Rehabilitation For The Postsurgical Ortho-2013

third edition
REHABILITATION
for the Postsurgical Orthopedic Patient
LISA MAXEY, PT
California Hand and Physical Therapy
Oxnard, California
JIM MAGNUSSON, PT, ATC

Owner
Performance Therapy Center, Inc.
Oxnard and Camarillo, California;
Team Physical Therapist
Oxnard College and Pacifica High School
Oxnard, California;
Wellness/Fitness Coordinator
Oxnard/Ventura Fire Departments
Oxnard and Ventura, California
3251 Riverport Lane
St. Louis, Missouri 63043
Rehabilitation for the Postsurgical Orthopedic Patient, Third Edition 978-0-323-07747-7
Copyright 2013 by Mosby, an imprint of Elsevier Inc.

Copyright 2007, 2001 by Mosby, Inc., an affiliate of Elsevier Inc.
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Permission is hereby granted to reproduce the Home Exercise Programs in this publication in complete pages,
with the copyright notice, for instructional use and not for resale.
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2007, 2001
Library of Congress Cataloging-in-Publication Data
Rehabilitation for the postsurgical orthopedic patient / [edited by] Lisa Maxey, Jim Magnusson.3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-07747-7 (hardcover: alk. paper)
I. Maxey, Lisa. II. Magnusson, Jim.
[DNLM: 1. Physical Therapy Modalities. 2. Postoperative Carerehabilitation. 3. Orthopedic
Proceduresrehabilitation. WB 460]
617.4706dc23
2012031888
Vice President: Linda Duncan

Content Manager: Jolynn Gower
Senior Content Development Specialist: Christie M. Hart
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Project Manager: Prathibha Mehta Working together to grow
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In thanksgiving for all His blessings.
Lisa Maxey
To my two children, Nicholas and Michelle.

Jim Magnusson
This page intentionally left blank
CONTRIBUTORS
Mayra Saborio Amiran, PT Andrew A. Brooks, MD, FACS
Owner Attending Orthopedic Surgeon
California Hand and Physical Therapy Southern California Orthopedic Institute
Newbury Park and Oxnard, California Van Nuys, California;
Attending Orthopedic Surgeon
James R. Andrews, MD Encino Hospital
Clinical Professor of Surgery Encino, California;
Division of Orthopaedic Surgery Attending Orthopedic Surgeon
University of Alabama at Birmingham School of Medicine Motion Picture and Television Hospital
Birmingham, Alabama; Woodland Hills, California;
Clinical Professor of Orthopaedics & Sports Medicine Attending Orthopedic Surgeon
University of Virginia Medical School Specialty Surgical Center
Charlottesville, Virginia; Encino and Beverly Hills, California
Clinical Professor
Department of Orthopaedic Surgery Tom Burton, PT
University of Kentucky Medical Center Director
Lexington, Kentucky; The Center for Rehabilitation Medicine
Senior Orthopaedic Consultant Van Nuys, California
Washington Redskins Professional Football Team
Washington, DC; Adam Cabalo, MD
Medical Director Orthopedic Surgeon
Tampa Bay Devil Rays Professional Baseball Team Kaiser Permanente Maui
Tampa Bay, Florida; Maui, Hawaii
Co-Medical Director
Intercollegiate Sports at Auburn University James H. Calandruccio, MD
Auburn, Alabama; Associate Professor
Orthopaedic Surgeon Department of Orthopaedic Surgery
Alabama Sports Medicine & Orthopaedic Center University of Tennessee
Birmingham, Alabama Memphis, Tennessee;
Physician, Hand and Upper Extremity
Danny Arora, MD Campbell Clinic Orthopaedics
Resident Germantown, Tennessee
Department of Surgery
Queens University Robert Cantu, PT, MMSc, MTC
Kingston, Ontario, Canada Clinic Director, Physiotherapy Associates
Woodstock, Georgia;
Babak Barcohana, MD Continuing Education Instructor
Southern California Orthopedic Institute University of St. Augustine for Health Sciences
Van Nuys, California St. Augustine, Florida;
Adjunct Instructor
Mark T. Bastan, DPT, CSCS School of Occupational Therapy
Coordinator of Clinical Research and Development University of Indianapolis
Elite Physical Therapy Indianapolis, Indiana
Warwick, Rhode Island
Clive E. Brewster, COO

Kerlan-Jobe Orthopaedic Clinic;
Administrator
Kerlan-Jobe Surgery Center
Los Angeles, California
v
vi CONTRIBUTORS
Erin Carr, PT, DPT Daniel A. Farwell, PT, DPT

Adjunct Faculty Adjunct Professor of Clinical Physical Therapy
Department of Physical Therapy Department of Biokinesiology and Physical Therapy
Mount St. Marys College University of Southern California
Los Angeles, California; Los Angeles, California;
Staff Physical Therapist Owner/Director
Knight Physical Therapy, Inc Private Practice
Garden Grove, California Body Rx Physical Therapy
Glendale, California
Diane Coker, PT, DPT, CHT
Associate Instructor Richard D. Ferkel, MD
Loma Linda University Assistant Clinical Professor
Riverside, California; Department of Orthopedic Surgery
Director, Hand Therapy Services University of California, Los Angeles
South County Hand Center Los Angeles, California;
Laguna Woods, California Sports Medicine Fellowship Director
Southern California Orthopedic Institute
Kyle Coker, MD Van Nuys, California
Medical Director
South County Hand Center Morgan L. Fones, PT, DPT, OCS, ATC
Laguna Woods, California Head Physical Therapist
Mt. Tam Physical Therapy
Steven L. Cole, MEd, ATC Larkspur, California
Athletic Trainer
College of William and Mary Jonathan E. Fow, MD
Williamsburg, Virginia Board Certified
Orthopaedic Surgery & Sports Medicine
Benjamin Cornell, PT, OCS Arroyo Grande, California
Adjunct Professor
Department of Physical Therapy Freddie H. Fu, MD
Mount St. Marys College Professor and Chairman
Los Angeles, California; Department of Orthopaedic Surgery
Physical Therapist School of Medicine
Department of Physical Therapy University of Pittsburgh
HealthCare Partners Medical Group Pittsburgh, Pennsylvania
Torrance, California
Ralph A. Gambardella, MD
Curtis A. Crimmins, MD Kerlan Jobe Orthopedic Clinic
Hand Surgery, Ltd. Los Angeles, California
Milwaukee, Wisconsin
Joshua Gerbert, DPM, FACFAS
Linda de Haas, PT, MPT, OCS, CHT Professor Emeritus
Professional Physical Therapy Associates Department of Podiatric Surgery
Whittier, California California School of Podiatric Medicine at Samuel Merritt
University
Rick B. Delamarter, MD Oakland, California;
Director Past Chairman
The Spine Institute Department of Podiatric Surgery
St. Johns Medical Center St. Marys Medical Center
Santa Monica, California San Francisco, California
Robert Donatelli, PhD, PTOCS Mark Ghilarducci, MD

National Director Department of Orthopedic Surgery
Sports Specific Rehabilitation and Performance Enhancement St. Johns Regional Medical Center;
Physiotherapy Associates Department of Sports Medicine
Las Vegas, Nevada Ventura Orthopedic Medical Group
Oxnard, California;
Ventura Orthopedics
Ventura, California
CONTRIBUTORS vii
Eric Giza, MD Reza Jazayeri, MD

Central Maine Orthopedics Group Department of Orthopaedic Surgery
Auburn, Maine Sports Medicine
Southern California Permanente Medical Group
Patricia A. Gray, MS, PT Woodland Hills, California
Physical Therapist
Rehabilitation/Health At Home Richard Joreitz, PT, DPT, SCS, ATC
San Francisco General Hospital Senior Physical Therapist
San Francisco, California UPMC Centers for Rehab Services;
Adjunct Clinical Instructor
Jane Gruber, PT, DPT, OCS Department of Physical Therapy
Department of Rehabilitation Services University of Pittsburgh;
Newton Wellesley Hospital Physical Therapist
Newton, Massachusetts Pittsburgh Penguins Team
Pittsburgh, Pennsylvania
Carlos A. Guanche, MD
Adjunct Clinical Professor Kelly Akin Kaye, PT, CHT
University of Southern California; Physical Therapist PRN
Teaching Faculty Campbell Clinic Orthopedics
Southern California Orthopedic Institute Germantown, Tennessee
Van Nuys, California
Paul D. Kim, MD
Will Hall, PT, DPT, OCS Orthopedic Surgery
Regional Vice PresidentSoutheast Spine Institute
Physiotherapy Associates San Diego, California
Cumming, Georgia
Linda J. Klein, OTR, CHT
Karen Hambly, PhD, MCSP Hand Surgery, Ltd.
Senior Lecturer Milwaukee, Wisconsin
School of Sport and Exercise Sciences
University of Kent Graham Linck, PT
Kent, United Kingdom Physiotherapy Associated
Las Vegas, Nevada
Timothy Hartshorn, MD
Resident Kristen G. Lowrance, OTR/L, CHT
Orthopaedic Surgery Occupational Therapist
University of Southern California Clinical Manager
Los Angeles, California Campbell Clinic
Germantown, Tennessee
George F. Rick Hatch III, MD
Assistant Professor of Orthopaedic Surgery Jim Magnusson PT, ATC
University of Southern California Owner, Performance Therapy Center, Inc.
Keck School of Medicine Oxnard and Camarillo, California;
Los Angeles, California Team Physical Therapist
Oxnard College and Pacifica High School
Eric S. Honbo, PT, DPT, OCS Oxnard, California;
Co-Owner Wellness/Fitness Coordinator
Advanced Physical Therapy & Sports Medicine Oxnard/Ventura Fire Departments
Thousand Oaks, California Oxnard and Ventura, California
Chris Izu, MPT, DPT, OCS Bert R. Mandelbaum, MD

Adjunct Professor Assistant Professor
Department of Physical Therapy Division of Orthopedic Surgery
Mount St. Marys College Department of Surgery
Los Angeles, California; University of California, Los Angeles
Physical Therapist Los Angeles, California;
Human Performance Center Chief Surgeon
Santa Barbara, California Medical Plaza Orthopedic Surgery Center;
Chief of Orthopedics
Department of Orthopedic Surgery
St. Johns Hospital and Health Center
Santa Monica, California
viii CONTRIBUTORS
Joel M. Matta, MD Luga Podesta, MD, FAAPMR

Associate Professor of Clinical Orthopaedics Clinical Assistant Professor
University of Southern California School of Medicine; Department of Physical Medicine and Rehabilitation
John C. Wilson Jr. Chair of Orthopaedic Surgery Western University of Health Sciences
Good Samaritan Hospital Pomona, California;
Santa Monica, California Medical Director
Podesta Orthopedic and Sports Medicine Institute
Lisa Maxey, PT Thousand Oaks, California;
California Hand and Physical Therapy Kerlan-Jobe Orthopedic Clinic;
Oxnard, California Team Physician
Los Angeles Angels of Anaheim
Neil McKenna, DPT, FAAOMPT, OCS, CSCS Los Angeles, California;
Physical Therapist Performance Medicine Consultant
Solana Beach, California Cirque du SoleilIRIS
Kai Mithoefer, MD Ben B. Pradhan, MD

Department of Orthopedics Spine Surgeon
Harvard Vanguard Medical Associates Director of Clinical Research
Harvard Medical School Los Angeles, California;
Boston, Massachusetts The Spine Institute
Erica V. Pablo, PT, DPT, OCS
Clinical Director Edward Pratt, MD
Knight Physical Therapy, Inc Memphis Spine Center
Garden Grove, California Germantown, Tennessee
David Pakozdi, PT, OCS Christine Prelaz, DPT, MS, OCS, CSCS
Director HealthPath Physical Therapy & Wellness
Kinetic Orthopaedic Physical Therapy Denver, Colorado
Brian E. Prell, MSPT, RRT
Mark R. Phillips, MD Rehabilitation and Performance Center
Clinical Assistant Professor Greensboro, Georgia
Department of Orthopedic Surgery
University of Illinois College of Medicine at Peoria; Michael M. Reinold, PT, DPT, SCS, ATC, CSCS
Department of Orthopedic Surgery Head Physical Therapist
Methodist Medical Center; Boston Red Sox Baseball Club
Department of Orthopedic Surgery Boston, Massachusetts
Proctor Hospital;
Orthopaedic Surgeon Michael D. Ries, MD
Great Plains Orthopaedics Professor of Orthopaedic Surgery
Peoria, Illinois University of California, San Francisco
San Francisco, California
Haideh V. Plock, PT, DPT, OCS, ATC, FAAOMPT
Manager Diane R. Schwab, MS, RPT
Department of Physical Therapy San Diego, California
Palo Alto Medical Foundation
Palo Alto, California Jessie Scott, PT, MBA
California Pacific Medical Center
San Francisco, California
Chris A Sebelski, PT, DPT, OCS, CSCS

Assistant Professor
Department of Physical Therapy & Athletic Training
Doisy College of Health Sciences
Saint Louis University
St. Louis, Missouri
CONTRIBUTORS ix
Holly J. Silvers, MPT Kevin E. Wilk, PT, OPT

Director of Research/Physical Therapist Adjunct Assistant Professor
US Soccer Federation Medical Team / CD Chivas USA / Physical Therapy Department
LA Galaxy Marquette University
Santa Monica, California Milwaukee, Wisconsin;
Clinical Director
Paul Slosar, MD Champion Sports Medicine;
Spine Care Medical Group Vice President of Education
Daly City, California Benchmark Medical, Inc.
Birmingham, Alabama
Renee Songer, DPT, OCS, FAAOMPT
Agile Physical Therapy Julie Wong, PT, CLT
Palo Alto, California Director/Owner
Julie Wongs Proactive Clinic
Jason A. Steffe, DPT, OCS, MTC San Francisco, California
Group Director
Physiotherapy Associates James Zachazewski, PT, DPT, SCS, ATC
Atlanta, Georgia Clinical Director
Department of Physical and Occupational Therapy
Derrick G. Sueki, PT, DPT, GCPT, OCS, FAAOMPT Massachusetts General Hospital
Adjunct Faculty Boston, Massachusetts;
Department of Physical Therapy Adjunct Assistant Clinical Professor
Mount St. Marys College Programs in Physical Therapy
Los Angeles, California; MGH Institute of Health Professions
President Charlestown, Massachusetts
Knight Physical Therapy, Inc
Garden Grove, California Boris A. Zelle, MD
Assistant Professor
Steven R. Tippett, PT, PhD, SCS University of Texas Health Science Center at San Antonio
Professor Division of Orthopaedic Traumatology
Department of Physical Therapy and Health Science Department of Orthopaedic Surgery
Bradley University San Antonio, Texas
Peoria, Illinois
Craig Zeman, MD
Timothy F. Tyler MS, PT, ATC Department of Orthopedics
Clinical Research Associate St. Johns Hospital
NISMAT at Lenox Hill Hospital Oxnard, California
New York, New York
PREFACE
We initially set out on this project to help bring knowledge We feel that this third edition will, like the previous two
that was lacking in the field regarding postoperative rehabili- editions, be an invaluable resource for every clinician prac-
tation for the orthopedic outpatient population. We knew ticing in an orthopedic setting. We have brought together
that it was a subject that would continue to grow, as in the over 70 authors from throughout the United States and
previous editions, as new surgical and rehabilitative tech- England. Many of the authors are widely published, and
niques were enhanced and/or refined. Our purpose remains some are just excellent clinicians who have agreed to share
the same with this third edition, adding new chapters and their experiential philosophy. We wanted the clinician to be
updating prior ones. We are confident that this book pro- able to visualize the common surgical approaches to each
vides the clinician with the most comprehensive evidence- case (through the physicians portion) and then follow the
based view of postoperative rehabilitation. therapists guidelines to establish an efficient treatment plan.
In this third edition, we are excited about the addition of When we first began this journey in 2001, the prototype of
a home exercise component (Exercise Pro online) to accom- this text had not been explored, to our knowledge, in this
pany the Suggested Home Maintenance Program. We also much depth (and with this many contributors). We believe
have included new chapters, Clinical Applications for Plate- it is a unique text, since we have continued to develop the
let Rich Plasma Therapy (Chapter 10), Lumbar Spine Disc content by going beyond the clinical setting and transition-
Replacement (Chapter 17), Autologous Chondrocyte ing the client back to his or her prior activity level.
Implantation (Chapter 25), and Bunionectomies (Chapter
32). In keeping in line with returning our clients to their
prior level of function, we have included Transitioning the HOW TO USE THIS BOOK
Patient Back to Running (Chapter 34) to augment the guide-
lines in Transitioning the Jumping Athlete Back to the Court This third edition has evolved and expanded, as has our
(Chapter 33) and Transitioning the Throwing Athlete Back knowledge base over the last 5 years. We have added five new
to the Field (Chapter 13). chapters, as mentioned previously. We have made the table
The third edition begins with an overview regarding the guidelines and Home Maintenance Programs easier to follow
principles of soft tissue healing and treatment presented by and added more vignettes to assist the clinician in problem-
experts in their field. Clinicians must remember the biology solving and clinical reasoning. We have also added Exercise
of the healing process and the many factors that influence it. Pro so that therapists can easily make custom home exercise
Some of the concepts touched on are controversial and programs to hand to their patients. We believe that these
experimental, but others that were once thought of as experi- additions to the book make it an invaluable tool for every
mental are being performed with increasing regularity (e.g., clinician treating postoperative orthopedic patients.
platelet rich plasma therapy). The descriptions are meant to This book gives the therapist a clear understanding of the
give the clinician visualization of the healing process from a surgical procedures required for various injuries and condi-
cellular level. tions so that a rehabilitation program can be fashioned
The practice of physical therapy continues to undergo appropriately. Each chapter presents the indications and
transformations. Over the past 60 years it has evolved into a considerations for surgery; a detailed look at the surgical
science that is continually being scrutinized by third-party procedure, including the surgeons perspective regarding
payers challenging us to prove that what we do is effective rehabilitation concerns; and therapy guidelines to use in
and efficient. We are at a crucial point in our profession in designing the rehabilitation program. During rehabilitation,
which we need to justify how many treatments are necessary areas that might prove troublesome are noted with appropri-
to manage a condition or ICD-9 code; at times, this practice ate ways to address the problems.
ignores the person we are treating. This book is not a cook- The indications and considerations for surgery and a
book for success but rather a compass from which the clini- description of the surgery itself are described by an outstand-
cian can find guidance. This text is our effort to provide a ing surgeon specializing in each area. All of the information
resource that the clinician can reference as a guideline in the presented should be valuable in understanding the mechan-
rehabilitation of the postsurgical patient. ics of the injury and the repair process.
x
PREFACE xi
The therapy guidelines section is divided into three parts: documentation also is significant in the case of the problem
Evaluation patient. Emphasizing active patient involvement in an exer-
Phases of rehabilitation cise program at home is even more imperative in light of the
Suggested home maintenance prescriptive nature of current managed care dictums.
Every rehabilitation program begins with a thorough The keys to an effective home maintenance program are
evaluation at the initial physical therapy visit, which structure, individuality, prioritization, and conciseness. The
provides pertinent information for formulating the treat- term structure refers to exercises that are well defined in
ment program. As the patient progresses through the terms of sets, repetitions, frequency, resistance, and tech-
program, assessment continues. Activities too stressful for nique. The patient must know what to do and how to do it.
healing tissues at one point are delayed and then reassessed Home programs with photographs or video demonstrations
when the tissue is ready for the stress. Treatment measures are helpful in assisting the patient to visualize what is
are outlined in tabular format for easy reference. intended. Some computer-generated home exercise pro-
The phases each patient faces in rehabilitation are clearly grams also offer adequate visual descriptions of the desired
indicated, both as a way to break the program into manage- exercises. Stick figures and drawings that the physical thera-
able segments and as a way to provide reassurance to the pist makes are often unclear and confusing to the patient.
patient that rehabilitation will proceed in an orderly fashion. Individuality, in the clearest sense, involves prescribing
The time span covered by each phase and the goals of the exercises that address the specific needs of a patient at a
rehabilitation process during that phase are noted. The exer- specific point in time. It includes being flexible enough to
cises are carefully explained, and photographs are provided allow the patient to work the home program into the daily
for assistance. schedule as opposed to following only an ideal treatment
Home maintenance for the postsurgical patient is an schedule. Other components inherent in the concept of indi-
essential component of the rehabilitation program. Even viduality include assistance available to the patient at home,
when the therapist is able to follow the patient routinely in financial implications, geographical concerns that influence
the clinic, the patient is still on his or her own for most of follow-up, and the patients cognitive abilities.
the day. The patient must understand the importance of Prioritization and conciseness involve maximizing the
compliance with the home program to maximize postopera- use of the patients time to perform the exercises at home. If
tive results. In the successful home maintenance program, the patient is being seen in the clinic, home exercises should
the patient is the primary force in rehabilitation, with the stress activities not routinely performed in the clinic. If the
therapist acting as an informed and effective communicator, patient is constrained for time, the therapist can identify the
an efficient coordinator, and a motivator. When the therapist most beneficial exercises and prescribe them. It is best not
successfully fulfills these obligations and the patient is moti- to prescribe too many exercises to be done at home. Ideally,
vated and compliant, the home maintenance program can be the patient should have to concentrate on no more than five
especially rewarding. or six at a time. To help keep the number of exercises man-
When the patient is not motivated or not compliant or ageable, the therapist should discontinue less taxing exer-
possesses less-than-adequate pain tolerance, a no-nonsense cises as new exercises are added to the program.
and forthright dialogue with the surgeon, referring
physician, rehabilitation nurse, or any other professional Lisa Maxey
involved is essential. Timely, accurate, and straightforward Jim Magnusson
ACKNOWLEDGMENTS
Once again I would like to thank Jim Magnusson, Clive My grandfather, Dr. James Logie, who helped me under-
Brewster, and all the contributing authors for their hard work stand the dedication of those who aspire to become the best
and dedication to their profession. I am continually amazed in their profession. I studied some of his own hand drawings
the people Ive met in the health care profession and their of the human anatomy when he was in school and have seen
dedication to serving others. And I am grateful to be a part how, through his dedication to serving his patients, his life
of the physical therapy profession. I have truly been blessed has been blessed. He has taught me the importance of
through the professionals I work with and the patients Ive patience and showed me the art of fly fishing.
treated. And I am especially grateful to my family: Albert In the course of a lifetime, we meet people who have made
and Yvonne Liddicoat, Albert Jr. Liddicoat, Brent Liddicoat, impressions on us. Good or bad, they change us and shape
Jim Maxey, Paul Maxey, Rebecca Maxey, Jessica Maxey, our vision of who we want to become. In my experience (25
Stephen Maxey, and Christine Maxey. years) working in the field of physical therapy, I also have
worked with individuals who, not only through clinical work
Lisa Maxey but also through life experience, have taught me the value of
compassion, dedication, empathy, and respect. Although a
I would like to acknowledge my wife, Tracy, who continues number of physical therapists have individually helped, the
to amaze me with her patience and understanding. My ones Ive singled out also have positively influenced count-
parents, Nancy and Chuck, who gave me the foundations of less other therapists: Dee Lilly, Rick Katz, Gary Souza, and
respect, honesty, and love. My brothers, Bill and Bob, who Charles Magistro.
remind me of the values of having faith, being humble, chal- I continue to thank God (and Dee) for helping me find
lenging ourselves, and never giving up on your dreams, and that special person in my wife, partner in life, and peer
my favoriteJames 3:13. Tracy Magnusson, PT.
Jim Magnusson
xii
CONTENTS
PART 1 13 Transitioning the Throwing Athlete Back

to the Field, 233
INTRODUCTION Luga Podesta
1 Pathogenesis of Soft Tissue and Bone Repair, 2

Boris A. Zelle, Freddie H. Fu
PART 3
2 Soft Tissue Healing Considerations SPINE
After Surgery, 15
Robert Cantu, Jason A. Steffe
14 Anterior Cervical Discectomy and Fusion, 256
Derrick G. Sueki, Erica V. Pablo, Rick B. Delamarter,
Paul D. Kim
PART 2
UPPER EXTREMITY 15 Posterior Lumbar Arthroscopic Discectomy and
Rehabilitation, 283
Haideh V. Plock, Ben B. Pradhan, David Pakozdi,
3 Acromioplasty, 28 Rick B. Delamarter
Steven R. Tippett, Mark R. Phillips
16 Lumbar Spine Fusion, 313
4 Anterior Capsular Reconstruction, 44 Chris Izu, Haideh V. Plock, Jessie Scott, Paul Slosar,
Renee Songer, Reza Jazayeri, Diane R. Schwab,
Adam Cabalo
Ralph A. Gambardella, Clive E. Brewster
17 Lumbar Spine Disc Replacement, 335
5 Rotator Cuff Repair and Rehabilitation, 73 Derrick G. Sueki, Erin Carr, Babak Barcohana
Lisa Maxey, Mark Ghilarducci
6 Superior Labral Anterior Posterior Repair, 99

Timothy F. Tyler, Craig Zeman PART 4
7 Total Shoulder Arthroplasty, 118 LOWER EXTREMITY
Chris A. Sebelski, Carlos A. Guanche
8 Extensor Brevis Release and Lateral

18 Total Hip Arthroplasty, 362
Patricia A. Gray, Edward Pratt
Epicondylectomy, 144
Kelly Akin Kaye, Kristen G. Lowrance, James H. Calandruccio 19 New Approaches in Total Hip Replacement:
The Anterior Approach for Miniinvasive Total
9 Reconstruction of the Ulnar Collateral Ligament
Hip Arthroplasty, 376
with Ulnar Nerve Transposition, 155
Lisa Maxey, Joel M. Matta
Mark T. Bastan, Michael M. Reinold, Kevin E. Wilk,
James R. Andrews 20 Hip Arthroscopy, 382
Jonathan E. Fow
10 Clinical Applications for Platelet Rich Plasma
Therapy, 171 21 Open Reduction and Internal Fixation
Eric S. Honbo, Luga Podesta of the Hip, 388
Patricia A. Gray, Mayra Saborio Amiran, Edward Pratt
11 Surgery and Rehabilitation for Primary Flexor
Tendon Repair in the Digit, 193 22 Anterior Cruciate Ligament Reconstruction, 404
Linda J. Klein, Curtis A. Crimmins Jim Magnusson, Richard Joreitz, Luga Podesta
12 Carpal Tunnel Release, 216 23 Arthroscopic Lateral Retinaculum Release, 427
Linda de Haas, Diane Coker, Kyle Coker Daniel A. Farwell, Andrew A. Brooks
xiii
xiv CONTENTS
24 Meniscectomy and Meniscal Repair, 441 30 Ankle Arthroscopy, 536

Morgan L. Fones, George F. Rick. Hatch III, Tom Burton, Danny Arora, Benjamin Cornell, Lisa Maxey,
Timothy Hartshorn Richard D. Ferkel
25 Autologous Chondrocyte Implantation, 457 31 Achilles Tendon Repair and Rehabilitation, 554
Karen Hambly, Kai Mithoefer, Holly J. Silvers, Jane Gruber, Eric Giza, James Zachazewski,
Bert R. Mandelbaum Bert R. Mandelbaum
26 Patella Open Reduction and Internal Fixation, 470 32 Bunionectomies, 579

Daniel A. Farwell, Craig Zeman Joshua Gerbert, Neil McKenna
27 Total Knee Arthroplasty, 480 33 Transitioning the Jumping Athlete Back

Julie Wong, Michael D. Ries to the Court, 603
Christine Prelaz
28 Lateral Ligament Repair of the Ankle, 504
Robert Donatelli, Will Hall, Brian E. Prell, Graham Linck, 34 Transitioning the Patient Back to Running, 616
Richard D. Ferkel Steven L. Cole
29 Open Reduction and Internal Fixation Index, 628

of the Ankle, 520
Graham Linck, Danny Arora, Robert Donatelli, Will Hall,
Brian E. Prell, Richard D. Ferkel
ENHANCE YOUR LEARNING AND

PRACTICE EXPERIENCE
The image to the right is a QR code. The code will take you Main Page Code.
to the companion site where you will find links to selected
Exercise Pro home exercise programs you can print and
deliver to patients, suggested home maintenance programs
you can print and/or edit as needed, and more. All can be
accessed on your mobile device for quick reference in a lab
or clinical setting.
For fast and easy access, right from your mobile
device, follow these instructions. You can also find them at
http://booksite.elsevier.com/Maxey_rehab3e/.
What You Need

A mobile device, such as a smart phone or tablet, equipped
with a camera and Internet access
A QR code reader application (If you do not already have
a reader installed on your mobile device, look for free
versions in your app store.)
How It Works
Open the QR code reader application on your mobile
device. E X E R C I S E S O F T W A R E
Point the devices camera at the code and scan.

The codes take you to a main page where you can link to
specific chapters for instant viewing of the references
where you can further access the website contentno
log-on required.
PART 1 Introduction
1 Pathogenesis of soft tissue and
bone repair, 2
2 Soft tissue healing considerations
after surgery, 15
1
CHAPTER 1
Pathogenesis of Soft Tissue
and Bone Repair
M
usculoskeletal injuries usually result from supra- (skeletal subgroup) and (2) ligaments connecting other
physiologic stresses that overwhelm the intrinsic organs, such as suspensory ligaments in the abdomen (vis-
stability of the musculoskeletal apparatus. The ceral subgroup). The skeletal ligaments are the focus of this
consequence is injury to the bone, tendon, muscle, ligaments, chapter. The nomenclature of the ligaments usually relates to
or a combination of these structures. The physiologic healing their anatomic location and bony attachments (i.e., medial
response varies among these tissues and is influenced by collateral, posterior talofibular), as well as their shape and
various intrinsic and extrinsic factors. Among these are the function (i.e., triangular, cruciate, or deltoid ligament).
degree and anatomic location of the injury, the patients physi- Structurally, ligaments contain rows of fibroblasts within
ology, and the mode of treatment rendered. The aim of this parallel bundles of collagen fibers. Approximately two thirds
chapter is to review the concept of soft tissue and bone healing of the wet weight of a ligament is water, whereas collagen
and to describe the factors that influence the healing response. fibers account for approximately 70% of the dry weight.
More than 90% of the collagen in ligaments is type I collagen.
INCISION AND WOUND HEALING Trace amounts of other collagens exist, such as type III, V,
X, XII, and XIV.1 The primary structure of the type I collagen
With regard to epithelial tissue, the surgical incision is consists of a polypeptide chain with high concentrations of
considered to be a controlled trauma. Incision and wound glycine, proline, and hydroxyproline. Almost two thirds of
healing begins immediately after surgery and progresses the primary structure of type I collagen consists of these
through four distinct phases: (1) the coagulation phase (Fig. three amino acids. Intermolecular forces cause three poly-
1-1), (2) the inflammatory phase, (3) the granulation phase peptide chains to combine into a triple helical collagen
(Fig. 1-2), and (4) the scar formation and maturation phase. molecule. This ropelike configuration imparts great tensile
Table 1-1 gives an approximate time frame for each of these strength properties (Fig. 1-3). Within the ligament, the col-
phases with hallmarks of what each phase accomplishes. lagen fibrils are usually organized in a longitudinal pattern
Wound healing requires a clean environment, good circula- and are held in place by the extracellular matrix (see Fig.
tion, appropriate approximation of wound edges, and a 1-1).2 Collagen fibers in the extracellular matrix are sur-
balance of the cellular mechanisms that ensure a proper rounded by water-soluble molecules, such as proteoglycans,
immune response in the wound environment. Wound glycosaminoglycans, and structural glycoproteins. Although
healing occurs through scar formation. Many intrinsic these molecules represent only approximately 1% of the dry
factors (e.g., age, metabolic and circulatory disorders, patient weight of ligaments, they are important for proper ligament
physiology, and comorbidities) and extrinsic factors (e.g., formation and organization of the ligament meshwork. Their
nutrition, hydration, smoking, wound exposure, and wound hydrophilic properties are crucial for the viscoelastic capac-
management) will influence the healing response and forma- ity of ligament tissue and ensure adequate tissue lubrication
tion of the scar. and proper gliding of the fibers. Moreover, proteoglycans
couple adjacent collagen fibrils together and support the
LIGAMENT INJURIES AND HEALING mechanical integrity of the ligaments.3
Ligament Anatomy and Function Ligament Injury

Ligaments are anatomic structures of dense, fibrous connec- From the clinical standpoint, ligamentous injuries are clas-
tive tissue. They can be divided into two major subgroups: sified into three grades.4 Grade I injuries include mild
(1) ligaments connecting the elements of the bony skeleton sprains. The structural integrity of the ligament is intact,
2
Chapter 1 Pathogenesis of Soft Tissue and Bone Repair 3
TABLE 1-1 Epithelial Tissue Healing

Coagulation Phase Vasoconstriction, Begins immediately and
(see Fig. 1-1) platelet lasts minutes
aggregation, clot
formation
Inflammatory Vasodilation, At the edges of wounds,
Phase polymorphonuclear epidermis immediately
(PMN) leukocytes, begins thickening;
phagocytes within the first 48
hours entire wound is
epithelialized; lasts
hours
Granulation Phase Fibroplasia, Fibroblasts appear in 2-3
epithelialization, days and are dominant
wound contraction cell by day 10
Scar Formation/ Collagen synthesis; Lasts weeks to months
Maturation rarely regain full and even up to 1 year
Phase (see Fig. elasticity and
1-2) strength
Adapted from Browner BD, etal: Skeletal traumabasic science,

management, and reconstruction, ed 3, Philadelphia, 2003, Saunders.
Glycine Glycine Glycine

Fig. 1-1 Coagulation phase of wound healing; wound gap is filled with a
HO
blood clot. (From Browner BD, etal: Skeletal traumabasic science, man- Polypeptide
agement, and reconstruction, ed 3, Philadelphia, 2003, Saunders.)
Hydroxproline
Proline Proline
Triple Helix
Collagen
Molecule
Microfibril
Fig. 1-3 Schematic drawing of the collagen structure. A linear polypeptide

with a high percentage of proline, glycine, and hydroxyproline is folded into
an -helix. Three polypeptide chains form a triple helix. The collagen mol-
ecules are packed to form the microfibrils. (Adapted from Gamble JC,
Edward C, Max S: Enzymatic adaptation of ligaments during immobiliza-
tion. Am J Sports Med 12:221-228, 1984.)
although edema, swelling, and punctate ligament bleeding

may be present. In grade II injuries, individual fibrils are
torn, but the overall continuity of the ligament is maintained.
Significant edema and bleeding is usually noted, and liga-
ment stability is reduced. Grade III injuries are characterized
by complete disruption of the ligament substance. Most liga-
mentous injuries can be diagnosed through a clinical exami-
Fig. 1-2 Granulation phase of wound healing, fibroplasias, angiogenesis,
epithelialization, and wound contraction. (From Browner BD, etal: nation and joint stability tests. Magnetic resonance imaging
Skeletal traumabasic science, management, and reconstruction, ed 3, (MRI) represents the most commonly performed imaging
Philadelphia, 2003, Saunders.) study for diagnosing ligamentous injuries.
4 PART 1 Introduction
Multiple healing studies involving the medial collateral in the ligament scar varied from the normal tissue, with type
ligament (MCL) of the knee have been performed and have III collagen being increased in the scar tissue.6
contributed to our knowledge of ligament healing. The The healing response varies among the different liga-
healing phases of ligaments are traditionally divided by their ments. While MCL injuries have the potential to heal
morphologic appearance into an inflammatory phase (first spontaneously, other ligament injuries, such as anterior cru-
days postinjury), a proliferative phase (1 to 6 weeks post ciate ligament (ACL) injuries, rarely show a spontaneous
injury), and a remodeling phase (beginning at 7 weeks healing response. Recent experimental studies in rabbits
postinjury) (Table 1-2).5 It is important to appreciate that have demonstrated an increased expression of myofibro-
these three phases represent a continuum rather than dis- blasts and growth factor receptors in the injured MCL as
tinct phases. The predominant cell types in the inflammatory compared with the injured ACL.7 Various reasons may
phase are inflammatory cells and erythrocytes. As the liga- account for the superior healing response of the MCL as
ment ruptures, its torn ends retract and have a ragged, mop- compared with the ACL. It must be assumed that the high
end appearance. The gap between these torn ends is filled stress carried by the ACL prevents the ruptured ligament
with hematoma from ruptured capillaries. Histologically, the ends from having sufficient contact. In addition, the ACL is
inflammatory reaction is characterized by increased vasodi- not embedded in a strong soft tissue envelope. Moreover, the
lation, capillary permeability, and migration of leukocytes. ACL is an intraarticular structure; when it ruptures, the
During the inflammatory phase, water and glycosaminogly- blood is diluted by the synovial fluid, preventing hematoma
cans are increased in the injured tissue. During the prolifera- formation and hence initiation of the healing mechanism.
tive phase, a highly cellular scar develops, with fibroblasts as Finally, it has been suggested that the synovial fluid is a
the dominating cell type. New collagen fibrils can be identi- hostile environment for soft tissue healing. Thus in
fied as early as 4 days after the injury. After approximately 2 ACL-deficient knees, the levels of proinflammatory cyto-
weeks, the newly formed collagen fibrils bridge the gap kines are elevated, leading to a potentially unfavorable
between the torn ligament ends. However, the water content intraarticular microenvironment.8
of the scar remains elevated, the collagen density remains
low, and the collagen fibrils still appear less organized than Effect of Mobilization and Immobilization on
in normal ligament tissue. During the remodeling phase, Ligament Healing
cellularity and vascularity decrease while collagen density An important aspect of the rehabilitation of patients with
increases. Moreover, the collagen arrangement becomes ligament injuries represents the timing of postinjury
more organized along the axis of the ligament. mobilization. Although aggressive mobilization obviously
MCL healing studies in rabbits demonstrated that the results in disruption of the scar tissue, prolonged immobili-
remodeling phase is a long, ongoing process.6 At 10 months zation may decrease the morphologic and biomechanical
after ligament midsubstance injuries, the scar could be properties of the newly formed scar. It remains unclear
identified macroscopically and a significantly increased what degree of immobilization is appropriate for healing
cross-sectional area of the scar was noticed. This scar tissue ligaments.
demonstrated an increased cellularity and highly organized The role of mobilization versus immobilization on liga-
scar tissue was not achieved, even at 10 months postinjury. ment healing has been investigated in numerous animal
Although the water concentration returned to normal value studies.9-11 In an MCL healing study in rats, Vailas and asso-
at 10 months, the glycosaminoglycan concentration of the ciates11 compared the healing properties of the transected
scar tissue remained elevated and the collagen concentration MCL across the following four groups: (1) surgical repair
remained lower. Despite a gradual increase throughout the with 2 weeks of immobilization and 6 weeks of normal cage
healing phase, the collagen concentration plateaued at 70% activity; (2) surgical repair with 2 weeks of immobilization
of uninjured ligament tissue. In addition, the collagen types and 6 weeks of treadmill exercise; (3) surgical repair with 8
weeks of immobilization; and (4) no surgical repair and no
exercise. All animals were sacrificed at 8 weeks. The authors
reported that the wet ligament weight, dry ligament weight,
TABLE 1-2 Ligament Healing
total collagen content of the ligament, and the ultimate load
Inflammatory Vasodilation, fibrin clot formation, Begins immediately at failure of the ligament substance was lowest in the com-
Phase increased capillary and lasts minutes pletely immobilized group and highest in the exercised
permeability, and migration of to hours group.11 In an MCL transsection model in the rabbit, Gomez
leukocytes and associates9 investigated the effect of continuous tension,
Proliferative Fibroblasts are the dominate cell 1-6wk postinjury as achieved by the implantation of a steel pin applying con-
Phase type, collagen fibrils (as early tinuous stress on the healing MCL. At 12 weeks after MCL
as 4 days postinjury) transection, the additional implantation of a tension pin
Remodeling Collagen synthesis and increased 7wk up to 1yr resulted in a significantly decreased varus and valgus laxity,
Phase density; rarely regain full decreased cellularity of the scar tissue, and a more longitu-
elasticity and strength dinal alignment of the collagen fibers. These authors con-
cluded that the application of controlled stress helped to
augment the biochemical, morphologic, and biomechanical

properties of the healing MCL.9 In a more recent study,
Provenzano and associates10 investigated the effect of hind
limb immobilization on the healing response of transected
MCLs in a rat model. The authors reported significantly
superior biomechanical ligament properties in the mobilized
group. Microscopic analysis revealed abnormal scar forma-
tion and cell distribution in the immobilized group, as sug-
gested by disoriented fiber bundles and discontinuities in the
extracellular ligament matrix.10 A
These experimental data clearly emphasize the impor-
tance of stress and motion for the functional recovery of
healing ligaments. However, the ideal amount of mobiliza-
tion and immobilization during ligament healing is difficult
to determine by animal studies, because animal studies are
limited by the differing physiology and joint kinematics of
animals. In addition, the amount of mobilization is difficult
to control, and an exact titration of the stress cannot be
performed with current in vivo models. Future clinical trials
are necessary to determine the optimal amount of applied
stress for the various ligament injuries.
TENDON INJURIES AND HEALING

Tendon Anatomy and Function B
Tendons are bands of dense, fibrous connective tissue inter-
Fig. 1-4 Microscopic longitudinal sections of the patellar tendon. A, The
posed between muscles and bones. They transmit the forces hematoxylin and eosin (H&E) staining demonstrates the parallel arrange-
created in the muscles to the bone, making joint motion ment of the collagen fibers and the fibroblasts under the light microscope.
possible. Some tendons may also connect two muscle bellies B, Electron microscopy demonstrates the wavy pattern of the fibers
(e.g., digastrics, omohyoid). The gross tendon structure (i.e., crimp). (From Fu FH, Zelle BA: Ligaments and tendons: basic science
and implications for rehabilitation. In Wilmarth MA, editor: Clinical appli-
varies considerably from tendon to tendon, ranging from
cations for orthopaedic basic science: Independent study course, La Crosse,
cylindrical rounded cords to flattened bands, called aponeu- Wis, 2004, American Physical Therapy Association.)
roses. The cross-sectional area of the more rounded tendons
usually correlates with the isometric strength of the muscle
from which they arise. The bony insertion site of the tendon
is often accompanied by a small synovial bursa (e.g., sub- According to their envelope, tendons can be divided into
acromial bursa, pes anserinus, retrocalcaneal bursa). The tendons within a synovial sheath (i.e., sheathed tendons) and
tendon bursae are usually located in those anatomic sites paratenon-covered tendons. In particular, tendons in the
where a bony prominence would otherwise compress the hand and foot are often enclosed in a synovial tendon sheath.
gliding tendon. The tendon sheath directs the path of the tendon and pro-
Microscopically, tendons and ligaments are similar. The duces a synovial fluid, which allows tendon gliding and con-
tendon tissue is a complex composite of parallel collagen tributes to tendon nutrition. True tendon sheaths are only
fibrils embedded in a matrix; cells are relatively rare, and found in areas with an increased friction or sharp bending
fibroblasts represent the predominant cell type within the of the tendons (e.g., flexor tendons of the hand). A simple
tendon; and the fibroblasts are arranged in parallel rows membranous thickening of the surrounding soft tissue,
between the collagen fibrils (Fig. 1-4, A and B). The bio- called the paratenon, usually surrounds tendons without a
chemical composition of ligaments and tendons are also very true synovial tendon sheath, such as the Achilles tendon. The
similar. Water is the major constituent of the wet tendon paratenon is composed of loose fibrillar tissue. It also func-
weight, whereas type I collagen accounts for approximately tions as an elastic sleeve and permits free movement of the
70% to 80% and elastin for approximately 1% to 2% of the tendon against the surrounding tissue, although it is not as
dry tendon substance. As in ligaments, other collagen types efficient as a true tendon sheath.
exist only in small amounts. The proteoglycans and glycos- Just like ligaments, tendons have a limited blood supply.
aminoglycans in the extracellular matrix play an important The vascular supply of tendons has been described by injec-
role for the viscoelastic properties and the tensile strength of tion studies, which demonstrated that tendons are usually
the tendon. Their hydrophilic capacity provides the tendon surrounded by a network of blood vessels.12 Arteries supply-
with lubrication and facilitates gliding of the fibrils during ing the tendon might come from the attached muscle, the
tensile stress. bony insertion site, the paratenon, or the tendon sheath
along the length of the tendon. However, there seems to be

a difference between the nutrition of the sheathed tendons
and the paratenon-covered tendons. The paratenon-covered
tendons receive the majority of their blood supply from
vessels in the paratenon. In sheathed tendons, the synovial
sheath minimizes the vascular supply to the tendon sub-
stance, and avascular regions have been identified within the
midsubstance of these tendons.12-14 Hence the diffusion of
nutrients through the synovial fluid of sheathed tendons is
critical for their homeostasis. Indeed, in sheathed tendons
this process may be even more important than vascular per-
fusion. The digital flexor tendons, for example, receive up to
90% of their nutrition by diffusion.15 For this reason, sheathed
tendons have also been referred to as avascular tendons,
whereas the paratenon-covered tendons have been referred
to as vascular tendons.
Tendon Injury
Tendon injuries may occur as a result of direct or indirect
trauma (Fig. 1-5, A and B). Direct trauma includes contu-
sions and lacerations, such as lacerations of the flexor tendons
of the hand. Indirect tendon injuries are usually a conse-
quence of tensile overload. Because most tendons can with-
stand higher tensile forces than their associated muscles or
osseous insertion sites, avulsion fractures and ruptures at the
A
myotendinous junctions are more likely than midsubstance
ruptures. Midsubstance ruptures of the tendon after indirect
trauma are usually associated with preexisting tendon degen-
eration. This has been supported by histologic investigations
of ruptured Achilles tendons, which demonstrated increased
tenocyte necrosis, loss of fiber structure, increased vascular-
ity, decreased collagen content, and increased glycosamino-
glycan content in previously ruptured tendons.16-18
Tendon Healing
The repair process in paratenon-covered tendons is also ini-
tiated by the influx of extrinsic inflammatory cells. As in
ligaments, the healing of the ruptured tendon proceeds
through an inflammatory phase, a proliferative phase, and
a remodeling phase.19-21 During the inflammatory phase,
healing is initiated by the formation of a blood clot bridging
the gap between the ruptured ends. During the first few days
after the injury, the proliferative phase begins; disorganized
fibroblasts are the dominating cell types, and collagen syn-
thesis can be detected. The collagen fibers orient themselves
along the axis of the tendon during the remodeling phase.
The remodeling phase continues for many months. It is char-
acterized by increased organization of the collagen fibers, an
increase in the number of intermolecular bonds between the
collagen fibers, subsequent reduction of scar tissue, and
increased tensile strength (Table 1-3).
Although it seems well accepted that the healing response
in paratenon-covered tendons is initiated by the influx of B
inflammatory cells, the initiation of the healing response of
sheathed tendons remains controversial. Both an intrinsic Fig. 1-5 Magnetic resonance imaging (MRI) evaluation of the Achilles
tendon. The T1-weighted sagittal cuts show normal continuity of the Achil-
mechanism and an extrinsic mechanism have been pro- les tendon (A) (arrow) and a ruptured Achilles tendon (B) (arrow).
posed. The extrinsic concept suggests that similar to
TABLE 1-3 Tendon Healing

Inflammatory Vasodilation, hematoma Begins immediately
Phase formation to bridge the defect and lasts minutes
(or gap), increased capillary to hours
permeability, and migration of
leukocytes; influx of extrinsic/
intrinsic inflammatory cells
Proliferative Fibroblasts are the dominant cell 1-6wk postinjury
Phase type, collagen synthesis
Remodeling Collagen synthesis and increased Can last for several
Phase density months
paratenon-covered tendons, the healing of sheathed tendons

occurs by granulation from the tendon sheath and the sur-
rounding tissue, although the tenocytes themselves play no
important role in this repair. According to the intrinsic
theory, cells from within the tendon proliferate at the wound
site, leading to production of collagen and extracellular
matrix.15,20 With regard to the initiation of the healing Fig. 1-6 Magnetic resonance imaging (MRI) evaluation of a partial tear of
response, it appears probable that both intrinsic and the pectoralis muscle. The T2-weighted axial cuts depict the edema forma-
extrinsic healing exist. tion (arrow) within the pectoralis muscle.
Effect of Mobilization and Immobilization

on Tendon Healing muscle fibers. The endomysium surrounds the individual
The ideal mobilization regimen for the various tendon inju- muscle fibers. Groups of muscle fibers are arranged together
ries is beyond the scope of this discussion. Clearly, overag- to fascicles surrounded by the perimysium. The fascicles are
gressive early mobilization may result in rerupture of the grouped together by the epimysium to form the whole
tendon. Scientific evidence suggests that motion and stress muscle belly.
increase collagen production, accelerate remodeling, Skeletal muscle contraction is accomplished by sliding of
and improve the biomechanical properties of healing its filaments.25,26 The basic contractile unit is the sarcomere.
tendons.22-24 However, the optimal level of stress and The active contractile units within the sarcomere are the
motion of the healing tendon must be established based actin and the myosin filaments. These myofilaments are
on clinical evidence. arranged in a parallel fashion in which the larger myosin
filaments interdigitate between the small actin filaments. The
SKELETAL MUSCLE INJURIES actin filaments actively slide along the surface of the myosin
AND HEALING filaments through cross-bridges originating from the myosin.
The coordinated sliding of actin and myosin filaments
Anatomy and Function of Skeletal Muscle throughout the muscle translates into contraction of the
Skeletal muscle represents the largest tissue mass in the body entire unit, which generates force and motion.
and accounts for almost 50% of the total body weight. Skel-
etal muscle originates from bone and inserts into bone via Muscle Injuries and Healing
tendon. The primary function of skeletal muscle is to provide Skeletal muscle injuries constitute the majority of sports-
mobility to the bony skeleton. This is accomplished by related injuries.27,28 Skeletal muscle injuries can be classified
muscle contraction (i.e., shortening) and force transmission as indirect and direct injuries. Indirect injuries result from
through the muscle-tendon-bone complex. an overload that overwhelms the muscles ability to respond
The basic structural element of the skeletal muscle is the normally, such as muscle strains and delayed-onset muscle
muscle fiber. The muscle fiber is a syncytium of many cells soreness. Direct injuries are usually a result of external
fused together with multiple nuclei. The muscle fibers consist forces, such as muscle contusions and muscle lacerations.
of contractile elements, the myofibrils, which give skeletal Most injuries are diagnosed clinically. MRI has been found
muscle a striated appearance by light microscopy. The myo- to be highly sensitive to muscle edema and hemorrhage and
fibrils consist of myofilaments (actin and myosin filaments). is the primary imaging modality for determining the type of
Individual muscle fibers are organized into muscle by sur- injury and the degree of muscle involvement (Fig. 1-6).18,29
rounding connective tissue (i.e., endomysium, perimysium, Large muscle injuries have a limited healing capacity, and the
epimysium) that provide integrated motion among the repair process usually results in the formation of scar tissue.
Severe muscle injuries may result in the inability to train or athletes resume their normal activities quickly after DOMS
compete for several weeks, and they have a high tendency to onset. Permanent impairment after DOMS does not occur.32
recur.30,31
Similar to ligaments and tendons, injured skeletal muscle Muscular Contusion
undergoes phases of disruption and degeneration, inflamma- Muscular contusions are caused by direct blunt trauma to
tion, proliferation, and fibrosis (Table 1-4). After trauma to the muscle resulting in damage and partial disruption of the
the muscle, the disrupted muscle ends retract and the gap is muscle fibers. Frequently, muscle contusions are associated
filled by a local hematoma. Disruption of the muscle fibers with capillary rupture and local hematoma formation. This
leads to increased extracellular calcium levels, activation of is associated with an inflammatory reaction, including
the complement cascade, and myofiber necrosis. Inflamma- increased neutrophil and phagocytic activity, release of
tion is an early response to muscle tissue injury. Neutrophils inflammatory cytokines, prostaglandin production, and
rapidly invade the injury site and release inflammatory cyto- local edema. Clinical signs and symptoms may include
kines followed by an increase in macrophages that phagocy- ecchymosis, superficial and deep soft tissue swelling, pain,
tose cell debris. Structural damage of the muscle fibers usually local tenderness, and decreased or abnormal range of motion
heals with formation of scar tissue (Fig. 1-7, A to D).29 (ROM). Jackson and Feagin36 classified the muscular contu-
The most common muscle injuries include delayed-onset sions into three degrees, according to the clinical symptoms.
muscle soreness (DOMS), muscular contusion, muscular A mild contusion is characterized by localized tenderness,
strain, and muscular laceration. Among these types of inju- near normal ROM, and near normal gait pattern. A moder-
ries, the mechanism of injury, pathologic changes, treatment, ate contusion usually includes a swollen tender muscle mass,
and outcome vary greatly. Therefore these issues will be dis- a 50% decrease in ROM, and an antalgic gait. A severe contu-
cussed in detail for each of these muscle injuries. sion is characterized by marked tenderness and swelling, a
75% decrease in ROM, and a severe limp.36
Delayed Onset Muscle Soreness The initial treatment consists of RICE to prevent further
DOMS is a consequence of extensive exercise and usually hemorrhage. This is followed by active and passive ROM
occurs approximately 12 to 48 hours after exercise. The exercises and eventually the use of heat, a whirlpool, and
symptoms of DOMS occur when the amount of stress applied ultrasound. Functional rehabilitation includes strengthening
to the muscle exceeds its ability to elongate without disrupt- exercises. Muscular contusions heal by formation of dense
ing the structural integrity. The symptoms of DOMS are connective scar tissue with variable amounts of muscle
particularly intense after eccentric muscle contraction exer- regeneration. Early stretching exercises of the injured
cises, whereas repetitive submaximal muscle contractions muscle play an important role in the functional scar tissue
cause less severe symptoms.32,33 DOMS is characterized by remodeling process and normal alignment of the newly
alterations of the structural integrity, an inflammatory formed collagen fibers. In contrast, it seems that prolonged
response, and the loss of functional capacity.34,35 The inflam- immobilization is associated with an inferior recovery of
matory component is most likely a response to the damage muscle function.36
of the structural muscle integrity and usually lasts for a few
days. To reduce the inflammatory response, the treatment Muscular Strain
during the first 2 to 3 days consists of rest, ice, compression, Muscular strains are tears in the muscle, which may occur
and elevation (RICE). Stretching exercises are recommended as a result of excessive stress (i.e., acute strain) or constant
thereafter to allow superior scar tissue remodeling and fiber overuse (i.e., chronic strain).33 In particular, muscles that
alignment of the repair tissue. However, most competitive cross two joints, such as the hamstring muscles and the gas-
trocnemius, seem to be particularly susceptible to muscular
strains. Chronic muscle strains usually occur as a result of
repetitive overuse, causing fatigue of the muscle. Acute
TABLE 1-4 Muscle Healing (Involving Disruption
strains, on the other hand, are the result of an excessive force
of Muscle Cell Structure)
applied to the muscle. The injury usually occurs at the
Inflammatory Phase Vasodilation, hematoma Begins immediately weakest part of the muscle, the myotendinous junction. His-
(Disruption and formation, increased and lasts minutes tologically, muscle strains are characterized by hemorrhage
Degeneration) capillary permeability, to hours and an inflammatory response. However, the extent of
increased extracellular muscle strain may vary. Mild strains occur when no appre-
calcium, and migration ciable structural damage exists to the muscle tissue and
of leukocytes pathologic changes are confined to an inflammatory response
Proliferative Phase Neutrophil and 1-6wk postinjury with swelling and edema, causing discomfort with exercise.
macrophage migration With moderate damage, an appreciable muscular defect
Remodeling/ Collagen synthesis and Can last for several occurs and the inflammatory response, edema, and discom-
Fibrosis Phase increased density; scar months fort are increased as compared with mild strains. Severe
formation strains are characterized by complete rupture of the muscle
belly or the myotendinous junction.
A B
C D
Fig. 1-7 Histologic pictures of muscle tissue from mice. A and B show normal muscle tissue. C and D show evidence of fibrosis and regenerating myofibers
in the trichrome stain at 2 weeks after experimental muscle laceration.
The treatment of muscular strains is completely depen- the functional recovery is usually limited after muscle
dent on the grade of the injury. Although mild strains are laceration.
usually treated symptomatically with RICE, severe strains
may require surgical reconstruction. Muscular strains usually Myositis Ossificans
heal with the formation of fibrous scar tissue that can be The term myositis ossificans is used to describe ectopic bone
visualized by MRI.29 formation within a muscle. Myositis ossificans represents
a common complication after muscle injuries. Although
Muscle Laceration common locations of myositis ossificans are the anterior
Muscle lacerations may be caused by penetrating trauma to thigh and the upper arm, it may occur in any muscle of the
the muscle and the surrounding soft tissue. Recovery of the body. The clinical symptoms suggesting myositis ossificans
muscle function depends on the orientation of the lacera- include localized tenderness, swelling, and muscle weakness.
tion. Lacerations perpendicular to the muscle fibers may Myositis ossificans can usually be detected on plain radio-
create a denervated segment, which is associated with a poor graphs (Fig. 1-8, A and B). MRI studies may provide addi-
recovery.37,38 Suture repair of these lesions usually results in tional information with regard to location within the muscle
scar formation across the laceration. Thus muscle regenera- and extent of the lesion. In addition, nuclear bone scans may
tion does not occur across the laceration site, and the play a role in the early detection of the lesion and may help
functional continuity is usually not restored after muscle judging the maturity and activity of the process. The patho-
laceration.37,38 In addition, the distal segment is often dener- genesis of myositis ossificans is not completely understood.
vated, and even surgical repair of the muscle belly may not Myositis ossificans commonly occurs adjacent to the
restore the innervation of this part of the muscle. Therefore bone shaft, suggesting that bone-forming cells from the
Other authors theorize that after the muscle injury, rapidly

proliferating nondifferentiated connective tissue forms cal-
cifications within the muscle.42
In the early stages of myositis ossificans, RICE is the pre-
ferred treatment. Ectopic calcification in the soft tissue
surrounding the hip joint after total hip replacement or treat-
ment of acetabular fractures represent a major clinical chal-
lenge. A meta-analysis of the literature demonstrated that
treatment with moderate to high doses of nonsteroidal anti-
inflammatory drugs (NSAIDs), such as indomethacin, at the
time of surgery decreases the risk of ectopic bone forma-
tion.43 The method by which NSAIDs prevent ectopic bone
formation has not been completely understood, but early
inhibition of prostaglandin-dependent osteogenic cells
appears to be the likely mechanism. Early surgery is contra-
indicated in myositis ossificans because reossification
commonly occurs. Surgical exploration and excision of het-
erotopic bone formations is only indicated in symptomatic
patients and when bone scans and consecutive radiographs
A D
suggest low activity and mature bone formation.40
BONE INJURY AND HEALING

Bone Morphology
Bone is a composite of material consisting of minerals, pro-
teins, water, cells, and other macromolecules (i.e., lipids,
sugar). The composition of the bone tissue varies and depends
on age, diet, and general health status. In general, minerals
account for 60% to 70% of the bone tissue, water accounts for
5% to 10% of the bone tissue, and the organic bone matrix
makes up the remainder. The mineral component is mainly
composed of calcium hydroxyapatite (Ca10(PO4)6(OH)2.
Approximately 90% of the organic bone matrix is type I col-
lagen; the remainder consists of minor collagen types, non-
collagenous proteins, and other macromolecules.
The major cell types of bone tissue are osteoblasts, osteo-
cytes, and osteoclasts. The osteoblasts represent the bone-
forming cells. The osteoblasts line the surface of the bone
matrix and the osteocytes are encased within the mineral-
ized bone matrix. Both cell types are derived from the same
osteoprogenitor cell type. A layer of unmineralized bone
matrix (osteoid) lies between the osteoblast and the mineral-
ized bone matrix. Once an osteoblast becomes surrounded
by mineralized bone matrix, it is referred to as an osteocyte.
B DOsteocytes are characterized by a higher nucleus-to-
cytoplasm ratio and contain fewer cell organelles than osteo-
Fig. 1-8 Radiographs of the right femur with anteroposterior (A) and
lateral view (B) demonstrate an ectopic bone formation lateral to the femur
blasts. Osteoclasts are the major resorptive cells of bone and
in the middle third of the bone. are characterized by their large size and multiple nuclei.
Osteoclasts derive from pluripotent cells of the bone marrow,
which are hematopoietic precursors that also give rise to
periosteum migrate into the muscle tissue and produce bone monocytes and macrophages. They lie in regions of bone
within the injured muscle or the muscle hematoma.39,40 In resorption in pits called Howship lacunae.
some cases, however, the ectopic calcifications occur within
the muscle and are not in the close proximity of the bone. Bone Injuries and Healing
For these lesions, the pathogenesis remains unclear. One A fracture of a bone is a complete or partial break in the
theory is that after the muscle injury, the circulation within continuity of the bone. Fractures usually occur as a result
the traumatized muscle decreases and leads to ossification.41 of trauma and may arise from low energy forces that are
cyclically repeated over a long time period (i.e., stress and overlap exists between these two stages because different
fractures) or from forces having sufficient magnitude to regions may progress at different rates. During the remodel-
cause structural failure after a single impact. Most fractures ing process, the woven bone slowly converts to lamellar bone
can be identified on plain radiographs. In some cases, com- and the trabecular structure responds to the loading condi-
puted tomography (CT) scans or MRI may provide additions according to Wolff s law.44 The remodeling process may
tional information on the fracture pattern. Fracture repair is continue for years after the fracture.
unique in that healing occurs without scar formation, and The vast majority of fractures (90% to 95%) are treated
only mature bone remains in the fracture site at the end successfully.45 However, a variety of local and systemic factors
of the repair process. This repair process consists of four may affect fracture healing. Local factors that may impede
stages, including inflammation, soft callus, hard callus, and fracture healing include extensive injury to the surrounding
remodeling (Table 1-5). soft tissue envelope, decreased local blood supply, inade-
The inflammation period begins immediately after the quate reduction, inadequate mobilization, local infection, or
fracture is sustained and is characterized by the presence of malignant tissue at the fracture site. Systemic factors may
hemorrhage, necrotic cells, hematoma, and fibrin clots. The include endocrinologic factors (e.g., diabetes mellitus, meno-
predominant cell types are platelets, polymorphonuclear pause), general bone loss (e.g., osteopenia, osteoporosis),
neutrophils, monocytes, and macrophages. Shortly thereaf- patient nutrition (smoking, insufficient vitamin or calcium
ter, fibroblasts and osteoprogenitor cells appear and blood uptake), and peripheral circulation (vascular disease). In
vessels start growing into the defect. This neoangiogenesis is many fractures that do not heal, multiple risk factors may
initiated and maintained by a tissue oxygen gradient and is exist. Impaired bone healing may present as delayed osseous
enhanced by angiogenic factors. union or osseous nonunion. Delayed union is usually defined
The stage of soft callus is characterized by fibrous or car- as the failure of the fractured bone to heal within the expected
tilaginous tissue within the fracture gap and a great increase time course, while maintaining the potential to heal. Non-
in vascularity (Fig. 1-9, A and B). The bony ends are no union is defined as a state in which all healing processes have
longer freely moveable. Clinically, subsiding pain and swell- ceased before fracture healing has occurred.
ing characterize this stage.
During the stage of hard callus, the fibrous callus is
replaced by immature woven bone. (Fig. 1-10, A and B). The
transition of soft callus to hard callus is somewhat arbitrary,
TABLE 1-5 Bone Healing for a Stable Fracture

Inflammatory Hemorrhage, necrotic cells; Begins immediately
Phase hematoma and fibrin clot
formed to bridge the gap
Soft Callus Fibrous and cartilaginous tissue 1-6wk postinjury
Phase forms between the fracture A D
ends, increase in vascularity
and ingrowth of capillaries
into the fracture callus;
increase in cellular
proliferation, osteoclasts
remove dead bone
fragments
Hard Callus Woven bone develops when 4-6wk postinjury
Phase the callus converts from
fibrocartilaginous;
osteoclasts continue
removing dead bone;
osteoblast activity abundant B D
Remodeling Woven bone slowly changes to 6wk and up to
Phase lamellar bone; medullary several months or Fig. 1-9 In the second stage of structural fracture healing (i.e., soft callus),
canal is then reconstituted; years (depends on subperiosteal bone and medullary callus have formed in the adjacent region,
fracture diameter decreases a number of but the central region has filled with cartilage and fibrous tissue, and the
peripheral region covers them with dense fibrous tissue forming a new
to the original width anatomic and periosteum (A), which is not evident radiographically (B). (From Browner
physiologic factors) BD, etal: Skeletal traumabasic science, management, and reconstruction,
ed 3, Philadelphia, 2003, Saunders.)
TABLE 1-6 Effects of Growth Factors on

Musculoskeletal Tissues
Ligament/
Muscle Cartilage Meniscus Tendon Bone
IGF-1 + + + + +
(a, b) FGF + + + + +
NGF +
PDGF (AA, + + + +
AB, BB)
A D
EGF + + +
TGF- +
TGF- + + + +
BMP-2 + + +
BMP-4 +
BMP-7 +
VEGF +
BMP-2, Bone morphogenetic protein-2; BMP-4, bone morphoge-

netic protein-4; BMP-7, bone morphogenetic protein-7; EGF, endo-
thelial growth factor; FGF, fibroblast growth factor; IGF-1, insulin-like
B Dgrowth factor-1; NGF, nerve growth factor; PDGF, platelet-derived
growth factor; TGF-, transforming growth factor-alpha; TGF-,
transforming growth factor-beta; VEGF, vascular endothelial growth
Fig. 1-10 The third stage of structural fracture healing (i.e., hard callus). factor.
A, Bone begins to form in the peripheral callus region supplied by vascular
invasion from the surrounding soft tissue. B, This early bone formation may
be very thin and not radiographically dense, and the central region is still
the bulk of the bridging tissue. (From Browner BD etal: Skeletal trauma
Growth Factors and Gene Therapy
basic science, management, and reconstruction, ed 3, Philadelphia, 2003, Growth factors are proteins that can be synthesized by both
Saunders.) the resident cells (e.g., fibroblasts) and by immigrating cells
(e.g., macrophages). Growth factors have the ability to stim-
ulate cell proliferation, cell migration, and cell differentia-
tion.46 Several authors have investigated the role of growth
Nonunions can be classified as hypertrophic and atro- factors in stimulating the musculoskeletal healing response.
phic. Nonunions lack the potential to heal and require Stimulating effects of various growth factors have been dem-
further interventions. Hypertrophic nonunions demon- onstrated in a variety of tissue (Table 1-6).47
strate excessive vascularity and callus formation. They are The use of most of these growth factors is limited by their
typically the result of biomechanical instability and have short biologic half-lives, requiring repeated applications.48,49
a good biologic healing potential. Treatment of hypertro- To overcome this problem, gene transfer techniques have
phic nonunions requires biomechanical stabilization of been tested in experimental studies. Gene therapy is based
the fracture site. Atrophic nonunions have a limited on the modification of cellular genetic information (Fig.
healing potential, decreased vascularity, and show 1-11). Thus the genes encoding for growth factors are trans-
decreased callus formation. Treatment of atrophic non- ferred into local cells at the injury site to modify their genetic
unions is challenging, and the treatment may include codes so that growth factors are continuously produced. This
dbridement, stabilization, and use of bone grafts or other continuous excretion of growth factors will result in an unin-
bone stimulating agents. terrupted stimulation of the injured musculoskeletal tissue.
To achieve gene expression, the DNA encoding for the
BIOLOGIC TREATMENT APPROACHES growth factors must be transferred into the nucleus of the
host cells. After gene transfer, the treated cells generously
The successful treatment of musculoskeletal injuries remains express the intended factor (Fig. 1-12). Usually, viral vectors
challenging. Both ligaments and tendons have a poor vascu- are used for the gene transfer, with adenoviruses and
lar supply and a low cell turnover. Recent experimental retroviruses representing the most commonly used vectors.
investigations have attempted to establish novel biologic Two strategies are used for the transfection of the host cells:
treatment methods, such as growth factor stimulation. (1) the in vivo approach and (2) the ex vivo approach.48,49
Although most of these novel techniques have not been The in vivo approach includes the injection of a virus (usually
established in the clinical practice, we provide a brief review an adenovirus) encoding the growth factor gene at the injury
of the current research and discuss future perspectives in site. The ex vivo approach includes harvesting cells from the
this area. host, genetic modification in vitro (usually by a retrovirus),
Continuous growth factor release

DNA coding for growth factor Injection
Integration of DNA into adenovirus
Growth Factor Concentration

Adenovirus carrying the Virus injection
growth factor gene
Cell transfection Ribosomes

Integration of DNA producing
into nucleus growth
factors
Growth factor injection
Cell
Time [d]
Fig. 1-11 Gene expression pathway. The DNA encoding for a growth
factor is inserted into a viral vector. The viral vector is transfecting the cell, Fig. 1-12 Growth factor concentration after injection of the pure protein
and the growth factor gene is inserted into the cell nucleus. The growth versus gene therapy. After injection of the pure growth factor, the concentra-
factor is then produced by the transfected cells and released into the extra- tion reaches a maximum and returns instantly to the baseline level. Gene
cellular space. (Adapted from Lattermann C, Fu FH: Gene therapy in ortho- therapy results in a continuous growth factor concentration in the target
paedics. In Huard J, Fu FH, editors: Gene therapy and tissue engineering in tissue over a longer time period. (Reprinted from Fu FH, Zelle BA: Liga-
orthopaedics and sports medicine, New York, 2000, Birkhauser Boston.) ments and tendons: basic science and implications for rehabilitation. In
Wilmarth MA, editor: Clinical applications for orthopaedic basic science:
independent study course, La Crosse, Wis, 2004, American Physical Therapy
Association.)
and reinjection of the modified cells to the injury site.
Although the in vivo approach appears to be technically
simpler, the ex vivo approach appears to be safer because the gene therapy is the safety of this technique. Potential risk
transfection of the cells occurs under controlled conditions factors include uncontrolled overstimulation and over-
in vitro. growth of the repair tissue, mutation of the viral vectors,
Although experimental data have demonstrated the great development of malignancies, and immunologic reactions.
potential of gene therapy techniques, gene therapy has not Future research is required to investigate and optimize the
been established as a standard treatment in patients with safety of gene therapy to translate this treatment approach
musculoskeletal injuries. The major concern surrounding into clinical practice.
CLINICAL CASE REVIEW
1 What can patients do to improve wound healing? spontaneously, other ligament injuries, such as ACL
injuries, rarely show a spontaneous healing response
due to:
Wound healing occurs through scar formation. Extrinsic 1. High stress carried by the ACL that prevents the
factors (e.g., nutrition, hydration, smoking, wound expo- ruptured ligament ends from having sufficient
sure, and wound management) will influence the healing contact.
response and the scar formation. 2. The ACL is not embedded in a strong soft tissue enve-
lope and it is an intraarticular structure; when it
2 Why can some ligaments heal, whereas others need to

be repaired?
ruptures, the blood is diluted by the synovial fluid,
preventing hematoma formation and hence initiation
of the healing mechanism.
The healing response varies among the different liga- 3. Increased expression of myofibroblasts and growth
ments. For this answer, let us consider the knee as an factor receptors were found in the injured MCL as
example. While MCL injuries have the potential to heal compared with the injured ACL.7
24. Mass DP, et al: Effects of constant mechanical tension on the healing of
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CHAPTER 2
Soft Tissue Healing Considerations
After Surgery
P
hysical therapists work daily on a variety of connec- that connective tissues respond in characteristic ways to
tive tissue types that are dynamic and have an amazing immobilization and trauma. Because surgery is itself a form
capacity for change. Changes in these types of tissues of trauma that is usually followed by some form of immobi-
are driven by a number of factors, including trauma, surgery, lization, the physical therapist must understand the way
immobilization, posture, and repeated stresses. The physical tissues respond to both immobilization and trauma.
therapist should have a good working knowledge of the This chapter begins by presenting the classical view of
normal histology and biomechanics of connective tissue. basic histology and the biomechanics of connective tissue.
Additionally, the astute therapist should have a thorough Next, the histopathology and pathomechanics of connective
understanding of the way connective tissue responds tissue (i.e., the way connective tissues respond to immobili-
to immobilization, trauma, and remobilization. Both zation, trauma, and remobilization) will be addressed. This
experienced and novice physical therapists can benefit chapter will also address some basic principles of soft tissue
from a good mental picture of how connective tissue oper- mobilization based on the basic science behind immobiliza-
ates as they think through, strategize, and treat postsurgical tion, trauma, and remobilization of the connective tissue.
patients. Finally, there will be a discussion of the more recent litera-
The classic view of connective tissue and its response to ture suggesting the limited contractility potential of connec-
trauma and immobilization is that these tissues are inert and tive tissue.
noncontractile, with muscle fibers being the only contractile
element. While the body of literature documenting this view HISTOLOGY AND BIOMECHANICS OF
is solid and well accepted, newer studies have uncovered CONNECTIVE TISSUE
some exciting possibilities regarding the contractility of
connective tissue. If fascia, ligaments, and tendons have a The connective tissue system in the human body is quite
limited ability to behave like contractile tissue, many of the extensive. Connective tissue makes up 16% of the bodys
changes therapists have felt immediately after performing weight and holds 25% of the bodys water.1 The soft connec-
manual techniques can be validated and substantiated. Addi- tive tissue forms ligaments, tendons, periosteum, joint cap-
tionally, treatment strategies would change, or if not change, sules, aponeuroses, nerve and muscle sheaths, blood vessel
be better explained. In the context of postsurgical manage- walls, and the bed and framework of the internal organs. If
ment, treating inert tissue as contractile could certainly the bony structures were removed, then a semblance of struc-
change treatment perspectives. ture would remain from the connective tissue.1-5
A majority of the tissue affected by mobilization are
SURGERY DEFINED inert connective tissue. During joint mobilization, for
example, the tissues being mobilized are the joint capsule
Because this text primarily considers postsurgical rehabilita- and the surrounding ligaments and connective tissue.
tion, an operational definition of surgery is in order. For the Arthrokinematic rules are followed, but the tissue being
purpose of considering injury and repair of soft tissue, mobilized is classified as inert connective tissue. Therefore,
surgery may be defined as controlled trauma produced background knowledge of the histology and histopathology
by a trained professional to correct uncontrolled trauma. of connective tissue is essential for the practicing physical
The reason for this specific, contextual definition is therapist.
15
Normal Histology and Biomechanics of TABLE 2-1 Classification of Connective Tissue

Connective Tissue Cells Tissue Type Specific Structures Characteristics of the Tissue
Connective tissue has two components: (1) the cells and Dense regular Ligaments, tendons Dense, parallel arrangement of
(2) the extracellular matrix. The two cells of primary impor- collagen fibers; proportionally
tance in connective tissue are the fibroblast and the myofi- less ground substance
broblast. The fibroblast synthesizes all the inert components Dense Aponeurosis, Dense, multidirectional
of connective tissue, including collagen, elastin, reticulin, irregular periosteum, joint arrangement of collagen
and ground substance.1-5 The myofibroblast is a specialized capsules, dermis of fibers; able to resist
cell that contains smooth muscle elements and has a capacity skin, areas of high multidirectional stress
to contract.6-9 mechanical stress
Loose irregular Superficial fascial Sparse, multidirectional
Extracellular Matrix
sheaths, muscle and arrangement of collagen
The extracellular matrix of connective tissue includes con- nerve sheaths, fibers; greater amounts of
nective tissue fibers and ground substance. The connective support sheaths of elastin present
tissue fibers include collagen (the most tensile), elastin, and internal organs
reticulin (the most extensible). Collagen, elastin, and reticu-
lin provide the tensile support that connective tissue offers. From Cantu R, Grodin A: Myofascial manipulation: Theory and clini-
Extensibility or the lack of it is driven by the relative density cal application, Gaithersburg, Md, 1992, Aspen.
and percentage of the connective tissue fibers. Tissues with
less collagen density and a greater proportion of elastin fibers
are more pliable than tissue with a greater density and pro-
portion of collagen fibers.1-3
The ground substance of connective tissue plays a very
different role in the connective tissue response to immobility,
trauma, and remobilization. The ground substance is the
viscous, gel-like substance in which the cells and connective
tissue fibers lie. It acts as a lubricant for collagen fibers in
conditions of normal mobility and maintains a crucial dis-
tance between collagen fibers. The ground substance also is
a medium for the diffusion of nutrients and waste products
and acts as a mechanical barrier for invading microorgan-
isms. It has a much shorter half-life than collagen and, as will
be discussed, is much more quickly affected by immobiliza-
tion than collagen.4,10 Fig. 2-1 Dense regular connective tissue. The parallel compact arrangement
of the collagen fibers should be noted. (Modified from Williams P, Warwick
Three Types of Connective Tissue R, editors: Grays anatomy, ed 35, Philadelphia, 1973, Saunders.)
Connective tissue is classified according to fiber density and
orientation. The three types of connective tissue found in the
human body are (1) dense regular, (2) dense irregular, and
(3) loose irregular (Table 2-1).11,12
Dense regular connective tissue includes ligaments and
tendons (Fig. 2-1).5 The fiber orientation is unidirectional for
the purpose of attenuating unidirectional forces. The high
density of collagen fibers accounts for the high degree of
tensile strength and lack of extensibility in these tissue. Rela-
tively low vascularity and water content account for the slow
diffusion of nutrients and the resulting slower healing times.
Dense regular connective tissue is the most tensile and least
extensible of the connective tissue types.
Dense irregular connective tissue includes joint capsules,
periosteum, and aponeuroses. The primary difference
between dense regular and dense irregular connective tissue
is that dense irregular connective tissue has a multidimen-
sional fiber orientation (Fig. 2-2). This multidimensional Fig. 2-2 Dense irregular connective tissue with multidimensional compact
orientation allows the tissue to attenuate forces in numerous arrangement of collagen fibers. (Modified from Williams P, Warwick R,
directions. The density of collagen fibers is high, producing editors: Grays anatomy, ed 35, Philadelphia, 1973, Saunders.)
Chapter 2 Soft Tissue Healing Considerations After Surgery 17
a high degree of tensile strength and a low degree of exten- The viscoelastic model combines the elastic and plastic
sibility. Dense irregular connective tissue also has low vas- components just described (Fig. 2-5). When subjected to a
cularity and water content, resulting in slow diffusion of mild force in the midrange of the tissue, the tissue elongates
nutrients and slower healing times.5 in the elastic component and then returns to its original
Loose irregular connective tissue includes, but is not length. If, however, the stress pushes the tissue to the end
limited to, the superficial fascial sheath of the body directly range, then the elastic component is depleted and plastic
under the skin, the muscle and nerve sheaths, and the bed deformation occurs. When the stress is released, some per-
and framework of the internal organs. Similarly to dense manent deformation has occurred. It should be noted that
irregular connective tissue, loose irregular connective tissue not all the elongation (only a portion) is permanently
has a multidimensional tissue orientation. However, the retained.1-3
density of collagen fibers is much less than that of dense Clinically, this phenomenon occurs frequently. For
irregular connective tissue. The relative vascularity and water example, a client with a frozen shoulder that has only 90 of
content of loose irregular connective tissue is much greater elevation is mobilized to reach a range of motion (ROM) of
than dense regular and dense irregular connective tissue. 110 by the end of the treatment session. When the client
Therefore, it is much more pliable and extensible, and exhib- returns in a few days, the ROM of that shoulder is less than
its faster healing times after trauma. Loose irregular connec- 110 but more than 90. Some degree of elongation is lost
tive tissue also is the easiest to mobilize.5 and some is retained.
This viscoelastic phenomenon can be further illustrated
Normal Biomechanics of Connective Tissue by the use of stress-strain curves. By definition, stress is the
Connective tissues have unique deformation characteristics force applied per unit area, and strain is the percent change
that enable them to be effective shock attenuators. This is in the length of the tissue. When connective tissue is initially
termed the viscoelastic nature of connective tissue.1-3,13 This stressed or loaded, very little force is required to elongate the
viscoelasticity is the very characteristic that makes connec- tissue. However, as more stress is applied and the slack or
tive tissue able to change based on the stresses applied to it. spring is taken up, more force is required and less change
The ability of connective tissue to thicken or become more occurs in the tissue (Fig. 2-6). When the tissue is subjected
extensible based on outside stresses is the basic premise to to repeated stresses, the curve shows that after each stress the
be understood by the manual therapist seeking to increase tissue elongates and then only partially returns to its original
mobility. length. Some length is gained each time the tissue is taken
In the viscoelastic model, two components combine to into the plastic range. This phenomenon is seen clinically in
give connective tissue its dynamic deformation attributes. repeated sessions of therapy. ROM is gained during a session,
The first is the elastic component, which represents a tem- with some of the gain being lost between sessions.1-3
porary change in the length of connective tissue subjected to
stress (Fig. 2-3). A spring, which elongates when loaded and
returns to its original position when unloaded, illustrates Preload Tensile force Postload
this. This elastic component is the slack in connective
tissue.1-3
The viscous, or plastic, component of the model repre-
sents the permanent change in connective tissue subjected
to outside forces. A hydraulic cylinder and piston illustrates
this (Fig. 2-4). When a force is placed on the piston, the
KG
piston slowly moves out of the cylinder. When the force is Fig. 2-4 The viscous, or plastic, component of connective tissue. (From
removed, the piston does not recoil but remains at the new Grodin A, Cantu R: Myofascial manipulation: theory and clinical manage-
ment, Centerpoint, NY, 1989, Forum Medical.)
length, indicating permanent change. These permanent
changes result from the breaking of intermolecular and
intramolecular bonds between collagen molecules, fibers, Preload Tensile force Postload
and cross-links.1-3
Preload Tensile force Postload
KG KG
Fig. 2-3 The elastic component of connective tissue. (From Grodin A, Fig. 2-5 The viscoelastic nature of connective tissue. (From Grodin A,
Cantu R: Myofascial manipulation: Theory and clinical management, Cantu R: Myofascial manipulation: Theory and clinical management,
Centerpoint, NY, 1989, Forum Medical.) Centerpoint, NY, 1989, Forum Medical.)
As an example, consider the patient who is referred for

therapy 4 weeks after rotator cuff repair, who has developed
significant capsular tightness of the shoulder, and who is
reactive and guarded with passive range of motion. Gentle
Stress released soft tissue work in the shoulder girdle, including the scapula-
(elongation)
thoracic area, lateral scapula, upper trapezius, and the pec-

Strain
toralis major and minor usually result in immediate increases

in range of motion and less reactivity from the patient.
Mechanical changes in the joint capsule are not likely to have
occurred in such a short time to explain the increased range
Stress reapplied of motion. A more plausible explanation would be that gentle
manual work around the shoulder complex created an
autonomic response, which in turn relaxed the contractile
Time elements present in the connective tissue.
Fig. 2-6 Stress-strain curves indicating the progressive elongation of con-
nective tissue with repeated stresses. (From Grodin A, Cantu R: Myofascial EFFECTS OF IMMOBILIZATION,
manipulation: Theory and clinical management, Centerpoint, NY, 1989,
REMOBILIZATION, AND TRAUMA
Forum Medical.)
ON CONNECTIVE TISSUE
Immobilization
New DevelopmentsConnective Tissue Is Immobilization and trauma significantly change the histol-
Contractile and Dynamic ogy and normal mechanics of connective tissue. A majority
The older model of connective tissue does not explain com- of the historic studies in the area of immobilization follow
pletely the quick changes that can occur in connective tissue the same basic experimental mode.13,20-27 Laboratory animals
during manual therapy. Several theories have emerged to are fixated internally for varying periods. The fixation
explain these quick changes. The most substantial body is removed and the animals are then sacrificed. Histo
of literature suggests that connective tissues have a limited chemical and biomechanical analyses are performed to
contractile ability resulting from the presence of myofibro- determine changes in the tissue. In some studies, the fixation
blasts. Myofibroblasts are differentiated fibroblasts that not is removed and the animals are allowed to move the fixated
only synthesize collagen and ground substance, but also joint for a period before performance of the analysis. This
retain the ability to contract. These specialized cells were first is done to determine the reversibility of the effects of
recognized to be present in immature scar tissue, and were immobilization.28
believed to be responsible for scar tissue shrinkage and Macroscopically, fibrofatty infiltrate is evident in the
contracture.6,7,14-16 recesses of the immobilized tissue. With prolonged immobi-
More recent literature has documented the presence lization, the infiltrates develop a more fibrotic appearance,
of both myofibroblasts and smooth muscle fibers in creating adhesions in the recesses. These fibrotic changes
normal connective tissue, including the fascia cruris occur in the absence of trauma. Histologic and histochemi-
and the lumbodorsal fascia.16,17 Myofibroblasts contain cal analyses show significant changes primarily in the ground
smooth muscle of type actin and myosin in the cytoplasm substance, with no significant loss of collagen. The changes
of the cell, and therefore respond to the same stimuli that in the ground substance consist of substantial losses of gly-
affect smooth muscle.20 Schleip and associates have described cosaminoglycans and water. Because a primary function of
several autonomic mechanisms by which connective tissue ground substance is binding water to assist in hydration, the
tone can possibly be affected.14,15,18,19 loss of ground substance results in a related loss of water.
First, manual stimulation of interstitial and Ruffini mech- Another purpose of ground substance is to lubricate
anoreceptors present in connective tissue affect the auto- adjacent collagen fibers and maintain a crucial interfiber
nomic nervous system in a way that creates changes in local distance. If collagen fibers approximate too closely, then
fluid dynamics through vasodilation of local blood vessels the fibers will adhere to one another. These cross-links create
and movement of fresh fluids into the interstitial tissue. a series of microscopic adhesions that limit the pliability
Second, stimulation of the autonomic system through tissue and extensibility of the tissue (Fig. 2-7). In addition,
mechanoreceptors has the effect of hypothalamic tuning, collagen that has been immobilized for extended periods
which results in a global decrease of muscle tone. Lastly, of time demonstrates less tissue strength and quicker
autonomic effects from manual work create a localized auto- failure during stress-strain studies and load-to-failure
nomic response that inhibits smooth muscle cells present in studies.10,25,27,29-33
connective tissue and relaxes actin/myosin activity in myo- Furthermore, because movement affects the orientation
fibroblasts that are also present in connective tissue. All three of newly synthesized collagen, the collagen in the immobi-
of these basic mechanisms can better explain the relatively lized joints studied was laid down in a more haphazard,
immediate changes that are palpable after manual therapy. haystack arrangement. This orientation restricts tissue
production of ground substance. When connective tissue is

stressed with movement, the tissue rehydrates, collagen
cross-links are diminished, and new collagen is laid down in
a more orderly fashion.13,20-28,34
Also, the collagen tends to be laid down in the direction
of the forces applied and in an appropriate length. In addi-
tion, early mobilization leads to enhanced ligament and
tendon strength, resistance to tensile forces, greater joint
stability, and improved resistance of the ligament to
avulsion.4,9,10,25-27,29,31,34-36
Additionally, macroadhesions formed during the immo-
bilization period partially elongate and partially rupture
during the remobilization process, increasing the overall
mobility of the tissue. Both passive mobilization and active
ROM produce similar results.
Trauma
Fig. 2-7 The basket weave configuration of connective tissue. With immo- The previously described studies have limited application
bilization, the distance between fibers is diminished, forming cross-link because they involve the immobilization of normal, healthy
adhesions. (From Cantu R, Grodin A: Myofascial manipulation: Theory and joints. To complete this discussion, we must superimpose the
clinical application, Gaithersburg, Md, 1992, Aspen.) effects of trauma and scar tissue on immobilization.
Scar
Scar tissue mechanics differ somewhat from normal connec-
tive tissue mechanics. Normal connective tissue is mature
and stable, with limited pliability. Immature scar tissue is
much more dynamic and pliable. Scar tissue formation
occurs in four distinct phases. Each of these phases shows
characteristic differences during phases of immobilization
and mobilization.1-3
The first phase of scar tissue formation is the inflamma-
tory phase. This phase occurs immediately after trauma.
Blood clotting begins almost instantly and is followed
by migration of macrophages and histiocytes to start dbrid-
ing the area. This phase usually lasts 24 to 48 hours, and
immobilization is usually important because of the potential
for further damage with movement. Some exceptions to
routine immobilization exist. For example, in an anterior
Fig. 2-8 The random haystack arrangement of immobilized scar tissue
creating additional adhesions. (From Cantu R, Grodin A: Myofascial cruciate ligament (ACL) reconstruction, in which the graft
manipulation: Theory and clinical application, Gaithersburg, Md, 1992, is safely fixated and damage from gentle movement is
Aspen.) unlikely, there may be a great advantage in moving the tissue
as early as the first day after surgery. Research indicates that
early mobilization leads to more rapid ligament regeneration
mobility further by adhering to existing collagen fibers and ultimate load to failure strength in surgically repaired
(Fig. 2-8). ACLs.32
Biomechanical analysis reveals that as much as 10 times The second phase of scar tissue formation is the granula-
more torque is necessary to mobilize fixated joints than tion phase. This phase is characterized by an uncharacteristic
normal joints. After repeated mobilizations, these joints increase in the relative vascularity of the tissue. Increased
gradually return to normal. The authors of these studies vascularity is essential to ensure proper nutrition to meet the
implicate both fibrofatty microadhesions and increased metabolic needs of the healing tissue. The granulation phase
microscopic cross-linking of collagen fibers in the decreased varies greatly depending on the type of tissue and the extent
extensibility of connective tissue.13,20-27 of the damage. Generally speaking, the entire process of scar
tissue formation is lengthened if the damaged tissue is less
Remobilization vascular in its nontraumatized state. For example, tendons
The classic research seems to suggest that mobility and and ligaments require more time for scar tissue formation
remobilization prevent the haystack development of collagen than muscle or epithelial tissue. Movement is helpful in this
fibers within ligaments and tendons, as well as stimulate the phase, although the scar tissue can be easily damaged. The
physician and therapist need to work closely to determine The scar tissue formed by surgery is usually more manage-
the extent of movement relative to the risk. able than scar tissue formed by uncontrolled trauma or
The third phase of scar tissue formation is the fibroplastic overuse.
stage. In this stage the number of fibroblasts increases, as When dealing with scar tissue after surgery, the physical
does the rate of production of collagen fibers and ground therapist should remember the following guidelines:
substance. Collagen is laid down at an accelerated rate and Assess the approximate stage of development of the scar
binds to itself with weak hydrostatic bonds, making tissue tissue. Although the timelines vary, vascular tissue
elongation much easier. This stage presents an excellent matures faster than nonvascular tissue.
window of opportunity for the reshaping and molding of Whenever possible, early movement is helpful in control-
scar tissue without great risk of tissue reinjury. This stage ling the direction and length of the scar tissue.
lasts 3 to 8 weeks, depending on the histologic makeup and Communicate with the referring physician regarding
relative vascularity of the damaged tissue. Scar tissue at this the amount of movement that is appropriate. In a study
phase is less likely to be injured but is still easily remodeled performed by Flowers and Pheasant,38 casted joints
with stresses applied (Fig. 2-9). Additionally, myofibroblasts regained mobility much faster than fixated joints. This is
are the most active in the last two phases of scar tissue matu- probably because a cast does not provide the same immo-
ration. Myofibroblasts are believed to be responsible for the bilization as rigid fixation. The small amounts of move-
scar tissue shrinkage that occurs in this and the next phase ment allowed in casted joints may be enough to prevent
of scar tissue healing.1,3,6-8,37 some of the changes caused by rigid fixation.
The final phase of scar tissue formation is the maturation Recognize the window of opportunity to stress scar tissue,
phase. Collagen matures, solidifies, and shrinks during this and keep in mind the associated risk of tissue injury or
phase. Maximal stress can be placed on the tissue without microtrauma (see Fig. 2-9). Although the potential to
risk of tissue failure. Because collagen synthesis is still change scar tissue may be greater in earlier stages, the risk
accelerated, significant remodeling can take place when of damage is higher. The third stage appears to be the
appropriate mobilizations are performed. Conversely, if stage at which the reward of mobility work exceeds the
they are left unchecked, then the collagen fibers can cross- risk.
link and the tissue can shrink significantly. At the end of Recognize that even the gentlest and soothing of soft
the maturation phase, tissue remodeling becomes signifi- tissue mobilizations can positively affect the autonomic
cantly more difficult because the tissue reverts to a more nervous system,39 and can relax the contractile element
mature, inactive, and nonpliable status. present in these tissues. This gentle, autonomic effect has
minimal risk and great potential reward. Touch your
Surgical Perspective patients!
Surgery has been defined in this chapter as controlled trauma
produced by a trained professional to correct uncontrolled GOALS OF MOBILITY WORK
trauma. Postsurgical cases are subject to the effects of immo-
bilization, trauma, and scar formation. However, they have In 1945 John Mennell wrote, There are only two possible
the advantage of resulting from controlled trauma. effects of any movement or massage: they are reflex (auto-
nomic) and mechanical.36 The following summary empha-
sizes the goals of the mechanical and autonomic changes of
mobility work:
Mobility work allows for the hydration and rehydration
Ri
of connective tissue through both mechanical and auto-

sk
of
nomic mechanisms.
tis
su
Mobility work causes the breaking and subsequent

e
da
prevention of cross-links in collagen fibers.

m
ag
Mobility work allows for the breaking and prevention of

e
macroadhesions.
Mobility work allows for the plastic deformation and
permanent elongation of connective tissue.
Pli
ab
Mobility work allows for the laying down of collagen
ility fibers and scar tissue in the appropriate length and direc-
po
ten tion of the stresses applied.
tia
l
Mobility work allows for the molding and remolding of
collagen fibers during the fibroplastic and maturation
stages of scar tissue formation.
Stage 1 Stage 2 Stage 3 Stage 4 Mobility work prevents scar tissue shrinkage through
Time both mechanical and autonomic mechanisms.
Fig. 2-9 Relationship of tissue pliability to relative risk of injury.
Mobility work allows for the generalized autonomic prolonged stretching but also can be accomplished with
effects of increased blood flow, increased venous and lym- other manual techniques. Dynamic splinting is another tech-
phatic return, and increased cellular metabolism. nique used to elongate connective tissue. The tissue should
Mobility work allows for specific autonomic effects, which be elongated along the lines of normal movement; however,
include the relaxation of smooth muscle fibers present in at times the restrictive lesion may not follow the line of
connective tissue and the relaxation of the actin-myosin movement. The therapist must identify the direction of the
complexes found in myofibroblasts. restriction and mobilize directly into the restriction. The scar
may be a transverse or horizontal plane. Mobilizing the scar
in the direction of the restriction usually results in more
PRINCIPLES FOR MOBILIZATION OF movement along conventional planes.1,3
CONNECTIVE TISSUES
The Contractile Characteristic of Soft Tissues
This section attempts to integrate the principles of basic sci- As previously mentioned, connective tissues have a contrac-
entific research and years of clinical experience into a series tile element by virtue of the presence of smooth muscle cells
of techniques useful for the physical therapist in treating and myofibroblasts. Instantaneous creep is an autonomic
immobilized tissue. phenomenon.14,15 Gentle manual work, through stimulation
of mechanoreceptors, can create the autonomic effect of
Three-Dimensionality of Connective Tissue relaxation, resulting in increased pliability of connective
Connective tissue is three-dimensional. Especially after tissue, increased range of motion, and decreased pain.
trauma and immobilization, the scar tissue can follow lines
of development not consistent with the kinesiology or Principle of Short and Long
arthrokinematics of the area. Therefore the ability to feel the The principle of short and long is the idea that tissues mobi-
location and direction of the restriction becomes important lized in a shortened range often become more extensible
in the mobilization of scar tissue. when they are immediately elongated (Fig. 2-10). For
example, in a lateral epicondylitis, cross-friction massage
Creep may be performed over the lateral epicondyle with the elbow
Creep is another term for the plastic deformation of connec- passively flexed and the wrist passively extended. Immedi-
tive tissue. Active scar tissue is more creepy than normal ately after the cross-friction in the shortened range, the tissue
connective tissue (i.e., it is more easily elongated by external is stretched into the plastic range. In the shortened range,
forces).2 Creep occurs when all the slack has been let out deeper tissue can be accessed. When tissue is taut, only the
of the tissue. It is best accomplished with low-load, more superficial layers can be accessed. When the tissue has
Fig. 2-10 The principle of short and long. Soft tissue immobilization is performed in a shortened range, then immediately elongated.
some slack, the deeper tissue can be accessed and prepared sheaths, overall mobility is enhanced along planes of normal
for stretching.2 movement.2
The principle of short and long has neuromuscular impli- Additionally, muscle bending specifically stimulates the
cations as well. If a muscle is guarded, then shortening the Ruffini type mechanoreceptor. Ruffini endings are particu-
muscle by mobilizing it has an inhibitory effect that makes larly sensitive to lateral/transverse type stretching. This type
immediate elongation easier. of stretching, therefore, has the autonomic effect of decreas-
ing sympathetic tone in the garden hose, creating greater
SAMPLE TECHNIQUES FOR MOBILIZATION connective tissue pliability.14,15
OF CONNECTIVE TISSUES
Bony Clearing
The following techniques and associated photographs illus- Bony clearing is similar to muscle splay, except the mobiliza-
trate some examples of simple manual techniques effective tion is applied longitudinally along the soft tissue that
in mobilizing soft tissue. borders or attaches to a bony surface (Fig. 2-14). A good
example of this is longitudinal stroking of the anterior lateral
Muscle Splay border of the tibia in conditions such as shin splints. The
Muscle splay is a term that implies a widening or separation connective tissue along the border of the tibia thickens and
of longitudinal fibers of muscle or connective tissue that have becomes adhered, and the therapist attempts to mobilize the
adhered to one another (Fig. 2-11). These adhesions limit the tissue in this plane.2
ability of the tissue to be lengthened passively or shortened
actively. When muscle bundles or connective tissue bundles
stick together, the muscle fibers become less efficient in their
contractions. For example, muscle splay in the wrist flexors
often produces a slightly greater grip strength immediately
after soft tissue work. This is not greater strength, but greater
muscle efficiency produced by increased soft tissue pliability.
The muscle can contract more efficiently within its connec-
tive tissue compartments.2
Transverse Muscle Bending

Transverse muscle bending takes the contractile unit and
mobilizes it perpendicular to the fibers (Fig. 2-12). This per-
pendicular bending mobilizes connective tissue in a way
similar to the bending of a garden hose (Fig. 2-13). The con-
nective tissue sheath surrounding a muscle may be likened
to the hose itself, with the muscle being analogous to the
water inside it. If the connective tissue sheath is stiff and
rigid, then the muscle inside has difficulty contracting. The
unforgiving sheath does not allow the muscle to expand
transversely, creating a lack of efficiency and a low-grade
compartment syndrome. By mobilizing these muscle
Fig. 2-12 The bending of the fascial sheath surrounding the muscles.
Fig. 2-11 The splaying, or longitudinal separation, of fascial planes. Fig. 2-13 Transverse movement of fascial planes.
TABLE 2-2 Classification of Postural and Phasic

Muscles of the Shoulder
Classification Muscles
Postural Upper traps

Levator scapulae
Pectoralis major
Pectoralis minor
Subscapularis
Teres major
Phasic Lower traps/middle lower rhomboids
Latissimus dorsi
Middle traps
Rhomboids
Fig. 2-14 Longitudinal stroke clearing fascia away from a bony surface. Teres minor, infraspinatus, supraspinatus
From Cantu R, Grodin A: Myofascial manipulation: Theory and clini-

Cross-Friction cal application, Gaithersburg, Md, 1992, Aspen.
Cross-friction massage, which was developed and advocated
by the late James Cyriax, is excellent for mobilizing scar TABLE 2-3 Classification of Postural and Phasic
tissue and nonvascular connective tissue. It is an aggressive Muscles of the Hip
form of soft tissue mobilization designed to break scar tissue
Classification Muscles
adhesions and temporarily increase the blood flow to non-
vascular areas. Ligaments and tendons struggling to heal Postural Iliopsoas
completely are excellent candidates for cross-friction Tensor fasciae latae
massage. This technique can be used on scar tissue as well, Hip adductors
and it should be performed at many different angles to access Hip internal rotators
fibers in all directions.2 Quadratus lumborum
Piriformis
MUSCLE BALANCING Phasic Gluteus maximus
Gluteus medius/minimus
As connective tissue pliability is increasing through manual Hip external
From Cantu R, Grodin A: Myofascial manipulation: theory rotators
and clinical
therapy and passive range of motion, attention is also given application, Gaithersburg, Md, 1992, Aspen. Transverse abdominis
to active range of motion and strengthening. Individual
muscles surrounding joints can be grouped together accord-
ing to their response to dysfunction. Typically, postural
muscles respond to injury, abnormal stress, and surgery by TABLE 2-4 Classification of Postural and Phasic
tightening or becoming facilitated. Phasic muscles tend to Muscles of the Knee
respond to injury, abnormal stress, and surgery by weaken- Classification Muscles
ing or becoming inhibited.2
Each joint complex in the body has groups of muscles that Postural Hamstrings
are dedicated to functioning as stabilizers and muscles Gastrocnemius
that function as prime movers. For example, it is well known Phasic Quadriceps (vastus medialis oblique [VMO])
that the vastus medialis oblique (VMO) at the knee functions Dorsiflexors
to stabilize the patella during knee flexion and extension. It
From Cantu R, Grodin A: Myofascial manipulation: Theory and clini-
is also well known that the VMO, along with the other three cal application, Gaithersburg, Md, 1992, Aspen.
quadricep muscles, responds to dysfunction by weakening,
becoming inhibited, and displaying atrophy. Conversely,
the hamstring muscle group responds to dysfunction by subscapularis, teres major, and pectoralis minor (all postural
tightening.2 muscles that act on the shoulder complex). After the patient
During postsurgical rehabilitation, the therapist should enters into the active phase of rehab, efforts should be shifted
expect to provide manual treatment for the postural muscles to strengthening of the external rotators, lower traps, rhom-
that act on the involved joint and strengthen (when healing boids, and serratus anterior (all phasic muscles that stabilize
constraints permit) the phasic muscles that have invariably the shoulder complex).2
weakened. A prime example is the shoulder after rotator cuff Tables 2-2 to 2-4 illustrate and summarize the groupings
surgery. Initially, during the acute and protective phases of of postural and phasic muscles by region, and agonist-
rehab, the therapist should treat levator scapulae, trapezius, antagonist relationships.
The physical therapist must understand connective tissue

SUMMARY responses to immobilization, trauma, remobilization, and
scar remodeling to treat injured tissue effectively. Addition-
This chapter outlines the basic principles and guidelines for ally, the therapist should be aware of the global and specific
soft tissue management after surgery and discusses the stages autonomic effects of manual therapy that affect tissue con-
of scar tissue formation. The time frames for these stages tractility. Awareness of both mechanical and autonomic
are variable based on the vascularity of the tissue and the principles of soft tissue management, along with good
surgical procedure performed. They are delineated in more physician-client communication, ensures consistently effec-
detail in the following chapters. tive management of postsurgical rehabilitation.
1 What is the mechanism by which ROM is achieved

during a session of manual therapy?
of time demonstrates less tissue strength and quicker
failure during stress-strain studies and load-to-failure
studies.
Stimulation of the autonomic nervous system through
manual stimulation of interstitial and Ruffini mechanore-
ceptors has the effect of hypothalamic tuning, which
results in a global decrease of muscle tone.
3 At what point is it advisable to stress scar tissue?
There is a window of opportunity to stress scar tissue.
2 Why is it important to be respectful of the connective

tissue following immobilization?
Keep in mind the associated risk of tissue injury or micro-
trauma if the scar tissue is overstressed in its immature
stage. Although the potential to change scar tissue
During immobilization collagen fibers become dehy- may be greater in earlier stages, the risk of damage is
drated, and if collagen fibers approximate too closely, higher. The third stage (fibroplastic) appears to be the
then the fibers will adhere to one another. These cross- stage at which the reward of mobility work exceeds the
links create a series of microscopic adhesions that limit risk. This stage lasts 3 to 8 weeks depending on the his-
the pliability and extensibility of the tissue. In addition, tologic makeup and relative vascularity of the damaged
collagen that has been immobilized for extended periods tissue.
REFERENCES 10. Goldstein WM, Barmada R: Early mobilization of rabbit medial liga-
1. Cummings GS, Crutchfield CA, Barnes MR: Orthopedic physical ment and collateral ligament repairs: Biomechanics and histological
therapy series: Soft tissue changes in contractures, Atlanta, 1983, Stokes- study. Arch Phys Med Rehab 65(5):239-242, 1984.
ville Publishing. 11. Copenhaver WM, Bunge RP, Bunge MB: Baileys textbook of histology,
2. Cantu R, Grodin A: Myofascial manipulation: Theory and clinical appli- Baltimore, 1971, Williams & Wilkins.
cation, Austin, Tex, 1992, ProEd Publishers. 12. Sapega AA, et al: Biophysical factors in range-of-motion exercise. Phys
3. Cummings GA: Soft tissue contractures: Clinical management continu- Sportsmed 9:57-65, 1981.
ing education seminar, course notes, Atlanta, March 1989, Georgia State 13. Woo S, et al: Connective tissue response to immobility. Arthritis Rheum
University. 18:257-264, 1975.
4. Ham AW, Cormack DH: Histology, Philadelphia, 1979, JB Lippincott. 14. Schleip R: Fascial plasticitya new neurobiological explanation: Part 1.
5. Warwick R, Williams PL: Grays anatomy, ed 35, Philadelphia, 1973, J Bodywork Movement Ther 7(1):11-19, 2003.
Saunders. 15. Schleip R: Fascial plasticitya new neurobiological explanation: Part 2.
6. Darby IA, Hewitson TD: Fibroblast differentiation in wound healing J Bodywork Movement Ther 7(2): 104-116, 2003
and fibrosis. Int Rev Cytol 257:143-175, 2007 16. Yahia LH, Pigeon P, DesRosiers EA: Viscoelastic properties of the
7. Gabbiani G: The myofibroblast in wound healing and fibrocontractive human lumbodorsal fascia. J Biomed Eng 15:425-429, 1993.
diseases. J Pathol 200:500-503, 2003. 17. Stecco C, et al: A histological study of the deep fascia of the upper limb.
8. Hinz B, et al: Biological perspectives: the myofibroblastOne function, J Anat Embryol 111(2):1-5, 2006.
multiple origins. Am J Pathol 190(6):1807-1816, 2007. 18. Schleip R: Active contraction of the thoracolumbar fasciaindications
9. Inoue M, et al: Effects of surgical treatment and immobilization on the of a new factor in low back pain research with implications for manual
healing of the medial collateral ligament: A long-term multidisciplinary therapy, 5th Interdisciplinary World Congress on Low Back and Pelvic
study. Connect Tissue Res 25(1):13-26, 1990. Pain, Melbourne, Australia, 2004.
19. Schleip R, Klinger W, Lehmann-Horn F: Active fascial contractility: 28. Evans E, et al: Experimental immobilization and mobilization of rat
Fascia may be able to contract in a smooth muscle-like manner and knee joints. J Bone Joint Surg 42A:737, 1960.
thereby influence musculoskeletal dynamics. Med Hypotheses 65:273- 29. Gelberman RH, et al: Effects of early intermittent passive mobilization
277, 2005. on healing canine flexor tendons. J Hand Surg Am 7(2):170-175, 1982.
20. Akeson WH, Amiel D: The connective tissue response to immobility: A 30. Hart DP, Dahners LE: Healing of the medial collateral ligament in rats.
study of the chondroitin 4 and 6 sulfate and dermatan sulfate changes The effects of repair, motion, and secondary stabilizing ligaments. J Bone
in periarticular connective tissue of control and immobilized knees of Joint Surg Am 69(8):1194-1199, 1987.
dogs. Clin Orthop 51:190-197, 1967. 31. Lechner CT, Dahners LE: Healing of the medial collateral ligament in
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chemical changes in periarticular connective tissue of the immobilized cyclic modulus compared to normal ligaments and immobilization
rabbit knee. Clin Orthop 93:356, 1973. further compromises healing ligament response to cyclic loading.
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nective tissue after 9 weeks of immobilization. Connect Tissue Res 5:15, dogs: An experimental study. Clin Orthop Relat Res 150:277-282, 1980.
1977. 35. Gomez, MA, et al: The effects of increased tension on healing medial
25. Woo S, et al: The biomechanical and morphological changes in the collateral ligaments. Acta Orthop Scand 54(6):917-923. 1983.
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J Orthop Res 5(3):425-432. 1987. 38. Flowers KR, Pheasant SD: The use of torque angle curves in the assess-
27. Woo SL, et al: Treatment of the medial collateral ligament injury. II: ment of digital stiffness. J Hand Ther 1(2)69-74, 1988
Structure and function of canine knees in response to differing treat- 39. Dicke E, Schliack H, Wolff A: A manual of reflexive therapy of the con-
ment regimens. Am J Sports Med 15(1):22-29, 1987. nective tissue, Scarsdale, NY, 1978, Sidney S Simon.
PART 2 Upper Extremity
3 Acromioplasty, 28
4 Anterior Capsular Reconstruction, 44
Renee Songer, Reza Jazayeri, Diane R. Schwab, Ralph A. Gambardella,
Clive E. Brewster
5 Rotator Cuff Repair and Rehabilitation, 73
6 Superior Labral Anterior Posterior
Repair, 99
Timothy F. Tyler, Craig Zeman
7 Total Shoulder Arthroplasty, 118
8 Extensor Brevis Release and Lateral
Epicondylectomy, 144
Kelly Akin Kaye, Kristen G. Lowrance, James H. Calandruccio
9 Reconstruction of the Ulnar Collateral Ligament
with Ulnar Nerve Transposition, 155
Mark T. Bastan, Michael M. Reinold, Kevin E. Wilk, James R. Andrews
10 Clinical Applications for Platelet Rich Plasma
Therapy, 171
Eric S. Honbo, Luga Podesta
11 Surgery and Rehabilitation for Primary Flexor
Repair in the Digit, 193
Linda J. Klein, Curtis A. Crimmins
12 Carpal Tunnel Release, 216
Linda de Haas, Diane Coker, Kyle Coker
13 Transitioning the Throwing Athlete Back
to the Field, 233
Luga Podesta
27
CHAPTER 3
Acromioplasty
B
efore the broad topic of acromioplasty is addressed, overhead-throwing athletes. Intrinsic degenerative tenopa-
the topic of subacromial impingement syndrome thy also has been discussed as an intrinsic cause of subacro-
must be explored. In 1972 Neer1 described subacromial impingement symptoms.14
mial impingement as a distinct clinical entity. He correlated Extrinsic or extratendinous etiologic factors form the
the anatomy of the subacromial space with the bony and soft second broad category of causes of impingement syndrome.
tissue relationships and described the impingement zone. Rare secondary extrinsic factors (e.g., neurologic pathology
Neer2 also described a continuum of three clinical and secondary to cervical radiculopathy, supraspinatus nerve
pathologic stages. This study provides a basis for under- entrapment) are not discussed here, but the primary extrin-
standing the impingement syndrome, which ranges from sic factors and their anatomic relationships are of primary
reversible inflammation to full-thickness rotator cuff tearing. surgical concern. The unique anatomy of the shoulder joint
The relationships among the anterior third of the acromion, sandwiches the soft tissue structures of the subacromial
the coracoacromial ligament, and the acromioclavicular space (i.e., rotator cuff tendons, coracoacromial ligament,
(AC) joint and the underlying subacromial soft tissue long head of biceps, bursa) between the overlying anterior
including the rotator cuffremain the basis for most of the acromion, AC joint, and coracoid process and the underly-
subsequent surgery-related impingement studies. Many ing greater tuberosity of the humeral head and the superior
other researchers have contributed to the current knowledge glenoid rim. Toivonen, Tuite, and Orwin15 have supported
regarding the subacromial shoulder impingement Bigliani, Morrison, and Aprils description16 of three primary
syndrome. The works of Meyer,3 Codman,4 Armstrong,5 acromial types and their correlation to impingement
Diamond,6 and McLaughlin and Asherman7 provide a his- and full-thickness rotator cuff tears. AC degenerative joint
torical perspective. disease also can be an extrinsic primary cause of impinge-
ment disease.1,2 Many authors support Neers original posi-
tion on the contribution of AC degenerative joint disease to
SURGICAL INDICATIONS AND the impingement process.17,18 The os acromiale, the unfused
CONSIDERATIONS distal acromial epiphysis, also has been discussed as a sepa-
rate entity and a potential etiologic factor related to impinge-
Anatomic Etiologic Factors ment.19 Glenohumeral instability is a secondary extrinsic
Any abnormality that disrupts the intricate relationship cause or contribution to impingement. Its relationship to the
within the subacromial space may lead to impingement. impingement syndrome is poorly understood, but it helps
Both intrinsic (intratendinous) and extrinsic (extratendi- explain the failure of acromioplasty in the subset of young,
nous) factors have been implicated as etiologies of the competitive, overhead-throwing athletes with a clinical
impingement process. The role of muscle weakness within impingement syndrome.11,20,21
the rotator cuff has been described as leading to tension
overload, humeral head elevation, and changes in the supra- Diagnosis and Evaluation of
spinatus tendon, which is used most often in high-demand, the Impingement Syndrome
repetitive overhead activities.8,9 Authors10-12 also have History and physical examinations are crucial in diagnosing
described inflammation and thickening of the bursal con- subacromial impingement syndrome. Findings may be
tents and their relationship to the impingement syndrome. subtle, and symptoms may overlap in the various differential
Jobe13 and Jobe, Kvitne, and Giangarra11 studied the role diagnoses; therefore, appreciating the impingement syn-
of microtrauma and overuse in intrinsic tendonitis and drome symptom complex may be difficult. The classic history
glenohumeral instability and their implications for has an insidious onset and a chronic component that
28
Chapter 3 Acromioplasty 29
develops over months, usually in a patient over 40 years old.

The patient frequently describes repetitive activity during SURGICAL PROCEDURE
recreation, recreational sports, competitive athletics, and
work. Pain is the most common symptom, especially pain Subacromial impingement syndrome that has not responded
with specific high-demand or repetitive away-from-the- to rehabilitation techniques and nonoperative means may
chest and overhead shoulder activities. Night pain is seen require surgery. If proven trials of rehabilitation, activity
later in impingement syndrome, after heightening of the modification, use of nonsteroidal antiinflammatory agents
inflammatory response. Weakness and stiffness may occur (NSAIDs), and judicious use of subacromial cortisone injec-
secondary to pain inhibition. If true weakness persists after tions are unsuccessful, then acromioplasty and subacromial
the pain is eliminated, then the differential diagnoses of decompression (SAD) should be considered.
rotator cuff tearing or neurologic cervical entrapment type Historically, open acromioplasties produced excellent
of pathologies must be addressed. If stiffness persists, then results and still have a significant role in surgical treat-
frozen shoulderrelated conditions (e.g., adhesive capsulitis, ment.1,19,27 Ellman28 is credited with the first significant
inflammatory arthritis, degenerative joint disease) must be arthroscopic SAD techniques and studies, and many surgeons
ruled out.22 Younger athletic and throwing patients need and investigators have developed techniques and arthroscopic
continual assessment for glenohumeral instability. SAD advancements for the surgical treatment of subacromial
The physical examination of a patient with impingement impingement syndrome.29-34 Indications for surgery to correct
syndrome focuses on the shoulder and neck regions. Physi- subacromial impingement syndrome include persistent pain
cal examination of the neck helps rule out cervical radicu- and dysfunction that have failed to respond to nonsurgical
lopathy, degenerative joint disease, and other disorders of the treatment, including physician- or therapist-directed physi-
neck contributing to referred pain complexes in the shoulder cal therapy, trials of NSAIDs, subacromial cortisone or lido-
area. The shoulder evaluation includes a general inspection caine injections, and activity modification.
for muscle asymmetry or atrophy, with emphasis on the The most controversial surgical indication topic concerns
supraspinatus region. Range of motion (ROM) and muscle the amount of time that should elapse before nonoperative
strength testing and generalized glenohumeral stability management is considered a failure.19 Most surgeons and
testing are emphasized during the evaluation. The Neer investigators recommend a trial period of approximately 6
impingement sign2 and Hawkins-Kennedy sign23 are gold months. However, this depends on the individual patient and
standard tests to help diagnose impingement. The impinge- pathologic condition and should be tailored to the circum-
ment test, which includes subacromial injection of a Xylo- stances. For example, a 42-year-old patient with a history of
caine type of compound and repeated impingement sign several months of progressive symptoms has an occupation
maneuvers, is most helpful in ascertaining the presence of or recreational activity that requires high-demand, repetitive
an impingement syndrome. The AC joint also is addressed overhead movement. In the absence of instability, with a
during the shoulder evaluation. The clinician should note hooked acromion (type III) and MRI-documented, partial-
AC joint pain with direct palpation and pain on horizontal thickness tearing, this patient need not endure the 6-month
adduction of the shoulder. Selective AC joint injection also trial period to meet surgical indications for the treatment of
may be helpful. Long head biceps tendon pathology, includ- his condition. On the other hand, a noncompliant patient in
ing ruptures, is rare but may occur in this subset of patients. a workers compensationrelated situation who has a flat
Physical examination will define the tendons contribution to acromion and equivocal, inconsistent clinical findings may
the symptom complex. Instability testing, especially in the never meet the surgical indications.
younger athletic patient, also should be performed. The
clinician should assess for classic apprehension signs and Procedure
perform the Jobe relocation test, recording any positive Both open acromioplasty and the arthroscopic SAD proce-
findings. dure are discussed in the following sections. Open acromio-
plasty techniques have been well documented, their outcomes
Radiographic Evaluation have been well researched, and their results have been rated
Standard radiographic evaluation is carried out with special as very good to excellent in numerous studies.1,27,29,30,35
attention to anteroposterior (AP), 30 caudal tilt AP, Because of these factors and the high technical demands of
and outlet views of the shoulder.24,25 These plain studies arthroscopic decompression, surgeons should never com-
are helpful in demonstrating acromial anatomy types, pletely abandon this proven technique for the surgical man-
hypertrophic coracoacromial ligament spurring, AC joint agement of persistent shoulder impingement. Surgeons
osteoarthrosis, and calcific tendonitis. These views, in com- also may resort to these open techniques in the event of
bination with an axillary view, can uncover os acromiale arthroscopic procedure failure or intraoperative difficulties.
lesions. Magnetic resonance imaging (MRI) also is helpful in Depending on surgical experience and expertise, an open
revealing relationships in impingement syndrome, especially procedure may be used in deference to an arthroscopic SAD
if rotator cuff tear and other internal derangement patholo- procedure.
gies (e.g., glenolabral or biceps tendon pathologies) are Arthroscopic SAD for the surgical treatment of impinge-
suspected.26 ment syndrome has a number of advantages. First, the
30 PART 2 Upper Extremity
arthroscopic technique allows evaluation of the glenohu- reproducible posterior, anterior, and lateral portal placement
meral joint for associated labral, rotator cuff, and biceps can be achieved.
pathology, as well as assessment of the AC joint and surgical Using the standard posterior portal, the surgeon inserts
treatment of any condition contributing to impingement. the arthroscope into the glenohumeral joint. In a routine and
Second, this technique produces less postoperative morbid- sequential fashion, the glenohumeral joint is evaluated with
ity and is relatively noninvasive, minimizing deltoid muscle attention directed to the biceps tendon and the labral and
fiber detachment. However, arthroscopic SAD is a techni- rotator cuff anatomy. Any incidental pathology can be
cally demanding procedure with a learning curve that can be addressed arthroscopically at this point. Subacromial space
higher than for other orthopedic procedures. arthroscopy can now be performed.
Many different arthroscopic techniques have been For subacromial procedures, a long diagnostic double-
described, but the authors of this chapter recommend cannula arthroscope is recommended. The cannula with a
the modified technique initially described by Caspari.36 The blunt trocar is placed from the posterior portal superior to
patient is usually anesthetized with both a general and a the cuff, and exits through the anterior portal.
scalene block regional anesthetic. In most community set- Using this cannula as a switch stick equivalent, the
tings this combination has been highly successful in allowing surgeon places a cannula with a plastic diaphragm over the
patients to have this procedure done on an outpatient basis. arthroscopic instrument and returns it to the subacromial
A scalene regional block and home patient-controlled anal- space. Gently retracting the arthroscopic cannula and
gesia (PCA) provide acceptable pain control and ensure a inserting the arthroscope allows the inflow and arthroscopic
comfortable postoperative course. cannulas to be close together. Adequate distention and main-
After the patient has reached the appropriate depth of tenance of inflow and outflow are crucial for visualization
anesthesia, the shoulder is evaluated in relationship to the and indirect hemostasis. This technique has been successful
contralateral side in both a supine and a semisitting beach in achieving these goals. At this point the lateral portal is
chair position. Any concern regarding stability testing can fashioned, generally on the lateral aspect of the acromion
be further assessed at this time, taking advantage of the just posterior and inferior to a line drawn by extending the
complete anesthesia. Then, using the standard beach chair topographic anatomy of the anterior AC complex (see Fig.
positioning, the surgeon begins the arthroscopic procedure. 3-1). A spinal needle may assist in the accurate placement of
An inflow pressure pump (Davol) is used to maintain appro- this portal, which is crucial to instrument placement and
priate tissue space distention. Epinephrine is added to the subsequent visualization.
irrigation solution to a concentration of 1mg/L, thus enhanc- Starting from the posterior portal and using an aggressive
ing hemostasis. synovial resector with the inflow in the anterior portal, the
Specific portal placement is important to eliminate tech- surgeon uses the lateral portal to perform a bursectomy and
nical difficulties. Carefully addressing the palpable bony dbride the soft tissue of the subacromial space. This is done
topography of the shoulder and marking the acromion, clav- in a sequential manner, working from the lateral bursal area
icle, AC joint, and coracoid process greatly facilitate portal to the anterior and medial AC regions. Spinal needles can be
placement (Fig. 3-1). First, the sulcus is palpated directly placed in the anterolateral and AC joint region to facilitate
posterior to the AC joint. From this universal landmark, visualization and reveal spatial relationships. After the sub-
appropriate orientation can be obtained and consistent acromial bursectomy and denudement of the undersurface
of the acromion, the superior rotator cuff can be visualized
along with the AC joint and anterior acromial anatomy is
more easily defined. The surgeon must take care not to
violate the coracoacromial ligament during this initial
bursectomy procedure.
At this point the surgeon inserts the arthroscope in the
lateral portal for visualization. Using the posterior portal and
following the posterior slope of the normal acromion, the
surgeon performs sequential acromioplasty with an acromi-
onizer instrument. In the technique described by Caspari,36
the shank of the acromionizer is directed flat against the
posterior acromial slope and acromioplasty is completed
from the posterior to the anterior aspect. This accomplishes
two goals. First, it provides a reliable and reproducible tem-
plate to convert any abnormal hooked, sloped, or curved
acromion to the therapeutic goal of a flat, type I configura-
tion. Second, it allows for the removal of the coracoacromial
Fig. 3-1 The lateral portal is fashioned on the lateral aspect of the acromion ligament from its bony attachment with minimal chance
just posterior and inferior to a line drawn by extending the topographic for coracoacromial artery bleeding, thereby maximizing
anatomy of the anterior acromioclavicular (AC) complex. arthroscopic visualization and minimizing technical
difficulties. At this point any further modification or fine

tuning may be done through both the lateral and the ante- Rehabilitation Concerns: The Surgeons
rior portals. Any residual coracoacromial ligament is Perspective
removed from its acromial insertion while its bursal exten- Therapists spend more time with postoperative patients than
sion is excised. most surgeons do, and their input and direction are impor-
The AC joint also may be assessed at this stage, and tant in achieving a successful outcome. Their understanding
minimal inferior osteophytes may be excised. Depending on of the procedure, postoperative pain, patient apprehension,
the results of the preoperative evaluation, distal clavicle pro- and general medical concerns is vital. Physical therapy
cedures can be performed at this point either through directed early diagnosis of any wound problems (evidenced
directed arthroscopic techniques or, as the authors of this by erythema) or superficial infection can eliminate potential
chapter prefer, through a small incision located over the AC major complications. Postoperative inflammation also can
joint region. If AC joint symptoms are present with horizon- be assessed with careful observation. Stiffness in frozen
tal adduction and direct palpation, if radiographs confirm shoulder syndrome, although rare, can develop postopera-
the pathology, or if both occur, then the surgeon should tively and is addressed optimally with early diagnosis and
proceed with a distal clavicle excision. A T-type capsular progressive physical therapy.
incision is located over the AC joint region, with the anterior
and posterior capsular leaves elevated subperiosteally from THERAPY GUIDELINES FOR
the distal clavicle. Using small Homan retractors, the surgeon REHABILITATION
can excise the distal clavicle (usually 1.5 to 2cm) with an
oscillating saw. The distal clavicle can then be easily palpated The goal of the therapeutic exercise program after a SAD
and rasped smooth. With a simple digital confirmation, the procedure is to augment the surgical decompression by
undersurface of the acromion also can be checked and any increasing the subacromial space. Additional clearance for
residual osteophytes rasped through this minimal-incision subacromial structures can be gained by strengthening the
technique. scapular upward rotators and humeral head depressors.
The soft tissue is then closed in anatomic fashion, with Exercises to enhance the surgical decompression are
essentially no deltoid detachment. A routine subcuticular straightforward.
skin closure is used. The patient is placed in a postoperative The challenge for the physical therapist is to implement
pouch sling, and cryotherapy is frequently suggested. The the appropriate therapeutic exercise regimen without
patient is discharged to continue treatment as an outpatient; overloading healing tissue.
if insurance or health demands require it, overnight obser The postoperative rehabilitation program can be divided
vation is used. Physical therapy may begin immediately on into three phases:
the first postoperative day and should follow the standard 1. Phase one emphasizes a return of ROM.
program discussed previously.36 2. Phase two stresses regaining muscle strength.
3. Phase three stresses endurance and functional
Outcomes progression.
The surgical outcomes for arthroscopic SAD, partial These three phases are not distinct entities and they do
acromioplasties, and distal clavicle excisions16,32,33 have overlap. Together they serve as a template on which the
been most favorable. Many studies have compared open physical therapist can build a management protocol for
and closed techniques and obtained similar overall find- the post-SAD patient. An absence of pain is the primary
ings.19,35,37 SAD procedures have three general goals: guideline for progressing to more strenuous activities.38 The
1. To return the patient to a premorbid ROM and strength phases are simply guidelines and should be adapted to each
perimeters patient. Patients with significant rotator cuff involvement,
2. To eliminate pain articular cartilage defects, significant preoperative motion or
3. To eliminate the anatomic mechanical component of the strength loss, perioperative or intraoperative complications,
impingement syndrome and glenohumeral instability require special consideration
and may not progress as rapidly as indicated in the standard
Challenges and Precautions rehabilitation program, which assumes that no glenohu-
The most common causes of surgical failures are associated meral instability exists and that the rotator cuff tendons
with incomplete bone resection and not addressing AC joint are intact.
arthropathy. These common pitfalls can be eliminated by Signs that therapeutic activities are too aggressive include
carefully considering surgical techniques and including (if the following:
necessary) distal clavicle excision or combined open tech- Increased levels of referred pain to the area of insertion
niques. Another common reason for failure of arthroscopic of the deltoid
SAD surgery is inappropriate diagnosis or patient selection. Night pain
Again, with careful assessmentespecially regarding insta- Pain that lasts more than 2 hours after exercising39
bility, underlying lesions, and differential diagnosesthese Pain that alters the performance of an activity or
failures can be lessened dramatically. exercise39
Evaluation BOX 3-1 Components of the Physical Therapy

Every rehabilitation program begins with a thorough evalu- Evaluation
ation at the initial physical therapy visit. This evaluation Background Information
provides pertinent information for formulating a treatment Status of capsule
program. As the patient progresses through the program, Status of rotator cuff
assessment is ongoing. Activities that are too stressful for Status of articular cartilage
healing tissue at one point are reassessed when the tissue is Previous procedures
ready for the stress. Measures to be included in the physical Associated medical problems that can influence
therapy evaluation are provided in Box 3-1. rehabilitation (e.g., cardiovascular concerns,
diabetes mellitus)
Phase I Work-related injury
Insurance status
TIME: First 2 to 3 weeks after surgery Motivation
GOALS: Emphasis on measures to control normal Comprehension
postoperative inflammation and pain, protect
healing soft tissue, and minimize the effects of
Subjective Information
immobilization and activity restriction (Table 3-1) Previous level of function
Present level of function
Control of Inflammation and Pain. The surgeon may Patients goals and expectations
have prescribed NSAIDs to control normal postoperative Intensity of pain
inflammation and pain. These can be an adjunct to the other Location of pain
means the physical therapist uses to decrease inflammation Frequency of pain
(i.e., gentle therapeutic exercise, cryotherapy). Presence of night pain
The therapist should determine whether a scalene block Assistance at home
was performed in addition to the general anesthetic. If a Access to rehabilitation facilities
block was performed, then the onset of immediate postop- Medication (dose, effect, tolerance, compliance)
erative pain may be delayed; the patient should be monitored Objective Information
for signs of delayed motor return and prolonged or abnormal Observation:
hypesthesia. If narcotics are used past the first few postopera- Muscle wasting
tive days, then the therapist must undertake the therapeutic Resting posture
exercise program cautiously. Use of sling
Cryotherapy can be used to help manage postoperative Wound status
pain. Crushed ice conforms nicely to the shoulder, but Swelling
commercially available cryotherapy and compression units Color
(PolarCare, Cryocuff), although tedious to use, can be less Range of motion (ROM) (active/passive):
messy. Sterile postoperative liners allow the source of the G/H PROM with in pain tolerance
cold to be placed under the initial bulky dressing. The physi- Upper thoracic spine
cal therapist should be aware of reimbursement practices for Scapulothoracic joint
these units and use them accordingly. Sternoclavicular joint
Acromioclavicular (AC) joint
Protection of Healing Soft Tissues. Decreased use of Scapulothoracic rhythm
the upper extremity is required to protect healing soft tissue Strength

after SAD. A sling may be prescribed depending on the sur- Rotator cuff
geons protocol and operative findings. The sling helps Scapular upward rotators
decrease the forces on the supraspinatus tendon by central- Scapular retractors
izing the head of the humerus in the glenoid fossa in a Scapular protractors
dependent position. Use of the sling is encouraged for the Deltoid
first 2 to 3 days after surgery in most cases, with the patients Biceps
level of discomfort dictating the degree of sling use.
Although the sling is used to minimize pain, it can add Note: Strength testing should be delayed until safe and appropri-
to the patients discomfort. A critical zone of hypovascular- ate. Bicep testing could be performed earlier than the deltoid
strength test. Care must be taken so that the recovering tissue
ity in the supraspinatus tendon initially described by Rathbun is not compromised and irritated.
and McNab40 may contribute to shoulder pain in a resting-
dependent position. Some authors debate the existence of
this critical zone, but recent work by Lohr and Ulthoff 41 cor-
roborates Rathbun and McNabs initial findings. This critical
TABLE 3-1 Acromioplasty
Criteria to
Rehabilitation Anticipated Impairments Progress to This
Phase Goals Intervention Rationale and Functional Limitations Phase
Phase Ia Decrease pain Cryotherapy 20-30 minutes Self-manage pain and manage edema Pain Postoperative
Postoperative Prevent infection Monitoring of incision site Prevent complications during healing Edema
1-2 days Minimize wrist and hand weakness Grip strength exercises (with arm elevated Minimize disuse atrophy and promote circulation Dependent upper extremity
from disuse if swollen) (usually in a sling or airplane
splint depending on degree of
repair)
Phase Ib Improve PROM, avoiding Continue intervention as in phase Ia with Increase PROM preparing to advance AROM As in phase Ia No wound drainage
Postoperative aggravating surgical site addition of the following: exercises or presence of
3-10 days Produce fair to good muscular PROM of shoulder as indicated Minimize reflex inhibition of rotator cuff infection
contraction of rotators Isometricssubmaximal to maximal Minimize disuse atrophy of scapula stabilizers
Restore/maintain scapula mobility internal and external rotation in sling or Use low-grade (resistance free) mobilizations to
Reduce pain/joint stiffness supported out of sling in neutral resting decrease muscle guarding and progress grades as
position tolerated to restore arthrokinematics
AROMscapular retraction/protraction
(position as with isometrics)
Joint mobilization to the SC and AC joints
as indicated
Phase Ic Flexion PROM to 150 Continue as in phases Ia & Ib: Increase capsular extensibility with flexion/ Intermittent pain Comfortable out
Postoperative External/internal rotation PROM to AROMExternal rotation (at 60-90 elevation and rotation exercises Limited upper extremity use of sling
11-14 days functional levels (or full ROM) abduction) Make rotator cuff ready for supine elevation with reaching/lifting activities No signs of
Scapulothoracic PROM to full Supine flexion Initiate strengthening of scapula stabilizers Limited ROM infection or night
mobility AROMSupine scapular protraction (elbow (proximal stability) Limited strength pain
Supine AROM flexion to 120 extended) punches side-lying (midrange) Support axilla to allow for vascular supply to cuff
Symmetric AC/SC mobility external rotation with support (towel) in during exercises
Increase AROM tolerance in water axilla Encourage AC/SC accessory motions required for
to 100 flexion Prone scapular retraction full shoulder mobility
Minimize cardiovascular Pool therapy (with appropriate waterproof Note that buoyant effects of water allow an
deconditioning dressing if incision site not fully closed) environment where the water assists in flexion
Improve general muscular strength Cardiovascular exercise (bike, walking Prescribe lower-extremity conditioning exercises to
and endurance program) promote healing and improve cardiovascular fitness
Chapter 3 Acromioplasty
Depending on job activities, return to Provide ergonomic education early to prevent future
limited work duties complications
AC, acromioclavicular; AROM, active range of motion; PROM, Passive range of motion; ROM, range of motion; SC, sternoclavicular.
33
zone corresponds to the anastomoses between osseous therapist should emphasize scapular stabilizer efforts for
vessels and vessels within the supraspinatus tendon. Vessels proximal stability before addressing distal mobility.
in this critical zone fill poorly when the arm is at the side,2 Townsend, Jobe, and Pink46 assessed the EMG output of
but this wringing out of the supraspinatus tendon is not three slips of deltoid, pectoralis major, latissimus dorsi, and
observed when the arm is abducted.42 If the patient experi- the four rotator cuff muscles during 17 exercises. Findings
ences increased shoulder discomfort after prolonged periods from this study indicate that the majority of the muscles
with the arm at the side, then he or she should place a small studied are most effectively recruited with the following:
bolster (2 to 3 inches in diameter) in the axilla (resting Scaption (with internal shoulder rotation)
the arm in a supported, slightly abducted position) to help Flexion
decrease the pain. Horizontal abduction with external rotation
Press-ups
Immobilization and Restricted Activities. Although Because the supraspinatus is the most frequently involved
the sling protects the healing tissue around the glenohumeral cuff muscle necessitating a subacromial decompression, dili-
joint, motion should be encouraged at proximal and distal gent efforts to return supraspinatus strength are vital. The
joints. Scapular protraction, retraction, and elevation can be most effective exercise position to maximally recruit the
performed in the sling. The patient should remove the arm supraspinatus has been evaluated in numerous studies with
from the sling at least three to four times daily to perform varying results. Elevation in the plane of the scapula (i.e.,
supported elbow, wrist, and hand ROM exercises. scaption) with the shoulder internally rotated is referred to
The patient should always perform warm-up activities. as the empty-can position (Fig. 3-2).
This enhances the rate of muscular relaxation, increases the To decrease the likelihood of compressing the supra-
mechanical efficiency of muscle by decreasing viscous resis- spinatus between the greater tuberosity of the humerus
tance, allows for greater hemoglobin and myoglobin disso- and the subacromial structures, care should be taken
ciation in the time spent working, decreases resistance in never to perform the empty-can exercise past 60 to 70 of
the vascular bed, increases nerve conduction velocity, elevation.
decreases the risk for electrocardiographic abnormalities, Scaption can also be performed with the humerus exter-
and increases metabolism.43 nally rotated (Fig. 3-3). Another position that is very effec-
The physical therapist should educate the patient and help tive in recruiting the supraspinatus is prone horizontal
him or her to understand that discomfort experienced with abduction of the shoulder, with the shoulder abducted to
passive stretching into external rotation comes from the
capsule and occurs because the supraspinatus muscle is
slack. Patients with sedentary occupations who do not have
lifting duties typically can return to work during phase one.
Those returning to work should perform scapular, elbow,
wrist, and hand exercises during working hours.
Phase II
TIME: From 3 to at least 6 weeks after surgery
GOALS: Emphasis on muscle strengthening, with
continued work on rotator cuff musculature and
scapula stabilizer strengthening (Table 3-2)
Many of the exercises used to strengthen the rotator cuff

and scapular stabilizers have been assessed by electromyog-
raphy (EMG).44 EMG (both superficial and fine wire) has
been used to document electrical activity in the rotator cuff
and intrascapular musculature during the performance of
various therapeutic exercises. Strengthening of the rotator
cuff muscles can be selectively progressed from supine active
exercises to upright resistive exercises.45 Muscles of the
rotator cuff (especially the supraspinatus) have relatively
small cross-sectional areas and short lever arms. When
working with them, the therapist should apply minimal
resistance, starting at 8oz, then increase to 1lb, and then
advance in 1 2 lb or 1lb increments as tolerated. Weights
seldom have to exceed 3 to 5lb for the supraspinatus. The
infraspinatus and subscapularis can be stressed to a greater Fig. 3-2 Scaption with internal rotation should be performed below 90 to
degree, and weights can be progressed from 5 to 8lb. The prevent impinging subacromial structures.
Rehabilitation Anticipated Impairments Criteria to Progress to This
Phase Goal Intervention Rationale and Functional Limitations Phase
Phase IIa PROM full in all ranges Continue exercises from previous phases as Restore previous functional use and ROM of Limited reach and lifting AROM to 120 flexion
Postoperative Symmetric AROM flexion indicated: the upper extremity abilities, especially above AROM improving trend
3-6 wk Symmetric accessory PREselastic tubing exercises for internal Begin strengthening; internal rotators shoulder height Gait with normal arm swing
motions of glenohumeral rotation (subscapularis) usually not affected by surgery Limited strength and Strength of rotators to 4/5
and SC/AC joints and scapular retraction Initiate scapular retraction as long lever arm endurance of arm above (manual muscle test
AROM flexion in standing At 3 wk, add external rotation and scapular forces are minimal (versus protraction) shoulder height [MMT]5/5 normal
to shoulder height without protraction Progress exercise to include external rotators Limited AROM Self-manage pain
substitution from Isotonicsside-lying external rotation (with and scapula protraction as tolerance to
scapulothoracic region axilla support) with 12 to 1lb exercises improves
Symmetric strength scapula Standing scaption with shoulder externally Recognize that supraspinatus is secondary
stabilizers and shoulder rotated mover for straight plane external rotation
rotators Standing shoulder flexion with 12 to 1lb Strengthen upper quarter musculature
Elbow and wrist PREs with appropriate Accompany gravity-resisted shoulder flexion
weight and abduction by substitution with scapular
Assess lateral scapular slide elevation
Phase IIb Symmetric strength of Continue with exercises from previous phases Continue to restore ROM and strength of upper Unable to work overhead for Gravity-resisted flexion and
Postoperative supraspinatus and deltoid as indicated; maintain rotator cuff strength quarter musculature prolonged periods of time abduction without
6-8 wk Restoration of normal arm AROM PREsstanding scaption with Strengthen supraspinatus as a prime mover Unable to participate in scapulothoracic substitution
strength ratios (involved/ shoulder internal rotation (empty can); Advance strength demand on the scapula overhead-throwing athletics Symmetric strength of external
uninvolved) perform below 70 scaption stabilizers rotators
Return to previous levels of Prone or bent over horizontal abduction with Progress resistance on a conservative basis
activities/sport as indicated shoulder at 100 abduction Progress activity on a sequential basis
by strength and tolerance Begin exercises unresisted, then add weight,
Prevention of poor beginning with 12 lb
mechanics with throwing Progress weight as indicated
Preparation of upper Initiate throwing program as outlined in
extremity for advanced Chapter 13
activities Begin gentle plyometrics
Chapter 3 Acromioplasty
AC, acromioclavicular; AROM, active range of motion; PREs, progressive resistance exercises; PROM, Passive range of motion; ROM, range of motion; SC, sternoclavicular.
35
BOX 3-2 Supraspinatus Strengthening Exercises*

Jobe EC
Blackburn HA (100 abduction) > EC
Townsend MP > EC
Worrell HA (100 abduction) > EC
Malanga EC = FC
Kelly EC = FC
Takeda EC = FC > HA
Reinold HA (100 abduction) > ER
*EC, Empty can; FC, full can; HA, horizontal abduction; MP, mili-
tary press.
significant role in activities involving abduction (in the plane

of the body and plane of the scapula) especially with com-
bined external rotation and when greater resistance is
applied.55 The teres minor assists the infraspinatus in the
above activities to a minor extent and is most effective in
horizontal abduction of the humerus along with scapular
retraction and glenohumeral extension.56 Two practical and
comprehensive reviews of shoulder muscle activity and func-
tion in common shoulder exercises may be of particular
Fig. 3-3 Scaption with external rotation can safely be performed through benefit to the reader.57,58
full available range of motion (ROM). Although isolation of specific muscles is vital to ensure a
comprehensive strengthening program, work with muscles
contracting in synchrony about a joint also is an important
consideration. Wilk59 and Toivonen, Tuite, and Orwin15 note
that in overhead activities the subscapularis is counterbal-
anced by the infraspinatus and teres minor in the transverse
plane, whereas the deltoid is opposed by the infraspinatus
and teres minor in the coronal plane. Because overhead
movements are incorporated in the rehabilitation program,
the physical therapist also should address the force couple of
the upper and lower trapezius for scapular upward rotation.
Upper and lower trapezius recruitment may increase during
glenohumeral flexion and abduction exercises when using
dynamic reactive instruments as opposed to elastic or cuff
weight resistance.60 Multiplanar work can be beneficial by
incorporating dynamic trunk, scapulothoracic, and gleno-
humeral activities simultaneously. Two activities in the
Fig. 3-4 Prone horizontal abduction with the humerus abducted to 100. standing position that recruit firing of the upper and lower
The physical therapist should take care with patients with concomitant trapezius before the serratus anterior include trunk exten-
anterior glenohumeral instability. sion with simultaneous unilateral scapular retraction/upward
rotation combined with elbow flexion, glenohumeral exten-
100 (Fig. 3-4). In cases of secondary impingement related sion, and external rotation (lawnmower exercise); and trunk
to glenohumeral instability, care must be taken not to posi- extension with simultaneous bilateral scapular retraction/
tion the arm to increase stress on static restraints. Inherent upward rotation with elbow flexion, glenohumeral exten-
humeral head localization is enhanced during strengthening sion, and external rotation (robbery exercise).61
exercises by performing these activities in the plane of When strengthening the shoulder internal rotators, do
the scapula.47 not work with the patient in a side-lying position. Lying on
Box 3-2 summarizes research findings relative to the most the involved shoulder often increases shoulder pain; there-
effective exercise position to recruit the supraspinatus.48-54 fore, internal rotation should be performed in the standing
Remaining muscles of the rotator cuff cannot be neglected. or prone position. When working on strengthening the
The infraspinatus is most actively recruited via external rota- supraspinatus and standing flexion and abduction in the
tion at zero degrees of abduction. This muscle also plays a same exercise session, perform the gravity-resisted elevation
exercises before the strengthening ones. This sequence allows

a nonfatigued supraspinatus to contribute effectively to BOX 3-3 Modified Kiblers Lateral Scapular Slide Test*
achieve an adequate force couple. Cadaveric analysis of 1. Patient stands with the arms resting against the
rotator cuff composition indicates that these muscles consist sides.
of a mix of type I and type II fibers.62 Resistance applied to 2. Therapist palpates the spinous process immediately
the muscles should be a healthy fix of function-specific between the inferior angles of the scapula
velocities and repetitions. (usually T-7).
Exercise combinations can be used effectively to 3. Therapist measures and records the distance from
strengthen the muscles of the shoulder girdle. Wolf 63 the spinous process to each scapular inferior angle.
describes a four square combination of tubing-resisted 4. Patient abducts the arms to 90.
flexion, extension, external rotation, and internal rotation 5. Patient internally rotates the shoulders so that the
(IR) followed by stretching of the external rotators and thumbs point to the floor.
abductors. A combination of around the world exercises of 6. Therapist measures and records the distance
flexion, abduction, and horizontal abduction followed by from the spinous processes to each scapular
rotator cuff stretching also can be used during phase two. inferior angle.
The physical therapist should use care when performing flex-
ibility exercises of the rotator cuff because horizontal adduc- *Normal test is symmetry between right and left sides.
tion can reproduce or cause impingement symptoms.
Strong scapular stabilizers are required to provide a stable
base for the glenohumeral joint, elevate the acromion, and
provide for retraction and protraction around the thoracic exercises progress. For patients with anterior instability,
wall.64 Moseley and associates65 studied eight scapular exercises should not stress extremes of horizontal abduction
muscles via indwelling EMG and identified a core group of and external rotation. Posterior glenohumeral instability
four strengthening exercises that include scaption with requires care with horizontal adduction and IR. Strengthen-
external rotation (i.e., full can), rowing, press-ups, and pushing programs for patients with glenohumeral instability are
ups with a plus. Ludewig and associates66 found a push-up best performed in the plane of the scapula.
with a plus to be effective in recruiting the serratus anterior
with less activity of the trapezius musculature. Lear and Phase III
Gross67 noted increased serratus anterior activity during a
TIME: Weeks 9 to 12
push-up with a plus with the feet elevated. Decker and asso-
GOALS: Emphasis on enhancing kinesthesia and joint
ciates68 noted push-ups with a plus (both traditional and on
position sense, building endurance, strengthening
the knees), punching, scaption, and a dynamic hug all
the scapular stabilizer, and performing work-specific
resulted in serratus anterior activity greater than 20% of a
and sport-specific tasks (Table 3-3)
maximum voluntary contraction. Ekstrom, Donatelli, and
Soderberg69 found a seated shoulder diagonal movement of After the patient has progressed through the first two
forward flexion, horizontal adduction, and external rotation phases, the obvious deficits resulting from surgery (i.e., pain,
to be most effective in recruiting the serratus anterior when limited motion, decreased strength) have essentially been
compared with nine other open-chain exercises. eliminated. Deficits in endurance and proprioception are not
In addition to careful observation of scapulohumeral as readily apparent. Violation of the capsule, decreased use
rhythm during overhead motions, scapular stabilizer effi- of the shoulder, and abnormal or restricted movement of the
ciency can be assessed with the lateral scapular slide test. shoulder may decrease endurance and proprioception. One
This test, which was initially described by Kibler,64 involves study73 has demonstrated decreased proprioception in lax
observing and measuring scapular motion during abduction shoulders, with patients able to sense external rotation
of the shoulder. The steps of the modified lateral scapular movements with greater ease than IR, especially at end
slide test are described in Box 3-3. The lateral scapular slide range. Exercises to improve both passive detection of shoul-
is a valid tool to assess scapular motion.70 Kibler64 described der movement and active joint repositioning may help
side-to-side differences of 1cm as an indicator of scapulo- enhance kinesthesia and joint position sense, respectively.
humeral dysfunction. Other authors assessing the reliability Voight and associates74 noted decreased glenohumeral joint
of the lateral scapular slide, however, note that a 1cm differ- proprioception with muscle fatigue of the rotator cuff.
ence cannot be used as an indicator of dysfunction and that Decreasing the weight used with strengthening exercises
1cm can fall within intertester variability.71 and increasing the repetitions address endurance training.
Continue ROM efforts during phase two, especially if Scapular stabilizer strengthening has been performed in sets
limited capsular extensibility detrimentally affects physio- of 30 repetitions to this point, and repetitions can be
logic motion. In addition to aggressive stretching exercises increased as required. Work- and sport-specific tasks should
and mobilization of the glenohumeral joint, self-mobilizations be used as guidelines to the number of prescribed repeti-
also may be of benefit.72 Patients with glenohumeral laxity tions. The supraspinatus tendon is the one most frequently
also require special consideration as ROM and strengthening involved in the injury, so it should be strengthened last.

Rehabilitation Anticipated Impairments Criteria to Progress
Phase Goals Intervention Rationale and Functional Limitations to This Phase
Phase III Unrestricted Formal return to Create a specific training Decreased work or Symmetric range of motion
Postoperative overhead work and throwing and principle to return the sport-specific endurance and strength of upper quarter
9-12 wk sporting activity overhead activities patient to the desired
activity
The physical therapist also can address proprioception by special situations typically involve patients with the follow-
having the patient perform functional tasks and emphasizing ing conditions:
the timing of muscle contraction and movement without Inadequate preoperative ROM
substitution. When rehabilitating overhead-throwing ath- Full-thickness rotator cuff pathology
letes, Pappas, Zawacki, and McCarthy75 suggest timing Biceps tendon or labral pathology
muscle recruitment to correlate with the throwing sequence Articular cartilage involvement
of active abduction, horizontal extension, and external rota- Secondary impingement
tion. Appropriate timing of muscle contraction also can be Tendency for excessive scarring
addressed using proprioceptive neuromuscular facilitation History of regional complex pain syndrome or reflex sym-
techniques.76 Although the majority of upper extremity pathetic dystrophy (RSD)
function in daily, work, or sport activities occur in the open
kinetic chain, closed kinetic chain activities provide stimula- TROUBLESHOOTING
tion to the glenohumeral joint to enhance joint awareness
and kinesthesia (important in secondary impingement). 1. Scapulothoracic concerns. If the patient cannot perform
Activities in the closed chain should progress from low gravity-resisted flexion or abduction without substituting
ground reaction forces (as a percent of body weight) to with scapular elevation, then keep all efforts within the
higher forces that have been shown to recruit greater shoul- substitution-free ROM. Monitor scapular dynamic stabil-
der girdle musculature as evidenced by the percentage of ity with the lateral scapular slide test. Because breakdown
maximum volitional isometric contraction.77 of the normal scapulothoracic muscle is more obvious
A functional progression program can be used to enhance with slow, controlled arm lowering, pay special attention
the return of proprioception and endurance. Functional pro- to the eccentric component of gravity-resisted flexion
gression involves a series of sport- or work-specific basic and abduction.
movement patterns graduated according to the difficulty of 2. Appropriate exercise dose. Dye82 has described the enve-
the skill and the patients tolerance. Providing a comprehen- lope of function, which is defined as the range of load that
sive functional progression program for every job or sport can be applied across a joint in a given period without
that a patient is involved in is impossible. Programs to return overloading it. The challenge is to stress the healing tissue
the patient to throwing, swimming, and tennis activities can to maximize functional collagen cross-linking without
be found in other sources.78,79 Plyometric activities help exceeding the envelope of function. As functional levels
restore endurance, proprioception, and muscle power.80,81 are increased, alter the therapeutic exercise dose. In cases
of significant scapulothoracic dysfunction (long thoracic
nerve neuropathy), scapulothoracic taping or figure-eight
SUGGESTED HOME MAINTENANCE FOR strapping may be used for additional stability.83
THE POSTSURGICAL PATIENT 3. Monitoring for complications. Postoperative complica-
tions after SAD are rare, but the therapist must guard
Box 3-4 outlines the shoulder rehabilitation the patient is to against RSD. Pain disproportionate to the patients condi-
follow. The physical therapist can use it in customizing a tion should be construed as RSD until proven otherwise.
patient-specific program. Institute aggressive ROM and pain control efforts daily.
Unlike more complex arthroscopic procedures or sophis- Prolonged (i.e., more than 3 weeks after surgery) loss of
ticated open operative procedures, the need for structured accessory joint motions may predispose the patient to
clinic-based rehabilitation of the SAD patient should be the adhesive capsulitis. Give treatments three times a week
exception rather than the rule. Most of the rehabilitation for for mobilization and aggressive ROM.
the patient after an uneventful SAD procedure can take place 4. Loading contractile tissue. Progressively load contractile
through a comprehensive home exercise program. Special tissue. Stress healing tissue initially as a secondary mover
cases may warrant a more formal and structured treatment (receiving assistance from other muscles) before using the
program after the SAD procedure to detect problems. These tissue in its role as a prime mover.
Suggested Home Maintenance for the Postsurgical Patient

Week 1 Weeks 3-6 (Only One or Two Visits
GOAL FOR THE WEEK: Control pain and swelling, Required Over 3-Week Period)
and begin regaining range of motion (ROM) for GOAL FOR THE PERIOD: Supply added resistance
joints. for greater demand on scapular stabilizers.
Days 0 to 2: Perform grip strength exercises. 1. Add tubing- or Theraband-resisted external
Elevate your arm if it is swollen. rotation. Do three sets of 15 repetitions twice
Days 3 to 7: each day.
1. Do pendulum exercises for 2 minutes, 3 to 4 2. Do full ROM unresisted exercises for standing
times each day. forward flexion and abduction. Begin PREs using
2. Go through the active ROM for your elbow, wrist, 8oz or 1lb weights.
and hand. Do three sets of 15 repetitions in all 3. Continue IR as previously, but decrease to daily;
directions, 3 to 4 times each day. then every other day.
3. Do internal and external rotation isometrics for 10 4. Add gravity-resisted scaption with the shoulder
seconds each, with 10 repetitions 10 times each externally rotated and unresisted. Do three sets of
day. 15 repetitions twice each day.
4. Apply ice after you exercise. 5. Add tubing- or Theraband-resisted scapular
protraction exercises. Do three sets of 30
Week 2 repetitions twice each day.
GOAL FOR THE WEEK: Prevent disuse atrophy. 6. Continue scapular retraction exercises as
Days 8 to 10: Continue your program from days 3 previously described.
to 7 and add these exercises: 7. Expand cardiovascular activities to include upper
1. Active assisted supine flexion to tolerance. Do extremity use (e.g., using stair-climbing machine,
three sets of 15 repetitions, twice a day. rowing machine, upper body ergometer [UBE]).
2. Supine scapular protraction at 90 of flexion. Do
three sets of 30 repetitions, twice a day. Weeks 7-8
3. Side-lying unresisted outward rotation to parallel GOALS FOR THE PERIOD: Return to normal work or
with the floor. Do three sets of 15 repetitions sports (with restricted activities as needed) and
twice a day. normal dominant-to-nondominant muscle strength
Days 11 to 14: Discontinue the exercises you did ratios.
on days 3 to 7 and only do the ones listed for days 8 1. Add scaption with the shoulder internally rotated
to 10. Continue to apply ice after you exercise. (use an empty can) at no greater than 70 of
abduction. Begin with unresisted exercises; then
Week 3 (Only One Visit Required) add weight beginning with 8oz and progressing
GOAL FOR THE WEEK: Prevent adhesive capsulitis in 8oz to 1lb increments. Do three sets of 15
and minimize disuse atrophy. repetitions twice each day.
1. If passive ROM is not within normal limits and 2. Add prone and bent over horizontal abduction
symmetrical, then institute organized outpatient with the shoulder at 100 of abduction. Begin
treatment for mobilization. Schedule three times unresisted exercises in the middle range. Do
per week. three sets of 15 repetitions twice each day.
2. Begin tubing- or Theraband-resisted IR. Do three 3. Begin return to throwing program (Appendix A).
sets of 15 repetitions each twice a day. 4. Begin gentle plyometrics.
3. Begin tubing- or Theraband-resisted scapular
retraction exercises. Do three sets of 30 Weeks 9-12 (Only One or Two Visits
repetitions each twice a day. Required Over 4 Weeks)
4. Begin side-lying external rotation (support under GOALS FOR THE PERIOD: Obtain ROM and muscle
arms) using 8oz to 1lb weights. Do three sets of strength sufficient to reintroduce more aggressive
15 repetitions each twice a day. occupational or sports demands.
5. Begin progressive resistance exercises (PREs) for 1. Make formal return to throwing and overhead
elbow flexion and extension. activities.
6. Assess lateral scapular slide.
5. Prevention. As the old adage goes, an ounce of prevention syndrome: relief of inflammation, strengthening (espe-
is worth a pound of cure. Preventing early primary cially the external rotators, abductors, and scapular stabi-
impingement symptoms from becoming chronic may lizers), flexibility (especially shoulder internal rotators
eliminate the need for surgery. Nirschl8 notes the follow- and adductors), general fitness, education, and proper
ing factors as keys in preventing chronic impingement equipment.
Copyright 2013 by Mosby, an imprint of Elsevier Inc. Copyright 2007, 2001 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
skills, along with a physical therapist with the expertise to

SUMMARY advance the patient through the postoperative phase, typi-
cally produces a favorable result. Of even greater importance
This chapter discusses the surgical procedure of SAD along is the rapport established between surgeon and therapist,
with principles that govern postoperative rehabilitation. A and the relationship between the health care providers and
surgeon with sound diagnostic, management, and surgical the patient.
1 Carl arrives for therapy 5 weeks after a shoulder acromio-

plasty. He is having difficulty performing shoulder
flexion and scaption exercises correctly. He occasionally
3 Kelly had an acromioplasty on her right shoulder 6
weeks ago. She complains of a pinching pain when
reaching above her head, through the last 20 of shoul-
demonstrates a mild shoulder hike with arm elevation der flexion and abduction. She also has a pinching pain
exercises above 70 of elevation. How can the therapist when actively reaching across her body in horizontal
sequence his exercises to maximize his ability to elevate adduction. With PROM for horizontal adduction,
his arm above shoulder height? shoulder flexion, and abduction, she has pain near the
end of the ranges. What type of treatment may be helpful
If the patient is going to be strengthening the supraspi- during her next session?
natus and performing shoulder elevation exercises (i.e.,
shoulder flexion, abduction, or scaption exercises), he Kelly was treated with joint mobilizations to the gleno-
should perform the gravity-resisted elevation exercises humeral joint as usual to increase shoulder flexion and
first. The supraspinatus works more efficiently, without shoulder abduction. AC mobilizations have been per-
fatigue, to achieve an adequate force couple, thereby formed in the past, with the arm in anatomic position
helping Carl to execute the elevation exercises while the patient was supine. However, today AC mobi-
correctly. lizations were performed with the shoulder in horizontal
adduction and again with the shoulder in flexion above
2 Drew is a 55-year-old plumber. He has a history of

shoulder pain over the past 2 years and has a slouched
posture. He had an acromioplasty performed 8 weeks
140. An assistant was required to hold the extremity of
the patient in place while the therapist performed the
mobilizations. AROM for shoulder flexion, abduction,
ago. He still has minimal deficits with average range of and horizontal adduction increased by 10 of pain-free
motion (AROM) for reaching overhead objects and motion. In addition, the complaints of pain intensity were
cannot reach into his back pocket. On evaluation, Drew less when experienced. After one more visit for the same
demonstrates near full passive range of motion (PROM) treatment, the patient exhibited full ROM.
for shoulder flexion. PROM for IR and a combined
movement of IR with shoulder extension is limited.
What are some essential points to address and treatment
techniques to use during Drews treatment?
4 Cynthia had an acromioplasty on her right shoulder
5 days ago. She complains of moderate to severe pain
intermittently throughout the day. She also has difficulty
sleeping secondary to shoulder pain. She is a mother of
After correction of Drews posture he was able to reach young children. Patient uses arm for light activities of
higher above his head. His slouched posture had previ- daily living (ADLs) when possible. ROM is limited in all
ously restricted full active shoulder flexion. The shoulder directions. Strength is not tested secondary to healing
capsule needs to be assessed immediately for restric- tissue and pain levels. How did the therapist advise her
tions. Emphasizing capsular mobilization of a restricted and treat her for pain management?
capsule allows for better joint arthrokinematics and
increased ROM. The anterior, posterior, and inferior The therapist encouraged her to use a sling for a couple
capsule were all restricted. General mobilizations were of days to prevent overuse of the healing extremity. She
performed for all areas of the capsule, and specific mobi- was told to use the sling when she was up and about
lizations were performed for the anterior capsule. Drew for protection and for rest. Children as well as others
then performed ROM and stretching to the shoulder, would be less likely to bump or grab her arm. She
including stretches with the hand behind the back. A was also encouraged to use cryotherapy intermittently
considerable increase in PROM and AROM for the hand throughout the day. The therapist advised her to try
behind the back was noted after this treatment. sleeping in a recliner chair or a semireclined position
with her shoulder supported in a loose packed position. may reveal one or more hypomobile segments. Restor-
Treatment consisted of assessing the cervical area. ing normal accessory motions in these areas may assist
Gentle mobilizations were done in the cervical area along in regaining full shoulder elevation.
with massage to the cervical and scapular musculature
to decrease muscle guarding and spasms. The patients
pain level decreased slightly after the treatment. Pain
began subsiding over the next couple of days.
7 John has been referred to you from a surgeon from out
of state. He states that he had a shoulder decompression
6 weeks ago and did not have postoperative physical
therapy. He found a rotator cuff strengthening program
5 Mike had an acromioplasty on his right shoulder 4

weeks ago. He notes aching in the shoulder after early
functional progression consisting of a short toss
online and has been doing those exercises daily and is
using 3 or 4lb. In addition to significant rotator cuff
weakness, your evaluation demonstrates scapular mal-
program. This discomfort is in the posterior aspect of position, inferior medial border prominence, pain at the
the shoulder. The discomfort is most pronounced during coracoids, and an abnormal scapulohumeral rhythm.
the follow though in the throwing motion. He has no How will you modify Johns program?
night pain but has minimal discomfort with daily over-
head activities. His rotator cuff strength is excellent, and Excessive loads can be placed on the rotator cuff with
he has a normal scapulohumeral rhythm. What addi- insufficient proximal stability afforded at the scapulo
tional concerns should be addressed? thoracic joint. In addition, muscles of the rotator cuff
(especially the supraspinatus) may not tolerate excessive
As Mike is a throwing athlete, the cause of his rotator external resistance due to short lever arms and a
cuff issues may have been due to secondary impinge- relatively small physiologic cross-sectional area. John
ment as a result of anterior glenohumeral instability. should not be performing progressive resistive exercises
Subtle anterior instability may be increased due to a tight for the cuff at this juncture. You should emphasize ante-
posterior capsule. Since this is where Mikes symptoms rior chest muscle flexibility and strengthening of the
are present, stretching of the posterior capsule may be scapular stabilizers.
indicated. Manual techniques the therapist can employ
include horizontal adduction without stabilization of the
axillary border of the scapula progressing to stabilizing
the scapula and focusing on glenohumeral motion. The
8 Ann works in a data entry position and has had right
shoulder pain off and on for 3 years with occasional
complaints of carpal tunnel. She had a SAD performed
sleeper stretch (side-lying on the involved shoulder with 3 weeks ago and has yet to start rehabilitation because
the arm forward flexed while passively pushing the of poorly localized postoperative pain. Two days after
forearm toward the floor) may be helpful, but should be your initial evaluation, Ann returned for a follow-up
done carefully with the arm flexed to no more than 70. visit with complaints of increased shoulder pain and
occasional numbness and tingling down the right
6 Tim is employed as a truck driver who has responsibili-

ties for overhead lifting and stacking. His SAD was done
5 weeks ago and he is readying to return to work. His
arm and into the hand. Is it safe to proceed with
rehabilitation?
rehab has gone well, with the only difficulty being the You should counsel Ann that any increase in activity may
last 5 to 8 of flexion needed to get to the upper shelves result in discomfort. Ann may be experiencing delayed
in his delivery truck. The restriction is not painful but onset muscle soreness and/or her level of activity may
is accompanied by stiffness. His motion preoperatively be in excess of what she is ready for. You can certainly
was also slightly restricted due to pain and stiffness. In trouble shoot Anns level of activities and exercise. You
addition to passive ROM of the shoulder what other can also determine if discomfort is delayed-onset muscle
areas may be of concern? soreness in nature or from joint and healing tissue. The
issue of occasional numbness and tingling is not a con-
The last few degrees of elevation can be troublesome. traindication for exercise, but it also cannot be ignored.
Many issues can contribute to decreased mobility at the If you have not yet done so, Anns cervical spine should
cervical-thoracic junction and throughout the midtho- be cleared, nerves cleared for adverse neural tension/
racic spine. Assessment of joint play in these regions compression, and peripheral nerve entrapments.
27. Rockwood CA Jr, Lyons FR: Shoulder impingement syndrome: Diagno-

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CHAPTER 4
Anterior Capsular Reconstruction
Renee Songer, Reza Jazayeri, Diane R. Schwab, Ralph A. Gambardella, Clive E. Brewster
INTRODUCTION internal rotation. The combination of these factors and the

repetitive nature of throwing sports can lead to internal
Anterior shoulder instability is one of the most commonly impingement with damage to the surrounding structures.
diagnosed and treated conditions of the shoulder in athletes. Many patients cannot be simply placed into categories
This encompasses a wide spectrum of pathology, and simi- represented by the eponyms TUBS and AMBRI. TUBS
larly various surgical approaches have been used to address stands for traumatic instability, unidirectional, Bankart
the specific pathoanatomy involved. Treatment of anterior lesion, treated with surgery. AMBRI stands for atraumatic
shoulder instability has evolved due to advances in instability, multidirectional, bilateral, with treatment being
arthroscopic techniques along with an improved under- initially rehabilitation; if nonoperative treatment fails, then
standing of shoulder anatomy and its complex biomechanics. surgical treatment is an inferior capsular shift. Shoulder
Although the treatment of anterior glenohumeral instability instability may be better addressed when classified into one
has been a topic of debate over the last couple of decades, a of four groups as shown in Box 4-1.
consensus exists regarding the necessity of an individualized Clinical examination of group 1 patients with anterior
treatment plan based on the patients functional demands shoulder instability commonly demonstrate glenohumeral
and their associated type and degree of instability. Treating internal rotation deficit (GIRD), with positive apprehension
anterior shoulder instability requires an accurate diagnosis, and relocation signs. Associated posterior capsular tightness
a detailed operative plan, experience with advanced contributes to anterior and superior shifting of the humeral
arthroscopic and open procedures, and individualized reha- head, leading to posterior impingement and labral pathol-
bilitation programs. ogy. If left untreated, this instability can lead to internal
impingement with rotator cuff and labral tearing (group 2).
ETIOLOGY/EVALUATION Some patients also have signs of external impingement or
a diagnosis of rotator cuff tendinitis, bursitis, or bicipital
Shoulder instability is often not an isolated diagnosis, but tendinitis. Generally, this group is older than those who
rather one point of a continuum of pathology (Fig. 4-1). This experience internal impingement. This group often has per-
is particularly evident in overhead-throwing athletes who sistent symptoms despite both nonoperative treatment and
place a tremendous amount of force on the shoulder joint surgical subacromial decompression.
and surrounding soft tissue structures. Repetitive micro- Young patients with generalized ligamentous laxity (group
trauma and stresses placed on the shoulder can lead to injury 3) are another group of patients that can have shoulder insta-
of the glenohumeral joint and various supporting structures bility, as well as a positive relocation test and internal
including the rotator cuff, glenohumeral ligaments, and impingement. Lastly, (group 4) a traumatic episode can lead
labrum. to anterior instability as a result of a Bankart lesion. These
Shoulder instability is often associated with internal patients, however, show no evidence of impingement.
impingement, a process where the posterosuperior labrum The majority of patients will respond to conservative
and the articular undersurface of the rotator cuff tendons treatment if the diagnosis of anterior shoulder instability is
impinge and become injured. The cause of internal impinge- made early during the pathologic course. As many as 95% of
ment is multifactorial in throwing athletes. Poor mechanics patients can return to their previous level of competition.
such as hyperangulation of the arm during the cocking phase The focus of these exercises is on posterior capsular stretch-
and poor endurance can lead to pathologic stretching of the ing, strengthening the periscapular muscles, and emphasis
anterior shoulder structures. This is often exacerbated by of proper throwing mechanics. Activity modification and
underlying weak periscapular stabilizers and deficits in rest from throwing combined with a supervised therapy
44
Chapter 4 Anterior Capsular Reconstruction 45
Internal Impingement Continuum suspension unit. The arthroscope is introduced into the
Poor mechanics
Post capsule shoulder via the posterior portal. The glenohumeral joint is
contracture evaluated for subtle changessuch as attenuation or absence
M
ic
Hyperangulation of the inferior glenohumeral ligament, a loose redundant
ro
tra
Hyper external Impingement
An tab
capsulewith a positive push-through test. Often an inter-
u
in
m
te ilit
rotation
a
rio y
nal impingement between the undersurface of the supraspi-
r
Stretching of
anterior RTC tear/SLAP natus tendon and the posterior labrum is evident with
structures Rehabilitation fraying or a partial articular supraspinatus tendon avulsion
Subluxation
(PASTA) lesion in more advanced cases.
In cases of traumatic anterior shoulder instability, a
Muscle weakness Bankart lesion, and occasionally a Hill-Sachs deformity can
Scapular dyskinesis Recurrent instability
be seen. The subacromial space usually appears normal in
Fig. 4-1 Instability continuum. the younger overhead-thrower who has an anterior instabil-
ity without the inflamed, thickened bursa and decreased
space that is characteristically found with external
impingement.
BOX 4-1 Classification of Shoulder Instability Based on the preoperative workup, evaluation under
anesthesia and diagnostic arthroscopy, the surgical approach
Group I: Pure impingement; no stability that will best address the patients issues is elected.
Group II: Primary instability due to chronic labral
microtrauma; secondary impingement
Group III: Primary instability due to generalized
ARTHROSCOPIC PROCEDURE
ligamentous hyperelasticity; secondary impingement
Group IV: Pure instability; no impingement Arthroscopic surgical stabilization is currently the preferred
method of treatment for most patients with anterior instabil-
ity. Surgical goals remain similar to open approaches, includ-
ing addressing any Bankart/anterior labral periosteal sleeve
program are instrumental in protecting the anterior shoul- avulsion (ALPSA) lesion back to its anatomic position on the
der structures. Persistence and attention to detail are both glenoid, eliminating any capsular hyperlaxity, and repairing
essential to a successful outcome: the elimination of pain and any clinically significant rotator interval laxity. Furthermore,
return to full activity without surgical intervention. an arthroscopic approach allows better identification and
Patients who do not respond to 3 to 6 months of appropri- treatment of associated pathologic conditions including
ate nonoperative management are possible candidates for superior labral anterior-posterior (SLAP) lesions, release of
anterior capsulolabral reconstruction (ACLR) for recurrent posterior capsular tightness, and any possible subacromial
instability or repair of their Bankart lesion for traumatic impingement.
instability. Traditionally, open stabilization has been the gold stan-
dard. However, more recent arthroscopic suture anchor
SURGICAL CONSIDERATIONS techniques have recurrence rates equal to open techniques,
even in high-demand contact athletes. Recent reports docu-
It is imperative to determine the correct etiology of instabil- mented 92% to 97% good to excellent results, with 91% of
ity by a thorough history, physical examination, and imaging high-demand contact athletes with traumatic anterior insta-
studies for selection of the appropriate procedure. A surgical bility returning to sports. Multidirectional instability also
approach that combines careful preoperative and intraopera- may be treated by arthroscopic stabilization with predictably
tive evaluation maximizes the possibility of good and excel- good results.
lent outcomes. Both open and arthroscopic surgical repairs Arthroscopy is minimally invasive; avoiding open surgi-
have a role in the management of anterior shoulder instabil- cal dissection decreases morbidity and facilitates an outpa-
ity. While arthroscopic capsulolabral repair has recently tient approach. Maintaining subscapularis integrity improves
become the standard of care for the treatment of anterior postoperative muscle function and facilitates rehabilitation,
shoulder instability, open approaches remain a reliable, time- particularly in the overhead athlete.
tested option and in certain cases continue to be the gold Initially, a diagnostic arthroscopy is performed through a
standard. standard posterior portal. An anterior superior portal is
All patients are examined under anesthesia. Subtle insta- created just anterior to the biceps tendon. This portal is used
bilities, which were not apparent previously, are often better for mobilization of the capsulolabral complex and for subse-
appreciated with the patient asleep. Regardless of surgical quent suture management. An anterior inferior portal is
approach, a thorough diagnostic arthroscopy is performed. placed just above the superior edge of the subscapularis and
The patient is placed in the lateral position, and the shoulder is used for inferior placement of suture anchors on the lower
is distracted with 10lb using an overhead traction aspect of the glenoid neck. Assessment of the mobility of the
capsuloligamentous complex is crucial in determining

whether the soft tissues have been displaced or are scarred OPEN PROCEDURE
in a medial position on the neck of the glenoid as in an
ALPSA lesion. Adequate inferior soft tissue mobilization to Open surgery remains the preferred method of treatment in
the 6 oclock position on the glenoid face is carried out using situations where even the most advanced arthroscopic tech-
a combination of probes, rasps, motorized shavers, and peri- niques cannot adequately address the pathoanatomy, such as
osteal elevators. anterior instability in the setting of large bone defects or soft
The anterior glenoid is rasped and decorticated in prepa- tissue deficiencies.
ration for suture anchor insertion. The anchors are then An anterior axillary approach is performed with the skin
placed on the edge of the articular surface in the 2 oclock, 3 incision in Langer lines. The incision starts 2cm distal and
oclock, and 5 oclock positions. A suture lasso* or similar lateral to the coracoid process and extends 5 to 7cm distally
device is used to shift the labroligamentous complex superi- into the anterior axillary crease. The deltopectoral interval is
orly and medially as needed. The suture is passed through identified, and the cephalic vein is retracted laterally with the
the tissue, and arthroscopic knots are then used to securely deltoid. The conjoined tendon is identified and retracted
fix the soft tissue to the glenoid. After all suture anchors are medially. With the shoulder in external rotation, the sub-
tied, the repair is evaluated for stable fixation and restoration scapularis tendon is split transversely in line with its fibers
of an anterior buttress to inhibit instability. at the junction of the upper two thirds and lower one third.
Adjunctive procedures may need to be performed to The subscapularis muscle is dissected free from the
completely correct all pathology associated with the instabil- underlying capsule, starting medially in the muscular portion
ity, such as rotator interval (RI) incompetence and capsular of the subscapularis and extending laterally. Retractors are
laxity. Arthroscopic findings consistent with RI tears are cap- positioned to maintain the subscapularis interval, allowing a
sular redundancy between the supraspinatus and subscapu- horizontal anterior capsulotomy to be made in line with the
laris, biceps tendon fraying, superior glenohumeral ligament split of the subscapularis tendon. Tag sutures are placed on
(SGHL) tear, and the superior border of the subscapularis either side of the capsular flaps just lateral to the labrum
fraying. Arthroscopic closure of the deep layer of the SGHL exposing the glenoid.
to the middle glenohumeral ligament (MGHL) imbricates If a Bankart lesion is noted, it is repaired using suture
the anterosuperior capsule and can address RI capsular anchors back to its anatomic location on the anterior-inferior
incompetence. glenoid neck. The capsule is assessed for its volume, quality,
Contraindications to arthroscopic treatment include large and ability to buttress the anterior inferior margin. The
Hill-Sachs lesions (25% to 35% of the humeral arc), Hill- degree of capsular shift is tailored to the degree of laxity. If
Sachs lesions that engage the anterior glenoid rim in the capsule is deemed lax or incompetent, it is overlapped to
abduction-external rotation, or a loss of more than 20% to obliterate the redundancy. The inferior leaf of the capsule
25% of the anteroinferior glenoid. and accompanying inferior glenohumeral ligament are
Multiple dislocations can lead to attenuated capsulolabral advanced proximally. The superior portion of the capsule is
tissue. This remaining poor quality tissue is often difficult to brought over the inferior portion and labrum, resting along
mobilize and repair arthroscopically, and an open stabiliza- the anterior scapular neck. The inferior and superior leaflets
tion may be preferred in these patients. Other relative indica- are overlapped using a vest-over-pants technique with non-
tions for open stabilization include recurrent instability after absorbable sutures. If the labrum is intact and does not
failed arthroscopic stabilizations and avulsion of the capsu- require repair, a capsular imbrication alone is adequate to
lolabral tissue from the humerus (the humeral avulsion of reduce the volume of the joint.
the glenohumeral ligaments [HAGL] lesion). After capsular closure, the arm is taken through a ROM,
Recent stabilization techniques have also expanded the noting the extent of motion which places tension on the
arthroscopic scope of treating anterior shoulder instability. repair. This will mark the limitation of motion that the
The Remplissage procedure (French for to fill) described patient is permitted postoperatively. The surgeon must
by Wolf consists of an arthroscopic capsulotenodesis of the clearly communicate with the therapist to ensure that this
posterior capsule and infraspinatus tendon to fill the Hill- safe zone is observed.
Sachs lesion. Although others have also demonstrated sat- After determining a safe postoperative motion, the
isfactory results with this technique, alterations in surgeon reapproximates the subscapularis and closes the del-
biomechanics of the shoulder remain a valid concern. topectoral interval, followed by subcuticular closure of the
skin with the addition of adhesive strips. The arm is splinted
in abduction and external rotation.
*Arthrex, Naples, Fla.
DISCUSSION
Hill-Sachs remplissage: an arthroscopic solution for engaging the Hill-
Sachs lesion.
Arthroscopic double-pulley remplissage technique for engaging Hill-Sachs The management of anterior shoulder instability continues
lesions in anterior shoulder instability repairs. to evolve as advances in arthroscopy provide an effective
Decreased range of motion following arthroscopic remplissage. alternative to traditional open surgery. Furthermore,
arthroscopic procedures allow improved evaluation and Taking care not to extend the inflammatory phase with
treatment of associated pathologies, including SLAP lesions, overly aggressive treatments will allow maximal collagen
partial rotator cuff tears, subacromial impingement, RI, and fiber deposition with minimal disruption leading to better
capsular laxity while avoiding the common morbidities asso- healing in the end. Avoid stressing the anterior capsule
ciated with open procedures. with your interventions.
Open surgical stabilization, however, continues to play an On the first visit, remove the sling and measure passive
important role in certain injury patterns that cannot be ade- range of motion (PROM) in flexion and abduction in the
quately addressed arthroscopically. Decision-making regard- scapular plane (scaption). Do not move into external rota-
ing surgery for instability is influenced by the relevant tion past zero degrees at this time to prevent excessive stress
pathologic findings and the surgeons experience. to the anterior capsule. Measure internal rotation to the
Careful patient selection and a thorough understanding limits permitted by pain tolerance because there is no
of the involved pathoanatomy are paramount in maximizing concern about disrupting healing tissue in this direction.
patient outcome. Regardless of the surgical approach Assess wrist and elbow motion at the first visit as well.
chosen, our success should be based on retaining range of Early mobilization has been shown to improve tissue healing
motion, decreasing recovery time, maintaining propriocep- following surgery.4,5 Without mobilization the patient is less
tive control, and ultimately returning patients to their prior likely to regain full motion; therefore, it is important to
level of activity. begin ranging the shoulder within the limits of discomfort
immediately. Because pain typically prevents independent
active range of motion (AROM) in the first few days
THERAPY GUIDELINES FOR after surgery, perform passive or manual active-assisted
REHABILITATION range of motion (AAROM). Independent AAROM can be
safely initiated using wand exercises, table slides, and
Because no muscles are cut during the surgical reconstruc- wall walks into flexion and scaption. When the postoperative
tion, rehabilitation proceeds promptly with two familiar pain subsides, measure active elevation in the scapular
goals: restore structural flexibility and strengthen dynamic plane.
glenohumeral and scapulothoracic stabilizers. This chapter Assess scapular positioning and active scapular mobility
includes exercises and manual interventions to restore the immediately and begin scapular positioning exercises.
trinity of normalcy: range of motion, strength, and endur- Emphasis should be placed on activation of the serratus
ance. The key to success is restoring all three components anteriors and the middle and lower trapezius muscles to
concurrently rather than addressing each component promote retraction and upward rotation of the scapula.6
sequentially. The best plan is an integrated one: do not wait Exercises may include (1) proprioceptive neuromuscular
for full range of motion to return before initiating strength- facilitation (PNF) interventions for scapular positioning,
ening, and address muscular endurance as gross strength which are very effective and safe immediately postopera-
improves. The likelihood of an optimal postoperative tively7; and (2) prone or standing scapular retraction. Avoid
outcome increases dramatically when the physical therapist excessive activation of upper trapezius or latissimus dorsi,
monitors postoperative exercises carefully to ensure correct which leads to improper scapular elevation or depression,
execution. Be cautious and avoid pushing for full ROM too respectively.6
early and disrupting the healing tissue. A home exercise program should begin immediately (Box
4-2). Remove the sling three to four times per day to perform
Phase IA exercises for 15 minutes including: scapular retraction,
AROM elbow flexion/extension, pronation/supination, wrist
TIME: Day 1 to 2 weeks (Table 4-1)
flexion, extension, radial and ulnar deviation, and squeezing
GOALS: Manage pain and protect the surgical wounds
a gripper ball. Follow this routine with ice and return to the
from infection
sling. Codmans pendulum exercises are also appropriate at
Protect the anterior capsule from excessive stress
home if the patient has no contraindications due to extreme
Activate scapular stabilizers and encourage proper
laxity.8
scapular positioning
Pain management modalities, such as electrical stimula-
Initiate passive and active assisted ROM with a goal of
tion and cryotherapy, may be used as needed throughout the
135 in the flexion plane
course of therapy. If the patient is having an excessive amount
Maintain functional ROM at the elbow and wrist
of pain, assessment and treatment of the cervical spine may
For 2 to 4 weeks, the arm will be in an abduction sling. be appropriate. Preoperative compensations, intraoperative
Protection of the surgically repaired tissue is essential for a positioning, and postoperative guarding can lead to joint
successful long-term outcome. Many of these patients have and soft tissue dysfunction in the neck. Comparable
some joint laxity and rarely have difficulty regaining motion objective findings locally at cervical levels 3, 4, and 5 may
with a normal course of rehabilitation. The inflammatory explain excessive pain, muscle inhibition, or excessive tight-
and initial fibroblastic/granulation stages of physiologic ness in the shoulder and the therapist should intervene
healing occur during the first 2 weeks following surgery.1-3 appropriately.9
TABLE 4-1 Anterior Capsular Reconstruction

Anticipated
Criteria to Impairments
Rehabilitation Progress to and Functional
Phase This Phase Limitations Intervention Goal Rationale
Phase 1A Postoperative Postoperative Modalities: Modalities: Modalities:

Postoperative pain Cryotherapy Manage pain and Minimize edema to minimize
1 day-2 wk Postoperative Electrical stimulation edema discomfort and inhibitory
Postoperative edema PROM: PROM: effects on local musculature
protection UE in All directions as needed if patient Produce 135 PROM:
abduction sling is unable to perform AAROM of flexion in the Maintain ROM if patient is
Limited ROM because of pain scapular plane unable to perform exercises
Limited AAROM: Wand exercises, table AAROM: independently due to pain
strength slides, and wall walks Produce 135 of AAROM:
Limited ADLs Shoulderflexion, internal flexion in the scapular Minimize ROM loss while
rotation, and abduction, avoiding plane protecting the anterior
stress on the anterior capsule ER limited to 0 capsule
AROM: AROM: AROM:
ElbowFlexion, extension, Maintain full ROM of Minimize loss at secondary
pronation, supination elbow and wrist joints
WristFlexion, extension, radial Isometrics: Isometrics:
and ulnar deviation Produce good-quality Activate rotator cuff and
Submaximal Isometrics: contraction of scapular stabilizers to
ShoulderAll movements in a shoulder girdle minimize atrophy
neutral position musculature Manual Intervention:
Scapular stabilization Manual Intervention: Minimize adhesions and
Manual Intervention: Function: manage pain
Grade I, II GH mobilization Allow ADLs below Facilitate muscle activation
PNF patterns shoulder height to and scapular positioning
Scapular Positioning Exercises: tolerance Function:
PNF for scapular positioning Maximize functional use
Prone and standing scapular within the limits of protecting
retraction the surgical repair
Core strengthening when able
AAROM, active-assisted range of motion; ADLs, activities of daily living; AROM, active range of motion; ER, external rotation; GH,
glenohumeral; PNF, propioceptive neuromuscular facilitation; PROM, passive range of motion; ROM, range of motion; UE, Upper extremity.
Begin core strengthening exercises immediately. Abdomi- Initiate rotator cuff exercises while protecting the
nals, lumbar extensor muscles, and gluteals are all critical anterior joint capsule
components in the kinetic chain for athletes and physical
laborers alike. Core and lower body strengthening are safe Typically, the arm comes out of the sling during this
and easy to incorporate into the training program. Once the phase. Physiologic healing is progressing from the granula-
patient is safe and independent, transition these exercises tion stage into the proliferative/fibroblastic stage.1-3 Due to
into a home exercise program to allow more time for close the deposition of collagen fibrils, the healing tissues are
supervision of the shoulder exercises during therapy developing some internal integrity enabling them to tolerate
sessions. gentle stresses. The skin wounds should be healing and pain
should be minimal.
Phase IB Measure active range of motion to the onset of discomfort
TIME: 2 weeks to 4 weeks (Table 4-2) including: flexion, scaption, and internal rotation. Measure
GOALS: external rotation to 45 or onset of discomfort, whichever
Progress from PROM to AAROM to AROM while comes first. Assess scapular mobility and quality of motion
protecting the anterior joint capsule during AROM looking for abnormalities in scapular winging,
Progress scapular stabilization exercises scapulothoracic or scapulohumeral rhythm, and quality of
BOX 4-2 Suggested Home Exercise Program for the Postsurgical Patient
Phase IA: 0-2 Weeks Dynamic hug below 90 elevation
15 minutes 2 to 4 times per day as discomfort permits Scapular retraction:
ROM Prone row, extension
Codmans pendulum exercises Rotator cuff strengthening:
Elbow: flexion, extension Side-lying external rotation, abduction, and horizontal
Forearm: pronation, supination flexion
Wrist: flexion, extension, radial and ulnar deviation Standing internal and external rotation with resistance
Scapular stability bands
Scapular retraction: in sling and out of sling OKC flexion, full can
Grip/squeeze ball Phase III: 2-3 Months
Ice as needed for discomfort throughout day/night
ROM: expected to be normalized at this time. Continue
Phase IB: 2-4 Weeks with ROM as indicated in any restricted directions
ROM: Stretching: continue as indicated
AAROM: Scapular stability:
Wand: flexion, full can, ER to 45, hand behind back Scapular protraction/upward rotation:
Wall walks: flexion, full can Serratus anterior:
Stretching if indicated: Wall slides into forward elevation above shoulder/head
Cross-body posterior capsule height
Scapular stability Hug at 120 elevation
Static hold Row Scapular retraction:
Static hold serratus press Prone full can
Rotator cuff strengthening Prone row with external rotation
Isometrics with elbow at side: flexion, extension, Rotator cuff strengthening:
abduction, internal and external rotation Supraspinatus mid-range overhead punch
Variable load isometrics (once scapular control is Supine internal and external rotation at 45 to 90
achieved and therapist is confident the patient can abduction with resistance bands
correctly perform exercises) General Strength:
Ice as needed for discomfort throughout day Biceps, triceps, latissimus, pectorals, trapezius strength
PRECAUTION: Do not force external rotation at this time. using traditional exercises as appropriate based on
Limit the patient to 45 to prevent excessive stretching scapular stability, overall strength, and safety.
while unsupervised at home.
Phase IV: 3-4 Months
Phase II: 4-8 Weeks
Scapular Stability:
ROM: Planks, walkouts pike press
AAROM/AROM: Endurance: ball bounce in overhead position for 30-90
Wand, progressing to full ROM in flexion, scaption, seconds
external rotation, hand behind back Rotator cuff strengthening:
Stretching if indicated: External rotations eccentric strengthening with
Sleeper stretch resistance bands
Scapular stability: General strengthening:
Scapular protraction: Becoming more sport specific as appropriate
Serratus press progression:
Wall: two arms > one arm Phase V: 4-6 Months
Table height: two arms > one arm Sport-specific training progresses
Plank: knees > full Full range of motion push-ups
muscle contraction. Gentle strength assessment of the rotator Active-assisted ROM exercises can include wand flexion
cuff in all planes from a neutral position is also appropriate and abduction in the scapular plane, external rotation to 45,
as pain tolerance allows. The goal is to assess muscle activa- and hand behind the back. The patient should move into the
tion rather than to perform break testing, which would ROM until he or she begins to feel an initial stretch. Make
require maximal force production and potentially damage certain the patient understands that the goal of therapy in
the surgically repaired tissue and cause pain. this phase is to initiate range of motion without stressing the

Anticipated
Criteria to Impairments and
Rehabilitation Progress to Functional
Phase 1B No signs of Patient comes out Modalities: Modalities: Modalities:

Postoperative infection of sling Continue modalities as Manage pain and edema Minimize edema to
2-4 wk Pain controlled Limited ROM needed by pain and AAROM/AROM: minimize discomfort and
Postoperative with medication Limited strength edema ShoulderFlexion, inhibitory effects on local
protection or modalities Minimal functional AAROM: as needed scaption, and internal musculature
ROM initiation No loss of ROM use of arm for AROM: rotation 70% of AAROM/AROM:
and muscle from initial self-care and ADLs ShoulderFlexion, uninvolved side for ShoulderProgress with
activation assessment due to weakness scaption, and internal functional requirements ROM quickly but safely
and discomfort rotation to tolerance; External rotation limited Avoid stress on the anterior
Full elbow and external rotation to to 45 to avoid stress on capsule
wrist AROM 45 the anterior capsule Isometrics:
Avoid stress on the Continue with elbow and Once good muscle activation
anterior capsule wrist as needed is achieved, quickly progress
Continue with elbow Isometrics: into more advanced
and wrist as needed Strong, tonic contraction exercises if able
Isometrics: of rotator cuff without Isotonics:
ShoulderProgressive pain Scapular control is required
load isometrics Isotonics: to advance into more
Isotonics: Good scapular control in challenging rotator cuff
Scapular stabilization standing and prone exercises
exercises standing and exercises without cues Through range motions in
prone Prone and side-lying safe positions to build
Prone extension series: good form strength and endurance
Side-lying series maintained through 310 Manual Intervention:
Static serratus press repetitions Decrease mechanical
Static hold row Manual Intervention: barriers preventing normal
Manual Intervention: Maximize ROM ROM and strength
Soft tissue mobilization Maximize mechanical Function:
GH and scapulothoracic alignment Minimize dependency for
mobilization Function: functional activities
Independent for self-care Maintain fitness to minimize
and ADLs below shoulder losses
height
Participation in core and
lower body strengthening
AAROM, active-assisted range of motion; ADLs, activities of daily living; AROM, active range of motion; ROM, range of motion; GH,
glenohumeral; UE, Upper extremity.
anterior capsule. These exercises can be incorporated into a grasps an exercise band with two hands, and performs a
home program. scapular retraction creating tension in the band, while the
During this phase the patient must learn to actively elbows remain bent to 90 and in the plane of the body.
control the position of the scapula without cues. The goal is The patient then walks slowly backward to increase tension
to maximize scapular stability and minimize scapular in the band while maintaining a scapular retraction to load
winging. Proper control of scapular position is required to the posterior scapular stabilizers. Static rows can be per-
progress with rotator cuff exercises. Three key muscles to formed with an isometric hold in the loaded position or
activate are the middle trapezius, lower trapezius, and ser- simply by moving repeatedly through the motion to load and
ratus anterior. Progress prone or standing scapular retrac- relax the muscles. Early activation of the serratus anterior
tions to a static row using an exercise band. The patient can be achieved with a static hold serratus press in a
modified push-up position at the wall (Fig. 4-2, A). This performed in a neutral position into shoulder flexion, exten-
position is similar to the plus position of the traditional sion, internal and external rotation, and abduction (Fig. 4-3).
push-up plus, which demonstrates high EMG activity in Progression of these initial rotator cuff exercises includes
the serratus anterior.10,11 The patient places the hands on the variable load isometrics using resistance bands. The patient
wall at shoulder height, with the head and spine in neutral stands holding the band as if to perform classic isotonic
alignment. Instruct the patient to press the hands into the internal and external rotation exercises. Yet rather than move
wall and the body away from the hands using a scapular the arm, the patient holds the arm still while stepping away
protraction motion to achieve the plus position. Progress from the anchor point of the band, thereby increasing resis-
into a more challenging position by lowering the hands to tance and loading the rotator cuff muscles in a safe manner.
the height of a table, thereby increasing gravitational forces Another technique for safe early strengthening is performing
and increasing the workload on the serratus (Fig. 4-2, B). active motion from the prone position with a stable scapula.
These are safe exercises to add to the patients home program Prone extension is an excellent exercise for initiating dynamic
because there is no active motion being performed at the scapular stabilization and activation of the middle trapezius
glenohumeral joint (see Box 4-2). (cools) (Fig. 4-4, A). The elbow should remain in full exten-
Once scapular positioning can be achieved and main- sion and the motion ends at the plane of the body to protect
tained by the patient, slowly progress rotator cuff strengthen- the anterior capsule.
ing as tolerance, strength, and proper form allow. Posterior shoulder soft tissue restriction or posterior
Caution the patient that the elbow should never be behind the capsule tightness can accompany anterior shoulder instabil-
plane of the body to avoid stressing the anterior capsule. To ity. If restriction is present, as determined by the Tyler test12
begin, submaximal isometric strengthening exercises can be and available horizontal adduction ROM,13 it may lead to
B C
Fig. 4-2 Serratus press: A, Wall press. B, Table press. C, Table press one-handed.
A B
C D E
Fig. 4-3 A, Isometric shoulder internal rotation. B, Isometric shoulder external rotation. C, Isometric shoulder abduction. D, Isometric shoulder flexion.
E, Isometric shoulder extension. (From Jobe FW: Operative techniques in upper extremity sports injuries, St Louis, 1996, Mosby.)
aggravation of the anterior shoulder structures and stress the

anterior capsular repair. Stretching the posterior capsule may
be a project that requires both manual interventions and
home self-stretching exercises over the course of many weeks
to normalize. Manually address posterior capsule tightness
with soft tissue mobilization and anterior-posterior GH joint
A mobilizations.14,15 The physical therapist should take care to
avoid excessive compression forces on the anterior shoulder
with hand-holds because this can be very painful for the
patient. Cross-body stretching of the posterior capsule can
be included in the home program if appropriate for the
patient (Fig. 4-5).16,17
Grade II manual GH mobilizations in the anterior-
posterior and cephalad/caudad directions can be used for
B
pain management18 and to prevent excessive adhesion for-
Fig. 4-4 Prone: A, Extension. B, Horizontal abduction. mation during this phase.14
Functional mobility begins to return during this phase.

Overhead reaching into flexion typically is the most com-
fortable direction and most easily regained after surgery.
Often, patients continue to complain of pain with functional
activities involving extension and external rotation, such as
putting on a jacket. The patient should have full PROM and
nearly full AROM by two months following surgery with the
exception of external rotation, which may lack approxi-
mately 10.20 Slowly begin exercises that gently stretch the
anterior capsule through the active range rather than forcing
a stretch by passive manual interventions, for example, wand
scaption or external rotation. If by 6 weeks postsurgery a
deficit in external rotation of 25 or larger remains, incorpo-
rate more aggressive manual techniques or self-stretching
exercises to regain full motion. It is the authors opinion that
a 5 to 10 loss of external rotation in a neutral position and
at 90 of abduction at 8 weeks postoperative is not uncom-
mon and not detrimental to the final outcome. The surgical
Fig. 4-5 Cross-body stretch. reconstruction will continue to stretch over the next 2 to 4
months. Keep in mind that the goal of the surgery was to
decrease pathologic laxity. Aggressively stretching the repair
site can put the patient back into their preoperative state of
Nighttime discomfort may continue to be a problem and excessive laxity and should be avoided during this phase. The
the therapist can advise the patient regarding sleeping posi- patient should continue with ROM exercises at home as
tions. Pillow support under the elbow maintains the shoul- needed (see Box 4-2).
der in the scapular plane while sleeping and reduces stress During this phase, emphasis must be on proper dynamic
on the anterior capsule. Pillows should not be placed under scapulothoracic and scapulohumeral rhythm. Allowing
the shoulder directly because this forces the scapula into a excessive motion at the glenohumeral joint as a compensa-
more protracted and anteriorly tipped position. tion for improper scapulothoracic motion can overstress the
anterior capsule and the repair. It is best to observe scapulo-
Phase II thoracic and scapulohumeral rhythm with the patient shirt-
less to ensure proper mechanics are present before advancing
TIME: 4 weeks to 8 weeks (Table 4-3)
the program. The scapular slide test,21 although inconsis-
GOALS:
tently validated in the literature, can be used as an assess-
Full ROM is expected by 8 weeks.
ment tool early in the rehabilitation process to quantify gross
Progress dynamic scapular stabilization and rotator
differences in scapular motion. The physical therapist mea-
cuff strengthening exercises.
sures the distance from the inferior angle of the scapula to
Return to ADLs and functional activities that do not
the midline of the thoracic spine at the level of the inferior
stress the anterior capsule.
angle of the scapula. The measurements should be symmetri-
Physiologically, the healing tissue is well advanced into cal for the involved and uninvolved shoulders at zero degrees
the proliferative/fibroblastic stage during this phase.1-3 There hands at sides, 45 hands on hips, and 90 of abduction with
is an abundance of collagen fibers in the region and the internal rotation. Assess the quality of the motion in addition
surgical repair has fair integrity. At a cellular level, the goal to the quantity of motion. The goal is to have a smooth con-
of physical therapy is to align these collagen fibers in the traction and appropriate firing patterns on both the concen-
proper orientation along lines of normal stress.15 This phase tric and eccentric phases of motion. A jerky pattern with
is the optimal time period for elongating tissue with a pro- visible muscle fasciculations would be considered abnormal
gressively lessening amount of risk for damage. Moving the and needs to be addressed before progressing into more dif-
arm through a large pain-free range of motion will allow ficult exercises.
appropriate stresses to the healing tissue, resulting in an Proper function of the serratus anterior muscle is critical
optimal outcome. to normal shoulder function and is essential if the patient is to
Typical manual muscle testing and active range of motion avoid an external impingement problem. Progress the serra-
assessment in all directions are appropriate at this time. tus press exercise into one-handed stabilization at table height
Include strength testing of the rotator cuff and scapular sta- (see Fig. 4-2, C). Further progression moves to the floor in a
bilizers to be certain all aspects of the kinetic chain are pro- kneeling plank position (Fig. 4-6, A), and finally a full plank
gressing as required. Do not force motion into extension, position on the floor (Fig. 4-6, B). The serratus dynamic hug
external rotation, or horizontal abduction to avoid stretch- below 90 of elevation is an excellent progression into func-
ing the anterior capsule. tional through range serratus activation10 (Fig. 4-7).

Anticipated
Rehabilitation Progress to This and Functional
Phase Phase Limitations Intervention Goal Rationale
Phase II Strong, tonic Limited ROM Modalities: Modalities: Modalities:

Postoperative isometric muscle Limited strength Continue modalities as needed Manage pain and edema Minimize edema to
4-8 wk activation Limited by pain and edema AAROM/AROM: minimize discomfort
Cautious ROM Independent tolerance of UE AAROM: As needed Full shoulder AROM by 8 and inhibitory effects
and initial with scapular for reach, lift, AROM: wk on local musculature
strengthening positioning and and carry Continue phase I as needed Possible limitation of 10 AAROM/AROM:
stability for activities ShoulderFlexion, scaption, in external rotation is ShoulderProgress
initial prone and ER and IR to tolerance expected with ROM quickly but
side-lying Isotonics: Isotonics: safely
exercises Continue phase I as needed Good scapular control in Avoid excessive stress
Pain controlled Scapular stabilization: serratus standing and prone and on the anterior capsule
with medication press progression on closed chain positions as indicated by
or modalities wall>table>floor>(4-4c) one Prone, side-lying, and discomfort
No loss of ROM handed standing exercises: good Isotonics:
Plank: knees>full (4-8A, 4-8B) form maintained through Scapular control is
Scapular retractionprone row 320 repetitions required to advance
extension Standing OKC: good form into more challenging
Scapular protraction/upward maintained through rotator cuff and
rotation 310 repetitions functional exercises
Dynamic hug below 90 Manual Intervention: Progressively challenge
4 wk: prone extension and row; Maximize ROM the scapular stabilizers,
through range ER/IR Maximize mechanical rotator cuff, and prime
6 wk: prone horizontal alignment movers to build
abduction; OKC in side-lying ER, Function: strength and endurance
IR, abduction, horizontal flexion Independent for self-care Manual Intervention:
8 wk: OKC flexion, scaption; and ADLs at and above Decrease mechanical
resistance bands for ER and IR head height without pain barriers preventing
UBE, initiate with involved arm Strength 60%-70% normal ROM and
being passive Lift 5lb strength
Manual Intervention: Participation in core, Function:
Soft tissue mobilization lower body strengthening, Minimize dependency
GH and ST mobilization and cardio program for functional activities
PNF patterns in diagonals and Maintain fitness to
functional positions minimize losses
AAROM, active-assisted range of motion; ADLs, activities of daily living; AROM, active range of motion; ER, external rotation; GH, glenohu-
meral; OKC, open kinetic chain; PNF, propioceptive neuromuscular facilitation; ROM, range of motion; ST, scapulothoracic; UBE, upper body
ergometer; UE, Upper extremity.
Prone horizontal abduction (see Fig. 4-4, B) and prone Once dynamic scapular control is achieved, advance with
row (Fig. 4-8) target the middle and lower trapezius muscles22 more specific rotator cuff muscle-strengthening exercises. Side-
and posterior rotator cuff.23 Begin with AROM only to lying external rotation,23 abduction, and horizontal forward
retrain proper scapular control and progress to light weight flexion,24 all limited to body plane range of motion, require
to increase the demand on the muscle. Because the patient more dynamic scapular stability while maintaining a safe range
is retrained in a manner minimizing risk to the anterior of motion for the shoulder. Watch carefully to ensure excessive
shoulder, these are excellent exercises for building muscle scapular adduction and trunk rotation do not substitute for
endurance. proper stabilization by the middle and lower trapezius.
following surgery and prevents the patient from regaining

full range of motion. Gentle soft tissue mobilization can ease
this restriction, allowing the patient to actively move into
increased range.
Phase III
TIME: 2 to 3 months (Table 4-4)
A GOALS:
Full range of motion in all directions
Progressive strengthening with resistance in all
planes of motion
Normal functional tasks without limitations with the
exception of sports
Physiologically, the capsular tissue is progressing out of

the proliferative/fibroblastic stage and into the remodeling/
maturation stage.1-3 As the collagen tissue matures, it becomes
B more resilient to stress, therefore more stress can be placed
on the capsule without risk of damage. Because of this
Fig. 4-6 Plank: A, Kneeling half plank. B, Full plank.
increasing tissue strength, the window of opportunity to
increase ROM is closing during this phase. Be certain you
have achieved the desired ROM, otherwise it may be very
Progress to through-range external and internal rotation hard to regain later.
with resistance bands, emphasizing scapular stability to The primary goal of the third postoperative month of
ensure proper rotator cuff activation.25,26 Use an axillary physical therapy is strengthening throughout the full active
towel roll to reinforce proper positioning, increase muscle range of motion. The patient may add resistance to an exer-
activation, and to improve synergistic function of the adduc- cise when (1) the motion can be performed with proper
tors and external rotators.23 scapulohumeral and scapulothoracic motion patterns; (2) he
Begin open kinetic chain exercises in standing, including or she can demonstrate good eccentric control through the
shoulder scaption in a full can position,23 flexion, and abduc- range of motion; and (3) such motion is pain-free.
tion using gravity as resistance. These exercises can be used It is necessary to perform break testing in all planes of
to train proper scapulohumeral rhythm through AROM and motion, including end range, to assess functional strength.
are less effective for specific muscle strengthening. Add light- Performing manual muscle tests only in neutral positions is
weight or resistance bands as movement patterns, scapular not a sufficient assessment to ensure adequate functional
stability, and overall strength increase. Poor eccentric control strength and endurance in athletes. If weakness is present in
and scapular winging tend to be limiting factors in progres- overhead positions, many overhead athletes will be unable
sion with added resistance. to regain all necessary function.
The upper body ergometer (UBE) may be incorporated Adequate strength of the serratus anterior is critical to
early in rehab. Initially the involved arm is passive to focus maintain scapular protraction and to prevent scapular
on mobility, with the uninvolved arm doing the majority of winging throughout open and closed kinetic chain activi-
the work. An easy five-minute program alternates forward ties.6 Concentric and eccentric control must be evaluated
and backward revolutions at a comfortable pace. With during all exercises. A modified minirange push-up plus
repeated use, the involved arm may begin to participate with a narrow grip and elbows hugged tightly to the body
more as tolerance allows, progressively increasing the effort can be the next step in strengthening.11 Begin these on the
until the patient is predominantly using the involved arm by wall and progress to table height, then the floor. Do not
2 months postoperation. jeopardize the anterior capsule by progressing too quickly.
If anterior shoulder pain, a protracted scapula,27 or an Patients should not be performing normal full range
anteriorly translated humeral head are noted, reassess for push-ups at this time, as the tensile strength of the healing
possible restriction in the posterior shoulder. If capsular or tissue is inadequate. Many athletes view a push-up as a
muscular restriction is present, incorporate more aggressive gold-standard of functional strength and will strive to
manual interventions and home exercises. Grade IV+ poste- return to push-ups too quickly, leading to pain or damage
rior mobilizations in varying angles of humeral flexion and in the shoulder. The serratus also functions to upwardly
rotation may be indicated to redress this dysfunction and rotate and posteriorly tip the scapula when the arm is over-
normalize mechanics.14 The sleeper stretch (Fig. 4-9) is a head.29 Use wall slides to train overhead motion, with the
good home exercise to improve the extensibility of the pos- emphasis on pushing the hands into the wall and the body
terior capsule.17,28 Additionally, the excursion and pliability away from the wall (Fig. 4-10).30 Once the motor pattern is
of the subscapularis muscle often becomes restricted learned, progress into a serratus punch at a 120 elevation
Fig. 4-7 Serratus dynamic hug below 90 elevation.
Fig. 4-8 Prone row. Fig. 4-9 Sleeper stretch.


Anticipated
Rehabilitation Progress to This Functional
Phase III Maintain full ROM Limited strength for Modalities: Modalities: Modalities:
Postoperative in all planes with overhead activities Continue modalities as Manage pain Minimize discomfort
2-3 months possible exception Limited strength for needed AROM: AROM:
Progressive of 10 loss of ER lift and carry AROM: Full shoulder AROM Normalized capsular
strengthening Independent with activities Continue phase II as all directions by 12 excursion in all planes
proper scapular Not participating in needed for ER loss if wk Isotonics: Add resistance to an
positioning and UE sports present Isotonics: exercise when:
stability for initial Isotonics: Good scapular Demonstrate proper SH and
prone, side-lying, Continue phase II control and proper ST motion pattern
and standing Advance scapular form for all prone, Demonstrate good eccentric
exercises stabilization with closed side-lying, and control
Execute 320 chain exercises: narrow standing exercises: Exercise is pain free at
repetitions of push-up, wall slides, 320 repetitions current level
prone and serratus punch at 120 Manual Scapular control in CKC and
side-lying exercises 8 wk: prone full can Intervention: overhead positions is critical
and 310 10 wk: supraspinatus Maximize ROM for normal athletic
repetitions of punch; prone row with Maximize participation and to avoid
standing OKC ER mechanical impingement
exercises with 12 wk: resisted alignment Progressively challenge the
proper form eccentric ER, IR Function: scapular stabilizers, rotator
UBE: progress into one Independent with cuff, and prime movers to
arm ADLs above head build strength and endurance
Initiate strengthening of height without pain Manual Intervention:
bicep, tricep, latissimus, Strength 80% Normalize GH and ST
deltoid, and pectoral Carry 5lb mechanics
muscles when scapular Participation in Window for gaining capsular
stability allows core, lower body excursion closes during this
Manual Intervention: strengthening, and phase
Soft tissue and GH cardio program Increase tolerance of
mobilization as needed anterior shoulder muscles to
PNF patterns in movement
diagonals and Function:
functional positions Maximize functional
with increased speed activities in an effort to
and resistance return patient to previous
level of function
ADLs, activities of daily living; AROM, active range of motion; CKC, closed kinetic chain; ER, external rotation; GH, glenohumeral; IR, internal
rotation; OKC, open kinetic chain; PNF, propioceptive neuromuscular facilitation; ROM, range of motion; SH, scapulohumeral; ST, scapulotho-
racic; UBE, upper-body ergometer; UE, Upper extremity.
(Fig. 4-11) which demonstrates high EMG activity through are adequate. Avoid pain at end range external rotation
a functional overhead motion.10 because this is a position that stresses the anterior capsule.
Lower and middle trapezius muscle strength and endur- Progress rotator cuff exercises described above by increas-
ance are progressed by moving the arm into different planes ing either resistance or repetitions. Given their role as
of motion. Prone full can (Fig. 4-12) emphasizes the lower dynamic glenohumeral stabilizers31,32 we must consider the
trapezius while a prone row emphasizes the middle trape- rotator cuff muscles as muscles of endurance rather than
zius.22 Prone rows can be progressed by adding external rota- power and focus on lighter weight with more repetition. This
tion into the 90/90 position (Fig. 4-13) when strength and is a more appropriate training strategy than using heavier
eccentric control of the scapular stabilizers and rotator cuff weight and fewer repetitions. The supraspinatus punch in
Fig. 4-10 Wall slide overhead.
Fig. 4-11 Serratus punch at 120 elevation.

Strengthening of the biceps, triceps, latissimus dorsi,

deltoid, and pectoral muscles becomes more important once
the therapist is certain there is adequate strength and endur-
ance of the rotator cuff muscles and scapular stabilizers. Ath-
letes often push toward lifting heavy weights for these larger
muscle groups, yet progressing with light to medium weights
is more appropriate. Remember that it has been several
months since the last true training session was possible and
the rotator cuff and scapular muscles must provide the nec-
essary stability to the shoulder complex. Allowing a patient
to return to 45lb bicep curls on the first attempt simply
because that is what I was lifting before surgery will cause
shoulder discomfort.
Progress the UBE to using only the involved arm with
emphasis on endurance training and increased speed.
Phase IV
TIME: 3 to 4 months (Table 4-5)
GOALS:
Continue with progressive strengthening exercises
into functional range of motion based on anticipated
sports or work demands
Initiate a return to an overhead sports training
program at approximately 4 months postoperatively
Fig. 4-12 Prone full can.

While tissue remodeling continues, we can be confident
the surgical repair is strong and can tolerate increasing
stresses. We become less and less concerned about damaging
the surgical repair as time goes on. Full range of motion is
expected at this time. Functionally, the patient should feel
normal with the exception of overall gross power for heavier
lifting and endurance for longer duration activities. Over-
head sports and work specific activities likely remain chal-
lenging from a strength and endurance perspective.
Consider sport-specific activities and positional require-
ments to identify ongoing impairments that need continued
attention. Have the patient move through patterns of motion
similar to their sport, without speed or load. If the patient is
a pitcher, assess objective ability and subjective tolerance to
the cocking position of the arm, then with the full body
pitching motion before allowing him or her to throw a ball.
If the patient is a volleyball player, mimic the serving and
blocking motions starting with just the arm and progressing
Fig. 4-13 Prone row with external rotation into 90/90 position. into slow, purposeful full body motion. Look for the ability
to control the concentric and eccentric phases of motion.
Question the patient about any pain, restriction, or weakness
midrange in the scapular plane is a good method of initiating with the action. Use this information to guide the next
overhead strengthening.10 Supine internal and external rota- several weeks of treatment ensuring that the patient is ready
tion with the arm positioned in 45 to 90 of abduction using to transition to sport-specific training at 4 months
resistance bands allows for a safe progression of range by postoperation.
moving the arm into more functional positions. Advance serratus anterior strength with planks or walk-
PNF continues to be a valuable manual tool in this patient outs on an exercise ball (Fig. 4-14), and continue to empha-
population. The therapist can use PNF patterns to strengthen size scapular protraction and upward rotation throughout
muscles in terminal ranges of motion, as well as for gross the exercise. Pressing from a plank into a pike position
motor patterning throughout the range of motion.7 Minimal (Fig. 4-15) on the floor will train closed chain overhead ser-
resistance is applied to focus the effort on proper muscle ratus control. Pikes can be performed using a stability ball
firing patterns more than gross power or speed. (Fig. 4-16) and are a very challenging high-level exercise,

Anticipated
Phase IV Full shoulder AROM Limited strength Modalities: Modalities: Modalities:

Postoperative all directions by 12 and endurance of As needed after exercise Manage pain Minimize discomfort
3-4 months wk UE AROM: AROM: AROM:
Functional Good scapular Unable to perform Maintenance stretching No deficits Normalized capsular
and eccentric control and proper sustained or Isotonics: Isotonics: excursion in all planes
strengthening form for all prone, repetitive reaching Continue phase III Good scapular Isotonics: Add resistance
side-lying, and and overhead Advance scapular stabilization control and proper to an exercise when:
standing exercises: activities exercises: floor/ball plank, form for all prone, Demonstrate proper SH
320 repetitions Limited tolerance floor/ball pike, table height side-lying, and and ST motion pattern
Independent with to carrying objects push-up plus standing exercises: Demonstrate good
ADLs above head Overhead OKC for eccentric 320 repetitions eccentric control
height without pain control 90% strength Exercise is pain free at
Strength 80% Sustained overhead endurance throughout shoulder current level
Carry 5lb work complex and core Scapular control in CKC
Eccentric strengthening rotator Manual and overhead positions
cuff in functional positions Intervention: is critical for normal
Advance power training of Maximize ROM athletic participation and
prime movers of the shoulder Maximize to avoid impingement
girdle mechanical Progressively challenge
Sport-Specific Strengthening: alignment the scapular stabilizers,
Strengthening in related Function: rotator cuff and prime
positions Gross strength 90% movers to build strength
Address power, speed, and 80% strength for and endurance
endurance components of overhead lifting Manual Intervention:
specific training 90% strength for Maintenance of ROM as
Plyometrics carrying below needed as patient
Manual Intervention: shoulder height returns to sports
Soft tissue and GH Initiate return to Function:
mobilization as needed sport programs Maximize functional
PNF patterns in diagonals and activities in an effort to
functional positions with return patient to
increased speed and resistance previous level of function
ADLs, activities of daily living; AROM, active range of motion; CKC, closed kinetic chain; GH, glenohumeral; OKC, open kinetic chain; PNF,
propioceptive neuromuscular facilitation; ROM, range of motion; SH, scapulohumeral; ST, scapulothors acic; UE, Upper extremity.
Fig. 4-14 Stability ball walk-out.
Fig. 4-15 Pike press on the floor.

Fig. 4-16 Pike press on stability ball.
B
which may be appropriate for only the strongest individuals
near the end of this phase of rehab. Full-range, overhead,
open kinetic chain exercises, such as forward flexion, full
can, and supraspinatus press, can be used to train eccentric
control of the scapula as the arm is lowered to the side. This
is more of a neuromuscular retraining exercise than a true
strength building exercise. Again, assess the quality of C
motion, not simply the quantity of motion or weight lifted.
If the patient is an overhead athlete or worker, endurance
for maintaining the arms overhead can be critical to return-
ing to these activities. Bounce a light ball, gym ball, or medi-
cine ball overhead for 30 to 60 seconds, focusing on scapular
stability in a retracted, posteriorly tipped, and upwardly
rotated position. D
It is essential to achieve good eccentric control of the
rotator cuff muscles before returning to sports activity. This Fig. 4-17 Eccentric external rotation. A, Start. B, Loading into 90/90
is particularly important when working with overhead ath- position. C, Loading with lower extremity extension. D, Eccentric control
to return to start position.
letes since the posterior rotator cuff is responsible for the
eccentric deceleration of the arm in activities such as throw-
ing, serving, or hitting.33,34 Therapist-assisted prone external
rotation can be used for eccentric strengthening of the pos-
terior rotator cuff. A heavier but controllable weight is Increase the speed and resistance applied when perform-
selected, and the therapist helps the patient preposition the ing PNF patterns.7 Speed work into internal and external
arm into the 90/90 position, then releases the weight, rotation in multiple planes in both the concentric and eccen-
forcing the patient to control the weight in the negative tric directions is effective training for overhead activities.
direction. To eccentrically strengthen internal rotation, have Sports such as volleyball, tennis, swimming, water polo, and
the patient lie supine and perform the same therapist-assisted throwing sports can benefit greatly from D1/D2 patterning
90/90 exercise. A home exercise for eccentric posterior into end ranges of motion. These exercises can also be per-
rotator cuff strengthening is performed with resistance formed with resistance bands and transitioned into sport-
bands. The patient lies supine with a resistance band tied specific warm-up drills as the patient progresses toward
to the foot and the band wrapped around the hand independence.
(Fig. 4-17, A). The arm is positioned at 90 abduction in Power training for the deltoids, biceps, triceps, latissimus
neutral rotation. With the band slack, the arm is externally dorsi, and pectoral muscles becomes more important in this
rotated into the 90/90 position, the thumb pointing toward last phase of therapy before returning to sports activity.
the floor (Fig. 4-17, B). The leg is extended tensioning Whereas the rotator cuff and scapular stabilizers are control
the band, while maintaining the arm in the 90/90 position and endurance muscles, the prime movers of the arm are the
(Fig. 4-17, C). Slowly, the arm is returned to the neutral power muscles.33-35 Incorporate lat pull-downs, bicep curls,
starting position in a controlled manner creating eccentric tricep extensions, and rows into the program with heavier
loading of the posterior cuff (Fig. 4-17, D). weight and fewer repetitions.
Phase V stress on the anterior joint capsule during the first postopera-
TIME: 4 to 6 months (Table 4-6) tive month. Conversely, the therapist should not push range
GOALS: of motion in patients with hyperelasticity. They will reac-
Return to sports or work quire motion quickly and should be allowed to heal before
Avoid recurrence of shoulder pain attempting extremes of motion.
At this time, many patients have returned to normal Anterior Shoulder Pain
activities including sports played below shoulder height or Despite surgery, some patients continue to have anterior
sports demanding very little of the upper extremity. Over- shoulder pain with palpation of the proximal biceps tendon
head athletes must have adequate strength and endurance to or transverse humeral ligament. This may be considered
transition into sport-specific training. leftover inflammation. Although the structural problem
Plyometrics are a critical part of rehabilitation for ath- has been rectified surgically, the residual inflammation does
letes. Ball toss to a trampoline while in tall kneel, half kneel, not disappear overnight. Assess the posterior cuff and
or standing can mimic required motions for sports. Playing capsule for adequate tissue length. Stretching may be neces-
catch with a light medicine ball allows concentric and eccen- sary to allow the humeral head to articulate with the glenoid
tric training of the throwing motion. While lying prone the at its normal contact point, which will eliminate stress on the
patient catches the ball in the 90/90 position, eccentrically anterior structures and allow the irritation to resolve. The
lowering the ball to 90 abduction with neutral rotation, then therapist can use modalities to reduce discomfort at
tosses the ball back to the therapist by externally rotating the the clinic and the patient should follow through at home
arm back to the 90/90 position. For larger motion patterns, with a cryotherapy routine.
throw a 5 to 10lb medicine ball against a wall in a chest pass,
side pass, or overhead toss. There is no limit to the options Posterior Shoulder Pain
for ball related plyometrics that can be very sport-specific. Many patients note pain in the posterior shoulder, especially
Isokinetic strength measurement is an excellent way to with activity that requires elevation above 120 and motion
determine overall power and endurance compared with the that requires horizontal abduction posterior to the frontal
uninvolved arm. Understand that the dominant arm is plane. Another potentially difficult motion is hyperextension
expected to be stronger, and this may alter the interpretation posterior to the plane of the body. Occasionally, patients
of strength testing. The authors of this chapter test isokinetic develop a tendinopathy of the rotator cuff external rotators,
strength at 120 per second for internal rotation and 240 per specifically the teres minor, which may be treated symptom-
second for external rotation. Sport-specific training begins atically. The therapist may note pain on palpation of the
when the involved arm demonstrates 70% to 80% strength posterior cuff insertion, the posterior capsule, or the proxi-
of the uninvolved arm. mal third of the axillary border of the scapula, as well as
Sport-specific programs are indicated in Boxes 4-3 decreased extensibility of the posterior structures, which
through 4-6. may affect the alignment of the humeral head in the glenoid.
Treat accordingly with modalities, stretching, and progres-
TROUBLESHOOTING sive strengthening.
Misapprehending Tissue Quality Insufficient Range of Motion

Patients with normal or tight connective tissue must work If too much time elapses after surgery before the
early and diligently to reacquire motion, while avoiding patient regains normal motion, capsular adhesion may

Rehabilitation Criteria to Progress to This Anticipated Impairments
Phase Phase and Functional Limitations Intervention Goal Rationale
Phase V Good concentric and eccentric Decreased endurance for Continue phase IV as Return Strengthen and improve
Postoperative control for all isotonic exercises sport-specific activities needed to sports endurance of shoulder
4 months and 90% strength throughout Push-up on floor muscles using high-speed
beyond shoulder complex and core Isokinetics for internal resistance training
Return to sport Gross strength 90% and external rotation at Return to sport or activity
Strength for carrying below 200 degree/sec safely and without injury
shoulder height 90% Sport-specific drills
Strength for overhead lifting 80% when strength is
80%-90% (see Chapter
13)
BOX 4-3 Rehabilitation Throwing Program for Pitchers*

Step 1: Toss the ball (no windup) against a wall on alternate Phase 5-2
days. Start with 25 to 30 throws, build up to 70 throws, and
gradually increase the throwing distance. Number of Throws Distance (ft)
10 40 (warm-up)
Number of Throws Distance (ft) 10 50-60
20 20 (warm-up) 20-30 80-90
25-40 30-40 20 50-60
10 20 (cool down) 10 40 (cool down)
Phase 5-3
Step 2: Toss the ball (playing catch with easy windup)
on alternate days. Number of Throws Distance (ft)
Number of Throws Distance (ft) 10 40 (warm-up)

10 60
10 20 (warm-up) 15-20 100-110
10 30-40 20 60
30-40 50 10 40 (cool down)
10 20-30 (cool down)
Phase 5-4
Step 3: Continue increasing the throwing distance while
Number of Throws Distance (ft)
still tossing the ball with an easy windup.
10 40 (warm-up)
Number of Throws Distance (ft) 10 60
15-20 120-150
10 20 (warm-up)
20 60
10 30-40
10 40 (cool down)
30-40 50-60
10 30 (cool down)
Step 6: Progress to throwing off the mound at one half
Step 4: Increase throwing distance to a maximum of 60 to three fourths speed. Try to use proper body mechanics,
feet. Continue tossing the ball with an occasional throw at especially when throwing off the mound:
no more than one half speed. Stay on top of the ball.
Keep the elbow up.
Number of Throws Distance (ft) Throw over the top.
Follow through with the arm and trunk.
10 30 (warm-up) Use the legs to push.
10 40-45
Phase 6-1
30-40 60-70
10 30 (cool down) Number of Throws Distance (ft)
Step 5: During this step, gradually increase the distance 10 60 (warm-up)

to 150 feet maximum. 10 120-150 (lobbing)
30 45 (off the mound)
Phase 5-1 10 60 (off the mound)
Number of Throws Distance (ft) 10 40 (cool down)
10 40 (warm-up) Phase 6-2

10 50-60
15-20 70-80 Number of Throws Distance (ft)
10 50-60 10 50 (warm-up)
10 40 (cool down) 10 120-150 (lobbing)
10 40 (cool down)
Continued
BOX 4-3 Rehabilitation Throwing Program for Pitcherscontd

Phase 6-3 Day 3
Number of Throws Distance (ft) Number of Throws Distance (ft)
10 50 (warm-up) 10 warm-up throws 120-150 (lobbing)

10 60 10 warm-up throws 60 (off the mound)
10 120-150 (lobbing) 30 pitches 60 (off the mound)
10 45 (off the mound) Rest 10 minutes
30 60 (off the mound) 10 warm-up throws 60 (off the mound)
10 40 (cool down) 20 pitches 60 (off the mound)
Rest 10 minutes
Phase 6-4 10 warm-up throws 60 (off the mound)
20 pitches 60 (off the mound)
10 50 (warm-up) Day 4
10 120-150 (lobbing) Off
10 45 (off the mound) Day 5
40-50 60 (off the mound)
10 40 (cool down) Number of Throws Distance (ft)
10 warm-up throws 120-150 (lobbing)

At this time, if the pitcher has successfully completed 10 warm-up throws 60 (off the mound)
phase 6-4 without pain or discomfort and is throwing 30 pitches 60 (off the mound)
approximately three fourths speed, then the pitching coach Rest 8 minutes
and trainer may allow the pitcher to proceed to step 7: 20 pitches 60 (off the mound)
up-down bullpens. Up-down bullpens is used to simulate a Rest 8 minutes
game. The pitcher rests between a series of pitches to 20 pitches 60 (off the mound)
reproduce the rest period between innings. Rest 8 minutes
Step 7: Up-down bullpens: (one half to three fourths 20 pitches 60 (off the mound)
speed)
Day 1 At this point the pitcher is ready to begin a normal
routine, from throwing batting practice to pitching in the
Number of Throws Distance (ft) bullpen. This program can and should be adjusted as
10 warm-up throws 120-150 (lobbing) needed by the trainer or physical therapist. Each step may
10 warm-up throws 60 (off the mound) take more or less time than listed, and the trainer, physical
40 pitches 60 (off the mound) therapist, and physician should monitor the program. The
Rest 10 minutes pitcher should remember that it is necessary to work hard
20 pitches 60 (off the mound) but not overdo it.
Day 2
Off
*Patients start at the step that is appropriate for them. Postsurgical patients begin at step 1. Patients progress depending on the mainte-
nance of their pain-free status and their strength and endurance.
From Jobe FW: Operative techniques in upper extremity sports injuries, St Louis, 1996, Mosby.
develop, permanently limiting the total motion available in ROM requirements without excessive motion. For example,
the shoulder. The best defense for this problem is a good a baseball pitcher may require 130 of external rotation for
offense: the physical therapist should know the patients function, while most other populations have more modest
tissue type and encourage motion early if appropriate. As requirements. While an athlete does need this amount of
noted earlier, normal ROM differs for different patients and external rotation, too much external rotation can lead to
a very carefully planned stretching program should be instability. A very narrow margin exists between being able
implemented based on the patients tissue type and func- to perform and having a problem. Precisely correct mechan-
tional requirements. This plan should include manual ics is crucial to prevent recurrence.
stretching by the therapist and stretching independently by If the patient is having difficulty gaining the last few
the patient with a goal of returning the patient to functional degrees of shoulder flexion because of pain or stiffness and
BOX 4-4 Rehabilitation Program for Catchers, Infielders, and Outfielders

Note: Perform each step three times. Step 5: Outfielders: Lead with your glove-side foot
All throws should have an arc or hump. forward. Take one step, crow hop, and throw the ball.
The maximum distance thrown by infielders and Infielders: Lead with your glove-side foot forward. Take
catchers is 120 feet. a shuffle step and throw the ball. Throw the last five throws
The maximum distance thrown by outfielders is 200 in a straight line.
feet.
Step 1: Toss the ball with no windup. Stand with your Number of Throws Distance (ft)
feet shoulder-width apart and face the player to whom you
are throwing. Concentrate on rotating and staying on top 5 70 (warm-up)
of the ball. 5 90
10 100
Number of Throws Distance (ft) 5 80 (cool down)
5 20 (warm-up) Step 6: Use the throwing technique used in step 5.

10 30 Assume your playing position. Infielders and catchers, do
5 20 (cool down) not throw farther than 120 feet. Outfielders, do not throw
farther than 150 feet (midoutfield).
Step 2: Stand sideways to the person to whom you are
throwing. Feet are shoulder-width apart. Close up and pivot Infielders and Outfielders
onto your back foot as you throw. Number of Throws Catchers Distance (ft) Distance (ft)
Number of Throws Distance (ft) 5 80 (warm-up) 80 (warm-up)

5 80-90 90-100
5 30 (warm-up) 5 90-100 110-125
5 40 5 110-120 130-150
10 50 5 80 (cool down) 80 (cool down)
5 30 (cool down)
Step 7: Infielders, catchers, and outfielders all may
Step 3: Repeat the position in step 2. Step toward the assume their playing positions.
target with your front leg and follow through with your back
leg. Infielders and Outfielders
Number of Throws Catchers Distance (ft) Distance (ft)
5 80 (warm-up) 80-90 (warm-up)
5 50 (warm-up) 5 80-90 110-130
5 60 5 90-100 150-175
10 70 5 110-120 180-200
5 50 (cool down) 5 80 (cool down) 90 (cool down)
Step 4: Assume the pitchers stance. Lift and stride with Step 8: Repeat step 7. Use a fungo bat to hit to the
your lead leg. Follow through with your back leg. infielders and outfielders while in their normal playing
positions.
5 60 (warm-up)
5 70
10 80
5 60 (cool down)
BOX 4-5 Rehabilitation Program for Tennis Players

The following tennis protocol is designed to be performed Week 1
every other day. Each session should begin with the Day 1:
warm-up exercises below. Continue with your strengthen- 25 forehand strokes
ing, flexibility, and conditioning exercises on the days you 25 backhand strokes
are not following the tennis protocol.
Day 2:
Warm-Up If no problems occur after the first-day workout,
Lower extremity: increase the number of forehand and backhand
Jog four laps around the tennis court. strokes.
Stretches: 50 forehand strokes
Gastrocnemius 50 backhand strokes
Achilles tendon Day 3:
Hamstring
50 forehand strokes (waist level)
Quadriceps
50 backhand strokes (waist level)
Upper extremity:
25 high forehand strokes
Shoulder stretches:
25 high backhand strokes
Posterior cuff
Inferior capsule Week 2
Rhomboid Progress to having the ball tossed to you in a timely manner,
Forearm/wrist stretches giving you enough time to recover from your deliberate
Wrist flexors follow-through (i.e., wait until the ball bounces on the other
Wrist extensors side of the court before tossing another ball). Always aim
Trunk: the ball at a target or at a spot on the court.
Side bends If you are working on basic ground strokes, have
Extension someone bounce the ball to you consistently at waist
Rotation height.
Forehand ground strokes: If you are working on high forehands, have the ball
Hit toward the fence on the opposite side of the court. bounced to you at shoulder height or higher.
Do not worry about getting the ball in the court. Day 1:
During all of the strokes listed previously, remember
these key steps:
50 waist-height forehand strokes
Bend your knees.
50 waist-height backhand strokes
Turn your body.
Step toward the ball.
Hit the ball when it is out in front of you. Day 2:
Avoid hitting with an open stance because this places 25 high forehand strokes
undue stress on your shoulder. This is especially more 50 waist-height forehand strokes
stressful during the forehand stroke if you have had ante- 50 waist-height backhand strokes
rior instability or impingement problems. This is also true 25 high backhand strokes
during the backhand if you have had problems of posterior Day 3:
instability.
Alternate hitting the ball crosscourt and down the line,
On the very first day of these sport-specific drills, start
using waist-high and high forehand and backhand
with bouncing the ball and hitting it. Try to bounce the ball
strokes.
yourself and hit it at waist level. This will allow for consis-
tency in the following:
50 waist-height forehand strokes
How the ball comes to you
50 waist-height backhand strokes
Approximating your timing between hits
Hitting toward a target to ensure follow-through and
full extension Week 3
Using the proper mechanics, thereby placing less Continue the three-times-per-week schedule. Add regular
stress on the anterior shoulder and high forehand and backhand volleys. At this point you
BOX 4-5 Rehabilitation Program for Tennis Playerscontd

may begin having someone hit tennis balls to you from a Week 5
basket of balls. This will allow you to get the feel of the ball Day 1:
as it comes off another tennis racket. Your partner should Find a partner able to hit consistent ground strokes (able
wait until the ball that you hit has bounced on the other side to hit the ball to the same area consistently [e.g., to your
of the court before hitting another ball to you. This will give forehand with the ball bouncing about waist height]).
you time to emphasize your follow-through and not hurry Begin hitting ground strokes with this partner alternat-
to return for the next shot. As always, emphasis is placed ing hitting the ball to your backhand and to your forehand.
on proper body mechanics. Rally for about 15 minutes, then add volleys with your
Day 1: partner hitting to you from the baseline. Alternate between
25 high forehand strokes backhand and forehand volleys and high and low volleys.
50 waist-height forehand strokes Continue volleying another 15 minutes. You will have rallied
50 waist-height backhand strokes for a total of 30 to 40 minutes.
25 high backhand strokes At the end of the session, practice a few serves while
25 low backhand and forehand volleys standing along the baseline. First, warm up by shadowing
25 high backhand and forehand volleys for 1 to 3 minutes. Hold the tennis racquet loosely and
swing across your body in a figure eight. Do not swing the
Day 2:
racquet hard. When you are ready to practice your serves
Same as day 1, week 3 using a ball, be sure to keep your toss out in front of you,
Day 3: get your racquet up and behind you, bend your knees, and
Same as day 2, week 3, with emphasis on direction (i.e., hit up on the ball. Forget about how much power you are
down the line and crosscourt). Remember, good body generating, and forget about hitting the ball between the
mechanics is still a must: service lines. Try hitting the ball as if you are hitting it
Keep knees bent. toward the back fence.
Hit the ball on the rise. Hit approximately 10 serves from each side of the court.
Hit the ball in front of you. Remember, this is the first time you are serving, so do not
Turn your body. try to hit at 100% of your effort.
Do not hit the ball with an open stance. Day 2:
Stay on the balls of your feet. Same as day 1, week 5, but now increase the number of
Week 4 times you practice your serve. After working on your
Day 1: ground strokes and volleys, return to the baseline and work
on your second serve hit up on the ball, bend your knees,
Continue having your partner hit tennis balls to you from
follow through, and keep the toss in front of you. This time
out of a basket. Alternate hitting forehand and backhand
hit 20 balls from each side of the court (i.e., 20 into the
strokes with lateral movement along the baseline. Again,
deuce court and 20 into the ad court).
emphasis is on good mechanics as described previously.
Alternate hitting the ball down the line and crosscourt. Day 3:
This drill should be done with a full basket of tennis balls Same as day 2, week 5, with ground strokes, volleys, and
(100 to 150 tennis balls). serves. Do not add to the serves. Concentrate on the
Follow this drill with high and low volleys using half a following:
basket of tennis balls (50 to 75 balls). This drill also is per- Bending your knees
formed with lateral movement and returning to the middle Preparing the racket
of the court after the ball is hit. Using footwork
Your partner should continue allowing enough time for Hitting the ball out in front of you
you to return to the middle of the court before hitting the Keeping your eyes on the ball
next ball. This is to avoid your rushing the stroke and using Following through
faulty mechanics. Getting in position for the next shot
Day 2: Keeping the toss in front of you during the serve
The workout should be the same as day 2, but if you
Same drill as day 1, week 4
emphasize the proper mechanics listed previously, then
Day 3: you should feel as though you had a harder workout than
Same drills as day 2, week 4 in day 2.
Continued
BOX 4-5 Rehabilitation Program for Tennis Playerscontd

Week 6 Day 2:
Day 1: Same as day 1, week 7, except double the number of over-
After the usual warm-up program, start with specific head shots (25 to 30 overheads).
ground stroke drills, with you hitting the ball down the line Day 3:
and your partner on the other side hitting the ball cross- Perform warm-up exercises and crosscourt drills. Add the
court. This will force you to move quickly on the court. overhead shot to the backhand, forehand, and volley drill,
Emphasize good mechanics as mentioned previously. making it the backhand, forehand, volley, and overhead
Perform this drill for 10 to 15 minutes before reversing drill.
the direction of your strokes. Now have your partner hit If you are a serious tennis player, you will want to work
down the line while you hit crosscourt. on other strokes or other parts of your game. Feel free to
Proceed to the next drill with your partner hitting the ball gradually add them to your practice and workout sessions.
to you. Return balls using a forehand, then a backhand, Just as in other strokes, the proper mechanics should be
then a put-away volley. Repeat this sequence for 10 to 15 applied to drop volley, slice, heavy topspin, drop shots, and
minutes. End this session by serving 50 balls to the ad court lobs (offensive and defensive).
and 50 balls to the deuce court.
Week 8
Day 2:
Day 1:
Day 2 should be the same as day 1, week 6, plus returning
Warm up and play a simulated one-set match. Be sure to
serves from each side of the court (deuce and ad court).
take rest periods after every third game. Remember, you
End with practicing serves, 50 to each court.
will have to concentrate harder on using good
Day 3: mechanics.
Perform the following sequence: warm-up; crosscourt and Day 2:
down-the-line drills; backhand, forehand, and volley drills;
Perform another simulated game but with a two-set match.
return of serves; and practice serves.
Day 3:
Week 7
Perform another simulated game, this time a best-of-three
Day 1:
match.
Perform the warm-up program. Perform drills as before and If all goes well, you may make plans to return to your
practice return of serves. Before practicing serving, work regular workout and game schedule. You also may practice
on hitting 10 to 15 overhead shots. Continue emphasizing or play if your condition allows it.
good mechanics. Add the approach shot to your drills.
the physical therapist determines the glenohumeral and or sport. Such substitutions and alterations are often the
scapular mobility are normal, the problem may be in the forerunners of tissue breakdown. The therapist should pre-
spine. Assess the lower cervical and upper thoracic spine for scribe focused strengthening exercises for specific muscle
hypomobility.36,37 The cervicothoracic junction is required to groups based on their functional use for shoulder motion.
move into extension during end range shoulder flexion. At The scapular upward rotators and the rotator cuff require
times, this region of the spine can become restricted and more endurance training, while the larger prime mover
actually limits functional end range shoulder flexion. Mobi- muscles of the shoulder, such as the shoulder flexors, exten-
lizing the spine into extension restores normal scapulotho- sors, and abductors, tend to require more power training.
racic and cervicothoracic motion and allows terminal One specific and often overlooked area of concern is
functional flexion to be achieved. scapular anterior tipping and winging with active motion.
Often this is a result of weakness or poor endurance in the
Strength and Endurance serratus anterior. It is easily observed during the eccentric
Often rehabilitation programs concentrate on increasing phase in open kinetic chain arm motions or in dynamic
strength. However, for most patients, including overhead closed kinetic chain activities such as stability ball walk-outs.
throwers, endurance is probably much more important to This lack of dynamic scapular control leads to excessive
overall function than gross strength. Endurance training is stresses throughout the shoulder and may contribute to a
equally important for patients who are hurt on the job. With recurrence of the original presurgery symptoms. If adequate
inadequate endurance, the patient will develop muscle sub- strength and endurance are present, the patient should be
stitution patterns to enable them to continue to perform an able to raise and lower the arm through a full range of motion
activity, which will lead to altered mechanics for a given task while maintaining the scapula flat against the thoracic wall.
For closed chain assessment, demonstrating dynamic control

BOX 4-6 Rehabilitation Program for Golfers under load, the athletic patient should be able to perform 10
This sport-specific protocol is designed to be performed walk-outs on a stability ball while maintaining the scapula
every other day. Each session should begin with the flush with the thoracic wall in a protracted position. Lastly,
warm-up exercises outlined here. Continue the strength- functional strength and endurance of the serratus must be
ening, flexibility, and conditioning exercises on the days observed during the actual motion pattern the patient
you are not playing or practicing golf. Advance one stage requires. For example, the physical therapist must observe a
every 2 to 4 weeks, depending on the severity of the pitcher mimicking the pitching motion repeatedly, at normal
shoulder problem, as each stage becomes pain-free in speeds, to ensure the scapular control is adequate to allow a
execution. safe return to pitching. The physical therapist must ensure
there is adequate dynamic control of the serratus anterior
Warm-Up
before allowing high-level functional activities.
Lower extremities: jog or walk briskly around the practice
green area three or four times; stretch the hamstrings, Stretching Considerations
quadriceps, and Achilles tendon. Patients with anterior instability may have a tight posterior
Upper extremities: stretch the shoulder (i.e., posterior capsule. Despite surgical correction, the posterior tightness
cuff, inferior cuff, rhomboid) and wrist flexors and may remain and, if left untreated, lead to a recurrence of the
extensors. original complaint. Two excellent self-stretching techniques
Trunk: do side bends, extension, and rotation stretch- for the posterior capsule are the cross body stretch with
ing exercises. scapular stabilization (see Fig. 4-5) and the sleeper stretch
(see Fig. 4-9).
Stage 1 Periscapular muscles that tend to be restricted include the
Putt 50 3 times/week pectoralis minor and levator scapula. Both of these muscles
Medium long 0 0 times/week will contribute to an anteriorly tipped and downwardly
Long 0 0 times/week rotated scapula, thus preventing normal rotation of the
Stage 2 scapula and therefore contributing to shoulder impinge-
Putt 50 3 times/week ment. The therapist should be suspicious if the patient has
Medium long 20 2 times/week rounded shoulders and a protracted scapula. Stretching of
Long 0 0 times/week both muscles can be performed manually or independently.
Soft tissue mobilization can be very effective in treating these
Stage 3 restrictions as well. Remember to protect the anterior capsule
Putt 50 3 times/week
from being overstretched when addressing these issues.
Medium long 40 3 times/week
The therapist must not stretch the anterior shoulder
Long 0 0 times/week
structures of any throwing athlete unless he or she is
Not more than one third best distance
certain that tightness exists. By and large, all these patients
Stage 4 can demonstrate anterior laxity in the dominant shoulder.
Putt 50 3 times/week Assess ROM carefully and consider all factors of the patient
Medium long 50 3 times/week and physical demands before proceeding with any stretching
Long 10 2 times/week of the anterior shoulder.
Up to one half best distance
Mechanics
Stage 5
Putt 50 3 times/week Even though the patient may have good ROM, strength, and
Medium long 50 3 times/week endurance in the shoulder itself, important work remains to
Long 10 3 times/week be done. Poor body mechanics may be one of the reasons the
patient was injured in the first place. Understanding the
Stage 6 mechanics of the sport the patient is resuming is essential.
Putt 50 3 times/week For example, in the throwing athlete, the physical therapist
Medium long 50 3 times/week must ensure the full kinetic chain is functioning properly,
Long 20 3 times/week including the front foot pointing toward the plate, appropri-
Play a round of golf in lieu of one practice session ate stride length, adequate balance, and that the front
per week. foot does not hit the ground before the arm is in the fully
cocked position. An awareness of the mechanics of tennis,
From Jobe FW: Operative techniques in upper extremity sports
volleyball, swimming, and golf is critically important when
injuries, St Louis, 1996, Mosby. working with these athletes. Without incorporating a review
of proper mechanics and a tune up when necessary, it is
likely that the player will return to old habits formed before
the shoulder surgery, possibly leading to reaggravation and
injury.
1 John is a 35-year-old surfer. He had several episodes of

shoulder dislocation while paddling his surfboard. He
also complained of anterior shoulder pain. Conservative
Recheck her shoulder internal rotation at 90 and above.
Despite her internal rotation being normal for the average
population, she is still lacking 30 compared with her
treatment failed, so he underwent an anterior capsular uninvolved side. By aggressively mobilizing the soft
reconstruction 11 weeks ago. Passive range of motion tissue in the posterior cuff, she is able to regain what is
(PROM) and AROM are good. Johns main complaint is normal mobility for her and the pain and clicking has
continuing anterior shoulder pain. The pain can be elic- resolved.
ited by palpation over the biceps tendon and transverse
humeral ligament. This symptom has delayed progress
with strengthening. How was the patient treated? 4 Lucy is a 13-year-old middle school competitive
swimmer who experienced anterior shoulder pain and
impingement signs primarily with backstroke. She is 3
John was treated for biceps tendonitis, or inflammatory weeks since the operation and has full PROM in exter-
symptoms occurring in the area of the proximal biceps nal rotation without resistance or pain. How do you
tendon and transverse humeral ligament. Despite proceed?
the structural corrections, these tissues may remain irri-
table. Because the posterior capsule also was slightly Educate Lucy and her parents regarding the physiology
restricted, posterior capsular mobilizations were per- and goal of the surgery and the concern you have about
formed to allow the humeral head to articulate with the her arm moving too far into external rotation. Explain
glenoid at its normal contact point, eliminating this as a that you would like her to limit this motion as much as
source of continuing aggravation for these anterior possible to allow physiologic healing to occur. Do not
structures. give her any stretching exercises involving external rota-
tion at this time.
2 Peter is a 20-year-old pitcher for a baseball team. He had

right-shoulder laxity and a painful shoulder secondary
to impingement problems. He underwent capsular 5 Steve is a 29-year-old computer programmer who is 4
weeks postoperation. His anterior shoulder pain is not
reconstruction on his right shoulder 10 weeks ago. His resolving as expected. Progress with ROM is hampered
shoulder flexion and abduction with PROM is still by pain more than stiffness and the end feel is empty in
limited by 15 for flexion and 20 for abduction. PROM all directions. He is also having difficulty sleeping at
for internal rotation also is limited by 20. At this time, night because of pain. What steps should you take?
should decreased ROM be a concern? If yes, what tech-
niques were used to improve ROM? Assess the cervical spine. Include ROM, palpation, and
cervical strength testing. Often times there is segmental
On further investigation a tight posterior capsule was cervical dysfunction, which can contribute to referred
noted. The therapist used posterior capsular mobiliza- shoulder pain and restriction. This is different than a
tions in the next treatment to increase shoulder flexion cervical radiculopathy because there are no hard neuro-
and internal rotation. The patient gained 10 to 15 more logic findings such as myotomal weakness, altered
for flexion and internal rotation and 5 to 10 more for reflexes, or sensation.
abduction. After mobilization and PROM were performed,
the patient executed AROM exercises for shoulder
flexion, abduction, and internal rotation. 6 Kari is a 40-year-old mother who plays recreational vol-
leyball and runs. She noted nondominant shoulder sub-
luxations with basic reaching activities of increasing
3 Caroline is an 18-year-old high school volleyball player

who experienced recurrent anterior subluxations during
play. At 16 weeks postoperation, she notes a clicking
frequency over the past 2 years. She had to stop playing
volleyball because of the shoulder instability. Kari is 6
weeks postoperation and notes minimal pain. She is able
with mild pain in the anterior shoulder while perform- to gain ROM during therapy sessions but is unable to
ing overhead motions mimicking a volleyball serve. Her maintain the range between sessions. What can be
involved shoulder motion and strength are considered addressed to help her maintain her range?
normal. However the uninvolved side had 30 more
internal rotation than the involved shoulder. What After the patient/therapist is done stretching the shoul-
structures are possibly at fault? der, PNF patterns can be useful to initiate muscle
contraction into the newly gained ROM. PNF D1 and D2 at this time and is wearing the sling only because my
patterns with minimal resistance performed in a pain- doctor told me to. What is your treatment on day one?
free range can facilitate the rotator cuff and scapular
muscles to help Kari maintain these gains. At home, the At a physiologic level, collagen fibers must be deposited
exercises can be performed with no resistance or light and bond together to limit the extensibility of the capsular
band resistance to reinforce the active end range control. tissue. If you work to increase ROM at this time, you may
be hampering the healing of the newly restricted capsule
7 Marc is a 42-year-old recreational basketball player who

is 5 months postoperation. He has full ROM in all direc-
tions but continues to have anterior shoulder pain at end
by excessively elongating the new fibers. Focus on
AAROM exercises within the guidelines of restricted ROM
despite her ability to move beyond the suggested precau-
range flexion in his initial attempts to return to play. tions. When more time has elapsed, progress ROM
Every time he reaches for a lay up, the shoulder pain is according to the doctors recommended limitations.
sharp but settles quickly. What would you expect to find
with your palpation examination?
Likely Marc has tightness in muscles of the posterior

9 Two muscles are particularly critical to create proper
scapulohumeral rhythm. What are they?
rotator cuff and tenderness over the proximal bicep Levator scapula and serratus anterior. If the levator
tendon. When he reaches with speed and force into full scapula is restricted and lacks the normal extensibility, it
flexion, impingement of the bicep tendon under the acro- will prevent the scapula from moving into upward rota-
mion may occur if the force couple of the rotator cuff tion as the arm moves into elevation. If the serratus
musculature is not functioning properly. anterior is weak, it will not properly guide the scapula
into upward rotation as the arm moves into elevation. If
8 Angela is a competitive gymnast who underwent ACR

surgery 2 weeks ago. She presents to you at her physical
therapy evaluation with empty end feels for external
either of these muscles is not performing properly, the
scapula becomes dysfunctional and will lead to second-
ary impingement. Be certain to assess and reassess the
rotation at 30, flexion at 150 with minimal pain, and function of these two muscles throughout the course of
abduction at 90. She notes minimal postoperative pain rehabilitation.
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7. Saliba V, Johnson GS, Wardlaw C: Proprioceptive neuromuscular facili- of comprehensive treatment for primary shoulder impingement syn-
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Baltimore, 1992, Williams & Wilkins. 19. Reference 19 deleted in proof.
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bilitation exercises. Am J Sports Med 27(6):784-791, 1999. 22. Ekstrom RA, Donatelli RA, Soderberg GL: Surface electromyography
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12. Tyler TF, et al: Reliability and validity of a new method of measuring 23. Reinold MM, et al: Electromyographic analysis of the rotator cuff and
posterior shoulder tightness. J Orthop Sports Phys Ther 29(5):262-269, deltoid musculature during common shoulder external rotation exer-
1999. cises. J Orthop Sports Phys Ther 34:385-394, 2004.
24. Cools AM, et al: Rehabilitation of scapular muscle balance: Which exer- 31. Escamilla RF, et al: Shoulder muscle activity and function in common
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25. Myers JB, et al: On-the-field resistance-tubing exercises for throwers: an 32. Lee SB, et al: Dynamic glenohumeral stability provided by the rotator
electromyographic analysis. J Athl Train 40:15-22, 2005. cuff muscles in the mid-range and end-range of motion: A study in
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27. Laudner KG, Moline MT, Meister K: The relationship between forward 34. Jobe FW, et al: An EMG analysis of the shoulder in pitching: A second
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29. Ludewig PM, Cook TM, Nawoczenski DA: Three-dimensional scapular 37. Boyles RE, et al: The short-term effects of thoracic spine thrust manipu-
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30. Hardwick DH, et al: A comparison of serratus anterior muscle activation
during a wall slide exercise and other traditional exercises. J Orthop
Sports Phys Ther 36(12):903-910, 2006.
CHAPTER 5
Rotator Cuff Repair and Rehabilitation
A rotator cuff tear may occur spontaneously after a

ETIOLOGY sudden movement or a traumatic event.9 Ruptures of the
rotator cuff have been estimated to occur in up to 80% of
Rotator cuff disorders are generally thought to have a mul- persons older than 60 years of age with GH dislocations.10
tifactorial cause, including trauma, glenohumeral (GH) Cuff tears usually occur late in the shoulder deterioration
instability, scapulothoracic dysfunction, congenital abnor- process (after secondary impingement) and in older adults.
malities, and degenerative changes of the rotator cuff. Intrin- In athletes who participate in repetitive overhead activi-
sic factors of primary tendon degeneration and extrinsic ties (e.g., throwers, swimmers, tennis players), small rotator
mechanical factors have been described extensively and are cuff tears may appear late in the deterioration process from
felt to be the primary contributors of rotator cuff pathology. secondary impingement. Secondary impingement is caused
Intrinsic tendon degeneration has been described. In 1931, by instability of the GH joint or by functional scapulotho-
Codman and Akerson1 suggested that degenerative changes racic instability.11 The primary underlying GH instability
in the rotator cuff lead to tears. Microvascular studies of may progress along a continuum from anterior subluxation
the vascular pattern of the rotator cuff have demonstrated to impingement to rotator cuff tearing. Treatment must be
a hypovascular zone in the supraspinatus adjacent to directed to the primary instability problem.12
the supraspinatus insertion into the humerus.2-4 Relative The throwing athlete also may have secondary impinge-
ischemia in this hypovascular zone is believed to lead with ment caused by functional scapular instability. Fatigue of the
aging to decreased tendon cellularity and the eventual dis- scapular stabilizers from repetitive throwing leads to abnor-
ruption of the rotator cuff attachment to bone. mal positioning of the scapula. As a result, humeral and
Compression of the rotator cuff between the acromion scapular elevation lose synchronization and the acromion is
and the humeral head may subject the cuff to wear as the not elevated enough to allow free rotator cuff movement.11
supraspinatus passes under the coracoacromial arch. Neer5,6 The rotator cuff abuts the acromion, causing microtrauma
postulated that 95% of rotator cuff tears are caused by and impingement. A tear may gradually or spontaneously
impingement of the rotator cuff under the acromion. Neer5 occur.
classified three stages of impingement as a continuum that In summary, rotator cuff disease has a multifactorial
eventually led to cuff tears. Stage I is characterized by sub- cause. Vascular factors, impingement, degenerative pro-
acromial edema and hemorrhage of the rotator cuff and cesses, and developmental factors all contribute to the overall
usually occurs in patients younger than 25 years old. Stage evolution and progression of rotator cuff disorders (Box 5-1).
II includes fibrosis and tendinosis of the rotator cuff and
occurs more commonly in patients 25 to 40 years old. Stage Clinical Evaluation
III is a continued progression characterized by partial or History
complete tendon tears and bone changes. Typically, this The majority of patients with rotator cuff dysfunction have
involves patients older than 40 years old.5 Bigliani, Morrison, pain. They may complain of fatigue, functional catching,
and April7 described three types of acromion shapes: (1) type stiffness, weakness, and symptoms of instability. An acute or
I is flat, (2) type II is curved, and (3) type III is hooked. An macrotraumatic presentation is important to distinguish
increased incidence of rotator cuff tears is associated with a from an overuse or microtrauma presentation. Most patients
curved (type II) or a hooked (type III) acromion. Other report a gradual onset of pain with no history of trauma. A
sources of extrinsic impingement postulated include acro- gradual onset of weakness is usually associated with a chronic
mioclavicular (AC) osteophytes, the coracoid process, and tear and an acute onset of weakness after years of shoulder
the posterosuperior aspect of the glenoid.8 pain is suggestive of an acute on chronic tear.
73
elevation and internal rotation) are performed to elicit pain.

