Elliot M. Greenberg

Evaluation and Management of Scapular Dysfunction

The scapula plays an important role in shoulder function and requires both significant mobility and stability. Normal motion is 3-dimensional, and during arm elevation consists of upward rotation, posterior tilting, and external rotation as well as clavicular elevation and retraction. Examination should include visual observation, symptom alterations tests, testing of muscle strength, and flexibility of key structures including the pectoralis minor, posterior shoulder and thoracic spine. Treatment consists of graded resistive exercise, neuromuscular retraining, stretching, manual therapy, and taping where necessary. Although several studies suggest a relationship between abnormal scapular motion and symptoms, strong evidence directly supporting a causal relationship is lacking and further work is necessary to clarify this relationship.

Strength and Functional Performance Recovery After Anterior Cruciate Ligament Reconstruction in Preadolescent Athletes

Background: In the skeletally immature population, the incidence of anterior cruciate ligament (ACL) injuries and ACL reconstructions appears to be increasing. Differences in surgical techniques, physiology, and emotional maturity may alter the rehabilitation progression and impact the outcomes when compared with adults. Reports of objective strength recovery and performance-based outcome measures after pediatric ACL reconstruction (ACLR) are limited. Study Design: Retrospective case series. Level of Evidence: Level 4. Methods: All patients that underwent all-epiphyseal ACLR from January 2008 to August 2010 were identified. Isokinetic peak quadriceps/hamstring torque values and functional performance measures in unilateral hopping tasks were extracted and compared with the noninjured limb. A limb symmetry index (LSI) of ≥90% was considered satisfactory. Results: Complete data were available for 16 patients (mean age, 12.28 years; range, 8.51-14.88 years). By a mean 7 months (range, 3.02-12.56 years) postoperatively, only 9 of 16 (56%) were able to achieve a satisfactory LSI for quadriceps strength. For hamstring strength, 15 of 16 (94%) were able to achieve satisfactory LSI. By a mean of 12 months (range, 5.39-24.39 months) postoperatively, only 6 of 16 subjects (38%) were able to achieve satisfactory performance on all functional hop tests. At a mean 15.42 months (range, 8.58-24.39 months) postsurgery, only 4 of 16 (25%) subjects were able to achieve an LSI of ≥90% on all testing parameters. Conclusion: For some pediatric patients, significant strength and functional deficits may be present at greater than 1 year after ACLR. This population may require more prolonged rehabilitation programs to allow for adequate recovery of strength and function because of unique characteristics of normal growth and development.

Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review.

Background: Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric‐specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: “prehabilitation” (exercises prior to surgery), bracing, weight‐bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return‐to‐sport criteria, and suggested ACL injury‐prevention programs. Results: Two hundred and two unique articles were identified. Twenty‐seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight‐bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return‐to‐sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury‐prevention plan described a formal prevention program. Conclusion: We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric‐specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone‐based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re‐rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return‐to‐sport criteria for young patients.

The Development of Humeral Retrotorsion and Its Relationship to Throwing Sports

Context: Several investigations have noted that throwing athletes exhibit a more posteriorly oriented humeral head (humeral retrotorsion) in the dominant arm. This asymmetry is believed to represent an adaptive response to the stress of throwing that occurs during childhood. The significance of this alteration and factors that affect its development are currently not clear. Evidence Acquisition: Basic science, research studies, and review articles were searched through PubMed with search terms including humeral torsion, humeral retrotorsion, and with 1 of the following: pediatric, adult, baseball, pitching, shoulder, and range of motion. The references from each article were reviewed for further inclusion. This review included articles through March 2015. Study Design: Clinical review. Level of Evidence: Level 4. Results: The throwing motion creates stressors that result in bony adaptations that occur while skeletally immature. These osseous changes likely contribute to the observed shift in the arc of rotational range of motion noted in throwing athletes and may play a protective role against injury. However, too much or too little retrotorsion may predispose the shoulder to injury. The degree of “optimal” humeral retrotorsion and factors that influence its development are not fully understood. Conclusion: Evidence supports the assertion that the throwing motion creates stressors that alter bony anatomy while young. It is important to determine what specific factors affect this adaptation and its relationship to injury.

Humeral Retrotorsion and Glenohumeral Motion in Youth Baseball Players Compared With Age-Matched Nonthrowing Athletes.

Background: Baseball players exhibit a more posteriorly oriented humeral head in their throwing arm. This is termed humeral retrotorsion (HRT) and likely represents a response to the stress of throwing. This adaptation is thought to occur while the athlete is skeletally immature, however currently there is limited research detailing how throwing activity in younger players influences the development of HRT. In addition, it is presently unclear how this changing osseous orientation may influence shoulder motion within young athletes. Purpose: To determine the influence of throwing activity and age on the development of side-to-side asymmetry in HRT and shoulder range of motion (ROM). Study Design: Cross-sectional study; Level of evidence, 3. Methods: Healthy athletes (age range, 8-14 years) were categorized into 2 groups based upon sports participation; throwers (n = 85) and nonthrowers (n = 68). Bilateral measurements of HRT, shoulder external rotation (ER), internal rotation (IR), and total range of motion (TROM) at 90° were performed using diagnostic ultrasound and a digital inclinometer. Side-to-side asymmetry (dominant minus nondominant side) in HRT and in shoulder ER, IR, and TROM were assessed. Statistical analysis was performed with 2-way analysis of variance and Pearson correlation coefficients. Results: Throwers demonstrated a larger degree of HRT on the dominant side, resulting in greater asymmetry compared with nonthrowers (8.7° vs 4.8°). Throwers demonstrated a gain of ER (5.1°), a loss of IR (6.0°), and no change in TROM when compared with the nondominant shoulder. Pairwise comparisons identified altered HRT and shoulder ROM in all age groups, including the youngest throwers (age range, 8-10.5 years). A positive correlation existed between HRT and ER ROM that was stronger in nonthrowers (r = 0.63) than in throwers (r = 0.23), while a negative correlation existed with IR that was stronger in throwers (r = −0.40) than in nonthrowers (r = −0.27). Conclusion: Throwing activity causes adaptive changes in HRT and shoulder ROM in youth baseball players at an early age. Other factors in addition to HRT influence shoulder motion within this population.

