Sports Rehab Course Syllabus - ISAKOS

Global Perspectives for 

the Physical Therapist 

and Athletic Trainer 

Sunday, May 12–Tuesday, May 14, 2013 

Sports Rehabilitation 

Concurrent Course 

www.isakos.com /2013congress 

5 | Questions? Email the ISAKOS office 

• isakos@isakos.com

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ISAKOS Congress 2013: Sports Rehabilitation Concurrent Course 

Global Perspectives for the Physical Therapist and Athletic Trainer 

May 12-14, 2013 • Toronto, Canada 

May 12, 2013 

Dear Colleagues, 

On behalf of the course chairs, we welcome you to Toronto and to the ISAKOS Sports Rehabilitation Concurrent 

Course: Global Perspectives for the Physical Therapist and Athletic Trainer. 

This course brings together world leaders in sports medicine, physical therapy and athletic training to discuss the 

most prevalent and innovative topics related to your daily practice. Special consideration will be given to 

understanding different modalities and treatment strategies utilized in other nations when dealing with similar 

injuries, and topics such as returning an athlete to play, and the use and misuse of performance enhancement 

substances and techniques. 

Our goal is to give physicians, athletic trainers, physiotherapists and coaches concerned with the management 

or prevention of injuries to the team athlete new insight and up to date information from an international 

perspective. Speakers and topics have been selected that will provide an international and current perspective 

on a wide range of issues, including the management of knee, shoulder and elbow, hip, foot and ankle and 

muscle injuries in athletes. 

We have assembled an international faculty, including experts from around the world, presenting on their areas 

of expertise. We thank them in advance for their time and their presentations. 

Thank you for your participation, and we hope you find the ISAKOS Sports Rehabilitation Concurrent Course: 

Global Perspectives for the Physical Therapist and Athletic Trainer to be a valuable educational experience. 

Best Regards, 

Trevor Birmingham, BSc PT, PhD, CANADA 

Moises Cohen, MD, PhD BRAZIL 

James Irrgang, PT, PhD, ATC, FAPTA USA 

Lynn Snyder-Mackler, PT, ScD, FAPTA USA




Course Chairs 

Trevor Birmingham, BSc PT, PhD, CANADA 



Lynn Snyder-Mackler, PT, ScD, FAPTA USA 

Faculty 

Greg Alcock, MScPT, BHScPT, BA HonsPE, Dip. Manip., FCA CANADA 

Annunziato Amendola, MD USA 

James Andrews, MD USA 

Michael Axe, MD USA 

Klaus Bak, MD DENMARK 

Eduardo Benegas, MD BRAZIL 

Mario Bizzini, PT, PhD SWITZERLAND 

Gary Calabrese, PT USA 

Constance Chu, MD USA 

Ramon Cugat, MD, PhD SPAIN 

George Davies, DPT, PT, ATC, CSCS USA 

David Dejour, MD FRANCE 

Benno Ejnisman, MD BRAZIL 

Lars Engebretsen, MD, PhD NORWAY 

Keelan Enseki, MS,PT,OCS,SCS,ATC,CSCS USA 

Julian Feller, FRACS AUSTRALIA 

Reed Ferber, ATC, PhD CANADA 

Freddie Fu, MD USA 

J. Robert Giffin, MD, FRCSC CANADA 

Christopher Harner, MD USA 

Timothy Hewett, PhD USA 

Per Hölmich, MD DENMARK 

Johnny Huard, PhD USA 

Elizaveta Kon, MD ITALY 

Robert LaPrade, MD, PhD USA 

Joy Macdermid, PT, PhD CANADA 

John Nyland, EdD, DPT USA 

Marc Philippon, MD USA 

May Arna Risberg, PhD NORWAY 

Kathryn Schneider, PT, DSc, FCAMT, PhD CANADA 

Karin Gravare Silbernagel, PhD, PT, ATC USA 

Guy Simoneau, PT, PhD USA 

Kevin Wilk, PT, DPT, FAPTA USA

ISAKOS Congress Sports Rehabilitation Concurrent Course: 



Financial Disclosure 

Each participant in the ISAKOS Biennial Congress has been asked to disclose if he or she has received 

something of value from a commercial company or institution, which relates directly or indirectly to the 

subject of their presentation. ISAKOS has identified the option to disclose as follows: 

1 Royalties 

2 Speaker 

3a Employee 

3b Paid Consultant 

3c Unpaid Consultant 

4 Stock 

5 Research or Institutional Support 

6 Financial or Material Support 

7 Royalties (Publisher) 

8 Editorial or Governing Board of Medical or Orthopaedic Publication 

9 Board of Directors, Owner or Officer for Healthcare Organization 

ISAKOS does not view the existence of these disclosed interests or commitments as necessarily implying 

bias or decreasing the value of the author’s participation in the ISAKOS Biennial Congress. An indication 

of the participant’s financial disclosure appears after their name, as well as the commercial company or 

institution that provided the support. 

Course Chairs 

Disclosure 

Birmingham, Trevor B. 

5 - Arthrex Inc. 

Cohen, Moises 

Nothing to Disclose 

Irrgang, James J. 

9 - President of the Orthopaedic Section of the American Physical 

Therapy Association 

Snyder-Mackler, Lynn 


Faculty 

Disclosure 

Alcock, Greg 


Amendola, Annunziato 

1 - Arthrex; Arthrosurface; 3b - Arthrex; MTP Solutions 

Andrews, James R. 3b - Bauerfiend, Biomet Sports Medicine, Theralase, MiMe; 4 - 

Patient Connection, Connective Orthopaedics - Stockholder; 6 - 

Medical Director, Physiotherapy Associates; 9 - Fast Health 

Corporation-Board Member 

Axe, Michael James 


Bain, Gregory Ian 


Bak, Klaus 


Benegas, Eduardo 

No Disclosure Provided 

Bizzini, Mario 


Calabrese, Gary 


Chu, Constance R. 


Cugat, Ramon 


Davies, George J. 


Dejour, David Henri 

1 - Tornier, SBM 

Ejnisman, Benno 

Tellus Brazil




Enseki, Keelan Ryan 


Feller, Julian A. 

3b - Tornier, Stryker 

Ferber, Reed 


Fu, Freddie H. 1 - ArthroCare - Fund Deposited to Univ of Pittburgh Account; 3a - 

Gordon Fu - Stryker Employee (son); 8 - Editor: Operative 

Techniques in Orthopaedics 

Giffin, J. Robert 

1 - Arthrex; 3b - Arthrex; 5 - Arthrex 

Gravare Silbernagel, Karin 

5 - LiteCure LLC 

Harner, Christopher D. 

5 - ConMed Linvatec, Smith & Nephew; 7 - Wolters Kluher; 9 - MTF 

Board of Directors, AOSSM Executive Committee, AOA 

Membership Committee 

Holme, Ingard 

No Disclosure Provided 

Hölmich, Per 


Huard, Johnny 

3b - Cook Myosite 

Kon, Elizaveta 

2 - Fidia; 3b - Cartiheal (Israel); Finceramica 

LaPrade, Robert F. 

3b - Arthrex; 6 - Arthrex; 7 - Arthrex, Linvatec, Smith & Nephew 

Logerstedt, David 


MacDermid, Joy 

7 - Slack, Evidence-based Rehabilitation; 8 - JOSPT, J Hand Ther, 

Journal of Physiotherapy; 9 - AAHS 

Philippon, Marc J. 

1 - Smith & Nephew, Arthosurface, Bledsoe, DonJoy; 3b - Smith & 

Nephew, MIS; 4 - HIPCO, Arthrosurface; 7 - Slack, Elsevier; 8 - ; 9 - 

ISHA, Steadman Philippon Research Institute 

Risberg, May Arna 


Schneider, Kathryn 


Simoneau, Guy 

7 - Journal of Orthopaedic & Sports Physical Therapy; 8 - Journal of 

Orthopaedic & Sports Physical Therapy 

Wilk, Kevin 

3c - Advisory Boards - Alter G. Treadmill , Intelliskin; 4 - Theralase 

Lasers; 5 - Educational Grants - Dynasplint, JAS, ERMI; 7 - WB 

Saunders, Elsevier 

ISAKOS Staff 

Disclosure 

Anderson, Kathryn 


Festo, Donna 


Galstan, Beverlee 


Reyes, Kathleen 


Johnson, Michele 


Matthews, Hilary 


Warden, April 

Nothing to Disclose




CME Hours 

The ISAKOS Sports Rehabilitation Concurrent Course: Global Perspectives for the Physical Therapist and 

Athletic Trainer is planned and implemented in accordance with the essential areas and policies of the 

Accreditation Council for Continuing Medical Education (ACCME) through joint sponsorship. 

CME Accreditation 

This activity has been planned and implemented in accordance with the Essential Areas and policies of 

the Accreditation Council for Continuing Medical Education (ACCME) through joint sponsorship of the 

American Academy of Orthopaedic Surgeons (AAOS) and the International Society of Arthroscopy, Knee 

Surgery and Orthopaedic Sports Medicine (ISAKOS). 

The AAOS is accredited by the ACCME to sponsor continuing medical education for physicians. 

The American Academy of Orthopaedic Surgeons designates this live activity for a maximum of 22.5 

AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of 

their participation in the activity. 

Course Objectives 

Upon completion of this course, participants should be able to: 

• Describe current developments in the management of knee, shoulder and elbow, hip, foot and 

ankle and muscle injuries in athletes 

• Better evaluate and manage sideline or onsite issues in sports medicine 

• Describe controversial issues concerning return to play in athletic events 

• Understand different modalities and treatment strategies utilized in other nations when dealing 

with similar injuries 

• Improve technical knowledge of the athlete’s sports return 

• Discuss the use and misuse of performance enhancement substances and techniques




ISAKOS thanks DJO Global for their generous donation to the 

ISAKOS Congress Sports Rehabilitation Concurrent Course: Global Perspectives for the Physical Therapist 

and Athletic Trainer. 

Their sponsorship allows this concurrent course to be more affordable to our attendees and we would 

not have been able to organize this course without their support. 

DJO Global is a leading global developer, manufacturer and distributor of high-quality medical devices 

and services that provide solutions for musculoskeletal health, vascular health and pain management. 

The Company’s products address the continuum of patient care from injury prevention to rehabilitation 

after surgery, injury or from degenerative disease, enabling people to regain or maintain their natural 

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Agenda

CONCURRENT COURSE AGENDA 




SUNDAY, MAY 12 

8:30 - 9:00 Welcome Address 

Chair: Trevor Birmingham, PT, PhD CANADA 

Chair: James Irrgang, PT, PhD, ATC, FAPTA USA 

Chair: Lynn Snyder-Mackler, PT, ScD, FAPTA USA 

8:45 - 9:00 Evidence Based Rehabilitation - The View of a Journal Editor 

Guy Simoneau, PT, PhD USA 

9:00 - 10:30 Session I: Knee - Sports Medicine 

Moderators: Trevor Birmingham, PT, PhD CANADA 


9:00 - 9:30 Running After Knee Injury 


9:30 - 9:45 Biomechanics of Exercise for the Knee and Lower Extremity 

Trevor Birmingham, PT, PhD CANADA 

9:45 - 10:00 Non-Operative Management of ACL Injuries 


10:00 - 10:15 Anatomic ACL Reconstruction 


10:15 - 10:30 Discussion 





10:30 - 10:45 Break 

10:45 - 12:00 Section II: Knee - Sports Medicine 

Moderators: Greg Alcock, MScP.T.,BHSc.P.T., B.A. Hons.P.E., Dip. Manip.,FCA 

CANADA 


10:45 - 11:00 Immediate Post-Operative Rehabilitation After ACL Reconstruction 


11:00 - 11:15 Intermediate and Late Stages of Rehabilitation After ACL Reconstruction 

Kevin Wilk, PT, DPT, FAPTA USA 

11:15 - 11:30 Return to Sports After ACL Reconstruction: A Surgeon's Perspective 


11:30 - 11:45 Functional Training and Return to Activity 






Kevin Wilk, PT, DPT, FAPTA USA

12:00 - 1:30 Lunch 




1:30 - 3:00 Session III: Knee - Sports Medicine 

Moderators: George Davies, DPT, PT, ATC, CSCS USA 


1:30 - 1:45 Procedure Modified Rehabilitation 


1:45 - 2:00 High Tibial Osteotomy in the Athlete's Knee - Rehabilitation and Biomechanics 


2:00 - 2:15 High Tibial Osteotomy in the Athlete's Knee 


2:15 - 2:30 Multiple Ligament Injury 


2:30 - 2:45 PCL and PLC Reconstruction 








3:00 - 3:30 Break 

3:30 - 5:00 Session IV: Knee - Sports Medicine 

Moderators: May Arna Risberg, PhD NORWAY 


3:30 - 3:45 Meniscus Repair and ACL Reconstruction in Athletes 


3:45 - 4:00 Rehabilitation for Meniscus Injuries 


4:00 - 4:15 Non-Operative Management of Patellofemoral Pain 

Greg Alcock, MScP.T.,BHSc.P.T., B.A. Hons.P.E., Dip. Manip.,FCA CANADA 

4:15 - 4:30 Surgical Management of Patellofemoral Pain and Instability 


4:30 - 4:45 Core Stabilization and Knee Injury Prevention 



Greg Alcock, MScPT,BHScPT, BA HonsPE, Dip. Manip.,FCA CANADA 




James Irrgang, PT, PhD, ATC, FAPTA USA




MONDAY, MAY 13 

8:30 - 10:00 Session V: Degenerative Knee 

Moderators: James Irrgang, PT, PhD, ATC, FAPTA USA 


8:30 - 8:45 Overview of Articular Cartilage Surgery 


8:45 - 9:00 Rehabilitation After Articular Cartilage Surgery 


9:00 - 9:15 Non-Operative Management of Knee Osteoarthritis 


9:15 - 9:30 Surgical Options for Osteoarthritis 


9:30 - 9:45 Functional Testing Algorithm for the Knee 







10:00 - 10:30 Break 

10:30 - 11:45 Session VI: Hip 

Moderators: Ingard Holme, Professor NORWAY 


10:30 - 10:45 Growth Factors and Healing 


10:45 - 11:00 Non-Operative Treatment of Extra-Articular Hip Pain 


11:00 - 11:15 Hip Arthroscopy 


11:15 - 11:30 Rehabilitation After Hip Arthroscopy 






11:45 - 1:30 Lunch / Lunchtime Lecture 

A New and More Effective Way to do Functional Rehab – The Role of Wireless Active 

Muscle Stim 

Supported by and educational grant from DJO Global 

Heiko van Vliet, Bachelor Physical Education 

Chattanooga Expert Electrotherapy Rehab & Training




1:30 - 3:00 Session VII: Muscle and Tendon Sports Injuries 

Moderators: Keelan Enseki, MS,PT,OCS,SCS,ATC,CSCS USA 


1:30 - 1:45 Evidence Based Prevention of Muscle and Tendon Injuries in Soccer Players 


1:45 - 2:00 Rehabilitation of Groin Pain and Athletic Pubalgia 


2:00 - 2:15 Rehabilitation of Hamstring, Quadriceps and Gastrocnemius Strains 


2:15 - 2:30 Treatment Options for Tendinopathy: What is the Evidence 


2:30 - 2:45 Muscle Healing and Regeneration 







3:00 - 3:30 Break 

3:30 - 4:45 Session VIII: Foot and Ankle 

Moderator: Greg Alcock, MScP.T.,BHSc.P.T., B.A. Hons.P.E., Dip. Manip.,FCA 

CANADA 

3:30 - 3:45 Orthopaedic Management of Ankle Instability 


3:45 - 4:00 Non-Operative Management of Ankle Sprains 


4:00 - 4:15 Achilles Tendinopathy 


4:15 - 4:30 Rehabilitation After Achilles Tendon Repair 





Karin Gravare Silbernagel, PhD, PT, ATC USA




TUESDAY, MAY 14 

8:30 - 10:15 Session IX: Elbow 

Moderator: Karin Gravare Silbernagel, PhD, PT, ATC USA 

8:30 - 8:45 Elbow Anatomy 

Gregory Bain, MB BS, FRACS, PhD AUSTRALIA 

8:45 - 9:00 Elbow Arthroscopy 


9:00 - 9:15 Elbow Instability 


9:15- 9:30 Medial and Lateral Epicondilitis of the Elbow 


9:30 - 9:45 Rehabilitation After Ulnar Collateral Ligament Reconstruction 


9:45 - 10:00 Management of Tennis Elbow 








10:15 - 10:45 Break 

10:45 - 12:00 Session X: Shoulder 

Moderator: Kevin Wilk, PT, DPT, FAPTA USA 

10:45 - 11:00 Shoulder Anatomy 


11:00 - 11:15 Biomechanics of Shoulder Function 


11:15 - 11:30 Throwing Progression for Youth Sports 


11:30 - 11:45 Functional Testing Algorithm for the Shoulder 






12:00 - 1:30 Lunch and Lunchtime Session 

12:00 - 1:30 Role of Radial Shockwave Therapy in the PT Practice – 

Practical Use in Evidence-based Indications 

Supported by and educational grant from DJO Global 

Freddy Romano, MSc Physical Therapy and Biomedical Physics




1:30 - 3:00 Session XI: Shoulder 

Moderators: George Davies, DPT, PT, ATC, CSCS USA 

David Logerstedt, PT, PhD USA 

1:30 - 1:45 Operative Management of Shoulder Instability 


1:45 - 2:00 Post Operative Rehabilitation After Rotator Cuff Repair 


2:00 - 2:15 Treatment of Stiff Shoulder 


2:15 - 2:30 Scapular Disfunction 


2:30 - 2:45 SLAP Lesions 







3:00 - 3:30 Break 

3:30 - 4:30 Session XII: Sports Medicine 

Moderators: Kevin Wilk, PT, DPT, FAPTA USA 


3:30 - 3:45 Olympic Sports Medicine: Lessons from London 


3:45 - 4:00 PT Management of Concussion 

Kathryn Schneider, PT, DSc, FCAMT, PhD, CANADA 

4:00 - 4:15 The Future of Joint Healing 





Kathryn Schneider, PT, DSc, FCAMT, PhD, CANADA 

4:30 - 5:00 Closing Remarks 

Chair: Trevor Birmingham, PT, PhD CANADA 

Chair: Moises Cohen, MD, PhD BRAZIL 

Chair: James Irrgang, PT, PhD, ATC, FAPTA USA 

Chair: Lynn Snyder-Mackler, PT, ScD, FAPTA USA

Session I 

Knee - Sports 

Medicine

Evidence-Based Rehabilitation – A Journal Editor’s Point of View 

Guy G. Simoneau, PhD, PT, ATC 

Editor-in-Chief, Journal of Orthopaedic & Sports Physical Therapy (JOSPT) 

Professor, Physical Therapy Department, Marquette University, USA 

Over the past few years, we have witnessed an exponential growth in musculoskeletal 

rehabilitation publications considered to be near the top of the evidence-based practice pyramid: 

randomized controlled trials, systematic literature reviews, and clinical practice guidelines. A 

more global view of the literature also shows a growing recognition of the importance of 

knowledge across the broader spectrum of evidence, including important areas of clinical 

management such as diagnosis, prognosis, prevention, and harm, in addition to the more 

commonly mentioned area of therapy. This broader view of the literature calls attention to the 

fact that not all clinical questions can be answered with the same standard research 

design. Noteworthy is also the increasingly higher standards placed on research methodologies 

as well as the publicly available tools that can help authors meet these standards. Similarly, 

advances in technology continue to support researchers who are asking questions that are often 

mechanistic in nature; their findings being critical to guiding clinical decision-making and the 

design of eventual clinical studies.

Running After Knee Injury 

Dr. Reed Ferber holds a Ph.D. in sports medicine and gait 

biomechanics from the University of Oregon and he is a board 

certified athletic therapist. He has completed post-doctoral 

research fellowships at the University of Delaware and the 

University of Calgary and specializes in the research and clinical 

treatment of lower extremity injuries. He is the Director of the 

Running Injury Clinic and an Associate Professor in the Faculties of 

Kinesiology and Nursing at the University of Calgary. Dr. Ferber is 

also a Population Health Investigator through the Alberta Heritage 

Foundation for Medical Research. 

In the past few years, several research studies from our lab, and 

labs around the world, have investigated the pathomechanics 

associated with running-related knee injuries. Of most concern is 

the research question: how do movement mechanics change as a 

result of injury and what are the optimal rehabilitation protocols to 

treat the injury and prevent injury reoccurrence? The purpose of 

this talk is to provide an overview of these research studies and 

discuss the role of muscle strengthening in the treatment and 

prevention of musculoskeletal injuries.

BIOMECHANICS OF EXERCISE FOR THE KNEE AND LOWER EXTREMITY 

Trevor Birmingham PhD, PT Fowler Kennedy Sport Medicine Clinic, London, ON Canada 

INTRODUCTION 

The purpose of this presentation is to outline some of the different types of biomechanical 

investigations used to inform rehabilitation methods, and highlight examples that have 

influenced clinical practice. 

BIOMECHANICAL INVESTIGATIONS 

Motion analysis labs capable of measuring 3D kinematics and kinetics during human 

locomotion, often in combination with EMG, are used extensively. These investigations rely 

on accurate measurements of body-segmental motion, the forces applied to the body, and 

precise knowledge of the anatomy (Pandy & Andriacchi 2010). 

3D positions and orientations of the body segments are most often measured using videobased 

motion-capture systems that monitor markers placed on the skin, while force 

platforms concurrently measure ground reaction forces during various activities (Pandy & 

Andriacchi 2010). 

Advanced methods exist to quantify joint motion using dynamic radiography (x-ray 

fluoroscopy), dynamic MRI and dynamic CT (Farrokhi et al. 2012; Goyal et al. 2012; Powers 

2003; Kalia et al. 2009). 

Some researchers have developed ways to directly measure knee joint forces in vivo using a 

total knee joint replacement telemetric implant, (Halder et al. 2012) and directly measure 

ACL strain using a transducer temporarily implanted arthroscopically (Fleming et al. 2001). 

Finite element analysis (FEA) is a mathematical technique that can be applied to joint 

images (CT and MRI) to model stresses and strains. The technique is growing in popularity 

with advances in imaging and computing power (Bei & Fregly 2004). 

These biomechanical measures (i.e. motion-capture, ground reaction forces, EMG, dynamic 

imaging, forces measured in vivo, FEA) can all provide important information independently, 

and may also be combined in computational models of varying complexity. There are 

considerable strengths and important limitations to all of these approaches.

EXAMPLE INFLUENCES ON REHABILITATION 

Biomechanical studies describing ACL strain and modeled ACL loads during open and closed 

kinetic chain exercises have helped guide exercise selection and parameters (Fleming et al. 

2005; Escamilla et al. 2012). Results of clinical trials vary, but including both open and closed 

kinetic chain exercises at appropriate time points after ACL reconstruction has been 

proposed (Mikkelsen et al. 2000). 

Biomechanical studies have emphasized the influence of proximal segments (hip, pelvis, 

trunk) on the knee. Implications on rehabilitation for tibiofemoral OA, the ACL, the 

patellofemoral joint and the iliotibial band have all been described (Crossley et al. 2012; 

Hewett et al. 2013; Powers 2010; Sritharan et al. 2012). 

An increasing focus of biomechanical and clinical studies is on the control of movement 

patterns during dynamic and sporting activities. Based on these findings, interventions 

focused on neuromuscular control and perturbation training are encouraged (Adams et al. 

2012; Hewett et al. 2013; Powers 2010). 

Exercise and rehabilitation goals may include weight-loss in patients who are overweight. 

Biomechanical studies have demonstrated a substantial decrease in knee joint load per step 

for each kilogram decrease in weight (Messier et al. 2005). 

References 

Adams, D., Logerstedt, D., Hunter-Giordano, A., Axe, M. J., Snyder-Mackler, L. (2012). Current 

concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation 

progression. Journal of Orthopaedic and Sports Physical Therapy. 42:601-614. 

Bei, Y., and Fregly, B. J. (2004). Multibody dynamic simulation of knee contact mechanics. 

Medical Engineering and Physics. 26:777-789. 

Crossley, K. M., Dorn, T. W., Ozturk, H., van den Noort, J., Schache, A. G., and Pandy, M. G. 

(2012). Altered hip muscle forces during gait in people with patellofemoral 

osteoarthritis. Osteoarthritis and Cartilage. 20:1243-1249. 

Escamilla, R.F., Macleod T.D., Wilk K.E., Paulos L., Andrews J.R. (2012). Anterior cruciate 

ligament strain and tensile forces for weight-bearing and non-weight-bearing exercises: 

a guide to exercise selection. Journal of Orthopaedic and Sports Physical Therapy. 

42:208-220. 

Farrokhi, S., Tashman, S., Gil, A. B., Klatt, B. A., and Fitzgerald, G. K. (2012). Are the kinematics 

of the knee joint altered during the loading response phase of gait in individuals with 

concurrent knee osteoarthritis and complaints of joint instability? A dynamic stereo X- 

ray study. Clinical Biomechanics. 27:384-389. 

Fleming, B. C., Oksendahl, H., and Beynnon, B. D. (2005). Open- or closed-kinetic chain exercises 

after anterior cruciate ligament reconstruction? Exercise and Sport Sciences Reviews, 

33:134-140.

Fleming, B. C., Renstrom, P. A., Beynnon, B. D., Engstrom, B., Peura, G. D., Badger, G. J., and 

Johnson, R. J. (2001). The effect of weightbearing and external loading on anterior 

cruciate ligament strain. Journal of Biomechanics. 34:163-170. 

Goyal, K., Tashman, S., Wang, J. H., Li, K., Zhang, X., and Harner, C. (2012). In vivo analysis of the 

isolated posterior cruciate ligament-deficient knee during functional activities. The 

American Journal of Sports Medicine. 40:777-785. 

Halder, A., Kutzner I., Graichen F., Heinlein B., Beier A., Bergmann G., (2012). Influence of limb 

alignment on mediolateral loading in total knee replacement. The Journal of Bone & 

Joint Surgery. 94:1023-1029. 

Hewett, T. E., Di Stasi, S. L., and Myer, G. D. (2013). Current concepts for injury prevention in 

athletes after anterior cruciate ligament reconstruction. The American Journal of Sports 

Medicine. 41:216-224. 

Kalia, V., Obray, R. W., Filice, R., Fayad, L. M., Murphy, K., and Carrino, J. A. (2009). Functional 

joint imaging using 256-MDCT: technical feasibility. American Journal of Roentgenology, 

192:W295-W299. 

Messier, S. P., Gutekunst, D. J., Davis, C., and DeVita, P. (2005). Weight loss reduces knee-joint 

loads in overweight and obese older adults with knee osteoarthritis. Arthritis and 

Rheumatism. 52:2026-2032. 

Mikkelsen, C., Werner s., Eriksson E. (2000). Closed kinetic chain alone compared to combined 

open and closed kinetic chain exercises for quadriceps strengthening after anterior 

cruciate ligament reconstruction with respect to return to sports: a prospective 

matched follow-up study. Knee Surg. Sports Traumatol. Arthrosc. 8:337–342. 

Pandy, M. and Andriacchi. Muscle and joint function in human locomotion. (2010) Annu. Rev. 

Biomed. Eng. 12:401-433. 

Powers, C.M., Ward, S.R., Fredericson M., Guillet M., Shellock F.G. (2003). Patellofemoral 

kinematics during weight-bearing and non-weight-bearing knee extension in persons 

with lateral subluxation of the patella: a preliminary study Journal of Orthopaedic and 

Sports Physical Therapy. 33:677-685. 

Powers, C. M. (2010). The influence of abnormal hip mechanics on knee injury: a biomechanical 

perspective. Journal of Orthopaedic and Sports Physical Therapy. 40:42-51. 

Sritharan, P., Lin, Y. C., Pandy, M. G. (2012). Muscles that do not cross the knee contribute to 

the knee adduction moment and tibiofemoral compartment loading during gait. Journal 

of Orthopaedic Research. 30:1586-1595.