BOX 5-1 Rotator Cuff Deterioration Process If these tests produce pain, then they are considered positive
In Older Persons or Laborers signs of impingement and suggest rotator cuff dysfunction.
Osteophyte develops The rotator cuff muscles are tested for strength. Subscapu-
Decreased subacromial space (more accentuated with laris muscle strength tests include the lift-off test and the
a slouched posture) belly-press test. The lift-off test places the arm behind
Continuous microtrauma from impingement leads to the back and up the spine. The patient is then asked to lift
degenerative cuff changes the hand off the back against restriction. The belly-press test
Gradual partial tear or complete tear develops places the arms onto the elbows bent to 90, and the elbows
are then lifted anteriorly against resistance. Examination for
In Athletes Secondary to Glenohumeral instability is performed. Apprehension sign, a positive-
(GH) Instability relocation test, or inferior sulcus sign are all indicative of
Overused biceps tendon and rotator cuff become weak instability. Stability testing should be performed in different
and fatigued positions (i.e., seated, supine) to eliminate instability as the
Passive restraints are overloaded cause of secondary impingement. Evidence of rotator cuff
Cuff laxity pathology includes painful impingement signs or weakness
Anterosuperior GH instability and a painful arc of motion.5
Humeral head migrates superiorly and impinges the
rotator cuff
Continuous microtrauma from recurrent impingement Diagnostic Testing
leads to degenerative cuff changes Diagnostic testing includes injections, radiographs, arthro-
Gradual or sudden rotator cuff tear occurs gram, or magnetic resonance imaging (MRI) or ultrasonog-
Secondary to Functional Scapular Instability raphy. An impingement test (subacromial space injection
Weak scapulothoracic muscles with at least 10mL of 1% lidocaine) is invaluable in evaluat-
Abnormal scapular positioning ing the origin of shoulder pain. Physical examination several
Humeral head elevation is not synchronized with minutes after the injection, including for ROM, impinge-
scapular elevation and upward rotation (disrupted ment signs, strength, and instability should be completed.
scapulohumeral rhythm) Resolution of the shoulder symptoms without instability
Acromion requires more elevation to allow unrestricted indicates primary rotator cuff pathology or impingement.
movement of the rotator cuff Relief of pain with evidence of instability indicates possible
Rotator cuff impinged under the coracoacromial primary instability with secondary rotator cuff changes
arch because of altered shoulder mechanics.
Continuous microtrauma from a recurrent impingement Convention radiography is an important tool in the eval-
leads to degenerative cuff changes uation of rotator cuff tear pathology and is used to rule out
Gradual partial tear or a complete tear develops arthritis and fractures, assess the morphology of the acro-
mion, and look for calcifications about the shoulder. Arthrog-
raphy is no longer the gold standard for identification of
rotator cuff tears. Although reliable for the diagnosis of com-
plete rotator cuff tears, it is less reliable for the evaluation of
Pain is typically localized in the upper arm in the region partial-thickness rotator cuff tears. MRI has evolved to
of the deltoid tuberosity and anterior lateral acromion. Pain provide an excellent noninvasive tool in the diagnosis of
is usually worse at night. Overhead activities often induce rotator cuff pathology and the shoulder labrum and is the
the patients symptoms. Typical findings are a loss of endur- modality of choice for the evaluation of cuff tear pathology,
ance during activities, catching, crepitus, weakness, and followed by ultrasonography. MRI provides information not
stiffness. available by other diagnostic testing, including muscle
atrophy, amount of rotator cuff retraction in full-thickness
Physical Examination tears, bursal swelling, the status of the AC joint, and the
A thorough examination of the shoulder should include shoulder articular cartilage. The combination of intraarticu-
evaluation of the cervical spine and an upper extremity neu- lar contrast (gadolinium) and MRI (magnetic resonance
rologic examination. The opposite shoulder must also be arthrography) has been developed to better delineate abnor-
examined for comparison. Inspection, palpation for tender- malities of the rotator cuff and labrum including partial
ness, and range of motion (ROM) tests should be completed. surface rotator cuff tears.15,16 Ultrasonography of the shoul-
Palpation should include the AC joint, sternoclavicular (SC) der has increased in popularity, and as technical advances
joint, subacromial space, biceps tendon, trapezius muscle, continue to improve, it has become an increasingly useful
and cervical spine. Impingement sign tests as described by tool in the diagnosis of cuff pathology. Ultrasonography has
Hawkins, Misamore, and Hobeika13 (i.e., forward flexion to several advantages. These include a relatively low cost, the
90 and internal rotation) and by Neer and Welch14 (forward lack of the contraindications as with MRI, and its use in the
Chapter 5 Rotator Cuff Repair and Rehabilitation 75
examination of the patient both statically and dynamically.

Unfortunately, the accuracy of ultrasonography is operator SURGICAL PROCEDURES
dependent and typically requires a long learning curve.
Tendonitis and Partial Rotator Cuff Tear
Treatment Surgical management for impingement syndrome generally
Symptoms of rotator cuff dysfunction are usually treated involves open anterior acromioplasty as described by Neer63
initially in a nonoperative fashion (tendonitis, partial- or or arthroscopic subacromial decompression (SAD) with
full-thickness rotator cuff tears). Nonsteroidal antiinflam- release or partial release of the coracoacromial ligament. The
matory drugs (NSAIDs), heat, ice, relative rest, cortisone coracoacromial ligament is released from the undersurface
injection, and rehabilitation programs are used in the treat- of the anterior and lateral acromion. An acromioplasty is
ment. The initial goal of treatment is restoration of normal performed using a burr to achieve a flat acromion. If osteo-
ROM. This is followed by a rotator cuff strengthening phytes are present on the inferior surface of the AC joint,
program. Stretch cords for resistance are initiated and are they are removed from the distal clavicle. Partial thickness
followed by free weights as tolerated. To avoid aggravation cuff tears may be bursal or articular sided. Partial thickness
of the rotator cuff, all strength training initially should be cuff tears may be treated with dbridement alone, dbride-
below shoulder level. External rotation strengthening with ment and acromioplasty, or rotator cuff repair. A subacro-
the arm at the side may minimize subacromial pressure and mial decompression/acromioplasty is generally indicated if
pain while increasing the cuff s ability to act as a humeral the partial tear is bursal sided or there are signs of mechani-
head depressor. cal impingement. Partial rotator cuff tears greater than 50%
Nonoperative treatment programs usually continue for 3 of the width of the tendon generally are treated with
to 6 months. Success varies from 50% to 90%.17-21 Approxi- arthroscopic repair insitu or transtendineus repair, or may
mately 50% of patients with complete symptomatic rotator be treated with takedown and repair of the rotator cuff either
cuff tears have satisfactory results with nonoperative mea- miniopen or arthroscopic.24 Repair of partial-thickness tears
sures, but these results may deteriorate with time.22 This wide improves results compared with dbridement alone in this
range of outcomes is likely the result of lack of uniformity in patient group. The overhead throwing athletes with rotator
classification, indications, and treatment. Some individuals cuff disease have different requirements. Acromioplasty is
have rotator cuff tears with no pain and normal function, rarely necessary in the throwing athlete.
whereas others may have debilitating pain. This demon- Results of surgical treatment of low-grade (<50%) partial-
strates a need for better understanding of the factors that thickness rotator cuff tears after dbridement with and
lead to symptoms. without acromioplasty have reported 75% to 88% satisfac-
tory outcome on short-term follow-up.18,25-27 Repair of a
Indications for Surgery high-grade (>50%) partial-thickness tear has had similar
Indications for rotator cuff surgery include failure of 3 to 6 outcome to dbridement of a low-grade partial-thickness
months of conservative care or an acute full-thickness tear in tear or repair of a small full-thickness cuff tear.28
an active patient younger than 50 years. Failure of treatment
can be determined before an entire rehabilitation course is Full-Thickness Tears
completed. Indications for earlier surgical treatment can The mainstay of treatment for full-thickness tears is surgical
include return to full strength with persistent symptoms, repair. The type, pattern, and size of the tear, as well as the
failure to tolerate therapy because of pain, or plateau of initial surgeons preference, dictate whether the repair is a full-
improvement with persistent symptoms. Early surgical inter- arthroscopic, miniopen, or a completely open procedure.
vention is also indicated for patients sustaining acute trauma Small- or moderate-sized (3cm or less) partial- or full-
with full-thickness tears associated with significant rotator thickness supraspinatus or infraspinatus tears may be
cuff weakness and posterior cuff involvement, particularly in repaired fully with an arthroscopic or miniopen technique.
young patients with higher functional demands. In addition, Large width (3 to 5cm) tears may also be repaired miniopen
patients with acute tears or extension of chronic cuff tears or arthroscopic if the cuff is mobile enough to allow ana-
may benefit from early surgery.23 tomic repair.
In general, the duration of nonoperative treatment must Large, immobile cuff tears involving the subscapularis or
be individualized based on pathology involved, the patients teres minor, as well as tears of the musculotendinosis junc-
response to treatment, and individual functional demands tion, may require an open approach. Massive chronic atro-
and expectations. phic cuff tears should be considered for arthroscopic
dbridement for pain control.
Surgical Goals
The primary goal of rotator cuff surgery is decreased pain, SURGICAL TECHNIQUE
including rest pain, night pain, and pain with activities of
daily living (ADLs). Arrest of the progression of rotator cuff All operative procedures discussed in recent literature for
pathology and improved shoulder function are additional primary repair of rotator cuff tears include use of an anterio-
surgical goals. inferior acromioplasty to decompress the subacromial space.
The author presently performs GH arthroscopy and subacro-

mial bursoscopy on all patients undergoing surgery for cuff
pathology.
Shoulder arthroscopy and decompression is performed as
previously described. After acromioplasty, the bursal surface
of the rotator cuff is evaluated. With shoulder rotation, the A
cuff can be completely visualized. Mobile tears may be treated
with a miniopen technique or with arthroscopic repair.
Arthroscopic Rotator Cuff Repair

In the past decade as arthroscopic repair of rotator cuff tears
has become more widespread, there have been significant Fig. 5-1 Line of incision for partially open repair. The deltoid split begins
at the lateral edge of the acromion (A) and should not extend more than
advances in arthroscopic surgical techniques and instrumen- 4cm lateral to the acromion to avoid injury to the axillary nerve.
tation. Arthroscopic repair involves the same general steps
as miniopen or open rotator cuff repair. Bony landmarks are
outlined and marked with a sterile pen. Multiple arthroscopic
portals are made. Posterior, anterior, and lateral portals are
made for all arthroscopic repairs. Additional portals are
made depending on the rotator cuff tear configuration and
include posterior lateral, anterior lateral, and lateral acromial
portals. These allow access to various rotator cuff configura-
tions and for suture anchor placement. The GH joint is com-
pletely and systematically evaluated followed by subacromial
bursoscopy. The subacromial bursa is excised, and the ante-
rior acromion is flattened with a burr. If symptomatic, then
the AC joint is excised arthroscopically. The rotator cuff is
visualized. The quality and the integrity of the rotator cuff
are evaluated. The mobility of the cuff is evaluated. Adhe-
sions on the bursal and articular sides of the tear are released.
The goal is a mobile cuff which can be repaired to the normal
footprint on the greater tuberosity with minimal tension. A
three dimensional understanding of the cuff tear configura-
tion is developed. Margin convergence repair principles are
used for U-shaped tears or L- or reverse L-shaped tears.
Sutures are placed in a side-to-side fashion through the ante-
rior and posterior leafs of the tear. This convergences the Fig. 5-2 Incision placed in Langer lines produces the best cosmesis.
edges of the tear and minimizes the tension on the tendon
to bone repair. The result may be an arthroscopic repair of
an otherwise irreparable tear. The greater tuberosity of the or with suture anchors. The permanent sutures are tied,
humerus is lightly decorticated with a burr. The tendon is pulling the rotator cuff down into its trough on the humerus.
then repaired to bone with suture anchors. The number of
suture anchors used is predicated on the size of the tear and Open Rotator Cuff Repair
its configuration. In general, one suture anchor is used for Tears that are fixed, retracted, but reparable, may be repaired
each one centimeter of cuff tear. open using principles developed by Neer.5,6 An oblique inci-
sion in Lagers line from the anterior edge of the acromion
Miniopen Rotator Cuff Repair to a point about 2cm lateral to the coracoid process is made.
In the miniopen procedure, the lateral subacromial portal The anterior deltoid is released from the anterior aspect of
incision is extended either longitudinally or transversely to the acromion and splitting the deltoid no more than 4cm
expose the deltoid fascia. The deltoid fascia is then split in lateral to the acromion (Fig. 5-2). The deltoid origin over the
line with its fibers directly over the tear. The anterior deltoid acromion is elevated subperiosteally. The coracoacromial
insertion of the anterior acromion is preserved. The deltoid ligament is released.
fibers should not be split more than 4cm lateral to the lateral The anterior acromion is osteotomized. The acromion
acromion to avoid axillary nerve injury (Fig. 5-1). Rotation anterior to the anterior aspect of the clavicle is removed, and
of the arm provides access to the tear. Digital palpation can the undersurface of the acromion is flattened from anterior
be used to assess the adequacy of the acromioplasty. A bony to posterior. The AC joint may be removed if arthritic and
trough is prepared in the greater tuberosity of the humerus. symptomatic. The distal clavicle is excised parallel to the AC
The rotator cuff may then be repaired through a bony bridge joint so that no contact occurs with adduction of the arm.
RESULTS OF TREATMENT OF FULL-

THICKNESS ROTATOR CUFF TEARS
Satisfactory results after rotator cuff repair for pain relief

occur 85% to 95% of the time5,13,32,33 and appear to correlate
with the adequacy of the acromioplasty and SAD. Functional
outcomes correlate with integrity of the cuff repair, preopera-
tive size of the cuff tear, and quality of the tendon issue. Poor
outcomes are also associated with deltoid detachment or
denervation.34
Arthroscopic-assisted miniopen rotator cuff repair pro-
vides favorable clinical results. Results comparable with open
cuff repair have been reported for small- and moderate-sized
rotator cuff repair (less than 3cm.).35-37 These studies have
shown the most important factor affecting outcome was cuff
tear size. Tears of small or moderate size had better results.
Fig. 5-3 Transosseous repair of rotator cuff tendon. A trough is created in
Blevins and associates,38 in a retrospective study, have shown
the proximal humerus just lateral to the articular surface. Sutures are tied
over the bone bridge in the greater tuberosity. 83% good or excellent results regardless of cuff size. Most
studies have shown more rapid return to full activities with
miniopen repair.
Fully arthroscopic repair studies have shown outcomes
The cuff tear is visualized and mobilized. A bony trough approaching the results of open rotator cuff repair or mini
0.5cm in width parallel to the junction of the humeral artic- open rotator cuff repair.39-47
ular cartilage and greater tuberosity of the humerus is made. A surgical technique that initially includes arthroscopy
The rotator cuff tear is repaired to bone with suture anchors has the advantage of providing identification and treatment
or through a bony bridge in the greater tuberosity using of intraarticular pathology (articular cartilage, labrum,
permanent sutures (Fig. 5-3). The goal is to repair the cuff biceps tendon). Additional advantages of arthroscopic
with minimal tension with the arm at the side. rotator cuff repair include decreased soft tissue dissection,
Watertight repairs are not necessary for good functional improved cosmesis, preservation of the deltoid attachment,
outcome. Excellent and good results have been shown in decreased postoperative pain, and earlier return of normal
patients with residual cuff holes.29,30 The anterior deltoid is ROM.
repaired back to the acromion by preserved periosteum or Unfortunately, rehabilitation cannot be accelerated for
through drill holes with permanent sutures. Routine skin arthroscopic or miniopen cuff repairs because the limiting
closure is performed. factor, tendon-to-bone healing, is not changed by the surgi-
Postoperative management of cuff repairs must be indi- cal technique.
vidualized to incorporate tear size, tissue quality, difficulty No ideal surgical technique exists. Each surgeon must
of repair, and patient goals. Passive motion is initiated imme- individualize treatment based on the type of lesion present,
diately. In general, supine active-assisted motion is started as well as the expertise of the physician. As has been noted
on the first postoperative day. Waist-level use of the hand can over the past decade with the widespread use of shoulder
usually be started after surgery. Active ROM and isotonic arthroscopy and improved surgical technique and instru-
strengthening are started 6 to 8 weeks after surgery. Progress mentation, arthroscopic rotator cuff surgery will continue to
of strengthening is individualized with full rehabilitation increase in frequency and open or miniopen cuff repairs will
taking from 6 to 12 months. Function can continue to continue to decrease in frequency. All these methods have a
improve for 1 year after surgery. role in the treatment of rotator cuff tears.
MANAGEMENT OF MASSIVE THERAPY GUIDELINES

TENDON DEFECTS FOR REHABILITATION
The management of massive irreparable tendon defects The general guidelines that follow are for the rehabilitation
remains controversial. Options include SAD and dbride- of a type 2 rotator cuff tear (a medium-to-large rotator cuff
ment of nonviable cuff tissue without attempt at repair, use tear that is larger than 1cm and smaller than 5cm). We have
of autogenous or allograft tendon grafts, and use of active also included a table of guidelines to follow for large tears.
tendon transfers. Operations that require tendon transfer to The protocol is designed for active patients (i.e., recreational
nonanatomic sites to cover rotator cuff defects are likely to athletes, laborers). Older, more sedentary individuals pro
alter mechanics of the shoulder unfavorably.31 Dbridement gress through the stages more slowly. These patients are not
may be pursued (either open or arthroscopic). appropriate candidates for the more aggressive exercises.
Recent studies suggest that longer periods of immobilization versus delayed ROM following a rotator cuff repair, we are
and a more conservative approach to restoring ROM early presenting a more conservative approach to rehabilitating
on leads to more successful outcomes in terms of fewer these patients in this third edition. Patients who have early
repeat tears following surgery or insufficient healing of the signs of stiffness should be treated with a more liberal
rotator cuff. Even if the tear is not completely healed, the approach to restoring ROM. Benefits to early ROM treat-
patient can be satisfied with the results. However, they are ments are minimal; however, the benefits to maintaining a
happier if the cuff is healed. Therefore, the goal is for a healed safe environment for optimal healing are far more beneficial.
rotator cuff repair. Too many ROM exercises or too much The goal is to avoid overstressing the healing tissues and pre-
stress on the repaired tissues early on may create an increase venting shoulder stiffness.
in scar tissue. This tissue has a poorer quality of intracellular These guidelines are designed to help guide therapists and
tissue. Studies have also shown that after 1 year there is no provide treatment ideas. The scope of this chapter does not
difference in the ROM of patients in different groups follow- include instructions on treatment methods or applications.
ing surgery.48 Groups that received early ROM treatment All modalities, mobilizations, and exercises suggested in this
versus groups that received delayed ROM treatments had the chapter are recommended only for therapists who have been
same ROM at 1 year. The group that delayed ROM treat- trained in these methods and can appropriately apply them.
ments actually had a higher rate of healing versus the group The therapist must choose the treatments that are beneficial
who received passive range of motion (PROM) early in the and safe for each patient while following the restrictions
rehabilitation process.48 outlined by the operating surgeon.
Many factors contribute to the healing rates of these
repairs: retraction of the tissue, age, early repair versus late Phase I
repair, surgical technique, patient selection, and postopera- TIME: 1 to 4 weeks after surgery
tive rehabilitation. Poorer outcomes have been noted with GOALS: Comfort, maintain integrity of repair,
patients over 65 years of age, manual laborers, those with increasing ROM as tolerated without progressing to
poor bone stock, tears greater than 5cm, workers compen- full range, decreased pain and inflammation,
sation cases, or active litigation clients. Better outcomes have minimal cervical spine stiffness, protection of the
been noted with younger patients, smaller tears, and early surgical site, maintenance of full elbow and wrist
surgical repair. In light of the recent discussion of early ROM (Table 5-1)
TABLE 5-1 Rotator Cuff Repair for Moderate-Sized Tears

Criteria to Anticipated
Rehabilitation Progress to Impairments and
Phase this Phase Functional Limitations Intervention Goal Rationale
Phase I Postoperative Limited ROM Cryotherapy Decrease pain Pain control

Postoperative Limited strength Electrical stimulation Manage edema Edema management
1-4wk Pain PROM: Pendulum exercises Improve PROM and Prevention of joint stiffness
Initial restriction to at 2-3wk; initiate PROM tolerance to Promotion of healthy articular
PROM of shoulder for shoulder flexion, ER, movement surface and collagen synthesis
Dependent upper and abduction in scapular Increase quality of and organization
extremity immobilized plane muscle recruitment Prevention of further atrophy of
in sling or airplane AROM: Elbow flexion and Maintain and upper-extremity musculature
splint extension improve ROM of Elimination of neuromuscular
PREs: Hand gripping, joints proximal and inhibition
exercises with putty distal to surgical site Prevention of associated
Joint mobilization resistance Maintain and weakness, stiffness, and
free to shoulder improve distal dysfunction of neighboring joints
Rx of C/S mobilizations as muscle strength Gaiting of pain and preparation
needed Control pain for stretches into resistance
Rx of soft tissue msg. to decreases muscle guarding,
C/S and upper back stiffness, and pain to shoulder
musculature as needed and cervical area
Instruct in AROM and allows for improved ROM at
appropriate stretches to shoulder
C/S area
AROM, active range of motion; C/S, cervical spine; ER, external rotation; PREs, progressive resistance exercises; PROM, passive range of
motion; ROM, Range of motion; Rx, treatment.
Refer to Box 5-2 for a shoulder evaluation following a rotator produce increased levels of scar tissue and tighten up quickly.
cuff repair. The therapist must maintain the protection of the For these cases, passive exercises provide nourishment to the
patient and the surgical repair while obtaining an evaluation; articular cartilage and assist in collagen tissue synthesis and
therefore, some tests will need to be deferred until later in organization.49-51 The organization of collagen may then
the treatment process. follow stress patterns, and adverse collagen tissue formation
To reduce pain and swelling, use cryotherapy. Electrical may be minimized. Limited periods of PROM and pendu-
stimulation may also be used for pain reduction. Instruct the lum exercises are initiated during this initial stage. For large
patient in posturing for comfort. Encourage the patient to to massive tears, consider withholding PROM exercises until
experiment with different positions. Usually a loose packed 4 weeks postsurgery. Recently, it has been suggested that
GH position (shoulder in some flexion, abduction, and early ROM or excessive ROM treatment of the GH joint may
internal rotation) with the arm supported by pillows while delay tissues from healing. Therefore, when conducting
supine or sitting is more comfortable. Usually patients cannot PROM treatments, be careful to protect healing tissues from
sleep much after surgery in the supine position. Therefore too much stress from ROM exercises. PROM exercises are
suggest sleeping semireclined in a recliner chair with the done in protected planes. PROM exercises for shoulder
upper extremity supported in the loose packed position. flexion are initiated in the scapular plane with the elbow
The patient may also try the supine position in bed, with the flexed 90, and external rotation is done with the palm facing
arm supported by pillows in a loose packed position. the patient and beginning at 45 of abduction.52 Performing
Gentle mobilizations using grades I and II oscillations, PROM exercises in the scapular plane is beneficial because
and distractions may help reduce pain, muscle guarding, and of decreased tension on the capsuloligament-tendon
spasms. These mobilizations also help maintain nutrient complex.52 Rotation exercises should be initiated at 45 of
exchange and therefore prevent the painful and degenerating abduction to minimize tension across the repair.52
effects that long periods of immobilization produce (i.e., a Remember to avoid horizontal adduction, extension,
swollen and painful joint).18 Occasionally, some people and internal rotation during this phase. Also advise
BOX 5-2 Components of the Physical Therapy Evaluation

Background Information Resting posture
Status of the capsule Use of sling
Status of rotator cuff Wound status
Status of articular cartilage Swelling
Previous procedures Color
Associated medical problems that can influence Passive Range of Motion (PROM) of Shoulder
rehabilitation (e.g., cardiovascular concerns, diabetes Shoulder flexion within the limits of tolerance
mellitus) Shoulder abduction within the limits of tolerance
Work-related injury Shoulder external rotation
Insurance status Scapulothoracic joint
Comprehension
Palpation
Subjective Information
Biceps tendon (when tenderness and swelling near
Previous level of function the surgical site have decreased)
Present level of function Trapezius muscle
Patients goals and expectations Cervical musculature
Intensity of pain Upper thoracic spine
Location of pain SC joint
Frequency of pain Acromioclavicular (AC) joint (2 weeks
Irritability of symptoms status after surgery)
Presence of night pain
Amount of hours able to sleep at night Modified Cervical Spine Evaluation
Assistance at home Delay active range of motion (AROM) testing of the shoul-
Access to rehabilitative facilities der until 7 to 8 weeks post surgery
Medication (i.e., dose, effect, tolerance, compliance) Delay strength testing until tissues have appropriately
healed and testing can be done without irritating the shoul-
Objective Information
der. Avoid strength testing directly on the rotator cuff until
Observations approved by surgeon.
Muscle wasting
Muscle spasms
patients to avoid leaning on the elbow, sleeping on the to resisted ROM exercises. Remember during this stage we do
affected side, sudden movements, pushing/pulling, lifting, not want full ROM. The superseding goal is to provide an
and carrying for 12 weeks.53 environment where the tissues can heal while preventing
A general guideline to use in judging the force being stiffness.
applied is slight discomfort with a slight increase in motion Patients usually exhibit protective muscle guarding from
after several repetitions. Remain sensitive and aware of the the necessary insult of the surgery and the preceding shoul-
feedback the patients body is exhibiting during ROM or der pathology. Muscle guarding is present in the cervical
mobilization techniques. The patients response will dictate region and the shoulder musculature. Therefore patients
the amount of force applied or the plane of movement perform cervical AROM exercises and stretches. Appropri-
chosen. If muscle guarding continues to increase after several ate cervical spine mobilization techniques may be valuable
repetitions, the force being applied should be reduced or the for decreasing cervical joint stiffness and muscle guarding,
plane of movement chosen needs to be slightly altered or allowing more unrestricted movement of the shoulder
decreased (or both need to be done) to avoid pinching sensa- complex.
tions or increased pain. The therapist usually can find a
groove (i.e., line of movement that can be progressed Phase II
more easily) or line of motion with less muscle guarding. TIME: 5 to 8 weeks after surgery
Therefore, constantly assess treatment application while GOALS: Protection of surgical site, improvement of
treating the patient with manual PROM. Vary the treatment ROM, increase in active strength, decrease in
application as the patients feedback dictates (i.e., exact pain and inflammation, maintenance of elbow and
plane of movement, force, and repetitions). An increase in wrist ROM, and minimizing of cervical stiffness
ROM will often accompany a decrease in pain if executed (Table 5-2)
with a sensitive hand. However, general treatment soreness During the second phase, the therapist should
may be expected. Treatment soreness is usually more pro- avoid overstretching muscles into positions that could
nounced when progressing the patient from PROM to active compromise the repaired tissues (e.g., horizontal adduc-
range of motion (AROM) and then again when progressing tion, internal rotation beyond 70, shoulder extension).

Anticipated
Rehabilitation Criteria to Progress Impairments and
Phase to this Phase Functional Limitations Intervention Goal Rationale
Phase II Incision area well Limited tolerance to Continue phase I exercises PROM shoulder Continuation of phase I
Postoperative healed ROM Initiate A/AROM (supine) flexion/abduction exercises to minimize
5-8wk Decreased pain to Limited strength at 6wk, progressing 150 to 180 ER stiffness of adjacent joints
minimum levels Relatively dependent toward AROM 70, internal Mimicking and
Improved ROM upper extremity Initiate A/AROM at 6wk rotation 55 strengthening of functional
Improved sleep for upper-extremity (PNF) A/AROM reach movements
patterns D1 and D2 patterns using above head height Improvement of ROM and
elbow and wrist Prevent increase of strength
movements in supine and pain Improvement of tolerance
progress to AROM Improve scar to movement and
A/AROM for shoulder mobility; decrease preparation for AROM
flexion, ER, abduction, and pain Performance of exercises to
scaption Improve fitness ease subacromial pressures
Soft tissue mobilization as level Normalization of skin
needed after incision has mobility and desensitization
healed of scar
Cardiovascular conditioning Provision of a good healing
(e.g., bicycling, walking environment and
program) normalization of arm swing
Initiate wand exercises for with gait
shoulder flexion, ER, and Allow for ROM exercises at
abduction home
A/AROM, Active/assisted range of motion; AROM, active range of motion; ER, external rotation; PNF, proprioceptive neuromuscular facilita-
tion; PROM, passive range of motion; ROM, Range of motion.
Strength should begin to improve, with the patient must be reported immediately, and exercises should be
progressing from PROM to active assistive range of discontinued.
motion (A/AROM) to AROM movements against gravity.
A/AROM can begin at 6 weeks, and AROM can be initi- Phase III
ated as able after 7 to 8 weeks. Submaximal isometrics can
TIME: 8 to 13 weeks after surgery
be initiated to eliminate neuromuscular inhibition, reiterate
GOALS: Expansion of ROM, avoidance of impingement
muscle firing, and retard muscle atrophy. The therapist can
problems, gaining of near full ROM, increased
incorporate active assistive proprioceptive neuromuscular
strength, alleviation of pain, increased function,
facilitation (PNF) D1 and D2 patterns to mimic functional
and decreased soft tissue restrictions and scarring
movements and strengthen the areas in functional planes.15
(Table 5-3)
In the D1 pattern, the shoulder moves into flexion-abduction-
external rotation. With the D2 pattern, the shoulder moves To advance to this phase, the patient should have minimal
into extension-adduction-internal rotation.21,41 Initiate these pain, near full ROM, and greater than three over five for
exercises in the supine position with the assistance of the strength generally throughout the shoulder movements. Often
therapist using PROM. Then progress to A/AROM in D1 when progressing a patient to a new level of exercises (i.e.,
and D2 patterns. Near the end of this phase, use independent going from A/AROM to AROM) muscle soreness will be
performance of the PNF patterns in the supine position, more pronounced initially. The patient will usually adapt to the
advancing to a standing position when able. Eventually, new demands of the program within the first week.
active shoulder flexion, external rotation, and scaption During the period from 9 to 12 weeks after surgery, the
exercises (Fig. 5-4) are performed after 7 weeks. Active patient should progress to full ROM. By 12 weeks the
shoulder flexion and scaption are usually initiated between repaired tissues are now strong enough to tolerate stretching
zero and 70 (with the elbow bent at 90) and progress within the patients tolerance level. Passive stretching of the
according to the patients ability to execute these exercises internal and external rotators is important. Tightness in
correctly. Incorrect performance of shoulder elevation exer- these areas could promote abnormal shoulder mechanics,
cises can lead to impingement problems. Again evaluate for particularly in the throwing athlete. Tight external rotators
cervical spine (C/S) and thoracic spine (T/S) issues that may lead to anterior translation and superior migration of the
be causing secondary issues of pain and muscle tightness. humeral head, which can produce impingement problems.54
Address joint or soft tissue issues. ROM will normally progress without much difficulty.
Precautions at this stage include no resisted exercises AC joint pain is common in many patients who have
for 8 weeks. Between 6 and 12 weeks, advise patient to undergone rotator cuff repair. The symptoms may result
only perform waist level activities and no heavy lifting from a previous trauma, be caused by primary generalized
for 4 to 6 months. Marked increases in swelling, pain, osteoarthritis (OA), or follow abnormalities in the GH joint,
or wound drainage (or the presence of red, streaking marks) such as degeneration and rupture of the rotator cuff.17 The
Fig. 5-4 Isotonic scaption exercises. These are elevation exercises done in the scapular plane. The patient holds the arm with the thumb up and the elbow
straight and lifts the arm at a 45 angle to shoulder level. Patient progresses to full elevation and then gradually adds weight.

Anticipated
Phase to this Phase Functional Limitation Intervention Goal Rationale
Phase III Steady improvement Limited AROM Continue exercises from phases Increase exercises Promotion of
Postoperative in ROM and strength Limited tolerance to I and II as indicated. that patient can self-management
8-12wk (tolerance to use of upper AROM: Wand exercises (i.e., perform at home Transition to AROM
movement) extremity flexion, extension, abduction) Full PROM program with emphasis
Pain controlled with Limited reaching progress to independent use of Strength of shoulder as appropriate on PROM
therapy and Limited lifting wand generally >55% Strengthening of
medication AROM progressing to isotonics Minimal pain shoulder and upper
Strength > 3/5 Begin shoulder ER with light associated with quarter musculature with
generally weights and axillary roll then overhead activity a variety of resistance
progress to using Thera-Band Able to perform devices and positions
near end of phase self-care activities Scapular exercises to
Isotonics: Shoulder flexion and using involved upper promote proximal
abduction in scapular plane extremity stability for distal
after 10wk mobility
Scapular exercises Progression from AROM
reverse rows to PREs as tolerance to
horizontal abduction (see activity improves
Fig. 5-8); prone at 90 Performance of
abduction then ER without cuff-stabilization exercises
weight with pain-free ranges
Scaption performed initially
without weight
Prone shoulder extension
Standing push-ups against the
wall
Initiate low-level Body Blade
exercises then progress as
appropriate
Manual resistance added to
PNF patterns
rhythmic stabilization and
slow reversal holds
AROM, Active range of motion; ER, external rotation; PNF, proprioceptive neuromuscular facilitation; PREs, progressive resistance exercises;
PROM, passive range of motion; ROM, Range of motion.
AC joint will especially be tender if an acromioplasty was The supraspinatus, infraspinatus, teres minor, and subscapu-
performed. When the AC joint is hypomobile and symptom- laris muscles pull the humeral head securely into the glenoid
atic, mobilization can help alleviate a portion of the symp- and control humeral rotation so that the humeral head stays
toms and allow greater mobility (Fig. 5-5). in good alignment with the glenoid.49 In addition, it should
After the incision is healed and closed, the therapist can be noted that the primary depressors of the humeral head
apply soft tissue mobilization over the incision areas and during shoulder elevation are the infraspinatus, teres minor,
instruct the patient in massaging the scarred area. Early and subscapularis muscles. Because the infraspinatus is
movement minimizes tightness from scarring. Normal skin involved in two critical force couples about the GH joint, the
mobility allows normal movement to occur.9 quality of shoulder motion is directly related to its
Resistance exercises are initiated around 10 weeks. function.52
Patients should demonstrate correct active movements When resisted exercises are initiated, begin external rota-
before resistance is added in a particular range. The patient tion with hand-held weights with the patient in a side-lying
must perform the resisted exercises correctly or the move- position on the unaffected side. The elbow is maintained in
ment needs to be altered. Isotonic exercises are important for 90 of flexion, and the patient starts with the shoulder in
strengthening and promoting dynamic shoulder stabiliza- internal rotation, then moves into external rotation (Fig. 5-6,
tion. The humeral head stabilizers are used during this phase. A and B). Eventually the patient can be progressed to
concentric-eccentric movements using a Thera-Band for

external rotation and internal rotation. An axillary roll can
be placed under the shoulder to avoid a fully adducted posi-
tion, which can cause a vascular stress on the supraspinatus
and biceps tendon.10,26 Resisted elbow flexion exercises can
be done with exercise tubing for the biceps. The long head
of the biceps brachialis has been revealed as a strong humeral
head depressor and acts to steer.52 Baylis and Wolf55 described
a four square combination of tubing-resisted exercises for
shoulder flexion, shoulder extension, internal rotation, and A
external rotation (see Fig. 5-6), followed by stretching of the
external rotators and abductors.
Remember that proximal stability is essential for control-
ling distal mobility.41 Moseley and associates56 reported that
four exercises appeared to significantly enhance recruitment
of the scapular muscles. These exercises included shoulder
elevation in the scapular plane, upright rowing, a press-up,
and a push-up with a plus.52 Shoulder flexion and abduc-
tion exercises in the scapular plane (instead of the straight
planes) are more functional and less problematic to the
rotator cuff. Prone rowing can also be done (Fig. 5-7).
B
Fig. 5-6 A, Patient lies on the unaffected side, in the side-lying position.
Patient maintains a 90 bend in the elbow while holding a hand-held weight
Fig. 5-5 Acromioclavicular (AC) mobilization through posteroanterior and moving the arm into external rotation. B, Again, the patient maintains
(PA) movement. The therapist stabilizes the midclavicle while applying PA the elbow in 90 of flexion while externally rotating the shoulder against
pressure through the spine of the scapula. resistance of the band.
Fig. 5-7 Prone rowing. Patient hangs arm over edge of table, pulls hand upward while bending the elbow and tightening the scapular muscles, and slowly
releases.
Fig. 5-8 Prone flies. Patient lies prone with elbow extended and arm hanging down. Therapist instructs patient to abduct the arm horizontally. Patient can
start without weights, then gradually add resistance. Patient can also perform this with the shoulder in 135 of abduction.
Fig. 5-10 Shoulder girdle depressions using a Swiss ball. Patient sits next
Fig. 5-9 Seated push-ups with a plus. Patient depresses the shoulders while to Swiss ball and places elbow on the ball. Patient maintains a 90 bend in
maintaining straight elbows, thereby lifting the torso. Patient then slowly the elbow while depressing the scapula to push the elbow down into the
lowers torso, attempting to avoid excessive superior translation of the ball. This exercise is good for those who cannot or should not perform
humeral head. seated push-ups with a plus (e.g., older patients).
Rowing is excellent for all portions of the trapezius, levator progressed to only balance assisted by the lower extremities.
scapula, and rhomboids. These muscles help maintain the These exercises help strengthen the serratus anterior muscle,
scapula in good alignment during shoulder movements. The which encourages humeral head depression with shoulder
higher and the lower trapezius musculature stabilizes elevation. Older, more sedentary patients can strengthen
the scapula for overhead activities. In addition, prone hori- their serratus anterior muscle using a Swiss ball (Fig. 5-10).
zontal abduction can be incorporated to strengthen the Resisted exercises also are performed in PNF patterns to
rhomboid major and minor and the middle trapezius muscles strengthen the muscles in functional patterns. A frequently
(Fig. 5-8).56 Dynamic hug exercises are a good way to begin used pattern is the D2 pattern using both concentric and
strengthening the serratus anterior muscle. Progressive eccentric contractions. This is particularly effective in throw-
push-up exercises will strengthen the serratus anterior and ers. Manual resistance is again incorporated for rhythmic
the pectoralis minor muscles. A seated push-up with a plus stabilization exercises and slow reversal hold techniques.21,41
was found to be effective in recruiting the serratus anterior If strength is not sufficient to overcome light resistance then
with less activity of the trapezius musculature.56 At this stage begin with a hold pattern or a hold position in the weak area
patients should use their legs to assist themselves with the of the range. During rhythmic stabilization, the most com-
exercise (Fig. 5-9). Push-ups are initiated into the wall at this monly used angles are 30, 60, 90, and 140 of shoulder eleva-
time; later they can be progressed to table height, then per- tion.52 This movement will stimulate muscle contractions
formed on the floor ladies style, and finally some patients around the GH joint, promoting the joint force couples to
are progressed to a complete push-up. Press-ups and seated work more efficiently and encouraging better dynamic sta-
push-ups are done with active patients. They can be initiated bilization of the humeral head.52 Good angles to work on
with support from the lower extremities and eventually with rhythmic stabilization are areas of increased weakness;
therefore one can specifically strengthen at the weakest begins during this phase. Patients begin on the upper body
point, allowing improvement for the entire movement. ergometer with short-duration and low-intensity bouts, and
Strengthening begins with normalizing AROM while ini- then they advance to longer durations and higher intensity
tiating light resistance into an appropriate arc of motion. bouts. Modalities are minimally used during this stage. Pain
AROM for shoulder elevation begins with the elbow flexed. is generally minimal but will increase with moderate to dra-
The patient can add light resistance when he or she performs matic changes in activity levels.
active elevation correctly with the elbow extended. Resis- Precautions are necessary when initiating isotonic shoul-
tance may be added for elevation up to 70 of motion and der elevation exercises. All exercises should be performed
progressed as the patient is able to perform AROM correctly with little or no joint pain. Complaints of muscle discomfort
through 80 and progressing to 150 of elevation. The patient are acceptable and even desirable.19 However, if the patient
must also demonstrate good scapular humeral mechanism complains of sharp pain through particular ranges, then
without pain and perform 20 repetitions. This must be exe- the therapist needs to modify the exercises to avoid a
cuted correctly before resistance is added.53 If challenged by painful arc.
10 repetitions but able to do 20, then maintain the level of
resistance. Do not train for power. The patient needs good Phase IV
muscle endurance over time, therefore do 30 repetitions
before gradually increasing the load.53 When using resis-
GOALS: Maintenance of full ROM, increased strength
tance, begin abduction movement to 45. Shoulder flexion
and endurance, improved function (Table 5-4)
can be performed between 70 and 80. External rotation can
be initiated in a supported position, then advanced to unsup- The patient should have full ROM by 13 to 16 weeks. If this
ported. When using a Thera-Band, have the patient begin is not the case, then progressing with ROM needs to be the
with yellow and do 10 repetitions. If challenged and eager to primary focus during treatments until this has been achieved.
rest, then go to another exercise. If easy then do 10 more The therapist can emphasize more aggressive mobilization
repetitions. If still easy then do another set of 10 repetitions using grades +3 and +4 on the GH capsule to stretch the
and move on. If the patient executes 30 repetitions well, the specific areas of capsular restrictions, thereby normalizing
therapist may gradually increase resistance.53 Even today, the arthrokinematics at the GH joint. These mobilizations also
low intensity resistance, high repetitions technique may be can be performed near the physiologic end ROM, and they
the best regimen for athletes with injuries of insidious onset can be performed near end of ranges in conjunction with
and during early rehabilitation phases.57 By 20 weeks, the combined movements (refer to the question-and-answer
athlete can advance to heavier weight lifting.48 scenario for an application example). Adequate capsule
In my experience, the Body Blade has been helpful for laxity is necessary to allow normal rolling and gliding
active patients. Exercises with the Body Blade are initiated between the bony surfaces of a joint. Patients should con-
with the shoulder and upper arm against the trunk. Eventu- tinue the necessary stretches to gain and maintain ROM in
ally patients progress to operating the Body Blade with the restricted areas (Figs. 5-11 through 5-13 illustrate some of
arm extended away from the body and elevated. In even the suggested stretches).
more advanced stages, patterns of motion can be followed
while maintaining the oscillations of the blade and proper
body mechanics. These exercises enhance contractions
around a joint, increase strength, a increase proprioception,
as well as improve coordination and increase endurance. The
Body Blade has also been shown to produce greater scapular
activity than traditional resistance techniques.58
Often times, older patients with fair tissue status and
massive tears have difficulty progressing to active shoulder
flexion against gravity. Eccentric shoulder flexion exercises
without weights help provide these patients with a transition
to active shoulder flexion. Help patients lift their arms in the
scapular plane above their heads; then instruct them to lower
their arms without allowing them to fall. These patients also
need to emphasize strengthening of their humeral head
depressors. Finally, have them exercise in front of a mirror
so that they can readily correct the tendency to hike their
shoulder.
Fig. 5-11 Corner wall stretch. Patient stands facing a corner approximately
Strengthening of the trunk and legs is important for ath-
one stride length away. The patient then places the forearms on the wall,
letes. Numerous studies indicate that the trunk and legs are keeping the elbows at shoulder height. The therapist instructs the patient to
responsible for more than 50% of the kinetic energy expended lean into the corner until he or she feels a stretch on the anterior portion of
during throwing (see Chapter 13). Endurance training also the shoulders.

Anticipated
Phase to this Phase Functional Limitations Intervention Goals Rationale
Phase IV Full ROM or near-full Limited tolerance to Exercises for phase III Self-management of Preparation of patient
Postoperative ROM overhead activities continued and progressed as home exercises for discharge and
13-16wk Pain controlled and Pain with activities appropriate Full AROM continued
self-managed involving prolonged use Stretches: Corner wall stretch Strength > 70% self-management
No loss of strength of upper extremity if necessary (see Fig. 5-11); (dependent on extent Improvement of
with addition of Limited strength of posterior capsule stretch if of tear) capsular mobility
phase III exercises rotator cuff restricted (see Fig. 5-12); Self-management of Restoration of
No increase in night hand-behind-back stretch (see pain associated with end-range joint
pain Fig. 5-13) overhead activity arthrokinematics
PREs progressed Reach in front and to Strengthening of
Prone horizontal abduction side for light-weight upper quarter,
at 90 degrees and ER of objects especially scapula
the shoulder for higher-level Carry light weight for stabilizers, in stable
patients short periods (i.e., but challenging
Closed-chain exercises; wall grocery bags) environment
push-ups plus progressing Co-contraction
to table push-ups then floor exercises to enhance
push-ups if able; seated dynamic joint stability
push-ups plus for active Preparation of patient
patients (see Fig. 5-9); for activity-specific
shoulder girdle depressions demands
using a Swiss ball for Maintenance and
sedentary patients (see Fig. improvement of
5-10) cardiovascular fitness,
May initiate plyometrics near incorporating upper
end of phase extremities
Movement patterns to Restoration of
simulate work or sport end-range joint
activity arthrokinematics
Progress with Body Blade
exercises
Trunk- and leg-strengthening
exercises for return to
previous level of functioning
Stretching/mobilization to
cervical and thoracic spine as
needed
AROM, Active range of motion; ER, external rotation; PREs, progressive resistance exercises; ROM, range of motion.
It should be noted that with throwing athletes the ante- function of the rotator cuff is to provide good humeral head
rior capsule does not need to be stretched as much. alignment with the glenoid fossa; this must be mastered
Patients with anterior instability issues should not exer- before any complex movements are initiated. The efficiency
cise near extreme ranges of abduction and external rota- of the GH force couples is vital for success. The primary
tion. Those with posterior GH instabilities should avoid couples of the GH joint are the subscapularis counterbal-
extreme ranges of horizontal adduction and internal anced by the infraspinatus and teres minor and the anterior
rotation. deltoid and supraspinatus counterbalanced by the infraspi-
If the patient cannot elevate the arm without shoulder natus and teres minor.
hiking (i.e., scapulothoracic substitution), then continue to Strengthening exercises are progressed with progressive
focus on the humeral headstabilizing exercises and exercise resistance exercises (PREs) progressing to 3 to 5lb or the
the humeral head depressors. Remember the primary green Thera-Band if able. See Fig. 5-16 for exercises using
or athletes can progress to the standard push-ups on the

floor, as previously mentioned. Closed-chain exercises help
promote cocontractions and enhance dynamic joint
stability.62
Therapists must also consider the neuromuscular system
that provides joint stability through proprioceptive aware-
ness, because proprioceptive training of the shoulder can
lead to improved neuromuscular control, which can improve
the overall dynamic stability of the GH joint.63 Appropriate
shoulder exercises using the Body Blade provide propriocep-
tive training, dynamic-stabilization training, and endurance
training. Eventually (during the later stages of rehabilitation)
the patient can be progressed using the Body Blade through
a vast range of shoulder movements, allowing athletes and
Fig. 5-12 Posterior capsular stretch. Patient horizontally adducts arm
workers to train and exercise in specific patterns or postures.
across body and then uses the other hand to pull the affected arm into
further horizontal adduction. These movements mimic a pattern of movement or a posi-
tion used during a sport or work activity. In a later phase,
resistance can be added to these movement patterns with the
use of a Thera-Band (see Fig. 5-17). Caution must be used
while progressing the patient from 10 to 18 weeks because
pain is usually absent.
Phase V
GOALS: Maintenance of full ROM, increased strength
and endurance, improvement of neuromuscular
control, return to functional activities, initiation of
sport-specific activities (Table 5-5)
The therapist can continue the stretching program and

instruct the patient in self-mobilization techniques if indi-
cated. The patient can maintain a shoulder-strengthening
program and continue PREs with increasing hand weights.
Isokinetic training can also be beneficial. These exercises can
be performed throughout the range because of the accom-
modation factor in isokinetic training. If a patient cannot
Fig. 5-13 Hand-behind-back stretch. Patient stands with towel in both move through the resistance at a particular arc of motion, he
hands and places the involved arm behind the buttock or low back. Patient or she still can train with resistance throughout the whole
places the uninvolved arm behind the head and slowly pulls with the supe- range.
rior hand up the back until he or she feels a stretch.
Athletes and other appropriate patients can begin plyo-
metric exercises, which involve a stretch-shortening cycle of
the Thera-Band. The supraspinatus and infraspinatus muscles the muscle. Plyometrics can be performed two times a week.
(also known as decelerators) produce slow, controlled move- All sporting movements involve this explosive stretch-
ments. These muscles are subjected to larger stresses and also shortening cycle (e.g., jumping, throwing, running, swim-
are injured more frequently in overhead sporting activities.59 ming).45 Progressive plyometric exercises are done with
Through the use of electromyographic studies, Blackburn appropriate patients who exhibit correct execution of the
found that the best isolation for the infraspinatus and teres exercises. Recreational and competitive athletes perform
minor muscles occurs during prone exercises incorporating exercises at higher speeds, using more eccentric muscle con-
horizontal abduction and external rotation. An optimal exer- tractions and higher level progressions. These exercises are
cise for athletes who need GH congruity and stability is excellent intermediate steps between traditional strengthen-
prone external rotation with the shoulder at 90 abduction ing exercises and training activities before initiating throw-
and the elbow flexed to 90.60 These exercises should be pering drills.63
formed at a functional speed starting without weight then Resisted exercises using tubing with concentric-eccentric
adding resistance.61 Resisted external rotation with abduc- contractions, isokinetics, and scapulothoracic strengthening
tion is another good strengthening exercise for athletes. can be done. Athletes or workers required to do continuous
Continue with push-ups while leaning into a wall and overhead activities can perform exercises with a Thera-Band
progress to ladies style push-ups if able. More active patients for external rotation, starting with an axillary pillow between

Anticipated
Phase to this Phase Functional Limitations Intervention Goal Rationale
Phase V Progression through Limited strength and Continuation of phase IV Pain free with Strengthening of rotator
Postoperative phase IV without loss endurance of rotator exercises as indicated overhead activity cuff in specific ranges
17-26wk of strength or cuff muscles Joint mobilization as Ability to perform (overhead and reaching
increase in pain Continued manageable appropriate ADLs without to the side)
Potential to return to pain with overhead PREs progressed increased pain Provision of optimal ROM
high level functional activities Prone shoulder abduction in Return to previous for client to perform
use of the upper various ranges with light level of functioning associated activity
extremity (i.e., weights Increase in Provision of vehicle for
competitive athletics) Thera-Band for ER with the strength, client to return at or
shoulder abducted to 90 endurance, and close to previous level of
and the elbow at 90 neuromuscular functioning
(athletes only) control
Initiation of strengthening in
sport-specific activity
Initiate isokenetic exercises
Plyometrics
Initiation of throwing program
when appropriate (see Chapter
13)
ADLs, Activities of daily living; ER, external rotation; PREs, progressive resistance exercises; ROM, range of motion.
gradual return to full activities. Athletes can return

the trunk and arm, then to the scapular plane position, and
to their sports usually between 6 and 12 months
then to the 90/90 position if able. D2 diagonal patterns can
be executed with tubing. Latissimus strengthening and scap-
ular retraction exercises can be performed using a Thera- During weeks 22 to 26 patients maintain a stretching and
Band.64 Athletes and higher level patients can perform these strengthening program. Athletes continue on strengthening
exercises at a faster and higher speed while maintaining and on a sports interval program. Others gradually progress
control over the movement. They can also perform at a to recreational activities. Older individuals continue to pro
slower and more deliberate pace. Specific applications of gress with PREs and work on more advanced ADLs. The
eccentric training to the posterior cuff using a Thera-Band ability to return to more high-level activities ranges from 26
and/or isokinetics are essential to pitchers and ball players. weeks to more than 1 year after surgery. After 26 weeks,
Later, when the patient is ready, initiate sport-specific patients continue with their stretching and strengthening
drills for athletes along with an interval sports program (see program as long as they anticipate using the shoulder aggres-
Chapter 13). Throwing techniques need to be evaluated. sively in ADLs or sports. The patient can maintain a shoulder-
If the patient is using bad body mechanics, using strengthening program and continue PREs with increasing
improper techniques while throwing, or both, then tissues hand weights up to 6 to 10lb for athletes or 1 to 5lb for more
may be overstressed, eventually causing rotator cuff prob- sedentary people. Isokinetic exercises may be initiated with
lems once again. Older, sedentary patients should work on athletes when they are able to lift 5 to 10lb in external rota-
specific ADLs. As appropriate, patients may progress to more tion and 15 to 20lb in internal rotation without pain or
difficult tasks. significant edema.38 The patient should begin strength and
In general golfers can usually start putting at 14 to 16 endurance training at 200/second.38,72
weeks and then progress as able. At 20 to 22 weeks tennis
players can begin hitting their forehand and backhand
strokes and progress to serving. And swimming can be initi- TROUBLESHOOTING
ated between 20 and 26 weeks. By 7 to 9 months the athlete
may be able to reengage in sports activities competitively. Considering influential factors outside the GH joint during
treatment will aid the therapist in helping the patient pro
Phase VI gress more efficiently. General suggestions are given;
TIME: 22 and more weeks after surgery however, it is beyond the scope of this book to instruct
GOAL: Return to normal activities, maintenance of full therapists in the use and application of techniques. The fol-
ROM, continued strengthening and endurance, lowing areas are addressed:
Cervical spine
Thoracic spine
Adverse neural tension (ANT)
AC joint
SC joint T2
Scapulothoracic joint
C4
Cervical Spine
Evaluation of the cervical spine may prove vital in addressing
cervical issues that may be inhibiting progress. Although the
cervical spine is not the primary cause of shoulder dysfunc- C5
tion when dealing with rotator cuff repairs, it may be a con- C6
tributory factor. Often cervical spine disorders occur in
conjunction with a traumatic shoulder injury (e.g., falling
onto the upper extremity may cause injury to the shoulder
C5
and the cervical spine). Furthermore, prolonged muscle C6
guarding secondary to the shoulder injury or pathology
affects the cervical area. Muscles in spasm originating or
inserting along the cervical spine can lead to cervical symp-
toms. Thus a patient may have a combination of cervical and C7
shoulder signs and symptoms. Treatment to the appropriate
cervical joints can alleviate a portion of the symptoms and
signs, thereby decreasing the complaints of pain and poten-
tially allowing more GH movement and function. Clinicians
may notice that after treating cervical spine dysfunctions,
treatment of the shoulder is more effective. T4 T3
T5
Common patterns in cervical pathology are addressed to T6
assist clinicians with differentiating shoulder and cervical
symptoms because they frequently occur together. Spinal
disorders may cause referred pain (Fig. 5-14). Joint move-
ment disorders may cause joint pain and be associated with
1 C1
an altered range of cervical spine joint movement or shoul-
der movement. Therefore the cervical spine should be C2
7
assessed for additional joint disorders that may be causing C2
2
local pain or pain that is referred into the shoulder and arm 6 C3
region.32 (Suggested readings for treatment of the cervical 3 5
spine are Practical Orthopedic Medicine by Corrigan and
Maitland32 and Vertebral Manipulation by Maitland.36) C3
4
C4
Thoracic Spine C3
Thoracic mobility affects shoulder mobility. During unilat- 8
9
eral shoulder flexion, contralateral side flexion of the spine C4
occurs; bilateral shoulder flexion produces spinal exten- Fig. 5-14 Dermatomal pattern of the upper extremity. (From Maxey L:
sion.22 Therefore decreased thoracic extensibility or increased Cervical spine. In Magee DJ, editor: Orthopedic physical therapy assess-
thoracic kyphosis can inhibit shoulder ROM.65 ment, ed 3, Philadelphia, 1997, Saunders.)
Postural education is important, especially with patients
who can voluntarily correct and maintain good posture.
Maintaining an erect posture while performing upper depressed forward-displaced shoulders and GH internal
extremity activities allows greater ROM at the shoulders. rotation. The potential for shoulder impingement increases
Better posture decreases the amount of impingement, which with this type of posture.65
a patient can see in the following maneuver: Evaluation and treatment of the thoracic spine may prove
1. Have the patient flex the shoulder through its available helpful for patients having difficulty progressing in ROM in
ROM while in a seated slouched position. the latter stages. Addressing issues of hypomobility and
2. Ask the patient to flex the shoulder while seated with decreased ROM of the thoracic spine and treating them
good posture. appropriately allows for better progress. Mobilization of a
The patient will be able to lift the arm higher when main- hypomobile thoracic spine and ROM exercises to increase
taining a more upright posture. A slouched position causes thoracic extension (e.g., supine on a Swiss ball) can be
beneficial. A foam roll also may be used when appropriate degeneration and rupture of the rotator cuff) that allow the
to increase thoracic spinal extension and mobility (Fig. head of the humerus to sublux upward.32 In our experience,
5-15). (Vertebral Manipulation36 offers instruction on evalu- many patients with repaired and unrepaired rotator cuff
ation and treatment of the thoracic spine.) With regard to tears have some symptoms arising from the AC joint.
positioning, the therapist also must consider protection of Because the movement of all of the joints affects the
the shoulder and the surgery site. shoulder complex, it is essential to evaluate and treat the
If complaints of pain persist in the cervical spine region, entire shoulder complex to improve upper extremity func-
then assess for contributing factors arising from the thoracic tion.68 Table 5-6 shows some of the joint movements that
spine. Mobilization to a stiff thoracic spine (if warranted) occur within the shoulder complex. Restrictions in one area
may alleviate some or all of the cervical pain that continues will affect other areas of the shoulder complex.
to persist.66 Complaints of AC joint pain are usually localized over the
joint. An active movement that may best implicate this joint
Adverse Neural Tension as a source of pain is horizontal adduction of the arm across
The nervous system can be directly mobilized through the chest. The therapist may determine whether the AC joint
tension tests and their derivatives.40 Adhesions in neural is hypomobile or hypermobile by passive accessory move-
tissue can affect shoulder movement and strength, and may ment tests of the joint.69 If the AC joint is stiff and tender, then
influence the patients progress. However, the therapist must its mobilization often relieves a portion of the symptoms and
be aware of any precautions or contraindications. A good promotes better shoulder ROM. The AC joint may also be
evaluation is necessary for addressing adverse neural tension tender from an acromion osteotomy if performed with the
issues. Neural tissue mobilization can be effective when used rotator cuff. Eventually gentle movements of the AC joint may
with appropriate patients to help relieve some of the symp- be beneficial when the patient can tolerate the treatment. If
toms and potentially improve ROM and strength. These the AC joint has been removed because it is arthritic or symp-
issues may be better addressed during the latter phases of tomatic then do not attempt to mobilize the area.
rehabilitation when the tissue repair has healed and shoulder Accessory movements can be applied to the clavicle or
ROM is only minimally limited or not restricted. Clinicians acromion. When applied to the clavicle, they affect only the
trained in neural tissue mobilization should only perform AC joint; however, when applied to the acromion, they affect
treatment to the nervous system. Avoid placing a stretch on both the AC and GH joint.6 Accessory AC joint movements
the nerves. should be used within the limits of pain. To increase motion
at the AC joint, the therapist can use an anterior glide to the
The objective is to move the nerves, mobilizing them acromion through the posterior spine of the scapula while
without stretching them. Increase in symptoms such as stabilizing the midclavicle. This allows mobilization of the
pain, numbness, tingling, and paresthesias down the arm AC joint without direct manual pressure over the joint or
may indicate the nerves are being stretched.73 inflamed tissues.
As the available shoulder ROM progresses, this same
Acromioclavicular Joint technique can be applied with the shoulder in some degree
OA in the AC joint is not uncommon.67 It may result of available flexion or in horizontal adduction (see Fig. 5-5).
from previous trauma or be part of a primary generalized Corrigan and Maitland32 describe a similar technique for
OA, impingement, or capsulitis. OA in the AC joint also the AC joint. In this method an anterior-posterior move-
may follow other abnormalities in the GH joint (e.g., ment is produced by applying pressure over the anterior
Fig. 5-15 Thoracic extension on foam roll or using tennis balls. Patient lies supine with both knees bent and places roll or balls at the middle thoracic spine
levels. Patient then places hands under head and slowly leans back (taking care not to arch over the roll or balls) until a stretch is felt.
TABLE 5-6 Shoulder ComplexRange and Axis of Treatment of the SC area includes rest, modalities, and
Motion* mobilization, depending on the condition of the joint.32 A
hypomobile SC joint may be correctly mobilized in several
Range ways depending on its restrictions. To increase shoulder ele-
Joint Motion (Degrees) Axis of Motion vation, a caudal glide to the proximal clavicle can be used.32,37
Sternoclavicular 0-50 Longitudinal axis of clavicle
Scapulothoracic Joint
rotation
(counterclockwise) Scapular muscles have been included in the rotator cuff
Glenohumeral (GH) 0-180 Coronal through repair protocol. However, some patients require more intense
flexion conditioning of these muscles. The scapula moves with
Abduction 0-180 Sagittal through concentric-eccentric motions. Patients with poor eccentric
Horizontal adduction 0-145 GH joint control of the scapular stabilizers demonstrate scapula
Vertical through GH joint winging on the return from full shoulder flexion. The ser-
Internal rotation 0-90 Vertical axis through ratus anterior is essential for stabilizing the medial border
External rotation 0-90 Shaft of humerus and inferior angle of the scapula, preventing scapula internal
Acromioclavicular (AC) 0-50 Vertical axis through AC joint rotation (winging) and anterior tilt.60 These same patients
winging of scapula may have full ROM and normal movement during flexion.
Abduction of scapula 0-30 Anteroposterior axis If muscle weakness is apparent, then ensuring normal muscle
Inferior angle of 0-30 Coronal axis from chest wall strength around the scapulothoracic and GH joints is the
scapula tilts away goal. If the scapular muscles are weak and overstretched,
Scapulothoracic then scapular motion during arm elevation may result in
Upward rotation 0-60 From 0-30 near vertebral border on excessive lateral gliding of the scapula. Abnormal scapular
spine of scapula; from 30-60 near muscle firing patterns, weakness, fatigue, or injury causes the
acromial end of spine of scapula shoulder to function less efficiently and the risk of injury
increases.60
*When conflicting information occurred, the most frequently cited The therapist can use various PNF techniques, such as
numbers were used. scapular slow reversal holds, rhythmic stabilization, and
Data from Codman EA, Akerson IB: The pathology associated with
timing for emphasis, to intensify the dynamic control and
rupture of the supraspinatus tendon. Am Surg 93:348, 1931; Akeson
WH, Woo SLY, Amiel D: The connective tissue response to immobil- kinesthesia of the scapulothoracic joint. Other recommended
ity: biomechanical changes in periarticular connective tissue of the exercises are scapular protraction, retraction, elevation, and
immobilized rabbit knee. Clin Orthop 93:356, 1973; Andrews JR, depression against manual resistance.71
Kupferman SP, Dillman CJ: Labral tears in throwing and racquet Exercises are encouraged that enhance dynamic control
sports. Clin Sports Med 10(4):901, 1991; Abrams JS: Special shoul-
of the scapulothoracic musculature.71 These should be
der problems in the throwing athlete: Pathology, diagnosis and
nonoperative management. Clin Sports Med 10:839, 1991; Bigliani directed to the scapular rotator muscles (i.e., the serratus
LU et al: Operative management of failed rotator cuff repairs. Orthop anterior, rhomboid, trapezius, levator scapula) to position
Trans 12:674, 1988; Bross R, et al: Optimal number of exercise the glenoid and coracoid appropriately for the humerus.
bouts per week for isokinetic eccentric training of the rotator cuff Exercises that mimic the rowing motion and shoulder hori-
musculature. Wisc Phys Ther Assoc Newsl 21(5):18, 1991 (abstract);
zontal abduction are both excellent for all portions of the
Butler DS: Mobilization of the nervous system, New York, 1991,
Churchill Livingstone. trapezius and for the levator scapulae and rhomboid muscles.
Flexion and scaption (i.e., scapular plane elevation) exercises
are valuable for most of the scapular muscles (see Fig. 5-4).
In addition, shoulder shrugs and press-ups with a plus are
surface of the outer third of the clavicle with counter pres- essential exercises for the levator scapula, upper trapezius,
sure along the spine of the scapula. serratus anterior, and pectoralis minor muscles. Also refer to
the Prone Program Plus for more exercise ideas.
Sternoclavicular Joint
Degenerative changes are not found as commonly in the SC SUMMARY
joint as in the AC joint but may occur as the result of trauma
or overuse of the shoulder.70 Movements such as shoulder The general guidelines described in this chapter help guide
abduction or flexion may increase pain originating from this therapists and provide treatment ideas. Rotator cuff repairs
joint because of rotation of the inner end of the clavicle. SC vary in size from small to massive. The condition of the torn
joint pain is usually localized to the SC area, but it may tissue and the joints (i.e., AC, GH) varies. Along with these
radiate to other areas. Signs that implicate the SC joint as a differences, therapists must consider the patients unique
contributing factor include reproduction of pain with hori- history, profile, and abilities. They must consider each case
zontal flexion and passive accessory movements of the SC and choose the treatment ideas that will work best, constantly
joint. The capsule and surrounding ligaments are likely to be assessing the patients responses. Therapists must always
thickened and tender.69 address the individual when deciding on a treatment plan.

The following is the suggested home maintenance 5. Massage the scar area when the incision has
for the postsurgical patient with minimal and appropriately healed.
moderate tears. Improvise to accommodate for
massive tears. Weeks 8-12
This home maintenance box outlines ideas for GOALS FOR THE PERIOD: Increase range of motion
rehabilitation the patient can follow after rotator cuff (ROM) to full, and continue to increase strength. Use
repair. The physical therapist can use it in upper extremity for light activities of daily living
customizing a patient-specific program. Patients (ADLs).
require a program that suits their needs and 1. Continue with wand exercises for ROM.
abilities. Some exercises may be appropriate for 2. Continue with active cervical ROM and UT
certain patients but not for others. Some patients stretches as needed.
progress slower than others. The therapist must take 3. Instruct the patient in self-mobilization of the
into account the patients age, the condition of the T/S using tennis balls or foam roll if needed
repaired tissues, the size of the tear, the cause of the (may not be appropriate for older or kyphotic
tear, the rate of healing, and the patients abilities patients).
and previous level of function. 4. Perform active shoulder flexion and abduction in
Older, more sedentary patients will progress the functional plane while facing a mirror; be
more slowly than younger, more active patients. sure to maintain voluntary humeral head
Some of the exercises suggested may be depression (keeping the shoulder from hiking).
inappropriate for the older patient. The therapist can Initially perform with elbow flexed to 90. Do 3
alter the home exercise prescription according to the sets of 10 repititions, 3/day.
individuals abilities, status, and needs. Improvise 5. Resisted elbow flexion with arm at side
this program to accommodate for rotator cuff repair 6. At 11 weeks, initiate isotonic exercises within a
(RCR) for large tears. controlled ROM using light weights (without
substitution patterns). Do 3 sets of 10 repititions
Weeks 1-4 for the following exercises 3/day:
GOALS FOR THE PERIOD: Achieve control of pain a. Deltoid (initiate at 10 to 12 weeks depending
and inflammation; increase ROM as tolerated, and on size of tear) (Fig. 5-16, C and D)
promote firing of muscles. b. Supraspinatus (initiate at 10 to 12 weeks
1. Do active cervical spine rotations. depending on size of tear)
2. Do upper trapezius (UT) stretches. c. Scaption exercises (initiate at 10 to 12 weeks
3. Do pendulum exercises. depending on size of tear)
4. Begin wand exercises or pulley exercises (for 7. Use tubing or Thera-Band for internal rotation at
passive range of motion [PROM]) after 2 to 3 8 weeks, then add external rotation (use axillary
weeks. Do 3 sets of 10 repititions 2/day for roll) and abduction at 11 to 12 weeks (see Fig.
flexion, scapular plane abduction, and external 5-16).
rotation. 8. Do standing reverse rows using tubing or
5. Apply a cold or ice pack intermittently Thera-Band.
throughout the day for pain control and 9. Do push-ups with a plus while standing and
inflammation. using a wall.
6. Instruct the patient in the use of pillows to 10. If necessary, add shoulder depression
maintain the shoulder in a more loose packed exercises using a Swiss ball for resistance (see
position when supine, sitting, semireclined, or Fig. 5-10).
side-lying. 11. Athletes can initiate prone horizontal abduction
in neutral position without weights at 10 or 11
Weeks 5-8 weeks if able. Also may perform same exercise
GOALS FOR THE PERIOD: Continue to increase at 135 of abduction (see Fig. 5-9).
ROM, decrease pain and inflammation, and increase
muscle activity. Weeks 13-16
1. Use cold or ice packs as needed. GOALS FOR THE PERIOD: Increase ROM, strength,
2. Continue with previous exercises. and endurance, and begin transitioning into higher
3. Initiate wand exercises for A/AROM at 6 weeks. activity levels.
Do 4 sets of 10 repititions 3/day. 1. Continue with the wand exercises.
4. Add active shoulder flexion in supine position 2. Continue with active ROM of the cervical spine,
when cleared by the surgeon (usually 6 to 8 UT stretches, and T/S mobilizations.
weeks postsurgery). Initiate this exercise with 3. Perform a corner wall stretch for pectoralis
elbow bent to 90. muscles and the anterior capsule if needed.
4. Use a horizontal adduction stretch for the 2. Continue with progressive resistance exercises
posterior capsule. (PREs) (i.e., isotonics).
5. Place a hand behind the back and stretch, using a 3. Continue to progress with tubing and Thera-Band
towel for assistance. exercises for reverse rows.
6. Continue and progress with isotonic exercises for 4. Complete proprioceptive neuromuscular
endurance and strength training. facilitation (PNF) patterns using a Thera-Band for
Do 10-15 repititions for 3 sets. resistance (Fig. 5-17).
7. Continue and progress resistance with tubing and 5. Begin an interval sports program, refer to
Thera-Band exercises (see Fig. 5-16). throwing program in Chapter 13.
8. Consider seated push-ups with a plus if patient is
more active (see Fig. 5-9). Weeks 22-26
9. Perform prone horizontal abduction exercises 1. Continue stretches.
without weights and then a light dumbbell if able. 2. Continue PREs.
3. Progress with interval sports program.
Weeks 17-21
1. Continue with previous stretches as
needed.
B C
D E
Fig. 5-16 A, Shoulder extension. B, External rotation. C, Internal rotation. D, Shoulder abduction. E, Shoulder flexion with elbow extension. (From Wirth
MA, Basamania C, Rockwood CA Jr: Nonoperative management of full-thickness tears of the rotator cuff. Orthop Clin North Am 28:59-67, 1997.)
Fig. 5-17 Diagonal proprioceptive neuromuscular facilitation patterns using Thera-Band for resistance. (From Trumble TE, Cornwall R, Budoff J: Core
knowledge in hand, elbow and shoulder, Philadelphia, 2006, Mosby.)
1 Paul just had a rotator cuff repair 3 days ago and says he
can hardly sleep because of the pain. How can you
advise him so that he gets more sleep during the night?
3 Brent is a 27-year-old who had a rotator cuff repair for
a large tear. He has progressed nicely with PROM. At 9
weeks after surgery, Brent can elevate his arm above his
head with little effort. However, he demonstrates a mild
Encourage patient to take pain medications as pre- shoulder hike with elevation above 70. How much
scribed. Time the medication so that it is most effective weight should Brent begin lifting when performing
at bed time. Advise patient to sleep in a recliner or a elevation exercises to 70?
semireclined position in bed. The shoulder should be
placed in a loose packed position using pillows or cush- Brent should not lift any weights above 70 during shoul-
ions. Demonstrate this for the patient. Also encourage der elevation until he can execute the exercise correctly.
patient to use cold packs around the shoulder and neck He should practice maintaining voluntary humeral head
area. During the treatment, mobilize the stiff C/S joints depression with active elevation in front of a mirror. He
and mobilize tight soft tissue around the cervical area should only do resisted exercises through the range he
emphasizing the area near the affected shoulder. Finally, can correctly perform. Brent needs to strengthen the
mobilize the GH joint using grades I and II. muscles that depress the shoulder while maintaining the
humeral head in good alignment with the glenoid (rotator
2 Jim is a 38-year-old weekend athlete who sustained a

large rotator cuff tear after falling onto an outstretched
arm during a flag football game. At 3 weeks after rotator
cuff muscles and serratus anterior). When he can elevate
the arm correctly above 70, he can begin adding weight
for resisted elevation above 70.
cuff repair surgery, he complains of moderate shoulder
pain that radiates through the upper trapezius area and
into the superior medial scapular area. Jim also com-
plains of neck stiffness that has worsened over the past
4 Rebecca had an RCR 10 weeks ago. Recently she has
been complaining of an intermittent pain that travels
from the lateral border of the AC joint down the lateral
few days. He remains guarded through most of his range side of the arm into the mid forearm. This usually occurs
when performing PROM. During todays session, what when reaching over head or to the side, but will occur
areas should the therapist address to improve the quality with different movements as well. On occasion she
of movement and increase the ROM? complains of this intermittent pain at rest with a decrease
of intensity. What do you need to evaluate during
The cervical spine needs to be assessed to determine todays treatment?
whether it may be contributing to some of the
patients complaints, particularly the neck stiffness and The AC joint should be evaluated. Cervical joints C5, C6,
the superior medial scapular pain. If cervical spine joint and C7 along with their facet joints should be checked.
stiffness or soft tissue tightness is noted, then appropri- Neural tension signs and soft tissue need to be addressed.
ate joint or soft tissue mobilizations may decrease these Finally, the elbow needs to be assessed.
symptoms. As pain decreases, muscle guarding will During the evaluation, adverse neural tension signs
lessen, allowing the shoulder to move more freely. were positive and reproduced pain in the
area of complaint. Neural mobilization techniques were of stiffness issues in her shoulder. Her main complaints
performed and the intensity and frequency of symptoms are reaching behind to grasp objects. Particularly diffi-
dramatically decreased. cult to reach toward the back seat of the car, which she
needs to do frequently (small children in the back seat).
5 Barbara is a 68-year-old woman who had a massive

rotator cuff repair 12 weeks ago. Her favorite hobby is
making jewelry. To work with the jewelry she needed to
She also would like to clasp her bra from the back. Upon
evaluation she exhibited minimal restrictions for shoul-
der flexion and shoulder abduction near the end of the
make a sawing motion with her affected (right domi- ranges. Shoulder internal rotation and extension were
nant) arm. At this point the patient had 3/5 strength also limited, but the combined movement of internal
for flexion and abduction. She exhibited +3/5 for exter- rotation and extension with hand-behind-the-back
nal rotation and 4/5 for internal rotation. The patient movements was the most restricted. The patients thumb
did not have the strength to make this sawing motion actively reached to T11 behind the back. What types of
against much resistance throughout the range. She was mobilization techniques would be particularly helpful?
weak, and her endurance was low. Tissue status was fair.
How should the therapist exercise this patient? Mobilizations were performed in various areas of the
capsule to improve all functional ranges. Mobilizations
Patient had full PROM throughout the affected shoulder. were also done near end ranges with combined move-
The therapist mostly performed manual assisted and ments using grades 3 and +4 to improve her hand-
resisted exercises with this patient to maximize strength- behind-the-back motions. The patient used her unaffected
ening at her weakest points in the range. The therapist upper extremity to hold her other hand behind her back
performed PNF patterns for the upper extremity and the while the therapist applied a posterior-anterior force to
scapular muscles. Manual resisted exercises for serratus the superior humerus. This was done to stretch the ante-
anterior strengthening and rotation strengthening. rior capsule of the GH joint near its end range of com-
Resisted shoulder depression exercises were also done. bined movement. This was followed by the
In addition, rhythmic stabilization was used. Shoulder hand-behind-the-back stretch using a towel as shown in
eccentric lowering was done for shoulder flexion strength- Fig. 5-13. The patients range improved dramatically
ening because she could not perform AROM shoulder after two treatments with the execution of home exer-
flexion against gravity (AROM shoulder flexion to 30 cises that reinforced the hand-behind-the-back
before initiating a shoulder hike). Manual exercises with movements.
light resistance were done (and progressed) to mimic the
sawing motion used with making jewelry. Surprisingly
the patient did return to making jewelry after 5 to 6 weeks
of exercising in physical therapy, along with home exer-
8 Yvonne is a 55-year-old female who had an RCR for a
5cm tear. She had surgery 4 weeks ago and has been
immobolized in a sling since surgery. She is coming to
cises. This patient was motivated and compliant. you for her first visit. Her physician wants her to use the
sling for another week to 2 weeks. Should this be a
6 Ruth is a 65-year-old sedentary female who had an RCR

10 weeks ago. She continues to demonstrate a moderate
shoulder hike with elevation above 70. What exercises
concern regarding her rehabilitation program?
If the patient demonstrates greater than l20 with shoul-

need to be emphasized to eliminate this movement der flexion without a leathery or hard end feel then she
dysfunction? should progress normally with ROM in therapy while
using the sling for another 2 weeks. However, if she has
Exercising the muscles that promote shoulder depres- a history of shoulder capsulitis, or stiff joints after surgery
sion with elevation is critical. These muscles would or injuries, or the ROM is limited to less than 120 of
include the rotator cuff, especially the infraspinatus elevation with PROM, then the therapist may want to
muscle. The serratus anterior also keeps the humeral make the physician aware of these concerns.
head depressed with elevation and the biceps help to
keep the humeral head in place. Because Ruth is an older
sedentary woman, she would have more success initially
with the shoulder girdle depression exercises using a
9 James is a weekend athlete who had an RCR 6 weeks
ago. His shoulder had been getting progressively worse
for many years. The surgery went well and hes been
Swiss ball. Other exercises are mentioned in the chapter. progressing nicely with PROM to his shoulder. After
Having her elevate her arm in front of a mirror while she PROM has been done to his shoulder then shoulder
concentrates on maintaining a depressed shoulder is flexion is 0 to 160. He complains of a moderate pain on
also very helpful. Exercising the shoulder flexors in the superior aspect of his shoulder near the end ranges
eccentric contractions also proved helpful. of shoulder flexion and abduction. Pain at end of range
is slowing progress with ROM. Slight tenderness with
7 Christine is a young mother who had a rotator cuff

repair 6 months ago. She is returning to therapy because
deep pressure is noted over the AC joint. No complaints
are made about cervical pain when asked.
AROM for cervical rotation and lateral side bending body causes pain. What are your thoughts, given
are within functional limits; however, it is slightly only the above information?
diminished with right rotation and, left and right side
Most likely the biceps tendon is inflamed. This may have
bending. What needs to be investigated?
happened during the initial fall. The biceps are one of the
primary humeral head depressors during shoulder move-
With further evaluation, the therapist noted tenderness
ment and the biceps are used for shoulder elevation. The
with right unilateral posterior anterior pressures over
biceps tendon can get over used, especially if already
C3-4 and C4-5. There was minimal tenderness with palpa-
strained. And if the rotator cuff is not functioning at its full
tion over the biceps tendon. Cervical musculature on the
capacity, there is an increased demand on the biceps.
right C/S area was tighter than on the left. The therapist
The patient had pain during AROM with flexion and
performed grade III mobilization techniques on the right
abduction. Manual muscle testing elbow flexion and
C3-4 and C4-5 facet joints. The therapist then retested the
forearm supination was pain free despite the irritation at
ROM for shoulder flexion. The therapist noted a 5 to 10
the tendon. Resisted shoulder flexion and abduction are
increase with shoulder flexion and slight decrease in
painful. Tenderness with palpation was noted over the
pain. The therapist then continued with another bout of
biceps tendon. Therefore the biceps tendon was treated
grade III right unilateral posterior anterior pressures fol-
for tendonitis.
lowed by some stretching to the right UT and right cervi-
11
cal musculature. Again ROM slightly increased and c/o
David is a 22-year-old athlete. He had a 5-cm RCR
pain diminished to a minimal level at end of range. After
8 weeks ago. He has been progressing with therapy
another treatment, ROM was within normal limits for the
and has full ROM for all directions. He is feeling
right shoulder in all directions.
good. What key issue needs to be addressed during
10
this next stage?
Silvia is a 45-year-old woman who fell onto her out-
stretched arm and obtained a rotator cuff tear. She Educate the patient regarding the importance of allowing
had a repair 14 weeks ago. She has been progressing the repair to heal. Active young men especially need to
but continues to have pain around the anterior, hear this warning. More healing needs to occur at this point
lateral, and superior area of the shoulder. She has full before much stress is applied. The patient needs to avoid
ROM. Resisted shoulder flexion and abduction with any substantial lifting or use of the affected arm and avoid
light weights increases the pain. The patient can overhead activities. The patient can perform light activities
perform resisted shoulder extension, resisted elbow with the hand at waist level or below. Light resisted exer-
flexion, resisted elbow extension, and resisted inter- cises will begin after 10 to 12 weeks. David feels great and
nal rotation and external rotation without much is eager to try new things. The therapist needs to explain
discomfort. No complaints are made of pain when that he will jeopardize the repair if he puts too much stress
carrying light objects close to her body. However, on the repair. He needs to know that he will feel great but
carrying objects or lifting objects away from her that is no indication that the repair is strong.
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CHAPTER 6
Superior Labral Anterior Posterior Repair
Timothy F. Tyler, Craig Zeman
INTRODUCTION SURGICAL INDICATIONS AND

CONSIDERATIONS
Superior labral anterior posterior (SLAP) lesions were not
realized until the advent of shoulder arthroscopy. Andrews, Cause
Carson, and McLeod1 were the first to describe labral tears The superior labral is part of the attachment of the long head
of the biceps anchor, but it was Synder2 who was the first to of the biceps.3,9,11,21 The role of the long head of the biceps is
classify them, outline their treatment, and describe four to be a humeral head depressor and an anterior stabilizer.7,10
basic types of lesions: I to IV (Fig. 6-1). Since then, several The SLAP area is in continuity with the anterior and poste-
other variants have been described. So as to not get caught rior labrum. Therefore a tear in the superior labrum can
up in the subtleties of the classifications, SLAP lesions can affect the entire labrum, and conversely a tear in the anterior
best be understood by how they are treated and by the or posterior labrum can disrupt the superior labrum. The
patients concurrent diagnosis. The two major ways that a classic mechanism to develop a SLAP lesion is force, which
SLAP lesion can be treated are by dbridement and repair. either pushes the humeral head over or pulls the humeral
SLAP lesions are seen in patients who either have instability head away from the superior labrum.8,22 The humeral head
or impingement, and the kind of rehabilitation patients will pull on the superior labrum and the biceps anchor
receive is determined by which factors they have. tearing them away from the glenoid.23,24 In addition, a tear
Overall, nonoperative management has proven unsuc- of the anterior or posterior labrum from a dislocation can
cessful for a large number of patients with unstable SLAP extend into the superior labrum. Repetitive overhead lifting,
lesions,1,3,4 but Edwards feels that a course of nonoperative which can pinch the superior labrum and pull on it in a
conservative management of nonsteroidal antiinflammatory downward fashion, can also cause degenerative SLAP tears.
drugs (NSAIDs) and physical therapy should be tried. A 50% In the deceleration phase of pitching, the biceps fires to stop
failure rate was observed in their study.5 In many studies, the elbow from hyperextending, which causes a force to be
patients underwent diagnostic arthroscopy at an average of placed across the superior labrum. It is this repetitive action
12 to 30 months from their initial symptoms. In one study, that is felt to cause SLAP lesions in pitchers.25
patients had an extended trial of activity modification and
rehabilitation exercises.6 Most patients had been treated with Clinical Evaluation
rest, physical therapy, steroid injections, and NSAIDs without The therapist should look in the patients history for an
relief of their symptoms before diagnostic arthroscopy. injury that placed an upward shear force across the
Arthroscopic tools, anchors, and sutures have continued to shouldera fall on an outstretched arm that was overhead
advance making the surgical treatment more effective and or that placed a traction force across the arm, a sudden grab
easier to perform.7-16 Treatment of these lesions is directed and pull on something, having the arm pulled forcefully
according to their type.* In general, type I and III lesions are (e.g., the shoulder getting pulled on while waterskiing)as
dbrided, whereas type II and many type IV lesions are well as mild instability in the shoulder with the repetitive
repaired.4,17-19 After all SLAP repairs, rehabilitation plays an throwing motion.26-28 Some patients can develop SLAP
integral part in the patients outcome.20 lesions with no apparent cause. In questioning for cause, it
is important to ask about repetitive overhead lifting and
throwing activities. Patient complaints can range from insta-
bility to a vague ache in the shoulder. Many patients can
*Tables detailing the rehabilitation guidelines for SLAP repair can be found show signs of impingement, and some have symptoms
on the CD. of locking, popping, and catching. No classic symptom
99
Fig. 6-1 SLAP lesions classifications. A, Type I. B, Type II. C, Type III. D, Type IV. (From Snyder SJ, et al: SLAP lesions of the shoulder. Arthroscopy 6[4]:
274-279, 1990.)
pinpoints a SLAP lesion. Many physical examination tests

have been described to help diagnose a SLAP lesion.4,17,20,29
The two most common are the Speeds test and OBrien test,
which are modified supraspinatus isolation tests and there-
fore can be positive if the patient has impingment.30 The
problem with diagnosing a SLAP lesion is that it is usually
found in combination with either impingement or instability.
Overall it appears that the primary authors of these tests
report overall good sensitivity and specificity but other
authors are unable to repeat their results when tested.31-39 The
clinician needs to be aware of other problems that can be
associated with SLAP lesions such as ganglion cyst, rotator
cuff tears, posterior instability, and acromioclavicular (AC)
joint arthritis.40-46
Diagnostic Testing Fig. 6-2 SLAP type I lesion. Fraying of the superior labrum.
Plain radiographs are of little use in evaluating a SLAP lesion.
Magnetic resonance imaging (MRI) with gadolinium is usually covers a portion of the superior glenoid; however, no
probably the best way to see a SLAP lesion.47-56 An MRI gross instability of the labral tissue exists. This lesion is com-
without gadolinium has been reported to have had some monly seen in patients with impingement or rotator cuff
success.57 The problem with an MRI is that it can be too tears. It is not usually seen in patients with instability and it
sensitive and tends to overread the lesion. A computerized does not seem to cause capsular laxity. These lesions are
tomography (CT) scan with contrast and three-dimensional simply dbrided down to the attached base of the superior
(3-D) reconstruction can also be used to see labral tears, but labrum with an arthroscopic shaver (Fig. 6-3).59
once again it can be too sensitive. A glenolabral cyst can be
seen on both MRI and CT scan and can be commonly caused Type II
by a SLAP lesion.58 These lesions have an unstable attachment of the superior
labrum. The base of the labrum is pulled away from the
SURGICAL PROCEDURE superior glenoid and is highly mobile (Figs. 6-1, B, and 6-4,
A). If the labrum pulls away from the superior glenoid more
The treatment of SLAP lesions is an arthroscopic procedure. than 3 to 4mm when traction is applied to the biceps tendon,
It is very difficult if not impossible to treat a SLAP lesion the tear is considered unstable.60-63 When the labrum is
open. Most SLAP lesions are found on diagnostic arthros- reduced, one will usually see a reduction in the capsular
copy; therefore the surgeon must be prepared to treat a SLAP volume and a change in the position of the anterior and
lesion at the time of surgery. posterior labrum to a more upright position (Fig. 6-4, B). A
type II lesion needs to be surgically reduced (Fig. 6-5, A and
Type I B). It is done through three portals: one posterior and two
These lesions are simply the fraying of the superior labrum anterior. Some type of anchor with suture attached will be
without any significant detachment of the labrum from the used to repair the tear. The detached labrum will be reat-
superior glenoid (Figs. 6-1, A, and 6-2). The frayed area tached to its anatomic position on the glenoid.
Chapter 6 Superior Labral Anterior Posterior Repair 101
Fig. 6-3 SLAP type I lesion after dbridement.
B
Fig. 6-5 A, SLAP type II lesion (repeat of tear probe picture RS). B, SLAP
type II lesion (repaired).
A
tissue. This can be done in a multitude of ways; the general

concept is as follows: A device with a loop on the end is
passed through the torn labral tissue. One end of the suture
is then placed into this loop, which is then pulled back
through the labral tissue pulling the suture through the
labrum. This process is repeated again so that both ends of
the suture are passed through the labrum. Using arthroscopic
tying techniques, the torn labrum is firmly reattached back
down to the bone of the glenoid (Fig. 6-6). Depending on
the size of the tear, more anchors may need to be used to get
a secure repair.
B Type III
A type III SLAP can be thought of as a bucket handle tear of
Fig. 6-4 A, SLAP type II lesion. Base of labrum pulled away from the
glenoid. B, SLAP type II lesion (repaired). the labrum (Figs. 6-1, C, and 6-7, A and B). The unstable
handle portion floats around inside the glenohumeral (GH)
joint, getting caught between the humeral head and the
Once the portals have been established, a burr is used to glenoid during shoulder range of motion (ROM). This pulls
dbride the bone of the superior glenoid under the torn on the labral and capsular tissue, producing pain in the
labrum. This exposes a bleeding bed of bone that will aid in shoulder. The portion of the labrum not involved in the tear
the healing process. Any loose or frayed ends of the labrum is normally firmly attached to the glenoid; therefore the
are dbrided down to a stable base, and an anchor is placed symptomatic part is the bucket handle tear, which can simply
into the prepared bone through the superior portal. The next be dbrided down to a stable base such as a meniscus
task is to pull the two suture ends through the torn labral tear in the knee.
labrum is stable, the torn part can be dbrided down to stable

tissue. The surgical options are much more complicated if
more than 30% of the biceps is torn. In a less active indi-
vidual, a good option would be to dbride the tear and
perform a biceps tenodesis. In a throwing athlete, the best
option might be to stabilize the labral tear like a type II lesion
and repair the tendon of the biceps. A repair would help
stabilize an unstable shoulder.
Combined Lesions
SLAP lesions can be seen with anterior and posterior labral
tears and with impingement and rotator cuff tears. All other
surgical lesions should be treated at the same time as the
SLAP repair. More times than not, the therapist will be reha-
bilitating patients who have undergone multiple procedures.
Fig. 6-6 SLAP type II lesion (repaired using sutures). There has been controversy over whether during a rotator
cuff repair a SLAP repair should be done. A review of these
papers would suggest that in middle-age patients, it is prob-
ably best not to repair the SLAP because this can lead to
increased stiffness after the surgery.64-66 In contrast, Levy and
associates67 demonstrated that predictable short-term surgi-
cal results and return to activity can be expected after repair
of type II superior labrum anterior posterior lesions in
patients younger than 50 years who have a coexistent rotator
cuff tear. It is important to understand every procedure
that has been done to the patient so that a proper treat-
ment plan can be designed.
OUTCOMES
Overall mixed results of operative treatment of SLAP lesions

A
and nonoperative care have been reported.68-71 Short-term
improvement can be seen in patients with just simple
dbridement, but at long-term follow-up, the patients had a
high failure rate.72 This failure is probably because the under-
lying instability was not addressed. Early treatment with
staple fixation yields good to excellent results in 80% of the
patients.68 The first reports of suture anchor repair had
100% success.29 A review of later reports using various tech-
niques of fixation have seen a success rate of about 85%.17,20,73
Stetson and associates4 reported on patients who had SLAP
repairs and no other procedures for whom an 82% success
rate was achieved. Recently, better results with longer
follow-up have been reported after type II SLAP repair, espe-
cially in those athletes with traumatic injury and repair.73,74
B
Properly performed treatment of SLAP lesions is a reliable
Fig. 6-7 A, SLAP type III tear (unstable bucket handle tear). B, SLAP type procedure.
III tear dbrided much like resolving a bucket handle tear in the knee
meniscus. THERAPY GUIDELINES FOR
REHABILITATION
Type IV Postoperatively, the shoulder is placed in a sling without a
This lesion involves a bucket handle tear of the labrum, swathe for 2 to 4 weeks to minimize biceps muscular activity
which extends into the biceps tendon (Figs 6-1, D, and 6-8, and protect any additional structures addressed during the
A-C). Treatment of these lesions depends on the extent of surgical procedure. The position of the arm is in internal
the tear and the age and activity level of the patient. If at least rotation (IR) slightly anterior to the frontal plane. Because
30% of the biceps remains and the remaining portion of the the early labral tensile strength is weak, the early rehabilita-
pillow under their elbow to support the shoulder may take

stress off the labrum and reduce discomfort. Modalities can
be useful tools in providing pain relief. The level of pain,
postoperative swelling, and type of SLAP tear that was surgi-
cally addressed will determine progression of the patient.48,49
As the treating clinician, good communication with the
surgeon is essential to proper care.48 Understanding the spe-
cific procedure, concomitant injuries, and tissue quality may
also affect the level of progression.
The rehabilitation process will focus on four keys to
success:
1. Regaining ROM
2. Providing scapular stabilization
A 3. Restoring posterior shoulder extensibility
4. Returning rotator cuff strength
Phase I (Early Protective Phase)

TIME: Day 1 to 4 weeks after surgery
GOALS: Protect surgical procedure, educate patient on
procedure and therapeutic progression, regulate
pain and control inflammation, initiate ROM and
dynamic stabilization, neuromuscular reeducation of
external rotators and scapulothoracic muscles
Initial Postoperative Examination

Outpatient physical therapy can begin as early as 3 days
B after SLAP repair. At this time the mobility of the sternocla-
vicular (SC) joint, AC joint, and scapulothoracic joint are
addressed and mobilized if indicated. Initial evaluation doc-
umentation should include the observation of the portal
sites, atrophy, swelling, posture, and functional difficulties.
Observation and documentation of ROM and general will-
ingness to move the shoulder and neurovascular measure-
ments should be documented. Care should be taken to
avoid contracting the biceps (active elbow flexion) until
week 2. Tests to assess shoulder instability or labral pathol-
ogy at this point would be inappropriate.
Early Protective Postoperative Rehabilitation

Once the milestone of mobility of the proximal joints is
C obtained, manual scapular stabilization is initiated. In the
side-lying position, manual resistance can be given to the
Fig. 6-8 A, SLAP type IV bucket handle tear that extends into the biceps scapula to resist elevation, depression, protraction, and
tendon. B, SLAP type IV bucket handle tear, dbrided and prepared for retraction (Fig. 6-9). Pain can be a limiting factor for starting
suturing. C, SLAP type IV repaired using sutures.
scapular stabilization and rotator cuff isometrics; however,
submaximal pain-free alternating isometrics for IR and
external rotation (ER) may begin as early as 7 days after
tion program is more conservative than other open- surgery (Fig. 6-10). Because the rotator cuff muscles are not
stabilization procedures.29,47,68 violated, this exercise can begin with the arm at the side.
The main focus of the early protective postoperative Early mobilization exercises such as the pendulums are rec-
period (up to 4 weeks) is to maintain proximal and distal ommended for pain relief and could prevent adhesions from
strength and mobility, provide pain relief, and prevent forming. Pendulums have been shown to produce very little
selective hypomobility of sections of the capsule as a result muscular activity and are considered to be a safe exercise
of iatrogenic change from the surgery. During this period, during this period for most shoulder surgeries.58
elbow ROM and gripping exercises are encouraged. The However, some surgeons feel the arm hanging in a
authors have found that instructing patients to sleep with a dependent position may put unwanted stress on the
Fig. 6-9 Mobilization and rhythmic stabilization position for the scapula.
Fig. 6-11 Dynamic hug exercise.
Early strengthening of the serratus anterior muscle is also

encouraged if it is maintained slightly below 90 of shoulder
flexion and is pain free. Subsequent atrophy of the serratus
anterior muscle, as a result of immobilization, may allow the
scapula to rest in a downwardly rotated position, causing
inferior border prominence. Decker and associates75 used
EMG to determine which exercises consistently elicited the
greatest maximum voluntary contraction (MVC) of the ser-
ratus anterior. It was revealed that the serratus anterior
punch, scaption, dynamic hug, knee push-up with a plus,
Fig. 6-10 Rhythmic stabilization exercise for internal rotation (IR) and and push-up plus exercises consistently elicited more than
external rotation (ER) in 0 of abduction. 20% of MVC. Most importantly, it was determined that the
push-up with a plus and the dynamic hug exercises main-
repaired labral. Initiation of active assistive range of motion tained the greatest MVC, as well as maintained the scapula
(A/AROM) using a pulley for sagittal plane flexion and scap- in an upwardly rotated position (Fig. 6-11). Although it
ular plane elevation is advised. In addition, a cane, golf club, would be too early in the rehabilitation process to perform
or umbrella can be used to assist with regaining flexion, these later exercises, Decker and associates75 highlighted the
abduction, adduction, and ER at 0 and 30 of abduction (or serratus anterior punch as a valuable exercise. Performed in
where the surgeon sets the shoulder during surgery). Gentle a controlled, supervised setting, this is an excellent choice to
mobilization (grades I and II) consisting of posterior glides initiate early serratus anterior strengthening. Transition to
can be performed at this time for pain relief. the more challenging serratus anterior exercises should
occur after 8 weeks and be based on logical exercise
Contraindications progression.
No ER past the set point for 3 weeks A fine line exists between pushing patients too hard
No ER in the 90/90 position for 6 weeks to avoid the and progressing them as planned. Often patients may feel
peel-back mechanism better than expected during this early protective phase, so
No active biceps contraction for 4 weeks therapists must always respect the laws of tissue healing.
Three milestones to achieve for progression to the next phase potentially limit progress, considering a tight posterior
of rehabilitation are (1) to educate the patient on the proce- capsule is thought to cause anterior-superior migration of
dure he or she had and what to expect during the rehabilita- the humeral head with forward elevation of the shoulder,
tion, (2) to provide some pain relief so that the patient is able possibly contributing to a SLAP tear.80 If posterior shoulder
to tolerate submaximal isometrics of the rotator cuff muscles tightness and a decrease in IR ROM are observed, careful
at 0 abduction, and (3) to attain symmetrical mobility of the assessment must be undertaken. The Tyler test for posterior
SC, AC, and scapulothoracic joints, as well as the ability to shoulder tightness can be performed to determine if poste-
protract, retract, elevate, and depress the scapula against sub- rior shoulder tightness is present (Fig. 6-12).79,81 Recently
maximal manual resistance. A/AROM goals include achiev- Mullaney and associates82 have made the measurement
ing flexion to 110 to 130, abduction to 70, scapula plane easier and shown its reproducibility using a digital level. To
IR to 60, and scapula plane ER to set point. further determine if the loss of IR is due to capsular contrac-
ture, a posterior glide must be performed (Fig. 6-13). An
effective method of stretching this area is to stabilize the
Phase II (Intermediate Phase) patients scapula at the inferior angle manually while the
patient provides a cross-chest adduction force in the supine
position (Fig. 6-14). Further stretch may be felt by having
GOALS: Normalize arthrokinematics, gains in
neuromuscular control, normalization of posterior
shoulder flexibility
During weeks 5 to 8, three visits per week should focus

on the return of scapular stability and GH ROM. Later in
this period, rotator cuff isotonic strengthening is initiated.
During this period, the patient removes the sling, and more
aggressive A/AROM exercises are initiated. These exercises
may include the use of a pulley or cane to assist in forward
elevation in the plane of the scapula and IR. Initially, ER
stretching is performed in the guarded neutral position with
the arm at the side, and then it is progressed into the scapular
plane. While progressing through rehabilitation, the thera-
pist should always consider patients morphology, under-
standing if they are hypermobile by nature and returning
motion quickly and easily; if so, they do not need to be
pushed.
Patients with excessive joint laxity or generalized joint
hypermobility must be progressed under a watchful eye.76
Excessively stretching ER in the 90/90 position in these
patients too early during their postoperative care may jeop- Fig. 6-12 The Tyler test for posterior shoulder tightness.
ardize the end result. Burkhart and Morgan77 discovered the
peel-back mechanism, which can occur during rehabilitation
when ER is forced passively in the 90/90 position before
healing has occurred. Kuhn and associates78 demonstrated
failure of the biceps superior labral complex in 9 of 10 cadav-
eric shoulders when the biceps was tensioned in the cocking
position. The peel-back phenomenon occurs when the
biceps-labral complex is abducted and externally rotated
causing a posterior biceps vector, and shearing the biceps
anchor repair off its origin.
One therapeutic intervention that can assist in decreasing
tension in the biceps-labral complex is restoring posterior
extensibility. By restoring posterior capsule extensibility, it
allows the humeral head to centralize in the glenoid fossa
and not be forced anterior. A tight posterior capsule forces
the humeral head anterior, creating unwanted tension in the
biceps-labral complex as the phenomenon occurs. Stretching
and mobilization of the posterior capsule should be empha-
sized because tightness of the posterior shoulder structures Fig. 6-13 A posterior glide in the plane of the scapula to distinguish pos-
has been linked to a loss of IR ROM.79 Loss of mobility can terior capsule tightness.
Fig. 6-14 Supine scapula stabilized assisted posterior shoulder stretch.

Fig. 6-15 Shoulder oscillation in the plane of the scapula keeping the wrist,
elbow, and shoulder steady.
the patient add slight pressure into IR by pressing inferiorly with straight arms just below 90 of shoulder flexion; and
on the dorsal aspect of the hand or wrist. This posterior (3) shoulder oscillation in the plane of the scapula, keeping
shoulder protocol has been shown to be effective in the cor- the wrist, elbow, and shoulder steady (Fig. 6-15). Finally, in
rection of posterior shoulder tightness in patients with inter- the later phases of rehabilitation, the patient can progress to
nal impingement, six of which were more than 6 months more demanding open and closed kinetic chain scapular
after SLAP repair.83 strengthening exercises.
Passive range of motion (PROM) of ER and abduction Strengthening exercises should progress to resistance
should be limited to 65 and 70, respectively, as to not put training with elastic bands for IR, ER, abduction, and exten-
stress on the healing biceps-labral complex. Initial ROM sion. Maintaining the GH joint in the scapular plane (30 to
goals are to achieve within 10 of full IR and 150 to 165 of 45 anterior to the frontal plane) will minimize the tensile
passive flexion in the plane of the scapular. The goal is to stress placed on the labral repair.93
maintain available mobility and prevent excessive scarring. The authors have found that giving verbal feedback to
Similar to Burkhart and Morgan84 and Burkhart, Morgan, lift the chest up and pinch the shoulders back can facilitate
and Kibler,85 isotonic strengthening exercises are initiated for scapular stabilization while training the external rotators.
abduction, scaption, IR, and ER in the scapular plane.86 In Hintermeister and associates94 found shoulder elastic resis-
addition, rhythmic stabilization at the end ROM can be per- tance training to have a low load on the shoulder and there-
formed at this time. To have normal scapulohumeral rhythm, fore to be safe for postoperative patients.
dynamic scapula stability of this joint needs to be restored. It is our opinion that the use of free weights with the arm
Scapula exercises are encouraged in this phase of rehabilita- in a dependent position should be used accordingly during
tion to counteract scapulohumeral dissociation and provide this period to minimize the potential for detrimental humeral
a stable base of support for active range of motion (AROM) head translation. Side-lying ER is typically initiated during
to be performed.87 Recently, the authors of this chapter the later portion of this phase (Fig. 6-16). Proper technique,
reported on the importance of scapula stability in generating weight, and ROM are important to execute this safely. Stabi-
shoulder rotation torque in microinstability patients. The lizing the humerus to the thorax and not allowing the elbow
results of the authors study demonstrated patients with to drift past the frontal plane of the body will place minimal
microinstability exhibited a significant decrease in peak winding on the labral repair.
shoulder ER and IR torque after exercise-induced fatigue of At this phase, minimal weight should be used within
the scapular stabilizer.88 Many authors have examined the the comfortable ROM to prevent ill-advised stress to the
EMG activity during scapular strengthening exercises; healing biceps-labral complex. It may also be recommended
however, when choosing the appropriate exercise, the clini- that the patient wait until the end of the intermediate post-
cian must keep the activity pain free and protect the surgical operative period to initiate jogging or running for this same
repair.89-92 Three relatively low-level exercises the authors like reason (the humeral head may be forcibly thrusted anteri-
to use after SLAP repair are (1) elastic resistance rows (not orly). It is imperative that the therapist maintain supervision
to brake the frontal plane with the involved elbow); of the ROM progression during this period to protect the
(2) standing scapular retraction against elastic resistance healing tissue.86 Clinical milestones to progress to the next
Fig. 6-16 External rotation strengthening in the side-lying position with

a free weight.
phase of rehabilitation include (1) achieving 160 of flexion

in the scapular plane, (2) scapular plane ER to 65, (3) ER at Fig. 6-17 Sleeper stretch for gaining internal rotation.
90 abduction to 45, (4) near full IR in the scapular plane,
(5) IR at 90 abduction to 45, (6) 150 of abduction, (7)
symmetrical posterior shoulder flexibility, and (8) improved
isotonic internal and external strength in available ROM. An arm upper body ergometer (UBE) using light resis-
tance can be beneficial at this time to facilitate ROM and
initiate active muscular control of the shoulder.
Phase III (Strengthening Postoperative Phase) The axis of rotation of the UBE should remain below
the level of the shoulder joint so as not to force forward
flexion above 80. To avoid stress to the biceps-labral
GOALS: Normalize ROM, progression of strength,
complex, the patient should be positioned at a distance from
normalize scapulothoracic motion and strength,
the axis of rotation that does not allow the elbow to move
overhead activities without pain
posterior to the frontal plane when performing ergometer
During weeks 9 to 14 (usually two to three treatment ses- revolutions. This exercise is not initiated earlier because the
sions per week), rehabilitation continues to work toward full amount of stress placed on the biceps-labral complex during
GH ROM and dynamic stability of the humeral head in the the use of an UBE is unknown.
glenoid fossa. Gaining or maintaining full AROM within 10 When designing the strengthening program, it is impor-
of flexion in the sagittal plane and ER are to be achieved later tant to match patients needs with their limitations and goals.
during this time phase. At this time, regaining ER, abduc- A properly designed strengthening program will address
tion, and flexion does not seem to be a limiting factor for their needs by attempting to get the most benefit from each
recovery. Once the patient has achieved the milestone of 70 exercise prescription. Previous EMG studies have set forth
to 80 ER in the plane of the scapula, he or she will begin to which shoulder exercises activate particular muscles, and
acquire ER ROM at 90 of abduction. Although in the past these should be considered as the clinician prescribes a
it has been expected that the patient will have full AROM 8 program.58,75,76,90,91 We have combined many of these pro-
weeks after SLAP repair, most patients do not achieve this at grams to address generalized specific weaknesses. From
8 weeks. In our experience, ER and IR ROM measured in the these studies, we have developed the prone program plus
supine position with the GH joint abducted 90 typically to address scapular stability and generalized weakness. The
does not achieve full ROM until 10 to 12 weeks or longer, prone program plus can be started in this phase of the reha-
depending upon the patient. bilitation if the exercises are pain free. The prone program
It is at this point that a sleeper stretch may safely be plus includes prone GH horizontal abduction with GH IR
given to a patient to regain passive IR ROM (Fig. 6-17). (thumb down), prone scapula adduction with GH ER (thumb
This is in agreement with other authors who demonstrated up), prone rows, prone shoulder flexion in the scapular
a lack of full return of ROM in patients 12 weeks after SLAP plane, prone 90/90 ER, push-ups with a plus (therapist
repair.84,85,95,96 In our opinion, the key to a successful rehabili- initiates exercise in quadruped), and ball press downs.
tation of these patients, at this phase, is finding the balance Patients can easily get into poor habits or begin performing
point between stretching ER and letting them naturally these exercises with improper form. It is recommended that
regain their ROM. clinicians educate their patients on these exercises and allow
ample time for them to develop proper form before prescrib- new visual technique that may help clinicians standardize
ing these as part of a home program. categorization. This dynamic technique categorizes the dys-
Proprioceptive neuromuscular facilitation (PNF) can be kinesis in one of four groups:
described as movements that combine rotation and diagonal Type Iinferior angle prominence (horizontal plane
components that closely resemble the movement patterns movement)
required for sport and work activities. PNF acts to enhance Type IImedial border prominence dorsally (frontal
the proprioceptive input and neuromuscular responses while plane movement)
stressing motor relearning in the postoperative phases of Type IIIshoulder shrug motion without winging (sagit-
rehabilitation. PNF patterns are initiated with the scapula tal plane movement)
because scapular stability is essential for total function of the Type IVbilaterally symmetrical movement (normal
shoulder. Scapular patterns are generally performed in the movement)
side-lying position, with the head and neck in neutral align- Like all scapular categorization techniques, the therapist
ment. The coupled patterns of anterior elevationposterior must be concerned with combined movements, a learning
depression and anterior depressionposterior elevation are curve, and patient experience; however, it does present clini-
used, respectively. Trunk rotation should eventually be com- cians with a valuable tool that, with practice, may enhance
bined with scapular and extremity PNF patterns to maximize clinical communication.
combined muscular movement patterns. Techniques such as The authors also believe that exercises directed toward
hold-relax, slow reversals, and contract-relax are used spe- facilitation of functional muscular firing patterns in both the
cifically to improve motion, whereas rhythmic stabilization, open and closed chain may provide useful input for return
repeated contractions, and combination isotonics are used to function after SLAP repair. Lear and Gross93 demonstrated
to enhance concentric and eccentric muscle action. Specifi- scapular muscle activity increases with a wall push-up
cally, the D2-flexion pattern combines flexion, abduction, progression. However, the strain on the biceps-labral
and ER, emphasizing the posterior rotator cuff and posterior complex is unknown and may be too great for patients
deltoid (Fig. 6-18). These neuromuscular control exercises after SLAP repair. This exercise should be gradually built
strive to reestablish scapular positioning and stability of the up to and proceeded to with caution. Clinicians should
humeral head in the glenoid.87 hold this exercise until the advanced strengthening postop-
As the patient progresses through the program, periodical erative phase to protect the healing tissue.
reevaluation of the scapular dyskinesis is highly recom- Isotonic exercises emphasizing light resistance and
mended. The authors stress this, especially as the patient increased repetitions are used for isolated and combined
gains full ROM and may no longer be inhibited by tight movement patterns of the shoulder. The authors use a pro-
soft tissue structures. The term scapular dyskinesis, gression from three sets of 10, to two sets of 15, and on to
although indicating that an alteration exists, is a qualitative one set of 30 repetitions. If the patient can perform one set
collective term that does not differentiate between types of of 30 repetitions with good form and no substitution, he or
scapular positions or motions.97 Therefore scapular evalua- she can be progressed to 1- to 2-lb weights and back down
tion and categorization is challenging. The most common to three sets of 10 to repeat the cycle. This rationale is based
techniques for objective quantification include visual evalu- on lending objectivity to the progression and the tonic nature
ation, the lateral scapular slide test (LSST), and 3-D tech- of the rotator cuff muscles and the scapular stabilizers. Iso-
niques. Kibler and associates97 have recently introduced a lated exercises are used to enhance or increase the strength
of a particular muscle. Combining isotonic exercises in
functional-movement patterns are performed with PNF pat-
terns using elastic resistance or the cable column to enhance
coordinated movement. In the case of a swimmer, the D1
pattern with elastic resistance will lead to a carryover to his
athletic function. Initiation of isokinetic strengthening at
this phase may enhance the shoulders ability to strengthen
in a pain-free ROM. It is encouraged that slower speeds be
used when strengthening patients with shoulder instability.
Isokinetic principles suggest that faster isokinetic speeds
create greater translational forces, whereas slower speeds
create stronger compressive forces (which stabilize the
shoulder). Milestones that should be met to move to the next
rehabilitation phase include (1) within 10 of full AROM in
flexion, abduction, IR, and ER in the plane of the scapula;
(2) normalized scapulothoracic motion and strength; (3)
moderate overhead activities without pain; and (4) isometric
internal and external strength should be at least 50% that of
Fig. 6-18 D2 flexion with manual resistance. the uninjured side.
potential. If the exercise movement is slow, such as in weight

Phase IV (Advanced Strengthening Phase) lifting, the energy is dissipated and nonproductive. However,
with rapid movement, this stored elastic energy can be used
to generate a force greater than that of the concentric con-
GOALS: Pain-free full ROM, improve muscular
traction of the muscle alone. Plyometrics use the principles
endurance, improve dynamic stability
of progressive loading with the ultimate goal of power devel-
After 15 weeks the patient is in the final phase of rehabili- opment. Using a trampoline will increase the EMG activity
tation. Full AROM should be attained at this time. The only and elevate the level of eccentric loading of the shoulder
restriction on ROM is that ER should not be stretched rotators.99 Therefore a progression from two-handed, side-
beyond 90. It may be preferable to allow the athlete to regain to-side throws to overhead throws to one-handed overhead
additional degrees of ER over time rather than stress the throws is encouraged to maximize the power development
biceps-labral complex, potentially stretching the repair. of the overhead athlete. A well-rounded program will address
Posterior capsule stretching is appropriate if full IR has both the internal and external rotators of the shoulder,
not been obtained yet. Performing the side-lying sleeper together with the core muscles of the trunk. Externally chal-
stretch encourages ROM for IR (see Fig. 6-17). At the onset lenging the patient, by permitting stability from a naturally
of this phase, a thorough strength assessment is needed to unstable surface, such as a ball, will challenge the entire
evaluate the direction of strengthening needed for the par- kinetic chain. Advanced exercises, such as the Physioball
ticular patient. This assessment may include manual muscle walk outs, exemplify this concept (Fig. 6-20). As the patient
testing, hand-held dynamometry, and isokinetic strengthen- walks out from the ball with the hands, core stabilizers, as
ing (or a combination of these techniques). Assessment well as GH stabilizers, are challenged. Milestones to progress
should include the primary shoulder movers, shoulder rota- to the final phase of rehabilitation include (1) pain-free full
tors, and scapula stabilizers. Results of this assessment should ROM, (2) less than 20% strength deficits for IR and ER at
be addressed with a well-rounded strengthening program to 90/second, and (3) 20% strength deficits in all positions.
include isotonic, concentric, and eccentric loading exercises.
When designing these programs, consider the everyday
demands of each patient. For an overhead-throwing athlete, Phase V (Return-to-Activity-and-Sport Phase)
strengthening in the throwing position is imperative (Fig.
TIME: 4 to 6 months after surgery
6-19). Once this phase of rehabilitation is reached, treatment
GOALS: Pain-free full ROM, normalized strength, return
should begin to streamline toward the functional demands
to sport or activity program
of the patient.98
Initiation of a properly designed plyometric training This is the phase of rehabilitation at which very few thera-
program is often the missing link to discharging a high-level pists have the opportunity to discharge patients.
patient. Plyometric training for the upper extremity is used All too often patients lose interest, exhaust insurance cov-
to generate rapid and powerful muscular contractions in erage, or just neglect the importance of fine-tuning their
response to a dynamic stretchinducing load to a muscle or shoulders before fully returning to their lifestyle. This stage
group of muscles. It is suggested that plyometrics train the is designed to prepare patients to return, without hesitation,
entire neuromuscular system, using the principles of stored to full participation in all activities. Milestones to success-
elastic energy to use strength as quickly and forcefully as fully complete this phase include (1) total confidence in the
possible. The myotatic stretch reflex develops stored elastic shoulder, (2) pain-free full ROM, and (3) an isokinetic or
hand-held dynamometry with less than 10% deficit in all
positions.100
Fig. 6-19 External rotation strengthening in the 90/90 position with

elastic resistance. Fig. 6-20 Physioball wall walkouts.
Exercises in this phase continue to emphasize functional based on the performer, the pathology, and the performance
positions, including the plyometric program (isokinetic demands. Exercise prescriptions should not be viewed as
strengthening at 90 of abduction). A gradual return to sport protocol but as guidelines upon which to base rehabilitation.
is permitted once the patient is pain free, has nearly full These rehabilitation guidelines are outlined in Box 6-1.
ROM in all planes, confidence in the shoulder, and 85% to
90% of the strength of the opposite side on isokinetic testing TROUBLESHOOTING
at 90, 180, and 300/second for IR and ER motions.
Confidence is achieved with the ability to perform pain- Hypomobility and Hypermobility of the
free functional movement in the patients sport. Our experi- Glenohumeral Joint
ence has demonstrated that the throwing athlete requires an In the process of rehab after a SLAP repair, it is not uncom-
additional 1 to 2 months to allow the shoulder to adjust to mon to have difficulty restoring a patients normal ROM.
the motion. Patients also report that it takes up to 1 year With these hypomobile patients, it is necessary to begin early
before the shoulder feels normal after SLAP repair. We mobilization and stretching to regain normal arthrokinema-
currently are using the American Shoulder and Elbow Sur- tic and osteokinematic motion. Using grade III and IV mobi-
geons Shoulder Evaluation Form to standardize the docu- lizations can help to increase capsular pliability, especially in
mentation of pain, motion, strength, stability, and function. the posterior and inferior directions.
Although it remains difficult to gather enough data to deter- The therapist should avoid stretching patients into
mine a criterion score for return to sports, once 6 months the apprehension position without applying a posterior
have passed and clinical milestones have been met, the relocation force because this may cause impingement
athlete is cleared for full throwing. This time frame is in internally.
agreement with other authors findings101 (Table 6-1). After SLAP repair, some patients will experience a hyper-
mobility issue. Often times this is due to generalized ligament
SUMMARY laxity that affects all joints. This is tested by thumb-to-fore-
arm, metacarpophalangeal and distal interphalangeal exten-
Considerations must be given if additional procedures are sion, as well as elbow and knee recurvatum. These patients
performed for reattachment of the labrum, ligaments, or the will regain normal ROM on their own as they progress to
biceps tendon. However, stronger fixation techniques have doing functional movements of the shoulder. Therefore it is
allowed the rehabilitation to progress more rapidly with necessary for the therapist to mobilize and stretch the GH
these procedures. These guidelines are a continuum of reha- complex. It is important to progress these patients more
bilitation phases based on the effect the surgery has on the slowly and allow them to regain the motion on their own.
tissue and the surrounding structures. Scientific rationale is
applied whenever possible; however, as surgical procedures Poor Scapular Stabilization
evolve, so must the rehabilitation. These guidelines are by no Scapular dyskinesis, or poor scapulohumeral rhythm, is
means set in stone, and all exercises are not distinct to par- often a problem that patients and therapists face after SLAP
ticular phases. The goals and exercises need to be modified repair surgery. Poor scapular stability may have been a
TABLE 6-1 Time to Return to Sports After SLAP Surgery

Study Year Surgery Type of SLAP Population Return to Sports* Full Throwing
Yoneda, et al68 1991 Repair Type II Athletes ND ND

Resch, et al102 1993 Repair Type II Not specified 6 months ND
Cordasco, et al72 1993 Dbridement Type II Not specified ND ND
Pagnani, et al6 1995 Repair Types II & IV Not specified 4 months 6 months
(not specified)
Field & Savoie29 1993 Repair Types II & IV Not specified ND ND
Berg & Ciullo103 1997 Repair Types II & IV Not specified ND ND
Segmuller, et al104 1997 Repair Types II & IV Not specified 6 months ND
Morgan, et al105 1998 Repair Type II Athletes & nonathletes 4 months 7 months
Samani, et al106 2001 Repair Type II Athletes & nonathletes ND ND
OBrien, et al30 2002 PAL, repair Type II Athletes & nonathletes ND ND
Jazrawi, et al107 2003 Repair with ATCS Type II Athletes 3-4 months 11.2 months
ATCS, Arthroscopic thermal capsular shift; ND, not documented; PAL, partial anterolateral acromioplasty.
*In most papers, time to return refers to the initial return, not to full return.
Data from OBrien SJ, et al: The trans-rotator cuff approach to SLAP lesions: Technical aspects for repair and a clinical follow-up of 31 patients
at a minimum of 2 years. Arthroscopy 18(4):372-377, 2002.
BOX 6-1 Rehabilitation Guidelines for SLAP Repair

I. Early Protective Phase (0 to 4 Weeks) Normalization of posterior shoulder flexibility
A. Goals: Limit PROM of ER/ABD to 65 to 70 to protect the
Protect surgical procedure healing biceps/labral complex
Educate patient on procedure and therapeutic B. Treatment plan:
progression ROM progression
Regulate pain and control inflammation Flexion in the scapula plane passively 150 to 165
Initiate ROM and dynamic stabilization ER in the scapula plane to 65
Neuromuscular reeducation of external rotators and IR in the scapula plane, full or to within 10
scapulothoracic muscles Initiate joint mobilizations as necessary

B. Treatment Plan (0 to 2 Weeks): Initiate posterior capsular stretching
Sling immobilization for 2 to 4 weeks Progress strengthening
IR/ER (with GH in the scapula plane) with elastic
Gripping exercises
Elbow, wrist, and hand ROM band
Side-lying ER
Pendulum exercises
Scaption full can (no weight if substitution patterns)
Shoulder PROM F/ABD/IR/ER Do not go beyond the
Clockwise/counterclockwise ball against wall
position set at time of surgery for ER (progress flexion
Body Blade at neutral or rhythmic stabilization
to A/AROM)
IR and ER proprioception training (controlled range) C. Milestones for progression:
Initiate gentle alternating isometrics for IR and ER in Forward flexion to 160
0 abduction to scapular plane ER in scapular plane to 65
Initiate passive forward flexion to 90 Full IR in scapular plane
Initiate scapular mobility Symmetrical posterior capsule mobility
C. Treatment Plan (2 to 4 Weeks): Progressing isotonic strength with IR and ER in
ROM progression available range
Forward flexion to 110 to 130
III. Strengthening Phase (9 to 14 Weeks)
ER in scapular plane to 35 (position set at time of
A. Goals:
surgery) Normalize ROM
IR in scapular plane to 60
Progression of strength
Progress submaximal alternating isometrics for IR and Normalize scapulothoracic motion and strength
ER in scapular plane Overhead activities without pain
Initiate scapular strengthening
Manual scapula retraction B. Treatment plan:
Resisted band retraction ROM progression; stretching ER at 90 of GH
(Note: No shoulder extension past trunk) abduction
Within 10 of full AROM in all plans
Deltoid isometrics in all directions
Biceps-triceps strengthening Progression of scapular retractors and stabilizers
Prone program; LT, MT, rhomboid
Initiate light band work for IR and ER
LT; scapular depression
D. Milestones For Progression: Progress strengthening
Forward flexion to 90 Challenging rhythmic stabilization
Abduction to 70 Upper body ergometer
ER in scapular plane to 30 Initiate isokinetic IR and ER in scapular plan
IR in scapular plane to 20 Initiate IR and ER at 90 of GH abduction
Tolerance of submaximal isometrics Isotonic strengthening; flex, abduction
Knowledge of home care and contraindications Closed kinetic chain exercise
Normalize mobility of related joints (AC, SC, ST)

C. Milestones for progression:
II. Intermediate Phase (5 to 8 Weeks)
Within 10 of full active range in scapular plane
A. Goals: Isometric strength IR and ER less than 50% deficit
Normalize arthrokinematics Less than 30% strength deficits; primary shoulder
Gains in neuromuscular control muscles and scapular stabilizers
Continued
BOX 6-1 Rehabilitation Guidelines for SLAP Repaircontd

IV. Advanced Strengthening Phase (15 to 24 Weeks) C. Milestones for progression:
A. Goals: Pain-free full ROM
Pain-free full ROM Strength deficits less than 20% for IR and ER at 90
Improve muscular endurance of GH abduction
Less than 20% strength deficits throughout
Improve dynamic stability
B. Treatment plan: V. Return-to-Activity and Sport Phase (4 to 6 Months)
Maintain flexibility A. Goals:
Progress strengthening Pain-free full ROM
Advanced closed kinetic chain exercise Normalized strength
Wall push-ups; with and without ball Return to sport or activity program
Continue with overhead strengthening B. Treatment plan:
Continue with isokinetic IR and ER strengthening; Continue isokinetic training
90 of GH abduction
Advance isotonic strengthening
Continue with stability training
Advance plyometric training
Advance rhythmic stabilization training in various
Continue with closed kinetic chain exercise
ranges and positions
Initiate plyometric strengthening C. Milestones for activity:
Chest passes Confidence in shoulder
Trunk twists Strength deficits less than 10% throughout
Overhead passes Pain-free full ROM
90/90 position single-arm plyometrics Completion of return to sport or activity program
A/AROM, active assistive range of motion; AC, acromioclavicular; AROM, active range of motion; ER, external rotation; GH, glenohumeral;
IR, internal rotation; LT, lower trapezius; MT, middle trapezius; PROM, Passive range of motion; SC, sternoclavicular; ST, scapulothoracic;
UBE, upper body ergometer.
precursor that helped lead to the SLAP tear, or it may be a capsule and musculature. If the therapist is lucky enough to
direct result of the disuse after surgery and wearing a sling. see the patient before surgery, this can be addressed. In fact,
In these cases it is necessary to establish a stable base by the surgeon may do a posterior capsule release during the
working the rhomboids, middle and lower trapezius, and the SLAP repair.
serratus muscles in an endurance fashion. Because normal More often the posterior shoulder tightness needs to be
motion requires these muscles to be tonically active, it is treated after the surgery by the physical therapist. Focus-
necessary to work them to fatigue. Failing to establish this ing on the posterior shoulder will ensure recovery of total
stable base will lead to the peal-back mechanism occurring ROM.
when the arm is in the 90/90 position. Winging of the
scapula causes an increased anterior force on the humeral Impingement Symptoms During
head that will increase the traction force on the long head of Return-to-Activity Phase
the biceps as the arm moves up into the throwing motion. It Sometimes after SLAP repair, a patient will report back to
is important to avoid rotator cuff strengthening in the 90/90 the physical therapist with shoulder pain after returning to
position until scapulohumeral motion has been activity. It is not uncommon for an athlete to forget about
normalized. the home exercise program or fail to complete rehabilitation.
The athlete commonly complains of mechanical shoulder
Posterior Shoulder Extensibility impingement symptoms. If this is the case, it is helpful to
The throwing athlete has been known to have an increase in closely examine ER strength in the 90/90 position, poste-
ER ROM and a decreased/limited IR ROM. Not maintaining rior shoulder strength, and scapulohumeral rhythm. It is
total ROM with a severe loss of IR ROM may lead to a SLAP more than likely that one or all of these parameters have not
tear. The cause of the IR ROM loss may be a tight posterior been normalized before the patient returned.

Because the patient spends only an estimated 2 to 3 3. Dynamic Strengthening (9 to 14
hours per week with the physical therapist, it is what Weeks)
the patient does on his or her own that influences ER at 90 abduction with Thera-Band
the eventual outcome. Physical therapists are Sleeper stretch
teachers; they intervene manually when necessary UE stabilization in quadriplegic
but direct the rehabilitation based on the basic Door stretch
science of healing tissue. Adherence to a home Throwers ten
exercise program is crucial for a successful outcome Eccentric biceps curls, shoulder unsupported with
after SLAP repair. The home program for any supination
patient must be individualized based on the patients PNF D1, D2 pattern with Thera-Band
postoperative condition, age, nutritional status, Mirroring exerciseStand in front of mirror, flex
limitations, and individual needs. Frequency, sets, good arm to 45, copy motion with bad arm and
and repetitions are determined based on the eyes closed
therapists professional opinion of the expected
outcome. 4. Return to Sports
ER 90/90 position with Thera-Band, three sets to
1. Early (0 to 4 Weeks) fatigue
Shoulder and elbow A/AROM flexion Definitions of fatigue
Pendulums Failure to complete full ROM (0 to 90)
No active biceps activity Upper arm breaking the frontal plane
Isometric ER at 0 abduction Dropping of elbow
Scapula pinches, gripping exercises Maintain full IR at 90/90 position
Sleeper stretch
2. Intermediate (5 to 8 Weeks) Push-ups with a plus
Isotonic ER at 45 of abduction with Thera-Band Rows
Rows with Thera-Band (not to break the frontal Horizontal ABD, front raises, lateral raises,
plane with the involved elbow) posterior raises
Wall crawls Completion of interval throwing program
Side-lying ER with soup can
Golf club ER stretch at 45 (limit ROM of ER/ABD
to 65 to 70)
Scaption
Biceps curls, elbow supported (no support later, A/AROM, Active assistive range of motion; ABD, abduction;
6 to 8 weeks) ER, external rotation; PNF, proprioceptive neuromuscular facilita-
Ball proprioception tion; UE, upper extremity.
1 Aimee just felt a pop in her shoulder 4 hours ago while

throwing a softball from center field to home plate. She
has iced her arm and now arrives at your clinic to deter-
2 Tom is continuing to have pain after his nonoperative
rehabilitation of his type I SLAP tear. His MRI is not
showing any increased pathology to the biceps complex.
mine the possible source of pain. What special test What associated injury could be causing pain in his
might you perform during your physical examination to shoulder?
evaluate for a SLAP tear?
Other problems that can be associated with SLAP lesions
The Speeds test and OBrien test are commonly include ganglion cysts, rotator cuff tears, posterior insta-
used tests. bility, and AC joint arthritis.
3 Sally is a 42-year-old female who arrives at the clinic 4

days after a SLAP repair. In passing, she tells the thera-
pist that she has not been feeling well since surgery; she
trapezius muscle both at rest and with execution of exer-
cises and is using substitution patterns secondary
to abnormal scapulohumeral rhythm. Scapulothoracic
reports feeling rundown with a low-grade fever and joint mobility should be assessed, as well as posterior
fatigue the last few days. She is also complaining of shoulder musculature tightness and posterior capsule
severe aching around the shoulder joint. She notes her mobility.
pain as 10 out of 10, and nothing she can do will make Treatment should consist of soft tissue mobilization/
it better. It even hurts when I dont move, and it often massage to the upper trapezius muscle, scapulothoracic
wakes me up. Upon inspection the therapist notices mobilizations, and joint mobilization to surrounding
that the entire area around the shoulder is red, swollen, joints as appropriate, including the GH and sternocla-
and has moderate wound seepage. The area surrounding vicular joints. Special attention should be paid to execu-
the incision is hot to the touch, and the skin is very firm. tion of exercises. Because he tends to activate the upper
What is the most likely cause of the patients pain and trapezius muscles when performing shoulder move-
discomfort? ments, visual and tactile cues to keep the shoulders
down and back should be used, as well as visual or
Sally is exhibiting signs of a postoperative sepsis infec- EMG biofeedback for upper trapezius muscle inhibition.
tion. A feeling of general malaise and low-grade fever Scapular stabilization exercises to strengthen the serra-
are signs of systematic infection. Sally should be referred tus anterior and other parts of the trapezius should also
back to her physician immediately. be added to assist in scapular upward rotation.
4 Tom is a 52-year-old male who arrives at the clinic 4

weeks after a SLAP repair. By recommendation of his
physician, Tom has worn a sling religiously for the past
6 Shannon is a 47-year-old college professor who had
a SLAP repair 12 weeks ago on her dominant arm. She
is compliant with physical therapy and postsurgical
4 weeks. Upon the therapists initial evaluation, it is precautions. She comes to the clinic complaining of
noted that Tom has painful and severely restricted increased pain and discomfort when writing on the
motion in all planes. What is the most likely cause of chalkboard and reaching for things. Upon assessment,
Toms ROM deficit, and how would this deficit be treated the therapist finds poor scapulohumeral rhythm, a
most successfully? winging scapular, and the following postmanual muscle
testing (MMT) grades: serratus anterior 3/5, rhomboids/
Tom most likely has some iatrogenic GH adhesive cap- midtrapezius 3/5, and lower trapezius 2/5. Based on the
sulitis (i.e., frozen shoulder). Because he is still in the clinical findings, what therapeutic exercise should be
tissue-healing phase of his rehabilitation, the therapist added to Shannons program to resolve her complaints?
cannot use grade III or IV mobilizations to normalize
arthrokinematic motion because it may disrupt the The following therapeutic exercises should be added to
repair. Toms treatment should be with PROM and Shannons program: dynamic hugs, push-ups with a
A/AROM to decrease and prevent further loss of ROM plus, serratus punches, scaption, and manual scapula
secondary to adhesive capsulitis. He should be encour- rhythmic stabilization.
aged to remove his sling several times a day and perform
pendulum exercises to provide distraction and gentle
ROM. 7 At 12 weeks after SLAP repair, Lily has 45 of GH IR
PROM and 40 of AROM. She has been doing the
sleeper stretch but has not made any gains in ROM in
5 Dwight, who is 6 weeks postoperation for SLAP repair

of the right shoulder, presents for his initial evaluation
complaining of aching pain on the top of the shoulder
the last 4 weeks. How does the therapist determine if the
limitation in IR ROM is capsular or muscular to ensure
that the correct therapeutic exercises are prescribed?
laterally and posteriorly, with a feeling of shoulder tight-
ness. You notice that he holds his shoulder in a protec- The therapist should perform a Tyler test and a posterior
tive, hiked position. While observing him performing glide looking for side-to-side restriction. If the Tyler test
therapeutic exercises, you notice he shrugs his shoul- is positive but the posterior glide is negative, the thera-
ders bilaterally with performance of rows and on the pist can determine that the lack of IR is caused by muscle
right side with scaption AROM. What do you think is tightness and not capsular tightness.
the culprit of his complaints, what should be evaluated,
and what should your treatment plan consist of?
Based on his subjective complaints, he is likely experi-

8 Demetrius is 20 weeks s/p type II SLAP repair when he
begins to get anxious about returning to his recreational
baseball team in time for the playoffs, which start in
encing upper trapezius muscle tightness with pain being 2 weeks. How should the therapist determine when
referred to the distal insertion site of the muscle. Based he is ready to return to sports and at what level of
on objective observation, Dwight is overusing the upper competition?
A patient must first meet the return to activity/sport tendonitis has subsided. In addition, Steves rotator cuff
goals which include pain-free full ROM, normalized strength should be checked because the biceps will often
strength (i.e., <15% measured contralaterally), and the be overused as a humeral head depressor if the rotator
confidence necessary for the specific sport. Once these cuff is weak and not functioning properly.
goals are met, the patient must then complete a return
to activity program (e.g., return to throwing program).
The American Shoulder and Elbow Surgeons Shoulder
Evaluation Form can be used for documentation and
10 Mariano arrives at the clinic after completion of
an interval throwing program after 24 weeks of
SLAP rehabilitation. He states his shoulder hurts
comparison purposes. The literature has generally dem- after he is done throwing. After taking a history, the
onstrated a return to sports between 4 to 6 months for therapist feels that he is having some mechanical
an athlete with a type II SLAP repair. impingement. What are three likely causes of this
impingement?
9 Steve is a 22-year-old collegiate baseball pitcher who the

therapist has been treating for the last 23 weeks after
right-sided SLAP repair (throwing arm). Steve began a
Three likely causes of this impingement are (1) poor
scapular stability, (2) tight posterior shoulder structure,
throwing program that the therapist designed 3 weeks and (3) weak external rotator.
earlier, and he has been throwing without problems.
However, now that the number of pitches has increased
in his throwing program, he has been complaining of
anterior shoulder pain that bothers him most during the
11 Jon is a 16-year-old male, s/p SLAP repair with a
small Hill Sachs lesion and is 26 weeks postopera-
tion. His primary complaint is an inability to make
ball release and follow-through phases of his pitch- the throw from third base to first base, stating he has
ing mechanics. Ruling out a possible compromise of the no velocity. His MMT is 4/5 in all shoulder motions;
SLAP repair, what else could possibly be causing Steves ER ROM is within normal limits; slight glenohu-
pain during the late period of his throw? meral IR deficit of 15. What should Jons continued
treatment consist of?
Because the biceps acts as an elbow flexor and a forearm
supinator, its functions in the late phases of throwing are Jon should respond well to continued stretching of
to decelerate the arm and extend the elbow. Overuse of his shoulder via sleeper stretch, and posterior
the biceps if it has not been properly strengthened can shoulder stretches. Included with stretching was contin-
lead to bicipital tendonitis. The therapist should have ued strengthening with the Throwers 10 exercises,
Steve back off the throwing program and begin eccentric and continued work with a return to throw interval
strengthening of the biceps once the inflammation of the program.
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repair rehabilitation. Arthroscopy 14(6):637-640, 1998. 96. Warner JJ, Kann S, Marks P: Arthroscopic repair of combined Bankart
78. Kuhn JE, et al: Failure of the biceps superior labral complex: a cadaveric and superior labral detachment anterior and posterior lesions: Tech-
biomechanical investigation comparing the late cocking and early nique and preliminary results. Arthroscopy 10(4):383-391, 1994.
deceleration positions of throwing. Arthroscopy 19(4):373-379, 97. Kibler WB, et al: Qualitative clinical evaluation of scapular dysfunc-
2003. tion: A reliability study. J Shoulder Elbow Surg 11(6):550-556, 2002.
79. Tyler TF, et al: Reliability and validity of a new method of measuring 98. Burkhart SS, Morgan CD, Kibler WB: Shoulder injuries in overhead
posterior shoulder tightness. J Orthop Sports Phys Ther 29:262-274, athletes: The dead arm revisited. Clin Sports Med 19(1):125-158, 2000.
1999. 99. Cordasco FA, et al: An electromyographic analysis of the shoulder
80. Harryman D, et al: Translation of the humeral head on the glenoid with during a medicine ball rehabilitation program. Am J Sports Med
passive glenohumeral motion. J Bone Joint Surg 72A(9):1334-1343, 24(3):386-392, 1994.
1990. 100. McFarland EG, et al: Results of repair of SLAP lesion. Orthopade
81. Tyler TF, et al: Quantification of posterior capsule tightness and 32(7):637-641, 2003.
motion loss in patients with shoulder impingement. Am J Sports Med 101. Park HB, et al: Return to play for rotator cuff injuries and superior
28(5):668-673, 2000. labrum anterior posterior (SLAP) lesions. Clin Sports Med 23(3):321-
82. Mullaney MJ, et al: Reliability of shoulder range of motion comparing 334, 2004.
a goniometer to a digital level. Physiother Theory Pract 26(5): 102. Resch H, et al: Arthroscopic repair of superior glenoid detachment (the
327-333, 2010. SLAP lesion). J Shoulder Elbow Surg 2:147-155, 1993.
83. Tyler TF, et al: Correction of posterior shoulder tightness is associated 103. Berg EE, Ciullo JV: The SLAP lesion: A cause of failure after distal
with symptom resolution in patients with internal impingement. Am clavicle resection. Arthroscopy 13(1):85-89, 1997.
J Sports Med 38(1):114-119, 2010. 104. Segmuller HE, Hayes MG, Saies AD: Arthroscopic repair of glenolabral
84. Burkhart SS, Morgan C: SLAP lesions in the overhead athlete. Orthop injuries with an absorbable fixation device. J Shoulder Elbow Surg
Clin North Am 32(3):431-441, 2001. 6(4):383-392, 1997.
85. Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: 105. Morgan CD, et al: Type II SLAP lesions: three subtypes and their
Spectrum of pathology. II. Evaluation and treatment of SLAP lesions relationships to superior instability and rotator cuff tears. Arthroscopy
in throwers. Arthroscopy 19(5):531-539, 2003. 14(6):553-565, 1998.
86. Diederichs S, Harndorf M, Stempfle J: Follow-up treatment with phys- 106. Samani JE, Marston SB, Buss DD: Arthroscopic stabilization of type II
iotherapy after arthroscopic reconstruction in SLAP lesions. Ortho- SLAP lesions using an absorbable tack. Arthroscopy 17(1):19-24, 2001.
pade 32(7):647-653, 2003. 107. Jazrawi LM, McCluskey GM III, Andrews JR: Superior labral anterior
87. Kibler WB: Shoulder rehabilitation: principles and practice. Med Sci and posterior lesions and internal impingement in the overhead
Sports Exerc 4S:40-50, 1998. athlete. Instr Course Lect 52:43-63, 2003.
CHAPTER 7
Total Shoulder Arthroplasty
CLINICAL EVALUATION be carefully examined. If any doubt exists as to the function

of the cuff, magnetic resonance imaging (MRI) is indicated.
History In cases in which a rotator cuff disruption coexists with
The most common complaint in patients with advanced severe OA, a determination should be made as to the pos-
osteoarthritis (OA) of the shoulder is painmore specifi- sibility of repairing the cuff. In those cases in which signifi-
cally, night pain. Most often, the pain is insidious in its onset, cant chronicity of the cuff is noted, either by history or MRI
although an occasional patient will report acute symptom- examination, a simple hemiarthroplasty or a reverse total
atology only to discover severe osteoarthritic changes in the shoulder replacement (in cases in which pseudoparalysis of
glenohumeral (GH) joint. In many cases night pain is a the arm exists) should be considered.6
major problem; specifically, difficulty with lying on the
affected side is a common complaint.1 SURGICAL INDICATIONS AND
A careful history should be taken with respect to prior CONSIDERATIONS
injuries and prior surgical procedures. For a total shoulder
replacement to be viable and functional, an intact rotator Those patients with refractory pain and limitation of motion
cuff is necessary. In certain patients with long-standing that do not respond to conservative methods of treatment
rotator cuff disruption, the initial clinical signs are progres- (i.e., a trial of physical therapy, antiinflammatory medica-
sive pain that comes with the developing secondary tions, activity modification, avoidance of inciting factors,
arthropathy.2 and intraarticular corticosteroid injections) are candidates
Another area of concern is whether the patient has under- for shoulder replacement. Ideally, the patients age should
gone any prior stabilization procedures. The reason this is also fit within the acceptable parameters for a joint replace-
important to remember is that preferential wear of certain ment. Although the ideal patient should be over the age of
parts of the glenoid can occur in long-standing cases that 65 and have a relatively limited activity level, the reality is
have undergone excessive capsular-tightening procedures.3 that many patients do not fit such criteria.
Most commonly, this is posterior wear. In addition, in certain In cases in which the patients age is significantly under
types of stabilization procedures, a variety of bony transfer 65 years or the activity level is not commensurate with their
procedures are performed, including a lateralization of the age, avoiding the surgery should be considered (in some of
lesser tuberosity and a transfer of the coracoid transfer. As a these patients, a case can be made for fusion of the joint). In
result, the surgical exposure in these cases can be difficult addition, a spectrum of replacement procedures can be used,
because of the distorted anatomy. including a partial humeral replacement (classically termed
a hemiarthroplasty), a hemiarthroplasty with a biologic
Physical Examination resurfacing of the joint, and a standard total shoulder
The most important predictor of the outcome of a total replacement; in more severe cases of patients with concur-
shoulder replacement is the preoperative range of motion rent unrepairable rotator cuff tears, a reverse total shoulder
(ROM).4,5 It is therefore incumbent on the physician to can be used.
document all directions of the patients motion and to
discuss the implications of lack of mobility on the overall SURGICAL PROCEDURE
outcome. Another important aspect is the integrity of the
rotator cuff; a successful standard replacement depends very The choice of anesthesia depends on the clinical experience
heavily on the presence of an intact cuff. The supraspinatus, of the surgeon and anesthesiologist. Ideally, the anesthesia
infraspinatus, teres minor, and the subscapularis should all would include an interscalene block, either by itself or as a
118
Chapter 7 Total Shoulder Arthroplasty 119
supplement to a general anesthetic. The use of such blocks exposure of the wound should the need arise for a more
has been shown to significantly affect the patients postopera- complex humeral approach, such as in complications associ-
tive course in a very positive manner.7 In cases in which ated with humeral shaft fractures on prosthetic insertion.
interscalene anesthesia is not used, the preemptive adminis- The exposure includes identification of the deltopectoral
tration of a long-acting anesthetic (Marcaine) is also well- interval with identification of the cephalic vein and subse-
founded in the literature and has been shown to positively quent medial retraction. The pectoralis tendon is identified
affect recovery.8 laterally and, in severe cases, released for a distance of 1 to
The standard approach to a shoulder replacement opera- 2cm for improved GH joint exposure. In addition, the del-
tion includes positioning the patient in a semirecumbent topectoral interval is exposed in its entirety from the leading
(beach chair) position, with a small bolster under the scapula edge of the clavicle to the lower end of the pectoralis muscle.
to effectively stabilize the glenoid for exposure. In addition, Commonly, significant subdeltoid adhesions need to be
the operative shoulder should be examined under anesthesia released for proper delivery of the humeral head out of the
with all of the directions of motion measured and docu- wound.
mented. Finally, it is important to ensure that the operative After complete exposure of the deltopectoral interval, the
arm can be extended and rotated appropriately for delivery conjoint tendon is identified and released at its proximal
of the humeral head and subsequent resection during the portion for a distance of 1cm, and the medial retractor is
surgical procedure (Fig. 7-1). This is called the ability to placed behind the tendon. Care should be taken to protect the
shotgun the arm into this position. musculocutaneous nerve when performing this maneuver.
The standard incision is a deltopectoral approach that is The subscapularis tendon is now identified and released
typically centered immediately lateral to the coracoid process from superior to inferior, beginning at its lateral corner. The
of the scapula and extends down the proximal arm, avoiding tendon is released directly off the lesser tuberosity and
the axilla (Fig. 7-2). It is important to allow for distal retracted medially. The release continues inferiorly, cauter-
izing the vascular leash consisting of the anterior inferior
humeral circumflex vessels and proceeding along the infe-
rior humeral head, while externally rotating the humerus
(Fig. 7-3). The extent of the release is variable. However, the
requirement is that the entire humeral head can be delivered
for resection and that adequate exposure of the glenoid is
possible if resurfacing of that portion is being performed.
Once the exposure is complete, a variety of humeral
resection techniques can be used, depending on the manu-
facturers individual surgical protocol. The design the author
of this chapter uses involves resection of the humeral head
at its anatomic base. Before completing this cut, the head
must be exposed and all peripheral osteophytes should be
removed to appropriately resect the head in an anatomic
Fig. 7-1 Position for total shoulder arthroplasty (TSA), ensuring that the fashion (Fig. 7-4).
arm can be positioned for the insertion of the humeral device.
Fig. 7-3 Right humeral head exposed through the wound. The complete
Fig. 7-2 Standard incision along the anterior aspect of the shoulder. The absence of normal cartilage on the surface and the peripheral osteophytes
typical incision is about 4 inches long. around the articular margin should be noted.
After resection of the head, the humeral canal is prepared advantages of one device over another are beyond the scope
for the prosthetic device being implanted. A series of reamers of this chapter; the reader is directed to the appropriate
are inserted down the medullary canal, stopping when the references.9-11
appropriate-sized device is used. The size is typically judged Attention is now directed to the glenoid. It is important
from templates that measure the size of the medullary canal to be able to access the entire area of the glenoid from ante-
based on their radiographic dimension. However, ultimately rior to posterior and superior to inferior to effectively prepare
the choice is made intraoperatively, based on the surgeons the bony surface for the implant. The capsule of the joint is
experience as he or she advances the device into the shaft. excised, beginning with the most anterior, superior portion
The humeral metaphysis is then prepared with a series of and extending inferiorly and posteriorly as far as necessary
broaches that contour the proximal humerus for insertion of to allow for adequate exposure (Fig. 7-6). Once the exposure
the actual component. The type of implant varies, with two is gained, the central point of the glenoid is identified; then
major types being available: (1) cemented and (2) cement- the surface is prepared for accepting the actual component.
less. A cementless device uses the bodys ability to grow bone Finally, the device is cemented into position using polymeth-
into some of its surfaces; these surfaces are often prepared ylmethacrylate cement.
with a sintered metal (Fig. 7-5). In a cemented device, The final decisions that need to be made include choosing
the prosthesis is implanted using polymethylmethacrylate the appropriately sized humeral head component to allow a
cement for immediate fixation of the device. The theoretic relatively normal passive range of motion (PROM) with
minimal to no instability before closure of the subscapularis
muscle tendon (Fig. 7-7). Once the appropriate head is
chosen and implanted, the subscapularis muscle tendon is
reapproximated to the lesser tuberosity with the use of
sutures that have been prepositioned through the bone
before implantation of the humeral component (Figs. 7-8
and 7-9). The repair of the subscapularis is the critical
element that needs attention during the first 6 weeks because
of the importance of the subscapularis for component stabil-
ity and overall shoulder girdle strength. Moreover, a disrup-
tion of the repair is notoriously difficult to diagnose in the
early phases and extremely difficult to salvage when a chronic
diagnosis is made.
The closure is done in layers, with a subcuticular skin
closure protected by Steri-Strips being the final step. In some
cases a drain may be exteriorized via a separate stab wound
incision. This is typically removed on the first postoperative
Fig. 7-4 Resection of the humeral head after removal of the peripheral day. The final and perhaps most important part of the surgi-
osteophytes and the normal anatomic reference is found. cal procedure occurs at this time. The surgeon takes the arm
through a PROM to assess the overall total motion possible
without joint instability of disruption of the subscapularis
Fig. 7-5 Typical shoulder (humeral) components. These are standard com-
ponents with a porous metal interface at that proximal portion to promote Fig. 7-6 Glenoid exposure after soft tissue resection circumferentially
bony ingrowth. around the joint.
tendon repair. This ROM will be used to guide the limits that
will be allowed in the first phases of rehabilitation. Final
radiographs are typically obtained immediately postopera-
tively to ensure an appropriate position of all the compo-
nents and also to ascertain that no intraoperative
complications such as a humeral shaft fracture have occurred
(Fig. 7-10).
THERAPY GUIDELINES FOR

REHABILITATION
Total shoulder arthroplasty is performed less frequently than

hip or knee total joint replacements in the United States.8
There is evidence that a decreased hospital stay and a higher
likelihood of discharge to home may be associated with those
patients treated in surgical centers with a higher volume of
Fig. 7-7 Prepared glenoid face after drilling of central canal and prepara-
tion of face. total shoulder arthroplasties.12,13 No attempts to correlate the
patients functional limitations and impairments on dis-
charge have been found with length of stay or successful
discharge. The clinician must use physiologic healing prin-
ciples to assist in gaining functional return of shoulder ROM
following surgical intervention.
Successful rehabilitation of a total shoulder arthroplasty
(TSA) depends in large part on the collegial communication
between the surgeon and the therapist. Appropriate rehabili-
tation needs to recognize and address the preoperative
history and impairments, the surgical technique, prosthetic
type, and the surgeons assessment of the tissue status upon
finalization of the repair.
The majority of these issues dictate the postoperative pre-
cautions and guidelines that are placed upon the rehabilita-
tion timeline to ensure that protection of the position of the
prosthesis and the appropriate healing of the subscapularis
occurs (Box 7-1).
The patient and therapist must be aware that the primary
Fig. 7-8 Final view of humeral and glenoid implants before closure of the goal for nontraumatic TSA is pain relief. It appears that the
subscapularis tendon. achievement of functional ROM goals are more achievable
today than 5 years ago; however, the improvement of ROM is
not as well substantiated in the literature as the successful
achievement of decreased pain.14 The preoperative diagnosis
also impacts the postoperative outcome. Completion of a
TSA because of primary OA is more likely to result in
functional use of the upper extremity than those completed
as a result of trauma, rheumatoid arthritis of the GH joint,
BOX 7-1 Potential Preoperative Impairments for Primary

TSA Because of OA14
Pain with attempted activities
Loss of elevation range of motion
Loss of external rotation range of motion
Inability to complete activities overhead
Inability to complete activities of daily living
Fig. 7-9 Prepared proximal humerus with sutures through the lesser tuber- Interrupted sleep patterns because of pain
osity in preparation for reattachment of the subscapularis tendon.
A B
C D
Fig. 7-10 A, Preoperative anteroposterior radiograph of severe glenohumeral (GH) arthritis. The lack of space between the humerus and glenoid and the
peripheral osteophytes should be noted. B, Axillary view showing GH relationship with no joint space. C, Final anteroposterior radiograph of total shoulder
replacement. D, Final axillary view of the total shoulder arthroplasty.
capsulorrhaphy, arthropathy, or rotator cuff arthropathy shoulder while under anesthesia. These factors can help the
(Box 7-2).15 clinician predict the maximal outcome that may be achieved.
To prognosticate functional outcomes, including achieve- Both the patients status before surgery and the underlying
ment of active ROM against gravity, the clinician should causative factors leading to surgery can be obtained via
examine the patients prior surgical history, duration of patient interview. It is rare that the treating physical therapist
impairments before surgery, presence and severity of a pre- would have the opportunity to perform a physical examina-
operative rotator cuff tear,15 the underlying cause for the tion to potentially address postural deficits preoperatively.
surgical technique, and finally, the postoperative ROM at the The surgical information including comments on ROM and
BOX 7-2 Preoperative Factors for Better Outcomes BOX 7-3 Common Postsurgical Precautions
Following TSA
Passive range of motion for up to 6 weeks
Better Outcomes Abduction pillow for up to 8 weeks
External rotation limited to 30 with humerus at 0 of
No previous surgery
adduction
Higher level of preoperative function54,56
Sling to be worn for comfort
Minimal rotator cuff pathology56
Overall well-being of the patient before surgery43
Surgery because of primary osteoarthritis The periodization of the rehabilitation program for a TSA
Worse Outcomes must balance protection of the healing tissues, structures
Surgery because of rheumatoid arthritis or trauma with the need for ROM gain to prevent overall stiffness of
Severe loss of passive range of motion the shoulder. There are indications that an increased immo-
Increased number of comorbidities56 bilization period increases the risk of a contracture of the
Radiographic evidence of humeral head subluxation deltoid and the rotator cuff. This soft tissue imbalance is
Loss of posterior glenoid bone theorized to be one of the reasons for revision surgery of a
Significant rotator cuff pathology TSA. Other reasons for surgical revision include glenoid
Increased fatty degeneration of the infraspinatus, loosening, rotator cuff tear, humeral head subluxation, prox-
subscapularis50 imal humeral head migration, and GH instability.1,14,20,55 The
following guidelines should not supersede the communi-
Data from Hettrich CM, et al: Preoperative factors associated cations from the surgeon nor should they override sound
with improvements in shoulder function after humeral hemiar-
clinical judgment to create an independent plan of care
throplasty. J Bone Joint Surg Am 86-A(7):1446-1451, 2004; Ian-
notti JP, Norris TR: Influence of preoperative factors on outcome based on your patients comorbidities, physical health,
of shoulder arthroplasty for glenohumeral osteoarthritis. J and functional needs.
Bone Joint Surg Am 85-A(2):251-258, 2003; Matsen FA III, et al:
Correlates with comfort and function after total shoulder Initial Postoperative Examination
arthroplasty for degenerative joint disease. J Shoulder Elbow
Patient examination following surgery typically occurs on
Surg 9(6):465-469, 2000; Edwards TB, et al: The influence of
rotator cuff disease on the results of shoulder arthroplasty for day 0 (day of surgery) or on postoperative day 1. The thera-
primary osteoarthritis: Results of a multicenter study. J Bone pist will note IV lines for postsurgical fluid intake, sanguine-
Joint Surg Am 84-A(12):2240-2248, 2002; Franklin JL, et al: ous drains, postoperative dressing, and the upper extremity
Glenoid loosening in total shoulder arthroplasty. Association with in a sling for comfort. Physical examination should include
rotator cuff deficiency. J Arthroplasty 3(1):39-46, 1988; Rozenc-
cognitive testing for orientation to name, time, place, and
waig R, et al: The correlation of comorbidity with function of the
shoulder and health status of patients who have glenohumeral reason and vital sign assessment on the noninvolved extrem-
degenerative joint disease. J Bone Joint Surg Am 80(8):1146- ity in supine, sitting, and standing. Testing specific to the
1153, 1998. involved upper extremity should adhere to the postoperative
restrictions according to the patients chart (Box 7-3).
Neural screening should be completed as allowed within
the postsurgical restrictions, including myotome, derma-
tome, and deep tendon reflex (DTR) testing. Active range of
the condition of the repaired tissue may be obtained from motion (AROM) of the cervical spine, thoracic spine, and
communications with the surgeon including the surgical elbow, wrist, and fingers should be assessed. PROM of the
report. shoulder should be assessed with the patient in supine,
Rehabilitation progression may further be guided by understanding that some limitation in mobility may be con-
precautions and recommendations directly from the tributable to the dressing or IV lines. Girth measurements
surgeon. In some instances formal physical therapy may should be noted at the elbow and at the wrist for comparison
not be used depending on the surgeons experiences.16 with the uninvolved extremity. Additionally, the anterior and
Typically, the patient will present in an abduction pillow posterior chest wall should be monitored for ecchymosis.
or at the very least a shoulder sling. Additional positioning Functional mobility assessment should be initiated
options or passive ROM (PROM) restrictions may be in with instructions cautioning against direct pushing or
place for a patient with a history of rheumatoid arthritis. A pulling of the involved upper extremity during transfer-
long history of rotator cuff pathology may require position- ring. Patients must be assessed for independent mobility
ing that decreases the mechanical stresses placed on the from supine to sit to stand and vice versa. Once standing is
healing structures. An external rotation restriction of less achieved, balance must be assessed for single limb support
than 30 to 40 is typical for protection of the healing without loss of balance. Frequently, postoperative day 0 or
subscapularis muscle and the anterior capsule, which is day 1 will require the patient to use a temporary single upper
disrupted during placement of the prosthetic. This restric- extremity support (IV pole or single point cane) because of
tion may last up to 6 weeks.17-19 anxiety and a deconditioned state. Monitoring of vitals and
orientation during the transfer and gait assessment is neces- of the home program. This caregiver must understand all
sary due to risk of hypotensive episodes. The clinician should postsurgical restrictions that limit ROM. Self-assisted ROM
encourage the use of coughing and incentive spirometry exercises can be based on patient comfort or surgeon
throughout the hospital stay because of the greater level of preference.
inactivity following surgery intervention. Pendulum exercises involve a static position of forward
flexion of the trunk with movement of the hips and trunk to
Phase I: Hospital Phase of Rehabilitation drive the dangling upper extremity into multiple planes of
motion (Fig. 7-11). The benefits of this activity for this
TIME: 2 to 6 days after surgery13
patient population includes the addition of traction to the
GOALS: Protection of healing structures, pain control,
joint, stretching of the capsule, and avoidance of active
independent functional mobility for transfers,
muscular contraction at the shoulder joint.21 Overall, the
dressing and ambulation, education, and the
goal is prevention of soft tissue contracture and possible
institution of a home exercise program within the
modulation of pain via the rhythmic movement of the upper
surgical restrictions (Table 7-1)
extremity through a PROM.17,22 There are several challenges
Treatment during the hospital phase of rehabilitation with the correct performance of this exercise as it applies to the
focuses on the achievement of appropriate pain control, patient with a recent TSA. Frequently, the patient demon-
independent functional mobility for transfers, dressing and strates inappropriate performance by recruiting excessive
ambulation, education, and the institution of a home exer- muscular action at the deltoid and pectoralis major muscles.
cise program within the surgical restrictions. Length of hos- The recommended posture for pendulum exercises empha-
pital stay depends on multiple factors including the volume sizes poor mechanical alignment of the scapula on the thorax
and experience of the hospital and the surgeon experienced with promotion of scapular abduction. And lastly, the exces-
in the total shoulder procedure. Home support, comorbidi- sive and unopposed stretching of the recently repaired mus-
ties, and demographic features play a smaller role. Unlike the culature and tissues from the surgical procedure may actually
total knee arthroplasty where a certain objective measure of generate greater pain response.
knee flexion is often one of the impairment goals for dis- The Neer protocol for TSA23 placed wall slides in the same
charge, common discharge goals regarding functional level, phase as pendulum activities with literary evidence of low
pain control, and impairment objective measurements for muscular activity about the healing structures.21 Modifica-
total shoulder procedures have not been established in the tion of this position to a lower gravitational demanding posi-
literature.12,13 tion would be self-assisted ROM using a table top. This table
Typically, PROM is initiated on day 0 or 1, with a progres- top modification is frequently used before wall slides during
sion to self-assisted ROM exercises including pendulum or this early intervention phase. The patient stands at a table
table top activities. top with bilateral upper extremities resting at a comfortable
The home exercise program should be completed multi- placement. The hands maintain a static position and then
ple times per day for short durations of 5 minutes maximum ROM is attained by the lower extremity stepping into the
per bout of exercise.18 If there is a strict passive ROM various planes of motion.17 There are several benefits to this
restriction in place, then this will require the education of type of exercise prescription. The position of weight bearing
a caregiver or family member to assist with the execution promotes ROM gains through planar lower extremity
TABLE 7-1 Total Shoulder Replacement

Anticipated
Phase to This Phase Functional Limitations Intervention Goal Rationale
Phase I Things to watch out Edema ROM of proximal and Modified independent Maintain ROM of proximal
(Hospital for: Pain distal joints to surgical bed-to-sitting transfers and distal joints to surgical
phase) Hypotension Inadequate ROM site Modified independent site
Postoperative Neurologic deficits Balance activities of sit-to-stand transfers For trunk activation
2-6 days trunk Instruction on sleeping Continue to progress with
Development of home positions home exercises
exercise program: Independent with home
closed kinetic chain exercise program
versus open kinetic Controlled pain
chain discussion
ROM, Range of motion.

A B
C D
Fig. 7-11 Pendulum. A and B, Sagittal plane. C and D, Frontal plane.
motion. The trunk is moving underneath the scapula, which is supine then flexion of the elbow should occur only with
promotes interaction of the scapula and thorax in prepara- the humerus supported by a towel underneath it to
tion for later stages of rehabilitation (Fig. 7-12). The patient decrease the strain on the biceps tendon at its insertion.
is able to control the excursion of the ROM of the shoulder Frequent bouts of exercise for short durations are recom-
via decreasing the step size. The supported position of the mended for the earlier stages of rehabilitation.
shoulder via the hand decreases the unopposed stress on the The home exercise program contains education for passive
healing tissue that may be achieved in the open kinetic chain and/or self-assisted ROM at the shoulder, active ROM for
position of the pendulum. Finally, closed kinetic chain activ- proximal and distal structures, and education on sleeping
ities at the shoulder reap similar benefits as stated for other postures. This should include positional support via the use
extremities including: muscular cocontraction, decrease of of pillows or an immobilizer to support the healing struc-
shear forces, increased joint compression, and increased sta- tures during the night. The encouragement of experimenta-
bility about the joint.3,24 tion to attain the best possible sleeping posture should be
The home exercise program should require AROM of the discussed. Anecdotally, patients following shoulder surgery feel
cervical and thoracic spines through the cardinal planes and better sleeping in a semireclined posture with the involved
active movement of the elbow, wrist, and hand. If the patient upper extremity supported by pillows or bolsters (Fig. 7-13).
A B C
D E
Fig. 7-12 Table top position. A, Starting position. B, Abduction. C, Flexion. D, External rotation. E, Internal rotation.
Phase II: Outpatient RehabilitationEarly Range demonstrate normalized posture, and increased
of Motion 0 to 6 Weeks ROM (Table 7-2)
TIME: 0 to 6 weeks Outpatient rehabilitation begins as a progression of the

GOALS: Protection of healing structures, pain control, home exercise program given during the hospital stay. It is
uninterrupted sleep pattern, normalized recommended to incorporate the use of a self-reported
circumference measurements between upper outcome measure tool, such as the simple shoulder test (SST)
extremities, mobilization of scar, ability to or the disability assessment of shoulder and hand (DASH)
to monitor functional changes through rehabilitation.7 It is
important to remind the patient that their rehabilitation will
continue past discharge from formal physical therapy as func-
tional return may proceed for 1 to 2 years after surgical
intervention.25
The focus of the first 6 weeks of rehabilitation is twofold:
protection of the healing structures and progression of ROM
for prevention of muscular contracture and joint capsule stiff-
ness. A limited amount of literature is available to support the
variety of intervention plans employed during this phase.18,26-28
Adherence to postsurgical precautions is paramount. Treat-
Fig. 7-13 Supine elbow support position. ment of the postsurgical impairments of pain, edema, and scar

Anticipated
Phase II Progression to next Edema ROM of proximal and distal joints Protection of Maintain ROM of proximal
(ROM) stage, physician Pain to surgical site healing structures and distal joints
Postoperative clearance of tissue Inadequate Balance activities Pain control Activation for trunk
0-6 wk healing ROM Soft tissue mobilization when Uninterrupted sleep Realignment of scar tissue and
Things to watch adequate healing has occurred pattern collagen (to allow more
for: (subscapularis, posterior cuff, Normalized unrestricted ROM)
Quick biceps tendon) circumference Prevent joint contractures
achievement PROM (performed in functional measurements (pain modulation)
of ROM before planes of movement and respecting between UEs Joint traction (stretching to
8-12 wk postsurgical limitations)Shoulder Mobilization of scar capsule, pain modulation)
Excessive ER with flexion, shoulder abduction, and ER when appropriate Proprioception training
UE at side (no greater than 30) Ability to (proximal segment over distal
Sustained edema ROM activities of the involved demonstrate segment promotes scapula
in the distal extremity normalized posture and thorax interaction,
UE greater than Wand versus Codman exercises Increased shoulder cocontractions around a joint
4 wk Closed kinetic chain ROMFlexion = increase stability of the joint)
ModalitiesIce, ES for pain 0-140 Modalities for pain control
control 0-30, ER Lymphatic massage for
Lymphatic massage 0-70, IR lymphatic drainage
Scapular mobility 0-110, abduction Prepares connective tissue
MWM, PNF patterns versus around the scapula for future
cat-camel (many patients will ROM
require scapular adduction, upward
rotation, and elevation because of
typical postural dysfunction of
scapular abduction and downward
rotation secondary to sling posture)
ER, External rotation; ES, electric stimulation, IR, internal rotation; MWM, mobilizations with movement; PNF, proprioceptive neuromuscular
facilitation; PROM, passive range of motion; ROM, range of motion; UE, upper extremity.
mobility will naturally lead to increased ROM in the stay, the patient had been instructed in cervical and thoracic
shoulder. AROM. Distally, the elbow and hand should be used during
Pain control should be assisted via the adherence to medi- daily functional activities, thereby limiting the extent of
cations prescribed by the surgeon and alleviating positions. distal disuse atrophy. Realization of the influence of the
Use of the sling should be gradually removed as the patient scapulothoracic juncture on GH motion can assist with res-
progresses through this phase. Control of pain will also be toration of this motion early in rehabilitation.
gained via the interventions to address the postsurgical Protective posturing from the postsurgical sling typically
inflammation and edema, and those interventions to improve places the scapula in an abducted and down rotated position.
the limited functional use of the upper extremity. Edema Lack of humeral motion in all of the planes through the
may be present in the distal upper extremity and ecchymosis initial weeks of rehabilitation leads to further disuse of the
may be present in the thorax from the overload of the lym- scapula and its contribution to shoulder ROM. Scapular
phatic system following surgery. Modality use including ice, mobilization on a stable thorax with the GH joint in its
elevation, and electric stimulation are appropriate for edema resting position for greatest volume prepares the scapula and
management.29 Diaphragmatic breathing followed by local- its connecting tissue for future shoulder ROM (Fig. 7-14).
ized lymphatic massage techniques beginning at the proxi- Because of the typical postural dysfunction of scapular
mal segments of the thorax and ipsilateral axilla and abduction and down rotation, many patients will require
progressing distally in sequential order may also be employed facilitation of adduction, upward rotation, and elevation. The
for effective management. lack of a true joint capsule about the scapula places this type
Sleeping postures should be recommended to include of intervention into a mobilization of the myofascial connec-
positional support of the humerus via the use of pillows or tions. The clinician should recall the scapulohumeral rhythm
a bolster. As mentioned, patients following shoulder surgery and carefully monitor the position of the humerus when
may prefer sleeping in a semireclined posture; the therapist facilitating positions of the scapula (Box 7-4). For example,
should encourage the patient to experiment. scapular mobilizations into upward rotation should only occur
Progression of ROM may be elicited via soft tissue mobi- with the humerus passively flexed greater than 60 or abducted
lization. Soft tissue mobilization, a form of massage, has the greater than 30, as these are the ranges at which the scapula
support of an animal model for potential cellular changes.30 and humerus begin a more associated phase of motion.32
Initiation of soft tissue mobilization techniques at the PROM via a family member in a gravity-eliminated posi-
posterior cuff and the deltoid will promote appropriate tion of supine or self-assisted ROM during table top weight
muscular length. Because of the probable postsurgical hyper-
sensitivity, care should be taken at or near the surgical
scar. For each of these techniques, the upper extremity
position should be adjusted to ensure the muscle or area of
skin being addressed is relaxed and in a protected posture.
Initial positioning should address the targeted muscle in a
position of a passively shortened length. This will decrease
sensitivity and spasm at the introduction of this type of
intervention.
The external rotation limitation is in place to promote
soft tissue healing and protection of those structures
injured during the surgical procedure, specifically the
subscapularis muscle. As outlined previously, the subscapu-
laris is taken down and reattached during the arthroplasty
procedure. Direct passive ROM to stretch this tissue is
contraindicated during the early phases of rehabilitation
and soft tissue mobilization is an appropriate intervention
to address the inflammatory condition of this muscle and Fig. 7-14 Scapular mobilization.
prevent adhesion development. The technique of soft tissue
mobilization promotes change to the myofascia via proposed
realignment of the scar tissue and collagen. Slow, deep BOX 7-4A Review of Scapulohumeral Rhythm for
strokes to the myofascia of the subscapularis will assist in Movement Analysis32
improvement of external rotation ROM, pain control, and
Initial phase: 0 to 60 primarily humeral motion
eventual overhead reach.31 The best patient position for
Mid phase: 60 to 140 (ratio is inconsistent throughout
improvements to the subscapularis length is approximately
motion with primarily humeral motion initially then
45 of humeral abduction with a neutral rotation of the
mainly scapular motion)
humerus.
Ending phase: 140 to 180 with the majority of motion
Consideration of the other joints of the shoulder complex
occurring at other joints
should be initiated during this phase. During the hospital
A B
Fig. 7-15 A, Sling with internal rotation. B, Sling with external rotation.
bearing will be the primary method to promote ROM during

this time frame (see Fig. 7-12). Progression should be dic- BOX 7-5 Goal of Passive Range of Motion Expected for
tated by the report of pain. PROM performed by the thera- Phase II (Supine)34
pist, patient, or caregiver should not exceed any precautions Flexion: 140
or restrictions given by the surgeon. A tip for improved External rotation: 30 to 45
pain tolerance for motion of the upper extremity is to bias Internal rotation: >70
toward the plane of the scapula instead of true sagittal plane Abduction: 110
flexion.33 A recommendation for moving into passive exter-
nal rotation is the alignment of the humerus perpendicular
to the center of the glenoid. This occurs at approximately 30 therapist activities elicit less muscular activity of the supra-
of abduction and ensures that the capsular structures will spinatus, infraspinatus, anterior deltoid, and trapezius
relax, achieving a better outcome.18 muscles. Therefore, therapist-assisted activities should be used
Self-assisted activities for ROM can be varied by direc- initially during this phase with a progression to wand or pulley
tion, surface, and patient position. These types of exercise activities as pain or surgical restrictions allow (Figs. 7-16, 7-17,
promote the mobility of the proximal segments over the and 7-18).18,26-28
involved upper extremity in a stable position. The trunk may Progression from the initial outpatient phase (phase II)
move away from the upper extremity in various directions to the late ROM phase (phase III) is listed in Box 7-5. The
to promote the cardinal planes.26 For example, in the early most significant requirement is physician clearance for
stages when the patient may still be most comfortable in the AROM, especially into external rotation. Many patients
sling or supported position, relative external rotation and restrictions will be lifted between weeks 2 and 6, thereby
facilitation of scapular control may be achieved via contra- blurring the activities of phase II and phase III. The therapist
lateral trunk rotation and a return to neutral.34 In an advanced should monitor the patients ROM to assist with staging the
stage of self-assisted exercises, the involved upper extremity patients rehabilitation. This is one of the most challenging
may rest on a stability ball and the patient rolls the stool away components of the transition from phase II to phase III. As
from the stability ball in the frontal plane, promoting self- noted, the passive motion goal of phase II is 40 while the
assisted abduction of the involved extremity. Or the patient patient will have achieved full PROM at the end of phase III.
may progress to gravity-dependent positions using the wall Additionally at the end of phase III, the patient should have
as the support and the trunk moving under the body to active external rotation ROM of 45. This ROM measure is
facilitate various planes of motions (Fig. 7-15). the key to successful overhead motion.
Other self-assisted activities that have been recommended Recall that optimal GH and scapular mechanics require
during this time include wand activities and pulley near normal ROM of external rotation of the GH joint to
stretches.18,26-28 Examination of pulley and wand activities complete functional tasks, such as touching the back of the
compared to therapist-assisted exercises35 indicate that head, reaching overhead, and donning/doffing shirts.36 If the
Fig. 7-17 Horizontal pulley.
B
Fig. 7-16 A, Starting wand position. B, Scaption plane with wand. BOX 7-6 Cautionary Signs and Symptoms During Early
Range of Motion
GH joint ROM into external restriction is restricted to 45, Sustained edema in the distal upper extremity greater
then a significant loss of function occurs, dramatically than 4 weeks
impacting a patients quality of life. As the patient will not Excessive humeral external rotation (>30) with upper
have near normal external rotation ROM at the end of phase extremity at side
II, it is ill-advised to focus on repetitive or strengthening activi- Quick achievement of range of motion before 8 to 12
ties that are overhead because the mechanics will be less than weeks
optimal. To prevent complications of overuse or tissue irrita- Biceps tendonitis
tion, exercises and activities should be performed with the Progressively increasing pain
correct mechanics and without symptoms before progres-
sion to the next phase.
associated or corroborating signs and symptoms. Sustained
Complications edema in the distal upper extremity may be indicative of a
There are several signs and symptoms that should alert the systemic issue, such as infection. Excessive external rotation
therapist for possible complications (Box 7-6). Each must be or quick achievement of ROM may indicate compromised
examined with close consideration to the context and muscular integrity. Biceps tendonitis indicates an overuse of
the biceps for shoulder motion or stabilization. The biceps

has an active role as a humeral depressor and with postsurgi-
cal muscular inhibition of the rotator cuff, successful accom-
plishment of shoulder flexion may rely on the biceps as the
primary humeral depressor.37 As a patient successfully pro-
gresses through the different stages of rehabilitation, pain is
expected to plateau, decrease, or alter to more muscular
fatigue or muscular soreness. Progressively increasing pain
is often thought of as an indicator of serious pathology.
Phase III: Outpatient RehabilitationLate ROM

and Early Strengthening
TIME: Approximately 6 to 12 weeks
GOALS: Return to everyday activities below 90 of
shoulder flexion, increased ROM, improved muscle
flexibility, improved neuromuscular control,
increased strength, protection of healing structures
(Table 7-3)
As the patients ROM progresses, the patient will enter a

mixed phase that consists of stretching to gain motion and
strengthening to use the range gained. Exercise selection
should place the protection of the healing structures as the
primary concern. This may include protection of the ante-
rior joint capsule and the subscapularis via limit of exter-
nal rotation when the humerus is in 0 of abduction and
A
a limitation of hyperextension of the humerus when in the
supine position for resting or exercise positioning.18,26
Communication with the surgeon will assist with determin-
ing which restrictions need to be maintained.
The emphasis of this phase is use of ROM and progression
to muscle strengthening. Interventions to address muscular
flexibility of the rotator cuff, deltoid, and scapular stabilizers
should be continued from the previous phase. Pain has been
found to inhibit muscular strength and therefore can be a
limitation for achievement of active ROM.6 Consideration
that the source of pain may be from structures other than
the traumatized muscle tissue will provide options for other
interventions. Gentle joint mobilizations (grade I to II oscil-
latory) to the GH joint may be used to decrease possible
capsular adhesions and to alter nociceptive input.18,26
There can be considerable discussion on the most appro-
priate exercises to initiate strengthening activities following
a TSA. The clinician should always consider how mobility is
achieved and what movement patterns may be adopted
during this time period. As the body transitions from limited
mobility and muscular inhibition, the patient is at risk of
developing faulty movement patterns that may later impede
the ability to achieve active ROM in gravity-resisted positions.
It is strongly encouraged to instruct the patient in activities
that promote the correct scapulohumeral rhythm for over-
head activities. Application of this movement reasoning
B includes activities that emphasize the separation of scapular
and the humeral motion during the initial phases and late
Fig. 7-18 A, Wall slides starting position. B, Finish position. phases of flexion and abduction and then emphasize coordi-
nation of the motion of the scapula and the humerus during
the mid phases of motion.

Rehabilitation Progress to This Impairments and
Phase Phase Functional Limitations Intervention Goal Rationale
Phase III No signs of Movement Continue STM Return to activities Realignment of scar
(Late ROM to infection dysfunctionEarly/ Joint mobility at GH joint if below 90 of tissue and collagen (to
strengthening) No increase in unopposed shoulder painful (greater than I-II) shoulder flexion allow more ROM with
Postoperative pain or loss of elevation NMESRotator cuff and Increased AROM of less soft tissue
6-12 wk ROM and Inadequate strength deltoid the shoulder in restrictions)
physician Inadequate ROM Isometric exercises (initially supine: flexion Decrease possible
clearance to submaximal) progress to walk 0-140, abduction capsular adhesions
progress aways 0-120, ER Decrease nociceptor input
Progression of table dusting to 0-40; with Targeting for specific
wall washing shoulder abducted to muscles
Progression of CKC from weight 90, then ER Promote muscle
bearing at table to wall to floor 0-40 contractions
Pseudo CKC to OKC with UE AROM sitting flexion Benefits of CKC exercises
supported but moving through 0-120 as stated before
ROM (angled table position) Improved muscle Progression for
Eccentric shoulder flexibility antigravity strengthening
strengthening for flexion, Improved Eccentric strengthening
abduction, and functional neuromuscular control Progression to next stage
planes (assisted elevation of Increase in strength
arm to shoulder height, then Protection of healing
have patient slowly lower arm) structures
AROM, Active range of motion; CKC, closed kinetic chain; GH, glenohumeral; NMES, neuromuscular electric stimulation; OKC, open kinetic
chain; ROM, range of motion; STM, soft tissue massage; UE, upper extremity; ER, external rotation.
Isometric training is supported for early strength train-

ing, especially in the cases where muscular contraction BOX 7-7 Goals of Active Range of Motion Expected for
is desired yet the patient lacks sufficient strength for Phase III
mobility through ROM.26 The clinician should be aware Full passive range of motion in supine
that significant muscular contraction can be elicited Active range of motion (AROM) humeral flexion in
during isometric contraction exercises and therefore these supine: 140
exercises may be inappropriate during a healing phase AROM humeral abduction in supine: 120
where maximum tissue protection is required.21 Initiation AROM humeral external rotation in supine with humerus
of isometric training of the deltoids with a contraction of the positioned at 0 of abduction: 45
rotator cuff establishes a muscular cocontraction or force AROM humeral external rotation in supine with humerus
couple that is required for motion (Figs. 7-19 and 7-20). positioned at 90 of humeral abduction: 45
Isometric training of the scapular stabilizers with an Active humeral flexion in a sitting/standing posture: 120
eccentric contraction of the deltoid and rotator cuff from a
prone position is an option for the introduction of strength
training below 90 of shoulder flexion. A slow lowering
toward the floor after a passive preposition into horizontal scapular rotation necessary to achieve shoulder motion
abduction at 90 will activate each of these key muscles. greater than 90 is recommended. Scapular rotation may
Introduction of concentric flexion and abduction may be be stimulated via the lateral rotator cuff muscles on the
introduced by progressively tilting supine positioning toward scapula or by stabilizing the scapula by stimulating the
upright with and without weights (Figs. 7-21 and 7-22).19 muscles with attachments to the medial border of the scapula.
If the patient is demonstrating significant difficulty per- Electrode size and placement are key points for effective use
forming an active contraction of targeted muscles in the of NMES.29
absence of a neurologic injury, neuromuscular electric Progression to the final phase requires an improvement
stimulation (NMES) may be used. Though specific param- in passive and active ROM. The patient must be able to
eters are outside the scope of this chapter, dual channel perform all home exercises with the correct form and
stimulation to provide for the deltoid activation and the minimal correction by the therapist (Box 7-7).
C B
Fig. 7-19 Isometric holds. A, Front view. B, Sagittal view. C, Progression.
Phase IV: Outpatient RehabilitationLate grades III and IV. Strengthening activities should address the
Phase Strengthening dynamic stabilization system of the shoulder that is neces-
sary for overhead movement.
TIME: 12 weeks and more postsurgery
GOALS: Return to normal activities including
Several underlying impairments may be responsible for
overhead, increased ROM, improved neuromuscular
the continued limited ability of the patient to demonstrate
control and strength. Full potential of function
appropriate sequential motion when attempting to raise the
achieved between 6 and 12 months (Table 7-4).7
arm above shoulder height. A number of factors may create
barriers to successful progression. These include appropriate
The goal of this phase of rehabilitation is strengthening of and timely surgical intervention, a rehabilitation course that
targeted muscles for use of the AROM gained and to estab- has minimal medical complications, and/or appropriate
lish a home exercise program that promotes continued motivation by the patient. If no barriers are apparent to
strengthening upon discontinuation of therapy. Interven- progress, the primary impairment for limited overhead
tions addressing pain control and edema should be progres- motion is due to inadequate motor performance of the force
sively phased out as they are no longer needed. Mobility of couples of the shoulder. The force couple between the deltoid
the scapula should occur with the humerus positioned into muscles and the rotator cuff musculature is the primary
greater ranges of motion into shoulder flexion or abduction focus.17,27 If the AROM demonstrated in the supine position
or completed in a mobilization with a movement model, is approaching the ROM goals for therapyyet the patient
with the patient performing the motion and the clinician is unable to demonstrate similar range in sittingthen this
providing overpressure to engage scapular motion at the type of motor control and/or pattern of weakness should be
appropriate time. The intention of mobilizations to the GH considered (Box 7-8).
joint should change from addressing pain relief to the resid- Though specific rehabilitation parameters for those
ual capsular stiffness or asymmetry through oscillation patients exhibiting weakness because of neural injury will
not be included in this discussion, this impairment should

be considered as a possible contributor to a continued move-
ment dysfunction. Typically, a neural injury associated with
the trauma that predates the surgery or a neural injury
from a recent surgical intervention is difficult to identify
because of the amount of surgically induced trauma during
the procedure. Neural injury may be identified via atrophic
changes to the muscle, inability of the patient to elicit an
isometric contraction of the muscle with the humerus
positioned in neutral, and possible sensory changes in the
upper extremity. Isolated neural injuries following shoulder
arthroplasty are considered a low risk because of the tran- A
sient nature of the injuries and the tendency for resolution
without eventual operative intervention.38 When denerva-
tion of the shoulder musculature is present before surgery,
the patient will most likely be placed in a limited goals cat-
egory.23 This category and the goals will be discussed later in
this chapter.
Evaluation of weakness in patients with adequate inner-
vation of the shoulder musculature should include manual
BOX 7-8 Cautionary Signs and Symptoms During Later

Stages of Rehabilitation57 B
Loss of shoulder range of motion
Progressively increasing pain
Clunk felt during passive or active range of motion
D
Fig. 7-21 A, Supine progressive tilt starting position. B, Finish. C, Supine
greater angle progressive tilt starting position. D, Finish.
Fig. 7-20 Walk aways with isometric deltoid and external rotation.
A B
C D
Fig. 7-22 Prone positions. A, Start and finish for Y-position exercise. B, Midposition. C, Overhead view of midposition. D, Start and finish for T-position
exercise. E, Midposition.

Anticipated
Rehabilitation Criteria to Progress to Impairments and
Phase This Phase Functional Limitations Intervention Goal Rationale
Phase IV No increase in pain or loss Movement Continue STM Return to activities Realignment of scar tissue and
(Late phase of ROM and physician dysfunctionEarly/ Joint mobility including overhead collagen (to allow more ROM
strengthening) clearance to progress unopposed shoulder strengthening Increased ROM with less soft tissue restrictions)
Postoperative Things to watch for: elevation continues (both Improved strength Decrease possible capsular
12 wk after Excessive external Inadequate strength OKC and CKC) Improved adhesions
surgery to rotation with UE at side Inadequate ROM Progression to neuromuscular Decrease nociceptor input
discharge from Sustained edema in the terminal end control Increase strength
therapy distal upper extremity ROM and home Increase endurance
exercise program Improve function
Progression to discharge
CKC, Closed kinetic chain; OKC, open kinetic chain; ROM, range of motion; STM, soft tissue massage; UE, upper extremity.
muscle testing and the presence of coordination between the progressed from earlier examples of exercise (Fig. 7-23) into
two primary force couples that move the shoulder. As a a standing exercise that maintains humeral external rotation
review, there is a delicate balance that must be maintained through an isometric contraction and a concentric contrac-
to move the shoulder through its full ROM. The muscular tion of the deltoid. An example of an eccentric exercise pro-
contribution to this coordinated effort is via the force couple gression is demonstrated through an alteration of the wand
of the deltoid muscles and the rotator cuff muscles, and the activity. The patient can complete a sitting or standing over-
scapular stabilizer muscles with the deltoid muscles. Both of head wand activity initially shown in supine in Fig. 7-24. At
these force couples must have a balanced contraction to the highest point of the wand lift, the patient releases the
facilitate shoulder flexion and abduction without impinge- involved upper extremity from the wand and slowly lowers
ment of the humerus at the subacromial arch.39 the involved extremity back toward the waist.40 This type of
Strengthening should respect the force couples of the training can also be initiated for strengthening into
shoulder while addressing both the concentric and eccentric abduction.
functions of the targeted muscles. The force couple of the As a final example, consider that strengthening must also
shoulder between the deltoid and the rotator cuff can be address specific deficits in the targeted muscles. Fig. 7-24
A B
Fig. 7-23 Clock reach. A, Start position. B, Finish position.
A B
Fig. 7-24 Sitting low trapezius. A, Start position. B, Finish position.

demonstrates an exercise targeting the function of the low alignment, and muscular balance. Additionally, the func-
trapezius. The exercise emphasizes an isometric contraction tional tool, the simple shoulder test, can provide guidelines
of the upward rotation and a concentric action of the low on how much to load the shoulder during the rehabilitation
trapezius as a scapular depressor. A movement dysfunction period. It includes the ability to lift 1lb to shoulder height,
at greater than 120 in either flexion or abduction or inad- ability to lift 8lb to shoulder level, and carrying an item
equate strength as noted in a manual muscle testing would weighing 20lb.25,43
assist in determining the necessity of this exercise. Additional assistance for decision-making may be found
Return to recreational activities should have been a goal considering studies of external moments of the shoulder
from the initial evaluation. Closer scrutiny to the move- during activities of daily living. The average external
ments necessary for the patients chosen recreation will be moments to reflect loading of the shoulder during several
strong consideration for formulation of the home program activities of daily living, including picking up a 5-kg box,
and strengthening program during this final phase. Success- moving a 10-kg suitcase, and transferring from sit to stand,
ful return to recreation has been noted especially with the have been evaluated. The performance of these activities has
sports of swimming, tennis, and golf. Though the timeframe been found to represent a large proportion of the upper
of return will vary, successful return has been noted as early extremity strength in normal men and women.44 Patients
as 6 months.4 who receive a TSA must be considered to possess less than
normal strength especially during the rehabilitation process.
CAUTION FOR STRENGTH TRAINING Therefore, current caution for heavy loading of the shoul-
der for strength training demonstrates appropriate
Strength training does impart increased loads upon the concern by the therapist for the external moments created
healing shoulder that the clinician should monitor as the by these lifts thereby protecting the prosthetic and
patient progresses through this phase. Heavier loading of its design. Limiting the intensity prescribed to the
the shoulder or the introduction of activities with patient for strength training exercises should be exam-
increased shear forces is discouraged until significant ined. Discussion with the referring surgeon may give the
bone healing is evident, typically around 12 weeks. therapist more specific guidelines for possible lifting
Changes in the GH translations and loading mechanics can restrictions.
also be attributed to an imbalance of muscular forces either Resolution of functional limitation in activities of daily
from length or strength impairments and the mobility of the living and ROM goals should guide the determination of
joint capsule.41 The surgical procedure also plays a role in timely discharge. Active ROM goals are listed in Table 7-5.
the ability of a patient to participate in heavy loading of the The therapist should not prognosticate attainment of full
shoulder either for recreation or work demands. With poor ROM following TSA. This has been demonstrated in
methods or inappropriate prosthetic placement in addition several studies on total shoulder procedures regardless of
to increased loads, the patient may be at risk for uneven wear the presence or the lack of underlying pathologies or
of the glenoid or loading of the glenoid rim, which may lead comorbidities.45-50 Additionally, both patient and therapist
to instability or component loosening.17,42 should be aware that function improvements continue beyond
It is the therapists responsibility to ensure that there the discharge of therapy up to approximately 1 year after
is appropriate resolution of joint mobility, optimal extremity surgery.17
TABLE 7-5 Range of Motion Goals to Advance to the Next Phase of Rehabilitation
Shoulder Motion In Hospital25 Early Rehabilitation40 Late Rehabilitation Phase IV45
Full PROM in supine Full PROM in supine

Flexion PROM supine 140 PROM supine 140 AROM supine 140 AROM sitting 145-15011
sitting 120
Abduction n/a PROM supine 110 AROM supine 120 n/a
ER with humerus positioned at 0 of humeral abduction PROM supine 40 PROM supine 30-45 AROM supine 45 AROM sitting 45-6047
ER with humerus positioned at 90 of humeral abduction n/a n/a AROM supine 45 n/a
IR with humerus positioned at 0 of humeral abduction n/a PROM supine >70 AROM supine >70 AROM supine >70
IR with humerus positioned at 90 of humeral abduction n/a PROM supine >30 AROM supine >70 AROM supine >70
AROM, Active range of motion; ER, External rotation; IR, internal rotation; n/a, not available; PROM, passive range of motion.
Data from Goldberg BA, et al: The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint
disease. J Shoulder Elbow Surg 10(5):464-469, 2001; Brems J: Rehabilitation following shoulder arthroplasty. In Friedman R, editor: Athroplasty
of the shoulder, New York, 1994, Thieme; Godeneche A, et al: Prosthetic replacement in the treatment of osteoarthritis of the shoulder: early
results of 268 cases. J Shoulder Elbow Surg 11(1):11-18, 2002; Gartsman GM, Roddey TS, Hammerman SM: Shoulder arthroplasty with or
without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am 82(1):26-34, 2000.
surgeon. The outcome worsens the longer the delay is

LIMITED GOALS CATEGORY FOR TOTAL between the date of the trauma and the initiation of surgery.
SHOULDER ARTHROPLASTY The skill of the surgeon directly relates to the ability to align
the humeral tuberosities. Finally, there are improved out-
The limited goals category following TSA was first men- comes with larger surgery centers and higher volume
tioned by Neer in 1982.23 Criteria for inclusion into the surgeons.52
limited goals category included the status of the rotator cuff For patients with a traumatic reason for their total shoul-
and the stability of the implant. Patients were placed into a der surgery, rehabilitation may be a longer period of immo-
limited goals category if the rotator cuff was detached and bilization with passive ROM only. This is to ensure appropriate
not capable of recovery secondary to denervation or irre- boney healing. Additional time with significant precautions
versible contracture or if the stability of the implant was may exist up to 6 weeks, further delaying the potential
problematic as evaluated by the surgeon during the proce- resumption of ROM.52 The most common complication fol-
dure (Boxes 7-9 and 7-10). Specific diagnoses typically asso- lowing a TSA procedure for a traumatic injury is superior
ciated in this category include: rheumatoid arthritis, massive migration of the humeral head, which the clinician may
rotator tear, component position failure, septic arthritis, or observe as unopposed scapular elevation or shoulder hike as
neurovascular injury.51 described in the next section or in Box 7-11. There are several
Specific ROM goals are seldom mentioned when preparing reasons why this may occur: failure of the rotator cuff
a patient for a TSA. This is true whether a patient is placed muscles, muscular imbalance with inappropriate muscular
in the standard goals category or the limited goals category. force couple production at the shoulder, or loosening of the
The primary focus for those patients in the limited goals glenoid component.55
category is pain relief with a decreased emphasis on ROM
gains. This group will achieve less than satisfactory gains in TROUBLESHOOTING
functional ROM.51
Shoulder Hike
Total Shoulder Secondary to Trauma The most common observable movement dysfunction is unop-
The goals for a patient with a TSA secondary to trauma are posed scapular elevation and/or inadequate separation of
the same as that for a patient with a TSA secondary to degen- scapular and humeral motion, or in laymans language: a
eration: pain relief and resumption of daily function in both shoulder hike. This is seen with attempts to raise the arm
patient populations. The most important preoperative factors overhead in either a frontal or sagittal plane of motion.
that influence postrehabilitation function are the timing of Weakness is only one of the impairments that may contrib-
the surgery in relation to the injury and the skill of the ute to shoulder hiking. Additional impairments contributing
to this movement dysfunction include inadequate transverse
plane ROM, inadequate length of the scapulohumeral mus-
BOX 7-9 Limited Goals Category23,26 culature, inadequate mobility of the glenohumeral (GH)
joint capsule, and inadequate mobility of the scapula on the
For Patients With Tissue Insufficiency, thorax. Determination of the primary impairment limiting
Rheumatoid Arthritis this motion will guide the plan of care to eliminate the unop-
Goal is joint stability posed scapular elevation. For example, if the movement
Initiation of motion delayed analysis of the patients shoulder noted inadequate separa-
Joint mobilizations are delayed tion of scapular and humeral motion during the first 30 of
Active range of motion delayed until after 8 weeks shoulder abduction, then the physical examination measures
would focus on inadequate GH inferior glide, inadequate
strength, or neuromuscular control of the scapular muscles
that provide a stabilizing force into scapular down rotation,
BOX 7-10 Limited Goals Category Range of Motion adduction, or scapular depression or the inadequate length
Achievement of the scapulohumeral muscles.
Shoulder flexion: 75 to 90
Shoulder abduction: 70 to 80
External rotation: 30 BOX 7-11Possible Complications Following TSA57
Functional internal rotation: hand behind back to L5
Glenoid loosening
Data from Sojbjerg JO, et al: Late results of total shoulder Glenohumeral joint instability
replacement in patients with rheumatoid arthritis. Clin Orthop Infection
Relat Res (366):39-45, 1999; Orfaly RM, et al: A prospective
functional outcome study of shoulder arthroplasty for osteoar-
Neurologic injury
thritis with an intact rotator cuff. J Shoulder Elbow Surg 12(3):214- Recurrent cuff tear
221, 2003. Periprosthetic fracture
Stiffness infection yields the best result, therefore the therapist should
Stiffness of the GH joint following TSA presents a complex recommend an urgent return visit to the physician for blood
problem with the origin of the stiffness including: inadequate laboratory testing.9
intraoperative tissue release, an intense postsurgical inflam-
matory response, or slow progress in rehabilitation. Com- Biceps Tendon Tendonitis
munication with the referring surgeon and the history of the Biceps tendon tendonitis is a preventable complication during
ROM impairment of the patient before surgical intervention the rehabilitation process. The biceps has a role in shoulder
may assist the therapists decision-making to decrease the flexion and is a primary humeral depressor.37 Following
risk of stiffness. Initiating therapy with good pain control total shoulder surgery, the rotator cuff typically demon-
immediately postoperatively may prevent the development strates muscular inhibition, thus increasing the demand
of pathologic stiffness. Presentation of stiffness later in the on the biceps as the primary humeral depressor during
rehabilitation process must be evaluated for the primary shoulder motion. Presentation of biceps tendon tendonitis
contributing impairments. Consideration should be given indicates continued overuse of this muscle, therefore impli-
to the GH joint capsule, flexibility of the scapulohumeral cating inadequate contribution from the rotator cuff muscles.
muscles, and the separation of scapular motion from humeral Beyond regional treatment for the inflammation of the
motion. biceps tendon such as modalities, active rest, and taping, the
rotator cuff muscles should be evaluated for length, neuro-
Infection muscular control, and strength. The patient will have pain
A patient who has decreasing ROM in conjunction with pain during active ROM, especially with shoulder flexion and
or increasing pain should alert the clinician to possible infec- shoulder abduction. Limited shoulder extension may be
tion.9 Infection may present in up to 15% of all total shoulder noted secondary to irritation as the biceps tendon is placed
cases53 and may occur more than 1 year following the surgi- at a lengthened position or required to activate eccentrically.
cal procedure.5 Though pain and loss of ROM may be the Manual muscle testing of the biceps activates this muscle for
most objective signs during therapy, the therapist should be its role as an elbow flexor and forearm supinator, therefore
alert for drainage, warmth at the site, erythema, and effusion. it may be pain free and strong despite the irritation at the
Interviewing questions regarding the presence of night tendon. Attempts at special tests for tendonitis may be
sweats, fever (as noted by taking body temperature), chills, inconclusive because of the surgical trauma to the area and
remote sites of infection, or any recent invasive procedures the inability of the patient to attain the necessary positions
should be asked.10 Early intervention in the acute phase of the for testing.

Early Phase: 0 to 6 Weeks Exercises:
GOALS FOR THE PERIOD: Aware of sleeping 1. Continue previously mentioned ROM
positions, independent with home exercise program, exercises.
control pain, maintain range of motion (ROM) of 2. Initiate submaximal isometrics (being careful not
proximal and distal joints, protect healing structures to irritate the healing subscapularis muscle).
Exercises: 3. Perform active assistive range of motion
1. Instruct the patient on sleeping positions and (A/AROM) exercises in supine, then progress
encourage experimentation (usually semireclined to AROM in supine, and finally AROM in
with upper extremities supported by pillows or sitting as able (the patient must perform exercise
bolster). correctly).
2. When appropriate, initiate passive range of
motion (PROM) or self-assisted ROM at the Late Phases: 13 Weeks to Discharge
shoulder (avoid external rotation beyond 40). GOALS FOR THE PERIOD: Return to activities
3. Wear a sling for comfort. (including overhead activities), increase ROM,
4. Have the patient perform active range of motion improve strength, improve neuromuscular
(AROM) of the wrist and hand, elbow flexion only control
with humerus supported to decrease strain on Exercises:
biceps tendon, and AROM of cervical spine and 1. Continue with previously mentioned exercises as
thoracic spine through the cardinal planes. needed.
2. Use AROM for concentric and eccentric
Mid Phases: 6 to 12 Weeks strengthening at the shoulder.
GOALS FOR THE PERIOD: Increase shoulder ROM, 3. Perform rotator cuff strengthening (elevation
initiate strengthening, increase functional activities exercises must be performed correctly).
1 SW is a 72-year-old female who slipped and fell 7 days

ago sustaining a four-part humerus fracture. Surgical
intervention resulted in TSA. She is currently 1 day
recommended. Infection risk may extend to 1 year after
the operation.
postoperation and presents in the hospital room with a

compression dressing over the surgical site. The surgical
team has requested that she be cleared for discharge by
4 AB is a 68-year-old male who is participating in reha-
bilitation for a total shoulder. His pain complaints have
recently moved to the anterior proximal biceps area
this evening if possible. What functional assessments especially with attempts to move his shoulder into
must be completed to ensure a safe discharge home? flexion. What may be one of the structures contributing
to this pain?
Because of her history of falls, the patients mobility from
bed to chair, sit to stand, and ambulation must be assessed The most likely structure is the proximal biceps brachii
for safety. Following TSA, patients typically self-limit tendon. The clinical presentation may also include: con-
weight bearing through the shoulder. The patient must be tractile pain with a midline resisted test of the shoulder
assessed for independent mobility with limited use of the flexors, pain-free contraction for midline resisted tests at
involved upper extremity. It would be of great benefit to the elbow, increased sensitivity to placing the biceps
the patient to integrate the treatment of potential contrib- tendon in a lengthened position, and limited or painful
uting impairments to lesson her fall risk. shoulder abduction. Presentation of tendonitis indicates
overuse of the biceps brachii as a shoulder flexor and
2 RP is a 68-year-old male who underwent a right TSA 18

weeks ago. His course has been uncomplicated thus far;
however, during observation of shoulder flexion, RP
humeral depressor, thereby implicating inadequate con-
tribution from the rotator cuff muscles. Beyond the
modality intervention for the inflammation of the biceps
demonstrates a shoulder hike. Continued assessment tendon, evaluation of the function of the rotator cuff
for what impairments needs to occur to alter the treat- should be considered.
ment plan?
Determination of the primary impairment contributing to

this movement dysfunction will guide the plan of care to
5 ML recently underwent a total shoulder surgery. Surgi-
cal indications included a significant loss of motion,
interrupted sleep, and pain secondary to rheumatoid
eliminate the shoulder hike. To be most efficient, the arthritis of the GH joint. He has many questions regard-
clinician must note during which phase of the shoulder ing his expected ROM. What role does his history play
motion the shoulder hike does occur. For example, if in your discussion of prognosticated ROM?
the shoulder hike occurs during the last phase of scapulo-
humeral rhythm, then there should be a separation of Because of his medical history of rheumatoid arthritis,
humeral and scapular motion. The resources necessary ML would have a higher chance of being placed in the
for this separation to occur must be evaluated for proba- limited goals category. A conversation with the surgeon
ble impairments. Potential impairments include inade- on what ROM was accomplished during the surgical pro-
quate GH joint mobility, inadequate humeral depression, cedure would be necessary to determine the impact of
inadequate length of the rotator cuff muscles, and inade- his significant presurgical loss of ROM. A limited goals
quate stabilization of the scapula by the lower trapezius. category means that expected ROM at the shoulder is
conservatively estimated to reach: flexion: 75 to 90,
3 It is 6 weeks after surgery for JK, who had a left TSA

secondary to progressive degeneration. Today there is
increased swelling noted and you have concerns of a
abduction: 70 to 80, external rotation: 30, and internal
rotation: hand behind back to L5.
possible infection. What signs and symptoms should

you look for? What special questions should you ask? 6 GR is 3 weeks after surgery on the right. His precautions
include PROM for another week. Your treatment plan
includes scapular mobilizations to prepare for appropri-
Loss of ROM with pain or increasing pain would be ate scapulohumeral rhythm upon discharge of his
associated with a potential infection following TSA. Cor- PROM precautions. Name three key considerations for
roborating signs may be drainage and warmth at the this intervention.
surgical site, erythema, effusion, and systemic signs of
infection such as fever. Early intervention is necessary, Scapular mobilizations are introduced to ensure appro-
therefore an urgent return to the surgeon should be priate mobility of the scapula on the thorax for the
scapulohumeral rhythm during active ROM. The rhythm every day but is curious about the discoloration on his
consists of phases when there is movement only by the chest. During the physical examination, you note large
humerus and not at the scapula and a phase where the patches of bruising along the right thorax and into the
scapula and the humerus are both in motion. Therefore, axilla. The wound appears dry and clean with some
the clinician must consider length and mobility issues dried blood along the incision. What are your
that will affect these relationships; namely, the mobility concerns?
of the scapula and those structures that attach from the
glenoid to the humerus (the GH joint capsule and the It is not uncommon following total shoulder surgery for
rotator cuff muscles). The patient should be positioned bruising to appear and extend into the thorax, trunk, and
in a manner that allows the humerus to be passively axilla. Two competing issues would be the presence of
positioned at greater than 30 of humeral abduction or petechiae or potential signs of infection. Petechiae are
60 of humeral flexion before initiating scapular mobility. minute hemorrhagic spots that may be present on the
The length of the rotator cuff muscles must be addressed. chest and are related to injury to the long bone of the
Glenohumeral joint mobility must be assessed and treat- humerus. Corroborating signs and symptoms of short-
ment initiated if hypomobility is present. ness of breath, increased pain, and traumatic injury
would lead to suspicions of fat embolism. For signs of
7 MJs ROM precautions have been discharged and you

wish to introduce him to active overhead activities.
What is the primary impairment that must be addressed
infection, the integumentary integrity of the wound
should be checked including drainage, warmth, redness,
and/or excessive edema into the axilla or the distal arm.
before initiating independent overhead activities? Following major surgery, all patients should be moni-
tored for signs and symptoms of infection including the
Shoulder overhead motion is a complex motion that taking of body temperature. JJ should be educated on
requires a significant amount of humeral external rota- these signs and symptoms.
tion ROM. This humeral motion is necessary to avoid
impingement of the greater tuberosity of the humerus
and the undersurface of the acromial arch as the humerus
approaches 90 of shoulder motion. As this is the typical
10 MP is a 71-year-old female who is 10 weeks postsur-
gery. Her chief concern is difficulty with overhead
motion. AROM of shoulder flexion is135. PROM of
osteokinematic motion that is restricted within postsurgi- shoulder flexion is 168. During your movement
cal precautions, many patients do not exhibit adequate analysis, you note inadequate scapular upward rota-
external ROM to immediately begin overhead motion tion during the mid phase of motion (60 to 160)
following discharge of precautions. To avoid the risk of of shoulder flexion. What are the hypotheses of pos-
subacromial impingement, external rotation ROM should sible contributing impairments?
be achieved first.
Inadequate scapular upward rotation could be a result of
8 TA is 65-year-old male retired construction worker. You

are reviewing his home program before discharge. He
comments that the pendulum exercise increases his
weakness of the upper trapezius, lower trapezius, and
the serratus anterior because all are upward rotators of
the scapula. Other hypotheses include inadequate mobil-
pain. What should you do? ity of the scapula on the thorax because of adaptive
shortening of the downward rotators or inadequate
It is not uncommon for the pendulum exercise to be motor planning of the force couples of the serratus ante-
misinterpreted or performed incorrectly. It was designed rior and trapezius muscles.
to be a passive motion of the involved upper extremity
generated by trunk and pelvis motion. You have two
immediate choices: reeducate TA on the proper perfor-
mance of the pendulum exercise and/or instruct him in
11 AB is progressing in therapy and wishes to begin
overhead repetitive activities. As a clinician you
would stage him as between phases II and III. What
the alternate of table top exercises. Table top exercises is a key measurement in shoulder ROM that assists
emphasize an active trunk and pelvis over a supported with recommending overhead motion activities?
upper extremity thereby mimicking the pendulum exer-
cise without the gravitational traction. The dosage is External rotation of the shoulder at 0 of humeral abduc-
dependent on the goal of prescribing the exercise. For tion and at 90 of humeral abduction should be closely
pain relief, multiple sessions per day with 60 seconds of monitored if the patient has had surgical restrictions to
performance is appropriate. If the goal is to generate avoid external rotation. The end of phase II recommends
ROM, then a numeric prescription is more appropriate the patient have 40 of PROM into external rotation.
such as 3 sets of 15 repetitions each. Although 45 of AROM and full PROM into external rota-
tion demonstrate the end of phase III, the clinician must
9 JJ is a 69-year-old male presenting to you 6 days after a

TSA on the right shoulder. He states that he feels better
not overemphasize overhead activities until the patient
has achieved an adequate amount of external rotation
for the movement to be completed without multiple YMs timeline for integumentary healing and bone healing
compensations and risk of tissue irritation. is appropriate. The therapist should be knowledgeable of
the stroke mechanics for freestyle swimming, especially
12 YM is nearing discharge. He is 14 weeks after surgery.

Though he has been walking in the pool and using
various flotation devices, he has not progressed to
the necessary ROM and muscle actions. If the active ROM
is appropriate, then the home program will have to
emphasize not only traditional strength training parame-
full, unassisted freestyle swimming. What are the ters but also a timed repetitive component to more aptly
key criteria for successful return to this activity? mimic the muscle activities during swimming.
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2003.
CHAPTER 8
Extensor Brevis Release and
Lateral Epicondylectomy
Kelly Akin Kaye, Kristen G. Lowrance, James H. Calandruccio
T
he pathologic condition of the elbow commonly rupture is noted in a large number of patients at the time of
termed lateral epicondylitis or simply tennis elbow surgical intervention.
refers to pathologic alterations in the extensor tendon Microtears can result from repeated sprains, repetitive
origin(s), which often are solely alterations in the extensor forceful wrist extension and gripping, and suboptimal
carpi radialis brevis (ECRB) tendon. However, this syn- mechanics in hitting. Inadequate racquet size or improper
drome of lateral elbow pain is rarely accompanied by acute tool grip size also can predispose to injury. Other factors that
inflammatory cells and hence is now termed lateral epicon- may influence the onset of symptoms are inadequate strength,
dylosis. Moreover, many patients who have focal tenderness endurance, and flexibility of the forearm musculature;
just distal and anterior to the lateral epicondyle and localized changes in regular activity; increasing age; and hormonal
pain in the same region with wrist extension do not play imbalance in women.3 The incidence is equal in men and
tennis nor related to athletic activity.1 women during the fourth and fifth decades, with 75% of all
cases involving the dominant arm.1 Among the older popu-
lation, the insult can possibly be work-related, in contrast to
SURGICAL INDICATION AND the sports-related injuries seen in the younger population.
CONSIDERATIONS Lateral epicondylitis can be successfully managed non-
surgically in 90% of patients with a combination of activity
Etiology modification, nonsteroidal antiinflammatory medication,
Injury to the extensor tendons at the elbow often can be functional and counterforce bracing, various therapeutic
attributed to repetitive trauma or overuse, leading to modalities, and injection therapy. A small percentage of
mechanical fatigue or biomechanical overload. Some litera- patients with persistent and disabling symptoms require sur-
ture reports the possibility of exostosis in the area of the gical intervention.4 Lesions caused by overuse during
extensor tendons or a degenerative process that causes pain job-related activities are more likely to require surgical inter-
at the lateral epicondyle.2 Symptoms may be described as an vention secondary to an inability to stop the aggravating
ache at the elbow with sharp pain that infrequently radiates activity.
to the dorsal forearm and occasionally to the middle and ring Indications for surgery are individualized according to
fingers with attendant loss of grip.3 patient demands and activity level. The period of disability
The most frequently involved tendon is that originating and previous conservative management must be considered
from the extensor carpi radialis brevis (ECRB). It is respon- before surgical management is chosen. There are no absolute
sible for static and dynamic wrist extension required for indications for surgical intervention to treat lateral epicon-
certain tasks and stabilizes the wrist while grasping. Lesions dylitis, and the clinician must exercise caution in cases in
can occur at the extensor digitorum communis, extensor which secondary gain may be important.
carpi ulnaris, extensor digiti minimi, and supinator tendon. The most important factors in considering surgical inter-
According to the current literature, microtraumatic ECRB vention are the intensity, frequency, and duration of disa
tendon tears may propagate to include the common exten- bility caused by pain. The Nirschl classification system
sors.1 Plancher and associates1 report that gross tendon indicating the severity phase of pain, its relation to activity
144
Chapter 8 Extensor Brevis Release and Lateral Epicondylectomy 145
TABLE 8-1 Nirschl Tendinosis Pain Phases tendinous tissue, most notably the ECRB origin. Hypervas-
cular granulation tissue is characteristically found on the
Phase 1: Mild pain after exercise activity, resolves within 24 hours undersurface of the ECRB attachment to the lateral epicon-
Phase 2: Pain after exercise activity, exceeds 48 hours, resolves with dyle and appears on gross inspection as dull, tan-gray, and
warm-up sometimes gritty degenerative regions. A limited approach
Phase 3: Pain with exercise activity that does not alter activity commonly incorporated into surgical techniques consists of
Phase 4: Pain with exercise activity that alters activity resection of the diseased section of the tendon and lateral
Phase 5: Pain caused by heavy activities of daily living epicondylectomy.
Phase 6: Intermittent pain at rest that does not disturb sleep, and pain caused A skin pen is used to outline the intended surgical
by light activities of daily living incision which is 4 to 5cm long, gently curved, and
Phase 7: Constant rest pain (dull aching) and pain that disturbs sleep centered over the lateral epicondyle along the lateral
supracondylar ridge proximally and along a line from the
lateral epicondyle center toward the Lister tubercle. The
and exercise, and symptom resolution following these activi- skin incision is made under tourniquet control and the
ties may have some impact on the therapeutic intervention skin edges are retracted. Gentle spreading of the subcutane-
(Table 8-1). Constant and unrelenting focal lateral elbow ous tissue is done to protect any cutaneous nerves,
discomfort is not tolerated well by active individuals and often passing through a very superficial bursa over the lateral
pain that accompanies exercise and activity (phase 4) may epicondyle. The extensor fascia is identified through this
indicate pathologic tendon architectural alteration. Most opening (Fig. 8-1, A). The anterior edge of the ECRB
patients treated surgically have symptoms for 1 year, but tendon origin is clearly developed by elevating the posterior
special consideration may be given to patients in whom border of the extensor carpi radialis longus, which at this
other therapies have failed after 6 months of compliance with level is muscular and partially overrides the ECRB origin.
a well-tailored therapeutic regimen. Calcification around The extensor digitorum communis origin may partially
the lateral aspect of the elbow may portend a less favorable obscure the deeper portion of the ECRB (Fig. 8-1, B). The
outcome to conservative measures. When symptoms are ECRB portion of the conjoined tendon is elevated at
present for more than 12 months, they will rarely respond to the midportion of the lateral epicondyle, distally in line with
further therapeutic management. Although cortisone injec- the forearm axis toward the radiocapitellar joint. The
tions have been the historical standard for acute pain relief abnormal-appearing ECRB tendon is sharply dissected from
in significant cases of tennis elbow, the high recurrence rate the normal-appearing Sharpey fibers. The diseased tissue
has prompted autologous whole blood, platelet rich plasma, may appear fibrillated and discolored, and can contain
sclerosing agents, botulinum toxin, and periarticular hyal- calcium deposits.
uronate injections to provide more long-lasting results. At Occasionally the disease process also involves the exten-
this time, despite some compelling reports, no consensus sor digitorum communis origin. Entrance into the radio-
exists regarding the ideal injection for a given patient in a capitellar joint may not be routinely indicated; however, an
particular phase of their lateral epicondylosis malady. intraarticular process such as loose bodies, degenerative
Similarly, less invasive surgical interventions are being joint disease, effusion, and synovial thickening on preopera-
investigated by some authors for a quicker return to activity tive examination may require a larger incision and arthrot-
and exercise. Arthroscopic treatment when compared with omy for joint exploration.
open management may provide athletes a shorter time The lateral 0.5cm of the lateral epicondyle is decorticated
period to functional recovery. In contrast to percutaneous with a rongeur or osteotome, with the surgeon taking
release, arthroscopic release appears to achieve outcomes care not to damage the articular cartilage or destabilize the
more quickly and provide a clearer visualization of the joint (Fig. 8-1, C). The ECRB is intimately associated
pathology. Nonetheless, the benchmark procedure for this with the annular ligament just proximal to the radial
condition is an open release for which various modifications head, thereby limiting distal migration of the ECRB
have been proposed. Regardless of the open method chosen, tendon. However, the remaining normal ECRB tendon
these procedures are technically simple and provide predict- may be sutured to the fascia or periosteum or attached
able and long-lasting results and rely on readily available with nonabsorbable sutures through drill holes in the
instrumentation. No single technique has been or will be epicondyle.
adopted by all surgeons. The extensor tendon interval is closed with absorbable
sutures, with the elbow in full extension to reduce the pos-
sibility of an elbow flexion contracture. The skin incision is
SURGICAL PROCEDURE (MODIFIED closed (often with absorbable subcuticular suture material
NIRSCHL METHOD) reinforced with adhesive strips) and a soft dressing applied.
An arm sling is given for comfort and home range of motion
The common denominator for most lateral epicondylosis exercises are encouraged before the first office visit in 10 to
procedures, however, is the dbridement of the diseased 14 days postoperative.

REHABILITATION
Phase I
TIME: 1 to 14 days after surgery
GOALS: Achieve full range of motion (ROM) of
A adjacent joints, promote wound healing, control
edema and pain, and increase active range of
Extensor carpi
motion (AROM) of the elbow (Table 8-2)
radialis brevis
degeneration
After surgery, the therapist instructs the patient concern-
ing the need to elevate the site to avoid edema and initiates
Extensor carpi gentle AROM exercises for the hand and shoulder. The
radialis longus
patient is to remain immobilized in the postoperative splint
with the elbow positioned at 90. On the fifth day after
Lateral surgery, the postsurgical dressing and splint are removed and
epicondyle
therapy is initiated to the elbow.
The initial postoperative examination is conducted by
a physical or occupational therapist. Upon removal of
Extensor the postsurgical dressing, the examination conducted
aponeurosis
B should measure and address ROM, edema, pain, functional
ability, and wound healing. ROM of the hand, wrist,
elbow, and shoulder along with girth measurements of the
hand, forearm, elbow, and upper arm are taken. Pain
levels can be monitored using a 0 to 10 VAS (Visual Analog
Scale). It is recommended to have patients use this during
Decortication of therapy sessions and with the home exercise program
anterior lateral for optimum accuracy. Functional ability can be monitored
condyle
using the DASH (disabilities of the arm, shoulder, and
hand) or PRTEE (patient-rated tennis elbow evaluation)
questionnaire. The above recorded data should be taken at
subsequent visits for comparison and assessment of the
C patients progress.
Fig. 8-1 Surgical technique for correction of tennis elbow. A, Skin incision. In this phase the patients wounds are kept clean and dry
B, Identification of the origins of the extensor carpi radialis longus and until the sutures are removed 10 to 14 days after surgery.
extensor digitorum communis. C, Osteotome decortication. (Redrawn from
After the operative site has been exposed, other forms of
Nirschl RP, Pettrone F: The surgical treatment of lateral epicondylitis. J Bone
Joint Surg 61A:832-839, 1972.) edema control can be used, including ice, pneumatic inter-
mittent compression (performed at a 3:1 on/off ratio at a
pressure of 50mmHg), and high-voltage galvanic stimula-
tion (HVGS). The recommended settings for the use of
Surgical Outcomes HVGS to prevent edema are negative polarity with continu-
According to Nirschl,5,6 85% of patients were able to return ous modulation at 100 intrapulse microseconds and intensity
to all previous activities without pain. Pain that occurred to the sensory level.7 The patient also can be fitted with a
during aggressive activities was noted in 12% of the cases light elastic compression wrap or stockinette (such as Coban
observed, and no improvement was apparent in 3% of the or Tubigrip) to wear intermittently throughout the day and
cases. When both medial and lateral releases are performed, at night for continued edema control at home (Fig. 8-2).
a high level of patient satisfaction was achieved in a group AROM exercises also are initiated for the elbow, forearm,
of 53 patients followed an average of 11.7 years, and 96% of and wrist after the postoperative dressing is removed.8
patients returned to their sports activity. Reasons for failure Passive ROM (PROM) and joint mobilization of the elbow
include misdiagnosis or the concomitant diagnosis of entrap- and forearm are contraindicated at this time.
ment of the posterior interosseous nerve, intraarticular dis- Some surgeons prefer to keep the elbow immobilized in
orders, or lateral elbow instability. Poor prognostic factors a removable posterior elbow splint until the second week
include poor initial response to cortisone injections, numer- after surgery. This splint is typically fabricated from
ous previous cortisone injections, bilateral lateral epicondy- a low-temperature plastic with the elbow positioned at 90;
litis, other concomitant associated disorders, and smoking. it is worn between exercise sessions and at night (Fig. 8-3).
TABLE 8-2 Extensor Brevis Release and Lateral Epicondylectomy

Phase I Postoperative Postoperative pain Monitoring of incision site Prevent infection Prevention of
Postoperative Postoperative edema Instruction of client in activity Decrease stress on postoperative
1-14 days Limited upper extremity modification surgical site complications
mobility Cryotherapy Decrease pain Decrease stress on the
Unable to grasp and Pneumatic intermittent compression Control and decrease common extensor
reach HVGS edema tendons
Elastic compression wrap or Protect surgical site Pain control
stockinette Maintain ROM of Edema management
Fabrication of removable splint joints proximal and Prevent associated joint
PROM-AROMShoulder (all distal to the surgical stiffness and dysfunction
ranges, maintaining elbow in site of neighboring joints and
neutral position) Full AROM of muscles
AROM neighboring joints AROM to assist with pain
Hand (finger flexion/extension) Elbow ROM to 60% control and promote
Wristflexion/extension (extension will be edema management
Elbow (initiate after operative more limited) Improve ROM of elbow
dressing is removed)Flexion/ (sutures are usually
extension pronation/supination removed at 10-14 days)
AROM, Active range of motion; HVGS, high-voltage galvanic stimulation; PROM, passive range of motion; ROM, range of motion.
Fig. 8-2 Edema control. Portable HVGS unit, portable intermittent com-
pression unit, and compressive garment (Isotoner glove). Fig. 8-3 Posterior elbow splint.
Pain can be managed using HVGS at the same settings as The primary mode of lifting should be a bilateral under-
those used for edema control; the physician also may pre- handed or neutral forearm approach (Fig. 8-4).
scribe oral medications. During this initial phase, the therapist should closely
The first postoperative visit is a good time to begin patient monitor the patients reports of pain and tolerance to ROM
education regarding activity modification and proper mechan- exercises, noting any sympathetic changes that may lead to
ics during work- and sports-related activities. Patients should a complex pain syndrome. Signs and symptoms to be noted
be educated to avoid forceful static grip, repetitive and static are as follows:
wrist extension, and resistive supination, which are com- Pain out of proportion to the stimulus
monly seen with use of hand tools such as screwdrivers, and Excessive edema
pliers, and with keyboarding. Patients should also be Temperature and color changes
advised to avoid the overhanded lifting technique. Excessive joint stiffness
home exercise program and attending the regular therapy

Phase II sessions.
ROM exercises to be included are as follows:
TIME: 15 days to 4 to 5 weeks after surgery
Elbow extension and flexion
GOALS: Control edema and pain, achieve full elbow
Wrist extension and flexion
PROM, maintain full ROM of adjacent joints, and
Forearm supination and pronation
promote mobility of the scar tissue (Table 8-3)
The patient should avoid positions that place maximal
After the immobilization phase, the therapist should initi- stress on the common extensor tendons such as elbow
ate gentle AROM exercises for the patients elbow three to extension with extreme wrist flexion (Fig. 8-5).3 To prevent
four times each day.9 During the first ROM phase, the thera- reinjury, progressive resistive exercises also should be
pist should emphasize the importance of complying with the avoided at this time. Sports-related activities to avoid
Fig. 8-4 Underhanded lifting technique. Fig. 8-5 Extreme wrist flexion with elbow extension.

Phase II Incision well Continued pain and Continuation of edema and Intermittent pain with 0/10 Management of edema
Postoperative healed with no mild edema pain management pain at rest and pain with progression
3-5 wk signs of Limited upper techniques as in phase I Pain rating of less than 4 of 10 to self-management
infection extremity mobility Soft tissue massage with personal care ADL Improvement of soft
Improving Unable to grasp and Retrograde massage with Edema within 2cm of tissue mobility
PROM of reach for functional elevation uninvolved side Use of compression to
elbow use Scar desensitization after Encourage limited activities of remodel scar
No increase in sutures are removed and daily living performance Promotion of normal joint
pain or edema incision is healed Promote scar mobility and arthrokinematics
Silicon gel sheet for scar proper remodeling Preparation of muscles for
pad Full elbow, forearm, and wrist further resistive training
PROMElbow flexion/ PROM at 5 wk postoperation Encourage quality muscle
extension (within pain 1 repetition dynamometer contraction
tolerance) testing of minimum of 10lb of
Isometrics (with wrist in surgical extremity
neutral position, between Encourage quality muscle
30 flexion/extension) contraction
Wrist flexion/extension
ADL, Activities of daily living; PROM, passive range of motion.

include tennis, golf, lacrosse, or forceful throwing of Patients will be limited to lifting no more than 10lb after
a ball. surgery. On grip strength testing, patients typically demon-
Stanley and Tribuzi3 recommend isometric exercises with strate a 50% deficit when the operative hand is compared
the wrist in a neutral position or at no more than 30 of with the nonoperative one.
extension or flexion in preparation for further resistive
training. Exercises should be performed three to four
times daily with 15 to 20 repetitions being sufficient. Phase III
Isometrics should be performed with submaximal effort
TIME: Between 4 to 6 weeks to 6 months after surgery
only.
GOALS: Control pain, maintain full elbow and forearm
As ROM progresses, the therapist should carefully
ROM, strengthen upper extremity, and regain
monitor the patients edema. The management of edema is
normal forearm flexibility (Table 8-4)
specific to the patient and only one technique may be
required. The following technique can be used for mild Between 4 to 6 weeks after surgery, the therapist should
edema: initiate a progressive strengthening program.9 At this point
1. Ice and elevation for 10 minutes at the end of treatment in the rehabilitative process the patient should have full
2. Compression wraps and stockinette ROM of the hand, wrist, and elbow, and the focus should be
3. HVGS for 15 minutes on building strength and training for endurance with the
Moderate edema is treated with the following: goal of returning the patient to work or sports.
1. Retrograde massage The goal of the strengthening program is to promote con-
2. Intermittent pneumatic compression with elevation ditioning of the entire upper extremity, particularly the
3. HVGS with elevation and ice for 20 to 30 minutes forearm, to prevent reinjury caused by overstretching or
After the sutures are removed and the incision has healed overloading. To ensure that maximal strengthening is
appropriately, scar management is needed. achieved, eccentric exercises are recommended for the
This includes both desensitization and scar remodeling. extrinsic forearm muscles.3 At this time it is appropriate to
Because hypersensitivity can limit functional use, desensiti- initiate extrinsic forearm stretching.
zation should begin during the patients first therapy session Each patients conditioning program is formulated
after suture removal.9 Scar remodeling consists of using according to activity tolerance, previous activity level, and
massage (when appropriate) to help maintain mobility of the requirements for return to work or sports. If the patient can
scar by freeing restrictive fibrous bands, increasing circula- perform active exercises without pain, he or she is well
tion, and allowing the pressure to flatten and smooth the scar enough to begin resistive and light work or sports-related
site (Fig. 8-6).9 The therapist also may consider using a sili- activities using free weights and a work stimulator such as
cone gel sheet or other silicone-based putty mix as a pad over Baltimore Therapeutic Equipment (BTE) or Lido (Fig. 8-7).
the scar to assist in remodeling. The key is to continue educating the patient and training her
The therapist should instruct the patient to rub the sensi- or him to lift with the forearm in a neutral position and avoid
tive area for 2 to 5 minutes three to four times daily postures that stress the extensor muscles.
with textures such as fur, yarn, rice, Styrofoam, or corn. The components of the program are as follows:
Other useful textures include towels, clothing, dry beans, Hand (grip and pinch) strengthening
and rice.9 Forearm strengthening
Upper arm strengthening
Shoulder strengthening
Endurance training
Normally a return to activity can be anticipated by the
fourth month after surgery.8
TROUBLESHOOTING
Problems encountered after a lateral epicondylectomy

include pain, recurrence of symptoms, edema, inadequate
ROM or stiffness, and scar expansion.
Increase in Pain Level or Recurrence

of Symptoms
The therapist should carefully monitor the patients pain level
throughout the rehabilitation process. The Magill pain ques-
tionnaire can aid in monitoring changes in levels or charac-
Fig. 8-6 Scar remodeling by manual massage technique. teristics of pain. Exercise progression should occur based on

Phase III PROM full and Minimal, intermittent Continue pain and edema Self-manage pain Avoidance of postures that
Postoperative AROM near full pain and edema management as indicated Prevent flare-up place stress on the extensor
6-24 wk Pain and edema Minimal mobility Patient education regarding with progression of musculature
controlled and self- limitations in elbow activity modification and functional activities Promotion of return to
managed Unable to grasp and performance of activities with Grip strength to functional activities without
No decrease in reach for functional use good mechanics 85% of uninvolved flare of symptoms
strength since last Progressive resistance side Increased strength and
phase exercisesPutty Symmetric strength endurance for return to work or
exercises, finger pinch and grip of shoulder and sports
Isotonics scapula region Strengthening of upper quarter
Shoulder (see Chapter 3) Wrist strength to to ensure optimal functional
Elbowflexion, extension, within 80% use of upper extremity
pronation, and supination Return to previous Monitoring of wrist isotonics to
Wristflexion, extension, radial activity/work level ensure safe, maximal
and ulnar deviation strengthening
Work simulator (12-16 wk) Simulation of work/sports
Return to sports program loads in the clinic to train
(refer to Chapter 13) muscles to allow safe return
(12-16 wk) to sports or work
AROM, Active range of motion; PROM, passive range of motion.
A B
Fig. 8-7 A, Baltimore Therapeutic Equipment work simulator for grip strengthening. B, Simulated work activity.
the patients reports of pain. In some cases of severe pain, the been used intermittently throughout the day and at night
physician may prescribe a transcutaneous electric nerve with some success to reduce edema. Decreasing the activity
stimulation (TENS) unit. If the pain persists or occurs at the level or suspending the use of resistive exercises also may be
end of the rehabilitative process, the therapist may consider necessary.
the use of a counterforce brace to allow the patient to return
to the previous level of activity. Inadequate ROM or Stiffness in Adjacent Areas
The most common mobility problem involves loss of full
Persistent Edema elbow extension. By 6 to 8 weeks after surgery, the therapist
Edema control involves ice, elevation, HVGS, pulsed ultra- can talk to the surgeon about using static progressive or
sound, compression wraps, retrograde massage, and lym- dynamic splints to improve extension. Static splinting is
phatic massage. Continuous passive motion machines have achieved by using custom-made, low-temperature plastic
A B
Fig. 8-8 A, Commercially available finger flexion glove for hand stiffness. B, Composite finger flexion using Coban.
material molded to the patient at the end ROM and adjusted Ultrasound
weekly. Dynamic splints are available commercially. For Mechanical vibration
hand and finger stiffness, use of a flexion glove or composite Compressive dressings or garments to prevent scar
flexion stretching with a Coban or elastic (Ace) wrap is adherence
usually successful (Fig. 8-8). Circumferential desensitization using fluidotherapy also
may be considered.
Painful Scar
If the scar management techniques detailed earlier do not
produce the desired result, additional methods include the
following:
Home Exercise Program

This program gives some general ideas for initiating hand to passively stretch surgical elbow. Patient
and following a home exercise program. However, can use moist heat for 10 minutes before
consideration of the patients age, needs, and stretches if edema is under control.
capabilities will ultimately guide the rate of
progression, intensity, and type of treatment Phase 3 (6 to 12 Weeks)*
provided. 1. Discontinue AROM exercises if full motion has
been achieved.
Phase 1 (1 to 2 Weeks) 2. Begin grip strengthening using light resistance
1. Active range of motion 3 to 4 times daily. Begin putty for 5 minutes two to three times daily.
with 1 to 2 sets of 10 repetitions progressing to 3. Begin light shoulder, arm, and forearm
3 sets of 15 as tolerated. strengthening to include shoulder flexion/
2. Exercises include: elbow flexion/extension, adduction/abduction/internal rotation/external
forearm supination/pronation, wrist flexion/ rotation, biceps/triceps curls, wrist flexion/
extension/radial deviation/ulnar deviation, finger extension/radial deviation/ulnar deviation, and
flexion/extension/abduction/adduction, and forearm supination/pronation. Progress from 1lb
shoulder flex/abduction/adduction/internal up to 5lb maximum for the forearm. Start light
rotation/external rotation. with shoulder weight, performing 1 set of 10
3. Edema control by using elevation and repetitions and progressing to 3 sets of 15.
compressive stockinette. Ice packs to elbow 10 Appropriate patients may progress to 10lb
minutes three to four times daily. maximum.
Phase 2 (3 to 5 Weeks) Phase 3 Advanced (>12 Weeks)

1. The previous exercises add passive range of 1. Patient independently progresses exercises
motion to the elbow for flexion and extension if introduced in phase 3.
not achieving this actively.
2. Hold stretch for 20 to 30 seconds for 5 to 10 *Patients usually released back to normal activity/work or
repetitions 3 to 4 times daily. Use unaffected work hardening program at this time.
1 Marvin is a 50-year-old diabetic who had extensor

brevis release and lateral epicondylectomy 14 days ago.
His sutures were removed, and he was taken out of the
Jim is aggravating his symptoms with the exercises. He
also may be doing the home exercises too aggressively.
The primary goal should be to alleviate pain and swell-
postoperative splint 2 days ago. He has full shoulder, ing. After pain and swelling are under control, gradual
forearm, and hand mobility with elbow AROM of 45 strengthening can be initiated in small doses with more
to 110. His pain remains 3 or 4 out of 10 even at rest, rest periods than before. Treatment soreness should be
and moderate edema is localized to the elbow and proxi- minimal and controllable with the administration of ice
mal one third of the forearm. His incision shows mild packs. The amount of exercise and resistance should be
dehiscence with small amounts of exudate. What is gradually increased.
appropriate intervention for his continued pain, edema,
and suspicious wound?
The therapist should begin by ruling out infection. The

4 Janet is a 35-year-old accountant. She had extensor
brevis releases and a lateral epicondylectomy after
various attempts at conservative treatment failed. At 7
patients basal and elbow surface temperatures should be weeks after surgery, Janets elbow extension ROM is 15.
assessed, and he should be checked for redness or streak- What type of treatment may be effective at this stage for
ing near the elbow and forearm. If the patient shows no increasing her elbow extension?
temperature or color change and exudate is clear, Steri-
Strips should be applied to the incision and the patients The patient should be placed in a dynamic splint or in a
physician should be contacted. Once infection is ruled static progressive splint at night to gain full extension.
out, the following should be done: edema control using
retrograde massage (avoiding the area of incision), HVGS
and elevation (or both), PROM, and A/AROM to the elbow
for flexion and extension. Scar remodeling should be
5 Matt is a 47-year-old business executive. He underwent
an extensor brevis release with lateral epicondylectomy
4 weeks ago. Initial wound healing was good; however,
delayed until the incision is well closed. he returned to frequent travel with his job. He now
returns to therapy complaining of increased pain at rest
2 Cindy is a 60-year-old housewife who had arthroscopic

release of her right tennis elbow 3 weeks ago. She is now
complaining about right shoulder pain. She does not
reported as an 8/10, and swelling in the entire forearm
and hand. He experiences shooting pains and describes
a burning sensation in the involved upper extremity.
remember any injury to her elbow; she wears her arm Upon inspection, he has global swelling in the forearm
sling for comfort during the day. On examination, her with mottled appearance of skin and fusiform swelling
active and passive motion of the right shoulder is painful around the finger joints. Range of motion has decreased
and somewhat limited. What should be added to her in the elbow, wrist, and hand and he is unable to fully
therapy program, and what instructions should she be fist. Would it be appropriate to progress this patient to
given? phase II treatment? What should your treatment consist
of this treatment session?
Cindy has developed an early adhesive capsulitis of her
shoulder and should be instructed to stop wearing her At week 4 postoperation, a patient should have increas-
arm sling. She should also be started on a shoulder ing range of motion and a decrease in pain. The above
program to work on her ROM. This could begin with symptoms can indicate complex regional pain syndrome.
Codman exercises and a PROM program followed by This treatment session should consist of modalities to
AROM and strengthening. decrease pain and edema. No progression to the next
phase in exercise regime should be made at this session.
3 Jim is 34 years old. Approximately 7 weeks ago he had

an extensor brevis release and lateral epicondylectomy
A referral back to the physician is indicated.
performed. He is anxious to recover quickly so he can

play softball on the weekends. Mild resisted exercises
were initiated 1 week ago, and Jim is performing them
6 Sharon is a 45-year-old woman. She works as a com-
puter programmer and had extensor brevis release and
lateral epicondylectomy 14 weeks ago. She is performing
at home. His pain level has noticeably increased over the a home exercise program of progressive resistive exer-
past 4 days. However, he can control the pain with ice cises and intrinsic stretches for the forearm and elbow
and antiinflammatory medication. Should Jims exercise four times a week and has returned to work full time.
program be altered? If so, how should it be altered? She now complains of pain at the end of the day, with
mildly noticeable swelling at the lateral elbow. She splint. She has full shoulder, forearm, and hand mobility
attends therapy once a week. What should the therapist with elbow AROM of 10 to 130. Further questioning
evaluate at this weeks appointment? What are the right reveals that her preferred sleeping position is side-lying
recommendations? with her arms tucked under her pillow. What are the
right recommendations for this patient?
The therapist should assess the patients grip strength
and forearm, elbow, and shoulder girdle strength as Madeleine has developed an ulnar neuritis likely because
compared with the uninvolved side and previous weeks of her sleeping position. She should be instructed to
values. Elbow mobility and edema (via palpation girth wear her elbow splint at night only to prevent her from
measurements) should also be checked. The patient sustained hyperflexion during sleep and to protect the
should be asked to fill out a pain questionnaire or visual ulnar nerve. She should progress to the phase II treat-
analog scale for pain. If strength values show a decrease ment plan as indicated.
of 10% or are less than 85% of the uninvolved side, the
patient might have returned to work too early. If strength
values are within desired limits but the patient shows
significant edema and increased pain, she should be
9 Nash is a 33-year-old basketball coach who is 6 weeks
postsurgery. He has full range of motion of the elbow, a
mobile scar, and is tolerating self-care/activities of daily
encouraged to decrease the weight with progressive living without pain. He has not yet progressed to resis-
resistive exercises and begin using ice packs for 10 to 15 tive training in his home exercise program but is doing
minutes at the end of her work day. Stretching technique well and seems to be ready to progress to phase III.
should be reviewed to make sure that the patient is not During a therapy session, he reveals that he has been
overstretching, as well as proper mechanics and activity teaching/demonstrating dribbling skills to his little
modification while at work. The patient should be asked league team on the weekends. Should his exercise
to wear a counterforce brace while at work (for up to 6 program be altered?
months after surgery).
Nash needs to be educated regarding the time frame of
7 Ben is a 38-year-old superintendent for a commercial

construction company. He is 16 weeks past his surgery
and was released from therapy 4 weeks ago with a rec-
the healing process after surgery. He should be reminded
that at this time, full pain-free range of motion is the
main goal and at this time participation in any sport or
ommendation for a functional capacity evaluation. He repetitive activity is prohibited. His lifting restriction con-
returns to the clinic for his 1-month reassessment. tinues to be 10lb or less.
Against physicians orders, he returned to work stating
that he did not do any heavy lifting with his job. He
reports difficulty using his tools and soreness in the
forearm when using tools with vibration. He also states
10 Ross is a 48-year-old professional race car driver. He
is now 18 to 20 weeks postsurgery. He has full range
of motion, equal grip strength bilaterally, and MMT
that approximately midway through his day, he feels of involved upper extremity of 5/5. He tolerates a
weak in the surgical hand. Upon reassessment, Ben 45-minute exercise session of the work simulator
demonstrates only 50% grip strength as compared with without residual pain. He is now ready to return to
the nonsurgical extremity. Range of motion continues competitive driving. What guidelines would he be
to be within normal limits. Resistive testing and palpa- given for returning to racing?
tion is negative for pain. What can be done to address
his complaints? Patient should be released to return to racing per physi-
cians okay. He should be advised to allow for adequate
Ben should benefit from wearing an antivibratory glove rest periods between race practice sessions and to watch
and padding tools that are used repetitively. Consulta- for return of symptoms, such as soreness, aching, or
tion with the surgeon regarding further rehabilitation weakness. He can use ice to the elbow after driving as
based on his functional capacity evaluation in a work needed.
hardening setting is also indicated to increase grip and
upper extremity strength and endurance required for this
patients job. 11 Tucker is a 21-year-old college football quarterback.
During the off season he had a modified Nirschl
procedure for lateral epicondylitis. He is now 12
8 Madeleine is a 40-year-old veterinarian who is 4 to 5

weeks postoperation. She presents with complaints of
numbness and tingling along the small and ring fingers
weeks after surgery. He has full active and passive
range of motion, is tolerating resistive strengthening
exercises without reproduction of symptoms, and
of the affected extremity. She still has mild pain rated as reports 0/10 pain at rest. He states he has only mild
3/10 and mild edema localized to the surgical site but is soreness in the elbow the day after he works out.
tolerating passive and active range of motion and iso- During his leisure time he decided to go camping
metric exercises well since the removal of the 90 elbow and presents to the clinic with a large pocket of
swelling near his olecranon. What should be the next 8-3). What are appropriate guidelines for the follow-
treatment? ing exercise components? Grip strength; sustained
grip; forearm and wrist strength; upper arm
This patient could possibly have an olecranon bursitis strengthening.
brought on by an infection from an insect bite. He needs
to be referred back to his surgeon for possible aspiration Grip strengthening with light resistive putty two to three
and medication as indicated. times daily for 2 minute sessions. Sustained grip with a
1-lb weight with light resistive putty for 2 minutes.
12 Elizabeth is a 55-year-old medical transcriptionist

who had an open extensor brevis release 7 weeks
ago. All goals for phase II have been met (see Table
Forearm and wrist PREs with No. 1 weight, 1 to 3 sets
of 10 repetitions. Upper arm strengthening varies with
general health, age, sex, and lifestyle/activity level.
REFERENCES 6. Ollivierre CO, Nirschl RP, Pettroe FA: Resection and repair for medial
1. Plancher KD, Halbrecht J, Lourie GM: Medial and lateral epicondylitis in tennis elbow: A prospective analysis. J Sports Med 23:2, 1995.
the athlete. Clin Sports Med 15(2):283-305, 1996. 7. Hayes KW: Manual for physical agents, ed 4, Norwalk, Conn, 1993,
2. Gellman H: Tennis elbow (lateral epicondylitis). Orthop Clin North Am Appleton & Lange.
23:75-82, 1992. 8. Jobe FW, Ciccotti MG: Lateral and medial epicondylitis of the elbow.
3. Stanley BG, Tribuzi SM: Concepts in hand rehabilitation, Philadelphia, J Am Acad Orthop Surg 2(1):1-8, 1994.
1992, FA Davis. 9. Hunter JM, Mackin EJ, Callahan AD: Rehabilitation of the hand: Surgery
4. Canale ST: Campbells operative orthopaedics, ed 9, St Louis, 1998, and therapy, ed 4, St Louis, 1995, Mosby.
Mosby.
5. Olliveierre CO, Nirschl RP: Tennis elbow: Current concepts of treatment
and rehabilitation. Sports Med 22(2):133-139, 1996.
CHAPTER 9
Reconstruction of the Ulnar Collateral
Ligament with Ulnar Nerve Transposition
Mark T. Bastan, Michael M. Reinold, Kevin E. Wilk, James R. Andrews
T
he ulnar collateral ligament (UCL) is the elbows humerus is a bony depression called the coronoid fossa. The
primary stabilizer to valgus stress within a functional olecranon process of the ulna glides into this concavity
range of motion (ROM). For the overhead-throwing during flexion. The olecranon fossa, located on the posterior
athlete, throwing motions promote valgus stress at the elbow aspect of the humerus, accepts the large olecranon process
that exceeds the ultimate tensile strength of the UCL. Repeti- during extension. The proximal ulna provides the major
tive throwing motions produce cumulative microtraumatic articulation of the elbow and is responsible for its inherent
damage and may eventually cause the ligament to overstretch stability. The trochlear ridge is a bony projection running
and create symptomatic medial elbow instability. To correct from the olecranon posteriorly to the coronoid process ante-
this, both surgical intervention and a carefully coordinated riorly. The trochlear notch is a concave surface located on
rehabilitation program are required if the athlete is to return either side of the trochlear ridge; it forms a close articulation
to full, pain-free function. This chapter describes the way the with the humeral trochlea.
anatomy and biomechanics of the elbow can be applied to a The proximal radius and distal lateral aspect of the
scientifically based rehabilitation program for use after UCL humerus articulate to form the humeroradial joint, which is
reconstruction. also a single-axis diarthrodial joint. Similar to the humeroul-
nar joint, the humeroradial joint contributes to flexion and
SURGICAL INDICATIONS extension movements by gliding around the coronal axis.
AND CONSIDERATIONS However, the humeroradial articulation also pivots around
a longitudinal axis with the superior radioulnar joint to
Bony Structures perform rotational movements. The proximal radial head is
The elbow joint has three articulations: the humeroulnar, mushroom shaped,2 with a central depression located above
humeroradial, and superior radioulnar joints. Collectively it. The radial head narrows distally to form the radial neck.
these joints may be classified as trochoginglymoid1 and are The head and neck are not colinear, with the shaft of the
enclosed by a single joint capsule. radius forming an angle of approximately 15. Further distal
The humeroulnar joint is a single-axis diarthrodial joint is the radial tuberosity, where the biceps tendon attaches. In
with 1 of freedomflexion and extension. The bony struc- the distal humerus the capitellum is almost spheric. A groove
tures of the joint include the distal humerus and proximal (the capitotrochlear groove) separates the capitellum from
ulna (Fig. 9-1). The distal humerus flares to form the medial the trochlea. The rim of the radial head articulates with this
and lateral epicondyles, which are directly above the capitel- groove throughout the arc of flexion and during pronation
lum and trochlea, respectively. The medial epicondyle is and supination.
much more prominent than the lateral epicondyle; the UCL The superior and inferior radioulnar joints function as
and flexor-pronator muscle group attach to it (Fig. 9-2). The single-axis diarthrodial joints that allow the elbow to pronate
flat, irregular surface of the lateral epicondyle serves as the and supinate. Proximally, the convex medial rim of the radial
attachment site for the lateral collateral ligament and head articulates with the concave radial ulnar notch. During
the supinator-extensor muscle groups. Just posterior to the supination and pronation, the radial head rotates within a
medial epicondyle is the cubital tunnel, or ulnar groove, a ring formed by the annular ligament and radial ulnar notch.
key depression that protects and houses the ulnar nerve. An interosseous membrane connects the shafts of the radius
Immediately above the anterior articular surface of the and ulna to form a syndesmosis. Distally, the ulnar head with
155
Humerus
Ulnar nerve
Anterior oblique
Lateral Coronoid
supracondyle fossa
ridge
Medial
Lateral epicondyle
epicondyle
Trochlear Posterior
Radial groove oblique
fossa
Capitellum Trochlea
Radial Transverse oblique

Coronoid
head process Fig. 9-3 The ulnar collateral ligament (UCL) complex of the elbow consists
Radial of three bundles: anterior, posterior, and transverse oblique. (From Stoyan
neck M, Wilk KE: The functional anatomy of the elbow. J Orthop Sports Phys
Ulnar
Radial Ther 17:279, 1993.)
tuberosity
tuberosity
Ulna
Radius
Ligamentous Structures
Fig. 9-1 The osseous anatomy of the elbow complex. (From Stoyan M, A single joint capsule surrounds the elbow joint and is lined
Wilk KE: The functional anatomy of the elbow. J Orthop Sports Phys Ther by a synovial membrane. Specialized thickenings of the
17:279, 1993.) medial and lateral capsule form the collateral ligament
complexes.
Ulnar nerve The UCL is traditionally described as having three por-
tions: the anterior, posterior, and transverse bundles (Fig.
Median nerve 9-3).2 The anterior bundle of the UCL is the strongest and
Biceps most discrete component, coursing from the medial epicon-
dyle to the sublime tubercle on the medial coronoid margin.
The anterior bundle consists of two layers: (1) a thickening
Brachialis
Pronator
within the capsular layers and (2) an added complex super-
teres ficial to the capsular layers.3 The anatomic design of this liga-
Palmaris longus
ment makes pathologic conditions in the central portion of
Brachioradialis the anterior bundle (as seen in a chronic, attenuated state)
Extensor carpi
Flexor carpi difficult to see during arthroscopic surgery. Functionally,
radialis
radialis longus the UCL is subdivided into two bands: (1) the anterior
Flexor carpi band, which is tight in extension, and (2) the posterior band,
Extensor carpi ulnaris
radialis brevis which is taut in flexion.4
Flexor digitorum The anterior oblique bundle of the UCL is the primary
superficialis
stabilizer to valgus stress at the elbow. Compromise of this
structure causes gross instability in all elbow positions except
full extension. The fan-shaped posterior bundle runs from
the medial epicondyle to the middle margin of the trochlear
notch. This band becomes especially taut in flexion beyond
60,5,6 but sectioning the posterior oblique ligament does not
Fig. 9-2 The medial epicondyle serves as the attachment site for the ulnar
collateral ligament (UCL) and flexor pronator group. (From Stoyan M, significantly affect medial elbow stability.7 The transverse
Wilk KE: The functional anatomy of the elbow. J Orthop Sports Phys Ther ligament (also known as the Cooper ligament) has an ulnar-
17:279, 1993.) to-ulnar attachment and contributes minimally to elbow
stability.5
the radial ulnar notch forms the inferior radioulnar joint The anatomy of the lateral collateral ligament complex
articulation. This joint is L-shaped and has an articular disk can vary significantly.8,9 Typically four components are
between the lower ends of the radius and ulna. During supi- found: (1) the radial collateral ligament (RCL), (2) the
nation and pronation, the ulnar notch and articular disk annular ligament, (3) the lateral UCL, and (4) the accessory
swing on the ulnar head. lateral collateral ligament (Fig. 9-4). The RCL originates
Chapter 9 Reconstruction of the Ulnar Collateral Ligament with Ulnar Nerve Transposition 157
advantage because it crosses so closely to the axis of rotation.

