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[mikeprebeg]

Cold water immersion for recovery

Is there an advantage to cold-water immersion (CWI) for athletes after a bout of exercise? 

A meta-analysis done by Leeder et al, looked at the effect of CWI on eccentric and high intensity exercise.

The duty cycle for each CWI was a bit different from study to study. Refer to Table 1.

The outcome measure were muscle power, muscle strength, delayed onset muscle soreness (DOMS) and creatine kinase levels (CK). Muscle power was measured through either vertical jump or 5 m sprint (not an exhaustive list). Muscle strength was defined as a test of isometric/isokinetic knee extension or elbow flexion only. DOMS was defined as a participant’s perception of muscle soreness, using visual analogue scales or algometry. Measurements of CK were defined as venous or capillary CK.

 Participants’ level of physical activity ranged from untrained to elite athlete groups. The mean age was 23.2 ± 3.5 years. The total number of participants was 239 and the distribution of gender was not equal (male, n = 182; female, n = 57).

 The results displayed a moderate effect in alleviating DOMS post exercise. CWI was highly effective in alleviating DOMS following high-intensity exercise at 24 and 48 hours. However, CWI did not reduce DOMS at 24 hours post eccentric exercise, but had a moderate effect at 48 hours post eccentric exercise.

 CWI was effective in reducing efflux of CK in the blood post exercise, although this finding was significant it was a small effect.

 CWI was not effective in improving rate of recovery of muscle strength post exercise. It is proposed that following the muscle damage; a disturbance took place in calcium homeostasis in the cytoplasm. This can lead to a sequence of metabolic events following the exercise that further damages the cell partly via oxidative mechanisms. It would appear CWI is not able to alleviate the metabolic damage and muscle strength loss.

CWI was effective in improving rate of recovery of muscle power post exercise. Furthermore, it was effective in improving recovery of muscle power at time points 24, 48 and 72 hours post exercise.

 One proposed mechanism of CWI is a reduction in muscle blood flow and tissue temperature causing decreased inflammation induced via strenuous exercise. The proposed reduction in inflammation is associated with a decrease in sensation of pain. This is caused by reducing the osmotic pressure of exudate, which normally up-regulates nociceptors signaling pain via type IV afferent fibres.        

Leeder, J., Gissane, C., Someren, K. V., Gregson, W., & Howatson, G. (2011). Cold water immersion and recovery from strenuous exercise: A meta-analysis. British Journal of Sports Medicine Br J Sports Med, 46(4), 233-240. doi:10.1136/bjsports-2011-090061

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Achilles Tendinopathy Rehab Protocol

According to a 2007 study in the Journal of Science and Medicine in Sport;

Patients should aim to complete three sets of 15 repetitions with one minute of rest between the sets twice a day seven days per week for 12 weeks.

Patients should start with one set of 10 repetitions in the first day of exercises and gradually progress to three sets of 15 repetitions by the seventh day, aiming to complete three sets of 15 repetitions twice a day by the second week of treatment.

Patients would progress by eventually adding some weight if needed.

Exercises should be done with both the knee bent (to work soleus) and the knee straight to work gastrocnemius.

Full Article

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Understanding the sticking point of a squat

When assessing athletes during a heavy compound lift, there is a common phenomenon known as the sticking point. When analyzing the squat, the sticking point (SP) is usually just above parallel.

Why does this occur?

The reason this is occurring is because your muscles do not produce a consistent amount of force throughout the entire ROM. The torque produced at the hip, knee and ankle change through the course of the lift.

According to the image, your muscles are the strongest when they are at their resting length. This occurs due to the fact that this is the maximal cross bridge formation.

Looking at the next image, as the muscle lengthens, the active tension will decrease and the passive tension (potential elastic energy) will increase. When both active and passive tension is added together we yield the green line.

Therefore, the dip in the green line outlines the SP.

At the bottom of the squat, your hip extensors are in a stretched position, meaning they have potential to produce a high amount of force. Once you surpass your SP, you are moving closer to your testing length therefore the movement becomes easier. Furthermore, the extension torque demands are less.

So what can you do to help beat the SP?

First off, focus on speed coming out of the hole. When doing strength-based compounds, it is paramount to be explosive during the concentric phase. Of course the weight is not going to move quickly, but it will help with overall force production.