Non‐Operative Management of ACL Injuries 

Lynn Snyder‐Mackler, PT, ScD, FAPTA USA

Anatomic ACL Reconstruction 

Freddie H. Fu, MD, DSc (Hon), DPs (Hon); 

University of Pittsburgh, Department of Orthopaedic Surgery 

Correspondence: ffu@upmc.edu 

I. Rationale for Anatomic Double-Bundle ACL Reconstruction 

• Anatomy is the basis of orthopedic surgery. The goals of anatomic ACL reconstruction are 

to restore 60-80% of the native ACL anatomy, and to maintain a long term knee health. 

• Traditional ACL-R has been successful in returning patients to sports activities. However, 

radiographic evidence of degenerative changes has been observed in up to 90% of patients 

at mid-term follow-up study after traditional single-bundle ACL reconstruction. 1-2 

• Critical review of the literature from the last ten years reveals that between 10% and 30% of 

patients complain of pain and residual instability following traditional single-bundle ACL 

reconstruction. 3 Meta-analysis showed that no more than 60% of the patients will make a 

full recovery after their ACL reconstruction. 4 

• The PL bundle, which is not traditionally reconstructed, plays a significant role in rotatory 

stability in the knee. Numerous clinical and basic science studies have demonstrated that: 1) 

traditional single-bundle ACL reconstruction does not adequately restore normal knee 

kinematics, particularly tibial rotation 5 , and 2) anatomic double-bundle reconstruction more 

closely restores normal knee kinematics when compared to single-bundle reconstruction. 6 

II. The principle of anatomic ACL double bundle reconstruction 

• Reproducing the two bundle anatomy of ACL 

- The ACL is composed of two functional bundles, the anteromedial (AM) bundle and 

the posterolateral (PL) bundle. 7 Cadaveric studies have demonstrated that the AM 

bundle is approximately twice as long as the PL bundle, and that the two bundles have a 

similar cross-sectional diameter. 

• Reproducing the insertion sites of ACL 

- The insertion sites of the AM and PL bundle should be identified and marked for 

anatomic tunnel placement. The femoral insertion sites of the AM and PL bundle are 

oriented vertically with the knee in extension and become horizontal in 90º of knee 

flexion (surgical position for ACL reconstruction surgery). In extension the two 

bundles are parallel and in flexion they become crossed. 7 

• Reproducing the tension pattern of ACL 

- The AM bundle has its highest tension at 45 degrees of knee flexion, and is taut 

throughout the range of motion. The PL bundle has its highest tension at full extension, 

NOTES:

and becomes lax as the knee flexes. The AM and PL graft should be fixed at these 

angles of knee flexion to closely reproduce the native tension pattern. 8 

• Individualized surgery 

- The insertion sites of each bundle should be identified and marked, and the size of the 

insertion sites should be measured to tailor the surgery for each individual. The concept 

of double bundle ACL reconstruction can be applied to all ACL reconstructive 

techniques (single bundle, double bundle, revision, one-bundle augmentation). The 

decision of whether to utilize either a single or a double bundle technique should be 

dictated by the unique anatomy of the patient. 9 

III. Pitfalls in Traditional ACL reconstruction 

• Femoral insertion sites orientation changes with knee flexion: The femoral AM and PL 

insertion sites are horizonally oriented when the knee is close to 90 degrees of flexion, 

while they are vertically oriented in knee extension. This important concept is often 

neglected in ACL reconstruction. 

• The use of clock face reference: The knee is a 3 dimensional structure. The clock concept is 

easy to use, but a 2 dimensional description and inaccurate in describing the location of 

femoral tunnel placement, which may lead to non-anatomic tunnel position. 

• Inability to observe the femoral insertion site: traditional 2portal techniques do not provide 

a clear view of the femoral insertion site. By using a 3portal technique with a high lateral 

portal (LP) a central portal (CP) and a medial portal (MP) this problem is overcome. The 

CP provides a clear view of the notch and femoral insertion site, while the MP can be used 

as a working portal. The LP provides a good view of the tibial insertion site. 

2

• Graft impingement: is caused by non-anatomic graft placement. The native ACL does NOT 

impinge with notch and PCL. Adequate restoration of the size, shape and orientation of the 

native ACL anatomy prevents from impingement. 

• Mismatch tunnels: With fear of impingement, we traditionally mismatch our tunnel 

placement by placing the tibial tunnel more posteriorly (close to the PL insertion site), and 

placing the femoral tunnel at the native AM or high AM position. 10-11 This non-anatomic 

ACL reconstruction leads to inferior biomechanical properties and inferior biological 

healing due to non-physiological biomechanical stress to the graft. 

• Double bundle ACL-R does not necessarily mean anatomic reconstruction, if the native 

anatomy was not followed as a guideline for double tunnel placement. 

IV. Anatomic Double Bundle ACL Reconstruction 

• Pre-operatively, the ACL insertion site and ACL length can be measured on the sagittal MRI. 

The ACL inclination angle can also be measured, as can be seen below. 12 

42° 51° 

• The MRI can also be used to measure the size of the certain autografts. Both the patellar 

tendon and the quadriceps tendon size can be measured on the sagittal MRI cut. As can be 

appreciated below, the quadriceps tendon is often much larger than the patellar tendon and 

provides a vigorous autograft. 13 

3

• Anatomic double-bundle ACL reconstruction is an “Insertion Site Surgery”. We utilize 

three portals: LP, CP and MP. 

LP 

CP 

CP 

• We routinely place the arthroscope in the CP and work through the MP. Doing so, 

visualization of the femoral insertion of the ACL is greatly enhanced and the need for 

notchplasty is virtually eliminated. 14 

• The anatomic insertion sites of each native ACL bundle are marked on the femur and tibia 

with a thermal device, with care taken to preserve the border of the bundles for later 

reference. This is a critical step in identifying the correct placement of the tunnels, and is 

performed prior to resection of any residual ACL tissue. In addition, the length and width of 

the AM and PL bundle insertion site are measured as references to decide tunnel diameters. 

The surgery is individualized for each patient. 

• There is a large area on the medial wall of lateral femoral condyle for potential nonanatomic 

tunnel placement. Our preliminary data suggested that it may occupy more than 

65% of the area on the wall. 

• A “lateral bifurcate ridge” is often seen on the femoral insertion between the AM and PL 

bundles, where as a “lateral intercondylar ridge” is often seen on the upper limit of both the 

AM and PL bundles. These are useful surgical landmarks in addition to the native insertion 

fibers. 15,16 

4

• Notchplasty destroys the femoral anatomy of the ACL insertion site and is not necessary if 

CP and MP are used. 

• The tibial and femoral tunnels are placed at their native insertion site, which are marked 

with a thermal device. 

• The PL femoral tunnel is always drilled through the anteromedial portal. A potential 

advantage of drilling the femoral AM tunnel transtibially is the creation of a longer tunnel 

which diverges from the PL femoral tunnel, and we routinely attempt this approach first 

before using the MP. However, oftentimes it cannot reach the anatomic insertion site. In 

that case, the tunnel will be drill through the anteromedial portal. 

• Finally, the grafts are passed. First the PL graft is passed, followed by the AM graft. 

Femoral fixation is typically performed with an EndoButton. 

• Post-operatively, MRI can be used to compare the pre- and post-op insertion site size to 

measure how much of the insertion site is restored. In addition, the pre- and post-operative 

inclination angle can be compared. 12 After anatomic ACL reconstruction, the ACL 

inclination angle should be similar to the native ACL inclination angle. 

CP 

5

• 3D CT scan can be used to evaluate tunnel position. 

V. Anatomic Single Bundle ACL Reconstruction 

• Except for one bundle augmentation (performed when only one of the two native bundles 

are torn), there are a few other scenarios where we prefer to perform single bundle surgery 

(30%): 17 

Small native ACL insertion site (< 14mm) 

Open growth plates 

Severe arthritic changes 

Multiple knee ligament injuries 

Severe bone bruises 

Narrow intercondylar notch 

• Our single bundle surgery is performed 

with careful attention to soft tissue and 

bony landmarks. We carefully investigate 

the rupture pattern of the ACL and we 

identify the native ACL insertion sites -just as we do for double bundle ACL surgery. 

Then, the tibial tunnel is placed at between the native insertion sites of the AM bundle and 

PL bundles, or at the center of the entire tibial insertion site. 

6

• The distance from anterior margin of ACL footprint to center of tibial tunnel should be 

measured, and the femoral tunnel should be placed at the same distance from the posterior 

margin (knee in 90º flexion) of the femoral ACL footprint. 

VI. One Bundle Augmentation 

• In cases only the AM or the PL bundle was torn, we save the intact bundle and “augment” 

this bundle with a single bundle graft. 

VII. Revision ACL Reconstruction 

• The same double bundle concept and its principles for primary anatomic ACL 

reconstruction can be applied to revision ACL surgery. 

• Pre-operative imaging can inform the surgeon about placement of the previous tunnels. 

Below is an example of a bilateral MRI. This shows that the inclination angle of the 

primary ACL reconstruction is higher than that of the contralateral native ACL, suggesting 

non-anatomic tunnel placement. This can then be confirmed by the 3D CT scan. 

• If the old tunnels are anatomic, they can be reused. If the old tunnels are non-anatomic, 

new tunnels need to be created. If there is enough room, new tunnels can be created in one 

stage. Alternatively, the graft can be placed “over the top” on the femoral side, or a twostaged 

procedure, with bone-grafting, can be considered. 

49° 

62° 

Non-anatomic 

Native ACL Insertion Inclination Angle after Nonanatomic 

Reconstruction ° 

90 PL AM 

Inclination Angle 

Non-anatomic Tunnel 

• After the revision surgery, the native inclination angle should be restored. 

7

VIII. Biological Enhancement 

• Typically the graft heals to the bone through bleeding created by drilling the tunnels. 

• We have begun using a “fibrin clot” to try to enhance the healing of the two bundles 

together and to the bone. 

• A fibrin clot is created from the patient’s own blood by gently stirring it in a glass beaker 

for 5–10 minutes and contains many of the same growth factors advertised as being present 

in commercially available blood preparation products, such as platelet rich plasma (PRP). 

Fibrin Clot 

“Sandwich” 

AM 

IX. Clinical Outcome of Anatomic ACL Reconstruction 

• Clinical improvements have been demonstrated in recent prospective and randomized level 

I and level II studies. These studies have shown superior outcomes for double bundle 

reconstruction than single bundle reconstruction. 18-20 

• While the first results are encouraging, additional work is needed to critically evaluate the 

outcomes of anatomic ACL reconstruction in terms of joint kinematics, degenerative joint 

changes, and patient-reported outcomes. Better methods for rotational laxity measurement, 

medium- and long-term outcomes are needed in the future. 

• In an excellent meta-analysis by Lubowitz et al. the results of pivot shift consistent with the 

convention of IKDC were summarized. The normal and nearly abnormal data were pooled 

together for pivot shift and therefore, SB and DB achieved 94.6% and 97.5% of good pivot 

shift results respectively with no difference between the two groups. This is how we 

reported clinical outcome for many years. However, if we want to review the data more 

critically by only comparing the “normal” category, DB provided significantly better results 

(83.1% DB vs. 67.9% SB). 21-22 

• To fully assess the outcome of ACL reconstruction, we need to improve our outcome 

measures. New outcome measures should be accurate, precise and reliable. Some examples 

are: in-vivo kinematics with dynamic stereo x-ray, high resolution/ 3D MRI and 3D CT 

scan. 

• Only when we have good outcome measurements, can we improve our surgical technique 

and protect the long-term knee health of our patients. 

X. Conclusion 

• The goals of anatomic ACL reconstruction are to restore 60-80% of the native ACL 

anatomy, and to maintain a long term knee health. 

8

• The double bundle anatomy, insertion sites, and tension pattern need to be reproduced to 

restore native ACL anatomy and knee kinematics 

• Anatomic Double-Bundle ACL Reconstruction is a concept that can and should be applied 

to single bundle, one-bundle augmentation and revision ACL surgeries 

• We need better, more objective outcomes measures, including biology, kinematics and 

imaging. 

References: 

1. Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM. Prospective trial of a 

treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med 2005;33- 

3:335-46. 

2. Keays SL, Newcombe PA, Bullock-Saxton JE, Bullock MI, Keays AC. Factors involved in the development of 

osteoarthritis after anterior cruciate ligament surgery. Am J Sports Med 2010;38-3:455-63. 

3. Yunes M, Richmond JC, Engels EA, Pinczewski LA. Patellar versus hamstring tendons in anterior cruciate 

ligament reconstruction: A meta-analysis. Arthroscopy 2001;17-3:248-57. 

4. Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R. ACL reconstruction: a meta-analysis of functional 

scores. Clin Orthop Relat Res 2007;458:180-7. 

5. Tashman S, Collon D, Anderson K, Kolowich P, Anderst W. Abnormal rotational knee motion during running 

after anterior cruciate ligament reconstruction. Am J Sports Med 2004;32-4:975-83. 

6. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M. Double-bundle ACL reconstruction can improve 

rotational stability. Clinical Orthopaedics and Related Research 2007-454:100-7. 

7. Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic, radiographic, biomechanical, 

and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am 

2006;88 Suppl 4:2-10. 

8. Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE. Distribution of in situ forces in the anterior cruciate 

ligament in response to rotatory loads. J Orthop Res 2004;22-1:85-9. 

9. van Eck CF, Schreiber VM, Liu TT, Fu FH. The anatomic approach to primary, revision and augmentation 

anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010;DOI 10.1007/s00167-010- 

1191-4. 

10. Kopf S, Forsythe B, Wong AK, Tashman S, Anderst W, Irrgang JJ, Fu FH. Nonanatomic tunnel position in 

traditional transtibial single-bundle anterior cruciate ligament reconstruction evaluated by three-dimensional 

computed tomography. J Bone Joint Surg Am 2010;92-6:1427-31. 

11. Forsythe B, Kopf S, Wong AK, Martins CA, Anderst W, Tashman S, Fu FH. The location of femoral and 

tibial tunnels in anatomic double-bundle anterior cruciate ligament reconstruction analyzed by three-dimensional 

computed tomography models. J Bone Joint Surg Am 2010;92-6:1418-26. 

12. Illingworth KD, Hensler D, Working ZM, Macalena JA, Tashman S, Fu FH. A simple evaluation of 

anterior cruciate ligament femoral tunnel position: the inclination angle and femoral tunnel angle. Am J Sports Med. 

2011 Dec;39(12):2611-8. 

13. Araujo P, van Eck CF, Torabi M, Fu FH. How to optimize the use of MRI in anatomic ACL reconstruction. 

Knee Surg Sports Traumatol Arthrosc. 2012 Aug 15. 

14. Cohen SB, Fu FH. Three-portal technique for anterior cruciate ligament reconstruction: use of a central medial 

portal. Arthroscopy 2007;23-3:325 e1-5. 

15. van Eck CF, Morse KR, Lesniak BP, Kropf EJ, Tranovich MJ, van Dijk CN, Fu FH. Does the lateral 

intercondylar ridge disappear in ACL deficient patients? Knee Surg Sports Traumatol Arthrosc 2010;DOI 

10.1007/s00167-009-1038-z. 

16. Fu FH, Jordan SS. The lateral intercondylar ridge--a key to anatomic anterior cruciate ligament reconstruction. 

J Bone Joint Surg Am 2007;89-10:2103-4. 

17. van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic Single- and Double-Bundle Anterior Cruciate 

Ligament Reconstruction Flowchart. Arthroscopy 2010;26-2:258-68. 

18. Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T. Prospective clinical comparisons of anatomic doublebundle 

versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. 

American Journal of Sports Medicine.36(9)()(pp 1675-1687), 2008.Date of Publication: Sep 2008. 2008-9:1675-87. 

9

19. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Prospective randomized clinical evaluation of 

conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament 

reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med. 2012 Mar;40(3):512-20. 

20. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Individualized anterior cruciate ligament surgery: a 

prospective study comparing anatomic single- and double-bundle reconstruction. Am J Sports Med. 2012 

Aug;40(8):1781-8. 

21. Meredick RB, Vance KJ, Appleby D, Lubowitz JH. Outcome of single-bundle versus double-bundle 

reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 2008;36-7:1414-21. 

22. Irrgang JJ, Bost JE, Fu FH. Re: Outcome of single-bundle versus double-bundle reconstruction of the anterior 

cruciate ligament: a meta-analysis. Am J Sports Med 2009;37-2:421-2; author reply 2. 

10

Session II 


Medicine

Immediate Post‐Operative Rehabilitation After ACL Reconstruction 


9 TH Biennial ISAKOS Congress 

May 12, 2013: 11:00am 

Toronto, Ontario Canada 

Current Concepts in Rehabilitation 

Following ACL Reconstruction: 

The Later Phases 

Kevin E. Wilk, PT, DPT 

Associate Clinical Director 

Champion Sports Medicine 

Birmingham, Alabama 

I. Introduction 

A. Rehabilitation Following ACL Surgery 

1. Plays a vital role in functional outcome 

2. Patients during rehabilitation have an improved outcome 

Howe et al: AJSM ‘91 

3. Rehabilitation process has changed dramatically since 90’s 

B. Current Rehabilitation Approach 

1. Immediate motion 

2. Full passive knee extension 

3. Immediate weight-bearing 

4. Closed kinetic chain exercise 

5. Early return to functional activities 

6. Earlier return to sports 

More Aggressive Rehabilitation Approach 

Dramatic Change in Rehabilitation Approach & Philosophy 

C. Rehabilitation Program multiple phases based on tissue healing 

1. Patient must progress through these phases of recovery 

2. Main purpose of phases: 

a. Return knee to “normal state” 

b. Return normal motion, strength, proprioception & 

Function

Successful Outcome Today and 10 Years Later!! 

Restore Knee Homeostasis 

Dye et al: CORR ‘96 

Dye et al: AJSM ‘93 

High Incidence of Osteoarthritis Following ACL Injury 

II. 

Specific Rehabilitation Phases & Goals: 

A. ACL Rehabilitation Program – 6 Phase Program 

1. Phase I: Pre-Operative Phase (from injury to surgery) 

a. Goals: 

1. “normalize the knee” 

2. reduce swelling & inflammation 

3. improve motion 

4. voluntary quadriceps contraction 

5. control activity level 

2. Phase II: Immediate Post-Operative (post-op day 1 till day 7) 

a. Goals: 

1. restore “full” passive knee extension 

2. diminish swelling & pain 

3. restore patellar mobility 

4. gradual restore knee flexion 

5. restore quadriceps control 

6. reestablish independent ambulation 

3. Phase III: Acute Phase (week 2 till week 4) 

a. Goals: 

1. full passive knee extension 

2. gradual improvement knee flexion 

3. restore proprioception & neuromuscular control 

4. independent ambulation 

5. control swelling & activity level 

4. Phase IV: Intermediate Phase (week 4 till week 10) 

a. Goals: 

1. gradually restore “full” knee flexion 

2. improve lower extremity strength 

3. enhance proprioception & neuromuscular control 

4. enhance endurance 

5. restore limb confidence

5. Phase V: Advanced Phase (week 10 till week 16) 

a. Goals: 

1. normalize limb function 

2. normalize lower extremity strength 

3. enhance neuromuscular control 

4. gradually restore function 

6. Phase VI: Return to Functional Activities Phase (month 4 - return) 

a. Goals: 

1. gradual return to sport specific activities 

2. gradual return to unrestricted activities 

3. continuation of lower extremity programs 

Wilk et al: Ortho Clin North Am ‘03 

Wilk et al: J Athl Trn ‘99 

Wilk et al: Am J Sports Med ‘96 

Wilk et al: JOSPT ‘93 

III. 

The ACL Reconstruction Rehabilitation Program 

The Later Phases – TCC Course 

A. Intermediate Phase (Weeks 4-10) 

1. Concepts: 

a. “stabilization the knee from above & below” 

i. Hip & core stabilization 

ii. Foot & ankle stability 

Powers et al: JOSPT ‘03 

b. “ muscles are shock absorbers” 

i. Quadriceps 

ii. Hip & Hamstrings 

c. “gradually increase stress on knee” 

i. Soft tissue hypertrophy 

ii. Graft strength 

d. “ restore neuromuscular control” 

i. Perturbation drills 

ii. Neuromuscular control drills 

iii. Gradually increase difficulty 

e. “ emphasis functional activities” 

i. Rehabilitation = Function 

ii. Gradual restoration 

2. Specific Exercise Drills:

B. Advanced Activity Phase (Weeks 10-16) 

1. Concepts: 

a. “normalize limb function” 

i. Control functional activities 

b. “normalize lower strength” 

i. Quadriceps hypertrophy- exercises 

c. “ restore neuromuscular control” 

d. “ gradual restore functional activities” 

2. Specific Exercises & Drills: 

Functional Progression 

Pool drills 

Dry land drills 

Plyos 

Running 

Lateral drills 

Backward drills 

Backward 

Forward running 

Running 

Cutting drills 

C. Return to Activity Phase (Weeks 16-26) 

1. Based on fulfillment of criteria (testing) 

a. KT results 

b. Isokinetic results 

c. Proprioception test 

d. Hop test 

2. Objective testing of ACL patient 

a. Subjective knee form (Noyes) 

b. Knee arthrometer testing (KT-2000) 

c. Isokinetic testing (Biodex) 

d. Functional hop testing 

Barber: Clin Orthop ’90 

Noyes: AJSM ’91 

e. Specific Testing sequence 

Irrgang: CSM 2013 

f. Correlation between isokinetic and function 

1. Correlation between quad strength and functional 

abilities

Wilk, Soscia, Romaniello: JOSPT ’94 

1) Neoprene sleeve and brace 

Noyes & Barber: Arthroscopy ’97 

IV. 

Key Points: 

Benefit 

Δ 

Risk 

1. Rehabilitation plays a key & vital role to outcome 

2. Rehabilitation program continues to change/progress 

“Push the envelope, how fast can we go” 

“ Faster is Not Better” Wilk: JOSPT ‘ 05 

Biology of Rehab 

Speed limits in Rehab 

3. Key Points for Me: 

a. all about milestones & goals 

b. gradually increase stresses & challenges 

c. progressive & sequential 

d. enhance neuromuscular control 

4. Today’s trend is more aggressive rehabilitation 

a. Accelerated rehabilitation 

b. Is it appropriate for all patients? 

4. Current trends 

a. Closed kinetic chain exercise 

b. Proprioception and neuromuscular control 

c. Plyometrics 

d. Specific concerns for the female athlete 

Successful Outcome Today (at 6 months) 

Asymptomatic Knee 5-10 Years Later!

KEW: 4/13 

Enclosure: ACL Protocol

Return to sports after ACL reconstruction: A surgeon’s perspective 

Julian A Feller 

Melbourne, Australia 

Most people undergoing ACL reconstruction want to return to some level of sporting activity. 

ACLR is generally reported to be successful, but a more critical analysis of return to pre-‐injury 

sport rates is less encouraging. 

Precise terminology is important. A fundamental question is what constitutes a return to sport? 

• Pre-‐injury sport may well be different to pre-‐operative sport or sports activity level, 

particularly in the setting of chronic ACL insufficiency. 

• If patient returns to the sport in which they previously participated, is it to training or 

competition. If competition, is at the same level of competition as prior to injury. 

• Even if returning to the same level of competition, does the patient play with the same 

competency? 

• Sports activity levels may appear to provide an objective measurement of sporting 

participating levels, but there may still be a discrepancy between the sports activity level 

and participation in pre-‐injury sport. 

Patient aspirations may change following surgery. 

• Age an important factor. Older patients may not be as likely to return to their pre-‐injury 

sport as younger patient. 

• Multiple reasons: work and family commitments, motivation and ability – perceived or 

real -‐ to recover from surgery. 

• Elite sportspeople, although facing potentially greater challenges in resuming their sport 

at the same level, may have a greater motivation and greater support to achieve a 

successful return to sport. 

What is the current reported rate of return to sport following ACL reconstruction? 

• Overall, typical rates are 80-‐90% return to some kind of sport, 60-‐65% return to pre-injury 

sport, but only 40-‐50% return to competitive sport. Rates do vary. 

• Impairment and activity-‐based outcomes indicate 85-‐90% are normal/near normal. 

• High drop off after 2-‐3 years. 

• 12 months may be too early to assess rates of return to sport. 

Relatively little is documented about when patients actually resume sport. 

• Mean values may be as short as 4 months, but wide range of values is usually reported, 

e.g. 2 to 24 months. 

• Patient groups are heterogenous in terms of type and level of sport. 

• Worth noting that clearance to return to sport at a certain time point does not 

necessarily mean that patients actually returned to sport at that time.

Many factors that influence an individual’s ability, desire and decision whether or not to return to 

sport and at what level. 

• Higher pre-‐injury activity level strong predictor of return to sport at two years. 

• Role of gender unclear. 

• Psychological factors important: 

o Fear of re-‐injury 

o ACL-‐RSI score predictive 

• Graft type does not appear to be important 

• Little information about the impact of other surgical variables on return to sport. 

Lack of correlation between rates of return to pre-‐injury sport and measurements of strength 

and knee laxity, or activity outcome measures. 

• What should we be measuring following ACL reconstruction? 

• Do current assessment tools address the appropriate issues? 

• Are they limited by a ceiling effect. 

Relatively little information about effect of rehabilitation protocols on outcome, in terms of 

return to sport. 

• Shelbourne and Nitz, and Beynnon et al papers refer to patellar tendon autograft. 

• Effect of an accelerated rehabilitation protocol on hamstring grafts has not been 

evaluated in a controlled fashion. 

Return to sport criteria. 

• Is the athlete is capable of resuming sport? 

• Is it safe for the athlete to resume sport? 

• Need data to establish whether the ability to resume sport, either effectively or safely, 

reflects having met the various criteria. 

• Minimum requirements: 

o No effusion 

o Essentially full ROM 

o Stable knee 

o Good strength (single leg press body weight – 3 sets of 5) 

o Normal running and landing 

o 4 weeks unrestricted training (full contact) 

Returning to sport puts the individual at rate of both ACL graft rupture and rupture of the 

contralateral ACL. 

• Risk of graft rupture: 6% at 5 years 

• Rate of contralateral ACL rupture is 12% at 5 years. 

Risk factors for further injury (graft and contralateral ACL) – conflicting evidence: 

• Young age (possibly a surrogate for other factors) 

• Return to pivoting sports 

• Allografts in young and active people

Early return to sport: 

• For patellar tendon grafts, not been shown to be a risk factor for further injury. 

• Effect on hamstring grafts unknown. 

• Animal models suggest distinct phases of graft maturation with revascularization being a 

potential period of risk for further injury. But mismatch with experience in humans. 

Returning to sport following ACL reconstruction puts knee at risk of sustaining damage to the 

menisci or articular surfaces, or of aggravating damage sustained at the time of ACL rupture. 

• May increase risk of OA 

• Should the athlete consider not returning to sport in an attempt to protect their knee 

from further injury long-‐term degeneration? If so, why reconstruct the ACL in the first 

place? 

• Little evidence to show a protective effect of ACL reconstruction in terms of 

osteoarthritis. 

Useful References 

Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate 

ligament reconstruction surgery: a systematic review and meta-‐analysis of the state of play. 

Br J Sports Med. 45:596–606 

Ardern CL, Taylor NF, Feller JA, Webster KE (2011) Return-‐to-‐Sport Outcomes at 2 to 7 Years 

After Anterior Cruciate Ligament Reconstruction Surgery. Am J Sports Med 39:41-‐48 

Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to the preinjury level of competitive 

sport after anterior cruciate ligament reconstruction surgery: two-‐thirds of patients have 

not returned by 12 months after surgery. Am J Sports Med 39:538–543 

Barrett GR, Luber K, Replogle WH, Manley JL (2010) Allograft anterior cruciate ligament 

reconstruction in the young, active patient: Tegner activity level and failure rate. 