As the brachialis crosses the anterior capsule, some muscle
fibers insert into the capsule and help retract the capsule
during flexion.
Annular
ligament Accessory collateral The anconeus and triceps brachii perform elbow exten-
ligament sion and are located posteriorly. The triceps brachii has three
heads (long, lateral, and medial) proximally that converge
Common
extensor distally to form a single insertion at the posterior olecranon.
tendon The much smaller anconeus originates at the posterior aspect
of the lateral epicondyle and inserts on the dorsal surface of
the proximal ulna. Besides extending the elbow, the anco-
neus may be a lateral joint stabilizer.
Anconeus muscle
Radial collateral The flexor-pronator muscles, which all originate com-
ligament
pletely or in part at the medial epicondyle, include the prona-
Fig. 9-4 The lateral collateral ligament complex of the elbow consists of tor teres, flexor carpi radialis, palmaris longus, flexor carpi
the radial collateral ligament (RCL), annular ligament, and lateral ulnar
ulnaris, and flexor digitorum superficialis. The primary role
collateral ligament (UCL). (From Stoyan M, Wilk KE: The functional
anatomy of the elbow. J Orthop Sports Phys Ther 17:279, 1993.) of these muscles is in hand and wrist function, but they also
act as elbow flexors and dynamically stabilize the medial
aspect of the elbow.
from the lateral epicondyle and terminates on the annular Finally, the extensor supinator muscles include the bra-
ligament. It provides varus stability by maintaining close chioradialis, extensor carpi radialis brevis and longus, supi-
approximation of the humeral and radial articular surfaces.8 nator, extensor digitorum, extensor carpi ulnaris, and
The annular ligament is a strong band of tissue encompass- extensor digiti minimi. Each of these muscles originates near
ing and stabilizing the radial head in the radial ulnar notch. or directly onto the lateral epicondyle of the humerus and
The anterior part of this ligament becomes taut with extreme provides dynamic support over the lateral aspect of the
supination and the posterior portion with extreme prona- elbow.
tion.10 The lateral UCL originates at the midportion of the
lateral epicondyle, passes over the annular ligament, and Neurologic Structures
attaches to the tubercle of the supinator. This ligament is The relationship of neurologic structures coursing through
analogous to the anterior band of the UCL and is the primary the elbow to their surrounding features can be crucial to
lateral stabilizer of the elbow, preventing posterolateral function, pathologic conditions, and treatment (Fig. 9-5).
rotary instability.9 Finally, the accessory lateral collateral liga- The radial nerve descends anterior to the lateral epicondyle,
ment extends proximally from the inferior margin of the behind the brachioradialis and brachialis muscles. At the
annular ligament and attaches distally on the tubercle of antecubital space, the nerve divides into superficial and deep
the supinator crest. branches, with the superficial branch continuing distally in
It further stabilizes the annular ligament during varus front of the lateral epicondyle and running under the bra-
stress.5,9-11 chioradialis muscle while on top of the supinator and prona-
tor teres muscles. The deep branch pierces the supinator,
Muscular Structures travels around the posterolateral radial neck, and emerges
The musculature surrounding the elbow joint may be divided distally 8cm below the elbow joint to the terminal motor
into four main groups: branches.
1. The elbow flexors The median nerve follows a straight course into the
2. The elbow extensors medial aspect of the antecubital fossa, medial to the biceps
3. The flexor-pronator group tendon and brachial artery. From the antecubital fossa, the
4. The extensor supinator group median nerve continues under the bicipital aponeurosis and
The flexor group is located anteriorly and comprises the usually passes between the two heads of the pronator teres,
biceps brachii, brachialis, and brachioradialis muscles. The then travels below the flexor digitorum superficialis.
biceps brachii acts both as a major elbow flexor and as a The musculocutaneous nerve innervates the major elbow
supinator of the forearm (primarily with the elbow flexed), flexors of the anterior brachium, then passes between the
with a distal insertion at the radial tuberosity and bicipital biceps and brachialis muscles to pierce the brachial fascia
aponeurosis, which attaches to the anterior capsule of the lateral to the biceps tendon. It continues distally to terminate
elbow. The brachioradialis originates at the proximal two as the lateral antebrachial cutaneous nerve, providing sensa-
thirds of the lateral supracondylar ridge of the humerus and tion over the lateral forearm.
attaches distally at the base of the styloid process of the Finally, the ulnar nerve travels anterior to posterior in the
radius, giving it the greatest mechanical advantage of brachium through the arcade of Struthers. It then extends
the elbow flexors. The cross-sectional area of the brachialis around the medial epicondyle and through the cubital
is the largest of the elbow flexors, but this has no mechanical tunnel. The cubital tunnel is the most frequent site for ulnar
To anconeus
Musculocutaneous
Ulnar
Radial
Median
A B
Fig. 9-5 A, Posterior view showing the ulnar nerve of the elbow ligament. B, Anterior view showing the neurologic innervation of the elbow. (From
Stoyan M, Wilk KE: The functional anatomy of the elbow. J Orthop Sports Phys Ther 17:279, 1993.)
nerve injury; length changes in the medial ligament struc- extended, and externally rotated about 130, with the elbow
tures during elbow flexion can lead to significant reduction flexed at about 90. In transition from cocking to accelera-
of the volume of the cubital tunnel, resulting in ulnar nerve tion, the shoulder then internally rotates and the elbow flexes
compression.12 This compression occurs as the cubital reti- another 20 to 30; this further increases the valgus load on
naculum, which forms a roof over the cubital tunnel, tight- the medial elbow. As the arm continues to accelerate, the
ens with elbow flexion.13 Absence of the cubital tunnel elbow extends from about 125 to 25 of flexion at ball
retinaculum has been associated with congenital ulnar nerve release.15,16 Dillman, Smutz, and Werner17 report that mean
subluxation. After passing through the cubital tunnel, the ultimate valgus torque measured from cadaveric testing was
ulnar nerve enters the forearm by traveling between the two 33N-m (newton-meters) (Fig. 9-6). During analysis of the
heads of the flexor carpi ulnaris. dynamic demands of the pitching motion, Fleisig and associ-
ates18 estimate that 35N-m of valgus torque is placed on the
Cause UCL. The flexor carpi ulnaris and flexor digitorum superfi-
Injury to the UCL and resultant medial elbow instability are cialis muscles are located directly over the anterior band of
secondary to valgus loads that exceed the ultimate tensile the UCL and assist in combating medial joint distraction
strength of the ligament. Although excessive valgus loads forces during the throwing motion. With any increased load
may be secondary to trauma, as with an elbow dislocation transmitted to the UCLwhether with improper mechanics,
caused by a fall or playing a sport such as football or wres- warm-up, or conditioningthe structural integrity of
tling, the most common mechanisms of injury are associated the primary medial stabilizer of the elbow may be
with repetitive overhead activities, such as baseball, javelin compromised.
throwing, tennis, swimming, and volleyball. The single Injuries to the UCL are described as either acute or
largest patient population experiencing medial elbow insta- chronic. An acute rupture of the UCL is frequently associ-
bility is undoubtedly overhead throwers.14 This is secondary ated with a pop, a feeling of pain during late acceleration
to the tremendous forces imparted to the elbow joint during or at ball release; it is often accompanied by swelling. More
the overhead-throwing motion. commonly, chronic injuries to the ligament are seen in the
The initiation of valgus stress occurs at the conclusion of overhead-throwing athlete.19 These occur from the accumu-
the arm-cocking stage. The throwers shoulder is abducted, lated repetitive microtrauma of overloading the ligament
150
Elbow torque, N-m 120 (C)
90
60 Extension (+)
Varus (+)
30
0
30 Flexion ()
Valgus ()
60
Biceps
Triceps
Wrist flexors
Fig. 9-6 Resting tensile strength of the ulnar collateral ligament (UCL) is
measured at 33N-m, but demands associated with pitching have been mea-
sured at 35N-m. (From Werner SL, et al: Biomechanics of the elbow during
baseball pitching. J Orthop Sports Phys Ther 17:274, 1993.)
Fig. 9-7 To begin the reconstruction procedure, a medial incision is made
in the elbow for ulnar collateral ligament (UCL) reconstruction and ulnar
with throwing and can result in symptomatic medial elbow nerve transposition. (From Andrews JR, et al: Open surgical procedures for
instability.20 Accurate identification of medial instability is injuries to the elbow in throwers. Oper Tech Sports Med 4[2]:109, 1996.)
often difficult with clinical examination alone because laxity
is only slightly increased. In addition, performing valgus
laxity assessment is often difficult because of humeral rota- to avoid neuroma development. After elevating the skin flaps
tion. Often magnetic resonance imaging (MRI) is used to to expose the deep fascia covering the flexor pronator
confirm diagnosis. Timmerman, Schwartz, and Andrews21 muscles, the surgeon identifies the ulnar nerve. Anterior
believe that use of saline-enhanced MRI improves the results transposition of the ulnar nerve must be performed before
when a UCL tear is suspected. The authors of this chapter the medial ligament complex is explored. To do so, the
have found a typical leakage of contrast fluid around the cubital tunnel is first incised to mobilize the nerve. Proxi-
ulnar insertion of the UCL when an undersurface tear is mally, the mobilization continues to include the arcade of
present, which has been called the T-sign.22 Struthers, and a portion of the intermuscular septum is
Surgical reconstruction of the UCL is indicated in athletes excised to prevent impingement of the nerve as it is trans-
who have persistent medial elbow pain, cannot throw or posed anteriorly. Distally, the flexor carpi ulnaris is incised
participate in desired sports, show documented valgus laxity, along the course of the nerve. The ulnar nerve is then trans-
and fail a 6-month conservative course of treatment. posed anteriorly and preserved throughout the remainder
of the procedure.
SURGICAL PROCEDURE To complete visualization of the UCL, the split in the
flexor carpi ulnaris is followed down to the insertion of the
The goal of reconstruction is to restore the static stability of anterior band of the UCL on the sublime tubercle of the ulna.
the anterior bundle of the UCL. The surgical procedure used Starting at the insertion of the ulna, the surgeon develops the
at the authors center by Dr. James Andrews is a modification interval between the UCL and flexor muscle mass, extending
of an earlier technique. proximally to the medial epicondyle. The flexor muscles are
The presence or absence of the palmaris longus must be then retracted anteriorly to provide full exposure to the liga-
documented before surgery because it is the preferred donor ment, at which point the pathologic condition can be
tendon. If it is not present, then alternate donor sites must assessed. In a complete rupture, the joint is exposed. If the
be evaluated, including the contralateral palmar longus, external surface appears normal, then a longitudinal incision
the plantaris tendon, and the extensor tendon from the is made in line with the fibers of the anterior bundle. This
fourth toe. incision may reveal pathology, including tissue discolor-
Surgery to correct for valgus instability is initiated with a ation, fraying of the tissue, and detachment from the bony
brief arthroscopic evaluation. The procedure itself begins insertion on the ulna indicative of an undersurface tear, as
with arthroscopic examination to assess the integrity of the described by Timmerman and Andrews.23
intraarticular structures and valgus instability. After that is The remnants of the ligament are preserved and aug-
completed, a medial incision is made with subcutaneous mented with the tendon graft. After the donor tendon has
ulnar nerve transposition. The incision is centered over the been secured, muscle is stripped off the graft, the ends are
medial epicondyle and extends about 3cm proximally and trimmed, and a nonabsorbable suture is placed at each end
distally (Fig. 9-7). The medial antebrachial cutaneous nerve with a locking stitch to help graft passage. Two drill holes are
is identified, preserved, and protected during the procedure made at right angles just anterior and posterior to the sublime
Fig. 9-9 A postoperative posterior elbow splint is used to protect healing

tissues.
Fig. 9-8 Figure-eight reconstruction of the ulnar collateral ligament (UCL)

using an autogenous graft. (From Andrews JR, et al: Open surgical proce- The complete rehabilitation program is outlined in the home
dures for injuries to the elbow in throwers. Oper Tech Sports Med 4[2]: maintenance box.
109, 1996.)
Phase I
tubercle at the level of insertion of the anterior bundle. The
GOALS: Decrease pain and inflammation, retard
drill holes are then connected with curettes and a towel clip.
muscle atrophy, protect healing tissues (Table 9-1)
Proximally, two convergent tunnels are drilled to meet at the
insertion of the ligament on the medial epicondyle. The graft The patient should be placed in a posterior elbow splint
is then passed through the ulna and crossed in a figure eight at 90 of flexion (Fig. 9-9), which allows initial healing of the
across the joint. Each end is then brought out through the UCL graft and soft tissue healing of the fascial slings for the
two tunnels at the humerus end. If the graft is long enough, transferred ulnar nerve.24 Edema and pain are managed with
then one end is passed through a second time. The graft frequent gripping exercises, cryotherapy, and a bulky dress-
tension is adjusted with the elbow in 30 of flexion and by ing. The dressing is applied immediately after surgery and is
application of a varus stress. The graft is then secured with removed between postoperative days 5 and 7.
nonabsorbable 2-0 sutures over the medial epicondyle. The The therapist initiates submaximal shoulder isometrics
remaining ligament is sutured to the graft for added stability, (except external rotation, which promotes a valgus stress
and the flexor carpi ulnaris is loosely closed (Fig. 9-8). at the elbow) and active wrist ROM to prevent neuromus-
Ulnar nerve transposition is now completed. An incision cular inhibition.
is made in the flexor pronator fascia, leaving attachments at The therapist evaluates ulnar nerve function postopera-
the medial epicondyle; these flaps are about 3cm long and tively and frequently throughout the rehabilitation process.
1cm wide. Muscle is dissected away from the fascia, and the Paresthesia and impaired motor function occur at rates as
defect is closed to prevent herniation. The nerve is then high as 31% with intramuscular ulnar nerve transposition.
transferred subcutaneously and anteriorly to lie under the The procedure described in this chapter uses fascial slings to
fascial flaps. The flaps are reattached loosely to provide a complete transposition of the nerve, so the chance of post-
sling to keep the nerve in position without compressing it. operative neurologic complications is extremely low, usually
A drain is placed subcutaneously, and the skin is closed with less than 3%.
an absorbable 3-0 subcuticular suture. Compression wraps that are too tight and ill-fitting
braces also may lead to transient ulnar nerve paresthesia
THERAPY GUIDELINES FOR and should be carefully assessed.
REHABILITATION Early ROM and frequent assessment are vital in the early
rehabilitative process. After 7 days, the posterior splint is
Rehabilitation after UCL reconstruction should match the removed and the elbow placed in a hinged brace set at 30
surgery used and meet the needs of the patient, which to 100 (Fig. 9-10). ROM is then advanced weekly by 10 of
include additional care for the individuals specific donor extension and 10 of flexion. Forearm supination and prona-
site. The following guidelines are based on the procedure just tion ROM are assessed and progressed in postoperative week
described and are geared to the overhead-throwing athlete. 2, given that these motions have no significant effect on graft
TABLE 9-1 Ulnar Nerve Transposition

Criteria to Anticipated Impairments
Phase I Postoperative Postoperative pain Posterior splint with elbow at 90 Protect surgical site Soft tissue healing
Postoperative Postoperative edema of flexion (see Fig. 9-9) Increase elbow ROM without irritating surgical
1-3 wk Arm immobilized in Remove splint at 7 days after Improve tolerance to site
postoperative dressing surgery and place in a hinged elbow ROM Hinged brace to avoid
Limited elbow and wrist elbow brace set at 30 extension Control pain valgus stress
ROM and 100 flexion Manage edema Gradual addition of stress
Limited UE strength Brace ROM progressed by 10 of Improve UE strength to surgical site, allowing
Limited reach, grasp, and extension and 10 of flexion each and muscle contraction ROM progression on a
lift capacity of UE week Improve active ROM graduated basis
Cryotherapy of wrist Self-management of pain
Compression dressing (5-7 days) and edema
IsometricsSubmaximal shoulder Prevention of associated
flexion, extension, abduction, and UE muscle atrophy
internal rotation (no ER) (at 2 wk, without stressing UCL
add wrist flexion/extension) (avoid ER)
At 2 wk, add wrist flexion and Nonpainful, safe
extension strengthening of wrist
After 2 wk, add forearm supination musculature
and pronation ROM (given that Increase in available
these motions have no significant active ROM gradually as
strain on the graft) function and strength
progress
ER, External rotation; ROM, range of motion; UCL, ulnar collateral ligament; UE, upper extremity.
strain.25 During the third postoperative week, active range

of motion (AROM) for the wrist, elbow, and shoulder may
be initiated.
Phase II
GOALS: Gradually increase ROM, heal tissues, restore
muscular strength (Table 9-2)
The intermediate phase begins approximately at week 4.

Advancement through the rehabilitation process is adjusted
based on the response of the patient to surgery, tissue healing
constraints, and a criterion-based progression.
Light wrist and elbow isotonics can be initiated during
week 4, as well as rotator cuff strengthening. The therapist
should advance the resistance with isotonic exercises as the
patients strength improves. Typically, the patient progresses
by 1lb per week.
Training the muscles in the way they are to perform with
throwing is the focus. For example, the flexor carpi ulnaris
and flexor digitorum superficialis muscles are located directly
over the anterior band of the UCL and may contribute
to dynamic stabilization of the medial elbow. Rhythmic sta-
bilization drills in the throwing position assist in training
Fig. 9-10 The postoperative range of motion (ROM) brace is used to
these muscles in a similar manner. In addition, the elbow
improve elbow ROM gradually while allowing soft tissue healing.
extensors act concentrically to accelerate the arm during the

Phase II No sign of Limited ROM Continue exercises as in phase I Elbow active ROM Promotion of elbow ROM
Postoperative infection Limited UE strength as indicated 0-145 Progression toward protected
4-8 wk No loss of Limited reach, grasp, Elbow ROM 0-135 Protect elbow from active ROM of elbow
ROM and lift capacity of UE at wk 5, discontinue brace at unprotected valgus Advancing of UE strength and
No increase Pain wk 5 force ROM in preparation to restore
in pain Isotonics (1-2lb)Wrist Increase functional previous level of functioning
flexion, extension; forearm strength of UE Continued avoidance of valgus
pronation, supination; elbow Improve tolerance to forces
flexion, extension active ROM By 6 wk, soft tissue healing
Rotator cuff exercises (after 6 Increase upper quarter should be stable enough to
wk, see Box 9-2) strength tolerate valgus stress
After 6 wk: Increase lift tolerance Attaining of full ROM
Active ROMElbow flexion, Objective progression of
extension exercises
Progression of all exercises as
indicated
ROM, Range of motion; UE, upper extremity.
acceleration phase, whereas the elbow flexors act eccentri-

cally to control the rapid rate of elbow extension during BOX 9-1 Stretching Program to Improve Elbow Motion
follow-through. Biasing the exercise selection appropriately 1. Passive warm-up (warm whirlpool) (7 to 10 minutes)
for these muscle groups allows more effective strength train- 2. Active warm-up (upper body ergometer) (10 minutes)
ing and provides neuromuscular training, allowing the 3. Joint mobilization
muscles to function more efficiently when performing skilled a. Distraction glides
movement patterns. b. Posterior ulnar glide for upward elbow extension
During this phase the therapist should pay careful atten- c. Mobilization of radial head
tion to the patients ROM. One of the most common com- 4. Low-load, long-duration stretching (12 to 15 minutes)
plications after UCL reconstruction is development of an 5. Manual proprioceptive neuromuscular facilitation
elbow flexion contracture and joint stiffness. In addition, stretches using contract-relax technique
flexion contracture is common in overhead-throwing ath- 6. Passive stretching
letes. Throwing athletes have demonstrated a 7.9 average 7. Repeat process twice
loss of elbow extension ROM before their competitive
season.26 Therefore early intervention and progressive
motion and stretching exercises are important preventatives
against elbow flexion contracture (Box 9-1).27 During this phase aggressive wrist, forearm, elbow, and
ROM is gradually progressed to achieve 0 to 135 by shoulder strengthening are advanced with a Throwers Ten
week 5. At this time, the brace may be removed. The intimate Program (Box 9-2). The patient may begin light plyometric
configuration of the elbow joint is prone to develop contrac- exercise during this phase. Plyometrics are initiated with
tures. In addition, scarring of the brachialis muscle to the two-hand drills, close to the body, such as a chest pass. These
capsule may further lead to loss of motion. ROM and stretch- exercises are progressed away from the body to include side-
ing techniques are continued to ensure the prevention of to-side and overhead throws and, finally, one-hand drills at
motion complications. Additionally, low-load long-duration week 12. These drills are used to develop power and explo-
stretching may be incorporated as needed. siveness with weighted balls, often incorporating the func-
tional throwing position (Fig. 9-11). Forearm plyometrics
Phase III should also be introduced in this phase (Fig. 9-12). Exercises
such as wrist flips and snaps will incorporate wrist flexors
TIME: 8 to 13 weeks after surgery while extension grips will address wrist extension strength.
GOALS: Increase strength, power, and endurance, Manual proprioceptive neuromuscular facilitation (PNF)
maintain full ROM, gradually add sports activities drills integrate elbow flexion and extension with respective
(Table 9-3) supination and pronation, helping to improve joint stability

Anticipated
Rehabilitation Criteria to Progress to Impairments and
Phase III No increase in pain Limited UE strength Continue exercises as in phases I Increase strength of Continuation of
Postoperative No loss of ROM Limited tolerance to and II UE strengthening UE and
9-13 wk Steady progression of reach, grasp, and lift Initiate plyometric exercises Increase muscular progressing resistance
elbow and wrist ROM activities Wrist flips and snaps (see Fig. control of UE Training of muscles in
9-12) Prepare for return to movement patterns
Elbow flexion and extension previous activities similar to overhead
with supination and pronation Improve recruitment activities
(see Fig. 9-13) of UE musculature Preparation of UE for
IsotonicsProgress wrist, elbow, Allow client to accelerating and
and shoulder exercises become pain free or decelerating activities
Initiate eccentric elbow flexion self-manage with Use of neuromuscular
and extension exercises gradual return to patterns to enhance
PlyometricsIncorporate activities functional strength
functional throwing position (see Strengthen UE with and dynamic joint
Fig. 9-11) sport-specific stabilization
Rhythmic stabilization activities Use of cross-training
Proprioceptive neuromuscular to vary stresses on UE
facilitation patterns Specificity of training
(see Fig. 9-14) principle
Proprioceptive neuromuscular
facilitation patterns
(see Fig. 9-14)
Light sporting activities (golf,
swimming)
Initiate Throwers Ten Program
(see Box 9-2)
Fig. 9-11 Plyometric exercise drills develop power and explosiveness. The one-handed baseball throw to simulate throwing mechanics is shown.
BOX 9-2 Throwers Ten Program

1. Diagonal pattern D2 flexion and extension
2. External rotation (ER) and internal rotation tubing
3. Shoulder abduction
4. Full can
5. Side-lying ER
6. Prone: horizontal abduction, horizontal abduction at
100, row, and row into ER
7. Press-ups
8. Push-ups starting from the wall in standing
9. Elbow flexion and extension
10. Wrist extension and flexion, pronation, and
supination
Fig. 9-13 Manual resistance proprioceptive neuromuscular facilitation

(PNF) at the elbow helps promote strength and dynamic joint stability
through a functional movement pattern.
Fig. 9-12 Forearm plyometric exercises such as wrist flips help increase
functional strength of the wrist flexors.
(Fig. 9-13). Emphasis should be placed on the concentric and

eccentric roles of each muscle during the throwing motion.
D2 flexion and extension PNF drills incorporate the shoul-
der, thus further encouraging strength and dynamic stabili-
zation in functional movement patterns (Fig. 9-14). Rhythmic
stabilization drills should also be incorporated in more func-
tional throwing positions to establish control through the
core stabilizers as well. Stability deficits throughout the
kinetic chain will place added stress on the repaired UCL
(Fig 9-15).
Phase IV
Fig. 9-14 Manual resistance proprioceptive neuromuscular facilitation
GOALS: Increase strength, power, and endurance of
(PNF) promotes strengthening in functional movement patterns and
upper extremity muscles, gradually return to sports dynamic joint stabilization. This movement pattern is referred to as a D2
activities (Table 9-4) flexion and extension upper extremity pattern.
In this final phase, the physical therapist should take care elbow, and forearm strength should continue to improve.
to return the patient to sports activities gradually; an interval Professional throwing athletes have significantly greater
sports program may help ensure that goal (Boxes 9-3 and forearm pronation and wrist flexion strength on the domi-
9-4). Other throwing programs are described in Chapters 3 nant arm.28 In addition, the athlete should continue flexibil-
and 13. An interval throwing program may be initiated for ity exercises for the elbow, wrist, and hand. The interval
an overhead thrower at 16 weeks after surgery, with throwing throwing program emphasizes a proper warm-up, correct
off the mound usually occurring around 5 to 6 months after throwing mechanics, and a gradual progression of intensity.
surgery.27 Return to competition typically occurs between 9 The therapist also must teach the athlete to listen to the
and 12 months. The competitive overhead athlete should arm: if pain is present, then the patient should not advance
participate in a year-round conditioning program that con- the program prematurely.
sists of isotonic strengthening, plyometric and neuromuscu-
lar training, and a sport-specific training program. Wrist,
SUGGESTED HOME
MAINTENANCE FOR THE
POSTSURGICAL PATIENT
The home maintenance box, as well as Box 9-2, reviews

exercises that are commonly prescribed for the patient to
perform at home. The exercises are progressed gradually to
allow the tissue proper healing time, with the ultimate goal
of full restoration of strength and ROM. The exercises are to
be performed at home in conjunction with treatment ses-
sions in the rehabilitation setting.
TROUBLESHOOTING
As already noted, the most common complication after UCL

reconstruction is a flexion contracture or stiff joint. Factors
that predispose the elbow joint to this loss of ROM include
the following:
1. The intimate congruency of the elbow joint complex,
especially the humeroulnar joint
2. The tightness of the elbow joint capsule
3. The tendency of the anterior capsule to scar and become
adhesive29
Box 9-1 outlines a program found to be effective in com-
bating flexion contractures of the elbow. It includes both
Fig. 9-15 Rhythmic stabilization in functional throwing positions helps passive and active warm-up, joint mobilizations, and manual
recruit core stabilizers and prepare for the balanced transfer of force through stretching techniques. One of the most effective components
the kinetic chain upon return to throwing. to the stretching regimen is the low-load, long-duration

Phase IV No increase in pain Limited tolerance to Initiate interval throwing Symmetric UE Normalization of UE strength
Postoperative No loss of range of repetitive overhead program (see Boxes 9-3 and strength to avoid reinjury with
14-26 wk motion activities Box 9-4) Gradual return to return-to-sport activities
No loss of strength Limited strength Continue strengthening as in unrestricted sport Gradual progression to sport
phases I through III activity
UE, Upper extremity.

BOX 9-3 Interval Throwing Program Phase I

45-Foot Phase 3. Rest 10 minutes 3. Rest 15 minutes 7. Warm-up throwing
Step 1 4. Warm-up throwing 4. Warm-up throwing 8. 150 feet (25 throws)
1. Warm-up throwing 5. 60 feet (25 throws) 5. 120 feet (25 throws) 180-Foot Phase
2. 45 feet (25 throws) 6. Rest 10 minutes Step 8 Step 11
3. Rest 15 minutes 7. Warm-up throwing
1. Warm-up throwing 1. Warm-up throwing
4. Warm-up throwing 8. 60 feet (25 throws)
2. 120 feet (25 throws) 2. 180 feet (25 throws)
5. 45 feet (25 throws) 90-Foot Phase 3. Rest 10 minutes 3. Rest 15 minutes
Step 2 Step 5 4. Warm-up throwing 4. Warm-up throwing
1. Warm-up throwing 1. Warm-up throwing 5. 120 feet (25 throws) 5. 180 feet (25 throws)
2. 45 feet (25 throws) 2. 90 feet (25 throws) 6. 120 feet (25 throws)
Step 12
3. Rest 10 minutes 3. Rest 15 minutes 7. Rest 10 minutes
2. 180 feet (25 throws)
5. 45 feet (25 throws) 5. 90 feet (25 throws) 150-Foot Phase 3. Rest 10 minutes
6. Rest 10 minutes Step 6 Step 9 4. Warm-up throwing
7. Warm-up throwing 1. Warm-up throwing 1. Warm-up throwing 5. 180 feet (25 throws)
8. 45 feet (25 throws) 2. 90 feet (25 throws) 2. 150 feet (25 throws) 6. Rest 10 minutes
60-Foot Phase 3. Rest 10 minutes 3. Rest 15 minutes 7. Warm-up throwing
Step 3 4. Warm-up throwing 4. Warm-up throwing 8. 180 feet (25 throws)
1. Warm-up throwing 5. 90 feet (25 throws) 5. 150 feet (25 throws) Step 13
2. 60 feet (25 throws) 6. Rest 10 minutes Step 10 1. Warm-up throwing
3. Rest 15 minutes 7. Warm-up throwing
2. 150 feet (25 throws) 3. Rest 10 minutes
5. 60 feet (25 throws) 120-Foot Phase 3. Rest 10 minutes 4. Warm-up throwing
Step 4 Step 7 4. Warm-up throwing 5. 180 feet (25 throws)
1. Warm-up throwing 1. Warm-up throwing 5. 150 feet (25 throws) 6. Rest 10 minutes
2. 60 feet (25 throws) 2. 120 feet (25 throws) 6. Rest 10 minutes 7. Warm-up throwing
8. 180 feet (25 throws)
stretching technique. The three most important components

of this technique are (1) duration of stretch (10 to 15
minutes), (2) intensity of stretch (low to moderate), and (3)
frequency of stretch (5 to 6 times daily) (Fig. 9-16).
This stretching technique may be enhanced by the use of
other modalities such as moist hot packs or ultrasound. The
rationale for the success of this technique is its ability to
produce a plastic response within the collagen tissue, result-
ing in permanent elongation.7,30-32
If ROM complications persist, the therapist may want to
prescribe a splint to be worn both day and night. A static
splint holds the joint in a constant position, whereas a
dynamic splint uses a spring to exert force and create a pro-
gressive stretch. Patients are encouraged to remove the splint
daily for strengthening and stretching exercises.
During the aggressive stretching program the patient
often experiences increased elbow soreness or pain. Pain Fig. 9-16 A low-load, long-duration stretch is performed to improve
control using cryotherapy, high-voltage galvanic stimulation elbow extension. A Thera-Band is secured at one end and wrapped around
(HVGS), transcutaneous electric nerve stimulation (TENS), the patients distal forearm.
and interferential current is highly effective.
BOX 9-4 Interval Throwing Program Phase II

Stage 1: Fastball Only Step 10:
Step 1: 45 throws off mound at 75%
Interval throwing 30 throws in batting practice
15 throws off mound at 50% Step 11:
Step 2: 45 throws off mound at 75%
Interval throwing 45 throws in batting practice
30 throws off mound at 50% Stage 3
Step 3: Step 12:
Interval throwing 30 throws off mound at 75% during warm-up
45 throws off mound at 50% 15 throws off mound; 50% breaking balls
Step 4:
45-60 throws in batting practice (fastball only)
Interval throwing Step 13:
60 throws off mound at 50% 30 throws off mound at 75%
Step 5:
30 breaking balls at 75%
30 throws in batting practice
Interval throwing
Step 6:
30 throws off mound at 75%
60-90 throws in batting practice; 25% breaking balls
Step 7:
Simulated game, progressing by 15 throws per workout
(use interval throwing to phase 12, No. 8 in Box 9-3 as
warm-up). All throwing off the mound should be done in the
presence of the pitching coach to stress proper throwing
Step 8: mechanics. Use speed gun to aid in effort control.
Stage 2: Fastball Only
Step 9:
15 throws in batting practice
Other complications include hand and grip weakness, the glenohumeral (GH) joint during the throwing motion.
ulnar neuropathy, rotator cuff tendonitis, and UCL failure. Integrating a Throwers Ten Program with the emphasis on
Intrinsic weakness of the hand may be avoided by initiating rotator cuff strengthening several weeks before throwing
gripping exercises immediately after surgery and increasing greatly reduces the chances of developing tendonitis.
intensity as rehabilitation progresses. Ulnar neuropathy gen- UCL failure is the most serious of all postoperative
erally develops immediately after surgery. Transposition of complications. Graft failure or poor bone quality with inad-
the ulnar nerve may cause sensory changes of the little finger equate graft stabilization necessitates subsequent surgery
and ulnar half of the ring finger. Motor deficits may include or the cessation of overhead activities. Fortunately,
the inability to adduct the thumb, weakness of the finger with advanced surgical and rehabilitation techniques, suc-
abductor and adductors, adduction of the little finger, and cessful outcomes are much more likely than failures. Andrews
weakness of the flexor carpi ulnaris. The most frequent and Timmerman33 found 78% of professional baseball
patient complaint is paresthesia through the ulnar nerve players returning to their previous level of play after UCL
sensory distribution, but this is usually transient and should reconstruction. Additionally, Cain and associates34 found
resolve within 7 days. that 83% of overhead athletes returned to their previous level
Inactivity can lead to rapid deterioration of rotator or higher upon 2-year follow-up. Major complications
cuff strength and a subsequent inability to stabilize occurred with only 4%.

Weeks 1 to 3: Weeks 6 to 7:
GOALS FOR THE PERIOD: Protect healing tissues, 1. ROM 0 to 145
decrease pain and inflammation, and limit muscle 2. Progress elbow-strengthening exercises
atrophy 3. Initiate shoulder ER strengthening
Week 1: 4. Progress shoulder program
1. Posterior splint at 90 elbow flexion
2. Wrist assisted range of motion (AROM) extension Weeks 8 to 13:
and flexion GOALS FOR THE PERIOD: Increase strength, power,
3. Elbow compression dressing (5 to 7 days) and endurance; maintain full elbow ROM; gradually
4. Gripping exercises, wrist range of motion (ROM), begin sports activities
shoulder isometrics (except shoulder external Week 8:
rotation [ER]), biceps isometrics, others as 1. Initiate eccentric elbow flexion and extension
indicated 2. Continue isotonic program for forearm and wrist
5. Cryotherapy 3. Continue shoulder program (Throwers Ten
Week 2: Program)
1. Application of functional brace 30 to 100 4. Begin manual resistance diagonal patterns
2. Initiation of wrist isometrics 5. Begin two-hand plyometrics
3. Initiation of elbow flexion and extension Weeks 9 to 11:
isometrics Continue as for week 8, progress strength
4. Continuation of all exercises listed previously Weeks 12 to 13:
Week 3: 1. Continue as for week 11
Advance brace (gradually increase ROM; 10 of 2. Begin one-hand plyometrics
extension and 10 of flexion per week) 3. Begin light sports activities (e.g., golf, swimming)
Weeks 14 to 26:
Weeks 4 to 7: GOALS FOR THE PERIOD: Continue to increase
GOALS FOR THE PERIOD: Gradually increase ROM, strength, power, and endurance of upper extremity
healing tissues, and regain and improve muscle muscles; gradually return to sports activities
strength Week 14:
Week 4: 1. Continue strengthening program
1. Begin light resistance exercises for arm (1lb), 2. Emphasize elbow and wrist strengthening and
wrist curls, extensions, pronation, and supination, flexibility exercises
and elbow extension and flexion Weeks 15 to 21:
2. Progress shoulder program, emphasizing rotator Continue with program
cuff strengthening Week 16:
Week 5: Begin phase I interval throwing program
Continue as for week 4, discharge brace, full passive Weeks 22 to 26:
range of motion (PROM) week 5 Return to competitive sports as appropriate
1 The patient is a 16-year-old female tennis player who

had UCL reconstruction 16 weeks ago. She has full
ROM and has been progressing with her isotonic
Before any overhead sporting activity such as hitting a
tennis ball, it is important that the patient has progressed
through a proper rehabilitation program, including iso-
strengthening program. She expresses that she is tonics, dynamic stabilization drills, a plyometric program,
ready to start playing. What types of intervention still and an interval sport program. These exercises are
need to be incorporated in her program before she can essential to enhancing functional strength and dynamic
begin sporting activities, and what is the rationale for joint stability, as well as preparing the upper extremity
doing so? for the acceleration and deceleration forces required of
her sport-specific activity.
2 The patient is a college baseball pitcher that had UCL

surgery with ulnar nerve transposition 7 weeks ago. He
is now performing some light isotonic exercises. What
These signs and symptoms are consistent with an ulnar
neuropathy, which is common after ulnar nerve transpo-
sition. The therapist can check for tight-fitting wraps or
two muscles should the therapist target to enhance the ill-fitting braces, but typically these complications resolve
dynamic stabilization of the medial elbow during a within 7 days after surgery.
throwing motion?
The focus should be on training the muscles in the way

they are to perform during throwing. The flexor carpi
7 Patient is a 19-year-old hockey player who had UCL
reconstruction following an acute UCL tear as a result
of a fall and subsequent elbow dislocation. How might
ulnaris and the flexor digitorum superficialis muscles are the acute mechanism of injury affect progression of this
located directly over the anterior band of the UCL and patients postoperative ROM?
may contribute to dynamic stabilization of the medial
elbow. Early postoperative PROM can be progressed more
quickly following reconstruction of acute tears. Full
3 The patient is a 20-year-old male pitcher who had UCL

reconstruction 6 weeks ago. He arrives from another
clinic with a 15 flexion contracture. What course of
PROM should be expected by week 5. Chronic tears will
progress more gradually, attaining full PROM closer to
postoperative weeks 6 through 8.
action should the therapist take to address this ROM
deficit immediately?
The patient is behind with his ROM. The elbow joint is

8 A 23-year-old pitcher is 6 weeks out of surgery following
an acute UCL tear. He is having trouble achieving full
extension. How aggressive should manual techniques be
prone to develop a flexion contracture as the result of when trying to restore full ROM?
the intimate joint congruency. In the instance of a flexion
contracture, the therapist should introduce treatments There are a few factors to consider when trying to deter-
designed to create a plastic response in the collagen mine if aggressive mobilization and stretching is indi-
tissue. These include a passive warm-up, followed by cated. Consider the end feel and what type of tissue is
active warm-up, joint mobilizations (including distraction constraining the ROM. An empty end feel with pain or
and posterior ulnar glides), low-load, long duration, as swelling should be a sign to use a more gradual, less
well as contract-relax and passive stretching. aggressive approach. Yet, a hard, bony end feel should
present as a situation where more aggressive mobiliza-
4 A patient who had UCL surgery 16 weeks ago wants to

begin throwing. Is this appropriate?
tion techniques would be indicated.
Provided the patient has full ROM, good strength, and is

pain free, an interval throwing program is initiated at
9 A 32-year-old NFL quarterback is postoperative week 2
following UCL reconstruction with ulnar nerve trans-
position. His posterior splint has been removed and
week 16. Each stage is to be performed twice, with a day early elbow flexion/extension ROM has been initiated.
of rest in between, before moving to the next stage. Is forearm pronation/supination ROM permitted during
Should the patient report pain or excessive soreness, he this phase?
or she should move back a stage and continue from there.
Pronation and supination of the forearm place no strain
5 A patient who had UCL surgery 8 months ago is

beginning to throw on the mound near full effort and
begins to report medial elbow pain. What should the
on the UCL graft. Therefore, PROM in these directions
can be initiated during week 2. Pronation and supination
isometrics also have no effect on the strain in the UCL,
therapist do? allowing for their addition during this phase. Initiate
pronation/supination isotonics during week 4, as you
The therapist should tell the patient to step back to a would for the wrist and elbow.
partial effort for a week and treat the pain symptoms. If
the patient continues to feel pain when progressing, then
he or she may need to see a physician and potentially
stop throwing to allow time to heal while continuing with
10 A professional baseball pitcher has met all of the
criteria to progress to phase IV of his rehabilitation
and is ready to begin an interval throwing program.
exercises. He is leaving our care to gradually return to sports
activities with his teams training staff. What are
6 A patient had UCL surgery 3 days ago and has been

unable to adduct his thumb, abduct or adduct his fingers,
and has weakness in the flexor carpi ulnaris. He also
some important things to stress to the trainers
during their progression through this phase?
reports numbness in the fifth digit. What is the assess- It is important to advance through an interval throwing
ment? Is this cause for concern? program step by step, including timely progression to
throwing off the mound. The overhead athlete should hamstring grafts might be preferable to palmaris
also participate in a year round conditioning program longus grafts?
that includes isotonic strengthening, and plyometric and
neuromuscular training. Forearm and elbow strength This type of questioning should always be referred to the
should continue to increase to greater than the nondomi- referring physician. However, generally speaking, use of
nant side. Professional throwing athletes have greater the contralateral gracilis muscle may be indicated when
wrist flexion and forearm pronation strength on their there is boney involvement of the UCL. The presence of
dominant arm, as well as greater strength on elbow bone within the UCL represents a chronic ligamentous
flexion and extension. deficiency, which requires use of a larger graft. Data
suggest use of the contralateral hamstring graft is reli-
11 Following UCL reconstruction, a patient asks why

a hamstring graft was used despite the presence
of palmaris longus. Are there situations where
able, reproducible, and may provide improved results
with return to play.35
REFERENCES 20. Conway JE, et al: Medial instability of the elbow in throwing athletes.
1. Steindler A: Kinesiology of the human body, Springfield, Ill, 1955, J Bone Joint Surg Am 74:67, 1992.
Charles C Thomas. 21. Timmerman LA, Schwartz ML, Andrews JR: Preoperative evaluation of
2. Guerra JJ, Timmerman LA: Clinical anatomy, histology, and pathome- the ulnar collateral ligament by magnetic resonance imaging and com-
chanics of the elbow in sports. Sports Med Arthrosc Rev 3(3):160, 1995. puted tomography arthrography. Am J Sports Med 22(1):26, 1994.
3. Timmerman LA, Andrews JR: Histology and arthroscopic anatomy of 22. Safran MR: Ulnar collateral ligament injury in the overhead athlete:
the ulnar collateral ligament of the elbow. Am J Sports Med 22(5):667, Diagnosis and treatment. Clin Sports Med 23(4):643-663, 2004.
1994. 23. Timmerman LA, Andrews JR: Undersurface tear of the ulnar collateral
4. Andrews JR: Ulnar collateral ligament injuries of the elbow in throwers. ligament in baseball players: A newly recognized lesion. Am J Sports
Paper presented at the Injuries in Baseball Course, Birmingham, Ala, Med 22(1):33, 1994.
Jan 28, 1990. 24. Wilk KE, Arrigo CA, Andrews JR: Rehabilitation of the elbow in the
5. Morrey BF, An RN: Articular and ligamentous contributions to the throwing athlete. J Orthop Sports Phys Ther 17:305, 1993.
stability of the elbow joint. Am J Sports Med 11:315, 1983. 25. Bernas G, et al: Defining safe rehabilitation for ulnar collateral ligament
6. Warwick R, Williams PL: Grays anatomy: Descriptive and applied, ed reconstruction of the elbow: A biomechanical study. Am J Sports Med
35, Philadelphia, 1980, Saunders. 37(12):2392, 2009.
7. Schums GH, et al: Biomechanics of elbow stability: Role of the medial 26. Wright RW, et al: Elbow range of motion in professional baseball pitch-
collateral ligament. Clin Orthop 146:42, 1980. ers. Am J Sports Med 34(2):190, 2006.
8. Morrey BF: Anatomy of the elbow joint. In Morrey BF, editor: The elbow 27. Wilk KE, et al: Rehabilitation following elbow surgery in the throwing
and its disorders, Philadelphia, 1993, Saunders. athlete. Oper Tech Sports Med 4(2):69, 1996.
9. ODriscoll SW, Bell DF, Morrey BF: Posterolateral rotary instability of 28. Ellenbecker TS, Mattalino AJ: The elbow in sport. Champaign, Ill, 1997,
the elbow. J Bone Joint Surg Am 73:440, 1991. Human Kinetics.
10. Martin BJ: The annular ligament of the superior radioulnar joint. J Anat 29. Reinold MM, et al: Interval sports programs: Guidelines for baseball,
52:473, 1958. tennis and golf. J Orthop Sports Phys Ther 32(6):293-298, 2002.
11. Martin BJ: The oblique of the forearm. J Anat 52:609, 1958. 30. Kottke FJ, Pauley DL, Ptak RA: The rationale for prolonged stretching
12. Jobe FW, Fanton GS: Nerve injuries. In Morrey BF, editor: The elbow for correction of shortening of connective tissue. Arch Phys Med
and its disorders, Philadelphia, 1985, Saunders. Rehabil 47:345, 1968.
13. Morrey BF: Anatomy and kinematics of the elbow. In Tullos HS, editor: 31. Warren CB, Lehman JF, Koblanski JN: Elongation of cat-tail tendon:
American Academy of Orthopaedic Surgeons instructional course lec- Effect of load and temperature. Arch Phys Med Rehabil 52:465,
tures 40, St Louis, 1991, Mosby. 1971.
14. Wilk KE, Azar FM, Andrews JR: Conservative and operative rehabilita- 32. Warren CG, Lehman JF, Koblanski JN: Heat and stretch procedures: An
tion of the elbow in sports. Sports Med Arthrosc Rev 3:237, 1995. evaluation using cat-tail tendon. Arch Phys Med Rehabil 57:122,
15. Pappas A, Zawack RM, Sullivan TJ: Biomechanics of baseball pitching: 1976.
A preliminary report. Am J Sports Med 13(4):216, 1985. 33. Andrews JR, Timmerman LA: Outcome of elbow surgery in profes-
16. Werner SL, Fleisig GS, Dillman CJ: Biomechanics of the elbow during sional baseball players. Am J Sports Med 23(4):407, 1995.
baseball pitching. J Orthop Sports Phys Ther 17:274, 1993. 34. Cain EL, et al: Outcome of ulnar collateral ligament reconstruction of
17. Dillman C, Smutz P, Werner S: Valgus extension overload in baseball the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year
pitching. Med Sci Sports Exerc 23:S135, 1991. follow-up. Am J Sports Med 38(12):2426, 2010.
18. Fleisig GS, et al: Kinetics of baseball pitching with implications about 35. Dugas JR, et al: Clinical results of UCL reconstructions done with
injury mechanisms. Am J Sports Med 23(2):233, 1995. boney involvement of ligament using gracilis tendon autograft.
19. Hyman J, Breazeale NM, Altchek DW: Valgus instability of the elbow in Unpublished data. Presented at 28th Annual Injuries in Baseball Course.
athletes. Clin Sports Med 20(1):25-45, 2001. Birmingham, Ala, ASMI (2010).
CHAPTER10
Clinical Applications for Platelet Rich
Plasma Therapy
Eric S. Honbo, Luga Podesta
O
ver the past several years, there has been significant PLATELET FUNCTION IN TISSUE HEALING
interest in the use of biologic treatment of muscle,
tendon, ligament, and bone injuries in orthopedic Platelets contain two unique types of granulesalpha gran-
and sports medicine. The use of orthobiologic tissue grafts, ules and dense granules. Alpha granules in platelets function
such as platelet rich plasma (PRP) to stimulate and promote as storage units containing a variety of hemostatic proteins,
tissue healing and regeneration, has received increasing inactive growth factors, cytokines, and other proteins such
notoriety since first being reported in the February 2009 as adhesion proteins. Dense granules store and release bioac-
article A Promising Treatment for Athletes, in Blood in the tive factors that promote platelet aggregation, tissue modula-
New York Times. This article increased the publics awareness tion, and regeneration including adenosine diphosphate
of PRP to treat the NFLs Pittsburgh Steelers football player (ADP), adenosine triphosphate (ATP), calcium, serotonin,
Hines Ward before the 2009 Super Bowl. histamine, and dopamine.12,13
The use of PRP to promote healing has been studied since Growth factors found in these granules include platelet
the 1970s in both the veterinary and human literature. derived growth factor (PDGF), transforming growth
Ferrari and associates first reported using PRP in 1987 factor-1 (TGF-1), vascular endothelial growth factor
during cardiac surgery as an autologous transfusion compo- (VEGF), basic fibroblastic growth factor (bFGF), insulin-like
nent after open heart surgery to avoid homologous blood growth factor (IGF-I, IGF-II), endothelial cell growth factor
product transfusion.1 PRP has successfully been used in (ECGF), and epidermal growth factor (EGF).4,6,10,14-16 Platelet
various specialties, such as maxillofacial surgery, cosmetic activation is required for discharge of granule content (B5)
surgery, orthopedics, and podiatry, and for general wound (Table 10-1). Upon clotting, platelets are activated, resulting
healing.2-9 In humans, the higher concentrations of autolo- in degranulation and release of their growth factors from the
gous growth factors and the secretory proteins found in alpha granules. Approximately 70% of the stored growth
PRP preparations are attributed to its ability to promote factors are released within the first 10 minutes. The majority
tissue healing and regeneration when applied to a variety of of growth factor release occurs within the first hour after
tissue. degranulation. Continued growth factor release has been
shown to occur throughout the period of platelet viability,
approximately 7 days.4,8,10
DEFINITION OF PRP PRP is a mechanism to deliver a physiologically natural
balance/ratio of growth factors, cytokines, and other bioac-
Platelets are small, nonnucleated cell fragments in the tive proteins in supraphysiologic concentrations directly into
peripheral blood known primarily for their role in homeo- an injured tissue to potentially optimize healing while main-
stasis. The normal platelet count ranges from 150,000L to taining the bodys homeostatic environment.4,17-19 Using PRP
400,000L. Platelets contain numerous proteins (growth to treat a variety of soft tissue pathologies is appealing to the
factors), cytokines, and bioactive factors that initiate and clinician because of its simplicity of acquisition and admin-
regulate tissue healing.10 The fluid portion of blood istration, relatively low cost when compared with surgical
plasmaalso contains clotting factors, proteins, and ions. treatments, and absence of significant adverse effects. Since
PRP is the result of concentrating the platelet count to at least PRP is an autologous tissue graft, the risk of tissue rejection,
1 million platelets per microliter in 5mL of plasma.10,11 immune response, or disease transmission is eliminated.
171
TABLE 10-1 Growth Factors in Platelet Rich Plasma

Growth Factor Function Target Cell and Tissue
Platelet-derived growth factor Stimulates the mitogenesis of mesenchymal cells Fibroblasts, smooth muscle cells, chondrocytes,
(PDGF) Stimulates fibroblast chemotaxis and mitogenesis osteoblasts, mesenchymal stem cells
Stimulates satellite cell proliferation
Transforming growth factor- Stimulates mesenchymal cell proliferation Blood vessel tissue, outer skin cells
(TGF-1) Regulates endothelial cells and fibroblast mitogenesis Fibroblasts, monocytes
Stimulates endothelial chemotaxis and angiogenesis Osteoblasts
Inhibits macrophage and lymphocyte proliferation
Inhibits satellite cell proliferation and differentiation
Vascular endothelial growth factor Blood vessel cells
(VEGF)
Basic fibroblastic growth factor Promotes growth and differentiation of chondrocytes and osteoblasts Blood vessels, smooth muscle, skin
(bFGF) Mitogenetic for mesenchymal cells, chondrocytes, and osteoblasts Fibroblasts, other cell types
Insulin-like growth factor (IGF-I, Promotes the mitogenesis of mesenchymal cells Bone, blood vessel, skin, other tissue
IGF-II) Promotes collagen synthesis
Stimulates fibroblast chemotaxis and mitogenesis
Stimulates the proliferation and fusion of myoblasts
Inhibits myoblast apoptosis
Endothelial cell growth factor Cell growth, migration, new blood vessel growth Blood vessel cells
(ECGF) Antiapoptosis
Epidermal growth factor (EGF) Stimulates endothelial chemotaxis and angiogenesis Blood vessel cells, outer skin cells
Regulates extracellular matrix turnover Fibroblasts and many other cell types
Stimulates fibroblast migration and proliferation
generation occurs. Fibroblasts begin to synthesize scar tissue

TISSUE HEALING and capillary neoformation begins to reestablish nutrients to
the injured tissue. Stage 2 ends with the beginning of wound
The healing process is defined as a complex and dynamic contracture. Stage 3 is characterized by collagen remodeling.
biologic progression that results in the restoration of ana- The process of tissue remodeling can last from 3 weeks to 12
tomic structure and function. Tissue healing is a process months.14
characterized by a predictable cascade of biologic tissue
response triggered by the injury itself. Physiologic healing FORMATION OF PRP
progresses through three overlapping stages: stage 1, the
acute inflammatory phase; stage 2, the proliferative or repair PRP can only be derived from anticoagulated whole blood.
phase; and stage 3, the remodeling phase. Since platelets form part of the clot in coagulated blood and
The inflammatory phase, stage 1 begins with a tissue are activated triggering degranulationthereby releasing
injury. Platelets are stimulated to provide hemostasis by their bioactive proteins, growth factors, and cytokines
forming a clot. Platelets in the clot then degranulate and clotted blood is not an appropriate source of blood to obtain
secrete several growth factors, hemostatic factors, and cyto- PRP. PRP preparation begins by adding citrate to whole
kines from alpha granules that are necessary in the early blood. Citrate binds to ionized calcium inhibiting the clot-
stages of the clotting cascade. Histamine and serotonin are ting cascade. The anticoagulated blood then undergoes a
released from the dense granules and function to increase centrifugation process to first separate red and white blood
capillary permeability, activate macrophages, and allow cells from plasma and platelets, and then a second centrifu-
inflammatory cells greater access to the injury site.10,20,21 The gation cycle further separating the platelet rich from the
inflammatory phase can last up to 72 hours and is character- platelet poor plasma. There are a number of commercially
ized by localized pain, swelling, erythema, and increased available devices on the market that produce PRP (Fig. 10-1).
local tissue temperature. The proliferative phase (stage 2) Current systems available to generate PRP differ in the
begins when polymorphonuclear leukocytes migrate to the amount of whole blood needed for processing, the antico-
inflamed tissue. During the ensuing 48 hours to 6 weeks, agulant used, the speed of the centrifuge, and the time neces-
anatomic structures begin to be restored while tissue sary to spin the blood. Systems also differ in the final volume
Chapter10 Clinical Applications for Platelet Rich Plasma Therapy 173
A B
Fig. 10-1 A, Magellan Autologous Platelet Separator System (Arteriocyte Medical Systems). B, Platelet rich plasma blood collection kit (Magellan Arteriocyte
Medical Systems.)
of PRP produced and the total number of platelets present

in the concentrated product. As defined by the American BOX 10-1 Pre-PRP and Post-PRP Treatment Instructions
Red Cross, PRP has 5.5 1010 platelets or greater per 50mL Before PRP Treatment:
of concentrate equaling a 2 to 7 times increase compared 1. Stop all nonsteroidal antiinflammatory drugs
with whole blood. Normal platelet counts can vary between (NSAIDs) (e.g., Advil, Motrin, Aleve, Naproxen,
individuals. Platelet concentrations can vary greatly ranging Celebrex) 2 to 3 weeks before the procedure.
from 2.5 to 8.0 times the concentration found in whole blood 2. Apply heat packs to the painful areas 15 minutes
depending on the commercial system used.4,22 Literature every 2 to 3 hours as needed for pain.
suggests that clinical benefits of platelet concentrations occur 3. Tylenol for pain as needed.
with the greatest predictability when a fourfold increase is After PRP Treatment:
achieved.4,23 Unfortunately, evidence is lacking with regard 1. Do not take NSAIDs after the procedure until told to
to the appropriate and most clinically beneficial concentra- resume use by your physician.
tion of platelets. 2. Apply heat packs to the painful areas 15 minutes
Leukocyte concentration in PRP has become a topic of every 2 to 3 hours as needed for pain. Use Tylenol or
debate. Leukocyte concentrations can vary depending on the prescribed pain medications for pain as needed.
PRP system used. There is concern that the release of acid 3. Perform range-of-motion exercises as tolerated after
hydrolases and proinflammatory proteases from leukocytes the procedure.
may act as cytotoxic agents causing secondary damage to 4. Increased pain and inflammation is expected in the
cells.14,24 treated tissue after the procedure.
5. Continue to use any braces, splints, or crutches as
PROCEDURAL TECHNIQUE recommended by your physician after the treatment.
FOR PRP DELIVERY
Treatment begins with the identification of the tissue (muscle,

tendon, or ligament) and anatomic structures to be treated instructions are discussed with patients and all questions are
after proper informed consent has been obtained and the answered. The patient is advised that it is normal to experi-
procedure has been explained to the patient. Before treat- ence an increase in pain at the injection site after the PRP
ment, pain medication is prescribed for the immediate treatment, which may last for several days (Box 10-1).
postinjection period (3 to 5 days) and we instruct patients The treatment area is cleaned with an alcohol/Betadine
that nonsteroidal antiinflammatory medication cannot be prep solution or Hibeclens solution before injection. Blood
used 2 to 3 weeks before and 6 to 8 weeks after the PRP is drawn using a large bore fenestrated needle. The amount
treatment has been completed. Postinjection pain is common of blood drawn is dependent on the amount of PRP required
after PRP treatment. The duration and severity varies from for treatment. On average, 60mL whole blood (to obtain
patient to patient and with the specific tissue being treated. 5mL PRP) is drawn from the patient. The whole blood is
Before treatment, pre-PRP and post-PRP treatment placed into the centrifuge and the separation process is
organ. When treatment is conducted with standard sterile

technique, the risk of transmitting an infection or developing
an allergic reaction after treatment with these autologous
tissue preparations is effectively eliminated. The most
common complaint from patients after PRP treatments is
localized pain from the PRP injection itself.
There are a number of conditions in which treatment with
PRP is contraindicated. Absolute contraindications for the
use of PRP include: platelet dysfunction syndromes, critical
thrombocytopenia, hemodynamic instability, septicemia,
and hypofibrinogenemia. PRP treatments are relatively
contraindicated in those patients that consistently used anti-
inflammatory medications and systemic corticosteroid med-
ications. It is also contraindicated in those who have received
Fig. 10-2 The platelet rich plasma concentrate is delivered into the injured a corticosteroid injection at the treatment site within 14 days
tissue through a 22-gauge needle under direct musculoskeletal ultrasound
before treatment, have HGB levels less than 10g/dL or plate-
guidance.
let counts less than 105/L, or have had recent fevers or
illness, a rash at the donor or receptor site, bone cancer or
begun requiring approximately 15 minutes. The treatment hematopoietic cancer, or a history of, or an active infection
site is then anesthetized, first with an ethyl chloride spray with, Enterococcus, Pseudomonas, or Klebsiella.12,25
followed by a local anesthetic injection of lidocaine.
When the separation process has been completed, the CLINICAL APPLICATION OF PRP
PRP concentrate is then delivered into the injured tissue
through a 22-gauge needle under direct musculoskeletal Despite the surge of interest in orthobiologic treatment
ultrasound (US) guidance (Fig. 10-2). The precise placement modalitiesand there recent widespread use for the treat-
of the PRP preparation is extremely important for overall ment of a wide variety of soft tissue and boney injuries
outcome and efficacy of the procedure. The exact technique involving muscle, tendon, ligament, and articular cartilage
of delivery is dependent on the location of the tissue treated there remains a lack of animal and clinical studies demon-
myotendinous, teno-osseous, or ligamentous. A peppering strating the efficacy of PRP. Although many studies report
technique is used when treating tendons and ligaments. It is excellent outcomes, many of these studies unfortunately are
also important to touch bone at the osseous interface. Layer- limited case reports at best. Many of the current published
ing the PRP graft throughout the entire injury site in muscle, studies are difficult to interpret because of the lack of stan-
tendon, and ligamentous injuries will also help ensure com- dardization of PRP dosing, platelet acquisition and prepara-
plete coverage with the PRP preparation. tion, platelet concentration, growth factor quantity, number
When treatment is completed, a sterile Band-Aid is of treatments given, small patient sample sizes, and lack of
applied. Protective splinting or bracing may be recom- control groups. Table 10-2 summarizes some of the recent
mended after treating large weight-bearing tendons, such as published clinical studies regarding PRP.
the Achilles tendon, or areas where an extensive percutane-
ous tenotomy peppering has been performed. Application REGULATION OF PRP IN
of heat after the procedure for 15 minutes every 2 to 3 hours SPORTS MEDICINE
is often recommended for postinjection pain management.
Strenuous activity for the first 7 days posttreatment is dis- The use of PRP in amateur and professional athletes remains
couraged. Establishing normal range of motion after the pro- controversial. In the United States, the use of PRP in profes-
cedure and performing activities of daily living (ADL) are sional sports, including the NFL, Major League Baseball,
encouraged as soon as possible posttreatment. At 4 to 6 weeks, National Basketball Association, National Hockey League,
the patient is reassessed. If pain persists at the treatment site a Major League Soccer, National League Lacrosse, and Major
second PRP treatment might be considered at that time. League Lacrosse, is not regulated or prohibited. In addition,
the National Collegiate Athletic Association currently does
RISKS AND CONTRAINDICATION not regulate or prohibit the use of PRP in its participating
FOR PRP TREATMENT institutions. Initially, the World Anti-Doping Agency
(WADA) prohibited the use of platelet-derived preparations
PRP therapy is a safe and potentially very effective treatment (PRP blood spinning) administered through an intramuscu-
modality for a variety of musculoskeletal soft tissue patholo- lar route. Both the WADA and the U.S. Anti-doping Agency
gies. Unfortunately, there is a paucity of randomized, originally prohibited the injections of any growth factors
placebo-controlled studies regarding treatment with PRP affecting muscle, tendon, or ligament protein synthesis or
and its possible adverse effects. Although inherent risk is degradation, vascularization, regenerative capacity, fiber
minimal, the same risks are present as with any percutaneous type switching, or energy use.14 Athletes required a therapeu-
needle technique, including infection or puncturing a hollow tic use exemption if this mode of treatment is
TABLE 10-2 Human Clinical Treatment Trials Using Platelet Rich Plasma4,10
Tissue Author Design Level of Evidence Study Results Study Critique
Chronic elbow Mishra et al46 2006 Cohort, treated 15 Level 2, only 5 PRP patients had 93% pain Underpowered, randomized,
tendinosis patients with PRP controls reduction not blinded, 3 of 5
controls left study at 8wk
Rotator cuff Randelli et al47 2008 14 patients Level 4, case series PRP safe and effective in Small sample size
treatment of rotator cuff
Achilles tendon Sanchez et al48 2007 Case study, 6 Achilles Level 3, 6 matched Plasma rich growth factor may be Underpowered, small sample
repairs with PRP retrospective a new option for enhanced size, not randomized
controls healing and functional recovery
Achilles tendon de Vos et al49 2010 Double-blind, randomized, Level 1, randomized Improvement between groups Underpowered, small sample
54 patients control nonsignificant size,
Patella tendinosis Kon et al50 2009 Pilot study, 3 PRP Level 4, case study Function and pain improvement Not controlled
injections, 20 patients after treatment with PRP
with physical therapy
Lateral epicondylitis Peerblooms et al51 2010 Double-blind randomized, Level 1, randomized Increased function exceeding the All patients had failed prior
100 patients, PRP vs. controlled effect of corticosteroid conservative treatment
cortisone
Anterior cruciate Silva et al52 2009 Prospective study, 40 Level 3, cohort PRP or thrombin did not appear to
ligament patients controlled accelerate tendon healing
Bone healing in Sanchez et al53 2009 Retrospective, case study Level 4, no control 84% healed after surgical Underpowered, randomized,
nonunions group treatment; affects of PRGF retrospective, small
unclear sample size
PRP, Platelet rich plasma.
deemed necessary and recommended by a physician. Both maximally withstand the physiologic stresses and forces
organizations recently have changed their stance on PRP, placed upon it with daily functional demands or sporting
since this is an autologous treatment of the patients own activities. Collagen fibers run in parallel alignment, which
blood products that have not been treated with any nonau- affords the tissue to withstand tensile forces and unilateral
tologous growth factors. stress placed upon it.26 The following information is based
on clinical experience with patients who have undergone
THERAPY GUIDELINES PRP injections to different tissues including muscle, tendon,
FOR REHABILITATION bone, and ligament.
Rehabilitation progression following PRP injection is based Phase I (Inflammatory Phase) (Table 10-3)
on several individual factors: the combination of time since
TIME: 0 to 7 days
injection, the physiologic healing mechanism, patients
GOALS: To allow the PRP to absorb at the injected
health and age, severity of injury, tissue integrity, response
tissue, to avoid cross-link disruption, and to facilitate
to physical therapy treatment dosage, and adherence to
integrity of cross link-formation
appropriate home programs. The goal of rehabilitation fol-
lowing PRP injections is to progressively and therapeutically Phase I consists of early mobilization, gentle self-
place appropriate amounts of physical stress to the injured stretching, and weight-bearing functional activities to
tissue to help facilitate healing. General guidelines following prevent the deleterious effects of immobilization and to
physiology are listed in Box 10-2. Physical stress to the tissue promote tissue healing. Because of the elevated inflamma-
(muscle tendon, ligament, and bone) may include tension, tory response, the patient commonly feels an increase in pain
torsion, compression, and shear. The stress or loading is for the next 1 to 3 days following the injection. Following
imparted via manual therapy techniques, dosed medical PRP injection, the majority of the growth factors are released
exercise therapy progressions, functional strengthening, and within the first hour of injection but continued release occurs
return to play phase exercises. There is limited evidence in up until about 7 days following injection.24 Thus, the home
the literature defining specific protocols following PRP injec- program for the first 7 days following PRP injection is aimed
tion and limited documentation regarding tissue healing at avoiding disruption of this physiologic mechanism and
time frames following PRP injection. There is no absolute includes: rest, gentle active elbow motion, submaximal iso-
progression or transition between phases and there can be metric holds in all pain-free planes and ranges to help fiber
variability between patients pending each individual case. alignment, and heat to control symptoms. Functional
The goal following PRP injection is to promote adequate outcome tools, such as the Kerlan-Jobe orthopedic score,
tissue healing such that the tissue is able to once again shoulder pain and disability index and patellofemoral index
BOX 10-2 Four-Stage Rehabilitation Overview Following PRP Injection

Phase I: PostinjectionInflammatory Phase (0 to 7 Days) Light deep transverse friction mobilizations, active
Pain peak and inflammatory response spikes and healing release techniques, myofacial release
process commenced Use of modalities to aid tissue proliferation
Patient response: Day 1 to 2: painful in the tissue/ (recommend pulsed ultrasound, laser, electrical
joint; day 3 to 6: diminishing pain, improving stimulation)
significantly; day 7: sometimes no pain at all, improved Begin-high repetition loading and concentrics
quality of ROM (recommend 3 sets of 25 repetitions to improve tissue
Allow the PRP to absorb at the location endurance and aid vascularization)
Cross-link initiation and homeostasis occurring as PRP Begin functional activities to mimic activities of daily
activating to prepare for cross-bridging living with focus on mechanics and correctness of
Complete functional index tool (KJOC score, SCOR, movements. Progress with patient tolerance
SPADI) to establish baseline score Include functional exercise in HEP
Initiate home exercise program (HEP)rest, gentle Increased loading in the healing tissue in the direction
motion, isometric submaximal holds on all pain-free of its fibers
planes and ranges, heat to control symptoms Active stretching: static and dynamic
Avoid ligament stress for 4 weeks with activities of
Phase II: Protection and Early MotionInflammatory
daily living and exercise
Phase (7 to 21 Days):
Progress to eccentrics in weeks 4 to 6
Avoid homeostasis and cross-link disruption
Maintain integrity of cross-link Phase IV: Eccentric Loading, Plyometric Training, Return
Continue active range of motion (ROM) and avoid to Sport/ActivityRemodeling Phase (6 to 12 Weeks*)
overstretching; 90% full active ROM without stretching Increased tensile strength of repaired tissue
by end of week 2 Improved ability to produce force and withstand
No ligament stressing or excessive muscle/tendon tensile stretching and increased elasticity
tension Continue tissue remodeling facilitation with deep
Light tissue mobilization to aid tissue fiber healing in transverse friction and soft tissue mobilizations
line of stress and fiber line Eccentric loading
2- to 4-week delay/slower progression with ligament Progress to plyometrics, ballistics, explosive sport-
injections because of decreased vascularization specific activities, and exercises at approximately week
8 to 10, depending on patient status
Phase III: High Repetition Loading and Light Activity
Diagnostic ultrasound (approximately 8 weeks) may be
Reparative Phase (3 to 6 Weeks)
repeated to determine extent of healing
Pain threshold significantly reduced Initiate interval sport programs (throwing, running, on
Adjust exercise progression based on type of tissue field drills) pending results of diagnostic ultrasound
and severity of injury (ligaments longer to heal/ Resume full functional or sporting activity at 10 to 12
proliferate) weeks, depending on progress with postinjection
Gap is filling in and matrix integrity improving program
Collagen synthesis, aligns in the longitudinal axis, Overlap of timelines is based on the patients condition
tissue beginning to withstand tensile forces and and severity of injury
loads No antiinflammatory medications at home. No iontopho-
Tissue stress testing/clinical examination to establish resis or phonophoresis in any of postinjection phases
baseline
*Depending on individual sport and postinjection status; variable from patient to patient.
(SCOR), are commonly used to establish the patients base- Phase II consists of continued gentle active elbow motion
line subjective functional status. and increased activity at home. The patient should obtain
greater than 90% of full ROM by the end of week 2. Light
Phase II (Inflammatory Phase) (Table 10-4) soft tissue mobilizations should commence to the ulnar col-
lateral ligament (UCL) and common flexor origin and pro-
TIME: 7 to 21 days nator teres at this time. However, to avoid disruption of
GOALS: To avoid disruption of collagen cross-link collagen cross-link bridging and formation, deeper soft
bridging and formation, and initiate early motion tissue techniques (transverse friction, etc.) are not imple-
and high repetition loading exercises. Obtain 90% of mented until the third week following injection. Gentle
full range of motion (ROM). early motion of the elbow facilitates the physiologic tissue
TABLE 10-3 Platelet Rich Plasma Injection of the UCL (Inflammatory Phase)
Rehabilitation Criteria to Progress Anticipated Impairments
Phase to this Phase and Functional Limitations Intervention Goal Rationale
Phase I Postinjection with no Edema Initiate HEP rest, gentle Allow the PRP to absorb at Minimizes stress on
postinjection signs of infection Day 1-2: painful in the active motion; isometric the injected tissue to cross-link injection site
(0-7 days) tissue/joint submaximal holds all disruption Allow the PRP to
Day 3-6: diminishing pain pain-free planes and Facilitate integrity of cross-link absorb at the location
and improving significantly ranges; heat to control formation Prepare for cross
Day 7: sometimes no pain symptoms Control edema and pain bridging
at all, improved quality of No weights or stretching Complete functional index tool
ROM (KJOC score, SCOR, SPADI) to
establish baseline score
HEP, Home exercise program; KJOC,Kerlan-Jobe orthopedic score; PRP, platelet rich plasma; ROM, range of motion; SCOR, patellofemoral
index; SPADI, shoulder pain and disability index; UCL, ulnar collateral ligament.
TABLE 10-4 Platelet Rich Plasma Injection of the UCL (Inflammatory Phase)
Rehabilitation Criteria to Progress to Anticipated Impairments
Phase This Phase and Functional Limitations Intervention Goal Rationale
Phase II No signs of infection Pain Continue AROM, avoid valgus Control edema and Minimizes stress on
7-21 days 2-4 wk delay/slower Limited ROM stress activities and pain injection site
progression with Pain with light UCL stress overstretching; 90% full AROM Minimize Allow the PRP to
ligament injections tests and activities of daily without stretching by end of deconditioning absorb at the
because of decreased living wk 2 Initiate high repetition location
vascularization Limited UE strength Continue modalities for loading exercises and Prepare for cross
symptom control home exercise bridging
Wk 3: initiate light tissue program
mobilization to aid tissue fiber
healing in line of stress and
fiber line
AROM, Active range of motion; PRP, platelet rich plasma; ROM, range of motion; UCL, ulnar collateral ligament; UE, upper extremity.
healing response following PRP injection, which proceeds Early motion restoration aids connective tissue lubrica-
through the inflammatory, reparative, and remodeling tion between collagen cross-links, increases collagen mass,
phases. Furthermore, early motion and self-stretching decreases abnormal collagen cross-links, and prevents adhe-
prevent joint adhesions, increases muscle contraction, sion development. Following PRP injections, articular carti-
muscle fiber size, and tension, and increases resting levels of lage responds to early motion, intermittent compression, and
glycogen and protein synthesis. Submaximal-maximal effort decompression loading with improved metabolic activity
elbow isometrics performed three times per day are also and increased health of the cartilage matrix. Muscle, tendon,
initiated in an attempt to create light tension in the direction ligament, and bone tissue all respond favorably to motion.
of the tendon fibers. Intermittent rest and care with resuming Restoring full elbow ROM is advocated during the first 10 to
work and normal daily functional activities are also encour- 14 days following PRP injection.
aged at home to help control postinjection symptoms and Modalities used in the first two phases of PRP rehabilita-
early inflammatory elevation. tion can include US, laser, and electrical stimulation. The use
Progressive full arc motion in the first two phases pre- of modalities during this phase is aimed at further stimulat-
vents ligament atrophy and increases ligament linear tissue ing tissue healing of the UCL and increasing local perfusion
stress and stiffness, particularly at the bone-ligament junc- and oxygen delivery to the site. Nonthermal US is commonly
tion. Ligament-stressing exercises or functional activities, as used to facilitate tissue repair and regeneration in damaged
well as excessive muscle or tendon tension, are avoided tissue. There is research that supports the use of therapeutic
during this phase. There may be a 2- to 4-week delay with US to increase bony and muscle tissue regeneration.27-29
ligament healing because of decreased tissue vascularization. However, most studies that support the use of nonthermal
Exercises that exert tension on the UCL (valgus stress) are US and a laser to aid tissue healing are based on animal
not begun until later (phase III). studies. It is still unclear if using a pulsed nonthermal US is
more effective than a low-intensity continuous protocol in scar formation as opposed to the normal tendon healing
terms of proliferation and tissue healing. The use of laser pathways of vascularization and inflammation mecha-
treatment in patients with lateral epicondylosis was found to nisms.33 Thus during the reparative and remodeling phase of
lower subjective overall pain levels, with reports of 90% to muscle and tendon tissue, the use of soft tissue mobilization
100% relief in over 45% of the patients who were treated with techniques (ASTYM, deep transverse friction mobilization,
a laser.30 Additionally, studies have found that the use of a active release, Graston technique) in conjunction with
low energy laser improves tensile strength and stiffness in appropriate exercise progressions is an important compo-
repairing the medial collateral ligament in rats at 3 and 6 nent of the healing process in order to help minimize scar
weeks after injury.31 When rehabilitating after tendon PRP, formation and to promote anatomic tissue fiber healing in
we have found positive results using Russian electrical stim- line of stress.
ulation to help increase endorphin release and minimize Deep transverse tissue massage (DTFM) and friction
tissue response to loading and manual mobilizations using massage had been employed with positive results. As
the following parameters: 2500Hz frequency, 50 pps, 10/10 described by Cyriax,34 DTFM is an aggressive form of soft
seconds duty cycle, and 2 seconds ramp time for 10 to 12 tissue mobilization in which localized pressure or distractive
minutes. manipulation of tissues is directed tangentially across the
Progressive loading with shoulder, elbow, and wrist exer- longitudinally oriented collagen component of the injured
cises during phases II to IV is a critical component of the tissue. To promote normal resolution of the collagen tissue,
post-PRP injection treatment plan. The first two phases the tissue to be treated should be in a moderate stretch posi-
include use of a concentric low-load, higher repetition exertion (not painful).35 Deep transverse friction mobilizations
cise regimen: 3 sets of 20 to 25 repetitions are recommended. and other soft tissue manipulation techniques have mechani-
Once the patient reaches 3 sets of 25 repetitions, the weight cal, physiologic, histologic, and neurologic effects on the
is increased by 1lb and progresses from there. Proper pos- tissue that facilitate the healing mechanism of PRP injections
tural alignment, proximal and distal joint positioning, and (Box 10-3). Reaction to DTFM may include rapid desensiti-
control throughout the range, etc., are emphasized. This sub- zation, latent posttreatment soreness, and moderate tissue
maximal intensity using higher repetition progression bruising covering the area of tissue contact.34
improves tissue vascularization, helps align collagen cross- Eccentric loading is initiated early in the reparative and
links, promotes tissue healing, and enables the tissue to start remodeling phases at approximately weeks 4 to 6, depending
adapting to controlled amounts of stress. Endurance training on the individual patients status. Because of its positive
versus strengthening has been used in the early phases with effect on improving tissue integrity, strength, and function,
success following PRP injections. Submaximal loading exer- eccentric loading is the other important component of the
cises reduce homeostasis, tissue breakdown, and symptom post-PRP injection rehabilitation. Eccentric contractions
exacerbation during the first 2 to 4 weeks. Studies have dem- function to decelerate a limb, provide shock absorption, and
onstrated that resistance exercise is more effective in induc-
ing acute muscle anabolism than high-load, low volume or
work matched resistance exercise modes (isometrics).32
Phase III (Reparative Phase) (Table 10-5) BOX 10-3Effects of Deep Transverse Tissue Mobilization
TIME: 3 to 6 weeks Mechanical
GOALS: Adjust exercise progression based on type of
Distortion and elongation of collagen fibers
tissue and severity of injury; use of modalities to aid
Increased interstitial mobility
tissue proliferation (recommend pulsed US, laser,
electrical stimulation); begin high repetition loading Physiologic
and concentric; begin functional activities Localized hyperemia
Stimulate white blood cell invasion and healing
NOTE: Avoid ligament stress for 4 weeks with ADLs
production
and exercise; progress to eccentric weeks 4 to 6.
Destruction of P substance
Pain levels have typically lessened by the third week. Col-
lagen synthesis is occurring and aligning in the longitudinal Histologic
axis. At this point, the tissue is beginning to withstand tensile Prevents scar formation and haphazard collagen
forces and loads. However, it is important to adjust exercise orientation
progression based on type of tissue and the severity of injury Stimulate collagen orientation along lines of stress
(ligament healing and proliferation take longer). Soft tissue via piezoelectric effect
mobilizations and progressive loading via resistance exercise Neurologic
are key components of the postinjection reparative and
Initial nociceptor stimulation
remodeling phases. The primary pathologic mechanism that
Mechanoreceptor stimulation
leads to tendinopathy includes chronic microscopic tearing
Pain inhibition via central biasing mechanism
in hypovascular tendon tissue. These repetitive tears heal by
TABLE 10-5 Platelet Rich Plasma Injection of the UCL (Reparative Phase)
Phase III Full ROM Limited UE strength Glenohumeral stretching (HBB Maintain glenohumeral Use modalities to
3-6 wk No increase in pain Limited tissue tolerance towel, glenohumeral flexion mobility facilitate collagen
Pain-free moving to valgus tensile doorway stretching, sleeper Break up tissue formation and remodeling
valgus, milking loading exercises or stretch) adhesions Cross bridging occurring
stress tests and functional activities Shoulder strengthening program: Protect from valgus and matrix integrity
UCL stress at 0, until wk 5-6 Jobe or throwers ten exercises, loading improving
30, and 90 by Pain (diminishing) prone Hughstons progression* Increase UE function Promote full elbow ROM
end of this phase Limited tolerance with Pulley concentrics 0-2lb weight Prepare for sport- Nonpainful safe elbow
heavier lifting, pushing, Elbow flexion, extension specific interval program and wrist strengthening
pulling functional (supinated grip to decrease UCL Start emphasizing biceps,
activities load), supination (3 sets, 15 reps) pronator teres, and FCU
Wrist flexion, extension, radial group concentrics to
deviation, ulnar deviation (3 sets, support medial elbow
15 repetitions) Increase proximal joint
PNF and rhythmic flexibility
Stabilization exercises to shoulder Cardiovascular training to
onlyproximal hand placement improve endurance
(humerus) Progress toward light
Scapulothoracic PNF patterns and valgus loading by end of
strengthening phase III
CKC weight shifting (elbows UE strength gains
unlocked) advancing toward
Wk 5-6: sport-specific retraining
Initiate light stretching and valgus phase
loading of elbow (if no pain UCL tensile strength
with moving valgus, milking should be strong enough
stress tests and UCL stress at 0, to initiate valgus loading
30, and 90) exercises
Continue deep transverse friction
mobilization/massage to increase
tissue vascularization and break up
tissue adhesions
*http://www.dynoswim.com/archives/ShoulderRotatorExer.pdf.
CKC, Closed kinetic chain; FCU, flexor carpi ulnaris, HBB, hand behind back; PNF, proprioceptive neuromuscular facilitation; ROM, range of
motion; UCL, ulnar collateral ligament; UE, upper extremity.
generate forces 14% to 50% greater than a maximal concen- tendinosis.40,41 Eccentric tendon loading exercise progres-
tric contraction does.36 This increased force generation sions are thus implemented into postinjection rehabilitation
improves musculotendinous integrity by inducing muscle by week 4, depending upon the individual patients response
hypertrophy and increased tensile strength, or by lengthen- through the first 2 to 4 weeks. By the end of week 6, more
ing the musculotendinous unit.37 advanced exercise may begin (Figs. 10-3 through 10-8).
Unlike with concentric phase I to II exercises, eccentric Whereas the prior table provides an overview of exercise
loading has been shown to aid in stable angiogenesis in early progressions for UCL following PRP injection, examples of
tendon injury.38 Daily eccentric loading was found not to tendon treatment and exercise progressions are also pro-
have any detrimental effect on tendon vascularity or micro- vided (Boxes 10-4 and 10-5).
circulation.38 A systematic review of tendinopathy found that There is no clear consensus on the best nonoperative
eccentric exercises had the most clinical efficacy in regener- treatment for muscle injuries beyond immediate rest and
ating function.39 Other studies have found that eccentric antiinflammatory medications or modalities.28 In chronic
exercise progressions are an effective treatment for chronic tendinosis injuries, rest has been found to be a less effective
Fig. 10-3 Proprioceptive neuromuscular facilitation pulley pattern using

lighter weight or speed pulley. Alter arm angle and arc of motion to simulate
functional task or sport-specific plane.
Fig. 10-5 Upper extremity D1 D2 proprioceptive neuromuscular facilita-

Fig. 10-4 Upper extremity pulley pattern to stress ulnar collateral liga- tion patterns using foam roller and Plyoball. Alter arm angle to challenge
ment. Can alter plane, elbow flexion angle, and/or forearm position to alter glenohumeral and stability or alter ulnar collateral ligament stress through-
stress through ulnar collateral ligament. Performing with hand in supinated out range. Maintain core contraction keeping trunk centered on roller. Bring
position (underhand Frisbee toss) places further stress on ulnar collateral knees and feet together to further challenge core stability while performing
ligament. the pattern.
Fig. 10-6 Upper extremity D1 D2 proprioceptive neuromuscular facilitation patterns using Physioball. Maintain transverse abdominis contraction, keeping
hips level and ball controlled. Bring knees closer together to challenge stability. Patient can perform at varying speeds while maintaining stability. Performing
with eyes closed further challenges balance mechanism.
Fig. 10-7 Upper extremity patterns using Body Blade. Progress from static holds in different ranges to performing functional throwing/serving patterns.
Emphasis is on endurance and longer duration holds.
treatment.39,42 In turn, eccentric exercise and loading has postinjection status [variable from patient to
been shown in many studies to be beneficial in treating patient]); continue tissue remodeling facilitation with
patients with tendinosis.37,38 However, the optimal dosage deep transverse friction and soft tissue mobilizations
and frequency of eccentric loading for treating chronic ten-
dinosis has not yet been established.43 Note: Diagnostic US (at approximately 8 weeks) may be
repeated to determine the extent of healing; resume full
Phase IV (Remodeling Phase) (Table 10-6) functional or sporting activity in 10 to 12 weeks depending
on progress with postinjection program.
TIME: 6 to 12 weeks The injected tissue commonly demonstrates increased
GOALS: Eccentric loading, plyometric training return to tensile strength by the remodeling phase. Tissue remodeling
sport/activity; (depending upon individual sport and facilitation is continued in phase IV with the use of deep
182
TABLE 10-6 Platelet Rich Plasma Injection of the UCL (Reparative Phase)
Anticipated
Phase IV Objective examination Limited UE strength Continue tissue remodeling and deep transverse friction mobilization Increase UE strength Reassess functional
6-14 wk results, functional Limited UCL tensile Progress Jobe exercises and add 3-4lb Increased muscular index score to
testing, and subjective strength early phase IV Start inner- to mid-range glenohumeral IR loading (3 sets, 15 reps) control correlate with
functional tool score Altered timing and ER progression to mid- and outer-range planes at 90/90 Improve UCL tensile objective examination
indicate patient is mechanics with Continue concentric to eccentric rotator cuff strengthening strength findings and
PART 2 Upper Extremity
ready to progress sport-specific and Start upright bilateral Plyoball patterns No pain with higher determine
through phase IV to functional activities Light concentric resistance pulley or tubing patterns speed valgus loading return-to-play status
return to play status Light resistance PNF using distal hand placements and initiating elbow and wrist motions exercises Specificity of training
Provocation stress test Light valgus loading functional pulley patterns Prepare for return to Use of neuromuscular
results negative Early CKC exercises play and prior level of reeducation patterns
(moving valgus, Wk 6-8: function to simulate functional
milking, and UCL Progress to fast twitch and dynamic exercises (nonthrowing medicine ball and tubing) Train with sport-specific activity, and enhance
stress tests at Increase speed and functional strengthening exercise progressions joint control and
30-70) Phase III-IV core strengthening Establish and transition stability
Overlap of timelines Add towel throw drills if no pain with UCL stress tests; focus on head/trunk position, balance and to independent home Improved ability to
is based on the alignment exercise program produce force and
patients condition Wk 8-10: withstand tensile
and severity of Depending upon repeated US imaging findings, progress to return to play phase loads
injury May begin controlled overhead return to sport activities (simulated towel drills, shadow Increased tissue
drills, controlled plyo pulley patterns, increased speed with mid- to outer-range exercises) elasticity
Progress to two-hand throwing with lighter weight medicine ball/rebounder drills; continue CKC Sport-specific interval
progression program to enable
Wk 10-12: safe return to prior
Progress to 50%-75% of activity effort (short toss-long toss) functional status
Begin interval return to sport program
Start interval throwing, batting, tennis strokes, volleyball hitting programs pending repeat
US imaging findings
Outer-range cuff strengthening, ballistics, speed pulley patterns
Inner-range slide board/fitter drills for valgus loading
Rebounder tossing progressions (2 hand chest pass, overhead throw ins, shot puts, single
overhead throws, eccentrics)
CKC plyometrics
Week 12: Progress from 75%-90% in controlled setting
Weeks 12-14: Gradual return to sport
CKC, Closed kinetic chain; ER, external rotation; IR, internal rotation; PNF, proprioceptive neuromuscular facilitation; UCL, ulnar collateral ligament; UE, upper extremity; US, ultrasound.
Fig. 10-8 Upper extremity patterns using Body Blade. Progress from static holds in different ranges to performing functional throwing/serving patterns.
Emphasis is on endurance and longer duration holds.
transverse friction and soft tissue mobilizations. Depending TABLE 10-7 Timeline for Return to Activity or
on the response to the eccentric strengthening progression, Interval Return Sport Phase IV
the patient progresses to speed and coordination drills, plyo-
metrics, ballistics, and more explosive, sport-specific phase Weeks
IV exercises (Figs. 10-9 through 10-18). <1-2 <3-4 >10-12 >11-12 weeks
At this point connective tissue has improved tensile
strength because its fiber orientation is better aligned and Rest and Therapy Muscle Belly Tendinosis Ligaments
suited to withstand more demanding tensile stress.44 The
Ligament healing may be delayed 2-4 weeks; avoid varus/valgus
functional strengthening, plyometrics, ballistics, neuromus-
stress for 6 weeks.
cular power, and coordination exercises are performed at
more intense levels to enable the patient to meet the demands
of his or her sport or job activity. Typically, selective tissue period following PRP injection, most patients have been able
tension tests (ligament stress tests, resistance muscle-tendon to resume full functional or sporting activity by 10 to 12
tests in lengthened position, weight-bearing and compres- weeks (Table 10-7).
sion tests for bone) are nonprovocative. The use of follow-up
functional tools is recommended to ascertain the patients CONCLUSIONS
readiness to resume higher level exercises, and return to
sport or work. Studies have not yet been published regarding The use of orthobiologic modalities such as PRP in orthope-
the efficacy of using scores on subjective functional tools or dics and sports medicine to deliver high concentrations of
questionnaires to help determine when a patient is ready to naturally occurring biologically active growth factors and
safely resume a particular activity or sport given a certain proteins to the site of injury is very promising. However,
subjective score. there remain significant clinical and basic science questions
There is no clearly defined or objective means of deter- that need to be answered regarding the use of PRP in clinical
mining when an athlete is able to safely return to play or a practice. Questions still remain regarding the optimal con-
patient is able to return to a functional activity (job duty). A centration of PRP, how many injections are optimal, and the
grading system has been used to describe tendinopathy.45 timing of treatments in the acute and or chronic settings.
However, the use of a detailed clinical examination together Other questions that need to be addressed include what is
with the repeat US imaging findings, as well as the patients the optimal physiologic environment for these injections to
subjective assertions and functional index score, are all used be performed and how can PRP be optimally used in specific
to assist the physician, therapist, and athletic trainer in deter- tissue, including muscle, tendon, ligament, or bone. Ques-
mining when the patient is ready to resume the desired activ- tions regarding optimal post-PRP treatment rehabilitation
ity. Interval running programs, on field agility progressions, also need to be defined. Although PRP is widely being used
and interval throwing programs are initiated in phase IV. in clinical practice today, a significant amount of basic science
Although there are several notable documented cases in and clinical research remains to be done to define the optimal
which an athlete has returned to play at an earlier time use and overall safety of PRP therapy in clinical practice.
Fig. 10-9 Upper extremity strengthening in half-kneel position using Fig. 10-10 Upper extremity strengthening in half-kneel position using
Body Blade. Emphasis on scapular control, upright head/trunk position, Plyoball. Emphasis on scapular control, upright head/trunk position, and
and stability throughout pattern. stability throughout pattern.
Fig. 10-11 Overhead rebounder tossing in half-kneel position. Emphasis placed on maintaining upright balance and trunk control through upper extremity
strengthening pattern. Recommend using lighter weight balls (4oz to 2lb). Encourage and facilitate pelvis/trunk rotation and uncoiling mechanism for
overhead athletes.
Fig. 10-12 Rotator cuff eccentrics. Patient is in half-kneel position and catches ball thrown from behind. Emphasize ball deceleration via rotator cuff and
periscapular muscles by counting to 5 seconds while eccentrically lowering the ball to completion of the follow-through phase of the throwing arc. Emphasize
a faster 2-second concentric acceleration toss back to thrower (clinician) standing behind the patient.
Fig. 10-13 Closed kinetic chain bilateral to single upper extremity progressions using balance disk, Bosu ball. Perform while maintaining scapula held in
different retraction/protraction positions. Maintain core stability throughout.
Fig. 10-14 Ulnar collateral ligament and upper extremity loading using slide board patterns. Recommend inner-range slides to assess ulnar collateral liga-
ment tolerance to loading and progressively increase slide out distance. Can perform straight planar patterns, up/down pluses, or diagonal angles to challenge
upper extremity. Progress from performing on two knees to performing in push-up position on toes.
BOX 10-4 Post-PRP Injection Exercise ProgressionsSupraspinatus/Infraspinatus Tendon Examples

Weeks 1 to 2: higher speed pulley and Plyoball patterns; UE isokinetic
No strengthening, gentle range of motion (ROM) activities strengthening; continue core strengthening and cardiovas-
only, low-grade cardiovascular training cular training; for throwers, integrate core strengthening
and check glenohumeral internal rotation range. Integrate
Week 2:
self-stretching (hand-behind-back towel, supine hand
Begin submaximal isometrics, progress to gravity elimi- behind back, sleeper stretch) for cuff or capsule if
nated strengthening or use of counterweighted pulley (3 appropriate
sets of 25 reps) to increase tendon vascularization, and
passive ROM and active/assisted ROM exercises within Weeks 5 to 7:
pain-free range (no stretching emphasis) Depending upon status, may begin controlled overhead
return to sport activities (simulated towel and throwing
Weeks 2 to 3:
drills, shadow drills). Progress to two-hand throwing
High repetition loading and submaximal to maximal medicine/plyometric ball drills and early bilateral closed
isometric mid and outer ranges. Begin prone Hughston kinetic chain (CKC) girdle exercises; overhead strengthen-
exercises (2 sets, 10 reps each); isolated supraspinatus/ ing with Plyoballs, pulleys, and rebounder
infraspinatus loading; Jobe or throwers ten exercises 0- to
2-lb-weight (3 sets 15 reps); concentric mid-range internal/ Weeks 6 to 8:
external rotation muscle energy technique pulley progres- Progress to 50% to 75% of activity effort. Begin interval
sions (3 sets, 25 reps); scapulothoracic program (scapular return to sport program (short-toss, long-toss progression;
pluses, depressions, lower/mid trapezius exercises, such 50% overhead tennis serves; free style swim strokes
as Ys, Ts, Ws over ball, scapular setting exercises) cardio- all in controlled arcs and ranges). Light contact and may
vascular training begin bilateral to single closed chain exercise progres-
Weeks 3 to 4: sions; progress to single overhead plyometrics, rebounder
tossing
Progress Jobe exercises and add 3 to 4lb. Glenohumeral
and scapulothoracic rhythmic stabilization (SRS) and pro- Weeks 7 to 10:
prioceptive neuromuscular facilitation ( PNF) light tubing or Progress from 75% to 90% in controlled setting. Return to
pulley patterns (high repetition loading); Body Blade pat- contact.
terns focusing on time/endurance; outer-range rotator cuff Weeks 8 to 10:
strengthening; cardiovascular training
Gradual return to sport
Weeks 4 to 5: Overlap of timelines is based on the patients condition
Progress to fast twitch, eccentrics, and dynamic exercises and severity of injury
(nonthrowing medicine ball and tubing); PNF reversals,
BOX 10-5 Post-PRP Patellar/Achilles Tendon Exercise Progression Example

Week 1: exercises; light trampoline weight shifts to low intensity
Begin passive range of motion (ROM) for physical therapy trampoline jog intervals; start submaximal effort, higher
only in the first week; towel slides in pain-free range for speed isokinetics
patellar tendon; PWB walking boot (Achilles); crutches if Weeks 6 to 7:
needed to unload tendon during gait Initiate LKC eccentrics (step up/down progressions, decline
squats, heel raises (2 up, 1 down eccentric loading), Bosu
Week 2:
ball progressions; SLS proprioception training on uneven
Begin low-level closed chain activity (ball sits with surfaces; initiate trot or light jogging activities and 50%
single-leg balance/stability/Biomechanical Ankle Platform effort ladder drills; continue higher speed isokinetics, 75%
System, standing weight shifts, standing single leg squat effort
balance). Should get 90% of ROM without stretching by
end of week 2; start submaximal isometric holds; 4-way Weeks 8 to 10:
straight leg raise; proximal joint strengthening; initiate joint Continue longer duration cardiovascular training (elliptical,
mobilizations to maintain normal osteokinematics; initiate stationary bike, swimming); continue eccentric loading and
core strengthening and home exercise program; walking isokinetic strengthening; begin bilateral counterweighted
and light stationary bike resistance only greater than body weight jump progressions on (shuttle/
total gym); increase speed of agility, ladder, and controlled
Weeks 3 to 4: change of direction drills; controlled and low intensity (in
Begin gentle self-stretching and home exercise program; place) return to sport drills, 50% to 75% effort; initiate jog,
progress submaximal to maximal isometrics; start station- stride, and light run straight planes (no decelerations); pro-
ary bike/swimming and cardiovascular training; form run at gressive 40 to 60 yards (jog and stride). Initiation of interval
walk pace; Thera-Band ankle foot proprioceptive neuro- programs (not long duration) depends on repeat ultrasound
muscular facilitation (PNF) patterns; initiate bilateral high imaging findings, objective examination results, functional
repetition, counterweighted, mid-range long kinetic chain testing, and subjective functional tool scores
(LKC) concentric strengthening (shuttle, total gym); bilat- Weeks 10 to 12:
eral heel raises from neutral to full plantar flexion ranges;
Continue eccentric strengthening; bilateral to single-leg
single-leg stance (SLS) proprioception training exercises;
jump progressions, cutting activities, sprints, and change
maintain proximal joint flexibility, progress with proximal
of direction drills; progress toward single plyometrics at
hip, and core strengthening exercises; phase II LKC pro-
approximately week 10; continue functional strengthening;
prioception retraining
begin sprinting and return to sport on field activities;
Weeks 5 to 6: maximal effort isokinetic strengthening
Single-leg, high repetition CKC strengthening progressions; Week >12:
single concentric heel raises (outer-range tendon strength- Gradual return to sport
ening); continue cardiovascular training (stationary bike, Overlap of timelines is based on the patients condition
can begin elliptical); integrate phase III SLS proprioception and severity of injury
Fig. 10-15 Eccentric Achilles loading two up, one down decelerations. Emphasize slow controlled eccentric dorsiflexion.
Fig. 10-16 Step down progression. Focus on sagittal plane long kinetic Fig. 10-17 Single Bosu ball squats.
chain alignment, frontal plane pelvic stability, and transverse plane subtalar
joint position throughout exercise. Shifting weight to metatarsal heads
(maintaining heel contact on ground) on forward step down adds further
tension to patellar tendon.
Fig. 10-18 Decline squat examples. Increased tension is placed through patellar tendon with decline squatting. Add hand weights or incorporate with closed
kinetic chain isokinetic strengthening.
Suggested Home Maintenance Program Post-UCL PRP Injection

Weeks 1 to 2: ER side-lying or pulleys progress to mid- and
No strengthening, no activity, gentle passive range outer-range planes @ 90/90
of motion (PROM) only Early CKC exercises (quadruped weight shifting,
Treatment: Avoid all valgus stressing activities/ alternate arm/leg lifts, scapular pluses)
exercises 4 weeks Continue scapular strengthening progressions;
1. Modalities (ice) add barrel hugs, modified push-ups on hands,
2. Isometric elbow strengthening (BID): inner- to knees
mid-range submaximal holds
3. HEP (rest, heat, passive to light active motion, no Weeks 6 to 8:
resistance exercises or loading) Progress to fast twitch and dynamic exercises
4. ROM emphasis: passive to light active ROM (nonthrowing medicine ball and tubing)
Increase speed and functional strengthening
Week 2: phase III to IV progressions
Begin active range of motion (AROM) exercise Continue all earlier phase exercise
elbow flexion, extension, and wrist; all planes within Add towel throws if no pain with UCL stress
pain-free range (no weights or stretching) tests; focus on head/trunk position, balance and
alignment
Week 3:
Avoid valgus loading (resistance shoulder internal Weeks 8 to 10:
rotation) or ligament stretching Pending follow-up US imaging findings progress to
Maintain glenohumeral flexibility (HBB towel, return to play phase IV exercises
glenohumeral flexion doorway stretching, sleeper May begin controlled overhead return to sport
stretch) activities (simulated towel drill, shadow drills,
Elbow flexion, extension (supinated grip to controlled plyometric pulley patterns, increased
decrease UCL load), supination (3 sets, 20 reps) speed with mid- to outer-range exercises,
Wrist flexion, extension, radial deviation, ulnar progress to two-hand throwing with lighter
deviation (3 sets, 20 reps) weight medicine ball/rebounder drills); CKC
Flexion, scaption, speeds with pulleys/free progression including walkouts, step overs
weights Isokinetic strengthening
Scapular mid and low rows
Closed kinetic chain (CKC) weight shifting (elbows Weeks 10 to 12:
unlocked); upright scapular pluses against wall Progress to 50% to 75% of activity effort (short toss,
Start emphasizing biceps, pronator teres, and long toss). Begin interval return to sport/throwing
flexor carpi ulnaris (FCU) group concentrics to program (Chapter 13). Start interval throwing,
support medial elbow batting, tennis serve, volleyball hitting programs
Shoulder exercises to be performed with physical pending repeat US imaging findings, objective
therapy in the clinic to ensure proper technique examination results, functional testing, and
subjective functional tool score
Weeks 4 to 6: Cuff strengthening: outer ranges, ballistics, speed
Add/begin functional diagonal and proprioceptive pulley patterns; inner range: slide board/fitter
neuromuscular facilitation (PNF) patterns drills for valgus loading
Initiate elbow, wrist, and hand resistance Rebounder progressions (two-hand chest pass,
exercises. Begin with concentrics in controlled overhead throw ins, shot puts, single overhead
ranges, light tubing with chest press, and rows (3 throws, eccentrics)
sets, 15 to 20 reps) CKC plyometrics
Add more scapular strengthening progressions
(lawn mower pulls, cross hearts, depressions, Weeks 10 to 12:
Kibler scapular exercises) Progress from 75% to 90% in controlled setting
Scapular pluses and standing wall push-ups, or
counterweighted (shuttle) scapular protractions Weeks 12 to 14:
Ball ER rolls against wall Gradual return to sport

Start inner- to mid-range glenohumeral IR (3 Overlap of timelines is based on the patients
sets, 15 reps) condition and severity of injury
1 Paul is 2 weeks post-PRP injection. He is complaining

of continued medial elbow pain. Is phonophoresis/
iontophoresis an appropriate choice for treatment?
recommended in the Return to Throwing chapter, and
videotaped initially and periodically thereafter to evalu-
ate his throwing technique and progression through the
throwing program.
No. Nonsteroidal antiinflammatory medication cannot
be used 2 to 3 weeks before and 6 to 8 weeks after the
PRP treatment has been completed. 5 What is the effectiveness of PRP injections?
2 Sam is 4 weeks post-PRP injection for a partial UCL

tear. He continues to experience medial elbow pain that
is limiting his progression through rehabilitation. What
The success rate for PRP injections has been reported as
high as 85% in some cases. The success of the treatment
depends on a number of factors, the most important
must be considered? being choosing the appropriate patient. I have noted a
high rate of success and publication of my data is
At this stage a call into the physician should be made pending. However, more studies need to be done to
and the potential of a second PRP injection should be validate the effectiveness before PRP injection can be
considered. considered a routine procedure for soft tissue injuries.
3 During the initial phases of rehabilitation, what exer-

cises should be avoided? 6 What is the best treatment course for an acute muscle
injury?
Any exercise that places a valgus stress on the elbow There is no clear consensus on the best nonoperative
(shoulder internal rotation and proprioceptive neuro- treatment for muscle injuries beyond immediate rest and
muscular facilitation [PNF] patterns with distal hand antiinflammatory medications or modalities.
placement should be avoided)
4 Doug is 8 weeks postinjection and is making excellent

progress. What must be considered before progressing
7 Is rest an effective tool in managing chronic soft tissue
dysfunction (tendinosis)?
to throwing activities? In the case of chronic tendinosis injuries, rest has been
found to be a less effective treatment. In turn, eccentric
Of prime concern is why the UCL was exposed and exercise and loading has been shown in many studies to
torn to begin with. Throwing mechanics should be a be beneficial in treating patients with tendinosis.
main concern. Doug should be performing exercises
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CHAPTER 11
Surgery and Rehabilitation for Primary
Flexor Tendon Repair in the Digit
Linda J. Klein, Curtis A. Crimmins
is mature along the lines of tension and the repair site

SURGICAL INDICATIONS strength is maximized. The maturation phase, as with all
AND CONSIDERATIONS healing tissue, lasts a number of months.10
Flexor tendon injuries have a long history of challenging the SURGICAL PROCEDURE
hand surgeon and therapist. Surgical and rehabilitation tech-
niques have evolved significantly since Bunnell1 suggested The principles of flexor tendon repair are well established and
that tendon lacerations over the proximal phalanx not be must be rigorously applied to achieve consistently good
repaired, but ultimately grafted. This basic premise went results. The first step is to educate the patient about the inher-
unchallenged until early mobilization techniques were devel- ent complexity of the injury. The patient should not only
oped in an attempt to prevent tendon adhesions during the understand the demanding technical nature of the injury but
healing process. In the 1960s multiple investigators were able also the extraordinarily demanding rehabilitation. The
to document that primary flexor tendon repair was superior patient must accept that a successful outcome will depend in
to delayed tendon grafting.2-4 large part on his or her commitment to and involvement in
Despite dramatic improvement in outcome over the past the rehabilitation protocol. If possible, the patient should be
25 years, research has continued with both clinical and labo- counseled by a hand therapist preoperatively to establish
ratory investigations at a breakneck pace. Biomechanical rapport and discuss the therapy protocol. Finally, every
studies of human cadaver tendons have been extraordinarily patient must be informed that a perfect outcome is unusual
useful. Investigators have established how much force is and multiple surgical procedures may be necessary.
applied to a tendon during rehabilitation motions and during Flexor tendon repairs should be done in the operating
normal hand activities.5-8 The most recent repair techniques room by experienced hand surgeons within 1 week of the
have greater tensile strength,9 which has allowed early injury. Precise surgical technique is rewarded by better out-
postrepair motion to advance from passive flexion to con- comes. Tendon ends usually retract after being cut, and an
trolled active flexion. The results are fewer adhesions, with adequately large surgical incision is generally needed to
better active motion and functional outcomes. locate and retrieve the tendon ends. Incisions require careful
planning to allow adequate exposure without compromising
Tendon Healing Stages the vascularity of the skin flaps. Zigzag or midaxial approaches
Tendon healing occurs in three general stages. The inflam- are preferred to prevent scar contracture (Fig. 11-1).
matory phase lasts about 1 week and begins with a fibrin clot The hallmark of successful flexor tendon repair surgery is
at the repair site. Macrophages and other inflammatory cells atraumatic handling of the soft tissue, especially of the
begin work by removing nonviable material and attracting tendon itself. Flexor tendons almost always retract and must
fibroblasts. Epitenon cells bridge the repair site to restore the be retrieved and advanced back through the flexor sheath.
gliding surface. The active repair phase lasts from 1 to 2 This may well be the most difficult part of the operation.
months. Collagen bundles form and reorient to strengthen Great care must be exercised to avoid injury to the delicate
the bond between the tendon ends. The tendon begins to synovial lining of the fibro-osseous sheath or the epitenon of
revascularize primarily from the intrinsic supply of the prox- the flexor tendon. Damage of one or the other may increase
imal stump. The remodeling phase follows until the collagen the probability of adhesion formation and a poor outcome.
193
B C
Fig. 11-1 Repair of lacerated flexor tendons in the ring and small fingers. A, Sheaths are empty because flexor tendons have retracted into the digit and palm.
FDP and superficialis tendons are retrieved from the palm. B, The profundus tendon is rethreaded through the chiasm of Camper of the superficialis tendon
before repair. C, Completed repair of flexor tendons, now placed within the sheath and pulley system, repaired between the A2 and A4 pulleys. (Courtesy
Curtis Crimmins.)
Once the tendon ends have been located and threaded provide a smooth juncture of tendon ends at the repair site,
back through the sheath and pulleys as carefully as possible, prevent gapping, maintain tendon vascularity, and be rela-
the tendons are repaired through a window between the tively straightforward to perform. Biomechanical studies
pulleys, while maintaining the anatomic relationship of the have definitively shown that multistrand core suture tech-
profundus and superficialis tendons. The flexor digitorum niques can withstand forces encountered during active
superficialis tendon divides into two slips over the proximal motion protocols. In general, at least four strands of 3-0 or
phalanx, then it merges again, creating a buttonhole type 4-0 sutures are needed to cross the repair site to ensure
opening referred to as the chiasm of Camper, just before adequate strength for an early active motion protocol.
inserting into the middle phalanx. The flexor digitorum pro- Numerous suture techniques to achieve a repair of at least
fundus (FDP), which lies deep to the superficialis until this four strands are described in the literature. The authors
point, emerges through the chiasm of Camper, continuing prefer a double Kessler suture to produce the four strands of
distally, to insert on the distal phalanx of the digit (Fig. 11-2). suture crossing the repair site, with a running epitendinous
When both tendons are lacerated over the proximal phalanx, suture9 (Fig. 11-3).
the surgeon must be certain to reestablish this special rela- During the process of repairing the flexor tendons, it is
tionship. Furthermore, each divided slip of the superficialis important to preserve as much of the flexor tendon sheath
has a tendency to derotate 180 as it retracts. This must also and pulley system as possible. The surgeon must attempt to
be corrected as the tendon is repaired. Only restoration of preserve the A2 and A4 pulleys to prevent tendon bowstring-
normal anatomic relationships will allow excellent return of ing (Fig. 11-4).
function after repair of lacerated flexor tendons. A tendon injury at the level of either of these pulleys is
The actual suturing of the flexor tendons has been a major technically demanding. Even repairs at other levels must be
focus in the evolution of stronger repairs. The current state technically precise to allow gliding of the repair under pre-
of the art suggests that suture repair achieve adequate served portions of the flexor sheath. Suture knots should be
strength to allow early active-flexion rehabilitation proto- placed to minimize impingement of the flexor tendon repair
cols. To achieve this, the repair must ensure secure knots, as it passes through the pulley system. Current techniques
Chapter 11 Surgery and Rehabilitation for Primary Flexor Tendon Repair in the Digit 195
Short A5
vinculum C3
Distal transverse
digital artery A4
Intermediate transverse
C2
Long digital artery
FDP vinculum A3
Short
vinculum
Chiasma of C1
Proximal transverse
Camper digital artery
Long
vinculum A2
FDS
Branch to vinculum
longus superficialis
A1
Common digital
artery
Fig. 11-2 The flexor digitorum superficialis lies volar to the FDP as the
tendons enter the sheath. At the level of the proximal phalanx, the superfi-
cialis divides and the two slips pass around the profundus tendon, merging Fig. 11-4 The fibro-osseous sheath or pulley system has five annular
and splitting again before inserting on the middle phalanx (chiasm of pulleys (A1 to A5) and three cruciform pulleys (C1 to C3). The A2 and
Camper). (From Schneider LH: Flexor tendon injuries, Boston, 1985, Little, A4 pulleys must be preserved to prevent bowstringing of the flexor
Brown.) tendons. (From Schneider LH: Flexor tendon injuries, Boston, 1985, Little,
Brown.)
THERAPY GUIDELINES
FOR REHABILITATION
A B
Flexor tendon repairs in the hand require a special rehabili-
tation effort. Flexor tendons will heal if positioned without
tension or stress; however, adhesions to surrounding tissue
D will prevent tendon gliding necessary to allow active flexion
C once the tendon has healed. Thus the need to move a flexor
Fig. 11-3 Types of flexor tendon repairs demonstrating different amounts tendon early in the healing process has been evident since
of suture strands crossing the repair. A, Modified Kessler is a two-strand repair of flexor tendons has begun.
repair. B, Double Kessler is a four-strand repair. C, Savage is a six-strand After repair it takes approximately 12 weeks for a flexor
repair. D, Indiana is a four-strand repair. (From Shaieb MD, Singer DI: tendon to regain enough tensile strength to avoid rupture
Tensile strengths of various suture techniques. J Hand Surg 22B[6]:765,
with normal strong use of the hand required to grasp,
1997.)
hold, or lift objects during daily activities. A variety of
protocols for flexor tendon rehabilitation have been devel-
oped over the past 50 years, making the choice of which
meet these requirements, and results are expectedly good, protocol to use difficult. No exact method exists to deter-
with 75% or more tendon repairs falling consistently within mine the strength of a tendon repair during the healing
the excellent to good categories. process; therefore the therapist and surgeon rely on general
Recent and future trends in flexor tendon surgery research guidelines regarding tendon healing, as well as factors that
include investigations of the ability of substances such as affect rate of healing to determine advancement of the patient
platelet-derived growth factor-BB, hyaluronic acid, and within a flexor tendon rehabilitation protocol. The factors
5-flourouracil to enhance tendon healing.11-13 Polyvinyl that are considered include the type of injury; status of the
alcohol shields and antiadhesion gels have been proposed tendon, sheath, and vessels at the time of repair; injury to
and studied with some success to decrease adhesions.14 As surrounding structures; patient health issues such as diabe-
these trends continue, we must stay abreast of current devel- tes; lifestyle factors such as smoking, which decreases
opments to maximize functional outcomes for patients after oxygen to the tissues; and ability to comply with the reha-
flexor tendon injury. bilitation program. Consideration of these factors and clear
communication with the surgeon are necessary to determine Limited active extension
the most appropriate approach to choose for each particular
patient. Before describing the variety of guidelines from Kleinerts splint
which to choose for flexor tendon rehabilitation, it is impor-
tant to understand how exercise concepts are modified for
Passive flexion
flexor tendon repair rehabilitation.
CONCEPTS OF HEALING AND EXERCISES

FOR FLEXOR TENDON REPAIR Lumbricalis
Role of Adhesions After Flexor Tendon Repair

Adhesion
Adhesions occur very early in many cases, often within 1
week after surgery, preventing gliding of the flexor tendon
needed to flex the digit. The end result of dense adhesions
can be a digit that does not flex any further than it did before
the tendon repair was performed, but with the additional
pain, discomfort, and cosmetic changes caused by extensive
surgical incisions in the digit, as well as many weeks of lost Fig. 11-5 Theoretic basis of passive flexion and limited active motion of
IP joints do not always move the suture site of the digital flexor tendon.
use of the hand while rehabilitation is attempted. Adhesions Passive flexion makes the distal segment of the tendon kink, which can be
are the most difficult to deal with in zones I and II of the stretched by active extension of IP joints, without moving the suture site.
hand. Zones I and II extend from the distal palmar crease of (From Tajima T: Indication and techniques for early postoperative motion
the hand to the distal phalanx, and they incorporate the area after repair of digital flexor tendon particularly in zone II. In Hunter JM,
of the digit in which the flexor tendons pass under a very Schneider LH, Mackin EJ, editors: Tendon and nerve surgery in the hand:
A third decade, St Louis, 1997, Mosby.)
tight pulley system, encompassed within a tendon sheath
filled with synovial fluid that allows the tendon to glide
under the tight pulleys (see Fig. 11-4). When adhesions form immediately after surgery, however, stronger suture tech-
within the sheath-pulley system in zones I and II of the digit, niques had to be developed.
they are very difficult (in many cases impossible) to over-
come, and the result is a digit that is limited in active flexion. Understanding Repair Strength
Historical perspectives on tendon healing help clinicians Flexor tendon surgery has undergone an evolution over the
understand the reasoning behind current approaches to past 10 to 20 years. This evolution has resulted in the devel-
flexor tendon surgery and rehabilitation. Before the 1960s, opment of stronger suture repair techniques that will with-
flexor tendons were allowed to heal by immobilization for stand the tension placed on the repair with controlled active
the first few weeks because it was thought that the tendon flexion immediately after the repair. These new and stronger
could not heal without nutrition from the surrounding scar tendon repair techniques, as discussed in the earlier
tissue.15 This immobilization for the first few weeks resulted portion of this chapter, allow immediate controlled active
in dense adhesions, especially with repairs in zones I and II, motion without rupture, preventing the formation of dense
with the inability to actively flex the digit. These results adhesions. In general, the more strands of suture material
spurred the development of immediate passive-flexion pro- that cross the tendon repair, the stronger the repair (Fig.
tocols. The goal was that by passively flexing the digit and 11-6).7-9,20,21
allowing partial, protected extension, the flexor tendon Traditional surgical procedure, using a two-strand repair,
would glide far enough under the pulley system to prevent will tolerate passive motion, but is not shown to be suffi-
dense restricting adhesions and allow active motion when ciently strong enough to tolerate active motion immediately
the tendon was adequately healed. However, in many cases, after repair.22 A four-strand repair will tolerate gentle active
tendinous adhesions still developed. Research has shown motion. An eight-strand repair will certainly tolerate active
that proximal gliding of the FDP tendon is inconsistent motion; however, it is technically demanding and may
during passive flexion.16 The flexor tendon, when the digit is become so bulky as to not glide under the pulleys, creating
passively flexed, is thought in some cases to kink, or bunch friction, possible wearing, and eventual rupture.20 Thus a
up, between the pulleys, rather than passively glide through four- to six-strand repair technique is frequently chosen to
the pulley system (Fig. 11-5). To ensure proximal gliding of apply an immediate active motion protocol.
the flexor tendon, an active contraction of the muscle is After the traditional two-strand repair, it is safe to
needed to pull the tendon proximally through the pulley perform immediate passive-flexion protocols (described
system. Because research has shown that tendons do heal later in the chapter), or where necessary by patient limita-
intrinsically without surrounding adhesions,17-19 an effort to tion, immobilization. Immediate active-flexion protocols
actively flex the repaired flexor tendon immediately after are generally not applied to the tendon with a traditional
repair was initiated to prevent the onset of dense adhesions. two-strand technique, but require a stronger four-strand
To avoid rupture of the flexor tendon with active motion technique and must be discussed with the surgeon. It is
Flexor Tendon Repair Strength versus Motion

Two, Four & Six Strand No Peripheral Suture
9000
8000
7000
6000 Passive
5000 Light Active
4000 Strong Grasp
3000 Pinch (Index)
2000 Two Strand

Four Strand
1000
Six Strand
0
Repair 1 Week 3 Weeks 6 Weeks
Fig. 11-6 Tensile strengths of flexor tendon repairs compared with the
tension developed within the tendon with use of the hand. The comparison A
shows that at its weakest point after surgery, a two-strand repair is not strong
enough to tolerate light gripping; however, four or more strand repairs have
adequate tensile strength to tolerate light gripping. (From Strickland JW,
Cannon NM: Flexor tendon repairIndiana method. Indiana Hand Center
Newsl 1:4, 1993.)
extremely important for the therapist to understand the

type of suture repair that was done for a flexor tendon
repair, to ensure that the protocol chosen for a particular
patient stays within the tension limits of the repair.
Edema Control and Scar Management After

Flexor Tendon Repair
Elevation is essential in the early phase after flexor tendon B
repair, because other forms of edema control are limited by Fig. 11-7 A, The patient performs wrist tenodesis exercises by relaxing the
the continuous splinting. Shoulder, elbow, and cervical wrist into flexion and extending the fingers to assist in gliding the flexor
motion exercises are performed to help with lymphatic func- tendon distally. B, The wrist is then extended to 20 to 30 while the fingers
tion and circulation. In the intermediate and late phases of are gently flexed to assist in gliding the flexor tendon proximally. (Courtesy
Linda Klein.)
flexor tendon healing, use of a light compressive wrap at
night is appropriate. This should not be used during the day
because compressive wraps will increase resistance to the
flexor tendon during active flexion. The therapist initiates flexion remains limited after sutures are removed, then other
gentle massage of the scar (for firmness) and edema massage therapy techniques may be used to assist in regaining passive
after sutures are removed; the patient can continue this flexion, such as heat combined with stretch into flexion
process at home when made feasible by the presence of the before manual passive flexion within the patients pain
splint. Commercially available scar management pads may tolerance.
be placed or formed over the scar, applied at night only, if
scars become thickened or raised. Because the splint is worn Wrist Tenodesis Exercises After Flexor
full time in the early phase of the rehabilitation programs, it Tendon Repair
is difficult for the patient to safely apply the scar management Wrist tenodesis exercises use wrist motion to assist in moving
pads at night, and they are often applied beginning in the the flexor tendons. The wrist is flexed to comfortable
intermediate phase for this reason. tolerance, and the fingers allowed to gently straighten at all
three joints. This will give the tendon slack at the wrist and
Passive-Flexion Exercises After Flexor glide the tendon distally during finger extension. Next, the
Tendon Repair fingers are relaxed, the wrist is extended to 30, and the
Passive flexion of the digits is performed through all the fingers are gently flexed. The wrist extension pulls the flexors
phases of flexor tendon rehabilitation. Passive flexion of the slightly proximally and gives slack to the finger extensors,
digit after a flexor tendon repair places the repaired tendon allowing the flexors to glide proximally (Fig. 11-7). The wrist
on slack. Very little tension develops within the flexor tendon tenodesis exercise is started in the intermediate phase of
during passive flexion of the digit, as long as the patient is rehabilitation after a two-strand repair, because it creates
truly relaxed and not actively assisting the passive flexion.5,6 tension in the tendon. It is started within 3 days after surgery
After flexor tendon repair, a finger will become stiff because within an immediate active-flexion approach after a four
of swelling, incisional scarring, and pain if passive flexion is (or more) strand repair unless otherwise directed by the
not performed within 1 week after the procedure. If passive physician.
after surgery). An assessment of flexor tendon gliding is done

Active Extension of the Fingers After Flexor to determine what type of active flexion is appropriate. To
Tendon Repair assess flexor tendon gliding, passive flexion is compared with
Full extension of all three finger joints at the same time must active flexion. The initial assessment of active flexion is
be limited immediately after flexor tendon repair to avoid done cautiously, with the wrist in 20 to 30 of extension
pulling the repair apart by stretch. Extension is limited in the (Fig. 11-8). When a difference exists in the repaired digit
early phase of tendon healing by positioning within the between passive and active flexion of 15 or more,23 it indi-
dorsal blocking splint that places the metacarpophalangeal cates the presence of adhesions, limiting tendon gliding.
(MP) joints in flexion. However, interphalangeal (IP) exten- When flexor tendon adhesions limit active more than passive
sion is very important to obtain shortly after the repair in flexion 3 to 4 weeks after surgery, active tendon-gliding exer-
zones I and II because the proximal interphalangeal (PIP) cises are initiated. Tendon gliding can be achieved by per-
and distal interphalangeal (DIP) joints contract into flexion forming a sequence of three fists: hook fist, straight fist, and
very quickly after repairs in these zones. All flexor tendon composite fist (Fig. 11-9). A hook fist is similar to a claw
protocols emphasize attaining full IP extension immediately position, flexing the PIP and DIP joints with the MPs
after surgery, unless a digital nerve has been lacerated or extended. This type of fist results in the largest differential
another injury prevents placement of the IP joints in full gliding of the FDP and flexor digitorum superficialis. A
extension, as directed by the surgeon. When a digital nerve straight fist results in the most excursion of the flexor digi-
has been repaired in the digit, the PIP joint is generally torum superficialis. A composite fist results in the most
allowed to extend to 15 less than full extension. Composite excursion of the FDP tendon.
extension of all three finger joints at the same time will Active flexion is begun in the early phase of tendon
place an adverse stretch effect on the flexor tendon repair healing when the patient is placed in an immediate active
in zone I or II initially after surgery, but it can be tolerated
at 4 weeks after surgery with the wrist in flexion. Wrist and
full finger extension are not performed at the same time
until the late stage of tendon healing.
Passive Finger Extension After Flexor

Tendon Repair
Passive extension of the fingers is potentially more danger-
ous than active extension, because if done overaggressively,
it may stretch the tendon repair apart. It is also possible for
the patient to have some tension within the flexor tendon
during the passive extension, resulting in resistance to the
repaired tendon and possible rupture.
In the early phase of tendon healing, passive IP exten-
sion is only performed when active IP extension is limited
(in the presence of PIP or DIP joint flexion contractures).
When IP joint flexion contractures appear early, passive IP
joint extension can be performed carefully, with the flexor A
tendon in a protected position and ensuring that the patients
hand is fully relaxed. The protected position for a flexor
tendon is with all other joints supported in flexion while one
joint is extended. For instance, to treat a PIP flexion contrac-
ture 3 weeks after repair, the therapist flexes the wrist and
MP joints as far as can be tolerated, then passively extends
the PIP joint by applying pressure under the middle phalanx
into extension. The DIP joint is not passively extended at the
same time as the PIP joint to avoid stressing the tendon
across two joints in the early phase of tendon healing.
Active Finger Flexion After Flexor

Tendon Repair B
Active flexion introduces significantly increased tension in
Fig. 11-8 The therapist assesses flexor tendon gliding by comparing
the repaired flexor tendon. Traditional approaches using
passive flexion of the repaired digit (A) with active flexion (B). When a large
immediate passive flexion or immobilization for the early difference exists between active and passive flexion, it signifies the presence
phase of tendon healing introduce active flexion of the of significant flexor tendon adhesions that limit active flexion. (Courtesy
repaired digit in the intermediate phase of healing (4 weeks Linda Klein.)
does not have limiting adhesions is more at risk for rupture

than the tendon with strong adhesions that surround the
tendon repair site. When tendon adhesions limit active
flexion more than passive flexion, the tendon can tolerate
more tension before rupture, and thus can be advanced to
the next level sooner than the tendon without limiting adhe-
Hook fist Straight fist Full fist
sions.23 Flexor tendon adhesions are assessed on a continual
basis to determine the level of the rehabilitation program
Fig. 11-9 Active flexor tendon-gliding exercises consist of three positions:
hook fist, straight fist, and full or composite fist. (From Pettengill K,
that is appropriate for the patient at that time. The time after
van Strien G: Postoperative management of flexor tendon injuries. In surgery, combined with the level of flexor tendon adhesion,
Skirven TM, et al, editors: Rehabilitation of the hand and upper extremity, determines the placement of the patient in the program.23
ed 6, Philadelphia, 2011, Mosby.) When adhesions prevent gliding of the flexor tendon, it
is appropriate to advance the patient to the next phase of
rehabilitation to encourage tendon gliding, with surgeon
motion flexor tendon rehabilitation approach. At the first approval. When flexor tendon gliding is adequate, the patient
postoperative physician or therapy visit 2 to 3 days after is kept in the current level of the program until the number
surgery, a controlled method of active flexion termed place- of weeks after surgery dictates that the repair is strong
hold is begun. Place-hold flexion uses the therapists or enough to tolerate the increased tension of the next phase of
patients other hand to passively place the fingers into a light the treatment protocol.
fist; then the patient holds the fingers actively in the light-fist The appropriate choice of which guideline to use and
position as the other hand is removed. This requires an active advancement of the patient within the chosen guideline
muscle contraction and flexor tendon gliding in a proximal require in-depth knowledge of flexor tendon healing and
direction to keep the finger in a flexed position actively. The tensile strength guidelines at various times after repair,
place-hold exercise is believed to result in less tension on the awareness of the type of repair, and the patients compliance
repaired tendon than if the finger were actively flexed without level, as well as communication with the referring surgeon.
the assistance of the patients opposite hand or the therapists
hand. Within an immediate active motion approach, the IMMOBILIZATION APPROACH
three types of fists described earlier are not performed
until the intermediate phase of tendon healing if flexor Indications for Immobilization
tendon adhesions develop in spite of early active motion Immobilization is rarely used after a flexor tendon repair;
attempts. however, some situations call for its application. Immobiliza-
tion is used for young children, who are unable to adhere to
Postoperative Guidelines a motion protocol with its specific precautions. Children
In general, three types of flexor tendon rehabilitation guide- younger than age 12 are most often placed in immobilization
lines exist. These are (1) immobilization, (2) immediate for the first 3 to 4 weeks, but each child should be evaluated
passive flexion, and (3) immediate active-flexion approaches. related to his or her maturity level. Other population types
The reasoning for choosing one approach over another is that may be placed in immobilization after a flexor tendon
based on the complexity of injury, the age of the patient, repair would be those that have cognitive limitations (e.g.,
patient compliance, patient health factors, and the suture Alzheimer disease, noncompliant patients). It is sometimes
repair technique. The choice of which set of guidelines within difficult to know the patients compliance ability at the first
which to place a patient is best determined in conjunction therapy session. When a patient demonstrates inability to
with the referring surgeon, with the final decision resting appropriately comply with the precautions and exercises
with the surgeon. within a certain approach, it may become necessary to change
Within each approach the patient progresses through the rehabilitation approach to one with less early motion, or
three general levels or phases: early, intermediate, and late a cast may be needed instead of a removable splint in the first
phases. The decision of when to advance a patient to the next 4 to 5 weeks after surgery. When a concomitant fracture or
level within each approach is determined by the amount of significant loss of skin requiring a skin graft occurs, a period
flexor tendon adhesion that limits the tendon gliding and the of immobilization may be necessary to allow the bone or skin
amount of time after repair. To determine the level of flexor to heal adequately before beginning motion. Not all fractures
tendon adhesion, the therapist compares passive flexion with require immobilization. Stable fractures or those that have
active flexion. When a large discrepancy exists between had open reduction internal fixation may tolerate immediate
passive and active flexion, with passive flexion 15 or more controlled motion, as determined by the surgeon. Few sets of
better than active flexion, it signifies the presence of flexor guidelines exist for therapy after immobilization of the
tendon adhesions. When adhesions limit gliding of the flexor repaired flexor tendon because of dense adhesion formation.
tendon, and the time period after repair is adequate to allow The most frequently sited guideline, described as follows,
increased tension on the tendon, the patient is progressed to encourages motion and light resistance to facilitate tendon
the next level of the rehabilitation approach. The tendon that gliding after the initial phase of tendon healing.24,25
gliding can be obtained with isolated tendon gliding exer-

Immobilization Guidelines cises. The therapist can isolate the FDP tendon by blocking
Phase I (Early) the MP and PIP in extension while performing active DIP
TIME: 0 to 4 weeks flexion. The flexor digitorum superficialis (FDS) tendon is
GOALS: Prevent joint stiffness, avoid tension on isolated with blocking of the FDP tendon by holding all other
tendon repair, prevent flexion contractures, patient fingers in complete extension and allowing the injured finger
and family education regarding tendon protection, to flex at the PIP joint. If improvement is noted in tendon
manage edema, full active range of motion (AROM) gliding 1 week later, then these exercises are continued until
of upper extremity (UE) joints proximal to the wrist 6 weeks after surgery.
(Table 11-1) If no improvement occurs in active flexion with block-
ing and tendon gliding exercises, then light resistance of
Splinting. When used, the immobilization approach will gripping with very soft putty is initiated at 5 weeks after
place the patients hand in a dorsal blocking cast (or in a surgery. This resistance is initiated in the intermediate phase
dorsal blocking splint wrapped securely in place, with of healing only in the presence of flexor tendon adhesions
instructions not to remove the splint at home). The position that limit active flexion more than passive flexion by 15 or
of the cast or splint in the early phase of immobilization is more.23 Extension of the fingers is performed with the wrist
20 to 30 of wrist flexion, and 40 to 50 of MP flexion, with flexed. When PIP flexion contractures are present, limiting
IP extension. This position keeps the flexor tendons on slack, the PIP joints, DIP joints, or both from full extension, they
yet prevents the most difficult joint problems (e.g., PIP are splinted in a volar extension splint at night, beginning at
flexion contractures). The cast or splint will stay in place for 4 or 5 weeks after surgery. Goals in the intermediate phase
3 to 4 weeks. of the immobilization approach include obtaining full passive
flexion and partial active flexion, full IP extension, and pro-
Exercises. Within phase I (zero to 3 or 4 weeks after tecting the repaired tendon from rupture with appropriate
surgery) the patient generally remains immobilized in the splinting between exercises and patient education, as well as
dorsal blocking splint or cast. When referred to therapy scar management.
during the early phase, the therapist may perform passive
flexion to prevent joint stiffness and a significant other, such Phase III (Late)
as a parent, may be taught to perform passive flexion at home TIME: 6 to 12 weeks
if he or she is reliable. Goals in the early phase of the immo- GOALS: Normalize PROM and AROM, improve strength
bilization approach include protecting the repaired flexor to allow a light fist, patient and family education to
tendon(s) from rupture with full time splinting and patient avoid tendon repair rupture (Table 11-3)
education, obtaining passive flexion when allowed, edema
control, and obtaining full active motion of the UE proximal Exercises. This phase generally lasts from 6 to 12 weeks
to the wrist. after surgery. All protective splinting is discontinued. When
passive flexion continues to be limited by joint stiffness and
Phase II (Intermediate) swelling, therapeutic techniques such as heat and PROM are
TIME: 3 or 4 weeks to 6 weeks continued. Active flexion, joint blocking, and tendon gliding
GOALS: Improve joint mobility (full flexion passive exercises continue to attempt to bring active flexion to match
range of motion [PROM], partial flexion AROM, full the level of passive flexion. Resistance can be introduced or
IP extension), patient and family education, scar advanced during this phase. Light resistance can be provided
management, splinting to prevent tendon repair with putty or light manual resistance of the therapist, and it
rupture between exercises (Table 11-2) can be advanced to light grippers in the middle of the late
phase of tendon healing.
Exercises. With phase II exercises, the splint position is If flexor tendon adhesions are minimal, then resistance
adjusted to bring the wrist to neutral. The splint is removed is initiated at 8 weeks after surgery, gently at first, with
for exercises hourly. Passive flexion is initiated first, to loosen strong resistance restricted until after 12 weeks after
stiff joints created by immobilization, swelling, and scarring. surgery. Goals in the late phase of the immobilization
After passive flexion, wrist tenodesis is initiated as described approach include obtaining full passive and active flexion
previously, to begin gentle tendon gliding (see Fig. 11-7). and extension of the injured finger or fingers, increasing
Tendon-gliding exercises are initiated, with three types of strength to obtain a light fist, and protecting the repaired
fisting exercises (i.e., straight fist, hook fist, and composite tendon from rupture with patient education.
fist; see Fig. 11-9), as described previously. Assessment of Regardless of the goals, active motion after use of an
flexor tendon adhesions is performed after 3 to 4 days of immobilization approach is frequently limited because of
these exercises by comparing passive flexion with active adhesion formation. Limited active flexion of the repaired
flexion of the digit or digits. When active flexion is signifi- digit, especially the DIP joint, is frequently seen, and there
cantly more limited than passive flexion, blocking exercises may be difficulty actively flexing the adjacent digits because
of the PIP and DIP joints are added. Additional flexor tendon of the common muscle belly of the FDP to the last three
TABLE 11-1 Flexor Tendon Repair in the Digit (Immobilization Approach)

Phase I Postoperative Edema Postoperative splint fabrication Avoid tension on the Prevent compromise of
0-3 or 4 wk and cleared Pain Inspect surgical site for drainage, repaired tendon tendon repair
by physician Limited ROM erythema Prevent infection Promote wound healing
to initiate Unable to grip, pinch, Pain assessment Decrease pain and Manage pain and edema
therapy lift, or carry objects Edema assessment and early edema to moderate or Prevent proximal joint
edema control less stiffness
AROM exercises for the shoulder Full AROM of shoulder Reduce stiffness in
and elbow emphasizing avoidance and elbow digits*
of stress to the repair site Patient/family to
Patient/family education regarding understand tendon
precautions and purpose of repair precautions and
immobilization approach as chosen purpose of
by physician immobilization
Passive flexion of the MP and IP Prevent joint stiffness
joints, in therapy only* and flexion
IP extension to limit of splint, in contractures*
therapy only*
*In cases cleared by physician.

AROM, Active range of motion; IP, interphalangeal; MP, metacarpophalangeal; ROM, range of motion.

Phase II No signs of Edema and pain Splint adjustment to wrist Full passive flexion of Improve joint mobility
3/4-6 wk infection Limited range of neutral finger joints Minimize resistance to
No significant motion Splint removed for therapy and Full active IP extension tendon gliding
increase in pain Limited strength home exercises Partial active flexion Initiate tendon gliding
Intact tendon Unable to grip, pinch, Modalitiesheat for stiffness Prevent tendon rupture Manage edema, pain
repair lift, or carry objects and pain as needed Reduce tendon adhesions Remodel tendinous
Passive flexion of finger joints Reduce scar thickness adhesions
Active IP extension Decrease edema Prevent complications/
Protected passive PIP extension Independent home rupture
in the presence of contracture exercise program
Wrist tenodesis Patient/family to
Gentle tendon gliding and fisting understand tendon repair
exercises (Figs 11-7 and 11-9) precautions
Gentle blocking exercises
Scar massage, scar pads at
night
Edema control/light compressive
wrap
Patient/family education of
home exercises and tendon
precautions
IP, Interphalangeal; PIP, proximal interphalangeal.


Anticipated
Phase III Tolerance of A/PROM Pain Discontinue splint Full PROM, Promote restoration of
6-12 wk No significant Limited range of Passive finger flexion maximize AROM of full joint mobility
increase in pain motion Passive IP extension in the fingers Pain management
Intact tendon repair Limited strength presence of contractures Pain-free motion Improve tendon gliding
Limited ability to grip, Composite active finger Increase strength to Promote functional use
pinch, lift, or carry extension facilitate light use of the injured hand
objects Modalitiesheat for Decrease thickness Prevent complications
stiffness and pain as needed and firmness of scar
Progress tendon gliding, Minimal edema by
fisting, and blocking 12 wk
exercises Independent home
Light strengthening exercises exercises
(putty) Prevent compromise
Light functional activities of tendon repair
night
Edema control/light
compressive wrap
Patient/family education
A/PROM, Active/passive range of motion; AROM, active range of motion; IP, interphalangeal; PROM, passive range of motion.
digits (i.e., quadriga effect). Grip strength will be dimin- immediate passive-flexion guidelines. These two categories
ished secondary to loss of active flexion. It is common for are approaches that use either elastic traction or static-
flexor tendons with adhesions to require a prolonged time positioning splints during the early phase of tendon healing.
of therapy, with a strong emphasis on a home program Both approaches use a dorsal blocking splint with the wrist
of blocking exercises and resistance even longer than the at 20 to 30 of flexion and the MPs at 50 to 60 of flexion,
12-week healing period, to continue to facilitate tendon with the IPs allowed full extension within the splint. The
gliding during the long remodeling process. Further surgical difference between the two approaches (the positioning of
procedures are available for the repaired flexor tendon with the fingers in either dynamic flexion or static IP extension
significant adhesions that limit functional use of the hand, in the early phase of healing) will be described within each
which are most often performed between 3 and 6 months guideline.
after repair. The static-positioning guideline follows the modified
Duran and Houser25-27 rehabilitation program, while the
IMMEDIATE PASSIVE-FLEXION APPROACH elastic traction guideline is patterned after the modified
Kleinert,3 Washington,28 or Chow29 rehabilitation programs.
Immediate passive-flexion approaches apply passive flexion These guidelines will be generalized in the following
to the fingers, beginning within 3 or 4 days after surgery. paragraphs.
These guidelines are appropriate for, and have been tradi-
tionally applied to, the patient with a two-strand repair of Immediate Passive Flexion With Static-
the flexor tendon. No active contraction of the repaired Positioning Guidelines
flexor muscle and tendon unit occurs; therefore limited Patients are placed into an immediate passive-flexion
proximal gliding of the flexor tendon occurs in the early approach that does not use elastic traction on the fingers
phase of tendon healing within this approach. The benefits when it is the preference of the surgeon and therapist or
of an immediate passive-flexion approach are that the finger when elastic traction is contraindicated. These contrain
does not become overly stiff, and a limited amount of gliding dications include questionable soft tissue tolerance to
of the repaired tendon occurs. Results vary widely regarding prolonged flexion, early development of IP flexion
results of the immediate passive-flexion approach and tendi- contractures, or presence of a concomitant injury such as
nous adhesions. Two main categories encompass all the a fracture that would not tolerate passive flexion.
Phase I (Early) exercises (Fig. 11-11). Active IP extension exercises to the

TIME: 0 to 4 weeks hood of the dorsal blocking splint are also performed.
GOALS: Attain full passive flexion, full active IP
extension, minimize edema, prevent rupture of Phase II (Intermediate)
flexor tendon by splinting and patient education, TIME: 4 to 7 weeks
full AROM of UE joints proximal to the wrist GOALS: Attain partial active flexion (at least 50%) of
(Table 11-4) the injured digit, full passive flexion, full active
extension, protect flexor tendon from rupture with
Splinting. A dorsal blocking splint is fabricated and splinting between exercises and patient education
applied within the first 5 days after surgery. The wrist is (Table 11-5)
placed in 20 to 30 of flexion, the MP joints are placed in
approximately 50 of flexion, and the IP joints are straight Exercises. Exercises continue to be performed in therapy
(Fig. 11-10). The patient is instructed to remain in the splint and at home, 10 repetitions every hour. Remove splint at
at all times for the first 4 weeks after surgery. It is removed home for exercises and bathing. Begin with wrist tenodesis
in therapy for cleansing of the skin and splint, as well as skin exercises, and place-active hold flexion. Advance to gentle
assessment for pressure and fit. active-flexion exercises. If flexor tendon adhesions are noted
(active flexion limited by 15 or more compared with passive
Exercises. Exercises should be performed in therapy and flexion), begin blocking exercises for PIP and DIP flexion.
at home, 10 repetitions every hour. Within the splint, passive Active finger extension is performed with wrist flexed until
PIP flexion to tolerance, passive DIP flexion to tolerance, and 6 weeks, then with the wrist neutral. Passive IP extension is
then composite passive flexion of MP, PIP, and DIP joints to begun if PIP or DIP flexion contractures exist, with the
tolerance. Duran and Houser25,26,30 described specific passive tendon in a protected position.
TABLE 11-4 Flexor Tendon Repair in the Digit (Immediate Passive-Flexion Approach)
Anticipated
Phase I Postoperative and Edema Postoperative splint Protect tendon repair Prevent compromise of
0-4 wk cleared by physician Pain fabrication Prevent infection tendon repair
to initiate therapy Limited range of Static positioning splint* Decrease pain and Promote wound healing
motion (see Fig. 11-10) edema to moderate Manage pain and
Unable to grip, pinch, Elastic traction splint* (see or less edema
lift, or carry objects Fig. 11-12) Full AROM of Prevent proximal joint
Inspect surgical site for shoulder and elbow stiffness
drainage, erythema Full passive flexion Prevent digital joint
Pain assessment all digit joints stiffness and flexion
Edema assessment and early Full IP extension* contractures
edema control Patient to understand Passively glide tendon
AROM exercises for the tendon repair
shoulder and elbow precautions and
Passive flexion of all finger home exercise
(or thumb) joints (see Fig. program
11-11 in addition to
composite flexion of all
finger or thumb joints)
Active IP extension with MPs
flexed (see Fig. 11-12,
B, for IP extension with
elastic traction approach)
regarding tendon precautions
and home exercise program
*Unless digital nerve is repaired, then slight flexion of the proximal interphalangeal or physician direction.
AROM, Active range of motion; IP, interphalangeal; MP, metacarpophalangeal.
IMMEDIATE PASSIVE FLEXION

WITH ELASTIC TRACTION APPROACH
(refer to Tables 11-4 through 11-6
for guidelines)
Indications
Elastic traction was added to the early phase of the passive-
flexion guidelines described previously in an attempt to
increase proximal tendon gliding by placement of the fingers
in flexion between exercises, in part by allowing more time
for the tendon to be resting proximally in relation to the
repair site and to the pulley system. It also decreases stiffness
Fig. 11-10 Dorsal blocking splint with the wrist and MP joints flexed
keeps slack in the repaired flexor tendon during the early healing phase. It of the digits in the direction of flexion by applying passive
is used for the immobilization protocol and the immediate passive-flexion flexion for a greater portion of time. Placement in passive
protocols that do not use elastic traction. (Courtesy Linda Klein.) flexion with elastic traction to the fingers between exer-
cises also decreases the potential for even inadvertent
active flexion of the fingers in the early phase of flexor
tendon healing, protecting the tendon from rupture. The
negative effect of elastic traction is the increased potential to
develop IP flexion contractures, as well as the increase in
complexity perceived by the patient by having a dynamic
splint on the hand (as opposed to a less complicated static
splint). Patients are placed into this approach by preference
of the surgeon-therapist team (those patients that are not
A B showing signs of IP flexion contracture, those that can be
compliant with the rehabilitation program, and those who
have no soft tissue healing complication).
Immediate Passive Flexion With Elastic

Traction Guidelines
Phase I (Early)
TIME: 0 to 4 weeks
GOALS: Attain full passive flexion, full active IP
C D extension, minimize edema, prevent rupture of
flexor tendon with splinting and patient education,
Fig. 11-11 Specific passive exercises described by Duran and Houser. With
full AROM of UE joints proximal to the wrist
the MP and PIP joints flexed (A), the distal phalanx is passively extended
(B). This moves the FDP tendon distally away from the flexor digitorum
superficialis tendon. The next step is with the DIP and MP flexed (C), the Splinting. The splint applied for this approach is the same
PIP joint is passively extended (D). This moves both repairs distally away dorsal blocking splint base as described for the static posi-
from the site of repair and any surrounding tissues to which they may tion approach, with the addition of elastic traction applied
adhere. (From Pettengill K, van Strien G: Postoperative management of
from the fingertip of the injured finger or fingers, which
flexor tendon injuries. In Skirven TM, et al, editors: Rehabilitation of the
hand and upper extremity, ed 6, Philadelphia, 2011, Mosby.) passes under a distal palmar pulley and is connected at the
midforearm level to the proximal splint strap on the volar
forearm (Fig. 11-12, A). The wrist is in 20 to 30 flexion, the
Phase III (Late) MP joints in 50 to 60 flexion, and the IP joints straight. The
TIME: 7 or 8 to 12 weeks elastic traction may consist of rubber bands, rubber band
GOALS: Attain full active and passive flexion and and monofilament line combination, or other elastic thread.
extension of digits, light grip strength, protect It can be attached to the tip of the finger by a suture placed
repaired tendon from rupture with patient education by the surgeon through the fingernail or an attachment such
as a dress hook glued to the fingernail. Some therapists have
Discontinue use of splint. Continue with active motion also used self-adhesive moleskin or other fabric with a hole
exercises. If flexor tendon adhesions are present, then begin for the elastic traction attachment applied to the fingertip.
light resistive exercises. Dynamic IP extension splinting after The line is threaded through a pulley at the level of the distal
8 weeks is initiated if flexion contractures persist. At 12 palmar crease and attached at the level of the forearm, gener-
weeks after surgery, the patient is allowed to perform normal ally to the proximal splint strap, around a safety pin. The
activities (Table 11-6). distal palmar pulley concept is important because it achieves
Anticipated
Phase II No signs of infection Edema and pain Continue use of splint except Full passive flexion Maintain/improve joint
4-7 or 8 wk No significant Limited range of for exercises and bathing of digits mobility
increase in pain motion until 6 wk after surgery. Full active extension Manage edema and
Intact tendon Limited strength May discontinue splint at of all digit joints with pain
Unable to grip, pinch, 6 wk if adhesions limit wrist flexed, advance Minimize resistance to
lift, or carry objects tendon gliding to wrist neutral tendon gliding
May eliminate elastic traction Partial to full active Decrease peritendinous
at 4 wk postoperation in digit flexion with adhesions
elastic traction approach wrist extended Improve tendon gliding
Passive digit flexion, active Reduce peritendinous Prevent compromise of
IP extension adhesions tendon repair
Gentle passive IP extension Decrease edema
for PIP flexion contractures Reduce scar
with wrist flexed thickness
Modalitiesheat for Independent home
stiffness and pain as needed exercise program
Initiate active digit flexion Patient/family to
with wrist tenodesis understand tendon
exercises: active finger (or repair precautions
thumb) flexion with wrist Prevent tendon
extended; finger (or thumb) rupture
extension with wrist flexed,
gradually bring wrist to
neutral
Advance to blocking
exercises and tendon gliding
for IP flexion if adhesions
limit active flexion
Edema control with light
compressive wraps at night
as needed
Scar massage/night pad as
needed
Patient education regarding
precautions
IP, Interphalangeal; PIP, proximal interphalangeal.
passive DIP flexion. A safety pin in the strap across the palm therapy for skin and splint cleansing and for skin assessment
is a simple method to obtain the distal palmar pulley. Other of pressure areas.
methods of designing a distal palmar pulley include line
guides or D rings embedded in splint material that is brought Exercises. Exercises should be performed in therapy and
across the palm. at home, 10 repetitions every hour. Passive flexion of the
It is important to assess IP extension on an ongoing basis fingers is performed within the splint. Full passive PIP
because of increased potential for PIP and DIP flexion con- flexion, DIP flexion, and composite finger flexion are per-
tractures (a result of the increased time in flexion during the formed passively to the strap across the palm. Full active PIP
day). Most therapists instruct the patient to remove the prox- and DIP extension are performed within the splint, to the
imal attachment of the elastic traction at night to allow the dorsal hood of the splint (Fig. 11-12, B). It is important to
fingers to be strapped to the dorsal hood of the splint. The maintain full IP extension, especially within this protocol,
splint is worn full time for the first 4 weeks. It is removed in unless a digital nerve repair has been made. Goals in the
Anticipated
Phase III Good progression/ Pain Passive finger or thumb Full PROM, AROM of Promote restoration of
8-12 wk tolerance of A/PROM Limited range of flexion fingers or thumb full joint mobility
No significant motion Passive IP extension in the Pain-free motion Pain and edema
increase in pain Limited strength presence of contractures, Increase strength to management
Intact tendon Limited ability to grip, dynamic IP extension splint facilitate light use Improve tendon gliding
pinch, lift, or carry with physician approval Decrease thickness Promote functional use
objects Composite active digit and firmness of scar of the injured hand
extension Minimal edema by Prevent compromise of
Full active flexion of fingers 12 wk tendon repair
or thumb Independent home
Modalitiesheat for exercises
stiffness and pain as needed Prevent tendon
Blocking, tendon gliding if rupture
adhesions limit active motion Functional use of
Gentle passive intrinsic injured hand
stretch as needed
Light strengthening exercises
if adhesions are present
Gradual, progressive
strengthening after 12 wk
night
Edema control/light
compressive wrap
A/PROM, Active passive range of motion; AROM, active range of motion; IP, interphalangeal; PROM, passive range of motion.
early phase of the immediate passive-flexion approaches If flexor tendon adhesions are noted (passive flexion is
include attaining full passive flexion and active IP extension, better than active flexion), blocking exercises are initiated
tendon gliding as possible within these exercises, edema for PIP and DIP flexion. Goals in the intermediate phase of
control, protecting the repaired flexor tendon from rupture the immediate passive-flexion programs include attaining at
with appropriate splinting and patient education, and attain- least half range of active flexion of the injured digit, full
ing full UE motion proximal to the wrist. passive flexion, full active finger extension, and protecting
the repaired tendon from rupture with appropriate splinting
Phase II (Intermediate) between exercises and patient education.
TIME: 4 to 7 or 8 weeks
GOALS: Attain partial (at least 50%) active flexion of Phase III (Late)
the injured digit, full passive flexion, full active TIME: 7 or 8 to 12 weeks
extension, protect repaired tendon from rupture with GOALS: Full active and passive flexion and extension,
splinting between exercises and patient education light grip strength, protect repaired tendon from
rupture with patient education
Exercises. Exercises should continue as in phase I, and the
patient can remove the splint for exercises and bathing. In Splinting is discontinued and light active use is initiated.
therapy and at home, active flexion is initiated. Begin with If flexor tendon adhesions are present, then advance to light
wrist tenodesis exercises and gentle place-active hold in resistive exercises at 8 weeks after surgery.
flexion exercises. Advance to active flexion and composite If good tendon gliding is evidenced by equal or nearly
finger extension with the wrist flexed. At 6 weeks, discon- equal active and passive flexion, then delay resistance until
tinue protective splinting and begin active extension of the 10 to 12 weeks after surgery and advance gradually. If IP
fingers with the wrist in neutral. flexion contractures are present, then passive IP extension
extension, and, most significantly, resistance, creates an

increase in tension at the repair site.
Full passive flexion and nearly full extension of the injured
finger or fingers should be expected following use of an
immediate passive-flexion approach. The amount of active
flexion achieved varies, and active DIP flexion is often
limited by adhesions. IP extension is occasionally limited by
flexion contracture. When composite extension of the wrist
and digits is limited in the late phase of tendon healing, a
resting pan splint in maximum composite extension, worn
at night, will help distal gliding of the tendon to allow com-
posite extension. A finger-length splint may be used if just
A the IP joints are contracted in flexion. Functional deficits in
motion or strength present after 12 weeks can be treated with
any traditional therapy approaches, including modalities and
dynamic splinting for stiffness or contractures, AROM
and PROM, joint mobilization, blocking exercises, and
strengthening.
IMMEDIATE ACTIVE-FLEXION APPROACH

Indications
Development of immediate active-flexion guidelines is the
most recent advancement in rehabilitation after flexor tendon
repairs. These guidelines have been developed after the onset
of surgical advancements of stronger repair techniques
B described earlier in this chapter. Active-flexion approaches
Fig. 11-12 A, Dorsal blocking splint with elastic traction places the MP have been developed to minimize flexor tendon adhesions
joints and wrist in partial flexion and attaches an elastic band to the fingertip in the early phase of tendon healing and have been very
of the injured finger. B, Exercises are to fully passively flex the digit and to successful in improving outcomes of flexor tendon
actively extend the IP joints to the hood of the splint. (Courtesy Linda
repairs.8,22,31-33 Immediate active-flexion approaches are
Klein.)
reserved for patients who have had a strong enough surgical
repair to tolerate the additional stress placed on the tendon
by active flexion, as well as those who can be compliant to
exercises and dynamic IP extension splinting may be initi- the splinting and exercise program. The presence of severe
ated with surgeon approval. Goals in the late phase of the edema, joint stiffness, or health factors that would slow
immediate passive-flexion approaches include full active and tendon healing would prohibit placement of a patient in
passive flexion and extension, regaining light grip strength, an active-flexion approach. It is important to minimize the
and protecting the repaired tendon from rupture with patient stress on the tendon, especially in the early phase of tendon
education. Full grip and pinch strength can be performed as healing, to prevent rupture.
part of a home exercise program 12 weeks after surgery, at
which time the repaired flexor tendon is considered to be Minimizing Tension on a Tendon With
strong enough to tolerate normal daily activities. Immediate Active-Flexion Approaches
In general, when a digit with a repaired flexor tendon Because active flexion results in an increase in tension within
demonstrates good active flexion within the first 5 or 6 weeks the flexor tendon, it is important to minimize this tension in
after surgery, advancement to resistance is delayed because the early phase of tendon healing to prevent rupture. Edema
minimal additional support of adhesions to the repair site and stiffness both present increased resistance to active
exists. When flexor tendon adhesions limit active flexion flexion, thereby requiring the flexor muscles to pull harder
more than passive flexion, the digit can be advanced through on the tendon, increasing the work of flexion within an
the phases listed previously at the earlier of the times indi- immediate flexion protocol. Work of flexion is a term that
cated because the tendon has the support of surrounding describes the amount of tension created within the tendon
adhesions and can tolerate the additional tension applied during active flexion.34 Work of flexion increases with swell-
within the advancing phases of treatment with less chance of ing, stiffness, or any internal friction encountered by the
rupture. The decision to advance a patient with a flexor tendon caused by bulk of repair, tight pulleys, or swelling of
tendon injury to the next phase of treatment is best done in the tendons, in addition to the tension normally developed
conjunction with the referring surgeon because advancing during active flexion.35 The therapists goal is to minimize the
the partially healed flexor tendon to active flexion, passive work of flexion, thereby minimizing stress on the repaired
tendon, when active motion is initiated immediately after

repair. The therapist does this by minimizing edema and Immediate Active-Flexion Guidelines
joint stiffness and using optimal joint positions that mini- Phase I (Early)
mize the amount of tension developed within the tendon TIME: 0 to 4 or 5 weeks
during active flexion.22 Studies have shown that the wrist GOALS: Attain full passive flexion, ability to actively
position that results in the least tension within the flexor hold the fingers in a light fist, minimize edema,
tendon during active flexion is partial wrist extension and protect flexor tendon from rupture with splinting
MP flexion.36 and patient education, attain full UE motion
When the wrist is flexed, an increased amount of work proximal to the wrist (Table 11-7)
is required by the flexor muscles to flex the fingers, com-
pared with when the wrist is slightly extended. By placing Splinting. A large variety of splints have been developed
the wrist in slight extension, the extensor tendons are to apply when the patient is placed in an immediate active-
given slack at the wrist, allowing the fingers to relax into flexion approach. The splint design was changed to bring the
partial flexion. It requires only a slight pull by the muscle to wrist into an optimal position, as described previously,
further flex the digits actively into a light fist. Thus most during the exercises that are done at home. The wrist posi-
immediate active-flexion protocols use a position of wrist tion in the traditional protocols (immobilization and passive-
neutral to slightly extended during the active-flexion exer- flexion protocols) was that of flexion to place slack in the
cises, and avoid active digit flexion with the wrist flexed. repaired flexor tendon and prevent tension on the tendon at
Attaining the end ranges of active flexion also significantly rest. During active digit flexion, however, the wrist is better
increases tension within the flexor tendon, and achieving a placed in a position of slight extension, as described earlier,
light fist with at least 45 of DIP flexion is the main goal in to prevent excessive tension within the tendon during active
the early phase of tendon healing. More than 45 of DIP flexion. A few of the most commonly used splints will be
flexion is allowed if attained easily by the patient, without described; however, additional options are sure to exist
excessive effort, when the surgeon has performed a four- because splinting and guidelines are evolving constantly.
strand (or more) repair. Education of the patient placed in The Indiana protocol uses a wrist hinge splint that allows
this protocol is very important because those patients that 30 of wrist extension and full wrist flexion, applied for exer-
attempt to do more than allowed are much more likely to cises only (Fig. 11-13, A and B).7,8,20,21 A static dorsal blocking
rupture. splint with the wrist and MPs flexed is worn at all times
TABLE 11-7 Flexor Tendon Repair in the Digit (Immediate Active-Flexion Approach)
Anticipated Impairments
Rehabilitation Criteria to Progress to and Functional
Phase I Repair technique of Edema Postoperative splint fabrication Protect tendon repair Prevent compromise of
0-4 wk adequate strength to Pain (see text for options) Prevent infection tendon repair
tolerate immediate active Limited range of motion Inspect surgical site for Decrease pain and Promote wound healing
motion approach Unable to grip, pinch, lift, drainage, erythema edema to moderate or Manage pain and
Postoperative and cleared or carry objects Pain assessment less edema
by physician to initiate Edema assessment and early Full AROM of shoulder Prevent proximal joint
therapy with immediate edema control and elbow stiffness
active motion approach AROM exercises for the shoulder Full passive flexion and Prevent joint stiffness
and elbow IP extension and flexion contractures
Passive flexion all finger joints Ability to actively hold Minimize resistance to
Active IP extension with MPs the fingers in 75 MP, tendon gliding
flexed 75 PIP, and 45 DIP Initiate active tendon
Place-active hold flexion of flexion or more gliding
fingers with wrist neutral or Patient to understand Minimize tendinous
extended 20-30 tendon repair adhesions
Patient/family education precautions and home
regarding tendon precautions exercise program
and home exercise program
AROM, Active range of motion; DIP, distal interphalangeal; IP, interphalangeal; MP, metacarpophalangeal; PIP, proximal interphalangeal.
palm is initiated. Active extension of the IP joints is per-

formed fully unless a digital nerve has been repaired (Fig.
11-14, B). The active-flexion portion of the exercises is per-
formed with place-active hold in flexion of the fingers. This
is performed by gently, passively flexing the fingers to the
palm using the patients other hand or the therapists hand.
After placing the fingers into gentle flexion, the other hand
is removed, while the patient actively holds the fingers of the
A injured hand in a fist (Fig. 11-14, C and D). In therapy, this
is done with the wrist extended 30 to decrease tension in
the extensor tendons during the place-active hold flexion. It
is important to attain DIP flexion during this exercise to
ensure FDP gliding. The patient should not place pressure
on the palm or squeeze the palm with any fingertips to
avoid increasing tension within the tendon. The place-
active hold flexion portion of the exercise is the main
B difference between the immediate active and immediate
Fig. 11-13 The wrist hinge splint, designed at the Indiana Hand Center, passive-flexion guidelines. When the patient is successful in
allows 30 wrist extension while performing place-hold flexion (A) and maintaining the actively flexed position of the digits without
wrist flexion with IP extension (B). (From Cannon N: Post flexor tendon the repaired digit being trapped or overly supported by the
repair motion protocol. Indiana Hand Center Newsl 1:13, 1993.) adjacent digit, proximal gliding of the repaired tendon
through the pulley system and the area of surgery has been
between the active exercises in the early phase of tendon achieved. This place-active hold exercise of the digits is
healing. This requires that the patient be trusted to change important to obtain within the first 5 days after surgery, or
splints at home for exercises without inadvertent stretch flexor tendon adhesions are much more likely to limit the
applied to the tendon, or use of the hand while the splint is ability to gain full active flexion at a later time. When active
removed. The wrist hinge splint, worn for exercises, maxi- flexion and passive flexion are nearly equal, it indicates good
mizes use of the wrist tenodesis exercises and ideal wrist to excellent flexor tendon gliding. If good flexor tendon
position of partial extension during active flexion of the gliding occurs, the patient is continued in this phase longer
fingers. than 6 weeks because increased tension within the well-
Silfverskiold and May32 use a cast (with the wrist neutral) gliding tendon is more likely to cause a rupture than in the
that is worn at all times, for both exercises and at rest between adherent tendon (where the tendon is supported by the sur-
exercises. Elastic traction is applied to all four fingers regard- rounding scar tissue). If IP flexion contractures develop,
less of the number of injured fingers, and the elastic traction passive PIP extension may be performed with the wrist and
is removed or loosened for the active-flexion exercises. This MP supported in flexion, as described in the previous discus-
concept eliminates the need for the patient to change splints sion of passive IP extension exercises. Avoid passively
at home, yet achieves the need to bring the wrist out of the extending the DIP joint while performing passive PIP
flexed position for exercises. This author has used this wrist- extension in the early phase of tendon healing. Goals in
neutral concept for both splinting and home exercises.31 The the early phase of an immediate active-flexion rehabilitation
authors preferred splint is a dorsal blocking splint with the program include attaining full passive flexion, ability to
wrist in neutral, MP joints flexed to 50, and the IP joints actively hold in a light fist including at least 75 of PIP and
allowed full extension unless a digital nerve has been 45 of DIP flexion, full PIP and DIP extension, edema
repaired. The use of elastic traction with this splint is optional. control, protecting the flexor tendon from rupture with
If IP flexion contractures begin, the fingers may be strapped appropriate splinting and patient education, and attaining
to the dorsal hood of the splint between exercises. If elastic full UE motion proximal to the wrist.
traction is used, it is applied to all four fingers (or if the
thumb flexor tendon was repaired, then elastic traction is Phase II (Intermediate)
applied to the tip of the thumb only), through a palmar TIME: 4 to 5 weeks to 8 weeks
pulley, attached on the proximal strap of the forearm GOALS: Attain full passive and active flexion and full
(Fig. 11-14, A). The splint is not allowed to be removed at finger extension, prevent intrinsic tightness, protect
home by the patient in the early phase of tendon healing, but the repaired flexor tendon from rupture with
it is removed in therapy for splint and skin cleansing, assess- splinting between exercises and patient education
ment of skin for pressure areas, and exercises as follows. (Table 11-8)
Exercises. Exercises should be performed in therapy and Exercises. The splint is removed at home for bathing and
at home, 10 repetitions every hour. The splint is worn at all exercises. If elastic traction was used in the early phase, it is
times except in therapy. Passive flexion of the digits to the discontinued at this time and the static splint is worn between
A B
C D
Fig. 11-14 Wrist-neutral dorsal blocking splint with elastic traction used in an immediate active-flexion protocol. Elastic traction is applied to all fingertips
between exercises in this option (A). Exercises consist of active extension to the hood of the splint with elastic traction released (B) and place-active hold in
flexion (C and D). The fingers are gently placed in flexion with the other hand and actively held in flexion when the supporting hand is removed. This requires
proximal gliding of the flexor tendon, minimizing potential adhesions in the early phase of healing in an immediate active-flexion protocol after a four-strand
or stronger repair technique. (Courtesy Linda Klein.)
Anticipated
Phase II No signs of Edema and pain Remove splint at home for Full passive flexion of all Maintain/improve
4-8 wk infection Limited range of exercises and bathing joints joint mobility
No significant motion Passive flexion, active IP extension Full active extension of all Manage edema and
increase in pain Limited strength Passive IP extension in presence digit joints with wrist flexed pain
Intact tendon Unable to grip, of flexion contracture Functional active digit Minimize resistance
Compliant with pinch, lift, or carry Modalitiesheat for stiffness and flexion with wrist extended to tendon gliding
splinting, home objects pain as needed Reduce tendon adhesions, if Prevent peritendinous
exercises, and Wrist tenodesis exercises: active present adhesions
precautions finger flexion with wrist extended; Decrease edema Maintain/improve
finger extension with wrist flexed Reduce scar thickness tendon gliding
Edema control with light Independent home exercise Prevent compromise
compressive wraps as needed program of tendon repair
Scar massage/night pad as Patient/family to
needed understand tendon repair
Patient education regarding precautions
precautions and tendon healing Prevent tendon rupture
IP, Interphalangeal.
exercises to protect the patient against inadvertent resistance tendon from rupture with appropriate splinting between
to the well-gliding tendon. Exercises continue as in the early exercises and patient education.
phase, with the addition of removing the splint to perform
active motion with wrist tenodesis as described below. Phase III (Late)
During this phase the patient gradually brings the wrist to TIME: 8 to 14 weeks
neutral with the fingers extended. In therapy, gentle intrinsic GOALS: Full active flexion and extension of the fingers,
stretch is performed by the therapist with the wrist flexed, prevent or minimize intrinsic tightness, prevent
MPs gently, passively extended while the IPs are held flexed. flexor tendon from rupture with splinting during
Active finger flexion is added during this phase, but no resistive activities and patient education (Table 11-9)
resistance is allowed. Wrist tenodesis exercises are per-
formed, allowing wrist extension as tolerated with the fingers The splint is removed except for activities that require
in flexion and wrist flexion with the fingers extended. Some pinching, lifting, or strong grip. Resistance to DIP flexion
protocols discontinue the protective splint in the intermedi- (e.g., hook grasp with resistance or squeezing with the tips
ate phase; however, with a well-gliding flexor tendon, it is of the fingers) is prohibited until after 12 weeks in the case
possible to rupture the repaired tendon when resistance is of a well-gliding flexor tendon that demonstrates flexion in
encountered during normal daily activities. Most patients are the good to excellent range according to the Strickland-
not able to predetermine how much resistance each activity Glogovac formula.27
they perform with the hand will cause, and this author A small hand-based dorsal blocking splint is used to
prefers to continue splinting during the intermediate prevent the patient from performing this type of activity
phase unless flexor tendon adhesions are present. If flexor while at work or during heavier home management tasks.
tendon adhesions limit active flexion more than passive Active and passive flexion and extension of the fingers is
flexion, then blocking exercises are initiated. If IP extension performed with the splint off. If flexor tendon adhesions are
is limited, then passive IP extension is performed with the present (active flexion more limited than passive flexion),
wrist and MPs held in flexion. Goals in the intermediate blocking exercises continue and resistance may be added,
phase of the immediate active-flexion guideline include full consisting of light gripping. At 12 weeks after surgery, the
passive and active flexion, full composite finger extension, patient is released to normal activities and instructed to avoid
preventing intrinsic tightness, and protecting the flexor maximal resistive activities for another 2 weeks, gradually
Anticipated
Impairments and
Rehabilitation Criteria to Progress Functional
Phase to This Phase Limitations Intervention Goal Rationale
Phase III Good progression/ Decrease in pain Adjust splint to free wrist, use at work Full PROM, AROM of Promote restoration
8-14 wk tolerance of PROM and edema and at night, to avoid strong use of fingers or thumb of full joint mobility
and AROM Minimally limited injured hand Pain-free motion Pain and edema
No significant range of motion Passive finger or thumb flexion Increase strength to management
increase in pain Limited strength Passive IP extension in the presence of facilitate light use Maintain/improve
Intact tendon Limited ability to contractures Decrease thickness tendon gliding
Compliance with grip, pinch, lift, or Composite active digit extension and firmness of scar Promote functional
home exercises and carry objects Full active flexion of fingers or thumb Minimal edema by use of the injured
precautions Modalitiesheat for stiffness and pain 12 wk hand
as needed Independent home Prevent compromise
Blocking, tendon gliding if adhesions exercises of tendon repair
limit active motion Prevent tendon
Gentle passive intrinsic stretch rupture
Light strengthening exercises only if Functional use of
adhesions are present before 12 wk; injured hand
gradual, progressive strengthening after
12 wk
Scar massage, scar pads at night
Edema control/light compressive wrap
AROM, Active range of motion; IP, interphalangeal; PROM, passive range of motion.
increasing tolerance to normal activities. Goals in the late which is

phase of the immediate active motion approach include full
(120 15) 175 100% = 60%
active flexion and extension of the fingers, prevention of
intrinsic tightness, and light functional use of the hand. Pre- Sixty percent would be classified as a fair result according
vention of flexor tendon rupture with appropriate splint- to this classification. MP motion is not used in this formula
ing during tip pinch, strong grip and hook fist, or lifting because it is infrequently affected by tendon repairs in zones
activities, as well as patient education, is emphasized. I or II. Results in the good and excellent categories are con-
Regaining full grip, pinch, and full UE strength is appropriate sidered functional, without need for further intervention.
after the 12- to 14-week flexor tendon healing process Fair and poor results may need further surgery or therapeu-
(through traditional strengthening exercises and activities). tic intervention to regain function of the hand, depending
on individual patient needs for ADLs and work.
REPAIRS IN ZONES PROXIMAL TO ZONE II
SUMMARY
The question often arises regarding guidelines for flexor
tendon repairs in other zones of the hand and distal forearm. The amount of information available regarding flexor tendon
This author uses the same guidelines described previously rehabilitation is overwhelming, and the task of determining
for all zones. Less complications of flexor tendon adhesions what approach to use for which patient is daunting. Patient and
occur when the tendons are repaired in the midpalm, where injury variables require the therapist to be aware of immobili-
no tight pulley system and synovial sheath is found in which zation, immediate passive flexion, and immediate active-
to become adherent. At the wrist and distal forearm, however, flexion guidelines for treatment of a flexor tendon repair.
there remains the problem of adhesions to the flexor reti- Within each hand treatment facility, it is typical to use one
naculum and the carpal tunnel. These areas respond more approach from the immediate passive-flexion group and one
easily to efforts at regaining tendon gliding in the intermedi- approach from the immediate active-flexion group for most
ate and late phases of tendon healing and rehabilitation than patients. Then, depending on the type of surgical repair, the
does the digit. When the repair is anywhere other than the recommendation of the surgeon and patient compliance,
digit itself, IP flexion contractures are much less common. placement of the patient within immediate passive- or imme-
diate active-flexion approach is less complex. It is good,
EVALUATING THE RESULTS OF A FLEXOR however, to be familiar with other options, because some
TENDON REPAIR patients will do better with elastic traction than others. Most of
this authors patients are placed in the immediate active flexion
Adding flexion of the IP joints and subtracting any loss of with elastic traction program as described previously, because
extension is the method used to evaluate the motion of a the referring surgeons are all performing four-strand repairs of
finger in which a flexor tendon has been repaired in the the flexor tendon. If IP flexion contractures develop, the
hand. Although a number of formulas exist, Strickland and program is changed to eliminate the elastic traction or instruct
Glogovacs following formula27 is commonly used. the patient to intermittently strap the IPs in extension to the
dorsal hood of the splint (as done at night) during the day.
{(PIP + DIP flexion) (loss of PIP extension +
For those therapists whose patients have traditional two-
loss of DIP extension)} 175 100 = % of normal
strand flexor tendon repairs, it is important to choose from
To clarify the formula, add PIP flexion + DIP flexion the passive-flexion guidelines. If active flexion is performed
(measured in full-fist composite flexion). From this total, with these patients in the early phase, then it is done very
subtract any loss of extension of the PIP and DIP joints, gently through partial range of flexion (and only under the
measured in full composite extension. Divide the result by supervision of the therapist).22
175, and multiply by 100 to determine the percent of normal It is important to keep in mind the occasional need to
motion. The normal amount of PIP and DIP flexion is 175, place a patient in an immobilization approach, as well. Indi-
and zero is the normal loss of extension of the IP joints. Thus vidualization of each of the guidelines is necessary. A young
if the total active PIP and DIP flexion equals 175 and no child may not advance as quickly as the immobilization
loss of extension of the IP joints occurs, then the patient guideline described in this chapter indicates. Discussion with
would have 100% of motion after the flexor tendon repair. the referring surgeon is necessary at each advancement point.
Classification includes excellent results as 85% to 100%, Understanding the concepts of flexor tendon healing in
good as 70% to 84%, fair as 50% to 69%, and poor as less the hand and the tensile strengths of the healing tendon
than 50% of normal motion. compared with tension demands of motion and use is impor-
An example is a patient whose final composite motion tant. Education of the patient regarding importance of com-
measurements are MP 0 to 85, PIP 10 loss of extension to pliance with the instructions within the guidelines and the
80 of flexion, and DIP 5 loss of extension to 40 of flexion. type of activity that is likely to result in rupture is important.
The formula applied would be as follows: Study of literature and supervised experience in treating
patients with this diagnosis is strongly recommended when-
{(80 + 40) (10 + 5)} 175 100% ever possible.
1 A new patient is scheduled for splint fabrication, evalu-

ation, and treatment after repair of flexor tendons. No
further information is available on the prescription.
allowed to be in an immediate active approach, then
the position of active hold in flexion can only
improve as passive flexion improves.
What steps should the therapist take before beginning This patient may be best placed in an elastic traction
the first session? approach between exercises because the elastic traction
will hold the digits in flexion at a tolerable level, gradu-
The therapist should contact the physician to determine ally increasing flexion as resistance of the tissue
the following: decreases. The next session should be scheduled for the
The type of repair performed (to determine whether next day because the patient is usually feeling better and
immediate passive- or immediate active-flexion can tolerate motion and better understand directions. If
approaches should be considered) the pain level continues to significantly limit the initial
The surgeons preference of elastic traction or static exercises, then the therapist may perform slow, gentle
IP positioning in the splint passive flexion to demonstrate the methods to be used
If the surgeon is not available, the therapist should begin at home. Ongoing frequent therapy visits may be needed
an immediate passive-flexion approach. If passive flexion in the early phase of tendon healing if improvement is
is limited, then therapy should begin with the elastic not seen quickly.
traction splint. If passive flexion is 50% or better, then
the therapist may consider the static IP positioning splint.
3 A patient had flexor tendons repaired in a digit 3 weeks
ago. During active IP extension exercises, the patient is
2 A new patient is being seen for the first time in therapy

after repair of both flexor tendons at the level of the
proximal phalanx of a single digit. During the initial
lacking 30 of PIP extension and 10 of DIP extension.
What steps can be taken to improve IP extension?
visit, the patient begins to sweat, becomes light-headed, In therapy, gentle PIP joint mobilization (i.e., accessory
and has significant pain with gentle passive flexion. The glides and gentle passive PIP extension) can be consid-
patient is unable to tolerate more than 30 of passive ered with the flexor tendon in the protected position of
flexion at each of the IP joints of the injured finger. What full wrist and MP flexion. The patient must be relaxed,
can the therapist do to maximize tendon gliding with no tension in the flexor tendons during the passive
and joint motion within the first week after surgery in flexion, to avoid resisting the repaired flexor tendons.
the immediate passive- or immediate active-flexion The therapist should emphasize the IP extension
approaches? portion of the home exercise program. Full passive MP
flexion assists IP extension. The patient should be
This patient is likely to have significant difficulty because instructed to passively flex the MP joint of the involved
of stiffness and adhesions unless he or she becomes finger fully using the other hand while actively extending
more comfortable with passive motion of the digit within the IP joints. A dynamic IP extension splint should not
a few days. The patients understanding of the cause of be considered in this early phase of flexor tendon healing.
the pain and what to expect in the next few days is
crucial at this point. A reassuring, gentle approach at the
first appointment is important. The therapist should
emphasize the following points:
4 A patient had both flexor tendons repaired 5 weeks ago
and has been advanced to the intermediate phase of an
immediate passive approach, including gentle active
Most of the initial pain is related to a fresh incision, motion. At this appointment, the patient shows a sudden
and swollen and sore joints need to be moved. decrease in active DIP flexion compared with the previ-
Although the digit is very painful during the first ous session, with only trace to no visible active flexion
attempts at motion, if performed to a tolerable level noted by the therapist. What should the therapist
on a frequent basis (every 1 1 2 to 2 hours), then the consider?
pain usually becomes minimal within a few days.
The finger motion may be permanently limited to the Whenever a sudden complete loss of flexion of the DIP
level of motion that is achieved within the first 1 or 2 joint occurs, a rupture of the FDP tendon must be con-
weeks because adhesions develop within this time. sidered. The therapist should have the patient make an
Explaining how a tendon glides and the way in which appointment with the referring surgeon as soon as
adhesions can limit this gliding helps motivate the possible because some surgeons consider immediate
patient to passively flex the digit to full tolerance. If repair. Other surgeons wait for maturation of the healing
process and consider later tendon grafting if a rupture The wrist and distal strap of the splint can be opened,
occurs. The therapist should discuss the patients activity allowing the wrist to flex and the fingers to relax. The
level to determine if he or she has used the hand actively, assisting individual may then apply the wrap to the
which would place the patient at risk for rupture. The swollen fingers lightly, not tight enough to decrease cir-
therapist should check tendon integrity by blocking the culation. The wrap is removed during the day to avoid
PIP joint in extension while the patient attempts to increasing resistance to flexion during exercises.
actively flex the DIP joint. Any active DIP flexion indicates
that the FDP tendon is intact.
7 My patient has very good ability to place and actively
hold the fingers in flexion. Can I advance them to the
5 A patient had flexor tendon repair 7 weeks ago. The

finger has 30 active DIP flexion when the PIP is blocked
in extension by the therapist but no active DIP flexion
next phase of rehabilitation and initiate strengthening?
No. When a repaired flexor tendon is gliding without the

when all finger joints are flexed into a fist. What does restriction of adhesions, the tendon repair will be more
this mean? strained by the resistance than a tendon that has the
additional support of adhesions. The better the tendon
The FDP tendon has adhesions. When the finger is held excursion (better active flexion of the IP joints), the
in extension at the MP and PIP joints, it takes only a small more protective the therapist is regarding advancement
amount of glide of the FDP tendon to result in partial DIP to resistance to avoid increasing tension across the
joint flexion. However, when the MP and PIP joints are repair, which may result in rupture. The patient should
flexed, such as in a composite fist, the FDP tendon must continue passive flexion, place-active hold flexion, and
glide much further to pick up the slack created in the advance to active flexion with the splint off at the appro-
tendon by flexion of the first two joints of the finger priate times according to the approach used, but avoid
before it can then flex the DIP joint. Adhesions limit full resistance until the tendon is fully healed when good
gliding of the tendon. The therapist should consider active flexion is present. Resistance is used to improve
increasing the exercises of blocking, gradually increas- tendon excursion in the presence of restricting
ing the amount of flexion at which the MP and PIP joints adhesions.
are blocked. The surgeon should be contacted to discuss
the potential of adding ultrasound or light resistance to
minimize adhesions. 8 Six weeks after surgical repair of a ring finger FDP, a
patient demonstrates active flexion of 80 MP, 80 PIP,
and 15 DIP. The uninjured small finger has normal
6 My patient has more than the expected amount of swell-

ing 2 weeks after surgery. Is there anything I can apply
at this early stage to decrease swelling in the involved
passive flexion; however, active flexion is limited to 90
MP, 80 PIP, and 25 DIP flexion. Why would active
flexion of an uninjured finger be limited?
fingers?
This is a good example of quadriga effect. When the
Elevation, overhead shoulder pumping, and light edema FDP tendon of one finger is not gliding proximally as in
massage proximal to the splint can be performed early this example, the adjacent digit(s) may demonstrate
after repair in all cases. In situations where there is limited active gliding of the FDP as well because of the
excessive swelling, once wounds are healed, the patient common muscle belly. When one flexor tendon is teth-
can be instructed in the application of a light compres- ered by a scar in the finger, the other flexor tendons are
sive wrap at night only, with the help of another person. unable to be fully pulled proximally by the muscle.
REFERENCES 6. Schuind F, et al: Flexor tendon forces: in vivo measurements, J Hand

1. Bunnell S: Repair of tendons in the fingers and description of two new Surg 17A(2):291-298, 1992.
instruments, Surg Gynecol Obstet 26:103-110, 1918. 7. Strickland JW: Development of flexor tendon surgery: Twenty-five years
2. Kessler I, Nissim F: Primary repair without immobilization of flexor of progress, J Hand Surg 25A:214-235, 2000.
tendon division within the digital sheath: An experimental and clinical 8. Strickland JW, Cannon NM: Flexor tendon repairIndiana method,
study, Acta Orthop Scand 40:587-601, 1969. Indiana Hand Center Newsl 1:1-12, 1993.
3. Kleinert HE, et al: Primary repair of lacerated flexor tendons in no 9. Shaieb MD, Singer DI: Tensile strengths of various suture techniques,
mans land, J Bone Joint Surg 49:577, 1967. J Hand Surg 22B(6):764-767, 1997.
4. Verdan CE: Practical considerations for primary and secondary 10. Joyce ME, Lou J, Manske PR: Tendon healing: Molecular and cellular
repair in flexor tendon injuries, Surg Clin North Am 44:951-970, regulation. In Hunter JM, Schneider LH, Mackin EJ, editors: Tendon
1964 and nerve surgery in the hand: A third decade, St Louis, 1997,
5. Powell ES, Trail IA: Forces transmitted along human flexor tendons Mosby.
during passive and active movements of the fingers, J Hand Surg 11. Moran S, et al: Effects of 5-fluorouracil on flexor tendon repair, J Hand
29B:386-389, 2004. Surg 25A(2):242-251, 2000.
12. Thomopoulos S, Das R, Silva MJ, et al: Enhanced flexor tendon healing 25. Pettengill K, van Strien G: Postoperative management of flexor tendon
through controlled delivery of PDGF-BB, J Orthop Res 27(9):1209- injuries. In Skirven TM, et al, editors: Rehabilitation of the hand and
1215, 2009 upper extremity, ed 6, Philadelphia, 2011, Mosby.
13. Zhao C, Zobitz ME, et al: Surface treatment with 5-fluorouracil after 26. Duran RJ, et al: Management of flexor tendon lacerations in zone 2 using
flexor tendon repair in a canine in vivo model, J Bone Joint Surg Am controlled passive motion postoperatively. In Hunter JM, et al, editors:
91(11):2673-2682, 2009. Rehabilitation of the hand, ed 3, St Louis, 1990, Mosby.
14. Kobayashi M, Oka M, Toguchida J: Development of polyvinyl alcohol- 27. Strickland JW, Glogovac SV: Digital function following flexor tendon
hydroget (PV-H) shields with a high water content for tendon injury repair in zone II: A comparison of immobilization and controlled
repair, J Hand Surg 26B(5):436-440, 2001. passive motion techniques, J Hand Surg 5:537-543, 1980.
15. Skoog T, Persson B: An experimental study of the early healing of 28. Dovelle S, Kulis Heeter P: The Washington regimen: Rehabilitation of
tendons, Scand J Plast Reconstr Surg 13:384-399, 1954. the hand following flexor tendon injuries, Phys Ther 69:1034-1040,
16. Silfverskiold KL, May EJ, Tornvall AH: Flexor digitorum profundus 1989.
tendon excursions during controlled motion after flexor tendon 29. Chow JA, et al: A splint for controlled active motion after flexor tendon
repair in zone II: A prospective clinical study, J Hand Surg 17A:122-133, repair: Design, mechanical testing and preliminary clinical results,
1992. J Hand Surg 15A:645-651, 1990.
17. Becker H, et al: Intrinsic tendon cell proliferation in tissue culture, 30. Pettengill KM: The evolution of early mobilization of the repaired flexor
J Hand Surg 6:616-619, 1981. tendon, J Hand Ther 18(2):157-168, 2005.
18. Lundborg G, Rank F: Experimental intrinsic healing of flexor tendons 31. Klein L: Early active motion flexor tendon protocol using one splint,
based upon synovial fluid nutrition, J Hand Surg 3(1)3:21-31, 1978. J Hand Ther 16(3):199-206, 2003.
19. Manske PR, Lesker PA: Biochemical evidence of flexor tendon participa- 32. Silfverskiold KL, May EJ: Flexor tendon repair in zone II with a new
tion in the repair process: An in vitro study, J Hand Surg suture technique and an early mobilization program combining passive
9B(2):117-120,1984. and active flexion, J Hand Surg 19(1):53-63, 1994.
20. Strickland JW: The scientific basis for advances in flexor tendon surgery, 33. Trumble TE, Vedder NB, Seiler JG, III, et al: Zone-II flexor tendon
J Hand Ther 18(2):94-110, 2005. repair: A randomized prospective trial of active place-and-hold therapy
21. Strickland JW: Flexor tendons: Acute injuries. In Green DP, Hotchkiss compared with passive motion therapy, J Bone Joint Surg Am 92(6):1381-
RN, Pederson WC, editors: Greens operative hand surgery, ed 4, vol 2, 1389, 2010.
Philadelphia, 1999, Churchill Livingstone. 34. Halikis MN, et al: Effect of immobilization, immediate mobilization,
22. Evans RB, Thompson DE: The application of force to the healing tendon, and delayed mobilization on the resistance to digital flexion using a
J Hand Ther 6:266-284, 1993. tendon injury model, J Hand Surg 22A:464-472, 1997.
23. Sueoka SS, Lastayo PC: Zone II flexor tendon rehabilitation: A proposed 35. Amadio PC: Friction of the gliding surface: Implications for tendon
algorithm, J Hand Ther 21(4):410-413, 2008. surgery and rehabilitation, J Hand Ther 18(2):112-127, 2005.
24. Cifaldi Collins D, Schwarze L: Early progressive resistance following 36. Savage R: The influence of wrist position on the minimum force required
immobilization of flexor tendon repairs, J Hand Ther 4:111-116, for active movement of the interphalangeal joints, J Hand Surg 13B:262-
1991. 268, 1988.
CHAPTER12
Carpal Tunnel Release
Linda de Haas, Diane Coker, Kyle Coker
C
arpal tunnel syndrome (CTS) continues to be one of injuries.1 These traumas produce a sudden and sustained
the most significant upper extremity (UE) injuries, increase in interstitial pressure within the carpal tunnel,
with more than 500,000 procedures performed each resulting in a median nerve conduction block from intra-
year.1 It results from compression of the median nerve as it compartmental and intraneural ischemia. This form of CTS
crosses the wrist and is characterized by numbness, tingling, is a medical emergency and requires immediate carpal
pain, and complaints of weakness in the hand. The symp- tunnel decompression.
toms of CTS can range from mild to severe. They may have Chronic CTS is the result of an insidious rise of the inter-
far-reaching effects on a persons job, hobbies, and activities stitial pressure in the carpal tunnel and is classified as early,
of daily living (ADL).2 intermediate, or advanced. Patients with early CTS experi-
CTS is also the most common entrapment neuropathy of ence mild, intermittent symptoms that have been present less
the UE.1 Paget described the complex of symptoms caused than 1 year. Intermediate CTS is characterized by more con-
by median nerve entrapment at the wrist in 1854, and stant symptoms, including numbness and paresthesia,
Moersch gave the syndrome its name in 1938. Brain, Wright, usually worse at night, with little or no atrophy of the thenar
and Wilkerson published the first series of carpal tunnel muscles. Surgery performed at this time uncovers a nerve
releases by division of the transverse carpal ligament (TCL) that has undergone chronic changes, including epineural
in 1947. Since that time, a number of variations of this pro- and intrafascicular edema. If decompression is performed at
cedure have been developed, all of which involve division of this time, then the neural changes are frequently reversible,
the TCL. although night symptoms may take a year to resolve.
The prevalence in the United States of self-reported CTS Advanced CTS is characterized by progressive paresthesia,
is approximately 1 to 3 cases per 1000 subjects per year in atrophy of the thenar muscles, and pinch and grip weakness.
the adult (working and nonworking) population.3-5 CTS Even after a successful surgical decompression, the chronic
affects people during their most productive years. Its preva- changes in the median nerve may be permanent.9
lence peaks between the ages of 35 and 44 years for both men CTS can affect anyone, although females tend to have a
and women. Women are three times more likely to be higher incidence. Medical and ergonomic histories have
affected than men.6 been identified as independent risk factors in developing
The Bureau of Labor Statistics tracks CTS under work- CTS, although controversy exists as to the contribution of
related musculoskeletal disorders. In 2008, 3.1% of 384,480 work activities to the development of CTS.10-12 Recent studies
musculoskeletal disorders were CTS cases.7,8 These data have looked at obesity as defined by body mass index; other
demonstrate the importance of clinicians fully understand- biologic factors, such as genetics or structural make-up; and
ing the prevention and treatment of CTS. wrist anthropometrics as possible contributing factors.13-18
There are some strong associations between CTS and age,
SURGICAL INDICATIONS AND gender, and female hormonal status as seen, for instance,
CONSIDERATIONS during menopause or pregnancy.12 Pregnancy can precipitate
CTS by causing edema around the structures traversing the
Causes carpal canal. During pregnancy the symptoms of CTS tend
The onset of CTS can be classified into two categories: (1) to occur in the last trimester, secondary to fluid retention.
acute and (2) chronic. Acute CTS is associated with a trau- The condition usually resolves within 6 to 12 weeks after
matic event, such as blunt trauma to the wrist, wrist fracture, delivery.9
infections, vascular disorders, rheumatologic disorders, CTS can also be associated with a number of other disease
hemorrhagic problems, burns, and high pressure injection processes, including thyroid disease, rheumatoid arthritis,
216
Chapter12 Carpal Tunnel Release 217
and diabetes, as well as with various anatomic anomalies The best evidence-based conservative physical therapy
such as a persistent median artery, median nerve variations, treatments for CTS include splinting, deep pulsed ultra-
extramuscle bellies, and extratendinous slips.15,18-20 Tumors sound (US), nerve-gliding exercises, carpal bone mobiliza-
and ganglions of the wrist, although rare, can precipitate CTS tion, and yoga.26,28 Splinting the patients wrist can be very
as the lesion occupies space within the carpal canal.21 Wrist helpful in controlling nighttime pain symptoms.29 The wrist
trauma can cause CTS because of the resulting edema and is splinted in a neutral position that maximizes the carpal
hematoma surrounding the median nerve. Variations in tunnel space30 and minimizes the carpal tunnel pressure.31
lumbrical origin, length, or width can increase carpal tunnel The splint is chosen based on the patients needs and comfort.
pressure as dynamic lumbrical incursion into the CT can The metal stay of a prefabricated wrist splint is easily replaced
occur during finger flexion movements.22 with a custom-molded thermoplastic stay to position the
From the ergonomic side, CTS is often seen in patients wrist in neutral. A positive Berger test (the patient holds a
who perform repetitive activities in their work or hobbies. full fist position for 30 to 40 seconds, with a positive test
One study of computer workers demonstrated that the angle reproducing paresthesia) result would suggest that the meta-
of wrist extension (more than 20) was associated with devel- carpal phalangeal joints should also be immobilized in the
oping CTS.23 splint, as the lumbricals can descend into the carpal tunnel
The diagnosis of CTS can usually be made based on a with active finger flexion and cause further space compro-
thorough history and careful physical examination. In cases mise of the carpal tunnel contents.10,32 All patients should
in which the diagnosis is uncertain, electrodiagnostic studies sleep in their splints. Patients who have constant or activity-
can be helpful in either confirming or ruling out the induced paresthesia may also wear their splints during the
disorder.24 day.30 When such conservative measures fail to resolve symp-
In general, patients who are diagnosed with early stage toms, surgery is indicated.
CTS are initially treated without surgery. Nonsteroidal anti- Classic CTS symptoms include the following5:
inflammatory drugs, although often prescribed, have not 1. Numbness and tingling in the median nerve distribu-
been shown to be effective in any controlled study to date25,26 tion in the hand
In some patients with recently developed CTS (less than 1 2. Nocturnal paresthesia
year), local injection of steroid medication into the carpal 3. Clumsiness/weakness of the hand
canal or oral steroids can significantly, although temporarily, 4. Weakness/atrophy in the thenar musculature (late
reduce the symptoms of median nerve compression (Fig. finding)
12-1). It has not been shown that a steroid injection can Sensory changes are commonly the first symptoms noted.
actually alter the progression of the disorder.5,27 The patient typically reports paresthesia and numbness of
the digits served by the sensory branches of the median
nerve and in the tips of the thumb, index finger, middle
finger, and radial half of the ring finger, although both sides
of the ring finger can be affected. Sensory symptoms may
also be restricted to a single digit, or even involve the entire
hand.1 Sensibility in the thenar eminence is usually unaf-
fected as this area is innervated by the palmar cutaneous
branch of the median nerve, which branches proximal to the
carpal tunnel, entering the hand volar to the TCL.
The onset of pain is most often the primary reason a
person with chronic CTS seeks medical attention. The pain
associated with CTS tends to begin in the latter aspects of
the early and then into the intermediate stages. The patient
complains of an intermittent, vague, dull aching in the wrist
or forearm. Less common is pain radiating to the elbow and
even the shoulder. Night pain is a common complaint most
likely caused by congestion of the venous system during
sleep.33 Neurologic muscle weakness associated with CTS
occurs late in the disease process. In advanced cases, atrophy
of the thenar musculature can be seen. The unlucky patient
with symptoms progressed to this state is at high risk for
permanent nerve damage and may require a tendon transfer
to substitute for the loss of palmar abduction.
The clinician must be able to visualize the anatomic struc-
tures that make up the carpal tunnel. The carpal canal is
Fig. 12-1 Local injection of a corticosteroid is infiltrated into the carpal bounded by the TCL volarly, the scaphoid tuberosity and the
tunnel through a 25-gauge needle. trapezium radially, the hook of the hamate and the pisiform
ulnarly, and the volar radiocarpal ligament and volar liga-

mentous extensions between the carpal bones dorsally.19,34
The carpal canal is traversed by the median nerve, the four
flexor digitorum profundus tendons, the four flexor digito-
rum superficialis tendons, the flexor pollicis longus tendon,
and the surrounding synovial membranes. Any condition
that causes enlargement of the contents of the carpal canal
(such as inflammation or edema) or occupies space within
the canal (such as a tumor or hematoma) compresses the
median nerve. This occurs because the structures that make
up the carpal canal are relatively inelastic and do not expand
as the contents of the canal enlarge. The resulting pressure
compromises circulation within the substance of the nerve,
leading to nerve ischemia, which in turn leads to the symp-
toms and signs seen in CTS.
SURGICAL PROCEDURE
The surgical treatment for carpal tunnel dates back to the

1940s.35,36
The condition could be thought of as a compartment
syndrome affecting the median nerve within the carpal Fig. 12-2 Exposure of the carpal canal is performed through an incision
canal.37 As such, the intracompartmental pressure surround- represented by the solid line. Dashed lines represent the course of the ulnar
ing the median nerve exceeds the local capillary pressure, artery and its branches (common digital and proper digital arteries) that
must be preserved during exposure.
thus preventing blood flow. Surgical treatment is directed at
increasing the volume of the carpal canal and reducing the
pressure within. Most methods rely on the release of the
TCL, which forms the soft tissue roof of the carpal canal.
There are three general surgical approaches to the release of
the TCL.
The first surgical approach is the classic open technique
in which an incision starting in the proximal third of the
palm is made that extends proximally along the axis of the
ring metacarpal to the wrist flexion crease (Fig. 12-2).
Keeping to the ulnar side of the median nerve reduces the
risk of injury to its motor branch, which will occasionally
arise on the ulnar side of the nerve and cross superficially
over to the thenar muscles. The incision is then continued
proximally across the volar flexion creases in a zigzag fashion
to avoid hypertrophic scarring. The incision is kept to the
ulnar side of the palmaris longus tendon to avoid injury to
the palmar cutaneous nerve. This incision gives complete
exposure to the area of constriction (Figs. 12-3 and 12-4).
The thick portion of the TCL between the trapezium and
scaphoid tubercle radially and the hook of the hamate and
pisiform on the ulnar side is divided under direct vision and
extended to the superficial palmar arch distally and approxi-
mately 4 to 5cm proximal to the volar flexion crease of the
wrist. The advantage of this approach is the direct exposure
to the median nerve along its entire length within the sus-
pected area of constriction. In addition, the contents of the
carpal canal can be thoroughly explored for masses, exces-
sive synovial tissues, and bone spurs. If indicated, synovec-
tomy or tenolysis can be performed. Disadvantages of this
approach include an increased incidence of pillar pain, pro- Fig. 12-3 The transverse carpal ligament has been exposed and is being
longed healing, prolonged weakness of grip because of scar tented proximally and distally by hemostats.
Fig. 12-4 The transverse carpal ligament has been divided, and the con-
tents of the underlying carpal canal are exposed. The median nerve is
demonstrated at the tip of the dissecting scissors.
Fig. 12-5 The image above shows the transverse carpal ligament as seen
tenderness, and destabilization of the flexor tendons and the
from the inside of the carpal canal. The image below shows the initial cut
pulley effect provided by an intact TCL. with the integrated scalpel.
The second and less invasive procedure could be referred
to as a limited open palm technique. By this method a
smaller incision is made in the palm following the same two portals to pass the endoscope and instruments under the
course as the palm segment of the classic open technique but TCL. Agee later introduced a single proximal portal tech-
avoids crossing the volar flexion crease of the wrist. The nique that employed an integrated instrument incorporating
distal portion of the TCL is incised under direct vision and the scope and surgical knife.40 There have since been minor
retractors are used to complete the division proximal to the modifications in technique and instrumentation for Chows
volar flexion crease. With more specialized instruments technique, but the principles remain the same.
and retractors, the palmar incision can be kept quite small. The endoscopic techniques were developed to minimize
The advantage of this procedure is to minimize injury to the recovery and absence from work. To this end the concept has
overlying skin and cutaneous nerves, thus reducing the been successful. Many studies have reported this in both the
chance of a tender scar. Since there is less destabilization of workers compensation population and the nonwork related
the flexor tendons, there is less potential for prolonged weak- groups.39,40 Several studies comparing recovery rates between
ness of grip. The disadvantage of this technique is the limited open carpal tunnel release and ECTR indicate that the
exposure and visualization of potential pathologic condi- advantages of ECTR diminish over time and there is very
tions, such as space occupying lesions within or just proxi- little difference at 3 months follow-up (Fig. 12-5).41
mal to the carpal canal. Surgery for carpal tunnel is not risk free.42 Complications
The third technique is endoscopic carpal tunnel release include:
(ECTR). There are several variations of this technique Injury to the median nerve including the motor branch
including one or two portalseither one proximal to the Injury to the ulnar nerve
wrist crease, one in the mid palm, or both. ECTR was intro- Injury to digital nerves; most often the common digital
duced by Okutsu and Chow in 1989.38,39 Chows technique, nerve to the third web space
which has become popular in the United States, employed Complex regional pain syndrome
Infection widely as much as 1 to 2cm. The limited incision technique

Injury to superficial palmar arch and digital arteries opens to a lesser degree and the ECTR by only a few milli-
Injury to the flexor tendons meters. This latter technique is usually enough to decom-
Lesser complications that usually resolve with time press the median nerve, but there have been reports of both
include: hematoma, wound dehiscence, pillar pain, and early and late failures that were relieved by reoperation using
weakness of grip. the open procedure.
The literature reports an overall higher rate of all of these Early return of symptoms following initial relief might be
complications with the endoscopic technique by a factor of caused by tight bandages or excessive stretch on the nerve
two to four times. However, most of these were reports from from improper splinting, hematoma, or excessive scar tissue.
the early and late 1990s, and although the specific techniques Late recurrences can also result from incomplete or even
were rarely reported, they were probably referring to the full open release if the underlying condition continues to
earlier two portal techniques. There have not been any direct progress. Enlarging masses, trauma, edema, inflammatory
comparisons between the two portal and single portal tech- conditions causing synovitis, or simply the aging process
niques that compare complication rates. might be to blame.
Postoperatively, most surgeons will splint wrists following Residual symptoms following carpal tunnel surgery are
the open technique to allow soft tissue healing and to posi- common, but in one of the authors experience, true recur-
tion the wrist in extension to prevent bowstringing of the rences and failed surgeries are very rare. Although symptoms
flexor tendons, which might push the medial nerve into the of CTS vary depending on the individual, age, and duration
area of the healing TCL. Although this was the early ratio- of symptoms, the most common symptom of carpal tunnel
nale for postoperative splinting, more recent studies have is numbness in the distribution of the median nerve, which
shown splinting to be less important than previously is worse at night. This is usually confirmed by evidence of
believed.43 Wrists are often not splinted following endoscopic significant slowing of the nerve conduction through the
release, although time must still be allowed for internal carpal canal. When patients with residual symptoms are
healing. properly questioned, they usually recall that they did in fact
have relief of their nocturnal numbness following release of
PILLAR PAIN the TCL. This indicates a successful treatment of their CTS;
however, they may still be dissatisfied with the result if they
Pillar pain is cited as a common postoperative complication still have symptoms that brought them to the physician in
and is a frequent reason to send the patient for postoperative the first place. These symptoms might include arm pain, arm
therapy.44 It is described as pain over either the thenar or numbness and tingling, shooting pains into various parts of
hypothenar eminence or both. These areas correspond to the the arm and hands, and weakness. The symptoms might be
scaphoid tubercle and hook of the hamate distally, and tra- reproducible when attempting to perform specific activities,
pezium and pisiform proximally, forming a rectangle. The giving rise to the notion that their condition is a repetitive
three thenar muscles are anchored to the scaphoid tubercle motion injury. In the experience of the authors of this
and trapezium, and the three hypothenar muscles are chapter, the vast majority of these patients are no longer suf-
anchored to the hook of the hamate and pisiform. The TCL fering from CTS but rather have a more proximal nerve
ties the two columns together and acts as a pulley to guide entrapment. There are several potential points of entrapment
the nine flexor tendons. The cause is still unclear, possibly of the median nerve at the elbow, including pronator syn-
because several different symptoms have been called pillar drome. If cervical radiculopathy can be ruled out, the
pain. It is unclear if the pain represents deep scar tissue, problem may be attributed to compression at the level of the
injury to sensory nerves in the TCL, loss of stability of the brachial plexus, the so-called thoracic outlet syndrome. This
attached muscles, or alteration of the carpal arch. Whatever diagnosis is often made by exclusion and then treated with
the cause, there appears to be a lowered incidence with a trial of therapy to address the thoracic outlet. Within a few
ECTR compared with limited open releases, which further weeks the patient will often notice a significant decrease in
improve on the full open incision. In all cases the pain tends pain and an increase in strength.46,47
to resolve in 3 months.44,45
Failed Carpal Tunnel Surgery REHABILITATION
Carpal tunnel surgery is highly successful in relieving the
symptoms caused by compression on the median nerve at Postoperative Rehabilitation
the wrist. Failures can be grouped into two categories: recur- The frequency and duration of treatment is highly variable
rent symptoms and residual symptoms. Both can result from after a carpal tunnel release. In most cases minimal therapy
incomplete or inadequate release of the TCL, progression of is required, with key contributions to postoperative care
the underlying disease, or misdiagnosis. being wound/scar management and proper instructions in
Whereas the TCL is seen in its entirety in the open carpal exercises to enhance tendon gliding, obtain full active range
tunnel release, it may not be when doing the ECTR. In fact, of motion (AROM), and minimize edema. The patient may
in the case of the open technique, the TCL is allowed to open need guidance on ergonomics and other principles to
facilitate full return to work or other activities.10 All patients The patient is asked to quantify the pain on a scale from
referred to therapy are instructed in a home exercise program 0 (representing no pain) to 10 (indicating severe pain requir-
appropriate to the phase of recovery and their individual ing medical attention). The patient is asked to rate the pain
needs. both at rest and with use. The quality of the patients pain is
In general, patients tend to do quite well after carpal obtained by documenting the descriptive terms the patient
tunnel release. However, because the extent of the damage to uses when discussing the symptoms.49
the median nerve cannot fully be known before surgery, Edema of the hand is recorded either by volumetric cir-
predicting the exact outcome of carpal tunnel release is dif- cumferential or figure of eight measurements. If edema is
ficult. Patients with mild to moderate symptoms can expect profuse throughout the hand, then volumetric measure-
full recovery of sensation and resolution of the numbness ments can be taken provided that stitches have been removed
and tingling caused by entrapment of the nerve. Patients and the patient has no open wounds. The volumetric assess-
with more advanced disease who have significant sensibility ment should be administered following the American Society
loss and muscle weakness usually achieve significant of Hand Therapists (ASHT) guidelines. If edema is minimal
improvement of their condition. Patients with muscle or the stitches have not yet been removed, then circumfer-
atrophy can expect a halt to progression of muscle wasting ential measurements recorded in centimeters should be
and in some cases can regain muscle mass. obtained at the distal wrist crease and the distal palmar
The recovery of the median nerve directly relates to the crease (DPC). The figure of eight method for assessing hand
success of the surgery. Ultrasonography postoperatively may edema has been shown to be as reliable and valid as the volu-
be helpful in identifying the initial beneficial morphologic metric method, and may be easier to perform in a busy clinic
changes. Nerve conduction studies could take as long as 3 to than the volumetric method.50
6 months to change.48 Patients must understand that they AROM measurements are obtained using a goniometer
may have some element of incisional pain after surgery, for the wrist and forearm. Individual finger AROM measure-
which can last as long as 3 to 6 months. They must also be ments may not be necessary when motion limitations are
informed that they will temporarily lose some strength in the minimal. A global measurement of finger flexibility is
hand, which usually improves after 3 to 6 months. obtained by measuring composite finger flexion to the DPC.
The distance from the middle of the pulp of a finger to the
Postoperative Evaluation DPC is measured in centimeters for each finger. Functional
In general, patients may be referred to therapy anywhere thumb opposition is recorded as the ability to oppose the
from 1 to 3 weeks postoperatively. The timing of the first visit thumb to each fingertip, and full composite flexion/
will dictate which tests are appropriate to perform and which opposition as the ability to touch the thumb to the DPC of
should be deferred until a later time. The initial evaluation the small finger. Full motion is recorded as zero, and lack
after carpal tunnel release includes the following: of full motion as a negative number.
Patient history To prevent bowstringing (i.e., subluxing, or anterior
Subjective pain report displacement, of the flexor tendons through the healing
Edema measurement TCL), simultaneous wrist/finger flexion measurements
AROM measurements (Depending on the procedure, should be deferred until 3 weeks after an open incision
simultaneous finger/wrist flexion may need to be surgery. As mentioned, bowstringing may be more of a
deferred until 3 weeks postoperatively to avoid the risk concern with open procedures than with endoscopic
of bowstringing.) procedures.51
Sensibility testing Sensibility testing is the evaluation of the ability to feel
Wound and scar assessment or perceive a stimulus applied to an area.52 Sensibility assess-
Documentation of the patients previous and present ment is completed using the Semmes-Weinstein pressure
functional status aesthesiometer kit (a five filament kit is adequate). This type
After 3 weeks postoperatively, in addition to the above of sensory test is a pressure threshold test. The patient is
measurements, the evaluation can include: seated comfortably for testing with the forearm supinated
Grip and pinch assessment and the hand supported on a towel roll. The therapist should
Finger dexterity assessment occlude the patients vision during the test and instruct the
Neural tension testing as needed patient to report when a finger is stimulated and which finger
Manual muscle testing (MMT) feels the stimulus. The volar fingertips and thumb pulp are
The patients history is obtained by patient interview. tested starting with the 2.83 monofilament. Each monofila-
Information to be noted in the history includes age, gender, ment is applied perpendicular to the skin for 1.5 seconds and
hand dominance, cause of CTS, type and date of the carpal lifted for 1.5 seconds.52 The therapist should apply monofila-
tunnel release, occupation, avocational interests, onset and ments 2.83 and 3.61 three times to the same spot, and apply
description of symptoms before surgery, and notes regarding monofilaments 4.31 through 6.65 once. The lowest-numbered
whether symptoms were unilateral or bilateral. The patient monofilament felt for each digit should be recorded on the
should be screened for medical or systemic problems that evaluation form.52 Full hand mapping is rarely required after
might contribute to the persistence of symptoms. a carpal tunnel release.
Two point discrimination values are most often normal discomfort in the patients hand. Several authors have pub-
in CTS, and if they are abnormal it indicates advanced lished normal values for grip strength but because of the high
disease.53,54 The therapist should complete two-point dis- standard deviation11 and inconsistencies in the studies,
crimination testing only if the patient demonstrates signifi- comparison of grip scores to the contralateral extremity or
cant deficits on the Semmes-Weinstein Monofilament Test. longitudinal comparison to earlier values for each patient is
Two point discrimination is an innervation density test.53 recommended by ASSH and ASHT.60,62,64
The difference between the pressure threshold test and an Three types of pinch can be recorded using a pinch meter.
innervation density test is the sensitivity of the pressure Finger positioning for a three-point pinch is performed with
threshold test to gradual loss or improvement in nerve func- the index and middle finger on the top of the pinch meter
tion versus an all-or-none response on an innervation and the thumb on the bottom. Lateral pinch positioning is
density test. performed with the pinch meter held between the radial side
The surgical incision or scar is evaluated for its stage of of the index finger and the thumb on the top of the meter.
healing. The therapist should document whether the scar is Tip pinch is thumb pulp against index finger pulp. Tip pinch
raised or flat, tough or soft, mobile or adherent. The color of has been reported as a better outcome measure of strength
the scar also is noted. Some authors have written that one of for postoperative carpal tunnel release than grip or lateral
the principle predictors of good outcomes and successful pinch.65 Early forceful pinch, however, is not recom-
back to work status is minimal scar tenderness.44,55 Thera- mended until 3 weeks after surgery.
peutic interventions by physical therapists that include scar Finger dexterity can be evaluated with various instru-
assessment and management techniques are necessary, ments such as the nine hole peg test, Jebsen-Taylor hand
therefore, to ensure a flat, nonadherent, nonpainful scar. function test, OConnor finger dexterity test, modified
The patients present functional status can be documented Moberg pick-up test, or the Minnesota rate of manipulation
in the areas of grooming, dressing, bathing, cooking, home test. These tests have been standardized and normative data
care, work, avocational activities, and driving. Standardized have been established for comparison purposes.
self-administered outcome measurement tools that can be Upper-limb tension testing of the median nerve is appro-
employed include the DASH, the Michigan Hand Outcomes priate to determine whether the patient has restrictions in
Questionnaire, and the Boston Carpal Tunnel Scales, which nerve gliding. Limited studies have shown a decrease in the
includes the symptoms severity scale and functional status symptoms during conservative treatment of CTS,66,67 and
scale. Each of these scales takes only about 5 minutes to neural gliding is recommended not only to minimize the
complete. These scales have been validated for use in CTS potential of adhesions on the nerve, but to increase range of
and even reported as more responsive to clinical improve- motion (ROM) and decrease pain.68 Local median nerve
ments than grip, MMT, or sensory testing by monofilaments gliding at the wrist can be addressed as well (Fig. 12-7).
or two-point discrimination (Fig. 12-6).56-58 Readers are referred to other authors such as Butler, Cop-
If the patient is 3 weeks postoperation, grip strength is pieter, and Elvey for more detailed information on neural
recorded using a dynamometer with the handle positioned tensioning principles and techniques.
at the second setting59,60 per American Society of Surgery of The hand can be assessed for any atrophy of the thenar
the Hand (ASSH) and ASHT guidelines. eminence, after which MMT of the upper quarter can be
To perform a grip test, the patient should be seated with performed. As mentioned previously, care is taken to avoid
the shoulder adducted and neutrally rotated, elbow flexed to undue stress on the flexor tendons until at least 3 weeks after
90, forearm in neutral position and unsupported.61,62 The surgery. In assessing the function of the median nerve, the
therapist may support the dynamometer to prevent drop- abductor pollicis brevis is the muscle of choice for clini-
ping; however, the dynamometer should not be allowed to cal assessment because it is superficial, and is solely inner-
rest on the table. The therapist should document three grip vated by the median nerve.69,70
measurements, alternating the right and left hands,63 unless
repetitive grasping of the dynamometer would increase the
Postoperative Splinting
The value of postoperative splinting has been debated, and
physical therapists should engage the patient in a decision
Color Clinical Correlation Filament Marking on the need for splint use.43,71 Neutral wrist splinting31,72 can
be helpful for controlling tension at the wound site/scar,
Green Normal 1.65 2.83
helping the patient to avoid simultaneous wrist/finger
Blue Diminished light touch 3.22 3.61 flexion, as well as functioning as a simple reminder for the
patient to minimize use of the operative hand. However,
Purple Diminished protective 3.84 4.31
according to one study,43 there was less pain and scar tender-
Red Loss of protective 4.56 6.65 ness but a greater delay in return to full activity level
and less strength in patients who wore a splint postopera-
Red-lined Untestable >6.65 tively for 2 weeks compared with those who did not wear a
Fig. 12-6 Monofilament interpretation. splint.
AROM wrist median nerve glide
Begin with making fist, wrist in a neutral position.

Straighten fingers and thumb.
Bend wrist back, move thumb away from the palm.
Turn wrist palm up.
Use other hand to pull thumb farther away from palm.
Perform 1 set of 1 repetitions, three times a day.
Fig. 12-7 Local median nerve glide/stretch.
Phase I (Inflammatory Phase)

TIME: Day 1 to 3 weeks after surgery
Treatment of the patient after carpal tunnel release is
based on the phases of wound healing and tissue
response to stress. Treatment is directed toward
patient education, edema control, scar modification,
restoration of ROM, and strength and full return of
hand function.
GOALS: Promote wound healing, maintain tendon
excursion, and prevent median nerve from adhering
to tendon, increase digit ROM to within normal
limits (WNL) and maintain proximal ROM, decrease
pain, decrease edema, independence with ADL,
independence with home program (Table 12-1) A B
A light postoperative dressing is usually worn for 7 to 10

days after surgery. The patient should be instructed to elevate
the hand and move fingers frequently to help decrease
edema. Exercises during phase I consist of AROM to the
shoulder, elbow, and digits. The patient is instructed in
tendon-gliding exercises (Fig. 12-8) to prevent adhesion of
the tendons through the carpal tunnel and to help decrease
edema.73 The patient is also instructed in nerve glides, which
include gentle wrist flexion and extension with the UE held
in a relaxed position at side of body. Many patients are not
referred to formal therapy and, after instruction, can perform
exercises as a home program and are instructed to use the
hand as tolerated.
Phase Ia
TIME: 10 days to 3 weeks postoperative C D
GOALS: Promote scar remodeling, decrease
Fig. 12-8 Tendon-gliding exercises. A, Tendon-gliding exercises are initi-
hypersensitivity and pain, increase wrist ROM to
ated in full finger extension. The patient then completes 10 repetitions in
WNL, begin to increase hand strength, the hook fist (B), straight fist (C), and full fist (D) to maximize differential
independence in home exercise program tendon gliding and full excursion of the tendons through the carpal tunnel.
(Table 12-2) (From Wehbe M: Tendon gliding exercises. Am J Occup Ther 41:164, 1987.)
TABLE 12-1 Carpal Tunnel Release

Phase to This Phase and Functional Limitations Intervention Goal Rationale
Phase I Postoperative Edema Instruct on surgical Monitor for infection or Prevent postoperative
Postoperative Pain site protection and other postoperative complications
1-10 days Limited ROM of upper monitor for drainage complications Patient self-management
extremity Elevate hand and wrist Manage edema of edema and pain
Limited functional use of as needed Decrease pain Restore ROM to prepare
upper extremity AROM Full AROM of shoulder, UE for functional use
Shoulder (all ranges), elbow, forearm Limit scar adhesions to
elbow (all ranges), Increase AROM of fingers tendons and nerves
forearm (supination within limits of
and pronation), postoperative dressing
fingers and thumb
(tendon-gliding)
AROM, Active range of motion; ROM, range of motion.
Within 48 hours of suture removal, scar mobilization muscle length. Splinting may be appropriate for patients who
techniques may be initiated. Begin with a light scar massage experience nighttime pain associated with flexed postures of
with lotion and progress to a more vigorous soft tissue mobi- the wrist and may also be used to provide rest to inflamed
lization as tolerated. tissues.
AROM should include composite flexion and extension The therapist should initiate scar desensitization when the
of the digits, isolated blocking to the FDS and FDP, full surgical incision is closed. The desensitization process is ini-
median nerve glides, and continued tendon-gliding exer- tiated gently and can be performed in many ways. These
cises. Seven to 10 repetitions are performed three to four methods include manual self-massage of the scar, immersion
times per day. At this time, composite flexion of the wrist in tubs of textured particles, and rubbing the scar with dif-
and fingers is generally avoided until 21 days postopera- ferent textures. When performing scar desensitization, the
tion to prevent bowstringing of the tendons through the scar is initially rubbed lightly with soft fabrics; treatment
healing carpal ligament. Some patients may be referred for progresses by using deeper pressure and coarser textures.
formal hand therapy for pain relief, scar desensitization, Scar massage is initiated with minimal force, and the force
hand strengthening, and to help facilitate return to maximum is increased as the incision increases in tensile strength (Fig.
activity (see Table 12-2). Modalities may be used to decrease 12-9). Scar massage can be done for 1 to 3 minutes, five times
pain and edema, to increase elasticity of tissues, and to per day.
promote tissue healing.74 Moist heat may be used for pain Limiting the development of scar adhesion to tendons,
control before exercise and to prepare tissues for soft tissue skin, and nerves is another important aspect of scar manage-
mobilization. The modalities of pulsed US, iontophoresis,74 ment after carpal tunnel release surgery. Tendon-gliding
and high-voltage galvanic stimulation74 are helpful in reduc- exercises are continued to move the flexor tendons differen-
ing the local swelling and pain experienced by patients after tially in the carpal tunnel. Nerve-gliding techniques are
carpal tunnel release. Phonophoresis has not been shown to helpful in maintaining mobility of the median nerve after a
be any more effective than US alone for pain relief.56 carpal tunnel release.75 The home program for median nerve
Iontophoresis with dexamethasone sodium phosphate gliding begins with the arm held at the side of the body, the
may be used for decreasing local edema about the incision elbow extended, and the forearm and wrist in a neutral posi-
site. However, the incision must be completely healed and tion. The patient is instructed to extend the wrist from a
able to tolerate the stimulation. neutral position in a gliding motion. The patient should be
Cryotherapy, if tolerated, may be administered after exer- cautioned not to be overzealous with these exercises and to
cises for 10 minutes to help in managing edema and pain. inform the therapist if symptoms increase.
Light retrograde massage also may facilitate lymphatic When the incision is fully closed, a scar conformer can
return. Patients with persistent edema may benefit from be fabricated from silicone elastomers or cut from silicone
wearing a compression glove in conjunction with other gel sheets (Fig. 12-10). Because the scar conformer works by
edema-controlling modalities. The compression glove should applying pressure over the scar, it needs to be held firmly in
be worn almost continuously at first, and then worn only at place. Silicone sheeting does not need pressure wrapping,
night as edema decreases. As discussed, splinting is declining because the intervention is simply direct contact with scar
in favor during postoperative treatment because of the del- tissue. Silicone gel sheeting is recommended for nightly
eterious effects of immobilization on joint mobility and application, for 8 to 10 hours per day. The therapist can use

Phase Ia No signs of Edema Hot pack Decrease postoperative Modalities to manage edema
Postoperative infection Pain ES pain and decrease pain; help in
11-21 days Sutures removed Limited functional use Ultrasound, Manage edema preparation for stretching and
of UE iontophoresis with Increase strength and strengthening
Limited AROM of hand dexamethesone facilitate gross grasp and Massage to facilitate
and wrist sodium phosphate wrist stabilization lymphatic return
Limited strength of Cryotherapy Full AROM of shoulder, Increased wrist stabilization
hand and wrist Retrograde massage elbow, and forearm strength
Scar sensitivity, Initiate pain-free AROM of wrist, radial Promote full return of UE
adhesions, and isometricsWrist deviation, ulnar deviation, AROM, continuation of
thickening (flexion, extension) thumb composite tendon-gliding exercises to
Persistent paresthesia, AROMProgress opposition, and finger decrease scar adhesion
especially at night exercises as indicated composite flexion Wrist flexion exercises are not
Limited hand function and add wrist extension, Decrease sensitivity of recommended until 21 days
Limited patient radial and ulnar scar after surgery, depending on
knowledge of neutral deviation Increase mobility of scar the type of surgical exposure,
wrist positioning Finger AROM Decrease scar adhesion to to prevent bowstringing of
No AROM for wrist flexor tendons, skin, and tendons
flexion until 3 wk after median nerve Strengthening and
surgery Decrease paresthesia improvement of endurance of
Wrist splint worn as Promote independent wrist and hand while
needed self-care maintaining neutral position
Scar desensitization: Maintain neutral wrist Encouragement of wrist
gentle manual massage position during exercises extension with finger flexion
Mobilization of the Encourage self- Neutral position to minimize
median nerve management of exercise pressure on median nerve
Instruct patient in the program Organized sensory input
following: Flatten and/or soften scar normalizes sensory
Proper use of hand interpretation
protection while Early motion organizes
performing self-care collagen development in scar
Neutral wrist positioning and limits scar from restricting
Nerve-gliding techniques median nerve
Fabricate scar conformer Initiation of self-management
or have patient use Minimizing possible
silicone gel sheeting development of pillar pain
Tendon-gliding exercises Incorporation of neutral
position during exercises and
ADL to prevent complications
Pressure applied over a scar
organizes collagen
ADL, Activities of daily living; AROM, active range of motion; ES, electrical stimulation; UE, upper extremity.
a self-adherent wrap such as Coban to secure the conformer scar conformer or silicone sheeting as needed to prevent skin
or gel sheeting over the scar. The patient should be instructed irritation and replace the scar conformer/sheeting if it
not to wrap the scar conformer or sheeting too tightly with becomes worn or soiled. The patient should observe the skin
the Coban because tight wrapping will cause edema and pain closely for signs of skin maceration or heat rash. If these
in the hand. An explanation should be given to the patient problems occur, then the patient should stop using the scar
regarding the purpose and importance of scar management conformer or silicone and inform the therapist. Decreasing
techniques for at least 3 months. The patient should wash the the amount of wear time or placing a light gauze or tissue
Fig. 12-9 Scar massage is initiated using manual techniques to decrease scar adhesion to the underlying tissues.
between the scar elastomer pad and the skin may control
skin maceration and heat rash.
After 3 weeks, the therapist can also initiate isometric
strengthening exercises for wrist extension and flexion.
Wrist isometrics are performed in a neutral wrist position.76
The patient applies enough resistance with the opposite hand
to create a muscle contraction, which is held for 5 seconds
without increasing pain. The exercises can be progressed by
increasing resistance and repetitions. Instruction on ways to
maintain a neutral wrist position during functional use of
the hand is emphasized with paper crunch activity and iso-
metric strengthening exercises. This education is further
emphasized with ergonomic instruction in phase II.
The patient should be encouraged to use the affected hand
for self-care while avoiding wrist flexion, forceful repetitive
grip, and lifting more than 3lb. Tasks that require forceful
grip, such as vacuuming, handling wet laundry, putting fitted
sheets on the bed, yard work, tool use, lifting, and pushing,
should be avoided for 6 to 8 weeks to allow complete healing.
Phase II (Proliferation Phase)

GOALS: Improve strength and endurance in hand
and UE for independence in ADL, progress
strength and endurance in hand to prepare for
return to work, return to full-time work activities
(Table 12-3)
Phase II focuses primarily on strengthening and educa-

tion (see Table 12-3). It begins on day 22 after surgery and
continues until day 42 (6 weeks after surgery). Phase I
modalities are continued for edema and pain control. Moist
heat may be continued before exercises. Scar desensitization
Fig. 12-10 The clinician fabricates an elastomer scar conformer by mixing is continued with scar massage and soft tissue mobilization.
the elastomer in the hands. Texture desensitization techniques are continued, especially
as part of the home program. Use of a gel sheeting to pad
the sensitive palm may increase comfort for performing self-
care and light home care. Tendon-gliding and nerve-gliding
exercises and scar massage are continued to prevent or
decrease scar adhesions. The pressure used for scar massage

Phase II Pain controlled Mild edema Continuation of modalities As in Tables 12-1 and 12-2 As in Tables 12-1 and 12-2
Postoperative No loss of range of Mild pain as indicated from phase I Resolve edema in fingers Decrease reliance on
3-6 wk motion Limited AROM of wrist, Continuation of the Decrease postoperative modalities and increase
No loss of strength fingers, and thumb following: pain patients ability to
Well-healed incision Scar sensitivity Scar desensitization Decrease sensitivity of self-manage edema and
Scar adhesion techniques scar and increase scar pain
Scar raised or thickened Retrograde massage mobility Continuation of exercises as
Limited UE strength AROM and PREs Decrease scar adhesion indicated to allow
Limited ability to perform Scar conformer or silicon to flexor tendon, skin, progression of program as
light ADL involving at night and median nerve tolerated by patient
gripping and twisting Progress firmness of AROM of wrist response to treatment
Limited knowledge of manual scar massage Full fist to DPC with Scar should now be able to
proper work environment AROMwrist flexion fingers handle increased
organization Putty exercises (light Thumb to DPC at base of mobilization techniques
(ergonomics) resistive putty)finger small finger UE stretches to elongate
Limited tolerance to pinch, finger grip Grip strength 30%-50% muscle tendon units for
repetitive finger and Isotonicsupper quarter of uninvolved hand increased function
hand use exercises Wrist strength 80%-90% Healing of transverse carpal
Wristweight well, flexion Proximal strength greater tunnel ligament is adequate
and extension than 85% to prevent bowstringing of
Forearmpronation and Lift and carry 3-5lb with the flexor tendons
supination (begin with involved hand Upper quarter strengthening
1-2lb and progress as Independence with ADL as a functional unit
indicated.) using assistive devices as Initiate exercises with low
Patient education necessary and limiting repetitions to prevent
regarding body mechanics, exposure to heavy development of
joint protection, and grasping activities tenosynovitis and pillar pain
modification of ADL using Organize work Use appropriate assistive
adaptive equipment (grip environment to decrease device to prevent reinjury
assistive devices) potential for reinjury and and increase independence
Ergonomic evaluation as maximize efficiency with ADL; avoiding heavier
needed Work simulation, gripping activities; use
Work simulated exercises, alternating tasks forearms to carry versus
as needed finger grip
Promote self-management
of symptoms and prevent
reinjury in the work
environment
Prepare for return to work
ADL, Activities of daily living; AROM, active range of motion; DPC, distal palmar crease; PREs, progressive resistance exercises; UE, upper
extremity.
is increased in intensity for manual massage. Use of the scar motions of (1) wrist flexion, forearm pronation, and elbow
conformer or gel sheeting is continued at night to soften and extension; (2) wrist extension, forearm pronation, and elbow
flatten the scar. extension; and (3) wrist extension, forearm supination, and
The patient can add active wrist flexion exercises after elbow extension.77
21 days with the expectation of full wrist flexion by the Resistive gripping and pinching exercises with light resis-
end of the sixth week after surgery. tive putty may be started 28 days after surgery. Putty exer-
Full UE stretching exercises and neural-gliding exercises cises must be comfortably tolerated before moving to more
are added at this time. UE stretches include composite resistive putty; however, if patients begin to complain of
pillar pain, this should be discontinued for another week or The patient starts on the weight well with no weight or on
two. Pillar pain is described in the literature as pain in the the work simulator at minimal torque and progresses as
thenar or hypothenar areas, and should be distinguished tolerated.
from incisional or local scar tenderness.44,78,79 Pillar pain Proximal muscle strengthening of the forearm, elbow,
occurs at the bony attachments of the TCL (the hook of the shoulder, and shoulder girdle can be started on day 28 after
hamate, pisiform, scaphoid tubercle, and the ridge of the surgery. Forearm rotation strength can be achieved using a
trapezium). Patients with pillar pain may have difficulty with hammer held with the elbow flexed at 90 and stabilized
gripping and palmar weight-bearing activities. Modalities against the side of the body. The therapist should ask the
may be used to decrease the inflammation and symptoms of patient to rotate the forearm from the neutral position into
pillar pain. Low-intensity continuous US80 (0.5 W/cm2, supination and pronation. Simply moving the hammerhead
3MHz) has been noted to help decrease this type of pain. away from the hand to increase the lever arm, or toward the
The therapist should instruct the patient that the maximum hand to decrease the lever arm, can change the resistance of
use of putty is two times a day for 5 minutes, and tell him or the exercise. Bicep curls and elbow extension exercises can
her to stop using the putty and notify the therapist if the pain be performed with dumbbells beginning at 1 or 2lb and
increases significantly. Wrist isometric exercises can be con- progressing as the patient tolerates. Shoulder and shoulder
tinued along with the initiation of grip isometric exercises. girdle exercises beginning with 1 to 2lb are important and
The patient can perform grip isometric exercises by squeez- are performed for flexion, abduction, internal and external
ing a towel roll in the hand. Light progressive resistance rotation, and scapular retraction. The patient should be
exercises (PREs) are added when pain is controlled. PREs are
added for both wrist extension and flexion (Fig. 12-11).76
Resistance should begin at 1 2 to 1lb and progressed to 3lb
as the patient tolerates it.
Wrist and grip strengthening are progressed to using a
weight well or computerized work simulator (Fig. 12-12).
B
Fig. 12-11 Progressive resistance exercises are important to strengthen the Fig. 12-12 Computerized equipment is an effective way of simulating
wrist extensor (A) and flexor (B) musculature. The table is padded with a many work tasks and strengthening muscles; it requires a relatively small
towel to prevent excessive pressure on the median and ulnar nerves. area in the clinic.

Phase III Patients who Limited UE and grip Continuation of exercises Decrease number of Increase efficiency of home
Postoperative 6 wk-1 perform jobs that strength and stretches in phases I exercises and exercises in self-management
year, until scar require heavy Limited UE and grip and II as indicated stretches of condition
maturation lifting endurance Progress UE strengthening Adequate strength to Promote muscle balance of UE
exercises, emphasizing return to work Assess potential to return to
endurance for return to activities full time work
work activities Self-management of Initiate appropriate program
Functional capacity symptoms (work hardening, work
evaluation conditioning, or supervised
Work simulated activities gym program)
Phase III (Remodeling and Maturation Phase)

monitored closely during the advancement of the proximal
TIME: 6 weeks after surgery, ending when the scar is
strengthening program to prevent the development of other
mature. This phase can last for 1 year or longer.
cumulative trauma disorders, such as shoulder impingement
GOALS: Adequate strength to return to full-time work
syndrome, lateral epicondylitis, de Quervains syndrome, or
activities, independent home exercise program,
trigger finger symptoms.
self-management of symptoms (Table 12-4)
Treatment of the patient after carpal tunnel release surgery
may also include instruction on ergonomic principles, The types of patients who progress to phase III are heavy
proper posture, and body mechanics to prevent recurrence laborers, construction workers, mechanics, and assembly
of CTS or the development of other repetitive stress injuries. workers. These patients should be able to progress to aerobic
Instruction should include general topics for all patients and exercise using a bicycle, treadmill, or UE ergometer. The
job-specific teaching for those returning to highly repetitive stretching program and scar management program from
or heavy-labor jobs. phase II is continued. Scar massage also continues, with the
patient wearing the scar conformer or gel sheeting until the
scar color is no longer reddened. Scar maturation can take
Ergonomic Recommendations as long as 1 year. Phase II strengthening exercises should be
Patients with jobs involving computers should be instructed continued and progressed as tolerated. Large muscle group
in workstation setup. According to the literature, the most exercises using gym equipment or free weights are appropri-
important factor in CTS and work is wrist position on the ate at this time for general body conditioning.
keyboard. Based on carpal tunnel pressure studies, in wrist Work activity simulation is an important aspect of the
extension angles greater than 15 can increase pressure in the phase III therapy protocol. These activities can include using
carpal tunnel, which could result in more pressure on a pipe tree or assembly boards and learning proper lifting
the median nerve. Neutral wrist extension could decrease the and carrying techniques. The use of work simulation equip-
probability of developing other musculoskeletal disorders ment can be helpful for strengthening and simulation of
affecting the hand and wrist. To maintain this position, specific work activities (see Fig. 12-12). Full return of pre-
elbows should be flexed to 90 or a little less with wrists in a surgical grip and pinch strengths often does not occur until
neutral position over the keyboard. A keyboard tray may 3 to 6 months following surgery.
need to be added to the desk to achieve proper positioning. Clearly, CTS affects patients physically, financially, and
Using ergonomic keyboards or negatively tilting the key- psychologically. Comprehensive management of the patient
board also may be useful for maintaining a neutral wrist recovering from surgery for CTS optimizes the potential to
position.81 If a wrist rest is used, the patient should be return to ADL, work, and avocational activities.
instructed not to press on it during typing but to use it to
rest the UEs when scanning the monitor screen. SUGGESTED HOME MAINTENANCE FOR
Patients with sedentary jobs are usually discharged to a THE POSTSURGICAL PATIENT
home program by the end of phase II. Heavy laborers gener-
ally progress to phase III at 6 to 8 weeks after surgery, where The home maintenance section outlines the postoperative
more emphasis is placed on increasing strength, endurance, rehabilitation the patient is to follow. The physical therapist
and return to work activities. can use it in customizing a patient-specific program.

Days 1 to 10 Days 22 to 42
GOALS FOR THE PERIOD: Decrease pain, manage GOALS FOR THE PERIOD: Decrease pain, manage
edema, improve AROM of UE, initiate self- edema, improve AROM of UE, initiate self-
management and patient education management and patient education
1. Protect incision 1. Continue all previous exercises and modalities as
2. Elevate the hand above the heart indicated
3. Ice frequently 2. Add wrist flexion AROM
4. AROM exercises for shoulder, elbow, forearm, 3. Add putty gripping and pinching exercises with
and thumb light resistive putty
5. Tendon-gliding exercises 4. Add grip isometric exercises by squeezing a
towel roll
Days 11 to 21 5. Add PREs for wrist extension and flexion with 1 2
GOALS FOR THE PERIOD: Decrease pain, manage to 1lb
edema, improve AROM of UE, initiate self- 6. Add PREs for shoulder girdle and elbow with 1 to
management and patient education 2lb
1. Moist heat 7. Add forearm strengthening using a hammer
2. Retrograde massage when incision has closed 8. Continue to use scar conformer at night
3. Scar massage when incision has closed 9. Practice ergonomic principles
4. Continue tendon-gliding exercises
5. Nerve-gliding exercises Days 43 to 90
6. Continue AROM exercises for shoulder, elbow, GOALS FOR THE PERIOD: Complete self-
forearm, and thumb management of symptoms and home maintenance
7. Add AROM exercises for wrist extension, radial program, return to full-time work activities
and ulnar deviation (avoid wrist flexion as 1. Aerobic warm-up exercise using a bicycle or
necessary) treadmill
8. Isometric exercises for wrist extension and 2. Continue previous exercises as indicated,
flexion progressing intensity and duration as indicated
9. Use scar conformer or silicone gel sheeting at
night
10. Use splint as needed to control symptoms
11. Ice as necessary
1 Sharon had carpal tunnel release 2 months ago. She has

been making good progress in therapy but continues to
complain of paresthesia that was present before surgery.
the edema is persistent. What are some treatment tech-
niques that may be helpful for decreasing her edema at
this point?
What could explain her continued symptoms?
Light retrograde massage may facilitate lymphatic return.
It is not uncommon for patients to continue with symp- Patients with persistent edema may benefit from wearing
toms postoperatively. The healing response of the nerve a compression glove in conjunction with other edema-
may take as much as 3 to 6 months. Besides the use of controlling modalities. Initially the glove should be worn
antiinflammatory modalities, wearing a night splint may almost continuously. As the edema decreases, the
help keep the wrist in a neutral position and facilitate the patient only needs to wear the glove at night.
healing response.
2 Yvonne is a 48-year-old grocery checker who has been

diagnosed with intermediate CTS; she has constant
3 Yvonne tends to heal quickly after having surgery. In fact,
she had difficulty regaining full knee ROM after knee
surgery because adhesions quickly formed around the
numbness and paresthesia but no thenar atrophy. She joint. Limiting the development of scar adhesions also is
had surgery 3 weeks ago for a carpal tunnel release, and important in the patient who has had carpal tunnel
release. What are some problematic areas Yvonne may

have after her carpal tunnel release? What types of treat-
ment can be used to limit scar adhesions in this area?
4 Lupe is returning to work (as a receptionist) 8 weeks
after carpal tunnel release. Her symptoms have resolved
but she is still tender over the incision. What ergonomic
recommendations should be made?
Limiting the development of scar adhesion to tendons,
skin, and nerves is another important aspect of scar man- In general, a worksite evaluation should be made. Close
agement in the patient after carpal tunnel release surgery. attention should be paid to the degree of wrist extension
Tendon-gliding exercises are continued to move the (neutral) and postural setup (i.e., head on neck, shoulder,
flexor tendons differentially in the carpal tunnel. Nerve- elbow, and overall spine and pelvis position while seated)
gliding techniques are helpful in maintaining mobility of as it relates to her monitor and job duties. A padded wrist
the median nerve after a carpal tunnel release. rest or padded gloves may also be useful.
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CHAPTER 13
Transitioning the Throwing Athlete
Back to the Field
Luga Podesta
Injuries to athletes happen every day. Some can be ASSESSMENT

easily treated, while others require surgery and/or
lengthy rehabilitation. An arm injury to a baseball Regardless of the surgical procedure performed, the physical
player is potentially career ending and therefore needs therapist (PT) must assess the athletes overall physical con-
very special attention. Every baseball player knows the dition before beginning a more aggressive conditioning and
demands put on an arm in training and competition, throwing program. Knowledge of the athletes flexibility,
so we also realize the need for very intense and special- strength, and endurance is essential for the development of
ized rehabilitation. During my playing career I had a program specific for his or her needs. The athletes throw-
three serious shoulder injuries. Much time and energy ing mechanics must be carefully evaluated throughout reha-
was spent on the strengthening of my shoulder, but the bilitation and the transition back to throwing sports.
critical time of rehabilitation was the transition from
physical therapy into a throwing program. An aggres- STRENGTHENING AND CONDITIONING
sive full-body conditioning program, including plyo-
metrics, was essential in assisting my shoulder to In the past a great deal of emphasis was placed on developing
function correctly when throwing a baseball. This mobility in the postoperative shoulder and developing
program paved the way for a smooth transition onto strength in the shoulder-supporting musculature, including
the field and a successful return to competition. the rotator cuff and scapular stabilizers. Very little attention
Mike Scioscia, Anaheim Angels was given to the remainder of the musculature that plays a
significant role in permitting the athlete to throw effectively
A great deal of literature exists detailing the surgical tech- and without injury.
nique and postoperative rehabilitation of the injured shoul- Dynamic stability of the throwing shoulder requires fine,
der. However, little has been written on the difficult task of coordinated action of the GH and scapulothoracic stabilizers
transitioning the throwing athlete from the rehabilitation to facilitate synchronous function of the GH joint. After
setting back to throwing sports after surgery. This chapter surgery, proper neuromuscular control must be reestab-
outlines a program to return the throwing athlete back to his lished to prevent asynchronous muscle-firing patterns,
or her sport after surgery. which can result in dysfunction.1,2
Numerous surgical procedures can be performed on a Neuromuscular control is defined as a purposeful act ini-
throwing athletes shoulder for a variety of pathologic condi- tiated at the cortical level.3 Payton, Hirt, and Newton3 stated
tions (e.g., glenohumeral [GH] instability, labral tears, rotor that motor control is an involuntary associated movement
cuff tears, impingement syndrome, acromioclavicular joint organized subcortically that results in a well-learned skill
injury). Because one short appendix cannot describe each operating without conscious guidance. The fine coordinated
surgical procedure and the postoperative rehabilitation activity necessary for propelling a ball rapidly and accurately
course recommended for it, the program described in this requires subcortical control of the muscles responsible for
chapter is based on the assumption that the athlete has throwing.
already been cleared to begin an advanced throwing and Kinesthesia is the ability to discriminate joint position,
conditioning program. relative weight of body parts, and joint movement, including
233
speed, direction, and amplitude.4 Proprioception is the levels and (2) preventing injury. Gambetta10 has outlined ten
ability to discriminate joint position. key principles that are basic to the development of a condi-
The ability to throw requires that joint proprioceptors tioning program for the throwing athlete (Box 13-1). The
(muscle and joint afferents present in ligament and synovial many components of the program must work together to
tissues) function normally. Joint proprioceptors within the produce optimal performance. The quality of the effort and
GH joint are responsible for signaling a stretch reflex when the overall intensity should be emphasized first. The clinician
the GH capsule is taut to prevent translation at extremes of should monitor each exercise and eventually scrutinize the
motion.5 Many throwers recovering from surgery, especially throwing technique to ensure the optimal training effect and
those who have undergone procedures for instability, com- minimize the potential for injury.
plain of stiffness and tightness in their shoulders. Neuromus- The development of muscle balance is essential for coor-
cular controls may have been arrested by trauma and surgery, dinated, efficient movement to occur, especially around the
resulting in a new subcortical sense of joint tightness during shoulder where muscle imbalance can easily develop. Muscles
throwing that was not present before the shoulder- (e.g., the rotator cuff) cannot simply be trained solely and in
stabilization procedure. isolation, as in the early phases of most postoperative
The upper extremity (UE) and shoulder represent the last programs. After base strength has been developed in the
link in the kinetic chain during the overhead-throwing postoperative shoulder, functional activities and more sport-
motion, which begins distally as ground reactive forces are specific exercises must be added to mimic the activities the
transferred caudally. Biomechanical analysis shows that tre- athlete will be performing.
mendous forces are generated and extreme motion occurs in The development of core strength in the abdominals,
the shoulder with overhand throwing. Angular velocities in trunk, and spinal-stabilizing muscles cannot be overempha-
excess of 7000/sec have been recorded during the transition sized. Without adequate core strength, the throwing athlete
from external rotation to internal rotation when throwing.6,7 becomes vulnerable to improper postural alignment, which
Shearing forces on the anterior shoulder are estimated at 400 can lead to compensatory movements that place even greater
N.6 Approximately 500N of distraction force occurs during stress on the shoulder, further predisposing the athlete to
the deceleration phase of the throwing motion.6 These forces injury. After adequate strength has been achieved in the
are short in duration, develop quickly, occur at extremely shoulder-supporting musculature, abdominals, spinal stabi-
high intensity, and must be performed repeatedly. The direc- lizers, and LEs, endurance training can be added.
tion and magnitude of the forces generated when throwing Only after sufficient strength and endurance have been
a ball cause anteroposterior translational and distraction developed and normal, synchronous muscle-firing patterns
vectors that stress the GH constraints. have been reestablished can a more functional and sport-
However, these forces are not entirely generated in the specific activity such as throwing be added. The ultimate
shoulder. The shoulder-supporting musculature is not success of the training program depends on its overall design
capable of generating the forces and motions measured at the in introducing a variety of training stimuli to maximize total
shoulder during throwing. Throwing a ball effectively conditioning. An ideal conditioning program should contain
requires the athlete to generate, summate, transfer, and regu- a preparation period, an adaptation period, and an appli
late these forces from the legs through the throwing hand. cation period.10 The preparation period should consist of
To generate the forces measured with throwing, the shoulder general work, including strength and endurance training.
relies on its position at the end of the kinetic chain. It has Specialized work incorporating joint dynamics of the sport
been reported that 51% to 55% of the kinetic energy created occurs during the adaptation period. Finally, the application
is generated in the lower extremities (LEs).8,9 Use of ground
reaction forces sequentially linked with the activity of the
large LE and trunk muscles generate a significant proportion
of the forces measured. Biomechanical data show that the BOX 13-1 Basic Conditioning Principles
shoulder itself contributes relatively little of the overall total
Develop muscle synergy.
energy necessary to the throwing motion. However, it pro-
Train for performance, not work capacity.
vides a relatively high contribution to the total forces (21%),
Train for muscle balance.
indicating that the shoulder, because of its position at the end
Train movements, not muscles.
of the kinetic chain, must effectively transfer and concentrate
Develop structural (core) strength before extremity
the developed energy. Conditioning of the shoulder and UE
strength.
musculature is important in returning throwing athletes
Use body weight resistance before external
back to their sports. Moreover, the trunk and LE muscula-
resistance.
ture must be adequately conditioned to provide the founda-
Build strength before strength endurance.
tion to generate the forces required for effective and safe
Develop synergists before prime movers.
throwing.
Promote joint integrity before mobility.
When designing a program to return a throwing athlete
Teach fundamental movement skill before specific
back to sports, the physical therapist (PT) should consider
sport skill.
two primary objectives: (1) enhancing current performance
Chapter 13 Transitioning the Throwing Athlete Back to the Field 235
period incorporates the specific joint actions and move-

ments required to perform the sport. PLYOMETRIC EXERCISES
ISOTONIC EXERCISES Plyometric training was first introduced in the late 1960s by
Soviet jump coach Yuri Verkhoshanski.12 American track
A progressive weight- and functional-training program coach Fred Wilt13 first introduced plyometrics in the United
should start with body weight exercise. This allows the States in 1975. The majority of the literature concerning
athlete to develop the proper exercise techniques and regain plyometric exercise discusses its use in the LEs. Adapting
the synchronous muscle-firing patterns required to perform these principles to the conditioning of throwing athletes is
the overhand sport. This method of training also is adaptable logical, considering the maximal explosive concentric con-
to the more advanced plyometric exercises that follow after tractions and rapid decelerative eccentric contractions that
base strength has been gained. occur with each throwing cycle. Although agreement regard-
Weight training is one of the most popular methods of ing the benefits of plyometric exercise in the training program
training and can be performed with either free weights or is well documented, controversy exists regarding its optimal
machines. Free weight training with dumbbells is preferable, use.14-17
because it allows for unilateral training while permitting a Plyometric exercise can be broken down into three phases:
full range of motion (ROM) of the extremity. Machines are (1) the eccentric (or setting) phase, (2) the amortization
better used in training the LEs. The use of rubber tubing or phase, and (3) the concentric response phase. The setting
bands is another popular method of early strength training phase of the exercise is the preloading period; it lasts until
for the overhand-throwing athlete. These exercises can be the stretch stimulus is initiated. The amortization phase of
performed as a warm-up for more strenuous weight resis- the exercise is the time that occurs between the eccentric
tance exercises or as a cool down exercise; they can accom- contraction and the initiation of the concentric contraction.
modate all muscle actions. Rubber tubing or band exercises During the concentric phase the effect of the exercise (a
also allow for unilateral training of the extremity through a facilitated contraction) is produced and preparation for the
full ROM. They can be performed during the rehabilitation second repetition occurs.
period and should continue when the thrower returns to Clinicians believe physiologic muscle performance is
play. Isotonic strengthening can be tailored to each athletes enhanced by plyometric exercise in several ways. The faster
needs and can be used to maintain strength in all muscle a muscle is loaded eccentrically, the greater the resultant
groups. Jobes UE exercise program11 is the most popular
group of isotonic exercises performed. They can be initiated
early in the rehabilitation period and continued throughout
the athletes career. However, they must be performed cor- TABLE 13-2 Isotonic Core-Strengthening Exercises
rectly to maximize their benefit (Table 13-1). Exercise* Sets/Repetitions
Core strength should first be developed using isotonic
training. Only after base strength is developed should the Chest
intensity of the exercise program be increased (Table 13-2). Bench press (close grip) 2-3/8-10
Legs squats 2-3/8-10
Leg press 2-3/8-10
Knee extensions 2-3/8-10
TABLE 13-1 Jobes Shoulder Exercises* Leg curls 2-3/8-10
Exercise Weight (lb) Sets/Repetitions Lunges 2-3/8-10
Calf press 2-3/8-10
Shoulder flexion 3-5 3-4/10-15 Toe raises 2-3/8-10
Shoulder elevation 3-5 3-4/10-15
Back
Shoulder abduction 3-5 3-4/10-15
Latissimus pull-downs 2-3/8-10
Shoulder scaption 3-5 3-4/10-15
Shoulder shrugs 2-3/8-10
Military press 3-5 3-4/10-15
Seated rows 2-3/8-10
Horizontal abduction 3-5 3-4/10-15
Bent-over rows 2-3/8-10
Shoulder extension 3-5 3-4/10-15
External rotation I (side lying) 1-5 3-4/10-15 Abdominals Crunches (to be performed in sequence)
External rotation II (prone) 1-5 3-4/10-15 Feet flat 3/15, rest 30 seconds
Internal rotation 1-5 3-4/10-15 Weight on chest 3/15, rest 60 seconds
Horizontal adduction 3-5 3-4/10-15 Knees bent 1/25, rest 60 seconds
Rowing 3-5 3-4/10-1 Knees up with weight 1/25
*All exercises should be performed three times a week. *All exercises should be performed two to three times a week.

