque. They also found a reduced hip flexor moment, which was similar to their pre-operative findings.

I wonder if, similarly to what we discussed about posterior hip joint mobility to take pressure off of the anterior structures (hip flexor), if you emphasized hip extensor moment, that would also aid in the anterior hip pain she is experiencing?

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[Katie Long]

Sarah, these articles look interesting, thanks for the synopsis of them. Ill try to read them in more depth soon. I recently evaluated a female in her 30’s s/p traumatic labral tear during child birth that was surgically repaired and we have started some quadruped work too. I think there will be some good carryover between these two patients in regards to treatments and gait training. Did your MD provide some sort of protocol for PAO? I’ve never seen this and I am interested in how the rehab differs from other hip arthroscopies.

[Katie Long]

Hey Sarah,

To add to the general consensus. I have not seen this either. I would agree with Justin about the gait in regards to d/c AD. In the literature I’ve encountered with pts s/p hip labral repair and FAI arthroscopy, the major components for progressing through the protocol phases are pain-free uncompensated gait. I feel like although the surgical intervention is not the same, the same philosophy may be applied. In addition to Justin’s suggestion of videoing the patient, I find that part-task breakdowns of gait are helpful once the patient understands what/why you are working on something, such as hip flexion.

I also wonder about her joint mobility. If she has some posterior capsule tightness and/or anterior capsular hypermobility, she may have increased stress to the (already weak) psoas as it crosses the anterior capsule, similar to patients with hypermobile-FAI leading to increased anterior hip pain. Joint mobs might have an added effect of some increased neural input to the psoas…

Keep us posted!

[Katie Long]

Hey Eric,

Although I do not see many runners at my clinic, I think this course was very good for me to get re-aquainted with the running world. I think that the overstriding screening/identification strategies that Bryan presented were very helpful. My coworker and I have discussed possibly putting together a screen for the local high school’s cross country team this summer so that they will hopefully be better prepared to start their season in the fall, so this analysis was very helpful.

I also thought the analysis of running gait months (and years) post-ACLr was very helpful. I think it will help me in the earlier stages of rehab to emphasize proprioception and eccentric quad strength in a functional excursion in order to promote improved running mechanics later down the line. It will also make me very aware of when I clear these athletes to return to run.

Lastly, I really enjoyed Jay’s lab portion on Saturday. I thought his elaboration on foot intrinsic strengthening and emphasis on functionality was great. I have already started using some of his techniques in my practice. I thought that was very, very helpful!

Thanks for such a good course!

[Katie Long]

Eric,

Firstly, I am happy to hear that you are feeling better! You gave us all quite a scare and we missed you at the last course weekend.

Secondly, thank you SO much for this post. I think this was very helpful for me, as tendinopathy is something I find myself struggling to adapt to with each different patient presentation. In the “field of grey” this provides some nice firmer “do’s” and “don’t”s that I think will be helpful for me moving forward with my prescription of exercises and manual therapy with patients in the future.

Thanks again!!

[Katie Long]

I agree with Tyler. I think this study was very helpful for me when considering exercise prescription, particularly early in the plan of care. I think it will be helpful for me when considering education for HEP. I think educating patients on taking appropriate rest breaks both during exercise and between exercise bouts is something I have plenty of room for improvement in. Thanks for this article, its a good “library builder”.

[Katie Long]

Hi Tyler,

Im wondering what her foot posture looks like? Did you assess her TCJ, STJ or midfoot mobility at all? Im wondering if there are some obvious impairments that might benefit from an off-the-shelf orthotic? I am not very familiar with taping at all, but it something I would like to become more familiar with for patients such as these. If it can be beneficial in the short-term in order to work on some long-term strategies/goals, I could see the benefit of trying to relieve some pressure off of the patella.

[Katie Long]

Hi Scott, these are all some good points, however he ended up only coming in for a couple of sessions before he hurt his shoulder and decided to seek care from an orthopedic surgeon for that and put this on hold. I contacted two pelvic floor PTs and they gave me some tips while I was seeing him so I had some help from them too! Thanks for the input!

[Katie Long]

Hi Tyler,

Good post, this is very relevant to a patient I am seeing right now, and this article was very helpful.

1. I usually try to stay away from the words “weak” or “unstable” core explanations in relation to LBP. What I explain is that our muscles and our joints work together during our day, and if one of the two is not working as much as it usually does, it causes the other part to have to work harder, and sometimes that makes us hurt. I usually emphasize that if we can get the other component to “pull its weight” so to speak, they will likely start moving (and feeling) better.
2. With these patients, I think compliance and competence with HEP (in addition to improved pain/initial symptoms) is my biggest discharge criteria. I like to make sure that they have a good pool of exercises to pull from in order to help manage their symptoms. That way if they are to notice their back starting to feel bad in the future, they are able to try some of these exercises and utilize them as a tool to help manage their symptoms before seeking care.
4. I do not think I would manipulate this patient. It seems to be a motor control issue. I would likely utilize some mobilizations for neural input if they were found to be effective, but this is not the patient I typically manipulate. He does not meet the CPR for lumbar manipulation, but he does meet the CPR for clinical instability, so I would likely focus my efforts on neuro re-ed and motor pattern training.

Looking forward to hearing more on Thursday!

[Katie Long]

Thanks AJ, this was helpful. This is a concept that I have always had some difficulty completely grasping. It definitely helped some!

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