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Movement Improvement
 
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Common Sports Injuries
 
Revolution specializes in the treatment of athletes and sport-related injuries.
 
Our therapists are former athletes who have competed at high levels and continue to practice the training methods used at Revolution.
 
We understand how important it is to not only recover fully from injury, but ensure safe return to sports through a comprehensive treatment plan that includes sport specific training.
 
Finally, an objective evaluation is performed to determine if an athlete is ready to return to play safely. We have rehabbed athletes from the youth level up through the professional level including Olympic athletes.
 
 
Anyone who engages in sports and exercise for either recreation or competition knows they are putting themselves at risk for injury.
 
The key is what happens following an injury. It has been shown that the sooner treatment is initiated following an injury; the sooner the person will be back to pain free participation in activities.
 
Sports injuries are caused by repetitive low impact movements or high intensity and magnitude movements such as being tackled in football. These injuries cause damage to our tissues and create imbalances in our musculoskeletal system as well as the nervous system.
 
Soft tissue healing is normally to 6-8 weeks in the average person. The time for return to sports following injuries that require orthopedic surgery such as rotator cuff repairs and ACL reconstructions can be up to 1 year.
 
 
 
So how does an elite athlete recover and return to play so quickly, in sometimes more than half the time? The average return to sports for an athlete following a meniscus excision is 2-3 weeks but for a normal person it is 6- 8 weeks.
 
 
Elite athletes are:
  • Typically stronger before the injury
  • Regimented people and are used to following a routine
  • Used to training
  • Highly motivated to get back to play
  • Much healthier overall
Elite athletes tend to heal at quicker rates secondary to:
  • Enhanced blood flow, i.e better cardiovascular status
  • Better nutrition and supplementation
  • Early access to rehabilitation
  • Evaluation based protocol
During the acute phase, 2-3 days following the injury sports physical therapist will:
  • Provide resources of pain modification and ways to limit inflammation and swelling.
  • Provide any assistive devices such as crutches or braces to limit any further damage
  • Refer the patient back to see their physician to rule out any orthopedic or medical pathology and to get any needed anti-inflammatory or pain relieving medications.
Physical Rehabilitation
Once the medical pathology is ruled out physical rehabilitation should begin. This can be a critical time to do the proper interventions. If wrong, it could significantly affect the amount of time it takes to make a full recovery. The therapist should begin to address any obvious muscle imbalances that can be assessed at this stage of the healing process.
 
Revolution Physical therapists are highly educated regarding strength, speed, agility, coordination, and power. This allows us to begin to address these components early on to facilitate functional ability during the final, return to sport, phase of the rehab process.
 
The most difficult part of the return to sport phase is return of muscle memory. Initially the athlete has to use great concentration of focus and conscious thought to perform even simple activities such as walking. The therapist will progressively increase the difficulty of the activities to challenge the athlete to eventually perform difficult movement skills without conscious efforts. This phase also requires a significant amount of ability to respond to unexpected obstacles and uncertain movements of other competitors.
 
Finally sports specific functional testing such as hop tests will be performed to determine appropriateness for a full return to sports participation; often conducted unilaterally and compared to the uninjured side.
 
 
 
The athlete should be progressed back into practices and competition slowly while being educated to continue to observe for indicators of swelling. They must inform their therapist or athletic trainer if swelling occurs. This can be a sign that the demands being placed on the tissue are too great for the healing phase and activity should be backed down and started over once the inflammation has subsided.
 
A sports physical therapist starts with the end in mind. Athletes need a program that is geared to allow them to run, jump, and cut better than they did before the injury. Many physical therapists are not well trained for sports performance enhancement. At Revolution Physical Therapy we have a residency trained sports therapist who was a 3 sport collegiate athlete and has spent his career working with athletes from the NFL to youth soccer leagues. Please choose wisely when recovering from a sports injury.
 
Common Youth Injuries
 
Pediatric injuries are not the same as adults and should not be treated the same. Pediatric and adolescents need to be approached with an understanding of their unique stage in development.
 
Children and teenagers are not just small adults. They have not fully developed and their growth plates are still open. This must be considered when identifying injuries, administering rehabilitation techniques, as well as, for strength and conditioning.
 
The cause of all musculoskeletal problems is movement related. Physical therapy can address these movement related issues. Interventions may include modalities such as electrical stimulation to decrease pain and inflammation. If symptoms are very acute and painful, rest and activity modification may be required to alleviate symptoms and decrease further progression of the injury. Revolution’s therapists understand how to treat pediatric patients safely to get the best results.
 
 
Common types of apophysitis and pediatric conditions:
Sever’s Disease – Achilles Tendon
The child usually experiences pain at the posterior or back of the ankle where the Achilles tendon attaches to the calcaneus or heel bone.
 
Sinding Larson Johansen Syndrome –Jumper’s Knee
Patella tendon and inferior or bottom pole of the patella. The child usually experiences pain in the anterior or front of the knee with jumping and squatting.
 
Osgood–Schlatter Disease or Syndrome
This is an irritation of the patellar ligament at the tibial tuberosity. It is characterized by painful lumps just below the knee and is most often seen in young adolescents. Risk factors may include excess weight and overzealous conditioning (running and jumping), but adolescent bone growth is at the root of it.
 
Little League Shoulder
Humeral head and rotator cuff attachments Panner’s disease is a compression injury, repetitive or acute, of the growth plate of the Radial head. Valgus forces from activities such as throwing cause compressive forces on the lateral elbow.
 
Slipped Capital Femoral Epiphysis
A disruption at the femoral head growth plate inside the hip joint causes a slippage of the head of the femur at the growth plate resulting in hip pain.
 
Legg Calve Perthes
Blood supply to the femoral head growth plate inside the hip joint ceases temporarily resulting in hip pain.
 
Spondylolysis or Spndylolisthesis
Lumbar spine pathologies that cause a stress fracture or fracture to the lumbar vertebra secondary to excessive stress in lumbar extension. This is a common weight lifting injury in adolescents secondary to poor supervision, technique and too much weight. In the American Journal of Sports Medicine 2007, Walsh examined 3D spine kinematics during free squat. Free squatting with a barbell on the back increased lumbar extension at 60-80% 1RM compared to 40%, with or without a weight belt. Lumbar extension is compensatory for inability to stabilize the trunk with the weight moving anterior to the lifter’s center of gravity. This is of greater implication to adolescent athletes secondary to the nature of the spinal growth plate injuries seen. Numerous studies have shown the vulnerability of the lumbar spine in adolescents with radiographic abnormalities identified.
 
The greatest mistake we see today occurs with the 8th or 9th grader who enters a strength and conditioning program at their high school.
They end up being grouped with and doing the same exercises with similar loads as a 17 or 18 year old junior or senior with a more b 15 11 Pediatric Orthopedic and Sports Injuriesmature and developed musculoskeletal system. They need to be on a program that takes their age, maturity and competence into consideration.
 
Children and adolescents need to focus on creating muscular balance, coordination, force absorption, flexibility, speed, balance and proprioception. Their rehabilitation and training programs should be comprehensive, focusing on motor learning and sports specific movements.
 
Common Adult Injuries
 
Injuries such as tendonitis, muscle strains, ligament sprains, joint pain, muscle pain, poor posture and cartilage tears are commonly treated in the physical therapy setting.
 