Modified from Jobe FW et al: Shoulder and arm exercises for the Wide-grip bench press, behind-neck pull-down, deep squats, and
athlete who throws, Inglewood, Calif, 1996, Champion Press. behind-neck military press should not be performed.
concentric force produced. Eccentric loading of a muscle TABLE 13-3 Plyometric Exercises
places stress on the elastic components, increasing the
tension of the resultant force produced. Exercise* Equipment Sets/Repetitions
Neuromuscular coordination is improved through Warm-Ups
explosive plyometric training. Plyometric exercise may Medicine ball rotation 9-lb ball 2-3/10
improve neural efficiency, thereby increasing neuromuscular Medicine ball side bends 9-lb ball 2-3/10
performance. Medicine ball wood chops 9-lb ball 2-3/10
Finally, the inhibitory effect of the Golgi tendon organs,
which serve as a protective mechanism limiting the amount Tubing
of force produced within muscle, can be desensitized by IR, ER, and 90 shoulder abduction Medium tubing 2-3/10
plyometric exercise, thereby raising the level of inhibition. Diagonal patterns (D2) Medium tubing 2-3/10
This desensitization and the resultant raise in the inhibition Biceps Medium tubing 2-3/10
level ultimately allow increased force production with greater Push-ups 2-3/10
applied loads. Throwing Movements
Through neural adaptation, the throwing athlete can Medicine ball soccer throw 4-lb ball 2-4/6-8
coordinate the activity of muscle groups and produce greater Medicine ball chest pass 4-lb ball 2-4/6-8
net force output (in the absence of morphologic change Medicine ball step and pass 4-lb ball 2-4/6-8
within the muscles themselves). The faster the athlete is able Medicine ball side throw 4-lb ball 2-4/6-8
to switch from eccentric or yielding work to concentric over-
coming work, the more powerful the resultant response. Tubing Plyometrics
Effective plyometric training requires that the amortization IR and ER repetitions 6-8
Diagonals repetitions 6-8
phase of the exercise be quick, limiting the amount of energy
Biceps repetitions 6-8
wasted as heat. The rate of stretch rather than the length of
Push-ups repetitions 6- to 8-inch box 10
stretch provides a greater stimulus for an enhanced training
effect. With slower stretch cycles the stretch reflex is not Trunk Extension and Flexion Movements
activated. Medicine ball sit-ups 4-lb ball 2-3/10
Before implementing a plyometric training program, the Medicine ball back extension 4-lb ball 2-3/10
patient must have an adequate level of base strength to
Medicine Ball Exercises (Standing and Kneeling)
maximize the training effect and prevent injury. Remedial
Soccer throw 4-lb ball 2-4/6-8
shoulder exercises focusing on the rotator cuff and shoulder-
Chest pass 4-lb ball 2-4/6-8
supporting musculature are continued in order to develop
Side-to-side throw 4-lb ball 2-4/6-8
and maintain joint stability and muscle strength in the arm
Backward side-to-side throws 4-lb ball 2-4/6-8
decelerators. These exercises also should be used to warm up Forward two hands through legs 4-lb ball 2-4/6-8
before the plyometric drill and cool down after it has been One-handed baseball throw 2-lb ball 2-4/6-8
concluded.
Plyometric exercise is contraindicated in the immedi- ER, External rotations; IR, internal rotations.
ate postoperative period, in the presence of acute inflam- *All exercises should be performed two to three times a week.
mation or pain, in athletes with gross shoulder or elbow
Throw with partner or pitchback device.
instability, or in both. Plyometric training also is contra- Modified from Wilk KE, Voight ML: Plyometrics for the shoulder
complex. In Andrews JR, Wilk KE, editors: The athletes shoulder,
indicated in athletes who do not have an adequate degree New York, 1994, Churchill Livingstone.
of base strength and who are not participating in a
strength-training program. This form of exercise is intended
to be an advanced form of strength training. Postexercise Warm-up exercises are performed to provide the shoul-
muscle soreness and delayed-onset muscle soreness are der, arms, trunk, and LEs an adequate physiologic warm-up
common adverse reactions that the clinician should be aware before beginning more intense plyometric exercise. The
of before beginning an athlete on this type of exercise. facilitation of muscular performance through an active
Tremendous amounts of stress occur during plyomet- warm-up has been ascribed to increased blood flow, oxygen
ric exercises; therefore they should not be performed for use, nervous system transmission, muscle and core tempera-
an extended period. A plyometric program should be used ture, and speed of contraction.4,19-22 The athlete should
during the first and second preparation phases of training. perform two to three sets of 10 repetitions for each warm-up
The plyometric training program for the UE can be exercise before proceeding to the next group of exercises.
divided into four groups of exercise as described by Wilk18 Throwing movement plyometric exercises attempt to
(Table 13-3): isolate and train the muscles required to throw effectively.
1. Warm-up exercises Movement patterns are performed similar to those found
2. Throwing movements with overhead throwing. These exercises provide an advanced
3. Trunk extension and flexion exercises strengthening technique at a higher exercise level than
4. Medicine ball wall exercises that of more traditional isotonic dumbbell exercises. The
exercises in this group are performed for two to four sets of musculature supporting the hips, knees, and ankle joints
six to eight repetitions two to three times weekly. Adequate during plyometric jump exercises. The PT must monitor
rest times should occur between each session for optimal exercise loads performed and allow adequate recovery time
muscle recovery. between sets. Proper technique in performing these exercises
Plyometric exercises for trunk strengthening include is vital to prevent injury. A variety of jump exercises can be
medicine ball exercises for the abdominals and trunk exten- used to train the LEs when preparing the throwing athlete
sor musculature. The athlete performs two to four sets of 8 to return to athletic competition (Table 13-4).
to 10 repetitions two to three times weekly. Rapid box jumps are performed to develop explosive
The final group of exercises, the Plyoball wall exercises, power in the calf and quadriceps musculature. An explosive
require the use of 2-lb and 4-lb medicine balls or Plyoballs but controlled jump up onto the box, then down off the box
and a wall or pitchback device to allow the athlete to perform is performed; box height can be increased as the exercise is
this group of exercises without a partner. This group of drills
starts with two-handed throws with a heavier 4-lb ball and
concludes with one-handed plyometric throws using the
lighter 2-lb ball. All the exercises in this phase of the program TABLE 13-4 LE Plyometric Exercises
should be performed in the standing and kneeling positions Exercise* Equipment Sets/Repetitions
to increase demands on the trunk, UE, and shoulder girdle
and eliminate the use of the LEs. The same number of repeti- Rapid box jumps Boxes of varying 2-3/8-10
tions and sets should be performed two to three times weekly (alternating height) heights
(Fig. 13-1). Box jumps 12- to 24-inch boxes 3-4 sets
Depth jump and sprint 24-inch box 5-8 repetitions
Plyometric training of the LEs is essential in developing
Depth jump and base steal 24-inch box 5-8 repetitions
the throwing athletes explosive strength needed for speed,
lateral mobility, and acceleration. LE plyometric training LE, Lower extremities.
also helps develop the coordination and agility necessary *All exercises should be performed two to three times per week.
to compete effectively. High demands are placed on the
Jump from a 24-inch box followed by an immediate 10-yard sprint.
B C
Fig. 13-1 A, Medicine ball wood chop warm-up exercises. B, Medicine ball soccer throw exercises from the knees. C, Plyometric push-up. (Photos by
Dr. Luga Podesta, Oxnard, Calif.)
mastered. The athlete should immediately jump back on the program. A thorough understanding of normal and abnor-
box, spending as little time as possible on the ground. mal throwing mechanics and the biomechanical forces
Alternating-height box jumps train the quadriceps, ham- placed on the throwing arm are essential for the therapist
strings, gluteals, and calf muscles and help develop explosive wishing to implement a throwing program in the rehabilita-
power. Box jumps are performed using three to five plyomet- tion setting.
ric boxes of varying heights (from 12 to 24 inches) placed in
a straight line 2 feet apart from one another. Starting at the Baseball Pitching
smallest box, the athlete performs controlled jumps from the Pitching a baseball is the most violent and dynamic of all
box to the ground to the next tallest box, spending as little overhead-throwing activities, producing angular velocities
time on the ground as possible; the athlete should rest for 15 in excess of 7000/sec across the shoulder. Maximal stability
to 20 seconds between sets. of the GH joint occurs at 90 of shoulder elevation.23 Because
The depth jump and sprint and the depth jump with base muscle weakness can result in abnormal compression and
steal focus on teaching muscles to react forcefully from a shear forces, muscle balance is necessary to maintain stabil-
negative contraction to an explosive positive contraction. ity of the humeral head in the glenoid fossa. A favorable
The athlete immediately explodes into a 10-yard sprint or balance between compression and shear forces occurs at 90
10-yard base steal after jumping off a 24-inch box. of shoulder elevation, placing the shoulder in the optimal
position for joint stability.1,3,23,24 All throwers therefore should
maintain 90 of GH elevation relative to the horizontal
AEROBIC CONDITIONING surface regardless of technique or pitching style.
Dynamic control of the GH joint during throwing
Although the initial postoperative emphasis is on rehabilita- depends on the rotator cuff and biceps muscle strength.1,2 An
tion of the shoulder, the transition from formal therapy to abnormal throwing pattern can result from GH instability
return to play requires the throwing athlete to regain the and inadequate control of the rotator cuff and biceps tendon.
preinjury aerobic condition. Therefore the aerobic condi- Neuromuscular conditioning and control of the GH joint
tioning component of the training program must not be allows for safer throwing by facilitating the dynamic coordi-
neglected. Aerobic fitness can be developed using a variety nation of the rotator cuff and scapulothoracic stabilizers.
of exercises (Box 13-2). The throwing or pitching motion can be divided into six
For any method of aerobic activity to be effective, the phases (Fig. 13-2):
exercise should be performed continuously for 20 to 40 1. Windup
minutes four to five times weekly. Because this type of con- 2. Early cocking
ditioning is long and repetitious, the athlete should enjoy the 3. Late cocking
activity being performed. 4. Acceleration
5. Deceleration
6. Follow-through
THROWING Windup is the preparatory phase of the throwing motion.
Relatively little muscle activity occurs during this phase.
The overhead-throwing motion is not unique to throwing a From a standing position, the athlete initiates the throw by
baseball. Similar muscular activity is required to throw a shifting the weight onto the supporting back leg. The weight
softball, football, or javelin. However, the majority of research shift from the stride leg to the supporting leg sets the rhythm
performed on overhead throwing has been conducted on the for the delivery. Windup ends when the ball leaves the gloved
overhead pitch. nondominant hand (Fig. 13-3, A).
The clinician must appreciate the highly dynamic nature The position of the stance foot is also important to help
of the throwing motion to be effective in preparing and generate forces up through the ankle into the leg. Reposi-
moving the rehabilitating athlete through a safe throwing tioning of the stance foot can significantly enhance the bio-
mechanical forces generated at push off. It is biomechanically
advantageous during push off to position the stance foot in
subtalar eversion (Fig. 13-4). Greater forces can be generated
BOX 13-2 Aerobic Conditioning Exercises in this position than if the foot is placed on the side of the
pitching rubber alone.
Running
During early cocking, the shoulder abducts to approxi-
Bicycling
mately 104 and externally rotates to 46.21 The scapular
Versa-Climber
muscles are active in positioning the glenoid for optimal
Stair-climbing machine
contact with the humeral head as the arm is abducted. The
Elliptical runner
supraspinatus and deltoid muscles work synergistically to
Cross-country ski machine
elevate the humerus. The deltoids position the arm in space,
Rowing machine
and the supraspinatus stabilizes the humeral head within the
Swimming
glenoid10 (Figs. 13-3, B-H, and 13-5).
Fig. 13-2 Phases of the baseball pitch. (From Jobe FW: Operative techniques in upper extremity sports injury, St Louis, 1996, Mosby.)
The stride forward is initiated during the early cocking extension, the elbow is flexed, and the shoulder externally
phase of throwing. The athlete should keep the trunk and rotates. When the trunk faces the target, the shoulder should
back closed as long as possible to retain the energy stored, have achieved maximal external rotation. At the end of this
which later results in velocity. phase, only the arm is cocked as the legs, pelvis, and trunk
As the stride leg moves toward the target, the ball breaks have already accelerated (see Figs. 13-3, I and J, and 13-5, F
from the glove and the throwing arm swings upward in and G).
rhythm with the body. The positioning of the breaking hands During the acceleration phase, the humerus internally
followed by the downward then upward rotation of the rotates approximately 100 in 0.005 seconds. Tremendous
throwing arm ensures optimal positioning of the arm (Fig. torque and joint compressive forces and high angular veloci-
13-6). Establishing this synchronous muscle-firing pattern ties across the GH joint are present at this time.6,21,25
is one of the most crucial aspects of the throw. If the throw- The acceleration phase begins when the humerus begins
ing arm and striding leg are synchronized properly, then to internally rotate. Just before the beginning of internal
the arm and hand will be in the early cocked position when rotation, the elbow should begin to extend (see Figs. 13-3,
the stride foot contacts the ground (see Figs. 13-3, H, and K, and 13-5, H and I). When ball release occurs, the trunk
13-5, D). is flexed, the elbow reaches almost full extension, and the
The direction of the stride should either be directly toward shoulder undergoes internal rotation (see Figs. 13-3, L, and
the target or slightly closed (to the right side of a right- 13-5, J). At ball release, the trunk should be tilted forward
handed thrower) (see Figs. 13-3, H, and 13-5, E). When the with the lead knee extending. Acceleration ends with ball
stride is too closed, the hips are unable to rotate and the release.
thrower is forced to throw across the body, losing kinetic The deceleration phase of the throwing motion is the first
energy from the LEs. When the stride is too open (i.e., the third of the time from ball release to the completion of arm
stride foot lands too far to the left of a right-handed thrower), motion (see Figs. 13-3, M and N, and 13-5, K). During decel-
the hips rotate too early, forcing the trunk to face the batter eration excess kinetic energy that was not transferred to the
too early and dissipating stored kinetic energy. This also ball is dissipated. High calculated forces and torque also
places tremendous stress on the anterior shoulder. After the occur during this phase.26,27
stride leg contacts the ground, the stride is completed and Follow-through occurs during the final two thirds of the
cocking of the throwing arm is initiated. throwing motion, during which time the arm continues to
During the late cocking phase of throwing the humerus decelerate and eventually stops (see Figs. 13-3, O, and 13-5,
maintains its level of abduction while moving into the scapu- L). After ball release, the throwing arm continues to extend
lar plane. The arm externally rotates from 46 to 170.21 In at the elbow and internally rotates at the shoulder. Internal
this position the humeral head is positioned to place an angular velocities drop from their maximal level at ball
anterior-directed force, potentially stretching the anterior release to zero. A proper follow-through is crucial in mini-
ligamentous restraints. mizing injury to the shoulder during this violent stage of
The trunk moves laterally toward the target, and pelvic throwing. Follow-through is completed when the throwing
rotation is initiated. As the trunk undergoes rotation and shoulder is over the opposite knee. This is achieved by
A B C D
E F G H
I J K L
Fig. 13-3 Front view of the throwing motion. A-E, The crow hop step begins the throwing motion. The pelvis and chest are rotated 90 from the target. The
hands separate as weight is shifted to the back leg. F-J, During the cocking phase of throwing, the throwing arm is elevated and externally rotated. Front view
of the throwing motion. The front foot is planted in a slightly closed position as the pelvis begins to rotate. Front view of the throwing motion. K-L, During
the acceleration phase, the elbow is above the height of the shoulder and weight is shifted to the front foot as the pelvis rotates.
M N O
Fig. 13-3, contd M-O, The deceleration and follow-through phases. (Photos by Marsha Gorman, Camarillo, Calif.)
throwing to the right, left, and on the run. Neuromuscular

conditioning and control of the LEs, core, and UEs allows
for safer throwing by facilitating the dynamic coordination
of the entire kinetic chain.
The football-throwing motion can be divided into six
phases:
1. Windup
2. Early cocking
3. Late cocking
4. Acceleration
5. Deceleration
6. Follow-through
Windup is the preparatory phase of the throwing motion.
From a squatting position, the quarterback steps backward
A B from behind the center varying distances (i.e., steps) posi-
tioning the body to initiate the throw by shifting the weight
Fig. 13-4 A, Foot placed on side of the pitching rubber. B, Foot placed
straddling the pitching rubber in subtalar joint eversion.
onto the supporting back leg. The weight shift from the stride
leg to the supporting leg sets the rhythm for the delivery.
Windup ends when the ball and supporting hand separate
allowing the supporting leg to rotate forward, finishing the (Fig. 13-7).
rotation of the trunk across the body. During early cocking, the shoulder abducts and exter-
nally rotates (Fig. 13-8). The stride forward is initiated during
Football the early cocking phase of throwing. The athlete should keep
The throwing mechanics necessary to throw a football are the trunk and back closed as long as possible to retain the
very similar to those required to throw a baseball.28 The most energy stored, which later results in velocity.
significant differences between the two are the size and As the stride leg moves toward the target, the ball breaks
weight of the ball and the positioning of the throwing hand from the hand and the throwing arm swings upward in
during the acceleration and ball release phases of the throw- rhythm with the body. Establishing this synchronous muscle-
ing motion. Although the precise throwing mechanics are firing pattern from the feet to the LEs through the pelvis and
not well defined, studies are currently underway to deter- trunk to the shoulder to the UE and finally the hand is one
mine and describe the specific mechanics. Similar forces and of the most crucial aspects of the throw. If the throwing arm
stresses appear to be applied to the shoulder and elbow. and striding leg are synchronized properly, then the arm and
Dynamic control of the entire kinetic chain during the foot- hand will be in the early cocked position when the stride foot
ball throw is essential for the quarterback to be effective contacts the ground.
A B C D
E F G H
I J K L
Fig. 13-5 Side view of the throwing motion. A-C, The windup and cocking phases of throwing. Side view of the throwing motion. D-G, The windup and
cocking phases of throwing. H-I, The acceleration phases. Side view of the throwing motion. J, The acceleration phases. K-L, The deceleration and follow-
through phases. (Photos by Marsha Gorman, Camarillo, Calif.)
The direction of the stride should either be directly toward trunk faces the target, the shoulder should have achieved
the target or slightly closed (to the right side of a right- maximal external rotation. At the end of this phase, only the
handed thrower) regardless of the direction of the throw arm is cocked because the legs, pelvis, and trunk have already
straight, right, or left. accelerated.
During the late cocking phase of throwing (Fig. 13-9), the During the acceleration phase (Fig. 13-10) the humerus
humerus maintains its level of abduction while moving into internally rotates, applying tremendous torque and joint
the scapular plane. The arm externally rotates, the trunk compressive forces and high angular velocities across the
moves laterally toward the target, and pelvic rotation is initi- GH.
ated. As the trunk undergoes rotation and extension, the The acceleration phase begins when the humerus begins
elbow is flexed and the shoulder externally rotates. When the to internally rotate. Just before the beginning of internal
Fig. 13-6 The proper technique for gripping the ball and releasing it from
the glove. The ball is gripped loosely across four seams in the fingertips of
the index and middle fingers. The thumb is placed under the ball, with the
index and middle fingers held together. The hands separate with a supinat-
ing motion of the forearms forcing the thumbs of both the glove and ball
hand downward. (Photo by Marsha Gorman, Camarillo, Calif.)
Fig. 13-8 The early cocking phase.
The deceleration phase of the throwing motion is the first

third of the time from ball release to the completion of arm
motion (Fig. 13-12). During deceleration, excess kinetic
energy that was not transferred to the ball is dissipated.
Follow-through (Fig. 13-13) occurs during the final two
thirds of the throwing motion, during which time the arm
continues to decelerate and eventually stops. After ball
release, the throwing arm continues to extend at the elbow
and internally rotates at the shoulder. A proper follow-
through is crucial in minimizing injury to the shoulder
during this violent stage of throwing. Follow-through is
completed when the throwing shoulder is over the opposite
knee. This is achieved by allowing the supporting leg to
rotate forward, finishing the rotation of the trunk across
the body.
INTERVAL BASEBALL THROWING

Fig. 13-7 The windup phase. PROGRAM
The purpose of the interval throwing program is to return

rotation, the elbow should begin to extend. When ball release motion, strength, and confidence gradually to the throwing
occurs, the trunk is flexed, the elbow reaches almost full arm after injury or surgery. The interval throwing program
extension, the shoulder undergoes internal rotation, and the allows the throwing patient the opportunity to reestablish
forearm maximally pronates (Fig. 13-11). At ball release the timing, movement patterns, coordination, and synchronicity
trunk should be tilted forward with the lead knee extending. of muscle firing before returning to competition.12 This is
Acceleration ends with ball release. accomplished by slowly increasing the throwing distances
Fig. 13-9 The late cocking phase.
Fig. 13-11 Maximal pronation occurs toward the end of the acceleration
Fig. 13-10 The acceleration phase. phase.
and eventually the velocity of the throws. The program

should be individualized to each athlete. No set timetable is
prescribed for the completion of the program; each patients
time spent completing the program may vary. The throwing
program is designed to minimize the chance of injury by
emphasizing proper prethrowing warm-up, stretching, and
cool down. It should be performed in the presence of a
coach, trainer, or therapist knowledgeable in throwing
mechanics. Careful supervision cannot be overstressed.
The participants must resist the temptation to increase
the intensity of the throwing program and understand
that this may increase the incidence of reinjury, which
would greatly retard the rehabilitation process.
Before initiating the interval throwing program, the ath-
letic patient must exhibit the following criteria:
1. Full and painless ROM
2. No pain or tenderness
3. Satisfactory muscle strength and conditioning
4. Normal or clinically stable examination
Specific attention throughout the interval throwing
program to the maintenance of proper throwing mechanics
is crucial (Box 13-3). Participants in the rehabilitation
program may find videotaping throwing sessions extremely
helpful in assisting with the analysis of the athletes throwing
mechanics.
Proper warm-up before beginning to throw cannot be
overemphasized. A common mistake is for the thrower to
Fig. 13-12 The deceleration phase. begin throwing to warm up. Instead, the thrower should
increase the blood flow to muscles and joints before
throwing. Running or jogging long enough to break a sweat
can accomplish this.
The athletic patient must warm up to throw, not throw
to warm-up.
A crow hop throwing technique uses a hop, skip, and
throw to accentuate LE and trunk involvement in the throw.
The use of the crow hop method simulates the throwing
motion and emphasizes proper throwing mechanics (see
Figs. 13-3, A to F, and 13-5, A to D).
BOX 13-3 Throwing Evaluation Checklist

Foot positionCrow hop, back foot 90 to the target
Body positionNondominant hip and shoulder to the
target
Hand breakBall release from glove, thumbs down
Ball hand and glove positionBall facing away from
the target, glove side elbow points to target flexed
90, glove down
Arm positionElbow above shoulder level
Front foot plantStep toward the target, toes to
target, slightly closed
Trunk rotationHips rotate before shoulders
BalanceStand tall, weight back
FinishStride foot posts, back leg and hip rotate
through
Fig. 13-13 The follow-through phase.
Throwing flat-footed encourages improper throwing 5. Standing in a regular throwing position at a distance
mechanics and places increased stress on the throwing of 40 feet, throwing medium effort for 10 repetitions,
shoulder. with emphasis on staying closed and pointing the front
The throwing athlete progresses through each step of the shoulder to the target
program, throwing every other day, or three times weekly.
The thrower progresses to the next step after the pre- DEVELOPING THROWING MECHANICS
scribed number of throws can be completed without pain
or residual pain. If pain or difficulty throwing occurs, then Once a flaw in a throwers mechanics has been identified, it
the athlete should regress to the previous level or attempt becomes extremely important for the clinician to implement
the same level during the next session. The ultimate goal is a change in that patients throwing mechanics to prevent
for the athlete to throw 75 repetitions at 180 feet without further injury from developing. It can be very difficult to
pain for positional players and 150 feet for pitchers. Box 13-4 change established faulty mechanics or bad habits especially
illustrates a progressive interval throwing program.29 in the older thrower. Having the ability to teach proper
When progressing through a pitcher-specific interval throwing mechanics becomes extremely important. To be
throwing program, it is extremely important to ensure that able to accomplish this we must provide the thrower with
the person or target receiving the throws is at the same exercises and techniques that will sequentially reestablish the
height as the thrower. When throwing on flat ground, the proper muscle firing patterns and muscle memory. The exer-
thrower should be throwing to a standing target. When cise programs are designed to reestablish proper kinematics
throwing off the pitching mound, the target can get into a from the feet up through the entire kinetic chain to the
squatting position. Throwing on flat ground to a squatting throwing hand.
catcher changes the point of ball release, which may lead to
increased stress across the anterior shoulder and elbow. Foot Placement (Crow Hop) Drill
Pattern throwing (Fig. 13-14) also can be implemented to To throw properly, foot placement becomes extremely
develop arm strength10: important. Proper foot placement during the windup phase
1. Proper warm-up before throwing (i.e., jogging, and early cocking phase of the throwing cycle are the foun-
running, bicycling) dation for development of the remainder of the sequential
2. Throwing from a kneeling position, facing the direc- motion patterns. It is important to get the thrower moving
tion of the throw with the arm already in the abducted toward the target. To accomplish this, we have the athlete
position for a distance of 20 feet, easy effort, for 10 perform a drill reinforcing proper back (drive) as well as
repetitions, with emphasis on proper grip front foot (land/post) placement. The proper positioning of
3. Kneeling on one knee facing the target with the arm the back foot is extremely important. The back foot needs to
in the abducted position (right-handed thrower on the be pointed outwardly (hip external rotation) 90 perpen-
right knee, left-handed thrower on the left knee) from dicular to the target allowing the pelvis and trunk to rotate.
a distance of 30 feet, easy effort, 10 repetitions, with This will allow the thrower to load the back foot, sequentially
emphasis on hitting the target and maintaining proper transfer ground reactive forces up the kinetic chain from the
follow-through foot through the pelvis into the trunk. To teach this we have
4. Standing with the feet in a straddle position facing the the athlete start the exercise facing forward. For the right
target with the shoulders turned and the ball in the hand thrower, they would take an exaggerated step forward
glove at a distance of 40 feet, medium effort, with with his back foot turning it outward 90. This forces the hip
emphasis on follow-through and then pelvis to rotate externally, positioning the throwers
BOX 13-4 Progressive Interval Throwing Program

Warm-up Step 2
Run to break sweat a. Warm-up throwing
Stretching b. 45 feet (25 throws)
45-foot Phase (half the distance to first base from home c. Rest 10 minutes
plate) d. Warm-up throwing
e. 45 feet (25 throws)
Step 1
f. Rest 10 minutes
a. Warm-up throwing25 feet g. Warm-up throwing
b. 45 feet (25 throws) h. 45 feet (25 throws)
c. Rest 10-15 minutes
d. Warm-up throwing
e. 45 feet (25 throws)
BOX 13-4 Progressive Interval Throwing Programrcontd

60-foot Phase (distance from home plate to pitching f. Rest 10 minutes
mound) g. Warm-up throwing
Step 3 h. 120 feet (25 throws)
a. Warm-up throwing 150-foot Phase (distance from home plate to grass
b. 60 feet (25 throws) behind second base)
c. Rest 10-15 minutes Step 9
d. Warm-up throwing a. Warm-up throwing
e. 60 feet (25 throws) b. 150 feet (25 throws)
Step 4 c. Rest 10-15 minutes
a. Warm-up throwing d. Warm-up throwing
b. 60 feet (25 throws) e. 150 feet (25 throws)
c. Rest 10 minutes Step 10
f. Rest 10 minutes c. Rest 10 minutes
g. Warm-up throwing d. Warm-up throwing
h. 60 feet (25 throws) e. 150 feet (25 throws)
90-foot Phase (distance from home plate to first base) f. Rest 10 minutes
Step 5 g. Warm-up throwing
a. Warm-up throwing h. 150 feet (25 throws)
b. 90 feet (25 throws) 180-foot Phase (distance from home plate to the outfield)
c. Rest 10-15 minutes Step 11
Step 6 c. Rest 10-15 minutes
a. Warm-up throwing d. Warm-up throwing
b. 90 feet (25 throws) e. 180 feet (25 throws)
c. Rest 10 minutes Step 12
f. Rest 10 minutes c. Rest 10 minutes
g. Warm-up throwing d. Warm-up throwing
h. 90 feet (25 throws) e. 180 feet (25 throws)
120-foot Phase (distance from home plate to second f. Rest 10 minutes
base) g. Warm-up throwing
Step 7 h. 180 feet (25 throws)
a. Warm-up throwing Step 13
b. 120 feet (25 throws) a. Warm-up throwing
c. Rest 10-15 minutes b. 180 feet (25 throws)
d. Warm-up throwing c. Rest 10 minutes
e. 120 feet (25 throws) d. Warm-up throwing
Step 8 e. 180 feet (25 throws)
a. Warm-up throwing f. Rest 10 minutes
b. 120 feet (25 throws) g. Warm-up throwing
c. Rest 10 minutes h. 180 feet (25 throws)
d. Warm-up throwing Step 14
e. 120 feet (25 throws) a. Return to position or begin throwing from the mound
Modified from Wilk KE, Arrigo CA: Interval sport programs for the shoulder. In Andrews JR, Wilk KE, editors: The athletes shoulder,
New York, 1994, Churchill Livingstone.
A B C
D E F
G H
Fig. 13-14 A-D, Pattern throwing from the

kneeling position. Emphasis is placed on proper
positioning of the hand, elbow, shoulder, and
trunk throughout the entire throwing motion.
E-H, Pattern throwing from the kneeling posi-
tion. Emphasis is placed on proper positioning
of the hand, elbow, shoulder, and trunk through-
out the entire throwing motion. I-J, Pattern
throwing from the kneeling position. Emphasis
is placed on proper positioning of the hand,
elbow, shoulder, and trunk throughout the entire
I J throwing motion. (Photos by Marsha Gorman,
Camarillo, Calif.)
body at 90 with the nonthrowing side hip, elbow, and shoul- throwing cycle. To teach proper hand placement on top of
der facing the target (Fig 13-15). The front foot or landing the ball, many young throwers are told during the late
foot is placed in a position just inside the nonthrowing cocking phase of the throwing cycle to take the ball off the
shoulder in a slightly closed position. This is repeated until shelf. This helps the athlete remember to place his hand on
the athlete is comfortable stepping to his target and rotating top of the ball but it essentially stops their trunk rotation.
his back foot and trunk during the windup through the early This drill is designed to further develop and incorporate the
cocking phase of the throwing cycle. This drill can then be previous drills while maintaining the athletes fluid trunk
advanced depending on the players position, starting from rotation without loosing the kinetic energy developed from
a crouch with catchers and from a fielding position for posi- the legs. The drill begins the same as the previous foot place-
tion players. ment and hand separation drills. However, the athlete is
holding a small hand towel instead of a ball while performing
Hand Position/Ball Transfer Drill the drill. The drill begins with the athlete facing the target.
The next drill we have young throwers practice is proper The back foot and leg step forward and rotate as in the previ-
hand break technique. This is accomplished by having the ous drill. The hands separate with the wrists pronating and
thrower practice transferring the baseball from the non- the thumbs facing down. As the throwing arm progresses
throwing hand to the throwing hand pronating both wrists. through the early cocking, late cocking, and then accelera-
This can be practiced in front of a mirror for further visual tion phases of the throwing cycle, pelvis, trunk, and shoulder
reinforcement (Fig 13-16). motion should continue and remain fluid with stopping. The
hand towel is used to provide a visual and tactile stimulus as
Trunk Rotation/Hand Towel Drill if the athlete was waving a flag (Figs. 13-17 and 13-18). The
This next drill is designed to develop a fluid trunk rotation flag should never drop as the thrower transitions from
during the late cocking through follow-through phases of the late cocking through the acceleration phase of throwing
A B C D
E F G
Fig. 13-15 A-D, Front view, foot placement (crow hop) drillas the athlete moves toward the target, stepping/hopping with the back foot toward the target
while rotating the foot 90. E-G, Side view, foot placement (crow hop) drillas the athlete moves toward the target, stepping/hopping with the back foot
toward the target while rotating the foot 90.
Fig. 13-16 Hand position/ball transfer drillThe athlete transfers the ball from the glove hand thumbs down, pronating the forearms.
Fig. 13-17 Front view, trunk rotation-hand towel drillThe back foot and
leg step forward, rotate 90 while the hands separate with the wrists and
forearms pronating. The thrower progresses through the entire throwing
motion with a fluid continuous movement, never allowing the towel to drop
or the throwing motion to stop.
Fig. 13-18 Side view, trunk rotation-hand towel drillThe back foot and leg step forward, rotate 90 while the hands separate with the wrists and forearms
pronating. The thrower progresses through the entire throwing motion with a fluid continuous movement never allowing the towel to drop or the throwing
motion to stop.
(Fig 13-19). This drill should be practiced so that a fluid by aerobic conditioning helps prepare the thrower recover-
throwing motion is consistently performed, incorporating ing from surgery for an eventual return to throwing. After
the feet, legs, trunk, and arms. throwing has been introduced into the rehabilitation
regimen, careful attention to throwing technique is impera-
SUMMARY tive to prevent reinjury. An interval throwing program is
followed to establish a time frame for a safe, gradual, and
Rehabilitation goals for the shoulder after surgery emphasize progressive return to throwing.
pain management, reestablishing ROM, and developing The program described in this chapter should only serve
strength in the shoulder-supporting musculature. To return as a guide for the progressive return of the thrower to throw-
the throwing athlete to sports after surgery requires further ing; it is not a specific postoperative protocol applicable to
intense strengthening and conditioning to regain preinjury all patient athletes. Each patients program requires individu-
form and performance. Progressive strengthening followed alization and should progress at its own rate.
Fig. 13-19 Trunk rotation-hand towel drillPoor technique allowing the throwing motion to stop and the towel to drop.
1 When designing a program to return a throwing athlete

back to sports, what two primary objectives should be
considered?
4 Trevor is 16 years old and recovered from a UCL sprain
in his throwing arm. He initiated a throwing program 1
week ago and is currently at step 3. He noted medial
elbow pain in yesterdays throwing session. What should
(1) Enhance current performance levels and (2) prevent be considered?
injury.
Throwing mechanics were reviewed and subsequent
2 Brandon returned from postoperative rehabilitation for

rotator cuff repair and has been cleared to initiate a
return to throwing program. Since this is his first visit
video analysis found that he was not following through
with his back leg, thus decelerating with his arm. As a
clinician you must not take for granted that the athlete
with you, what must be considered before he picks up a is performing the throwing motion correctly, no matter
baseball? what age or level of performance. This simple correction
along with backing down to step 2 for a week allowed
A complete physical examination must be completed to Trevor to progress through the program successfully.
assess his LE, core, and UE flexibility, strength, and coor-
dination. An aerobic capacity test also should be
performed. 5 Kyler has completed step 10 of the interval throwing
program. After yesterdays session he complained of
fatigue and inability to throw the full 150 feet. What
3 Paul is eager to begin his baseball interval throwing

program but has not been cleared by the physician yet.
What factors must be met before initiating a return to
could be the problem?
Upon questioning him further it was noted that he per-

throwing program (besides physician clearance)? formed his throwing exercises before performing his
throwing program, thus fatiguing his throwing muscles
Full and painless ROM and increasing the potential for injury (altered throwing
No pain or tenderness with palpation mechanics because of fatigue). It was emphasized that
Satisfactory muscle strength and conditioning if he was going to be lifting on the same day as throwing,
Normal or clinically stable examination that he should throw first and lift after.
6 During videotaping Ians throwing motion you note that

he does not fully pronate his hand during the cocking
phase. What exercises can be done to improve his
Trunk rotation/hand towel drill and hand position/ball
transfer drill are two effective ways to improve mechan-
ics during the cocking phase. This can be practiced in
mechanics? front of a mirror for further visual reinforcement.
REFERENCES 15. Chu D: Plyometric exercise. Nat Strength Cond Assoc J 6:56, 1984.
1. Atwater AE: Biomechanics of overarm throwing movements and of 16. Lundin PE: A review of plyometrics. Strength Cond J 7:65, 1985.
throwing injuries. Exerc Sport Sci Rev 7:43, 1979. 17. Scoles G: Depth jumping: does it really work? Athletic J 58:48, 1978.
2. Cain PR, Mutschler TA, Fu FH: Anterior instability of the glenohumeral 18. Wilk KE, Voight ML: Plyometrics for the shoulder complex. In Andrews
joint: a dynamic model. Am J Sports Med 15:144, 1987. JR, Wilk KE, editors: The athletes shoulder, New York, 1994, Churchill
3. Payton OD, Hirt S, Newton RA: Scientific bases for neurophysiologic Livingstone.
approaches to therapeutic exercise, Philadelphia, 1972, FA Davis. 19. Adams T: An investigation of selected plyometric training exercises on
4. McArdle WD, Katch FL, Katch VL: Exercise physiology: energy, nutri- muscle leg strength and power. Track Field Q Rev 84:36, 1984.
tion, and human performance, Philadelphia, 1981, Lea & Febiger. 20. Astrand P, Rodahl K: Textbook of work physiology, New York, 1970,
5. Dickoff-Hoffman SA: Neuromuscular control exercises for shoulder McGraw-Hill.
instability. In Andrews JR, Wilk KE, editors: The athletes shoulder, 21. Feltner M, Dapena J: Dynamics of the shoulder and elbow joints of
New York, 1994, Churchill Livingstone. the throwing arm during a baseball pitch. Int J Sports Biomech 2:235,
6. Pappas AM, Zawaki RM, Sullivan TJ: Biomechanics of baseball pitching, 1986.
a preliminary report. Am J Sports Med 13:216, 1985. 22. Franks BD: Physical warm up. In Morgan WP, editor: Ergogenic aids
7. Perry J: Anatomy & biomechanics of the shoulder in throwing, swim- and muscular performance, Orlando, Fla, 1972, Academic Press.
ming, gymnastics, and tennis. Clin Sports Med 2:247, 1973. 23. Siewert MW, et al: Isokinetic torque changes based on lever arm place-
8. Broer MR: Efficiency of human movement, Philadelphia, 1969, WB ment. Phys Ther 65:715, 1985.
Saunders. 24. Smith RL, Brunolli J: Shoulder kinesthesia after anterior glenohumeral
9. Toyoshima S, et al: Contribution of the body parts to throwing dislocation. Phys Ther 69:106, 1989.
performance. In Nelson R, Morehouse CA, editors: Biomechanics IV, 25. Gainor BJ, et al: The throw: biomechanics and acute injury. Am J Sports
Baltimore, 1974, University Park Press. Med 8:114, 1980.
10. Gambetta V: Conditioning of the shoulder complex. In Andrews JR, 26. Browne AO, et al: Glenohumeral elevation studied in three dimensions.
Wilk KE, editors: The athletes shoulder, New York, 1994, Churchill J Bone Joint Surg 72B:843, 1990.
Livingstone. 27. Ferrari D: Capsular ligaments of the shoulder anatomical and functional
11. Jobe FW, et al: Shoulder and arm exercises for the athlete who throws, study to the anterior superior capsule. Am J Sports Med 18(1):20,
Inglewood, Calif, 1996, Champion Press. 1990.
12. Verkhoshanski Y: Perspectives in the improvement of speed-strength 28. Fleisig GS, et al: Kinematic and kinetic comparison between baseball
preparation of jumpers. Yessis Rev Sov Phys Educ Sports 4:28, 1969. pitching and football passing. J Appl Biomech 12:207, 1993.
13. Wilt F: Plyometrics what it is and how it works. Athletic J 55:76, 1995. 29. Wilk KE, Arrigo CA: Interval sport programs for the shoulder. In
14. Cavagna G, Disman B, Margari R: Positive work done by a previously Andrews JR, Wilk KE, editors: The athletes shoulder, New York, 1994,
stretched muscle. J Appl Physiol 24:21, 1968. Churchill Livingstone.
PART 3 Spine
14 Anterior cervical discectomy
and fusion, 256
Derrick G. Sueki, Erica V. Pablo, Rick B. Delamarter, Paul D. Kim
15 Posterior lumbar arthroscopic discectomy
and rehabilitation, 283
Haideh V. Plock, Ben B. Pradhan, David Pakozdi, Rick B. Delamarter
16 Lumbar spine fusion, 313
Chris Izu, Haideh V. Plock, Jessie Scott, Paul Slosar, Adam Cabalo
17 Lumbar spine disc replacement, 335
Derrick G. Sueki, Erin Carr, Babak Barcohana
255
CHAPTER 14
Anterior Cervical Discectomy and Fusion
Derrick G. Sueki, Erica V. Pablo, Rick B. Delamarter, Paul D. Kim
C
ervical spondylosis or degeneration presents as dif- exacerbated by neck flexion and rotation away from the more
ferent clinical syndromes with the most common painful side. In cases of lower cervical degenerative disease,
being degenerative disc disease, radiculopathy, and the pain often radiates to the shoulder, upper arm, or infra-
myelopathy. Cervical degenerative disc disease may present scapular areas, and upper cervical disease may present as
as axial neck pain, neck stiffness, or as headaches. Cervical temporal pain and retroorbital headaches.2
radiculopathy classically shows symptoms of arm pain with Cervical radiculopathy typically presents as pain and par-
sensory or motor deficits in the upper extremities (UEs), esthesia in a single or multiple nerve root distribution. Spurl-
which is caused by disc herniation or osteophyte formation. ing sign is a reproduction of radicular pain caused by
Cervical spondylotic myelopathy (Figs. 14-1 and 14-2) may extending the neck and rotating the head to the symptomatic
occur with gait abnormalities, hand clumsiness, or upper side, which leads to narrowing of the neuroforamina. Axial
motor neuron signs. Studies on the natural history of degen- compression and the Valsalva maneuver may also reproduce
erative disc disease demonstrate that the majority of patients symptoms. The shoulder abduction sign is the reduction of
suffering from axial neck pain or radiculopathy improve radicular symptoms caused by placing the hand of the
with conservative treatment. Cervical myelopathy, however, affected arm on top of the head, which decreases tension on
tends to progress with time and close clinical follow-up is the nerve roots.3
warranted. Cervical myelopathy typically has gait abnormalities,
hyperreflexia, and loss of fine motor skills, which result
PATHOPHYSIOLOGY AND from mechanical compression of the spinal cord in the cervi-
CLINICAL EVALUATION cal region. Motor weakness and muscle wasting may be
present, as well as sensory abnormalities. Patients may also
Cervical spondylosis is a progressive degenerative cascade complain of neck pain and/or radicular symptoms, so careful
that occurs with aging. Annular tears and biochemical evaluation must be done to determine the exact cause of
changes in the cervical disc can lead to decreased water symptoms. Typical examination findings include upper
content, shrinking or herniation of nuclear pulposus tissue, motor neuron signs and hyperreflexia manifested as a posi-
and disc collapse. This places increased stress on associated tive Hoffman reflex, clonus of deep tendon reflexes, and an
facet and uncovertebral joints, causing them to degenerate, upgoing Babinski reflex.
eventually leading to axial neck pain and stiffness. In addi- History and physical examination remain the most
tion, this can lead to the formation of bony spurs and disc important processes in the diagnostic workup. Imaging and
herniations that may encroach on the neuroforamina, result- electromyography or nerve conduction studies can be used
ing in radiculopathy.1 to supplement the diagnostic workup. Plain radiographs,
The clinical presentation of cervical spondylosis can vary including anteroposterior, lateral, oblique, and lateral flexion
and must be distinguished from referred shoulder or visceral and extension views, can demonstrate developmental steno-
pain. A careful history and physical examination must be sis, disc space narrowing, abnormal alignment, dynamic
done to determine the exact cause of the neck pain. Nonme- instability, and osteophyte formation. Radiographic findings
chanical neck pain is less likely to be related to disc disease, may occur with normal age-related degenerative changes, so
and other sources including tumor and infection must be radiographic findings must be correlated with clinical find-
considered. Radicular symptom neck pain will often be exac- ings.4 Magnetic resonance imaging (MRI) is commonly used
erbated by neck extension and rotation to the affected side and is the most sensitive modality for demonstrating spinal
(Spurling sign). In contrast, muscular neck pain is often cord morphology in relation to the surrounding bony and
256
Chapter 14 Anterior Cervical Discectomy and Fusion 257
Fig. 14-1 Preoperative lateral radiograph demonstrating a small bony spur Fig. 14-2 Preoperative sagittal MRI showing C6-7 disc degeneration and
formation and disc height loss at C6-7. a large herniation.
soft-tissue structures (Fig. 14-3). Computed tomography Some patients also may respond to oral corticosteroids.9 All
myelography is highly sensitive for detecting foraminal ste- medications should be prescribed only with careful regard
nosis, but it is invasive and does have a risk of complications.5 for the potential adverse reactions and interactions with
Electromyography and nerve conduction studies can help other medications that the patient is taking. Physical therapy
distinguish between nerve root compression and a periph- is an essential component of conservative treatment and
eral neuropathy and are useful in patients with unclear includes modalities, such as traction and heat or cold therapy,
diagnose. In cases of mechanical neck pain without radicu- as well as an isometric neck and shoulder-stabilizing exercise
lopathy, several studies support the use of provocative dis- program. The specifics of a physical therapy program are
cography to confirm discogenic origin of the pain and to often left up to the discretion of the particular therapist.
clarify which disc levels are appropriate to treat.6,7 Surgical treatment depends on the clinical entity treated
and success of nonoperative treatment. Conservative treat-
TREATMENT AND SURGICAL INDICATIONS ment is the mainstay of initial treatment for cervical radicu-
lopathy and degenerative disc disease with acceptable
The majority of patients with axial neck pain experience results.10 Surgical intervention for patients with cervical
acceptable resolution of symptoms without surgical inter- radiculopathy is indicated when the symptoms are persistent
vention. Cervical radiculopathy responds well to conserva- or recurrent or they are severe or debilitating enough to
tive treatment, but many patients progress to experience merit surgery.11 A prolonged conservative course is recom-
recurrent or persistent symptoms.8 Initially, activity modifi- mended for treatment of axial neck pain. If surgery is being
cation and a brief soft collar immobilization are often recom- considered for axial neck pain and diagnostic evaluation has
mended, but prolonged inactivity may lead to deconditioning. failed, a discogram is obtained to identify the exact correct
Early pharmacologic treatment is initiated with nonsteroidal level(s) responsible for discogenic pain. As with any elective
antiinflammatory drugs or acetaminophen. With severe surgical procedure, appropriate patient expectations and
acute pain, narcotic analgesics may be used. Paraspinal selection must be considered before any surgical interven-
muscle spasm may be relieved with muscle relaxants but is tion (Box 14-1). In general, workers compensation patients
often improved with a soft collar immobilization alone. and those involved in litigation can be expected to have
258 PART 3 Spine
SURGICAL PROCEDURE
Single-level cervical disc disease is most commonly treated

with anterior cervical discectomy and fusion (ACDF). For
one or more adjacent levels, some surgeons choose to
perform a corpectomy of the intervening vertebral bodies
instead of multilevel ACDF. After the discectomy, graft
choices include an iliac crest bone graft, structural allograft,
or a synthetic/metallic spacer. Currently, most surgeons use
anterior cervical plating to prevent graft displacement ante-
riorly and to provide stability while cervical fusion occurs.
In cases of severe stenosis or instability, intraoperative neu-
romonitoring is often used in an attempt to prevent injury
and assess adequacy decompression.
Surgery begins with the induction of general endotra-
cheal anesthesia. The patient is then placed in the supine
position on a radiolucent operative table to allow imaging in
both the anterior-posterior and lateral planes. A soft bump
is placed beneath the scapula, and gentle traction is then
applied to the cervical spine. In addition, gentle skin traction
pulling toward the foot of the bed is applied with wide tape
on the shoulders. Traction helps to radiographically visualize
the lower cervical levels during surgery. The anterior neck is
then prepped and draped, with care taken not to restrict the
surgical field. Palpating the bony landmarks (or alternatively
by using a radiopaque skin marker and a lateral radiograph)
determines the level of the skin incision. A transverse inci-
Fig. 14-3 Preoperative axial MRI showing large right-sided disc herniation sion is then made through the skin and subcutaneous fat,
at C6-7. and bleeding is controlled using electrocautery. The platysma
muscle is carefully cut in line with the incision to avoid
cutting the large superficial veins just beneath it. Beneath the
platysma muscle, the deep cervical fascia is identified and
BOX 14-1 Indications for ACDF in Cervical Disc Disease divided laterally to the anterior border of the sternocleido-
Strong indications: mastoid muscle, where it is dissected inferiorly and superi-
Progressive cervical myelopathy orly off of the muscle belly. A finger is then used for blunt
Relative indications: dissection between the carotid sheath laterally and the
Radiculopathy that has failed to respond to trachea and esophagus medially down to the prevertebral
conservative treatment regimen of at least fascia. Retractors are then used to retract the midline struc-
6 weeks tures, allowing direct visualization of prevertebral fascia and
Recurrent radiculopathy underlying longus colli muscles and disc spaces.
Progressive neurologic deficit Once the appropriate level is confirmed, the longus colli
Severe, incapacitating axial neck pain that fails muscles are dissected off of the bone laterally and a self-
to respond to prolonged course of conservative retaining retractor is placed, exposing the disc space to the
treatment with consistent examination and uncovertebral joints. The operating microscope, sterilely
diagnostic studies confirming cervical disc disease draped, is then brought into the field (Fig. 14-4). Under
direct visualization using the microscope, the disc is incised
with a scalpel and the anterior portion is removed using a
pituitary forceps and an angled curette. A high-speed drill
may be used to complete the discectomy and expose the
worse outcomes even after successful fusion surgery.12,13 posterior longitudinal ligament (PLL). After exposure, the
Cervical myelopathy must be considered separately, PLL is elevated off of the posterior aspect of the vertebral
however, because clinical progression usually occurs even bodies using a small 4-0 forward-angled curette; it is then
with conservative treatment. Classically, patients with cervi- excised using 1mm and 2mm Kerrison rongeurs. The PLL
cal myelopathy have periods of clinical stability interspersed does not need to be routinely removed if no nuclear protru-
with stepwise degeneration and careful follow-up must be sion or extrusion is found, but this has to be carefully
used to monitor disease progression.14 explored. The foramina can be probed with the 90 angled
Fig. 14-4 Intraoperative photo showing primary surgeon and assistant

using the microscope during discectomy.
nerve hook to confirm adequate decompression or any

remaining loose disc fragments. When the discectomy and
foraminotomies are complete, the disc space is measured and
an appropriately sized graft is chosen. While increased trac-
tion is applied on the halter traction device, the graft is gently
impacted into position. When it is adequately positioned, all
traction is removed. An appropriate-sized plate is then
chosen and applied on the anterior aspect of the cervical
spine. Care is taken when drilling screw holes to choose a Fig. 14-5 Postoperative lateral radiograph showing solid fusion of C6 and
length that will be contained in the vertebral body and be C7 with anterior cervical plate and screws.
parallel with the endplate of the disc space. When the plate
is in position, a lateral radiograph is obtained and graft and
hardware positioning is checked (Figs. 14-5 and 14-6). treated for radicular symptoms achieve excellent clinical
After instrumentation is complete, the wound is copi- results (up to 90% satisfactory results), whereas those treated
ously irrigated and thoroughly checked for hemostasis. for axial neck pain achieve good results.15,16 One concern in
Often a drain is used even if the wound appears very dry, the postoperative period is overactivity before fusion is
because a postoperative hematoma may cause significant achieved. Solid consolidation of fusion often requires 6 to 12
morbidity. The platysma muscle and subcutaneous tissue are weeks, so excessive motion and loading are discouraged
then closed with interrupted absorbable sutures. A running during this period. Often patients are maintained in a rigid
subcuticular layer of suture may follow this closure, followed cervical collar for 6 to 12 weeks to restrict their activities, but
by a sterile dressing. The patient is then placed into a rigid patients frequently recover from surgery much sooner and
cervical orthosis before extubation. desire to remove the orthosis and resume normal activities.
Postoperatively, the head of the patients bed is main- This relative immobilization can result in significant patient
tained in an elevated position to decrease swelling in the deconditioning, which can be a challenge to the therapist. In
neck. The patient should be able to walk, void, swallow the early period of return to activity and therapy, it is impor-
liquids, and tolerate a diet before discharge. Most patients tant to avoid injury caused by an overly strenuous exercise
are discharged the day after surgery. Patients commonly program or an overzealous patient.
complain of a sore throat and pain with swallowing a few
days after surgery. If these complaints seem more severe than FUTURE DIRECTIONS
usual, then a single dose or short course of oral corticoste-
roids may be given in an attempt to minimize swelling. ACDF is a generally well-tolerated and successful procedure;
however, recent data has shown that cervical fusion may lead
OUTCOMES to less satisfying results than previously thought.17 Concerns
about adjacent segment disease has led to the development
Postoperatively, patients with radicular symptoms will often of cervical total disc replacement.18 Recently, results of a
note immediate relief of pain after surgery. Most patients multicenter, randomized, prospective Federal Drug Admin-
report a change in the quality of their axial neck pain to one istration clinical trial of cervical disc replacement (Synthes
more typical of postoperative pain. Generally, patients Prodisc-C) versus ACDF has shown clinical equivalence or
260 PART 3 Spine
superiority of cervical disc replacement over fusion.19 Other

clinical studies have demonstrated similar consistent evi-
dence with other cervical disc prosthese.20,21 These treat-
ments have the potential of offering shorter recovery times
and more rapid return to activity and may help prevent the
progression of adjacent-level degeneration. Our view is that
cervical disc replacement is superior to fusion.
THERAPY GUIDELINES
FOR REHABILITATION
Rehabilitation after a surgery is a science and an art. The

science of rehabilitation relies on a solid understanding of
the bodys normal response to injury and trauma. The art of
rehabilitation rests in the clinicians ability to interpret the
individual patients unique signs and symptoms. The ability
to formulate a plan of care that maximizes an individuals
healing potential relies on the ability to blend the science and
the art of rehabilitation. The initial portion of this chapter is
designed to provide the clinician with an understanding of
the role that tissue healing plays in the development of a
rehabilitation program. This will serve as a scientific founda-
tion upon which a clinician can base his or her clinical rea-
soning process. This tissue-healing model will then be placed
in the context of ACDF. The activities and precautions of
each phase of the rehabilitation process will be rooted in
A
current understanding of the phases of tissue healing. Spe-
cific treatment options are provided throughout the chapter,
but these should only serve as a guide to treatment and
should not replace sound clinical reasoning or judgment
when rehabilitating after ACDF.
The decision to operate on the cervical spine may be
driven by localized tissue damage and subsequent focal pain,
but the majority of spinal surgeries are initiated because of
damage to (or threat of damage to) the neural network of the
body. Myelographic computed tomography and MRI studies
have all demonstrated that 20% to 30% of people who have
disc herniation and stenosis do not have radicular symp-
toms, and many of these people do not have neck pain.22 It
has also been shown that under anesthesia, only nerves that
are inflamed will produce radicular symptoms when com-
pressed or placed under traction. Therefore, although the
intervertebral disc or stenosis can be the source of neck pain,
it is generally injury to the nerve that drives the decision to
undergo surgery. Protecting the nervous system from further
damage and providing an environment in which the nerve
can heal are primary goals of the surgery and rehabilitation
thereafter.
Within the spine, injury or damage to the nerve often
occurs at the spinal nerve root or the dorsal root ganglia.
Anatomically, differences in the nerve root make it more
susceptible to injury than at other regions of the peripheral
nerve. The nerve root is not as well protected, less able to
B
withstand deformation, and less able to repair itself than
Fig. 14-6 A, Preoperative lateral radiograph showing multilevel cervical the remainder of the peripheral nerve. The other structure
disc degeneration. B, Postoperative lateral radiograph of the same patient within the intervertebral foramen that is susceptible to
after three-level cervical disc replacement. damage is the dorsal root ganglia. The position of the dorsal
root ganglia is not constant and can be found inside the bodies, to aid in the mineralization and fixation of the region.
foramen, outside the foramen, or in the spinal canal, which The iliac crest is used as the primary source of graft material
can increase the likelihood that it will be injured. In addition, because of its cancellous bone composition. Cancellous bone
unlike the spinal nerve root and peripheral nerve, the dorsal has a greater potential for revascularization and osteogenesis
root ganglia do not have a blood-nerve barrier, which is than grafts from denser cortical bone sources. Healing after
necessary to prevent foreign substances from invading the a cortical bone graft can take up to two times longer than
nerve. These anatomic differences predispose the dorsal root its cancellous bone graft counterpart.31,32 As will become
ganglia to edema and mechanical compression.22-24 apparent later in the chapter, the healing and mineralization
Nerves must also be able to move and glide within the of bone at the site of fusion is a major factor driving
tissue. For this to occur, some slack in the system must exist. progression through the rehabilitation process.
The spinal cord changes length by 7cm from flexion to
extension. Studies in the arm show that a 7-mm excursion Phase I (Inflammation)
occurs in the nerves with movement. In addition to com- The inflammation phase is the first phase of tissue healing.
pression, increased tension of the nerve can result in nerve It begins with injury to the tissue, reaches its peak within the
damage. first 72 hours after injury, and is generally completed within
More specifically, tension in nerves causing a 20% to 14 days. During these first 14 days, several events occur.
30% increase in length will cause the nerve to break. Boyd Vascular structures in the immediate area constrict to
and associates25 demonstrated that as little as 6% strain prevent blood loss, and vascular tissues in the surrounding
decreases the amplitude of action potentials by 70%, and areas dilate to provide conduits through which healing mate-
10% to 12% strain causes complete conduction block. They rials can enter the injured site. Cells and chemical mediators
have also shown that nerve stretch of as little as 8% greater are brought into the area to remove all foreign debris and
than the resting length will cause a 50% decrease in blood dead or dying tissue and are responsible for the closure of
flow to the nerve and stretch of 15% will cause 80% to the wound. Both of these actions are important in the pre-
100% reduction in blood flow. Therefore, exercises that vention of infection.31,32 During the inflammation phase in
place undue stress and tension on the nerves should be bone healing, a hematoma is formed at the site of the surgery.
avoided.26 This begins immediately after surgery and is usually com-
Neurons are incapable of dividing and migrating; there- pleted within 7 days. The hematoma will form around the
fore regeneration occurs only through existing neurons. If graft and fusion site, and granulation tissue will fill any open
the connective tissue sheathing remains intact, then a poten- space between the graft, the vertebral bodies, and the
tial for nerve regrowth exists. If the sheath is disrupted, then instrumentation.31-34 Clinically, rehabilitation during the
the potential for regrowth diminishes. Initially, like any inflammation phase of tissue and bone healing should focus
tissue, an inflammatory process is seen within the nerve. on the prevention of blood loss, reduction of inflammation,
Within hours after injury, the nerves start to grow back from and managing the pain that accompanies tissue damage
the distal stump at 1 to 2mm per day. In addition to trans- (see Table 14-1).
mitting nerve impulses, the axon of the nerve functions to
transmit nutrients and chemicals down its lumen. These Phase II (Reparative)
axons are filled with axoplasm, which is necessary for nerve The reparative phase is the second phase of tissue healing.
health and survival. Axoplasm is a viscous substance and is This phase begins almost immediately after injury and is
thixotropic, which means that it needs constant agitation or completed in 21 days. The primary function of this phase is
it will gel.22-24 Thus care must be taken to encourage move- the formation of the dense connective tissue needed to repair
ment and gliding of the nerve, but at the same time, posi- the wound and reestablish structural continuity of the affected
tions that place tension on the nerve should be avoided. region. The process of repairing the tissue to its original state
ACDF surgery affects the sternocleidomastoid, platysma, is a time-consuming process, and little evidence supports the
anterior scalene, middle scalene, and the longus colli muscles. notion that tendons, ligaments, or large muscle injuries heal
It also requires the resection of the anterior longitudinal liga- by regenerating into their original tissue. Thus the reestab-
ment, PLL, joint capsule, and synovium.27-30 After the trauma lishment of structural continuity and integrity of tendons,
incurred during surgery, the body is only capable of repair- ligaments, and large muscle lesions is completed through the
ing small muscle lesions with regeneration of muscle tissue. creation of dense connective scar tissue. Reparation with
Large lesions will fill in with dense connective scar tissue. dense connective tissue patches or scar tissue is a fast process
Although dense connective scar tissue can function to rees- that can allow for quicker recovery of the tissue. Angioblasts
tablish tissue continuity, it lacks the contractile elements of and fibroblasts begin to enter the injured region within 5 days
normal muscle tissue and the tensile strength of normal liga- of the injury. These cells begin the process of tissue repair and
ment and tendon tissue. Therefore the ability to generate the revascularization of the region. Most of the actual dense
contractile forces or resist tensile loading through the region connective tissue development is completed by day 21.
of repair is compromised.31-34 During bone healing at this time, a synthesis and organiza-
Bone grafts from the iliac crest or from bone donors are tion of collagen is seen in the hematoma. Once the hematoma
often used within the disc space, between two vertebral is organized, blood vessels invade the area. This allows
262 PART 3 Spine
TABLE 14-1 Soft Tissue and Bone Healing The maturation subphase occurs from day 60 to 360 when
Time Frames the tissues are fully fibrous in nature. For this reason, a pro-
gression in the strengthening of the affected tissues may
begin. For bone remodeling, the hard callus begins to adapt
Phase Events Time Frames to the stresses placed upon it. These stressors can be internal
Phase I: Vasoconstriction in immediate area 0-14 days and external and include low serum calcium levels, skeletal
inflammation Vasodilation in surrounding areas microdamage, and changes in mechanical stress. The bone-
Wound closure remodeling process generally takes 6 months from initiation
Removal of foreign and necrotic tissue to completion, but it can take up to 4 years.31-34 Clinically,
Hematoma formation in the bone rehabilitation programs must provide appropriate levels of
Phase II: Fibroblasts enter region to create dense 0-21 days stress to the bone to encourage bone strengthening and
reparative connective tissue scars remodeling without creating or exacerbating tissue injury
Angioblasts enter region for (see Table 14-1).
revascularization
Summary
Soft callus formation in the bone
Phase IIIa: Dense connective tissue is converted 22-60 days Although guidelines can provide generalized time frames for
remodeling from cellular to fibrous healing and recovery, it is important to realize that a firm
Hard callus formation in the bone grasp of the factors listed previously will enable the clinician
Phase IIIb: Dense connective tissue is strengthened 61-84 days to individualize the rehabilitation program for each patient.
remodeling Bone is remodeled and strengthened No two patients are identical. Therefore no two rehabilitation
Phase IIIc: Dense connective tissue is strengthened 85-360 days programs should be identical. Solid clinical reasoning
remodeling Bone is remodeled and strengthened regarding the patient and the nature of the injury and surgery
will ultimately drive the rehabilitation process.
Certain key components should be kept in mind during
each phase of the rehabilitation process for ACDF.
osteoblasts to migrate into the region and form woven bone, Phase I:
which is known as a soft callus.31-34 Clinically, the goal of The initial goal of rehabilitation should be the reduction
rehabilitation in this phase should be to promote the develop- of inflammation, closure of the wound, and reduction in
ment of the new dense connective reparative tissue and pain.
woven bone (see Table 14-1). Phase II:
The surgical site should be protected until dense connec-
Phase III (Remodeling) tive tissue is formed and the bone shows evidence of
The remodeling phase is the last phase of the tissue healing mineralization.
process. The purpose of this phase is to strengthen the newly Movement of the UEs below shoulder levels to promote
formed scar tissue. Two subphase make up tissue remodel- nerve mobility and healing should be encouraged.
ing: (1) consolidation and (2) maturation. During the con- Phase III:
solidation subphase, tissue is undergoing conversion from a Gliding of the neural tissue through the surgical site to
cellular type to one that is fibrous in nature. The actual size prevent the formation of adhesions should be promoted.
of the scar stops growing by 21 days, although the scar will The clinician should begin placing stress on the soft tissue
continue to strengthen in response to stress. This subphase and bone in graded increments to promote proper soft tissue
lasts from 22 to 60 days. During this phase of bone remodel- and bone growth and development.
ing, the soft callus phase begins to mineralize and form a
hard callus. Variations in mineralization time exist, but gen-
erally mineralization is completed by day 64. Mineralization DESCRIPTION OF REHABILITATION
of the callus is used diagnostically as a marker for when it is AND RATIONALE FOR USING
appropriate to begin rehabilitation. The patient will not be INSTRUMENTATION
referred for rehabilitation until radiographic evidence indi- Phase I (Inflammatory Phase)
cates that the callus has mineralized.31-34 Clinically, rehabili-
TIME: 1 to 2 weeks after surgery (days 0 to 14)
tation should address protection and prevention of excessive
GOALS: Protect the surgical site, decrease pain and
motion through the fusion site.
inflammation, maintain UE flexibility, and initiate
Excessive motion at the fusion site can lead to excessive
patient education regarding neutral cervical spine
callus formation and delay of the reparative process. The
mechanics (Table 14-2)
goal of rehabilitation in this phase should be the strength-
ening of the newly formed connective tissue. Care must be During the initial phase of rehabilitation, the primary
taken during this phase not to exceed the mechanical focus of physical therapy is to protect the surgical site and
limits of the newly formed tissue, because overstress of the make sure that the patient is educated on the mechanics of
tissue will result in tissue injury and delay healing. maintaining a proper neutral cervical spine (Fig. 14-7).
TABLE 14-2 Anterior Cervical Discectomy and Fusion

Phase I Postoperative Pain Patient education Decrease pain and Encourage self-
Acute Inflammatory Edema regarding: edema management of pain
Phase Limited neck ROM Proper use of Protection of surgical and edema
Postoperative Limited nerve mobility cervical support repair (soft tissue and Prevent adhesions of
weeks 1-2 Limited tolerance to upright Protection of bone) neural tissue
(days 0-14) activities surgical site Restoration of UE ROM Prevent reinjury with
Limited cardiovascular Correct body Understand the time patient education on
endurance mechanics and frame for healing body mechanics and
maintenance of structures maintenance of neutral
neutral cervical Understand correct body cervical spine with
spine mechanics and activity
Daily walking maintenance of neutral Gradually improve
program cervical spine cardiovascular
Gradual increase in endurance
walking speed and
duration
Physical evaluation during this time may include

wound assessment and the assessment of bed mobility and
gait. Because of the fragility of the wound and fusion
sites, assessment of cervical range of motion (ROM) and
UE strength are not appropriate in this phase. The
primary physical impairments that the patient is likely to
experience are pain, limited cardiovascular endurance, and
limited tolerance to upright activities. During this time the
injured vasculature around the wound begins to close and
the noninjured vessels dilate, which may lead to increased
warmth and redness around the incision site. This may be
accompanied by neck pain and a sore throat. Oral analgesics
may be given by the physician to manage the pain and
inflammation.
The inflammatory phase lasts approximately 2 weeks.
During this time activities should center on resuming normal
daily activities. Ambulation to and from the restroom should
begin immediately, with assistance as needed, and progress
until the patient is independent. The patient should be
encouraged to increase the daily sitting tolerances. Pain and
fatigue should guide the progression. Once discharged from
the hospital, the patient will be instructed to protect the
cervical region. The cervical collar issued earlier should be
Fig. 14-7 Neutral cervical spine. Proper alignment of the cervical, tho-
racic, and lumbar spine in which stress to the joints, muscles, and vertebrae
worn 24 hours a day unless otherwise ordered by the
is minimized. physician.
Before discharge from the hospital, it is important that
the therapist educate the patient on proper cervical spine
Hospitalization after ACDF in most cases will be for 1 to 2 mechanics during activity, as well as the need to restrict
days. During this time the patient will be given a cervical large amounts of movement in the neck to prevent soft
collar to wear to immobilize the neck and encourage soft tissue and bone injury. (Refer to Box 14-2 for specific
tissue and bone healing. Instructions regarding the fre- patient guidelines to follow after discharge.) Because of the
quency of collar wear will be determined by the physician many muscular attachments of the shoulder girdle to the
and may differ on a case-by-case basis. cervical spine, the patient should be advised to refrain from
264 PART 3 Spine
heavy lifting and from activities above shoulder level. Before

BOX 14-2 Discharge Instructions After ACDF Surgery discharge, the need to continue a home walking program
Wear cervical collar as instructed. and use of the cervical collar should also be addressed.
Do not pick up or carry anything heavier than a 12
gallon of milk. Phase II (Reparative Phase)
Do not sleep with arms over head. TIME: 3 weeks after surgery (days 0 to 21)
Do not lift anything above shoulder level. GOALS: Understand neutral spine concepts, increase
Sleep on a firm pillow to help support the neck. UE soft tissue mobility and flexibility, improve
Avoid sitting or standing for prolonged periods of upright tolerance, improve activities of daily living
time. Change positions frequently. (ADLs), increase cardiovascular function (Table 14-3)
Get plenty of rest, but do not spend all of your time
in bed. In many instances, phase II of the rehabilitation process
Gradually increase walking time. Do not get will take place independently in the patients home. Home
overtired. therapy is rarely indicated; therefore education regarding
Avoid strenuous exercise or activities. patient progression through the first month after surgery is
Keep incision dry. Showering is allowed 10 days an important aspect of hospital care. The patient will be
after surgery if wound is not red or draining. progressed to phase III once sufficient radiographic evidence
You may sleep in any position that is comfortable, of callus formation and mineralization is seen. During the
except on your stomach or with arms over head. reparative phase of tissue and bone healing, the body begins
Do not drive until approved by your physician. to form and lay down scar tissue at the surgical site, enhanc-
Notify your doctor if any of the following occur: ing the integrity of the musculature to withstand gradual
Temperature greater than 101 F increases in loads to the tissues. Within the bone fusion site,
Redness or swelling around your incision callus formation is nearing completion. Rehabilitation
Any drainage from your incision throughout this phase should be a continuation of phase I,
Separation of wound edges and a broadening of the focus to include the restoration of
Any new bruising around the wound UE ROM to shoulder level and independence with self-care
New numbness or tingling in your hands or fingers skills while protecting the surgical site (Fig. 14-8). At this
Increased pain in neck, shoulders, or arms time in the rehabilitation process, the patient may begin
New weakness of either arm, hands, or legs active range of motion (AROM) exercises of the shoulders.
Nerves and soft tissue require movement to heal properly.
Movement also prevents the formation of scar tissue adhe-
sions between the nerve and the healing tissue surrounding

Phase II No signs of As in phase I Continue interventions in Same goals as phase I with Restore UE ROM and
Reparative phase infection Limited upper body phase I with the the following: tissue tension to allow
Postoperative week Incision site is strength following: Improve upright tolerance for proper movement
3 (days 15-21) healing well Limited upper body Initiate gentle stretching Restore functional ROM to mechanics
ROM of chest (corner stretch) UEs Reduce stiffness in
Limited tolerance to Gentle UE AROM Restore patient surrounding joints
prolonged sitting/ Trunk-bracing techniques independence with Prepare patient to be
standing positions in multiple planes self-care skills independent in self-care
Progress walking Improve upper body skills
program to 15-20 standing/sitting posture Restore proper posture
minutes as tolerated Improve ADLs while throughout trunk to
protecting surgical site allow patient to achieve
Increase cardiovascular overall neutral spine
function concept
Independent with home Improve cardiovascular
exercise program endurance
ADLs, Activities of daily living; AROM, active range of motion; ROM, range of motion; UE, upper extremity.
Once the surgical site has sufficiently mineralized, the physi-

cian may permit additional rehabilitation.
Postural Rehabilitation
Rehabilitation specialists should expect to see patients in an
outpatient setting at approximately 6 weeks after ACDF.
Upon initial evaluation, observation of the patients posture
will give the clinician a significant amount of information
concerning weakness, elongation, and strength of specific
musculature, as well as the patients ability to maintain a
neutral cervical spine. According to Janda,35 a common pos-
tural alignment seen in people with upper quarter pathology
is known as upper crossed syndrome (Fig. 14-9). Regardless
of the cause, this alignment will consist of an upper quarter
muscle pattern in which certain muscles will be weakened
and lengthened and others will be strong and shortened,
resulting in an increased thoracic kyphosis, increased mid-
Fig. 14-8 Corner stretch. The patient stands facing a corner with the arms cervical lordosis, and increased upper cervical extension.
placed on the wall and elbows bent 90. The patient leans the entire body Protraction of the scapula will often accompany this postural
forward with the knees slightly bent. Note that many patients will tend to deviation. More specifically, a weakening and lengthening
lead with their chin into the corner, which promotes poor cervical posture.
of the rhomboids, middle and lower trapezius, deep
To avoid this, instruct the patient to maintain a neutral cervical spine and
lead with their chest into the corner. neck flexors, supraspinatus, infraspinatus, and the deltoid
musculature occurs. This is combined with a tightening and
shortening of the pectoralis major and minor, levator scapu-
the surgery. Therefore movement of the arms below shoulder lae, upper trapezius, scalenes, subscapularis, and sterno-
level should be encouraged. Exercises incorporating flexion cleidomastoid muscles. Thus knowledge of how each muscle
and extension of the elbow, wrist, and fingers should also be has been affected after surgery is necessary to guide the
implemented at this time. Motion above shoulder level rehabilitation program. Postural rehabilitation should be
should still be avoided. implemented, and interventions should focus on the stretch-
Throughout all activities and exercises, the patient should ing of shortened musculature, strengthening of the weak-
be encouraged to maintain a neutral cervical spine. As neck ened muscles of the trunk and neck, and performing UE
pain and inflammation begin to subside in this phase and movements while maintaining a neutral cervical spine. The
the patient continues to progress in activity level, trunk sta- clinician should be constantly weighing the intervention
bilization exercises may be introduced to allow the patient required against the limitations imposed by healing tissue.
to achieve the overall neutral spine concept. Trunk stabiliza- In the case of upper cross patterns, it is appropriate for the
tion exercises will allow loads to be properly distributed patient to stretch the pectoralis and subclavius muscles, but
along the spine so as not to adversely increase loads to the stretching of the sternocleidomastoid or levator scapulae
cervical region during activities. Moreover, improved trunk muscle should be postponed due to these muscles proximal
stability and overall neutral spine will contribute to improv- attachment to the cervical spine. Good evidence of fusion
ing tolerance to upright postures. healing should be present before stretching of these cervical
muscles commences (Fig. 14-10).
Phase IIIa (Remodeling Phase)
Cervical Stability
ACDF surgery requires the partial resection of the longus
GOALS: Enhance nerve healing and mobility, prevent
colli muscle.27 From a functional recovery perspective, the
scar tissue formation, increase UE strength and
longus colli has an important role in maintaining cervical
endurance, improve thoracic spine mobility
stability. Although research is lacking regarding cervical sta-
(Table 14-4)
bility, numerous studies have been conducted on the role of
During this period of recovery, the patient (along with the lumbar stability to control motion and stabilize spinal seg-
soft tissues and bone of the surgical site) begins to experience ments.36 Richardson and associates37 performed a series of
numerous changes. Between the end of the fourth week and studies on the ability of deep lumbar muscles to stabilize
up to the sixth postoperative week, the physician will reas- spinal segments in patients with lumbar pain. Their findings
sess the patient. Generally this reassessment will include a suggest that deep muscle activation is a necessary compo-
new radiographic study. nent in the reestablishment of spinal control after a low back
Protection of the surgical site and proper immobiliza- injury. Subjects that did not reestablish segmental control
tion should continue until the physician has seen evidence continued to experience low back pain. Recently, the same
of mineralization and callus formation of the bone graft. group has turned its attention to the cervical spine.38 They
266
PART 3 Spine

Phase IIIa Patient understanding Limited nerve mobility Continue with phase II interventions as needed with the Same as phase II with the Prevent soft tissue adhesions at surgical
Remodeling phase of neutral spine Limited UE strength following: following: site
(consolidation) concepts Limited ability to perform PROM to shoulder above 90 Enhance nerve healing and Prevent neural adhesions
Postoperative No increase in pain overhead activities Begin gentle AROM of cervical spine as tolerated mobility Increase stabilization while performing
weeks 4-8 symptoms Limited mobility in thoracic Begin neuromobility techniques Prevent scar tissue formation daily activities to prevent reinjury
(days 22-60) No increase in nerve region Begin strengthening deep neck flexors Increase UE muscular strength Decrease joint stiffness to allow proper
related symptoms Limited cardiovascular Begin progressive resistance exercise program of the UEs and endurance movement with decreased pain
endurance below 90 of shoulder elevation (biceps curls, isometric Increase coordination in Independence with self-care activities
Limited neck mobility shoulder exercises) activating trunk and scapular
Poor cervical proprioception Trunk stabilization exercises with cocontraction of stabilizing muscles
scapular stabilizers Improve mobility of thoracic
Begin gentle soft tissue mobilization of thoracic region spine
Begin gentle thoracic spine mobilizations to the mid or Improve aerobic capacity
lower thoracic spine only Improve cervical proprioception
Thoracic AROM exercises (wall angels, scapular
retractions)
Walking tolerance to 30 minutes
Cervical position sense and proprioception
exercises
AROM, Active range of motion; PROM, passive range of motion; UE, upper extremity.
Weak: Tight:
Deep neck flexors Levator scapulae
Upper trapezius
Sternocleidomastoid
Tight: Weak:
Pectoralis major Rhomboids
Pectoralis minor Serratus anterior
Thoracic paraspinals
Fig. 14-9 Upper crossed syndrome. An imbalance of shortened and weak musculature that are in opposition in the cervical spine region. Tightened muscles
are generally the upper trapezius, sternocleidomastoid, pectoralis major and minor, and levator scapulae. Weakened muscles include rhomboids major and
minor, deep neck flexors, middle and lower trapezius, and the serratus anterior. (Courtesy Tamiko Murakami.)
suggest that deep cervical muscles are necessary for normal patient will need to begin at a different level after taking into
cervical spine stability. The role may be even greater than account his or her present functional status and familiarity
that seen in the lumbar region because of the large role cervi- with the exercises. The focus should be on the use of light
cal spine muscles play in the maintenance and control of a weights to build endurance of the musculature initially
region designed to provide mobility. Thus exercises designed to assist with return-to-work activities and maintenance of
to recruit deep neck flexors will be imperative to provide ade- prolonged postures.
quate stability of a highly mobile region. These exercises can
include supine chin tucks in a neutral spine using a rolled Joint Mobilization
towel or pillow if necessary, progressing to an inclined posi- Decreased flexibility in thoracic spine segments and the soft
tion and eventually a sitting position (Fig. 14-11). Jull38 has tissue of the thoracic region may prevent proper body align-
proposed the use of a blood pressure cuff behind the neck as ment, including full glenohumeral ROM. Thus treatment
a means of monitoring the amount of cervical muscle recruit- should include soft tissue mobilization to the mid and lower
ment (Fig. 14-12 and Box 14-3). A recent study by OLeary thoracic spine. Later mobilization to the midthoracic spine
and associates39 showed a significant improvement in iso- can be included with the authorization of the physician.
metric craniocervical muscle performance with the use of a It is appropriate to begin AROM and passive range-of-
pressure biofeedback device. In this study, patients were ini- motion activities at this time (Fig. 14-13). The clinician
tially instructed to achieve the correct cervicoflexion action should keep in mind that the biomechanics of the cervical
without increased activity of superficial musculature. Once spine will be altered by cervical fusion surgery. An under-
achieved, the use of a blood pressure cuff was used to guide standing of how it will be affected is critical in assessing a
the training of the craniocervical muscle contraction at dif- patients progress and ultimate outcome. The cervical verte-
ferent levels of pressure.39 brae are the smallest and most mobile of all spinal vertebrae.
A progressive resistance exercise (PRE) program for the The cervical region functions to provide mobility for the
UEs may be initiated with light weights during this phase. head on the trunk. It also functions to protect vital struc-
Biceps curls, triceps extensions, wrist and hand exercises, tures, such as the spinal cord, as they route distally down the
and isometric shoulder exercises are all appropriate at this body. In total, the functional units of the cervical region
time. must work together to provide 45 to 50 of flexion and 85
The strengthening program should still be carried out of extension, for a total of 130 to 135 of total sagittal plane
below 90 of glenohumeral elevation to ensure that the motion. In the horizontal plane, the cervical spine must be
musculature of the neck is not being overstressed. Each able to provide 90 of unilateral motion and 180 of total
268 PART 3 Spine
Fig. 14-12 Blood pressure cuff technique. The patient lies supine, with the
blood pressure cuff placed under the neck and inflated to 20mmHg and
the display held in front to monitor the dial. The patient nods or retracts
the head to raise the pressure 2mmHg. Once the patient is able to maintain
this pressure without fatigue, he or she may progress and increase the pres-
sure by 2mmHg.
rotational motion. Finally, 40 of unilateral frontal plane

motion occursor 80 in total (Table 14-5).40,41 Segmentally,
two adjacent spinal vertebrae and the intervertebral disc
between the two comprise a functional motion segment.
Each functional spinal unit provides varying degrees to the
total motion seen in the cervical region. The fusing of one
or several of the functional motion segments will alter the
Fig. 14-10 Wall angels. The therapist has the patient stand with the head, mechanics of adjacent segments. The body will eventually
back, and arms against the wall, knees slightly bent, chin tucked, and shoul- adjust; the result is transitional degeneration.
ders slightly abducted. The patient continues to elevate the arms against the Therefore, initially a fusion to the C5-6 motion segment
wall and bring them down, making the shape of angel wings.
may result in a loss of 10 to 15 of unilateral rotation.36,42
Therefore the objective goal of rehabilitation should not
be to attain 90 of unilateral rotation. Instead normal uni-
lateral rotation after fusion to C5-6 would be 65 to 70 of
motion.
Mobilization techniques are a mainstay of physical
therapy. In practice, they are used to increase ROM within
targeted regions by moving specific joints or specific muscles.
Care must be taken in choosing the appropriate time to
begin implementation of soft tissue and particularly passive
joint mobilization techniques because of the potential trans-
lational effect they may have on the cervical spine at the
region of the fusion. Although studies are lacking in the area
of mobilization of the cervical spine, several studies have
addressed the effects of mobilization in the lumbar region.
Researchers43-46 studied the effects of a posterior to anterior
force placed on the spinous process of L3. Their study showed
a force at L3 could result in movement as far away as T8; in
a follow-up study by the same group, the same posterior to
anterior force resulted in an anterior rotation of the sacrum.
The implications of these findings for the patient after a
cervical fusion are that even mobilizations to distant seg-
ments may have a translatory effect on the fusion site. There-
fore mobilization of the spine should not be initiated until
Fig. 14-11 Chin tucks. In a sitting or standing posture, the patient tucks the fusion site itself has shown radiographic evidence of
in the chin and extends the cervical spine. sufficient mineralization and callus formation. This
BOX 14-3 Strengthening and Retraining of Deep

Cervical Flexors Using Blood Pressure Cuff
Patient Position
Patient is supine in hook-lying position.
The head is placed in a neutral position.
Towels may be placed beneath the patients head to
achieve neutral cervical position.
The patients chin may need to be tucked in and
down to achieve a neutral cervical spine.
Procedure
A pressure biofeedback unit or blood pressure cuff
is placed beneath the patients neck.
Inflate pressure biofeedback unit or blood pressure
cuff to 20mmHg.
The patient holds the display in one hand and gently
retracts or nods the upper cervical region until
pressure rises to 22mmHg. This process is repeated
for 24mmHg, 26mmHg, 28mmHg, and 30mmHg.
Above 30mmHg is not relevant. The pressure that
the patient can hold for several seconds without
activation of the superficial neck muscles is the
beginning exercise value.
The patient is instructed to retract or nod until target
pressure is achieved. This amount of force is held for
10 seconds and repeated 10 times.
When the patient can contract for the designated
duration and repetitions without fatigue or
discomfort, it is appropriate to increase pressure
2mmHg.
To discourage substitution with the superficial neck
muscles, the patient can be instructed to place the
tongue on the roof of the mouth with lips together
and teeth just separated when completing the
exercise.
Fig. 14-13 Active cervical ROM. The patient is placed in a comfortable
Adapted from Jull G: Management of cervicogenic headaches. sitting position and asked to complete each cervical ROM movement slowly
In Grant R, editor: Physical therapy of the cervical and thoracic through the full ROM.
spine, St Louis, 2002, Churchill Livingstone.
information and the authorization of mobilization to the common long-term complication after a spinal fusion, par-
cervical spine should come from the surgeon. Moreover, ticularly in multilevel fusions. It consists of segmental articu-
research has revealed transitional degeneration in the seg- lar degeneration and spondylytic changes in the spine. It has
ments directly above and below the fusion. Once this is been hypothesized that these changes are the result of the
found, proper mobilization and joint forces may be added to increased stress placed on these segments because of the
begin stimulating proper formation and modeling of bone decreased mobility of the fusion spinal segments. Goffin and
tissue. colleagues48 studied 120 patients after ACDF surgery and at
Although it is difficult to imagine an instance when a mean follow-up period of 98 months. They found that 92%
direct mobilization to the fusion site would be warranted, of the patients demonstrated segmental degenerative
mobilization to adjacent structures and segments is justi- changes. Eventually, when dense connective tissue and bone
fied to increase spinal ROM and decrease the demands has been adequately strengthened and stabilized, then distant
placed upon the fusion site. spinal segments can be mobilized when needed.
However, therapists should be wary of applying mobi-
lization techniques close to the fusion site. Research has Neural Mobilization and Neural Dynamics
revealed transitional degeneration in the segments directly Neural mobility techniques should also be progressed in this
above and below the fusion.47 Transitional degeneration is a phase to prevent neural adhesions to the surrounding tissue.
270 PART 3 Spine
TABLE 14-5 Approximate ROM for the Three

Planes of Movement for the Joints of the
Craniocervical Region
Axial Lateral
Flexion/ Rotation Flexion
Joint or Extension Unilateral Unilateral
Region (Degrees) (Degrees) (Degrees)
Atlanto-occipital Flexion: 5 Negligible Approximately 5

Extension: 10
Total: 15
Atlantoaxial Flexion: 5 40 to 45 Negligible
Extension: 10
Total: 15
Midcervical Flexion: 35 45 35
Extension: 70
Total: 105
Total cervical Flexion: 45 to 50 90 Approximately
Extension: 85 40
Total: 130 to 135
Fig. 14-14 ULNT 1 technique.
Adapted from Neumann D: Axial skeleton: osteology and arthrology.
In Neumann D, editor, Kinesiology of the musculoskeletal system:
Foundations for physical rehabilitation, ed 2, St Louis, 2009, Mosby.
in relation to the soft tissue structure that surrounds them.
Scar tissue has the ability to restrict joints; scar tissue can Elvy50 developed the upper limb neurodynamic tests
adhere to nerves and affect their mobility. (ULNTs) as a method for differentiating potential sources of
Because the patient is likely to have experienced nerve- cervicobrachial symptoms. Upper limb neurodynamic test 1
related symptoms as a contributing factor for undergoing (ULNT 1) (Fig. 14-14) was designed to assess the movement
surgery, an understanding of neurodynamics, or the rela- capabilities of neural tissues associated with the median
tionship between the nervous system and associated con- nerve. Given the mechanical continuity of the nervous
nective tissues, will ensure proper interventions will be system, it has recently been recognized that all upper quarter
chosen that will not aggravate or overstretch the neural neural tissues are stressed during ULNT 1; however, compo-
tissue. While the concept of neurodynamics has been around nents of the test are specifically biased toward the median
for some time, empirical data supporting its clinical use has nerve trunk and C5-C7 nerve roots51 (Table 14-6). Although
been lacking. Neurodynamic techniques are commonly clas- originally designed to test the median nerve, clinicians are
sified into two categories: techniques that glide the nerve and using it as a general clearing test for UE neuromobility
techniques that stretch the nerve. An example of a gliding because all three major peripheral nerves in the UE are
technique in the upper quarter would be placing tension on stressed by the ULNT 1 position (Box 14-4).
the nerve at the wrist with wrist extension while simultane- Treatments using the ULNTs have generally been a point
ously reducing tension at the neck by side-bending toward of confusion for clinicians. A positive test is indicative of
the same side. An example of a tensioning technique would restricted mobility in the nerve being tested. Therefore using
be placing tension on the wrist with wrist extension while the test position to stretch the nerve and release any adhe-
simultaneously side-bending the neck toward the opposite sions along the course is a common treatment philosophy.
side. Research by Coppieters and associates49 has shown that Coppieters and associates52 also found that adding positions
sliding techniques produce a greater amount of nerve excur- of tension to a joint reduced the amount of nerve mobility
sion through the surrounding tissue than tensioning tech- in the adjacent joints. For example, adding wrist extension
niques. Furthermore, an increase in muscle activity also to a median nerve mobility test decreases the range of exten-
occurred with the addition of dorsiflexion. It has been sion available at the elbow. This finding was corroborated in
hypothesized that muscles are recruited to protect the nerve a study by Boyd and associates53 in which straight leg raise
and prevent injury when the nerve is placed in tension. Thus ROM was reduced when dorsiflexion was added to the ankle
clinicians should ensure that soft tissue surrounding the compared with the addition of plantar flexion. Thus when
nerve is free to achieve optimal neural movement. Therefore using ULNT test positions to glide the nerve, therapists
treatment should address the gliding and not stretching need to be aware that muscle tissue has the potential to
of nerves. elongate and stretch, whereas neural tissue is not as elastic
Neurodynamic testing of the upper limb enables the and responds adversely to stretching as explained above
clinician to assess the movement capabilities of neural tissues (Fig. 14-15).
TABLE 14-6 Upper Limb Neurodynamic Testing BOX 14-4Testing Procedure for ULNT 1
(ULNT) Positions
1. First, establish the patients baseline resting
Nerve symptoms. Remember to reassess baseline
Test Assessed Test Position symptoms, resistance, and range of motion with the
addition of each new component.
ULNT 1 General Supineleg straight and uncrossed
2. The patient is positioned in supine near edge of
Spine in midline position
table.
Stabilization of shoulder girdle
3. Therapist position:
Shoulder abduction
a. The therapist takes a stride-stance position facing
Wrist and finger extension
the patients head.
Forearm supination
b. Next, the therapist uses a pistol grip handhold on
Shoulder lateral rotation
the fingers of the limb to be tested. It is important
Elbow extension
to maintain finger extension and thumb abduction
Cervical lateral flexion away
during the procedure.
Cervical lateral flexion toward
c. The therapist will then lean his or her elbow on
ULNT 2a Median Supineleg straight and uncrossed
the table for support and stabilize the patients
shoulder girdle in neutral.
d. Alternatively, the clinician may stabilize the
Shoulder girdle depression
patients shoulder girdle by pushing his or her fist
Elbow extension
vertically downward on the examination table
Whole arm lateral rotation
with the shoulder girdle in neutral.
Wrist and finger extension
4. Procedure:
Shoulder abduction
a. The shoulder is abducted in the neutral coronal
ULNT 2b Radial Supineleg straight and uncrossed
plane from 100 to 130. Care must be taken to
prevent any shoulder girdle elevation.
b. Next, the therapist adds wrist extension, finger
Shoulder depression
extension, and forearm supination.
Elbow extension
c. Add shoulder lateral rotation.
Whole-arm internal rotation
d. Add elbow extension.
Wrist flexion
5. Sensitizing maneuvers include:
ULNT 3 Ulnar Supineleg straight and uncrossed
a. Contralateral cervical lateral flexion
b. Ipsilateral cervical lateral flexion
c. Release of wrist extension
Wrist extension
Forearm pronation ULNTs, Upper limb neurodynamic tests. Adapted from Butler
Elbow flexion D: The sensitive nervous system, Adelaide, Australia, 2000,
Shoulder lateral rotation Noigroup.
Shoulder girdle depression
Shoulder abduction postural stability and cervical joint position sense. Although
the exact physiologic mechanism is not clear, these changes
Adapted from Butler D: The sensitive nervous system, Adelaide,
Australia, 2000, Noigroup. are believed to be the result of a traumatic injury to the
nerves themselves, chemical mediators within and around
Soft tissue structures along the course of the nerve can the joint that inhibit the proprioceptive nerves, as well as
be mobilized to allow for nerve mobility. Movement of the central changes occurring at the spinal cord and cortical
UE can be combined with small movements of the neck to regions that alter the bodys response to proprioceptive
encourage gliding of the nerve rather than stretching. input. Research has shown that rehabilitation of the cervical
Finally, communication with the patient is essential, spine thus far has traditionally focused on the strength and
because radicular pain or paresthesia is indication that length of muscles in the region, as well as joint and nerve
the nerve is being stretched and potentially irritated. The mobility, which may not be as effective in addressing pro-
patient and therapist should work in ROMs that do not prioceptive and sensorimotor disturbances in patients with
reproduce the patients radicular symptoms. neck pain.54 According to recent studies by Trevelean,55,56 the
abundance of mechanoreceptors in the cervical region plays
Cervical Proprioception an important role in providing proprioceptive input to the
As the healing process continues in bone and soft tissue central nervous system. There are high densities of muscle
structures, the patient may also have sensorimotor deficits, spindles in the cervical region, especially in the suboccipital
such as unsteadiness, visual disturbances, and changes in muscles, which have up to 200 muscle spindles per gram of
272 PART 3 Spine
B
Fig. 14-15 Self-neurogliding techniques. A, Median. B, Ulnar. C, Radial.
muscle. This amount is significant when compared with the

16 muscle spindles per gram of muscle in the first lumbri-
cal.55,56 In addition, the visual and vestibular systems of the
cervical spine region have been shown to influence the pro-
prioceptive input provided by the cervical mechanorecep-
tors. Therefore, the visual, vestibular, and proprioception
systems are integrated to provide the sensory input for
proper cervical function. In terms of cervical rehabilitation,
these findings suggest balance, proprioception, and visual
training should be added to a patients exercise program to
address sensorimotor and proprioceptive deficits.
Symptoms of poor head and neck awareness or a wob-
bling head may be due to poor cervical position sense. To
assess for disturbed joint position sense, Treleaven advocates
the use of a small laser pointer mounted on a lightweight
headband. The patient is seated 90cm away from a wall and
the point where the laser shines at initial setup is marked.
The patient proceeds to close his or her eyes and then pro-
vides a neck motion (for example, right or left rotation). The
patient is then instructed to return the head to the initial Fig. 14-16 Exercise for joint position sense retraining using a laser pointer.
head position. A greater than 4 to 5cm error is indicative of (Adapted from Treleaven J: Sensorimotor disturbances in neck disorders
cervical proprioception deficits (Fig. 14-16).57,58 This assess- affecting postural stability, head and eye movement control. Man Ther
ment technique can be used as an exercise in which the 13:2-11, 2008.)
patient practices relocating the beam of light to the initial
position with the eyes open, trying to improve the accuracy seated patient (Fig. 14-17). The use of joint positioning/neck
of the movements each time. To improve deficits in neck movement control exercises, coupled with focused treatment
movement control, in which patients complain of fatigue in on balance training, has proven to be effective in treating
the neck or difficulty with AROM movements because of patients with acute and chronic neck pain.54 Balance training
increased muscle contraction to protect the cervical spine, to improve postural stability included exercises incorporat-
the patient may use the laser pointer to trace a pattern on ing tandem stance and single-leg stance, with both eyes open
the wall such as a figure eight placed 90cm in front of the and closed, and alterations of stance surfaces. The stance and
In addition, balance exercises may cause increased pain or

headaches, and the tasks might need to be altered to more
supportive positions. Mild dizziness may occur with balance
exercises to allow for vestibular habituation, but the patients
symptoms should be monitored closely. If the presence of
any central nervous system signs appears without explana-
tion or diagnosis, it may be considered a red flag and the
therapist should refer the patient to a physician for further
tests. Thus far, incorporating proprioceptive, balance, and
visual training interventions to a cervical rehabilitation
program have achieved positive outcomes.
To facilitate the return-to-work transition in this phase,
cardiovascular endurance should be continued. A daily
walking program should be continued and progressed as
tolerated.
Phase IIIb (Remodeling Phase)

Fig. 14-17 Exercise for neck movement control using a laser pointer GOALS: Restoration of strength to the cervical spine,
mounted on the head to trace a pattern on the wall. (Adapted from Tre- maintenance of neutral spine for prolonged periods
leaven J: Sensorimotor disturbances in neck disorders affecting postural of time with concurrent UE movement, improvement
stability, head and eye movement control. Part 2: Case studies. Man Ther
in scapulothoracic mechanics (Table 14-8)
13:266-275, 2008.)
Progression to this phase of rehabilitation should begin
once the patient is able to tolerate the exercises of phase IIIa
TABLE 14-7 Exercises and Progressions to without an increase in neck or arm symptoms. Interventions
Improve Cervical Proprioception from the previous phase have focused on loading the upper
Task Progression and lower body without directly loading the cervical spine.
The purpose of this precaution is to prevent overstressing
With laser pointer on headband for Eyes closed, check eyes open newly healed structures. This particular stage in the rehabili-
feedback, relocate back to neutral Increase speed tation process will slowly begin to incorporate direct treat-
head position from different head Perform in standing ment to the cervical spine structures and therefore should
movements with eyes open not be started until the patient has adequately demonstrated
With laser pointer mounted on headband, Increase speed tolerance to the loads placed on the neck. The patient should
practice tracing over a pattern placed More difficult patterns also be able to demonstrate proper neutral cervical spine
on the wall with eyes open Small finer movements concepts.
Balance training in standing position for Eyes open and closed The thoracic spine musculature such as the rhomboids
30seconds Change surfaces from hard to soft and middle and lower trapezius can be further challenged
Different stances: comfortable, from the previous phase by adding resistance with light
tandem, narrow, single limb weights on a seated or standing rowing machine or through
Sitting in a neutral neck position, keeping Eyes up and down, H pattern the use of resistance tubing (Figs. 14-18 and 14-19). Proprio-
the head still and the hands on the Increase speed ceptive neurofacilitation techniques may also be used to
lap, move the laser light back and Increase range of movements strengthen thoracic paraspinals and scapulothoracic muscu-
forth across the wall while the patient Perform standing lature. PREs may be increased in weight, sets, and repetitions
has to follow the laser with the eyes Perform on uneven surfaces as tolerated. Exercises above 90 shoulder elevation may be
initiated to further strengthen cervical musculature. Isomet-
ric cervical spine strengthening may begin in all planes.
Attention should be given to complete these exercises in the
surface were dependent upon the patients capabilities. The neutral cervical spine to strengthen the musculature of the
visual training exercises consisted of asking the patient to cervical spine to allow for proper posture and force produc-
place the head in various positions and then asking the tion of these muscles. The patient is placed in a comfortable
patient to visually track objects or visual targets on the wall. sitting position. For flexion, the patient places both hands on
Beams of light or a laser pointer provided a target that the the forehead and brings the forehead into the hands without
patient could track with his or her eyes (Table 14-7). Since moving. In extension, the patient places both hands on the
the patient has recently begun AROM exercises, the therapist back of the head and brings the head backwards into the
should use sound clinical judgement as to when these exer- hands without moving (Fig. 14-20). During the side bend,
cises should be incorporated into the patients plan of care. the patient places one hand on the side of the head and
274 PART 3 Spine

Anticipated
Phase IIIb Surgical site has Same as phase II with Continue with phase II Restore strength to Independent with
Remodeling healed the following: interventions as needed with cervical spine self-care and ADLs
phase No increase in pain Limited ability to the following: Improve Prevent reinjury with
(maturation) symptoms perform activities in a Begin isometrics of the cervical scapulothoracic increase in dynamic
Postoperative Patient prolonged sitting/ spine mechanics activities
weeks 9-12 demonstrates standing position Begin gentle UE strengthening Maintenance of Knowledge of
(days 61-84) neutral spine Patient is not fully above 90 of shoulder neutral spine in pain-relieving strategies/
concepts independent with ADLs elevation various positions/ positions during
PREs: Shoulder shrugs, triceps planes with prolonged activities
push down, wall push-ups concurrent UE
Scapulothoracic and thoracic movement
paraspinal strengthening using
PNF techniques
Thoracic exercises: Scapular
retractions with resistance
Progress abdominal
strengthening exercises in
different positions: Standing,
quadruped
Initiate upper body exerciser
as tolerated in neutral spine
ADLs, Activities of daily living; PNF, proprioceptive neuromuscular facilitation; PREs, progressive resistance exercises; UE, upper extremity.
Fig. 14-18 Scapular retractions using resistance tubing. The patient sits or
stands (with knees slightly bent) with resistance tubing secured in front. He
or she pulls the tubing simultaneously to the sides by retracting the scapula
and bending the elbows. The patient is instructed to relax the shoulders and
pinch the shoulder blades together.
Fig. 14-19 Prone scapular retraction progression. The patient is placed in

a prone position on the table with the arms at the sides. The therapist
instructs the patient to lift the forehead off the table, keeping the chin tucked
in a neutral cervical spine position. The patient can then perform scapular
retraction exercises.
attempts to bring the ear to the shoulder without moving. In he or she be assisted in the development of strategies to
rotation, the patient places one hand to the side of the head increase muscle endurance so that the patient may gradually
in front of the ear and looks over the shoulder without allow- build a tolerance to these positions. Strategies may include
ing movement. Strength and trunk control can be further limiting the time spent in any one position, the use of cryo-
challenged through the addition of an unstable base of therapy to the neck, or active cervical ROM exercises to
support, such as a half foam roller placed under the feet or relieve stiffness and soreness. Cardiovascular endurance and
the use of a stabilization ball. A clinician should be assisting strength should continue during this phase, and the use of
the patient at all times during these exercises. Synchronized an upper body exerciser may be initiated for short amounts
UE movements, such as biceps curls while balancing on an of time.
unstable support, will further challenge the trunk and neck
complex simultaneously. Placing the patient in positions such Phase IIIc (Remodeling Phase)
as quadruped or prone on the stabilization ball should warrant
caution and be delayed if the patient has yet to demonstrate
GOALS: Return to presurgical strength and endurance,
deep neck flexor strength or the ability to maintain a neutral
return to prior level of functioning, prepare for
cervical spine in an antigravity position. Proper neck align-
discharge from physical therapy (Table 14-9;
ment should be maintained during execution of all therapeutic
see also Suggested Home Maintenance Box)
activities.
At this stage of rehabilitation, the patient may find it dif- The remaining phase of the rehabilitation process centers
ficult to perform activities that require prolonged sitting or on regaining presurgical strength and endurance. By the end
standing postures. It is important to assist the patient in of this phase, the patient should be able to function indepen-
recognizing methods or activities that have the ability to dently at home and in the workplace. As the patient
relieve some of the pain or soreness. It is also important that progresses through the rehabilitation process, functional
retraining of work- or sport-specific activities should be
assessed. Activities that require increased loads on the cervi-
cal spine should be evaluated; pending physician approval,
rehabilitation geared toward functional training can be initi-
ated. Return to activities or sports that require contact
between players or heavy lifting will require the physicians
approval. At this time the physical therapist may implement
a gym- or home-based exercise program to assist in mainte-
nance of proper strength and muscle function. Discharge of
the patient should occur once the patient, physical therapist,
and physician have all determined that the patient has
reached his or her functional goals and is able to continue
the rehabilitation process safely and independently.
Clinical Pearl: Cervical Classification

In the 1980s, Sahrmann and associates began to lay the foun-
Fig. 14-20 Extension. The patient places both hands on the back of the dation for the development of a clinical reasoning method
head and brings the head backward into the hands without moving. that focused on subgrouping patients of a larger entity into

Phase IIIc Patient able to Difficulty lifting heavy Progress sets and Return to prior level Improve patients ability to
Remodeling self-manage pain objects repetitions of UE-resisted of functioning manage work-related schedule
phase No decrease in Difficulty maintaining exercise program as Return to presurgical Promote continuance of proper
(maturation) functional ability prolonged postures tolerated by patient level of strength and postures and home
Postoperative Functional retraining endurance maintenance program after
weeks 13-24 activities (work or sport Prepare patient for discharge from physical therapy
(days related per physician discharge
85-168) approval)

276 PART 3 Spine
smaller homogeneous groups to identify specific interven-

tions that will address each subgroups specific signs and Dysphagia
symptoms.59 Regions such as the neck and low back are large The incidence of dysphagia in patients after ACDF has been
heterogeneous groups and proving efficacy of treatment with reported as high as 28%.62,63 Additional studies have noted
such a diversity of patients and pathology is difficult. If the that 51% of patients will have swallowing difficulty at 1
characteristics of this subgroup can be identified and paired month after surgery, 31% at 2 months, and 15% at 6 months.64
with the most effective interventions, then prognosis and the Therefore speech and swallowing problems after ACDF are
quality of patient care will improve. In recent years, the not uncommon, although dysphagia is one of the primary
development of classification-based research has taken on symptoms accompanying plate and screw loosening. Persis-
renewed interest. Childs and associates proposed such a tent symptoms should be cause for further examination by
classification-based system for the treatment of the cervical the physician.
region.60 While recovery from cervical fusion surgery does
not completely fit within the scope of this classification Esophageal Injury
system, we can apply the principles of their findings toward Esophageal injury is rare but can occur up to 1 year after
the treatment of patients following cervical fusion. The study surgery.65 The mechanism behind the injury has been attrib-
suggests five pairings of outcome goals with specific inter- uted to laceration or pressure necrosis of the esophagus by
ventions. The outcome goals are mobility, centralization, graft displacement. Signs and symptoms of an esophageal
conditioning and increased exercise tolerance, pain control, injury include increased neck and throat pain, odynophagia,
and reduced headaches. Of these five outcomes, pain control erythema, swelling, tenderness, crepitus, subcutaneous
and conditioning and increased exercise tolerance most emphysema, unexplained tachycardia, sepsis, and difficulty
closely reflect the goals following a cervical spine fusion. swallowing.
Pain control is a primary goal in the first and second phases
of cervical rehabilitation and the interventions linked to this Neural Injury
outcome are AROM exercises within pain tolerance, ROM The recurrent laryngeal nerve is susceptible to nerve injury
exercises for adjacent regions, physical modalities as needed, after ACDF surgery. Incidence of injury has been reported
and activity modification. The outcome goal of increased to be between 0.07% and 11%.66 Injury to the recurrent
exercise tolerance and conditioning takes place in the second laryngeal nerve may be the result of endotracheal tubing that
and third phases of cervical rehabilitation. Strengthening/ may compress and damage the nerve. Symptoms of nerve
endurance exercises of the upper quarter, as well as aerobic injury include vocal cord paralysis. Spinal cord injury sec-
exercises, are the interventions proposed to achieve this ondary to ACDF is 0.4%.67 Most often the source of the
clinical outcome. spinal cord injury is posterior displacement of the bone graft.
Nerve root injury is also low at 0.6%. The most affected nerve
TROUBLESHOOTING root is C5. Most incidence of injury resolved in 6 weeks.
Red Flags Vascular Complications

The majority of postoperative complications and red flags The exact prevalence of vascular complications after ACDF
will occur within the first several weeks after surgery. Clini- is unknown. Most studies report values in the neighborhood
cians should be aware of these complications and should of 0.6% or less for vertebral artery injury after ACDF
educate the patient to notify his or her physician immedi- surgery.68,69 Signs and symptoms of vertebral artery injury
ately if any of the following complications should occur. include dizziness, dysphagia, dysarthria, diplopia, and drop
Although the majority of the red flags will occur before a attacks.
patients release to outpatient rehabilitation, the outpatient
clinician should be cognizant of any drastic changes that Cervical Spine Bracing
would warrant communication with the physician for further Skin breakdown and soft tissue injuries are common with
assessment and testing. the long-term use of cervical bracing. In addition, muscle
atrophy, dysphagia, and gastrointestinal dysfunction have
Infection also been reported. Signs and symptoms of pressure sores or
The risk of infection after cervical spine surgery is difficult swallowing dysfunction must be monitored.61
to determine. Postoperative infection rates of up to 6% have
been reported. Several factors affect a patients risk for Graft Failure
acquiring an infection, including a patients age, duration of Graft failure after ACDF may be caused by the following:
surgical procedure, and the patients preoperative physical graft displacement, nonunion, instrumentation failure, host
condition.61 Obesity is also a risk factor for infection because factors including osteoporosis or extreme kyphosis, and
adipose tissue is poorly vascularized. Uncontrolled diabetes technical factors such as a short or long graft. Graft failures
also increases the risk of infection. Signs and symptoms of are highest with multilevel fusions at 60%, and graft dis-
infections include erythema, edema, purulent wound drain- lodgement has been reported in 5% to 50% of multilevel
age, tenderness, fever, and increased pain. surgeries without instrumentation. Nonunion rates are
higher in iliac crest allografts (60%) versus autografts (17%), fixation. As a clinician, it is important to realize that not all
although they are the same rate at 5% for single level fusions.70 pain is a reflection of actual tissue damage. Some pain is the
Clinical symptoms for patients who are symptomatic from result of tissue changes, and this will affect the ability to
nonunion include increasing neck pain and worsening axial rehabilitate patients.26,71-73
pain 6 months after surgery. Patients may have difficulty
swallowing and breathing after an anterior graft displace- SUMMARY
ment. Patients who experience a worsening of pain and
symptoms should be referred to the physician for additional Rehabilitation of a patient after ACDF surgery is unique in
evaluation and testing procedures. terms of the close relationship the neck has with the shoulder
region and its neural network. Unlike other regions of the
Chronic Pain body, such as the shoulder and the wrist, complete immobi-
Changes in the peripheral and central nervous system occur lization of the cervical spine is difficult, which can affect the
almost immediately after an injury. Some of these changes healing potential of the fusion site. Therefore educating
are reversible, and other changes are nonreversible. Many of the patient on the need to adhere to surgical protection
these changes have been proposed as the pathomechanisms guidelines immediately after surgery is important. Protection
behind the chronicity of pain. It is beyond the scope of this of the surgical site is the key aspect of early rehabilitation, and
chapter to describe all the neural changes that occur with stressing of the fusion site should not begin before mineraliza-
injury; however, from a clinicians viewpoint it is important tion of the callus. Moreover, the shoulder girdle and UE,
to realize that not all patients will have full resolution of unlike the hip and lower extremity (LE), rely on coordinated
symptoms after surgery. Surgery may have addressed the muscle actions to maintain function and stability. Many of
structures that were originally the source of the patients these muscles have their proximal attachments at the cervical
symptoms, but the adaptations that have occurred in the spine. Therefore protection of the fusion must also address
central and peripheral nervous system may not be reversible. limiting UE activity until the surgical site is fully healed.
Rehabilitation after ACDF has 80% to 90% satisfactory Finally, because radicular pain and UE paresthesia are often
results. There remain an elusive 10% to 20% of patients who the symptoms driving the decision for ACDF, the prevention
continue to experience pain despite the fact that the offend- of neural adhesions and promotion of nerve healing should
ing structures have been addressed through removal or be addressed appropriately.

The patient can use the following home Weeks 4 to 8
maintenance program during the rehabilitation GOALS FOR THE PERIOD: Increase upper extremity
process. The contents of the home maintenance (UE) ROM, improve thoracic spine mobility, begin
program may change, depending on the mild weight training
patients tolerance and ability to complete the 1. Continue use of collar per physician
exercises properly and without the onset of pain 2. Continue proper body mechanics and
symptoms. maintenance of neutral spine
3. Progress walking program
Weeks 1 to 3 4. Active UE ROM in flexion, abduction, horizontal
GOALS FOR THE PERIOD: Protection of the surgical abduction, and adduction (maintaining ROM
site, decrease pain and edema, understanding of below 90 of shoulder elevation).
proper body mechanics and posture, increase 5. Wall angels
walking speed and endurance 6. Scapular retractions
1. Protection of the surgical incision 7. Begin biceps curls using light weights
2. Proper use of the cervical collar per 8. Begin cervical proprioceptive training at home,
physician including balance exercises as tolerated
3. Knowledge of correct body mechanics and 9. After removal of collar, patient may begin AROM
cervical neutral spine during activities to tolerance of cervical spine in rotation, side
4. Increase upright sitting tolerance bend, flexion, and extension (with physician
5. Daily walking program as tolerated approval)
278 PART 3 Spine
Weeks 9 to 12 1. Continue previous exercises and progress as

GOALS FOR THE PERIOD: Increase cervical strength, tolerated
UE strength, independence with ADLs 2. Develop independent gym exercise program
1. Continue with previous exercises and progress a. Seated or standing rows
repetitions, weight, or sets as tolerated b. Latissimus pull-downs
2. Scapular retractions with light resistance tubing c. Tricep push-downs
3. Wall push-ups d. Bicep curls
4. Chin tucks in sitting position 3. Patient may perform previously mentioned
5. Tricep push-downs using light resistance tubing exercises while sitting on stabilization ball and
6. Latissimus pull-downs using light resistance using resistance tubing
tubing 4. Self-resistance to cervical spine: isometrics
7. Home neural mobility exercises a. Flexion
b. Extension
Weeks 13 to 24 c. Side bend
GOALS FOR THE PERIOD: Return to previous d. Rotation
functional level and review home conditioning
program
1 Angel is a 45-year-old woman who has arrived at the

outpatient clinic for an initial evaluation status after
ACDF. The surgery was 4 weeks ago. Her chief com-
and advise the patient not to lift and only move his arms
minimally above 90.
plaint is stiffness and soreness in her neck with difficulty

sleeping at night. She also notes continued difficulty
swallowing and complains of a dry mouth. She asks the
3 Sam is a 54-year-old man who underwent ACDF 12
weeks ago. He started outpatient physical therapy ser-
vices 6 weeks ago and has made significant improve-
therapists opinion regarding whether she should see her ments in his upper quarter ROM and strength. Recently,
doctor. What should the therapist tell her? Sam has begun a gym exercise program as he prepares
for discharge from physical therapy. However, after
Angel is likely experiencing dysphagia, which is a approximately 2 weeks at the gym, Sam reports feeling
common short-term side effect of the surgery. The the soreness in his neck and shoulders after performing the
rapist should ask the patient for further information following exercises: seated scapular rows, latissimus
on the duration and intensity of the symptoms. Mild pull-downs, biceps curls, inclined bench press, and an
symptoms of dysphagia may be expected, although introductory spinning or cycling class for aerobic con-
increased symptoms related to cardiovascular signs ditioning. Which of the previously mentioned exercises
such as difficulty breathing, shortness of breath, or may be causing Sams symptoms?
symptoms of sleep apnea would warrant a physician
consultation. The introductory spinning or cycling class may be the
cause of Sams pain symptoms because of the cervical
2 Ned is a 41-year-old man who was involved in a motor

vehicle accident 2 years ago. His primary pain symp-
toms because of the accident included paresthesia and a
positioning this type of bike provides. This style of bike
usually places the cervical spine in hyperextension and
the thoracolumbar spine in flexion, causing Sam to feel
burning sensation throughout his right UE. He under- soreness after maintaining this extreme position for the
went ACDF surgery 4 weeks ago and continues to have duration of the class. Use of a stationary upright bike
neural paresthesia in his right arm. What interventions may place the cervical spine in a more comfortable posi-
should be administered? tion and relieve Sams symptoms. In addition, it would
be prudent for the therapist to advise Sam to postpone
Possible interventions include gentle UE AROM exer- latissimus pull-downs at this time. They can be started
cises to the elbow in flexion and extension (as well as to later in the rehabilitation process; however, at this time
the wrists and fingers) below 90 of shoulder elevation it is not wise to complete resisted activities above shoul-
to allow the nerves to glide. The therapist should encour- der level. Finally, the therapist should assess the amount
age the patient to move the arms below shoulder level of weight the patient is using.
4 Sherry is a 50-year-old woman who had ACDF surgery

6 weeks ago and has just recently removed her cervical
collar and returned to work as an accountant. She has a
is simply compressed, then function of the nerve should
return once the source of the compression is removed.
forward head posture, rounded and slumped shoulders,

and bilateral scapular winging. She also continues to
have numbness and tingling in her right UE, and her
6 Stacey is a 52-year-old woman who underwent ACDF 8
weeks ago. She has been attending physical therapy for
the last 2 weeks but continues to complain that her neck
pain level reaches a 6 out of 10 (10 being the worst) by motion is limited. Although she is not currently working,
lunchtime. She is worried that the fusion has been she is worried that she will not be able to resume her
unsuccessful. What is the therapists response? position as a bus driver because she is unable to turn her
head to look for oncoming traffic. How should the ther-
In this case patient education on the need for proper apist address this problem?
posture throughout the spine appears warranted. The
explanation should address proper ergonomic position- At 8 weeks after surgery, the patient can begin active
ing in the workplace to provide the neck and spine an cervical ROM exercises in all planes. Stacey should be
optimal position for work-related activities. In addition, instructed in how to perform these motions beginning in
an explanation concerning the effects and stress her neutral cervical spine position. She should also be told
posture imposes on nerves and soft tissues will put her to monitor her symptoms and only move her head until
at ease. Tight musculature of the pectoralis major and she feels the muscles stretching. Pain should be avoided
other anterior tissues may be pinching on the brachial when completing cervical ROM exercises. This may be
plexus, or the nerve roots may be affected secondary to added to the patients home exercise program, but she
the forward posturing. Interventions to improve her should be advised that if she experiences increased pain
posture should be initiated to relieve undue stresses, and during or after the exercises, then she should stop them
light strengthening of weakened muscles from upper until she has an opportunity to talk with her physical
crossed syndrome can be addressed as tolerated. The therapist.
patient should also be advised to take regular breaks
while at work to allow her to change positions and
prevent prolonged static postures. The therapist should
encourage the patient to lie down or sit in a reclined
7 Daniel is a 40-year-old man who underwent C5-6 ACDF
surgery 10 weeks ago. He has made improvements with
his active cervical ROM but is still unable to side bend
position during these breaks to allow the postural stabi- much or rotate his head in either direction without
lizers of the neck to rest. moving his trunk. He lacks full shoulder elevation in the
sagittal and coronal plane. He also notices difficulty and
5 Angela underwent ACDF surgery to C5-C6 8 weeks ago.

She started outpatient physical therapy last week. Her
chief complaint is decreased neck mobility. She also
discomfort while driving slightly longer distances. What
form of intervention should the therapist follow?
reports that she is experiencing a nagging pain in her Daniels loss of ROM is normal after ACDF. His cervical
right anterior superior iliac crest. This is where the graft rotation ROM will likely continue to improve given that
for the cervical fusion was harvested. Angela wants to C1-2 is a major source (accounting for up to 50%) of
know if the hip pain is normal and whether it will rotation. The therapist should keep in mind that AROM
resolve. How should the therapist respond? expectations for the cervical spine are less than full (65
to 70 of unilateral rotation versus 90). The fact that he
At approximately 8 weeks after surgery, bone is undergo- also has limits in shoulder elevation may indicate a tho-
ing a transformation from a soft callus to a hard callus. racic spine mobility issue. Soft tissue mobilization tech-
Although mineralization of bone may have been com- niques to the upper and midthoracic segments may
pleted in the cervical region based on radiographs, the relieve the tension on the shoulder and neck, allowing
affected hip rarely undergoes a series of radiographs for increases in AROM. Improved posture should also
before outpatient physical therapy is initiated. Generally, follow, allowing a better distribution and absorption of
no contraindications exist to physical therapy for hip forces while driving.
pain. The harvest site may be tender for several months
after the graft removal because of the trauma of surgery
and bone-remodeling process, but the pain should grad-
ually abate. Occasionally the lateral femoral cutaneous
8 Joe is a 49-year-old man who has been referred to the
clinic by his physician 5 months after undergoing ACDF
to C4-5 and C5-6. His primary impairments include
nerve may be affected by the graft harvest. If this is the numbness and tingling in his left UE, decreased cervical
case, then the patient will experience numbness or par- ROM, and poor cardiovascular function. After 1 month
esthesia down the lateral aspect of the thigh. Recovery of of physical therapy, Joe has increased his neck ROM and
the nerve will depend on whether the nerve was cut aerobic capacity but still complains of numbness and
during the surgery or simply compressed by inflamma- weakness in his left arm. He asks if the numbness will
tion. If it was excised, then recovery potential is poor. If it resolve. What should the therapist tell him?
280 PART 3 Spine
Several categories of nerve injury are based on the in the right hand and forearm. However, since he has
amount of tissue damage occurring at the nerve. A neu- removed his collar over 3 weeks ago, he has complained
ropraxia is a local conduction block of the nerve. It usually of a heavy head and notes he feels tiredness in the
occurs with compression injuries in which the nerve back of his neck. He reports that he did not have these
lumen is compressed and neural and chemical transition types of symptoms when he was wearing his collar and
down the nerve axon is impaired. The axon and sur- although he has been doing his deep neck flexor exer-
rounding neurium tissue remains intact. Axonotmesis cises, he is unsure if he is doing them correctly as he
refers to a condition in which a loss of axon continuity continues to have fatigue in the neck and jerky head
occurs. The neurium tissue remains intact, but because movements. How should the therapist address his
of the loss of axon continuity, degeneration of distal concerns?
nerve occurs. This condition can be the result of traction
to the nerve or severe compression. Neurotmesis is the The deep neck flexors have shown to be an important
loss of axon continuity in which the neurium tissue is factor in maintaining spinal segment support. Fatigue of
damaged. Similar degeneration of distal nerve occurs, as these muscles might cause an increase in activation of
seen in axonotmesis; however, because no neurium superficial neck muscles, which has the potential to over-
tissue exists, the nerve has very little chance to heal. This load painful cervical structures and affect cervical move-
type of injury generally occurs with injuries in which the ment control. Furthermore, this can lead to a lack of
nerve is severed. Recovery will depend on whether the confidence in the patient and result in increased muscle
nerve axon can regrow back to its distal muscular attach- contraction to try and protect the movements of the
ment before scar tissue infiltrates the region and blocks cervical spine, which can lead to diminished active
axon growth. When the axon and neurium are damaged, ranges of cervical motions. In this case, the therapist
little potential exists for full recovery of the nerve. There- may want to reassess the patients ability to perform his
fore the therapist should advise the patient that after 6 deep neck flexor exercises and assess the patients cervi-
months, resolution of numbness and weakness is unlikely cal control by using the laser beam exercise described
to occur. Strength can continue to increase, but this is by Treleaven. In this case, the patient sits in a chair 90cm
generally the result of muscle hypertrophy and not from away from the wall with a laser pointer mounted onto a
innervation of muscle tissue. lightweight headband. He tries to trace a pattern on the
wall with the light beam. The therapist can make a sub-
9 Robert is a 44-year-old man who underwent ACDF

surgery 9 weeks ago. He reports that he has made sig-
nificant gains in terms of overall neck pain and improve-
jective analysis of the accuracy and quality of movement,
and if deficits exist, the therapist can use this technique
as an intervention to improve joint position sense and
ments in his original neural symptoms of burning pain cervical movement control.
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CHAPTER 15
Posterior Lumbar Arthroscopic Discectomy
and Rehabilitation
Haideh V. Plock, Ben B. Pradhan, David Pakozdi, Rick B. Delamarter
L
umbar herniated nucleus pulposus (HNP) falls within no trauma, although patients frequently report a bending or
the spectrum of degenerative spinal conditions and twisting motion as the inciting event, causing the onset of
can occur with little or no trauma. Lumbar disc abnor- symptoms. Common causes of lumbar herniations include
malities increase with age.1,2 The actual incidence of lumbar falls, car accidents, repetitive heavy lifting, and sports inju-
disc herniations is unknown because many people with her- ries of all types.
niations are asymptomatic.1,3,4 Approximately 90% of lumbar
herniations occur at the L4-L5 and L5-S1 levels.1,5,6 More Diagnosis
than 200,000 discectomies are performed in the United The radiographic diagnosis of lumbar disc herniation has
States each year, and this number is likely increasing.7 The been made rather simple with magnetic resonance imaging
success of this procedure, as with all surgical procedures, (MRI). The clinical diagnosis is frequently straightforward
depends vastly on proper patient selection and to a lesser as well. A patient with a lumbar herniation generally has
extent on surgical technique. However, it is incumbent on some element of low back pain with radiation into the but-
the spinal surgeon to be absolutely meticulous with intraop- tocks, thigh, leg, and foot. The leg radiation almost always
erative technique once the decision for surgery is made. To follows a dermatomal distribution. Patients frequently
this end, the use of a microscope is recommended for lumbar complain of numbness, tingling, or weakness in the affected
discectomy. Once the learning curve has been mastered, the dermatome. Lying down may relieve the symptoms, whereas
microscope not only offers advantages over loupes but also sitting, walking, and standing may exacerbate them. Pro-
forces one to think at a much higher level of clarity about vocative maneuvers that increase abdominal pressure
what and where root encroachment pathology is present.8 (coughing, sneezing, defecating) may intensify symptoms as
More importantly, the patient has less morbidity and an well. Complaints of bowel and bladder dysfunction may
earlier hospital discharge compared with standard or limited signal a cauda equina syndrome and may necessitate emer-
discectomy.5,9-14 gent workup and treatment.
SURGICAL INDICATIONS Physical Examination

AND CONSIDERATIONS Visual inspection may reveal lumbar muscle spasm, fascicu-
lations, and postural changes, including listing to the side
Pathophysiology and a forward flexed position. Gait observation can reveal a
Intervertebral discs cushion and tether the vertebrae, provid- listing antalgic walk. Weakness can give a dropped foot type
ing both flexibility and stability. The normally gelatinous gait (anterior tibialis), buckling of the leg (quadriceps), or
nucleus pulposus is surrounded by the ligamentous annulus Trendelenburg gait (gluteus medius). Range of motion
broses. In the young and healthy disc, the nucleus and (ROM) testing may be limited secondary to pain. Neurologic
annulus blend. Degenerative or pathologic changes can testing is extremely important and should include motor,
cause separations of the two entities, as well as compromise sensory, and reflex testing. Lumbar herniations may cause
the integrity of the annulus, such that a sufficient load can varying degrees of dermatomal weakness, sensory deficits,
cause nuclear fragments to migrate and impinge on neural and reflex changes. Straight-leg raises (SLRs) are a good indi-
elements.15 This pathophysiology is reflected in a clinical cator of nerve root impingement in lower lumbar hernia-
presentation of acute sciatica pain with a prior history of tions, and a positive femoral stretch can indicate an upper
back pain. Lumbar disc herniations may occur with little or lumbar herniation.
283
284 PART 3 Spine
A B
Fig. 15-1 A, Sagittal magnetic resonance imaging (MRI) showing herniated discs at the bottom two lumbar discs, at L4-5 and L5-S1. B, An axial cut of a
lumbar spine MRI revealing a left-sided broad-based paracentral disc herniation effacing the thecal sac, causing left-sided lateral recess, foraminal stenosis,
and neural compression.
Imaging and Other Tests recently, the Spine Patient Outcomes Research Trial results
MRI is clearly the imaging study of choice to diagnose a have contributed to the favorable opinion of surgical out-
lumbar disc herniation (Fig. 15-1). Plain radiographs comes as well. Treatment effects were statistically significant
should always be obtained to evaluate overall alignment, at 2 years and maintained at 4-year follow-up for primary
bony integrity, and stability. Patients who cannot obtain an outcomes in favor of surgery.19
MRI can be diagnosed using computed tomography (CT), In the absence of cauda equina syndrome or progressive
CT myelogram, or CT discogram. These imaging tests are so or significant neurologic deficits, most practitioners attempt
sensitive that a discectomy is not indicated if a disc is not conservative care before suggesting surgical intervention.
found to be herniated by one of these techniques. Other tests
can include an electromyogram (EMG) or nerve conduction Nonoperative Treatment
study. Nonoperative treatment may include:
1. Modified activity
Management 2. Modified bed rest for 2 to 3 days (prolonged bed rest
It is important to understand that most patients with symp- should be avoided)20-22
tomatic herniated lumbar discs will get better over time, 3. Analgesic, antiinflammatory medication (e.g., nonsteroi-
regardless of the type of treatment. Webers classic study16 dal antiinflammatory drugs, steroids, or both)
reported that sciatica from HNP would improve 60% of the 4. Physical therapy (as tolerated) or external support (e.g.,
time with nonsurgical methods and 92% of the time with corset, brace)
surgery at 1 year. By 4 years out, no statistical difference was 5. Epidural steroid injections (we recommend up to three)
found (51% improvement in conservative group versus 66%
in the surgical group), and no difference was found at 10-year Indications for Surgery
follow-up. The 5-year outcomes from the Maine Lumbar Surgical indications, as currently recommended by the
Spine Study are similar to the 4-year results of the Weber North American Spine Society (NASS), include a definite
study. At 1-year follow-up, 71% of surgical patients reported diagnosis of ruptured lumbar intervertebral disc and the
relief of leg symptoms compared with 43% of conservatively following23,24:
managed patients.17 They reported long-term follow-up at 5 1. Failure of conservative treatment
years, with 70% of patients in the operative group describing 2. Unbearable or recurrent episodes of radicular pain
improvement versus 56% in the nonoperative group.18 More (or both)
Chapter 15 Posterior Lumbar Arthroscopic Discectomy and Rehabilitation 285
3. Significant neurologic deficit 1. Lumbar discectomy (microscopic or standard open

4. Increasing neurologic deficit (absolute indication) technique)
5. Cauda equina syndrome (absolute indication) a. Hemilaminotomy and discectomy
Conservative treatment consists of nonoperative manage- b. Laminectomy and discectomy
ment and careful observation. Some may benefit from a 2. Minimally invasive percutaneous techniques
short trial of nonoperative treatment even after 8 weeks if no a. Chemonucleolysis
prior care was given. Failed conservative treatment is the b. Percutaneous discectomy (suction, shaver, laser, endo-
most common indication for lumbar discectomy. Those who scopic tools)
have not improved sufficiently and are not experiencing con-
tinued improvement might then be offered treatment by Use of an Operating Microscope
surgical excision of the disc. Such patients should be advised The attempt to improve visualization and illumination has led
that this is an elective operation but that delay for longer many spine surgeons to use loupes and a headlight. We believe
than 3 to 6 months in the face of persistent and severe symp- the magni cation and illumination built into the microscope
toms may compromise the best ultimate result.24,25 The other offer many surgical advantages, the most important of which
indications (2 to 5) are exceptions to the 4- to 8-week rule. is reduced wound size and decreased tissue manipulation
Excruciating pain may not be relieved by nonoperative (Fig. 15-2). The surgeon can limit the amount of tissue dissec-
means and may require earlier surgical decompression. tion by working through a small exposure directly over the
Recurrent sciatica should also receive consideration for pathology to be removed. Microsurgical techniques can also
surgery: the chance of recurrent sciatica after the second be used to preserve the ligamentum flavum and epidural fat
episode is 50% and after the third episode is almost 100%.25 to minimize postoperative epidural broses and improve clini-
An example of a significant neurologic deficit may be a foot cal results by preserving natural tissue planes.8,34 With this
drop or weakness that prevents normal posture, gait, or approach, the disc herniation can be easily removed, lateral
affects the patients profession or a particular skill. Any defi- recess stenosis can be decompressed, and nerve root manipu-
nite progression of neurologic deficit is an absolute indica- lation is kept to a minimum. The senior author has used this
tion for surgery. Cauda equina syndrome is relatively rare. It technique since 1986 for most lumbar disc herniations and
is reported in 1% to 3% of patients with confirmed disc has found the approach to be safe, with fewer dural tears and
herniations,26,27 and it is an orthopedic or neurosurgical nerve root injuries and less postoperative epidural broses
emergency. Features include rapid progression of neurologic than with standard discectomy.5,8,10,35
signs and symptoms, bilateral leg pain, caudal sensory deficit, However, the microscope is not without its disadvantages.
bladder overflow incontinence or retention, and loss of rectal Peripheral vision is lost, with the field of vision limited to
sphincter tone with or without fecal incontinence. approximately 4 to 5cm. Because of this, the surgeon needs
to know detailed anatomy of the spine. The line of vision is
Contraindications for Discectomy axed through the microscope. To look over structures (to
NASS and the American Academy of Orthopaedic Sur- overcome tissue overhang), the patient or microscope has to
geons have identified the following factors as absolute or be adjusted during the surgery. This can be avoided by proper
relative contraindications for discectomy24,28: retraction or dissection of tissue away from the line of vision.
1. Lack of clear clinical diagnosis, anatomic level of lesion,
and radiographic evidence of HNP
2. Lack of trial of nonoperative treatment (with the excep-
tions mentioned previously)
3. Disabilities with major nonorganic components (i.e.,
multifocal, nonanatomic, or disproportionate signs and
symptoms)
4. Systemic disease processes that can negatively influence
outcome of surgery (e.g., diabetic neuropathy)
5. Medical contraindications to surgery (e.g., major comor-
bidities, unfavorable survival)
6. Disc herniation at a level of instability (may need addi-
tional stabilization)
SURGICAL PROCEDURES
One only has to review the natural history of lumbar disc

Fig. 15-2 A surgeon and an assistant surgeon using the operative micro-
disease to realize that spinal surgeons play a palliative role in scope with a high-intensity light source and microscopic magnification. The
the management of HNP.29-33 Surgical procedures as treat- two surgeons can work hand-in-hand with unobstructed view of the opera-
ment for lumbar HNP include the following: tive field.
286 PART 3 Spine
Researchers reported increased disc space infection after subperiosteal muscle dissection and elevation are confined
microsurgery.36,37 This was most likely caused by contamina- to the interlaminar space and approximately half of the ceph-
tion from unsterile parts of the microscope during surgery, alad and caudad lamina. The facet capsules are carefully
although no one has looked at the potential for an increased preserved. A Cobb elevator and Bovie cautery are used. A
infection rate when two surgeons with loupes and headlights framed retractor is then placed. The surgeon should expose
bump heads over the wound! Recent reports by those who the lateral border of the pars as a landmark for preserving
have experience with the microscope do not show any enough of the pars during laminotomy to prevent fracture.
increased infection rates.5,10,14,38, At this time another localizing lateral radiograph should
be obtained to confirm the proper level. A forward-angled
Lumbar Microdiscectomy curette can be placed underneath the cephalad lamina of the
Microscopic discectomy (microdiscectomy) has become the interspace. With this intraoperative radiographic verifica-
gold standard for operative treatment of lumbar disc herniation, wrong-level surgery is impossible. The radiograph will
tions, and the latest minimally invasive percutaneous tech- also indicate how much of the cephalad lamina needs to be
niques have not been shown to be more effective.8,39,40 removed to expose the disc space. The microscope is then
Although no statistical differences can be shown in the ulti- brought into position.
mate long-term outcomes of microscopic versus standard
open discectomies,11,13,14,32,41-43 the microscope provides Spinal Canal Entry
improved illumination and magni cation, and patients have After exposure of the interlaminar space and placement of
less morbidity and earlier hospital discharge when compared the retractor, a high-speed burr is used to remove several
with standard discectomies. millimeters of the cephalad lamina and 2 to 3mm of the
medial aspect of the inferior facet, taking care to leave at least
Operative Setup a 6-mm bridge of bone at the level of the pars (Fig. 15-3).
General anesthesia is preferable because of patient comfort, Once the cephalad lamina and medial aspect of the inferior
as well as airway and sedation control. Another advantage is facet have been removed, the ligamentum flavum is easily
the option of hypotensive anesthesia. The procedure can also seen because its bony attachments are exposed. The ligamen-
be done under epidural or local anesthesia with sedation, tum attaches at the very cephalad edge of the lower lamina,
although this is not our preference. The patients position is but approximately halfway up the upper lamina, and it
always prone with the abdomen free, thus relieving pressure attaches to the medial aspect of the superior facet. Thus the
on the abdominal venous system and, in turn, decreasing high-speed burr can be used relatively safely on top of the
venous backflow through the Batson venous plexus into the
spinal canal. This has the effect of decreasing bleeding from
the epidural veins intraoperatively. Several frames are avail-
able for this, but we prefer a Wilson frame on a regular
operating table because of the ease of setup.
Identification of Level and Side

A preincision lateral radiograph or fluoroscopy image, with
a radiopaque skin marker placed according to preoperative
radiographs and anatomic landmarks, will identify the
appropriate incision location for the disc space to be exposed.
This is best done by placing a spinal needle as straight verti-
cally as possible, approximately 2cm from midline contra-
lateral to the side of surgery. The side of surgery is usually
the more symptomatic side, although occasionally a midline
HNP can be approached from either side.
Skin Incision and Interlaminar Space Exposure

A 2- to 3-cm incision is made midline or up to 1cm lateral
to the spinous process on the symptomatic side at a level
directly over the disc space based on the localizing lateral
radiograph. At L5-S1, this incision tends to be directly over
the interlaminar space; but as one moves up the lumbar
spine, this incision will be progressively over the cephalad Fig. 15-3 After skin exposure and subsequent subperiosteal elevation, the
retractor in position reveals the interlaminar interval, with exposure of the
lamina. The dissection is carried down to the lumbodorsal
upper and lower laminae. Several millimeters of the cephalad lamina and 2
fascia, which is sharply incised. The fascial incision is placed to 3mm of the medial edge of the inferior facet are removed with the high-
carefully, just lateral to the spinous processes to avoid damage speed burr. This bone can be safely removed because the undersurface is
to the supraspinous and interspinous ligament complex. The protected by the ligamentum flavum.
bottom half of the superior lamina, as well as the medial pedicle and up into the foramen, and it allows easy access to
aspect of the inferior facet. the lateral disc space. If needed, some of the lateral ligamen-
tum flavum, particularly into the foramen, can be removed
Free Ligamentum Flavum with the Kerrison rongeurs.
The ligamentum flavum is then released from the medial
edge of the superior facet with a forward-angled curette. It Nerve Root and Ligamentum Retraction
can also be released from the undersurface of the upper and Bipolar cautery can be used at this time to cauterize any
lower lamina (Fig. 15-4). It is safest to start the curette infero- epidural bleeding over the lateral disc space, directly cepha-
laterally toward the superior aspect of the pedicle (caudal lad to the pedicle. We recommend finding the pedicle and
aspect of the foramen). then using it as a guide to release the epidural nonneural
A ligamentum and epidural fat-sparing approach, per- tissues above the disc space. At this point a nerve root retrac-
formed by creating a flap of the ligamentum as described tor can be placed on the disc space, and the ligamentum
previously, decreases postoperative epidural broses and can flavum, epidural fat, and nerve root are retracted toward the
improve results.8,34 However, this can make it more difficult midline, generally exposing the herniation (Fig. 15-6). Again,
to get a good view of the nerve root. Certainly this is easier the bipolar cautery can be used to cauterize any epidural
with a microscope than without one. The less-experienced veins over the disc herniation. Any free large fragments of
surgeon may perform partial removal of these tissues. The disc can now be removed (Fig. 15-7). If needed, a forward-
ligamentum flap is also not recommended for large midline angled curette can be used to scrape the inferior and poste-
disc herniations (with or without cauda equina syndrome) rior bony margins of the foramen, using a unidirectional
and severely stenotic canals because the ligamentum itself pulling motion. Using the bony pedicle as a starting point
occupies more room in the already severely compromised ensures that the end of the curette does not include any
spinal canal and would also interfere with direct visualiza- neural tissue before scraping.
tion for the delicate manipulation of the thecal sac.
Discectomy
Lateral Recess Exposure Frequently the annular defect of the disc herniation is all that
After release of the ligamentum flavum, the medial edge of is necessary to allow cleaning out of any loose nucleus pulpo-
the superior facet is resected with 2- to 4-mm Kerrison ron- sus inside the disc space, although the annulotomy can be
geurs. This resection goes from the lower pedicle to the tip enlarged with a No. 11 blade. The herniated nuclear material
of the superior facet (Fig. 15-5). This medial facet resection is then cleaned out with straight or angled pituitary rongeurs
decompresses any lateral recess stenosis at the level of the and small back-angled curettes. Care should be taken not to
Fig. 15-5 A 3- or 4-mm Kerrison rongeur is used to remove the lateral

Fig. 15-4 A small, forward-angled curette frees the ligamentum flavum recess (subarticular) stenosis (i.e., the medial edge of the superior facet)
from its attachment to the medial edge of the superior facet. The ligamen- back to the pedicle of the lower vertebra and cephalad to the top of the
tum flavum also can be freed from the undersurface of the upper and lower superior facet. This bony resection removes the lateral recess (subarticular)
laminae. stenosis and allows exposure of the lateral disc space.
288 PART 3 Spine
cartilaginous endplates. Critics of this approach point out

that no matter how long the surgeon works, it is impossible
to remove all disc material in this fashion. They also argue
that this method increases risk of damage to anterior visceral
structures and increases risk of chronic back pain induced
by conditions, such as sterile discitis and instability. Although
some surgeons believe that extensive intradisc dbridement
decreases the rate of recurrent HNP, others refute that posi-
tion.36,45-47 In the end, the only reasonable prospective con-
trolled study is Spenglers,48 which suggests that limited disc
excision is all that is necessary. The advantages of limited disc
excision are less trauma to endplates and less dissection, less
nerve root manipulation, a lower prevalence of infection,
reduced risk of damage to structures anterior to the disc
space, and less disc space settling postoperatively (theoreti-
cally reducing the incidence of chronic back pain).
Disc Space Irrigation

After the HNP and any remaining loose material is removed,
the disc space is irrigated under some pressure with a long
angiocatheter; then the pituitary rongeur is again used to
Fig. 15-6 A nerve root retractor is used to retract the ligamentum flavum, remove any loose fragments. The spinal canal is then pal-
nerve root sleeve, and epidural fat toward midline over the herniated disc. pated underneath the nerve root and across the vertebral
Bipolar cautery can be used to cauterize the epidural plexus over the disc bodies above and below for any residual fragments. In doing
herniation.
the limited disc excision, one must also be sure to probe
under the posterior annulus (both medially and laterally) for
loose fragments. This is an important step to ensure that no
displaced or sequestered fragments are missed. Residual disc
material will feel rough, whereas the native dural surface is
quite smooth. In the end the patient must be left with a freely
mobile nerve root. The preoperative MRI should be carefully
studied for displaced fragments, but it is important to keep
in mind that fragments may have moved since the MRI was
taken.
Closure
Once the decompression is complete, the entire surgical
wound is thoroughly irrigated with antibiotic-containing
irrigant. Any final bleeding is controlled with bipolar cautery,
thrombin-soaked gel foam, or FloSeal hemostatic gel. After
complete hemostasis and removal of all gel foam, the closure
is performed in layers. Many attempts have been made to
design substances to seal the laminotomy defect and prevent
scar formation, including fat grafts, hydrogel, silicone,
Dacron, and steroids.49 We simply prefer the ligamentum
flap (Fig. 15-8).5,8,25 The dorsal lumbar fascia is closed with
No. 1-0 sutures, the subcutaneous layer with 2-0 sutures, and
Fig. 15-7 After exposure of the disc herniation, large free fragments can the skin with 3-0 subcuticular sutures. Using this ligamen-
be removed with a pituitary rongeur, the natural annulotomy from the disc tum flavumsparing approach, blood loss should be no more
herniation can be enlarged with a No. 11 blade, or both can be done. than 10 to 20ml. With good hemostasis, drainage of the
surgical wound is not necessary.
damage or curette the endplates. The annulotomy can be
performed in various shapes, which are not discussed in Postoperative Course
detail here.36,44 Many microdiscectomy procedures can be done on an out-
One unresolved issue is how much disc to remove from patient basis.12,50,51 Most patients are encouraged to walk as
the disc cavity. Removal of as much disc as possible implies tolerated. Sitting is also tolerated but may be more limited.
curettage of the interspace, including possible removal of the Many return to work within 5 to 10 days, especially those
Fig. 15-8 After thorough irrigation, the nerve root retractor is released, allowing the ligamentum flavum and nerve root sleeve to return to their normal
anatomic positions.
with desk type of work. All patients are required to partici- Cauda Equina Syndrome
pate in lumbar physical therapy, primary stabilization, and The classic teaching in cauda equina syndrome is that (1) it
mobilization beginning at approximately 4 weeks after is an orthopedic emergency, and (2) a wide decompression
surgery. Most athletes return to their normal athletic activi- through a bilateral approach is necessary. We agree with the
ties within 8 weeks after surgery. However, the postoperative first point but not the second. Few disc herniations are too
course is variable, and return to normal activities depends big to be addressed microsurgically. A wider hemilaminec-
on the patients overall medical condition, as well as neuro- tomy may be needed. The microscope is invaluable when
logic and overall recovery.16,52,53 working in the severely stenotic canal. If the disc cannot be
easily or totally excised unilaterally, then bilateral hemilami-
Unusual Disc Herniations notomies may be done.26,27
Herniated Nucleus Pulposus at High Lumbar
Levels (L1-L2, L2-L3, L3-L4) Herniated Nucleus Pulposus in
High lumbar HNPs are uncommon (5%). When they occur the Adolescent Patient
they are likely to be foraminal or extraforaminal.25,54 Impor- The risk for recurrence of HNP after surgical excision is
tant skeletal anatomy in the higher lumbar spine for the higher in adolescents than in adults. Because of the high
spinal surgeon to be aware of includes the following: (1) the proteoglycan content in adolescent discs and the prevalence
pars are narrower, and facet integrity is easily lost with exces- of disc protrusions rather than disc extrusions, some have
sive laminotomy; (2) the laminae are broader; (3) the inter- recommended percutaneous chemonucleolysis rather than
laminar window is narrower; (4) the inferior border of the surgical intervention in this age group.25,57,58 Studies have
lamina overhangs more of the disc space; (5) at L1-L2, the been published with controversial results for surgical discec-
conus cannot be retracted like the cauda equina at lower tomy in this patient population.59-61 Chemonucleolysis may
levels; (6) the nerve roots exit more horizontally and are have merit in the treatment of symptomatic disc protrusions,
less mobile; and (7) epidural veins may be more prevalent. but discectomy is necessary in the setting of an extruded or
At these levels, because of the limited size of the interlaminar sequestered disc causing significant or progressive neuro-
space, ligamentum excision rather than sparing is logic deficit or pain. These extruded or sequestered frag-
recommended. ments are frequently heavily collagenized.24,62 Long-term
follow-up studies of more than 12 years after discectomy in
Recurrent Disc Rupture this group have reported good to excellent results in 87% to
The incidence of recurrent HNP at the same level and side 92% of patients.63,64
of a previously operated on disc is 2% to 5%.5,55,56 The micro-
scope is especially valuable in this scenario because of the Complications
scar between tissue planes, including neural elements. Ade- Complications for the discectomy procedures include dural
quate time must be spent carefully teasing the tissues apart tears, neural injury, visceral injuries, postoperative infection,
with a blunt instrument (e.g., bipolar, curette, Penfield) recurrence of herniation, inadequate decompression, and
before forcefully mobilizing the nerve root. The incidence iatrogenic instability.
of complications is understandably higher in revision Dural tears occur in 1.0% to 6.7% of cases, although the
discectomies. incidence decreases with experience.5,16,38,65-67 If possible,
290 PART 3 Spine
repair should be done by direct suture (5-0 to 7-0 silk, nylon, ligamentum flavum as a flap, and do a limited discectomy.
or polypropylene) with or without a dural patch.65 The These steps theoretically reduce iatrogenic instability, epidu-
patient should be kept flat for a few days after surgery to ral broses, sterile discitis, and loss of disc height. All of these
lower the hydrostatic pressure in the lumbar thecal sac while steps are facilitated by the use of a microscope, but no proof
the repair seals. exists that these steps reduce the incidence of back pain.
Neural injuries are rare, although the risk is greater with The most frequent cause of poor result from lumbar disc
unusual disc herniations as described previously. Visceral surgery is faulty patient selection because of erroneous or
injuries occur when an instrument penetrates the anterior incomplete diagnosis. Technical errors, such as wrong-level
annulus. Among these, vascular injuries are the most surgery, incomplete decompression, and intraoperative com-
common.65,68 If these are recognized, then immediate lapa- plications, explain a small percentage of failures. A 1981
rotomy for surgical repair is indicated. study assigned the following frequency of missed diagnoses
Postoperative discitis occurs in 1% of cases or less in as sources of failure: lateral spinal stenosis, 59%: recurrent
experienced hands, although clearly a learning curve exists or persistent herniation, 14%; adhesive arachnoiditis, 11%;
in developing facility with the microscope. Higher infection central canal stenosis, 11%; and epidural broses, 7%. Finally,
rates (up to 7%) have been reported with the use of a micro- the results of repeat surgery are not as good as primary
scope during surgery, although in experienced hands this has surgery, regardless of the reason or whether a microscope
been shown not to be true.65 An MRI is the best diagnostic was used, because of scar tissue, higher incidence of compli-
imaging tool. An image-guided needle biopsy may be per- cations, or larger dissections. In the past decade, a substantial
formed to assist in organism-specific antibiotic selection. increase in interest in minimally invasive procedures has
Reoperation may not be necessary unless the patient occurred in all areas of medicine, particularly for spinal dis-
develops root compression, cauda equina syndrome, or an orders. Several methods to remove HNP have been proposed
epidural abscess. as alternatives to standard open discectomy. Injected chymo-
The literature reports recurrent HNP at a previously oper- papain can dissolve much of the central nucleus, but is not
ated site occurring anywhere from 2% to 5% after lumbar likely to act on extruded or sequestered fragments, which are
discectomy.25,69 When reoperating for a recurrent HNP, it is often heavily collagenized.24,57,62 Likewise, percutaneous
important to get adequate exposure of the dural sac above suction discectomies and removal of nucleus (either mechan-
and below the disc space. Then using a combination of blunt ically or by laser from the center of the disc) may reduce
(nerve hook, Penfield, bipolar) and sharp (Kerrison) dissec- intradisc pressure but are unlikely to influence the effects of
tion, the dural sac and nerve root are exposed and mobilized extruded or sequestered disc material. Therefore although
above the HNP. alternative minimally invasive techniques hold considerable
Iatrogenic mechanical instability is fortunately a rare promise, lumbar microdiscectomy is still the gold standard
occurrence after discectomy, even if a decompressive lami- for surgical treatment of lumbar HNP with radiculopathy.
nectomy was required for a stenotic canal or to excise a large However, the skills and technology to remove herniated discs
disc.6 Symptomatic mechanical treatment may require surgi- by such alternatives are evolving.24,39,40,71-73
cal stabilization. Suboptimal results after discectomy can be
the result of several other problems that, unfortunately, do THERAPY GUIDELINES
not have a straightforward medical or surgical treatment. FOR REHABILITATION
Although very rare, these can include epidural broses, arach-
noiditis, and complex regional pain syndrome.65 Postoperative spine rehabilitation allows for a safer and
faster return to functional activities. The early return to
Discussion appropriate activities has been encouraged after surgeries of
Most modern studies using microscopic techniques for the extremities for many years. The same approach should
treatment of herniated lumbar discs report 90% to 95% be applied to the spine. Careful instruction and frequent
success rates.* A multicenter, prospective trial has proved reevaluation enable a therapist to progress the patients func-
what cannot be repeated often enough: If the therapist selects tional activities to premorbid levels safely. The therapist
patients with dominant radicular pain (compared with back should apply a functionally appropriate and suitably aggres-
pain), with neurologic changes and painful SLRs, and with a sive postoperative protocol to the patient recovering from
study confirming a disc rupture, then he or she can anticipate lumbar microdiscectomy.
a high level of success for discectomy, with or without a Lumbar disc herniations can do more than compromise
microscope.41 The rate of successful outcome drops signifi- the nerve root. Compensatory movement patterns, altered
cantly as more of these inclusion criteria are not met. Persis- mechanics of the motion segment, and muscle splinting may
tent back pain occurs in up to 25% of patients who undergo result in misleading referred pain patterns (e.g., myofascial
microdiscectomy.66,67 This has led to the opinion that it is trigger points). Furthermore, the literature suggests that
important to save the supraspinous and intraspinous liga- abnormal changes in paraspinal muscle activity occur after
ment complex, remove as little lamina as possible, save the an HNP.74,75 Triano and Schultz76 found a high correlation
between the absence of the flexion-relaxation phenomenon
*References 5, 8, 9, 11-14, 29, 34, 37, 38, 42, 43, 55, 66, 69, and 70. (i.e., the relaxation of the lumbar paraspinal muscles at
terminal flexion in standing) and poor results on the Oswes- program. It has been suggested that the greatest indicator for
try Pain Disability Scale (Box 15-1). postoperative results is preoperative psychologic testing, not
Microdiscectomy is designed to decompress neural MRI or clinical signs.80-83 Additionally, patients who have
tissues by removing the disc material that is causing the active litigation or workers compensation claims have been
neurologic signs and symptoms not alleviated through shown to return to activity later than patients who do not.84
aggressive conservative care.77 Surgery cannot correct poor These factors must be considered in evaluating patients, pro-
posture and body mechanics, relieve myofascial pain syn- gressing exercise programs, and assessing clinical results.
dromes, or remedy faulty motor patterns of synergistic activ-
ity accompanying muscle substitution that occur in many Phase I (Protective Phase)
patients with low back pain. Additionally, Hides, Richard- TIME: 1 to 3 weeks after surgery
son, and Jull78,79 have found that the lumbar multifidi, a GOALS: Protect the surgical site to promote wound
primary segmental stabilizer, do not spontaneously recover healing, maintain nerve root mobility, reduce pain
after low back pain, so it is doubtful that they will spontane- and inflammation, educate patient to minimize
ously recover after the trauma of spine surgery. The loss of fear and apprehension, establish consistently good
these crucial active segmental stabilizers may lead to recur- body mechanics for safe and independent self-care
rent lumbar pain syndromes. To avoid this and aid the (Table 15-1)
patients rehabilitation after spinal surgery, the therapist must
tirelessly question and reassess, using a problem-solving The first postoperative week typically consists of protec-
approach. tive rest, progressive ambulation, and appropriately limited
The following guidelines are not intended to be a substi- activities. Activity tolerance is the result of progressive activ-
tute for sound clinical reasoning. Rather they are intended ity, not rest. The patient should be encouraged to walk at a
as a guide for the successful postoperative rehabilitation of comfortable pace for short distances several times a day.
patients after lumbar microdiscectomy. The primary goals Patients are usually allowed to shower 7 days after surgery,
after a lumbar microdiscectomy are the reduction of pain, depending on wound healing.
prevention of recurrent herniation, restoration of normal Driving is usually not allowed for 1 to 2 weeks, although
muscle activity and biomechanics, maintenance of dural this may be extended if the right LE is significantly com-
mobility, improvement of function, and early return to promised. Typically patients can return to office work within
appropriate activities. Each patients program must be indi- 1 week. Because the patient in phase I has difficulty tolerat-
vidualized to attain these goals for the following reasons: ing sustained positioning, he or she may require support
1. Patients have slightly different pathoanatomic abnormali- during driving, sitting, and lying postures. Additionally,
ties and surgical procedures. patients may need to be directly educated in changing posi-
2. Patients have different levels of strength, flexibility, and tions frequently. Patients may have significant incisional
conditioning after surgery. pain, especially with flexion movements.
3. Patients goals vary. The therapist must avoid all loaded lumbar flexion in
4. Patients have varying psychosocial factors. patients in phases I and II. The patient can apply cold packs
5. Patients possess different levels of kinesthetic- to the surgical site for 15 to 20 minutes several times a day
proprioceptive coordination that affect their rate of motor to help control pain, muscle spasm, and swelling.
learning. The therapist may begin outpatient physical therapy as
Each patient must therefore receive care in accordance soon as the patient can comfortably come to the clinic,
with individual needs. To this end the guidelines should be usually in the second or third week. Treatment begins only
progressed as tolerated, and the therapist should not try to after the patient is evaluated to ascertain the following:
keep the patient on schedule. A thorough history of the condition, including previous
Increasing lower extremity (LE) symptoms, progressive treatments or surgeries and time out of work
neurologic deficit, and incapacitating pain are obvious The present pain pattern (intensity and frequency) plus
red flags that require prompt reevaluation. Although the activities or postures that alter these symptoms
therapist must not ignore pain, an acceptable level of dis- The status of the wound site
comfort is reasonable if the patient is increasing functional Anthropometric data, and postural and body mechanics
activities and progressing in the program as anticipated. Pain assessment
should be monitored in three parameters, with the therapist Limited mechanical testing (Standing motion testing
carefully noting the pain pattern (e.g., left lateral thigh to and end-of-range movements are not assessed until after
knee), observing the frequency (e.g., constant, intermittent, the fifth week postoperatively.)
rare), and having the patient rate the intensity (0 to 10). This Neurologic status (examination includes neural tension
allows close tracking of changes in pain with exercise and testing)
activity so that the program can be progressed or modified Baseline core strength testing in nonaggravating position
accordingly. (i.e., supine)
Finally, any successful spinal rehabilitation program must The therapist must take care during the initial evalua-
not ignore psychosocial factors that negatively affect the tion to avoid any testing that may injure an already
292 PART 3 Spine
BOX 15-1 Oswestry Low Back Pain Disability Questionnaire

This questionnaire has been designed to give your physical Pain prevents me from sitting more than 10
therapist (PT) information as to how your back pain has minutes.
affected your ability to manage in everyday life. Please Pain prevents me from sitting at all.
answer every question by marking the one box that applies. 6. Standing
We realize you may consider that two of the statements in I can stand as long as I want without extra pain.
any one section relate to you, but please just mark the box I call stand as long as I want, but it gives me extra
that most closely describes your problem. pain.
Name: Pain prevents me from standing more than
Date: Initial Interim/Discharge 1 hour.
1. Pain intensity Pain prevents me from standing more than 12
I can tolerate the pain I have without having to hour.
use painkillers. Pain prevents me from standing more than 10
My pain is bad, but I manage without taking minutes.
painkillers. Pain prevents me from standing at all.
Painkillers give me complete relief from my pain. 7. Sleeping
Painkillers give me moderate relief from my pain. Pain does not prevent me from sleeping well.
Painkillers give me very little relief from my pain. I can sleep well only by taking medication for
Painkillers have no effect on my pain, and I do not sleep.
use them. Even when I take medication, I have less than 6
2. Personal care hours of sleep.
I can look after myself normally without causing Even when I take medication, I have less than 4
extra pain. hours of sleep.
I can look after myself normally, but it causes Even when I take medication, I have less than 2
extra pain. hours of sleep.
It is painful to look after myself, and I am slow and Pain prevents me from sleeping at all.
careful. 8. Sex life
I need some help, but I manage most of my My sex life is normal and gives me no extra pain.
personal care. My sex life is normal but causes some extra pain.
I need help every day in most aspects of My sex life is nearly normal but is very painful.
self-care. My sex life is severely restricted by pain.
I do not get dressed, wash with difficulty, and stay My sex life is nearly absent because of pain.
in bed. Pain prevents any sex life at all.
3. Lifting 9. Social life
I can lift heavy objects without causing extra pain. My social life is normal and gives me no extra
I can lift heavy objects, but it gives me extra pain. pain.
Pain prevents me from lifting heavy weights off My social life is normal but increases the degree
the floor, but I can manage light to medium of pain.
objects if they are conveniently positioned. Pain has no significant effect on my social life
I can lift only very light objects. apart from limiting my more energetic interests,
I cannot lift anything at all. such as dancing.
4. Walking Pain has restricted my social life, and I do not go
Pain does not prevent me from walking any out as often.
distance. Pain has restricted my social life to my home.
Pain prevents me from walking more than 1 mile. I have no social life because of pain.
Pain prevents me from walking more than 12 mile. 10. Traveling
Pain prevents me from walking more than 1 4 mile. I can travel anywhere without extra pain.
I can only walk using a cane or crutches. I can travel anywhere, but it gives me extra pain.
I am in bed most of the time and have to crawl to Pain is bad, but I manage journeys of more than 2
the toilet. hours.
5. Sitting Pain restricts me to journeys of less than 1 hour.
I can sit in any chair as long as I like. Pain restricts me to short, necessary journeys of
I can sit only in my favorite chair as long as I like. less than 12 hour.
Pain prevents me from sitting more than 1 hour. Pain prevents me from traveling except to the
Pain prevents me from sitting more than 12 hour. doctor or hospital.
TABLE 15-1 Microdiscectomy

Anticipated
Phase I Postoperative Edema Cryotherapy Manage edema Promote self-management
Postoperative Pain Electrical stimulation Control pain of edema and pain
1-3 wk Limited tolerance to Supportive corset or brace as indicated Decrease pain with Provide abdominal support
transfers Body mechanics training upright postures and decompression
Limited tolerance to maintenance of lumbar lordosis and Prevent complications Initiate education to prepare
strained positions avoidance of trunk flexion with the and reinjury patient for independence
Limited ADLs following: Good understanding with ADLs, avoiding reinjury
Limited nerve Sitting and driving (supported as and use of proper body Maintain lordosis and avoid
mobility appropriate) mechanics flexion postures to avoid
Limited LE ROM Sleeping (supported as necessary, Sit up to 20 minutes excessive longation tension
Limited trunk and avoiding fetal position) Resume driving after on surgical site
LE strength Standing and walking (limit based 2 wk Promote protective rest and
Limited mobility of on symptoms) Improve sleep patterns resumption of limited
neighboring regions TransfersSpine or sit-stand, in Use log roll activities
Limited walking and out of car, and floor to stand technique with Transfer while avoiding
Limited Self-care transfers unnecessary stress on
cardiovascular Avoid lifting Independent with surgical site
endurance Bending using hip hinging and self-care Avoid lifting to prevent risk
neutral spine method Improve nerve mobility of reinjury
Spine dural mobilization Prevent adhesions that Decrease stress on surgical
Prone dural mobilization limit nerve mobility site
PROM stretchesHip (flexion [knee Restore ROM to LE Prevent nerve fibrosis and
bent], SLR [gently], ER, standing Improve mobility of dural adhesions
[gastrocnemis-soleus]) restricted joints Improve LE flexibility to
Joint mobilization of hip and thoracic Increase tolerance to decrease stress in the
spine as indicated walking level surfaces lumbar spine
Progressive walking program on for 30 minutes Avoid irritating sciatic nerve
treadmill or flat surfaces Establish a healthy Maintain and improve
Begin progressive exercise program (in environment for the proximal and distal mobility
unloaded positions only) disc to reduce stress in the
Pelvic rocks Good neutral control of surgical site
Supine pelvic rocks (midrange lumbar lumbar spine while Prepare patient to resume
flexion AROM) supine and prone ADLs and promote good
Side-lying pelvic rocks (midrange Increased LE strength cardiovascular conditioning
lumbar lateral flexion) Controlled lumbar
Quadruped pelvic rocks (midrange movements are beneficial
lumbar AROM) after microdiscectomy
Prone pelvic rocks (midrange lumbar secondary to hydrostatic
extension AROM) changes of the disc to
Supine abdominal bracing (isolated promote vascularity
transverse abdominis contraction) Increase strength of trunk
Supine abdominal bracing with arms musculature to stabilize and
behind head, progressed to alternating protect the spine from injury
arm raises Increase tolerance to upright
Prone abdominal bracing with postures
alternating arm raises, progressed to Help with maintaining good
unilateral arm raises body mechanics
Partial squatting to 60
ADLs, Activities of daily living; AROM, active range of motion; LE, lower extremity; PROM, passive range of motion; ROM, range of motion; SLR, straight-leg raises.
294 PART 3 Spine
treats himself or herself several hours each day with a home

BOX 15-2 Waddell Signs exercise program and self-treatment techniques. Further-
1. Superficial tenderness to light touch in the lumbar more, avoiding reinjury is perhaps the single most important
region or widespread tenderness to deep palpation postoperative factor responsible for a rapid progression in
in nonanatomic distributions the program and ultimately full recovery. Through patient
2. Increased symptoms with simulated axial loading or education, a safe and relatively rapid return to activities can
simulated rotation tests occur. The physical therapist (PT) should educate the patient
3. Inconsistent supine and sitting SLR tests regarding proper postures, home exercises, self-care tech-
4. Regional weakness or sensory abnormalities that are niques, and body mechanics for the safe performance of
not myotomal or dermatomal activities of daily living (ADLs). Proper postures and body
5. Physical overreaction or disproportionate mechanics are crucial during the postoperative healing
verbalization during assessment phase. Ideally the therapist should instruct the patient before
surgery, but if this does not occur, then the first postopera-
tive task is to teach the patient correct postures and body
mechanics.
compromised patient. We typically include Waddell signs85
late in the rehabilitation process to help delineate nonorganic Proper Postures
physical signs (Box 15-2). The PT teaches the patient to maintain normal lumbar
The mechanical examination must be very limited in lordosis.
the phase I and phase II patient. It is intended to elicit Patients should avoid lumbar flexion in standing or
symptomatic and mechanical responses that suggest mechan- sitting because intradisc pressures are increased and
ical problems and so dictate the treatment course. Because excessive shear forces occur. Intolerance to prolonged
weight-bearing motion testing and end-of-range move- postures is typical in phase I, and frequent movement breaks
ments are typically not performed until after the fifth are recommended. The concept of abdominal bracing should
week postoperatively, the therapist uses responses to posi- be taught early. The therapist also should investigate the
tioning and midrange movements in prone, supine, and ergonomics of the patients workstation to avoid potential
side-lying positions to determine mechanical problems in problems.
the initial weeks.
Hip muscle strength testing should be postponed in the Sitting and Driving. The therapist should do the
early stages of healing to prevent stressing inflamed lum- following:
bosacral tissues. Neural tension testing is an integral part of Caution the patient to never slouch while sitting.
the lumbar evaluation. Therefore the therapist should have Instruct the patient in the use of a lumbar roll or similar
the patient perform the SLR, Cram test, femoral nerve device to maintain lordosis during sitting and driving.
tension test (prone knee flexion), and supine dural tension Advise the patient to try to always sit on firm, straight-
and do the appropriate measuring, recording, and compari- back chairs and never sit on soft sofas or chairs.
son with the opposite limb. Caution the patient to avoid all backless seating. If the
Slump testing should not be performed until after the patient eventually will need to sit in bleachers or similar
fourth or fifth week postoperatively. Core strength testing backless seating, then a Nada-Chair (Nada Concepts, Inc.,
may be performed in a variety of ways; however, Lee86 Minneapolis) or a similar device should be recommended
describes a nice functional approach based on grouping core that supports the lumbar spine during this type of sitting.
musculature into slings. A good understanding of soft tissue Encourage frequent movement breaks. Instruct the
healing rates, spinal mechanics, and the specific surgical pro- patient to avoid sitting longer than 20 minutes at a time
cedure helps avoid needless soft tissue trauma. For further for the first 2 weeks. This increases in subsequent weeks,
evaluation of the patients physical limitations and guidance depending on tolerance to pain.
toward appropriate functional training, the therapist can use Allow patients to return to driving for short periods after
the Modified Low Back Pain Oswestry Questionnaire87 (see about 1 to 2 weeks. Remind the patient that safety is a
Box 15-1) or the Roland-Morris Functional Disability Ques- prioritynot a convenience.
tionnaire.46 These are easily administered and helpful. The
therapist should document the patients perceived disability Sleeping. The therapist should do the following:
status before treatment and at predetermined intervals to Teach the patient to sleep in supported supine, supported
monitor functional progress and determine the appropriate side lying, or supported prone three-quarter lying with
direction of functional training exercises. the spine straight.
After evaluation the therapist thoroughly explains the Instruct the patient to avoid sleeping in the fetal posi-
existing problems and the treatment plan to the patient. tion because of the prolonged lumbar flexion.
Therapist and patient should work together to reach mutual Have the patient avoid unsupported prone three-
agreement on realistic goals. Patient education is crucial to quarter lying positions because of the rotational
achieving positive results because the patient ultimately component.
Caution the patient to avoid lying on soft mattresses or position (i.e., lunge) and then reaching to lift a light
sofas. object. The exercise is then performed in reverse.
Standing and Walking. The therapist should do the Bending. The therapist should do the following:
following: Advise the patient to avoid all bending at the waist.
Advise patients to limit standing at the kitchen sink or Lumbar flexion with loading is arguably the most haz-
bathroom counter to short periods and avoid bending at ardous movement in the first two phases. The interdisk
the waist. pressures are significantly increased, and tension on the
Encourage the patient to maintain lumbar lordosis during healing posterior annulus compounds the problem. Pro-
standing and walking while performing an abdominal longed or repetitive bending is especially injurious.88
brace. Remember that, on occasion, limited bending is neces-
sary. Teach the patient the correct way to bend and
Body Mechanics instruct him or her to avoid lumbar flexion while bending.
To allow the patient to progress rapidly, the therapist The patient can safely bend by simultaneously flexing at
should do everything possible to avoid reinjury. Minor set- the knees and hips (hinge at the hips), while maintain-
backs may delay progression of the program, and a ing a neutral spine and an abdominal brace. This is easy
major setback may be irreparable. The therapist should pay to teach by placing a 4-foot wooden pole (1 to 2 inches
close attention to the patients movements. Patients may in diameter) along the spine with contact at the thoracic
say they understand correct mechanics but display and sacral regions. By flexing slowly at the hips and knees
incorrect movement patterns. Frequent and critical observa- while maintaining a neutral spine position and viewing
tion allows the therapist to evaluate the patients themselves in a mirror, patients can practice this impor-
spinal mechanics and determine whether the patient has tant movement.
integrated the correct postures and mechanics. A checklist Occasionally, patients with low back pain possess poor
of basic functional movements (i.e., rising from lying, rising kinesthetic-proprioceptive coordination. A simple technique
from sitting, sitting in neutral, reaching overhead, bending to improve the patients sense of lumbar movement and posi-
to knee level) is helpful to record the performance of these tion involves the use of tape. First, the therapist places the
skills and whether the patient requires cues to complete the patient on all fours and has him or her assume a neutral
tasks. spine position. The therapist places a 12- to 18-cm long piece
of tape on the paraspinals parallel to the spine (Fig. 15-9),
Transfers. The therapist should do the following: while avoiding placing the tape directly over the incision site.
Teach the patient to move correctly from supine to The therapist then asks the patient to make small movements
sitting, from standing to lying on the floor, and from into flexion and extension, always returning to neutral. The
sitting to standing. Rolling in bed as a unit and rising additional feedback from the tape pulling or wrinkling will
from bed must be performed correctly. In addition, give assist the patient in learning spinal proprioception. Various
instruction on entering and exiting a car. postures can then be tried, including kneeling, side lying,
Remember that all twisting motions are prohibited. sitting, and standing, with small motions of the lumbar spine
Instruct them to move their feet to turn instead. while in each position. The patient then progresses to func-
tional movements (e.g., transfers, walking, bending).
Dressing. The therapist should do the following:
Instruct the patient in the correct way to put on pants, Exercise
socks, and shoes in the supine position. Slip-on shoes are Dural mobilization (i.e., mobilization of the nervous system,
the easiest to handle in the first 2 weeks. Tying shoes neurodynamic exercise, nerve root gliding, neural tension
can later be performed safely by putting the foot on a stool exercises) should begin as soon as possible in the first week.
or chair. The preoperative neural compromise and the postoperative
inflammation in and around the epidural space contribute
Hygiene. The therapist should do the following: to neural broses and dural adhesions. They are occasionally
Explain that showering can begin after the second week. problematic and are easily preventable. An excellent presen-
Have the patient shave her legs in the standing position, tation of neural mobilization principles and techniques can
with the foot on the tub or shower seat, avoiding lumbar be found in Butler.89
flexion.
Technique. The therapist should do the following:
Lifting. The therapist should do the following: Supine dural mobilization (lower lumbar neural
Remember that correct lifting techniques should be mobilization)Have the patient lie supine on a firm
taught early and instruct patients to try to avoid all lifting surface with both knees extended. While the patient holds
in phase I. Swoop lifting is usually a safe and well- the back of the thigh with both hands, he or she slowly
tolerated technique for light lifting in phase II. The patient extends the knee with the ankle dorsiflexed to the point
performs it by taking a long stride forward to the kneeling of stretch. He or she then slowly flexes and relaxes the
296 PART 3 Spine
A B
Fig. 15-9 Patient assumes a quadruped position, while the therapist places a 12- to 18-cm strip of tape on the paraspinals adjacent to the spine. The therapist
should take care to avoid the incision site. A, Appearance of tape in squatting position. B, Close-up view of tape with return to standing position.
limb. Any symptoms and the maximal amount of knee the more superficial abdominal muscles (the obliques)
extension attained should be recorded to monitor are important in lumbar stability, they are trained later in the
progress. program for their rotational contribution to limit lateral shear
Prone dural mobilization (upper lumbar neural and torsional stresses and create trunk rotation. Early in phase
mobilization)Have the patient lie prone on a firm II, the lumbar multifidi are isolated and trained because of
surface with both knees extended. Initially the patient their ability to stabilize segmentally.102,104,105 In addition, it has
may use a pillow under the abdomen for comfort if been found that the lumbar multifidi atrophy in patients with
needed. Have the patient slowly flex the knee to the point low back pain and there is a decrease in muscle thickness
of stretch, then slowly extend the knee and relax. Make change with activation.100,106 Literature has also investigated
sure the patient maintains the abdominal brace throughout the importance of the pelvic floor musculature in stabilizing
the exercise to stabilize the lumbar spine. Alternate legs. the lumbar spine.80,107,108 Evidence shows that the pelvic floor
Dural mobilization should be done several times a day. muscles cocontract with the transverse abdominus; therefore
The therapist must caution the patient that this exercise may recruiting the pelvic floor muscles should be considered
provoke neural symptoms, and that he or she must allow the when instructing in bracing. Bracing has been shown to
pain or tingling to resolve to baseline levels before beginning immediately increase posteroanterior spinal stiffness and sta-
the next repetition. The patient should not overmobilize the bility.109 Eventually a cocontraction of transversus abdominis,
neural tissues. As with any exercise, self-mobilization of multifidus, and pelvic floor (abdominal bracing) is performed
the nervous system at home is inappropriate until a posi- during all exercises and functional activities.110,111 All the
tive response has been established from repeated move- exercises should focus on control and technique and be pro-
ments in the clinic. The dural mobilizations are progressed gressed as tolerated to improve endurance of these primary
as tolerated to include other components of the affected stabilizers.
nerve (e.g., ankle dorsiflexion, hip internal rotation [IR]). The PT should instruct the patient in the neutral spine
Eventually (in phase III) the patient can perform neural concept and help the patient find the neutral spine position
mobilizations while sitting (sitting slump). in various postures. The patient can then be taught to control
The early initiation of a progressive spinal-stabilization the transverse abdominus with electromyographic (EMG)
program is crucial to the eventual tolerance of more strenuous biofeedback, pressure biofeedback,* or rehabilitative ultra-
functional activities and sports skills. Because the lumbar sound imaging102,112-116 in several positions (e.g., supine, all
spine is inherently unstable around the neutral zone, the fours, prone). Feedback available by rehabilitative ultrasound
trunk musculature must be sufficiently strong and coordi- imaging has been shown to improve transverse abdominus
nated to stabilize and protect the spine from injury.90,91 The and lumbar multifidus muscle recruitment up to 4 months
stabilization program progresses from unloaded spinal posi- posttraining.117,118 After that, the patient can progress the
tions to partially loaded and eventually fully loaded func- postures to include sitting and standing and increase the
tional training. The posterior pelvic tilt exercise is the least duration of the contractions to 60 seconds.
desirable exercise to obtain active lumbar stability.90,92-94 The Based on the information obtained in the history, the
transversus abdominis must be isolated from the remaining responses to various positions, and the limited clinical
abdominal musculature because it has consistently been testing performed during the initial evaluation, the therapist
shown to be active before the other abdominal muscles or the determines which midrange lumbar movements are toler-
primary movers during limb motions, regardless of direc- ated and are indicated for exercise. Correct and controlled
tion.95,96 In addition, the transversus abdominis can become lumbar movements are beneficial to the patient after micro-
dysfunctional in patients with low back pain.95,97-100 Therefore discectomy because hydrostatic changes of the disc promote
the transversus abdominis possesses a superior ability to sta-
bilize the lumbar spine actively and locally.38,101-103 Although *Stabilizer, Inc., Chattanooga, Tenn.
improved vascularity.119,120 To this end, the therapist teaches

pelvic rocks in pain-free positions (e.g., all fours, prone). A
pelvic rock is a repetitive and continuous pelvic tilt from an
anterior to a posterior position. A bias toward lumbar exten-
sion is typical in the patient who has undergone microdisc
ectomy because lumbar extension reduces tangential stress
posteriorly. A flexion bias is usually not recommended
because the surgical entry is into the posterior disc and
flexion positions tend to create stress to this area and tension
on the incision. A healthy respect for soft tissue healing
periods is essential. Fig. 15-10 Hip flexion is very important. When stretching the gluteals, the
patient should pull the thigh toward the belly rather than toward the nose.
The therapist instructs the patient in most of the following
This patient is attempting to increase the hip flexion angle rather than draw
exercises in phase I, but he or she should not prescribe any the pelvis into a posterior tilt.
exercise or position for the home program until repeated
trials in the clinic have proven painless. Stabilization, flexi-
bility, coordination, and spinal mobility exercises are
included in an attempt to address all parameters. The exer-
cise sequence is important and should be considered by the
PT when adding exercises. Good technique and control of
movement are essential. No exercise should increase the pain
pattern or cause lingering pain. Clearly some muscular sore-
ness may accompany the program, but this should be well
tolerated and transient. The typical patient should be able to
contract the transversus abdominis for 60 seconds in various
positions within approximately 1 week after the initial visit.
The following exercises are taught in phase I:
1. Abdominal bracing on all fours (i.e., isolated transverse
abdominis contraction, lumbar multifidus, and pelvic
floor cocontraction) progressed to quadruped abdomi-
nal bracing with alternate arm raises
2. Quadruped pelvic rocks (i.e., midrange lumbar active
range of motion [AROM])
3. Supine dural stretching (or prone dural stretching for
upper lumbar disorders) Fig. 15-11 Gastrocnemius and soleus stretching. While keeping the foot
4. Supine abdominal bracing (isolated transverse abdomi- and heel of the back leg on the floor, the patient shifts the weight forward
nis contraction, lumbar multifidus, and pelvic floor to the front leg. A stretch should be felt in the calf area. The patient should
cocontraction) maintain the spine in neutral with an abdominal brace as the weight is
shifted toward the front foot and the supporting thigh is kept directly below
5. Supine pelvic rocks (i.e., midrange lumbar flexion
in the frontal plane.
AROM)
6. Supine abdominal bracing with arms behind head pro-
gressed to abdominal bracing with alternating arm Spinal Mobilization
raises Spinal mobilization of the lumbar spine is rarely used in
7. Supine gluteal, hip external rotator, and hamstring phase I or II. Mobilization of the hips or thoracic spine may
stretches to correct myofascial limitations; actively be needed and is best addressed on an individual basis.
holding neutral spine during these low-load, long-hold When progress is poor with active movements and deemed
exercises is important (Fig. 15-10) secondary to a hypomobile segment, mobilization to restore
8. Side-lying pelvic rocks (i.e., midrange lumbar lateral lumbar movement may be necessary in phase II. In phase
flexion AROM) III, mobilization can play an important role and is used
9. Prone pelvic rocks (i.e., midrange lumbar extension frequently to reduce pain during specific lumbar motions,
AROM) especially at end of range. A review of Maitland,121 Mulli-
10. Prone abdominal bracing with alternate arm raises pro- gan,122 and Paris56 may assist in clinical reasoning.
gressed to prone abdominal bracing with bilateral arm
raises Cardiovascular Conditioning
11. Gastrocnemius and soleus stretching in standing posi- Cardiovascular conditioning is an important part of the
tion (Fig. 15-11) rehabilitation program and is beneficial both for patients
12. Partial squats to 60 of knee flexion while maintaining recovering from lumbar microdiscectomy and those with
neutral spine with abdominal bracing chronic low back pain.123 In addition, endurance training of
298 PART 3 Spine
the LE musculature improves tolerance to prolonged stand-

ing and walking. When LE muscles fatigue, poor body
mechanics soon follow. The patient typically performs
aerobic training by progressive walking (on a treadmill or
outdoors without hills), stationary cycling (on recumbent or
upright bikes with the patient paying close attention to the
maintenance of lordosis and avoidance of hip sway), or
swimming (initially only the freestyle stroke with avoidance
of craning during the breathing phase). Craning is suboc-
cipital extension with rotation (occipitoatlantal to atlanto-
axial) or cervical extension with rotation (C2 to C7). Fig. 15-12 Materials to manufacture compression patch (10- 6-cm Neo-
Swimming and aqua therapy are usually delayed until the prene pad, 2-inch elastic tape).
second or third week after surgery to ensure complete wound
healing and sufficient lumbar stabilization. The PT must
caution patients never to jump or dive into the water, but
rather use the ladder or steps. Aquatic therapy for postop-
erative lumbar rehabilitation is not covered in this chapter,
but Watkins , Williams, and Watkins124 present a good source
for the interested clinician.
The therapist determines the patients training heart rate
and adheres to this guideline during all conditioning exer-
cises. Patients who have no prior history of aerobic exercise
or who are very deconditioned must progress slowly and be
carefully monitored. Aerobic conditioning in phase I (with
focus on correct postures and mechanics) may include
walking, stationary cycling, and water exercises. Patients
should avoid stair climbers and cross-country skiing
machines until phase II, when adequate trunk stability is
usually attained. In addition, rowing, running, and in-line Fig. 15-13 Inspection of scar before application of compression patch.
skating should be avoided until phase III, when significant
active lumbar stability has been achieved.
The progression of cardiovascular training is highly vari- patients posture during modalities is always important and
able and depends on the patients prior level of conditioning varies depending on positional tolerance. Supported prone
and present goals. He or she can usually begin with 5- to lying or supported supine lying is usually quite comfortable
10-minute bouts and progress at 5-minute intervals up to 30 in this phase.
or 60 minutes. The therapist must pay careful attention to
patient position because correct postures deteriorate as Wound Care
fatigue increases. Neurologic weakness of the hip flexors or Along with the patients history, the inspection of the inci-
abductors, quadriceps, hamstrings, ankle dorsiflexors, and sion site during the initial evaluation helps determine
plantar flexors significantly alters gait and requires modifica- whether extra measures are needed. Any signs of infection
tion of the aerobic program to avoid abnormal mechanical are a red flag that requires prompt medical intervention.
stress. Some patients desire invisible scars, whereas others are
much less concerned. Because patients scar differently, the
Modalities therapist should monitor their progress and offer solutions
In general, the use of passive treatment techniques alone to excessive scarring or scar stretching. A compression
should be avoided; however, occasionally they may be neces- taping technique can be used to limit hypertrophic scar for-
sary to augment the functional restoration program. The mation and reduce surgical scar widening. First, the thera-
therapist should use pain control modalities only as needed pist folds a 10- 6-cm Neoprene pad in half and secures it
to support the exercise program. Cryotherapy and interfer- with a 2-inch wide elastic tape (Elastikon tape)* (Fig. 15-12).
ential stimulation applied to the low back for 15 to 20 The pad is then affixed horizontally over the closed wound
minutes after an exercise session are helpful. Some therapists (Figs. 15-13 and 15-14) to provide both compression and
may prefer electric myostimulation (EMS), microstimula- approximation of the surgical scar. The patient wears the
tion, or transcutaneous electrical nerve stimulation for compression patch constantly for 6 to 10 weeks, removing it
muscle spasm reduction and pain control. However, EMS only to bathe. It should not be applied until the wound site
that is delivered too intensely in the first several weeks after is completely healed (approximately 2 weeks).
surgery may unwittingly jeopardize the healing paraspinal
muscle tissue and should therefore be used judiciously. The *Johnson & Johnson, New Brunswick, NJ
Phase II (Functional Recovery Phase)

GOALS: Understand neutral spine concept,
improve cardiovascular condition, increase trunk
strength to 80%, increase soft tissue mobility and LE
flexibility and strength, maintain nerve root mobility
(Table 15-2)
As surgical site pain diminishes and active spinal stability

improves, the PT can increase the patients program of func-
tional activities and exercise. The patient in phase II should
have complete wound healing, although some tenderness
and paraspinal spasm may persist. Neural tension signs
should be negative, but neurodynamic testing may reveal
Fig. 15-14 The pad is affixed horizontally over the closed wound and held limitations. The patient should be gaining tolerance to
in place by 2-inch elastic tape.
TABLE 15-2 Microdiscectomy

Anticipated
Phase II No signs of Pain Continue as in phase I and progress Cardiovascular Improve cardiovascular fitness
Postoperative infection Limited nerve cardiovascular activities as exercise 20 minutes Restore neural-gliding
4-6 wk No increase in mobility appropriate Minimal to no neural mechanics
pain Limited trunk Self-nerve mobilization using a belt tension signs Prevent neural fibrosis and
Gradual increase strength to enhance the stretch Trunk strength 80% dural adhesions
in tolerance to Limited scar Isometrics with ROMSpine Use of neutral spine Strengthen trunk musculature
activity mobility abdominal bracing with alternate concepts in a variety via neutral spine concepts
Demonstration of Limited soft SLRs; progressed to cycling and of positions Perform exercises in midrange
good knowledge tissue mobility dying bug when appropriate Avoidance of lumbar of lumbo-pelvic mobility
of body mechanics Limited tolerance Partial sit-ups with added rotation spine extension Stabilize and strengthen trunk
Performance of of ADLs and for obliques when appropriate while performing hip while moving extremities,
self-care with sustained Prone (abdominal bracing with SLR extension progressing from passive
minimal postures extension): Begin with single leg Partial press-ups repositioning to dynamic
modifications Limited trunk and progress to double leg without pain stabilization
stability and Prone on-elbows lying, progress to Good neutral control Restore full extension in
strength in partial press-ups of lumbar spine in non-weight-bearing position
numerous AROM with isometricsAll fours variety of postures Strengthen paraspinals and
postures (abdominal bracing with single-leg Increased strength of abdominals in a neutral
Limited mobility raise, progress to opposite arm and LEs position
of lumbar spine leg raises); standing (abdominal Improved sitting Promote maintenance of a
soft tissues bracing with squats to 60, tolerance neutral spine in an upright
Poor recruitment progress to 90 for 2-3 minutes); Isolated contraction posture to improve tolerance to
of paraspinal sitting on Swiss ball (abdominal of lumbar spine compression positions
muscles bracing with hip flexion, arm paraspinal muscles Increase tolerance to upright
Limited LE ROM flexion, and combinations of Increased LE postures
Limited opposite arm and leg) flexibility Use biofeedback to improve
cardiovascular EMG training of lumbar spine Increased soft tissue recruitment of paraspinals
endurance multifidus muscles mobility Improve flexibility of LEs to
PROM (stretches), then add decrease stress on the spine
iliopsoas and quadriceps Improve myofascial interface
Soft tissue massage and restore soft tissue mobility
ADLs, Activities of daily living; AROM, active range of motion; EMG, electromyographic; LE, lower extremity; PROM, passive range of motion; ROM, range of motion;
SLRs, straight-leg raises.
300 PART 3 Spine
functional activities and be able to perform all self-care with Typical Phase II Exercises. The therapist should do the
minor modifications. The patients tolerance to aerobic exer- following:
cise also should be improving. Correct body mechanics and 1. Supine abdominal bracing with alternate SLRs, pro-
postures should be maintained as functional activity gressed to abdominal bracing with unsupported LE
increases. Patients should have confidence in their ability to extension (i.e., cycling), progressed to abdominal bracing
stabilize the lumbar spine actively in all loaded positions. with unsupported upper extremity (UE) and LE exten-
Pain-free lumbar AROM should be increasing to end-of- sion (i.e., dying bug) (Fig. 15-15)
range strain only, although terminal flexion may still provoke 2. Supine dural mobilization, progressed to incorporate a
pain. belt or towel around the foot to enhance the effect
The patient should continue to avoid loaded lumbar 3. Supine partial sit-ups, progressed to partial sit-ups with
flexion. Through brief reevaluations in each treatment rotation to facilitate oblique strengthening (Fig. 15-16)
session, the therapist collects additional lumbar motion data. 4. Double-leg bridging, progressed to single-leg bridging
For example, if prone pelvic rocks are well tolerated, then the and then to single-leg bridging with opposite knee
patients positional tolerance to elbow lying and partial extended (Fig. 15-17)
extension in lying can be assessed safely. 5. Prone elbow lying, progressed to partial press-ups
The therapist should avoid standing motion testing and 6. Prone abdominal bracing with single-leg raises, pro-
sitting testing except for the most conditioned patients gressed to prone double-leg raises
who are doing very well. 7. Standing repetitive squats to 60, progressed to 90 for
2 to 3 minutes
Exercise
A recent Cochrane systematic review of randomized con-
trolled trials concluded that high-intensity exercise pro-
grams initiated 4 to 6 weeks postmicrodiscectomy lead to
decreases in pain and disability faster than no treatment or
low-intensity programs.125 However, although early exercise
intervention resulted in faster decreases in pain and disabil-
ity, clinical outcomes at 1-year follow-up had similar results
versus low-intensity or no exercise.126,127 The therapist should
instruct the patient in the correct way to contract and control
the lumbar multifidus with EMG biofeedback. Special atten-
tion to the training of this important segmental stabilizer is
essential.128 Retraction of the paraspinal muscles during
surgery can denervate the multifidus muscle.129 Fortunately,
lumbar microdiscectomy requires a minimal wound opening,
so this complication is lessened. The patient should perform
abdominal bracing (holding neutral spine with a cocontrac-
tion of the transverse abdominis, multifidus, and pelvic
Fig. 15-15 Dying bug. This exercise teaches the patient to control exten-
floor) in supine, prone, and all-fours positions, progressing sion and side-bending at the same time. The patient starts with the hands
to transition movements. Ultimately, the cocontraction is touching the knees directly over the hips and then extends the same-side
used to stabilize the lumbar spine during all ADLs. The ther- arm and leg slowly and deliberately. The PT monitors the patient for side-
apist can progress the patients midrange lumbar movements bending or extension. The patient can modify this exercise by moving the
and spinal-stabilization program as tolerated, using Swiss arms and legs in smaller increments.
ball exercises to improve balance and dynamic lumbar sta-
bilization during sitting. The patient should continue to
avoid axial loading during end-range lumbar flexion or
lateral flexion movements. As the patient shows control and
tolerance, the exercise level may be increased. Pain during
exercise typically requires correction of the technique or
exercise modification. In addition, muscle groups that may
have been weakened by neurologic compromise (e.g., hip
abductors, quadriceps, ankle plantar flexors, dorsiflexors)
must be strengthened. The slow twitch fibers are most
involved and are easily fatigued. The longer that neural com-
Fig. 15-16 Partial sit-ups are done in many positions. The important point
pression and inflammation have been present, the longer the
is that the spine must remain in neutral, the abdominals must remain con-
period before regeneration occurs. Careful attention to back- tracted throughout the exercise, and eccentric control must be emphasized.
protected positions during strengthening exercises is crucial The lift is of the chest, not the head. Legs can be in extended position to
to avoiding reinjury. bias lumbar extension.
Fig. 15-17 Bridging. This exercise teaches the patient to brace the spine first, then lift the trunk as a unit. The patient is moving in and out of a hip hinge
and emphasis is on coordinating the trunk and hip muscles.
Fig. 15-18 From the quadruped position, the therapist should teach the
patient to keep the hands under the shoulders and knees under the hips,
extending the opposite arm and leg.
8. Abdominal bracing on all fours with single-leg raise,

progressed to opposite arm and leg raises (Fig. 15-18)
9. Balance board training on both limbs, progressed in
duration
10. Isolated strengthening of neurologically compromised
muscles Fig. 15-19 Hamstring stretching is taught in a standing position if possible
11. Swiss ball sitting exercise progression (in neutral spine so that the patient can work on contralateral hip stability and trunk control
with abdominal brace) while stretching. The patient can work the foot up and down while main-
12. Stretching of the quadriceps, gluteals, hip external rota- taining the stretch to increase the nerve-gliding component. A slight bend
in the knee with more hip hinge will move the stretch up from the muscu-
tors, iliopsoas, hamstrings, and calves as required to
lotendinous junction into the muscle belly.
correct myofascial limitations (Figs. 15-19 through
15-22; see also Fig. 15-11)
from microdiscectomy, and certain techniques are particu-
Soft Tissue Mobilization larly beneficial before paraspinal strengthening (e.g., side-
Scarring of myofascial elements with collagen cross-fibers or lying paraspinal pull from midline). Careful questioning and
fibrofatty tissue limits muscle broadening during contraction soft tissue examination will uncover gluteal trigger points
and connective tissue elasticity during movement.130 Muscle that can cause buttock or LE pain patterns.76 These myofas-
spasm and protective guarding of the gluteals and low back cial pain syndromes are not uncommon preoperatively and
musculature may persist. Soft tissue mobilization of the may linger postoperatively. With appropriate treatment they
lumbar paraspinals and buttock musculature is frequently can be relieved so that the functional restoration program
needed to improve muscle function and reduce spasm.131 may progress. Scar massage to release adherent soft tissue
The PT must exercise care when performing soft tissue also may be needed.
mobilization to the paraspinals before the third or
fourth week after surgery because the tissue healing is Spinal Mobilization
incomplete. The mechanical and reflexive effects of soft Spinal mobilization using nonthrust maneuvers may be ben-
tissue mobilization are well suited for patients recovering eficial for patients in phase II if they do not have protective
302 PART 3 Spine
Fig. 15-20 Initially the quadriceps stretch is performed in a prone position

and then is taught in standing position if possible to develop trunk control Fig. 15-22 Adductor flexibility is important for squatting. The patient can
against an extension moment. If the patient does not have sufficient ROM, vary the trunk angle or apply pressure to the inner knee to increase the
then he or she should modify the stretch by placing the foot on a table. stretch.
Abdominal control prevents lumbar extension.
Cardiovascular Conditioning
The PT should continue to progress the cardiovascular
program in intensity and duration of aerobic training. The
use of cross-country ski machines, stair climbers, and swim-
ming for aerobic exercise is allowed if sufficient trunk stabil-
ity has been achieved. Patients should avoid rowing and
in-line skating until phase III.
Running is not recommended until after the twelfth
week after surgery because of the degree of spinal stabili-
zation required and the repetitive axial loading sustained
by the disc.
Modalities
The therapist and patient should use modalities only as
needed to support the exercise program. Cryotherapy and
interferential stimulation to the low back after exercise may
be beneficial.
Phase III (Resistive Training Phase)

GOALS: Ensure patient is independent in self-care and
ADLs with minimal alterations, increase tolerance to
activities, progress return to previous level of
Fig. 15-21 Gracilis stretch is important for squatting to the side. function
The patient in phase III should consistently perform

muscle spasm, bone disease of the spine, or hypermobile or correct body mechanics and postures without prompting
irritable adjacent motion segments. Muscle energy tech- and should tolerate almost all functional activities. Pro-
niques are usually well tolerated and best suited for phase II. longed positioning (e.g., unsupported sitting) may still
Thrust maneuvers (grade V or high-velocity manipula- provoke low back pain, but this should be easily relieved with
tions) are not indicated. change of position or simple stretching exercises. Soft tissue
healing at this stage is largely complete, although some surgi- that these symptoms will subside with continued neural
cal site tenderness may still be present. All self-care and mobilization and time.
ADLs should be performed confidently and painlessly with Researchers132 and clinicians note that flexibility, strength
minimal modifications. Patients in phase III should have (stability), and coordination return at different rates after
good tolerance to midrange lumbar movements and suffi- injury. During spinal rehabilitation, flexibility should precede
cient spinal stabilization to perform spinal movements in strength, proximal strength should precede distal strength,
loaded positions. and strength should precede coordination. This culminates
The resumption of lifting activities must be progressive in the more rapid and fluid functional movements seen in
and occur with careful instruction. Because approximately uninjured persons. The PT must be sure to consider the
half of all workers compensation claims for low back injury sequence of return of these various elements, the existing
result from lifting objects, this patient group needs propor- limitations uncovered during mechanical testing, and the
tionally more instruction and functional training. patients realistic goals when planning the progression of the
Because soft tissue healing is nearly complete by phase III, exercise program.
more extensive mechanical testing can be performed to
ascertain tolerance to various lumbar movements, as well as Exercise
the end range sensation. Functional training exercises (i.e., sports-specific drills,
Standing motion testing (without overpressure) and work-hardening activities) typically begin in phase III. Preset
seated testing can be performed safely on most patients goals determine the kinetic activities that are to be the focus
after 6 weeks. The outcome of the movement testing deter- of rehabilitation. The therapist closely supervises the pro-
mines to a great extent the treatment and exercise progres- gression of these activities, paying careful attention to the
sion. Neural tension signs should be negative unless scarring quality of spinal mechanics and lumbar stabilization. Func-
has occurred. Occasionally some neurologic signs and symp- tional training is focused on trunk movements that simulate
toms persist into the third phase, but with monitoring and activities to which the patient will return. Sports-specific
calm encouragement the PT can reassure affected patients training (Figs. 15-23 through 15-26) can begin if the patient
A B
Fig. 15-23 A, Landing from a jump is invariably more difficult for jumping athletes. It is imperative that they learn to land in a hip hinge position and
be trained to absorb as much shock as possible eccentrically through the hips, knees, and ankles, before it reaches the spine. Plyometric drills are helpful.
B, While in the air with the arms overhead, the therapist should train the jumping athlete to perform a brace with the transverse abdominals to prevent
extraosseous lumbar motion. When blocking a ball with the arms overhead (as in volleyball), the athlete should brace more intensely to resist the impact of
the ball. Medicine ball drills are helpful. Continued
304 PART 3 Spine
Fig. 15-23, contd C, In some contact sports the athlete will be hit while in the air (e.g., basketball, football). For a frontal impact, the athlete should give
way at the hips; for a hit from an angle, he or she should learn to pivot away from the blow. Drills such as those shown here with progressively more difficult
blows are helpful to train this specialized skill.
has achieved sufficient active lumbar stability and spinal

mobility in fully loaded positions, as well as adequate myo-
fascial flexibility and conditioning. The therapist can use
proprioceptive training with balance boards and Swiss balls.
Initially, athletes who take part in running and jumping
activities are most safely trained with unloading devices,*
during supervised treadmill running or jump training. These
patients are typically well conditioned before surgery and
have progressed postoperatively without setbacks.
Golfers need to be trained to hold the neutral spine
dynamically during all five phases of the swing. The PT can
incorporate specific strength, flexibility, and balance exer-
cises to achieve a safe and mechanically sound golf swing.124
Work-hardening activities for medium to heavy work
classifications typically begin at 8 weeks and include lift
training from 25 to 50lb. Workers in these fields need special
Fig. 15-24 A three-point stance is frequently used in football. It is essen- attention with regard to materials handling and should have
tially an exaggerated hip hinge. Adequate hip flexibility is essential, as well a functional capacity evaluation 10 to 12 weeks after surgery
as preaction abdominal bracing. to determine appropriate return-to-work status.
The exercise program progresses in intensity and diffi-
culty to include rotational trunk stability, overhead activities,
and balance training using a balance board. Training the
patient in diagonal patterns in loaded positions better simu-
lates real-life situations. A new stabilization exercise for
patients in phase III challenges the obliques and transverse
abdominals with minimal stress to passive tissues.76 McGill133
refers to this exercise as isometric side-support on knees or
on feet (depending on the degree of difficulty). Therapists
should prescribe this exercise for home performance only
after proving patient tolerance during clinic sessions.
The spinal mobility program attempts to restore painless
and full lumbosacral ROM. The PT should prescribe appro-
priate exercises and incorporate mobilization to achieve full
and pain-free lumbar ROM and continue the stretching
exercises needed to attain normal myofascial flexibility.
Soft Tissue Mobilization

Soft tissue mobilization should continue as needed to ensure
Fig. 15-25 In rugby and football, an athlete is frequently required to a pliable surgical scar, proper gluteal and paraspinal muscle
prevent someone from running around him or her. Stick drills such as this
function, and soft tissue extensibility.
can teach a patient to adapt quickly to changing forces, while maintaining
a neutral spine with an abdominal brace.
Spinal Mobilization
Spinal mobilization should be used when necessary to restore
motion at hypomobile segments and reduce pain associated
with movement. Because the restoration of normal spinal
motion is a primary goal, the therapist must identify and
correct aberrant arthrokinematics. The expanded mechani-
cal testing in phase III will reveal limitations or provoke
symptoms that require attention. Maitland,121 Mulligan,122
and Paris56 can be reviewed to assist in clinical reasoning.
Cardiovascular Conditioning
Cardiovascular conditioning should continue to progress in
intensity and duration. The patients aerobic fitness program
Fig. 15-26 When diving for a ball (as in baseball or volleyball), an athlete is determined by the ultimate activity goals. A typical
is taught to go low to the ground, stay horizontal, and land as a unit. A
significant abdominal brace is required. *Vigor Equipment, Inc., Stevensville, Mich.
306 PART 3 Spine
sedentary office worker obviously does not train as intensely exercise program (or with both). The exercise program is to
as a professional athlete. However, the therapist should not be maintained indefinitely. As always, the postsurgical
underestimate the aerobic demands placed on a manual patient should try to return to premorbid activity levels.
laborer and should encourage appropriate endurance Because goals vary dramatically among patients, some may
exercises. require substantially more training than others, such as over-
Aerobic conditioning (focusing on correct postures and head lift training, plyometric jump training, or sport-specific
mechanics) may include treadmill walking, stationary skill training. A reasonable level of tolerance to strenuous
cycling, the use of cross-country ski machines and stair work activities or recreational sports should be attained
climbers, swimming, and skating (in-line or on ice). Patients before these higher activity level patients are discharged.
who have had previous experience with rowing may resume The comprehensive lumbar evaluation performed in
this exercise. Attention to proper stroke form is important, phase III reveals any limitations in motion, weaknesses,
and modification to maintain lordosis may be necessary. neural restrictions, and painful movements that still need to
Patients should not start a running program until after be addressed. The PT can obtain additional information
the twelfth week postoperatively because of the high com- from computerized testing devices132* that provide objective
pressive and repetitive axial loads at heel strike. A walk- data on lumbar motion speed, acceleration and deceleration,
run program should be initially implemented on a treadmill, and degree of ROM. Other testing equipment, such as com-
with the therapist supervising and analyzing gait. When the puterized isokinetic machines, determines objective trunk
patient does resume running, it should be in the morning hours strength values at various speeds of lumbar ROM. This infor-
when the disc is maximally hydrated.124 mation can be helpful in guiding the therapist to choose
appropriate exercises to remedy any weaknesses or limita-
Modalities tions, especially in more physically active patients.
Cryotherapy may still be beneficial after intensive training Most patients recovering from lumbar microdiscectomy
sessions. EMS, transcutaneous electrical nerve stimulation, progress uneventfully if properly educated and carefully
microcurrent, interferential stimulation, and other modali- rehabilitated. The PT can facilitate the systematic training
ties are seldom necessary. program to achieve a safe and rapid return of function by
applying clinical knowledge and manual skills.
Discharge Planning
When the anticipated goals and desired outcomes have been
attained, the patient is discharged with a home or club *Lumbar Motion Monitor, Chattanooga Group, Inc., Chattanooga, Tenn.

Week 1 1. Progress walking program to 20 to 30 minutes.
GOALS FOR THE WEEK: Protect the surgical site to 2. Maintain nerve root mobility.
promote wound healing, maintain nerve root 3. Begin progressive exercise program (unloaded
mobility, reduce pain and inflammation, educate positions only):
patient, establish consistently good body mechanics a. Pelvic rocks in quadruped and prone positions
for safe and independent self-care b. Abdominal bracing in several positions
1. Protect the incision site. c. Supported dying bug at end of 3 weeks or
2. Begin gentle nerve root gliding. when appropriate
3. Maintain lumbar lordosis and correct body d. Elbow lying to partial extension in lying
mechanics. e. Prone alternating arm raises
4. Avoid holding positions for prolonged periods f. Partial squatting (to 60)
and avoid all lumbar flexion. g. Gentle stretching of hamstrings, calves,
5. Walk daily with a gradual increase in the duration gluteals, hip adductors, and rotators as needed
and speed. 4. Maintain proper postures and body mechanics.
6. Use ice as needed for discomfort. 5. Practice isolated contractions of transverse
abdominal muscles used frequently during daily
Weeks 2-3 activities.
GOALS FOR THE PERIOD: Protect the surgical site 6. Begin scar compressive taping as needed.
to promote wound healing, maintain nerve root 7. Use ice as needed for discomfort.
mobility, reduce pain and inflammation, educate
patient to minimize fear and apprehension, establish Weeks 4-6
consistently good body mechanics for safe and GOALS FOR THE PERIOD: Understand neutral spine
independent self-care concept, improve cardiovascular condition, increase
trunk strength to 80%, increase soft tissue mobility 8. Massage the scar as needed.
and LE flexibility and strength 9. Continue compressive scar care as needed.
1. Maintain nerve root mobility.
2. Progress exercise program (partially loaded Weeks 7-11
positions): GOALS FOR THE PERIOD: Ensure patient is
a. Partial press-ups to full press-ups independent in self-care and ADLs with minimal
b. Prone alternating leg raises to prone double- alterations, increase tolerance to activities, progress
leg raises return to previous level of function
c. Unsupported dying bug 1. Progress exercise program (loaded positions):
d. Double-leg bridging progressing to single-leg a. Press-ups
bridging b. Prone Superman (simultaneous arm and leg
e. Partial sit-ups with rotation raises)
f. Side-lying double-leg raises c. Dying bug with weights
g. All-fours arm and leg raises d. Single-leg bridging with weights
h. Repetitive squatting (starting at 60 and e. Partial sit-ups with rotation
progressing to 90) f. Side-lying double-leg raises with weights
3. Strengthen neurologically compromised muscles g. Isometric side support on elbow and knees
as needed (e.g., hip abductors, ankle dorsiflexors, progressed to feet
plantar flexors, evertors). h. All-fours arm and leg raises with weights
4. Gentle stretching of hamstrings, calves, i. Standing rotary-torso with resistive tubing
quadriceps, gluteals, hip adductors, and rotators j. Repetitive squatting (to 90)
as needed. 2. Begin functional training exercises (sports- and
5. Progress aerobic conditioning (e.g., walking, work-specific activities) at end of phase if able.
swimming, cycling) to 30 to 60 minutes. 3. Continue LE myofascial stretching as needed.
6. Practice cocontractions of transverse abdominal 4. Continue strengthening neurologically
muscles and multifidus frequently during daily compromised muscles.
activities. 5. Develop and segue into final home or club
7. Use ice as needed for discomfort. exercise program (or into both).
1 What are the goals for the first week following

microdiscectomy? 3 Myrna had microdiscectomy 2 weeks ago. She wants to
go to her sons baseball game this weekend. What should
her therapist tell her?
(1) Protect the incision site; (2) maintain nerve root
mobility; (3) reduce pain and inflammation; (4) educate Her therapist should tell her the following:
the patient; (5) establish consistent body mechanics. Caution her to avoid sitting in bleachers or on
benches without any back support.
2 Mikayla has been progressing well over the first couple

of weeks following her microdiscectomy. Today she
comes in complaining of a general feeling of fatigue. She
Suggest she take some type of alternative seating
device that has some back support.
Recommend frequent changes of position (avoid
also reports that she thinks she has had a fever for about sitting greater than 20 minutes at a time).
a week. What should you do? She should avoid slouching while sitting to prevent
increased intradisc pressures and shear forces that
You should inspect Mikaylas wound site for signs of can be caused by flexing in a sitting position.
infection. Look for any oozing or discharge from the
wound. Note any increased redness or warmth about the
incision site. Fever and malaise can be a sign of infection
(or just a cold). If you suspect an infection, prompt refer-
4 Rick is 41 years old. He has had progressing back pain
episodes over the past 2 years. An MRI shows a herni-
ated disc at L4-L5. Rick also has intermittent complaints
ral back to her surgeon is indicated. of left radicular leg pain. He had microdiscectomy
308 PART 3 Spine
surgery 2 weeks ago and has come to outpatient physical Karla should be instructed to do the following:
therapy for evaluation and treatment. How should a She should avoid lifting and carrying her child as
spinal evaluation be altered to assess a patient who has much as possible for the first 3 to 4 weeks after her
recently had microdiscectomy surgery? surgery. This may require educating her family
members that she will require assistance initially.
Mechanical testing should be limited (standing motion She should be instructed in proper body mechanics
testing and end-of-range movements are not assessed and correct lifting techniques when lifting or carrying
until 5 weeks after surgery). Hip muscle strength testing her daughter.
should be postponed in the early stages of healing to She should be taught that hip hinging and swoop
prevent stressing inflamed lumbosacral tissues. Slump lifting are necessary when bending to pick up after
testing is not performed until much later. A good under- her child.
standing of soft tissue healing rates, spinal mechanics,
and the specific surgical procedure helps avoid needless
soft tissue trauma. 9 Jason works in a warehouse where he must repeatedly
carry heavy boxes and walk for most of the day. He had
surgery 9 weeks ago and does not understand why his
5 Summer continues to have difficulty performing a

proper brace. What can you do to assist her?
therapist has him riding a bicycle and walking on a
treadmill as part of his lumbar microdiscectomy reha-
bilitation. If he has to do aerobic exercise, he would
You can use EMG, pressure biofeedback, or rehabilita- rather run. What is the therapists rationale for these
tive ultrasound imaging to help Summer learn how to exercises?
properly brace again.
The following explains the therapists rationale:
6 Edna was a sedentary person before her surgery. You

find that she is resistant to doing any exercises and
appears afraid of messing up her surgery. What should
Cardiovascular conditioning is beneficial for patients
recovering from microdiscectomy surgery.
Jasons job requires prolonged walking; he will need
you tell Edna? endurance of his LEs to prevent fatigue of his legs,
which can lead to poor body mechanics.
Edna should be educated on the changes in muscle func- Running should not be initiated until after the twelfth
tion following microdiscectomy. Also, she should know week of surgery, when the patient is able to stabilize
that not properly rehabilitating those muscles can lead his spine well and the repetitive axial loading is not
to chronic back problems in the future. Assure her that as much of a concern.
you will be tailoring her exercise program to her indi-
vidual needs and will be respecting pain.
10 Raquel is having difficulty finding a comfortable
position while sleeping after her microdiscetomy.
7 Verlyn is a 40-year-old woman. She had microdiscec-

tomy surgery for the L5 disc 6 weeks ago. Back pain is
minimal. LE flexibility and strength is gradually improv-
After questioning her you find that she typically
sleeps on her side in the fetal position. What should
you tell Raquel?
ing. Trunk strength also is progressing. She is now
seeing a PT for treatment. Previous treatments have Raquel should avoid sleeping in the fetal position as this
included modalities for pain control, LE flexibility places the lumbar spine in prolonged flexion, which you
exercises, trunk and general strengthening, cardiovas- want to avoid after microdiscectomy surgery.
cular conditioning, and body mechanics. Verlyn is Recommend the following positions instead:
concerned about the intermittent radicular pain in her Supported supine lying with a pillow under the knees
right leg. Prolonged sitting, walking, or standing aggra- Supported sidelying with a pillow between the knees
vates her right leg. She reports reproduction of calf pain and arms
with hamstring stretching. What treatment technique Supported prone three-quarter lying with the spine
should be used to decrease calf pain frequency and straight (see Fig. 16-7, A through C)
intensity?
Verlyn tested positive for adverse neural tension in the

right leg. After several treatments of mobilization to the
11 Summer is almost 3 months postmicrodiscectomy.
She had been making excellent progress until last
week when she returned to her Pilates class. Now she
nervous system, complaints of pain decreased signifi- is complaining of low back pain, which occurs when
cantly in intensity and frequency. she does a postpelvic tilt as instructed in the class.
What should you tell Summer?
8 Karla has a 5-month-old daughter at home. She arrives

at therapy 3 weeks after a microdiscectomy procedure.
What should Karla be instructed to do immediately?
Posterior pelvic tilting should be avoided because it puts
the lumbar spine in a flexed position. Be aware of your
patients activities and what they require so that you may Russell to run first thing in the morningwhen he pro-
adequately prepare them to return to their previous rec- gresses to outdoor runningwhen his discs are maxi-
reational or professional activities. Summer may also mally hydrated and can offer the most shock absorbing
need to review the proper way to brace her lumbar spine capability.
by engaging her transverse abdominis, multifidi, and
pelvic floor muscles.
14 Ken had an L4 microdiscectomy 3 weeks ago. Today
he has 9/10 pain and return of pain down his poste-
12 Kristy is a 36-year-old mother of two who had a

microdiscectomy over 3 months ago. She is currently
off work from her job as a waitress where she injured
rior leg. Upon examination you note that his knee
jerk reflex is absent and he has weakness of his quad-
riceps. What should you do?
her back. Objectively she appears to have made a
great recovery from her surgery; however, she consis- Incapacitating pain and neurologic deficit are red flags.
tently reports high pain levels with any activity. What Joe should be referred back to his surgeon immediately
may be contributing to her report of pain? for reevaluation.
Psychosocial factors need to be considered in every

patients prognosis. Patients who have workers com-
pensation claims have been shown to return to activity
15 Lynne had a microdiscectomy over 10 years ago but
never had physical therapy. She is now having lower
back pain and her physician has sent her to therapy.
later than patients who do not. She has poor segmental motion and inability to sta-
bilize her trunk with extremity motions. Why might
13 Russell is ready to return to running. What is the

safest way he can do this following his microdiscec-
tomy 3 months ago?
this be?
Lumbar segmental stabilizers do not spontaneously

recover after injury and this can lead to recurrent lumbar
Initially a walk-run program should be implemented on pain syndromes. Also, Lynne may have developed faulty
a treadmill with supervision by the PT analyzing his bio- motor programs and muscle substitutions, which could
mechanics. An unloading device can also be used. Advise also contribute to her current problem.
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CHAPTER 16
Lumbar Spine Fusion
Chris Izu, Haideh V. Plock, Jessie Scott, Paul Slosar, Adam Cabalo
I
n the early 1900s two surgeons began performing lumbar enlarge. As the joint becomes more disrupted, normal
fusions. Dr. Russell Hibbs and Dr. Fred Albee pioneered motion at that segment becomes impossible. The disc begins
the posterior approaches for arthrodesis.1,2 Over the sub- to undergo greater strain. The disc wall weakens further,
sequent decades, many surgeons improved fusion tech- begins to bulge, and can eventually herniate. The disc con-
niques, with extension of the fusion laterally to incorporate tinues to lose fluid and height, causing narrowing of the
the transverse processes and the sacral ala.3-6 The patients neural foramen, or foraminal stenosis. This process is out-
autogenous iliac crest is the standard source of bone graft lined in Table 16-1.
material.7,8 A rapid evolution has occurred in the develop- Patients with severe back pain that is refractory to con-
ment and use of spinal fixation devices. Although tracing the servative care may be candidates for surgical evaluation.
historical evolution of these devices is beyond the scope of Conservative care should include a rigorous attempt at
this chapter, they can simply be categorized as anterior or exercise-based dynamic stabilization training, therapeutic
posterior fixation devices. The most common and most con- injections, and medications. Surgical treatment should only
troversial are the pedicle screw and rod/plate systems. Ante- be discussed with the patient after a firm diagnosis has been
rior fixation devices include screw and rod/plate systems, as made.
well as the recently introduced interbody cages. This chapter
describes the indications for elective lumbar fusions and dis- Diagnostic Tests
cusses the various methods of arthrodesis. Spinal radiographs show osteophytes and segmental disc
space narrowing in patients with degenerative spondylosis.
A defect in the pars interarticularis is seen in patients with
SURGICAL INDICATIONS spondylolysis. Anterolisthesis, or a forward slippage of one
AND CONSIDERATIONS vertebra on the next, is the hallmark radiographic finding in
spondylolisthesis. Flexion and extension films can help to
In the elective patient population, most indications for detect hypermobility or excessive motion in degenerative
lumbar arthrodesis are based on the presence of severe, dis- lumbar conditions.
abling back or leg pain. Posttraumatic cases of segmental Computed tomography (CT) reliably evaluates the bone
instability or potential neurologic injury also may require or spondylosis compression against the nerves. Computer-
fusions, but this chapter focuses on patients with degenera- enhanced reformatted CT images are as effective in evaluat-
tive spinal pathology. ing spinal stenosis as myelography. CT scanning is more
Patients with low back pain experience symptoms result- sensitive than magnetic resonance imaging (MRI) in the
ing from tissue aggravation during the degenerative cascade.9 evaluation of bony stenosis, whereas MRI gives useful infor-
Trauma or overuse causes the disc wall to begin to develop mation about the health of the discs and nerves. Combining
microtears; this eventually results in a loss of disc height that the two imaging modalities gives a very accurate, thorough
alters the alignment of the facet joints. This may lead to pain, picture of the lumbar spinal pathoanatomy.
with accompanying spasm and guarding. The joints begin to Provocative discography can be a useful diagnostic tool
develop synovitis, articular cartilage degeneration, and adhe- in the work-up of patients with painful degenerative lumbar
sions. This alters the spinal motion mechanics at that disc disease. The lumbar discs are deep within the abdominal
segment, further stressing the annulus of the disc and accel- cavity and do not have true dermatomal pain patterns in
erating the degenerative process of the facet. Increased axial discogenic cases. Overlapping sclerodermal referred
wearing of the cartilage and hypermobility of the facet also pain patterns in the lumbar spine make the localization of
occur. The superior and inferior facet surfaces begin to the true pain generator difficult. Discography has evolved as
313
314 PART 3 Spine
TABLE 16-1 The Degenerative Cascade

Damage at Each Stage
Structure Stage 1: Dysfunction Stage 2: Instability Stage 3: Stability
Intervertebral disc Circumferential tears Radial tears Loss of proteoglycans and water, fibrotic resorbtion
Inflammatory exudates and irritation Loss of disc height Sclerosis and eventual bony ankylosis
Internal disruption
Disc bulges and herniations
Facet joints Synovitis Laxity of joint capsule Significant bony overgrowth
Minor cartilage degeneration Moderate cartilage degeneration Grossly degenerated cartilage
Muscles Spasm, guarding Chronic shortening and fibrosis Further shortening and fibrosis
Neural foramen Unaffected Narrowed through annular bulges Significant stenosis
Disc narrowing Disc narrowing
Bony overgrowth
a test to examine the lumbar discs morphologically and,

most importantly, provocatively. On injection into the disc,
the patient must communicate to the discographer if that
disc is concordantly painful. Many degenerative discs are
either not painful or discordantly painful. This information
can be useful for the surgeon and the patient contemplating
lumbar arthrodesis. The test is not used as frequently as in
the past, as authors have described conflicting results and
there is emerging concern that the injection itself may cause
eventual disc deterioration.10
Diagnosis
Among patients undergoing elective lumbar arthrodesis,
painful degenerative disc disease is the most prevalent diag-
nosis. Confirmatory diagnostic testing often includes MRI
scanning and discography for equivocal cases. Overlap
occurs among patients who have had previous surgery and
have a diagnosis of failed back surgery syndrome, a non-
specific diagnosis. Before surgery is contemplated, every
effort must be made to arrive at a diagnosis that specifically
isolates the source of pain.
Patients often have numerous diagnoses, each of which Fig. 16-1 Pedicle screw instrumentation in a circumferential lumbar
fusion.
may be valid. For example, a 45-year-old man who had a
laminotomy performed 5 years ago for a herniated nucleus
pulposus comes to his physician complaining of 50% low
back pain and 50% right leg pain and numbness. Diagnostic TYPES OF FUSIONS
imaging is significant for L4 to L5 segmental degeneration
with osteophytes and narrowing of the disc space. A multi- Instrumentation Versus Noninstrumentation
planar CT scan reveals moderate spondylosis (bone spurs) The goal of a lumbar arthrodesis is the successful union of
with stenosis along the right neural foramen. Discography is two or more vertebra. Controversy exists over the most effi-
concordant with pain reproduction at the L4 to L5 disc. The cient way to achieve this result. Instrumentation can be used
appropriate diagnoses include painful degenerative disc to immobilize the moving segments while the fusion becomes
disease, lumbar spondylosis with stenosis, and postlaminec- solid. One of the original and most popular systems is the
tomy syndrome. Harrington hook/rod construct. Although this distraction
The absolute requisite for a successful lumbar surgery type of fixation immobilizes the spine in certain planes, it
outcome is matching concordant patient symptoms with the causes a loss of physiologic lordosis, or a flat-back syn-
appropriate surgical procedure. Patients who cannot manage drome, in many patients.
their pain with conservative measures and have demonstra- Today, most spine surgeons use pedicle screw constructs
ble, concordant pathology on diagnostic testing may benefit to immobilize the vertebrae rigidly while preserving the
from lumbar arthrodesis. normal lumbar lordosis2 (Fig. 16-1). Typically, external
Chapter 16 Lumbar Spine Fusion 315
orthosis bracing is not needed in these cases. As well- posterolateral fusions. Radical excision of the disc and ante-
controlled studies emerge, data support the use of internal rior column support with rigid bone grafting are performed.
fixation for fusion.11 Most studies support the use of pedicle The available area for successful bone union is greatly
screw fixation to obtain a more reliable bony union, although increased by using the interbody space.
complication rates tend to be higher with these devices Using a posterior lumbar approach, a surgeon performs
as well.12,13 a posterior lumbar interbody fusion (PLIF). After a wide
Some surgeons do not routinely use pedicle screws for laminectomy the posterior two thirds of the disc is resected
arthrodesis. In most of these situations (when pedicle screws and an interbody graft is placed into the evacuated disc
are used) the patient must wear a lumbar orthosis for an space. This provides anterior interbody stability through a
extended period postoperatively. To immobilize the L5 to posterior approach. PLIF is a technically demanding proce-
S1 motion segment effectively, an orthosis with a thigh-cuff dure associated with a higher incidence of postsurgical nerve
extension must be applied. Patients with noninstrumented injuries.
fusions may take an extensive amount of time to stabilize
and become comfortable in their rehabilitation. Conversely, Transforaminal Lumbar Interbody Fusion. In an
most patients with internal fixation become mobile and effort to reduce the incidence of nerve injury performed
independent more rapidly, making early rehabilitation more through a PLIF, a transforaminal lumbar interbody fusion
predictable. (TLIF) technique was developed. Studies have shown the
results of TLIF with posterior pedicle screw instrumentation
Posterior Fusion to be equivalent to that of anterior-posterior fusions with an
Posterolateral Lumbar Fusion anterior lumbar interbody fusion (ALIF). However, despite
Different surgeons use different techniques to perform a the intention of reducing nerve injury through a transfo-
lumbar fusion. The traditional approach is through a midline raminal approach, nerve root injury has been reported as a
posterior incision. If necessary the surgeon performs a complication of the procedure.16 In addition to nerve root
laminectomy/laminotomy to address the pertinent pathol- injury, TLIFs can cause a kyphotic alignment in the lumbar
ogy. Most surgeons perform a posterolateral fusion, which spine.
means that the transverse processes, pars interarticularis, After exposing the spine through either a midline or para-
and, if needed, the sacral alae are decorticated. The patients median posterior approach, the facet joint and pars interar-
own iliac crest bone graft or a bone graft substitute is then ticularis above the proposed fusion level is resected. This
placed on the decorticated surfaces, forming a fusion bed allows access to the posterolateral aspect of the disc. Care is
contiguous with all the surfaces to be fused. Pedicle screws taken to avoid injury to both the existing and transversing
and rods or plates may be placed to immobilize the motion nerve root. A standard discectomy and insertion of an inter-
segments rigidly and augment the formation of a solid union. body device is then performed.
The problems with a posterolateral fusion are both
mechanical and physiologic. The fusion is attempting to Anterior Lumbar Interbody Fusion. Because the risks
form at a mechanical disadvantage because of tension. Bone associated with PLIF were too great for routine use, many
heals more reliably under protected physiologic loads of surgeons moved to ALIF. Using the same principles of disc
compression, not tension. Also, the available area for the excision and interbody bone grafting, many surgeons
bone union to occur is limited to the remaining posterolat- achieved excellent results. However, ALIF alone cannot
eral bone surfaces. After extensive decompression of the withstand the forces across the grafts, so many collapse or
neural elements (laminectomy), the available fusion area is do not fuse. Surgeons who perform ALIF have learned to
reduced and often poorly vascularized. These local factors protect the grafts with posterior instrumentation, leading to
reduce the likelihood of a successful arthrodesis. Nicotine a predictable fusion rate and good clinical results.
use negatively influences the formation of posterolateral From a technical standpoint, anterior lumbar surgery is
lumbar fusions. most easily and safely accomplished through a retroperito-
Finally, the usual source of pain in these patients is the neal approach. After the anterior disc is exposed, it is rela-
disc itself, hence the term discogenic. In routine cases tively simple to perform a discectomy and insert the bone
of posterolateral fusions the disc is not radically resected. graft of the surgeons choice. Posterior fusion and instrumen-
Biomechanical studies have shown that people bear load tation can be placed through a separate posterior approach
through the middle and posterior thirds of the disc. Several on either the same day or in a staged procedure. A cir
reports describe a persistently painful disc under a solid cumferential fusion is accomplished in this manner (see
posterior fusion.14 As surgeons recognized the biomechani- Fig. 16-1).
cal and physiologic aspects of the discs, they began perform-
ing interbody fusions.15 Lateral Interbody Fusion. An alternative to performing
an ALIF is through a lateral interbody approach. The use of
Interbody Fusion a lateral approach avoids the need for exposure of the great
Posterior Lumbar Interbody Fusion. Interbody fusions vessels and therefore has less potential for vascular injury.
evolved to address many of the drawbacks of traditional However, it does not come without inherent risks, the most
316 PART 3 Spine
Fig. 16-2 BAK interbody cage device. (Sulzer-Spine Tech, Minneapolis).
A
notable of which is nerve stretch injury. The most common
is an L4 nerve root injury.17 The lateral approach cannot be
used for the L5-S1 intervertebral disc as the pelvis blocks
access.
With a lateral approach, the disc is accessed through the
psoas muscle under neuromonitoring to avoid injury to the
lumbar plexus. After gaining access to the disc, a procedure
similar to an ALIF is carried out including discectomy and
insertion of an interbody graft.
Interbody Cages. Ongoing technologic advances have

been made in interbody cages. Essentially, these devices are
hollow cylinders made of titanium, carbon, or bone (Fig.
16-2). They are filled with autogenous bone graft or a bone
graft substitute and inserted between the vertebral bodies. B
Newer devices have implemented bone ingrowth surfaces Fig. 16-3 A, Pedicle screw instrumentation and an anterior interbody cage
and large footprint areas to aid in the fusion process and in a circumferential fusion. B, CT scan of a titanium cage with bone forma-
decrease rates of subsidence. tion through the center of the device.
Research is moving rapidly to find a reliable substitute for
the autogenous bone graft, most likely with the use of bone-
morphogenic protein. There are other biologic alternatives
available to surgeons that can be used to fill the interbody harvests the necessary amount of cortical and cancellous
fusion cages and reduce the need for bone graft harvest. bone graft from the posterior iliac crest. This bone graft
material is then carefully placed in the recipient site.
SURGICAL PROCEDURE If screws are used to augment the fusion, a pilot hole is
made over the entry site of the pedicle with a burr (Fig. 16-3).
The basic lumbar fusion is the posterolateral fusion. The Usually probes are placed in the pedicles and a radiograph
patient is placed in a prone position on a Jackson frame, is taken to confirm the position of the pedicle probes. After
allowing the abdomen to hang free. This decompresses the confirmation, the pedicles are tapped and appropriate length
lumbar epidural veins and minimizes bleeding. A skin inci- screws are placed into the pedicles. Again, an intraoperative
sion is made over the operative levels, and the paraspinal radiograph is taken to confirm the position of the screws.
muscles are stripped off the posterior elements (spinous The rods or plates are connected to the screws, and lordosis
process, lamina, and transverse processes). Deep retractors is preserved in the construct. The wound is usually irrigated
hold back the muscles to allow the surgeons to expose the with an antibiotic solution to minimize the chance of infec-
bone for fusion. Using small curettes or a high-speed burr, tion and closed over a deep suction drain. The drain is
the surgeon decorticates the dorsal aspect of the transverse removed when the postsurgical drainage is minimal. Patients
processes and facet joints in preparation for the bone graft are mobilized out of bed as tolerated on the first or second
placement. Through a separate fascial incision, the surgeon day after surgery.
Postoperative precautions
THERAPY GUIDELINES Bed mobility and transfers
FOR REHABILITATION Initial postoperative exercises
Gait training with any necessary assistive devices
Description of Rehabilitation and Rationale for Donning and doffing any required braces
Using Instrumentation Wound care
Opinion about the degree of rehabilitation needed after General overview and prognosis of the postoperative
spinal surgery ranges from the optimistic view that no reha- rehabilitation process
bilitation is needed to others who argue for aggressive exer- An effective preoperative program before lumbar fusion
cise- and education-based programs. As noted earlier there surgery should also address any other relevant patient
has also been mounting evidence that failing to address psy- concerns and include other advice from the members from
chosocial factors in this population may also be neglecting other disciplines included in the rehabilitation team. A tour
an integral part of the rehabilitation and recovery process. of the facility and operating room along with meeting with
This chapter is written from the point of view that the patient individuals who have already undergone such a procedure
who has undergone surgery needs not only a program that may also help to decrease patient anxiety surrounding the
will protect the surgical area and create an effective healing surgery and hospital experience.21 For the rehabilitation spe-
environment, but also addresses relevant and contributing cialists, an understanding of the specific procedure per-
changes in motor control dealing with both the active sub- formed is essential for safe rehabilitation. Before beginning
systems and neural control subsystems as outlined by a rehabilitation program, the therapist must know whether
Panjabi18,19 (Box 16-1). Although the surgery itself deals with the patient has had a fusion with or without instrumentation.
improving the passive subsystem, which include such ana- Patients who were operated on with instrumentation can
tomic structures as the vertebral bodies, facets, and liga- generally be progressed more aggressively in the first phase
ments, capsule, it is our job as specialists in rehabilitation to of rehabilitation. Patients who were operated on without
address these other systems.20 It is also important to realize instrumentation require more time for the bony fusion to
that those individuals with more chronic pain symptoms will take place. Generally a callus should form within 6 to 8
most likely exhibit altered pain processing, which may be weeks; the surgeon monitors this by radiograph and usually
addressed through including cognitive-behavioral interven- does not refer to outpatient therapy before a callus has
tions during the recovery process. formed. The therapist also must know the surgical approach
The following guidelines are not intended to substitute for and the levels fused. After a motion segment is fused,
sound clinical reasoning but rather serve as a foundation on increased stress is placed on the levels above and below the
which a trained physical therapist (PT) can base the rehabili- fusion. This creates risk for acceleration of the degenerative
tation of a patient after spinal fusion. It is assumed that the cascade at the adjacent levels. Obviously the more levels that
therapist will know the basics of spine and extremity evalu- have been fused, the greater the stress placed on the remain-
ation in order to monitor the patient for symptoms that ing segments. When the fusion includes the L5-S1 motion
require prompt reevaluation, along with addressing relevant segment, abnormal forces are then translated to the sacroil-
contributing factors in other body regions that have a sig- iac joints. To minimize these forces, the therapist must be
nificant impact on the lumbar spine. sure that normal motion exists at all remaining segments,
including the thoracic spine, shoulders, and lower extremi-
Preoperative and Planning Phase ties (LEs).
Before an individual elects to undergo lumbar spinal fusion, During a posterior fusion, the multifidi are retracted from
it is generally assumed that conservative measures have not the spine. This partially tears the dorsal divisions of the
had a significant impact on the patients condition and that spinal nerves, resulting in partial denervation of the mul-
they have gone through an extensive therapy program. tifidi.5,22 If an anterior fusion also has been performed, then
Hopefully the individual has been taught stabilization-based a midline skin incision will be apparent and the abdominal
exercises and has begun to address other relevant physical muscular incision is lateral. The incision passes through the
and cognitive dysfunctions. Once surgery is deemed neces- obliques, also partially denervating them. For this reason the
sary by the patient and rehabilitation team, preoperative therapist should teach the patient the proper way to recruit
management may be very useful in determining functionally the transverse abdominis (TA), multifidi, and pelvic floor
relevant outcomes along with realistic goals.21 This is also the muscles and watch for any substitution patterns to promote
time to start on patient education regarding issues such as: proper spinal stabilization.
Phase I
BOX 16-1 Spinal Stability System Components TIME: 1 to 5 days after surgery (inpatient) and up to 6
weeks
1. Passive spinal column
GOALS: Patient education about daily movements,
2. Active spinal muscles
abdominal stabilization, neural mobilization, and
3. Neural control unit
home care principles (Table 16-2)
318 PART 3 Spine
TABLE 16-2 Lumbar Fusion and Laminectomy

Phase I Postoperative Pain Inpatient care Independent with the following: Promote restoration
Postoperative 1-5 (inpatient) Limited bed mobility Bed mobility training, 1. Bed mobility of independent
days (inpatient) Limited self-care log roll technique with 2. Don/doff clothing, and function
and up until Limited ADL supine-sit-stand corset if indicated Use log roll to avoid
outpatient Limited tolerance to ADL training with assistive 3. Transfers placing stress on the
therapy begins prolonged postures devices as necessary 4. Gait, using assistive device surgical site
(sit/stand) (dressing, bathroom as appropriate Emphasize walking to
Limited tolerance to transfers) Demonstrate appropriate improve tolerance to
walking Body mechanics training body mechanics with upright postures
Gait training, with walker self-care and basic ADL Use proper body
if necessary mechanics to avoid
Initial training in reinjury
abdominal isometric (TA
and pelvic floor)
Self-neural mobilizations
ADL, Activities of daily living; TA, transverse abdominis.
Inpatient Phase the recent surgery and therefore have difficulty recalling or
Most patients remain in the hospital for several days after applying what they have just been taught. Most patients are
fusion surgery. Physical therapy management during this referred for physical therapy anywhere between 4 to 7 weeks
phase consists of teaching patients the proper way to get in after their discharge from the hospital.
and out of bed, dress and perform other self-care activities,
and walk (perhaps with a walker for the first 1 or 2 days). Phase II
Strenuous abdominal stabilization exercises are not recom-
mended at this time; however, attempts should be made to
GOALS: Increased activity, tissue remodeling,
perform light TA and pelvic floor contractions to begin to
stabilization, and reconditioning (Table 16-3)
practice them in different positions. The patient may use a
large sigh or more forceful exhalation such as blowing out During phase II, patients gradually increase their activity
a candle to start to facilitate other abdominal muscles that level. While taking soft tissue healing into account, the PT
assist with bracing. The therapist also can teach basic and can safely begin to influence the direction of tissue modeling
simple neural mobilization for the nerves involving the lum- through carefully applied stress. Patients should begin to
bosacral plexus. Because of the sensitivity of the nervous approximate normal activities while the therapist controls
system, more focus should be on activities such as sliders the intensity of movement and exercise.
versus tensioners. These are described well by Bulter.12 Patients progressing to the latter portion of phase II
Patients and their family should leave the hospital with an increase the intensity of the stabilization program begun in
understanding of the home care required until they begin the earlier stages of the phase. They may increase repetitions
their outpatient physical therapy, especially in the absence of and level of difficulty. Also toward the end of this phase,
home PT during the interim. If the physician requests patients should be slowly working up to 30 minutes of exercise
bracing of any kind, then the patient should understand the and physical activity at least 5 days a week as recommended
way to get in and out of the brace and when to wear it. by the American College of Sports Medicine.23 They can begin
Patients will be given instructions from the physician to a light weight-training program, avoiding exercises that inap-
avoid driving, prolonged sitting, lifting, bending, and propriately load the lumbar spine but making sure to include
twisting. These, along with any other specific precautions, some exercise for the lumbar paraspinals and other muscles
should be understood by the patient. The PT should rein- that attach to the thoracodorsal fascia. Patients should no
force this information and teach patients the proper way to longer require assistance with most daily activities.
avoid these activities by hip hinging or pivoting. This infor- Common restrictions are no lifting greater than 10lb
mation should be provided in written and visual form, and no overhead lifting. Examples of exercises for this
because many patients may be medicated or overwhelmed by phase are listed in the following sections.
Phase II Outpatient candidate Pain limited with ADL Cryotherapy Independent with the following: Self-manage pain
Postoperative No signs of infection Limited nerve root mobility Relative rest 1. Bed mobility Prevent reinjury
6-10 wk Cleared by physician Limited trunk stability Review of body mechanics training 2. Don/doff clothing, and corset if indicated Perform ADL without adding increased
to begin therapy Limited mobility of regions Nerve mobilization 3. Transfers stress to the lumbar spine
adjacent to surgical site PROM/LE and UE stretches: 4. Gait, using assistive device as appropriate Prevent neural adhesions
Limited endurance and Hip flexors (gently initiate after 8 wk with Demonstrate appropriate body Improve mobility of LEs to decrease
tolerance to physical activity physician approval) mechanics with self-care and basic ADL stress on the lumbar spine
Gluteals Demonstrate proper motor control using Initiate trunk stabilization while
Hip rotators transverse abdominis, pelvic floor, and performing ADL to decrease potential
Quadriceps multifidus for reinjury
Hamstrings Demonstrate bracing and begin to Perform cardiovascular conditioning
Calf incorporate this with activities and tiny steps to avoid excessive
Shoulders lumbar spine movement during gait
Isometrics with active range of motion: Improve mobility of thoracic spine to
Abdominal bracing with squats, transfers, and gait decrease stress on the lumbar spine
Spinal stabilization exercises: Improve mobility of soft tissue
Bridging Reduce volitional muscle guarding
Dying bug (after 8 wk, with physician approval) Perform cardiovascular conditioning
Quadruped activities
Superman (after 8 wk, with physician approval)
Prone (much later in phase, with physician
approval)
Walking program
Joint mobilization to upper and mid T/S,
gentle if mobilizing lower T/S
Soft tissue massage after incision is closed
Patient education
Upper body ergometer
ADL, Activities of daily living; LE, lower extremity; PROM, passive range of motion; T/S, thoracic spine; UE, upper extremity.
Chapter 16 Lumbar Spine Fusion
319
320 PART 3 Spine
Evaluation
Before initiating treatment the therapist should perform a
thorough examination to assess the patients status and help
to create an individualized program. The examination should
include relevant tests and measures, such as posture, gait,
range of motion (ROM), strength, balance, body mechanics,
and specific functional tasks while making sure not to over-
load the lumbar spine. The therapist and patient can then
begin to collaborate on and establish goals for treatment.
This evaluation should include ROM for the LEs and
upper extremities (UEs) but not for the lumbar spine. A
complete neurologic examination should be performed to
establish a baseline and should include neural tension testing.
The therapist can perform strength testing for the LEs Fig. 16-4 To rise from a lying position, the patient begins with bracing to
with the exception of testing hip flexor strength. He or she maintain a neutral spine and rolls to the edge of the bed as a unit. The patient
also can check the patients ability to stabilize or brace the then pivots off the elbow while throwing the legs to the ground. This
lumbar spine isometrically, which is a test of the patients momentum makes an otherwise difficult movement easier. To avoid twist-
ing the trunk, the patient should reach toward the top foot with the top arm.
ability to recruit the core trunk muscles to control the spine.
Core strength testing may be performed in a variety of ways;
however, Lee24 describes a functional approach based on
grouping core musculature into slings. The patients spon-
taneous body mechanics and the way the patient responds
to the challenge of daily activities should be assessed. The
goals of phase II are as follows:
Demonstrate good body mechanics for activities of daily
living (ADL)
Protect the surgical site from infection and mechanical
stress
Maintain nerve root mobility at the involved levels
Control pain and inflammation
Minimize patient fear and apprehension
Begin a stabilization and reconditioning program
Improve scar and surrounding soft tissue mobility
Treat restrictions of thoracic, UEs, and LEs that can lead
to more strain on the lumbar spine
Education to minimize sitting time and maximize walking
time
Fig. 16-5 To get out of a chair, the patient places one foot under the chair,
Body Mechanics Training hinges the hip, and then raises off the thigh. The hips should be the first to
If body mechanics training was provided preoperatively, leave the chair and the last to land. The patient should not attempt to keep
then it should be reviewed after surgery. If body mechanics the back vertical, merely straight. To get into the chair the process is
training is new to the patient, then the therapist should go reversed. If no room is available to get the foot under the chair, such as in
a couch, then the patient pivots on the hips until perpendicular to the chair.
through the entire program, which is as follows:
This offsets the feet and allows for easier rising.
In and out of bed (Fig. 16-4)
In and out of a chair (Fig. 16-5)
Up and down from the floor (Fig. 16-6) for and prepare meals. A patient who can do these activities
Lying postures (Fig. 16-7) without stressing the surgical site will heal faster and with
Sitting (Fig. 16-8) less discomfort. Patients can accomplish all these tasks
Standing without lumbar motion if they move their hips rather than
Dressing the spine.
Bending (Fig. 16-9) Instead of flexing the lumbar spine, they can hip
Reaching hinge (see Fig. 16-9). Rather than twist in the lumbar spine,
Pushing and pulling (Fig. 16-10) they can pivot on another body part (e.g., knees, elbows,
Lifting (Fig. 16-11) hips). When teaching a hip hinge, the PT should point out
Carrying (Fig. 16-12) that the hips should move back rather than down. After
Patients must perform these activities to get dressed, use surgery, patients tend to guard and move cautiously. Showing
the bathroom, travel to physicians appointments, and shop them the way to use their momentum safely in many
C
C
Fig. 16-7 A, Supported supine lying. Patients generally prefer to have the
Fig. 16-6 When getting up and down from the floor, the patient moves whole leg supported rather than just the knees. Any unsupported area
from a single leg hip hinge (A) through a reverse lunge position to double becomes uncomfortable and causes the patient to shift and wake. The shoul-
kneeling (B). Next, the patient hinges the hips from double kneeling to ders also should be supported in whatever degree of protraction exists. Any
about 45. Another balance point occurs here (C). From this balance point, soft tissue subjected to prolonged stretch eventually becomes uncomfort-
the patient rocks forward onto the elbows and rolls as a unit onto the side. able. B, Supported side lying. The patient needs enough pillows to support
To avoid uncontrolled extension, the stomach should never touch the the UEs. A body pillow frequently works well. The patient should pull the
ground. The process is reversed to rise from the ground. support directly into the upper thigh and chest and then roll slightly onto
it; he or she should not lie on the same side all night. C, Three-quarter prone
lying is the most popular position. It is similar to supported side lying,
except that the patient rolls one-quarter turn more. A wedge-shaped pillow
minimizes cervical strain in this position.
322 PART 3 Spine
Fig. 16-8 Alternate sitting postures are important to teach, because patients will want to change sitting postures frequently. As long as a neutral spine position
is maintained, the variations are limitless. These positions successfully take the weight off the left pelvis, thereby relieving pressure on the piriformis and sensi-
tive sciatic notch.
maneuvers makes the postoperative transition easier. For

example, getting out of bed requires less bracing if the legs
are moved quickly to the floor, transferring the momentum
to the torso (see Fig. 16-4).
Nerve Root Gliding. Patients should extend the knee

while lying supine with the spine in a neutral position and
the hip flexed to a 90 angle. When tension is encountered,
the therapist helps the patient work the knee or ankle gently
back and forth, gradually increasing the ROM (Fig. 16-13).
This stretch may cause increased symptoms during the
stretch, which should resolve immediately on relaxing. Edu-
cation should be provided to the patient regarding expected
and adverse reactions to neural gliding.
Any lingering symptom is reason to halt the stretch
until the therapist can reassess the problem. Butler12 and
Shacklock25 describe an excellent approach to evaluation and
treatment of neural mobility.
Local inflammation occurs after lumbar spine surgery.
Because the body forms scar tissue in response to inflamma-
tion, the nerve root can become adherent to the neural
foramen or lose elasticity. It is theorized that a nerve root
that is kept moving within its sheath cannot develop adhe-
sions.12,25 Patients with nonirritable chronic leg symptoms
Fig. 16-9 Hip hinging is flexing the hips and knees while maintaining a tend to respond well to neural mobilization. However, the
neutral spine. A dowel can be helpful for patients with difficulty perceiving patient must keep the spine stabilized while moving the leg.
spinal motion. The spine should not be kept vertical but merely straight.
This is one of the essential motions patients use to perform functional activi- Decreasing Pain and Inflammation. Patients should
ties. Hip hinging also can be done on one leg (as in Fig. 16-6, A). This is
use medication as directed by the physician and cold packs
especially useful when getting up and down from the ground. The position
shown is a balance point that patients should learn because it requires little for about 20 minutes three or four times per day to help
or no effort to maintain. Patients should attempt to move from one balance control pain and inflammation. Patients can be taught to
point to another. alternate rest periods with periods of light activity, because
A B
Fig. 16-10 A, To push an object, the patient leans into it with a hip hinge until the body weight begins to move it forward. The heavier the object, the more
the patient needs to line the shoulders up behind the hands. Arms can be bent or straight. The patient should take tiny steps, because if the feet move anterior
to the hips, then a lumbar flexion moment will occur. B, To pull an object, the patient leans back, maintaining neutral position, until the body weight begins
to move the object. The heavier the object, the more the patient needs to flex at the hips and knees. The patient should take tiny steps and hold the upper
body erect, because the weight tends to pull the body into flexion.
A B
Fig. 16-11 A, Lifting from a hip hinge position. The spine remains straight but not vertical. This method works for conveniently placed objects. B, To lift a
less conveniently placed object safely, the patient goes down onto one knee, then hinges the hips and tilts the object to its maximal height. The patient then
locks the object to the chest, reverses the hip hinge, and places the object on the thigh. As the patient stands up, the thigh lifts the majority of the weight.
Fig. 16-13 Nerve gliding. In a hooklying or supine position, the patient

can hold on to the back of the thigh or place their legs up on a bolster while
Fig. 16-12 Slight knee flexion reduces the tendency toward lumbar exten- slowly extending the knee until a gentle stretch is felt. In addition, ankle
sion while the patient carries objects. It may feel funny at first, but with dorsiflexion and plantarflexion could be used to assist with nerve
continued practice this flexion becomes simple. mobility.
324 PART 3 Spine
sustained postures can increase swelling and pain. The thera- diminishes; conversely, decreasing leg symptoms is a good
pist may apply modalities in the clinic to control pain after sign, even if low back pain is increasing. Less leg pain is
therapy. It is very important to minimize inflammation to consistent with less neurologic involvement, whereas the low
decrease the risk of forming scar tissue. back is expected to be sore because of the incision and altered
Ultrasound should not be applied over a healing bony facet mechanics.27 Incisional pain can be expected to decrease
fusion. Patients with severe pain problems can try using a gradually over 6 to 8 weeks. As patients begin to return to
home transcutaneous electrical nerve stimulation (TENS) normal activities, an associated increase in muscle soreness
unit or interferential unit. frequently occurs. The sooner they recondition themselves,
the better they will feel. Patients should be aware that their
Minimizing Patient Fear and Apprehension. If bodies will be adapting to and remodeling from the surgery
patients know they can control their pain level, they may be for as long as 1 to 2 years. Symptoms often shift and change
less fearful of trying activities that may cause a pain flare-up during that time. The therapist should teach patients to
or those that have been painful in the past. They will rely less manage flare-ups using ice, rest, and resumption of previous
on inactivity and medication to control pain. The therapist activities within 1 or 2 days.
should spend some time initially discovering the patients
fears and alleviating those that are groundless. Greater prog- Stabilization, Strength, and Reconditioning. Differ-
ress will occur in the long run if the therapist initially allays ent approaches have been suggested to improve the active
patient fears and teaches the patient ways to control pain. stabilization system of the lumbopelvic region, and it is
More recent publications have pointed toward not only to beyond this chapter to compare and contrast each. However,
the need for additional resources addressing pain and cogni- a more thorough program would include:
tion but have also suggested that group meetings with other Cocontraction of the TA, multifidus, and pelvic floor
patients undergoing rehabilitation after lumbar fusion are an muscles with and without using pressure biofeedback
integral part of the healing process.13,26 (BFB) (Fig. 16-14)
Social support is suggested to help abate pain-related fear Abdominal breathing
and also allow for sharing of experiences and coping strate- Abdominal bracing with appropriate progression
gies. Psychosocial variables have been shown to have a large (Fig. 16-15)
influence on disability and function in individuals with Abdominal bracing and supine marching are good exer-
chronic back pain, so ignoring these concepts could be a cises to begin strengthening the trunk. Before bracing is
large detriment to the patients functional improvement.11 initiated, it is best to make sure the patient can isometrically
Patients are generally very fearful after lumbar spine surgery.
Excessive anxiety and worry may cause increased muscular
tension along with altered movement patterns and altered
pain processing. Patients are typically afraid to move, think-
ing they will somehow disrupt the surgery. Patients can
better tolerate flare-ups and variations in their symptoms if
they expect them and have been instructed in self-
management of these flare-ups. Patients are generally less
apprehensive if the therapist is not apprehensive. Most
people recover well and should start with that expectation.
If the patient appears to be developing neuropathic pain,
nerve root signs, symptoms from a new level, or any other
complications, then the therapist should note the symptoms
calmly and convey the information to the treating surgeon
for advice without conveying anxiety to the patient.
Patient Education. Patients who are sensitive to load

bearing through the spine should take frequent short unload-
ing rests throughout the day. Those who cannot tolerate any
one position for a length of time can learn to make a circuit
of their activities, frequently changing tasks (avoiding pro-
longed sustained postures). Patients with specific position
intolerance can benefit from learning ways to avoid that
position while doing daily activities. Lumbar rolls are not
recommended during this phase, because most patients
cannot tolerate pressure on the incision site after surgery.
Patients should understand the expected postoperative Fig. 16-14 Using pressure biofeedback can be a very helpful way to teach
course of events, particularly concerning postoperative pain. patients to contract their TA while minimizing a forceful contraction of the
Increasing leg pain is not a good sign, even if low back pain rectus abdominis.
Fig. 16-15 Bracing with marching. The patient creates an abdominal

brace by contracting the TA, multifidi, and pelvic floor. It is important to
remember to move the abdominals without moving the spine. While main-
taining the brace, the patient slowly takes the weight off one foot (removing
only as much weight from the foot as possible without allowing the hips to
rotate or the spine to extend). Eventually the patient should be able to lift
the leg up to 90 of hip flexion with the knee bent. The patient then alter-
nates feet.
Fig. 16-17 Balance activities sitting on an exercise ball. Before starting

sitting exercises on an exercise ball, the patient must demonstrate proper
posture and be comfortable in this position. The therapist might want to
start with postural exercises in this position while making sure to avoid
excessive lumbar spine lordosis or slumped sitting. Arm or leg movements,
single-leg balance activities, or resisted Thera-Band activities could provide
an adequate challenge to improve balance and motor control.
Fig. 16-16 Quadruped alternating opposite arm and leg lift. While in
quadruped, the patient can draw in the deep abdominal muscles to perform proprioceptive component to the active system.34 To add
an isometric contraction. Holding this contraction the patient will slowly more proprioceptive feedback to the stabilizing system, it is
extend the opposite arm and leg while maintaining good pelvic and lumbar integral to challenge the patient on both stable and unstable
spine alignment. Before this exercise the patient should be able to perform
(but not unsafe) surfaces. General balance activities would
this activity first with just opposite arm movements and second with just
leg movements. also help with this type of challenge. Examples of these types
of exercises may include:
UE or LE activities while sitting on an exercise ball (Fig.
contract the TA, multifidi, and pelvic floor muscles.6,9,28-31 16-17)
After the patient is able to do such, it is important to progress Supine/hooklying activities laying vertical on a foam roll
those stabilization exercises, eventually working toward (Fig. 16-18)
functional goals that have been established. The patient Standing activities on a disc or rocker board
should be able to contract the appropriate stabilization (Fig. 16-19)
muscles in different postures and positions, so it is recom- Trunk or hip perturbations in sitting or standing
mended that these be practiced also in sitting, standing, and (Fig. 16-20)
quadruped. A supine progression of lower abdominal General strength and conditioning exercises should also
strengthening has been well outlined by Sahrmann.32 be initiated during this phase of rehabilitation after it is
In quadruped (four-point kneeling) the patient should be cleared by the physician and the patient demonstrates appro-
able to more easily work on contracting TA while keeping priate stabilization. Examples of exercises would include:
other global muscles relaxed. Adding bracing along with arm Wall squats and sit to stand
and leg movements in this quadruped position is also a great Half lunges
way to activate the multifidus and lumbar spine paraspinals Step ups and step downs
without placing the lumbar spine under undue axial load32,33 Walking
(Fig. 16-16). Cardiovascular reconditioning (using stair climber,
It has also been hypothesized that the deep stabilizers brisk walking, and pool exercises once the incision is
of the spine, such as the multifidus, also have a large closed)
326 PART 3 Spine
Fig. 16-18 Supine activities on foam roll. Lying on a foam roll provides
opportunity to challenge the trunk muscles and improve motor control.
Adding marching with bracing or arm movements can challenge the trunk
and lower extremitys ability to maintain balance on the foam roll. Because Fig. 16-19 Standing balance activities. Many varieties of standing balance
of the sensitivity of the incision site or more focused pressure from the foam activities can be done to retrain the muscles that contribute to postural and
roll on the middle of the spine, some patients may not tolerate this motor control of the spine. An example shown here is with a rocker board.
position. The therapist must find an appropriate challenge for the patient by modify-
ing variables, such as the standing surface, base or support, vision, or doing
concurrent activities.
Fig. 16-20 Resisted trunk motions in standing. Here the therapist is adding perturbations to the shoulders or hips while the patient meets the resistance,
maintaining good standing posture and alignment. This helps to activate stabilizing muscles. These activities should begin with very light force until the patient
demonstrates the ability to tolerate more.
Care should be taken when starting more vigorous and use bracing to stabilize the spine while leaning his or her
strengthening activities, because it is recommended that the back against the wall.
patient be able to use the appropriate stabilization muscles
during components of the exercise before doing the full exer- Maintaining Scar and Soft Tissue Mobility. The
cise. For example, before a patient performs a wall squat, therapist should use soft tissue techniques to maintain good
they should be able to isometrically contract the inner unit scar and soft tissue mobility without disrupting the healing
Fig. 16-23 Lumbar flexion stretch. Occasionally when the patient has been
working the spinal extensor muscles hard, these muscles may get sore and
tight. From an all-fours position, the patient can gradually spread the knees
Fig. 16-21 Maintaining scar and tissue mobility. It is imperative that the and sit back on the heels, allowing the spine to relax and stretch.
healed incision and surrounding tissue/fascia have adequate movement to
allow motion through the spine. The therapist may use a variety of tech-
niques to improve mobility in different planes and at different depths of
tissue.
Fig. 16-24 Up and down from the floor. This photo shows the midpoint
of getting up or down from the floor.
Fig. 16-22 Hip flexor stretch. The patient kneels on one leg with the other
leg in front, braces the spine, and gradually begins to shift weight forward
to the front foot. The patient should feel a stretch in the groin area of the
Quadriceps stretches (begin with prone knee flexion
kneeling leg. The spine should not be extended. before progressing )
Lumbar flexion stretch (Fig. 16-23) with surgeon approval
When initiating this stretch, the therapist must not be
of these tissues (Fig. 16-21). Scar tissue tends to contract overly aggressive, obtaining ROM at the expense of com-
while healing. This can create a tight scar that restricts promising the fusion site. Fig. 16-23 demonstrates an ideal
mobility.35 In cases of prolonged incisional pain it may be ending position for this stretch, which may take several
beneficial to use techniques to desensitize the tissue starting months to obtain.
with very soft and gentle surfaces progressing to more firm Up and down from the floor (Fig. 16-24)
and vigorous materials. Hip rotator stretches (Fig. 16-25)
Latissimus dorsi stretches (Fig. 16-26)
Assessment and Treatment for Restrictions of The loss of motion caused by the spinal fusion places
Thoracic, Shoulder, and Hip Mobility. The following additional demands for motion on the adjacent segments.
steps will help ease restrictions of the thoracic spine and hip: One of the most stressful motions in the lumbar spine is rota-
Manual therapy for thoracic motion restrictions tion, which causes a shearing effect across the disc. Since the
LE and UE stretches for soft tissue restrictions thoracic spine is designed to allow more rotation, limited
Hamstring stretches motion here may increase strain on the lumbar spine during
Hip flexor stretches (Fig. 16-22) can be initiated in later twisting motions. The PT can use manual mobilization tech-
stages with permission from the surgeon niques to increase thoracic spine mobility. Many different
328 PART 3 Spine
fusion. This may also occur at the shoulder complex. If

inadequate shoulder flexion/elevation exists when a patient
attempts to reach overhead, they may compensate with
increased lumbar spine extension. Stretches to address
glenohumeral ROM or latissimus dorsi (lats) tightness
should also be included if needed. All stretching should
involve stabilizing one area while pulling against it with
another. For example when stretching the lats the patient
should perform somewhat of a posterior pelvic tilt to avoid
excessive extension of the lumbar spine (see Fig. 16-26).
Iliopsoas stretching is initiated in a later phase with the per-
mission of the physician. The aggressiveness of any hip
Fig. 16-25 Hip rotator stretch. While lying on the back, the patient crosses stretching is dictated by the patients ability to control the
the ankle of one leg over the knee of the other leg. The patient performs the spine while stretching.
stretch by pulling the knee and ankle toward the chest. The patient should In addition, stretches that pull on the lumbar spine or
feel a stretch deep in the back of the hip. healing soft tissues should be avoided until adequate
healing has occurred. Therefore permission should be
obtained from the surgeon.
Examples of other exercises (performed while bracing)
initiated in the later stages of phase II include the following:
Bridging
Heel lifts
Superman (avoiding lumbar extension)
Lateral pulls (light resistance with approval of surgeon)
(Fig. 16-27)
Seated upright rowing machine
Scapular depression (avoid resisting more than 40% of
body weight)
Fig. 16-26 Latissimus dorsi stretch. It is important to maintain lat mobility Push-ups standing and leaning into the wall
as short or tight lats may pull the lumbar spine into excessive lordosis with
Stair climber
overhead arm movements. In supine, the patient should be cued to use
abdominal muscles to avoid lumbar spine extension while stretching the Upper body ergometer (UBE)
arms overhead. A callus is forming at this stage, and patients are expected
to tolerate slowly increasing their activity level and returning
to normal activities. What the therapist is attempting to
approaches to spinal mobilization exist. One can reference develop at this stage is not so much muscle power as kines-
Maitland,36 Mulligan,37 and Paris38 for some examples. PTs thetic sense for the muscles and their role in protecting the
can teach patients to use two tennis balls taped together to spine. Therefore the proper form of each exercise should be
form a fulcrum that can lie over a segment of the thoracic emphasized.
spine and localize motion to the segment above, thus main-
taining good segmental mobility of the thoracic spine at Phase III
home. This can be done in a standing or, later (when appro- TIME: 11 to 19 weeks after surgery
priate), in a semireclined position for the upper and midtho- GOALS: Return to work, continue to advance/progress
racic spine. A similar procedure can be done using a half or exercise program, practice specific skills program,
a full foam roll. initiate resistance training program (Table 16-4)
The hip joint is a large ball-and-socket joint with free
motion in all planes. This joint can compensate for the lack During this phase, patients may start to return to work,
of motion in the lumbar spine and should remain as flexible especially if they have sedentary jobs or occupations that do
as possible. This can be achieved with stretching of the hip not require vigorous activity. They often return to work with
musculature. Stretching throughout phase II should be modified duties or on a part-time schedule. At this time they
very gentle and only pushed to the point the patient can should be independent with self-care duties and also with a
brace to prevent lumbar motion. Because these muscles moderately challenging home exercise program. The use of
attach directly to the lumbar spine or pelvis, the patient proper mechanics should be becoming a habit but will need
should review the principles of stretching. To stretch a to be continually reinforced during specific activities. Exer-
muscle, one end must be fixed by something, while the other cises that address functional movement may be a great time
end is pulled away from the fixed end. If patients are not to reinforce those principles. More strenuous stabilization
stabilizing the spine while stretching the hips, then they activities, such as half and full front and side planks could
will invariably pull on the lumbar spine, jeopardizing the be added.
Patients should be extremely careful with overhead

lifting because of the axial load and compressive forces
placed on the spine. Endurance and cardiovascular exer-
cises should also be progressed at this stage and start to
progress gradually. For some individuals it may be advised
to do more cardiovascular or resisted exercises in an aquatic
rehabilitation environment. The buoyancy of the water may
help to unload the spine but allow the patient to do partial
weight-bearing exercises along with core and resisted
extremity activity.
At this stage the expectation is that pain continues to
decrease and be at a minimal level. Those patients that con-
tinue to have an unexpected degree of pain may need to be
reassessed by the PT or by the surgeon. In the absence of any
physical explanation of the pain, the rehabilitation team
needs to reinforce the functional improvements and mini-
mize the importance of pain as a marker of improvement.
Phase IV
TIME: 20 weeks to 1 year after surgery
GOALS: Restore preinjury status, continue home
program of conditioning and stabilization (Table 16-5)
During phase IV the body finishes remodeling and adapt-

ing to the changes induced during and after surgery. Patients
should be progressing to full restoration of their preinjury
level of function and be independent with conducting their
previous home and gym program. They should have a good
grasp of not only the exercises and physical activity required
to reach their goals but also ways to modify those activities,
because at this stage it might be expected that the patient
may be finishing with outpatient therapy. Proper body
mechanics should be consistently demonstrated during
functional tasks and patients understanding of these
mechanics should allow them to maintain minimal strain on
Fig. 16-27 Lat pull downs. Strengthening muscles that attach to the tho- their back during novel situations. They should also have a
racodorsal fascia can help with improving overall trunk stability. Before
good understanding of pain mechanisms, tactics to manage
using weight machines at the gym, it would be beneficial to use Thera-Bands
and have the patient leaning against a supportive surface where they can flare-ups, and time to contact the physician or therapist.
use the appropriate muscles to adequately stabilize the spine. The bone continues to remodel and adapt to the fusion
for as long as 1 year. Patients with fusions frequently develop
problems at the level above or below the fusion. For these
Patients should still avoid strenuous lumbar rotation, reasons, the patient should learn that spinal care is now
flexion, or extension. The early development of these a lifetime habit and must be maintained with regular
muscles in their role as spinal stabilizers rather than spinal exercise and good mechanics during all daily activities (not
movers is a crucial component of this phase. The previous just those the patient perceives as stressful). It is important
trunk stabilization activities should be progressed within the to consider patient motivation at this time to help design a
patient tolerance by modifying, for example, the number of program that will have the most realistic chance of consistent
repetitions, adding Thera-Band resistance, or performing the follow-through.
exercise on a more challenging surface. Patients returning to a more strenuous job or sports
As long as the patient is able to perform the previous are now developing the extra degree of strength and skill
stabilization exercises, they may begin a light resistance exer- to do so. Later in this phase (and with clearance from the
cise program. It is not advised to do complex weight lifting surgeon) they may begin agility and sport-specific drills, such
tasks, but to focus on light free weight activity and machine- as running, cutting, and jumping. If a more comprehensive
based exercises that allow the patient to perform them with weight training program is called for it should be again
proper posture, technique, and bracing. Patients with a poor geared to the specific activity faced by the patient. The
tolerance for any one position may do better on a circuit- program may require a greater focus on power, endurance,
training program. or skill, depending on the activity. Patients should work on
330 PART 3 Spine

Phase III No increase in Mild pain Continue intervention from phase II Independent with Promote return to
Postoperative pain Limited tolerance to as indicated most ADL independent lifestyle
11-19 wk Improved upright positions Isometrics with active range of motion Increased trunk and Develop kinesthetic sense
tolerance to (sit/stand) Abdominal bracing with the following: extremity strength for the muscles and their
upright postures Limited trunk, lower Bridging Maintenance of role in protecting the
extremity, and upper Dying bug neutral spine while spine
extremity strength Quadruped with arm and leg raise performing Improve the ability to
Heel lifts strengthening brace the spine and
Superman (avoiding lumbar spine exercises maintain a neutral
extension) Performance of 20-30 position
Scapular depressions minutes of Increase strength of trunk
Push ups cardiovascular exercise and extremities to avoid
Progressive resistance exercises: daily excess stress on the spine
Lateral pull-downs Start weight training to
Seated upright/rows triceps dips begin hypertrophy of
Cardiovascular conditioning associate musculature
Stair stepper upper body ergometer Promote good
Brisk walking cardiovascular fitness
ADL, Activities of daily living.