Arthroscopy 26:1593–1601 

Beynnon BD, Uh BS, Johnson RJ, Abate JA, Nichols CE, Fleming BC, et al. (2005) Rehabilitation 

after anterior cruciate ligament reconstruction: a prospective, randomized, double-‐blind 

comparison of programs administered over 2 different time intervals. Am J Sports Med 

33:347–359 

Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Andrish JT, et al. (2012) Return to Play 

and Future ACL Injury Risk After ACL Reconstruction in Soccer Athletes From the 

Multicenter Orthopaedic Outcomes Network (MOON) Group. Am J Sports Med 

10.1177/0363546512459476 

Claes S, Verdonk P, Forsyth R, Bellemans J (2011) The “ligamentization” process in anterior 

cruciate ligament reconstruction: what happens to the human graft? A systematic review of 

the literature. Am J Sports Med 39:2476–2483 

Dunn WR, Spindler KP, MOON Consortium (2010) Predictors of activity level 2 years after 

anterior cruciate ligament reconstruction (ACLR): a Multicenter Orthopaedic Outcomes

Network (MOON) ACLR cohort study. Am J Sports Med 38:2040–2050 

Kvist J, Ek A, Sporrstedt K, Good L (2005) Fear of re-‐injury: a hindrance for returning to sports 

after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol 

Arthrosc.13:393–397 

Langford JL, Webster KE, Feller JA (2009) A prospective longitudinal study to assess 

psychological changes following anterior cruciate ligament reconstruction surgery. Br J 

Sports Med 43:377–378 

Lohmander LS, Ostenberg A, Englund M, Roos H (2004) High prevalence of knee osteoarthritis, 

pain, and functional limitations in female soccer players twelve years after anterior cruciate 

ligament injury. Arthritis Rheum 50:3145–3152 

Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE (2006) Rehabilitation after anterior 

cruciate ligament reconstruction: criteria-‐based progression through the return-‐to-‐sport 

phase. The Journal of orthopaedic and sports physical therapy 36:385–402 

Myklebust G, Bahr R (2005) Return to play guidelines after anterior cruciate ligament surgery. Br 

J Sports Med 39:127–131 

Oiestad BE, Engebretsen L, Storheim K, Risberg MA (2009) Knee Osteoarthritis After Anterior 

Cruciate Ligament Injury: A Systematic Review. Am J Sports Med 37:1434–1443 

Porat von A, Roos EM, Roos H (2004) High prevalence of osteoarthritis 14 years after an anterior 

cruciate ligament tear in male soccer players: a study of radiographic and patient relevant 

outcomes. Ann Rheum Dis. 63:269–273 

Scheffler SU, Unterhauser FN, Weiler A (2008) Graft remodeling and ligamentization after 

cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16:834–842 

Shelbourne KD, Gray T (1997) Anterior cruciate ligament reconstruction with autogenous 

patellar tendon graft followed by accelerated rehabilitation. A two-‐ to nine-‐year followup. 

Am J Sports Med 25:786–795 

Shelbourne KD, Nitz P (1990) Accelerated rehabilitation after anterior cruciate ligament 

reconstruction. Am J Sports Med 18:292–299 

Smith FW, Rosenlund EA, Aune AK, MacLean JA, Hillis SW (2004) Subjective functional 

assessments and the return to competitive sport after anterior cruciate ligament 

reconstruction. Br J Sports Med 38:279–284 

Webster KE, Feller JA, Lambros C (2008) Development and preliminary validation of a scale to 

measure the psychological impact of returning to sport following anterior cruciate ligament 

reconstruction surgery. Phys Ther Sport 9:9–15 

Wright RW, Magnussen RA, Dunn WR, Spindler KP (2011) Ipsilateral graft and contralateral ACL 

rupture at five years or more following ACL reconstruction: a systematic review J Bone Joint 

Surg 93-‐A:1159–1165

Session III 


Medicine

Procedure Modified Rehabilitation 


HIGH TIBIAL OSTEOTOMY – BIOMECHANICS AND REHABILITATION 

Trevor Birmingham PhD, PT Fowler Kennedy Sport Medicine Clinic, London, ON Canada 

INTRODUCTION 

High tibial osteotomy (HTO) is a surgical option for patients with frontal plane malalignment and 

tibiofemoral OA primarily affecting one compartment. It is most commonly performed in relatively 

young (e.g. 40’s & 50’s) active patients. Overall goals are to improve pain and function, and delay 

disease progression. 

The purposes of this presentation are to review the biomechanical rationale and general 

rehabilitation strategies for HTO. 

BIOMECHANICAL RATIONALE 

Medial opening wedge HTO aims to decrease excessive loads on the medial compartment by 

correcting varus alignment. Surgical biomechanical considerations include the amount of correction 

desired, and the potential effects on the tibial slope and the patellofemoral joint (1-3). 

Knee OA more commonly involves the medial compartment, largely because of biomechanical 

factors related to how the knee is loaded during walking. During the stance phase of gait, the line 

of action of the ground reaction force typically remains medial to the weight-bearing knee, thereby 

producing a lever arm in the frontal plane, an external adduction moment about the tibiofemoral 

joint and greater loads on its medial relative to lateral compartment (4,5). 

Varus alignment (6,7) and a high knee adduction moment (8,9) are strong risk factors for disease 

progression. As medial OA progresses, so do varus alignment, the knee adduction moment, and 

medial compartment loading. An important goal of HTO is to break that viscous cycle. 

HTO causes large reductions in the knee adduction moment (approximately 50%) and therefore a 

lateral shift in the distribution of loads across the tibiofemoral joint (10-12). Large decreases in the 

knee adduction moment imply substantial decreases in medial compartment load. Other factors 

affecting internal loading, such as the contribution of muscular co-contraction, soft tissues and 

geometry of the femoral condyles, must also be considered (13,14). 

REHABILITATION 

Early rehabilitation after HTO focuses on attaining full range of motion and limiting muscle atrophy. 

Weight-bearing activities depend largely on bone healing where the osteotomy cut is performed. 

Later rehabilitation focuses on deficits typical of patients with knee OA that are present before HTO 

and may worsen after surgery. Muscular strengthening and neuromuscular training programs 

generally suggested for knee OA are often indicated. Any persisting decreases in range of motion 

are addressed. Weight-loss is advised where appropriate.

Increased muscle co-contraction during gait may lessen after HTO (15,16) and may depend on the 

accuracy of correction (17). 

Quadriceps activation and strength deficits typically remain and may worsen after surgery (15,18). 

HTO does not appear to affect postural control when tested using tests of standing balance (19). 

Decreased sagittal plane kinematics during walking can be present after HTO (15). 

Many patients gain rather than decrease weight after surgery (20). Even small changes in weight 

can have substantial changes in knee joint loading (21,22). 

Pre-operative strength gains are achievable, but largely diminish after surgery (23,24). Preoperative 

strengthening can result in greater postoperative patient-reported sport and recreation 

outcomes (24). 

Clinically important increases in patient-reported outcomes, including sports and recreation, exist 

two (11) and five years after medial opening wedge HTO. 

Most patients can return to sports and recreational activities similar to their preoperative level 

(25). 

Systematic reviews and national registry data suggest approximately 70-80% of patients receiving 

HTO retain their native knee joint 10 years after surgery (26-28). 

References 

1. Rossi R, Bonasia DE, Amendola A (2011) The role of high tibial osteotomy in the varus knee. J Amer 

Acad Orthop Surg. 19:590-599 

2. Giffin JR, Vogrin TM, Zantop T, Woo SL, Harner CD (2004) Effects of increasing tibial slope on the 

biomechanics of the knee. Am J Sports Med 32:376–382 

3. Giffin JR, Shannon FJ (2007) The role of the high tibial osteotomy in the unstable knee. Sports Med 

Arthrosc 15:23–31 

4. Andriacchi TP (1994) Dynamics of knee malalignment. Orthop Clin North Am 25(3):395–403 

5. Hunt MA, Birmingham TB, Giffin JR, Jenkyn TR (2006) Associations among knee adduction moment, 

frontal plane ground reaction force, and lever arm during walking in patients with knee osteoarthritis. J 

Biomech 39:2213–2220 

6. Sharma L, Chniel JC, Almagor O, Felson D, Guermazi A, Roemer F, et al., (2012) The role of varus and 

valgus alignment in the initial development of knee cartilage damage by MRI: the MOST study. Annals 

of Rheumatic Diseases http://dx.doi.org/10.1136/annrheumdis-2011-201070 

7. Sharma L, Song J, Dunlop D, Felson D, Lewis CE, Segal N, Torner J, Cooke TD, Hietpas J, Lynch J, Nevitt 

M. (2010). Varus and valgus alignment and incident and progressive knee osteoarthritis. Annals of the 

Rheumatic Diseases 69:1940-1945 

8. Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S, (2002) Dynamic load at baseline can 

predict radiographic disease progression in medial compartment knee osteoarthritis. Annals of 

Rheumatic Diseases 61:617-622 

9. Bennell KL, Bowles K, Wang Y, Cicuttini F, Davies-Tuck M, Hinman R, (2011). Higher dynamic medial 

knee load predicts greater cartilage loss over 12 months in medial knee osteoarthritis. Annals of the 

Rheumatic Diseases 70:1770-1774

10. Prodromos CC, Andriacchi TP, Galante JO (1985) A relationship between gait and clinical changes 

following high tibial osteotomy. J Bone Joint Surg Am. 67:1188–94 

11. Birmingham TB, Giffin JR, Chesworth BM, Bryant DM, Litchfield RB, Willits K, Jenkyn TR, Fowler PJ 

(2009) Medial opening wedge high tibial osteotomy: a prospective cohort study of gait, radiographic, 

and patient-reported outcomes. Arthritis Rheum 61:648–657 

12. Leitch KM, Birmingham TB, Dunning CE, Robert Giffin JR. (2013) Changes in valgus and varus alignment 

neutralize aberrant frontal plane knee moments in patients with unicompartmental knee osteoarthritis. 

J Biomech. Mar 13. pii: S0021-9290(13)00066-3. doi: 10.1016/j.jbiomech.2013.01.024 

13. Andriacchi A. (2013) Valgus Alignment and Lateral Compartment Knee Osteoarthritis: A Biomechanical 

Paradox or New Insight Into Knee Osteoarthritis? Arthr Rheum. 65:2310-313 

14. Amis A. Biomechanics of high tibial osteotomy (2013) Knee Surg Sports Traumatol Arthrosc 21:197–205 

15. Ramsey DK, Snyder-Mackler L, Lewek M, Newcomb W, Rudolph KS (2007) Effect of anatomic 

realignment on muscle function during gait in patients with medial compartment knee osteoarthritis. 

Arthritis Rheum. 57(3):389–97 

16. Kean CO, Birmingham TB, Garland JS, Jenkyn TR, Ivanova TD, Jones IC, Giffin RJ (2009) Moments and 

muscle activity after high tibial osteotomy and anterior cruciate ligament reconstruction. Med Sci 

Sports Exerc 41(3):612–619 

17. Briem K, Ramsey DK, Newcomb W, Rudolph KS, Snyder-Mackler L (2007) Effects of the amount of valgus 

correction for medial compartment knee osteoarthritis on clinical outcome, knee kinetics and muscle 

co-contraction after opening wedge high tibial osteotomy. J Orthop Res. 25:311-8 

18. Machner A, Pap G, Krohn A, et al (2002) Quadriceps muscle function after high tibial osteotomy for 

osteoarthritis of the knee. Clin Orthop Relat Res 399:177-83 

19. Hunt MA, Birmingham TB, Jones IC, Vandervoort AA, Giffin JR (2009) Effect of tibial re-alignment 

surgery on single leg standing balance in patients with knee osteoarthritis. Clin Biomech. 24:693-6 

20. Boulougouris A, Birmingham T, Moyer R, Jones I, Giffin JR (2011) Increased dynamic knee joint load on 

the non-operative limb after high tibial osteotomy. In: Proceedings of the World Congress on 

Osteoarthritis, San Diego, CA 19 (1):S17 

21. Messier SP, Gutekunst DG, Davis C, DeVita P (2005) Weight Loss Reduces Knee-Joint Loads in 

Overweight and Obese Older Adults With Knee Osteoarthritis. Arthr Rheum 52:2026-2032 

22. Moyer RF, Birmingham TB, Chesworth BM, Kean CO, Giffin JR (2010) Alignment, body mass and their 

interaction on dynamic knee joint load in patients with knee osteoarthritis. Osteoarthritis Cart. 18:888- 

893 

23. King LK, Birmingham TB, Kean CO, Jones IC, Bryant DM, Giffin JR (2008) Resistance training for medial 

compartment knee osteoarthritis and malalignment. Med Sci Sports Exerc 40(8):1376–1384 

24. Kean CO, Birmingham TB, Garland SJ, Bryant DM, Giffin JR (2011) Preoperative strength training for 

patients undergoing high tibial osteotomy: a prospective cohort study with historical controls. J Orthop 

Sports Phys Ther 41(2):52–59 

25. Salzmann GM, Ahrens P, Naal FD, El-Azab H, Spang JT, Imhoff AB, Lorenz S (2009) Sporting activity after 

high tibial osteotomy for the treatment of medial compartment knee osteoarthritis. Am J Sports Med. 

37:312-8 

26. Spahn G, Hofmann GO, von Engelhardt LV, Li M, Neubauer H, Klinger HM (2013) The impact of a high 

tibial valgus osteotomy and unicondylar medial arthroplasty on the treatment for knee osteoarthritis: a 

meta-analysis. Knee Surg Sports Traumatol Arthrosc. 21:96-112 

27. Niinimäki TT, Eskelinen A, Mann BS, Junnila M, Ohtonen P, Leppilahti J (2012) Survivorship of high tibial 

osteotomy in the treatment of osteoarthritis of the knee: Finnish registry-based study of 3195 knees. J 

Bone Joint Surg (Br) 94:1517-21 

28. W-Dahl A, Robertsson O, Lohmander LS (2012) High tibial osteotomy in Sweden, 1998-2007: a 

population-based study of the use and rate of revision to knee arthroplasty. Acta Orthopaedica. 83:244- 

8

High Tibial Osteotomy in the Athlete's Knee 

J. Robert Giffin, MD, FRCSC CANADA

Multiple Ligament Injury 

Christopher Harner, MD USA

4/9/2013 

Combined Anatomic PCL 

and PLC Reconstruction 

ISAKOS Sports Rehabilitation Course: 

Global Perspectives for the Physical 

Therapist and Athletic Trainer 

Toronto, Canada 

May 12, 2013 

Robert F. LaPrade, M.D., Ph.D. 

Chief Medical Officer 

Steadman Philippon Research Institute 

Deputy Director, Sports Medicine Fellowship 

Complex Knee and Sports Medicine Surgeon 

The Steadman Clinic Vail, CO 

Adjunct Professor, University of Minnesota 

Disclosures 

I, Robert F. LaPrade, have relevant The Steadman Philippon Research 

financial relationships to be discussed, Institute is a 501(c)(3) non-profit 

directly or indirectly, referred to or 

illustrated with or without recognition 

within the presentation as follows: 

institution supported financially by 

private donations and corporate 

support from the following entities: 

• Editorial Boards for AJSM & KSSTA • Smith & Nephew Endoscopy 

• Consultant : Arthrex 

• Arthrex, Inc. 

• AOSSM Research Grant 

• Siemens Medical Solutions USA, 

• OREF Career Development Grant; Inc. 

OREF Clinical Research Award • Sonoma Orthopedics, Inc. 

2013 

• ConMed Linvatec 

• Health East Norway Research • Össur Americas 

Grant 

• Small Bone Innovations, Inc. 

• Minnesota Medical Foundation 

• Opedix 

Grants 

• Evidence Based Apparel 

Incidence of PLC Injuries with 

PCL Tears 

• Fanelli et al. Arthoscopy 

1995 

─ 222 pts with hemarthrosis, 

27% with injury PLC 

─ Of 85 PCL injuries, 53 

had ( 62 % ) PLC injury 

• Most patients with grade 

3 posterior drawer (≥ 12 

mm on stress xrays) 

Combined > Isolated PLC Injuries 

Two Studies –173 

total patients 

(LaPrade, 1996; 

Geeslin, 2010) 

Isolated 28% 

Combined 72% 

* Lachman or posterior drawer 

3+ - Think posterolateral 

Clinically Relevant Biomechanics of 

the Posterolateral Knee and PCL 

Posterior Translation 

• PCL - main restraint: 

8 mm PT (grade 2) 

• Combined PCL/PLT: 

>12 mm PT (grade 3) 

1

4/9/2013 

Dial test at 30° and 90° 

• External rotation of 

tibial tubercle (10° - 

15° increase): 

(Grood, 1988; Fanelli, 1998) 

• If increases at 90° > 

5°, PCL (Grood, 1988) 

and / or ACL also 

injured (Wroble, 1993) 

• PCL injuries alone 

don’t have ER 

Effect of PLC Injuries on a PCL 

Reconstruction Graft 

(LaPrade, AJSM, 2002) 

Relative Change in PCL Graft 

Force (N) 

50 

45 

40 

35 

30 

25 

20 

15 

10 

5 

0 

PFL Cut 

PLT Cut 

ALL Cut 

30 60 90 

Flexion Angle (Degrees) 

• PCL grafts loaded 

with Varus 

Relative Change in PCL Graft 

Force (N) 

20 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

PFL Cut 

PLT Cut 

ALL Cut 

30 60 90 

Flexion Angle (Degrees) 

• PCL grafts also 

loaded with PD & ER 

Effect of PLC Injuries on a PCL 

Reconstruction Graft 

(LaPrade, 2002) 

• Repair / reconstruct 

posterolateral structures 

at time of PCLR to 

decrease chance of postreconstruction 

PCL graft 

failure 

• Assess for PLC knee injury 

prior to PCL graft fixation 

Combined PLC/PLC 

Treatment Overview 

• Acute – timing, 

concurrent 

injuries, peroneal 

nerve 

• Chronic – 

alignment, 

concurrent 

injuries 

Treatment of Acute Combined 

PLC/PCL Knee Injuries 

Preoperative Planning 

Identify injury pattern 

(exam, MRI) 

Try to operate within 

first 2-3 weeks 

ID peroneal nerve injuries 

Address all torn 

structures 

Approach PLC first 

2

4/9/2013 

Systematically ID 

PLC Injury Locations 

1. Fibular based 

2. Tibial based 

3. Femoral based 

4. Lateral meniscal 

attachments 

(Geeslin, JBJS 2011) 

PLC Lateral Hockey Stick 

Incision 

Gerdy’s Tubercle 

Along posterior 

border of ITB 

Develop 

posteriorly based 

flap 

Peroneal Neurolysis 

Along posterior 

border of long head 

of biceps 

Gain Access to PFL / 

posterior knee 

Use caution for 

biceps avulsions 

Identify Fibular and Tibial 

Attachment Injuries 

• Proximal release of avulsed biceps 

• Identify common peroneal nerve 

• Identify FCL, PFL and meniscotibial lateral capsule 

Copyright © Steadman Philippon Research Institute 

Expose FCL-Biceps Bursa 

FCL attachment 

on Fibula 

PEARL: Traction 

suture to find 

proximal FCL 

injury 

Identify Femoral Attachment Sites 

• Split superficial layer of iliotibial band 

• Identify FCL and popliteus attachments 

• Separate out underlying lateral capsule 

Copyright © Steadman Philippon Research Institute 

3

4/9/2013 

Lateral Arthrotomy Incision 

1 cm anterior to FCL 

Access to popliteus 

attachment, 

popliteomeniscal 

fascicles, LM 

Arthroscopic Evaluation 

(LaPrade, AJSM, 1997) 

Perform after exposure to 

avoid fluid extravasation 

“Drive-through sign” 

> 1 cm of lateral joint 

line opening 

Assists with surgical 

incision placement 

Femoral or tibial based 

lesions 

Arthroscopic Evaluation 

Popliteus avulsion 

Mid-third lateral 

capsular ligament 

─ mensicofemoral 

─ meniscotibial 

Popliteomeniscal 

fascicles 

Coronary ligament 

Double Bundle PCL Reconstruction 

Steps 

• Identify/mark 

femoral 

attachments 

(Johannsen AJSM 2013) 


Steps 

• Establish 

posteromedial 

portal 


Steps 

• Identify tibial 

attachment/ drill pin/ 

fluoroscopy 

(Johannsen AJSM 2013) 

4

4/9/2013 


Steps 

• Ream femoral tunnels 

(endoscopic closed 

sockets) 


Steps 

• Ream tibial tunnel 

last 

• Verify guide pin 

placement 

• Protect posterior 

structures with 

currette 


Steps 

• Endoscopically pass 

grafts into femur 

• Secure grafts in 

femur 

• Pass grafts down 

tibia 

• Hold tibial fixation 

Systematic PLC Repair / 

Reconstruction Method 

1. Femoral attachments 

2. Meniscal attachments 

3. Tibial attachments 

4. Fibular attachments 

*Same stepwise Rx 

almost every case 

Avulsions Off Femur 

Popliteus avulsion – 

recess procedure 

(Jakob, 1982; LaPrade, 1997; Geeslin, 

JBJS, 2011) 

─ Transfemoral eyelet pin 

─ Ream 1 cm tunnel 

─ Pull sutures across 

femur, tie over medial 

button 

*Secure in full extension 

Meniscal - Based Tears 

• Coronary ligament 

of posterior horn of 

meniscus – direct 

repair 

• Popliteomensical 

fascicle tears – 

direct repair if 

lateral meniscus 

unstable 

5

4/9/2013 

Repair Lateral Capsule 

Anchors at joint line 

Suture into undersurface LM 

Separate capsule from ITB 

Avulsion Off Fibular Head / Styloid 

Popliteofibular ligament 

– suture anchors 

Biceps femoris 

– suture anchors 

FCL – suture anchors 

Allow for secure repair / 

early ROM 

Midsubstance Tears of FCL 

or Popliteus Tendon 

Consider augmentation 

(biceps femoris, 

ITB, hamstrings) 

Anatomic 

reconstructions of 

FCL, popliteus tendon 

or entire PLC 

FCL Reconstructions 

(Coobs, 2007; LaPrade, 2010) 

Anatomic FCLR 

Midsubstance tears, 

unable to reduce in 

extension 

Semitendinosus 

autograft harvested 

Popliteus Tendon Reconstructions 

(LaPrade, 2010) 

Nonrepairable 

PLT tear 

• FCL at 20° 

PLC Graft Fixation 

Restores ER 

Often concurrent 

with PCLR 

Consider with PCL 

stress XR > 12 mm 

and collaterals intact 

• PLT at 60° 

6

4/9/2013 

PCL Reconstruction Fixation - 

Tibia 

• Fix tibial graft ends 

once PLC repair/ 

reconstruction 

grafts secured on 

femur 

• AL bundle at 90° 

• PM bundle in 

extension 

Determine “Safe Zone” of 

Knee Motion 

• Full extension a must 

• Amount of safe flexion assessed (>90°) 

Postop Rehab of Acute PLC/PCL 

NWB 6 weeks 

ROM 

─ Start POD #1 

─ Stress full extension 

─ Prone flexion 0 - 90º 

for 2 wks, then ROM 

─ No isolated hamstrings 

for 4 months 

─ Avoid posterior sag! 

─ PCL brace x 6 months 

Treatment of Chronic 

Grade III PLC/PCL Injuries 

Chronic Grade III 

PLC Injuries 

Assess for varus alignment first 

─ Long leg standing x-ray is 

necessary 

─ Correct for varus alignment or 

soft tissue reconstruction will 

stretch out 

Sagittal Plane 

─ Posterior tilt in 

PCLD knee 

Healed Proximal Tibial Osteotomy 

• Reassess at 6 months 

postop osteotomy for 

need for soft tissue 


• If still unstable, consider 

2nd stage PLC 


7

4/9/2013 

Indications for Chronic and 

Combined PLC/PCL Reconstruction 

Case Based Video – 

Chronic PLC Injury 

Normal or corrected 

(varus) alignment 

Chronic PLC/PCL 

Anatomic Posterolateral Knee 

Reconstruction Technique 

Reconstructs FCL, PLT, PFL 

Biomechanically validated 

Prospective study (>200 pts) 

30 minute procedure 

Anatomic PLC Reconstruction 

Overview 

2 grafts 

FCL, PLT, PFL 

reconstructed 

PA 

Lateral 

Surgical Steps – Abbreviated Overview 

1. Posteriorly based flap 

2. Peroneal neurolysis 

3. Prepare tunnels at 

attachment sites 

4. Address intraarticular 

pathology 

5. Prepare grafts *No tourniquet needed 

6. Pass / fix grafts 

Chronic PLCR/PCLR Post-op Rehab 

• NWB 6 wks; start ROM 

POD #1 

• Prone knee flexion 0- 

90° x 2 weeks then ↑ 

as tolerated 

• Exercise bike – POW #7 

• Avoidance of isolated 

hamstrings x 4 months 

• PCL brace x 6 months 

8

4/9/2013 

Posterolateral Outcomes Studies 

(LaPrade, AJSM 2007; LaPrade, JBJS 2010; LaPrade, AJSM 2010; 

Geeslin JBJS 2011) 

Outcomes of Acute Hybrid-Anatomic 

Repairs/Reconstructions 

• Early identification and 

treatment Important! 

• Geeslin, LaPrade (JBJS, 2011) 

– 30 Knees, 2.4 yr F/U 

– IKDC Preop = 29.1, 

Postop = 81.5 

– Varus Stress Preop = 6.2 mm, 

Postop = 0.1 mm 

– 8 isolated, 22 combined 

• Midsubstance repairs do not do well 

(37- 40% failure) (Stannard 2005, Levy 2010) 

PTO for Chronic PLC Injury 

• 21 pts, 3.8 year avg. f/u 

• 38% did not need PLCR 

• Most isolated PLC 

injuries did not need 

PLCR 

• Low velocity < high 

velocity 

Outcomes of Anatomic Posterolateral 

Knee Reconstructions 

• 64 pts., 4.3 year f/u 

• Final Cincinnati 

scores 65.7 

• Varus preop (IKDC): 

1-B, 4-C, 49-D 

• Varus postop: 

45-A, 5-B, 4-D 

Outcomes of Anatomic FCLR 

• Prospective – 20 Patients 

• Preop varus stress xrays 

3.9 mm 

• Postop varus stress xrays 

-0.4 mm 

• IKDC improved from 34.7 

to 88.1 

Outcomes of DB-PCLR 

• 39 Pts, 2.5 yr avg. f/u (8 lost) 

• 7 isolated PCLR, 32 

combined reconstructions 

• Cincinnati and IKDC subjective 

scores improved from 

34.5 & 39.3 73.2 & 74.3 

• On post stress x-rays, post tib 

translation 15 mm 0.9 mm 

9

4/9/2013 

Conclusions – Combined 

PCL-PLC Reconstructions 

• Most PCLR = combined 

• Utilize stress x-rays 

• Combined acute/chronic PCL-PLC 

reconstructions provide excellent 

objective/subjective pt outcomes 

• Anatomically placed PLC/PCL grafts 

do not stretch out with early ROM 

Steadman Philippon 

Research Institute 

Biomechanics 

Research Department 

THANK 

YOU 

10

Session IV 


Medicine

Meniscus Repair and ACL Reconstruction in Athletes 

Moises Cohen, MD, PhD BRAZIL

Rehabilitation for Meniscus Injuries 


Non‐Operative Management of Patellofemoral Pain 

Greg Alcock, MScP.T.,BHSc.P.T., B.A. Hons.P.E., Dip. Manip.,FCA CANADA

18/04/2013 

Surgical Management of 

Patellofemoral 

Pain &Instability 

What makes you having that ! 

David DEJOUR 

Unlucky 

schedule 

Genetics 

? 

Traumatic 

Fortune 

teller… 

FRANCE 

The question Is : 

Who is your patient ? 

General agreement 

Abnormalities in the “pulley system” 

• Average annual incidence of 

primary patellar dislocations is 

5.8 per 100,000 

• Incidence increases to 29 per 

100,000 in the 10-17 year age 

group 

Patello-Femoral anatomy ? 

Local system 

• Trochlear shape 

• Patellar shape 

• Cartilage shape and status 

• Soft tissue restraints 

Alignment ? 

