STUDY DESIGN: Case report. BACKGROUND: Traumatic glenohumeral dislocations with concomitant rotator cuff and capsular injuries present a unique and challenging surgical and rehabilitative condition, particularly in the overhead-throwing athlete. Multiple injuries of the shoulder complex create the potential for complications in the course of recovery and place a full return to high-level sport at risk. The purpose of this case report is to present the multiphased rehabilitation approach of an elite professional quarterback after an acute 330° capsulolabral reconstruction and rotator cuff repair as a result of a luxatio erecta injury. CASE DESCRIPTION: A 26-year-old male professional football player, a quarterback, sustained a right luxatio erecta shoulder dislocation while trying to recover a fumble during a regular-season game. The injury occurred when he was hit in the back of his throwing shoulder, which was in an abducted and externally rotated position, while lying on the ground. Five days postinjury, he underwent a 330° capsulolabral repair, with concomitant rotator cuff repair and subacromial decompression. He completed 28 weeks of a multiphased rehabilitation program. OUTCOMES: The patient returned to play in the National Football League (NFL) 8 months later, for the start of the next season, during which he had his most productive year as a professional quarterback, leading the league in passing yards and finishing third in the league for the number of touchdowns. Since the injury, the patient has played 6 consecutive seasons, starting over 96 consecutive, regular-season games and maintaining a very high level of play. DISCUSSION: This case report highlights the clinical decision-making process and management of this rare, severe injury. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2013;43(3):142-153. Epub 12 February 2013. doi:10.2519/jospt.2013.3726

KEY WORDS: dislocation, luxatio erecta, shoulder, SLAP

In this issue of the Journal, which complements the knee special issue published in March 2012, 4 groups of authors contribute their clinical perspectives on rehabilitation strategies and clinical as well as functional criteria for return to sports. What makes this group of papers unique is that each addresses a different sport (soccer, alpine skiing, football, and basketball) and, therefore, different functional and sports performance criteria. While several facets of rehabilitation are similar among these contributions, especially in the earlier stages of the rehabilitation process, noteworthy differences exist in how each group approaches strategies to return the athlete to their sports in the intermediate and final phases of rehabilitation.

J Orthop Sports Phys Ther 2012;42(4):300-301. doi:10.2519/jospt.2012.0106

KEY WORDS: ACL, alpine skiing, American football, anterior cruciate ligament, basketball, soccer, rehabilitation

SYNOPSIS: There is a growing body of evidence documenting loads applied to the anterior cruciate ligament (ACL) for weight-bearing and non–weight-bearing exercises. ACL loading has been quantified by inverse dynamics techniques that measure anterior shear force at the tibiofemoral joint (net force primarily restrained by the ACL), ACL strain (defined as change in ACL length with respect to original length and expressed as a percentage) measured directly in vivo, and ACL tensile force estimated through mathematical modeling and computer optimization techniques. A review of the biomechanical literature indicates the following: ACL loading is generally greater with non–weight-bearing compared to weight-bearing exercises; with both types of exercises, the ACL is loaded to a greater extent between 10° to 50° of knee flexion (generally peaking between 10° and 30°) compared to 50° to 100° of knee flexion; and loads on the ACL change according to exercise technique (such as trunk position). Squatting with excessive forward movement of the knees beyond the toes and with the heels off the ground tends to increase ACL loading. Squatting and lunging with a forward trunk tilt tend to decrease ACL loading, likely due to increased hamstrings activity. During seated knee extension, ACL force decreases when the resistance pad is positioned more proximal on the anterior aspect of the lower leg, away from the ankle. The evidence reviewed as part of this manuscript provides objective data by which to rank exercises based on loading applied to the ACL. The biggest challenge in exercise selection post–ACL reconstruction is the limited knowledge of the optimal amount of stress that should be applied to the ACL graft as it goes through its initial incorporation and eventual maturation process. Clinicians may utilize this review as a guide to exercise selection and rehabilitation progression for patients post–ACL reconstruction.

J Orthop Sports Phys Ther 2012;42(3):208-220. doi:10.2519/jospt.2012.3768

KEY WORDS: ACL, anterior shear force, exercise therapy, reconstruction, strain

SYNOPSIS: Rehabilitation following anterior cruciate ligament surgery continues to change, with the current emphasis being on immediate weight bearing and range of motion, and progressive muscular strengthening, proprioception, dynamic stability, and neuromuscular control drills. The rehabilitation program should be based on scientific and clinical research and focus on specific drills and exercises designed to return the patient to the desired functional goals. The goal is to return the patient’s knee to homeostasis and the patient to his or her sport or activity as safely as possible. Unique rehabilitation techniques and special considerations for the female athlete will also be discussed. The purpose of this article is to provide the reader with a thorough scientific basis for anterior cruciate ligament rehabilitation based on graft selection, patient population, and concomitant injuries.

