MikeReinold.com - A Blog for Physical Therapy, Athletic Training, and Sports Medicine

Are Tennis Elbow Straps Effective?

noreply@blogger.com (Mike Reinold) — Thu, 16 Jul 2009 10:00:00 +0000

Lateral epicondylitis, or tennis elbow, is one of my least favorite injuries. It can be disabling, nagging, and sometimes even relentless! A commonly recommended treatment involves the use of a tennis elbow strap. There has been some support in the literature regarding these orthotics, however results in the literature have varied.

A nice new study published in a recent issue of JOSPT assessed the efficacy of these devices in a group of 52 subjects with lateral epicondylitis. The study examined the amount of pain-free grip strength and maximum grip strength is subjects with a variety of tennis elbow straps, including a placebo strap.

How Do Tennis Elbow Straps Work?

The theory behind counter-force bracing is similar to the mechanics of a guitar. When a finger is placed on a string along the neck of the guitar, it reduces tension on the string distal to the fret where your fingers are located. A counter-force tennis elbow strap can be thought of as your fingers on the neck of the guitar (your forearm) and the extensor muscles, especially the extensor carpi radialis brevis, would be the guitar string, thus reducing tension of the muscles as they attach to the lateral epicondyle. The authors of the study review this concept well.

Counter-force Bracing is Effective

Results indicate that strapping was effective in allowing subjects to produce significantly more pain-free force. Subjects were able to produce 16% more strength without pain using a strap. There was no difference between two of the devices they used (a strap vs. a sleeve with a built in strap), indicating the strap itself is likely the significant factor. The image below on the left is just the strap and the image on the right is the sleeve with a built in strap:

One of my original concerns with the study involved the rest time between repetitions of grip strength. As anyone that routinely assesses grip strength knows, the amount of force produced can drop significantly if the rest time between repetitions is not adequate. However, the study design used a mean of 4 repetitions for each device and allowed 5 minutes of rest between testing sessions. This was adequate for me and I was happy to see this methodology.

Clinical Implications

I like this study because bracing is simple, cheap, and effective. People can go to any CVS or Target and get a nice tennis elbow strap these days.
Counter-force tennis elbow straps are effective at allowing patients with lateral epicondylitis to produce more grip strength with less pain.
The strap should be placed around 2.5 cm distal to the lateral epicondyle.
While it is unclear if the size of the strap is important, the study used straps that were between 5-8cm in width. Considering there is some conflicting results in the literature, I would recommend you try to replicate the width of the strap. There are some straps on the market that are very skinny.
Straps can be an effective way to allow people with lateral epicondyltis to return to athletics or weight lifting when painful gripping can severely limit activities.

Fahimeh Sadat Jafarian, Ebrahim Sadeghi Demneh, Sarah F. Tyson (2009). The Immediate Effect of Orthotic Management on Grip Strength of Patients With Lateral Epicondylosis J Orthop Sports Phys

New Webinar Next Week! Biomechanical Implications of Patellofemoral Rehabilitation

noreply@blogger.com (Mike Reinold) — Mon, 13 Jul 2009 10:00:00 +0000

I am happy to announce that my next live webinar will be held next week on Tuesday July 21, 2009 at 12:00 noon EST. I wanted to continue with the theme of patellofemoral pain after our series on solving the patellofemoral mystery and present some of my thoughts and treatments strategies for patellofemoral pain

Biomechanical Implications of Patellofemoral Rehabilitation

Tuesday July 21st, 12:00 Noon EST
The webinar will overview the anatomical and biomechanical implications associated with patellofemoral rehabilitation with specific emphasis on the influence of the kinetic chain on patellofemoral pain.
The presentation will flow nicely after reading my post on the influence of the kinetic chain on patellofemoral pain and include more details and video demonstrations of further exercise recommendations.
The presentation will be ~45 minutes with 15 minutes of interactive Q&A. You will be able to interact and ask questions.
You will need internet access but can view the webinar on any computer.
The webinar is being put together by AdvancedCEU.com and will cost $25 to attend. Space is limited to register soon, webinars do fill up and get closed for registrations.
To register for the event visit the below link:

Click Here to Register for the Webinar

Look forward to seeing you at the webinar! If you can’t make it, no worries, there will be a recorded version of the event at AdvancedCEU.com in a few weeks. Be sure to view my past recorded webinars as well.

Interact with the Experts at ASMI

noreply@blogger.com (Mike Reinold) — Mon, 06 Jul 2009 10:00:00 +0000

There is an exciting forum on the website of the American Sports Medicine Institute that has tons of information for both the clinician and the athlete. For those that are not aware, the American Sports Medicine Institute (ASMI) is the research and education institute of Dr. James Andrews in Birmingham, AL under the direction of Dr. Glenn Fleisig.

ASMI is one of the world-wide leaders in sports medicine research and education, especially in the field of baseball. In fact, ASMI was the leading force behind many of the protective guidelines that are now in place in within Little League Baseball and USA Baseball to prevent youth baseball injuries. I have posted about these guidelines and how they help prevent little league injuries in the past.

I worked at ASMI for years and was a graduate of their Sports Physical Therapy Fellowship program so I know first hand that this is a great forum. When I offer advice for physical therapy students, one of the first I recommend is to seek out the leaders in the field that you would like to work in one day. Well, I sought out ASMI.

The forum has frequent posts by Dr. Fleisig and his staff and is a great opportunity to learn, interact, and to ask questions from a variety of sports medicine experts. Visit the forum today:

ASMI Sports Medicine Forum

The Influence of the Hip and Foot on Patellofemoral Pain

noreply@blogger.com (Mike Reinold) — Mon, 29 Jun 2009 13:43:00 +0000

The influence of the kinetic chain on the patellofemoral can not be underestimated. Because the knee is located mid-way through a weightbearing extremity, it is vulnerable to excessive force from biomechanical faults located both proximally and distally to the knee itself.

While forces from the foot and ankle have been associated with patellofemoral pain for some time now, the influence of the hip is becoming more of a hot topic as research has demonstrated significant increases in forces and injuries originating from biomechanical faults associated with the hip. A particular pioneer in this research has been Dr. Christopher Powers from the University of Southern California. A Pubmed search on Dr. Powers reveals several significant papers on the topic, specifically one of my favorites from JOSPT on the influence of the kinetic chain on patellofemoral biomechanics.

Examination of the joints proximal and distal to the knee is imperative in the treatment of patellofemoral pain.

I believe a significant reason why “patellofemoral pain” has been such a challenging diagnosis in the past is because we are treating the symptoms, not the cause of the pain, which is many times may be coming from elsewhere within the kinetic chain.

The following is part 7 of the series on solving the patellofemoral mystery:

Part 1: Introduction – Solving the patellofemoral mystery
Part 2: What causes patellofemoral pain?
Part 3: Differential diagnosis of patellofemoral pain
Part 4: Principles of patellofemoral joint rehabilitation
Part 5: Specific treatment guidelines for patellofemoral pain
Part 6: Biomechanics of the patellofemoral joint – clinical implications
Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

The Influence of the Hip on Patellofemoral Pain

The influence of the hip on the patellofemoral joint has been well documented over the last decade. The biomechanical works of Dr. Powers have shown that excessive hip adduction and internal rotation places the patellofemoral joint in a disadvantageous position.

Unfortunately, our population is dominated by sagittal plane strength and weakness in the coronal and transverse planes. It seems like it is a normal part of daily living now as the majority of our functional tasks take place in the sagittal plane. Even more unfortunate is the fact that exercises outside of the sagittal plane are often neglected in rehabilitation and strength training programs. This creates a significant biomechanical disadvantage.

To fully understand the significance of this, imaging the weightbearing knee. When the hip moves into adduction and internal rotation while the foot is planted, the femur will change position around a relatively stable patella (there is movement, just using this as an example). It is the reverse concept that is commonly seen in patellofemoral rehabilitation. The movement, or “tracking” of the patella on the femur is less relevant in this weightbearing position. It is the movement of the femur on the patella that is significant. Below is an example of how the femurs moves on the patella in the weightbearing position, note the patella is fairly stable while the femur rotates internally:

This is likely the mechanism of patellar subluxations and dislocations and the cause of wear and tear of the joint. Patients often describe an injury that occurs when planting and pivoting or planting on an unstable surface. The quadriceps contracts to stabilize the knee while the femur is adducted and internally rotated, resulted in a lateral displacement of the patella in relation to the femur. This can cause an acute injury as well as degeneration over time.

A recent study by Dr. Powers in JOSPT showed that females with patellofemoral pain had greater hip rotation during running, jumping, and stepping down. This also lead to subsequent decrease in hip strength. In fact, another study by Dr. Powers’ group published in AJSM demonstrated that patellofemoral pain in women is the results of decreased hip strength not anatomical variations (wider hips, etc.).

Treatment of these patients requires training the hip to abduct and externally rotate. Also, it is important to train the hip abductors and external rotators to isometrically stabilize the knee during sagittal plane movements and to eccentrically control hip adduction and internal rotation. A simple test I perform is the step-down exercise. I am specifically looking for the ability to eccentrically lower the body in the sagittal plane while preventing the hip from dipping into adduction and internal rotation. This is harder than it looks and will often be an issue in your patients. But trust me, overtime this will improve, and POOF! Your patient’s patellofemoral pain while climbing stairs and running will have vanished! You are a genius now, the last three times she went to rehabilitation elsewhere they perform ultrasound on her knee and had her squeeze a ball between her knees during mini-squats to “strengthen her VMO.”

Which brings up a great topic, do you still want to squeeze that ball between your knees and emphasize hip adduction and internal rotation? I would actually recommend just the opposite. I frequently use a piece of Theraband (or even those new knee resistance straps that Theraband just started making) around the patient’s knees during exercise. This will require the patient to isometrically control the hip from adducting and internally rotating while performing mini-squats, wall squats, leg press, and other sagittal plane exercises

The Influence of the Foot and Ankle of Patellofemoral Pain

Just as forces located proximal to the knee can have a significant impact on the patellofemoral joint, forces distal to the knee may also contribute. Treatment for patellofemoral patients should include a thorough assessment of the foot and ankle to establish biomechanical factors that need to be addressed. Orthotic fabrication is often necessary, though off-the-shelf orthotics have had some success in the literature.

Pronation. Excessive pronation of the foot causes a reciprocal internal rotation moment of the tibia. This turn increases the resultant Q-angle at the knee. As we previously discussed in our previous post on the biomechanics of the patellofemoral joint, an increased Q-angle will cause a greater amount of force on a more focal portion of the patella. Furthermore, an internal rotation moment of the tibia also results in internal rotation of the femur and a more laterally displaced patella. This may be a cause of ELPS as discussed previously when we discussed the differential diagnosis of patellofemoral pain.
Leg Length Discrepancy. I chose to include leg length discrepancy with the group of distal forces as the impact of a longer leg length tends to impact the positioning of the foot and ankle. The longer leg will tend to have a toe-out and pronated position to compensate for the longer length.
Supination. Patients labeled as “pronators” seem to get all the attention, but excessive supination is likely just as bad. Not only do you diminish the foot’s ability to dissipate force, supination will result in external rotation of the tibia and more force to the patella.

You can see that the position of the foot and ankle when the foot hits the ground is important to evaluate as it will alter the arthrokinematics and patellofemoral joint reaction forces.

It can not be stressed enough that it is imperative that the proximal and distal aspects of the kinetic chain need to be evaluated and treated in patients with patellofemoral pain. I am sure that your outcomes will begin to improve by not neglecting this important aspect of treatment.

Have We Solved the Patellofemoral Mystery?

Probably not, but although the patellofemoral joint may still be a complicated area of sports medicine, I hope that this series has helped take the some of the mystery out of patellofemoral pain! Be sure to go back and review if you missed some of the articles in this series on the patellofemoral joint. In putting the pieces of this series together, remember to:

Understand the source of patellofemoral pain and realize it might not be from “chondromalacia.”
Perform a thorough examination and attempt to identify a specific diagnosis, lets stop using the term “patellofemoral pain” and describe the actual diagnosis!
Consider the basic principles of patellofemoral pain rehabilitation, including understanding the biomechanics of the joint and the biomechanics during exercise.
Look proximal and distal within the kinetic chain to identify a potential true “source” of patellofemoral pain and stop treating the “symptoms!”

Powers CM (2003). The Influence of Altered Lower-Extremity Kinematics on Patellofemoral Joint Dysfunction: A Theoretical Perspective J Orthop Sports Phys Ther DOI: 14669959

Biomechanics of Patellofemoral Rehabilitation

noreply@blogger.com (Mike Reinold) — Tue, 23 Jun 2009 14:50:00 +0000

As we continue our journey through the diagnosis and treatment of patellofemoral injuries, it is time to shift gears from the basic principles of care and discuss our final two topics – the biomechanics of the patellofemoral joint itself and the biomechanical influence of the kinetic chain on the patellofemoral joint. To me, these are two extremely important topics that are often not addressed as much as they should.

The following is part 6 of the series on solving the patellofemoral mystery:

Part 1: Introduction – Solving the patellofemoral mystery
Part 2: What causes patellofemoral pain?
Part 3: Differential diagnosis of patellofemoral pain
Part 4: Principles of patellofemoral joint rehabilitation
Part 5: Specific treatment guidelines for patellofemoral pain
Part 6: Biomechanics of the patellofemoral joint – clinical implications
Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

Articulation of the Patellofemoral Joint

The patella really is an amazing bone in our body. Did you realize that the artiuclar cartilage on the undersurface of the patella is the thickest in the body? That really is amazing and shows just how much force is applied to the joint. Take a look at the picture on the right, notice how thick the cartilage is in comparison to the bone?

