The session today, we're going to discuss the topic of return to sport after injury. We're going to share a practical approach to the decision-making process. My name is Gerardo Miranda. I'm a faculty at the University of Puerto Rico and Mount Sinai in New York. I have no relevant financial disclosures. The outline of the whole session, I'm just going to present two cases. We're going to go and do an overview of the return to sport continuum. Then Dr. William Michero will talk about return to sport after injury, include clinical evaluation, psychological assessment, strength and functional testing. And then we're going to try to put everything together in the discussion of those cases that I mentioned. So as objectives, hopefully we'll be able to discuss these concepts after this, apply a practical approach to this decision-making process, and understand our role as physicians, as rehabilitation physicians in the medical team during this process as well. Number one, we're going to keep in mind this is a first case, a 35-year-old man, a recreational basketball player who suffers a knee injury. He was diagnosed with an ACL tear. His MRI had bone contusion in the lateral condyle and lateral tibia. The meniscus were intact. We're going to consider several factors to keep in mind. Does this person require surgery immediately? What are the factors that can predict a good return to sport or risk of recurring injury? What criteria can we use to determine when this individual can return to their activity and when they should return to their activity? Number two, we're going to discuss a right-handed baseball player with right shoulder pain. There was no acute trauma, worse after throwing, better with rest. This is an insidious onset pain, located in the posterior glenoma joint, worse with shoulder abduction and external rotation, so sort of like in the throwing motion in the cocking, early cocking, late cocking phase. He was diagnosed with a labral injury. Again, does this individual need non-surgical or surgical treatment? What are the intrinsic and extrinsic risk factors that led to this injury that need to be assessed during the rehabilitation process? What criteria should we use to allow this individual to return to their activity and when this individual should return to their activity? Initially, we were going to discuss a running injury. The data and the evidence available for return to sport to really evaluate these concepts, we chose more of a shoulder injury and a post-surgical injury just because there's better evidence for us to show you guys and understand the concept a little better. Now, we're going to go to a couple of slides to just review the concept of the return to sport continuum. A big question, right? When we have an injured individual, whether it's in the field, practice, recreational, the first question somebody's going to ask, when are they going to be able to do their activity again? This is a question that is not easy to answer. You're going to see that we might not. There's multiple factors that need to be considered, and that's what we're going to try to get to. In 2016, there was a consensus in the Sports Physical Therapy World Congress that has a lot of renowned, mostly physical therapists, worldwide renowned individuals who came together and put some of these concepts for us to understand a little better. This is a good resource to read, to review this, everything that we're going to discuss. The return to sport continuum is termed continuum because it starts from the moment that the person gets hurt. It's not a decision to be taken in isolation at the end of the recovery or the rehabilitation process. It should be something that starts early on, so that there's an injury, there's treatment, we start with the rehab. We go through different phases, and there are different players, different providers that can be, that have different roles throughout this continuum. And the rehabilitation process should overlap a little bit with the return to sport, including the, so we have our rehab phases that Dr. Michaud is going to go a little bit more in depth into them. Then we have, in the bottom, the OFR, which is on-field rehabilitation, so we translate from our rehab in the office, we translate that into the field. Then we have RTT, which is return to training, then we have return to competition, and then hopefully we go to return to performance, which is what's added in this consensus, is that we want our patients not to get back to their same level, hopefully we get them to a higher level. And this should be parallel, the return to sport decision-making process should be parallel with the rehabilitation process. We should be able, we should document from the beginning, and very important, define the roles and responsibilities of each individual in this process, and who are those individuals, right? So we call it a shared decision-making process, because it should be shared between different players. There are different stakeholders. The main stakeholders is going to be the athlete, who can provide, their contribution is going to be more subjective, how they feel, mental readiness, how they feel physically. The healthcare professional, our main contribution is going to be objective, so evaluation, physical exam, functional data, health status. And then we have a third player that sometimes is the coach, it might be family, it might be at different levels, owners, athletic director, management of organizations. When can we get out of this shared decision-making process? Whenever there's a health risk to the athlete, right? A good example of this are concussions, for example, right? So that's when we can make the decision to take somebody out and not allow them to come back depending on the injury. So how do we determine when somebody is ready to return to play? So the big question is physical readiness, physical recovery enough? The answer is no. There's going to be multiple other factors that can be, that play into this. For us as a clinician, maybe our biggest role is to understand the injury, understand the injury pathophysiology, especially tissue healing, time, mechanism, function, and that can separate us a little bit from other providers in the medical team. General factors to consider. So clinical factors, and maybe this is where we might be more skilled. Talking about pain, swelling, range of motion, then we talk about functional status, and that can be evaluated with functional maximal strength, functional tests, biomechanical evaluation, psychological, right? So psychological plays a big role. Mental readiness. That's a concept that maybe 15 years ago when I did my education, we did not talk about it as much as we do now, and maybe we don't have as many tools as we have now. And this is important. In terms of injury, we talk about fear of injury, and then mental readiness, psychological attitudes towards getting back to the sport. And then any sport-specific issues, right? Being able to tolerate the training load, being able to tolerate the psychological load that the sport is going to undertake on the individual. And here in this area, the sport-specific goes beyond just that. It goes beyond the factors of readiness of the individual. We have to assess the time of the season, what type of season, the level of play, all those things. And that, we're going to go more in depth in this guide. So guides to the return to sport process. There are different models that have been described. I personally use very frequently the first one, the START framework, or strategic assessment of risk and risk tolerance, and we're going to go more in depth. But there's other proposed models like evidence-based model, a psychosocial model, and optimal loading. The reality is that the factors that are described in each of these guides, they overlap so much that at the end of the day, we use a little bit of every single one of them. So this model, this is a good diagram to have, to have the reference. The reference is down. This was published in 2010. So this decision-making-based return to play model, what it does is evaluates the risk, right? So we have step one. Step one, we evaluate the health status. So the health status means patient demographics, symptoms, medical history, their functional testing, their psychological state and mental readiness, and the seriousness of the injury. So this is pretty much our, sort of like our office-based evaluation and more of a medical history and physical exam. Then we evaluate the risk of participation. That's when the type of sport comes into play. What position does the individual play? Is the individual higher risk because they're a running back versus if they are a kicker? The limb dominance, right? Competitive level and the ability to protect the injury. So those are risk evaluation, part of the risk evaluation. Then we have the risk modifier. So the step three is the timing of the season, the pressure from the athlete, external pressure, conflict of interest, right? This goes into financial interest and fear of litigation, that all those come into play in our decision. And we put all that together to decide when the individual can return to