Secondly, drive the hips underneath the bar as you reach your SP. This can help decrease the hip extension demands at the SP level.

Lastly, ensure you are bracing effectively by engaging your pelvic floor and breathing using your diaphragm.

Bryanton, Megan A., Jason P. Carey, Michael D. Kennedy, and Loren Z.f. Chiu. "Quadriceps Effort during Squat Exercise Depends on Hip Extensor Muscle Strategy." Sports Biomechanics 14.1 (2015): 122-38. Web.

Nuckols, Greg. "Strengtheory * The Online Home for Thinking Lifters." Strengtheory. Web. 25 Feb. 2016.

- Dr. Michael Prebeg and Taran Ohson

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Acupuncture and blood flow

Acupuncture is often used clinically to alleviate pain symptoms and to promote healing. Researchers have demonstrated that acupuncture stimulation changes microcirculation and inflammatory mediators, influences the activity of adenosine (an amino acid that becomes active in the skin after an injury to ease pain), raises skin temperature, and causes muscular contractions (resulting in vasodilation responses), all of which are potential mechanisms behind pain reduction.

Several studies have also demonstrated that acupuncture increases both skin and muscle blood flow, however, the methods of acupuncture delivery, including location and duration, are not standardized.

In a study published last year in the British Medical Acupuncture Society Journal, Mori et. al compared the therapeutic effects of different electroacupuncture (EA) stimulation durations in order to determine whether skin blood flow (SBF) and muscle blood volume (MBV) responses differ according to the duration of EA stimulation in human subjects.

Two experiments were conducted for this study.  In experiment 1, 20 healthy males were randomly divided into two groups, an EA group and a no-stimulation group.   EA stimulation on the quadriceps femoris was administered at a frequency of 1Hz. for 15 minutes.  SBF and MBV were estimated before, during and after stimulation (immediately, 5 minutes and 10 minutes post stimulation).  In this first experiment, there was a significant difference between the groups. In the EA stimulation group, MBV increased immediately following EA and also at 5 minutes and 10 minutes afterwards compared with baseline. No significant change was observed in the no-stimulation group.

In experiment 2, 37 healthy males were randomly divided into three groups with different stimulation durations of EA (5, 10 and 15 minutes). EA stimulation on the quadriceps femoris muscle was administered again with a frequency of 1 Hz. and SBF and MBV were estimated before, during and after stimulation. They found no significant difference between the groups. All three stimulation durations (5, 10 and 15 minutes) showed increases in MBV after stimulation compared with baseline. SBF increased in the 5 and 10-minute groups compared with baseline, but there was no significant difference between the groups.

Based on these findings, the authors concluded that 10 minutes of EA stimulation could be a sufficient duration to induce a blood flow response in a clinical situation when increasing the blood flow is desirable (for example for pain control or to promote healing).

In a study published in JMPT in 2012, Cagnie et. Al. investigated the effect of dry needling on blood flow and oxygen saturation of the trapezius muscle. It was hypothesized that this needling would be able to immediately increase oxygen saturation and blood flow in the region being treated, and no changes would recur at non-needled sites.

In this study, one single dry needling procedure was performed in the right upper trapezius of 20 healthy participants, at a point located midway between the acromion edge and the seventh cervical vertebrae. Blood flow and oxygen saturation were evaluated at the treated point and at three distant points (a similar point in the left upper trapezius and 30 mm laterally from this midpoint on both sides). Measurements were taken at baseline and at 0, 5, and 15 minutes post treatment. It was found that after removal of the needle, the blood flow and oxygen saturation increased significantly from the pretreatment level in the treated point, and these values remained high throughout the 15-minute recovery period. There were only minor changes in the distant points. Theres results suggested that dry needling enhances the blood flow in the stimulated region of the trapezius muscle but not in a distant region used in this study.

While these studies demonstrate that both electroacupuncture and dry needling can increase blood flow, which is promising for pain control and muscle healing, it is noted that these studies were conducted in healthy subjects and therefore the results may not be applicable to patients who have pain symptoms or compromised blood flow.  The acupuncture was also performed on fixed locations, which may not apply to clinical practice where the determination of the location of needling is based on palpation and clinical signs and symptoms instead of on fixed points. Further studies are therefore required in participants with myofascial pain.