J Orthop Sports Phys Ther 2012;42(3):153-171. doi:10.2519/jospt.2012.3741

KEY WORDS: ACL, knee, neuromuscular training, proprioception

The knee is one of the most frequently injured joints in the human body, with the treatment of knee injuries representing a significant portion of physical therapists’ and orthopaedic physicians’ clinical practice. Consequently, the knee is also one of the most frequently studied and written-about joints in the literature. So why publish a special issue on the knee when it is already so frequently discussed in the literature? The main reason is that things change, and certainly things are changing rapidly in the treatment of specific knee lesions. Also, the sheer volume of literature on surgical techniques and rehabilitation concepts makes it a challenge for any clinician to remain up to date. It is therefore the intent of this special issue to provide clinicians with key updates on the management of selected knee injuries.

J Orthop Sports Phys Ther 2012;42(3):150-152. doi:10.2519/jospt.2012.0104

KEY WORDS: ACL, anterior cruciate ligament, articular cartilage, MCL, medial collateral ligament, meniscus, rehabilitation

STUDY DESIGN: Case report. BACKGROUND: Joint stiffness, also called arthrofibrosis, remains the primary complication following any reconstructive knee surgery. Acute anterior cruciate ligament surgery, performed with concomitant multiple ligamentous repair and/or reconstruction, further increases the likelihood of developing impaired knee motion following surgery. The purpose of this case report is to present a criteria-based approach to the postoperative management of a multiligament knee injury. CASE DESCRIPTION: A 25-year-old male professional football player sustained a contact injury to his right knee while making a tackle during a regular season game in 2007. He underwent an acute anterior cruciate ligament reconstruction, with concomitant posterolateral corner repair, biceps femoris/iliotibial band repair, lateral collateral ligament repair, and a medial meniscocapsular junction repair. He completed 17 weeks of a multiphased rehabilitation program that emphasized immediate range of motion, low-load long-duration stretching, therapeutic exercise, neuromuscular reeducation/perturbation training, plyometrics, and sport-specific functional drills. Electrical neurostimulation was implemented during the early stages of rehabilitation to control postoperative pain and to promote a steady progression of therapeutic exercise activity. OUTCOMES: The patient was cleared to begin sport-specific activity 7 months after major multistructure reconstructive knee surgery. He began the 2008 season on the physically-unable-to-perform list, but was activated midseason and played in every game thereafter. During the 2009 and 2010 seasons, he played all regular season games and all playoff games as a starter, and continues to start as a defensive cornerback in the National Football League. DISCUSSION: This case report highlights the clinical decision-making process and management involved in an acute multiple ligamentous knee injury/reconstruction. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2011;41(9):675-686. doi:10.2519/jospt.2011.3453

KEY WORDS: ACL, anterior cruciate ligament, arthrofibrosis, posterolateral corner

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To test for kinematic and kinetic differences between baseball pitching from a mound and long-toss on flat ground. BACKGROUND: Long-toss throws from flat ground are commonly used by baseball pitchers for rehabilitation, conditioning, and training. However, there is controversy over the biomechanics and functionality of such throws. METHODS: Seventeen healthy, college baseball pitchers pitched fastballs 18.4 m from a mound to a strike zone, and threw 37 m, 55 m, and maximum distance from flat ground. For the 37-m and 55-m throws, participants were instructed to throw “hard, on a horizontal line.” For the maximum-distance throw, no constraint on trajectory was given. Kinematics and kinetics were measured with a 3-dimensional, automated motion analysis system. Repeated-measures analyses of variance, with post hoc paired t tests, were used to compare the 4 throw types within pitchers. RESULTS: At foot contact, the participant’s shoulder line was nearly horizontal when pitching from a mound and became progressively more inclined as throwing distance increased. At arm cocking, the greatest amount of shoulder external rotation (mean ± SD, 180° ± 11°), elbow flexion (109° ± 10°), shoulder internal rotation torque (101 ± 17 Nm), and elbow varus torque (100 ± 18 Nm) were measured during the maximum-distance throws. Elbow extension velocity was also greatest for the maximum-distance throws (2573°/s ± 203°/s). Forward trunk tilt at the instant of ball release decreased as throwing distance increased. CONCLUSION: Hard, horizontal, flat-ground throws have biomechanical patterns similar to those of pitching and are, therefore, reasonable exercises for pitchers. However, maximum-distance throws produce increased torques and changes in kinematics. Caution is, therefore, advised in the use of these throws for rehabilitation and training.

J Orthop Sports Phys Ther 2011;41(5):296-303, Epub 5 January 2011. doi:10.2519/jospt.2011.3568

KEY WORDS: crow-hop, elbow, interval throwing program, kinematics, shoulder

The shoulder, by combining the actions across the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints, provides an extraordinarily wide range of functional versatility to the upper extremity. In this special issue of the Journal, we have assembled some of the leading clinical and research authorities on the rehabilitation of the shoulder to share their expertise, insights, and clinical pearls.