Anticipated
Phase IV No increase in pain Limited trunk and Continue exercises from Return to work Patients with sedentary jobs
Postoperative 20 No loss in extremity strength previous phases as indicated Increase trunk and should be able to resume
wk-1 year functional status Limited tolerance to Advance exercises with extremity strength their schedule
Patient has sustained postures regard to repetitions and Increase muscular Continue reconditioning to
decreased reliance Mild pain weight endurance an expected level of function
on formal therapy associated with For appropriate patients, Prepare to return to while protecting
Clearance from activities initiate running, cutting, and more strenuous activities the spine
physician for Limited with lifting jumping progression. This Return to previous level Carefully apply stress to the
progression to and carrying would not be indicated in a of activity as appropriate body in tolerable doses to
phase IV majority of lumbar fusion Discharge patient to increase the spines ability
patients. self-management of to withstand stress
Specific activity drills related flare-ups Evaluate the ability to return
to home, work, or sport Improve trunk strength to previous function
environment to previous levels of Because patients with
Functional capacity functioning lumbar spine fusion may
evaluation continue to have problems
Continue progression of with joints above and below
interventions in phases II the fusion site, continuation
through IV of some level of
Progress home exercises maintenance must be
Continue patient education emphasized
with regard to activity Fusion patients must also
modification and performance maintain constant body
with assistive device awareness, always using
proper body mechanics
maintaining control of a neutral spine during job- or sport- alleviate. This is a difficult concept for some patients to
specific challenges during this phase, and the PT should understand, and they may not be willing to accept it. Focus
obtain the clearance of the surgeon to begin working on should again be on improving function and less on pain
these higher-level activities. The patient must demonstrate abatement. Cognitive-behavioral interventions can continue
good trunk strength and control and good LE strength and to help with pain-related fear, social adjustments, and coping
flexibility before initiating agility drills. At this time it may strategies that may still be difficult for patients during these
also be necessary to perform a functional capacity evaluation later stages. Therapists should make every effort to help
and develop a work hardening program before returning the patients accept this reality and learn to care for themselves
patient to full duty. without seeking constant medical intervention. Most people
Although all therapists would like to relieve pain, some can manage chronic pain and maintain a high functional
suffering is beyond the ability of current medical science to level despite the pain.

Days 1 to 5 and up to starting d. Calves (gastrocnemius and soleus)
outpatient therapy e. Adductors
GOALS FOR THE PERIOD: Educate patient about f. Piriformis
simple movements, teach nerve mobilization and g. Hip flexors (gently initiate only with
light isometric abdominal contraction, review home physician approval)
care principles h. Latissimus dorsi
1. Gentle nerve gliding 7. Initiate gentle balance activities
2. Initiate abdominal isometric contraction (TA,
pelvic floor) Weeks 11 to 19
3. Walking daily as tolerated (should slowly increase GOALS FOR THE PERIOD: Increase activity,
in time and speed) emphasize tissue modeling, stabilization,
4. Consistent use of proper body mechanics reconditioning, weight programs, and return
5. Icing as needed to work
6. Protection of incision 1. Progress walking tolerance to 30 to 60 minutes
7. Ankle pumps and deep vein thrombosis (DVT) daily
prevention 2. Increase aggressiveness of stabilization
program slowly and to patients tolerance
Weeks 6 to 10 a. Supine marching
GOALS FOR THE PERIOD: Initiate outpatient therapy, b. Bridging
perform a thorough evaluation (avoid LS ROM and c. Dying bug
resisted hip flexion), patient education, neural d. Squats (to 90 of knee flexion)
mobilization, abdominal stabilization, begin e. Quadruped
conditioning activities and home care principles f. Prone over pillow or exercise ball
1. Progress walking tolerance to 20 to g. Planks (half progressing to full) front and
30 minutes side
2. Isometric stabilization 3. Continue to maintain nerve root mobility
a. TA, pelvic floor, mulifidus 4. Initiate resistance training using weights
b. Abdominal breathing, hollowing, bracing (generally after 12 weeks)
c. Bracing during light functional a. Seated upright rowing machine
movements b. Latissimus pulls
3. Initiate light strengthening exercises c. Scapular depressions
a. Wall slides (to approximately 60 of knee d. Dips
flexion) 6. Continue cardiovascular training using the
b. Side-lying hip rotation following:
4. Reinforce body mechanics a. Stair climber
5. Continue neural mobilization b. Brisk walking
6. Begin stretching hips, LEs, and shoulders while c. Standing or floatation deviceassisted pool
maintaining bracing exercises
a. Hamstrings
b. Quadriceps
c. Gluteals
332 PART 3 Spine
Week 20 and Beyond 4. Develop gym or home program for

GOALS FOR THE PERIOD: Restore preinjury status, independent management that should include
continue home program of conditioning and the following:
stabilization a. Cardiovascular exercises
1. Progress stabilization program to level b. Stabilization exercises
required by patients activity level c. Strengthening exercises
2. Continue to work on hip, LE, and shoulder d. Flexibility exercises
flexibility 5. Begin sport-specific drills or work-specific
3. Initiate light LS flexibility exercises with proper activity (refer to examples in Chapter 14)
form
1 Tom is 50 years old. He had a lumbar fusion at L4-L5

and L5-S1, 3 weeks ago. He is now in therapy. The PT
gives Tom an exercise to facilitate nerve root gliding.
3 After being discharged from the hospital, Bill, who is 58
years old, is concerned that he is not starting outpatient
therapy for another 5 to 6 weeks. He is wondering what
The patient asks, What is the significance of this exer- he should do until that period. What should the thera-
cise? What should the therapist tell the patient? pist tell him?
Local inflammation occurs after lumbar spine surgery, After being discharged from the hospital, the physician
and the body forms scar tissue in response to inflamma- or case manager might suggest home therapy to make
tion. It is possible for the nerve root to become restricted sure the patient is safe and can manage the home
by surrounding scar tissue as it exits through an opening environment without problems. In the absence of home
called the intervertebral foramen. Because of the inflam- PT, the patient should understand their precautions,
matory process, the nerve also can lose elasticity. By which usually include avoiding bending, lifting, twisting,
doing activities that move the nerve within its neural driving, and prolonged sitting, and know strategies to
container (sheath), it may help to prevent or free-up minimize strain on the lumbar spine. They should also
adhesions, which can cause pain, numbness, tingling, understand all of the concepts taught in the inpatient
and other symptoms. setting, which should include bed mobility, ergonomics,
body mechanics, and gait training that will help them
2 The surgeon approaches the PT with some concern

because the patient told the staff that the therapist was
having them do abdominal exercises and was worried
with their ADL. During these first weeks at home, it may
also be a good time to meet with others who have had
the same surgery. Exercises are not recommended at
about such aggressive techniques early in the recovery this stage, but the patient should understand how to
period. What should the therapist tell the patient and perform abdominal bracing along with a cocontraction
the surgeon? of the TA and pelvic floor muscles.
The abdominal exercises that the patient had been

taught were not the aggressive style core exercises that
might resemble gym activities. Much later in the patients
4 Lindsey is 38 years old. She had a lumbar fusion at L4-L5
about 7 weeks ago. She tells her PT that her back pain
has been increasing over the past 7 to 10 days. Lindsey
rehabilitation, they may need to perform such exercises; has complied with all instructions and restrictions. The
however, early intervention is focused on just teaching PT reviews her chart and exercise program. Over the
the patient how to isometrically contract the TA, which past 2 weeks, Lindsey has begun doing squats and using
helps to stabilize the spine in a corsetlike fashion. Because the treadmill along with the UBE for cardiovascular
these muscles do not cause the lumbar spine to flex or exercise. She has been stretching her hamstrings, hip
extend, no shearing or abnormal forces should be placed flexors, quadriceps, and calf muscles. She also has been
on the surgical site. In fact, being able to control (con- doing trunk stabilization exercises in the prone, supine,
tract) these muscles should actually help to prevent and quadruped positions. Lindsey also has been
those unwanted forces. strengthening her upper body with bicep curls, seated
military presses, and push-ups. Which of these exercises their clothes. It would also be a good time to remind
may be aggravating her condition and why? them about the negative impact that factors such as
smoking, poor nutrition, and lack of sleep have on
It is most likely that the hip flexor stretches are aggravat- healing, which is an integral part of the recovery from
ing her condition and should not be initiated until later, surgery. If other medical conditions such as obesity or
when sufficient healing has occurred. The iliopsoas diabetes are present, it may also be integral to assist the
originates at the anterior surfaces of the T12-L5 vertebra patient in nutritional management or direct them to
and intervertebral discs, so a forceful contraction or other services to address these factors.
stretching may cause an unwanted anterior pull on those
segments. In addition, exercises such as the military
press that load the lumbar spine should be avoided.
Finally, all exercises should be executed correctly, with
8 During outpatient therapy the therapist notices that the
patient is walking with a slight antalgic gait because of
pain and when asked, the patient states that the leg has
proper mechanics and abdominal bracing. been a little swollen. Why might this be a concern?
5 Jerry is 60 years old. He routinely used swimming as

his form of aerobic exercise and is anxious to get back
into the pool again. He just started outpatient physical
With a recent onset of pain and swelling in the patients
leg, the therapist should be concerned about the patient
having thrombophlebitis or a DVT. Other signs and
therapy after his surgery 6 weeks ago and has asked the symptoms to look out for would be warmth and redness
therapist about when he can begin an aquatic program in the leg, especially in the calf region. In the presence
and what exercises he could do. What should the thera- of those symptoms, the patient should undergo testing
pists response be? as soon as possible to rule out a DVT.
The buoyancy of the water could certainly be advanta-

geous in creating an exercise program to aid in the
recovery after lumbar fusion surgery. However, there are
9 Because psychosocial factors, such as anxiety, have an
influence on pain perception, how can the therapist
address this to help decrease the patients pain levels?
a few concerns in regards to swimming; the incision site
must be healed to prevent the increased risk of infection, Besides patient education in body mechanics and pos-
and the type of exercises in the pool must not place tures, the therapist needs to increase the patients
unwanted stresses on the back. It is best practice to awareness of pain expectations. The patient needs to
consult the referring physician/surgeon as to when it allow 6 to 8 weeks for the incision area to decrease in
would be appropriate to start an aquatic program and pain. Increased activity levels at home or in the clinic are
the initial exercises should be upright and not include associated with an increase in muscle soreness, which
lap swimming. Later in the program, certain strokes like can be expected. The therapist should reassure patients
butterfly and breaststroke may still be undesirable as that their bodies will be adapting to and remodeling for
they require increased lumbar extension to perform 1 to 2 years, and symptoms often change during that
efficiently. time. Patients also need to know how to self-manage
flare-ups and that most people recover well (they should
6 During the initial outpatient treatment, what should be

the main focus of the treatment?
have that expectation). Meeting with other patients who
share in their experiences has also been shown to be
helpful during recovery from lumbar fusion. Other pro-
Patient education should be emphasized to ensure professionals, such as a psychologist, may help with imple-
tection of the surgery site and allow for a better recovery menting cognitive-behavioral techniques to help reduce
with less discomfort. Good body mechanics proper the patients pain.
posture, and maintaining precautions are integral at this
stage. In addition, the therapist must take care to avoid
any testing that may irritate the condition. Lumbar spine
ROM and strength testing of the hip flexors are some
10 Why are stabilization exercises so important for
rehabilitating these patients?
examples of testing that should be avoided. While the surgery is meant to help with the passive sta-
bilization subsystem of the lumbar spine, both the active
7 For the second therapy visit in a row, the patient smells

of smoke and although they had originally quit to have
the surgery the therapist is worried that they have
and neural systems are addressed through stabilization
exercises. In the most common lumbar spine fusion pro-
cedure, a posterolateral fusion, the paraspinal muscles
started smoking again. How should the therapist handle including the multifidi are stripped off the posterior ele-
the situation? ments (i.e., spinous process, lamina, transverse pro-
cesses). This allows for partial tears of the dorsal division
Without accusing the patient of smoking, the therapist of the spinal nerves, therefore having partial denervation
might confront the patient about the smell of smoke on of the multifidi. Multifidi are the primary segmental
334 PART 3 Spine
stabilizers, and they do not spontaneously recover after Initially back extension exercises should be avoided as
low back pain or back surgery. The TA is another impor- they may cause excessive shear on the lumbar spine and
tant muscle that may be cut during a fusion surgery. place unwanted stress on the surgical site. Research has
Trunk stabilization exercises are important for reeducat- shown that performing exercises in the quadruped posi-
ing the multifidi muscles and the other trunk-stabilizing tion, such as alternate leg or arm lifts, recruits the lumbar
musculature. spine extensors sufficiently to improve trunk stability.
Patients that need to get back to more strenuous activi-
11 A patient asks the therapist if they should be doing

back extension exercises to strengthen their lumbar
spine. What should the therapists response be?
ties may need to do lumbar extension activities much
later in the last phase of rehabilitation and should only
perform them if able to stabilize appropriately.
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CHAPTER 17
Lumbar Spine Disc Replacement
Derrick G. Sueki, Erin Carr, Babak Barcohana
out other causes of pain such as infections, tumors, and

ETIOLOGY visceral conditions, which may result in back pain. A careful
history is taken regarding trauma, fevers, chills, weight loss,
Low back pain is a potentially disabling condition with a cancer history, and other associated symptoms. Questions
lifetime prevalence of 60% to 80% in the U.S. adult popula- regarding the back are also obtained, including timing of
tion. Pain may be due to a simple muscle sprain, sciatica injury, aggravating factors, description of pain (sharp, dull,
caused by a disc herniation, vertebral fractures, or a number numbness), radicular complaints, and weakness.
of other conditions, but degeneration of the spine is often the Subsequently, imaging studies are obtained, including
number one cause. plain radiographs (Fig. 17-1), MRI studies, and CT scans.
Disc degeneration in the lumbar spine has a significant Alignment, disc heights, signs of degenerative changes, and
effect on the functional behavior of the lumbar discs. As the neural compression is noted. Electrodiagnostic studies, bone
proteoglycan content is lost and the osmotic pressure densitometry, and discograms are occasionally ordered.
decreases within the nucleus, there is a diminished ability to Once the diagnosis is established, treatment is initiated.
retain water within the disc. The loss of volume leads to a Absent neurologic deficits and unbearable pain, nonopera-
reduced disc height, which commonly results in interverte- tive treatment is recommended. This may include physical
bral foraminal stenosis, inappropriate stress concentrations therapy for stretching, strengthening, and modalities. Back
causing osteophyte formation, and central stenosis. This braces may be used for short periods of time to allow the
causes lumbar instability, axial back pain, and radicular leg muscles to relax. Medications are prescribed, including anti-
pain, which can become disabling and chronic, resulting in inflammatory medications, pain medications, and muscle
depression, loss of work, and the inability to enjoy simple relaxants. Acupuncture, chiropractic care, physical therapy,
activities of daily living. heat, ice, traction, epidural injections, and facet injections
The goals of lumbar spinal surgery are to alleviate pain, may be ordered as well.
restore stability, and improve neurologic injury. Lumbar disc When the diagnosis is certain and nonoperative measures
degeneration is a continuum with a spectrum of etiologic have failed, surgery is recommended. Based on the diagno-
conditions resulting in pain. Based on where in the spectrum sis, various surgical procedures may be recommended. For
the patient falls, various surgical techniques and approaches example, for an isolated disc herniation, a lumbar microdisc
will be offered. This chapter focuses on artificial lumbar disc ectomy may be considered whereas decompression and
arthroplasty. instrumented fusion may be considered for an unstable
spondylolisthesis.
SURGICAL INDICATIONS There are a select group of patients for which lumbar disc
AND CONSIDERATIONS arthroplasty is an option. These are patients for whom an
isolated decompression or discectomy is insufficient. Addi-
Patients with pain related to the lumbar spine have various tionally, these patients have symptoms arising from a single
complaints ranging from axial low back pain, sensation of lumbar disc level with complaints of axial low back pain with
instability, difficulty bending forward, pain with prolonged disc dysfunction. Based on U.S. Food and Drug Administra-
sitting or standing, inability to lift heavy items, and/or radic- tion (FDA) guidelines, lumbar disc replacement is approved
ular leg complaints. The goal of the clinician is to identify only for one level procedures. These patients would other-
the cause of the pain. wise be candidates for a lumbar fusion procedure.
Various diagnostic tests are employed in the detection of Criteria for disc replacement includes degenerative disc
the pain generator. Initially, a thorough history and physical disease with discogenic back pain isolated to one level from
examination are of utmost importance. The goals are to rule L3-S1 in skeletally mature patients who have failed 6 months
335
336 PART 3 Spine
A B
Fig. 17-1 A, Lateral x-ray study of the lumbar spine. B, AP x-ray study of the lumbar spine.
chromium, titanium, and ultra-high molecular weight

polyethylene.
The goal and potential advantages of artificial disc replace-
ment are to maintain motion at the operated level, thereby
replicating the biomechanics of the normal disc. This serves
to reduce the mechanical forces that would be transmitted
to adjacent segments, which are seen with rigid fusion pro-
cedures and which may lead to early adjacent segment
disease and degeneration. The device would serve to ana-
tomic disc height while maintaining structural integrity. It
would need to withstand lumbar forces with long-term sta-
bility and endurance. Given that it is not a fusion device but
a motion sparing device, pseudarthrosis is not a concern.
However, the implant requires integration of bone into its
surfaces. There is a potential concern that fusion may still
occur at the operated level.
Fig. 17-2 Synthes ProDisc-L implant. SURGICAL PROCEDURE
The surgical approach for artificial disc procedures is similar

of nonoperative treatment. Contraindications include spon- to that performed for an anterior lumbar interbody fusion.
dylolisthesis greater than grade I, significant instability or Currently available lumbar disc replacement devices are
facet arthrosis, infection, bony spinal stenosis, allergy or sen- placed from an anterior lumbar approach.
sitivity to implant, compromised or small vertebral bodies, The patient is positioned on the operating room table in
isolated radicular compression syndromes, or pars defects. a supine position with all bony prominences well padded
As of the writing of this chapter, two lumbar artificial disc after induction of general endotracheal tube anesthesia (Fig.
replacement devices have been granted FDA approval in the 17-3). Once the surgical level is identified with intraopera-
United States, including Synthes ProDisc-L (Fig. 17-2) and tive C-arm fluoroscopic images, the skin is prepped and
Charit artificial discs. These implants consist of cobalt draped in the usual sterile fashion. A retroperitoneal
Chapter 17 Lumbar Spine Disc Replacement 337
approach to the spine is performed. A paramedian trans-

verse or vertical skin incision is made. The rectus sheath is
incised and the rectus muscle is retracted laterally. The pos-
terior rectus sheath is encountered and incised to reach the
preperitoneal space. The abdominal muscles, including the
external oblique, internal oblique, and transverses abdomi-
nis, are divided. The transversalis fascia is then divided to
allow exposure of the extra retroperitoneal space. The
peritoneum and its contents are carefully retracted to allow
access to the retroperitoneal space. Here, various neurovas-
cular and visceral structures are encountered, including the
ureter, genitofemoral nerve and branches, psoas muscula-
ture, aorta, vena cava, sympathetic chain, and iliac vessels
(Fig. 17-4).
Injury to the sympathetic nerves in males can result in
retrograde ejaculation. Deep venous thrombosis may occur
Fig. 17-3 Intraoperative patient positioning.
L R
L. rectus m.
Ureter
L. iliac a.
Ligated
segmentals L. iliac v.
A B
C D
Fig. 17-4 A, Localization of level and approach to spine. B, Operative dissection to access anterior spine. C, Mobilization of great vessel for spinal access
(L4-L5). D, Great vessel bifurcation (L5-S1).
338 PART 3 Spine
in addition to injury to any of the neurovascular and visceral eliminate the risks associated with the anterior approach.
structures in this approach. Although many spine surgeons Research is being performed to evaluate various nucleus
perform the anterior approach themselves, often general or replacement devices to either replace or rejuvenate the
vascular surgeons are employed to access the spine. nucleus of the disc. This will significantly alter the approach
Once the spine is exposed and the adjacent structures are to and treatment of spinal related conditions.
protected, a radical discectomy is performed. If necessary,
neural decompression may also be performed. Next, various LUMBAR DISC REPLACEMENT SURGERY
trials are placed to measure the size of the implant. Great
care is taken to position the implant properly to maintain the Therapy Guidelines for Rehabilitation
appropriate center or rotation in the spine (Fig. 17-5). Mul- The lumbar spine can be one of the most challenging regions
tiple intraoperative images are obtained in addition to direct of the body to treat. There are many factors associated with
visualization to achieve this. The final implant is placed and the lumbar spine that contribute to the challenge of this
is evaluated, ensuring that it is rigid with good contact (Fig. region. Anatomically, the lumbar spine consists of 5 moving
17-6). The instruments and retractors are removed and a spinal segments and 10 articulating joints. Multiple liga-
meticulous layered wound closure is performed. ments give the region its passive stability while multiple
Complications from this procedure include vascular muscles provide the active stability of the region. The nerve
injury, ureteral injury, wound infection, postoperative ileus, roots of the cauda equina run through the spinal canal in the
neurologic injury, dural tear, deep venous thrombosis, retro- lumbar region and exit through the intervertebral canal.
grade ejaculation, vertebral fracture, hardware failure or These are just a few of the structural components of the
migration, subsidence, malpositioned implant, or fusion. lumbar spine that must work in concert to provide for pain-
The complication rate is reported to be less than 10%. free and seamless movement within the region.1-3 Biome-
The outcomes of lumbar artificial disc replacements have chanically, the lumbar spine is designed to provide motion
been quite favorable. The results have been similar to lumbar as well as stability. It is a transitional zone that allows upper
fusion results with respect to functional outcomes and pain body motion on a relatively fixed sacrum. The sacrum in
relief. Further research is necessary to determine whether turn will transition the weight of the central axis outward
disc replacement surgery reduces the rate of adjacent segment into the hips and lower extremities.
disease as compared with fusion procedures, but the early The concept of replacing a lumbar disc is not new.
data are promising. Attempts were made in the 1950s and 1960s, but both
Physical therapy is key after all lumbar spinal procedures attempts failed to produce successful results.4 In East
to strengthen and increase the flexibility of the spine with Germany during the early 1980s, Shellnac and Buttner-Jans
decreasing postoperative scar formation. Signs of infection designed the first successful artificial disc, the SB Charit
should be watched for in the immediate postoperative disc. Since developed, the artificial disc and surgical tech-
period. If the patient exhibits increased pain, loss of pulses, nique have been used in Europe, yet it wasnt until 2004 that
leg pain, lower extremity swelling, or changes in neurologic the SB Charit disc was even approved by the FDA in the
examination, the physician should be contacted. United States. By comparison, in 1911, lumbar fusion, or
Various disc replacement products are being developed, arthrodesis, was first employed in the United States and is
not only for anterior approaches but also for placement still considered the gold standard for lumbar surgery. Reha-
through lateral or posterior approaches, which would bilitation following lumbar fusion/arthrodesis has been well
Fig. 17-5 Trial placement.

B
Fig. 17-6 A, Implant placement. B, Lumbar radiographs with implant in place.
established. Clinical guidelines and empirical data validating and continues until 2 to 3 months after injury. Symptoms
rehabilitation have also been generated for the surgery. In lasting longer then 2 to 3 months are considered chronic.
comparison, very few clinical guidelines have been estab- Conversely, other systems of classification are based upon
lished for lumbar disc replacement surgery and no research the physiologic goal of the phase. This type of physiologic
currently exists validating any of the suggested protocols. based system of classification will provide the framework of
The guidelines that follow will be a synthesis of established this chapter.
tissue healing guidelines, protocols for similar spinal surger- Phase 1 is considered the inflammation phase and is so
ies, and treatment geared specifically for the attributes named because of the phases physiologic goal of producing
unique to lumbar disc replacement. They are not meant to inflammation within the injured area. Inflammation is the
replace or supplant clinical reasoning processes. Instead they bodys initial response to any injury or surgery. Immediately
are meant as a supplement to clinical reasoning and decision- after surgery, the body begins the process of repair. Inflam-
making. Each patient who has undergone total lumbar disc mation occurs and intensifies in the surgical region over the
replacement surgery is unique. The guidelines presented course of the next several days and reaches its peak produc-
should be used as a point of departure from which the clini- tion within the first 72 hours after injury. The generation of
cian can customize the program to the individuals needs. acute inflammation is generally completed within 14 days
and during these first 14 days, several events occur.6,7 Clini-
Principles of Tissue Healing5,6 cally, rehabilitation during the inflammation phase of tissue
A clinician must have a firm grasp of the tissue healing healing should focus upon the prevention of blood loss,
process if they are to effectively rehabilitate any patient. reduction of inflammation, and managing the pain that
Variation exists in the categorization of healing; some clini- accompanies tissue damage.
cians prefer to use a system based upon symptom acuity. The second phase of tissue healing is the reparative
Acute symptoms are present for the first 3 weeks immedi- phase. The chief physiologic goal of this phase is to repair
ately following injury. The subacute phase begins at 3 weeks the injured tissue. Chronologically, this phase begins
340 PART 3 Spine
immediately after injury and concludes around 21 days after TABLE 17-1 Soft Tissue Healing Timeframes
injury, running concurrently with the inflammation phase of
healing. It is valuable for the clinician to know the exact Phase Events Timeframe
surgical technique used by the surgeon. With the disc
replacement surgery, the injured tissue is actually removed Phase I: Inflammation Vasoconstriction in immediate area 0-14 days
and replaced with an artificial disc. Healing of the disc is not Vasodilation in surrounding areas
an issue in this case. Instead reparation focuses on providing Wound closure
an environment of healing for the tissue that was incised in Removal of foreign and necrotic tissue
the process of replacing the disc. The surgical technique will Phase II: Reparative Fibroblasts enter region to create 0-21 days
influence the rehabilitation. The primary function of this dense connective tissue scars
phase is the formation of the dense connective scar tissue Angioblasts enter the region for
needed to repair the wound and reestablish structural con- revascularization
tinuity of the affected region. Most of the actual dense con- Phase IIIa: Remodeling Dense connective tissue is converted 22-60 days
nective tissue development is completed by day 21. Clinically, from cellular to fibrous
Phase IIIb: Remodeling Dense connective tissue is 61-84 days
the goal of rehabilitation in this phase should be to promote
strengthened
the development of the new dense connective reparative
Phase IIIc: Remodeling Dense connective tissue is 85-360 days
tissue.
strengthened
The final phase of the healing process is the remodeling
phase. The main purpose of this phase of healing is to Data from Nitz A: Soft tissue injury and repair. In Placzek J, Boyce
strengthen the newly formed dense connective scar tissue. D, editors: Orthopaedic physical therapy secrets, Philadelphia, 2001,
Classically, this phase is divided into two subphases, the Hanley and Belfus; Frenkel S, Grew J: Soft tissue repair. In Spivak
consolidation subphase and the maturation subphase. While J, etal, editors: Orthopaedics: A study guide, New York, 1999,
the purpose of the two subphases is essentially the same, they McGraw-Hill.
are characterized by several key factors. During the consoli-
dation subphase, tissue is being formed and converted.
Therefore, there are large quantities of fibroblast and angio-
blast cells present within the tissue. This subphase lasts from BOX 17-1 Indications for Lumbar Disc Replacement
22 to 60 days. Strengthening of the newly formed connective
Strong Indications
tissue should be the goal during this subphase. Care must be
taken during this phase so as not to exceed the mechanical 1. Progressively worsening bowel and bladder
limits of the newly formed tissue, as overstress to the tissue will symptoms related to nerve impingement in the
result in tissue injury and delayed healing. The second sub- lumbar spine (cauda equina syndrome)
phase, the maturation subphase, occurs from day 60 to 360 2. Saddle paresthesia (numbness and tingling in the
and is hallmarked by dense connective scar tissues that are groin in the area that would be in contact with a
fully fibrous in nature. For this reason, a progression in the saddle)
strengthening of the affected tissues may begin more aggres- Relative Indications
sively. As in the consolidation subphase, a rehabilitation pro- 1. Radiculopathy that has failed to respond to
grams must provide appropriate levels of stress to encourage conservative treatment regimen of at least 6 weeks
dense connective scar tissue formation without creating or 2. Recurrent radiculopathy
exacerbating tissue injury. 3. Progressive neurologic deficit
4. Severely limited functional ability secondary to
Summary Statement lumbar pain or paresthesia associated with disk
Although guidelines can provide generalized timeframes for pathology
healing and recovery, it is important to realize that a firm
grasp of the factors listed above will enable the clinician to
individualize the rehabilitation program for each patient
(also consideration is always given to the patients signs and Attributes Unique to Lumbar Disc
symptoms). No two patients are identical. Therefore, no two Replacement Surgery
rehabilitation programs should be identical. Solid clinical The gold standard for surgical treatment of chronic low back
reasoning regarding the patient and the nature of his or her pain is the lumbar fusion surgery. But like all surgeries, no
injury and surgery will ultimately drive the rehabilitation surgical technique has 100% success rate and in the case of
process. Table 17-1 summarizes the soft tissue healing time- lumbar fusion surgery, 20% of patients will require addi-
frame for all three phases of healing. Adequate muscle activ- tional surgery within 5 years after the initial surgical
ity and protection must accompany the healing process to technique.8-12 See Box 17-1 for indicators that lumbar disc
progress activity levels. Healing tissues may be compromised replacement surgery may be required. The most common
because of increased levels of strain without adequate muscle reasons for failure of the surgery are bone graft donor mor-
support and protection. bidity, the formation of pseudoarthrosis, and adjacent spinal
segment degeneration. One of the major factors believed to While in the hospital setting, the patient will be instructed
be associated with these failure factors is the loss of normal in how to protect the surgical site. This is accomplished by
lumbar biomechanics following spinal fusion. The lumbar instructing the patient on maintaining proper neutral spine
disc replacement surgery has been designed to eliminate during motion. Additionally, a lumbar stabilization brace is
these factors. The disc replacement is designed to maintain issued to the patient for additional support and protection.
normal spinal biomechanics at the surgical site, decompres- Instructions regarding the duration of its use are determined
sion of the lumbar facets and neural structures, and restore by the physician and may vary on a case-by-case basis. Log
the normal disc height between spinal segments.13-16 The disc rolling and abdominal bracing techniques are used to get
replacement surgery is performed anteriorly and requires into and out of bed, and transitioning from supine to a sitting
incisions through the rectus abdominis and the anterior position. Care should be taken to avoid overstressing the
aspect of the disc space. Following surgery, these two struc- abdominal muscles since the rectus was surgically incised
tures are weak and vulnerable to injury. Rehabilitation pro- and is subsequently weak and subject to tearing or injury.
grams should address the unique aspects of this surgery and Initial examination and evaluation should include assess-
interventions designed accordingly. ment of the wound, hip passive range of motion (ROM)
testing, bed mobility, and gait assessment.
Description of Rehabilitation and Rationale for Hospital rehabilitation should also include gentle abdom-
Using Instrumentation inal activation/core strengthening. The goal is not strength,
Phase I: Inflammatory Phase but muscle recruitment. Circulation exercises are also incor-
TIME: Weeks 1 to 2 (Days 0 to 14) porated early in the rehabilitation process. Ankle pumping
GOALS: Protection of the surgical site, decrease pain exercises and thromboembolic hose hose stockings are used
and inflammation, initiate patient education to prevent pooling of blood in the lower extremities. Dia-
regarding neutral lumbar spine mechanics, begin phragmatic breathing exercises can be used to mobilize the
walking program (Table 17-2) abdominal muscles and abdominal contents to stimulate
the lymphatic system and encourage circulation. Since the
Hospital Rehabilitation. Immediately following surgery, abdominal region is the site for most of the surgery, it is not
the goals while in the hospital should focus on patient educa- uncommon for inflammation and edema to accumulate in
tion, protection of the surgical site, reduction in pain and the abdomen.
inflammation, and restoration of independent activities of Weight-bearing activities should also begin early in the
daily living. The normal hospital stay is between 5 to 7 days, rehabilitation process. Sit to stand and gait activities should
with discharge either to a home environment or a skilled be initiated. Initially, standing and gait training will be
nursing facility.14,15 accomplished with the aid of a front wheel walker. By the
TABLE 17-2 Inflammatory Phase of Healing

Phase I Postoperative Pain Patient education: Decrease pain and edema Encourage self-
Inflammatory Edema Proper use of lumbar Protection of surgical repair management of pain and
phase Limited lumbar range of support brace (soft tissue) edema
Postoperative motion Protection of surgical site Understand the timeframe Prevent adhesions of
wk 1-2 Limited nerve mobility Correct body mechanics for healing structures neural tissue
(days 0-14) Limited sitting tolerance and maintenance of Understand correct body Prevent reinjury with
Limited standing tolerance neutral lumbar spine mechanics and patient education on
Limited walking tolerance Splinting and guarding maintenance of neutral body mechanics and
during coughing, lumbar spine maintenance of neutral
sneezing, and defecating Gradual increase in walking lumbar spine with activity
Exercise: speed and duration Gradually improve
Daily walking program Instruction on protecting cardiovascular endurance
For specific examples, lumbar spine during
refer to Table 17-8 functional activities
Avoidance of lumbar Prepare patient for
extension, rotation, and discharge from hospital and
side bend first month of independent
home exercise and self-care
342 PART 3 Spine
end of the hospital stay, the patient should be ambulating coughing or sneezing. Before discharge, the need for a con-
with the aid of a single point cane. Ambulation to and from tinued home exercise program should also be addressed.
the restroom should begin immediately with assistance as Patients can be discharged once they are able to walk unas-
needed. These activities should progress until the patient is sisted or with minimal assistance depending on their post-
independent. Gentle lumbar spinal ROM can also be initiated surgical care and rehabilitation plans. They also must be free
in the hospital. Lumbar flexion exercise is the only direction of of complications, have normalized their bowel and bladder
motion allowable initially. Because the disc space and abdom- function, and show a good understanding of their surgical
inal cavity was incised anteriorly, it is the weakest portion of precautions and activity limitations.
the body. Overstressing these tissues should be avoided. The
clinician should avoid excessive and repetitive extension Initial Posthospital Rehabilitation. The second post-
exercises, as well as lateral flexion and rotation. These preoperative week will occur at home or a skilled nursing facil-
cautions are generally in place for 6 to 8 weeks. Prone lying ity. Activities during this later stage of the inflammation
should also be avoided during this time period because of phase are a continuation of the care received while in the
weakness and sensitivity of the anterior tissues. hospital. During this time, activities should center on resum-
Before discharge from the hospital, it is important that ing protected normal daily activities. The patient should be
the clinician educates the patient on proper lumbar spine encouraged to increase their daily sitting, standing, and
mechanics during activity and the need to avoid excessive walking tolerances. Pain and fatigue should guide the pro-
trunk extension, side bend, or rotation. Refer to Box 17-2 for gression. The lumbar stabilization belt should be worn 24
specific patient guidelines to follow after discharge. The hours a day unless otherwise ordered by the physician.
patient should be advised to refrain from heavy lifting, bearing Patient exercises may progress. The patient can begin gentle
down during defecation, and abdominal splinting during neutral spine lumbar stabilization exercises. Once again care
must be taken to avoid overstressing the abdominal muscles.
The goal is muscle recruitment, not strengthening. The
BOX 17-2 Hospital Discharge Instructions Following patient may begin gentle lower extremity strengthening
Lumbar Disc Replacement Surgery exercises, but care must be taken to stabilize the lumbar
region. The clinician should keep in mind throughout this
Wear lumbar brace continuously unless instructed
phase that the primary goal of this phase of rehabilitation is
otherwise.
protection of the surgery, pain abatement, and restoration of
Do not pick up or carry anything heavier than 5lb.
protected daily activities.
Limit twisting or bending backward. You may bend
forward as tolerated with physician approval.
Phase II: Reparative Phase
Keep your low back braced and stabilized as
TIME: Week 3 (Days 0 to 21)
instructed when completing daily activities
GOALS: Understand neutral spine concepts, increase
Avoid sitting or standing for prolonged periods of
lower extremity mobility, improve upright tolerance,
time. Change positions frequently.
improve protected activities of daily living, increase
Get plenty of rest, but do not spend all of your time in
cardiovascular function (Table 17-3)
bed.
Gradually increase walking time. Do not get
In many instances, phase II of the rehabilitation process
overtired.
will take place independently in the patients home. Home
Avoid strenuous exercise or activities.
therapy is rarely indicated. Therefore, education regarding
Keep incision dry. Showering is allowed 10 days
patient progression through the first month following
following surgery if wound is not red or draining.
surgery is an important aspect of hospital care. The clinicians
You may sleep in any position that is comfortable,
advice and instructions will be followed for the next 3 to 4
except sleeping on your stomach or with arms
weeks. During the reparative phase of tissue healing, the
overhead.
body begins to form and lay down scar tissue at the surgical
Do not drive until approved by your physician.
site, thus enhancing the integrity of the musculatures, liga-
Continue home exercise program.
ments, and capsule to withstand gradual increases in loads
Notify your doctor if any of the following occur:
to the tissues. Therefore, as time progresses, increasing load
Temperature greater than 101 F
can be placed upon the surgically repaired tissue. Rehabilita-
Redness or swelling around your incision
tion should be a continuation of phase I and progress restor-
Any drainage from your incision
ing lower extremity ranges of motion and independence
Separation of wound edges
with self-care skills. Movement improves circulation and
Any new bruising around wound
prevents the formation of scar tissue adhesions between the
New numbness or tingling in your hands or fingers
nerve and the healing tissue surrounding the surgery. Fol-
Increased pain in low back or legs
lowing lumbar disc replacement surgery, scar tissue forma-
New weakness in the legs
tion is inevitable in and around the surgical site. In certain
Changes in bowel or bladder function
instances, scar tissue can adhere to surrounding tissues,
TABLE 17-3 Reparative Phase of Healing

Phase II No signs of As in phase I Continue interventions in Same goals as phase I with Restore lower extremity
Reparative phase infection Limited upper body and phase I the following: ROM and tissue tension
Postoperative Incision site is lower body strength Exercise: Improve upright tolerance to allow for proper
wk 3 healing well Limited walking tolerance Initiate gentle ROM of Restore functional ROM to movement mechanics
(days 15-21) Limited tolerance to the hip lower extremities Prepare patient to be
prolonged sitting/standing Begin core/lumbar Restore patient independence independent in self-care
positions stabilization exercises in with self-care skills skills
supine (see Fig. 17-7) Improve activities of daily Restore proper posture
Progress walking program living while protecting throughout trunk to
to 15-20 minutes as surgical site allow patient to achieve
tolerated Increase cardiovascular overall neutral spine
For specific examples, function Improve cardiovascular
refer to Table 17-8 Independent with home endurance
Increase lumbar flexion exercise program
ROM as tolerated
impacting mobility of any structure to which it attaches. and stabilizing. Objectively, the physician will order a spinal
Therefore, movement of the lower extremity and lumbar radiograph to assess the position of the prosthetic. If all of
region should be encouraged to promote circulation and these factors are acceptable, the physician will allow the
prevent adhesion formation. Throughout all activities and patient to begin outpatient rehabilitation.
exercises, the patient should be encouraged to maintain a The first postoperative outpatient examination should
neutral lumbar spine. Activities should not increase symp- include evaluation of the patients scar, assessment of posture
toms. Protection of the surgical site and proper immobiliza- and gait, balance testing, and active range of motion assess-
tion should continue until the physician has seen evidence ment. ROM can be tested in all directions of motion, but end
that the prosthetic is well situated. At this time, the physician range extension, rotation, and side bending must be avoided
will approve additional lumbar motion and activities. for 6 weeks. Additionally, the clinician should conduct a
neurologic examination if nerve involvement is suspected.
Phase IIIa: Remodeling Phase The clinician should also assess the patients lumbar soft
TIME: Weeks 4 to 8 (Days 22 to 60) tissue, looking for muscle guarding and atrophy. Quick
GOALS: Enhance nerve healing and mobility, prevent screening of the patients lower extremity should also be
scar tissue formation, increase lower extremity completed. Once the patient has been screened and deemed
strength and endurance, improve thoracic spine and appropriate for phase III rehabilitation, the clinician can
sacral mobility, begin normalization of functional begin to design his or her treatment plan.
daily activities, restoration of lumbar ROM
(Table 17-4) Postural Rehabilitation. Upon initial evaluation, obser-
vation of the patients posture will give the physical therapist
Between the end of the fourth week and up to the sixth a significant amount of information concerning weakness,
postoperative week, the patients physician will reassess the elongation, and strength of specific musculature as well as
patient. Generally, this reassessment will include a new the patients ability to maintain a neutral lumbar spine.
radiographic study. Most physicians will release the patient According to Janda, a common postural alignment seen in
to begin outpatient rehabilitation following this reassess- people with lower quarter pathology is known as the lower
ment. This decision will be dependent upon several factors, cross syndrome.17 Regardless of the cause, this alignment will
including patient symptoms and function. At 4 to 6 weeks consist of a lower quarter muscle pattern in which certain
following surgery, it is anticipated that the patient will con- muscles will be weakened and lengthened and others will be
tinue to have mild (possibly moderate) low back pain and strong and shortened, resulting in an increased lumbar lor-
achiness. This will most likely be present in the morning and dosis and increased hip flexion. More specifically, there is a
at the end of the day. Functionally, the patient should be weakening and lengthening of the gluteal and abdominal
walking limited community distances with a single point muscles. This is combined with a tightening and shortening of
cane for balance. Neurologic symptoms that are the result of the hip flexors and lumbar extensors. Although a very
spinal compression or inflammation should be improving common posture following spinal surgery, this position is
344 PART 3 Spine
TABLE 17-4 Remodeling Phase of Healing 1

Anticipated
Phase IIIa Patient understanding Limited nerve mobility Continue with phase II interventions Same as phase II with Prevent soft tissue
Remodeling phase of neutral spine Limited upper as needed with the following: the following: adhesions at surgical
(consolidation) concepts extremity strength Exercise: Enhance nerve healing site
Postoperative No increase in pain Limited ability to Progress lumbar stabilization and mobility Prevent neural
wk 4-8 symptoms perform overhead activities Prevent scar tissue adhesions
(days 22-60) No increase in activities At 6 wk, begin gentle AROM/ formation Increase stabilization
nerve-related Limited mobility in PROM of lumbar spine as Increase upper and while performing daily
symptoms thoracic region tolerated (see Fig. 17-8) lower extremity activities to prevent
Follow-up visit with Limited cardiovascular Begin progressive resistive muscular strength and re-injury
physician and endurance exercise program of the upper endurance Decrease joint stiffness
approval to progress Continued pain or and lower spine while maintaining Increase lumbar range to allow proper
rehabilitation discomfort with lumbar stability of motion movement with
sustained postures Increase walking tolerance to 30 Improve mobility of decreased pain
(i.e., standing and minutes thoracic spine and Correct abnormal lumbar
sitting) Neuromobility: sacrum movement patterns
Begin neuromobility techniques Correct abnormal Independence with
(see Box 17-5 and Table 17-6) lumbar movement self-care activities
Mobilization: patterns
Begin soft tissue mobilization Improve functional
Begin joint mobilization to the ability
thoracic spine and sacroiliac joint Improve aerobic
at 4 wk capacity
Begin joint mobilization to the
lumbar spine at 8 wk
For specific examples, refer to
Table 17-8
Initiate gentle LE flexibility for
hamstrings and quadriceps near
end of phase in protected
postures
Initiate soleus and gastrocnemius
stretches
AROM, Active range of motion; LE, lower extremity; PROM, passive range of motion.
not advisable for the patient because it places the lumbar Therapeutic Exercise. While no research or clinical
spine in an extended or lordotic position. During gait, the practice guidelines have been developed specifically for
clinician may notice that the patient walks with a shortened lumbar disc replacement surgery, systematic reviews and
stride length because with long strides the spine is further clinical practice guidelines have been developed for the reha-
extended during the terminal stance phase of gait if tight hip bilitation after lumbar disc surgery and can be extended to
flexors are present. Physiologically, lumbar extension rehabilitation after lumbar disc replacement surgery. While
should be avoided because of the increased stress it most studies are mixed in terms of intervention efficacy, the
places upon the prosthetic and the weakened anterior one intervention that is uniformly beneficial is therapeutic
musculature. exercise.
Postural rehabilitation should be implemented and inter-
ventions should focus upon the stretching of shortened hip Lumbar Stabilization. Core stabilization, lumbar stabi-
flexor and lumbar extensor muscles and strengthening of the lization, transverse abdominis training, and multifidus train-
weakened gluteal and abdominal muscles of the lumbar ing are all rehabilitation programs developed to activate local
region. Posturally, the patient should be instructed to muscle groups, stabilize the lumbar region, and normalize
avoid anterior pelvic tilt that will lead to increased lumbar the recruitment of lumbar musculature. Normal muscle
lordosis. activity involves a coordinated recruitment of both local and
global muscle groups. Local muscles work to stabilize the examples of therapeutic exercises appropriate for this phase
region while global muscles function as movers of the body. of healing.
In the lumbar spine, the local muscles, such as the multifidus
and transverse abdominis, engage to stabilize spinal seg- Stretching. Following most surgeries, tissue mobility in
ments. The global muscles, such as the quadratus lumborum and around the surgical area will be tight and restricted. In
and hip flexors, function as primary movers of the lumbar the presence of tissue injury or damage, muscles play a
region. When injury occurs, local muscle groups are inhib- primary role of protection. Muscle tightness is commonly
ited, requiring global muscles to activate and stabilize the found in the hip flexors, quadratus lumborum, and the
region. Theoretically, localized inflammation inhibits neuro- erector spinae of disc replacement patients. Stretching and
muscular control systems. Richardson and associates per- ROM exercises should target these muscles, because normal-
formed a series of studies on the ability of deep lumbar ization of muscle length is a key component of the restora-
muscles to stabilize spinal segments in patients with lumbar tion of muscle function and of normal lumbar mechanics.
pain.18 Their findings suggest that deep muscle activation is Normalization of lumbar motion should occur by 8 weeks
a necessary component in the reestablishment of spinal following disc replacement surgery. Although individual
control following a low back injury. Subjects that did not variations will occur, by 6 weeks, the patient should have
reestablish segmental control continued to experience low exercises that actively and passively promote normal spinal
back pain. Therefore, whether the clinician chooses to use motion in all directions, including rotation, side bend, and
core stabilization, lumbar stabilization, transverse abdominis extension. Care should be taken when initiating each of these
training, or multifidus training, the program should have a motions, and patients should be advised to stretch slowly
component of deep local muscle activation. Once the local and within pain tolerances. All stretches should be pain free.
muscle can be recruited, rehabilitation should progress to See Fig. 17-8 for examples of therapeutic exercises appropri-
coordinating local and global muscle activation. Exercises ate for this phase of healing. Typical ROM exercises for this
focused upon the recruitment of local muscle groups are phase of rehabilitation include single knee to chest, seated
appropriate for this phase of healing.19-21 See Fig. 17-7 for flexion, prone press ups, prayer stretch, supine piriformis
stretch, hip flexor stretch, supine and seated trunk rotations,
and lateral side bend exercises. See Boxes 17-3 and 17-4 for
normal sequencing of motion during lumbar flexion and for
normal ranges of motion in the lumbar spine during lumbar
flexion.
Soft Tissue Mobilization. As a lone intervention,

massage and soft tissue mobilization have been shown
largely to be ineffective at reducing a patients symptoms or
improving a patients functional capacities. When used in
B
Fig. 17-7 Therapeutic exercises. A, Transversus abdominis strengthening. B
In hooklying, isometrically contract the transversus abdominis by drawing
in your belly button. Make sure to maintain a neutral spine and not poste- Fig. 17-8 Therapeutic exercises. A, Single knee to chest. Begin in hookly-
riorly tilt the pelvis causing lumbar flexion. Normal breathing should also ing position. Hug one knee to chest allowing pelvis to posteriorly tilt. Oppo-
be maintained. B, Transversus abdominis and hip dissociation. Contract the site knee can stay flexed in early phase of healing and can be progressed to
transversus abdominis in hooklying with a neutral spine. Lift one leg off the knee extension. B, Prone press-ups. Begin in prone position with hands
ground 1 to 2 inches. Alternate legs. Transversus abdominis contraction placed under shoulders. While maintaining chin tuck, push-up, promoting
should be maintained throughout concentric and eccentric movement of lumbar spine extension. This exercise can be progressed with elbow exten-
both legs. sion, therefore increasing lumbar spine extension.
346 PART 3 Spine
BOX 17-3 Normal Sequencing of Motion for Lumbar TABLE 17-5 Approximate Range of Motion for the
Forward Bend Three Planes of Movement for the Joints of the
Lumbar Region
1. When the patient initiates the forward bend, the first
event that occurs is a posterior sway of the pelvis. Flexion/
This occurs as the body attempts to maintain its Joint or Extension Axial Rotation Lateral Flexion
center of gravity within its base of support. Region (Degrees) Unilateral (Degrees) Unilateral (Degrees)
2. As the body continues to bend forward, the hips
L1-L2 12 2 6
begin to flex and the lumbar spine begins to reverse
L2-L3 14 2 6
its lordotic curve.
L3-L4 15 2 8
3. The lumbar curve fully reverses and the hips
L4-L5 16 2 6
continue to flex forward to complete the forward
L5-S1 17 1 3
bending motion.
Total Lumbar 74 9 29
NOTE: The lumbar spine should not complete more than
50% of its motion before hip flexion motion is initiated. Adapted from White AA III, Panjabi MM: The basic kinematics of
the human spine: A review of past and current knowledge. Spine
Data from Delilitto A, Woolsey NB, Sahrmann S: Comparison of 2:12, 1978; White AA, Panjabi MM: Clinical biomechanics of the
two noninvasive methods for measuring lumbar spine excursion spine, Philadelphia, 1990, Lippincott.
which occurs in forward bending. Phys Ther 67:743, 1987; Sah-
rmann S: Diagnosis and treatment of movement impairment
syndromes, St Louis, 2002, Mosby.
targeted regions by moving specific joints or specific muscles.

Care must be taken in choosing the appropriate time to
begin implementation of joint mobilization techniques
BOX 17-4 Lumbar Spine Motion With Forward Bend because of the potential translational effect they may have on
the lumbar spine and more specifically at the replacement
The lumbar spine is typically positioned between 20 and site. Research has studied the effects of a posterior to anterior
30 of lumbar extension with a normal standing posture. force placed on the spinous process of L3. Studies by Lee
With a full lumbar forward bend, the patient should et al showed a force at L3 could result in movement as far
reverse the lumbar lordosis. The final position of lumbar away as T8, and in follow-up studies by the same group, the
flexion is between 20 and 30 of lumbar flexion. same posterior to anterior force resulted in an anterior rota-
tion of the sacrum.22-25 The implications of these findings for
Data from Loebl WY: Measurement of spinal posture and range
of spinal movement. Ann Phys Med 9(3):103-110, 1967.
the patient following a lumbar disc replacement surgery is
that even mobilizations to distant segments may have a
translatory impact upon the surgical site. Initially, the clini-
cian must use caution when directly mobilizing the lumbar
spine. The anterior aspect of the joint and the prosthetic
conjunction with other intervention, soft tissue mobilization are particularly vulnerable to injury. Posterior to anterior
can be an effective adjunct to allow the body to recover mobilization of the lumbar spine is not advisable for the
mobility and function. Muscles will contract to protect any first 8 weeks following surgery. After that time, the lumbar
area of the body vulnerable to injury. Chronically, this pro- spine can be mobilized in this direction. Posterior to anterior
tective contraction can result in postural changes and these mobilization should focus on segments adjacent to the pros-
postural changes can result in abnormal forces being placed thetic. Mobilization of adjacent segments can be used to
upon normal tissue. Over time these alterations in posture normalize motion in these segments and decrease the
and loads can result in tissue breakdown and pathology. demands placed upon the replacement site. There is no need
Retraining and maintaining muscles and soft tissue tension to mobilize the segment with the prosthetic in a posterior
is an important aspect of normalizing lumbar motion. Soft to anterior manner since the prosthetic is a fixed unit and
tissue mobilization to the hip flexors, quadratus lumborum, posterior to anterior motion of the prosthetic does not
and the erector spinae can be used effectively as an adjunct occur. The more appropriate mobilizations for the prosthetic
to normalizing lumbar motion and mechanics. segment are techniques focused on improving segmental
flexion, extension, and rotation, for these are the motions
Joint Mobilization. Normalization of the biomechanics provided by the new prosthetic. Mobilization in flexion can
of the lumbar spine should be a large consideration in any begin before mobilization into other ranges of motion. As
rehabilitation program that is developed for disc replace- with any mobilization, the clinician should use patient symp-
ment surgery. Mobilization techniques have taken on toms and status as a guide for how much mobilization to use.
increased prominence in rehabilitation programs. In prac- See Table 17-5 for normal ranges of motion for lumbar spinal
tice, they are used to increase ranges of motion within segments.
Lumbar pain and pathology can lead to or be the result indicative of restricted mobility in the nerve being tested.
of movement dysfunction and compensations in other Using the test position to stretch the nerve and release any
regions of the body. While mobilization of the lumbar spine adhesions along its course is a common treatment philoso-
may not be advised immediately because of postsurgical phy. See Box 17-5 and Table 17-6 for lower limb nerve test
tissue weakness, mobilization of regions adjacent to the positions and methods. Unlike muscles, neural tissue is not
lumbar spine is appropriate. Initially, the clinician can begin as elastic and responds adversely to stretching.29 Neural
to mobilize the thoracic spine or sacrum. Decreased flexibil- mobility techniques are commonly classified into two cate-
ity in thoracic spine segments and the soft tissue of the gories: techniques that glide the nerve and techniques that
thoracic region may prevent proper body alignment, includ- stretch the nerve. Sliding techniques produce a greater
ing normal lumbar lordosis. Thus treatment should include amount of nerve excursion through the surrounding tissue
soft tissue mobilization to the thoracic spine musculature than tensioning techniques. Joint motions can influence the
and passive joint mobilization techniques to the thoracic mobility of the nerve.30,31 Muscle activity in the test leg also
spine.26,27 Mechanics and proper functioning of the sacrum increases when the ankle is placed in a tensile position.32,33
can also directly impact the functioning of the lumbar spine. It has been hypothesized that increased muscle activity could
The sacrum is required to provide a stable base from which indicate the muscles plays a protective role with regard to
the rest of the spine can move. The sacrum and sacroiliac nerve mobility testing. When the nerve is placed in tension,
joint are an important link between the lower extremities
and the spine. If they are not functioning correctly, the forces
are transmitted to the lumbar spine. Mobilization of the tho-
racic and sacral regions can help to alleviate the pressure
placed upon the disc. Both mobilizations are an appropriate
early intervention for this phase of rehabilitation.
Neural Mobilization. At this phase of rehabilitation,

neural mobilization should show progress. The clinician
should assess the mobility of neural structures. The common
base test for neural mobility is the straight leg raise test. This
test can be used as a starting point from which the clinician
can test specific peripheral nerves of the lower extremity.
Fibular, tibial, sural, and femoral all have specific test posi-
tions that place the nerve into a position of tension.28 See
Figs. 17-9 through 17-11 for examples of neural mobility
testing and testing sequences. If the nerve does not glide
Fig. 17-9 Straight leg raise base test. This test is designed to assess the
through its surrounding tissue, the nerve is stretched. In
mobility of the sciatic nerve. The knee is kept in extension and the foot ankle
response to the tensile load, symptoms such as numbness, in a neutral position. The leg is lifted up until tightness or the patients
tightness, and tingling are produced. These symptoms lessen symptoms are reported. Pillow is optional, but should be consistent between
when tension is removed from the nerve. A positive test is testing sessions.
A B C
Fig. 17-10 Straight leg raise test foot positions for biasing peripheral nerves. A, Position for the sural nerve (dorsiflexion and inversion). B, Position for the
peroneal nerve (plantar flexion and inversion). C, Position for the tibial nerve (dorsiflexion and eversion).
348 PART 3 Spine
Phase IIIb: Remodeling Phase

TIME: Weeks 9 to 12 (Days 61 to 84)
GOALS: Restore strength and ROM in the lumbar
spine, maintenance of neutral spine with concurrent
upper and lower extremity movements, improve and
normalize function movements, improve the
coordinated recruitment of local and global muscle,
address musculoskeletal issues that may have
contributed to the patients low back pain (Table
17-7)
The primary goal of this phase of rehabilitation is restora-

tion of function. Progression to this phase of rehabilitation
should begin once the patient is able to tolerate the exercises
of phase IIIa without an increase in low back or lower
extremity symptoms. Interventions from the previous phase
Fig. 17-11 Side-lying femoral nerve test. This test is also known as the have focused on loading the body in a manner that protected
side-lying slump test. The patient is positioned in side lying. The cervical the lumbar spine. The purpose of this precaution was to
and thoracic regions are flexed forward. The clinician takes the upward prevent overstressing newly healed structures. By week 9
lower extremity from a position of hip flexion toward hip extension. The leg after surgery, most scar tissue should have been formed.
is extended until the patient reports the onset of tightness or symptoms are
reproduced.
Edema and inflammation should be minimal and patient
function should be returning to normal. From a tissue per-
spective, the newly laid dense connective tissue requires
appropriate loading to promote strength in the tissue. Basic
muscles are recruited to protect the nerve and prevent injury strengthening and protection should be continued but pro-
to the structure. Nerves are sensitive structures and can be gressed to include movement outside the basic framework of
easily damaged. the core. The goal is protected restoration of function and
Treatment, therefore, should address the gliding and functional motion.
not stretching of nerves. Before gliding the nerve, soft tissue
structures along the course of the nerve can be mobilized to Functional Retraining. Functional retraining is not a
allow for nerve mobility. Movement of the lower extremity new concept in rehabilitation. It challenges strength, balance,
can be combined with small movements of the neck to and coordination in functional positions. It involves systems
encourage gliding of the nerve rather than stretching. Finally, of core training and lumbar stabilization in a weight-bearing,
communication with the patient is essential since radicular functional environment. At this phase of rehabilitation, it is
pain or paresthesia are indications that the nerve is being appropriate to begin to train the body to work in outside of
stretched and potentially irritated. The patient and therapist its center of mass (Fig. 17-12). Earlier in the chapter, it was
should work in ranges of motion that do not reproduce discussed how local muscles are inhibited and global muscles
the patients radicular symptoms. Neural mobilization recruited in response to injury. Initial exercises involved
techniques, as well as all techniques mentioned in this recruitment of local muscles such as the transverse abdomi-
book, should only be used by therapists specifically trained nis and the multifidus muscles. As the patient continues his
in the technique. or her progress and rehabilitation, it becomes appropriate to
start to challenge the patient outside of midline and in
Summary Comments. At this stage of rehabilitation, the upright functional positions. Patients need to operate outside
patient may find it difficult to perform activities that require of a neutral spine and perform normal function where
prolonged sitting or standing postures. These limitations are strength, flexibility, motor control, and proprioception are all
normal. It is important to assist the patient in recognizing required. Activities such as front lunges and side lunges can
methods or activities that have the ability to relieve some of be progressed to include upper extremity motions and upper
the pain or soreness. It is also important that they be assisted body rotation or side bends. Near the end of this phase,
in the development of strategies to increase muscle endur- patients can be evaluated for advanced strengthening (i.e.,
ance so that they may gradually build a tolerance to these planks, pointer dog, and supine bicycle). Squats and sit to
positions. Strategies may include limiting the time spent in stand can incorporate trunk rotation. Single-leg balance can
any one position, the use of cryotherapy to the back, or active be combined with single-leg squats and forward or side
lumbar ROM exercises to relieve stiffness and soreness. reaching. By changing position of the upper body and lumbar
Improving protected functional abilities and normalizing spine, and adding active functional based activities, the body
nerve mobility are appropriate for this phase of healing. Car- can begin to recruit the local muscles while at the same time
diovascular endurance and strength should continue during selectively targeting weakened groups of muscles. Various
this phase. positions of the hip and trunk can force the selective
BOX 17-5 Straight Leg Raise and Side-Lying Femoral Nerve Testing Procedure
Testing Procedure for Straight Leg Raise Testing Hip abduction should decrease patient symptoms.
1. First, establish the patients baseline resting Hip adduction should increase patient symptoms.
symptoms. Remember to reassess baseline symptoms/ Testing Procedure for Femoral Nerve Testing
resistance/range of motion with the addition of each 1. First, establish the patients baseline resting
new component. symptoms. Remember to reassess baseline symptoms/
2. Patient is positioned in supine near edge of table. resistance/range of motion with the addition of each
Therapist position new component.
1. The clinician is positioned adjacent to the patients 2. Patient is positioned in side lying with a pillow placed
thigh. beneath the head to maintain a midline position.
2. Next, the clinician will grasp the patients foot with Therapist position
one hand while the other hand is placed on the 1. The clinician is positioned adjacent to the patients
patients knee and will be used to keep the knee gluteal region.
straightened. 2. Next, the clinician will support the patients knee and
3. Alternatively, the clinician may grasp the patients lower extremity with the hand and forearm of one arm.
ankle with one hand while the other hand is placed on The other hand is placed on the patients hip to
the ball of the patients foot and will be used to control stabilize the pelvis.
the patients foot position.
Procedure
Procedure
1. The clinician pre-positions the patients thoracic and
1. The clinician positions the foot and ankle to test cervical spine into flexion.
specific nerves. 2. The clinician takes the hip from a flexed position to an
2. The patients leg is raised into flexion while the knee extended position until the patient reports the initial
is kept in an extended position. onset of tightness in the leg.
3. The clinician raises the leg until the patient reports the 3. The clinician next extends the patients head while
initial onset of tightness in the leg. maintaining the hip position. If neural structures are
4. The clinician next releases the foot and ankle position involved, the symptoms should lessen.
to see if the symptoms in the leg change. If neural 4. The clinician can vary the sensitizing positions to
structures are involved, the symptoms should lessen. further implicate the nerve as the source of the motion
5. The clinician can vary the sensitizing positions to restriction.
further implicate the nerve as the source of the motion
restriction. Sensitizing positions
Cervical flexion should increase patient symptoms.
Sensitizing positions
Cervical extension should decrease patient symptoms.
Contralateral cervical lateral flexion should increase Hip abduction should decrease patient symptoms.
patient symptoms. Hip adduction should increase patient symptoms.
Ipsilateral cervical lateral flexion should decrease
patient symptoms.
Adapted from Butler D: The sensitive nervous system, Adelaide Australia, 2000, Noigroup Publications.
recruitment of one muscle group while inhibiting others. See proprioceptive changes is not clear. Regardless of the exact
Fig. 17-13 for examples of therapeutic exercises appropriate physiologic mechanisms, research has shown that rehabilita-
for this phase of healing. Progression to this phase of rehabili- tion can improve joint proprioception. In response to these
tation should not be permitted until the patient shows good findings, rehabilitation experts have included proprioceptive
motor recruitment and control of the basic set of exercises and training in rehabilitation programs to address and change
the patients symptoms are minimal. the proprioceptive system.34
While a mainstay in many extremity rehabilitation pro-
Lumbar Proprioception. Proprioceptive training has grams, proprioceptive training has not factored into most
played a large role in the rehabilitation of individuals spinal programs. Recently, research has surfaced that sug-
following injury. In the lower extremities, it has been estab- gests that proprioception should play a larger role in spinal
lished for quite some time that injury impacts joint proprio- rehabilitation programs.35-39 In response to these findings, as
ception. The mechanism of this impairment can vary and in a patients functional and physical capabilities progress, it is
some cases the exact physiologic mechanism behind the appropriate and necessary to begin to progress exercises in
350 PART 3 Spine
TABLE 17-6 Lower Limb Nerve Testing Positions

Test Nerve Assessed Test Position Test Motion
Straight leg raise General Supine: Knee in extension

Leg straight and uncrossed Foot in neutral position
Spine in midline position Hip flexed until initial onset of symptoms
Arms resting at the patients side Check sensitizers: ankle DF/PF, cervical flexion,
No pillow under head hip abduction/adduction
Straight leg raise with peroneal bias Peroneal Supine: Knee in extension
Leg straight and uncrossed Foot in DF and inversion
Arms resting at the patients side Check sensitizers: inversion/eversion, ankle DF/
No pillow under head PF, cervical flexion, hip abduction/adduction
Shoulder abduction
Straight leg raise with tibial bias Tibial Supine: Knee in extension
Leg straight and uncrossed Foot in DF and eversion
Arms resting at the patients side Check sensitizers: ankle inversion/eversion,
ankle DF/PF, cervical flexion, hip
abduction/adduction
Straight leg raise with sural bias Sural Supine: Knee in extension
Leg straight and uncrossed Foot in PF and inversion
Arms resting at the patients side Check sensitizers: ankle inversion/eversion,
No pillow under head ankle DF/PF, cervical flexion, hip
abduction/adduction
Femoral nerve Femoral Side lying: Knee in flexion
Bilateral hips and knees flexed Foot/ankle in neutral
Thoracic and cervical spine in flexed position Hip extended until initial onset of symptoms
Pillow under head to maintain neck in midline Check sensitizers: cervical flexion/extension, hip
abduction/adduction
DF, Dorsiflexion; PF, plantar flexion.

Adapted from Butler D: The sensitive nervous system, Adelaide Australia, 2000, Noigroup Publications.

Phase IIIb Surgical site has healed Same as phase II with the Continue with phase II Restore strength to upper Independent with
Remodeling phase No increase in pain following: interventions and lower extremities self-care and ADL
(maturation) symptoms Limited ability to perform Exercise: Normalize lumbar range of Prevent reinjury with
Postoperative Patient demonstrates activities in a prolonged Progressive resistive motion increase in dynamic
wk 9-12 neutral spine concepts sitting/standing position exercises with lumbar Improve lumbar mechanics activities
(days 61-84) Correct abnormal lumbar Patient is not fully stabilization at the end of Maintenance of neutral Knowledge of
movement patterns independent with ADL the phase, if appropriate spine in various positions/ pain-relieving
Patient able to complete Walking tolerance still (see Fig. 17-13, D) planes with concurrent strategies/positions
most normal daily limited by lumbar fatigue Begin functional retraining upper and lower extremity during prolonged
activities while (see Fig. 17-12) movement activities
maintaining lumbar Balance training: Begin to increase motion
stability and without an Begin balance and and function outside of
increase in symptoms proprioceptive training the base of support
Mobilization: Improve proprioception in
Progress thoracic, lumbar, the lumbar spine
and sacral joint and soft
tissue mobilization
ADL, Activities of daily living.

B C
Fig. 17-12 Functional retraining. A, Single-leg reach. Begin exercise with single-leg balance. Flex knee, as if performing minisquat. While knee is flexing,
simultaneously extend opposite arm and leg. Rotate trunk toward the side of the standing limb. B, Forward lunge with ipsilateral side bend. Exercise can be
varied and the upper body can be positioned in contralateral side bend, extension, or flexion. Each position will selectively recruit different muscle groups.
C, Forward lunge with ipsilateral rotation. Exercise can also be completed with contralateral rotation. Weighted medicine ball is used in this picture, but
exercise can be completed with a variety of objects and weights to simulate work and sports-related environments.
352 PART 3 Spine
A B C
F
Fig. 17-13 Therapeutic exercises. A, Minisquats. Feet are placed a hip width apart. While maintaining abdominal contraction, squat with 30 to 45 of knee
flexion as if sitting in a chair. B, Tandem balance. Place one foot in front of the other while maintaining trunk control. Hold position 30 to 45 seconds in each
direction. C, Heel raises. Standing with knees and ankles, hip width apart, lift up onto balls of feet. Weight should be placed over the first digit on each foot.
D, Planks. Begin in the prone position with elbows in-line with shoulders. Contract transversus abdominis and push up onto forearms as well as toes. Iso-
metrically contract abdominals, maintain neutral spine and chin tuck. E, Pointer dog. Begin in quadruped position (hips and knees in 90 of flexion), neutral
spine, chin tucked. While maintaining trunk control and transversus abdominis contraction, extend one lower extremity with opposite upper extremity. Lower
each limb and repeat with opposite limbs. F, Bicycles. Begin in hooklying position. Place hands behind head. Bring both legs into 90 of hip and knee flexion.
Contract transversus abdominis, bring right armpit to left knee promoting slight trunk rotation. Extending opposite lower extremity simultaneously. Do not
lift scapulas off mat.
manners that challenge proprioception and balance. See TABLE 17-8 Therapeutic Exercise List
Figures 17-12 and 17-13, F, for examples of therapeutic exer-
cises appropriate for this phase of healing. Phase Appropriate Therapeutic Exercises
Phase I: Neutral spine abdominal bracing with bed mobility

Summary Comments. As the patient progresses, it is Inflammation Lumbar stabilization/transverse abdominis muscle activation
important for him or her to begin to normalize lumbar (see Fig. 17-7)
motion with functional activities. Functional activities Single knee to chest hip ROM exercise
that change balance and proprioception while at the same Ankle pumps
time challenging strength and endurance are the most Abdominal breathing
appropriate types for this phase of healing. Patients do not Gait training
function in a small, limited amount of lumbar motion. Transfer training
They must bend, twist, and rotate through large ranges of Bed mobility training
motion and their backs must be capable of functioning Hooklying isometric abdominal contractions
during these larger ranges of motion. See Table 17-8 for Phase II: Lumbar stabilization/transverse abdominis exercises in supine
a list of therapeutic exercises for the various phases of Reparative Progress walking program
rehabilitation. Increase sitting and walking tolerances
Phase IIIa: Progress supine stabilization and walking programs
Phase IIIc: Remodeling Phase Remodeling Add standing core and lumbar stabilization exercises:
TIME: Weeks 13 to 52 (Days 85 to 360) Squats (see Fig. 17-13, A)
GOALS: Return to work or sport, return to prior level of Heel raises (see Fig. 17-13, C)
functioning, preparation for discharge from physical Sit to stand
therapy (Table 17-9). Some of these goals may be Standing bicep curls
reached at 6 months and some may be reached at 1 Add movement assessment and correction of abnormalities:
year. Seated knee flexion and extension
Quadruped rocking
From a prognostic standpoint, it takes a full year for a Supine
patient to totally recover from lumbar surgery. That is Add lumbar ROM exercises:
not to say that it will take a full year for the patient to Prone extension (see Fig. 17-8, B)
restore function and return to normal daily activities. It is Supine trunk rotation
simply that the remodeling phase takes a full year and that Seated trunk rotation
changes in tissue can take up to year to reach their ultimate Seated flexion
strength. The remodeling phase of the rehabilitation process Add straight leg neural gliding techniques in supine (see
focuses on return to work, sport, or normal daily activities. Table 17-6)
By the end of this phase, the patient should be able to Add recumbent bicycle and treadmill as tolerated
function independently at home and in the workplace. As Phase IIIb: Continue and progress phase IIIa exercises:
the patient progresses through the rehabilitation process, Remodeling Planks (see Fig. 17-13, D)
functional retraining of work or sport-specific activities Side planks
should be assessed. Activities that require increased loads Standing rows
on the lumbar spine should be evaluated and, pending phy- Add functional training:
sician approval, rehabilitation geared towards functional Single-leg squats
training can be initiated. Return to activities or sports Single-leg squat reaches (see Fig. 17-12, A)
that require contact between players or heavy lifting will Forward lunges with trunk side bend (see Fig. 17-12, B)
require a physicians approval. At this time, the clinician may Side lunges with trunk side bend
implement a gym- or home-based exercise program to Lunges with shoulder flexion
assist in maintenance of proper strength and muscle Add balance and proprioception training:
function. Discharge of the patient should occur once the Single-leg stance
patient, rehabilitation personnel, and physician have all Standing on air discs or BOSU balls
determined that the patient has reached his or her functional Single-leg squats with eyes closed
goals and is able continue the rehabilitation process safely Progress walking and recumbent bicycle
and independently. Phase IIIc: Continue with phase IIIb exercises
Remodeling Add sports- and work-related training
Troubleshooting Add running on treadmill, elliptical trainer
Red Flags Add work simulated activities
There is a 30% to 40% chance complications will occur
during and/or after lumbar spine surgery because of expo- ROM, Range of motion.
sure and mobilization of anterior structures.40 Those requir-
ing multilevel versus single level exposure are at a higher risk
354 PART 3 Spine

Phase IIIc Patient able to Difficulty lifting heavy objects Exercise: Return to prior Improve patients
Remodeling phase self-manage pain Difficulty maintaining Progress sets and repetitions of level of functioning ability to manage
(maturation) No decrease in prolonged postures upper and lower extremity Return to work-related schedule
Postoperative functional ability Unable to complete work- or resisted exercise program as presurgical level of Promote continuance of
wk 13-24 sports-related activities tolerated by patient strength and proper postures and
(days 85-168) Functional retraining activities endurance home maintenance
(work or sport related per Prepare patient for program after discharge
physician approval) discharge from physical therapy
Preparing to run with treadmill,
minitrampoline
for such complications, as are the elderly, obese, and those Neural Complications
with cardiovascular disease.40,41 It is important the clinician There are a variety of nerves that can be injured during
is aware of these potential complications to educate the lumbar spine surgery. The lumbar sympathetic chain runs
patient on the importance of reporting any signs or symp- along the spine, controlling genitourinary organs. If damaged,
toms to his or her physician immediately. one may be left with a warm lower extremity, often mistaken
for vascular damage, and a variation of incontinence.40 The
Infection iliohypogastric, ilioinguinal, and genitofemoral somatic
Infection has been reported in approximately 1% to 2.4% of nerves are also at risk for damage resulting in decreased
patients undergoing lumbar spine surgery.42 Incisional sensation to the groin and external genitalia.40 After surgery,
hernias, sterile discharge, and other superficial wounds at the increased radicular pain may occur because of epidural fibro-
incision site can occur.43 Periincisional abdominal bulges can sis causing nerve root traction during surgery.49,50 This has
also occur because of intercostal denervation.40 Deeper been shown to resolve by the third month postoperatively.50
infection can also occur, leading to more serious complica-
tions including bone destruction and resorption as well as Genitourinary Complications
osteomyelitis in vertebrae adjacent to the surgical site.42 Signs Genitourinary complications can occur from damage from
and symptoms of infection include fever, hypotension, the mobilization of the hypogastric sympathetic plexus.
tachycardia, tachypnea, increased pain, edema, wound Injury to urinary tract organs, decreased genital sensation,
drainage, tenderness, and general malaise.44 retrograde ejaculation, and impotence in males can result.40,51
Damage to ureters occurs in 0.3% to 8.0% of cases and can be
Vascular Complications injured whether spine surgery requires an anterior or poste-
Injury to vascular structures is the most common complica- rior approach.40 Retrograde ejaculation occurs in up to 28%
tion when using an anterior approach for lumbar spine of males undergoing lumbar spine surgery with an anterior
surgery.40,41,45 Potential damage to the arterial and venous approach.40,51 When this occurs during lumbar spine surgery
systems occurs in 2.8% of cases because of mobilization it is often irreversible. Elderly men, diabetics, and those with
of the aorta, inferior vena cava, and iliac arteries.46-48 vascular disease are at a higher risk for such complications.40
Thrombosis is the most likely postoperative arterial com-
plication, yet can be prevented with use of anticoagulants, Spontaneous Fusion and
compressive hoses, and calf pumps.40 When exposure of Heterotropic Ossification
the L4-L5 lumbar spine segments is required, mobilization Unlike spinal fusion surgery, the goal of total disc replace-
of renal, iliac, and iliolumbar veins is necessary, placing an ment (TDR) surgery is to preserve movement and restore
increased risk for complications. With this in mind, intradisc height and segmental lumbar lordosis. Spontaneous
operative bleeding can occur when venous structures are interbody fusion of segments above and below the surgical
damaged. Individuals who are diabetic, obese, elderly, or site has occurred in greater than 60% of patients after a
have cardiovascular disease are not only at a higher risk 17-year follow-up.48,50 Approximately 1.4% to 15.2% of
for experiencing such complications, but they are also at patients have also experienced heterotropic ossification with
risk for postoperative ischemia.40 Signs and symptoms of the use of ProDisc and SB Charit prostheses.48
arterial or venous damage may include calf pain, lower
extremity edema, diminished pedal pulses, temperature Implant Materials
changes, discoloration, and heaviness in the lower The polyethylene metal used in TDR is the same type of
extremities. metal used in total knee and hip replacements. Although
there havent been any reported cases of wear debris, creep,

or osteolysis occurring in disc replacement surgery, there is BOX 17-6 Factors Contributing to Chronic Pain
a potential for permanent deformation and wear of the metal
Peripheral Changes
similar to total knee and hip replacements.45,48 This may take
as little as 1 year or as long as 10 years to occur, both leading Changes in tissue sensitivity at the site of injury and
to a necessary anterior and posterior spinal fusion of the along the peripheral nerve
involved segments.45,48,50 Possible dislocation or loosening of Spinal Cord Changes
the polyethylene metal can also occur over time, resulting in Inhibition and processing changes at the spinal cord
chronic pain and requiring spinal fusion because of biome- level
chanical failure.52
Alteration In Midbrain Function
Biomechanics Changes in midbrain process leading to changes in:
The purpose of having a TDR rather than spinal fusion is to Immune function
preserve the normal movement of the lumbar spine.48 During Autonomic function
surgery, malpositioning of the disc implant, whether anterior Motor control
or posterior, can occur.48 This can ultimately cause decreased Endocrine function
ROM and/or an increase in load to posterior structures. Alteration In Cortical Processing
Malpositioning also affects the sagittal balance of the lumbar Changes in ways pain is interpreted and processed
spine, resulting in decreased lumbar lordosis and possible Changes in memories, emotions, and stress in the
degeneration of adjacent segments.48 interpretation and the processing of pain
Chronic Pain Data from Butler D: The sensitive nervous system, Adelaide,
Australia, 2000, Noigroup Publications; Gifford L, Butler D: The
Changes in the peripheral and central nervous system occur integration of pain sciences in clinical practice. J Hand Ther
almost immediately following an injury. Some of these 10:86-95, 1997.
changes are reversible and other changes are nonreversible.
It is beyond the scope of this chapter to describe all the
neural changes that occur with injury, but from a clinicians
viewpoint it is important to realize that not all patients will to allow the surgical site to heal. Therefore, patient education
have full resolution of symptoms following surgery. Surgery regarding surgical protection guidelines immediately follow-
may have addressed the structures that were originally the ing surgery is a must. Aside from healing the surgical site,
source of the patients symptoms, but the adaptations that specific rehabilitation protocols and guidelines created for
have occurred in the central and peripheral nervous system TDR surgery are similarly based on protocols for other
may not be reversible. It is important to realize that not all lumbar spine surgeries (i.e., microdiscectomies and fusions).
pain is a reflection of actual tissue damage. As a result, not Balancing abdominal stability and lumbar mobility in con-
all patients will have full resolution of symptoms.28,53,54 See junction with lower extremity strength and cardiovascular
Box 17-6 for factors that contribute to chronic pain. exercise is most important. Considering the variety of indi-
viduals requiring a lumbar disc replacement surgery, it is
SUMMARY necessary to create and progress a program specific to each
patients needs. Finally, since radicular pain and lower
Rehabilitation of a patient following a TDR is unique, con- extremity paresthesia are often the symptoms driving the
sidering its goal is to maintain lumbar ROM and overall decision for lumbar disc replacement surgery, prevention of
mobility. Although it is pertinent to begin mobility exercises neural adhesions and promotion of nerve healing should be
early on in the rehabilitation process, it is just as important addressed appropriately.

The patient can use the following home program Inflammation and Reparative Phases I and
during the rehabilitation process. The contents of II (Weeks 1 to 3)
the home maintenance program may vary Goals For This Period: Protection of the surgical site,
depending on the patients prior level of function, decrease pain and edema, understand proper body
single versus multilevel TDR and tolerance and mechanics and posture, increase walking tolerance,
ability to complete the exercises properly speed, and endurance. Extension exercises past
without the onset of pain symptoms or aberrant neutral should be avoided during this phase of the
motions. healing process.55
356 PART 3 Spine
1. Protection of the surgical site 3. Begin lumbar extension, side bend, and rotation
2. Manage swelling/edema in lower extremities ROM exercises between week 6 and 8 as long as
a. Ankle pumps incision site has healed; begin progressing to end
b. Compression stockings of range movements after 6 weeks55
c. Leg elevation a. Prone press ups
3. Bracing as needed during seated and standing 4. Nerve gliding
activities to encourage healing a. Nerve gliding for those experiencing radicular
4. Knowledge and understanding the need for symptoms (i.e., sciatica) into lower extremities
regaining normal lumbar spine ROM postsurgery.55 Perform with caution, careful not to
5. Gentle flexion exercises encouraged,56 performed
stretch the nerve.
after 2 weeks in supine
5. Cardiovascular
a. Hook lying isometric abdominal contractions
a. Progress walking program
emphasizing transverse abdominis and
b. Recumbent bike
multifidus recruitment55
6. Return to performing basic activities of daily
b. Bed mobility
living including reaching, stooping, and squatting
6. Lower extremity strengthening for quadriceps
Avoid heavy lifting and high impact activities
and gluteal muscles
such as jumping and running.
a. Sit to stands
b. Minisquats
c. Heel raises Remodeling Phases IIIb (Weeks 9 to 12)
d. Daily walking program Goals For This Period: Progress lower extremity
7. Neuromuscular reeducation strength, aerobic capacity, and functional activities.
a. Tandem balance 1. Progress abdominal, erector spinae and gluteal
b. Single-leg balance strength
a. Planks (initiate near end of phase)
Remodeling Phase IIIa b. Pointer Dog
(Weeks 4 to 8) c. Abdominal bicycles (must have enough muscle
Goals For This Period: Increase lumbar spine ROM control to perform correctly)
in all directions and begin to return to normal d. Latissimus dorsi pull downs
activities of daily living e. Bosu ball squats
1. Increase lumbar flexion mobility f. Lunges
a. Progress abdominal strengthening with hip g. Single-Leg reach
dissociation, (i.e., hip flexion, hip internal/
external rotation in hook lying) Remodeling Phase IIIc (Weeks 13 to 24)
b. Single knee to chest stretch Goal For This Period: Independence with
c. Quadruped rocking progressive home exercise program, return to sport.
2. Begin upper extremity and lower extremity 1. Continue previous exercises and progress reps
strengthening exercises with proper abdominal and weights as tolerated
bracing 2. Begin sport-specific drills
a. Rows 3. Increase walking speed and distance
b. Bicep curls 4. Preparations for running and more aggressive
c. Hamstring curls exercises may begin at week 12
d. Step-ups 5. Lifting mechanics with weight; twisting and
e. Squats bending may begin after 12 weeks if ready
1 Your patient is a 34-year-old male who underwent a

L4-L5 lumbar disc replacement surgery 1 day ago. The
physician states that the surgery was a complete success
Initial evaluation in the hospital will involve taking the
patients vital signs and assessing the patients wounds.
Given that both of these objective measures are satisfac-
and that the patient is ready to begin in-hospital reha- tory, the clinician should have several goals on day 1.
bilitation. You have been asked to evaluate and begin the First is to educate the patient on neutral spine bracing
rehabilitation process. What will your evaluation and and mechanics. The patient should be educated on how
initial treatment involve? to move in bed and progress from lying to sitting with
the lumbar region braced. The patient should be fitted

with a lumbar support brace and shown how to use the
brace. The brace is worn 24 hours a day unless otherwise
4 Your patient is once again the 42-year-old female who
underwent a lumbar disc replacement surgery. She is
now in an outpatient orthopedic clinic 5 weeks follow-
ordered by the physician. Sit to stand mobility should be ing her surgery. She saw her doctor yesterday and has
assessed using the front wheel walker for support. The been cleared to begin outpatient orthopedic rehabilita-
patient should be able to walk from the hospital bed to tion. What will your evaluation and initial treatment
the bathroom with minimal assistance. A front wheel involve?
walker will be used for support. The patient should be
encouraged to sit, walk, and stand for limited times ini- The patient will guide your initial evaluation. Most
tially. No position should be held for greater than 15 patients will have a little low back pain and stiffness, but
minutes. The patient should be advised not to transfer, the symptoms are getting better. The initial evaluation
stand, or walk without assistance for the first day. will involve assessing posture and motion. ROM can be
tested in all directions of motion, but end-range exten-
2 Your patient is a 53-year-old male who underwent

an L4-L5 TDR 4 weeks ago. He has type II diabetes and
is 100lb overweight. During his initial evaluation for
sion, rotation, and side bend should be avoided until 6
weeks. Lower extremity ROM and lower extremity
strength should also be tested. Care must be taken not
outpatient physical therapy, he reports that he ran out to overtax the patients injured regions. A neurologic
of his blood thinners 1 week ago and has been experi- examination should be completed to determine the
encing right lower extremity leg pain and swelling for amount of nerve damage sustained during surgery. The
the past 5 days. Symptoms seem to be progressively patient should avoid lying on her stomach for the first 6
worsening. The patient has not yet spoken with his weeks following surgery. Interventions will include
physician. reviewing the patients current exercises and the pro-
gression of exercises as needed. Walking tolerance
Red Flag: This patient is at risk for a deep vein thrombo- should be encouraged. Lumbar and core stability exer-
sis. He is diabetic and overweight, both predisposing cises should be included and progressed at week 6. Soft
him to vascular complications during and after surgery. tissue mobilization in side lying may begin at this time.
Symptoms including lower extremity pain, severe The patient should be warned to avoid trunk extension,
edema, discoloration, temperature changes, diminished rotation, and side bend. The patient may begin to wean
pedal pulses, and heaviness are all signs of deep vein off of the lumbar brace at 6 weeks pending physician
thrombosis. This patient should be advised to see his approval. The weaning process should involve coming
physician or go to the nearest hospital as soon as pos- out of the brace for 1 hour on day 1, 2 hours on day 2,
sible to prevent further complications, including a pul- 3 hours on day 3, etc.
monary embolus.
3 Your patient is a 42-year-old female who underwent a

lumbar disc replacement surgery 5 days ago. She is pro-
5 Your patient is a 29-year-old female who is 5 weeks
postsurgical L4-L5 lumbar disc replacement. She is in
your clinic for her first outpatient rehabilitation session.
gressing well and without complications and is prepar- You are assessing her posture and ROM. She stands with
ing for discharge from the hospital tomorrow. She will increased hip flexion and increased lumbar lordosis.
be returning to her home where her husband and family When asked to forward flex, her motion is guarded and
will help care for her. What must be done with the she is unable to fully flex because of low back tightness
patient before her discharge tomorrow? and pain. What are the implications of these finding in
your clinical decision-making process?
The patient will mostly likely not have home rehabilita-
tion care. The instructions given in the hospital at time Pain and guarding are normal symptoms at 5 weeks
of discharge should be followed until the patient is postoperation. Lumbar lordosis should be avoided in
released to physical therapy in approximately a month. patients following disc replacement. The patient should
Therefore, several instructions need to be purveyed to be taught abdominal bracing and lumbar protection
the patient. The patient should be given the hospital strategies. Neutral lumbar spine positioning should be
discharge instructions (See Box 17-2). The patient should incorporated to avoid lumbar lordosis. With lumbar
be instructed to maintain the lumbar stabilization flexion, the patient should be able to bend forward and
program and joint protection precautions. A progres- the lumbar spine should flatten or reverse its lordotic
sively increasing walking program should be encour- curve. The patient has a normal response for her phase
aged. Lumbar flexion should be promoted and lumbar of healing. The clinician should begin manual therapy
extension, rotation, and side bend avoided. A lumbar and exercises to restore normal lumbar motion.
brace should be worn 24 hours a day unless otherwise
ordered by the physician. Lumbar core stabilization
should be used with all daily activities. 6 Your patient is a 65-year-old male who underwent a
TDR surgery with dynamic stabilization 5 weeks ago.
358 PART 3 Spine
He complains of shooting pain and numbness down

his left lower extremity. He has difficulty when transi-
tioning from supine to sit and sit to stand, and can only
9 Your patient is a 35-year-old male who had lumbar disc
replacement surgery 3 months ago. He is progressing
well and would like to begin running. What is your
walk 100 feet before having to sit and rest because of advice for the patient and should he be allowed to begin
pain. He asks why this is happening after surgery and running?
wonders how long it will take for these symptoms to
resolve. Generally, running can begin in some patients at 3
months following surgery, but most people will begin at
Radicular symptoms into the lower extremity following a running regime at 5 to 6 months following surgery.
disc replacement surgery are not an uncommon com- Before that time, the patient can begin prerunning activi-
plaint. Multiple factors can be the cause of the symp- ties. Prerunning would include several weeks of walk/
toms. In certain instances, the radicular symptoms can running on the treadmill, use of an elliptical trainer, and
be the result of nerve root traction during surgery sec- running on a minitrampoline before beginning running
ondary to epidural fibrosis. Such symptoms usually on the street. In the beginning, the patient should only
resolve by the twelfth week, postoperatively. It is impor- begin running for 10 to 15 minutes and then increase the
tant that the clinician educates the patient on such symp- running time 5 minutes a day as tolerated. Ultimately the
toms, so he also knows what to expect and to follow up decision to begin running will need to be approved by
with his physician in case symptoms worsen. the surgeon, but will be based upon the patients symp-
toms and whether he can complete daily activities with
7 Your patient is a 37-year-old male who is 6 weeks

postsurgical L3-L4 lumbar disc replacement. He is pro-
good lumbar control and stability.
gressing well but continues to experience limitation in

ROM. Low back pain is improving, but stiffness in the
lumbar region continues to persist. You decide to incor-
10 Your patient is a 34-year-old male who has been
making steady progress in physical therapy. He is 9
weeks postlumbar disc replacement surgery at L4-L5
porate joint mobilization into your treatment plan. and wants to know when he can return to surfing
What joints and techniques should you use in your and snowboarding.
treatments?
Surfing and snowboarding are considered extreme
At 6 weeks after surgery, prone techniques are appropri- sports. It is recommended to postpone participation in
ate for the patient. The clinician can begin mobilization such activities for at least 6 months post-TDR and in
of the thoracic region at 4 weeks and mobilization of the most cases it is closer to 9 months. This time frame is
lumbar spine at 6 weeks. The patients symptoms will be variable and depends upon the nature of the sport and
your guide to mobilization intensity and duration. Poste- the patients functional and symptom progression. At 12
rior to anterior mobilization can be used at the thoracic weeks, he is able to begin light running, lifting, twisting,
and lumbar spine, but is not appropriate at the L3-L4 and bending activities. Sport-specific activities can begin
spinal segment. Sacral mobilization can also be incorpo- when the patient can run pain free. The patient will
rated. Rotational and flexion/extension mobilization require clearance from his physician before returning to
techniques are most appropriate for the L3-L4 spinal sports. This patient needs to be educated on the proper
segment. exercise progression to prepare for such recreational
activities and requires clearance from his physician to
8 Your patient is a 55-year-old female who had L2-L3

lumbar disc replacement surgery 2 months ago. She is
participate in such activities.
progressing well with her initial exercises and would like

to begin further exercise progression. What and how
can she progress her exercises?
11 Your patient is a 38-year-old male who had lumbar
disc replacement surgery 6 months ago. He is now
running for short distances and has not noticed any
increase in symptoms. His chief limitation is running
Lumbar exercises can be progressed in the following greater than 30 minutes. The physician has approved
manner: him to return to work and discontinued outpatient
Increase the number of repetitions for each exercise orthopedic rehabilitation. What is his program and
Increase the amount of resistance the patient is using what is your advice to him in terms of his ultimate
for each exercise prognosis?
Progress core stabilizing exercises from supine to
more functional positions such as standing If the patient is running and has been approved to return
Decrease base of support while completing exercises to work. He is now appropriate for discharge. He will
and begin to challenge balance continue to heal and strengthen for up to 1 year follow-
Begin to work outside of the patients base of support ing the surgery. So, he should continue to progress his
and begin functional-based exercises exercises at home and in a gym setting. He can begin to
return to playing sports at 6 months, but this will be to the sport. The patient should be given a home- and
dependent upon the nature of the sport and the patients gym-based program to continue for the next 6 months.
symptoms. Higher impact sports that require contact or The patient should also be advised to respect his pain
repetitive jumping may require additional time. These and symptoms, and to progress his home program in a
athletes may require 9 to 12 months of time before return pain-free manner.
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PART 4 LOWER EXTREMITY
18 Total hip arthroplasty, 362
19 New approaches in total hip replacement: the
anterior approach for miniinvasive total hip
arthroplasty, 376
20 Hip arthroscopy, 382
Jonathan E. Fow
21 Open reduction and internal fixation of the hip, 388
22 Anterior cruciate ligament reconstruction, 404
Jim Magnusson, Richard Joreitz, Luga Podesta
23 Arthroscopic lateral retinaculum release, 427
Daniel A. Farwell, Andrew A. Brooks
24 Meniscectomy and meniscal repair, 441
Morgan L. Fones, George F. Rick. Hatch III, Timothy Hartshorn
25 Autologous chondrocyte implantation, 457
Karen Hambly, Kai Mithoefer, Holly J. Silvers, Bert R. Mandelbaum
26 Patella open reduction and internal fixation, 470
Daniel A. Farwell, Craig Zeman
27 Total knee arthroplasty, 480
Julie Wong, Michael D. Ries
28 Lateral ligament repair of the ankle, 504
Robert Donatelli, Will Hall, Brian E. Prell, Graham Linck,
Richard D. Ferkel
29 Open reduction and internal fixation of the ankle, 520
Graham Linck, Danny Arora, Robert Donatelli, Will Hall, Brian E. Prell,
Richard D. Ferkel
30 Ankle arthroscopy, 536
Tom Burton, Danny Arora, Benjamin Cornell, Lisa Maxey,
Richard D. Ferkel
31 Achilles tendon repair and rehabilitation, 554
Jane Gruber, Eric Giza, James Zachazewski, Bert R. Mandelbaum
32 Bunionectomies, 579
Joshua Gerbert, Neil McKenna
33 Transitioning the jumping athlete back to the
court, 603
Christine Prelaz
34 Transitioning the patient back to running, 616
Steven L. Cole
361
CHAPTER 18
Total Hip Arthroplasty
E
ach year in the United States approximately 250,000 SURGICAL PROCEDURES
people undergo a total hip replacement (THR) proce-
dure1 hoping to eliminate persistent pain and to In its essence, THR consists of two parts. First, the remaining
improve their ability to function in daily life. The majority arthritic bone and articular cartilage is reamed from the
of these people have failed to find relief from their symptoms acetabular cup, and a new metal cup with a polyethylene
with conservative medical intervention. plastic inner liner is press fit into place. Second, the arthritic
femoral head is removed and replaced by a femoral head and
SURGICAL INDICATIONS AND stem component that is secured into the medullary canal of
CONSIDERATIONS the proximal femur (Figs. 18-1 through 18-3).
Several aspects of the procedure greatly affect the course
THR is used to correct intractable damage resulting from of postoperative rehabilitation. First, two approaches are
osteoarthritis, rheumatoid arthritis, avascular necrosis, and commonly used, each with its own risks and advantages.
the abnormal muscle tone caused by cerebral palsy.2 Non- Second, controversy still exists as to whether it is better
elective THR procedures are performed for fractures in to cement or press fit the femoral stem into position.5
which open reduction internal fixation is deemed Noncemented implants tend to be more expensive and
inappropriate. technically demanding to implant; however, they are easier
Contraindications for THR surgery include inadequate to revise when they fail. It is not yet clear which technique
bone mass, inadequate periarticular support, serious medical produces the most durable hip replacement. However, it
risk factors, signs of infection, and lack of patient motivation is generally accepted that noncemented implants are
to observe precautions and follow through with rehabilita- best suited for younger, more active patients and more com-
tion. Surgery also is contraindicated if it is unlikely to plicated revisions.6 Recently, resurfacing arthroplasty has
increase the patients functional level.2 been recommended for young patients with avascular necro-
The prostheses used currently have a projected life span sis, because it preserves bone for later conversion to THR
of less than 20 years. Therefore candidates for THR are if necessary because of implant failure or pain. Many
usually more than 60 years old. Younger patients elect this surgeons believe that noncemented femoral components
surgery when their functional status is severely compro- should not have weight borne on them for 6 weeks, whereas
mised and their pain becomes intolerable. In the case of a cemented femoral components can support weight immedi-
fracture, younger patients are treated with an open reduction ately after surgery. This has been contested recently, and
internal fixation whenever practical. Given the projected life many surgeons now allow patients with noncemented hips
span of current prostheses, younger THR candidates may to bear weight from the outset.7 Both approaches have in
require a revision surgery later in life. common the creation of instability around the hip during
THR predictably improves function and reduces pain in the early postoperative period. The release of muscle, bone,
virtually all patients with disabling disease. Patient satisfac- and joint capsule during accessing of the joint renders
tion (with a rating of very good or excellent) regarding pain the hip vulnerable to dislocation at its extreme ranges of
relief and improvement of function has been measured as motion. Patient education of hip precautions becomes
high as 98% at 2 years after THR. The long-term survivability extremely important during early convalescence and is
rate has been reported as high as 87.3% to 96.5% at 15 alluded to later in this chapter. Controversy remains as
years.2-4 to which approach provides the lowest postoperative
362
Chapter 18 Total Hip Arthroplasty 363
Fig. 18-1 Hybrid cemented total hip arthroplasty. (From Biomet Integral Design, Warsaw, Ind.)
Fig. 18-2 Resurfacing arthroplasty for avascular necrosis. (From Wright Medical Design, Memphis.)
Fig. 18-3 Noncemented modular total hip arthroplasty. (From Biomet Impact Design, Warsaw, Ind.)
dislocation rate, the shortest operative time, and the least today in revision surgery. Its main advantage lies in an
blood loss.8 Because of problems with trochanteric nonunion excellent view of the proximal femoral shaft. The two
and long-term abductor weakness, the original transtro- exposures discussed in the following paragraphs are the
chanteric approach (in which the greater trochanter or the posterolateral approach (Gibson) and the anterolateral
gluteus medius is completely released) is used most often approach (Watson-Jones).
364 PART 4 Lower Extremity
large self-retaining retractor to hold the fascia apart. The

Posterolateral Approach sciatic nerve is then either exposed or palpated to ensure that
The posterolateral approach accesses the hip in the interval it is not being stretched or traumatized (Fig. 18-6). The pos-
between the gluteus maximus and medius. The capsule and terior border of the gluteus medius is identified, as well as
short external rotators are released, and the hip is dislocated the interval between the gluteus minimus and piriformis as
posteriorly. In extremely large or contracted patients, the they pass into the posterior greater trochanter. This interval
surgeon must occasionally release the gluteus maximus and is developed and a retractor is placed around the medius and
even the adductor magnus at their femoral insertions to minimus as they are pulled anteriorly. The remainder of the
translate the proximal femur anteriorly, gaining acetabular posterior structures is released from the posterior femoral
exposure. This exposure places traction on the gluteus neck and intertrochanteric line, including the piriformis,
maximus, medius, and tensor fascia lata. Care must be taken obturator internus, superior and inferior gemelli, and the
not to place traction on the sciatic nerve or the superior superior half of the quadratus femoris (Fig. 18-7). The
gluteal nerve and artery, which may cause nerve palsy. Repair surgeon releases the posterior hip capsule with the short
of the posterior capsule and short external rotators remains external rotators, allowing them to retract together (Fig.
controversial, although several recent reports suggest 18-8). This decreased dissection around the crucial nervous
decreased rates of posterior dislocation and heterotopic bone plane under the inferior border of the piriformis leaves a
formation when this is done. The posterolateral approach is stronger posterior cuff of tissue to repair at the end of the
the authors personal preference for THR, because it pre-
serves the gluteus medius and minimus, as well as the vastus
lateralis, making rehabilitation of these muscle groups easier.
It also provides for a quicker normalization of gait in the
postoperative period, although this is personal surgeon pref-
erence and may be disputed by surgeons who prefer the
anterolateral approach.
The patient is placed in the lateral decubitus position with
the affected hip up; the entire limb is washed, prepared, and
surgically draped. The incision is begun 4 to 5 inches supe-
rior and medial to the top of the greater trochanter (Fig.
18-4). The line of incision runs down to the greater trochan-
ter, then 3 or 4 inches along the course of the posterior femur.
The skin and subcutaneous tissues are incised, and the deep
fascia is exposed and divided in line with the skin incision
(Fig. 18-5). After mobilizing the fascia, the surgeon inserts a
Fig. 18-5 The fascia lata is split in line with the skin incision, and the
gluteus maximus is split proximally. (From Cameron HU: The technique of
total hip arthroplasty, St Louis, 1992, Mosby.)
Fig. 18-4 The incision for a posterior approach is centered over the greater
trochanter, the distal limb being straight and the proximal limb curved Fig. 18-6 The short external rotators are exposed by blunt dissection. The
posteriorly. (From Cameron HU: The technique of total hip arthroplasty, sciatic nerve lies superficial to the external rotators. (From Cameron HU:
St Louis, 1992, Mosby.) The technique of total hip arthroplasty, St Louis, 1992, Mosby.)
rasped in the same manner until good proximal fill of the

femur is obtained. A provisional head is applied, and the
joint is placed back together and ranged to check for stability
and length. At this stage a stable hip should allow 80 to 90
of flexion, 60 to 80 of internal rotation (IR), and 20 to 30
of external rotation (ER) while being held in neutral abduc-
tion. After this the surgeon press fits or cements the implant
in place and begins closure. Many surgeons prefer repair of
the capsule and short external rotators as a single cuff of
tissue held by large No. 2 nonabsorbable sutures through
drill holes in the bone. The gluteus maximus and hip adduc-
tors are repaired if they were released, and the deep fascia is
repaired again with nonabsorbable suture. After closure of
subcutaneous tissue and skin, the patient is placed in a
Fig. 18-7 The short external rotators are divided. When the upper part of triangular-shaped pillow that holds the hip in approximately
the quadratus is released, brisk bleeding usually ensues from the medial 30 of abduction. The pillow straps should not be tightened
circumflex femoral artery. (From Cameron HU: The technique of total hip to the point that they compress the common peroneal nerve.
arthroplasty, St Louis, 1992, Mosby.)
Rehabilitation begins as soon as the patient is coherent.
Ankle pumps, quadriceps sets, and leg lifts help reestablish
the distal venous circulation, minimizing the risk of throm-
boembolic disease and helping with postoperative edema.
Standing, sitting, and walking can be started on the first day
after surgery if hip precautions are followed carefully.
Anterolateral Approach
The anterolateral approach, made popular by Smith-
Peterson,3 provides better visibility without the risk of pos-
terior dislocation associated with the posterolateral approach.
It avoids the need for postoperative abduction pillows and
can allow the patient greater freedom of movement during
the initial postoperative period, because hip precautions
become less crucial. Because of the reported decreased inci-
dence of posterior dislocation, the anterolateral approach is
Fig. 18-8 Retraction now exposes the hip joint capsule. (From Cameron
sometimes preferred in patients who have suffered strokes
HU: The technique of total hip arthroplasty, St Louis, 1992, Mosby.) or those who have cerebral palsy and therefore have a sig-
nificant muscle imbalance or spasticity that induces flexion
and IR of the hip. This approach has been associated with a
procedure. The limb is next measured for its length between greater incidence of heterotopic bone formation, greater
the ilium and greater trochanter, and the hip is posteriorly blood loss, and longer operative times. However, individual
dislocated. A reciprocating saw is used to cut through the surgical expertise seems to have a greater influence on these
femoral neck, and the arthritic femoral head is delivered variables than the exposure chosen.9,10
from the field. The hip annulus is dbrided sharply, and a The anterolateral approach uses the interval between the
minimal anterior capsulotomy is performed to help mobilize gluteus medius and tensor fascia lata. The superior gluteal
the proximal femur. As mentioned previously, the surgeon nerve near the ilium innervates both of these muscles. Injury
must sometimes go back and release the gluteus maximus, to this nerve can result in a partial or complete abductor
adductor longus, and occasionally even the adductor magnus paralysis that can vary from a temporary neurapraxia to
from the proximal femur so that it can be translated anteri- complete and permanent paralysis. In addition, the femoral
orly. A cobra retractor is placed under the femur and over nerve can be injured through overretraction of soft tissues
the front edge of the acetabulum, allowing the femur to be in the front of the hip, leaving significant quadriceps weak-
levered anteriorly out of the way of the acetabulum. The ness. This approach preserves the short external rotators of
acetabulum is then reamed and the acetabular component the hip and prevents direct exposure of the sciatic nerve. The
inserted. tissues violated include the gluteus medius and minimus,
The clinician begins femoral preparation by placing a the tensor fascia lata, the vastus lateralis, the referred head
large retractor under the femur and levering it out of the of the rectus femoris, the anterior hip capsule, and the ilio-
wound. The surgeon then reams the femoral shaft, increasing psoas tendon.
the reamer size by 2mm each pass until good bony contact The patient is placed in the lateral decubitus position with
is made. The intertrochanteric area is then broached or the affected hip up (Fig. 18-9, A); a lateral incision is made
Fig. 18-10 The anterior fibers of the gluteus medius are released from the
greater trochanter. The muscle incision is not extended proximally. (From
Cameron HU: The technique of total hip arthroplasty, St Louis, 1992,
Mosby.)
B
Fig. 18-9 A, The skin incision is roughly C-shaped and centered over the
back of the greater trochanter. B, The fascia lata is divided over the summit
of the greater trochanter. (From Cameron HU: The technique of total hip
arthroplasty, St Louis, 1992, Mosby.)
with a slight anterior curvature in its proximal aspect. After

dividing the subcutaneous tissue, the surgeon incises the Fig. 18-11 An anterior capsulectomy is carried out with a blunt Homan
lateral fascia and finds and develops the interval between the retractor above and below the femoral neck and a medium Homan retractor
gluteus medius and the tensor fascia lata (Figs. 18-9, B, and placed on the pelvic brim. (From Cameron HU: The technique of total hip
18-10). The surgeon must be careful not to extend the inci- arthroplasty, St Louis, 1992, Mosby.)
sion too far proximally, because the investing nerve of both
muscles (the superior gluteal nerve) can be injured, resulting
in paralysis of the tensor. The vastus lateralis origin is often ER and flexion must be avoided postoperatively to prevent
dissected off its vastus ridge origin to access the anterior hip dislocation. Hip range of motion (ROM) precautions remain
capsule fully. The capsule is then bluntly released from the important, especially during the first 6 weeks. Normalization
front of the femoral neck to gain access to the hip joint itself of gait via abductor and quadriceps strengthening remains
(Fig. 18-11). The last deep layer of exposure requires the the focus during early rehabilitation. Pool exercise appears
release of the anterior aspect of the gluteus medius off the to be extremely helpful in this regard.
greater trochanter and the reflection of the rectus femoris off Generally a walker or crutches is required for 3 weeks
the anterior acetabulum (Fig. 18-12). The gluteus release can after THR. A cane is used for an additional 3 weeks before
be done either through the tendon or through trochanteric unassisted walking is allowed. This varies depending on the
osteotomy (although trochanteric osteotomy has fallen out age and preoperative condition of the patient. Driving and a
of favor to some extent because of the incidence of non- return to sedentary activities may be allowed at 3 weeks, and
union). After the gluteus release, the hip can be dislocated some of the hip precautions can be relaxed at 6 weeks.
anteriorly and joint replacement begun much as in the pos- Improvement in strength and ROM can be expected for as
terolateral approach. long as 6 months with a motivated patient.
The preoperative session generally includes an assessment

of the patients strength (including upper-extremity [UE]
potential), ROM, neurologic status, vital signs, endurance,
functional level, and safety awareness. Any existing edema,
contractures, and leg length discrepancies should be noted
at this time, as well as knowledge of the patients scar healing
ability.12 If the assessment takes place in the patients home,
check the stairways, hallways, sidewalks and elevators (or
lack of) and recommend the necessary safety adaptations
(e.g., moving furniture and electrical cords). Evaluate the
need for durable medical equipment such as a shower chair,
walker, or bedside commode.
Instruction in THR precautions should begin during the
preoperative session and be repeated throughout the reha-
bilitation process as necessary. The precautions after a
posterolateral approach to THR prohibit flexion of
the hip past 90, adduction past the bodys midline,
and IR of the hip. After an anterolateral THR, the
patient should observe these precautions and
avoid hip ER (especially with flexion). A review of
Fig. 18-12 The acetabulum is exposed with a medium Homan retractor
proper body mechanics for safe functional mobility at home,
on the pelvic brim, a long sharp Homan retractor inferiorly, and a bent along with appropriate postoperative sleeping and sitting
Homan retractor posteriorly levering down on the stump of the femoral positions should accompany the precautions training. Often
neck. (From Cameron HU: The technique of total hip arthroplasty, St Louis, a patient is able to recite these precautions but will still move
1992, Mosby.) in a dangerous fashion. Ask the patient to demonstrate an
understanding of these precautions with safe transitional
THERAPY GUIDELINES FOR movements and transfer techniques.
REHABILITATION Teach the proper use of assistive devices such as walkers
and crutches according to the patients projected weight-
The following text can be used as guidelines for rehabilitation bearing status. A nonweight-bearing (NWB) order
after a THR. Flexibility on the part of the therapist is essen- may be given if the prosthesis is noncemented.
tial because individual surgeons may impose their own Maintain adherence to both weight-bearing and
protocols. ROM precautions throughout the entire rehabilita-
The therapists role is crucial at the postsurgical stage. tion process.
Santavistas study11 revealed that the majority of THR patients Postoperative exercises can be taught at this time. These
report that they received most of their information regarding exercises may include the following:
their surgical recovery phase from physical therapists. These Ankle pumps (Fig. 18-13)
patients will depend on their therapists for encouragement Quadriceps sets
and advice. A therapist should set the patients expectations Gluteal sets
toward independence and wellness early on. Each client Active hip and knee flexion (heel slides) while main-
should anticipate his or her own unique recovery progres- taining hip ROM within the physicians recommended
sion and avoid comparisons with other patients. guidelines for the surgical technique performed
Isometric hip abduction
Phase I (Preoperative Training Session) Active hip abduction
TIME: a few days before surgery The patient should not perform hip abduction if a tro-
GOALS: To teach THR precautions so that patients will chanteric osteotomy was performed. A dislocation of the
transfer and move safely after surgery and avoid THR prosthesis is possible if inappropriate stresses are
dislocation of the prosthetic joint, to teach a basic placed on the new joint.
exercise program for the postoperative phases of Traditional THR exercise programs have become contro-
recovery versial in recent years. The contact pressure on the hip
joint during specific activities has been measured and
Many institutions have initiated preoperative THR train- compared with pressure on the hip during gait. Although
ing sessions to increase their patients confidence and reduce some practitioners dispute the methodology used, the results
the length of their hospital stays. These sessions may take of these studies have caused many to question the prescrip-
place in the physical therapy department or in the patients tion of some of the standard THR exercises. Consult the
home through a home care agencys physical therapist. Edu- surgeon regarding exercise programs that include straight-
cational videos are now available as an adjunct teaching tool. leg raising.
Strickland found that active hip flexion and isometric hip

extension produced the greatest stresses on the joint. Based
on these findings, Lewis and the consensus group recom-
mend performing gluteal sets at submaximal levels of con-
traction to avoid the possibility of dislocation.
Givens-Heiss and colleagues13 found that a maximal iso-
metric hip abduction contraction generated greater peak
pressure than both the straight leg raise (SLR) and unsup-
ported gait. The Krebs study14 also found that maximal con-
traction during exercise generated greater pressure at the hip
than did gait. Lewis and Knortz15 recommend that isometric
hip abduction be done at submaximal levels based on the
results of these studies and suggests slow, supine hip abduc-
tion as an alternative.
Phase IIa (Hospital Phase)

GOALS: To prevent complications, to increase muscle
contraction and improve control of the involved leg,
to help patient to sit up for 30 minutes, to reinforce
understanding of the THR precautions
Day of Surgery
Postoperative physical therapy (Table 18-1) may begin on the
day of surgery when the patient regains consciousness. The
Fig. 18-13 Ankle pumps. The patient lies supine with both knees straight patient will be resting in the supine position and wearing
and pumps the feet up and down as far as possible.
TABLE 18-1 Total Hip Replacement

Phase IIa Postoperative Pain Adjust abduction pillow Avoid the following: Decrease strap pressure
Postoperative (inpatient) Immobilized ankle straps Peripheral nerve on legs
1-2 days No signs of postoperatively in bed Order foot cradle damage Decrease prolonged,
infection with abduction pillow Provide patient education Heel ulcers unchecked pressure
Medically Limited respiratory regarding total hip Dislocations of against heels
stable exchange precautions prosthesis Prevent excessive stresses
IsometricsQuadriceps Pooling of fluid in on hip
sets, gluteal sets legs Promote distal venous
AROMAnkle pumps Fluid buildup in circulation
Encourage use of cough lungs Initiate muscle
and incentive spirometer Improve volitional contractions
On postoperative day 2, control of involved Prevent respiratory
begin the following: leg complications
Bed mobility training Initiate mobility Reinforce precautions to
Transfer training training avoid complications
Gait training (weight Sit up in chair 30 Prepare patient to
bearing per physicians minutes perform transfers
orders) as appropriate Maintain precautions independently
while performing Use assistive device
mobility activities during ambulation for
safety and protection of
hip
AROM, Active range of motion.

thromboembolic disease (TED) hose with the legs abducted considerable amount of time for this task and emphasize the
and strapped to a triangular foam cushion. To avoid damage use of the UEs when shifting weight. Avoid pivoting on the
to the peripheral nerves, the therapist is expected to check operative leg. Surgeons usually allow a patient to transfer to
the tightness of the cushions around the patients legs. an appropriate bedside chair and sit up as tolerated, rarely
Pulmonary hygiene exercises typically begin immediately more than 30 to 60 minutes. The therapist then super-
after awakening. The patients lower-extremity (LE) exercise vises the return to bed.
program also may be initiated at this point with ankle pumps, If a patient is not complaining of excessive pain, fatigue,
quadriceps sets, and gluteal sets. The heel booties which are or dizziness, then gait training may begin on the first
used to prevent bedsores can be removed for these postoperative day. More frequently, gait training begins on
exercises. day 2.
Since the client may be groggy and unable to remem-
ber the THR precautions at this point, a review is in order. Postoperative Day 2
Some may benefit from a sign placed by the bed that lists Treatment on postoperative day 2 includes a review of the
the ROM precautions. A knee immobilizer placed on the previous days activities. The client must maintain hip ROM
affected leg can reduce the possibility of making dangerous within the physicians recommended guidelines. The physical
movements. therapist expands the exercise program to include heel slides
Repositioning of the patient every 2 hours (with the and isometric or active assistive hip abduction. Short arc
abductor pillow in place) is critical at this stage to avoid quadriceps sets may require active assistance at this time.
pressure ulcers. Foot cradles are often attached to the foot of Again, submaximal force is recommended for isometric hip
the bed to avoid IR of the operated hip and to prevent the abduction. Assistance from the therapist may be necessary
heel sores that may develop as a result of pressure from the for some exercises. The use of verbal cues such as point the
blankets. Many hospitals protocols will assign these func- moving knee or big toe toward the ceiling to avoid rotation
tions to the nursing staff and then begin physical therapy of the leg may also be helpful.
intervention on the first day after surgery. All personnel ren- Gait training usually begins during this session. The
dering care to the patient should monitor changes in the patients assistive device is adjusted to the clients height
limbs vascular and neurologic status closely. before instruction and practice begin. Older patients are
typically issued a front-wheeled walker. Younger patients
Postoperative Day 1 may be issued crutches and instructed in the three-point
Acute care physical therapy sessions vary in frequency from crutch pattern. Patients who have undergone bilateral THR
one to three times per day and from 5 to 7 days per week, are instructed in the four-point crutch pattern.
depending on the medical centers protocol.16 The therapist The weight-bearing status after a noncemented THR is
will proceed after being informed of the surgical approach up to the surgeons discretion. A NWB order on the opera-
used, any special precautions, and the patients weight- tive extremity may be in effect for several weeks. Most
bearing status. Assessment and treatment are conducted at patients with cemented prostheses are instructed to bear
the patients bedside while the patient is situated as described weight as tolerated at this stage.
previously. Complex surgeries may require more caution. When
The THR precautions should be repeated at this time. the postoperative order calls for only touch down weight
These precautions remain in place until the scheduled bearing (TDWB), taping a cracker to the sole of the patients
follow-up visit with the orthopedist 3 to 6 weeks later. The operative forefoot with instruction not to break the cracker
surgeon may then relax the precautions or decide to continue can be helpful in teaching this concept. Stepping onto
them for another 6 weeks. a bathroom scale with the affected extremity helps the
The physical therapist can initiate ankle pumps (see Fig. partialweight-bearing (PWB) patient to determine the
18-13), quadriceps sets, and gluteal sets if the patient did not appropriate amount of pressure (usually 50% of body weight
begin them on the day of surgery. Bilateral UE or less) to be put on that leg. Those who are still experiencing
exercises can also begin at this time. Ankle circles are difficulty can practice weight shifting at the parallel bars
not indicated, because the patient may inadver- before using a walker.
tently internally rotate the affected extremity while Patients who have undergone THR frequently walk with
performing the exercise. As stated previously, sub- the affected leg in abduction. Encourage normalization of
maximal contraction of the muscles is recom- their gait pattern early in the recovery phase. Most facilities
mended. Ideally these exercises should be repeated 10 set a short-term goal for discharge at walking on a level
times every hour.17 Be aware that some patients may not surface for 100 feet with an appropriate assistive device.
meet this expectation.
Transfer training begins by assisting the patient to move Phase IIb
safely from a supine to a sitting position and then from TIME: 3 to 7 days after surgery
sitting to a standing position while observing precautions. GOALS: To promote transfer and gait independence
Frequently patients are struggling with pain and anxiety and (using assistive devices as indicated), to reinforce
need encouragement. The physical therapist should allot a THR precautions, to discharge to home
Postoperative Day 3 (Until Discharge) The patient is able to demonstrate independence on

Patients are often moved from the acute care section to a stairs.
rehabilitation center or skilled nursing facility on day 3 Written instructions with illustrations pertaining to these
(Table 18-2). Some patients (usually those who are younger criteria are included in a discharge packet for home use.
and more fit) may be discharged to home care at this time. Patients are typically discharged between 5 to 10 days after
Treatment at the rehabilitation center is conducted in the surgery. Zavadak and colleagues18 found that independence
physical therapy gym. Stair training generally begins on day in functional activities required the following number of
3. A step-to gait pattern with minimal weight bearing on the physical therapy sessions:
affected leg is taught for ambulation on even surfaces; on Supine to sit: 8.1
steps or stairs, the patient leads up the stairs with the unaf- Sit to stand: 5.5
fected leg and down the stairs with the affected leg. Patients Ambulate to 100 feet: 8.1
should become comfortable climbing the number of stairs Independent on stairs: 9.5
demanded by the home situation. When the patient is not However, the therapists expectations should not be
competent with stair climbing, arrangements are sometimes unduly influenced by statistics. Munin and colleagues19
made for the patient to live on the ground floor. found that fewer than 40% of patients who undergo THR are
Refinement of these skills continues daily at the rehabili- independent in performing all the basic tasks at the time of
tation center until the time of discharge. By the discharge discharge from the rehabilitation center. Approximately 80%
date, family members or other caregivers must be trained to of patients were at the supervision level of performance.
assist the patient safely whenever necessary. Advanced age, solitary living conditions, and an increased
Common discharge criteria for THR are as follows: number of comorbid conditions were the factors that pre-
The patient is able to demonstrate and state the THR dicted the duration of a patients treatment stay.19
precautions.
The patient is able to demonstrate independence with Phase III (Return to Home)
transfers. TIME: 1 to 6 weeks after surgery
The patient is able to demonstrate independence with GOALS: To evaluate the safety of the home, to assure
the exercise program. patient independence with transfers and ambulation,
The patient is able to demonstrate independence with to plan the clients return to work or previous
gait on level surfaces to 100 feet. community activities as appropriate
TABLE 18-2 Total Hip Replacement

Phase IIb Good Limited bed mobility Continue interventions Maintain postoperative Prevent prosthesis dislocation
Postoperative tolerance to Limited transfers from phase IIa with precautions Restore volitional control of
3-7 days phase IIa Limited gait progression of activity Improve involved LE involved LE
No signs of Limited understanding as tolerated AROM within boundaries Prepare arms to assist during
infection of postoperative AROMHeel slides, of precautions transfer and gait
No significant precautions hip abduction (if able; Improve arm strength Emphasize restoration of
increase in otherwise do active Become independent independence with self-care
pain assisted hip abduction), with transfers activities (bed mobility,
Medically terminal knee Become independent transfers)
stable extension, UE exercises with gait using Promote independence with
Gradual Bed mobility training appropriate assistive activities of daily living
improvement Transfer training; initiate device Ambulate safely and decrease
in tolerance car transfers when Promote carryover of stress on the involved LE
to inpatient appropriate precautions at home Ensure patient and caregiver
program Gait training; initiate safety (reinforce precautions)
stair training when and prevent falls
indicated (up with
good, down with bad)
Evaluation of equipment
needs at home
Caregiver training
AROM, Active range of motion; LE, lower extremity; UE, upper extremity.
Home Care Phase pattern if worn after THR surgery. Replace the patients old
Physical therapy home assessment usually occurs within 24 misshapen shoes if possible.
hours after hospital discharge. The elements to be assessed Progression from the use of a front-wheeled walker or
are those listed in the preoperative section, with the addition crutches to a single-point cane usually occurs at 3 to 4 weeks
of the status of the surgical incision. The number of visits after surgery. Occasionally, a four-point cane is used as an
authorized by the patients insurance company may limit the interim device. Use of the cane is usually discontinued 3 to
goals set by the therapist. Medicare coverage at this stage is 4 weeks later. The patient should walk safely on level and
restricted to patients who are homebound or severely limited sloped surfaces, jagged sidewalks, curbs, and stairs before
in their ability to go out. Most patients are no longer home- discharge.
bound after 3 to 4 weeks. Enough strength may have been recovered to allow step-
Because managed care insurance has placed constraints over-step stair climbing during the home phase. At first, the
on the number of nursing visits allowed, physical therapists patient can practice stepping up onto books or other house-
are now being trained to remove staples, traditionally a hold items that provide a stable, shallow rise. A modified
nursing function. Staple removal normally occurs 12 to 14 lunge with the affected extremity placed on the upper step is
days after surgery. another helpful prestair climbing exercise.
After hospital discharge, expect to advise the patient Driving is allowed 3 to 6 weeks after surgery at the ortho-
regarding appropriate sitting and sleeping positions, furni- pedists discretion. Permission may be given sooner, depend-
ture adjustments, and other home safety issues such as slip- ing on the patients lifestyle requirements and rate of progress.
pery rugs or strung-out electrical cords. A home care agency Instruct the patient in getting on and off a bus or in and out
admission assessment includes a review of patient medica- of a car safely. A clean plastic trash bag placed over the seat
tions. Check to see if the patient and/or caregiver have the of a car provides a surface that allows the patient to glide-
appropriate medications in the home and are taking them as pivot around on the seat to assume the riders position more
prescribed. easily.
A postural assessment should be done and contractures
noted should be addressed through a cautious stretching Outpatient Clinic
program. Careful straight leg hamstring stretches done with Physical therapy intervention often ends with the home care
the therapists assistance may be added to the supine exercise phase. Patients with physically demanding lifestyles may
series (not to exceed 90 of hip flexion). The Achilles tendon require additional strength and endurance training. Some
stretch can be done at a kitchen countertop, walker, or at the patients are referred to the clinic because of lingering gait
wall. Closed kinetic chain exercises (with involved leg firmly problems, others because they didnt meet homebound
planted on the ground or on exercise equipment), such as requirements at the time of hospital discharge. The outpa-
heel raises and minisquats, can also be done at the counter- tient therapist should check with the surgeon for the status
top. Open chain exercises done while standing at this loca- of precautions and activity level before designing an aggres-
tion include hip flexion, hip abduction, and hip extension. sive exercise program.
Sidestepping is a functional abduction exercise that stimu- The patient reassessment at this point includes posture,
lates both sets of glutes and engages eccentric hip rotators in balance, strength (both concentric and eccentric at the hips),
stance phase. gait pattern, and core control. A stretching and exercise
Frequently patients will substitute hip flexion for true regime begun in the home or hospital can be expanded upon
abduction. They have difficulty firing the glut medius and in the clinic. Continue to improve posture with trunk and
glut minimus because of chronically flexed posture. Good hip flexor stretching. Normalize the gait pattern with weight
hip extension and good concentric and eccentric control of shifting and hip strengthening exercises. Core strengthening
the hip rotators are needed for a normal gait pattern.20 Lunges, to support good posture should be present in the program.
done standing in a doorway with elevated arms on either side Pool exercise is recommended after THR. Equipment such
of the door frame, can effectively stretch the plantar flexors, as a treadmill, exercise bike, and elliptical cross-trainer can
hip flexors, arms, and trunk while strengthening the opposite be incorporated into a home program so that the patient may
LE quads.20 Stronger, more mobile patients may be able to continue at his or her own gym later on.
assume a prone position to stretch shortened hip flexors. As in home care, the goals at this stage depend on the
Progress the client to wall slides done with the patients number of visits authorized by the patients insurance
back resting against a wall and feet placed about 12 inches company. Quick independence with a home exercise program
in front of the wall. Balance training and a core/trunk should be encouraged.
strengthening program to reinforce good postural habits
may begin now or in the outpatient clinic depending on the After Rehabilitation Intervention
patients level of progress. Exercise equipment already in the The surgeon will determine the patients return-to-work
patients home may be added to the existing program if it can date. Job modification may be needed and some may not be
be used safely. allowed to return to their previous jobs. Heavy manual labor
Shoes often adapt in shape to the stresses imposed by an is not permitted after THR surgery and vocational counsel-
abnormal gait pattern and may encourage a return to the old ing may be necessary.21
High-impact sports such as running, waterskiing, foot- A positive Trendelenburg sign that does not resolve with
ball, basketball, handball, karate, soccer, and racquetball treatment, possibly caused by damage to gluteal
traditionally have been contraindicated after THR.22 The innervation
results of the 2007 Survey23 also list snowboarding and Severe rubor and swelling at the surgical site with
high-impact aerobics as not allowed. Activities allowed accompanying fever, possibly indicating a wound
with experience are downhill skiing, cross-country skiing, infection
weightlifting, ice-skating/rollerblading, and Pilates.23 The Unexplained swelling of the limb that does not dissipate
sports allowed by the 2007 Survey20 respondents are swim- with elevation, possibly indicating TED hose
ming, scuba, golf, walking, speed walking, hiking, stationary General systemic effects, possibly indicating an allergy to
cycling, bowling, road cycling, low-impact aerobics, rowing, the implant materials (rare), postoperative anemia, pul-
dancing (ballroom, jazz, square), weight machines, monary embolus, or other medical complications
stair climber, treadmill, and elliptical.23 Doubles tennis is Persistent, severe pain (even referred medial knee
considered less stressful than singles tennis.14 The survey pain, unexplained limb shortening or extreme rotation,
results were undecided regarding singles tennis and the or pain with rotation of the limb), possibly resulting from
martial arts. dislocation of the prosthesis, heterotopic ossification, or
Patient compliance with home exercise programs is often a fracture of the adjacent bone or reflex sympathetic
questionable after the first few weeks and especially after dystrophy
discharge from therapy services. No agreement seems to Many times the therapist is the first to see a developing
exist among surgeons as to how long exercise programs complication; therefore, good communication with the
should be continued. The surgeon may release the patient surgeon is extremely important. Leg length discrepancy is an
from the home exercise program at his or her discretion. example. The patient can continue gait training with a tem-
Sheh and colleagues24 state that flexion showed the slowest porary shoe insert or with shoes of different heel heights. The
rate of recovery in diseased hips. Persistence of weakness was surgeon may later prescribe a permanent orthotic. Persistent
noted in all patients for at least 2 years after hip surgery edema may be treated with medication. Patients should be
despite the return of normal stride and phasic activity of advised to elevate their legs, rest more often, wear TED hose,
muscles. Gluteus maximus or minimus weakness can result pump their ankles, and apply ice to swollen areas. Pain flare-
in aching near the hip during endurance activities. Sheh ups in unaffected areas of the body are usually managed with
states that muscular weakness reduces the protection of the medication. Possible side effects of the medication include
implant fixation surfaces during endurance activities. This nausea, constipation, and hypertension. The therapist can
may contribute to higher loosening rates reported in active assist in pain reduction with modalities, exercises, and posi-
patients.24 Therefore, therapists should encourage long-term tioning. Significant abnormalities should always be reported
continuation of exercise programs when this does not con- to the surgeon.
tradict the surgeons orders.
CONCLUSION
TROUBLESHOOTING
A rapid, substantial improvement in quality of life can be
The THR procedure has been refined so that patient progress expected after THR surgery. Better physical function, sleep,
is now fairly certain and predictable. However, most compli- emotional behavior, social interaction, and recreation are
cations call for a referral back to the surgeon. Examples usually experienced in the first few months. At 2 years after
include the following: surgery, patients who had undergone THR have reported
Thigh pain with walking that clears quickly with sitting greater satisfaction with their results than they had predicted
down, possibly indicating intermittent claudication in their best preoperative hypothetical scenarios.25

Days 1 to 2 (in Hospital) Days 3 to 7 (in Hospital)
GOALS FOR THE PERIOD: Protect healing tissues, GOALS FOR THE PERIOD: Improve lower-extremity
prevent postoperative complications, improve (LE) and upper-extremity (UE) strength
volitional control of involved lower extremity (LE) AROM Exercises
Isometric Exercises 1. Heel slides
1. Gluteal sets 2. Hip abduction
2. Quadriceps sets 3. Terminal knee extension
Active Range of Motion (AROM) Exercises Resistive Exercises
3. Ankle pumps 4. Resisted shoulder IR and ER with Theraband
5. Shoulder depressions and triceps dips while 1. Closed-chain exercises (progression to gym
seated equipment and inclined sled): step-ups,
minisquats, heel raises, SLRs, and hip abduction
Weeks 1 to 6 (after Discharge to Home 2. Pool therapy
Setting or as Appropriate in Interim 3. Treadmill (as part of gym program)
Setting) 4. Heel cord stretches
GOALS FOR THE PERIOD: Improve strength and
balance of LEs, promote return to activities and
hobbies as indicated
1 Anita had a minimally invasive THR. How will the reha-

bilitation process change because her procedure was less
invasive?
higher loosening rates reported in active patients. There-
fore Tracy and other active patients should continue on
a long-term exercise program to maintain good muscu-
lar strength around the hip.
Pain and swelling will be less because the trauma to soft
tissue is less. The procedure is performed using a smaller
opening. This may allow the patient to progress with bed
mobility and transfers more quickly and with greater
4 Karen is a 75-year-old female who had a THR 3 weeks
ago. She is receiving physical therapy at home and has
had two treatments. Today is her third treatment. Her
ease and comfort. The surgeon will determine weight- main complaint is the swelling in her foot. Her last treat-
bearing status and rehabilitation progression. However, ments emphasized mobility training. She lives with her
the hip precautions remain and the rehabilitation is daughter. She demonstrates stand by assist for most
usually similar (because the procedure is similar but per- transfers; however, she requires minimal assistance for
formed with a smaller opening and in a smaller area). her affected LE when getting in and out of bed. What
New materials such as metal-on-metal implants or should be addressed during todays treatment?
ceramic implants are starting to be used. It is hoped that
these prosthetic hips will have a longer life span. The patient was sitting upon arrival of the therapist.
Physical therapy performed transfer training back to bed.
2 Sabrina had a noncemented THR surgery 3 days ago.

She is TDWB with a walker but continues to place a
moderate amount of weight on her affected LE. Because
When the patient was supine, the therapist massaged
her foot and lower leg, milking the fluid up toward the
heart. The therapist followed up with AROM for SLR with
she has difficulty maintaining TDWB during gait, what eccentric lowering of the LE using minimal assistance for
can be done to help her? guidance. In addition, active assistive hip abduction and
adduction (before reaching midline and within the area
A cracker can be taped to the sole of the patients fore- of hip precautions) were done. Heel cord stretching was
foot. If the patient still has difficulty maintaining TDWB, also addressed. A discussion regarding using a TED hose
then she should try using a thick-soled shoe only on the and maintaining LE elevation while sitting and in bed
affected leg. If the patient is PWB, say 50%, then a scale followed. In addition, the therapist encouraged the
can be used to give feedback regarding how it feels to patient to do ankle pumps every hour throughout the
bear 50% of the weight on the LE. day.
3 Before having severe hip pain, Tracy was biking 20 to 30

miles a day, 4 days a week. She also competed in bicycle
races and worked out in the gym with light weights
5 Why is it not enough to quiz the patient about THR
precautions?
three times a week. Should Tracy participate in a long- Frequently, patients are able to recite the precautions
term exercise program after having a THR if it does not correctly but they do not demonstrate their understand-
contradict the surgeons orders? Why? ing of them through safe movement. They may still turn
their bodies in a way that creates relative IR at the hip
Sheh and associates26 state that muscular weakness or flex their hips to greater than 90 while sitting down
reduces the protection of the implant fixation surfaces or standing up. Sitting surfaces often need to be raised
during endurance activities. This may contribute to up to be used safely. Many patients with NWB orders
will put their foot on the ground while turning. Explain since other causes of infection may be due to dental
the difference between NWB and TDWB to the client as work or other medical procedures unrelated to the THR.
many times as necessary to change this behavior. Refer the patient back to the surgeon for further
evaluation.
6 Following her THR operation, Mary is concerned that

her surgical cement may not adhere at the joint and asks
if this will cause a dislocation of her prosthesis. 9 Robert is having difficulty with transferring into and out
of his car safely. What adjustments can help him?
The THR surgery disrupts the integrity of the hips joint A clean plastic trash bag placed over the passengers
capsule. Movement beyond the limitations of the THR seat provides a slippery surface, which allows the patient
precautions places too much strain on the compromised to glide-pivot around on the passengers seat and assume
joint capsule. This is the most frequent cause of postsur- the riders position more easily. If the height of the seat
gical dislocation. Surgical cement is dry and at its full is adjustable, then raise the seat to the highest possible
strength within 10 minutes of its application and is not position. The back of the seat may need to be tilted back-
a factor in dislocation although many patients worry ward to maintain the precaution of less than 90 flexion
about it. Knowledge of this can motivate the patient to at the hip.
adhere to his or her precautions and to the strengthening
program.
10 John was running 3 to 5 miles a day before hip pain
necessitated a THR surgery. Should he resume
7 Why should the surgeon be consulted about the pre-

scription of SLR exercises?
running at the end of his rehab phase?
Running is not recommended following a THR surgery.

Enloes consensus group16 eliminated the SLR from their Alternatives for John could include speed walking,
ideal THR rehabilitation plan, because Strickland and the treadmill, stair climber, and the elliptical cross-
colleagues27 found that it created greater stresses than trainer. John should be set up with a stretching program
the amount incurred at the hip during normal unsup- that will allow him to pursue his activities showing
ported gait. Lewis and Knortz15 found that SLRs should good posture. This could help to avoid the uneven
be initiated when the patient has regained partial or full wear and tear on joints that can encourage further
weight bearing in the operative leg. Gilbert believes that deterioration.
SLRs are unnecessary and may cause dislocation; he
warns therapists against using them.28
11 What advice can be given when the patient asks
about sexual activity following a THR?
8 Upon the physical therapists arrival at the patients

home, the patients operative limb is found to be
ruborous, warm, severely swollen, and very painful in
Sexual activity after an uncomplicated THR
may resume in approximately 1 to 2 months
spite of elevation and the use of ice. What needs to be with the surgeons approval. Studies have
done? shown that most patients feel uncomfortable
asking for this type of information. Women
Be sure that the patient was discharged with the appro- tend to prefer the supine position or side lying
priate number of enoxaparin syringes and has followed on the nonoperated side. Men prefer the
through with these injections as prescribed. The patient supine position. The patient is advised to take
may have a clot in his leg. Check the status of the surgical the more passive role and the prone position
scar. There is the possibility of an infection. Make sure may be resumed in 2 to 3 months after
that the patient has taken any antibiotics prescribed surgery.9
5. Mulroy RD Jr, Harris WH: The effect of improved cementing techniques

REFERENCES on component loosening in total hip replacement: An 11-year radio-
1. Buckley R, MD: Total joint replacement: What you really need to know, graphic review. J Bone Joint Surg 72B:757, 1990.
John Muir MC Orthopedic Update presentation 2008. 6. American Academy of Orthopaedic Surgeons: Orthopedic knowledge
2. Hicks JE, Gerber LH: Rehabilitation of the patient with arthritis and update 3, Rosemont, Ill, 1987, the Academy.
connective tissue disease. In DeLisa JA, editor: Rehabilitation medicine: 7. Whitesides L: Personal communication (Total Hip Conference).
Principles and practices, Philadelphia, 1988, Lippincott. St Louis, 1993.
3. Smith-Peterson MN: A new supra acetabular subperiosteal approach to 8. American Academy of Orthopaedic Surgeons: Orthopedic knowledge
the hip. Am J Orthop Surg 15:592, 1917. update 4: home study syllabus, Rosemont, Ill, 1992, the Academy.
4. Stern FH, et al: Sexual function after total hip arthroplasty. Clin Orthop 9. Roberts JM, et al: A comparison of the posterolateral and anterolateral
269:228, 1991. approaches to total hip arthroplasty. Clin Orthop 187:205, 1984.
10. Vicar AJ, Coleman CR: A comparison of the anterolateral, transtrochan- 20. OHalloran J: Are you boomer readyJoint replacement rehabilitation,
teric, and posterior surgical approaches in primary total hip arthro- Birlingame, Calif, 2010, Cross Country Education.
plasty. Clin Orthop 188:152, 1994. 21. McGrorey BJ, Stewart MJ, Sim FH: Participation in sports after hip and
11. Santavista N, et al: Teaching of patients undergoing total hip replace- knee arthroplasty: a review of the literature and survey of surgical pref-
ment surgery. Int J Nurs Stud 31(2):135, 1994. erences. Mayo Clin Proc 70B:202, 1995.
12. Petty W: Total joint replacement, Philadelphia, 1991, Saunders. 22. Engh CA, Glassman AH, Suthers KE: The case for porous-coated hip
13. Givens-Heiss DL, et al: In vivo acetabular contact pressures during implants: the femoral side. Clin Orthop 261:63, 1990.
rehabilitation. II. Postacute phase. Phys Ther 72(10):700, 1992.
23. Klein G, et al: Return to athletic activity after total hip arthroplasty:
14. Krebs D, et al: Exercise and gait effects on in vivo hip contact pressures. Consensus guidelines based on a survey of the Hip Society and Ameri-
Phys Ther 71(4):301, 1991. can Association of Hip and Knee Surgeons. J Arthroplasty 22(2) 171-
15. Lewis C, Knortz K: Total hip replacements. Phys Ther Forum May 20, 1994. 175, 2007.
16. Enloe LJ, et al: Total hip and knee replacement programs: A report using
24. Sheh C, et al: Muscle recovery and the hip joint after total hip replace-
consensus. J Orthop Sports Phys Ther 23(1):3, 1996.
ment. Clin Orthop 302:115, 1994.
17. Jan MH, et al: Effects of a home program on strength, walking speed,
25. Kavanagh BF, et al: Charnley total hip arthroplasty with cement: Fifteen
and function after total hip replacement. Arch Phys Med Rehabil
year results. J Bone Joint Surg 71A:1496, 1989.
85(12):1943-1951, 2004.
18. Zavadak KH, et al: Variability in attainment of functional milestones 26. Munin M, et al: Rehabilitation. In Callaghan J, Rosenberg A, Rubash H,
during the acute care admission after total hip replacement. J Rheumatol editors: The adult hip, Philadelphia, 1998, Lippincott-Raven.
22:482, 1995. 27. Strickland EM, et al: In vivo acetabular contact pressures during reha-
19. Munin MC, et al: Predicting discharge outcome after elective hip and bilitation. I. Acute phase. Phys Ther 72(10):691, 1992.
knee arthroplasty. Am J Phys Med Rehabil 74:294, 1995. 28. Gilbert R: Personal communication. June 10, 1998.
CHAPTER 19
New Approaches in Total Hip Replacement:
The Anterior Approach for Miniinvasive
Total Hip Arthroplasty
tensor in a posterior and proximal direction. Dissection by

SURGICAL TECHNIQUE feel is most efficient at this point, and the lateral hip capsule
can be easily palpated just distal to the anteroinferior iliac
After administration of general or regional anesthesia, both spine. A cobra retractor should be placed along the lateral
feet are placed in the boots. The patient is placed in the hip capsule to retract the tensor and gluteus minimus later-
supine position on the PROfx or HANA table, a perineal post ally, and the sartorius and rectus femoris muscles should be
is placed, and the boots are attached to the table (Fig. 19-1). retracted medially with a Hibbs retractor. The reflected head
The hip that will not be operated on is placed in neutral or of the rectus that follows the lateral acetabular rim will be
mild internal rotation (to maximize offset), neutral exten- visible. A small periosteal elevator placed just distal to the
sion, and slight abduction and will serve as a radiographic reflected head and directed medial and distal elevates the
reference for the operated side. Avoiding external rotation iliopsoas and rectus femoris muscles from the anterior
(ER) of the hip to be operated on will make the external capsule. The elevator opens the path for a second cobra
landmarks of the hip more reliable and enhance the land- retractor placed on the medial hip capsule. Using this tech-
mark of the natural bulge of the tensor fascia lata muscle. nique, a view of 180 of the circumference of the hip capsule
The typical team consists of the surgeon, an assistant, an is obtained within a few minutes (Fig. 19-3).
anesthesiologist, a scrub nurse, a circulating nurse table The medial and lateral retraction of the cobras brings the
operator, and a radiograph technician. Although the incision lateral femoral circumflex vessels into view as they cross the
is normally small (8 to 10cm), the author prefers to drape a distal portion of the wound. These vessels are clamped, cau-
relatively wide area. The normal incision starts 2 to 3cm terized, and transected. Further distal splitting of the apo-
posterior and 1 to 2cm distal to the anterosuperior iliac neurosis that overlies the anterior capsule and vastus lateralis
spine. This straight incision extends in a distal and slightly muscle (and at times excision of a fat pad) enhances expo-
posterior direction to a point 1 to 3cm anterior to the greater sure of the capsule and the origin of the vastus lateralis. The
trochanter. On thinner people the bulge of the tensor fascia anterior capsule may be either excised or opened as flaps and
lata muscle marks the center of the line of the incision. After repaired as part of the closure. (The author prefers to retain
incision of the skin and subcutaneous tissue, the tensor can the capsule in most cases.) The surgeon should open the
be seen through the translucent fascia lata. The author places capsule with an incision that parallels the anterolateral
a vinyl circumferential skin retractor (Protractor) under- femoral neck. The proximal portion of this incision crosses
mining slightly the fat layer off the underlying fascia. The the anterior rim of the acetabulum and the reflected capsular
fascial lata should be incised in line with the skin incision origin of the rectus femoris. The distal portion exposes the
over the tensor where the fascia lata is translucent and ante- lateral shoulder of the femoral neck at its junction with the
rior to the denser tissue of the iliotibial tract. The fascial anterior greater trochanter. The junction of the capsule and
incision should be continued slightly distal and proximal the origin of the vastus lateralis muscle identify the intertro-
beyond the ends of the skin incision (Fig. 19-2). chanteric line. The distal anterior capsule should be detached
The surgeon should lift the fascia lata off the medial from the femur at the anterior intertrochanteric line and
portion of the tensor and follow the interval medial to the suture tags placed on the anterior and lateral capsule at the
376
Chapter 19 New Approaches in Total Hip Replacement: The Anterior Approach for Miniinvasive Total Hip Arthroplasty 377
Fig. 19-1 Patient positioned supine on PROfx table.
ASIS
Greater
trochanter
Fig. 19-2 Eight-centimeter incision.
Fig. 19-4 Ninety-degree external rotation allows femoral head dislocation

Neck exposed for further exposure.
a more medial position. The traction is partially released. The

patients hip should be externally rotated about 20, and a
femoral head corkscrew should be inserted into the head in
a vertical direction. As the extremity and hip are externally
rotated and leverage is applied to the skid and corkscrew, the
hip should be dislocated anteriorly and the femur externally
rotated 90 (Fig. 19-4).
After dislocation, the surgeon should place the tip of a
narrow Hohmann retractor distal to the lesser trochanter
and beneath the vastus lateralis origin. The capsule should
be detached from the medial neck and the lesser trochanter,
Fig. 19-3 Incision of anterolateral capsule.
and the medial posterior neck exposed. The patients hip is
then internally rotated and reduced, the cobra retractors are
distal portion of the incision that separates them. The cobra replaced around the medial and lateral neck, and the vastus
retractors should be placed intracapsular medial and lateral origin and distal tensor are retracted with a Hibbs. The
to the neck. Exposure of the base of the neck is facilitated by surgeon cuts the femoral neck with a reciprocating saw at the
a Hibbs retractor that retracts the vastus and distal tensor. desired level and angle as indicated by the preoperative plan
A narrow Hohmann retractor is now placed on the (Fig. 19-5). The neck cut is completed with an osteotome that
anterolateral acetabular rim. With this exposure, the antero- divides the lateral neck from the medial greater trochanter
lateral labrum (and often associated osteophytes) is excised. and is directed posterior and slightly medial to avoid the
Distal traction on the extremity will create a small gap posterior greater trochanter. The head is extracted with the
between the femoral head and the roof of the acetabulum. A corkscrew. Light traction will distract the neck osteotomy
femoral head skid is placed into this gap and then placed in and facilitate this extraction.
Posterior cortex
Greater trochanter
Hook behind femur
Fig. 19-5 Lateral neck cut finalized with osteotome. Head removed. Fig. 19-7 Hip hyperextended and adduction with external rotation allows
delivery of proximal femur for femoral broaching.
and adequate circumference. The indicators of torque and

acetabular appearance are also used. The author then inserts
the acetabular prosthesis. Most experienced surgeons can
easily recognize a properly positioned cup on a radiograph
(40 to 45 abduction and 15 to 25 anteversion), and good
position can be achieved consistently with the image tech-
nique. The liner is inserted in the normal fashion (prior
excision of labrum and the inferior capsule release will
facilitate this). An osteotome or rongeur should be used to
excise projecting osteophytes. The radiograph is the final
judge as to whether computer guidance led to the correct
result.
After acetabular insertion, the gross traction control on
the leg spar is released and the femur is internally rotated to
Fig. 19-6 Excellent acetabular exposure is achieved. neutral. The vastus ridge is palpated, and the femoral hook
placed just distal to this and around the posterior femur. The
femur is then externally rotated 90 and the hip hyperex-
Throughout the procedure the surgeon will find that the tended and adducted.
tensor fascia lata muscle is potentially vulnerable to injury. For proximal femoral exposure, the author uses a long-
If an initial injury to the muscle fibers is avoided, then the handled cobra with the tip on the posterior femoral neck and
muscle seems to hold up well through the procedure. On the places the tip of a trochanteric retractor over the tip of the
other hand, an early laceration to the surface of the tensor trochanter. The femoral hook now raises the proximal femur
seems to hurt its capability of resisting further damage. until the tissues come under moderate tension.
The acetabulum is now visualized and prepared. ER of the After this initial maneuver, the posterior ridge of the
femur of about 45 usually facilitates acetabular exposure greater trochanter may lie posterior to the posterior rim of
(Fig. 19-6). Light traction also limits femoral interference. the acetabulum. The femur needs to be mobile enough so
The author prefers to use a bent Hohmann retractor above that lateral and anterior displacement brings the posterior
the distal anterior rim of the acetabulum to retract the ante- edge of the trochanter lateral and anterior to the posterior
rior muscles. The surgeon should take care to place the tip rim of the acetabulum. The lateral capsular flap and its tag
of this retractor on bone and not into the anterior soft tissues. suture will be clearly visible distal to the trochanteric retrac-
The author places a cobra retractor with the tip on the mid tor and attaching to the remnant of the lateral neck. Detach-
posterior rim. The labrum is then excised circumferentially. ment of this flap from the base of the neck in an anterior
A transverse release of a prominent band of inferior capsule to posterior direction facilitates visualization of the medial
will facilitate later placement of the acetabular liner. The greater trochanter and enhances femoral mobility (Fig.
author usually begins reaming under direct vision and later 19-7). The surgeon should use a rongeur to excise the
checks with the image intensifier to confirm depth of reaming remnant of the lateral neck.
Fig. 19-8 Broach insertion easily accomplished through anterior incision.
It should be remembered that the obturator internus and

piriformis tendons insert on the anterior superior greater
trochanter. After release of the lateral capsule, the surgeon
should place the tip of the trochanteric retractor closer to the
upper border of the trochanter to retract the gluteus minimus
muscle and piriformis, and obturator internus tendons.
Depending on the requirements for femoral mobility, the
surgeon may choose to release one or more of the short
external rotator tendons and the obturator internus tendon,
particularly when it cannot be flipped over the posterior tip
of the trochanter. However, the author prefers to preserve all
tendon attachments and strives in particular to preserve the
attachment of the obturator externus tendon, because its
medial pull on the proximal femur is an important active Fig. 19-9 Broaching easily accomplished through anterior incision.
restraint against dislocation.
In general, prostheses with less prominence in the proxi- length and offset and serves as the immediate postoperative
mal lateral area will be easier to insert, will allow preserva- radiograph. Before discharge, radiographs are obtained in
tion of the rotator attachments, and will present a lower the radiology department (Fig. 19-11).
risk of trochanteric fracture. However, the instrumentation A check is made for bleeding and the wound is irrigated.
required most determines the applicability of a stem to the The closure is simple. The anterior and lateral capsular tag
anterior approach. The tip of the first broach enters the neck sutures are tied together, and further capsular closure is per-
near the posterior medial cortex (Fig. 19-8). When the formed if desired. The fascia lata is closed with a running
broaching is complete, a trial reduction is made, with the suture, followed by subcutaneous tissue and skin.
neck length estimated from the preoperative template. After surgery the patient does not follow antidislocation
During trial phase I, the surgeon should check for hip precautions. The patient is encouraged to weight bear imme-
stability in extension and ER with the traction released. The diately, use the hip, and discard external support as symp-
surgeon should also check for impingement with osteophytes toms permit.
and excise appropriately. The author of this chapter feels that From November 1996 to April 2005, the author of this
it is best to rely on the radiograph for length and offset deci- chapter performed 657 primary anterior total hip arthroplas-
sions rather than soft tissue tension and intraoperative ties (THAs), including 67 bilateral THAs. This series of 657
stability. anterior approaches is unselected and consecutive. The sur-
After the decision is made for the femoral prosthesis, the geries were performed on a Judet or Tasserit table until 2003.
femoral hook is replaced behind the proximal femur, trac- Beginning in 2003 the PROfx table became available and is
tion is applied to distract the head, and the hip is dislocated now preferred. The average patient age is 66 and ranges from
with ER. The femur is then placed into the preparation posi- 29 to 91. The average operative time is 1.2 hours. Average
tion (i.e., 90 ER, hyperextension, adduction, proximal eleva- blood loss is 345mL. The median hospital time is 4 days, and
tion). The femoral prosthesis is then inserted in the normal the mode is 3 days. Two early anterior dislocations and one
fashion. The appropriate-length permanent head can be posterior dislocation occurred that were reduced closed and
placed at this time (Figs. 19-9 and 19-10). With the hip flexed did not recur or require revision. The median time to doing
to neutral, the acetabulum is visualized before reduction to some ambulation without external support is 8 days. The
ensure that it is clear of bone or cement fragments. Another median time for doing all ambulation without external
transparency printed with the image intensifier confirms leg support is 15 days. It is the authors impression that pain is
Fig. 19-10 Delta ceramic head placed and reduced.
In the hospital bed, mobility, transfer training, and gait

training are done during the initial treatments. The patient
is instructed in ankle pumps. Isometrics such as hip abduc-
tion, hip adduction, quadriceps sets, and gluteus sets can also
be started immediately. In addition, heel slides are encour-
aged with assistance, then without any assistance. The patient
then progresses to active range of motion for hip abduction,
adduction, and straight leg raises. Patients can be taught
pelvic tilts and knee to chest (using the unaffected lower
extremity) for low back discomfort. Heel cord stretches can
be done carefully with the leg slightly back and a wedge
under the forefoot. Closed-chain exercises like minisquats,
step-ups, and heel raises are begun when the patient can
safely perform them.
Fig. 19-11 Intraoperative imaging ensures length and cup position.
GENERAL COMMENTS REGARDING
HIP REPLACEMENT
reduced and the recovery rate greatly enhanced. (See the The first very successful hip prosthesis was designed and
THA slide show at www.hipandpelvis.com for more detailed implanted in the 1960s by John Charnley of England. Charn-
statistics.1) leys design used a one-piece metal stem with a 22-mm diam-
eter head that was cemented into the proximal femur. The
REHABILITATION AFTER ANTERIOR TOTAL acetabular component was made entirely of polyethylene
HIP ARTHROPLASTY and cemented into the acetabulum. Follow-up studies of the
Charnley prosthesis and other similar cemented designs
With this procedure tendon attachments, such as the obtura- have shown sufficient longevity that the majority of prosthe-
tor externus, rotator attachments, and gluteus medius, have ses in surviving patients are still functioning 20 years after
been preserved. In fact, all the muscle attachments are pre- implantation. Despite the great success of these hip prosthe-
served. The obturator externus has a medial pull on the ses, it is recognized that the failure rate increases over time.
proximal femur and is an important active contractor against The mode of failure is typically loosening of the secure bond
hip dislocation. With the preservation of these muscle between the prosthesis and the bone and bone loss associ-
attachments and other soft tissues, total hip precautions ated with this process.
are not required. Pain is reduced and the recovery rate is Because of the recognized limits to longevity of these
enhanced. Weight bearing is immediately encouraged, and early designs, continued work to improve the design has
assistive devices are discarded when possible. been conducted, and thereby longevity of hip prostheses has
The rehabilitation process is similar to most total hip been achieved. Currently the U.S. Food and Drug Adminis-
replacement regimens. However, the patient will progress tration (the federal agency regulating hip prostheses) has
through the process more quickly and with a lower risk of over 750 approved designs for hip prostheses on file. The
hip dislocation. majority of new designs, however, have proven to be not as
good as Charnleys hip. In addition, some new designs have which means that this surface wears at a slower rate. Although
been shown to equal the longevity of the Charnley hip but metal against extremely high-density polyethylene is the
have not proven superior to it. best-proven bearing, evidence also supports the use of metal-
What is the significance of this history for todays hip on-metal and ceramic bearings.
replacement patient? Just because a hip prosthesis is the Today, development of hip replacement surgery is not
latest design does not mean it is better; in fact, it could be limited to efforts to improve the prostheses. Improvements
worse. Time gives us the answers. We need to continue to also include surgical approaches that limit the surgical
look for prostheses with improved longevity; however, a trauma to the soft tissue, thereby accelerating recovery and
quantum improvement may not be just around the corner, limiting the possibility of dislocation. The author applauds
and the current expected longevity may be with us for some this trend because it is the basis of the anterior approach for
time to come. hip replacement described herein.
What has changed? The acetabulum is now almost always Possible complications of hip replacement surgery include
implanted without cement. The results of the uncemented infection, injury to nerves and blood vessels, fracture of
acetabulum appear equal to cement, and clinicians hope that the femur or acetabulum, hip dislocation, and need for
the longevity will prove better over time. Some designs of revision surgery. Patients should remember that recovery
uncemented femoral stems have also shown good longevity means not only recovery from the surgical procedure but
comparable with the best-proven cemented stems. It is also time to recover from the condition they were in before
widely felt that the bearing surfaces have been improved, surgery.
REFERENCE Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for

1. Matta JM, Klenck RE, Hipandpelvis.com: Available at: http:// total hip arthroplasty on an orthopaedic table. Clin Orthop Rel Res
www.hipandpelvis.com/. 441:115, 2005.
Yerasimides JG, Matta JM: Primary total hip arthroplasty with a
FURTHER READING minimally invasive anterior approach. Semin Arthroplasty 16(3):186,
Matta JM, Ferguson TA: The anterior approach for hip replacement. 2005.
Orthopedics 28(9):927, 2005.
CHAPTER 20
Hip Arthroscopy
Jonathan E. Fow
ETIOLOGY and other causes of intraarticular or extraarticular hip pain

must be confirmed while other possible sources of pain are
Arthroscopy of the hip has been performed for many years, ruled out. At the very least, patients should be aware of the
but has become more mainstream over the last few years. risk that hip pain can be, and often is, multifactorial. Arthros-
Initially, it was used as a minimally invasive method of copy of the hip may only be able to address a percentage of
removing loose bodies. As we have learned more about vari- the pain they experience.
ations in hip morphology, both congenital and acquired, the
useful applications of hip arthroscopy have grown. Overall, INDICATIONS/CONSIDERATIONS
hip arthroscopy can improve pain and function in 68% to
96% of surgical patients1 (Fig. 20-1). Patients who are seen in the office with hip pain are initially
examined, their history reviewed, and radiographs taken.
ANATOMY History of the patients hip pain may include chronic psoas
strains, lumbar spine, and sacroiliac joint dysfunction. Tran-
Femoral acetabular impingement (FAI) is a cause of hip pain sitioning to a higher or different level of activity (e.g., high
and debility. An anomalous, aspherical femoral head or school to college track) may precipitate hip pathology, as well
anterosuperior bump on the femoral head and neck are as previous involvement and previous injuries in sports. FAI
features of controlled action motion (CAM) impingement can also become symptomatic with changes in equipment,
(Fig. 20-2). An anterosuperior acetabular lip or retroverted which affect body position such as shoes and bicycles.
acetabulum causes pincer impingement (Fig. 20-3). There is Hip pathology is often described by a patient as groin or
often a mixed morphology involving attributes of both CAM gluteal pain. Because hip pain can also radiate to the thigh
and pincer impingement. Femoral osteoplasty to reshape the and knee, patients may have had inappropriate knee
femoral head and neck can treat CAM impingement, whereas arthroscopy.
acetabular osteoplasty can reshape the acetabular rim to PHYSICAL EXAMINATION: Examining the lumbar
improve pincer impingement.2 Both osteoplasty procedures spine, hip, and knee and observing posture and gait are very
result in improved range of motion (ROM) and function. important in evaluating a patient with hip pain. Consider
Hip arthroscopy can address labral tears by both dbride- pursuing evaluation in functional positions, especially
ment and repair. Surgeons may perform microfracture or during sporting activities (e.g., running, pushing, jumping,
abrasion chondroplasty on the acetabulum also to dbride skating, lunging). Observe the relationship of the pelvis to
cartilage lesions, and extraarticular pathology, such as the lower extremities, then examine the extremities. Examine
gluteus medius tears, chronic iliotibial (IT) band snapping the patient walking, standing, supine, lateral, and prone.
syndrome, and snapping psoas syndrome, can also be Standing:
addressed endoscopically. Gait: Observe stride length, foot progression angle, pelvis
The complex mechanical interrelationships of the lumbar rotation, stance phase, foot drop, clicking, popping, antalgic
spine, hip, and lower extremity can functionally cause FAI gait, Trendelenburg gait, pelvic wink (external rotation >40),
despite near normal architecture. There can be functional short leg limp (IT band pathology, true/false leg length
impingement caused by hyperlordosis or the type of stress discrepancy).
or activity imposed on the joint. In addition, often there Patient recreation of click: Psoas or IT band.
exists multiple sources of pain such as degenerated discs, Alignment: Note shoulder height, scoliosis, pelvic tilt;
sacroiliac disorders, hip bursitis and IT band syndrome, hip grossly measure anterosuperior iliac spine (ASIS) to medial
flexor strains, and hernias. Diagnosis of FAI, loose bodies, malleolus; note spinal alignment posterior and lateral (flat
382
Chapter 20 Hip Arthroscopy 383
Fig. 20-3 Computed tomographic 3-D reconstruction of the pelvis helps

Fig. 20-1 Arthroscopy of the hip uses small incisions to address an gain appreciation for acetabular pathology, such as pincer lesions, retrover-
increasing range of pathology via small incisions. sion, and os acetabuli.
Supine:
ROM: External rotation, internal rotation in hip neutral
and 90 of hip flexion, popliteal angle, supine abduction, frog
leg abduction (knee height), adduction.
Palpate: Inguinal region, pubis, ASIS, anteroinferior iliac
spine (AIIS), Stinchfield test (straight leg raise versus resis-
tance causing pain indicates iliopsoas and/or intraarticular
pathology), inferior to AIIS (labrum, anterior capsule, rectus
reflected). Note: Nondisplaced or stress fracture will also
hurt with straight leg raise, heel strike, and log roll.
Provocative: FADIR (flexion, adduction, internal rota-
tion) indicates FAI and labral pathology, FABER (flexion,
abduction, external rotation) or Patrick test for groin, ilio-
psoas, lateral FAI, lateral-FAI flexion to extension in abduc-
tion (abduction), posterior labrum, and sacroiliac pathology);
Thomas test: click may indicate labral tear and tightness
represents iliopsoas contracture; McCarthy: full ROM from
extension to flexion with external/internal rotation; Scour
test: full flex and palpate superior acetabular rim for
irregularity.
Lateral:
Palpate ischial tuberosity, greater trochanter, tensor fascia
Fig. 20-2 Anteroposterior radiographs of left hip showing a large CAM
lesion. lata, IT band, piriformis, gluteus, sacrum, coccyx, sciatic
nerve.
Ober (knee flexion and extension), test strength gluteus
medius, gluteus minimus, Ely test in lateral tight quadriceps
lumbar spine) hyperlordotic; and consider that which would mechanism.
functionally affect pelvic and acetabular orientation (e.g., Prone:
weak abdominal musculature, gluteus, lumbar spine, tight Palpate sacroiliac joint, ischial tuberosity, spine, muscu-
hamstrings). Observe single-leg stance for pelvic balance. lature. Ely test: rectus/quadriceps contracture.
Sitting:
Leg length, rotation, neurologic (motor: abduction: supe- OTHERS
rior gluteal nerve L4 to S1; adduction: obturator nerve L2 to
4; knee extension: L2 to 4; knee flexion: L4 to S3 sciatic ROM is examined with the hip in flexion and extension. The
nerve; great toe extension: L5; extensor hallucis longus, hip is fully passively ranged and observed for pain with
plantar flexion: L4 to S1; sensory: dermatomal sensation). FADIR and FABER. Popliteal angle is evaluated to check for
hamstring tightness. A loss of the arc of motion of the hip,

especially internal rotation, is suspicious for significant FAI
or arthritis. A low lumbar spine examination can help rule
out or reveal concurrent lumbar spine pathology. Strength of
abductors, adductors, hip flexors, and extensors, as well as
knee and ankle muscles, can be very revealing about the
functional contributions of deficits and imbalance that con-
tribute to hip pain. Even a foot drop can contribute to
overuse of hip flexors and subsequent hip pain.
IMAGING
Radiographs include AP pelvis, cross-table, and frog lateral

A
hip views. Simple radiographs can demonstrate dysplasia
(decreased center-edge angle), acetabular retroversion
(crossover sign), CAM lesions (increased alpha angle), loose
bodies, and radiographic signs of arthritis (joint space nar-
rowing, osteophyte formation, subchondral sclerosis, and
cysts) (Fig. 20-4). Newer studies suggest that joint space nar-
rowing with less than 3mm of space remaining, inferior
osteophytes, and a center-edge angle of less than 20 (measure
of dysplasia/shallow acetabulum) are reasons to not perform
a hip arthroscopy but rather prepare the patient for a hip
replacement when symptoms warrant the procedure despite
conservative treatment.3 Other considerations are lumbar
spine and sacroiliac pathology.
If examination and radiographs support the diagnosis of
a hip problem, an MRI can be performed to observe for
labral pathology, chondral injury, and loose bodies (Fig.
20-5). An arthrogram at the time of the MRI improves the
accuracy of the examination, and allows injection of a local
anesthetic and cortisone type of medication into the joint
and observation for pain relief. If pain relief occurs, then
intraarticular causes of hip pain are suggested. More specifi-
cally, response to the injection implies chondral damage.4 B
Depending on the cause, a computed tomographic scan with
Fig. 20-4 Anteroposterior radiographs of pelvis (A) and frog lateral (B)
3-D reconstructions may help better analyze the pincer are useful for observing crossover sign, CAM lesions, alpha angle, center-
impingement lesion and how much rim trimming may edge angle, inferior osteophytes, joint space narrowing, and other bony
need to be performed to correct that pathology (Fig. 20-3). pathology.
Hip arthroscopy is an excellent, minimally invasive
method of addressing femoral acetabular pathology previ-
ously only addressed with open hip disarticulation.
SURGICAL PROCEDURE
Hip arthroscopy can be performed from two surgical posi-

tions: supine and lateral. Arthroscopic portals are identical
in both positions, and the choice is really based on surgeon
training and preference.
Supine hip arthroscopy can be performed with easier
operating room setup. However, the posterior lateral portal
is difficult to establish, and the entire procedure can be more
difficult in an obese to large patient (Fig. 20-1).
Lateral hip arthroscopy requires a more complex room
setup with a specialized table attachment to apply traction Fig. 20-5 MRI arthrograms of the hip help identify labral tears, as seen
and position the leg. It does provide excellent access to the here on the superior acetabulum, as well as loose bodies, CAM lesions, bone
hip joint anterior and posterior, even in large patients. cysts, some cartilage lesions, and ligamentum teres pathology.
Once the patient is positioned, the anterolateral portal is The anterior portals may put branches of the lateral femoral
established first. Various arthroscopic portals penetrate the cutaneous nerve at risk; thus the portals are carefully closed
tensor fascia lata, gluteus medius, and sartorius and rectus with absorbable and/or nonabsorbable suture. A bulky dress-
femoris. After careful placement with fluoroscopic guidance, ing and an abduction pillow are placed. The surgery can be
the anterior portal is established next, with care taken to performed outpatient in a surgery center or a hospital. The
avoid injury to the lateral femoral cutaneous nerve. The surgical time can be quite prolonged, and an overnight stay
capsule is opened between the portals and then split in a T may be considered.
or H shape to gain access to the femoral CAM lesion. Most The protocol for postoperative management varies based
surgeons start in the central compartment to look for loose on whether microfracture or labral repairs are performed.
bodies, cartilage injuries, ligamentous injuries, and notch Indomethacin is given for 2 weeks to help prevent postopera-
osteophytes (Fig. 20-6). Cartilage injuries are often adjacent tive heterotopic ossification (HO).5 Extra effort is taken to
to labral injuries. In the peripheral compartment, the labrum, lavage the joint and soft tissues after the femoral osteoplasty,
acetabular rim, and anterosuperior femoral neck are evalu- but HO is still possible and one reason for reoperation. After
ated. Labral tears can be dbrided or repaired with suture surgery, the patient can be sent home with arrangements for
anchors. At the same time, a rim-trimming or acetabular a continuous passive motion machine, crutches or walker,
osteoplasty can be performed where the pincer impingement and a hip cryo-sleeve.
is removed and the acetabular retroversion is improved. Care
is taken via preoperative planning not to remove so much OUTCOMES
acetabulum as to destabilize the hip by respecting the CEA.
The femoral CAM lesion can also be removed via a femoral Depending on the condition of the acetabular cartilage and
osteoplasty (Figs. 20-7 and 20-8). Multiple portals can be possibly the labrum, patients can do quite well. Long-term
used to access the central and peripheral compartments. A outcomes can be very satisfying, delaying or preventing the
posterolateral portal, accessory anterolateral portal, and need for hip replacement. A more severe or involved acetab-
the mid anterolateral portal can be used to assist with the ular cartilage damage predicts a poorer outcome and earlier
femoral osteoplasty, rim trimming, or anchor placement. need for arthroplasty.
Surgical challenges are related to the acetabular cartilage
damage, severity of the CAM impingement, and labral take-
down and rim-trimming for pincer impingement. Recent
studies suggest superior outcomes in labral repair (Harris
Hip Score 89.7% vs. 66.7% good to excellent results).
Although it may make sense to recreate the labral gasket, a
large definitive study needs to be published.6 The labrum
contributes to hip stability. Hip stability is not reduced until
2cm has been removed.7
Although hip arthroscopy is safer and has a faster reha-
bilitation rate than an open procedure, complications can
still occur. Various studies quote an up to 18% complication
rate.8 They include neuropraxia of the sciatic, femoral, or
lateral femoral cutaneous nerve; HO (1.6%); portal wound
Fig. 20-6 Initial arthroscopy often starts with the hip distracted to observe bleeding; and instrument breakage. Other case reports
the central compartment where a cartilage injury is often identified. describe complications that include femoral neck fracture,9
A B C
Fig. 20-7 In the peripheral compartment, distraction can be discontinued as CAM lesions are identified (A) and removed with the assistance of fluoroscopy
(B and C).
A B C
D E F
Fig. 20-8 Arthroscopy shows the central compartment labrum and the inverted horseshoe of articular cartilage around the fovea (A). Labral tears are identi-
fied (B) and dbrided with capsular, anteroinferior iliac spine pathology. The acetabulum is dbrided then burred (D) to remove diseased tissue and to allow
the labral repair (E) to heal into healthy bone. The burr can also be used to remove pincer lesions and os acetabuli in a similar process. CAM lesions are
removed (F) under fluoroscopic guidance.
dislocation,10 trochanteric bursitis, abdominal compartment is important so that the therapist can properly mobilize the
syndrome,11 intrathoracic extravasation of fluid,12 avascular hip; this seems to be a focus over the first several weeks.
necrosis,13 and penetration of the acetabulum by anchors.14 Maintaining weight-bearing status is also important for pro-
A common reason for reoperation is underresection of the tecting the healing labrum and microfracture bed. Sudden
CAM lesion. Postoperative radiographs can show the stiffness or mechanical signs may forebode reinjury of the
improvement in CAM lesions and elimination of the cross- labrum, worsening cartilage injury (or frank rapid-onset
over sign. The need for a conversion to a total hip arthros- osteoarthritis), avascular necrosis, or developing HO and
copy is as high as 26%. would necessitate communication with the surgeon.
Neuropraxias can be related to portal placement or dis- Various types of procedures can be performed to correct
traction. Symptoms are usually short-lived and resolve com- hip pathology through hip arthroscopy surgery. Cartilage
pletely. HO can occur, and indomethacin is given after and lesions can be dbrided. For example, labral tears can
surgery to help prevent its formation. Patients can develop be dbrided or repaired. Osteoplasty procedures can be
painful stiffness several weeks after surgery despite early done to improve ROM and function, including chondro-
good ROM. Therapy is essential to try to restore and main- plasty to the acetabulum for microfractures and abrasions.
tain ROM at this point. If HO forms and is symptomatic, it Also, extraarticular pathology, such as gluteus medius
can be resected. The patient is given indomethacin and radia- tears, chronic IT band snapping syndrome, and snapping
tion to help prevent recurrence at the time of the resection of psoas syndrome, can also be addressed. The rehabilitation
HO. After labral repair, care must be taken to avoid impinge- progression will vary depending on the hip pathology and
ment, which may stress the repair before healing (6 weeks). procedure.
Furthermore, after microfracture in the hip, it is recom-
mended to limit weight bearing, and many surgeons advo- SUMMARY
cate the use of a postoperative continuous passive motion for
reasons similar to its use after microfracture in the knee. This chapter equips the rehabilitation professional with an
understanding of the various procedures performed using
POSSIBLE COMPLICATIONS hip arthroscopy. Also, a description of a hip arthroscopy is
provided so that the reader can appreciate the different
In addition to the complications previously listed, there tissues that are compromised, altered, or repaired during this
are a few other potential rehabilitation concerns. Pain control surgery.
REFERENCES
1. Clohisy JC, St John LC, Schutz AL: Surgical treatment of femoroacetab- 8. Botser IB, et al: Open surgical dislocation versus arthroscopy for femo-
ular impingement: A systematic review of the literature. Clin Orthop roacetabular impingement: A comparison of clinical outcomes. Arthros-
Relat Res 468(2):555-564, 2010. copy 27(2):270-278, 2011.
2. Colvin AC, Koehler SM, Bird J: Can the change in center-edge angle 9. Ayeni OR, et al: Femoral neck fracture after arthroscopic management
during pincer trimming be reliably predicted? Clin Orthop Relat Res of femoroacetabular impingement: A case report. J Bone Joint Surg Am
469(4):1071-1074, 2011. 4;93(9):e47, 2011.
3. Larson CM, Giveans MR, Taylor M: Does arthroscopic FAI correction 10. Matsuda DK: Acute iatrogenic dislocation following hip impingement
improve function with radiographic arthritis? Clin Orthop Relat Res arthroscopic surgery. Arthroscopy 25(4):400-404. Epub 2009 Feb 1,
469(6):1667-1676, 2011. Epub 2010 Dec 22. 2009.
4. Kivlan BR, Martin RL, Sekiya JK: Response to diagnostic injection in 11. Fowler J, Owens BD: Abdominal compartment syndrome after hip
patients with femoroacetabular impingement, labral tears, chondral arthroscopy. Arthroscopy 26(1):128-130, 2010.
lesions, and extra-articular pathology. Arthroscopy 27(5):619-627, 12. Verma M, Sekiya JK: Intrathoracic fluid extravasation after hip arthros-
2011. copy. Arthroscopy 26(9 Suppl):S90-S94. Epub 2010 Aug 5, 2010.
5. Randelli F, et al: Heterotopic ossifications after arthroscopic manage- 13. Scher DL, Belmont PJ Jr, Owens BD: Case report: Osteonecrosis of the
ment of femoroacetabular impingement: The role of NSAID prophy- femoral head after hip arthroscopy. Clin Orthop Relat Res 468(11):3121-
laxis. J Orthop Traumatol 11(4):245-250. Epub 2010 Nov 30, 2010. 3125. Epub 2010 Feb 10, 2010.
6. Larson CM, Giveans MR: Arthroscopic debridement versus refixation 14. Hernandez JD, McGrath BE: Safe angle for suture anchor insertion
of the acetabular labrum associated with femoroacetabular impinge- during acetabular labral repair. Arthroscopy 24(12):1390-1394. Epub
ment. Arthroscopy 25(4):369-376. Epub 2009 Mar 5, 2009. 2008 Oct 10, 2008.
7. Smith MV, et al: Effect of acetabular labrum tears on hip stability and
labral strain in a joint compression model. Am J Sports Med 39(Suppl):
103S-110S, 2011.
CHAPTER 21
Open Reduction and Internal Fixation
of the Hip
H
ip fractures are the bony injuries that require surgi- reported.3 This is not surprising, because most hip fractures
cal intervention in the United States most fre- occur in the older adult population.
quently. The annual expense for the treatment of The traditional goal of rehabilitation has been to restore
these patients has been estimated as high as $7.3 billion. patients to the level of function that they had before the
Because the incidence of osteoporosis in our steadily aging injury. In many cases this may not be realistic. Only 20% to
population is increasing, the number of hip fractures is 35% of patients regain their preinjury level of independence.
expected to increase from 275,000 per year in the late 1980s Some 15% to 40% require institutionalized care for more
to more than 500,000 by the year 2040.1 than 1 year after surgery. Many50% to 83%require
devices to assist with ambulation.4
SURGICAL INDICATIONS AND Rehabilitation goals must be individualized, with the
CONSIDERATIONS therapist taking into account all comorbidities, fracture
severity, and motivational level of the patient.
Numerous classification systems have been devised to Displaced or minimally displaced femoral neck fractures
describe hip fractures. However, in the context of surgical represent the least severe injuries in the spectrum of hip
exposure, soft tissue injury, and rehabilitation potential, they fractures. They are stable and can bear the full weight of the
can be simplified into five main categories: patient immediately after surgery. Moreover, they require no
1. Nondisplaced or minimally displaced femoral neck limitations on range of motion (ROM) or exertion in the
fractures immediate postoperative period. The preferred surgical pro-
2. Displaced femoral neck fractures cedure is a fluoroscopically aided placement of cannulated
3. Stable intertrochanteric fractures 6.5-mm screws through a limited or percutaneous lateral
4. Unstable intertrochanteric fractures approach. This approach violates the skin, subcutaneous fat,
5. Subtrochanteric fractures deep fascia of the fascia lata, and fascia and muscle fibers of
All categories of these fractures can demonstrate good the vastus lateralis. Typically blood distends the joint capsule,
outcomes with surgical intervention and early mobilization.2 creating some limitation in hip ROM and pain. No major
This is true regardless of age, gender, or comorbidities. The nerves or vessels are at risk in this approach.
rare exception is an incomplete or impacted femoral neck The patient is brought to the operating room, and anes-
fracture in a nonambulatory or extremely ill individual. The thesia is induced. The patient is positioned supine on a frac-
expected postoperative stability of the hip is directly propor- ture table capable of distracting and manipulating the
tional to the severity of the injury, the quality or density of affected limb. After satisfactory position of the fracture frag-
the bone to be repaired, and the technical expertise of the ments is verified with an image intensifier, surgery is begun.
surgeon. A 2-cm incision is made along the lateral femur in line
The patients overall preinjury physical and mental condi- with the fractured femoral neck. A guide pin is then placed
tion is also a predictor of postoperative success. Patients with percutaneously through the lateral musculature at or about
major cardiopulmonary afflictions, obesity, poor upper body the level of the lesser trochanter. The pin is introduced up
strength, osteoporosis, or dementia in its various forms have the femoral neck and across the fracture into the subchon-
increased risk for complications in the treatment of hip frac- dral bone of the femoral head. After two to four guide pins
tures. Overall mortality rates of 20% after 1 year, 50% at 3 have been placed, the outer cortex is drilled with a cannu-
years, 60% at 6 years, and 77% after 10 years have been lated drill and cannulated screws are introduced over the
388
Chapter 21 Open Reduction and Internal Fixation of the Hip 389
treated by bipolar, endoprosthetic, or THR procedures using

a posterolateral approach.
The posterolateral approach involves violation of the skin;
subcutaneous tissue; fascia lata; gluteus maximus; and short
external rotators of the hip, including the piriformis, obtura-
tor internus, gemelli, and quadratus femoris. The capsule is
incised posteriorly and often released anteriorly. Traction is
applied on the gluteus maximus, gluteus medius, and gluteus
minimus throughout the procedure. Nerves and vessels at
risk include the sciatic nerve, the superior gluteal nerve, the
inferior gluteal nerve, and their accompanying vessels.
Although the psoas is left alone, it is often inflamed and can
scar down and across the anterior hip capsule if adequate
postoperative mobilization is not encouraged. Generally
A incisions are healed by 2 weeks, deep soft tissue healing is
well advanced by 6 weeks, and full bony healing is expected
at 12 weeks.
The patient is anesthetized and placed in the lateral decu-
bitus position with the injured hip up (see Fig. 15-4); the
torso is stabilized, and the hip and affected leg are draped to
move freely. The initial incision is centered over the greater
trochanter and taken distally 3 inches along the femoral
shaft, then proximally and medially 4 inches along the course
of the fibers of the gluteus maximus. The deep fascia is
incised over the greater trochanter and carried distally along
the same line as the skin incision, exposing the origin of the
vastus lateralis without violating it. The surgeon digitally
palpates the interval between the gluteus maximus and
tensor fascia lata proximally, then extends the deep incision
B in this interval. A large, self-retaining retractor is then posi-
tioned to hold the deep fascia apart. The greater trochanteric
Fig. 21-1 A, Anteroposterior radiograph of the pelvis showing proper bursa is incised to expose the short external rotators. The
placement of three cannulated screws across a minimally displaced subcapi-
tal femoral neck fracture. B, Lateral view of the case illustrated in A.
interval between the piriformis, gluteus medius, and gluteus
minimus is identified, and the glutei are retracted anteriorly.
Carefully the short external rotators are taken off the poste-
rior femoral neck along the posterior hip capsule as a single
guide pins (Fig. 21-1). The soft tissues are repaired, and a cuff of tissue for later repair. Alternatively the capsule can be
dressing is applied. Femoral neck fractures that occur more released separately with a T incision. Generally the surgeon
toward the base of the femoral neck require fixation that is must release the piriformis, gemelli, obturator internus, and
able to resist the bending movement between the femoral half of the quadratus to expose the femoral neck to the level
neck and shaft. These are treated much like intertrochanteric of the lesser trochanter. The hip is then flexed and internally
fractures, and the operative procedure is described in that rotated to bring the fracture into view. A saw is used to cut
section. the femoral neck smoothly at the proper level, and the
femoral head is retrieved from the acetabulum. The acetabu-
Displaced Femoral Neck Fractures lum is examined, and bone fragments are removed along
Femoral neck fractures in which the femoral head has been with the ligamentum teres. After exposure is completed, the
separated widely from the neck do not heal if reduced and prosthesis is installed. It is often inserted in 15 to 20 more
fixed by screws or pins. In these fractures the vascular supply anteversion than was present with the biologic hip to mini-
to the femoral head (specifically the medial and lateral mize the risk of dislocation. This occasionally limits external
femoral circumflex arteries) are often severed. In younger rotation (ER) after surgery but usually not enough to create
patients it is still desirable to attempt fixation despite the high a functional impairment.
rate of nonunion and osteonecrosis. When open reduction Closure is somewhat more controversial. The author
is attempted, the anterolateral exposure of Watson-Jones is prefers to repair the capsule and short external rotators with
preferred because it preserves the blood supply to the femoral a large No. 2 nonabsorbable suture extending through drill
head, which enters through the posteroinferior femoral holes in the greater trochanter and intertrochanteric line.
neck.5 This approach is discussed in the section on total hip This limits the formation of heterotopic bone, decreases the
replacement (THR). Older adult patients are often best incidence of postoperative dislocation, and improves
proprioception during rehabilitation. The deep fascia is then left free, limiting hip flexion strength in the initial postopera-
repaired, followed by the subcutaneous tissue and skin. tive period.
The initial postoperative rehabilitation is predicated on Controversy exists as to whether it is better to align unsta-
early mobilization to prevent morbidities associated with ble fractures anatomically with a highly angled 145 to 150
recumbency, such as deep venous thrombosis, atelectasis, compression plate and allow them to collapse into stability
pneumonia, decubiti, and loss of muscle strength and joint under physiologic loads or to perform a medical displace-
mobility. Full weight bearing is encouraged. After arthrot- ment osteotomy to obtain good posteromedial cortical
omy each patient must be educated and drilled regarding abutment and stability during surgery (Fig. 21-2).
potentially dangerous hip positions that can lead to disloca- Both methods can lead to stability or instability; therefore
tion. The risk inherent in the posterolateral approach is each case must be discussed with the surgeon to ascertain
greatest with hip flexion greater than 90 and internal rota- the degree of stability obtained and the permitted amount of
tion (IR), adduction, or both across the midline. weight bearing. In addition, both methods shorten the dis-
Patients with prosthetic hips should be instructed to tance between the insertion of the hip abductors in the
follow their hip precautions religiously for the first 6 greater trochanter and the center of rotation of the hip, creat-
weeks after surgery, at which time the soft tissue has ing a mechanical disadvantage for the abductors. This can
regained most of its tensile strength. Even then they are at lead to Trendelenburg gait, which must be overcome during
greater risk of dislocation than they were before surgery. the postoperative rehabilitation period.
The patient is placed supine on a fracture table with the
afflicted limb in the traction boot. Care is taken to place the
Intertrochanteric Hip Fractures correct rotation on the distal limb to prevent malalignment.
Intertrochanteric hip fractures tend to be the most techni- Reduction is carried out under an image intensifier until
cally challenging. The intertrochanteric region joins the satisfactory reduction is achieved. Occasionally a satisfac-
femoral shaft and neck at an angle of about 130. The tory preoperative reduction is not possible because of poste-
angular movement created by weight bearing is rior sag of the bony fragments, and further reduction must
greatest here, and often weight bearing in the be done manually. After the limb has been prepared and
initial postoperative period is not feasible. Morbid- draped, a lateral incision is made from the level of the greater
ity tends to be higher after these fractures, owing to signifi- trochanter distally approximately 7 inches, depending on the
cant comminution of bone and the resultant inadequate length of plate to be used. The incision is developed in the
stabilization provided by the internal fixation. same line through skin, subcutaneous fat, and fascia lata. At
These patients often must remain at touch down weight this point the fascia of the vastus lateralis is followed poste-
bearing (TDWB) or nonweight bearing until fracture riorly to its origin in the linea aspera. By incising it here the
healing is demonstrated. The most important prognostica- surgeon limits the amount of muscle denervated by the
tor in this subset of patients is the evaluation of fracture exposure and protects the main muscle mass from damage.
stability (i.e., the tendency of the fracture to collapse or The surgeon accesses the lateral cortex of the femoral shaft
angulate under physiologic loads after surgery). Fractures and places a retractor to maintain anterior retraction of the
with an intact posteromedial cortex and those at the base of vastus lateralis, exposing the lateral femoral shaft. After
the femoral neck are stable. These fractures tolerate limited exposure is completed, placement of the fixation device is
weight bearing in the initial postoperative period without begun (Fig. 21-3). Closure involves interrupted repair of the
shifting. Surgeons best treat patients with these fractures by fascia of the vastus lateralis, fascia lata, subcutaneous tissue,
placing a sliding compression hip screw device in an ana- and skin. The dynamic-compression screw device was not
tomically aligned fracture. designed to hold the head and neck segment firmly (Fig.
The best surgical approach for the unstable fracture is 21-4). Rather it allows the ambient muscle forces across the
controversial. Suggested approaches include hip screw hip joint to pull the fracture fragments together until encoun-
devices with or without medial displacement, third- tering good bony resistance. In many comminuted osteopo-
generation intermedullary reconstruction nail fixation, and rotic fractures, the ability of the screw device to contract is
calcar replacement endoprostheses. The surgical exposure exceeded before good cortical abutment is obtained between
for placement of a calcar replacement prosthesis is as the fracture fragments.
described under the use of endoprostheses for displaced In such cases weight bearing must be curtailed until
femoral neck fractures. The exposure and morbidity involved bony healing ensues, or the screw will cut out and all
in the placement of an intermedullary nail are discussed in stabilization will be lost. Again, the skin is healed by 2
the section on subtrochanteric fractures. The exposure for weeks, the deep fascia and soft tissues are healed by 6 weeks,
placement of a dynamic compression hip screw is the same and good bony healing is expected by 12 weeks. In older
regardless of whether a stable or unstable fracture is being adult osteoporotic patients with severely comminuted frac-
addressed. Typically a long lateral approach is used. This tures, bony healing can sometimes be delayed for as long as
approach violates the skin, subcutaneous tissue, fascia lata, 4 to 6 months. In patients with obviously unstable fractures,
vastus lateralis fascia, and muscle belly. Generally in unstable weight bearing should be delayed until good bony healing is
fractures the lesser trochanter and inserting psoas tendon are demonstrated on radiographs. The resultant collapse can
Steinmann
pin
Wire guide
A B
C D
Fig. 21-2 Dimon-Hughston method of internal fixation of unstable trochanteric fractures. A, Transverse osteotomy of the lateral shaft. B, Insertion of a guide
pin with a Steinmann pin for control of fragment. C, Insertion of nail in the proximal fragment. D, Fixation of the side plate to the shaft. (From Hughston
JC: Intertrochanteric fractures of the hip. Orthop Clin North Am 5[3]:585-600, 1974.)
often leave a limb significantly shorter. Leg length should be implant failure and nonunion rate than in other regions. The
checked after healing and a lift provided if appropriate. femur can be stabilized with a static locked intermedullary
nail without exposing the fracture or disturbing its periosteal
Subtrochanteric Hip Fractures blood supply. The two preferred methods of fixation for
The use of advanced intermedullary nailing techniques has patients with these fractures are a routine lateral approach
revolutionized the treatment of subtrochanteric fractures. for the placement of an extended compression screw device
Traditionally, these fractures have been difficult to fix because and the placement of a static locked intermedullary nail. The
of the extreme angular force centered in this region, as well exposure for the lateral compression plate is discussed in the
as the muscular deforming forces and minimal bony intersection on intertrochanteric fractures and deviates only in
face between the two fragments available for healing (Fig. that the exposure must be taken more distally, causing more
21-5). damage to the fascia lata and the vastus lateralis.
Moreover, the bone in this region is more cortical in Although this design stabilizes the fracture, weight
character, with a poorer blood supply and less osteogenic bearing usually must be delayed, soft tissue exposure is
activity than in the intertrochanteric region. The use of a extensive, and healing is often delayed because of destruc-
sliding compression screw device has yielded a higher tion of periosteal blood supply around the fracture.
Fig. 21-4 Unstable intertrochanteric fracture of the hip treated with a

four-hole compression screw device. The lesser trochanter is often left float-
A ing, which can lead to weakness.
lliopsoas flexes
Gluteus and
abducts rotates externally
proximal femur
B
Adductors
C
Fig. 21-3 Internal fixation of a trochanteric fracture. A, A guide pin is
inserted, and its position and that of the fracture are checked by roentgeno-
grams. A cannulated Henderson reamer, placed over the guide pin, is used Fig. 21-5 Diagram of pathologic anatomy of subtrochanteric fracture. The
to make a hole through the lateral cortex. Left insert, skin incision; right proximal fragment is flexed, abducted, and externally rotated, whereas the
insert, proper position of guide pin in anteroposterior view. B, A Jewett nail femoral shaft is shortened and adducted. (From Froimson AI: Treatment of
is inserted over the guide pin. C, The plate part of the Jewett nail has been comminuted subtrochanteric fractures of the femur. Surg Gynecol Obstet
fixed to the femoral shaft with screws. 131[3]:465-472, 1970.)
The more limited exposure for a static locked or recon- pass lateral to medial through the lateral cortex of the femur
struction nail runs more proximally through the abductors, the nail, and finally the medial femoral cortex. This design
with a second stab incision for the interlocking screws at the effectively neutralizes deforming forces across the subtro-
level of the greater or lesser trochanter and a third stab inci- chanteric femur, allowing full weight bearing from the outset
sion laterally along the supracondylar femur. The newer (Fig. 21-6).
reconstruction nails run the more proximal interlocking The patient is placed supine on a fracture table with both
screws from the lateral femoral cortex (at the level of the legs inserted into traction boots. Traction is applied over a
lesser trochanter), and across and through the prefabricated perineal post. The legs are positioned with the involved leg
holes in the nail in the intermedullary canal. The nails then adducted across the midline and slightly flexed at the hip.
run up the femoral neck, ending in the hard bone of the The uninvolved leg is abducted and extended at the hip, lying
subarticular femoral head. The distal interlocking screws adjacent to the operative leg (Fig. 21-7). An incision is started
Fig. 21-8 Skin incision at the greater trochanter. (From Crenshaw AH:
Campbells operative orthopaedics, vol 3, ed 7, St Louis, 1987, Mosby.)
Fig. 21-9 Distal-locking block assembly is attached to the handle of the

proximal drill guide. (From Crenshaw AH: Campbells operative orthopae-
dics, vol 3, ed 7, St Louis, 1987, Mosby.)
Fig. 21-6 A subtrochanteric fracture of the femur fixed with Richards
compression screw-plate device. (From Crenshaw AH: Campbells operative
orthopaedics, vol 3, ed 7, St Louis, 1987, Mosby.)
and fluoroscopy, the surgeon makes a small entry point at
the base of the superior posterior femoral area, the piriformis
fossa. The guide pin is passed down the femoral shaft approx-
imately 6 inches, and a cannulated reamer is placed over the
guide pin to enlarge the entry hole and begin the reaming
process. A larger ball-tip guide that is run down across the
fracture and down the intermedullary canal to the intercon-
dylar notch replaces the initial guide pin. After this the canal
is reamed with flexible reamers in progressively larger sizes
A until obtaining a good cortical fit. After overreaming a mil-
limeter or two, the surgeon carefully inserts the nail across
the fracture under fluoroscopic guidance and then inserts
the interlocking screws. The screws at the proximal end
of the nail are aimed with the use of a special jig that attaches
to the proximal end of the nail (Fig. 21-9). They are inserted
percutaneously through the deep fascia and vastus lateralis.
The distal screws are usually placed freehand, again percu-
taneously, using the image to visualize the holes in the nail
B passing through the iliotibial band and vastus lateralis.
Closure consists of repairing the deep fascia, subcutaneous
Fig. 21-7 Russell-Taylor interlocking nail technique. A, Patient in supine tissue, and skin.
position. B, Patient in lateral decubitus position. (From Crenshaw AH:
Rehabilitation efforts during the initial postoperative
Campbells operative orthopaedics, vol 3, ed 7, St Louis, 1987, Mosby.)
period should consist of regaining control of the proximal
hip musculature. Good functional quadriceps contraction
1 inch proximal to the greater trochanter (Fig. 21-8). It is and the ability to lift and maneuver the hip against gravity
developed proximally and slightly medially 3 inches. The are prerequisites to adequate ambulation. Because of the
surgeon then extends the incision through the skin and sub- strength of the fixation, patients can begin full weight bearing
cutaneous tissue to the fascia of the gluteus medius, which immediately after intermedullary reconstruction nailing.
is divided for about 2 inches in line with the skin incision Healing normally requires 3 months (Fig. 21-10); nail
and the fibers of the gluteus medius. Using a small guide pin removal should not be considered before 18 to 24 months.

REHABILITATION
The course of physical therapy after an open reduc-

tion internal fixation (ORIF) procedure at the hip is
individualized and depends on the health status of
the patient before the fracture, the type of ORIF
procedure used, and the precautions ordered by
the surgeon. This chapter provides some general guide-
lines for the rehabilitation process. The physical therapist
(PT) must manage the patients progress, keeping in mind
the patients ability to heal and the constraints of the patients
insurance carrier. The rehabilitation process can be described
in three phases: (1) hospital, (2) home care, and (3) outpa-
tient. In many cases, depending on lifestyle demands, the
patient may only go through one or two of these phases.
Phase I (Hospital Phase)

GOALS: To help the patient become independent with
transfers and gait using appropriate assistive
devices, to ready the patient for discharge from
acute care (Table 21-1)
Treatments performed on the day of surgery, such Fig. 21-10 Appearance 2 months after closed reduction of dislocations and
medullary nailing of fractures. (From Crenshaw AH: Campbells operative
as incentive spirometry exercises, management of air
orthopaedics, vol 3, ed 7, St Louis, 1987, Mosby.)
TABLE 21-1 Hip Open Reduction Internal Fixation

Anticipated
Phase I Postoperative Pain Inpatient on pain Independent or stand-by Emphasize restoration
Postoperative (inpatient) Limited bed medication assistance with bed of independence with
1-7 days mobility Bed mobility training mobility transfers and gait self-care activities (bed
Limited transfers Transfer training 200 feet using mobility, transfers)
Limited gait Gait training front-wheel walker Ambulate safely to
Limited strength Isometrics Independent with home return to home
of involved LE Quadriceps sets, exercise program environment with some
gluteal sets Caregiver trained to assist degree of independence
A/AROMHip with basic skills Provide exercises to
(flexion, extension, Discharge to home help patient regain
abduction, muscular control of
adduction) involved LE
AROMHeel Provide assistance to
slides, ankle pumps patient to perform hip
Patient education range of motion
emphasizing safety Ensure patient and
with all mobility caregiver safety and
training prevent falls
A/AROM, Active assistive range of motion; AROM, active range of motion; LE, lower extremity.
compression equipment, and donning thromboembolic

disease (TED) hose, are generally assigned to the nursing
staff. When a good recovery from surgical trauma is demon-
strated, hospital-phase physical therapy usually begins on
the first day after surgery.
Physical therapy treatment on postoperative day 1 con-
sists of an evaluation, bed mobility, transfer training, gait
training, and a beginning exercise program. The patients
initial goal is to transfer out of bed safely and walk to the
bathroom independently using a front-wheel walker (FWW).
Some confusion or an emotional reaction to the event that
precipitated the surgery may be encountered on the first
postoperative day, and the patient may be groggy or in a
great deal of pain. Because ORIF is normally an emergency
surgery, the patient does not have the advantage of a preop-
erative training session. However, bed mobility and transfer
training may be easier here than with a patient who has
undergone THR, because usually no ROM precautions are
in place.
Patients who received sacral anesthesia may show a faster
initial rate of progress than those who were administered
general anesthesia. The patients pain medications should be
Fig. 21-11 Quadriceps set with the adductor squeezed. The patient sits
timed to reach peak effectiveness during therapy sessions. with legs stretched out in front. With a pillow between the knees and thighs,
The PT should be informed of the patients weight-bearing the patient squeezes the knees together and tightens the top of the thighs at
status, the type of fracture and surgery performed, and any the same time, holding for a count of 10 seconds.
special ROM restrictions. On the first postoperative day, the
patient will attempt to walk to a chair and then sit up for
approximately 1 hour before returning to bed. This may be
repeated two to three times on the first day. The patient will weight-bearing restrictions. However, patients who are
be encouraged to sit up longer each day. assigned nonweight bearing status may feel more secure
The patients skin should be checked daily for pressure using a pick-up walker. A platform walker may be appropri-
sores, especially at the heels. Be sure the patient is placed ate if UE injuries are present. Agile patients are issued axil-
properly in bed to preclude the tendency to lie in a frog- lary crutches immediately regardless of weight-bearing
legged position with the hips in extreme ER and flexion. status.
Ankle pumps are the first exercises to be assigned. They Patients having difficulty with TDWB, defined as less than
help to prevent blood clots and to decrease edema in the legs. 10lb of pressure through the affected leg,6 or with partial
The patient should perform at least 10 to 20 repetitions every weight bearing (PWB), approximately 40% of normal weight
30 minutes. Quadriceps sets with and without adductor bearing on the involved extremity, will benefit from weight
squeezes (Fig. 21-11), gluteal sets, hamstring sets, and hip shift training on the parallel bars. A very thick-soled shoe
abduction sets should be performed three times per day with worn on the uninvolved leg helps to lift the patient (to facili-
10 repetitions of each exercise to begin restoration of proxi- tate TDWB with the involved leg). With PWB status, step-
mal hip strength. This program may be expanded to include ping onto a bathroom scale helps the patient to determine
active assistive and then active hip abduction, adduction, the appropriate amount of pressure to place on the involved
and hip-knee flexion. Encourage the client as much as neces- extremity.
sary to complete the program. Electrical galvanic stimulation is sometimes used to
Ankle proprioceptive neuromuscular facilitation patterns manage edema and electrical stimulation (ES) in the muscle
done in both diagonal planes can help prepare the patient reeducation mode can help facilitate quadriceps (especially
for weight bearing. Lower extremity (LE) stretching may be the vastus medialis oblique) contraction. However, elec-
done to avoid contractures and to prepare the patient for a trical modalities tend to be very uncomfortable
normal gait pattern. The patient can strengthen the upper for most patients, especially those with metal
extremities (UEs) using a Theraband or the hospital beds implants. These treatments may be more appropriate at the
triangle as a pull-up bar. Pelvic tilts and single knee-to-chest outpatient stage. The surgeon, as always, should be consulted
stretches of the uninvolved extremity can help decrease before the application of these modalities.
lumbar soreness and stiffness. Transfer to the skilled nursing facility from acute care is
The patients weight-bearing status, assigned by the expected on the third day after surgery. Patients are dis-
surgeon, will vary depending on the type of procedure per- charged from the hospital when they are medically stable
formed. An FWW is recommended for patients with and demonstrate independence with bed mobility, transfers,
and ambulation (using an appropriate assistive device). Typically the goal of the home care therapist is to ensure
Home caregivers should be trained to assist with these tasks the patients safety at home and to enable a return to previous
safely before the patient leaves the hospital. community activities with the use of an appropriate walking
Discharge goals are usually attained within 1 or 2 weeks device. These goals may depend on the patients overall
after surgery. Patients may be kept in an extended-care wing health status, motivation level, or previous level of function.
longer if no home caregiver is available and assistance is still In such a case, the patient is discharged when the PT deter-
required for basic mobility. A written exercise program for mines that no more progress can be made.
home use is presented at the time of discharge. The visiting PT During the initial home care visit, the PT evaluates the
in the home will reinforce the skills learned in the hospital. patients ROM, strength, bed mobility, transfer ability, gait
pattern, stair-climbing ability, ability to perform the home
Phase II (Home Phase) exercise program, endurance, pain level, leg length, overall
TIME: 2 to 4 weeks after surgery safety awareness, and skin status. The ability of caregivers to
GOALS: To improve hip active range of motion assist the patient will also be assessed.
(AROM) to 90, to educate patient regarding a home A home care admission assessment will include a review
maintenance program, to help the patient become of the patients medications. If enoxaparin injections are pre-
independent with transfers and to ambulate at home scribed to avoid blood clots, be sure that the patient has the
with appropriate assistive devices, to encourage appropriate number of syringes and follows through with the
limited community ambulation (Table 21-2) injection series.
Equipment needs can include a bedside commode, a
Home care physical therapy is normally authorized for raised toilet seat (if the patient has not attained 90 of hip
patients who are homebound or would incur undue hard- flexion), a shower chair, grab bars installed in the bathroom,
ship by leaving home for treatment. Homebound status is a railings installed by stairways, and appropriate assistive
requirement for reimbursement through Medicare and most devices for the progression of gait. Furniture and electrical
other insurance plans. PTs usually schedule visits two to cords may need to be moved to ensure a clear pathway.
three times per week until the patient is no longer home- The patients understanding of any weight-bearing restric-
bound or until goals have been met. This is usually achieved tions and ROM precautions prescribed should be recited and
within 2 to 4 weeks of the patients returning home from the demonstrated. Caregivers should be present during this
hospital. review.

Phase II No signs of Limited hip ROM Continuation of exercises Increase AROM to Develop flexibility to
Postoperative infection Limited LE strength as in phase I hip flexion 90, improve sitting posture
2-4 wk No increase Limited with transfers PROMStretches as abduction 20, knee and tolerance
in pain in and out of car indicated (calf, hamstring, flexion 90 Improve strength to
Usually Limited gait quadriceps, single knee to Independent with ensure safety with
home health chest) home exercises ambulation and
status but AROMStanding (hip Increase strength in transfers, decreasing
may be flexion, extension, hip to 60%, knee to dependence on
transitioned abduction, adduction); 70% uninvolved LE
to outpatient minisquats, lunges, heel Initiate UE Restore presurgical UE
when raises, wall slides; sitting strengthening strength
appropriate (long arc quadriceps, pelvic program Promote independence
tilt) GaitIndependent with community
Elastic tubing exercises for with cane at home; ambulation
UEs SBA with cane in Improve balance to
Gait/stair training community (1000 prevent falls
Standing balance training feet) Encourage return to
(balance boards) with Improve balance previous activities of
assistance as needed Perform independent daily living and
Car transfers transfers community activities
AROM, Active range of motion; LE, lower extremity; PROM, passive range of motion; ROM, range of motion; UE, upper extremity; SBA,
stand by assist.
PTs are now being trained to remove staples because of The integrity of the abductors is especially compromised
constraints imposed on nursing visits by insurance carriers. by ORIF surgeries and often the hip abductors were weak
Staples are usually removed at about the fourteenth postop- before the injury that precipitated the surgery. It may be
erative day. Proper sanitary technique protocols must be fol- necessary to stretch chronically flexed hip and trunk muscles
lowed. Consult the physician if any irregularity is noted in before the abductors can be in a position to fire effectively.
scar healing.
Advance the patient from isometric to active ROM exer-
cises during the home phase. Patients who require an active
assist should soon be performing their exercises indepen-
dently. Bilateral tiptoes (plantarflexion) (Fig. 21-12) and heel
cord stretches (Fig. 21-13) while standing can be performed
while using a walker or countertop for support. Closed
kinetic chain exercises (with the involved leg firmly planted
on the ground or on exercise equipment), such as heel raises
and minisquats, can also be done at the countertop. Open
chain exercises done while standing at this location include
hip flexion, hip abduction, and hip extension. Other closed-
chain exercises such as modified lunges and wall slides
(Fig. 21-14) are added as appropriate.
Hip flexion, extension, and abduction performed while
standing are beneficial for the involved leg. They may be
alternated bilaterally, depending on the patients weight-
bearing restrictions. With a status of weight bearing as toler-
ated (WBAT), the patient may attempt balancing exercises
on the involved leg.
The PT should address chronic deficits in flexibility,
strength, and balance that may have precipitated the patients
injury. The postsurgical program should focus on restoring
proximal hip strength.
Fig. 21-13 Heel cord stretch. The patient stands with the involved leg and
foot back, with the toes turned in slightly. He or she then places the hands
against a wall and leans forward until a stretch is felt. The patient keeps the
heel down, holds for 20 seconds, and slowly releases.
A B
Fig. 21-14 Wall slides using an adductor pillow. A, The patient stands with
the back against a wall, feet shoulder-width apart, with a pillow between the
Fig. 21-12 Bilateral tiptoes. The patient stands on the floor with the knees thighs. B, He or she then bends the knees to a 45 angle, tightens the thighs,
straight and then lifts onto the toes, holds for 5 seconds, and slowly releases and squeezes the pillow. The patient holds for 10 seconds, then extends the
downward. knees and slides up the wall.
a manual muscle test), and the patient should be able to

perform all exercises actively.
The majority of ORIF patients are older people with fairly
sedentary lifestyles. They may refuse further rehabilitation
past the home care phase. Walking programs should be
strongly encouraged with these patients. Swimming and
bicycle riding are recommended, when realistic, for long-
term exercise programs; tai chi has been shown to decrease
the risk of falls in older adults.7 Active patients with more
rigorous lifestyle requirements should go on to outpatient
therapy for further strengthening.
With osteoporosis so prevalent in this population, the
patient may be advised to consult the primary care physician
regarding the propriety of a calcium replacement program
or hormone replacement therapy.
Phase III (Outpatient Phase)

GOALS: To encourage patient self-management of
Fig. 21-15 Sitting hamstring stretch. The patient sits with the involved leg exercises, to help the patient become independent
straight and the other leg bent off the edge of a table or bed. He or she then in community ambulation, to increase the strength
hooks a towel around the foot, keeps the back straight, and leans forward of the LEs (Table 21-3)
until a stretch is felt. The patient holds this position for 20 seconds and
slowly releases. Older patients with less flexibility may simply lean back on
their hands, initially. Outpatient physical therapy is intended to increase the
involved extremitys flexibility toward full ROM and increase
Hamstring and calf stretches may be done in the supine its strength to at least the good minus level (4-/5 manual
or the sitting position using a towel (Fig. 21-15). The quad- muscle test). Gait pattern irregularities are to be normalized.
riceps can be stretched using a towel, with the patient lying Cardiovascular capacity also may be improved. These treat-
prone with knees bent. Pelvic tilt, knee-to-chest, hip rotator ments should be conducted two to three times per week if
stretches, and trunk rotation exercises benefit the low back the patients insurance policy permits. The duration of out-
and the hip. patient rehabilitation depends on the patients ability to make
The patient progresses from using an FWW or two crutches objective progress and on whether the intervention or treat-
to a cane during this phase. The ability to ambulate safely ment requires the skill of a PT.
without an assistive device is sometimes attainable within the All exercises should be done actively by this time. Exer-
time period authorized. Special care should be taken to cises previously performed in gravity-eliminated positions,
correct uneven stride length (leading with the involved such as supine hip abduction (Fig. 21-16) and adduction
extremity and stepping-to with the uninvolved extremity), (Fig. 21-17), are progressed to side-lying gravity-resisted
knee flexion in the late stance phase, forward flexion at the positions. Ankle weights can be added if appropriate.
waist, and overstriding with crutches.6 Trendelenburg signs The closed-chain exercises mentioned previously also are
in gait following an ORIF are common because of disruption performed in the outpatient clinic. Minisquats and wall
of the abductors. Be sure to cue and facilitate the engagement slides can emphasize a vastus medialis oblique contraction
of the abductors in both exercises and gait. with the addition of an isometric hip adductor squeeze using
Gait training includes stair climbing. Initially the patient a pillow or small ball. Lunges with the involved leg on a small
should walk up the stairs leading with the strong leg and step can progress to stair climbing on larger, more normal-
descend the stairs leading with the operative leg in a step-to sized steps. If the patient is still doing stairs in a step-to
pattern. pattern, progress him or her to a step-over-step pattern if
Training to step up and down safely from curbs, to walk possible. Standing balance exercises on the affected leg are
on uneven surfaces, and to transfer in and out of cars also is appropriate with WBAT status.
provided in the home phase. Cardiovascular exercise is important during this phase to
A balance retraining program may benefit patients who increase circulation throughout the body and endurance for
have vestibular or neurologic involvement. Vision problems ambulation. An upper body ergometer or a stationary bicycle
should be referred to the physician. can be introduced at this phase. The patients tolerance for
Home health physical therapy is usually finished within 2 these activities could be built up to a combined 15 to 30
to 4 weeks. The patient should have 90 of hip flexion and minutes, if possible.
20 of hip abduction at this point. The quadriceps and hip The modalities mentioned in the hospital phase may be
abductor strength should be fair to fair plus (3/5 to 3+/5 with performed here with the approval of the surgeon. Balance
A B
Fig. 21-16 Active hip abduction. A, The patient lies on the uninvolved side with the bottom knee bent. B, Keeping the top leg straight, he or she lifts upward,
holds for 5 seconds, then slowly returns to the starting position.
A B
Fig. 21-17 Active hip adduction. A, The patient lies on the involved side with the bottom leg straight. B, He or she then bends the top knee and places the
foot in front of the bottom leg. The patient lifts the bottom leg up approximately 6 to 8 inches and holds for 5 to 10 seconds before slowly returning the leg
to the starting position.

Anticipated
Phase III Independence Limited AROM and Progression of exercises in Control pain Progress strength and ROM
Postoperative with transfers strength of involved phases I and II, adding Regain full of involved LE
5-8 wk in and out of LE resistance where appropriate AROM of Use modalities to control
car Limited tolerance to Modalities as necessary: involved LE any residual activity or
No loss of community heat, ice, electrical Increase LE prepare tissue for stretching
hip ROM ambulation stimulation strength to Promote safety with
Limited tolerance to Trunk stabilization exercises 75% ambulation on all types of
cardiovascular Upper body ergometer Become surfaces
exercises Stationary bicycle independent Regain cardiovascular
Limited with Treadmill with conditioning
resuming more Gait training for uneven community Resume all activities of
advanced activities surfaces and stairs ambulation daily living and community
activities
AROM, Active range of motion; LE, lower extremity; ROM, range of motion.
retraining programs may be expanded to include various TROUBLESHOOTING

balance boards. Spine stabilization exercises can include those
done in the prone and quadruped positions. Core strengthening Complications may arise in the course of rehabilitation.
should be included, as well as Pilates exercises when realistic. Examples that should be referred to the surgeon include the
Inclusion of the leg press (Fig. 21-18) and other weight- following:
training equipment may be appropriate in the clinic phase. Thigh pain with walking that clears with sitting (may
At the PTs discretion, a treadmill also may be used to con- represent intermittent claudication)
tribute to balance and gait retraining. The therapist should A positive Trendelenburg sign that does not resolve with
consider activities that the patient can carry on in life when treatment (may result from damage to the gluteal
the rehabilitation phase is over. innervation)
A B
Fig. 21-18 Leg press machine. A, The patient should adjust the machine so that the knees are bent approximately 90 while the back is flat. B, The patient
straightens the legs while exhaling without locking the knees, then slowly releases.
Severe rubor and swelling at the surgical site with accom- prescribe a permanent orthotic. Persistent edema is treated
panying fever (may indicate a septic infection) with medication. Patients should be advised to elevate their
Persistent, severe pain (may result from an expansion of legs, rest more often, wear TED hose, pump their ankles, use
the fracture or loosening of the fixation devices) kinesio tape, and apply ice to swollen areas.
Other problems that may arise are the responsibility of Pain exacerbations are usually treated with medication.
the surgeon, but the PT can use palliative measures to assist Possible side effects of the medication include nausea,
the patient. Leg length discrepancy is an example. The patient constipation, and hypertension. The therapist can assist
can continue gait training with a temporary shoe insert or in pain reduction with modalities, exercise, ice, and
with shoes of different heel heights. The surgeon may later positioning.

Days 1 to 7 (in Hospital) AROM Exercises
GOALS FOR THE PERIOD: Increase volitional control 2. Standing hip flexion, extension, abduction, and
of involved LE, improve and maintain ROM adduction
Isometric Exercises 3. Minisquats
1. Quadriceps sets 4. Lunges
2. Gluteal sets 5. Wall slides
AROM Exercises 6. Pelvic tilt
3. Heel slides 7. Long-arc quadriceps
4. Ankle pumps 8. Upper body exercises as indicated
Weeks 2 to 4 Weeks 5 to 8
GOALS FOR THE PERIOD: Increase LE strength and GOALS FOR THE PERIOD: Promote return to
functional ROM, initiate upper-extremity previous level of function (as cleared by physician)
strengthening program 1. Continue exercises from weeks 2 to 4
1. Stretching as indicated by evaluation 2. Progress to gym activities as indicated and
prepare for discharge to community or home
gym (treadmill, stationary bicycle)
1 Why do ORIF patients differ emotionally from other

postsurgical orthopedic patients?
an accident where other loved ones have been injured.
Their situation needs to be appreciated and respected.
The mortality rate following a hip fracture is high and
They cannot prepare for their surgery because it is an elderly patients are aware of this. They may be worried
emergency surgery. Some have sustained their injury in that they will not recover or may not be able to return to
their homes. Expect to give these patients a lot of stretch can be done at a kitchen countertop, walker, or
encouragement. at the wall. The patient can stand in a doorway and
perform a lunge while her UEs are placed on either side
2 How can the treadmill be useful at the outpatient phase?
At slow speeds, the hip abductors, core trunk muscles,

of the doorframe to stretch a chronically tight trunk,
shoulder, and hip flexors.
and glutes are forced to engage during the stance phase

on the unstable surface of a treadmill. Placement of a
mirror in front of the treadmill can help the patient to
6 What should a PT consider when performing a home
safety evaluation for a patient who has sustained a frac-
ture from a fall?
observe and correct gait pattern irregularities. The tread-
mill may be a beneficial activity following discharge from Are steps, floorboards, and tiles secure?
the outpatient clinic. Are rugs, especially carpet on stairs, secure?
Which scatter rugs should be removed?
3 Upon the PTs arrival at the patients home, the patients

operative limb is found to be ruborous, warm, severely
swollen, and very painful despite elevation and the use
Are railings and banisters secure?
Which electrical cords should be taped down or removed?
Are stairways, hallways, and entryways clear of obstacles?
of ice. What needs to be done? Are pets and small children under control when near the
patient?
Be sure that the patient was discharged with the appro- Are grab bars available in the bathroom?
priate number of enoxaparin syringes and has followed Are there nonskid mats in the shower/tub?
through with these injections as prescribed. The patient Is durable medical equipment adjusted to proper height?
may have a clot in his leg. Check the status of the surgical Should home furniture be raised?
scar. There is the possibility of an infection. Make sure Is lighting adequate? Are night lights available?
that the patient has taken any antibiotics prescribed since Is the patient wearing nonslippery shoes or slippers?
other causes of infection may be due to dental work or Are emergency numbers posted near the telephone?
other medical procedures unrelated to the THR. Refer the Is an occupational therapy evaluation needed for home
patient back to the surgeon for further evaluation. adjustment?
Should the patient have an emergency call system
4 Why do so many patients have difficulty performing hip

abduction exercises?
installed?
Are caregivers well trained to assist?
Are the eyeglasses that the patient is wearing clean?
Frequently patients will substitute hip flexion for true Many patients who think that they have lost most of
abduction. They have difficulty firing the glute medius their vision are trying to see through filthy
and glute minimus because of their chronically flexed eyeglasses.
posture. Good hip extension is needed for true abduction
to occur and good concentric and eccentric control of the
hip rotators are needed for a normal gait pattern. Lunges,
done standing in a doorway with elevated arms on either
7 During gait training Julie has difficulty maintaining
TDWB on the affected LE. She tends to place approxi-
mately 20% of her weight onto her affected leg. She
side of the door frame, can effectively stretch the plantar attempts to respond to verbal cues but is unsuccessful.
flexors, hip flexors, arms, and trunk while strengthening A scale was placed under the affected leg so that Julie
the opposite LE quads. Stronger, more mobile patients could see and feel how much weight she was transfer-
may be able to assume a prone position to stretch chron- ring onto her leg. Although she improved after using the
ically shortened hip and trunk flexors. Sidestepping is a scale, she still could not maintain a safe level of TDWB
functional abduction exercise that challenges balance through the affected leg. What is another way to assist
and stimulates both sets of glutes and engages eccentric her in maintaining TDWB status?
hip rotators in stance phase. Backstepping can challenge
even more aspects of balance and posture. A very thick-soled shoe worn on the uninvolved foot
helps lift the patient and facilitates TDWB status. Also a
5 Mary, 73 years old, had an R hip ORIF and has a chroni-

cally flexed trunk and hips. What should the therapist
consider in designing a rehab program for Mary?
saltine cracker packet taped to the bottom of the opera-
tive foot can give the necessary feedback during stance
phase. When the patient progresses to PWB, use the
bathroom scale again to help the patient determine how
A postural assessment should be done and the contrac- much weight to put on the operative LE.
tures noted should be addressed through a cautious
stretching program. Careful straight leg hamstring
stretches done with the therapists assistance may be
added to the supine exercise series. The Achilles tendon
8 Ruth is 70 years old. She sustained a hip fracture at home
when she tripped and fell. She had an ORIF on her left
hip 3 months ago. Before her fall, she could walk without
an assistive device. Presently she walks at home without recommended for home use to improve balance,
an assistive device but needs a cane to ambulate around strength, and endurance.
the community. She rarely goes out because she is so
fearful of falling. She has maintained a strengthening
home exercise program. Ruth feels that her leg remains
weak despite all her exercising. Her LE flexibility is gen-
11 How can a patient build enough hip strength to
allow normal stair climbing?
erally restricted throughout. The left leg is more The patient with WBAT status can practice step-ups onto
restricted than the right. Ruths balance and coordina- a book or a step with a very narrow rise using the opera-
tion also are impaired. Movements other than forward tive leg (Fig. 21-19). An initial isometric contraction can
gait appear labored and slow. Left hip strength is gener- precede the step-up onto progressively taller rises until
ally 4-/5. Should strengthening, stretching, ROM, the patient is able to walk up and down stairs in a normal
balance training, or coordination training be empha- step-over-step pattern while holding a railing.
sized initially during treatment?
The therapist ascertained the conditions that were ham-

pering progress with strength, balance, and ease of
12 How can problems because of abductor weakness
manifest in the hip ORIF patient?
movement during gait. LE flexibility exercises with the Surgical disruption of the abductor tendons can cause
guidance and careful assistance of the therapist were traction neurapraxia on the superior gluteal nerve. A
emphasized during the first four visits. Balance, coordi- shortened abductor lever arm can cause a Trendelen-
nation, gait, and strength issues also were addressed. As burg sign to appear with gait. With abductor weakness,
the flexibility of the LEs increased, advances with strength secondary joint pain can develop at the spine, knees, and
could be obtained more easily. In addition, the patient opposite hip because of the added stresses of the shift-
was able to move her LEs more freely during lateral or ing of the center of gravity while ambulating.
backward movements. Therefore balance and coordina-
tion also progressed. Ruths confidence grew, and in a
few weeks she was safely walking and maneuvering
around the community without an assistive device.
9 Robert is having difficulty with transferring into and out

of his car safely. What adjustments can help him?
A clean plastic trash bag placed over the passengers

seat provides a slippery surface, which allows the patient
to glide-pivot around on the passengers seat and assume
the riders position more easily. If the height of the seat
is adjustable, then raise the seat to the highest possible
position. The back of the passenger seat may need to be
tilted backward if a precaution of less than 90 flexion at
the hip is in place.
10 What activities are recommended following dis-

charge from outpatient physical therapy?
By the end of the outpatient phase, the patient should

have a well-rounded program that can be continued at
home or at a fitness center. Bicycling, recreational
walking, tai chi, and swimming are excellent long-term A B
options for the active patient recovering from hip ORIF Fig. 21-19 Step-ups. A, The patient slowly steps onto a step with the
surgery. Wii Fit or Wii Sport, now being featured at involved extremity while tightening the muscles of the thigh. B, The patient
nursing homes and senior center exercise programs, are must control the knee while stepping up.
REFERENCES 5. White BL, Fisher WD, Laurin CA: Rate of mortality of elderly patients
1. American Academy of Orthopaedic Surgeons: Orthopedic knowledge after fracture of the hip in the 1980s. J Bone Joint Surg Am 69(9)1335-
update 3: home study syllabus, Rosemont, Ill, 1990, the Academy. 1340, 1987.
2. American Academy of Orthopaedic Surgeons: Orthopedic knowledge 6. Fagerson TL: The hip handbook, Newton, Mass, 1998,
update 4: home study syllabus, Rosemont, Ill, 1992, the Academy. Butterworth-Heinemann.
3. Elmerson S, Zetterberg C, Andersson G: Ten-year survival after frac- 7. Clark GS, Siebens HC: Geriatric rehabilitation. In DeLisa JA, editor:
tures of the proximal end of the femur. Gerontology 34:186-191, 1988. Rehabilitation medicine: Principles and practice, ed 3, Philadelphia,
1988, Lippincott.
4. Jette AM, et al: Functional recovery after hip fractures. Arch Phys Med
Rehabil 68:735-740, 1987.
CHAPTER 22
Anterior Cruciate Ligament Reconstruction
Jim Magnusson, Richard Joreitz, Luga Podesta
A
nterior cruciate ligament (ACL) injuries can occur because of secondary restraint pathology.19-21 The surgeon
at any stage of life from 5 to 85 years old.1-3 However, should thoroughly evaluate the patients desired level of
most often they occur in the relatively young active activity to ensure a successful outcome. Multiple studies have
(athletic) population. The age group more commonly associ- made reference to the sequelae of degenerative arthritis and
ated with ACL ruptures is between 14 and 29 years old.3-8 potential for meniscal tears in the ACL-deficient knee.21-25
The extent of the injury and desired level of activity usually Both anatomic and physiologic risk factors have been
dictate when surgical intervention is required. This chapter researched. Some of the anatomic risk factors that may pre-
describes the current surgical considerations, techniques, dispose an individual to ACL injury include the following:
and rehabilitative guidelines with supportive rationale. The hypermobility (laxity of joints), hormonal influences on
individual clinician must determine the speed and intensity hypermobility, a narrow intercondylar notch, ligament
appropriate for each patient. width, tibial rotation, pronated feet, and increased width of
the pelvis in the female athlete.26 Although some causes exist
SURGICAL INDICATIONS AND to suggest certain anatomic features, conclusive evidence has
CONSIDERATIONS not been established between ligament failure and the ana-
tomic risk factors. Physiologic risk factors include poor core
Cause and Epidemiologic Factors strength, lower extremity (LE) deficits in muscular strength
ACL injury has been well documented and classically and coordination, and foot wearground interface. It may be
involves a noncontact mechanism involving rapid decelera- a combination of the previously listed factors that leads to
tion in anticipation of a change of direction (i.e., pivoting ACL injury, but women are two to eight times more likely to
motion) or landing motion.9-13 Boden and colleagues14 sustain injury than males.13,27-29 Hormonal influences that
reported that 72% of ACL tears occurred as a result of non- affect ligament laxity have been explored, with evidence
contact. Most injuries are sustained at foot strike, with the leaning toward this as a nonfactor. However, menstrual
knee close to full extension and with the ground reaction hormones may indirectly contribute to injury by influencing
forces lateral to the knee joint causing a valgus collapse9,15; neuromuscular performance and muscle function.29,30
sagittal plane motion seems to have less influence on the Although there may be some influence on laxity, more com-
ACL during injury.9,16,17 The incidence of individuals sustain- pelling arguments point to strength and coordination differ-
ing a ruptured ACL has been reported at 1 in 3000.12 ences. Many researchers have further studied the relationship
Patients describe feeling and sometimes hearing a pop18 of neuromuscular performance as a potential risk factor.
and are 1000 times more likely to be participating in a sport- They have identified significant differences in neuromuscu-
ing event.4 Swelling is immediate, which implicates a liga- lar control after the onset of maturation. This deficit was
mentous injury because of its associated vascularity. Patients observed in females landing after a jump. The neuromuscu-
exhibiting instability of the knee that affects pivot shift dem- lar deficit allowed migration of the knee into a valgus col-
onstrate a positive Lachman test; positive magnetic reso- lapse position, placing the ACL at risk.9,30-32 Hewett, Myer,
nance imaging (MRI) for ACL rupture should be thoroughly and Ford30also noted that after maturation (i.e., neuromus-
evaluated for surgical considerations. Functionally, these cular spurt) males regained their control; however, females
patients have difficulty performing pivoting and deceleration did not make similar adaptations. The drop jump screening
related to activities of daily living (ADLs) or sports. Although test is a useful examination to help prevent and further
individuals who have sustained isolated rupture of the ACL understand the mechanisms of an ACL injury.33 Leetun and
may continue to be functional, their level of function is com- associates34 looked at lumbopelvic (core) stability as a risk
promised and may require future surgical intervention factor for LE injury in female athletes. They concluded that
404
Chapter 22 Anterior Cruciate Ligament Reconstruction 405
athletes who did not sustain an injury demonstrated better findings in the knee, and developmental-psychologic
hip abduction and external rotation strength, and that hip factors.53,54 Drilling across the physis has not been advocated
external rotation strength was the only useful predictor of because of the risks of arresting bone growth. However, Shel-
injury status. bourne and colleagues51 presented information on a small
Overall, the therapist must be aware of the potential group of SI patients (Tanner stage 3 or 4 with clearly open
risk factors that were present leading up to the ACL injury. growth plates) who underwent intraarticular patella tendon
In this way, the rehabilitation program can safely return graft. Surgery emphasized the importance of not overten-
the patient to the sport and prevent future injury. sioning the graft and meticulous placement of the bone plugs
proximal to the physes. The patients had no growth distur-
Treatment Options bances on follow-up; when confronted with the potential of
The timing of when to perform reconstruction (acute versus new meniscal tears, recurrent instability, effusion, and pain,
chronic) has been a source of debate. It has been accepted ACL reconstruction in the SI patient appears to be a viable
that a higher risk for complications exists if surgery is per- option.26,55
formed (1) before obtaining a homeostatic environment, (2) The anticipated functional limitations (modification of
if range of motion (ROM) is limited (especially extension), activities involving pivoting and deceleration) must be
and (3) when quadriceps and hamstring contraction is inad- explored and explained to the patient who chooses not
equate (i.e., unable to perform a straight leg raise [SLR]).23,35 to have an ACL-deficient knee reconstructed. Ciccotti
It is also apparent that with postponing reconstruction in an and associates56 reported on nonoperative management of
active population, the risk is higher for meniscal and chon- patients from 40 to 60 years. They found that 83% of the
dral surface damage.22,36-38 patients had a satisfactory result with guided rehabilitation.
A topic of debate is how soon after injury should recon- However, they also mentioned that surgery might be an
structive surgery be performed. When using a bone-patella option for individuals wishing to continue sporting and
tendon-bone (BPTB) autograft, evidence exists that surgery pivoting activities.
should not occur before 3 weeks after injury to decrease the Surgical techniques to replace the deficient ACL continue
risk of arthrofibrosis.23,39-41 to evolve. Advances in arthroscopic surgery provide surgeons
Other authors propose that loss of motion is not with the ability to perform these reconstructive procedures
dependent upon time when performing surgery after an using a one-incision endoscopic technique. Research contin-
injury.42-45 ues in the search for the optimal graft, fixation technique, and
Bottoni and associates also showed through a randomized surgical reconstructive procedure. In 1920, Hey-Groves57 and
controlled trial that early ACL reconstructions with a ham- Campbell58 (in 1939) first described the use of the patella
string autograft can be performed and will not increase the tendon as an ACL graft. Because of these original surgical
likelihood of arthrofibrosis because long rehabilitation descriptions, numerous procedures to repair or reconstruct
emphasizes extension and early ROM.45 Sterett and associ- the ACL have been advocated. Attempts at primary repair of
ates did not find an association between incidence of motion the ACL with and without augmentation59-61 were of limited
loss and timing of surgery but used the minimal criteria of success.37 Extraarticular ACL reconstruction also was sug-
active ROM of 0 to 120, active quadriceps control, and the gested as a technique to reconstruct the ACL-deficient knee.62,63
ability to perform an SLR without a lag as determinants of However, long-term results were disappointing.64,65 Intraar-
successful outcome. In a systematic review, Smith and asso- ticular ACL reconstruction using various tissues, including the
ciates did not find a consensus for the optimal time after patellar tendon, iliotibial band, and combinations of ham-
injury to perform reconstructive surgery to return to activity string tendons (semitendinosus, semitendinosus-gracilis), has
faster with limited complications.46,47 been extensively described in the literature.20,66-69
Typically, surgeons will require the patient to achieve full The biologic grafts most widely used today are the central
extension, be able to do an SLR without a lag, and have third patellar tendon (i.e., BPTB complex) or multistrand
minimal to no swelling present before operating. hamstring tendon grafts. Although the hamstring graft has
Researchers have speculated about an age when recon- some advantages,70,71 both procedures are equally successful
struction is not recommended; however, to date no literature (surgeon preference dictates choice if problems such as
has noted any detrimental outcomes based on the age of the patella dysfunction are not present).72-75
patient. In fact, studies have shown no significant difference In general the endoscopic patellar tendon autograft
in outcomes in comparing individuals at the age breaks of reconstruction remains the most popular.10,76-78
35 and 40 years.7,48-50 Reconstruction of the skeletally imma-
ture (SI) patient remains controversial, but the current litera- Graft Selection
ture appears to be leaning toward performing reconstruction. The selection of the appropriate graft to replace the ACL is
Younger populations are sustaining ACL tears; although it crucial to the ultimate success of the reconstruction. Primary
has been generally advisable to await physeal closure before concerns in the selection of an autogenous graft to replace
reconstruction, some surgeons are having successful out- the incompetent ACL include the biomechanical properties
comes.51,52 Appropriateness for reconstruction should be of the graft (e.g., initial graft strength and stiffness relative to
evaluated based on chronologic age, Tanner stage, radiologic the normal ACL), ease of graft harvest and fixation, potential
for donor-site morbidity, and individual patient concerns. studied soft tissue fixation to bone and determined the screw
Other factors that ultimately influence graft performance with washer and the barbed staple to be the strongest
include biologic changes in graft materials over time and methods of fixation.
their ability to withstand the effects of repetitive loading and
stress.79 Noyes and colleagues80 studied the biomechanical Graft Maturation
properties of a number of autograft tissues and showed that Graft maturation has an influence on the patient whose goals
an isolated 14-mm-wide BPTB graft has 168% the strength include a return to sports, most of which require pivoting
of an intact ACL. A graft 10mm wide is about 120% as and cutting. The healing properties of autografts have been
strong. The study also determined that a single-strand semi- discussed in the literature.14,87-90 Although a majority of the
tendinosus graft displayed only 70% of the normal ACL studies we have reviewed describe the maturity of the graft
strength. The data show that BPTB grafts have comparable at 100% 12 to 16 months postoperatively, return to sports
tensile strength but increased stiffness in relation to the participation in some protocols occurs at 6 months (if func-
normal ACL, whereas single-strand semitendinosus grafts tional tests and isokinetics meet criteria).91,92
have decreased tensile strength but comparable stiffness. The graft maturation process begins at implantation and
Other researchers have shown that multiple strands of semi- progresses over the next 1 to 2 years. Autografts are strongest
tendinosus or semitendinosus-gracilis composite grafts are at the time of implantation. The implanted graft undergoes
stronger relative to the normal ACL. a process of functional adaptation (ligamentization), with
The graft of choice varies among surgeons. They currently gradual biologic transformation. The tendon graft undergoes
include BPTB autografts and allografts; single-, double-, and four distinct stages of maturation14,87,89:
quadruple-stranded semitendinosus autografts; and com- 1. Necrosis
posite grafts using semitendinosus-gracilis autografts. The 2. Revascularization
enthusiasm surrounding the use of allograft replacement of 3. Cellular proliferation
the ACL has recently declined because of the small but tan- 4. Collagen formation, remodeling, and maturation
gible risk of infectious disease transmission. The risk of Within the first 3 weeks after implantation, necrosis
human immunodeficiency virus transmission has been esti- occurs in the patella tendon intrinsic graft cells. The graft
mated to be 1 in 1.6 million using currently available bone- consists of a collagen network that to this point has relied on
and tissue-banking techniques.81 Sterilization by means of a blood supply. As this blood supply is interrupted, the graft
fresh freezing of allograft tissue may have an advantage over undergoes a necrotizing process. Necrosis commences
gamma radiation and ethylene oxide. Fielder and associates82 immediately and generally lasts 2 weeks.88-90 Native patella
have determined that 3 mrads or more of gamma radiation tendon (graft) cells diminish, and replacement cells can be
are required to sterilize HIV. Furthermore, sterilization pro- present as early as the first week. Cellular repopulation
cedures have been associated with alterations in graft prop- occurs before revascularization. These cells are thought to
erties and shown to cause a significant average decrease in arise from both extrinsic sources (i.e., synovial cells, mesen-
stiffness (12%) and maximal load (26%),83 and a marked chymal stem cells, bone marrow, blood, ACL stump) and
inflammatory response with ethylene oxide use. Further intrinsic sources (i.e., surviving graft cells). Early full ROM
studies must be conducted regarding poststerilization ACL is desirable because as new collagen is formed, its formation
allograft performance. Although the use of allografts as ACL and strength are dictated by the stresses placed on it.
replacements can diminish operative time and prevent graft As the new cells find their way to this frame and add
harvest site morbidity, they are not recommended for routine stability to this weak structure, rehabilitation must be careful
use in primary ACL deficiency. Currently, either BPTB or not to disrupt or stretch them. Necrosis of the graft allows
multistrand semitendinosus autografts are the most widely the metamorphosis of the graft from tendon to ligamentous
used ACL substitutes to reconstruct the ACL-deficient knee. process. Necrosis of the graft is highlighted by the formation
of granulation tissue and inflammation. The bone blood
Graft Fixation supply and synovial fluid nourish the graft by synovial
Adequate fixation of the biologic ACL graft is crucial during diffusion.93 Revascularization occurs within the first 6 to 8
the early postoperative period after ACL reconstruction. weeks after implantation. By this time the graft is revascular-
Fixation devices must transfer forces from the fixation device ized via the fat pads, synovium, and endosteum,88-90 and the
to the graft and provide stability under repetitive loads and inflammatory response should be under control. Further
sudden traumatic loads. Various techniques are now avail- inflammatory problems signify a delayed healing process
able for fixation, including interference screws, staples, and potential graft problems; the physician and therapist
sutures through buttons, sutures tied over screw posts, and should be alert for them.94,95
ligament and plate washers. Kurosaka, Yoshiyas, and Amiel and colleagues93 in 1986 described ligamentization
Andrish84 determined the interference screw to be the stron- of the rabbit patella tendon ACL graft. However, the graft
gest method of fixation of BPTB grafts. Interference screw never obtained all the cellular features of normal ACL tissue.
strength depends on compression of the bone plug,79 bone Although the graft takes on many of the physical properties
quality,79,84 length of screw thread-bone contact,85 and direc- of the normal ACL, the cellular microgeometry of the
tion of ligament forces.79 Robertson, Daniel, and Biden86 remodeling graft does not closely resemble that of a normal
ACL. The revascularization process progresses from periph-

eral to central.
Bone plugs incorporate into their respective bone tunnels
over a 12-week period but are felt to near completion by
approximately the sixth postoperative week. The compara-
tive strength of the healed tendon-to-bone attachment versus
the healed bone-plug attachment is unknown. Tendon-bone
healing begins as a fibrovascular interface develops between
the bone and tendon. Bony ingrowth occurs into these inter-
faces, which extends into the outer tendon tissue. A gradual
reestablishment of collagen fiber continuity between bone
and tendon occurs, and the attachment strength increases as
collagen fiber continuity increases. These ACL autografts
approximate 30% to 50% of the normal ACL strength 1 to 2
years postoperatively.89
Cellular proliferation and collagen formation take place
Fig. 22-1 Exposure of the patella tendon in preparation for harvesting.
as a continuing process throughout the maturation process.
The function of collagen in the ligament is to withstand
tension, and certain types of catalysts are present during the midpatellar tendon. Two small incisions 10mm apart are
healing process. Transforming growth hormone factor b1 made in the patellar tendon and then extended superiorly
has been isolated during the healing of the medial collateral and inferiorly with a hemostat. The patellar and tibial bone
ligament in rats. Administration of this growth hormone plugs are measured to provide graft lengths of 20 to 25mm
during the first 2 weeks after injury was found to increase of patella and 25 to 30mm of tibial bone. To facilitate bone
strength, stiffness, and braking energy of the ligament.90 graft harvest, the corners of the bone plugs are predrilled
Other catalysts of collagen formation (platelet-derived with a 2-mm drill to decrease stress risers. The perimeters of
growth factor 1 [basic fibroblast growth factor]) have had the bone plugs are then sawed out with a reciprocating saw
equally good results in improving the tensile strength of to a depth of 10 to 11mm, depending on the size of the
healing ligaments. Since our last edition, more human studies patella and tibial tubercle. The graft (Fig. 22-2, A and B) is
are being presented with varying degrees of success.96 With then taken to the back table, where it is prepared and fash-
the relatively recent expansion of platelet rich plasma injec- ioned to allow passage through the appropriate guides. The
tions to assist in soft tissue repair, more research is coming surgeon completes the graft by placing one No. 5 Tycron
out on its use in anterior cruciate ligament reconstruction suture in the femoral and three No. 5 Tycron sutures into the
(ACLR). Recent studies have looked at the use of platelet rich tibial bone plugs to facilitate graft passage through the knee.
growth factor in assisting the reconstruction.97 Future studies The graft is preserved in a saline-moistened gauze sponge for
should be performed to validate this intervention. later use.
During the rehabilitation program, pain and edema The remnant of the ACL is resected, along with any
should dictate the speed at which the patient may progress. hypertrophic tissue. Arthroscopically, the intercondylar
In clinics in which it is available, an assessment using the notch is then prepared with the aid of a burr to prevent graft
KT-1000 (Medmetric, San Diego) is helpful as well.4,23,98-102 impingement. A site is chosen for placement of the tibial
tunnel. Through the midline incision, a small area medial to
SURGICAL PROCEDURE the tibial tubercle is prepared with subperiosteal elevation.
Using a tibial guide and under direct visualization, the
Endoscopic Bone-Patella Tendon-Bone surgeon drills a guide pin into the knee from the outside in,
Complex Anterior Cruciate exiting within the knee at a site chosen anteromedial to the
Ligament Reconstruction ACL insertion. The tibial tunnel is reamed to the size of the
The procedure begins with a complete examination of the harvested graft. A curette placed over the guide pin during
knee under anesthesia followed by a thorough diagnostic reaming helps protect the articular cartilage and posterior
arthroscopic evaluation. The menisci, joint surfaces, and cruciate ligament from damage. The tibial tunnel must be
ligamentous structures are evaluated and additional injuries larger than the femoral tunnel to allow passage of the graft
assessed arthroscopically. The leg is then exsanguinated, and into the knee. The tibial tunnel edges are smoothed with a
a tourniquet is inflated with 350mm of pressure. A medial rasp to prevent graft abrasion after implantation. A fenes-
parapatellar incision is made from the inferior pole of the trated plug is then placed into the tibial tunnel to prevent
patella to the tibial tuberosity. The skin is dissected down to fluid extravasation yet allow passage of instruments.
the peritenon, and skin flaps are made superiorly, inferiorly, The femoral isometric point is determined on the medial
medially, and laterally. The peritenon is incised and the aspect of the lateral femoral condyle, usually 3 to 5mm
patella tendon is exposed. The width of the patellar tendon anterior to the posterior cortex near the superior intercon-
is noted (Fig. 22-1), and a 10-mm graft is measured from the dylar notch margin (over-the-top position); it is marked with
and a continuous subcuticular skin closure is performed. The

wounds are dressed sterilely. A light compressive wrap and
continuous ice water cryotherapy system are applied, and the
patient is taken to the recovery room with the knee in a knee
immobilizer in full extension.
PHYSICAL THERAPY GUIDELINES

FOR REHABILITATION
Rehabilitation following ACL reconstruction has dramati-

cally changed over the past 20 years. While the gold standard
of graft choice still remains a BPTB autograft, previous reha-
bilitation protocols were tailored for this surgery.89,91,94,102-119
Physical therapy therefore must adapt its rehab protocols
A and tailor them to the individual patient based on graft
choice and concomitant injuries and/or surgery. Regardless
of the surgical procedure, the rehab protocol must be based
on biologic healing. This section will discuss preoperative
management following injury, including decision making for
conservative management, and postoperative management
from the acute inflammatory phase to return to activity.
Preoperative Management (Table 22-1)

Goals:
Decrease swelling and inflammation
Increase ROM
Increase quadriceps strength
Evaluate the entire LE
Regardless of when surgery is scheduled, the patient
B almost always is evaluated and receives treatment to increase
ROM, especially extension, increase quadriceps/hamstrings
Fig. 22-2 Removal of the bone-tendon-bone graft from the patella.
strength, and achieve a normal gait pattern. The evaluation
A, Graft removed from the distal patella. B, Graft completely removed.
commonly begins with an assessment of gait when the
patient enters the premises. The patient will often exhibit a
flexed-knee gait or a quadriceps avoidance pattern.120 The
a curette or burr. With the knee flexed past 90, a fenestrated patient will commonly have a rehabilitation brace locked in
guide pin is inserted into the knee through the tibial tunnel extension and will use two crutches. While the brace is
and drilled through the femoral isometric point and out thought to limit ROM and varus-valgus forces to the knee,121
through the skin with the aid of an over-the-top guide. The the evidence is inconclusive that braces improve extension,
femoral tunnel is then reamed to the size of the femoral bone and decrease pain and graft strain following ACL recon-
plug to a depth of 30mm. struction.122 Clinically speaking, the brace is used preopera-
The sutures from the femoral bone plug are inserted into tively and postoperatively to limit external forces that may
the femoral pin and pulled out through the skin. The graft is cause further damage to the knee. For example a patient
delivered into the knee, through the tibial tunnel, and into before having ACL reconstruction may fall and tear their
the femoral tunnel under direct visualization. A cannulated meniscus or have some osteochondral damage. Active and
interference screw is then inserted into the knee over a nidal passive knee ROM, patella mobility, presence of edema,
guide pin and screwed into the femoral tunnel, compressing hamstring and gastrocnemius flexibility, quadriceps strength,
the femoral bone plug within the tunnel. Graft isometry is and weight-bearing capacity should be assessed. During the
evaluated. The tibial bone plug within the tibial tunnel is preoperative phase, the patients whole kinetic chain should
secured with interference screw fixation. ROM and stability be evaluated. Strength, flexibility, and mobility of the foot,
testing are then performed. The graft is evaluated arthroscop- ankle, hip, and core should be assessed. Particular attention
ically to assess graft excursion and placement within the should be given to the mechanism of injury to start planning
intercondylar notch. prevention strategies for postoperative rehabilitation. Assess-
The tourniquet is released, hemostasis is obtained, and ing the entire kinetic chain before the surgery is easier and
the knee is irrigated. Loose closure of the patellar tendon is more comfortable for the patient than after surgery because
performed with the peritenon approximated to close the of the amount of pain and how inflamed the knee will be.
anterior defect. The subcutaneous tissue is approximated, Exercises and modalities should be used to decrease
TABLE 22-1 Preoperative Anterior Cruciate Ligament Reconstruction

Rehabilitation Criteria to Progress
Phase to This Phase Intervention Goal Rationale
Phase 1a Preoperative Cryotherapy 20-30min By the end of 4 wk: Pain control

Preoperative Elevation with ankle pumps (10 Self-manage pain Edema management
1-4 wk repetitions per minute) 20-30min Decrease edema Gait training for safety and ease with
Gait training (emphasizing normal ROM 0 extension to 130 transition postoperation
gait pattern weight shift) flexion ROM stretches to prevent
PROM stretchessupine knee Independent straight leg raise complications going into surgery
extension, prone hangs, supine wall Full weight bearing (brace as Muscle pump to assist lymph drainage
slides, seated knee flexion appropriate) Graduated exercise to improve
Isometric exercisequadriceps/ Good isometric quadriceps neuromuscular coordination
hamstring sets (cocontraction) contraction Emphasize self-management of ROM
A/AROMseated knee flexion Maintain hip and ankle program
AROM-PREsheel raises, hip strength Prepare for transfers (supine-sit)
abduction/adduction, external ROM and muscle contraction to assist
rotation with edema management and improve
Joint and soft tissue mobilization ROM
Decrease pain through soft tissue and
joint mobilization techniques
A/AROM, Active assistive range of motion; AROM, active range of motion; PREs, progressive resistance exercises; PROM, passive range of
motion; ROM, range of motion.
inflammation and swelling, restore patellofemoral mobility flow cold therapy should be used over crushed ice.128,129 Ele-
and increase quadriceps strength as well as global LE strength vation with muscle pumping (ankle pumps, quad sets) can
and flexibility. help the lymph system remove tissue debris and inflamma-
tory byproducts (free-floating proteins too large to filter
Phase 1: 0 to 4 Weeks (Table 22-2) through the capillaries).127 Cryotherapy with compression
Goals: and elevation should occur after each treatment session, as
Protect the healing graft well as up to 5 times daily for 20 minutes when pain, inflam-
Decrease swelling and inflammation mation, and swelling are present. Girth measurements
Attain full extension should be taken at the midpatella, as well as proximally and
Increase quadriceps strength distally, to monitor progress of swelling reduction.
Rehabilitation following ACL reconstruction can be Patients will typically have two crutches and a postopera-
broken down into phases. Phase 1 begins immediately after tive brace locked in extension for the first week following
surgery and lasts 4 weeks. In this phase, emphasis is placed surgery. After 1 week, the brace can be unlocked for exercise
on decreasing pain and inflammation, protecting the healing and gait. If the patient demonstrates a normal pain-free gait
graft, and restoring strength and ROM. While inflammation pattern, they may wean from two to one crutch, and then
after surgery is normal, the swelling and subsequent pain discharge them entirely. The brace will typically be dis-
must be reduced as soon as possible. Swelling can increase charged once the patient has approximately 100 of flexion,
pain and quadriceps muscle inhibition.123,124 is able to do an SLR without a lag, and has a normal pain-free
Hopkins and associates showed that transcutaneous elec- gait cycle. This process usually occurs 4 to 6 weeks after
tric neuromuscular stimulation can be used to control pain surgery. Table 22-3 shows commonly used guidelines for
and edema.125 Jarit and associates showed that home inter- using and discharging the brace and crutches.
ferential current therapy can help to reduce pain and swell- As previously stated, there should be an emphasis on early
ing, and increase ROM following knee surgery.126 However, ROM following surgery. Full passive knee extension should
the time parameters for transcutaneous electric neuromus- be achieved within the first week to decrease abnormal joint
cular stimulation125 was 30min/day and interferential arthrokinematics and prevent arthrofibrosis.130,131 Bracing in
current therapy treatment126 was 3 sessions per day for 28 extension22,132 or hyperextension133 can be used as a means
minutes per session, which may not be feasible for both the to prevent flexion contractures. Patellar mobilizations, espe-
patient and treating physical therapist. Cryotherapy, whether cially superiorly and inferiorly, should be applied to regain
in the form of continuous flow cold therapy, crushed ice, or full mobility. Patellar immobility could result in ROM
commercial cold gel packs, is effective at reducing secondary complications and difficulty recruiting quadriceps
hypoxia, pain, and edema.125,127 When available, continuous contraction.4,92,100,134-145
TABLE 22-2 Phase 1 Anterior Cruciate Ligament Reconstruction

Phase 1 Postoperative Brace should be worn for all exercises Achieve the following by the Provide support and proprioceptive
Postoperative in bold type end of wk 4: feedback
1-4 wk Edema and pain management ROM 0-125 Prevent complications
program Transfers (supine-sit) Control pain
PROMsupine knee extension, prone without assisting involved Manage edema
heel hangs, supine wall slides leg (SLR independent) Provide PROM to improve joint mobility
Isometricsquadriceps/hamstring sets, Good quality thigh and calf and decrease pain
coconcoction, towel squeeze muscle contraction Initiate home exercise program
AROMheel slides Full weight bearing Teach isometrics to improve muscle
SLR (brace locked at 0); hip Walk without crutches or recruitment in preparation for functional
(flexion, extension, abduction, cane (household and limited activities
adduction); standing hamstring curls community distances) Provide AROM to improve
PREssupine leg press (0-45 Self-manage edema/pain neuromuscular coordination, strength,
as indicated), heel raises, bicycle, transfers, and gait
and when appropriate (full weight Promote self management of pain
bearing pain free), step-up exercises Educate on positions/movements that
(initiate on a 2-inch step) will stress the graft
Gait training using crutches: weight Provide gait training to progress
bearing as tolerated, normalize gait independent ambulation without
(use small obstacle [foam cup] to assistive device
emphasize hip and knee flexion in Increase strength and tolerance to
conjunction with ankle dorsiflexion) weight bearing
Weight shiftingjoint mobilization as Joint mobilization to restore ROM and
indicated improve arthrokinematics
Patella glides tibia-femoral (posterior)
glides
AROM, Active range of motion; PREs, progressive resistance exercises; PROM, passive range of motion; ROM, range of motion; SLR, straight
leg raise.
TABLE 22-3 Guidelines for Using and Discharging

Brace and Crutches
Brace Locked in full extension for the first week
Unlocked for exercises in physical therapy
Discharged when the patient has full extension, no lag with
an SLR, and at least 100 of flexion
Crutches Bilateral crutches following surgery for first 4 wk
After 4 wk, wean to one crutch and then discharge as long
as the patient has a normal gait pattern without pain Fig. 22-3 Prone heel hangs. Patient is in the prone position with the
involved leg hanging over the edge of the table or bed. Care is taken to avoid
SLR, Straight leg raise. pressure on the patella.
Exercises to achieve full extension include, but are not

limited to, hamstring and gastrocnemius stretching, quad educate the patient to avoid putting a pillow under the knee
sets with the heel propped under a wedge, superior patella when resting at home so that the patient does not develop a
mobilizations, a prone or supine (Figs. 22-3 and 22-4) hang, flexion contracture. Tables 22-4 and 22-5 show examples of
and overpressure of up to 10lb. Remember that the ACL commonly used exercises to increase ROM.
prevents anterior tibial translation and posterior femoral Within the first 2 weeks following isolated ACL recon-
translation. With joint mobilizations, take caution with over- struction, the patient should achieve 100 to 120 of flexion.
pressure to avoid pushing the joint in the direction that the If a concomitant meniscal repair is performed, the patient
healing ACL graft limits (Fig. 22-5). The heel should also be will be limited to 90 flexion for the first 4 to 6 weeks follow-
propped up when icing and/or resting at home. You must ing surgery. Common causes of decreased flexion include
TABLE 22-5 Knee Flexion Exercises

Active exercises Active heel slides
Standing heel slide curls
Bicycle
Passive exercises Passive heel slides
Use of continuous passive motion machine
Manual therapy Inferior patellar mobilizations on
nonbone-tendon-bone graft patients
Posterior tibial mobilizations
a stationary bicycle. It is difficult to stretch the quadriceps

when there is decreased knee flexion. However, the physical
Fig. 22-4 Passive knee extension. Patient is supine or sitting with involved
therapist can stretch the patient in the side-lying position
leg straight, into full extension. A towel is placed under the heel, allowing
the knee to hang. Care is taken to avoid rotating the hip. with the knee flexed as much as tolerated and stretching into
more hip extension. Despite conflicting evidence of long-
term benefits,146-148 the use of a continuous passive motion
device may also be used at home for 4 hours per day until
the patient reaches 120 flexion.
Increasing quadriceps strength is another goal of phase 1.
A hallmark in the early rehabilitation process is the ability
to perform an SLR without a lag. To achieve full active exten-
sion, the patient must also have full passive extension and
adequate superior patella mobility. As mentioned previously,
there should be minimal pain and swelling to decrease quad-
riceps inhibition.55,123,124,127
Early initiation of quadriceps strengthening has been
shown to increase ROM and quadriceps muscle torque
safely.149
Debate exists on the most appropriate type of strengthen-
ing. Closed kinetic chain (CKC) exercises are more func-
tional and were previously thought to be safest for the healing
Fig. 22-5 Mobilization for extension range of motion. A posterior glide of graft.92,150-155
the tibia on the femur can be accomplished, avoiding stress to the graft CKC exercises can begin with isometrics (Fig. 22-6) and
and donor site. Care must be taken to avoid unprotected hyperextension of progress to include minisquats and the leg press in the range
the knee.
of 0 to 45 to minimize patellofemoral joint stress (Fig.
22-7).47,156 However, it has been shown that controlled open
TABLE 22-4 Knee Extension Exercises kinetic chain (OKC) quadriceps strengthening is both safe
and advantageous following ACL surgery.157-161 These
Active exercises Quad sets authors157-161 reported that active OKC knee extension
SLRs without resistance did not strain the ACL from 90 to 40 of
Terminal knee extensions (closed chain) flexion. Mikkelsen and associates159,162 showed that it was
Passive exercises Hamstring and gastrocnemius stretches safe to add OKC knee extension exercises from the sixth
Prone hang week postsurgery in the range of 90 to 40, and progressing
Supine or long-sitting with heel propped to 90 to 10 by the twelfth week. Steinkamp and associates156
Manual therapy Superior patella mobilizations showed that OKC knee extension can be performed with
Overpressure <10lb minimal patellofemoral joint stress from the range of 90 to
45. Heijne 163 began OKC knee extension exercises at 4
SLR, Straight leg raise.
weeks and 12 weeks for both hamstring tendon and patellar
tendon grafts. Quadriceps muscle torque was not signifi-
arthrofibrosis, patella immobility (particularly with the infe- cantly different for any group. But the early addition of OKC
rior glide), posterior capsular hypomobility, decreased quad- exercises for patients receiving hamstring tendon autografts
riceps flexibility, and excessive swelling. Exercises to increase resulted in significant increased laxity over time. They there-
knee flexion include active and active-assisted heel slides, fore concluded that further studies are needed to determine
posterior tibial and inferior patella mobilizations (in non the optimal time to add OKC quadriceps strengthening fol-
bone-tendon-bone autograft graft patients), and pedaling on lowing ACL reconstruction with a hamstring graft. Because
of the potential increased strain to the graft with OKC exer-

cises in low levels of flexion (<30), isometric quadriceps
exercises should be done at 0, 90, and 60. Emphasis should
be on achieving a superior patellar glide with each quad set,
and an inferior patellar glide when they relax. OKC knee
extension should be in the range of 90 to 40 in the early
weeks following ACL reconstruction. If a hamstring graft is
used, the patient should wait until after the fourth week. If a
lag is present, an SLR will cause strain to the healing graft
because the quadriceps is active with the knee in low levels
of flexion. Therefore, the patient should wear their postop-
erative brace with it locked in extension for the exercise until
the lag is gone. When performing SLRs, the patient should
actively do a quad set with each repetition to increase neu-
romuscular control.
Even in the acute phase, the entire kinetic chain can be
strengthened. OKC hamstring curls and/or CKC hamstring
sets and bridges may be used to strengthen the hamstrings.
Caution should be given, if a hamstring autograft was used,
when strengthening the hamstrings. If, for example, the
patient receives a concomitant meniscal repair, weight-
bearing and/or hamstring strengthening exercises may be
delayed for 4 to 6 weeks. Four-way SLRs hip external rotation
and abduction can be used to strengthen the hip. Weight-
bearing heel and toe raises or use of a resistance band or cuff
weight can be used to strengthen the ankle. Weight shifting
side-to-side and front-to-back should be employed as the
precursor to gait training.
Neuromuscular electrical stimulation (NMES) should be
used to increase quadriceps strength and improve gait164 fol-
Fig. 22-6 Spider killers. Patient is seated with the involved knee (in this lowing ACL reconstruction. Their protocol used a 2500-Hz
case the left) flexed to a comfortable position (70 to 90). The patient is
alternating current, with intensities that induced at least 50%
instructed to palpate over the vastus medialis oblique while applying pres-
sure down through the heel (ankle dorsiflexed), eliciting a quadriceps and of maximum voluntary isometric torque measured by a
hamstring cocontraction. dynamometer positioned at 60 to 85 of flexion. The con-
traction time was for 10 seconds followed by a 50-second
rest, for a duration of 10 to 15 contractions. Their results
demonstrated a greater increase in quadriceps strength than
voluntary exercise alone.164-166
Fig. 22-7 Inclined sled. The use of an inclined sled can be initiated early to recruit volitional muscle contraction in a limited weight-bearing (resistance)
environment.
Fitzgerald and associates167 modified the protocol that the patient be educated on the importance of doing his
described by Snyder-Mackler and associates in which the or her home exercise program. It is the job of the treating
patient receives the NMES with the knee in full extension. physical therapist to provide the patient with a detailed yet
The NMES and exercise group demonstrated moderately easily understood list of exercises to perform, teach the
greater quadriceps strength at 12 weeks and moderately patient the proper form for each exercise, and maximize time
higher levels of self-reported knee function at both 12 and spent in each physical therapy appointment.
16 weeks postsurgery compared with the exercise only group.
If a dynamometer is available, the physical therapist should Phase 2: 4 to 16 Weeks (Table 22-6)
apply the parameter described by Snyder-Mackler and asso- Goals
ciates.164,166 However, Fitzgerald and associates demonstrated Increase LE strength
positive gains with his modified protocol.167 Increase neuromuscular control
Some patients are given portable NMES units to use at Normalize gait
home in addition to exercises, depending on whether they Prepare for running
are unable to receive formal physical therapy twice per week Phase 2 begins when the patient has full passive ROM and
or are having difficulty achieving adequate volitional quad- normalized pain-free independent gait and lasts until the
riceps strength. The Empi 300PV (Empi, St. Paul, Minn.) has patient begins to run (if and when appropriate).
been shown to produce comparable levels of average peak In phase 2, the primary focus of rehabilitation is to
torque for quadriceps strengthening.44 increase strength and neuromuscular control in preparation
Because of the limited number of physical therapy visits for dynamic tasks and be independent with ADLs.
paid for by insurance, the patient may only be treated once Strength training should follow the principle of progres-
per week for the first 4 to 6 weeks. It is therefore imperative sive overload, which means to gain strength, the muscles

Phase 2 Postoperative Braces should be worn (if indicated) for all Achieve the following by the Wear brace for additional
Postoperative exercises in bold type end of wk 8: proprioceptive input to the
4-16 wk Continue phase 1 exercises (patient may have Range of motion 0-135 knee and to increase stability
functional brace by 6 wk, depending on 100% single-leg squat Increase muscle strength to
physician) 90-0 progress functional activities
Exercise intensity progressed from AROM to Gait with functional brace 1 Use limited range on
PREs mile open-chain exercises to protect
PREsstep up/down, progress to Transfer sit-stand (equal graft
6-inch step weight bearing) Prepare for return to sport or
Isokineticslimited range (90-30) Self-manage pain activity
Walking program inclusive of boxes Stand for 1 hour Increase patient self-reliance
and figure eights Achieve the following by the for exercise and
Balance exercises end of wk 16: self-management
Patient education Come within 10% of full Improve joint mechanics and
Continue joint mobilization range flexion normalize arthrokinematics
Brace should be worn if any quadriceps Isokinetic test within 25% of Increase stability of the knee
insufficiency is present uninvolved knee while limiting stress on the
Phase I and II exercises as indicated Run 1 mile without pain graft
PREs using closed and open chain (isokinetic) (patient dependent) Prepare for functional activities
(open chain 90-30) Initiate sport- or activity- such as jumping and hopping
Trampoline jogging progressing to single-leg specific training, modifying Prepare to return to sports
balance/hopping, initially bilateral, appropriately
progressing to unilateral in later phase
Initiate running when cleared by physician
(usually by third month)
Sport- and activity-specific drills as appropriate
AROM, Active range of motion; PREs, progressive resistance exercises.

must be gradually loaded beyond the point to which they are trampoline, a tilt-board, and rocker-board, and with the eyes
normally loaded.168 However the clinician must keep in mind open or closed.180,181
that the reconstructed joint (mechanics), patellofemoral Dynamic single-leg stance exercises can include doing
control, and joint surfaces may be the limiting factors for another task while balancing, such as throwing and catching
progressing exercise intensity. a ball or reaching in multiple directions like a star.182
Ideally, a one repetition maximum (RM) can be found for Isolated quadriceps strengthening should progress from
each exercise, and exercise prescription can be based on that. simple quad sets and SLRs to knee extensions in the pro-
Initially, strength training in the early phases after surgery tected ranges. Quadriceps strengthening that incorporates
will start with 1 to 3 sets of 8 to 12 repetitions with 70% to the entire kinetic chain should include double- and single-
80% of 1 RM. Once this initial goal is met, muscle endurance leg squats, forward and lateral step-ups, wall squats and
should be progressed, consisting of 3 to 5 sets of 15 to 25 lunges in multiple planes (Figs. 22-8 through 22-12). Global
repetitions with 50% to 70% of 1 RM. hip strengthening should progress from SLRs on the table to
To build muscular power, exercise prescription should use of a machine, or sidestepping and diagonal stepping with
change to 1 to 3 sets of 3 to 6 repetitions (with >80% of 1 a resistance band. Hamstring strengthening should progress
RM) but also performed at a fast velocity (usually performed from prone or standing curls with cuff weights to use of a
during phase 3).169 Exercises should be both concentric and machine, Romanian deadlifts, and curls with a Physioball
eccentric, and isolate specific muscles as well as combine the while doing a bridge. Core strengthening should include
entire kinetic chain. However, it is still important to remem- double- and single-leg bridges, prone and side planks, and
ber to protect the healing graft by keeping exercises in the the chop and lift183 in a lunge position. By the ninth week
protected ranges. Approximately 6 to 8 weeks after surgery, postoperation, patients should have close to full ROM, be
the mechanical strength of the healing graft is at its weakest.170 able to perform a unilateral squat with 100% body weight (0
However, during that time, bony plugs from BPTB grafts to 90), walk up to 1 mile, tolerate standing for at least 1 hour,
heal within the tibial and femoral tunnels.171 It is not until 8 and demonstrate independence in self-management of exer-
to 12 weeks after surgery that the soft tissue to bone healing cises. The hallmark of this phase is progression from being
within the tunnels occurs with hamstring grafts.172 a functionally independent person with ADLs to initiating
Recently, Gerber and associates173 demonstrated increased exercises/activities in preparation of returning to the previ-
quadriceps and gluteus maximus strength after a 12-week ous level of physical activity (Return to running, hiking, and
eccentrically focused resistance training program at 1 year sport-specific activities which will be progressed in phase 3).
following ACL reconstruction compared with standard reha- We suggest a simple progression for the return to running
bilitation. Lately, neuromuscular training protocols are being based on activity or sport need and allowing a rest day
integrated into the rehabilitation process. Neuromuscular between runs (as shown in Box 22-1). For a more complete
training is such that enhances unconscious motor responses return to a running program refer to Chapter 34.
by stimulating both afferent signals and central mechanisms
responsible for dynamic joint control. The goal is to induce Phase 3: 16 Weeks to 6 Months (Table 22-7)
compensatory changes in muscle activation patterns.174 Goals:
Previous studies show positive results following ACL Continue to increase muscle strength, power, and
injury.93,175-177 These programs consist of balance exercises, endurance
dynamic joint stability exercises, plyometric exercises, agility Initiate/progress return to running program
drills, and sport-specific exercises. Risberg and associates178 Phase 3 begins when the patient is cleared to run, but
showed that a 6-month neuromuscular training program there is no consensus about when to start following ACL
versus a traditional strength training program resulted in reconstruction. During phase 3, the patient should progress
significantly improved Cincinnati Knee Scores and visual all exercises to increase LE flexibility and muscular strength,
analog scales for pain and function. Risberg and associates179 power, and endurance. Commonly, the surgeon will wait
also showed that at a 2-year follow-up, there were no signifi- between 3 to 6 months following surgery to clear the patient
cant differences between a neuromuscular exercise training for running based on graft healing and concomitant
protocol and a traditional strength training protocol for the surgeries.142,170,172,184
Cincinnati knee score but there was significantly improved Few studies are available that give criteria to begin running
knee function and reduced pain. It is the opinion of the following ACL reconstruction. Myer and associates,185
authors of this chapter that rehabilitation programs after however, used the criteria of: (1) minimum Internation Knee
ACL reconstruction should include traditional strength Documentation Committee subjective knee form score of
training, both concentrically and eccentrically focused, as 70, (2) either no postsurgical history of giving way or a nega-
well as neuromuscular training. tive pivot shift, and (3) a minimum baseline strength knee
Balance exercises can begin as soon as the patient is com- extension peak torque/body mass of at least 40% (male) and
fortable with weight bearing. They can begin with forward 30% (female) at 300/sec, and 60% (male) and 50% (female)
and lateral weight-shifts and transition to tandem standing. at 180/sec. A major obstacle to using their guideline can be
Single-leg stance exercises can be performed in a variety of if the treating physical therapist does not have access to a
ways: on the floor, on unstable surfaces such as foam, a dynamometer. The authors of this chapter recommend that
Fig. 22-8 Step up and down. Patients progress from 2-inch to 6-inch high steps. Care is taken to prevent increased stress on the graft and patella (knee is
kept in line with the foot and not allowed to migrate anterior to the toes during the exercise).
Fig. 22-9 Single-limb balance into terminal extension. This exercise can Fig. 22-10 Single-limb balance using elastic band. Standing on the
be initiated with both feet on the floor and resistance band around the distal involved leg (in good alignment), the patient performs hip movements (i.e.,
femur pulling into flexion. The patient should maintain terminal knee flexion, extension, abduction, adduction) with the uninvolved leg. Resisted
extension while avoiding any pain. This exercise can be progressed to allow hip adduction is pictured here.
the patient to perform terminal knee extension movements maintaining
balance.
the patient use a leg press and knee extension machine (12
weeks after surgery) to find the 1 RM for the involved and
uninvolved leg and use 70% for the minimum strength cri-
teria to begin running. It is also recommended that the
patient have no episodes of giving way before initiating
running and have the ability to walk as fast as possible on a
treadmill for 15 minutes without an increase in pain or signs/
symptoms of inflammation. A trampoline can be used ini-
tially to increase tolerance to absorption of ground reaction
forces before running. Patients should simulate bouncing on
a trampoline but without letting their feet leave the surface
because they are not yet cleared for plyometric activities,
BOX 22-1Running Program

Fig. 22-11 The skatersingle-limb balance on the involved leg with
partial knee flexion. Slowly (maintaining a neutral spine with slight exten- Week 1
sion bias) have the patient flex at the hip, maintaining alignment of the knee Walk 1 4 mile; then run 1 4 mile (50% effort) for four repeti-
in both the coronal and sagittal planes. Progress the degree of difficulty by tions, three times a week.
increasing hip flexion so that the torso is parallel to the floor.
Week 2
Walk 1 4 mile; then run 12 mile (50% effort) for two repeti-
tions, three times a week.
Week 3
Walk 1 4 mile, run 1 mile (50% effort); then walk 1
4 mile for
one repetition, three times a week.
Week 4
Walk 1 4 mile, run 1 4 mile (50% effort), walk 1 4 mile, run
1 mile (75% effort); then walk 1 mile for two repetitions,
2 4
three times a week.
Week 5
4 mile
for two repetitions, three times a week.
Week 6
Walk 1 4 mile, run 1 4 mile (75% effort), walk 1 4 mile, run
1 mile (100% effort); then walk 1 mile for 2 repetitions,
2 4
3 times a week.
Week 7
4 mile
Fig. 22-12 Single-limb balance using medicine ball. Toss and catch activ- for 2 repetitions, three times a week.
ity, maintaining good alignment and slight knee flexion.