Many of us will experience these types of injuries throughout our lifetimes, especially low back pain. As we age we experience diminishing:
  • Elasticity, hydration and calcium from our bones
  • Creation of new bone cells
  • Strength and flexibility muscles
  • Sensitivity of our skin
  • Ability to create and absorb high forces
  • Acuity in vision and hearing
  • Proprioception and balance
 
 
 
Revolution’s physical therapists will not only address the acute symptoms of pain and inflammation but address the underlying movement problem as well.
 
 
Post Surgical Protocols
 
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Most Common Ailments in Physical Therapy
 
 
Anterior Knee Pain
 
Anterior Knee Pain (Patellofemoral Dysfunction) is one of the most prevalent pathologic knee conditions seen in the physical therapy clinic. Many conditions fall under the broad heading of patellofemoral dysfunction. Also known as Jumper’s Knee or Runner’s Knee. This includes Patellar Tendonitis, Osgood-Schlatter’s disease, and Sinding-Larsen-Johansson syndrome. Osgood-Schlatter’s disease and Sinding-Larsen-Johanssen are seen in adolescents in the form of apophysitis. Osgood-Schlatter occurs at the tibial tubercle and Sinding-Larsen-Johanssen occurs at the distal patellar pole.
 
Anterior knee pain is often the phrase used to describe any condition that leads to pain in the extensor mechanism, patellofemoral joint, at the knee. Because the diagnosis is often one of a very general nature, rehabilitation can be viewed as general in nature as well. As with other over-use injuries, rehabilitation is often done to correct or improve the biomechanics of the entire lower extremity in an attempt to decrease the patient’s complaints of pain and dysfunction. The functioning of the patella depends on a fine balance between ligaments and muscles because of the lack of inherent bony stability at the patellofemoral joint. When this balance is disrupted because of weakness, tightness, or other biomechanical problems, improper tracking of the patella can occur. Lateral tracking of the patella is the most common tracking abnormality seen at the patellofemoral joint. Common causes of lateral tracking can include VMO dysfunction, tight lateral patella retinaculum and Iliotibial band, weak hip and thigh musculature, ankle and foot pronation and various lower extremity biomechanical problems that increase the tendency of the patella to track laterally.
 
VMO dysfunction can be a weakness of the VMO due to disuse or effusion-induced neuromuscular shutdown. If the VMO is not creating enough force, it cannot offer the medially directed dynamic stability that is required to counteract the other heads of the quadriceps and keep the patella tracking appropriately. Tight lateral soft tissues around the knee can also increase the lateral tracking of the patella. If structures such as the patellar retinaculum, iliotibial band, gluteus medius, and tensor fascia lata are tight, they can cause the patella to track more laterally and possibly lead to pain in the area. Biomechanical problems anywhere along the lower extremity that affect the alignment of the femur on the tibia can affect the tracking of the patella. Many of these malalignment problems can be bony in nature, and it is not possible for the rehabilitation specialist to change them. For example, a wide pelvis that leads to an increased genu valgum angle at the knee cannot be “corrected” by rehabilitation. However, there are some malalignment problems that are able to be treated. For example, excessive pronation of the subtalar joint can lead to an increased Q angle at the knee and possibly increased lateral tracking at the patellofemoral joint.
 
Rehabilitation of patellofemoral dysfunction, after a comprehensive evaluation, should concentrate on recruiting the VMO, normalizing patellar mobility, increasing general flexibility and muscular control of the entire lower extremity, and addressing any other biomechanical problems that can be altered by treatment. The most important concept to keep in mind when the patellofemoral joint is rehabilitated is that no exercise should cause pain at the joint. Any knee extension exercise that elicits a contraction of the VMO and does not cause pain at the patellofemoral joint is appropriate. Use of a biofeedback unit to monitor VMO contraction is one method that is extremely helpful in ensuring that exercises are having an impact on the VMO. Electrical stimulation units may also be used to obtain a strong contraction in the VMO. Key areas to evaluate and address during rehabilitation include hip abductor strength, foot alignment and the flexibility of the rectus femoris, hamstrings, gastroc-soleus, and ilitotibial band.
 
After a comprehensive lower extremity evaluation:
  • Facilitate recruitment of VMO
  • Normalize patellar mobility
  •  Increase lower extremity flexibility
  • Address any alterable lower extremity biomechanical problems
  • Be sure that ALL activities are pain-free at the patellofemoral joint
CLASSIFICATION OF PATELLAR TENDONITIS
  • Phase 1 – Pain only after participation
  • Phase 2 – Pain during participation that does not limit performance
  • Phase 3 – Pain during participation that limits performance
  • Phase 4 – Complete tendon disruption
 
 
Rotator Cuff Tears and Roator Cuff Tendinits
 
The rotator cuff consists of the supraspinatus, infraspinatus, teres minor, and subscapularis..  The etiology of rotator cuff tears can be one or a combination of the following: repetitive microtrauma, disuse, overuse tendonitis, anatomic factors, and attrition. 3-8% of all cuff tears occur as a result of trauma. It has been suggested that rotator cuff tears result after the commonly diagnosed “cuff tendonitis” and that rotator cuff tears may actually represent failure of the rotator cuff fibers. Typical causes of rotator cuff tears can be generalized into a simple explanation. Over time the cuff is subject to adverse factors such as contusion, impingement, inflammation, injections, and age-related degeneration. Each of these factors puts the cuff at increased risk. Cuff fibers may fail in mid-substance or at its insertion into bone.  Failing fibers cause 3 things to happen: (1) They increase the load on the neighboring fibers; (2) They detach muscle fibers from bone (diminishing the force that the cuff muscles can deliver); and (3) they risk the vascular elements of the rotator cuff as a whole. These factors increase even more the risk of further fiber failure with subsequent loading. Ultimately, the cuff is weakened, its function is impaired, it is more prone to additional failure with weaker loads, and is less able to heal.
 
The emphasis of a rehabilitation program for rotator cuff tendonitis is to correct any asymmetric capsular tightness. Motions one would find difficult to perform include forward flexion, internal and external rotation, and horizontal adduction. It may also be hard to reach behind the back. Because this movement elongates the musculotendinous unit and compresses it as it is pulled with internal rotation, modalities, mobilization, and stretching exercises for the posterior capsule and muscles may be indicated. Initiation of a general shoulder flexibility program and a rotator cuff PRE (progressive resistance exercise) program are necessary to prevent shoulder degradation. The program should concentrate on the posterior rotator cuff muscles, because these muscles are responsible for humeral head depression and contract eccentrically to slow the arm down during the deceleration phase of throwing.
 
 
 
Achilles Tendonits
 
The Achilles tendon is the common tendon of the gastrocnemius and soleus muscles.  It is a common site of pathologic changes in competitive and recreational athletes.  The major blood supply to the Achilles tendon is provided through the paratenon.  An area of reduced vascularity found 2-6 cm proximal to the Achilles insertion.  This avascularity may play a role in the etiology of Achilles tendonitis symptoms.  Achilles tendonitis is defined as disruptive lesions (damage) within the substance of the tendon itself.  The onset of Achilles tendonitis is usually gradual.  Typical dull, aching pain is experienced during or after an activity.  Slightedema or tendon thickening may be present and the tendon can be quite tender.  Pain usually increases with passive dorsiflexion and resisted plantar flexion.
 
