https://wexnermedical.osu.

edu/departments/sports-medicine/education/medical-professionals/rehabilitation-protocols

Foldere / Tematica : Tenex - Concussion - HIP - Knee, ankle and foot - Other - descarcate la 04.05.2019

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1. Shoulder and Elbow AdhesiveCapsulitis.pdf PosteriorShoulderStabilization.pdf
2. Shoulder and Elbow ArthroscopicShoulderStabilization.pdf ReverseTotalShoulderArthroplasty.pdf
3. Shoulder and Elbow Arthroscopic_SLAP_Repair.pdf RTC_LargeMassive.pdf
4. Shoulder and Elbow BicepsTenodesis.pdf RTC_SmallMedium.pdf
5. Shoulder and Elbow DistalBicepsRepair.pdf ThrowingProgressionBaseball.pdf
6. Shoulder and Elbow DistalTricepsRepair.pdf ThrowingProgressionSoftball.pdf
7. Shoulder and Elbow Latarjet.pdf TotalShoulderArthroplasty.pdf
8. Shoulder and Elbow Medial Epicondyle ORIF.pdf UlnarCollateralLigamentReconstruction.pdf
9. Shoulder and Elbow PectoralisMajorTendonRepair.pdf UnstableShoulderNonsurgicalManagement.pdf

10. Tenex Achilles MidSub Tenotomy.pdf HipLabral.pdf

11. Tenex AchillesTenotomy.pdf LabralRepair.pdf
12. Tenex ElbowPNTandPRP.pdf PatellarQuadTenotomy.pdf
13. Tenex GlutealTenotomyAndPRP.pdf PlantarFasciotomy.pdf
14. Tenex HamstringTenotomy.pdf RotatorCuffTenotomy.pdf

15. Concussion ConcussionOT.pdf NVScreening.pdf

16. Concussion ConcussionPT_CPG.pdf

17. HIP GluteTendonRepair.pdf HipMicrofracture.pdf

18. HIP GreaterThochantericPainSymdrome.pdf ProximalHamstringAvulsionRepair.pdf
19. HIP HipArthroscopy.pdf TotalHipReplacement.pdf
20.
21. Knee, ankle and foot AchillesTendonRepair.pdf KneeMicrofracture.pdf
22. Knee, ankle and foot ACI.pdf MedialPatellofemoralLigamentReconstruction.pdf
23. Knee, ankle and foot ACLMCLCombined.pdf MeniscalRepairwithWeightRestrictions.pdf
24. Knee, ankle and foot ACLPCLCombined.pdf MensicusRepairClinicalPracticeGuideline.pdf
25. Knee, ankle and foot ACL_Reconstruction.pdf MPFLFulkerson.pdf
26. Knee, ankle and foot CHRONIC EXERTIONAL COMPARTMENT SYNDROME.pdf PCLReconstruction.pdf

27. Knee, ankle and foot ChronicAnkleInstability.pdf PlantarFasciotomy and PRP.pdf

28. Knee, ankle and foot CompartmentSyndromePostOp.pdf QuadricepsTendonPatellarTendon.pdf
29. Knee, ankle and foot GeneralKneeDebridementPartialMeniscectomy.pdf Unicompartmental Knee Arthroplasty Uka
Protocol.pdf
30. Knee, ankle and foot HighTibialOsteotomy.pdf

31. Other AdvancedReturnToRunning.pdf ProximalDeepVeinThrombosis.pdf

32. Other BasicReturnToRunning.pdf Strength Protocol.pdf
33. Other Cervical Manipulation CPG Final.pdf Temporomandibular Joint Disorder.pdf
34. Other Chronic Pain Protocol.pdf Tendinopathy.pdf
35. Other IntermediateReturnToRunning.pdf


POSTCONCUSSIVE SYNDROME (PCS)

CLINICAL PRACTICE GUIDELINE: OCCUPATIONAL
THERAPY
Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Patient
evaluated
by
physician
and referred
to:

Speech-
Physical Occupational
Language
Therapy Therapy
Pathology

Background
The Centers for Disease Control and Prevention (CDC) defines a concussion as a type of mild traumatic brain
injury (TBI) caused by a bump, blow, or jolt to the head. Concussions can also occur from a fall or a blow to the
6
body that causes the head and brain to move quickly back and forth. Most people with a concussion recover
quickly and fully. But for some people, symptoms can last for days, weeks, or longer. Persistent symptoms are
referred to as post-concussive syndrome (PCS). A definition of PCS is provided by the World Health
Organization’s International Classification of Diseases (ICD-10), including 3 or more of the following: headache,
dizziness, fatigue, irritability, insomnia, concentration difficulty or memory difficulty. In general, recovery may be
slower among older adults, young children, and teens. Those who have had a concussion in the past are also at
6
risk of having another one and may find that it takes longer to recover if they have another concussion. Lingering
symptoms of a concussion typically fall into four categories (1) physical, (2) cognitive, (3) emotional/mood, (4)
6
sleep. Individuals with post-concussive symptoms often have difficulty transitioning back to activities such as
11
work, school, and play. The role of occupational therapists (OT) is to address performance skills and patterns to
4
promote return to engagement in meaningful and purposeful activities.

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.


Evaluation

Client History • Relevant information: Age, date of injury, mechanism of injury, symptoms at time of injury
and and present, did client lose consciousness, was post-traumatic amnesia present, number
Occupational and impact of previous concussions, other past-medical history including medical co-
2,4
Profile morbidities and psychosocial client factors
• Comparison of prior level of function and current level of function: ADL, IADL, school, work,
and/or sport, and other meaningful interests
• Current symptom ratings: Concussion Grading Scale (CGS), Refer to Appendix A
Physical Symptoms associated with PCS may include headache, blurry or double vision, nausea,
6
dizziness, sensitivity to noise or light, balance problems, fatigue or low energy
• OT screening of UE ROM, strength, coordination, sensation, and posture.
• If neck or balance issues are present, collaboration with PT is recommended. See PT CPG.
11
• Vision – Oculomotor function
o Research has identified objective findings that show difference in saccadic eye
16
movements, smooth pursuits and tracking in control group vs PCS group
o Assess through observation as well as standardized assessments
o Standardized assessments to consider
14,25
§ Developmental Eye Movement Test* (DEM)
,13
§ King-Devick Assessment*
,19
§ NSUCO Saccades Testing*
,19
§ NSUCO Pursuits Testing*
§ *See Visual Screening CPG for additional details
• Vision – Convergence and Accommodation
o Changes in accommodation and convergence have been identified in individuals with
22
PCS
o Assess through questionnaire and standardized assessments
24
§ Convergence Insufficiency Symptom Survey (CISS)
• Scores >21 can indicate impairment, recommend referral to optometrist
,23,26
§ Near point of convergence*
,27
§ Amplitude of accommodation*
§ *See Visual Screening CPG for additional details
o Occupational therapists can work collaboratively with optometrists to improve near
11
focus, convergence, and accommodative function
• Sensory Processing
o Assess through interview and questionnaire
§ Interview may include asking about screen time tolerance, light and sound
sensitivities
5
§ Adult Sensory Profile
• Vestibular Function
o Assess through screening and questionnaire
7
§ The Vestibular Disorders Activities of Daily Living Scale
1,21
§ The Vestibular Activities and Participation Measure
§ VOR, VOR cancellation, Head Impact Testing (HIT). See PT CPG.
§ Recommend collaboration with Physical Therapy in this area

Cognitive Symptoms may include difficulty thinking clearly, feeling slowed down, difficulty concentrating,
6
or difficulty remembering new information
• Work collaboratively with speech-language pathologists to address cognitive deficits, with
4
overarching goal of improving occupational performance
• SLP to focus on standardized testing and remediation of deficits of executive functioning,
4
memory, cognitive endurance
4
• OTs and SLPs collaborate on return to school or work plans and accommodations
• May also seek input from physicians and rehabilitation psychologists as part of
collaborative treatment team
• Montreal Cognitive Assessment (MoCA), if not completed by SLP, is a standardized
assessment that can be utilized to measure cognitive skills. See SLP CPG.
Emotional Symptoms following concussion may include irritability, sadness, nervousness, or an overall
6
feeling of being more emotional
• Symptoms may be identified with utilization of CGS questionnaire or through discussion
• Research suggests mindfulness is key to occupational engagement and may enhance
10
health and well-being
• May also seek input regarding emotional health from physicians, rehabilitation
psychologists, and social workers as part of collaborative treatment team
6
Sleep Symptoms may include trouble falling asleep or sleeping more or less than usual
• Symptoms may be identified with utilization of CGS questionnaire or through discussion
• It could be the case that sleep disturbances are secondary to other symptoms such as
depression or anxiety. Management strategies should take this potential interaction of
20
symptoms into account.

Intervention

Physical • Vision – treatment interventions may include teaching compensatory strategies to address
11
Symptoms difficulties with light sensitivity or visual tracking. A rehabilitative approach would involve
working in collaboration with optometrists and/or ophthalmologists to address impairments
in oculomotor function, binocular vision and accommodation. See neurovision CPG for
additional detail.
• Sensory Processing – treatment intervention includes recommendations of environmental
11
adaptations to modify reactions to sensory stimulation.
• Fatigue Management – education on energy conservation strategies including planning,
prioritizing, and pacing during ADL/IADL completion. Fatigue coping strategies can be
20
found in Appendix 12.3 of cited article, pg 96.
Emotional • Training in mindfulness-based techniques and goal directed techniques to help manage the
Symptoms emotional and physical symptoms of PCS and improve participation in daily activities and
8,15
occupation
• Mindfulness-based techniques include
3
o Stress reduction techniques
18,20
o Relaxation techniques
• When individuals anticipate that activities will provoke autonomic symptoms of dizziness or
headache, relaxation techniques can be implemented to prolong the ability to engage in a
4
functional task
• May also benefit from mindfulness and relaxation techniques during OT treatment sessions
4
to increase tolerance for therapeutic activity
• Goal directed interventions include: symptom management, assertiveness training, and
4
guided return to engagement in meaningful occupations
o Assertiveness training can be vital following “invisible injury,” such as concussion, to
empower individuals to ask for accommodations needed for successful return to school
9
or work
17
Cognitive • Executive function – remediating executive function skills affecting daily routines
Symptoms • Establishing healthy routines
o Strategies may include taking breaks and utilizing organizational tools
o Aim to assist in completion of daily routine while minimizing symptoms
• Work in collaboration with SLP to address cognitive deficits
4
Sleep • Provide education on the role of sleep in recovery
12
Symptoms • Facilitate healthy daily routines and sleep habits
o Plan rest breaks
o Make environmental modifications
o Manage symptoms
20
o Sleep hygiene advice (Appendix 7.1, pg 82)
• Other strategies
o Gradually reducing daytime naps, while increasing physical activity to promote a return
to nighttime sleeping
4
o Environmental modifications may include
§ Limiting screen usage in bed
§ Use of light-blocking curtains
§ Blue-light filters for electronic devices

Occupational Planning for return to school and work should occur in collaboration with treatment team,
Performance including physician, psychologist, SLP, PT and OT.
11 11
Return to school Return to work
• Research suggests the importance of returning • Recommendation for initial
individuals to structured activities, including school, as period of rest, followed by
soon as possible to establish general sense of graduated return to work if
improved well-being and restore a consistent routine. one’s job permits
Modifications for visual difficulties: • Therapists can work with
• Using a line guide or tinted transparency when reading patients and their employers
to help with visual tracking or reduce glare on strategies to help manage
• May benefit from larger print or access to lesson notes symptoms
ahead of time o Creating modified
Modifications for general sensory sensitivity, including workstations
decreased tolerance for crowds and visual motion: o Using anti-glare
• Allow student to change classes ahead of time computer screens
• Provide alternative to eating lunch in a busy cafeteria o Implementing frequent
Modifications at the college level: rest breaks
• Recommend accommodations such as preprinted
notes, increased test time, use of recording devices for
taking notes
• Compensatory strategies for visual tracking when
reading
• Line guide, glare reduction transparencies, reducing
screen brightness
• Social activities recommendations
• Therapists can assist in identifying activities that are
less stimulating, therefore less likely to provoke
symptoms
• Avoid studying or eating lunch with a large group of
peers, and meet with small groups in less stimulating
environments

Appendix A: Ohio State Concussion Grading Scale
Circle the number in each row that best describes the way you have been feeling relative to the
symptom. Patient Name

Symptom None Mild Moderate Severe

Headache 0 1 2 3 4 5 6
“Pressure in Head” 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Nausea or Vomiting 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6
Blurred Vision 0 1 2 3 4 5 6
Balance Problems 0 1 2 3 4 5 6
Sensitivity to Light 0 1 2 3 4 5 6
Sensitivity to Noise 0 1 2 3 4 5 6
Feeling Slowed Down 0 1 2 3 4 5 6
Feeling Like “In a Fog” 0 1 2 3 4 5 6
Don’t Feel Right 0 1 2 3 4 5 6
Difficulty Concentrating 0 1 2 3 4 5 6
Difficulty Remembering 0 1 2 3 4 5 6
Fatigue or Low Energy 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Trouble Falling Asleep 0 1 2 3 4 5 6
More Emotional 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
Nervous or Anxious 0 1 2 3 4 5 6
Sleeping More Than Usual 0 1 2 3 4 5 6
Sleeping Less Than Usual 0 1 2 3 4 5 6
Difficulty Sleeping Soundly 0 1 2 3 4 5 6
Ringing in Ears 0 1 2 3 4 5 6
Numbness or Tingling 0 1 2 3 4 5 6

1. Over the past week, my sleeping pattern has changed. ☐ Yes ☐ No If NO, skip to #2
a. Have you been taking naps during the middle of the day? ☐ Yes ☐ No
b. Are you waking during the night? ☐ Yes ☐ No
2. Over the past week, my participation in work or school has been % of what it would be
normally.
3. Over the past week, my participation in physical activity (sports, working out, etc.) has been
% of what it would be normally.
4. Do you feel like you are putting more effort more effort into maintaining schoolwork/grades and/or work
productivity? (Circle corresponding number below)
0 1 2 3 4 5 6
No More Effort -------------------------------------------------------------------------------------------------------------------------A Lot More Effort

5. Please indicate the type of visual changes you are experiencing:

☐ Eye Fatigue ☐ Double Vision ☐ Blurry Vision ☐ Other ☐ n/a
6. Do your symptoms get WORSE with physical activity? ☐ Yes ☐ No
7. Do your symptoms get WORSE with thinking/cognitive activity? ☐ Yes ☐ No
8. Do your symptoms IMPROVE with physical rest? ☐ Yes ☐ No
9. Do your symptoms IMPROVE with thinking/cognitive rest? ☐ Yes ☐ No

Authors: Tierney M. Bumgardner, MOT, OTR/L
Reviewers: Julie M. Omiatek, MS, OTR/L, CHT; Carol Gains, OTR/Ll Susan Bowman Burpee, CNP
Completion Date: July 2017

References
1. Alghwiri, A. et al. (2012). The development and validation of the Vestibular Activities and Participation Measure. Archives
of Physical Medicine and Rehabilitation. 93, 1822-31.
2. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd
ed ). American Journal of Occupational Therapy, 68(Suppl. 1), S1– S48.
3. Azulay, J., Smart, C.M., Mott, T., & Cicerone, K.D. (2013). A pilot study examining the effect of mindfulness-based stress
reduction on symptoms of chronic mild traumatic brain injury/postconcussive syndrome. Journal of Head Trauma
Rehabilitation, 28, 323-331.
4. Brayton-Chung, A. et al. (2016). Action: The role of occupational therapy in concussion rehabilitation. OT Practice. 11-
21-2016, 9-12.
5. Brown, C., Tollefson, N., Dunn, W., Cromwell, R., & Filion, D. (2001). The Adult Sensory Profile: Measuring patterns of
sensory processing. American Journal of Occupational Therapy, 55, 75-82.
6. Centers for Disease Control and Prevention. (2017). Traumatic brain injury & concussion. Retrieved from
http://www.cdc.gov/traumaticbraininjury/index.html
7. Cohen, H. (2014). Use of the Vestibular Disorders Activities of Daily Living Scale to describe functional limitations in
patients with vestibular disorders. Journal of Vestibular Research. 24, 33-38.
8. Doig, E., Fleming, J., Kulpers, P., Cornwell, P., & Khan, A. (2011) Goal-directed outpatient rehabilitation following TBI: A
pilot study of programme effectiveness and comparison of outcomes in home and day hospital settings. Brain Injury, 25,
1114-1125.
9. Donker-Cools, B.H.P.M., Daams, J.G., Wind, H., & Frings-Dresen, M.H.W. (2016). Effective return-to-work interventions
after acquired brain injury: A systematic review. Brain Injury, 30, 113-131.
10. Elliot, M.L. (2011). Being mindful about mindfulness: An invitation to extend occupational engagement into the growing
mindfulness discourse. Journal of Occupational Science, 18, 366-376)
11. Finn, C. & Waskiewicz, M. (2015). The role of occupational therapy in managing Post-Concussive Syndrome, published
by the American Occupational Therapy Association, Inc., Physical Disabilities Special Interest Section Quarterly, 38(1), 1-
4.
12. Fung, C., Wiseman-Hakes, C., Stergiou-Kita, M., Nguyen, M., & Colantonia, A. (2013). Time to wake up: Bridging the gap
between theory and practice for sleep in occupational therapy. British Journal of Occupational Therapy, 76, 384-386.
13. Galetta, K.M., et al. (2011). The King-Devick test and sports-related concussion: study of a rapid visual screening tool in
a collegiate cohort. Journal of the Neurological Sciences. 309, 34-39.
14. Garzia, R. et al. (1990). A new visual –verbal saccade test: The Developmental Eye Movement test (DEM). Journal of
the American Optometric Association. 61(2), 124-135.
15. Hardison, M.E., & Roll, S. C. (2016). Mindfulness interventions in physical rehabilitation: A scoping review. American
Journal of Occupational Therapy, 70, 7003290030p1-7003290030p9. http://dx.doi.org/10.5014/ajot.2016.018069
16. Heitger, M. et al. (2009). Impaired eye movements in post-concussion syndrome indicate suboptimal brain function
beyond the influence of depression, malingering, or intellectual ability. Brain. 132; 2850-2870.
17. Kennedy, M.R.T., Coelho, C., Turkstra, L., Yivisaker, M., Moore Sohlberg, M., Yorkston, K., & Kan, P. (2008). Intervention
for executive functions after traumatic brain injury: A systematic review, meta-analysis, and clinical recommendations.
Neuropsychological rehabilitation, 18, 257-299.
18. Lazar, S.W., Bush, G., Gollub, R.L., Fricchione, G.L., Khalasa, G., & Benson, H. (2000). Functional brain mapping of the
relaxation response and meditation. Neuroreport, 11, 1581-1585
19. Maples WC. NSUCO Oculomotor test. Santa Ana, CA: Optometric Extension Program. 1995.
20. Marshall S, Bayley M, McCullagh S, Velikonja D, Berrigan L. Clinical practice guidelines for mild traumatic brain injury and
persistent symptoms. Can Fam Physician. 2012; 58: 257-267.
http://onf.org/system/attachments/60/original/Guidelines_for_Mild_Traumatic_Brain_Injury_and_Persistent_Symptoms.pdf
21. Mueller, M. et al. (2015). Subscales of the Vestibular Activities and Participation questionnaire could be applied across
cultures. Journal of Clinical Epidemiology. 68, 211-219.
22. Poltavski, D.V., & Biberdorf, D. (2014). Screening for lifetime concussion in athletes: Importance of oculomotor measures.
Brain Injury. 28, 475-485.
23. Radomski, M. et al. (2014) Composition of a vision screen for service members with Traumatic Brain Injury: Consensus
using a modified nominal technique. American Journal of Occupational Therapy. July/August 2014, Vol. 68, 422-429.
24. Rouse, M et al. (The CITT Investigator Group). (2009) Validity of the CISS: A confirmatory study. Optom Vis Sci. 86(4).
357-63.
25. Richman, J.E. & Garzia, R. P. (2015). The Developmental Eye Movement test, version 2.5. South Bend, IN: Bernell.
26. Scheiman, M. et al. (2003). Nearpoint of Convergence: Test procedure, target selection, and normative data. Optometry
and Vision Science. 80(3). 214-225.
rd
27. Scheiman, M. et al. (2011). Understanding and Managing vision deficits: A guide for occupational therapists (3 ed).
Thorofare, NJ: Slack.
POSTCONCUSSIVE SYNDROME (PCS)
CLINICAL PRACTICE GUIDELINE: PHYSICAL
THERAPY
Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Patient
evaluated
by
physician
and referred
to:

Speech-
Physical Occupational
Language
Therapy Therapy
Pathology
Purpose
The primary purpose of this guideline is to improve the diagnosis of impairments related to PCS, improve the
quality of care and outcomes for patients with impairments related to PCS, and to decrease variations in the
evaluation and management of PCS. This guideline addresses these needs by encouraging accurate and efficient
diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-
term sequelae or evaluation of new or worsening symptoms not indicative of mTBI/concussion. The guideline is
intended for all clinicians in any setting who are likely to diagnose and manage patients with impairments related
to PCS. The target population is inclusive of both adults and adolescents presenting with impairments related to
PCS. This guideline is intended to focus on a limited number of quality improvement opportunities deemed most
important by the CPG and is not intended to be a comprehensive guide for managing PCS.

The recommendations outlined in this guideline are not intended to represent the standard of care for patient
management, nor are the recommendations intended to limit treatment or care provided to individual patients. The
guideline is not intended to replace clinical judgment for individualized patient care. The goal is to create a
guideline with a specific set of focused recommendations based on an established and transparent process that
considers levels of evidence, harm-benefit balance, and expert consensus to resolve gaps in evidence. These
specific recommendations are designed to improve quality of care and may be used to develop performance
measures.

Background
Concussions are a form of mild traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head or body
with resultant bouncing and twisting of the brain within the skull. According to the Centers for Disease Control and
Prevention, concussion is a complex pathophysiologic process induced by traumatic forces secondary to direct or
1
indirect forces to the head that disrupt s the function of the brain. Concussions results in multiple system
impairments including physical, cognitive, emotional and/or sleep-related symptoms which may or may not involve
1
a loss of consciousness. Majority of patients reach full neurologic recovery within 1-2 weeks, however, 15-20%
2,3
will have persistent signs and symptoms beyond 2 weeks. Persistent symptoms are referred to as Post-
concussion Syndrome (PCS) and is diagnosed according to clinical criteria of physical signs and subjective
4
somatic, cognitive and neurobehavioral symptoms, as there is no gold standard diagnostic test. The broadest
and most sensitive PCS definition is provided by the World Health Organization’s International Classification of
Diseases (ICD-10), including 3 or more of the following: headache, dizziness, fatigue, irritability, insomnia,
2,5
concentration difficulty or memory difficulty, refer to Appendix A. Furthermore, PCS has been delineated into
subtypes of post-concussion disorders (PCD) of physiologic PCD, vestibulo-ocular PCD and cervicogenic PCD
3
based on clinical history, physical examination and graded exercise testing.
Summary of Recommendations
Etiology • There are an estimated 1.7-3 million sports and recreation-related concussions each
2,3,6
year
• Symptoms of acute concussion are believed to be secondary to a global cerebral energy
crisis characterized by alterations in cell membrane permeability, ion transport regulation,
3
neurotransmitter release, cellular metabolism and cerebral blood flow (CBF)
• 15-20% patients will have persistent signs and symptoms beyond 2 weeks.
2,3

• PCS has been delineated into subtypes of post-concussion disorders (PCD) of physiologic
PCD, vestibulo-ocular PCD and cervicogenic PCD based on clinical history, physical
3
examination and graded exercise testing – Appendix B
• Current guidelines recommend a period of cognitive and physical rest early post-injury as
2
symptoms/recovery can increase with cognitive and physical exertion
o No scientific evidence suggests that prolonged rest for more than several weeks is
2
beneficial
2
o No scientific evidence that medication speeds recovery
• Encouraged to prioritize treatments in a hierarchical fashion that address symptoms that
5
could delay recovery first
o Primary: depression, anxiety, irritability, sleep disorder, post-traumatic headache
o Secondary: Balance, dizziness, vertigo, cognition impairment, fatigue, tinnitus,
phonophobia
Risk Factors • Prior h/o concussion(s), previous physical limitations, post-traumatic amnesia (PTA),
posttraumatic migraine, skull fracture, dizziness at time of incident, cognitive deficits in first
2,5,7
few days, reduced balance or dizziness in acute stage, nausea after injury
• H/o psychiatric disorders, learning disability, migraines or family h/o migraines
7

• Female gender or younger age

2,7

Examination • Objective examination measures include assessing components of ROM, posture, joint
mobility and strength testing of the cervicothoracic spine and shoulder complex
• Screening includes neurologic tests, vision, vestibular and c-spine clearance
Outcome • Recommended patient-reported outcome measures include: Concussion Grading Scale,
Testing Post-concussion Symptom Inventory (PCSI- SR5, PCSI-SR8, PCSI-SR13), Neck Disability
1
Index (NDI), Headache Disability Index (HDI), Dizziness Handicap Inventory (DHI) ,
10
Convergence Insufficiency Symptom Survey (CISS) , SF-36, SF-12
• Recommended family/support reported outcome measures include: Post-Concussion
Symptom Inventory – Parent (PCSI-P)
• Recommended balance centered outcome measures include: Balance Error Scoring
1
System(BESS), Mini-BESTest, Dynamic Gait Index (DGI) , Functional Gait Assessment
1 1
(FGA) HiMAT, Timed Up and Go (TUG) TUG Cognitive, Modified Sensory Organization
1 1
Test (mSOT) , 10-meter walk test (10MWT)
• Recommended vestibular centered outcome measures include: VOR, VOR cancellation,
Head Impulse Test (HIT), Dynamic Visual Acuity (DVA), Dix Hall Pike, Joint Position Error,
Motion Sensitivity Quotient (MSQ)
• Recommended cervicogenic centered outcome measures include: joint position error (JPE),
postural stability – with vibration to head/neck as indicated, craniocervical flexion test
(CCFT), head-neck differentiation test, smooth pursuit neck torsion test (SPNT)
• Recommended physiologic centered outcome measures include: Buffalo Concussion
9
Treadmill Test /Balke Protocol
3,8 3,11 3
Key Physiologic PCD Vestibulo-ocular PCD Cervicogenic PCD
Interventions • Physical and cognitive rest • Vestibular rehabilitation • Cervical spine manual
• School/work program therapy
accommodations • Vision therapy program – • Head-neck proprioception
• Sub-symptom threshold refer to OT Vision P2P re-training
aerobic exercise programs • School/work • Balance and gaze
accommodations stabilization exercises
• Sub-symptom threshold • Sub-symptom threshold
aerobic exercise program aerobic exercise program
Recommendations for Outcome Testing

Patient Reported Outcome Measures

Concussion Grading Appendix C
Scale (CGS)
Graded Symptom http://knowconcussion.org/wp-content/uploads/2011/06/graded_symptom_checklist.pdf
7
Checklist
Rivermead Post- http://www.chiropractor-sacramento.com/wp-content/uploads/2010/02/Rivermeade.pdf
Concussion Symptom
7
Questionnaire
Post-Concussion http://www.globalconcussions.org/resources/Post-Concussion-Symptom-Scale.pdf
7
Symptom Scale
Post-Concussion http://www.nhmi.net/media/pdf-files/Parent-Symptom-Scale.pdf
Symptom Inventory -
7
Parent
Neurobehavioral http://dvbic.dcoe.mil/files/DVBIC_-_NSI_Information_Paper_Final.pdf
Symptom Inventory
7
(military specific)
Neck Disability Index https://www.sralab.org/rehabilitation-measures/neck-disability-index
(NDI)
Headache Disability http://www.nwcchiro.com/wp-content/uploads/2015/02/Headache_Disability_Index.pdf
Index (HDI)
Dizziness Handicap
1
https://www.sralab.org/rehabilitation-measures/dizziness-handicap-inventory
Index (DHI)
Convergence http://www.sankaranethralaya.org/pdf/patient-care/Convergence-Insufficiency-Symptom-
Insufficiency Symptom Survey.pdf
10
Survey (CISS)
SF-36 https://www.sralab.org/rehabilitation-measures/medical-outcomes-study-short-form-36
SF-12 https://www.sralab.org/rehabilitation-measures/short-form-12-item-version-2-health-
survey
Balance Outcome Measures
Balance Error Scoring https://www.sralab.org/rehabilitation-measures/balance-error-scoring-system
System (BESS)
Mini-BESTest https://www.sralab.org/rehabilitation-measures/mini-balance-evaluation-systems-test
Dynamic Gait Index https://www.sralab.org/rehabilitation-measures/dynamic-gait-index
1
(DGI)
Functional Gait https://www.sralab.org/rehabilitation-measures/functional-gait-assessment
1
Assessment (FGA)
High Level Mobility https://www.sralab.org/rehabilitation-measures/high-level-mobility-assessment-tool
Assessment Tool
(HiMAT)
Timed Up and Go
1
https://www.sralab.org/rehabilitation-measures/timed-and-go
(TUG)
Modified Sensory https://www.sralab.org/rehabilitation-measures/sensory-organization-test
Organization Test
1
(mSOT) https://www.sralab.org/sites/default/files/2017-06/204Lmctsib.pdf
10-meter Walk Test https://www.sralab.org/rehabilitation-measures/10-meter-walk-test
1
(10MWT)
Physiological Testing
Buffalo Concussion Refer Below – Test and Measures: Activity Tolerance Testing
8
Treadmill Test
9,12
Balke Protocol Refer Below – Test and Measures: Activity Tolerance Testing
Vestibular Outcome Measures
VOR https://www.youtube.com/watch?v=j_R0LcPnZ_w
VOR Cancellation https://www.youtube.com/watch?v=ExOs7HSHv-c
Head Impulse Test https://www.sralab.org/rehabilitation-measures/head-impulse-test-head-thrust-test
(HIT)
Dynamic Visual Acuity https://www.sralab.org/rehabilitation-measures/dynamic-visual-acuity-test-non-
(DVA) instrumented
Vestibulo-oculomotor https://nora.cc/images/documents/VOMS.pdf
Screen (VOMS)
Dix Hall Pike https://www.sralab.org/rehabilitation-measures/dix-hallpike-maneuver
Joint Position Error https://www.sralab.org/rehabilitation-measures/cervical-joint-position-error-test
Motion Sensitivity https://www.sralab.org/rehabilitation-measures/motion-sensitivity-quotient-test
Quotient (MSQ)
Cervicogenic Outcome Measures
Joint Position Error https://www.sralab.org/rehabilitation-measures/cervical-joint-position-error-test
(JPE)
Craniocervical Flexion http://portalsaude.dominiotemporario.com/doc/teste_cranio_cervical.pdf
Test (CCFT)
Head-Neck https://www.sralab.org/rehabilitation-measures/seated-cervical-rotation-test
Differentiation Test
Seated Cervical
Rotation Test
Smooth Pursuit Neck https://www.youtube.com/watch?v=Yh4W5HoU1AU
Torsion (SPNT)
Examination2,7
History • Age, date of injury (DOI), mechanism of injury (MOI), sport specific – wearing helmet or
mouth guard at time of injury, symptoms present at time of injury, loss of consciousness (if
yes, how long?), post-traumatic amnesia (PTA – retrograde or anterograde), current
school/work status, sport participation, exercise habits, disturbance/change of sleep habits,
psychosocial changes, headaches, number of previous concussions (DOI, MOI, symptom
type and duration, time off from school/work/sport/activity)
• Past medical history significant for: Attention Deficit Hyperactivity Disorder (ADHD), seizures,
learning disorder, migraines/headaches, family history of migraines, anxiety, depression
• Pharmacological management : sleep dysregulation, headaches, memory, concentration,
13

mood disturbances
• Systems review and administration of Concussion Grading Scale (CGS) – current symptoms
Screening • Postural alignment in sitting and standing: forward head, head tilt, rounded shoulders,
shoulder elevation, scapular winging, pelvic alignment/symmetry
• Neurologic screen: sensation/dermatomes, upper and lower extremity myotomes, deep
tendon reflexes (DTR), Hoffman’s, Babinski’s, CN screen
• Visual/oculomotor screen: spontaneous nystagmus, gaze holding nystagmus, smooth
pursuit, saccades, convergence insufficiency, accommodation insufficiency
• Cervical clearing: compression, distraction, spurling’s maneuver, alar ligament, sharp-purser,
transverse ligament, vertebral artery insufficiency
• Vestibular screen: Central/peripheral vestibular screens, joint position error (JPE), postural
16

stability – with vibration to head/neck as indicated, craniocervical flexion test (CCFT), head-
neck differentiation test, smooth pursuit neck torsion test (SPNT)
Tests and • Cervical, thoracic and shoulder A/PROM
Measures • Palpation
• Joint mobility/alignment
• Strength testing: cervical flexion, extension, lateral flexion, rotation, deep neck flexor
isometric hold / cranial cervical flexion test with biofeedback cuff)
• Impairment based outcome measures
o Patient-reported outcome measures: Concussion Grading Scale, Neck Disability Index
1
(NDI), Headache Disability Index (HDI), Dizziness Handicap Inventory (DHI) ,
Convergence Insufficiency Symptom Survey (CISS), SF-36, SF-12

o Family/support reported outcome measures include: Post-Concussion Symptom

Inventory – Parent (PCSI-P)
3
o Balance outcome measures: Balance Error Scoring System (BESS) , Mini-BESTest,
3 3
Dynamic Gait Index (DGI) , Functional Gait Assessment (FGA) , High Level Mobility
Assessment Tool (HiMAT), Timed Up and Go (TUG), TUG cognitive, Sensory
Organization Test (SOT), 10-meter walk test (10MWT)

o Vestibular outcome measures: VOR, VOR cancellation, Head Impulse Test (HIT),
3
Dynamic Visual Acuity (DVA), Dix Hall Pike , Joint Position Error, Motion Sensitivity
Quotient (MSQ), Vestibulo-oculomotor Screen (VOMS)

o Cervicogenic centered outcome measures: Joint Position Error, Postural Stability- with
vibration to head/neck as indicated, craniocervical flexion test (CCFT), head-neck
differentiation test, smooth pursuit neck torsion test (SPNT)

o Activity tolerance testing:

 Degree of exercise intolerance shortly after [1-9 days post] sports related concussion
18
(SRC) strongly predicts time to recovery
 Treadmill testing in patients with symptoms persistent >10 days should not be
performed before 3-weeks post-injury with intent to implement Return to Activity
2
Protocol
 9,12
Buffalo Concussion Treadmill Test Balke Protocol
8,14
(BCTT) – Appendix D • Treadmill speed set at 3.3 mph at 0%
• Treadmill Speed incline. After 1 min, treadmill grade
o 3.6 mph for patients >/= 5’5” increased to 2.0% maintaining same speed.
o 3.2 mph for patients < 5’5” At the start of the third minute treadmill
o Speed may be adjusted +/- .2 mph to grade raised by 1%.
3.4 mph as needed for taller/shorter or • Blood pressure (sphygmomanometer)
athletic/sedentary patients to facilitate a measured every 2 minutes. Heart rate (HR
normalized walking speed. monitor) and rate of perceived exertion -
• Patient starts at 0% incline. Incline is RPE (Borg scale) measured every minute,
increased by 1% at minute 2 and by 1% as well as patient rating of symptom change
each minute thereafter until max incline is and therapist observation.
reached. If patient is able to continue, • Test is terminated at report of exacerbation
speed is increased by 0.4 mph until of PCS symptoms
stopping criteria is fulfilled.
• Stopping Criteria
o PCS symptoms increase per CGS –
clinical judgement
o 20 min time cap
o RPE of 19-20
• RPE, HR and assessment of new PCS
symptoms assessed every 1-minute
• BP assessed every 2-minutes
Patient • Several studies demonstrate brief, single session education-oriented treatment is superior to
5,13
Education standard procedures and even as effective as more intensive interventions
• Education session can include but not limited to:
o Common symptoms, reassurance, typical time and course of recovery, how to manage
or cope, gradual reintegration to regular activities, how to access further support, regular
stress management
• Strongly suggested education handouts
o https://patienteducation.osumc.edu/Documents/concuss.pdf
o http://www.michigan.gov/documents/mdch/TBI_Recovery_Guide_10.8.08_252053_7.pdf
Recommendations for Physiologic PCD Interventions
Etiology
• Persistent alterations in cell membrane permeability, ion transport regulation, neurotransmitter release,
3,8
cellular metabolism and CBF.
o Magnetic resonance spectroscopy studies, athletes who report being symptom free at 3-15 days did
not have complete metabolic recovery until 30 days post-injury, with mitochondrial metabolism taking
2,8
an additional 15 days with a second concussion
• Exacerbation of symptoms during cognitive activity and/or physical exercise secondary to persistent
3
cerebral metabolic energy deficiency.
• Autonomic nervous system dysfunction characterized by higher rates of sympathetic nervous system
output (resting HRs and HR during cognitive and/or physical activity) proportional to TBI severity and
2,3
improves during TBI recovery
• Exercise testing and rehab should be employed only if patients have persistent symptoms for 3-6 weeks
2
or more – Appendix B
o For sports related concussion (SRC) OSU’s Return to Sport Guidelines should be followed days 1-
14 – Appendix F
o Treadmill testing in patients with symptoms persistent >10 days should not be performed before 3-
2
weeks post-injury with intent to implement Return to Activity protocol

Physical and • Animal experiments found premature exercise within first week post-injury led to
Cognitive Rest impaired cognitive performance and reduced brain-derived neurotrophic factor
3
(BDNF)
• Patient’s with symptoms at rest should be managed conservatively with cognitive
3
and physical rest
• Continued cognitive and physical rest is recommended for children
3

Prognostic • Exercise intolerance testing may be emerging as one of the best systemic
18
Utility physiological biomarkers in concussion recovery
• Degree of exercise intolerance shortly after [19- days post] SRC strongly predicts
18
time to recovery
o Subjects with a low HR threshold (<135 bpm) are approximately 45x more likely
18
to have prolonged recovery
Sub-symptom • Animals with mTBI exposed to exercise 14-21 days post exercise were found to
3,8
Threshold improve cognitive performance and high levels of BDNF
8
Aerobic o Exercise-induced BDNF is dependent on injury severity
Exercise  i.e. – moderate TBI = 30-36 days after injury
Program • Sub-symptom threshold programs should be considered in adolescent and adults
3
with symptoms persisting beyond 3 weeks
• Subthreshold aerobic exercise treatment has been shown to restore fMRI brain
8
activation patterns to normal vs a sham (stretching) program
• OSU’s Return to Activity Protocol – Refer to Appendix E
o Establish sub-symptom threshold with BCTT per physician recommendation
 % HRmax at which BCTT was terminated
o Decrease % above by 15-20% = Prescribed HR
o Correlate Prescribed HR to Phase I-VI of OSU RTA Protocol
o Progress through phases as indicated by min to no symptom exacerbation
8
 Patients who are more fit or athletes generally respond faster
• Physiological resolution of concussion = ability to exercise at 85-90% age-predicted
8
HRmax for 20 min without exacerbation of symptoms for several consecutive days
o Athletes must be cleared by their physician of record prior to return to
sport

• For additional resources/questions contact alicia.almond@osumc.edu

Recommendations for Vestibulo-ocular PCD Interventions
Etiology
• Vestibular, oculomotor and somatosensory systems consist of special sensory organs with primary
processing units that share direct, indirect and reciprocal projections to the spinal cord, autonomic
3
nervous system, brainstem nuclei, cerebellum, thalamus, basal ganglia and cerebral cortex
• Symptoms such as vertigo, dizziness (23-81% in first days, 16-18% at three months, 32.5% at 5 years),
1,11
nausea, light-headedness, gait instability and postural instability can originate from vestibular
dysfunction
3,11
o Vestibulo-ocular reflex (VOR) regulates gaze stabilization during head acceleration
o Vestibulo-spinal reflex (VSR) coordinates head, neck and trunk positioning during dynamic body
3
movements
o Post-traumatic benign paroxysmal positional vertigo (BPPV), labyrinthine concussion, perilymphatic
3
fistula, endolymphatic hydrops, otolith disorders and central vestibular disorders
3
 >1 of the above mechanisms present in up to 46% concussion patients
• Symptoms such as blurred vision, diplopia, difficulty tracking objects, difficulty reading, motion sensitivity,
eye strain brow-ache, trouble focusing or headache can originate from accommodation, version (pursuits,
saccades and fixation), convergence insufficiency, photosensitivity and rarely visual field defects and CN
3
palsies
o Warrants referral to vision specialist/OT - refer to OT Vision P2P

BPPV • Repositioning techniques

•
1,3,11
Eye-Head VORx1 and VORx2 (yaw and pitch planes)
Coordination • Modify frequency, BOS, stability of surface and complexity of visual background
•
11
Prescribed in 95% of patients
•
11
Sitting Supported and unsupported sitting, weight shifts, bouncing
Balance
Standing • Modifiers refer to Appendix G
•
3,11
Static Balance Modify base of support (rhomberg, tandem, single leg stance, etc)
•
11
Weight shifting in variable directions
•
11
Prescribed in 88% of patients
•
11
Standing Sit to stand
Dynamic • Marching, step forward or backward, step to the side, step up or down, turn
11
Exercises around
Ambulation • Walking forward, backwards, tandem, on stairs, with whole body turns and head on
11
body turns, braiding/grape vine, skipping, jogging and running
• Prescribed in 76% of patients
•
3,11
Sensory Modify stability of surface (foam, rocker board, etc.)
•
11
Re-integration Modify BOS
•
11
Modify positioning of trunk and arms
•
11
Incorporate head movements and modify direction of movement
•
11
Visual Integration (Eyes open, eyes closed, distraction)
•
11
Dual Tasking
• Refer to Appendix F for progression of each modifier
Recommendations for Cervicogenic PCD Interventions
Etiology
• Structural and functional injury to the cervical spine can be associated with symptoms such as headache,
4
dizziness, blurred vision and vertigo as rotational forces can effect nerve tracts and proprioceptive fibers
o Cervical afferents carry proprioceptive information to the cerebellum via spinocerebellar tracts and to
the dorsal column nuclei via posterior column-medial lemniscal pathways, which project to the
3
thalamus and primary somatosensory cortex
o Cervical afferent project to central cervical nucleus, vestibular nuclei and superior colliculi to mediate
head and neck position send through coordination of the cervicocollic reflex (CCR), vestibulocollic
3
reflex (VCR) and cervico-ocular reflex (COR) respectively
• Cervicogenic dizziness is a diagnosis of exclusion
o Neck pain, stiffness, decreased range of motion, dizziness, impaired balance, impaired head-neck
position sense
o No evidence of central or peripheral vestibular involvement
o Negative BCTT
o Appendix B
• Difference in cervical muscle strength development, ligamentous laxity, head-body proportions and
3
cervical spine mobility may place children and adolescents at increased risk
o Neck strength is a significant predictor of concussion among high school athletes; for every one
15
pound increase in neck strength, odds of concussion decrease by 5%

Cervical • Passive and active range of motion

Mobility and • Soft tissue mobilization
Pain
3
• Grade I-IV mobilizations
Management o Upper cervical spine
o Cervico-thoracic junction
•
17
Minimal evidence to support Grade V manipulations
•
16
Mulligan techniques – SNAGs
• Traction/distraction
•
16
Muscle energy techniques – contract/relax
Cervical • Joint position error training
3
Proprioception o Progress to tracing figures and/or complex designs
• Gaze stabilization – VORx1 and VORx2 progressions
Cervical • Strength and stabilization retraining
Strengthening o Deep neck flexors
o Cervical extensors
Postural • Biofeedback using mirrors
Retraining • Ergonomic training/education
• Movement control training/education
o Sport specific activity, job related tasks, activities of daily living
• Abdominal/trunk strengthening
• Scapular strengthening
Appendix A: PCS Diagnostic Criteria

Diagnostic Criteria for Post-Concussion Syndrome (ICD-10)

A. History of head trauma with loss of consciousness preceding symptom onset by a maximum of 4 weeks.
B. Symptoms in 3 or more of the following symptom categories
• Headache dizziness, malaise, fatigue, noise tolerance
• Irritability, depression, anxiety, emotional lability
• Subjective concentration, memory or intellectual difficulties without neuropsychological evidence of
marked impairment
• Insomnia
• Reduced alcohol tolerance
• Preoccupation with above symptoms and fear of brain damage with hypochondriacal concern and
adoption of sick role

Diagnostic Criteria for Postconcussional Disorder (DSM-IV)

A. A history of head trauma that has caused significant cerebral concussion.
The manifestations of concussion include loss of consciousness, posttraumatic amnesia, and less
commonly, posttraumatic onset of seizures. The specific method of defining this criterion needs to be
established by further research.
B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty in attention
(concentrating, shifting focus of attention, performing simultaneous cognitive tasks) or memory (learning or recall
of information).
C. Three (or more) of the following occur shortly after the trauma and last at least 3 months:
• Becoming fatigued easily
• Disordered sleep
• Headache
• Vertigo or dizziness
• Irritability or aggression on little or no provocation
• Anxiety, depression or affective instability
• Changes in personality (e.g. social or sexual inappropriateness)
• Apathy or lack of spontaneity
D. The symptoms in criteria B and C have their onset following head trauma or else represent a substantial
worsening of preexisting symptoms.
E. The disturbance causes significant impairment in social or occupational functioning and represents a significant
decline from a previous level of functioning. In school-age children, the impairment may be manifested by a
significant worsening in school or academic performance dating from the trauma.
F. The symptoms do not meet criteria for Dementia Due to Head Trauma and are not better accounted for by
another mental disorder (e.g. Amnestic Disorder Due to Head Trauma, Personality Change Due to Head Trauma)
Appendix B: Proposed Algorithm for Differential Diagnosis of PCD Subtypes
Summary of pathophysiology, predominant symptoms, pertinent physical examination findings, graded treadmill
test results and treatment options in patients with PCDs

Physiologic PCD Vestibulo-ocular PCD Cerviogenic PCD

Pathophysiology • Persistent alterations in • Dysfunction of the • Muscle trauma and
neuronal depolarization, vestibular and oculomotor inflammation
cell membrane symptoms • Dysfunction of cervical
permeability, spine proprioception
mitochondrial function,
cellular metabolism and
cerebral blood flow
Predominant • Headache exacerbated by • Dizziness, vertigo, • Neck pain, stiffness and
Symptoms physical and cognitive nausea, lightheadedness, decreased range of
activity gait instability and postural motion
• Nausea, intermittent instability at rest. • Occipital headaches
vomiting, photophobia, • Blurred or double vision, exacerbated by head
phonophobia, dizziness, difficulty tracking objects, movements and not
fatigue, difficulty motion sensitivity, physical or cognitive
concentrating, slowed photophobia, eye strain or activity
speech brow-ache, and headache • Lightheadedness and
exacerbated by activities postural imbalance
that worsen vestibule-
ocular symptoms (i.e.
reading)
Physical exam • No focal neurological • Impairments on • Decreased cervical
findings findings standardized balance and lordosis and range of
• Elevated resting HR gait testing motion
• Impaired VOR, fixation, • Paraspinal and sub-
convergence, horizontal occipital muscle
and vertical saccades tenderness
• Impaired head-neck
position sense
Graded treadmill • Often terminated early due • Patients typically reach • Patients typically reach
test to symptom onset or maximal exertion without maximal exertion without
exacerbation exacerbation of vestibulo- exacerbation of
ocular symptoms cervicogenic symptoms
Management • Physical and cognitive • Vestibular rehabilitation • Cervical spine manual
options rest program therapy
• School accommodations • Vision therapy program • Head-neck
• Sub-symptom threshold • School accommodations proprioception re-training
aerobic exercise • Sub-symptom threshold • Balance and gaze
programs should be aerobic exercise stabilization exercises
considered for programs should be • Sub-symptom threshold
adolescent and adult considered for aerobic exercise
athletes adolescent and adult programs should be
athletes considered for
adolescent and adult
athletes
Appendix C: Ohio State Concussion Grading Scale
Circle the number in each row that best describes the way you have been feeling relative to the
symptom. Patient Name

Symptom None Mild Moderate Severe

Headache 0 1 2 3 4 5 6
“Pressure in Head” 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Nausea or Vomiting 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6
Blurred Vision 0 1 2 3 4 5 6
Balance Problems 0 1 2 3 4 5 6
Sensitivity to Light 0 1 2 3 4 5 6
Sensitivity to Noise 0 1 2 3 4 5 6
Feeling Slowed Down 0 1 2 3 4 5 6
Feeling Like “In a Fog” 0 1 2 3 4 5 6
Don’t Feel Right 0 1 2 3 4 5 6
Difficulty Concentrating 0 1 2 3 4 5 6
Difficulty Remembering 0 1 2 3 4 5 6
Fatigue or Low Energy 0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Trouble Falling Asleep 0 1 2 3 4 5 6
More Emotional 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6
Nervous or Anxious 0 1 2 3 4 5 6
Sleeping More Than Usual 0 1 2 3 4 5 6
Sleeping Less Than Usual 0 1 2 3 4 5 6
Difficulty Sleeping Soundly 0 1 2 3 4 5 6
Ringing in Ears 0 1 2 3 4 5 6
Numbness or Tingling 0 1 2 3 4 5 6

1. Over the past week, my sleeping pattern has changed. ☐Yes ☐No If NO, skip to #2
a. Have you been taking naps during the middle of the day? ☐Yes ☐No
b. Are you waking during the night? ☐Yes ☐No
2. Over the past week, my participation in work or school has been % of what it would be
normally.
3. Over the past week, my participation in physical activity (sports, working out, etc.) has been
% of what it would be normally.
4. Do you feel like you are putting more effort more effort into maintaining schoolwork/grades and/or work
productivity? (Circle corresponding number below)
0 1 2 3 4 5 6
No More Effort -------------------------------------------------------------------------------------------------------------------------A Lot More Effort

5. Please indicate the type of visual changes you are experiencing:

☐Eye Fatigue ☐Double Vision ☐Blurry Vision ☐Other ☐n/a
6. Do your symptoms get WORSE with physical activity? ☐Yes ☐No
7. Do your symptoms get WORSE with thinking/cognitive activity? ☐Yes ☐No
8. Do your symptoms IMPROVE with physical rest? ☐Yes ☐No
9. Do your symptoms IMPROVE with thinking/cognitive rest? ☐Yes ☐No
Appendix D: Buffalo Concussion Treadmill Test

Name _________________________________ Date ____________________

Symptoms ______________________________________________________________________________

HRmax = 220 – age = _______ Resting HR ________ Resting BP ________ Speed________

Min HR BP RPE Symptom Change Observations

0
1 -
Incline increased by 1% at start of minute 2
2
3 -
4
5 -
6
7 -
8
9 -
10
11 -
12
13 -
14
15 -
16
17 -
18
19 -
20
2-min
post
5-min
post
Notes:
Appendix E: Return to Activity Protocol
Each phase to last 1 to 2 weeks, all phases should be progressed to patient tolerance avoiding all concussion signs and
symptoms, patient should participate in monitored home program 6 days per week.