Global system 

• Extensor mechanism 

• Tilting observation 

• Torsionnal data 

• Recurrence rates of 15-44% after 

non-op treatment 

Fithian et al AJSM 2004 

Hawkins et al AJSM 1986 

Power activation? Central system 

• Muscle 

• Brain 

Malalignment 

Clinical testing :Subjective 

Question ? • Torsion 

angle evaluation • Dynamic evaluation 

• Tilting 

• Mobility 

Malalignment 

Radiological testing : Objective 

Axial 30° 

CT Scan 

MRI 

No statistical threshold 

correlated to PF 

dislocation… 

C. Chu 

1

18/04/2013 

CT Scan 

Information - Advantage 

CT Scan Evaluation 

Lyon’s Protocol 

CT Scan Evaluation 

Lyon Protocol 

Patient installation 

56 % > 20 mm 

Dislocation population 

Abnormal if > 20° 

83% in the dislocation population 

1. Femoral torsion 

2. Knee rotation 

3. TT-TG 

4. Patellar Tilt 

5. Trochlear slope 

6. Tibial rotation 

- supine position 

- on a wood board 

- knee extended 

- feet closed together 

- symetrical position 

- fixed with strap 

TT -TG 

Control 12 mm P = 0,003 

chnical Note 

Te 

Tibial Tubercle Transfer 

Is Indicated IF… 

Patella Alta 

True Patellar Instability 

+ 

Or/ And 

“malalignment” 

Excessive TT-TG 


Distalisation 

• 2 Bicortical Screw 

• Perpendicular 

5 to 6 Cm Osteotomy 

Medialisation 

• Distal Hinge 


Patellar tendon 

exposure 


Technical Tricks 

Pre drilling 3.2 

Osteotomy saw 

Indication for TT Transfer 

Only for Objective Patellar Instability 

Distalisation 

If Patella Alta > 1.2 

Medialisation 

If excessive TT-TG > 20 mm 

Quantify the correction 

Fixing with 

4.5 AO screw 

perpendicular 

2

18/04/2013 

chnical Note 

Te 

Medialisation 

• 5 to 6 cm Osteotomy 

• Distal Hinge +++ 


Te echnical Note 

Medialisation 

• Medialisation 

• No advancement 

1. Kneeling pain 

2. Skin healing 

3. Unaesthetic aspect 

echnical Note 

Te 

Amount of Medialisation 

10 < TT-TG< 15 mm 

23,2 mm 

Medialisation = 10 mm 

Rehabilita ation program 

Post operative care 

- Full weight bearing with crutches 

- Extension brace for walking 30 days 

- Isometric Muscle strengthening 

g 

- Passive motion 0° / 100° 30 days 

New TT-TG 13,2 mm 

Cl linical results 

Medialisation 

10 mm < TT - TG < 15 mm 

88 % 

Satisfed , VS 

linical results 

Cl 

Correlation 

Medialisation & Trochlear shape 

Flatter trochlea is, higher could be the transfer 

Hypercorrection 

Hypercorrection 

TT-TG TG < 10 mm 

30% Poor 

D.Dejour and All. Ortopedia Reumatologia Spinger 2008 

3

18/04/2013 

Patella Index… 

Patella Alta gives specific 

Cartilage damage 

Pain 

and +/- 

Instability 

Blackburne 

& 

Peel 

Insall 

& 

Salvati 

Insall 

& 

Salvati 

Modified 

TKA Analysis Patellar shape +/- ++ 

Caton 

Deschamps 

Normal = 1 

Alta ≥ 1,2 

Distalisation if index > 1,2 

Distalisation could relocate the 

patella where the groove is deeper 

I = 1,05 

But also if 

- Index border line 

No patella on the CT scan 

No trochlear groove 

Mild distal. = 5 mm 

Patellar tendon length correction 

Distalisation leads 

to automatic medialisation = 4 mm 

Patellar tendon tenodesis (Ph Neyret 2002) 

Decreased TT-TG 

Medialised the patella 

4

18/04/2013 

Conclusion 

The best indication for 

Tibial Transfer 

is the Patella Alta 

Mostly combined to a MPFL 

Procedure to correct the tilt 




Local system 





Alignment ? 

Global system 


• Muscle 

• Brain 




Soft tissues 

Medial 

E Arendt 

Lateral 

MPFL reconstruction 

BONY Approach 

Biomechanical studies from A. Amis… 

Important Principles 

‣ Position the graft anatomically. Placing the femoral tunnel too far proximal 

results in excessive PF forces. 

‣ Tension the graft with the knee in flexion. Over-tightening the graft causes 

excessive PF forces. Too loose is better than too tight 

‣ Drill patellar tunnels cautiously. Violation of the anterior cortex increases 

the risk of fracture. 

‣ Autologous hamstring grafts are frequently used because they are strong 

and long enough, readily available and easily harvested. 

‣ An MPFL reconstruction is sturdy enough to allow “aggressive 

rehabilitation” with early weightbearing and unrestricted motion ??? 

MPFL Techniques … 

Numerous techniques but the first was Brazilian ! 

Ellera Gomes JL. Medial patellofemoral reconstruction for recurrent 

dislocation of the patella: a preliminary report. Arthroscopy. 1992 

• Soft tissus procedure 

• Bony procedure 

• Mix procedure 

5

18/04/2013 

Soft tissus MPFL … 

Bony procedure MPFL … 

Vincent Chassaing (Fr) 

All in sub cutaneous technique 

Third adductor fixation 

Anchor on patella 

Blind tunnel on femur 

Trans patella tunnel… 

Fixation Options- Patella 

Complications… 

Fracturere 

Farr & Schepsis, 2006 Brown & Ahmad, 2007 LeGrand et al, 2007 

Bone Anchors 

Bone Tunnel Bridge 

MPFL Plasty 

MPFL Reconstruction 

2 bony Tunnels anterior cortex patella 

Gracilis 

Tunnel femoral epicondyle 

D.Dejour 

• Gracilis 

• Tension = Full flexion 

• Lateral Release if no medial displacement 

6

18/04/2013 

The Best Indication 

Low Grade Abnormalities 

No patella Alta TT-GT < 20 mm Dysplasia Type A 

Patello-Femoral Anatomy ? 

Local system 

C. Fink 

Index = 1 

TAGT = 17 mm 

Cartilage & Patella Deep Trochlea MPFL & Soft Tissus 

? 

MPFL rupture or distension 

Trochleoplasty 

Why doing a Trochleoplasty ? 

The surgical technique… 

David DEJOUR 

How doing a Trochleoplasty ? 

Patellar Shift/mm 

5 

0 

-5 

-10 

-15 

-20 

Patellar medio-lateral tracking 

A A Amis, C Oguz , A M J Bull, W Senavongse, D Dejour 

Normal Knee 

JBJS 2008 

0 50 100 150 

Biomechanical effect on patellar tracking 

Only for dislocation !!!! 

Trochlear Dysplasia Type B and D 


Tibial Flexion/degrees 

Trochlear 0 Dysplasia 

-50 -5 0 50 100 150 

-10 

-15 

-20 

-25 


yp 


0 

-50 -5 0 50 100 150 

-10 

-15 

-20 

-25 



A Amis : Imperial College 

London (UK) 

Trochlea Bump +++ impingement with Patella 

7

18/04/2013 

High grade Trochlear dysplasia 

Maltracking : Horizontal plane 

Elevation 

Lateral Facet 


Closing wedge 

trochleoplasty 

Impingement : Sagittal plane 

Deepening and 

create a groove 

ALBEE Procedure 

Elevating trochleoplasty 

? 

Grade Grade B +/- B 

Grade C 

ALBEE Procedure 

• Very efficient : Stability 

• Good if no proeminence, if short trochlea 

(Biedert) 

• Increase lateral pressure 

• Increase trochlear proeminence 

Pain ?? Future arthritis ?? Medial Tilt !!! 

Grade D 

Closing Wedge trochleoplasty 

Goutallier 2002 (RCO) 

Closing Wedge trochleoplasty 

Reduce the bump 

No change of the trochlear shape 

Ph Beaufils 

Ph Beaufils 

8

18/04/2013 

Deepening 

TROCHLEOPLASTY 

H. Dejour 1987 (Masse 1978) 

Create a new groove – remove the prominence +++ 

Deepening TROCHLEOPLASTY 

H Bereiter technique 

Total Trochlear Flap 

Cancellous bone modelling (burr) 

PDS Band in the groove 

Knot in the gutter 

under the synovium 


Arthroscopic Technique Blond-Schottle technique 

Blønd L, Schöttle PB. 

Knee Surg Sports Traumatol Arthrosc. 2010 


S. Donell technique 

Modified Dejour trochleoplasty for severe dysplasia: operative technique and early 

clinical results. 

Donell ST, Joseph G, Hing CB, Marshall TJ. 

Knee. 2006 

Arthroscopic control of the bone resection 

Courtesy Of S. Donell 

Deepening 

TROCHLEOPLASTY 

Lyon’ Procedure ( H. Dejour) 1987 

The sulcus deepening trochleoplasty-the Lyon's 

procedure. Dejour D, Saggin P. 

Int Orthop. 2010 

Osteotomies in patello-femoral instabilities. 

Dejour D, Le Coultre B. 

Sports Med Arthrosc. 2007 

Deepening Trochleoplasty 

H. Dejour 

1987 

9

18/04/2013 

The supra trochear spur 

++++ 

Supra-trochlear 

Dysplasia and Bump 

Cartilaginous 

trochlea 

Patellar tilt 

Missed engagement 

Trochleoplasty effect 

Decrease the TT-TG value 

“Trochlear Groove Lateralisation” 

Proximal re-alignment 

TT-TG : 19 mm 

TT-TG : 14 mm 

Proximal Re-Alignment 

Original Groove 

Lateralization of the Groove 

Reduce the TT- TG 

MPFL has to be repaired !!! 

VMO plasty shouldn’t be done !!! 

Sulcus angle 172° Sulcus angle 155° 

As a combined procedure 

Indication for 


• Rare & high demanding 

• Very efficient on the stability 

• Aetiologic 

• Indicate for Type B et D 

Grade D 

Grade B 

FAQ about trochleoplasty ? 

• Cartilage viability ? 

No influence “Shoettle KSSTA 2007” 

f 

• Congruence with the patella ? 

• Associated instability factors ? 

MPFL rupture or distention ++++ 

10

18/04/2013 

Congruence with patella ? 

Patellar Dysplasia ? 

Congruence Trochlea - Patella 

Patella Osteotomy : Rare !!! 

Be aware of a hypermedialisation !!!!! 

Deepening Trochleoplasty 

Salvage procedure +++ 

Difficult population 

Very efficient on stability +++ 

Good correction of patellar tilt & MPFL +++ 

Good and difficult indication dedicated to 

very special patients 

Bony structures 

Trochlear shape 

Patellar Height 

Patellar shape 

Stability = Balancing 

Soft tissues balancing 

Surgical Algorythm 

“lemenuàlacarte” 

la Extensor mechanism 

de LYON 

alignment 

Vastus medialis 

Correct One by One 

anatomical abnormalities 

Thank You !!! 

MPFL 

Henri Dejour 1987 

Lateral retinaculum 

Surgical planning 

“menu à la carte” 

H. Dejour 

Correct one by one all anatomical abnormalities 




Local system 

Alignment ? 

Global system 








Dysplasia B&D 

Patella Alta TT-TG > 20mm Tilt > 20° 

Trochleoplasty Distalisation Medialisation MPFL 

+/- +/- +/- 


• Muscle 

• Brain 

11

18/04/2013 

Management 

Patello-Femoral Pain 

Primitive Patellar Painful Symdrome 

Adolescent 

Mostly female 

Sometime initial trauma 

Uni or bilateral 

None sport addicted 

No swelling knee 

Patient analysis 

GLOBAL 

ANALYSIS 

David DEJOUR 

FRANCE 

Relationship between 

morphotype and the 

muscle organisation ? 

Post. Chains 

Ant. Chains 

Stiffness and morphotype 

Stiffness or muscle asymmetry 

External analysis rest position 

Think to the back 

Increase the Patello-femoral pressure in flexion 

Quad 

Hamstrings 

Pain !!! 

Management of 

Patellar painful syndrome 

Do not say ! 

• It's nothing ! 

• It's psychological ! 

• It's not surgical : Goodbye ! 

Treatment Patellar Painful Syndrome 

But EXPLAIN ! 

• No future arthritis 

• No surgery 

• Always back to normal 

• No sport limitation 

• What is muscle stiffness !!! 

12

18/04/2013 

• With Physiotherapist first 

To learn exercises 

• Patient education two times / Week (15 Min) 

13

Core Stabilization and Knee Injury Prevention 

Timothy Hewett, PhD USA

Session V 

Degenerative 

Knee

Overview of Articular Cartilage Surgery 

Ramon Cugat, MD, PhD SPAIN

Rehabilitation After Articular Cartilage Surgery 

Lynn Snyder‐Mackler, PT, ScD, FAPTA USA

Non‐Operative Management of Knee Osteoarthritis 

May Arna Risberg, PhD NORWAY

4/9/2013 

Surgical Options for 

Osteoarthritis 


Global Perspectives for the Physical 

Therapist and Athletic Trainer 

Toronto, Canada 

May 13, 2013 

Robert F. LaPrade, M.D., Ph.D. 

Chief Medical Officer 


Deputy Director, Sports Medicine Fellowship 

Complex Knee and Sports Medicine Surgeon 

The Steadman Clinic Vail, CO 

Adjunct Professor, University of Minnesota 

Disclosures 

I, Robert F. LaPrade, have relevant The Steadman Philippon Research 

financial relationships to be discussed, Institute is a 501(c)(3) non-profit 

directly or indirectly, referred to or 

illustrated with or without recognition 

within the presentation as follows: 

institution supported financially by 

private donations and corporate 

support from the following entities: 

• Editorial Boards for AJSM & KSSTA • Smith & Nephew Endoscopy 

• Consultant : Arthrex 

• Arthrex, Inc. 

• AOSSM Research Grant 

• Siemens Medical Solutions USA, 

• OREF Career Development Grant; Inc. 

OREF Clinical Research Award • Sonoma Orthopedics, Inc. 

2013 

• ConMed Linvatec 

• Health East Norway Research • Össur Americas 

Grant 

• Small Bone Innovations, Inc. 

• Minnesota Medical Foundation 

• Opedix 

Grants 

• Evidence Based Apparel 

Background: Osteoarthritis 

• OA is a complex interaction of biological, 

mechanical, and biochemical (Goldring, J Cell Phs 2007) 

– Aging is the primary risk 

factor (Loeser, Clin Geri Med 2010) 

– Greater stress to joints 

due to decreased dissipation 

of forces (Chen, JAAOS, 2005) 

– Injury and malalignment 

accelerate the process 

(Muthuri, OA Cartilage 2011, 

Felson, Arthritis Rheum 2004) 

Background: Osteoarthritis 

• Older athletes are prone to develop 

symptoms of OA, but should not avoid sports 

– Active, enjoyment of sports and 

exercise can improve and extend 

life (Hunter, Sport Med 2004) 

– Less bone loss with exercise 

(Howe, et al. Cochrane Syst Rev. 2011) 

– Moderate exercise has an 

anabolic effect on cartilage 

(Arokoski, Scand J Med Sci Sports 2000) 

Treatment Modalities 

• OA can be treated with numerous modalities: 

– Dietary & lifestyle modifications, physical therapy, bracing 

– Pharmacotherapies: most are systemic drugs that target 

pain relief, but have potential GI, renal, hepatic, and 

cardiac side effects (Sinusas, Am Fam Physician 2012) 

– Injections/Biologics 

– Knee Replacements 

Surgical Interventions 

• The focus of this talk will be on: 

• Arthroscopic Treatments 

• Osteotomy 

1

4/9/2013 

Arthroscopic Treatment 

• Knee OA involves Pain Generators 

– Stiffness 

– Synovitis 

– Loose bodies 

– Meniscus tears 

– Closed spaces due to adhesions 

– Contractures 


• Removal of unstable cartilage/loose bodies 

• Synovectomy 

• Remove adhesions to restore normal 

biomechanics 

• Partial meniscectomies 

• Remove osteophytes to improve ROM 


• In OA, joint mobility is important 

• Suprapatellar and infrapatellar 

adhesions effect knee kinematics 

– Subtle patella infera 

– Increased patellofemoral joint 

reaction force 

– Increased tibial-femoral reaction 

force (Ahmad, Mow, Steadman, et al. 1998) 

Microfracture 

• If pain generators are addressed 

arthroscopically, then symptoms decrease 60 

to 70% of the time without microfracture 

• Microfracture not used in OA where 

surrounding cartilage is thin to none 

Osteophyte Excision 

• Lack of Extension 

• Proximal Anterior Tibial 

Osteophytes 

• Notchplasty 

Arthroscopic Rehab Principles 

• Structured Rehab: Start POD#1, 

Daily (1-2x/day) for 1-2 weeks 

• Key to regaining full activity is 

obtaining full mobility 

• Protected weight bearing 

• Delayed/gradual strengthening 

to avoid stiffness and scar 

tissue recurrence 

2

4/9/2013 

Arthroscopic Rehab: Early 

• Ice, CPM, GameReady to decrease swelling 

• Manual patellar mobility 

– Medial-Lateral 

– Superior-Inferior 

• ROM/muscle activity without joint strain 

– Stationary bike without resistance 

– SLR 

– Wall slides 

– Water exercise when wound OK 

Arthroscopic Rehab: At 6 Weeks 

• Increase strengthening IF NO PAIN: 

– Increased intensity on bike 

– Uphill treadmill 

– Elliptical 

– Short knee bends (0 to 30°) 

– Emphasize closed chain 

exercises 

Arthroscopy for OA Outcomes 

Arthroscopy for OA Outcomes 

• 69 knees with 10 year minimum f/u 

• Mean age of 58 at time of treatment 

• Kellgren-Lawrence grade 3 or 4 radiographic 

changes 

• TKA recommended, none wished to undergo 

• Endpoint defined at TKA for survivorship 

• Repeat arthroscopy in 21% 

• 62% were converted to TKA 

at an average of 4.4 years 

• Failures were older, KL4 and 

kissing lesions 

Role of MM Root Tears and OA 

• Meniscal extrusion 

• Joint overload 

MM Root/Radial Root Repairs 

• Restore joint loads 

• Restore contact area 

• Osteonecrosis, 

insufficiency fracture 

3

4/9/2013 

Knee Osteotomy 

• Proximal tibial osteotomy 

for medial compartment OA 

and genu varus alignment 

• Distal femoral osteotomy for 

lateral compartment OA and 

genu valgus alignment 

• Indications: 

– Single compartment OA 

– Active lifestyle 

• Contraindications: 

– Age > ~55 or Severe OA 

Preop Radiographs 

• Long leg standing AP X-ray 

– Determine mechanical axis / 

coronal plane correction 

amount 

• Lateral X-ray to consider 

sagittal plane correction 

– Anterior tilt – ACLD knee, 

flexion contracture, posterior 

OA 

– Posterior tilt – PCLD knee, 

recurvatum 

Pre-op Planning – Varus Knee 

• Goal – restore corrected mechanical axis through 

the apex of the lateral tibial eminence (LTE) 

• Draw lines from LTE 

apex through center of 

the femoral head and 

center of talar dome 

• Angle formed provides 

osteotomy correction 

angle 

Mechanical Axis Weight Bearing 

Line Landmarks: 

• Analysis on 274 knees with AP 

notch x-rays determined apex 

of LTE to be 56% width of 

proximal tibia 

• Goal for correction of 

mechanical axis because it 

produces 10° anatomic axis 

• (When mechanical axis is 0 o , 

the anatomic axis is 6 ° ) 

LaPrade Arthroscopy 2012 

Biplanar Slope Issues 

• Consider staple of anterior cortex when 

slope desired and posteromedial plate 

position 

• Hyperextend knee to close anterior cortex 

• Anterior plate 

position to 

increase slope 

Postop Rehab = Key to Success 

• Indwelling pain 

catheters for 48 hrs 

• Full ROM 

(90° minimum 2 weeks) 

• NWB x 8 weeks 

• Exercise bike – no 

resistance @ 6 weeks 

• Progress WB 25% / wk 

• Wean off crutches if 3 

month xrays - WNL 

4

4/9/2013 

Unloader Bracing for Knee OA 

• Increased use in past decade 

• Recommended by AAOS 

• Reduces pain/stiffness and 

improves function (Briggs J 

Knee Surg 2012) 

Postop Rehabilitation 

• Low impact – exercise bike, 

walking, deep pool floatation 

jogging 

• Can use as trial before 

osteotomy to see if it 

relieves symptoms 

PTO for Medial OA Outcomes 

• 47 patients, mean age of 40.5 years 

• Modified Cincinnati 

Knee Scores improved 

from 42.9 to 65.1 at 

a mean 3.6 years f/u 

Distal Femoral Opening Wedge 

Osteotomy 

• Isolated lateral compartment 

arthritis, genu valgus 

• Genu valgus with: 

– LFC OCD ORIF (consider) 

– LM transplant 

– Lateral compartment 

cartilage resurfacing 

DFO Post-op Rehabilitation 

• Similar to PTO 

• NWB x 8 weeks, 

FROM 

• Progress WB weeks 

9-12 

DFO Outcomes Studies 

• Jacobi, Arch Orthop Trauma Surg, 2011 

– 14 pts, 45 month follow up 

– Good outcomes once plate removed 

• Koscachvili, Int Orthop, 2010 

– 31 patients, 15 year follow up 

– 50% converted to TKA 

– Viable option in younger patients 

5

4/9/2013 

Conclusions 

• Arthroscopic treatment in 

carefully selected patients is 

effective for mild to moderate 

OA and can delay the need for 

knee replacement 

• Osteotomy is effective for 

unicompartmental OA 

associated with malalignment 

in pts >~55 yrs old 

Steadman Philippon 

Research Institute 

BioEngineering 

Research Department 

THANK 

YOU 

6


Global Perspectives for the Physical Therapist & Athletic Trainer 

Toronto, CAN 

May 12-14, 2013 

Functional Testing Algorithm for Return to Play Following Knee Injuries 

George J. Davies, DPT,MEd,PT,SCS,ATC,CSCS,PES,FAPTA 

Professor, Armstrong Atlantic State University, Savannah, GA. 

Coastal Therapy, Savannah, GA. & Gundersen Lutheran Sports Medicine, LaCrosse, WI. 


II. Importance of establishing discharge criteria: safety for patient, legal implications, etc. 

III. Literature review 

IV. Functional Testing Algorithm: 

• Visual Analog scale 

• Basic Measurements 

o Time/soft tissue healing 

o VAS (0-10 scale) (

Sport Specific Testing for the Lower Extremity in Athletes 

o 

Key Points: 

No consensus on which test(s) are best or most reliable/valid 

No consensus on which values to use| 

Numerous really excellent test methods available 

What’s appropriate for your practice 

Professional Athlete ------------- Recreational Athlete 

Football Player ------------------ Basketball Player 

If you do test – you will not know if a deficit exists 

We need objective criteria 

Summary and Conclusions 

References: 

1. PubMed Search, January 1, 2013 

2. Obremskey, WT, et.al. Level of evidence in orthopaedic journals. J Bone Joint Surg-A. 87:2632-8, 2005 

3. Bhandari, M, et.al. Design, conduct, and interpretation of nonrandomized orthopaedic studies: a practical 

approach. (ALL) EVIDENCE MATTERS. J Bone Joint Surg-A. 91:Suppl 3:1, 2009

4. Sackett, DL, Straus, SE, Richardson, WS, et.al. Evidence-Based Medicine. Churchill Livingstone, New York, 2000 

5. Creighton, DW, et.al. Return-to-play in sport: a decision-based model. Clin J Sports Med. 20(5):379-385, 2010 

6. Taber’s Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, 1997 

7. Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Ortho Phys Ther 

Clin of North Am, 9:103-118, 2000. 

8. Myer, GD, Chimielewski, TL, Kauffman, D, Tillman, S. Plyometric Exercise in the Rehabilitation of Athletes: 

Physiological Responses and Clinical Application. J Ortho Sports Phys Ther, 36(5):2006. 

9. Hurd, W, Axe, M, Snyder-Mackler, L. A 10-Year Prospective Trial of a Patient Management Algorithm and 

Screening Examination for Highly Active Individuals With Anterior Cruciate Ligament Injury Part 1, Outcomes. 

Am J Sports Med. 36(1):40-47, 2008 

10. Meyer, GD, Schmitt, LC, Brent, JL, Ford, KR, Barber Foss, KD, Scherer, BJ, Heidt, RS, Divine, JG, Hewett, TE. 

Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL 

reconstruction. J Ortho Sports Phys Ther. Jun;41(6):337-387, 2011 

11. Yenchak, AJ, Wilk, KE, Arrigo, CA, Simpson, CD, Andrews, JR. Criteria-based management of an acute multistructure 

knee injury in a professional football player: a case report. J Ortho Sports Phys Ther. 41(9):675-686, 

2011 

12. Barber-Westin, SD, Noyes, FR. Factors used to determine return to unrestricted sports activities after ACL-R. 

Arthroscopy. 27:1697-1705, 2011 

13. Davies, GJ, Heiderscheit, B, Clark, M. Closed Kinetic Chain Exercises-Functional Applications in Orthopaedics. 

Wadsworth, C (Ed) Strength and Conditioning Applications in Orthopaedics. Orthopaedic Section, Home Study 

Course, LaCrosse, WI., 1998. 

14. Ellenbecker, TS, Davies, GJ. Proprioception and Neuromuscular Control. Chapter in Andrews, J, Harrelson, GL, 

Wilk, K. (Eds), Physical Rehabilitation of the Injured Athlete , 3rd. Ed., W.B. Saunders, Philadelphia, PA, 2012 

15. Davies, GJ. A Compendium of Isokinetics in Clinical Usage , First Edition, S & S Publishers, La Crosse, WI, 1984. 

16. Davies, GJ, Ellenbecker, T. The Scientific and Clinical Application of Isokinetics in Evaluation and Treatment of 

the Athlete. Chapter in Andrews, J, Harrelson, GL, Wilk, K. (Eds), Physical Rehabilitation of the Injured Athlete , 

3rd. Ed., W.B. Saunders, Philadelphia, PA, 2012 

17. Ellenbecker, T, Davies, GJ. Closed Kinetic Chain Exercise: A Comprehensive Guide to Multiple Joint Exercise. 

Human Kinetics, IL, 2001 

18. Meyer, GD, et.al. Utilization of modified NFL combine testing to identify functional deficits in athletes following 

ACL reconstructions. J Ortho Sports Phys Ther. 41: 377-387, 2011 

19. Arden, CL, et.al. Return to preinjury level of competitive sport after ACL Reconstruction surgery. Am J Sports 

Med. 39:538-543, 2011 

20. Grindem, H, et.al. Single-legged hop tests as predictors of self-reported knee function in nonoperatively 

treated individuals with ACL injury. Am J Sports Med. 39:2347-2354, 2011 

21. Collins, DR, Hedges, PB. A Comprehensive Guide to Sports Skills Tests and Measurements. Springfield, IL., 

Charles C. Thomas, pp. 330-333, 1978 

22. Davies, GJ, et.al. Functional progression of a patient through a rehabilitation program. Orthop Phys Ther Clinics 

North America, 9:103-118, 2000 

23. Myer, GD, et.al. Rehabilitation after ACL Reconstruction: criteria-based progression through return-to-sport 

phase. JOSPT. 36:403-414, 2006 

24. Hurd, WJ, et.al. A 10-year prospective trial of a patient management algorithm and screening examination for 

highly active individuals with ACL injury. AJSM 36: 48-56, 2008 

25. Lentz, TA, et.al. Factors associated with function after ACL-R. Sports Health, 2009 

26. Yenchak, AJ, et.al. Criteria-based management of an acute multistructure knee injury in a professional football 

player. JOSPT. 41:675-686, 2011 

27. Verstegen, M, et.al. Suggestions from the field for return to sports participation following ACL-R: American 

football. JOSPT. 42:337-344, 2012 

28. Myer, GD, et.al. An integrated approach to change the outcome Part I: Neuromuscular screening methods to 

identify high ACL injury risk athletes. JSCR. 26:2265-2271, 2012 

29. Myer, GD, et.al. An integrated approach to change the outcome Part II: Targeted neuromuscular training 

techniques to reduce identified ACL injury risk factors. JSCR. 26:2272-2292, 2012 


Arthroscopy. 27:1697-1705, 2011 

31. Barber-Westin S.D., Noyes F.R., McCloskey J.W.: Rigorous statistical reliability, validity, and responsiveness 

testing of the Cincinnati Knee Rating System in 350 subjects with uninjured, injured, or anterior cruciate 

ligament-reconstructed knees. Am J Sports Med 1999; 27:402-416. 

32. Noyes F.R., Barber S.D., Mangine R.E.: Bone–patellar ligament–bone and fascia lata allografts for 

reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 1990; 72:1125-1136. 

33. Noyes F.R., Barber S.D., Mangine R.E.: Abnormal lower limb symmetry determined by function hop tests after 

anterior cruciate ligament rupture. Am J Sports Med 1991; 19:513-518. 