When rehabilitating a patient with a known lesion of the patellofemoral joint, it its important to understand the joint arthrokinematics. Articulation between the inferior margin of the patella and the femur begins at approximately 10 – 20 degrees of knee flexion. The patella does not articulate with the trochlea near terminal knee extension. As the knee proceeds into greater degrees of knee flexion, the contact area of the patellofemoral joint moves proximally along the patella and posterior along the condyles.

This is an important concept to understand and emphasizes the importance of good communication between the physician and rehabilitation specialist. If we know the specific area of articulation, we can work around that area, otherwise we don’t know when a lesion will articulate and will have to be more conservative.

Contact Area of the Patellofemoral Joint

In addition to understanding when the patellofemoral articulates, it is important to discuss the area of contact. Obviously, contact between the patella and trochlea that covers a larger surface area will distribute the load over a greater area. This is a driving factor in exercise selection and will be talked about below. At 30 degrees, the area of patellofemoral contact is approximately 2.0cm². The area of contact gradually increases as the knee is flexed. At 90 degrees of knee flexion contact area triples, increasing up to 6.0cm². As you can see, The contact area initially is small and gradually increases as the joint become more congruent.

Alterations in Q-angle are often associated with patellofemoral disorders and may alter the contact areas and thus the amount of joint reaction forces of the patellofemoral joint. Huberti and Hayes examined the in vitro patellofemoral contact pressures at various degrees of knee flexion from 20 – 120 degrees. Maximum contact area occurred at 90 degrees of knee flexion and was estimated to be 6.5 times body weight. A increase or decrease in Q-angle of 10 degrees resulted in increased maximum contact pressure and a smaller total area of contact throughout the range of motion. This information may be applied when prescribing rehabilitation interventions so that exercises are performed in ranges of motion that place minimal strain on damaged structures.

Patellofemoral Joint Reaction Forces

Patellofemoral joint reaction forces are observed during all movements of the knee. Often times, it is the goal of rehabilitation to exercise the lower extremity while minimizing patellofemoral joint reaction forces. Forces occur from a combination of:

Articulation and contact area
Resultant force vector between the quadriceps and patellar tendon
Muscle contraction

We have already discussed the articulation and contact area. Again, joint forces are reduced when distributed over a large surface area. When we discuss lever arms, remember that the patella’s true function is to increase the mechanical advantage of the quadriceps muscle. Take a look at the diagram below, notice how the resultant force (red arrow) vector increases as the knee flexes and the line of pull from the quadriceps and patellar tendons causes a more compressive force?

I wish it were that simple and we could say that joint reaction forces are always highest as the knee flexes. Unfortunately, we have to take muscle contraction into consideration as well. The quadriceps is designed to cause compression of the patellofemoral joint. The force of the quadriceps is greatest at terminal knee extension, that is why patients with patellectomies have such a difficult time extending their knees, they lost the biomechanical advantage of the patella and can not produce enough quadriceps force to fully extend the knee.

Now put the contact area together with the quadriceps force. The quadriceps provides the greatest compressive force near extension when the contact area of the patellofemoral joint is smallest. Thus, a high force on a small area produces considerable patellofemoral joint reaction forces.

To demonstrate just how significant these forces are, take a look at the below table that I put together from various sources for a 200 pound person. Notice how deep squatting applies close to 4000 lbs of force to the patellofemoral joint (still want to squat?).

Activity	Force	% Body Weight	Pounds of Force
Walking	850 N	1/2 x BW	100 lbs
Bike	850 N	1/2 x BW	100 lbs
Stair Ascend	1500 N	3.3 x BW	660 lbs
Stair Descend	4000 N	5 x BW	1000 lbs
Jogging	5000 N	7 x BW	1400 lbs
Squatting	5000 N	7 x BW	1400 lbs
Deep Squatting	15000 N	20 x BW	4000 lbs

Biomechanics of Rehabilitation Exercises

The effectiveness and safety of open kinetic chain (OKC) and closed kinetic chain (CKC) exercises have been heavily scrutinized in recent years. While CKC exercises replicate functional activities such as ascending and descending stairs, OKC exercises are often desired for isolated muscle strengthening when specific muscle weakness is present.

Steinkamp et al analyzed the patellofemoral joint biomechanics during the leg press and extension exercises in 20 normal subjects. Patellofemoral joint reaction force, stress, and moments were calculated during both exercises. From 0 – 46 degrees of knee flexion, patellofemoral joint reaction force was less during the CKC leg press. Conversely, from 50 – 90 degrees of knee flexion, joint reaction forces were lower during the OKC knee extension exercise. Joint reaction forces were minimal at 90 degrees of knee flexion during the knee extension exercise.

Escamilla et al observed the patellofemoral compressive forces during OKC knee extension and CKC leg press and vertical squat. Results were similar to the findings of Steinkamp et al; OKC knee extension produced significantly greater forces at angles less than 57 degrees if knee flexion while both CKC activities produced significantly greater forces at knee angles greater than 85 degrees.

When analyzing the biomechanics of the OKC knee extension, remember the concept from above regarding the quadriceps force near extension. Grood et al reported that quadriceps force was greatest near full knee extension and increased with the addition of external loading. The small patellofemoral contact area observed near full extension, as previously discussed, and the increased amount of quadriceps force generated at these angles may make the patellofemoral more susceptible to injury. At a lower range of motion, the large magnitude of quadriceps is focused onto a more condensed location on the patella.

My friend Rafael Escamilla has published a few new studies on patellofemoral joint forces during the lunge and squatting exercises. The first study, published in Clinical Biomechanics, demonstrated that the front and side lunge exercises showed the same pattern of force as the squatting and leg press, with more force the deeper the lunge. Interestingly, performing the lunge from a split-stance position (not actually striding to perform the lunge) also showed a decrease in force and should be used initially. His follow-up study demonstrated that a longer stride has less force than a shorter stride during the forward lunge.

Escamilla also analyzed the patellofemoral joint reaction forces between the wall squat (performed with feet close to wall and far away from wall) and the single leg squat. Results indicate that the closer your feet are to the wall, the greater the force during the wall squat exercise. At deeper angles > 60 degrees, the wall squat produced greater force than the one legged squat. Interesting results that should be applied to our exercise prescription.

Clinical Implications

When applying the results of Steinkamp(38), Escamilla(39), and Grood(40), it appears that during OKC knee extension, as the contact area of the patellofemoral joint decreases the force of quadriceps pull subsequently increases, resulting in a large magnitude of patellofemoral contact stress being applied to a focal point on the patella. In contrast, during CKC exercises, the quadriceps force increases as the knee continues into flexion. However, the area of patellofemoral contact also increases as the knee flexes leading to a wider dissipation of contact stress over a larger surface area.

Recently, Witvrouw et al (41) prospectively studied the efficacy of open and closed kinetic chain exercises during non-operative patellofemoral rehabilitation. 60 patients were participated in a 5-week exercise program consisting of either open or closed kinetic chain exercises. Subjective pain scores, functional ability, quadriceps and hamstring peak torque, and hamstring, quadriceps, and gastrocnemius flexibility were all recorded prior to and following rehabilitation as well as at 3 months proceeding. Both treatment groups reported a significant decrease in pain, increase in muscle strength, and increase in functional performance at 3 months following intervention.

Thus it appears that the use of both open and closed kinetic chain exercises may be used to maximize outcomes for patellofemoral patients if performed within a safe range of motion. I prescribe the form of exercise based on the clinical assessment. If CKC exercises are less painful than OKC exercises, than that form of muscular training is encouraged. Additionally, in postoperative patients, regions of articular cartilage wear is carefully considered before an exercise program is designed. Most frequently, I’ll allow open kinetic exercises such as knee extension from 90 – 40 degrees of knee flexion. This range of motion provides the lowest amount patellofemoral joint reaction forces while exhibiting the greatest amount of patellofemoral contact area. Closed kinetic chain exercises such as the leg press, vertical squats, lateral step-ups, and wall squats (slides) are performed initially from 0 to 30 degrees and then progressed to 0 to 60 degrees where patellofemoral joint reaction forces are lowered. As patient symptoms subside, the ranges of motion that are performed are progressed to allow greater muscle strengthening in larger ranges. Exercises are progressed based on the patient’s subjective reports of symptoms and the clinical assessment of swelling, painful crepitus, and discomfort.

Continue on to Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

ESCAMILLA, R., ZHENG, N., MACLEOD, T., EDWARDS, W., HRELJAC, A., FLEISIG, G., WILK, K., MOORMANIII, C., & IMAMURA, R. (2008). Patellofemoral compressive force and stress during the forward and side lunges with and without a stride Clinical Biomechanics, 23 (8), 1026-1037 DOI: 10.1016/j.clinbiomech.2008.05.002

What is Your Favorite New Book?

noreply@blogger.com (Mike Reinold) — Thu, 18 Jun 2009 16:03:00 +0000

I have an interesting question for all my readers, what is your favorite new “medical” book that you would recommend everyone to read? I say “medical” because I am sure you enjoyed Twilight or the new Harry Potter books, but I want to hear what new rehab, physical therapy, athletic training, massage, manual therapy, orthopedic, sports medicine, strength and conditioning, and any other medical book you would recommend from the last couple of years.

I am wrapping up the last couple of posts for patellofemoral pain series and preparing for my next series on my “essential reading list.” I want to hear your contributions.

I will include a “reader’s choice” list of essential books in this series so please do reply to this post with your suggestion. Thanks!

Photo by juhansonin

Michael Boyle’s 25 Mistakes in 25 Years

noreply@blogger.com (Mike Reinold) — Tue, 16 Jun 2009 10:00:00 +0000

It is with great pleasure that Strength and Conditioning Guru Michael Boyle has allowed me to reprint his magnificent article “25 Mistakes in 25 Years.” I remember reading this when it was first published and being blown away. I recently stumbled upon it again when I was browsing through Michael’s website StrengthCoach.com (which, if you haven’t checked out yet could possible be one of the best websites available on Strength and Conditioning).

This is probably a timely reprint of the post as Michael has just release a DVD of a presentation of the material in this article, called “Evolution of a Strength Coach,” available through Perform Better.

Thank you Michael for allowing me to share this with my readers, I know that this will be a valuable benefit for us all and if you’ve been living under a rock for the last 25 years, be sure to follow the links to learn more from Michael. Strength and conditioning concepts are extremely valuable for rehabilitation specialists.

25 Mistakes in 25 Years – The Evolution of a Strength Coach

Michael Boyle, MS, ATC

This year I'll enter my twenty-fifth year as a strength and conditioning coach. Last month I watched Barbara Walters celebrate her thirtieth year with a special called "30 Mistakes in 30 Years." I'm going to celebrate my twenty-fifth anniversary by telling you my top twenty-five mistakes. Hopefully I'll save you some time, pain, and injury. Experience is a wonderful but impatient teacher. And unfortunately, our experiences in strength and conditioning sometimes hurt people besides us.

Mistake #1: Knowing it all

I love Oscar Wilde's quote, "I'm much too old to know everything." Omniscience is reserved for the young. As the old saying goes, you have one mouth and two ears for a reason. I'd take it a step further and say the ratio is four to one: two eyes, two ears, and one mouth.

To continue down the cliché road, how about this one: "It's what you learn after you know it all that counts." When I was young I had many answers and few questions. I knew the best way to do everything. Now that I'm older I'm not sure if I even know a good way to do anything.

Mistake #2: Not taking interns sooner

I was so smart that no one was smart enough to help me. (See mistake number one.) My productivity increased drastically when I began to take interns.

Note: Interns aren't janitors, laundry workers, or slaves. They're generally young people who look up to you and expect to learn. Take your responsibility seriously. Remember the golden rule.

Mistake #3: Not visiting other coaches

God, it seems everything goes back to number one! I was too busy running the perfect program to attempt to go learn from someone else. Plus, when you know it all, how much can you learn?

Find the good coaches or trainers in your area (or in any area you visit) and arrange to meet them or just watch them work. I often will just sit with a notebook and try to see what they do better than I do.

I can remember current San Francisco 49'ers strength and conditioning coach Johnny Parker allowing us to visit when he was with the New England Patriots and then asking us questions about what we saw and what we thought he could do better. Coach Parker is a humble man who always provided a great example of the type of coach and person I wanted to be.

Mistake #4: Putting square pegs in round holes

The bottom line is that not everyone is made to squat or to clean. I rarely squatted with my basketball players as many found squatting uncomfortable for their backs and knees.

It killed me to stop because the squat is a lift I fundamentally believed in, but athletes with long femurs will be poor squatters. It's physics. It took me a while to realize that a good lift isn't good for everybody.

Mistake #5: Not attending the United States Weightlifting Championships sooner

My only visit as a spectator to an Olympic lifting meet made me realize that Olympic lifts produced great athletes. I know this will piss off the powerlifters, but those Olympic lifters looked so much more athletic.

I remember being at the Senior's when they were held in Massachusetts in the early eighties and walking away thinking, "This is what I want my athletes to look like." Understand, at that time I was a competitive powerlifter and my programs reflected that.

Mistake #6: Being a strength coach

How can that be a mistake? Let's look at the evolution of the job. When I started, I was often referred to as the "weight coach." As the profession evolved, we became strength coaches, then strength and conditioning coaches, and today many refer to themselves as "performance enhancement specialists."

All these names reflect the changes in our job. For too many years, I was a strength coach. Eventually I realized that I knew more about conditioning than the sport coaches did, so we took on that responsibility. Later, I realized that I often knew more about movement than the sport coaches too, so we began to teach movement skills. This process took close to eighteen of my twenty-five years. I wish it had been faster.

Mistake #7: Adding without subtracting

Over the years we've continued to add more and more CNS intensive training techniques to our arsenal. Squatting, Olympic lifting, sprinting, pulling sleds, and jumping all are (or can be) CNS intensive.

I think I do too much CNS intensive work, and intend to change that. My thanks go out to Jason Ferrugia for pointing out this one.