Cagnie, K, et al. The Influence of Dry Needling of the Trapezius Muscle on Muscle Blood Flow and Oxygenation.. J Man Manip Ther. 2012 Nov-Dec;35(9):685-91.

Mori H, Juge H, Tanaka TH, et. al, W. Influence of Different Durations of Electroacupuncture Stimulation on Skin Blood Flow and Muscle Blood Volume. Acupunct Med 2014; 32:167-171.

Dr. Michael Prebeg and Dr. Jennie Gillis

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Potential mechanisms of neural mobilization

This is a great scientific article explaining some of the concepts used when applying Soft Tissue Micro Conditioning Techniques to peripheral nerves.  Over the years I have been focusing more and more on peripheral nerves in my treatments.  This has been one of the more successful approaches I have taken over the years to achieve results in cases ranging from the complicated to pure performance.  I recommend everyone read this article and start thinking about peripheral nerves when assessing.  A lot of time when you think it is scar tissue ... it could be a peripheral nerve... - Mike Prebeg

Neural mobilization techniques are used clinically to treat neuropathic pain and dysfunction, and to restore neural mobility.  Even though studies suggest improvement in patient symptoms as a result of these techniques,the mechanisms for clinical symptom improvement are not clear. In a recent study soon to be published online in the Journal of Manual and Manipulative Therapy, Gilbert et. Al. considered the role of fluid, mainly intraneural edema, in neuropathic pain and dysfunction.

Nerve injury commonly leads to intraneural edema,and can dramatically affect nerve structure and function. Peripheral nerve tissue trauma, leading to edema, can be caused by compression,excessive tension,or vibration.  Epineurial edema may be caused from relatively mild injury, whereas long standing compression may lead to endoneurial edema.  Without lymphatic vessels the endoneurium is unable to drain this fluid accumulation,which leads to fibrosis, adhesions, and impaired intrafascicular gliding.

In this article, the authors looked at the effects of neural mobilization, via in vitro simulated stretch/relax techniques, on fluid dispersion in peripheral nerve tissue.  

This was a cadaveric study where bilateral sciatic nerve sections were harvested. Matched pairs of nerve sections were secured in a tissue tester and injected with a dye solution. Once the initial dye spread stabilized, the experimental nerve sections underwent 25 stretch/relaxation cycles (e.g. simulated neural mobilization) produced by a mechanical tissue tester. Post-test dye spread measurements were compared to pre-test measurements as well as control findings (no simulated mobilization). They found that the post-test intraneural fluid movement (dye spread) in the experimental section increased significantly with simulated neural mobilization compared to pre-test measurements and control measurements.

The authors concluded that repetitive simulated neural mobilization, incorporating stretch/relax cycles, of cadaveric peripheral nerve tissue produced an increase in intraneural fluid dispersion. Therefore, neural mobilization may alter the nerve tissue environment, promoting improved function and nerve health, by dispersing tissue fluid and diminishing intraneural swelling and/or pressure. This study contributes to the understanding of the possible underlying mechanisms of neural mobilization efficacy.

To date, the primary justification for using neural mobilization has been based on a few clinical trials and primarily anecdotal evidence and case studies. The biomechanical, physiological, and morphological theories underlying neural mobilization still need to be studied further.

The use of cadaveric tissue in this study created an environment where changes in dye spread could be attributed to the intraneural mechanical effects of passive neural mobilization instead of active physiological effects (such as blood flow, lymphatics, or axonal transport).  Considering this, it is possible that the benefits in live, physiologically active tissue, may be even greater when coupled with changes from dynamic functions, such as blood flow, lymphatic drainage, and axoplasmic transport. Future studies therefore need to involve objective in-vivo measurements of neural movement. It is also important to eventually substantiate clinical improvements with objective measurement of neural movement.

Gilbert, K, et al. Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: implications for the treatment of neuropathic pain and dysfunction. J Man Manip Ther. Published online 27 Nov 2014.

Ellis, R. Hing, W. Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic efficacy. J Man Manip Ther. 2008;16(1):8-22.