play. There's other ways to look at it. For example, evidence-based practice. We have three big players, the clinician, patient, and the evidence that's available. And everything overlaps. What's more, what has a little bit better evidence in terms of factors to consider include the physical exam, the injury prevention, so the ability to protect the injured area, the symptoms, and injury medical history. So prior injury increases the risk of further injury. And those are factors that can be considered or should be considered a little bit more than other ones. We have the biopsychosocial model where we have injury characteristics and social demographic factors as the two main factors that are going to affect physical factors, psychological factors, social contextual factors that are going to affect performance and interchangeably. And that will lead to our return to sport decision. And lastly, the optimal loading. This is a topic that load management is something that has been discussed more as in prevention of injury rather than in the return to sport continuum. But it should be part of our rehabilitation and our decision. So there are different ways to look at it. So how much can we load a tissue when we are planning that return to sport? So it's going to vary. There's a general rule that people talk about a 10%. How much do we increase the load that it should be increased 10% weekly. However, depending on the time of season, depending on the stress that the individual needs to put in the injured tissue is where you should start or whether that 10% applies or not. For example, somebody who starts way low in the middle of the season and their fitness level needs to be a little bit higher, they might be starting too low. And they never reach that at least floor of safety that they need to reach. And there's going to be people that are going to load a little bit higher and they're going to go through the roof and increase their risk of injury. Another way to look at load management or optimal load is looking at the acute and chronic workload ratio. This is measuring the load in different ways, measuring volume, measuring intensity on a weekly basis and averaging that out in four weeks and making sure that that ratio does not go beyond 1.5, 1.8 because that increases the risk of injury. And that's one of the things that we really want to make sure that doesn't happen. So in my part, this is a very brief summary of a very complex topic. The time to return to sport will vary. So we are getting away a little bit more from time-based criteria and more to goal-oriented criteria or in terms of making decisions of advancing somebody in their rehabilitation process and their return to sport decision. We are constantly, during this process, we are constantly assessing, sort of like that start framework as to how aggressive can we be, how slow we should go, how the tissue is doing. So we take multiple factors into consideration and that hopefully will go more into depth next. Those are my references. Good morning. Thank you, Jerry. That was an excellent, excellent overview of the difficult topic. Could we have the next talk, please? Thank you. A few brave people here after sauerkraut and schnitzels last night. We thank you for coming. As Dr. Miranda said, I'm Dr. Micheo. I am chair of the Department of Physical Medicine, Rehab, and Sports Medicine at the University of Puerto Rico, and I direct the sports medicine program there for the last 11 years. I'm a recent graduate, 1985, so I've been in practice quite a bit. I have no conflicts of interest that would affect this presentation. My objectives for this talk is first allowing time for discussion in the cases, but I want to review a few things. I want to review how to determine physical readiness prior to allowing an athlete or an individual to return to play or to activity. You could use the same concepts for any injured individual that goes back to activity. Present how psychologic factors affect this process, and how you as a clinician could assess these factors in the clinic, and at the end, I'm going to discuss the role of strength and functional testing in this process. We have at our center an exercise physiology component, and we've been doing functional and exercise testing for many years, and we have some data that we've been looking at for the last 20 years at least. So the first thing that you need to know as a clinician in allowing an individual to return to sports or activity is has he completed a rehabilitation process? This has bio, injury, psychologic, readiness, and social components such as age of the athlete, level of competition, timing of the injury, timing of stage of the season. All these things affect your decision process in these individuals. What are the goals of rehab that we should look at prior to allowing an athlete going to competition? Is the tissue healed? Can the athlete return to sports in a timely manner based on all the factors that we're going to assess? Can we understand that the athlete is ready and injury can be prevented going forward, and can he achieve high level of performance, which at the end of the day is what the athlete wants? The programs typically consist of three phases. In our institution, we use a three-phase model, an acute phase, a recovery, and a functional phase. Other programs you'll see have up to five phases. We have over time added this fourth return to sports phase, and the key point of this slide is that the longest period that the athlete will be following injury will be in this return to training, transitioning to sports that Dr. Miranda mentioned. Many of these will be out of your clinical realm, so they'll be out of the therapy gym. So we need to have a follow-up plan for athletes. Once they complete the rehab under your supervision, how are we going to interact with training and fitness professionals to make sure that the athlete is ready for when you assess this return to sports? So that's a key point. So this fourth phase of the program should be added, and you should be in charge of that, getting information, and you should assess the patient frequently. So we, after we discharge patients from clinic, we'll see them every four to six weeks prior to allowing them to going back to competition. Second concept, you need to make sure that you have a complete assessment of the athlete, not only the injured side. So let's say for the ACL, symptoms that we look that will be problematic for the athlete going back to athletics is recurrent pain with activity, swelling, which means there's some intra-ventricular issues, and the feeling of instability. So these symptoms are problematic for us. For the athlete with shoulder injury, having pain with overhead activity, pain at rest, pain following activity, those are things that we look that tell us the athlete may not be ready to go through. So this process will allow you to have the athlete go forward, but it also allows you to say, you are not ready. You got to step back, go back to rehab, and these are the deficits you need to assess. Second thing is, what is the primary tissue injury? For ACL injury, we know that the ligament is the main side of injury, but also there are secondary players that we need to be sure that we're protecting the articular cartilage, the menisci. So these are things that we need to understand, that the athlete that goes back too quick can injure other parts of the knee or the shoulder that would affect his long-term, not only performance, but long-term articular health. So that's an important component. What tissues are overloaded? The kinetic chain is a key component here. So we know that athletes with knee injury will have weak or overloaded gluteal muscles, weak core muscles. Post-tib is also an area that we look closely to make sure that the ankle-foot component is functional well. And finally, what are the functional alterations? As rehabilitation sports medicine physicians, we need to understand function. What is happening here? Why can't the athlete jump? Why can't the athlete move? Is it a component of neuromuscular control or weakness or lack of training? And finally, what are the performance changes that we need to address by having interaction with the coaching professionals that work with this athlete? That's the second point. The third point is, we should understand a rehabilitation model. This is based on the ICF, the International Classification of Function. This substitutes a prior disability and impairment and handicap model. So we, as rehab doctors and sports medicine professionals, we may see an athlete with a heel fractured or the ACL x-rays and MRI look well, but they still have weakness, contracture, neuromuscular imbalances. So our impairment, we need to address with our rehabilitation. Then we have to see why is the athlete still limited in his activity and why he is not going back to participation or participation restriction. So yesterday they had an interesting session on the shoulder and all the experts there said that the MRI is not needed to treat the patients, but all of them got MRIs because the MRI may give you false information about what's happening with the patients. Anyway, third