Mistake #8: Listening to track coaches

Please don't get me wrong. Some of the people who were most influential in my professional development were track coaches. I learned volumes from guys like Don Chu, Vern Gambetta, Charlie Francis, and Brent McFarland.

However, it took me too long to realize that they coached people who ran upright almost all the time and never had to stop or to change direction. The old joke in track coaching is that it really comes down to "run fast and lean left."

Mistake #9: Not meeting Mark Verstegen sooner

Mark may be the most misunderstood guy in our field. He's a great coach and a better friend. About ten years ago a friend brought me a magazine article about Mark Verstegen. The article demonstrated some interesting drills that I'd never seen. I decided my next vacation would be to Florida's Gulf Coast as Mark was then in Bradenton, Florida.

I was lucky enough to know Darryl Eto, a genius in his own right, who was a co-worker of Mark's. In the small world category, Darryl's college coach was the legendary Don Chu.

Darryl arranged for me to observe some training sessions in Bradenton. I sat fascinated for hours as I watched great young coaches work. Mark was one of the first to break out of the track mold we were all stuck in and teach lateral and multi-directional movement with the same skill that the track coaches taught linear movement. This process was a quantum leap for me and became a quantum leap for my athletes.

This was my step from strength and conditioning coach to performance enhancement specialist (although I never refer to myself as the latter). The key to this process was accepting the fact that Mark and his co-workers were far ahead of me in this critical area.

Mistake #10: Copying plyometric programs

This goes back to the track coach thing. I believe I injured a few athletes in my career by simply taking what I was told and attempting to do it with my athletes. I've since learned to filter information better, but the way I learned was through trial and error... and the error probably resulted in sore knees or sore backs for my athletes.

Track jumpers are unique and clearly are involved in track and field because they're suited for it. What's good for a long jumper is probably not good for a football lineman. It took me too long to realize this.

Mistake #11: Copying any programs

Luckily for me, I rarely copied strength programs when training my athletes. This mistake might be beyond the statute of limitations as it was more than twenty-five years ago.

I think copying the training programs of great powerlifters like George Frenn and Roger Estep left me with the sore back and bad shoulders I've carried around for the last twenty-five years. What works for the genetically gifted probably won't work for the genetically average.

Mistake #12: Not teaching my athletes to snatch sooner

We've done snatches for probably the last seven or eight years. The snatch is a great lift that's easier to learn than the clean and has greater athletic carryover. Take the time to try it and study it. You'll thank me.

Mistake #13: Starting to teach snatches with a snatch grip

When I realized that snatches would be a great lift for my athletes I began to implement them into my programs. Within a week some athletes complained of shoulder pain. In two weeks, so many complained that I took snatches out of the program. It wasn't until I revisited the snatch with a clean grip that I truly began to see the benefits.

Just remember, the only reason Olympic lifters use a wide snatch grip is so that they can reduce the distance the bar travels and as a result lift more weight. Close-grip snatches markedly decrease the external rotation component and also increase the distance traveled. The result is a better lift, but less weight.

Mistake #14: Confusing disagree with dislike

I think it's great to disagree. The field would be boring if we all agreed. What I realize now is that I've met very few people in this field I don't like and many I disagree with. I probably enjoy life more now that I don't feel compelled to ignore those who don't agree with me.

Mistake #15: Confusing reading with believing

This concept came to me by way of strength coach Martin Rooney. It's great to read. We just need to remember that in spite of the best efforts of editors, what we read may not always be true.

If the book is more than two years old, there's a good chance even the author no longer agrees with all the information in it. Read often, but read analytically.

Mistake #16: Listening to paid experts

Early on, many of us were duped by the people from companies like Cybex or Nautilus. Their experts proclaimed their systems to be the future, but now the cam and isokinetics are the past. Just as in any other field, people will say things for money.

Mistake #17: Not attending one seminar per year just as a participant

I speak approximately twenty times a year. Most times I stay and listen to the other speakers. If you don't do continuing education, start. If you work in the continuing education field, go to at least one seminar given by an expert in your field as a participant.

(Note: Mistakes 18-25 are more personal than professional, but keep reading!)

Mistake #18: Not taking enough vacation time

When I first worked at Boston University we were allowed two weeks paid vacation. For the first ten years I never took more than one.

Usually I took off the week between Christmas and New Years. This is an expensive week to vacation, but it meant that I'd miss the least number of workouts since most of my athletes were home at this time. I think the first time I took a week off in the summer was about four years ago. My rationale? Summer is peak training time. Can't miss one of those weeks.

I think there's a thin line between dedication and stupidity, and I often crossed it. I think in my early years I was more disappointed that the whole program hadn't collapsed during any of my brief absences. I felt less valuable when I returned from a seminar and realized that everything had gone great.

Stephen Covey refers to it as "sharpening the saw." Take the time to vacation. You'll be better for it.

Mistake #19: Neglecting your own health

This is an embarrassing story, but this article is all about helping others to not repeat my errors. Every year in February I'd find myself in the doctor's office with a different complaint: gastro-intestinal problems, headaches, flu-type illnesses, etc. I had a wonderful general practitioner who took a great interest in his patients. His response year after year was the same: slow down. You can't work 60-80 hours a week and be healthy.

Like a fool I yessed him to death and went back to my schedule. After about the fifth year of this process my doctor said, "I need to refer you to a specialist who can help you with this problem" and he handed me a card. I was expecting an allergist or perhaps some type of holistic stress expert. Instead I found myself holding a card for a psychiatrist.

My doctor's response was simple. I can't help you. You need to figure out why you continue to do this to yourself year in and year out. I went outside and called my wife. I told her it was a "good news-bad news" scenario. I wasn't seriously ill, but I might be crazy. Unfortunately, she already knew this.

Mistake #20: Not recognizing stress

Again I remember talking to a nurse who was treating me for a gastrointestinal problem. I seemed to have chronic heartburn. Her first question was, "Are you under any stress?" My response was the usual. Me? Stress? I have the greatest job in the world. I love going to work every day!

Do you know what her response was? She said, "Remember, stress isn't always negative." It was the first time I'd really thought about that. My job was stressful. Long days, weekend travel, too many late nights celebrating victories or drowning sorrows. A part-time job to make extra money meant working at a bar on Friday and Saturday until 2 AM, and that was often followed by drinks until 4 AM.

Sounds like fun, but it added up to stress. The lesson: stress doesn't have to be negative. Stress can just be from volume.

Mistake #21: Not having kids sooner

As a typical type-A asshole know-it-all, I was way too busy to be bothered with kids. They would simply be little people who got in the way of my plans to change the world of strength and conditioning. I regret that I probably won't live to 100. If I did I'd get to spend another 53 years with my kids.

Mistake #22: Neglecting my wife

See above. It wasn't until I had children that I truly realized how my obsession with work caused me to neglect my wife. I have often apologized to her, but probably not often enough.

Mistake #23: Not taking naps

Do you see the pattern here? Whether we're personal trainers or strength and conditioning coaches, the badge of honor is often lack of sleep. How often have you heard someone say, "I only need five hours a night!"

In the last few years I've tried to take a nap every day I'm able. As we age we sleep less at night and get up earlier. I'm not sure if this is a good thing. I know when I'm well-rested I'm a better husband and father than when I'm exhausted at the end of a day that might have begun at 4:45 AM.

There's no shame in sleep, although I think many would try to make us believe there is.

Mistake #24: Not giving enough to charity

Most of us are lucky. Try to think of those who have less than you. I'm not a religious person, but I've been blessed with a great life. I try every day to "pay it forward." If you haven't seen the movie, rent it. The more you give, the more you get.

Mistake #25: Reading an article like this and thinking it doesn't apply to you

Trust me, denial is our biggest problem.

For more information, please visit the below sites:

Patellofemoral Treatment Guidelines

noreply@blogger.com (Mike Reinold) — Tue, 09 Jun 2009 10:00:00 +0000

Now that we have spent some time discussing the differential diagnosis of patellofemoral pain and principles of patellofemoral rehabilitation, we can move on to discussing specific treatment strategies for each of the differential diagnoses we previously discussed. If you have not read part 3 of this series on the classification of patellofemoral pain, you may want to go back as the following suggestions are based on that information.

Remember, if you take one thing away from this series, treatment should be based on an accurate diagnosis! Diagnosing someone with patellofemoral pain syndrome is like giving up and saying you don’t know what is wrong with the patient!

The following is part 5 of the series on solving the patellofemoral mystery:

Part 1: Introduction – Solving the patellofemoral mystery
Part 2: What causes patellofemoral pain?
Part 3: Differential diagnosis of patellofemoral pain
Part 4: Principles of patellofemoral joint rehabilitation
Part 5: Specific treatment guidelines for patellofemoral pain
Part 6: Biomechanics of the patellofemoral joint – clinical implications
Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

Specific Treatment Based on an Accurate Diagnosis

Patellar Compression Syndromes

In general, the main goals of treating a patient with a compression syndrome is to loosen the restrictions and minimize the subsequent inflammation. These are the patients that respond well to what I call a “loss of motion” protocol:

Heat/whirlpool to warm up the tissue and prepare for treatment
Continuous ultrasound to tight area. We can argue about the efficacy of US but I think this is a good time for it’s use. I am aggressive - continuous, jack it up to 2.0 and keep the area small, of course use patient tolerance as a guideline!
Soft tissue massage progressing to aggressive massager or friction as inflammation subsides. Specific trigger point and muscle energy techniques can be helpful as well, especially in the patient with tight hips that are contributing to ELPS.
Patellofemoral joint mobilization in whatever direction is needed
For a patient with ELPS, I would consider trying patellar taping. I don’t use this to really change the alignment or biomechanics of the patellofemoral joint, study after study shows this does not happen with tape. I do however believe that the tape can be applied to potentially cause a low-load, long-duration stretch of the soft tissue/retinaculum around the knee. Remember, that stress and tension of the surround tissue may be the cause of patellofemoral pain.
Generalized stretching of the lower extremity with specific emphasis on tight structures impacting the PF joint (i.e. the IT band).
As with anything else related to the patellofemoral joint, look at the hip and foot to see if any biomechanical factors are contributing to lateral tightness of the knee.

There are also some things that should be avoided in these patients:

Bike riding – it is just going to compress the PJ joint and cause more symptoms
Exercises with high PF joint reaction forces, such as knee extension. Again, just going to cause more compression and more irritation.
In the patient with global compression syndrome, I would recommend you avoid taping. Again, just going to cause undue compression.
In general, I would be conservative in strengthening exercises for the global compression patient. Straight leg raises, pool work, and other basic exercises should be enough while you loosen up the soft tissue.

Patellar Instability

The treatment for patellar instability depends on the chronicity of symptoms. For acute episodes, treatment will revolve around the “damage control,” or settling down the acute effusion and trauma associated with the incident.

For the later phases of acute instability or those with chronic recurrent instability, we are basically dealing with a lack of “static” stability from the osseous and ligamentous structures of the knee. Thus, treatment should focus on enhancing stability in two ways:

Enhance static stability. If this is an anatomical issue, this may be difficult if not impossible. This is the perfect patient for a patellofemoral brace. While a general donut knee sleeve or some of the older patellofemoral braces may be enough for some patients, there are a lot of newer and more advanced bracing. I have used the DonJoy Tru-Pull brace with success. What types of braces have you tried and preferred?
Enhance dynamic stability. This is the general long term goal for these patients. It starts with enhancing strength and progresses to neuromuscular control exercises. This in itself is a lengthy topic, but I recommend you check out a DVD of the principles of neuromuscular control during knee treatment that Kevin Wilk and I have produced (more information here from AdvancedCEU). This will include dynamic stability of the entire lower extremity as any weakness in the kinetic chain could cause an excessive lateral stress on the patellofemoral joint. More to come on this in a future post in this series.

Biomechanical Dysfunction

As previously stated in my post on the classification of patellofemoral pain, the knee appears to take a good amount of stress when biomechanical faults are present both proximally and distally within the kinetic chain. Alterations in foot and ankle mechanics, hip strength, leg length discrepancy, flexibility deficiencies, and any combination of these factors can have a negative impact on the forces observed at the patellofemoral joint. Not only can biomechanical dysfunction lead to increased stress, it can also lead to chronic adaptations over time. Take for example someone with weak hip external rotation. This could lead to a dynamic inability to control the hip adduction and IR moment at the knee and cause the femur to rotate into internal rotation during activities. This will cause the patella shift laterally and can cause articular cartilage and soft tissue changes that will mimic a typical ELPS patient. You can loosen up the lateral soft tissue but without treating the true cause, the hip weakness, symptoms will continue to occur.

This will be discussed in greater detail in a future post in this series as this is an important factor to consider.

Direct Patellar Trauma

Ouch, I hate even thinking about direct patellar trauma. My knee hurts just thinking of it! With this pathology, we are worried about either a patellar fracture or articular cartilage damage.

Once the initial trauma subsides, treatment should attempt to enhance cartilage healing. This means frequent ROM of the knee. In addition to standard PROM, this can be in the form of a bike, if minimal resistance is applied. You do not want to compress too much but a little bit of motion is better for cartilage healing. I also like the pool for these patients if possible. You’ll have to limit patellofemoral joint reaction forces with exercises but this should subside with time.

If symptoms do not resolve, the patient should be sent back to their doctor for further evaluation to rule out a fracture or a OCD type cartilage lesion.