Dr. Michael Prebeg and Dr. Jennie Gillis

[mikeprebeg]

Prevalence of Femoracetabular Impingement

Femoroacetabular Impingement (FAI) is a common cause of hip pain, caused when abnormal bony features of the acetabulum or femoral head (or both) lead to abnormal joint contact and stresses with deep flexion and rotation motion. Three types of FAI are generally recognized: A cam deformity involves excess bone along the upper surface of the femoral head.  A pincer deformity is an excess of growth of the upper lip of the acetabulum.  The third type, and most common, is a combination of the two.

FAI is frequently associated with labral injury and some studies have shown that nearly all participants with labral tears have variable degrees of FAI features.   It is also thought that FAI may be a precursor to idiopathic hip osteoarthritis.

The true frequency of FAI is under debate, given thatseveral studies have reported the presence of radiographic findings suggestive of FAI in groups of asymptomatic patients including the recent article by Frank et al. from Rush University Medical Center.

A systematic review of the literature was performed for studies reporting radiographic, CT, or MRI findings (or findings from a combination of these studies) that were suggestive of FAI and labral injuries in asymptomatic volunteers. Each study was analyzed for several radiographic variables suggestive of FAI.  Cam, pincer and combined pathologic conditions were investigated, in addition to radiographic signs of hip osteoarthritis.  A total of 26 studies were identified for inclusion, comprising of 2, 114 asymptomatic hips, 33% of which were in athletes.   The mean participant age was 25 years.

The overall prevalence of an asymptomatic cam deformity was 37%.  Comparing the athletic group to the general population, there was an almost 3:1 prevalence of cam deformity.  The overall prevalence of asymptomatic hips with pincer deformities was 67%, with 49.5% of athletes demonstrating this deformity. Labral injury was found on MRI in 68.1% of hips; 65.4% of hips in athletes.

In summary, this study concluded that FAI morphologic features and labral injuries are common in asymptomatic patients, and may have an increased presence in athletes. Clinical decision-making should therefore emphasize patient history and physical examination and not rely on radiographic imaging.

Frank JM, Harris, JD, Erickson, BJ, et al.  Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy. 2015 Jan 28. (Epub ahead of print)

Dr. Michael Prebeg and Dr. Jennifer Gillis

[mikeprebeg]

The effect of electro-acupuncture on the healing process of a tibia fracture in a rat model

Previous studies have shown that electrical stimulation can be used to promote bone union, however the previous methods of embedding electrodes is quite invasive and risky.  More non-invasive techniques have been developed more recently (i.e. low intensity pulsed ultrasound and pulsed electromagnetic fields), however applying stimulation only to a local fracture site is challenging with these methods, and studies have shown that it is most effective when the cathode is applied directly to the fracture site.

This group from Japan suggested that the use of acupuncture needles as electrodes can eliminate the invasive procedure and allow for selective stimulation to deeper regions, making simple, quick and frequent applications possible.  They conducted a randomized control trial to examine the effect of electroacupuncture on the healing process of a tibia fracture in rats.

In this study, thirty male rats underwent unilateral osteotomies of the tibiae and then were assigned randomly to three groups of 10: 1. Electroacupuncture group (EA group) 2. Sham group 3. Control group

In the EA group, a cathodal electrode was connected to an acupuncture needle (30mm No 24, stainless steel, Seirin) percutaneously penetrating directly at the fracture site. Another acupuncture needle was inserted 15 mm proximal to the fracture site as an anode. Electroacupuncture was performed daily for 3 weeks. Using an electrical stimulator, 5ms square pulses at a frequency of 50 Hz were delivered at 20 μA for 20 minutes. In the sham group, no electrical stimulation was given to the acupuncture needle inserted at the same site as the EA group. In the control group, no treatment was given.

The response was determined at one, three, four, and six weeks after surgery by radiographic, macroscopic and mechanical examinations.

Results: The EA group showed accelerated bone healing and enhanced callus development after surgery compared to the other groups. Biomechanically, the strength of the callus in the EA group was significantly higher compared with the other groups.  There was no difference between the sham and control group in any evaluation.

Conclusion: Callus formation was promoted in the EA group over the sham and control group. The authors therefore concluded that the use of electroacupuncture can enhance callus development and bone mineralization of the bone healing process.

This study is promising and provokes discussion on the applicability of this method to human subjects.  The bones of the rats in this study were very small, so further studies would be required to evaluate how effective EA would be in bone forming for larger bones, over larger areas and in more "natural" fracture situations. In addition, the appropriate stimulation conditions need to be determined and safety parameters have to be established.