J Orthop Sports Phys Ther 2009;39(2):37. doi:10.2519/jospt.2009.0109

KEY WORDS: shoulder special issue

SYNOPSIS: The overhead throwing motion is an extremely skillful and intricate movement. When pitching, the overhead throwing athlete places extraordinary demands on the shoulder complex subsequent to the tremendous forces that are generated. The thrower’s shoulder must be lax enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability. We refer to this as the "thrower’s paradox." This balance is frequently compromised and believed to lead to various types of injuries to the surrounding tissues. Frequently, injuries can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program. The key to successful nonoperative treatment is a thorough clinical examination and accurate diagnosis. Rehabilitation follows a structured, multiphase approach, with emphasis on controlling inflammation, restoring muscles’ balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing. Athletes often exhibit numerous adaptive changes that develop from the repetitive microtraumatic stresses occurring during overhead throwing. Treatment should include the restoration of these adaptations. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther. 2009;39(2):38-54. doi:10.2519/jospt.2009.2929

KEYWORDS: baseball, glenohumeral joint, labral lesions, pitching, rotator cuff

SYNOPSIS: Rotator cuff tears lead to debilitating shoulder dysfunction and impairment. The goal of rotator cuff repair is to eliminate pain and improve function with increased shoulder strength and range of motion. The clinical outcomes of the surgical methods of rotator cuff repair (open, mini-open, and all-arthroscopic cuff repair) vary, as each method provides an array of advantages and disadvantages. Although the open surgical technique has long been considered the gold standard of rotator cuff repair, surgeons are becoming more adept at decreasing patient morbidity through decreased surgical trauma from an all-arthroscopic approach. In addition to a surgery-specific rotator cuff rehabilitation program, effective communication, and coordination of care by the physical therapist and surgeon are essential in optimal patient education and outcomes. In the ideal situation, a very well-educated therapist who has great communication with the treating surgeon can mobilize the shoulder early, re-establish scapulothoracic function safely and minimize the risk of stiffness and retear, while facilitating return to function. Treatment options can be individualized according to patient age, size and chronicity of tear, surgical approach, and fixation method. We recommend that patients who have undergone an all-arthroscopic rotator cuff repair undergo an accelerated postoperative rehabilitation program. A rational approach to therapy involves early, safe motion to allow optimal tendon healing, yet maintenance of joint mobility with minimal stress. As the field of orthopedics and, particularly, rotator cuff repair continues to develop with new technologies, the patient, physical therapist, and doctor need to work together to ensure optimal outcomes and patient satisfaction. LEVEL OF EVIDENCE: Therapy, Level 5.

Note: Appendices B, C, and D are online-only and are included in this downloadable PDF. 

J Orthop Sports Phys Ther. 2009;39(2):81-89.doi:10.2519/jospt.2009.2918

KEY WORDS: arthroscopy, rotator cuff tear, shoulder, supraspinatus

SYNOPSIS: The biomechanical analysis of rehabilitation exercises has led to more scientifically based rehabilitation programs. Several investigators have sought to quantify the biomechanics and electromyographic data of common rehabilitation exercises in an attempt to fully understand their clinical indications and usefulness. Furthermore, the effect of pathology on normal shoulder biomechanics has been documented. It is important to consider the anatomical, biomechanical, and clinical implications when designing exercise programs. The purpose of this paper is to provide the clinician with a thorough overview of the available
literature relevant to develop safe, effective, and appropriate exercise programs for injury rehabilitation and prevention of the glenohumeral and scapulothoracic joints. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther. 2009;39(2):105-117. doi:10.2519/jospt.2009.2835

KEY WORDS: electromyography, infraspinatus, serratus anterior, supraspinatus, trapezius

STUDY DESIGN: Controlled laboratory biomechanics study using a repeated-measures, counterbalanced design. OBJECTIVES: To compare patellofemoral joint force and stress between a short- and long-step forward lunge both with and without a stride. BACKGROUND: Although weight-bearing forward-lunge exercises are frequently employed during rehabilitation for individuals with patellofemoral joint syndrome, patellofemoral joint force and stress and how they change with variations of the lunge exercise are currently unknown. METHODS AND MEASURES: Eighteen subjects used their 12-repetition maximum weight while performing a short- and long-step forward lunge both with and without a stride. Electromyography, ground reaction force, and kinematic variables were put into a biomechanical optimization model, and patellofemoral joint force and stress were calculated as a function of knee angle. RESULTS: Visual observation of the data show that during the forward lunge, patellofemoral joint force and stress increased progressively as knee flexion increased, and decreased progressively as knee flexion decreased. Between 70° and 90° of knee flexion, patellofemoral joint force and stress were significantly greater when performing a forward lunge with a short step compared to a long step (P<.025). Between 10° and 40° of knee flexion, patellofemoral joint force and stress were significantly greater when performing a forward lunge with a stride compared to without a stride (P<.025). CONCLUSIONS: When the goal is to minimize patellofemoral joint force and stress during the forward lunge performed between 0° to 90° knee angles, it may be prudent to perform the lunge with a long step compared to a short step and without a stride compared to with a stride, because patellofemoral joint force and stress magnitudes were greater with a short step compared to a long step at higher knee flexion angles and were greater with a stride compared to without a stride at lower knee flexion angles.