34. Irrgang J.J., Anderson A.F., Boland A.L., et al: Development and validation of the International Knee 

Documentation Committee subjective knee form. Am J Sports Med 2001; 29:600-613.

35. Irrgang J.J., Anderson A.F., Boland A.L., et al: Responsiveness of the International Knee Documentation 

Committee subjective knee form. Am J Sports Med 2006; 34:1567-1573. 

36. Irrgang J.J., Ho H., Harner C.D., Fu H.F.: Use of the International Knee Documentation Committee guidelines to 

assess outcome following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 

1998; 6:107-114. 

37. Irrgang J.J., Snyder-Mackler L., Wainner R.S., et al: Development of a patient-reported measure of function of 

the knee. J Bone Joint Surg Am 1998; 80:1132-1145. 

38. Davies GJ: The Compendium of Isokinetics in Clinical Usage & Rehabilitation Techniques, 4 th Ed, S & S 

Publications, Onalaska, WI. 1992. 

39. Tabor M, Davies GJ, et al: A multi-center study of the test- retest reliability of the lower extremity functional 

test. J Sport rehabil 2002: 11:190-201. 

40. Davies GJ: The need for critical thinking in rehabilitation. J Sport Rehab. 1995: 4:1-22. 

41. Wilk KE, Marcina LC, Cain EL, et al: Recent advances in the rehabilitation of ACL injuries. J Orthop Sports Phys 

Ther 2012:42:208-220. 

42. Wilk KW: Are there speed limits in rehabilitation? J Orthop Sports Phys Ther 2005: 35:50-51. 

43. Simoneau GG, Wilk KE: The challenge of return to sports for patients post ACL reconstruction. J Orthop Sports 

Phys Ther 2012: 42:300-301. 

44. Wilk KE, Romaniello WT, Soscia SM, et al: The relationship between subjective knee scores, isokinetic testing & 

functional testing in the ACL reconstructed knee. J Orthop Sports Phys Ther 1994: 20-60-69. 

45. Smith, MV, et.al. Lower extremity-specific measures of disability and outcomes in orthopaedic surgery. J Bone 

Joint Surg-AM, 94:468-77, 2012

Session VI 

Hip

Elizaveta Kon, Giuseppe Filardo, Berardo Di Matteo, Francesco Perdisa, Luca Andriolo, Francesco 

Tentoni, Alessandro Di Martino, Maurilio Marcacci 

AFFILIATION 

Nano-Biotechnology Lab and II Orthopaedic Clinic, Rizzoli Orthopaedic Institute, Via di Barbiano 

1/10, 40136 Bologna, Italy 

INTRODUCTION 

Recent years have seen the flourishing of a completely new approach for the treatment of cartilage 

lesions. What we have seen is the transition from a traditional approach focusing on the concept of 

“repair” to the revolutionary idea of “regeneration” [1,2,3]. This fascinating perspective is one of 

the hottest topics of the current pre-clinical and clinical cartilage research: although orthopaedic 

practitioners have been always managing chondropathy and osteoarthritis, the most recent 

discoveries in the field of growth factors (GFs) have led to widespread enthusiasm about the 

application of innovative biological strategies for treating these conditions. A new figure is 

emerging: the “orthobiologist”, i.e. an orthopaedic surgeon specializing in biological and bioengineered 

treatments, both conservative and surgical. In this particular field, the role played by 

blood derivatives, and in particular Platelet-rich Plasma (PRP), is preeminent. Platelet-derived GFs 

contained in PRP are the most exploited way to administer a biological stimulus to several different 

damaged tissues, such as cartilage, tendons and muscle that might benefit from this particular 

approach [4]. Being able to treat patients with a product derived directly from their own blood is an 

attractive proposition due to the theoretical reduced risks of intolerance and side effects than those 

commonly ascribed to traditional commercial drugs. Concerning the application of this biological 

treatment, cartilage is one of the most targeted tissues [5]. In fact, the incidence of this kind of 

lesions is increasing in relation to the ever-growing interest in sport which, beyond some 

unquestionable beneficial effects on health, is also responsible for both traumatic and degenerative 

lesions of musculo-skeletal tissues [6, 7 ]. Young people, the most sport-active population, are often 

affected by these lesions. The treatment of cartilage pathology in these patients is often 

conservative, due to the limits of the current surgical treatments for cartilage lesions and the lack of 

indication for invasive joint metal resurfacing [3]: the constant research for innovative solutions has 

been one reason for the booming interest in biological approaches.

BIOLOGICAL RATIONALE AND DEFINITION OF PRP 

The biological rational behind this kind of treatment is the topical administration of several 

important molecules normally involved in joint homeostasis, healing mechanism and tissue 

regeneration. First of all platelet-derived GFs: a group of polypeptides playing important roles in 

the regulation of growth and development of several tissues, including cartilage. Platelets contain 

storage pools of GFs [4,8,9] such as: platelet-derived growth factor (PDGF); transforming growth 

factor (TGF-β); platelet-derived epidermal growth factor (PDEGF); vascular endothelial growth 

factor (VEGF); insulin-like growth factor 1 (IGF-1); fibroblastic growth factor (FGF); epidermal 

growth factor (EGF) etc… 

Alpha granules are also a source of cytokines, chemokines and many other proteins [4] involved in 

stimulating chemotaxis, cell proliferation and maturation, modulating inflammatory molecules and 

attracting leukocytes [4]. Besides alpha granules, platelets also contain dense granules, which store 

ADP, ATP, calcium ions, histamine, serotonin and dopamine, that also play a complex role in tissue 

modulation and regeneration [10]. Finally, platelets contain lisosomal granules which can secrete 

acid hydrolases, cathepsin D and E, elastases and lisozyme [11], and most likely other not yet well 

characterized molecules, the role of which in tissue healing should not be underestimated. Several 

in vitro and in vivo animal studies have showed the potential beneficial effect of PRP in promoting 

cellular anabolism and tissue regeneration [8] and set the rational for the application of platelet 

concentrates in humans. 

PLATELET DERIVED GROWTH FACTORS AND HIP PATHOLOGY 

Some studies concerning injective application of PRP in hip osteoarthritis have been published. The first one, 

authored by Battaglia et al. [12] reported the results of PRP ultra-sound-guided injective treatment in 20 

patients affected by hip OA (Kellgren-Lawrence Score from I to III): 3 intra-articular injections 2 weeks 

apart were performed and patients were followed-up for 1 year. The clinical outcome was positive but a 

worsening occurred after 3 months up to the final evaluation, thus confirming the time-dependent effect of 

PRP. The same group led a randomized trial comparing PRP and viscosupplementation in a cohort of 100 

patients affected by hip OA. Results were encouraging: both PRP and viscosupplementation provided time 

dependant symptomatic relief, even if a clear superiority of the biological treatment was not proved. 

The second one was recently published by Sanchez et al. [13], who treated 40 patients affected by 

OA with 3 weekly ultrasound-guided injections of PRP. Evaluation was carried out for up to 6 

months using the WOMAC, Harris, and VAS scores for pain. Satisfactory results were reported with 

a significant reduction in pain level at the first evaluation after 6 weeks, which was confirmed even

at the final follow-up of 6 months. Functional recovery was encouraging as evaluated through a 

specific subscale of the WOMAC score. However, 11 out of 40 patients did not have any beneficial 

effect after injective treatment: in these cases, a metal resurfacing was required. 

Beyond cartilage application, PRP has also been tested in the treatment of avascular hip 

osteonecrosis: a case series has been published by Guadilla et al [14] describing an original 

treatment consisting in the association of core decompression and PRP therapy. Four patients were 

treated and the biological augmentation provided by PRP resulted in a good clinical outcome in all 

the cases considered and the patients were able to get back to their common everyday activities. 

More recently a case report by Hibrahim and Dowling [15] described the positive result obtained 

after a single PRP injection in a woman refusing more invasive treatment. 

Furthermore, this biological treatment, associated with bone marrow concentrate, was used to treat a 

27 years old football player suffering from a gluteus minimus tendon and hip anterolateral capsular 

lesions [16]: a good results was achieved and resumption of sport practice was possible after a few 

weeks from the end of the injective treatment. 

CONCLUSION 

For what concerns the current understanding on the potential and feasibility of applying PRP in the 

management of cartilage pathology, it is not possible to draw definite conclusions about the efficacy 

of this approach, especially when applied during surgical procedure as a biological augmentation: 

high quality comparative studies aimed at assessing the specific role of PRP are needed. Growth 

factors’ administration is certainly a fascinating approach to treat cartilage pathology and at the 

present moment lots of researches are ongoing to establish which particular molecules could 

provide the best therapeutic effects and to determine the best application protocol. PRP is a widely 

exploited way to supply platelet-derived growth factors in the articular environment. However, the 

current available literature is not conclusive on the real efficacy of this approach in treating hip 

disorders. There are difficulties related to the great number of variables concerning PRP production, 

storage and administration, which make study comparison very challenging. Beyond that, the 

average quality of the published articles is low, with lack of randomized controlled double blind 

trials. Thus, no clear indication can be asserted in favour of PRP application for hip pathology with 

respect to other traditional approaches. What we need is more biological studies to identify the best 

formulation for PRP preparation and more high level clinical trials to define the best application 

protocol and the real therapeutic potential of this biologic treatment option.

REFERENCES 

1. Gomoll AH, Filardo G, de Girolamo L, Esprequeira-Mendes J, Marcacci M, Rodkey WG, 

Steadman RJ, Zaffagnini S, Kon E. Surgical treatment for early osteoarthritis. Part I: cartilage repair 

procedures. Knee Surg Sports Traumatol Arthrosc. 2012;20(3):450-66. 

2. Gomoll AH, Filardo G, Almqvist FK, Bugbee WD, Jelic M, Monllau JC, Puddu G, Rodkey WG, 

Verdonk P, Verdonk R, Zaffagnini S, Marcacci M. Surgical treatment for early osteoarthritis. Part II: 

allografts and concurrent procedures. Knee Surg Sports Traumatol Arthrosc. 2012;20(3):468-86. 

3. Kon E, Filardo G, Drobnic M, Madry H, Jelic M, van Dijk N, Della Villa S. Non-surgical 

management of early knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2012;20(3):436-49. 

4. Boswell SG, Cole BJ, Sundman EA, Karas V, Fortier LA. Platelet-rich plasma: a milieu of 

bioactive factors. Arthroscopy. 2012;28(3):429-39. 

5. Fortier LA, Barker JU, Strauss EJ, McCarrel TM, Cole BJ. The role of growth factors in cartilage 

repair. Clin Orthop Relat Res. 2011 Oct;469(10):2706-15. Review. 

6. Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review 

of 31,516 knee arthroscopies. Arthroscopy. 1997;13(4):456-60. 

7 . Widuchowski W, Widuchowski J, Trzaska T. Articular cartilage defects: study of 25,124 knee 

arthroscopies. Knee. 2007;14:177-182. 

8. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from 

basic science to clinical applications. Am J Sports Med. 2009 Nov;37(11):2259-72. 

9. Sanchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A 

current review. Int J Oral Maxillofac Implants 2003;18:93–103. 

10. Mishra A, Woodall J Jr, Vieira A. Treatment of tendon and muscle using platelet-rich plasma. 

Clin Sports Med. 2009 Jan;28(1):113-25. 

11. Anitua E, Andia I, Ardanza B, Nurden P, Nurden AT. Autologous platelets as a source of proteins 

for healing and tissue regeneration. Tromb Haemost 2004;91:4-15 

12. Battaglia M, Guaraldi F, Vannini F, Buscio T, Buda R, Galletti S, Giannini S. Platelet-rich 

plasma (PRP) intra-articular ultrasound-guided injections as a possible treatment for hip 

osteoarthritis: a pilot study. Clin Exp Rheumatol. 2011;29(4):754. 

13. Sánchez M, Guadilla J, Fiz N, Andia I. Ultrasound-guided platelet-rich plasma injections for the 

treatment of osteoarthritis of the hip. Rheumatology (Oxford). 2012;51(1):144-50. 

14. Ibrahim V, Dowling H. Platelet-rich plasma as a nonsurgical treatment optionfor osteonecrosis. 

PM R. 2012 Dec;4(12):1015-9. 

15. Campbell KJ, Boykin RE, Wijdicks CA, Erik Giphart J, Laprade RF, Philippon MJ. Treatment 

of a hip capsular injury in a professional soccer player with platelet-rich plasma and bone marrow 

aspirate concentrate therapy. Knee Surg Sports Traumatol Arthrosc. 2012 Oct 7. 

16. Guadilla J, Fiz N, Andia I, Sánchez M. Arthroscopic management and platelet-rich plasma 

therapy for avascular necrosis of the hip. Knee Surg Sports Traumatol Arthrosc. 2012 

Feb;20(2):393-8.

2/2/13 

NON-OPERATIVE TREATMENT OF 

EXTRA-ARTICULAR HIP PAIN 

Keelan R. Enseki, PT,MS,OCS,SCS,ATC,CSCS 

University of Pittsburgh 

Centers for Rehab Services 

University of Pittsburgh Center for Sports Medicine 

Pittsburgh, PA 

USA 

DISCLOSURES 

n No personal disclosures/conflicts 

n No institutional disclosures/conflicts 

Hip vs Lumbosacral 

Spine 

Eval and Treat 

Lumbosacral Pathology 

SCREENING FOR HIP JOINT 

INVOLVEMENT 

Extra vs Intra-Articular 

Eval and Treat Extra - 

Articular Pathology 

FABER Test 

Scour Test 

Traumatic 

Impingement 

Hypomobility 

Hypermobility 

COMMON EXTRA-ARTICULAR 

CONDITIONS OF THE HIP REGION 

EXTRA-ARTICULAR CONDITIONS 

u Strains 

u Tendonopathy 

u Bursitis 

u Painful snapping 

hip syndrome 

u Athletic Pubalgia 

u etc. 

n Pain and/or weakness with strength testing 

n Tightness and/or weakness with flexibility 

testing 

n Potential pain with palpation of specific 

suspected structures 

n …and negative tests for intra-articular 

involvement 

1

2/2/13 

COXA SULTANS: THE SNAPPING HIP 

(Allen & Cope) 

Three Forms: 

n 

External: occurs when the thickened area of the posterior 

ITB or leading edge of the anterior gluteus maximus 

snaps forward over the greater trochanter with hip flexion 

n 

Internal: occurs when the musculotendinous portion of 

the iliopsoas snaps over deep structures; usually the 

femoral head and anterior capsule 

n 

Intra-articular: is due to lesions within the joint itself 

(example: labral tear) 

EXTRA-ARTICULAR SNAPPING HIP 

n Relative rest/activity modification 

n Identify and treat 

u Flexibility issues (iliopsoas, ITB) 

u Strength asymmetries 

n Central stabilization 

n Soft tissue mobilization 

n Re-screen for intra-articular involvement if 

not responsive to treatment 

GLUTEAL TENDONOPATHY AND 

TROCHANTERIC BURSITIS 

n Two tests have show high sensitivity 

and specificity: 

u 30 second single leg stance test 

u Resisted external de-rotation test 

(supine) 

(Luquesne, Arthritis Rheum 2008) 

ADDUCTOR LONGUS STRAIN 

n Common in 

sports requiring 

repetitive, 

explosive 

movements or 

heavy 

eccentric 

demands 

TREATMENT PRINCIPLES 

n Strength in all planes of motion 

n Central stability 

n Perturbation 

n Soft tissue mobilization techniques 

n Functional considerations 

2

2/2/13 

SYMMETRY 

TOP OVER BOTTOM ROTATIONAL 

STRENGTH 

n 

n 

n 

Side-to-Side 

u Attempt to minimize the discrepancy between 

dominant and non-dominate sides 

Group-to-Group 

u External vs. internal rotators 

u Abdominal vs. lumbar extensors 

* Not specifically equal strength, but appropriate 

ratio 

Strength-to-Flexibility 

u Avoid over-emphasizing stretching without an 

appropriate strength foundation 

u Do not create motion that can not be controlled 

REPRODUCE FUNCTIONAL 

DEMANDS 

n Attempt to 

recreate 

demands of 

activity 

u Planes of 

movement 

u Concentric vs. 

eccentric activity 

u Speed 

progression 

MANUAL PERTURBATION 

3

2/2/13 

SOFT TISSUE MOBLIZATION 

BIOMECHANICAL CONSIDERATIONS 

n Recurrent cases my be the result of 

biomechanical asymmetries; consider: 

u Foot/ankle: over-pronation 

u Knee: Poor motor control with loaded activities 

REFERENCES 

n Allen WC, Cope R. Coxa Saltans: The Snapping Hip Revisited. J 

Am Acad Orthop Surg. 1995 Oct;3(5):303-308. 

n Lequesne M, Mathieu P, Vuillemin-Bodaghi V, Bard H, Djian P. 

Gluteal tendinopathy in refractory greater trochanter pain 

syndrome: diagnostic value of two clinical tests. Arthritis 

Rheum. 2008 Feb 15;59(2):241-6. 

n Martin RL, Sekiya JK. The interrater reliability of 4 clinical tests 

used to assess individuals with musculoskeletal hip pain. J 

Orthop.Sports Phys Ther. 2008;38:71-77. 

n Maslowski E, Sullivan W, Forster Harwood J, et al. The 

diagnostic validity of hip provocation maneuvers to detect intraarticular 

hip pathology. PM & R : The Journal of Injury, Function, 

and Rehabilitation. 2010;2:174-181. 

n SutliveT, Lopez H, Childs J, et al. Development of a clinical 

prediction rule for diagnosing hip osteoarthritis in individuals with 

unilateral hip pain. Journal Of Orthopaedic& Sports Physical 

Therapy [serial online]. September 2008;38(9):542-550. 

4

Hip arthroscopy in the athlete 

Marc J. Philipon, MD 


I- Introduction 

Vail, CO 

Epidemiological aspects: 

Greater incidence of symptomatic FAI in athletes 

Association between labral tears, capsular laxity and rotational 

movements 

Greater incidence of CAM in males and Pincer in females 

Mixed-type FAI is the most common pathology 

Tip: 

Always look for the cause of the labral tear: associated pathology is the 

rule and must be addressed during treatment 

Differential diagnosis: 

Groin pain is the most common complaint for labral tears, 

however it is not patognomonic. Sports hernia is an important 

differential diagnosis that must be made in advance. Both 

conditions may co-exist in athletes (labral tear and sports 

hernia) 

Labral tear can also present as lateral or posterior hip pain, and 

Greater Trochanteric Pain Syndrome, Piriformis syndrome, 

irradiated pain and sacroiliac joint pain must be identified. 

Mechanical symptoms (popping, clicking and locking) may be 

of intra or extra-articular etiology. Physical examination can 

usually differentiate between sources.

Indications: 

Labral tears 

Capsular laxity 

Femoroacetabular impingement 

Ligamentum teres injuries 

Loose bodies 

Chondral Injuries 

Tip: 

More than one procedure is usually necessary during hip arthroscopy. The 

most common association is the need to address the labral tear and the 

bony impingement, but other combinations are not rare. Address all the 

possible causes of pain to optimize the chances of a successful procedure 

II- Hip arthroscopy 

Setting: 

Supine position 

Traction table 

Padded bolster 

Padded boots 

Step-by-step positioning 

Team: 

Scrubbed assistant to hold the leg 

Non-scrubbed to move the leg 

Systematic preparation ease and fasten the procedure 

Anesthesiologist: 

o Hypotensive anesthesia 

o Complete relaxation 

o Minimum post-operative pain 

o Allow early mobilization 

Instruments: 

Flexible radiofrequency 

Adequate cannulas (long enough) 

Slotted cannula and switcher-sticks 

Arthroscopic pump (set initially at 50mmHg)

Portals: 

Epinephrine in fluid bags 

Curved shavers 

Burrs 

Referred to patient landmarks 

Antero-lateral (AL) portal: 1cm proximal and 1cm anterior to 

the tip of the greater trochanter. 

Mid-anterior (MA): about 7 cm distal and medial to the anterolateral 

portal in a line subtending 45-60º to the long axis of the 

femur. 

AL is performed first with aid of fluoroscopy 

Tricks: 

1- Be sure that adequate traction and join space are available 

2- Use spinal needle and nitinol wire before using a canula 

3- Tactile sensation of the capsule and its perforation are a good method 

to confirm adequate positioning 

4- Aim closer to the head to avoid labrum penetration 

5- Confirm the location of the needle by injecting saline and observing 

rebound of fluid under pressure 

6- Avoid scratching the head by being gentle with instrument insertion. 

Rotatory movements usually allow easier penetration with less trauma. 

MA portal performed under direct visualization of the 

anterior triangle (capsule, labrum and head) 

Tricks: 

1-Rotate the limb internally to “open” the anterior triangle 

2- Aim at the apex of the triangle: coming to close to your camera may 

difficult triangulation before the capsulotomy 

Capsulotomy: 

Keep it parallel to the labrum about 1 cm distant from the free 

edge of the labrum 

A sleeve of capsule allows easier instrumentation in the 

capsule-labral space

Keep it small: usually connecting both portal is just enough to 

obtain adequate visualization and instrumentation on both 

central and peripheral compartments 

If extended capsulotomy is needed keep in mind that the 

lateral epiphyseal vessels must be inspected laterally and that 

further extension medially may compromise the iliofemoral 

ligament (IFL) 

If the IFL is divided, usually a repair with a strong suture in the 

end of the procedure is able to prevent iatrogenic instability. 

Central compartment: 

Use both portals for inspection 

Document your findings 

Use curved instruments and flexible RF to reach the fossa, 

medial head and inferior acetabulum 

Peripheral compartment: 

Use camera and instruments as retractors 

More flexion gives access to the medial part of this 

compartment and less flexion ease the access to the lateral 

part. 

Don’t remove too much capsule: it will make fluid containment 

more difficult 

Use the medial and lateral synovial fold as landmarks 

Don’t do deep osteoplasties. In most cases few millimeters 

depths form larger extensions are enough to avoid 

impingement and restore the labral seal. 

Deep bone resections create a hook effect that can put 

traction on the labrum and disrupt the labral seal.

POSTOPERATIVE REHABILITATION 

FOLLOWING HIP ARTHROSCOPY 

Keelan R. Enseki, PT,MS,OCS,SCS,ATC,CSCS 

University of Pittsburgh 

Centers for Rehab Services 

University of Pittsburgh Center for Sports Medicine 

Pittsburgh, PA 

USA 

DISCLOSURES 

n No personal disclosures/conflicts 

n No institutional disclosures/conflicts 

POSTOPERATIVE REHABILITATION 

POSTOPERATIVE BRACING 

n 

n 

n 

Surgical options available for pathological conditions 

of the hip have evolved significantly 

Rehabilitation protocols for individuals undergoing 

such procedures must evolve as well 

Postoperative protocols for hip arthroscopy patients 

should be designed based on: 

u Healing properties of involved tissues 

u Available evidence 

u Demands of patient population 

u Clinician experience 

n 

n 

Typically limits sagittal 

plane ROM from neutral/ 

slight extension to 80 or 

90 degrees of flexion 

Time varies 

u 10 days to 4 weeks 

NIGHT IMMOBILIZER 

n Night immobilizer system may be prescribed to 

prevent hips from falling into external rotation 

while sleeping 

n Typically prescribed from one to four weeks 

depending on the concern for limiting rotation 

n Immobilizer system consists of a cylinder placed 

between legs and straps to keep the lower 

extremities secure and toes in an upward position 

Passive 

(Bony, Labrum, 

Capsuloligamentous) 

Neural 

(Proprioceptive) 

Active 

(Muscular) 

Rehab 

Focus 

1

IMMEDIATE POSTOPERATIVE 

TREATMENT 

n Early ROM 

n Stationary bike 

n Strength Integrity 

u Emphasis on maintaining strength of lower 

extremity and lumbopelvic musculature 

n Aquatic Program 

u Typically initiated after suture removal 

u Early gait training and AROM 

u Early cardiovascular conditioning 

EARLY RANGE OF MOTION 

n Gentle ROM permitted within the first week 

n Excessive flexion and abduction is initially 

avoided, to avoid tissue impingement 

n Circumduction motion 

n Typically allow full PROM after 2 weeks 

u Anterior capsular procedure: avoid forced 

external rotation and extension for 3-4 weeks 

u Posterior capsular procedure: avoid forced 

internal rotation and flexion for 3-4 weeks 

n Initiate gentle stretching at approximately 3 

weeks 

FLEXION IN QUADRUPED 

WEIGHT BEARING 

n 10 –14 days, partial weight bearing for more 

basic procedures (labral resection) 

n Up to 4 weeks (occasionally longer) for more 

involved procedures (osteoplasty,microfracture, 

labral repairs in weight bearing region of joint) 

n Progression off crutches often guided by 

symptoms 

STRENGTH 

n Tendon release procedures 

u Iliopsoas: Defer supine straight leg raise 4 

weeks 

« Short lever hip flexion to 90 degrees is usually 

well tolerated 

u ITB: Hold side-lying straight leg raise 2 – 3 

weeks 

n Open chain activities replaced with weight 

bearing activities as weight bearing status 

permits 

n Guided primarily by symptoms after 4 weeks 

EXTERNAL ROTATION STRENGTH 

PROGRESSION 

2

COMBINATION PROCEDURES 

n Combination of combined procedures is not 

uncommon 

n Commonly will see labral resction/repair 

combined with another procedure 

u Labral resection/repair & osteoplsty 

u Labral resection/repair & capsular modification 

COMBINATION PROCEDURES 

n Rehabilitation protocols usually follow the most 

conservative aspect of each procedure 

n Labral resection & osteoplasty 

u ROM as tolerated at 2 weeks 

u PWB until 4 weeks 

n Labral resection & capsular modification 

(anterior) 

u Caution with external rotation & extension until 4 

weeks 

u Weight bearing progression as tolerated at 2 

weeks 

LUMBOPELVIC STABILIZATION 

n Similar to shoulder and scapular stabilization 

principles 

n Recurrent hip pain often associated with 

lumbopelvic dysfunction 

3

FUNCTIONAL PROGRESSION 

ENDURANCE TRAINING 

n General Considerations 

u Patient tolerance to required ROM 

u Patient tolerance to weight-bearing activities 

u Known integrity of the joint 

u Patients previous cardiovascular status 

ESTIMATED RETURN TO OCCUPATIONAL 

DUTIES 

n Varies secondary to: 

u Individual patient characteristics 

u Nature of surgical procedure 

n Low load occupation 

u 6 to 12 weeks 

n Manual labor 

u 8 to 24 weeks 

ESTIMATED RETURN TO ATHLETIC 

ACTIVITIES 

n Varies by: 

u Individual athlete characteristics 

u Demand of sport 

u Nature of procedure 

n Return to sport 

u 8 weeks minimal for isolated labral resection 

u 12 to 24 weeks for capsular procedures 

u 12 to 32 weeks for osseous/chondral or involved 

combination procedures 

*return to sport may occasionally be accelerated in highlevel 

athletes, within the boundaries of tissue healing 

properties 

n 

n 

n 

THE FUTURE DIRECTION… 

Basic science and 

biomechanical studies 

Develop appropriate 

outcome scales 

u Hip Outcome Scale 

(HOS) 

u International Hip 

Outcome Tool (iHOT-33) 

Refine rehabilitation 

protocols 

u Tissue Healing properties 

u Evidence-based 

approach 

u Clinical experience 

n 

n 

n 

REFERENCES 

Enseki KR, Martin RL, & Kelly BT. Rehabilitation after arthroscopic 

decompression for femoroacetabular impingement. Clin Sports 

Med. 2010; 29:247–255. 

Enseki KR, Martin RL, Draovitch P, et al. The Hip Joint: 

Arthroscopic Procedures and Postoperative Rehabilitation. JOSPT. 

2006;36(7):516-525. 

Kelly BT, Williams RJ, Philippon MJ. Hip arthroscopy: current 

indications, treatment options, and management issues. Am J 

Sports Med. 2003; 31:1020-1040. 

