Correcting Posterior Shoulder Tightness for Internal Impingement

Internal glenoid impingement is the most common cause of posterior shoulder pain in the throwing and overhead athlete. The problem also occurs at an alarming rate in weight lifters (from poor lifting technique) and patients such as mechanics, electricians and shelf-stockers, who are involved in occupational overhead activities.

Patients with internal impingement frequently have range-of-motion (ROM) deficits that include glenohumeral internal rotation deficit (GIRD) and posterior shoulder tightness (PST). Traditional treatments have focused on resolving GIRD; however, little attention has been paid to correct PST. In this study, Tyler et al from PRO Sports Physical Therapy, New York, assessed whether improvements in GIRD and/or PST would result in symptom resolution for patients with internal impingement.

Twenty-two patients (11 men, 11 women; mean age, 41 ± 13 years) with internal impingement diagnosed by clinical and magnetic resonance imaging findings were studied. At the initial evaluation. GIRD, PST and external ROM were evaluated. Patients also completed a 12-item shoulder symptom questionnaire called the Simple Shoulder Test (SST). Patients were seen 3x/week and prescribed a daily home-exercise program.

The physical therapy intervention included manual mobilization and stretching of the posterior shoulder. Physical therapy was continued until symptom relief, with an average duration of 7 weeks.

Following the intervention, GIRD, PST and loss of external rotation ROM all significantly improved (p < .01). Twelve patients experienced complete resolution of symptoms on the SST score, and 10 patients showed improved SST scores but still had residual symptoms. An examination of the relationship between GIRD, PST, external rotation ROM and residual symptoms showed that the patients who had the most pronounced PST also had the greatest improvement in symptoms after intervention (Figure 1)

The findings of this study suggested that patients with internal impingement with marked PST may have better outcomes than those with greater deficits in glenohumeral internal and external rotation ROM when following the proposed interventions.

NEUROMUSCULAR VS. STRENGTH TRAINING: LONG-TERM FOLLOW-UP AFTER ACL RECONSTRUCTION

Neuromuscular and strength deficits are considered the main functional impairments following anterior cruciate ligament (ACL) reconstruction. Although quadriceps muscle strength has been considered a key component of successful functional outcomes, neuromuscular control, described as dynamic stability during functional activities, has been shown to significantly affect rehabilitation outcomes, perhaps even more strength recovery.

To date, most studies have compared strength and neuromuscular training following ACL reconstruction for only a short-term duration (≤6 months). In this prospective randomized study. Risberg and Holm from Oslo University Hospital, Norway, assessed the long-term outcomes of a 6-month traditional strength exercise program vs a neuromuscular exercise program in patients following ACL reconstruction. Seventy-four patients (27 women, 47 men; mean age, 28.4 years) who had undergone arthroscopic ACL bone-patellar tendon-bone graft were randomized into either a standard muscle strengthening exercise (SE) or a neuromuscular exercise (NE) program.

The SE program was based on the American College of Sports Medicine's recommendations for intensity and frequency, and on current recommendations of strength training following ACL surgery. The NE program consisted of balance exercises, dynamic joint stability exercises, plyometric exercises, agility drills and sport-specific exercises. The outcome measures included

• the Cincinnati knee score
• a visual analogue scale (VAS) for pain
• the Short-Form 36
• functional knee tests (single-leg hop tests) and isokinetic knee flexion
• extension muscle strength

Patients were seen in outpatient clinics 2-3x/week, and both rehabilitation programs lasted for 6 months. No knee braces were used following surgery. Patients were evaluated preoperatively, at 6 month, 1 year and 2 years after ACL reconstruction.

At 6 months and 1 year, 65 patients (89%) returned for follow-up; 60 patients (81%) returned at the 2-year follow-up. Six months after surgery, the NE group recorded significantly improved knee function by Cincinnati knee score (p = .01; Figure 2) and global function rating (p = .02; Figure 3), compared with knee function in the SE group. These scores remained higher at 1 year for the NE group. Hamstring strength at 240˚/second was the only variable better in the SE group than in the NE group at the 2-year follow-up (p = .005). This did not relate to any differences in functional outcomes. The patients' perception of pain and global function was significantly better in the NE group at the 1-year follow-up.

Because the NE program included a component of strength training in the plyometric exercises, the investigators recommended that both neuromuscular training and sport-specific strength training continue to be included in rehabilitation programs following ACL reconstruction. Risberg MA, Holm I. The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction. Am J Sports Med 2009;37:1958-1966

INTENSIVE, PROGRESSIVE EXERCISE BENEFICIAL FOLLOWING MICRODISKECTOMY

Up to 85% of people will experience low-back pain at some point in their lives. One source of low-back pain is lumbar disk herniation. While the majority of cases will resolve without surgery, for whose cases with resultant sciatica unresponsive to conservative measures, patients often undergo lumbar diskectomy. Although the surgery may be successful, symptoms and funtional deficits persist in up to 35% of cases. Months of pain and reduced activity prior to surgery often result in atrophy, weakness and greater back muscle fatigue, which may explain why functional deficits persist.