The best treatment for micro-traumatic injuries such as Achilles tendonitis is prevention of the onset.  The severity of inflammatory Achilles injuries may be reduced by following these guidelines: (1) Select appropriate footwear.  The athletic shoe should have a firm, notched heel, and a moderate heel flare in the midsole that provides adequate wedging and allows flexibility of the forefoot; (2) Avoid training errors.  Steady, gradual increases of no more than 5-10% per week in training mileage and speed on appropriate terrain should be emphasized.  Cross training might also help; (3) Keep your gastrocnemius and soleus muscles flexible; (4) Control pronation forces.  Excessive pronation forces cause a whipping and bowstring effect on the medial edge of the Achilles tendon.  Orthotics may correct this if the abnormal pronation is of structural origin; (5) Ensure adequate strength.  A plantar flexion-to-dorsiflexion ratio of 3:1 or 4:1 is recommended; (6) Perform postural screening for biomechanical malalignments.  This may detect any abnormalities that could adversely affect the kinetic chain and increase stress on the Achilles tendon.
 
 
 
Adhesive Capsulities "Frozen Shoulder"
 
Adhesive capsulitis, also known as “frozen shoulder”, is a condition where patients have a painful restriction of both active and passive glenohumeral joint motion in all planes, or a global loss of glenohumeral joint motion.  This condition is most commonly found in people 40-60 years of age and is more common in women than men and is sometimes idiopathic (unknown cause).  Other potential causes of adhesive capsulitis could be extended immobilization, mild trauma, and surgical trauma, especially breast or chest wall procedures.  Adhesive capsulitis is associated with medical conditions such as diabetes, hyperthyroidism, ischemic heart disease, inflammatory arthritis, and cervical spondylosis.  The most significant association is with insulin-dependent diabetes.
 
Adhesive capsulitis can occur in as high as 40% of patients with a history of insulin-dependent diabetes.  There are 3 stages that classically characterize adhesive capsulitis: (1) The “freezing” stage.  Characterized by the onset of an aching pain in the shoulder.  The pain is usually more severe at night and with activities.  The pain may radiate down the arm.  As symptoms progress, there are fewer arm positions that are comfortable.  This stage lasts anywhere from 3-6 months; (2) The “frozen” stage.  In this stage the patient’s shoulder becomes progressively stiff.  Pain at rest diminishes at this stage, leaving the patient with a shoulder that has restricted motion in all planes.  ADLs (activities of daily living) become more and more difficult such as reaching into the back pocket, fastening a bra, combing hair, or washing the opposite shoulder.  Pain at night is common and is not easily treated with medications or physical modalities.  This stage lasts anywhere from 3-18 months; and (3) the “thawing” stage.  This stage is characterized by a slow recovery of motion.  Aggressive treatment with physical therapy, closed manipulation, or surgical release may accelerate recovery, moving the patient from the frozen stage into the thawing stage.  This will only occur if ROM (range of motion) activities occur on a daily basis.  The diagnosis of adhesive capsulitis may be suggested by a careful history and physical examination.  In general, a global loss of active and passive motion is present; the loss of external rotation with the arm at the patient’s side is a hallmark of this condition.  The loss of passive external rotation is the single most important finding on physical examination and helps to differentiate the diagnosis from a rotator cuff problem because problems of the rotator cuff generally do not result in a loss of passive external rotation.
 
Once adhesive capsulitis is diagnosed, aggressive treatment is required to avoid severe disabling for an extended period of time.  The physical therapy program should focus on regaining shoulder motion.  For those in the painful freezing stage, pain relief can be obtained with a course of anti-inflammatory medications, glenohumeral joint corticosteroid injections, or therapeutic modality treatments.
 
 
Posterior Tibialis Tendinitis/ Shin Splints
 
Posterior tibialis tendinitis, commonly known as shin splints, is a condition of shin pain due to athletic overuse causing inflammatory microtrauma to the tendon of the posterior tibialis muscle.  Because the tendon of the posterior tibialis muscle is positioned a certain way, pain and swelling are present over the posteromedial(inside and back side) aspect of the tibia.  The etiology of posterior tibialis tendinitis is due to excessivetraction stress placed on the posterior tibialis tendon with hyperpronation.  The muscles of the posterior compartment contract in a stretched position and are overworked in an attempt to stabilize the foot during propulsion.  Common predisposing factors include improper training on crowned or banked surfaces, inappropriate footwear, and any structural condition that increases the varus attitude of the lower extremity.  Treatment is focused on alleviating abnormal pronation using a semirigid orthosis with medial heel wedge.  Attention should also be given to the training regimen and to finding shoes with a stable, firm, and snug heel counter.
 
 
 
Ankle Sprains
 
Pathologic trauma to the ligamentous structures of the ankle is a common athletic injury.  The majority of these injuries occur to the lateral side of the joint with an inversion mechanism of injury.  Injuries to the medial side are less common and typically involve a hyperpronation force, such as when an athlete plants the foot and then cuts in the opposite direction.  Ligaments affected include the anterior talofibular ligament,calcaneofibular and posterior talofibular ligaments.
 
Inversion Ankle Sprain – Varying degrees of pain, swelling, point tenderness, and functional disability are usually evident.  After inversion trauma, radiographic studies of the joint and bone structure are of paramount importance.  Potential problems that could arise include bimalleolar fractures, proximal fibular fractures, andavulsion-type fractures all are possible and may require surgical fixation or longer periods of immobilization.  Abnormalities include anterior, posterior, or varus instability.  Each potential problem must be addressed in the rehabilitation program.  The damaged ligament must be allowed to heal as a flexible restraint, the contractile elements must regain dynamic stabilization capabilities, and the proprioceptive system must be completely restored.
 
MANAGEMENT OF INVERSION ANKLE SPRAINS:
  • Aggressive management of acute swelling
  • Normalization of gait pattern as soon as possible
  • Maintenance of closed-pack position of neutral dorsiflexion during acute and subacute healing phases
  • Addressing of structural abnormalities that would cause compensatory supination in gait
  • Compensated forefoot valgus
  • Uncompensated rearfoot varus
  • Greater than 10 deg. tibial varum without adequate compensatory calcaneal eversion range of motion
  • Reestablishment of proprioceptive and kinesthetic skills and awareness
  • Enhancement of gluteus medius and peroneal frontal plane muscle control and stabilization ability
High Ankle Sprain -  Known as a syndesmotic ankle sprain because of the anatomic location of the injury.  Commonly, the athlete has tenderness and mild swelling over the anterior inferior tibiofibular ligament.  The mechanism of injury is usually a combination of foot external rotation with lower leg internal rotation.  This type of sprain is very slow to respond to conservative care.  Most athletes with this type of ankle sprain typically miss more games and required more treatment than did athletes who sustained lateral ankle sprains.
 
 
Plantar Fasciitis
 
The plantar fascia is a dense band of fibrous connective tissue that originates from the calcaneal tuberosityand runs forward to insert on the metatarsal heads.  As a tension band, it supports the medial longitudinal arch and assists in the push-off power of running and jumping.  Biomechanical abuse of this tissue results in microtrauma and inflammation.  This condition is most often seen in the running athlete who hyperpronates or has a rigid cavus foot and tight Achilles tendon.  In both instances, excessive traction is placed on the fascia, which can be magnified with uphill or hard-surface training terrain.  It has been noted that decreased active and passive ranges of motion at the first metatarsal-phalangeal (MTP) joint correlate with the onset of plantar fasciitis.
 