Phase I (no impact)

Cardiovascular Conditioning (elliptical, stationary bike, spinner)
• 30 to 50% max heart rate times 15 to 20 minutes
Strengthening
• 50% max time 4 way plank
• Upper and lower body strengthening without resistance with low sets and reps
Phase II (low impact) Cardiovascular Conditioning (elliptical, stationary bike, spinner, walking on treadmill)
• 30 to 50% max heart rate times 20 to 30 minutes
• 10 min at 30 to 50%, 3-5 min at 60 to 80%, 5 min at 30 to 50%, 3-5 min at 60 to 80%, 5-10 min at 30 to 50%
• 60 to 80% max heart rate times 5 to 10 minutes
Strengthening/Balance
• 75 to 100% max time 4 way plank
• Upper and lower body strengthening with body weight at low sets and high reps
• Upper and lower body strengthening with body weight at low sets and low reps
• Initiate static balance activities on firm surface with eyes open per Balance Error Scoring System (BESS)
Phase III (impact)
Cardiovascular Conditioning (initiate running on treadmill to tolerance)
• 60 to 80% max heart rate times 10 to 15 minutes
Strengthening/Balance
• 100% max time 4 way plank, dynamic core strength and stability
• Upper and lower body strengthening with body weight at low sets and high reps
• Upper and lower body strengthening with resistance at low sets and reps
• Progress balance activities to eyes closed per BESS
Phase IV (agility)
Cardiovascular Conditioning (continue treadmill running, initiate running on sport specific surfaces)
• Warm up: 60% max heart rate times 15 minutes
• Circuit training: 60-80% max HR for 30 minutes [Borg 11-14 (light to somewhat hard)]
Each interval should be 30 seconds in duration. May complete extra cycles if time and symptoms allow
Cardio LE Strength Balance Cardio UE Strength Agility Cardio Core Rest
Cycle 1 Jog Squats SLS Eyes Jog T-band Shoulder Box Drill Jog Prone Plank 2 min
Closed Extension
Cycle 2 Jog Walking SLS with Jog Push-ups Pro-Agility Jog R side Plank 2-min
Lunges UE Chop (modified) (T-drill)
Cycle 3 Jog T-Band Star Drill Jog T-Band Star Pulls W-Drill Jog L side Plank 2-min
Resisted
Sidestep
Phase V (return to activity)
Cardiovascular Conditioning (continue treadmill running, continue running on sport specific surfaces)
• Warm up: 60 to 80% max heart rate times 20-30 minutes
• Circuit training: 60-80%max HR for 30 minutes [Borg scale 14-18 (Hard to very hard)]
Each Interval should be 30-45 seconds in duration. May complete extra cycles if time and symptoms allow
Cardio LE Strength Balance Cardio UE Strength Agility Cardio Core Rest
Cycle 1 Jog 2-foot Jumps SLS on Foam Jog Med Ball Box Drill Jog Med Ball 2 min
in Place + Rebounder Slams Twists
Cycle 2 Jog Lateral Bench SLS with UE Jog T-Band Rows Pro-Agility Jog R side Plank 2 min
Jump Plyos Shop (T-Drill) with Rotation
Cycle 3 Jog Lunge SLS with Floor Jog Med Ball W-Drill Jog L side Plank 2 min
hops/switch Touch Chest Pass with Rotation
(wall)
Phase VI (return to full contact practice) - Check in briefly to determine if PT needs persist
 Appendix F: Return to Sport Protocol

Prior to beginning the return to sport progression, the athlete must complete a period of cognitive and
physical rest – 24-48 hrs. Length of rest period will be determined by physician or appropriate medical
professional.
• Symptom checklist should be completed by athlete before and after each treatment/exercise
session
• If symptoms are elevated with exercise beyond permissible criteria, do not progress to next
phase. Return athlete to previous phase which did not elevate symptoms.
• Communication with physician required prior to advancing beyond day/phase 3.
If athlete is unable to progress through phase 5 after 14 days, athlete should be referred back to a
physician for additional multidisciplinary testing, and a Buffalo Concussion Treadmill Testing (BCTT)
may be considered
Light aerobic
Day/Phase 1

activity
(30-40% max HR) Target Heart Rate = ((max HR − resting HR) × %Intensity)
- 5 min warm up
- 15 min duration

Moderate aerobic Each cycle completed one time. Each exercise in cycle 1-2 performed for 30 sec
activity
Day/Phase 2

Cycle 1 Jog Squats Jog Push ups Jog Lunges Jog Bridges Jog 2 min rest
(40-60 % max HR)
- 5 min warm up Cycle 2 Jog Squats Jog Push ups Jog Lunges Jog Bridges Jog 2 min rest
- 15 min duration Single Leg Single Leg
Prone Plank
- 15 min circuit Cycle 3 balance on Right Balance on Left
(30 sec-1 min)
based exercise (30 sec) (30 sec)

Higher intensity Each cycle completed one time. Each exercise in cycle 1-2 performed for 30 sec
aerobic activity Lunge Box
(60-80% max HR) Cycle 1 Jog Hops Jog Skips Jog Jog Jog 2 min rest
hops Drill
Day/Phase 3

-5 min warm up Lunge Box

Cycle 2 Jog Hops Jog Skips Jog Jog Jog 2 min rest
-20 min duration hops Drill
-15 min circuit Single Leg stance Single Leg stance
Side plank Left Side plank Right
Cycle 3 with perturbations with perturbations
based exercise (30 sec) (30 sec)
(30 sec) (30 sec)
-Sport specific
Non-contact sport specific aerobic drills x 5 min: i.e. – Running, Skating, etc.
non-contact drills
Day/Phase 4

Return to practice Non-contact sport specific drills to tolerance: initiate harder training drills, agility and passing drills. May
Non-contact Drills start to progressive resistance training.

Communication with physician required before advancing beyond phase 4

Day/Phase 5: Full Contact Practice

Day/Phase 6: Return to Sport

Appendix G: Modifiers for Vestibular Rehabilitation11

Each phase to last 1 to 2 weeks, all phases should be progressed to patient tolerance avoiding all concussion
signs and symptoms, patient should participate in monitored home program 6 days per week.

Modifier Choices

Posture 1: Sitting, 2: Standing, 3 Walking, Not applicable/Not specified (NA/NS)

Surface 1: Level, 2: Form, 3: Uneven, 4: Obstacle, 5: Stairs, 6: Ramps, NA/NS)
Base of support 1: Feet apart, 2: Feet together, 3: Semi-tandem, 4: Tandem, NA/NS
Trunk position 1: Upright, 2: Learning, 3: Rotated, NA/NS
Arm position 1: Weight-bearing, 2: Close to body, 3: Away from body, 4: Reaching,
5: Carrying, 6: Picking up objects, 7: Juggling, NA/NS
Head movement direction 1: Still, 2: Yaw, 3: Pitch, 4: Roll, NA/NS
Direction of whole body movements 1: Anterior-posterior, 2: Medial-lateral, 3: Multi-directional, NA/NS
Visual movement 1: Eyes closed, 2: Eyes open, 3: Complex patterns, NA/NS
Cognitive dual task 1: Yes, 2: No
Special circumstances For example, note if the VORx1 exercise was performed with near or
far target
Authors: Alicia Almond PT, DPT, NCS
Reviewers: Chaundra Catrone PT, MPT and John Dewitt PT, DPT, SCS, AT
Updated: March 2018

References
1. Alsalaheen BA, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion.
JNPT. 2010; 34: 87-93.
2. Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer B. Rehabilitation of concussion and post-concussion
syndrome. Sports Health. 2012; 4(2): 147-154.
3. Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders:
An evidence-based classification system with directions for treatment. Brain Injury. 2015; 29(2): 238-248.
4. Leddy JL, Baker JG, Merchant A, Picano J, Gaile D, Matuszak J, Willer B. Brain or strain? Symtpoms
alone do not distinguish physiologic concussion from cervical/vestibular injury. Clin J Sport Med. 2014: 1-
6.
5. Marshall S, Bayley M, McCullagh S, Velikonja D, Berrigan L. Clinical practice guidelines for mild traumatic
brain injury and persistent symptoms. Can Fam Physician. 2012; 58: 257-267.
http://onf.org/system/attachments/60/original/Guidelines_for_Mild_Traumatic_Brain_Injury_and_Persisten
t_Symptoms.pdf
6. Concussion Facts and Statistics. UPMC Sports Medicine. 2017. http://www.upmc.com/Services/sports-
medicine/services/concussion/Pages/facts-statistics.aspx.
7. Concussion Clinical Summaries. American Physical Therapy Association (APTA). 2015.
http://www.ptnow.org/ClinicalSummaries/CollectionDetail?resourceId=8d77866e-c1da-4556-acdc-
1dcb04ff206f.
8. Leddy J, Hinds A, Sirica D, Willer B. The role of controlled exercise in concussion management. PM R.
2016: 91-100.
9. Leddy JJ, Kozlowski K, Donnelly JP, Pendergast DR, Epstein LH, Willer B. A preliminary study of
subsymptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;
20: 21-27.
10. Rouse MW, et al. Validity and reliability of the revised convergence insufficiency symptom survey in
adults. Ophthal Physiol Opt. 2004; 24: 384-390.
11. Alsalaheen BA. Exercise prescription patterns in patients treated with vestibular rehabilitation after
concussion. Physiother Res Int. 2013; 18(2): 100-108.
12. Leddy JL, Baker JG, Kozlowski K, Bisson L, Willer B. Reliability of a graded exercise test for assessing
recovery from concussion. Clin J Sports Med. 2011; 21: 89-94.
13. Hunt T, Asplund C. Concussion assessment and management. Clin Apoera Med. 2010; 29: 5-17.
14. Leddy JJ, Willer B. Use of graded exercise testing in concussion and return-to-activity management.
ACSM. 2013; 12(6): 370-376.
15. Collins CL, Fletcher EN, Fields SK, Kluchurosky L, Rohrkemper MK, Comstock RD, Cantu RC. Neck
strength: a protective factor reducing risk for concussion in high school sports. J Primary Prevent. 2014;
35: 309-319.
16. Landel R. Cervicogenic Dizziness: An Evidence Based Competency Course. APTA
17. Chappel C, Dodge E, Dogbey GY. Assessing the immediate effect of osteopathic manipulation on sports
related concussion symptoms. Osteopathic Family Physician. 2015; 7(4): 30-35.
18. Leddy JJ, et al. Safety and prognostic utility of provocative exercise testing in acutely concussed
adolescents: a randomized trial. Clin J Sport Med. 2018; 28:13-20.


NEUROLOGICAL VISION SCREENING

AFTER TBI CLINICAL PRACTICE GUIDELINE
The following are recommendations for a thorough screening of neurological vision impairment, based on the
current scientific literature, which can then be used to develop a client-centered treatment plan, in collaboration
with an OD or MD (vision specialist). A visual screener can be completed by a trained, non-vision specialist
clinician, but it does not substitute for a full evaluation by a vision specialist. It allows us to identify appropriate
candidates, make needed referrals, and opens up the line of communication between the therapist and doctor. It
is not within an OT’s scope of practice to diagnose. Many conditions can be treated by a licensed therapist who
has been trained in vision therapy techniques, but must be in collaboration with a vision specialist. This
collaboration allows integration of assessments of the eye/lower-order cerebral mechanisms (visual function) and
37
person-level dysfunction/higher-order cerebral mechanisms (functional vision), targeting quality of life.

Vision Specialists
• Optometrist – Doctors of Optometry (OD) diagnose and treat vision problems, eye diseases and related
conditions, prescribe eyeglasses and contact lenses and provide medication to treat eye disorders. They
cannot perform surgery but often provide pre and post-surgical care.
• *It is important to refer neuro/concussion patients to an Optometrist who can provide a neuro-
optometric/sensorimotor evaluation, as not all Optometrists perform this type of assessment.
(See specialists on page 10).

• Ophthalmologist – MD who specializes in the medical and surgical care of the eyes and visual system and in
the prevention of eye disease and illness

• Neuro Ophthalmologist – Subspecialists of neurology and ophthalmology who address visual problems
related to the nervous system

• American Optometric Association – www.aoa.org

• Neuro-Optometric Rehabilitation Association – www.nora.cc

• College of Optometrists in Vision Development – www.covd.org/

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.


Terminology
The 3 subsystems of version, vergence and accommodation must be precisely synchronized for efficient
oculomotor control during activities such as reading.

Accommodation The ability of the eye to change focus from distance to near objects, and is achieved by the
ciliary muscle adjusting the shape of the intraocular lens. Accommodative dysfunction may
result in Accommodative Insufficiency, Spasm (overstimulation), or Infacility (slowed)

Vergence Eye The simultaneous movement of both eyes, in opposite directions, as needed for single,
Movements binocular vision, and stereopsis. Stereopsis is binocular depth perception, as the two separate
images from each eye are successfully combined /fused into one image in the brain. Includes
convergence and divergence.
Binocular Strabismic - eyes are misaligned, may be Non-strabismic
Vision constant or intermittent • Esophoria – eyes have a tendency to turn in
Disorders • Esotropia – eyes turn in • Exophoria – eyes have a tendency to turn out
• Exotropia – eyes turn out • Hyperphoria – One eye has a tendency to turn up
• Hyper tropia – one eye turns up
Diplopia Double vision that suggests misalignment of the eyes. Occurs when the object at which the
individual is looking stimulates the fovea (part of the retina that contains the area of most acute
vision) of one eye, and a non-foveal part of the retina of the other eye.

Suppression A condition in which the visual system ignores the input from one eye, usually associated with
strabismus or amblyopia.
Versional Eye Saccades - fast, simultaneous eye movements Pursuits - eye movements that allow smooth,
Movements in the same direction, to change the fixation continuous viewing of a moving object, and
point. During visual scanning, as in reading, play a significant role in driving and sports.
the eyes make saccadic movements and stop
Pursuit dysfunction can include ataxia (jerky
several times, moving very quickly between
each stop. Saccadic dysfunction may include quality), and decreased velocity.
impaired velocity, accuracy, and or initiation of
eye movements (ocular motor apraxia)
Peripheral/ Allows awareness of position in space, and provides general information needed for balance,
Ambient Vision movement, coordination, and posture. Unstable ambient vision after BI may cause vertigo,
sensitivity to light and motion, and nausea. Also, having intact visual fields does not necessarily
correlate with intact peripheral awareness or intact central/peripheral vision integration.

Vestibulo- The VOR is one of the fastest reflexes in the human body. At least slight head movement is
Ocular reflex present all of the time, so the VOR is always important for gaze stabilization. Reflexive eye
(VOR) movements stabilize images on the retina during head movement by producing a compensatory
eye movement in the direction opposite to the head movement. In order to have clear vision,
head movements must be compensated for almost immediately. Individuals with VOR
impairment may complain of vision “looking like a photograph taken with a shaky hand”, or
seeing “trails”, dizziness, and imbalance.

Background
Subtle changes in brain function can occur even after mild TBI/Concussion. Approximately 80% of our perception,
23
learning, cognition and activities are mediated through vision, and greater than half of the circuits in the brain are
3
involved in vision , including many regions susceptible to shearing during head impacts. Visual system tests
probe higher cortical functioning, and assist in detecting functional changes in patients. Abnormal oculomotor and
binocular vision skills (ie convergence, accommodation, ocular muscle balance, saccades, and pursuits),
3,18,19,48,49
vestibular-ocular reflex, and subjective visual complaints are common following TBI, including mTBI .
Oculomotor dysfunction has been estimated to be as high as 90% in individuals with TBI, followed by
37,47
accommodative and convergence deficits . Further, early detection of vision abnormalities may predict
49
individuals at risk of more severe head impacts . Also, it is worth noting that approximately 95% of patients with
visual symptoms/complaints caused by TBIs have normal fundoscopic (exam of the retina) findings. An individual
can have normal acuity (ie 20/20), but still have impaired oculomotor or eye teaming skills, and therefore impaired
functional vision.

Poorer oculomotor function is correlated with more post-concussive

21,48
symptom s and problems with ADL . Likewise, a recent study by
32
, found that Convergence Insufficiency was common (~42%) in
athletes evaluated within 1 month after a sport-related concussion,
and that these athletes had worse neurocognitive impairment and
32
higher symptom scores than did those with normal NPC . In such
cases, more effort will constantly be required for the individual to
perform these lower-level actions (ie basic oculomotor control to
focus/fuse words) which should be automatic. Subsequently, higher
level skills such as comprehension, attention, short-term visual
32 ,46
memory, and executive function, will be compromised. The
concept of visual skill hierarchy is illustrated by the Mary Warren
50
Triangle :

Incidence
Common • Blurred vision • Visual field impairments
visual • Difficulty with reading • Photosensitivity
impairments • Diplopia/eye strain • Color blindness
in first year • Dizziness or disequilibrium in visually
17
post-TBI crowded environments

Incidence High prevalence in abnormalities of: • Accommodation

specific to • Saccades • Vestibulo-ocular reflex (VOR)
17,30,48
mTBI • Pursuits • Photosensitivity
• Vergence (most likely convergence)


Recommendations
(Radomski, 2014). A consensus panel of experts using a nominal group technique has recommended the
screening items below. These have been proposed as “better practice” for vision screening post-TBI with adults,
until a validated option becomes available for non-vision specialist clinicians. Items are to be performed in this
35
order. Assessments in italics can also be considered.

Direct • Direct observation of occupational performance, with attention to behaviors suggesting

Observation vision dysfunction.
• Also, consider possible time-dependency of symptoms, as they may not manifest
immediately. The individual may report complaints only after performing a visual task for
certain duration of time.
Questionnaires/ Often, patients have difficulty describing their symptoms, and may not recognize them as
Surveys related to visual deficits (i.e. fatigue, poor attention, dizziness, headache). Using one or more of
3
the following self-report surveys can help the clinician obtain informative answers.
12,35
• COVD QOL outcomes assessment plus photosensitivity interview question
38
• CISS – score of >21 can indicate impairment
19
• Goodrich, et al. history questions
3
• The Visual Interview
Questionnaires if Vestibular Impairment is Suspected
10
• The Vestibular Disorders Activities of Daily Living Scale
2,29
• The Vestibular Activities and Participation Measure
35,43
Far Acuity • Chronister Portable Acuity Test (www.guldenophthalmics.com)
• Snellen Acuity Chart
Referral to OD is necessary if vision is 20/40 or worse. The numerator refers to the testing
distance at which the person recognizes the letter, and the denominator refers to the distance
at which the letter being viewed could be identified by a person with normal (20/20) visual
43
acuity.
35,43
Near • Chronister Portable Acuity Test reading card
Acuity/Reading Referral to OD is necessary if vision is 20/40 or worse
43
Accommodation* • Accommodative amplitude testing
1. Patch L eye
2. Hold a target (ie, fixation stick) with a 20/30 letter about 1 inch in front of the R eye (it
will be blurry at this distance)
3. Slowly move the target away, and ask the patient to report as soon as he or she can
identify the target letter
4. Using a ruler, measure the distance from the eye to the target at which the patient was
able to identify the letter. Record this measurement in inches
5. Divide 40 by the measurement to determine the amplitude of accommodation. The
amplitude should be within 2Diopters of the expected finding (see Addendum A for
expected amplitude by age).
6. Patch R eye and repeat.


Recommendations (continued)
35,40
Motor Fusion • Near Point of Convergence
Testing/Eye 1. Use a 20/30 letter target, or pencil tip, placed just above the nose at the brow between
Alignment the eyes
Testing* 2. Move the target toward the patient at a rate of about 1-2cm/s, encouraging pt to keep
the target single
3. Measure the patient’s reported subjective break (target becomes double) in
centimeters
4. Then slowly move the target away from the eyes until reported subjective recovery
(single again). Measure in centimeters.
5. If the pt does not report diplopia (doubling of the target), the point at which the eyes are
observed to lose alignment, and then regain alignment, are recorded as the break and
recovery
6. If the eyes are observed to lose alignment and the patient does not report diplopia, this
may indicate suppression
*Norms – 5cm break and 7 cm recovery
35,43
• Eye Alignment test (options include the cover tests)
• Modified Thorington test, using the Bernell Muscle Imbalance Measure card tests (near
7,51
and far). http://www.bernell.com
16,35,39
Saccades • Developmental Eye Movement test
• Northeastern State University College Optometry Oculomotor Test (NSUCO) of saccades
27,35

*test without corrective lenses*

Score is based on patient’s ability, accuracy, and the presence of head or body movement
27
during saccadic eye movements. See reference for procedure and norms
14,49
• King-Devick
27,35
Pursuits • NSUCO test of pursuits
• Test without corrective lenses.
• Score is based on patient’s ability, accuracy, and the presence of head or body
27
movement during pursuit eye movements. See reference for procedure and norms
Visual • OSU Visual Tracing test?
Scanning/Tracki • Groffman Visual Tracing Test - Designed by Sidney Groffman, OD., www.bernell.com (no
ng studies)
1,35
Visual Fields • Confrontation field testing – finger counting
• Test without corrective lenses.
• This test simultaneously screens for the extinction phenomenon that can accompany
unilateral brain damage. See Addendum B.

* Should be trained by a vision specialist before performing fusion tests or accommodative tests.

Visual field impairment and cranial nerve injury is more likely to occur following
moderate or severe TBI.48
• mayfieldclinic.com/PE-VisualFieldTest.HTM

Three Cranial Nerves that Supply Innervation to the Six
Extraocular Muscles of Each Eye
• ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=23&seg_id=417

Nerve Symptoms Typical Examination Findings Differential Diagnosis

Palsy
Normal n/a n/a

Oculomotor Diplopia, • Posterior circulation

(CN III) horizontal and aneuryism
Palsy vertical • Brainstem lesion
• Microvascular ischemia
(if pupil spared)
• Cavernous sinus
disease

Trochlear Torsional • Brainstem lesion

(CN IV) (“tilted”) diplopia • Posterior circulation
Palsy worse on aneurysm
downward gaze • Cavernous sinus
disease

Abducens Horizontal • Brainstem lesion

(CN VI) diplopia on • Elevated intracranial
Palsy lateral gaze to pressure
the ipsilateral • Cavernous sinus
side disease

Resources for Neuro-Optometric/Sensorimotor Evaluation

OSU College of Optometry

th
338 W. 10 Ave
Columbus, OH 43210
(614) 292-1113

Galloway Eye Care

Jennifer Mattson, OD
5688 W. Broad St.
Galloway, OH 43119
(614) 853-2020

Riverview Eye Associates

Steven J. Curtis OD, FCOVD
3600 Olentangy River Rd, Unit B
Columbus, OH 43214
(614) 451-7244

Heritage Family Eye Care (primarily pediatric through college age)

Sara Huffman OD, MS
5123 Norwich St., Ste 120
Hilliard, OH 43026
(614) 850-6151

SouthWest Eyecare
Michelle F. Miller, OD
4140 Hoover Rd.
Grove City, OH 43123
(614) 801-2020

Appendix A: Expected Amplitude of Accommodation by Age Expected
Number (D)
Age43 15 13
18 12
21 11
24 10
27 9
30 8
33 7
36 6
39 5
42 4
45 3
48 2
51 1
54 0

Appendix B: Rapid Confrontation Screening for Peripheral Visual Field Defects

and Extinction
Clinical and Experimental Optometry
Volume 92, Issue 1, pages 45-48, 29 DEC 2008 DOI: 10.1111/j.1444-0938.2008.00280.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1444-0938.2008.00280.x/full#f1

Rapid finger‐counting confrontation screening requires four responses from the patient (panels A through D). The
schematics are shown from the perspective of the clinician, with the patient's eye and covering hand shown in the
grey oval. The combinations of fingers shown are examples only, although the clinician must always present
either one or two fingers on each hand. A correct response from the patient is always ‘two’, ‘three’ or ‘four’ and
never ‘one’.

Author: Julie M. Omiatek, MS, OTR/L, CHT
Reviewers: Dr. Steven J Curtis, OD, FCOVD; Karen Rasavage, OTR/L; Michelle F. Miller, OD; Carol Gains,
OTR/L; Tierney Bumgardner, MOT, OTR/L
Completion date: July 2017

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HIP ABDUCTOR
(GLUTEUS MEDIUS/MINIMUS) REPAIR
CLINICAL PRACTICE GUIDELINE

Background
Gluteus medius and/or minimus partial- or full-thickness tears can be the source of significant functional
impairments and chronic peritrochanteric hip pain. These tears are similar in morphology to the soft tissue
anatomy of rotator cuff tears in the shoulder (Domb 2013). Often, gluteus medius and/or minimus tears do not
have a clear mechanism of injury; however, it is thought that the progression of these tears is gradual with
degradation that occurs within the musculotendinous junction and at its attachment to the bone. These changes
eventually cause insertional failure and tendinopathy that leads to partial undersurface tearing. Occasionally,
these tears progress to complete avulsion of the abductor attachment on the greater trochanter (Domb 2013).
Gluteus medius tears are more common than gluteus minimus tears and partial thickness tears are more common
than full thickness tears (Connell 2003). Lastly, women more commonly demonstrate symptomatic tears
compared to men (Tibor 2008). Many of these tears often go undiagnosed or misdiagnosed for a prolonged time.
Hip abductor repair is most commonly an open procedure in order to best expose the tissues and fully perform the
repair. Due to the nature of the repair, certain precautions must be taken early on during post-operative
rehabilitation in order to protect the repaired and healing tissues.

The surgical procedure involves an incision over the lateral aspect of the hip carried down to the iliotibial (IT)
fascia. The IT fascia is opened longitudinally and the trochanteric bursa is removed or debrided. The gluteal
tendons are then identified and cleaned. Anchors are placed into the greater trochanter and the stitches are used
to secure the gluteal tendons back to the bone. The IT fascia is partially closed with the extent of closure
dependent on presentation. The wound is closed through the deep soft tissues and the skin.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.


Summary of Recommendations

Precautions • WB restrictions: 50% WB w/ walker or crutches

(6 wks) • Hip abduction brace when OOB
• No flexion > 90° and no adduction past neutral/0°

Corrective • Proper activation and recruitment of all hip and core musculature without compensation
Interventions required prior to initiating strengthening
• Neuromuscular re-education for balance and correction of functional movement patterns
• Therapeutic exercise and neuromuscular re-education for LE strength (progressing from
DL to SL activities)
ROM/Manual • PROM as tolerated
Therapy o No hip flexion > 90° and no adduction past neutral/0° (6 wks)
• No AROM hip abduction, ER, or IR (6 wks)
Outcome • Pre-op, evaluation, 6 wks, and discharge
Testing o May increase frequency if warranted
• Hip Outcome Score (HOS)
o ADL (17 items)
o Sports (9 items)
Criteria for To Initiate Plyometric Program To Initiate Running Program
Progression • Full, functional, pain-free ROM • Pass all plyometric program criteria
• > 80% quadriceps, hamstring, and hip • Hop and hold with proper mechanics
(using hand-held dynamometer) strength (uninvolved à involved)
compared to uninvolved leg • Ability to tolerate 200-250 plyometric foot
• Squat > 150% BW (barbell squat or leg contacts without reactive pain/effusion
press) • No gross visual asymmetry and rhythmic
• 10 forward and lateral step downs from 8” strike pattern with treadmill or over
step with proper mechanics ground running
Criteria for • Physician clearance at last check-up • Patient reported outcome measures:
Return to • Strength: > 90% compared to uninvolved o Score ≥ 90% on HOS (ADL and
Sport/Discharge hip (using hand-held dynamometer) Sports subscales)
• > 90% BW with SL leg press ** Criteria for discharge from PT is less
• Functional Performance: rigorous for those not returning to sport.
o > 90% limb symmetry with SL hop for Ensure the patient is able to perform all
distance, SL triple crossover hop, and ADLs and recreational activities without
SL 6-meter timed hop (with pain, reactive effusion, and with
demonstration of proper LE landing appropriate functional mechanics.**
mechanics)
o Ability to complete sport-specific drills
with correct mechanics - at maximum
speed w/o pain

Abbreviations: AD, assistive device; ADLs, activities of daily living; AROM, active range of motion; BW, body
weight; DL, double leg; LE, lower extremity; PROM, OOB, out of bed; passive range of motion; pre-op, pre-
operative;
ROM, range of motion; SL, single leg; WB, weight bearing; wks, weeks


Phase I: Protection - Post-Op until D/C Assistive Device (0-6 weeks)

Goals • Protect healing tissues

• Pain and edema control
• Improve pain-free ROM
• Normalize muscle activation
• PT Frequency: recommend 1x/week starting at week 2 or per MD instruction
Precautions • 50% weight bearing with crutches or walker for 6 wks
• Use hip abduction brace when OOB for 6 wks
• No hip flexion > 90° and no hip adduction past neutral/0°
• No active hip abduction, ER, or IR ROM for 6 wks
• Avoid sidelying position when sleeping
• Avoid irritation of lateral hip pain
• Avoid sitting > 30 minutes at a time to avoid hip flexor tightness
o Instruct to keep hips above knees (i.e. > 90° hip flexion)
ROM/Stretching • PROM (painfree): Hip flexion, extension, abduction, prone hip IR and ER
o Limit hip flexion to 90° and hip adduction to 0° for 6 weeks
• Stretches: prone quadriceps, supine iliopsoas (uninvolved knee to chest)
• Soft tissue mobilization as warranted (adductors, TFL, hip flexors, etc.)
• GENTLE scar mobilizations can begin after incisions closed
• Upright bike for ROM (raise saddle height so that hip flexion is 90° or less)
st
Neuromuscular this section is 1 priority à do not progress to strengthening until pt is able to perform isolated
Control muscle activation
• Gluteal muscle activation without compensation (prone, supine, seated), transverse
abdominis (TA), quadriceps
Therapeutic Early Exercises (wks 0-3):
Exercises • Hip adductor isometrics (not past neutral), prone hamstring curls, seated knee extension,
TA progression in hooklying (respecting ROM precautions)
Advanced Exercises (wks 4-6):
• Criteria to begin this section: minimal reactive pain and edema
o Flexion/extension SLR, quadruped cat/camel, quadruped weight shifts, DL bridges,
standing TKE (with AD)
o Gradually increase resistance on stationary bike as tolerated
o Initiate hip abduction and ER isometrics at 4 weeks
§ Begin with 50% MVC and progress as tolerated)
o Recommend iliopsoas progression at 4 weeks if poor lumbopelvic control persists
(Appendix A)
o Aquatic therapy may be appropriate and can be initiated once incision is well-healed
and patient is cleared by physician
Criteria to • Normalized gait pattern with AD
Progress to • Minimal to no reactive pain and swelling with ADLs and PT exercises
Phase II • Muscle activation and isolation is normalized
• Pass the Prone Hip Extension Test (Appendix B)
• 10 repetitions
st nd
• Proper gluteal muscle activation (gluteus maximus 1 , hamstrings 2 )
• Leg extends 10° past neutral


Phase II: D/C Crutches to Painfree with ADLs (6-8 Weeks)
Goals • Progress to full PROM and AROM in all directions
• Progressively improve strength of the proximal hip musculature (gluteals, iliopsoas, hip
rotators)
• Normalize postural/lumbopelvic control with DL and SL activities
• Normalize gait at preferred walking speed for community distances without AD
• Tolerate ADLs without pain or limitation
Precautions • Avoid soft tissue aggravation due to early/excessive progression of activity
o Soft tissue irritation suggests need for regression of activities and/or exercises
• Avoid aggressive stretching into hip adduction/IR/ER including ITB stretches
• Avoid running or impact activities
• Continually assess patient’s current activity level outside of PT
Crutch • 2 crutches or walker for 6 weeks
Progression • 2 à 1 crutch or caneà 0 recommended to slow patient progression, limit walking
distance, and reduce stress through repaired tissue
o 2 crutches à 0 recommended to promote normalized gait mechanics IF patient is
unable to demonstrate appropriate mechanics with 1 crutch or cane
Criteria for • Adequate hip ROM for normalized/pain free gait pattern (10° hip extension)
Ambulation • Normalized gait pattern without AD
Without o No Trendelenburg sign demonstrated during stance phase of gait
Assistive
Device
ROM/Stretching • Soft tissue and joint mobilization to achieve symmetrical PROM
• Upright bike, butterfly/reverse butterfly stretches
• May benefit from referral to massage therapist if patient is developing soft tissue
dysfunction/irritation (commonly affects TFL, adductors)
Therapeutic • DL squat, leg press, calf raises, forward/lateral step ups, 4 way hip (standing), SL balance
Exercise (focus on pelvic stabilization), bridge progression, quadruped progression (UE/LE lifts)
• Hip rotation AROM (ER/IR) with involved knee on stool
Cardiovascular • May progress time on upright bike as tolerated
Exercise • Ensure patient can perform 30 minutes with no resistance and without symptoms prior to
adding resistance
• Decrease time to ≤15 min when adding resistance
• Appropriate to recommend freestyle or backstroke swimming at end of phase II
o MUST use a pull buoy to allow legs to rest in a neutral position (no kicking allowed)
§ Use buoy at highest point between legs
Criteria to • Symmetrical and pain free hip ROM to meet the demands of patient’s activities
Progress to • Symmetrical DL squat to 70° of knee flex
Phase III • Score of 0-1 performing 10 repetitions of Active Hip Abduction Test (Appendix C)
• 10 repetitions of 8” step downs with good neuromuscular control
• Normalized gait pattern for community distances of ambulation
o No compensatory movement patterns at pelvis (no Trendelenburg sign)


Phase III: Painfree ADLs to Return to Impact Activities (8-12 Weeks)

Goals • Gradually progress gluteus medius/minimus strength and core/proximal hip stability
• Correct abnormal or compensatory movement patterns with functional tasks
• Optimize neuromuscular control, balance, and proprioception
• Increase volume and intensity of non-impact aerobic activities
Precautions • Avoid secondary muscle irritation (hip flexor and lateral hip)
• Monitor ROM, quality of movement, and activity level
ROM/Stretching • Maintain full AROM/PROM and progress through multidirectional end range movements
as required for vocational or recreational activities
• Use manual techniques including STM and joint mobilization as needed for soft tissue and
joint tightness
• Address any persistent lumbar or pelvic dysfunctions with manual or stretching
interventions
Therapeutic • Gradually progress gluteus medius/minimus strength
Exercise o Progressive resisted hip abduction and IR/ER strengthening in NWB and WB positions
• Continue progressive LE/core strength and stability
o Begin to address multiplanar movements near end of phase III
• Balance/Proprioception
o Rocker board, BOSU ball, SLS on foam pad
Cardiovascular • Upright Bike/Elliptical/Stairmaster Progression (see return to biking protocol)
Exercise o Gradually progress resistance and/or speed (cross ramp on elliptical) as tolerated
• Swimming Progression (see return to swimming protocol)
o Return to freestyle and backstroke kicking but NO use of kickboard
o May also return to elementary backstroke (slowly) and dolphin dives
Plyometrics • Criteria to initiate plyometric program
o Full, functional, pain-free ROM
o > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength
compared to uninvolved leg
o Squat 150% BW (barbell squat or leg press)
o 10 forward and lateral step downs from 8” step with proper alignment (Appendix D)
• Progressive weight bearing, DL à SL demands
o Shuttle plyometrics (DL à SL)
o Forward hop and hold (uninvolved à involved)
o DL mini hops/place jumps
• Proper take off/landing mechanics emphasized à NO knee valgus, good pelvic stability,
soft/quiet landing with equal distribution of force
• Agility ladder can be initiated if appropriate form and tolerance to plyometrics


Return to Running
Walk/jog progression can be initiated towards end of phase if patient demonstrates:

• Full, functional, pain-free ROM

• > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength compared to uninvolved
leg
• Squat 150% BW (barbell squat or leg press)
• 10 forward and lateral step downs from 8” step with proper alignment (see appendix D)
• Hop and hold with proper mechanics (uninvolvedàinvolved x10 repetitions)
• Ability to tolerate 200-250 plyometric foot contacts without reactive pain/effusion
• No gross visual asymmetry and rhythmic strike pattern with treadmill or over ground running

Phase Walk/Run Ratio Total Time

1 4 min / 1 min 10-20 min
2 3 min / 2 min 10-20 min
3 2 min / 3 min 10-20 min
4 1 min / 4 min 10-20 min
5 • Jog every other day until able to run 30 consecutive minutes
• Begin with 5 min walking warm up
• End with 5 min walking cool down

General Guidelines

• To complete each phase, follow the Total Time guidelines below.

• 10 minutes x2 sessions
• 15 min x1 session
• 20 min x1 session
• After completing any phase pain free for 20 minutes, patient is appropriate to move forward to next phase
• Allow at least one day of rest between runs
• Gradual increase in distance is priority before increased pace
• It is common for runners to experience increased pain and/or reactive edema at least x1 during this return to
run progression. When pain occurs, runner must stop running immediately and rest at least 1 day before
restarting program. With restart, perform last walk/jog ratio cycle completed painfree x2 before attempting the
previously painful ratio cycle.
• Ten Percent Rule: only increase weekly mileage by 10% of the previous week

Phase IV: Return to Sport/Full Activity (3 to 6+ Months)

Goals • Initiate return to run program if not initiated in phase III

• Return to physically demanding job
• Progressively return to sport or prior/desired level of function (4-6 months for full return to
sport)
Precautions • Continue to emphasize proper landing mechanics (DL and SL)
• Avoid progression of plyometric exercises if increased pain
o If yes, re-assess and address any underlying strength or neuromuscular impairments
• Ensure patient maintains full flexibility and painfree ROM as strength continues to increase
• Closely monitor return to sport progression
ROM/Stretching • Continue ROM interventions and stretches from previous phases
o Include multiplanar lumbar and hip ROM/flexibility
• Emphasis on dynamic warm-up and stretching (i.e. walking lunges, hurdle steps, etc.)
• Monitor sport-specific stretching with gradual return to end range stretching
Therapeutic • Hip and core strengthening with focus on pelvic stability
Exercise o Maintain DL strength but emphasize SL strengthening (involved and uninvolved)
• Progress multiplanar movements (static to dynamic activities)
Neuromuscular • Progress agility and plyometrics by adding in higher level activities (i.e. forward/backwards
Control and hopping, side shuffles, carioca, cutting, box drills, T drills, tuck jumps, DL/ SL jump turns)
Functional • Focus on hip and pelvic stability
Performance o Incorporate unstable surfaces with plyometrics
• Impact exercises: 2 feet to 2 feet à 1 foot to other foot à 1 foot to same foot
o Single plane drills à multi-plane drills
• Dynamic control exercise: low velocity, single plane activities à higher velocity,
multiplanar activities
• Continue to advance dynamic stability tasks (both endurance and multidirectional stability)
• Sport specific drills in clinic (moderate speed à maximum speed)
• Prior to initiating speed training, patient must first complete entire return to run program
• Ensure tolerance with DL and SL plyometrics prior to initiating power-focused or resisted,
explosive training
Cardiovascular • Swimming Progression: return to freestyle and backstroke kicking
Exercise • Able to use kickboard
• May return to breaststroke and butterfly (one arm drillsàdouble arm as able
Return to • Physician clearance at last check-up
Sport/Discharge • Strength: > 90% compared to uninvolved hip (using hand-held dynamometer)
• > 90% with SL leg press at body weight (# of repetitions to fatigue) OR >90% on Isokinetic
testing with quad/hamstring ratio
• Functional Performance
o 90% limb symmetry with SL hop for distance, SL triple crossover hop, and SL 6-meter
timed hop (with demonstration of proper LE landing mechanics)
Ø Crossover hop most important to ensure proper mechanics with increased lateral
loading through hip
• Ability to complete sport-specific drills with correct mechanics (at maximum speed without
pain)
• Patient reported outcome measures
o Score ≥ 90% on HOS (ADL and Sports subscales)

Appendix A: Psoas Progression

Clinicians may choose either of the two iliopsoas strengthening progressions based on clinician/patient
preference. All exercises are performed with simultaneous abdominal drawing in maneuver and lumbar spine in
neutral alignment.

A) Supine short-lever hip flexion A) Marching

B) Seated hip flexion B) Walk Out
C) Seated hip flexion on Swiss ball C) Heel Slide
D) Standing hip flexion with theraband D) Heel Slide with SLR
resistance
Tyler TF, Fukunaga T, Gellert J. Rehabilitation of Dewitt, JD. Non-surgical/post-op management.
soft tissue injuries of the hip and pelvis. Int J Presented at: APTA’s NEXT Conference &
Sports Phys Ther. 2014;9(6):785-797. Exposition; June 5, 2015; National Harbor, MD.

Appendix B: Prone Hip Extension Test

The prone hip extension test assesses ability to fire the
gluteus maximus while maintaining lumbo-pelvic-hip control.
Criteria to pass test:

• 10 repetitions
st
• Proper gluteal muscle activation (gluteus maximus 1 ,
nd
hamstrings 2 )
• Leg extends 10° past neutral
• No compensatory movement patterns at pelvis (no
anterior pelvic tilt)
• No anterior hip pain


Appendix C: Active Hip Abduction Test

Score Cues for Examiner

0 Able to maintain position of
pelvis in the frontal plane
1 Minimal loss of pelvis position Slight wobble at initiation or throughout any movement; may show
in the frontal plane
2 Moderate loss of pelvis
position in the frontal plane
3 Severe loss of pelvis position
in the frontal plane
Smoothly and easily performs movement; lower extremities, pelvis, trunk
and shoulders remain aligned in frontal plane.
noticeable effort or “ratcheting” of moving limb
Has at least 2 of the following: noticeable wobble through movement;
tipping of pelvis, trunk or shoulder rotation; increased hip flexion and/or
rotation of the moving limb; rapid or uncontrolled movement
Has more than 3 of the above characteristics and/or unable to regain
control of movement once lost or may lose balance (has to place hand
on table)

(A) Demonstration of the active hip abduction test from the starting
position
(B) Demonstration of good control of the pelvis in the frontal plane; this
would receive a score of 0. The alignment of lower extremities, pelvis
and trunk has not changed from the start position, and upper extremity
remains relaxed on the abdomen.
(C) Demonstration of poor control of the pelvis in the frontal plane; this
would receive a score of 3. The upper extremity is placed on the table to
prevent loss of balance, the pelvis has rotated forward and the top hip
has flexed and internally rotated.

Davis, AM, Bridge P, Miller J, Nelson-Wong, E. Interrater and intrarater reliability of the active hip abduction test. J
Orthop Sports Phys Ther. 2011;41(12):953-960.


Appendix D: Forward Step Down Test

Definition of errors Interpretation of errors

Arm strategy: subject uses an arm strategy in an attempt to recover 0-1 errors Good quality
balance (1 point) mechanics
Trunk movement: trunk leans right or left (1 point)
Pelvic plane: pelvis rotates or elevates on one side compared to
the other (1 point)
Knee position: knee deviates medially and the tibial tuberosity
crosses an imaginary vertical line over 2nd toe (1 point); knee
deviates medially and the tibial tuberosity crosses an imaginary 2-3 errors Medium quality
vertical line over medial boarder of the foot (2 points) mechanics
Balance: subject steps down on the uninvolved side or the subject’s
tested leg becomes unsteady (1 point)

4+ errors Poor quality

mechanics

Park K, Cynn H, Choung S. Musculoskeletal predictors of movement quality for the forward step-down test in
asymptomatic women. J Orthop Sports Phys Ther. 2013;43(7):504-510.

Authors: Chelseana Davis PT, DPT, SCS; Kathy Wayman, PT, DPT, SCS; Kate Glaws, PT, DPT, SCS; Joann
Walker, PT, DPT, SCS

Reviewers: John DeWitt, PT, DPT, SCS, AT, William Vasileff, MD; and John Ryan, MD

References

Connell DA, Bass C, Sykes CA, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus
tendinopathy. Eur Radiol. 2003; 13: 1339-1347.

Davis, AM, Bridge P, Miller J, Nelson-Wong, E. Interrater and intrarater reliability of the active hip abduction test. J
Orthop Sports Phys Ther. 2011;41(12):953-960.

Dewitt, JD. Non-surgical/post-op management. Presented at: APTA’s NEXT Conference & Exposition; June 5,
2015; National Harbor, MD.

Domb BG, Dotser I, Giordano BD. Outcomes of endoscopic gluteus medius repair with minimum 2-year follow-up.
Am J Sports Med. 2013; 41(5): 988-998.

Park K, Cynn H, Choung S. Musculoskeletal predictors of movement quality for the forward step-down test in
asymptomatic women. J Orthop Sports Phys Ther. 2013;43(7):504-510.
Tibor LM, Seklya JK. Current concepts: differential diagnosis of pain around the hip joint. Arthroscopy. 2008;
24(12): 1407-1421.

Tyler TF, Fukunaga T, Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis. Int J Sports Phys Ther.
2014;9(6):785-797.

GREATER TROCHANTERIC PAIN SYNDROME
CLINICAL PRACTICE GUIDELINE

Disclaimer
This guideline is intended as an aid for clinicians treating patients diagnosed with greater trochanteric pain
syndrome, utilizing an evidence-based load management treatment strategy. Progression is time and criterion-
based, dependent on soft tissue healing, patient demographics and clinician evaluation. Contact Ohio State
Sports Medicine at 614-293-2385 if questions arise.

Background
Greater trochanteric pain syndrome (GTPS) has been defined as lateral hip pain to palpation of the
peritrochanteric region. The pain can radiate down the thigh and into the posterior hip, but rarely distal to the
knee. Previously, the cause of pain has been attributed solely to trochanteric bursitis. However, the origin of pain
can include the trochanteric bursa, gluteus medius and minimus tendons, and iliotibial band. MRI examination in
studies involving GTPS show trochanteric bursitis was an uncommon finding and was not found in isolation; when
15
found, bursal distension coexisted with gluteal pathology. Recent studies have shown gluteal tendinopathy to be
1
the primary cause of lateral hip pain. The greatest incidence of GTPS often occurs between the fourth and sixth
15
decades of life with a female to male ratio of 4:1.

Recent studies of gluteal tendinopathy demonstrate the deep undersurface fibers of the gluteal tendons
preferentially develop pathology and tears and yet are relatively stress-shielded from tensile load in the lower
1
ranges of hip abduction. They are exposed to high compressive loads in the ranges of hip adduction against the
1 1
bony insertion. Normal daily function of the hip is in the low ranges of abduction or slight hip adduction. These
compressed sides of the tendons adapt to form somewhat of a cartilaginous or atrophic area in response to a lack
15
of tensile load. This makes the tendon vulnerable to becoming symptomatic even with small changes in activity.
For this reason, tendinopathy can occur in the absence of a traditional overuse injury model and explains how
15
tendinopathy is more common in the older patients. Because the turnover rate of collagen decreases with
10
advancing age, it may take longer for older athletes to recover from tendinopathy. Compressive forces (not
solely tensile loads) may be at fault and need correction for treatment of GTPS.

A key determinant in rehabilitation progression of tendinopathy is whether or not a tendon reacts, or develops an
5
increase in pain that does not return to baseline pain level within 24 hours. Load management and prescribing
effective loading variables (duration, frequency, nature, magnitude, direction, and intensity is important in guiding
the rehabilitation process. Monitoring changes in pain and immediate adjustment of load is essential. The pain-
monitoring model includes use of an objective measure to assess pain intensity 0-10/10 to monitor exercise
progression. It is recommended to assess at the same time every day at home.

Progressive mechanical loading has been found to be an effective management strategy. Different modes of
strength training, including isometric, isotonic, isolated eccentric, and isokinetic can be used to control pain,
improve motor control, and enhance function in pathological tissue. Although traditional rehabilitation approaches
have focused on isolated eccentric tissue loading, recent literature suggests that isolated eccentric exercise may
not be a superior choice compared with other types of loading, particularly heavy-slow resistance (HSR) loading
4
(resistance performed up to an individual’s 6RM). In fact, eccentric-based exercise may contribute to worse
5
outcomes for an in-season athlete or be too high load for the tendon to tolerate to begin treatment. HSR loading
4
also has been found to promote better collagen turnover than isolated eccentric loading. Important throughout
rehabilitation, isometrics have been found to reduce pain while reducing cortical inhibition of muscles. Emerging
research is indicating the presence of changes in central pain processing, such as central sensitization, in some
cases of tendinopathy. Generally clinical management of tendinopathy should include aspects of load
management and education, progressive mechanical loading, treatment of kinetic chain deficits, and a graded
return to activity.