J Orthop Sports Phys Ther. 2008; 38(11):681-690, Epub 24 October 2008. doi:10.2519/jospt.2008.2694 

KEY WORDS: knee, knee kinetics, patella, rehabilitation

The manner of acquiring strength-testing data may influence the results of an investigation. The purpose of this study was to determine if a significant difference exists between windowed and unwindowed data collection during isokinetic testing of the shoulder abductors/adductors. Fifty healthy professional baseball pitchers participated in this study. Testing was performed on a Biodex isokinetic dynamometer at 180 and 300°/sec for both the throwing and nonthrowing shoulders. Testing procedures regarding testing protocol, repetitions, positioning, and stabilization followed established guidelines for each subject. Statistical analysis was performed using a paired t-test with a p < 0.01 level of significance. Statistically significant differences were demonstrated between windowed and unwindowed mean peak torque data for both shoulders at both test speeds. The results indicated an average nonthrowing arm difference of 20.2 ft/lbs at 180°/sec and 51.7 ft/lbs at 300°/ sec for the abductors. In each instance, the unwindowed mean peak torque values were higher than the windowed values, and significant end range torque spikes were elicited during unwindowed data collection. The nonthrowing adductors exhibited an average of 39.3 and 48.3 ft/lb differences at 180 and 300°/sec, respectively. The throwing shoulder demonstrated average abductor differences of 25.6 ft/lbs at 180°/sec and 47.7 ft/lbs at 300°/sec. The average throwing adductor difference was 24.4 ft/lbs and 54.6 ft/lbs, respectively, at both test speeds. This investigation offers clinical relevance for those using isokinetic testing of the shoulder abductors/adductors in demonstrating the significant differences between windowed and unwindowed data, identifying torque spike data misinterpretation, and describing a clinical means of controlling aberrant torque production during testing.

J Orthop Sports Phys Ther 1992;15(2):107-112.

Key Words: isokinetics, shoulder testing, torque spikes, windowed data

J Orthop Sports Phys Ther 1992;15(6):279-293.

Key Words: anterior cruciate ligament reconstruction, rehabilitation, clinical outcome

The purpose of this study was to compare the effects of proximal single resistance pad placement (PSPP) and distal single pad placement (DSPP) on tibial displacement during isokinetic exercise on anterior cruciate ligament (ACL)-deficient knees. This study is important to the clinician because it documents tibial displacement during open chain isokinetic knee extension exercise at various isokinetic speeds. In addition, this study documents the range of motion where the greatest amount of anterior tibial displacement occurs. The anterior displacement of the tibia was recorded by a computerized knee laxity testing device during isokinetic exercise. Data were collected from 12 ACL-deficient knees. Each subject was tested on an OSI Knee Signature System for quantifiable tibial displacement during a Lachman's test, anterior drawer test, and active vs. passive knee extension. Following this, each subject was tested on a Biodex isokinetic dynamometer at isokinetic velocities of 60, 180, and 300°/sec with the computerized knee laxity testing device in place. Pad placement consisted of distal single pad placement, which is 1 inch proximal to the medial malleolus, and proximal single pad placement, which is 3 inches proximal to the DSPP location. The testing procedure was standardized, and peak torque was monitored to ensure consistent maximal effort throughout the study. The results indicated that PSPP resulted in less anterior tibial displacement at all three test speeds. The peak anterior tibial displacement occurred in a range from 30 to 15° of knee flexion at both pad placements and all three test speeds. Lastly, the greatest amount of anterior tibial displacement occurred at the 60°/sec isokinetic velocity, whereas less displacement occurred at 180 and 300°/sec, respectively. This study documents that high-speed isokinetics result in less anterior tibial displacement than low-speed isokinetics, and if ACL graft strength or maturation is questionable, a 30° extension block or a proximal resistance pad may be used.

J Orthop Sports Phys Ther 1993;17(1):24-30.

Key Words: anterior cruciate ligament, tibial displacement, resistive exercise

Enhanced athletic performance emphasizes the muscle's ability to exert maximal force output in a minimal amount of time. Exaggerated maximal muscular force develops due to athletic movements producing a repeated series of stretch-shortening cycles. The stretch-shortening cycle occurs when elastic loading, through an eccentric muscular contraction, is followed by a burst of concentric muscular contraction. A form of exercise called plyometrics employs a quick, powerful movement involving a prestretch of the muscle, followed by a shortening, concentric muscular contraction, thus utilizing the stretch-shortening muscular cycle. The literature contains numerous references to plyometric training for the lower extremity, but there is a lack of information on the upper extremity plyometric program. Overhead activities, such as throwing, necessitate elastic loading to produce maximal, explosive, concentric muscular contractions. Plyometric exercise employs the concept of the stretch-shortening muscular cycle. The rehabilitation concept of specificity of training suggests plyometric exercise drills should be performed by the throwing athlete. This paper discusses the basic neurophysiological science and theoretical basis for plyometric exercise, and it describes an upper extremity stretch-shortening exercise program for the throwing athlete.