There is a gradual insidious onset of pain, which can radiate along the path of the fascia, along the plantar aspect of the foot.  The most consistent finding is exquisite pain with weight-bearing forces of the first few steps in the morning.  The phenomenon of “physiologic creep,” in which the tissues contract during the non-weight bearing period at night and then are forcefully stretched with initial morning weight bearing, may explain this common complaint.  Because the fascia is a noncontractile structure, active or passive dorsiflexion at the ankle and first MTP usually elicit the symptoms.  These signs and symptoms can mimic those of other pathologic conditions but should be differentiated from medial plantar nerve irritation, tarsal tunnel syndrome, and infracalcaneal bursitis.  Treatment should be initially focused on controlling the inflammatory response and then on alleviating or reducing the excessive tension being placed on the plantar fascia and its associated structures, which have their origin at the calcaneal tuberosity.
 
During the acute state, ice massage, anti-inflammatory medications, dexamethasone inotophoresis, and rest from aggravating activities are prescribed.  A cold pop bottle with ridges can be used like a rolling pin under the arch of the foot to provide gentle stretch and cryomassage to the plantar fascia.  Sponge rubber heel lifts with a doughnut-shaped cutout may provide weight-bearing relief on the injured structures.  A night splint will hold the ankle joint in dorsiflexion, the subtalar joint in neutral, and the first MTP in extension to reduce plantar fascia contracture.  Correction of abnormal stresses can be provided through Low-Dye taping for the hyperpronator, shock-absorbing inserts for the rigid cavus foot, and joint mobilization for the hypomobile first MTP joint.
 
 
The Thrower's Shoulder
 
Also known as impingement syndrome.  With thrower’s shoulder, both the supraspinatus insertion to the greater tubercle and the bicipital groove lie anterior to the coracoacromial arch with the shoulder in the neutral position and that with forward flexion of the shoulder, these structures must pass beneath the coracoacromial arch, providing the opportunity for impingement.  Impingement of the rotator cuff may occur in some athletes such as baseball players, quarterbacks, swimmers, and others whose activities involve repetitive use of the arm at or above 90 deg. of shoulder abduction.  Impingement usually involves the supraspinatus tendon.  When the supraspinatus muscle assists in stabilizing the head of the humerus within the glenoid, the greater tubercle cannot butt against the coracoacromial arch.  Whether impingement is the primary event causing rotator cuff tendinitis or whether rotator cuff impingement results from rotator cuff disease is undetermined.  In all likelihood both mechanisms of injury can occur.  With time and progression of wearing and attrition, microtears and partial-thickness rotator cuff tears may result.  The goal in treating athletes with an impingement syndrome, either nonoperatively or surgically, is to reduce the compression and friction between the rotator cuff and subacromial space.
 
FACTORS NECESSARY TO MINIMIZE COMPRESSION
  • Shape of the coracoacromial arch, which allows passage of the adjacent rotator cuff mechanism
  • Normal undersurface of the acromioclavicular joint
  • Normal bursa
  • Normal function of the humeral head stabilizers (rotator cuff)
  • Normal capsular laxity
  • Smooth upper surface of the rotator cuff mechanism
  • Normal function of the scapular stabilizers
In an acute impingement syndrome, time, rest from noxious stimuli, non-steroidal anti-inflammatory drugs, local modalities such as cold, heat, and electrical stimulation, and a general shoulder rehabilitation program of flexibility are indicated.
 
 
Low Back Pain and Neck Pain
 
Low back pain (LBP) is a nearly universal experience among the adult population.  Studies have documented the lifetime prevalence rate of LBP to be as high as 80%.  Although most cases are self-limiting and recover with little intervention, those who recover are prone to recurrences at a rate of up to 60%.  The past few decades have witnessed numerous advances in the medical community’s understanding of the lumbar spine.  The functional anatomy of the lumbar spine has been investigated in detail, the biomechanics of the lumbar motion segments have been studied, and new technology has allowed for more precise diagnostic imaging of the spine.  Despite these advances, the prevalence of LBP and the associated costs have been growing at an alarming rate in recent decades, leading to the characterization of back pain as an epidemic.
 
LBP is also a prevalent and problematic condition in athletes.  Up to 20% of all sports-related injuries are reported to involve the spine.  Athletes in certain sports appear to be particularly prone to LBP.  For example, high rates of LBP in athletes participating in the following sports have been reported: gymnastics, swimming, tennis, volleyball, football, and others.  The rehabilitation of individuals with LBP, including athletes, remains largely enigmatic.  Numerous approaches to rehabilitation have been advocated, yet for any given individual with LBP, the selection of a treatment method from among the many competing approaches has been said to take on the characteristics of a lottery, often leaving the rehabilitation specialist uncertain of the best course of action to undertake with any particular patient.   Many approaches exist and one such approach seeks to classify patients with LBP on the basis of clusters of signs and symptoms.  The patient’s classification is then matched to a treatment strategy believed to be most effective for that individual patient.
 
 
Hip Arthritis and Knee Arthritis
 
Results of trauma to synovial joints can lead to subsequent development of some degree of a condition known variously as osteoarthritisosteoarthrosis, hypertrophic arthritis, or degenerative joint disease.  It is essentially a degenerative condition of articular cartilage with subsequent formation of marginalosteophytes, subchondral bone changes, bone marrow changes, inflammatory reaction of synovium, capsular thickening, alteration of the synovial fluid and damage to intra-articular structures.  Most authors distinguish between primary (idiopathic) osteoarthritis and secondary osteoarthritis (secondary to an infectious, traumatic, inflammatory, metabolic, or aging process).  Often, however, the etiology of one type cannot be delineated from that of the other.  Two common locations of arthritis include the hip and knee.
 
Treatment of arthritis includes heat application in the form of hot packs, diathermy, or ultrasound.  During the initial acute exacerbation of synovitis, some form of cryotherapy may also prove effective.  If the patient is overweight, weight reduction is mandatory.  Evaluation of daily activities must be undertaken – low chairs should be avoided and sustained postures should not be maintained.  Active flexion and extension exercises of the joint should be done every morning before weight bearing is attempted.  Walking is encouraged for daily activities but not forced for the sake of prolonged exercise as therapy.  Deep knee bends should be avoided and faulty posture that places a strain as a result of stance should be corrected if the involved joint is the knee or any other joint in the lower extremity or the back.  In the case of knee involvement,  exercises should include those to strengthen the quadriceps muscles, hamstrings, and gastrocnemius-soleus muscles.  If conservative treatment is unsuccessful, surgical debridement of the joint is indicated.  Osteophytes are removed along with any damaged intra-articular structures and/or villous projections of the synovial membrane.
 
 
Meniscus Tear
 
The meniscus serves a number of important functions including increasing of the stability and congruence of the knee joint, load distribution and transmission, shock absorption, joint proprioception, and aiding in joint lubrication and nutrition.  Its shape, attachments, and collagen arrangement allow the meniscus to effectively transmit compressive forces across the tibiofemoral joint.  Removal of the meniscus reduces the contact area between the femur and tibia.  This substantially increases the force per unit area between the two articular surfaces.  It is likely that the increase in force per unit area leads to the degenerative changes that often occur after removal of the meniscus.  The structure and attachments of the menisci also allow for early controlled weight bearing after longitudinal meniscal repairs because the sutured edges are approximated by weight-bearing.
 