Acupunct Med 2010;28: 140-143

Dr. Michael Prebeg and Dr. Jennie Gillis

[mikeprebeg]

Superior Labral Lesions (SLAP lesions): A review

Superior labral lesions (SLAP lesions) are a common occurrence in the athletic population, especially in overhead athletes. These lesions are often challenging to both rehabilitation specialists and orthopaedic surgeons, as the clinical diagnosis can be difficult and it is common to have associated pathology with a SLAP lesion. Most notably, patients who have SLAP tears can also have concomitant rotator cuff tears and other labral pathology. Andrews et al. reported that 45% of patients (and 73% of baseball pitchers) with SLAP lesions also had partial-thickness tears of the supraspinatus. Mileski and Snyder reported that 29% of their patients with SLAP lesions had partial-thickness rotator cuff tears, 11% complete rotator cuff tears, and 22% Bankart lesions. They also demonstrated that type I SLAP lesions are typically associated with rotator cuff pathology, while types III and IV are associated with traumatic instability. Finally, they noticed that in patients with type II lesions, older patients tended to have associated rotator cuff pathology, while younger patients had associated anterior instability.

Untreated, SLAP lesions can be potentially lead to chronic pain, as well as a significant loss of function and performance. Conservative management of SLAP lesions is unfortunately often unsuccessful, particularly when there is a component of glenohumeral joint instability or when a concomitant rotator cuff tear is present. However, there are patients who are amenable to conservative treatment, particularly those with type I SLAP lesions. The initial phase of conservative management consists of cessation of throwing activities, followed by a short course of anti-inflammatory medication and modalities to reduce pain and inflammation.

Once the pain has subsided, physical therapy is initiated, with a focus on restoring normal shoulder motion. Strengthening of the shoulder girdle musculature is also crucial to restore normal scapulothoracic motion. An excessive loss of glenohumeral internal rotation (GIRD) is common in overhead athletes and a particular emphasis should be placed on stretching the posterior capsule and restoring internal rotation, which may prevent pathologic contact between the supraspinatus tendon and the posterosuperior labrum.

Although it is unclear if GIRD is a risk factor for SLAP lesions, restoring shoulder internal rotation may improve pathomechanics that could possibly reduce some of the patient's symptoms. The patient is eventually advanced to a strengthening phase, which includes core, rotator cuff, and scapular musculature. In throwing athletes, a progressive throwing program can be initiated after 3 months, directed toward the patients' specific sport and position. The goal of a nonoperative program is to reduce pain, improve motion, and restore strength in patients.

While only level 4 evidence, Edwards et. al surveyed their patients using validated, patient-derived outcome instruments to show that successful nonoperative treatment of isolated superior labral tears results in improved pain relief and functional outcomes compared with pretreatment assessments. Patients in their group with successful nonoperative treatment had significant improvements in pain, function, and quality of life. At an average follow-up of 3.1 years, function improved significantly in those patients with successful nonoperative treatment. Quality of life also improved after treatment. Pain relief was significant, as VAS pain scores decreased from 4.5 to 2.1. All patients with successful nonoperative treatment returned to sports, which was comparable with patients with successful surgical treatment. Seventy-one percent of all athletes were able to return to pre-participation levels, but only 66% of overhead athletes returned to their sport at the same or higher level.

Based on these findings, a trial of nonoperative treatment may be considered in patients with the diagnosis of an isolated superior labral tear. In overhead athletes and in those patients where pain relief and functional improvement is not achieved, surgical treatment should be considered.

Typical indications for surgery are patients who fail conservative management, patients who have a SLAP lesion with significant rotator cuff tears, and patients with large associated labral tears who exhibit severe mechanical symptoms.

Kinsella et al. suggest 3-4 months of dedicated physical therapy before the decision for surgery is reached, and longer if the athlete demonstrates improvement over each successive evaluation.  It is suggested that the majority of throwers, especially younger ones, are able to recover once the biomechanical issues of GIRD and scapular dyskinesis are resolved.  However, if there are mechanical issues such as locking and catching, surgical intervention must be considered.