J Orthop Sports Phys Ther 1993;17(5):225-239.

Key Words: stretch-shortening cycle, exercise, muscle spindle

J Orthop Sports Phys Ther 1993;17(6):305-317.

Key Words: rehabilitation, elbow joint complex, baseball injuries

The functional anatomy of the elbow joint complex is unique in orientation and configuration. Three bones, the ulna, radius, and humerus, articulate to form four articulations: the humeroulnar, humeroradial, superior radioulnar, and inferior radioulnar joints. This unique osseous structure provides the elbow excellent static stabilization, which is enhanced by the ulnar collateral ligament, the lateral collateral ligament, and the elbow joint capsule. Twenty-three muscles are directly associated with the elbow joint and can be classified into four main groups: the elbow flexors and extensors and the flexor-pronator and extensor-supinator groups. These muscles provide dynamic stabilization to the elbow and enable the hand to perform skilled, precise motions. The purpose of this review article is to provide the clinician with an understanding of the unique anatomy at the elbow joint and to enhance the clinician's knowledge of the biomechanics, clinical examination, and rehabilitation of the elbow complex.

J Orthop Sports Phys Ther 1993;17(6):279-288.

The physical examination of the thrower's elbow presents the clinician with the clinical challenge of differentially diagnosing specific pathologies. The examination should include a thorough history and a well-organized physical examination, which relies on an extensive knowledge of the functional anatomy of the elbow. The components of an elbow examination include inspection/observation, palpation of bony and soft tissues, range of motion assessment, resisted muscle testing (both manual and mechanical), neurologic testing, and special tests. The special tests commonly performed on the thrower's elbow are the Tinel test, tennis elbow sign, ulnar collateral ligament stability testing, valgus extension overload test, and radiocapitella chondromalacia test. Other tests include radiographic examination, such as computerized tomograph arthrogram and magnetic resonance imaging testing. Information presented in this paper will provide the clinician with a systematic and thorough evaluation process for the thrower's elbow.

J Orthop Sports Phys Ther 1993;17(6):296-304.

Key Words: elbow joint complex, elbow pathologies, stability testing

J Orthop Sports Phys Ther 1993;18(1):365-378.

Key Words: shoulder joint, rehabilitation, current concepts

Paper submitted before conversion to SI units was required.

Surgical reconstruction of the anterior cruciate ligament (ACL) using a patellar tendon autograft is a common orthopaedic procedure. Complications such as arthrofibrosis, patellar fracture, significant donor site pain, and quadriceps muscle weakness can occur from this procedure. Previous studies have not documented the effects of isolated graft procurement without concomitant ligamentous reconstruction on the donor extremity.

This case study documents the clinical outcome results of an individual who underwent a central one-third graft harvest from his contralateral uninjured knee for an ACL graft of his injured ACL-deficient knee. The results indicate that at 4 months following graft procurement, the knee extensors were equal to the preoperative isokinetic test results of that leg. In addition, the patient exhibited full range of motion and no patellofemoral complaints or dysfunction. At 12 months postsurgery, the graft donor leg was 5-9% stronger than the preoperative test results. The results of this case study suggest that isolated harvesting of a 10-mm central patellar tendon free graft may not result in significant quadriceps muscle weakness or contribute to donor site pain.

J Orthop Sports Phys Ther. 1993;18(6):692-697.

Study Design: Descriptive postoperative follow-up research. Objectives: The purpose of this investigation was to describe the return-to-competition rate and functional outcome of overhead athletes following arthroscopic thermal-assisted capsular shrinkage (TACS). Background: Traditional open procedures to correct instability in overhead athletes, such as capsulolabral repairs and capsular shifts, have produced less-than-favorable results, which have led to the development of TACS. Currently there are no long-term follow-up studies documenting the efficacy of this procedure in groups greater than 31 subjects or for a time period greater than 27 months. Methods and Measures: Two hundred thirty-one consecutive overhead athletes who due to symptoms of hyperlaxity had previously undergone a TACS procedure from 1997 to 1999 were selected for inclusion in the study. During a 1-month period, 130 of these athletes (mean age ± SD, 24 ± 6 years; 113 male, 17 female) were contacted by phone for follow-up at a mean of 29.3 months postoperatively (range, 15.4-46.6 months). Of the 130, 105 participated in baseball (80 pitchers), 14 in softball, 4 in football (quarterbacks), 4 in tennis, and 3 in swimming. Fifty-four (42%) subjects were professional, 49 (38%) collegiate, 16 (12%) high school, and 11 (8%) recreational athletes. One hundred twenty-three of the 130 (95%) underwent 1 or more concomitant procedure(s) at the time of TACS. Most commonly performed were labral debridements (69%), rotator cuff debridements (65%), and superior labral repairs (35%). Subjects who returned to competition were retrospectively evaluated using a modified Athletic Shoulder Outcome Rating Scale to subjectively assess pain, strength and endurance, stability, intensity, and performance. Overall results were based on a 90-point scale with scores of 80 to 90 representing excellent, 60 to 79 good, 40 to 59 fair, and less than 40 poor results. Results: One hundred thirteen out of 130 subjects (87%) returned to competition. Mean (±SD) time from surgery to return to competition was 8.4 ± 4.6 months. Mean outcome score for all subjects was 79/90; 75 (66%) subjects had excellent, 24 (21%) good, 11 (10%) fair, and 3 (3%) poor result. The mean outcome score for males was 80/90 and for females was 70/90. Conclusions: The majority of overhead athletes (87%) successfully returned to competition following a TACS procedure with good-to-excellent long-term outcomes (88%). Based on the results of this study, TACS of the glenohumeral joint is a viable option for overhead athletes with pathological instability.