Meniscal lesions (damage areas of tissue) have been treated by total meniscectomy, partial meniscectomy, and meniscal repair.  Total meniscectomy by arthrotomy quickly alleviates the mechanical symptoms, and short-term results have usually been good.  However, long-term outcomes have been disappointing because of the degenerative articular changes that occur in the knees after a total meniscectomy.  For this reason total meniscectomy is rarely indicated.  Meniscal lesions are now treated by partial meniscectomy or repair.  Partial meniscectomy is performed by removing as little of the meniscus as possible.  Maintaining as much of the meniscus as possible is felt to aid in minimizing long-term degenerative changes at the knee.  Rehabilitation after a partial meniscectomy is symptom driven.  Usually athletes are able to return to sports rapidly, often within 2-3 weeks, after an uncomplicated partial meniscectomy.
 
Repair of the meniscus has become a viable surgical option in recent years.  A greater understanding of the overall function of the meniscus has led surgeons to prefer to repair, rather than remove, parts of the meniscus whenever possible.  Repairs are most often performed on the peripheral third of the meniscus because this area has a blood supply to allow for healing of the repair site.  Repairs can be performed arthroscopically or through a small incision at the knee.
 
 
ACL Tear
 
Rehabilitation after an injury to the ACL varies widely.  The time frames discussed in the protocols can be adapted to fit various situations, but there are certain criteria that should be met before an athlete is progressed through any protocol.  After an injury to the ACL, immediate attention must be given to thehemarthrosis in the knee and the general inflammatory process.  The athlete should be given crutches and instructed in a pain-free partial weight-bearing gait, and the traditional anti-inflammatory program of ice, compression, and elevation (I.C.E.) should be started.  A brace is not required unless there are other associated injuries such as an MCL sprain.  Motion exercises should be started immediately, concentrating on passive extension to help prevent rapid scarring in the intercondylar notch.  Full extension also allows for greater ease in quadriceps recruitment, which is extremely important after ACL injury.  There is a decrease in quadriceps strength after injury because of defects in afferent inflow from the ACL-deficient knee.  It is also thought that the lack of voluntary contraction of the quadriceps after ACL injury may be due to the reflex inhibition or arthrogenous muscle inhibition.  weight bearing should be increased as pain decreases, joint effusion decreases, quadriceps control increases, and full active knee extension is achieved.
 
Rehabilitation should progress with emphasis being placed on quadriceps strengthening as well as neuromuscular control of the hamstrings.  Emphasis has been placed on increasing general muscle control around the knee.  The importance of the hamstrings in the ACL-deficient knee might lie more in hamstring control and proprioception.  Studies indicate that athletes with complete tears of the ACL experience a decrease in proprioception at the knee.  The loss in proprioception may be due to the “ACL-mechanoreceptor reflex arc” to the hamstrings.  Improving recruitment time of the hamstrings may place less stress on the ACL during functional activities.    Also, using active hamstring control to reduce the pivot shift found with an ACL injury might be the key to successfully avoiding reconstructive surgery.  Based on this information, the rehabilitation specialist should concentrate on facilitating control of the hamstrings, as opposed to simple strengthening in the sagittal plane.  Success has been reported in achieving this type of hamstring control in ACL-deficient knees with a program that uses proprioceptive neuromuscular facilitation (PNF) exercises for the hamstrings.  More advanced exercises, using devices such as the BAPS board, Slide Board, and Medi-Ball Rebounder, facilitate hamstring control and proprioception in functional positions and at higher speeds to control anterior tibial translation during more aggressive functional activities.  PNF patterns and seated Thera-Band exercises can also be used to help incorporate the tibial rotation component of the function of the hamstrings.  It has been shown that patellofemoral arthrokinematics are altered in ACL-deficient knees.  This should be kept in mind during rehabilitation of the ACL-deficient knee, and care should be taken to not irritate or damage the patellofemoral joint.
 
Although surgery is usually the most common treatment option after injury to the ACL, the decision should be delayed until the acute inflammatory process has run its course at the knee.  There is great concern that performing surgery on an acutely inflamed joint will lead to more complications during rehabilitation.  When the period of acute inflammation has passed, the athlete, using information provided by the sports medicine team, must decide if a reconstructive procedure is the most appropriate treatment to choose.  Many factors should be considered when this decision is made, the most important being the ultimate level of function the patient wishes to achieve.  It’s recommended that to have the best results, competitive or recreational athletes need surgical intervention, whereas light recreational athletes and nonathletes, both of whom can limit their activities, may be able to avoid surgery.  Clinically, it appears that generally the competitive athlete does not perform well with an ACL-deficient knee.  In one study, the majority of people who did not undergo surgical reconstruction, knee “giving way” episodes became a common problem.  These giving way episodes increase the possibility of occurrence of a meniscal tear or chondral injury.  It is well documented that ACL-deficient knees demonstrate abnormal joint kinematics during gait and functional activities, both of which increase the possibility of developing early degenerative changes.
 
When surgery is the chosen treatment, the ACL must be reconstructed (not just repaired) because of the lack of success with direct repair of the ligament.  Concerns that must be addressed when surgery is the treatment of choice include timing of the procedure, graft selection, and surgical technique.  The timing of surgery in relation to the inflammatory condition of the joint can greatly affect rehabilitation and ultimate outcomes.  It has been shown that reconstructions performed on an acutely inflamed joint are more prone to postoperative complications such as ROM loss and functional deficits.  Allowing the patient to go through rehabilitation before surgery helps decrease the number and severity of postoperative complications.
 
Rehabilitation protocols emphasize early motion, developing quadriceps control early, obtaining full passive extension, controlled weight bearing, and initiation of closed-chain exercises.  Even though the exact time frames vary from protocol to protocol, it has been found that achieving the goals of full passive extension, good quadriceps control, and minimal joint effusion/inflammation leads to better ultimate outcomes for the patient.  Progression through a protocol should be based on the athletes achieving certain goals rather than simply reaching a certain date postoperatively.  In addition to the goals stated earlier, it is important to promote patellar mobility early in the rehabilitation program.  Facilitation of early quadriceps recruitment will help in obtaining patellar movement.  Electrical stimulation can be extremely valuable in facilitating a quadriceps contraction great enough to result in superior mobilization of the patella.  Developing quadriceps control at full knee extension is extremely important for several reasons.  Quadriceps contractions increase patellar mobility, these quadriceps contractions help maintain full extension ROM, and good quadriceps contractions at full extension are required before a patient can fully bear weight with a normal gait.  When passive knee extension ROM is obtained during rehabilitation, it can be very difficult to maintain unless the patient has enough quadriceps strength to actively go into full extension.
 
Weight bearing status varies between protocols, but most commonly at least partial weight bearing is initiated within days of surgery.  It is extremely important to have patients walk with as normal a gait as possible while they are on crutches.  Poor habits during gait can be developed in this early stage of rehabilitation and once a poor gait pattern becomes ingrained it can be very difficult to break the habit.  The most common gait deviation is the patient ambulating with the knee in flexion and never going into full extension.  This lack of full extension in gait may be due to a lack of strength and/or ROM, a habit pattern developed before surgery due to instability at the knee, or a habit pattern developed after surgery.  Some protocols require the patient to wear a brace at 0 degrees immediately after surgery so ambulating with the knee in flexion is not as common a complication.
 
As the athlete gains lower extremity strength and coordination, he or she can start the functional progression of the rehabilitation program.  The time postoperatively at which these various activities begin varies widely with different protocols.  However, it is extremely important that the rehabilitation specialist remember that reaching specific postoperative dates is only one criterion for allowing an athlete to progress through the rehabilitation protocol.  It is just as important that the athlete have the appropriate strength (concentric and eccentric), ROM, coordination, and stability in the lower extremity to progress the difficulty of their rehabilitation program.  It the athlete’s condition warrants it, running and more aggressive hopping progressions are most often allowed at 3 to 4 months postoperatively, with a return to athletics commonly at 6 months postoperatively.
 