thing that we mentioned is understanding the phases of rehab. The phases of rehab in the acute phase is the inflammatory process. We're protecting and healing tissue. In the recovery phase, we're working on strength, flexibility, mobility, and neuromuscular control. And finally, at the end of rehab, we should be acting actively on a sport-specific neuromuscular control, sport-specific related activities. And these are the things that we need to ask in our history and we make sure that as we follow our patients along, we document on our clinical notes that they're progressing through all these three phases. As Dr. Miranda said, rehabilitation has changed from a time-based model to a goal and criteria-based model. That doesn't mean we don't take into account how long does it take for a fracture to heal, the ligament to heal, the ligament to incorporate into bone, all these factors we need to know as clinicians, but that is not the primary factor in allowing the patient to going back to play. What about the return to sports progression? And this certainly overlaps with a clinical assessment and as Dr. Miranda mentioned, we are looking more and more to integrate the fitness component into our management. Sometimes it's very difficult because these areas are not under our control, but we need to work in our community to identify professionals that will work with the athlete in sport-specific training outside the therapy gym, following recommendations for protection of the athlete. Many times the athlete feels better than the tissue allows him to go back to. So the concept of tissue healing is the last one that we will do prior to the assessment. So we know that, for example, for the ACL, it takes six weeks for the bone patellar tendon, bone graft to incorporate into bone. That's the first thing that we keep in mind for not allowing resisted extension exercises for six weeks at least. We know that it takes about a year to 14 months to the ligament to heal. So many athletes feel better at five to six months, but their ligament is still no heal. So we know that in younger patients, they may even worse. So what information do we give your patients based on this? So we tell an adult athlete that he probably won't be able to go back to sports prior to nine months because there's good literature showing that prior to that, the risk of re-injury is very high. And for younger athletes, we tell them at least a year prior to they go back to sports. It has been reported at about 20% to 30% recurrent rate in athletes that are young that go back to sports prior to one year. And if you go back to sports prior to six months, about a 50% failure rate or recurrent rate. And the key point about recurrence is that many athletes injure the opposite knee. So we know that there's a slightly higher risk of injury to the opposite knee than the operated knee if you go back to sports early. So that's a lot of information to give your patients. So how do we determine in the clinic physical readiness? So it's determined by a combination of objective and subjective components or factors. As anything in medicine, it should include a complete history, physical examination. And as rehab doctors, we need to incorporate a simple functional assessment that I'll show you how we do it in our system. And we have the advantage of having objective testing in our center, so we do isokinetic testing. And we also do supervised objective, which means hop tests and running tests in our exercise physiology facility. An issue that you may have as clinicians, you may not have access to some of these advanced testing procedures. So you need to be clear in your clinical assessment when you allow the athlete to go back. So how do we do that? First, history, key components. Pain at rest during activity or following activity is something that would not allow the athlete to progress in the return to sports continuum. Swelling during or following activity is one of the things that you need to look at. I mean, the subjective feeling of swelling is different than you assessing an athlete and finding that it has a knee effusion. So if somebody's getting knee effusions, and our athletes who are progressing well, in the initial stages of rehab may have knee effusions, and that is something that we use as a guide of stepping back a little bit on the training. So instead of doing five days a week of running, we'll cut them back to three, do biking, do swimming, do other things, and follow the health of the knee. So those patients we would follow much closer, being maybe two to four weeks assessment instead of six to eight weeks assessment. Feeling of instability, which is subjective, but this needs to be also followed by a good clinical exam on the status of the ligament and the healing of the ligament, and athlete unable to perform sport-specific tasks. We've had athletes that we treat for ACL injury without surgery because they're at a higher age, they're at a higher stage. We had an athlete who was competing for the Olympics, and he tore his ACL about six months prior to the Olympics, and this is a dream for any athlete. So if you operated that athlete, he would not be able to go to the Olympics. So this athlete progressed well in all three phases of rehab, but he got to the fourth phase, returned to sports. He was a taekwondo athlete. Every time he jumped, he felt subjectively unstable, so he was not able to go to the Olympics. We had a second case. This was a judo athlete. He was close to 30 years of age, tore his ACL, isolated injury, no meniscal tear, progressed well in rehab. He had nine months prior to the Central American Games, so he progressed, and he was able to get a bronze medal. Different sport, less jumping, older athlete, shorter career. Adult athlete can make a decision. It would not apply the same for maybe a 17-, 18-year-old athlete. That athlete, you would say, no, we got to protect your knee. You need surgery. You need to recover, take a year off. Physical examination. Same components we use for all our patients. Normal flexibility and motion, particularly knee extension, is something we need to address. We know that if you don't achieve full knee extension, the risk of OA post-ACL surgery is high, so we need to address full extension. But flexion is also something that needs to be clearly addressed. Normal isolated strength of affected muscles. We know that if you don't address specifically the quads and the gluteal muscles and use multi-joint exercise, such as closed kinetic chain exercises, those muscles may stay inhibited for years. So that's a key component. Then we need to incorporate those muscles into the kinetic chain. Normal strength of proximal and distal muscles. Tests both in isolation and in functional activities. And stable joints in special tests. So the test model that we use is we use Lachman's test to look for the ligament injury is the most specific test for knee injury, and we use the lateral pivot shift for specificity. So we find somebody that is pivoting and following either surgery or following injury, that tells me that maybe the ligament is still loose and we need to do more work with that athlete or the ligament has failed. So we use a very thorough exam on these patients for prior to diagnosis, during diagnosis, and for follow-up. During the examination, we'll not injure the operated ligament. So you could examine the patient. The forces that you apply are much lower than those forces that would receive in sports, so you're doing a test for ligament laxity following surgery, would not injure the ligament. What about clinical functional testing? And this is something that we have evolved through the years. So in our system, in the early stages, we do single leg stance for balance. I know how many of you have read this new literature saying that if you can stand in one leg for 10 seconds, your life expectancy is higher. It was published recently, and so we use a simple, we do single leg stance, then we do single leg squats. We then do step down from a bench. Those are for individual limbs. We do jump landing on two legs. Then we progress to jump landing. We jump in two legs and land in one leg. And finally, we do jump landing with somebody throwing you a ball or switching directions. It's something you could do. So how do we decide to progress? So if somebody cannot do single leg stance, I don't progress to single leg squats. So if you do single leg stance, single leg squats, then we do step down. So once you progress to that in my clinic, then you keep doing more advanced. So at the end, when I send somebody for functional testing, they already have passed all these in my clinical assessment. It's very simple. So you just look at the patient, and I'll show you. So when you do a single leg squat, you got to make sure that your trunk is aligned. You don't have lateral trunk lean. That your knee is aligned with your second metatarsal. Second toe is not lateral, or it's not going into valgus. Okay? And you have to look for the ankle foot that doesn't collapse. And that's something that you look at. Trendelenburg, knee valgus, foot collapse. Those are the three things you look for. And then when you do landing