J Orthop Sports Phys Ther. 2003;33(8):455–467.

Key Words: acquired laxity, baseball, rehabilitation, shoulder, shoulder instability

Study Design: Prospective single-group repeated-measures design. Objectives: To quantify electromyographic (EMG) muscle activity of the infraspinatus, teres minor, supraspinatus, posterior deltoid, and middle deltoid during exercises commonly used to strengthen the shoulder external rotators. Background: Exercises to strengthen the external rotators are commonly prescribed in rehabilitation, but the amount of EMG activity of the infraspinatus, teres minor, supraspinatus, and deltoid during these exercises has not been thoroughly studied to determine which exercises would be most effective to achieve strength gains. Methods and Measures: EMG measured using intramuscular electrodes were analyzed in 10 healthy subjects during 7 shoulder exercises: prone horizontal abduction at 100° of abduction and full external rotation (ER), prone ER at 90° of abduction, standing ER at 90° of abduction, standing ER in the scapular plane (45° abduction, 30° horizontal adduction), standing ER at 0° of abduction, standing ER at 0° of abduction with a towel roll, and sidelying ER at 0° of abduction. The peak percentage of maximal voluntary isometric contraction (MVIC) for each muscle was compared among exercises using a 1-way repeated-measures analysis of variance (P<.05). Results: EMG activity varied significantly among the 7 exercises. Sidelying ER produced the greatest amount of EMG activity for the infraspinatus (62% MVIC) and teres minor (67% MVIC). The greatest amount of activity of the supraspinatus (82% MVIC), middle deltoid (87% MVIC), and posterior deltoid (88% MVIC) was observed during prone horizontal abduction at 100° with full ER. Conclusions: Results from this study provide initial information to develop rehabilitation programs. It also provides information helpful for the design and conduct of future studies.

J Orthop Sports Phys Ther. 2004;34(7):385-394. doi:10.2519/jospt.2004.0665 

Key Words: dynamic stabilization, infraspinatus, supraspinatus, teres minor

During the course of rehabilitation of a patient, I often wonder if there are speed limits to our rehabilitation program. This dilemma usually occurs when a patient is recovering exceedingly fast, making me wonder if we are progressing too quickly and violating the soft tissue healing constraints. In the specific case of patients who have undergone ACL reconstruction, the primary healing constraints we should be concerned about are revascularization of the graft, graft remodeling, graft incorporation, and regeneration of graft strength. With these patients, I'm mainly concerned about the consequences of a fast or accelerated rehabilitation process. Does the accelerated rehabilitation program lead to increased laxity, a higher rate of graft failure, articular cartilage damage, or early degenerative changes of the joint? By returning someone back to sports quickly, are we placing the patient at risk for other problems now or years later? Is our ultimate goal of rehabilitation to return someone to sports as quickly as possible or to return them when it's safe for them? The case report by Roi et al, along with the invited commentaries by Drs Fithian and Shelbourne, published in this month's Journal raise many issues we must all ponder when considering the speed of the rehabilitation process.

J Orthop Sports Phys Ther. 2005; 35(2):50-51. doi:10.2519/jospt.2005.0102

Key Words: rehabilitaion; soft tissue healing constraints

Pathology of the superior aspect of the glenoid labrum (SLAP lesion) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important to determine the most appropriate nonoperative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum, while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions, including 3 newly described tests. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

J Orthop Sports Phys Ther. 2005;35(5):273-291. doi:10.2519/jospt.2005.1701

Key Words: dynamic stability, glenohumeral, rehabilitation, shoulder

Patellofemoral disorders are among the most common clinical conditions managed in the orthopaedic and sports medicine setting. Nonoperative intervention is typically the initial form of treatment for patellofemoral disorders; however, there is no consensus on the most effective method of treatment. Although numerous treatment options exist for patellofemoral patients, the indications and contraindications of each approach have not been well established. Additionally, there is no generally accepted classification scheme for patellofemoral disorders. In this paper, we will discuss a classification system to be used as the foundation for developing treatment strategies and interventions in the nonsurgical management of patients with patellofemoral pain and/or dysfunction. The classification system divides the patellofemoral disorders into eight groups, including: 1) patellar compression syndromes, 2) patellar instability, 3) biomechanical dysfunction, 4) direct patellar trauma, 5) soft tissue lesions, 6) overuse syndromes, 7) osteochondritis diseases, and 8) neurologic disorders. Treatment suggestions for each of the eight patellofemoral dysfunction categories will be briefly discussed.