Soft Tissue Lesions

Treatment of soft tissue lesions to the plica, IT band, fat pad, or medial patellofemoral ligament involves an understanding of the basic principles of patellofemoral pain rehabilitation, but there are a few things to consider as well. In general, you should stop the activity that is causing the irritation and avoid direct pressure on that area, so no transverse friction massage initially. This may be appropriate when chronic to stimulate healing, but in my experience this tends to make things worse for soft tissue lesions. I have found that direct anti-inflammatory modalities, such as an iontopatch, is helpful for these superficial areas of inflammation. Other treatment strategies for specific lesions include:

Suprapatellar plica syndrome. The plica will get stressed over the medial femoral condyle with knee flexion, so avoid activities with repetitive flexion, such as bike riding and running.
IT band friction. Similarly to above but with the lateral femoral condyle. Lengthening massage to the IT band has been helpful in my practice.
Fat pad syndrome. The patient should avoid excessive quadriceps activities, especially if this causes irritation to the fat pad as the patellar tendon can compress the area when contracting the quad.
Medial patellofemoral ligament injury. These patients should actually have treatment similar to the ELPS patient above. A brace to control lateral patellar translation may be helpful too.

Overuse Syndromes

Overuse syndromes include tendonopathy to the patellar tendon, and less commonly quadriceps tendonitis superiorly, and apophysitis of the tibial tuberosity or inferior patellar pole.

For tendonopathy, treatment begins with assessing the chronicity of symptoms. If acute, reduce inflammation and restore strength and flexibility. I hate to be vague, but I doubt you’ll see a lot of patients that are this acute. Realistically, people put off treatment for months and end up with chronic tendonosis. This is another lengthy topic, but the key here is that the patellar tendon is not actually inflamed, it is degenerative due to a lack of healing blood supply (that is why the surgery for this is debridement to stimulate healing). Thus, traditional treatment to reduce inflammation is not going to work. In a way, you need to induce a certain amount of trauma, such as with transverse friction massage. I also recommend that general orthopedic patients need to feel about a 3-4/10 on a pain scale during exercises to actually stimulate healing. Any less and you probably aren’t stressing the area enough and any more and you may overloading.
Apophysitis of the tibial tuberosity or inferior patellar pole can be a pretty limiting pathology. The two best treatments are time and avoiding the activity that causes symptoms. That means many youth injuries will need to take some time off from basketball, or whatever may be causing their symptoms, as their body grows and the symptoms resolve. Treatment is basically to reduce symptoms, there isn’t much you can do to actually “heal” the injury.

Now that we have discussed the basic principles of patellofemoral rehabilitation and some specific treatment guidelines for various diagnoses, you should have a good basis to improve the care of your patients. The principles discussed so far are extremely important to understand and apply to each patient to assure you are optimizing your treatments and enhancing your outcomes. The next two posts in this series will take treatments one step further as we talk about the biomechanics of the patellofemoral joint during exercises and the influence of the kinetic chain on the patellofemoral joint.

Continue reading to part 6 – Biomechanics of Patellofemoral Rehabilitation

Please comment on your experiences as well, specifically your experience with taping and bracing of the patellofemoral joint. I know many people swear that taping is extremely effective. Maybe some of those people can share their perspective and some advice on indications and how to maximize the effectiveness of taping?

Strength and Conditioning Webinars

noreply@blogger.com (Mike Reinold) — Sun, 07 Jun 2009 13:20:00 +0000

I am not usually a fan of posting new information over the weekend, I don’t want to take away from your families. However, this is a special situation as there is a limited time offer that expires on Monday for subscriptions to a new website for strength and conditioning webinars.

StrengthAndConditioningWebinars.com is a new website featuring some the world’s greatest strength and conditioning coaches, as well as other rehabilitation specialists such as physical therapists and athletic trainers. As a physical therapist, I find that it is a huge benefit to myself and my patients by learning from the experts in the field of strength and conditioning, including Michael Boyle, Gray Cook, Alwyn Cosgrove, and many more. The site will feature quality webinars for you to view in the comfort of your home at your own pace.

The normal monthly subscription is going to be $29.99 but if you sign up by the end of the day Monday June 8th you can gain access for a huge discount of $19.99. You’ll get at least 2 webinars a month, which is a great deal considering most webinars you find on the internet are $25-30 each. This is really a great deal, even at the regular price of $30 a month. Follow the link below for more information:

Signup by Monday June 8th for a Huge discount

My readers know that I am a fan of the webinar concept and think that this will be the premier continuing education model in the future. In fact, I have many of my own continuing education webinars available at AdvancedCEU.com and even more being schedule as we speak.

I already have my subscription, see you there in the forums!

Why You Want to Subscribe to My FREE Newsletter

noreply@blogger.com (Mike Reinold) — Thu, 04 Jun 2009 10:00:00 +0000

I am happy to introduce the addition of a newsletter to this website. What is the difference between reading my website and subscribing to my newsletter? Why would you want to subscribe to my newsletter? Let me explain.

I have been very pleased with the direction of this website and the feedback I have received within our professions. Many blogs and websites have frequent updates, sometimes even several a day. I do not want to increase the frequency of postings on this site because I fear that they will become diluted. I enjoy letting everyone get a chance to read my posts and comment and discuss among each other. I like the idea of posing questions and receiving comments from all my readers.

However, I still enjoy my “Plays of the Week” posts and other quick and informative notes about other topics or information I am reading on other websites. If I were to post on everything I wanted to share, it would be difficult for you as a reader to truly find the educational articles on this site and participate in any discussions.

Hence the development of a newsletter. I hesitate to call it a “weekly” newsletter as I likely will send one out 2-3 times a month, but maybe more during my offseason.

Benefits of Subscribing to my FREE Newsletter

Additional quick clinical commentaries and pearls not found on this website
Links to other great information and videos around the web. The newsletter will now officially replace the very popular “Plays of the Week” posts.
Answers to reader questions. I am looking forward to this one. Realistically, I receive A LOT of emails from this website and I do my best to answer them. I have found that there are many questions that all my readers would like benefit from hearing.
Recaps of some of the great discussions on this website
Special offers, contests, and promotions from myself and AdvancedCEU.com
And more things to come!

Best of all, the newsletter is free. And trust me, I hate spam too, you will not be bombarded with spam and your email will not be shared.

So what are you waiting for? Sign up now below!

Celebrating My 100th Post: A Special FREE Offer You Can’t Miss!

noreply@blogger.com (Mike Reinold) — Mon, 01 Jun 2009 10:00:00 +0000

I wanted to take this opportunity to celebrate my 100th post on this website with a few exciting bits of news including a FREE offer and information on my new newsletter! When I started this website last fall, I really had no idea what to expect. I wanted to provide a website that I could post information on new techniques and research in the fields of physical therapy, athletic training, sports medicine, and strength and conditioning. I had no idea how successful the website would be and at the time it didn’t really matter, I was writing for myself, to keep myself sharp and to motivate myself to stay current on new research. If a few people took that journey with me, great.

100 posts and over 50,000 visitors later, I am happy to say that I am not alone in this journey, and that is a huge part of this website’s success. Because of your interaction, your comments to posts, your discussions, this website has become a resource and more importantly, fun. Thank you.

Open Discussion Forum

We are deep in the middle of a series of clinical commentaries on patellofemoral pain. While I do enjoy writing and sharing this information, the lack of comments and discussions in these types of posts can make them a little less fun to write. Please do continue to comment.

For this week, I again open up the comments section of this post for any and all questions. Feel free to ask myself and my readers anything and be sure to get involved in the discussion. This will be the 3rd open discussion forum and I know it will continue to be popular. This can be anything, maybe a clinical question, troublesome patient, or if you are looking for recommendations, please do reply to this post.

A special FREE Offer

This is an unheard of special offer to celebrate my 100th post. For three days only this week, June 1-3, 2009, AdvancedCEU.com will offer readers of my website their most popular education product, their Rehabilitation Protocols for the Knee and Shoulder on CD by myself and Kevin Wilk, FREE when you purchase our 4 DVD set on the examination and treatment of the knee and shoulder. This CD combo is normally $100! These are the quality protocols you have seen in our publications and extremely popular, in fact, they are the best sellers at AdvancedCEU.com. Details and a link to the offer are below.

Not interested in buying the 4 DVD set? AdvancedCEU.com has an offer for you too. Use the coupon code “100posts” and receive the Rehabilitation Protocols for the Knee and Shoulder on CD for 25% off! Visit AdvancedCEU.com’s rehabilitation protocol page for more information or click this link to purchase the CDs. Be sure to use coupon code “100posts” (without the quotes!).

I do ask one simple favor in return, using the honor system of course: If you use this offer or coupon, please subscribe via email to this site and please tell your colleagues about this website!

Here are the details of the free offer:

If you purchase the four DVD set of the Examination and Treatment of the Knee and Shoulder by myself and Kevin Wilk, you will receive a FREE copy of the Knee and Shoulder Rehabilitation Protocols on CD. This is a $100 value, FREE. In total, this is a 4 DVD and 2 CD set.
All orders within the USA will receive FREE shipping
This offer is only valid on 6/1-3/09 and not eligible on past sales, no substitution of products allowed.
No coupon is required, however, you MUST use the below link to make this purchase, normal purchases through the AdvancedCEU website are not eligible for the discount. Link:

CLICK HERE: FREE Knee and Shoulder Rehabilitation Protocol CDs

More Exciting News and a New Newsletter

The series of patellofemoral rehabilitation will continue next week, we are getting close to wrapping up.
A new series will begin shortly after. In this series, I have asked many of the leaders in our fields to provide a list of essential books that they feel were vital to their clinical development. This is going to be a fun series as I have posts from George Davies, Eric Cressey, Sue Falsone, Ken Crenshaw, Leon Chaitow, Michael Boyle and more. After posting each list of books, I will summarize with a few additions of my own and finally create an Essential Reading List! I am excited about this series.
I am also excited to introduce a newsletter in the next few weeks. We have so many people that receive all my posts via email already, this is just an extension of that. I hesitate to call it a “weekly” newsletter, because there will be times when it is frequent and times where I need to skip a week. I want to introduce the newsletter so that I can provide more information to my readers. With all the great content, it is to fit in posts on some exciting new research or articles I am reading on the internet. I want to share these but I don’t want to bog down the content on this blog. So posts like my “plays of the week” that are so popular, will actually be in the newsletters only. I will be doing other things with the newsletter, such as new exercises, links to rehab videos, special Q&A sessions with other experts, and special contests and promotions. I will also use it to answer some of the many emails that I receive to share some of your questions with everyone. It will be well worth subscribing, and why not, it’s free and I hate spam so your email is safe with me! Details coming soon.

Thanks again everyone for 100 posts!

Photos courtesy: D Sharon Pruitt and Pkeleher

10 Principles of Patellofemoral Rehabilitation

noreply@blogger.com (Mike Reinold) — Thu, 28 May 2009 10:00:00 +0000

Although the key to successful rehabilitation program for patellofemoral pain requires an accurate differential diagnosis, there are several principles to patellofemoral rehabilitation that should be considered when designing any program. Below are what I would consider the 10 key principles of patellofemoral rehabilitation. They can be used as a backbone to many programs and customized based on the specific diagnosis.

This is part 4 of a series on solving the patellofemoral mystery:

Part 1: Introduction – Solving the patellofemoral mystery
Part 2: What causes patellofemoral pain?
Part 3: Differential diagnosis of patellofemoral pain
Part 4: Principles of patellofemoral joint rehabilitation
Part 5: Specific treatment guidelines for patellofemoral pain
Part 6: Biomechanics of the patellofemoral joint – clinical implications
Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

1. Reduce Swelling

The first principle of patellofemoral rehabilitation is the reduction of swelling. Patellofemoral patients often present with joint effusion following injury and postoperatively. Chronic edema may also exist due to repetitive microtrauma of the soft tissues surrounding the patellofemoral joint.

Numerous authors have studied the effect of joint effusion on muscle inhibition. DeAndrade et al (JBJS 1965) were the first to report in the literature that joint distention resulted in quadriceps muscle inhibition. A progressive decrease in quadriceps activity was noted as the knee exhibited increased distention. Spencer et al (Archive Phys Med Rehab 1984) found a similar decrease in quadriceps activation with joint effusion. The authors reported the threshold for inhibition of the vastus medialis to be approximately 20-30ml of joint effusion and 50-60ml for the rectus femoris and vastus lateralis. This is really not a lot of fluid, so any amount of effusion is significant. An unpublished study by Bob Mangine in the 1990’s showed that just a 30-40ml increase in fluid to the knee resulted in almost a 50% drop in quadriceps peak torque.

The reduction in knee joint swelling is crucial to restore normal quadriceps activity. Treatment options for swelling reduction include cryotherapy, high-voltage stimulation, and joint compression through the use of a knee sleeve or compression wrap. I personally really like the Bauerfeind knee sleeves for knees that have some effusion. In patients who have undergone a lateral retinacular release, a foam wedge shaped to form around the lateral patella can be utilized in conjunction with a wrap to provide patella medialization and increased compression around the lateral genicular artery I would not hesitate to use a knee sleeve or compression wrap to apply constant pressure while performing everyday activities in an attempt to minimize the development of further effusion.

2. Reduce Pain

The second principle of patellofemoral rehabilitation is the reduction of pain. Pain may also play a role in the inhibition of muscle activity observed with joint effusion. Young et al (MSSE 1983) examined the electromyographic activity of the quadriceps in the acutely swollen and painful knee. An afferent block by local anesthesia was produced intraoperatively during medial meniscectomy. Patients in the control group reported significant pain postoperatively and pronounced inhibition of the quadriceps (30-76%). In contrast, patients with local anesthesia reported minimal pain and only mild quadriceps inhibition (5-31%).

Pain can be reduced passively through the use of cryotherapy and analgesic medication. Immediately following injury or surgery, the use of a commercial cold wrap, such as a DonJoy Iceman, can be extremely beneficial. Passive range of motion may also provide neuromodulation of pain during acute or exacerbated conditions. Various other therapeutic modalities such as ultrasound and electrical stimulation may also be used to control pain via the gate control theory if that is your belief.

3. Restore Volitional Muscle Control

The next principle involves reestablishing voluntary control of muscle activation. Inhibition of the quadriceps muscle is a common clinical enigma in patellofemoral patients, especially in the presence of pain and effusion during the acute phases of rehabilitation immediately following injury or surgery. Electrical muscle stimulation and biofeedback are often incorporated with therapeutic exercises to facilitate the active contraction of the quadriceps musculature.