Rehabilitation Criteria to Progress to
Phase this Phase Intervention Goal Rationale
Phase 3 Same as in phase 2 Continuation of exercises from Achieve the following before return to Improve LE neuromuscular response
16 wk-6 phases 1-2 as indicated sport or activity: to sports-related activity
months Neuromuscular training Isokinetic test within 10% Improve the muscular stability of
Plyometricshopping and Functional tests within criteria to the knee
jumping activities return to sport Return to sport/activity safely and
Sport-specific activities Return to sport by 8-12 months confidently
LE, Lower extremity.

much less activities on an unstable surface. Running should pivoting, and cut-and-spinning. Again, the physical therapist
begin at a comfortable pace for short durations (1 to 2 should look for any compensation when decelerating.
minutes), followed by walking for 30 seconds to 1 minute. Returning to sport should be a collaborative decision
The running duration should increase as tolerated. The phys- made between the surgeon and the physical therapist. It is
ical therapist should look for any evidence of pain, such as the responsibility of the physical therapist to prepare the
audible differences from foot to foot or different stride patient for all tasks they could encounter in their particular
lengths. The patient should not progress in time or speed of sport. The patient must demonstrate each exercise at 100%
running if there are any complaints of pain, instability, or effort with no episodes of giving way, increased pain, or
signs/symptoms of inflammation. signs/symptoms of inflammation. The patient should return
to practice (if applicable) and perform at 100% effort without
Phase 4: 6 to 9 Months episodes of giving way, increased pain, or signs/symptoms of
Goals: inflammation before participating in games. Although the
Normalize running pattern time frame varies with the demands of the activity, Malone
Begin agility exercises and Garrett94 note that it is possible to return to the sport at
Begin plyometric exercises 6 months if the patient has successfully completed con-
Prepare for return to sport trolled physiologic rehabilitation. Thus initiating the train-
The last phase of rehabilitation focuses on the actual ing at the 4-month point allows 2 months of functional
return to the activity or sport. The correct timing of when to training and progression. Isokinetic testing is another piece
release an athlete back to sport participation has been contro- of the puzzle used to determine whether the patient is ready
versial. Although criteria for return to sport may be fulfilled to return to sport.188 Shelbourne and associates136 described
before the desired time frame, the clinician must discuss and criteria for return as follows:
weigh short-term and long-term risks and rewards with the Full ROM
athlete should he or she desire to participate. A recent study Strength at 65%
found that only 63% of National Football League players who Completion of prescribed running and agility drills
underwent ACLR returned to play. The 63% who returned to The factors that most rehabilitation programs use to eval-
play took an average 10.8 months to do so.78 uate readiness for return to sport are KT-1000 stability, iso-
Phase 4 is the final phase of rehabilitation, focusing on kinetic equivalence, and functional tests.4,91,92,135,189-191 The
preparation for return to sport. In this phase, rehabilitation most useful of these, without denying the importance of
will focus on sport-specific exercises such as agility, plyomet- others, is functional testing. By using a complement of
rics, and sprinting. The rehabilitation protocol should be functional and isokinetic tests, the therapist and physician
individualized to meet the demands of not only the patients can determine when return to sport is appropriate. An
sport, but also their position. A receiver in football has dif- average timeframe for functional exercises is running at 4.3
ferent physical demands than a lineman; just as a shortstop months, jumping at 6.5 months, return to light sports at 5.0
has different demands versus a centerfielder in softball. It is months, return to moderate sports at 5.8 months, and return
difficult to decide when to initiate each of these exercises to strenuous sports at 8.1 months.142
because there is little evidence available. While there are Currently, there is not a specific, validated return to sport
some guidelines available,138,186,187 they may not apply to your criteria following ACL reconstruction. There are, however, a
patient based on machines needed, graft type, and/or con- variety of tests that have been described in the literature.
comitant surgery. The further direction of initiating func- Neeter and associates184 showed a high ability to determine
tional exercises is the opinion of the treating clinician. Once deficits in leg power 6 months after both ACL injury
the patient can tolerate running 1 to 2 miles, they can begin and ACL reconstruction using a test battery of OKC knee
low level agility drills such as forward/backward shuttle runs, extension, OKC knee flexion, and CKC single-leg press.
lateral shuffling, and carioca. Speed should start at 50% of Reid and associates160 found the use of the single hop for
the patients self-perceived effort and increase as tolerated. distance, a 6-m timed hop, a triple hop, and crossover hops
The physical therapist should look for any compensation for distance to be reliable and valid following ACL recon-
when the patient decelerates and pushes off the involved LE. struction with intraclass correlation coefficients for limb
Plyometric training should begin next in all planes of motion. symmetry index values ranging from 0.82 to 0.96. The tuck
Jumping (two feet) should begin forward, at short distances. jump may be used to identify LE valgus and side-to-side
Emphasis must be placed on avoiding a valgus collapse when differences.192
loading before the jump, as well as landing. When the patient Intrarater within-session reliability was 0.84 (range, 0.72
demonstrates adequate dynamic control of forward jumps, to 0.97) when scoring the tuck jumps.186 Ground reaction
they should progress in distance jumped, jumping in the forces can be assessed via hopping on force plates. A decrease
frontal and transverse planes, jumping onto boxes, and con- in quad strength could result in decreased knee flexion
secutive jumping. Hopping (one foot) should follow the angles when landing, which would increase the force at
same progression after the patient demonstrates dynamic landing.193 Maximum vertical ground reaction force
control with jumping. The last functional exercises that shows high within-session reliability on both the dominant
should be added are high-level agility drills such as cutting, (r = 0.823) and nondominant (r = 0.877) sides.194
It is recommended that athletes have a side-to-side dis- eventually cause articular damage. Paulos and colleagues206
crepancy of less than 10%.194 have defined three stages in the arthrofibrotic knee:
Differences in drop landing195 and drop vertical jump196 1. In the early stage, stage 1 (2 to 6 weeks), decreased exten-
should be addressed to within 10%. Because unsuccessful sion is noted, in addition to quadriceps lag, diminished
ACL reconstruction can range from 3% to 52%,197 ACL patellar mobility, joint swelling, and failure to progress in
injury prevention techniques should be incorporated rehabilitation.
throughout the rehabilitation process. 2. The active stage, stage 2 (6 to 30 weeks), is defined by a
In an effort to avoid excessive genu valgum, the hip marked decrease in ROM, decreased patellar mobility,
abductors should be strengthened. The responsibility of the quadriceps atrophy, skin changes, and osteopenia. These
hip abductors is to prevent and control the excessive Tren- patients walk with a significant limp.
delenburg position and subsequent dynamic valgus position 3. The residual stage, stage 3 (beyond 8 months), is defined
at the knee. Studies have found this to be predictive of ACL by a marked decrease in ROM, patellar rigidity, quadri-
injuries.15,198 ceps atrophy, patella baja, osteopenia, and possibly
It has been shown that athletes are more injury prone if arthrosis.
side-to-side strength and flexibility differences are present.199 The physical therapist should manage arthrofibrosis early
In conclusion, rehabilitation following ACL reconstruction to attempt restoration of full mobility.
must prepare the patient to return to his or her prior level of A knee with a significant flexion contracture can cause
function. This long process begins immediately following greater impairment than an ACL-deficient knee. Antiinflam-
injury with accurate diagnosis and determination if the matory agents, aggressive physical therapy, and patellar
patient will be a potential coper.180,200 Following surgery, mobilization are the initial treatments for all stages of arthro-
protecting the healing graft, immediately decreasing swell- fibrosis. Arthroscopic dbridement, open dbridement, and
ing, increasing ROM, and strengthening in protected ranges dynamic splinting are usually required in the later stages.207
is warranted. Global kinetic chain strengthening and neuro- Another potential complication in obtaining and main-
muscular training, as well as injury prevention tactics, should taining full-extension ROM is the presence of a cyclops
be incorporated to best prepare the patient to safely return lesion.208,209 This lesion is usually the result of the prolifera-
to the prior level of function. tion of fibrous tissue surrounding the graft and has been
shown to be a cause of failure to regain or to lose full exten-
TROUBLESHOOTING sion in the early postoperative period. Some patients who
have achieved full extension will develop a gradual loss of
Carson and associates201 reviewed 90 failed ACL reconstruc- full extension and joint line pain with terminal extension.
tion surgeries. Based on their findings, a majority of the MRI can verify the presence of this nodule that ultimately
failures were the result of surgical technical errors. The most must be surgically removed. The patient responds quite well
common complications from ACL reconstruction are joint once the lesion is dbrided. The therapist must be alert for
stiffness, flexion contractures, patellar irritability (as high as the patient with delayed onset of ROM loss, especially in
34%), and quadriceps weakness.95,202-204 Less frequently, com- extension. They should undergo careful evaluation, includ-
plications include reflex sympathetic dystrophy (less than ing radiographs and MRI. If a cyclops lesion is confirmed,
1%), neurovascular injury (less than 1%), deep venous then arthroscopic resection should be performed.208
thrombosis, infection and possible fluid extravasation,
and compartment syndromes (especially with endoscopic Anterior Knee Pain
techniques). Patellofemoral (PF) pain commonly occurs after ACL recon-
The incidence of stiffness is reduced after ACL reconstruction, although it occurs more frequently after BPTB
struction by using proper surgical technique combined with autograft reconstructions than with hamstring autograft
an aggressive rehabilitation program. Improper graft place- reconstructions. Bach and colleagues42 reported an 18% inci-
ment with the tibial tunnel too far anterior or inadequate dence of mild PF symptoms in a 2- to 4-year follow-up study,
notchplasty can cause graft impingement, blocking terminal whereas Kartus and associates202 reported a 33.6% incidence.
knee extension. Intraoperative inspection of the graft Emphasis should be placed on quadriceps strengthening in
throughout a full ROM should always be conducted to protected ranges of 0 to 45 for CKC and 90 to 45 for OKC,
ensure that the graft is not impinging within the intercondy- and avoidance of pain.
lar notch.205 Patellar fractures have been reported in the literature as a
late complication of BPTB graft harvest. These are believed
Arthrofibrosis to be stress fractures that develop because of the decreased
One of the most devastating complications after ACL recon- vascularity of the patella. Patellar fracture also can occur
struction is the development of arthrofibrosis. The knee intraoperatively during graft harvest and has been reported
synovium and fat pad become inflamed, leading to a thick- after surgery. Brownstein and Bronner210 reported the inci-
ened joint capsule. This in turn begins to obliterate the dence of patellar fractures at 0.5% and noted that it usually
medial and lateral gutters and suprapatellar pouch. The occurs as a result of a fall. They put the patella at highest
patellar tendon can shorten, produce patella baja, and risk for fracture during rehabilitation at 10 to 14 weeks
postoperation. Pain over the tibial tubercle is less frequently obtained by the eighth week.63 If reflex sympathetic dystro-
encountered but may occur in those with prominent phy occurs, then it is usually seen by the fifth week after
tibial tubercles. If the patient has limited joint motion surgery.
before surgery, especially in extension, then a continuous Motion limitations are of primary concern and require
passive motion device should be used immediately after aggressive management, as mentioned earlier. Some patients
surgery.189 may need to be manipulated or evaluated for surgery during
During the first postoperative phase, ROM complica- phase 2. As the patient progresses with strengthening exer-
tions, if present, usually occur in extension. If mobilization cises, the physical therapist should pay careful attention to
and home exercises are not effective, then the patient should any residual pain or edema. The PF mechanism must be
try adding weight to the ankle during the prone hanging continually evaluated as the resistance of the exercises is
exercises. Duration and intensity are determined individu- progressed.
ally, but the authors of this chapter generally start with 3 to
5lb for a 5-minute increment and have the patient follow Phase 2
through at home three to five times a day. In addition, the Complications 9 weeks or more after surgery are usually the
patient can add weights to the knee while performing supine result of edema or pain after activity. This can result from the
knee extension (towel propped under the heel) and progress addition of new stressors (e.g., exercises) on the knee joint
in a similar manner. and soft tissue. If not already initiated, then pool exercises
may be a helpful adjunct in continuing to develop strength,
Treatment for Complications maintain ROM, and improve mechanics of the LE in a less
and Troubleshooting than full weight-bearing posture. Exercises in the form of
Phases 1 and 2 deep-water running and activity-specific drills are a good
Strength complications are addressed using NMES over the adjunct to land-based rehabilitation.
affected muscles in conjunction with exercise. The physical
therapist also can initiate biofeedback on the vasti to assist
with balanced muscle contraction. Anterior knee pain related SUMMARY
to PF dysfunction can be treated with modalities (i.e., cryo-
therapy and ultrasound), soft tissue mobilization, patella In conclusion, rehabilitation following ACL reconstruction
taping (after the incision has healed), emphasis on proper LE must prepare the patient to return to his or her prior level of
alignment during the offending activity, and hip strengthen- function. This long process begins immediately following
ing; assessment of foot biomechanics (the need for orthotics) injury with accurate diagnosis and determination if the
can also be useful in addressing PF issues. patient will be a potential coper.9,211 Following surgery, pro-
Persistent swelling may indicate hemarthrosis, synovitis, tecting the healing graft, immediately decreasing swelling,
reinjury, or infection.201 If by 4 to 6 weeks the patient has not increasing ROM, and strengthening in protected ranges is
gained full extension, then the cause may be patellar entrap- warranted. Global kinetic chain strengthening and neuro-
ment. Use of patellar mobilization to a greater extent and muscular training, as well as injury prevention tactics, should
with more vigor and serial casting may be considered. be incorporated to best prepare the patient to safely return
Arthroscopy is usually considered if full extension is not to the prior level of function.

Home exercises are progressed through the four Strength
phases of rehabilitation based on the patients 1. Isometrics: quadriceps and hamstring sets
tolerance to activity. Any increase in edema, pain, or isolation and cocontraction, 10 to 30 repetitions
laxity should be addressed early, and exercises (can also be done with elevation)
should be modified to eliminate complications. ROM Exercises
1. Supine knee extension
Weeks 1 to 4 2. Prone heel hangs
GOALS FOR THE PERIOD: Manage pain and edema, 3. Heel slides
improve quadriceps/hamstring contractions, improve 4. Supine wall slides (supine with involved foot
ROM against the wall, gravity assisted into flexion)
Pain and Edema Active Range of Motion Exercises (Brace Locked)
1. Cryotherapy with elevation 20 to 30 minutes with 1. Hip: flexion, extension, abduction, adduction,
ankle pumps (10 repetitions every minute) abduction with external rotation
2. Use of home electrical stimulation unit 2. Standing hamstring curls
Gait Training Weeks 9 to 16

1. Gait training using crutches: weight bearing as GOALS FOR THE PERIOD: Progress functional
tolerated, weaning as appropriate activities, prepare to return to sport or activity
2. Use small obstacles to work on swing phase of ROM Exercises
gait clearing involved leg (hip flexion, knee 1. Should be close to full ROM by this time.
flexion, and ankle dorsiflexion) Maintenance program should be initiated.
3. Once full weight bearing obtained, work on Strength
single-limb balance activities 1. Periodize gym program; initiate running program
(Perform exercises three times a day with when appropriate (usually about 3 months).
repetitions and sets determined by strength 2. Progress neuromuscular (balance and
usually two sets of as many as 30 repetitions.) coordination) training emphasizing proper LE
alignment with activities.
Weeks 5 to 8 3. Progress balance and coordination activities and
GOALS FOR THE PERIOD: Progress ROM, increase continue education on injury prevention with
functional strength of hip, knee, and ankle return to specific sport or activity.
ROM Exercises 4. Add one-legged hopping and jumping
1. Continue passive range of motion (PROM) activities once cleared for running
exercises on an as-needed basis (ROM as needed, (usually about week 12).
progress to prescribed duration with weight on 5. Begin foundational exercises for return to sport
top of knee if full extension is not reached at emphasizing LE control and neuromuscular
this time). training principles.
2. Add seated passive flexion.
Strength Week 17 and Beyond
1. Add step up and down with appropriate-height GOALS FOR THE PERIOD: Progress back to sport or
object (local phone book versus county phone activity
book) and single-limb balance activities. ROM Exercises
2. Follow a walking program (as much as 45 1. Maintenance
minutes of continuous walking on level Strength
surfaces daily). 1. Gym-based workouts continuing to emphasize
3. Progress back into therapy or community gym proprioceptive and neuromuscular training
environment for cardiovascular exercises: bike, techniques
elliptical, treadmill (forward and reverse). 2. Perform exercises specific to sport
Progress upper extremity exercise program 3. Reassess and progress the periodization program
to weight-bearing position gym activities for the athlete to adequately prepare for return to
(progressed to include cardiovascular sport
and proprioceptive and neuromuscular
training techniques).
Gait Training
1. Work on single-limb balance and walking figure-
eight and box patterns.
2. Try walking box and figure-eight patterns.
1 Michelle is 3 weeks post-ACLR and wants to know when

she can discontinue her postoperation knee brace.
4 weeks, the patient may be weaned from two crutches
to one, and then ultimately discharged. A requirement
for discharging crutches is that the patient must have a
The brace should be discharged when the patient has full normal pain-free gait pattern. In both situations, consul-
extension, no lag with an SLR, and at least 100 of flexion. tation and approval from the surgeon should take place.
This typically occurs 2 to 3 weeks after surgery. Most
rehabilitation protocols require crutch use with weight
bearing as tolerated for 4 weeks following surgery. After 2 When strengthening the quadriceps, what range is safe
for exercises? Why is this important?
For OKC exercises, the quadriceps should be strength- complaints of pain, giving way episodes, or signs/
ened in the range of 90 to 45 to guard against straining symptoms of inflammation.
the healing ACL graft and to protect against patellofemo-
ral pain. OKC exercises should begin 4 weeks after
surgery. Before that, the patient can perform isometric
quadriceps exercises at 90 and 60. When performing
5 Tracy is 50 years old and had ACLR 1 week ago. She
arrives at her first outpatient visit with moderate edema
about the knee and ankle. She states that she has been
CKC exercises, the patient should stay in the range of 0 compliant with weight bearing and uses her crutches
to 45 to guard against straining the healing ACL graft and brace as instructed. What further questions can help
and to protect against patellofemoral pain. CKC exer- the therapist provide a successful edema management
cises may be incorporated into the treatment regime program?
when the patient can be full weight bearing without pain.
The most effective way to manage swelling (at home) is
3 Charlie is 10 weeks post-ACLR and demonstrates good

ROM and strength. He is eager to begin running again.
In terms of graft healing, when is it generally safe to
with elevation, compression, and ice. Upon further ques-
tioning she has not been elevating her leg (above heart
level) regularly or performing ROM or isometric exer-
begin running following ACL reconstruction? cises. A program was initiated consisting of elevation
an ice (20 minutes, four times a day) with ankle pumps
The mechanical strength of the healing graft is at its (10 repetitions every minute).
weakest from 4 to 8 weeks. Bone-to-bone healing, as
with the use of a BPTB autograft, occurs approximately
at 10 weeks. Soft tissue to bone healing, as with the use
of a hamstring or quadriceps autograft, occurs approxi-
6 Randy is 45 years old and tore his ACL while horseback
riding. He had ACLR 3 weeks ago. Knee flexion ROM is
progressing nicely. Knee extension is limited, with a
mately at 12 weeks. Therefore, running should never be PROM of 10. Inflammation is decreasing. He has pain
initiated before 3 months postsurgery because of the while performing quadriceps sets and SLRs. What treat-
lack of healing. Additionally, the patient must demon- ment techniques can be used to gain knee extension?
strate adequate strength and neuromuscular control of
the LE with particular emphasis on the quadriceps. This Tibiofemoral anterior-posterior mobilization movements
typically occurs at 4 to 6 months postsurgery. A collab- into resistance at end range (using grades III and IV) can
orative decision with the surgeon as to when the patient be performed with the knee in extension. Care must be
should begin running is necessary. taken not to elicit any increased tension on the graft. Full
extension will decrease stress on the patellofemoral and
4 George is 4 months post-ACLR and wants to return to

playing soccer. How do you best prepare the patient to
tibiofemoral articulations.
return to sport following ACL reconstruction?
Given that there are no complications along the way,

7 Steve is a 45-year-old fireman. He had an ACLR 9 weeks
ago on his left knee. Because of mishaps and personal
reasons, physical therapy was not initiated until 5 weeks
sport-specific exercises can be introduced into the ago. Presently (9 weeks after surgery) PROM for knee
program (at low intensity) beginning at 3 to 4 months. flexion is 110. The end range is beginning to feel leath-
The best way to prepare the patient is to gradually ery. Soft tissue restrictions appear to be present in the
expose the patient to everything he or she will encoun- quadriceps. Swelling and complaints of pain are usually
ter. Therefore, the patient must be able to tolerate minimal. Strength is gradually progressing. What treat-
running, going up/down steps, and figure eights, again ment techniques could be used to promote increased
starting at a low intensity level (walk figure eights before knee flexion?
jog, jog before run, etc.). Plyometrics are introduced
(usually around 5 months) as the patient begins to Tibiofemoral posterior glides can also be performed with
show that he or she are able to tolerate and have eccen- the knee in flexion (into resistance, grade IV), followed
tric as well as concentric control of the LE before agility, by PROM into flexion with overpressure. Patellofemoral
plyometric, and cutting exercises are progressed. The glides can be performed. While PF glides superiorly will
patient should eventually perform all of the exercises in assist in gaining extension, PF glides inferiorly will assist
all three planes of motion. For example, jumping should with knee flexion and should be mobilized accordingly.
be forward/backward, to each side, and clockwise/ In the prone (better for rectus femoris [RF]/Psoas) and
counterclockwise. Also, the patient should be able to supine positions, gentle contraction and relaxation
perform any and all exercises at 100% effort in physical stretches can be performed with the quadriceps. Also,
therapy before returning to practice. To return to soft tissue mobilization to the distal quadriceps and
competition, the patient must be able to participate lateral retinaculum can be performed to address PF
in full practice and perform at 100% effort without any restrictions.
8 Nancy is making excellent progress in therapy. However,

at 10 weeks after surgery the therapist notices a palpable
clunk with her AROM, and extension has become
crepitation or a palpable clunk in addition to pain with
extension could signify an ACL nodule. Nancy was
referred back to her surgeon and an MRI confirmed the
quite painful. What could be the origin of her problem? presence of a cyclops lesion (nodule). Surgery was
scheduled to remove the fibroproliferative tissue.
Limitations with extension usually are the result of
posterior capsule or notch problems. The presence of
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CHAPTER 23
Arthroscopic Lateral Retinaculum Release
Daniel A. Farwell, Andrew A. Brooks
SURGICAL INDICATIONS joint, the focus should be on the relationship between patella
AND CONSIDERATIONS tilt compression and associated tightness in the lateral reti-
naculum. The function of the patella is to increase the lever
While surgical treatment (lateral patellar retinacular release) of the quadriceps muscle, thus increasing its mechanical
for maltracking of the patella has shown promising results,1 advantage. For functional and efficient knee motion, the
it is becoming less popular as an isolated procedure.2 The patella must be aligned so that it can travel in the trochlear
surgery appears less successful in patients that have severe groove of the femur. The ability of the patella to track prop-
chondromalacia, patella instability, or evidence of trochlear erly depends on the bony configuration of the trochlear
dysplasia.3-5 Latterman and associates6 state that isolated groove and the balance of forces of the connective tissue
lateral retinacular release has little or no role in the treatment surrounding the joint.
of acute or recurrent patella instability. This procedure Weakness and stiffness from the hip are factors that
should be reserved for the few patients with a clearly identi- appear to influence poor patella alignment (gluteus medius
fied lateral patella compression syndrome in presence of a weakness and iliotibial band [ITB] tension). Tensor fascia
tight lateral retinaculum and clearly discernable lateral reti- latae and gluteus maximus fibers combine to form a very
nacular pain. Currently it appears that lateral patellar reti- thick, fibrous structure that attaches distally into the lateral
nacular release is usually performed as an adjunct to other tibial tubercle (Gerdy tubercle).8 The ITB slips into the lateral
knee surgeries where patellofemoral misalignment is an border of the patella, which interdigitates with the superficial
issue.6 This chapter will deal with patellofemoral rehabilita- and deep fibers of the lateral retinaculum. This design often
tion that should be considered an adjunct to any knee surgery leads to excessive compression over the lateral condyle and
where patella pain is an issue. lateral border of the patella during dynamic activity.
Adaptation resulting from chronic compression in the Tilt compression is a clinical radiographic condition of
patellofemoral joint can lead to significant arthrosis in a wide the patellofemoral joint that can lead to retinacular strain
variety of patients, both young and old. Pain, attributed to (i.e., peripatellar effect) and excessive lateral pressure syn-
increased patellofemoral compression, occurs in different drome (i.e., articular effect).9 A case can definitely be made
aspects of the joint, but the most common site is along for a cause-and-effect relationship between tilt compression
the lateral aspect. This patellofemoral pain can originate and retinacular strain. Chronic patella tilting and associated
from mechanical malalignment, the static or dynamic soft retinacular shortening cannot only produce significant
tissue stabilizers, or increased load placed across the joint lateral facet overload but also a resultant deficiency in medial
as a result of various activities.7 Symptoms may include contact pressure. This tilt compression syndrome may have
diffuse aches and pains that are exacerbated by stair climbing simple soft tissue pain related to the shortening of the lateral
or prolonged sitting (i.e., flexion of the knees). Crepitus and retinacular tissue. If left untreated, then histologic studies of
mild effusion are often associated with patellofemoral painful retinacular biopsies may reveal degenerative fibro-
arthralgia. Although complaints of giving way or collapse neuromas within the lateral retinaculum of patients with
are more often linked with ligamentous instability, these chronic patellofemoral malalignment.10 Excessive lateral
symptoms also can be associated with patellofemoral pain. pressure syndrome results from chronic lateral patella tilt,
Patients may even complain of joint pain and locking adaptive lateral retinacular shortening, and resultant chronic
when they are experiencing poor patella stabilization during imbalance of facet loads. It is prevalent in active, middle-
flexion of the knee. aged adults. In younger patient populations, excessive lateral
In examining the way lateral retinacular release proce- pressure during growth and development can alter the shape
dures may affect the arthrokinematics of the patellofemoral and formation of both the patella and trochlea.10
427
Nonoperative treatment of patella tilt should focus on assessment of patella orientation, a specifically designed tape
mobilization of tight quadriceps muscles and the lateral reti- is used to correct for each patella orientation. The patello-
naculum. Patellofemoral taping, bracing, and antiinflamma- femoral joint is principally a soft tissue joint, which suggests
tory medications also are quite helpful. Gait deviation and that it can be adjusted through appropriate mechanical
excessive foot pronation should be corrected to eliminate means (i.e., physical therapy). Two primary components
possible secondary influences on patellofemoral malalign- (glide and tilt) may be present either statically or dynami-
ment.7 The use of resistant weight training or isokinetic exer- cally. Patella orientation varies among patients and even
cise (in conjunction with patella taping) can be beneficial in from left to right extremities.
building quadriceps muscle strength.11
Patellofemoral Taping
McConnell patellofemoral taping has become a useful
technique in the conservative (nonsurgical) rehabilitation
of patellofemoral pain; it can also benefit patients after
surgical lateral release as well. Controversy exists as to the
mechanism behind the pain relief from taping. Whether
via cutaneous stimulation, enhancement of patellofemo-
ral ligaments, or improved vastus medialis oblique (VMO)
timing, clinically we know that patellofemoral pain can be
reduced or eliminated via its appropriate application.12,13
Patellar taping has been shown to increase vasti muscle
activity14,15 and may enhance knee joint proprioception after
surgery.16 The McConnell patellofemoral program empha-
sizes closed-chain exercises to correct patella glide (Fig.
23-1), tilt (Fig. 23-2), and rotation, (Fig. 23-3) and allows for
pain-free rehabilitation. The patient is evaluated dynamically
during a functional activity such as walking, stepping down,
or squatting. According to Maitland,17 The aim of examin-
ing movements is to find one or more comparable signs in
Fig. 23-2 Patella tilt. Place the tape on the medial superior half of the
an appropriate joint or joints. These comparable signs, or patella. Pull the tape medially to lift the lateral border. Lift the soft tissue
reassessment signs, are reevaluated after each patella correc- over the medial femoral condyle toward the patella to ensure a more secure
tion to determine the effectiveness of the treatment. After an fixation.
Fig. 23-1 Patella glide. Place a piece of tape on the superior half of the Fig. 23-3 Patella rotation. Place a piece of tape on the inferior-medial
lateral border of the patella and pull the tape medially. Lift the soft tissue quarter of the patella and perform an upward rotation movement of the
over the medial femoral condyle toward the patella to ensure a more secure patella. Place another piece of tape on the superior-lateral half of the patella
fixation and less tape slippage. and perform a downward rotation movement of the patella.
Chapter 23 Arthroscopic Lateral Retinaculum Release 429
Glide Component Results may be disappointing for lateral release in the

The amount of glide correction depends on the tightness presence of the following conditions:
of the structures and the relative amount of activity in the 1. Patellofemoral pain syndrome (anterior knee pain)
entire quadriceps musculature. The corrective procedure 2. Advanced patellofemoral arthritis
involves securing the edge of the tape over the lateral border 3. A Q angle greater than 20
of the patella and pulling or gliding the patella more medi- Patients with instability may require medial retinacular
ally. Although this technique is useful for most patellofemo- imbrication or a distal realignment in addition to an isolated
ral pain, it is not often used in the postoperative care lateral release.
of patients recovering from lateral retinacular release (see The Southern California Orthopedic Institute (SCOI)
Fig. 23-1). technique of arthroscopic lateral release is performed in the
supine position without the use of a leg holder; the tourni-
Tilt Component quet is inflated only when necessary. The procedure is per-
Tilt correction is quite often used to stretch the deep reti- formed with the arthroscope in the anteromedial portal.
nacular fibers along the lateral borders of the knee. Increased Routine arthroscopic fluid is used. An 18-gauge spinal needle
tension in the lateral retinaculum along with a tight ITB is inserted at the superior pole of the patella and is used
(which inserts into the lateral retinaculum) can produce a as a marker for the proximal extent of the release. The
lateral dipping, or tilt, of the lateral border of the patella needle must be withdrawn as the electrosurgical electrode
(see Fig. 23-2). approaches it. With experience, the surgeon can omit the
When focusing on patients recovering from lateral reti- needle marker. The electrosurgical lateral release electrode is
nacular release, the physical therapist (PT) should remember inserted through the inferior anterolateral portal using a
that the very tissues these taping techniques address have plastic cannula to protect the skin. The procedure is per-
been surgically released. Although patella orientations have formed with the generator setting at approximately 10 to 12
definitely been altered in patients after surgical release, W of power. With the patients knee extended, the surgeon
muscle recruitment patterns and joint loading characteris performs the release approximately 1cm from the patella
tics that may have contributed to the symptoms are still edge, progressing from distal to proximal using the cutting
present. mode. The deep and superficial retinaculum, as well as the
McConnell taping procedures produce improved joint lateral patellotibial ligament, are released under direct visu-
loading and allow the patient to return to a more active, alization until subcutaneous fat is exposed. The extent of the
pain-free lifestyle when used in conjunction with closed- proximal release is only to the deforming tight structures and
chain functional exercises.18,19 should never extend beyond the superior pole of the patella.
Although conservative management remains the corner- An incomplete release is often secondary to inadequate
stone of treatment for patients with anterior knee pain, some release of the patellotibial ligament. Again, the tourniquet is
patients will not respond and continue to have pain and not inflated during the procedure, and vessels are coagulated
functional disability. If conservative (nonsurgical) treatment as they are encountered. An adequate release is confirmed
is unsuccessful in providing the patient with appropriate by the ability to evert the patella 60. After the release, the
pain relief and function, then surgical intervention should knee is passively moved through a range of motion (ROM)
be considered.20 and correction of lateral overhang during knee flexion is
In addition to subjective complaints and functional limi- confirmed. The arthroscope should be switched back to the
tations, other indications for surgery include dislocation, accessory superolateral portal for this assessment. Usual
subluxation, and failure of previous surgery with or without postoperative dressings are applied after the arthroscopic
medial patella position. procedure (sterile dressings and an absorbent pad held in
Operative procedures that modify patella mechanics are place by an elastic toe-to-groin support stocking previously
most successful in treating patients with patella articular measured for the patient).
cartilage lesions. Lateral release procedures should ultimately Postoperative rehabilitation includes muscle strengthen-
produce a mechanical benefit to the patient, such as relieving ing and ROM exercises the day of surgery, including quad-
documented tilt.21 riceps sets and straight leg raising. The patient continues to
do these exercises at home the night of surgery and is given
SURGICAL PROCEDURE weight bearing as tolerated status with crutches immediately.
Crutches are discontinued when adequate quadriceps muscle
Review of the literature suggests strict indications for lateral control has been obtained and patients can walk safely. The
release9: vast majority of patients use their crutches for less than 7
1. Chronic anterior knee pain despite a trial of a nonopera- days, although some may need them for 2 to 3 weeks depend-
tive program for at least 3 months ing on quadriceps control.
2. Minimal or no chondrosis (Outerbridge grade 2 or less) The SCOI experience with arthroscopic lateral retinacu-
3. A normal Q angle lum release (ALRR) has been reported previously.22 The
4. A tight or tender lateral retinaculum with clinically and researchers monitored 39 patients with a history of recurrent
radiographically documented lateral patella tilt patella subluxation or dislocation in 45 knees for an average
of 28 months and noted good to excellent results in 76% of After knee surgery the goal of rehabilitation is to prevent
patients. Similar experiences with ALRR have been reported loss of muscle strength, endurance, flexibility, and proprio-
in the literature, with favorable results in 60% to 85% of ception. These issues often are difficult to address immedi-
cases.23 Arthroscopic treatment compares favorably with ately after lateral release. The procedure is often associated
open realignment and has a lower complication rate. No with significant hemarthrosis resulting from sacrifice of the
postoperative hemarthrosis occurred in the SCOI series; lateral geniculate artery.25 Therefore the acute phase of treat-
hemarthrosis is the main complication reported in the litera- ment should focus on managing edema and decreasing pain.
ture, occurring in 2% to 42% of cases. Smalls review24 of 194 The use of vasopneumatic compression, electrical stimula-
cases of ALRR, performed by 21 arthroscopic surgeons, tion, ice, and intermittent elevation of the limb can assist in
found hemarthrosis associated with 89% of the 4.6% total decreasing the patients swelling.
complications. Careful coagulation of vessels without an Other strategies to both decrease joint effusion and begin
inflated tourniquet can reduce hemarthrosis. If strict criteria restoring joint mobility include grade II (mobilizations per-
are met and proper surgical techniques are used, then a formed shy of resistance in an effort to decrease pain)26
consistent result can be obtained with these patients. patella mobilizations, active calf pumping exercises, and the
The complexity of the patellofemoral articulation and its application of McConnell taping27 specific to acute lateral
associated disorders are evident by the significant body of release rehabilitation (Fig. 23-4). This procedure places a
literature on the subject and the abundant surgical proce- very mild tilt on the patella, providing a small amount of
dures involving the joint. A thorough clinical evaluation, length to the repair site or lateral retinacular tissue. The tape
including history and physical and radiographic examina- maintains the new alignment, preventing adhesions that may
tion, helps to clarify the diagnosis of patellofemoral disorder. bind down the released retinaculum during tissue healing.
Use of the arthroscope for the electrosurgical lateral release Other taping procedures such as unloading the lateral soft
is an effective component in the armament of knee surgeons tissue may assist in decreasing pain and discomfort during
for patients with persistently symptomatic patellofemoral exercise (Fig. 23-5). This procedure is beneficial in decreas-
disorders who meet the surgical indications described. ing joint effusion and adds joint stability. It is often used in
combination with a patella tilt correction.
THERAPY GUIDELINES
FOR REHABILITATION Phase II (Subacute Phase)
Phase I (Acute Phase) GOALS: Continue to manage edema and pain, improve
TIME: 1 to 2 weeks after surgery sit-to-stand transfer activities, improve strength and
GOALS: Decrease pain, manage edema, increase stability of the patellofemoral joint, progress
weight-bearing activities, facilitate quality functional training to return activity to previous
quadriceps contraction (Table 23-1) levels (Table 23-2)
TABLE 23-1 Lateral Retinaculum Release

Phase I Postoperative Postoperative pain Ice Decrease pain Decrease edema and pain
Postoperative Postoperative edema Vasopneumatic compression Manage edema Increase neuromuscular
1-2 wk Gait deviations Grade II patella mobilization Decrease gait deviations coordination with muscle
Limited tolerance to Neuromuscular stimulation Increase tolerance to contraction
weight-bearing Patellar taping weight-bearing activities Restore joint mechanics
activities Knee AROMankle pumps ROM 0-135 Improve joint mobility and
Limited range of Knee PROMhamstring and Quality contraction of the stability
motion Iiliotibial band stretches quadriceps Prevent adhesions
Limited strength Isometricsquadriceps/ Initiate volitional muscle
hamstring sets, quadriceps control and increase strength
sets at 20-30 Increase patient
Home exercises (refer to self-management
Suggested Home
Maintenance Box)
AROM, Active range of motion; PROM, passive range of motion.

As the patients swelling and pain subside (1 to 2 weeks), waste products within the joint. Their influence on the car-
the patient moves into a subacute phase. During this phase diovascular system produces increased capillary permeabil-
a more direct and aggressive type of treatment is imple- ity and vasodilation. The vasodilation brings increased
mented for the knee. Heat modalities (i.e., moist heat, ultra- oxygen and nutrients to the knee, which assist in the healing
sound) are used to assist in the absorption and removal of and repairing of the surgically altered tissue.28 Increased
blood flow produces increased capillary hydrostatic pres-
sure. Therefore heat modalities can be very beneficial at this
stage of rehabilitation, but only if the patients effusion is
Fig. 23-5 Unloading of lateral soft tissue structures. Taping allows for a
decrease in the tension produced over the surgical repair site by inhibiting
the effective pull from the ITB and vastus lateralis. Unloading the lateral
Fig. 23-4 Stabilization taping. After surgery the lateral tissue is often retinaculum may significantly reduce the patients symptoms. Tape from the
hypersensitive to any type of stretching or pulling. The application of a posterior aspect of the lateral joint line down to the tibial tubercle and from
taping correction for both internal rotation and external rotation results in the posterior lateral joint line to the distal midthigh (approximately 2 to 3
a low-level patella stabilization that the patient finds much easier to tolerate. inches above the patella). The tissue inside the tape should be pulled toward
Taping enables the patient to perform normal knee flexion-extension activ- the joint line as you pull and secure the tape. The tape should look like a
ity without pain or with less pain. It also decreases effusion. wide V lateral to the knee and should not inhibit active motion.

Anticipated
Phase II Incision healed Pain with squatting Continuation of interventions Achieve full ROM Decrease swelling and
Postoperative Edema controlled and sit-to-stand from phase I, progressed Decrease pain pain
3-4 wk Full weight bearing, Gait deviations as indicated: Increase mobility Increase neuromuscular
although full ROM Limited stability of Moist heat and ultrasound Increase strength coordination with
and strength may patellofemoral joint (if edema is under control) Sit-to-stand without pain muscle contraction
be deficient Limited tolerance (if Soft tissue mobilization Decrease gait deviations Restore joint mechanics
any) to prolonged when pain is significantly Increase stability of Functional strengthening
walking, standing, diminished on palpation patellofemoral joint using closed-chain
running, or jumping Neuromuscular stimulation Tape only for skill-specific exercises
Closed-chain exercises, activity Biofeedback with
lunges, standing wall exercise to improve
slides, and step-downs tonic activity of vastus
(see Figs. 23-6 to 23-8) medialis oblique
Biofeedback in conjunction Improve joint mobility
with exercises and stability
Patellofemoral taping Increase patient
(refer to Patellofemoral self-management
Tape-Weaning Protocol)
Home exercises

under control. If the patients effusion is displacing the patella (constant) pattern of activation throughout a full (0 to 135)
from the trochlear groove or the patient cannot perform arc of motion in pain-free patients; a phasic (intermittent)
active isometric quadriceps contractions, then the joint activity pattern was observed in patients with patellofemoral
effusion is significant. pain. A consistent activation of the entire quadriceps is
Heat applications may be contraindicated until edema the goal in quadriceps strengthening. Quality of motion
is no longer a concern. Soft tissue mobilization can be ben- should be emphasized over relative quantity. Exercise beyond
eficial at this stage to increase circulation, decrease swelling, 20 flexion (20 to 135) increases the surface area of con
mobilize healing tissue, and decrease hypersensitivity in the tact and gives better stability within the trochlear groove.
knee joint.10 Deep massage can assist in the reabsorption of Although the development of muscle strength is important,
fluid within the knee, yet manipulation of soft tissue struc- it is not the only goal of rehabilitation. Muscle endurance,
tures over the lateral aspect of the knee should be avoided to flexibility, and the development of correct proprioceptive
prevent aggravation of the trauma from surgery. Soft tissue loading through the entire lower extremity (LE) must be
mobilization should not be initiated in the area of lateral addressed as well. These goals can be accomplished in
structures before the tissues have begun to heal (1 to 2 patients recovering from surgical lateral release by protecting
weeks) and pain is significantly diminished on palpation the surgical repair through modalities that speed the tissue
of the entire patellofemoral joint. repair process and protective taping that adds stability
Electrical stimulation (ES) is used to assist in activation and promotes early functional rehabilitation. Wittingham,
of the quadriceps muscle. Specific benefits include decreas- Palmer, and Macmillan35 recently concluded that a combina-
ing joint edema, increasing local blood flow to the muscle, tion of patellar taping and exercise was superior to the use
promoting increased muscle tone, and controlling post of exercise alone. Early quadriceps activation includes iso-
operative pain.29,30 Electricity also can be used to retard metric quadriceps sets in varying degrees of flexion pro-
quadriceps atrophy, which results from immobilization or duced by a proximal load-bearing shift with increased knee
inhibition of the muscle.31 When used in combination with flexion.36 This allows for early muscle strengthening even
active isometric and isotonic exercises, ES retrains trans- while joint effusion may still be causing pain in a closed-
posed muscles and promotes muscle awareness in regaining chain (joint loaded) position.
volitional muscle control postoperatively.28 When effusion and pain have been eliminated for 7 to
Experiments conducted by scientists in the USSR in the 14 days, a gradual increase in activity may begin, with
1970s examined the possibility of producing greater intensity cryotherapy being used after activity. During LE rehabilita-
of muscle contraction with electrical current. Some studies tion, after the patient can stand or load the joint, the empha-
have found the use of ES during immobilization produces a sis should be on closed-chain activity because of its relevance
significant increase in muscle strength.24,27 By using ES early to function. The goal is to advance the patient toward func-
in the rehabilitative process, PTs can prevent the loss of oxi- tional activities and then slowly introduce a patient-specific
dative capacity, thus shortening postoperative rehabilitation exercise program. Specific closed-chain exercises allow for
and conditioning time and allowing a more rapid return to the selection and stimulation of the appropriate muscles at
functional activities.32 Although ES can be of great benefit, the proper time.37 These factors, combined with gradual
it should not be used as a replacement for postoperative muscle inhibition of the antagonist, produce smooth, coor-
rehabilitation and strengthening exercise programs.33 dinated loading of the entire LE.
In summary, the use of modalities is beneficial in aiding Although McConnell patellofemoral taping is the modal-
healing by decreasing acute reactions and altering blood ity of choice used by the authors of this chapter to bolster
flow, which may provide low-level analgesic effects.29,34 stability at the onset of exercise, a variety of braces may be
Understanding the action of these modalities and the way beneficial in supporting the patellofemoral joint after surgery.
they influence healing is important in predicting their use- Almost any elastic, compressive support around the patel-
fulness and appropriateness in the rehabilitation of patients lofemoral joint produces an improved ability to exercise. The
after lateral retinacular release. concept of proprioceptive feedback, together with comfort
and affordability, makes postoperative McConnell patello-
Strengthening femoral taping or nonspecific bracing of the knee desirable
Strengthening of the entire lower kinetic chain is the goal in in patients who do not respond to exercise alone.
most patients suffering from anterior knee pain. This goal is
no different for patients after lateral retinacular release. Phase III (Advanced Phase)
Although special attention is paid to the quadriceps muscle,
particularly the VMO, it is the balanced contraction in the
GOALS: Patient self-manages edema and pain,
vasti group as a whole that is the ultimate goal. Richardson20
performs gait without deviations, and has unlimited
examined the activity level of the quadriceps, specifically the
ambulation (Table 23-3)
VMO, to better understand the activation patterns of the
quadriceps during dynamic motion. The quadriceps were By phase III patients should have their pain under control
monitored with surface electromyography through a full arc using little if any external support (brace or tape). They may
of motion in both patients suffering from patellofemoral continue to benefit from stretching, patella mobilization, and
pain and normal patients. The VMO produced a tonic taping in addition to ice after exercise. However, this phase

Anticipated
Phase III Pain-free during Limited endurance Closed-chain and stretching No gait deviations Functional strengthening
Postoperative functional activity with prolonged exercises as listed in Tables Good patella stability Decrease pain with
4-6 wk (sit-to-stand, squat functional activities 23-1 and 23-2 without taping functional activities
0-90) Mild instability of Patella taping Unlimited community Improve joint mechanics
Limited tolerance to patellofemoral joint Patella mobilization ambulation Improve joint mobility
walking, running, during skill-specific Lunges with weights, Leg press body weight and stability
and standing exercises increased repetitions and Pain-free with specific Improve endurance of
Continued reliance on speed with exercises activity vastus medialis oblique
patellofemoral taping PREs on leg press Increase strength and Increase strength
Functional specific activity velocity of muscle Specificity of training and
isokinetic training contraction progression to
Knee flexion and extension Patient can self-manage community-based gym
270-300/sec, 10 symptoms program (if appropriate)
repetitions at each speed is Use isokinetic principles
one set (2-10 sets) of strength training
Home exercises Discharge patient
PREs, Progressive resistance exercises.
Fig. 23-6 Closed-chain lunge. Instruct the patient to take a normal step forward. Have the patient slowly flex the knee to 30 flexion, hold for 3 seconds,
and return to 0 extension while maintaining proper postural alignment (i.e., anterosuperior iliac spine over midpatella and second toe). The patient should
be able to activate the quadriceps tonically (constantly) during the entire motion.
is designed to take the patient back to the preinjury level of Closed kinetic chain progression consists of the
function. Exercises are progressed through specificity of following:
training principles. By breaking down the activity into its 1. Lunges with 5lb weights in a long-stride position (Fig.
core components, the PT can assess patellofemoral and LE 23-6)Patients must activate the quadriceps and hold
function for any deviations or barriers to performance. the contraction from 0 to 30 eccentrically and back
Again, any exercise that increases knee pain and/or swell- to 0 concentrically without stopping, while moving
ing needs to be modified or discontinued. After further slowly and maintaining proper alignment.
progress has been gained, the therapist can reassess the 2. Wall slides at various degrees of flexion with 1-minute
patient and attempt the exercise again. holds to promote fatigue (Fig. 23-7)The patient
6. Step-down exercises with an increase in height of step

and speed of movementProper alignment is crucial,
along with slow, controlled movement. The patient
must activate the quadriceps before motion is initiated
and hold the contraction until heel contact with the
opposite leg (Fig. 23-8).
7. Resistive leg press using progressive resistance exercise
protocols for weight38,39
8. Standing (four-wall) elastic tubing exercises for hip
flexion, extension, abduction, and adduction (the
involved knee acts as the stabilizing leg)The LE that
anchors the body is the working leg. The patient
should activate the quadriceps and hold throughout
the entire active motion of the opposite leg. This may
be performed in terminal extension or 10 to 20 of
knee flexion of the involved (stabilizing) leg.
Activity-specific exercises (Fig. 23-9) may include the fol-
lowing: stationary cycle, stair-climbing machine, slide board,
and treadmill. The authors of this chapter recommend a
6-week progression to presurgery activity level. Isokinetic
exercise is introduced in this phase at a training velocity
spectrum protocol between 270 and 300/sec.40 The patient
performs 10 repetitions at each speed in a ladder progression
(50 repetitions equal one set). Patient tolerance for exercise
determines the number of sets performed (2 to 10 sets). After
patients can perform the exercises with good control of the
patellofemoral joint, they are weaned from formal physical
therapy and encouraged to continue their home exercise
program as appropriate.
Once you have arrived at the decision to move the patient
into a home program, it is important to understand how
variable the long-term results can be following this proce-
dure. Recent studies describe favorable results (73% to 86%)
after 1 year.41 This same study indicates that the results are
far less favorable (29% to 30%) if the follow-up period is
Fig. 23-7 Closed-chain wall slide. This exercise allows the patient to main-
tain better alignment simply by locking in pelvic tilt. The patient can then extended to 4 or 5 years. Questions exist concerning the
move through a particular ROM or the PT can have the patient perform appropriateness of an isolated lateral release procedure alle-
isometric contractions at various ranges of weakness. viating the biomechanical symptoms it is designed to
address.42 This evidence underscores the importance in iden-
should progress from 0 to 45; if a certain angle in the tifying muscle strength and muscle length imbalances in the
arc of motion appears weaker, then the patient can entire lower limb. Any abnormal LE alignment needs to be
perform isometric holds at the angle of weakness. addressed in advance of discharge to a self-guided program.
3. Functional single-limb squats from 0 to 30Deep
flexion squats can be performed by two different TROUBLESHOOTING
methods. In the first, both LEs are aligned directly
below the hips, and bilateral knee flexion is initiated. Postural Alignment
The patient should maintain proper patella alignment A lateral retinacular release procedure produces immediate
directly over the midfoot. The second method is a effects on the patella orientation of the knee, yet the entire
shortened stride position with the involved LE forward. lower kinetic chain may still have alignment issues that
The patient initiates the squat until the knee is flexed need to be addressed. When assessing a patients functional
90 and then rises back to full extension. status, the PT should consider equalizing leg lengths, balanc-
4. Functional double-limb squats with elastic tubing ing foot posture, restoring normal gait, and regaining appro-
5. Sit-to-stand at increased speed and repetitionThe priate muscle flexibility and strength, which will lead to a
patient initiates sit-to-stand activity (and stand-to-sit restoration of normal posture and balance.10 By observing
activity) without upper extremity assistance. This exer- static alignment issues, PTs can gather valuable information
cise can be adjusted from easier to more difficult by regarding the way the patient will function dynamically. The
lowering the height of the chair. interaction of poor alignment measures and quadriceps
Fig. 23-8 Closed-chain step-down. Patients need to begin on a low-level step (3 to 4 inches) and work up to a standard step (8 inches). Patients must focus
on improved alignment. Because the patient is now performing single-limb support activity, he or she should focus on gluteal muscle activation to better
stabilize the femur during dynamic activity.
Fig. 23-9 Skill-specific training. After the patient is without pain and has developed a quality contraction that is consistent throughout full knee ROM,
a sport- or activity-specific exercise program is needed to aid in the development of an improved loading pattern and promote coordinated balance in
patellofemoral mechanics.
contraction has been examined.43 This study compared static

and dynamic patellofemoral malalignment measures in sub- Patellofemoral Tape-Weaning Protocol
jects with anterior knee pain. Quadriceps contraction altered Patients using McConnell taping need to learn how to tape
the malalignment in both type and severity in more than themselves. The tape loosens according to the aggressiveness
50% of cases. of the patients activity. The patient should therefore be
The literature suggests that excessive pronation at the foot taught to tighten the tape when necessary.
is a primary problem because of its association with patel- The patient only needs to wear tape while training the
lofemoral pain, which inhibits the balance of the entire lower quadriceps to maintain the newly acquired length in the
kinetic chain.7 Increased pronation may lead to increased lateral structures. The tape should be removed at night and
valgus, compensatory external rotation of the foot and tibia, the skin should be cleaned. This gives the skin a resting
and a resultant predisposition to lateral patella tracking with period from the pull and friction produced by the tape.
dynamic activity.44 In such cases, orthotic correction may be The patient begins closed-chain exercises when pain and
indicated even after a lateral retinacular release procedure to effusion are under control. Early home exercises stress little
restore proper loading mechanics through the knee. bits often, meaning multiple VMO sets or quadriceps con-
tractions are performed throughout the day and are linked
Quadriceps Inhibition with a patients lifestyle. For example, the PT may instruct a
Many clinicians tend to use the term quadriceps inhibition as patient to perform a quadriceps contraction every time he
though it were synonymous with quadriceps weakness, which or she sits down in a chair, palpating the VMO for feedback.
is not an accurate description. Reflex quadriceps inhibition is When driving a car, the patient may perform a quadriceps
defined as the inability to perform a quadriceps contraction set at every stoplight, taking care to leave the foot firmly on
voluntarily because of direct neurologic suppression.30,45 the brake. As the patient begins to recruit a quality quadri-
Does true quadriceps inhibition exist? Numerous research ceps contraction successfully, goal setting enters into the
articles on the subject describe several mechanisms that program and the patient is asked to attempt repetitions of
could produce a neurogenic influence on voluntary control closed-chain exercises (i.e., lunges, wall slides, squats, step-
of the quadriceps.46,47 The effect of pain on the overall activa- downs). The more the patient practices, the faster the skill to
tion of the quadriceps has been examined as a possible activate a quality quadriceps muscle contraction is learned.
cause.48,49 Effusion also can impair activation of the quadri- The patient is ready to be weaned off the taping protocol
ceps muscle.50,51 Mechanical receptors within the patello- and continue the program with specific sports-related activ-
femoral joint may influence quadriceps function through ity and training when he or she can do the following:
proprioceptive input.52,53 Other factors may include training 1. Sustain a quarter squat for 1 minute against the wall
methods, joint position, aging, and even the possible effects without pain.
of medication. 2. Sustain a half squat for 1 minute against the wall
Any problem resulting in decreased activation of the without pain.
quadriceps is detrimental to the rehabilitation process. 3. Perform 10 step-downs (off an 8-inch step) for at least
With full activation of the quadriceps femoris muscle, proper 5 seconds per step with good control and alignment
strengthening exercises should produce excellent results. and without pain.
However, if voluntary control is absent or compromised, If functional activity produces pain and the patient is
then atrophy and weakness may result. If this situation per- using patella taping, the PT should first assess the taping
sists, then volitional exercise protocols may be ineffective procedure to ensure it is correct. The clinician may need to
and thus temporarily inappropriate for these patients. make small adjustments in tension and direction. At the time
Because of the nature of a lateral retinacular release proof discharge from the clinical facility, the patient needs to
cedure, pain and especially effusion are quite common after remember how to self-mobilize the patella (Fig. 23-10), as
surgery. Therefore any treatment techniques that address well as proper alignment and the postural issues associated
pain and swelling will ultimately assist in improved recruit- with closed-chain exercises; the patient should be reminded
ment of the quadriceps femoris muscle. that exercise should be painless.

Weeks 1 to 2 2. Perform ankle pumping and hamstring stretches
GOALS FOR THE PERIOD: Decrease pain, manage while elevated on ice (20 to 30 minutes).
edema, increase weight-bearing activities, and 3. Perform gentle patella self-mobilizations
facilitate quality quadriceps contraction (Fig. 23-10).
1. Elevate and ice at home two to three times per 4. Perform active heel slides: 1 set of 10 repetitions
day (preferably after exercises). performed three to four times per day.
5. Perform quadriceps sets: 2 sets of 10 repetitions the patient should perform two sets of 10 to 20
performed three to four times per day. repetitions per day (more or less depending on
The PT should always remember that even fatigue).
though general protocols such as this one may 2. Perform closed-chain exercises (see Figs. 22-6 to
prescribe a number of sets and repetitions, if the 22-9) at home depending on quadriceps and LE
patient fatigues and cannot continue to recruit a control.
quality quadriceps contraction, then the exercise is 3. Perform self-taping as deemed appropriate by the
over. Patients are only to count repetitions with therapist. Taping should be tailored to the
quality quadriceps contractions. Quadriceps sets are activity.
performed in the sitting or long-sitting position with 4. Continue using ice after exercises.
the knee positioned at 20 to 30 flexion. The heel
stays on the floor. Quadriceps sets also may be Weeks 5 to 6
performed standing if the patient finds it is easier to GOALS FOR THE PERIOD: Patient self-manages
activate the quadriceps in this position. The key to edema and pain, performs gait without deviations,
early strengthening is to find which position gives and has unlimited ambulation
the patient the most success in recruiting a quality 1. Depending on remaining deficits, exercises from
quadriceps contraction. weeks 1 to 4 are continued. The need for taping
should be minimal; however, if continued taping
Weeks 3 to 4 is required, then patients should be instructed in
GOALS FOR THE PERIOD: Continue to manage self-taping techniques.
edema and pain, improve sit-to-stand transfer 2. Patient should gradually return to functional
activities, improve strength and stability of the activities, with both patient and therapist
patellofemoral joint, progress functional training to monitoring for pain and joint effusion.
return activity to previous levels
1. Perform the same exercises as in weeks 1 to 2,
but increase the number of repetitions. Generally
Fig. 23-10 Self-mobilization. The patient should be able to perform active self-stretching to the lateral retinacular tissues. The patient is instructed to place
the heel of the hand over the medial half of the patella and push the medial border of the patella down into the trochlear groove. If the exercise is done properly,
then the lateral border tilts anteriorly, stretching the lateral retinacular tissue. The knee should be placed in at least 30 of flexion to ensure stability in the
trochlear groove and guard against lateral gliding of the patella. The patient progresses into deeper ranges of flexion as pain and lateral tissue tension subside.
Each stretch should be held for 5 seconds for two to three repetitions, three to four times a day.
1 George has been having chronic anterior (patellofemo-

ral) knee pain with recurrent subluxation. He is seeing
you for his shoulder rehabilitation and wants to know if
initiated along with therapy treatment consisting of ES
in conjunction with quadriceps isometrics. A single-point
cane was used in the interim until she could demonstrate
surgery (ALRR) is an option for him. What should you adequate quadriceps control with walking.
consider in your response?
Isolated lateral retinacular release has little or no role in

the treatment of acute or recurrent patella instability.
5 Diane is 33 years old. She has a history of anterior
knee pain for 2 years. Before having ALRR, she used
orthotics because she overpronated during gait. She
This procedure should be reserved for the few patients had surgery 6 weeks ago. Complaints of pain are minimal
with a clearly identified lateral patella compression syn- to nonexistent if she avoids all aggravating factors.
drome in the presence of a tight lateral retinaculum and However, she generally has some soreness from activi-
clearly discernable lateral retinacular pain. ties of daily living around the home and from taking
care of two young children. Diane is performing all the
2 Kathy is a 17-year-old soccer player that underwent

ALRR because of chronic anterior knee pain. She comes
for her 2-week postoperative evaluation. What should
exercises mentioned in phase I and most exercises in
phase II without pain. However, she has pain during
functional double-leg squats with knee flexion exceed-
be the main focus of her postoperative rehabilitation? ing 60 and knee pain with step-downs from a 4-inch
step. What may help Diane progress with her exercise
Given the chronicity of her symptoms, the therapist program?
should evaluate LE mechanics during gait and with
dynamic activities when appropriate. The clinician should Diane was evaluated for patellofemoral symptoms and
focus initially on hip strength and ankle mechanics (pro- treated with the McConnell method of taping. She was
nation dysfunction). Hip weakness can cause a valgus able to progress with the closed-chain exercises when
position of the knee, creating increased patellofemoral the appropriate McConnell taping procedure was used.
stress. The hip external rotators and abductors (espe- She was able to perform double-limb squats to 80 of
cially the gluteus medius) are a major component in knee flexion without pain. She also could perform two
positioning the knee in proper alignment. Ankle mechan- sets of 10 repetitions of step-downs on the 4-inch step
ics should also be fully explored and orthotics initiated without pain. Pain with the single-limb squat persisted
if appropriate. but lessened. Therefore, single-limb squats were not per-
formed until they could be done without pain.
3 Rebecca is 24 years old. She had ALRR performed on

her right knee 18 days ago. Treatment has focused on
decreasing joint effusion, pain, and discomfort. Over the 6 Travis is 3 weeks postoperation and is having trouble
with maintaining a good quadriceps contraction. What
past 2 days her pain has increased, with redness around exercises can be performed to address this issue?
the knee. What should be done?
Early quadriceps activation should include isometric
Because of the increase in temperature and redness quadriceps sets in varying degrees of flexion produced
(signs of potential infection), the clinician should notify by a proximal load-bearing shift with increased knee
the physician immediately. flexion. This allows for early muscle strengthening even
while joint effusion may still be causing pain in a closed-
4 Sarah is a 17-year-old basketball player who had ALRR

3 weeks ago. She is complaining about her knee giving
chain (joint loaded) position.
out during walking. She notes minimal pain, but con-

tinues to note pronounced swelling around the knee,
especially laterally.
7 What closed-chain exercises are appropriate to perform
once ROM is obtained and pain is under control?
Lunges in a long-stride position (see Fig. 23-6)

In exploring her situation further, it was noted that she Wall slides at various degrees of flexion with
was not able to perform an adequate quadriceps contrac- 1-minute holds to promote fatigue (see Fig. 23-7)
tion. Quadriceps inhibition is a result of the continued Functional single-limb squats from 0 to 30 directly
edema. A more aggressive edema management program over the midfoot
(i.e., elevation, compression, ES three times a day) was Functional double-limb squats with elastic tubing
Sit-to-stand at increased speed and repetition resting period from the pull and friction produced by the
Step-down exercises with an increase in height of tape. Patients using McConnell taping will need to learn
step and speed of movement (see Fig. 23-8) how to tape themselves. The tape will loosen according
Resistive leg press using progressive resistance to the aggressiveness of the patients activity. The patient
exercise should therefore be taught to tighten the tape when
Standing (four-wall) elastic tubing exercises for hip necessary.
flexion, extension, abduction, and adduction The patient is ready to be weaned off the taping
protocol and continue the program with specific sports-
8 Brian is making good progress in his rehabilitation

program with the adjunct of patella taping (medial
glide). He asks how long can he leave the tape on and
related activity and training when he or she can do the
following:
Sustain a quarter squat for 1 minute against the wall
will he have to tape his knee forever? without pain
Sustain a half squat for 1 minute against the wall
The patient only needs to wear tape while training the without pain
quadriceps to maintain the newly acquired length in the Perform 10 step-downs (off an 8-inch step) for at
lateral structures. The tape should be removed at night least 5 seconds per step with good control and
and the skin should be cleaned. This gives the skin a alignment and without pain
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CHAPTER 24
Meniscectomy and Meniscal Repair
Morgan L. Fones, George F. Rick. Hatch III, Timothy Hartshorn
A
lthough meniscal repair was introduced more than partially excised lateral meniscus tears. The surgery was
100 years ago, only within the past 10 to 20 years has performed in conjunction with ACL reconstruction and the
the meniscus successfully outlived its characteriza- repair was performed using an inside-outside technique.
tion as a functionless remain of leg muscle.1 Only a few They noted that although no significant statistical difference
years ago it was standard practice to excise the meniscus with existed between the two groups (International Knee Docu-
impunity because of the perception that it played little role mentation Committee grade), the partial meniscectomy
in the function of the knee. Fairbanks2 called attention to group had more pain.5 Shelbourne and Heinrich6 also noted
the frequency of degenerative changes after removal of the that certain types of lateral meniscus tears could be success-
meniscus and stimulated a new era of research into the fully treated with abrasion and trephination or just left in
anatomy and function of this poorly understood structure. situ. Noyes and Barber-Westin4,7 studied two different age
Researchers eagerly investigated the role of the meniscus in groups and their response to meniscus repair. They used an
load transmission and joint nutrition, and soon the pendu- inside-outside technique with a majority of the patients
lum of orthopedic popular opinion swung in the direction undergoing concomitant ACL reconstruction. In looking at
of determining new ways to preserve the injured meniscus. the outcomes, 87% of the older (over 40 years old) group,
With the advent of arthroscopic surgery, partial menis- and 75% of the younger (under 20 years old) group were
cectomy rapidly supplanted total meniscectomy, and research asymptomatic for medial compartment symptoms. They also
continued to determine the healing capacity of the torn noted significant improvement in outcomes when the repair
meniscus. From these efforts, meniscal repair has evolved as was done in conjunction with an ACL reconstruction. Age
a successful technique. Ultimately, recognition of the intact may not be as significant a factor as the type of tear (degen-
meniscus as a crucial factor in normal knee function has led erative or nondegenerative).8 The current trend appears to
to widespread acceptance of preservation of torn menisci lean toward the preservation of the meniscus whenever
through partial meniscectomy or repair. possible based on the patients current and future activity
levels. More research is being performed looking at the
SURGICAL INDICATIONS long-term results and categorizing further the indications
AND CONSIDERATIONS for meniscus repair.9 Outside of these parameters, little
consensus exists regarding the relative indications for menis-
When assessing the suitability of a meniscal tear for repair, cal repair.
the surgeon must consider several factors: patient age; The arthroscopic surgeon should be prepared to perform
chronicity of the injury; type, location, and length of the meniscal repair at the time of any knee arthroscopy. The
tears (the blood supply of the meniscus exists primarily at identification of reparable menisci is usually not possible
the peripheral 10% to 25%); and associated ligamentous preoperatively, but often magnetic resonance imaging (MRI)
injuries.3 The perfect candidate for a meniscal repair is a can help demonstrate the location of tears.
young individual with an acute longitudinal peripheral tear Four techniques for repair currently exist:
of the meniscus that is 1 to 2cm long, to be repaired in 1. Open meniscal repair
conjunction with an anterior cruciate ligament (ACL) recon- 2. Arthroscopic inside-out repair
struction. Success rates for meniscal repairs in conjunction 3. Arthroscopic outside-in repair
with ACL reconstruction has been as high as 90% compared 4. All-inside arthroscopic repair
with 75% for isolated meniscus repairs.4 It appears that the Each of these techniques has advantages and disadvan-
medial meniscus is more suitable for repair than the lateral tages; application of individual techniques is largely a matter
meniscus. Shelbourne and Dersam5 performed a repair of of individual preference.
441
SURGICAL PROCEDURE Outside-In Meniscal Repair

The outside-in meniscal repair technique allows suture
Open Meniscal Repair placement using an 18-gauge spinal needle placed across the
Open meniscal repair (Fig. 24-1) is the oldest technique tear from outside the joint to inside. Absorbable polydioxa-
for meniscal repair and has been popularized by Dr. Ken none suture17 is passed through the needle into the joint; it
DeHaven.10 It has a good record of success, even at 1-year is secured with a mulberry knot tied to the end of the sutures.
follow-up.11 Open meniscal repairs are best suited for These sutures are tied to adjacent sutures at the end of the
extremely peripheral tears. DeHaven still advocates routine procedure over the joint capsule; separate small incisions are
arthroscopic evaluation before considering open repair. The made for each pair of sutures. Morgan and colleagues18 noted
arthroscope is removed from the joint and the knee is an 84% success rate and found the primary reason for failure
prepared. After exposing the capsule through a longitudinal was an associated ACL deficiency.
incision, the surgeon prepares the meniscal rim and capsular
attachment, and places vertically oriented sutures at 3- to All-Inside Meniscal Repair
4-mm intervals. The incision is closed in a layered fashion. All-inside meniscal repair allows the meniscus to be repaired
Long-term follow-up has shown success rates of 70% without any additional incisions outside the knee. This is
to 79%.12-14 truly an all-arthroscopic technique. It is popular because it
avoids additional incisions and therefore diminishes neuro-
Inside-Out Meniscal Repair vascular risk and decreases operative time.14 Success rates
The inside-out meniscal repair technique was popularized by have been noted as high as 90%.14,19
Henning15 in the early 1980s and is the most popular tech- All-inside meniscal repair can be accomplished with
nique for meniscus repair. The surgeon uses long, thin can- either suture or biodegradable darts.20 The suture tech-
nulas to allow placement of vertical or horizontal sutures. nique is accomplished using a specially designed cannulated
After identifying the tear arthroscopically, he or she prepares suture hook to pass suture through both sides of the tear. The
the tear by using a meniscal rasp to create a better biologic sutures are then tied arthroscopically using a knot pusher.
environment for healing. A small posterior incision is carried The biodegradable darts are passed across the tear using
down to the capsule, and sutures are placed arthroscopically specially designed cannulas. After preparing the torn menis-
using specially designed long Keith needles to pass the cal surface, the surgeon reduces the tear and holds it in place
suture. The assistant protects the popliteal structures with a with a cannula. A thin cutting instrument is used to make a
retractor while grasping the suture needles. After placing all pathway across the meniscal tear, and the biodegradable dart
sutures, the surgeon ties them over the capsule. Success rates is passed through the same cannula, fixing the tear. The darts
have been noted to be 75% to 88%.14,16 generally completely resorb by 8 to 12 weeks.
THERAPY GUIDELINES
FOR REHABILITATION
Gastrocnemius muscle
Limited research is available regarding physical therapy
Common peroneal nerve
Plantaris muscle protocols after meniscus repair and long-term outcomes.
Biceps tendon Clinic protocols vary with the degree of weight bearing,
duration of immobilization, control of range of motion
(ROM), and time frame for a return to sports or work.
Recent studies have shown the success rates after accelerated
rehabilitation programs to be similar to those in conserva
Lateral collateral tive rehabilitation programs. These studies found no sta
ligament tistically significant difference in success and repair failure
Popliteus tendon rates between groups using conservative or accelerated pro-
grams. The hallmarks of accelerated programs are early full
weight-bearing tolerance, unrestricted ROM, and return to
pivoting sports.21-23 Recent studies have shown that dynamic
loading can help meniscal repair healing in inflammatory
environments.24
Several crucial factors must be considered before initiat-
ing a rehabilitation program. These factors influence the
speed and aggressiveness of the rehabilitation program. The
Fig. 24-1 Meniscus repair. (From Noyes FR, Barber-Westin SD: Meniscus
tears: diagnosis, repair techniques, clinical outcomes. In Noyes FR, Barber- size of the tear, repair stabilization technique, suture mate-
Westin SD, editors: Noyes knee disorders: surgery, rehabilitation, clinical rial, number of sutures, and location of the meniscal repair
outcomes, Philadelphia, 2009, Saunders.) influence initial postoperative weight-bearing tolerance,
Chapter 24 Meniscectomy and Meniscal Repair 443
ROM, and exercise restrictions. Other factors to consider potential to drive tibial internal rotation, creating a mecha-
before initiating a rehabilitation program include degenera- nism for excessive transverse friction at the knee joint. In
tive pathology in the weight-bearing articulations or patel- addition, hip abduction and external rotation strength need
lofemoral joint, previous patella dysfunction, concomitant to be examined to avoid excessive femoral adduction and
injuries, possible joint laxity (i.e., ACL deficiency or recon- internal rotation distally. Reassessment continues post
struction, medial collateral ligament injury), and severe operatively with each progression of weight bearing. Girth
kinetic chain movement dysfunctions proximally or distally measurements also are taken about the knee. The remainder
that alter knee alignment and forces. These injuries do not of the preoperative visit should include instruction in proper
necessarily indicate a potentially unsatisfactory result, but use of crutches, education regarding ROM (heel slides with
accommodations may be required in the protocol to accom- a 30-second hold for 10 repetitions), instruction in anti
modate the effects of these pathologies. Barber and Click21 embolic exercises (ankle pumps with a 30-second hold for
evaluated the results of 65 meniscal repairs in patients who 10 repetitions), and prescription of LE strengthening exer-
underwent an accelerated rehabilitation program. Successful cises in the form of isometrics (quadriceps sets, hamstring
meniscal healing occurred in 92% of patients with a con- sets, and cocontraction of quadriceps and hamstrings;
comitant ACL reconstruction, compared with 67% of all three exercises should be held for 10 seconds for 10 to
patients with ACL-deficient knees and 67% of patients with 20 repetitions) and active range of motion (AROM) of the
meniscal pathology alone. hip (working the adductors, abductors, and external rotators
An understanding of the clinical implications of knee and for 10 to 20 repetitions). Cryotherapy and elevation (for
meniscus biomechanics helps guide the therapist through 15 to 30 minutes) and compression wrapping should be
the rehabilitation process. Communication among all reha- reviewed for postoperative pain and swelling management.
bilitation team membersthe physician, therapist, patient, Depending on individual clinic and physician preference,
family, and coachis crucial to a successful rehabilitation the patient may be instructed in the use of electrical stimu
outcome. Most importantly, the meniscal repair rehabilita- lation (ES). The patient should be instructed in activities of
tion protocol must be individually tailored to the patients daily living, such as bathing and dressing, as appropriate.
needs. Home exercises are to be performed three times a day
The rehabilitation process can be broken down into three until return for the initial postoperative physical therapy
phases: initial, intermediate, and advanced. These phases evaluation.
may overlap and should be based on objective and functional
findings rather than time. Phase I (Initial Phase)
The early phase of the rehabilitation program should
emphasize decreasing postoperative inflammatory reaction,
GOALS: Manage pain and swelling, increase ROM and
restoring controlled ROM, and encouraging early weight
strength, increase weight-bearing activities and
bearing as tolerated. Exercise intensity is increased in the
prevent excessive loads/stresses through the joint
later phases of rehabilitation. Closed kinetic chain exercises
surfaces (Table 24-1)
are progressed through a variety of positions, from simple
linear movements to complex multidirectional, multiplanar The patient is typically seen for physical therapy 4 to 7
motions. The final phase of treatment is directed toward days after surgery. He or she may complain of mild to mod-
return to normal activity (sport or work). erate pain, swelling, impaired balance, and decreased weight-
The length of rehabilitation varies among patients. Treat- bearing tolerance. The patient may or may not be using pain
ments may be equally distributed among each of the phases medication.
of rehabilitation if the number of patient visits must be Generally, patients undergoing partial or total menis-
managed. Fewer treatments are required in the initial phases cectomy may be weight bearing as tolerated immediately
of rehabilitation if swelling and pain are adequately con- or soon after surgery whereas those undergoing repair are
trolled and ROM is progressing without complications. usually nonweight bearing (NWB) or partial weight
bearing (PWB) with crutches for a period of 2 to 6 weeks.
Preoperative Care Noyes recommends 4 weeks of PWB for complex and avas-
Ideally the patient should be seen at a preoperative visit, cular tears, with up to 6 weeks of toe touch weight bearing
which includes a brief clinical evaluation to record baseline when the patient has a radial tear.26 Tibiofemoral loads
physical data and identify potential latent biomechanical induce a circumferential stress (so-called hoop stress) in
deficits. The evaluation format encompasses a subjective the meniscus, which would distract the radial tear margins.27
history as outlined in Maitland,25 and objective data are Based on physician preference, the patient may have a post-
gathered primarily to record baseline measurements. The operative hinged knee brace, which will either be statically
lower extremity (LE) is evaluated as a functional unit. locked at a particular setting for 7 to 10 days or set between
Strength and ROM are recorded for the hip, knee, ankle, and certain parameters to allow for immediate postoperative
foot. Foot mechanics also are evaluated for any biomechani- ROM. Meniscal repairs in the red-red zone and larger
cal faults that may lead to excessive tibial motions in the peripheral repairs may be braced up to 90 for up to 14 days.
frontal or transverse planes. For example, pes planus has the White zone repairs may be braced at 20 to 70. Extension
TABLE 24-1 Meniscus Repair

Criteria to Anticipated Impairments
Phase I Postoperative Mild to moderate pain Cryotherapy, heat and ice Manage pain and Decrease pain and
Postoperative Peripheral repairs: Partial contrast, ES swelling minimize swelling
1-4 wk weight bearing by 2 wk, PROMHamstring stretches, Knee ROM 0-120 Prevent ROM complications
weight bearing to gastrocnemius-soleus stretches Increased muscle Assist in restoration of joint
tolerance at 3-4 wk Wall slides or passive heel slides strength and endurance mechanics
Complex tears: Partial (see Fig. 24-2) Normalization of gait Facilitate return of
weight bearing by 6 wk, IsometricsCocontraction within healing and neuromuscular control
weight bearing to quadriceps and hamstring weight-bearing Minimize disuse atrophy
tolerance at 7-8 wk (depending on the repair site), limitations Strengthen knee
Decreased strength quadriceps sets, hip adductor musculature while
Minimal to moderate sets, hamstring sets, resistive protecting the repair site
effusion exercises Increase muscle endurance
Decreased ROM Four-quad program, weight added Use the properties of water
distally as tolerated during exercise
Elastic tubing exercises performance
Gait training Functional strengthening
Low-resistance, moderate-speed
stationary cycling
Aquatic therapy; closed kinetic
chain activities (initiate near end
of phase for peripheral tears
only)
Leg press machine
Partial squats
Heel raises
Standing terminal knee extension
with tubing
ES, Electrical stimulation; PROM, passive range of motion; ROM, range of motion.
is increased to 0, and flexion is increased to 90 after 7 to distal LE. Depending on the patients weight-bearing status
10 days as healing allows. or tolerance, gait assessment is either brief or detailed. Gait
On the first postoperative visit a comprehensive evalua- assessment should focus on proper mechanics and weight-
tion is performed, with the physical therapist collecting the bearing tolerance. If the patient is NWB or PWB, the assess-
new objective data and reviewing and updating the previous ment is brief and focuses primarily on safety, correct
subjective data.25 Subjective data that need to be reviewed mechanics (with crutches), and includes a discussion regard-
postoperatively include medication usage, sleep pattern, pain ing weight-bearing restrictions. If the patient does not have
levels at rest and during activity, and aggravating and easing weight-bearing limitations and has good gait tolerance, then
factors. In addition, the therapist should review the postop- a more detailed assessment of gait can be made. The patients
erative report dictated by the operating surgeon that describes ability to ambulate with normal mechanics throughout each
the extent and nature of the repair, as well as any unique phase of gait is very important and should be assessed.
patient-specific postoperative instructions. Goals and reha- Remedial corrective actions are required to decrease poten-
bilitation expectations are established and reviewed with the tially harmful loading onto healing structures. Typically
patient during the initial visit. patients require cueing to avoid hip external rotation during
The new and updated objective and clinical data should the stance phase, because this puts abnormal stresses through
include visual examination, gait assessment, ROM measure- the knee, ankle, and foot. Crutches should be used through-
ment, strength assessment, palpation, and girth measure- out the initial phase of treatment until adequate strength,
ment (as described in the section on the preoperative initial ROM, and normal gait mechanics are achieved. Static and
visit). Visual observation should focus on areas of atrophy, dynamic foot function (as related to normal gait mechanics)
in particular the quadriceps and gastrocnemius; healing continues to be assessed during this phase of rehabilitation.
status of incision sites; and swelling about the knee joint and Dysfunctions must be addressed to decrease abnormal
tensile or compressive force affecting healing of the meniscus swelling. The importance of home cryotherapy cannot be
repair. overemphasized. The study of Lessard and colleagues30 on
Flexibility of the hip musculature, hamstring, and the use of cryotherapy after meniscectomy found statistically
gastrocnemius-soleus complex should be assessed. The significant differences between groups with and without
patellofemoral joint should be assessed, especially if the postoperative cryotherapy. Patients reported decreased pain
patient reports previous or present patella symptoms. Patella ratings per the McGill pain questionnaire, decreased medi-
tracking and glides are part of this assessment. Joint mobili- cation consumption, improved exercise compliance, and
zation or patellofemoral taping may be helpful in mitigating improved weight-bearing status.
these symptoms.28 All major muscle groups in the LE should
be assessed bilaterally for strength capacity. In addition, Range of Knee Motion and Flexibility
visible observation and palpation of the quadriceps during Restoration of ROM is vital to a return to the patients prior
an isometric quad set or straight leg raise (SLR) can give the level of function. Typically on initial evaluation, the patient
clinician insight into the patients ability to be safe and secure exhibits a loss of extension of 5 to 10; flexion ROM is typi-
in an upright position. The remaining LE musculature should cally 70 to 90. The patient usually exhibits a guarded end
be assessed, with the therapist identifying any potential feel with motion improving with repetition. The time param-
weakness that may alter normal closed kinetic biomechanics eter to achieve full ROM is longer with meniscal repair than
and therefore increase tensile or compressive forces across it is in partial arthroscopic meniscectomies. Although early
the meniscus repair site. restoration of ROM is important to normalize joint function,
No standard method has been established for assessing the healing process of the meniscus repair dictates caution,
girth about the knee joint. Consistency among the team especially with full circumferential peripheral repairs.
members providing patient care is important when reassess- Any exercises used to increase ROM should not be
ing the patients condition. Atrophy as measured by girth forced because of the risk of stressing healing repair sites.
measurements is not diagnostic of weakness or atrophy in a Wall slides, sitting passive knee flexion, or passive heel slides
specific muscle group. Circumference measurement assesses (Fig. 24-2) may be used to increase knee flexion. ROM exer-
girth of all muscle and joint structures underlying the mea- cises are to be performed within pain tolerance, held at least
surement area. Typical measurement sites for a bilateral 30 seconds, and repeated as tolerated (generally 5 to 10
comparison include the midpatella, 5 and 10cm above the times). As part of the home exercise program, ROM activity
knee joint and 5 and 10cm below the knee joint. can be repeated three to five times per day.
Treatment is initiated after the clinical evaluation is com- Appropriate remedial flexibility exercises can be imple-
pleted (see Table 24-1). Initial phase treatment goals are to mented as tolerated in this phase, with the patient avoiding
decrease pain and manage swelling, restore ROM, increase forced knee flexion and rotation about the knee joint. Patients
muscle strength and endurance, and normalize gait within should perform slow static stretches, avoiding ballistic move-
healing and weight-bearing limitations. ments, to maintain control of the lower limb and minimize
the chance of affecting the healing meniscus repair.32,33
Pain and Edema Management Hamstring and gastrocnemius-soleus flexibility exercises are
Minimal to moderate effusion will likely be evident at the typically indicated at this time. Stretches should be held at
evaluation. Modalities such as cryotherapy, heat and ice con- least 30 seconds and repeated 5 times, three times a day.
trast, and ES can be used to decrease pain and swelling.29-31 Stretches should be sustained and passive in nature, allowing
Instructions in home use of cryotherapy, compression wrap- the patient or therapist to control knee joint motions, avoid-
ping, and elevation as discussed in the section on preopera- ing potential complications from ballistic type of stretch-
tive management is initiated for postoperative pain and ing.34 The hamstring group can be stretched passively using
Fig. 24-2 Heel slides. While lying supine the patient slides the involved heel toward the buttock, maintaining the knee in a straight plane and avoiding any
hip or tibial rotation.
Fig. 24-3 Hamstring stretching. In a long-sit position, the patient leans forward from the hip, avoiding lumbar flexion.
supine position. A towel can be used to assist with the raising

of the leg (Fig. 24-3). The gastrocnemius-soleus can be
stretched using a towel or strap in the early phases of reha-
bilitation. Progression to stretching of the hip musculature
and quadriceps can be performed as the patients increase in
knee ROM dictates. The knee needs to be kept in a relative
neutral position to avoid any rotational or compressive forces
on the repaired meniscus site. Standing gastrocnemius-
soleus stretching can be initiated as weight-bearing tolerance
increases.
It is important to keep the foot in a neutral position to
avoid any tibial rotation caused by supination or prona-
tion, which may increase knee joint compression and
tensile forces across the repaired meniscal site.
Patients who develop limitations in either flexion or Fig. 24-4 Patella mobilizations. Aggressive Maitland grade IV mobiliza-
extension of the surgical knee require manual patella mobi- tions are typically needed if there are ROM concerns early on.
lizations (Fig. 24-4) and home exercises for aggressive long
static stretches. Patella mobilizations should be done in the the patient. All strengthening exercises should be closely moni-
superior, inferior, medial, and lateral directions and are vital tored for potential adverse reactions and increased pain or
to achieving full ROM. In addition, the patient is instructed swelling.
in prolonged flexibility stretches. For a flexion contracture, Strengthening exercises for all LE musculature are initi-
the foot and ankle are propped up on a rolled towel, allowing ated with an emphasis on restoration of quadriceps muscle
the knee to drop into full extension. Then a 5- to 10-lb weight function to minimize potential patellofemoral dysfunction.
is placed on top of the knee for 10 minutes. This is done daily Isometric exercises should be held for 10 seconds and per-
6 to 8 times. Flexion exercises can be done in the seated formed for 10 to 20 repetitions. Quadriceps sets can be per-
position with the other leg providing overpressure. Other formed within the patients tolerance. A small towel may be
ways are to use a rolling chair, a supine wall slide, or a quad- required under the posterior aspect of the knee if the patient
riceps stretch. lacks full extension or if muscle setting in full extension is
painful to the knee joint area. The patient is instructed to
Strengthening extend at the hip while tightening the quadriceps muscle,
Initial strengthening is performed as tolerated in open-chain straightening the knee as tolerated. This exercise also may
positions. Closed kinetic strengthening can be initiated, help restore knee extension. The towel should be removed as
depending on the weight-bearing status and tolerance of knee extension increases or becomes less painful. Adductor
isometric contractions can be performed isolated or in con- be two to three times normal body weight. The meniscus
junction with quadriceps sets.35 assumes 40% to 60% of the weight-bearing load. Variations
Hamstring isometrics can be performed; they should ini- in knee joint angulation or rotation can increase the force
tially be performed at a submaximal level, with vigor across the meniscus 25% to 50%.1 Variations in foot mechan-
increased based on patient tolerance and response. ics that cause rotation or angulation of the knee into varus
Caution should be exhibited when performing ham- or valgus can have potentially significant effects on meniscal
string exercises early in rehabilitation, especially with compressive and tensile forces that may affect the repair site.
larger peripheral rim or posterior horn meniscus repairs. As a result, some physicians recommend initiating closed-
Active knee flexion pulls the medial and lateral meniscus chain exercises only for peripheral tears during this phase
posterior. Because the lateral meniscus is more loosely while waiting until phase II (5 to 11 weeks) for complex
attached, it can migrate posteriorly as much as 1cm as a tears39 (Table 24-2).
result of pull from the popliteus muscle. The medial menis- Partial weight-bearing, closed kinetic chain activities
cus may move a few millimeters via the posterior attachment using leg press or inclined squat machines, partial squats,
to the joint capsule and influence from the nearby semimem- and heel raises can be initiated later in the initial phase.
branosus attachment.3 Cocontraction isometrics of the Standing terminal knee extension with tubing can be added
quadriceps and hamstrings may be used in the first 2 to 4 to increase quadriceps strength and control with full weight
weeks in patients with the aforementioned repairs to allow bearing.
adequate meniscal healing.36 Aquatic therapy is an additional treatment option during
Short arc quadriceps exercises can be added if the patient the third and fourth week of the initial phase, especially if
tolerates end-range extension movement. Resistance should the patient has limited weight bearing and cannot tolerate
be added carefully, with the therapist remaining mindful of traditional therapy because of pain.40
the role of the quadriceps in pulling the meniscus anteriorly
by way of the meniscopatellar ligament, as well as the ante- Balance and Proprioceptive Training
rior posterior compressive force exerted by the femoral When patients achieve PWB, balance and proprioceptive
condyle during knee extension.28 Another effective open training can begin. Crutches are used to assist during these
chain exercise for the quadriceps is active assisted knee exercises. Initially, the patients begin with tolerable weight
extension in sitting from 90 to 30. An open-chain (SLR) 4 shifts in the sagittal and frontal planes. Tandem balancing
quad program (i.e., four quadrants: hip flexion, abduction, can also be initiated during the partial weight-bearing phase.
adduction, and extension) can be initiated with the knee Gait training with small obstacles like water cups can help
fully extended if the patient has adequate LE and quadriceps develop adequate stance phase stability, symmetry between
control. The 4 quad program is a series of SLR exercises the surgical and contralateral limbs, and improved proprio-
held for 10 seconds and 10 to 20 repetitions: ception. Some patients may be able to progress to a single-leg
1. Supine SLR balance exercise, where the knee is held at 20 to 30 of
2. Side-lying hip abduction flexion. Different surfaces can be added as needed.
3. Side-lying hip adduction
4. Prone hip extension Conditioning
Progression of this program is based on patient signs and A conditioning program can be initiated 2 to 4 weeks post-
symptoms. Resistance can be added distally as tolerated. The operatively with an upper body ergometer. Low-resistance,
DeLorme strength progression protocol37 can be used, with moderate-speed stationary cycling can be initiated when
gradual increases in resistance based on patient signs and knee flexion ROM is around 110. Toe clips may be optional
symptoms. if hamstring activity is to be minimized because of the loca-
Weight-bearing status and patient tolerance may limit the tion of the repair. Progression is determined by the patients
ability to strengthen the distal musculature. Strengthening tolerance to stationary cycling. The goal of initial phase
of the ankle can be aided by exercises using elastic tubing; cycling is to increase muscle endurance.
the patient should perform three sets of 10 to 20 repetitions. Complications in the initial phase of treatment include
Ankle movements of dorsiflexion, plantar flexion, inversion persistent pain and swelling, arthrofibrosis, adhesions at
and eversion, and hip proprioceptive neuromuscular facili the porthole sites, patella tendonitis, and patellofemoral
tation (PNF) patterns (with the knee extended) can be pain. Activity modification, use of modalities, heat and cold
performed to the patients tolerance. As with other healing contrast, cryotherapy, and ES may be helpful in decreasing
collagen structures, controlled tensile and compressive pain and swelling. Adhesion of the porthole sites within the
loading may assist in scar conformation, revascularization, distal fat pads may cause painful limitation of knee flexion
and improvement in the tensile properties of the meniscal and active knee extension. Ultrasound or phonophoresis,
repair through the maturation process.38 Gradual progres- along with soft tissue mobilization of incision sites, may be
sion and reassessment of activity is crucial. helpful in mitigating distal patella symptoms. Assessment of
When initiating any of the closed kinetic chain exercises, patellofemoral mechanics (active and passive) is an ongoing
the patient must keep the knee and LE in a neutral position. process. Patellofemoral taping should be used to control pain
In normal gait the compressive forces on the knee joint may and dysfunction.41

Postoperative Weeks Postoperative Months
1-2 3-4 5-6 7-8 9-12 4 5 6 7-12
Brace: long-leg postoperative C, T C, T C, T

Range of Motion Minimum Goals
0-90 X
0-120 X
0-135 X
Weight Bearing
Toe touch to 12 body weight P
3 4 to full body weight P
Toe touch to 14 body weight C, T
12 - 3 4 body weight C, T C
Full body weight T C
Patellar mobilization X X X
Stretching
Hamstring, gastrocnemius, soleus, iliotibial band, quadriceps X X X X X X X X X
Strengthening
Quadriceps isometrics, straight leg raises, active knee extension X X X X X X X X X
Weight bearing: gait retraining, toe raises, wall sits, minisquats P C X X X X X
Knee flexion hamstring curls (90) P C X X X X X
Knee extension quads (90-30) X X X X X X X
Hip abduction-adduction, multihip X X X X X X X
Leg press (70-10) P P X X X X X
Balance/Proprioceptive Training
Weight-shifting, minitrampoline, BAPS, KAT, plyometrics P X X X X X X X
Conditioning
UBE X X X
Bike (stationary) X X X X X X X
Aquatic program X X X X X X
Swimming (kicking) P, C X X X X
Walking X X X X X
Stair-climbing machine P, C P, C P, C P, C X
Ski machine P, C P P C X
Running: straight* P P C X
Cutting: lateral carioca, figure 8s* P P X
Full sports* P P X
BAPS, Biomechanical Ankle Platform System (Camp, Jackson, Mich); C, complex meniscus repairs extending into central one-third region;
KAT, Kinesthetic Awareness Trainer (Breg, Inc., Vista, Calif); P, peripheral meniscus repairs; T, transplants; UBE, upper body ergometer, X, all
meniscus repairs and transplants.
*
Return to running, cutting, and full sports based on multiple criteria. Patients with noteworthy articular cartilage damage are advised to return
to light recreational activities only.
ROM gradually increases during the initial phase of treat- and swelling as attempts to increase ROM (especially knee
ment, approaching full ROM by the end of this phase. Passive flexion) continue.
and dynamic splints may be helpful in gaining ROM if In addition, the therapist should be cognizant of and rec-
the joint does not respond to conservative treatment. Initia- ognize meniscus lesion signs and symptoms. These include
tion of vigorous stretching or knee joint mobilization persistent joint effusion, joint line pain, and locking or giving
should be discussed with the patient and physician. The way of the knee (as opposed to buckling or weakness from
therapist should be aware of knee joint symptoms, pain, decreased LE or quadriceps strength).
If activity modification and use of modalities does not is being treated conservatively secondary to repair of a
improve the patients symptoms and objective findings, or if complex or avascular tear, they should be able to tolerate full
the patient exhibits classic signs of a meniscus tear, then weight bearing without pain or swelling. The patient should
referral to the physician is indicated. exhibit normal gait mechanics. Good control of the LE mus-
culature should be evident before activity is progressed. The
Phase II (Intermediate Phase) goals of the intermediate phase are to normalize strength,
ROM, gait, and endurance, as well as progress the patient
into functional activities. Muscle flexibility exercises are con-
GOALS: Gain full ROM and 90% to 100% strength,
tinued as needed during this phase. Quadriceps and ilio-
progress functional activities, progress to gym
psoas stretching to improve knee flexion and hip extension
program (Table 24-3)
can be initiated. Strength exercises are continued and
Objective findings rather than time ranges give an indica- advanced as tolerated. Hamstring strengthening (with iso-
tion of progression into the intermediate phase of rehabilita- tonic exercise) can be advanced during this phase. Progres-
tion. In general this phase occurs around 4 to 6 weeks, in sion is based on DeLormes principles.37 Resistance can be
part based on improved patient signs and symptoms but also applied to the hamstring group gradually, based on patient
because enough time has elapsed to allow sufficient healing tolerance.
of the meniscal repair. This phase lasts until the patient is Closed-chain activity can be advanced during this phase
ready to enter a return-to-sport program (usually by week of rehabilitation. Progression of activity should be from
12). Pain and swelling should be minimal and easily con- simple linear movements to complex multidirectional move-
trolled before initiation of this phase. ROM should be full. ments. Patients are instructed to perform three sets of 10
However, the patient may have a slight restriction of knee to 30 repetitions as indicated. The patient must demonstrate
flexion, with discomfort at the end ROM. Unless the patient adequate control of LE mechanics and not have adverse

Anticipated
Phase II Minimal pain and Decreased strength Continue exercises as outlined in Full ROM Restore knee and LE
Postoperative swelling 4 to 6 wk Minimal effusion phase I 90%-100% LE strength function
5-11 wk to allow sufficient Decreased ROM Resistive exercise: Normal gait and Increase muscle
healing (flexion) IsotonicsHamstrings standing tolerance strength
Full weight bearing IsokineticsA submaximal Progression to Use specificity of
for peripheral tears; multispectrum isokinetic program functional activities training principles to
complex tears begin Closed-chain exercises (now can Prepare patient for return the patient to
at 7-8 wk begin for complex tears as discharge previous level of
Normal gait well), heel raises, lateral functional activity
mechanics step-up, forward step up/down, Enhance response of
Good control of the wall squats, knee flexion at joint proprioceptors
LE musculature 45-60, minisquats, partial and neuromuscular
lunges, progression in knee coordination
flexion ROM Emphasize stability/
Balance/proprioceptive training: strengthening of
Weight shifting, minitrampoline, involved leg
BAPS, BBS, balance board Improve cardiovascular
Elastic tubing activity, T kicks fitness
(see Fig. 24-5)
At 9 wk can begin stationary
cycling, aquatic program,
swimming, stair-stepping
machine, ski machine (wait until
5-6 months for complex tears),
or treadmill
BAPS, Biomechanical Ankle Platform System (Camp, Jackson, Mich); BBS, Biodex Balance System (Shirley, NY); LE, lower extremity; ROM,
range of motion.
reactions (pain and swelling) from the simple linear move- tubing T kicks (Fig. 24-5). The uninvolved extremity has a
ments before progressing to complex multidirectional move- cord attached distally; the involved extremity remains sta-
ments. Variables of time, repetitions, ROM, and resistance tionary with the knee in about 10 of flexion. The patient
are used in functionally progressing the rehabilitation moves the uninvolved extremity into flexion, extension,
program. Full weight-bearing heel raises, lateral step-ups, abduction, adduction, and diagonal planes. Initially the
wall squats, minisquats with tubing, and partial lunges can patient performs 10 to 15 repetitions for two sets in each plane
be performed. ROM should be limited initially, with most of movement. The patient may require support for balance.
activity being from 0 to 90. The exercise can be progressed by altering the tubing resis-
Constant reassessment should occur, and patient toler- tance, increasing the repetition or time (up to 30 seconds in
ance to the particular activity must be demonstrated before each plane), and altering the speed of movement (Fig. 24-6).
any exercise progression. Balance and coordination exer- Cycling can be continued, with the patient modifying the
cises can be added to the rehabilitation program during the workload parameters of speed, resistance, and duration
intermediate phase. Initial training is done bilaterally based on response to the activity. Additional cardiovascular
and progressed as tolerated to unilateral activities. Balance activity (e.g., stair-stepping machine, cross-country ski
boards, trampolines, and elastic cords can be used. Single- machine, treadmill) can be added based on patient response
limb balance and control can be performed with exercise and tolerance.
A B
C D
Fig. 24-5 T kicks. This exercise is performed in a standing position, with elastic tubing around the ankle of the uninvolved LE (foot off ground). The unin-
volved LE moves into flexion (A), extension (B), adduction (C), and abduction (D). The emphasis is on maintaining proper LE alignment and avoiding tibial
rotation.
A gradual walking-to-running program can be estab- advanced phase and gradually introduced with progressive
lished toward the end of this phase based on weight-bearing loading toward the end of the phase. Normal strength in
tolerance and adequate closed-chain control and LE strength. all major muscle groups should be exhibited. The patient
(Refer to Chapter 34 for a detailed progressive running should exhibit good closed-chain control in linear and
program.) Assessment of foot function with appropriate multidirectional activity. The goals of this phase are to estab-
modifications may be helpful in minimizing abnormal joint lish a training program and return to sports or preinjury
and meniscus stress before initiating a running program. The activity levels.
running program can start with jogging in place on a tram- Progression of strength and endurance training contin-
poline and be progressed to treadmill running. Continued ues. New loads and demands are placed on the LE through
progression is based on patient tolerance and absence of pain running, agility, and plyometric training. Depending on pre-
and swelling. vious activity level and functional requirements, agility,
Isokinetics strength and endurance training can be initi- sprinting, and track running can be initiated. An indicator
ated during this phase. Tolerance to resisted quadriceps of patient progress in these activities is the ability to jog on
and hamstring strengthening must be demonstrated before a treadmill 10 to 15 minutes at a pace of 7 to 8mph without
an isokinetic program is initiated. A submaximal multi adverse signs and symptoms. As with other knee disorders,
spectrum program with a lower velocity speed of 180/sec adequate isokinetic strength (70% of the uninvolved extrem-
(three sets of 15 to 20 seconds) and higher velocity speed of ity) can be used as an indication for progression to a running,
300/sec (three sets up to 30 seconds) can be initiated. Pro- agility, and plyometric program. A deficit of 10% or less is a
gression is based on patient tolerance and adequate response reliable indicator of return to sport or activity participation.23
to training. An initial plyometric program may include squat jumps in
water. It serves as an effective alternative to dry land jumps
Phase III (Advanced Phase) by keeping adequate intensity while limiting the loads placed
through the joint.42 However, other functional tests need to
be assessed to ensure safe return. Refer to Chapter 34 for a
GOALS: Return to sport or preinjury activities, establish
more complete return to running program.
an ongoing training program (Table 24-4)
Progression to the advanced phase of rehabilitation is SUGGESTED HOME MAINTENANCE FOR

based on tolerance to intermediate phase treatment. Typi- THE POSTSURGICAL PATIENT
cally this phase is initiated around 12 to 18 weeks. ROM
should be complete without pain. An exercise program has been outlined at the various phases.
Caution should be exhibited with full squat or lunge The physical therapist can use it in customizing a patient-
activity. These activities should be avoided early in the specific program.
A B C
Fig. 24-6 A, Side steps with resistance loop. Starting position is an athletic stance. Slowly side step 50 to 100 feet, avoiding trunk compensations and dragging
of nonlead leg. B, Wall squat with resistance loop. Squats are done to varying degrees of knee flexion depending on what is indicated at that time. Mirror is
recommended so patient can see faulty movement patterns. C, Frontal plane lunges. Step length and knee flexion are to patient comfort and therapist discre-
tion. Patient can avoid hip external rotation with step or emphasize it depending on the forces wanted in the knee.

Anticipated
Phase III Tolerance to Isokinetic strength and Progression and Establish an ongoing Continued progression
Postoperative intermediate phase endurance deficit continuation of exercises as training program of endurance and
12 wk-12 treatment Decreased ability to listed in phases I and II, Return to preinjury strength training
months Full ROM perform full squat depending on previous activity or sport Safe return to
Normal manual or lunge activity level and functional Appropriate performance functional activity
muscle test Fair balance and requirements functional and isokinetic
Good closed-chain control with higher For peripheral tears, tests as indicated for
control in linear and level activity running straight at return to sport or activity
multidirectional activity 4 months, cutting at
Treadmill 10-15 5 months, full sports at
minutes at a pace of 5-6 months.
7-8 mph without For complex tears, running
adverse signs and straight at 6 months,
symptoms cutting at 7-12 months, full
Isokinetic strength sports at 7-12 months
70% of the uninvolved IsokineticsStrength and
extremity endurance training
CONCLUSION cartilage, flattening of the articular surfaces, and subchon-

dral bone sclerosis. Numerous techniques are available to
Meniscal repair is an effective technique for preserving achieve this goal and selection is primarily a matter of
certain types of tears. Long-term results are still unknown, surgeon preference. A rehabilitation program must be indi-
but the current literature supports preservation of the vidually tailored based on tear specifics (size, location, repair
meniscus whenever possible to avoid the late sequelae of technique), scientific evidence, clinical signs and symptoms,
meniscectomy: progressive degeneration of the articular and patient needs.

GOALS FOR THE PERIOD: Manage pain and GOALS FOR THE PERIOD: Manage pain and
swelling, increase ROM and strength, increase swelling, increase ROM and strength, increase
weight-bearing activities weight-bearing activities
1. Heel slides10 repetitions to be held 30 seconds; 1. Supine wall slides or passive heel slides, 10
pressure within patients tolerance repetitions to be held 30 seconds; pressure within
2. Ankle pumps20 to 30 repetitions patients tolerance
3. Isometric muscle contractionsquadriceps, 2. Cocontraction isometrics of the quadriceps and
hamstring (if appropriate), adductor, and gluteal hamstrings, 10 to 20 repetitions to be held 10
isometric contractions (10 to 20 repetitions to be seconds (depending on the repair site)
held 10 seconds) 3. Isometric quadriceps, adductor, and hamstring
4. Cryotherapy with elevation to be performed contractions, 10 to 20 repetitions to be held 10
as needed throughout the day for 10 to 15 seconds
minutes 4. Flexibility exercises for the hamstring and
5. Additional compression garment or wrapping gastrocnemius-soleus; stretches should be held at
may be helpful least 30 seconds and repeated 5 to 10 times
5. Four-quad program, two to three sets of 10 sets of 10 repetitions; wall squats, knee flexion at
repetitions, weight added distally as tolerated 45 advanced to 60, two sets of 10 repetitions to
6. Elastic tubing exercises (dorsiflexion, plantar be held 10 seconds; minisquats, partial lunges,
flexion, inversion and eversion, and hip PNF and progression in knee flexion ROM (add tubing
patterns), two to three sets of 10 repetitions or weight to progress resistance as tolerated),
7. Low-resistance, moderate-speed stationary two to three sets of 10 repetitions to be held 5 to
cycling 10 seconds
8. Home aquatic therapy (performing AROM 4. Balance activities (bilateral progressed as
exercises of the hip, knee, and ankle in chest-high tolerated to unilateral)balance board,
water) trampoline (side-to-side and forward-to-back
9. Continued cryotherapy with elevation to be steps), two sets of 1 minute each
performed as needed throughout the day for 10 5. Exercise cords activity, T kicks, two to three sets
to 15 minutes of 10 repetitions
6. Stationary cycling, modifying the workload
Weeks 5 to 11 parameters of speed, resistance, and duration
GOALS FOR THE PERIOD: Gain full ROM and 90% to based on the response to the activity
100% strength, progress functional activities, 7. Stair-stepping machine, cross-country ski
progress to gym program machine, or treadmill, with workload progression
1. Continued open-chain exercise program, four- based on patient response and tolerance
quads, short arc quadriceps, and PNF patterns
with tubing Weeks 12 to 18
2. Hamstring, gastrocnemius-soleus, quadriceps, GOALS FOR THE PERIOD: Return to sport or
and iliopsoas stretching, 5 to 10 repetitions to be preinjury activities, establish an ongoing training
held at least 30 seconds program
3. Heel raises, two to three sets of 10 repetitions; 1. Progression of strength and endurance training
lateral step-ups and forward step up and down 2. Functional or sport-specific drills
(using 2-inch height progressions), two to three 3. Agility, sprinting, and track running
1 Jonathan is a 52-year-old man who underwent an

inside-out repair of a medial meniscus posterior-horn
tear. On his first postoperative visit, he complains
knee AROM (30 to 70). What is most concerning at
this point and why?
of numbness on the inside of his calf extending down The patient has a 30 extension lag, and this is very con-
the medial side of his leg. What do you tell the patient? cerning. The inability to fully extend affects gait biome-
chanics and can lead to the development of permanent
The patient underwent an inside-out repair of a medial flexion contractures if not addressed early. The patient
meniscus tear, so the surgeon likely made a posterome- may benefit from more aggressive stretching exercises,
dial incision through which he or she gained access as well as a dynamic extension brace. Knee swelling and
to tie the sutures. The saphenous neurovascular struc- pain can persist a few weeks after surgery and should be
tures lie an average of 22.6mm away from this incision43 evaluated, but this patient should have obtained full
and is at risk during this approach (the peroneal nerve is extension within the first week or two after surgery. Also,
at risk during the posterolateral incision). The patients the patient underwent a partial meniscectomy and not a
nerve injury is likely a neuropraxia (stretching of the meniscal repair, so it would be extremely unlikely that
nerve but still in continuity) and should return, but the patient has sustained a new meniscal tear this early
the therapist should direct these types of questions after surgery.
to the operating surgeon.
2 Martha is a 47-year-old woman who had a partial

lateral meniscectomy for a complex tear approximately
3 Marek is a 49-year-old golfer who had a lateral posterior
horn meniscal repair 3 weeks ago. You find his ham-
string musculature remains weak. What would be an
3 weeks ago. This is her second visit, and she is com- appropriate strengthening exercise. At what point will
plaining of pain, moderate knee swelling, and limited you apply a prone hamstring curl and why?
Bridging with a gym ball requires hip extension while Side steps with resistance band to her right only, so no
maintaining knee ROM from 0 to 30. Therefore, both valgus force is placed through her medial collateral liga-
gluteal and hamstring musculature are active in the hip ment and medial meniscus. Frontal plane lunges with
extension role, without any active knee flexion. Active glut dominant movement pattern, placing the knee at no
knee flexion pulls the medial and lateral meniscus pos- more than 90 flexion. Wall squats with a resistance band
terior. The lateral meniscus migrates 1cm posterior, around the distal thigh. This requires an isometric hip
because the popliteus muscle pulls it during knee flexion. abduction contraction, strengthening the patient in the
This activity places increased stress on the repaired and frontal plane.
healing tissues.
4 Silvia is 40 years old. Before tearing her meniscus, she

had two episodes of anterior knee pain over the past 3
7 John is a 44-year-old recreational tennis player who
underwent repair of his medial meniscus 8 weeks ago.
He has progressed rapidly through his exercise program
years. Silvia had a medial meniscal repair 5 weeks ago. without any significant obstacles. He notes a sudden
She has been progressing nicely with exercises, and the onset of swelling in his knee, which he relates to per-
exercises have been advanced. After treatment she forming yard work (i.e., raking leaves, squatting down).
reports pain in the anterior inferior patella region with Although his knee is swollen, no crepitation or locking
most of the exercises. Silvia is concerned because she is seen. His mild pain symptoms appear localized to the
almost slipped and fell after her last physical therapy medial joint line. What changes should be made in his
visit. She denies any episode of her knee locking or program?
becoming stuck. What might be the source of her pain?
It appears that he aggravated his repair site with squat-
Silvias history, along with the pain distribution pattern, ting and pivoting activities. This activity should be
indicates a patellofemoral joint problem that may have avoided until he can clinically demonstrate tolerance to
become irritated. Meniscal pain often produces com- this stress. Use of minisquats or an inclined sled allows
plaints of pain near the joint line. Of course, a detailed for the careful control of how much compression is deliv-
assessment should be made and the physician notified. ered to the knee. Pivoting should be avoided for 6
In this case the patellofemoral joint was the source of months. John was cautioned about the risk of retearing
the anterior inferior knee pain. Therefore the patient his meniscus and his swelling was managed with rela-
should be treated for both the patellofemoral symptoms tive rest, ES, ice, and elevation.
and the meniscal repair. Necessary restrictions should
be maintained for each condition. After the patellofemo-
ral symptoms have been significantly reduced or elimi-
nated, the exercise program for the meniscal repair can
8 Tammy is an active 45-year-old female who had a medial
meniscal repair for a radial tear of the posterior horn 2
months ago. She has active knee ROM of 0 to 120 and
again be the focus, with consideration of the patello- is currently beginning closed-chain exercises to increase
femoral joint. quadriceps and hamstring strength. She asks you if she
can return to her Pilates class, which requires deep
5 Darby is a 19-year-old female soccer player who had

medial meniscal repair and ACL reconstruction of her
right knee. She is 6 weeks postoperation but has noted
flexion squats without weight. What should the thera-
pist tell her?
progressive episodes of clicking in her knee with sit-to- There are many reasons why Tammy should not return
stand transitions. Her swelling has increased, and she to Pilates at this time. First, she has not yet completed
has had increased difficulty with walking and standing. the closed-chain portion of her strengthening regimen,
What course of action should be taken? which includes toe raises, wall sits, and minisquats. After
sufficient strength has been obtained, she must then
She was reinstructed in an edema management program progress to open-chain knee extension and flexion exer-
(i.e., elevation, compression, ice). Her therapeutic exercises and ultimately to balance/proprioceptive training
cises and home exercise program were reevaluated for before any type of strenuous activity can be initiated.
any provocative weight-bearing activities. The physician Second, she underwent repair of a radial tear, and this
was called and an MRI was ordered (which revealed that type of tear should be treated more conservatively as it
the repair had torn). Complex tears have a higher inci- is more difficult to heal than longitudinal or peripheral
dence of failures than simple tears. tears. Third, the load-sharing percentage of the meniscus
increases from 50% in full extension to 90% in 90 of
6 Angie had a complicated radial repair of her right

medial meniscus 7 weeks ago. You want to initiate
weight-bearing frontal plane exercises without stressing
flexion, with most of the force transmitted to the poste-
rior horns of the menisci. This patient should refrain
from forceful deep knee flexion activities for a period of
the repair site. Prescribe three exercises with rationale. 4 to 6 months.
9 Tim is 3 months out of medial meniscal repair. He is

progressing well except for the medial pain he feels as
he approaches 90 of knee flexion while doing wall
a result of weak gluteal musculature, both hip abductors
and external rotators. Therefore exercises based on
recruitment of these muscles is optimal for correcting
squats. Your movement analysis reveals excessive the alignment. These exercises would progress to
femoral adduction and internal rotation during the wall weight-bearing exercises with resistance. For example,
squat. What is your strategy to correct this? squats with resistance tubing wrapped around the distal
thigh promotes recruitment of hip abductors, and cues
Tims faulty movement pattern is most likely stressing the patient to maintain proper form while squatting.
his repair. The femoral adduction and internal rotation is
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30B:664, 1948. copy 7:120, 1991.
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2004. repair in the presence of interleukin-1. Osteoarthritis Cartilage 18(6):
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tion. Arthroscopy 20(4):346-351, 2004. Heinemann.
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16(8):822-829, 2000. 27. Starke C, et al: Meniscal repair. Arthroscopy 25(9):1033-1044, 2009 Sep.
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18. Morgan CD, et al: Arthroscopic meniscal repair evaluated by second- plantation: Indications, techniques, rehabilitation, and clinical outcome.
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40. Tovin BJ, et al: Comparison of the effects of exercise in water and on 42. Colado JC, et al: Two-leg squat jumps in water: an effective alternative
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41. McConnell J, Fulkerson J: The knee: Patellofemoral and soft tissue inju- Neurovascular anatomic relationships during arthroscopic transverse
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and rehabilitation, Philadelphia, 1996, Saunders.
CHAPTER 25
Autologous Chondrocyte Implantation
Karen Hambly, Kai Mithoefer, Holly J. Silvers, Bert R. Mandelbaum
S
ince its first description by Brittberg in 1994,1 chondro- of previous surgeries should be recorded since these factors
cyte implantation (also known as chondrocyte trans- have been shown to affect the outcome after chondrocyte
plantation) has been performed in more than 15,000 implantation.
patients worldwide and many studies have clinically vali- Physical examination includes the evaluation of the
dated this technique as a reliable method for biologic restora- patients gait pattern and lower extremity alignment. Hip,
tion of injuries of articular cartilage surfaces.2-12 Based on the knee, and ankle range of motion (ROM) should be assessed
recent evolution and better understanding of the treatment and any joint effusion noted. Since articular cartilage lesions
of articular cartilage defects and cell-based implantation are frequently found in patients with acute hemathrosis,
techniques, this challenging surgical technique has under- acute or chronic ligamentous instability, patellar dislocation
gone several technical modifications. These recent develop- or maltracking, or lower extremity malalignment, these
ments can help to reduce patient morbidity and factors should be routinely evaluated. Depending on the
technique-specific complications as chondrocyte implanta- defects location and size, mechanical symptoms may or may
tion techniques continue to evolve using modern tissue engi- not be present and may overlap with meniscal tests. The
neering technologies. patients body mass index should be assessed because it has
been shown to correlate with functional outcome after artic-
PREOPERATIVE CONSIDERATIONS ular cartilage repair.
History and Clinical Symptoms Diagnostic Imaging

Obtaining a thorough history in patients with chondral Plain radiographs including weight-bearing anterior/
defects presents a critical first step in the treatment process posterior and lateral views, Rosenberg and tunnel views,
and selection of patients that are appropriate candidates for long-leg films, and Merchant views can help to identify osteo-
chondrocyte implantation. Articular cartilage defects may chondral lesions, joint space narrowing, patellar maltracking,
present acutely after joint trauma such as knee ligament or lower extremity malalignment. Cartilage sensitive mag-
tears, or more chronically as part of a degenerative process. netic resonance imaging (MRI) presents a sensitive, specific,
Pain is often present with weight bearing and impact activi- and accurate tool for noninvasive diagnosis of articular carti-
ties. Joint effusion is frequently reported, particularly after lage injury.13,14 Cartilage sensitive MRI provides useful infor-
demanding impact activities. Cartilage defects of the femoral mation about meniscal and ligamentous status, subchondral
condyles may produce point tenderness over the femoral bone, lesion size, location, and depth. Because of the patho-
condyle rather than the joint line. Catching and locking sen- logic changes in the surrounding cartilage, the final size of the
sation can occur from cartilage flaps or larger cartilage defect intraoperatively usually is larger than defect size mea-
defects but are nonspecific and may also result from other sured on a preoperative MRI. Besides its use for preoperative
knee pathology such as meniscal tears. Defects of the patella diagnosis, cartilage sensitive MRI can be very helpful for
or trochlea usually lead to pain when ambulating stairs, postoperative evaluation of cartilage repair. Routine postop-
driving a car, or getting out of a chair or squatting position. erative MRI is recommended to evaluate the cartilage repair
Symptoms of patellar instability may be reported. Patients tissue and detect potential complications such as graft hyper-
considered for chondrocyte implantation techniques may trophy. If available, newer technologies such as T2 mapping,
have undergone prior cartilage repair procedures and a delayed gadolinium enhanced MRI of cartilage, or T1 rho
detailed evaluation of the prior surgical procedures should relaxation mapping can be used to obtain additional detail
be performed. The time since the initial injury and the type about cartilage morphology before and after surgery.14
457
Indications and Contraindications
Chondrocyte implantation is indicated for symptomatic,

high-grade chondral and osteochondral defects of the knee
in active patients that are physiologically too young for
arthroplasty. This technique can be successfully used as a
first-line treatment for lesions more than 2cm2 of femoral
condylar, trochlear, and patellar lesions or used as a revision
technique for failed prior cartilage repair procedures.2,10-12
The technique can be successfully used for isolated, multiple,
and kissing cartilage defects. Prerequisites for successful
30 70
autologous chondrocyte implantation (ACI) include ade-
quate ROM, appropriate axial alignment or patellar tracking,
ligamentous stability, and the ability to comply with the post-
operative rehabilitation. Adjuvant procedures may be indi- Fig. 25-1 The exact location and range of articulation of the defect is noted
cated to correct coexisting knee pathology and can be carefully to facilitate postoperative rehabilitation in the nonloading safe
performed simultaneously with chondrocyte implantation zone
without negative effects of these complex procedures on the
postoperative functional outcome and activity level. of a kissing lesion or signs of low-grade cartilage injury.
Absolute contraindications for ACI include generalized Partial meniscectomy and meniscal repair can be performed
osteoarthritis, inflammatory arthropathies, or joint sepsis. because it minimally affects the course after the initial
Patients unable to comply with the postoperative rehabilita- arthroscopy and decreases operative time during the second-
tion and weight-bearing protocol should also not be stage procedure. However, surgical treatment of meniscal
treated with this technique. A body mass index greater than deficiency or ligamentous pathology should be performed
30kg/m2 has been associated with limited improvement simultaneously with ACI to avoid repetitive operative joint
after knee articular cartilage repair and presents a relative trauma and prolonged rehabilitation.
contraindication. Patients with severe meniscal deficiency
should be considered for meniscal allograft transplantation Step 2: Chondrocyte Harvesting
at the time of chondrocyte implantation. Following initial arthroscopic evaluation, 200 to 300mg of
normal articular cartilage is obtained from a lesser weight-
Preoperative Patient Counseling bearing area of the injured knee, generally the medial or
Based on the history, physical examination, and radiologic lateral superior ridge of the femoral condyle or intercondylar
information, the indication for ACI or adjuvant procedures notch. The intercondylar notch is preferred for patellofemo-
is discussed with the patient. In-depth preoperative patient ral lesions. Using cartilage that has been dbrided from the
counseling is critically important to determine the patients cartilage defect as graft is not recommended because chon-
demands, to assess his or her ability to comply with the drocyte quality from this area has been shown to be inferior.
postoperative rehabilitation plan, and to create realistic The grafted cartilage tissue is sent for standardized commer-
expectations and goals for postoperative knee function and cial isolation and culturing of chondrocytes. Implantation of
activity level. cultured chondrocytes is performed after 2 to 4 weeks when
a sufficient number of cells have been obtained for the size
SURGICAL TECHNIQUE of the defect (range, 4 to 12 million cells). Chondrocyte
viability is routinely tested and should be more than 95%
Stage 1: Chondrocyte Harvest before implantation.
Step 1: Diagnostic Joint Arthroscopy
ACI of the knee presents a two-stage procedure. The first Stage 2: Chondrocyte Implantation
stage involves a complete arthroscopic evaluation. Besides Step 1: Adjuvant Procedures
identification of the index cartilage defect, the entire articular Ligamentous instability, meniscal injury and deficiency, or
cartilage surface is inspected to rule out any additional carti- malalignment have been shown to contribute to the develop-
lage pathology. During the first-stage arthroscopy, the carti- ment of articular cartilage lesions, and surgically addressing
lage defect is identified and existing cartilage flaps are these concomitant pathologies is critical for an effective and
dbrided back to a stable and healthy peripheral margin. Fol- durable articular cartilage repair.10-12 Concomitant ligament
lowing thorough dbridement, the size of the articular carti- reconstruction, meniscal allograft, or osteotomy should be
lage lesion is measured and its containment documented. The performed before ACI. Isolated or combined adjuvant pro-
knee is taken through a full ROM and the arc of motion, cedures do not negatively affect postoperative activity levels
during which the lesion articulates with the opposing joint after ACI.8 Concomitant rather than staged adjuvant proce-
surface, is carefully recorded (Fig. 25-1). The opposing joint dures avoid prolonged rehabilitation, promote postoperative
surface should always be carefully inspected for the presence activity, and provide a significant cost benefit.
Chapter 25 Autologous Chondrocyte Implantation 459
A B C
Fig. 25-2 A, Articular cartilage defect of the femoral condyle before implantation. B, Covered cartilage defect. C, Cartilage sensitive MRI image demonstrat-
ing complete fill of the cartilage defect after 36 months.
Step 2: Autologous Chondrocyte Implantation using the sandwich technique. The osseous defect is filled
Following parapatellar arthrotomy, the cartilage defect is with a cancellous bone graft from the iliac crest or proximal
dbrided back to a healthy cartilage margin and the calcified tibia to the level of the subchondral plate. One periosteal
cartilage and intralesional osteophytes are carefully removed flap or collagen membranesized for the defectis then
without violating the subchondral bone (Fig. 25-2, A). If anchored using fibrin glue applied between the patch and the
bleeding is encountered, hemostasis of the defect bed can be bone graft. A second sized periosteal flap or membrane is
achieved by application of thrombin or fibrin glue. A tem- then placed facing into the defect and sutured to the sur-
plate of the defect is created to then harvest an appropriately rounding cartilage. The rim is again sealed with fibrin glue
sized periosteal flap from the proximal medial border of the and the cultured chondrocytes are then implanted between
tibia. When using periosteum, the tissue patch should be the two periosteal flaps or collagen membranes (sandwich
slightly larger than the defect because of a tendency of the technique).
periosteum to contract. Any adherent fatty or connective
tissue needs to be carefully removed to minimize the poten- POSTOPERATIVE MANAGEMENT
tial for graft hypertrophy. The periosteal flap is then sutured
flush to the articular cartilage defect using interrupted 6-0 Complications
Vicryl* with the cambium layer facing into the defect. As an Complications after chondrocyte implantation include stiff-
alternative to the periosteum, a type I/III collagen membrane ness and adhesions in up to 10% of patients. Graft hypertro-
can be used to cover the defect (Fig. 25-2, B and C). This phy is seen in 25% to 63% of postoperative magnetic
allows for smaller incisions, reduces patient morbidity, and resonance images but described as clinically symptomatic in
minimizes the potential for graft hypertrophy. The rim of the only 13% to 15%.1-12 Symptomatic hypertrophy can be effec-
periosteal flap or collagen membrane is sealed watertight tively treated by arthroscopic chondroplasty. Hypertrophy
with fibrin glue except for one corner, where the implanted may lead to partial detachment or graft delamination. Sub-
chondrocytes are injected into the defect. Following cell stituting the periosteum with collagen membranes or second
injection, the remaining corner of the periosteal flap is generation matrix-associated chondrocyte implantation
secured with sutures and sealed with fibrin glue. Drains are (MACI) effectively reduce the risk for periosteal hypertro-
not normally used to prevent injury to the periosteal cover phy.15 Graft failure has been described in 6% to 7% of cases.
or fibrin seal of the defect from direct abrasion by the drain Grafts usually fail between 12 to 24 months after surgery and
during postoperative joint mobilization. A compression frequently show central degeneration. Treatment with revi-
dressing is placed over the involved joint and cryotherapy is sion chondrocyte implantation has been shown to be effec-
used routinely. Bracing is not indicated for isolated chondro- tive in many cases.12 All patients with graft failure should be
cyte transplantations but may be used if simultaneous adju- carefully evaluated for the presence of subtle instability, axial
vant procedures require postoperative protection. malalignment, or patellar maltracking, which has been
shown to lead to lower success rates after ACI.
Deep Chondral or Osteochondral Defects
In patients with lesions deeper than 1cm, autologous bone SURGICAL PEARLS AND PITFALLS
grafting should be performed in combination with ACI.
Implantation of chondrocytes in these cases is performed Pearls
1. Assess for and address concomitant joint pathology
*Ethicon Inc., New Brunswick, N.J. (alignment, instability, and meniscal pathology).
2. Avoid staging adjuvant procedures to reduce prolonged expansion of specific chondrocyte subpopulations capable of
rehabilitation and facilitate return to activity. producing more hyaline-like repair cartilage tissue or
3. Record location and articulation of defect to facilitate implantation of neocartilage tissue produced in specifically
postoperative rehabilitation in safe zone. designed bioreactors.19,20
4. Substitution of periosteum with collagen membrane or
MACI can reduce invasiveness and risk for graft THERAPY GUIDELINES
hypertrophy. FOR REHABILITATION
5. Sandwich technique useful for deep chondral/
osteochondral defects. Rehabilitation has been identified as an important compo-
nent in articular cartilage repair with the potential to influ-
Pitfalls ence both the patient outcome and the quality of repair
1. Failure to recognize and treat concomitant joint tissue.21 In the last 10 years, the fastest evolving surgical
pathology repair of articular cartilage has been ACI. The first published
2. Limited success rate for tibial defects and kissing lesions review of ACI postoperative care and rehabilitation was in
3. Graft delamination from failure to treat symptomatic 2006.22
graft hypertrophy The goal of any ACI rehabilitation program is to provide
a mechanical environment for the local adaptation and
Surgical Summary remodeling of the repaired tissue that will enable the patient
ACI has been successfully used for hyaline-like restoration to safely return to the optimal level of function. The chal-
of full-thickness articular cartilage lesions in the knee with lenge is to construct an individualized rehabilitation program
long-term durability of functional improvements of up to 11 that matches mechanical loading to the status of the repair
years.10,11 Good to excellent results were found in 92% of tissue at any postoperative time point. Successful ACI reha-
isolated femoral condyle lesions, 89% of osteochondritis dis- bilitation is reliant on a collaborative environment, with
secans, 75% of femoral condyle lesions with concomitant thorough communication between the surgeon, therapist,
anterior cruciate ligament reconstruction, 67% of patients and patient. A graded rehabilitation program incorporating
with multiple lesions, and in 65% of patella lesions.1-12 Return preoperative counseling, progressive weight bearing,30 and
to sport is possible in 33% to 96%, with best return rates in controlled exercise31 is generally recommended following
competitive and adolescent athletes. Patients with single ACI. An understanding of applied clinical biomechanics and
lesions, younger age, and short preoperative intervals appreciation of the forces and loads that will be exerted on
have the best results.8,9 Correcting axial malalignment, patel- the repair tissue are essential in the design of an ACI reha-
lar maltracking, and ligamentous laxity is critical for the bilitation program. This chapter focuses on the principles
functional improvement. Limitations of this technique behind effective ACI rehabilitation and the rationale behind
include its invasiveness, long postoperative rehabilitation, the components of the rehabilitation.
and periosteal hypertrophy, which may lead to acute graft There are a number of elements that are essential in the
delamination. This cartilage repair technique provides designing of an individualized ACI rehabilitation program,
significant functional improvement with high return rates including the following:
to demanding sports and excellent durability even under 1. Recognition of factors that led to the acute or chronic
high athletic demands both in the primary and revision degeneration of the articular cartilage surface
setting. 2. Recognition of factors that affect functional outcome after
Scaffold-associated second-generation autologous carti- ACI
lage implantation techniques use three-dimensional biode- 3. Respect for the biologic timeframes for healing
gradable scaffolds to temporarily support the chondrocytes 4. Application of exercise programming knowledge
until they are replaced by matrix components synthesized 5. Establishment of criteria for modification or progression
from the implanted cells. MACI has been used with promis- of exercise
ing results in Europe and Australia but is not routinely avail- 6. Acknowledgement and incorporation of the expectations
able for use in the United States.15,16 The use of the biomatrix and goals of the patient
seeded with chondrocytes reduces surgical invasiveness and The three main components required within an ACI
has the theoretic advantages of less chondrocyte leakage, rehabilitation program are progressive weight bearing;
more homogeneous chondrocyte distribution, and less graft restoration of ROM; and enhancement of muscle control,
hypertrophy. Arthroscopic MACI has been described with proprioception, and strength.22-25 The ACI-specific evi-
improvement of knee function up to 90%.16 Future develop- dence base to directly support the frequency, intensity, type,
ments are aimed at improving cellular matrix production by and timing of exercise modalities during rehabilitation is
using more productive characterized chondrocytes and limited. Studies have advocated avoidance of certain ranges
more sophisticated bioactive scaffolds that include growth of knee movement, for example, active knee flexion between
factors and stimulate a more natural spatial distribution of 40 and 70 in the early stages after patellofemoral ACI.22
chondrocytes within the repair cartilage.17,18 Other promis- However, virtually all exercise activities, including common
ing future approaches include identification and selective activities such as walking, cycling, and rowing, involve a
knee flexion/extension pattern within this range.31 The

incorporation of exercises into the ACI rehabilitation POSTOPERATIVE REHABILITATION
program may be better considered in terms of minimizing
joint stress as opposed to the complete avoidance of specific The repair site is at its most vulnerable during the first few
ranges of movement. This can be achieved through the selec- months after ACI. Although chronologic time frames have
tion, introduction, and progression of exercise activities that been established for the rehabilitation phases, it is more
are appropriate for the graft status, size, and location. Exer- important that the patient achieves the qualitative goals of
cises should complement and not replace functional move- each phase. An important rehabilitation principle is program
ment retraining. individualization. Patients may progress through rehabilita-
The guidelines that follow are designed to help guide tion at different paces because of multiple factors, including
therapists through the rehabilitation process. It should be lesion size, lesion location, preoperative duration of symp-
noted that these guidelines are for first-generation ACI using toms, preoperative baseline physical condition, age, and
either periosteal flap or collagen membrane and that there is patient motivation. When a patient achieves all the func-
currently considerable variation in rehabilitation practice tional goals of a particular rehabilitation phase, they may
between clinical centers. The therapist should evaluate each advance to the next phase of the rehabilitation.
patient on an individual basis and select appropriate reha-
bilitation content and criteria for progressions for the indi- Phase I: Recovery and Protection
vidual, working around any restrictions imposed by the TIME: 0 to 6 weeks
surgeon. GOALS: Protection of the repair tissue, restoration of
joint homeostasis, and improving ROM (Table 25-1)
Initial Evaluation
Several factors have been associated with superior functional The evidence basis for optimal timing of return to full
outcome following cartilage repair surgery.26 These include: weight bearing (FWB) following ACI is limited. Historically,
Younger age of patient as with most new surgical interventions, rehabilitation has
Shorter preoperative duration of symptoms been conservative and has included lengthy periods of non
Fewer number of previous surgeries weight bearing and partial weight bearing (PWB). Newly
Smaller size of defect (cm2) emerging research indicates that it is possible to accelerate
Medial femoral condyle repairs do better than patello- weight-bearing loads in certain patient populations with
femoral repairs good clinical and functional outcome after 2 years without
Isolated defects do better than multiple and/or kissing jeopardizing the graft.27,28 Research indicates that moderate
defects. dynamic compression and shear loading are beneficial to
The correction of mechanical malalignment before extracellular matrix biosynthesis; chondrocyte proliferation;
surgery and repair tissue maturation, whereas static compression
Professional/competitive athletes do better than recre- and immobilization are associated with adverse effects.29,32
ational athletes. High shear stress may lead to mechanical failure of ACI
Participants of low impact sports do better than partici- grafts in the early postoperative rehabilitation phase and
pants of high-impact sports. it is therefore necessary to implement a graded increase
A preoperative evaluation should be made for each in loading. Weight-bearing status should be predicated
patient. Overt muscle imbalances should be noted and based on the location of repair, secondary to the biome-
addressed in a home exercise program before surgery. The chanical differences between ACI to a tibiofemoral joint
patients occupational demands and their access to rehabili- surface and a patellofemoral joint surface.
tation facilities and modalities is extremely useful informa- For femoral condyle defects:
tion when designing an individualized rehabilitation Toe-touch weight bearing for 1 to 2 weeks at minimal
program. body weight (<10%) and as tolerated
Begin heel-toe touch down weight bearing (approxi-
PREOPERATIVE MANAGEMENT mately 10 to 15kg) at week 2
Progress to PWB (approximately 30% of body weight)
A preoperative session is beneficial for both patient and at week 4
therapist. To maximize the benefits of ACI surgery, it is Aim for FWB by weeks 8 to 10
essential for patients to understand and consequently comply For trochlea and patella defects:
with their ACI rehabilitation program. Preoperative assess- Immediate heel-toe touch down weight bearing in full
ment should include ROM, muscle strength, proprioception, extension with approximately 25% body weight as
function, gait, and an assessment of problematic activities of tolerated
daily living (ADL). A preoperative therapy session provides Progress to 50% body weight in full extension at week
an ideal opportunity to explain the rehabilitation program; 2
teach ambulation with crutch(es); and demonstrate early Progress to 75% body weight in full extension at week 4
home exercises to the patient. Aim for FWB by weeks 6 to 8
TABLE 25-1 Autologous Chondrocyte Implantation

Anticipated
Rehabilitation Criteria for Progress Impairments and
Phase I Postoperative and Edema Weight-bearing control with Avoid excessive Protection of repair
Postoperative cleared by the Pain crutches stress on ACI tissue from excessive
0-6 wk surgeon to initiate Limited ROM CPM Restore full PROM load and shear forces
therapy Limited strength AROM exercises (ankle, knee extension Allow cell adherence
There may be specific Limited weight bearing knee, and hip) Gradually increase Prevent adhesions
precautions Altered gait Education and coaching pain-free knee Improve ROM
Quadriceps setting exercises flexion Gradual increase in ROM
Cryotherapy, elevation, and Ensure safe transfers and weight bearing for
compression for home and protection of repair
Patellar mobilization transportation tissue
Biofeedback and electric Regain quadriceps Restore proprioception
muscle stimulation control Increase reliance on
Aquatic therapy once incision Gradual increase in patient
has healed weight bearing self-management
Balance for control of PWB Improve PF mobility
ACI, Autologous chondrocyte implantation; AROM, active range of motion; CPM, continuous passive motion; PF, patellofemoral; PROM,
passive range of motion; PWB, partial weight bearing; ROM, range of motion.
Exercises: Lateral hip (abduction) side-lying, hip extension work (glut activation) without knee flexion, isometric glut squeezes.
It is important to note that patients are not completely

reliable in PWB and tend to overestimate weight in the early
rehabilitative stages even after instruction.33 The accuracy of
weight bearing can be practically assessed, taught, and rein-
forced with patients using two pairs of identical scales (Fig.
25-3).22 This is also a useful technique for controlling weight
shift exercises and for the correction of body posture, and
any residual unloading of the involved limb later in the reha-
bilitation process.
Continuous passive motion (CPM) is reported to increase
the quality of chondral repair tissue34-36 and stimulate the
metabolism of proteoglycan 4.37 Consequently, CPM is a
standard inclusion in ACI rehabilitation in many centers.25
However, for patients with small, isolated defects of the
femoral condyle, results may not be negatively affected by
the replacement of CPM with graded weight bearing and
active ROM (AROM); however, the evidence base is
limited.38,39 The recommendation for the use of CPM is cur-
rently based on basic science, usual practice, case series, and
disease-orientated evidence.25 Once again, there is a need to
differentiate the rehabilitation based on the defect location:
For femoral condyle defects:
Initiate CPM day 1 for a total of 6 to 8 hours per day
at 0 to 60
Progress CPM by 5 to 10 per day as tolerated
Continue CPM for a total of 6 to 8 hours per day for
6 weeks Fig. 25-3 PWB can be practically assessed, taught, and reinforced using
Knee flexion ROM goal is 90 by week 2; 105 by week standard bathroom scales.
3; 115 by week 4; and 125 by week 5.
Fig. 25-5 Patellar mobilizations can be taught to the patient for self-
management on a daily basis.
Fig. 25-4 Heel slides using a crepe bandage donut under involved limb
to assist sliding.
For trochlea and patella defects: of the pool. The water depth should reflect the weight-
Initiate CPM day 1 for a total of 6 to 8 hours per day bearing status of the individual. Stationary cycling can be
at 0 to 40 introduced with minimal resistance once knee flexion ROM
Progress CPM by 5 to 10 per day as tolerated is at least 100.22 There is currently no evidence-based con-
Continue CPM for a total of 6 to 8 hours per day for sensus to support or refute the use of postoperative bracing
6 weeks for ACI. Some centers will use bracing for patellofemoral
Knee flexion ROM goal is 90 by week 3; 105 by week ACI repairs for the first 4 to 6 weeks, especially if the defects
4; and 120 by week 6. are large or kissing or if there is a quadriceps lag. Neuromus-
No active open kinetic chain (OKC) knee extension cular electrical stimulation can be introduced and is a valu-
exercises during this phase. able adjunct to the program, especially where voluntary
CPM is not consistently used across cartilage repair control of the quadriceps mechanism is limited.
centers and is often not available to patients. Where CPM is
not available, it can be substituted by 500 active assisted heel Phase II: Transition
slides performed three times per day with the same ROM TIME: 6 to 12 weeks
progressions and goals as indicated for CPM (Fig. 25-4). GOALS: Inauguration of the repair tissue, restoration of
ROM exercises should progress through a controlled full ROM, and initiation and progression of muscle
increase in ROM through passive, active-assisted, and strengthening (Table 25-2)
then active movements. Repetitive dynamic movement
through the available ROM provides mechanical stimulation During the transition phase, many of the interventions
to chondrocytes, as well as increasing synovial fluid flow over from phase I are continued and incorporated into a mainte-
the graft.40,41 nance program. AROM exercises can be progressed to light
In addition to weight bearing, CPM, and ROM guidance, resistance in safe ranges while simultaneously maintaining
most rehabilitation guidelines will provide further informa- no resistance over the repaired area. Safe ranges will be dic-
tion regarding exercise and therapeutic modalities. In the tated by the articulation surfaces, contact area, and size and
early postoperative time period, the application of cryother- location of the graft. For example, as the posterior aspect of
apy, compression, and elevation are important to lower tissue the medial femoral condyle contacts the tibia between 90
temperature, slow metabolism, decrease secondary hypoxic and 120,48 light resistance in the range from 0 to 80 may
injury, and reduce edema formation.42 Gentle patellar mobi- be appropriate. Several research articles provide detailed
lizations in all directions 4 to 6 times per day are important information on the clinical biomechanics of the tibiofemoral
to prevent adhesions and arthrofibrosis (Fig. 25-5).43-46 Knee and patellofemoral joints.11,49-52 Once FWB has been restored,
surgery results in proprioceptive deficits47 that should be forward lunges and forward and lateral step-ups can be
addressed at the earliest postoperative opportunity. Proprio- introduced and treadmill walking can be initiated within safe
ception can be initiated in phase I of rehabilitation as long ranges as dictated by the repair location and size.
as weight-bearing restrictions are applied. This may require Quadriceps setting exercises can be progressed from iso-
adaptation of exercises to PWB. Gait training focuses on metric multiangle exercises. Gluteal muscle retraining is an
crutch walking to minimize soft tissue constrictions (espe- important component of ACI rehabilitation, especially where
cially tightness in hamstrings, gastrocnemius, and soleus patients have altered lower extremity kinematics.53 Gluteus
muscles) and increasing the acceptance of load on the medius and minimus play an important role in the neuro-
involved leg through controlled weight shifting. Aquatic muscular and valgus control of the knee54 and consequently
therapy to enhance gait training and improve lower extrem- normal posture and gait patterns, so exercises should be
ity strength/ROM can commence once the surgical incision targeted at these muscles (Fig. 25-6, A and B).55,56 Proprio-
has healed and the patient is able to safely transfer in and out ception and balance exercises can be progressed in line with

Criteria for Anticipated
Phase II Minimal pain and Edema WB control with crutches moving to Increase to full active, Quadriceps control and
Postoperative swelling Pain FWB in control conditions pain-free ROM coordination
6-12 wk Able to perform Reduced ROM Stretching program for the hip, Progress to FWB Aquatic therapy for gait
daily joint Limited strength ankle, and knee (as appropriate) Regain full quadriceps coordination and joint
circulation PWB AROM exercises (no resistance over control circulation exercises
exercises within Altered gait repaired zone and light resistance in Increase ADL Restore proprioception
homeostasis safe ranges) Regain optimal Gradual increase in
Surgical incisions Education and coaching coordination for weight bearing and
healed Quadriceps setting exercises walking and stairs ROM for protection of
Full passive knee progressing to isometric multiangle Increase repair tissue
extension exercises proprioception Gradual increase in
Voluntary Balance for control of weight Improve PF mobility functional activities
quadriceps bearing for ADL Increase Improve coordination in
activity and able Patellar mobilization neuromuscular control multidirectional tasks
to perform Biofeedback and electric muscle and muscle activation Increase reliance on
quadriceps stimulation Increase quad patient self-management
setting exercise Quadriceps isometric multiangle strength and overall Improve gait while
with no lag exercises joint stability limited with WB
Active, pain-free Aquatic therapy Increase strength, Improve single-limb
knee flexion of Gluteal muscle retraininghip endurance, and stance
120 extension, external rotation, stamina while
abduction diminishing WB
ADL, Activities of daily living; AROM, active range of motion; FWB, full weight bearing; PF, patellofemoral; PWB, partial weight bearing; ROM,
range of motion; WB, weight bearing.
Exercises: Gluteal strength: standing hip extension (with appropriate knee angle), standing abductionuse mild resistance (i.e., Thera-Band)
to address gluteus medius and gluteus maximus deficiencies.
A B
Fig. 25-6 Gluteal muscle exercises can be adapted for the repair location. A, For tibiofemoral joint repairs, a side-lying clam exercise can be used. B, For
patellofemoral joint repairs, a hip hike exercise can be used during standing, with the involved knee in full extension.
increased weight-bearing status. The therapist must monitor

any progressions in exercises and check that symptoms are
not increased.
Phase III: Remodeling

TIME: 12 to 26 weeks
GOALS: Improvement of muscle strength and
endurance and reintroduction of functional activities
(Table 25-3)
Phase III continues with the maintenance program of

exercises within phase II with appropriate progressions in
resistance, repetitions, sets, and frequency, with close moni-
toring of patient response. Proprioception and balance train-
ing can be progressed to involve multidirectional functional
tasks. Feed-forward muscular control exercises, such as
lunges and unilateral step up/downs (Fig. 25-7) in a con-
trolled therapy environment will not only assist in strength-
ening and restoring dynamic control but will also help to
enhance the patients confidence in the involved knee. Gait
analysis allows the therapist to assess the patient dynami-
cally, identifying asymmetries in pressure transfer, compen-
satory mechanisms, and movement-related problems during Fig. 25-7 Single-leg steps are a good way to evaluate neuromuscular
the gait cycle (Fig. 25-8). Cardiovascular and muscular control and body posture.

Anticipated
Rehabilitation Criteria for Progress to Impairments and
Phase III Minimal pain and swelling Reduced strength AROM exercises (no Increase muscle Improve control in
Postoperative Full ROM Altered gait resistance over repaired strength exercise conditions
12-26 wk Full voluntary quadriceps Reduced endurance zone and light resistance Restore gait Increase reliance on
activity Reduced balance in safe ranges) Increase ADL patient
Acceptable muscle Reduced confidence in FWB control in exercise Progress OKC self-management
strengthhamstrings knee conditions strengthening with Improve
within 20% of Possible kinesiophobia Preparatory (feed-forward) minimal resistance over coordination in
contralateral leg and neuromuscular control angles where defect multidirectional
quadriceps within 30% of exercises articulates tasks
contralateral leg Gait reeducation Progress walking Increase functional
Balance testing within Gluteal muscle retraining distance, cadence, and activities
30% of contralateral leg Single-limb stance incline Aquatic exercises
Able to walk 1-2 miles exercises as appropriate Continue maintenance help reduce stress
(level ground) or bike for Patellar mobilization program with weight-bearing
30 minutes (stationary Aquatic therapy, further Decrease gait activities
cycle low resistance) progression of gait deviations in stance
training, and single-limb phase
stance activities in the
water
ADL, Activities of daily living; AROM, active range of motion; FWB, full weight bearing; OKC, open kinetic chain; ROM, range of motion.
Exercises: Increase progressive resistive therapeutic exercise for quadriceps (knee extension with appropriate knee angles), knee flexion, hip
extension/flexion/abduction/adduction in standing with resistance at ankle joint, supine core/trunk stability work (i.e., Pilates), physioball (supine
and prone), and proprioceptive work on unstable surface (wobble boards, Bosu, Airex mat).
Fig. 25-8 Clinical gait analysis is very useful for revealing abnormal patterns of functional movement and residual asymmetries.
Fig. 25-9 Positive air pressure treadmills can provide an opportunity for an earlier return to jogging and running in a PWB environment.
endurance can be increased with the introduction of low will depend on which leg is involved and whether the vehicle
impact exercise activities, such as swimming, rowing, or is manual or automatic transmission.
elliptical training, and through the progression of the walking Return to sport times will depend on the type of sport
program with increases in distance, cadence, and incline. that the individual wants to return to and the ability of the
individual to accept the demands of that sport without short-
Phase IV: Maturation or long-term adverse effects. Low impact exercise activities
TIME: 26 weeks onward such as swimming, cycling, and rowing can be started at
GOALS: Returning the patient to full unrestricted 4 to 6 months. Higher impact exercise activities, such as
activity (Table 25-4) jogging, running, and aerobics, may be performed from 8
months. Jogging can be introduced earlier for athletes by
During the maturation phase, return to work times will using a positive air pressure treadmill at reduced body weight
depend on the demands of the occupation. Sedentary work (Fig. 25-9). High impact sports such as basketball, ice hockey,
can be resumed earlier than manual labor. A phased return badminton, tennis, football, and soccer are allowed at 12 to
to work allows for a more controlled return, with initial 18 months. Return to sport rates after ACI from published
recovery time for the body to adapt. Return to driving times clinical studies average 67%, but there is a considerable range

Anticipated
Rehabilitation Criteria for Progress Impairments and
Phase IV Full nonpainful ROM Limited endurance Impact loading program Progress maintenance Preparing patient for
Postoperative Strength within Reduced confidence in individually designed for program return to full unrestricted
26-52+ wk 80%-90% of knee patients needs Progress resistance as functional activities
contralateral leg Asymmetry in lower Balance exercises in tolerated Prevent further injury
Balance within limb strength and challenging, coordinative Emphasis on entire lower Gradually restore loading
75%-80% of flexibility tasks limb strength and to repair tissue
contralateral leg Possible kinesiophobia Aquatic therapy flexibility Prepare patient for return
No pain, swimming (kick Return to sports activities to sports activities if
inflammation, or emphasis) for general if appropriate appropriate
swelling endurance Improve confidence in
Able to perform daily Functional and knee
joint exercises for at sport-specific agility Increase intensity, load,
least 60 minutes training and volume of exercise
within homeostasis Functional strength Aim for unrestricted
training (progressing to function
full resistance over Restore symmetry
repaired zone for both including lower limb
OKC and CKC) strength and flexibility
Presports conditioning Prevent further damage/
(if appropriate) injury
Education and coaching
CKC, Closed kinetic chain; OKC, open kinetic chain; ROM, range of motion.
Exercises: Address any pathokinematics during joint loading (i.e., dynamic valgus). Improve single-leg balance with combined balance/strength
activities. Increase intensity, duration, and resistance of therapeutic exercise for core/trunk, hip, knee, and ankle joints. Increase time duration
for supine plank work. Aerobically (cardiovascular), incorporate interval work for incline and speed to return to prior level of fitness.
(33% to 96%).26 Average time to return to sport is reported 8. Recognize that not all patients will return to sports
to be 18 months (range, 12 to 36 months), varying on the activities.
individual factors and the nature of the sport.26 It is impor-
tant to note that not all individuals will return to sport after Pitfalls
ACI and this will be key to managing patient expectations. 1. Failure to recognize and adjust rehabilitation to individ-
ual patient presentation
REHABILITATION PEARLS AND PITFALLS 2. Biologic timescales for cartilage repair not fully
understood
Pearls 3. Functional rehabilitation principles not consistently
1. Agree on realistic expectations and goals with the patient. applied
2. Obtain details on the surgery, size, location, and articula- 4. Rehabilitation not differentiated based on location and
tion of the defect. size of defect
3. Address the faulty pathokinematics that may have led to
the defect in the first place. SUGGESTED HOME MAINTENANCE FOR
4. Focus on what the patient can do rather than the THE POSTSURGICAL PATIENT
restrictions.
5. Closely monitor clinical signs of pain or swelling; modify The rehabilitation following ACI is a lengthy process that
or regress rehabilitation as appropriate. requires considerable input from the patient. The home
6. Accelerated postoperative weight-bearing protocol can maintenance suggested for the postsurgical ACI patient is
help to promote postoperative function and the patients integral within the general rehabilitation guidelines as pre-
overall satisfaction with the procedure. sented earlier. The therapist needs to provide guidance on
7. Provide emotional support for the patient through the the progression and the exercise parameters (intensity, fre-
rehabilitation process. quency, repetitions, duration) based on the individual
patients age, needs, and rehabilitative status. Where particu- process is critical and referral back to the surgeon should be
lar facilities and modalities are not available to a patient, the considered where appropriate. Signs that the rehabilitation
therapist should recommend suitable alternatives that allow program should be reviewed include the following:
the patient to achieve the rehabilitation goal. Individualiza- Increased levels of pain, especially pain after cessation
tion of the rehabilitation program is critical to patient of activity
compliance. Swelling or joint effusion
Sustained plateau or reduction in ROM, weight
TROUBLESHOOTING bearing, or strength
Increased difficulty in performing functional
Mechanical complications are fairly common after ACI.57 activities
Graft failure and delamination accounted for almost half of If concomitant surgical procedures such as ACL recon-
the adverse events reported to the United States Food and struction or meniscus repair are performed, the rehabilita-
Drug Administration up until 2003.57 Tissue hypertrophy tion program should be revised on an individual basis to
was shown to be one of the more common adverse events,57 incorporate the requirements of the concomitant procedure
but this is predominantly associated with periosteal ACI. The in concert with the ACI requirements.
introduction of second generation ACI has resulted in lower
levels of hypertrophy.15 One of the complications of ACI SUMMARY
surgery that potentially has the most impact on the patient
is the development of arthrofibrosis.43-46 ACI rehabilitation is This chapter has focused on the principles behind effective
lengthy and noncompliance to the rehabilitation program ACI rehabilitation and the factors in developing an individu-
can be an issue with some patients. Education and counsel- alized rehabilitation program. A general rehabilitation
ing regarding the rehabilitation program and why restric- guideline has been provided for first generation ACI. The
tions are imposed can be useful. emergence of newer, cell-based articular cartilage repair
The rehabilitation guidelines provided in this chapter technologies and variations of ACI surgery are likely to
should provide a framework for ACI rehabilitation but require modification to the existing rehabilitation
should not be viewed as strict protocols. Monitoring of guidelines.
patient status and progression throughout the rehabilitation
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treatments. Arthroscopy 21(2):152-158, 2005. Joint Surg Am 88(3):503-507, 2006.
CHAPTER 26
Patella Open Reduction and
Internal Fixation
Daniel A. Farwell, Craig Zeman
P
atella fractures can occur in a wide variety of individu- but using screws with tension band technique appears the
als. Both genders have similar fracture rates. Age- strongest.14-16 With the production of Kevlar sutures, the use
related incidence of patella fractures tends to be of sutures to fix patella fractures has been reported.17-19
shifted to a mature population. Patella fractures are usually Smith and associates20 performed a retrospective review
caused by direct trauma or a blow to the patella,1-4 or can be of postoperative complications after ORIF of patella frac-
a postoperative complication from ACL or total knee replace- tures. They followed 51 patients treated with the tension
ment surgery.5-8 Depending on the force of the injury, the band fixation technique until complete healing had occurred
fracture can be nondisplaced or highly comminuted with at a minimum of 4 months. The authors objective was to
significant injury to the extensor mechanism complex. focus on acute, short-term complications after ORIF of
Active extension of the knee is usually preserved with a patella fracture. Although the study did not specifically
nondisplaced fracture. However, in a displaced fracture the assess clinical parameters, such as pain or strength, it did
extensor mechanism is disrupted to the extent that active point out two important factors to consider during rehabili-
extension is not possible. Displaced fractures require open tation. Approximately 22% of the patella fractures treated
reduction internal fixation (ORIF) to maximize active exten- with modified tension band wiring and early ROM displaced
sion of the knee and decrease the incidence of posttraumatic significantly during the early postoperative period.
arthritis. Failure of fixation was related to unprotected ambula-
tion and noncompliance. Patient noncompliance in
SURGICAL INDICATIONS AND restricting early ROM and weight bearing can cause
CONSIDERATIONS failure of even technically correct tension band wire
fixation.3,13,21-23
Physicians use two main criteria to determine whether Joint congruity must be restored to decrease the develop-
surgery is indicated: ment of arthritis, and the extensor mechanism must be
1. Fracture displacement of more than 3 or 4mm restored to regain full extension. Most patients with dis-
2. Loss of ability to extend the knee actively placed fractures are candidates for ORIF. If the patient was
Different surgical treatments are based on the type or ambulatory before the injury and can medically tolerate
severity of the fracture. Tension band wiring is still the most surgery, then surgery should be performed regardless of age.
accepted treatment for displaced patella fractures.9-11 Weber Situations in which nonambulatory patients with patella
and colleagues12 noted that if stability and early range of fractures lack lower-extremity (LE) function and sensation
motion (ROM) is to be performed, there must be a stable (neurologic impairment) can be managed conservatively.
repair of the fracture site to avoid displacement of the repair. Patients with simple two-part fractures have a better
They noted increased stability by repairing cadaveric patella chance of a successful outcome than those with highly com-
fractures with a technique in which the wire is anchored minuted fractures. The variability of outcomes relates to the
directly in bone. They also noted that the retinaculum should degree of fixation and the ability of the fracture site or sites
be repaired because it added to stability. Bostman and col- to consolidate. In some cases of irreducible comminution,
leagues13 examined several different approaches and tech- the fragments may have to be removed, resulting in a partial
niques to repair patella fractures and discovered the tension or total patellectomy.4,21,24-32 Patellectomy procedures have a
band wiring procedure to be far superior to other methods, lower success rate than stable internal fixation procedures.33-36
470
Chapter 26 Patella Open Reduction and Internal Fixation 471
To place the tension wire as close to the bone and k-wire

SURGICAL PROCEDURE as possible, the surgeon usually passes a hollow needle under
the k-wire and over the bone to guide the tension band wire.
Most methods of ORIF incorporate tension band wiring The tension band wire is then passed through the needle and
techniques.12,21,22,37,38 Makino and associates described an brought around the patella. The two ends of the tension band
arthroscopically assisted technique.39 The tension band wire wire are then twisted together with pliers to add tension to
is placed around the proximal and distal pole of the patella the system. The surgeon must be careful not to add too much
through the quadriceps and patella tendons. This wire com- tension to the wire because this may cause the wire to break
presses the fracture site. The surgeon maintains rotational early in the rehabilitation process (Fig. 26-2, G and H).
control with one or two screws placed across the fracture site The surgeon then repairs the extensor mechanism. The
from the proximal to the distal pole. The tension band wire medial and lateral retinacula are commonly torn in line with
is passed under the k-wires or screws to add compressive and the fracture. These tears are simply repaired using nonab-
rotational stability to the fixation. Another method is to use sorbable sutures. After this last repair, the surgeon checks the
cannulated screws through which the tension band wire ROM to ensure that the patient can easily obtain full exten-
may be passed. Suture can be used instead of wire in sion and at least 90 of flexion. The surgical site is then closed
certain cases.17-19 in the following order: first the peritenon, then the subcuta-
The integrity of the skin over the patella must be evalu- neous tissue, and finally the skin. The wound is dressed with
ated before surgery because of its potential to produce post- a bulky dressing and placed in an immobilizer. A postopera-
operative complications. The therapist should assess this area tive water-cooling system or ice pack may be used to assist
continually for infection and poor healing because vascular with pain control immediately.
supply may have been disrupted during the trauma that A partial patellectomy may be performed in patients with
caused the patella fracture. comminuted displaced fractures who have at least 50% of the
Surgery is performed under either general or regional patella remaining.33 The inferior pole of the patella usually
anesthesia. The patient is positioned supine, and a tourni- suffers the most trauma, resulting in its removal (Fig. 26-3,
quet is applied to the thigh. It is important that the knee can A). To do a partial patellectomy, the surgeon dbrides the
fully flex and extend so that the surgeon can determine the bone fragments from the tendon end and then weaves two
stable postoperative ROM. The leg is then prepped and large 5-0 nonabsorbable sutures into the tendon (5-0 Fiber-
draped in sterile fashion. If the skin allows, then a longitu- Wire is now available that has the strength of 18-gauge wire
dinal midline incision is made over the patella. This incision and the flexibility of suture). The surgeon then drills two
(Fig. 26-1) is carried down to the peritenon, and full- holes longitudinally into the remaining piece of the patella.
thickness flaps are developed both medially and laterally to The sutures in the tendon are brought through the holes in
expose the entire patella and extensor mechanism. The peri- the patella and tied over the bone bridge formed by the two
tenon is then incised to expose the fracture and the tendons. holes (Fig. 26-3, B and C).
The fracture hematoma is dbrided from the fracture site, Most patients require a second operation to remove the
and the raw cancellous bone is delineated to aid in fracture hardware placed in the patella.40 The wires and sutures can
reduction. Two k-wires are then run from the fracture site become prominent and bother the patient during rehabilita-
of the proximal fragment and out the proximal pole of the tion, slowing progress in gaining ROM.
patella (Fig. 26-2, A to C). The proximal and distal fragments The fixation of simple fractures is usually the most stable
of the patella are brought together to reduce the fracture. The immediately after surgery. If the tension band wire is not
fracture is then held together with bone-holding forceps placed right next to the screw, then the wire can cut through
while the knee is in extension (Fig. 26-2, D). The k-wires are the tendon until it butts up against the screw, decreasing the
passed back through the middle of the patella and out the compressive effect of the wire and possibly allowing the frac-
distal pole. The bone-holding forceps are then removed (Fig. ture to displace. Stable fixation of a simple fracture is usually
26-2, E). Next the tension band wire is placed around the strong enough to allow early passive range of motion
patella and k-wires. It should be positioned as close to the (PROM). The amount of ROM is dictated by the surgical
bone and k-wires as possible to minimize complications after procedure and pain tolerance. Time frames to initiate physi-
ROM is initiated postoperatively (Fig. 26-2, F). cal therapy vary depending on the degree of comminution.
The repair is most vulnerable between 4 to 6 weeks when the
bone and tendon have not completely healed and the pins
and wires have loosened. After 8 weeks, the repair should be
stable enough to allow aggressive therapy with the goal of
regaining full ROM.41
The exception to this time frame is the patient who has
a comminuted fracture with unstable fixation. This type
of situation may require 12 weeks before the initiation of
therapy. Most patients return to preinjury activities (sports)
Fig. 26-1 The incision line from which repair of the fracture is initiated. by 6 months after surgery.
A B C D
E F G H
Fig. 26-2 The open reduction internal fixation procedure for transverse fracture of the patella. A to C, The patella is prepared for the k-wires by drilling
congruent holes through both pieces of the fracture. D and E, Bone forceps are used to approximate the fracture while wires are placed through the drill holes.
F to H, The surgeon finishes the process of tension band wiring, creating stable postoperative fixation.
A B C
Fig. 26-3 The process of partial patellectomy. A, Comminuted fracture involving the inferior pole of the patella. Front view (B) and side view (C) after
dbridement of inferior fragments; sutures are woven into the tendon.
Outcomes aggression of the rehabilitation program. A poorly reduced

A successful outcome is a knee with full active extension, full joint will make ROM exercises more painful and limit the
ROM, and without significant pain. The things that can speed at which the patient will tolerate increases in ROM and
prevent a successful outcome are unstable fixation, incon- strengthening exercises. This procedure is painful. Patients
gruous reduction, poor patient compliance, and delays in with poor pain tolerance will not regain strength and ROM
early PROM exercises. Unstable fixation will decrease the as easily as patients who are motivated and who can handle
an aggressive rehabilitation program. Some early postopera- information the PT collects from both the physician and the
tive ROM exercises need to be started to get the best results. patient aids in determining the design and time parameters
If ROM exercises are delayed in the first few weeks for any of the rehabilitation program.
reason, then it will be more difficult to get back full ROM The remainder of this chapter deals only with the simple
and strength. transverse fracture. However, the clinician is reminded to
Maximal function after patellar fracture is usually not respect the previously discussed four factors influencing
achieved until 1 year after sugery.42 Stiffness and anterior treatment when planning rehabilitation for all patella
knee pain especially with stair climbing or prolonged sitting fractures.
with the knee flexed are common.* Total patellectomy
patients can have an extension lag. Around 70% to 80% of Phase I (Acute Phase)
patients with ORIF will end up with a good to excellent result
and 20% to 30% with a fair to poor result.3 A loss
GOALS: Control pain, manage edema, gain 0 to 90 of
of 20% to 49% of extensor mechanism strength can be
PROM, improve quadriceps and hamstring
expected.36,43,44 About 70% of patients followed long-term
contraction (Table 26-1)
will have some complaint about the knee. Long-term results
after total patellectomy range from 22% to 85% (good to The acute phase of rehabilitation (the first 4 weeks) after
excellent) and 14% to 64% (fair to poor). ORIF of the patella is the time when reinjury is most likely.
The therapist should call the surgeon with any signs of Attention to detail and communication with the treating
wound infection. Wound infections after ORIF in patella physician are crucial during this period.
fractures need to be dealt with quickly because the hardware Controversy exists over when to initiate ROM. Hung
is superficial and can easily become infected, which can lead and colleagues10 initiate knee motion 1 week after surgery,
to a deep infection requiring long-term antibiotics. whereas Lotke and Ecker47 often immobilize patients for as
If in the course of therapy the patient develops an exten- long as 3 weeks before beginning any type of motion.
sion lag greater than he or she had earlier in rehabilitation, Bostman and associates9,13 not only immobilize their patients
the surgeon should be called because a loss of fixation has an average of 38 days but also state that they see no correla-
possibly occurred. To help confirm this, the fracture site can tion between the initial time of immobilization and the final
be palpated for a gap. outcome. Biomechanical studies that have demonstrated the
appropriateness of tension band wiring and early ROM have
generally used a simple transverse fracture pattern as the
THERAPY GUIDELINES model.48 Complications such as poor bone quality and com-
FOR REHABILITATION minuted patella fractures may prevent the desired fixation
and thus preclude any early joint ROM.
The treatment of patients who have undergone ORIF for The PT performs an evaluation on the first postoperative
patella fractures requires a cooperative approach from the visit, respecting the surgical procedure and any restrictions
orthopedist and the physical therapist (PT). This concept is noted by the surgeon. Observation of the surgical site is
most evident when considering the challenge in treating documented and continually assessed to prevent wound
patients after surgery. The goal of treatment is to provide a complications.
structurally stable patellofemoral joint and allow for full If the surgical site shows any signs of infection, then the
functional recovery of the involved LE. Factors that influence PT should notify the surgeon immediately. Crutches are
the choice of treatment include the following: used postoperatively, and weight bearing is as tolerated with
1. The overall health of the patient and the way it may influ- the immobilizer in place. Patients may eventually progress
ence wound and fracture healing to independent ambulation (with the immobilizer still in
2. The location and configuration of the fracture place) after they tolerate full weight bearing (FWB) and are
3. Immobilization after surgery (osteopenia of the entire LE, cleared by the physician (usually between 3 to 6 weeks).
muscle atrophy, and possible contracture of the knee Smith and associates20 reported four complete failures after
joint) versus ORIF (which allows for early ROM and ORIF with tension band wiring. No inadequacies were
patella mobilization) detected during the initial procedures, and all four failures
4. Patient compliance with the prescribed treatment plan resulted from falls while walking unprotected in the early
(home program) postoperative period.
Although rehabilitation after a patella fracture treated ROM measurements of the knee are taken passively, with
with ORIF is crucial, a wide range of protocols may be used the PT again observing any restrictions. Quality of muscle
depending on the factors listed previously, the physicians contraction in the extensor mechanism is noted, and active
chosen fixation technique, and the patients goals (which knee flexion is assessed. Girth measurements may be taken
differ among athletes, sedentary adults, and children). The to assess atrophy of the thigh and calf; however, this has little
overall benefit compared with functional assessment.
*References 24, 29, 34, 36, 43, 44. Early ROM is the goal in any operative treatment of
References 3, 29, 34, 36, 43, 44-46. patella fractures, yet the definition of early ROM varies,
TABLE 26-1 Patella Open and Reduction Internal Fixation

Anticipated
Impairments
Rehabilitation Criteria to Progress and Functional
Phase I Postoperative and Edema Cryotherapy Control pain Initiate self-management of

Postoperative cleared by physician Pain ES for muscle stimulation Manage edema pain
1-4 wk to initiate therapy Limited ROM PROMknee extension, Improve muscle Use ES to improve muscle
There may be Limited strength knee flexion, supine wall contraction contraction
specific precautions, Limited transfers slides PROMknee extension Restore joint ROM as indicated
depending on Limited gait Isometricsquadriceps/ 0, flexion 90 by physician
stability of fixation hamstring sets, quadriceps Initiate volitional muscle Prepare for independence with
(communicate with sets at 20-30 contraction transfers (SLR independent)
physician) AROMstanding hamstring Improve tolerance to Begin to prepare extensor
curls, supine heel slides flexion ROM mechanism to accept load
Gait training using crutches Avoid excessive stress Restore independence with
and weight bearing as on the extensor ambulation
tolerated in immobilizer mechanism during Improve stability of involved LE
Weight shifting ambulation Control pain through
Gentle joint mobilization to Decrease pain resistance-free mobilization to
the patella (resistance free) the patella
AROM, Active range of motion; ES, electrical stimulation; LE, lower extremity; PROM, passive range of motion; ROM, range of motion; SLR,
straight-leg raising.
depending on who performs the procedure.9,10,13,47 Although are initiated to aid in increasing muscle control and pro-
the acute phase of rehabilitation tends to focus on knee joint gressing ROM.
range, gait deviations can produce problems later in rehabili- Isometric exercises involve quadriceps and hamstring
tation if they are not addressed early. Patients often are cocontraction and isolated quadriceps contractions at 20
treated in some type of immobilizer. A hinged brace can be to 30 flexion. Quality is observed and ES is helpful in
used to allow for motion while stabilizing the fracture. recruitment.
Initial treatments focus on restoring ROM (0 to Gait training focuses on increasing the acceptance of
90), improving quadriceps activation and hamstring weight on the involved leg. Weight shifting can be given as
muscle control, progressing gait (weight-bearing tolerance), part of the home program. After the incision is healed and
managing edema, and controlling pain. A program of eleva- the surgeon allows it, aqua therapy can be initiated with an
tion and ice (20 to 30 minutes three times a day) is used as emphasis on proper weight shifting and gait mechanics.
necessary to manage edema and control pain.
Electrical stimulation (ES) for pain control is avoided Phase II (Subacute Phase)
because of the proximity of the screw and wires. However,
ES can be used to assist in quadriceps contraction when
GOALS: Self-manage pain, increase strength, increase
appropriate. Gentle mobilization (grades 1 and 2 shy of resis-
ROM to 90%, initiate quadriceps AROM (6 to 8
tance) of the patella also is used to control pain.
weeks), have minimal gait deviations on level
Initial exercises of the knee involve PROM, limited active
surfaces (Table 26-2)
range of motion (AROM), and isometrics. Passive stretches
are performed to restore flexion and extension. The vigor of The subacute or midphase of rehabilitation (from weeks
the stretch should be in concert with the guidelines estab- 5 to 8) is the transition from limited functional activity to
lished by the surgeon. In general, patients are expected to aggressive functional activity. The actual exercise protocol is
reach 90 of flexion and full extension by 4 weeks. Supine similar to any other type of patellofemoral rehabilitation. The
wall slides can be easily performed in the clinic or at home. only real difference with ORIF patella fracture is that a true
(See the section on Suggested Home Maintenance for the fixation of the fracture has been obtained. Motion at the
Postsurgical Patient.) Regaining full extension is usually not fracture site tends to activate secondary callus formation,
a problem; however, limitations of extension can be treated especially with tension band wiring of a patella fracture. The
quite successfully. danger in moving a nonfixated fracture (i.e., a fracture with
Active exercises primarily focus on using the hamstrings no established callus formation) is that a nonunion may
to flex the knee. Heel slides and standing hamstring curls develop. A nonunion of bone is caused by excessive motion
TABLE 26-2 Patella Open Reduction and Internal Fixation

Anticipated
Phase II No signs of infection Pain Continuation and progression Self-manage pain Prepare patient for discharge
Postoperative No significant Limited ROM of interventions from phase I Decrease gait Assist patellofemoral
5-8 wk increase in pain Limited strength Patellofemoral taping deviations mechanics
No loss of range of Limited gait Gait training; discontinue Increase LE Promote return to unassisted
motion crutches when indicated strength gait in the community
LE exercises continued from PROM of knee to Restore LE stability and
phase I 90% strength
A/AROMstationary bike Independent with Promote restoration of
used as a ROM assist for home exercises normal joint mechanics
flexion Initiate extensor mechanism
AROMknee extension strengthening and improve
(when cleared by physician, tolerance to patellofemoral
usually between 6-8 wk) compression with tracking
A/AROM, Active assistive range of motion; AROM, active range of motion; LE, lower extremity; PROM, passive range of motion.
directly at the fracture site, which keeps the callus from The rehabilitation at this point begins to mimic that pre-
forming sufficiently. This underlines the importance of scribed for the patient recovering from lateral release in
maintaining immobility in some patella fractures during the terms of exercises and progressions. Taping can be initiated
rehabilitative process.49 in this phase as deemed appropriate by the therapist.
Another factor to consider is that patella fractures involve
joint surfaces. Incongruency of the articular surfaces can Phase III (Advanced Phase)
lead to articular cartilage degeneration and possible early TIME: 9 to 12 weeks after surgery
arthritis if not treated. Incongruity of the patellofemoral GOALS: Return to full function, develop endurance
joint may alter the joint mechanics, producing areas of non- and coordination of the LE, continue to address
contact or excessive pressure over the patella.50 Issues of limitations with steps and running (with physician
patellofemoral contact area and joint reaction force must be clearance) (Table 26-3)
evaluated during this phase of rehabilitation. The use of
patellofemoral taping (see Figs. 20-1 to 20-3) can be useful The advanced stage of rehabilitation (from weeks 9 to 12)
in limiting imbalances over the fractured surface of the focuses on functional, skill-specific activity. Most of the
patella. By this phase, the patient is demonstrating increased effort and work is spent on building back the patients
competency in ambulating with the brace and decreased quadriceps, hamstring, and gastrocnemius-soleus muscle
reliance (if any) on the crutches. Exercises are progressed as strength.
in phase I, and the patient is instructed to perform two sets Depending on remaining deficits, exercises from the pre-
per day (repetitions to fatigue). Closed-chain exercises are vious two phases are continued. The therapist should keep
initiated on a progressive basis based on patient healing and in mind that the time frame will vary depending on many
quadriceps and LE control. factors, including type of fracture, fixation, and the patients
Modalities at this stage are primarily ice for pain control. response to rehabilitation.
ES of the quadriceps is continued as indicated to progress Furthermore, isokinetics should be avoided until the
muscle recruitment. Moist heat can be used to prepare the physician approves them. The need for taping should be
knee for stretching after edema is controlled. minimal, but if continued taping is needed, patients are
PROM stretches are progressed as indicated to obtain full instructed in self-taping techniques. Monitoring for pain
flexion. The vigor of grades of mobilization is increased into and joint effusion gives the therapist feedback on the way to
resistance as indicated. AROM for the quadriceps is initiated progress activities aggressively. Long-term strengthening of
between 6 to 8 weeks (or when the fracture is deemed stable the muscles surrounding the patellofemoral joint with the
enough to tolerate it). The stationary bike can be used as a development of endurance and coordination over time are
ROM assistive device and progressed for strengthening and the goals of this phase.
cardiovascular purposes after flexion allows full revolution By this stage, patients should be close to discharge because
without hip hiking. Surgeon approval is required before ini- they are fairly functional with sitting, standing, and walking
tiating resistance training on a bicycle. tolerances. Limitations with stairs and squatting activities
TABLE 26-3 Patella Open Reduction and Internal Fixation

Phase III Pain free at rest Limited endurance with Closed-chain and Unlimited community Decrease pain with
Postoperative Range of motion prolonged functional stretching exercises as ambulation functional activities
9-12 wk 0-90 activities listed in phases I and II No gait deviations Improve joint mechanics
Good quadriceps Mild pain of patellofemoral Patella taping Good sitting and Improve joint mobility
control during gait joint during skill-specific Patella mobilization standing tolerances and stability
Minimal gait exercises PREs on leg press Good patella stability Provide functional
deviations Limited tolerance to stairs Function-specific activity: without taping strengthening
and single-limb squat and bicycle, treadmill, Patient self- Improve endurance of
balance isokinetic training (when management of vastus medalis oblique
cleared by physician) symptoms Increase reliance on
Home exercises (see patient self-management
Suggested Home
Maintenance section)
PREs, Progressive resistance exercises.
continue to be present. Prolonged standing and walking delays in early PROM exercises. Patients with poor pain
should be continually improving, with the focus on a pro- tolerance do not regain strength and ROM as easily and may
gressive increase in activities. Running and jumping should be left with residual deficits. Return of maximal function
be initiated on an individual basis as determined by the after a patella fracture can take as long as 1 year.10 Residual
surgeon (potentially after removal of hardware). problems of anterior knee pain and stiffness are common
complications.* An estimated 70% to 80% of patients recov-
SUGGESTED HOME MAINTENANCE FOR ering from patella ORIF have good to excellent results,
THE POSTSURGICAL PATIENT although 20% to 30% have fair to poor results.3 Residual loss
of extensor strength has been recorded in the 20% to 49%
An exercise program has been outlined at the various phases. range.
The home maintenance section outlines rehabilitation guide- Prolonged immobilization is detrimental to the final
lines the patient may follow. The PT can use it in customizing result regardless of the treatment.3 Although it produces a
a patient-specific program. risk of wound infection, the benefits of ROM outweigh the
risk of wound complications. However, this situation is espe-
TROUBLESHOOTING cially tenuous in patients who suffer open patella fractures
because they are at a higher risk for infection.
Issues that prevent a successful outcome are unstable fixa-
tion, incongruous reduction, poor patient compliance, and *References 24, 29, 34, 36, 43, 44..

Weeks 1 to 4 4. Perform active heel slidesone set of 10
GOALS FOR THE PERIOD: Control pain, manage repetitions performed three to four times per day.
edema, gain 0 to 90 of PROM, improve quadriceps 5. Perform quadriceps sets (on clearance from the
and hamstring contraction physician)two sets of 10 repetitions performed
1. Elevate and ice at home two to three times per three to four times per day. Even though general
day (preferably after exercises). guidelines such as this may prescribe a number
2. Perform ankle pumping and hamstring stretches of sets and repetitions, if the patient fatigues and
with the extremity elevated and on ice (20 to 30 cannot continue to recruit a quality quadriceps
minutes). contraction, then the exercise is over. Patients are
3. Perform supine wall slides (when appropriate) only to count repetitions with quality quadriceps
one set of five repetitions three to four times a contractions. The heel should stay on the floor.
day. Quadriceps sets also may be performed standing
if the patient finds it easier to activate the 3. Perform self-taping as deemed appropriate by
quadriceps in this position. The key to early therapist.
strengthening is to find which position the patient 4. Continue use of ice after exercises.
is most successful in recruiting a quality
quadriceps contraction. Weeks 9 to 12
GOALS FOR THE PERIOD: Return to full ADL
Weeks 5 to 8 function, develop endurance and coordination of the
GOALS FOR THE PERIOD: Self-manage pain, LE, continue to address limitations with steps and
increase strength, increase ROM to 90%, initiate running (with physician clearance)
quadriceps AROM (6 to 8 weeks), have minimal gait 1. Depending on remaining deficits, continue
deviations on level surfaces exercises from the previous 8 weeks. The need
1. Perform the same exercises as in weeks 1 to 4, for taping should be minimal; if continued taping
increasing the number of repetitions. Exercises is required, then patients are instructed in
should generally be performed in two sets of 10 self-taping techniques.
to 20 repetitions per day (based on fatigue). 2. Progress closed-chain exercises to include
2. Initiate closed-chain exercises based on patient stepping exercises at home using threshold of
tolerance to resistance. Spider killers are initiated doorway for balance.
in pain-free ranges. In addition, simulated leg 3. Gradually return to functional activities while
press exercises with elastic tubing can be monitoring for pain and joint effusion.
performed. Patients begin with two sets of 10
repetitions and progress based on tolerance.
1 James is 45 years old and had patella ORIF 3 weeks ago.

He arrives for his initial evaluation in an immobilizer
with his incision well healed. He weighs 250lb and is
must gain flexion ROM. At some point she needs to
take responsibility for her care. After this intervention,
her ROM improved as did her tolerance to manual
5-feet 10-inches tall. What modality and procedures techniques.
would be most appropriate to improve his gait pattern?
Given his size, pool therapy would be the most appropri-

ate tool to improve his gait pattern and limit body weight
3 Jessica is 40 years old. She fractured her patella when
she fell off a footstool and onto her knees. She had a
patella ORIF surgery 9 weeks ago. Her knee flexion
stress on the patella. Warm water can help improve ROM ROM is limited, and peripatella pain is a factor when
and decrease pain, and stresses that land-based therapy performing ROM stretches. ROM exercises for knee
place on the joint. flexion have been emphasized during the past few treat-
ments along with modalities for pain control. Little
2 Meghan is 25 years old and had patella ORIF 6 weeks

ago. She has only 60 of flexion and guards with any
attempts at manual therapy (soft tissue mobilization,
progress has been noted. What treatment techniques
may be the most helpful?
joint mobilization) to improve ROM. The end feel of The PT should assess the patellofemoral and the tibio-
her flexion is a soft end feel that does not provide much femoral joints for limited mobility. If mobility is limited,
resistance (no catching or hard end feel). She also has which is likely, then patella mobilizations using grades
been negligent in performing her home exercise into resistance (grades 3 and 4) can be helpful. The thera-
program. What changes did the therapist suggest to pist should receive clearance from the physician before
improve Meghans outcome? initiating mobilization into resistance. If it is limited, then
increasing inferior patella movement may particularly
Meghan was instructed to, when possible, take her pain help knee flexion ROM. The patellofemoral contact area
medication before coming to therapy. The therapist also and reaction forces also must be evaluated. Patellofemo-
explained that 20% to 30% of patients have a poor ral taping can be useful in limiting imbalances over the
outcome. If her case was to be successful (and the fractured surfaces of the patella. Complaints of pain with
surgeon saw no reason why it should not be), then she flexion may decrease, particularly with closed-chain
exercises. If restrictions are found in the tibiofemoral

joint, mobilizations (grade 3 and 4) can be performed
to increase flexion (posterior glides of the tibia on
6 George is 7 weeks postoperation and has limited
tolerance to weight bearing because it causes some
increased pain around the patella. What procedures/
the femur). techniques can be used to assist in managing his
symptoms?
4 Jessicas knee ROM is now full 12 weeks after

surgery. She performs a series of exercises for leg
strengthening. She begins by stretching her hamstrings
The use of patellofemoral taping can be useful in limiting
imbalances over the fractured surface of the patella. By
and gastrocnemius-soleus muscles. She then performs this phase, the patient is demonstrating increased com-
the following: petency in ambulating with the brace and decreased
Standing minisquats against the wall reliance (if any) on the crutches.
Leg presses using 100lb and keeping knee flexion less than
60
Lunges with 5-lb weights in a long-stride position
Wall slides between 0 and 45 with a 1-minute hold
7 Lissette is 12 weeks postoperation and is frustrated that
she is not able to return to running activities because of
pain. What can be done to assist the patient with return
Sit-stand to prior activities.
Standing (four-wall) elastic tubing hip flexion, abduction,
and adduction on the uninvolved side First and foremost the therapist should keep in mind, and
Step-downs on an 8-inch step, holding contraction until educate the patient, that the time frame to return to prior
the heel of the opposite leg makes contact activites will vary depending on many factors, including
Although she has minimal discomfort during the exercise type of fracture, fixation, and the patients response to
regimen, she has increased complaints of pain for 2 days after rehabilitation. Accomplishing this early on and setting
the exercises. Which of these exercises is most likely to be an interim goals (i.e., partial weight bearing to FWB, double-
aggravating factor? to single-leg squat, single-leg squat with 50% body
weight to 100% body weight) are helpful. Monitoring for
The 8-inch step-downs are the most aggressive exercises pain and joint effusion gives the therapist feedback on
because they produce the highest patellofemoral com- the way to progress activities aggressively. Long-term
pression forces. The knee is most likely flexed beyond strengthening of the muscles surrounding the patello-
50 while performing an eccentric contraction during femoral joint with the development of endurance and
FWB on the affected extremity. coordination over time are the goals of this phase.
5 David is 3 weeks after surgery and just started therapy.

He has been a patient in the past and his pain tolerance
is not that good. He notes a constant 5/10 pain in his
8 George is 12 weeks postoperation and has made slow
progress (0 to 115, fair quadriceps contraction, resid-
ual mild antalgia during gait/single-limb stance). What
knee without evidence of infection or instability of the instructions can you give him to be successful over the
repair. What pain management techniques can be used? next 6 months?
ES for pain control is avoided because of the proximity Patients with poor pain tolerance do not regain strength
of the screw and wires. However, ES can be used to and ROM as easily and may be left with residual deficits.
assist in quadriceps contraction when appropriate. George was instructed to continue his home stretching/
Gentle mobilization (grades 1 and 2 shy of resistance) of strengthening program with monthly reassessments.
the patella also is used to control pain in addition to ice Return of maximal function after a patella fracture has
and elevation. been noted to take as long as 1 year.
REFERENCES 6. Keating EM, Haas G, Meding JB: Patella fracture after post total knee
1. Bhler L: Technik der Knochenbruch Behandlung 12-13. Auflage. Wien: replacements. Clin Orthop Relat Res 416:93-97, 2003.
W. Maudrich, 1957. 7. Miller MD, Nichols T, Butler CA: Patella fracture and proximal patellar
2. McMaster PE: Fractures of the patella. Clin Orthop 4:24, 1954. tendon rupture following arthroscopic anterior cruciate ligament recon-
3. Nummi J: Fracture of the patella: A clinical study of 707 patellar frac- struction. Arthroscopy 15(6):640-643, 1999.
tures. Ann Chir Gynaecol Fenn 179(suppl):1-85, 1971. 8. Viola R, Vianello R: Three cases of patella fracture in 1,320 anterior
4. Watson-Jones R: Fractures and other bone and joint injuries, Edinburgh, cruciate ligament reconstructions with bone-patellar tendon-bone
1939, E&S Livingstone. autograft. Arthroscopy 15(1):93-97, 1999.
5. Piva SR, et al: Patella fracture during rehabilitation after bone-patellar 9. Bostman O, et al: Fractures of the patella treated by operation. Arch
tendon-bone anterior cruciate ligament reconstruction: 2 case reports. Orthop Trauma Surg 102:78, 1983.
J Orthop Sports Phys Ther 39(4):278-286, 2009.
10. Hung LK, et al: Fractured patella: Operative treatment using tension 29. Peeples RE, Margo MK: Function after patellectomy. Clin Orthop
band principle. Injury 16:343, 1985. 132:180, 1978.
11. Lexack B, Flannagan JP, Hobbs S: Results of surgical treatment of 30. Thompson JEM: Comminuted fractures of the patella: Treatment of
patellar fractures. J Bone Joint Surg Br 67:416, 1985. cases presenting with one large fragment and several small fragments.
12. Weber MJ, et al: Efficacy of various forms of fixation of transverse J Bone Joint Surg 58A:537, 1976.
fractures of the patella. J Bone Joint Surg Am 62:215, 1980. 31. Watson-Jones R: Excision of the patella (letter). Br Med J 2:195, 1945.
13. Bostman O, et al: Comminuted displaced fractures of the patella. Injury 32. West FE: End results of patellectomy. J Bone Joint Surg 62A:1089, 1962.
13:196, 1981. 33. Burton VW: Results of excision of the patella. Surg Gynecol Obstet
14. Carpenter JE, et al: Biomechanical evaluation of current patella fracture 135:753, 1972.
fixation techniques. J Orthop Trauma 11(5):351-356, 1997. 34. Duthie HL, Hutchinson JR: The results of partial and total excision of
15. Rabalais RD, et al: Comparison of two tension-band fixation materials the patella. J Bone Joint Surg 40B:75, 1958.
and techniques in transverse patella fractures: A biomechanical study. 35. Sanderson MC: The fractured patella: A long-term follow-up study. Aust
Orthopedics 31(2):128, 2008. N Z J Surg 45:49, 1974.
16. Schnabel B, et al: Biomechanical comparison of a new staple technique 36. Sutton FS, et al: The effect of patellectomy on knee function. J Bone Joint
with tension band wiring for transverse patella fractures. Clin Biomech Surg 58A:537, 1976.
(Bristol, Avon) 24(10):855-859, 2009. 37. Magnusen PB: Fractures, ed 2, Philadelphia, 1936, Lippincott.
17. Hughes SC, et al: A new and effective tension-band braided polyester 38. Zionts LE: Fractures around the knee in children. J Am Acad Orthop
suture technique for transverse patellar fracture fixation. Injury Surg 10:345-355, 2002.
38(2):212-222, 2007. 39. Makino A, et al: Arthroscopic-assisted surgical technique for treating
18. Sturdee SW, Templeton PA, Oxborrow NJ: Internal fixation of a patella patella fractures. Arthroscopy 18(6):671-675, 2002.
fracture using an absorbable suture. J Orthop Trauma 16(4):272-273, 40. Johnson EE: Fractures of the patella. In Rockwood CA, Green DP,
2002. Bucholz RW, editors: Fractures in adults, ed 3, Philadelphia, 1991,
19. Patel VR, et al: Fixation of patella fractures with braided polyester Lippincott.
suture: A biomechanical study. Injury 31(1):1-6, 2000. 41. Bray TJ, Marder RA: Patellar fractures. In Chapman MD, Madison
20. Smith ST, et al: Early complications in the operative treatment of patella M, editors: Operative orthopaedics, ed 2, Philadelphia, 1993, JB
fractures. J Orthop Trauma 11(3):183, 1997. Lippincott.
21. DePalma AF: The management of fractures and dislocations, Philadel- 42. Crenshaw AH, Wilson FD: The surgical treatment of fractures of the
phia, 1959, Saunders. patella. South Med J 47:716, 1954.
22. Muller ME, Allgower M, Willinegger H: Manual of internal fixation: 43. Einola S, Aho AJ, Kallio P: Patellectomy after fracture: Long-term
Technique recommended by the AO group, New York, 1979, follow-up results with special reference to functional disability. Acta
Springer-Verlag. Orthop Scand 47:441, 1976.
23. Rorabeck CH, Bobechko WP: Acute dislocation of the patella with 44. Wilkinson J: Fracture of the patella treated by total excision: A long-
osteochondral fracture: A review of eighteen cases. J Bone Joint Surg term follow-up. J Bone Joint Surg 59B:352, 1977.
58A:237, 1976. 45. MacAusland WR: Total excision of the patella for fracture: Report of
24. Andrews JR, Hughston JC: Treatment of patellar fractures by partial fourteen cases. Am J Surg 72:510, 1946.
patellectomy. South Med J 70:809, 1977. 46. Lachiewicz PF: Treatment of a neglected displaced transverse patella
25. Anderson LD: In Crenshaw AH, editor: Campbells operative orthopae- fracture. J Knee Surg 21(1):58-61, 2008.
dics, ed 5, St Louis, 1971, Mosby. 47. Lotke PA, Ecker ML: Transverse fractures of the patella. Clin Orthop
26. Brooke R: The treatment of fractured patella by excision: A study of 158:1880, 1981.
morphology and function. Br J Surg 24:733, 1937. 48. Benjamin J, et al: Biomechanical evaluation of various forms of fixation
27. Heineck AP: The modern operative treatment of fracture of the patella. of transverse patella fractures. J Orthop Trauma 1:219, 1987.
I. Based on the study of other pathological states of bone. II. An analyti- 49. Klassen JK, Trousdale RT: Treatment of delayed and non-union of the
cal review of over 1,100 cases treated during the last ten years, by open patella. J Orthop Trauma 11(3):188, 1997.
operative method. Surg Gynecol Obstet 9:177, 1909. 50. Sanders R: Patella fractures and extensor mechanism injuries. In
28. Jakobsen J, Christensen KS, Rassmussen OS: Patellectomya 20-year Bronner BD, et al, editors: Skeletal trauma, Philadelphia, 1992,
follow-up. Acta Orthop Scand 56:430, 1985. Saunders.
CHAPTER 27
Total Knee Arthroplasty
Julie Wong, Michael D. Ries
INTRODUCTION SURGICAL INDICATIONS AND

CONSIDERATIONS
Osteoarthritis (OA), also called osteoarthroses or degenera-
tive joint disease, is the most common type of arthritis and TKA is an effective treatment for symptomatic OA or inflam-
one of the leading causes of disability worldwide. OA is a matory arthritis of the knee that is not responsive to conser-
chronic condition characterized by the breakdown of the vative therapy. Earlier stages of arthritis may be treated with
joints cartilage. Cartilage is the part of the joint that cushions nonsteroidal antiinflammatory drugs, activity restrictions,
the ends of the bones and allows easy movement of joints. exercise, bracing, orthotics, and weight loss. Other treat-
The breakdown of cartilage causes the bones to rub against ments include injections of hyaluronic acid or cortisone.
each other, causing stiffness, pain, and loss of movement in However, when conservative measures fail and arthritic
the joint. In the United States, it is estimated that OA may symptoms limit functional activity, surgery is a more appro-
affect 33 million adults.1 When conservative management priate treatment option. If symptoms are mechanical and
fails to decrease pain or restore mobility, surgical interven- associated with catching or locking more than weight-
tion becomes the treatment of choice. Arthroscopic surgeries bearing pain, they may result from a torn or degenerative
may be beneficial in early stages with mechanical symp- meniscus. Magnetic resonance imaging (MRI) is useful to
toms,2 but when this also fails, a total knee arthroplasty delineate meniscal pathology from degeneration of the arti
(TKA) is usually recommended. cular cartilage. Arthroscopic dbridement may be beneficial
According to the American Academy of Orthopaedic for treatment of meniscal pathology but does not appear to
Surgeons, approximately 581,000 knee replacements are per- be as helpful for management of articular cartilage degenera-
formed each year. Most were performed on people aged 60 tion.5 If cartilage degeneration occurs primarily in the medial
to 80,3 reflecting the aging population of Baby Boomers. tibiofemoral (TF) compartment with varus deformity, then
Understanding the surgical procedure of the TKA and valgus osteotomy of the tibia can be effective in relieving
designing appropriate programs for rehabilitation are essen- medial-sided knee pain and delay the need for total joint
tial to ensure successful and cost-effective outcomes in replacement.6 Osteotomy is most appropriate for treatment
anticipation of this future growth. Self-report measures of of unicompartmental OA in a young active patient, a knee
perceived functional ability indicate that 1 year following with adequate range of motion (ROM), and limited varus
TKA, individuals have regained 80% of normal functions. deformity. Relative contraindications include obesity, flexion
However, despite improvement compared with preoperative contracture, significant lateral compartment or patellofemo-
status, pain and stiffness can remain a problem for some of ral arthritis, TF subluxation, and advanced age. For lateral
these people.4 compartment OA with valgus deformity, distal femoral
The scope of this chapter focuses on primary TKA. It is rather than proximal tibial osteotomy is preferred. However,
referred to as TKA, rather than total knee replacement osteotomy generally requires a longer rehabilitation period,
(TKR), to distinguish it from total knee revision (which is and outcomes are less predictable than for TKA.7
also referred to as TKR). In addition, minimally invasive Prosthetic options include metallic interposition hemiar-
surgery (MIS)-TKA is also described. throplasty, as well as unicompartmental, bicompartmental,
480
Chapter 27 Total Knee Arthroplasty 481
and TKA. The McKeever and MacIntosh metallic interposi- since bicompartmental arthroplasty is a relatively new pro-
tion hemiarthroplasties were used before the development of cedure, long-term results are not known.
TKA.8,9 The implant is a metallic spacer placed between the TKA is an effective treatment for severe arthritic knee
femoral and tibial surfaces. Favorable results may be achieved pain. Both the medial and lateral TF, and usually the PF
most commonly in a patient with arthritic changes in one compartments, are resurfaced in TKA. After TKA, reliable
compartment who was not considered an appropriate can- improvement in pain and function can be expected, and
didate for osteotomy because of obesity, limited motion, or survivorship rates of 90% to 95% after 10 years have
arthritic involvement of the opposite compartment.10,11 frequently been reported.17-22 Early failures may result
However, pain may develop from articulation of the joint from infection, instability, malalignment, stiffness, reflex
surface with the metallic implant. More recently a mobile sympathetic dystrophy, and patellar problems. Relative
metallic Uni spacer* has been used which is intended to contraindications include active infection, extensor mech-
distract the medial compartment and transfer loads to the anism disruption, severe loss of bony or ligament support,
lateral compartment.12 However, results appear less predict- and uncontrolled cardiac disease or medical comorbidi-
able than unicompartmental or TKA. ties that substantially increase the risk of perioperative
Unicompartmental, bicompartmental, and TKA resur- morbidity and mortality. However, using proper surgical
face both the femoral and tibial articular portions of the joint technique, implant selection, appropriate postoperative pain
and are effective in relieving arthritic pain. Unicompartmen- management, and rehabilitation can avoid these problems.
tal arthroplasty is indicated for degenerative arthritis limited Recent developments including computer-assisted surgery,
to either the medial or lateral TF compartment with preser- more kinematic or high-flexion implant designs, use of MIS,
vation of the opposite TF and patellofemoral (PF) com and MRI-derived custom cutting blocks may further improve
partments. Unicompartmental arthroplasty preserves both the results of TKA. TKA performed through a conventional
cruciate ligaments, the opposite TF compartment, and the skin incision centered over the rectus tendon proximally and
PF joint, which is typically associated with more favorable extending distal to the tibial tubercle, with a medial parapa-
knee kinematics, ROM, and overall joint function than TKA. tellar arthrotomy, is associated with reliable pain relief,
However, failure of unicondylar arthroplasty may occur improvement in function, and 90% to 95% 10-year
from the development of arthritic symptoms in the PF or survivorship.17-22 However, many patients experience signifi-
opposite TF compartment, requiring conversion to TKA. cant pain and inflammation, which typically occurs to some
Mechanical failure or polyethylene wear may also limit the extent for 6 months after arthroplasty and may limit partici-
longevity of unicondylar replacement. Although the indica- pation in rehabilitation exercises. Less invasive or MIS
tions for use of unicondylar replacement as an alternative to permits TKA to be performed with reduced soft tissue
TKA are controversial, unicondylar replacement is generally trauma, with average skin incision of 9.4 to 10.9cm in the
considered less predictable in terms of longevity of the MIS group and 13.7 to 17.1cm in the conventional group.23
arthroplasty, particularly when used in situations in which Reports indicate that MIS is associated with less blood
some arthritic involvement of the opposite TF or PF com- loss, less pain, and earlier return of quadriceps function
partment exists. Recent literature shows favorable functional and ROM.24-26
results and patient satisfaction from unicompartmental knee Recent literature shows favorable results in the MIS
arthroplasty (UKA), especially in the younger, high-demand, surgery. In selected patients, the Berger and associates study
and active patients.13 The advantages of UKA versus TKA showed that outpatient MIS TKA was safe for discharge on
include better ROM at discharge and a shorter hospital stay the day of surgery with no short-term readmission or com-
(77 versus 67 and 1.3 to 1.4 days versus 2.2 days). The plications in 96% of the patients.27 In Tanavalees study, 82%
average arc of motion at initial 6-week follow-up was 116 of the MIS patients were able to do active knee extension on
for the UKA patients and 110 for the TKA patients, with day 1 while none were able to do active knee extension in
56% of knees having greater than 120. Early discharge for the conventional group. Additionally, patients who could
the patients appeared to be safe; in 97% of cases, patients walk on day 1 were 17 versus 2.23 In another study, in the
were discharged directly to home, but 18% of the first 12 weeks after surgery, the MIS group had less flexion
cases required home health physical therapy and 76% of contracture and better flexion.28 At 1 year postoperative,
the cases required outpatient physical therapy. Only 3% of average passive range of motion was 131 in the MIS group
the patients required a skilled nursing or postdischarge reha- and 121 in the conventional group; while active range of
bilitation stay.14 motion was 125 in the MIS group and 115 in the conven-
Bicompartmental (combined medial and PF) arthroplasty tional group.29
is indicated for treatment of symptomatic medial compart- However, a minimally invasive approach may compro-
ment and PF OA.15 Early results with bicompartmental mise surgical exposure and result in increased complica-
arthroplasty indicate that satisfactory clinical results and res- tions. With use of small cutting blocks and avoiding
toration of normal kinematics can be achieved.16 However, dissection of the suprapatellar pouch, reliable results can be
achieved with a complication rate that is not greater than
conventional TKA.24-26 Particularly, when combined with a
*Centerpulse, Austin, Texas. preoperative patient education program and multimodal
postoperative pain management, TKA performed through a

minimally invasive approach appears to offer advantages
compared with conventional TKA. However, more muscular
patients, those with prior surgery, stiffness, poor skin vascu-
larity, or significant deformity requiring soft tissue releases
may not be appropriate candidates for a minimally invasive
approach.
Mechanical axis
is
Anatomic ax
SURGICAL PROCEDURESTRADITIONAL
Preoperative Evaluation
Preoperative evaluation always includes a thorough history
and physical examination, determination of the type of
arthritis, other joint involvement and functional status,
walking distance, current and expected activity level, and
sports involvement. Other significant concerns include Transverse axis
history of deep venous thrombosis (DVT) or pulmonary
embolus (PE) and previous surgery such as joint replace-
ment, corrective osteotomy, and internal fixation of a hip,
femur, or tibial fracture. Close attention is paid to joint align-
ment (varus or valgus), stability, ROM (especially the pres-
ence or absence of flexion contracture), muscle tone, and leg
lengths.
Preoperative radiographs should include long weight-
bearing films to demonstrate any femoral or tibial deformity
and aid in determining overall lower extremity (LE) align-
ment. The angle between the mechanical and anatomic axis
is measured on the femur to ensure that the distal femoral
osteotomy will be perpendicular to the mechanical axis and
parallel to the proximal tibial osteotomy (Fig. 27-1). Routine
roentgenograms should also include anteroposterior (AP) Fig. 27-1 The anatomic axis parallels the femoral shaft, whereas the
standing films, as well as lateral and patellar views. mechanical axis is a straight line from the center of the femoral head to the
center of the knee and the center of the ankle. (Courtesy Zimmer, Inc,
Procedure Warsaw, Ind.)
Numerous implant and fixation choices are available for

TKA:
1. Cemented, uncemented, or hybrid fixation peripheral nerve block of the femoral nerve has been shown
2. Metal-backed tibia or all-polyethylene tibia to be effective in controlling pain whether through a local
3. Patella resurfacing or patella retaining infusion (24 hours) or administered via percutaneous inser-
4. Posterior cruciate or bicruciate substituting, posterior tion of a catheter adjacent to the femoral nerve (a 2- to 3-day
cruciate-retaining, or mobile-bearing surfaces ambulatory continuous femoral nerve block).35,36
The technique described here is the primary TKA using A sandbag is taped to the operating room table, or a com-
cemented fixation, a metal-backed tibia, an all-polyethylene mercial leg-holding device is often used to help stabilize the
patella, and posterior cruciate substitution (Fig. 27-2). Cur- leg during the procedure. The entire LE is sterilely prepared
rently, this combination is the most commonly used with and draped. The LE is exsanguinated with an Esmarch
consistent long-term results published to date.30-34 bandage, and a tourniquet is inflated to an appropriate
pressure.
Surgical Technique
An antithrombotic stocking or pump is placed on the unin- Exposure
volved leg. The patient is questioned as to which knee is to A longitudinal midline skin incision is made extending from
be replaced as a final check to avoid the mistake of operating proximal to the patella to just distal to the tibial tuberosity.
on the wrong knee. An intravenous antibiotic, usually first- Full-thickness skin flaps, including the deep fascia, are devel-
generation cephalosporin, is given before the skin incision is oped medially and laterally (Fig. 27-3). A medial arthrotomy
made. The patient is placed supine on the operating room is made extending from the quadriceps tendon and ending
table with a tourniquet about the proximal thigh. A general medial to the tibial tuberosity. The patella is everted or sub-
endotracheal or regional anesthetic is required. However, luxed laterally. After flexing the knee to 90, the surgeon
trims osteophytes from the femoral condyles, intercondylar

notch, and tibial plateaus. The cruciate ligaments are excised.
Ligament Balancing
Ligamentous balance is addressed by inserting spreaders in
the medial and lateral femoral tibial joints, both in flexion
and extension. Equal spacing is then attained by excision of
osteophytes and soft tissue releases. The three most common
deformities encountered are varus, valgus, and flexion.
Release of contracted soft tissues on the concave side of the
deformity is achieved either by sequential subperiosteal
longitudinal release of individual anatomic soft tissue con-
straints or use of multiple transverse stab wound incisions
(pie crusting) into the contracted soft tissues.
Varus Deformity. Osteophytes protruding off the medial

tibia are removed and the medial capsule is incised. If neces-
sary, then the medial collateral ligament is subperiosteally
stripped off the tibia. For deformities with combined varus
and flexion contracture, release of the semimembranosus
insertion is often necessary.
Valgus Deformity. A lateral retinacular release is com-

monly required. If the valgus deformity is more rigid in
Fig. 27-2 Primary TKA using all polyethylene patella and posterior cruci-
ate substitution. (Some physicians favor this approach; it is not the prefer- extension than in flexion, the iliotibial band is released. The
ence of Dr. Ries.) popliteus tendon, lateral collateral ligament, and posterolat-
eral capsule may also be released, depending on the severity
of the deformity. Peroneal nerve neuropraxia can occasion-
ally occur, especially with correction of flexion contracture
in association with valgus deformity.
Flexion Deformity. Excising posterior femoral osteo-

phytes and releasing posterior capsular adhesions usually
address a minor contracture. Further correction requires
resection of more bone from the distal femur and posterior
capsular release.
Osseous Preparation. An intramedullary femoral guide

is placed through a drill hole in the center of the trochlea
(Fig. 27-4). The intramedullary rod must parallel the femoral
shaft in both the AP and lateral planes, ensuring placement
parallel to the anatomic axis of the femur. Cutting guides are
attached to the intramedullary guide to allow precise oste-
otomies of the anterior and distal femur. The distal femoral
osteotomy is usually made 6 to the anatomic axis to produce
distal femoral alignment perpendicular to the mechanical
axis (Fig. 27-5).
Either intramedullary or extramedullary tibial cutting
guides are used. The proximal tibia is osteotomized with a
sagittal saw perpendicular to its long axis, approximately
5mm distal to its articular surface, and angled posteriorly
approximately 3 to 5. Small tibial defects are effectively
addressed with cement. Larger defects require either bone
grafting or metal augments.
Fig. 27-3 Surgical exposure of the left knee. Note the full-thickness skin An AP measuring guide is used to determine the appro-
flaps, medial arthrotomy, and eversion of the patella. This varus knee priate size and position of the femoral component. An AP
demonstrates severe wear of the medial femoral condyle. cutting block is placed to remove the anterior and posterior
Fig. 27-4 The intramedullary femoral guide ensures placement parallel to the anatomic axis. (Courtesy Zimmer, Inc, Warsaw, Ind.)
Fig. 27-6 Anterior and posterior femoral osteotomies. (Courtesy Zimmer,

Fig. 27-5 The distal femoral guide attaches to the intramedullary guide Inc, Warsaw, Ind.)
with a proper amount of valgus (usually 6) to ensure the osteotomy is made
perpendicular to the mechanical axis. (Courtesy Zimmer, Inc, Warsaw, Ind.)
femoral condyles. This affords excellent visibility and access soft tissue tension and ligamentous balance. If full extension
to remove any remaining meniscus, cruciate ligament, and is not attained, then further bone is removed from
osteophytes (Fig. 27-6). the distal femur. For very severe flexion contractures,
The flexion and extension gaps are measured with stan- such as those encountered in some cases of hemophilic
dardized spacer blocks. Ideally, the same gap has been arthropathy or juvenile rheumatoid arthritis, resection of
produced between the distal femur and tibia in extension the distal femur to the level of the collateral ligament inser-
and posterior femur and tibia in flexion. This ensures proper tions may be required. Further bone resection is a relative
Fig. 27-7 Single guide used to perform anterior and posterior chamfers
and to remove the intercondylar notch. (Courtesy Zimmer, Inc, Warsaw,
Ind.)
contraindication to conventional TKA if the ligament inser-

tions are compromised, and use of a more highly constrained
or revision prosthesis is necessary. A guide is then used to
chamfer the anterior and posterior femoral condyles and
remove bone from the intercondylar notch (Fig. 27-7).
Sizing guides are used to determine the proper-sized
tibial component.
After orienting the guide in the AP, medial, and lateral
planes, the surgeon ensures proper rotation with the use of
an alignment rod extending to the middle of the ankle joint.
A bone punch is then used to compress the soft cancellous
Fig. 27-8 A tibial template is rotationally aligned and sized appropriately
bone in the tibial metaphysis to accommodate the keel on to allow proper placement of the tibial stem punch. (Courtesy Zimmer, Inc,
the tibial component (Fig. 27-8). Trial tibial and femoral Warsaw, Ind.)
components are placed to ensure proper sizing, soft
tissue tensioning, ligamentous balance, patellar tracking,
and ROM. The wound is irrigated thoroughly and closed over a
Patellar thickness is measured with a caliper. The articular suction drain. A sterile dressing is applied. An antithrom-
surface is removed with a power saw or reamer. A guide is botic stocking or compressive dressing is applied over the
used to drill one or more holes in the patella for additional sterile dressing (Fig. 27-11).
peg fixation (Fig. 27-9). The component is usually placed
slightly medial on the patella to assist in patella tracking. The MINIMALLY INVASIVE SURGERY
thickness is again checked with the caliper; if the patella is
thicker than before resection, then more patella is removed Surgical Technique
to restore normal patella thickness. Patella tracking is The minimally or less invasive skin incision extends from the
observed (Fig. 27-10) and if the patella tracks laterally, then superior pole of the patella to the tibial tubercle (Fig. 27-12).
a lateral retinacular release is performed. Efforts are made to In most patients the length of the incision is approximately
preserve the superior lateral geniculate artery, thereby pre- 10 to 12cm, but it may be longer or shorter depending on
serving the blood supply to the patella. the size of the patient. Full-thickness skin and subcutaneous
All trial components are removed, bony surfaces are tissue flaps are raised to mobilize the skin and subcutaneous
cleansed with pulse lavage, and bone cement is mixed. All layer and permit adequate deep exposure.
components may be cemented at one time, or a second batch Either a medial parapatellar, midvastus, or quadriceps-
of cement may be prepared to allow sequential implantation sparing (subvastus) arthrotomy may be used to expose the
of the components. All excess cement is trimmed while soft. knee. Excellent results have been reported using the
After the cement has hardened, the tibial spacer may be minimidvastus approach, whereas the quadriceps-sparing
exchanged to allow final adjustments with regard to ROM approach is more restrictive and may only be appropriate
and stability. The tourniquet is released and bleeding for thin patients with mobile extensor mechanisms and
controlled. no intraarticular deformity. Typically for muscular male
Fig. 27-9 A patella template ensures the proper size and placement of the patella component. (Courtesy Zimmer, Inc, Warsaw, Ind.)
Fig. 27-10 Final component cemented in place. Central tracking of patella Fig. 27-11 The wound is closed in layers with nonabsorbable sutures in
without finger pressure should be noted. arthrotomy incisions, running absorbable sutures in subcutaneous layer
incorporating the Scarpa fascia, and staples in the skin. Suction drainage is
performed supralaterally to avoid quadriceps mechanism.
A
Fig. 27-12 Skin incision extends from the proximal pole of the patella to
the tibial tubercle.
B
Fig. 27-14 A, To expose the distal femur, the knee is partially flexed to 45
to 60, which moves the center of the skin incision more proximally. B, The
distal femoral cutting block is positioned, and the distal femoral cut is made
with the knee partially flexed.
Fig. 27-13 The patella is subluxed laterally but not everted while the knee
is flexed.
patients, either more proximal dissection of the vastus medi-

alis (in a midvastus approach) or a medial parapatellar
arthrotomy is necessary to displace the extensor mechanism
laterally. A portion of the fat pad is excised to facilitate expo-
sure. Lateral patellar subluxation is necessary, but eversion
of the patella while the knee is flexed does not necessarily
increase exposure and may contribute to quadriceps inhibi-
tion and postoperative knee pain (Fig. 27-13). The skin and
subcutaneous tissue may be considered as a mobile window.
By extending the knee, the skin incision is moved more
proximally and exposure is centered over the distal femur,
whereas flexing the knee permits more distal exposure over
the proximal tibia (Figs. 27-14 and 27-15). Cutting guides
for MIS-TKA are smaller than conventional instruments but
permit accurate bone cuts. Alternatively, custom disposable
cutting guides can be used. These are derived from preopera- Fig. 27-15 To expose the proximal tibia and resect the tibial surface, the
tive three-dimensional MRI images of the arthritic knee and knee is fully flexed.
3. Cardiovascular conditioning as an adjunct to weight loss

4. An individualized exercise program to address strength
and flexibility issues
5. Functional training to maximize the patients ability
Much can be done for these patients in this phase of the
disease process. A successful outcome for postoperative TKA
can be predicted by the patients functional ability and status
preoperatively.38-40
In the event that a TKA is the intervention of choice, then
preoperative treatment is modified to include the assembly
of a multidisciplinary team. This group includes the ortho-
pedic surgeon, PT, nursing staff, occupational therapist,
and social service worker. Although each team member is
responsible for his or her area of expertise, all are committed
A to the common goal of providing the best possible care to
get the maximal benefit and outcome.
During this phase the patient should be educated and
familiarized with the surgical procedure and the phases of
the rehabilitation process. This serves both to identify and
anticipate any special problems or needs that the patient
should incur. It will also reinforce the active role of the
patient in his or her own long-term care. Recommendations
may involve home planning, dental hygiene, and social
planning.
In the era of managed care, many hospitals have formed
preoperative educational classes for this purpose. In a group
atmosphere, patients can begin to understand the rehabilita-
tion process and formulate realistic goals and expectations.
Informational pamphlets outlining all pertinent information
B are also helpful. Good preoperative care and communication
between the team and the patient can guarantee a smooth
Fig. 27-16 A, The femoral and tibial components are implanted. B, With
transition through the postoperative process.
the knee fully extended, the patella is everted and resurfaced.
Phase I (Inpatient Acute Care)

GOALS: Prevent complications, reduce pain and
intended to provide precise orientation of the bone cuts.
swelling, promote ROM, restore safety and
With the knee in extension, tension in the extensor mecha-
independence (Table 27-1)
nism is reduced and the patella may be everted for resur
facing without traumatizing the suprapatellar pouch The goals for this initial period of rehabilitation are
(Fig. 27-16). standard for any postoperative care. These pertain to the
prevention of any possible complications. Medical consider-
THERAPY GUIDELINES FOR ations include (1) the prevention of infection, (2) the preven-
REHABILITATION tion of PE, (3) the prevention of DVT, and (4) the reduction
of pain and swelling. Functional goals include (1) the promo-
Successful postoperative management of the patient ideally tion of ROM and (2) the restoration of safety and indepen-
begins preoperatively. In many cases, the patient has already dence in activities of daily living (ADLs) and gait. The
been seen by a physical therapist (PT) for a conservative treatment plan is formulated with these specific consider-
course of treatment. Prescription of high- and low-resistance ations in mind.
training exercises is an essential aspect of management for
knee OA and both have significantly improved clinical Medical Considerations
effects.37 Although the goal of rehabilitation at this time may Intravenous antibiotics are continued for 24 hours. DVT
be to avoid surgery, the PT must bear in mind that the treat- prophylaxis is initiated. This typically consists of antithrom-
ment plan is similar to those for preoperative care: botic pumps, Coumadin, low molecular weight heparin, or
1. Patient education regarding the disease process and a combination of these treatments.
prognosis Monitoring the surgical incision for drainage, erythema,
2. Behavioral and health modification for joint protection excessive pain, or swelling is continued throughout the
TABLE 27-1 Total Knee Arthroplasty

Phase I Postoperative and Edema CPM setup and patient Independent with the Restore ROM of knee
Inpatient acute cleared by physician Pain instruction beginning with following: (1) Bed Improve wound healing,
care 1-5 days to initiate therapy Limited ROM 0-40 and progressing mobility; (2) don/ reduce adhesion
Limited strength 5-10 as tolerated doff clothing, and formation, prevent
Limited bed mobility and 5-10hr/day corset if indicated; complications
transfers Inspect wound for (3) transfers; (4) Wound and surgical site
Limited gait drainage, erythema, and gait using assistive protection is important
excessive pain device as appropriate as patient begins to
Breathing exercises Demonstrate perform exercises and
Patient education to appropriate body ambulation (Note:
control edema (elevation mechanics with Infection and deep
and pumps) and self-care and basic venous thrombosis are
positioning to prevent activities of daily major postoperative
knee flexion contracture living complications of total
PROMknee extension Independent with gait knee arthroplasty.)
and flexion, supine heel for 100ft on level Use gravity feed and
slides surfaces using muscle pump to
Isometricsquadriceps, appropriate assistive minimize edema and
hamstrings, and gluteal device prevent deep venous
sets: 10 repetitions three Progress self- thrombosis
times management of ROM Reduce reflex inhibition
AROMankle exercises of quadriceps resulting
dorsiflexion, plantar Decrease pain and from pain and edema
flexion, and circumduction edema Prepare patient for
Transfer and bed mobility independence with
training transfers
Gait training with weight Begin to prepare
bearing as tolerated or as extensor mechanism to
physician orders (using accept loads
walker or crutches) in Restore independence
immobilizer until adequate with ambulation
quadriceps control is Improve stability of
attained involved lower extremity
After second day, progress Prevent disuse atrophy
to: and reflex inhibition
Initiation of A/AROM Prepare for home
exercises twice daily disposition, facilitate
AROMheel slides independence
(supine and seated) TKEs,
SLRs
A/AROM, Active assistive range of motion; AROM, active range of motion; CPM, continuous passive motion; PROM, passive range of motion;
ROM, range of motion; SLR, straight leg raises; TKE, terminal knee extension.
patients stay. It is vital for the therapist to be aware of the and DVT is ruled out or an appropriate level of anticoagu-
signs and symptoms of wound infection, as well as other lation therapy is achieved. Specific signs, symptoms, and
complications such as DVT or PE. If signs and symptoms tests are discussed in the Troubleshooting section of this
of possible DVT develop, further knee ROM exercises chapter. Any symptom must be brought to the immediate
should be restricted until diagnostic testing is completed attention of the nursing staff and surgeon.
Fig. 27-17 With the leg straight, a pillow is positioned under the ankle to increase end-range extension and venous drainage and decrease compression of
the posterior tibial vein.
Functional Considerations Exercises are taught at bedside beginning on postopera-

Restoration of functional ROM is essential for the success of tive day 2 or 3.44,62 Breathing exercises promote full excursion
TKA. Continuous passive motion (CPM) has been used and of the rib cage. Ankle ROM exercises (i.e., pumping,
shown to be beneficial in regaining early mobility, but may circumduction) along with instruction in proper elevation
not necessarily affect the final ROM achieved. CPM can be and positioning of the LE is encouraged (Fig. 27-17).
initiated immediately after surgery in the recovery room. The purpose of these exercises is to engage the muscle pump
In one study, CPM patients were able to achieve 90 of and passive gravity feed to decrease distal edema and avoid
flexion in 9.1 days versus their non-CPM counterparts, who DVT.
required 13.8 days to reach the same goal.41,42 Unfortunately, Isometric gluteal sets, hamstring sets, and quadriceps sets
CPM was found to be ineffective in the enhancement of knee are taught to prevent disuse atrophy and quadriceps reflex
extension.41,43 inhibition. Patients are encouraged to do these exercises
Many surgeons choose to begin immediate postoperative independently, thereby increasing their active participation.
CPM.44,45 Because of wound concerns, others choose to It is recommended that this program be initially performed
begin on postoperative day 2.46 The beneficial effects of CPM 10 repetitions every hour, and progressed to 20 repetitions,
include the improvement of wound healing,47 accelerated three times daily.62
clearance of hemarthrosis,48 reduced muscle atrophy,49,50 This exercise program is advanced throughout the first
reduced adhesion formation,51-54 reduction in the incident of week of rehabilitation. Active assistive range of motion (A/
DVT,55 decreased hospital stay,56 and decreased need for AROM) exercises, such as seated heel slides or therapist-
medication.57,58 Although excellent function and ROM can assisted knee flexion and passive knee extension, are per-
be achieved without the use of CPM, many surgeons and formed to improve mobility. Straight leg raises (SLRs) and
patients find that CPM is useful in reducing the frequency terminal knee extensions (TKEs) further strengthen the
of complications after TKA.45,46,59 quadriceps muscles, thus improving the dynamic stabilizers
The protocol of CPM application varies in the literature. of the knee.62,63 These exercises will become part of the home
In general, the initial settings range from 0 to 25 to 40 of program once the patient is discharged.
flexion. The range is then either increased 5 to 10 per day The patient is also instructed in ADLs, such as dressing,
or to patient tolerance. CPM can be used from 4 to 20 hours bathing, transfers, reaching, and picking up items. Usually
per day. Its use is discontinued at the end of the acute hos- this comes under the supervision of the occupational thera-
pital stay or when maximum knee flexion of the CPM pist, although particularly in some smaller hospital settings,
machine is attained. the PT may be responsible. The ADLs should be reviewed
Another modality that has been shown to be useful in and performed until the patient can demonstrate safety and
improving ROM and quadriceps strength is neuromuscular independence. The need for any special assistive devices is
electrical stimulation (NMES). Mitigating quadriceps assessed and they are issued.
muscle weakness immediately after TKA using early Progressive gait training begins with a walker or crutches
NMES may improve functional outcomes, because quad- on postoperative day 2 or 3,62 proceeding throughout the
riceps weakness has been associated with numerous func- acute care hospitalization. Safety, balance, and patient inde-
tional limitations and an increased risk for falls.60 When pendence are the primary goals for this intervention. Nego-
NMES was added to a voluntary exercise program, deficits tiating level surfaces, ramps, curbs, stairs, or other activities
in quadriceps muscle strength and activation resolved relevant to the patient are practiced.
quickly after TKA.61 In conjunction with the CPM, the appli- Current clinical care pathways recommend that the
cation of NMES was shown to reduce extensor lag and the average length of stay in the acute hospital should be approx-
length of stay in the acute care setting.59 imately 3 to 4 days,62,64 with physical therapy sessions twice
daily. The patient is discharged when deemed medically with physical therapy scheduled twice a day for a length of
stable. Specifically, from a rehabilitation standpoint, the stay of approximately 3 to 7 days or until goals are met.
patient should be able to demonstrate 80 to 90 of motion, Sometimes it becomes necessary to begin training family
30 transfer supine to sit and sit to stand independently, members or caregivers in assisting the patient during gait
ambulate 15 to 100 feet, and ascend and descend three steps65 and transfers. Social services are often necessary to assist in
or as the home situation dictates.62 If unable to do these tasks planning home care needs or placement in long-term care
or if any medical postoperative complications occur, then the facilities.
patient may be transferred to an extended care unit (ECU)
or skilled nursing facility for further care. Phase IIb (Outpatient Home Health)
TIME: 2 to 3 weeks after discharge to home
Phase IIa (Inpatient Extended-Care or Skilled GOALS: Become safe in home environment with
Nursing Facility) transfers, gait, and most ADLs (Table 27-3)
Once discharged home, physical therapy treatments are
GOALS: Prevent complications, reduce pain and
reduced to three times weekly. During this phase of rehabili-
swelling, promote ROM, restore safety and
tation, the goals are expanded to facilitate functional ROM,
independence (Table 27-2)
endure safe and independent ADLs, transfers, and gait in
The goals of this short-term rehabilitation phase are the the community. It is important for the therapist to assess
same as for in the acute hospital. Treatment efforts continue, the home for safety and make changes as appropriate.

Anticipated
Impairments and
Phase IIa No signs of infection Edema and pain Continuation and Self-management of CPM may be discontinued if
Extended care No significant Limited ROM progression of interventions pain and edema ROM is improving
or skilled increase in pain Limited strength from phase I Independence with Prepare for discharge from
nursing No loss of ROM Limited gait tolerance Transfer training (car, bed mobility and ECU (transition to home
(inpatient) Discharge from acute sit-stand with varying seat transfers health or outpatient)
6-14 days care heights) Independent gait in Promote return to unassisted
Progressive stiffness, Progressive gait training community distances gait in the community
wound drainage, using appropriate assistive (300-500ft) Obtain close to if not
other complications device Knee PROM functional ROM (110
that may preclude Aggressive knee extension 0-110 necessary for stair climbing)
home discharge and flexion exercises Advance Maximize lower extremity
If patient is unsafe PROMflexion (prone independence with strength and stability
for home disposition, and standing) home exercises Prevent disuse atrophy
transfer to ECU A/AROMflexion Improve functional Treat hip weaknesses
Discharge to home (seated, on step, on lower extremity resulting from altered
bicycle) strength weight-bearing and
AROMSLR, heel raises, compensatory postural
leg curls, step-ups, strategies
step-downs, one-fourth (Note: Postoperative stiffness
squats is a major complication of
Joint mobilization total knee arthroplasty.
Soft tissue and myofascial Manipulation criteria varies
release (respecting incision) among surgeonssee
Careful ongoing monitoring text.)
of edema
A/AROM, Active assistive range of motion; AROM, active range of motion; CPM, continuous passive motion; ECU, extended care unit;
PROM, passive range of motion; ROM, range of motion; SLR, straight leg raises.