J Orthop Sports Phys Ther. 1998;28(5):307-322.

Key Words: patellofemoral dysfunction, rehabilitation, classification

Significant contemporary advances have permitted a more comprehensive understanding and development of some interesting concepts about the glenohumeral joint. The purpose of this review paper is to discuss current concepts related to the anatomic stabilizing structures of the shoulder joint complex and their clinical relevance to shoulder instability. The clinical syndrome of shoulder instability represents a wide spectrum of symptoms and signs that may produce various levels of dysfunction, from subtle subluxations to gross joint instability. The glenohumeral joint attains functional stability through a delicate and intricate interaction between the passive and active stabilizing structures. The passive constraints include the bony geometry, glenoid labrum, and the glenohumeral joint capsuloligamentous structures. Conversely, the active constraints - also referred to as the active mechanisms - include the shoulder complex musculature, the proprioceptive system, and the musculoligamentous relationship. The interactions of the active and passive mechanisms, which provide passive and active glenohumeral joint stability, are thoroughly discussed in this paper.

J Orthop Sports Phys Ther. 1997;25(6):364-379.

Key Words: glenohumeral joint, anatomy, instability

Thorough descriptions of specific physical examination tests used to determine glenohumeral instability are lacking in the scientific literature. The purpose of this paper is to discuss the importance of the subjective history and illustrate the physical examination of the glenohumeral joint. Additionally, the authors illustrate specific stability assessment tests for the glenohumeral joint based on current basic science and clinical research. The physical examination of a patient whose history suggests subtle glenohumeral joint instability may be extremely difficult for the clinician due to the normal amount of capsular laxity commonly present in most individuals. An essential component of the physical examination is a thorough and meticulous subjective history, which includes the mechanisms of injury and/or dysfunction, chief complaint, level of disability, and aggravating movements. The physical examination must include an assessment of motion, static stability testing, muscle testing, and a neuralgic assessment. It is important that the clinician have a comprehensive understanding of various stability testing maneuvers. The evaluation techniques discussed in this paper should assist the clinician in determining the passive stability of the glenohumeral joint.

J Orthop Sports Phys Ther. 1997;25(6):380-389.

Key Words: glenohumeral joint, instability, assessment

1993 Breg Excellence in Research Award paper. Presented at the 15th Annual Sports Physical Therapy Section Team Concept Meeting, Williamsburg, VA, October 15-17, 1993.

It is important to examine the functional relationships between commonly performed clinical tests and to resolve inconsistencies in previous investigative results. The purpose of this study was to determine if a correlation exists between 3 commonly performed clinical tests: isokinetic isolated knee concentric muscular testing, the single-leg hop test, and the subjective knee score in anterior cruciate ligament reconstructed knees. To determine if a relationship exists would be beneficial to clinicians in determining patient progression, treatment modification, and return-to-sport objective parameters. Several investigators have analyzed 2 of these parameters, but no one has investigated 3 parameters to date. Additionally, this study explored the concept of limb acceleration and deceleration during high-speed isokinetics and its relationship to function. Fifty patients were randomly selected (29 males) with a mean age of 23.7 years (range 15-52). The subjects completed a subjective knee score questionnaire that rated symptoms (pain, swelling, giving way) and specific sport function and completed an overall knee score assessment. The patients were then evaluated performing 3 1-legged functional tests: 1) hop for distance, 2) timed hop, and 3) cross-over triple hop. Isokinetic testing was performed on a Biodex dynamometer at 180,300, and 450°/sec for knee extension/flexion. The patients' mean value of the self-assessed knee rating was 86 points. Sixty-four percent of the patients exhibited normal limb symmetry (within 85%) on all 3 single-leg hop tests. Sixteen percent exhibited quadriceps strength at least 90% of the contralateral limb isokinetically. A positive correlation was noted between isokinetic knee extension peak torque (180, 300°/sec) and subjective knee scores, and the 3 hop tests (p<.001). A statistical trend was noted between knee extension acceleration and deceleration range at 180°/sec and 300°/sec for the timed hop test and triple crossover hop (r = 0.48, r = 0.49, r = 0.51, r = 0.49). No positive correlations were found for isokinetic test results for the knee flexors.

J Orthop Sports Phys Ther. 1994;20(2):60-73.