Snyder-Mackler et al (JBJS 1991) examined the effect of electrical stimulation on the quadriceps and musculature during 4 weeks of rehabilitation following ACL reconstruction. The authors noted that the addition of neuromuscular electrical stimulation to postoperative exercises resulted in stronger quadriceps and more normal gait patterns than patients exercising without electrical stimulation. Delitto et al (PT 1988) and Snyder-Mackler et al (JBJS 1995) reported similar results of both the quadriceps and hamstrings using electrical stimulation for a 3-week and 4-week, respectively, training period following ACL reconstruction.

The use of electrical stimulation and biofeedback on the quadriceps musculature appears to facilitate the return of muscle activation and may be valuable additions to therapeutic exercises. Clinically, I use electrical stimulation immediately following injury or surgery while performing isometric and isotonic exercises such as quadriceps sets, straight leg raises, hip adduction and abduction, and knee extensions. I also use this as a maintenance program with many of my athletes with chronic knee issues.

4. Emphasize the Quadriceps

The next principle of patellofemoral rehabilitation is to strengthen the knee extensor musculature. Some authors have recommended emphasis on enhancing the activation of the VMO in patellofemoral patients based on reports of isolated VMO insufficiency and asynchronous neuromuscular timing between the VMO and VL.

While the literature offers conflicted reports on selective recruitment and neuromuscular timing of the vasti musculature, the VMO may have a greater biomechanical effect on medial stabilization of the patella than knee extension due to the angle of pull of the muscle fibers at approximately 50-55 degrees. Wilk et al(JOSPT 1998) suggest that the VMO should only be emphasized if the angle of insertion of the VMO on the patella is in a position in which it may offer a certain degree of dynamic or active lateral stabilization. As you can see by the figure, if the fibers are not aligned in a position to assist with patellar stabilization, VMO training will likely not be effective. This orientation of the muscle fibers will differ from patient to patient and can be visualized.

Several interventions and exercise modifications have been advocated to effectively increase the VMO:VL ratio, based mostly on anecdotal observations. These include hip adduction, internal tibial rotation, and patellar taping and bracing. Powers(JOSPT 1998) reports that isolation of VMO activation may not be possible during exercise, stating that several studies have shown that selective VMO function was not found during quadriceps strengthening exercises, exercises incorporating hip adduction, or exercises incorporating internal tibial rotation. Powers also states that although the literature offers varying support for VMO strengthening, successful clinical results have been found while utilizing this treatment approach.

My belief is that quadriceps strengthening exercises should be incorporated into patellofemoral rehabilitation programs. Strength deficits of the quadriceps may lead to altered biomechanical properties of the patellofemoral and tibiofemoral joints. Any change in quadriceps force on the patella may modify the resultant force vector produced by the synergistic pull of the quadriceps and patellar tendons, thus altering contact location and pressure distribution of joint forces. Furthermore, the quadriceps musculature serves as a shock absorber during weightbearing and joint compression, any abnormal deviations in quadriceps strength may result in further strain on the patellofemoral and/or tibiofemoral joint.

In reality, I believe that quadriceps strengthening is very important for patellofemoral rehabilitation, but many exercises designed to “enhance VMO” strength or activation may actually be disadvantageous to the joint. Take for example the classic squeezing of the ball during closed kinetic chain exercises such as squatting and leg press. This creates an IR and adduction moment at the hip that is now known to be detrimental to patellofemoral patients. I would actually propose that we work on quadriceps strengthening without an adduction component and rather emphasize hip adbuction and external rotation. This can be performed with the use of a piece of exercise band around the patient’s knees during these exercises. We will get into this in more detail in an upcoming post in this series.

5. Control the Knee Through the Hip

Again, I don’t want to get to much into this as we will spend an entire post on this topic, but the importance of hip strength can not be overlooked. Every patellofemoral patient should be assessed for hip weakness and poor dynamic control of their knee during functional activities. You will be shocked at how many of your patients have absolutely no strength outside of the sagittal plane. It is amazing.

Emphasize the hip’s ability to eccentrically control the valgus moment at the knee produced by hip IR and adduction. I can’t say it enough, work on hip abduction and ER. This tip alone will greatly enhance your patellofemoral outcomes. More on this in a future post.

6. Enhance Soft Tissue Flexibility

Another principle of patellofemoral rehabilitation is the enhancement of joint flexibility with emphasis on quadriceps, hamstrings, hip adductors, gastrocnemius, and iliotibial band stretching. Any deficit in flexibility of these areas will cause significant biomechanical faults throughout the kinetic chain.

Rehabilitation should focus on restoring full passive knee extension initially to minimize the development of a flexed knee posture exhibited by some patients with patellofemoral disorders. Ambulating and performing daily activities with a knee flexion contracture may result in increased patellofemoral joint reaction forces and requires a great deal of motor control to stabilize the knee joint. Full passive knee extension is important for improved quadriceps activity and also allows the knee to lock out while standing, thus allowing relaxation of the surrounding musculature.

Restoring full knee flexion is also a significant priority. In postoperative patients, knee flexion is gradually restored especially in the presence of an effusion. In non-operative patients, knee flexion is gradually restored through controlled stretching exercises. The goal of restoring full knee flexion is not merely reestablishing quadriceps flexibility but improving soft tissue flexibility of the retinacular tissues as well.

Witvrouw et al (AJSM 2000) prospectively studied the risk factors for the development of anterior knee pain in the athletic population over a 2-year period. A significant difference was noted in the flexibility of the quadriceps and gastrocnemius muscles between the group of subjects that developed patellofemoral pain and the control group, suggesting that athletes exhibiting tight musculature may be at risk for the development of patellofemoral disorders.

7. Improve Soft Tissue Mobility

Soft tissue mobility is another rehabilitation principle that must be addressed. The goal of rehabilitation is to restore the soft tissue flexibility of the medial and lateral retinacular and capsular tissues. This may assist in controlling patellofemoral joint reaction forces by balancing the soft tissue pliability medially and laterally, and by correcting a possible tilt or rotation of the patella. Additionally, patellar mobilization techniques should be utilized to restore superior and inferior patellar mobility as well. Treatment techniques include patellar mobilizations and the application of patellar tape.

While taping of the patella has received conflicting reports in the literature regarding its efficacy for correcting biomechanical deficits of the patella, taping may assist in restoring soft tissue flexibility by providing a low-load prolonged stretch of the retinacular tissues. Study after study shows that tape does not impact patella position or tracking (don’t get me wrong there are some that show that it does, but there are more that says tape does not). My personal belief is that this is the reason for a reduction in symptoms with the application of tape. Remember that the source of patellofemoral pain may not be from the articular cartilage but rather from the retinacular tissue.

The utilization of a brace which imparts a medial glide or force to the patella may also be beneficial. There are many on the market and I truly have no preference at this time. It seems like a new and improved brace comes out every 6 months. Preliminary MRI studies have documented the effectiveness of bracing.

8. Enhance Proprioception and Neuromuscular Control

Rehabilitation programs must also include drills designed to restore proprioceptive and neuromuscular control skills in patellofemoral patients. Proprioception and postural balance training begins immediately postinjury or postoperatively. Specific drills initially include weight shifting side-to-side, weight shifting diagonally, mini-squats, and mini-squats on an unstable surface such as a tilt board. As the patient advances, tilt board squats can be progressed from double leg to single leg.

Perturbations can further be added to challenge the neuromuscular system. Initially, the clinician can apply manual perturbations. As the patient sustains a vertical squat on a tilt board at 30 degrees of knee flexion, the clinician adds perturbations by tapping the board with his or her foot.

Ball tosses can be incorporated with manual perturbations to provide additional challenge. The patient progresses to perform a vertical squat to 30 degrees of knee flexion while performing a chest-pass with a 3-5 pound weighted ball. The rehabilitation specialist continues to add manual perturbations by tapping the board. Ball throws are progressed from chest-passes to side-to-side throws, and then overhead soccer throws. Again, these exercises can be progressed from double-leg to single-leg stance to further challenge the patients neuromuscular control.

Depending on their sport participation, jump and landing training may also be necessary to teach the athlete how to avoid detrimental positions.

9. Normalize Gait

Gait training is also a critical component to patellofemoral rehabilitation. A variety of factors contribute to antalgic and inefficient gait patterns including joint effusion, pain, soft tissue tightness, and scar tissue formation.

Strategies used to minimize the flexed knee gait pattern that is commonly exhibited by patellofemoral patients include minimizing joint effusion and enhancing sift tissue flexibility, particularly the hamstring and gastrocnemius musculature. Specific techniques include retrograde walking over cones. This particular exercise requires adequate quadriceps control and involves the patient ambulating while high stepping over successive cones. As the patient moves backward, the foot strikes the ground in a toe to heel pattern to produce an extension moment at the knee.

10. Gradually Progress Back to Activities

Lastly, as the patellofemoral patient progresses through the rehabilitation program, emphasis should shift towards functional activities that replicate activities specific to each patient. The rate of progression with functional activities is dictated by the patient’s unique tolerance to the activities. Exercise must be performed at a tolerable level without overstressing the healing tissues. Pathological loading that produces detrimental stress on the patellofemoral joint should be avoided to prevent exacerbations of symptoms. Functional stresses are gradually increased leading to a steady return to function. The functional progression of activities should follow a progressive and sequential order to ensure proper amounts of stress are applied to facilitate healing without producing disadvantageous forces.

I hope that these principles are helpful in establishing a proper and comprehensive treatment program. Next post will focus on specific treatments for each diagnosis previously discussed based on the classification of patellofemoral pain. As always, I would love to hear your thoughts on what other principles you feel are important. I am sure there are some thoughts on bracing and taping. In my experience, the benefits have been limited but I am eager to hear your thoughts as I am sure there are many of you with far more experience with these techniques than myself.

Continue reading to Part 5: Specific Treatment Guidelines for Patellofemoral Pain

Dynamic Neuromuscular Stabilization

noreply@blogger.com (Mike Reinold) — Mon, 25 May 2009 10:00:00 +0000

Is strength alone enough to assure proper function of a specific muscle? Can a specific muscle function well without proper stabilization?

Today’s guest post is from Steve Smith, PT, DPT, SCS, CSCS. Steve is the Manager of Performance Physical Therapy at the Athlete’s Performance Center in the Andrews Institute in Gulf Breeze, FL. Steve is discussing an interesting topic on dynamic neuromuscular stabilization from a Pavel Kolar seminar last year. I hear it was a great seminar, unfortunately I was also supposed to attend and am still disappointed that I missed out! But I guess the birth of child takes precedence! Thanks for sharing Steve.

Muscle Function is Determined by It’s Specific Function AND Stabilization

This is the first time I’ve posted on Mike’s blog and I’d like to thank him for inviting me to do so. I’ve been on the site several times and found it to be a valuable resource. Hopefully this will add to it and stir up some good clinical discussion so here it goes.

I was fortunate enough to be able to attend a seminar at our Tempe, Arizona facility last November. It was put on by Athletes’ Performance, Dr. Craig Liebenson, and Ken Crenshaw. Dr. Liebenson is a well known chiropractor in L.A. and Ken is the head athletic trainer for the Arizona Diamondbacks. The seminar topic was “Dynamic Neuromuscular Stabilization” or DNS and it was presented by Prof. Pavel Kolar. His mentor was, among others, Vladimir Janda. DNS is a method designed to restore and stabilize locomotor function.

His theories have really stuck with me and have changed the way I approach treatment of my athletes. I wanted to talk about one thing in particular. The theory or fact, depending on who and what you believe, that:

“The functioning of any muscle is determined not only by its specific function but also by its stabilization.”

This leads to the conclusion that a muscle may not be weak in or of itself but rather test weak because it has insufficient stabilization proximally. In other words, every muscle or group of muscles needs a fixation point or “punctum fixum” (as Dr. Kolar calls it) in order to be able to perform its function in athletics. For example, the muscles of the rotator cuff may test weak because they are not getting sufficient stabilization from the muscles that control scapular position. In turn, the parascapular muscles may also test weak because they are not getting sufficient stabilization from the muscles that control trunk/spinal position. Conclusion? With upper and lower extremity function, everything really does come back to how efficiently the athlete stabilizes their trunk.

Some exercises/activities we commonly use to evaluate how well an athlete stabilizes their trunk (controls the position of their trunk) can also be used as trunk stabilization exercises. A few examples are as follows (from least to most difficult):

Supine Overhead Upper Extremity Elevation

Both arms are elevated overhead and we are watching for rib flare anteriorly/upwardly which could potentially indicate poor rib fixation by the obliques/poor thoracolumbar stabilization. Start and finish positions:

Poor mechanics are shown below, notice the lumbar spine and rib movement needed to achieve full overhead motion:

Quadruped Multiplanar Lower Extremity Movements

The hip is flexed, extended, or externally rotated from the starting position and attention is focused on how well the athlete controls thoracolumbar position during these movements. Start and finish positions:

Poor mechanics are shown below, notice the excessive trunk movement:

Half Kneeling Chop and Lift

Use a bar/cable, band, or tricep rope/cable for resistance and execute a chop or lift pattern with the upper extremities while in a one-knee-down half-kneeling position. Focus attention on how well the athlete activates and stabilizes all 3 parts of their pillar (scapula, torso, hips). Make sure the rib cage is engaged by the obliques and does not flare, the glute on the side of the down knee is activated, and scapular position/control is maintained throughout the movement. Start and finish positions:

Poor mechanics are shown below, notice again the lack of control of the scaps, torso, and hips, allowing excessive motion in these areas:

When thinking about how the human body truly functions, it is important to understand specific muscle function and the consequence of lack of stabilization around the area. This is an interesting and important concept that can be applied to several aspects of rehabilitation and sports training to help achieve optimal function and performance. Have you had any success using this or similar concepts in the rehab or training of people? What other tests and exercises do you find helpful to enhance dynamic neuromuscular stabilization?