Kinsella SD, Thomas SJ, Huffman GR, Kelly JD 4th, The thrower's shoulder. Orthop Clin North Am. 2014 Jul;45(3):387-401

Edwards SL, et al. Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life. Am J Sports Med. 2010 Jul;38(7):1456-61

Dodsor, CC, Altchek, DW. Slap lestions: an update on recognition and treatment. J Orthop Sports Phys Ther 2009;39(2): 71-80

Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg. 1998;6:121-131.

Andrews JR, Carson WG. The arthroscopic treatment of glenoid labrum tears in the throwing athlete. Orthop Trans. 1984;8:44.

Dr. Michael Prebeg and Dr. Jennie Gillis

[mikeprebeg]

A current review of platelet rich plasma

Platelet rich plasma (PRP) has been an on going topic of interest in the world of sport rehabilitation. However, is therapy able to live up to its theoretical hype? Or does it fail to elicit a favorable response.

PRP is defined as a sample of autologous blood with supra-physiological concentrations of platelets. A gross simplification of the theory states that once activated, platelets will release active proteins and growth factors. The aforementioned factors theoretically facilitate tissue repair.  The following image displays the potential benefits and drawbacks.

(Image from Current Review of Musculoskeletal Medicine, Micheal J. Mocosa & Scott A. Rodeo)

According to the Chochrane In Clinical Orthopedics and Related Research systematic review and meta-analysis published in 2015, there is no significance attributed to PRP for any short or long-term function. Among several studies, there seems to be a general lack of standardized dosage, concentration of platelets and growth factors. Furthermore, the ideal timing of interventions and kinetics of growth factors requires further research. There is not enough current evidence to justify that PRP will provide clinical benefit for soft tissue injuries.

The Clinical Side by Dr. Mike Prebeg

I have personally received PRP for a torn pec muscle and a torn ACL and I have had many athletes receive PRP treatments from progressive sports doctors in the field.  And I have seen the positive results first hand

Now there are some caveats, as with any intervention when it is applied without a very precise reason or diagnosis.  There is also a huge variance in practitioners (but this is true in every technical skill, even piano players).

I have had numerous cases where I have treated an athlete for a prolonged time and then I send them for a PRP injection in a very specific area and the athlete improves. These results cannot be argued. I would NOT have gotten the results without PRP. In addition, if you have an acute soft tissue injury there is a standard timeline for recovery, however, I have sent athletes for PRP injections and their recovery time is faster.

As with any intervention, when it is NEW it will face a lot of criticism and skepticism, as it should.  BUT you must take the time to understand the basic science behind the intervention.  If the basic science makes sense, the side effects are minimal and/or the benefit out ways the risk, then the intervention may be an appropriate choice.

I work in a field where results matter! If I'm not getting consistently better results then other practitioners then I will not have the access to the patients that I see. I will continue to do whatever it takes to get results and let the researchers figure out the why and the how.

I am confident that researchers will improve their study designs to better measure the proper outcomes and/or look at things differently and then PRP will be more accepted. However, by then the trailblazers in rehabilitation will be onto the next innovative therapy while other therapists will do as they always do, and follow behind.

Khan, M., & Bedi, A. (2015). Cochrane in CORR ®: Platelet-rich Therapies for Musculoskeletal Soft Tissue Injuries (Review). Clinical Orthopaedics and Related Research® Clin Orthop Relat Res, 2207-2213. doi:10.1007/s11999-015-4207-z

Mosca, M., & Rodeo, S. (2015). Platelet-rich plasma for muscle injuries: Game over or time out? Current Reviews in Musculoskeletal Medicine Curr Rev Musculoskelet Med, 145(53), 145-153. doi:10.1007/s12178-015-9259-x.

Dr. Michael Prebeg and Taran Ohson

[mikeprebeg]

Acute knee synovitis: A review

Synovitis occurs when the synovial membrane, which lines and lubricates joints, becomes inflamed.

Symptoms of acute knee synovitis include pain, swelling and stiffness in the knee joint. There will usually be an increased skin temperature and redness over the area, and it is tender to palpation. The patient may have difficulty walking and the knee is often held in slight flexion.

Some degree of synovitis may occur with most knee injuries, however, it is often related to repetitive strain, with the patient recently being exposed to prolonged, repetitive movements of the knee (such as running, climbing or jumping).