Key Words: knee joint stability, anterior cruciate ligament, muscle strength, functional testing

Postoperative rehabilitation programs following articular cartilage repair procedures will vary greatly among patients and need to be individualized based on the nature of the lesion, the unique characteristics of the patient, and the type and detail of each surgical procedure. These programs are based on knowledge of the basic science, anatomy, and biomechanics of articular cartilage as well as the biological course of healing following surgery. The goal is to restore full function in each patient as quickly as possible by facilitating a healing response without overloading the healing articular cartilage.

The purpose of this paper is to overview the principles of rehabilitation following articular cartilage repair procedures. Furthermore, specific rehabilitation guidelines for debridement, abrasion chondroplasty, microfracture, osteochondral autograft transplantation, and autologous chondrocyte implantation will be presented based upon our current understanding of the biological healing response postoperatively.

J Orthop Sports Phys Ther. 2006; 36(10):774-794. doi:10.2519/jospt.2006.2228

Key Words: autologous chondrocyte implantation, chondroplasty, microfracture, osteochondral autograft transplantation

Articular cartilage lesions of the knee joint are common in patients of varying ages. Some articular cartilage lesions are focal lesions located on one aspect of the tibiofemoral or patellofemoral joint. Other lesions can be extremely large or involve multiple compartments of the knee joint and these are often referred to as osteoarthritis. There are numerous potential causes for the development of articular cartilage lesions: joint injury (trauma), biomechanics, genetics, activities, and biochemistry. Numerous factors also contribute to symptomatic episodes resulting from lesions to the articular cartilage: activities (sports and work), joint alignment, joint laxity, muscular weakness, genetics, dietary intake, and body mass index.

Athletes appear to be more susceptible to developing articular cartilage lesions than other individuals. This is especially true with specific sports and subsequent to specific types of knee injuries. Injuries to the anterior cruciate ligament and/or menisci may increase the risk of developing an articular cartilage lesion. The treatment for an athletic patient with articular cartilage lesions is often difficult and met with limited success. In this article we will discuss several types of knee articular cartilage injuries such as focal lesions, advanced full-thickness lesions, and bone bruises. We will also discuss the risk factors for developing full-thickness articular cartilage lesions and osteoarthritis, and describe the clinical evaluation and nonoperative treatment strategies for these types of lesions in athletes.

J Orthop Sports Phys Ther. 2006; 36(10):815-827. doi:10.2519/jospt.2006.2303

Key Words: chondral lesion, exercise, nonoperative treatment, nutrition, tibiofemoral joint

Rehabilitation specialists commonly observe upper-extremity injuries in golfers, baseball players, and tennis players. Traditional nonoperative and postoperative rehabilitation programs for these athletes involve a gradual restoration of range of motion (ROM), strength, muscular endurance, dynamic stabilization, and neuromuscular control. Upon successful completion of the early phases of the rehabilitation program, a gradual and controlled return to sport activities has been advocated by several authors. The term ‘‘interval sport programs’’ has been used to refer to functional rehabilitation guidelines that simulate sport activities. These programs are designed to progressively apply forces to the healing structures and are intended to gradually return the athlete to full athletic competition as quickly and safely as possible. The purpose of this paper is to describe specific interval sport programs currently utilized at our center to return golfers, baseball players, and tennis players to competition following an injury or surgery. In using an interval sport program (ISP) in conjunction with a structured rehabilitation program, the athlete should be able to return to full competition status. The general guidelines and specific programs outlined are used to minimize the chance of reinjury and to facilitate the return of function and confidence in the athlete. The program and its progression should be modified to meet the specific needs of each individual athlete. A comprehensive program consisting of a proper maintenance rehabilitation program incorporating strengthening, flexibility, plyometric, dynamic stabilization, and neuromuscular controls drills, as well as appropriate warm-up procedures and biomechanics, is essential in returning athletes to competition as quickly and safely as possible.

J Ortho Sports Ther. 2002; 32(6):293-298.

Glenohumeral joint instability is a common pathology observed in the orthopedic and sports medicine settings. Overhead athletes often exhibit a certain degree of acquired laxity that can lead to various pathologies. Unfavorable results often observed with traditional open procedures to correct instability in the overhead athlete have led to the development of arthroscopic thermal-assisted capsular shrinkage (TACS). TACS is not commonly used as an isolated procedure in overhead athletes; various procedures are often performed concomitantly. The overall outcome greatly depends on a postoperative rehabilitation program that must be assessed and adjusted frequently based on several factors. Knowledge of the basic science of TACS as well as emphasis on dynamic stabilization, proprioception, and neuromuscular control are vital to the rehabilitation program for overhead athletes. The purpose of this paper is to discuss the basic science and clinical application of thermal-assisted capsular shrinkage of the glenohumeral joint as well as the postoperative rehabilitation for the overhead athlete and the patient with congenital laxity and related multidirectional instability.

J Orthop Sports Phys Ther. 2002; 32(6):268–292.

Key Words: dynamic stabilization, glenohumeral instability, neuromuscular control, overhead athlete, SLAP lesions