mechanics on two knees, you got to make sure that the knee doesn't collapse into valgus, is aligned with the second toe. And the most important thing, if you ask a young athlete to jump and land, most of them land with extended knees. They need to land softly in the ball of the feet with the knee flex. So that center photo is the correct way to land from jumping. And that's probably the most important key component that we need to address in rehab. Landing and running mechanics for these young athletes. The next step, after doing our assessment, the patient has no swelling, no pain, full motion, stable lachman's, clinical exam, and then functional exam, we do isokinetic and functional testing. We may do the isokinetic testing at two stages. We do it around six months to allow return to training. And then we do it between nine to 12 months to allow return to sports participation. Isokinetic testing uses velocity-limited isokinetic dynamometers that measure peak torque at different velocities. We use 60 degrees per second and 180 degrees per second. Those are the most commonly used concentric isokinetic tests. A caveat is that the velocity that we can reproduce with isokinetic testing is much lower than the velocities that are required for sports. So this is a proxy for knee, quads and ham strength, but it's not necessarily a proxy for function. So that's why people have moved to add additional testing, not just the isokinetic testing. So what do you do? We know that the hamstrings are somewhat weaker than the quads, about 20 to 30%. So we use hamstring over quads ratio, compare that to the opposite knee. So we do ipsilateral hamstring quads ratios, and then we compare the quads to the opposite knee and the hamstrings to the opposite knee. So that's called the limb symmetry index. So if you operated leg is 50% weaker than the opposite side, you fail the test. If you operate leg is 85 to 90% of peak torque compared to the opposite leg, you may pass a test depending on the stage. Some people would like 100% symmetry, which is many times not achieved. So this test requires that the athlete puts maximal effort so he should not have pain, one point. And the second key point is many athletes don't train in the gym doing leg extensions anymore. So if you're gonna do a test that's specific for leg extension or leg flexion, you should have your athletes train with this type of exercise prior to doing the test. If not, they will fail the test. So we get a lot of patients refer to our center for decision to return to play. First thing I ask them, have you been to the gym? No, I have not. I'm just doing bicycle running and exercises at home. So I say, you should not be tested. You should go back to the gym for six weeks, come back, and then we'll do this test because you're not ready to go back to sports, okay? That's important. Next component is what we call functional testing. And functional testing here has a combination of jumping vertically or horizontally or in the transfer plane from side to side. We use five tests in our center. We use vertical and transverse plane hopping, single hop, three hops, and then we do transverse plane hopping and we do a T-test. And I'll show you a photo of that. And it's, sorry, because it's somewhat mobile. You see in the left side is a single leg hop for distance. You do that with the operated leg and the non-operated leg. And then you apply a limb symmetry index for the distance. So if somebody jumps three feet versus four feet, you put three feet over four feet and divide it. And that's your limb symmetry index, okay? The second one is we do a single leg time hop, six meters. Then we do a single triple leg hop and compare it to the other side. And we do the crossover hop. Of these four tests, we find that the crossover hop is the more difficult one for athletes when they have to jump from side to side on a single leg. And they tend to fail that the most. And then we do this T-test where you run straight, then you run side to side, and then you run backwards. And that's a time-based measurement. So you measure in seconds how many seconds it takes, and then you compare the athlete to a normative data. So what are the evidence, what is the evidence for strength and functional testing? And this is very important. This could be done preoperatively. We know that 20% deficit of the quad's strength prior to surgery predicts functional outcome at two years. That's good evidence for that. We know that postoperative strength deficits correlate with higher risk of reinjury and not returning to same level of performance. This is something we could discuss when we do the case. Not passing functional tests is associated to higher risk of fracture or rupture and contralateral injury. And a high number of athletes at a year do not meet this criteria. So if you apply strict criteria, and I see patients that I still see at 18 months, younger athletes who are not passing this criteria. Sometimes it's very frustrating for the athlete, extremely frustrating for the orthopedic surgeon, which many still use time-based criteria. And they say, I went to my orthopedic surgeon and said I could go back to sports, and I said, you know, quads atrophy, cannot stand on single limb, cannot jump, but the ACL graft is healed clinically. So this is something that's frustrating. And so you have to have good communication with the referring physician, have them understand this is not something that you did poorly with your surgery. It's because it's been documented that many young athletes take up to two years to get. There's a good editorial by Tim Hewitt, who's like a legend in rehab testing, and he has written this editorial saying, should we wait two years for young athletes to go back because of the high risk of re-injury in that population? So what are the limitations for functional testing? And a lot of people do criticize this testing. Detraining effect for the opposite limb, so you may have a weaker limb on the other side, so you may get false negatives. Neurogenic inhibition of the other limb, so you may still have false negative. Limited attention in testing for proximal and distal muscles. The athlete may manipulate test performance with the opposite limb to get a better result. That, not that common. And there's a small number of studies in very young patients that get this injury. So what do we do with that? So we have some normative data for populations of athletes, and use those as the numbers we use for comparison. So if I have an athlete who looks clinically weak, and then does very well in the test, we apply normative data, and we find that many of these athletes fail compared to normative data that has been published. Quickly about psychologic readiness, which is the last portion of the lecture. Psychologic readiness is certainly one criteria, although we're not psychologists, we deal with psychosocial aspects of function every day. There's some reactions that you could identify in the athletes, lack of confidence and apprehension. Fear, re-injury, what's called kinesiophobia, or inability to return to previous level of activity. Isolated athletes who are team athletes feel isolated, they feel that the medical team is not helping them to go back. And abnormal pain responses. So these we could identify different processes in the rehabilitation. And these are examples of what you could look in your history. I cannot play, I will lose my spot on the team. I will do twice as much if I get quicker. Are you doctors, you're terrible. I've been 10 months, I'm still here, you know. The father comes in, the mother comes in. What are you doing with my son? I mean, I thought you had a good rehab program here. What's happening? I said, well, I give them all this long talk and they think I'm smart, but they're still not happy. So who do we refer for assessment, for psychological assessment? So we do have a sports psychology in our center. So we have people who have high levels of pain and not progressing treatment, muscle inhibition, fear of re-injury. So anybody who's slowly progressing in rehab, and this may be an issue, we do get psychological help for those athletes early on in the process. That is prior to the return to decision or sports. And internal or outside pressures is something that we get very frequently in athlete. What tools do you have as a clinician? Well, there are some scales. There's one called the ACL-RSI, which is ACL Injury Return to Sports After Injury Scale. It's been very well published and it tells you who can and cannot go back better than physical examination. Individuals' positive psychological responses go back. Those who perceive knee-related quality of life to be high and were satisfied with the knee function, those go back. And as recent as two days ago, I saw the publication that said that reasons for not returning in a large cohort of patients were not physical, were not trusting their knee, fear of new injury, and perceived poor knee function. Not clinically assessed, but perceived poor knee function by the athlete. This is an example. The ACL-RSI is very simple to apply. It has questions such as, are you confident that you can perform on your previous level of