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.
Definitions
• Strong level evidence: supported by systematic review, meta-analysis, or >5 RCT
• Moderate level evidence: supported by 3-4 RCT
• Low level evidence: supported in 1-2 RCT or clinical case series
• Expert opinion: supported by case studies, expert opinions or opinions of the authors

Summary of Recommendations
Risk factors • Sudden increase in activity
• Repetitive compressive/tensile loads
• Lumbopelvic and LE mechanics
• Female>40 years
Differential • Gluteal tendon tear
Diagnosis • Ischiofemoral impingement, quadratus femoris tear, piriformis syndrome
• Intra-articular hip pathology (hip OA, AVN, FAI/labral tear, SCFE)
• Stress fracture
• Lumbar/SI pathology
• Systemic disease (CA, RA)
Examination • Gait, posture (lumbopelvic), kinetic chain, functional movement assessment
• Lumbar/SI screen
• Special tests: 30 second SLS, resisted external derotation test, TTP over
• Greater trochanter, painful hip abductor MMT
• Outcome tools: VISA-G, HOOS, HOS
• Pain Reduction and Load Management (isometric loading and avoiding positions of
compression)- refer to appendix
• Isotonic Loading (Heavy-slow resistance through concentric-eccentric phases)
• Energy-Storage Loading (plyometric loading)
• Return to Activity/Sport
Phases of • Patient education regarding load management (Lateral hip precautions)
Progression • Gluteal isometric contractions with tendon in shortened positions
Interventions • Progressive muscle-tendon loading program
• Correction of kinetic chain deficits (emphasis on mechanics during gait and ADLs)
Criteria for • Full ROM/strength/power
Discharge • Pain-free resistance test, high load, in compressed positions
• Achieved patient goal(s)
• Proper long-term maintenance program implemented for self-management of symptoms
• RTS activity without reactive pain
Examination
Subjective Symptoms commonly attributed to GTPS include pain/difficulty with:
• lying on the ipsilateral side
• prolonged standing or walking
• climbing up or down stairs
• sit to stand transfers
• walking up/down hills or inclines
• sitting
Objective • MMT hip abduction/dynamometry
• Hip ROM
• Lumbar spine and SI screening
• Pain provocation with palpation to greater trochanteric region
• Examination of gait on level surfaces and stairs/examination of body mechanics with
transfers and sport-specific activity
• Lumbopelvic control during high and low level tasks
Special Tests • 30 second single leg stand test: Recommended for up to 30 seconds (or until onset of
greater trochanteric pain) allowing light fingertip support with trunk maintained in vertical
position. Although not part of the test, observing the patient’s ability to control the pelvis can
1
help guide treatment (Low load test)
3
• Lateral hip pain with resisted external derotation test
Patient: supine with hip Movement: Patient is asked to return the leg to the neutral hip
and knee passively flexed position against resistance of the clinicians hand at the ankle.
up to 90 degrees. Hip The test is positive when the lateral hip pain is reproduced.
passively placed into
external rotation. If any
pain is present in that
position, slightly decrease
the external rotation
position just enough to
relieve pain.
Clinician: standing just
to the side of the leg
being tested. One hand
supporting knee, other
hand at lateral ankle.

Outcome • In a recent study, maximum walking distance and ability to manipulate shoes and socks on
23
Study Harris Hip Score domains helped differentiate GTPS from hip osteoarthritis.
Classification
Tendinopathy has been described as a continuum of tissue pathology, which can be classified as reactive,
18
degenerative, or reactive-on-degenerative phases.
• Reactive tendinopathy is a non-inflammatory proliferative response in the cell and matrix. It is usually a
result of a burst of unaccustomed physical activity and is more common in a younger person. At this
stage, it remains possible for the tendon to regain its normal structure with optimal management.
Treatment at this stage should be aimed at improving the load capacity of the area of aligned fibrillar
structure through a progressive loading program. Unloading or performing heavy load, eccentric exercise
could cause deleterious effects in this stage.

• Degenerative tendinopathy demonstrates progression of both matrix and cell changes. There is little
capacity for reversibility of pathological changes at this stage. Progressive loading does not necessarily
result in a restructure of the matrix.

• Reactive-on-degenerative describes the concept of some areas of the tendon may be in different stages
of tendinopathy at the same time. Structurally normal areas of the tendon may be vulnerable to reactive
tendinopathy concurrent with other areas in the tendon in the degenerative phase. Treatment strategies
should be directed at optimizing adaptation of the tendon as a whole.

Image from Cook et al. 2016

Corrective Interventions
Patient education in reducing compression (including postural changes to sitting and sleeping posture, transfers
and exercise) for reducing hip adduction:

• Avoid lying on affected side (change to supine with pillow under knees or ¼ position from prone)
• Avoid crossing legs
• Avoid piriformis, ITB, and adduction stretching
• Avoid standing and “hanging” on one hip (uneven LE weight bearing)
• Avoid running on uneven surfaces/hills and improve lumbopelvic stability

See appendix for patient education handout.

Phase I: Pain Reduction and Load Management

Indications 1. Patient experiences reactive pain (More than 3/10 pain during or after activity/isotonic
loading that lasts greater than 24 hours). Range of acceptable pain levels may vary
dependent on patient tolerance and understanding of therapeutic ranges
2. Unable to maintain current activity levels due to pain
3. Localized tenderness at tendon
4. Pain with single leg standing test and external derotation test
5. Pain lying on affected side

Activity 1. Patient education in reducing compressive forces on the tendon (including no end-range
Modifications stretching) and the pain-monitoring model
expert opinion 2. Reduced loading and modified volume of activity
3. Patient Education: expected recovery progression, cognitive behavioral therapy if indicated
4. If indicated, use of crutch or STC for load management and gait normalization
5. Cross training with biking, swimming, as tolerated
6. Increase in night pain may indicate load was too high and needs to be adjusted

Prolonged Perform with tendon in shortened/non-compressed/midrange position.

Isometric
Contractions Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to 70%
strong level maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily. Isometrics
evidence can be done with theraband, side lying abduction (affected side uppermost and pillow between
legs), or standing. All exercises should be done in slight abduction to avoid compression. (See
appendix)

Treatment of
1. Correction of kinetic chain deficits and restore active trunk stability
Kinetic Chain
2. Functional retraining in weight-bearing double-leg and single-leg tasks with emphasis on
Impairments
avoiding hip adduction during dynamic tasks.
expert opinion

Criteria to 1. Can complete isotonic loading with minimal reactive pain (<3/10 pain or no increase in
Progress to baseline pain lasting longer than 24 hours)
Phase 2 2. Decreased pain with ADLs
expert opinion 3. Normalized gait
Phase II: Isotonic Loading Progression

Indications 1. Strength deficits of the gluteus medius and minimus

2. History of painful loading

Heavy, Slow Prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and
Resistance progressing to 6 repetitions, performed every other day
Exercise
(HSR) *Initially, complete exercise in modified ROM (avoiding hip adduction) to avoid
strong level compression of tendon then progress into full ROM as strength and pain levels allow
evidence Suggested exercises: upright skating, skating in squat, sidestepping, band side glide,
bridges, clamshells, and side lying hip abduction. (See appendix)

Stretching End-range stretching to address ROM deficits (avoid stretching ITB and piriformis)
exercises
low level
evidence

Prolonged Perform with tendon in shortened/non-compressed/midrange position.

Isometric
Contractions Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to
strong level 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily.
evidence

Cognitive Only indicated for cases of chronic pain or central sensitization

Behavioral
Therapy/
Graded
Exposure
low level
evidence

Criteria to 1. Full ROM

Progress to 2. Able to complete 3-4 sets of 6 repetitions throughout full ROM with minimal pain and
Phase 3 no increase in pain lasting greater than 24 hours (patients should be at about 7/10
expert opinion on Borg Rate of Perceived Exertion scale for strengthening purposes)
3. No pain with ADLs
4. No tenderness to palpation of gluteal tendons
5. Able to perform single leg stand test for 30 seconds without pain or trunk deviation
Phase III: Energy Storage Loading Progression (Plyometrics)

Indications 1. Symmetrical strength bilaterally (recommended strength tests: 10 RM, Manual

muscle testing)
2. Tolerates introduction of energy storage exercises (hop testing) with minimal pain

Sport or 1. Progressing volume then intensity.

Activity- Prescription: every third day, progressing to a volume required by the sport/activity
Specific 2. Functional corrections including squats/lunges/single leg activities keeping pelvis
Movements level and avoiding hip adduction
expert opinion

Heavy, Slow Prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and
Resistance progressing to 6 repetitions, performed every other day
strong level
evidence *Initially, complete exercise in modified ROM to avoid compression of tendon then
progress into full ROM as strength and pain levels allow

Prolonged Perform with tendon in shortened/non-compressed/midrange position. This is done as

Isometric needed at this phase for pain management.
Contractions
strong level Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to
evidence 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily.

Criteria to 1. Able to complete energy storage exercises with minimal pain and at a volume that
Progress to would replicate the demands of the sport/activity
Phase 4 2. Proper long-term maintenance implemented for self-management of symptoms
expert opinion

Example of Initial Weekly Structure at Phases III and IV

Day 1: Plyometrics/return to play, isometrics if needed
Day 2: Strengthening, isometrics if needed
Day 3: Isometrics
Day 4: Rest
Day 5: Plyometrics/Return to play, isometrics if needed
Day 6: Strengthening, isometrics if needed
Day 7: Isometrics
Phase IV: Return to Sport/Activity
It is important to have a gradual and controlled progression that allows the athlete sufficient time to
recover and gives the therapist time to evaluate symptoms. The evaluation of symptoms such as
stiffness, pain, and swelling after training, especially the following day, can assist in determining
appropriate increases in training intensity or volume. Because individual patients have different
baseline abilities, using their perceived exertion will assist in determining how to progress the specific
sport activities.

Indications Can complete introduction of sport/activity-specific exercise with minimal pain

Proper Gentle, dynamic movement relevant for the sport or activity
Warmup
Routine
expert opinion

Sport/ Reintegration into competition (no greater than every three days initially)
Activity-
Specific
Drills
expert opinion

Heavy, Slow Prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and
Resistance progressing to 6 repetitions, performed at least twice per week
strong level
evidence *Initially, complete exercise in modified ROM to avoid compression of tendon then
progress into full ROM as strength and pain levels allow
Prolonged Perform with tendon in shortened/non-compressed/midrange position. This is done as
Isometric needed at this phase for pain management.
Contractions
strong level Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to
evidence 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily.

Criteria for 1. Full ROM and strength/power

Discharge 2. Pain-free high load resistance test, ensuring no pain in positions that normally
expert opinion compress the tendon
3. Full training with minimal pain

Failing to maintain a customary level of mechanical loading will result in a rapid tissue-specific shift
towards catabolic activity. It is vital to emphasize the importance in the off-season management
because tendons require a certain level of load maintenance. Continuing the loading program to
prevent reduction in tendon integrity and stiffness is important.
Authors: Ann-Marie Walters, PT, cert MDT; Robin A. Sopher, PT, DPT; J.J. Kuczynski, PT, DPT, OCS
Reviewer: Kate Glaws, PT, DPT, SCS; John Ryan, MD
Date: July 12, 2017

References
1. Allison K, Wrigley T et al. Kinematics and Kinetics During Walking in Individuals with Gluteal Tendinopathy. Clinical
Biomechanics. 2016; 32: 56-63
2. Almekinders LC, Weinhold PS and Maffulli N. Compression Etiology in Tendinopathy. Clin Sports Medicine. 2003; 22
(4);703-10
3. Bird PA, Oakley SP, Shnier R and Kirkham BW. Prospective Evaluation of Magnetic Resonance Imaging and Physical
Examination Findings in Patients with Greater Trochanteric Pain Syndrome. Arthritis and Rheumatism. 2001; 44 (9): 2138-145
4. Malliaras P, Cook J, Purdam c, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for
Challenging Case Presentations. JOSPT. 2015; 45:887-897.
5. Collee G, Dijkmans BA et al. Greater Trochanteric Pain Syndrome (Trochanteric Bursitis) in Low Back Pain. Scand. J.
Rheumatol. 1991; 20 (4): 262-6
6. Cook JL, Purdam CR. Is Compressive Load a Factor in the Development of Tendinopathy? Br J of Sports Med. 2012; 46
(3): 163-8
7. Cook JL, Purdam CR. Is Tendon Pathology a Continuum? A Pathology Model to Explain the Clinical Presentation of Load-
Induced Tendinopathy. Br J Sports Med. 2009; 43 (6): 409-16
8. Cook JL, Purdam CR. The Challenge of Managing Tendinopathy in Competing Athletes. Br J Sports Med. 2014; 48(7):506-
9
9. Cook JL, Rio E, Purdam CR and Docking SI. Revisiting the Continuum Model of Tendon Pathology:What is its Merit in
Clinical Practice and Research? Br J of Sports Med. 2016; 50(19): 1187-91
10. Del Buono A, Papalia R et al. Management of the Greater Trochanteric Pain Syndrome: A Systematic Review. Br. Med.
Bull. 2012; 102 (1): 115-131
11. Fearon AM, Ganderton C. Development and Validation of a VISA Tendinopathy Questionnaire for Greater Trochanteric
Pain Syndrome, the Visa-G. Manual Therapy. 2015; 1-9
12. Fearon AM, Scarvell JM, Neeman T, Cook JL, Cormick W and Smith PN. Greater Trochanteric Pain Syndrome: Defining
the Clinical Syndrome. Br J Sports Med. 2013; 47(10): 649-53
13. Fearon AM, Stephens S, Cook JL et al. The Relationship of Femoral Neck Shaft Angle and Adiposity to Greater
Trochanteric Pain Syndrome in Women. A Case Control Morphology and Anthropometric Study. Br J Sports Med. 2012; 46;
888-92
14. Grimaldi A and Fearson A. Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in its Management.
JOSPT. 2015; 45 (11): 910-22
15. Hart DA, Scott A. Getting the Dose Right When Prescribing Exercise for Connective Tissue Conditions; the Yin and the
Yang of Tissue Homeostasis. 2012; 46 (13):953
16. Lequesne M, Mathieu P et al. Gluteal Tendinopathy in Refractory Greater Trochanter Pain Syndrome: Diagnostic Value of
Two Clinical Tests. Arthritis and Rheumatism. 2008; 59 (2): 241-246
17. Naugle KM, Fillingim RB, Riley JL. A Meta-Analytic Review of the Hypoalgesic Effects of Exercise. The Journal of Pain.
2012; 13(12); 1139-1150
18. Rio E, Van Ark M, Docking S et al. Isometric Contractions are More Analgesic than Isotonic Contractions for Patellar
Tendon Pain: An in Season Randomized Clinical Trial. Clin J Sport Med. 2017; 27(3) 253-9
19. Scott A, Backman L et al. Tendinopathy- Update on Pathophysiology. JOSPT. 2015; 45 (11) 833-841.
20. Scott A, Docking S. et al. Sports and Exercise-Related Tendinopathies: A Review of Selected Topical Issues by
Participants of the Second International Scientific Tendinopathy Symposium. Br J Sports Med. 2013; 47 (12): 774
21. Silbernagel KG, Crossley KM. A proposed Return to Sport Program for Patients with Midportion Achilles Tendinopathy:
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22. Tyler T, Fukunaga T, Gellert J. Rehabilitation of Soft Tissue Injuries of the Hip and Pelvis. Int J. Sports Phys. Ther. 2014;
9(6): 785-797
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Season? A Randomised Clinical Trial. Journal of Science and Medicine in Sport. 2016; 19 (9): 702-706
24. OSU Tendinopathy. J.J. Kuczynski, PT, DPT
Appendix A: Activities to Avoid/Change

The structures at the side of your hip have increased
compression when your hips are flexed over 90⁰ and
when you cross your leg past the midline of your
body. This compression causes pain and irritation to
occur.
Irritation or pain at the side of your hip will delay tissue
healing, and the pain cycle will continue. Modifying your
activities is necessary to allow for healing to occur. It is
important you follow these changes to notice a decrease
in your symptoms, and to eventually alleviate pain.

Activities to Avoid Activities to Change

Avoid crossing legs Use towel roll between
while sitting knees to avoid knees
coming together

Avoid sitting in Raise seat height so that

“figure 4” position hips are at an angle
greater than 90⁰

Avoid “hanging” on When sleeping on your

either hip while non-painful side, put two
standing pillows between our
knees

Avoid flexibility and

stretching exercises
targeting IT
Band/piriformis

Avoid sleeping on If you must sleep on painful

painful hip hip, use an egg crate to
soften surface
Appendix B: Abduction

Low-Load Isometric Abduction Low-Velocity, High-Load

Cue patients for attention on gentle “trochanteric abductor” Abduction
activation (gluteus medius and minimus) while attempting to
keep the iliotibial band tensioners relaxed (TFL, upper gluteus
maximus, and vastus lateralis

Supine with belt/band Upright skating or

skating in squat

Sidelying abduction Alternative home

isometric (cue patient to version: Band side
imagine preparing to lift slides. Maintain
the top leg into optimal pelvic and
abduction-shin trunk alignment
horizontal) Upright side
stepping with band

Standing (instruct Alternative home

patient to imagine doing version: Upright
the side side stepping with
splits (without band
movement occurring)


HIP ARTHROSCOPY/
FEMOROACETABULAR IMPINGEMENT
OSTEOPLASTY/LABRAL REPAIR
CLINICAL PRACTICE GUIDELINE
Femoroacetabular impingement (FAI) is a common cause of intra-articular hip pathology and secondary
hip osteoarthritis. There are three types of FAI: pincer impingement (excessive prominence of the
anterolateral rim of the acetabulum), cam impingement (overgrowth of the femoral head rotating inside
the acetabulum) and a combination of pincer and cam impingements (Byrd, 2010). The abnormal
abutment of the proximal femur against the rim of the acetabulum produced by the FAI causes limitations
in range of motion and produces shear forces that lead to hip dysfunction, chondral abrasion,
delamination/labral injuries, and eventually, full-thickness cartilage loss. The natural history of this
impingement process is initially acetabular cartilage injury, which is followed by labral injury and ultimately
joint arthrosis (Edelstein, 2012).

Hip arthroscopy allows for a minimally invasive procedure to correct the offending bony lesions.
Osteoplasty is performed to reshape the impingement lesion on the femoral and/or acetabular side
(removing either the non-spherical portion of the femoral head and/or resection of the anterior acetabular
over-coverage). Labral repairs are performed, if possible, to avoid disruption of joint mechanics and
abnormal distribution of forces around the joint. Anchors are placed on the rim of the acetabulum and the
suture is passed through the labrum and around the split portion, and then the labral tissue is re-
approximated (Enseki, 2006).

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.\


Summary of Recommendations

Precautions • WB restrictions: foot flat WB with crutches (2 wks)

• Walk without crutches 2-4 wks
o 2à0 crutches preferred
• Avoid any “pinch” feeling in the hip
• Avoid hip flexor/adduction aggravation as strengthening and activity progresses
ROM/Manual • Early motion as required to prevent adhesions
Therapy • Circumduction (only after PT instruction) OR no resistance upright biking for PROM
• Limit external rotation and extension ROM during early post-op phase
• No aggressive PROM or stretching until at least 8 wks (only if excessive hypomobility
is present)
Corrective • Proper activation and recruitment of all hip and core musculature without
Interventions compensation required prior to initiating strengthening
• Neuromuscular re-education for balance and correction of faulty mechanics
• Therapeutic exercise and neuromuscular re-education for LE strength (focus on DL
and SL activities)
st
Outcome • 1 visit, 6 wks, and discharge (may increase frequency if warranted)
Testing • Hip Outcome Score (HOS)
• ADL (17 items) | Sports (9 items)
Criteria to • Full, functional, pain-free ROM
Initiate • > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength
Plyometric compared to uninvolved leg
Program • Squat > 150% BW (barbell squat or leg press)
• 10 forward and lateral step downs from 8” step with proper mechanics
Criteria to • Full, functional, pain-free ROM
Initiate • > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength
Running compared to uninvolved leg
Program • Squat > 150% BW (barbell squat or leg press)
• 10 forward and lateral step downs from 8” step with proper mechanics
• Hop and hold with proper mechanics (uninvolvedàinvolved)
• Ability to tolerate 200-250 plyometric foot contacts without reactive pain/effusion
• No gross visual asymmetry and rhythmic strike pattern with treadmill or over ground
running
Criteria for • Physician clearance at last check-up
Return to • Strength: > 90% compared to uninvolved hip (using hand-held dynamometer)
Sport/ • > 90% BW with SL leg press
Discharge • Functional Performance:
• > 90% limb symmetry with SL hop for distance, SL triple crossover hop, and SL
6-meter timed hop (with demonstration of proper LE landing mechanics)
• Ability to complete sport-specific drills with correct mechanics (at maximum
speed w/o pain)
• Vail Sport Test
• Patient reported outcome measures: Score ≥ 90% on HOS (ADL and Sports
subscales)
Criteria for discharge from PT is less rigorous for those not returning to sport. Ensure the
patient is able to perform all ADLs and recreational activities without pain, reactive
effusion, and with appropriate functional mechanics.


Phase I: Day 1 Post-Op until D/C crutches (0-4 weeks)

Goals • Protect healing tissue

• Pain and edema control (recommend compression garments/shorts to assist)
• Improve pain-free ROM
• Normalize muscle activation
Precautions • No sitting > 2 hours
• Avoid hip extension (slow walking speed and no treadmill use)
• Gentle external rotation (ER) per patient’s tolerance
• Avoid twisting/pivoting
• No active straight leg raises (SLRs) or crunches/sit-ups
• No lifting/carrying > 10 lbs
• Avoid pain
Crutch • 2 crutches à 0 crutches highly recommended to promote normalized gait mechanics
Progression • 2 à 1 à 0 crutches only when appropriate to slow patient progression or to limit walking
distance
Criteria for • Adequate hip ROM for normalized/painfree gait pattern (10° hip extension)
Community • Score of 0-1 performing 10 repetitions of Active Hip Abduction Test (Appendix B)
Ambulation • 60 secs of single leg stance (SLS) without compensation (hip drop, trunk lean) or pain
without • Normalized gait pattern without assistive device
Crutches
st
ROM/ • Circumduction (begin only after PT education; review mechanics with family at 1 PT visit)
Stretching • 30° and 70° of hip flexion à 6 min each (3 mins clockwise, 3 mins counterclockwise)
• Can be replaced with 10-15 mins of upright biking with no resistance (x2 daily)
• PROM (painfree): Hip flexion, abduction, prone hip internal rotation (IR) and ER
• Stretches: prone quadriceps, supine iliopsoas (uninvolved knee to chest)
• Prone lying à prone prop on elbows 5-10 mins (x2 daily)
• GENTLE scar mobilizations can begin after incisions closed
st
Neuro- This section is 1 priority à do not progress to strengthening until muscle activation and
muscular isolated control is normalized
Control • Gluteal muscles (prone, supine, seated, ½ kneel, tall kneel, standing), transverse
abdominis, hamstrings, quadriceps
• Supine hip abduction/adduction, prone hip IR/ER, prone terminal knee extension (TKE)
Therapeutic Early Exercises Advanced Exercises
Exercise • Supine butterflies and reverse • Criteria to begin this section: normalized gait pattern,
butterflies, quadruped minimal reactive pain and edema
cat/camel, quadruped • Sidelying clams, supine marches (w/o bridge), heel
backward rocking, prone slide to march, standing TKE à with focus on pelvic
hamstring curls, bridges stability and appropriate weight shifting, passive
FABER slides
Criteria to • Normalized gait pattern for household distances
Progress to • Minimal to no reactive pain and swelling with ADLs and PT exercises
Phase II • Muscle activation and isolation is normalized
• Pass the Prone Hip Extension Test (Appendix A)
• 10 repetitions
st nd
• Proper gluteal muscle activation (gluteus maximus 1 , hamstrings 2 )
• Leg extends 10° past neutral
• No compensatory movement patterns at pelvis (no anterior pelvic tilt)
• No anterior hip pain


Phase II: D/C Crutches to Painfree with ADLs (4-8 weeks)

Goals • Restore full PROM and AROM

• Progressively improve strength of the proximal hip musculature (gluteals, iliopsoas, hip
rotators)
• Normalize postural/pelvic control with DL and SL activities
• Normalize gait at preferred walking speed for community distances
• Tolerate ADLs without pain or limitation
Precautions • Avoid joint and/or soft tissue aggravation due to early/excessive progression of activity
• Avoid aggressive stretching into hip extension/ER including modified Thomas test position
(consider structures involved: i.e. labral repair, capsular plication, generalized laxity)
• Avoid running or impact activities
ROM/ • Soft tissue and joint mobilization to achieve symmetrical PROM
Stretching • Avoid aggressive end range stretching
• Upright bike, butterfly/reverse butterfly stretches, FABER slides, half kneeling hip flexor
stretch, prone IR/ER PROM
• May benefit from referral to massage therapist if patient is developing soft tissue
dysfunction/irritation (commonly affects TFL, adductors)
• Soft tissue irritation suggests need for regression of activities and/or exercises
• Continually assess patient’s current activity level outside of PT
Therapeutic • Ensure appropriate gluteal activation Late Exercises
Exercise and timing • Prior to initiating full WB SL exercises patient
• Integrate psoas progressive exercises should pass criteria for community ambulation
(Appendix C) and demonstrate mastery of DL tasks
Early Exercises • Forward and lateral step ups, heel taps, ER
• Bridge progression, quadruped progression (on stool, standing on ipsilateral
progression, DL squat, leg press, side LE), SL Romanian dead lift (RDL), SLS with
planks, modified forward plank perturbations
progression, resisted side stepping • Aquatic therapy may be appropriate and can
(start with band at knees) be initiated once incision is well-healed and
patient is cleared by physician
Cardio- • May progress time on upright bike as tolerated
vascular • Ensure patient can perform 30 mins with no resistance and without symptoms prior to
Exercise adding resistance
• Decrease time to ≤15 min when adding resistance
• May begin elliptical when patient demonstrates adequate hip extension, gluteal activation,
and lumbopelvic stability
Criteria to • Symmetrical and painfree hip ROM to meet the demands of patient’s activities
Progress to • Symmetrical DL squat to 70° of knee flex
Phase III • 10 repetitions of 8” step downs with good neuromuscular control
• Normalized gait pattern for community distances of ambulation


Phase III: Painfree ADLs to Return to Impact Activities (8-12 Weeks)

Goals • Correct abnormal/compensatory movement patterns with higher level strengthening

activities Avoid any “pinch” feeling in the hip
• Optimize neuromuscular control/balance/proprioception
• Increase volume/intensity of aerobic activities; begin to restore non-impact cardiovascular
fitness
• Initiate progressive plyometric activities
• Return to run program can be initiated towards end of phase III if criteria met
Precautions • Avoid sacrificing quality for quantity during strengthening
• Avoid hip flexor/adductor inflammation as activity increases
• Ensure patient maintains full flexibility and painfree ROM as strength continues to increase
• Avoid aggressive stretching within this phase unless significant hypomobility noted
ROM/ • ROM should be checked periodically to ensure that loading the hip with new exercises does
Stretching not alter neuromuscular response and normal joint mechanics
• If full ROM is not achieved by week 10, terminal stretches should be initiated
Therapeutic • Continue progressive LE/core strengthening: Slow to fast, simple to complex, stable to
Exercise unstable, low to high force
• DL strengthening advancement to SL strengthening
• Progress core stability tasks with emphasis on rotational and side-support tasks (Side
planks, cable crossovers, kneeling chops/lifts, windmill / Plank to pike, plank over SB)
• LE strengthening tasks with multi-planar movements: Emphasize core stability and hip/knee
control (no valgus) during these tasks
• Proprioception: Vary surfaces, add perturbations, include variety of positions, etc.
Cardio- • Dynamic warm-up initiated (inchworm, progressive lunges towards end of phase)
vascular • Upright Bike/Elliptical Progression (see return to biking protocol)
Exercise • Progress resistance (and cross ramp on elliptical) as tolerated
• Swimming Progression (see return to swimming protocol)
• Can begin freestyle kick; continue to avoid rotational kicks
Plyometrics • Criteria to initiate plyometric program
• Full, functional, pain-free ROM
• > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength
compared to uninvolved leg
• Squat 150% BW (barbell squat or leg press)
• 10 forward and lateral step downs from 8” step with proper alignment (Appendix D)
• Progressive weight bearing, DL à SL demands
• Shuttle plyometrics (DL à SL)
• Forward hop and hold (uninvolved à involved)
• DL mini hops/place jumps
• Proper take off/landing mechanics emphasized à NO knee valgus, good pelvic stability,
soft/quiet landing with equal distribution of force
• Agility ladder can be initiated if appropriate form/tolerance to activity in progressive
plyometrics


Return to Running
Walk/jog progression can be initiated towards end of phase if patient demonstrates:

• Full, functional, pain-free ROM

• > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength compared to
uninvolved leg
• Squat 150% BW (barbell squat or leg press)
• 10 forward and lateral step downs from 8” step with proper alignment (see appendix D)
• Hop and hold with proper mechanics (uninvolvedàinvolved x10 repetitions)
• Ability to tolerate 200-250 plyometric foot contacts without reactive pain/effusion
• No gross visual asymmetry and rhythmic strike pattern with treadmill or over ground running

Phase Walk/Run Ratio Total Time

1 4 min / 1 min 10-20 min
2 3 min / 2 min 10-20 min
3 2 min / 3 min 10-20 min
4 1 min / 4 min 10-20 min
5 • Jog every other day until able to run 30 consecutive minutes
• Begin with 5 min walking warm up
• End with 5 min walking cool down

General Guidelines

• To complete each phase, follow the Total Time guidelines below.

• 10 minutes x2 sessions
• 15 min x1 session
• 20 min x1 session
• After completing any phase pain free for 20 minutes, patient is appropriate to move forward to
next phase
• Allow at least one day of rest between runs
• Gradual increase in distance is priority before increased pace
• It is common for runners to experience increased pain and/or reactive edema at least x1 during this
return to run progression. When pain occurs, runner must stop running immediately and rest at least
1 day before restarting program. With restart, perform last walk/jog ratio cycle completed painfree x2
before attempting the previously painful ratio cycle.
• Ten Percent Rule: only increase weekly mileage by 10% of the previous week


Phase IV – Return to Sport / Full Activity (3-6+ Months)

Goals • Initiate return to run program if not initiated in phase III

• Return to physically demanding jobs
• Progressively return to sport or prior/desired level of function
Precautions • Continue to emphasize proper landing mechanics (DL and SL)
• Avoid progression of plyometric exercises if increased pain (if yes, re-assess and address
any underlying strength or neuromuscular impairments)
• Ensure patient maintains full flexibility and painfree ROM as strength continues to increase
• Closely monitor return to sport progression
ROM/ • Continue ROM interventions and stretches from previous phases
Stretching • Include multi-planar lumbar and hip ROM/flexibility
• Emphasis on dynamic warm-up and stretching (i.e. walking lunges, hurdle steps, etc.)
• Monitor sport-specific stretching with gradual return to end range stretching
Therapeutic • Hip and core strengthening with focus on pelvic stability
Exercise • Maintain DL strength but emphasize SL strengthening (involved and uninvolved)
Neuro- • Progress agility and plyometrics by adding in higher level activities (i.e. forward/backwards
muscular hopping, side shuffles, carioca, cutting, box drills, T drills, tuck jumps, DL/ SL jump turns)
Control and • Focus on hip and pelvic stability
Functional • Incorporate unstable surfaces with plyometrics
Performance • Sport specific drills in clinic (moderate speed à maximum speed)
• Prior to initiating speed training, patient must first complete entire return to run program
without reactive pain/inflammation
• Ensure tolerance with DL and SL plyometrics prior to initiating power-focused or resisted,
explosive training
Criteria to • Physician clearance at last check-up
Return to • Strength: > 90% compared to uninvolved hip (using hand-held dynamometer)
Sport/ • > 90% with SL leg press at body weight (number of repetitions to fatigue)
Discharge • Functional Performance
• 90% limb symmetry with SL hop for distance, SL triple crossover hop, and SL 6-meter
timed hop (with demonstration of proper LE landing mechanics)
• Ability to complete sport-specific drills with correct mechanics (At maximum speed
without pain)
• Vail Sport Test (Appendix E)
• Patient reported outcome measures
• Score ≥ 90% on HOS (ADL and Sports subscales)


References
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2010. 2; 4: 321-333.

Bruno P. The importance of diagnostic test parameters in the interpretation of clinical test findings: the
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Davis, AM, Bridge P, Miller J, Nelson-Wong, E. Interrater and intrarater reliability of the active hip
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Dewitt, JD. Non-surgical/post-op management. Presented at: APTA’s NEXT Conference & Exposition;
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Edelstein J, Ranawat A, Enseki KR, Yun RJ, Draovitch P. Post-operative guidelines following hip
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Enseki KR, Kohlrieser D. Rehabilitation following hip arthroscopy: an evolving process. Int J Sports Phys
Ther. 2014;9(6):765-773.

Enseki KR, Martin RL, Draovitch P, et al. The hip joint: arthroscopic procedures and postoperative
rehabilitation. J Orthop Sports Phys Ther. 2006. 36; 7: 516-525.

Garrison JC, Osler MT, Singleton SB. Rehabilitation after arthroscopy of an acetabular labral tear. N Am J
Sports Phys Ther. 2007;2(4):241-50.

Garrison JC, Shanley E, Thigpen C, et al. The reliability of the Vail Sport Test™ as a measure of physical
performance following anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2012;7(1):20-30

Grzybowski JS, Malloy P, Stegemann C, Bush-Joseph C, Harris JD, Nho SJ. Rehabilitation following hip
arthroscopy—a systematic review. Front Surg. 2015;2(21):1-10.

Park K, Cynn H, Choung S. Musculoskeletal predictors of movement quality for the forward step-down
test in asymptomatic women. J Orthop Sports Phys Ther. 2013;43(7):504-510.

Tyler TF, Fukunaga T, Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis. Int J Sports
Phys Ther. 2014;9(6):785-797.

Wahoff M, Dischiavi S, Hodge J, & Pharez JD. Rehabilitation after labral repair and femoroacetabular
decompression: criteria-based progression through the return to sport phase. Int J Sports Phys Ther.
2014;9(6):813-826.


Appendix A: Prone Hip Extension Test

The prone hip extension test assesses ability to fire
the gluteus maximus while maintaining lumbo-pelvic-
hip control. Criteria to pass test:

• 10 repetitions
• Proper gluteal muscle activation (gluteus maximus
st nd
1 , hamstrings 2 )
• Leg extends 10° past neutral
• No compensatory movement patterns at pelvis (no
anterior pelvic tilt)
• No anterior hip pain

Appendix B: Active Hip Abduction Test

Score Cues for Examiner

0 Able to maintain position of
pelvis in the frontal plane
1 Minimal loss of pelvis position Slight wobble at initiation or throughout any movement; may show
in the frontal plane
2 Moderate loss of pelvis
position in the frontal plane
3 Severe loss of pelvis position
in the frontal plane
Smoothly and easily performs movement; lower extremities, pelvis, trunk
and shoulders remain aligned in frontal plane.
noticeable effort or “ratcheting” of moving limb
Has at least 2 of the following: noticeable wobble through movement;
tipping of pelvis, trunk or shoulder rotation; increased hip flexion and/or
rotation of the moving limb; rapid or uncontrolled movement
Has more than 3 of the above characteristics and/or unable to regain
control of movement once lost or may lose balance (has to place hand
on table)

(A) Demonstration of the active hip abduction test from the starting
position
(B) Demonstration of good control of the pelvis in the frontal plane; this
would receive a score of 0. The alignment of lower extremities, pelvis
and trunk has not changed from the start position, and upper extremity
remains relaxed on the abdomen.
(C) Demonstration of poor control of the pelvis in the frontal plane; this
would receive a score of 3. The upper extremity is placed on the table to
prevent loss of balance, the pelvis has rotated forward and the top hip
has flexed and internally rotated.

Davis, AM, Bridge P, Miller J, Nelson-Wong, E. Interrater and intrarater reliability of the active hip
abduction test. J Orthop Sports Phys Ther. 2011;41(12):953-960.


Appendix C: Psoas Progression

Clinicians may choose either of the two iliopsoas strengthening progressions based on clinician/patient
preference. All exercises are performed with simultaneous abdominal drawing in maneuver and lumbar
spine in neutral alignment.

A) Supine short-lever hip flexion A) Marching

B) Seated hip flexion B) Walk Out
C) Seated hip flexion on Swiss ball C) Heel Slide
D) Standing hip flexion with theraband D) Heel Slide with SLR
resistance
Tyler TF, Fukunaga T, Gellert J. Rehabilitation of Dewitt, JD. Non-surgical/post-op management.
soft tissue injuries of the hip and pelvis. Int J Presented at: APTA’s NEXT Conference &
Sports Phys Ther. 2014;9(6):785-797. Exposition; June 5, 2015; National Harbor, MD.


Appendix D: Forward Step Down Test

Definition of errors Interpretation of errors

Arm strategy: subject uses an arm strategy in an attempt to recover 0-1 errors Good quality
balance (1 point) mechanics
Trunk movement: trunk leans right or left (1 point)
Pelvic plane: pelvis rotates or elevates on one side compared to
the other (1 point)
Knee position: knee deviates medially and the tibial tuberosity
crosses an imaginary vertical line over 2nd toe (1 point); knee
deviates medially and the tibial tuberosity crosses an imaginary 2-3 errors Medium quality
vertical line over medial boarder of the foot (2 points) mechanics
Balance: subject steps down on the uninvolved side or the subject’s
tested leg becomes unsteady (1 point)

4+ errors Poor quality

mechanics

Park K, Cynn H, Choung S. Musculoskeletal predictors of movement quality for the forward step-down
test in asymptomatic women. J Orthop Sports Phys Ther. 2013;43(7):504-510.


Appendix E: Vail Sports Test

Total Points: _____/54 (Patient must score 46/54 on the test in order to pass)

Single Leg Squat (Goal: 3 minutes): subject must perform each repetition at a cadence of 1 second up
and 1 second down against resistance of a sportcord (placed under the foot of the leg that the test is
being performed on).

Yes (1) No (0) Minute 1 Minute 2 Minute 3

1. Knee flexion angle between 30° and 60°

2. Patient performs repetitions without dynamic knee valgus
3. Patient avoids locking knee during extension
4. Patient avoids patella extending past the toe during knee flexion
5. Patient maintains upright trunk during knee flexion

Single Leg Squat Total Points _____/15

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 1-minute timeframe).

Lateral Bounding (Goal: 90 seconds): subject performs a lateral hopping motion against resistance of a
sportcord attached to the subject’s waist via a belt and on the other end to an immoveable object that is
level with the waist. The injured leg is positioned as the inside leg or the leg closest to the wall. The
patient is instructed to hop from one leg to the other (leg length distance), absorbing energy while they
land by bending at the knee and hip. Landing boundaries (distance of the hop) are demarcated on the
floor with two pieces of tape, one of which begins at the point of resistance of the sportcord as it is
stretched away from the wall and the other is the measured distance of the subject’s leg length from the
first piece of tape.

st nd rd
Yes (1) No (0) 1 30 2 30 3 30
seconds seconds seconds

1. Knee flexion angle is 30° or greater during landing

2. Patient performs repetitions without dynamic knee valgus
3. Patient performs repetitions within landing boundaries
4. Landing phase does not exceed 1 second in duration
5. Patient maintains upright trunk during knee flexion

Lateral Bounding Total Points _____/15

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 30 second timeframe).


Forward Jogging (Goal: 2 minutes): subject performs forward jogging against resistance of the sportcord
with the belt around waist. The patient is instructed to hop from one leg to the other in an up and down
manner (similar to jogging in place) while using proper form and absorbing energy with each landing by
bending at the knee and hip.

Yes (1) No (0) Minute 1 Minute 2

6. Knee flexion between 30° and 60°
7. Patient performs repetitions without dynamic knee valgus
8. Patient performs repetitions within landing boundaries
9. Patient avoids locked knee during extension
10. Landing phase does not exceed 1 second in duration
11. Patient maintains upright trunk during knee flexion

Forward Jogging Total Points _____/12

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 1-minute timeframe).

Backward Jogging (goal: 2 minutes): subject performs backward jogging against resistance of the
sportcord with the belt around waist. The patient is instructed to hop from one leg to the other in an up
and down manner (similar to jogging in place) while using proper form and absorbing energy with each
landing by bending at the knee and hip.

Yes (1) No (0) Minute 1 Minute 2

12. Knee flexion between 30° and 60°

13. Patient performs repetitions without dynamic knee valgus
14. Patient performs repetitions within landing boundaries
15. Patient avoids locked knee during extension
16. Landing phase does not exceed 1 second in duration
17. Patient maintains upright trunk during knee flexion

Backward Jogging Total Points _____/12

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 1-minute timeframe).

Garrison JC, Shanley E, Thigpen C, et al. The reliability of the Vail Sport Test™ as a measure of physical
performance following anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2012;7(1):20-30.


HIP MICROFRACTURE
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Overview
•
Avoid aggravation of inflammatory response, protect fibrocartilage formation
•
All progression based on soft tissue healing response
•
Weightbearing
o Non-weightbearing first six weeks or per physician’s recommendations
o Discontinue assistive device as gait mechanics normalize
Range of • Flexion within pain-free range and no anterior impingement
Motion • Anterior Repair
o Extension and external rotation within pain-free range and no overpressure
• Posterior Repair
o Flexion, adduction and internal rotation within pain-free range and limit overpressure
• Utilize both weightbearing and non weight bearing mobility techniques
• Chondroplasty procedure follow same parameters
Bracing • No post-operative bracing unless indicated by surgeon

Other • Don’t push through hip flexor pain/inflammation

• No ballistic stretching or forced stretching

Phase I: Initial Exercise

Goals 1. Protect integrity of the repaired tissue
2. Improve ROM within parameters
3. Reduce pain and inflammation
4. Prevent muscular inhibition
Precautions • Do not push through hip flexor pain

Weeks 0-2 • Passive hip circumduction: First post-op visit until gait is normal and pain free
o 3 minutes clockwise/counterclockwise each at slight flexion (6 total minutes)
o 3 minutes clockwise/counterclockwise each at 70º flexion (6 total minutes)
• “Belly time”: lie prone for 20 minutes, twice daily
• Ankle Pumps
• Glut, quad, hamstring, transverse abdominus isometrics
• Stationary bike with minutes resistance (1/2 revolutions, progressing to full)
• Active assisted ROM all directions avoid anterior impingement with IR and flexion.
• Passive ROM log rolling IR/ER
• Heel slides
• Quadruped rocking
• Hip abduction/adduction isometrics
• Prone IR/ER isometrics

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Weeks 2-4 • Stationary Bike • Double leg bridges
• Continue AROM • Short lever hip flexion
• Begin aquatic therapy program, if available • Half kneeling hip flexor stretch
• Progress hip abd/add isometrics to • Quadruped rocks
progressive resistance • Piriformis stretch
• Progress hip extension progressive • Clamshells (supine progress to sidelying)
resistance • Oscillatory grade I-II joint mobilizations -
• Progress hip IR/ER isometrics to distraction
progressive resistance
• 3-way straight leg raises (abduction,
adduction, extension)
Weeks 4-6 • Stationary bike
• Continue aquatics program
• Straight leg raises – initiate flexion (pain-free)
• Continue short lever hip flexion if flexion SLR is pain full
• Hip progressive resistance (extension, abduction, adduction, IR, ER)
• Sidelying clamshells
• Kneeling hip flexor stretch
• Prone planks
• Oscillatory grade I-II joint mobilizations – distraction
Criteria for 1. Minimal pain with all Phase I exercises
Progression to 2. ROM ≥ of the uninvolved side (with exception of ER)
Phase II: 3. Proper muscle firing patterns for initial exercises
4. Do not progress to Phase II until full weightbearing is allowed

Phase II: Intermediate Exercise

Goals 1. Protect integrity of repaired tissue

2. Restore full ROM
3. Restore normal gait pattern
4. Progressively increase muscle strength
Precautions • No ballistic or forced stretching
• Avoid painful treadmill use
• Avoid hip flexor/joint inflammation

Weeks 7-12 • Stationary bike with resistance • Advanced bridging (double leg to single
• Elliptical leg, Swiss Ball)
• Stairclimber • Pelvic stability exercise
• Manual long axis distraction (gradual) • Side planks
• Manual A/P mobilizations – emphasis on • Side steps
posterior • Lateral stepdowns
• Mini squats to 45 degrees • Partial single leg squats
• Single leg stance (progress from stable to
unstable surfaces)
Criteria to 1. Full ROM
Progress to 2. Pain free, normal gait pattern
Phase III 3. Hip flexion strength > 60% of the uninvolved side
4. Hip add, abd, ext, IR, ER strength > 70% of the uninvolved side


Phase III: Advanced Rehabilitation
Goals 1. Restoration of muscular endurance and strength
2. Restoration of cardiovascular endurance
3. Improvement of coordination, balance and neuromuscular control

Precautions • Avoid hip flexor irritation • Begin treadmill use gradually

• Avoid hip joint irritation • No contact activity
• No ballistic or forced stretching

Weeks 12-16 • Lunges • Forward/backward cord exercises

• Lateral agility exercises • Side steps with cord
• Increased aquatic therapy • Running progression

Criteria to 1. Hip flexion strength > 70% of the uninvolved side

Progress to 2. Hip add, abd, ext, IR, ER strength > 80% of the uninvolved side
Phase IV 3. Cardiovascular fitness returning to pre-injury levels
4. Demonstration of initial agility drills with proper mechanics

Phase IV: Sport Specific Training

Goals 1. Return to Sport

Weeks 17- 26 • Z-Cuts • Initial agility drills

• W-Cuts • Sports-specific drills
• Cariocas • Functional tests
• Running progression • Recommended: Lower Extremity
• Plyometrics Functional Scale (LEFS) and Hip Outcome
• Score (HOS)
Criteria for 1. Full pain-free ROM
Return to 2. Hip strength > 85% of the uninvolved side
Competition 3. Ability to perform sports-specific drills at full speed without pain
4. Functional tests

References
Enseki, KR, Martin, RL, Draovich P, Kelly BT, Philoppon MJ, and Schenker ML. The hip joint: arthroscopic
procedures and postoperative rehabilitation. JOSPT. 2006; 36(7):516-525.

Stalzer S., Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clinics in Sports Medicine. 2006; 25:
337-357.

Smith GD, Knutsen G, Richardson JB. A clinical review of cartilage repair techniques. The Journal of Bone and
Joint Surgery. 2005; 87(4): 445-449.

Lienert JJ, Rodkey WG, Steadman JR, Philippon MJ, Sekiya JK. Microfracture techniques in hip arthroscopy.
Operative Techniques in Orthopaedics. 2005; 15: 267-272.

Crawford K, Philippon MJ, Sekiya JK, Rodkey WG, Steadman JR. Microfracture of the hip in athletes. Clinics in
Sports Medicine. 2006; 25: 327-335.

PROXIMAL HAMSTRING AVULSION REPAIR

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Rehabilitation Precautions
• Non-weight bearing without bracing for 2 weeks. Toe-touch weight bearing Weeks 2-4
• No terminal/end-range hamstring stretching for 6 weeks
• Avoid long-sitting position for 6 weeks
• No isolated isotonic hamstring strengthening for 8 weeks

Phase I: • Home exercises only

• Maintain non-weight bearing status
Weeks 0-2 • Compression, cryotherapy, ankle pumps

Goals to 1. Control pain and inflammation

Progress to 2. Wound healing
Next Phase

Phase II: • Begin physical therapy

• Toe-touch weight bearing using crutches or walker
Weeks 2-4 • Initiate gentle hip, knee and ankle PROM within patient tolerance → avoid lengthened
hamstring positions
• Initiate quad sets, straight leg raises in abduction only
• Initiate gentle soft-tissue mobilization at proximal insertion/incision site, if wound is fully
closed

Goals to 1. Full hip, knee, and ankle PROM in protected positions, avoiding lengthened hamstrings
Progress to 2. Good quad control in non-weight bearing position
Next Phase 3. Continue pain and inflammation control

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Phase III: • Begin weight bearing progression, per patient tolerance
• Aquatic activities (if available): forward and retro ambulation, gentle AROM (avoid terminal
Weeks 4-6 stretching), gentle partial weight bearing squats (small range)
• Initiate gentle PROM straight leg hamstring stretching per patient tolerance
• Continue soft tissue mobilization
• Initiate single leg stance and static proprioceptive activities
• Initiate sub-maximal hamstring isometrics. Avoid lengthened hamstring positions initially.
• Begin at 30°, 45°, 60°, 90° knee flexion, patient supine.
• Initiate closed-chain terminal knee extensions (resisted quad sets)
• Straight leg raises in flexion (0° to 30° maximum ROM), abduction, adduction, per patient
tolerance
• Initiate core strengthening program: pelvic tilts, transverse abdominus activation

Goals to 1. Normalization of gait at 6 weeks

Progress to 2. Achieve 45° SLR PROM
Next Phase 3. SLR without quad lag

Phase IV: • Initiate terminal/end-range hamstring stretching, per patient tolerance

• Progress full lower extremity stretching program per patient tolerance
Weeks 6-8 • Initiate gentle isotonic resistive hamstring exercises
o Bilateral only, progress eccentric to concentric
o Begin with mid-range strengthening initially. Avoid lengthened hamstring position
initially.
• Progress core strengthening/dynamic lumbar stabilization program
• Progress proprioceptive activities: Include single leg stance on various surfaces, single leg
stance with perturbations (“steamboats”)

Goals to 1. Full range of motion at each lower extremity joint

Progress to 2. SLR 0°-70° PROM
Next Phase 3. Improved closed chain proprioception/stability without symptom increase

Phase V: • Full hamstring and quad strengthening program, per patient tolerance
Weeks 8- • Progress bilateral to unilateral, eccentric to concentric for hamstring strengthening
• Advanced core strength and stabilization program
12 • Include single knee balance activities on BOSU
• Bridging, Swiss ball bridging
• Advanced dynamic proprioceptive activities
• Initiate partial weight bearing plyometrics on shuttle or Total Gym
• Resisted ambulation, all directions, with cable-column or resistance bands – use
caution with resisted forward ambulation due to increased hamstring activation

Goals to 1. SLR range of motion within normal limits

Progress to 2. 5/5 straight plane strength in MMT positions
Next Phase 3. Tolerate PWB plyometrics on shuttle without symptom increase


Week 12 • Progress to FWB hop-downs, light, per patient tolerance
• Begin with 1 to 2 inch height box/step. Progress slowly to higher step. Progress from
bilateral to unilateral.
• Lunges: Forward and retro
• Slide Board

Goal 1. Perform hop-downs with appropriate mechanics, no evidence of dynamic instability, and
without symptom increase in order to progress difficulty and/or intensity.