 
 
Impingement Syndrome - Biceps Tendonitis/ Subacromial Bursitis
 
Impingement of the rotator cuff may occur in some athletes such as baseball players, quarterbacks, swimmers, and others whose activities involve repetitive use of the arm at or above 90 degrees of shoulder abduction.  Matsen and Arntz defined impingement as the encroachment of the acromion, coracoacromial ligament, coracoid process, or acromioclavicular joint on the rotator cuff mechanism that passes beneath them as theglenohumeral joint is moved, particularly in flexion and internal rotation.  Impingement usually involves thesupraspinatus tendon.  When the supraspinatus muscle assists in stabilizing the head of the humerus within the glenoid, the greater tubercle cannot butt against the coracoacromial arch.  Whether impingement is the primary event causing rotator cuff tendinitis or whether rotator cuff impingement results from rotator cuff disease is undetermined.  In all likelihood both mechanisms of injury can occur.
 
Impingement syndrome is perpetuated by the cumulative effect of many passages of the rotator cuff beneath the coracoacromial arch.  this results in irritation of the supraspinatus and, possibly, the infraspinatus tendon, as well as in enlargement of the subacromial bursa, which can become fibrotic, thus further decreasing the already compromised subacromial space.  Furthermore, with time and progression of wearing and attrition, microtears and partial-thickness rotator cuff tears may result.  If these continue, secondary bony changes (osteophytes) can occur under the acromial arch, propagating full-thickness rotator cuff tears.  The etiology of the impingement syndrome is usually multifocal, and the supraspinatus tendon is the most likely structure to be involved.
 
A weakened rotator cuff mechanism can predispose an athlete to rotator cuff impingement.  The rotator cuff functions to stabilize the shoulder against the actions of the deltoid and pectoralis major muscles.  In the presence of a weakened cuff mechanism, contraction of the deltoid causes upward displacement of the humeral head, squeezing the remaining cuff against the coracoacromial arch.  Other factors that can result in rotator cuff impingement include degenerative spurs, chronic bursal thickening, rotator cuff thickening related to chronic calcium deposits, tightness of the posterior shoulder capsule, and capsular laxity.
 
Three progressive stages of impingement syndrome have been described.  Stage I is a reversible lesion usually seen in individuals younger than 25 years of age.  These patients present with an aching type of discomfort in the shoulder.  This stage usually involves only inflammation of the supraspinatus tendon and long head of thebiceps brachii.  Stage II is generally seen in individuals 24-40 years of age and involves fibrotic changes of the supraspinatus tendon and subacromial bursa.  Again, an aching type of pain is present, which may increase at night, and there may be an inability to perform the movement that produces in the impingement syndrome.  Injuries in this stage sometimes respond to conservative treatment, but it may require surgical intervention.  Stage III seldom occurs in those younger than age 40.  In this stage, the individual has had a long history of shoulder pain, and often there is osteophyte formation, a partial-thickness or eventually a full-thickness rotator cuff tear, and an obvious wasting of the supraspinatus and infraspinatus muscles.  Injuries in this stage usually do not respond well to conservative treatment.
 
The goal in treating athletes with an impingement syndrome, either nonoperatively or surgically, is to reduce the compression and friction between the rotator cuff and subacromial space.  The primary complication of impingement syndrome is a rotator cuff tear.  If the impingement syndrome is diagnosed in its early stages, the prognosis in encouraging.  In an acute impingement syndrome, time, rest from noxious stimuli, non-steroidal anti-inflammatory drugs, local modalities such as cold, heat, and electrical stimulation, and a general shoulder rehabilitation program of flexibility, and a PRE program are indicated.  Active range of motion may be limited with an empty or muscular guarding endfeel as a result of pain.  This may be caused by posterior capsule stiffness.  In such instances, moist heat, ultrasound, joint mobilization, and a general shoulder flexibility program with emphasis on supine internal and external rotation and horizontal adduction are appropriate.  Most young throwers will exhibit a functional loss of internal rotation and, therefore, have a tight posterior capsule.  It is important to stretch the posterior capsule (if tight) and inferior capsule and normalize the degree of internal rotation.  Modalities can be used initially after surgery to help control pain and inflammation, with the concurrent initiation of early range-of-motion exercises.  In the early stages the athlete may complain of joint crepitus and a painful arc or catching points; these should be worked through as tolerated.  As active range of motion is restored, a PRE program can be initiated.
 
Internal impingement is one of the most commonly observed injuries in the overhead throwing athlete.  One suggested cause for the impingement is excessive anterior shoulder laxity.  One of the primary goals of the rehabilitation program is to enhance the athlete’s dynamic stabilization capacity, thus, controlling anterior humeral head translation.  Another essential goal is to restore flexibility to the posterior rotator cuff muscles of the glenohumeral joint.  The program should emphasize muscular strengthening of the posterior rotator cuff to re-establish muscular balance and improve joint compression abilities.  Exercise drills such as PNF patterns with rhythmic stabilization are incorporated.  Also, stabilization drills performed at the end range of external rotation are beneficial in enhancing dynamic stabilization and neuromuscular control.
 
After the clinician has restored posterior flexibility, normalized glenohumeral strength ratios, enhanced scapular muscular strength, and diminished the patient’s symptoms, an interval throwing program may be initiated.  Abstinence from throwing is suggested for 2 to 12 weeks depending on the thrower’s symptoms.  Once the thrower begins their interval throwing program, the clinician or pitching coach should observe the athlete’s throwing mechanics often.  Occasionally, throwers who exhibit internal impingement will allow their arm to lag behind the scapula, thus, throwing with excessive horizontal abduction and not throwing with the humerus in the plane of the scapula.  This type of fault (known as hyperangulation of the arm) leads to excessive strain on the anterior capsule and internal impingement of the posterior rotator cuff.  Correction of throwing pathomechanics is critical to returning the athlete to asymptomatic and effective throwing.
 
 
Medial Epicondylitis/ Lateral Epicondylitis
 
Medial and lateral epicondylitis may result from numerous factors.  The majority of causes are related to repetitive sports-specific microtrauma and poor biomechanics.  Medially, overhead throwers most often exhibit pronator tendonitis and golfers have wrist flexor tendonitis, whereas lateral epicondylitis is most often seen in tennis players.  Athletes most often are seen with tenderness near the epicondyle and along the flexor-pronator or extensor-supinator muscle masses, which may be exacerbated by contraction or stretching of the musculature.  For medial epicondylitis, manual resistance of wrist flexion should be performed as well as pronation to determine whether a pronation strain has occurred.  For lateral epicondylitis, testing of theextensor carpi radialis longus is performed with elbow flexed to 30 degrees and resistance given to the second metacarpal bone.  In addition, the extensor carpi ulnaris can be differentiated by resisting ulnar deviation.
 
The nonoperative program focuses on diminishing pain and gradually improving muscular strength.  The primary goals of rehabilitation are to control the applied loads and create an environment for healing.  The initial treatment consists of warm whirlpool, phonophoresis, transverse friction massage, stretching exercises, and light strengthening exercises to stimulate a healing response.  High-voltage pulsed galvanic stimulation and cryotherapy are used after treatment to decrease pain and post-exercise inflammation.  The athlete should be cautioned against excessive gripping activities.  When the athlete’s symptoms have subsided, an aggressive stretching and strengthening program with emphasis on eccentric contractions can be initiated.  A gradual progression through plyometric activities precedes the initiation of an interval sport program.  Because poor mechanics are often a cause of this condition, an analysis of sport mechanics and proper supervision through the interval sport program are critical for successful return to symptom-free athletic participation.
 