Only a Few Weeks Remaining to Register for MGH Sports Medicine 2009!

noreply@blogger.com (Mike Reinold) — Thu, 21 May 2009 10:00:00 +0000

If you are in the Boston area June 14th-16th, you’ll want to check out Massachusetts General Hospital’s Sports Medicine 2009 Conference that I am co-directing with Dr. Tom Gill and Dr. Bill Palmer. This is my favorite type of conference, integrating multiple disciplines together for one huge course, ranging from physical therapists, to orthopedic surgeons, to internists, to radiologists, to strength and conditioning specialists.

We decided that we needed to have a greater emphasis on rehabilitation during the conference this year and I am proud to say the response has been outstanding! We already have well over 200 registrations and have surpassed last years final attendance. I am especially looking forward to the afternoon of open lab sessions that we are performing on Monday. Come join myself, Kevin Wilk, Eric Cressey, and more for the premier sports medicine course in New England! Please do grab me during breaks and introduce yourself, I always enjoy talking with my readers.

Click for more information –> MGH Sports Medicine 2009

Classification of Patellofemoral Pain

noreply@blogger.com (Mike Reinold) — Mon, 18 May 2009 10:00:00 +0000

In 1998, one of the most influential publications of the last 2 decades was published on treatment of the patellofemoral joint. Four of the leaders and pioneers of sports medicine and orthopedic rehabilitation – Kevin Wilk, George Davies, Bob Mangine, and Terry Malone - teamed up to develop a classification system for the differential diagnosis of patellofemoral pathologies. This manuscript was the first to offer treatment strategies based on specific diagnoses for patellofemoral pain. Today, this manuscript still holds extreme value and if you haven’t read it, I highly recommend finding a copy.

By far the most critical component of treating the patellofemoral joint is an accurate diagnosis. I will always challenge me students in this regard – find the cause of their symptoms and STOP using “patellofemoral pain” as a diagnosis. At first this can seem like a daunting task as the true source of patellofemoral pain can be misleading. However, using a classification system to group types of diagnoses can be extremely helpful in the formation of your treatment program.

The following is part 3 of the series on solving the patellofemoral mystery:

Part 1: Introduction – Solving the patellofemoral mystery
Part 2: What causes patellofemoral pain?
Part 3: Differential diagnosis of patellofemoral pain
Part 4: Principles of patellofemoral joint rehabilitation
Part 5: Specific treatment guidelines for patellofemoral pain
Part 6: Biomechanics of the patellofemoral joint – clinical implications
Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

Differential Diagnosis of Patellofemoral Pain

Patellar Compression Syndromes

Patellar compressive syndromes are described as pathologies involving excessive compression between the patella and the trochlea due to tight surround soft tissue. These can result in significant changes to the articular surfaces of the patella and trochlea over time. This can be broken down into two distinct types of compression syndromes:

Excessive lateral pressure syndrome (ELPS). ELPS was originally described as occurring when the patella is overconstrained by soft tissue tightness, specifically the lateral retinacular tissue. The patient will exhibit a lateral tilted and/or shifted patella and decreased medial glide. There is often times medial discomfort as the medial retinacular tissue is stretched due to a laterally displaced patella. I often find palpating the medial patellofemoral ligament elicits a decent amount of discomfort. I believe proximal and distal influences in the kinetic chain also effect the alignment of the patellofemoral joint and can cause an ELPS-like syndrome, though through a different mechanism. This should be assessed and is discussed more below.
Global patellar pressure syndrome (GPPS). GPPS occurs when there is a general and diffuse medial and lateral soft tissue tightness that results in the patella being excessively compressed within the throclea. This is more commonly see after direct trauma, immobilization due to fracture, or knee surgery with the development of arthrofibrosis. Have you ever had a patient lose patella mobility after an ACL reconstruction? This is a good example of GPPS. These patients may also have decreased superior patellar mobility as the knee is immobilized in flexion.

Patellar Instability

On the other side of the spectrum is patellar instability, which can range from an acute dislocation to recurrent instability. On examination, patients will have excessive patellar mobility laterally. This is often associated with a shallow trochlea, so many patients may be predisposed to this condition. I would suspect this with the patient with chronic subluxations. Also, acute episodes of subluxation or dislocation may result in rupture of the medial patellofemoral ligament and subsequent medial pain. Patients with chronic subluxation usually don’t have as much sensitivity medially as their tissue adapts and/or tears over time.

Try this – perform patellar gliding at 0 degrees of flexion and then again at ~30 degrees of flexion. If the patella continues to have excessive gliding at 30 degrees, then they likely have a shallow trochlea and poor static stability. These patients are challenging to treat as the static stability is a primary cause of their symptoms.

Biomechanical Dysfunction

The knee appears to take a good amount of stress when biomechanical faults are present both proximally and distally within the kinetic chain. Alterations in foot and ankle mechanics, hip strength, leg length discrepancy, flexibility deficiencies, and any combination of these factors can have a negative impact on the forces observed at the patellofemoral joint. Not only can biomechanical dysfunction lead to increased stress, it can also lead to chronic adaptations over time. Take for example someone with weak hip external rotation. This could lead to a dynamic inability to control the hip adduction and IR moment at the knee and cause the femur to rotate into internal rotation during activities. This will cause the patella shift laterally and can cause articular cartilage and soft tissue changes that will mimic a typical ELPS patient. You can loosen up the lateral soft tissue but without treating the true cause, the hip weakness, symptoms will continue to occur.

This will be discussed in greater detail in a future post in this series as this is an important factor to consider.

Direct Patellar Trauma

This is my least favorite pathology as I seem to always be a victim of direct patellar trauma myself. Have you ever hit your knee against a table leg? Every time I do, and it seems frequent, I think of the acute trauma my articular cartilage just took! This is also seen with patients falling on their knee, which is common up here in the northeast during the winter when it gets icy. Subjective exam should lead you this way, but you may have to probe, sometimes patients will forget that they fell 3 weeks ago or not correlate their symptoms with the incident.

Patients in this classification can include bone bruises, articular cartilage lesions, and even fractures.

Soft Tissue Lesions

There are a few common soft tissue lesions that can occur to the patellofemoral joint. Accurate diagnosis of these syndromes usually involves direct palpation to these areas and a certain mechanism of trauma to the area.

Suprapatellar plica syndrome. The plica is an interesting and debatable structure. I have always been of the belief that plica is very individual and some people have larger synovial folds than others. Most common is the suprapatellar plica, which is located medial and superior to the patella. This structure gets tight against the femoral condyle as the knee flexes so repetitive activities such as bike riding can cause this.
IT band friction. Similarly, ITB friction can occur laterally as the patellar tract of the IT band gets taught against the lateral femoral condyle during flexion.
Fat pad syndrome. The fat pad of the knee is highly vascularized and has rich nerve fibers. When a patients falls on their knee, they may inflame this structure. You can easily palpate on either side of the patellar tendon and find discomfort. Be sure to assure that you are not palpating the patellar tendon as treatment for this will vary.
Medial patellofemoral ligament injury. This was previously discussed above, but realize that any issues with chronic ELPS or patellar instability will cause MPF ligament pathology.

Overuse Syndromes

Overuse syndromes include patellar tendonitis and less commonly quadriceps tendonitis superiorly. Patellar tendonitis most commonly occurs at the inferior pole of the patella, but may also occur mid-tendon or at the tibial tuberosity. Patients will present with typical symptoms of a tedonopathy.

Two types of apophysitis can occur in the knee. These are common in adolescents during growth spurts and in athletes participating in jumping sports. These can easily be palpated and may be seen I’m not a big fan of naming things after people as they don’t offer any description of what the pathology is so I will use two versions of the terminology.

Traction apophysitis of the tibial tuberosity (Osgood-Schlatter).
Traction apophysitis of the inferior patellar pole (Sindig-Larsen-Johansson).

As you can see, there are many different pathologies that can occur to the patellofemoral joint. The above list is not intended to be all-encompassing, but rather to create categories of diagnoses that share similar treatment guidelines. There are other potential source of PF issues, including neurologic origins from the lumbar spine or reflex sympathetic dystrophy, however I wanted to keep this discussion orthopedic. Once I rule out orthopedic issues I will explore other origins and a likely referral back to the doctor or specialist.

To vaguely classify each patient as “patellofemoral pain syndrome” would be doing a disservice to the patient and will likely not result in optimal outcomes. A clear and accurate differential diagnosis is by far the most important aspect of treating the patellofemoral joint.

Next time a patient comes to you with a referral stating “PFPS” or “anterior knee pain,” I challenge you to attempt to classify the patient appropriately. Treatments will vary greatly for each diagnosis. These will be discussed in a future post.

Continue on to Part 4: The 10 Principles of Patellofemoral Rehabilitation

Wilk KE, Davies GJ, Mangine RE, Malone TR. (1998). Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. JOSPT DOI: 9809279

What Causes Patellofemoral Pain?

noreply@blogger.com (Mike Reinold) — Wed, 13 May 2009 10:00:00 +0000

Patellofemoral disorders are often considered the most common knee pathology encountered by orthopedic and sports medicine clinicians. Some sources say that in the general population, 1 out of 4 will likely experience patellofemoral symptoms at some time in their life. Although patellofemoral disorders represent a common pathology, there is no consensus on the optimal management of this condition. This may be explained, in part, due to the various sources of pain that may be contributing to the disorder. Unfortunately, terms such as “anterior knee pain” and “patellofemoral pain” have become accepted diagnoses with treatment often implemented without clear definitions of the underlying pathophysiology. The common use of such ambiguous and non-specific terms only adds to the confusion regarding optimal care for these patients.

This is part 2 of a series on solving the patellofemoral mystery:

Part 1: Introduction – Solving the patellofemoral mystery
Part 2: What causes patellofemoral pain?
Part 3: Differential diagnosis of patellofemoral pain
Part 4: Principles of patellofemoral joint rehabilitation
Part 5: Specific treatment guidelines for patellofemoral pain
Part 6: Biomechanics of the patellofemoral joint – clinical implications
Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

Source of Patellofemoral Pain

Rehabilitation programs designed for the patellofemoral patient must match the specific disorder and dysfunction. Part 4 of this series will discuss the differential diagnosis of patellofemoral pain, however it is important to understand the source of patellofemoral pain in addition to any possible diagnosis. In recent years, several authors have attempted to provide an explanation for the potential source of patellofemoral pain.

Dye et al (AJSM 1998) examined the conscious neurosensory mapping of the lead author’s knee during arthroscopy without intraarticular anesthesia. (This in itself is an amazing study, he literally had his partner scope his own knee without anesthesia!) The authors rated the level of conscious awareness from no sensation to severe pain. These findings were further subdivided based on the ability to accurately localize the sensation. Palpation to the anterior synovial tissues, retinaculum, fat pad and capsule produced moderate to severe pain that was accurately localized. The insertion sites onto the tibia and femur of the cruciate ligaments produced poorly localized moderate to severe pain. Slight to moderate poorly localized sensation was produced at the capsular margins. No sensation was detected on the patellar articular cartilage even though asymptomatic grade II and III chondromalacia was noted on the central ridge the patella.

Within the clinical setting, patients often complain of diffuse patellofemoral pain while undergoing physical examination. The results of this study may provide an explanation for the vague description of pain that is often reported by patellofemoral patients; the majority of structures palpated produced poorly localized sensation.

The implications of this are interesting. It appears that degenerative changes to the patellofemoral joint, or chondromalacia, was not a source of pain. The author/subject didn’t even know his patella had degenerative changes. Numerous authors (Chrisman OD: Clin North AM 1986, Dye SF: Orthop Clin North AM 1986, Fulkerson: Disorders of the Patellofemoral Joint 2004 – as an aside, this may be a glitch but this is a great book by Fulkerson and listed at $2.76 on Amazon right, now, follow the link to purchase…) have also documented that patellofemoral chondromalacia does not necessarily produce patellofemoral pain. Based on the results of these studies, it appears that the majority of patellofemoral symptoms may be originating from the anterior synovial tissues, retinaculum, fat pad and capsule, rather than from degeneration of the patellofemoral articular surfaces.

It appears that the majority of patients complaining of patellofemoral pain originates from the surrounding soft tissues and not from the osseous or articular cartilage structures.

Furthermore, several authors have also postulated that patellofemoral pain may originate in the lateral retinacular soft tissues. Fulkerson et al (Clin Orthop 1985) performed a histological analysis on lateral retinacular and underlying synovial tissue of patellofemoral patients biopsied during lateral retinacular releases. These biopsies were compared to cadaveric specimens and biopsies taken from asymptomatic, non-patellofemoral patients undergoing surgery to address anterolateral rotary instability. Nerve fibers originating in the lateral retinaculum appeared enlarged with moderate lose of myelinated fibers in the patellofemoral patient. The authors state that nerves within the retinaculum may degenerate from the chronic stretching associate with muscular imbalances around the patellofemoral joint and present as a potential source of patellofemoral pain.

Sanchis-Alfonso et al (AJSM 1998) biopsied the lateral retinaculum of patients undergoing a lateral retinacular release to address patellofemoral complaints. The authors found neuromas within the biopsied tissues similar to the results of Faulkerson et al (Clin Orthop 1985). The authors reported a direct relationship between the severity of pain and the severity of neural damage within the lateral retinaculum; patients presenting with moderate to severe complaints of pain were found to have the highest number of nerves and neural area. These findings were further supported in a follow-up study by Sanchis-Alfonso and Rosello-Sastre (AJSM 2000). The authors repeated the prior experiment, noting similar results with the additional finding of increased levels of substance P within the lateral retinaculum of patellofemoral patients.