Phase VI: • Continue progression of full-weight bearing plyometric activities

o Double leg side/side and diagonals
Weeks 12- o Single leg multi-directional
16 • Continue core stabilization program
o Swiss ball lower extremity curl-ups
• Initiate walk-jog progression
• Criteria to begin jogging:
1. Perform hop-downs with appropriate mechanics, no evidence of dynamic
instability, and without symptom exacerbation.
• Perform 10 single-leg hops on involved side, with good mechanics, without symptom
increase, and symmetrical with uninvolved side.
Goals to 1. Jog on treadmill and even surfaces with symmetrical mechanics and no symptoms.
Progress to
Next Phase

Phase VII: • Continue multi-directional/advanced plyometric program

• Hops to/from BOSU, multi-directional
Weeks 16-
• Initiate sport-specific drills, per patient tolerance
20 Ø Patient must tolerate all above activities without symptom increase prior to initiating
sport-specific activities.
o Include in sport-specific progression: running, cutting/diagonals, carriocas: progress
o 50% to 75% to full-speed
• Resisted forward running
Weeks 16-28 • Functional testing: Must demonstrate >85% performance of involved side when compared
Criteria to with uninvolved.
Return to o Include single-leg hop for distance test, 3-single-leg hop for distance
Sports
• Isokinetic testing:
o Must demonstrate >85% strength of involved side versus uninvolved side at 60°/sec,
180°/sec, and 300°/sec testing.
o Demonstrate hamstring to quadriceps strength ratio of 55-65% bilaterally
• No symptom increase with sport-specific progression or testing as described above.


References
Colosimo AJ, Wyatt HM, Frank KA, Mangine RE: Hamstring Avulsion Injuries. Oper Tech Sports Med (2005);
13:80-88
Brueker PU, Imhoff AB: Functional assessment after acute and chronic complete ruptures of the proximal
hamstring tendons. Knee Surg Sports Traumatol Arthrosc (2005); 13: 411-418
Clanton TO, Coupe KJ: Hamstring Strains in Athletes: Diagnosis and Treatment. J Am Acad Orthop Surg (1998);
6:237-248
O Mohamed et al: Relationship between wire EMG activity, muscle length, and torque of the hamstrings. Clinical
Biomechanics (2002); 17: 569-579
Lempainen L, Sarimo J, Heikkila J, Mattila K, Orava S: Surgical treatment of partial tears of the proximal origin of
the hamstring muscles. Br J Sports Med (2006); 688-691
Sherry MA, Best TM: A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. J of
Orth Sp Phys Ther (2004); 34:3: 116-125

TOTAL HIP REPLACEMENT POST-OP

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Overview
Total hip arthroplasty (THA), also known as a total hip replacement is an elective surgical procedure to treat
patients who experience pain and dysfunction from an arthritic hip joint. THA is an effective option if the patient’s
pain does not respond to conservative treatment and has caused a decline in their health, quality of life, or ability
to perform activities of daily living. This procedure removes the arthritic structures that make up the hip joint and
replaces them with artificial implants. The head of the femur, which makes up the ball of the hip joint, is removed
and replaced by a smooth ball with a stem fixed within the femur. The acetabulum, which makes up the socket
portion of the hip joint, is fitted with a metal socket with a smooth inner lining. Once in place, the artificial pieces
allow improved function of the hip joint.

With advancements in modern medicine, there have been several effective surgical approaches developed for
THA, including anterior, posterior, anterolateral, posterolateral, and lateral approaches. The surgeon will
determine the best surgical approach to use for each individual. For each approach, there are different
precautions that must be followed to decrease risk of dislocation based on the tissues that were affected during
surgery. Patients are encouraged to participate in early mobilization while adhering to precautions in order to
improve function and limit post-operative complications.

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Summary of Recommendations
Precautions Anterior approach:
(strictly adhered • No hip extension past 20 degrees
to for first 6
weeks, guarded • No hip external rotation past 50 degrees
progression Posterior approach
thereafter) • No hip flexion past 90 degrees
• No hip internal rotation or adduction past neutral
General precautions
• WBAT, with use of assistive device (AD) as needed (crutches, walker)
• No crossing legs (crossing ankles OK)
• Use good bending/lifting mechanics (keep back straight and bend at knees)
• Keep hips above knees when sitting, avoid sitting in deep chairs
ROM/Manual • Early range of motion (ROM) as tolerated within the restricted range
Therapy • Soft tissue mobilization as needed, scar mobilization once incision heals (>2-3 wks)
Corrective • Proper activation and recruitment of all hip and core musculature without
Interventions compensation required prior to initiating strengthening
• Neuromuscular re-education for balance and correction of faulty mechanics
• Therapeutic exercise for lower extremity strength (double and single limb)
Outcome • Select based on the needs of the patient and practice setting recommendations
Testing • Patient reported outcomes: VAS/NRPS, Lower Extremity Functional Scale, Hip
Osteoarthritis Outcome Score, Hip Outcome Score: ADL (17 items) | Sports (9 items)
• Performance tests: 30-Second Chair Stand Test, Gait Speed, TUG, Functional
Reach Test, 6-min Walk Test
Criteria to High impact activities such as plyometrics and running are generally not advised following
Initiate total joint replacements. First priority following these surgeries is to prevent damage to the
Plyometric new artificial joint. Due to lack of evidence on how high impact activities affect the integrity
Program of artificial joint replacement, patients are advised to participate in low impact
exercise/activities. Patients considering plyometrics with the intent to resume running
should consult with their physician.
• Full, functional, pain-free ROM
• > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength
compared to uninvolved leg
• Squat > 150% BW leg press
• 10 forward and lateral step downs from 8” step with proper mechanics
Criteria to • Full, functional, pain-free ROM
Initiate • > 80% of uninvolved quadriceps, hamstring, hip strength (hand-held dynamometer)
Running • Squat > 150% BW (barbell squat or leg press)
Program • 10 forward and lateral step downs from 8” step with proper mechanics
• Hop and hold with proper mechanics (uninvolvedàinvolved)
• Ability to tolerate 200-250 plyometric foot contacts without reactive pain/effusion
• No gross visual asymmetry and rhythmic strike pattern with running
Criteria for • Physician clearance at last check-up
Return to • Strength: > 90% compared to uninvolved hip (using hand-held dynamometer)
Recreational • > 90% BW with SL leg press
Activities/ • Demonstrate ability to simulate functional sport specific movement
Discharge • Patient reported outcome measures: Score ≥ 90%
***Criteria for discharge from PT is less rigorous for those not returning to sport. Ensure
the patient is able to perform all ADLs and recreational activities without pain, reactive
effusion, and with appropriate functional mechanics.



Phase I: Day 1 Post-Op until D/C of Assistive Device (0-6 weeks)

Goals • Protect healing tissue

• Pain and edema control (recommend compression garments/shorts to assist)
• DVT prevention
• Improve pain-free ROM
• Normalize muscle activation
• Ambulate independently without AD
• Independent with all ADL’s
Precautions Anterior approach
• No hip extension past 20 degrees
• No hip external rotation past 50 degrees
Posterior approach
• No hip flexion past 90 degrees
• No hip internal rotation or adduction past neutral
General precautions
• WBAT, with use of AD as needed (crutches, walker)
• No crossing legs
• Use good bending/lifting mechanics (keep back straight and bend at knees)
• Keep hips above knees when sitting, avoid deep chairs
AD • Walker à less restrictive (cane) or no device
Progression • 2 à 1 à 0 crutches as tolerated
Criteria for • Adequate hip ROM for normalized/painfree gait pattern (10° hip extension)
Community • 60 secs of single leg stance (SLS) without compensation (hip drop, trunk lean) or pain
Ambulation • Normalized gait pattern without assistive device
without AD
ROM/ • PROM (painfree): Hip flexion, extension to neutral if contracture present
Stretching • Gentle PROM, flexion AAROM in supine per guidelines
• Upright bike for ROM (maintain hip flexion precautions by starting with higher seat)
• Soft tissue mobilization and scar mobilization once incisions are closed
st
Neuro- This section is 1 priority à do not progress to strengthening until muscle activation and
muscular isolated control is normalized
Control • Glute sets, quad set, transverse abdominis, hamstrings, performed in supine or hook lying
to maintain hip precautions.
Therapeutic Early Exercises Late Exercises
Exercise • Isometrics – in hooklying hip • Criteria to begin this section: normalized gait pattern,
adduction with ball/towel roll, minimal reactive pain and edema
hip abduction with belt • SLR – flexion, abduction, extension (extension
• SAQ, LAQ, ankle pumps performed in safe range. For lateral and anterior
• Standing hamstring curls, approach no extension until week 6)
marches • Step ups (forward, lateral) and step downs
• SLR, standing 4 way hip • Begin bridge progression
• Weight shiftingàSLS to wean • Calf raises
out of AD
Criteria to • Normalized gait pattern for household distances without AD
Progress to • Minimal to no reactive pain and swelling with ADLs and PT exercises
Phase II • Muscle activation and isolation is normalized
• SLS for >20 seconds without presence of hip drop



Phase II: D/C AD to Pain Free ADLs (6-12 weeks)

Goals • Restore full PROM and AROM

• Progressively improve strength of the proximal hip musculature (gluteals, iliopsoas, hip
rotators)
• Normalize postural/pelvic control with DL and SL activities
• Normalize gait at preferred walking speed for community distances
• Tolerate ADLs without pain or limitation
Precautions • See above (Summary of Recommendations)
ROM/ • Soft tissue and joint mobilization to achieve symmetrical PROM
Stretching • Avoid aggressive end range stretching
• AROM upright bike (maintain hip flexion precautions), progress to light resistance
• Soft tissue mobilization as appropriate
• May benefit from referral to massage therapist if patient is developing soft tissue
dysfunction/irritation (commonly affects TFL, adductors)
• Soft tissue irritation suggests need for regression of activities and/or exercises
• Continually assess patient’s current activity level outside of PT
Therapeutic Early Exercises Late Exercises
Exercise • Mini squats to 70 degrees of flexion • Progress closed chain strengthening
• Resisted side stepping (start with TB exercises: leg press, increase mini squat depth
around knees) • SLS on unstable surface with perturbations
• SLS on unstable surface • Aquatic therapy may be appropriate and can
• Progress 3-way SLR to standing with be initiated once incision is well-healed and
TB or ankle weights (steamboats) patient is cleared by physician. Begin with
• Progress hip external rotation controlled walking in water at shoulder height,
strengthening progress to waist level water

Cardio- • May progress time on upright bike as tolerated

vascular • Ensure pt can perform 30 mins with no resistance and without symptoms prior to
Exercise adding resistance
• Decrease time to ≤15 min when adding resistance
• May begin elliptical when patient demonstrates adequate hip extension, gluteal activation,
and lumbopelvic stability
Criteria to • Symmetrical and painfree hip ROM to meet the demands of patient’s activities
Progress to • Good (4/5) lower extremity strength
Phase III • Symmetrical DL squat to 70° of knee flex
• Good quality movement as graded on Forward Step Down Test (Appendix A)
• Normalized gait pattern for community distances of ambulation



Phase III: Pain Free ADLs to Return to Recreational Activities (12-20 wks)
This phase is only required for patients who wish to participate in recreational sport outside of general
therapeutic exercise. Patients who don’t plan on sport participation can be discharged with maintenance
program following completion of phase II.

Goals • Correct abnormal/compensatory movement patterns with higher level multi directional
strengthening activities
• Optimize neuromuscular control/balance/proprioception
• Increase volume/intensity of aerobic activities; begin to restore low impact and sport specific
cardiovascular fitness
• Initiate progressive plyometric activities (per clearance of physician)
• Progressively return to sport or prior/desired level of function
Precautions • Avoid sacrificing quality for quantity during strengthening
• Avoid hip flexor/adductor inflammation as activity increases
• Ensure patient maintains full flexibility and painfree ROM as strength continues to increase
• Avoid aggressive stretching within this phase unless significant hypomobility noted
• Closely monitor return to sport progression
ROM/ • ROM should be checked periodically to ensure that loading the hip with new exercises does
Stretching not alter neuromuscular response and normal joint mechanics
• If full ROM is not achieved by week 12, terminal stretches should be initiated
Therapeutic • Continue progressive LE/core strengthening: Slow to fast, simple to complex, stable to
Exercise unstable, low to high force
• DL to SL strengthening, for leg press and other closed chain exercises
• Progress core stability tasks with emphasis on rotational and side-support tasks (Side
planks, cable crossovers, kneeling chops/lifts, plank over BOSU ball)
• LE strengthening tasks with multi-planar movements: Emphasize core stability and hip/knee
control (no valgus) during these tasks
• Proprioception: Vary surfaces, add perturbations, include variety of positions
• Aquatic therapy: may begin free style swimming once full ROM is achieved
Cardio- • Dynamic warm-up initiated
vascular • Upright Bike/Elliptical Progression (see return to biking protocol)
Exercise • Progress resistance (and cross ramp on elliptical) as tolerated
• Swimming Progression (see return to swimming protocol)
• Can begin freestyle kick; continue to avoid rotational kicks
Plyometrics High impact activities such as plyometrics are generally not advised following total joint
replacements. First priority following these surgeries is to prevent damage to the new artificial
joint. Due to lack of evidence on how high impact activities affect the integrity of artificial joint
replacement, patients are advised to participate low impact exercises. Patients considering
plyometrics with the intention of resuming running should consult with their physician.
• Criteria to initiate plyometric program
• Full, functional, pain-free ROM
• > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength
compared to uninvolved leg
• Squat 150% BW (barbell squat or leg press)
• 10 forward and lateral step downs from 8” step with proper alignment (Appendix A)
• Progressive weight bearing, DL à SL demands
• Shuttle plyometrics (DL à SL)
• Forward hop and hold (uninvolved à involved)
• DL mini hops/place jumps



• Proper take off/landing mechanics emphasized à NO knee valgus, good pelvic stability,
soft/quiet landing with equal distribution of force
• Modified agility work can be initiated if appropriate form/tolerance to activity in progressive
plyometrics
Running • See appendix B (only for appropriate patients)

Author: Chelseana Davis, PT, DPT, SCS

Reviewers: John DeWitt, PT, DPT, SCS; Joann Walker PT, DPT, SCS, OCS; Kate Glaws, DPT, SCS; Mengai Li,
MD; W. Kelton Vasileff, MD; and John Ryan, MD
Completion Date: June 2018

References

Enloe, L. J., Shields, R. K., Smith, K., Leo, K., & Miller, B. (1996). Total Hip and Knee Replacement Treatment
Programs: A Report Using Consensus. Journal of Orthopaedic & Sports Physical Therapy,23(1), 3-11.
doi:10.2519/jospt.1996.23.1.3

Kornuijt, A., Das, D., Sijbesma, T., & Weegen, W. V. (2016). The rate of dislocation is not increased when minimal
precautions are used after total hip arthroplasty using the posterolateral approach. The Bone & Joint Journal,98-
B(5), 589-594. doi:10.1302/0301-620x.98b5.36701

Monaghan, B., Grant, T., Hing, W., & Cusack, T. (2012). Functional exercise after total hip replacement
(FEATHER) a randomised control trial. BMC Musculoskeletal Disorders,13(1). doi:10.1186/1471-2474-13-237

Nankaku, M., Ikeguchi, R., Goto, K., So, K., Kuroda, Y., & Matsuda, S. (2016). Hip external rotator exercise
contributes to improving physical functions in the early stage after total hip arthroplasty using an anterolateral
approach: A randomized controlled trial. Disability and Rehabilitation,38(22), 2178-2183.
doi:10.3109/09638288.2015.1129453

Total Hip Replacement: How Long Does It Take to Recover? (2011). Journal of Orthopaedic & Sports Physical
Therapy,41(4), 240-240. doi:10.2519/jospt.2011.0502

Appendix A: Forward Step Down Test

Definition of errors Interpretation of errors

Arm strategy: subject uses an arm strategy in an attempt to recover 0-1 errors Good quality
balance (1 point) mechanics
Trunk movement: trunk leans right or left (1 point)
Pelvic plane: pelvis rotates or elevates on one side compared to the other
(1 point)
Knee position: knee deviates medially and the tibial tuberosity crosses an
nd
imaginary vertical line over 2 toe (1 point); knee deviates medially and the
tibial tuberosity crosses an imaginary vertical line over medial boarder of
the foot (2 points) 2-3 errors Medium quality
Balance: subject steps down on the uninvolved side or the subject’s tested mechanics
leg becomes unsteady (1 point)

4+ errors Poor quality

mechanics

Park K, Cynn H, Choung S. Musculoskeletal predictors of movement quality for the forward step-down test in
asymptomatic women. J Orthop Sports Phys Ther. 2013;43(7):504-510.

Appendix B: Return to Running

Walk/jog progression can be initiated towards end of phase if patient demonstrates:
• Full, functional, pain-free ROM
• > 80% quadriceps, hamstring, and hip (using hand-held dynamometer) strength compared to uninvolved
leg
• Squat 150% BW (barbell squat or leg press)
• 10 forward and lateral step downs from 8” step with proper alignment (see appendix D)
• Hop and hold with proper mechanics (uninvolvedàinvolved x10 repetitions)
• Ability to tolerate 200-250 plyometric foot contacts without reactive pain/effusion
• No gross visual asymmetry and rhythmic strike pattern with treadmill or over ground running
Phase Walk/Run Ratio Total Time
1 4 min / 1 min 10-20 min
2 3 min / 2 min 10-20 min
3 2 min / 3 min 10-20 min
4 1 min / 4 min 10-20 min
5 • Jog every other day until able to run 30 consecutive minutes
• Begin with 5 min walking warm up
• End with 5 min walking cool down

General Guidelines

To complete each phase, follow the total time guidelines below.

• 10 minutes x2 sessions
• 15 min x1 session
• 20 min x1 session
• After completing any phase pain free for 20 minutes, patient is appropriate to move forward to next phase
• Allow at least one day of rest between runs
• Gradual increase in distance is priority before increased pace
• It is common for runners to experience increased pain and/or reactive edema at least x1 during this return to
run progression. When pain occurs, runner must stop running immediately and rest at least 1 day before
restarting program. With restart, perform last walk/jog ratio cycle completed pain free x2 before attempting the
previously painful ratio cycle.
• Ten Percent Rule: only increase weekly mileage by 10% of the previous week

ACHILLES TENDON REPAIR

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Background
Achilles tendon repair is performed after injury occurs to the Achilles tendon. The injury is often accompanied by
an audible and palpable pop, with limited ability to push off of the injured limb. Repair is typically carried out
within 2 weeks of the injury, and recovery is expected to take between 6 to 9 months, and return to athletics may
take 9-12 months depending on the severity of injury and nature of sport.

Summary of Recommendations
Risk Factors • Exceeding ROM goals
• Age (30-50 years)
• Male
• Fluoroquinolone use

Corrective • Modalities for pain & swelling

Interventions • Patient education
• Manual: PROM, AAROM, AROM to restore normal ROM per guidelines
• Ther-ex and neuromuscular re-ed for posture, general strength and stability
• Therapeutic activity for sport and work specific activity to progress/prepare to RTW/RTS

Precautions • Recommend WB in protective device at post-op week 1 (level 1 evidence, strong)

• Target neutral ankle weight bearing by post-op week 4-6

Outcome • FAAM
Testing
Manual • Recommend starting post-op week 1 PROM and soft issue mobilization
therapy • DF PROM to minimal stretch, DO NOT AGGRESSIVELY STRETCH
• PF PROM as tolerated
• Subtalar, midfoot and forefoot mobilizations as tolerated

Criteria for • D/C boot for shoe: After pt in neutral weight bearing, can wear shoe and able to walk
discharge without limp
• Return to running: 5 x 25 single leg calf raises, 95% symmetry ROM (DF/PF), 95%
symmetry calf circumference at 10 cm distal to tibial tubercle (Saxena 2011)
• Return to sports: 90% symmetry SL hop testing (check current concepts course), 90%
symmetry Y balance (anecdotal experience)

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.

Phase I
Weeks 0-2 • Maintain post-operative splint • Recommended exercises (pain-free)
Protection • Manual therapy: Accessory joints o Toe wiggles
• Gait: WBAT in splint starting post-op week 1, o Doming
with crutches o Towel crunches
o 3 heel wedges o Ankle AROM/alphabets

• Goal: Reduce edema, ensure closure of incision, educate on DVT/thromboembolism, begin

ambulation without crutches

Phase II
Weeks 2-6 • Walker boot, begin weaning from heel lift (1 lift every 2 weeks as tolerated)
Return to • Mobility: Active ROM up to 15° plantar flexion (PF) without boot)
Walking • Initiate ankle strengthening in protected positioning
After 2 weeks After 4 weeks
o Isometrics all planes o Active ROM up to 10° PF without boot
o Active plantar flexion with light t-band o 4 way t-band, PF up to 10°
in up to 15° o Seated heel raise with light weight
o Sitting heel raises – no weight bearing o Initiate balance/proprioception training
o 4 way straight leg raise on stable surface once pt can
o Bicycle for ankle ROM in boot comfortably weight bear in neutral
o BAPS (seated àstanding) as tolerated o Leg press, light weight

• May initiate soft tissue mobilization after adequate wound closure

• Pool therapy may begin at post-op week 4 (if wound closed and weight bear in ankle neutral
in gravity minimized position)

Phase III
Weeks 6-12 • Wean off boot, initiate walking in shoe/neutral heel position
Strength o Use of heel wedges (≤2) in shoe PRN
Progression § Start at number of wedges where no pain is felt and patient demonstrates proper
gait mechanics
Normal Gait Abnormal Gait
Pain free weight bearing in No heel life, proceed with rehab No heel lift, add gait training
shoe
Painful weight bearing in Add heel lift, wean out with Add heel lift, gait training
shoe rehab, ensure normalized gait
• Initiate weight bearing strengthening exercises
• Exercise progression:
o Calf raise progression: shuttle 2 leg in neutralàshuttle single leg in neutralàshuttle 2
leg in DFàshuttle single leg in DFàstanding 2 leg calf raise in neutralàneutral 2 up 1
downàsingle leg (Mullaney, 2011)
o Continue BAPS for ankle ROM
o Closed chain hip/knee strengthening per pt tolerance
o Repetition progression for calf raises (progress daily if pain free) – (Saxena, 2011)
3 x 10 à 4 x 10 à 5 x 10 à 3 x 15 à 4 x 15 à 5 x 15 à
3 x 20 à 4 x 20 à 5 x 20 à 3 x 25 à 4 x 25 à 5 x 25
o Initiate balance training on unstable surfaces
o Initiate heel tap


Phase IV

>12 Weeks • Criteria for initiating return to running (straight plane jogging)
Return to o 5 x 25 single leg calf raises
Sport/Activity o Normal landing mechanics
o Complete 20 single leg squats without compensation
o 95% symmetry ROM (DF/PF)
o 95% symmetry calf circumference at 10 cm distal to tibial tubercle (Saxena, 2011)
• Return to Sport
o 90% symmetry in all SL hop testing
o 90% symmetry Y balance
• Initiate hop training when cleared to return to jogging for landing mechanics
• **Emphasize strengthening at end range PF**
• Continuation of self-stretching
• Joint mobilizations as needed
• Continued progression of strength/stability/balance exercise on stable and unstable surfaces
to correct altered mechanics
• Plyometrics progression: Single-leg shuttle plyometrics, B LE straight-plane, B LE diagonal-
plane, Rotational, Multi-directional, tuck jumps
• Resisted jogging in place with resistance in all planes
• Sports specific exercise/agility progression, emphasis on proper mechanics

Authors: Lucas VanEtten, JJ Kuczynski

Reviewers: Chelseana Davis, John DeWitt
Completion date: 5/18/15

References
Mullaney M, et al. Electromyographic analysis of the triceps surae muscle complex during Achilles tendon
rehabilitation program exercises. Sports Health. November 2011; 3(6): 543-546.
Saxena A, Ewen B, Maffulli N. Rehabilitation of the operated achilles tendon: parameters for predicting return to
activity. J Foot Ankle Surg. 2011;50:37-40.
Kearney RS, McGuinness KR, Achten J, Costa ML. A systematic review of early rehabilitation methods following
a rupture of the Achilles tendon. Physiotherapy. 2012;98:24–32.
Calder, J. D., & Saxby, T. S. (2005). Early, active rehabilitation following mini-open repair of Achilles tendon
rupture: a prospective study. Br J Sports Med, 39(11), 857-859. doi: 10.1136/bjsm.2004.017509
Carcia CR, Martin RL, Houch J, Wukich DK. Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles
Tendinitis Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and
Health from the Orthopaedic Section of the American Physical Therapy Association. J Sport and Orthop. 2010.
40(9) A1-A26
Chiodo, C. P., & Glazebrook, M. (2010). American Academy of Orthopedic Surgeons Clinical Practice Guideline
on Treatment of Achilles Tendon Ruptures. Journal of Bone and Joint Surgery, 92, 2466-2468.
Costa, M. L., MacMillan, K., Halliday, D., Chester, R., Shepstone, L., Robinson, A. H., & Donell, S. T. (2006).
Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achillis. J Bone
Joint Surg Br, 88(1), 69-77. doi: 10.1302/0301-620X.88B1.16549
Costa, M. L., Shepstone, L., Darrah, C., Marshall, T., & Donell, S. T. (2003). Immediate full-weight-bearing
mobilisation for repaired Achilles tendon ruptures: a pilot study. Injury, 34(11), 874-876.


Kangas, J., Pajala, A., Ohtonen, P., & Leppilahti, J. (2007). Achilles tendon elongation after rupture repair: a
randomized comparison of 2 postoperative regimens. Am J Sports Med, 35(1), 59-64. doi:
10.1177/0363546506293255
Lansdaal, J. R., Goslings, J. C., Reichart, M., Govaert, G. A., van Scherpenzeel, K. M., Haverlag, R., & Ponsen,
K. J. (2007). The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and
functional aftertreatment. Injury, 38(7), 839-844. doi: 10.1016/j.injury.2006.12.010
Maffulli, N., Tallon, C., Wong, J., Lim, K. P., & Bleakney, R. (2003). Early weightbearing and ankle mobilization
after open repair of acute midsubstance tears of the achilles tendon. Am J Sports Med, 31(5), 692-700.
Ozkaya, U., Parmaksizoglu, A. S., Kabukcuoglu, Y., Sokucu, S., & Basilgan, S. (2009). Open minimally invasive
Achilles tendon repair with early rehabilitation: functional results of 25 consecutive patients. Injury, 40(6), 669-672.
doi: 10.1016/j.injury.2008.10.033
Sadoghi, P., Rosso, C., Valderrabano, V., Leithner, A., & Vavken, P. (2012). Initial Achilles tendon repair strength-
-synthesized biomechanical data from 196 cadaver repairs. Int Orthop, 36(9), 1947-1951. doi: 10.1007/s00264-
012-1533-6
Strauss, E. J., Ishak, C., Jazrawi, L., Sherman, O., & Rosen, J. (2007). Operative treatment of acute Achilles
tendon ruptures: an institutional review of clinical outcomes. Injury, 38(7), 832-838. doi:
10.1016/j.injury.2006.06.005
Suchak, A. A., Bostick, G. P., Beaupre, L. A., Durand, D. C., & Jomha, N. M. (2008). The influence of early
weight-bearing compared with non-weight-bearing after surgical repair of the Achilles tendon. J Bone Joint Surg
Am, 90(9), 1876-1883. doi: 10.2106/JBJS.G.01242
Twaddle, B. C., & Poon, P. (2007). Early motion for Achilles tendon ruptures: is surgery important? A randomized,
prospective study. Am J Sports Med, 35(12), 2033-2038. doi: 10.1177/0363546507307503

AUTOLOGOUS CHONDROCYTE IMPLANTATION

(ACI) CLINICAL PRACTICE GUIDELINE

Background
Autologous chondrocyte implantation (third generation) is a two stage surgical procedure indicated for medium to
2
large (≥2 cm ) symptomatic full thickness chondral lesions. Stage one is performed arthroscopically, where a
small sample of healthy cartilage is harvested from a non-weight bearing area of the knee. The chondrocyte
sample is sent to a laboratory where the cells are cultivated on a scaffold for 4-6 weeks. Stage two is performed
through an open procedure, or arthrotomy. The cartilage defect is exposed and debrided to an area with vertical
margins. The scaffold implant is placed in the defect and secured fibrin sealant. These third generation ACI
techniques eliminate the suture fixation previously required with second-generation ACI procedures. The various
implantation procedures are as follows:
• Matrix-Induced Autologous Chondrocyte Implantation (MACI)- thin scaffold seeded with chondrocytes
• NeoCart- chondrocytes growing and producing extracellular matrix throughout scaffold
• NovoCart- full thickness scaffold seeded with chondrocytes

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. If you are working with an Ohio State Sports Medicine patient and questions arise, please call 614-
293-2385.

Summary of Recommendations
Expectations • PT and CPM should begin at post-op day 7-10 days
• Return to sport: 12-15 months
• Please review operative report as lesion size and location may dictate speed of progression

Risk Factors • CI requires extensive rehabilitation and can often exhaust insurance approved PT visits.
Consider decreasing initial visit frequency, use of home NMES unit and daily self-ROM.
• Long-term quadriceps strength deficits typically present >1 year post-operatively.

Concomitant • Do not change protocol based on multiple defects, meniscus repair or ligamentous
Procedures reconstruction
• If multiple defects include a patellofemoral lesion, following the patellofemoral
precautions
• TTO Adjustments:
• Open brace to 0-35° at weeks 5-6
• All CKC interventions performed through protected ROM (90-45°) before transition to
full ROM

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.



Weight Bearing Tibiofemoral (No Brace) Patellofemoral (TROM Extension Brace)
Progression • Phase 1 (week 1): NWBing • Phase 1-3 (weeks 1-5): Full BW, brace
• Phase 2 (week 2-3): 25% BW (weeks 1-2) locked in full extension
to 50% BW (week 3) o Open brace at week 5-6
• Phase 3 (weeks 4-5): 60% BW (week 4) to • Phase 4 (weeks 6-7): Discharge brace
80% BW (week 5) • Phase 5 (weeks 8-10): Normal gait without
• Phase 4 (weeks 6-7): 90% to100% BW brace
• Phase 5 (weeks 8-10): Full BW with
normal gait pattern
Range of • Phase 1/2 (weeks 1-3): 0-45° (week 2) to 0-90° (week 3)
Motion • Phase 3 (weeks 4-5): 0-105° (week 4) to 0-120° (week 5)
Progression • Phase 4 (weeks 6-7): 0-125° (week 6) to 0-135° (week 7)
• Phase 5 (weeks 8-10): Full AROM
• *Same ROM progression for tibiofemoral and patellofemoral lesions*
Functional • Isometric testing: 4-5 months (at 90 degrees)
Testing • Isokinetic testing: 6, 9, 12 months and discharge
• Hop testing (Appropriate after 80% symmetry achieved on isokinetic testing)
o SL hop for distance
o Triple hop
o Cross over hop
o Timed 6m hop
*Functional strength testing and hop testing should be reserved for patients returning to high-
level activity*
Patient Collect at least one of the following at initial evaluation, every 6 weeks and discharge. Be
Reported consistent with which outcome tool is collected.
Outcomes • Knee Injury and Osteoarthritis Outcome Score (KOOS)
• International Knee Documentation Committee (IKDC)

Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure

Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar glide
Assistive and able to perform 2x10 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation
*Tibiofemoral lesions: PWBing for 6-8 weeks. See above WBing progression*
Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and 300º/sec
Running and 3. Effusion: 1+ or less
Jumping 4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place
Criteria for 1. ROM: full, painfree knee ROM, symmetrical with the uninvolved limb
Return to Sport 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and 300º/sec
3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance

Chondrocyte Rehabilitation Maturation Phases

*Phases of post-operative rehabilitation and the associated graft maturation timeline*

Rehabilitation Phase Stage of Repair Tissue

Phase 1: weeks 0-1
Phase 2: weeks 2-3 Implantation and protection (0-6 weeks)
Phase 3: weeks 4-6
Phase 4: weeks 7-12 Transition and proliferation (6-12 weeks)
Phase 5: months 3-6
Remodeling (12-26 weeks)
Phase 6: months 6-9
Phase 7: months 9-RTS Maturation (26 weeks onward)
*The graft will continue to remodel for up to 1 year post-op*

Red/Yellow Flags
Red Flags
(signs/symptoms that
require immediate referral
for re-evaluation)
Yellow Flags
(signs/symptoms that
require modification to
plan of care)
• Signs of DVT (Refer directly to ED)
• Localized tenderness along the distribution of deep venous system
• Entire LE swelling
• Calf swelling >3cm compared to asymptomatic limb
• Pitting edema
• Collateral superficial veins
• Mechanical block or clunk (Refer to surgeon for re-evaluation)
• Lack of full knee extension by 4-6 weeks (Refer to surgeon for re-evaluation)
• Persistent reactive pain or effusion following therapy or ADLs
• Decrease intensity of therapy interventions, continue effusion
management and provide patient education regarding activity modification
until reactive symptoms resolve

Phase I: Weeks 0-1

Patients will not begin physical therapy until post-operative days 7-10. Phase 1 will be completed independently
through a home exercise program provided on the day of surgery. Formal physical therapy will begin in Phase 2.

Goal Maintain joint mobility and muscle tone while adhering to all post-operative precautions

Range of • 0-45°
Motion • CPM to start at day 7-10

Weight Bearing Tibiofemoral: ≤20% BW

Patellofemoral: Full BW, brace locked in full extension

Suggested • Ankle pumps

Interventions • Quadriceps, hamstring and gluteal isometrics
• Diaphragmatic breathing
• Effusion management strategies, including RICE

Phase II: Weeks 2-3

Goals The patient should achieve pain-free and full passive knee extension. Focus is placed on
maintaining muscle tone, ensuring proper wound healing and effusion management.
Range of 0-90°
Motion *Achieved though CPM and AAROM (heel slides, wall slides, AAROM row machine)*
• Total volume: 300+ repetitions per day
Goal: early AROM though safe range
Weight Bearing Tibiofemoral: 30% to 50% BW
Patellofemoral: Full BW, brace locked in full extension

Suggested • Ankle pumps

Interventions • Quadriceps, hamstring and gluteal isometrics
• Prone TKE
• SLR-4 way
• Patellar mobilization in all directions
• Gait training
• Extension ROM: Seated towel stretch, prone hang, bag hang
• Flexion ROM: heel slides, wall slides, AAROM row machine
• Recumbent cycling- for ROM only (week 3)
• SAQ (no resistance)
• LAQ (no resistance, through protected ROM (90-45 degrees)
• Continue CPM, effusion management and NMES in long sitting
For PF lesions only: (Must be performed in locked knee brace)
o Weight shifting
o DL heel raise
o SL balance
• NMES in long sitting
NMES • NMES pads are placed on the proximal and distal quadriceps
Parameters (in • Patient: Seated in long sitting (knees extended)
long sitting) • The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional quadriceps contraction OR maximal tolerable amperage without knee joint pain
• 10-20 seconds on/ 50 seconds off x 15 min
Criteria to By the end of week 3:
Progress to • Pain-free knee flexion of 90°
Phase 3 • Pain-free and full passive knee extension
• Proficient heel-to-toe gait with 50% BW for tibiofemoral grafts or full BW for patellofemoral
grafts
• Reduced and well-controlled post-operative pain and edema
• Ability to perform a strong isometric quadriceps contraction (full tetany and superior patellar
glide)
• Proficiency with home-exercise program


Phase III: Weeks 4-6
Goals Emphasis is placed on increasing knee flexion ROM and improving quadriceps, gluteal and
core strength
Range of 0-105° (week 4) to 0-125° (week 6)
Motion *Achieved though CPM and AAROM (heel slides, wall slides, AAROM row machine)*
• Total volume: 300+ repetitions per day
Goal: early AROM though safe range
Weight Bearing Tibiofemoral: 60% BW (week 4) to 80% BW (week 5)
Patellofemoral: Full BW, open brace at weeks 5-6

Suggested • Continue Phase 1 and 2 interventions

Interventions • SLR-Flexion progressions
o Semi-reclined or seated
o Add ER
o Perform with eyes closed (cortical training)
o Speed
o Isometric holds at end-range
• Heel slides
• Clamshells
• Seated or standing hip ab/adduction (depending on WBing status)
• Trunk stability interventions
o TrA isometric progression
o Prone/side planks
• Upright cycling (weeks 5-6)
• Standing TKE (weeks 6-8)
• Partial BW Shuttle Press (week 6-8)
• OKC Hamstring strengthening (week 6-7)
• Progress NMES to seated with tibia fixed at 60° of knee flexion
• Discharge CPM at 6 weeks
• Continue effusion management strategies
NMES • NMES pads are placed on the proximal and distal quadriceps
Parameters • Patient: Seated with the knee in at least 60º flexion, shank secured with strap and back
(with tibia fixed support with thigh strap preferred. The ankle pad/belt should be two finger widths superior
at 60° of knee to the lateral malleoli
flexion) • The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction against a fixed resistance OR maximal tolerable amperage without
knee joint pain
• 10-20 seconds on/ 50 seconds off x 15 min
Criteria to By the end of week 6:
Progress to • Pain-free active knee flexion to 125°
Phase 4 • Pain-free gait with 80% BW for tibiofemoral grafts or full BW for patellofemoral grafts
• 3x10 SLR without quadriceps lag
• Proficiency with home exercise program


Phase IV: Weeks 7-12
Goals The patient works toward movement independent of ambulation devices and knee braces. Full
ROM should be achieved and balance/proprioception interventions are initiated.
Range of 0-125° (week 6), 0-135° (week 7) to full ROM (week 8-10)
Motion

Weight Bearing Tibiofemoral: 90% BW (week 6), 100% BW (week 7) to full WBing without obvious gait
deviation (week 10)
Patellofemoral: Discharge brace
Suggested • Continue Phase 2 and 3 interventions
Interventions • Continue ROM interventions until symmetrical ROM is achieved
• Partial BW Shuttle Press (week 6-8)
• OKC Hamstring strengthening (week 6-7)
• Multi-angle isometrics
• Balance and proprioception interventions
• Mini squats: 0-45 degrees (week 8-10)
• Heel Taps: 2-4” (weeks 10-12)
• Step Ups: 6-8” (weeks 10-12)
• Resisted OKC quadriceps strengthening through 90-45° protected ROM (week 10-12)
• Continue NMES (seated with tibia fixed at 60° of knee flexion)
• Continue effusion management strategies as needed
Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure
Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar glide
Assistive and able to perform 2x10 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation
Criteria to By week 12:
Progress to • Pain-free active ROM
Phase 5 • Pain-free upright cycle ergometry
• Pain-free ambulation without visible gait deviation
• Proficiency in home exercise program


Phase V: Months 3-6
Goals The majority of patients return to work either on a part-time or full-time basis. Patients should
continue skilled physical therapy to progress functional, CKC strengthening.
Range of Full AROM
Motion

Weight Bearing Full WBing, normal gait without brace

Suggested • Continue Phase 3 and 4 interventions

Interventions • Bridging
• Standing SL calf raises
• Resisted OKC quadriceps strengthening through full ROM (week 12-14)
• Lunges
• SL sit to stand, through protected ROM
• Elliptical
• Outdoor cycling if desired (months 5-6)
• Rowing ergometry as tolerated (months 5-6)
• Continue NMES until 80% symmetry is obtained
• Continue effusion management as needed
Isometric Isometric testing is appropriate at 4-4.5 months
Testing

Criteria to By 6 months:
Progress to • Ability to negotiate stairs and mild gradients without pain or reactive effusion
Phase 6 • Return to work, depending on the demands of the job
• Ability to perform 3x10 heel raise on 6” step with neutral frontal and sagittal plane
alignment
• Proficiency in home exercise program




Phase VI: Months 6-9
Goals Patient progress OKC interventions. Strength testing is performed to determine readiness to
initiate light plyometrics and walk-jog progression.
Range of Full AROM
Motion

Weight Bearing Full WBing, normal gait without brace

Suggested • Continue phase 3-5 interventions

Interventions • Progress and increased difficulty of OKC exercises
• Continue to progress SL eccentric strengthening through body weight and machine
interventions
• Once strength criteria have been met, perform the following progression:
o PBW jumping on the shuttle (DL à SL)
o Full body weight jumping progression
• Walk-jog program


Isokinetic Isokinetic testing is appropriate at 6 and 9 months
Testing *Functional strength testing should be reserved for patients returning high-level activity*

Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and 300º/sec
Running and 3. Effusion: 1+ or less
Jumping 4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place
Criteria to By 9 months:
Progress to • Quadriceps and hamstring symmetry of 80% or greater
Phase 7 • Ability to tolerate walking distances of 3 miles or greater without reactive pain or
effusion
• Ability to effectively negotiate uneven ground, including soft sand, without reactive pain
or effusion
• Ability to return to pre-operative low-impact recreational activities, including cycling,
elliptical and weight training



Phase VII: Months 9-Return to Sport
Goals The patient is able to resume all normal functionality and will continue to progress towards
return to sport.
Range of Full AROM
Motion

Weight Bearing Full WBing, normal gait without brace

Suggested • Continue phase 3-6 interventions

Interventions • Step-hold progression to SL hop progression
• Sports-specific training
• Agility
• Plyometrics
Isokinetic Isokinetic testing is appropriate at 12 months and discharge
Testing *Functional strength testing and hop testing should be reserved for patients returning high-level
activity*
Criteria to 1. ROM: full, painfree knee ROM, symmetrical with the uninvolved limb
Return to Sport 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and 300º/sec
3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance
Activities that generate high compression, shear and rotational loads are to be avoided
until 12-18 months, or as directed by orthopaedic surgeon

Full RTS expected between 12-15 months post-operatively

Author: Caroline Lewis, PT, DPT, SCS, AT

Reviewers: Laura C. Schmitt, PT, MPT, PhD; David C. Flanigan, MD, Jay Ebert, PhD

References
Minas T, Peterson L. Autologous chondrocyte implantation. Op Tech in Orth. 1997;7(4):323-333.

O’Driscoll S, Keeley F, Salter R. Durability of regenerated articular cartilage produced by free autogeneous
periosteal grafts in major full-thickness defects in joint surfaces under the influence of continuous passive motion.
J Bone Joint Surg Am. 1988;70:595-606.

Rodrigo J, Steadman R, Fulstone H. Improvement of full-thickness chondral defect healing in the human knee
after debridement and microfracture using continuous passive motion. Am J Knee Surg. 1994;7:109-16.

Salter RB. The physiologic basis of continuous passive motion for articular cartilage healing and regeneration.
Hand Clin. 1994;10(2):211-9.
McAllister DR, Joyce MJ, Mann BJ, Vangsness CT Jr. Allograft update: the current status of tissue regulation,
procurement, processing, and sterilization. Am J Sports Med. 2007;35:2148-2158.
Minas T. The role of cartilage repair techniques, including chondrocyte transplantation, in focal chondral knee
damage. Instructional Course Lectures. 1999;48:629-43.

Ebert JR, Ackland T, Lloyd DG, Wood DJ. Accuracy of partial weight bearing after autologous chondrocyte
implantation. Arch Phys Med Rehabil. 2008;89(8):1528-34.

Ebert JR, Robertson WB, Lloyd DG, Zheng MH, Wood DJ, Ackland T. Traditional vs accelerated approaches to
post-operative rehabilitation following matrix-induced autologous chondrocyte implantation (MACI): comparison of
clinical, biomechanical and radiographic outcomes. Osteoarthritis Cartilage. 2008;16:1131-40.
Enright PL. The six-minute walk test. Respir Care. 2003;48(8):783-5.

ACL CLINICAL PRACTICE GUIDELINE

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician
evaluation. Contact Ohio State Sports Medicine Physical Therapy at 614-293-2385 if questions arise.

Summary of Recommendations
Precautions 1. No testing of repaired or reconstructed ligaments (Lachman, Anterior/Posterior Drawer,
Varus/Valgus Stress) prior to 12 WEEKS
2. No isotonic resisted hamstring exercises for 8 weeks with hamstring autograft
3. No loaded open kinetic chain knee extension beyond 45 degrees for 8 WEEKS
4. Meniscus Repair:
a. No weight-bearing (WB) therapeutic exercise >90º x 8 WEEKS
b. PWB x4 WEEKS
c. No forced flexion beyond 90º x4 WEEKS

Outcome Collect at least one of the following at initial evaluation, monthly and discharge. Be consistent
Tools with which outcome tool is collected each time.
1. IKDC
2. KOOS
3. ACL-RSI
4. Tegner
Strength 1. Isometric testing anytime- fixed at 90º
Testing 2. Isokinetic testing no earlier than 12 weeks

Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure

Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar
Assistive glide and able to perform 2x10 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation

Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and
Running 300º/sec
and Jumping 3. Effusion: 1+ or less
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place

Criteria for 1. ROM: full, painfree knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and
Sport 300º/sec
3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.



Early Post-Operative Phase (Post-ACLR – 4 weeks)
Appointments Post-operative evaluation should be performed 3-5 days following surgery. Follow-up
appointments 1-2x per week, depending on progression towards goals.
Precautions 1. No testing of repaired or reconstructed ligaments (Lachman, Anterior/Posterior Drawer,
Varus/Valgus Stress) prior to 12 WEEKS
2. No loaded open kinetic chain knee extension for 8 WEEKS
3. Meniscus Repair:
a. No weight-bearing (WB) therapeutic exercise >90º x 8 WEEKS
b. PWB x4 WEEKS
c. No forced flexion beyond 90º x4 WEEKS

Pain and ≥ 2+ (using Modified Stroke Test)

Effusion Cryotherapy and compression (ie. Donut, ace wrap, limited WB therapeutic exercise)
ROM Extension: Emphasis on achieving full knee extension immediately following surgery. If full
extension is not achieved by 4 weeks, contact surgeon regarding ROM concerns.
Flexion: No forced flexion past 90º for meniscus repairs. ACLR and meniscectomy are able to
push for symmetrical flexion as appropriate.
Therapeutic • Emphasis on quad activation without gluteal co-contraction
Exercise • Restore patellar mobility
• Symmetrical ROM
• Decrease effusion
• Ambulation with appropriate joint loading and without obvious gait deviation
Suggested • Extension ROM: bag hangs or prone hangs
Interventions • Flexion ROM: heel slides, wall slides, upright bike
• Patellar mobilization: superior, inferior, medial, lateral
• Quad Isometrics; SLR 4-way
• TKE: prone and standing
• LAQ
• Weight shifting, SL balance
• Neuromuscular re-education using electrical stimulation (NMES) at 60º knee flexion
NMES • NMES pads are placed on the proximal and distal quadriceps
Parameters • Patient: Seated with the knee in at least 60º flexion, shank secured with strap and back
support with thigh strap preferred. The ankle pad/belt should be two finger widths superior to
the lateral malleoli
• The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction against a fixed resistance OR maximal tolerable amperage without
knee joint pain
• 10-20 seconds on/ 50 seconds off x 15 min
Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure
Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar glide
Assistive and able to perform 2x10 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation

Criteria to ROM: ≥ 0-120 degrees

Progress to Strength: Quadriceps set with normal superior patellar translation, SLR x 10 seconds without
Middle Phase extensor lag
of Rehab Goals: (These do not limit progression to next phase; however, should be addressed with
interventions)
Effusion: 2+ or less with Modified stroke test
Weight Bearing: Able to tolerate CKC therex program without increased pain and ≥≤ 2+ effusion


Middle Phase of Rehabilitation (4-12 weeks)

Appointments Goal to increase lower extremity strength. 1-2 visits per week with emphasis on patient
compliance with resistance training as part of HEP (2-3 days per week outside of therapy).
Precautions Open Chain knee extension:
• Initiate submaximal leg extension 90-45 degrees
• Initiate active knee ROM 90-0 degrees (modify if painful)
No isolated resisted hamstrings strengthening until 8 weeks
Pain and Cryotherapy/compression as needed for reactive effusion.
Effusion Patellar taping to reduce PF symptoms if present
ROM • Monitor and progress knee ROM, patellar mobility, and LE flexibility
• Begin more aggressive techniques to achieve/maintain full knee extension (i.e. weighted
bag hang) as needed
• Continue bike for ROM and warm up
• If full AROM knee extension is not achieved by 4 weeks, contact surgeon regarding ROM
concerns.