participation? It's based on one to 10. Fully confident to not confident at all. Are you confident that you could play your sport without concern for your knee? And these could be applied by you. We are using, we have an intern who's interning with us in our sports injury clinic, so we're doing this serially for patients now. We have looked at isokinetic data. We're looking at ISO, our functional data, and now we're gonna look at the ACL-RSI to correlate with this data. And I gave you this question. This has been, this is from the Moon Group, which is a very well-known multi-center group that looks at outcomes for ACL. And this is for the IKDC scale, International Knee Classification. And this question you could ask at different stages. So how would you rate the function of your knee on a scale from one to 10 or zero to 10, zero being the worst and 10 being excellent on your daily activities or your knee? And what we use is zero to three is something for the early stages, four to six. Later stages, return to sports between nine and 10 in this question. And it has been validated by this group in the return to play criteria. Very simple. It's been published, you can look it up, in the IKDC scale, question number 10. You could apply this serially to the patient. So what are the return to play criteria? And we're almost done. No functional complaints, full motion, stable on exam, stable single leg stance, landing from a jump, 85 at six months, 95 at nine to 12 months, LSI, progression of sport-specific practice activity, that's outside our realm with coaches, trainers, this is by history, and subjective feeling of confidence and psychological readiness if needed, a psychological clearance by a psychology professional. And this is an example of the return to sports continuum that Dr. Miranda has talked about, ACL injury, surgery, physical therapy, sport-specific rehab, clinical assessment, isokinetic test at six months to allow sport-specific training. We were doing functional and objective testing at six months, we have cut back on that. So we do first isokinetic, looking for 80, 85%, physical training, come back at nine months, and then do the sport-specific testing in addition to the isokinetic testing. We have found, and we have published that if you don't pass the isokinetic testing, we don't progress you to the functional testing because there is a high risk of failure of that test. What are some knowledge gaps? And you can go back to your clinic, your practice, your academic center, and look at research. What combination of physical and psychological factors best predict return to sports and result in risk of reinjury for different population, different ages, different sports? Specific return to sports protocols based on specific sports. As you see, these protocols are biased for jumping and running sports. So you have somebody that does strength sports, other things, gymnastics, other things you may need to look at other things. And it's certainly something to look at. And how to integrate strategies that emphasize external or locus of control in rehab, such as video, artificial intelligence, so you could train somebody looking at video and doing things that use the brain. Because we know that their brain changes, and this is topic for another talk, there's been documented some brain changes on functional MRI following injury that affects maybe the neuromuscular controls. There's this whole new area of research in recovery from injury. What is the take-home message? Return to sports success depends on tissue healing, clinical and psychological factors, as well as the demands of the sport. We should complete a rehab program divided in phases and understand that we have this long return to training phase that is not in our realm that we need to work closely with fitness professionals. We need to have a clinical assessment, symptoms exam, functional testing, and progress the athlete based on the findings. We may have to cut some people back. And that is something that we do frequently. I said, somebody, it's better for you to no go back than to go back and have a torn ACL. And we do have people that pass a test and do get a re-tear. And that's something that's sad also. Psychological readiness is key, and you could get involved in assessing this with simple questions and working with psychological professionals as well that may help you in an interdisciplinary. One last point. Return to sports is not a paternalistic sports medicine doctor decision. It is a team-based decision. So we get input from the psychologist, the physical therapist, the training professional, the coach, and the athlete. And many athletes who understand this process when we explain it to them, tell you, Doc, I am not ready. I am really not ready. Thank you very much for coming this morning, and we'll look forward to discussion in the cases. Dr. Miranda. All right. Thank you, Dr. Micheo. That's why I recruited him for this session. So we're going to discuss the cases that we mentioned earlier. We can open up for questions between the cases. We have two cases. We're going to do the knee case, and Dr. Micheo is going to be answering questions for us. He didn't know that. Now he knows. I got to learn how to turn the microphone on. They're on. They're probably on. Are those microphones on? Yeah, there you go. Can you hear me now? Yes. All right. So while he's put up there, the first case was a 35-year-old basketball player who injured his ACL. He's a recreational basketball player. So the question number one is a 35-year-old recreational basketball player. Diagnostic ACL tear with contusions in the lateral condyle, lateral femoral condyle, and lateral tibia. No meniscus injury. So does this patient require surgery? What do we recommend to this patient? Dr. Micheo, tell us a little bit about that. Any comments from the audience or questions at this point? No? First is the age, 35, key point. So for ACL decision for surgery, usually younger people, less than 25, you consider surgery. Older athletes, recreational athletes, you don't. There's a study that you should look at from Frobo, published in the New England Journal. It was a prospective study at two years. And then they published it in the British Medical Journal at five years for exactly recreational basketball players. And they found that they had 120 patients, 60 no surgery, 60 surgery followed by rehabilitation. They found that the group that was not operated, about half of them ended up in surgery for different reasons, meniscus tears, recurrent injury. Some of them quit sports, and about 25% of the total population did OK, at least up to five years. But the caveat for the study was that after six months, you could still make a decision to operate in somebody. And at two to five years, the results for x-rays and subjective findings in a COOS questionnaire were the same. So for an athlete that's 35, recreational, they don't need surgery up front. They need rehabilitation and addressing the things that we taught. And it's based on prospective data. If you look at Cochrane data, they quote this article to tell you at this point in time that it's not certain that surgery is better than non-surgical treatment for ACL tears. OK. Any questions from the audience? So go ahead. Yes. This athlete, this individual is... The question was, the question was whether six going back to the early on gym exercise, is that too early within the six weeks of injury. That's the question. That's the question. Not in the similar way, saying, what's the big deal about being in the system before you go into the surgery and you respond to that. No, no. The data says that you work after six months comparing the patients. You could get a later surgery and the results are the same at two years and five years based on x-ray data and a questionnaire. What do we do with an athlete who's not operated? Is that your question? Yeah. I don't want to do something just right by the emergency room or OR next week. No, no. We, well, this is not a rehab talk, but let's talk about ACL rehab so we understand what we're talking about. Somebody that gets an ACL injury should not get surgery prior to having full motion and good strength. So surgery may take two weeks in a pro athlete that has to trainers and it makes six weeks for a buddy who's not an athlete. So this is considered the prehabilitation phase of somebody who's going to get surgery. If you're not going to get surgery based on this criteria, somebody goes skiing at Vail, not an athlete, tears their ACL, comes to see me, this patient will get conservative treatment. So we'll follow the same criteria. You get rehab when they get full extension, we get normal strength, and see how you do. Some individuals will get symptoms with daily living activities, and those may be counsel, you may need surgery, but the majority of people who are not athletes don't need to be operated, but you treat them with rehab with goals of achieving full motion, normal strength, and protecting the secondary stabilizer. So if somebody has an intact meniscus and no bone bruise or bone contusion reduces their risk of post-op or post-injury arthritis, we're talking here about a disease that