In this study of patients who had undergone a single-level lumbar microdiskectomy, Kulig et al from the University of Southern California evaluated the early effects of a recently developed intensive postoperative program on self-reported and physical performance measures of function and disability. Unlike previous investigations that did not assess outcomes earlier than 6 months following surgery, this study evaluated patients 12 weeks after surgery.

Ninety-eight participants (53 men, 45 women; mean age, 40 years) underwent lumbar microdiskectomy for disk protrusion confirmed by magnetic resonance imaging and clinical symptoms.

They were randomized into 2 groups:

• education-only group: received 1 session of back-care education
• exercise-and-education group: received 1 session of backcare education followed by a 12-week exercise program

The education-only session was a one-on-one, 1-hour session conducted 4-6 weeks after surgery. It was individualized to each patient's needs. The exercise-and-education session started after the education portion and took place 3x/week for the remainder of the 12 weeks. The exercise program was comprised of graded back extensor strength and endurance training, as well as mat and therapeutic exercise training. A progression of increasing difficulty was established for the abdominal, back and lower extremity muscles. It is important to note that none of the participants withdrew from the intervention due to symptom exacerbation.

The primary outcome measure was the Oswestry Disability Index (ODI). Additionally, performance in the repeated Sit-to-Stand Test, the 50-Foot Walk Test and the 5-Minute Walk Test were assessed.

The results indicated a 20% improvement in the ODI scores in the exercise-and-education group, compared with 9% in the education-only group (p ≤ .016). Walking distance was also improved in the exercise-and-education group.

Although this study assessed the short-term benefits of exercise intervention, the results were positive for improvements in daily function without adverse effects.

Kulig K, Beneck GJ, Selkowitz DM, et al; physical Therapy Clinical Research Network (PTClinResNet). An intensive, progressive exercise program reduces disability and improves functional performance in patients after single-level lumbar microdiskectomy. Phys Ther 2009;89:1145-1157

OPTIMIZING GASTROCNEMIUS MUSCLE STRETCHING

Various lower-extremity injuries have been linked to limitations in ankle dorsiflexion secondary to gastrocnemius muscle tightness. Plantar fasciitis, metatarsalgia, Achilles tendonitis, patellofemoral pain syndrome and forefoot ulcerations in persons with diabetic neuropathies are just some of the pathologies associated with gastrocnemius muscle tightness. Stretching continues to remain the first-line intervention for many of these pathologies, and numerous techniques have been recommended.

The standing wall stretch is commonly prescribed, yet the effect of this stretch on the displacement of the myotendinous junction (DMTJ) of the medical gastrocnemius has not been reported. If the arch is not stabilized during this technique, there may be excessive stress on the arch. This concern has been noted for people with pes planus who already have compromised arch structure.

A study that included participants with neutral foot alignment and pes planus was conducted by Jung et al from the College of Suncheon First, Republic of Korea, to examine the effects of standing wall stretching with and without medial arch support on the

• DMTJ of the medial gastrocnemius
• rearfoot angle
• navicular height

Thirty patients (mean age, 24.2 years) participated. Fifteen patients (11 men, 4 women) with neutral foot alignment and 15 patients (9 men, 6 women) with pes planus performed wall stretching with and without medial arch support. While facing the wall, the foot not stretched was placed forward at a distance equal to the patient's step length. Patients were asked to lean forward until the ankle attained 25˚ of dorsiflixion, and the stretch was held for 30 seconds. Ultrasonography was used to measure the DMTJ, videography was used to record rearfoot angles and a ruler was used to measure the navicular height.

The results showed that standing wall stretching with medial arch support significantly increased the DMTJ compared with stretching without the support both in patients with neutral foot alignments (10.5 mm vs 9.6 mm, respectively) and in those with pes planus (12.7 mm vs 10.0 mm, respectively). Similarly, stretching with the medial arch support also decreased rearfoot angle and increased the navicular height (Figure 4). The major findings of this study supported the use of a medial arch to maintain a neutral subtalar joint position and enable maximal lengthening of the gastrocnemius.

Jung D-Y, Koh E-K, Kwon O-Y, et al. Effect of medial arch support on displacement of the myotendinous junction of the gastrocnemius during standing wall stretching. J Orthop Sports Phys Ther 2009;39:867-874

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