Suggested • Multi-angle knee isometrics from 60-90⁰ for patients unable to tolerate high-intensity NMES
Interventions
• Initiate open chain knee extension exercises
and timelines
o Unweighted full range LAQ
o Protected range with isotonic progression
• Progress WB quadriceps and hamstring exercises with emphasis on proper LE mechanics
(no isolated HS strengthening until 8 weeks)
• Progress gluteal and lumbopelvic strength and stability
• Progress single leg balance
• Endurance: low impact - treadmill walking, stepper, elliptical (6 weeks)
• Initiate PWB plyometrics on shuttle (8-10 weeks, see precautions to begin full WB
plyometrics)
• NMES (see parameters in week 1-4)
Criteria to d/c • <20% quadriceps deficit on isometric or isokinetic testing
NMES OR- If a Biodex machine in not available:
1. 10 SLR without quad lag
2. Normal gait
3. 10 heel taps to to 60 degrees with good quality
4. 10 rep max on LP and similar effort bilaterally
5. Inability to break quad MMT

Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and 300º/sec
Running and 3. Effusion: 1+ or less
Jumping 4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place
Criteria to 1. ROM: Maintain full, pain free AROM including PF mobility
Progress to 2. Effusion: 1+ or less
Late Phase of 3. Strength: Isometric or isokinetic quadriceps and hamstrings strength >/= 80%
Rehab
4. Weight Bearing: Able to tolerate therapeutic exercise program, including jogging
progression, without increased pain or >1+ effusion
5. Neuromuscular Control: Demonstrates proper lower extremity mechanics with all therapeutic
exercises (bilaterally)
6. Outcome Tools: >/=7/10 on #10 IKDC Questionnaire


Late Phase of Rehabilitation (weeks 12-Return to Sport)

Appointments Increased frequency from previous stage to 1-2x per week when appropriate to initiate
plyometric training and return to running program.
Precautions Criteria to initiate hopping
• Full, pain free ROM
• ≤ 1+ effusion
• ≥ 7 /10 on #10 IKDC Questionnaire (Appendix A)
• ≥ 80% isometric strength symmetry (hamstrings and quadriceps) OR 20 heel touches
on 8 inch step with good mechanics

Criteria to initiate jogging (in addition to above criteria)

• Hop downs with appropriate landing mechanics
• Audible rhythmic strike patterns and no gross visual compensation
Pain and Effusion may increase with increased activity, ≤1+ and/or non-reactive effusion for progression of
Effusion plyometrics
ROM Full, symmetrical to contralateral limb, and painfree with overpressure
Therapeutic • Performance of the quadriceps, hamstrings and trunk dynamic stability
Exercise • Muscle power generation and absorption via plyometrics
• Sport- and position-specific activities
• Begin agility exercises between 50-75% effort (utilize visual feedback to improve mechanics
as needed)
• Advance plyometrics: Bilateral to single leg, progress by altering surfaces, adding ball toss,
3D rotations, etc.
Suggested Therapeutic Exercise/Neuromuscular Re-education
Interventions • Squats, leg extension, leg curl, leg press, deadlifts, lunges (multi-direction), crunches,
rotational trunk exercises on static and dynamic surfaces, monster walks, PWB to FWB
jumping
• Single-leg squats on BOSU with manual perturbation to trunk or legs, Single-leg BOSU
balance, single-leg BOSU Romanian deadlift
Agility
• Side shuffling, Carioca, Figure 8, Zig-zags, Resisted jogging (Sports Cord) in straight
planes, backpedaling

Plyometrics
• Single-leg hop downs from increasing height (up to 12” box), Single-leg hop-holds,
Double and single-leg hopping onto unstable surface, Double and single-leg jump-turns,
Repeated tuck jumps
Criteria for 1. ROM: full, pain free knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and 300º/sec
Sport 3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance

ACLR AND MCL REPAIR

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician
evaluation. Contact Ohio State Sports Medicine Physical Therapy at 614-293-2385 if questions arise.

Background
ACL Reconstruction and MCL Repair occur after a contact or non-contact knee injury when the ACL and MCL are
both fully torn, often with involvement of the medial meniscus. Surgery uses an allograft or autograft to reconstruct
the torn ACL ligament arthroscopically. The MCL is repaired where it was torn, either distally near the insertion on
the tibia, in the middle of the ligament, or proximally near the origin on the femur. Progression of range of motion
after surgery depends on where the MCL was torn. Long-term outcomes should include full range of motion and
return to prior level of function. Return to sport is expected to take between 8-12 months depending on
comorbidities and nature of the sport.

Summary of Recommendations
Precautions 1. No testing of repaired or reconstructed ligaments (Lachman, Anterior Drawer, Valgus
Stress) prior to 12 WEEKS
2. No isotonic resisted hamstring exercises for 8 weeks with hamstring autograft
3. No loaded open kinetic chain knee extension beyond 45 degrees for 8 WEEKS
4. Meniscus Repair:
a. No weight-bearing (WB) therapeutic exercise >90º x 8 WEEKS
b. No forced flexion beyond 90º x4 WEEKS
Weight 1. NWB for 0-2 weeks with brace locked in extension
Bearing 2. TTWB for weeks 2-4 with brace locked in extension
Guidelines 3. WBAT 4-6 weeks with brace locked in extension
4. WBAT at 6 weeks with brace unlocked, wean from brace
MCL Lesion 1. Distal: Cautious knee flexion ROM to allow healing and prevent long-term valgus laxity.
Site a. Weeks 0-2: 0-30°
Considerations b. Weeks 2-4: 0-60°
c. Weeks 4-6: 0-90°
d. Weeks 6+: flexion ROM as tolerated
2. Proximal or Mid-substance: Accelerated knee flexion ROM to prevent scar formation and
loss of functional ROM.

Outcome Tools Collect at least one of the following at initial evaluation, every 6 weeks, and discharge. Be
consistent with which outcome tool is collected each time.
1. IKDC
2. KOOS
3. ACL-RSI
4. Tegner
Strength 1. Isometric testing any time after week 8- fixed at 90º
Testing 2. Isokinetic testing no earlier than 12 weeks

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.



Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure
Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar glide
Assistive and able to perform 20 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation
Criteria to • <20% quadriceps deficit on isometric or isokinetic testing (can use HHD for isometric
Discharge testing)
NMES OR- If testing equipment is not available:
1. 20 SLR without quad lag
2. Normal gait
3. 10 heel taps to to 60 degrees with good quality
4. 10 rep max on LP and similar effort bilaterally
5. Inability to break quad MMT
Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and 300º/sec
Running 3. Effusion: 1+ or less
and Jumping 4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place without dynamic knee valgus
Criteria for 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and 300º/sec
Sport 3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance

Early Post-Operative Phase (0 – 4 weeks)

Appointments Post-operative evaluation should be performed 3-5 days following surgery. Follow-up PT
appointments 1-2x per week, depending on progression towards goals.
Precautions 1. No testing of repaired or reconstructed ligaments (Lachman, Anterior Drawer, Valgus Stress)
prior to 12 WEEKS
2. No loaded open kinetic chain knee extension for 8 WEEKS
3. Weight-bearing:
a. NWB for 0-2 weeks with brace locked in extension
b. TTWB for weeks 2-4 with brace locked in extension
Pain and Goal is ≤ 2+ (using Modified Stroke Test)
Effusion Cryotherapy and compression
ROM Extension: Emphasis on achieving full knee extension immediately following surgery. If full
extension is not achieved by 4 weeks, contact surgeon regarding ROM concerns.
Flexion:
• Flexion PROM/AAROM 0-30° for distal MCL lesion weeks 0-2
• Flexion PROM/AAROM 0-60° for distal MCL lesion weeks 2-4
• No forced flexion beyond 90º with meniscal repairs


Therapeutic • Emphasis on quad activation without gluteal co-contraction
Exercise • Restore patellar mobility
• Symmetrical extension ROM
• Decrease effusion

Suggested • Extension PROM: bag hangs or prone hangs

Interventions • Flexion PROM/AAROM: heel slides or wall slides with slight varus position
• Bike: Begin with ½ and progress to full revolutions only with proximal MCL lesions; keep
knee in slight varus positions
• Patellar mobilization: superior, inferior, medial, lateral
• Quad Isometrics; SLR 4-way with brace on until no extensor lag
• TKE: prone weeks 0-2; standing TTWB weeks 3-4
• Non-involved single leg balance with involved leg multidirectional hip (Reverse Steamboats)
• Begin Neuromuscular re-education using electrical stimulation (NMES) in long sitting with
pads on proximal and distal quadriceps. Once 60º knee flexion is easily obtained, then
perform NMES following instructions below.
NMES • NMES pads are placed on the proximal and distal quadriceps
Parameters at • Patient: Seated with the knee in at least 60º flexion, shank secured with strap and back
60º support with thigh strap preferred. The ankle pad/belt should be two finger widths superior to
the lateral malleoli
• The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction against a fixed resistance OR maximal tolerable amperage without
knee joint pain
• 10-20 seconds on/ 50 seconds off x 15 min
Criteria to ROM: ≥ 0-90 degrees. If full AROM knee extension is not achieved by 4 weeks, contact surgeon
Progress to regarding ROM concerns.
Middle Phase Strength: Quadriceps set with normal superior patellar translation, 20x SLR without extensor lag
of Rehab Effusion: 2+ or less with Modified stroke test

Middle Phase of Rehabilitation (4-12 weeks)

Appointments Goal to increase lower extremity strength and regain flexion ROM. 1-2 visits per week with
emphasis on patient compliance with resistance and ROM training as part of HEP (2-4 days per
week outside of therapy).
Precautions • Avoid dynamic knee valgus with all interventions, including warm-up and endurance
activities
• Open Chain knee extension:
o Initiate submaximal leg extension 90-45 degrees
o Initiate knee AROM 90-0 degrees (modify if painful)
• No isolated resisted hamstrings strengthening until 8 weeks with hamstring autograft
• Weight-bearing:
• WBAT 4-6 weeks with brace locked in extension
• WBAT at 6 weeks with brace unlocked, wean from brace
Criteria to • ROM: Full active knee extension; no pain on passive overpressure
Discharge • Strength: Able to perform strong quad isometric with full tetany and superior patellar glide
Assistive and able to perform 20 SLR without quad lag
Device • Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
• Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation


Pain and Cryotherapy/compression as needed for effusion
Effusion Patellar taping to reduce PF symptoms if present
ROM • Distal MCL lesion: Continue cautious knee flexion ROM to allow healing
o Weeks 4-6: ROM 0-90°
o Weeks 6+: flexion ROM as tolerated
• Monitor and progress knee ROM, patellar mobility, and LE flexibility
• Begin more aggressive techniques to achieve/maintain full knee extension (i.e. weighted
bag hang) as needed
• ROM progression from AAROM to AROM
• Initiate bike for ROM and warm-up for distal MCL lesions, keeping knee in slight varus
position
Suggested • Multi-angle knee isometrics from 60-90° for patients unable to tolerate high-intensity NMES
Interventions • Initiate open chain knee extension exercises
and timelines o Unweighted full range LAQ
o Protected range with isotonic progression
• Initiate and progress WB strengthening/stability with emphasis on proper LE mechanics
avoiding knee valgus
o Lunges, shuttle, steamboats, side-stepping, leg press, step up/down
• Progress gluteal and lumbopelvic strength and stability
• Progress single leg balance and proprioceptive exercises
• Endurance:
o Biking at week 6
o Treadmill walking, stepper, elliptical at week 8
• Initiate PWB plyometrics on shuttle at weeks 8-10 weeks (see criteria to begin full WB
plyometrics)
• NMES (see parameters in week 0-4)
Criteria to • <20% quadriceps deficit on isometric or isokinetic testing (can use HHD for isometric
Discharge testing)
NMES OR- If testing equipment is not available:
1. 20 SLR without quad lag
2. Normal gait
3. 10 heel taps to to 60 degrees with good quality
4. 10 rep max on LP and similar effort bilaterally
5. Inability to break quad MMT
Criteria to 1. ROM: Maintain full, pain free AROM including patellofemoral mobility
Progress to 2. Effusion: 1+ or less
Late Phase of 3. Strength: Isometric or isokinetic quadriceps and hamstrings strength >/= 80%
Rehab 4. Weight Bearing: Able to tolerate therapeutic exercise program, including PWB plyometrics,
without increased pain or >1+ effusion
5. Neuromuscular Control: Demonstrates proper lower extremity mechanics with all therapeutic
exercises (bilaterally)
6. Outcome Tools: ≥7/10 on #10 IKDC Questionnaire


Late Phase of Rehabilitation (weeks 12-Return to Sport)

Appointments Increased frequency from previous stage to 1-2x per week when appropriate to initiate
plyometric training and return to running program.
Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and 300º/sec
Running and 3. Effusion: 1+ or less
Jumping 4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place
Pain and Effusion may increase with increased activity, ensure ≤1+ and/or non-reactive effusion for
Effusion progression of plyometrics
ROM Full, symmetrical to contralateral limb, and pain-free with overpressure
Therapeutic • Performance of the quadriceps, hamstrings and trunk dynamic stability
Exercise • Muscle power generation and absorption via plyometrics
• Sport- and position-specific activities
• Begin agility exercises between 50-75% effort (utilize visual feedback to improve mechanics
as needed)
• Advance plyometrics: Bilateral to single leg, progress by altering surfaces, adding ball toss,
3D rotations, etc.
Suggested Therapeutic Exercise/Neuromuscular Re-education
Interventions • Squats, leg extension, leg curl, leg press, deadlifts, lunges (multi-direction), rotational
trunk exercises on static and dynamic surfaces, resisted side steps, monster walks,
PWB to FWB jumping
• Single-leg squats on BOSU, Single-leg BOSU balance with manual perturbation to trunk
or ball, single-leg BOSU Romanian deadlift
Agility
• Side shuffling, carioca, figure 8, zig-zags, resisted jogging (Sport Cord) in straight
planes, backpedaling, ladder drills
Plyometrics
• Single-leg hop downs from increasing height (up to 12” box), Single-leg hop-holds,
Double and single-leg hopping onto unstable surface, Double and single-leg jump-turns,
Repeated tuck jumps
Criteria for 1. ROM: full, pain free knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and 300º/sec
Sport 3. Effusion: No reactive effusion and ≤ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high
level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance


Author: Kat Rethman, PT, DPT, SCS
Reviewer: John DeWitt, PT, DPT, SCS, AT

References
rd
Andrews JR, Harrelson G, Wilk KE; Physical Rehabilitation of the Injured Athlete, 3 Ed. Philadelphia, PA,
Saunders, 2004.
English, R et al. The relationship between lower extremity isokinetic work and single-leg functional hop-work test.
Journal of Sport Rehabilitation. 2006; (15) 95-104.
Fanelli, G et al. “Management of complex knee ligament injuries.” The Journal of Joint and Bone Surgery. (2010);
92(12):2235-2246.
Griffin et al. “Medial Knee Injury: part 1, static function of the individual components of the main medial knee
structures.” American Journal of Sports Medicine (2009); 37(9): 1762-1770.
Hewett, T et al. “Biomechanical measures of neuromuscular control and valgus loading of the knee predict
anterior cruciate ligament injury risk in female athletes: a prospective study.” American Journal of Sports Medicine.
2005; 33(4): 492-501.
Levy, B et al. “Decision making in the multiligament-injured knee: an evidence based systematic review.”
Arthroscopy: The Journal of Arthroscopic and Related Surgery (2009) 25(4): 430-438.
Medvecky, M et al. “A multidisciplinary approach to the evaluation, reconstruction and rehabilitation of the multi-
ligament injured athlete.” Sports Medicine (2007); 37(2):169-187.
Myer, G et al. “Rehabilitation after anterior cruciate ligament reconstruction: Criteria-based progression through
the return-to-sport-phase.” Journal of Orthopedic and Sports Physical Therapy (2006); 36(2): 385-402.
Neitzel et al. “Loading response following anterior cruciate ligament reconstruction during the parallel squat
exercise.” Clinical Biomechanics. (2002); 17(7):5551-554.
Peskun et al. “Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-
based review." Sports Medicine and Arthroscopy Review (2011); 19(2): 167-173.
Romeyn et al. “Surgical treatment and rehabilitation of combined complex ligament injuries.” North American
Journal of Sports Physical Therapy. (2008); 3(4):212-225.
Skendzel, J et al. “Diagnosis and management of the multiligament-injured knee.” Journal of Orthopedic and
Sports Physical Therapy (2012); 42(3): 234-242.

MULTIPLE LIGAMENT KNEE INJURIES

(ACL AND PCL RECONSTRUCTION)
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician
evaluation. Contact Ohio State Sports Medicine Physical Therapy at 614-293-2385 if questions arise.

Background
ACL and PCL Reconstruction occurs after a multi-ligamentous knee injury, most often sustained during a contact
force causing a knee dislocation. This accounts for <0.02% of all orthopedic injuries. Surgery may be delayed or
staged for optimal outcomes. Surgery uses an allograft or autograft to reconstruct the torn ACL and PCL
ligaments, and may repair the MCL, LCL, and/or posterolateral corner of the knee if needed as well. Long-term
complications after surgery include chronic pain, knee instability, arthrofibrosis, and loss of knee flexion ROM.
rd
Research finds that only 1/3 of athletes return to sport at prior level of function. If return to sport is possible, it is
expected to take 9-12 months depending on comorbidities and nature of the sport.

Summary of Recommendations
Weight Bearing 1. Non-weight bearing for 2 weeks, brace locked in extension
Guidelines 2. TTWB - 25% at 2 weeks, brace locked in extension
3. PWB 25-50% at 5-6 weeks, brace locked in extension
4. WBAT at 7 weeks, gradually unlock and wean from brace
ROM Guidelines 1. No knee flexion >90° for 6 weeks
2. No active hamstring /OKC flexion exercises for 8 weeks
3. No resistive OKC hamstring exercise for 12 weeks
4. Do not allow proximal tibia to rest unsupported for 12 weeks

Concomitant 1. MCL Repair: 2. LCL/Posterolateral Corner Repair:

Pathology a. Femoral origin or mid-stance lesion
will need more accelerated ROM
b. Tibial insertion lesion will need
more cautious progression of ROM
a. No extension past 0° for 12 weeks
b. Use slight valgus force during
PROM flexion for 12 weeks
c. Ensure no hyperextension/varus
thrust when return to ambulation

Outcome Tools Collect at least one of the following at initial evaluation, every 6 weeks, and discharge. Be
consistent with which outcome tool is collected each time.
1. IKDC 2. KOOS 3. ACL-RSI 4. Tegner

Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure

Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar
Assistive Device glide and able to perform 20 SLR without quad lag
3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation
Criteria to 1. <20% quadriceps deficit on isometric or isokinetic testing (can use HHD for isometric
Discharge NMES testing)
OR- If testing equipment is not available:
1. 20 SLR without quad lag
2. Normal gait
3. 10 heel taps to to 60 degrees with good quality
4. 10 rep max on LP and similar effort bilaterally
5. Inability to break quad MMT

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.



Strength Testing 1. Isometric testing no earlier than 12 weeks- fixed at 60º knee flexion
2. Isokinetic testing no earlier than 16 weeks
Criteria to Initiate 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Running and 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and
Jumping 300º/sec
3. Effusion: 1+ or less
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place
Criteria for 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Return to Sport 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and
300º/sec
3. Effusion: No reactive effusion and ≤ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with
high level agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance

Weeks 0-4
Weight 1. Non-weight bearing for 2 weeks, in brace locked in extension
Bearing 2. TTWB - 25% at 2 weeks with brace locked in extension
ROM 1. Begin Passive ROM (no flexion beyond 90º for 6 weeks)
o Goal of achieving full terminal knee extension (stop at 0º if PLC repaired)
o Prone knee flexion with 10# manual anterior drawer force to protect PCL
o Use varus/valgus force during PROM to protect MCL/LCL repair if needed
2. Patellar mobilizations
3. Edema control
4. ROM 6-8 times daily
Strengthening 1. Quad Sets
2. Flexion and abduction SLR with brace on; emphasis on eliminating extensor lag
3. NO active strengthening with knee flexion for 8 weeks
NMES 1. NMES pads are placed on the proximal and distal quadriceps
Parameters 2. Patient: Sitting with knee straight in long-sitting position with back supported. Towel roll
under proximal tibia to prevent posterior translation.
3. The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction OR maximal tolerable amperage without knee joint pain
4. 10 seconds on/ 50 seconds off x 15 min. 2 second ramp up and down. Frequency=
75pps. Pulse Width= 400microseconds
Stretching 1. Calves

Goals to 1. Able to perform strong quad isometric with full tetany and superior patellar glide
Progress to 2. SLR with no extensor lag
Next Phase 3. Good patellar mobility
4. PROM 0-70°

Weeks 4-6
Weight 1. WB 25-50% at 5-6 weeks, brace locked in extension
Bearing
ROM 1. Continue prone PROM; do not force ROM
2. Patellar mobilizations
3. Edema control
Strengthening 1. Continue NMES
2. Increase duration of Quad Sets
3. SLR with eyes open and closed; fast and slow
4. Core, Glutes
Goals to 1. PROM 0-90°: if not achieved refer back to MD
Progress to 2. Tolerance of partial weight bearing without residual pain or reactive joint effusion
Next Phase 3. ≤ 2+ joint effusion
4. 20 repetitions SLR with no extensor lag

Weeks 6-8
Weight 1. WBAT at 7 weeks, gait training and wean from brace if 20 SLR without extensor lag
Bearing 2. Ensure no knee hyperextension/varus thrust with ambulation
Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure
Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar glide
Assistive and able to perform 20 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation
ROM 1. Gradual advancement of prone passive knee flexion
2. Stationary bicycle avoiding deep knee flexion
3. Maintain passive knee extension

Strength 1. CKC (Shuttle) PWB Eccentrics within protected range (10°-40°)

2. Weights shifts and progression to single leg balance
3. Active OKC Resisted Knee Extension within protected range (60°-30°)

New NMES 1. NMES pads are placed on the proximal and distal quadricep
Parameters 2. Patient: Seated with the knee at 60º flexion, shank secured with strap and back support with
thigh strap preferred. The ankle pad/belt should be two finger widths superior to the lateral
malleoli.
3. If this position creates knee pain, continue NMES in long-sitting
4. The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction against a fixed resistance OR maximal tolerable amperage without knee
joint pain
5. 10 seconds on/ 50 seconds off x 15 min. 2 second ramp up and down. Frequency= 75pps.
Pulse Width= 400 microseconds.
Goals to 1. Normalized gait mechanics without assistive device
Progress to 2. PROM 0-110º
Next Phase 3. Completion of exercises without exacerbation of symptoms or reactive effusion
4. ≤ 2+ joint effusion

Weeks 8-12
ROM 1. Progress prone flexion to achieve full symmetrical ROM

Strength 1. Gradual increased depth of CKC strengthening (0-70°)

2. Sub-max knee extension isometrics at 45° if pain-free
3. Step ups/downs with correct movement patterns
4. Progress single leg stance activities to compliant surfaces
5. Proprioceptive training for knee angle replication. Move uninvolved knee into various degrees of
flexion and patient has to match angle with involved knee; perform in prone throughout ROM
and short sitting (90-30 degrees only if pain-free).
6. CKC Hamstring exercises
7. Active prone knee flexion for hamstring
8. Continue NMES to quadriceps
Goals to 1. Increased strength/stability/proprioception with therapeutic exercise without exacerbation of
Progress to symptoms
Next Phase 2. No reactive instability or effusion with WB activity
3. ≤ 1+ joint effusion
4. PROM 0-130°
a. If flexion <125° refer back to MD
5. Ability to perform reciprocal stair ascent and descent without compensation or deficit

Weeks 12-16
ROM 1. ROM as needed
2. Progression to elliptical and stair stepper use with proper mechanics
Strength 1. Progress CKC 0°-90°
2. Resisted OKC knee extension 90°-30°
3. Progress neuromuscular strength, balance, and stability exercise (Squats, lunges, heel taps,
etc)
4. Perturbation training (slow to fast and proactive to reactive)
5. Initiate landing mechanics exercise and light plyometric activity in PWB
Criteria to 1. <20% quadriceps deficit on isometric or isokinetic testing (can use HHD for isometric testing)
Discharge OR- If testing equipment is not available:
NMES 1. 20 SLR without quad lag
2. Normal gait
3. 10 heel taps to to 60 degrees with good quality
4. 10 rep max on LP and similar effort bilaterally
5. Inability to break quad MMT
Goals to 1. ≤ 1+ joint effusion
Progress to 2. Full symmetrical flexion and extension ROM
Next Phase 3. Appropriate landing mechanics and no instability with PWB plyometric activities
4. Met criteria to discharge NMES


Weeks 16-24 (4-6 months)
Strength 1. Increase resistance and endurance with all exercises
2. OKC knee flexion exercises (0-90°)
3. Resisted OKC knee extension 90°-10°
4. Progress landing mechanics to full WB
5. Initiate walk-jog progression at 5-6 months if criteria below is met
Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and 300º/sec
Running and 3. Effusion: 1+ or less
Jumping 4. Weight Bearing: normalized gait and jogging mechanics with no gross visual compensation
5. Neuromuscular Control: Pain-free hopping in place with appropriate landing mechanics
Criteria to 1. Met criteria for running and jumping
Progress to 2. No reactive effusion or instability with FWB plyometrics
Next Phase

Weeks 24+ (6-12 months)

Strength 1. Increased resistance and endurance with all exercises
2. Progress landing mechanics from sagittal to frontal/transverse/diagonal planes
3. Begin agility exercises at 50% at 8 months
o Side shuffling
o Carioca
o Figure 8
o Cutting
o Backward running
o Ladder drills
4. Sport specific drills- use equipment, shoes, and specific surface
5. Incorporate power/acceleration training
6. Return to Sport no sooner than 10-12 months if criteria below is met
Criteria for 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and 300º/sec
Sport 3. Effusion: No reactive effusion and ≤ 1+ with sport-specific activity
4. Weight Bearing: normalized running mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with high level
agility, plyometrics, and high impact movements
6. Functional Hop Testing: LSI 90% or greater for all tests
7. Physician Clearance


Author: Kat Rethman, PT, DPT, SCS
Reviewer: John DeWitt, PT, DPT, SCS

References
rd
Andrews JR, Harrelson G, Wilk KE; Physical Rehabilitation of the Injured Athlete, 3 Ed. Philadelphia, PA,
Saunders, 2004.
Azar et al. “Ultra-low velocity knee dislocations.” The American Journal of Sports Medicine (2011); 39(10):2170-
2174.
Fanelli, G et al. “Management of complex knee ligament injuries.” The Journal of Joint and Bone Surgery. (2010);
92(12):2235-2246.
Goudie et al. “Functional outcome following PCL and complex knee ligament reconstruction.” The Knee. (2010);
230-234.
Griffin et al. “Medial Knee Injury: part 1, static function of the individual components of the main medial knee
structures.” American Journal of Sports Medicine (2009); 37(9): 1762-1770.
Hewett, T et al. “Biomechanical measures of neuromuscular control and valgus loading of the knee predict
anterior cruciate ligament injury risk in female athletes: a prospective study.” American Journal of Sports Medicine.
2005; 33(4): 492-501.
Hirschmann et al. “Surgical treatment of complex bicruciate knee ligament injuries in elite athletes: what long-term
outcome can we expect?” American Journal of Sports Medicine. (2010); 38(6):1103-1109.
Hirschmann et al. “Clinical and radiographical outcomes after management of traumatic knee dislocation by open
single stage complete reconstruction/repair.” BMC Musculoskeletal Disorders. (2010); 11:102
Jiang et al. “The timing of surgical treatment of knee dislocations: a systematic review.” Knee Surg Sports
Traumatol Arthrosc (2015) 23:3108-3113.
Levy, B et al. “Decision making in the multiligament-injured knee: an evidence based systematic review.”
Arthroscopy: The Journal of Arthroscopic and Related Surgery (2009) 25(4): 430-438.
Lunden et al. “Current concepts in the recognition and treatment of PLC injuries of the knee.” Journal of
Orthopedic and Sports Physical Therapy (2010); 40(8): 502-516.
Medvecky, M et al. “A multidisciplinary approach to the evaluation, reconstruction and rehabilitation of the multi-
ligament injured athlete.” Sports Medicine (2007); 37(2):169-187.
Medina et al. “Vascular and nerve injuries after knee dislocation.” Clinical Orthopedics and Related Research
(2014) 472(9): 2621-2629.
Myer, G et al. “Rehabilitation after anterior cruciate ligament reconstruction: Criteria-based progression through
the return-to-sport-phase.” Journal of Orthopedic and Sports Physical Therapy (2006); 36(2): 385-402.
Neitzel et al. “Loading response following anterior cruciate ligament reconstruction during the parallel squat
exercise.” Clinical Biomechanics. (2002); 17(7):5551-554.
Peskun et al. “Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-
based review." Sports Medicine and Arthroscopy Review (2011); 19(2): 167-173.
Romeyn et al. “Surgical treatment and rehabilitation of combined complex ligament injuries.” North American
Journal of Sports Physical Therapy. (2008); 3(4):212-225.
Skendzel, J et al. “Diagnosis and management of the multiligament-injured knee.” Journal of Orthopedic and
Sports Physical Therapy (2012); 42(3): 234-242.
Yinchuan et al. “Criteria-based management of an acute multistructure knee injury in a professional football
player: a case report.” Journal of Orthopedic and Sports Physical Therapy (2011); 41(9): 675-686.

CHRONIC EXERTIONAL COMPARTMENT SYNDROME
SUMMARY OF RECOMMENDATIONS
By: Trisha Conlan, SPT
Reviewed by: Kelly Henschen, PT, DPT, SCS, AT and JJ Kuczynski, PT, DPT

Risk Factors • Age of 25 to 28 years

• Male gender
• Aberrant running biomechanics including over-striding, over-
pronation, and rearfoot strike pattern at initial contact
• Participation in sport with running
• Significant increase in weight-bearing activities and training
volume
• Use of anabolic steroids and creatine supplementation
• Active military duty
Differential Diagnosis • Medial tibial stress syndrome
• Stress fracture
• Popliteal artery entrapment
• Tibial nerve entrapment
Examination • Outcome Measures: UWRI (University of Wisconsin Running
Injury and Recovery Index), SANE (Single Assessment
Numerical Evaluation); LEFS (Lower Extremity Functional
Scale); pain free running distance
• Body structure and function impairments
• Running gait biomechanical deficits
Phases • Symptom Relief
• Running Gait Re-training
Interventions • Risk Factor Modification
• Activity Modification
• Running Gait Retraining
• Functional Manual Therapy
• Patient Education
Criteria For Discharge • Symptom relief during and after exertion
• Return to running without pain
• Home exercise plan to maintain physical and functional
improvements
Alternate Treatment Options • Botulinum toxin A injection
o May provide symptom relief within 5 months after
singular injection

• Ultrasound fascial fenestration

o Health care provider first administers local anesthesia,
then surgically creates opening in the fascia to relieve
pressure
ay provide symptom relief lasting up to 18 months

• Surgical Release of Involved compartments – refer to post-

operative guideline for more information
A. Symptom Management
Patient Presentation 1. Patient experiences pain at anterolateral leg or deep in the calf with
Moderate level evidence specific amount and intensity of exertion and pain ceases with rest
Neurological symptoms may or may not be present including numbness,
tingling or foot drop in some cases
2. Inability to perform activity due to pain onset

3. Palpable leg compartment tenderness and tightness during and after

exertion

Activity Modification 1. Reduce load and volume of inciting activity, ranging from significant
Moderate level evidence volume reduction to complete cessation

2. Oral non-steroidal anti-inflammatory drugs, stretching, ultrasound,

orthotics, and electrical stimulation are not effective unless paired with
activity restriction

3. Patient Education: cessation of aggravating activity indefinitely is one of

the only successful non-operative treatment strategies supported by the
literature for symptom management

Conservative Interventions Manual Therapy

Expert opinion • Decreased flexibility, joint mobility or soft tissue adhesions may be
contributing to increased round reaction forces or poor shock
attenuation.
• Incorporating a combination of soft tissue techniques and joint
mobilizations may help to reduce symptoms.

Fasciotomy • Surgical decompression where the fascia is opened to reduce

Strong evidence constriction on the muscles
• Success rate is compartment dependent
o 81 to 100% with anterior, best outcomes with surgical
release
o Poor prognosis with deep posterior involvement
o 66% cumulative success rate
• 3 to 17% overall complication rate
o Negative outcomes include infection, ankle pain, recurrence,
sensory changes
• o to 44% recurrence rate
B. Running Gait Retraining
Patient Presentation • Rear foot running pattern at initial contact
Expert opinion • Running cadence less than 180 steps/min
• Symptoms exacerbated by running and cease with stopping
activity

Running Modifications • Encourage midfoot or forefoot strike during running

Expert opinion • Train runner to achieve cadence of 180 steps/minute or
higher using digital metronome, increasing at gradual rate
between 5 to 10% at a time
• Include running drills to improve body weight perception,
motor control, and running mechanics (see appendix)
• Train hamstring activation over gastrocnemius/soleus complex
use for swing phase initiation to reduce intracompartmental
pressure (see appendix)
• Alter proximal mechanics including increasing hip flexion while
running to reduce impact loading

• Performing running drills or some running in barefoot has

been suggested to help with proprioception during training
• Running modification is expected to take about 6 weeks to
implement
Cueing • “Take shorter faster steps”
• “Increase step rate”
• “Run quietly”
• “Land with foot closer to underneath the body”

• Use visual feedback, with two-dimensional video tape of

running to assist with patient education
References
1. Vajapey S, Miller T. Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome: a review of
current literature. The Physician and Sports Medicine. 2017.
2. Rajasekaran S, Hall M. Nonoperative management of chronic exertional compartment syndrome: a systematic review.
ACSM. 2016; 15(3):191-198.
3. Tucker A. Chronic exertional compartment syndrome of the leg. Curr Rev Musculoskeletal Med. 2010; 3:32-37.
4. Campano D, Robaina J, Kusnezov N, Dunn J, Waterman B. Surgical management for chronic exertional compartment
syndrome of the legs: a systematic review of the literature. Arthroscopy: JARS. 2016; 32 (7): 1478-1486.
5. Breen D, Foster J, Falvey E, Franklyn-Miller A. Gait re-training to alleviate the symptoms of anterior exertional lower leg
pain: a case series. IJSPT. 2015; 10(1): 85- 94.

6. Waterman BR, Liu J, Newcomb R, Schoenfeld AJ, Orr JD, Belmont P. Risk factors for chronic exertional compartment
syndrome in a physically active military population. Am J Sports Med. 2013; 41(11):2545-9.
7. Wuellner JC, Nathe CD, Kreulen CD, Burnham KJ, Giza E. Chronic exertional compartment syndrome: the athlete’s
claudication. Oper Tech Sports Med. 2017; 25:52-58.
8. de Bruijn JA, Zantvoort A et al. Factors predicting lower leg chronic exertional compartment syndrome in a large
population. Int J Sports Med. 2018; 39: 58-66.
9. Collins CK, Gilden B. A non-operative approach to the management of chronic exertional compartment syndrome in a
triathlete: a case report. IJSPT. 2016; 11 (7): 1160- 1176.
10. Helmhout P, Diebal AR et al. The effectiveness of a 6-week intervention program aimed at modifying running style in
patients with chronic exertional compartment syndrome. Orthop J Sports Med. 2015; 3(3): 1 – 10.
11. Barton CJ, Bananno DR, Carr J et al. Running retraining to treat lower limb injuries: a mixed methods study of current
evidence synthesized with expert opinion. Br J Sports Med. 2016; 50: 513-526.
Appendix
Foot tapping
• Purpose: Hamstring engagement over gastrocnemius/soleus use for initiation of swing phase in attempt to
reduce ICP; pull the foot versus push off
• Cues: Use hamstrings to lift leg, let gravity assist lowering of leg to ground

High hopping
• Purpose: To facilitate improved hip flexor and quadriceps flexibility and improve hamstring activation
• Cues: Touch buttocks with heels, keep quadriceps relaxed
Falling Forward
• Purpose: To promote forward lean while in running position
• Cues: A controlled fall towards the wall; progress in distance away from wall to make it harder

Weight Shifting
• Purpose: To improve body awareness of center of mass alterations, shifting weight from heel to balls of foot
• Cues: Hinge at the ankles, not the trunk; chest leads
Forward lean drill
• How: Stand upright with feet flat on the ground, lean forward until you are about to lose your balance, then jog
forward maintaining your forward position of your trunk.
• Make sure the lean is a true lean of the entire body, and not just hinging forward at the hips.
• Practice 3-5 times to get a feel for what running feels like with a forward trunk lean and your feet under your body.


CHRONIC ANKLE INSTABILITY

CLINICAL PRACTICE GUIDELINE
Background
Chronic ankle instability (CAI) is a common clinical condition characterized by the tendency of the ankle to “give
way” during normal activity and may occur in the absence of true mechanical instability. It may develop after a
single event, or may be part of an ongoing process that leads to functional ankle instability and the subjective
feeling of the ankle giving way. Up to 40% of acute ankle sprains will develop CAI, however progression from
acute ankle sprains to CAI is not well understood. It becomes termed CAI if instability has persisted for greater
than 6 months.

It is hypothesized that CAI may develop due to a loss of mechanoreceptors within the ankle joint. Furthermore,
clinical laxity may be a confounding factor in CAI and may not be present in all those with perceived instability.
Less than 50% of CAI patients demonstrate true clinical laxity, while 20% of copers demonstrate clinical laxity.
CAI likely results from a combination of several factors including poor proprioception, impaired strength and
patient perception.

Current literature classifies CAI into two groups: mechanical and functional instability. Mechanical instability
implies loss of normal anatomic restraint to lateral ankle stability, while functional instability results secondary to a
loss of proprioception and neuromuscular control.

Proprioception has been found to be a key management strategy in CAI. Several studies show that patients with
CAI demonstrate reduced performance on several proprioceptive and functional tests such as the Y-Balance,
single-leg balance and hop testing. Furthermore, literature reveals that the inclusion of proprioceptive and
neuromuscular control training strategies result in improved functional performance and improved patient reported
outcomes.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Definitions
• Strong level evidence: supported by systematic review, meta-analysis, or >5 RCT
• Moderate level evidence: supported by 3-4 RCT
• Low level evidence: supported in 1-2 RCT or clinical case series
• Expert opinion: supported by case studies, expert opinions or opinions of the authors

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.


Summary of Recommendations
Risk Factors Modifiable Risk Factors (strong level evidence):
• Indoor and court sports
• High intensity training > 3 days/week
• Poor neuromuscular control (impaired proprioception)
Non-modifiable risk factors (strong level evidence):
• Female
• Younger age
• Higher BMI and height
• Hindfoot and midfoot alignment (hindfoot varus, midfoot cavus)
Examination • Standing foot alignment • Mechanical Instability Testing
o Neurovascular exam (Repeated o Anterior Drawer Test
sprains may propagate peroneal o Talar Tilt
neuropathy • Functional Instability Testing
• Beighton Scale for Systemic o Y-Balance
Hypermobility o Foot Lift Test
• ROM: Weight Bearing DF lunge • Functional Hop Testing
• Strength (Dynamometry)
Differential • Chronic Ankle Instability
Diagnosis • Peroneal Neuropathy
• Peroneal Tendinopathy
Manual Therapy • Talocrural joint mobilizations
• Hindfoot, midfoot mobilizations
• Soft tissue mobilization PRN
Corrective • ROM – emphasis on dorsiflexion
Interventions • Ankle strength, foot intrinsic strengthening
• Hip/core stability
• Balance/proprioception progressions into functional movement training
Outcome Tools Consider patient reported outcome
and Testing measures
1. FAAM
2. TSK-11
Functional Testing
1. Y-Balance
2. Foot Lift Test
3. Functional Hop Testing
Criteria for Return 1. Subjective Outcome Measure > 90%
to Sport/Discharge 2. DF Lunge > 7.5 cm
3. Y-Balance > 90% composite
4. Foot Lift Test < 5 errors
5. Functional Hop Testing > 90% LSI
6. Physician clearance (if required)

Phase I: Acute Phase of Rehab and Return to Activity

Neuromuscular Optimize and restore active stability by training with examples such as:
Control/Balance
Training • Proprioceptive and balance training • Wobble Board
strong level • Balance training • Trampoline training
evidence • Single leg stance • De-stabilization device training
• Single leg squat • Jump training
• Heel raise • Agility testing
• Lunge/jump exercise • Multi-directional hopping
• Tandem stance • Combined functional movement
• Drop jump
Strengthening Strengthening exercises have been shown to improve strength and perceived instability, but
Exercises may not have functional benefits for individuals with CAI. The goal of strength training for
low level individuals with CAI is to provide improved dynamic stability of the ankle to reduce potential
evidence subsequent episodes. Recommended intervention progression includes:

• Band strengthening • Foot intrinsic strengthening

• 4 way ankle o Splaying
• Inversion strengthening most o Doming
effective (preventative effect for • Seated à functional movements
improving control of foot) o Great toe extension
• Proprioceptive neuromuscular facilitation o Ankle PF with great toe flexion
diagonals o Toe curls

Manual Therapy Manual therapy may have a role in improving joint mobility for ankle dorsiflexion.
low level Considerations should include soft tissue surrounding the ankle (triceps surae), as well as
evidence accessory joint mobility of the talocrural, subtalar, and distal tibio-fibular joints. The goal of
utilizing manual therapy techniques for individuals with CAI is to promote improved
arthrokinematics of the foot and ankle joints, and to facilitate improved dorsiflexion ROM and
proprioception of the ankle/foot complex.
Bracing/Taping Evidence indicates that bracing may or may not provide additional therapeutic benefit. It may
strong level be added at the treating therapist’s discretion to improve postural control by increasing the
evidence stability of the ankle joint, increasing foot control motion or increasing proprioceptive
capabilities. As bracing has been shown to potentially alter muscular recruitment around the
ankle, it is NOT recommended that the patient wear bracing during treatments. No injury
prevention benefits have been recognized in literature. Recommended bracing/taping
techniques to consider:
• Low dye taping (modified or standard)
• Ankle taping
• K-tape (Facilitation of ankle evertors with posterior glide of distal fibula)
• Figure 8 brace (lace up with lateral stirrups)
Discharge • DF ROM 90% of uninvolved side
Criteria / • FAAM score ≥ 1 MCID improvement
Criteria to • ≤ 1 incidences of perceived instability with functional activities in a 2 week period
Progress
expert opinion

Rehabilitation Phase II: Return to Sport Considerations

Factors to • Demands of the athlete’s sport
Consider Prior • Position
to Return to • Competition level
Play • Rules on taping/bracing
Strengthening Utilize end range strengthening for ankle plantarflexors, evertors, and invertors. Manipulate
Exercises training to include both endurance and power considerations based on sport. Include proximal
low level stabilization of the hips and core to reduce burden on ankle strategy. Interventions can include:
evidence
• Single leg calf raises (Neutralàstart in DF) • Planks
• Triple extension exercise • Side planks
• Foot intrinsic strengthening • RDL’s
o Splaying • Hip Abductors
o Doming • Hip Extensors
§ Seated à functional movements • Bridging
o Great toe extension
o Ankle PF with great toe flexion
o Toe curls
Neuromuscular Neuromuscular training for athletes with CAI should focus on improving proximal core
Control/Balance activation/control, dynamic (reactive) ankle strategies, and control of functional movements.
Training Suggested interventions include
strong level
evidence • Diaphragmatic breathing/breathing • Movement re education
patterns o Lunging
• Rolling patterns o Squatting
• Balance on dynamic surfaces (tilt board à o SL dead lift
BOSU) o Heel tap
• Crawling patterns o Step up
o Step outs
o Hops
Agility Training Consider periodization (in season v. out of • Cone drills
and Sport season athlete), power v. endurance and • Back pedal
Specific Drills cardiovascular conditioning with these • Ladder drills
low level intervention options: • Resisted jogging (sport cord)
evidence • Lateral shuffling • Hop training
• Carioca • Drop counter jump
• Figure 8 drills • Change of direction drills
Criteria for • Functional Hop Testing
Return to Play • LSI ≥90% for all tests
moderate level • Star Excursion Balance Test within 4 cm in anterior direction
evidence • Single leg stance time within 90% of contralateral limb
o Consider addition of eyes closed
o < 5 errors on foot lift test
• Strength within 90% of contralateral limb using hand held dynamometry
• Pain ≤ 1/10 with activity
• No reactive edema in 24 hours post activity
• Ankle ROM: within 90% of contralateral limb using standard techniques
o DF Lunge > 7.5 cm
• Outcome Tool
o FAAM with ≤ 1 MCID from full score (9 points)
o Consider utilization of TSK-11


Failure of Conservative Management

Definitions
Failure of conservative management for chronic ankle instability can be managed surgically with a Brostrom
procedure. Several factors may contribute to failure of conservative treatments, and failure can be identified as
the continued presence of mechanical or functional ankle instability for 6 months following injury and 3 months of
treatment. Brostrom procedures typically are performed with two variations: The Brostrom Evans or the Brostrom
Gould procedure. Each procedure seeks to repair or recreate the ATFL to restore ankle stability. Post-operative
outcomes are generally rated as excellent, with 90-95% of patients reporting full return to pre-morbid activity.
Additionally, 90-95% of high level athletes return to sport within 6 months, although longevity of career and
performance level have not been well followed.

Brostrom Gould Procedure

The ATFL is debrided and repaired, and a portion of the inferior extensor retinaculum is stretched over the ATFL
to reinforce the ligament.

Brostrom Evans Procedure

In addition to the above, 1/3 of the peroneus brevis muscle is split off and threaded through the fibula, anchoring it
to the lateral talus.

Operative considerations: Surgical repair is not indicated for individuals with systemic hypermobility. The
following symptoms are considered to be a negative prognostic factor for outcomes following a Brostrom repair:
• Osteochondral defects ~20%
• Synovitis ~63%
• Impingement ~10%
• Tendon dysfunction
• Medial ankle instability (MRI)
• Syndesmotic instability (MRI)
2
• Obesity (BMI ≥ 30 kg/m )
Intra and extra-articular confounders, such as synovitis and OCD, can be managed with arthroscopic repair. This
repair is typically performed in conjunction with the primary repair.

Most frequent post-operative changes: The following are all considered normal changes following Brostrom
repairs:
• Loss of inversion ROM up to 15 degrees
• Ankle eversion strength deficit of 10%
• Decreased balance, with increased postural sway
• Decreased proprioception

Rehabilitation Recommendations: Acute Stage (weeks 0-6)

Weight Bearing • NWB 4-6 weeks
strong level
evidence
ROM Passive ROM within tolerance
Interventions • Avoid forceful inversion
strong level
evidence
Strengthening Primarily focused on activation of musculature surrounding the ankle.
strong level • Sub maximal 4 way ankle isometric
evidence o Multiple angles as tolerated
o Caution with inversion and eversion positioning
• Foot intrinsic strengthening
o Splaying
o Doming
• Seated à functional movements
o Great toe extension
o Ankle PF with great toe flexion
o Toe curls
Manual As needed:
Therapy • Low grade joint mobilizations of accessory joints surrounding the repair. DO NOT INLUDE
low level TALOCRURAL/SUBTALAR
evidence • Retrograde mobilization
Modalities • Should be utilized in the acute stage of rehabilitation to minimize edema
low level
evidence
Criteria to • Progression into weight bearing
Progress • PROM ≥ 75% of uninvolved
moderate level • Ability to bear weight without increase in pain
evidence

Rehabilitation Recommendations: Return to Function Stage

(weeks 6-12)
Weight Bearing Full weight bearing, progressing to normal gait pattern. Normal ambulation without an AD no
Restrictions later than week 9.
ROM Active ROM within tolerance
Interventions • Monitor inversion
moderate level • Utilize kneeling DF stretch
evidence
Strengthening Focused on full ROM, with special emphasis • Foot intrinsic strengthening
moderate level on end range training. o Splaying
evidence • Calf raise series o Doming
o Double legà 2 up, 1 down à Single o Seated à functional movements
leg Great toe extension
o Progression of forces o Ankle PF with great toe flexion
§ Seatedà partial weight bearing o Toe curls
(shuttle, leg press)àbody weight • Core strengthening (see return to function
against gravity considerations above)
o Maintain neutral ankle positioning (no • Functional movement training
inversion at end range) o Squat
o Lunge
o Heel tap
o Step up
Neuromuscular Evidence supports the improvement of passive and dynamic (reactive) balance for return to
reeducation activity. Suggested interventions include:
strong level • BAPS board
evidence o Seatedàstanding
• Single leg stance
o Firm surfaceàfoam surfaceàdynamic surface
• Functional movement training
o Squat
o Lunge
o Heel tap
• Step up
Manual • Manual therapy should be utilized sparingly at this stage of rehabilitation. Joint
Therapy mobilizations to improve ROM PRN
low level
evidence
Modalities • Modalities are not recommended at this time. Patient may require ice bags after treatment
expert opinion
Criteria to • Normalized gait pattern without compensation
Progress • PROM ≥ 90% of uninvolved
• Single leg stance ≥ 90% of uninvolved limb on firm surface
• Inversion/Eversion Strength ≥ 90% of uninvolved via hand held dynamometry
• Plantar Flexion strength: 25 SL calf raises
• No edema (figure of 8 or volumetric measurement)
o May return to running if all of the above are met.

Return to Sport Stage (12-26 weeks): see non-operative criteria above

Authors: Lucas Vanetten, PT, DPT, OCS; Matthew Longfellow PT, DPT; Mathew Lopez PT, DPT; Daniel
Chelette PT, DPT
Completed: 2016

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CHRONIC EXERTIONAL
COMPARTMENT SYNDROME RELEASE
CLINICAL PRACTICE GUIDELINE
Background
Chronic exertional compartment syndrome (CECS) is a condition caused by repetitive physical activity, commonly
seen in athletic and military populations. It causes an increase in intramuscular pressure within fascial
compartments of the body, leading to reduced local blood flow and resulting in pain, tightness, paresthesia, and
possible muscle weakness. Symptoms are increased with exertion, and relieved with rest. CECS can occur in any
fascial compartment of the body, most commonly in the anterior and lateral compartments of the lower leg.
Intracompartmental pressure tests are the gold standard for diagnosing CECS, however diagnosis is not
dependent on a positive test result, as false negatives are possible. A positive test is often defined as pressure
≥30 mm Hg 1 minute after exercise, or pressure ≥20 mm Hg 5 minutes after exercise.

CECS can be treated non-operatively, however it is often treated with a surgical fasciotomy if conservative
treatment is not successful. This procedure releases the pressure on the compartment and is considered the most
successful and definitive treatment for CECS. This protocol will focus on the open fasciotomy for the lower leg,
which involves 1-2 incisions approximately 6-10mm in length on the skin. Despite the small skin incisions the
fascia can be completely released from just below the knee to just above the ankle.