causes between 50 to 80% who have an ACL injury get arthritis. If you have an intact meniscus, the risk is lower. If you have torn meniscus, the risk is higher. So this is something that we need to address. So if somebody doesn't get surgery, needs to get rehab, counseling, modification of activity, and periodic assessment. Somebody who needs surgery gets prehabilitation, normal strength, normal motion, and then goes to surgery. Who goes to surgery? Younger athletes, elite athletes, people who participate in sports that require changing direction, jumping, they call 11 walls, level one sports, basketball, football, soccer, those athletes may need rehab. If you're an athlete that does swimming, running, triathlon, you may not need surgery up front. And that's a personal decision. Does that answer your question? Yeah. Good. Okay. I have a question for the audience, a raise of hands. How many of you will refer this individual from day one to the orthopedic surgeon? A referral, not necessarily surgery, but a referral in a practical sense. You see this individual has an ACL tear, diagnosed with MRI, that may or may not require surgery. You will educate the patient as to treatment options, pros and cons, but in a practical sense, how many of you will write a referral to the orthopedic surgeon? So maybe half. What will you do, Dr. Machado? In the majority of case, when I see somebody like this, this is a serious injury, and I work with teams. So in the majority of patients, I would offer the option of seeing the orthopedic surgeon. But prior to doing that, I would educate the patient and say, this is, you're a recreational athlete, or you had this injury skiing, or you're not a skier. And I would tell them what the literature says in a simple way. You don't want to overburden patients with excessive information in the first time. But I will, in the majority of patients, somebody that has this type of injury, we work together with orthopedic surgeons. I don't feel less of a professional by doing that. I think it's better. Now, you know who to refer to. Because I would know who would understand this concept and who would offer the patient surgery on the first day. So definitely that. I second that. I personally refer, I will refer, I will educate and refer, but not refer to just anybody. That's why it's important to get a community network of trusted providers, trusted physicians that understand the injury, understand the whole concept. Okay. So what factors in the, so let's say this individual, no, it's the other talk. It's the one that was alone by itself that you found in the agenda. So this individual underwent surgery. He had a bone, patellar bone graft. He has been doing rehab. He's 10 months out of rehabilitation. And let me see what else I wrote in the case. So he is 10 months out and let's say he had a complete rehab. At 10 months we do the clinical testing. So he passes single leg stance, single leg squat, single leg jump, landing on two legs and one leg. Then we allow them to do testing. So they would go first to isokinetic testing and if they pass the test we bring them back at a different date and then we do functional testing. If they don't pass the isokinetic testing we encourage it and we write to the fitness professional to include strengthening of isolated quads and hams in addition to the training they're doing because many, many people move mostly to functional testing at these stages and some people may remain inhibited. While they may remain weak they may be getting symptoms. They may not be emphasizing that type of strengthening. Some people do have neuromuscular inhibition and it's really not clear why some people get more neuromuscular factors that involve what we call arthrogenic inhibition. So these are things that we would do. If they pass the isokinetic test then they come back between around four weeks or maybe quicker depending on what the athlete. So we have a lead athlete, we may do it next week. They do back to back. So go ahead. and I've never seen them again. Yeah. So how would you recommend to have that conversation with the surgeon so that the PMRR provider can still be involved in the decision making of the return to play? See, I think that that's a big, a big, we just published an article at PMRR. And recently, there was a supplement in sports medicine. We wrote an article on isokinetic and functional testing. And some of the people that looked at it said, well, this is not something within the realm of PMRR. We've been doing it for 30 years. I think it takes hard work because there is some misconception that you're going to say that they're not doing well. And surgeons always think that we're criticizing the surgery. We just got to educate them and go give them talks. But it still happens, no? Because the athlete will feel subjectively, the majority of times, they'll feel subjectively better between three to four months. That would allow them to run. And they feel better because it's a single plane exercise. So you need to send them, talk to them, and say, we would like to be involved. Because the model has been surgery, therapy, supervised by the physical therapists. We have some great physical therapists. But it's more than just physical therapy. It's the whole concept of pain, pain inhibition. And many times, they just get better. But they don't comply with all these criteria. So in many centers, also, they don't have isokinetic and functional testing. So what could you do? I mean, some people are looking at literature and doing isometric testing. So I would recommend that you, when you assess your patients, include some of these assessments in your, and then communicate that to the surgeon. And many of the systems, some systems work that way. And that's what they call the system-wide line of service. So you've got to insert yourself. Sometimes it's difficult. But it's not uncommon. It's not uncommon. Any other questions, comments? So when we look at the return to sport model, I like always to look at the start framework, which you evaluate, you assess risk. And then you have modifier risk, risk tolerance. So assessing risk in this individual, he's 35, a recreational basketball player. If assessing risk in terms of clinical, it seems like he's doing very well. No swelling, normal range of motion, functional testing. The numbers look excellent. Psychological readiness. So in terms of risk assessment, clinically, it seems like he's ready to go. Risk assessment in terms of his activity. So basketball. Does that play a role into our decision? Yeah, I think that. Recreational basketball player, right? No specific timeline. I think it does. I mean, there's this concept of copers, which means that there is a subgroup of patients who do well with a torn ACL. And you could identify this by doing functional testing like this. We do clinically earlier, within six weeks. They have no swelling, no lack of motion. And so this patient may be a coper. He may do well. So we got to tell him that going back to type 1 sports increases the risk of reinjury. And he has not been operated. He has an intact meniscus. He's doing well in rehab. He could try. What I'd say is if you feel subjectively unstable, we need to consider surgery. The other thing I do is I follow the examination. So many, many individuals have like this honeymoon period where secondary stabilizers keep your knee stable. So after six months to a year, then you start feeling a pivot shift, which is a proxy for anterolateral rotatory instability, which is what causes the knee to give out. So if I start feeling the knee more unstable, the athlete is doing well. He's very active in tennis. Other sports, I say you may consider surgery because your meniscus is still preserved. And that's what I do. But this patient would meet criteria to try to go back to sports. Now, last point, bracing. So bracing gives a subjective feeling of control, but it's not enough to keep your knee stable at the velocities required for basketball. So ACL bracing, which is a functional brace that would limit hyperextension, the ACL is torn near extension. So that would be something that I would give this patient as well, but I would tell him that it's not protective 100%. The key point here, Jerry and I wanted to make this, is that people abandon their rehab. So they do rehab for six weeks. They go back to the sports, and they stop training in the gym. So you've got to tell them, if you want to prevent your knee, you've got to keep training physically in addition to playing basketball. And that's part of the concept of the return to training, return to sport, and return to performance. And that's a part that involves continuing, improving your fitness level to return to performance. Quick question, what are type 1, type 2, the type of sport that they do? So type 1 is cutting and jumping soccer, basketball, football. Type 2 may be baseball, volleyball, tennis. Type 3, jogging, running, swimming. So type 3 sports have much less risk of recurrence. This is based on this international knee classification. And so you could see what type of sport. So there's some literature, and I didn't want to make this an ACL talk, but if you play sports more than 