Anticipated
Phase IIb No signs of Limited ROM Assess home safety Safe and independent Prevent complications such
Home health 2-3 wk infection Limited strength and make changes in home setting as falling
(depending on No significant Difficulty with gait on as appropriate Independent Return to independent living
need for extended increase in pain uneven surfaces and Car transfers and gait ambulation using Prepare for discharge to
care unit or skilled No loss of ROM stairs training on uneven appropriate assistive outpatient rehabilitation
nursing facility) If at home, good Unable to attend surfaces device facility
family support for outpatient Continuation of Independent in Strengthen lower kinetic
assistance with rehabilitation exercises as listed community distances chain
ADLs and safety (homebound) previously to increase ROM 0-110 Prevent disuse atrophy
knee ROM and 110 of flexion required for
strength stair climbing and use of
Progressive weight stationary bicycle
bearing per Avoid postoperative
physicians orders contracture and need for
and patients ability manipulation
ADLs, Activities of daily living; ROM, range of motion.
assistive exercises are given (Fig. 27-19, A to C). Functional

strengthening exercises are progressed in both the open- and
closed-chain positions. Examples of closed-chain exercises
are bilateral toe raises, sit-to-stand exercises (Fig. 27-20, A
and B), one-quarter squats, and progressive step-ups and
step-downs (Fig. 27-21, A and B). Closed-chain exercises
have been shown to be highly effective in recruiting the
vastus medialis oblique and vastus lateralis as compared
with open-chain isometric exercises.66-68 Specific transfers
in the home and the car are practiced. Progression in
gait includes advancing the patient to crutches or a cane as
his or her balance dictates. Ambulation on uneven, ramped,
and outdoor surfaces is also reviewed. Home physical
therapy is discontinued when the patient is no longer home
bound.
Fig. 27-18 TKE with passive overpressure. With the knee straight, a pillow
is positioned under the ankle. Manual overpressure is applied above and Phase III (Outpatient Care)
below the patellofemoral joint to increase TKE passively.
GOALS: Normalize gait; reduce reliance on assistive
devices; increase ROM; improve weight bearing,
balance, strength, endurance, and proprioception
Recommendations may include but are not limited to the
(Table 27-4)
installation of nonskid rugs, safety rails and ramps, and the
elimination of potential obstacles around the house. This phase of rehabilitation may begin on postoperative
The home exercise program initiated in the inpatient week 2 to 4 for the highly advanced and active patients or
setting is reviewed and refined. If extension mobility is week 4 to 6 for those proceeding more routinely. The length
lacking, then more aggressive knee extension exercises are of this stage is also dependent on factors such as the patients
instructed (Fig. 27-18). Postoperative pain may limit a goals and potential functional abilities. The therapist should
patients ability to perform knee ROM exercises. If postop- review the insurance benefits and explain to the patient
erative pain is not adequately controlled, then more effective all options for rehabilitation if there are any insurance
pain management strategies should be considered, including limitations.
inpatient pain management for very severe cases. If knee Common difficulties encountered with TKAs include
flexion is limited, then more progressive active and active patellar instability and lack of motion. Routine functional
B C
Fig. 27-19 A, Prone knee flexion. In a prone position the patient bends the operated knee as far as possible while using the uninvolved knee to apply passive
overpressure to increase knee flexion. B, Standing open-chain knee flexion. In a standing position with upper extremity support, the patient actively bends
the involved knee, bringing the heel to the buttocks while maintaining upright posture. C, Standing closed-chain knee flexion. In a standing position, the
patient places the foot of the involved leg flat on a step; then the patient places the hands above the knee, slowly leans forward on the involved leg, and guides
the knee into more flexion.
activities usually require ROM from 0 to 110. Full exten- flexion.73,74 Manipulation carries a small risk of fracture or
sion is necessary to normalize the gait cycle69-71 and to other complications that may further compromise the
facilitate quadriceps strength.64 Full normal ROM may not outcome of the TKA.73 Relative contraindications to mani
be a realistic goal for all patients. Postoperative ROM may pulation include severe osteoporosis and markedly restricted
be restricted, particularly if preoperative and intraoperative intraoperative ROM.
ROM is restricted. Stair climbing, sitting on a regular toilet Muscle strength and flexibility imbalances of the
seat or chair (17-inch height), and stationary bike riding hip, knee, ankle, and foot can occur after knee injury or
requires 110 of knee flexion.72 If motion is limited, then a surgery.75-78 Reflex inhibition, faulty joint mechanics, altered
manipulation under anesthesia (MUA) may be warranted. gait, presurgical disuse atrophy, immobilization, or nerve
General indications for a manipulation include less injury have been shown to cause altered function of the
than 90 at postoperative week 673 or a progressive loss of muscles in the lower kinetic chain.79-82 Therefore it is
A B
Fig. 27-20 Sit-to-stand exercise. A, Start position. B, End position.
Without using the upper extremities for support, the patient practices con-
trolled and balanced sit-to-stand transfers from various heights. A B
Fig. 27-21 A, Step-up progression. Patient practices controlled step-up
with the involved leg from progressive heights. B, Step-down progression.
essential for the PT to fully assess the entire LE for any loss Patient practices controlled step-downs with the uninvolved leg from pro-
of ROM or muscle strength and then develop a comprehen- gressive heights.
sive rehabilitation program to address the findings.
A successful plan must include aerobic conditioning and,
for overweight patients, weight reduction.83 Because obesity Changes in equilibrium after LE injuries have been cited
(defined as body mass index of more than 30) is often associ- in the medical literature.90-94 Balance activities and single-leg
ated with OA, many patients with a TKA are overweight and exercises should be incorporated to offset any compensatory
deconditioned. postural changes that have occurred as a result of decreased
Increased forces such as those found in obesity can be the weight bearing, altered gait, and pain. The use of rocker
cause of wear to the weight-bearing surfaces.84,85 One study boards, half foam rollers, and other balance apparatuses can
found that subjects were 12 to 13kg (25 to 30lbs) heavier be helpful to improve the patients proprioception, balance,
and had 4% to 6% more body fat 1 year after TKA.120 On the and postural control strategies.
other hand, after total joint replacement, many patients have With regard to long-term rehabilitation goals, the patients
been shown to resume routine walking and recreational primary concern should be to maintain a pain-free func-
activities that improved maximum oxygen consumption 1 tional activity level for as long a period as possible. With a
year after the surgery.86 Nonimpact activities such as station- TKA, certain restrictions in activities are warranted. Gener-
ary bicycling, distance walking, and swimming are suggested ally those recreational activities and sports that involve high
for cardiovascular conditioning.85 repetitive compression or impact loading are not encouraged
Aquatic therapy programs have proven to be effective in because of the possibility of loosening or osteolysis of the
rehabilitation of total joint replacements.87-89 The buoyant joint implant.76,95,96 Joint forces at the TF interface are 1.5 to
and warm environment can provide pain relief, increase cir- 4.0 times body weight when walking,38 1.2 times body weight
culation, and decrease weight bearing for the patient. Many when cycling, and increase to 2.0 to 8.0 times body weight
can immediately start to work on ROM, strengthening, and when running.97 Patellofemoral joint forces also show com-
normalizing gait without the assistance of a walker. The parable increases. During walking, these are 0.5 times body
therapist can challenge the patient by progressing him or weight98 and with running they increase to 3.0 to 4.0 times
her from shoulder-deep water (approximately 24% weight body weight.99 Failures of TKAs may occur because of
bearing) to waist-deep water (50% weight bearing). mechanical loosening or wear of the implant. Therefore

Anticipated
Phase III No longer Limited ROM Initiate aquatic Normalize gait pattern and Decrease stress on the
Outpatient care homebound Limited therapy if available reduce reliance on assistive uninvolved leg with sit-stand
3-8 wk Safe and community with concurrent device transfers
independent with ambulation land-based treatment Increase ROM to 110-125 or Increase vastus medialis
ambulation using using assistive Continuation of ROM as indicated by comparison with oblique and vastus lateralis
assistive device device stretches and soft uninvolved knee in closed-chain exercises
Safe and Limited lower tissue procedures Single-leg half- squat to 65% Provide aerobic conditioning for
independent with extremity Progression of body weight weight control
care transfers strength (repetitions or Full weight bearing with Address hip weakness caused
Patients may weight) intensity single-leg stance by altered weight-bearing and
access outpatient with previous Improve balance, strength, compensatory postural
care if caregiver exercises endurance, and proprioception of strategies
or family Squats, leg press, lower extremity Improve tolerance to community
member is and bridging Reduce stress on the ambulation and prevent falls
assisting with Bicycling, walking, or compensatory muscle and joints Resume previous activities to
transfers and swimming for to prevent chronic imbalance restore quality of life
gait cardiovascular issues
conditioning 20 Aquatic (buoyant) environments
minutes three to five allow for increased ease of
times a week (as mobility and load-bearing stresses
indicated per general on joints
health issues) 0-110 or 125 of flexion
Hip external rotator required to use bicycle and stairs
exercises Improved extension and flexion
BAPs (foam roller) reduces compensatory gait
Return to previous patterns such as hip hiking
activities (see text)
BAPs, Balance and proprioception exercises; ROM, range of motion.
patients with joint replacement are encouraged to participate blood loss, deletion of patella eversion procedure, and reduc-
in those activities that maintain cardiovascular fitness while tion of pain, rehabilitation can occur on an accelerated time-
subjecting the implant to reduced impact-loading stresses. line. Shorter hospital stays; less overall use of analgesics; and
In the gym, using a treadmill (walking only), ski machine, more rapid return of ROM, strength, and function are the
stair-climbing machine, elliptical machine, or stationary benefits.100-102
bicycle is acceptable. Outdoor sports that are allowable In one observation, hospital length of stay was decreased
include golfing, hiking, cycling, cross-country skiing, swim- from 7 days to 2 to 3 days.89 Physical therapy can begin on
ming, fishing, hunting, scuba diving, sailing, and occasional postoperative day 1, with ROM, ADLs, and gait training. It
light doubles tennis.85 Baseball, basketball, football, martial has been shown that the average MIS-TKA patient regained
arts, parachuting, singles tennis, racquetball, running, soccer, 90 of flexion within 3.2 days after surgery.101
and volleyball are generally discouraged. Depending on the patients age, motivation, previous
function, and fitness level, gait and ADL training is pro-
gressed immediately. Early studies after MIS-TKA show that
REHABILITATION FOR MINIMALLY OR patients used crutches or walkers for 1 to 2 weeks, then
LESS INVASIVE SURGERY TOTAL advanced to a cane for 1 to 2 weeks thereafter. Many ambu-
KNEE ARTHROPLASTY lated without the use of an assistive device 4 weeks after
surgery. Most were independent with bed and bath transfers
Minimally invasive surgery is one of the most recent advance- and all other ADLs after 2 weeks. Many were climbing stairs
ments in primary TKA. Because of the smaller incision, at 1 month and descending stairs at 2 months. Driving is
quadriceps muscle and tendon sparing, less intraoperative allowed at 3 to 6 weeks.
As with traditional TKAs, light-impact activities such as Pulmonary Embolus

hiking, swimming, and cycling are permitted when comfort- PE is a potentially fatal, but rare, complication. PE can be
able. High-level activities such as running and singles tennis life threatening and requires prompt diagnostic testing and
remain unadvisable in the long term.100,103 treatment. Patients at risk for PE are those who may have
MIS-TKA outcomes show that a large percentage of proximal LE DVT. Proximal LE DVTs are located at or proxi-
patients were satisfied with the cosmetic benefit as well as mal to the trifurcation of the popliteal vein and considered
the quicker recovery and excellent early function. Patients the more dangerous form of LE DVT because the thrombi
achieved discharge goals 18% faster than those who had are larger than those associated with calf DVT and are more
traditional TKA. Good function and knee scores were likely to embolize.106
achieved after 3 to 4 months as compared with the usual Clinical signs of PE include tachycardia, distended cer
1-year result.100,101,103 vical veins, hypotension, and chest pain. Pulmonary
symptoms include tachypnea, rales, wheezing, and pleural
effusion.104 Sudden dyspnea is the most frequent symptom.
TROUBLESHOOTING Pleuritic pain is also common in patients with severe embo-
lization. If any of these signs or symptoms occur, then
Although the treatment guidelines given here provide a the PT should immediately notify the nursing staff and
framework for postoperative rehabilitation of TKA, they physician.
should not be used as strict protocols. In fact, modifications
are expected because each patient has individual needs, Deep Venous Thrombosis
abilities, and goals. Continual reassessment of the Because of decreasing lengths of hospitalization, patients are
patients status and subsequent alterations in the treatment seen in outpatient settings with elevated risks of DVT. Sig-
plan are necessary to achieve optimal results. The therapist nificant signs and symptoms of DVT include complaints of
must have the necessary abilities and skills to anticipate pain and swelling in the involved extremity, calf tenderness,
any potential complications and implement appropriate and a positive Homans sign. Specifically, the patient may
changes in the treatment plan. The following section report a dull ache, tight feeling, or frank pain in the calf or
describes additional procedures and modalities that can entire leg. The signs and symptoms include slight swelling in
be used to refine the therapy to meet the patients individual the involved calf; distention of the superficial venous col-
needs. laterals; tenderness, induration, or spasm of the calf muscles,
with or without pain, produced by dorsiflexion of the foot
Medical Complications (Homans sign); warmth of the affected leg when both legs
During the initial stage of postoperative care, the most are exposed to room temperature; and a slight fever or tachy-
serious complications are wound infection, PE, DVT, persis- cardia.92 However, DVTs are also often asymptomatic. When
tent joint effusion, and lymphedema. As previously stated, signs and symptoms of possible DVT develop, further ROM
the therapist must know all symptoms and signs that may exercises should be restricted until definitive diagnostic
indicate any of these medical problems. Any of these com- testing is performed.
plications can severely deter rehabilitation progress in Additionally, improved assessment of risk for DVT can
terms of time frame and overall prognosis. be obtained by the use of a clinical decision rule (CDR). A
series of studies found that patients could be categorized into
Wound Infection low-, moderate-, and high-risk groups based on their CDR
Systemic signs of a potential wound infection include scores. The use of the CDR may aid in improving the accu-
patient complaints of fever or chills. Knee pain can be racy of probability estimates of DVT and subsequent referral
severe and not relieved with rest. Knee flexion can increase decisions.106
skin tension. If skin necrosis develops, then ROM exercises
should be limited until adequate soft tissue healing has Persistent Joint Effusion
occurred. Other symptoms of infection include increased A patient sometimes complains of postoperative stiffness,
warmth and erythema about the surgical site and wound pain, and swelling. The patient should be reassured that this
drainage.104 Wound dressings should be checked and changed usually decreases within the first few weeks after surgery.
daily until the staples are removed.72 Although uncommon Persistent joint effusion can forestall the rehabilitation
(less than 1%), infection remains a serious problem, usually process. Knee ROM exercises can be continued if an effusion
requiring additional surgery and intravenous antibiotic is present, but the effusion may limit motion and should be
therapy. treated with ice before and after exercise. Soft tissue mobili-
Methods to reduce the risk of infection include proper zation is an effective procedure that can enhance muscle
preoperative skin preparation; prophylactic antibiotics and recovery and reduce soreness after intense physical activ-
local antibiotics in cement, particularly for immune- ity.107,108 Increasing blood flow may increase oxygen delivery
compromised patients (e.g., rheumatoid arthritis, diabetes to the injured tissue, enhance healing, and restore homeo-
mellitus, human immunodeficiency virus, cancer); and min- stasis.109 If edema, swelling, and inflammation are significant
imizing the length of surgery and tissue trauma.105 factors in muscle soreness sensation,110,111 then massage may
be able to reduce soreness in the involved muscles. Persistent displays an inability to walk or stand on the heel because of
effusion may be aspirated, not only to relieve pressure and the weakness of the ankle dorsiflexors. Additionally, instabil-
stiffness but also to rule out an indolent infection. ity when attempting toe walking results from the muscle
imbalance and associated sensory abnormalities at the ankle
Lymphedema and Total Knee Arthroplasty joint. The muscles affected are those in the anterior and
Lymphedema is abnormal swelling caused by the presence lateral compartments of the leg.
of excess lymphatic fluid within the tissues. This swelling When the superficial peroneal nerve is compressed, a
occurs when the lymphatic system malfunctions or is decrease in sensation is noted over the dorsum of the foot,
damaged from a decrease in developmental transport capac- with the exception of the first web space. The involvement of
ity of the lymph vessels, trauma, surgery, radiation, or infec- the deep peroneal nerve produces a diminution of sensation
tion. Although lymphedema is a minor complication, in the first web space of the foot and affects the muscles of
persistent swelling can occur.112 the anterior compartment, including the extensor hallucis
Lymphedema that is present before surgery should be brevis and the extensor digitorum brevis.
minimized with use of support stockings and, if necessary, Complete common peroneal nerve palsy results in a
diuretic medications. If lymphedema develops after surgery, severely affected gait pattern. Without an ankle-foot ortho-
rehabilitation can be continued, but compressive stockings sis, the patient suffers from a foot drop with associated step-
should be used to limit the amount of swelling. Because page gait in profoundly affected cases or foot slapping in
abundant lymph vessels are found at the medial aspect of the milder ones. The ankle is unstable and vulnerable to ankle
knee, trauma to this area or surgery can lead to lymphedema. inversion sprains. The functional result of partial peroneal
Lymph flow swelling in this area of bottleneck occurs as a nerve palsy depends on which nerve components are the
result of tissue trauma in this area. A patient who has venous most affected. Loss of the peroneal muscles in the lateral
insufficiency and undergoes TKA also has an increased risk compartment results in a chronically inverted foot, with
of developing lymphedema after surgery.112,113 weight bearing occurring more laterally than normal and
In treating lymphedema, therapy consists of manual invariably affecting the position and stability of the foot and
lymph drainage, special compressive bandaging, exercise, ankle throughout the stance phase of the gait cycle. Loss of
and skin care. With proper treatment, edema can be reduced the anterior compartment muscles, especially the tibialis
by as much as 60% and in some cases up to 74%. Once the anterior, affects the entire gait cycle. The loss of the dorsal
limb is reduced, the patient graduates from the compressive intrinsic muscles of the foot has a relatively minor effect on
bandages to a proper compression class stocking. Antiembo- basic weight-bearing functions.
lism stockings, such as TED hose stockings114 (12 to Physical therapy interventions for nerve entrapment
20mmHg), are worn postsurgery as DVT prophylaxis from include examination of the joint mechanics of the proximal
bed rest, mild edema, or mild varicosities. Class I (20 to and distal tibiofibular joints and determination of the spe-
30mmHg) are used for mild lymphedema, mild venous cific muscle weakness and sensory loss. Manual techniques
insufficiency, moderate varicose veins, or DVT prevention in include joint mobilization as appropriate, facilitation of the
individuals with clotting disorders. Higher grades of class recruitment of the affected muscles, and dural nerve root
II to IV (30 to 50mmHg) are available for individuals stretches for the sciatic and peroneal nerves.
with moderate to severe lymphedema or cardiovascular
insufficiency or for prevention of DVT in postthrombotic Muscle Imbalance
syndrome.113,115 A detailed evaluation of the entire lower kinetic chain is
necessary for the successful treatment of patients with TKA.
Functional Complications Altered gait, faulty mechanics, and muscle imbalances have
Peroneal Nerve Neuropraxia more than likely existed before the TKA. These factors con-
Peroneal nerve neuropraxia may arise more frequently in tribute greatly to the eventual surgical outcome. Most of the
patients with (1) flexion contractures associated with valgus present understanding regarding muscle imbalances and
deformity, (2) those who had epidural anesthesia for post neuromotor retraining comes from the work of Janda,118,119
operative control of pain or previous laminectomy, and (3) Lewit,120 and Sahrmann.82 Muscle imbalance is a multifacto-
those who had a previous proximal tibial osteotomy.116 rial problem and can be highly complex. In simplistic terms,
In peroneal nerve neuropraxia, the common peroneal the result of muscle imbalance is that the tight muscles
nerve and its branches are tethered at the fibular neck. Clini- become tighter, weak muscles become weaker, and motor
cal findings of nerve entrapment or injury include local ten- control becomes asymmetric.121
derness around the fibular neck with pain, diminished According to Janda,118,119 muscle balance is continually
sensation, or paresthesia radiating over the lateral surface of adapting the bodys posture to gravity. When an injury
the lower leg and the dorsum of the foot.11,117 Nerve conduc- occurs, faulty posture and weight bearing alter the bodys
tion velocity testing and electromyographic studies will be center of gravity, which initiates mechanical responses
positive for neuropathic dysfunction in the motor distribu- requiring muscle adaptation. Change in the mechanical
tion of the common peroneal nerve distal to the injury or behavior of a joint causes neuroreflexive alteration of
entrapment site at the fibular neck. Clinically, the patient muscle function through aberrant afferent mechanoreceptor
stimulation of articular reflexes.122 Postural-tonic muscles recruitment of the quadriceps. In cases of patella instability,
respond to dysfunction with facilitation, hypertonicity, and quadriceps strength should be restored as soon as possible.
shortening. Dynamic-phasic muscles respond with inhibi- Soft tissue work, friction massage, and assisted stretches to
tion, hypotonicity, and weakness. In the lower quadrant, the iliotibial band may be beneficial.
Janda118,119 identified a common pattern of muscle imbal- Faulty joint mechanics at the hip, knee, and ankle affect
ance. Hyperactive muscles include the iliopsoas, rectus the overall surgical result. A study by Dorman and associ-
femoris, tensor fascia latae, quadratus lumborum, the thigh ates123 found that inhibition or facilitation of the gluteus
adductors, piriformis, hamstrings, and the lumbar erector medius is influenced by the position of the sacroiliac joint.
spinae musculature. Muscles that display inhibition or reflex- An anterior rotation (an apparent long leg) manifested a
ive weakness include the gluteus maximus, medius, and significantly weaker muscle than one in posterior rotation
minimus; quadriceps (vasti); rectus abdominis; and external (an apparent short leg). Exercises that address gluteus
and internal obliques. Sahrmann,82 Dorman and associ- medius weakness include hip abduction and lateral hip rota-
ates,123 and Bullock-Saxton, Janda, and Bullock,79 similarly tion (Fig. 27-22).
identified weakness in the entire LE in the presence of knee Altered ankle movements and instability disturb the
dysfunction. overall sense of balance and influence gait safety accordingly.
Quadriceps weakness, especially in the early stages of Joint mobilization techniques to correct associated dysfunc-
TKA rehabilitation, must be addressed. Failure to adequately tions in the joints of the LE can be helpful. A stiff knee can
address the chronic muscle impairments has the potential to be helped with contraction and relaxation techniques to the
limit the long-term functional gains that may be possible muscles that may be guarding or fatigued.73,87
following TKA. Postoperative rehabilitation addressing
quadriceps strength should mitigate these impairments Kneeling
and ultimately result in improved functional outcomes.124 Kneeling is an important functional activity frequently not
These impairments with significant worsening of knee ROM, performed after knee replacement, thus affecting a patients
quadriceps strength, and performance on functional tests ability to carry out basic daily tasks. Kneeling ability before
occurred 1 month after surgery. Quadriceps strength went surgery was poor in osteoarthritic patients but improves with
through the greatest decline of all the physical measures knee arthroplasty surgery.126 Despite no clinical reason pre-
assessed and never matched the strength of the uninvolved venting kneeling, many patients fail to resume this activity.
limb. The high correlation between quadriceps strength and Patients avoided kneeling because of uncertainties or recom-
functional performance suggests that improved postopera- mendations from third parties (doctors, nursing staff, or
tive quadriceps strengthening could be important to enhance friends). Inability to kneel may also be caused by scar posi-
the potential benefits of TKA.125 A knee immobilizer may be tion, skin hypoaesthesia, restricted range of flexion, involve-
needed for ambulation in the hospital setting if quadriceps ment of other joints, or pain. The solution to this problem is
strength is not great enough to stabilize the knee. Biofeed- to incorporate kneeling activity with PT intervention at 6
back or NMES can be beneficial in jump starting the weeks after surgery because there was significant
B
Fig. 27-22 Hip lateral rotation. A, Start position. The patient lies on the uninvolved side with the shoulders and hips perpendicular to the table and the knees
flexed to 45. B, End position. The patient then lifts the top knee toward the ceiling, keeping the feet in contact. The patient should emphasize movement from
the hip and not allow the pelvis to roll backward.
improvement in patient reported kneeling 1 year after surgery reduction and functional improvement was made in the first
in patients who received kneeling intervention.125,127 3 months after TKA, with little change after 12 months.133,134
Walsh and associates83 also showed that at 1 year after TKA,
OUTCOMES little pain was noted during activities of walking, stair climb-
ing, and concentric muscle testing. However, after implanta-
TKA is a method to improve quality of life. This is accom- tion of a total knee prosthesis, it only partly improved
plished primarily through pain relief, resulting in increased performance from sit to stand movement. After TKA,
functional mobility. Results are generally reported using the patients were able to fully load their operated leg, but they
Hospital for Special Surgery128 or the Knee Society129 rating could not generate enough knee angular velocity during
systems. Haas patients24 from the Hospital for Special rising.135 Additionally, the minimum 96 of hip and knee
Surgery who had MIS showed favorable outcomes (Table flexion is required at initial sit to stand movement. Without
27-5) compared with the traditional TKA. They were able to effective hip and knee joint extension post lift off from the
do an SLR on postoperative day 1, walk without a cane on chair, people were not able to do this task.136 Sled and associ-
postoperative day 8, alternate stair climbing by week 6, and ates found in their study that following implementation of
perform full knee ROM by week 8. an 8-week home strengthening program for the hip abductor
It should be noted that despite extensive rehabilitation muscles, participants with knee OA had a decrease in knee
efforts, various studies have shown outcomes of diminished pain and demonstrated a significant improvement in hip
functional capacity. Self-report measures of perceived abili- abductor strength and improved function in sit to stand.137
ties indicate that at 1 year after TKA, most individuals have Other functional deficits, including slower walking speeds
regained 80% of normal function. However, stiffness and for both males and females, were reported (62% and 25%
pain occasionally still remained a problem.93,130,131 Lingards decrease at normal pace and 31% and 6% decrease at fast
study39,132 showed that the most improvement in pain pace, respectively). Clinical relevance points to the fact that
17% of these individuals were not able to cross safely at a
typical city intersection. Other recent studies have shown
TABLE 27-5 Functional OutcomesMinimally slower sit-to-stand and up-and-go tests,138 quadriceps weak-
Invasive Surgery Compared with Traditional ness,46,47 and smaller girth circumference47 for individuals at
Total Knee Arthroplasty greater than 1 year after surgery. Lastly, the first study that
demonstrated patients with TKA had impaired balance and
Minimally Invasive Traditional Total Knee
movement control because of lack of exercise interventions
Functional Measure Surgery Arthroplasty
for this problem was done by Piva and associates. In this
SLR Postoperative day 1 Unable to do SLR study, exercise programs that target balance and movement
Walk without a cane Postoperative day 8 Days 6-14 with control improved functional performance, stiffness, and pain
Knee flexion at 3 122 flexion assistive device in patients after TKA.139
months after surgery With these studies in mind, the development and imple-
Knee flexion at 1 125 flexion 110 flexion mentation of a well-designed, comprehensive treatment plan
year after surgery 116 flexion is paramount. Addressing the entire lower quadrant with
an appropriate exercise program will enhance the course of
SLR, Straight leg raises. rehabilitation and ensure a more successful outcome.
1 John is 69 years old. He had a left TKR 8 days ago. He

is now semireclined in his hospital bed. When the thera-
pist helps him out of bed during transfer, John com-
Cardiovascular signs may include tachycardia, distended
jugular veins, hypotension, and chest pain. Pulmonary
symptoms include tachypnea, rales, wheezing, and
plains of feeling light-headed. He usually requires a few pleural effusion. Sudden dyspnea is the most common
moments for his head to clear, but today he needs a little symptom.
more time to adjust. Gait training is initiated, and sud-
denly John has difficulty breathing. What do these
symptoms indicate?
Rapid heart rate, hypotension, and dyspnea are signs

2 Randy is 52 and had a TKA 2 weeks ago. He presented
for his initial evaluation with 30 extension and 75
flexion. What should be considered and addressed
of a possible PEa potentially fatal complication. during his initial evaluation?
Prior functional level and preoperative ROM treatments to manage pain and maintain and improve
Prior response to surgery and potential to develop the gains in ROM made from the MUA.
adhesions
General health status (e.g., diabetes, PVD, CHF).
Current state of incision (infection potential) and
edema (girth measurements)
6 Gemma is 55 years old. She had severe degenerative
joint disease in her right knee and underwent a TKR 8
weeks ago. She says the pain around the knee has con-
Discussion with his home health PT will also give siderably decreased. However, she complains of pain
you an indication of his current response to treatment around the area of the fibular neck. The area also is
thus far. sensitive to palpation. Gemma has intermittent pain
All of the above are important to consider when evalu- radiating down the lateral surface of the lower leg. What
ating and making a treatment plan. is the probable cause of these symptoms?
3 What exercises should be emphasized with Randy?
Passive stretches (prone and supine hangs) should be

The peroneal nerve travels around the fibular neck. The
symptoms described indicate peroneal nerve irritation.
On further investigation, the PT noted altered sensation
performed regularly and, as appropriate and pain allows, over the dorsum of the foot, with the exception of the
weight should be added to the ankle and knee to provide first web space. In addition, right dorsiflexion and ever-
increased compliance into extension. Passive flexion sion strength both equaled 4/5 to 5/5 (5/5 is normal
stretches should include supine heel slides with a towel strength on a manual muscle test [MMT]). Normal
or strap to allow the patient to provide overpressure as strength was demonstrated throughout the left LE. Dural
able. Also supine wall slides (with weight as appropri- nerve root stretches for the sciatic and peroneal nerve
ate). Duration of stretches should be progressed as able were initiated. After the first treatment using nerve tissue
taking into account the response of the knee to stretches mobilization to target these nerves, strength returned to
(minimalno increase in residual pain, edema, or normal for dorsiflexion and eversion. After three treat-
weight-bearing tolerance). ments using dural mobilization, the pain was decreased
by 90% and the sensation tested normal.
4 Sharon is a 60-year-old patient who had TKA 4 weeks

ago. She complains that her operative leg is shorter than
the other leg. No preoperative leg length difference was 7 Ginny is 12 weeks postoperation, and while she demon-
strates excellent ROM, she complains of medial knee
noted, and the physician noted that there were no pain with single-leg squat (SLS) exercises. What can be
relative changes made that would account for decreased done to address this issue?
leg length. What possible explanation could there be
for this? Up to this point in her rehabilitation she had not com-
plained of any pain until SLS resistance increased. In
Upon further evaluation it was found that the patient had observing her technique with SLS, it was noted that she
a posteriorly rotated ilium, creating an apparent leg began to allow her hip to internally rotate, causing a
length difference. Faulty joint mechanics at the hip, knee, valgus collapse at the knee. With reinstruction in
and ankle affect the overall surgical result. Manual tech- technique and hip abduction/external rotation strength-
niques and exercises were used to address the posterior ening, her symptoms subsided. It is important that
rotation. Exercises that address gluteus medius weak- strengthening exercises continue to progress inclusive
ness include hip abduction and lateral hip rotation (see of the entire LE.140
Fig. 27-22).
5 Noreen is a 55-year-old patient who had TKR 7 weeks

ago. Her pain levels have prevented ROM gains beyond
8 Nancy is 3 months postop and continues to complain of
knee pain that has not improved and limits her weight
bearing tolerance. What should be considered as a
8 to 95. Her preoperative ROM was 5 to 120. Her potential explanation of her symptoms?
ROM in the last week has plateaued and may have even
decreased. What should the therapists next course of Chronic knee pain is unfortunately a side effect for some
care be? patients. Differential diagnosis of continuing extra articu-
lar knee pain should consider:
A phone call to the orthopedist is warranted to explore Neurologic (lumbar origin, neuroma, complex regional
if she is appropriate for an MUA. After consultation with pain syndrome)
the physician, an MUA was scheduled and performed. Vascular claudication
The patient returned to therapy and gained full extension Musculoskeletal (Hip arthritis, tendinitis, bursitis,
and 125 of flexion. The patients post-MUA physical stress fracture, and periprosthetic fracture)141
therapy should also include taking medication before her
25. Laskin RS, et al: Minimally invasive total knee replacement through a
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CHAPTER 28
Lateral Ligament Repair of the Ankle
Robert Donatelli, Will Hall, Brian E. Prell, Graham Linck, Richard D. Ferkel
T
he ankle requires both static and dynamic stability. than that of the ATF ligament.15 The PTF ligament is the
Mobility is crucial for normal ankle function in the strongest of all the ligaments and is rarely injured with inver-
midst of rapidly changing postures of the foot during sion sprains or associated with chronic ankle instability.14
sporting and everyday weight-bearing activities. Lateral liga- The unstable ankle is generally caused by a traumatic event
ment injuries of the ankle account for 13% to 56% of all such as an ankle sprain. It also can be associated with ankle
injuries in sports requiring running or jumping such as fractures but virtually never develops insidiously.
soccer, basketball, and volleyball.1,2 Ankle sprains also com-
promise 10% of the emergency room visits in the United SURGICAL INDICATIONS AND
States, with an incidence of 30,000 injuries per day.3 The large CONSIDERATIONS
majority of these injuries can be successfully treated conser-
vatively with casting, bracing, nonsteroidal antiinflamma- A lateral ankle reconstruction is an elective surgery used to
tory drugs, and physical therapy. Approximately 85% of all treat chronic instability that results from a continuum of
ankle sprains involve the lateral structures of the ankle.4,5 The ankle injuries. Ankle injuries can result in permanent damage
majority of ankle sprains heal without any residual func- to the ligaments that support the lateral ankle. Various
tional instability.4 Despite adequate trials of conservative studies have examined the benefits of surgical versus func-
measures, however, approximately 10% to 30% of all acute tional treatment in lateral ligament injuries of the ankle.
ligamentous injuries have recurrent symptoms of chronic These studies have shown that operative repair was associ-
pain, swelling, and instability with activities.4,6-9 Functional ated with patients delayed return to work, restricted range
instability of the ankle is reported to be as high as 20% after of motion (ROM), impaired ankle mobility, and increased
ankle sprains.10,11 Ligamentous instability has been thought complications after surgery, including undefined pain.16-19
to be related to the loss of mechanoreceptors12 and can lead This is in contrast to conservative treatment, which includes
to the development of ankle joint degenerative changes.13 functional bracing and early mobilization. Kannus and Ren-
When conservative measures fail to produce satisfactory strom reviewed 12 prospective studies and found that func-
proprioceptive performance and mechanical stability, surgi- tionally or conservatively managed patients with grade III
cal repair or reconstruction of the injured lateral ligament ankle sprains returned to work two to four times faster than
structures should be considered. those patients who underwent acute repair of the damaged
ligaments.20 Therefore, the surgical option is used when non-
ANATOMY AND MECHANISM OF INJURY operative treatments have failed, such as physical therapy,
bracing, activity modification, and steroid injections. Post-
The etiology of the unstable ankle is usually a forced plantar operative physical therapy is a vital link in returning the
flexion inversion injury in which the bodys center of gravity patient to an active lifestyle.
rolls over the ankle. This type of force results in injury to the Indications for reconstruction of the ankles lateral
anterior talofibular (ATF) ligament; and possibly the calca- ligaments include recurrent giving way with activities of
neofibular (CF) ligament, the anterior inferior tibiofibular daily living (ADLs) and sports that is refractory to conserva-
ligament, or the posterior talofibular (PTF) ligament.3 The tive treatment, a positive physical examination, abnormal
ATF ligament is the weakest of the lateral ligaments and inversion, and/or positive anterior drawer stress x-rays
blends with the ankle joint capsule. The CF ligament is the (Fig. 28-1).
only extraarticular ligament among the complex and is larger Patients of all ages and types are candidates for this type
and stronger than the ATF ligament14; it has been found able of surgery, but few patients older than 50 years undergo
to withstand forces two to three-and-a-half times greater ankle reconstruction because of decreased activity levels and
504
Chapter 28 Lateral Ligament Repair of the Ankle 505
anterior drawer) are taken. The thigh is then secured on a

well-padded thigh holder in preparation for ankle arthros-
copy, as described in Chapter 30. The lower extremity is
prepared and draped in standard fashion. Arthroscopy is
performed first; the authors of this chapter have found that
93% of patients have additional intraarticular ankle pathol-
ogy associated with lateral ankle instability in one study.5
More recently, in another study, we found 95% of patients
had associated intraarticular problems noted at arthroscopy
before the Brostrm procedure.25 In addition, a similar
report by Taga showed 95% of patients have additional
intraarticular pathology at the time of ankle reconstruc-
tion.26 Hua and associates27 found 91% of patients to have
intraarticular lesions at the time of the modified Brostrm
reconstruction.
The intraarticular pathology is identified and addressed
through arthroscopic surgery. The scarred anterior talofibu-
lar (ATF) ligament is identified and assessed to make sure it
is adequate for the modified Brostrm repair. After the
A B arthroscopy is completed, the nurse removes the thigh
Fig. 28-1 Inversion stress testing on the Telos device. The right ankle (A)
support and places the leg flat on the surgical table. The ankle
demonstrates increased talar tilt compared with the left ankle (B). is reswabbed with a sterile antibacterial solution. An addi-
tional clean surgical drape is placed over the foot and ankle,
and gloves are changed. New sterile instruments are used to
an increased ability to adjust functions and lifestyle to avoid perform the open portion of the procedure. Arthroscopic
recurrent buckling episodes. Surgeons should take care when methods are now available for surgical reconstruction of the
considering this procedure for patients with generalized liga- lateral ankle ligaments, but at this time open stabilization as
mentous laxity and collagen disorders that may result in described by Brostrm gives a better, more reproducible
failure. In addition, advanced degenerative joint disease or result. Recently, Corte-Real and Moreira,11 Lui,28 Nery and
arthrofibrosis may be relative contraindications to this associates29 reported on their arthroscopic method for
surgery. chronic lateral ankle instability. The results had a high per-
centage of good-excellent results, but long-term studies are
SURGICAL PROCEDURES necessary to compare the arthroscopic with the open proce-
dures before a recommendation can be made for switching
More than 50 different surgical procedures for correction of to all-arthroscopic techniques.
lateral ankle instability have been described.21 The majority After arthroscopy the ankle is prepared and the tourni-
of reconstructive procedures use part, or all, of the peroneal quet inflated. An incision is made over the lateral aspect of
brevis tendon. Common procedures include the Watson- the ankle. This incision may be obliquely shaped in the skin
Jones, Evans, Chrisman-Snook, and Elmslie procedures and folds or more vertical from the fibula toward the sinus tarsi,
their modifications. Anatomic repair with direct suturing depending on the surgeons preference and the clinical situ-
of the torn ligaments, imprecation, reinsertion to the bone, ation. The senior author prefers the vertical incision because
and in some instances augmentation with local tissue have it allows better assessment of the peroneal tendons and can
increased recently in popularity.10,22,23 Direct repair of the be extended distally and proximally if other procedures need
ATF and CF ligaments was described by Brostrm in 1966 to be done. Dissection is carried down through the subcuta-
and later modified by Gould in 1980.22,24 Direct repair of torn neous tissues and the extensor retinaculum is carefully
lateral ligaments has the advantage of being simple and reli- exposed because it is to be used for later reattachment. The
able, avoiding the use of normal tendons. It restores the surgeon must take care to avoid the intermediate dorsal cuta-
original anatomy, requires less exposure, and maintains full neous nerve, the lateral branch of the superficial peroneal
ankle motion. nerve (which often lies near the end of the ATF ligament),
and the sural nerve (which lies over the peroneal tendons).
ProcedureModified Brostrm An oblique capsular incision is then made along the anterior
The modified Brostrm procedure, also termed the Brostrm- border of the fibula from the AITF ligament to the CF liga-
Gould procedure, is the method of choice for most patients ment, leaving a small 3- or 4-mm cuff of tissue on the fibula
with lateral ankle instability. The patient is taken to the oper- for reattachment of the torn ligament complex (Fig. 28-2).
ating room and examined under anesthesia. If the surgeon The stretched ATF ligament is found as a thickening in the
has any questions about the degree of ankle instability, stress anterior capsule, and the CF ligament is found in the distal
x-ray films (stressing the ankle in both inversion and portion of the wound under the tip of the fibula, running
Anterior inferior
tibiofibular lig.
Anterior
talofibular lig.
Capsular Extensor
incision retinaculum
Calcaneofibular
Sural n. lig.
Peroneal Intermediate
tendons dorsal cutaneou n.
Skin
incision B
A C
Fig. 28-2 Modified Brostrm reconstruction. A, An oblique incision is made over the fibula, in line with the ATFL and the extensor retinaculum and lateral
ligaments are exposed. B, An oblique capsular incision is made along the anterior border of the fibula from the AITF ligament to the CF ligament, leaving a
small 3- to 4-mm cuff of tissue on the fibula for reattachment of the ligament complex. C, Operative picture demonstrating opening the capsule with an oblique
incision. (A and B copyright Richard D. Ferkel, MD.)
sutured to the fibular periosteum. ROM is again checked, as

is the stability of the ankle. The tourniquet is released, and
Anterior bleeding tissues are coagulated. The subcutaneous tissue and
talofibular
lig. skin are then closed in the standard fashion. The patient is
placed in a short-leg well-padded cast that is split in the
Calcaneofibular
lig.
recovery room to allow for swelling.
The patients cast is changed at 1 and 2 weeks and the
A stitches are removed. Weight bearing is started at week 3 in
a cast or cast boot, at the surgeons discretion. Physical
therapy with mobilization starts usually at week 6 or some-
times sooner.
ProcedureAnatomic Hamstring
Reconstruction
Indications for an anatomic hamstring reconstruction
B C include a high-stress, heavy athlete, generalized ligamentous
Fig. 28-3 Modified Brostrm procedure. A, The ATF and CF ligaments
laxity, deficient ATF ligament tissue for direct repair, talar
are reefed in a pants-over-vest fashion with nonabsorbable suture. B and tilt greater than 10o more than the opposite ankle, and a
C, Operative pictures showing the sutures in place before being tied. In C, varus hindfoot. The incision used is the same as shown in
the sutures are pulled proximally and a posterior drawer is applied on the Fig. 28-2, A. The lateral ligaments are released in the same
ankle while the sutures are tied. (A copyright Richard D. Ferkel, MD.) oblique fashion for later reattachment over the hamstring
repair. An autogenous or allograft semitendinosus graft is
deep to the peroneal tendons. The CF ligament often is atten- prepared with nonabsorbable sutures at both ends. A guide-
uated or avulsed from the fibular tip. pin is inserted into the fibula to create two converging bony
A pants-over-vest overlapping suture technique is used tunnels, beginning from insertion of the ATF ligament on
to imprecate or shorten the torn ligaments and provide a the fibula, as well as the insertion of the CF ligament on the
double layer of reinforcement to the repair. Suturing is done fibula. These tunnels are connected using a curved curette.
starting from the ligament portion attached to the talus, so Alternatively, as option B, the holes can be drilled out the
that the knots are tied distal and inferior to the fibula (Fig. posterior fibula to increase the bone bridge between the
28-3). This helps prevent postoperative knot prominence anterior talofibular ligament (ATFL) arm and the calcaneo-
and skin irritation with shoe wear. O nonabsorbable fibular ligament (CFL) arm. A reamer is then placed over the
sutures are used in the majority of the repair, but one absorb- guidepin to create 5-mm tunnels. A guidepin is then inserted
able suture is used for the CF ligament near the peroneal along the talar neck at the nonarticular portion and reamed
tendon, to avoid irritation. The sutures are tied with the to a predetermined size based on the diameter of the graft
ankle in neutral position, and a posterior drawer is applied (Figs. 28-4 and 28-5). A passing device is placed from pos-
to reduce the talus. The ankle is checked to make sure full terior to anterior through the fibula to facilitate graft passage
ROM has been maintained during the repair. The extensor (Fig. 28-6). The graft is then fixated on the talus with a
retinaculum is then pulled proximal over the repair and special interference screw that helps push the tendon into
Fig. 28-6 The passing device is placed from posterior to anterior through
the fibula to help make graft passage easier.
Fig. 28-4 The location of the tunnels on the talus and fibula are drawn in
and the guidepin is inserted, aiming posteromedially on the talus.
Fig. 28-7 The graft is fixated initially on the talus using an interference
screw that helps push the graft into the talar tunnel.
A
Fig. 28-5 Creating the tunnels. A, The tunnels created in a semicircular
fashion in the fibula and the location and direction of the drill for the talar
hole. B, An alternative placement of the drill holes coming out the posterior
fibula.
the bone socket (Fig. 28-7). Alternatively, in option B, the

graft can be passed from anterior to posterior and the ATF
arm can be separately tensioned and fixed with an interfer-
ence screw before tensioning the CFL arm (Fig. 28-8). This
is usually done in slight plantar flexion because this is when
the ATF ligament is the tightest. The tensioning on the CFL
arm is done in slight dorsiflexion, and the tendon is passed
underneath the peroneal tendons to exit into a drill hole
made through the calcaneus. The CFL arm is cut so that
20mm of the tendon will be in the calcaneus when it is
secured with an interference screw (Fig. 28-9). This is done
with the ankle in neutral position by bringing the sutures out
through a poke hole on the medial heel and pulling tension Fig. 28-8 Option B involves a fibular hole exiting the posterior fibula in a
on the sutures while the screw is inserted in the calcaneus V fashion. This allows separate tensioning of each limb.
Fig. 28-9 The CFL is cut to the appropriate length so that at least 20 mm
of tendon will end up in the calcaneus. A
Fig. 28-11 Completed construct. A, The graft is fixated in the talus and
calcaneus with a semicircular hole. B, A similar technique using the
V-wedged holes.
procedures in 40 cadaveric ankles. They found no significant

difference between the Watson-Jones and Chrisman-Snook
procedures, but the modified Brostrm procedure produced
the least anteroposterior displacement and talar tilt at all
different forces tested.
Hennrikus31 prospectively compared the Chrisman-
Snook and modified Brostrm procedures in 40 patients.
Although both produced 80% good-to-excellent results, the
former procedure had a much greater proportion of compli-
cations and the latter procedure had a higher functional
score. Hamilton et al34 performed the modified Brostrm
procedure on 28 ankles; 54% of the patients were high-level
ballet dancers. At 64 months follow-up, he noted 27 of 28
Fig. 28-10 The calcaneal hole is partially drilled, the guidepin creates a good-to-excellent results. Peters33 reviewed the literature and
hole for the suture to exit medially. With the foot in appropriate position,
found 460 ankles treated with anatomic modified Brostrm
tension is applied on the medial sutures through the calcaneus and an
interference screw is inserted. repairs had an average of between 87% and 95% good-to-
excellent results.
Ferkel and Chams25 reviewed the results of 21 patients
(while pulling the graft into the tunnel) (Fig. 28-10). The who underwent the modified Brostrm procedure. The
final constructs gives anatomic reconstruction of the ATFL average patient age was 27.5 years and the average follow-up
and CFL (Fig. 28-11). A modified Brostrm repair is then occurred at 57 months. They found 95% good-to-excellent
done over the hamstring reconstruction. results with an American Orthopaedic Foot and Ankle Soci-
The patient is then placed in a cast which is split in the etys (AOFAS) ankle/hindfoot score of 97.1. When the ATF
recovery room. The cast is changed at 1 and 2 weeks, and the ligament is not adequate to use for a Brostrm repair, we use
stitches removed. Weight bearing is started at week 3 in a either an autogenous or allograft hamstring graft with biote-
cast or a cast-boot at the surgeons discretion. Physical nodesis screws through the talus and calcaneus to recon-
therapy usually starts in the pool at week 6 or 8, depending struct the ATFL and CFL.34-36
on what else is done at surgery. Alternatively, the Brostrm-Evans procedure can be used
in patients with the same indications as the hamstring recon-
SURGICAL OUTCOMES struction. In this procedure, the peroneal brevis is split using
one third of it through a drill hole in the tip of the fibula,
A lateral ankle reconstruction is considered to be successful exiting the posterior fibula. The peroneal tendon is then
when the patient has full ROM and a pain-free ankle and can secured with an interference screw and the Brostrm is
return to all ADLs and sports without restriction. Liu and placed over it. Results with the Brostrm-Evans procedure
Baker30 studied the static restraints of various surgical have also been good.22
passive range of motion (PROM). PROM is measured within

CHALLENGES a pain-free range, especially while measuring forefoot
inversion.
Despite having a stable ankle postoperatively, some patients The physical therapist has a responsibility to the
still complain of pain, aching, swelling, and crepitation.26 surgeon and the patient to protect the lateral ligamentous
Many of these complaints may be related to preexisting reconstruction. Forefoot inversion stresses the recon-
intraarticular pathology such as degenerative joint disease, structed tissues and must be carefully engaged. Manual
osteochondral lesions of the talus, loose bodies, chronic syno- muscle testing to determine strength of the lower extremity
vitis, and chronic scarring. Occasionally the ankle can be can be part of the initial evaluation. However, muscle testing
made too tight at the time of reconstruction; this severely at the ankle is delayed until the patient has progressed and
limits the patients ability to invert. This is the single most accommodated to resisted exercises at the ankle. The thera-
serious complication after ankle reconstruction. If a patient pist should avoid having the patient perform a singleleg
does not have full motion after surgery, especially full inver- heel raise, which is usually advocated to determine normal
sion and eversion, rehabilitation is significantly compromised gastrocnemius-soleus strength, because of decreased pro-
and the patient tends to develop a painful valgus hindfoot. prioception and the significant muscle deficits resulting
from the effects of immobilization. The incision is assessed
PRECAUTIONS AND CONTRAINDICATIONS for mobility and hypersensitivity after complete healing has
occurred. Operative damage to the sural nerve and the lateral
The physical therapist should increase the level of rehabilita- branch of the superficial peroneal nerve has been reported
tion gradually for the patient after surgery. Too-vigorous as a cause of decreased sensation in the involved ankle.10,37
exercise and the use of isokinetic machines can lead to Joint effusion and soft tissue edema can be factors in limited
increased pain, shear stress, and swelling that can last for ROM, proprioception deficits, and the inability to strengthen
weeks to months and stretch the reconstruction. If this the joint. Joint and soft tissue mobility also are assessed at
occurs, the ultimate results can be compromised and the the limits of ROM.
patient, physician, and physical therapist can all become
quite frustrated. Every patient progresses at a different rate Phase I
and the exercise program should be customized to the indi- TIME: Weeks 4 to 6 after surgery
vidual needs of each patient. GOALS: Decrease pain and swelling, restore joint and
soft tissue mobility, increase strength in lower
REHABILITATION CONCERNS extremity and ankle, increase proprioception,
normalize gait, maintain cardiovascular fitness, and
The therapist should contact the physician whenever pain provide patient education (Table 28-1)
appears to be out of proportion to expectations. In addition,
any wound drainage, evidence of fever or infection, and During this maximal protection phase the patient is
increased laxity should alert the therapist to interact with the casted and allowed to progress from nonweight bearing to
surgeon. If the patient has an acute episode of pain or feels weight bearing. The patient remains nonweight bearing and
a pop or significant change during rehabilitation or ADLs, the cast is removed at the first postoperative visit for wound
the surgeon should be alerted immediately. inspection. A second cast is applied for an additional week
and the stitches are removed. Weight bearing is initiated
THERAPY GUIDELINES FOR during the third week and the cast is removed at the sixth
REHABILITATION week. At this point the patient is placed in a controlled action
motion (CAM) walker brace and compression stocking or in
The first 6 weeks after surgery are important for the succes a small brace, depending on the individual patient. At 6
of the surgery. Whether the reconstruction was done with weeks the patient is started on ROM and strengthening exer-
primary ligamentous repair (as in the Brostrm procedure), cises in physical therapy, as well as pool exercises. Some
with tendon augmentation (as in the Chrisman-Snook pro- authors have advocated a limited ROM of 10 dorsiflexion
cedure), or with hamstring reconstruction, the initial tissue and 10 of plantar flexion, with partial weight bearing from
healing stage is important.9,31 The surgical reconstruction to 2 to 6 weeks after surgery.30 Formal physical therapy is
correct the ligamentous instability is only as good as the usually initiated at 6 weeks when the cast is removed. At this
stability gained from soft tissue healing. Soft tissue healing time the tissues should be adequately healed and ready to
is considered the maximal protection stage. tolerate stresses within a pain-free ROM. Studies have shown
that motion is beneficial to nourish cartilage, prevent soft
Evaluation tissue contractures, and restore joint mobility.37After per-
The initial postoperative evaluation gives the therapist a forming the initial evaluation, the physical therapist can
baseline from which to proceed in returning the patient to implement appropriate treatment. Initially, the therapist per-
desired independent function. Initial ROM measurements forms grades I and II joint mobilization along with PROM,
are taken both for active range of motion (AROM) and especially inversion, within pain-free ranges. At 6 weeks after
TABLE 28-1 Lateral Ligament Repair

Phase I Postoperative Edema Patients usually begin therapy at Manage edema Provide maximal
Postoperative Cleared by Pain about 6 weeks Decrease pain protection in this phase;
4-6 weeks physician to begin Patient casted for 6 Modalities as needed Increase ROM patient is casted for 6
rehabilitation weeks PROM(stretches within Increase tolerance weeks; communication
Limited weight bearing pain-free ranges) plantar flexion, of muscle with physician is
(nonweight bearing dorsiflexion, and eversion; take contraction imperative regarding
for 3 weeks, then care when gently stretching into weight-bearing status
progressive weight inversion Begin restoring joint and
bearing per physician) Isometricssubmaximal soft tissue mobility
Limited ROM multiangle exercises for all planes Initiate muscle contraction
Limited strength AROMankle:supine and seated and prepare for
plantar flexion and dorsiflexion strengthening exercises
Progressive resistance exercise Improve hip strength to
hip (all ranges) prepare for normal gait
Soft tissue mobilization Provide gait training to
Joint mobilization as indicated improve tolerance to
Gait trainingprogress to full accepting weight on
weight bearing using appropriate involved leg
assistive device Avoid overstressing healing
Patient education tissues; adapt program as
symptoms dictate
AROM, Active range of motion; PROM, passive range of motion; ROM, range of motion.
surgery the ligaments should have healed sufficiently to Careful monitoring of exercise progression and inten-
allow gentle active movement.38 sity of the workout session is crucial to avoid overstressing
However, at this stage the soft tissue is unable to with- healing tissues. The therapist must caution the patient to
stand significant forces into inversion.4 The patient is able avoid aggressive stretching and strengthening of lateral
to perform AROM for plantar flexion and dorsiflexion using ankle tissues early in the rehabilitation program; progress
pain as a guide; submaximal multiangle isometrics for all should be cautious and slow. Exercises that cause increased
planes also are used at this stage of the rehabilitation. Soft symptoms in the lateral ankle complex must be modified
tissue and joint mobilizations are started to reverse the or avoided.
effects of immobilization and surgical trauma. Effusion,
pain, and soft tissue edema are treated with the appropriate Phase II
modalities. Research has suggested that ice independently is TIME: Weeks 6 to 8 after surgery
not effective in reducing postoperative edema. Instead, GOALS: Return gait within normal range, maintain
studies have reported an increased effectiveness of reducing normal ROM, increase strength, control pain and
postoperative edema using cold compression therapy.39-41 swelling, increase proprioception (Table 28-2)
Efforts to normalize full weight-bearing gait without assis-
tive devices should include gait training drills. Proper foot Phase II is overlapped with phase I as the patients ROM
mechanics throughout the stance phase of gait can be begins to progress and therapeutic exercise options are
emphasized if pain is minimal or absent. A home exercise expanded. At this stage rehabilitation is similar to that advo-
program emphasizing increased frequency and decreased cated in the literature for lateral ankle sprains.11 Multiplane
intensity of exercises should be initiated at this time. The isometrics and AROM against gravity progress to exercises
therapist should clearly instruct the patient on precautions with appropriate grades of submaximal resistance using
to protect healing tissues. The program may be altered as weights or rubber tubing. Peroneal strengthening is a major
needed by the therapist. focus because repeated trauma resulting from the instability
may lead to weakness of these muscles.4 Activities to increase
Precautions strength may occur on land or in a pool. On land, early
The therapist should take a few precautions during this proprioceptive activity is initiated with the use of a balance
phase. board as a means of increasing functional stability.42,43 The

Phase II No increase in pain Mild edema Continuation of phase I Control edema and Continue modalities to
Postoperative 6-8 No loss of ROM Mild pain interventions as indicated pain control edema and pain
weeks Improved tolerance Limited strength Isometricsmultiplane Increase strength Improve strength and
to weight bearing Limited ROM submaximal inversion and Promote equal stability of ankle joint in
Limited gait eversion (pain-free) weight bearing with numerous directions
AROMankle (all ranges sit-stand Improve strength with mild
against gravity) Minimize gait resistance initially
Standing bilateral heel deviations on level Progress exercises
raises surfaces incorporating functional
Squats and lunges Increase tolerance activities
Treadmill to single-limb stance Maintain consistent cadence
Stationary bicycle (using low Improve and work on endurance
resistance) proprioception and Later in phase II, ankle
Elastic tubing (light resistance) stability of ankle should be able to tolerate
exercises indicated late phase Increase tolerance increased resistance with
II; dorsiflexion, plantar flexion, to advanced inversion and eversion
inversion, and eversion activities motions
Balance board progressed Proprioception exercises
from seated to standing with with varying degrees of
bilateral, then unilateral, weight bearing and manual
support resistance aids in return of
Proprioceptive neuromuscular proprioception
facilitation Buoyancy effect of water
Pool therapydeep water aids progression of more
running and light jumping advanced activities
patient progresses from sitting to standing, with bilateral When ROM and gait are within normal limits, isokinetic
and then unilateral support. One-leg standing also is initi- strengthening for inversion and eversion can be initiated. At
ated. Bilateral heel raises are started and progressed to uni- this time the patient should be able to tolerate a submaximal
lateral as tolerated by the patient and according to the strengthening program without exacerbation of symptoms.
therapists discretion. Proprioceptive neuromuscular facilita- Resistive exercises for plantar flexion and dorsiflexion are
tion (PNF) is an excellent strengthening tool for the lower initiated at 8 weeks. Inversion and eversion resistive exercises
kinetic chain. In the pool, activities may include light jogging must be performed to the tolerance of the patient. Single-leg
and jumping exercises in shallow water. Lunges and squats stance with opposite leg-resisted flexion, abduction, exten-
also are effective. The patient should continue with deep sion, and adduction can be performed with increasing resis-
water running exercises for increased cardiovascular fitness. tive band tension. Patients may begin performing exercises
Gait training is an important aspect of the rehabilitation on partialweight bearing equipment such as the Shuttle
program and should be given priority. An aberrant pattern MVP, including single/double leg press and toe raises. All
reinforces itself and leads to continued limitations in ROM resistive exercises should be performed without pain. Three-
and strength. Walking on a treadmill at a moderate speed way lunge, single-leg stance with three-point reach and
with a low-to-moderate grade as tolerated aids in gait three-point step with the opposite leg can be initiated cau-
training. tiously. The ability to perform pain-free weight training and
isokinetic training is a good indication that soft tissue
Phase III strength is progressing well.
TIME: Weeks 8 to 10 after surgery The therapist must monitor the progression of resistive
GOALS: Focus on training to allow return to work exercises to ensure that symptoms are not exacerbated.
and sports, continue ankle mobilization and The patient may be ready for discharge after phase III or may
passive stretching, prevent pain and swelling progress to phase IV depending on the prior level of fitness
(Table 28-3) or activity and goals.

Phase III No loss of ROM Limited gait on uneven Continue interventions as in phases I Full AROM and By the end of this
Postoperative No increase in pain surfaces and II (joint and soft tissue PROM phase, the patient
8-10 weeks Continued progress Limited ROM mobilization performed as indicated) 80% ankle should have full ROM
in therapy Limited strength Elastic tubing (mild to moderate strength and hands-on care can
Mild edema and pain resistance)ankle (all ranges) Self-management be eliminated
associated with Isotonicsankle (all ranges) of edema and Exercises should use a
increased activity IsokineticsPerformed at pain-free pain combination of varying
intensities resistance in different
Joint mobilization: grades III and IV to positions to acquire
decrease stiffness and increase ROM proprioceptive strength
Single-leg stance with opposite and stability
leg-resisted flexion, abduction, Exercises are
extension, and adduction can be progressed to include
performed with increasing resistive activity-specific drills
band tension emphasizing specificity
Three-way lunge, single-leg stance of training principles
with three-point reach, and three-point
step with the opposite leg can be
initiated cautiously

Anticipated
Phase IV Good progression Limited strength and Continuation of exercises from Prevent reinjury Patients opportunity for
Postoperative through previous tolerance to phases I through III as with return to reinjury is highest with the
11-18 phases with the higher-level activities indicated sport addition of advanced
weeks need to return to Use ankle brace as appropriate Discharge to gym exercises; clinicians should
higher-level activities Plyometrics, trampoline program ensure proper performance
and sports activities, figure-8 drills, Return to sport of drills (plyometrics,
Normal ROM carioca, slide board, and pivoting, cutting)
Normal strength lateral shuffle Functional training for
Increase demand of pivoting sports
and cutting exercises After patients can perform
Four-square hopping ankle drills safely and adequately,
rehabilitation (see Fig. 30-13) they are discharged with
Progress towards box drills communication to coaches
and trainer
Phase IV
TIME: Weeks 11 to 18 after surgery
activities.10,31 Exercise should continue with the therapist
GOAL: Return to sporting activities (Table 28-4)
monitoring patient progress. Exercises in this phase are more
advanced, and chances of reinjury are greater. In this final
The goal of rehabilitation is, in general, for the patient phase of rehabilitation the patient should be able to perform
to return to sporting activity 11 to 18 weeks after surgery; all exercises safely and correctly, with proper form and tech-
an ankle brace is used initially on return to sporting nique and with little verbal cueing from the therapist. After
the AROM and PROM are within normal limits and strength joint restrictions and soft tissue tightness. If restrictions exist
has returned to normal, sport-specific and functional train- at the talocrural joint, long-axis distraction thrust techniques
ing can be implemented. Exercise options include plyomet- are useful. In addition, mobilization of the talus, tibia, and
rics, trampoline activities, box drills, figure-8 drills, carioca, fibula can be useful. Anterior and posterior glides to these
slide board, and lateral shuffles (Figs. 28-12 through 28-15). bones help restore dorsiflexion. The gastrocnemius and
Many of the initial ankle injuries resulted from sporting soleus muscle group can be the major limiting factor in
activities such as cutting activities and movements requiring dorsiflexion ROM. Low-load prolonged stretching tech-
quick reflexes and balance. Although not in the scope of this niques in combination with heat can be beneficial in increas-
chapter, retraining the vestibular system is also an important ing soft tissue extensibility.44 The load of the stretch is to
part of an athlete returning to their sport of choice. Incor- the patients tolerance for 20 to 30 minutes, one or two times
porating vestibular exercises with sport-specific movements per day.
and exercises can help the athlete achieve his or her goals
(Fig 28-16). These activities should be incorporated into the
rehabilitation program.
SUGGESTED HOME MAINTENANCE FOR

THE POSTSURGICAL PATIENT
An exercise program has been outlined at the various phases.

The home maintenance box outlines rehabilitation sugges-
tions the patient may follow. The physical therapist can use
it in customizing a patient-specific program.
TROUBLESHOOTING
Limited dorsiflexion can be a problem with most patients

because of limited talar tibia-fibula mobility as a result of
Fig. 28-13 Trampoline stork standing.
Fig. 28-12 Carioca. Fig. 28-14 Balance board exercise.

Fig. 28-15 Step-ups.
Another method to prevent chronic ankle sprains is to use

biomechanical foot orthotics. In theory, biomechanical foot
orthotics are designed to enhance joint position, increasing
the shock-absorbing capabilities of the lower limb and
Fig. 28-16 Balance training with basketball.
improving muscle function.
SUMMARY instability on returning to daily activities or sporting activi-

ties. The first step toward a good outcome is adequate post-
A successful outcome for lateral ligamentous reconstruction operative stabilization. However, the success of the surgical
includes no recurrent instability, normal ROM and strength, procedure depends on postoperative rehabilitation in which
and no pain with weight-bearing activities. A successful the patient, surgeon, and therapist work closely to achieve a
functional outcome is achieved if the patient experiences no functional ankle.

Weeks 6 to 8 Exercise Progression: Begin all exercises with two
GOALS FOR THE PERIOD: Improve gait, increase sets of 10 repetitions. If no adverse effects are noted
ROM to normal, gradually increase strength, control to previous intensity level, progression can proceed
pain and swelling, and increase proprioception to three sets of 10 repetitions, followed by 3 sets
1. AROM in plantar flexion, dorsiflexion, and of 12 to 15 repetitions, and finally three sets of
eversion 20 repetitions. Once a patient is able to perform
2. Isometrics for plantar flexion, dorsiflexion, and three sets of twenty repetitions of an exercise; the
eversion intensity of the exercise must be increased in some
3. Towel calf nonweight bearing stretch for form (i.e., more resistance, longer duration) and the
gastrocnemius-soleus muscle group patient should start back with two sets of 10
4. Towel-crunching exercise repetitions and follow the same progression.
5. Four-way hip nonweight bearing exercise to
initiate total lower extremity strength
6. Seated heel and toe raises
GOALS FOR THE PERIOD: Maintain normal ROM, GOALS FOR THE PERIOD: Progress with
continue to increase strength and improve strengthening, increase endurance, and return to
proprioception previous level of function (sport activity)
1. Rubber tubing with appropriate resistance for 1. Standing gastrocnemius-soleus stretch
dorsiflexion and plantar flexion 2. Increased resistance of rubber tubing
2. Submaximal isometric exercises of inversion and 3. Straight-ahead running if gait is normal
eversion (performed without pain) 4. Heel raises progressing to single-leg raises
3. Stationary bicycle 5. Sports-specific training
4. Heel raises (bilateral) 6. Functional training
5. Step-ups, step-downs 7. Return to sport as cleared by the therapist and
6. Single-leg stance physician with ankle bracing
1 Will, who is 18 years old, tore his ATF ligament while

playing basketball. The tear occurred over a 1-year
period after accumulating multiple ankle sprains. He
walking more than 8 minutes on the treadmill. What
types of activities can be performed for her unilateral
imbalances while increasing core stability?
had an ATF ligament repair 8 weeks ago. Since then his
physical therapy has consisted of massage, ultrasound, The therapist explained to Leigh that any activities
AROM and PROM exercises, cryotherapy with com- causing her to substitute secondary to increased pain
pression, and a home exercise program. His main com- must be modified. The patient was reassessed, and asso-
plaint is stiffness during gait, while ascending stairs, and ciated restrictions at the pelvis were recorded. A long
during attempts to squat partially. Dorsiflexion is limited axis distraction was performed to correct pelvic asym-
by 10 with moderate edema noted. What treatment is metry. Appropriate hamstring stretches were performed
most likely to improve Wills dorsiflexion ROM and to increase muscle length. As exercises were modified
decrease edema? and asymmetries were corrected, Leigh was able to
perform the following closed-chain exercises: forward
The patient was reassessed for associated restrictions. A lunges, backward lunges, lateral lunges, heel raises with
mobilization technique was performed at the proximal minisquat, and single-heel raises performed on a leg
and distal fibula. An AP movement was applied to the press machine using 70lb. She was also able to perform
proximal fibular head, and a posteroanterior (PA) move- backward walking, minimal walking on a treadmill, and
ment was applied to the lateral malleolus to increase jogging or running in the pool. As strength and tolerance
dorsiflexion. This was followed by stretching and ROM to exercise increased, Leigh progressed to more chal-
exercises to reinforce dorsiflexion. Wills dorsiflexion lenging exercises, which included core stabilization
PROM increased to 18. Pain with gait, stairs, and squat- activities.
ting was dramatically decreased after the first
treatment.
3 Karen is 22 years old and plays basketball primarily on
the weekends. She tore her ATF during a pick-up game
2 Leigh is a 30-year-old woman who tore her left ATF

ligament while performing step aerobics. She had an
ATF ligament repair 10 weeks ago. She has complained
when she stepped abnormally causing her ankle to turn
into extreme inversion. She had an ATF ligament repair
11 weeks ago. Progress with exercise has decreased
of knee and back pain on the unilateral side. She has because of pain during many closed-chain activities.
asymmetric pelvic imbalance, with left iliac crest higher What factors could be involved that would cause pain
than the right and the left anterosuperior iliac spine during these activities?
(ASIS)/posterior superior iliac spine (PSIS) higher than
the right. Decreased knee extension left versus right. During an additional assessment, it was found that Karen
Progress with exercises has decreased because of pain had restrictions with AP proximal fibular glides and PA
during many of the closed-chain exercises such as distal fibular glides. Calcaneal eversion was also limited.
single-leg stance, double-heel lifts, minisquats, and Graded mobilizations were performed at the proximal
and distal fibular heads, which released the calcaneal tapping method to rule out possible fracture, which was
eversion and decreased the patients pain during negative. Radiographs later showed no fracture present.
activity. The patient was positive with talar tilt, anterior drawer,
and high ankle sprain. The patient demonstrated MMT
4 Jason is a 30-year-old man who suffered an ATF tear

after slipping on wet grass while performing yard work.
He had an ATF ligament repair 12 weeks ago. He reports
within normal limits for all ankle motions except ankle
eversion, which showed pain and weakness at 3+/5.
Grossly, the patient had full ROM with pain at end range.
that his ankle pain has started to decrease but that he is The course of treatment included initial edema reduction
noticing progressively increased pain at the third and pain management while maintaining full ROM.
through fifth distal metatarsal heads. The pain is pro- Because of peroneal involvement, the therapist was able
gressing to affect gait. What should the therapist assess? to begin strengthening in all planes except eversion,
which was limited to isometrics. The patient later per-
The therapist, when learning of this clinical change, formed proprioception and plyometric exercises and
assessed the foot position and compared findings bilat- returned to pole-vaulting after 8 weeks, with an ankle-
erally. The patient was found to have increased rear foot stabilizing orthosis (ASO) ankle brace.
pronation and forefoot supination on the affected side
as compared with the unaffected side. The therapist
attempted a temporary orthotic trial and posted the
patient using a 3 medial rear foot wedge and a 3 lateral
7 Elizabeth is a 15-year-old competitive gymnast with a
history of chronic ankle sprains to her right ankle during
her gymnastics competitions. The most frequent occur-
forefoot wedge on the affected extremity. At the next rence of her injury involves the vault and tumbling with
session, the patient reported decreased ankle and distal floor exercises. She has not undergone any surgical
metatarsal pain on the affected side. The patient would intervention but wishes to continue competing in her
later be fitted for permanent orthotics. sport. What type of treatment plan should the therapist
initiate to allow Elizabeth to return to her sport?
5 Jim is 17 years old and tore his ATF while rounding

second base during a high school baseball game. He had
an ATF ligament repair 16 weeks ago. He has progressed
Upon evaluation, the therapist finds that she has the fol-
lowing objective findings: Restricted passive dorsiflexion/
well through rehabilitation but was having difficulty ini- talar gliding, weakness with MMT to the peroneals, ten-
tiating higher-level activities. How did the therapist derness to palpation along the ATF ligament/sinus tarsi
progress this athlete for him to return to baseball for the and also tenderness in her Achilles tendon, she was also
next season? noted to have significant propriocpetive deficits, and
posterior hip strength deficits as well. Treatment began
The therapist initiated activities that were sports specific with modalities to decrease pain/inflammation and to
to increase functional stability. The patient performed help start scar tissue remodeling including: infrared
multidirectional single-leg hopping, including forward, light, ultrasound, crossfriction massage and soft tissue
backward, and side to side. The patient began box exer- mobilization of the gastroc/soleus and Achilles tendon.
cises, including shuffle sprint and box X with pivot. He The restricted dorsiflexion was addressed with long-axis
was progressed in proprioceptive activities, including distraction to the talocrural joint. She was put on a pro-
unilateral leg stand with opposite LE resistive-band gressive strengthening program for her posterior hip
flexion, extension, and abduction, and biomechanical muscle deficits, as well as an eccentric training regimen
ankle platform system (BAPS) board activities. The exer- for her Achilles tendon. She was also performing pro-
cises were progressed, increasing the time from 1 to 2 gressive inversion/eversion strengthening with thera-
minutes. band and PNF diagonal strengthening with the therapist
providing manual resistance. She then progressed to
6 Steve is an 18-year-old senior track athlete being actively

recruited by several Division I universities for pole
vaulting. During a track meet, the patient performed his
plyometric training first with partialweight bearing
equipment, such as the Shuttle MVP, and then to more
aggressive plyometric training on devices such as the
vault and, upon landing, severely inverted his right Vertimax with an emphasis on her landing mechanics.
ankle. He entered the clinic with severe bruising around The patient was also placed on a progressive perturba-
the ankle with +2 pitting edema. He was tender over the tion training program to address her proprioceptive defi-
lateral malleoli and peroneals, as well as the lateral liga- cits. Elizabeth was also advised to either tape her ankle
ments. He has no significant gait deviations and has or obtain a brace for her to use during competitions.
reported that he has been jogging. What is the differen-
tial diagnosis and course of treatment?
The therapist first instructed Steve to cease jogging

8 Elaine is 45-year-old female who injured her right
ankle in an MVA while on vacation. Once she returned
home, she was found to have torn her ATF ligament
activities immediately and used the tuning fork and and underwent the Brostrm-Gould procedure to
reconstruct the ligament. Upon coming to physical to his talocrural joint. Ryan was a previous patient
therapy 6 weeks following the procedure, Elaine is who the therapist had treated for other injuries over
ambulating with crutches and a CAM boot. She reports the past year. The day after the surgery, Ryan calls
pain over the lateral malleoli, ATFL, sinus tarsi, and the therapist because he is concerned about his
lateral syndesmosis. She also has impaired sensation and increase in pain/swelling following the procedure.
increased scar tissue surrounding the incision. Atrophy He also reports numbness/tingling in his foot and
and limited soft tissue mobility of the gastros/soleus tenderness in his calf. What should the therapist do?
comlex are noted as well. How would the therapist initi-
ate treatment at her current level? Without the patient being seen in the clinic, assessment
is limited. But the therapist should tell Ryan to follow-up
The patient was instructed in a HEP consisting of towel with his surgeon immediately to rule out any possible
gastrocnemius/soleus stretching, desensitization and compartment syndrome or deep vein thrombosis which
scar mobility exercises, submaximal and pain-free iso- may have occurred as a result of the procedure. If the
metrics for inversion/eversion, and AROM exercise for therapist is familiar with the surgeon, he or she should
plantar and dorsiflexion. While in the clinic; high-voltage then also call the surgeon to relay these symptoms and
electrical stimulation was used to address muscular concerns to the physician so that he or she can appro-
atrophy of the gastrosnemius/soleus complex and cryo- priately address these issues.
therapy with interferential electrical stimulation was
used if there was pain following treatments. The patient
began a progressive gait training program under the
supervision of the therapist which began on two crutches,
11 Cliff is a 26-year-old Air Force officer who injured
his ankle while doing his routine physical training
regimen. While running he stepped off the side of
next to one crutch on the contralateral side, then a single- the track and experienced a plantar flexion with
point cane and finally no assistive device. The final stage inversion injury to his ankle. He then underwent
was allowed once the patient was able to ambulate with surgical reconstruction and is currently 4 months
proper mechanics and a nonantalgic gait pattern. postop and would like to begin running again. How
should the therapist assist Cliff to return to running
9 Brandon is a 16-year-old male basketball player who has

had recurrent ankle sprains. At the end of the season,
he again sprained his ankle by landing on an opposing
without exacerbating his pain?
Before beginning a running program, Cliff must demon-

players foot and severely inverting his foot while strate certain objective findings before attempting to
running. Brandon and his parents are concerned about begin the program. He should demonstrate no restric-
the new injury/possible fracture and want to address the tions in ankle mobility specifically dorsiflexion, be able
continued recurrent instability in his ankle that has to perform three sets of 15 repetitions of singleleg calf
occurred over the last year. What should the therapist raises without ankle pain, demonstrate near symmetric
do to address these issues? single-leg balance, and appropriate strength in the other
lower extremity muscle groups (i.e., hip, quadriceps, and
To rule out the possible fracture the therapist can use the hamstring strength) involved with running. A nice pre-
Ottawa ankle rules for fracture. The therapist can also cursor to running can be the elliptical machine, or
use the tuning fork technique or attempt ultrasound over running in deep water (no impact), or on an underwater
the painful area. If there is a fracture, ultrasound over the treadmill at a certain percentage of his body weight. If
area will usually reproduce the patients pain and indi- Cliff has had no adverse reactions to the above precur-
cate possible bony pathology. The therapist should sors he can start with a progressive treadmill running
arrange or contact the patients orthopedic doctor and program. He may begin with a light warm-up at a nice
relay these concerns so that the surgeon can give the cadence for 3 to 5 minutes and then begin with an inter-
patient and family all of the possible treatment options val program at a pace that simulates a light jog for him.
and initiate diagnostic imaging if warranted. The thera- Intervals should start with 1 minute of jogging, followed
pist can also educate the patient and his family on the by a minute of walking at a fast pace; then 2 minutes of
problems associated with recurrent ankle instability; jogging with 1 minute of walking and then 3 minutes of
such as early joint degeneration, impaired balance/ jogging; again followed by a walking/cool down period.
proprioception, and decreased function with higher level He should remain with this intensity of training for at
activities (i.e., running, jumping, cutting sports). least a week to see how he is responding. If he is respond-
ing well he may begin to increase both the speed and
10 Ryan is a 25-year-old who injured his ankle after

falling off of his bicycle. He was taken to the emer-
gency room and was stabilized. After the initial
duration of his jogging/running bouts over the ensuing
weeks.
swelling had decreased Ryan underwent surgical

reconstruction of his ATF ligament with arthroscopy 12 Ashley is a 17-year-old tennis player who has had
recurrent ankle sprains to her left ankle over the past
2 years. She has increased inversion with the talar tilt program, Ashley will need to reduce her tennis training,
test compared with her right ankle. She does not and it was recommended that she tape or brace her ankle
report any recurrent instability with normal daily in some fashion until her strength and mechanical issues
activities, only with her athletic activities. She does were resolved.
not wish to undergo surgery and would like a con-
servative approach to address her ankle issues. What
should the therapist do? 13 Describe a progressive training program for the
peroneals.
The therapist should do a full lower extremity evaluation Initially after injury or surgery, the patient may begin
examining lower extremity muscle strength, ROM, joint with submaximal isometrics. Progression with isomet-
mobility/gliding, balance/vestibular testing, and foot/ rics can increase with the amount of force or with the
ankle mechanics for possible orthotic intervention. Defi- duration of holding the isometric contraction. The next
cits were found in Ashleys posterior hip musculature phase would be pain-free active range motions. The
and ankle eversion strength. She was found to have patient may begin first while sitting or lying and then to
proprioceptive deficits on the left with balance testing. progress to a sidelying position so that the ankle is evert-
Observation of her static and dynamic mechanics ing against gravity. Following this stage, he or she may
revealed increased femoral Q angle contributing to progress to elastic tubing/Theraband exercises. Focus
increased knee valgus with dynamic movements, she should also be placed on the eccentric component of
also demonstrated increased foot pronation with col- these exercises which will assist with tendon strengthen-
lapse of the midtarsals during the stance phase of gait. ing. The therapist may also do PNF diagonals with
So to address these deficits, Ashley should be put on a manual resistance at this stage. Once he or she has
progressive strengthening program for her posterior hip completed these phases of the program, which were
muscles and peroneals. She should also be fitted for designed to isolate the peroneals, the focus of the
orthotics to address her foot/ankle mechanics. A pro- program should shift to more whole body and sport-
gressive balance and proprioceptive training program specifc movements, with emphasis on lateral and diago-
should also be initiated. While undergoing this treatment nal movement patterns.
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13. Harrington KD: Degenerative arthritis of the ankle secondary to long- and long-term results. Foot Ankle Int 28:24-31, 2007.
standing ligamentous instability. J Bone Joint Surg Am 61(3):354-361, 26. Taga I, et al: Articular cartilage lesions in ankles with lateral ligament
1979. injury: An arthroscopic study. Am J Sports Med 21:120-126, 1993.
27. Hua Y, et al.: Combination of modified Brostrm procedure with ankle 40. Bleakley C, McDonough S, MacAuley D: The use of ice in the treatment
arthroscopy for chronic ankle instability accompanied by intraarticular of acute soft-tissue injury: A systematic review of randomized controlled
symptoms. Arthroscopy 26:524-528, 2010. trials. Am J Sports Med 32(1):251-261, 2004.
28. Lui TH: Arthroscopic-assisted lateral ligamentous reconstruction in 41. Scheffler NM, Sheitel PL, Lipton MN: Use of Cryo/Cuff for the control
combined ankle and subtalar instability. Arthroscopy 23:554.e1-555.e5, of postoperative pain and edema. J Foot Surg 31(2):141-148, 1992.
2007. 42. Wilke B, Weiner RD: Postoperative cryotherapy: Risks versus benefits
29. Nery C, et al: Arthroscopic-assisted Brostrm-Gould for chronic ankle of continuous-flow cryotherapy units. Clin Podiatr Med Surg 20(2):307-
instability: A long term follow-up. Am J Sports Med 39:2381-2388, 2011. 322, 2003.
30. Liu SH, Baker CL: Comparison of lateral ankle ligamentous reconstruc- 43. Eils E, Rosenbaum D: A multi-station proprioceptive exercise
tion procedures. Am J Sports Med 22:313-317, 1994. program in patients with ankle instability. Med Sci Sports Exerc 33(12):
31. Hennrikus WL, et al: Outcomes of the Chrisman-Snook and modified- 1991-1998, 2001.
Brostrm procedures for chronic lateral ankle instability: A prospective, 44. Lentell G, et al: The use of thermal agents to influence the effectiveness
randomized comparison. Am J Sports Med 24:400-404, 1996. of a low-load prolonged stretch. J Orthop Sports Phys Ther 16(5):200-
32. Hamilton WB, Thompson FM, Snow SW: The modified Brostrm pro- 207, 1992.
cedure for lateral ankle instability. Foot Ankle 13:1-7, 1993.
33. Peters WJ, Trevino SG, Renstrom PA: Chronic lateral ankle instability. ADDITIONAL READINGS
Foot Ankle 12:182-191, 1991. Chrisman OD, Snook GA: Reconstruction of lateral ligament tears of the
34. Coughlin MJ, et al: Comprehensive reconstruction of the lateral ankle ankle: An experimental study and clinical evaluation of seven patients
for chronic instability using a free gracilis graft. Foot Ankle Int 25:231- treated by a new modification of the Elmslie procedure. J Bone Joint
241, 2004. Surg 51A:904-912, 1969.
35. OShea KJ: Technique for biotenodesis screw fixation in tendon- Ferkel RD, Chams RN: Chronic lateral instability: Arthroscopic and long
enhanced ankle ligament reconstruction. Tech Foot Ankle Surg 2:40-46, term results. Foot Ankle Int 28(1):24-31, 2007.
2003. Girard P, et al: Clinical evaluation of the modified Brostrm-Evans proce-
36. Takao M, et al: Anatomical reconstruction of the lateral ligaments of the dure to restore ankle stability. Foot Ankle Int 20:246-252, 1999.
ankle with a gracilis autograft. Am J Sports Med 33:814-823, 2005. Haraguchi N, Tokumo A, Okamura R, et al: Influence of activity level on
37. Gebhard JS, et al: Passive motion: The dose effects on joint stiffness, the outcome of the treatment of lateral ankle ligament rupture. J Orthop
muscle mass, bone density, and regional swelling. JBJS 75A:1636-1647, Sci 14(4):391-396, 2009.
1993. Shahrulazua A, et al: Early functional outcome of a modified Brostrm-
38. Karlsson J, et al: Comparisons of two anatomic reconstructions for Gould surgery using bioabsorable suture anchor for chronic lateral
chronic lateral instability of the ankle joint. Am J Sports Med 25:48-53, ankle instability. Singapore Med J 51(3):235-241, 2010.
1997. Watson-Jones R: Fractures and other bone and joint injuries, Baltimore,
39. Sammarco GJ, Carrasquillo HA: Surgical revision after failed lateral 1940, Williams & Wilkins.
ankle reconstruction. Foot Ankle Int 16:748, 1995.
CHAPTER 29
Open Reduction and Internal Fixation
of the Ankle
Graham Linck, Danny Arora, Robert Donatelli, Will Hall, Brian E. Prell, Richard D. Ferkel
INTRODUCTION SURGICAL INDICATIONS

AND CONSIDERATIONS
The treatment of ankle fractures dates back to antiquity. Evi-
dence of healed ankle fractures has been noted in the remains Ankle fractures can be treated conservatively if the ankle
of mummies from ancient Egypt.1 Hippocrates recom- mortise remains stable. The medial clear space (space
mended that closed fractures be reduced by traction of the between medial malleolus and talus) or lateral clear space
foot, but few other advances in the understanding and treat- (space between lateral malleolus and talus) must measure less
ment of ankle fractures were made until the middle of the than 3mm on a mortise radiographic view, or less than 5mm
eighteenth century.2-4 Operative treatment of ankle fractures on a stress radiographic view. It is important to ensure that
was popularized by Lambotte5 and Danis6; the AO group the talus is well reduced beneath the tibia plafond and not
began a systematic study of fracture treatment in 1958.7-9 subluxated forward or backward. The following specific inju-
Since these original investigators, significant progress has ries are indications for conservative treatment: isolated non-
been made in the treatment of ankle fractures. displaced medial malleolar fracture or tip avulsion fracture,
Much of the current understanding of the mechanism of isolated lateral malleolar fracture with less than 3mm dis-
ankle fractures has developed from the work of Lauge- placement and no talar shift, and a posterior malleolar frac-
Hansen.4 In his system, the position of the foot (pronation ture with less than 25% joint involvement or less than 2-mm
or supination) at the time of the injury is described first and stepoff. Conservative management usually entails immobili-
the direction of the deforming force is described second. zation in a short-leg cast or boot, which extends to the tips
Ankle fractures currently are classified most commonly of the toes with the foot in an appropriate position for the
by two systems: Lauge-Hansen4 and Danis-Weber10,11 (Fig. type of fracture deformity. Any fracture of the ankle with a
29-1). The latter system is based on the location of the frac- residual talar tilt or subluxation, in which the ankle mortise
ture of the fibula: infrasyndesmotic, transsyndesmotic, and is not anatomically reduced, warrants surgical fixation.
suprasyndesmotic. Fractures also are classified by the number In general, ORIF should be performed on all patients,
of bones that are affectedthat is, a bimalleolar fracture regardless of age, gender, activity level, or vocation, as long
involves injury to both medial and lateral malleoli, whereas as they are healthy enough to undergo the procedure.
a trimalleolar fracture indicates that the medial, lateral, and However, exceptions do exist, including paraplegics and
posterior malleoli have all been fractured. quadriplegics, and patients who are nonambulatory and lack
An ankle fracture is a debilitating injury, especially if the sensation to the lower extremities.
fracture is unstable. The treatment of choice for an unstable Preoperative variables that predict a successful outcome
ankle fracture is open reduction and internal fixation (ORIF). include an otherwise healthy patient who is well motivated
Surgical treatment of a displaced, unstable ankle fracture to recover after surgery. Systemic diseases such as osteopo-
centers on anatomic restoration of the bony and ligamentous rosis, diabetes, peripheral vascular disease, alcoholism, and
structures that surround the joint. As technology and surgi- tobacco abuse can all affect the ultimate outcome of surgery.
cal techniques have advanced, so have the outcomes for These variables affect wound healing, as well as the healing
ORIF.12-14 of the fracture itself.
520
Chapter 29 Open Reduction and Internal Fixation of the Ankle 521
Fig. 29-1 The Lauge-Hansen and Danis-Weber classification systems for ankle fractures. (From Browner BD, etal: Skeletal trauma, Philadelphia, 2009,
Saunders.)
skin tension, is important to a successful outcome. In some

SURGICAL PROCEDURES cases surgery may have to be delayed for as long as 14 days
to allow swelling to resolve so the skin can be closed at the
Patient Evaluation end of surgery without a wound slough. Recently, a foot and
It is important to get a history on the mechanism of injury, ankle pump device has been used to reduce swelling rapidly
and if possible, the position of the ankle, as well as the direc- to permit earlier surgery and fewer complications.
tion of force. This will not always be possible, because most Initially, patients may be too swollen to wear a cast. In
patients will only be able to describe a twisting or rolling type this instance a bulky dressing with cast padding and bias
of injury. Completing your history with current medical type of compression wrap is applied with a posterior splint.
comorbidities and social habits is necessary for patient out- The patient remains nonweight bearing with crutches and
comes. Physical examination includes inspection, palpation, elevates the injured ankle above the heart to promote reduc-
and neurovascular examination. It is crucial to note any tion of swelling.
gross deformity, which may indicate possible dislocation,
and would necessitate early closed reduction and splinting, Surgical Technique
as well as any wounds around the ankle, which may indicate The currently accepted method for fracture ORIF is the AO
an open fracture, and would require emergent surgical irri- (Arbeitsgemeinschaft fr Osteosynthesefragen, or Associa-
gation and dbridement. tion for the Study of Internal Fixation) technique developed
A careful preoperative assessment of not only the patients in Switzerland. This technique emphasizes the use of plates,
health, but also the fracture and the patients swelling and screws, and wires as needed to achieve rigid fixation.
Four criteria must be fulfilled to achieve the best possible

functional results in the treatment of ankle fractures:
1. Dislocations and fractures should be reduced as soon
as possible.
2. All joint surfaces must be precisely reconstituted.
3. Reduction of the fracture must be maintained during
the period of healing.
4. Motion of the joint should be instituted as early as
possible.
Anesthesia and Positioning

The patient is taken to the operating room and a popliteal
block is done to help control postoperative pain. General or
epidural anesthesia is administered. Prophylactic antibiotics
are given, and a fluoroscopy table is used. A
The patient is usually placed supine with a bump under
the ipsilateral hip to ease the access to the lateral ankle. A
pneumatic tourniquet can be applied to the proximal ipsilat-
eral thigh and used if required. The affected limb is prepped
and draped in a sterile fashion. The prone position may be
used in rare instances where a posterolateral approach would
be required to allow access to the posterior malleolus.
Procedure
Recent research at the Southern California Orthopedic Insti-
tute indicates that a high percentage of patients have intra
articular pathology associated with ankle fractures.13 Almost
75% of patients with displaced ankle fractures have an osteo- B
chondral lesion of the talus that is not evident on preopera-
tive x-ray films and can only be seen on arthroscopy before Fig. 29-2 A, Intraoperative fluoroscopy view confirming parallel guide
ORIF. On the basis of these results and Lantzs research8 wire insertion used to manipulate the medial malleolus fragment. Fracture
reduction is checked arthroscopically as the wires are advanced proximally
(which found a 49% incidence of injuries to the talar dome across the fracture site. B, Cannulated screws are subsequently inserted and
articular cartilage in isolated malleolar fractures), the authors checked under fluoroscopy and also arthroscopically to verify anatomic
recommend arthroscopy before ORIF of all ankle fractures. reduction.
This approach is also supported by Hintermanns study15 that
showed a 79% incidence of osteochondral lesions of the talus
with an ankle fracture. subsequent tearing of the interosseous membrane, which
The arthroscopic evaluation is done as described in may result in a high fibular fracture. This type of fracture,
Chapter 30. All intraarticular pathology is documented and which also is known as a Maisonneuve type of fracture, could
appropriately treated. The surgeon must examine carefully even occur at the fibular head and may be missed if the
for osteochondral lesions of the talus, tears of the deltoid, surgeon is not diligent. In this instance, the medial malleolar
anterior talofibular and syndesmotic ligaments, and disloca- fracture is reduced anatomically, usually with two screws
tions of the posterior tibial tendon, which may impede frac- inserted proximally through a small incision from the tip of
ture reduction. Some fractures can be reduced and internally the medial malleolus. The deltoid ligament is split in line
fixated by arthroscopic means alone.16 A typical example is with its fibers, and the two screws are inserted parallel to
a patient with a fracture of the medial malleolus that was each other under fluoroscopic control. If the syndesmosis
dbrided arthroscopically and fixated percutaneously with and interosseous membrane have been torn and are unstable,
two cannulated screws (Fig. 29-2). We have also had good one or two syndesmotic screw(s) are inserted through the
long-term results treating Tillaux fractures in an arthroscopic fibula and tibia, exiting the medial border of the tibia with
manner. After the arthroscopic portion of the procedure is the foot in dorsiflexion. The screw(s) are not placed with
completed, if the fracture is not amenable to all-arthroscopic compression because compressing the syndesmosis restricts
reduction, the ankle is prepared and draped again, gloves are motion postoperatively.
changed, and new sterile instruments are used. When a Weber B fracture occurs with disruption of the
Incisions are made over the lateral, medial, or posterior deltoid, syndesmosis, and interosseous membrane, anatomic
malleolus, depending on the nature of the fractures. When reduction of the medial and lateral clear spaces is critical
a fracture apparently involves only the medial malleolus, the (Fig. 29-3). After arthroscopically dbriding the ankle and
surgeon should search for an injury to the syndesmosis with cleaning out the torn ligaments, ORIF is performed.
A B C
Fig. 29-3 Weber C fracture-dislocation. Anteroposterior (AP) (A), mortise (B), and lateral (C) radiographs showing a high fracture of the fibula with disrup-
tion of the syndesmosis and deltoid ligaments.
Fig. 29-4 The lateral malleolus fracture of the right ankle is exposed and Fig. 29-5 The fracture is reduced anatomically with clamps and checked
the periosteum is elevated with sharp dissection to reveal the fracture site. under fluoroscopy.
The surgeon makes an incision over the fracture site and sized plate is centered over the fracture site and stabilized
extends it proximally and distally on the fibula. Dissection with screws.
is carried down to the periosteum and the fracture site. Care One or two syndesmosis screws or a screw and tightrope
is taken to identify the superficial peroneal nerve, which are then inserted to reduce the ankle, and the reduction is
crosses the field approximately 7cm proximal to the distal checked under fluoroscopy (Fig. 29-6). Postoperative radio-
tip of the fibula. The fracture is exposed and the periosteum graphs are taken to verify anatomic reduction of the frac-
is elevated with sharp dissection (Fig. 29-4). The surgeon tures and syndesmosis, and appropriate positioning of the
uses a curette to remove the hematoma and applies reduc- screws and plate (Fig. 29-7).
tion clamps to assist in reducing the fracture. Reduction of When both the medial and lateral malleoli have been
the fracture usually also requires traction and rotation of fractured, the lateral malleolus is approached first (Fig. 29-8).
the foot and ankle (Fig. 29-5). When anatomic reduction An incision is then made over the medial malleolus as previ-
has been achieved, frequently one or two lag screws are ously described, the fracture site is exposed, the hematoma
used to provide interfragmentary compression across the is removed, and the fracture is reduced. The surgeon inserts
fracture site. After this is accomplished, an appropriately one or two screws. Postoperative x-ray films demonstrate
anatomic reduction of the fractures with good position of fragment in place. In general, posterior malleolar fracture
the plate and screws (Fig. 29-9). fragments do not require internal fixation if they involve less
In ORIF of a trimalleolar fracture, the lateral and medial than 25% of the articular surface. If the posterior malleolus
malleoli are addressed as previously mentioned. Using the needs to be addressed directly, a posterolateral approach can
fluoroscope, the surgeon then reduces the posterior malleo- be used.
lar fracture by manipulating the fragment into place and
making a small incision along the anterolateral aspect of the Postoperative Plan
distal tibia. Two guide pins are inserted to reduce the frag- After surgery the patient is splinted in a well-padded short-
ment and one or two cannulated screws are inserted from leg cast in the neutral position; the cast is split in the recovery
anterior to posterior to hold the posterior malleolar room to allow for swelling. Patients are asked to keep the
limb elevated as much as possible for the first postoperative
week. The procedure can be done on an outpatient basis if
the pain level is not too severe, but in some instances the
patient may be required to stay 1 or 2 days in the hospital.
After discharge the patient is nonweight bearing on crutches
for at least 4 weeks. The cast is changed at 1 week after
surgery, the wound is inspected, and all new dressings are
applied. At 2 weeks after surgery, the stitches are removed
and a new short-leg cast is applied for 2 additional weeks. At
4 weeks after surgery, another short-leg cast is applied and
the patient starts partial weight bearing, gradually increasing
to full weight bearing without crutches. After the fracture
has healed, the patient can wear a supportive brace and start
pool and then land physical therapy. In patients with stable,
reliable fixation, early motion can sometimes be initiated
after the third or fourth postoperative week to facilitate early
Fig. 29-6 A lag screw is used to provide interfragmentary compression
across the fracture site. An appropriately sized plate is then centered over return of motion and strength.17 Patients are restricted from
the fracture site, and the fracture is stabilized with screws. A syndesmosis operating an automobile for 9 weeks following right-sided
screw and tightrope are then inserted to reduce the mortise. ankle fractures.
A B C
Fig. 29-7 Postoperative radiographs. AP (A), mortise (B), and lateral (C) radiographs demonstrate anatomic reduction of the mortise with normal measure-
ments of the medial and lateral clear spaces with hardware in place.
Fig. 29-8 Bimalleolar ankle fracture. AP (A) and

lateral (B) radiographs demonstrating fractures of the
medial and lateral malleoli.
A B
Fig. 29-9 Postoperative radiographs. AP (A) and

lateral (B) radiographs demonstrating anatomic reduc-
tion of the fractures with appropriate position of the
screws and plate.
If a syndesmosis screw or screws were inserted during Several different grading systems, including subjective,
fixation, the patient must be nonweight bearing for 6 to 8 objective, and functional data, are used to evaluate ankle
weeks. The screw(s) is removed at 12 to 16 weeks postopera- fracture results. However, ankle fracture results are difficult
tively, since it can break with weight bearing if left in place. to compare because of the multitude of fracture patterns and
Physical therapy is started 6 to 8 weeks after surgery. After different circumstances of treatment. Results can be affected
the screw(s) is removed, the patient can be more aggressive by many things, including severity and type of injury, associ-
with physical therapy and weight-bearing activities. ated intraarticular problems, preexisting arthritis,3 age and
reliability of the patient, quality of the bone, and other site
Surgical Outcomes injuries. Finally, it should be noted that there is a potential
A successful outcome is defined as a fully healed fracture, for superficial nerve injury after surgical repair, as well as
with the patient achieving near full or complete range of syndesmosis instability.18
motion (ROM) with normal strength and function.9 Func- Younger age, male sex, absence of diabetes, and a lower
tion is defined differently for each patientan athletes func- American Society of Anesthesia class are predictive of a
tion is different from that of a sedentary, elderly patient. good functional recovery at 1 year following ankle fracture
surgery.11 Anand and Klenarman19 report that, in a sample found that early motion was associated with increased risk of
of 80 patients older than 60 years, 88.5% were satisfied with wound infection.23,24 Some authors also suggest early active
their postoperative outcome. Ankle fractures are the fourth range of motion (AROM) for plantar flexion and dorsiflexion
most common fracture in those older than 65 years and as soon as the surgical incision has healed.24,25 For those
usually are the result of significant trauma.12 Recent studies patients who are having issues with wound healing, a number
have not demonstrated any age-related risks to surgery of new technologies have been developed to try to accelerate
beyond those posed by other comorbidities.14,20 Therefore, wound healing, such as hyperbaric oxygen therapy, low level
the criteria for surgery should not be different for elderly laser therapy, nano/microcurrent technology, and infrared
patients than for younger individuals. light.22,26-28
Postoperative Considerations EVALUATION

In patients with stable, reliable fixation, sometimes early
motion can be initiated after the third or fourth postopera- The initial evaluation establishes the baseline deficits from
tive week to facilitate early return of motion and strength.17 which further goals and treatment are formulated (Box
Early motion and exercise have been found to have beneficial 29-1). AROM and passive range of motion (PROM) are
effects following ankle ORIF. Patients have demonstrated assessed within the patients tolerance. ROM is a primary
decreased activity/functional restrictions, decreased pain, and limitation noted at the initial evaluation. Joint effusion and
improved ankle range of motion with early mobility. However, soft tissue edema are evaluated as well using either a figure
a higher rate of adverse events following ankle ORIF was 8 technique, with a standard measuring tape, or by applying
associated with early exercise/mobility so care must be taken volumetrics. The patients ambulation is assessed to deter-
by both the therapist and patient to not overstress healing mine abnormal movement patterns secondary to an antalgic
tissues.21 gait. At this stage the patient may have acute pain and be in
When a syndesmosis screw has been inserted, the patient a fracture boot or other type of orthosis. Often, the patient
must be nonweight bearing for 6 to 8 weeks; the screw is may experience hardware-related pain, which may have an
removed at 10 to 12 weeks postoperatively. The screw will affect on functional outcomes.29 The physical therapist
break with weight bearing if it is left in place. Physical therapy inspects and evaluates scar mobility. Joint and soft tissue
is started 6 to 8 weeks after surgery. After the screw is mobility is assessed with an emphasis on the way restrictions
removed, the patient can be full weight bearing and initiate limit ROM and function. After enough mineralization and
physical therapy. calcium formation have occurred according to the physician,
an assessment of the arthrokinematic movements of the
Complications ankle joint can be done. For example, posterior glide of the
Minor complications include incidence of 4% to 5% wound talus is often markedly restricted and has been correlated to
problems (epidermolysis and superficial infection) and pero- restrictions in dorsiflexion and normal gait. In addition, pos-
neal tendinitis with painful hardware. Major problems terior and anterior glide of the proximal and distal fibular
include nonunion, hardware failure, 1% to 2% deep infec- heads have been shown to increase AROM and PROM.
tions (up to 20% in diabetic patients with peripheral After evaluation and discussion, the physical therapist
neuropathy), posttraumatic arthritis, and compartment syn- and patient formulate a treatment plan and goals. Belcher
drome. Patients who have any condition (i.e., diabetes, periph- et al30 reported impaired function as long as 24 months after
eral artery disease) that might compromise circulation in the an ORIF surgery for a trimalleolar fracture.
distal extremities are at an increased risk for complications
relating to wound healing and closure.22 PHASE I
THERAPY GUIDELINES TIME: Weeks 6 to 8 after surgery

FOR REHABILITATION GOALS: Minimize pain and swelling, normalize ROM,
initiate AROM and therapeutic exercises, normalize
The physical therapist normally evaluates the patient approx-
imately 6 weeks after surgery. In most cases, the patient has BOX 29-1Evaluation Goals
been in a cast for those 6 weeks and has had partial weight-
Assess PROM within pain tolerance.
bearing status between 2 and 4 weeks. Studies have reported
Assess AROM within pain tolerance.
that clinical outcomes may be improved in patients with
Assess joint effusion and soft tissue edema.
trimalleolar fractures who have full weight-bearing status in
Assess ambulation secondary to antalgic gait.
an ankle orthosis between 2 to 4 weeks after surgery.23 A
Assess scar mobility.
recent systematic review article evaluated nine randomized
Assess soft tissue mobility (including muscle tightness).
control studies that compared early motion of the ankle with 6
Assess joint mobility after 8 to 10 weeks (after enough
weeks of cast immobilization and found that early mobility is
mineralization and calcium formation has occurred
associated with quicker return to work and improved ankle
per physician).
range of motion after 12 weeks. However, other articles authors
gait, increase joint and soft tissue mobility, maintain includes gait training and lower extremity strengthening in
cardiovascular fitness, and provide patient education shallow and deep water in addition to land therapy. Recently,
(Table 29-1). Treatment goals initially are to some harness treadmill systems have been developed that
decrease pain and swelling, increase ROM and can unload the patients body weight and decrease his or her
strength, and normalize gait. AROM and PROM are fear of falling, allowing the patient to focus more on his or
initiated immediately for all planes of movement her gait mechanics. Ankle AROM exercises also are initiated
under the supervision of the physical therapist. in the pool.
AROM can progress from movement with lessened The patient should avoid jumping and running exer-
gravity (e.g., in a pool) to movement using gravity cises in shallow water at this time. However, if lack of ROM
as resistance. Soft tissue mobilization of restricted and gait are significant problems at the time of the patients
structures is particularly useful in decreasing initial physical therapy evaluation, the therapist may decide
pain and increasing ROM. Around 8 weeks, with to begin land therapy in combination with pool therapy to
physician approval, joint mobilization of the address specific problems and monitor the patient more
ankle is implemented using distraction and glide closely.
maneuvers.31 A compressive stocking is useful to help control soft tissue
edema and joint effusion, especially during initial weight-
Ankle joint mobilizations into resistance are deferred bearing activities. The patient is instructed in a home exer-
until enough mineralization and calcium formation have cise program incorporating ice, elevation, compression, and
occurred (usually 8 weeks). The rehabilitation program also light active exercises, such as stationary bicycling or AROM
TABLE 29-1 Ankle Open Reduction and Internal Fixation

Phase this Phase Functional Limitations Intervention Goal Rationale
Phase I Cleared by Limited weight-bearing Encourage use of compression Manage edema Control edema and decrease
Postoperative physician to begin per physician stocking Decrease pain pain using ES, rest, ice with
6-8wk rehabilitation Pain Cryotherapy with compression Increase PROM compression, and elevation
postoperation Edema ES (with pads carefully placed) Increase strength Improve ROM in pain-free
Limited ROM Elevation Decrease gait ranges to avoid increase in
Limited strength PROM (pain free) for ankle deviations, edema and pain
dorsiflexion, plantar flexion, improve tolerance Movement nourishes the
inversion, and eversion to weight bearing articular cartilage and
Joint mobilization grades II and Improve soft improves tolerance to
III (at 8wk with physician tissue mobility exercise
approval) Improve joint Physician must give
Isometrics (submaximal) for mobility weight-bearing status to
ankle dorsiflexion, plantar progress gait; weight-shifting
flexion, inversion, and eversion exercises and intermittent
AROM (pain free) for ankle loading (bicycle) can be
dorsiflexion, plantar flexion, useful in progressing
inversion, and eversion tolerance of the ankle and
PNF patterns foot to compression
Weight-shifting exercises Soft tissue and joint
Stationary bicycle mobilization is useful in
Seated balance board activities restoring ROM and gating
Soft tissue mobilization pain
Gait training as indicated by Core stabilization to maintain
weight-bearing status neutral pelvic position and
Instruction for locating neutral improve gait biomechanics
pelvic position Self-manage exercises
Initial core stabilization exercises
Home exercise program
AROM, Active range of motion; ES, electrical stimulation; PNF, proprioceptive neuromuscular facilitation; PROM, passive range of motion;
ROM, range of motion.
exercises, to reduce soft edema and joint effusion. Pain and phase of treatment blends with the first as ROM and gait
swelling are managed with appropriate modalities, such as progress to normal. Progressive resistive exercises are used
pulsed ultrasound or electrical stimulation. However, these to strengthen the anterior and posterior tibialis, peroneals,
modalities should not be performed over the metal implants. and gastrocnemius and soleus muscle groups. A home
Just as with quadriceps stimulation following knee surgery, program, using elastic tubing for resistance, is helpful to
high voltage electrical stimulation may be beneficial in the augment supervised physical therapy in the office. Treatment
early phase of recovery to retard any further muscle atrophy options for strengthening exercises include the stationary
of the gastroc/soleus complex that may have resulted secondary bicycle, stair-climbing machine, step-ups, step-downs, calf
to immobilization or weight-bearing restriction.32 raises, and isokinetic exercises. Specific muscle strengthen-
ing for the gastrocnemius and soleus muscles is important
to examine because of the likelihood of muscle atrophy. A
PHASE II total lower extremity strengthening program is indicated, as
well as a program to maintain cardiovascular fitness. Joint
TIME: Weeks 9 to 12 after surgery and soft tissue mobilization is continued as indicated. Sub-
GOALS: Minimize pain and swelling, normalize ROM, maximal isokinetics can be implemented using high speeds
normalize gait, decrease soft tissue restrictions, such as 120 to 180 per second. The higher velocities prevent
increase strength of intrinsic and extrinsic foot and excessive resistance that could exacerbate the patients symp-
ankle muscles (Table 29-2) toms. Proprioceptive activities are increased as the patient
begins to demonstrate increased balance; use of a balance
The second phase is initiated after pain and swelling have board is helpful in developing proprioception. The patient
subsided, usually 9 to 12 weeks after surgery. The second progresses heel raises from sitting to standing to single-leg

Phase II No signs of Edema and pain Continue interventions, as in phase I, Self-manage edema Progress home exercises
Postoperative infection present but under as indicated Decrease pain and use modalities as
9-12wk No loss of ROM control Modalities as needed Increase ROM indicated
No significant Limited ROM PROM (stretches)Gastrocnemius/ Increase strength Provide specific LE
increase in pain Limited strength soleus, tibialis posterior and anterior Decrease gait stretches
Gait deviations AROMSitting heel raises (bilateral deviations Improve tolerance to body
and progressed to single leg and from Improve functional weight as resistance for
sitting to standing). strength of gait exercises
Isotonic or elastic tubing exercises Increase endurance Use varying resistance to
dorsiflexion, plantar flexion, inversion, Increase progress strength
eversion proprioception and Use gym equipment to
Passive resistance exercises prevent reinjury progress functional
Treadmill strength and endurance;
Stationary bicycle progress to cardiovascular
Stair-climbing machine levels when able
Multihip exercises Use closed-chain and
Knee flexion/extension balance exercises to
Closed-chain exercises strengthen foot intrinsic
Leg press machine and ankle muscles in a
Bilateral heel raises weight-bearing position
Step-ups and step-downs
Lateral step ups and step-downs
Minisquats
Partial lunges
Isokinetics (submaximal)120-
180 per second
Balance exercises
AROM, Active range of motion; LE, lower extremity; PROM, passive range of motion; ROM, range of motion.
standing. Modalities such as compression wraps and ice times. The ninth and tenth repetitions should be difficult for
packs are used as indicated for postexercise pain and swell- the patient. Isokinetic strengthening programs can be initi-
ing. Electrical stimulation may be used if the pads are appro- ated. The use of various speeds during the workout session
priately placed away from plates and pins. The intensity of is referred to as velocity spectrum. We have found velocity
the rehabilitation should be altered if pain or swelling limit spectrum training useful in promoting strength and power
the rehabilitation progression. Weight-bearing exercises of the extrinsic muscles of the foot and ankle.
and resisted exercises done too aggressively will exacer- Functional training should be initiated for the patient
bate the symptoms and could delay the rehabilitation wishing to return to sporting activities or vigorous work.
process for several weeks. Treadmill walking on an incline or retrograde can be an
excellent method of training for the endurance athlete. Pool
PHASE III activities can be used initially for running and jumping.
TIME: Weeks 13 to 18 PHASE IV

GOALS: Maintain normal limits of ROM, joint and soft
tissue mobility, gait, and muscle strength; increase TIME: Week 19 and beyond
coordination for higher level activities; improve GOALS: Return to sporting activities or daily activities
balance and proprioception (Table 29-3) without restrictions (Table 29-4)
The third phase of rehabilitation begins approximately 13 Phase IV is the last phase, starting at 19 weeks after
to 18 weeks from the time of surgery. The fracture is usually surgery. This phase is used to condition the patient for a
healed by this phase of rehabilitation.25 The patient has pro- return to sports, work, or any activity requiring vigorous
gressed to normal ROM and demonstrates a normal gait and movement. Sport-specific activities are carefully imple-
increased strength with manual muscle testing. Before pro- mented with the use of an ankle brace.
gressing to a more aggressive program the patient should be Plyometric exercises simulate many sporting activities
cleared by the surgeon. Therapeutic exercises should pro because of the prestretch to the muscle before contraction.
gress to include strengthening exercises that are 60% to 70% Some examples of plyometric exercises include depth
of maximal effort. This submaximal effort is best determined jumping, trampoline, hopping, and jumping over obstacles.
by the patients ability to lift a specific amount of weight 10 However, plyometric exercises are stressful to joints and soft

Phase III Continued Limited strength Continuation of phase I and Full ROM Progress phases from I and II as
Postoperative progression with Limited gait II interventions as indicated No gait deviations indicated; discontinue reliance on
13-18wk phase II Limited progression Treadmill using incline and Ankle muscle modalities to control pain.
activities with jumping and retrograde strength 80%-90% Use uneven surface ambulation and
No loss of ROM running* Isokinetic velocity spectrum Increase agility drills to improve tolerance of
No increase in Agility drillsLateral coordination, the ankle and foot to the community
pain shuffles, carioca, and balance, and environment, and return to sport
initiate low-level proprioception Progress isokinetics to train ankle for
plyometrics Prepare for return endurance activities
Pool therapyRunning to sport Use water to aid in progression of
and jumping in chest- to tolerance to advance activities while
waist-deep water as unweighted
indicated Use FCE to determine work tolerances
if activity is in question
FCE, Functional capacity evaluation; ROM, range of motion.

*The patient should begin on progressive run and jump training programs during this phase. However, care needs to be taken to ensure that
the patient does not experience exacerbations. Adequate rest and recovery time between bouts of activities is essential. If a patient experi-
ences a problem (e.g., increased pain or swelling), the therapist should treat it as an acute injury and should reduce the symptoms before
progressing to the next phase.

Phase IV Continued Limited with higher level Continuation of exercises from Return to work and Use specificity of training
Postoperative progress in activities phases I to III as indicated sport activities principles to return to previous
19+ wk phases Plyometrics activities
I to III Work- and sport-simulated Use FCE to determine work
exercises tolerances if activity is in
FCE question
FCE, Functional capacity evaluation.
tissue structures and should be initiated after normal muscle swelling, and perceived instability. The cause of such poor
strength is obtained throughout the lower limb. outcomes is often unclear, but it may be related to missed
occult intraarticular injury.10,33-35 Other postoperative prob-
PRECAUTIONS lems that can develop include malunion or nonunion, loos-
ening or fracture of the internal fixation devices, infection,
A trimalleolar fracture is a serious injury. Secondary prob- and wound problems. These complications are rare. Unless
lems and complications can occur during postoperative contraindicated, the physical therapist must work on mobi-
rehabilitation. Occasionally low back or sacroiliac pain lization of the scar or scars, as well as general stretching
develops as a result of the antalgic gait with the cast or frac- and mobilization of the joint. Care should be taken to
ture boot. This is treated symptomatically with emphasis on increase soft tissue and ankle flexibility gradually and not
the need to normalize gait as soon as possible or restrict to stretch or stress the joint excessively to gain more rapid
ambulation activities. and improved ROM. Pool therapy should be used initially,
Overuse injuries such as plantar fasciitis secondary to a with some land therapy; as the patient progresses, land
preexisting overpronation may be treated with modalities therapy increases and pool therapy diminishes. The physical
and foot orthosis. Because limited dorsiflexion is sometimes therapist also must take care to avoid pushing the ankle too
an issue, a low-load prolonged stretch for dorsiflexion over hard, resulting in increased swelling, pain, and subsequent
2 to 30 minutes is effective. This can be done in conjunction loss of motion.
with moist heat or ultrasound to the gastrocnemius and The physician should be notified immediately if the
soleus muscle group. patient develops significantly increased pain, swelling, loss
of motion, or wound healing problems. In addition, if signs
SUGGESTED HOME MAINTENANCE of infection or loosening of the internal fixation develop, the
FOR THE POSTSURGICAL PATIENT physician should be notified immediately.
An exercise program has been outlined at the various phases. SUMMARY

The home maintenance box outlines rehabilitation sugges-
tions the patient may follow. The physical therapist can use In the next century, continued advances in surgical tech-
it in customizing a patient-specific program. niques and rehabilitation will allow patients to return earlier
to their work and sports activities. As additional physicians
TROUBLESHOOTING and physical therapists specialize in foot and ankle prob-
lems, more basic and clinical research will be carried out
Residual problems after surgical anatomic restoration of the to push the envelope of progress to improve foot and
ankle joint include chronic pain, loss of motion, recurrent ankle care.

Weeks 6 to 8 3. Step-ups and step-downs
GOALS FOR THE PERIOD: Minimize pain and 4. Single-leg standing progressed to standing on a
swelling, improve ROM, initiate AROM and pillow with eyes open and then with eyes closed
therapeutic exercises, improve gait, and maintain (for balance and proprioception)
cardiovascular fitness 5. Walking program, including hills as appropriate
1. AROM of the ankle (plantar flexion, dorsiflexion, 6. Lower extremity conditioning using a stationary
inversion, and eversion) bicycle, stair-climbing machine, treadmill, pool,
2. Stretching exercises for the gastrocnemius and leg press, and toe raises
soleus muscle groups in a nonweight-bearing 7. Weight-bearing stretching exercises to the
position (use of a towel or strap to stretch these posterior calf muscles
muscles is recommended)
3. Seated heel and toe raises Weeks 13 to 18
4. Ice, elevation, and compression GOALS FOR THE PERIOD: Maintain normal ROM,
5. Lower extremity conditioning using the stationary gait, and strength; increase coordination for higher
bicycle and/or pool level activities; improve balance and proprioception;
Exercise progression: Begin all exercises with and transition to sporting activities
2 sets of 10 repetitions. If no adverse effects are 1. Strengthening exercises with increasing
noted to previous intensity level, progression can resistance
proceed to 3 sets of 10 repetitions, followed by 3 2. Pool activities such as jumping, running, and
sets of 12 to 15 repetitions, and finally 3 sets of 20 cutting drills
repetitions. Once a patient is able to perform 3 sets 3. Agility drills such as side shuffles, backward
of 20 repetitions of an exercise, the intensity of the walking, and carioca
exercise must be increased in some form (i.e., more 4. Lower extremity conditioning continued from
resistance, longer duration, etc.) and the patient phase II
should start back with 2 sets of 10 repetitions and
follow the same progression. Week 19 and Beyond
GOALS FOR THE PERIOD: Return to previous level
Weeks 9 to 12 of function (sport- and activity-specific exercises)
GOALS FOR THE PERIOD: Normalize ROM and gait, without restrictions
increase strength of the intrinsic and extrinsic foot 1. Maximal strengthening of lower extremity
and ankle musculature, and improve cardiovascular muscles
condition 2. Land-based functional activities, such as running,
1. Standing heel raises jumping, and cutting
2. Resistive exercises using elastic bands or tubing 3. Sports simulated activities
for all ankle movements
1 Amy is a 30-year-old female who suffered a bimalleolar

fracture while playing soccer. She underwent an ORIF
procedure on her ankle 15 weeks ago. Amy complains
glides. These were treated appropriately, and the patient
immediately noticed a decrease in her stiffness.
of tightness, which progressively increases throughout

the day as she performs her functional daily activities.
How did the therapist address this issue in her treatment
2 Lauren is a 23-year-old female who suffered a bimalleo-
lar fracture secondary to a motor vehicle accident.
Lauren has progressed well; however, she has noticed
plan? increased purulent discharge from her incision at an
area that is having difficulty closing. Upon assessment,
When a patient complains of stiffness, it is always neces- increased skin temperature and redness around the inci-
sary to determine if the problem is joint or soft tissue in sion was also noted. What was done?
nature. The therapist assessed the patient and found
significant restrictions with proximal fibular anteropos- The physician was notified, and the patient was sent
terior (AP) glides and distal fibular posteroanterior (PA) for a follow-up visit. Tests showed the patient had
developed an infection at the incision site, and she was also noted to have 5 of dorsiflexion. How did the thera-
placed on a broad-spectrum antibiotic. Whirlpool treat- pist proceed?
ment was initiated, maintaining the water at 98 F to 100
F for 20 minutes, three times per week. General wound Grades III and IV joint mobilization was performed for
care was provided, and her rehabilitation schedule con- AP talar glides and grades III and IV physiologic calca-
tinued in a modified fashion. neal abduction. A contract-relax technique was initiated
to increase dorsiflexion. The patient was then taught
3 Brittany is a 30-year-old female who suffered a bimal-

leolar fracture and had ORIF 16 weeks ago. Brittany has
returned to her position as an art teacher, which requires
how to perform the contract-relax technique as a home
exercise. Exercises to increase strength in the peroneals
and the gastrocnemius and soleus complex were
her to stand frequently throughout the day. Since return- also performed. Additionally, a 3 wedge was inserted
ing, Brittany reports she has had increased lateral ankle into the right shoe medially to decrease the angle
pain, which is greater in the afternoon and evening. of pronation. The patient was later casted for custom
How did the therapist treat this patient? orthotics.
Brittany was assessed and it was found that her AROM

and strength were within normal limits. She had the
option of having the hardware removed once healing
6 Eric is a 26-year-old football player who injured his
ankle when his foot got caught under another player. His
injury resulted in a compound fracture to both his right
occurred; however, Brittany refused to have additional tibia and fibula. His injury was treated with ORIF, and
surgery. Brittany was issued a home TENS unit and was he is presenting to the therapist for his initial evaluation
instructed in its use, as well as precautions and contra- 8 weeks following the surgery. He was nonweight-
indications. She was also issued an ankle-stabilizing bearing for the entire period before beginning therapy.
orthosis (ASO) brace to wear during work and with activ- How should the therapist begin treatment of Eric at this
ities requiring prolonged walking and running. Finally, time?
the therapist discussed various options for allowing
changes in the length of time she stands during the day The initial assessment should include examination of the
(the therapist recommended she use a stool while ankles active and passive range of motion within limits
lecturing). of his pain tolerance. The therapist should inspect the
surgical sites for signs of possible infection. Strength
4 Sarah is a 23-year-old college senior who suffered a right

ankle bimalleolar fracture and had ORIF 6 weeks ago.
On arriving to the clinic for a treatment session, she
testing should be deferred at this stage. Treatment may
begin with modalities to promote healing and reduce
excessive scar tissue formation, such as infrared light,
complained of experiencing increased right calf pain ultrasound, and scar massage if warranted. If visible
exacerbated with weight bearing. Sarah also reported atrophy of the gastroc/soleus complex is noted, the ther-
that she noticed her right calf felt hot to touch as apist can take circumferential or volumetric measure-
compared with the left. She has not slept well the last ments and initiate high-voltage electrical stimulation.
two nights secondary to the previously mentioned The patient should be given a home program, including
symptoms. How did the therapist proceed? active and active assistive range of motion exercises, for
plantar flexion, dorsiflexion, inversion, and eversion,
Further assessment by the therapist revealed a positive which should not induce pain. Eric then should be edu-
Homans sign at the right calf. The physician was notified, cated on how to progress with his gait training. For
and the patient was sent immediately to the hospital for example, he should start with bilateral axillary crutches
an ultrasound, which showed the patient had developed and WBAT. Once he has proper mechanics and is able
a deep vein thrombosis (DVT). The patient was admitted to ambulate without pain he can be weaned to one axil-
to the hospital where anticoagulant therapy was lary crutch on the contralateral side, then to a single
initiated. point cane, and finally no assistive device.
5 Braeden is a 19-year-old male who suffered a bimalleo-

lar fracture 20 weeks ago with corresponding ORIF. He
received physical therapy at another facility after his
7 Lorraine is 30-year-old female who injured her ankle in
a rollover all terrain vehicle (ATV) accident. She was
found to have fractured her left distal tibia, along with
surgery for 10 weeks. Braeden has been referred to the a Lis Franc fracture in her left foot. Both injuries were
therapists facility with a chief complaint of pain inferior addressed with ORIF. After undergoing rehabilitation
to the lateral malleolus and at the Achilles tendon inser- for the first 4 months, she has now begun to return to
tion. Pain is minimal in the morning and progressively work at a retail sales position. She reports increased
worsens throughout the day. The patient was noted to lateral foot pain, lateral swelling, and pain along the
have decreased calcaneal abduction and demonstrated distal medial tibia extending into her arch. How would
increased pronation on the affected side. The patient was the therapist address her complaints?
Upon evaluation of Lorraines gait mechanics, a collapse After a severe traumatic injury, such as an ankle fracture
of the midtarsal joints was found during the stance phase that requires ORIF, the immediate concern is to stabilize
of gait. To address this and her medial distal tibia tender- the injury and prevent any secondary injury; for example,
ness, custom orthotics were fabricated to help support compartment syndrome or infection. Sometimes in
the midtarsal area during ambulation. Lorraine also was these types of injuries, other pathology further up the
noted to have restricted dorsiflexion of the talocrural kinetic chain may not be recognized until later in the
joint, restricted cuboid mobility, and limited first meta- treatment process once the patient begins to perform
tarsophalangeal joint mobility. The following manual more aggressive weight-bearing activities. The patient
therapy techniques were used to improve her joint should be referred back to her orthopedist, and the thera-
mobility: talocrural distraction; anterior and posterior pist should contact the orthopedist and relay his or her
glides of the talus; anterior/posterior glides of the cuboid; concerns and objective findings. In Sallys case, she had
and traction with anterior/posterior glides of the first medial joint line tenderness, occasional crepitus, and
metatarsophalangeal joint. Lorraine was educated on pain with stair climbing, as well as positive Apley com-
trying to take more frequent breaks while working, so pression and Thessaly meniscal special tests. The patient
that her ankle does not become as swollen following her underwent imaging after seeing the orthopedist and was
work activities. found to have a medial meniscus tear, which was
addressed with arthroscopy.
8 Kate is a 21-year-old who fractured both of her ankles

in a fall. She required both external fixation and ORIF
procedures to restore proper alignment and to allow for 10 Allan is a 25-year-old basketball player who frac-
tured his right ankle while landing on an opponents
proper bone healing. Kate was nonweight-bearing for foot during a game. His fracture was stabilized with
4 months after the injury. She now presents to PT ORIF, and he was placed in a controlled ankle move-
approximately 1 year after the injury. She has recently ment (CAM) boot approximately 4 weeks after the
began to return to running and is complaining of bilat- procedure. He has been progressing with his reha-
eral Achilles tendinitis. What type of exercise program bilitation and is now 6 months after his surgery. He
should Kate be placed on to address her problem? has recently begun sport-specific activities, such as
running, jumping, and cutting. Describe a proper
Eccentric exercise programs have been shown to have exercise progression for Allan at this stage of his
beneficial results in tendon strengthening. However, ini- rehabilitation.
tially the patient must be started at an exercise intensity
that does not exacerbate the tissue while it is still Before beginning higher impact activities, including
inflamed. The initial treatments may consist of modalities running, jumping, and cutting required for sports like
to reduce pain, swelling, or tenderness in the area and basketball, the patient must demonstrate necessary
begin a gentle gastroc/soleus towel stretching program. lower extremity strength and sufficient soft tissue and
The exercise progression may begin starting with double joint mobility before attempting more vigorous activi-
leg calf raises, three sets of 15 repetitions, adding one to ties. Also, the patient should have been placed on a
two sets every week of treatment, depending on the neuromuscular and perturbation training program with
patients response to the exercise program. After 4 to 6 an emphasis on landing mechanics and proprioception
weeks of double leg calf raises, the patient may progress before beginning the more advanced weight-bearing
to single leg calf raises and start the program over along activities. To begin, Allan may begin jumping either in a
the same progression as before. Kate will start the exer- pool or on devices (i.e., Shuttle MVP) that allow for
cise by standing on the edge of a step and raising up on partial weight-bearingfirst beginning with bilateral
her toes as high as she can. After pausing at the apex, lower extremity exercises and then progressing to uni-
she should then start slowly lowering herself back to the lateral. Once he has progressed through this phase,
ground, if possible, at a 5- to 7-second descent is ideal. Allan may begin more full weight-bearing exercises,
such as jump squats, single leg hops over obstacles,
9 Sally is a 45-year-old female who fractured her left ankle

when she fell off of her horse. She was treated with ORIF
in the days following the injury and has progressed
and multidirectional lunges. The last phase should incor-
porate sport-specific agility drills while maintaining
focus on proper mechanics and joint protection. For
through rehabilitation after initially being nonweight- example, Allan may perform a shuttle drill with a differ-
bearing for 8 weeks. She is now approximately 4 months ent basketball skill or maneuver required at each station
out from surgery and is ambulating without any assistive of the drill.
device. Sally has been complaining of left medial knee
pain and swelling with prolonged weight-bearing activi-
ties. Upon further evaluation the therapist is concerned
of possible cartilage/meniscal pathology, how should
11 Angela is a 55-year-old female who experienced an
open fracture of her left ankle when she fell off
of a step. She underwent surgical repair of the injury,
the therapist proceed? but had issues with wound closure following the
procedure and required a skin graft. Angela is a dia- surgeon and therapist include hyperbaric oxygen treat-
betic and has issues with circulation to her distal ments, infrared light therapy, microcurrent/nanocurrent
extremities secondary to her diabetes. She presents electrical stimulation devices, and traditional wound care
to physical therapy 8 weeks after the injury. Her (using a variety of topical creams and/or dressings).
wound has still not fully healed but does not dem- Angela should be educated on not trying to stress the
onstrate signs of infection (i.e., warmth, redness, healing area excessively while the tissue is still fragile;
tenderness, or drainage surrounding the wound). for example, being on her feet for a number of hours
What should the therapist do to assist with wound continuously leading to increased swelling, which may
healing at this stage in her recovery. further delay healing. Also, the patient needs to be edu-
cated on reducing other lifestyle factors, which might
The therapist should contact the referring doctor to relay impede healing, such as smoking or illicit drug use, nutri-
concerns regarding the patients slow wound healing. tional status, proper rest and recovery, or any medica-
Recently, newer technologies have been developed to tions that may delay healing. Wound healing needs to
assist those who may have issues with wound healing. be obtained first before the patient may progress to the
Treatment options that may be considered by the next phase of the rehabilitation process.
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2001. 2:270-280, 1994.
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Hughes SPF: A historical view of fractures involving the ankle joint. Mayo 2006.
Clin Proc 50:611, 1975. Stone JW: Osteochondral lesions of the talar dome. J Am Acad Orthop Surg
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CHAPTER 30
Ankle Arthroscopy
Tom Burton, Danny Arora, Benjamin Cornell, Lisa Maxey, Richard D. Ferkel
T
he first arthroscopic inspection of a cadaveric joint contraindications include complex regional pain syndrome
was performed by Takagi in Japan in 1918.1 In 1939 (CRPS), moderate DJD with restricted range of motion
he reported on the arthroscopic examination of an (ROM), severe edema, and tenuous vascular supply.
ankle joint in a human patient.1 With the advent of fiberoptic
light transmission, video cameras, instruments for small PATIENT EVALUATION
joints, and distraction devices, arthroscopy has become an
important diagnostic and therapeutic modality for disorders Successful outcomes following ankle arthroscopy depend on
of the ankle. Arthroscopic examination of the ankle joint accurate diagnosis and concise preoperative planning. It is
allows direct visualization during stress testing of intraar- important to understand the nature of the patients com-
ticular structures and ligaments about the ankle joint. plaint and gather the following information: date of injury,
Various arthroscopic procedures have been developed with duration and severity of symptoms, provocative events, pre-
less attendant morbidity and mortality to patients.2-6 With vious injuries and presence of any redness, swelling, instabil-
the advent of better, smaller joint arthroscopes and instru- ity, stiffness, locking, or popping.
mentation, and the introduction of more efficient noninva- A general medical examination should be obtained, with
sive distraction devices, ankle arthroscopy is now state of the special attention to rheumatologic disorders. The physical
art. It has become a standard procedure in many institutions examination should include: inspection, palpation, ROM,
as a diagnostic and therapeutic tool for the practicing and special tests. The contralateral side should always be
surgeon. inspected for comparison. Stability of the ankle and the sub-
talar joint should be evaluated. Often, a local anesthetic
SURGICAL INDICATIONS AND agent can be injected into a specific joint to aid in
CONTRAINDICATIONS diagnosis.
Routine blood tests should be performed to check for
Foot and ankle arthroscopy has become a valuable adjuvant systemic and rheumatologic conditions and infection. Aspi-
to the diagnosis and treatment of an increasing amount of ration of the ankle joint and analysis of the joint fluid can be
disorders. Diagnostic indications (Box 30-1) for ankle helpful in distinguishing inflammatory from septic condi-
arthroscopy include unexplained pain, swelling, stiffness, tions of the ankle joint.
instability, hemarthrosis, locking, and abnormal snapping or Routine radiographs (anteroposterior [AP], lateral, and
popping. mortise view) should be obtained for all patients. Stress
Operative indications for ankle arthroscopy include loose radiographs can provide useful information when instability
body removal, excision of anterior tibiotalar osteophytes, is suspected. Computed tomography (CT) and/or magnetic
dbridement of soft tissue impingement and arthrofibrosis, resonance imaging (MRI) are often helpful in evaluating soft
and treatment of osteochondral lesions and ankle instability. tissue and bony disorders about the foot and ankle. Three-
Other indications include arthrodesis for posttraumatic phase bone scans can also aid in distinguishing soft tissue
degenerative arthritis and treatment for ankle fractures and from bony pathology.
postfracture defects.
Absolute contraindications for ankle arthroscopy SURGICAL TECHNIQUE
include localized soft tissue or systemic infection, and
severe degenerative joint disease (DJD). With end-stage Ankle arthroscopy is usually performed in one of four ways:
DJD, occasionally successful distraction may not be possible, (1) in the supine position, (2) with the knee bent 90 over
precluding visualization of the ankle joint. Relative the end of the table, (3) in the decubitus position, or (4) in
536
Chapter 30 Ankle Arthroscopy 537
BOX 30-1 Surgical Indications and Contraindications
Indications
Loose bodies
Anterior tibiotalar osteophytes
Soft tissue impingement
Osteochondral lesions
Synovectomy
Lateral instability
Arthrodesis
Ankle fractures
Contraindications
Infection*
Severe degenerative joint disease* Fig. 30-1 Setup for ankle and foot arthroscopy with the patients thigh
Complex regional pain syndrome secured on a support and soft tissue distraction applied across the ankle.
Moderate degenerative joint disease
Severe edema
Tenuous vascular supply
branches on the skin with a marker. Identification of the
*Absolute contraindications. superficial peroneal nerve and its branches is facilitated by

Relative contraindications.
inverting and plantar flexing the foot and flexing the toes.
Arthroscopic Portal Placement

The surgeon uses three primary portals or access areas to
insert the arthroscope and instrumentation (Fig. 30-2).
the prone position for posterior ankle arthroscopy. The These include the anteromedial, anterolateral, and postero-
method of choice is a surgeons preference, while taking into lateral portals. Accessory portals can be used as needed but
account specific surgical circumstances. Different types and are rarely required. Portals are made by nicking the skin only,
sizes of arthroscopic equipment can be used depending on then with the use of a clamp spreading through the subcu-
surgeons preference and availability of equipment. The pro- taneous tissue and into the ankle joint. The surgeon must
cedure described is that used most commonly by the senior take great care to avoid injuring the neurovascular and ten-
author of this chapter; a more detailed description of ankle dinous structures.
arthroscopy can be found in his textbook.2 The anteromedial portal is established first and a 2.7-mm,
30 oblique small joint videoscope is inserted. The surgeon
Positioning establishes the anterolateral portal under direct vision, using
The patient is taken to the operating room and placed in the extreme care to avoid injuring the superficial peroneal nerve
supine position. The hip is flexed to 45, and the thigh is branches. The arthroscope is then positioned in the posterior
placed onto a well-padded support placed proximal to the portion of the ankle so the posterolateral portal can be made
popliteal fossa and distal to the tourniquet. The lower just lateral to the Achilles tendon, entering the ankle beneath
extremity (LE) is then prepared and draped so that good the posterior ankle ligaments.
access is available posteriorly. A tourniquet is applied as In recent years, techniques have been developed for
needed. A noninvasive distraction strap is placed over the arthroscopy in the prone position, using the posterolateral
foot and ankle. Distraction is used to separate the distal tibia and posteromedial portals. This allows access for treatment
from the talus so that at least 4mm of joint space opening of a variety of problems, including osteochondral lesions of
is obtained (Fig. 30-1). Without distraction, the surgeon has the talus (OLT), os trigonum, and flexor hallucis longus ten-
difficulty positioning the arthroscopic instruments in the dinitis or tears.7-10 The senior author of this chapter occasion-
ankle without scuffing the articular cartilage; visualizing the ally uses this position.
central and posterior portions of the ankle also is difficult
without adequate joint separation. The distraction device is Arthroscopic Examination
carefully positioned so as not to injure the neurovascular A 21-point arthroscopic examination of the ankle is per-
structures, and approximately 30 to 40lb of force is placed formed to ensure a systematic evaluation.2 After completing
across the ankle for no more than 60 to 90 minutes. Before the arthroscopic evaluation, the surgeon identifies the
applying the distraction strap, the surgeon should identify pathology and treats it accordingly, using small joint instru-
and outline the dorsalis pedis artery, the deep peroneal mentation ranging in size from 2.0 to 3.5mm. These instru-
nerve, saphenous vein, tibialis anterior tendon, peroneus ments include baskets, knives, intraarticular shavers, and
tertius tendon, and superficial peroneal nerve and its burrs. Scar tissue is removed using baskets and an
Great saphenous vein
Superficial peroneal nerve
Anterior tibial tendon
Anterolateral portal
Anterocentral portal
Anteromedial portal
Anterior tibial neurovascular bundle
Peroneus tertius tendon
Sural nerve
A Small saphenous vein
Posterior tibial
neurovascular bundle
Posterolateral portal
Trans-Achilles portal
Posteromedial portal
Fig. 30-2 A, Anterior arthroscopic ankle portals. The anterocentral portal is usually not used. B, Posterior arthroscopic ankle portals. The Achilles portal is
not normally used. (From Ferkel RD: An illustrated guide to small joint arthroscopy, Andover, MA, 1989, Smith & Nephew Endoscopy.)
intraarticular shaver. Synovectomy is performed with an promote fibrocartilage formation and new circulation in the
intraarticular shaver (Fig. 30-3). OLT are carefully evaluated avascular area (Fig. 30-4). Acute ankle fractures can be eval-
and, if they are found to be loose, excised with a ring curette uated arthroscopically; the surgeon can perform percutane-
and banana knife. The surgeon can use transmalleolar or ous screw insertion while monitoring fracture reduction
transtalar drilling, and/or microfracture techniques, to arthroscopically (see Chapter 29).
Fig. 30-3 Arthroscopic surgery of the right ankle. Notice the small joint
arthroscope is in the anteromedial portal, the intraarticular shaver is in the
anterolateral portal, and inflow is coming in through the posterolateral
portal.
Fig. 30-5 Sagittal T-1 weighted MRI showing low-signal intensity, consis-
tent with anterolateral soft tissue impingement of the ankle.
has been estimated that 10% to 50% of patients will have

some degree of chronic ankle pain.
The primary cause of chronic ankle pain after an ankle
sprain is soft tissue impingement. This can occur along the
syndesmosis, the syndesmotic interval between the tibia and
fibula, or the medial, lateral, and/or posterior gutters. Most
commonly it is located anterolaterally given the common
occurrence of a common inversion ankle sprain.11 Diagnosis
is done by careful history, physical examination, and selec-
tive injections. MRI can also be very helpful in assessing the
Fig. 30-4 Transmalleolar drilling of a medial osteochondral lesion of the problem (Fig. 30-5).12
talus in a right ankle. Notice the arthroscope is visualizing through the The sequence of lateral ankle pain after a sprain can be
anterolateral portal. explained as shown in Fig. 30-6.
A distraction device may be necessary to identify some of
After the procedure is performed, the wounds are closed the synovial pathology involving the posterolateral corner of
with a nonabsorbable suture, and a compression dressing the ankle, because such identification can be sometimes diffi-
and posterior splint are applied. cult. The inflamed synovium, thickened adhesive bands, osteo-
phytes, and loose bodies are dbrided arthroscopically using
Postoperative Plan motorized shavers and burrs, graspers, and baskets (Fig. 30-7).
The patient remains nonweight bearing on crutches for 1 Postoperatively, patients are splinted for 1 week, and then
week. The splint and the stitches are then removed. If an put into a CAM (controlled angle motion) walker for 2 to 3
osteochondral lesion has been treated with one of the previ- weeks. Subsequently, they wear a soft ankle brace and begin
ously mentioned methods, the patient may be required to be formal physiotherapy. Return to activity or sport is allowed
non-weight bearing for 4 to 6 weeks. During this time, the only after all rehabilitation goals are achieved.
patient is initially in a removable splint and is allowed to Arthroscopic treatment of anterolateral soft tissue
exercise the ankle actively to promote new fibrocartilage for- impingement of the ankle has been proven successful at alle-
mation. The type of arthroscopic procedure performed and viating chronic ankle pain after an inversion sprain. Numer-
individual patient goals determine weight-bearing status and ous authors have reported a good to excellent outcome in
rehabilitation. approximately 80% to 85% of patients.11,13,14
SOFT TISSUE IMPINGEMENT OSTEOCHONDRAL LESIONS
Ankle sprains are one of the most common injuries in sports. Controversy persists regarding the cause, treatment, and
One inversion sprain occurs per 10,000 persons per day. It prognosis of osteochondral and chondral lesions of the
Inflamed ligament ends Arthroscopic treatment of OLT has proven to be compa-

rable with open surgery, with less morbidity and less recov-
ery time. Ankle arthroscopy has proven to be one of the most
reliable methods in classifying OLT. Recently, clinical man-
agement of articular cartilage defects has generated signifi-
Synovitis Scar tissue
cant research interest in the orthopedic world. Attempts to
stimulate a hyaline cartilage response have included trans-
plantation of various cells, including periosteal and peri-
chondral tissues, woven carbon-fiber pads, and osteochondral
Hypertrophic soft tissue autografts/ allografts.
In addition, chondrocyte transplantation has been studied
extensively now in the United States. With further research,
it is hoped that osteochondral defects can be successfully
covered by articular cartilage instead of fibrocartilage
Impingement in lateral gutter
replacement.9
OVERALL SURGICAL OUTCOMES
Numerous papers have been published regarding the

outcome of arthroscopic surgery of the ankle. Results vary
Chronic lateral pain
depending on the type of procedure and the study that was
Fig. 30-6 Sequence of lateral ankle pain.
undertaken.15-23 In general, a large percentage of patients
should achieve a successful outcome depending on the
nature of the pathology. Expectations after surgery include a
full ROM, strength, and full function. The preoperative
ROM, strength, and severity of the pathologic condition
ankle. OLT comprise 4% of all osteochondral defects. Males heavily influence the results.
are slightly more predominant than females between the ages
of 20 to 30 years. Medial talar dome lesions are more common COMPLICATIONS
than lateral.
There are many possible causes for OLT. Trauma is All arthroscopic procedures have potential complications.24
believed to play a major role, but there are also instances The most common complications in foot and ankle arthros-
where atraumatic presentations are possible, secondary to copy are injuries to the neurovascular structures, especially
idiopathic avascular necrosis. The diagnosis of OLT requires the superficial peroneal nerve.8 The overall complication rate
a high index of suspicion because symptoms may be mild has varied with the transition from invasive to noninvasive
and imaging is not readily available. Patients may present in distraction. Current complication rates are between 6.8%
an acute traumatic setting, complaining of persistent ankle and 9%.25,26 The physical therapist should report to the physi-
pain (i.e., inversion ankle sprain), or may have a chronic cian any problems they note after surgery. Sometimes, exces-
complaint of ongoing ankle pain. The literature has shown sive massage over the portals can even irritate the nerves and
that the location of pain is not correlative with the location cause tingling and numbness. In general, we wait 2 to 3
of the lesion, therefore adding to the vague nature of the weeks to initiate physical therapy after ankle and foot
condition. Other common symptoms include stiffness, deep arthroscopy to avoid wound problems and increased pain
aching pain, swelling, clicking, locking, or even instability. while the soft tissues are healing.
OLT that do not respond to conservative treatment are
treated arthroscopically. Most chronic OLT in adults are THERAPY GUIDELINES FOR
loose and have to be excised. The osteochondral lesion bed REHABILITATION
is then microfractured and/or drilled. Occasional they can
be pinned back (Fig. 30-8). Several factors must be considered in planning a successful
Postoperatively, patients are splinted for 1 week in neutral rehabilitation program for the postoperative ankle arthros-
position. Once the portal incisions have healed (approxi- copy patient. Rehabilitation guidelines can vary greatly for
mately 1 to 2 weeks), ROM exercises are begun, since early the same injury depending on the patients age, severity/
motion appears to facilitate cartilage healing. Patients remain chronicity of injury, healing rate of tissue, general medical
nonweight bearing for 6 to 8 weeks, depending on the size health, and previous level of activity. The physician, physical
of the lesion. Usually by 4 to 6 weeks, patients start physical therapist, and patient must work together as a team to create
therapy in the pool and then progress to land exercises. an appropriate, effective, and efficient treatment plan that
Cutting, shear stress, or impact activities are avoided for 6 will allow the patient to optimize his or her recovery. The
months. phases in each of the following rehabilitation protocols may
Anterolateral portal
Anteromedial portal
Lateral gutter Meniscoid lesion

C
Fig. 30-7 Soft tissue impingement of the ankle. A, Arthroscopic picture in a right ankle of synovitis and scarring of the anterolateral talar dome. B, Dbride-
ment of anterolateral soft tissue impingement with synovitis and fibrosis at the anterolateral gutter in a right ankle. C, Arthroscopic drawing showing the scar
bands and inflammation as a portion of the anterior inferior talofibular ligament fascicle abrading the lateral talar dome in a right ankle. (B and C from Ferkel
RD: An illustrated guide to small joint arthroscopy, Andover, MA, 1989, Smith & Nephew Endoscopy.)
overlap 1 to 3 weeks depending on the factors mentioned tive training in conjunction with the patients strength-
previously and individual progress. ening program will improve overall outcomes.
The physical therapist should consider the following 6 3. Minimize the effects of immobilization.
basic principles when planning an ankle rehabilitation 4. Encourage a neutral subtalar position during exercise
protocol: to optimize functionally efficient training. This may
1. Protect the healing tissue. What tissues were directly require orthotics.
and indirectly affected during the procedure? Was the 5. The ultimate goal of rehabilitation is to optimize the
tissue healthy or frayed? patients function, minimize pain, and restore the
2. It is not just about strengthening. Control of acute patient to a reasonable and acceptable quality of life.
symptoms and restoration of normalized mobility 6. Take into account the whole patient. The ankle is just
need to be addressed before embarking on an ankle one part of the patients kinetic chain. It is this kinetic
strengthening regimen. Incorporation of propriocep- chain that needs to be addressed in optimizing
Medial malleolus
Fig. 30-8 Treatment of osteochondral lesion of the talus. A, Arthroscopic picture viewed from the posterolateral portal of an osteochondral lesion of the
medial talar dome with microfracture holes being placed through the anteromedial portal in a right ankle. B, Transmalleolar drilling of the osteochondral
lesion through the medial malleolus into the talus, while viewing from the anterolateral portal. C, Arthroscopic drawing showing how the K-wire goes through
the medial malleolus into the talus to create bleeding channels. (B and C from Ferkel RD: An illustrated guide to small joint arthroscopy, Andover, MA, 1989,
Smith & Nephew Endoscopy.)
outcomes. Putting a plan of care that includes the underwent an arthroscopic procedure to dbride the antero-
patients UEs, trunk, core, and LEs will improve suc- lateral soft tissue because of impingement.
cessful return to function. Recognizing and addressing
any dysfunctions within the kinetic chain will improve Preoperative Phase
functional outcomes and lessen future problems. GOALS: Restore functional ROM; normalize gait; apply
The following rehabilitation program was designed for a corrective orthoses to improve mechanical
patient who has chronic pain because of a recurring inver- neutrality; gait train with the appropriate assistive
sion sprain suffered during the basketball season. The patient device(s), taking into consideration postoperative
weight-bearing status; create patients initial
TABLE 30-1 Ankle Arthroscopy

Progress to Impairments and
Preoperation Physician Limited ROM ROM, mobilization, HEP Restore functional Patients return of ROM
determines Poor gait quality to improve ROM ROM postoperation improves if ROM
patient is a No formal exercise Gait training specific to Normalize gait preoperation is improved
surgical program assistive device needed pattern using the Patient safety is important during
candidate Patient uncertainty as and weight-bearing necessary assistive early preoperative phase. Poor gait
to what to expect restrictions considering devices following the or poor weight-bearing status
community barriers normal postoperative follow-through could limit overall
Educate patient on an weight-bearing outcomes
HEP for preoperative and statuses Patients ability to practice HEP
postoperative wk 1 with Independent HEP to before surgery will improve
hand out include postoperative likelihood of correct HEP technique
Educate patient on HEP after and patient compliance
surgery and usual Patient well Patients will do better if they have a
postoperative care and informed as to better understanding of what to
timelines upcoming events expect and what is expected of
them
HEP, Home exercise program; ROM, range of motion.
postoperative home exercise program (HEP) to Functional disability measure

bridge the gap from surgery to initiation of formal Lower extremity functional scale
postoperative rehabilitation with surgeons input; Foot and ankle disability index
educate patient as to what the next few months will Tests requiring caution
entail and answer any questions the patient may Weight-bearing tests if nonweight bearing
have (Table 30-1) Strength testing if patients irritability is high
TIME: Week 1 Postoperative
Phase I: Acute Phase GOALS: Protect the healing tissue; control
postoperative pain and swelling; initiate HEP;
Initial Postoperative Examination
maintain patients overall level of fitness (Table 30-2)
Palpation
Incision site Postoperatively, the patient will be in a splint and have
Local muscles and tendons (gastrocnemius, soleus, weight-bearing restrictions. The patient should follow all post-
Achilles tendon) operative instructions unless told otherwise by the surgeon.
Check for pitting edema Elevation and intermittent icing (including cryopneumatic
Dorsalis pedis pulse device) will help control postoperative swelling and pain. The
Active range of motion (AROM)/passive range of motion patients HEP can be initiated based on the program designed
(PROM) measurements preoperatively. This may include upper extremity (UE)
Dorsiflexion, plantar flexion, inversion, eversion AROM/resistive exercises, trunk and core training, isometric
Hallux dorsiflexion strengthening of the glutes, and quads and hamstrings bilater-
Knee and hip joints ally with AROM exercises for the uninvolved side.
Girth measurements
Figure 8 or volumetric measure
Strength of uninvolved LE muscles Phase II: Early Rehabilitation
Quadriceps TIME: Weeks 2 to 5 Postoperative
Hamstrings GOAL: Decrease inflammation and pain; increase ankle
Hip flexors ROM; restore soft tissue flexibility/mobility; restore
Hip extensors normal gait; progress weight-bearing and non
Hip abductors weight bearing exercises; maintain patients general
Hip adductors cardiovascular fitness (Table 30-3)
Hip internal rotators
Hip external rotators The splint can be removed under the surgeons directive.
Abdominals Patient can progress to weight bearing as tolerated (WBAT)

Anticipated
Criteria to Progress to Impairments and
Phase I Patient is postoperation Protect healing tissue Follow surgeon-directed Protect Quickly progressing to
Postoperative and cleared to initiate Pain and swelling weight-bearing restrictions healing tissue weight bearing could lead to
wk 1 therapy by the surgeon Patients overall fitness Elevate, frequent ice Control pain worsening of symptoms and
Specific precautions, if applications and swelling delay of therapy
any, are communicated (cryopneumatic device or Initiate home Control of pain and swelling
by the surgeon to the cold packs) exercise will improve patient
therapist Patient to begin exercise program tolerance to slow, steady
for noninvolved leg, Maintain progressions
trunk, and upper overall Patient will need to maintain
extremities physical fitness when it is time to
Initiate surgeon-approved fitness safely return to activity
home exercise program

Progress to Impairments and
Phase II Surgeon has Pain and swelling Ice, electrical stimulation, Reduced pain and Status postsurgery +
postoperative cleared patient Immobility manual therapy (soft tissue swelling pain + swelling +
wk 2-5 for weight Difficulty walking and grade I-II joint Improved ROM immobilization is a
bearing as Decreased strength mobilizations) Restore soft tissue common formula for
tolerated Potential for decreased ROM exercises and progress on flexibility restriction of normal joint
Surgeon- general fitness home exercise program Restore gait with good and tissue function
approved Gait training compliance to weight- Pool therapy offers a
removal of Pool therapy (where available) bearing restrictions. very functional means of
splint Beginning proprioception Maintain/progress LE, training a patient while
General fitness program UE, and trunk exercises controlling weight
keeping any operative side program. bearing
restrictions in mind
LE, Lower extremity; ROM, range of motion; UE, upper extremity.
and eventually full weight bearing (FWB) as long as there is Start with static positioned exercises such as single-limb
no evidence of compensation. If the surgical sites are closed/ stance (SLS) and progress by varying the standing surfaces
dry/healed and the surgeon has approved, initiate pool (pads/towels/trampoline) and adding dynamic activities
therapy when available. Pool therapy should include normal- such as the PlyoBack.
ized gait, weight-bearing exercises, balance, and deep water The following are some ideas to address the goals for
cardiovascular exercises. Land therapy may also begin pro- phase 2.
gressing through AROM exercises, exercise bike, beginning
weight-bearing exercises, and passive resistance exercises. Decrease Inflammation and Pain
Care needs to be taken to not progress the patient too quickly, Ice and elevate. The incorporation of compression is also
which could lead to an unwanted inflammatory response very helpful. This can be found in devices like the Game
and probable setback. General physical fitness should con- Ready and CryoCuff .
tinue to be addressed. PROM, A/AROM, AROM, and joint Electrical stimulation.
mobilization can be initiated to address the patients restricted Kinesio tape.
ROM at the ankle and the surrounding joints. The soft tissue Soft tissue mobilization. This can help with concomitant
will need to be addressed as well, since it is an integral com- spasms that are not uncommon after surgery or injury.
ponent of normal joint function Balance activities can also Lymphedema techniques can also assist with
be progressed as the patient is able to tolerate when on land. inflammation.
Phonophoresis/iontophoresis. The use of ultrasound or Increase Ankle Joint ROM and Restore Soft
electricity to drive medication into the affected area. Tissue Flexibility
Oftentimes this can be a steroid. This will need to be The use of joint mobilization and soft tissue mobilization
cleared by the surgeon. Introduction of medications into combined with exercise is an effective way to improve
an area too soon in the postoperative phase can slow/ ROM and soft tissue function. As would be expected, a
deter healing. patient who has had an injury or surgery and is splinted or
Active ankle pumps and circles. immobilized can quickly develop restrictions in the soft
Grade I to II forefoot, midfoot, and hindfoot joint mobi- tissues and joints at and around the affected area. The fol-
lization. Sustained stretching techniques after ankle and lowing techniques should be considered if deemed safe to
foot mobilization can be used as a beginning technique the surgical area:
to stretch the joint capsule. The gentle oscillations involved Joint Mobilizations. Progressing to grade II to III joint
with grade I and II mobilizations can assist in decreasing mobilizations will help restore normalized joint function
swelling and pain. Grade III and IV mobilizations can be and decrease capsular restriction.
used to improve limited joint ROM once pain and swell- Soft tissue mobilization to reduce any soft tissue restric-
ing have been reduced. The following are a few recom- tions including adhesions, spasm, edema.
mendations for accessory joint mobilizations: Gastroc/soleus, FHL, anterior tib, hamstring, quads,
Forefoot and metatarsal anterior and posterior glides glutes, and hip flexor stretching in weight bearing and
Talar rock (for calcaneal movement) nonweight bearing.
Anterior glide of the talocrural joint (to increase AROM exercises in all planes.
plantar flexion)
Posterior glide of the talocrural joint (to increase dor- Increase Strength
siflexion) (see Fig. 29-8) It is important to progress slowly in a well-paced manner to
Distraction of the talocrural joint (increase joint play avoid aggravating the ankle. Aggravation of symptoms could
in the mortise) (see Fig. 29-6) and subtalar joint (see require a 1 to 2 week delay. This can be avoided by making
Fig. 29-8) the patient aware that over activity with exercises and or
Medial and lateral subtalar glides (to increase eversion functional weight bearing could lead to irritation and over-
and inversion) (Fig. 30-9) stressing the healing tissues. Adding a few exercises at a time,
working at minimal resistances, and progressing with each
Restore Normal Gait success by either adding new exercises or progressing the
As the patient transitions to partial weight bearing (PWB), resistance/repetitions of their present exercises is one method
WBAT, and FWB, emphasis on proper heel to toe patterning of lessening the risk of any exacerbations. The following are
should be made. This will limit compensatory patterning as a few examples:
the patient transitions off of assistive devices. This should Manual resistance exercises in all planes. Resistance is
carry over into the pool with his or her aquatic program and mild progressing to moderate.
on land. It needs to be noted that normalizing ROM and Intrinsic muscle strengthening (towel curls, marble pick
strength not only in the involved foot and ankle, but in the up) to stabilize the metatarsophalangeal joints during
proximal lower quarter of the surgical side as well as the propulsion.
nonsurgical side will lessen the possibility of a compensated Windshield wipers.
patterning. Use of orthotics can be considered to assist in Active resistive exercises using elastic bands (progress
supporting the foot in a mechanically correct position. from lightest to heavier) (Fig. 30-10).
A B
Fig. 30-9 A, Medial glide of the calcaneus on the talus to increase calcaneal eversion (pronation). B, Lateral glide of the calcaneus on the talus to increase
calcaneal inversion (supination). (From Andrews JR, Harrelson GL, Wilk KE: Physical rehabilitation of the injured athlete, ed 3, Philadelphia, 2004,
Saunders.)
A B C
Fig. 30-10 Elastic bands or surgical tubing can be used for resisted exercises. A, Eversion; B, Inversion; C, Dorsiflexion. (From Andrews JR, Harrelson GL,
Wilk KE: Physical rehabilitation of the injured athlete, ed 4, Philadelphia, 2012, Saunders.)
Very low resistance leg presses and total gym within pain- There is a variety of unweighting equipment that can be
minimized ranges. used in conjunction with a treadmill.
Incorporate weight bearing toe ups/heel ups.
Continue UE, trunk, and proximal lower quarter Increase Patient Knowledge and Awareness
exercises. By educating the patient, the physical therapist is involving
Incorporate beginning cardiovascular exercises with the the patient as an active participant in his or her own care.
exercise bike at low resistance. The therapist can empower the patient by having a dramatic
effect on his or her response to therapy, including how to
Increase Proprioception avoid exacerbations and how to progress with each success.
Strengthening the stabilizing muscle groups will offer The following are ways to increase a patients knowledge and
improved support through movement and increased safety awareness:
on surfaces that are less stable. It will also offer improved Allow the patient a safe enough environment to ask ques-
reaction when loss of balance occurs. The following are some tions. Encourage an open line of communication.
examples to help improve this: Give specific instructions concerning the pathology of an
SLS exercises (see Fig. 28-5). Beginning with static flat injury, how healing occurs, precautions and limitations
surface SLS progressing to the use of variable firmness with activities to avoid flare ups, what to do for them-
balance pads. With success, progression to dynamic SLS selves in the case of a flare up, keys to progression,
activities such as using the rebounder and Thera-Band. expectations/goals with treatment, why each component
The BAPS (Biomechanical Ankle Platform System) Board of the treatment is chosen, and the importance of consis-
can be used in sitting as a mild weight-bearing AROM tency in treatment.
exercise program and progressed to FWB in stance (see
Fig. 28-6). Phase III: Advanced Rehabilitation
TIME: Weeks 6 to 8 Postoperative
Maintain Cardiovascular Fitness GOALS: Alleviate pain and swelling; normalize
It is important to support and progress the overall fitness of functional ROM; normalize functional strength;
the patient while in rehab. A patients general fitness level is normalize functional proprioception (Table 30-4)
important to his or her ability to sustain activity in a safe,
mechanically correct manner. If a body part fatigues but the At this point, the patient should be progressing well with
activity continues, other areas of the body must work harder therapy. ROM and strength should be to a point that the
to sustain that activity. This can lead to overuse issues and patient is able to walk with a near normal gait pattern and
potentially to injury. The following are ideas to help sustain progressing with the exercise program that should consist
fitness: of a variety of weight-bearing and nonweight-bearing
Stationary (exercise) bike. There are standard and recum- exercises.
bent options.
Upper body ergometer. Alleviate Pain and Swelling
Deep water pool running/bicycling. Modalities specific to the issue(s) being treated should con-
High repetition, lower resistance exercises progressed in tinue. Work with the patient to help problem solve if there
a manner of a push followed by a pull exercise without are mechanical dysfunctions or behaviors that may be pre-
a break between the alternating sets. cipitating the patients symptoms. The patient is far enough
The elliptical is an excellent piece of equipment (once the into the healing phases to consider iontophoresis or phono-
patient is allowed FWB) that trains a patient in a more phoresis (it should still be cleared by the surgeon as to not
functional way with minimal impact. interrupt any anticipated healing). Encourage the patient to

Anticipated
Criteria to Progress to Impairments and
Phase III Able to walk with a Residual pain and Modalities, electrical Alleviate pain and Soft tissue
postoperative normal or near-normal gait swelling stimulation as needed swelling healing
wk 6-8 pattern Residual joint and soft Continued soft tissue and Normalize functional ROM timeframes
ROM progressing tissue restrictions joint mobilizations Normalize functional normally indicate
Strengthening progressing inhibiting full (progressed to grade strength 6 wk as a time
Pain and swelling reduced functional ROM III-IV) Normalize functional that soft tissue is
Tolerating a variety of Strength not full Progressed therapeutic proprioception healed
weight-bearing and Potential for decreased exercises, proprioceptive Progressed HEP
proprioceptive exercises general fitness exercises, cardiovascular Maintain/progress
exercises cardiovascular and
muscular fitness
HEP, Home exercise program; ROM, range of motion.
continue using home applied modalities such as ice. Lateral steps, lateral shuffles, lateral sidestep with elastic
Modification of activities may need to continue with some band.
refining. Slide board.
Continued ongoing UE and trunk strengthening and
Restore Normalized ROM conditioning.
The patient should be near normal ROM at this point with
the goal to achieve normalized ROM during this phase. Improve Proprioception and Balance
Mobilizations should continue combined with a strong soft Balance and proprioception become more important in this
tissue mobilization program and stretching program. ROM phase because the patient is getting nearer to returning to
during this phase can be made more aggressive with the use sport. With that in mind, modifications in the stability of the
of body weight for stretching. Muscle energy can be an effec- base of support should be added (i.e., wobble boards, Dyna-
tive technique to improve ROM. Continue with general LE Disc, etc.). Additionally, perturbations to balance using
ROM as well. Stretching before and after a workout can be manual contact or external loads such as weight or bands
very effective. Help the patient in realizing that the efforts will challenge the patients balance strategies.
made outside of therapy (under the therapists guidance) will SLS varied surface static and dynamic including unin-
not only bridge the gap between treatments, but continue his volved side resistive exercises
or her progress. BAPS board
Wobble boards
Improve Strength DynaDisc
As the patient is able to tolerate, progress the resistances in Trampoline for balance weight shifting
the therapeutic exercise program: Varied position on incline board (Fig. 30-12)
Proprioceptive neuromuscular facilitation (PNF) for the Continue with precautions and limitations with activities,
ankle and the lower quarter to progress to moderate and rate of progression, and specific goals.
maximal resistances.
Increase elastic band resistance. Phase IV: Specificity of Sport
Add resistance to Windshield wipers and towel curls. TIME: Weeks 9 to 12 Postoperative
Concentric and eccentric gastrocnemius/soleus training GOALS: Provide sport-specific training to allow
in weight bearing. Increase resistance by either holding return to the required physical demands of the sport
onto weights, resistance bands, or weight vests. If using a and the athletes specific position; independent
leg press machine, increase weight. home and gym exercise program (HEP, GEP) (Table
Step up/downs. Add resistance and increase heights of 30-5)
steps (see Fig. 28-15).
Increase resistance and time on exercise bike, elliptical, This final phase of rehab is critical to the success of the
treadmill. Okay to incorporate elevation. athletes return and is oftentimes an area not included in his
Closed kinetic chain exercises using elastic bands, sports or her rehabilitation. It is often heard that an athlete can
cord (start with light resistance and progress) (Fig. 30-11) return to play when he or she has full strength and ROM.
Front and side LE lunges (add weight as tolerated). The problem is full strength and full ROM does not imply

Progress to This Impairments and
Phase IV Surgeon approval Inability to perform Sport-and Successful return to Full ROM and strength do not
postoperative Normal ROM and sport- and position- position-specific full functional activity indicate that an athlete or
wk 9-12 strength specific physical skills training patient will be able to safely
Pain free at appropriate speeds progressing to and successfully perform at the
Good proprioception and efforts expected full speeds and efforts necessary to
speeds and efforts their sport or position
A B
Fig. 30-11 A, Contralateral kicks to simulate closed chain pronation and supination. The elastic band goes around the unaffected LE. B, Tubing-resisted side
steps. (From Andrews JR, Harrelson GL, Wilk KE: Physical rehabilitation of the injured athlete, ed 4, Philadelphia, 2012, Saunders.)
readiness to return to a sport safely and successfully. This position. A football kicker would require a much different
safety and readiness comes with sport- or position-specific training regimen than a football offensive lineman. That said,
training. As the athlete prepares to return to sports, he or she the following exercises and progressions are useful for reha-
will need to be progressed through a grouping of higher-level bilitating a basketball player:
activities to recreate the expected stresses, forces, and move- Running on a treadmill
ments for his or her sport and position. Vary the speeds from jogging to sprint (if
It is important to note that an athlete before starting available).
this phase of their rehabilitation should be: Vary the elevations.
Pain free Consider lateral shuffle and carioca.
Without swelling Jogging to sprint on flat hard surface
Full ROM Resisted running (chute, sport cord)
Full strength Bilateral jumping
Good proprioception Agility drills (progressing to sport-specific surface and
During this phase, the athlete will be working on advanced to competition speeds) (see Fig. 28-12)
strengthening/proprioceptive/conditioning training. The A skip (high knees skip)
exercises need to be tailored not only for the physical require- B skip (high knees skip with knee extension)
ments of the sport, but also the physical requirements of the Carioca
Running
Bilateral jumping and hopping
Backpedaling
Figure 8 running
Cutting and twisting
Plyometrics
Single-leg hopping and jumping
The program should be challenging for the athlete while
keeping in mind where that patient is in the healing cycle.
Stresses should be progressed when the physiology will allow
for it and as the patient is able to demonstrate success. Con-
tinue to train the athlete into the physical requirements of
his or her sport and position. Safe and successful return is
the ultimate goal.
Before ending the formal rehabilitation program, the
physical therapist should review proper training technique
as it applies to the athletes HEP. The athlete needs to be
independent in his or her program.
If the athlete is part of a team that has training staff, with
the athletes approval, discuss the ongoing training program
with the team trainer for consistency during this transition.
Fig. 30-12 Proprioceptive training on inclined surfaces. The elastic band
goes around the unaffected LE. (From Andrews JR, Harrelson GL, Wilk KE: Speed and duration of these exercises should meet what is
Physical rehabilitation of the injured athlete, ed 4, Philadelphia, 2012, expected for the sport or activity to ensure a safe return. If
Saunders.) the patient has increased swelling or pain that lasts more
than a day or two with these activities, then the patient is not
ready to return to that particular level of play. Be sure to
Back pedaling communicate with the surgeon the athletes status in the
Figure 8 drills discharge note. Be sure to comment on the HEP and that the
Cutting drills training staff has been contacted.
Plyometrics all directions
Trampoline work TROUBLESHOOTING
Four-square hopping (single limb) (Fig. 30-13)
Sports drills It is not uncommon after ankle surgery to have soreness,
Dribbling numbness, and tingling over the portal sites. There may also
Lay ups be residual swelling and discoloration. Physical therapy can
Shooting begin within 1 to 3 weeks postoperatively. If the therapy is
Boxing out too aggressive too soon, significant swelling and pain may
Pick and rolls develop and lead to loss of motion, loss of strength, decreased
Videotaping the athlete playing and reviewing the functional ability, and diminished confidence. It will take
tape with him or her to discuss any noted areas of time to reverse this and it can delay therapy for 2 to 3 weeks
weakness or biomechanic issues that could predispose or more. Although it is desirable to achieve weight bearing
him or her to further reinjury or new injury (Correct early in the rehabilitation process, caution should be taken
these areas to remove weakness and mechanical in removing assistive devices if the patient is continuing to
issues). walk with an antalgic gait. Some patients may require special
In review, the athlete can be guided in returning to sports precautions depending on the surgery performed, the tissues
activities with some basic progressions: involved, and the normal physiologic healing that is expected.
Nonweight-bearing exercises The physical therapist should review the operative notes and
PWB exercises discuss any precautions with the surgeon.
Full weight-bearing exercises Complications can occur in ankle arthroscopy as with any
Stable surface balance training surgery. It was previously discussed that a 6.8% to 9% com-
Walking plication rate exists. The most common of these complica-
Weight-bearing balance board training (start with tions is injury to the surrounding nerves, with injury to the
bilateral and go to unilateral) superficial peroneal nerve accounting for the most frequent
Stepping in all planes complication seen with ankle arthroscopy. There would be
Cariocas transient or permanent numbness on the dorsum of the foot
Rebounder jogging extending into the toes. The therapist should notify the
Jogging surgeon immediately if:
2 2 3
1 2 1 1 4
Side to side: Hop Front to back: Hop Four square: Hop from
laterally between two forward and backward square to square in a
quadrants. between two quadrants. circular pattern. Sets are
performed clockwise and
counterclockwise.
2 3 3 2 1 2 2 1
1 1 3 3
Fig. 30-13 Four-square hopping ankle rehabilitation.

The eight basic hopping patterns in the four-square ankle
rehabilitation program are arranged in order of increas-
Triangles: Hop within three different quadrants. There are four triangles, each
ing difficulty. The arrows denote the direction the athlete
requiring a different diagonal hop.
is facing. No. 1 is the starting point. (From Toomey SJ:
Four-square ankle rehabilitation exercises. Phys Sports
Med 14:281, 1986.) 3 4 4 3
1 2 2 1
Crisscross: Hop in an X pattern. Straight-line hop: Hop forward and then

backward along a 15- to 20-ft. line.
Line zigzag: Hop from side to side Disconnected squares: While

across a 15- to 20-ft. line while moving performing the first five patterns, hop
forward and then backward. into squares marked in the quadrants.
Drainage, redness, swelling, increased pain is evident made, any issues that exist, and any recommendations to
at any of the surgical sites. consider with his or her ongoing care. Keep the lines of com-
Patient develops a fever. munication open always.
Abnormal redness, swelling of the lower leg is seen.
Lack or loss of sensation develops. CONCLUSION
Sudden inability to tolerate therapy, HEP, function is
evident. Therapy for the postoperative ankle should follow an agreed
Patient stops attending therapy. upon plan set up by the surgeon. Sticking to a program that
Patient is noncompliant to any part of or all of allows for progression of a patient taking into account the
rehabilitation. physiologic healing that is occurring will allow for a well-
Be sure that the athlete/patient always has a progress note progressed rehabilitation with a minimal amount off exacer-
when returning to the physician. This will allow the surgeon bations. Progressing the patient with success and making
to know where the patient is in rehabilitation, any gains sure the patient has met all goals before progressing to the
next phase of rehabilitation will continue steady, forward surgical ankle. Remember, the patient will need to be able to
progress. Only when the athlete/patient has successfully perform all required functions of his or her normal activities,
returned to full functional ROM/strength/proprioception in which means the need to be fully functional and strong. The
a pain minimized/alleviated state and is able to meet the patient must also exhibit sustained endurance. Lastly, and
necessary physical requirements of normal activities should perhaps most importantly, if there are any questions or issues
he or she be allowed to return to normal activities (whether that come up, talk with the surgeon. This open line of com-
it be professional sports or gardening at home). Do not forget munication is paramount to the patients/athletes ultimate
the other three-fourths of the patient when rehabilitating the outcome.
1 Paul had arthroscopic ankle surgery for an excision of

an anterior tibiotalar osteophyte. He had surgery 7
weeks ago and has returned to working as a store
and ROM exercises to reinforce dorsiflexion. The increase
in ROM to 15 with this treatment addition reduced her
pain dramatically with gait, stairs, and squatting.
manager. He is on his feet most of the day. He is anxious
about recovering quickly and doing his usual routine.
During his last visit he complained of increased soreness
at times. The pain has not been decreasing, and swelling
3 Jessica is a 40-year-old woman who had an ankle arthros-
copy done with the removal of a loose body from an
osteochondral lesion 9 weeks ago. She was nonweight
persists. During his home exercises, Paul works hard on bearing for 5 weeks and has been in therapy; progress
the resisted exercises. How can the therapist help Paul with exercise has decreased because of pain during many
to progress? of the closed chain exercises, such as SLS, double heel
lifts, minisquats, and walking more than 8 minutes on
Paul was told that progressing his function or exercising the treadmill. What type of closed chain exercises can
too aggressively could lead to increased symptoms and Jessica do to progress with her strengthening?
potential delays in his progress. Pauls physician was
able to write a prescription for compression stockings to The therapist explained that any activities that cause
help with the swelling and Paul was advised to sit and prolonged pain and swelling need to be put on hold and
elevate his leg whenever possible. Paul was put on an techniques reviewed with the physical therapist. Any
icing regimen to elevate and ice three times a day as changes and modifications can be made so the exercise
well. Pauls HEP was reviewed, with adjustments to is successful. If success is not able to be achieved, the
resistances and repetitions to lessen the likelihood of exercises that are symptomatic should be stopped until
irritation. Steady progress staying below the threshold such time that the patient is able to perform without
of symptoms and exacerbations will keep Paul progress- symptoms. Jessica was able to perform the following
ing with his therapy/function with minimal delays and exercises without issue: forward lunges, backward
setbacks. lunges, lateral lunges, and single heel raises performed
on a leg press machine set at 75lb. She could backward
2 Christine is a 32-year-old woman who underwent an

ankle arthroscopy procedure for dbridement of soft
tissue impingement 5 weeks ago. Since then her physical
walk and lessen the time on the treadmill. Use of a pool
for gravity-minimized exercises is ideal in this situation
as well. As her tolerance improved, she was able to
therapy has consisted of massage, ultrasound, AROM progress her therapeutic exercises successfully and
and PROM exercises, resisted exercises, cryotherapy, without exacerbation.
and a HEP. Her main complaint is pain during gait,
while descending stairs, and during attempts to squat
partially. Dorsiflexion is limited, and minimal swelling
persists. What treatment may be particularly helpful to
4 Rebecca is a 45-year-old mother of young children. She
underwent ankle arthroscopy surgery for a synovec-
tomy 5 weeks ago. When she is on her feet for more than
Christine? a couple of hours, she has prolonged soreness. Yesterday,
she was on her feet for several hours in the afternoon
Mobilization of the talocrural joint was performed with and intermittently for the rest of the day. Today, she is
an AP movement applied to the talus while stabilizing in for treatment. She has minimal to moderate swelling
the distal tibia. Distal fibular mobilizations were per- and complains of minimum to moderate levels of pain
formed as well to assist with the talus ability to move with weight-bearing activities. What type of treatment
into the ankle mortise. This was followed by stretching should Rebecca receive today?
When pain and/or swelling limits the progress of reha- running straight up and down the field. What can be
bilitation, the intensity of rehabilitation needs to be mod- done to help James achieve his goal of returning to
ified. The therapist, in this case, focused on controlling soccer when he is unable to run on grass pain free?
pain and decreasing swelling. Joint mobilizations using
glides and distraction maneuvers were performed on the Despite James pain-free running on flat surfaces, the
talocrural joints. Gentle PROM was performed. AROM grass poses a new challenge because of its inherent
and resisted exercises were placed on hold because of instability. James may need to spend more time working
the pain and swelling. Soft tissue mobilization was per- on his ankle proprioception during dynamic activities
formed to assist with swelling and to address any soft before running on grass. Running on level ground with
tissue/fascial restrictions. Ice packs with compression small changes in direction will provide his ankle the
was performed as well. The patient was encouraged to stimulus to control the lateral movements of the subtalar
avoid any known aggravating factors. The patients joint. He may also be able to achieve his goal by breaking
swelling and pain lessened and the patient was able to down the task and doing shorter jogs on the grass with
get back on track. rest before discomfort to allow his body to adjust to the
new situation.
5 Jennifer is a 22-year-old ballet dancer. She underwent

arthroscopic ankle surgery 10 weeks ago for posterior
soft-tissue impingement. She has begun to resume dance 7 You have been seeing Sharon in physical therapy for 1
week following her surgery for ankle arthroscopy 2 weeks
practice but still feels some pinching discomfort in her ago. Today she is complaining of worsening pain and
posterior ankle when in an en pointe (on toes) position. redness along her surgical portals. Upon inspection you
What treatment may be particularly helpful to Jennifer notice localized edema, erythema, and warmth along the
at this stage of her rehabilitation? surgical portal. In addition, there is a small amount of
yellow exudate from the wound. How should your physi-
A mobilization technique was performed at the talocrural cal therapy plan change based on todays findings?
joint. A posterior to anterior (PA) glide was applied to the
talus, while stabilizing the distal tibia, to increase plan- You should immediately contact the surgeon as there is
tarflexion. To address the end range position needed for a chance that the wound has become infected.
ballet, the mobilization was performed in an end range
plantarflexion position with a grade IV technique to
improve capsular stretching. Following treatment, Jen-
nifer was able to go en pointe with significantly less
8 For 2 weeks following arthroscopic surgery for synovitis
of his ankle, Bill complains of numbness and tingling
along his lateral foot. He noticed it to be more pro-
pinching in her posterior ankle. nounced after splint removal and the onset of weight
bearing 1 week ago. He often feels it when pointing his
6 James is a 30-year-old recreational soccer player. Because

of multiple ankle sprains over many years of playing, he
suffered an osteochondral lesion of his medial talus. He
toes during his active ROM exercises. What other objec-
tive testing should you perform at this time to help in
your treatment of Bill?
underwent arthroscopic loose body dbridement 9
weeks ago. He has been jogging without symptoms for Decreased neural mobility in the foot and ankle can
up to 15 minutes on a treadmill or a track. Over the occur following any immobilization. Straight leg raise or
weekend, he went out to run on the soccer field and slump testing should be completed to determine if this
began to feel soreness. He states he did no cutting, only might be causing Bills symptoms.
REFERENCES
1. Takagi K: The arthroscope. J Jpn Orthop Assoc 14:359, 1939. 6. Stetson WB, Ferkel RD: Ankle arthroscopy. Part I: Technique and
2. Ferkel RD: Arthroscopic surgery: The foot and ankle, Philadelphia, complications. Part II: Indications and results. J Am Acad Orthop Surg
1996, Lippincott-Raven. 4(1):17-34, 1996.
3. Ferkel RD, Hommen JP: Arthroscopy of the ankle and foot. In Mann 7. Acevedo JI, et al: Coaxial portals for posterior ankle arthroscopy: An
RA, Coughlin M, Saltzman C, editors: Surgery of the foot and ankle, ed anatomic study with clinical correlation on 29 patients. Arthroscopy
7, St Louis, 2006, Mosby. 16:836-842, 2000.
4. Ferkel RD, Scranton PE, Jr: Arthroscopy of the ankle and foot. J Bone 8. Sitler DF, et al: Posterior ankle arthroscopy. J Bone Joint Surg 84A:763-
Joint Surg Am 75(8):1233-1242, 1993. 769, 2002.
5. Jackson J, Ferkel RD, Nam EK: Ankle and subtalar arthroscopy. In 9. van Dijk CN, de Leeuw PAJ, Scholten PE: Hindfoot endoscopy for
Thordarson DB, editor: Foot and ankle: Orthopaedic surgery essentials, posterior ankle impingement: surgical technique. J Bone Joint Surg Am
ed 2, Philadelphia, 2012, Lippincott Williams & Wilkins. 91(Suppl 2):287-298, 2009.
10. van Dijk CN, Scholten PE, Krips R: A 2-portal endoscopic approach for 19. Ferkel RD, et al: Arthroscopic treatment of osteochondral lesions of the
diagnosis and treatment of posterior ankle pathology. Arthroscopy talus: Long-term results, submitted for publication Am J Sports Med
16:871-876, 2000. 36:1750-1762, 2008.
11. Ferkel RD, et al: Arthroscopic treatment of anterolateral impingement 20. Gregush RV, Ferkel RD: Treatment of the unstable ankle with an osteo-
of the ankle. Am J Sports Med 19:440-446, 1991. chondral lesion: Results and long-term follow-up. Am J Sports Med
12. Ferkel RD, et al: MRI evaluation of anterolateral soft tissue impingement 38:782-790, 2010.
of the ankle. Foot Ankle Int 31(8):655-661, 2010. 21. Loren GJ, Ferkel RD: Arthroscopic assessment of occult intra-articular
13. Bassett FH, et al: Talar impingement by the anteroinferior tibiofibular injury in acute ankle fractures. Arthroscopy 18:412-421, 2002.
ligament: A cause of chronic pain in the ankle after inversion sprain. 22. Williams MM, Ferkel RD: Subtalar arthroscopy: Indications, tech-
J Bone Joint Surg 72A:55-59, 1990. niques, and results. Arthroscopy 14:373-381, 1998.
23. Zengerink M, et al: Current concepts: treatment of osteochondral ankle
14. Liu SH, et al: Arthroscopic treatment of anterolateral ankle impinge-
defects. Foot Ankle Clin 11:331-359, 2006.
ment. Arthroscopy 10:215-218, 1994.
24. Ferkel RD: Complications in ankle and foot arthroscopy. In Ferkel RD,
15. Bazaz R, Ferkel RD: Results of endoscopic plantar fascia release. Foot
editor: Arthroscopic surgery: The foot and ankle, Philadelphia, 1996,
Ankle Int 28(5):549-556, 2007.
Lippincott-Raven.
16. Ferkel RD, Chams RN: Chronic lateral instability: Arthroscopic findings 25. Nickisch F, et al: Postoperative complications in patients after posterior
and long-term results. Foot Ankle Int 28(1):24-31, 2007. ankle and hindfoot arthroscopy. J Bone Joint Surg Am 94:439-446, 2012.
17. Ferkel RD, Hewitt M: Long-term results of arthroscopic ankle arthrod- 26. Young BH, Flanigan RM, Digiovanni BF: Complications of ankle
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18. Ferkel RD, et al: Surgical treatment of osteochondral lesions of the talus. nique. J Bone Joint Surg Am 93(10):963-968, 2011.
Instr Course Lect 59:387-404, 2010.
CHAPTER 31
Achilles Tendon Repair and Rehabilitation
Jane Gruber, Eric Giza, James Zachazewski, Bert R. Mandelbaum
A
chilles tendon injuries, whether acute or chronic, The Achilles tendon is supplied with blood and nutrients
occur in many individuals. The severity of these by three different sources.2 The most abundant supply is at
injuries varies from mild, overuse-related inflam- the proximal and distal portions of the tendon, and the
matory responses to acute, traumatic tendon rupture. Non- poorest is in the central portion of the tendon. As originally
operative treatment options are immobilization with a cast demonstrated by Lagerrgren and Lindholm3 and corrobo-
or functional bracing, while surgical options are operative rated by others,4,5 a gradual decrease occurs in the number
repair with open or percutaneous procedures. Postoperative of blood vessels in the central part of the tendon 2 to 6cm
management varies with the length of immobilization and proximal to the calcaneal insertion (Fig. 31-1).
timing of early motion. This chapter describes current trends Nutrient branches emanate directly from the muscle to
in surgical intervention, outlines rehabilitative guidelines nourish the distal gastrocnemius aponeurosis and proximal
and techniques, and details the rationales associated with portion of the tendon.6 The insertion of the Achilles tendon
treating Achilles tendon ruptures. is supplied by anastomotic branches between the periosteal
vessels and the tendon vessels. As already noted, the major
SURGICAL INDICATIONS AND blood supply comes from the mesotendon. Vessels enter the
CONSIDERATIONS tendon itself via a network of fine connections with
the deepest peritendinous layer. These vessels come off the
Anatomy deepest layer radially and enter the tendon perpendicular to
The Achilles tendon complex is composed of contributions its long axis. They then course proximally and distally.
from the gastrocnemius, soleus, and plantaris (collectively Because of the external forces that may be encountered by
known as the triceps surae) and inserts directly into the the posterior aspect of the tendon as a result of friction sup-
central third of the posterior calcaneal surface. The tendon plied by the skin, most of these fine vessels are found along
is round in cross section to a level 4cm proximal to calca- the anterior aspect of the tendon, where they are afforded
neus, where it flattens and rotates 90 so that its medial fibers more protection (Fig. 31-2).
insert posteriorly. This biomechanical winding of the fibers
increases stored energy for higher shortening velocity and
muscle power.1 Pathogenesis
During dorsiflexion, the tendon articulates with the supe- The theoretic explanation for tendon injuries suggests a con-
rior third of the calcaneus. This articulation is cushioned by tinuum of events, including hypovascularity and repetitive
the retrocalcaneal bursa, which lies between the tendon and microtrauma, that results in localized tendon degeneration
the superior third of the calcaneus. and weakness and ultimately rupture with the application of
The Achilles tendon does not possess a true synovial an otherwise normal load that exceeds the tendons physio-
sheath. The peritendinous structures of the Achilles are com- logic capacity. Based on clinical and histologic findings,
posed of a triple-layered tissue.2 The superficial layer of tissue the traditional description of Achilles tendonitis is not pre-
is the most durable and is analogous to the deep fascia. This ferred,7 and Achilles tendon pathology is classified into three
layer comprises the posterior boundary of the superficial different categories: (1) paratendinitis, (2) paratendinitis
posterior compartment. The middle layer, the mesotendon, with tendinosis, and (3) pure tendinosis.8-10
provides the major blood supply for the central portion of Paratendinitis involves inflammation only in the paratenon,
the Achilles tendon. The deepest layer of tissue is quite deli- regardless of whether it is lined by synovium. The paratenon
cate and thin; however, it can always be isolated from the thickens, and adhesions may form between the paratenon
most superficial layer of the tendon, the epitenon. and the tendon.11 However, patients will rarely have isolated
554
Chapter 31 Achilles Tendon Repair and Rehabilitation 555
220 degeneration, lipomatous infiltration, and calcifying tendi-

210
nopathy have been noted at the time of surgical repair of
acute ruptures.10,12
200 Hippocrates was the first to record an injury to the Achil-
190 les tendon, while Ambrose Pare was the first to describe
Achilles tendon ruptures in 1575, and Gustave Paoaillon was
180
the first to report operative repair of the tendon.1,2,13 Theories
Number of vessels
170 implicating the degenerative changes that take place in the

160 Achilles tendon with the increased mechanical loads associ-
ated with various activities are the most common explana-
150 tions of the pathogenesis of these ruptures.13,14 A combination
140 of hypovascularity and repetitive microtrauma results in
degenerative changes and inflammation, putting the tendon
130
at risk for rupture. Healing and regeneration are hindered or
120 halted because of poor blood supply to the tendon and recur-
110 rent microtrauma. Alfredson, Thorsen, and Lorentzon15 have
shown that microtears in the tendon lead to areas of chronic
100
0 2 4 6 8
damage that lack normal levels of prostaglandin E2, which
are needed for healing. The combination of these factors may
Distance from calcaneus (CM)
account for the fact that most ruptures occur 2 to 6cm proxi-
Fig. 31-1 The number of intratendinous vessels of the Achilles tendon
mal to the tendons insertion into the calcaneus. Associated
varies depending on the distance from the calcaneus. (From Carr AJ, Norris
SH: The blood supply of the calcaneal tendon. J Bone Joint Surg Br 71B:100, intrinsic factors include age (which leads to decreased vascu-
1989.) larity and decreased deoxyribonucleic acid [DNA] synthe-
sis),16-18 endocrine function, and nutrition.19 Extrinsic factors
of compression and friction on the posterior aspect of the
tendon (from the skin and inappropriately compressive foot-
wear) further hinder vascularity, healing, and regeneration.
C Fluoroquinolone antibiotics are also associated with Achilles
A tendon rupture. Their use inhibits transcription of decorin, a
B protein important in collagen architecture, and the odds ratio
for tendon rupture in patients taking the medication is 4.2.20
Acute Achilles ruptures are also often the result of corticoste-
roid injection for chronic inflammation of the tendon.7
Normally, tendons are able to tolerate high forces associ-
ated with daily activities and athletics. However, if degenera-
tive changes take place, then the mechanical load usually
Fig. 31-2 Diagram of the blood vessels of the Achilles paratenon, showing
supply for the osseous junction (A), the mesotendon (B), and the musculo- tolerated may exceed the tendons physiologic capacity.
tendinous junction (C). (From Carr AJ, Norris SH: The blood supply of the Mechanically, a tendon may be damaged or ruptured by
calcaneal tendon. J Bone Joint Surg Br 71B:100, 1989.) a sudden application of force. This often involves a
forceful lengthening or eccentric muscle contraction. Sudden
maximal muscle activation results in a larger than normal
paratendinitis, and some authors believe that this process is force that is applied rapidly to the tendon, causing the
the predecessor to tendinosis.7 rupture. The high load forces that cause such rupture are
Paratendinitis with tendinosis involves not only inflam- usually associated with vigorous activities such as sports. The
mation of the paratenon but also a degenerative change forces to which the Achilles tendon is exposed during activi-
within the substance of the tendon. Paddu, Ippolito, and ties such as running and jumping have been calculated to be
Postacchini10 and Kvist and Kvist11 have noted thickening, between 4000 and 5500 N21-23; they are summarized in Fig.
softening, and yellowing of the tendon, as well as cleavage 31-3.19 Arner and Lindholm24 describe three activities that
planes and vascular budding during surgery for this condi- can rupture a tendon:
tion. As in tendinitis, pain also is commonly noted because 1. Pushing off with weight bearing on the forefoot while
of the inflammatory process. extending the knee (e.g., running, sprinting, jumping)
Pure tendinosis often appears as a nodule that is mobile 2. Sudden dorsiflexion with full weight bearing as might
with plantar flexion.7 It can present as a chronic nodule in occur with a slip, fall, or sudden deceleration
the sedentary middle-aged person or as a contribution 3. Violent dorsiflexion when jumping from a height and
to the pathology of rupture in the tendons of persons older landing on a plantar-flexed foot
than 35 years who have suffered spontaneous rupture.12 Curwin19 best summarized the possible progression of
Histopathologic changes such as hypoxic and mucoid tendon injury (Fig. 31-4).
6000
5000
4000
Force (N)
3000
2000
1000
0
Slow (2) Slow (1) Fast (2) Fast (1) Fast + Run Jump Push-off
weight
Activity
Fig. 31-3 Increasing Achilles tendon forces during toe-raising exercises over the edge of a step and three sports-related activities. Slow (2), weight on both
feet, slow speed; Slow (1), weight on one foot, slow speed; Fast (2), weight on both feet, fast speed; Fast (1), weight on one foot, fast speed; Fast + weight, extra
weight added to body; Run, spring running; Jump, landing from 50cm; Push-off, change in direction from backward to forward running. The slow and fast
movements represent progressive steps in the clinical exercise program to treat Achilles tendinitis. (From Curwin SL: Tendon injuries: pathophysiology and
treatment. In Zachazewski JE, Magee DG, Quillen WS, editors: Athletic injuries and rehabilitation, Philadelphia, 1996, Saunders.)
Epidemiology professional or white collar workers who tended to have

Reports regarding the incidence, cause, and conservative, generally sedentary lifestyles except when involved in sports.
surgical, and postoperative management of Achilles tendon A review of numerous studies demonstrates that athletic
ruptures have increased during the past 50 to 60 years. The activities that require sudden acceleration or deceleration are
number of cases reported may be attributed not only to the most likely to cause a rupture (Table 31-1). Ruptures not
observation and diligence of the health care community in attributed to athletic activity are usually caused by falls or
publishing their research and thus improving patient care stumbles that also produce sudden acceleration and decel-
but also to the fact that the general population has increased eration movements. Overall, Achilles tendon ruptures have
its level of participation in recreational activity. been demonstrated to be more common in men than in
Although spontaneous tendon ruptures are rare, the women. Ratios of 2:1,29 4:1,30 1.6:1,31 8.7:1,28 10:1,25 and
Achilles tendon appears to be the one that is most frequently 12:110 have been reported.
ruptured. Kannus and Jozsa12 report that 44.6% (397 out of
891) of tendon ruptures treated surgically between 1968 and Diagnosis of Acute Achilles Tendon Rupture
1989 involved the Achilles tendon, whereas the biceps brachii In most situations the history is diagnostic. Patients describe
accounted for 33.9%. Achilles tendon ruptures are usually hearing a pop as though someone had shot them in the back
traumatic and occur between the ages of 30 and 40 years,25-27 of the ankle. Prodromal symptoms of Achilles aching have
which is younger than for other tendon ruptures (Fig. 31-5). been reported in 5% to 30% of cases.12,32 The rupture com-
Most ruptures are suffered by recreational athletes rather monly occurs in the watershed area, between 2 and 6cm
than highly competitive, very active athletes. Of the 105 proximal to the calcaneus.3 Avulsion fractures of the calca-
patients with Achilles ruptures described by Nistor,28 only 9 neus are relatively uncommon.4 A careful history and physi-
participated in competitive sports. Of the remaining patients, cal examination are important because it has been shown
35 exercised twice a week, 41 once a week, 20 took walks and that 22% of primary care physicians miss the diagnosis of
occasionally exercised, and two were physically inactive. Of acute Achilles rupture.26 The physical examination is charac-
the 111 patients who ruptured their Achilles tendon while terized by palpation of the defect and documentation by
participating in a sports activity in Cetti and colleagues Thompson test,33 which indicates discontinuity and loss of
report,26 92 (83%) averaged only 3.6 hours of athletic activity plantar flexion when the calf is squeezed. The Thompson test
per week. Of the 292 Achilles tendon ruptures documented is performed by asking the patient to kneel on a chair with
by Jozsa and associates,27 59% occurred during recreational the feet hanging over the edge and the calf muscles relaxed.
athletic activity141 of these (83.2%) in men and 29 (16.8%) In this prone position, the examiner can usually denote a
in women. No patients in this study by Jozsa and colleagues difference in resting angle from the contralateral side. Radio-
participated in competitive athletics. In their study, more graphic evaluation rules out the presence of a bony injury.
than 625 of the Achilles tendon ruptures occurred in Magnetic resonance imaging (MRI) can be helpful in
Increased mechanical
load beyond
tissue tensile strength
Submaximal Maximal
Microfailure Microfailure
(partial rupture) (complete rupture)
Failed healing Inflammatory

response response
Continued Surgery
damage
Degenerative Degenerative
changes in the changes and sheath Healing
tendon inflammation
Tendinosis Tendinitis
With continued loading

Progressive dysfunction
With less loading
Decreased dysfunction
Fig. 31-4 Progression of tendon injury. The inflammatory response may be limited and barely noticed by the athlete, even as degenerative changes continue.
As the remaining collagen fibers are overloaded and more are damaged, the inflammatory response recurs, possibly weeks or months after the initial injury.
After the tendon is in the inflammatory stage, it can be treated as an acute injury and should heal normally. In rare cases the tendon may rupture because
applied forces exceed the tensile strength of the now-weakened tendon. (Adapted from Curwin SL: Tendon injuries: Pathophysiology and treatment. In
Zachazewski JE, Magee DG, Quillen WS, editors: Athletic injuries and rehabilitation, Philadelphia, 1996, Saunders.)
160
demonstrating the presence, location, and severity of tears
140 Achilles
Others of the Achilles tendon. MRI also is helpful in assessing the
120 status of an Achilles tendon repair.34 Ultrasonography has
100 been used to define Achilles tendon discontinuity35 in coun-
Frequency
80 tries where MRI is not routinely used. No one clinical test

has been shown to be superior; however, a combination of a
60
complete history and physical examination along with radio-
40 graphic studies (if necessary) will lead to an accurate
20 diagnosis.36
0
After an accurate diagnosis is made, a definitive physical
0 <20 21-30 31-40 41-50 51-60 61-70 71+ therapy and rehabilitation program can be implemented by
Age establishing the objectives for management. If any questions
Fig. 31-5 Age distribution of patients with Achilles tendon ruptures. remain regarding the diagnosis or severity of the tear, then
(From Josza L, et al: The role of recreational sport activity in Achilles tendon MRI and ultrasonography can be used to enhance diagnostic
rupture. Am J Sports Med 17:338, 1989.) accuracy. The physical therapist (PT) should define the
558
TABLE 31-1 Distribution of Achilles Tendon Ruptures According to Sport
Study
Nillius, Inglis Cetti and Schedl Zolinger Kellam, Jozsa, Cetti,
Frings129 et al 130 et al 31 Christenson131 Holz 132 et al 133 et al 134 et al 99 et al135 et al 26 Soldatis, Karjalainen,
(1969) (1976) (1976) (1983) (1983) (1983) (1983) (1985) (1987) (1983) et al100 et al 90 (1997)
Sport Germany Sweden USA Denmark Germany Austria Switzerland Canada Hungary Denmark (1997) USA Finland
PART 4 Lower Extremity
Soccer 102 35 18 7 168 13 300 33 58 10 3 2

Handball 32 9 4 19 57 10 7 1
Volleyball 4 6 14 5 3 3 4 2
Basketball 29 6 23 10 1
Badminton 4 38 20 58 7
Tennis 5 15 23 4 12 3 3 3
Table tennis 4 5 20 2
Other ball games 9 20 230 5
Gymnastics 43 19 5 47 7 110 12 10
Running 46 6 42 5 14 1
Jumping 31 5 18 17 14
Climbing 1
Rock climbing 3
Weight lifting 6
Trampoline 1
Bicycling 1 39 3
Skiing 6 12 73 19 570 4 4
Dancing 10 7 1 1
Jogging 9
Racquetball 2
Aerobics 1
Baseball 4
Others 30 7 6 30 19 4 1
Total 317 134 131 53 479 68 1240 59 173 111 30 20
Adapted from Jozsa L, et al: The role of recreational sport activity in Achilles tendon rupture: A clinical, pathoanatomical, and sociological study of 292 cases. Am J Sports Med 17(3):338,
1989.
patients functional and athletic goals, personal needs, and complications (particularly infection) in the percutaneously
temporal priorities before making therapeutic judgments. treated group has been noted.41,44,45 Studies comparing open
versus percutaneous techniques have a relatively small
Nonoperative Versus Operative Management number of subjects, limiting their reliability.
Treatment for Achilles tendon ruptures was nonoperative The patient selected for operative repair should be an
until the twentieth century. It included immobilization with individual who is extremely interested in optimal functional
strapping, wrapping, and braces for varying periods of time.37 restoration.
In 1929 Quenu and Stoianovitch38 stated that a rupture of In 2010 the American Academy of Orthopaedic Surgeons
the Achilles tendon should be operated on without delay. published guidelines on the treatment of acute Achilles
Christensen30 (1953) and Arner, Lindholm, and Orell4 (1958) tendon ruptures. A meta-analysis of all existing literature
compared patients treated surgically and those managed showed similar outcomes in operative and nonoperative
nonoperatively; the surgical group had better results. As the treatment. The study demonstrated two moderate-strength
field of sports medicine progressed with new surgical tech- recommendations that included suggestions for early post-
niques, including rigid internal fixation combined with reha- operative protective weight bearing and for the use of protec-
bilitation, the optimal treatment for Achilles tendon rupture tive devices that allow for postoperative mobilization in
became controversial. Some studies supported nonoperative those patients who have surgical treatment.36
management of Achilles ruptures,28,39 as shown in the follow- Functional postoperative treatment programs, regardless
ing editorial statement made in 1973: In view of the excel- of surgical technique, avoid cast immobilization and are
lent results obtainable by conservative treatment, it is well tolerated, safe, and effective with well-motivated athletes
doubtful whether surgical repair in closed rupture of the and patients who especially desire the highest functional
Achilles tendon can be justified.40 In an updated meta- outcome.13,46-50
analysis of reports on Achilles tendon injury, Khan and asso-
ciates41 found that open operative treatment of acute Achilles Acute Care of the Achilles Tendon Rupture
tendon ruptures significantly reduces the risk of rerupture In the last century, the literature has proposed numerous
compared with nonoperative treatment, but it produces a approaches to the management of acute Achilles tendon rup-
significantly higher risk of other complications, including tures. The most important design principles of the option
wound infection. Significance varied among studies included. selected should include the following:
In total, reruptures in the operative groups were 3.5% vsersus 1. The option and procedure are safe and effective.
12.5% in the nonoperative groups. Rates for other complica- 2. The method allows the patient to accomplish realistic
tions (infection, adhesions, disruptions in sensation) in the goals.
operative groups were 34% versus 2.7% in the nonoperative 3. The surgeon can execute the method successfully.
groups. 4. The risks of the method are acceptable to the patient and
In 2003, Weber and colleagues42 compared the results of surgeon.
acute ruptures in 23 patients treated nonoperatively to 24 The categorical options for the surgical treatment of acute
patients treated operatively. Patients in the nonoperative Achilles tendon rupture include repair, repair with augmen-
group were allowed full weight bearing in 20 patellofemoral tation, and reconstruction.
casts for 6 weeks and were verified with weekly ultrasono
graphy and cast changes. Patients in the operative group were SURGICAL PROCEDURE
placed in casts and were nonweight bearing for 6 weeks with
variable rehabilitation protocols. The results showed a Repair
decreased return to work and crutch time for nonoperative The rationale for any repair method is to restore continuity
cases, with 4 of 23 reruptures at 7 to 12 weeks. Patients in the of the ruptured tendon end, facilitate healing, and restore
operative group had only 1 of 24 reruptures at 3 years. This muscle function. The technical difficulty is taking relative
study demonstrates that nonoperative treatment may be mop ends and opposing them in a stable fashion. Bunnell51
acceptable for some patient populations, but that operative and Kessler52 were the first to popularize the end-to-end
treatment, even with traditional postoperative immobiliza- suture technique for ruptured tendons. Ma and Griffith43
tion, yields a lower rerupture rate. The surgeon must explore described a percutaneous repair in 1977; however, a higher
the goals and expectations of the patient and decide which rerupture rate also occurred in their series. Beskin25 intro-
treatment is most appropriate. Indications for nonoperative duced the three-bundle suture, and Cetti46 demonstrated
treatment include concomitant illness in the patient, a seden- the suture weave in 1988, which was further modified by
tary lifestyle, or lower functional and athletic goals. Mortensen and Saether53 in 1991 as a six-strand suture tech-
Early nonoperative options were well accepted and toler- nique. Nada54 described the use of external fixation for
ated. But in the past 20 years, patient expectations and func- Achilles tendon ruptures in 1985. Richardson, Reitman, and
tional goals have increased so that surgical options have Wilson55 described good results using a pull-out wire, which
gained acceptance and preference. has the advantage of minimal suture reaction but requires a
Less invasive surgical procedures were first noted in the second procedure for suture removal. More recently, a com-
literature by Ma and Griffith.43 A lower overall rate of mercial device has become available that allows for the
percutaneous passing of a suture to repair a rupture through Cartilage atrophy

a minimally invasive incision. Jung and colleagues evaluated Degenerative arthritis
30 patients with limited open repair for Achilles tendon Adhesion formation
rupture using a commercial device with an average 18 Deep venous thrombosis
months follow-up and found that 16 patients were very satis- Immobilization after tendon surgery was considered the
fied, 11 were satisfied, and 3 were dissatisfied.56 single factor most responsible for postsurgical complications
Each of these techniques has advantages and disadvan- as long ago as 1954.24,30,43 Various clinical studies in the
tages, hence the wide spectrum of options. The surgeons literature document residual isokinetic strength deficits
selection of a method should be based on technical training, between 10% and 16% after cast immobilization of Achilles
an accurate pathoanatomic diagnosis, and the patients goals tendon injuries, regardless of whether they were managed
and desires. operatively or nonoperatively.9,28,71-73
The AO Group of Switzerland found that stable and rigid
Repair With Augmentation internal fixation of bone fractures allows early range
Historically, augmentation procedures evolved to supple- of motion (ROM) and maximal rehabilitation, thus mini-
ment the repair construct of mop ends plus suture. Most mizing atrophy and the manifestations of cast disease. This
augmentation procedures involved the local use of gastroc- principle indicates that early mobilization of tendon ruptures
nemius fascia flaps or the plantaris tendon if available. should be promoted as long as stable fixation is ensured. In
Christensen30 described the use of the gastrocnemius support of this concept, it has been demonstrated that early
aponeurosis flap to augment Achilles tendon repair in 1981. motion limits atrophy,74 promotes fiber polymerization to
Silfverskiold57 described a central rotation gastrocnemius collagen,75 and increases the organization of collagen at the
flap, and Lindholm58 devised a method of two turndown repair site, leading to increased strength.76-79 Krackow,
flaps. Lynn59 used the plantaris tendon, fanning it out to use Thomas, and Jones80 initially described a suture technique
the membrane to reinforce the repair. Kirschembaum and that allows rigid internal fixation without tendon necrosis.
Kellman60 modified the technique in 1980 by placing the This technique, coupled with complete repair of the peri-
fascial flaps centrally rather than separating them. Chen and tenon, should result in progressive and successful healing
Wertheimer61 demonstrated the use of suture anchors dis- of the Achilles tendon rupture without postoperative cast
tally at the calcaneus to repair the gastrocnemius turndown immobilization.
flap with semirigid fixation. Overall, these methods can Mandelbaum, Myerson, and Forster13 reported on the
facilitate the continuity and strength of the repair construct successful use of the Krackow modified suture technique
when doubt persists concerning the repairs integrity. in a series of 29 athletes with acute Achilles tendon rupture.
In practice these techniques are applied only in limited Postoperatively the patients were not rigidly immobilized
situations, but they should still be in the surgeons and were started on early ROM and conditioning programs.
armamentarium. No patients in this series experienced rerupture, persistent
pain, frank infection, or skin necrosis as a complication.
Reconstruction By 6 weeks after surgery, 90% of patients had full ROM.
Acute ruptures are usually managed with the repair tech- By 6 months, 92% had returned to sports participation;
niques already described with or without augmentation. strength deficits were less than 3% on isokinetic testing.
Usually these are appropriate to promote continuity and Rigid internal fixation of Achilles tendon tears allowed
healing of acute ruptures. Neglected, chronic ruptures, a more functional rehabilitation process in this series,
however, require reconstruction with endogenous or exog- including early motion and weight bearing. Maffulli and
enous materials. Endogenous materials include fascia lata,62 colleagues,32 who reported on the operative results of 42
peroneus brevis transfer,63 flexor digitorum longus,64 and patients who were randomized to a traditional protocol of
flexor hallucis longus.65 Exogenous materials include carbon postoperative immobilization or a full weight bearing proto-
fiber,66 Marlex mesh,67 Dacron vascular grafts,49 polylactic col, strengthened these results. In the full weight-bearing
acid implant, and a polypropylene braid.68 Once again, the group, patients were placed in a full weight-bearing cast for
surgeon must be familiar with these procedures and under- 2 weeks, then a full weight-bearing dorsiflexion splint for 4
stand their advantages and disadvantages before applying weeks. In the traditional protocol, the patients were immo-
them in appropriate scenarios. bilized in a cast for 4 weeks, then a full weight bearing cast
for 2 more weeks. They found that the full weight-bearing
Concepts of Achilles Tendon Repair group had no crutch use at 1.5 weeks, a quicker return to
Prolonged cast immobilization has been used with both work, less calf atrophy, greater patient satisfaction, less
operative and nonoperative treatment of Achilles tendon patient visits, and isometric strength equal to the traditional
ruptures. Although cast immobilization may promote group.32 This method of accelerated but controlled post
healing, it also promotes one or more of the following mani- operative management has proven to be safe and highly
festations of cast disease69,70: effective at returning the athlete and patient to activities of
Muscle atrophy daily living (ADLs) and sports with the highest level of
Joint stiffness function.13,14,81
contralateral side may be used for comparison. The suture

knots are passed to the anterior aspect of the tendon and
secured. The peritenon is then closed anatomically with 4-0
absorbable suture. The ankle is taken through a ROM to
evaluate the stability of the repair construct. The wound is
closed with dermal mattress sutures, with the knots based on
the medial side to protect the tendon; a posterior splint is
applied. On the second day after surgery, the splint is removed
and the ankle is taken gently through active range of motion
(AROM). Gentle ROM exercises are begun. The sutures are
removed by about day 14, and a progressive weight-bearing
program is initiated using a walker boot.
Percutaneous Repair
Percutaneous repair of the Achilles tendon has become an
acceptable alternative method to open repair. Proponents of
the technique have cited a lower wound complication rate
Fig. 31-6 Krackow suture technique. (Courtesy Santa Monica Orthopae-
and similar rerupture rates.83-87 Halasi, Tallay, and Berkes46
dic and Sports Medicine Group, Santa Monica, Calif.) performed an endoscopically assisted repair on 123 patients
and had no wound problems, a return to sport in 4 to 6
months, and no wound complications. Although sural nerve
Preoperative Treatment irritation can be a complication of the technique, it has been
After the diagnosis is made, the patient should be placed in postulated that endoscopic assistance of the procedure
a compressive elastic or cohesive tape wrap to minimize lowered the sural nerve complication rate.
swelling. They should be encouraged to use ice and elevate
the extremity. If possible, the patient should be allowed to Percutaneous Repair Technique
ambulate in a cam walker boot or with a cane to promote Buchgraber and Pssler83 described the following surgical
circulation and prevent venous thrombosis. Surgery should technique. Patients are placed in a prone position and given
be performed in an outpatient setting 7 to 10 days after the a short-acting general anesthetic. The tendon defect is iden-
injury. This delay allows consolidation of the tendon ends, tified by palpation, and a transverse or longitudinal incision
making repair technically easier. is made along the skin folds across its center. The associated
hematoma is deliberately left in place. Using a 15.3-mm
Surgical Technique blade, stab incisions are made at the medial and lateral
Surgery is performed with the patient in the prone position aspects of the tendon approximately 10 to 12cm above the
under general, regional, or local anesthesia. Care should be site of the tear. Another two stab incisions of the same length
taken to note the resting tension of the opposite foot. To be are made above the calcaneus, medial and lateral to the
most accurate, both feet can be prepped to allow accurate insertion of the Achilles tendon. To prevent sural nerve
side-to-side comparison of tendon length. Either a straight injury, a mosquito clamp is placed in the proximal lateral
midline or an anteromedial incision is made just medial to stab incision to retract the skin and the underlying fascia.
the gastrocnemius. A direct incision is made through the With the help of a cutting needle,* a 1.2-mm polydioxanone
peritenon, which is split and tagged. Before repair of suture (PDS) cord is pulled through proximally from the
the tendon, any adhesions between the anterior surface of medial to the lateral stab incision. Then the cutting needle is
the muscle and tendon unit and the paratenon are removed. introduced through the incision overlying the tear, passed
A relaxing incision in the anterior surface of the paratenon through the tendon proximally, and advanced toward the
is made down to the muscle of the flexor hallucis longus, lateral proximal stab incision. Using the cutting needle, the
which will facilitate closure of the paratenon. Each end of the end of the PDS cord at this site is passed out through
tear is sewn with a No. 2 nonabsorbable suture using the the central incision. Next the cutting needle is pushed into
Krackow suture technique (Fig. 31-6). The recently intro- the tendon tissue from the lateral distal stab incision, brought
duced synthetic, polyethylene sutures such as Fiberwire* or out centrally to load it with the lateral end of the PDS cord,
Orthocord are now commonly used for the repair and have and pulled out distally. This end of the cord is grasped with
been shown to have superior strength to traditional braided the needle and introduced through the medial distal stab
sutures.82 The sutures are tensioned appropriately to achieve incision, brought out through the lateral distal stab incision,
the same resting angle as the contralateral extremity. If any and pulled through medially. In the final step, the needle is
doubt exists regarding the amount of tension, then the passed through the proximal tendon end from the central
*Arthrex, Naples, Fla.
DePuy Mitek, Norwood, Mass. *Aesculap, Tuttlingen, Germany

incision and brought out at the medial proximal stab inci-

sion. The foot is put repeatedly through the full ROM to THERAPY GUIDELINES FOR
ensure that the cord will dig into the tendon tissue. The ends REHABILITATION
of the cord are tied with the foot in slight plantar flexion.
Once the first knot is tied, the foot is dorsiflexed several Consideration Toward the Healing Tendon
times to check the tension on the cord. The procedure is The use of early motion during postoperative rehabilitation
concluded with another two knots added in a crisscross requires the PT to have a working knowledge of the process
pattern.83 of tissue healing. With this knowledge, the therapist can
apply appropriate amounts of stress at the correct times,
Potential Complications progressing the rehabilitation program at an optimal pace
The major complication with nonoperative treatment is a and ensuring a good clinical outcome. Extensive summaries
higher rerupture rate and an incomplete return of function by Leadbetter,89 Curwin,19 and Curwin and Stanish22 fully
and performance. Complications associated with the surgi- describe tendon physiology and healing.
cal technique include infection, anesthetic problems, rerup- Fig. 31-7 summarizes the stages of the healing process
ture, deep vein thrombosis, and an incomplete return of and the implications they have for traditional postoperative
function. Infection can be a disastrous complication because management of Achilles tendon repairs and motion in the
soft tissue coverage is a major problem and can only be early postoperative period. Tendon healing occurs in four
resolved with vascularized flaps and a reconstructive tendon consecutive, related phases, with somewhat overlapping time
procedure.88 frames.
PMN leukocytes
Collagen
Macrophages Lymphocytes Fibroblasts
Fibrin platelets
Histologic
changes and Epithelium
cellular activity
Phase III
Phase II
Remodeling and
Phase I maturation
Tensile
strength of d
an n
repair and p air ratio
collagen Re olife
pr
ry
mato
Inflam
Clot
2 5 7 2 4 6 8 12 16 20 24
Days Weeks Weeks
Time of surgery
Traditional Phase I Phase II Phase III

treatment
Initial cast Second cast Start rehabilitation
Early Phase I Phase II Phase III

motion
IA IB IIA IIB IIIA IIIB
Fig. 31-7 Phases of tissue healing and rehabilitation timelines.

strength. The deposition of type I collagen accelerates and

Stages of Healing continues throughout this stage and well into the remodeling
Inflammatory Response and maturation stage.
Minutes after injury, laceration, or the initiation of surgical Changes in the postoperative internal structure of 21 sur-
repair, a coagulation response occurs, triggering the forma- gically repaired Achilles tendons have been documented by
tion of a fibrin clot. This clot contains fibronectin, which is Karjalainen and colleagues90 during the healing process
essential to reparative cell activity. Fibronectin eventually using MRI. After surgery, patients were placed in casts in
creates a scaffold for cell migration and supports fibroblastic equinus position for 3 weeks without weight bearing and for
activity. Soon after this clot forms, polymorphonuclear leu- another 3 weeks in a short walking cast in neutral position,
kocytes and macrophages invade the area to clear cellular with weight bearing as tolerated. After cast removal, patients
and tissue debris. The resulting arachidonic acid cascade is began AROM and walking exercises. MRI was repeated at 3
the primary chemical event during this stage. This stage is weeks, 6 weeks, 3 months, and 6 months after repair to docu-
usually complete in less than 6 days unless infection and ment changes (Fig. 31-8). During this stage the postoperative
wound disturbance occur. cross-sectional repaired area Achilles tendon increased dra-
matically, measuring 2.9 and 3.4 times the size of the unin-
Repair and Proliferation jured contralateral tendon at 3 and 6 weeks, respectively. A
The repair and proliferation stage may begin as early as 48 diffuse, high-intensity heterogeneous signal was present at
hours after injury and may last for 6 to 8 weeks. Tissue mac- the repair site for all 21 tendons at 3 weeks and in 13 of 21
rophages are the key factors early in this stage. The macro- tendons at 6 weeks. In the other eight tendons, early forma-
phage is mobile and capable of releasing various growth tion of high-intensity intratendinous signal was present in
factors, chemotactants, and proteolytic enzymes when nec- the center of the tendon at the level of repair.
essary or appropriate for the activation of fibroblasts and
tendon repair.89 Fibroblastic proliferation continues and pro- Remodeling and Maturation
duces increasing amounts of collagen. Type III collagen, Remodeling and maturation of collagen fibrils and cross-
which has poor cross-link definition, small fibril size, and links characterize the third healing stage. Overall a trend
poor strength, is initially deposited rapidly. As the repair toward decreased cellularity and synthetic activity, increased
process continues, collagen deposition shifts to type I col- organization of the extracellular matrix, and a more normal
lagen, which has greater cross-link definition, fibril size, and biochemical profile is evident.91 Functional linear alignment
A B
C D E
Fig. 31-8 T2 weighted MRI (TR, 2000msec; TE, 80msec) of the normal reunion process of ruptured and surgically repaired Achilles tendon. A, The affected
tendon shows a high-intensity signal (arrow) with a peripheral thin rim of low-intensity signal area and also low-intensity elements centrally. B, The unaffected
side. C, At 6 weeks the intratendinous lesion and the margin of the Achilles tendon are better visualized. D, At 3 months the periphery of the healing tendon
has returned to its normal low-intensity signal level. The intratendinous lesion inside the tendon is rather small. The cross-sectional area is seven times as
large as the unaffected side (B). E, At 6 months the scar is barely visible and the edema around the tendon has decreased compared with previous images.
(From Karjalainen PT, et al: Magnetic resonance imaging during healing of surgically repaired Achilles tendon ruptures. Am J Sports Med 25[2]:164, 1997.)
of the collagen fibrils is usually present by 2 months.89 studies have compared different early motion rehabilitation
Although maturation appears to be complete a number of regimens. Varying protocols make comparison between
months after the injury, biochemical differences in collagen studies difficult. The guidelines presented are a compilation
type and arrangement, water content, DNA content, and of various approaches considering appropriate tendon
glycosaminoglycan content persist indefinitely. The material healing.
properties of these scars never become identical to those of
intact tendon.8 Biomechanical properties can be reduced by Outcomes Measurements
as much as 30% despite the completion of all stages of healing Several outcomes measurement instruments have been used
and maturation.8,22,92,93 Karjalainen and associates61 found in Achilles tendon rupture research. In addition to objective
that the cross-sectional area of the tendon continues to clinical measures such as ROM, calf circumference, and
increase. The area is 6.1 times the size of the unaffected muscle testing, instruments for function and patient satisfac-
tendon at 3 months and 5.6 times the size at 6 months. A tion help the clinician to set goals and determine success of
variably sized, high-intensity signal demonstrating a central treatment. Early research used nonvalidated scoring methods
intratendinous lesion was detected in 19 of 21 repaired for pain, stiffness, activity limitations, footwear restrictions,
tendons at 3 months. The development of an intratendinous patient satisfaction, strength, and ROM.111-114 The Victorian
lesion appears to be a normal part of the healing process after Institute of Sport Assessment was validated as an index of
surgical repair and casting. severity for patients with Achilles tendinopathy and has been
used in Achilles tendon rupture research.32,115 Although
Future Directions found to be reliable and valid, the degree of responsiveness
Gene therapy and growth factors have an emerging role in has not been established. Patients use a visual analogue scale
the treatment of bone, cartilage, and tendon healing.94,95 to score eight items for morning stiffness, pain with walking,
Tendon callus can be influenced by cartilage derived mor- descending stairs, heel raises, single-leg hops, and ability to
phogenic protein-2 (CDMP-2).95 Using an animal model of participate in sports and physical activities.116
rabbit Achilles tendon tears, Forslund and Aspenberg96 The foot and ankle ability measure (FAAM) assesses
showed that failure load and stiffness in a CDMP-2 group activity limitations and vocational and avocational restric-
were greater at 14 days compared with controls. Future tions for individuals with general musculoskeletal foot and
treatments may include addition of growth factors to the ankle disorders. The FAAM uses a Likert scale for a 21-item
repair site. ADL/activities subscale and an 8-item sport subscale for a
perfect score of 100 with a minimal clinically important dif-
Postoperative Management: Traditional ference (MCID) of 8 points for ADL and 9 points for
Immobilization and Remobilization sports.117,118 In 2007 an outcomes measurement specific to
Versus Early Motion Achilles tendon ruptures was developed and found to be
Since surgical repair of Achilles tendon ruptures began valid and reliable but has not been reported in a randomly
almost 50 years ago,37 the traditional method of postopera- controlled trial.110,119,120 The Achilles tendon total rupture
tive management has been to immobilize the repair in a score (ATRS ) uses 10 items rated on a 10-point scale for
plaster cast or other type of restrictive device until healing is difficulty with strength, fatigue, stiffness, pain, ADLs, walking
considered complete, and then begin ROM and strengthen- on level surfaces, ascending stairs or hills, running, jumping,
ing exercises.12,26,31,32,97-102 Based on an understanding of con- and physical labor. We suggest that a change of 10 points in
nective tissue physiology and the success achieved with other the score is clinically relevant.119
types of surgical repairs, such as anterior cruciate ligament
reconstruction, several authors have begun using early post- Guidelines for Traditional Immobilization
operative motion to minimize the deleterious effects of and Remobilization
immobilization on joints (e.g., stiffness and loss of muscle Immobilization might be in a conventional cast12,32,45,101,102 or
strength, endurance, and flexibility)74,93,103,104 and facilitate an a fixed-angle ankle foot orthosis.109 The time of immobiliza-
earlier return to preoperative functional levels.* Numerous tion has been reported from 4 weeks102,109 to 8 weeks.101 Cast
studies have compared immobilization to early postoperative changes can occur during the immobilization period for
motion12,32,101,108-110 and early weight bearing.12,32,101,102,109-111 In wound care or decreasing the degree of plantar flexion.
a meta-analysis, Khan found that functional bracing and Weight bearing has been reported as early as 2 weeks.102
early motion resulted in fewer adhesions, disturbed sensitiv-
ity, hypertrophic scarring, and infection with no difference
in the rerupture rates between early motion and traditional Phases I and II
immobilization groups.41 Early functional programs provide TIME: 1 to 8 weeks after surgery
better patient satisfaction without an increase in rerupture GOALS: Minimize deconditioning, control edema and
rates compared with cast immobilization.109 However, no pain, encourage independent gait (nonweight
bearing until cleared by the physician to progressive
weight bearing, usually at 4 weeks) with assistive
*References 12-14, 32, 49, 101, 102, 105-108. device as appropriate
During traditional postoperative rehabilitation of surgi- With the traditional approach, the rehabilitation program
cally repaired Achilles tendon ruptures, a cast is usually in does not truly begin until phase III. The scar and tissue have
place throughout phases I and II of the healing process begun to mature and therefore ROM, joint mobilization,
(Table 31-2). The PT can do little to influence healing and stretching, strengthening, gait training, and return to func-
affect the outcome of the surgical repair. Casting incorpo- tion may progress as tolerated (Table 31-3). The sequence of
rates varying degrees of plantar flexion to protect the repair treatment depends more on resolving the patients physical
from stress. Casts that were initially applied with the foot in impairments and functional limitations than on the timeline
plantar flexion are usually changed to neutral (0 dorsiflex- of healing. Impairments are resolved to reestablish function,
ion) for the final 3 to 4 weeks of immobilization. During this develop skills, and return the patient to full activity and
period, a conditioning program is designed to maintain the sports participation.
patients general strength and cardiovascular conditioning. The initial goal is to restore ROM. Restoration of mobility
After the cast is removed, the PT can further protect the must occur before the patient can begin to work on strength.
tendon from full stress by using a heel lift of varying heights Active exercises in the sagittal (dorsiflexion and plantar
for as long as 8 weeks, if needed. Crutches with progressive flexion) and transverse (inversion and eversion) planes are
weight bearing also may be used to control mechanical initiated and progressed with the knee flexed and extended.
stress. The therapist should use joint mobilization techniques to
assist in gaining joint ROM and stretching exercises to gain
muscle flexibility and improve joint ROM (see figures in
Phase III the Chapter 29 describing mobilization of the ankle).
TIME: 9 to 16 weeks after surgery Any symptoms of pain and swelling that occur must
GOALS: Normalize gait, increase ROM and strength, be controlled during this phase through the use of appro-
improve scar mobility priate modalities and adjustments in the intensity of the
TABLE 31-2 Achilles Tendon Repair (Traditional Rehabilitation)

Anticipated
Impairments and
Phase I Postoperative Edema Immobilize in equinus Control edema and Immobilization in equinus
Postoperative Pain Provide elevation and ice pain minimizes stress on surgical
1-4 wk Nonweight Instruct and monitor Protect repair repair during healing process
bearing progressive weight-bearing Minimize Elevation and ice assist in
Cardiovascular and crutch gait on all surfaces deconditioning minimizing pain and
muscular Design and implement swelling
deconditioning cardiovascular- and Nonweight bearing status
muscular-conditioning protects repair
program Maintenance of
cardiovascular and muscular
conditioning crucial to
general health and return to
preoperative level of function
when out of cast
Phase II Stable edema and Abolished or Recasted in neutral Control symptoms of Decreased rate of atrophy
Postoperative pain diminishing dorsiflexion edema and pain if occurs when muscles are
5-8 wk Well-healed incision postoperative pain Elevation and ice as needed they occur immobilized in a lengthened
present at cast and swelling Instruct in progressive Continue to protect position93
change Atrophy of lower leg weight bearing to full repair Progressive weight bearing
and foot muscles weight bearing using Encourage full weight to full weight bearing allows
Progressive appropriate assistive devices bearing during gait loading and proprioceptive
weight-bearing Modify cardiovascular and cycle input
status allowed muscular conditioning Minimize Conditioning program should
Cardiovascular and program as appropriate deconditioning be progressed as the
muscular patients condition allows
deconditioning
TABLE 31-3 Achilles Tendon Repair (Traditional Rehabilitation)
Rehabilitation Criteria to Progress Anticipated Impairments and
Phase III Out of cast Altered gait cycle (preswing Ice, elevation, and nonsteroidal Control edema and pain if occur Modalities have been demonstrated to improve
Postoperative No increase in pain phase of gait) antiinflammatory drugs Initiate normalization of gait cycle ease of tissue deformation when used in
9-16 wk No increased loss of Limited joint ROM and muscle Therapeutic ultrasound and/or whirlpool Obtain full ROM conjunction with mobilization and stretching
ROM flexibility PROM (stretches)gastrocnemius-soleus, Improve strength of all foot and ankle Restore normal ROM
Incision healed Atrophy and limited strength peroneals, tibialis anterior, tibialis posterior musculature Initiate strength through ROM to improve overall
Soft tissue edema and joint Exercises, pool therapy, and joint mobilization Reduce scar tissue adhesion function
swelling as listed under the early motion program Promote cardiovascular and muscular Increase strength and endurance
Tendon hypertrophy AROM and isometrics in all directions, conditioning Gait deficits in the preswing phase may result
Scar tissue adhesion progressing to resisted exercises using tubing from limited dorsiflexion and decreased plantar
Limited cardiovascular fitness or manual resistance (proprioceptive flexion strengthheel lifts assist in reducing
neuromuscular facilitation) stress on musculotendinous structures in foot and
Gait trainingheel lift if required; return to ankle during the early gait cycle out of cast; heel
progressive weight bearing with appropriate lift can be decreased or eliminated as indicated
assistive devices (crutches or cane) to obtain Overuse symptoms should be addressed as
normal gait cycle if necessary to avoid appropriate to minimize their severity and
secondary overuse/tendonitis syndrome; longevity
progress as indicated based on symptoms of
gait cycle
Phase IV No symptoms from Mild or minimal alteration in Continue intervention from phase III as indicated Normal gait cycle on level surfaces; Progress intensity of rehabilitation program as
Postoperative ROM, flexibility, and gait cycle without assistive Continue joint mobilization techniques as initiate running program when normal indicated
17-20 wk strengthening devices appropriate gait cycle is evident Restore arthrokinematics
exercises initiated Restricted joint ROM and muscle Continue stretching exercises; initiate body Full symmetric ankle joint ROM and Promote patient self-management and stretching
during wk 9-16 flexibility weight stretching over edge of step muscle flexibility program
Able to sustain Unable to do repeated single-leg Continue strength program for foot and ankle Continue to improve foot and ankle Prepare for discharge
isometric single-leg heel raise musculature as listed in early motion program strength; repeated single-leg heel raise Promote symmetric strength of foot and ankle via
toe raise and lower Limited strength Modify cardiovascular and muscular Symmetric single-limb balance single-limb balance, isokinetic testing, and
body weight Limited proprioception conditioning program as needed Reduce scar tissue adhesion progressive plyometric program initiated in water
eccentrically under Soft tissue edema Isokinetics and body weight resistance Promote cardiovascular and muscular and progressed to land
control Tendon hypertrophy exercises such as heel raises (if no increase in conditioning Continue and progress based on each patients
AROM dorsiflexion 5 Minimal scar tissue adhesion symptoms occurs with previous exercises) response to intervention
PROM dorsiflexion Cardiovascular and muscular Balance and proprioceptive activities (e.g., Provide a good cardiovascular maintenance
10 deconditioning Biomechanical Ankle Platform System board, program based on patients needs
Symmetric plantar single-leg balance activities) Increase strength and improve function
flexion, inversion, and Near the end of the phase, begin running Improve balance and coordination on uneven
eversion progression and sport-specific skill surfaces
No assistive devices development Transition into high-level occupational activities or
required for sports
ambulation
treatment plan and home program. For return to progres- isokinetic deficits at several speeds, ranking results poor to
sive weight bearing use appropriate assistive devices excellent, with good to excellent results in 71% to 79% of the
(crutches or cane) to obtain normal gait cycle if necessary subjects.112,114 Outcome measures in studies that have been
to avoid secondary overuse/tendonitis syndrome. Prog- reported in the literature are difficult to use in comparing
ress as able based on symptoms of gait cycle. Soft tissue various studies.37 These studies used different operational
mobilization can be used to reduce scar adhesion. These definitions, set forth different methodologies, and collected
adjuncts for restoring ROM, muscle and tendon flexibility, data at different times, making meaningful comparison
and strength are continued throughout the program as difficult.
appropriate (see Table 31-3).
Guidelines for Early Motion

Phase IV As early as 1984, in an effort to reduce the effects of immo-
TIME: 17 to 20 weeks after surgery bilization, various authors began to present methods of
GOALS: Demonstrate normal gait on level surfaces, repair that would allow early motion and rehabilita-
initiate running program, have full ROM, increase tion.13,49,86,106,120-123 Orthoses or specialized splinting were
strength, improve balance and coordination developed to protect the repair after surgery.* Only one
report, a case series, described an early motion protocol, no
The therapist can initiate strengthening as ROM pro- postoperative fixation, and no postoperative complications
gresses. Initially, isometric techniques are used for all within 24 weeks. Protected AROM begins as early as day 1.120
motions. Strength training then progresses to the use of In some cases AROM begins at 2 weeks.32,109,123 The func-
elastic tubing and manual resistive techniques, such as pro- tional orthosis is removed most frequently at 6 weeks, some-
prioceptive neuromuscular facilitation. Isokinetic exercise times with use of a heel lift for several weeks. Weight bearing
and body weight resistance can be added if symptoms do not begins immediately32,101,110 or up to 2 weeks after surgery109
arise from the other techniques. The patient should begin and is generally progressed as tolerated. Regardless of the
double-heel raises before single-heel raises to reduce tensile type of repair, rehabilitation programs that emphasize
stress and the potential for symptoms such as pain and swell- early motion must consider the strength and integrity of
ing. The heel raises should initially be performed on a level, the repaired Achilles tendon as it changes during the
flat surface, after which the patient can progress to doing various stages of healing.
them over the edge of a stair to use the full ROM available.
Proprioceptive and balance activities should be initiated Phase Ia
concurrently with strengthening. The PT can begin a running TIME: 1 to 2 days after surgery
progression, sport-specific skill development, and functional GOALS: Prevent infection, control edema and pain,
activities after the patient has a normal gait and full ROM increase AROM, prevent complications, promote
and can rapidly perform heel raises. Isokinetic measurement independent gait using assistive device as
of strength, power, and endurance at 4 to 6 months may appropriate
assist in the determination of return to sport activity, but it
is not the sole determining factor. Phase Ib
The success of Achilles tendon repair using traditional
immobilization and rehabilitation has been favorably mea-
GOALS: Demonstrate AROM dorsiflexion to 5 and
sured, primarily by rerupture rates, strength, calf circumfer-
plantar flexion 50% of uninvolved side, control
ence, tendon width, and return to previous activity levels. In
edema and pain
a meta-analysis comparing cast immobilization and func-
tional bracing, Khan reported a pooled rerupture rate for When using an early motion program for postoperative
traditional immobilization of 5% and other complications rehabilitation, the therapist must keep in mind the phases
(adhesions, infection, and disturbed sensibility) at 35.7%.41 of tissue healing and the degree to which tissues can toler-
Early weight bearing in a cast was found to have no adverse ate tensile stress. During phases Ia and Ib of the early motion
effect as compared with the nonweight bearing group.102 program, the primary concerns are evaluating wound status,
The weight-bearing group discarded crutches approximately decreasing swelling, and initiating ROM exercises (Table
3 weeks earlier than the nonweight bearing group, with no 31-4). However, ROM should not be pushed aggressively. The
differences noted in tendon size measured by ultrasound and patient should work through PROM within the limits of pain
in isometric strength. Strength measurements include the and swelling intermittently throughout the day. The PT may
ability to perform single-toe raises, manual muscle tests, prescribe ice, compression, and elevation to decrease
and isokinetic strength measurements. Authors using peak swelling.
torque measurements of isokinetic plantar flexion strength
have reported that the gastrocnemius and soleus strength of
the repaired Achilles tendon ranges from 83% to 101% of the
uninvolved extremity.37 Some authors use combined *References 12, 32, 101, 105, 107, 109, 123.
TABLE 31-4 Achilles Tendon Repair (Early Motion)

Criteria to
Rehabilitation Progress to Anticipated Impairments and
Phase Ia Postoperative Pain Instruct in surgical site Monitor wound status Surgical site inspection
Postoperative Soft tissue and joint edema protection for drainage and cleanliness is crucial
1-2 days Altered weight bearing, Provide ice, compression, Prevent wound when patient is out of
nonweight bearing with and elevation infection splint for ROM
crutches Teach toe curls and pumps Control pain and Ice, compression, and
AROM (out of splint) swelling elevation with an ice cuff
ankle dorsiflexion, plantar Increase AROM over a sterile wound
flexion within pain limits Prevent complications dressing minimizes
two times a day swelling
Patient education Toe curls and AROM
Instruction and monitoring dorsiflexion and plantar
of nonweight bearing flexion provide muscle
crutch gait pump to minimize
edema
Phase Ib No signs of Pain Monitor wound for Minimize joint As in phase Ia
Postoperative infection Soft tissue and joint edema infection stiffness Therapeutic ultrasound
3-7 days Altered weight bearing, Provide ice, compression, Facilitate healing has been demonstrated
nonweight bearing with and elevation Reduce soft tissue to assist in fibroblastic
crutches until day 14 AROMincrease and joint swelling proliferation and facilitate
frequency to three times a Active dorsiflexion to collagen development
day for dorsiflexion and 5 along lines of
plantar flexion 50% active plantar stress.124,125,127
Therapeutic ultrasound flexion ROM
Instruction and monitoring compared with
of progressive crutch gait opposite side
Phase IIa changes in collagen synthesis and breaking strength as early

TIME: 2 to 4 weeks after surgery as 5 days after injury when giving continuous therapeutic
GOALS: Increase AROM and PROM, strength, and ultrasound at 1.5W/cm2 for 4 minutes over 8 consecutive
weight-bearing tolerance days and then every other day for up to 21 days. Freider and
associates127 reported similar results in partially ruptured,
During phase IIa (Table 31-5) of the early motion program, nonsurgically repaired Achilles tendons of Marland rats that
emphasis is placed on gaining active dorsiflexion past neutral, received continuous therapeutic ultrasound at 1.5W/cm2
following a full weight-bearing program in a protective splint three times a week for either a 2- or a 3-week period. Ng
or boot with a fixed hinge (Fig. 31-9), and initiating a gentle reported no significant difference among treatment groups
strength-training program of all the muscle groups in a in the collagen fibril size in severed rat Achilles tendons after
range that minimizes tensile stress on the repair. treatment with 1Mhz continuous therapeutic ultrasound
During phases Ia and IIa, therapeutic ultrasound can be at 0.5, 1.2, and 2W/cm2. There was a significant difference
used to assist in the healing response. In some instances comparing treatment groups to control of sham
therapeutic ultrasound has been shown to increase collagen ultrasound.128
synthesis and tensile strength in experimentally repaired Although the results of studies using animal models may
rabbit Achilles tendon.79,124-126 Enwemeka125 and Enwemeka, not be directly applicable to the human response, the thera-
Rodriguez, and Mendosa124 reported favorable results that peutic use of therapeutic ultrasound in the inflammatory
enhanced the healing response using 1MHz at doses of and proliferative stages could prove beneficial. Using thera-
0.5W/cm2 and 1W/cm2 for 5 minutes during nine consecu- peutic ultrasound during these stages is a common clinical
tive treatments. Jackson, Schwane, and Starcher126 noted intervention.
Anticipated
Criteria to Progress Impairments and
Rehabilitation Phase to This Phase Functional Limitations Intervention Goal Rationale
Phase IIa Absence of wound Diminishing Continue interventions as noted in phase I Minimize joint stiffness Therapeutic ultrasound is most effective in first 3
Postoperative drainage and infection postoperative pain Joint mobilization progress techniques for Facilitate healing wk and less effective thereafter; discontinued by
2-4 wk Stable edema and Diminishing soft tissue distractionanteroposterior and medial-lateral Decrease edema late phase IIa
pain levels and joint swelling glides Minimize scar adhesion Repair is strong enough and symptoms are
Diminishing Scar adhesion Progressive soft tissue mobilization and scar Increase weight bearing stable enough to initiate full weight bearing in
postoperative pain Touchdown and massage tolerance to full weight protective brace; reduce weight-bearing status as
No increase in pain progressive weight- Progressive weight-bearing exercises and gait bearing, beginning on necessary based on symptom fluctuation and
with touchdown bearing status training in walking splint day 14 patient activity pattern
weight bearing using Restricted ROM Start touchdown weight bearing on day 8; Initiate isometric strength Isometrics to facilitate strengthening and to
crutches Decreased strength progress from partial to full weight bearing as pain program diminish edema and atrophy are performed in
A well-healed incision Altered cardiovascular and symptoms allow beginning on day 14 Improve general muscular neutral position to reduce stress on repair
should be present by endurance and Isometricsout of splint strength and endurance Pool exercises facilitate ROM and strength in
wk 3 to progress to conditioning Ankle in neutralinversion and eversion Early phase IIa: active nonweight-bearing environment
the more active Start plantar flexion isometrics in late phase IIa dorsiflexion to 0 with Ice, compression, and elevation with a Cryo Cuff
interventions (pool Pool therapywalk or run under full buoyancy knee extended, 5 with over sterile wound dressing minimizes swelling
therapy) outlined in conditions (nonweight bearing only!) knee flexed Toe curls and AROM dorsiflexion and plantar
this phase AROM (out of splint)ankle (early phase IIa, all Late phase IIa: active flexion provide muscle pump to minimize edema
directions, knee flexed and extended; late phase dorsiflexion to 0-5 with Sufficient strength present at repair site based
IIa, gentle dorsiflexion stretching with towel or knee extended, 5-10 on healing and surgical technique to allow AROM
strap, knee flexed and extended towel curls with with knee flexed to 0 dorsiflexion and all other motions to
toes) Minimize cardiovascular symptom tolerance with knee flexed and
Gait training wearing protective splint, with weight deconditioning extended
bearing to tolerance Towel curls facilitate muscle pump action to
Elastic tubing or band exercisesinversion, diminish edema and atrophy
eversion, and plantar flexion and dorsiflexion; By 4 wk, sufficient strength to allow start of
progress as tolerated if pain and symptoms allow plantar flexion isometrics and isotonics within
Isotonicsweight training program for all symptom limits, using light resistance; performed
unaffected muscle groups in nonweight bearing
Cardiovascular exercise using stationary bicycle to Maintenance of general muscular strength and
tolerance in walking sprint cardiovascular endurance necessary to resume
full activities of daily living and recreational
Chapter 31 Achilles Tendon Repair and Rehabilitation
activities when feasible; walking splint protects

repair during activity

569
Phase IIb
GOALS: Demonstrate normal gait on level surfaces,
encourage full ROM (symmetric), increase strength
and proprioception
During phase IIb (Table 31-6), the patient should strive

to obtain full symmetric ROM, achieve a normal gait cycle
on level surfaces and in controlled environments without the
protective boot, progress the strength program, and initiate
proprioceptive training.
Phase IIIa
GOALS: Demonstrate normal gait for all activities, have
full weight bearing, increase strength and
endurance; initiate walking with progression toward
a jogging program (as appropriate), isokinetics, and
pool therapy plyometrics as appropriate (toward end
of phase)
Fig. 31-9 Protective splint and boot for initiating progressive and full
weight bearing. A fixed hinge should be used.

Anticipated
Phase IIb No loss of ROM Minimal Continue interventions as noted Full symmetric ROM Continue mobilizations to
Postoperative No increase in postoperative in phases I and II in all motions increase soft tissue strength
5-8 wk symptoms pain PROMinitiate weight-bearing Normal gait cycle on and mobility and restore joint
Full weight bearing Limited ROM dorsiflexion stretch with knee level surfaces and ROM sufficient to initiate gait
in walking splint Limited strength extended and flexed controlled training out of splint; gait
Incision healed Tendon AROM (out of splint) environments out of should be practiced in
Mild edema hypertrophy and Gait training out of walking walking splint controlled environment out of
Pain controlled continued soft splint to tolerance Initiate isokinetic splint for safety as appropriate;
AROM tissue swelling Strength traininginitiate and isotonic discontinue use of splint at
Dorsiflexion to Altered gait double-leg heel raises strength-training physicians and therapists
neutral or better cycle out of Isokineticssubmaximal program for discretion
Plantar flexion, walking splint velocity spectrum gastrocnemius-soleus Weight-bearing dorsiflexion
inversion/eversion Unable to do a Plantar flexion and dorsiflexion, complex required for normal ADLs;
symmetric single-leg heel emphasizing endurance Improve repair should be sufficiently
raise Weight training program for all cardiovascular strong; discontinue if
Altered unaffected muscle groups conditioning symptoms occur
proprioception Stationary bicycle to tolerance Improve muscular Gastrocnemius-soleus/repair
and joint without walking splint strength and initially conditioned with
reaction time Pool therapy for ROM (walking endurance isometrics; repair now strong
or running under total buoyant Improve enough to tolerate increased
conditions); heel raises in proprioception and strength training on a
waist- to chest-deep water joint reaction time progressive weight and force
basis
ADLs, Activities of daily living; AROM, active range of motion; PROM, passive range of motion; ROM, range of motion.
Phase IIIb a functional progression. During phase IIIb (Table 31-8), a

full functional progression is initiated to return the patient
to the desired level of function.
GOALS: Return to preoperative level of activity or
All authors using an early functional program, regardless
sport
of the type of augmentation used during surgery, have
During phase IIIa (Table 31-7), emphasis is on increasing reported excellent results. Success was measured by the same
the velocity of activity, increasing the patients strength to methods as for traditional rehabilitation. Limitation of ROM
perform a repeated single-leg heel raise, and improving the for dorsiflexion and plantar flexion are rare; patients are able
endurance of the gastrocnemius and soleus group to tolerate to walk heel-toe and do single-leg raises at the time of

Phase IIIa No longer requires Gait deviations in Continue Discontinue use Plantar flexion weakness will
Postoperative walking splint for preswing phase of gait interventions from of walking splint compromise gait; emphasis is
9-16 wk ADLs; may require resulting from limited phases I and II as Repeated placed on improving functional
use of splint for plantar flexion, strength, indicated, especially single-leg heel plantar flexion strength and
extended and endurance, not weight-bearing raise from level endurance (single-leg heel raise);
ambulatory periods insufficient dorsiflexion dorsiflexion stretch surface higher gait velocities affected until
in early parts of Unable to perform AROMprogress Normal gait cycle late in this phase or into phase
phase single-leg heel raise toward single-leg for all ADLs IIIb
Pain-free gait during Unable to jump and run heel raises, add Full symmetric Incline treadmill use will develop
ADLs walking out of Mild pain and muscle and resistance up to 1.5 weight-bearing strength and endurance of
splint tendon fatigue at end of times body weight dorsiflexion gastrocnemius-soleus muscles
Minimal difference day if walking for a as symptoms dictate Initiate Uneven surface and stair training
in dorsiflexion range significant period Gait training fast-walking or improves proprioception and
of motion versus Limited tolerance to treadmill walking on jogging program community ambulation
uninvolved side tendon-loading activities level surfaces and Decrease Jogging and running must be
Full plantar flexion, (concentric and eccentric) slight incline, uneven complaints of initiated only if patient is
inversion, and surface walking, mild pain or symptom free, has a normal gait,
eversion stair climbing; muscle and and is able to perform multiple
progress to jogging tendon fatigue at single-leg heel raises at moderate
toward end of phase end of day with to high velocities to avoid
if symptom free (no walking activities overloading tendon and initiating
sprinting, cutting, or Increase plantar an inflammatory cycle
jumping activities); flexion strength Use of minitrampoline will
jogging on and endurance facilitate achievement of
minitrampoline Improve plantar dorsiflexion at varying velocities,
Isokinetics flexion strength simulate higher level function, and
submaximal effort and endurance at develop higher velocity eccentric
velocity spectrum maximal load tolerance
plantar flexion and velocities Continued development of
dorsiflexion Prepare for strength and endurance required
Pool therapy land-based agility throughout this phase to achieve
(waist-deep) drills full ADLs and recreational function
plyometrics Improve Plyometric activities in the pool
(hopping, bounding, cardiovascular facilitate functional use without
and jumping in fitness level full weight-bearing stress
waist-deep water) Use gait training activities and
Cardiovascular stair machine to provide aerobic
exercises training
ADLs, Activities of daily living; AROM, active range of motion.


Anticipated
Phase IIIb Normal gait on all Unable to hop or jump Review of past Resolve all Most patients and athletes have
Postoperative surfaces and inclines on single leg without rehabilitation program impairments and only minor performance deficits
17-20 wk Able to fast walk or performance deficit or to address areas that functional by this time; deficits (which may
jog without gait compensatory may not have been limitations that continue to exist) require
deficits movement appropriately limit full return individualized attention based on
Able to do repeated Difficulty with sprinting addressed to preoperative their presentation and the way
single-leg heel raises or cutting during higher Development of level of function they affect the athlete or patient
with moderate to level recreational individualized in question; these areas may not
high velocities activities strength, flexibility, have been appropriately
Asymptomatic with all ROM, and functional addressed earlier or the patient
activities of daily progression program might have tried to progress too
living, treadmill to alleviate fast; any impairments or
walking, and jogging impairments and functional limitations are usually
functional limitations resolved within this phase and
time period
follow-up examination. In addition, isokinetic peak torque that the results are excellent, the different rehabilitation phi-
levels are within 5% of the uninvolved side.13,105 losophies cannot be compared critically because of dif
Reruptures are rare and are usually attributed to lack ferences in operational definitions, criteria monitored,
of retraining before a return to sports123 or return to vigor- postoperative time when the data are collected, and
ous activity against advice.101 However, these outcomes are surgical technique. Although the ultimate level of function
also difficult to compare for the same reasons as cited for achieved appears to be the same regardless of the rehabilita-
traditional rehabilitation programs. tive program, the authors of this chapter believe that using
early motion after Achilles tendon repair enables the patient
SUMMARY to obtain a more independent and active quality of life
sooner than that seen with traditional postoperative casting.
The superiority of early motion for Achilles tendon repairs However, patient compliance and ongoing oversight of the
compared with traditional postoperative casting cannot yet rehabilitation program are crucial factors that must always
be fully determined. Although studies reported to date state be considered.