Thus it appears that the source of pain in patellofemoral patients is multifactoral, with the surrounding soft tissues showing evidence of localized pain perception and neural adaptations that appear to contribute to the source of patellofemoral pain.

Have you found that the majority of your patients have vague and diffuse pain? I’ve had patients with pretty severe changes to their patella and trochlea, what do you think about degenerative changes NOT being associated with patellofemoral pain? Is this always true?

Continue on to Part 3: Classification and differential diagnosis of patellofemoral pain.

Dye SF, Vaupel GL, Dye CC. (1998). Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med DOI: 9850777

Solving the Patellofemoral Mystery

noreply@blogger.com (Mike Reinold) — Mon, 11 May 2009 19:36:00 +0000

Disorders of the patellofemoral joint continue to present as some of the most perplexing pathological conditions in orthopedics and sports medicine. Previously described as the “black hole of orthopedics” by Dr. Scott Dye, the patellofemoral joint continues to cause dysfunction for patients and confusion for clinicians. Patellofemoral pain syndrome is often described as a diagnosis that tends to result in poor outcomes. Despite years of research and attention to the joint, the vague use of the term “patellofemoral pain syndrome” continues to be prevalently ~~abused~~ used to categorize patients. This becomes evident when analyzing the myriad of surgical and rehabilitative interventions that are currently being utilized to alleviate symptoms and restore function in patellofemoral patients. It appears that a single surgical or rehabilitative approach cannot be efficaciously used to treat patellofemoral disorders.

Welcome to a new series of posts dedicated to the evaluating and treating the patellofemoral joint.

There will be several posts tied together, similar to my series on SLAP lesions. Each post will have links to one another and a table of contents to help you navigate.

In this series, we will discuss the evaluation and treatment of the patellofemoral joint with topics ranging from differential diagnosis to treatment strategies that can be applied to any rehabilitation or fitness program. My goal will be to develop an easy to understand and implement system to treat patellofemoral pain based on an accurate differential diagnosis and an understanding of the normal biomechanics of the joint.

Solving the Patellofemoral Mystery

Continue on to Part 2: The source of patellofemoral pain or skip around below:

Part 1: Introduction – Solving the patellofemoral mystery
Part 2: What causes patellofemoral pain?
Part 3: Differential diagnosis of patellofemoral pain
Part 4: Principles of patellofemoral joint rehabilitation
Part 5: Specific treatment guidelines for patellofemoral pain
Part 6: Biomechanics of the patellofemoral joint – clinical implications
Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint

I hope you enjoy and interact with each post, please share your thoughts and experience!

Photo credit: Wallpapergate

How Long Do You Immobilize the Shoulder After a Dislocation?

noreply@blogger.com (Mike Reinold) — Mon, 04 May 2009 14:39:00 +0000

A recent guest post from Dan Lorenz discussed immobilizing the shoulder in a position of external rotation following an anterior dislocation. While this concept appears counterintuitive at first glance, there is enough evidence now to support the use of this position of shoulder immobilization. Studies have shown better approximation of the capsule to the glenoid and a reduced rate of recurrent instability when immobilized in external rotation. I would not say that any of this is currently definitive as there are also some studies that challenge the exact mechanism of this concept, however, it is certainly worth watching and the early results appear reasonable enough to try this in our practices.

How Long Should You Immobilize the Shoulder After Dislocation?

Another common question regarding the immobilization of shoulders after dislocations involves the length of immobilization. A new study in AJSM sought to examine how long acute anterior dislocations should be immobilized in external rotation.

The study involved 22 subjects split evenly between a group that was immobilized for 3 weeks and another that was immobilized for 5 weeks. Both groups were immobilized in a position of 30 degrees of external rotation in a DonJoy Ultrasling. Displacement and separation of the capsulolabral complex was measured using MRI.

The authors report that immobilization yielded improved results regardless of the length of immobilization. There was no significant difference in results when comparing the group immobilized for 3 weeks with the group immobilized for 5 weeks. The results of this study are interesting and certainly support the use of an immobilization brace in external rotation, though it doesn’t seem that lengthy immobilization of more than 3 weeks will achieve superior results.

Standardized or Individualized?

I personally think that there should be a little variation in the immobilization protocol based on the specific patient. I would say that I routinely immobilize patients anywhere from 2 to 6 weeks based on their history of dislocations, amount of concomitant trauma, their tissue type, and the status of their dynamic stabilizers. For example, patients with congenital laxity that suffer frequent dislocations probably need to be immobilized longer than a person with an acute, first-time, dislocation.

This study also examined the effect of rotation on the approximation of the labrum and again noted that the more external rotation the better. A word of caution, there are some braces on the market that I do not believe achieve enough external rotation. My brace of choice has always been the DonJoy Ultrasling in slight abduction and 30 degrees of external rotation, I highly recommend it. Your patients will also like it as it seems to be one of the more comfortable braces available.

What has your experience been with acute anterior dislocations? How long do you usually immobilize? Do you have a brace you prefer? Do you see large variations in protocols from different physicians in your area?

Also, there was a great discussion last week on the role of the transverse abdominis. Feel free to continue that discussion and join in, let us know how or why not you work on the transversus abdominis group in your patients with low back pain.

Scheibel, M., Kuke, A., Nikulka, C., Magosch, P., Ziesler, O., & Schroeder, R. (2009). How Long Should Acute Anterior Dislocations of the Shoulder Be Immobilized in External Rotation? The American Journal of Sports Medicine DOI: 10.1177/0363546509331943

Plays of the Week 5/1/09

noreply@blogger.com (Mike Reinold) — Fri, 01 May 2009 14:56:00 +0000

Happy May everyone, hopefully the weather is starting to improve near you as spring time approaches! Before we get to the latest Plays of the Week, I wanted to take the opportunity to send out some thanks and to make a few announcements:

Thank you!

I want to thank the 41,000 people that have visited my physical therapy blog,
More importantly I want to thank the 555 subscribers, 262 followers on Twitter, and 54 friends on Facebook. If you haven’t yet, feel free to follow me on any of these social media websites. We just started a great discussion on kettlebells on Facebook. Also, don’t forget that if you subscribe via email you will receive all my latest posts in your email but also gain access to my other website with all the latest articles from orthopedic and sports medicine journals.
I want to thank all the many people that comment on posts and create such a nice discussion each week. This is truly the highlight of my week. Keep up the comments and interaction. If you haven't commented yet, please do so and join the discussions!
I also want to thank the guest contributors, Christie Downing, Trevor Winnegge, Harrison Vaughn, and Dan Lorenz for the excellent contributions of articles on Transversus Abdominis, the QUADAS tool, the relationship between hip pain and low back pain, immobilizing the shoulder in external rotation, complications following distal radius fractures, and predicting which patients will not respond to physical therapy.
I welcome all readers to contact me to discuss some ideas on guest posts. I know you all have a lot of experience and ideas to share, please do so! You can contact me with any idea that would fit the theme of this blog. It can be a discussion about a new concept or technique that you use or a review of a book or journal article you have recently read. I would still love any posts related to: spine, manual therapy, hip, foot and ankle, or trigger points.
An update on the webinars: The response to my webinars so far has exceeded my expectations, thank you for that. To present these is time consuming and expensive. I am still working on making this more automated and upgrading my website to allow the downloading of recorded webinars. I plan on working on this the next month or so and then releasing a schedule of monthly webinars. Once this gets rolling it should be easy to keep going. Here is an example of my past webinar on NMES of the rotator cuff

Leon Chaitow has a new post about a new approach to fascial manipulation from Italy. Interesting and anything new and excited to Dr. Chaitow is a read for me. I picked up a copy of the book, click here to join me.
Among other things, Eric Cressey discusses a little bit about the current trend towards Vitamin D supplementation.
If you are a student or interested in working in professional sports, be sure to read my post on 5 tips on landing a sports medicine job in professional sports.
Alwyn Cosgrove wants to help you fit into a bathing suit by Memorial Day… 3 weeks left!
Video of the Week. So you want to get your groove on while picking out a soda during a break at work? There is nothing wrong with that, just realize you never know who is watching you…

The Role of the Transverse Abdominis in Low Back Pain

noreply@blogger.com (Mike Reinold) — Mon, 27 Apr 2009 14:31:00 +0000

Today’s guest post is written by Harrison Vaughan, PT, DPT. Harrison is a physical therapy practicing in South Hill, VA at In Touch Therapy. His professional interests include clinical diagnostic tests and treatment consisting of orthopedic manual therapy, predominantly spinal manipulation. Harrison previously contributed an excellent article on the QUADAS tool to assess the quality of research on studies examining the efficacy of clinical examination tests.

Transversus Abdominis: Are we on the right bandwagon?

Many physical therapists base their low back pain treatments around strengthening the transversus abdominis (also know as the transverse abdominis, or TrA) muscle for stability. Strengthening of the TrA is often incorporated in treatments with a wide variety of patients with a wide variety of pathology. However, what really is the dysfunction that we are trying to manage and is this really effective?

What does Transverse Abdominis do?

The function of the TrA is to stabilize the pelvis and low back prior to movement of the body. It acts within a feedforward bilateral muscle activation rationale from spinal perturbations with everyday activities. Rehabilitation is typically aimed at restoring motor control of this key stabilizing muscle. Literature points to effective means of treating low back pain with trunk stabilization and strengthening of deep abdominal musculature to improve motor control¹.

Diane Lee gives a great description of how to activate the TrA through abdominal drawing-in maneuver (ADIM)². However, how long does it take for someone to learn this and do you think they will really do this correctly and efficiently if they are pain? It has been shown that teaching a patient to perform the ADIM maneuver can be time consuming and difficult.³

How effective is activating the Transversus Abdominis?

It has been shown that the TrA is activated after the deltoid (~50ms) with arm movement task studies with LBP patients.⁴ A recent study showed that during a volitional recruitment task for the TrA , induced pain was shown to attenuate the activity of the TrA.⁵ It has also been discovered that pain will alter a muscle’s role as an agonist or antagonist to control movement for protection through the pain adaptation model.⁶ This has also been demonstrated with many prior studies of reduced TrA muscle thickness with chronic LBP. In turn, the delay of TrA timing and optimal muscle activation is altered, potentially making exercises that activate it ineffective when pain is present.

If we abolish the pain, would motor control and activation of TrA resolve itself? There has not been any conclusive data to show that the spine is controlled less when the activation of TrA is changed and altered timing of the TrA leads to poor core stability. The feed-forward activation of TrA can be interpreted differently from a small study that showed 3 of 8 pain-free individuals did not have the feedforward responses in 70% of trials with bilateral arm tasks.⁷ Even prophylactically, the isolated muscle pattern in pain-free subjects is controversial.⁸ This goes to show further that low back pain is complex, multimodal and overall challenging to treat.

Is a lack of strength or stability really the reason for the low back pain?

Do we claim to 'stabilize' every patient? A recent study stated that some patients are not unstable at all and showed that LBP patients actually have increased stability rather than decreased stability.⁹ Even if we feel a patient is unstable, how do we diagnose it as unstable? Special tests to clarify this are inconclusive. P/A force over specific segments of lumbar spine have been found to be useful to identify the segmental impairment. However, will activating the TrA fix this? PPIVMs for extension & flexion have poor sensitivity values. A common test practiced is the prone instability test also giving poor diagnostic values.¹⁰ You might as well flip a coin to determine instability by the values.

Some thoughts…

As musculoskeletal specialists, we have significant knowledge and a pertinent role in management of low back pain. We need to concentrate on teaching the patients how to control their symptoms independently. To me, this means giving the patient tools to provide self-pain relief through therapeutic means. Activating transverse abdominis stating it will give stability when everyday aches and pains arise just doesn’t seem feasible. The use of foam rolls, towel rolls or any other affordable methods can be very effective in not only giving relief, but obtaining joint motion and allowing an exercise program to be more advantageous. If a treatment doesn't give someone relief or change, he or she will not be adherent to it, consecutively, returning to health care providers and starting the sequence again.

Since low back pain re-occurs in 70% of cases depending on source, we may not be challenging this problem appropriately. I think having the transversus abdominus as an active component in the treatment is somewhat useful but not conclusive. Pain relieving exercises and education need to be the forefront of each program so muscle activation can be optimal.

What are your opinions? Do you get good results from concentrating on TrA as your main intervention? If so, how effective do you find it and what is your approach? Is there any technique or method that you would recommend others to try?

References

Teyhen DS, Miltenberger CE, Deiters HM, et al.. The use of ultrasound imaging of the abdominal drawing-in maneuver in subjects with low back pain. J Orthop Sports Phys Ther. 2005 Jun;35(6):346-55.
Accessed 3 March 2009. http://dianelee.ca/services/TRANSVERSUSABDOMINIS.pdf
O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine.1997;22:2959-2967.
Cresswell AG, Thorstensson A. Changes in intraabdominal pressure, trunk muscle activation and force during isokinetic lifting and lower. Eur J Appl Physio Occup Physiol. 1994; 68: 315-21.
Kiesel et al. Rehabiliation ultrasound measurement of select muscle activation during induced pain. Manual Therapy. 2008. 13. 132-138
Lund et al. 1991. The pain adaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity. Can J Physiol. Pharmac. 69: 683-694.
Hodges P, Cresswell A, Thorstennson A. Preparatory trunk motion accompanies rapid upper limb movement. Exp Brain Res 1999;124:69-79.
Allison GT. The push – throw continuum and core stability – are Physiotherapists teaching the correct motor patterns? in APA National Conference – Sports Physiotherapy Australia. Cairns, Queensland, Australia: 2007.
Hodges P, Van den Hoorn W, Dawson A, et al. Changes in the mechanical properties of the trunk in low back pain may be associated wtih recurrence. J Biomech. In press.
Cook C, Hegedus E. Orthopedic Physical Examination Tests: An Evidence-Based Approach. Prentice Hall. 2007.