200 hours a year, 200, and your knee is lax, more than 5 millimeters on Lachman's testing, and you play type 1 sports, you have a higher risk. So you play less than 50 hours a year of sports, and your knee is stable, and you play type 3 sports, the risk of re-injury is lower. So you could clinically assess your patient based on your examination, activity level, and type of sport. So yeah, so our risk tolerance might be a little bit less if the person wants to go to basketball, type 1 sport, versus if the person wants to go back to double tennis, if the person, which would be like type 2, and type 3, the person wants to go back to swimming, running, jogging, things like that. Our tolerance level would be lower? Lower. Lower, yes. But I think recreational players, it's a big, big gamut of people. People play with their buddies, Saturday, beer. But other people play recreational leagues, and they travel. So even adult, now we have this whole concept of the master's athlete. So I'm very careful in the master's athlete. So I do treat them slightly different. So you have a competitive master's athlete who would like to compete in leagues up to 50 years, 60 years. You could play tennis competition, tennis up to 90 years of age category. So these individuals, you may have to counsel them a little different. So this is a practical summary. We're looking for no functional complaints, full range of motion, stable knee on exam, functional testing at least higher than 85%. Some data suggests that maybe we should look for that 90% number. Progression of sport-specific activity, important to tolerate it with no brace. And that subjective feeling, so that mental readiness, which is key. The second case that we had was a 20-year-old right-handed pitcher, college level, had insidious onset of pain for the last three weeks. He was diagnosed with a labral injury. His pain morphed more in that early cocking, late cocking phase, I mean. Late cocking phase, that's where his pain was the most. Does this individual require surgery? Anybody who was in the Game of Bones lecture yesterday, we got answers for that. Anybody, yes, surgery? Raise of your hands. No surgery? More people, no surgery. We agree. This is probably a non-surgical treatment. On exam, so things that you would look for, intrinsic and extrinsic factors. Intrinsic factors are the factors that have to do with the individual itself. So for example, scapula dyskinesia, core weakness, GERD, which is glenohumeral internal rotation deficit, and extrinsic factors. So this is a college player who was playing at the end of the season of his college career, but he was ready to go to summer ball. So his training load was pretty high. He was one of the main pitchers. He was used as a starter pitcher. He was used as a reliever at the end of the season. Now he's been doing rehab for the last three months, and he has gone well. So in terms of clearing this individual to return to their usual sport. So again, we go to that START framework, which is the main one that I use that I think about. So risk assessment, so clinical status. So he has no swelling. Scapula dyskinesia is still present. So you can see an asymmetry of that scapula movement, but it's painless. Internal rotation, range of motion difference of 15 degrees when compared to the control lateral side has equal eccentric external rotation and isometric internal rotation strength. When we first saw him, he had poor core control in single leg squat, single leg stand. He improved that. We know a pitcher, they constantly do this single leg stand. So if they cannot dominate that, that's a big red flag. And he completed a throwing program. He completed eight weeks of a throwing program, which throwing programs can be modified, but eight weeks is a good number. And psychologically, he was evaluated by a sports psychologist, and he was confident on his ability to return to play. So this is a clinical evaluation that we have to assess. Then we assess risk. So he's a pitcher, college level, division one, so high level. His right hand is in terms of limb dominance. We take into consideration that. So he's obviously at higher risk of re-injury the dominant shoulder as a pitcher. Right now, he wants to go back to playing as soon as possible. So that in terms of time, he's in the off season. But as in risk tolerance, he wants to go back to play. So Dr. Michaud, what do we do to cancel this individual? So for the labrum, there's a high incidence of abnormalities in the labrum in people who play sports. And some baseball players at age 20 have been playing since age six, so maybe 14, 15 years. The better athletes, what are the risk factors for throwing injuries? Higher velocity thrower, taller kid, plays more than one position, plays more than one team. So these things are already studied. Once they're injured, there are four things that we look for in the shoulder injured athlete. Kinetic chain, dominant limb is very important because they need to do a stance and push off of that leg. Scapular dysfunction, rotator cuff weakness, particularly the external rotators, and loss of shoulder, internal rotation, and maybe adduction, adduction. So those are the things we address in rehab. When they do well in rehab, we'll still have to reassess those at a finer point. So we need to look for loss of hip rotation in the dominant side, loss of internal rotation, non-dominant side, loss of external rotation. We have to look for scapular function after some fatiguing and exercise, and because there's not enough data in return to sports for the shoulder. So most people use the clinical exam, the findings after a throwing program, and progression of activity, let's say throwing one inning, two inning, three inning. So this athlete may be counseled to go back. Now one key point about the shoulder is that it has been shown that resting the shoulder three to four months of throwing per year reduces the risk of injury. So this athlete, if he's in the off-season, as Dr. Miranda said, may be counseled to rest maybe four to six weeks of throwing, and then do all the physical training that we're talking to address any issue that's left, such as scapular dysfunction. Excellent. Go ahead. So we mentioned the ACL, the kind of like knock on the surgery, but if this was the UCL injury, in addition to this, what would you say to that? Okay, perfect. So let me ask one question first. In this individual, labral tear on imaging, we got an MRI, because he came with an MRI from outside, because we're not gonna order an MRI. So we have a labral injury, diagnosed labral injury. Do we refer this individual to an orthopedic surgeon? How many of you would refer the individual? So this is a little bit different. This is an overuse injury that definitely has some changes that we have to explain to the individual that some of these changes might be just adaptations. Some of them can be maladaptations. Some of them can be good adaptations for the sport that the individual performs. But this is an individual I feel most of us in the musculoskeletal world can feel safe and can feel secure treating them without the consultation of a surgical colleague. So UCL injury. So that will depend, right? So that will depend in terms of, does every single person with a UCL tear require surgery? That's something that you put in your initial evaluation. You have to assess risk as well, right? So how, here's a picture, high-level picture. If it's a complete UCL tear with physical extent of instability, right? Then definitely something that, a UCL tear is something, somebody that I will refer to my colleague from orthopedic surgery, but I will definitely start in rehab because more often than not, there are factors that you can at least educate the patient on training load, the type of exercise, number of pitchers, number of pitching, pitching volume. And the exam, you can assess kinetic change problems and you can start rehab right away. So I wouldn't wait to start rehab to get a surgical consult, but I will definitely get a surgical consult depending on the injury. So Jerry, do you ultrasound them in your clinic? I do. Even if they come with a positive study by? I do, to do dynamic testing, right? So I do ultrasound them to do dynamic testing and see if there's a significant valgus stress test. But this is an individual UCL tear and acute tear, I do refer. Partial tears though, I not necessarily do, right? So partial tears is good evidence that we can do non-surgical treatment, especially now with newer modalities that we can use that might get an individual sooner to their sport. That is an important topic because there is a higher incidence of surgery in that population at this point. So younger patients, they may have a misconception that because pro athletes get throw harder after the UCL reconstruction, they should get surgery. So one thing about MRI and sports injury is, I mean, there's a wide gamut of radiological interpretation of findings in MRI. So you may see somebody call this a full partial thickness, a high grade partial thickness. So you got to examine the patient, first of all. And the same issue, when you have sports injuries, including the elbow, it's a combination