Adherence to a home exercise program is crucial for on the patients postoperative condition, anticipated
a successful return to full ADLs and recreational follow-through, and individual needs. Frequency,
function after Achilles tendon repair. The sets, and repetitions are determined similarly based
suggestions provided in this chapter do not on the therapists professional opinion of what is
constitute a fixed protocol. The home program for needed in a particular situation.
any patient must be individually determined based
Suggested Home Maintenance for the Postsurgical

Patient: Traditional Rehabilitation Program
Weeks 1 To 4 3. For function:
GOALS FOR THE PERIOD: Manage symptoms a. Begin ambulation out of cast to symptom
(edema and pain), improve function, minimize tolerance.
deconditioning b. Use heel lift and cane or crutches as
1. For edema and pain: Use ice and elevation; appropriate to limit symptoms.
perform toe curls and pumps.
2. For function: Use nonweight bearing crutch gait, Weeks 17 To 20
progress depending on surgeon preference, type GOALS FOR THE PERIOD: Improve ROM, continue
of immobilization, and as tolerated. strength training, achieve functional improvement
3. For deconditioning: Modify cardiovascular and 1. For ROM: Continue all stretching exercises.
muscle conditioning as tolerated. (Continue 2. For strength training:
progressive program throughout rehabilitation.) a. Initiate single-leg heel raises.
b. Progress to additional weight heel raises with
Weeks 5 To 8 up to 1.5 times body weight provided no
GOALS FOR THE PERIOD: Manage symptoms, symptoms of pain, swelling, or inflammation
improve function develop.
1. For symptoms: Use ice, compression, and 3. For function:
elevation as needed; perform toe curls and a. Initiate walking on all types of surfaces and
pumps as needed. inclines and declines.
2. For function: Progress to full weight bearing to b. Progress to fast walking and jogging toward
tolerance with appropriate assistive devices if the end of this phase if no symptoms have
needed. occurred and patient is able to do single-leg
toe raises repeatedly.
Weeks 9 To 16 c. No sprinting, cutting, or jumping allowed.
GOALS FOR THE PERIOD: Improve ROM, continue
strength training, and achieve functional Week 20 And Beyond
improvement GOALS FOR THE PERIOD: Continue strength
1. For ROM: training, achieve functional improvement
a. Initiate nonweight bearing stretching 1. For strength training:
exercises for all ankle motions (dorsiflexion, a. Do single-leg heel raises over the edge of a
plantar flexion, inversion, and eversion). step.
b. Initiate weight-bearing dorsiflexion stretch with b. Do weight lifting to tolerance.
knee flexed and extended. 2. For function:
2. For strength training: a. Initiate jogging when able.
a. Initiate isometric and elastic band b. Initiate hopping, skipping, and jumping
strengthening exercises for all muscle activities.
groups. c. Return to all recreational and sports activities.
b. Progress to double-leg heel raises as tolerated.
Suggested Home Maintenance for the Postsurgical

Patient: Early Motion Program
Week 1 Weeks 5 To 8
GOALS FOR THE WEEK: Manage symptoms (edema, GOALS FOR THE PERIOD: Improve ROM, continue
pain), improve ROM, begin work on function, strength training, improve function
minimize deconditioning 1. For ROM:
1. For symptoms: Use ice, compression, and a. Continue phase IIa activities as appropriate.
elevation; perform toe curls and pumps. b. Initiate weight-bearing dorsiflexion stretch with
2. For ROM: Perform active range of motion (AROM) knee flexed and extended.
three times daily; perform plantar flexion and 2. For strength training:
dorsiflexion out of the splint within pain limits a. Continue phase IIa activities as appropriate.
with the knee flexed and extended. b. Initiate double-leg heel raises.
3. For function: Use nonweight bearing crutch gait; 3. For function:
progress depending on surgeon preference, type a. Begin ambulation out of the walking splint to
of immobilization, and as tolerated. symptom tolerance.
4. For deconditioning: Modify cardiovascular b. Use heel lift and cane as appropriate to limit
and muscle conditioning as tolerated. symptoms.
(Continue progressive program throughout
rehabilitation.) Weeks 9 To 16
GOALS FOR THE PERIOD: Improve ROM, continue
Weeks 2 To 4 strength training, improve function
GOALS FOR THE PERIOD: Manage edema, improve 1. For ROM: Continue phase IIb activities as
ROM, continue strength training, work on function appropriate to gain full ROM.
1. For edema: Use ice, compression, and elevation 2. For strength training:
as needed; perform toe curls and pumps as a. Progress towards single-leg heel raises.
needed. b. Progress to additional weight heel raises with
2. For ROM in early phase IIa (days 7 to 21): up to 1.5 times body weight if no symptoms of
Perform AROM three times daily in all directions pain, swelling, or inflammation occur.
out of the splint (plantar flexion, dorsiflexion, 3. For function:
inversion, and eversion) with the knee flexed and a. Initiate walking on all types of surfaces and
extended. inclines and declines.
3. For ROM in late phase IIa (days 21 to 28): Perform b. Progress to jogging toward end of phase if no
gentle dorsiflexion stretching with a towel or symptoms have occurred.
strap with the knee flexed and extended three c. No sprinting, cutting, or jumping allowed.
times daily.
4. For strength training in early phase IIa (days 7 to Weeks 17 To 20
21): Perform isometric inversion and eversion in GOALS FOR THE PERIOD: Continue strength
neutral dorsiflexion. training, achieve functional improvement
5. For strength training in late phase IIa (days 21 to 1. For strength training:
28): Perform isometric plantar flexion and a. Do single-leg heel raises over the edge of a
dorsiflexion; progress to light elastic band step.
exercises if free of pain and swelling. b. Perform weight lifting to tolerance.
6. For function (note: use walking boot at all times): 2. For function:
Start touchdown weight bearing on day 8; a. Initiate hopping, skipping, and jumping
perform progressive weight bearing at day 14 if activities.
no increase in pain and symptoms is noted. b. Return to all recreational and sports activities.
1 What are the three stages of healing?
(a) Inflammatory responseMinutes after injury, lacera-

I collagen, which has better cross-link definition, fibril
size, and strength.
tion, or the initiation of surgical repair. (b) Repair and

proliferationThe repair and proliferation stage may
begin as early as 48 hours after injury and may last for
5 Kim is 40 years old and ruptured her Achilles tendon
playing tennis. She had surgery 7 weeks ago and is eager
to resume her prior activity level. What exercises can she
6 to 8 weeks. (c) Remodeling and maturationcan last safely perform, laying the foundation for her return to
months. the court?
2 Scott is 35 years old and is undergoing his initial evalu-

ation 7 days after surgery. What part of his history will
help the therapist avoid being too aggressive and putting
At this stage of Kims rehabilitation, she can safely
perform deep-water running (in a floatation vest without
her feet touching the bottom), core training exercises
the repair at risk? that avoid straining the repair (sitting or supine using a
medicine ball), and upper extremity exercises (scapula
His general health, family, and past medical history are stabilization and rotator cuff program).
keys to determining if any factors may delay the healing
process. Diabetes, peripheral vascular disease, medica-
tions (corticosteroids/NSAIDs), anticoagulants, smoking,
past responses to healing (surgical, nonsurgical, or
6 Doug is 43 years old and underwent an Achilles tendon
repair 9 weeks ago. The physician has chosen the tradi-
tional immobilization approach for rehabilitation. He
both), pain tolerance, nutrition, and high body mass presented today 1 week after cast removal and is still
index all influence soft tissue healing response. quite painful with ambulation (stance phase). What can
the therapist do to help control his symptoms?
3 Nancy is following an early motion program and began

therapy at 1 week postoperation with an ATRS score of
10. At 6 weeks, she has made clinically significant prog-
The PT can assist in protecting the tendon from full
stress by using a heel lift of varying heights, and wean
ress as demonstrated by an ATRS score of 44. How do the height as able. In addition, by using crutches, pro-
you use this data to plan her continued therapy? gressive weight bearing may be used to control mechan-
ical stress. Modalities can also be used to help manage
Review the detailed scores to find that Nancy is limited any residual pain and inflammation.
more so in her activity scores than in pain, stiffness, and
strength which correlates with your objective findings.
Evaluate Nancys ADLs, vocational, and recreational
activity goals to begin activity-specific training.
7 Brian is 3 months postoperation and is concerned that
his repaired Achilles tendon looks much larger than his
unaffected side. Is this normal?
4 Kerry had an Achilles tendon repair 7 weeks ago. She is

partial weight bearing and uses a fixed protective splint.
At 9 weeks she will initiate nonweight bearing stretch-
The area of repair can be 6.1 times the size of the unaf-
fected tendon at 3 months and 5.6 times the size at 6
months. A variably sized, high-intensity signal demon-
ing exercises for all ankle motions. During phases I and strating a central intratendinous lesion was detected in
II (weeks 1 through 8) of the healing process, fibroblas- 19 of 21 repaired tendons at 3 months. The development
tic proliferation continues, producing a rapid increase of an intratendinous lesion appears to be a normal part
in the amount of collagen. Even though collagen of the healing process after surgical repair and casting.
amounts are increased, the repaired tissue is weak and
requires protection (e.g., restricted weight bearing and
nonaggressive ROM stretches). Why do the healing
tissues remain weak despite the increase in collagen
8 Tom is 3 weeks postoperation in the early motion guide-
lines. What can be done to assist his healing response.
fibers? Once the incision is healed and dry, therapeutic ultra-

sound can be used to help assist in the healing response.
Type III collagen is deposited; it has poor cross-link defi- In some instances therapeutic ultrasound has been
nition, small fibril size, and poor strength. As the repair shown to increase collagen synthesis and tensile
process continues, the collagen deposition shifts to type strength.
9 Dan is 22 weeks postoperation and demonstrates good

ROM and strength. He has a normal gait on level sur-
faces, and he initiated the Return to Running program.
Reruptures are rare and are usually attributed to lack of
retraining before a return to sports. The demands of his
sport should be broken down into phases and accom-
He appears to be holding back his effort on some agility plished one phase at a time. This will allow him to be
drills and he mentions that he just doesnt feel that he successful in smaller demand activities and gain confi-
can trust it. What can you do as a clinician to alleviate dence that he can trust his repair. Refer to the chapters
his concerns? on Return to Running and Return to Jumping for a com-
plete program.
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CHAPTER 32
Bunionectomies
Joshua Gerbert, Neil McKenna
DEFINITIONS It should be noted that once the intrinsic and extrinsic

muscles of the LE abnormally function during gait and the
The term bunion refers to the any enlargement around the patient significantly pronates, the hallux begins to deviate
first metatarsal phalangeal joint (MTPJ). The term hallux toward the second toe and retrograde forces on the first
valgus has been used as a catch-all phrase to include all metatarsal begin to move this bone more medially. The more
types of bunions without being specific. The actual definition transverse plane mobility that exists at the first metatarsal
of hallux valgus is a frontal plane deformity of the great toe cuneiform joint (MCJ), the more the first metatarsal may
in which the plantar aspect of the toe is beginning to face splay from the second metatarsal. The more sagittal plane
the second toe. Hallux abductus is a transverse plane defor- mobility that exists at the first MCJ, the more the first meta-
mity of the great toe in which it is moving toward, abutting, tarsal will migrate dorsally and produce limited first MTPJ
overriding, or underriding the second toe. In most cases the motion (hallux limitus rather than a medial bunion defor-
surgeon will make a diagnosis of hallux abductus with mity with a hallux abductus).
bunion deformity (Fig. 32-1) or hallux abducto-valgus
with bunion deformity depending upon the preoperative INDICATIONS AND CONSIDERATIONS FOR
position of the great toe. A dorsal bunion is an enlargement SURGICAL CORRECTION
over the dorsal aspect of the first MTPJ and in most situa-
tions is indicative of limited first MTPJ motion known as A very detailed clinical examination of the foot and LE is
hallux limitus. required both nonweight bearing and weight bearing to
determine areas of pathology contributing to the bunion
ETIOLOGIES deformity. Objective measurements of the first MTPJ range
of motion (ROM) (dorsiflexion and plantarflexion) are
Bunion deformities are complex problems and dynamic, obtained nonweight bearing (Fig. 32-2). The amount of
meaning that over time the deformity will most likely prog- dorsiflexion deemed necessary for a normal propulsive gait
ress regardless of the conservative measures employed. This is approximately 65 (Fig. 32-3). Since plantarflexion of the
is especially true if there is any structural malalignment of first MTPJ is not a motion required for gait, there are really
the bones that comprise the first ray. Once a bunion defor- no normal values usually considered other than knowing
mity has developed there are no conservative measures that that the first MTPJ can plantarflex to some degree without
will reverse the situation. Conservative measures may halt discomfort. Evaluation of mobility at the first MCJ on both
the progression of the deformity and/or reduce the symp- the transverse and sagittal planes is important to detect any
toms associated with it. The etiologies are varied and at times hypermobility. If sagittal plane hypermobility of the first ray
are the result of several different causes. The following are appears to exist, then one should dorsiflex the hallux at the
the more common causes of bunion deformities: first MTPJ and evaluate the motion again. By dorsiflexing
Structural malalignment of one or more of the bones that the hallux, one is engaging the plantar fascia (windlass
make up the first ray mechanism). If the abnormal sagittal plane motion is no
Biomechanical imbalance in the lower extremity (LE) in longer present, then the use of an orthotic device will most
which the patient functions with abnormal pronation likely halt any deforming forces caused by hypermobility
during gait of the first ray, which are usually jamming of the first MTPJ
Metabolic (arthritides creating degenerative joint disease in gait, limited first MTPJ motion, and transfer metatarsal-
of the first MTPJ and bone spur proliferation) gia. However, if by engaging the windlass mechanism by
579
Fig. 32-3 The 65 of dorsiflexion that is needed for a propulsive gait. Some
patients may not need this amount of dorsiflexion to achieve a normal
Fig. 32-1 Photograph showing a patient with a hallux abductus with
propulsive gait.
bunion deformity.
Fig. 32-4 A weight-bearing anteroposterior radiograph showing the defor-

mity demonstrated in Fig. 32-1. The hallux is deviated toward the second
digit and the intermetatarsal angle between the first and second is increased.
In this case there is a soft tissue imbalance at the first metatarsal phalangeal
joint and a structural malalignment of the first metatarsal.
Fig. 32-2 A, A nonweight bearing measurement of dorsiflexion of the Weight-bearing radiographic evaluation of the foot is
first metatarsal phalangeal joint. A line is drawn along the declination angle extremely important in the evaluation of the bunion defor-
of the first metatarsal and extended straight out. Any movement in a dorsal mity to determine any structural malalignment of the first
direction from that line is measured as dorsiflexion. B, The actual measure-
ray and at which level or levels the pathology exists (Fig.
ment of first dorsiflexion with a tractograph.
32-4). A unique aspect of the first MTPJ is the presence of
two sesamoid bones on the plantar aspect of the metatarsal
dorsiflexing the hallux and the hypermobility appears to head (Fig. 32-5), which serve as a fulcrum for the tendons
remain, then a surgical procedure aimed at stopping this of the flexor hallucis brevis muscle that attaches to the plantar
motion is usually needed, such as a fusion of the first MCJ aspect of the base of the proximal phalanx. At times the
known as a Lapidus procedure. Symptoms may not always fibular sesamoid bone may become a very powerful deform-
be the indication for pursuing a surgical correction of the ing force and the surgeon may need to release its soft tissue
bunion. A patient who has a progressive hallux abductus attachments or excise it (Fig. 32-6). This maneuver can create
and a bunion deformity in which the hallux is significantly scar formation to such an extent as to limit first MTPJ dor-
abutting the second toe but is asymptomatic may require a siflexion postoperatively.
surgical correction of the deformity to prevent deformity of Various angular measurements are taken and correlated
the second toe and dislocation of the second MTPJ. with the clinical examination.
Chapter 32 Bunionectomies 581
bunion deformities. However, the following are the more

common ones.
Category 1
Category 1 procedures are those in which the patient can
begin immediate propulsive ambulation following surgery
and return to high impact activities within 2 to 3 weeks.
1. Soft tissue rebalancing of the first MTPJMcBride type
(rarely performed as an isolated procedure) (Fig. 32-7)
2. First MTPJ prosthesistotal or hemi (Fig. 32-8)
3. Cheilectomyremoval of bone spurs from the dorsal
aspect of the first MTPJ in hallux limitus (dorsal bunion
Fig. 32-5 A weight-bearing plantar axial radiograph showing the two sesa-
deformity) (Fig. 32-9)
moid bones plantar to the first metatarsal head that make up part of this 4. Resectional arthroplasty of the first MTPJKeller type
joint complex. They serve to provide a better mechanical advantage for the (usually performed in a very elderly patient with a non-
flexor hallucis brevis muscle in maintaining good hallux toe purchase. salvageable first MTPJ) (Fig. 32-10)
Category 2
Category 2 procedures are those in which the patient can
bear weight immediately; however, the propulsive phase of
gait must be eliminated for 2 to 3 weeks following surgery
and the patient cannot resume high impact activities for 8
weeks.
1. Metatarsal head procedures to create a relative reduction
of the intermetatarsal angle (Fig. 32-11)
2. Decompressional metatarsal head procedure to shorten
the metatarsal and open the first MTPJ space to allow for
more joint motion (Fig. 32-12)
3. SCARF metatarsal shaft procedure (Fig. 32-13)
Category 3
Fig. 32-6 An intraoperative photograph showing a release of the fibular
sesamoid apparatus in the first interspace through the dorsal incision used Category 3 procedures are those in which the patient can
to correct the bunion deformity. At times the dissection to perform this bear weight immediately; however, the propulsive phase of
maneuver or excise the sesamoid can produce excessive scar formation and/ gait must be eliminated for 4 to 6 weeks following surgery
or a hematoma in the interspace, creating postoperative problems for the and the patient cannot resume high impact activities for 12
patient.
weeks.
1. Hallux osteotomiesAkin type (Fig. 32-14)
2. Fusion of the first MTPJ (Fig. 32-15)
The surgeon must also take into consideration the patients
overall medical health, body type, age, occupation, and home Category 4
environment before deciding which surgical procedure or Category 4 procedures are those in which the patient must
procedures would best correct that patients bunion defor- remain nonweight bearing for 6 to 7 weeks following
mity. While the clinical and radiographic evaluation data surgery and the patient cannot resume high impact activities
may indicate an ideal surgical correction, the specific for 12 to 16 weeks.
medical and/or social data on that specific patient may 1. Metatarsal base osteotomies (Fig. 32-16)
dictate a lesser surgical correction. 2. Fusion of the first MCJ (Fig. 32-17)
SURGICAL PROCEDURES Category 5

Category 5 procedures are those in which a bone graft was
Since there are a wide variety of surgical procedures used used at the osteotomy site or fusion site and the patient must
to correct a bunion deformity, and in many cases the remain nonweight bearing until the bone graft has become
surgeon may perform more than one procedure to correct incorporated, which depending upon the size of the graft
the deformity, I thought it would be beneficial to the physical may take 3 months.
therapist to put the procedures in categories as they relate 1. Metatarsal base osteotomy with bone graft (Fig. 32-18)
to postoperative management and to briefly describe the 2. Fusion of the first MTPJ or first MCJ with bone graft
major aspect of the procedure. This chapter does not (Fig. 32-19)
allow me to cover every type of procedure used to correct Text continued on page 589
B C
D E
Fig. 32-7 A, An intraoperative photograph showing a dorsal incision with exposure of the dorsal and medial aspect of the first metatarsal phalangeal joint
in the initial stages of performing a soft tissue type bunionectomy to rebalance the tissues around the joint. B, An intraoperative photograph showing the
medial aspect of the joint capsule being dissected and cutting the collateral ligament to expose the bunion site. C, The medial aspect of the first metatarsal
head exposed to remove a portion of the medial aspect of the metatarsal head that is enlarged. D, The dissection that is now performed into the first interspace
to release abnormally tight lateral structures and release of the fibular sesamoid if necessary. E, The closure of the medial and dorsal aspects of the first meta-
tarsal phalangeal joint capsule in which redundant tissue was removed to realign the hallux into a better transverse plane position.
A B C
D E F
G H I
Fig. 32-8 A, A hemi type metallic joint prosthesis that replaces the base of the proximal phalanx. B, An anteroposterior weight-bearing preoperative
radiograph showing a degenerative first metatarsal phalangeal joint that was painful with motion, an abnormal increase in the intermetatarsal angle with a
bunion deformity, and a hallux abductus deformity. The treatment for this condition was a combination of a metatarsal head osteotomy to reduce the distance
between the first and second metatarsals, realign the soft tissue structures around the first metatarsal phalangeal joint, and to replace the base of the proximal
phalanx with a hemiimplant. C, A postoperative radiograph following the metatarsal osteotomy with two screws for fixation, soft tissue rebalancing around
the joint, and insertion of a hemiimplant with resultant adequate first metatarsal phalangeal joint dorsiflexion and elimination of pain. D, A lateral radiograph
of this patient simulating propulsion to demonstrate the movement of the implant gliding over the metatarsal head. E, Implant sizers for a total silicone hinge
joint prosthesis. F, An implant inserted into a sawbone model to demonstrate its position and the amount of bone that is needed to be removed both from
the metatarsal head and base of the proximal phalanx. Minimal bone is normally removed from the metatarsal head and the majority of bone is removed
from the base of the proximal phalanx to preserve some weight bearing under the first metatarsal head. Because of the amount of bone needed to be removed
from the base of the proximal phalanx, the insertion of the flexor hallucis brevis muscle is eliminated. G, An intraoperative photograph from a medial view
showing the total hinge implant. H, The total hinge implant from a dorsal view. I, A postoperative anteroposterior weight-bearing radiograph showing the
total hinge implant.
A C
Fig. 32-9 A, A cheilectomy procedure in which the dorsal, medial, and lateral bone spurs are removed from the metatarsal head and base of the proximal
phalanx. B, A lateral preoperative radiograph simulating propulsion showing the significant bone spurs at the dorsal aspect of the first metatarsal phalangeal
joint that were the cause of the pain and limitation of motion. C, A postoperative lateral photograph stimulating propulsion with normal motion once the
bone spurs had been removed.
A C
Fig. 32-10 A, The amount of bone to be removed from the base of the proximal phalanx in performing a resectional arthroplasty (Keller) bunionectomy.
B, A dorsal view intraoperatively following this procedure in which a k-wire has been inserted through the hallux and into the metatarsal head to hold the
hallux in a corrected position on the transverse and sagittal planes until scarring can occur within the void that was created by removing the base of the
phalanx. C, A postoperative view following the surgery with the k-wire inserted through the hallux and metatarsal. Note that the hallux does shorten as a
result of this procedure, which will result in transfer metatarsalgia in many patients.
A B C
D E F
Fig. 32-11 A, A preoperative anteroposterior weight-bearing radiograph showing a hallux abductus with bunion deformity in which the underlying patholo-
gies are soft tissue imbalance around the first metatarsal phalangeal joint and an increase in the intermetatarsal angle creating the bunion. B, A paper template
constructed to demonstrate the metatarsal osteotomy to be performed in which the metatarsal head is transposed laterally to achieve a relative reduction of
the intermetatarsal angle and eliminate the bunion. A soft tissue procedure (McBride) will need to be performed to rebalance the soft tissue structures around
the joint. C, A medial view intraoperatively following a chevron (Austin) osteotomy through the metatarsal neck. D, A postoperative weight-bearing radio-
graph following the Austin/McBride bunionectomy. Fixation was accomplished with absorbable rods. E, An anteroposterior radiograph showing the same
type of procedure in which the osteotomy was fixated with two screws. F, A lateral radiograph showing the procedure fixated with two screws.
A B C
Fig. 32-12 A, A decompressional osteotomy performed at the metatarsal head level in which a section of bone is removed to allow shortening of the first
metatarsal, which relaxes the soft tissue structures around the first metatarsal phalangeal joint permitting increased range of motion. B, A dorsal view during
surgery of the first metatarsal head following removal of a section of bone to allow shortening of the first metatarsal. C, A medial view following fixation of
the decompressional osteotomy using two screws from dorsal to plantar.
B C
Fig. 32-13 A, An intraoperative photograph showing the medial aspect of the first metatarsal in which a long Z type osteotomy is performed in the shaft
of the metatarsal known as a SCARF procedure. B, A preoperative weight-bearing radiograph showing a long first metatarsal, an increase in the intermetatarsal
angle, and a hallux abductus deformity. C, A postoperative weight-bearing radiograph following the SCARF procedure along with soft tissue rebalancing of
the first metatarsal phalangeal joint fixated by several screws. Note that the intermetatarsal angle has been reduced, the metatarsal length has been reduced to
a more normal parabola, and the first metatarsal phalangeal joint has been realigned.
A B C
Fig. 32-14 A, A preoperative weight-bearing radiograph showing an abnormal abductus at the level of the interphalangeal joint of the hallux. The patient
does not have a bunion. B, A dorsal intraoperative photograph showing a medial wedge of bone having been removed from the distal aspect of the proximal
phalanx. When this osteotomy is closed it will reduce the abnormal abductus deformity and straighten the toe. C, A weight-bearing postoperative anteropos-
terior radiograph showing the reduction of the deformity using a distal Akin osteotomy with stainless steel wire fixation. No soft tissue rebalancing was
performed in this procedure.
Fig. 32-15 A postoperative weight-bearing radiograph showing a primary fusion of the first metatarsal phalangeal joint using two crossed screws. Once the
fixation is secured, the position of the hallux on the frontal plane, sagittal plane, and transverse plane cannot be altered.
A B
C D
Fig. 32-16 A, A preoperative anteroposterior weight-bearing radiograph showing a hallux abductus with bunion deformity in which there is a significant
increase in the intermetatarsal angle and a deviated first metatarsal phalangeal joint. The intermetatarsal angle is too large to be corrected with a metatarsal
head osteotomy. B, The same radiograph with a paper template demonstrating the proposed metatarsal base osteotomy to be used to reduce the large inter-
metatarsal angle. It shows the removal of a lateral wedge of bone with the apex medially. C, A postoperative radiograph showing the reduction of the inter-
metatarsal angle following the base osteotomy in which two screws were used for fixation and a McBride soft tissue rebalancing was performed at the first
metatarsal phalangeal joint. D, A lateral radiograph of that patient showing the normal sagittal plane alignment of the first metatarsal following the procedure.
Note that the dorsal cortex of the first metatarsal is parallel to that of the second metatarsal, thus ensuring a normal weight-bearing position of the first.
A B C
Fig. 32-17 A, A preoperative anteroposterior weight-bearing radiograph showing a hallux abductus with bunion deformity in which there is a significant
increase in the intermetatarsal angle. Clinically the first metatarsal was shown to be hypermobile with abnormal sagittal plane motion at the first metatarsal
cuneiform joint. The second metatarsal phalangeal joint has dorsal dislocated and the second toe has migrated over the dorsal aspect of the hallux because of
the long-standing bunion deformity. B, A postoperative anteroposterior radiograph following a fusion of the first metatarsal cuneiform joint (Lapidus proce-
dure) along with a McBride soft tissue rebalancing of the first metatarsal phalangeal joint. Two screws were used to fixate the fusion site. Several procedures
were performed to relocate the second metatarsal phalangeal joint and realign the second digit. C, A lateral radiograph following the metatarsal cuneiform
joint fusion showing that the first metatarsal is in normal sagittal plane alignment relative to the lesser metatarsals. The dorsal cortex of the first metatarsal is
parallel to the dorsal cortex (dotted lines) of the second metatarsal.
A B
Fig. 32-18 A, A preoperative anteroposterior weight-bearing radiograph in which a paper template has been constructed to demonstrate a medial opening
wedge osteotomy at the metatarsal base to reduce a significantly high intermetatarsal angle. A bone graft will need to be inserted into the opening osteotomy
site. B, An anteroposterior radiograph following the opening wedge osteotomy with bone graft in which a staple was used for fixation. A McBride soft tissue
rebalancing was performed at the first metatarsal phalangeal joint.
A B C
D E F
Fig. 32-19 A, A postoperative lateral radiograph following a first metatarsal phalangeal joint fusion in which a bone graft was used. This was necessary
because a total implant failed, and once removed the graft was needed to preserve length of the hallux. A low profile bone plate was used dorsally to fixate the
site. B, An anteroposterior postoperative radiograph at 24 hours following the procedure with the graft. C, An anteroposterior radiograph at 3 months fol-
lowing the graft arthrodesis procedure. D, A lateral radiograph at 3 months following this procedure. E, An anteroposterior radiograph of that patient at 1
year with complete reconstitution of the bone and solid first metatarsal phalangeal joint fusion. F, A lateral view of that patient at 1 year postoperative.
of the procedure is performed to release any abnormally

Underlying Pathology tight soft tissue structures that are holding the hallux in the
In the majority of bunion deformities, the underlying abductus position. Using some type of power instrumenta-
pathology is a combination of both a soft tissue imbalance tion, the bone is cut completely through from medial to
at the first MTPJ and a structural malalignment involving lateral, severing all cortical surfaces as shown in Fig. 32-11,
one or more of the bones comprising the first ray. Therefore C. Then based upon the surgeons evaluation of the preopera-
the surgeon may need to perform combinations of proce- tive x-ray and/or preoperative template, the metatarsal head
dures, such as an Akin osteotomy of the hallux, a McBride is transposed laterally toward the second metatarsal by a
soft tissue rebalancing around the first MTPJ, and a metatar- certain number of millimeters. Once the metatarsal head has
sal base osteotomy. The postoperative management would be been transposed to the desired amount, the osteotomy site
dictated by the procedure that requires the most protection. is fixated based upon the surgeons preference and the medial
So in the example given, the patient would need to remain overhang of bone on the metatarsal shaft is removed flush.
nonweight bearing for 6 to 7 weeks because of the metatar- Fig. 32-11, D is a postoperative radiograph in which the
sal base osteotomy. If the surgeon used rigid internal fixation osteotomy site was fixated with absorbable rods, which are
and believed the patient to be compliant, then the patient radiolucent. Fig. 32-11, E and F, are postoperative radio-
may be allowed to begin early first MTPJ ROM and not be graphs in which the osteotomy site for this type of procedure
placed in a below the knee cast. This would of course allow was fixated with two cannulated screws.
for faster rehabilitation once the patient could resume weight Once fixation is completed, the structural component
bearing and return to normal activities. now has been corrected. The next portion of the procedure
is the completion of the soft tissue rebalancing. In this spe-
SURGICAL PROCEDURE FOR A cific example an inverted L capsulotomy was performed
METATARSAL HEAD OSTEOTOMY medially. The surgeons assistant holds the hallux into a cor-
(CATEGORY 2) AND SOFT TISSUE rected position on the transverse plane, and the surgeon can
REBALANCING OF THE FIRST MTPJ then appreciate how much redundant medial capsular tissue
(CATEGORY 1) is present. This medial redundant tissue is excised and the
medial capsule closed using suture material of the surgeons
One of the more common bunionectomy procedures involves preference (see Fig. 32-7, E). The dorsal portion of the
a first metatarsal osteotomy (Austin or Chevron procedure) capsule is then closed again using suture material of the
and a soft tissue rebalancing (McBride procedure) to correct surgeons preference. Some surgeons will elect to close
both a positional and a structural malalignment (see Fig. the subcutaneous tissues and others will insert several buried
32-11, A). A pneumatic ankle cuff is used to stop all blood knot sutures in the dermal layer to take the tension off the
flow into the foot and allow for a dry field during the proce- skin before skin closure. Skin closure is accomplished usually
dure, which usually requires 45 to 60 minutes to complete. with a nonabsorbable material, again based on the surgeons
After a sterile preparation of the foot, a dorsal medial inci- preference.
sion is made over the first MTPJ and by using blunt and Bandages are applied in such a manner as to control post-
sharp dissection the subcutaneous tissues and neurovascular operative edema and reinforce the soft tissue realignment of
elements are separated from the dorsal and medial aspect of the first MTPJ. The patient is placed either in a surgical
the first MTPJ capsule (see Fig. 32-7, A). The surgeon then postoperative shoe or a removable walking boot. Both
uses one of many capsulotomies to enter and expose the first devices allow for the patient to begin immediate ambulation
MTPJ. with elimination of the propulsive phase of gait, which is
Fig. 32-7, B shows an inverted L capsulotomy having needed because of the osteotomy procedure.
been performed and the incision through the medial suspen-
sory and collateral ligaments. Following this maneuver, the POTENTIAL COMPLICATIONS
surgeon then is able to expose the medial and dorsal aspects
of the first metatarsal head as shown in Fig. 32-7, C. Based For the physical therapist to better develop an effective reha-
on the preoperative x-ray and a preoperative template, if bilitation program for a specific patient following a bunio-
constructed, the surgeon is able to determine how much of nectomy, the therapist needs to appreciate certain inherent
the medial eminence of the metatarsal head needs to be anatomic changes associated with the procedures being per-
removed as seen in Fig. 32-11, B. Once the medial eminence formed. Furthermore, there are certain complications created
has been removed, the surgeon can use a sterile marker and intraoperatively by the surgeon that no amount of physical
create the proposed osteotomy site. At this time and before therapy will resolve. If possible the physical therapist should
performing the osteotomy, the surgeon decides whether to attempt to at least see a preoperative x-ray of the deformity
perform a lateral release of the first MTPJ or remove the because there are patients who have unrealistic cosmetic
fibular sesamoid bone; then further dissection is performed expectations of the end result.
in the first interspace as shown in Fig. 32-7, D. Some sur- The following are some of the more common complica-
geons elect to perform this maneuver through a second inci- tions associated with a bunionectomy procedure and possi-
sion over the dorsal aspect of the first interspace. This portion ble causes:
1. Chronic edema at the surgical site

a. Surgical correction involving multiple osteotomy PHYSICAL THERAPY CONSIDERATIONS
procedures that resulted in increased surgical BEFORE DEVELOPMENT OF A
dissection TREATMENT PLAN
b. Noncompliant patient who kept the foot in a depen-
dent position for prolonged periods immediately The following are some facts that the physical therapist
following the surgery should attempt to know before establishing a treatment plan
c. Development of a hematoma, especially in the first for a specific patient following a bunionectomy.
interspace 1. Was an osteotomy performed and, if so, where was it
d. Prolonged cast immobilization performed and what type of fixation was used? Bone
2. Delayed bone healing following a procedure involving normally requires 6 weeks to heal in the best circum-
an osteotomy stances. An osteotomy performed in the diaphyseal
a. Noncompliant patient who ambulated too soon fol- section of the proximal phalanx or first metatarsal will
lowing the procedure usually take 7 weeks to adequately heal. Bone healing is
b. Poor internal fixation of the osteotomy site prolonged in a patient who is a smoker. Two points of
c. Medical factors (smoker, systemic steroid usage, fixation, especially screws, will allow for a more aggressive
osteoporosis, etc.) approach to establishing good first MTPJ ROM.
d. Traumatic event involving the surgical foot follow- 2. Was a bone graft used and if so how large and where
ing surgery was it inserted? Bone grafts take longer to heal than an
3. Limited first MTPJ ROM osteotomy since they need to be revascularized and new
a. Overtightening of soft tissue structures around first bone produced to take the place of the graft material. The
MTPJ larger the graft the longer the healing. A bunionectomy
b. Dorsiflexion of the first metatarsal following an that at times requires bone grafting is the Lapidus proce-
osteotomy of the metatarsal dure (first metatarsal-cuneiform fusion). For these
c. Prolonged immobilization patients the need to remain nonweight bearing may be
d. Capsulodesis following removal of significant bone 3 months, again depending upon the size of the graft.
from the dorsal surface of the first metatarsal head Further, unless a plate was used across the dorsal aspect
e. Failure of surgeon to create a congruous first MTPJ of the MCJ, attempts to reestablish first MTPJ ROM must
f. Soft tissue fibrosis and/or damage of the hallucal be limited since any aggressive dorsiflexion movements
sesamoids at the plantar aspect of the first MTPJ will create plantarflexion forces on the first metatarsal and
g. Noncompliant patient who will not exercise first could disrupt the fusion site.
MTPJ or ambulate with a propulsive gait 3. What type of fixation was used and how much? Large
h. Weakness of the peroneus longus muscle or over- metallic fixation devices, especially if located at the dorsal
powering of the anterior tibial muscle aspect of the first MCJ, may be a contraindication to the
4. Lack of hallux toe purchase when the patient is use of ultrasound because of the build up of heat in the
standing devices.
a. Shortening osteotomy of the first metatarsal, which 4. How long was the patient kept either nonweight
creates loss of tension of the flexor tendons and bearing or in a nonpropulsive type gait and was the
plantar fascial slip to the hallux (decompressional patient immobilized in a cast? The longer the period of
procedures) time that the first MTPJ motion was eliminated or limited,
b. Loss of insertion of the flexor hallucis brevis tendons the greater incidence of restricted motion once the patient
into the base of the hallux (joint prosthesis, resec- is seen by the physical therapist. If the therapist deter-
tional arthroplasty procedures) mines that there is significant fibrosis of the first MTPJ
c. Capsulodesis of the first MTPJ following remodel- and/or the patient is not performing adequate exercises
ing of the dorsal aspect of the first metatarsal head to increase ROM, the patient should be referred back to
(cheilectomy, joint prosthesis procedures) the surgeon as soon as possible for reevaluation to make
d. Overtightening dorsally of soft tissue structures at certain that the lack of motion is not due to some abnor-
first MTPJ mal malalignment of the joint. If the joint and associated
e. Chronic edema at plantar aspect of the first MTPJ structures are in good alignment, then the surgeon should
(metatarsal head osteotomy procedures) anesthetize the first MTPJ and forcibly manipulate the
5. Hallux separation from the lesser toes (Hallux varus) joint and record the amount of dorsiflexion and plan-
a. Overtightening of soft tissue structures at medial tarflexion obtained at that visit. The patient should be
aspect of first MTPJ referred back to the therapist along with this information
b. Overcorrection of the intermetatarsal angle so that further joint manipulation can be performed.
c. Overcorrection of an osteotomy procedure of the 5. Is the patient compliant? Most surgeons have an appre-
hallux ciation of whether or not the patient is compliant and this
information should be related to the physical therapist. understand the full extent of the patients preoperative defor-
Unfortunately, most physical therapy prescription forms mity. Refer to Box 32-1 for objective measures that should
do not ask for this information and surgeons are reluctant be included in the evaluation.
to state this information on the form. Perhaps a box Please remember that patients who have undergone
should be added on the physical prescription form that procedures in categories 4 and 5 (metatarsal base osteoto-
the surgeon can check requesting the therapist to contact mies with or without a bone graft, fusion of the first MCJ,
the surgeon for additional information regarding that and fusion of the first MCJ or MTPJ with bone graft)
specific patient. require additional time for healing. Passive range of
motion of these joints would be contraindicated if healing
EXPECTED OVERALL OUTCOME is not sufficient at this point. Therefore, it is imperative to
FOLLOWING A BUNIONECTOMY consult with the surgeon regarding the integrity of the
region before applying any therapist- or patient-generated
For the majority of bunionectomies the following signs and/ forces across these joints.
or symptoms to some extent may be present for 5 to 6 months
postoperatively, even if the surgery was performed correctly THERAPY GUIDELINES
and the patient had an uneventful postoperative recovery.
1. Residual edema at surgical site after prolonged ambula- There are no specific time parameters associated with these
tion or after exercise that resolves upon rest and elevation phases because of the variations in the types of procedures
of the foot used. Procedures that include a metatarsal base osteotomy
2. Dermatologic color changes over the dorsum of the foot require 6 to 7 weeks of nonweight bearing. In comparison,
at the end of the day or after having the foot immersed in the SCARF procedure allows for immediate weight bearing;
warm water for a prolonged period of time however, the propulsive phase of gait cannot begin until the
3. Mild transient neuritis of some superficial nerves at the third to fourth week postoperatively.
surgical site The use of a bone graft in category 5 of the surgical
4. Increased sensitivity at the surgical scar procedures will preclude a patient from beginning therapy
5. Some limited first MTPJ ROM, especially in plantarflex- until the fusion site has adequately healed. The surgeon will
ion as compared with the preoperative measurements ascertain this on subsequent postoperative follow-up visits.
6. Induration with palpation of the first interspace This may occur as early as 8 weeks, but can take up to 3
months. When this patient can begin physical therapy, you
THERAPY GUIDELINES FOR will place him or her in the appropriate treatment category
REHABILITATION depending on the weight-bearing status and specific postsur-
gical precautions.
Preoperative Considerations Those patients that receive a procedure in category 4
A biomechanical imbalance of the LE that results in exces- (metatarsal base osteotomies and fusion of the first MCJ)
sive foot pronation is a common cause for bunion deformi- may begin therapy earlier than those in category 5. The
ties. Physical therapists have a role in evaluating this surgeon will refer the patient to physical therapy once the
inefficient motor plan. They can get the rehabilitative process area is adequately healed; however, the patient may still be
started before surgery since this will ultimately need to be nonweight bearing.
addressed. Plantar pressure of the medial foot during normal In summary, selection of the appropriate rehabilitation
gait should be included in the preoperative evaluation if the phase depends on the patients weight-bearing status and
therapist has the means to assess it. First metatarsal phalan- associated stage of healing. Please refer to the tables for the
geal (MTP) joint dorsiflexion and plantar flexion ROM mea- guidelines related to each specific treatment category.
surements should be ascertained for baseline purposes.
Strength testing of the LE musculature, in particular the Phase I (NonWeight Bearing) (Table 32-1)
peroneals and flexor hallicis longus/brevis, should be It is common for the patient to demonstrate edema in the
performed. Schuh and associates1 recommend using the foot after a bunionectomy. It is imperative to control this via
metatarsophalangeal-interphalangeal score of the American modalities, manual treatment, graded exercise, and patient
Orthopedic Foot and Ankle Society as a functional survey. compliancy with limited dependent positioning. Since the
patient is nonweight bearing, he or she should be indepen-
Initial Postoperative Examination dent in the use of the assistive device. This will help avoid
Patients should be both cognizant and compliant with their falls and compensatory pain patterns from occurring.
weight-bearing precautions, depending on the procedure(s) The ROM limitations that likely result from immobiliza-
performed, to decrease their risk for complications. There- tion of the foot and ankle need to be addressed to avoid
fore, it is imperative that the physical therapist is aware of contractures that can lead to gait compensations and func-
the type of surgery that was performed and discusses it with tional limitations. In the case in which the patient received
the patient. It is also helpful to view the imaging studies to a bone graft or fusion of a joint, it is imperative to protect
BOX 32-1 Initial Postoperative Examination

Measurement of edema: volume change is preferred kinematics and its relationship to foot pronation for
method, less reliable are girth measurements the full weight-bearing patient.
Range of motion (ROM): first joint metatarsal Muscle strength:
phalangeal (MTP) dorsiflexion and plantarflexion; First MTP joint plantarflexion for the full weight-
nonweight bearing, and weight bearing only if not bearing patient: Shamus etal.3 recommend using a
contraindicated (as described by Shamus etal3) (Fig. pinch gauge dynamometer for assessing this
32-20) MMT of the peroneal muscle complex, since
Talocrural joint dorsiflexion midfoot pronation is required for optimal loading of

Subtalar joint eversion and inversion the medial forefoot
Joint arthrokinematics: all joints of the foot, including MMT of hip and knee musculature, especially if the
the talocrural joint and distal/proximal tibiofemoral patient was initially nonweight bearing after the
joints. Please be aware of the type of procedure, since procedure
a fusion may have been performed. Some procedures Soft tissue mobility:
also remove or reposition the sesamoids. Pay particular attention to the peroneal tendon
Assessment of the surgical site: tract. There needs to be optimal gliding to

Look for possible signs of infection appropriately strengthen this muscle complex
Assess for tethering of the scar to underlying Techniques to the anterior tibialis are helpful to
structures without directly pulling on the incision decrease muscle tone and allow improved function
itself of the peroneals
Note the boundaries of edema Assessment of the abductor hallucis, adductor
Note any vasomotor dysfunction (pale and cyanotic hallucis, and flexor hallucis longus because of
compared with red and warm) chronic length changes
Look for trophic changes (coarse hair, brittle nails, Lower extremity peripheral nerve mobility:
and change in skin texture) As long as ROM of the ankle is allowed, gliding
Movement assessment (if not contraindicated): dynamics of the sural, tibial, and peroneal nerves
If patient is nonweight bearing, make sure that he should be assessed in either the slump position or
or she is completely independent in the use of the straight leg raise position
selected assistive device with ambulation. You Proprioception for the full weight-bearing patient:
should reassess the assistive device to make sure Single-limb stance assessment with eyes open and
that it fits him or her properly. closed

For the full weight-bearing patient, plantar pressure Pay particular attention to the willingness of the
assessment during gait is a valuable tool to help patient to allow for midfoot pronation. If you
identify decreased medial toe loading. This can be observe relatively decreased ipsilateral midfoot
achieved with the use of a Harris Mat, force plate, pronation, you may need to encourage this motion
or other device. Step-downs and squats should during subsequent treatment sessions to restore
also be included to assess lower extremity proper plantar loading of the medial foot.
the region as mobility is gained elsewhere. The physical his program should include core and upper extremity
therapist should consult with the surgeon before applying strengthening exercises because of the relative disuse of these
any manual forces across a surgically fixated joint. All of systems during this period.
the structures that cross the ankle have the potential of dem-
onstrating tightness; therefore the treatment needs to address Phase IIa (Partial Weight Bearing) (Table 32-2)
myofascial and neural mobility as well. The patient in this category will likely have a walking boot
The surgical site needs to be monitored for excessive scar or supportive shoe. Edema control remains imperative at this
formation and possible tethering because of the decrease in stage. This is an opportune time to educate the patient on
overall functional movement. If this area requires treatment, the relationship of swelling and initial weight bearing. It is
avoid tensioning the healing skin directly because this may not uncommon to experience increased swelling as the
adversely affect wound healing. patient transitions into partial weight bearing. The patient
Disuse atrophy and weakness is another potential com- should understand that a large increase in swelling that does
plication resulting from this nonweight bearing status. The not subside with rest may indicate periods of prolonged and/
physical therapist needs to take into consideration the prior or excessive weight bearing. The patient will therefore need
functional level of the patient when creating this portion of to modify her activity level to help minimize this inflamma-
the program. For example, if the patient is a tennis player, tory response. Mobility of the foot and ankle complex should
joint dorsiflexion by the end of this stage. There should be

enough first MTP joint plantarflexion so that the metatarsal
head can rest normally on the ground. Regarding joint
mobilizations, manual distraction of the first MTP joint
should not occur until the sixth week postoperatively if
absorbable rods were used. Symmetric soft tissue integrity
of the foot/ankle complex and neural mobility should be
accomplished as well. There should be no signs of scar tissue
hypomobility by the end of this phase.
The strengthening program should be progressed to allow
for functional weight-bearing exercises, such as squatting,
stepping, heel raising, and lunging. Prescription of these
exercises depends on the type of procedure. Category 2 pro-
cedures do not allow for forward propulsion during the first
2 to 3 weeks postoperatively. Therefore, this patient cannot
step down with the nonsurgical foot first, as this will create
Fig. 32-20 As described by Shamus and associates,3 first draw a line bisect- the dorsiflexion at the affected first MTP joint that occurs
ing the first metatarsal and a line bisecting the first phalanx. Place a dot on
the center of the metatarsal phalangeal joint. Then place table paper on the
during propulsion (Fig. 32-21). This is the same for category
floor. Have the patient take eight steps on this paper, thereby creating a 3 patients; however, they need to avoid propulsion for the
footprint template. Then guide the patient back to the footprints and have first 4 to 6 weeks. As a safety precaution, step-downs should
them place their feet in the respective footprints. You will be assessing the begin from a step 7 inches or less in height. Forward lunges
trail limb in this instance. Ask the patient to raise his or her heel as high as are appropriate; however, extension of the affected first MTP
he or she can while maintaining both the step length and the hallux contact
on the ground. You will measure with a goniometer using the landmarks
joint should again be avoided. This is accomplished by
you have already marked. Take three measurements, and record the highest lunging forward in place and avoiding heel-off of the trail leg
measurement you get. (Fig. 32-22).
As the patient performs these exercises, the physical ther-
apist needs to monitor the quality and quantity of medial
be progressed as well. Remember to consider the various foot loading. Excessive medial loading needs to be imme-
tissues that cross the ankle in addition to the arthrokinemat- diately controlled. Limited medial loading may result from
ics of the foot and ankle. Since the patient is beginning to a combination of several factors: weakness or poor control
ambulate, normal talocrural dorsiflexion should be achieved of the peroneals and/or flexor hallucis brevis/longus, tight-
in this stage. Scar tissue monitoring and treatment of the ness of the medial foot (in the absence of an arthrodesis),
surgical area needs to be included in this stage as well. Direct limited subtalar joint eversion and/or talocrural joint dorsi-
scar tissue massage on the affected skin should be avoided flexion, restricted first metatarsal plantarflexion, or limited
for the first 4 weeks postoperatively. hip internal rotation. Pain and/or apprehension are another
Strengthening of the LE and other functionally dependent possibility. Once identified, the therapist should include
regions should be initiated or maintained. Unloaded exercise treatment of the impairment(s) in the plan of care. Kernozek
is a valuable adjunct to this treatment as it helps to restore and associates2 demonstrated that although patients who
neuromuscular coordination associated with functional received a distal metatarsal osteotomy 12 months prior
movement. Since the patient has begun to bear weight, pro- had favorable outcomes (appropriate joint motion of both
prioception of the LE becomes very important. Sitting on an the ankle and first MTP joint and decreased pain with
exercise ball with unilateral leg support is an effective means ambulation), they did not increase the loading of their
for both assessment and treatment. He or she should dem- medial foot compared with their presurgery data. These
onstrate symmetry between both sides by the end of this patients performed ROM exercises given by the surgeon and
phase. did not receive physical therapy. Shamus and associates3
found that increasing the ROM of the first MTP joint,
Phase IIb (Initial Full Weight Bearing) improving the strength of the flexor hallucis, and gait
(Table 32-3) training achieved a decrease in pain that was statistically
The patient in this category may have a walking boot or sup- significant from the control group in those diagnosed with
portive shoe. The patient will likely demonstrate increased hallux limitus. These studies illustrate the need for gait train-
swelling with the onset of full weight bearing. He or she ing and functional exercises that encourage appropriate LE
needs to be educated on the direct relationship of excessive mechanics, especially during this phase of the rehabilitative
and/or prolonged loading and the inflammatory response. process.
This will help to gradually return the patient to pain-free, full Proprioception training should progress to standing
weight-bearing status. activities. These should be tailored to the individuals current
The patient should have symmetric ankle dorsiflexion impairment level and progressed in a fashion that best rep-
during this stage, and demonstrate at least 55 of first MTP licates the patients prior functional level.
594
TABLE 32-1 Bunionectomy Rehabilitation

Phase I Postoperative Edema and pain Effleurage techniques Control edema and pain Assist in lymphatic and venous circulation
Nonweight Nonweight bearing Patient education on elevation and icing Make sure that patient is To control the amount of edema
bearing Decreased mobility Use of cryotherapy independent with the assistive Constant compression may facilitate
Postoperative and disuse Intermittent compression (avoid constant device they are using avascular necrosis of the distal segment
weakness compression) Maintain or progress the To avoid a fall that can ultimately compound
Gait training arthrokinematic motion of the the recovery process
Graded mobilizations of the first MTP, sesamoids, various joints To allow for improved foot and ankle
talocurural, subtalar, Lisfranc, transverse tarsal, and Normalize tissue mobility mechanics upon return to full weight bearing
tibiofibular joints. Because of the nature of the Normalize muscle play and tendon To help prevent tethering and excessive scar
procedure, grade IV mobilizations should not be sliding formation
attempted until patient response has been thoroughly Improve the sliding mechanism of To allow for optimal contractile functioning
ascertained via implementation of grade II then III the lower extremity neural system during strengthening activities
mobilizations. Distraction of the first MTP joint is Increase strength To help prevent excessive tensioning of the
contraindicated during the early stages of nerves once higher level functional activities
rehabilitation, especially if absorbable rods were used are initiated
for osteotomies of the hallux head. To minimize gait impairments when weight
STM of skin adjacent to surgical incision. Make sure bearing is allowed
to avoid tensioning the incision itself. To eventually allow for the forefoot pronation
STM of peroneals, anterior tibialis, abductor hallucis, that is required for optimal plantar loading
adductor hallucis, and flexor hallucis longus during gait
Gliding techniques of the lower extremity neural To improve great toe function
system in slump sitting or straight leg raise positions Strengthening of first MTP joint plantarflexion
if restrictions are noted will help with plantar loading when
Nonweight bearing gluteals strengthening: clam ambulation begins
shells, side-lying hip abduction, prone hip extension
Quadriceps and hamstring strengthening: SLR, SAQ,
prone knee flexion, bridging with heels on exercise
ball
Peroneals: begin with manually resisted, than
progress to Thera-Band once movement pattern is
correct
AROM great toe: AROM flexion, extension,
abduction; progress to manually resistive as
tolerated. Marble pickups, towel curls, and isometric
contractions of the flexor hallucis should be included.
AROM, Active range of motion; MTP, metatarsal phalangeal; SAQ, short arc quadriceps; SLR, straight leg raise; STJ, subtalar joint; STM, soft tissue mobilization; TCJ, talocrural joint.
Phase IIa Partial weight bearing Edema and pain Continue interventions from phase I as Control edema and pain Assist in lymphatic and venous circulation
May be in a walking Decreased mobility needed Maintain or progress the quality of To control the amount of edema
boot or supportive shoe Postoperative impairments in Talk with surgeon regarding the use of motion of the various joints and To allow for improved foot and ankle
muscle function Coban or other compression garment if soft tissues mechanics upon return to full weight bearing
Gait impairments the edema has been present for at least Increase strength and motor control To minimize gait impairments when weight
Impaired proprioception 4 wk Pain-free partial weight-bearing bearing is allowed
Continue interventions from phase I as ambulation To eventually allow for the forefoot
needed. Avoid grade IV mobilizations for Symmetrical control of bilateral pronation that is required for optimal plantar
the first 3 wk of the first MTPJ, unless lower extremity loading during gait
your patient progressed to this phase To improve great toe function
from phase I To help minimize the potential for
Distraction of the first MTPJ should be compensatory gait pattern upon return to
avoided during the first 6 wk from full weight bearing
surgery if absorbable rods were used To allow for improved foot and ankle
during an osteotomy of the hallux head mechanics upon return to full weight bearing
Continuation of previous phase exercises
Unloaded squatting (total gym), seated
heel raises; the resistance will need to be
less than body weight
Unloaded walking (body weight supported
system or pool ambulation)
This needs to be pain-free
Seated on exercise ball with affected
lower extremity as support lower
extremity
MTPJ, Metatarsal phalangeal joint.

Chapter 32 Bunionectomies
595
596

Phase IIb Full weight bearing with Decreased mobility Continue interventions from phase IIa as By the end of this phase, patient To allow for optimal foot and ankle
ground reaction forces not Postoperative impairments needed. Grade IV mobilizations are should have 55 of first MTPJ PROM mechanics
to exceed those of normal in muscle function appropriate for this stage. Use of ROM dorsiflexion and enough plantarflexion To minimize gait impairments as weight
ambulation Gait impairments splinting is appropriate at this stage if ROM so that the first metatarsal head can bearing is progressed
May be in a supportive shoe Impaired proprioception gains are slow; however, in many cases this rest on the ground To eventually allow for the forefoot
treatment option may not be covered by Any soft tissue dysfunctions should be pronation that is required for optimal
insurance. improved as well by the end of this plantar loading during gait
Continuation of previous phase exercises phase To improve great toe function
Standing squats The peroneals and intrinsics should be To allow for return to higher level
Forward lunge avoiding trail limb forefoot adequately strong by this point activities
rocker (heel stays on ground) (see Fig. Pain-free ambulation To allow for optimal proprioceptive
32-22) Symmetric control of bilateral lower control required for higher level
Steps (however, the affected foot needs to extremity activities
lead the step-down motion) (see Fig.
32-21, A)
Unloaded heel raises on Total Gym
(performed with resistance less than body
weight)
Monitor for appropriate plantar loading of
first MTPJ and the compensation of
excessive adduction of the ipsilateral hip
(see Fig. 32-25, B)
Manual cueing for medial foot loading during
midstance and terminal stance
This needs to be pain-free
Single-limb stance, perturbations
MTPJ, Metatarsal phalangeal joint; PROM, passive range of motion; ROM, range of motion.
A B
Fig. 32-21 A, Starting position for the step up for the affected right lower extremity. Notice the amount of first metatarsal phalangeal joint dorsiflexion in
the trail limb at the onset of this exercise. For this reason, the patient needs to have no propulsive precautions in the event that she was to alternate the legs.
B, End position for an unaffected left lower extremity step down. Notice the amount of first metatarsal phalangeal joint dorsiflexion in the right foot as it
maintains contact on the step. For this reason, the patient needs to have no propulsive precautions to perform this portion of the exercise.
dorsiflexion, at least 55 to 65 of first MTP joint dorsiflex-

ion, and the first metatarsal head should be resting on the
ground naturally during stance.
The main emphasis during this phase is to achieve the
above stated goals and to begin with progressive loading
beyond the normal gait pattern. This program should be
highly individualized and based primarily on the prior func-
tional level of the patient. The exercises should not produce
pain, rather they should gradually progress pain-free loading.
By the end of this phase, the patient should have no gait
deviations (especially limited medial foot loading). He or she
should be able to perform a bilateral heel raise with full body
weight with little to no pain. In terms of higher functioning
patients, running and jumping will depend on the precau-
tions associated with the type of procedure they received.
TROUBLESHOOTING
The physical therapist may encounter a patient who com-

plains of hyperesthesia near the surgical region toward the
onset of therapy. Desensitization techniques are extremely
valuable at the onset of care to help manage complex regional
pain dysfunctions. The patient should also be educated on
Fig. 32-22 Lunge stretch with heel maintained on the ground. This is the the importance of self-desensitization techniques, as well as
end position for the affected right lower extremity. Avoiding the forefoot graded exposure to weight bearing and self-ROM methods
rocker will restrict the first metatarsal phalangeal joint from dorsiflexing.
to help reduce the patients anxiety over great toe function.
This patient will require extra helpings of positive feedback
Phase III (Full Weight Bearing Without regarding their progress throughout therapy.
Precaution) (Table 32-4) Nerve entrapment of the superficial nerves surrounding
The patient in this category has no restrictions. They may the first MTP joint is another potential problem. As a precau-
have continued edema because of the progressed functional tion, activities that encourage toe flexion with concomitant
level. The patient should have symmetric bilateral ankle ankle plantarflexion will help to mobilize this region. An

Anticipated
Phase III Full weight bearing Decreased mobility Continue with aggressive By the time of discharge, To allow for optimal
without precaution Postoperative mobilizations and stretching patient should have foot and ankle
impairments in muscle Continuation of previous 55-65 of first MTPJ mechanics upon return
function phase exercises PROM dorsiflexion and to high-level activities
Anxiety and/or Standing heel raises with enough plantarflexion so To normalize motor
impaired motor control ball squeeze between heels, that the first metatarsal control of the lower
during impact activities lunges with promotion of head can rest on the extremity for return to
forefoot rocker, and step ground high level activities
training (see Fig. 31-28) The patient does not
Monitor for appropriate require cueing for
plantar loading of first MTPJ appropriate loading of the
and the compensation of medial foot during all
excessive adduction of the exercises
ipsilateral hip Patient is pain-free with all
Jump: stops on exercises
minitrampoline or foam pad, Pain-free jumping and
unloaded jogging (body running (dependent on
weight support system or procedure and surgical
pool) progressed to full precautions)
impact jogging (dependent
on procedure and surgical
precautions)
MTPJ, Metatarsal phalangeal joint; PROM, passive range of motion.
example of this would be the use of marble pickups with the

patients calcaneus hovering above the ground. Soft tissue SUGGESTED HOME MAINTENANCE FOR
techniques during the onset of therapy should help to miti- THE POSTSURGICAL PATIENT
gate this problem as well.
In the case that you suspect nerve compression (burning The home maintenance section outlines the postopera
symptoms, cramping of the dorsal region, and/or unrelent- tion rehabilitation the patient is to follow. The physical
ing pain), confer with the surgeon regarding the use of therapist can use it in customizing a patient-specific
iontophoresis. program.

Phase I Approved: seated hip abduction machine,
1. Edema control seated or prone hamstring curls, and leg
Recommend icing and elevation extensions as approved by therapist
2. Soft tissue mobilization of scar
3. Gentle self-mobilizations/stretching of first MTPJ Phase IIa
4. Strengthening of peroneals and foot intrinsics 1. Edema control as needed
Windshield wipers, towel curls, marble 2. Soft tissue mobilization of scar as needed
pick-ups 3. Self mobilizations in nonweight bearing positions
5. Strengthening of gluteals and knee musculature 4. Strengthening
as appropriate Seated heel raises
6. Gym equipment Continue with phase I exercises as appropriate
Avoid: any standing exercises and those that 5. Proprioception training
put pressure through the foot (e.g., leg presses) UE supported (elbows on table) weight shifting
6. Gym Equipment Phase III

Avoid: any standing exercises 1. Continue with self-mobilizations if range is not
Approved: leg presses with sub-body weight acceptable at this point
load, as long as it is pain-free 2. Continue with strengthening exercises from
phase II if strength is not acceptable
Include lunges with trailing leg forefoot rocker
Phase IIb 3. Monitor for excessive knee valgus of the trailing
1. Edema control as needed limb during the lunge
2. Soft tissue mobilization of scar as needed 4. Try to encourage plantar loading the medial
3. Self-mobilizations forefoot (Fig. 32-25)
These have progressed to weight-bearing Bilateral heel raises with ball squeeze (Fig.
stretches to allow for more ROM gains 32-26)
4. Wedge first MTP joint extension (Fig. 32-23) 5. The following exercise will help to keep the
5. Calf stretching against wall patients weight from shifting to the lateral borders
6. Lunge stretch with first MTP dorsiflexion (Fig. of the feet as the patient rises onto his or her toes
32-24) Unilateral squatting with multiplanar LE reaches
7. Strengthening 6. Proprioception training
Resisted lateral walking Unilateral stance with triplanar perturbations
Bilateral heel raises with elbows on table top progressed to labile surface
through pain-free ROM
8. Proprioception training After Discharge
Single-limb stance progressed to perturbations 1. Any underlying impairments that may have been
and eyes closed identified throughout the course of therapy that
9. Gym Equipment contributed to the deformity should be addressed
Avoid: any activities that load the foot beyond as the patient returns to their prior functional level:
typical gait, such as plyometric and jumping Restricted ankle dorsiflexion
exercises Limited hip extension
Approved: weighted sitting heel raises, leg Lunges and heel raises to help maintain first
presses, and squatting MTP joint dorsiflexion
Fig. 32-24 Lunge stretch for the affected right lower extremity, allowing
first metatarsal phalangeal joint dorsiflexion. The end position is gauged by
how much the patient can dorsiflex their metatarsal phalangeal joint. The
patient should not push through the restriction during this stretch but
Fig. 32-23 Wedge self first metatarsal phalangeal joint dorsiflexion stretch.
should bring it up to the level of tightness and hold for 5 to 10 seconds.
This is the end position for the right lower extremity. The patient should
not push through the restriction during this stretch; rather, he or she should
bring it up to the level of tightness and hold for 5 to 10 seconds. After a few
repetitions, the range of motion should improve and the patient should be
able to dorsiflex further.
A B
Fig. 32-25 A, An example of appropriate medial forefoot plantar loading during the lunge exercise. B, An example of insufficient medial forefoot plantar
loading. Notice how the weight is shifted toward the center and lateral aspects of the foot. This should be improved throughout therapy to allow for eventual
effective propulsion and to decrease the risk of compensatory pain patterns from the beginning.
Fig. 32-26 The use of a ball between the posterior aspects of the tibias allows for adduction of the hip, helping to shift weight to the medial aspects of the
feet during a heel rise. This will allow for use of first metatarsal phalangeal joint dorsiflexion. Placing the ball at the calcanei tends to create hindfoot inversion,
possibly shifting the weight to the lateral borders of the feet.
1 What information can the physical therapist give regard-

ing postdischarge shoe fitting for the patient who
received a bunionectomy?
longest toe to the end of the shoe; the ball of the foot
should fit well into the widest portion of the shoe; do not
purchase shoes that feel tight in hopes of stretching
them to fit; and there should be a minimum amount of
Recommendations from the American Academy of heel slippage.
Orthopaedic Surgeons4: have the feet measured regu-
larly as this can change with aging; measure both feet
and fit to the largest foot; perform the fitting at the end
of the day when the feet are the largest; stand during
2 Katrina comes to the physical therapy department for
her initial evaluation. She brings her intake information
and her prescription. The prescription states, s/p bun-
the fitting; make sure there is 3 8 to 1 2 inch from the ionectomy, PT evaluation and treat. Is this enough
information for the therapist before he or she manually peroneal nerve bias would be helpful in identifying
assesses the foot? altered neurodynamics when compared with the unin-
volved side.
The physical therapist needs to know the type of
procedure(s) that were performed for the bunionectomy.
Each procedure has its own set of precautions in terms
of weight-bearing status, when propulsion during gait
6 Simone underwent a SCARF procedure 3 weeks ago.
During her treatment session, the therapist prescribes
marble pickups and great toe flexion isometrics. Why?
can be initiated, and whether or not the therapist can
apply manual forces across the joints of the medial Having the appropriate ROM and strength of first MTP
forefoot. joint flexion will facilitate medial foot loading. This
motion is important for propulsion during activities such
3 What other areas should be included in a physical

therapy evaluation besides assessment of the local region
following a bunionectomy?
as running and jumping. Decreased medial foot loading
may also place increased stress to the lateral foot, lateral
knee, hip joint, and lumbar spine.
Because of the functional significance of regional inter-

dependence, the therapist should identify the quality and
quantity of motion at the individual links of the kinetic
7 Brian underwent a bunionectomy, is currently in
stage 3, and has no weight-bearing precautions. He has
been performing heel rises at home; however, he has
chain. This should be conducted with the patients surgi- begun to complain of ipsilateral fifth metatarsal pain.
cal precautions in mind. Of particular importance are the What should the physical therapist inspect in relation to
hip and ankle joints. To minimize the transverse stress this exercise?
on the first MTP joint, one needs to have appropriate hip
extension and ankle dorsiflexion ROM. Weakness of the Brian may be excessively loading the lateral aspect of his
gluteus medius and/or posterior tibialis may also con- foot upon the heel rise motion. This could be due to
tribute to poor control of pronation, leading to an increase many variables, including decreased strength of the
in stress. There are many other possibilities that may flexor hallucis, limited first MTP joint dorsiflexion, pain,
contribute to the hallux valgus deformity. Therefore, the apprehension, peroneal weakness, and/or poor move-
physical therapist should have a thorough understand- ment strategies. If the impairment were apprehension
ing of each patients functional movement and address and/or poor movement strategy, placing a ball between
what can be improved upon throughout the rehabilita- both posterior tibias would help to facilitate the plantar
tive process. loading of the medial foot. Otherwise, the physical thera-
pist would need to treat the impairment and then reas-
4 Keri received a cheilectomy and McBride soft tissue

rebalancing 1 week ago and has come for her physical
sess the response subsequently.
therapy initial evaluation. Why should the physical

therapist assess the integrity of the first medial MTP
joint soft tissue during this visit?
8 Bernice received a fusion of the first MCJ with a bone
graft 8 weeks ago. She has begun to bear weight, but
reports a significant increase in swelling. Should the
physical therapist be concerned? Why?
A portion of Keris medial MTP joint capsule may have
been excised during this procedure. There may have It is common to report an increase in swelling upon an
been a surgical release of the lateral sesamoid as well. increase in functional demand. However, the therapist
Therefore, it is imperative for the physical therapist to needs to always consider the integrity of the graft, espe-
help prevent excessive scarring on the medial and cially at transitional times of function. The duration and
medial-plantar aspects of this joint. This will help to mini- frequency of weight bearing needs to be gradually pro-
mize the likelihood of resultant limited hallux adduction, gressed within patient tolerance. The presence of ipsilat-
and possibly a hallux valgus deformity. eral pitting edema in the absence of vascular disease
may indicate potential strain to the graft and should be
5 What peripheral nerve may be affected in patients who

receive a bunionectomy? How would it present if it were
communicated to the surgeon.
affected?
Because of the location of the incision either dorsomedi-

9 When trying to increase dorsiflexion at the first MTP
joint, how should the physical therapist mobilize the
joint?
ally or medially, the dorsal digital branches of the super-
ficial peroneal nerve may become entrapped if there is Since the head of the metatarsal is convex and the
excessive scar formation. Paresthesia of the medial great proximal end of the phalanx is concave, the proximal
toe, and possibly second and third toes, may be reported. phalanx should be dorsally mobilized to improve
A slump test and/or straight leg raise with superficial dorsiflexion.
10 Casey is currently full weight bearing without pre-

caution following her bunionectomy 8 weeks ago.
Casey demonstrates minimal loading of the medial
There are many possibilities that can explain this gait
pattern. The therapist needs to ascertain if only one
factor is responsible, or if there is an interaction of
aspect of her foot during the stance phase of gait several impairments. Pain and/or apprehension are
when compared with the nonoperative side. Her likely. If Casey demonstrates normal and pain-free squat-
ambulation is currently pain-free. The physical ther- ting and stepping mechanics, then apprehension is the
apist has noted that her first MTP joint passive range likely culprit. Restrictions in subtalar joint eversion, hip
of motion and active range of motion dorsiflexion adduction, and hip internal rotation are likely explana-
and plantarflexion are within normal limits. The tions as well. In this case, the therapist would likely
manual muscle testing of the flexor hallucis was a observe the same dysfunction upon squatting and step-
5/5 bilaterally. What could this scenario indicate? ping motions.
Chang TJ: Distal metaphyseal osteotomies in hallux abducto valgus surgery.

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1. Schuh R, et al: Rehabilitation after hallux valgus surgery: importance of
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stance phase. Phys Ther 89(9):934-945, 2009. et al, editor: McGlamrys comprehensive textbook of foot and
ankle surgery, Philadelphia, 2001, Lippincott Williams and Wilkins.
2. Kernozek TW, Sterriker SA: Chevron (Austin) distal metatarsal oste-
otomy for hallux valgus: Comparison of pre- and post-surgical charac- Coughlin MJ, Mann RA: Surgery of the foot and ankle, ed 8, Philadelphia,
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2004. prehensive textbook of foot and ankle surgery, Philadelphia, 2001,
4. American Academy of Orthopaedic Surgeons: Bunion surgery. Retrieved Lippincott Williams and Wilkins.
August 11, 2010, from http://orthoinfo.aaos.org/topic.cfm?topic=a00140, Mothershed RA: Osteotomies of the first metatarsal base. In Banks AS,
2001. et al, editor: McGlamrys comprehensive textbook of foot and
ankle surgery, Philadelphia, 2001, Lippincott Williams and Wilkins.
ADDITIONAL READING Yu GV, Shook JE: Arthrodesis of the First metatarsophalangeal joint.
Burns AE: Surgical Procedures of the Hallux. In Banks AS, et al, editor: In Banks AS, et al, editor: McGlamrys comprehensive textbook of
McGlamrys comprehensive textbook of foot and ankle surgery, foot and ankle surgery, Philadelphia, 2001, Lippincott Williams and
Philadelphia, 2001, Lippincott Williams and Wilkins. Wilkins.
CHAPTER 33
Transitioning the Jumping Athlete
Back to the Court
Christine Prelaz
L
ower extremity injuries are prevalent in athletics. factors that were surveyed.5 Other factors included in the
These injuries can range from minor sprains or strains survey were weight bearing, immobilization, bracing, length
to those that result in significant functional limitation of physical therapy, and when to return to a sport. Such vari-
and loss of time from work and/or sport.1 An estimated 3 to ability in protocols can lead to confusion as to what is appro-
5 million injuries occur each year among recreational and priate and/or foster the practice of a one size fits all
competitive athletes in the United States1 with the worldwide rehabilitation approach. Whatever the injury, a team
annual cost being estimated at $1 billion.2 The National Col- approach consisting of close communication between the
legiate Athletic Association (NCAA) reported that more physician, physical therapist, athletic trainer, and other
than 50% of injuries occurred in the lower extremity with medical specialists should provide the best environment for
the most common sites being the ankle and knee over a returning the athlete to the sport. The clinician must have a
16-year period.3 These data come from the NCAA Injury comprehensive understanding of the structures involved, the
Surveillance System, which summarized surveillance data surgical procedures, surgeon preferences, and tissue healing
for 15 NCAA sports over a 16-year period.3 Research studies constraints. Because it is beyond the scope of this chapter to
indicate that both intrinsic and extrinsic factors play a role outline a program for each specific sport or injury, the goal
in sustaining lower extremity injuries.2,4 Recent attention in of this chapter is to provide general rehabilitation guidelines,
the literature has focused on identifying modifiable and non- ideas, and resources for returning jumping athletes back to
modifiable associated risks with the overall goal of reducing their respective sports successfully and safely.
such injuries. Given the frequency and cost of these injuries,
the clinician is challenged not only with restoring function Readiness to Prepare for Return
of the injured athlete but also with implementing interven- Regardless of the injury or surgical procedure, it is the clini-
tions to prevent future injury. In todays competitive envi- cians responsibility to determine the athletes level of readi-
ronment, the health care team is faced with higher levels of ness to progress to each phase of rehabilitation.
pressure from the athlete, coaches, and parents to return the Continual monitoring of tissue tolerance by the clinician
athlete back to sport as expediently and as safely as possible. as the athlete progresses through each rehabilitation phase is
Ongoing assessment and proper program design based on critical. Knowledge of the type and extent of injury, surgical
current evidence-based research can provide the clinician procedure, pain levels, swelling, ROM, strength, endurance,
with the best information possible and guide him or her to flexibility, patients goals, and psychologic readiness are all
determine an athletes readiness to return to sport. factors that should assist in the clinical decision process.
Individual goals must be set for each athlete dependent
PROGRAM DESIGN upon his or her current functional level, the level of competi-
tion to which they are to return, and the specific sport of the
Numerous lower extremity rehabilitation protocols exist for athlete. In general, the goals of the training program are to
both conservative management and surgical procedures. restore and/or improve flexibility, endurance, strength,
Each clinician has his or her unique approach to the reha- balance, and agility. Once the athlete has completed his or
bilitation of a specific athletic injury. For example, a survey her acute phase rehabilitation, the concept of a needs analy-
of practices in ACL reconstruction by the American Ortho- sis may assist in establishing more sports-specific goals. The
pedic Society for Sports Medicine showed that rehabilitation needs analysis takes into account the fitness needs of both
protocols were the most variable factor among other practice the activity/sport and the individual athlete, thus designing
603
a more customized versus a cook book program. To develop

a needs analysis, both a physiologic and biomechanical anal- BOX 33-1 Flexibility
ysis must be completed. When considering a specific event, General Guidelines for Static Stretching
one must look at the muscles involved, the energy system Initial warm-up
needs, speed/strength/power/endurance requirements, and Stretch slowly, no bouncing
any other specific needs of the event itself.6 Next, the current Stretch until mild tension is felt, not painful
status and prior history of the athlete is determined and a Hold each stretch 20 to 30 seconds
program is then designed to progress him or her toward Repeat 2 to 3 repetitions for each muscle group
those specific goals. Sport-specific training is fundamental
in returning the athlete back to his or her respective sport. Major Muscle Groups to Stretch
The rehabilitation program should incorporate a whole body Hamstrings
approach including core strengthening and exercises for the IT band
noninjured extremity. Gastrocnemius-soleus complex
Quadriceps
Flexibility Low back
Controversy exists in the literature regarding static stretch- Hip flexors
ing.7 Several studies have shown that there is little evidence to Pectorals/biceps
support its role in injury prevention and determined that Latissimi/triceps
preexercise static stretching may actually negatively affect
performance.8 Some researchers found decreases in muscle
strength9 and decreases in jumping ability10 after passive reported by Shelbourne and associates12 at an average
stretching. The concept of using a dynamic warm-up instead follow-up of 4 years following ACL surgery. Debate exists
of static stretching has gained popularity in both the literature between the uses of open kinetic chain (OKC) versus closed
and on the field. Some of the proposed benefits of a dynamic kinetic chain (CKC) exercises to build quadriceps strength
warm-up versus static stretching are that the muscles are in (Fig. 33-1). Several authors have advocated the use of both
more continuous movement, thus increasing the overall tem- after ACL reconstruction.13,14 A literature review by Ross and
perature and achieving a more true warm-up. Dynamic associates15 on OKC versus CKC exercises following ACL
stretching can also use more sports-specific movements to reconstruction indicates that the greatest amount of ACL
incorporate balance and motor control and mental prepara- strain and patellofemoral joint stress occurs at approximately
tion for the athlete, which may help to prime the neuromus- 40 of knee flexion to full extension.16,17 It was therefore
cular system for the upcoming event.11 A few examples of recommended that OKC exercises for quadriceps strength-
dynamic warm-up exercises are heel/toe walking, marching, ening be performed with knee angles greater that 40 to
skipping, long leg kicks, gluteal kicks, lunge walking, carioca, avoid excessive stress on these structures. Closed chain activ-
and lateral slides. This does not mean that static stretching ities beyond 60 were to be avoided since maximum stress
should be abandoned, however. Shrier8 contends that regular on the patellofemoral joint occurs between 60 and 90 of
stretching as part of a comprehensive program and not before flexion.17
exercise can increase force, jump height, and speed.8 Athletes Because of the predominant atrophy of type I (slow
who need greater range of motion or need to increase overall twitch) muscle fibers following injury or immobilization,
flexibility may still benefit from static stretching (Box 33-1). high repetitions (6 to 10 sets, 12 to 15 repetitions) with low
Stretching after activity may also tend to relax the tissues and resistance is recommended early in the rehabilitation
prevent general postactivity stiffness. program.15 Establishing normal muscle balance for both
involved and uninvolved limbs is one of the primary goals.
Strength A comprehensive strength training program should address
Before starting any training program, it is important to have core, hip, calf, and ankle musculature, as well as establish
a full understanding of the demands of the sport and the appropriate quadriceps/hamstring ratios. Strengthening of
individual athlete. The needs analysis will enable the clini- the hamstrings using both closed and open chain methods
cian to design a comprehensive specific program to develop is important because of their role in assisting in the control
strength, endurance, power, speed, agility, and balance. of anterior tibial translation. Traditional and functional tech-
Special considerations must be given to injured athletes niques can be incorporated for both variety and effectiveness
with regard to strengthening. Rehabilitation of knee injuries (Box 33-2).
in particular has presented the clinician with a challenge. For There has been an increasing amount of literature in
example, the main goal of rehabilitation following ACL recent years regarding the relationship of hip and core
reconstruction is to restore lower extremity strength while strength as factors in lower extremity injuries. Unfortunately,
protecting the reconstructed graft and the patellofemoral this relationship is not quite clear. For example, weakness
joint from excessive stresses. Selective quadriceps muscle of the hip abductors and external rotators has been shown
atrophy occurs following injury and/or immobilization. to contribute to increased hip adduction and internal rota-
Strength deficits in the quadriceps of up to 10% have been tion motion observed in female runners with patellofemoral
Chapter 33 Transitioning the Jumping Athlete Back to the Court 605
A B
C
Fig. 33-1 CKC exercises. A, Example of closed chain strengthening: multiangle lunges. B, Minisquat. C, Single-leg squat on the Total Gym.
BOX 33-2 Strengthening

Guidelines: high repetitions, low resistance4 to 6 sets Hamstrings
of 12 to 15 repetitions for lower extremity exercises in Hip abductors/adductors
early rehabilitation phases. Upper extremity and core Calf raisesbent and straight knee
strengthening can follow standard strengthening guide- Core strengtheningabdominals, hip musculature,
lines. Use combinations of traditional and functional train- low back
ing techniques. Upper body:
Open kinetic chain knee extension 90 to 45 (as per Chest
physician and clinician philosophy) Deltoids
Closed kinetic chain exercises 0 to 60 Latissimus/posterior shoulder
Total Gym squats (double leg, single leg) Bicep
Leg press (double leg, single leg) Triceps
Minisquats (double leg, single leg) with proper form
and control
Lungesmultidirectional (weights, sport cord,
cable column resistance)

Forward/backward/lateral step
pain or iliotibial band syndrome. However, it has also

been shown that these motion abnormalities can exist even BOX 33-3 Plyometrics Guidelines
though no strength deficits are present. This indicates an Proper footwear
apparent disconnect between muscle strength and observed Resilient surface
abnormal kinematics in some cases. Therefore, it has been Sturdy, safe equipment
suggested that additional factors such as altered propriocep- Sufficient and safe training area
tion and neuromuscular control of the lumbo-pelvic and Proper control and technique for all drills before
hip regions should also be considered in the clinical assess- progressing
ment and treatment plan of individuals with lower extremity Warm-up: static/dynamic stretching; skipping,
injuries.18 marching, bounding, etc.
Frequency: 2 to 3 times per week depending on
Plyometrics intensity and other program components
General Principles Volume:
Plyometric exercises use the stretch-shortening cycle to store Beginner60 to 100 foot contacts
potential energy. The stretch-shortening cycle consists of the Intermediate100 to 150 foot contacts
eccentric phase where preloading occurs as the muscle is Advanced120 to 200 foot contacts
placed on stretch, thus storing potential energy. The amorti- Elite200 to 400 foot contacts
zation phase refers to the time period between the eccentric Intensity: Low, medium, high. Decrease volume as
and concentric contraction. The amortization phase must be intensity increases.
kept short; the longer it is, the greater the loss of stored Recovery: 30 seconds to 3 minutes between
energy. The final phase is the concentric phase, in which the repetitions, depending on intensity level. Allow 48 to
stored energy is used in an opposite reaction (i.e., the muscle 72 hours between training sessions.
contracts concentrically to provide the force necessary for Direction: choose drills that are sport specific for
the required movement).19 enhancing vertical, horizontal, lateral, or
When designing a plyometric training program, consid- combinations or directions
eration must be given to age, body weight, current strength
Progression
and conditioning level, experience, previous injury, and
Basic Guidelines
demands of the sport (Boxes 33-3 through 33-5).19,20
Start simple, progress to complex
Warm Up/Cool Down Low volume to higher volume
Warm-up exercises can consist of a combination of general General drills progressing to sport-specific exercises
and specific skill enhancement drills such as marching, skip- Bilateral to unilateral exercises
ping, shuffling, and footwork drills.20 Static and dynamic Stable to unstable surfaces
stretching should also be performed. Slow speed to faster speeds
Level of Difficulty Progression
Proper Technique Jumps in place
Proper instruction and monitoring of technique is critical Standing jumps
not only for proper neuromuscular retraining but also to Multiple hops/jumps
avoid injury. Verbal, visual, and manual cues may be used to Bounding/cone drills
teach the athlete proper control. If the athlete fails to dem- Box/depth jumps
onstrate proper control during any part of the exercise, he or
she should be stopped and given a brief rest period before Data from Nutting M: Practical progressions for upper body
continuing. If improper technique is still present, the exer- plyometric training. NSCA Performan Train J 3(2):14-19, 2004.
cise should be discontinued for that session. Explaining and
reinforcing the importance of proper technique to the athlete
will help to prevent overuse and injury during the training to 150 for intermediate level and 120 to 200 for advanced
program. off-season workouts.20 If intensity is high, volume should be
low to medium. Volume may also be expressed as a specific
Frequency distance.21 Adjust the number of contacts down for younger,
Perform one to three sessions per week. Two sessions is the inexperienced or postinjury individuals. Elite athletes may
norm for most off-season sports programs.21 Frequency perform 200 to 400 foot contacts.19
should be determined by the intensity of the sessions and the
phase of rehabilitation or cycle in the sport season. Intensity
Intensity refers to the amount of stress on the tissues during
Volume the plyometric activity. It can be classified as low (Fig. 33-2),
Volume is expressed in number of foot contacts per workout. medium, or high (Fig. 33-3). In general, as intensity
Volume should be 60 to 100 foot contacts for beginners; 100 increases, volume should decrease. Athletes weighing
BOX 33-4 Plyometric Exercise Examples BOX 33-5 Plyometric Guidelines

Low Intensity General Principles
Prancing, galloping, skipping, marching Frequency:
Skipping rope One to three sessions per week
Wall jumps Two sessions is the norm for off-season
Squat jumps Intensity:
Two feet ankle hops Low, medium, high
Side, forward/backward hops As intensity increases, volume should decrease
Dot drilldouble leg Recovery:
Broad jumps 30 seconds to 3 minutes between sets
Medium Intensity Allow 48 to 72 hours between sessions
Tuck jumps Volume
Split squat jumps Expressed as number of foot contacts per session
Scissor jumps Beginners: 60 to 100 contacts
Barrier jumps (forward/backward, lateral) Intermediate: 100 to 150
Single-leg hops Advanced: 120 to 200
Dot drillsingle leg If intensity is high, volume should be medium to low
Bounding Adjust down for younger, inexperienced, or
Double-leg diagonal barrier jumps postinjury individuals
Single-leg dot drills Elite athletes may perform 200 to 400 contacts per
Hip-twist ankle hops session
180 twist Progression
High Intensity Adequate strength and conditioning levels should be
Single-leg triple jump and sticks present before beginning a plyometric program
Single-leg diagonal jumps Start with simple, progress to more complex drills
Single-leg vertical power jumps Start with low volume and intensity, progressing to
Single-leg tuck jumps high
Shock Start with general drills, progressing to sport specific
Start with bilateral, progressing to single leg
Depth jumps
Stable surfaces before unstable
Box jumps
Slow speed to faster speeds
Low height to higher heights
more than 220lb should not perform depth jumps from

heights greater than 18 inches.19 Recovery
Adequate recovery time must be given between repetitions
Progression and sets, as well between workout sessions. Plyometrics
Adequate strength and conditioning levels should be present are not intended to be an aerobic conditioning workout.
before the athlete can progress. It is recommended that the Rest time between repetitions and sets is dependent upon
athlete be able to squat 1.5 times body weight before starting the intensity of the exercise and the individual. Allow 30
shock types of plyometric training such as depth jumps.22 seconds up to 3 minutes for recovery.19 Plyometric sessions
Progression should be based on a current evaluation of the should not be performed on consecutive days. In general,
athlete, the establishment of sport-specific goals, attainment plyometric workouts should allow 48 to 72 hours between
of proper technique and control, and the absence of any signs sessions.24
or symptoms of overuse. In general, the following progres-
sion guidelines are suggested to avoid overtraining and to Direction of Motion
prevent injury during the plyometric program23: A needs analysis should determine if the sport requires speed
Start with simple drills and progress to complex and power in a vertical plane, horizontal plane, lateral or
Low volume progressing to high volume diagonal directions, or a combination. Most sports require a
General to specific drills/exercises combination of directions. Drills that specifically enhance
Bilateral to unilateral exercises the required components of the sport should be chosen for
Use stable before unstable surfaces the program.
Slow speed to faster speeds Proper technique and control is crucial before progress-
Low height to higher height ing to the next level.
A
Fig. 33-2 Low-intensity plyometric exercises. A, Marching. B, Simulated jumping on the Pilates Reformer.
Speed and agility should be performed early in the train-

ing session or preferably on separate days to maximize
training effect, avoid fatigue, and prevent overuse
Allow adequate rest between sets and repetitions.
Heart rate and respiration should return to almost
normal levels after the drill. A 1:4-6 work-to-rest ratio is
recommended.22
Number of sessions per week may vary depending on the
sport, the individuals current level, history of injury,
intensity of the drill, and/or period of the mesocycle. Two
times per week can be used as a general rule.
Volume: two to five sets of each exercise
Fig. 33-3 High-intensity plyometric drill: box jumps. Quality not quantity
Box 33-6 lists various speed and agility drills. This list
provides examples only; the reader may wish to refer
to specific resources on speed, agility, and plyometric train-
Speed and Agility ing for a more comprehensive list and description of
Agility is the ability to rapidly change body direction, accel- drills.20,22,25,26
erate, or decelerate. It is influenced by balance, strength,
coordination, and skill level. Agility can be improved by first Neuromuscular Training
developing an adequate base of strength and conditioning Neuromuscular control is the ability to produce controlled
that is appropriate for the difficulty level of the athlete. After movement through coordinated muscle activity.27 It is the
this is achieved, drills designed to enhance reactive and efferent motor response to sensory input from the somato-
explosive motor skills can be progressively incorporated sensory (proprioceptive and kinesthetic) system, the visual
(Fig. 33-4). system, and the vestibular system. Stability is achieved by
Guidelines for speed and agility training are as follows: continuous feedback to the central nervous system from the
Allow adequate warm-up integration of input from these three systems. The somato-
The athlete should have an appropriate strength/ sensory system uses several different types of sensory input
conditioning base for the selected drills from proprioceptors and the sensory nerve terminals found
A B
Fig. 33-4 Agility drills. A, Lateral shuffles. B, Slide board.
balance. Dynamic joint stability is the ability of the joint to

BOX 33-6 Speed/Agility
remain stable under the rapidly changing loads during
Speed and Agility Guidelines activity.27
Adequate strength/conditioning base Following an injury, deafferentation to ligament and cap-
Warm-up sular mechanoreceptors may occur. The presence of tissue
Perform early in the training session, preferably on swelling and pain can also compound sensory damage by
separate days disrupting sensory feedback that can alter reflexive joint sta-
Allow adequate rest between sets and repetitions. A bilization and neuromuscular coordination.
1:4-6 work-to-rest ratio is recommended Neuromuscular training programs aimed at enhancing or
Number of sessions per week may vary; two times restoring neuromuscular control following injury have been
per week can be used as a general rule developed and have been shown to reduce the incidence
Volume: two to five sets of three to five exercises; 15 of injury.28-32 A comprehensive neuromuscular program
seconds progressing to 30 seconds or measured in would integrate exercises that challenge all three regulatory
distance systems: the somatosensory, visual, and vestibular systems.
Emphasize quality not quantity The neuromuscular program should incorporate a multilevel
approach, which includes combinations of strength training,
Speed and Agility Exercise Examples
flexibility, balance, agility, and plyometric exercises. Activi-
High knees ties that induce adaptations to the system may include open
Gluteal kickers and/or closed chain exercise, eccentric training, balance
Resisted running drills activities, reflex facilitation, stretch-shortening, biofeedback
Step hurdles training, and controlled position training. Balance training
Foot-tapping might include stationary and dynamic surfaces, such as
Shuttle runs wobble boards, balance beams, and foam pads, to enhance
Ladder drills both static and dynamic balance. Functional training, such
Cariocas as jumping and landing, agility, and perturbation training,
Lateral shuffles should also be included depending on sport demands. Fig.
Side to side box shuffles 33-5 illustrates several examples of neuromuscular training
Directional mirror drills exercises.
T drills As mentioned previously, the clinician must continually
5 dot drillsdouble leg, single leg monitor the athlete for tissue tolerance and to determine
Figure eights with cones readiness to proceed to the next phase in the rehabilitation
process. Myer and associates have proposed a progressive
end-stage return to sport protocol following ACL recon-
struction that is based on the athlete meeting specific criteria
in muscles, tendons, and joint capsules. Proprioceptors relay before being able to progress to the next phase.33 The proto-
information relating to movement and position sense. col consists of four stages: dynamic stabilization, functional
Visual input received in the cortex and vestibular nuclei strengthening, power development, and sports performance
provides information for the vestibular and somatosensory symmetry. One significant limitation of this protocol is that
systems to make adjustments to maintain stability and some of the criteria were based on the use of specialized
testing equipment such as a stabilometer and isokinetic

equipment, which most clinicians would not have available.
Returning to Sport
As previously stated, the goal of the rehabilitation program
is to return the athlete to the highest functional level. Reha-
bilitation programs are based on current scientific principles
that include knowledge of the healing process, anatomy/
physiology, biomechanics, and kinematics. Keep in mind
that these principles and concepts are ever-changing as new
research becomes available.
Typically, return to sport is based on various subjective and
A objective criteria. Many clinicians have either developed their
own compilation of tests or have adopted those used by others
to determine when an athlete is ready to return to sport.
Single-leg hop tests are commonly used to determine an
athletes progress in his/her rehabilitation program and to
determine the readiness to return to sport. Various single-leg
hop tests either used alone or in combination have been
described in the literature.34-38 These tests include single-leg
hop and stop tests,36 single-leg hop for distance and time,
triple hop, and the triple crossover hop.34-39 Several studies
have shown these tests to be reliable with intraclass coeffi-
cients between 0.66 to 0.97.40-42 Barber and associates recom-
mended using at least two hop tests and achieving a limb
symmetry score of 85%.34
Other test measures have been used to determine return
to sport as well. Vertical jump height (Fig. 33-6) and
C D
Fig. 33-5 Neuromuscular training exercises. A, Cone reachesbalance
exercise. B, Plyotossproprioception drill/neuromuscular control. C,
Functional activity incorporated with balance (on BOSU). D, Four way leg
kicksbalance/proprioception.
Fig. 33-6 Vertical jump test.

C B D
5 yards 5 yards
10 yards
A
Equipment: four cones, stopwatch, adequate space
Testing Procedure:
Arrange the four cones in a T formation as seen in the figure above.
Athlete should perform adequate warm-up and stretching prior to testing.
The athlete starts at point A.
On GO, the athlete sprints to point B, touches the base of the cone with the right hand shuffles to
the left 5 yards and touches the base of the cone at point C with the left hand shuffles to the right 10
yards and touches the base of the cone at point D with the right hand shuffles to the left, touches the
base of the cone at point B with the left hand then runs backward past point A. The timer stops the
watch as the athlete passes point A.
Complete two trials, recording the best trial time
Disqualification occurs if the athlete does not touch the base of the cone, crosses the feet when shuffling,
fails to face front at all times, or demonstrates poor control.
Fig. 33-7 T test. (Adapted from Semenick DM: Testing protocols and procedures. In Baechle TR, editor: The essentials of strength training and
conditioning, Champaign, Ill, 1994, Human Kinetics.)
isokinetic testing have been used to assess function and incorporated into the testing protocol and compared with
strength.43,44 A 1 repetition maximum (RM) leg press test or available normative data.
squat can also be used to assess strength. The shuttle run and Davies48 has developed a functional testing algorithm that
figure eight run have been used to test the ability to run, cut, uses a systematic functional progression of testing and exer-
and pivot.34,45,46 The T-test (Fig. 33-7) and the Edgren side cise. It is designed to progressively increase stresses on the
step test are two tests that can be used to assess agility and athlete while gradually lessening clinical control. The algo-
body control.47 These tests can also be used in the rehabilita- rithm includes the following: subjective information,
tion program as functional drills. basic measurements, KT 1000 test, balance testing, closed
Speed tests measure the bodys displacement per unit of and open chain strength testing, two-leg jump test, unilat-
time. Testing speed for clinical purposes is usually limited eral hop test, lower extremity functional test, and sports-
because of lack of appropriate space. The majority of the specific testing.48 Very specific criterion must be met before
research on these tests has been with ACL deficient or ACL the athlete is allowed to progress to the next level. Fre-
reconstruction individuals; however, the tests may be used quent testing and monitoring of the patient allows the
in other lower extremity patient populations as well. Stan- clinician to always know the status of that patient. A spe-
dard health and fitness tests for flexibility, local endurance, cific rehabilitation program can then be designed to address
aerobic power, and agility/speed such as those described in individual deficits instead of following a preset clinical
The Essentials of Strength and Conditioning47 may also be protocol.
A B
Fig. 33-8 A, Proper landing form with good lower extremity alignment. B, Improper landing form with increased lower extremity valgus.
Recent research by Hewett and associates49 has focused

BOX 33-7Example of Criteria Return to Sport Criteria
on biomechanical loading measurements in female athletes
in an attempt to predict those who are at risk for ACL injury. Assessment
They concluded that increased valgus motion and valgus Range of motion
moments at the knee were key predictors for potential ACL Self-report scores (optional): Lysholm, Knee Outcome
injury (Fig. 33-8). If predictive factors associated with lower Survey, International Knee Documentation
extremity injuries can be identified, specific screening pro- Committee, Cincinnati Knee Rating Scale, foot/ankle
grams and training programs could potentially be designed outcomes, or other functional outcome assessment
to reduce the risk for injury. self-reports
In general, there is currently no standard accepted series Strength: 1 RM leg press, squat test, isokinetics
of tests to determine when an athlete is ready to return Stability: Manual tests, KT-1000
safely to sport. The decision should be based on ROM, Functional Tests:
strength, symptomatology, and functional testing. Box 33-7 Vertical jump
provides a list of tests that the clinician may select to Hop tests (single-leg hop for distance, triple hop
assist in the decision. It is recommended that a minimum of for distance, single-leg hop for time over 6
two hop tests,34 a strength assessment, and an agility/body meters, cross-over hop)
control test be used. The athlete must demonstrate proper Agility/body control: T-test, Edgren side step test,
form and technique throughout the test procedures. A deficit shuttle run
of 10% or less with good control is currently used in many Lower extremity functional test
facilities to allow return to sport. There are obvious limita- Balance testing
tions to the tests; however, they appear to be the most com-

Criterion for Return to Sport
monly used in various combinations. Further research is
needed not only to determine risk factors, but also to deter- No complaints of pain
mine what testing procedures would be best to predict safe No giving way/sensation of instability
return to sport. No effusion
Full and pain-free range of motion
Strength deficit 10% or less compared with
SUMMARY uninvolved side
Establish proper muscle balance ratios
Returning the jumping athlete back to sport as safely and Functional test score 10% or less deficit compared
efficiently as possible is the primary goal of the rehabilitation with uninvolved side. Must demonstrate good
program. The length of time to return depends on many technique and control.
factors. It is the clinicians responsibility to have the scientific
knowledge base and clinical skills to determine when and
how the athlete is to progress through the program. Current a cookbook approach. Table 33-1 provides only one example
testing procedures have their limitations; however, they of how the various training components can be combined.
provide some objective data to assist the clinician in deciding It was the goal of this chapter to provide the clinician with
when the athlete may resume sport activities. It is impossible guidelines, ideas, and resources for returning the jumping
to design one rehabilitation protocol for all athletes lest it be athlete back to sport; hopefully, it accomplished its goals.
TABLE 33-1 Example Program

Day Weeks 1-3 Weeks 4-6 Weeks 5-8
Monday Strengthening Strengthening Strengthening

Upper body plyometrics Upper body plyometrics Upper body plyometrics
Core strength Core strength Core strength
Cardio Cardio Cardio
Tuesday Low-intensity plyometrics4 drills 2 low-intensity, 2 medium-intensity plyometric drills 2 medium-intensity plyometric drills, 2 high-intensity
Agility Progress to 4 medium-intensity plyometric drills plyometric drills
Cardio Agility Progress to 4 high-intensity drills
Sport-specific drills Agility
Cardio Sport-specific drills
Cardio
Wednesday Strength training Strength training Strength training
Upper body plyometrics Upper body plyometrics Upper body plyometrics
Thursday Low-intensity plyometrics4 drills 2 low-intensity, 2 medium-intensity plyometric drills 2 medium-intensity plyometric drills, 2 high-intensity
Agility Progress to 4 medium-intensity plyometric drills plyometric drills
Cardio Agility Progress to 4 high-intensity drills
Sport-specific drills Agility
Sport-specific drills
Cardio
Friday Strength training Strength training Strength training
Cardio Cardio Cardio
1 Matt is a 42-year-old male who has had an ACL recon-

struction. He has completed his early postoperative
rehabilitation and is in phase I (dynamic stabilization
clinicians. However, the clinician may still incorporate
this criterion-based approach by using other low tech-
nology tests and measures: a 1 RM test, the lateral step
and strengthening) of his return to a sport program. test, and the Star Excursion Balance test are a few
What criteria might you use to assess whether Matt is examples.
ready to progress to functional strengthening exercises
(stage II)?
No pain
2 Matt is now 6 months after surgery for an ACL/meniscal
repair. He had been going to the gym to work on his
strengthening and cardiovascular training while attend-
No swelling ing rehabilitation sessions once per week to progress
Full ROM and focus on his functional training. He had been pro-
Single-limb squat and hold symmetry (60 knee gressing extremely wellgood control with landings
flexion, 5-second hold) and agility exercises, etc. He is very motivated and eager
Audibly rhythmic foot strike patterns with treadmill to return to basketball. At 6 months after surgery, he
running performed a functional assessment that included four
Acceptable single-leg balance measures single-leg hop tests. Although he had no pain or symp-
These criteria are based on the Return to Sport algorithm toms during the test, the following day Matt experienced
developed by Myer and associates.33 Matt should have significant swelling and discomfort in the knee. How
been allowed to progress from stage I into stage II by would you modify his program at this point?
having a minimum International Knee Documentation
Committee score of 70 and baseline strength scores. This Reexamine the knee for signs of instability or
algorithm is somewhat limiting because much of the possible meniscal pathology
testing uses equipment that is not available to most Apply modalities to reduce effusion and pain
Notify physician and/or refer to physician if any recommendations for diagnosis, rehabilitation progres-
suspicion of reinjury sion, and injury prevention. Factors that may contribute
ROM and light strengthening as indicated if no signs to reinjury may include persistent weakness, decreased
of significant reinjury to prevent loss of ROM and extensibility of the musculotendinous unit, and/or com-
strength pensatory changes in biomechanics and motor patterns
As symptoms subside, gradually progress him back following injury. Proper diagnosis through examination,
to the appropriate rehabilitation stage based on the appropriate phase progression, and use of the best avail-
Return to Sport algorithm able evidence to determine return to sport may be ben-
eficial in reducing recurrence rates. Therapeutic exercises
3 Julie is a 36-year-old woman with a grade II ankle sprain

who plays recreational volleyball. She has had several
sprains in the past, but this was her worst. Her walking
that strengthen and promote neuromuscular control of
the lower extremity and lumbo-pelvic musculature
should be key components of the program. Manual
boot was discontinued several weeks ago and she is therapy techniques to restore mobility should be included
progressing well with her rehabilitation. Although Julies as indicated.50
physician released her to return to volleyball, she still Strength testing to assist with determining return to
has mild swelling and slight pain with some of the light play should be performed prone with the knee at both
plyometric exercises. Should she be allowed to return 90 and 15 of flexion. The athlete should be able to
to play? perform four pain-free maximal effort contractions.
Isokinetic testing would be more optimal if available
Julie did not return to play at that time for the following and should demonstrate a less than 5% deficit in the
reasons: ratio of eccentric hamstring to concentric quadriceps
She had pain with even light plyometric and agility strength.50
drills
She demonstrated 4/5 ankle evertor strength
She had balance deficits on the Star Excursion
Balance test
5 Matt is now 7-months postoperation for an ACL/
meniscal repair. What testing criteria might you use to
determine if he is ready to return to basketball?
Julie is a recreational player and not under any
pressure to return The choice of testing depends on the physician and/or
clinicians preference, as well as the specific sport
4 Andy has completed a rehabilitation program following

a grade II hamstring strain. He returned to tennis but
reinjured the hamstring after only 3 weeks. He had no
demands of the patient. The following are examples of
commonly used criteria:
No complaints of pain
complaints of pain with jogging, cutting, or jumping. He No giving way/sensation of instability
demonstrated 5/5 strength with manual muscle testing. No effusion
What factors could have lead to his reinjury? Full and pain-free ROM
Strength deficit of 10% or less compared with
It has been reported that nearly one third of hamstring uninvolved side
strain injuries will recur within the first year after return Establish proper muscle balance ratios
to sport. This high recurrence rate suggests inadequate Functional test score of 10% or less deficit compared
rehabilitation, premature return to sport, or a com with uninvolved side. Must demonstrate good
bination of both. Heiderscheit and associates50 proposed technique and control (see Box 33-7).
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CHAPTER 34
Transitioning the Patient Back to Running
Steven L. Cole*
F
or many patients a return to prior activity is a measure physical condition level must be assessed: aerobic capacity
of the success of their rehabilitation. Usually an ath- (usually submaximal on bike), flexibility (ROM), strength (of
letes first question is When can I start running? As the whole body not just the injured body part), balance, and
clinicians our responsibility is to make sure that patients coordination. A thorough gait analysis is also performed to
can return to some form of physical activity that stresses assess any biomechanical deficiencies. Shoe wear should be
their cardiovascular system. For the purposes of this chapter, assessed by a qualified professional and the patients shoes
that form of exercise is running. Dr. Fries of Stanford Uni- should be properly fit before this program is initiated.
versity1 completed a 21-year longitudinal study comparing
runners against a control group, and although the study had FLEXIBILITY, STRENGTH,
some limitations, it found that runners tended to have AND BALANCE/COORDINATION
decreased disability and a better survival rate than the control
group. In the running motion the clinician must consider all the
Regardless of the injury or the surgical procedure, it is the joints that are directly involved once the foot hits the ground
clinicians responsibility to determine the patients level of and transitions that force up the kinetic chain. While
readiness to progress to each stage of rehabilitation. Many acknowledging that the upper quarter (cervical spine, tho-
programs exist on how to progress patients back to running racic spine, and upper extremities) also play an important
and it the goal of this chapter to provide the clinician a frame- role in the running motion, for the purposes of this chapter
work from which to develop a comprehensive program while we will focus on the lumbar spine down to the foot. After a
keeping in mind the factors that led to the initiation of a return period of immobilization from surgery, the patient needs to
to run program. The factors to consider are age, type and extent reestablish normal ROM and efficient flexibility in the hip,
of injury, current and prior surgical procedures, pain levels, knee, and ankle regions. The following major muscle groups
swelling, range of motion (ROM), strength, endurance, flexi- should be assessed: lumbar paraspinals, latissimus dorsi,
bility, patient goals, and psychological readiness.2 multifidus, gluteals, piriformis, hip flexors/adductors, ham-
Most clinicians who will be initiating a return to run strings, iliotibial band, hip rotators, quadriceps (especially
program are the same ones who have been treating patients rectus femoris), gastrocnemius, and soles complex.
through their postoperative rehabilitation. However, it is
imperative in cases in which the patient is seen for the first AMBULATION
time to initiate a running program and to communicate with
the sports medicine team physician (surgeon, team: physi- The patient needs to reestablish a normal gait pattern before
cian), physical therapist, certified athletic trainer, and so starting an aggressive closed-chain exercise program. In
forth. most cases, gait training should have been completed during
the patients postoperative rehabilitation. As a rule, if the
ASSESSMENT patient cannot walk without a limp, he or she should be using
crutches and/or a shortened stride length. If ambulation
Knowledge of the patients prior physical status and progres- results in increased swelling, the patient should be using
sion through his or her postoperative rehabilitation course crutches and is not ready to progress until he or she can
is important in setting achievable goals. The patients overall ambulate without deviations.
The tests in the following paragraphs are used to assess
*Special Acknowledgement: Assistance with the Core Stability section pro- the ability of the lower extremity to provide a stable base
vided by Kristina Carter, DPT, Advanced Specialty Center, Williamsburg during static and dynamic postures. The patient must suc-
Physical Therapy, Williamsburg, Va. cessfully complete these tests before progressing.
616
Chapter 34 Transitioning the Patient Back to Running 617
Baseline Balance Test Core Stability

Have patient can stand on both feet with equal distribution, Testing core stability forces the patient to move and control
free standing, with his or her eyes closed, and maintain motion in multiple planes: sagittal, frontal, transverse, and
balance for 20 seconds. multiplanar. It is essential to stabilize the proximal segment
(in this case, trunk and pelvis) to allow efficient distal
Tandem Stance mobility.3-5 The following are simple tests for core stability
Have patient stand heel to toe with his or her nondominant that are easy to administer and can be measured both quali-
foot in back, weight evenly distributed on both feet, with tatively and quantitatively.
his or her hands on the hips and eyes closed. Count the Sagittal plane tests motion in a forward/backward or
number of times he or she moves out of that position in a anteroposterior directionstability here helps the runner
20-second period. To progress, the patient should have no move the body forward or slow down when stopping or
more than 4 errors (such as lifting the hands off the hips, descending a hill.
opening eyes, lifting the forefoot or heel, step, stumbling, or BridgeSagittal Plane:
falling). Instructions:
Lie on your back with knees bent
Balance Progression Tighten abdominal and gluteal muscles
Have the patient stand on both feet with equal weight Slowly raise buttock from the table
distribution. Start with assisted balance with hands on the Attempt to hold for 30 seconds
edge of a table, eyes open, and progress to free standing Bridge with Good Stability (Fig. 34-1):
away from table and then with eyes closed. Hips remain level (Fig. 34-1, A)
Have the patient stand on both feet, dominant foot in Lower extremities remain in proper alignment
front of the other, heel to toes, with equal weight distribu- (Fig. 34-1, A)
tion. Start with assisted balance with hands on the edge
of a table, eyes open, and progress to free standing away
from table and then with eyes closed.
Have the patient stand on the involved leg. Start with
assisted balance with hands on the edge of a table, eyes
open, and progress to free standing away from table and
then with eyes closed.
Have the patient stand on the involved leg approximately
24 inches from a wall, throw a tennis ball against the wall,
and catch it. Progress to place four marks on the wall
two at a level approximately 12 inches above head level
and 12 inches beyond shoulder width; the other two
should be at waist level and 12 inches beyond hip width.
Throughout the exercise, alternate the mark at which to
throw the ball.
Time each attempt at each level; as balance improves and
the patient is able to maintain a stable position, progress to
the next level.
STRENGTH/ENDURANCE A
Strength of the trunk/core and the entire lower extremity

should be assessed. The assessment should encompass not
only isometric testing but also concentric and eccentric,
since all are important to the acceleration and deceleration
involved in the running motion. The patient must have the
ability to maintain active control of spinal and pelvic posture
during dynamic loading and movement. During running,
good core strength will allow the patient to appropriately
distribute force, allow for efficient and controlled movement,
absorb ground impact forces, and decrease compression
forces. The patient will need good core strength and balance B
before progressing into an aggressive return to running Fig. 34-1 Bridge with good stability. A, Hips remain level, and lower
program. extremities remain in proper alignment. B, Back does not arch or sag.
B Fig. 34-3 Prone bridge with good stability. A, Back does not arch or sag.
B, Hips are level.
Fig. 34-2 Bridge with poor stability. A, Side view. B, Top view.
Back does not arch/sag (Fig. 34-1, B) Side Bridge (Plank)Frontal Plane:
Able to hold for 30 seconds Instructions:
Bridge with Poor Stability (Fig. 34-2): Begin on one side (test both sides)
Back sags, and she wobbles with wobbling (Fig. 34-2, A) Prop on forearm and the foot that is in contact with
Hips not level (and shes cheating by squeezing her the table
knees together to use her adductors as a compensatory Tighten abdominals
movement) (Fig. 34-2, B) Attempt to hold for 30 seconds
Prone BridgeSagittal Plane: Side Bridge with Good Stability (Fig. 34-5):
Instructions: Able to hold for 30 seconds
Begin lying on stomach Hip that is facing downward does not sag
Tighten abdominals and gluteals while propped on (Fig. 34-5, A)
forearms and balls of feet Shoulders and feet remain in alignment (Fig. 34-5, B)
Attempt to hold for 30 seconds Side Bridge with Poor Stability (Fig. 34-6):
Prone Bridge (Plank) with Good Stability (Fig. 34-3): Cannot keep shoulders and feet alignment or maintain
Able to hold for 30 seconds balance (Fig. 34-6, A)
Back does not arch/sag (Fig. 34-3, A) Hips sag (Fig. 34-6, B)
Hip level (Fig. 34-3, B) Bridge with Knee ExtensionTransverse Plane (Fig. 34-7):
Prone Bridge with Poor Stability (Fig. 34-4): Instructions:
Back sags (Fig. 34-4, A) Lie on back with both knees bent
Hips not level (Fig. 34-4, B) Contract abdominal and gluteal muscles
Frontal plan stability and transverse plane stability help Slowly raise bottom from the table
to keep the runner moving forwardweakness here makes Extend one knee while remaining in the bridge
the movement inefficient; there is wasted energy with side to position
side or rotational motion. Attempt to hold for 10 seconds on each side
A
A
B B
Fig. 34-4 Prone bridge with poor stability. A, Back sags. B, Hips are not Fig. 34-6 Side bridge with poor stability. A, Shoulders and feet are not
level. aligned, and balance is not maintained. B, Hips sag.
B B
Fig. 34-5 Side bridge with good stability. A, Hip that is facing downward Fig. 34-7 Bridge with knee extension: transverse plane. A, The hips are at
does not sag. B, Shoulders and feet remain in alignment. a high level, and there his no movement or hip sag. The extended leg is
parallel with the opposite leg. B, The hips are level.
Bridge with Knee Extension with Good Stability: Quadruped Opposite Arm/Opposite LegMultiplanar
Able to hold for 10 seconds on each side (Fig. 34-9):
Hips remain level Instructions:
Knee remains straight Begin on hands and knees
Back remains flat against the table Tighten abdominals
Bridge with Knee Extension with Poor Stability Slowly extend one arm and the opposite leg
(Fig. 34-8): Attempt to hold for 10 seconds
Hips sag and not level (Fig. 34-8, A) Quadruped Opposite Arm/Opposite Leg with Good
Cannot keep knee straight Stability:
Shoulders and back are not flat against the table Able to hold for 10 seconds on each side
(Fig. 34-8, B) Back does not arch/sag
Multiplanar stability is the most functional, because Arm and leg do not drop downward
running is a dynamic movement of the body in three dimen- Quadruped Opposite Arm/Opposite Leg with Poor Sta-
sions simultaneously with one side of the body working bility (Fig. 34-10):
independently of the other, all the while controlling ground Hips sag and not level (Figure 34-10, A)
reaction forces and delivering propulsion forces. Lack of Arm and leg drop (Fig. 34-10, B and C)
adequate multiplanar stability has been shown to increase Cannot maintain balance
the risk of lower extremity injuries.6
Lower Extremity Stability
In preparation to return to running, it is important to estab-
lish a strong initial contact base (gastroc-soleus). This can be
accomplished progressively through closed-chain exercises
focusing on technique and quality with progression into
quantity.
Calf Raise Progression into Single-Leg Hop:
Calf raise off both legs, with equal weight distribution;
start with assistance with hands on the edge of a table;
progress to free standing away from table.
Calf raise on the uninvolved leg, maintaining a bal-
anced, stable position (10 to 25 reps). This will serve
as the norm for the involved side.
Calf raise on the involved leg; start with assisted with
hands on the edge of a table, progress to free standing
away from table. The movement should be of the same
A quality (height, speed, and control of movement) as
that of the uninvolved leg.
Hop off both legs, with equal weight distribution.
Hop off the uninvolved leg multiple times (10 to 25
reps). This will serve as the norm for the involved side.
Hop off the involved leg. The movement should be of
the same quality (height, speed, and control of move-
ment) as that of the uninvolved leg.
The emphasis should be on the quality of the movement
and high repetition. Points of emphasis on quality are the
B
Fig. 34-8 Bridge with knee extension with poor stability. A, Hips sag and
are not level. B, Shoulders and back are not flat against the floor. Fig. 34-9 Quadruped opposite arm/opposite leg: multiplanar.
B C
Fig. 34-10 Quadruped opposite arm/opposite leg with poor stability. A, Hips sag and are not level. B and C, Arm and leg drop.
height of the movement, rapid raise, slow controlled descent

and landing, and maintaining balance. Repetitions should
start with 5 and progress to 25.
Single-Leg Squat TestMultiplanar (Fig. 34-11):
Instructions:
Stand with one foot on a stool, keep foot flat on stool
during descent
Keep lower leg perpendicular to the floor and knee
behind and within toes
Slowly lower the other foot toward the ground
Perform this five times on each side
Single-Leg Squat Test with Good Stability:
Able to complete five repetitions with good form
Knee remains in line with the second toe
Hip does not internally rotate
Patient does not lose balance
Single-Leg Squat Test with Poor Stability (Fig. 34-12):
Top lefttoo much adductionweak glutes
(Fig. 34-12, A)
Top rightknee wobbleweak quads or weak glutes
Bottomhip drop (Fig. 34-12, C)
Useful objective measurement tools for assessing a
A B
patients ability for force absorption and force production
with a lower extremity injury are the leap test and the hop Fig. 34-11 Single-leg squat test: multiplanar. A, There is good body stabi-
and stop test (Fig. 34-13).7 Before attempting either test, the lization. The knee is over the toes on descent. The foot on the step is pointed
straight ahead. The shoulders are level. B, The back is straight, and the knee
patient must have established normal ambulation, pro-
does not extend past the toes.
gressed through the calf raise progression, and phase I
(walking program) and progressed through phase II (plyo-
metric program) of the return to running progression. getting worse, staying the same, or gradually dissipating? Use
a pain scale of 0 to 10, in which 0 is normal and 10 is the
PAIN MANAGEMENT worst.8
Getting worse: need total rest; decrease to previous activ-
It is important to have a consistent, objective way of grading ity level and decrease intensity of exercise.
the patients pain level. Try grading the level of pain the Staying the same: decrease activity level to previous level
patient has over a period of several days to weeks. Is the pain and maintain until pain decreases.
A B
Fig. 34-12 Single-leg squat test with poor stability. A, Top left. B, Bottom.
Leap Test (Takeoff on uninvolved leg and land on the involved leg; stick the landing)
Leap Test:
1: _________ Inches
2: _________ Inches
3: _________ Inches
Divide distance of involved leap test by distance of involved hop test for percentage: ________%
Goal: Distance of involved leap test should be less than 109% of the involved hop test; less than
109% indicates that the patient needs to work on force absorption for the involved leg.
Developed by: Paul Juris, PhD

A
Hop and Stop Test (Takeoff and land on same leg, stick the landing)
Hop Test: Uninvolved Involved
1: _________ Inches ________ Inches
2: _________ Inches ________ Inches
3: _________ Inches ________ Inches
Patients Height: ___________________ (inches)
Divide distance of uninvolved hop by patients height for percentage: ________%
Divide distance of involved hop by distance of uninvolved hop for percentage: ________%
Divide distance of involved hop by patients height for percentage: ________%
Goal: Distance of uninvolved hop test should equal the patients height; a score of less than 89%
indicates that the patient needs to work on force production for the uninvolved leg. A score of
less than 89% indicates that the patient needs to work on force production for the involved leg.
Developed by: Paul Juris, PhD

B
Fig. 34-13 A, Leap test. B, Hop and stop test.
For the successful progression of the return to running

program, it is critical to understand the level, location, and RETURN TO RUNNING PROGRAM
nature of discomfort that may develop as the patient increases
the activity level. In general the patient should apply moist Phase I: Walking Program
heat before the activity and stretch thoroughly, then ice To progress to phase II (plyometric routine), the patient
immediately after the activity for 15 to 20 minutes. If the must be able to walk pain-free, aggressively (roughly 4.2 to
patient develops swelling in a joint or muscular pain that 5.2 miles per hour), and preferably on a level treadmill, for
lasts longer than 72 hours, he or she has done too much 30 minutes before beginning the plyometric and walk/jog
and needs to decrease activity (duration and/or intensity) program. The patient must be pain-free, without residual
and increase rest between workouts. Consultation with the swelling or loss of strength/ROM on the following day, espe-
physician should occur immediately if there is pain with cially upon waking.
weight bearing or antalgic persists. Start each session with an easy warm up for at least 5
Here are some useful tips: If the patient develops tightness minutes. During the warm up, the patient should be able to
during activity, he or she should stop and perform a static maintain normal, comfortable stride mechanics and main-
stretch (at least 3 repetitions, hold each for a 30 count each) tain a conversation. After the initial 2 minutes, the patient
of the affected area, then resume activity. If tightness returns, should increase the speed by 0.5 mph every 30 seconds for
the patient should stop and stretch the affected area again. If the remaining 3 minutes of the warm up.
pain develops or after three stretching sessions and the tight- End each session with an easy cool down for at least 5
ness remains, the patient needs to stop the activity and apply minutes. During cool down, the patient should be able to
ice to the involved area for 20 minutes. maintain normal, comfortable stride mechanics and main-
It is important for the patient to identify the exact loca- tain a conversation. Decrease the speed by 0.5 mph every 30
tion of the pain and to differentiate if the pain is in a constant seconds for the 5 minutes of the cool down period.
location or if it moves around in a general area. If the patient experiences pain or is unable to complete
Constant location: be very cautious, incorporate an exercise, stop, stretch, and apply ice to the involved
more rest between exercise sessions, and keep area. If the patient is pain-free the next day, attempt to
the intensity low and exercise on level, soft restart the routine.
surfaces.
Moves around: continue with progression but do Progression
not increase the intensity. Complete a walking session (5 minute warm up, 30 minutes
It is important for patients to identify when they have of aggressive walking, 5 minute cool down) for 2 consecutive
pain: days; take a day off, complete 2 more consecutive days. If
Type I: After activity. Plan: stretch affected area well pain-free, without residual swelling or loss of strength/ROM,
(at least 3 to 5 repetitions, hold each for at least a 30 progress to phase II after a day off.
count); do long, slow, gentle stretches, then ice for 20
minutes. Continue to progress program if discomfort Goal
appears to be muscle soreness. If any joint pain and/ The patient should be able to walk, pain-free, aggressively
or swelling develops, increase rest between exercise (roughly 4.2 to 5.2 mph), preferably on a level treadmill, for
sessions and decrease activity level to previous level. 30 minutes. He or she should be able to aggressively walk at
Consult physician. a pace and stride mechanics just below the threshold where
Type II: During activity (muscular), or at beginning he or she would be jogging. During an aggressive walk, the
then dissipates. Plan: maintain same activity level and patient maintains a heel/toe gait pattern without a flight
low intensity until symptoms dissipate. segment (maintains contact with the surface with both feet).
Type III: During activity (muscular), gradually devel-
oping and intensifying with activity. Plan: decrease Phase II: Plyometric Routine
intensity of activity, stop and stretch to relieve symp- Plyometric exercises are essential to include in a return to a
toms; stop activity if these steps do not relieve symp- running program. Plyometrics works on the stretch-
toms. Maintain same activity level; if symptoms shortening cycle of the running motion to improve running
continue, decrease activity to previous level. efficiency and performance.9 To progress to the phase III
Type IVa: Upon waking in the morning then dissipat, walk/jog progression, the patient should complete the entire
which is usually a sign of more to come. Plan: decrease cycle within the time intervals without residual swelling, loss
activity to previous level and keep intensity low. of strength or ROM, and pain. The patient must be pain-free
Type IVb: At night, keeps patient up or wakes patient. the following day, especially on waking.
This is a warning sign that the patient is doing too
much or that the muscle/joint is not tolerating the Rationalization
amount of work. Plan: total rest until symptom free; A mile run generally consists of 1500 foot contacts, 750 per
decrease activity to previous level and keep intensity foot. The program integrates 470 foot contacts per leg, which
low. would be equivalent to two thirds the foot contacts of a mile.
TABLE 34-1 Closed-Chain Progression TABLE 34-2 Walk/Jog Progression

Foot Total Foot Stage Walk Jog Repetitions Total Time
Exercise Sets Contacts/Set Contact
Stage I 5 minutes 1 minute 5 times 30 minutes
Step 1: Two-leg ankle hops: in place 3 30 90 Stage II 4 minutes 2 minutes 5 times 30 minutes
Step 2: Two-leg ankle hops: 3 30 90 Stage III 3 minutes 3 minutes 5 times 30 minutes
forward/backward Stage IV 2 minutes 4 minutes 5 times 30 minutes
Step 3: Two-leg ankle hops: side to 3 30 90 Stage V 1 minute 5 minutes 5 times 30 minutes
side Stage VI Jog every other day with a goal of reaching 30 consecutive
Step 4: One-leg ankle hops: in place 3 20 60 minutes. Begin with 5 minutes of walking, gradually
Step 5: One-leg ankle hops: 3 20 60 increasing the pace. End with 5 minutes of walking,
forward/backward gradually decreasing the pace to a comfortable walk.
Step 6: One-leg ankle hops: side to 3 20 60
side
Step 7: One-leg broad hop 4 5 20 residual swelling, or loss of strength or ROM, and pain,
especially on waking. If pain/discomfort remains or
22 sets for a total of 470 total foot contacts. increases, the patient should continue to return to a previ-
Note: The one-leg activities are performed on the involved ous level until discomfort stabilizes or decreases.
extremity. If there is no pain when doing this activity level or after-
Rest intervals: Between sets, 90 seconds; between exercises,
ward and there is no discomfort or tightness that limits
3 minutes.
normal movements the next morning, the patient should
proceed to the next stage.
Successfully completing the routine (Table 34-1) is a good The patient should not attempt more than two stages on
indicator of a patient returning to running a half to three consecutive days; he or she should take a day off before
quarters of a mile distance. progressing to next the stage.
I prefer that the exercises be performed on a forgiving
surface, such as a rubber mat. Gastrocnemius-soleus, quad- Phase IV: Timed Running Schedule
riceps, and hamstrings should be stretched between exer- During this phase, the duration of the running program
cises. Clinicians should stress quality of the movement, progresses. The patient should try to jog/run on a flat, forgiv-
emphasizing toe-heel landing, triple flexion (hip and knee ing surface (i.e., golf course, athletic field) before hilly courses
flexion, ankle dorsiflexion), triple extension (hip and knee or even surfaces and follow the Ten Percent Rule10: only
extension, plantar flexion), and soft landing. Patients recov- increase the weekly mileage by 10% of the previous week. If
ering from a knee, thigh, or hip injury should incorporate a no pain is experienced when doing an activity level or after-
greater degree of knee and hip flexion. ward and there is no discomfort or tightness that limits
If the patient develops persistent tightness or increased normal movements the next morning, he or she can proceed
discomfort during the exercise session, he or she should stop to the next stage.
and note the foot count for the activity upon the onset of The intensity (how hard/fast) of the jog/run is increased
symptoms, such as if pain developed on repetition 21 of the before the duration (how long). When the patient increases
third set in step 3, which is foot contact no. 261. This will the frequency (how many days per week) of the jog/run
provide a measurement of progress for future attempts. workouts, the clinician should also have them decrease the
If the patient experiences pain or is unable to complete duration of the workout. When the patient begins running
an exercise, he or she should stop, stretch, and apply ice to multiple days in a row, increases (duration or intensity) are
the involved area. If pain free the next day, he or she made on the first day of activity after a day of rest, the dura-
should attempt to restart the routine. tion of activity is decreased to the previous level.
If the patient develops persistent tightness or increased
Phase III: Walk/Jog Progression (Table 34-2) discomfort to a point of dysfunction (develops a limp or
The patient may begin this program on level ground if he or altered gait pattern) during the activity, he or she should stop
she: and note the time of onset of symptoms (during a 30-minute
1. The patient completed phases I and II planned exercise session, symptoms develop after 21
2. The patient has no pain or swelling with normal daily minutes). Consider splitting the duration of activity between
activities (on a pain scale of 0 to 10, in which 0 is normal two workouts, with each exercise session shorter than the
and 10 is the worst, he or she must be at 0) time of the onset of symptoms during the previous attempt.
3. The injured area no longer hurts when pressed on For example, if during a 30-minute planned exercise session,
symptoms develop after 24 minutes, each of the two exercise
Program Progression sessions would be 20 minutes long. The exercise sessions
If jogging hurts, the patient should stop, apply ice, and should be separated by 6 to 8 hours. The clinician should refer
return to the previous stage the next day if there is no to the section on Pain Management in this chapter if the
patient begins to develop pain/swelling and remember: If

pain/discomfort remains or increases, continue to return FUTURE CONSIDERATIONS
to a previous level until discomfort stabilizes or decreases.
Currently there is a lot of interest in the mechanics of running
Phase IV: Timed Running Schedule and the use (or nonuse) of running shoes. Of consideration
Intermediate (Table 34-3) is foot contact while running. Some authors have found a
The patient may begin this program on level ground if they reduced rate of injury in barefoot runners whose initial
have completed phases I, II, and III.
The intermediate schedule is designed for the patient
restarting running training or recovering from an injury, TABLE 34-4 Timed Running ScheduleAdvanced
such as a stress fracture or significant illness that has kept
them off their feet or on nonweight bearing activities for Day
4 weeks or longer. To allow for soft tissue adaptation, the 1 2 3 4 5 6 7 Week
patient should run every other day for 8 weeks. He or she
Minutes 30 30 30 35 30 1
should cross-train or be on active or total rest on days off.
35 35 40 35 2
The patients pace should be 8 to 9 minutes per mile.
40 40 45 40 45 3
Phase IV: Timed Running ScheduleAdvanced 45 45 40 30 45 4
(Table 34-4) 40 35 45 40 40 5
45 45 40 45 45 45 6*
The advanced schedule is designed for the patient/runner
45 50 50 45 50 8
who is recovering from a soft tissue injury, such as a strained
50 50 55 50 50 9
muscle, which has forced him or her to cross-train for less
55 55 50 55 55 55 10
than 4 weeks. The patient may begin this program on level 60 55 55 60 60 11
ground if he or she has completed phases I, II, and III. To 55 60 60 60 65 12
allow for soft tissue adaptation, the patient runs every other
day for 8 weeks. He or she should cross-train or be on active *This activity level at 6 weeks is the same as the activity level at
or total rest on days off. The patients pace should be 7.5 to 12 weeks with the intermediate program and uses a higher intensity
8 minutes per mile. (faster running pace).
Mileage Schedule
To allow for soft tissue adaptation. The patient should run
every other day for 2 weeks, then a maximum of 5 days a TABLE 34-5 Mileage Table for Runners Below 4
week for the next 4 weeks. If the patient/runners previous Miles Per Session
level of training was less than 4 miles per session, the patient Day
should follow the mileage schedule indicated in Tables 34-5 1 2 3 4 5 6 7 Week
through 34-7.
Miles 1
2
1
2
1
2
1 1
1 1 2 2
TABLE 34-3 Timed Running 2 1 2 2 3 3
ScheduleIntermediate 2 3 3 4 3 4
Day 4 4 4 4 5
1 2 3 4 5 6 7 Week
Minutes 30 30 30 35 1
30 30 35 2
TABLE 34-6 Mileage Table for Runners Between
35 30 35 35 3
35 40 35 4 4 and 6 Miles Per Session
35 40 40 35 5 Day
40 40 40 6 1 2 3 4 5 6 7 Week
45 40 40 45 7
45 40 45 30 8* Miles 1 1 1 2 1
45 35 45 40 9 2 2 3 2
45 45 45 45 30 10 3 2 3 3 4 3
45 45 35 45 45 40 11 3 4 4 5 4 4
45 45 45 45 45 12 5 5 6 5 5
*Run multiple days in a row after 8 weeks. Note: Return to previous preinjury mileage level in 4-6 weeks.
TABLE 34-7 Mileage Table for Runners Between and ankle plantarflexor soreness). Although there is contro-
40 and 60 Miles Per Week versy surrounding these mechanics, it is an interesting
approach and may allow patients to run with less compres-
Day sive force on the skeletal system. Running shoes provide an
1 2 3 4 5 6 7 Week important barrier to environmental hazards (surface irregu-
larities, sharp objects, extreme hot/cold) and foot mechanic
Miles 2 2 2 3 1 deviations (e.g., over pronation). Further research is needed
3 3 4 2 to quantify the benefit to foot contact and the need for
4 3 4 4 5 3 running shoes.11,12
4 5 5 6 5 4
6 6 7 6 6 5
SUMMARY
Note: Return to preinjury mileage level in 4-6 weeks.
Many programs are available to clinicians to return their
patients to running. The progression and tables in this
chapter have been effective for me in successfully returning
patients to running. The clinician should continually evalu-
contact is on the forefoot instead of the heel. Mechanically, ate the patients mechanics and ensure that they are perform-
this make sense from a force distribution standpoint because ing their strength, flexibility, and balance program regularly
the ground forces acting on the lower extremity are deceler- and cross-training as appropriate. Mileage progression may
ated via eccentric dorsiflexion (using forefoot-gastrocnemius- vary depending on a number of factors (e.g., muscle sore-
soleus) versus heel strike, which absorbs and distributes the ness, level of fitness). Shoe wear is another factor to consider
forces through the calcaneus-tibia and deceleration happen- when returning to running. Assessments of show wear
ing at the knee. There is, however, a learning curve to adapt should be performed by qualified professional, with foot
to this type of training, which stresses the soft tissues (foot mechanics thoroughly evaluated and taken into account.
1 The patient has been progressing through the return to

running program and is pain free with activity. However,
the morning after completing phase II (plyometric
multiple days in a row. Describe for the patient
how increasing timed running periods should be
approached.
routine), the patient has tightness and pain in the Achil-
les tendon with the first several steps of the day. After Increase the timed session by 5 minutes after a day off,
walking around the house for a short period, the pain then decrease the timed session by 5 minutes the next
and tightness dissipates. What should the patient do for day, then take a day off. When running 3 days in a row,
activity that day? the timed sessions are built on the front end of the
sequence.
Take the day off, do gentle stretching, and ice the involved
area. The following day, the patient should repeat the
activity level from the previous attempt. 4 The patient has passed the balance baseline test. What
functional activities should be considered before the
patient begins a running progression?
2 The patient presents 3 months after partial hip labrum

resection and wishes to return to running activity. What
factors should be considered before he or she returns to
The patient must have normal ambulation and core
stability.
running?
He or she should be fully evaluated for adequate ROM/

flexibility, strength, and balance, making sure to focus
5 What is the importance of good core strength for a
runner?
on the whole body, not just the surgical site. It allows for the appropriate distribution of forces, leads
to the control and efficiency of movements, helps with
3 The patient is progressing through the timed running

schedule (phase IV) and is ready to start running
the absorption of ground impact forces, and decreases
compression forces.
6 Paul had a meniscus repair and was cleared to begin a

return to running program. He has made good progress
through phase I and initiated phase II, but after the
On reexamination it was found that his symptoms were
aggravated by tibial compression and rotation (suspi-
cious of a tear of the repair). Edema management tech-
second week he has delayed onset of pain and swelling niques were initiated, and he was referred back to his
in his knee. What should be considered? surgeon.
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runners: A 21-year longitudinal study. Arch Intern Med 168(15):1638- morphine.html.
1646, 2008. 9. Kawamoto J-E: Go ahead and jump: Using plyometric training to
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Williams, and Wilkins. magazine.ca/2010/06/sections/health-nutrition/body-work/
go-ahead-and-jump-using-plyometric-training-to-improve-running-
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10. Buist I, et al: The GRONORUN study: Is a graded training program
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for novice runners effective in preventing running related injuries?
function and injury. J Am Acad Orthop Surg 13(5):316-325, 2005.
Design of a randomized controlled trial. BMC Musculoskelet Disord
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8:24, 2007.
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jour/0103/mw.htm.
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INDEX
Page numbers followed by f indicate figures, t indicate tables, and b indicate boxes.
A Achilles tendon repair/rehabilitation Acromion
Abdominal bracing, 324-325 (Continued) accessory movements, application, 90
Abdominal breathing, 324 healing, stages, 563-564 anterior third, relationships, 28
Abdominal muscles, weakening/lengthening, immobilization, 564 lateral aspect, lateral portal (impact), 30f
343-344 guidelines, 564 Acromioplasty
Abdominals, core strength (development), 234 inflammatory response, 563 activities, restriction, 34
Abduction, prone position, 52f outcomes measurements, 564 anatomic etiologic factors, 28
Abductors, integrity, 544 percutaneous repair, 561 arthroscopic techniques, recommendations,
Acceleration technique, 561-562 30
football throwing motion, 241 phases, 564-567 cannula, usage, 30
phase characteristics, 565t-566t challenges/precautions, 31
humerus, internal rotation, 239, 242 polydioxanone suture (PDS) cord, pulling, clinical case review, 40-41
photographs, 244f 561-562 complications, monitoring, 38
throwing/pitching motion, 238 postoperative internal structure, changes, 563 considerations, 28-29
Accessory movements, application, 90 postoperative management, 564 contractile tissue, loading, 38
Acetabulum, exposure, 367f postsurgical patient, home maintenance, evaluation, 32-38
Achilles paratenon, blood vessels (diagram), 555f 573b-574b phases, 32-38
Achilles tendon preoperative treatment, 561 exercises
acute rupture, diagnosis, 556-559 proliferation, 563 assessment, EMG (usage), 34
blood/nutrient supply, sources, 554 protective splint/boot, usage, 570f combinations, usage, 37
cast immobilization, prolongation, 560 reconstruction, 560 dose, appropriateness, 38
early range of motion, allowance, 560 rehabilitation extrinsic/extratendinous etiologic factors, 28
forces, increase, 556f therapy guidelines, 562-572 Hawkins-Kennedy sign, 29
healing, stages, 563-564 timelines, phases, 562f immobilization, 34
intratendinous vessels, 555f remobilization, 564 impingement syndrome, diagnosis/
magnetic resonance imaging (MRI) guidelines, 564 evaluation, 28-29
evaluation, 6f remodeling/maturation, 563-564 inflammation/pain, control, 32
nonoperative management, operative repair, 559-560, 563 inflow pressure pump (Davol), usage, 30
management (contrast), 559 augmentation, 560 lateral portal visualization, arthroscope
nutrient branches, emanation, 554 concepts, 560 (insertion), 30-31
pain/swelling, symptoms, 565-567 reunion process, T2 weighted MRI, 563f magnetic resonance imaging (MRI), 29
peritendinous structures, 554 strength training program, 568 modified Kiblers lateral scapular slide test,
repair success, 567 37b
early motion phases, characteristics, surgery, performing, 561 multiplanar work, 36
568t-572t surgical indications/considerations, 554-559 muscles, isolation, 36
traditional rehabilitation, 565t-566t surgical procedure, 559-562 Neer impingement sign, 29
repair, status (assessment), 556-557 surgical technique, 561-562 outcomes, 31
distribution, 558t Achilles tendon ruptures patient-controlled analgesia (PCA), 30
reruptures, rarity, 572 acute care, 559 phases, 33t, 35t, 38t
synovial sheath, absence, 554 increase, 556 progression, 37
tears, internal fixation, 560 Krackow modified suture technique, 560 physical examination, 29
Thompson test, 556-557 nonoperative options, 559 physical therapy evaluation, components, 32b
tissue healing, phases, 562f patients, age distribution, 557f portal placement, importance, 30
Achilles tendon injuries, 555 reconstruction, 560 posterior portal, usage, 30
epidemiology, 556 recreational sport activity, role, 557f postsurgical patient, home maintenance, 38
occurrence, 554 reunion process, T2 weighted MRI, 563f goals, 39b
pathogenesis, 554-555 suffering, 556 proprioception, physical therapist analysis, 38
Achilles tendon repair/rehabilitation surgical repair, postoperative rehabilitation, radiographic evaluation, 29
anatomy, 554 565 rehabilitation
augmentation procedures, evolution, 560 treatment, 559 concerns, surgeon perspective, 31
clinical case review, 575-576 watershed area, 556-557 therapy guidelines, 31-38
complications, 562 Acromioclavicular (AC) joint, 28, 90-91 ROM efforts, continuation, 37
early motion assessment, 31 scaption
guidelines, 567 pain, complaints, 90 external rotation, 36f
phases, 567-568, 570-572 Acromioclavicular (AC) mobilization, internal rotation, 34f
postoperative rehabilitation, 567 posteroanterior (PA) movement, 83f scapular stabilizers, requirements, 37
628
INDEX 629
Acromioplasty (Continued) Ankle arthroscopy (Continued) Ankles

scapulohumeral rhythm, observation, 37 blood tests, 536 circles, avoidance, 369
scapulothoracic concerns, 38 cardiovascular fitness, maintenance, 546 joint mobilizations, resistance, 527
soft tissues chronic ankle pain, primary cause, 539 joint ROM, increase, 545
closure, 31 clinical case review, 551-552 movements, alteration, 498
healing, protection, 32-34 complications, 540 proprioceptive neuromuscular facilitation
surgical failures, causes, 31 occurrence, 549-550 patterns, 543
surgical indications, 28-29 contralateral kicks, 548f pumping exercises, 341
consideration, 29 distraction device, necessity, 539 pumps, 368f
surgical procedure, 29-31 early rehabilitation (phase II), 543-546 assignation, 543
synovial resector, usage, 30 four-square hopping ankle rehabilitation, soft tissue impingement, 541f
therapeutic activities, 31 550f Ankles, lateral ligament repair
troubleshooting, 38-39 gait, restoration, 545 AROM, performance, 510
warm-up activities, usage, 34 inclined surfaces, proprioceptive training, arthroscopy, preparation, 505-506
Active-assisted range of motion (AAROM), 549f balance board exercise, 513f
usage, 47 inflammation/pain, decrease, 544-545 balance training, basketball (usage), 514f
Active cervical ROM, 269f initial postoperative examination, 543 calcaneal hole, drilling, 508f
Active finger flexion, 198-199 joint mobilization, 545 calcaneo-fibular ligament (CFL) cut, 508f
addition, 211 joint ROM, increase, 545 carioca, 513f
Active flexion lateral ankle pain, sequence, 540f challenges, 509
assessment, 198 medical examination, 536 clinical case review, 515-518
improvement, absence, 200 normalized ROM, restoration, 547 completed construct, 508f
initiation, 198-199 operative indications, 536 controlled action motion (CAM) walker,
Active flexor tendon gliding exercises, 199f osteochondral lesions, 539-540 usage, 509-510
Active hip abduction, 399f pain/swelling, alleviation, 546-547 fibular hole, exit, 507f
Active hip adduction, 399f patient evaluation, 536 gait limits, 511
Active hip flexion, 368 patient knowledge/awareness, increase, 536 graft, fixation, 507f
Active range of motion (AROM) phases, 543-549 injury, anatomy/mechanism, 504
assessment, 53 characteristics, 543t-544t, 547t-548t intraarticular pathology, identification, 505
initiation, 54 phonophoresis/iontophoresis, 545 mobility, importance, 504
measurement, 48-49, 221 positioning, 537 modified Brostrm procedure, 505-506
prevention, 47 postoperative plan, 539 ATFLs/CFLs, pants-over-vest fashion, 506f
support, 106 postoperative splint, 540 modified Brostrm reconstruction, 506f
wrist median nerve glide, 223f preoperative phase, 542-543 passing device, placement, 507f
Active wrist flexion exercises, addition, 227 proprioception phases, 509-513
Active wrist ROM, promotion, 160 improvement, 547 characteristics, 510t-512t
Acute Achilles tendon rupture increase, 546 postsurgical patient, home maintenance, 513,
diagnosis, 556-559 radiographs, usage, 536 514b-515b
Krackow modified suture technique, 560 rehabilitation, therapy guidelines, 540-549 precautions/contraindications, 509
Acute carpal tunnel syndrome, 216 right ankle reconstruction indications, 504
Adductor flexibility, importance, 302f arthroscopic surgery, 539f rehabilitation
Adenosine diphosphate (ADP), 171 talus, medial osteochondral lesion concerns, 509
Adenosine triphosphate (ATP), 171 (transmalleolar drilling), 539f evaluation, 509
Adhesion formation, 560 setup, 537f therapy guidelines, 509-513
Adolescent patient, herniated nucleus pulposus soft tissue flexibility, restoration, 545 ROM limits, 511
(HNP), 289 soft tissue management, 539 step-ups, 514f
complications, 289-290 sport specificity (phase IV), 547-549 surgical indications/considerations, 504-505
Advanced intermedullary nailing techniques, strength surgical outcomes, 508
usage, 384 improvement, 547 surgical procedures, 505-508
Adverse neural tension, 90 increase, 545-546 Telos device, inversion stress testing, 505f
Aerobic conditioning, 238 surgical indications/contraindications, 536 trampoline stork standing, 513f
exercises, 238b list, 537b troubleshooting, 513-514
Agility drills, 609f surgical outcomes, 540 tunnels
Albee, Fred, 313 surgical technique, 536-539 creation, 507f
All-inside arthroscopic repair, 441 talus location, 507f
All-inside meniscal repair, 442 calcaneus, medial glide, 545f Ankles, open reduction/internal fixation (ankle
accomplishment, 442 osteochondral lesion, treatment, 542f ORIF)
Alternating-height box jumps, 238 troubleshooting, 549-550 anatomic reduction, postoperative
Anconeus, elbow extension, 157 Ankle fractures, 520 radiographs, 525f
Angiogenesis, granulation phase, 3f bimalleolar ankle fracture, 525f anesthesia/positioning, 522
Ankle arthroscopy conservative treatment, 520 arthroscopic evaluation, 522
absolute contraindications, 536 Danis-Weber classification systems, 521f bimalleolar ankle fracture, 525f
acute phase (phase I), 543 Lauge-Hansen classification system, 521f clinical case review, 531-534
advanced rehabilitation (phase III), 546-547 site, incision, 523 complications, 526
anterior arthroscopic ankle portals, 538f treatment, functional results, 522 compressive stocking, usefulness, 527-528
anterolateral soft tissue impingement, sagittal Ankle lateral ligament repair (ALRR) evaluation, 526
T-1 weighted MRI, 539f anatomic hamstring reconstruction fracture
anteromedial portal, establishment, 537 procedure, 506-508 healing, 529
AROM/PROM, 543 anterior talofibular ligament (ATFL) arm, reduction, 523f
arthroscopic examination, 537-539 506-508 incisions, 522
arthroscopic portal placement, 537 calcaneo-fibular ligament (CFL) arm, interfragmentary compression, lag screw
balance improvement, 547 506-508 (usage), 524f
630 INDEX
Ankles, open reduction/internal fixation (ankle Anterior capsular reconstruction (Continued) Anterior capsular reconstruction (Continued)
ORIF) (Continued) introduction, 44 through-range external/internal rotation,
jumping/running, avoidance, 527 isokinetic strength measurement, 62 resistance bands (usage), 55
pain/swelling, reduction, 528-529 isometric shoulder internal rotation, 52f tissue quality, misapprehension, 62
parallel guide (confirmation), intraoperative latissimus dorsi, strengthening, 59 tissue remodeling, continuation, 59
fluoroscopy (usage), 522f lower trapezius muscle strength/endurance, treatment, response, 44-45
patient evaluation, 521 progression, 57 triceps, strengthening, 59
phases, 526-530 manual muscle testing, 53 troubleshooting, 62-69
characteristics, 527t-530t mechanics, 69 upper body ergometer (UBE), usage, 55
plyometric exercises, impact, 529-530 middle trapezius muscle strength/endurance, wall slide overhead exercise, 56f
postoperative considerations, 526 progression, 57 Anterior capsulectomy, 366f
postoperative plan, 524-525 nighttime discomfort, 53 Anterior capsulolabral reconstruction (ACLR),
postoperative radiographs, 524f open procedure, 46 45
postsurgical patient, home maintenance, 530, open stabilization, 45 Anterior cervical discectomy/fusion (ACDF)
531b open surgery, 46 active cervical ROM, 269f
precautions, 530 open surgical stabilization, 47 anterior cervical plate/screws, 259f
preoperative assessment, 521 pain management modalities, 47 blood pressure cuff technique, 268f
preoperative variables, 520 passive range of motion (PROM), 47 bony spur formation, preoperative lateral
procedure, 522-524 pectoral muscles, strengthening, 59 radiograph, 257f
rehabilitation periscapular muscles, restriction, 69 cervical classification, 275-276
therapy guidelines, 526 phases, 48t, 50t, 54t, 57t, 60t, 62t cervical proprioception, 271-273
residual problems, 530 physical therapy, goal, 55 improvement, exercises/progressions, 273t
right fracture, lateral malleolus fracture, 523f pike press, 60f-61f cervical spine
surgery, patient splinting, 524 plank exercise, 55f bracing, 276
surgical indications/considerations, 520 plyometrics, importance, 62 mobilization, surgeon (authorization),
surgical outcomes, 525-526 positional requirements, consideration, 59 268-269
surgical procedures, 521-526 posterior capsule tightness, 51-52 cervical stability, 265-267
surgical technique, 521-525 posterior shoulder pain, 62 chin tucks, 268f
syndesmosis screws, insertion, 525 posterior shoulder soft tissue restriction, chronic pain, 277
trimalleolar fracture, 524 51-52 clinical case review, 278-280
troubleshooting, 530 postsurgical patient, home exercise program, corner stretch, 265f
Weber B fracture, occurrence, 522 49b craniocervical region joints, movement
Weber C fracture-dislocation, 523f prone full can exercise, 59f planes (ROM), 270t
Antalgic walk, 283 prone horizontal abduction, 54 C5-6 motion segment, fusion, 268
Anterior acromion, osteotomy, 76 prone row exercise, 56f C6-7 disc degeneration, preoperative sagittal
Anterior brachium (major elbow flexor external rotation, 59f MRI, 257f
innervation), musculocutaneous nerve proprioceptive neuromuscular facilitation C6-7 fusion, postoperative lateral radiograph,
(impact), 146 (PNF) 259f
Anterior capsular reconstruction continuation, 59 deep cervical flexors (strengthening/
active-assisted range of motion (AAROM), interventions, 47 retraining), blood pressure cuff (usage),
usage, 47 range of motion, insufficiency, 62-68 269b
active range of motion (AROM) rehabilitation dysphagia, 276
assessment, 53 phases, 47-62 esophageal injury, 276
prevention, 47 programs, 63b-69b extension exercise, 275f
active scapular mobility, 47 therapy guidelines, 47-62 fusion site, motion (excess), 262
adjunctive procedures, usage, 46 throwing program, 63b-64b future, 259-260
anterior axillary approach, 46 Remplissage procedure, 46 graft failure, 276-277
anterior glenoid, rasping/decortication, 46 rotator cuff exercises, 57-59 head awareness problems, symptoms,
anterior-posterior directions, grade II manual rotator cuff muscles, eccentric control 272-273
GH mobilizations, 52 (achievement), 61 history/physical examination, 256-257
anterior shoulder pain, 62 scapular anterior tipping/winging, 68-69 indications, 258b
arthroscopic procedure, 45-46 scapular positioning infection, 276
arthroscopic treatment, contraindications, 46 achievement/maintenance, 51 inflammation phase (phase I), 261
arthroscopy, invasiveness, 45 assessment, 47 duration, 263
Bankart lesion, observation, 46 scapulothoracic/scapulohumeral rhythm, instrumentation, usage (rationale), 262-276
biceps, strengthening, 59 53 intraoperative photo, 259f
break testing, performing, 55 serratus anterior muscle joint mobilization, 267-269
capsular closure, 46 function, 53 joint position sense retraining exercise, 272f
capsular tissue, progression, 55 strength, advancement, 59-61 longus colli muscles
cephalad/caudad directions, grade II manual serratus dynamic hug, 56f dissection, 258-259
GH mobilizations, 52 serratus press, 51f partial resection, 265-267
clinical case review, 70-71 serratus punch, 58f midthoracic spine, mobilization, 267
cross-body stretch, 53f shoulder instability, 44 neck awareness problems, symptoms,
deltoid muscles, strengthening, 59 classification, 45b 272-273
diagnostic arthroscopy, usage, 45-46 sleeper stretch exercise, 56f neck movement control exercise, 273f
discussion, 46-47 sports-specific activities, consideration, 59 nerve-related symptoms, 270
eccentric external rotation, 61f stability ball walk-out, 60f nerves, movement, 261
etiology/evaluation, 44-45 stabilization techniques, expansion, 46 neural injury, 276
functional mobility, initiation, 53 strength/endurance, 68-69 neural mobilization/dynamics, 269-271
healing tissue, advancement, 53 stretching considerations, 69 neurons, division/migration (inability), 261
home exercise program, initiation, 47 subscapularis muscle, dissection, 46 outcomes, 259
horizontal abduction, 52f surgical considerations, 45 pathophysiology/clinical evaluation, 256-257
INDEX 631
Anterior cervical discectomy/fusion (ACDF) Anterior cruciate ligament (ACL) Anterior cruciate ligament (ACL)
(Continued) reconstruction (Continued) reconstruction (Continued)
phases, 261-262 arthrofibrosis, 418 surgical indications/considerations, 404-407
characteristics, 263t-264t, 266t, 274t-275t balance exercises, 414 surgical procedure, 407-408
physical therapy, mobilization techniques, biologic grafts, usage, 405 timing, 405
268-269 bone-patella-tendon-bone (BPTB) autograft, tourniquet, release, 408
postoperative lateral radiograph, 259f usage, 405 treatment options, 405
postsurgical patient, home maintenance, cellular proliferation, 407 troubleshooting, 418-419
277b-278b clinical case review, 420-422 phases, 419
postural rehabilitation, 265 closed kinetic chain (CKC) exercises, 411-412 Anterior cruciate ligament (ACL) replacement,
presurgical strength/endurance, regaining, initiation, isometrics (usage), 411-412 surgical techniques, 405
275 collagen formation, 407 Anterior cruciate ligament (ACL) resection, 407
problems, 276 complications, treatment, 419 Anterior femoral osteotomies, 484f
progressive resistance exercise (PRE) phases, 419 Anterior knee pain, 418-419
program, initiation, 267 dynamic single-leg stance exercises, 414 Anterior lumbar interbody fusion (ALIF), 315
prone scapular retraction progression, 274f endoscopic bone-patella tendon-bone Anteriorly translated humeral head, assessment,
rehabilitation complex anterior cruciate ligament 55
description, 262-276 reconstruction, 407-408 Anterior oblique bundle, 156
inflammatory phase (phase I), 262-264 extension range of motion, mobilization Anterior shoulder instability, management,
phases, 262-273 (usage), 411f 46-47
physical evaluation, 263 femoral bone plug, sutures (insertion), 408 Anterior shoulder pain, 62
remodeling phase (phase IIIa), 265-273 femoral isometric point, determination, assessment, 55
reparative phase (phase II), 264-265 407-408 Anterior shoulder structures, stretching
therapy guidelines, 260-262 graft fixation, 406 (avoidance), 69
remodeling phase (phase III), 262 graft maturation, 406-407 Anterior spine, operative dissection, 337f
surgical site, protection, 265 process, initiation, 406 Anterior talofibular ligament (ATFL)
reparative phase (phase II), 261-262 graft selection, 405-406 bone bridge, increase, 506-508
rehabilitation process, 264-265 variation, 406 identification, 505
shoulder motion, avoidance, 264-265 inclined sled, 412f Anterior total hip arthroplasty, rehabilitation,
right-sided disc herniation, preoperative axial intrarater within-session reliability, 417 380
MRI, 258f knee extension exercises, 411t Anterocentral portal, avoidance, 538f
scapular retractions, resistance tubing knee flexion exercises, 411t Anteroinferior iliac spine (AIIS), palpation, 383
(usage), 274f muscular power, building, 414 Anterolateral soft tissue, arthroscopic treatment,
self-neurogliding techniques, 272f neuromuscular electrical stimulation 539
soft tissue structures, mobilization, 271 (NMES), usage, 412 Arcade of Struthers, 157-158
strengthening program, glenohumeral open kinetic chain (OKC) Arm and leg drop, 621f
elevation (relationship), 267 hamstrings, 412 Arms, warm-up exercises, 236
surgery quadriceps strengthening, 411-412 Arm upper body ergometer (UBE), light
discharge instructions, 264b pain/edema control, TENS (usage), 409 resistance (usage), 107
initiation, 258 passive knee extension, 411f Arthritides, 579
surgical indications, 257-258 patella Arthrofibrosis, 418
surgical procedure, 258-259 BTB graft, removal, 408f Arthrofibrotic knee, stages, 418
surgical treatment, dependence, 257-258 tendon, exposure, 407f Arthroscope, insertion, 30-31
thoracic spine patellofemoral (PF) pain, occurrence, 418 Arthroscopic-assisted miniopen rotator cuff
musculature, challenge, 273-275 phases, 409-418 repair, results, 77
segments, flexibility (decrease), 267 characteristics, 410t, 413t, 416t Arthroscopic examination, 537-539
treatment, 257-258 portable NMES units, 413 Arthroscopic inside-out repair, 441
ULNT, usage, 270 postsurgical patient, home maintenance, Arthroscopic lateral release, SCOI technique,
troubleshooting, 276-277 419b-420b 429
upper crossed syndrome, 265 preoperative anterior cruciate ligament Arthroscopic lateral retinaculum release
musculature, imbalance, 267f reconstruction, phase characteristics, (ALRR)
upper limb neurodynamic test (ULNT), 270 409t activity-specific exercises, 434
positions, 271t preoperative management, 408-409 acute phase, 430
treatments, 270 prone heel hangs, 410f adaptation, chronic compression, 427
ULNT 1 technique, 270f quadriceps strength, increase, 411 advanced phase, 432-434
ULNT 1 testing procedure, 271b quadriceps strengthening, early initiation, clinical case review, 438-439
vascular complications, 276 411 closed-chain lunge, 433f
wall angels, 268f rehabilitation closed-chain step-down, 435f
Anterior cruciate ligament (ACL) injuries, 4 phase dissection, 409 closed-chain wall slide, 434f
brace/crutches, usage/discharge guidelines, physical therapy guidelines, 408-418 closed kinetic chain progression,
410t repetition maximum (RM), 414 components, 433-434
cause/epidemiologic factors, 404-405 ROM, increase, 408-409 electrical stimulation (ES), usage, 432
feeling, description, 404 running program, 416b glide component, 429
occurrence, 404 side-to-side strength, 418 heat application, contraindication, 432
physiologic risk factors, 404-405 single-limb balance, elastic band (usage), 415f lateral soft tissue structures, unloading, 431f
positive results, 414 single-limb balance, medicine ball (usage), McConnell patellofemoral taping, selection,
Anterior cruciate ligament (ACL) 416f 432
reconstruction, 19 single-limb balance, terminal extension, 415f McConnell taping procedures, 429
activity/sport, return, 417 skater, single-limb balance, 416f patella glide, 428f
collaborative decision, 417 spider killers, 412f patella rotation, 428f
anatomic/physiologic risk factors, 404-405 step up and down exercise, 415f patella tilt, 428f
anterior knee pain, 418-419 strength training, 413-414 patellofemoral tape-weaning protocol, 436
632 INDEX
Arthroscopic lateral retinaculum release Autologous chondrocyte implantation (ACI) Baseline balance test, 617
(ALRR) (Continued) (Continued) Basic fibroblastic growth factor (bFGF), 171
patellofemoral taping, 428-429 plain radiographs, usage, 457 Basketball, usage (balance training), 514f
phases, 430-434 positive air pressure treadmills, usage, 466f Biceps, strengthening, 59
postoperative rehabilitation, 429 postoperative management, 459 Biceps tendon tendonitis, 139
postsurgical patient, home maintenance, complications, 459 Bicompartmental arthroplasty, 481
436b-437b postoperative rehabilitation, 461-467 Bicompartmental resurfacing, 480-481
postural alignment, 434-436 postsurgical patient, home maintenance, Bilateral tiptoes, 397f
quadriceps inhibition, 436 467-468 Bimalleolar ankle fracture, 525f
rehabilitation preoperative considerations, 457-458 Biologic ACL graft, fixation, 406
therapy guidelines, 430-434 diagnostic imaging, 457 Biologic grafts, usage, 405
SCOI experience, 429-430 history/clinical symptoms, 457 Biologic treatment approaches, 12-13
self-mobilization, 437f indications/contraindications, 458 Blood pressure cuff technique, 268f
skill-specific training, 435f preoperative management, 461 Body Blade, usage, 85, 181f
stabilization taping, 431f preoperative patient counseling, 458 Body mechanics, 295
strengthening, 432 progressive weight bearing (PWB), 460-461 training, 320-328
subacute phase, 430-432 assessment/education/reinforcement, 462f Body posture (evaluation), single-leg step
surgical indications/considerations, 427-429 proprioception, enhancement, 460-461 (usage), 465f
surgical procedure, 429-430 recovery/protection (phase I), 461-463 Bone-patella-tendon-bone (BPTB) autograft,
tilt component, 429 characteristics, 462t usage, 405
tilt compression, 427 rehabilitation, 467 Bone plugs
troubleshooting, 434-436 guidelines, information, 463 compression, 406
Arthroscopic outside-in repair, 441 problems, 467 incorporation, 407
Arthroscopic portal placement, 537 program, elements, 460 Bones
Arthroscopic rotator cuff repair, 76 program, goal, 460 cell types, 10
Arthroscopic treatment, contraindications, 46 therapy guidelines, 460-461 composite, 10
Arthrotomy incisions, nonabsorbable sutures remodeling (phase III), 465-466 fractures, internal fixation (impact), 560
(wound closure), 486f characteristic, 465t graft
Artificial disc replacement, goal/advantages, 336 ROM exercises, progression, 463 necessity, 588f
Athletes, goals, 603-604 ROM restoration, 460-461 usage, 590
Atrophic nonunions, 12 sandwich technique, 459 hard callus stage, 11
Autologous chondrocyte implantation (ACI) scaffold-associated second generation ACI healing, 10-12
absolute contraindications, 458 techniques, three-dimensional fracture stability, 11t
body posture (evaluation), single-leg steps biodegradable scaffolds (usage), 460 inflammation period, 11
(usage), 465f single-leg steps, usage, 465f injury, 10-12
chondrocyte harvest, 458 strength, enhancement, 460-461 morphology, 10
chondrocyte harvesting, 458 surgery, summary, 460 remodeling, continuation, 329
chondrocyte implantation, 458-459 surgical problems, 459-460 removal, 584f-585f
adjuvant procedures, 458 surgical technique, 458-459 right femur, radiographs, 10f
clinical gait analysis, usefulness, 466f tibiofemoral joint repairs, side-lying clam soft callus stage, 11
clinical symptoms, 457 exercise (usage), 464f structural fracture healing, 11f
continuous passive motion (CPM), impact, transition (phase II), 463-465 Bone-to-bone (BTB) graft, removal, 408f
462 characteristics, 464t Bony skeleton, ligament connection, 2
deep chondral defects, 459 trochlea defects, 461, 463 Bony spur, preoperative lateral radiograph, 257f
defect troubleshooting, 468 Bony structures, 155-156
articulation location/range, 458f Avascular necrosis, resurfacing arthroplasty Bony surfaces
cambium layer, direction, 459 (usage), 363f cleansing, 485
diagnostic imaging, 457 longitudinal stroke, 23f
diagnostic joint arthroscopy, 458 B Boston Carpal Tunnel Scales, 222
exercises, maintenance program, 465-466 BAK interbody cage device, 316f Bosu ball
femoral condyle Balance activities, exercise ball (usage), 325f squats, 189f
articular cartilage defect, 459f Balance board exercise, 513f usage, 185f
defects, 461-462 Balance disk, usage, 185f Bowstringing, prevention, 221
gluteal muscle exercises, 464f Balance exercises, 414 Box jumps, 608f
heel slides, crepe bandage donut (usage), 463f Balance improvement, 547 performing, 237-238
history, 457 Balance proprioceptive training, relationship, Bracing, marching (combination), 325f
collection, importance, 457 447 Break testing, performing, 55
indications/contraindications, 458 Balance retraining program, 398 Bridge, stability problem, 618f
initial evaluation, 461 Balance training, basketball (usage), 514f Bridging exercise, 301f
maturation (phase IV), 466-467 Ball, diving movement, 305f Brostrm-Evans procedure, usage, 508
characteristics, 467t Baltimore Therapeutic Equipment work Bunionectomies
mechanical complications, 468 stimulator, usage, 121f bone healing, delay, 590
muscle control, enhancement, 460-461 Bankart lesion, observation, 46 bunion deformities, causes, 579
neuromuscular control (evaluation), Baseball cheilectomy procedure, 584f
single-leg steps (usage), 465f gripping technique, 243f complications, 589-590
osteochondral defects, 459 interval baseball throwing program, 243-246 definitions, 579
patella pattern throwing, kneeling position, 248f deformity, weight-bearing anteroposterior
defects, 461, 463 pitch, phases, 239f radiograph, 580f
mobilizations, education, 463f release technique, 243f disuse atrophy/weakness, impact, 592
patellofemoral joint repairs, hip hike exercise Baseball pitching, 238-241 dorsiflexion, non-weight bearing instrument
(usage), 464f stance foot, position (importance), 238 (usage), 580f
physical examination, 457 stride forward, initiation, 239 etiologies, 579
INDEX 633
Bunionectomies (Continued) Bunionectomies (Continued) Carpal tunnel release (CTS) (Continued)

first metatarsal postoperative weight-bearing radiograph, local edema (decrease), iontophoresis (usage),
line, bisection, 593f 586f 224
medial aspect, intraoperative photograph, sesamoid bones, weight-bearing plantar axial local median nerve glide/stretch, 223f
586f radiograph, 581f Michigan Hand Outcomes Questionnaire,
first metatarsal phalangeal joint (first MTPJ) soft tissue rebalancing, surgical procedure, 222
primary fusion, postoperative weight- 589 monofilament interpretation, 222f
bearing radiograph, 587f strengthening program, progression, 593 nerve-gliding exercises, 217
ROM, limitation, 590 structural malalignment, 579 onset, classification, 216
fixation, completion, 589 superficial nerves, nerve entrapment, patient functional status, documentation, 222
full-weight bearing without precaution phase 597-598 phases, 224t-225t, 227t, 229t
(phase III), 597 surgical correction, indications/ physical therapy treatments, 217
hallux abductus, bunion deformity, 580f considerations, 579-581 postoperative dressing, 223
preoperative anteroposterior weight- surgical procedures, 581-589 postoperative evaluation, 221-222
bearing radiograph, 585f, 588f categories, 581 postoperative rehabilitation, 220-229
hallux interphalangeal joint, abductus surgical site postoperative splinting, 222
abnormality (preoperative weight- chronic edema, 590 postsurgical patient, home maintenance, 229,
bearing radiograph), 586f monitoring, 592 230b
hallux toe purchase, absence, 590 symmetric ankle dorsiflexion, 593 rehabilitation
hemi type metallic joint prosthesis, 583f therapy guidelines, 591-597 inflammatory phase (phase I), 223
initial full-weight bearing phase (phase IIb), tibia (posterior aspects), ball (usage), 600f phases, 223-229
593 treatment plan, development, 590-591 proliferation phase (phase II), 226-229
initial postoperative examination, 591 troubleshooting, 597-598 therapy guidelines, 220-229
initial preoperative examination, 592b wedge self first metatarsal phalangeal joint remodeling/maturation phase (phase III), 229
inverted L capsulotomy, 589 dorsiflexion stretch, 599f residual symptoms, 220
left lower extremity step down, end position, scar
597f C evaluation, 222
lesser toes, hallux separation, 590 Calcaneo-fibular ligament (CFL) arm, 506-508 massage, initiation, 226f
lower extremity, strengthening, 593 Calcaneus self-reported CTS, prevalence, 216
lunge stretch, heel maintenance, 597f lateral glide, 545f sensibility testing, 221
medial foot loading, quality/quantity medial glide, 545f significance, 216
(monitoring), 593 Calcium hydroxyapatite, 10 splinting, 217
medial forefoot plantar loading, 600f Calf raise, single-leg hop progression, 620 surgery
metatarsal head level, decompressional Calf stretches, 398 complications, 219-220
osteotomy, 585f Callus formation, radiographic evidence, failure, 220
metatarsal head osteotomy, surgical 268-269 surgical incision, evaluation, 222
procedure, 589 Capsular closure, 46 surgical indications/considerations, 216-218
metatarsal osteotomy, postoperative Capsular tissue, progression, 55 symptoms, 217
radiograph, 583f Cardiovascular capacity, improvement, 544-545 early return, 220
metatarsal phalangeal joint, dorsal/medial Cardiovascular conditioning, 297-298, 302, late recurrences, 220
aspects (intraoperative photograph), 305-306 transverse carpal ligament, exposure, 218f
582f weight loss adjunct, 488 wrists, splinting, 220
non-weight bearing phase (phase I), Cardiovascular exercise, importance, 398 yoga, 217
591-592 Cardiovascular fitness, maintenance, 546 Cartilage atrophy, 560
osteotomy, performing, 590 Carioca, 513f Catchers, rehabilitation program, 65b
outcome, 591 Carpal bone mobilization, 217 Cauda equina syndrome, 289
partial weight bearing phase (phase IIa), anatomic structure, visualization, 217-218 Cellular proliferation, 406-407
592-593 corticosteroid, local injection, 217f Cellular scar, development, 4
pathology, 589 pain, onset, 217 Central nervous system, changes (occurrence),
patients, compliance, 590-591 pillar pain, 220 355
phases, 591-593, 597 surgical procedure, 218-220 Cervical classification, 275-276
physical therapy, considerations, 590-591 Carpal canal Cervical disc disease, ACDF (indications),
preoperative anteroposterior weight-bearing contents, exposure, 219f 258b
radiograph, paper template exposure, incision (usage), 218f Cervical myelopathy, gait abnormalities/
(construction), 588f Carpal tunnel release (CTS) hyperreflexia, 256
preoperative considerations, 591 active range of motion measurements, 221 Cervical pathology patterns, 89
proprioception training, 593 association, 216-217 Cervical proprioception, 271-273
propulsion, simulation (lateral preoperative Boston Carpal Tunnel Scales, 222 improvement, exercises/progressions, 273t
radiograph), 584f carpal bone mobilization, 217 Cervical radiculopathy, presentation, 256
propulsive gait, dorsiflexion (requirement), causes, 216-218 Cervical range of motion, assessment, 263
580f clinical case review, 230-231 Cervical spine
rehabilitation cryotherapy, administration, 224 bracing, ACSD, 276
phases, characteristics, 594t-596t, 598t DASH, 222 mobilization, surgeon authorization, 268-269
therapy guidelines, 591-597 deep pulsed ultrasound, 217 neutral cervical spine, 263f
resectional arthroplasty (Keller) diagnosis, 217 operation, decision, 260
bunionectomy, 584f discrimination values, 222 Cervical spine, evaluation, 89
right lower extremity endoscopic techniques, 219 Cervical spondylosis, 256
lunge stretch, 599f ergonomics, 217 clinical presentation, variation, 256
starting position, 597f recommendations, 229 Cervical stability, 265-267
ROM limitations, 591-592 grip strength, recordation, 222 Chair, exiting (instruction), 320f
SCARF procedure impact, 216 Charnley, John, 380
comparison, 591 limited open palm technique, 219 Chin tucks, 268f
634 INDEX
Chondral repair tissue quality (increase), Connective tissue (Continued) Crow hop drill (foot placement drill), 246-249
continuous passive motion (usage), 462 fascial planes, splaying/longitudinal front view, 249f
Chondrocyte implantation, indication, 462 separation, 22f Crow hop throwing technique, 225
Chondrocyte transplantation, 540 ground substance, 16 Crutches, non-weight bearing, 539
Chrisman-Snook procedure, 508 purposes, 18 Cryocuff, usage, 32
Chronic ankle pain, primary cause, 539 histology, 15-18 Cryotherapy, usage, 166
Chronic carpal tunnel syndrome, 216 immobilization, 18-19 Cyriax, James, 23
result, 216 impact, 18-20 C5-6 motion segment, fusion, 268
Chronic low back pain, surgical treatment, immobilized scar tissue, haystack C6-7 disc degeneration, preoperative sagittal
340-341 arrangement, 19f MRI, 257f
Chronic muscle strains, occurrence, 8 impact, 183
Chronic pain inert connective tissue, 15 D
ACSD, 277 interstitial mechanoreceptors, manual Danis-Weber classification system, 521f
factors, 355b stimulation, 18 Deceleration
Chronic patella tilting, 427 joints, fixation (biomechanical analysis), 19 football throwing motion, 241
Circumferential fusion, pedicle screw macroadhesions, formation, 19 phase, photographs, 240f-241f, 245f
instrumentation (anterior interbody cage), mobility work, goals, 20-21 throwing/pitching motion, 238
316f mobilization Decline squat examples, 189f
Circumferential lumbar fusion, pedicle screw principles, 21-22 Deep cervical flexors (strengthening/retraining),
instrumentation, 314f techniques, 22-23 blood pressure cuff (usage), 269b
Circumferential measurements, 221 muscles Deep cervical muscles, necessity, 265-267
Citrate, binding, 172-173 balancing, 23 Deep chondral defects, 459
Clavicle, accessory movements (application), 90 splay, 22 Deep pulsed ultrasound, 217
Clinical gait analysis, usefulness, 466f plastic deformation (creep), 21 Deep transverse tissue massage (DTFM), 178
Clock reach, 136f pliability, increase, 23 effects, 178b
Closed-chain lunge, 433f postsurgical rehabilitation, 23 Deep venous thrombosis (DVT), 496, 560
Closed-chain progression, 624t principle of short and long, 21-22 clinical decision rule (CDR), 496
Closed-chain step-down, 435f remobilization, 19 complication, 488-489
Closed-chain wall slide, 434f impact, 18-20 history, 482
Closed kinetic chain (CKC) Ruffini mechanoreceptors, manual Homans sign, 496
balance disk, usage, 185f stimulation, 18 Degenerative arthritis, 560
exercises, 411 scar tissue formation, phases, 19-20 Degenerative cascade, 314t
examples, 605f shoulder, postural/phasic muscles Delayed onset muscle soreness (DOMS), 8
progression, components, 433-434 classification, 23t Delta ceramic head, placement/reduction, 380f
sets/bridges, usage, 412 soft tissues, contractile characteristics, 21 Deltoid muscles, strengthening, 59
Coagulation phase, epithelial tissue, 2 surgical perspective, 20 Deltopectoral interval, 119
Cobras, medial/lateral retraction, 376-377 three-dimensionality, 21 exposure, 119
Collagen transverse muscle bending, 22 Dense irregular connective tissue, 16-17
fibrils, remodeling/maturation, 563-564 trauma, 19-20 collagen fibers, arrangement, 16f
formation/remodeling/maturation, 406-407 impact, 18-20 Dense regular connective tissue, 16
structure, schematic drawing, 3f types, 16-17 components, 16f
synthesis, movement (impact), 18-19 viscoelastic model, 17 Depth jump, usage, 238
Collagen fibers, fibroblasts (presence), 2 components, combination, 17 Diagnostic joint arthroscopy, 458
Composite finger flexion, Coban (usage), 121f viscous/plastic component, 17 Diagonal proprioceptive neuromuscular
Compression patch viscoelastic nature, 17f facilitation patterns, Thera-Band (usage),
application, scar inspection, 298f viscous/plastic component, 17f 94f
manufacturing materials, 298f Continuous passive motion (CPM) Dimon-Hughston method, 383f
Compression units (PolarCare/Cryocuff), usage, application, protocol, 490 Disabilities of the arm, shoulder, and hand
32 impact, 462 (DASH), 123
Compression wraps, 176 usage, 490 Disability assessment of shoulder and hand
Conditioning principles, 234b Contractile tissue, loading, 38 (DASH), 127
Cone reaches-balance exercise, 610f Contralateral kicks, 548f Discectomy, 287-288
Connective tissue Controlled action motion (CAM) contraindications, 285
basket weave configuration, 19f impingement, 382 Disc herniation, 289
biomechanics, 15-18 lesion, anteroposterior radiograph, 383f exposure, 288f
bony clearing, 22 walker, usage, 509-510 Disc replacement, criteria, 335-336
bony surface, longitudinal stroke, 23f Controlled trauma, 15 Disc rupture, recurrence, 289
cells, histology/biomechanics, 16 production, 20 Disc space irrigation, 288
classic view, 15 Coracoacromial ligament, relationship, 28 Discomfort, active range of motion
classification, 16t Core stability, 617-620 (measurement), 48-49
clinical case review, 24 Core strength (development), isotonic training Dislocations, closed reduction, 546f
components, 16 (usage), 235 Distal femur, exposure, 487f
contractility, 18 Corner stretch, 265f Distal interphalangeal (DIP) joints, contraction,
creep (plastic deformation), 21 Corner wall stretch, 85f 198
cross-friction, 23 Corticosteroid, local injection, 217f Distal-locking block assembly, 393f
deformation characteristics, 17 Craniocervical region joints, movement planes Distal mobility (control), proximal stability
developments, 18 (ROM), 270t (importance), 83-84
dynamic characteristics, 18 Creep, connective tissue, 21 Distal palmar crease (DPC), circumferential
elastic component, 17f Cross-body stretch, 53f measurements, 221
elongation, stress-strain curves, 18f Crossed screws, usage, 587f Distal wrist creases, circumferential
extensiveness, 15 Cross-friction, 23 measurements, 221
extracellular matrix, 16 massage, development/advocacy, 23 DNA encoding, 13f
INDEX 635
Dorsal blocking splint, 204f Elbow (Continued) Extracellular matrix

Dorsiflexion, 555 ulnar collateral ligament (UCL) complex, collagen fibers, presence, 2
Double Kessler flexor tendon repair, 195f 156f connective tissue, 16
Double kneeling, 321f Electrical galvanic stimulation, usage, 543 proteoglycans/glycosaminoglycans, role, 5
Dropped foot type gait, 283 Electrical stimulation, avoidance, 474 Extreme wrist flexion, elbow extension, 120f
Dural mobilization Electric myostimulation (EMS), usage, 298
frequency, 296 Electromyography (EMG), usage, 34 F
initiation, 295 End-of-range movements, assessment, 291 Fascia (clearing), longitudinal stroke (usage),
Dural tears, occurrence, 289-290 Endoscopic bone-patella tendon-bone complex 23f
Dying bug exercise, 300f anterior cruciate ligament reconstruction, Fascia lata, split, 364f
Dynamic hug exercises, 83-84, 104f 407-408 Fascial planes
Dynamic joint Endoscopic carpal tunnel release (ECTR), 219 splaying/longitudinal separation, 22f
stability, promotion, 164f Endothelial cell growth factor (ECGF), 171 transverse movement, 22f
stabilization, functional movement patterns, End-range lumbar flexion, axial loading Fascial sheath, bending, 22f
164f (avoidance), 300 Fasciculations, visual inspection, 283
Dynamic scapular control, achievement, 54 Epidermal growth factor (EGF), 171 Feet
Dynamic single-leg stance exercises, 414 Epidural fat (retraction), nerve root retractor arthroscopy, 536
Dysphagia, ACSD, 276 (usage), 288f setup, 537f
Epithelialization, granulation phase, 3f neutral position, 446
E Epithelial tissue placement drill (crow hop drill), 246-249
Early cocking healing, 3t front view, 249f
football throwing motion, 241 surgical incision, 2 weight-bearing radiographic evaluation, 580
phase, photograph, 243f Esophageal injury, ACSD, 276 Femoral acetabular impingement (FAI), impact,
shoulder, abduction, 238, 241 Extension exercise, 275f 382
throwing/pitching motion, 238 Extensor brevis carpi radialis (ECRB) tendon Femoral bone plug, sutures (insertion), 408
Eccentric Achilles loading, two-up, one-down anterior edge, development, 120 Femoral CAM lesion, access, 385
decelerations, 188f Extensor brevis carpi radialis (ECRB) tendon, Femoral condyle
Eccentric external rotation, 61f alterations, 118 articular cartilage defect, 459f
Eccentric loading, initiation, 178-179 Extensor brevis release defects, 461-462
Eccentric posterior rotator cuff strengthening, clinical case review, 138 Femoral head dislocation, external rotation
home exercise, 61 composite finger flexion, Coban (usage), (usage), 377f
Ectopic bone formation (description), myositis 121f Femoral isometric point, determination,
ossificans (usage), 9-10 conditioning program, 129-130 407-408
Edema disabilities of the arm, shoulder, and hand Femoral neck fractures
control, 119f, 197 (DASH), 123 displacement, 382
persistence, 127-131 edema, control, 119f femoral head, separation, 537
Elastic traction, usage, 210f etiology, 118 Femoral prosthesis, decision, 379
Elastomer scar conformer, fabrication, 226f extreme wrist flexion, elbow extension, 120f Femoral shaft, lateral cortex (access), 536-537
Elbow grip strengthening, Baltimore Therapeutic Femur (subtrochanteric fracture), Richards
complex, osseous anatomy, 156f Equipment work stimulator (usage), compression screw-plate device (usage),
exercises, progressive loading, 178 121f 385f
extension hand stiffness, finger flexion glove, 121f Fibroblasts, row, 2
anconeus/triceps brachii, impact, 157 high-voltage galvanic stimulation (HVGS), Fibro-osseous sheath, annular pulleys, 195f
improvement, low-load long-duration 123-124 Fibroplasias, granulation phase, 3f
stretch (performing), 166f home exercise program, 121b Fibula, tunnels (location), 507f
extensors, 157 microtears, 118 Figure-eight reconstruction, ulnar collateral
tendons, injury, 118 pain level, increase, 124-126 ligament, 183f
flexors, 157 patient-rated tennis elbow evaluation Filaments, sliding, 7
innervation, musculocutaneous nerve (PRTEE), 123 Fine motor skills, loss, 256
(impact), 146 phases, 121-137 Finger dexterity
functional throwing positions, rhythmic characteristics, 127t, 132t, 135t assessment, 221
stabilization, 165f posterior elbow splint, 119f evaluation, instruments (usage), 222
isotonics, initiation, 161 range of motion (ROM), inadequacy, Fingers (active extension), flexor tendon repair
joint, musculature, 145 130-131 (usage), 198
lateral collateral ligament complex, 157f rehabilitation, therapy guidelines, 118-121 First metatarsal, medial aspect (intraoperative
ligament, ulnar nerve (posterior view), 158f scar, pain, 131-132 photograph), 586f
manual resistance proprioceptive skin pen, usage, 120 First metatarsal phalangeal joint (first MTPJ)
neuromuscular facilitation (manual stiffness, 130-131 dorsiflexion, non-weight bearing
resistance PNF), 164f strengthening program, 129 measurement, 580f
medial incision, reconstruction procedure, surgical indication/considerations, 118 fusion, postoperative lateral radiograph, 588f
159f surgical outcomes, 118 postoperative weight-bearing radiograph,
motion (improvement), stretching program symptoms, recurrence, 124-126 587f
(usage), 162b troubleshooting, 123-124 soft tissue rebalancing, surgical procedure,
postoperative posterior elbow splint, usage, Visual Analog Scale (VAS), 123 589
150f Extensor digitorum communis, origin, 120-121 Fists, types, 199f
proximal muscle strengthening, 228-229 Extensor supinator group, 157 Flexion adduction internal rotation (FADIR),
range of motion (improvement), Extensor supinator muscles, 157 indications, 383
postoperative range of motion brace Extensor tendon interval, closure, 121 Flexion deformity, 483
(usage), 161f Extensor tendons, injury, 118 Flexor digitorum profundus (FDP)
strengthening, 162-164 External rotators flexor digitorum superficialis, relationship,
Thera-Band, securing, 166f exposure, blunt dissection (usage), 364f 195f
Throwers Ten Program, 164b short external rotators, division, 365f location, 194
636 INDEX
Flexor digitorum superficialis, location, Football, 241-243 Glenohumeral (GH) joint

195f acceleration phase, 244f dynamic control, 238
Flexor group, location, 145 deceleration phase, photograph, 245f evaluation, 76
Flexor-pronator group, 157 early cocking phase, photograph, 243f hypomobility/hypermobility, 110
Flexor-pronator muscles, origination, 157 football-throwing motion, phases, 241 Gluteal muscle exercises, 464f
Flexor tendon repairs late cocking phase, 244f Gluteus maximus, split, 364f
adhesions, role, 196 maximal pronation, occurrence, 244f Gluteus medius, anterior fibers (release),
clinical case review, 213-214 stick drills, 305f 366f
edema control, 197 three-point stance, usage, 305f Glycosaminoglycans, role, 5
fingers, active extension, 198 windup phase, 243f Golfers, rehabilitation program, 69b
healing/exercises, concepts, 196-199 Forearm Golgi tendon organs, inhibitory effect, 236
immediate active flexion, 208t, 210t-211t plyometric exercises, 164f Gracilis stretch, importance, 302f
immediate passive flexion approach, proximal muscle strengthening, 228-229 Grade III injuries, 2-3
203t strengthening, 162-164 Grade II injuries, 2-3
characteristics, 203t, 205t-206t Forward lunge, ipsilateral side bend, 351f Grade I injuries, 2-3
immobilization Four-hole compression screw device, usage, Graft
approach, phases, 201t-202t 539f arthrodesis procedure, anteroposterior
usage, rarity, 199 Four-square hopping ankle rehabilitation, 550f radiograph, 588f
passive finger extension, 198 Four-way leg kicks-balance/proprioception, failure, ACSD, 276-277
process, 194 610f fixation, 406, 507f
results, evaluation, 212 Fractures maturation, 406-407
scar management, 197 hard callus, third stage, 12f process, initiation, 406
splinting, continuation, 211 medullary nailing, 394f Granulation phase, 2
strength, understanding, 196-197 soft callus, second stage, 11f Greater trochanter
tensile strength, 197f stability, bone healing (impact), 11t posterior approach, incision, 364f
types, 195f structural healing, 11f posterior ridge location, 378
wrist tenodesis exercises, 197 treatment, success, 11 skin incision, 386f
Flexor tendons Friction massage, 178 Great vessel mobilization/bifurcation, 337f
adhesions, resistance (initiation), 200 Frontal plane pelvic stability, focus, 189f Grip
double Kessler repair, 195f Front-wheeled walker (FWW), usage, 395, 398 strength, recordation, 222
gliding, therapist assessment, 198f Full fist, 199f strengthening, Baltimore Therapeutic
hand-based dorsal blocking splint, usage, Full plank exercise, 55f Equipment work stimulator (usage),
211-212 Full-thickness rotator cuff tears, treatment 121f
immediate active flexion results, 77 test, performing, 222
approach, 207-212 Full-thickness tears, 75 weakness, 167
guidelines, 208-212 treatment, surgical repair, 75 Grip and pinch assessment, 221
indications, 207 Full upper extremity stretching exercises, 227 Ground substance, purposes, 18
phases, 208-212 Full weight bearing (FWB), 543-544 Growth factors, 12-13
tension, minimization, 207-208 Functional mobility concentrations, 13f
immediate passive flexion, elastic traction assessment, initiation, 123-124 DNA encoding, 13f
guidelines, 204-207 initiation, 53 impact, 12t
phases, 204-207 Functional testing algorithm, 611 presence, 171
immediate passive flexion, static positioning Functional throwing positions, rhythmic usage, l imitation, 12-13
guidelines, 202-204 stabilization, 165f
phases, 203 Functional training H
immediate passive flexion approach, exercises, initiation, 303-305 Half-kneel position
202-204 impact, 488 overhead rebounder, 184f
immobilization Functional training program, initiation, 219 upper extremity strengthening, 184f
approach, 199-202 Fusions, types, 314-316 Hallux abductus, 579
guidelines, 200-202 Fusion sites, fragility, 263 bunion deformity, 580f
indications, 199 preoperative anteroposterior weight-
phases, 200-202 G bearing radiograph, 585f, 588f
Indiana repair, 195f Gait abnormalities, 256 Hallux limitus, 579
injuries, challenges, 193 Gait improvement, NMES (usage), 412 Hallux toe purchase, absence, 590
lacerations, repair, 194f Gait restoration, 545 Hallux valgus, 579
modified Kessler method, 195f Gait training, 544 Hamstring
rehabilitation Gastrocnemius-soleus complex, flexibility exercises, performing, 447
postoperative guidelines, 199 (assessment), 445 flexibility, assessment, 445
therapy guidelines, 195-196 Gastrocnemius stretching, 297f stretches, 398, 446f
repair surgery, 193 Gene expression pathway, 13f stretching, 301f
Savage repair, 195f Gene therapy, 12-13 Hand
splinting, 200 pure protein therapy, contrast, 13f stiffness, finger flexion glove, 121f
static-positioning guideline, 202 Genitourinary complications, lumbar spine disc weakness, 167
suturing, 194 replacement, 354 Hand-based dorsal blocking splint, usage,
two-strand repair, 196-197 Glenohumeral (GH) arthritis, preoperative 211-212
zone II, repairs, 212 anteroposterior radiograph, 122f Hand-behind-back stretch, 87f
Foam roller, usage, 180f Glenohumeral (GH) elevation, strengthening Hand position/ball transfer drill, 249
Follow-through program, 267 photograph, 250f
football throwing motion, 241 Glenohumeral (GH) instability, 73 Hard callus stage, 11
occurrence, 239-241, 243 secondary extrinsic cause/contribution, 28 Hawkins-Kennedy sign, 29
phases, photographs, 240f-241f Glenohumeral internal rotation deficit (GIRD), Head awareness problems, symptoms,
throwing/pitching motion, 238 demonstration, 44 272-273
INDEX 637
Healing Hips (Continued) Hips, open reduction/internal fixation

inflammatory phase, 341t flexion, importance, 297f (Continued)
process, definition, 172 flexor stretch, 327f subtrochanteric hip fractures, 383-384
Heel cord stretch, 397f hinge, 320-322 pathologic anatomy, diagram, 384f
Heel raises, 352f hinging, flexing, 322f surgical indications/considerations, 382
usage, 447 lateral rotation, 498f thigh pain, walking, 399
Heel slides, 445f mobility, restrictions (assessment/treatment), touch down weight bearing (TDWB) patient,
crepe bandage donut, usage, 463f 327-328 383-384
Herniated discs, sagittal MRI, 284f muscle strength testing, postponement, 294 difficulty, 395
Herniated nucleus pulposus (HNP), 283 musculature, flexibility (assessment), 445 Trendelenburg sign, nonresolution, 399
complications, 289-290 pain/debility, femoral acetabular troubleshooting, 386
discussion, 290 impingement (impact), 382 wall slides, adductor pillow (usage), 397f
high lumbar levels, 289 pathology, description, 382 weight bearing as tolerated (WBAT) status,
iatrogenic mechanical instability, 290 postural/phasic muscles, classification, 23t 397
Heterotropic ossification, 354 replacement, comments, 380-381 Histamine, release, 172
Hibbs, Russell, 313 sag, 621f Homans sign, 496
High-impact sports, 372 weakness/stiffness, 427 Hook fist, 199f
High-intensity plyometric drill, box jumps, 608f Hips, open reduction/internal fixation Hop and stop test, 622f
High-voltage galvanic stimulation (HVGS), 146 active hip abduction, 399f Horizontal pulley, 130f
effectiveness, 166 active hip adduction, 399f Humeral avulsion of the glenohumeral
elevation/ice, usage, 139 advanced intermedullary nailing techniques, ligaments (HAGL) lesion, 46
portable HVGS unit, 119f usage, 384 Humeral canal, preparation, 120
Hip arthroscopy bilateral tiptoes, 397f Humeral head, resection, 120f
acetabulum, debridement, 386f calf stretches, 398 Humeral metaphysis, preparation, 120
anatomy, 382 capsule, T incision, 389 Humeral trochlea, articulation, 155
anteroinferior iliac spine (AIIS), palpation, cardiovascular exercise, importance, 398 Humeroradial joint, 155
383 clinical case review, 400-402 Humeroulnar joint, single-axis diarthrodial
anterolateral portal, establishment, 385 closure, controversy, 383 joint, 144
burr, usage, 386f dislocations, closed reduction, 394f Humerus
complications, 386 electrical galvanic stimulation, usage, 395 distal lateral aspect, 144
occurrence, 385-386 emergency surgery, 395 external rotation, scaption (usage), 34-36
controlled action motion (CAM) femoral neck fractures, displacement, 382 maintenance, 223
impingement, 382 fractures prone horizontal abduction, 36f
distraction, discontinuation, 385f medullary nailing, 394f proximal radius, 144
etiology, 382 table, patient placement, 384 Hybrid cemented total hip arthroplasty, 363f
femoral CAM lesion, access, 385 front-wheeled walker (FWW), usage, 395, Hyperactive muscles, 497-498
flexion adduction internal rotation (FADIR), 398 Hyperreflexia, 256
indications, 383 greater trochanter, skin incision, 386f Hypertrophic nonunions, 12
frog lateral radiographs, 384f hamstring stretches, 398 Hypovascularity, repetitive microtrauma
hip distraction, initiation, 385f heel cord stretch, 397f (combination), 555
imaging, 384 home care physical therapy, 396
incisions, usage, 383f home care therapist, goal, 396 I
indications/considerations, 382-383 home health physical therapy, completion, Iatrogenic mechanical instability, 290
labral tears, identification, 386f 398 Iliotibial band (ITB) tension, 427
lateral hip arthroscopy, 384 home phase (phase II), 385-386 Immediate active flexion
left hip, CAM lesion (anteroposterior hospital phase (phase I), 384-385 approach, 207-212
radiographs), 383f initial postoperative rehabilitation, indications, 207
MRI arthrograms, usage, 384f predication, 383 protocol, elastic traction (usage), 210f
outcomes, 385-386 intertrochanteric hip fractures, 382-383 tendon, tension (minimization), 207-208
pathology, description, 382 instability, four-hole compression screw Immediate passive flexion
pelvis device (usage), 384f approach, 202-204
anteroposterior radiographs, 384f lateral femur, incision, 383 phases, 203
CT 3-D reconstruction, 383f leg press, 400f static-positioning guidelines, 202-204
performing, 384 inclusion, 399 Immobilization, 18-19
physical examination, 382 outpatient phase (phase III), 386 connective tissue impact, 18-20
portal placement/distraction, neuropraxis outpatient physical therapy, 398 effect, 4-5, 7
(relationship), 386 pelvis, cannulated screws (anteroposterior role, 4-5
postoperative management protocol, 385 radiograph), 383f Immobilized scar tissue, haystack arrangement,
prone position, examination, 383 phases, 384-386 19f
radiographs, usage, 384 postsurgical patient, home maintenance, Impingement syndrome
sitting position, examination, 383 400b diagnosis/evaluation, 28-29
standing, examination, 382 proximal drill guide, distal-locking block surgical treatment, arthroscopic SAD (usage),
supine hip arthroscopy, 384 assembly, 393f 29-30
supine position, examination, 383 quadriceps set, adductor (addition), 395f Incision, healing, 2
surgical procedure, 384-385 rehabilitation Inclined sled, 412f
Hip joint capsule (exposure), retraction (usage), efforts, 385-386 Inclined squat machines, usage, 447
365f goals, individualization, 383 Inclined surfaces, proprioceptive training, 549f
Hippocrates, 555 therapy guidelines, 384 Indiana flexor tendon repair, 195f
Hip rotator stretch, 328f Russell-Taylor interlocking nail technique, Inert connective tissue, 15
Hips 385f Infection
access, posterolateral approach, 364 sitting hamstring stretch, 398f lumbar spine disc replacement, 354
downward direction, 619f skin, posterolateral approach, 383 Infection, ACSD, 276
638 INDEX
Inferior radioulnar joints, single-axis Jumping athlete, transition (Continued) Krackow suture technique, 561f
diarthrodial joint function, 144 CKC exercises, 605f KT-1000 stability, 417
Infielders, rehabilitation program, 65b clinical case review, 613-614
Inflammation, decrease, 322-324 cone reaches-balance exercise, 610f L
Inflammatory phase, epithelial tissue, 2 criteria, return, 612b Lachman test, positive value, 404
Inflow pressure pump (Davol), usage, 30 flexibility, 604 Langer lines, incision (cosmesis), 76f
Injury (risk), tissue pliability (relationship), guidelines, 604b Late cocking
20f four-way leg kicks-balance/proprioception, football throwing motion, 241
Inside-out meniscal repair, 442 610f phase
popularization, 442 frequency, 606 humerus, abduction level, 239
Insulin-like growth factor (IGF-I), 171 functional testing algorithm, 611 photograph, 244f
Interbody cages, 316 high-intensity plyometric drill, 608f throwing/pitching motion, 238
Interbody fusion, 315-316 intensity, 606-607 Lateral ankle pain, sequence, 539
Intercondylar notch, removal, 485f landing form, 612f Lateral collateral ligament complex
Interferential current, effectiveness, 166 lateral shuffles, 609f anatomy, 156-157
Interfragmentary compression, lag screw low-intensity plyometric exercises, 608f elbow components, 157f
(usage), 524f motion, direction, 607 Lateral epicondylectomy
Interlaminar space, exposure, 286 neuromuscular training, 608-610 clinical case review, 138
Internal fixation, Dimon-Hughston method, exercises, 610f composite finger flexion, Coban (usage), 121f
383f programs, 609 conditioning program, 129-130
Interphalangeal (IP) joints, active motion plyometric exercise examples, 607b disabilities of the arm, shoulder, and hand
(limitation), 196f plyometric guidelines, 606b-607b (DASH), 123
Interstitial mechanoreceptors, manual plyotoss-proprioception drill/neuromuscular edema, control, 119f
stimulation, 18 control, 610f etiology, 118
Intertrochanteric hip fractures, 382-383 program extreme wrist flexion, elbow extension, 120f
instability, four-hole compression screw design, 603-612 grip strengthening, Baltimore Therapeutic
device (usage), 384f example, 613t Equipment work stimulator (usage),
Interval baseball throwing program, 243-246 progression, 607 121f
Interval return sport, phase IV, 183t recovery, 607 hand stiffness, finger flexion glove, 121f
Interval throwing program return, readiness, 603-604 high-voltage galvanic stimulation (HVGS),
phases, 166b-167b single-leg hop tests, 610 123-124
purpose, 243-245 slide board, 609f home exercise program, 121b
Intramedullary guide, distal femoral guide speed/agility, 609b microtears, 118
(attachment), 484f speed tests, 611 modified Nirschl method, 118
Inverted L capsulotomy, 589 sport, return, 610-612 nonsurgical management, 118
Iontophoresis, usage, 224 static stretching, controversy, 604 pain level, increase, 124-126
Ipsilateral rotation, forward lunge, 351f strength, 604-606 patient-rated tennis elbow evaluation
Isokinetics strengthening, 605b (PRTEE), 123
avoidance, 475 technique, 606 phases, 121-137
equivalence, 417 T test, 611f characteristics, 127t, 132t, 135t
strength measurement, 62 vertical jump test, 610f posterior elbow splint, 119f
Isolated quadriceps strengthening, progression, visual input, 609 range of motion, inadequacy, 130-131
414 volume, 606 rehabilitation, therapy guidelines, 118-121
Isometric bands, usage, 133f warm up/cool down, 606 scar, pain, 131-132
Isometric deltoid/external rotation, 134f skin pen, usage, 131
Isometric hip abduction, submaximal force K stiffness, 130-131
recommendation, 369 Keller (resectional arthroplasty) bunionectomy, strengthening program, 129
Isometric hip extension, 368 584f surgery, indications, 118
Isometric shoulder internal rotation, 52f Kinesthesia, defining, 233-234 surgical indications/considerations, 118
Isometric training, support, 132 Knee extension surgical intervention, factors, 118-119
Isotonic core-strengthening exercises, 235t ability, loss, 470 surgical outcomes, 118
Isotonic exercises, 235 exercises, 411t surgical procedure (modified Nirschl
Isotonic scaption exercises, 81f stability problem, 620f method), 118
Isotonic training, usage, 219 transverse plane, 618, 619f symptoms, recurrence, 124-126
Kneeling, 498-499 troubleshooting, 123-124
J functional activity, 498-499 Visual Analog Scale (VAS), 123
Jebsen-Taylor hand function test, 222 Kneeling half plank exercise, 55f Lateral flexion movements, axial loading
Jobes shoulder exercises, 235t Knees (avoidance), 300
Joints clinical implications, understanding, 443 Lateral hip arthroscopy, 384
congruity, restoration, 470 examination, 407 Lateral interbody fusion, 315-316
effusion, persistence, 496-497 exercises, 474 Lateral ligament repair, phases (characteristics),
mobilization, 267-269, 346-347 flexion 510t-512t
position sense retraining exercise, 272f deformity, 483 Lateral patellar retinacular release, 427
proprioceptor function, requirement, exercises, 411t Lateral recess
234 medial collateral ligament (MCL) healing, exposure, 287
Jump, landing, 303f-304f 4 stenosis (removal), Kerrison rongeur (usage),
Jumping athlete, transition motion/flexibility, range, 445-446 287f
agility drills, 609f postural/phasic muscles, classification, 23t Lateral retinaculum release, phases, 430t-431t,
atrophy, 604 ROM measurements, 473 433t
biomechanical loading measurements, vastus medialis oblique (VMO), function, Lateral shaft, transverse osteotomy, 383f
612 23 Lateral shuffles, 609f
box jumps, 608f Krackow modified suture technique, 560 Lateral soft tissue structures, unloading, 431f
INDEX 639
Lateral subacromial portal incision, extension, Lower lumbar neural mobilization (supine dural Lumbar spine disc replacement (Continued)
76 mobilization), 295-296 indications, 340b
Lateral UCL, origination, 157 Lower trapezius muscle strength/endurance, infection, 354
Latissimus dorsi progression, 57 inflammatory phase (phase I), 341-342
strengthening, 59 Low-intensity plyometric exercises, 608f initial posthospital rehabilitation, 342
stretch, 328f Low-load long-duration stretch, performing, intraoperative patient positioning, 337f
Latissimus pull downs, 329f 166f ipsilateral rotation, forward lunge, 351f
Lauge-Hansen classification system, 521f Lumbar arthrodesis, goal, 314 joint mobilization, 346-347
Leap test, 622f Lumbar artificial disc replacements, lower limb nerve testing positions, 350t
Left knee, surgical exposure, 483f outcomes, 338 lumbar disc replacement surgery
Legs Lumbar disc herniation attributes, 340-341
buckling, 283 impact, 290-291 hospital discharge instructions, 342b
press, 400f radiographic diagnosis, 283 lumbar extension, avoidance, 343-344
inclusion, 399 Lumbar disc replacement surgery lumbar forward bend, motion sequencing,
usage, 447 attributes, 340-341 346b
strengthening, 85 hospital discharge instructions, 342b lumbar proprioception, 349-353
Lesser toes, hallux separation, 590 Lumbar extension lumbar region, joints movement (ROM), 346t
Lifting avoidance, 329, 343-344 lumbar spine
activities, resumption, 303 reduction, knee flexion (usage), 323f biomechanics, normalization, 346
primary mode, 124 Lumbar flexion lateral x-ray/AP x-ray, 336f
underhanded technique, 120f avoidance, 329 motion, forward bend (usage), 346b
Ligament healing, 2-5 exercises, 341-342 lumbar stabilization, 344-345
functional recovery, stress/motion stretch, 327f nerves, gliding/stretching, 348
(importance), 5 Lumbar forward bend, motion sequencing, neural mobilization, 347-348
mobilization/immobilization, effect, 4-5 346b patient reassessment, 343
phases, 4t Lumbar herniated nucleus pulposus (lumbar peroneal nerve, position, 347f
reasons, 13 HNP), 283 phases, 341-353
response, 4 Lumbar intervertebral disc, rupture (diagnosis), physical therapy, 338
Ligamentization, description, 406-407 284-285 postoperative outpatient examination, 343
Ligaments Lumbar microdiscectomy, 286-289 postsurgical patient, home maintenance,
anatomy/function, 2 interlaminar space exposure, 286 355b-356b
balancing, 483-485 lateral recess exposure, 287 postural rehabilitation, 343-344
fibroblasts, presence, 2 level/side, identification, 286 implementation, 344
injuries, 2-5 ligamentum flavum, release, 287 problems, symptoms, 353-354
classification, 2-3 nerve root/ligamentum retraction, 287 proprioceptive training, 349
stress, avoidance, 178 operative setup, 286 rationale, instrumentation (usage), 341-353
subgroups, 2 skin incision, 286 rehabilitation
Ligamentum flavum spinal canal entry, 286-287 description, 341-353
release, 287 Lumbar muscle spasm, visual inspection, process, phase II, 342-343
curette, usage, 287f 283 therapy guidelines, 338-340
retraction, nerve root retractor (usage), 288f Lumbar pain/pathology, impact, 347 remodeling phase (phase IIIa), 343-348
Light wrist isotonics, initiation, 161 Lumbar rotation, avoidance, 329 remodeling phase (phase IIIb), 348-353
Lister tubercle, 120 Lumbar spine disc replacement reparative phase (phase II), 342-343
Local median nerve glide/stretch, 223f abdominal muscles, weakening/lengthening, side lying femoral nerve
Longus colli muscles 343-344 test, 348f
partial resection, ACDF surgery requirement, ankle pumping exercises, 341 testing procedure, 349b
265-267 anterior spine access, operative dissection, soft tissue
Longus colli muscles, dissection, 258-259 337f healing timeframes, 340t
Loose irregular connective tissue, 16 biomechanics, 355 mobilization, 345-346
components, 17 chronic pain, 355 spine
Low back pain, symptoms, 313 factors, 355b exposure, 338
Lower extremity (LE) clinical case review, 356-359 level, localization, 337f
biomechanical imbalance, 579 complications, 338 spontaneous fusion, 354
deficits, 404-405 concept, 338-339 straight leg raise (SLR)
injuries, equilibrium (changes), 494 diagnosis, establishment, 335 base test, 347f
kinetic energy, creation, 217 diagnostic tests, usage, 335 test foot positions, 347f
muscles, strength, 543 etiology, 335 testing procedure, 349b
musculature, strengthening exercises, forward lunge, ipsilateral side bend, 351f stretching, 345
446-447 function, restoration goal, 348 summary
plyometric exercises, 237t functional retraining, 348-349 comments, 348, 353
plyometric training, 221 single-leg reach, 351f statement, 340-341
importance, 237 genitourinary complications, 354 sural nerve, position, 347f
range of motion evaluation, 320 gluteal muscles, weakening/lengthening, surgery, 338-355
stability, 620-621 343-344 surgical indications/considerations, 335-336
strengthening, 593 great vessel mobilization/bifurcation, 337f surgical procedure, 336-338
strength testing, 320 healing surgical site, protection, 341
stretching, 395 inflammatory phase, 341t Synthes Prodisc-L implant, 336f
warm-up exercises, 236 remodeling phase, 344t, 350t, 354t TED hose stockings, usage, 341
Lower limb nerve testing positions, 350t reparative phase, 343t therapeutic exercises, 344
Lower lumbar herniation (nerve root heterotropic ossification, 354 heel raises, 352f
impingement indication), straight-leg hospital rehabilitation, 341-342 list, 353t
raises (usage), 283 implant placement, 339f minisquats, 352f
640 INDEX
Lumbar spine disc replacement (Continued) Lumbar spine fusion (Continued) Median nerve
plank exercise, 352f preoperative phase, 317 course, 157
pointer dog exercise, 352f pressure biofeedback, usage, 324f recovery, 221
prone press-ups, 345f provocative discography, usefulness, 313-314 upper-limb tension testing, 222
single knee to chest exercise, 345f quadruped alternating opposite arm/leg lift, Medicine ball soccer throw exercises, 237f
tandem balance, 352f 325f Medicine ball wood chop warm-up exercises,
transversus abdominis strengthening, 345f rehabilitation 237f
tibial nerve, position, 347f description, 317 Medullary callus, structural fracture healing, 11f
tissue healing therapy guidelines, 317-331 Meniscectomy/meniscal repair
phases, 339-340 resisted trunk motions, 326f advanced phase, 451
tissue healing, principles, 339-340 restrictions, 318 aquatic therapy, 447
trial placement, 338f reverse lunge, 321f arthroscopic surgeon, involvement, 441
troubleshooting, 353-355 scar mobility, maintenance, 326-327, 327f balance, proprioceptive training, 447
vascular complications, 354 shoulder mobility, restrictions (assessment/ biodegradable darts, passage, 442
weight-bearing activities, initiation, 341-342 treatment), 327-328 clinical case review, 453-455
Lumbar spine fusion sitting postures, 322f closed-chain activity, advancement, 449-450
abdominal bracing, 324-325 slides/tensioners, 318 conditioning, 447-449
abdominal breathing, 324 soft tissue mobility, maintenance, 326-327, endurance training, progression, 451
anterior lumbar interbody fusion (ALIF), 315 327f feet, neutral position, 446
BAK interbody cage device, 316f spinal radiographs, 313 flexibility exercises, 445-446
balance activities, exercise ball (usage), 325f spinal stability system components, 317b flexion/extension limitations, development,
body mechanics training, 320-328 stabilization/strength/reconditioning, 324-326 446
bones, remodeling (continuation), 329 standing balance activities, 326f gait assessment, 444-445
bracing, marching (combination), 325f strength/conditioning exercises, initiation, girth measurement, 443-445
chair, exiting, 320f 325 hamstring exercises, performing, 447
circumferential fusion, pedicle screw strength testing, 320 hamstring stretch, 446f
instrumentation (anterior interbody stretching, impact, 328 heel slides, 445f
cage), 316f supine activities, foam roll (usage), 326f initial phase, 443-449
circumferential lumbar fusion, pedicle screw supine lying, support, 321f intermediate phase, 449-451
instrumentation, 314f supine marching, 324-325 knee motion/flexibility, range, 445-446
computed tomography evaluation, 313 surgical indications/considerations, 313-314 lower extremity musculature, strengthening
degenerative cascade, 314t surgical procedure, 316 exercises, 446-447
diagnosis, 314 thoracic mobility, restrictions (assessment/ objective findings, 449
diagnostic tests, 313-314 treatment), 327-328 pain/edema management, 445
double kneeling, 321f transforaminal lumbar interbody fusion palpation, 444-445
evaluation, 320 (TLIF), 315 partial weight-bearing closed kinetic chain
hip flexor stretch, 327f types, 314-316 activities, 447
hip hinge, 320-322 up and down from the floor exercise, 327f patella mobilizations, 446f
hip hinging, flexing, 322f Lumbar spine motion, forward bend, 346b patient tolerance, 447
hip mobility, restrictions (assessment/ Lumbar stabilization, 344-345 phases, 443-451
treatment), 327-328 Lunge exercise, medial forefoot plantar loading, physical therapy protocols, 442
hip rotator stretch, 328f 600f postsurgical patient, home maintenance, 451,
inpatient phase, 318 Lunge stretch, right lower extremity, 599f 452b-453b
instrumentation Lying position, rising, 320f reassessment, occurrence, 450
noninstrumentation, contrast, 314-315 Lymphedema rehabilitation, therapy guidelines, 442-451
usage, rationale, 317 presence, 497 ROM increase, 445, 448
interbody cages, 316 total knee arthroplasty, relationship, 497 ROM measurement, 444-445
interbody fusion, 315-316 treatment, 497 short arc quadriceps exercises, addition, 447
laminectomy, phases, 318t-319t, 330t side steps, resistance loop (combination),
lateral interbody fusion, 315-316 M 451f
latissimus dorsi stretch, 328f Magellan Autologous Platelet Separator System, strength assessment, 444-445
latissimus pull downs, 329f 173f strengthening, 446-447
lumbar extension (reduction), knee flexion Manipulation under anesthesia (MUA), strength training, progression, 451
(usage), 323f 492-493 surgical indications/considerations, 441
lumbar flexion stretch, 327f indications, 493 surgical procedure, 442
lumbar fusion, phases, 318t-319t, 330t Manual muscle testing (MMT), 221 techniques, 441
lying position, rising, 320f Manual resistance proprioceptive T kicks, 450f
nerve gliding, 323f neuromuscular facilitation (manual treatment
nerve root gliding, 322 resistance PNF), 164f initial phase, complications, 447
objects Maximal pronation, occurrence, 228f initiation, 445
lifting, hip hinge position, 323f Maximum voluntary contraction (MVC), 104 visual examination, 444-445
pushing, 323f McBride soft tissue, rebalancing, 588f weight-bearing status, 447
overhead lifting, care, 329 McConnell patellofemoral (PF) taping, 428 Meniscus biomechanics, clinical implications
pain/inflammation, decrease, 322-324 selection, 432 (understanding), 443
patient education, 324 McConnell taping procedures, 429 Meniscus repair, 442f
patient fear/apprehension, reduction, 324 Medial collateral ligament (MCL), healing phases, characteristics, 444t, 448t-449t,
phases, 317-329 studies, 4 452t
planning phase, 317 Medial elbow instability, 147 Mennell, John, 20-21
posterior fusion, 315-316 Medial epicondyle, service, 156f Metacarpophalangeal (MP) joints
posterior lumbar interbody fusion (PLIF), Medial forefoot plantar loading, 600f flexion, 204f
315 Medial tibiofemoral (medial TF) compartment, passive exercises, 204f
posterolateral lumbar fusion, 315 cartilage degeneration (occurrence), 480 placement, 198
INDEX 641
Metallic interposition hemiarthroplasty, Mobility work, goals, 20-21 Neuromuscular coordination, improvement,
480-481 Mobilization 236
Metatarsal cuneiform joint (MCJ), 579 effect, 4-5, 7 Neuromuscular electrical stimulation (NMES),
Metatarsal head level, decompressional role, investigation, 4-5 490
osteotomy, 585f Moderate-sized rotator cuff tears, repairs, 80t, usage, 412
Metatarsal head osteotomy, surgical procedure, 82t, 83f, 86t Neuromuscular training
589 Modified Brostrm procedure, 505-506, 508 exercises, 610f
Metatarsal phalangeal joint (MTPJ), 579 Modified Kessler flexor tendon repairs, 195f programs, 609
dorsal/medial aspects, dorsal incision Modified Kiblers lateral scapular slide test, Neutral cervical spine, 263f
(intraoperative photograph), 582f 37b Nine-hole peg test, 222
dorsiflexion, non-weight bearing Modified Moberg pick-up test, 222 Nirschl tendinosis pain phases, 124t
measurement, 580f Monofilament interpretation, 222f Nonabsorbable sutures, usage, 486f
Mice, muscle tissue (histologic pictures), 9f Movement analysis, scapulohumeral rhythm, Non-bone-to-bone (BTB) autograft graft
Michigan Hand Outcomes Questionnaire, 128b patients, 410-411
222 Muscles Noncemented modular total hip arthroplasty,
Microdiscectomy balance, development, 234 363f
design, 291 balancing, 23 Nonunions, classification, 12
phases, characteristics, 293t, 299t cell structure, disruption, 8t Non-weight bearing (NWB) patient, 443-444,
Microscopic discectomy (microdiscectomy), control, enhancement, 460-461 536
286 contusion, 8 North American Spine Society (NASS), surgical
Microstimulation, usage, 298 fascial planes indication recommendations, 284-285
Middle glenohumeral ligament (MGHL), splaying/longitudinal separation, 22f
impact, 46 transverse movement, 22f O
Middle trapezius muscle strength/endurance, fascial sheath, bending, 22f Objects
progression, 57 healing, 8t lifting, hip hinge position, 323f
Midthoracic spine, mobilization, 267 isolation, importance, 36 pushing, 323f
Mineralization, radiographic evidence, 268-269 laceration, 9 OConnor Finger dexterity test, 222
Miniinvasive total hip arthroplasty, anterior lesions, suture repair, 9 One-handed baseball throw, usage, 163f
approach spasm, reduction, 298 Open kinetic chain (OKC)
acetabular exposure, achievement, 378f splay, 22 hamstring curls, 412
acetabular insertion, 378 strains, 8-9 quadriceps strengthening, 411-412
acetabulum, visualization/preparation, 378 occurrence, 8 Open meniscal repair, 441
anterior superior greater trochanter, strengthening, 228f Open reduction internal fixation (ORIF),
obturator internus/piriformis tendon tears, occurrence, 8 539
insertion, 379 tissues, histologic pictures, 9f emergency surgery, 395
anterior total hip arthroplasty, rehabilitation, training, 161-162 patients, age, 544
380 Muscular power, building, 414 performing, 520
anterolateral capsule, incision, 377f Muscular strength/coordination, lower Open rotator cuff repair, 76-77
bleeding, observation, 379 extremity deficits, 404-405 Organs, ligament connection, 2
broaching, accomplishment, 379f Musculocutaneous nerve, impact, 157 Orthobiologic tissue grafts, usage, 171
broach insertion, accomplishment, 379f Musculoskeletal tissues, growth factors Orthobiologic treatment modalities, interest,
cobras, medial/lateral retraction, 376-377 (impact), 12t 174
delta ceramic head, placement/reduction, Myositis ossificans, 9-10 Osteoblasts, 10
380f Osteochondral defects, 459
fascia lata, lifting, 376 N Osteochondral lesions, 539-540
femoral broaching, proximal femur National Collegiate Athletic Association Osteochondral lesions of the talus (OLT), 537
(delivery), 378f (NCAA) injuries report, 603 arthroscopic treatment, 540
femoral head dislocation, external rotation Neck awareness problems, symptoms, 272-273 nonresponse, 540
(usage), 377f Neck movement control exercise, 273f Osteoclasts, 10
femoral prosthesis, decision, 379 Necrosis, 406 Osteocytes, 10
greater trochanter, posterior ridge location, Neer impingement sign, 29 Osteophytes, spinal radiographs, 313
378 Neer protocol, 124-126 Osteotomy, performing, 590
hip hyperextension/adduction, external Nerve gliding, 323f Oswestry low back pain disability questionnaire,
rotation (inclusion), 378f Nerve root 292b
Hohmann retractor, anterolateral acetabular gliding, 322 Outfielders, rehabilitation program, 65b
rim placement, 377 impingement (indication), straight-leg raises Outside-in meniscal repair, 442
incision (photograph), 377f (usage), 283 Overhead lifting, care, 329
lateral neck cut (finalization), osteotome retractor, release, 289f Overhead rebounder tossing, half-kneel
(usage), 378f sleeve (retraction), nerve root retractor position, 184f
length/cup position, intraoperative imaging (usage), 288f Overhead throwing motion, 238
(usage), 380f Nervous system, direct mobilization, 90
PROfx table, supine position, 377f Neural adaptation, 236 P
surgical team, 376 Neural complications, lumbar spine disc Pain management modalities, 47
surgical technique, 376-380 replacement, 354 Palmaris longus, presence/absence
wound irrigation, 379 Neural gliding exercises, 227 (documentation), 159
Minimally invasive surgery (MIS) TKA, 480, Neural injury, ACSD, 276 Pants-over-vest overlapping suture technique,
485-488 Neural mobilization/dynamics, 269-271 506
outcomes, 496 Neural tension testing, 221 Paoaillon, Gustave, 555
Miniopen rotator cuff repair, 76 Neurologic structures, relationship, 157 Paratendinitis, 554
Minisquats, 352f Neuromuscular control, 608-609 inflammation, involvement, 554-555
exercises, 605f defining, 233 tendinosis, inclusion, 554
Minnesota rate of manipulation test, 222 evaluation, single-leg step (usage), 465f inflammation, involvement, 555
642 INDEX
Paratenon-covered tendons Patellar fractures Platelet rich plasma (PRP)

healing response, 6-7 maximal function, achievement, 473 blood collection kit, 173f
repair process, 6 report, 418-419 blood spinning, 174-175
Pare, Ambrose, 555 Patellar tendon, microscopic longitudinal Bosu ball squats, 189f
Partial meniscectomy, usage, 441 sections, 5f clinical application, 174
Partial patellectomy, process, 472f Patellar thickness (measurement), caliper clinical case review, 191
Partial rotator cuff tear, 75 (usage), 485 closed kinetic chain, 185f
Partial sit-ups, 300f Patellofemoral (PF) joint concentrate, delivery, 174f
Partial squats, usage, 447 arthrokinematics, 427 concentric phase, 179
Partial weight bearing (PWB), 395 repairs, hip hike exercise (usage), 464f decline squat examples, 189f
closed kinetic chain activities, 447 Patellofemoral ligaments, enhancement, 428 deep transverse tissue massage (DTFM),
patient, 443-444 Patellofemoral (PF) pain 178
Passing device, placement, 507f occurrence, 418 definition, 171
Passive finger extension, flexor tendon repair, origination, 427 delivery, procedural technique, 173-174
198 Patellofemoral (PF) tape-weaning protocol, derivation, 172-173
Passive flexion 436 early motion restoration, 177
application, 202 Patellofemoral (PF) taping, 428-429 eccentric Achilles loading, two-up, one-down
theoretic basis, 196f Patient-rated tennis elbow evaluation (PRTEE), decelerations, 188f
Passive IP extension, 198 123 formation, 172-173
Passive knee extension, 411f Pattern throwing, kneeling position, 248f growth factors, 172t
Passive overpressure, usage, 492f Pectoralis muscle, partial tear (MRI evaluation), home maintenance program post-UCL PRP
Passive range of motion (PROM), measurement, 7f injection, 190b
47 Pectoral muscles, strengthening, 59 inflammatory phases (phase I), 175-176
Patella Pedicle screw constructs, usage, 314-315 injection, 182t
defects, 461, 463 Pedicle screw instrumentation, 314f four-stage rehabilitation overview, 176b
glide, 428f anterior interbody cage, 316f mechanism, 171
lateral subluxation, 487f Pelvis overhead rebounder, half-kneel tossing,
mobilizations, 446f cannulated screws, anteroposterior 184f
education, 463f radiograph, 537f pain levels, reduction, 178
rotation, 428f CT 3-D reconstruction, 383f phases, 175-183
simple fractures, fixation, 471 Pendulum exercises, usage, 124 post-PRP injection
template, usage, 486f Peripheral nerves (biasing), straight leg raise exercise progressions, supraspinatus/
tendon, exposure, 407f test foot positions (usage), 347f infraspinatus tendon examples, 187b
tilt, 428f Peripheral nervous system, changes treatment plan, 178
Patella open reduction/internal fixation (patella (occurrence), 355 post-PRP patellar/Achilles tendon exercise
ORIF) Peripheral osteophytes, removal, 120f progression example, 188b
clinical case review, 477-478 Periscapular muscles, restriction, 69 post-PRP treatment instructions, 173b
extensor mechanism, repair, 471 Peroneal nerve pre-PRP treatment instructions, 173b
fixation, failure, 470 neuropraxia, 497 progressive full arc motion, 177
fracture fibular neck, presence, 497 proprioceptive neuromuscular facilitation
displacement, measurement, 470 palsy, 497 pulley pattern, 180f
early ROM, operative treatment goal, position, 347f protection/early motion-inflammatory phase
473-474 Phasic muscles (phase II), 176-178
incision line, 471f hip, classification, 23t regulation, 174-175
isokinetics, avoidance, 475 knee, classification, 23t rehabilitation
joint congruity, restoration, 470 shoulder, classification, 23t modalities, 177-178
knee extension ability, loss, 470 Physical therapy therapy guidelines, 175-183
pain control, electrical stimulation evaluation, components, 32b remodeling phase (phase IV), 181-183
(avoidance), 474 intervention, 371 reparative phase (phase III), 176, 178-181
partial patellectomy mobilization techniques, 268-269 rotator cuff eccentrics, 185f
performing, 471 Physioball wall walkouts, 109f separation process, 174f
process, 472f Physiologic muscle performance, enhancement, shoulder/elbow/wrist exercises, progressive
phases, 473, 475-476 219 loading, 178
characteristics, 474t-476t Pike press, 60f-61f step down progression, 189f
postoperative complications, 470 Pillar pain, 220 treatment
postsurgical patient, home maintenance, 476, occurrence, 227-228 completion, 174
476b-477b Pinch treatment, risks/concentration, 174
rehabilitation, therapy guidelines, 473-476 meter, usage, 222 ulnar collateral ligament (UCL) stress, upper
skin integrity, evaluation, 471 recordation types, 222 extremity pulley pattern (usage), 180f
surgery Pinching exercises, resistive putty (usage), upper extremity
criteria, 470 227-228 loading, slide board patterns (usage), 186f
general/regional anesthesia, usage, Pitchers, rehabilitation throwing program, patterns, Body Blade (usage), 181f
471 63b-64b pulley pattern, usage, 180f
outcomes, 472-473 Pitcher-specific interval throwing program, strengthening (half-kneel position),
surgical indications/considerations, 470 progression, 246 BodyBlade/PlyoBall (usage), 184f
surgical procedure, 471-473 Pitching motion, phases (division), 222 upper extremity D1 D2 proprioceptive
surgical site, infection signs, 473 Pitching rubber, foot placement, 219f neuromuscular facilitation patterns
tension band wiring techniques, 471 Plank exercise, 55f foam roller/Plyoball, usage, 180f
tension wire, placement, 471 Platelet derived growth factor (PDGF), Physioball, usage, 181f
transverse fracture, ORIF procedure, 171 upper extremity D1 D2 proprioceptive
472f Platelet-derived preparations, usage (WADA neuromuscular facilitation patterns,
troubleshooting, 476 prohibition), 174-175 usage, 180f
INDEX 643
Platelet rich plasma (PRP) (Continued) Posterior lumbar arthroscopic discectomy/ Posterior lumbar arthroscopic discectomy/
usage, 171 rehabilitation (Continued) rehabilitation (Continued)
controversy, 174-175 end-range lumbar flexion, axial loading pathophysiology, 283
human clinical treatment trials, 175t (avoidance), 300 phases, 291-306
Platelets, granule types, 171 exercises, 295-297, 300-301, 303-305 physical examination, 283
Plyoball instruction, 297 postoperative discitis, occurrence, 290
usage, 180f techniques, 295-297 postsurgical patient, home maintenance,
wall exercises, 237 functional recovery phase (phase II), 299-302 306b-307b
Plyometric exercises, 235-238 exercises, 300-301 postures, instruction, 294-295
amortization phase, 219 functional training exercises, initiation, problems, signs, 291
characteristics, 236t-237t 303-305 progressive spinal-stabilization program,
concentric response phase, 219 gastrocnemius stretching, 297f initiation (importance), 296
contraindication, 236 gracilis stretch, importance, 302f prone dural mobilization (upper lumbar
drills, 163f hamstring stretching, 301f neural mobilization), 296
eccentric/settling phase, 219 herniated discs, sagittal MRI, 284f protective phase (phase I), 291-298
examples, 607b herniated nucleus pulposus (HNP) quadriceps stretch, 302f
phases, 219 adolescent patient, 289 quadruped position
stress, occurrence, 236 complications, 289-290 exercise, 301f
trunk strengthening, 221 discussion, 290 tape application, 296f
Plyometrics, 606-607 high lumbar levels, 289 resistive training phase (phase III), 302-306
guidelines, 606b-607b hip flexion, importance, 297f scar, inspection, 298f
importance, 62 hip muscle strength testing, postponement, sitting/driving, postures, 294
principles, 606 294 skin exposure, subperiosteal elevation, 286f
push-ups, 217f hygiene, instruction, 295 sleeping, posture, 294-295
routine, 623-624 iatrogenic mechanical instability, 290 slump testing, timing, 294
training, introduction, 235 imaging/tests, 284 soft tissue mobilization, 301, 305
Plyometric training program landing, hip hinge position, 303f-304f soleus stretching, 297f
group, division, 236 lateral flexion movements, axial loading spinal mobilization, 297, 301-302, 305
implementation, 236 (avoidance), 300 standing motion testing
Plyotoss-proprioception drill/neuromuscular lateral recess assessment, 291
control, 610f disc space irrigation, 288 performing, 303
Pointer dog exercise, 352f exposure, 287 standing/walking, posture, 295
PolarCare, usage, 32 stenosis (removal), Kerrison rongeur stick drills, 305f
Polydioxanone suture (PDS) cord, pulling, (usage), 287f supine dural mobilization (lower lumbar
561-562 lifting neural mobilization), 295-296
Positive air pressure treadmills, usage, 466f activities, resumption, 303 surgery, indications, 284-285
Posterior capsular stretch, 87f instruction, 295 surgical indications/considerations, 283-285
Posterior capsular stretching, appropriateness, loaded lumbar flexion, avoidance, 291 surgical procedures, 285-290
109 lumbar microdiscectomy, 286-289 therapy guidelines, 289-290
Posterior capsule tightness, distinction, 105f closure, 288 three-point stance, 305f
Posterior elbow splint, 119f disc herniation, exposure, 288f thrust maneuvers, avoidance, 302
Posterior femoral osteotomies, 484f disc space irrigation, 288 transfers, instruction, 295
Posterior fusion, 315-316 interlaminar space exposure, 286 visual inspection, 283
Posterior lumbar arthroscopic discectomy/ lateral recess exposure, 287 Waddell signs, 294b
rehabilitation level/side, identification, 286 work-hardening activities, initiation, 305
adductor flexibility, importance, 302f ligamentum flavum, release, 287 wound care, 298
ball, diving movement, 305f nerve root/ligamentum retraction, 287 Posterior lumbar interbody fusion (PLIF), 315
bending, 295 nerve root retractor, release, 289f Posterior shoulder
body mechanics, 295 nerve root retractor, usage, 288f extensibility, 112
bridging exercise, 301f operative setup, 286 pain, 62
cardiovascular conditioning, 297-298, 302, postoperative course, 288-289 tightness, Tyler test, 105f
305-306 skin incision, 286 Posterolateral lumbar fusion, 315
cauda equina syndrome, 289 spinal canal entry, 286-287 Postoperative discitis, occurrence, 290
clinical case review, 307-309 management, 284-285 Postoperative posterior elbow splint, usage, 160f
closed wound, coverage, 299f microdiscectomy Postoperative range of motion brace, usage,
compression patch design, 291 161f
application, 298f phases, characteristics, 293t, 299t Postoperative spine rehabilitation, 290
manufacturing materials, 298f microscopic discectomy (microdiscectomy), Postoperative splinting, value, 222
conservative treatment, 285 286 Post-SAD patient, management protocol, 31
diagnosis, 283-284 modalities, 298, 306 Postural education, 89
discharge planning, 306 nerve root retractor, usage, 288f Postural muscles
discectomy, 287-288 neural injuries, rarity, 290 hip, classification, 23t
contraindications, 285 neurologic deficit, 285 knee, classification, 23t
disc herniation, 289 nonoperative treatment, 284 shoulder, classification, 23t
exposure, 288f operating microscope Preoperative anterior cruciate ligament
disc rupture, recurrence, 289 disadvantages, 285-286 reconstruction, phase characteristics,
disc space irrigation, 288 usage, 285-286 409t
dressing, instruction, 295 operative microscope, usage (photograph), Pressure biofeedback, usage, 324f
driving, avoidance, 291 285f Primary flexor tendon repair
dural mobilization, initiation, 295 Oswestry low back pain disability clinical case review, 213-214
dying bug exercise, 300f questionnaire, 292b surgical indications/considerations, 193
end-of-range movements, assessment, 291 partial sit-ups, 300f surgical procedure, 193-195
644 INDEX
Principle of short and long, 21-22 Quadriceps strength Rotator cuffs (Continued)
soft tissue immobilization, 21f increase, 411 arthroscopic-assisted miniopen rotator cuff
PROfx table, supine position, 377f increase, NMES (usage), 412 repair, results, 77
Progressive gait training, initiation, 490 isolated quadriceps strengthening, arthroscopic repair, 76
Progressive internal throwing program, progression, 414 Body Blade, usage, 85
246b-247b Quadruped alternating opposite arm/leg lift, cervical spine, 89
Progressive resistance exercises (PREs), 86-87, 325f evaluation, 89
228f Quadruped opposite arm/opposite arm leg clinical case review, 94-96
program, initiation, 267 multiplanar exercise, 620f clinical evaluation, 73-74
Progressive spinal-stabilization program, stability problem, 621f compression, 73
initiation (importance), 296 corner wall stretch, 85f
Progressive weight bearing (PWB), 460-461 R deterioration process, 74b
assessment/education/reinforcement, 462f Rabbits, MCL healing studies, 4 diagnostic testing, 74-75
Pronation, maximum (occurrence), 228f Radial ulnar notch, formation, 155-156 diagonal proprioceptive neuromuscular
Prone bridge, stability problem, 618f-619f Range of motion (ROM) facilitation patterns, Thera-Band (usage),
Prone dural mobilization (upper lumbar neural complications, persistence, 166 94f
mobilization), 296 insufficiency, 62-68 disorders, etiology, 73-75
Prone flies, 84f progression, 127, 162 distal mobility (control), proximal stability
Prone full can exercise, 59f restoration, 460-461 (importance), 83-84
Prone heel hangs, 410f Rats, MCL healing studies, 4-5 dynamic hug exercises, 83-84
Prone horizontal abduction, 54 Recreational activities, return, 137 dysfunction
Prone knee flexion, 493f Refractory pain, 118 pain, appearance, 73
Prone press-ups, 345f Remobilization, 19 symptoms, 75
Prone row exercise, 56f connective tissue impact, 18-20 eccentrics, 185f
external rotation, 59f Remplissage procedure, 46 exercises, 57-59
Prone rowing, 83f Repetitive microtrauma, hypovascularity force, application (judgment), 80
Prone scapular retraction progression, 274f (combination), 555 full-thickness tears, 75
Proprioception Resectional arthroplasty (Keller) bunionectomy, hand-behind-back stretch, 87f
enhancement, 460-461 584f healing rates, factors, 78
improvement, 547 Resistance exercises, initiation, 82 history, 73-74
increase, 546 Resisted exercises horizontal adduction, avoidance, 79-80
physical therapist analysis, 38 initiation, 82-83 incision, healing/closure, 82
Proprioceptive neuromuscular facilitation tubing, usage, 87-88 Isotonic scaption exercises, 81f
(PNF) Resisted trunk motions, 326f Langer lines, incision (cosmesis), 76f
active assistive PNF D1/D2 patterns, 81 Resistive gripping exercises, resistive putty miniopen repair, 76
continuation, 59 (usage), 227-228 mobilizations, grades I/II oscillations (usage),
description, 108 Rest Ice Compression and Elevation (RICE), 8 79
interventions, 47 initial treatment, 8 MRI, usage, 74-75
patterns Resurfacing arthroplasty, usage, 363f nonoperative treatment programs,
performing, 61 Revascularization, 406 continuation, 75
resisted exercises, performing, 84-85 Reverse lunge, 321f open repair, 76-77
pulley pattern, 180f Rhythmic stabilization, 165f pain/swelling reduction, cryotherapy (usage),
Proprioceptive training, balance (relationship), Richards compression screw-plate device, usage, 79
447 540f partially open repair, incision line, 76f
Propulsive gait, dorsiflexion (requirement), 580f Right ankle partial rotator cuff tear, 75
Proteoglycans, role, 5 anterolateral talar dome, synovitis/scarring passive range of motion (PROM), 77-78
Proximal drill guide, distal-locking block (arthroscopic picture), 541f physical examination, usage, 74
assembly, 393f arthroscopic surgery, 539f physical therapy evaluation, components, 79b
Proximal fragment, nail (insertion), 383f talus, medial osteochondral lesion posterior capsular stretch, 87f
Proximal humerus, sutures (usage), 121f (transmalleolar drilling), 539f postsurgical patient, home maintenance,
Proximal interphalangeal (PIP) joints Right femur, radiographs (anteroposterior/ 92b-93b
contraction, 198 lateral view), 10f postural education, 89
flexion, 204f Right fracture, lateral malleolus fracture, progressive resistance exercises (PREs), 86-87
Proximal tibia, exposure, 487f 523f prone flies, elbow extension, 84f
Pulley system, annular pulleys, 195f Right humeral head, exposure, 119f prone rowing, 83f
Pulmonary embolus (PE), 496 Right lower extremity radiography, importance, 74-75
clinical signs, 496 lunge stretch, 599f range of motion (ROM), 77-78
history, 482 starting position, 597f rehabilitation, therapy guidelines, 77-88
Pulmonary hygiene exercises, 369 Right-sided disc herniation (C6-7), preoperative repairs, 78t
Pure protein therapy, gene therapy (contrast), 13f axial MRI, 258f moderate-sized tears, 80t, 82t, 86t, 88t
Pure tendinosis, 554 Ring finger, flexor tendons (repair), 194f phases, 78-85, 87-88
appearance, 555 Robbery exercise (external rotation), 36 postoperative management, 77
Rotator cuff muscles resistance exercises, initiation, 82
Q attention, 36 resisted exercises
Quadriceps eccentric control, achievement, 61 avoidance, 81
inhibition, 436 EMG output, 34 initiation, 82-83
mechanism, avoidance, 486f Rotator cuffs tubing, usage, 87-88
muscles (activation), electrical stimulation accessory movements, application, 90 scapulothoracic joint, 91
(usage), 432 acromioclavicular (AC) joint, 90-91 seated push-ups, 84f
set, adductor (addition), 395f acromioclavicular (AC) mobilization, shoulder extension, 93f
stretch, 302f posteroanterior (PA) movement, 83f shoulder girdle depressions, Swiss ball
weakness, 498 adverse neural tension, 90 (usage), 84f
INDEX 645
Rotator cuffs (Continued) Running patient, transition (Continued) Scar (Continued)

side-lying position, elbow bend, 83f management, 621-623 evaluation, 222
sternoclavicular (SC) joint, 91 types, identification, 623 formation, maturation phase, 2
strength phases, 623-625 management, 197
strength, improvement, 81 plyometric routine (phase II), 623-624 massage, initiation, 226f
strengthening program return, 623-625 mobility, maintenance, 326-327, 327f
exercises, progression, 86-87 prone bridge pain, 131-132
normalizing AROM, 85 sagittal plane, 618 remodeling, 127
progression, 51 stability problem, 618, 618f-619f manual massage technique, usage, 120f
surgery quadruped opposite arm/opposite leg, 620 tissue formation
goal, 75 multiplanar exercise, 620, 620f fibroplastic phase, 20
indication, 75 stability problem, 621f granulation phase, 19-20
surgical goals, 75 side bridge, 619f inflammatory phase, 19
surgical procedures, 75 frontal plane, 618 maturation phase, 20
surgical technique, 75-77 stability problem, 618, 619f phases, 19-20
tears, occurrence, 73 single-leg squat test, 621, 622f trauma, 19-20
tendonitis, 75 multiplanar characteristic, 621, 621f SCARF procedure, 586f
tendons stability problem, 621 comparison, 591
defects, management, 77 strength, 616-621 Scarpa fascia incorporation, 486f
transosseous repair, 77f tandem stance, 617 Scar tissue
Thera-Band, usage, 86-87 timed running schedule (phase IV), 624-625 development stage, assessment, 20
thoracic extension, foam roll/tennis balls advanced level, 625 direction/length (control), movement
(usage), 90f intermediate level, 625 (impact), 20
thoracic spine, 89-90 list, 625t mechanics, behavior, 19
treatment, 75 walking program (phase I), 623 mobilizations, 20
troubleshooting, 88-91 walk/jog progression (phase III), 624 post-surgical interaction, 20
trunk/legs, strengthening, 85 list, 624t stress, 20
tubing-resisted exercises, four square Russell-Taylor interlocking nail technique, 385f Sciatica, HNP (impact), 284
combination, 82-83 Scioscia, Mike, 233
upper extremity, dermatomal pattern, 89f S Seated push-ups, 84f
watertight repairs, necessity, 77 Sagittal plane long kinetic chain alignment, Segmental disc space narrowing, spinal
Rotator cuff tears focus, 189f radiographs, 313
arthroscopic repair, 76 Sandwich technique, ACI, 459 Self-mobilization, 437f
full-thickness rotator cuff tears, treatment Savage flexor tendon repair, 195f Self-neurogliding techniques, 272f
results, 77 SB Charit disc, approval, 338-339 Semmes-Weinstein Monofilament Test, deficits,
moderate-sized tears, rotator cuff repair, 78t Scaffold-associated second generation ACI 222
repair, 76 techniques, three-dimensional Sensibility testing, 221
visualization/mobilization, 77 biodegradable scaffolds (usage), 460 Serotonin, release, 172
Ruffini mechanoreceptors, manual stimulation, Scan desensitization, initiation, 224 Serratus anterior, maximum voluntary
18 Scaption contraction (MVC), 104
Rugby, stick drills, 305f external rotation, 36f Serratus anterior muscle
Running patient, transition internal rotation, 34f early strengthening, 104
ambulation, 616-617 performing, 34-36 function, 53
arm and leg drop, 621f plane, wand (usage), 130f strength
assessment, 616 Scapula advancement, 59-61
balance, 616 mobilization/rhythmic stabilization, 104f importance, 55-57
progression, 617 posterior glide, 105f Serratus dynamic hug, 56f
baseline balance test, 617 Scapular anterior tipping/winging, 68-69 Serratus press, 51f
bridge, 617f Scapular control, achievement, 54 Serratus punch, 58f
knee extension, 620 Scapular mobilization, 128f Sesamoid bones, weight-bearing plantar axial
knee extension, stability problem, 620 Scapular plane (scaption), flexion/abduction radiograph, 581f
knee extension, transverse plane, 618 (passive range of motion), 47 Sheath-pulley system, 196
stability problem, 618f Scapular positioning Short arc quadriceps exercises, addition, 447
calf raise, single-leg hop progression, 620 achievement/maintenance, 51 Short external rotators
clinical case review, 626-627 assessment, 47 division, 365f
closed-chain progression, 624t proprioceptive neuromuscular facilitation exposure, blunt dissection (usage), 364f
considerations, 625-626 (PNF) interventions, 47 Shoulder
coordination, 616 Scapular retractions, resistance tubing (usage), abduction, 93f
core stability, 617-620 274f early cocking, relationship, 238
endurance, 617-621 Scapular stabilization, problem, 110-112 anterior aspect, incision, 119f
flexibility, 616 Scapular stabilizers complex, range/motion axis, 91t
hips sag, 621f isometric training, 132 exercises, progressive loading, 178
hop and stop test, 622f usage, 37 extension, external/internal rotation, 93f
intensity, increase, 624 Scapulohumeral rhythm, 53 flexion, elbow extension, 93f
knee extension observation, 37 girdle
stability problem, 620f Scapulothoracic dysfunction, 73 depressions, Swiss ball (usage), 84f
transverse plane, 619f Scapulothoracic joint, 91 proximal muscle strengthening, 228-229
leap test, 622f Scapulothoracic rhythm, emphasis, 53 hike, usage, 138
lower extremity stability, 620-621 Scar humeral components, 120f
mileage schedule, 625 adhesion, development (limitation), 224 instability, 44
mileage table, 625t-626t assessment, 221 classification, 45b
pain conformer, fabrication, 226f internal rotators, strengthening, 36-37
646 INDEX
Shoulder (Continued) Soft tissues (Continued) Superior labral anterior posterior (SLAP)
isometrics, initiation, 148 rebalancing, 589 lesions (Continued)
Jobes exercises, 224t resection, glenoid exposure, 120f dynamic hug exercise, 104f
kinetic chain, 234 structures, mobilization, 271 D2 flexion, manual resistance, 108f
mobility Soleus stretching, 297f early protective phase (Phase I), 103-105
restrictions, assessment/treatment, 327-328 Southern California Orthopedic Institute early protective postoperative period, focus,
thoracic mobility, impact, 89 (SCOI) arthroscopic lateral release 103
oscillation, 106f technique, 429 early protective postoperative rehabilitation,
postural/phasic muscles, classification, 23t Spider killers, 412f 103-104
proximal muscle strengthening, 228-229 Spinal mobilization, 297, 301-302, 305 external rotation (ER)
replacement operation, approach, 119 Splinting, usage, 217 passive range of motion (PROM), 106
upper extremity range of motion, restoration, Spontaneous fusion, 354 rhythmic stabilization, 104f
264-265 Sporting activities (simulation), plyometric strengthening (side-lying position), free
warm-up exercises, 236 exercises (usage), 529-530 weight (usage), 107f
Shoulder-supporting musculature, 234 Sports medicine, PRP regulation, 174-175 strengthening (90/90 position), elastic
Side bridge, stability problem, 619f Sports-related injuries, 7-8 resistance (usage), 109f
Side lying femoral nerve Sports-specific activities, consideration, 59 glenohumeral (GH) joint, hypomobility/
test, 348f Stability ball walk-out, 60f hypermobility, 110
testing procedure, 349b Stabilization taping, 431f internal rotation (IR)
Side-lying position, elbow bend, 83f Stabilization techniques, expansion, 46 rhythmic stabilization exercise, 104f
Side steps, resistance loop (combination), 451f Stance foot, position (importance), 222 sleeper stretch, 107f
Simple shoulder test (SST), 127 Standing balance activities, 326f isotonic exercises, light resistance (emphasis),
Single-leg hop Standing motion testing 108
progression, 620 assessment, 291 lesions, combination, 102
tests, 610 performing, 303 nonoperative management, 99
Single-leg reach, 351f Static positioning guidelines, 202-204 outcomes, 102
Single-leg squat Static stretching, controversy, 604 Physioball wall walkouts, 109f
exercise, 605f Steinmann pin, usage, 383f portals, establishment, 101
multiplanar characteristic, 621f Step down progression, 189f posterior capsule stretching, appropriateness,
test, 621, 622f Step up and down exercise, 415f 109
multiplanar exercise, 621 Step-up progression, 494f posterior shoulder
stability problem, 621 Step-ups, 514f extensibility, 112
Single-limb balance, elastic band (usage), 415f Sternoclavicular (SC) joint, 91 stretch, supine scapula stabilization, 106f
Single-limb balance, medicine ball (usage), 416f Stick drills, 305f posterior shoulder tightness, Tyler test,
Single-limb balance, terminal extension, 415f Straight fist, 199f 105f
Sitting hamstring stretch, 398f Straight leg raise (SLR) proprioceptive neuromuscular facilitation
Sitting low trapezius, 136f base test, 347f (PNF), 108
Sitting postures, 322f test foot positions, 347f rehabilitation, therapy guidelines, 102-110
Sit-to-stand exercise, 494f testing procedure, 349b return-to-activity phase, impingement
Skater, single-limb balance, 416f usage, 283, 490 symptoms, 112
Skeletal muscles Stretching program, 162b scapula
anatomy/function, 7 Stride direction, 223-224 mobilization/rhythmic stabilization, 104f
contraction, 7 Stride forward, initiation, 223 posterior glide, 105f
filaments, sliding, 7 Stride leg, movement, 239, 241 scapular stabilization, problem, 110-112
healing, 7-10 Structural fracture healing shoulder oscillation, 106f
injuries, 7-10 hard callus, third stage, 12f supine scapula, stabilization, 106f
phases, 8 soft callus, second stage, 11f surgery, sports return (time lapse), 110t
sports-related injuries, 7-8 Subacromial depression (SAD) surgical procedure, 100-102
structural element, 7 clinic-based rehabilitation, 38 troubleshooting, 110-112
Skill-specific training, 435f consideration, 29 type I lesion, 100
Skin exposure, subperiosteal elevation, 286f procedures, goals, 31 debridement, results, 101f
Skin incision, extension, 487f Subacromial procedures, double-cannula superior labrum, fraying, 100f
Skin pen, usage, 120 arthroscope (recommendation), 30 type II lesion, 100-101
Sleeper stretch exercise, 56f, 107f Subacromial soft tissue, relationship, 28 labrum base, 101f
Slide board, 609f Subacromial structures, impingement repair, 101f
Slow twitch (type I) muscle fibers, atrophy, 604 (prevention), 34f sutures, usage, 102f
Slump testing, timing, 294 Submaximal shoulder isometrics, initiation, 148 type III lesion, 101
Small fingers, flexor tendons (repair), 194f Subperiosteal bone, structural fracture healing, tear, 102f
Soft callus stage, 11 11f type IV lesion, 102
Soft tissues Subscapularis muscle, dissection, 46 bucket handle tear, 103f
closure, anatomic fashion, 31 Subtrochanteric hip fractures, 383-384 upper body ergometer (UBE), light resistance
contractile characteristics, 21 pathologic anatomy, diagram, 384f (usage), 107
healing Superficial nerves, nerve entrapment, 597-598 verbal feedback, 106
protection, 32-34 Superficial peroneal nerve, compression, 497 Superior labral anterior posterior (SLAP) repair
timeframes, 340t Superior glenohumeral ligament (SGHL) tear, advanced strengthening phase (phase IV),
immobilization, principle of short and long, 46 109
21f Superior labral anterior posterior (SLAP) clinical case review, 113
impingement, 541f lesions, 99 contradictions, 104-105
management, 539 cause, 99 early protective phase, 103-105
mobility, maintenance, 326-327, 327f classifications, 100f initial postoperative examination, 103
mobilization, 301, 305, 345-346 clinical evaluation, 99-100 intermediate phase (phase II), 105-107
avoidance, 432 diagnostic testing, 100 phases, 103-110
INDEX 647
Superior labral anterior posterior (SLAP) repair Tendons (Continued) Throwing motion
(Continued) spontaneous ruptures, rarity, 556 deceleration phase, 162
postsurgical patient, home maintenance, 113b tension, minimization, 207-208 front view, 156f
rehabilitation guidelines, 111b-112b Tennis elbow glenohumeral (GH) joint, 167
return-to-activity and sport phase (phase V), patient-related tennis elbow evaluation phases, division, 238
109-110 (PRTEE), 123 side view, 242f
return-to-activity phase, impingement surgical technique, 119f windup, preparatory phase, 224
symptoms, 112 Tennis players, rehabilitation program, 66b-68b Thrust maneuvers, avoidance, 302
strengthening postoperative phase (phase Tensile strength (improvement), connective Tibia (posterior aspects), ball (usage), 600f
III), 107-108 tissue (impact), 183 Tibial nerve, position, 347f
surgical indications/considerations, 99-100 Tension band wiring techniques, usage, 471 Tibial surface, resection, 487f
Superior labrum, fraying, 100f Terminal knee extensions (TKEs), usage, 490 Tibial template, rotationally alignment, 485f
Superior radioulnar joints, single-axis Thera-Band Tibiofemoral joint repairs, side-lying clam
diarthrodial joint function, 144 securing, 166f exercise (usage), 464f
Supine activities, foam roll (usage), 326f usage, 86-87 Tilt compression, 427
Supine dural mobilization (lower lumbar neural Thigh pain, walking, 399 Tissue
mobilization), 295-296 Thompson test, 556-557 healing, 172
Supine elbow support position, 127f Thoracic extension, foam roll/tennis balls phases, 562f
Supine greater angle progressive tilt starting (usage), 90f platelet function, 171
position, 134f Thoracic mobility principles, 339-340
Supine hip arthroscopy, 384 impact, 89 identification, 173
Supine lying, support, 321f restrictions, assessment/treatment, 327-328 mobility, maintenance, 327f
Supine marching, 324-325 Thoracic spine, 89-90 pliability, risk injury (relationship), 20f
Supine progressive tilt starting position, 134f evaluation/treatment, 89-90 quality, misapprehension, 62
Supraspinatus musculature, challenge, 273-275 remodeling, continuation, 59
involvement, 34 segments, flexibility (decrease), 267 tolerance, continual monitoring, 603
strengthening exercises, 36b Three-pont stance, usage, 305f T kicks, 450f
Sural nerve, position, 347f Thromboembolic disease (TED) hose, 368-369, Toe-raising exercises, Achilles tendon forces
Surgery 394-395 (increase), 556f
definition, 15 Through-range external/internal rotation, Total disc replacement (TDR) surgery, goal, 354
perspective, 20 resistance bands (usage), 55 Total hinge implant, medial view (intraoperative
Surgical incision Thrower, progression, 246 photograph), 583f
controlled trauma, 2 Throwers Ten Program, 162-164 Total hip arthroplasty (THA)
evaluation, 222 components, 164b anterior total hip arthroplasty, rehabilitation,
Symmetric ankle dorsiflexion, 593 Throwing 380
Syndesmosis screws, usage, 525 evaluation checklist, 245b study, 379-380
Synovial sheath, tendon divisions, 5 flat-footed approach, 246 Total hip replacement (THR)
Synthes Prodisc-L implant, 336f foot placement, importance, 246-249 acetabulum, exposure, 367f
late cocking phase, 239 active hip flexion, 368
T humerus, maintenance, 242 ankle circles, avoidance, 369
Table press (serratus press), 51f mechanics, development, 246-251 ankle pumps, 368f
Table top position, 126f movement, plyometric exercises, 236-237 anterior capsulectomy, 366f
Talus pitcher-specific interval throwing program, anterolateral approach, 365-366
osteochondral lesion, treatment, 542f progression, 246 clinical case review, 373-374
tunnels, location, 507f progressive internal throwing program, discharge, 370
Tandem balance, 352f 246b-247b criteria, 370
Tandem stance, 617 shoulder, dynamic stability, 233 femoral preparation, 365
TED hose stockings, usage, 341 Throwing athlete, transitioning gluteus medius, anterior fibers (release), 366f
Telos device, inversion stress testing, 505f abdominals, core strength (development), high-impact sports, 372
Tendonitis, 75 234 hip joint capsule (exposure), retraction
Tendons aerobic conditioning, 238 (usage), 365f
anatomy/function, 5-6 assessment, 233 home care phase, 371
blood supply, limitation, 5-6 baseball pitching, 238-241 hospital discharge, 371
characteristics, 5 clinical case review, 252-253 hospital phase (phase IIa), 368-369
defects, management, 77 conditioning principles, 234b hybrid cemented total hip arthroplasty, 363f
controversy, 77 Golgi tendon organs, inhibitory effect, 236 impact, 362
direct trauma, 6 injuries, 233 isometric hip abduction, submaximal force
divisions, 5 isotonic exercises, 235 recommendation, 369
forces, impact, 555 kinesthesia, 233-234 isometric hip extension, 368
gliding, exercises, 223f muscle balance, development, 234 noncemented modular total hip arthroplasty,
healing, 5-7 neural adaptation, 236 363f
considerations, 562 neuromuscular control, defining, 233 non-weight-bearing (NWB) order, 367
early phase, passive IP extension, 198 neuromuscular coordination, 236 outpatient clinic, 371
mobilization/immobilization, effect, 7 plyometric exercises, 235-238 patient
phases, 7t characteristics, 236t compliance, 372
healing stages, 193 contraindication, 236 lateral decubitus position, 365-366
injuries, 5-7, 194-195 phases, division, 235 repositioning, 369
occurrence, 6 plyometric training program, 236 phases, 367-372
progression, 557f program development, 234 phases, characteristics, 368t, 370t
midsubstance ruptures, 6 strengthening/conditioning, 233-235 physical therapy intervention, 371
nutrition, 5 throwing, 238-243 posterolateral approach, 364-365
rupture, activities, 555 weight training, popularity, 235 precautions, 367
648 INDEX
Total hip replacement (THR) (Continued) Total knee arthroplasty (TKA) (Continued) Total shoulder arthroplasty (TSA) (Continued)
postoperative sequences, 369-370 medical considerations, 488-489 disability assessment of shoulder and hand
postsurgical patient, home maintenance, minimally invasive surgery, 485-488 (DASH), usage, 127
372b-373b advancements, 495 early range of motion, signs/symptoms, 130b
postural assessment, 371 comparison, 499t exposure, 119
preoperative training session (phase I), muscle imbalance, 497-498 external rotation limitation, 128
367-368 muscle strength, 493-494 functional limitation, resolution, 137
prostheses, usage, 362 neuromuscular electrical stimulation functional mobility assessment, initiation,
pulmonary hygiene exercises, 369 (NMES), 490 123-124
rehabilitation osseous preparation, 483-485 functional outcomes, prognostication,
center, treatment, 370 outcomes, 499 122-123
initiation, 365 outpatient care (phase III), 492-495 glenohumeral (GH) arthritis, preoperative
intervention, 371-372 outpatient home health (phase IIb), 495-496 anteroposterior radiograph, 122f
therapy guidelines, 367-372 passive overpressure, usage, 492f glenoid face, preparation, 121f
return home (phase III), 370-372 patella, lateral subluxation, 487f glenoid implants, 121f
short external rotators patellar thickness (measurement), caliper home exercise program, 126
division, 365f (usage), 485 horizontal pulley, 130f
exposure, blunt dissection (usage), 364f patella template, usage, 486f humeral head, resection, 120f
skin incision, shape/location, 366f peroneal nerve neuropraxia, 497 humeral implants, 121f
surgery, 368-369 phases, characteristics, 489t, 491t-492t, 495t impairments, impact, 133
contraindications, 362 pillow, positioning, 490f incision, 119f
surgical indications/considerations, 362 polyethylene patella, usage, 483f deltopectoral approach, 119
surgical procedures, 362-366 posterior cruciate substitution, usage, 483f infection, 139
touch down weight bearing (TDWB), 369 posterior femoral osteotomies, 484f initial postoperative examination, 123-124
troubleshooting, 372 preoperative evaluation, 482 internal rotation, sling (usage), 129f
usage, 362 components, 482 isometric bands, usage, 133f
walker/crutches, requirement, 366 preoperative radiographs, 482 isometric training, support, 132
weight-bearing status, 369 procedure, 482 limited goal category, 138
Total knee arthroplasty (TKA) progressive gait training, initiation, 490 range of motion achievement, 138b
anterior femoral osteotomies, 484f prone knee flexion, 493f tissue insufficiency, 138b
anterior/posterior chamfers, performing, 485f prosthetic options, 480-481 movement analysis, scapulohumeral rhythm,
aquatic therapy programs, effectiveness, 494 proximal tibia, exposure, 487f 128b
clinical case review, 499-500 pulmonary embolus (PE), 496 Neer protocol, 124-126
continuous passive motion (CPM), usage, quality of life, improvement, 499 neural screening, completion, 123
490 rehabilitation outpatient rehabilitation
difficulties, 492-493 phases, 488-495 complications, 130-131
distal femoral guide, attachment, 484f therapy guidelines, 488-495 early range of motion (phase II), 127-131
distal femur, exposure, 487f resurfacing, 480-481 initiation, 127
effectiveness, 480 sandbag, usage, 482 late phase strengthening (phase IV),
equilibrium, changes, 494 sit-to-stand exercise, 494f 133-137
exposure, 482-483 skin incision, extension, 487f late ROM/early strengthening, 131-132
failures, 481 step-up progression, 494f pain, control, 128
femoral components, implantation, 488f straight leg raises (SLRs), usage, 490 passive range of motion (PROM), goal, 129b
femoral shaft, anatomic axis (parallel), 482f suction drainage, 486f patient position, 119f
flexibility imbalances, 493-494 surgery, rehabilitation, 495-496 patient weakness, evaluation, 134-136
flexion deformity, 483 surgical incision, monitoring, 488-489 pendulum exercises
forces, increase, 494 surgical indications/considerations, 480-482 sagittal plane/frontal plane, 125f
full extension, 484-485 surgical procedures, 482-485 usage, 124
necessity, 492-493 surgical technique, 482-488 peripheral osteophytes, removal, 120f
functional complications, 497-499 terminal knee extensions (TKEs), usage, phases, 124-137
functional considerations, 490-491 490 characteristics, 124t, 127t, 132t, 135t
functional outcomes, 484f tibial components, implantation, 488f physical examination, 118
hip lateral rotation, 498f tibial surface, resection, 487f postsurgical patient, home maintenance, 139b
home exercise program, initiation, 492 tibial template, rotationally alignment, 485f postsurgical precautions, 123b
infection, risk (reduction methods), 496 treatment, effectiveness, 481 postsurgical sling, protective posturing, 128
inpatient acute care (phase I), 488-491 trial components, removal, 485 preoperative factors, impact, 123b
inpatient extended care/skilled nursing troubleshooting, 496-499 preoperative impairments, 121b
facility (phase IIa), 480 valgus deformity, 483 preoperative range of motion, 118
intramedullary/extramedullary tibial cutting varus deformity, 483 PROM, initiation, 124
guides, usage, 483 wound prone positions, 135f
intramedullary femoral guide, usage, 484f closure, 486f proximal humerus, sutures (usage), 121f
intravenous antibiotics, continuation, 488 infection, 496 range of motion (ROM)
joint effusion, persistence, 496-497 Total knee replacement (TKR), 480 goals, 137t
kneeling, 498-499 Total shoulder arthroplasty (TSA) progression, 128
left knee, surgical exposure, 483f biceps tendon tendonitis, 139 self-assisted activities, 129
ligament balancing, 483-485 clinical case review, 140-142 recreational activities, return, 137
long-term rehabilitation goals, 494-495 clinical evaluation, 118 refractory pain, 118
lymphedema, 497 history, 118 rehabilitation
manipulation under anesthesia (MUA), clock reach, 136f cautionary signs/symptoms, 134b
492-493 complications, 138b hospital phase (phase I), 124-126
indications, 493 deltopectoral interval, 119 progression, 123
medical complications, 496-497 direct passive ROM, 128 therapy guidelines, 121-137
INDEX 649
Total shoulder arthroplasty (TSA) (Continued) T-sign, 171 Underhanded lifting technique, 120f
right humeral head, exposure, 119f T test, 611f Unicompartmental knee arthroplasty (UKA),
scaption plane, wand (usage), 130f Tubing-resisted exercises, four square 480-481
scapular mobilization, 128f combination, 82-83 Unicompartmental resurfacing, 480-481
scapular stabilizers, isometric training, 132 Tunnels, creation, 507f Unstable fracture, surgical approach, 536
shoulder hike, usage, 138 Type I (slow twitch) muscle fibers, atrophy, 604 Up and down from the floor exercise, 327f
simple shoulder test (SST), usage, 127 Upper body ergometer (UBE), usage, 55
sitting low trapezius, 136f U Upper crossed syndrome, 265
sleeping postures, recommendation, 128 Ulnar collateral ligament (UCL) musculature, imbalance, 267f
sling, internal rotation, 129f anterior oblique bundle, 156 Upper extremity (UE)
soft tissue resection, glenoid exposure, 120f attachment site, medial epicondyle service, AROM/resistive exercises, 543
starting wand position, 130f 156f dermatomal pattern, 89f
stiffness, 139 complex, 156f injuries, 216
strengthening, impact, 136 description, 156 kinetic chain, 234
strength training, caution, 137 elbow ROM (improvement), postoperative loading, slide board patterns (usage),
supine elbow support position, 127f range of motion brace (usage), 161f 186f
supine greater angle progressive tilt starting extensor supinator muscles, 157 patterns, Body Blade (usage), 181f
position, 134f failure, 167-168 plyometric training program, group division,
supine progressive tilt starting position, 134f figure-eight reconstruction, autogenous graft 236
surgical indications/considerations, 118 (usage), 160f progressive resistance exercise (PRE)
surgical procedure, 118-121 flexor-pronator muscles, 157 program, initiation, 267
table top position, 126f injury pulley pattern, 180f
T-position exercise, 135f cause, 158-159 range of motion
trauma, 138 description, 158-159 evaluation, 320
troubleshooting, 138-139 ligamentous structures, 156-157 restoration, 264-265
walk aways, isometric deltoid/external median nerve, course, 157 strengthening, 395
rotation, 134f muscular structures, 157 half-kneel position, Body Blade/Plyoball
wall slides starting/finishing positions, 131f neurologic structures, 157-158 (usage), 184f
Y-position exercise, 135f PRP injection Upper extremity, D1 D2 proprioceptive
Total shoulder replacement, 124t, 127t, 132t, 135t inflammatory phases, 177t neuromuscular facilitation patterns
Touch down weight bearing (TDWB), 369 reparative phase, 182t foam roller/Plyoball, usage, 180f
patient, 383-384 range of motion (ROM), progression, 162 Physioball, usage, 181f
difficulty, 395 reparative phase, PRP injection, 179t Upper limb neurodynamic test (ULNT)
T-position exercise, 135f resting tensile strength, 159f development, 270
Trampoline stork standing, 513f compression wraps, impact, 160 positions, 271t
Transcutaneous electric nerve stimulation slide board patterns, usage, 186f ULNT 1 technique, 270f
(TENS) unit, 131 stress, upper extremity pulley pattern, 180f ULNT 1 testing procedure, 271b
effectiveness, 166 visualization, 159 Upper-limb tension testing, 222
usage, 298 Ulnar collateral ligament (UCL) reconstruction Upper lumbar neural mobilization (prone dural
Transforaminal lumbar interbody fusion (TLIF), anatomy, 155-159 mobilization), 296
315 bony structures, 155-156
Transforming growth factor-B1 (TGF-B1), 171 complications, 167 V
Transverse carpal ligament (TCL) goal, 159 Valgus deformity, 483
appearance, 219f humerus, proximal radius/distal lateral Valgus instability (correction), surgery (usage),
division, 216 aspects, 155 159
carpal canal, exposure, 219f interval throwing program, phases, Valgus stress, initiation (occurrence), 158
exposure, 218f 166b-167b Varus deformity, 483
initial cut, integrated scalpel (usage), 219f manual resistance proprioceptive Varus-valgus forces, 408-409
Transverse muscle bending, 22 neuromuscular facilitation (manual Vascular complications
Transverse plane subtalar joint position, focus, resistance PNF), 164f ACSD, 276
189f one-handed baseball throw, usage, 163f lumbar spine disc replacement, 354
Transversus abdominis strengthening, 345f phases, 160-165 Vascular endothelial growth factor (VEGF),
Trauma, 19-20 plyometric exercise drills, 163f 171
connective tissue impact, 18-20 postsurgical patient, home maintenance, 165 Vascular structures, injury, 354
Trendelenburg gait, 283 range of motion complications, 166 Vastus lateralis fascia, repair, 536-537
Trendelenburg sign, nonresolution, 399 rehabilitation, therapy guidelines, 160-165 Vastus medialis oblique (VMO), 432
Triceps, strengthening, 59 stretching technique, 165-166 function, 23
Triceps brachii, elbow extension, 157 submaximal shoulder isometrics, initiation, timing, improvement, 428
Trimalleolar fracture, 524 160 Verkhoshanski, Yuri, 235
Trochanteric fractures, internal fixation, 383f superior/inferior radioulnar joints, single-axis Vertical jump test, 610f
Dimon-Hughston method, 383f diarthrodial joint function, 155-156 Viscoelastic model, 17
Trochlea, defects, 461, 463 surgical indications/considerations, 155-159 Viscoelastic phenomenon, 17
Trunk surgical procedure, 159-160 occurrence, 17
lateral movement, 239 Throwers Ten Program, 164b Visual Analog Scale (VAS), 123
rotation, development, 249-251 troubleshooting, 165-168 Volar radiocarpal ligament, 217-218
rotation/hand towel drill, 249-251 T-sign, 171
front view, 250f ulnar nerve transposition, phase W
side view, 251f characteristics, 161t-163t, 165t Waddell signs, 294b
technique, problem, 252f Ulnar nerve transposition Walk aways, isometric deltoid/external rotation,
strengthening, 85 completion, 160 134f
plyometric exercises, 237 phases, characteristics, 161t-163t, 165t Walking-to-running program, 451
warm-up exercises, 236 Uncontrolled trauma, correction, 15 Walk/job progression, 624t
650 INDEX
Wall angels, 268f Windup (Continued) Wrist

Wall press (serratus press), 51f phase, 243f composite flexion, 224
Wall slides throwing/pitching motion, 238 dorsal blocking splint, 204f
adductor pillow, usage, 397f Work activity simulation, 229 exercises, progressive loading, 178
closed-chain wall slide, 434f Work-hardening activities, initiation, 305 flexion
overhead exercise, 58f Work tasks, simulation, 228f elbow extension, 120f
starting/finishing positions, 131f World Anti-Doping Agency (WADA), flexion, work (requirement), 208
Warm up/cool down, 606 platelet-derived preparation prohibition, flexors, functional strength (increase),
Warm-up exercises, performing, 236 174-175 164f
Watershed area, 556-557 Wound flips, 164f
Weber B fracture, occurrence, 522 assessment, 221 median nerve glide, 223f
Weber C fracture-dislocation, 523f care, 298 splinting, 220
Wedge self first metatarsal phalangeal joint closure, 486f strengthening, 162-164
dorsiflexion stretch, 599f contraction, granulation phase, 3f tenodesis exercises, 197
Weight bearing as tolerated (WBAT), 543-544 gap, blood clot (impact), 3f example, 197f
status, 397 infection, 496 Wrist-neutral dorsal blocking splint, elastic
Weight training, 219-220 site, fragility, 263 traction (usage), 210f
program, initiation, 219 Wound healing, 2
Wilt, Fred, 235 clinical case review, 13 Y
Windup coagulation, 3f Yoga, usage, 217
football throwing motion, 241 granulation phase, 3f Y-position exercise, 135f

Rehabilitation For The Postsurgical Ortho-2013

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third edition

JIM MAGNUSSON, PT, ATC

Rehabilitation for the Postsurgical Orthopedic Patient, Third Edition 978-0-323-07747-7

Copyright 2013 by Mosby, an imprint of Elsevier Inc.

Previous editions copyrighted 2007, 2001

Library of Congress Cataloging-in-Publication Data

Vice President: Linda Duncan

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my two children, Nicholas and Michelle.

Clive E. Brewster, COO

Erin Carr, PT, DPT Daniel A. Farwell, PT, DPT

Robert Donatelli, PhD, PTOCS Mark Ghilarducci, MD

Eric Giza, MD Reza Jazayeri, MD

Chris Izu, MPT, DPT, OCS Bert R. Mandelbaum, MD

Joel M. Matta, MD Luga Podesta, MD, FAAPMR

Kai Mithoefer, MD Ben B. Pradhan, MD

Chris A Sebelski, PT, DPT, OCS, CSCS

Holly J. Silvers, MPT Kevin E. Wilk, PT, OPT

PART 1 13 Transitioning the Throwing Athlete Back

1 Pathogenesis of Soft Tissue and Bone Repair, 2

6 Superior Labral Anterior Posterior Repair, 99

8 Extensor Brevis Release and Lateral

24 Meniscectomy and Meniscal Repair, 441 30 Ankle Arthroscopy, 536

26 Patella Open Reduction and Internal Fixation, 470 32 Bunionectomies, 579

27 Total Knee Arthroplasty, 480 33 Transitioning the Jumping Athlete Back

29 Open Reduction and Internal Fixation Index, 628

ENHANCE YOUR LEARNING AND

What You Need

Point the devices camera at the code and scan.

Ligament Anatomy and Function Ligament Injury

TABLE 1-1 Epithelial Tissue Healing

Adapted from Browner BD, etal: Skeletal traumabasic science,

Glycine Glycine Glycine

Fig. 1-3 Schematic drawing of the collagen structure. A linear polypeptide

although edema, swelling, and punctate ligament bleeding

augment the biochemical, morphologic, and biomechanical

TENDON INJURIES AND HEALING

along the length of the tendon. However, there seems to be

TABLE 1-3 Tendon Healing

paratenon-covered tendons, the healing of sheathed tendons

Effect of Mobilization and Immobilization

Other authors theorize that after the muscle injury, rapidly

BONE INJURY AND HEALING

TABLE 1-5 Bone Healing for a Stable Fracture

TABLE 1-6 Effects of Growth Factors on

BMP-2, Bone morphogenetic protein-2; BMP-4, bone morphoge-

Continuous growth factor release

Growth Factor Concentration

Cell transfection Ribosomes

CLINICAL CASE REVIEW

2 Why can some ligaments heal, whereas others need to

Normal Histology and Biomechanics of TABLE 2-1 Classification of Connective Tissue

Preload Tensile force Postload

As an example, consider the patient who is referred for

thoracic area, lateral scapula, upper trapezius, and the pec-

toralis major and minor usually result in immediate increases

production of ground substance. When connective tissue is

of connective tissue through both mechanical and auto-

Mobility work causes the breaking and subsequent