Weightbearing • WBAT immediately following surgery

Guidelines • Crutches during the first few postoperative days if needed (usually 3-5 days)

ROM Guidelines • Progress ROM as tolerated starting within the first few postoperative days

Criteria to • Pain-free ambulation with normalized gait pattern

Discharge
Assistive Device

Criteria to Initiate • Ability to tolerate 15-30 minutes of continuous aerobic activity without onset of
Running/Jumping symptoms/pain
• 5/5 pain-free ankle strength of involved compartment
• Ability to complete single leg functional movements (i.e. squats and lunges) with
proper mechanics and no pain
• No increase in swelling 12-24 hours following physical activity
• No pain 1-2 hours following physical activity
Criteria to Return • Meet criteria to initiate running/jumping
to Sport • Proper neuromuscular control of eccentric and concentric multi-planar activities with
absence of pain, instability and swelling
• At least 90% plantarflexion strength of uninvolved side assessed with unilateral heel
raises on leg press or maximum heel raise repetitions with equal heel height
Outcome Tools • FAAM (ADL and Sports subscales)
• LEFS

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.


Weeks 0-3: Protection and Mobility
Weightbearing • WBAT with progression to full, pain-free weight bearing with ambulation
• Axillary crutches (or other AD) if needed in the first few postoperative days
• Discontinue crutches when gait is normalized
Precautions • Avoid activities that increase swelling (i.e. extended sitting, tight clothing proximal to
site of surgery, and excessive heat such as a hot pack or bath)
• Avoid friction over new scar formation at incision site
• Avoid high impact activity such as running, jumping, and hopping
Edema Control • Gentle distal to proximal massage of lower leg to assist with venous return and reduce
swelling
• Ankle pumps (can perform with lower extremity elevated to assist with swelling
reduction)
ROM • NWB ankle PROM and AROM
• PF, DF, inversion, eversion
• Alphabet exercise
• Seated BAPS
• Knee PROM and AROM as needed

Strengthening • Sub-maximal isometric strengthening

• Ankle PF, DF, inversion, eversion
• Quad sets
• Progress to SAQ, LAQ and SLR
• 4-way hip
• Progress from non-weight bearing to standing
Goals to • Lower leg circumference within 2 cm of uninvolved side
Progress to • Knee and ankle AROM equal to uninvolved side
Next Phase • Normalized gait mechanics including full pain-free weight bearing on level surface, and
equal step length bilaterally


Weeks 4-6: Light Strengthening
Precautions • Limit swelling by minimizing prolonged weight bearing activity
• Continue to avoid friction over new scar formation at site of incision
• Avoid excessive weight bearing eccentric loading
• Avoid high impact activity such as running, jumping and hopping
ROM • Initiate scar massage/mobility and desensitization when incision is fully healed
• Gentle ankle stretching
• 30-60 second holds
• Nerve mobilizations in supine
• Focus on involved compartment (i.e. ankle PF and inversion to focus on common
peroneal nerve)
• Progress repetitions and range of motion as tolerated
• BAPS progression (seated àstanding)
Strengthening • Start open kinetic chain ankle strengthening
• 4 way ankle with theraband resistance
• Balance and proprioception exercises
• Bilateral à unilateral
• Level, firm surface à soft/unstable surface (foam or BOSU) à balance board
• Eyes open à head turns à eyes closed
• Double leg squats: mini-squats àfull squats
• Gait drills
• Sagittal plane à frontal and transverse planes
• Forward and retro marching (sagittal plane), side-stepping (frontal plane), and
carioca/grapevine walking (transverse plane)
Cardiovascular Only initiate the following when incision is fully healed:
• Stationary bicycle starting with 5-10 minutes at a low resistance and speed
• Treadmill walking starting with 5-10 minutes at 2-3 mph and progress time and speed as
able
• If desired, may begin aquatic activities/swimming starting with 10-15 minutes and
progressing time/amount as able
Goals to • Lower extremity circumference within 1 cm of uninvolved side
Progress to • Ability to maintain single leg stance with eyes open on unstable surface for 30-60 seconds
Next Phase • Ankle DF ROM equivalent to uninvolved side measured in weight bearing lunge position
• Proper lower extremity mechanics with no pain during functional double leg squats


Weeks 6-8: Progression of Strengthening/Return to Jogging

Precautions • Continue to limit activities which increase swelling

• Limit friction over scar tissue
• No strenuous or painful activities

ROM • Continue stretching and nerve mobilizations as needed

• Lower extremity soft tissue mobilization to improve flexibility and soft tissue mobility of the
lower leg
• Instrument assisted, foam roller, massage stick roller
Strengthening • Progression of closed chain functional strengthening
• Lunges, step-ups, single leg squats
• Double leg heel raise à single leg heel raise
• Can combine with gait drills such as marching, or heel/toe walking
• Initiate plyometric exercises at 6 weeks
• Plyometric shuttle (DLàSL jumping)
• DL jumping àSL jump to contralateral foot (leaping) à SL jump to same foot (hopping)
• Progress repetitions, and height/distance as able
Cardiovascular • Initiate or progress aquatic activities/swimming if wounds are fully healed
• Progressive treadmill walking time and speed
• Light jogging can be initiated on level surface
• 6-8 weeks for 1-2 compartment release
• 8-10 weeks for 4 compartment release
• Progressive walk-jog interval training
Goals to • Complete 15-30 minutes of continuous aerobic activity without symptoms or pain
Progress to • 5/5 pain-free ankle strength of muscles in involved compartment
Next Phase • Ability to complete SL functional movements (such as SL squats and lunges) without pain,
and with proper mechanics
• No residual swelling 12-24 hours following physical activity
• No pain 1-2 hours after physical activity


Weeks 8-12+: Return to Sport/Impact Training

Precautions • Continue to avoid pain and increased swelling during and following activity

ROM • Continue knee and ankle stretching and ROM exercises as appropriate

Strengthening • Progress strengthening exercises to promote stability and neuromuscular control with
increased loads and speeds
• Low velocity, single plane activities àhigher velocity, multi-plane activities
• Forward and backward àside-to-side and transverse plane movements
• Sport-specific training beginning at a low-intensity
• Instruct patient on gradual return to sport/activity progression
• Biomechanical assessment of specific sport activity with video analysis as needed
• Running gait: Forefoot strike running pattern reduces intracompartmental pressure
Goals to • Meet criteria to initiate running/jumping
Progress to • Proper neuromuscular control of eccentric and concentric multi-planar activities with absence
Return to of pain, instability, and swelling
Sport/Work • At least 90% plantarflexion strength of uninvolved side assessed with unilateral heel raises on
leg press or maximum heel raise repetitions with equal heel height

Author: Anna Lamb, DPT

Reviewers: Kat Rethman, PT, DPT; Bryant Walrod, MD; Timothy Miller, MD

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report. Int J Sports Phys Ther. 2014;9(1):125-34.
18. Tjeerdsma J. Outcome of a Specific Compartment Fasciotomy Versus a Complete Compartment
Fasciotomy of the Leg in One Patient With Bilateral Anterior Chronic Exertional Compartment Syndrome:
A Case Report. J Foot Ankle Surg. 2016;55(5):1027-34.
19. Vajapey S, Miller TL. Evaluation, diagnosis, and treatment of chronic exertional compartment syndrome:
a review of current literature. The Physician and Sportsmedicine. 2017;45(4):391-398.

GENERAL KNEE DEBRIDEMENT, PARTIAL

MENISCECTOMY, PLICA RESECTION
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise

Phase I: Weeks 0-1

Considerations • Pain control
• Edema control
• Wound healing/incision site care/scar massage- pt education
• Begin FWB independent of crutches when pt without signs of antalgia,
increased pain and/or effusion, full knee extension present during gait, and
demonstrates sufficient quadriceps activation
ROM • Full active knee extension
• Patellar mobilization
• Knee flexion at least 90º
Neuromuscular • Quadriceps/VMO recruitment: estim or biofeedback as necessary for
Control/Strengthening quadriceps re-education
• Hip ABD/core strength
• Eccentric knee control with CKC therex
Mobility • Quadriceps
• Hip flexors
• Hamstrings
• IT Band
• Gastroc/soleus
Goals to Progress to 1. Minimal to no edema
Next Phase 2. Minimal to no pain
3. Normalized gait
4. Full active knee extension
5. Normal patellar mobility
6. SLR without extensor lag
7. Well-healing incisions without signs of infection

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Phase II: Weeks 2-3
ROM • Edema control
• 0-125 º

Mobility • Quadriceps
• Hip flexors
• Hamstrings
• IT Band
• Gastroc/soleus
Neuromuscular • Proprioception exercises
Control/Strengthening • Multi-angle CKC exercises
• Balance training
• Quadriceps recruitment
• Hip ABD/core strength
• Light plyometrics: emphasize correct landing mechanics
Functional Activities • Ascend/descend stairs with reciprocal gait pattern independent of UE support

Goals to Progress to 1. Full ROM at least 90% of contralateral limb

Next Phase 2. No pain with strengthening exercises
3. Good eccentric knee control with CKC exercises and light plyometrics.

Phase III: Weeks 4-8

ROM • Full AROM

• No effusion

Mobility • Quadriceps
• Hip flexors
• Hamstrings
• IT Band
• Gastroc/soleus
Neuromuscular • Sport-specific drills
Control/Strengthening • Plyometrics
• Core strength
• Begin interval running program
• Functional testing: hop tests, star test, Y balance, etc


Goal: Return to sport

Functional Tests Single hop for distance: Have the
subject line their heel up with the zero
mark of the tape measure, wearing
athletic shoes. The subject then hops as
far as he can, landing on the same push
off leg, for at least 3 seconds. The arms
are allowed to move freely during the
testing. Allow him to perform 4 practice
hops on each leg. Then, have the
subject perform 4 trials, recording each
distance from the starting point to the
back of the heel. Average the distances
for each limb.
Cross-over hop for distance: This test
is set up with a 15cm strip, extending 6
meters. The subject lines his heel up at
the zero mark of the tape measure and
hops 3 times on one foot, crossing over
the center line each time. Each subject
should hop as far forward as he can on
each hop, but only the total distance
hopped is recorded Allow the subject to
perform 4 practice rounds before
recording. Average the distances for
each limb.

Scoring
• Begin with the uninvolved leg. If using tape to mark distance, remove it before
the next trial to minimize visual cues.
• Greater than a 15% difference in average distance between the right and left
limbs should be cause for concern, indicating quad, and hamstring
weaknesses that should be addressed prior to return to sport.
• If patient fails test, evaluate and implement appropriate
trength/stability/balance exercise strategies. Once resolved, test again.

References
Andrews JR, Harrelson GL, Wilk KE. Physical Rehabilitation of the Injured Athlete. Saunders:
Philadelphia; 2004.
Wilk KE, Romaniello WT, Soscia SM, Arrigo CA, Andrews JR. The relationship between
subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J
Orthop Sports Phys Ther.1994;20(2): 60-73.

HIGH TIBIAL OSTEOTOMY

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise

Rehabilitation Precautions
• Patient will remain in long-leg post-operative brace for 8 weeks gradually increasing weightbearing status
from none/toe-touch to full
• AROM is restricted to 110o for the first two weeks
• AROM is progressed to 135 o after two weeks

Weeks 1-2 • Long-leg brace • AROM up to 110º

• Weightbearing • Stretching
o None to toe-touch o Hamstrings, gastrocnemius/soleus,
• Patellar mobilizations iliotibial band, quadriceps
• Modalities for pain/edema management • Strengthening
o Cryotherapy o Quad sets
o Electrical Stimulation o Straight leg raises
o Active knee extension
Weeks 3-4 • Long-leg brace • Strengthening
• Weightbearing o Quad sets
o 25% body weight o Straight leg raises
• Patellar mobilizations o Active knee extension
• Modalities for pain/edema management o Closed-chain exercises: toe raises,
o Cryotherapy mini-squats, wall sits, TKE
o Electrical Stimulation • Conditioning
• AROM up to 135º o UBE
• Stretching
o Hamstrings, gastrocnemius/soleus,
iliotibial band, quadriceps

Weeks 5-6 • Long-leg brace • Strengthening

• Weightbearing o Quad sets
o 50% to 75% body weight o Straight leg raises
• Patellar mobilizations o Active knee extension
• Modalities for pain/edema management o Closed-chain exercises: toe raises,
o Cryotherapy mini-squats, wall sits, TKE
o Electrical Stimulation o Leg Press (70º-10º)
• Stretching • Conditioning
o Hamstrings, gastrocnemius/soleus, o UBE
iliotibial band, quadriceps o Stationary bike
o o Aquatics program

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Weeks 7-8 • Long-leg brace o Active knee extension
• Weightbearing o Closed chain exercises: toe raises,
o 75% to full weight mini-squats, wall sits
• Patellar mobilizations o Leg press (70-10 o)
• Modalities for pain/edema management o Hip abduction/adduction and/or multi-
o Cryotherapy hip machine
• Stretching o Knee flexion hamstring curls (90 o)
o Hamstrings, gastrocnemius/soleus, o Knee extension quadriceps (90-30 o)
iliotibial band, quadriceps o Core strengthening
• Strengthening • Conditioning
o Quad sets o UBE
o Straight leg raises o Stationary bike
o Aquatics program

Weeks 9-12 • Modalities for pain/edema management • Balance/Proprioceptive Training

o Cryotherapy o Weight-shifts
• Stretching o Mini trampoline
o Hamstrings, gastrocnemius/soleus, o BAPS board
iliotibial band, quadriceps o Step-downs
• Strengthening o BOSU mini-squats
o Quad sets • Conditioning
o Straight leg raises o Stationary bike
o Active knee extension o Aquatics program
o Closed-chain exercises: toe raises, o Swimming (kicking motion)
mini-squats, wall sits o Walking
o Leg Press (70-10 o) o Stairclimber/elliptical
o Hip abduction/adduction and/or multi- • Sport-Specific Activity
hip machine o Jogging/running in a straight line
o Knee flexion: hamstring curls (90º)
o Knee extension: quadriceps (90-30º)
o Core strengthening
4 Months • Modalities for pain/edema management o BAPS board
o Cryotherapy o Step-downs
• Stretching o BOSU mini-squats
o Hamstrings, gastrocnemius/soleus, o Plyometric progression
iliotibial band, quadriceps • Conditioning
• Strengthening o Stationary bike
o Leg press (70-10º) o Aquatics program
o Hip abduction/adduction steamboat o Swimming (kicking motion)
and/or multi-hip machine o OSU Sports Medicine Revised 2010
o Knee flexion: hamstring curls (90º) o Walking
o Knee extension: quadriceps (90-30º) o Stairclimber/elliptical
o Core strengthening • Sports-specific exercise (50-75%)
• Balance/Proprioceptive Training o Line jumps
o Weight-shifts o Carioca
o Mini trampoline o Ladder drills


5 Months • Modalities for pain/edema management o Step-downs
o Cryotherapy o BOSU mini-squats
• Stretching o Plyometric progression
o Hamstrings, gastrocnemius/soleus, • Conditioning
iliotibial band, quadriceps o Stationary bike
• Strengthening o Aquatics program
o Leg Press (70-10º) o Swimming (kicking motion)
o Hip abduction/adduction steamboat o Walking
and/or multi-hip machine o Stairclimber/elliptical
o Knee flexion: hamstring curls (90º) • Sports-specific exericise (75-100%)
o Knee extension: quadriceps (90-30º) o Line jumps
o Core Strengthening o Carioca
• Balance/Proprioceptive Training o Ladder drills
o Weight-shifts
o Mini trampoline
o BAPS board
6 Months • Maintain the above therapeutic exercise plan at six months
• Sport-Specific Activity (75-100%)
o Running straight
o Cutting movements
§ Carioca
§ Figure 8s
§ 45 degree cuts
§ 90 degree cuts
• Return to Sport

References

Noyes FR, Mayfield W, Barber-Westin SD, Albright JC, Heckmann TP. Opening wedge high tibial osteotomy: an
operative technique and rehabilitation program to decrease complications and promote early union and function.
Am J Sports Med. 2006; 34: 1262- 1273.

Wolcott M. Osteotomies around the knee for the young athlete with osteoarthritis. ClinSports Med. 2005; 24: 153-
161.

Mangine RE, Eitert-Mangine M, Burch D, Becker BL, Farag L. Postoperative management of the patellofemoral
patient. JOSPT. 1998; 28(5): 323-335.

KNEE MICROFRACTURE
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Rehabilitation Precautions

General • WB status varies based on lesion location, size and physician

• It is very important to know the location and size of the lesion
o Small lesion <2cm2
o Large lesion >2cm2
• All progression is based on soft tissue healing
Brace • Femoral condyle (FC): No brace, may use elastic wrap to control swelling
• Patellofemoral (PF): Brace locked in 0o extension; may progress opening of brace Weeks
6-8
Weight-bearing Femoral Condyle Patellofemoral lesions
2
• Small FC lesions (<2.0 cm ): • Immediate TTWB of approximately 25%
• Weeks 1-4: NWB body weight with brace locked in full
• Weeks 4-6: Wean off crutches to extension;
FWB • Week 2: progress to 50% WB - brace
• Large FC lesions (>2.0 cm2): locked in full extension
• Weeks 1-6: NWB • Week 3: progress to 75% WB - brace
• Weeks 6-8: Wean off crutches to locked in full extension,
FWB • Week 4: progress to full WB - brace
locked in full extension
• Weeks 6-8: progress opening of brace to
D/C of brace
Range of • Immediate motion exercise Day 1
Motion (ROM) • Full passive knee extension immediately
• CPM 6 weeks for large FC & PF lesions; 3 weeks for small FC lesions
o Initiate CPM day 1 for total of 8-12 hours/day (0°-60°; if PF >6.0 cm, 0°-40°)
o Progress CPM ROM as tolerated 5°-10° per day
o CPM for total of 6-8 hours/day for up to 6 weeks
• Patellar mobilization (4-6 times per day)
• Range of motion exercises throughout the day
• Passive knee flexion ROM at least 2-3 times daily
• Progress passive knee ROM as tolerated, NO FORCED FLEXION BEYOND 90°
• ROM goals: (PF lesions may be limited due to location and size)
o Week 1: 0°-90°
o Week 2: 0°-105°
o Week 3: 0°-115°
o Week 4: 0°-125°
o Week 8: Full (equal) ROM
• Stretch hamstrings and calf

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Phase I: Proliferation (Weeks 0-6)
Goals 1. Protect healing tissue from load and shear forces
2. Decrease pain and effusion
3. Restoration of full passive knee extension
4. Gradually restore knee flexion
5. Regain quadriceps control

Brace • See above guidelines

Weightbearing • See above guidelines

ROM • See above guidelines

Strengthening • Ankle pumps

Program • Quadriceps setting
• Multi-angle isometrics
• Active knee extension 90°-40° for FC lesions (no resistance)
• NO active NWB knee extension exercises for PF lesions
• Straight leg raises (4 directions)
• Initiate weight shifting exercises with knee in extension Week 1-2 for PF lesions, Week
4 for small
• FC lesions, Week 6-8 for larger FC lesions
• Partial weight bearing leg press 0°-60° Weeks 4-6 for small FC lesions and PF lesions,
progress to 0°-90° Weeks 6-8
• Toe calf raises week 4-6 for small FC and PF lesions
• May begin use of pool for gait training and exercises Week 3-4 (when incisions fully
healed)
• May begin stationary bike week 4, low resistance with appropriate seat height
Functional • Gradual return to daily activities
Activities • If symptoms occur, reduce activities to reduce pain and inflammation
• Swelling control: Ice, elevation, compression, and modalities as needed
Criteria to 1. Full passive knee extension
Progress to 2. Knee flexion to 125°
Next Phase 3. Minimal pain and swelling
4. Voluntary quadriceps activity


Phase I: Transition Phase (Weeks 6-12)
Goals 1. Gradually improve quadriceps strength/endurance
2. Gradual increase in functional activities

Weightbearing • Refer to above WB guidelines

ROM • Gradual increase in ROM

• Maintain full passive knee extension
• Progress to full knee flexion by week 8 (refer to above ROM guidelines)
• Continue patellar mobilization and soft tissue mobilization as needed
• Continue stretching program
Strengthening • Progress WB exercises
Exercises • Initiate partial weight bearing leg press for large FC lesions Week 8
• Mini-squats 0°-45° Week 8-10
• Toe-calf raises week 6-8 for FC lesions
• Progress balance and proprioception drills
• Initiate front lunges, wall squats, front and lateral step-ups Week 6-8 for small FC and
PF lesions, Week 8-10 for large FC lesions
• For FC lesions, progress non-WB knee extension, 1lb/wk
• Continue stationary bicycle, low resistance (gradually increase time)
• Continue use of pool for gait training and exercise
Functional • As pain and swelling diminish, the patient may gradually increase functional activities
Activities • Gradually increase standing and walking
Criteria to 1. Full ROM
Progress to 2. SLR with no extensor lag
Next Phase 3. 10 repeated single leg step downs with good form and no reactive effusion or
exacerbation of symptoms
4. 10 repeated single leg knee bends with good form and no reactive effusion or
exacerbation of symptoms
5. Star Excursion Balance Test 20-30% of contralateral extremity with good form and no
reactive effusion or exacerbation of symptoms (see references)
6. Timed balance testing within 30% of contralateral extremity
7. Able to bike for 30 minutes without exacerbation of symptoms or reactive effusion


Phase III: Remodeling (Weeks 12-16)

Goals 1. Improve muscular strength and endurance

2. Increase functional activities

ROM • Patient should exhibit full flexion

Exercise • Leg press (0°-90°)

Program • Bilateral squats (0°-60°)
• Unilateral step-ups progressing from 5 to 20 cm
• Forward lunges
• Walking program week 10-12
• NWB extension
o FC lesions: Progress NWB extension (0°-90°)
o PF lesions: Begin NWB extension (90°-40°) or avoid lesion articulation
• Continue progressing balance and proprioception
• Bicycle
• Stairmaster
• Swimming
• Nordic-Track/elliptical
Functional • Increase walking (distance, cadence, incline, etc.)
Activities
Conditioning • Initiate at weeks 12-16
program • Bicycle: low resistance, increase time
• Progressive walking program
• Pool exercises for entire lower extremity
• Leg press
• Wall squats
• Hip strengthening (abduction/adduction)
• Front lunges
• Step-ups
• Stretch quadriceps, hamstrings, calf
Criteria to 1. Full non-painful ROM
Progress to 2. 20 repeated single leg step downs with good form and no reactive effusion or
Next Phase exacerbation of symptoms
3. 20 repeated single leg knee partial squat with good form and no reactive effusion or
exacerbation of symptoms
4. Star Excursion Balance Test 85-90% of contralateral extremity
5. Timed balance and/or stability within 85%-90% of contralateral extremity
6. No reactive pain, inflammation, or swelling with activities


Phase IV: Maturation Phase (Weeks 16-26)

Goals 1. Gradual return to full unrestricted functional activities

2. Single leg hop test within 75%-80% of contralateral extremity in order to progress to jogging
activities
3. 10 single leg hops with good form
4. All activities should be with good form and have no reactive pain, inflammation, or effusion
with exercises
Exercise • Impact loading program should be individualized to the patient’s needs
Program • Continue conditioning program progression 3-4 times per wk
• Progress resistance as tolerated
• NWB extension
o PF lesions: Add 1lb every 2 weeks beginning Week 20 if no pain or crepitus.
Perform from 90°-40° or avoid angle where lesion articulates. Must monitor
symptoms!
• Emphasis on entire lower extremity strength and flexibility
• Weeks 16-18 initiate PWB/aquatic plyometric and hopping activities
• Weeks 18-20 progress double and single leg hopping (e.g., hop downs from a small step,
double and single leg hops in place, quick hops front/back/side, etc.) as long as there is no
reactive pain, inflammation, or effusion – see impact guidelines below for progression of
activities
• Progress agility and balance drills
Functional • Patient may return to various sport activities as progression in rehabilitation and cartilage
Activities healing allows. (Be sure to communicate with surgeon.)
• Low-impact sports, such as swimming, skating, rollerblading, and cycling, are permitted at
o 2 months - small FC and PF lesions
o 3 months - large FC lesions
• Higher-impact sports such as jogging, running, and aerobics may be performed at:
o 4-5 months - small lesions
o 6 months - large lesions
• High-impact sports such as tennis, basketball, football and baseball are allowed at:
o 6-8 months - small lesions
o 9-12 months - large lesions
Goals to 1. Physician clearance
Return to 2. Symmetry with functional testing (3 single-leg cross-over hopping, etc.)
Sport 3. No reactive pain, inflammation, effusion, or instability with sport-specific activity

References
Andrews JR, Harrelson G, Wilk KE. Physical Rehabilitation of the Injured Athlete, 3rd Ed. Philadelphia, PA,
Saunders, 2004.

Gill T, Asnis, P, Berkson E. The Treatment of Articular Cartilage Defects using the Microfracture
Technique. J Orthop Sports Phys Ther. 2006;36(10):728-738.

Gillogly SD, Myers TH, Reinold MM. Treatment of Full-Thickness Chondral Defects in the Knee With
Autologous Chondrocyte Implantation. J Orthop Sports Phys Ther. 2006;36(10):751-764.

Hertel J, Braham RA, Hale SA, Olmsted-Kramer LC. Simplifying the Star Excursion Balance Test: Analyses
of Subjects with and without Chronic Ankle Instability. J Orthop Sports Phys Ther. 2006;36(3):131-7.

Kim HT, et al. A Peek Into the Possible Future of Management of Articular Cartilage Injuries: Gene
Therapy and Scaffolds for Cartilage Repair. J Orthop Sports Phys Ther. 2006;36(10):765-773.

Kinzey SJ, Armstrong CW. The Reliability of the Star-Excursion Test in Assessing Dynamic Balance. J
Orthop Sports Phys Ther. 1998;27(5):356-60.

Kreuz PC, et al. Importance of Sports in Cartilage Regeneration After Autologous Chondrocyte
Implantation: A Prospective Study With a 3-Year Follow-Up. The American Journal of Sports Medicine.
2007;10:1-8.

Lewis PG, et al. Basic Science and Treatment Options for Articular Cartilage Injuries. J Orthop Sports Phys
Ther. 2006;36(10):717-727.

Manske RC. Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder. St. Louis, MO, Mosby;
2006:383-407.

Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Progression Through the Return-to-Sport-Phase.
J Orthop Sports Phys Ther. 2006;36(2):385-402.
Reinold MM. Articular Defects in the Knee: Recent Advances and Future Optimism. J Orthop Sports Phys
Ther. 2006;36(10):715-716.

Reinold MM, et al. Current Concepts in the Rehabilitation Following Articular Cartilage Repair Procedures
in the Knee. J Orthop Sports Phys Ther. 2006;36(10):774-794.
Wilk KE, et al. Rehabilitation of Articular Lesions in the Athletes Knee. J Orthop Sports Phys Ther.
2006;36(10):815-827.

MEDIAL PATELLOFEMORAL LIGAMENT

RECONSTRUCTION CLINICAL PRACTICE
GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Background
The medial patellofemoral ligament (MPFL) is a ligament on the medial apsect of the knee which helps stabilize
the patella against lateral movement. This ligament may be injured in a patella dislocation. A MPFL reconstruction
surgery uses a ligament from somewhere else in the body to reconstruct this ligament stabilizing the patella.

Summary of Recommendations
Risk Factors • Patellar instability
• Altered mechanics with functional movement
• Bony morphology
• Quadriceps strength deficits

Corrective • Manual for patellar mobility and knee ROM

Interventions • Neuromuscular re-traning to improve LE strength and normalize mechancis
• NMES for quadriceps activation
• Sport-specific activity training
• Vasopneumatic device for edema control

Precautions • WBAT with crutches (until no extensor lag with SLR)

• Protected electrical stimulation program if warranted
• Patellar Glides/Mobilization: passive
• superior and medial glide only until 6 weeks
• NO LATERAL PATELLA GLIDES
• Avoid isolated hamstring strengthening if autograft used until 8 weeks

Outcome • Isometric testing at 10 weeks

Testing • Isokinetic Testing at 12 weeks
• Functional Test: Hop testing

Manual therapy • Patellar Mobilization: Passive superior glide and medial glide only until 6 weeks
• Knee extension/flexion PROM
• Scar massage
• Soft tissue mobilization as appropriate
Criteria for • Functional Test
discharge o Single leg and triple cross-over hop test for distance (within 15% of uninvolved limb)
• Isokinetic Testing
o ≤10% difference in isokinetic peak torque with knee extension and knee flexion (60º/sec,
and 300º/sec) between involved and uninvolved limbs
o Quadriceps to hamstring isokinetic strength ratio = 60%
• No signs of patellar instability with clinical testing.
• Complete sport-specific drills without compensatory movements, exacerbation of
symptoms or reactive effusion

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Phase I Weeks 0-2: Protection (Post-Operative 2 weeks)
Gait • WBAT with crutches
o Confirm with surgeon if WB status is not documented in the chart
• Gait training: focus on equal weight distribution bilaterally and normalization of gait
mechanics
o Begin ambulation with 2 crutches, then progress to 1 crutch then no support once gait
mechanics are normalized
o Evaluate for symmetrical joint loading during stance phase, heel strike with full knee
extension at initial contact, appropriate push-off at toe off
ROM • Begin passive, active-assisted, and active ROM as tolerated
• Biking: bike with ½ revolutions and progress to full revolutions per precautions
• No forced flexion beyond 90º with meniscal repairs
• Patellar mobilization
o Emphasis on superior and inferior mobility
o NO lateral mobilization
• Heel slides
• IT Band stretch and soft tissue mobilization
• Gastroc/Soleus Stretching in seated position
Strengthening • Quad sets
• Glute sets
• SLR in flexion, abduction
o Avoid extensor lag
o Neuromuscular Electrical Stimulation to quadriceps at 60°-90°
o Multi-angle knee extensor isometrics from 60º-90º are also appropriate for those
patients who cannot tolerate high-intensity neuromuscular electrical stimulation
Pain and • Ice/cryotherapy, compression, elevation to reduce post-operative effusion
Effusion
Goals to 1. Full active quadriceps contraction with superior patellar glide
progress to 2. Full passive knee extension
next phase 3. Effusion: ≤ 2+ (effusion can at least be swept out of medial sulcus)
4. SLR x 10 seconds without extensor lag
5. Patient is able to tolerate full WB without increased pain or 3+ effusion
6. Patient able to walk with assistive device, without obvious deviations on observation


Phase I Weeks 2-4: Protection (Days 14-28)
Gait • WBAT
• Gait training emphasizing avoidance of flexed or stiff-knee gait and normal push-off with
gastrocnemius/soleus complex to restore normal gait speed and cadence
ROM • Continue passive, active-assisted, and active ROM as tolerated
• Meniscal repairs: no forced flexion beyond 90º
• Towel stretching, prone hangs, ‘bag hangs’ to achieve and maintain knee extension
symmetrical to the contralateral limb
• Bike with NO resistance
• Patellar mobilization with emphasis on superior/inferior glides
• Begin light Quad and HAMSTRING stretching
Strengthening • Continue weeks 0-2
• Quad set progression (i.e. prone QS, supine, TKE)
• SLR in flexion, abduction, adduction, extension
• NMES at 60º knee flexion
• Initiate HAMSTRING activation exercises (heel slide, hamstring sets, bridges)
• Step-ups (2” starting height) progressed without increased pain and good technique
• Begin trunk and lumbopelvic strengthening
o Bridging, planks, pelvic tilts, teach abdominal bracing
• Shuttle/Leg Press (90º – 0º)
o bilateral to single-leg presses per patient tolerance and good mechanics/control
o increase resistance per patient tolerance
• Single leg stance
o Eyes open to eyes closed
o Progress to dynamic movements and/or unstable surface
• Heel/toe raises
• Squat correct in modified range
Goals to 1. Effusion: ≤ 2+
progress to 2. Patient is able to tolerate full WB without increased pain or effusion
next phase 3. Patient able to walk on level surfaces without assistive device and normal mechanics
4. Patient able to stand on single-leg at least 30 seconds without loss of balance


Phase II Weeks 4-6
ROM • Continue passive, active-assisted, and active ROM as tolerated
***Concerns with limited ROM should be communicated directly with surgeon***
• Continue patellar mobilization as needed
• Bike-light resistance
• Continue with quadriceps and hamstring flexibility
Strengthening • Continue NMES
• Weighted multi-angle SLRs
• Resistance exercises for gluteal strengthening
o Resisted side stepping, and backward walking, clamshells, reverse clamshells
• Progressive resistance quadriceps and hamstring exercises per patient tolerance
o Partial ROM lunges
• Progress WB/CKC (shuttle, aquatics, Total Gym, etc.) strengthening
• Squat progressions on stable and unstable surface with good mechanics
• NO JOGGING OR SINGLE-LEG PLYOMETRICS
Goals to 1. Patient is able to tolerate therapeutic exercise program without increased pain or effusion
progress to grade (≤1+)
next phase 2. Full, pain-free AROM is equal to contralateral limb (***CONTACT MD IF ABNORMAL***)
3. Normal patellofemoral mobility without apprehension
4. Patient demonstrates normal mechanics without pain during reciprocal stair ascent and
descent

Phase II Weeks 6-10

Strengthening/ • Progress WB strengthening exercises for quadriceps and hamstring
Dynamic o Lunges, shuttle, steamboats, sidestepping, leg press, squats, single leg Romanian
Control dead lifts (RDLs), etc.
• Step up and step downs (heel touch)
o Progress step height as tolerated by patient
• Begin sub-maximal leg extensions, 90º - 45º only
• Begin bilateral shuttle jumping = 50% body weight (shuttle, Total Gym, etc.)
o emphasizing symmetry in landing and take-off phases
• Work on endurance with low impact activities - Treadmill walking, stepper, elliptical
• Progress single leg balance activities
• Begin full weight landing mechanics if good mechanics on shuttle with visual cueing
o Double to single leg loading response
o Double leg jumping in place
• Week 8: Initiate isolated hamstrings strengthening per tolerance.
Goals to 1. Effusion ≤ 1+ (can be swept out of medial sulcus and returns only with lateral sweep)
progress to 2. Patient is able to tolerate therapeutic exercise program without increased pain or effusion
next phase grade
3. Maintain Full, pain-free AROM is equal to contralateral
4. Normal patellofemoral mobility
5. Patient demonstrates normal mechanics with CKC exercise and early jumping activities


Phase III Weeks 10-12
ROM • Continue with stretching and Bike
Strengthening/ • Full weight bearing (FWB) strengthening exercises
Dynamic • Strength progression from stable to unstable surface
Control/ • Progress full range open-chain knee extension exercises as tolerated without pain
Functional • Progress hamstrings strengthening as tolerated (i.e. Double leg hamstrings curls with
Activities physioball, resisted leg curls, etc.)
• Plyometric progression
o Squat jumps/ broad jumps initially at 50% effort for height/distance then progress when
correct technique is demonstrated
• Introduce single leg jumping and rotational activities and jogging with increasing resistance
• Initiate walk-jog progression
o Criteria to initiate jogging
• Full active knee extension
• Normal landing mechanics and single leg squat pattern
• Strength of involved limb is at least 80% of uninvolved limb
• Audible rhythmic strike patterns and no gross visual antalgic pattern
Goals to 1. Effusion ≤ 1+ (can be swept out of medial sulcus and returns only with lateral sweep)
progress to 2. Patient is able to tolerate therapeutic exercise program without increased pain or effusion
next phase grade
3. Maintain Full, pain-free AROM is equal to contralateral
4. Normal patellofemoral mobility
5. Patient demonstrates normal mechanics with all CKC exercise and early jumping activities


Phase IV: Return to Sport/Activity Weeks 12-16
ROM • Maintain ROM equal to uninvolved limb
Strengthening • Emphasize performance of the quadriceps, hamstrings and trunk dynamic stability
• Emphasize muscle power generation and absorption
• Focus on activities that challenge muscle demand in intensity, frequency, and duration of
activity
• Emphasize sport- and position-specific activities
Consider Examples
• Double leg and single leg activities and • Weight lifting: squats, leg extension, leg
transitions curl, leg press, deadlifts
• Vary planes of movement and change of • Lunges-forward, backward, rotational, side
direction • Rotational trunk exercises on static and
• Perturbations and alter support surface dynamic surfaces
(indoor and outdoor) • Unilateral shuttle jumping with increasing
• Challenge multiple muscle groups (lower resistance and mid-air rotations
extremity and core) simultaneously
Return to • Emphasize appropriate symmetry in weight-bearing, joint loading and technique during
Sport performance of all therapeutic activities and plyometrics
Activities • Emphasize sport- and position-specific activities
• Add ball, racquet, stick

Consider: Examples:
• Impact loading and appropriate • Single-leg hop downs from increasing
attenuation strategy, cue regarding height (up to 12” box)
“hard” landings • Single-leg hop-holds (stable surface
• Double leg and single leg activities and ..Airex pad)
transitions • Double and single-leg hopping onto
• Vary planes of movement and change of unstable surface (i.e. Airex pad)
direction • Tuck jumps (focus on increasing multi-
joint flexion during landing and holding
stable position)
• 90º to 180º jumps
• Begin agility exercises between 50-75% (utilize visual feedback to improve mechanics)
o Side shuffling o Figure 8 o Resisted jogging (Sports
o Hopping o Zig-zags Cord) in straight planes, etc
o Carioca o Back pedaling
Goals to • Functional Test
progress to o Single leg and triple cross-over hop test for distance (within 15% of uninvolved limb)
Independent • Isokinetic Testing
Program o ≤10% deficit in isokinetic peak torque with knee extension and knee flexion (60º/sec,
and 300º/sec) compared to uninvolved limb
o Quadriceps to hamstring isokinetic strength ratio = 60%
• Complete sport-specific drills without compensatory movements, exacerbation of
symptoms or reactive effusion

Authors: Adam Ingle PT, DPT, Chelseana Davis, PT, DPT

Reviewers: John DeWitt, PT, DPT, SCS, ATC
Completion date: 4/8/15

MENISCAL REPAIR WITH WEIGHT RESTRICTIONS

CLINICAL PRACTICE GUIDELINES
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Precautions
• Weight bearing as tolerated (Dr. Kaeding)
• Non-weight bearing without bracing for 4 weeks post-op (Dr. Jones, Dr. Flanigan)
• No weight bearing flexion beyond 90o for eight weeks
• No resistive hamstring exercises for 8 weeks
• Isotonic Strengthening
o 40-90º open-chained to avoid patellofemoral irritation
o < 90º closed-chained to avoid patellofemoral irritation
• All progression based on soft tissue healing

Weeks 1- 4
ROM • Begin ROM progression from active-assisted to active (no force flexion beyond
90º)
• Patellar mobilization
• Edema control
• Exercise bike: Half revolutions
Strengthening • Neuromuscular re-ed with stim and/or biofeedback (if warranted)
• Initiate NWB strengthening if weight restrictions in place
o Modify ROM (See above)
o Quad Set
o SLR
• Initiate both WB and NWB strengthening if weight bearing as tolerated
o Modify ROM (See above)
o Quad Set, TKE, etc
o SLR
o Balance exercise
• Partial WB Shuttle/Leg Press
Goals to 1. Good quad set
Progress to 2. ROM 0-90º
Next Phase 3. Little to no extension lag with SLR
4. Minimal to no edema

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.



Weeks 4-6
Progress partial to full weight bearing by week 6
• Discontinue crutches appropriately per normalization of gait
Advance exercise if already weight-bearing per soft tissue healing

ROM • Continue as before (no forced flexion beyond 90º)

• Full exercise bike revolutions for ROM and endurance

Strength • Progress partial to full weight bearing by Week 6

• Begin seated BAPS and heel/toe raises
• Partial to FWB shuttle/Total Gym/aquatics strengthening
o Bilateral LE progression to single LE strengthening
• Trunk and lumbosacral strengthening
Goals to 1. No antalgic gait without use of assistive devise
Progress to 2. Good quad set
Next Phase 3. Able to stand on single-leg
4. No exacerbation with PWB strengthening

Weeks 6-8
ROM • Continues with emphasis on terminal extension and pain-free flexion
• Exercise bike for endurance

Strengthening • Begin FWB strengthening < 90 o and progress as tolerated

• Progress NWB and WB strengthening/stability/balance/proprioception
exercises
o Lunges, steamboats, side-stepping, leg press, modified leg extensions
• Progress shuttle/Total Gym/Aquatics strengthening
• Continue to progress lumbosacral strengthening

Goals to 1. Increased strength/stability/proprioception with therapeutic exercise and

Progress to without exacerbation of symptoms
Next Phase 2. No reactive instability or effusion with WB activity

Weeks 8-10
ROM • Continue with exercise bike and stretching

Strengthening • Begin PWB shuttle plyometrics

o Shuttle jogging
o Progress from bilateral to single LE
o Progress from straight plane to rotational movements
• Initiate isolated hamstring strengthening per tolerance
• Progress LE and trunk strength and stability exercises
• Hop downs
• Emphasis on appropriate mechanics
Goals to 1. Increased strength/stability/proprioception with therapeutic exercise without
Progress to exacerbation of symptoms
Next Phase 2. No reactive instability or effusion with WB activity

Weeks 10-12
ROM • Continue and progress WB and NWB strengthening
• Full weight bearing plyometrics
o Bilateral
o Shuttle
o Rotational and single leg jumping
• Initiate walk-jog progression
o Criteria to initiate jogging
§ ≥ 7 /10 on #10 IKDC Questionnaire (Appendix A)
§ Complete single leg hop-downs without medial/lateral knee
displacement
§ Normalized ROM
§ Audible rhythmic strike patterns and no gross visual antalgia
Goals to 1. ≥ 7 /10 on #10 IKDC Questionnaire - Appendix A
Progress to 2. Complete plyometric and jogging activity without pain and/or dynamic
Next Phase instability
3. No reactive effusion
4. ROM 0-135º

Weeks 12- 16
ROM • Continue per tolerance and pre-exercise warm-up

Strengthening • Full weight bearing plyometrics

o Progress from straight-plane to diagonal/rotation exercise
• Continue jogging progression
• Strength progression stable to unstable surface
o Emphasis on quad, hamstring and trunk dynamic stability
• Shuttle/aquatics/Total Gym, etc.
o Progress rotational and single leg jumping
• Begin agility exercises between 50-75% (utilize visual feedback to improve
mechanics)
o Side shuffling
o Hopping
o Carioca
o Figure 8
o Zig-Zag
o Resisted jogging (Sports Cord) in straight planes
Goals to Functional Test
Progress to • 3 cross-over hop test for distance (within 15% of uninvolved limb) -
Next Phase Appendix A
Isokinetic Testing
• Contact Ohio State Sports Medicine to schedule test @ 4 months post-op if
your clinic does have isokinetic equipment or with questions
• Side to side symmetry isokinetic peak torque with knee extension and knee
flexion (within15% at 60º/sec, 180º/sec and 300º/sec)
• Quad to Hamstring isokinetic strength ratio ≥ 60%
Complete sport specific drills without exacerbation of symptoms or reactive
instability

Month 4-6: Sports Specific Training

This sports specific phase should transition from the rehab specialist in the clinic to athletic trainer
in the field as appropriate
Strengthening • Emphasis on quad, hamstring and trunk dynamic stability
• Continue sport-specific agility exercises (utilize visual feedback to improve
mechanics) – See above
o Progress gradually to 100% per tolerance
o Emphasis on power and change of direction
o Utilize both indoor and outdoor surfaces
Goals to 1. Physician clearance at 6 month check up
return to sport 2. Symmetry with functional testing (3 single-leg cross-over, etc)
3. No reactive effusion or instability with sport-specific activity

Appendix A: IKDC Questionnaire

“How would you rank the function of your knee on the scale of 0 to 10 with 10 being normal, excellent function
and 0 being the inability to perform an of your usual daily activities which may include sports?”

FUNCTION PRIOR TO YOUR KNEE INJURY

0 1 2 3 4 5 6 7 8 9 10
Couldn’t perform No limitation in
daily activities daily activities

CURRENT FUNCTION OF YOUR KNEE

0 1 2 3 4 5 6 7 8 9 10
Couldn’t No limitation in
perform daily activities
daily activities

Functional tests
1. Single hop for distance: Have the subject line their heel up with the zero mark of the tape measure,
wearing athletic shoes. The subject then hops as far as he can, landing on the same push off leg, for at
least 3 seconds. The arms are allowed to move freely during the testing. Allow him to perform 4 practice
hops on each leg. Then, have the subject perform 4 trials, recording each distance from the starting point
to the back of the heel. Average the distances for each limb.

2. Cross-over hop for distance: This test is set up with a 15cm strip, extending 6 meters. The subject lines
his heel up at the zero mark of the tape measure and hops 3 times on one foot, crossing over the center
line each time. Each subject should hop as far forward as he can on each hop, but only the total distance
hopped is recorded Allow the subject to perform 4 practice rounds before recording. Average the
distances for each limb.

Scoring

• Begin with the uninvolved leg. If using tape to mark distance, remove it before the next trial to
minimize visual cues.
• Greater than a 15% difference in average distance between the right and left limbs should be cause
for concern, indicating quad, and hamstring weaknesses that should be addressed prior to return to
sport.
• If patient fails test, evaluate and implement appropriate strength/stability/balance exercise strategies.
Once resolved, test again.


References
Brindle T, Nyland J, Johnson DL The Meniscus: Review of Basic Principles with Application to Surgery and
Rehabilitation. J of Ath Train June 2001 32(2)

Chang HC, Nyland J, Caborn AN, Burden R: Biomedical Evaluation of Menical Repair Systems. Am J Sports
Med2005;33: 1846-1852

Andrews JR, Harrelson G, Wilk KE (2004):Physical Rehabilitation of the Injured Athlete, 3rd Ed. Philadelphia, PA,
Saunders.

Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE; Progression through the return-to-sport-phase, J
Orthop Sports Phys Ther, 2006;36(2): 385-402.

Hewett TE. Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the
knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med.
2005;33: 492-501.

English R, Brannock M, Chik WT, Eastwood LS, Uhl T. The relationship between lower extremity isokinetic work
and single-leg functional hop-work test. J Sport Rehabil. 2006; 15 95-104

Bolgla LA, Keskula DR. Reliability of lower extremity functional performance tests. J Orthop Sports Phys Ther.
1997; 26 (3): 138-142

ADVANCED MENISCAL REPAIR
CLINICAL PRACTICE GUIDELINE
CONSIDERATIONS FOR RADIAL, ROOT AND HORIZONTAL CLEAVAGE REPAIRS

Background
Meniscal root/radial tears present in a variety of forms, ranging from partial to complete avulsion. Root
and radial tears can have a profound effect on the health of the articular cartilage of the knee with the
potential for meniscal extrusion and accelerated arthritic degeneration if left untreated. Horizontal
cleavage tears can result in advanced degeneration of the meniscus tissue and underlying cartilage,
especially during high-impact activity. The listed clinical practice recommendations are more conservative
than traditional meniscus repair protocols due to the complexity of the surgical technique. The direct
attachment of the hamstring and popliteus tendons to the menisci requires limited knee flexor active
contraction during the protection phase of recovery for the meniscus root/radial repair. Additional
protection of these repairs requires extended non-weight bearing precautions and special consideration of
CKC knee flexion due to biomechanical stresses of healing tissues.