of overload, either acute or chronic or chronic overload, biomechanical deficits, which for the elbow usually include the same kinetic chain principles we said for the shoulder. And the majority of people will tell you by history, I just came back from a shoulder or a back injury and that's why they injure the elbow. But certainly, certainly, I mean, the technology for surgery has improved and kids do well. But you got to counsel, this is a one year off of their life and many that I see with medial elbow pain respond to the same principles of addressing the shoulder. If it's a torn UCL, I think we should consult an orthopedic surgeon who's an expert in the elbow. Some are even using PRP as an initial management tool for this partial thickness. And now they are becoming more aggressive in treating partial thickness tears surgically. So one of the things that's important is that any of these interventions, so let's talk about the ACL. In the best hands, about 60% of ACL reconstructed athletes go back to the same level of competition. That's across all patients. We know that professional athletes go back 85 to 90% following any of these surgeries, but their life expectancy or their sport is lower. So if you take somebody who's a kid, high school, and then you do an UCL surgery prior to college, so this is a big issue. So the best scenario is for them to have some kind of partial tear that responds to rehab and you could treat non-surgically and to address the biomechanical deficits or the volume overload. And if you do that, they may do well. But certainly, there's no rush to get them better, but you gotta get them off of throwing. So important in the history right to know where the pain is right so the pain is throwing in this leg cocking so obviously you want to avoid painful range of motion. Thankfully for most exercises that you do you don't have to go all the way out here to have the same force that he needs for pitching. So for him you divide in two things right so you have to work with that scapular control right so exercises and scapular control and rotator cuff strengthening so you do your basic external rotation internal rotation. Initially you do more you can start isometric if it's painful then you start concentric. There's a big role for eccentric training we talk about eccentric training more in the lower limbs less in the upper extremities and we talk about plyometrics more in the lower limbs rather than the upper extremities and plyometrics play a role here as well especially at eccentric. So that's when you see in the gym your physical therapist working in a trampoline throwing a ball and catching it right with a weighted ball so that you you work on that eccentric training eccentric strengthening of the external rotators. But more important than anything I think is that that core core strength right that that's that's what's going to be key I think that's what will differentiate some of the rehab and some of the outcomes right whether those individuals that had poor single leg stance they're able to do that so a lot of single limb strength training and at times the the training for for upper limb injuries will look very similar to for example in ACL I reconstruct the knee in phases three and four of training squats probably yes but but shoulder press it depends it depends on the progression right yeah so so exercises is like everything else in that you should follow it but anyway the concept that we use is we activate muscle pain-free then we use exercising pain-free ranges of motion then we activate a full motion sport specific in in the clinic and the gym and then we integrate into into groups of models so so if you have somebody that came you do your rotator cuff exercises you do your your chest exercises in mid-range and you progress it to full range and an overhead press may be no different with the weight that the athlete can handle no so how you determine the weight so if you do 12 to 15 repetitions is a lightweight 8 to 12 is a mod is a weight the target weight and 6 to 8 repetitions maximum is a heavy weight so we do active lightweight so the the principles are loading now this is good literature calling tendon loading exercises or and it's isometric heavier isometrics concentric heavier slow concentrics and then eccentrics as dr miranda says at the end because they have a higher risk of muscle tendon injury but that's a great question so you should follow how he's progressing in your in the rehab and so you give them a basic simple exercises tubing lightweight lower extremity exercises core then you see him again in the clinic you re-examine them so they have no impingement the motion is better in internal rotation so you say you could do some machines mid-range 50 weight and then you progress them this is how we do it this is a non-surgical case right so we're not necessarily waiting for tissue healing right and and that's one concept for example i see a reconstructing needs that you want to avoid some open kinetic change movements to avoid stressing the ligament an isolated ligament here you're not necessarily stressing that so you can start open kinetic chain exercise and close kinetic chain exercise very simultaneously depending on the tolerance of the individual a shoulder press will be like more closed kinetic chain exercise but important about that is that you want to activate muscles and open kinetic chain exercise are very good at activating individual muscles so if you have an individual who has that medial scapula is very very shut down then you don't want to start with shoulder presses because otherwise bigger muscles like the delta will dominate the movement and you'll never activate those muscles so it's important to do some open kinetic chain exercises and adding some close kinetic exercise and making sure that the that the muscle activation is appropriate so so the the answer for your question is and it's a great question is you when you see an athlete and tells you which at which point can i do this is that when you are able to do it based on these concepts so you would see your patient if at day one then you would see it maybe at four to six weeks and then you re-examine them and then you would progress the exercise based on a criteria no pain at rest no pain with exercise isolated no pain with functional exercise and then that's how you do it so so we moved away because the athlete the first thing is when i'm going back when i kind of do so i said let's let's do this let's make sure that you have no pain no pain at rest which is a something that's we don't like no pain at night for the shoulder pain at night as a key key historical finding no pain with activity and then you progress them as you see him back and then you could get involved in some of these processes that i would be saying because we we have to although we're not physical therapists and we respect their you know field of action we have to use these concepts as we manage our patients and able to guide them because time based information is is not the only one you could use for this any other questions 9 15 so we're done with the session any other questions um here i put criteria for shoulder some of the criteria has been suggested for shoulder uh injuries so no functional complaints is similar to the other stuff normal range of motion so what is normal range of motion in this individual is that there should not be uh there should be some people argue differences in total range of motion of maybe 18 degrees less than 18 degrees some people argue that maybe the difference can be closer to 25 especially in overhead athletes um uh i mean the the internal rotation deficit the total range of motion should be closer to five degrees um muscle strength uh there's different ways to do muscle strength testing you can use isokinetic testing you can do there's good evidence for handheld dynamo dynamo meters so you can compare isokinetic external and internal rotation uh strength it should be closer to close to 60 60 percent or isometric external rotation internal rotation ratio that should be close to 75 to 100 percent now it's moving towards more of this eccentric external rotation to to isometric internal rotation that should be close to to even um one important thing is that scapula symmetry you don't have to obtain complete scapula symmetry to clear somebody some some people can stay with scapula dyskinesia that is painless that there there are activating muscles that there's clinical improvement this is more you know more a little bit of a subjective um uh measure um but you but but you don't have to be very specific as to following that scapula symmetry in this individual in particular it's very important that they completed a throwing program that's a that's a way to try to to translate into field performance and mental readiness so those are criteria that we can use that are very practical all right we're done thank you thank you very much we'll be here for a few minutes if you'd like

return to sport

ACL injuries

labral injuries

readiness to return to play

surgery

functional complaints

range of motion

risk of reinjury

scapula dyskinesia

throwing program

interdisciplinary approach