 
Apophysitis
 
An apophysis is a bony protuberance that exists as the location of a muscle’s insertion.  This area is predisposed to breakdown and failure at these sites is common to youth athletes.  Osgood Schlatter’s disease, failure at the tibial tubercle, and Sever’s disease, failure at the calcaneus.  Overuse syndromes in young athletes have received greater attention than those of a more violent nature.  Little Leaguer’s elbow can result from repetitive stress to the unmatured elbow structure during the accelerating phase of pitching. Epiphyseal plate deformities, apophysitis, and medial epicondylar avulsion fractures occur medially while compressive forces laterally produce osteochondrotic conditions of the radial head and capitellum.  Osgood-Schlatter’s disease is an overuse syndrome of the tibial tubercle area.  It too can involve lesions of the growth plate or the tendinous insertion area (apophysis).  Overuse of developing cartilaginous surfaces can result as well in lesions unique to the adolescent athlete.  Chondromalacia, a softening of the patellar articular cartilage, and osteochondritis dissecans (Konig’s disease), a roughening of the articular surfaces of thefemoral condyles, have both been identified as disorders of the young athletes often responsible for persistent symptoms, restrictions from competition, and adult sequelae.
 
Little League Elbow - This term encompasses a spectrum of pathologies about the elbow joint in young developing (pediatric) throwers.
  • medial elbow tension overload
  • lateral articular surface compression overload
  • posterior medial shear forces
  • extension overload of the lateral restraints
 
Rehabilitation of the elbow complex in a throwing athlete requires a carefully directed program to ensure full restoration of motion and function.  This rehabilitation generally follows a four-phase progression:
  • Phase 1 – Regaining motion
  • Phase 2 – Regaining strength and endurance
  • Phase 3 – Return to functional participation
  • Phase 4 – Return to activity
 
 
Hip Bursitis
 
The most common form of bursitis around the hip is the greater trochanteric bursitis.  The greater trochanteric bursa lies between the tendon of the gluteus maximus and the posterolateral surface of thegreater trochanter.  There are many possible causes for this bursitis, a major one relating to the iliotibial band into which the gluteus maximus muscle inserts.  The iliotibial band moves anteriorly with flexion and posteriorly with extension.  If its flexibility is compromised, the result may be irritation of the greater trochanteric bursa.  If a habit of standing on one leg with the other leg adducted is followed repeatedly by an activity such as running, the result could be a trochanteric bursitis on the side of the adducted leg.  Similarly an imbalance between the adductor and abductor muscles in a runner with a broad pelvis and increased Q-anglecan cause a painful trochanteric bursa.  Other possible causes of trochanteric bursitis related to running activities are excessive posterolateral heel wear on the shoe or running on a banked surface.  Excessive posterolateral heel wear results in an increased supination at heel strike, which is transmitted proximally to the lateral side of the leg.  This increased pull on the gluteus maximus muscle via the iliotibial band is a logical cause of trochanteric bursitis.  Running with one foot on a lower surface than the other or running with a leg-length discrepancy causes an abnormal pelvic tilt and thus an imbalance that could irritate the greater trochanteric bursa.  Even a repeated adduction of the limb, such as occurs in soccer, can create a similar result.
 
This disorder produces pain over the lateral aspect of the hip and thigh, radiating down to the knee in some cases.  The client will often report an insidious onset and complain of pain while walking and when attempting to cross the legs when seated or when lying on either side.  The pain often increases gradually, especially if activity is not reduced at its onset.  Palpation reveals an area of increased temperature and tenderness over the greater trochanter.  The position of palpation with the client side-lying on the uninvolved side may create discomfort because of the flexed and adducted position of the involved leg.  Ober’s test will usually be positive, and resisted abduction will increase the symptoms.
 
As in any case, discovering the cause is essential to the treatment of this syndrome.  Treating the symptoms with the classical routine of ultrasound or diathermy with no regard for the cause is unacceptable practice.  Gait, posture, flexibility, running patterns, and shoes must be carefully assessed.  Treatment may include ice in the acute stages, ultrasound, or diathermy as well as a stretching program for the iliotibial band, a recommendation of new shoes or a new running pattern, or an orthosis to correct leg-length differences or faulty mechanics in gait.
 
The ischial bursa, lying between the tuberosity of the ischium and the gluteus maximus, is most often inflamed in persons with occupations requiring prolonged sitting.  Ischial bursitis is found much less frequently than greater trochanteric bursitis and is easier to treat.
 
Tenderness is localized over the ischial tuberosity, which is easily palpated in the side-lying position with the hip flexed or in the prone position with the involved leg in the frog-leg position.  Pain often radiates into the hamstring muscles.  The client will report pain with walking, climbing stairs, and flexion of the hip or trunk.  It will be painful to sit on the affected side, and a customary practice of carrying a wallet in the back pocket may aggravate the symptoms.
 
Often the best treatment for ischial bursitis is to suggest chair padding or appropriate positioning to prevent aggravation of the ischial bursa. To relieve pain, ice or heat may be used effectively.
 
 
Total Joint Replacement
 
Total joint replacement typically refers to hip, knee, and shoulder arthroplasty.  Of all total joint replacements, these three are seen the most in physical therapy clinics.  Total joint replacements can be done as an optional or last resort treatment method for osteoarthritis.
 
Osteotomies, such as pelvic and intertrochanteric osteotomies, were popular in the past, and they still may have a limited role in selected situation.  Fusion still does have a role but in very early childhood only.  The mainstay of surgical treatment is total hip replacement.  In general, for elderly patients with low activity demands, both the acetabular and the stem components can be cemented.  For young, high-demand patients, the current trend is to use noncemented implants.  These are only general guidelines.  In revisions with poor-quality bone, the surgeon makes fixation choices based on intraoperative findings.  Weight bearing restrictions are very different after arthroplasty with cemented and cementless hip devices.  Cement is strong as it will ever be 15 minutes after insertions.  Some surgeons believe that some weight-bearing protection should be provided until the bone at the interface with the cement (which has been damaged by mechanical and thermal trauma) has reconstituted with the development of a peri-implant bone plate.  This phenomenon takes 6 weeks.  Most surgeons, however, believe that the initial stability achieved with cement fixation is adequate to allow immediate full weight-bearing with a cane or walker.  With a noncemented hip prosthesis, the initial fixation is press-fit, and maximal implant fixation is unlikely to be achieved until some tissue ongrowth or ingrowth into the implant has been established.  Stability is usually adequate by 6 weeks.  However, maximal stability is probably not achieved until approximately 6 months with noncemented prosthesis.  For these reasons, many surgeons advocate toe-touch weight-bearing for the first 6 weeks.  Some believe that the initial stability achieved is adequate to allow weight-bearing as tolerated immediately after surgery.  Straight-leg raises (SLR) can produce very large out-of-plane loads on the hip and should be avoided.  Side-leg-lifting in the lying position also produces large loads on the hip.  Even vigorous isometric contractions of the hip abductors should be practiced with caution, especially if a trochanteric osteotomy has been done.  Initial rotational resistance of a noncemented hip may be low, and it may be preferable to protect the hip from large rotational forces for 6 weeks or more.  The most common rotational load comes when arising from a sitting position, so pushing with hands from a chair is strongly recommended.  After full weight-bearing is established, is is essential that the patient continue to use a cane in the contralateral hand until the limp stops.  This helps prevent the development of a Trendelenburg gait, which may be difficult to eradicate at a later date.  In some difficult revisions in which implant or bone stability has been difficult to establish, a patient may be advised to continue to use a can indefinitely.  In general, when a patient gets up and walks away, forgetting about the cane, this is an indicator that the cane may be safely discarded.
 