*If the symptoms are not obviously activity-related, causes such as infection, allergic reaction, or inflammatory disease should be investigated to rule out underlying conditions causing the synovitis.

The goal of rehabilitation for synovitis is to decrease inflammation and pain to the synovium and affected joint and then to restore range of motion and strength. If the synovitis is caused by injury, immediate treatment is RICE (rest, ice, compression, and elevation) to suppress the inflammation and restore normal joint function. Consideration of anti-inflammatory and pain medication may also be warranted, as well as splinting for part of the day or night to immobilize and support the joint.

Acute, isolated episodes usually respond well to conservative treatment and in most cases the inflammation subsides and the fluid is resorbed without further medical or surgical intervention. If the affected joint is rested properly, synovitis can improve within a few days, but may take up to 8 weeks to fully resolve.

When pain and inflammation have lessened, studies have shown heat modalities and ultrasound may be used to help relieve joint pain and stiffness and to increase blood flow to the synovium to promote healing. Dr. Prebeg has found that acupuncture combined with various soft tissues techniques targeted to the lymphatic drainage channels to be extremely successful with the swelling as well as to restore full range of motion and function.

Patients who do not respond to conservative treatment may need steroid injections in the knee to reduce the swelling. And while this condition rarely requires surgical intervention, when inflammation does not respond to conservative treatment arthroscopic partial or subtotal synovectomy may be considered, but only after other causes have been ruled out and after failure of nonsurgical treatment.

Dr. Michael Prebeg and Dr. Jennie Gillis

[mikeprebeg]

A research review on PCL tears

Most authors recommend nonoperative treatment for acute isolated PCL tears.The key to nonoperative treatment is to control the swelling, instability, and pain. This usually involves initial splinting in extension followed by progressive weight bearing, range-of-motion and strengthening exercises. Recovery of quadriceps strength is necessary to compensate for the posterior tibial subluxation and to facilitate return to pre-injury activity levels.

Overall, rehabilitation for a PCL injury is longer than for an ACL injury. The natural history of sports-related PCL injuries that are treated non-operatively is quite good. In one study, with a mean follow-up of 6.2 years, 80% of patients were satisfied with their knees and 84% had returned to their previous sport (68% at the same level of performance, 16% at a decreased level of performance).

In another study, after completing a proper rehabilitation program, 68% of patients return to their previous level of competitive function.

Another prospective study with a mean follow-up of 5.4 years found that 50% of athletes with isolated posterior laxity returned to the same sport at the same or higher level of performance and that 33% returned to the same sport at a lower level of performance (no patient had greater than grade II injuries). In addition, the grade of laxity noted on physical examination did not change over the course of follow-up, and the grade of laxity did not correlate with radiographic joint-space narrowing.

Another study involving MRI follow-up imaging found that all low-grade and midgrade PCL injuries healed with continuity, and 19 of 22 high-grade injuries healed (4 healed with normal contour; 15 healed with continuity and altered morphology).

In most cases that involve less severe PCL tears, patients are recommended to undergo conservative therapy with a progressive rehabilitation program. However, if the patient continues to experience chronic pain and instability despite therapy and functional bracing, a PCL reconstruction may be required. One study found that operative intervention was required in 42% of patients at some point.

In isolated PCL tears, surgery is usually only done for acute bone avulsions, symptomatic chronic high-grade PCL tears, and when in combination with other ligament injuries.

In terms of surgical treatment, it's usually done arthroscopically.  A single-tunnel reconstruction improves posterior laxity only moderately. Double-tunnel and tibial-inlay techniques have theoretical advantages, but the available clinical results are only preliminary.

So... there isn't a lot of prospective long-term follow-up studies comparing operative versus nonoperative outcomes. The results of operative reconstruction are variable and may be no better than nonoperative treatment. Single bundle PCL reconstruction reduces posterior tibial translation significantly, but it cannot restore the kinematics of the knee.

Dr. Michael Prebeg and Dr. Jennie Gillis

[mikeprebeg]

After recovering from surgery to treat avascular necrosis of the hip and an extensive rehab, NHL goalie Ray Emery went on to win the Stanley Cup with the Chicago Blackhawks in 2013.

[mikeprebeg]

Electro-acupuncture input for bar room fracture to help neuro-modulate interdigital nerve.

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Going over a hip exam to help design a treatment plan with predictive outcomes

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