Week in Review

Joe Heiler

This article is a compilation of some of the interesting things I've seen this week, and some things I've been thinking about for awhile. More to do with knees and shoulders than anything. This is something I'm considering doing more often as it's something members could contribute to quite easily. My goal is to continue to get more members involved in sharing their expertise whether its in the forum or in articles, videos, and interviews. So if anyone has anything they want to share that can be thrown into a quick article, please let me know. [email protected]

This was my last patient Friday afternoon: 56 yo female 2 weeks post-op R shoulder scope for decompression and distal clavicle excision. Her pain is minimal at this point, but actively she gets stuck around 110 degrees. Passively standing I took her to about 150 degrees. At this point the goals are to facilitate healing and to get motion without increasing pain and swelling so we normally start with posture and AAROM.

I always start with posture, facilitating thoracic extension and head position, and then working on scapular depression and retraction to prevent the typical shrug we see with attempts at elevation. This is exercise #1 and I expect them to correct their posture as often as possible.

This is where it gets interesting. I put her supine with a small roll between her scapulae to give her the ability to retract/depression, and had her do your standard dowel rod shoulder flexion exercise. Watching her breathing pattern I noticed her using her diaphragm well at rest but once she started to go overhead with the bar her pattern changed to one of apical breathing. Also noticed her tensing her calves and hamstrings with every repetition. Talk about a high threshold strategy! I stopped her and coached her on relaxing the legs and using the proper breathing pattern throughout the exercise. By her 3rd rep her arm was hitting the plinth at about 170 degrees (+15 degrees at least).

I guess I shouldn't have been surprised but it's very cool when things work that quick. She activated her inner core with proper breathing which probably reduced tone in the traps, levator, SCM, etc and her arm just dropped back overhead. Less pain and more motion.

Immediately took her back to standing and worked on her breathing pattern. Did a set of 10 wall slides into flexion focusing on breathing and posture. Then came off the wall and she actively took her shoulder to 160 degrees which was equal to the other side. Just a great example of what firing the core will do for the rest of the body.

The patient in this case was a 26 yo female who was in a MVA 4 months ago with a fractured tibia mid-shaft. She does have a rod traversing the fracture. Lack of ankle and knee mobility were addressed early on and now we are putting the final touches on her stability and strength as she gets back to work and eventually wants to get back to jogging and weight lifting.

Her squat pattern is quite good and she can get below parallel to lift without any sort of weight shift. When it comes to more of a single leg type activity like lunging/kneeling or stairs, she struggles with strength and still has some anterior knee pain.

She can get up and down stairs with a reciprocal pattern but it isn't a thing of beauty. Compensatory strategies everywhere. Her doctor says it's ok to start pushing it and do things even if it hurts. My contention is, I want the mechanics at her knee and ankle to be appropriate for the task at hand to prevent more problems down the road. This is one reason why we see a lot of pes bursitis in patient's post TKA. Research has shown that even one year post-op and without pain, these people are still using a hip dominant strategy to get up and down the stairs.

Check out her form in the videos below.

The first video is of her non-involved L leg. What I'm watching is how far forward the knee glides over the foot. As you can see she goes about to the end of the toes.

In this video, the first 5 reps shows her current step up pattern. You can see how she hangs back on her involved leg, trying to use more of a hip/hamstring strategy to get up. The second 5 reps she is trying to 'correct' the movement and glide her knee over her toes. At this point in her recover she feels a good amount of pulling on her patellar tendon as she describes it, but not pain. What you can't really appreciate from the video is all the shaking going on in that leg. This is a ton of work for her.

I want her to use every last bit of dorsiflexion in that ankle and force the quadricep to pull its own weight so that she can regain her normal pattern. Does that mean she doesn't force herself to go downstairs with a reciprocal pattern quite yet? In my opinion "Yes". What good is it doing her to try it right now? She isn't really building strength, just reinforcing compensatory movement.

Just something to keep in mind with these types of patients, and especially athletes. If an athlete is resorting to this type of strategy, what will happen when he or she needs to cut off that leg? One reason I like to use single leg squats as a return to sports benchmark. Can't do them using a hip strategy.

This is another one of those things I wish I had started doing earlier. Works great on athletes/patients who test positive on the scapular repositioning test. Taped up a few post-op patients this week, two with scope decompressions and one post rotator cuff repair.

Couple things I see with this technique: 1) facilitating lower trap will decrease that urge to shrug during shoulder elevation, 2) slight scapular retraction/depression will offset the forward shoulder/pec tone, and 3) the improved positioning and lower trap facilitation is sometimes all they need to break through that sticking point at 90 degrees.

I will try to get a picture of this up in the next few days, but basically tape from the anterior acromion back over the scapula diagonally to the thoracic spine (following the lower trapezius). If they show a lot of upper trap tone, I'll add another strip from from the posterior acromion along the upper trap to the cervical spine (to inhibit the UT). If you happen to have Gray's "Functional Taping" DVD, he shows this technique as well.

Those were the highlights for the week. Just some neat things I thought I would share since they work out well for me. Like I said before, if you have any ideas you think could help out other members, please let me know.