4

Session VII 

Muscle and 

Tendon Sports 

Injuries

Evidence Based Prevention of Muscle and Tendon Injuries in Soccer Players 

Per Hölmich, MD DENMARK

ISAKOS 2013 

SPORTS REHABILITATION COURSE 

Rehabilitation of Groin Pain and Athletic Pubalgia 

Mario Bizzini, PT, PhD, FIFA-‐Medical Assessment Research Centre, Schulthess 

Clinic, Zürich, Switzerland (mario.bizzini@f-‐marc.com) 

Groin and hip injuries in football are common, yet often difficult to diagnose and 

treat. Whereas the differential diagnoses previously consisted of more than 90% 

of tendinopathies and muscle weakness/hernias, the new knowledge of the hip 

joint anatomy and impingement symptoms in the young player has necessitated 

a shift in diagnostic focus and clinical skills during the last decade (however, to 

date, there is little knowledge about the prevalence and incidence of femoro-acetabular 

impingement in football). In general, the correct diagnosis is the 

paramount for a targeted treatment of groin/groin area’s problems. 

Groin injuries are among the four most common types of injury in football. They 

account for 7-‐11% of all injuries in some Olympic sports, including ice hockey, 

football, and athletics. Groin strain injuries have been cited as accounting for 

20% of all muscle strain injuries at elite levels of football. Groin injuries may be 

acute but often become chronic in nature. 

The most common location (>50%) of groin pain reported in athletes in general 

is the adductor muscle tendon region. Acute onset pain in this region is 

commonly attributable to an adductor longus muscle insertional tendinopathy 

but may also be related to the iliopsoas and/or the abdominal muscles. The 

differential diagnoses for groin pain in football players are multiple (ref). 

Three major areas of anatomy require attention to and knowledge of the groin 

and hip area. The adductor group consisting of adductor longus, magnus, brevis 

and gracilis and the rectus femoris and pectineus, the pelvis groin group 

consisting of tranversus abdominis, obliquus externus and internus and rectus 

abdominis, and the anatomic structures of the hip (femur, acetabulum), the 

labrum and the surrounding muscles and tendon of the hip all require the 

attention of the clinician in a footballer with pain in the groin or the hip. 

It can be estimated that about 40% of players experienced an acutely painful 

incident during training or competition, and that 60% experienced gradually 

developing pain in the groin region, which is typical of an overuse injury. An 

acute strain usually involves one or more muscles and happens during forceful 

action. In most cases, the lesion lies within the musculo-‐tendinous junction, but 

in some cases the site of the injury is the tendon itself or the entheses where the 

tendon inserts into the bone. Adductor muscles are often acutely strained during 

an eccentric contraction (e.g. in a forced abduction), when this muscle is at its 

weakest and as such more prone to injury. This could be the sudden resistance of 

an opponent’s foot in an attempt to reach a ball or a sliding tackle. Another 

mechanism is forceful concentric adduction, for instance during a kick for a ball

in the air, or after direct blunt trauma by an opponent. 

Previous groin injury is one of the major risk factors for sustaining a new groin 

injury. Consequently, rehabilitation needs to be completed prior to the return to 

play (i.e. pain-‐free and functional range of motion completely regained, full 

strength on resistance testing, concentric and eccentric muscle-‐specific function 

fully retrained). The treatment needs to be specifically geared to the individual 

injury, and must be functional for the demands of the player, i.e. including 

football activities. To successfully prevent the recurrence of groin injuries, 

treatment aimed at healing the structural damage should be combined with 

correction of the initial dysfunction causing the pain. Otherwise there is a risk 

that the factors that originally led to the structural damage will again “take over” 

and, combined with fatigue due to lack of sport specific rehabilitation, may 

eventually lead to groin re-‐injury. 

Recently prevention programs (focusing on: core stabilization/strength, abductor 

& adductor muscle strength, specific balance and agility drills) have shown to 

significantly reduce (by ca 30%) groin injuries in professional soccer players. 

References 

Dvorak J, Junge A, Bizzini M, et al (Ed). Football Medicine Manual. FIFA 

Publications, 2009, Zürich 

Tyler TF, Silvers HJ, Gerhardt MB. Groin Injuries in Sports Medicine. Sports 

Health 2010 

Falvey EC, Franklyn-‐Miller A, McCrory PR. The groin triangle: a patho-‐anatomical 

approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med 2009 

McAuley D, Best T (Ed). Evidence-‐based Sports Medicine. BMJ Books, 2007, 

London 

Biedert RM et al. Symphisis Syndrome in Athletes. Clin J Sports Med 2003 

Nicholas et al. Adductor muscle strains in sports. Sports Med 2002 

Hölmich et al. Effectiveness for active treatment in adductor-‐related groin pain 

in athletes. Lancet 1999 

Soligard T et al. Comprehensive warm-‐up programme to prevent injuries in 

young female footballers: cluster randomised controlled trial. BMJ. 2008 Dec 

9;337:a2469. doi: 10.1136/bmj.a2469. 

Silvers HJ et al. Groin Injury Prevention Program in the Professional Soccer 

Athlete. (unpublished)

ISAKOS 2013 

SPORTS REHABILITATION COURSE 

Rehabilitation of Hamstring, Quadriceps and Gastrocnemius Strains 

Mario Bizzini, PT, PhD, FIFA-‐Medical Assessment Research Centre, Schulthess 

Clinic, Zürich, Switzerland (mario.bizzini@f-‐marc.com) 

Thigh muscle injuries occur frequently as contusion injuries in contact sports, 

and as strains in sports involving maximal sprints and acceleration. Because 

football combines maximal sprints with frequent player-‐to-‐player contact, it is 

not surprising that up to 30% of all football injuries are thigh muscle injuries. In 

fact, results from the elite leagues in England, Iceland and Norway show that 

hamstring strains are the most common type of injury in male football, 

accounting for between 13% and 17% of all acute injuries. Other studies have 

shown that muscle contusion injuries to thigh account for up to 16% of all acute 

football injuries at an elite level. 

Muscles are injured by two different mechanisms, through direct contact or by 

muscle strain. The quadriceps muscles are the muscle group most susceptible to 

contusion injuries because they are located ventrally and laterally on the thigh. 

The hamstrings are the muscle group at the posterior thigh, and injury to these 

muscles typically occurs when they are acutely stretched beyond the limits of 

tolerance during maximal sprints. Since, in the vast majority of cases, the 

hamstrings are injured through strains and the quadriceps muscles through 

contusions. Classification systems exist to classify muscle injuries according to 

the amount of tissue damage and bleeding seen. One aspect of particular 

importance, at least for the prognosis, is whether the haematoma is 

intermuscular or intramuscular. Bleeding is classified as either intramuscular, 

where there is no injury to the muscle fascia, or intermuscular, where the blood 

escapes from the muscle compartments through a defect in the muscle fascia. In 

general, healing time is significantly longer with intramuscular bleeding than it is 

with intermuscular bleeding. 

A number of candidate risk factors have been proposed for hamstring strains, 

the most prominent being the following three internal factors: previous injury, 

reduced range of motion (ROM), and poor hamstring strength. 

Intramuscular bleeding will gradually subside, but after significant injuries there 

will be some bleeding for as long as 48 hours after the injury. The main objective 

– whether treating a contusion injury or a muscle strain – is to control 

haemorrhage – through rest and compression with a compression bandage. 

Massage is contraindicated during this period. If the patient has a major injury, it 

may be necessary to wait four or five days before beginning active exercises, but 

rehabilitation of minor injuries should begin two or three days after the injury. 

The goals of the subsequent rehabilitation phases are, first, to restore pain-‐free 

range of motion and, second, to reach a performance level that allows return to 

play through a functional rehabilitation programme. Progression from one stage 

to the next is guided by function, not time. Massage may be used at this stage to 

improve circulation. The rehabilitation of most minor thigh injuries should begin

with active mobilisation. The player should start with gentle motion exercises of 

the relevant joints and should allow the pain to control how long to move. 

Pressure should not be applied during the start phase. Use of a cycle ergometer 

is a gentle and effective method of increasing mobility. The seat should be 

adjusted so that it is high, and the foot should be placed further forward on the 

pedal than normal. This position reduces the demand on knee flexion and makes 

it easy to pedal when cycling. If mobility is reduced to the extent that the player 

cannot pedal, then the player should oscillate gently forth and back as far as 

possible on the bicycle. Exercises are of primary importance during the 

rehabilitation phase, but other physical therapy may be useful in removing 

bleeding residue and avoiding scar tissue formation in the injured area. Massage, 

stretching and various types of electrotherapy may be indicated. 

The exercise programme should include various stretching exercises, strength 

exercises, neuromuscular exercises and functional exercises aimed at a return to 

football. The progression of the exercises is individually controlled by pain and 

function. In general, numerous repetitions and low loads (up to a total of 100 

repetitions split into four to five series) are emphasised early in the 

rehabilitation phase. Then load is gradually increased, and the number of 

repetitions decreased. Easy exercises are used during the start-‐up phase, later 

the tempo is gradually increased. Football players with muscle strain injuries 

must not run at their maximum pace during training until the injury is 

completely healed. It often takes as long as six to eight weeks before the 

musculature will tolerate maximum spurts or turns. Light running training in a 

relaxed manner may begin as soon as the pain allows. An insulating neoprene 

sleeve is useful during the retraining phase to keep the muscles warm. A good 

warm-‐up, including gentle stretching, is critical before more vigorous exercises 

are undertaken. Building maximal strength, especially eccentric strength, is key 

to avoiding re-‐injuries. One such exercise, Nordic hamstring lowers (see: The 

11+), has been shown to be much more effective than regular hamstring curls in 

improving eccentric strength, and has also been shown to reduce the risk of 

hamstring strains in footballers. 

Healing often takes as long as six to twelve weeks after intramuscular bleeding. 

However, an injury with intermuscular bleeding can heal within a couple of 

weeks. If the injury is minor, after a week the muscles will regain strength and 

the ability to contract. About 50% of the strength is regained within 24 hours. 

After seven days, 90% of the strength returns. The player should be able to train 

without symptoms at the intensity level of a competition, and be tested 

thoroughly before participating in matches or competitions. Returning to 

explosive sports such as football too early may however cause a re-‐injury. 

Dvorak J, Junge A (Eds). The F-‐MARC Football Medicine Manual. 2 nd Edition. 

FIFA Publications, Zürich. 2009 

Bahr R et al. The IOC Manual of Sports Injuries. IOC publication. Wiley-‐Blackwell, Chichester 

(UK). 2012 

Mueller-‐Wohlfahrt HW et al. Terminology and classification of muscle injuries in sport: The 

Munich consensus statement. Br J Sports Med. 2012

ISAKOS Congress Sports Rehabilitation Concurrent Course 

Global perspectives for the Physical Therapist and Athletic Trainer 

Treatment options for tendinopathy: What is the evidence. 

This lecture will review the reasoning and scientific evidence behind the most common 

conservative treatments for tendinopathy such as exercise, deep friction massage, ultrasound, 

shock-wave therapy, laser therapy, nitric oxide, injection therapies (for example autologous 

blood and platelet-rich plasma) and sclerosing therapy. An emphasis will be placed on the use 

of these treatments in sports medicine.

Muscle Healing and Regeneration 

Johnny Huard, PhD USA

Session VIII 

Foot and Ankle

ISAKOS Rehabilitation Course 

Orthopedic Management of Ankle Instability 

A. Amendola MD 

Professor of Orthopaedic Surgery 

Kim and John Callaghan Endowed Chair 

Director, UI Sports Medicine 

University of Iowa 

A. Most Common Foot and Ankle Injuries in Athletes 

1. Ankle Sprains 

i. Lateral Ankle ligament injury 

ii. Syndesmosis /High ankle sprains 

iii. Deltoid injuries 

2. Osteochondral Lesions of the Talus 

i. Medial 

ii. Lateral 

3. Ankle impingement 

4. FHL tenosynovitis/OS trigonum 

5. Midfoot sprains 

6. Stress Fractures 

i. Navicular 

ii. Base of 5 th MT 

iii. Sesamoid fractures 

7. Plantar plate ruptures 

i. 1 st MTP ( turf toe) 

ii. 2 nd MTP 

8. Tendon Disorders 

i. Peroneal tendon tears / instability 

ii. Achilles tendinopathy/ ruptures 

9. Periarticular fractures 

i. Lateral process of the talus 

ii. Anterior process of the calcaneus 

iii. Medial and lateral malleoli avulsions 

10. Subtalar joint sprain/instability 

B. Acute inversion Ankle Sprain 

i. Probably the most common soccer / sports injury ; ~ 25% -35 %of all MS 

injuries 

ii. Vast literature on the topic, many reviews available , but still many areas 

controversial: diagnosis; treatment; operative vs non operative; return to 

play considerations 

iii. Still a high incidence of residual pain/dysfunction likely secondary to 

associated injuries

iv. Therefore treatment needs to be individualized depending on severity, 

associated injuries 

1. Common associated or missed diagnosis: 

i. Bone 

1. anterior process fracture calcaneus 

2. lateral/posterior talar process fracture 

3. malleolar fractures 

4. base of 5 MT 

5. subtalar joint injury 

6. os peroneum syndrome 

ii. Cartilage 

1. osteochondral lesions tibia/talus 

iii. Soft Tissue 

1. syndesmosis injury 

2. subtalar joint/sinus tarsi 

3. peroneal tendinopathy/instability 

iv. Neural 

1. neuropraxia 

a. superficial peroneal nerve 

b. sural nerve 

v. Other causes/issues to consider 

1. chronic causes of ankle/hindfoot pain following sprains 

a. tibiotalar bony impingement 

b. anterolateral soft tissue impingement 

c. tarsal coalition 

d. alignment / pes cavus 

2. Management of the isolated acute ankle sprain 

i. Diagnosis 

1. Clinical exam still the best 

2. Xrays/MRI to asses for suspected associated injury 

ii. Treatment 

1. Early functional non operative treatment 

a. Reduce swelling, pain, obtain full ROM 

b. Functional strengthening 

c. Progression to ground based participation / functional drills 

with bracing /taping 

d. Return to play as tolerated with bracing /taping 

iii. Surgery 

a. At present, no indication for isolated, mild or severe sprains 

b. Consider with associated displaced osteochondral talar 

fracture

3. Chronic Ankle Instability 

I. Functional instability ankle 

II. Mechanical Instability 

III. Subtalar Instability 

a) Instability with Osteochondral Lesions of Talus 

• lateral subluxation with rotation of the talus about the deltoid ligament axis 

(with inversion sprain) 

• this mechanism may cause medial or lateral osteochondral lesions of the talus 

with convex talus abutting against the anterior edge of the tibia 

Lippert, Sportverletz Sportschaden, 1989 

962 patients - 7% (osteochondral lesion) 

Bosien, JBJS, 1955 

133 patients - 6.7% (osteochondral lesion) 

b) Acute Ankle Arthroscopy Following Inversion Sprain 

van Dijk, PhD Thesis Amsterdam, 1994 

30 patients - 66% incidence of medial talar chondral lesion 

B) CHRONIC INSTABILITY 

* If pain is present between giving way episodes or is the cause of giving way, you must rule out 

all other causes of functional instability. 

* If pain is a result of the sprain and is not present between sprains or prior to the inversion 

sprain, this may be true mechanical instability. 

1. Assessment 

a) history 

b) physical exam: anterior drawer test 

c) x-ray 

d) value of stress x-rays: talar tilt?: anterior drawer most valuable with anterior 

subluxation >/= 10 mm 

e) CT/MRI - specific indications cartilage/ bone anatomy 

• CT/MRI: 

− osteochondral lesions of the talus 

− arthrosis 

− tarsal coalition 

− associated bony injuries 

C) FUNCTIONAL INSTABILITY 

Definition: 

Freeman, JBJS Br, 1965

subjective feeling of giving way during physical activity 

Tropp et al, Med Sci Sports Exerc, 1984 

mobility beyond voluntary control, but the physiologic range is not exceeded 

Causes: 

• peroneal (muscular) weakness 

• proprioceptive deficit 

• subtalar instability 

• other associated conditions (above) simulating “giving way” 

D) MECHANICAL INSTABILITY 

Definition: ankle mobility beyond the physiologic range of motion, demonstrated by abnormal 

laxity.* 

*Criteria: these are controversial 

• stress x-rays may be useful but controversial 

• in general anterior drawer test demonstrates > 10 mm translation of talus vs. 

tibia and > 3 mm side to side difference accepted as abnormal (Karlsson) 

• talar tilt stress test not as useful in predicting chronic instability 

Authors Approach: history and physical exam are most useful investigations, does not utilize 

stress x-rays routinely for diagnosis 

E) SUBTALAR INSTABILITY 

Definition: not a clearly defined entity but estimated in 10% of ankle instability. 

Diagnosis: based on history and examination consistent with subtalar joint irritation, joint line 

tenderness and possibly positive subtalar stress view. 

Imaging: 

• talar tilt/subtalar stress view 

• MRI/CT 

F) OTHER CAUSES OF INSTABILITY (MALALIGNMENT) 

Note: if foot or ankle malalignment is present, should be corrected or else soft tissue 

reconstruction will fail. 

ie. 

1. valgus forefoot with dropped 1 st ray needs a 1 st , possible 2 nd MT dorsiflexion osteotomy 

• often in cavovarus feet, ie. CMT, but can be idiopathic

2. hindfoot varus may need calcaneal / forefoot osteotomy 

G) TREATMENT 

1. Acute Sprains 

a) functional nonoperative treatment 

b) prophylactic bracing 

c) muscle strenghthening 

d) proprioceptive program 

2. Chronic 

Conservative Management 

a) correct diagnosis 

b) proper rehabilitation 

• muscular strengthening (invertors & evertors) 

• proprioceptive/balance program 

• taping, bracing 

− prophylactic 

− chronic bracing 

3. Surgical Indications 

a) symptomatic mechanical instability AND 

b) failure of appropriate conservative treatment 

Goal of surgery - to prevent recurrent giving way episodes 

Some evidence that instability predisposes to arthrosis 

H) SURGICAL OPTIONS: 

• Anatomic 

− Brostrum (and modifications) 

− Free graft (ie. Colville, Engebretsen, Coughlin) 

(i) autograft 

(ii) allograft 

• Non-anatomic 

− Evans 

− Watson-Jones 

− Chrisman-Snook 

− Others 

2. Authors Approach: 

a) Chronic Ankle Instability: 

Anatomic Repair 

• Brostrum repair 

• direct repair to bone

• Gould (extensor retinaculum) 

• +/- Arthroscopy at time of repair 

b) Problem: Subtle instability: 

stability: ATFL, CFL intact but very subtle laxity? 

• Brostrum 

• inferior extensor retinaculum (Gould advancement) 

c) Problem: Peroneal tendon symptoms and instability: 

Approach: 

• modify incision to expose peroneals 

• repair peroneal tendon/retinaculum 

• modified Brostrum type repair 

d) Problem: Recurrent instability post repair or reconstruction: 

Approach 

• failed tenodesis ie. Evans 

− release tenodesis 

− Brostrum repair (modified) 

• failed Brostrum 

− anatomic repair ie. Colville 

− free graft 

• tenodesis is “too tight”: reduced subtalar motion/pain 

− release tenodesis (extra capsular) 

e) Chronic Ankle Instability: Revision with free graft 

Authors Approach: 

if failed Brostrum (ie. revision): allograft in “anatomic” repair 

• revision: Achilles allograft: 7mm, interference screw fixation 

• comprehensive reconstruction using a free gracilis graft 

f) Indications for Arthroscopy in Chronic Ankle Instability 

Ankle lesions at time of ligament stabilization: 

• osteochondral injuries 

• impingement lesions 

• synovitis 

Literature review: 

Komenda, Ferkel, Foot&Ankle, 1999 

Hintermann, Boss, Schafer, AJSM 2002 

Kibler, Clin Sports Med, 1996 

Taga, Shino, Inoue, Nakata, Maeda, AJSM, 1993 

Hintermann et al., AJSM 2002

148 patients with chronic ankle instability (greater than 6 months) 

• pre op: talus lesions in 4%, 

• at arthroscopy: 50% had cartilage lesions of the talus. 

• tibial pilon (8%), medial malleolus (11%), and lateral malleolus (2.5%) 

Authors Approach: 

if any evidence of intraarticular pathology or pain: 

• arthroscopy first to treat intra-articular pathology 

• ligament reconstruction : concerns : swelling 

I. Syndesmosis Sprains (Normal mortise relationship) 

1. Diagnosis 

i. Clinical Exam still the best 

ii. Investigations: 

1. X-ray 

a. Normal mortise relationship, if not, RX is easy decision 

b. May see post tibial avulsion ( early) or calcification ( late) ; 

c. syndesmotic calcification late 

2. MRI – non specific acutely but can identify deltoid and may be related 

to severity of the injury 

3. CT SCAN 

a. Avulsion # anterior / post tib-fib joint 

b. Bone scan ( chronic )Increased uptake in syndesmotic area 

2. Treatment : 

i. Acute Diagnosis: 

1. Wide mortise on x-ray or stress x-ray → ORIF 

2. Normal x-ray relationships Operative vs. non-operative 

a. Non-op: 

i. ?longer time to recovery 

ii. ↑ incidence residual dysfunction 

iii. chronic (micro) instability 

iv. calcification interposers space 

b. Author’s preferred Rx: Operative 

i. Arthroscopy to confirm diagnosis 

ii. Anterolateral debridement 

iii. Syndesmotic fixation / tightrope (vs screws) 

iv. Early ROM, strengthening and gradual progression as if 

non- op treatment 

v. WBAT / strengthening, return to sport as tolerated 

3. Controversies 

a. Indications for fixation

. Type of fixation 

c. Return to play 

d. complications of surgery 

• hardware complications ( screw breakage) 

• heterotopic ossification 

• syndesmotic pain 

I) Deltoid Ligament Injuries 

a) More commonly recognized 

b) Usually associated with other injuries , ie syndesmosis 

c) Usually stable grade 1-2 injuries , conservative treatment with early mobilization 

d) Need to carefully assess with pes planus and spring ligament injuries 

e) 

J) SUMMARY: 

1. Giving way episodes of the ankle does not always equal mechanical instability, therefore 

a detailed history and examination is most important in diagnosis. 

2. Dysfunction following ankle sprains is common, most often due to a missed or 

associated injury. 

3. Rehabilitation to correct muscular and proprioceptive deficits is essential in chronic 

ankle instability prior to contemplating surgery. 

J) REFERENCES 

1. Bahr R, Pena F, Shine J, Lew WD, Tyrdal S, Engebretsen L. Biomechanics of ankle ligament 

reconstruction. An in vitro comparison of the Brostrom repair, Watson-Jones reconstruction, 

and a new anatomic reconstruction technique. Am J Sports Med. 1997 Jul-Aug;25(4):424-32. 

2. Baumhauer JF, Alosa DM, Renstrom AF, Trevino S, Beynnon B. A prospective study of ankle 

injury risk factors. Am J Sports Med. 1995 Sep-Oct;23(5):564-70. 

3. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone 

Joint Surg Am. 1955 Dec;37-A(6):1237-43. 

4. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991 May- 

Jun;19(3):294-8. 

5. Brostrom L. Sprained ankles. 1. Anatomic lesions in recent sprains. Acta Chir Scand. 

1964;128:483-95. 

6. Brostrom L. Sprained ankles. 3. Clinical observations in recent ligament ruptures. Acta Chir 

Scand. 1965 Dec;130(6):560-9. 

7. Colville MR, Grondel RJ. Anatomic reconstruction of the lateral ankle ligaments using a split 

peroneus brevis tendon graft. Am J Sports Med. 1995 Mar-Apr;23(2):210-3. 

8. Colville MR, Marder RA, Zarins B. Reconstruction of the lateral ankle ligaments. A 

biomechanical analysis. Am J Sports Med. 1992 Sep-Oct;20(5):594-600. 

9. Coughlin MJ, Schenck RC Jr, Grebing BR, Treme G. Comprehensive reconstruction of the 

lateral ankle for chronic instability using a free gracilis graft. Foot Ankle Int. 2004 

Apr;25(4):231-41. 

10. Freeman MA, Dean MR, Hanham IW. The etiology and prevention of functional instability of

the foot. J Bone Joint Surg Br. 1965 Nov;47(4):678-85. 

11. Frost SC, Amendola A. Is stress radiography necessary in the diagnosis of acute or chronic 

ankle instability? Clin J Sport Med. 1999 Jan;9(1):40-5. 

12. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated 

with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998 

Oct;19(10):653-60. 

13. Hennrikus WL, Mapes RC, Lyons PM, Lapoint JM. Outcomes of the Chrisman-Snook and 

modified-Brostrom procedures for chronic lateral ankle instability. A prospective, randomized 

comparison. Am J Sports Med. 1996 Jul-Aug;24(4):400-4. 

14. Hintermann B, Boss A, Schafer D. Arthroscopic findings in patients with chronic ankle 

instability. Am J Sports Med. 2002 May-Jun;30(3):402-9. 

15. Karlsson J, Bergsten T, Lansinger O, Peterson L. Surgical treatment of chronic lateral instability 

of the ankle joint. A new procedure. Am J Sports Med. 1989 Mar-Apr;17(2):268-73; discussion 

273-4. 

16. Karlsson J, Bergsten T, Peterson L, Zachrisson BE. Radiographic evaluation of ankle joint 

stability. Clin J Sport Med. 1991;1(1):166-175. 

17. Karlsson J, Eriksson BI, Bergsten T, Rudholm O, Sward L. Comparison of two anatomic 

reconstructions for chronic lateral instability of the ankle joint. Am J Sports Med. 1997 Jan- 

Feb;25(1):48-53. 

18. Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly KD, Struijs PA, van Dijk CN. Immobilisation for 

acute ankle sprain. A systematic review. Arch Orthop Trauma Surg. 2001 Sep;121(8):462-71. 

19. Kibler WB. Arthroscopic findings in ankle ligament reconstruction. Clin Sports Med. 1996 

Oct;15(4):799-804. 

20. Komenda GA, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle 

Int. 1999 Nov;20(11):708-13. 

21. Krips R, Brandsson S, Swensson C, van Dijk CN, Karlsson J. Anatomical reconstruction and 

Evans tenodesis of the lateral ligaments of the ankle. Clinical and radiological findings after 

follow-up for 15 to 30 years. J Bone Joint Surg Br. 2002 Mar;84(2):232-6. 

22. Krips R, van Dijk CN, Lehtonen H, Halasi T, Moyen B, Karlsson J. Sports activity level after 

surgical treatment for chronic anterolateral ankle instability. A multicenter study. Am J Sports 

Med. 2002 Jan-Feb;30(1):13-9. 

23. Labovitz JM, Schweitzer ME. Occult osseous injuries after ankle sprains: incidence, location, 

pattern, and age. Foot Ankle Int. 1998 Oct;19(10):661-7. 

24. Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of 

syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001 Jan-Feb;29(1):31-5. 

25. Pijnenburg AC, Bogaard K, Krips R, Marti RK, Bossuyt PM, van Dijk CN. Operative and 

functional treatment of rupture of the lateral ligament of the ankle. A randomised, 

prospective trial. J Bone Joint Surg Br. 2003 May;85(4):525-30. 

26. Pijnenburg AC, Van Dijk CN, Bossuyt PM, Marti RK. Treatment of ruptures of the lateral ankle 

ligaments: a meta-analysis. J Bone Joint Surg Am. 2000 Jun;82(6):761-73. 

27. Schafer D, Hintermann B. Arthroscopic assessment of the chronic unstable ankle joint. Knee 

Surg Sports Traumatol Arthrosc. 1996;4(1):48-52. 

28. Taga I, Shino K, Inoue M, Nakata K, Maeda A. Articular cartilage lesions in ankles with lateral 

ligament injury. An arthroscopic study. Am J Sports Med. 1993 Jan-Feb;21(1):120-6;

discussion 126-7. 

29. Tropp H, Ekstrand J, Gillquist J. Stabilometry in functional instability of the ankle and its value 

in predicting injury. Med Sci Sports Exerc. 1984;16(1):64-6. 

30. Barg A, Tochigi Y, Amendola A, Phisitkul P, Hintermann B, Saltzman CL.Subtalar instability: 

diagnosis and treatment.Foot Ankle Int. 2012 Feb;33(2):151-60 

31. Bonasia DE, Rossi R, Saltzman CL, Amendola A. The role of arthroscopy in the management of 

fractures about the ankle J Am Acad Orthop Surg. 2011 Apr;19(4):226-35. 

