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: 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

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

The goal of this special issue is to provide a comprehensive overview of our current knowledge in the treatment of articular cartilage and meniscal lesions from leaders in the field.

J Orthop Sports Phys Ther. 2006; 36(10):715-716. doi:10.2519/jospt.2006.0111

Autologous chondrocyte implantation (ACI) has now been performed for over a decade in the United States. ACI has been demonstrated as a reproducible treatment option for large, full-thickness, symptomatic chondral injuries of the knee. As clinical experience has expanded and indications broadened to more complex cartilage defects, it has become evident that aggressive treatment of coexisting knee pathology is essential for optimal results. This includes management of malalignment, ligamentous, and/or meniscal deficiency, and subchondral bone loss to make the intra-articular environment as ideal as possible for successful cartilage restoration. Additionally, refinements in the rehabilitation necessary for biologic cartilage repair have been made, based on better understanding of the maturation process of the repair cartilage, allowing for earlier initiation of knee range of motion, strengthening exercises, and weight bearing.

These changes have enhanced the recovery for the patient and decreased the risk of motion deficits. This article will discuss patient selection for ACI, review ACI surgical technique, including management of coexisting knee pathology, present postoperative ACI rehabilitation guidelines, and summarize clinical outcomes after ACI.

J Orthop Sports Phys Ther. 2006; 36(10):751-764. doi:10.2519/jospt.2006.2409

Key Words: cartilage, cartilage transplantation, chondrocyte transplantation, tibiofemoral joint

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