As surgical techniques continue to be refined, the literature regarding protocols throughout the
rehabilitation continuum of care are lacking. The listed clinical practice guideline is based on anatomical,
biomechanical and surgical principles with criterion-based progressions.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and
clinician evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.
Summary of Recommendations
Meniscal Root Illustrations of the meniscal root tear
Classification classification system in 5 different
System groups based on tear morphology. All
meniscal tears are shown as medial
meniscal posterior root tears for
consistency in this illustration. The 5
tear patterns were classified based on
morphology; partial stable root tear
(type 1), complete radial tear within
9mm from the bony root attachment
(type 2), bucket-handle tear with
complete root detachment (type 3),
complex oblique or longitudinal tear with
complete root detachment (type 4), and
bony avulsion of the root attachment
(type 5). LaPrade et al 2015

Meniscal Studies report CKC loading to medial and lateral posterior horns:
Loading • 4x more pressure at 90° than 0°
• Significant pressure increase from 30° to 60°
• Unlikely to stress roots in a safe CKC progression from 0° to 45°
Mueller et al 2016

Weight Weeks 0-6:

Bearing • NWB
Precautions • Brace- Total range of motion (TROM) locked in knee extension for 4-6 weeks
Weeks 7-12
• Progressive weightbearing (WB) with goal of full WB by 8-9 weeks
• Closed kinetic Chain (CKC) WB knee flexion less than 40 degrees until weeks 7-9
• CKC WB knee flexion <70° until weeks 10-15
Week 12-21
• Until week 20, maximum of 90° CKC WB knee flexion
Weeks 22+
• Until 6 months, no deep squatting >90° of knee flexion

Hamstring • No isometric hamstrings activity x 7 WEEKS

Precautions • No isotonic isolated hamstring interventions x12 WEEKS
(Root/Radial
Repair ONLY) *No hamstring precautions for horizontal cleavage repairs (HCT)*

Outcome Collect at least one of the following at initial evaluation, every 6 weeks and discharge. Be
Tools consistent with which outcome tool is collected each time.
1. IKDC
2. Tegner Activity Level
3. Lyshome Knee Score

Strength 1. Isometric testing

Testing • HCT: 3 months
• Root/Radial Repairs: 4 months
2. Isokinetic testing
• HCT: 4 months
• Root/Radial: 6 months
 *Isokinetic testing only warranted if patient’s goal is to return to sport*
• Many of these patients will be older with a goal of return to low-impact activity (ie- IADLS,
recreational walking, biking)

Criteria to *NWBi x 6 WEEKS, Full Wg with no assisted device (AD) by week 8-9
Discharge 1. ROM: Full active knee extension; no pain on passive overpressure
Assistive 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar
Device glide and able to perform 2x10 SLR without quad lag
3. Effusion: 1+ or less is preferred
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation for 3
minutes at self-selected speed

Criteria to 1. ROM: full, pain-free knee ROM, symmetrical with the uninvolved limb
Initiate 2. Strength: Isokinetic testing 80% or greater for hamstring and quad at 60º/sec and
Running and 300º/sec
Jumping 3. Effusion: 1+ or less
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular Control: Pain-free hopping in place

Criteria for 1. ROM: full, painfree knee ROM, symmetrical with the uninvolved limb
Return to 2. Strength: Isokinetic testing 90% or greater for hamstring and quad at 60º/sec and
Sport 300º/sec
3. Effusion: No reactive effusion ≥ 1+ with sport-specific activity
4. Weight Bearing: normalized gait and jogging mechanics
5. Neuromuscular control: appropriate mechanics and force attenuation strategies with
high level agility, plyometrics, and high impact movements
6. Functional Testing:
o Vail Sports Test, >46/54
o Anterior reach on Y-Balance test, <5cm difference
o Y Balance composite score, >94%
o Modified Agility T Test, >90% of uninvolved
o Single-leg hop series, >90% of uninvolved
7. Physician Clearance
Phase 1 (Weeks 0-6): Protection, ROM, Muscle Activation
Goals 1. Protect surgical repair
2. Resolve joint effusion to 1+ or less
3. Restore full ROM

Precautions 1. NWB
2. PROM: 0-90 degrees for 2 weeks
3. Progress ROM as tolerated thereafter
4. No isolated hamstrings activation for radial/root repairs

Pain and ≥ 1+ (using Modified Stroke Test)

Effusion

ROM Extension: Emphasis on achieving full knee extension immediately following surgery. If
full extension is not achieved by 4 weeks, contact surgeon regarding ROM concerns.
Flexion:
• Root/Radial Only: Limited to PROM due to hamstring/popliteus attachment to
meniscus
• Limited 0-90 degrees for first 2 weeks
• After 2 weeks, gentle full PROM is allowed

Therapeutic 1. Emphasis on quad activation without gluteal co-contraction

Exercise 2. Restore patellar mobility
3. Symmetrical ROM
4. Decrease effusion

Suggested • Extension ROM: bag hangs or prone

Interventions hangs
• Flexion ROM (Root/radial only): Supine
wall slides with PROM with self-monitoring
for hamstring activation (see photo below)
• Patellar mobilization: superior, inferior,
medial, lateral
• Quad Isometrics; SLR 4-way
• Terminal knee extension (TKE): prone
• Initiate open chain knee extension
exercises
o Unweighted SAQ, LAQ
• Protected range with isotonic progression
• Neuromuscular re-education using
electrical stimulation (NMES) at 60º knee
flexion
Mueller et al 2016

NMES • NMES pads are placed on the proximal and distal quadriceps
Parameters • Patient: Seated with the knee in at least 60º flexion, shank secured with strap and
back support with thigh strap preferred. The ankle pad/belt should be two finger
widths superior to the lateral malleoli
• The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction against a fixed resistance OR maximal tolerable amperage
without knee joint pain
• 10-20 seconds on/ 50 seconds off x 15 min Frequency= 75pps. Pulse Width= 400
microseconds.
Criteria to 1. ROM: Full active knee extension; no pain on passive overpressure
Discharge 2. Strength: Able to perform strong quad isometric with full tetany and superior patellar
Assistive glide and able to perform 2x10 SLR without quad lag
Device 3. Effusion: 1+ or less is preferred (2+ acceptable if all other criteria are met)
4. Weight Bearing: Demonstrates pain-free ambulation without visible gait deviation

Criteria to 1. ROM: Symmetrical to uninvolved limb

Progress to 2. Strength: Quadriceps set with normal superior patellar translation, SLR x 10 seconds
Phase 2 without extensor lag
3. Effusion: 1+ or less with Modified stroke test

Phase 2 (7- 9 weeks): Weight Bearing Tolerance

Precautions 1. Gradual progression of WB to full WB with no AD by weeks 8-9
2. Knee flexion <40 degrees with CKC activity
3. CKC activity limited to WBstatus

Pain and Cryotherapy/compression as needed for reactive effusion.

Effusion

ROM • Monitor and progress knee ROM, patellar mobility, and LE flexibility
• Begin more aggressive techniques to achieve/maintain full knee extension (i.e.
weighted bag hang) as needed
• Continue bike for ROM and warmup
• If full AROM knee extension is not achieved by 4 weeks, contact surgeon
regarding ROM concerns.

Suggested • Multi-angle knee isometrics from 60-90⁰ for patients unable to tolerate high-
Interventions intensity NMES
and timelines • Progress WB quadriceps and hamstring exercises with emphasis on proper LE
mechanics
o Root/Radial Repairs: no isometric HS activity until 8 weeks, no isolated
hamstring isotonics until 12 weeks
• Progress gluteal and lumbopelvic strength and stability
• Progress single leg balance
• NMES (see parameters in week 0-6)

Criteria to 1. Achieve full WBing

Progress to 2. Normalize gait pattern on flat ground
Phase 3 3. Maintain trace to zero joint effusion
4. Tolerate 25 minutes or standing and walking activity
Phase 3 (weeks 10-15): Endurance
Precautions Knee flexion <70 degrees with CKC activity

Pain and Effusion may increase with increased activity, ≤1+ and/or non-reactive effusion for
Effusion progression of endurance activities

ROM Full, symmetrical to contralateral limb, and pain free with overpressure

Therapeutic Performance of the quadriceps, hamstrings and trunk dynamic stability with low load,
Exercise high repetitions

Suggested Therapeutic Exercise/Neuromuscular Re-education

Interventions • Double-leg squats (<70 degrees)
• Stationary lunges progressing to walking lunges
• Step down- starting at 2” step and progressing to 6”
Cardiovascular Conditioning: permitted week 12
• Stationary bike with resistance
• Treadmill walking
• Freestyle swimming (no fins until week 16)

Criteria to d/c <20% quadriceps deficit on isometric testing

NMES OR- If a Biodex machine in not available:
1. 10 SLR without quad lag
2. Normal gait

Criteria to 90 second hold in single leg squat position at 45 degrees of knee flexion
Progress to
Phase 3

Phase 4 (weeks 16-21): Strength

Precautions Until week 20, maximum of 90 degrees of knee flexion with CKC activity

Pain and Effusion may increase with increased activity, ≤1+ and/or non-reactive effusion
Effusion

ROM Full, symmetrical to contralateral limb, and pain-free with overpressure

Therapeutic Performance of the quadriceps, hamstrings and trunk dynamic stability with high
Exercise resistance, low repetitions

Suggested Therapeutic Exercise/Neuromuscular Re-education

Interventions • Single-leg squats
• Single-leg deadlifts
• Single-leg sit to stand
• Multi-directional lunges

Criteria to • Quadriceps index >80% (isokinetic testing)

Progress to • Anterior reach on Y balance test, <8-cm difference compared to uninvolved side
Phase 5
Phase 5 (weeks 22-Return to Sport (RTS)): Power, Running and
Return to Sport
Precautions • No deep squatting for 6 months
• Expected RTS by 9 months

Pain and Effusion Effusion may increase with increased activity, ≤1+ and/or non-reactive effusion
for progression of plyometrics

ROM Full, symmetrical to contralateral limb, and pain-free with overpressure

Therapeutic Performance of the quadriceps, hamstrings and trunk dynamic stability with
Exercise sports-specific activity

Suggested Therapeutic Exercise/Neuromuscular Re-education

Interventions • Double and single leg jump training
• Ladder drill agility
• Lateral hops with and without resistance
• Progressive cutting activities

Criteria to 1. Pass Vail Sport Test, >46/54

Progress to RTS 2. Anterior reach on Y balance test, <5 cm difference
3. Y balance test composite scores, >94
4. Quadriceps index >90% (isokinetic)
5. Modified Agility T Test >90% of contralateral limb
6. Single-leg hop series >90% LSI
• SL hop for distance
• Triple hop
• Cross over hop
• Timed 6m hop
Authors: Caroline Lewis, PT, DPT, SCS and Josh Pintar, PT, DPT, SCS

References
Arno S, Bell CP, Uquillas C, Borukhov I, Walker PS. “Tibiofemoral Contact Mechanics Following a
Horizontal Cleavage Lesion in the Posterior Horn of the Medial Meniscus.” J Orthop Res. 2015; 33(4):
584-590.
Becker R, Wirz D, Wolf C, Göpfert B, Nebelung W, Friederich N. “Measurement of meniscofemoral
contact pressure after repair of bucket-handle tears with biodegradable implants.” Arch Orthop Trauma
Surg. 2005;125:254-260. http://dx.doi. org/10.1007/s00402-004-0739-5.
Bhatia S, LaPrade CM, Ellman MB, LaPrade RF. “Meniscal Root Tears: Significance, Diagnosis and
Treatment.” Am J Sports Med. 2014; 42(12): 3016-3030.
Chung KS, Ha JK, Ra HJ, Kim JG. “A Menta-Analysis of Clinical and Radiographic Outcomes of Posterior
Horn Medial Meniscus Root Repairs.” Knee Surg sports Traumatol Arthrosc. 2016; 24: 1455-1468.
Frizziero A, Ferrari R, Giannotti E, Ferroni C, Poli P, Masiero S. “The meniscus tear: state of the art of
rehabilitation protocols related to surgical procedures.” Muscles, Ligaments and Tendons Journal.
2012;2(4):295-301.
Kurzweil PR, Lynch NM, Coleman S, Kearney B. “Repair of Horizontal Meniscus Tears: A Systematic
Review.” Arthroscopy. 2014; 30(11): 1513-1519.
LaPrade CM, et al. “Meniscal Root Tears: A Classification System Based on Tear Morphology.” Am J
Sports Med. 2015; 43(2): 363-369.
LaParade CM, et al. “Biomechanical Consequences of a Nonanatomic Posterior Medial Meniscus Root
Repair.” Am J Sports Med. 2015; 43(4): 912-920.
Lavender CD, Hanzlik SR, Caldwell PE, Pearson SE. “Transosseous Medial Meniscal Root Repair Using
a Modified Mason-Allen Suture Configuration.” Arthroscopy Techniques. 2015; 4(6): e781-e784.
Mueller BT, Moulton SG, O'Brien L, LaPrade RF. “Rehabilitation Following Meniscal Root Repair: A
Clinical Commentary.” J Orthop Sports Phys Ther. 2016; Feb;46(2):104-13.
Chimera NJ, Warren M. Use of clinical movement screening tests to predict injury in sport. World Journal
of Orthopedics. 2016; 7(4):202-217
Myer GD, Schmitt LC, Brent JL, et al. Utilization of Modified NFL Combine Testing to Identify Functional
Deficits in Athletes Following ACL Reconstruction. The Journal of orthopedic and sports physical therapy.
2011:41(6):377-387
Garrison JC, Shanley E, Thigpen C, et al. The reliability of the Vail Sport Test as a measure of physical
performance following anterior cruciate ligament recontruction. Int J Sports Phys Ther. 2012; 7(1):20-30.
Appendix A: Vail Sports Test

Total Points: _____/54 (Patient must score 46/54 on the test in order to pass)

Single Leg Squat (Goal: 3 minutes): subject must perform each repetition at a cadence of 1 second up
and 1 second down against resistance of a sportcord (placed under the foot of the leg that the test is
being performed on).
Yes (1) No (0) Minute 1 Minute 2 Minute 3

1. Knee flexion angle between 30° and 60°

2. Patient performs repetitions without dynamic knee valgus
3. Patient avoids locking knee during extension
4. Patient avoids patella extending past the toe during knee flexion
5. Patient maintains upright trunk during knee flexion

Single Leg Squat Total Points _____/15

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 1-minute timeframe).

Lateral Bounding (Goal: 90 seconds): subject performs a lateral hopping motion against resistance of a
sportcord attached to the subject’s waist via a belt and on the other end to an immoveable object that is
level with the waist. The injured leg is positioned as the inside leg or the leg closest to the wall. The
patient is instructed to hop from one leg to the other (leg length distance), absorbing energy while they
land by bending at the knee and hip. Landing boundaries (distance of the hop) are demarcated on the
floor with two pieces of tape, one of which begins at the point of resistance of the sportcord as it is
stretched away from the wall and the other is the measured distance of the subject’s leg length from the
first piece of tape.
st nd rd
Yes (1) No (0) 1 30 2 30 3 30
seconds seconds seconds

1. Knee flexion angle is 30° or greater during landing

2. Patient performs repetitions without dynamic knee valgus
3. Patient performs repetitions within landing boundaries
4. Landing phase does not exceed 1 second in duration
5. Patient maintains upright trunk during knee flexion

Lateral Bounding Total Points _____/15

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 30 second timeframe).
Forward Jogging (Goal: 2 minutes): subject performs forward jogging against resistance of the sportcord
with the belt around waist. The patient is instructed to hop from one leg to the other in an up and down
manner (similar to jogging in place) while using proper form and absorbing energy with each landing by
bending at the knee and hip.
Yes (1) No (0) Minute 1 Minute 2

6. Knee flexion between 30° and 60°

7. Patient performs repetitions without dynamic knee valgus
8. Patient performs repetitions within landing boundaries
9. Patient avoids locked knee during extension
10. Landing phase does not exceed 1 second in duration
11. Patient maintains upright trunk during knee flexion

Forward Jogging Total Points _____/12

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 1-minute timeframe).

Backward Jogging (goal: 2 minutes): subject performs backward jogging against resistance of the
sportcord with the belt around waist. The patient is instructed to hop from one leg to the other in an up
and down manner (similar to jogging in place) while using proper form and absorbing energy with each
landing by bending at the knee and hip.
Yes (1) No (0) Minute 1 Minute 2

12. Knee flexion between 30° and 60°

13. Patient performs repetitions without dynamic knee valgus
14. Patient performs repetitions within landing boundaries
15. Patient avoids locked knee during extension
16. Landing phase does not exceed 1 second in duration
17. Patient maintains upright trunk during knee flexion

Backward Jogging Total Points _____/12

If patient repeats error on 3 consecutive repetitions after correction, they are not eligible to receive a point
for that particular standard (within each 1-minute timeframe).
Appendix B: Y Balance Test
___________ ___________
Anterior Anterior

Stance LEFT Stance RIGHT

Posterolateral Posteromedial Posterolateral Posteromedial

____________ ____________ ____________ ____________

Left Right Difference

Anterior
Posteromedial
Posterolateral
Difference should be less than 4 cm for return to sport and preparticipation screening.

(Anterior + Posteromedial + Posterolateral)

Composite Score = x 100
(3 x Limb Length)

Right
Left
Appendix C: Modified Agility T-Test

The modified agility T-test was developed from the standard T-test to evaluate lower extremity side-to-
side differences in cutting and running maneuvers. The participant is initially guided through the course by
the test administrator, who emphasizes the importance of performing a shuffling movement and not
running or using crossover steps during the lateral movement portions of the test. Participant will
performs test the test to each direction after adequate rest (2min). The total time is compared between
each limb, the shuffle push-off limb determines involved or uninvolved limb.

Involved Time: _____________

Uninvolved Time: ___________
Appendix D: Single Leg Hop Series
1) Single hop for distance: Have the subject line their heel up with the zero mark of the tape
measure, wearing athletic shoes. The subject then hops as far as he/she can, landing on the
same push off leg, for at least 3 seconds. The arms are allowed to move freely during the testing.
Allow him/her to perform 2 practice hops on each leg. Then, have the subject perform 2 testing
trial, recording each distance from the starting point to the back of the heel. Average the
distanced hopped for each limb. The Limb Symmetry Index: Involved limb distance/Uninvolved
limb distance X 100%.
2) Cross-over hop for distance: The subject lines their heel up with the zero mark of the tape
measure and hops 3 times on one foot, crossing fully over the center line each time. Each subject
should hop as far forward as he/she can on each hop, but only the total distance hopped is
recorded. The arms are allowed to move freely during the testing. Allow him/her to perform 2
practice hops on each leg. Then, have the subject perform 2 testing trial, recording each distance
from the starting point to the back of the heel. Average the distanced hopped for each limb. The
Limb Symmetry Index: Involved limb distance/Uninvolved limb distance X 100%.
3) Triple hop for distance: The subject lines their heel up with the zero mark of the tape measure
and hops 3 times on one foot. Each subject should hop as far forward as he/she can on each
hop, but only the total distance hopped is recorded. The arms are allowed to move freely during
the testing. Allow him/her to perform 2 practice hops on each leg. Then, have the subject perform
2 testing trial, recording each distance from the starting point to the back of the heel. Average the
distanced hopped for each limb. The Limb Symmetry Index: Involved limb distance/Uninvolved
limb distance X 100%.
4) Timed 6-meter hop: The subject lines their heel up at the zero mark of the tape measure and
hops, on cue with the tester, as fast as they can the length of the 6-meter tape. The arms are
allowed to move freely during the testing. Allow him/her to perform 2 practice hops on each leg.
Then, have the subject perform 2 testing trial, recording each distance from the starting point to
the back of the heel. Average the distanced hopped for each limb. The Limb Symmetry Index:
Involved limb time/Uninvolved limb time X 100%.


MEDIAL PATELLOFEMORAL LIGAMENT

RECONSTRUCTION-FULKERSON PROCEDURE
CLINICAL PRACTICE GUIDELINE
Rehabilitation Precautions: All restrictions and/or precautions will be set by the referring surgeon, based upon
the stability of the repair and procedure performed. All precautions are subject to change per physician.

General Precautions
• WBAT in immobilizer first 4 weeks (and/or until no quad lag) May unlock with sitting
• Perform protected electrical stimulation program if warranted
• Patella Mobilizations: Passive superior glide and lateral to medial glide only until 6 wk
• No isolated hamstring strengthening if autograft used
• No OKC quadriceps strengthening for 6 weeks
Considerations:
• Edema/swelling control
• Scar massage
• Ankle, core, hip abduction and external rotation strength
• IT-Band stretch for tight lateral retinaculum
• Evaluate for excessive pronation of feet
• Patella taping only to exercise without pain ( if needed)
• Hamstring/gastroc stretches

Post-Operative-2 weeks
Gait • WBAT locked in extension at 0 degrees @4 weeks
ROM • Patella Glides Superior and medial
• No lateral patella glide
• 0-60 degrees AAROM only
• Heel slides (0-60 degrees) AAROM
• IT-Band stretch and soft tissue work
Strengthening • Quad sets
• Glute Sets
• SLR in Flexion, Abduction (Use brace if extensor lag in flexion)
• NMES to quad
Goals to 1. Full active quadriceps contraction with superior patellar glide
progress to 2. Full passive knee extension
next phase 3. WBAT in immobilizer (use crutches until safe without)

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Weeks 2-4
Gait • WBAT locked in extension at 0 degrees (0-4 weeks)
ROM • 0-90 degrees AAROM/AROM
• Bike with NO Resistance
• Patella mobs with emphasis on superior/inferior glides
Strengthening • Continue weeks 0-2
• Quad set progression (i.e. prone QS, supine, TKE)
• SLR flexion, abduction, adduction, extension (in brace if quad lag)
• NMES to quad
Goals To 1. ROM to equal 0-90 degrees
Progress to
Next Phase

Weeks 4-6
Gait • Hinged brace max 90 degrees flex with WBAT—Normalize gait
ROM • 0-120 degrees AROM
• Patella Mobs
Strengthening • Bike-light resistance
• Closed-chain ex (TKE, calf press, lateral step ups, side-stepping, etc.)
o Wall squats/partial leg press (0-60 degrees)
Aerobic • Treadmill (walking progress with speed and incline-6 weeks post op)

Weeks 6-10
Gait • Discharge brace if no quad lag and normal gait

Strengthening/ • Begin mild to moderate resistive quad exercise in protected range

Dynamic • Initiate proprioception/coordination/stability
Control • Forward plyometrics
• Hamstring PRE’s (week 8)

Weeks 10-16
Strengthening/ • Progress OKC and CKC quad strengthening
Dynamic • Progress core and hip strengthening
Control/ • Functional agilities-progressing to sport specific drills
Functional • Initiate walk to jog progression (when quadriceps index ≥ 80%, ROM is full, and pt is ≥ 12
Activities weeks post op) if:
o Full active knee extension
o Normal landing mechanics
o Strength to 80% of uninvolved side

Goals to 1. No reactive effusion or instability with sport-specific exercise

Progress to 2. Good strength with functional and isokinetic testing (Within 15% of uninvolved side)
Next Phase 3. Achieve MCID on patient self-report (LEFS, IKDC, etc.)

Week 16
ROM • Maintain ROM equal to uninvolved

Strengthening • Emphasize performance of the quadriceps, hamstrings and trunk dynamic stability
• Emphasize muscle power generation and absorption
• Focus on activities that challenge muscle demand in intensity, frequency, and duration of
activity
• Emphasize sport- and position-specific activities
• Consider:
o Double leg and single leg activities and transitions
o Vary planes of movement and change of direction
o Perturbations and alter support surface (indoor and outdoor)
o Challenge multiple muscle groups (lower extremity and core) simultaneously
• Examples:
o Weight lifting: squats, leg extension, leg curl, leg press, deadlifts
o Lunges-forward, backward, rotational, side
o Rotational trunk exercises on static and dynamic surfaces
o Unilateral shuttle jumping with increasing resistance and mid-air rotations
Return to Sport • Emphasize appropriate symmetry in weight-bearing, joint loading and technique during
Activities performance of all therapeutic activities and plyometrics.
• Emphasize sport- and position-specific activities
o Add ball, racquet, stick

Consider
o Impact loading and appropriate
attenuation strategy, cue regarding
“hard” landings
o Double leg and single leg activities
and transitions
o Vary planes of movement and
change of direction
Examples
o Single-leg hop downs from increasing
height (up to 12” box)
o Single-leg hop-holds (stable surface
à Airex pad)
o Double and single-leg hopping onto
unstable surface (i.e. Airex pad) Tuck
jumps (focus on increasing multi-joint
flexion during landing and holding
stable position)
o 90º to 180º jumps

• Begin agility exercises between 50-75% (utilize visual feedback to improve mechanics)
o Side shuffling o Zig-zags
o Hopping o Resisted jogging (Sports Cord) in
o Carioca straight planes, etc
o Figure 8 o Back pedaling

Goals to Functional Test

Progress to o Single leg and 3 cross-over hop test for distance (within 15% of uninvolved limb)
Independent Isokinetic Testing
Program o ≤10% deficit in isokinetic peak torque with knee extension and knee flexion (60º/sec, and
300º/sec) compared to uninvolved limb
o Quadriceps to hamstring isokinetic strength ratio ≥ 60%
Complete sport-specific drills without compensatory movements, exacerbation of
symptoms or reactive effusion

PCL RECONSTRUCTION
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Rehabilitation Precautions
• Weight bearing as tolerated with brace locked in full extension 0-6 weeks.
• Isotonic strengthening
• Avoid isolated active/resistive hamstring strengthening for 5 months.
• Closed chain co-contraction activities may begin at 6 weeks.
• Posterolateral Corner Repair—Non weight bearing for 4 weeks, then increase weight bearing in brace
locked at 0º. Unlock brace at 6 weeks with goal of progressing out of brace by 8 weeks.

Post-operative: 0- 4 weeks
Bracing • Locked in full extension except for ROM activities.

ROM • Maintain/obtain full knee extension

• Supine/long sitting passive heel slide with posterior tibia support to avoid
posterior tibial sag (0-90°)
• Patellar mobilizations
• Maintain hamstring and calf flexibility, via posteriorly supported positions. (No
90/90 or supine straight leg stretching of hamstrings due to possible posterior
tibial sag)
• Edema control
o Vasopnuematic device
o Ice education
Strengthening • No active/resistive hamstring activities
• Neuromuscular re-education with e-stim and/or biofeedback if needed
• Quad sets, supine or prone
• Straight leg raises with brace: flexion, abduction, and adduction
• Weight bearing activities with brace (weight shifts, heel/toe raises)
Goals to 1. Good quad set
Progress to 2. ROM 0-90º
Next Phase 3. Straight leg raise without knee extensor lag

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Phase II: Weeks 4-6
ROM • Brace may be unlocked for ranging activities
• Supine/long sitting passive heel slide with posterior tibia support (0-100°)
• Continue with hamstring and calf flexibility in available range (light towel
stretch)
Strengthening • Continue closed chain activities in locked brace
• Straight leg raises with brace: flexion, abduction, and adduction
• Contralateral hip PRE’s/Steamboats (No Extension)
• Continue quadriceps strengthening
Goals to 1. ROM 0-100 degrees
Progress to 2. Pain free full weight bearing in brace locked at 0 degrees
Next Phase 3. Able to perform single leg stance with moderate to good balance

Phase III: Weeks 6-8

Patient able to discontinue brace after 6 weeks when normal pain free gait pattern is demonstrated.

ROM • Full seated and supine active ROM 0-130°. No resistance.

• Able to perform passive ROM beyond available active ROM (avoid direct
anterior to posterior force on tibia)
• Begin bike, no resistance
Strengthening • Initiate multidirectional hip PRE’s/steamboats all directions.
• Progress partial weight bearing strengthening (Total Gym, Shuttle, Aquatics,
etc.)
• Mini Squats, wall slides, step ups
• Gait training
• Proprioceptive activities
• Trunk and lumbosacral strengthening (No Bridging)

Goals to 1. Ability to progress therapeutic exercise without pain or reactive swelling

Progress to 2. Active ROM 0-130° pain free
Next Phase 3. Normal gait pattern

Phase IV: Weeks 8-12

ROM • Full active and passive ROM

• Initiate passive stretching of all major LE muscle groups.
• Continue bike with low level resistance
Strengthening →No active open kinetic chain hamstring exercises (may begin closed chain)
• Initiate step down begin with 2 inch step and progress to 4 inch.
• Retro treadmill ambulation
• Mini lunges, squatting 0-90°
• Progress LE/trunk strength and stability exercises (may initiate bridging)
• Resisted lateral stepping
• Proprioceptive activities progressed from stable to unstable surfaces
• Begin bilateral total gym/shuttle plyometrics (at week 10)
Goals to 1. Demonstrate ability to descend 6 inch step without reactive instability
Progress to 2. ROM within normal limits
Next Phase 3. No dynamic valgus with squat to 90º

Phase V: Weeks 12-16

ROM • Continue per tolerance and use for pre-exercise warm up

Strengthening • Shuttle/ Total Gym

o Partial weight bearing jogging
o Rotational and single leg hopping
• Initiate walk-jog progression (14 weeks)
• Criteria to initiate jogging
o ≥ 7 /10 on #10 IKDC Questionnaire (Appendix A)
o 20 heel touches with good alignment
o Appropriate landing mechanics
o Normalized ROM
o Audible rhythmic strike patterns and no gross visual antalgia
• Initiate agility exercises 50-75% speed (14-16 weeks) Side shuffle, carioca,
figure eight, zig zags, resisted jogging with sports cord, back pedaling, etc.
Note: No acceleration/deceleration work due to delayed hamstring activation
Goals to 1. Pain free jogging
Progress to 2. No reactive effusion
Next Phase 3. ROM equal to contralateral side.
4. Pain free bilateral plyometrics without reactive instability.

Phase VI: 4-6 Months

ROM • Continue per patient ability – recumbent bike, upright bike, elliptical, treadmill

Strengthening • Initiate active resistive hamstring dominant exercises (5-6 months)

• Continue jogging progression, increase speed and duration
• May begin single leg full weight bearing plyometric training
• Progress agility exercises 75-100% speed
• May begun acceleration/deceleration and change of direction training
• Continue emphasis on quad, hamstring, and core stability
• Bilateral full weight bearing plyometrics
Goals to 1. Functional Tests
Progress to a. Single leg and cross over hop for distance within 10-15%
Next Phase b. FMS with score of at least 15 out of 21
c. Complete sports specific drills without exacerbation of symptoms
or reactive instability

Phase VII: 6 Months

Strengthening • This sport-specific phase should transition from the rehab specialist in the
clinic to athletic trainer or sports performance specialist as appropriate.
• Continue sports specific agility exercises
• Progress gradually to 100% per tolerance

Appendix A: IKDC Questionnaire

“How would you rank the function of your knee on the scale of 0 to 10 with 10 being normal, excellent function
and 0 being the inability to perform an of your usual daily activities which may include sports?”

FUNCTION PRIOR TO YOUR KNEE INJURY

0 1 2 3 4 5 6 7 8 9 10
Couldn’t perform No limitation in
daily activities daily activities

CURRENT FUNCTION OF YOUR KNEE

0 1 2 3 4 5 6 7 8 9 10
Couldn’t No limitation in
perform daily activities
daily activities

Functional tests
1. Single hop for distance: Have the subject line their heel up with the zero mark of the tape measure,
wearing athletic shoes. The subject then hops as far as he can, landing on the same push off leg, for at
least 3 seconds. The arms are allowed to move freely during the testing. Allow him to perform 4 practice
hops on each leg. Then, have the subject perform 4 trials, recording each distance from the starting point
to the back of the heel. Average the distances for each limb.

2. Cross-over hop for distance: This test is set up with a 15cm strip, extending 6 meters. The subject lines
his heel up at the zero mark of the tape measure and hops 3 times on one foot, crossing over the center
line each time. Each subject should hop as far forward as he can on each hop, but only the total distance
hopped is recorded Allow the subject to perform 4 practice rounds before recording. Average the
distances for each limb.

Scoring

• Begin with the uninvolved leg. If using tape to mark distance, remove it before the next trial to
minimize visual cues.
• Greater than a 15% difference in average distance between the right and left limbs should be cause
for concern, indicating quad, and hamstring weaknesses that should be addressed prior to return to
sport.
• If patient fails test, evaluate and implement appropriate strength/stability/balance exercise strategies.
Once resolved, test again.

PLANTAR FASCIA ULTRASOUND GUIDED

PERCUTANEOUS FASCIOTOMY/PRP INJECTION
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Make every effort to avoid these medications before and after your procedure.
They may impair your ability to heal and may increase risk of bleeding.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might reduce the beneficial effects of the procedure.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• Crutches
• Walking boot
• Therapy appointment times
• Follow-up times

Post-procedure Care
• Plan to have a family member or friend drive you home after your procedure.
• Bring your crutches / scooter / boot to your procedure appointment.

Weight Bearing Activity and Rehab

Day 1 (day of • No weight bearing on treated • Protect your foot by resting and keeping it elevated to
your foot; use crutches/scooter and reduce swelling.
procedure) boot to get around.

Days 2-3 • Begin light partial weight • Elevate at least 3 times a day to control swelling. Begin
bearing, placing your foot on gentle ankle range of motion exercises 3 times per day.
the ground for balance; use
crutches/scooter and boot to
get around.

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Days 4-7 • Discontinue crutches. Begin
walking using the boot only.
• If you use a scooter, begin
partial weight bearing by
placing untreated leg on
scooter and bearing some
weight on the treated foot in
your boot.
Week 2 • Discontinue the use of the
boot / scooter. Begin walking
normally in your home and
then in the community as you
are able.
Week 3-4
Week 5
Week 6
• Continue ankle range of motion. Perform isometric
ankle strengthening and toe crunches 1-2 times per
day.
• Continue ankle range of motion 3 times per day.
Perform isotonic ankle strengthening, toe crunches and
foot intrinsic strengthening 1-2 times per day. Begin
non-impact aerobic exercise with a stationary bike
without the boot. You can start gentle swimming and
pool exercise when the wound is healed.
• Advance strengthening by adding more resistance.
Continue ankle range of motion. Begin balance
exercises like single-leg stance.
• Begin using an elliptical machine (begin with no incline
and low resistance) and increase walking pace for
exercise. Advance lower body strengthening as
tolerated at the discretion of your care team.
• Increase the intensity of biking, swimming, elliptical, fast
walking and resistance exercises. Once you are working
hard at these without pain, progress to higher impact
activities (like jogging, running, sprinting and jumping)
as directed by your care team. For running, consider
using an anti-gravity treadmill to start.

Orthotics/Braces
You do not need to sleep in boot. Do not drive while you are wearing the boot. If you have an orthosis, wear this
in your boot/shoe as you normally would.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily. If you are concerned about your pain, please
contact your care team.

Bandage
• If a bandage/dressing was applied, remove dressing after 24-48 hours. Replace with simple bandage.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep procedure area
clean and dry for 1 week after the procedure until your doctor has seen you for your wound check.

Bathing
Do not soak/submerge the foot in water for 1 week. Showering is OK, but keep incision site covered for the first
week.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine (614-293-3600) during normal clinic hours. Otherwise seek care at your
local emergency room.

For Therapists Only

All strength work should be performed every other day, 2-3 sets of each exercise to fatigue without reactive pain.
Manual work may begin 2 weeks after the procedure date.
Last reviewed August 2017

QUADRICEPS TENDON/PATELLAR TENDON

CLINICAL PRACTICE GUIDELINE

Rehabilitation Precautions
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise. All restrictions and/or
precautions will be set by the referring surgeon, and will be based upon the stability of the repair and procedure
performed. All precautions are subject to change per physician instructions.

General Precautions

Dr. • Brace is locked to block flexion beyond what is tolerated by the repair, 0-6 weeks. This will
Kaeding be set by Dr. Kaeding in the O.R.
• 6-8 weeks post-op, push ROM to full flexion, blocking brace at just beyond what is achieved
in therapy.
• D/C brace once full flexion is achieved, and once patient can perform SLR without extensor
lag, after 6-8 week post-op period.

Dr. • WBAT with knee brace locked at 0 degrees for 6 weeks.

Flanigan • ROM during first 6 weeks based on stability of repair as tested in OR- usually 0 to 60-90
degrees.
• At 6 weeks progress ROM without restriction.
• Brace unlocked at 6 weeks post-op, and D/C’d once full flexion achieved, and patient can
perform SLR without extensor lag.

Dr. Jones • NWB with knee brace locked at 0 degrees for 6 weeks. Pt. may slowly progress to WBAT,
Dr. Bishop with brace locked, with crutches, per physician and therapist discretion.
• PROM may begin at 2 weeks post-op, progressing 20 degrees every 4-5 days, with goal of
90 degrees flexion achieved by 5-6 week post-op period.
• Brace unlocked fully by 6 weeks, and D/C’d once full flexion achieved, and patient can
perform SLR without extensor lag.

Dr. Miller • Pt. may slowly progress to WBAT, with brace locked, with crutches, per physician and
therapist discretion.
• Lock brace in full extension when ambulating. May unlock brace while sitting or for ROM
exercises 0-30 degrees. Further PROM may begin at 3 weeks post-op, progressing 20
degrees every 4-5 days, with goal of 90 degrees flexion achieved by 5-6 week post-op
period.
• Brace unlocked fully by 6 weeks, and D/C’d once full flexion achieved, and patient can
perform SLR without extensor lag.

Additional • For quadriceps tendon repair, no terminal/end-range quad stretching x 8 weeks.

• No isolated, open-chain isotonic quadriceps strengthening for either repair x 8 weeks

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Weeks 0-2 • Weight-bearing as described above

(Days 1-14) • Prone knee passive ROM to 60-90 degrees (or per surgeon restrictions - see above)
• Supine passive knee ext to 0 degrees
• Gentle medial and lateral patellar mobilizations
• Ankle pumps, gluteal sets, hamstring sets
• Modalities to control pain and edema
Goals:
1. Protect repair
2. Control pain and edema
3. Fair to good volitional quad activation
Weeks 2-4 • Continue weight bearing as described above
(Days 14-28) • Continue focus on passive knee extension to 0 degrees
• Passive ROM for knee flexion per surgeon guidelines
• May progress to active-assistive knee flexion (heel slides)
• Gentle grade I- II patellar mobilizations.
o ***Gently progress to superior andinferior mobilizations.
• Ipsilateral calf, hamstring and hip stretching (passive), with brace locked in
• extension.
• Quadriceps sets – Begin with sub-maximal, progressing gently per patient tolerance.
• Progress to 4-way SLR with brace locked in extension.
• Seated ipsilateral hamstring curls, no resistance, within ROM restrictions
• Continue modalities as indicated
Goals:
1. Protect Repair
2. Continue to manage pain and edema
3. Extension ROM to neutral, flexion to 45-60°
4. Normalization of gait, brace locked per physician, WBAT
5. SLR without extensor lag
Weeks 4-6 • Continue weight bearing as described above
• PROM/AAROM/AROM for knee flexion per surgeon guidelines
• Gently progress patellar mobilizations, all directions.
• SLR may be performed without brace if patient can perform without extensor lag
• Seated ipsilateral hamstring curls, progressing to light T-band within ROM restrictions.
• Begin gentle core stabilization activities – abdominal brace with use of biofeedback as
needed
• Continue modalities as needed
Goals:
1. Continued ambulation with appropriate mechanics and without reactive effusion
2. Knee ROM to physician limits
3. Good scar quality and mobility

• Wean from extension brace per physician guidelines above

Weeks 6-8 • Progress flexion ROM as tolerated to full flexion
• AROM knee extension and flexion
• Stationary bike
• Begin closed chain quadriceps strengthening- bilateral
• Weight shifts, progressing to single leg stance/ proprioceptive activities on firm surface
• Progress core and hip stabilization
Goals:
1. Restore full AROM and patellar mobility of the knee
2. Normalize gait without brace or assistive device
3. Initiation of resistive exercises without reactive effusion or pain


Weeks 8-12 • May initiate terminal/end-range quadriceps stretching for quad tendon repairs
• Continue stationary bike for cardiac conditioning
• May initiate elliptical and/or stairmaster at 10 weeks
• Progress closed chain strengthening, bilateral to unilateral, eccentric to concentric
• Isolated isotonic quadriceps strengthening- leg extensions in protected range
• Proprioceptive activities - single leg stance on various surfaces
• Continue and progress core and hip stabilization
Goals:
1. Full ROM
2. Single leg stance for 30 seconds with good quad control
3. 5/5 strength of all other lower extremity musculature
Weeks 12-16 • Continue lower extremity endurance exercises
• Continue quadriceps PRE’s per patient tolerance
• Initiate partial weight bearing plyometrics (e.g. shuttle)- bilateral to unilateral, straight plane to
rotational
• May progress to bilateral FWB step downs, beginning with 2 inch block, if patient performs
partial weight bearing plyometrics with good mechanics and no reactive effusion/pain
• Slideboard
Goals:
1. Appropriate mechanics with above activities, without pain or reactive effusion
Weeks 16-24 • May initiate recreational swimming
• Initiate sports-specific exercise
• Progress hop downs bilateral to unilateral – progress step height per patient tolerance and
upon demonstration of normal mechanics/control
o Initiate jogging progression
• Criteria to begin jogging:
a. 20 single leg squats with good mechanic
b. 5/5 isometric strength
c. Perform 10 FWB single leg hops with good control, symmetric bilaterally
d. >7/10 on IKDC confidence scale
• Progress to dynamic functional activities: Figure-8, zig-zag, sideshuffle, grapevine. Begin at
25-50% intensity.
Criteria to 1. Full ROM and 5/5 lower extremity strength
return to 2. >85-90% performance of involved side versus uninvolved on functional hop testing, e.g.,
sport- single leg hop for distance; single leg 3-hop crossover test; 6-meter timed hop test
specific 3. >85-90% performance during isokinetic strength testing of involved versus uninvolved side
drills and
activities

UNICOMPARTMENTAL KNEE ARTHROPLASTY (UKA) PROTOCOL
Background
Unicompartmental knee arthroplasty (UKA) is a procedure designed to relieve pain caused by joint
degeneration due to osteoarthritis involving only one compartment of the knee (medial, lateral, OR
patellofemoral). The knee joint is opened by splitting the joint capsule and the quad tendon if
needed. The procedure then involves resection of the arthritic bone and cartilage and
replacement with highly specialized metal (Cobalt-chromium alloy) components that are cemented to
the bone with a plastic (ultra-high molecular weight polyethylene) insert between the metal
components. This procedure preserves the remaining healthy bone, cartilage and ligaments of the
knee while selectively targeting the damaged area.
Impact activities are not recommended. Bicycling, golfing, walking, rowing (if flexion range of motion
allows), swimming, elliptical are encouraged.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and
clinician evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Summary of Recommendations
Expectations • PT will begin in the hospital on the day of your surgery. You will transfer to outpatient
physical therapy 5-7 days after surgery.
• Return to impact activity is not recommended. “Knee friendly” activities including
bicycling, elliptical, golf and swimming.
Risk Factors • The patient should be monitored for signs and symptoms of DVT
• Emphasis should be placed on achieving full knee extension by end of Phase 1 and full
knee flexion by end of phase 2
Weight Bearing • The patient will be WBAT with an assistive device for the first 2-3 weeks. Assistive
Progression device should be discharged once full knee extension is achieved and the patient is able
to ambulate without obvious gait deviations
Range of Motion • 5-7 days post-op: 0-70°
Progression • 1-3 weeks post-op: 0-100°
• 3-6 weeks post-op: symmetrical extension, flexion 0-120°
• 6 weeks to return to PLOF: symmetrical and pain-free ROM

Patient Reported Collect at least one of the following at initial evaluation, every 6 weeks and discharge. Be
Outcomes consistant with which outcome tool is collected.

• Knee Injury and Osteoarthritis Outcome Score (KOOS)

• International Knee Documentation Committee (IKDC)
• Lower Extremity Functional Scale (LEFS)
• The Forgotten Joint Score (FJS-12)

Functional • Timed Up and Go (TUG)

Assessments • Appendix A
Criteria to Return to • Normal gait on all surfaces and ability to walk 1 mile or greater without pain or reactive
Non-Impact Sport effusion
• Dynamic neuromuscular control with multi-plane activities without pain or reactive
effusion

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RED/YELLOW FLAGS

Red flags are signs/symptoms that require immediate referral for re-evaluation. Yellow flags are
signs/symptoms that require modification to plan of care.

Red Flags • Signs of DVT (Refer directly to ED)

o Localized tenderness along the distribution of deep venous system
o Entire LE swelling
o Calf swelling >3cm compared to asymptomatic limb
o Pitting edema
o Collateral superficial veins
• Mechanical block or clunk (Refer to surgeon for re-evaluation)
• Lack of full knee extension by 4-6 weeks (Refer to surgeon for re-evaluation)
Yellow Flags • Persistent reactive pain or effusion following therapy or ADLs
o Decrease intensity of therapy interventions, continue effusion management
and provide patient education regarding activity modification until reactive
symptoms resolve

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PHASE 1 (Weeks 0-3)

Patients will begin rehabilitation in the hospital on the day of surgery. The patient should transfer the
outpatient physical therapy 5-7 days after surgery. Rehabilitation frequency is based on patient
progress, but typically occurs 1-2 times every week.

In this phase, focus is placed on restoring range of motion, ensuring proper wound healing and effusion management.
Interventions should address lower extremity strength, gait mechanics and safety with IADLs.
Precautions • Monitor for signs/symptoms of DVT
• Monitor incision for signs of infection
• No lunges x8 weeks
Goals • By 5-7 days post-op
o ROM: 0-70°
o Strength: Ability to perform independent straight leg raise (SLR)
• By 1-3 weeks post-op
o ROM: 0-100°
o Strength: Ability to perform SLR without evidence of extensor lag
Weight Bearing WBAT with assistive device until full knee extension is achieved and patient is able to
ambulate without obvious gait deviations
Suggested Interventions • ROM
o Extension: heel prop towel stretch, bag hangs, patellar mobilizations
o Flexion: heel slides, wall slides, active-assist flexion off edge of bed, upright
bike
• Strength
o Quad sets, SLR (4-way), SAQ, standing mini-squats, calf raises, shuttle
press, steamboats
• Effusion Management
o Ice, elevation, compression
NMES Parameters • NMES pads are placed on the proximal and distal quadriceps
(Do not initiate until • Patient: Seated with the knee in at least 60º flexion, shank secured with strap and
week 2-3) back support with thigh strap preferred. The ankle pad/belt should be two finger
widths superior to the lateral malleoli
-See Appendix B • The patient is instructed to relax while the e-stim generates at least 50% of their max
volitional contraction against a fixed resistance OR maximal tolerable amperage
without knee joint pain
10-20 seconds on/ 50 seconds off x 15 min

Cardiovascular • Upper body circuit training or upper body ergometer, if desired by patient
Endurance
Criteria to Progress to • Normal gait without assistive device on level indoor surfaces
Phase 2 • Full knee extension
• No evidence of extensor lag during SLR
• Able to perform double leg squat to 45° without upper extremity support

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PHASE 2 (WEEKS 3-6)

During Phase 2, emphasis is placed on increasing knee flexion ROM and improving quadriceps, gluteal and core
strength.
Precautions • Post-activity soreness should resolve within 24 hours
• No impact activities
• No lunges x8 weeks
Goals • Reciprocal stair negotiation by 6 weeks
• Return to work by 6 weeks
• Double leg sit to stand from a chair without upper extremity assist
• Single leg balance x15 seconds or greater OR ability to put socks on in standing
Range of Motion Extension: symmetrical to contralateral limb
Flexion: 0-120°
Weight Bearing Full weight bearing, no assistive device
Suggested Interventions • ROM
o Continue ROM strategies from Phase 1
• Strength
o SLR-Flexion progressions (semi-reclined or seated, add ER, eyes closed
for cortical training, speed, isometric holds), LAQ, side stepping, step ups,
step downs, sit to stands, wall sits
• Balance/Proprioception
o Double leg  single leg
o Eyes open/eyes closed
o Compliant surfaces
• Effusion
o Continue effusion management strategies from Phase 1
• Continue NMES
Cardiovascular • Treadmill walking, elliptical, swimming if tolerated
Endurance o Incision must be healed and completely closed prior to swimming (typically
~4 weeks post-op)
Criteria to Progress to • Ambulation >2 blocks without assistive device
Phase 3 • Reciprocal gait on stairs by 6 weeks without upper extremity support
• Symmetrical ROM
• Double leg sit to stand without upper extremity support x10 repetitions
• Single leg balance x15 seconds or greater

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PHASE 3 (WEEKS 6 – Return to Prior Level of Function)

During Phase 3, emphasis is placed on safely returning to prior level of function and knee-friendly activities
Appointments PT frequency will vary depending on progress. However, frequency may taper to one time
every 1-2 weeks during this phase.
Precautions • Post-activity soreness should resolve within 24 hours
• No impact activities
Goals • Ability to perform all IADL, work and non-impact sport related activity without
complaints of pain or evidence of reactive effusion
• Able to ambulate 1 mile or greater without pain, gait deviation or reactive effusion
Range of Motion Symmetrical and pain-free compared to contralateral limb
Weight Bearing FWBing without assistive device
Suggested Interventions • ROM
o Continue ROM strategies from Phase 1
• Strength
o Continue interventions from phases 1 and 2, leg press machine, hamstring
curl machine, knee extension machine, progress towards SL CKC
interventions per patient’s tolerance
• Balance/Proprioception
o Double leg  single leg
o Eyes open/eyes closed
o Compliant surfaces
o Perturbations
o Chops/lifts/ball toss
• Effusion
o Continue effusion management strategies from Phase 1
Cardiovascular Replicate sport or work specific energy demands (non-impact only)
Endurance
Criteria to Return to • Normal gait on all surfaces and ability to walk 1 mile or greater without pain or
Non-Impact Sport reactive effusion
• Dynamic neuromuscular control with multi-plane activities without pain or reactive
effusion

Author: Caroline Brunst, PT, DPT, SCS, AT

Reviewers: Robert Duerr, MD, Nicholas Greco, MD, Andrew Glassman, MD, Katie Dyer, MBA

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References:
Fransen, M., Nairn, L., Bridgett, L., Crosbie, J., March, L., Parker, D., … Harmer, A. R. (2017). Post-Acute Rehabilitation
After Total Knee Replacement: A Multicenter Randomized Clinical Trial Comparing Long-Term Outcomes. Arthritis
Care & Research, 69(2), 192–200. https://doi.org/10.1002/acr.23117
Harikesavan, K., Chakravarty, R. D., Maiya, A. G., Hegde, S. P., & Y Shivanna, S. (2017). Hip Abductor Strengthening
Improves Physical Function Following Total Knee Replacement: One-Year Follow-Up of a Randomized Pilot Study.
The Open Rheumatology Journal, 11, 30–42. https://doi.org/10.2174/1874312901711010030
Li, Y., Kakar, R. S., Fu, Y.-C., Mahoney, O. M., Kinsey, T. L., & Simpson, K. J. (2018). Knee strength, power and stair
performance of the elderly 5 years after unicompartmental knee arthroplasty. European Journal of Orthopaedic
Surgery & Traumatology, 28(7), 1411–1416. https://doi.org/10.1007/s00590-018-2198-7
Mistry, J., Elmallah, R., Bhave, A., Chughtai, M., Cherian, J., McGinn, T., … Mont, M. (2016). Rehabilitative Guidelines
after Total Knee Arthroplasty: A Review. Journal of Knee Surgery, 29(03), 201–217. https://doi.org/10.1055/s-0036-
1579670
Outpatient Rehabilitation Guidelines for MAKOplasty UKA. (2014). Retrieved from
https://www.uwhealth.org/files/uwhealth/docs/sportsmed/RE-38786-14_MAKOplasty.pdf
Reilly, K. A., Beard, D. J., Barker, K. L., Dodd, C. A. F., Price, A. J., & Murray, D. W. (2005). Efficacy of an accelerated
recovery protocol for Oxford unicompartmental knee arthroplasty—a randomised controlled trial. The Knee, 12(5),
351–357. https://doi.org/10.1016/J.KNEE.2005.01.002
Witjes, S., Gouttebarge, V., Kuijer, P. P. F. M., van Geenen, R. C. I., Poolman, R. W., & Kerkhoffs, G. M. M. J. (2016).
Return to Sports and Physical Activity After Total and Unicondylar Knee Arthroplasty: A Systematic Review and
Meta-Analysis. Sports Medicine, 46(2), 269–292. https://doi.org/10.1007/s40279-015-0421-9

For OSUWMC USE ONLY. To license, please

contact the OSU Technology Commercialization
Office at https://tco.osu.edu.
Appendix A: Timed Up and Go Test

1. Equipment- arm chair, tape measure, tape, stop watch

2. Begin the test with the patient sitting in a chair with arm rests (hips all the way to the back of the seat).
3. Place a piece of tape or other marker on the floor 3 meters away from the chair so that it can be easily seen by
the subject
4. Instructions: “On the work ‘GO,’ you will stand up, walk to the line on the floor, turn around and walk back to the
chair and sit down. Please walk at your regular pace.”
5. Start timing on the word ‘GO’ and stop timing when the subject is seated with their back rested on the back of the
chair.
6. The patient should wear their regular footwear and may use any gait aid they would normally use during
ambulation. They may not be assisted by another person. There is no time limit. They may stop and rest (but not
sit down) if they need to.
7. Normal healthy controls complete the task in 10 seconds or less.
8. The patient can complete a practice trial before testing.
9. Interpretation:
• ≤ 10 seconds = normal
• ≤ 20 seconds = fair mobility
• ≤ 30 seconds = impaired mobility
• A score of ≥ 14 seconds has been shown to indicate high risk of falls
10. Age matched norms:
• 60-69 years old: 7.9 ± 0.9 seconds
• 70-79 years old: 7.7 ± 2.3 seconds
• 80-89 years old
• No device: 11.0 ± 2.2 seconds
• With device: 19.9 ± 6.4 seconds
• 90-101 years old:
• No device: 14.7 ± 7.9 seconds
• With device: 19.9 ± 2.5 seconds

1. Bohannon RW. Reference values for the Timed Up and Go Test: A Descriptive Meta-Analysis. Journal of Geriatric Physical Therapy, 2006;29(2):64-8.
2. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Phys
Ther. 2000;80:896-903.
3. Kristensen MT, Foss NB, Kehlet H. Timed "Up and Go" Test as a predictor of falls within 6 months after hip fracture surgery. Phys Ther.
2007.87(1):24-30.