32. Williams GN, Jones MH, Amendola A.Syndesmotic ankle sprains in athletes.Am J Sports Med. 

2007 Jul;35(7):1197-207. Epub 2007 May 22. Review. 

33. McCollum GA,van den Bekerom M;Kerkoffs G,Calder J ; van Dijk N: Syndesmosis and deltoid 

ligament injuries in the Athlete ; KISSTA April 2012 

34. Devries JS; Krips R, et al : Interventions for treating Chronic Ankle Instability : Cochrane 

Database ; Issue 8 , 2011 

35. Van den Bekerom; Kerkoffs G; et al: Management of Acute Lateral Ankle Injury in the Athlete: 

KSSTA , April 2012

Non‐Operative Management of Ankle Sprains 

Gary Calabrese, PT USA



Achilles tendinopathy 

For athletes with Achilles tendinopathy the consensus is that the initial treatment should be an 

exercise program. It should consist of strengthening exercises, including an eccentric 

component, for the Achilles tendon and calf musculature. The rehabilitation process is, 

however, time consuming and often frustrating for the athlete, athletic trainer, physical 

therapist, coach and doctor. Moreover many questions arise such as regarding how much pain 

is allowed, can the athlete continue to run and how should the return to sport phase be 

designed? This presentation will review the scientific evidence and give recommendations for 

how this is applied to the clinical practice.



Rehabilitation after Achilles tendon repair 

An Achilles tendon rupture mostly occurs without any preceding warning sign. The recovery 

following an Achilles tendon rupture takes up to a year or longer and many athletes are not 

able to return to their pre-injury level. Complications such as rerupture, calf muscle weakness, 

tendon elongation and gait abnormalities are reported after this injury. How should then the 

rehabilitation program be designed to achieve optimal functional outcome while minimizing 

the occurrence of complications? This lecture will review the scientific evidence and give 

recommendations for how this is applied in the clinical situation.

Session IX 

Elbow

Elbow Anatomy 

Gregory Bain, MB BS, FRACS, PhD AUSTRALIA

ELBOW ARTHROSCOPY 

BENNO EJNISMAN, MD – FEDERAL UNIVERSITY OF SÃO PAULO 

Arthroscopic surgery of the elbow is challenging because of the joint's 

anatomy. Elbow arthroscopy is a minimally invasive technique used by 

orthopaedic surgeons to diagnose and treat a range of conditions affecting 

the joint. The bones lie close together, and nerves and blood vessels are 

located very close to the joint. Although it is a difficult procedure, 

arthroscopic surgery is often the ideal choice for treating certain elbow 

conditions. 

Burman first discussed elbow arthroscopy in 1931, but he stated that the 

elbow is “.. Unsuitable for examination since the joint space is so narrow for 

the relatively large needle”. 

In contrast to traditional surgery, using large incisions to open the joint, 

there is no injury to surrounding soft tissues with arthroscopy. Moreover, 

the technique allows the surgeon to view the elbow joint from multiple 

angles, allowing for a more thorough evaluation. 

• Anatomy 

• Indications 

o removal of osteophytes due to impingement or osteoarthritis ) 

o synovectomy in patients with inflammatory arthritis ) , 

o removal of adhesions and capsular release in patients with 

contractures, 

o resection of symptomatic plicae ) ,

o removal of loose bodies, 

o evaluation of patients with chronic elbow pain. 

o osteochondritis dissecans, 

o septic arthritis ) , 

o Epicondylitis 

o elbow fractures 

• Equipment 

• Portal placement: 

o Medial 

o Lateral 

o Posterolateral 

o Posterior 

• Complications 

• Postoperative Management 

REFERENCES 

• ADOLFSSON L. Arthroscopy of the elbow joint: a cadaveric study of 

portal placement. J Shoulder Elbow Surg. 3: 53-61, 1994. 

• ANDREWS JR, CARSON WG. Arthroscopy of the elbow. 

Arthroscopy. 1: 97-107, 1985

• Baker CL, Cummings PD: Arthroscopic management of 

miscellaneous elbow disorders. Oper Tech Sports Med 6: 16–21, 

1998 

• Baker CL Jr, Shalvoy RM: The prone position for elbow arthroscopy. 

Clin Sports Med 10: 623–628, 1991 

• Baker, C, Champ L. Baker III. Long-term Follow-up of Arthroscopic 

Treatment of Lateral. AJSM, February 2008; vol. 36, 2: pp. 254-260 

• Bernas, GA, Ruberte, RA et AL Biomechanical Study Defining Safe 

Rehabilitation for Ulnar Collateral Ligament Reconstruction of the 

Elbow : A Biomechanical Study. Am J Sports Med 2009 37: 2392, 

2009 

• Burman MS: Arthroscopy of the elbow joint. A cadaver study. J Bone 

Joint Surg 14: 349–350, 1932 

• Burman MS: Arthroscopy or the direct visualization of joints: An 

experimental cadaveric study. J Bone Joint Surg 13: 669–695, 1931 

• Champ L. Baker, Jr and Grant L. Jones Arthroscopy of the Elbow Am 

J Sports Med 1999 27: 251 

• Cohen, SC et al . Return to Sports for Professional Baseball Players 

After Surgery of the Shoulder or Elbow. Sports Health: A 

Multidisciplinary Approach 2011 3: 105, 2010 

• O'DRISCOLL S. "Elbow arthroscopy: loose bodies." The Elbow and 

its Disorders. Morrey B ed. 2000 W.B. Saunders Company. 

Philadelphia: 510-514 

• Poehling GG, Whipple TL, Sisco L, et al: Elbow arthroscopy: A 

newtechnique. Arthroscopy 5: 222–224, 1989 

• SCHNEIDER T, HOFFSTETTER I, FINK B, JEROSCH J. Long-term 

results of elbow arthroscopy in 67 patients. Acta Orthop Belg. 60: 

378-383, 1994

Elbow Instability 

James Andrews, MD USA

Medial and Lateral Epicondilitis of the Elbow 

Eduardo Benegas, MD BRAZIL

9 th Biennial ISAKOS Congress 

May 14, 2013: 9:30-9:45am 

Toronto, Ontario, Canada 

Rehabilitation Following UCL Reconstruction in Throwers 

Kevin E. Wilk, DPT 

Associate Clinical Director 


Birmingham, AL 

I. INTRODUCTION: 

A. Elbow Injuries in Overhead Sports 

1. Appear to be increasing 

Second most common injury in professional baseball (22%) 

Conte et al: AJSM ‘01 

2. Repetitive forces – overhead throwing (baseball, javelin) 

3. Increasing injury rates due to numerous factors: 

a. bigger stronger athletes 

b. tremendous forces generated 

c. specific pitches may increase forces 

d. split-finger, & slider 

4. Better recognition of injuries 

a. improved clinical exam skills 

b. MRI 

B. Principles of Elbow Rehabilitation 

1. Must be specific to imposed demands of sports 

a. Overhead thrower - 

b. Tennis players - 

c. Weight lifting – 

d. Collision sports (football) - 

Demands of each are different 

Rehabilitation must be specific to patient’s demands 

C. The Overhead Thrower’s Elbow Joint 

1. Tremendous forces during the acceleration and deceleration 

phases of the pitch

a. Max. elbow extension velocity ≈ 2300 0/sec 

b. Acceleration phase: valgus stress 60 NM 

c. Humeroulnar compression of 800 N 

d. High level of muscular activity 

Werner, Fleisig, Andrews: JOSPT ‘93 

2. Range of motion during the throw 

a. Extension 19 + 4 o to flexion 99 + 11 

Flexion contracture commonly seen 

Fleisig et al: JOSPT ‘93 

II. 

PHYSICAL CHARACTERISTICS OF THE THROWER’S ELBOW: 

A. Range of Motion 

1. Normal elbow/forearm ROM 

a. Ext/flexion: 0-145 degrees 

b. Supination 90 degrees, pronation 85 degrees 

Morrey & Askew: JBJS ’81 

2. Thrower’s ROM 

a. Extension: 12 ± 7 o 

Flexion: 147 + 4 o 

Pronation: 98 o , Supination: 93 o 

Wilk, Reed, Reinold: Unpub ’05 

Loss of Extension “Flexion Contracture” Most Common 

Motion Adaptation in Throwers 

b. Thrower’s elbow less elbow extension (7 deg) & flexion (5 

deg) compared to non-throwing elbow 

Total ROM difference 13 degrees 

Wright, O’Neal, Paletta: AJSM ‘05 

c. Loss of motion post-throwing – elbow extension loss 5 

degrees 

Reinold, Wilk, Crenshaw, Porterfield: AJSM ‘08 

d. Functional ROM 

Necessary motion to perform tasks! 

3. Muscular strength

a. Overhead throwers: 

1) Flex peak torque/BW ratios: 18-23% 

2) Extension peak torque/BW ratio: 22-28% 

3) Flex/ext ratio: 73-80% (75%) 

Wilk et al: Elb Injuries ’91 

b. General population 

1) Bilateral differences 5-8% 

60 o /s 180 o /s 

Flex PT/BW 29% 17% 

Ext PT/BW 23% 17% 

Flex/Ext Ratios 128% 99% 

Schexneider,Davies: Isokin Ex Sci ’91 

4. Dynamic stabilization of the elbow 

a. Flexor carpi ulnaris overlying the UCL flexor digitorum 

superficialis contributes somewhat 

Davidson et al: AJSM ’95 

b. Stabilization during throwing 

1) During throwing FCU high levels of EMG data (112% 

MVIC) 

2) FDS (80% MVIC) acceleration 

DiGiovine et al: JSES ’92 

c. EMG analysis in pitchers with UCL insufficiency 

FCU significant less EMG activity 

FCR significant greater 1 cm EMG 

Extensor group tended to exhibit slightly greater EMG 

activity 

Hamilton et al: JSES ’96 

d. EMG studies indicate minimal stabilizing capability – 

anatomical overly 

Funk et al: J Orthop Res ’87 

5. Proprioception 

a. Elbow proprioception testing 

Khabie et al: JSES ’98 

1) 20 uninjured male subjects (Biodex System)

6. Elbow laxity 

2) Joint reposition sense and detection of motion 

3) No difference b/t dominant and nondominant arms 

4) Reposition sense within 3.3 o + 1.3 o of actual 

5) Significant improvement in proprioception after 

application of elastic bandage 

1) Valgus laxity in throwers 

2) Baseball players more medial laxity compared to 

other overhead athletes 

3) Not significantly greater than non-throwing side 

4) Displacement values approx. 0.5 mm 

Singh et al:AJSM ‘01 

III. 

ELBOW INJURIES IN OVERHEAD THROWERS: 

A. Valgus Extension Overload (VEO) Syndrome 

1. Pathomechanics 

a. Medial traction 

b. Lateral compression 

c. Posteromedial osteophyte 

Wilson, Andrews, Blackburn: AJSM ’83 

2. Clinical examination 

a. Pain posteromedial 

b. Pain early acceleration 

c. Carefully assess laxity 

d. Plain radiographs 

3. Operative procedure 

a. Excision of posteromedial osteophyte 

Azar, Andrews: Op Tech Sports Med ‘96

4. Postoperative rehabilitation 

Wilk, et al: Op tech Spts Med ’96 

a. Immediate motion to tolerance (swelling) 

b. Emphasis on passive elbow extension (gradually) 

c. Stretch & restore normal shoulder ROM for thrower 

d. Full ROM in 2-3 weeks 

e. Gradual strengthening program 

f. Caution with triceps extension, bench press, etc early 

g. Throwers ten program week 4 

h. Emphasize medial elbow dynamic stabilization 

Strengthening & NM drills for Flexor/Pronator muscles 

i. Begin Plyometrics week 4-6 

j. Initiate throwing week 6-8 

k. Gradual return to competition 

B. UCL Injuries in Throwers (Overhead Athletes) 

Reconstruction of the UCL 

1. Rehabilitation must be based on surgerical technique 

Osseous Tunnel ------------------------------- Docking Procedure 

Andrews: Op Tech Spts Med ’96 Altchek: AJSM ‘02 

2. Modification of Jobe procedure 

Jobe: JBJS ’86 

Andrews: Op Tech Spts Med ’96 

3. Surgical procedure 

a. Graft source 

1) Palmoris longus graft (contralateral/ipsilateral) 

2) Gracilis graft (contralateral side) 

4. Rehabilitation guidelines 

Wilk, Reinold, Andrews: Clin Spts ‘04 

Wilk, Reinold, Andrews: Spts Med Arthroscopy ‘03 

5. Recent Adaptations to Our Rehabilitation Program

a.. 

Earlier restoration of motion 

• *With strict compliance, earlier restoration of full ROM 

• Previous protocol: 8 weeks full ROM & discontinue brace 

• Recent protocol: full ROM 6 weeks and discontinue brace 

5-6 weeks 

external 

b. Emphasis on wrist flexors, elbow flexors and shoulder 

rotators 

• Emphasize dynamic stabilization of wrist flexor/pronator 

muscles 

• Focus on shoulder external rotators 

• Emphasis on dynamic stabilization drills 

• Grip strength 

throwing 

c. Performing plyometrics for longer period of time prior to 

• Plyometric drills for 4 weeks instead of previously advocated 

2 weeks (initiated at 12 weeks postoperative) 

• Emphasize biomechanics and proper mechanics 

d. Throwing program 

• Delaying throwing for at least 4-5 months 

• More time in long toss program 

• Slower progression to “off the mound” throwing 

C. Phase One - Immediate Motion (week 0-4) 

Goals: 

- Re-establish non-painful ROM 

- Decrease pain and inflammation 

- Retard muscular atrophy 

- Protect healing tissue 

1. Range of Motion Progression 

a. Posterior splint at 90 o flexion for one week 

b. Week two - functional ROM brace (30-100)

- progress ROM; 5 o extension and 10 o flexion per week 

c. Full ROM* - 6 weeks (if able full ROM at week 5) 

- prevent flexion contracture 

2. Elbow Joint Compression Dressing (2-3 days) 

a. Wrist and hand ROM and gripping exercises 

b. Ice and compression* 

c. Isometrics for shoulder and elbow joint 

*Assessment of neurologic status 

3. Week 2 

a. Initiate AROM (ROM 30-100) 

• Safe ROM following UCL reconstruction 

Bernas et al: AJSM ‘10 

b. Continue AAROM 

c. Manual resistance drills (isometrics, RS) 

4. Week 3 

a. ROM 15 to 110 o (at least) 

b. Continue stretching and ROM exercises 

c. Initiate isotonic program (AROM, lightweight #1) 

d. Treat soft tissue restrictions – graft site 

B. Intermediate Phase (Week 4-8) 

Goals: 

- Gradually restore full ROM 

- Promote healing of repaired tissue 

- Restore strength, power and endurance 

1. Week 4 

a. Functional brace 10-120 o (at least) 

b. Initiate isotonics for entire arm and shoulder 

c. AAROM, PROM, stretching 

d. Continue soft tissue techniques 

e. Initiate a “modified Thrower’s ten program” 

2. Week 5-6 

a. Discontinue functional ROM brace 

b. Full ROM 0-145 o 

c. Progress isotonic strengthening

d. *Manual resistance exercises for elbow and wrist 

- Isotonic strengthening 

- Manual resistance RS 

*Assess for flexion contracture of LOM 

- May enhance dynamic joint stability 

- Increased muscular stiffness 

Treatment of Flexion Contracture 

1. Warm-up (active or passive) 

2. Joint stretch (passive stretch, PROM) 

3. LLLD stretch 

4. Heat or ultrasound 

5. CR techniques 

6. Passive stretching and joint mobilization (HR HU, RU joints) 

7. Strengthening in new ROM 

8. Repeat 2-7 steps 

9. Perform program 2-3 times per day 

10. Consider use of splint 

Treatment of LOM (Flexion) 

1. Contract-relax technique (CR) 

2. LLLD 

3. Joint mobilization 

4. Passive stretching 

Tissue Remodeling vs. Transient Tissue Changes 

*Efficiency of low load long duration stretching 

The Elbow Joint is a Unforgiving Joint 

C. Advanced Strengthening Phase (Weeks 8-13) 

Goals: 

- Improve arm strength, power and endurance 

- Maintain full ROM 

- Gradually initiate sport activities 

1. Week 8-10 

a. Thrower’s Ten Program 

b. Emphasize following: 

(1) concentric biceps 

(2) concentric triceps 

(3) stabilization wrist flex/pronaturs

(4) shoulder ER 

c. Neuromuscular drills 

2. Week 11-13 

a. *Initiate plyometric (3-4 weeks of plyos) 2 hand drills 

b. Continue all exercises 

c. Interval sport program (golf, swimming) 

d. Advanced Thrower’s Ten program - week 12 

D. Return to Activity Phase (Weeks 14-20) 

Goals: 

- Continue improvement of power, strength and endurance 

- Gradual return to sports 

1. Week 14 

a. Initiate one hand plyometric throwing drills 

b. Continue Throwers’ Ten Program 

c. Maintain flexibility and stretching 

2. Week 16 

a. Initiate interval throwing program (Phase I) 

Reinold, Wilk: JOSPT ‘02 

Fleisig, et al: JOSPT ‘11 

b. Continue all exercises listed above 

c. Emphasize alternating day training 

3. *Week 22-26 

a. Initiate interval throwing from mound Phase II 

throwing 

Continue isotonics 

Utilize periodization model – adjust intensity (wts) 

Criteria to Return to Throwing 

- Full ROM 

- Satisfactory stability 

- Isokinetic test 

Complications Following UCL Reconstruction

CLINICAL FOLLOW-UP STUDIES: 

1. Ulnar Neuropathy 

2. Loss of motion 

3. Loss strength 

1. Post-operative instability 

Andrews, Azar, Wilk, Groh: AJSM ’00 

1. 91 UCL reconstruction 

2. 41% professional players, 45% collegiate 

3. Average follow-up 35.4 months 

4. 79% returned to play, return to play 9.8 months 

Cain, Andrews, Dugas, Wilk, et al: AJSM ‘10 

1. 1281 UCL reconstructions (from 1988-2006) 

2. 959 baseball players 

3. 942 available for at least 2 yr follow-up 

4. Average follow-up 38.4 months 

5. 83% return to higher or previous level 

6. Average time surgery to throwing 4.4 months 

7. Average time to competition 11.6 months 

IV. 

PREVENTION OF ELBOW INJURIES: 

A. Several Specific Concepts 

1. Proper throwing mechanics 

a. “Leading with elbow” 

b. “Opening up too soon” 

2. Adequate flexor/pronator strength 

3. Proper shoulder strength, especially posterior cuff 

4. Adequate rest 

5. Not throwing (i.e. pitching) too often 

6. Fatigue; emphasize muscular endurance 

a. leading cause of elbow injuries in adolescent throwers

Lyman, Fleisig et al: AJSM ‘02 

Lyman et al: Med Sci Spts Ex ‘01 

Olsen, Fleisig et al: AJSM ‘07 

7. Types of pitches – elbow pain 

8. Recommendations: when to throw curve ball (what age)? 

9. Lateral epicondylitis 

10. Not all tennis elbow is the same!! 

V. KEY POINTS AND SUMMARY: 

A. Key Points 

1. Elbow joint is frequently injured 

2. Elbow injuries are increasing 

3. Proper mechanics may assist in preventing injuries 

4. Restoring motion is often difficult 

5. Nonoperative treatment – first treatment option 

6. Gradually increase applied loads 

7. Dynamic stabilization is critical 

8. Gradual return to throwing 

KEW: 4/13 – attachments 

UCL rehab protocol

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Management of Tennis Elbow 

Joy Macdermid, PT, PhD CANADA

Session X 

Shoulder

Shoulder Anatomy 


Biomechanics of Shoulder Function 


Throwing Progression for Youth Sports 

Michael Axe, MD USA



Toronto, CAN 

May 12-14, 2013 

Functional Testing Algorithm for Return to Play Following Shoulder Injuries 





II. Importance of establishing discharge criteria: safety for patient, legal implications, etc. 

III. Literature review 

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o Time/soft tissue healing 

o VAS (0-10 scale) (

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58. Limbaugh, GK, Traylor, D, Riemann, BL, Davies, GJ. Comparing one-arm seated shot put throw performance 

between baseball and non-baseball athletes, Poster Presentation, ACSM, Seattle, WA., 2010 

59. Negrete, RJ, Davies, GJ, Hanney, WJ, Riemann, BL. Modified pull-up is the best predictor of a softball throw for 

distance. Inter J Sports Phys Ther, June, 2011. 

60. Rankin, SA, Roe, JR, Malone, T. Test-Retest reliability analysis of Davies clinically oriented functional throwing 

performance index (FTPI) over extended time periods. Univ Kentucky MS Thesis, 1996. 

61. Collins, DR, Hedges, PB. A Comprehensive Guide to Sports Skills Tests and Measurements. Springfield, IL., 

Charles C. Thomas, pp. 330-333, 1978 

62. Reiman, MP, Manske, RC. Functional Testing in Human Performance. Human Kinetics. Champaign, IL., 2009 

63. Wilk KE, Obma P, Simpson CD, Cain EL, Dugas JR, Andrews JR. Shoulder injuries in the overhead athlete. J 

Orthop Sports Phys Ther. 39(2):38-54, 2009 

64. Lentz, TA, et.al. The relationship of pain, intensity, physical impairment, and pain-related fear to function in 

patients with shoulder pathology. J Ortho Sports Phys Ther. 39:270-277, 2009 

65. Bhagwant, S, et.al. Influence of fear-avoidance beliefs on functional status outcomes for people with 

musculoskeletal conditions of the shoulder. Phys Ther. 92:992-1005, 2012

Session XI 

Shoulder

Operative management of shoulder instability 

Klaus Bak, MD, Parkens Privathospital, 

Teres Medical Group, Copenhagen, Denmark 

The operative management of shoulder instability is constantly under evolution. Non-operative 

treatment programs develop and implies better outcome prognosis. Diagnostic 

options are improved as well. This gives a much larger palet of treatment possibilities. It has 

been proposed by the French shoulder surgeon Pascal Boileau, that surgical treatment of 

shoulder instability should be regarded as looking at a menu at a restaurant. In this way you 

are abl to individualize the treatment and hopefully decrease the risk of redislocation. It is not 

possible to recommend one single type of stabilizing procedure for all patients. Boileau 

developed the Injury Severity Index (JBJS 2007) that evaluated the risk of recurrence after 

arthroscopic surgery. According to this study, patients with a total score over 6 points had a 

risk of recurrence of 70 % after arthroscopic Bankart repair. 

Pascal Boileaus Instability severity index score JBJS 2007 

Prognostic factors 

Points 

Age at surgery (yrs) 

< 20 2 

> 20 0 

Preoperative sports activity 

High level/competition 2 

Recreational or no sport 0 

Type of sport (preoperative) 

Contact or forced overhead 1 

Other 0 

Shoulder hyperlaxity 

Shoulder hyperlaxity (anterior or inferior) 1 

Normal laxity 0 

Hill-Sachs on antero-posterior x-ray 

Visible in external rotation 2 

Not visible in external rotation 0 

Glenoidal defect on AP- rtg 

Loss of contour 2 

No lesion 0 

Total (points) 10 

Indications for operative treatment 

Indications are widely individual, but some trends can be extracted from the literature. 

Indications for surgery should consider several factors:

• Age of the patient – the younger the patient – the higher the risk of recurrence without 

operation. One exception is teenagers with atraumatic instability where non-‐operative 

treatment should be encouraged for as long as possible 

• The rate of dislocations – the more common -‐ the less likely of success of non-operative 

treatment 

• The patient’s activity demands – the higher the risk of collision involving the arm the 

more likely to chose operation. 

Arthroscopic Bankart 

Arthroscopic treatment of glenohumeral instability has been an established surgical option 

for more than 25 years. Primary reports showed unacceptably high failure rates. With 

increasing evolution of techniques, implant strength, suture quality, and proper patient 

selection, the results are more promising. Studies comparing arthroscopic and open repair 

still show that the failure rate is lower in open repair, in particular in contact athletes, but the 

trend is moving towards choosing a technique tailored for the individual patient, rather than 

selecting one technique over the other. Over the last years bone block procedures are 

becoming more widely used in particular in high-‐risk athletes. 

Arthroscopy has advantages over open repair in more easily detecting and addressing 

associated lesions (SLAP, PASTA etc.) and more rare lesions like HAGL. 

Before arthroscopic repair is planned a number of factors should be taken into consideration: 

• The age of the patient (under 25 is a high indicator of surgical repair) 

• The activity level (participation in contact or throwing sports indicates repair) 

• Associated lesions that affects outcome and function (cuff, brachial plexus) 

• Inherent hypermobility (additional repair needed or longer rehabilitation) 

Patients suited for Arthroscopic repair will score less than 6 points on Pascal Boileau’s 

instability severity index score (Table 1). Patients well-‐matched for arthroscopic repair are 

young, active first time dislocators, or patients with few recurrent dislocations and no severe 

glenoid bone loss (< 20%), bony Bankart lesions, presence of a HAGL-‐lesion, and patients with 

associated cuff tears. In multidirectional unstable shoulders (MDI), arthroscopic capsular

plication or capsular-‐labral reconstruction results in good outcome in those patients where 

there is no progression in dysfunction after intensive physiotherapeutic training emphasizing 

scapular function. Closing of the rotator interval remains a controversy but may be indicated 

in some individuals with severe inferior instability in order to create a temporary increase 

contact between the glenoid and the humeral head. It seems that the capsule and ligaments of 

the MDI-‐patients gradually get loose with time, but during the time where stability is present 

the MDI-‐patient may have the possibility of regaining normal neuro-‐muscular control of the 

shoulder girdle. 

Surgical choices 

There seem to be a least four different groups to consider for treatment 

1. Simple unidirectional anterior instability – arthroscopic Bankart 

2. Instability with significant bone loss 

a. Bone block procedure (Latarjet or Edin Hybinette, J-‐span and others) 

3. Isolated Hill-‐Sachs w Bankart – Reimplissage 

4. Multidirectional instability and isolated posterior instability – open inferior capsular 

shift or arthroscopic capsule-‐labral plication 

Tips and tricks – arthroscopic repair 

I prefer arthroscopic Bankart over a mini-‐open procedure, but there may be no difference in 

outcome between the two procedures. The arthroscopy bears the advantage of detecting un-expected 

associated lesions that were overlooked on MR. 

Tips and tricks: 

• The first task is: Identification of the lesion and associated pathology 

• The second task of mobilizing the capsulolabral complex may be the most important 

part of the procedure. A sharp ablator is the preferred instrument together with an 

aggressive shaver blade 

• I prefer a knotless anchor and a non-‐resorbable suture

Postoperative treatment 

Postoperatively the arm should be immobilised in a sling with or without abduction pillow. 

The length of immobilisation is depending on the quality of the tissue and the repair. Usually 4 

weeks as a standard, and 6-‐8 weeks in cases of weak tissue or weak repair. 

Early passive range of motion and isometric muscle training/activation with arms at the side 

is allowed the first postoperative day. Addressing scapular function in the rehabilitation is 

crucial. Increasing resistance exercise is allowed after six weeks and functional rehab from 

week 10-‐12. The time to resume normal sports activities depends on the sport. Contact and 

throwing sports can normally be resumed after 4-‐6 months. When the indication is right and 

the patient is compliant in restrictions and rehabilitation, the recurrence rate is lower than 10 

%. 

References 

1. Neer CS, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J 

Bone Joint Surg (Am) 62-‐A 1980 : 897-‐907. 

2. Bottoni CR, Wilckens JH, DeBerardino TM, D'Alleyrand JC, Rooney RC, Harpstrite JK, Arciero RA. A prospective, 

randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, 

traumatic, first-‐time shoulder dislocations. Am J Sports Med 2002; 30: 576-‐580. 

3. Jakobsen BW, Johannsen HV, Suder P, Søjbjerg JO. Primary repair versus conservative treatment of first-‐time 

traumatic anterior dislocation of the shoulder: a randomized study with 10-‐year follow-‐up. Arthroscopy 2007; 23: 

118-‐23. 

4. Kirkley A, Werstine R, Ratjek A, Griffin S. Prospective randomized clinical trial comparing the effectiveness of 

immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior 

dislocations of the shoulder: long-‐term evaluation. Arthroscopy 2005; 21:55-‐63. 

5. Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, Pavón F. Arthroscopic management of traumatic anterior 

shoulder instability in collision athletes: analysis of 204 cases with a 4-‐ to 9-‐year follow-‐up and results with the 

suture anchor technique. Arthroscopy 2006; 22: 1283-‐9. 

6. Hovelius L, Olofsson A, Sandström B, Augustini BG, Krantz L, Fredin H, Tillander B, Skoglund U, Salomonsson B, 

Nowak J, Sennerby U. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age 

and younger. a prospective twenty-‐five-‐year follow-‐up. J Bone Joint Surg Am 2008; 90: 945-‐52. 

7. Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, Wakabayashi I, Nozaka K. Immobilization in 

external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone 

Joint Surg Am 2007; 89): 2124-‐31. 

8. Kibler WB. Management of the scapula in glenohumeral instability. Techniques in Shoulder and Elbow Surgery 2003; 

4: 89-‐98. 

9. Hobby J, Griffin D, Dunbar M, Boileau P. Is arthroscopic surgery for stabilisation of chronic shoulder instability as 

effective as open surgery? A systematic review and meta-‐analysis of 62 studies including 3044 arthroscopic 

operations. J Bone Joint Surg Br 2007; 89: 1188-‐1196. 

10. Cole BJ, L'Insalata J, Irrgang J, Warner JJ. Comparison of arthroscopic and open anterior shoulder stabilization. A two 

to six-‐year follow-‐up study. J Bone Joint Surg Am. 2000; 82-‐A: 1108-‐14.

11. Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F, Mulas PD. Arthroscopic versus open treatment of Bankart 

lesion of the shoulder: a prospective randomized study. Arthroscopy 2004; 20: 456-‐62. 

12. Jørgensen U, Svend-‐Hansen H, Bak K, I Pedersen. Recurrent post-‐traumatic anterior shoulder dislocation -‐ open versus 

arthroscopic repair. Knee Surg Sports Traumatol Arthrosc. 1999; 7:118-‐124. 

13. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic 

Bankart repairs: significance of the inverted-‐pear glenoid and the humeral engaging Hill-‐Sachs lesion. Arthroscopy 

2000; 16: 677-‐94. 

14. Provencher MT, Mologne TS, Michio H, Zhao K, Tasto JP, An KN. Arthroscopic versus open rotator interval closure: 

Biomechanical evaluation of stability and motion. Arthroscopy 2007; 23: 583-‐592. 

15. Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic rotator interval closure: 

effect of sutures on glenohumeral motion and anterior-‐posterior translation. Am J Sports Med 2006; 34: 1656-‐61. 

16. Mologne TS, Zhao K, Hongo M, Romeo AA, An KN, Provencher MT. The addition of rotator interval closure after 

arthroscopic repair of either anterior or posterior shoulder instability: effect on glenohumeral translation and range 

of motion. Am J Sports Med 2008; 36: 1123-‐31. 

17. Kim SH, Ha KI, Jung MW, Lim MS, Kim YM, Park JH. Accelerated rehabilitation after arthroscopic Bankart repair for 

selected cases: a prospective randomized clinical study. Arthroscopy 2003; 19: 722-‐31. 

18. Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder 

instability. J Shoulder Elbow Surg 2004; 13: 279-‐85. 

19. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy 

and biomechanics. Arthroscopy 2003; 19: 404-‐420. 

20. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part II: evaluation and 

treatment of SLAP lesions in throwers. Arthroscopy 2003; 19: 531-‐539. 

21. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK 

scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 19[6], 641-‐661. 200. 

22. Porcellini G. Shoulder instability and related rotator cuff tears: arthroscopic findings and treatment in patients aged 

40 to 60 years. Arthroscopy 2006; 22: 270-‐276. 

23. Berbig R, Weishaupt D, Prim J, Shahin O. Primary anterior shoulder dislocation and rotator cuff tears. J Shoulder 

Elbow Surg 1999; 8: 220-‐225.


May 14, 2013 13:45-14:00 


Rehabilitation Following Rotator 

Cuff Repair Surgery 

Kevin E. Wilk, DPT 



I. INTRODUCTION 

A. The Post-Operative Rehabilitation – Overview 

1. Gradual change in past several years 

a. Slightly more progressive and aggressive 

b. Due to: 

1) Patient selection – move active patients 

2) Increased functional demands 

3) Improved surgical techniques (stronger fixation 

methods) 

4) Minimizing deltoid involvement 

2. Arthroscopic repairs 

a. Increasing popularity among orthopaedic surgeons 

b. Gradual increase in numbers 

c. Patients experience less pain & less stiffness 

d. Special concerns for this type of patient 

3. Rehabilitation program must allow for tissue healing constraints 

4. Keys to successful rehab in rotator cuff repaired shoulder 

a. establish passive range of motion 

b. restore ER muscular strength 

c. establish shoulder balance 

d. improve scapular position & posture 

e. gradually increase applied loads 

f. caution against over-aggressive activities - early 

e. control applied forces for first 6 months 

f. gradual return to functional activities

B. Primary Goals of Surgery/Rehabilitation 

1. Restore functional abilities of the upper limb 

a. Maintain integrity of repair 

b. Re-establish passive mobility 

c. Re-establish muscular balance 

e. Reduce pain; muscular inhibition 

f. Improve dynamic stabilization 

2. The rehabilitation formula following rotator cuff repair 

a. Restore passive motion 

b. Control active motion for 2 weeks up to 8 weeks 

c. Allow soft tissue healing then progress to active motion 

C. Specific Clinical Questions: 

1. When is the repaired cuff the weakest? 

2. When is the repaired cuff the strongest? 

3. When is it safe to perform specific activities? weight lifting? sports? 

II. 

FACTORS INFLUENCING THE REHABILITATION PROGRAM 

A. Ten Critical Factors to Consider Before Initiating the Program 

1. Type of repair 

a. Deltoid split (mini-open) 

b. Deltoid take down (open) 

c. Arthroscopic technique 

2. Tissue quality 

a. Soft tissue integrity 

c. Osseous integrity 

3. Size of tear 

1) Fixation strength 

a. Absolute size 

b. Number of tendons/muscles involved 

4. Location of tear

a. Which musculotendinous structures are involved 

1) Isolated supraspinatus 

2) Supraspinatus and infraspinatus 

3) Subscapularis 

4) Etc. 

Burkhart SS: Clin Orthop ‘92 

5. Surrounding tissue quality 

a. Integrity of infraspinatus, teres minor and subscapularis 

b. Important for force couples 

6. Mechanism of failure (onset) 

a. Traumatic (approx. 3-5%) 

b. Gradual and progressive failure 

7. Patient’s variables: 

a. Activities (work, sports) 

b. Motivation 

c. Worker’s compensation 

Hawkins: JBJS ‘85 

d. Healing potential 

8. Rehabilitation potential 

a. Supervised rehabilitation 

b. Unsupervised rehabilitation 

9. Physician’s philosophical approach 

Conservative 

Continuously Aggressive 

10. Type of rotator cuff tear 

a. Horizontal 

b. Vertical 

c. Avulsion 

B. Classification of Rotator Cuff Tears

Small 

Medium 

Large 

Massive 

< 1 cm 

1-3 cm 

3-5 cm 

> 5 cm 

C. Five Types of Rehabilitation Programs 

Type I - Small Tear (Excellent Tissue) 

Type II - Medium to Large Tear (Good Tissue) 

Type II - Large to Massive Tear (Poor Tissue) 

Arthroscopic Repairs – small to medium 

Arthroscopic Repairs – medium to large 

The Rehabilitation Program Must Match the Surgical Procedure 

Physician – Therapist communication is vital for successful outcome! 

III. 

REHABILITATION FOLLOWING MINI-OPEN ROTATOR CUFF REPAIR 

Example: Mini-Open Repair Type II 

A. ROM Guidelines 

1. Immediate PROM to tolerance 

2. Sling 14-21 days 

3. Elbow/hand ROM and gripping exercises 

4. PROM for 1-3 weeks 

5. Full PROM at weeks 2-4 

6. AAROM L-bar ROM ER/IR days 7-10 

7. AAROM L-bar ROM flex days 10-14 (with arm support) 

B. Muscle Training Guidelines 

1. Isometrics submaximal and sub-painful 

Use of Electrical muscle stimulation to rotator cuff 

Emphasize: ER, IR and Scapular Muscles 

2. Rhythmic stabs ER/IR week 2 

3. Rhythmic stabs flex/ext week 3 

4. Scapular strengthening weeks 3-4 

5. Active ROM flexion and abduction 

6. Use of EMS to shoulder musculature 

a. ER/IR ratio 

b. Time from surgery

Factors which determine rate of progression 

C. Functional Activity Guidelines 

1. Sports activities interval sport programs 

a. Golf weeks 14-16 

b. Tennis weeks 20-22 

c. Swimming weeks 22-26 

d. Weight lifting activities 

- May begin at 4-5 months close to body than away from 

body 

D. Long Term Exercises Program 

1. Fundamental shoulder exercise program 

2. Control heavy lifting for 6-9 mos. 

3. No lifting overhead for 6-9 mos. 

IV. 

ARTHROSCOPIC ROTATOR CUFF REPAIR 

A. Advantages of Arthroscopic Repair 

1. Less soft tissue disruption 

2. Diminished scar formation and adhesions 

3. Less postoperative pain 

B. Surveyed 25 Orthopaedic Surgeons (2000 &2005) 

1. 85% routinely perform arthroscopic repairs (2000) 

2. Criteria for arthroscopic repair – size & ability to mobilize 

3. Rehab slower, faster or the same? 

4. 100% routinely perform arthroscopic repairs (2005) 

C. Arthroscopic Repair Fixation Strength 

Burra, Jablonski, Cain, Andrews: AOSSM ’02 

- Significant differences between mini-open and arthroscopic technique 

- Arthroscopic gap formation at 320 N 

- Mini-open gap formation at 510 N 

Waltrip, Zheng, Dugaset al : AJSM ‘03 

- significant difference in number of cycles to failure 

- single row arhroscopic technique failed at 6x fewer cycles

D. Rehabilitation Guidelines 

1. Abduction pillow splint 30 days for 2-3 weeks 

2. Immediate PROM exercises 

3. ER/IR at 45 degrees Abd scapular plane 

4. Full PROM 3-4 weeks 

5. ER/IR tubing at side weeks 4-5 

6. Sidelying flexion 

7. Progress to resistance exercises weeks 12-16 

8. Initiate interval sport programs 

V. RE-ESTABLISH DYNAMIC HUMERAL HEAD CONTROL 

A. Re-Establish Dynamic Stabilization of GH Joint! (Key Goal) 

1. Initiate rhythmic stabilization drills 

“Balance Position” - supine position 

Wilk: Athlete’s Shoulder ‘93 

2. Dysfunctional arc of motion 

Arc of motion 0-30° then 100-125 o – Why? 

a. “Balanced Position” 

100 o flexion 

20 o horizontal abd 

1) Perform RS flex/ext 

2) Perform RS horizontal flex/ext 

b. Muscular force vectors 

1) Deltoid compresses humeral head at 100 o and above 

2) Supraspinatus compressor throughout ROM 

3) Rhythmic stabilization drills 

Flexor/extensor above 90° 

ER/IR in scapular plane @ 45 o Abd 

c. Gradual progression in muscular strength 

1) Exercise tubing ER/IR 

2) Initiate scapular muscle strengthening

3) Continue isometrics 

VI. 

FUNCTIONAL OUTCOMES 

A. Shoulder Strength Following Rotator Cuff Repair Surgery 

Rokito et al: JSES ’96 

1. 42 consecutive patients 

2. Isokinetic testing every 3 months for one year 

3. Recover of strength correlated with size of the tear 

4. Greatest improvement occurred in first 6 months (80%) 

5. Slowest muscular group to regain strength, ER! 

B. Evaluation of the Shoulder Functionally 

1. Rate comfort (pain) 

2. Satisfaction level 

3. AROM/PROM 

4. Functional abilities 

Harryman et al: JBJS ‘91 

C. Success vs. Failure 

1. What determines outcome? 

a. Integrity of repair? 

b. Re-establishing dynamic stability 

Harryman et al: JBJS ‘91 

Patients 5 years following surgery, approximately 48% recurrent deficit however 87% 

with recurrent defect satisfactory outcome. 

D. Wilk et al: Tech Shoulder and Elbow Surg ’00 

1. 22 patients, mini-open repair 

2. Average follow-up 40 months 

3. Average age 64.7 years (40-76) 

4. Size of tears: 1, 9, 8, 4 

5. Results: 

a) 73% excellent 

b) 22% good 

c) 4% fair

6. Average score (ASES) 

a) Pre-op: 30.7 

b) Postop: 92.0 

VII. 

IRREPARABLE ROTATOR CUFF TEARS 

A. Rehab Guidelines 

1. Re-establish full PROM 

2. Reduce pain – muscle inhibition 

3. Activate rotator cuff muscles 

4. Re-establish unilateral muscle ratio 

5. Turn on and strengthen rotator cuff 

6. EMS to rotator cuff musculature 

Re-assess – Adjust weekly 

Balance of Muscular Forces – Wilk 

Suspension bridge concept - Burkhart 

VIII. 

SUMMARY 

A. Key Points 

1. Rehabilitation must be based on type of surgery, tissue quality, and 

size of tear 

2. Communication is vital 

Physician ↔ therapist 

3. Gradual restoration of motion 

4. Re-establish dynamic stability 

a. Emphasize muscular balance (ER/IR ratio) 

b. Do not exercise through shoulder shrug sign 

c. Scapular strength 

5. Muscular balance (ER/IR ratio) 

6. Watch out for “empty can” - may be painful if - 

7. Do not overload healing tissue 

8. Gradual restoration of function 

Keys to successful rehab in rotator cuff repaired shoulder 

a. establish passive range of motion 

b. restore ER muscular strength

KEW: 03/13 

c. establish shoulder balance 

d. improve scapular position & posture 

e. control applied forces for first 6 months 

f. gradual return to functional activities

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839 

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2003 

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18:519-526, 2002 

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Treatment of Stiff Shoulder 




Toronto, CAN 

May 12-14, 2013 

Scapular Dysfunction 





II. Scapulo-Thoracic Kinematics 

III. Scapulo-Thoracic Dyskinesis (Pathomechanics) 

IV. Classification of scapular dysfunction: 

Kibler Type I (Inferior Angle Pattern) 

Kibler Type II (Medial Border Pattern) 

Kibler Type III (Superior Border Pattern) 

Kibler Type IV (Symmetrical Scapulohumeral Pattern) 

V. Scapulo-Thoracic Dyskinesis (Pathomechanics)-Proximal causative factors 

VI. Scapulo-Thoracic Dyskinesis (Pathomechanics)-Distal causative factors 

VII. Examination of Scapulo-Thoracic Joint 

VIII. Examination Techniques 

A. Scapular Assistance Test 

B. Scapular Retraction Test 

C. Others 

IX. How do we measure the scapular kinematics? 

a. Modified Lateral Scapular Slide test 

X. How do we measure the scapular muscle function? 

a. MMT 

b. Hand Held Dynamometry 

1. Rank order of muscle groups (UT, SA, MT, R, LT) 

2. Unilateral ratio of muscles 

Unilateral Ratios: 

• Elevation/depression (UT/LT): 2.62 

• Protraction/retraction (SA/R): 1.45 

• UR/DR (SA/MT): 

• 1.23 

c. Isokinetic Testing 

XI. Examination Techniques – Others 

XII. Treatments 

XIII. Posture/Spine/LE 

XIV. Flexibility 

XV. Rehabilitation of the entire kinematic chain 

XVI. Others 

XVII. Reductionist approach to rehabilitation of the scapula

XVIII. Moseley-Jobe Scapulo-thoracic exercises 

XIX. Rehabilitation of the entire shoulder complex 

XX. TAS 

XXI. Neuromuscular Dynamic Stability Exercises 

XXI. Neuromuscular Dynamic Stability Exercises-Open Kinetic Chain Exercises 

XXI. Neuromuscular Dynamic Stability Exercises-Closed Kinetic Chain Exercises 

XXII. Functional Exercises 

IX. References: 

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Scapular dysfunction: 607 references 

Currrent concepts in scapular dyskinesis: 3 

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18


May 14, 2001: 14:30-14:45 


Rehabilitation Following SLAP Surgery in 

the Overhead Athlete 

Kevin E. Wilk, DPT, PT 


Physiotherapy Associates 


I. INTRODUCTION 

A. Glenoid Labrum Lesions 

1. Common injury seen clinically 

2. May occur in isolation or concomitantly 

3. SLAP lesions 

4. SLAP first described by James Andrews, MD 

Andrews & Carson: AJSM ‘85 

5. Superior labrum lesion anterior posterior 

Snyder: Arthroscopy ’90 

Maffet et al: AJSM ‘95 

Powell et al: Op Tech Spts Med ‘04 

Tokish et al: JBJS ‘09 

6. SLAP lesions in throwers are common 

a. Some have established 70-90% occurrence 

Miniaci et al: AJSM ’02 (79%) 

Connor et al: AJSM ‘03 

Wilk et al: (Unpub) ’00 (90%) 

b. Injury or Adaptation 

c. Isolated lesion or Concomitant lesion 

1. rotator cuff lesions 

2. humeral head changes – cystic changes 

3. is the SLAP lesion the cause of the athlete’s pain 

7. SLAP lesions in the general population 

a. 84% exhibited degenerative changes of their labrum 

b. 50% exhibited a labrum detachment 

Kohn et al: Arthroscopy ‘87 

8. SLAP repair surgeries reported in the literature

a. SLAP repair surgery from 1.1% to 26% in Orthopaedist 

Practice 

Snyder et al: JSES ‘95 

Weber: Spts Med Arthroscopy ‘10 

Kim et al: JBJS ‘03 

Weber: AOSSM ‘10 

9. SLAP lesions are often difficult to diagnosis 

a. Often subtle symptoms 

1) Clicking, popping, grinding, pain 

2) Sometimes apprehensive ROM 

3) Internal Impingement complaints 

4) Symptoms from SLAP or Cuff 

b. Can be a cause of functional limitation 

c. Numerous special tests for SLAP 

Some tests are better for overhead throwers than 

for non-overhead athletes 


Myers et al: AJSM ‘05 

II. 

MECHANISMS OF INJURIES 

A. Macrotraumatic Forces 

1. Fall onto outstretched arm 

2. Traction force applied while lifting 

3. Pushing heavy object 

4. Weight lifting activities 

5. Blow to shoulder 

B. Repetitive Microtraumatic Forces 

1. Commonly seen in overhead athletes 

a. Throwers, swimmers, tennis players, divers, etc. 

Andrews et al: Orthop Trans ’84 

Reported 83% of throwers undergoing arthroscopy exhibited 

SLAP lesion 

b. Thrower’s undergoing thermal capsular shrinkage 

Wilk, Reinold, Andrews: JOSPT ’02 

91%of patients exhibited labral pathology present

c. MRI exam on asymptomatic pitchers 

79% Miniaci et al: AJSM ‘02 

90% Wilk: Unpublished ‘00 

d. “Peel back” Lesion 

Due to excessive shoulder ER 

Burkhart et al: Arthroscopy ‘98 

Shepard et al: AJSM ‘04 

III. 

CLASSIFICATION OF SLAP LESIONS 

A. Original Classification System 

Snyder et al: Orthopaedics ’90 

Type I: 

Type II: 

Type III: 

Type IV: 

Superior Labrum Frayed 

Superior Labrum Frayed/Detached 

Bucket handle Tear, Displaced 

Bucket Handle Tear/Biceps Involvement 

B. Additional SLAP Lesion Classification 

Burkhart & Morgan: Arthroscopy ’98 

Type II Subclass “Peel Back Lesion” 

IIA: Anterior type II 

IIB: Posterior type II 

IIC: Combined anterior-posterior lesion type II 

Maffet, Gartsman: AJSM ’98 

38% of patients with labrum lesion did not fit into Snyder classification 

Type V: An anterior-inferior Bankart lesion continuous superiorly to 

include separation of the biceps tendon 

Type VI: An unstable flap tear of labrum and biceps tendon separation 

Type VII: Superior labrum-biceps tendon separation extends anteriorly 

beneath MGH ligament 

Powell et al: Op Tech Sports Med ‘04 

Type VIII: SLAP extending posterior to the 6 o’clock position

Type IX: pan-labral lesion, entire circumference of glenoid 

Type X: SLAP with reverse Bankart lesion 

IV. 

TREATMENT GUIDELINES 

A. Specific Surgical Approach 

1. Type I: Arthroscopic debridement to intact labrum, preserve biceps 

attachment 

2. Type II: Arthroscopic debridement and re-attachment of labrum to 

glenoid (ensure stability) 

a. Type IIB: Stabilize labrum and capsule 

3. Type III: Excision of bucket handle tear, maintain stability of labrum 

to glenoid 

4. Type IV: Excision of bucket handle tear, biceps tenodesis of greater 

than 50% (age), biceps tenotomy , 

5. Type V: Bankart repair with SLAP repair – biceps tendon pathology 

treatment is dependant 

6. Type VI: Debridement of flap tear and repair Type II SLAP 

7. Type VII: Repair capsular tear and repair Type II SLAP 

8. Type VIII: Repair posterior labral tear and SLAP repair 

9. Type IX: Repair entire SLAP tear – maybe 360 deg repair 

10. Type X: Posterior Bankart Repair with SLAP Type II repair 

B. Rehabilitation Guidelines 

Wilk, et al : JOSPT ‘05 

1. Postoperative rehabilitation program must match the surgical 

procedure 

a. Based on type of SLAP 

b. Concomitant lesions – rotator cuff lesions 

c. Based on severity of lesion 

d. Concomitant procedures (stabilization, acromionplasty) 

e. Consider patient’s age 

f. Emphasize dynamic stabilization 

g. Maintain static stability 

h. Minimize biceps activity (esp. Types II & IV) 

i. Repetitive overhead athletes – think dynamic stability 

C. Specific Rehabilitation Guidelines

1. SLAP Type I & III: Post-Op Rehabilitation Program 

SLAP Debridement – Post-Op Rehab 

Arthroscopic Debridement Program: 

a. Immediate ROM exercises, POM, AAOM 

b. Full PROM by 2 weeks 

c. Active ROM week 2 

d. Isotonics at 2 weeks 

e. Thrower’s Ten Program at week 3-4 

f. Emphasis on dynamic stabilization 

g. Advanced strengthening program at weeks 4-6 

Advanced Thrower’s Ten Program 

h. Return to sports (criteria-based) 

Rate of Progression Based on Rotator Cuff Involvement 

2. SLAP Type II: Post-Op Rehabilitation Program: 

a. Sleep in immobilizer for 3-4 weeks 

b. No motion above 90 o for 4 weeks 

c. Full ROM at week 8 

d. No isolated biceps for 6-8 weeks 

e. Isotonics at weeks 4-6 

f. Advanced strengthening at weeks 10-12 

g. Interval throwing week 14-16 

3. Type IV: Arthroscopic SLAP Lesion Repair Program 

a. Same protocol as for Type II 

b. Depends on what id done on biceps 

1. Biceps tenodesis: Biceps precautions for 12 weeks 

2. Biceps tenotomy: rest biceps initial then full activity 

D. Rehabilitation Following Type II SLAP Repair in Throwers 

1. Precautions: 

a. control forces & loads on repaired labrum 

b. no excessive ER & IR for 8-12 weeks 

c. no weight bearing forces for 10-12 weeks 

d. no isolated biceps for 8 weeks 

e. no heavy lifting (overhead, bench press, push-ups) 12wks 

f. no throwing for 4 months 

2. Protection: 

a. abduction pillow sling for 4 weeks

. immobilization while sleeping for 4 weeks 

c. no excessive elevation for 4-6 weeks 

d. no excessive ER or IR for 12 weeks 

Protection is based on Severity of Lesion (Size) 

3. Range of Motion Progression: 

a. immediate restricted PROM 

b. flexion to 90 degrees fro 4 weeks 

c. ER/IR at 30-45 deg abduction for 4 weeks 

d. ER/IR at 90 deg begin at week 4 

e. Gradually increase ER/IR PROM till 8 weeks 

f. Progress ER beyond 90 deg at 8-12 weeks 

Gradually Increase PROM 

4. Muscular Strengthening Exercises: 

a. Immediate submax isotonic muscle training 

b. Immediate dynamic stabilization drills (RS) 

c. Active ROM- week 3 

d. Thrower’s ten program – week 4 

e. Advanced Thrower’s Ten Program – week 12 

f. Plyometrics: 

i. 2 hand plyos week 12 

ii. 1 hand plyos – week 14 

g. Lifting program – week 12-14 

h. Closed chain exercises – week 12 

5. Functional Progression: 

a. Throwing programs: 

b. Interval throwing program – Phase I – at 4 months 

c. Phase II Throwing – off mound – 5 ½ months 

E. SLAP repairs with concomitant procedures 

Voss et al: AJSM ‘07 

Coleman et al: AJSM ‘07 


a. SLAP repair with decompression – 

b. SLAP repair with cuff repair – 

c. SLAP repair with cuff debridement - 

d. SLAP repair with capsular stabilization Bankart – 

e. SLAP repair with thermal shrinkage – 

f. SLAP repair in degenerative shoulder – 

Beware of SLAP repairs with concomitant surgeries – stiffness 

Monitor Patient Closely & Adjust Appropriately

F. SLAP Repair with Anterior Bankart (Type V) 

1. Immediate motion – but controlled restricted motion 

2. Protection against excessive ER PROM & AROM 

3. Sling with pillow for 4 weeks 

4. Flexion to 90 degrees first 2 weeks then gradually increase flexion 

5. ER/IR at 45 deg abd first 3-4 weeks then initiate ER/IR at 90 deg of 

abduction – gradually increase PROM 

6. Full ROM at 8-10 weeks post-op 

7. Isometrics for first 2 weeks 

8. Isotonics week 3-4 (AROM first then 1 lb dumbbell) 

9. Weight lifting at 12 weeks 

10. Plyometrics at week 12-14 

11. Sport specifc training at week 16 

12. Return to sports: collision sports 6 months 

13. Return to sports:overhead sports 7-9 months 

G. SLAP Repair with Posterior Bankart (Type X) 

Slower rehabilitation program anterior bankart 

More precautions – esp IR, Horizontal adduction 

1. Immediate motion – but controlled restricted motion 

2. Protection against excessive IR &/or Hz Add PROM & AROM 

3. Sling with pillow – arm in ER for 6 weeks 

4. Flexion to 90 degrees first 2 weeks then gradually increase flexion 

5. ER at 45 deg abd first 3-4 weeks then initiate ER at 90 deg of 

abduction – gradually increase PROM 

6. No IR PROM for 4-6 weeks (depends) 

7. Full ROM at 10-12 weeks post-op 

8. Isometrics for first 2 weeks 

9. Isotonics week 3-4 (AROM first then 1 lb dumbbell) 

10. Weight lifting at 14-16 weeks (no bench for 4 mos) 

11. Plyometrics at week 16 

12. Sport specifc training at week 20-22 

13. Return to sports: collision sports 9 months 

14. Return to sports: overhead sports 9 months 

H. Rehabilitation a Type IX Repair 

1. Difficult rehabilitation program 

2. Slow rehab but immediate motion 

3. Rehab program dependent on type of patient 

Overhead Athlete -------------------- Non Overhead Athlete 

4. Needs to be individualized 

5. Let’s talk specifics 

V. SUMMARY & KEY POINTS

A. Recognition of Labral Lesions (SLAP) Is often difficult 

1. Monitor patients, subjective complaints, pathomechanics 

B. Rehabilitation Must Match the Type of Lesion 

1. Type I through Type IV 

2. Severity of Lesion (How many anchors) 

3. Concomitant procedures 

C. Emphasize Dynamic Stability! 

1. Throwers did well initially but at 2 years 70% had recurrent of 

symptoms with debridement 

Altchek et al: Orthop Trans ’90 

D. Minimize Biceps Brachii Activity in Types II and IV 

1. Especially with biceps tenodesis 

E. Closely monitor patient’s signs and symptoms 

KEW:3/13 attachments: Type II SLAP Repair Rehab

Session XII 

Sports 

Medicine

PT Management of Concussion 

CANADA

The Future of Joint Healing 

Constance Chu, MD USA

Sports Rehab Course Syllabus - ISAKOS

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