Physical and Functional Differences in Youth Baseball Players With and Without Throwing-Related Pain:

Background: Identifying risk factors that contribute to shoulder and elbow pain within youth baseball players is important for improving injury prevention and rehabilitation strategies. Hypothesis: Differences will exist between youth baseball players with and without a history of upper extremity pain on measures related to growth, shoulder performance, and baseball exposure. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 84 youth baseball players were divided into 2 groups based on self-reported history of throwing-related arm pain. Group differences for growth-related, shoulder performance, and baseball exposure variables were analyzed by use of parametric and nonparametric tests, as appropriate. Multivariate logistic regression was used to assess variables most predictive of pain. Results: The group of athletes with pain (n = 16) were taller and heavier, played more baseball per year, and had greater pitching velocity. Athletes with pain also had greater loss of internal rotation range of motion and greater side-to-side asymmetry in humeral retrotorsion (HRT), attributable to lower degrees of HRT within the nondominant humerus. Multivariate analysis revealed that player height was most predictive of pain, with a 1-inch increase in height resulting in a 77% increased risk of pain. Conclusion: Vertical growth that accompanies adolescence increases the risk of experiencing throwing-related pain in youth baseball players. Players who are taller, particularly those with faster pitching velocities, are at the greatest risk for developing pain and should be more carefully monitored for resultant injury. The degree of nondominant HRT may have a relationship to the development of pain, but further research is required to better understand the implications of this observation.

Changes in humeral retrotorsion and the development of little league shoulder: A case study

OBJECTIVE To present the case of a 15 year-old baseball player with Little League Shoulder (LLS) and describe how developmental changes in the angle of humeral retrotorsion (HRT) may contribute to the underlying pathology of this condition. DESIGN Case report. SETTING Two years earlier, the patient had participated in a healthy player screening program at which time measurements of height, weight, shoulder motion, and HRT were obtained. These same measures were obtained during the initial evaluation after injury. Between measurements, the patient grew more than 12 cm in height and demonstrated a large shift in proximal humeral torsional alignment with a change of 13° and 19° of HRT in the dominant and non-dominant sides respectively. PARTICIPANT 15 year-old male (1.88 m, 79.8 kg), right hand dominant baseball pitcher and 3rd baseman diagnosed with right LLS. CONCLUSION The pathoanatomical factors contributing to LLS are not well understood. The degree of HRT is a developmental characteristic that changes over the course of physiological maturation. The large changes in HRT seen in this case, may implicate rapid changes in HRT angle create a window of increased susceptibility to physeal damage, and contribute to the development of LLS.

Rehabilitation Practice Patterns Following Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists

BACKGROUND: Recovery from anterior cruciate ligament reconstruction (ACLR) requires an intensive course of postoperative rehabilitation. Although guidelines outlining evidence‐based rehabilitation recommendations have been published, actual practice patterns of physical therapists are unknown. OBJECTIVES: To analyze the current landscape of clinical practice as it pertains to rehabilitation progression and the use of time and objective criteria in rehabilitation following ACLR. METHODS: In this cross‐sectional study, an online survey was distributed to members of the Academy of Orthopaedic Physical Therapy, the American Academy of Sports Physical Therapy, and the Private Practice Section of the American Physical Therapy Association between January and March 2017. RESULTS: The study analyzed a sample of 1074 responses. Supervised physical therapy was reported to last 5 months or less by 56% of survey respondents. The most frequent time frames for activity progression were 3 to 4 months (58%) for jogging, 4 to 5 months (50%) for modified sports activity, and 9 to 12 months (40%) for unrestricted sports participation. More than 80% of respondents reported using strength and functional measures during rehabilitation. Of those physical therapists who assessed strength, 56% used manual muscle testing as their only means of strength testing. Single‐limb hop testing (89%) was the most frequently reported measure used to allow patients to begin modified sports activity following ACLR. Performance criteria for strength and functional tests varied significantly across all phases of rehabilitation. The 45% of respondents who reported using patient‐reported outcome measures indicated that just under 10% of those measures involved fear or athletic confidence scales. CONCLUSION: Considerable variation in practice exists among American Physical Therapy Association members regarding rehabilitation following ACLR. This variability in practice may contribute to suboptimal outcomes and confusion among practitioners and patients.

Differential Diagnosis of a Pathological Spine Fracture

A 71-year-old woman with a 10-month history of atraumatic low back pain was referred to physical therapy after an insidious exacerbation of symptoms. Red flags raised suspicions for spinal compression fracture, necessitating the physical therapist to contact her physician and recommend imaging. Radiographs and magnetic resonance imaging were ordered, the latter of which showed an acute fracture at T10, with lesions at T9 and in the liver suggesting metastasis. Following bone scintigraphy and an ultrasound-guided biopsy of a liver lesion, she was diagnosed with metastatic breast cancer. J Orthop Sports Phys Ther 2018;48(7):595. doi:10.2519/jospt.2018.7768.