The protocols outlined here for rehabilitation after total hip replacement are general and should be tailored to specific patients.  For example, weight-bearing should be limited to toe-touch if an osteotomy of the femur has been done for any reason.  Osteotomies can be required for alignment correction, either angular or rotational; shortening, such as a calcar episiotomy or subtrochanteric shortening; or exposure, such as a trochanteric osteotomy or slide, extended trochanteric osteotomy or slide, or a window.  Expansion osteotomies allow the insertion of a larger prosthesis, and reduction osteotomies allow narrowing of the proximal femur.  In patients with any of these osteotomies, weight-bearing should be delayed until some union is present.  These patients should also avoid SLR and side-leg-lifting until, in the opinion of the surgeon, it is safe to do so.
 
Some patient instructions after total hip replacement include: avoid crossing your legs, bringing your legs together, bringing the knee too close to your chest, and turning the foot in toward the other leg.
 
Many surgeons use identical routines after total knee replacement, whether the implants are cemented or noncemented.  Their rationale is that the initial fixation of noncemented femoral and tibial components is in general so good that loosening is very uncommon.  The tibia is largely loaded in compression.  The stability achieved with pegs, screws, and stems on modern implants is now adequate to allow full weight-bearing.  However, if the bone is exquisitely soft, weight-bearing should be delayed.  The progression to weight-bearing, therefore, must be based solely on the surgeon’s discretion and intraoperative observations.  The guidelines for rehabilitation given here are general guidelines and should be tailored to individual patients.  Concomitant osteotomies and significant structural bone grafting are indications for limited weight-bearing until healing has been achieved.  Similarly, if the bone is extremely osteoporotic, full weight-bearing is delayed until the peri-implant bone plate develops.  Exposure problems requiring a tibial tubercle osteotomy or a quadriceps tendon division may require that SLR be avoided until adequate healing has occurred, which typically takes 6-8 weeks.  Component design, fixation methods, bone quality, and operative techniques all affect perioperative rehabilitation.  The implant choice no longer determines rehabilitation methods.  It does not or should not make much difference whether the implant is unconstrained, semiconstrained, or full constrained.  Postoperative return of 90 degrees of knee flexion is generally considered the minimal requirement for activities of daily living with an involvement of one knee.  However, if both knees are replaced, it is essential that one knee reach more than 105 degrees of knee bend to allow the patient to rise from a normal low toilet seat.  Immediately after surgery, patients frequently have a flexion contracturebecause of hemarthrosis and irritation of the joint.  These flexion contractures generally resolve with time and appropriate rehabilitation.  However, patients who have been left with a fixed flexion contracture at the time of the surgery frequently are unable to achieve full extension.  It is important, therefore, that full extension be achieved in the operating room.  Goals of rehabilitation after total knee arthroplasty include: prevent hazards of bedrest (pulmonary embolism, pressure ulcers, etc…), assist with adequate and functional range of motion, strengthen knee musculature, assist patient in achieving functional independent activities of daily living, and independent ambulation with an assistive device.
 
Shoulder arthroplasty is one of the few surgical procedures involving the shoulder that require the patient to spend time in the hospital after surgery.  As a result, a supervised rehabilitation program is started during the hospitalization on the first day after surgery to begin mobilization of the reconstructed shoulder joint.  Rehabilitation after shoulder arthroplasty follows the normal sequence of allowing time for tissue healing, joint mobilization, and finally, muscle strengthening and function.  The ability to begin the rehabilitation process so soon after surgery is the direct result of improvements in the surgical approach to theglenohumeral joint.  Earlier approaches required release of the deltoid origin to expose the shoulder for prosthetic replacement.  This necessitated a more conservative, delayed rehabilitation program to avoid postoperative detachment of the deltoid repair.  At present, the only muscle violated during the surgical exposure is the subscapularis muscle, and the rehabilitation protocol must be mindful of the time required for the subscapularis tendon to heal.  The amount of external rotation and active internal rotation that the patient can perform in the first 4 to 6 weeks is limited to motion parameters that can be achieved at the time of surgery.  The goal of rehabilitation is to establish a range of motion that will allow a functional recovery.  Long-term function and rehabilitation progression are affected by the presence or absence of good functional rotator cuff tissue.  Postoperative rehabilitation protocols often are divided into rotator cuff tissue deficient and rotator cuff tissue intact groups.
 
 
Sciatica (Nerve Root Pain)
 
The term nerve root pain is preferable to the use of “sciatica” because it more accurately describes the pathologic origin.  Nerve root pain may arise from disc herniation, spinal stenosis, or postoperative scarring.  Nerve root pain radiates down one leg in a dermatomal pattern.  The leg pain (unilateral) is described by the patient as worse than the back pain.  Numbness and paresthesia (if present) are found in the same nerve root distribution.  Straight-leg raise (SLR) testing reproduces the leg pain.  Motor, sensory, or reflex changes are classically limited to a single nerve root.  Thus, the term “sciatica”, or nerve root pain, is used to describe leg pain that predominates in the distribution of a lumbosacral nerve root, with or without neurologic deficit.
 
Disc herniation describes the protrusion of the gelatinous material of the disc (nucleus pulposus) through theannulus fibrosis.  Several studies have shown gradual resorption and disappearance of herniated discs on serial MRIs without surgical intervention.  The larger disc herniations were found to have had more resorption.  This favorable natural history shows why up to 50% of patients with confirmed, painful herniated discs recover without surgery within 1 to 6 months.
 
Gordon Waddell’s recommended text (1998) critically reviews the poor methodology and science behind studies that have described risks for LBP including: Heavy manual labor, repetitive lifting and twisting, postural stress, whole body vibration, monotonous work, lack of personal control at work, low job satisfaction, poor physical fitness, poor or inadequate trunk strength, and smoking.  It has been concluded that most people get back pain; heredity, gender, and body build make little difference.  It is good general health advice to stop smoking, avoid or correct obesity, and get physically fit.  These may possibly help reduce the likelihood of developing new episodes of back pain.  The prevalence of back pain appears to be slightly higher in those patients who perform more manual types of labor.  They are more likely to stay off work and stay off longer than “clerical” laborers.  This may be a reflection of the effect of their back pain (i.e. patient cannot lift the heavy loads required at work) or may reflect the medical advice given to them by their physicians (stay off work because of the possibility of aggravating the back pain with resumption of heavy labor).  The examiner should evaluate and rule out potential emergent causes of LBP during history and physical examination.  Careful history and review of systems may detect non-musculoskeletal origin of LBP.  Our approach to the work-up of LBP is to first rule out emergent or non-musculoskeletal causes of LBP.  Once this is done, the appropriate examinations and tests are performed to confirm or rule out mechanical , nerve root, tumor, infectious, traumatic, systemic, or inflammatory etiology.
 
 
 
 
 
     
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