Flynn, T. (2005). The Use of Ultrasound Imaging of the Abdominal Drawing-in Maneuver in Subjects With Low Back Pain Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2005.1780

Photos from Wikipedia

Free Evidence Based Practice Course

noreply@blogger.com (Mike Reinold) — Wed, 22 Apr 2009 21:11:00 +0000

If you haven’t seen it yet, the folks over at www.evidenceinmotion.com are now offering a free 45-minute online course reviewing the basics of evidence based practice. I just had a chance to sit down a watch the presentation and was impressed, certainly worth your time and for a great price! Here is there description:

Why should you want to learn about Evidence-Based Practice? It is important to stay current with the best treatments for your patients, resulting in improved outcomes, fewer visits, and lower costs. Evidence in Motion is dedicated to enhancing the PT world, and this is one way we can contribute to your success. This free introduction to EBP, by one of the Evidence in Motion authors, is an opportunity to take your profession as a PT to the next level!

Evidence in Motion is doing a great job promoting EBP and offer continuing education seminars and residencies. Click the link above to register or visit myphysicaltherapyspace.com for more details. Also, be sure to check out the seminars and products from AdvancedCEU that also embrace the EBP concept. Don’t forget that readers of this blog get 10% off all AdvancedCEU products with entering coupon code “Reinold” during check out.

Immobilizing the Shoulder in External Rotation

noreply@blogger.com (Mike Reinold) — Mon, 20 Apr 2009 10:00:00 +0000

Today’s post comes from Dan Lorenz, MS, PT, ATC/L, CSCS. Dan is a graduate of the sports physical therapy fellowship at Duke University and is currently a sports medicine specialist at Providence Medical Center. He has great experience with a wide variety of orthopedic and sports medicine patients, including stints with the US Olympic Training Center, Chicago White Sox, and most recently the Kansas City Chiefs. Dan has previously guest posted on the relationship between hip motion and low back pain.

Challenging 2000 Years of Conventional Wisdom – Immobilizing the Shoulder in External Rotation

For 2000 years, individuals with shoulder dislocations have been immobilized with their upper extremity resting on the trunk in the hopes of preventing recurrence^1,2. While this has been the standard practice, no literature on the scientific basis of this exists. Recurrent dislocation rate varies from 47% to 100%^3-7. Within the last few years, researchers have proposed a new position for immobilization, external rotation, after anterior shoulder dislocations. While the concept may seem radical, it certainly is thought-provoking, and it truly challenges us to “think outside the box.”

A cadaveric study by Itoi and others⁸ sought to determine the position of a Bankart lesion following immobilization in different positions. Researchers found that with the arm in adduction and from full internal rotation to 30° of external rotation, the Bankart lesion was “coapted”, or re-united, with the glenoid. With the arm in 30° of flexion or abduction, the edges of the lesion were coapted in neutral and internal rotation but were separated in external rotation. The study suggested that positions that increase soft tissue tension, such as adduction and ER or abduction and neutral rotation, may be preferable to the conventional position. Similarly, Miller et al⁹ found that the glenoid-labrum contact in ten cadaveric shoulders immobilized in external rotation was much higher, potentially increasing the healing of a Bankart lesion.

Itoi and colleagues¹⁰ sought to use MR imaging to measure the affect of arm rotation on the approximation of Bankart lesions following dislocation of the shoulder. Eighteen patients with traumatic anterior dislocations were included in the study. Twelve had recurrent dislocations, and six were first time dislocations. MR imaging of the glenohumeral joint was taken at neutral and at the range of external rotation that felt most comfortable to the patient. Imaging studies showed that in internal rotation, the joint cavity of the glenoid was wide open. With the arm in external rotation, the anterior joint cavity was closed and the labrum lay on the glenoid rim.

The same group of researchers then followed up this study with a prospective study to determine if positioning the arm in external rotation would reduce the rate of recurrence¹¹. Forty patients with initial dislocations were assigned to conventional internal rotation and 10° of external rotation. The first ten were alternatively assigned, and then the remaining thirty were randomly assigned. Both groups were immobilized for three weeks, and compliance rates were reported. Recurrence rate was 30% in the internal rotation group and 0% in the external rotation group. It is interesting to note that in the subjects younger than thirty years old, recurrence in internal was 45% and 0% in external. The average follow up was 15.5 months. An anterior apprehension test was performed at follow-up, and the test was positive in 14% of internal and 10% of external.

Deyle and Nagel¹² described a six-week immobilization period in 30° of abduction and neutral rotation in a 19 year-old recreational basketball player. In addition to the prolonged immobilization, the patient had protected range of motion activity for 6 additional weeks. At 20 month follow up, the patient had no recurrent instability. Recently, Itoi et al¹³did a randomized, controlled trial of 168 patients with initial anterior dislocations who were randomly assigned to be treated with immobilization for three weeks in either internal rotation or external rotation. After a two-year follow up, the recurrence rate was 26% and 42% in external and internal rotation, respectively. Additionally, in subjects aged thirty years or younger, the relative risk reduction was 46%.

EDITOR’S NOTE: Very interesting information. Looks like the evidence to support immobilizing in external rotation is becoming available as many sources are reporting similar research. What has your experience been with immobilizing in external rotation? Have you found it successful?

References

1. Havelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients: a ten-year prospective study. J Bone Joint Surg Am 1996; 78: 1677-84.

2. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956; 38: 957-77.

3. Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med. 1994; 22:589-94.

4. Henry JH, Genung JA. Natural history of glenohumeral dislocation – revisited. Am J Sports Med. 1982; 10: 135-7.

5. Hovelius L, Eriksson K, Fredin H, et al. Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am. 1983; 65: 343-9.

6. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am. 1992; 74: 1242-4.

7. Vermeiren J, Handelberg F, Casteleyn PP, Opdecam P. The rate of recurrence of traumatic anterior dislocation of the shoulder. A study of 154 cases and a review of the literature. Int Orthop. 1993; 17: 337-41.

8. Itoi E, Hatakeyama Y, Urayama M, et al. Position of immobilization after dislocation of the shoulder: a cadaveric study. J Bone Joint Surg. 1999; 81: 385-390.

9. Miller BS, Sonnabend DH, Hatrick C, et al. Should acute anterior dislocations of the shoulder be immobilized in external rotation? A cadaveric study. J Shoulder Elbow Surg. 2004. 13: 589-592.

10. Itoi E, Sashi R, Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint: a study with use of magnetic resonance imaging. J Bone Joint Surg. 2001; 83: 661-667.

11. Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003; 12: 413-415.

12. Deyle GD, Nagel KL. Prolonged immobilization in abduction and neutral rotation for a first-episode anterior shoulder dislocation. J Orthop Sports Phys Ther. 2007; 37: 192-198.

13. Itoi E, Hatakeyama Y, Sato T, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence: a randomized controlled trial. J Bone Joint Surg. 2007; 89: 2124-2131.

Itoi, E., Hatakeyama, Y., Sato, T., Kido, T., Minagawa, H., Yamamoto, N., Wakabayashi, I., & Nozaka, K. (2007). Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk of Recurrence. A Randomized Controlled Trial The Journal of Bone and Joint Surgery, 89 (10), 2124-2131 DOI: 10.2106/JBJS.F.00654

Cincinnati Sports Medicine Advances on the Knee and Shoulder Conference

noreply@blogger.com (Mike Reinold) — Thu, 16 Apr 2009 10:00:00 +0000

There is another exciting course that I wanted to bring to everyone’s attention. If you are not planning on attend the MGH Sports Medicine 2009 conference this June, Cincinnati Sports Medicine’s annual Advances on the Knee and Shoulder course is being held this May on Hilton Head Island. I have been fortunate enough to attend this conference before and it is definitely top notch. Plus, who wouldn’t want to spend a nice long Memorial Day weekend ~~at the beach on your company’s dime~~ at a continuing education meeting! In addition to top notch faculty and topics, there is ample time each afternoon to spend in the sun at the beachside resort.

Cincinnati Sports Medicine Research and Education Foundation’s 2009 Advances on the Knee and Shoulder Course - May 24 – 27, 2009 - Westin Resort, Hilton Head Island, South Carolina

Why You Should Attend This Course:

Earn 32 CEU/CME credits in an ocean side setting.
Enjoy the holiday weekend combining a great educational meeting with relaxation in a resort setting
Hear internationally recognized experts on the knee and shoulder present their preferred techniques and clinical outcomes
Review advanced orthopaedic and rehabilitation products and educational materials in our Exhibitors’ Gallery
Talk personally throughout the conference with our course faculty during breaks, panel discussions and break-outs
Network with other professionals
Relax, enjoy the beachside atmosphere, and rekindle old friendships at our Chairmen’s Memorial Day Event
We have an Internationally Recognized Faculty:

Frank R. Noyes, M.D.
Thomas N. Lindenfeld, M.D.
Marc T. Galloway, M.D.
Samer S. Hasan, M.D., Ph.D.
Matthew L. Busam, M.D.
Robert T. Burks, M.D.
Richard J. Hawkins, M.D.
Stephen J. O’Brien, M.D.
Felix H. Savoie, III, M.D.
Edward M. Wojtys, M.D.
Timothy P. Heckmann, PT
Michael A. McCormack, Jr., PT
Julie Jasontek, PT, MHS
Russell M. Paine, PT
Kevin E. Wilk, DPT

For more information please visit:

Cincinnati Sports Medicine

5 Tips for Landing a Sports Medicine Job in Professional Sports

noreply@blogger.com (Mike Reinold) — Mon, 13 Apr 2009 05:42:00 +0000

There are a lot of students that I have worked with and that read this website that ask me one recurring questions – “My dream is to work for [insert your favorite sports team here]. How do I get a job in professional sports?”

I like your dream! I too had the dream of being the PT/ATC of the professional team in the town I grew up in, Boston. I was also a big fan of baseball, and obviously the Red Sox. I was lucky enough to achieve my dream, here is what I would say to help you:

“Luck is when preparation meets opportunity” - Seneca, Roman Philosopher, 5 BC – 65 AD

1. Determine what exactly you would call a “dream job.”. I know when I started college, I really had no idea what my career would be like or what exactly I wanted to focus on. I applied to some colleges as an athletic training major and others as a physical therapy major. I often reflect and think that it is so difficult for a 16-17 year old to make a decision as to what they want to do for the rest of their lives. I had so many classmates drop out or switch majors because they realized that physical therapy was not for them. To be successful, you need to love what you do.

I would recommend you spend some time in your potential field in high school or early in college to see what a day-in-the-life is for people in the field you want to go into. Many people don’t realize how challenging sports medicine is as a profession. You need to be energetic, compassionate, patient, and love to interact with people. People also don’t often realize what a normal work day is like. I work 12-hour days, 7-days a week, for 9 straight months. I am not kidding or exaggerating, check out a baseball schedule, there are no days off. Even on our off-days we have treatments and have to prepare for upcoming games. It is amazing that I have a supportive family. As a physical therapist in a clinic, you are performing a service and your fate is determined by your patients. If they come late, you miss lunch.

2. Associate yourself with the best. My next tip may be one of the most important. You need to seek out the best people in your field and learn, work, and grow with them. With hard work, time, and a lot of effort you will become one of them. That is what I did, I searched out the best sports medicine people in baseball and discovered Dr. Andrews and ASMI in Birmingham, AL. Over the course of almost 8 years, I progressed from a student research position, then did a year long sports medicine fellowship, 5 years later I was the Director of Rehabilitation. I put myself in a position where I was desirable to baseball teams.

This also goes for networking. Unfortunately, it is all about politics and who you know. The more you can network and join associations or attend conferences with people that are in a position that you want to be in one day, the better. Look for mentors, look for friends, and look for opportunities.

3. Work your way up. It is near impossible to reach the level of professional sports without spending time in the trenches. High school and collegiate athletics is a step in the right direction. Internships are very popular in professional sports and essential to getting your foot in the door. Seek out the professional sports medicine association of the sport you are interested in (we are PBATS in baseball, not sure about other sports) and look into doing an internship or volunteering, even if it is just for training camp. Nothing beats experience, so the more specific your experience can be the better.

4. Set yourself apart from your peers. This one is important and difficult. I was lucky and figured out what I wanted to do with my career early on in college. When I was taking my neurological and pediatrics classes, I would spend my book money on buying new orthopedic and sports medicine books and just obtain my neuro and pedi required reading from the library. OK, so this may not be good advice, but it shows and example of how I used my time and energy to set myself apart. I read everything I could on my topic of interest, baseball sports medicine.

The easiest way to set yourself apart from your peers early on is to show an extreme desire to learn and achieve. I really do feel that hard work will beat out intelligence every time when the race is close. As your career advances, try to set yourself apart. How can you do this? Maybe conduct some research, submit manuscripts to journals and newsletters, take charge and organize journal club, work extra hours, take on extra projects, and volunteer your time. Remember, this isn't going to be easy, if you want a top level job, there will be sacrifices.

5. Be patient. I don't think there are many new grads working in professional sports, probably wont be any time soon either. Use the above thoughts to make yourself standout from the crowd. Using baseball as an example, you are trying to get a job with only 30 positions in the entire world. For my dream job, there was only one position. I am lucky to say that I obtained my dream job and I am grateful for this. Realize that it will take a little luck and timing, make sure you do everything you can do to be sure you are ready when an opportunity presents itself.

Good luck and best wishes!

Photos by Kaibara87 and exquisitur

Funny Exercise Ball Videos

noreply@blogger.com (Mike Reinold) — Fri, 10 Apr 2009 14:49:00 +0000

As I am spending the next week ramping up the content to the site after a long spring training, I thought I would share a hilarious video I found on some of the dangers of exercise balls! Not sure if these count as stability or plyometric exercises, but at least a break from work on a Friday. My favorite is the clip at 0:50, those two guys just looked too serious anyway! Enjoy, and more posts and webinars coming soon!

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