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Office at https://tco.osu.edu.
Appendix B: NMES Set Up
2 or 4 pad set-up is appropriate

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ADVANCED RETURN TO RUNNING

REHABILITATION GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

• Ideal for athletes with non-surgical injuries, post-surgical patients following Alter G or Deep Water
Running Progression, and runners that average 40-60 miles per week
• This guideline is intended for end stage rehabilitation return to running and the clinician should use their
own clinical judgement when it is safe to return the athlete to plyometrics and running
• Supplement with Alter G and Deep Water Running Progression for post-surgical patients

Phase I: Walking and Plyometrics

Criteria to • Ability to walk 30 minutes pain-free
Start Phase I • Full joint range of motion
• At least 80% strength compared to the unaffected limb (specifically post-surgical
injuries)
• Trace to no edema present
Goals • Tolerate single leg impact activities
• Demonstrate proper lower extremity biomechanics
• Walking without limitations
• Demonstrate equal quality and power bilaterally
Guidelines • Double limb jumps progressed to Sample Functional Hop Progression
single limb hops
Double Leg Single Leg
• Unilateral to multi-directional plane
hops Hop in Place Hop in Place
Forward Hop Forward Hop
Backward Hop Backward Hop
Triple Hop Triple Hop
Side-to-Side Hop Side-to-Side Hop
Crossover Cross-over
Scissor Hops Dot Drills
Dot Drills Lateral Bounds/Skaters
180 Degree Hops 90 Degree Hops

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.



Phase II: Walk to Run Progression
Criteria to • Athlete is able to tolerate 200-250 foot contacts
Start Phase II o Athlete is able to tolerate number of foot contacts for ~1/3rd of a mile of running
• No symptoms reported by the patient and demonstrates adequate plyometric form with
minimal to no knee valgus, toe to heel landing, no trunk lean, and demonstrates soft
landing
• Ability to perform 15 heel taps with proper LE mechanics
Goals • Progression back to continuous running without aggravation of symptoms and antalgia

Guidelines • Prior to walk to run progression complete 5 minute dynamic warm-up (example at
wexnermedical.osu.edu/sports-medicine/treatments/endurance-medicine)
• Athlete must take at least one running off day in between each return to running
workout, non-impact cross training during off days
• Take at least one complete rest day a week
• If athlete develops pain, return of other symptoms, or cannot complete the phase they
remain at that phase until they are able to complete it without symptoms
• Complete only one phase per day

Advanced
Walk to Run Warm-up Run: Walk Repetitions Cool down Total Days
Program
Phase 1 5-10 min 4 min:1 min 2-4 5-10 min 20-30 min 2
Phase 2 5-10 min 6 min:1 min 2-4 5-10 min 25-35 min 2
Phase 3 5-10 min 8 min:1 min 2-4 5-10 min 30-40 min 2
Phase 4 5-8 min 10 min:1 min 2-4 5-8 min 35-45 min 2

Phase III: Running Progression

Criteria to • Able to complete Phase II without pain or symptoms
Start Phase III • At least 90% strength and Limb Symmetry Index compared to the unaffected limb
(specifically post-surgical injuries)
• Ability to perform 12 inch hop downs from box with proper LE mechanics
Goals • Increase daily and weekly mileage gradually
• Return to normal running routine within 5 weeks
• No return of pain or symptoms
Guidelines • Athlete can cross train or rest on off days, but must take at least one rest day a week
• Prior to run progression complete 5 minute dynamic warm-up and 5-10 min walking
warm-up
• After run complete 5-10 min walking cool down and post-run stretch

Advanced
Running Day1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Total
Progression Miles
Week 1 2 - 2 - 3 - 3 10
Week 2 - 4 - 4 - 3 3 14
Week 3 - 5 - 5 4 - 4 16
Week 4 5 - 6 5 - 6 - 22
Week 5 6 - 7 7 - 9 4 32
Week 6 - 7 10 4 - 12 7 40

ADVANCED RETURN TO RUNNING PROGRAM

(FOR PATIENTS)
Step 1: Walk to Run
• Only complete one phase per day, performing workout every other day
• On off days, either cross train or rest but must take one day of complete rest each week
• Stop running if you begin to experience pain, swelling, or altered running/walking pattern
• Complete each phase without symptoms before moving on to the next phase

Advanced Walk to Run

Program Warm-up Run:Walk Repetitions Cool down Total Days
Phase 1 5-10 min 4 min:1 min 2-4 5-10 min 20-30 min 2
Phase 2 5-10 min 6 min:1 min 2-4 5-10 min 25-35 min 2
Phase 3 5-10 min 8 min:1 min 2-4 5-10 min 30-40 min 2
Phase 4 5-8 min 10 min:1 min 2-4 5-8 min 35-45 min 2

Step 2: Running Progression

• On off days, either cross train or rest but must take one day of complete rest each week
• Avoid hill running until you have returned to your normal weekly mileage and pace
• Stop running if you begin to experience pain, swelling, or altered running pattern
• Work to increase speed before increasing distance

Advanced
Running Day1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Total
Progression Miles
Week 1 2 - 2 - 3 - 3 10
Week 2 - 4 - 4 - 3 3 14
Week 3 - 5 - 5 4 - 4 16
Week 4 5 - 6 5 - 6 - 22
Week 5 6 - 7 7 - 9 4 32
Week 6 - 7 10 4 - 12 7 40

Recommendations to Prevent Injuries in the Future

• Give yourself at least one rest day a week
• Continue with strengthening exercises from physical therapy at least 2-3 times a week
• Perform a dynamic warm-up prior to running and perform static stretching after your run (example at
wexnermedical.osu.edu/sports-medicine/treatments/endurance-medicine)
• Decrease mileage or stop running if your injured, slowly return to your normal routine
• Increased mileage increases your risk of injury, gradually increase mileage and intensity


References

Bates NA, Ford KR, Myer GD, Hewett TE. Impact differences in ground reaction force and center of mass
between the first and second landing phases of a drop vertical jump and their implications for injury risk
assessment. J Biomech. 2013;46(7):1237-41.
Brumitt J. A return to running program for the postpartum client: a case report. Physiotherapy Theory and Practice.
2009;25(4):310-325.
Fields KB, Sykes JC, Walker KM, Jackson JC. Prevention of running injuries. Current Sports Medicine Reports.
2010;9(3):176-182.
Fredericson M, Cookingham CL, Chaudhar AM, et al. Hip abductor weakness in distance runners with ITB. Cli. J.
Sport Med. 2000;10:169-175.
Gottschall JS, Kram R. Ground reaction forces during downhill and uphill running. Journal of Biomechanics.
2005;38:445-452.
Hreljac A. Etiology, prevention and early intervention of overuse injuries in runners: A biomechanical perspective.
Phys Med Rehabil Clin N Am. 2005;16:651-667.
Ryan ED, Everett KL, Smith DB, et al. Acute effects of difference volumes of dynamic stretching on vertical jump
performance, flexibility and muscular endurance. Clin Physiol Funct Imaging. 2014;34(6):485-492.
Ryan MB, Maclean ML, Taunton JE. A review of anthropometric, biomechanical and neuromuscular and training
related factors associate with injury in runners. International Sportmed Journal. 2006;7(2):120-137.
Sim AY, Dawson BT, Guelfi KJ, et al. Effects of static stretching in warm-up on repeated sprint performance.
Journal of Strength and Conditioning Research. 2009;23(7):2155-2162.
Stracciolini A, Meehan WP, d’Hemecourt PA. Sports rehabilitation of the injured athlete. Clin Ped Emerg Med.
2007;8:43-53.
Warden SJ, Davis IS, Fredericson M. Management and prevention or bone stress injuries in long-distance
runners. JOSPT. 2014;44(10):749-765.

BASIC RETURN TO RUNNING

REHABILITATION GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

• Ideal for athletes with returning from surgical or non-surgical injuries and recreational runners that average
less than 20 miles per week.
• This guideline is intended for end stage rehabilitation return to running and the clinician should use their
own clinical judgment when it is safe to return the athlete to plyometrics and running.
• Supplement with Alter G and Deep Water Running Progression for post-surgical patients

Phase I: Walking and Plyometrics

Criteria to • Ability to walk 30 minutes pain-free

Start Phase I • Full joint range of motion
• At least 80% strength compared to the unaffected limb (specifically post-surgical
injuries)
• Trace to no edema present
Goals • Tolerate single leg impact activities
• Demonstrate proper lower extremity biomechanics
• Walking without limitations
Guidelines • Double limb jumps progressed to Sample Functional Hop Progression
single limb hops
Double Leg Single Leg
• Unilateral to multi-directional plane
hops Hop in Place Hop in Place
Forward Hop Forward Hop
Backward Hop Backward Hop
Triple Hop Triple Hop
Side-to-Side Hop Side-to-Side Hop
Crossover Cross-over
Scissor Hops Dot Drills
Dot Drills Lateral Bounds/Skaters
180 Degree Hops 90 Degree Hops

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.

Phase II: Walk to Run Progression

Criteria to • Athlete is able to tolerate 200-250 foot contacts

Start Phase II • No symptoms reported by the patient and demonstrates adequate plyometric form with
minimal to no knee valgus, toe to heel landing, no trunk lean and demonstrates soft
landing
• Ability to perform 15 heel taps with proper LE mechanics
Goals • Progression back to continuous running without aggravation of symptoms and antalgia

Guidelines • Prior to walk to run progression complete 5 minute dynamic warm-up (example at
wexnermedical.osu.edu/sports-medicine/treatments/endurance-medicine)
• Athlete must take at least one running off day in between each return to running
workout, non-impact cross training during off days
• Take at least one complete rest day a week
• If athlete develops pain, return of other symptoms, or cannot complete the phase, they
remain at that phase until they are able to complete it without symptoms
• Complete only one phase per day

Basic Walk
to Run Warm-up Run:Walk Repetitions Cool down Total Days
Program
Phase 1 5-10 min 1 min:1-3 min 2-4 5-10 min 20-30 min 2
Phase 2 5-10 min 2 min:1-3 min 2-4 5-10 min 20-30 min 2
Phase 3 5-10 min 3 min:1-2 min 2-4 5-10 min 20-30 min 2
Phase 4 5-8 min 4 min:1 min 2-4 5-8 min 25-30 min 2
Phase 5 5-8 min 5 min:1 min 2-4 5-8 min 25-35 min 2

Phase III: Running Progression

Criteria to • Able to complete Phase II without pain or symptoms
Start Phase III • At least 90% strength and Limb Symmetry Index compared to the unaffected limb
(specifically post-surgical injuries)
• Ability to perform 12 inch hop downs from box with proper LE mechanics
Goals • Increase daily and weekly mileage gradually
• Return to normal running routine within 5 weeks
• No return of pain or symptoms
Guidelines • Athlete can cross train or rest on off days, but must take at least one rest day a week
• Prior to run progression, complete 5 minute dynamic warm-up and 5-10 min walking
warm-up
• After run complete 5-10 min walking cool down and post-run stretch

Basic Running Total

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Progression Miles
Week 1 - 1 - 1 - 2 - 4
Week 2 - 2 - 3 - 3 - 8
Week 3 - 4 - 4 - 2 - 10
Week 4 4 - 2 2 - 4 - 12
Week 5 4 - 3 3 - 4 - 14

BASIC RETURN TO RUNNING PROGRAM

(FOR PATIENTS)

Step 1: Walk to Run

• Only complete one phase per day, performing workout every other day
• On off days, either cross train or rest but must take one day of complete rest each week
• Stop running if you begin to experience pain, swelling, or altered running/walking pattern
• Complete each phase without symptoms before moving on to the next phase

Basic Walk
to Run Warm-up Run:Walk Repetitions Cool down Total Days
Program
Phase 1 5-10 min 1 min:1-3 min 2-4 5-10 min 20-30 min 2
Phase 2 5-10 min 2 min:1-3 min 2-4 5-10 min 20-30 min 2
Phase 3 5-10 min 3 min:1-2 min 2-4 5-10 min 20-30 min 2
Phase 4 5-8 min 4 min:1 min 2-4 5-8 min 25-30 min 2
Phase 5 5-8 min 5 min:1 min 2-4 5-8 min 25-35 min 2

Step 2: Running Progression

• On off days, either cross train or rest but must take one day of complete rest each week
• Avoid hill running until you have returned to your normal weekly mileage and pace
• Stop running if you begin to experience pain, swelling or altered running pattern
• Work to increase speed before increasing distance

Basic Running Total

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Progression Miles
Week 1 - 1 - 1 - 2 - 4
Week 2 - 2 - 3 - 3 - 8
Week 3 - 4 - 4 - 2 - 10
Week 4 4 - 2 2 - 4 - 12
Week 5 4 - 3 3 - 4 - 14

Recommendations to Prevent Injuries in the Future

• Give yourself at least one rest day a week
• Continue with strengthening exercises from physical therapy at least 2-3 times a week
• Perform a dynamic warm-up prior to running and perform static stretching after your run (example at
wexnermedical.osu.edu/sports-medicine/treatments/endurance-medicine)
• Decrease mileage or stop running if your injured, slowly return to your normal routine
• Increased mileage increases your risk of injury, gradually increase mileage and intensity


References

Bates NA, Ford KR, Myer GD, Hewett TE. Impact differences in ground reaction force and center of mass
between the first and second landing phases of a drop vertical jump and their implications for injury risk
assessment. J Biomech. 2013;46(7):1237-41.
Brumitt J. A return to running program for the postpartum client: a case report. Physiotherapy Theory and
Practice. 2009;25(4):310-325.
Fields KB, Sykes JC, Walker KM, Jackson JC. Prevention of running injuries. Current Sports Medicine Reports.
2010;9(3):176-182.
Fredericson M, Cookingham CL, Chaudhar AM, et al. Hip abductor weakness in distance runners with ITB. Cli. J.
Sport Med. 2000;10:169-175.
Gottschall JS, Kram R. Ground reaction forces during downhill and uphill running. Journal of Biomechanics.
2005;38:445-452.
Hreljac A. Etiology, prevention and early intervention of overuse injuries in runners: A biomechanical perspective.
Phys Med Rehabil Clin N Am. 2005;16:651-667.
Ryan ED, Everett KL, Smith DB, et al. Acute effects of difference volumes of dynamic stretching on vertical jump
performance, flexibility and muscular endurance. Clin Physiol Funct Imaging. 2014;34(6):485-492.
Ryan MB, Maclean ML, Taunton JE. A review of anthropometric, biomechanical and neuromuscular and training
related factors associate with injury in runners. International Sportmed Journal. 2006;7(2):120-137.
Sim AY, Dawson BT, Guelfi KJ, et al. Effects of static stretching in warm-up on repeated sprint performance.
Journal of Strength and Conditioning Research. 2009;23(7):2155-2162.
Stracciolini A, Meehan WP, d’Hemecourt PA. Sports rehabilitation of the injured athlete. Clin Ped Emerg Med.
2007;8:43-53.
Warden SJ, Davis IS, Fredericson M. Management and prevention or bone stress injuries in long-distance
runners. JOSPT. 2014;44(10):749-765.

CERVICAL MANIPULATION CLINICAL PRACTICE GUIDELINES
SUMMARY OF RECOMMENDATIONS
Purpose: To create a document of clinical practice guidelines for physical therapists in The Ohio State
University network to utilize and reference when establishing patient safety and appropriateness for cervical
manipulation based on the most recent literature recommendations.

Proposed 1. Mechanical
Benefits • Increase joint space, improve range of motion, improve biomechanics,
decrease soft tissue tone
2. Neurophysiological
• Modulate nerve activity in afferent fibers, alter sympathetic activity, elicit
hypoalgesic response, increase descending inhibition mechanisms
3. Psychological
• Patients with a high positive expectation of success regarding manual
therapy may obtain psychological benefits

Contraindications 1. Contraindications
and Precautions • Worsening neurological function
• Upper motor neuron lesion
• Spinal cord damage
• Multi-level nerve root pathology
• Unremitting night pain
• Relevant recent trauma
• Unremitting, severe non-mechanical pain
• Patient refuses to give consent
• Evidence of suspected cervical artery dissection

2. Precautions
• Hypermobility syndromes
• Local infections
• Osteoporosis/Osteopenia
• Active or history of cancer
• Age > 55 years old
• Long-term corticosteroid use
• Inflammatory disease
• High fear avoidance behaviors
Indications

Cervicogenic headache Positive flexion-rotation test

Possible
Indications

Cervical hypomobility with

Neck pain with radiating
reproduction of concordant
symptoms in non-acute phase
symptoms
Clinical 1. See Appendix A for updated level of evidence from 2017 JOSPT neck pain clinical
Prediction Rule practice guideline for cervical and thoracic mobilization/manipulation

2. Cervical Manipulation Clinical Prediction Rule: Puentedura, et al. JOSPT 2012

1. Symptom duration <38 days

2. Side-to-side difference in cervical rotation >10 degrees
3. Positive expectation manipulation will be beneficial
4. Pain with P-A spring testing of middle cervical spine

Stage of CPR Development: Derivation

Variables Sensitivity Specificity LR+ Prob of Success

3 0.81 0.94 13.50 90%
4 0.50 1.00 Infinite 100%

Examination Testing and Screening

Subjective 1. Mechanism of Injury

Questioni • Most likely cause of cervical vascular compromise is a history of minor mechanical
ng trauma
2. Screening Questions
• Dizziness, Dysphagia, Diplopia, Dysarthria, Drop attacks, Numbness, Nausea,
Nystagmus (5 D’s and 3 N’s)
• Thomas et al: 66% of individuals experienced one of these transient ischemic features
in the month prior to diagnosis of dissection. This indicates a portion of individuals will
not present with these symptoms even if a dissection is present
3. Myelopathy Screening Questions
• Numbness/tingling/weakness bilaterally or in all four limbs
• Difficulty walking
• Difficulty with fine motor skills
• Change in bowel or bladder
4. General Health Questions
• Yearly physician follow-ups / Current medications
• Smoking History
• Corticosteroid Use
• High Blood Pressure
Objective 1. Blood Pressure
Measures • Hypertension is predictor of cardiovascular disease and is a risk factor for carotid or
vertebral artery disease, but must be analyzed in context of other findings
• See Appendix B for updated 2017 AHA blood pressure guidelines
2. Palpation of Carotid Artery
• Only necessary if abnormal subjective symptoms or abnormal BP is present
3. Neurological Exam
• Cranial nerve exam
• Upper motor neuron testing
 • Muscle stretch reflexes
• Sensory exam
4. Canadian C-Spine Rules
• Sensitivity of 0.90-1.00 in identifying individuals with cervical spine fractures
• See appendix C for specific guidelines
5. Craniovertebral Ligament Testing
• Current evidence on predictive ability of these tests is poor, so the PT must consider
whether this testing is prudent or safe when subjective symptoms of instability are
present
6. Vertebral Artery Test
• Numerous studies have brought into question the validity of the vertebral artery
insufficiency (VAI) test
• Results of the test must be taken into context of all clinical examination findings
7. Cervical Examination
• Range of motion
• Passive accessory joint mobility
• Flexion rotation test
Patient- 1. Fear-Avoidance Belief Questionnaire (FABQ)
Reported • Scoring <19 on FABQ-work subscale is included in the lumbar manipulation CPR
Outcome • Puentedura et al. include “positive expectation that manipulation will be beneficial” in
Measures the 2012 cervical manipulation clinical prediction rule
• This may indicate a higher positive expectation and/or lower level of fear-avoidance
may increase likelihood of success with cervical manipulation
2. Neck Disability Index (NDI)
• Tseng et al. identified six predictors of success for cervical manipulation, one being
“initial score on NDI < 11.50”
Prior to 1. Informed Consent
Performin • Obtain express consent in written or verbal form
g Cervical • Record in a standardized manner in patient’s clinical record
Manipulati 2. Positional Testing
on • Sustained pre-manipulative hold must be performed to assess patient response
o Hold position for 10 seconds
o Instruct patient to keep eyes open during the hold
o Patient’s eyes should be in therapist’s view to assess for nystagmus
• Only perform manipulation if patient has appropriate response
Risks of Spinal Manipulation – How Safe Is It Actually?

By the 1. Risk of vertebral artery insufficiency event estimated at roughly 6 in 10 million

Numbers 2. Thiel, et al: Risk of any serious adverse event is at-worst 1 in 10,000
3. Puentedura, et al: Analyzed 134 cases of adverse events following cervical
manipulation and estimated that roughly half could have been prevented with proper
screening
Mechanical vs. 1. Most common cause of vascular-related referred pain is hx of minor mechanical
Vascular Pain trauma
2. Commonly presents as ipsilateral headache and neck pain
3. Monitor patient for transient ischemic features (5 D’s and 3 N’s) and refer to ER for
angiogram if suspecting vascular involvement
Does Age 1. Age > 55 years old is a “precaution” due to increased prevalence of spondylosis
Matter? 2. Over 90% of individuals > 70 years old estimated to have some form of asymptomatic
degenerative spine changes
3. Sound clinical reasoning must be utilized and documented when considering a
manipulation in this patient population
Upper Cervical 1. Specific comparative risk not established in the literature
vs. Mid- 2. Extreme ranges of cervical rotation elicit the greatest
Cervical amount of stress on vertebral artery
Manipulation 3. Upper cervical rotation, mainly coming from the atlantoaxial
joint, has been shown to place more stress on the vertebral
artery than overall cervical rotation
4. It may be prudent for therapists to try and avoid end-range
upper cervical rotation when performing cervical
manipulations

https://sciencebasedmedicine.org/category/chiropractic/

Positioning 1. Maximal cervical extension and rotation combined provide the greatest strain on the
vertebral artery
2. Evidence suggests the strain on vertebral arteries during manipulation is similar to that
of the strain during general ROM testing
3. Positioning of the neck may be more significant than the actual thrust manipulation
when determining risk
Can we ever 1. There seems to be no compelling evidence that clinical examination findings or even
be 100% sure? results of an ultrasonography can identify patients at risk for VBI, so thorough clinical
reasoning and shared decision-making with the patient must always be utilized by the
therapist
Documentation 1. When documenting a cervical manipulation, must include:
• Consent obtained
• Technique used
• Set up / Utilization of pre-manipulative hold
• Grade
• Patient response
Patient 1. Estimated that 20-45% of patients can expect minor to moderate adverse events
Response following manual therapy intervention, with 50% of those resolving within 48 hours.
2. Common minor to moderate symptoms
• Worsening of neck/shoulder pain
• Dizziness
• Light-headedness
 3. Onset of severe headache, severe neck pain, slurred speech or onset of paralysis or
numbness could indicate possible artery dissection
• If these symptoms occur and persist, the therapist must monitor the patient
closely and ensure they receive emergency care immediately

Literature Review on Overall Effectiveness

Manipulation 1. Gross et al 2004 systematic review determined there is currently not sufficient research
vs. indicating the superiority of either mode of treatment
Mobilization 2. Gross et al updated 2015 systematic review provided following conclusions:
• Multiple sessions of cervical manipulation produced similar changes in pain,
function, QOL, global perceived effect and patient satisfaction when compared
to multiple sessions of cervical mobilizations at all follow-up time frames
• For acute and sub-acute neck pain, multiple sessions of cervical manipulation
may be more beneficial in improving pain and function than some medications
• For sub-acute and chronic neck pain, cervical mobilization alone may not be
different from ultrasound, TENS, acupuncture, or massage
Manipulation 1. Gross et al: Strong evidence to support use of multi-modal treatment consisting of
vs. cervical mobilization and/or manipulation plus exercise when compared to wait-and-see
Exercise approach
2. Hoving et al: Patients with nonspecific neck pain > 2 weeks in duration
• Manual therapy-only group showed significantly better outcomes than exercise-
only group and group who continued with their primary practitioner
Cervicogenic 1. Gross et al: For chronic CGH, multiple sessions of cervical manipulation may be more
Headaches effective than massage and TENS in pain reduction at immediate and short-term follow-
up
2. Dunning et al: Upper cervical manipulation and upper thoracic manipulation group
showed significantly greater reduction in headache intensity and disability at 3-month
follow-up than mobilization + exercise group
Thoracic 1. Gross et al: Thoracic manipulation significantly reduced pain in patients with acute and
Manipulation sub-acute neck pain
2. B level evidence in 2017 Neck Pain CPG for variety of neck conditions (see Appendix A)
3. Usually mid to upper thoracic manipulations utilized for cervical pain conditions
4. Nielsen et al: No reports of life-threatening or ‘severe’ adverse events from thoracic
manipulation
McKenzie 1. Numerous studies have investigated the effectiveness of the McKenzie method for low
Approach back pain in comparison to manual therapy, but similar studies are currently lacking for
cervical pain
Example Plan of Care/Progression for Appropriate Patient

First Visit 1. It is advised to avoid performing cervical manipulation during the initial visit
2. Recent research gives support to building therapeutic alliance (TA) with a patient, even
suggesting patient-reported level of TA is a significant predictor of outcomes in back
pain
3. Suggested/possible initial manual interventions:
• Cervical mobilizations
• Thoracic mobilizations
• Cervico-thoracic junction mobility
• Sub occipital release techniques
• SNAGS
• Upper cervical flexion-rotation MET
Second Visit 1. Suggested/possible manual interventions:
• Cervical mobilizations
• Thoracic manipulation
• Cervico-thoracic junction manipulation
Third Visit 1. Cervical manipulation if patient is indicated
• Waiting a few visits allows time to gauge patient response to prior manual
interventions, build therapeutic alliance, and increase patient trust

Fourth Visit 1. Always re-assess patient at the beginning of the visit following a cervical manipulation to
measure patient response and change in status
2. Continue with interventions as appropriate based on patient response

***This example progression is not an all-inclusive approach and does not take in to account specific patient
presentations; instead, it aims to provide a framework for clinical decision-making and the implementation of
proper progression of forces prior to performing a cervical manipulation

***See Appendix D for example techniques

Appendix A

Level of Evidence: JOSPT 2017 CPG for Neck Pain

Acute Neck Pain + Mobility “C” for cervical mobilization and “B” for thoracic manipulation and exercise
Deficits manipulation
Subacute Neck Pain + “C” for cervical mobilization and “C” for thoracic manipulation and exercise
Mobility Deficits manipulation
Chronic Neck Pain + “B” for cervical manipulation “B” for thoracic manipulation
Mobility Deficits
Chronic Neck Pain + “B” for cervical manipulation “B” for thoracic mobilization and manipulation
Radiating Pain
Chronic Neck Pain + “B” for cervical mobilization and “B” for cervicothoracic manipulation
Headaches manipulation
***Note that for most conditions it is recommended manual techniques be combined with shoulder girdle and
neck stretching, strengthening, and endurance exercises.

Appendix B
2017 American Heart Association Blood Pressure Guidelines
Appendix C
Canadian C-Spine Rule
Appendix D
Example manual techniques: All techniques should be performed by a licensed Physical Therapist

Upper 1. Indications: Headache and/or upper cervical hypomobility

Cervical
Flexion- Assessment: Take patient into end-range
Rotation flexion, stabilizing head on your epigastric
Muscle region. Rotate the patient’s head to the right
Energy and left to assess for restriction and pain.
Technique
Treatment: Take patient into end-range
flexion, rotate head toward the side of the
restriction. Patient looks opposite direction
with their eyes and holds for 6 seconds.
Have patient look straight ahead and take
patient further into rotation. Repeat 3 times.
Re-assess.

Example 1. Seated upper thoracic / CT junction HVLAT

Thoracic
Manipulation Patient position: Sitting facing opposite direction on the plinth with
Techniques buttock to the back of the plinth. Patient will place their hands
behind their neck, interlocking their fingers.

Therapist: It is recommended to use a rolled up towel between

therapist’s chest and the patient. Assume a staggered stance and
grasp the patient’s wrists while bringing patients elbows into
horizontal adduction. The contact point can either be the
therapist’s mid-sternum or pectoral region. Introduce compression
by adducting your elbows. Bring patient into slight upper thoracic
flexion while maintaining strong contact point at the targeted
segment. The HVLA is directed cephalad and posterior.

2. Supine mid-thoracic HVLAT

Patient position: Supine with arms folded across the chest, far arm
on top. Towels can be used between patient’s chest and arms as
needed to create “V” posture.

Therapist: Roll patient towards you, reach around thorax and place
contact point at targeted level. Roll patient back to neutral.
Patient’s elbows should point vertical and be directly anterior to the
segment you are targeting. Contact epigastric region onto the
patient’s elbows. The HVLA thrust is provided directly anterior to
posterior.

Cervico- 1. CT junction lateral flexion HVLAT in prone

Thoracic
Junction
Manipulation Patient position: Prone lying with ipsilateral arm abducted and hand
Technique on the plinth, contralateral arm resting at side.

Hand position: Lower hand contacts T1 using MCP of index finger,

wrist in neutral with forearm in treatment plane. Upper hand
contacts frontal bone, zygoma, or temporal bone.

Components: Have patient look up toward their hand. Lower hand

performs a side-shift across bringing T1 towards the therapist. The
upper hand is then used to provide a side-bending force, NOT
ROTATION, which cocks C7 over T1. The HVLAT is performed by
combining these two components, with 70% of the force coming
from the lower hand and 30% coming from the upper hand.

Middle 1. Cervical upward glide / rotation cradle hold HVLAT

Cervical
Manipulation Thrust hand contact: Articular pillow of targeted segment with
radial border of proximal phalanx. Cradle hand placed on
posterior/lateral occiput

Cradle hold: Weight of patient’s head is balanced between your

right and left hands

Create barrier: Therapist’s elbows are held close to sides.

Introduce contralateral rotation, then opposite side-bending using
the nose as the axis

Thrust: Into rotation toward the mouth with the thrust hand while
simultaneously rapidly supinating opposite forearm

2. Cervical upward glide / rotation chin hold HVLAT

Therapist position: Side of the table in staggered stance

Thrust hand contact: Articular pillow of targeted segment with

radial border of proximal phalanx. Rotate the patient’s head
onto your opposite forearm and grip the chin lightly with your
fingers

Create Barrier: Introduce contralateral rotation, then opposite

side-bending using the nose as the axis

Thrust: Into rotation toward the mouth using an equal

combination of motion with both hands
 1. Upper cervical HVLAT
Upper
Cervical Thrust hand contact: Radial border of proximal phalanx on arch
Manipulation of Atlas, elbow at 90 degrees in direction of thrust; cradle hand at
posterior/lateral occiput

Create barrier: Utilize ipsilateral side-bend, side shift away by

lunging forward, P-A extension, and rotation away

Thrust: Into the arc of rotation toward the undersurface of the

eyes with the thrust hand while simultaneously rapidly supinating
opposite forearm

Author: Kyle Smith, PT

Reviewers: Cody Mansfield, PT; Paul Tadak, PT; Jake Bleacher, PT; Zaki Afzal, PT
Editors: John DeWitt, PT; J.J. Kuczynski, PT
Updated: July 19, 2018
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L. Hoving, Francis LeBlanc. “Manipulation and Mobilisation for neck pain contrasted against an inactive
control or another active treatment.” Cochrane Database of Systematic Reviews. 2015. Issue 9. Web
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CHRONIC PAIN CLINICAL PRACTICE GUIDELINE
Lauren Tiemeier, PT, DPT
Sean Meers, PT, DPT

Why Focus on Chronic Pain?

• Background
o Chronic pain is ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury, or
more than 3-6 months (Ratter, 2014). Chronic pain adversely affects an individual’s well-being. Chronic
pain can also contribute to disability, anxiety, depression; sleep disturbances, poor quality of life, and
high healthcare costs (Cochrane, 2014).
o Chronic pain persists and is often a self-limiting problem. Pain signals fire continuously in the nervous
system for weeks, months, and even years. Chronic pain can be due to an initial injury or, an ongoing
cause of pain such as arthritis, cancer, or infection. However, some people suffer from chronic pain in
the absence of any past injury or evidence of body damage. Common chronic pain complaints can
include headache, low back pain, cancer pain, arthritis pain, neurogenic pain, and/or psychogenic pain
(American Chronic Pain Association).

• Prevalence and Cost

o The total incremental cost of health care due to chronic pain is estimated at $261-$300 billion annually.
The value of lost productivity is based on three estimates: days of work missed ($11.6-$12.7 billion),
hours of work lost ($95.2-$96.5 billion), and lower wages ($190.6-$226.3 billion). According to the
National Institute of Health in 2011, the total financial cost of pain to society, which combines the health
care cost estimates and the three productivity estimates, range from $560-$635 billion annually.

• Population
o Chronic pain is defined as persistent pain that extends beyond normal tissue healing time greater than
three to six months (Ratter, 2014). Patients with persistent pain can have reduced or complete disability
in normal daily activities including self-care activities, household chores, cooking, grocery shopping,
driving, and sexual dysfunction (Ratter, 2014). Patients included in this clinical practice guideline are any
patients with persistent pain including but not limited to the musculoskeletal, neuromuscular,
inflammatory, or visceral/genitourinary tract systems. Common diagnoses seen in patients with
persistent pain include fibromyalgia, complex regional pain syndrome, migraines, headaches, peripheral
pain including osteoarthritis, rheumatoid arthritis and the vast array of spine pain disorders including
cervical, thoracic and lumbar spine pain (Nijs, 2015).

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• Risk Factors
o Can include, but are not limited to the following:
 Previous history of pain
 Psychological distress
 Dissatisfaction with work
 Lack of exercise
 Overuse/Heavy lifting
 Smoking
 Increased Age
 Persistent post-surgical pain
 Persistent post trauma pain
 Frequency of seeing medical providers

• Diagnosis/Classification
o Neuropathic Pain- pain caused by damage or disease affecting the somatosensory nervous system.
Neuropathic pain may be associated with abnormal sensations called dysesthesia or pain from normally
non-painful stimuli (allodynia). It may have continuous and/or episodic components.
 Peripheral- nerve pain that is a symptom of damage or dysfunction of the peripheral nervous
system, which is the vast network of nerves that send messages to and from the central nervous
system. Examples include complex regional pain syndrome, metabolic disorders, and phantom
limb.
 Central- nerve pain or symptoms which are neurological and caused by a dysfunction that
specifically affects the central nervous system, which includes the brain, brainstem and spinal
cord. Examples include Parkinson’s disease, multiple sclerosis, post-stroke pain, fibromyalgia,
and myelopathies.

o Musculoskeletal Pain- pain that can affect bones, muscles, ligaments, tendons, and nerves.
Musculoskeletal pain can be localized in one area, or widespread. Pain can be caused from injury,
overuse, poor posture, and/or prolonged immobilization. Examples can include low back pain, myalgia,
Myofascial Pain Syndrome, stress fractures, and tendonitis.

o Inflammatory Pain- localized reaction that produces redness, warmth, swelling, and pain as a result of
infection, irritation, or injury. Inflammation can be external or internal. Examples can include
arthropathies, infection, post-operative pain, and tissue injuries.

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Outcome Measures

• Suggested Outcome Measures to Utilize:

o PROMIS
(http://www.healthmeasures.net/administrator/components/com_instruments/uploads/PROMIS%20SF%
20v2.0%20-%20Physical%20Function%208b%2011-29-2016.pdf)
o Fear Avoidance Beliefs Questionnaire (FABQ) (http://www.clinicalprediction.com/wp-
content/uploads/2015/06/FABQ.pdf)
o The Brief Pain Inventory (http://prc.coh.org/pdf/BPI%20Short%20Version.pdf)
o The Pain Catastrophizing Scale
o Chronic Pain Acceptance Questionnaire (https://www.div12.org/wp-content/uploads/2015/06/Chronic-
Pain-Acceptance-Questionniare-Revised.pdf)
o Oswestry Disability Questionnaire (http://www.pro-
pt.net/files/pdf/Outcome%20Measures/Revised%20Oswestry.pdf)
o 2 Minute Walk TesT
o 6 Minute Walk Test
o 5x Sit to Stand

• Fear is a distressing negative experience induced by a perceived threat. The most commonly used outcome
measure for fear is the Fear Avoidance Beliefs Questionnaire (FABQ). The FABQ is designed to quantify fear
and avoidance beliefs in individuals with chronic pain. The FABQ has two subscales to measure fear-avoidance
beliefs about work and physical activity. The higher the score represents an increase in fear-avoidance beliefs.
(Burton, W et al., 1999) (Fritz, et al. 2002)

o Chronic pain is one of the most common disabling and persistent pain diagnoses (Baird, Sheffield,
2016). Beliefs about one’s pain and ability to cope with pain determine physical and mental health
outcomes in patients with chronic pain (Baird, Sheffield, 2016). The Brief Pain Inventory has been
found to be responsive to detecting and reflecting improvement in pain over time for chronic
nonmalignant pain. The Brief Pain Inventory maintains consistency and validity of measuring pain
intensity and pain interference within chronic pain patients. The measure is also considerably sensitive to
detecting and measuring changes in pain, such as demonstrating improvement (Tan, 2004).
o The Pain Catastrophizing Scale is multi-dimensional and considers rumination, magnification, and
helplessness as important components of catastrophizing. The Pain Catastrophizing Scale is a robust
tool that has clinical and non-clinical applications and seems to generalize across populations and
cultures (Van Damme, 2002). The Pain Catastrophizing Scale is a useful measure for predicting pain
intensity (Sullivan, 1995).
o Based on completion rates, distances walked, reliability and the high correlation between the distance
walked in 2 and 6 minutes, the distance walked over 2 minutes can be considered to be a legitimate
alternative to the distance walked over 6 minutes for indicating functional endurance among relatively
healthy community-dwelling individuals. Even if the 6 minute walk test is used, it may be useful to
document 2 minute walk test distance so that useful information is still obtained from individuals unable
to complete the full 6MWT (Bohannon, R, et al, 2014).

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• Chronic Pain Program Interventions

o Interdisciplinary Chronic Pain Program uses the integration of physical rehabilitation, psychosocial,
and medical interventions combined to create the most cost-effective and clinically-effective long term
care (Gatchel, 2014). A systematic review found intensive (>100) hours of multidisciplinary
biopsychosocial rehabilitation with functional restoration resulted in greater pain reduction and function
for patients with chronic, disabling low back pain (Guzman, 2001). Self-management interventions to
reduce pain limitations and improve physical activity have strong evidence for treatment of chronic
musculoskeletal pain conditions (Smith, 2016). Interventions should be focused on disrupting the vicious
cycle of fear avoidance behavior, pain, and disability (Bunzil, et al., 2017).

o Pain Neuroscience Education is used to treat patients with pain by changing cognitions, beliefs, and
fear before engaging a movement based approach of therapeutic exercise, graded exposure and pacing,
guided motor imagery, cognitive behavioral therapy, acceptance and commitment therapies (Louw,
Diehere, et al., 2011). The goal is to decrease fear and catastrophization. Pain neuroscience education
is an educational intervention which aims to reduce pain and disability by explaining the biology of the
pain experience to a patient (Moseley, 2005. Ryan, G et al., 2010).
 Delivery Methods
• Verbal instruction (1:1 is most effective)
• Duration & Frequency: 10-15 minutes; 1-2x/week; 1x/week when interspersed with
homework
• Group Sessions can be performed but should not exceed 12 patients, patients need to
be like-minded and can be seen 1x/week for 6-8 week.

o Graded Motor Imagery (GMI) is an intervention that may be effective for patients with persistent pain by
treating their cortical disruption (Bowering, 2013). The goal of GMI is to target cortical disruption and
normalize sensory stimulation without triggering the pain response (Bowering, 2013). GMI increases
cortical and spinal motor excitability. Visual input enhances tactile sensitivity. There is currently limited
evidence to support GMI and mirror therapy for treatment of chronic pain; however, early research does
support improvement in pain compared to traditional physical therapy interventions (Bowering, 2012).
Evidence demonstrates an increased analgesic benefit for individuals with Complex Regional Pain
Syndrome presenting with symptoms for 1 year or less (McCabe, 2008).
 Delivery Methods
• GMI should be organized starting with left-right discrimination, motor imagery, and then
mirror therapy.
• Duration & Frequency: Daily practice for optimal results; duration should be increased
per patient tolerance (may only tolerate 1-2 minutes at first to not experience increased
pain) (Moseley, G, et al., 2012)

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o Exercise is a common treatment for patients with persistent musculoskeletal pain aimed at reducing the
central nervous system sensitivity to movement with graded exposure (Nijs, 2015). It is recommended
that an exercise program be dosed and progressively loaded based on the individual’s own physical and
psychological capabilities (Smith, 2016). Exercise therapy is found to be more effective with an
individually designed stretching and strengthening program (Hayden, 2005). A systematic review and
meta-analysis found significant improvement in pain and function up until 12 months but no long-term
(>12 months) significant difference when patients exercised regardless of pain (Smith,2016). Another
exercise progression discussed the role of cognitive preparation before participating in therapeutic
exercise (Nijs, 2015). One randomly controlled trial found significant short-term pain reduction in favor of
McKenzie exercise techniques compared to regular lumbar stabilization for treatment of subacute and
chronic low back pain, but no long term differences were found (Peterson, 2002). Exercise can reduce
pain and improve function (van Middelkoop, 2010).

o Cognitive behavioral therapy (CBT) is the prevailing psychological treatment for individuals with
chronic pain (Edhe, 2014). CBT focuses on the development of personal coping strategies that target
solving current problems and changing unhelpful patterns in cognitions (e.g. thoughts, beliefs, and
attitudes), behaviors, and emotional regulation. Depression and physical disability are found to be
directly linked to self-efficacy beliefs (Asghari, 2008). CBT focuses on reducing maladaptive behaviors,
improving thoughts and beliefs, and increasing self-efficacy for pain management (Turner and Romano,
2001). CBT is effective in reducing pain and distress, and reducing disability in systematic and meta-
analysis reviews (Edhe, 2014). Multiple trials have shown that CBT is more effective for pain, functional
status, and behavioral outcomes than placebo or no treatment (Airaksinen, 2006).

o Acceptance and Commitment Therapy (ACT) is a type of behavior therapy that is used to treat chronic
pain and conditions that often go along with pain, such as anxiety, depression, and substance use
problems. ACT is an evidence-based treatment for chronic pain. ACT does not aim to reduce pain
intensity, but rather increase pain acceptance and reduce avoidance due to pain (Veehof, 2011). ACT is
a promising alternative to CBT, particularly in older populations. Mindfulness training can be a
particularly useful tool in restructuring patients’ avoidance cognitions, so that they can return to activities
of value despite pain (Okifuji, 2015). The literature is limited, but there is an indication that cognitive
reconstruction and acceptance allow for a greater pain tolerance, both in acute and chronic pain settings.
Acceptance seems to be effective in both settings (Kohl, 2014).

o Aquatic Therapy is an advantageous intervention for patients with chronic pain due to its anti-gravity
effects to minimize compressive forces and promote muscle strengthening, aerobic exercise, increase
blood circulation, reduce pain and improve quality of life (Lim, 2010). A randomized controlled trial found
after an eight week program, three times per week for 40 minutes consisting of aerobic exercise and
lower extremity strengthening exercises resulted in greater body mass reduction, reduced pain and
improved compliance and consistency (Lim, 2010). Benefits have been found to reduce pain, improve
mood, increase quality of life and increase aerobic capacity when treating patients with fibromyalgia
(Assis, 2006). Patients with chronic low back pain have improved disability and increased quality of life
compared to land-based therapy (Dundar, 2009), and a meta-analysis found moderate effect in reducing
pain, improving quality of life and physical function (Barker, 2014).
 Duration & Frequency: 3x/week for 8 weeks of 40 minute sessions for greater body mass
reduction, reduced pain and improved compliance and consistency (Lim, 2010)

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 o Pilates is a low impact program that focuses on core strength, stability, and proper breathing mechanics.
Goal is to increase circulation, decrease muscular tension, and improve postural awareness allowing for
improvement in pain and decreasing amount of stress placed on the body. A systematic review found
short term, significant benefits compared to normal physical activity and similar results to other therapies
for treating patients with chronic low back pain (Wells, 2014).

o Tai Chi has been shown to be beneficial for the treatment of chronic pain (Hall, 2011). Tai Chi is a
blanket term that has many variations that have different intensities, and an understanding of the type of
Tai Chi being performed is needed to appropriately place a chronic pain patient in the correct group.
Research shows that slow motion and weight shifting can improve musculoskeletal strength and stability
which therein are effective in decreasing associated pain and restrictions. Significant positive results for
treatment in chronic pain were found for low back pain, osteoporosis, and osteoarthritis (Kong, 2016)
(Lee, 2009).

o Yoga has been shown by several studies to offer significantly better pain reduction than usual care,
education, or conventional exercises (Posadzki, 2011). Combines postural awareness, breathing
techniques, and meditation or relaxation to significantly better pain reduction. Positive effect sizes of
yoga on all pain-related disorders as measured by pain intensity/frequency and pain-associated
disability. Yoga also demonstrates a positive effect with diminished anxiety, greater improvements in
functional disability, and depression (Dunleavy, 2016).

Algorithm Appendix **
• Patient History
o Description of current pain, including time of onset
o Systemic diseases check (osteoporosis, cancer, arthritis, infection, etc.)
o Neurological symptoms
o Bowel/bladder symptoms
o Biological and psychosocial risk factors

• (B) Physical Examination

o Motor weakness and reflex changes
o Sensory deficits
o Range of motion
o Pain patterns, including location and description
o Functional mobility assessment

• (C) Red Flags

o Suspected cauda equine syndrome
o Myelopathy/upper motor neuron changes
o Suspected cancer
o Suspected infection
o Recent undiagnosed trauma

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• (D) Yellow Flags
o Fear-avoidance behavior
o Low mood/withdrawal
o Expectation of passive treatment
o Negative pain beliefs
o Family concerns
o Job issues
o Persistent pain
o Different explanations
o Failed Treatment

• (E) Inclusion/Exclusion Criteria

o Inclusion
 Chronic nonmalignant pain >6 months
 Reasonably high functioning, roughly average intelligence, able to keep up with group
 Comorbid functional impairment and/or mood difficulties
 Motivated for treatment
 Willing to do group based treatment, generally gets along with others
o Exclusion
 Active (uncontrolled) substance use (except tobacco)
 Severe mental illness requiring higher level of care
 Unmotivated or unwilling to change
 Any other factors you think might interfere with group process

• (F) Referral Considerations

o Multidisciplinary Team Approach
o Initiate and encourage regular exercise and conditioning program (PT/OT)
o Psychosocial evaluation (psychology referral)
o Patient education and pain management plan (multidisciplinary)
o Medication management (PM&R)

• (G) 8 Week Group Therapy Program- refer to Chronic Pain Rehabilitation Program flyer

• (H) Treatment Guidelines- refer to Table H

• (I) Community resources- refer to Table I

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Flyer G:

Chronic Pain Rehabilitation Program

Description: The Comprehensive Pain Rehabilitation Program (CPRP) is an 8-week program for adults living with
chronic pain conditions. This program teaches healthy lifestyle and specialized skills for living a full life with pain. The
focus is on learning to pursue personal values and meaningful life goals in spite of physical and emotional pain.
CPRP uses an interdisciplinary team approach and includes staff from psychology, physical therapy, nutrition,
pharmacy, and medicine.

Schedule: Tuesday, 1:00 to 4:30 PM

• Group education & behavior therapy (1:00-3:00 PM)
• Group physical therapy (3:15-4:30 PM)

Check-in: Outpatient Care East Family Practice Center

nd
• 543 Taylor Avenue (2 floor), Columbus, OH 43203 On the first and last days of the program, please check in
by 12:30 pm to complete paperwork.

Attendance Policy: If you miss more than 2 appointments, you may be asked to participate at a later date. If for
whatever reason you are unable to attend, please contact Dr. Laurie Greco at (614) 366-8358.

Treatment Format:
• Eight (8) group sessions led by a clinical-health psychologist, physical therapist, and other members of the
treatment team, including: resident physician, clinical pharmacist, registered dietitian, and social worker
• Individual counseling, nutrition and pharmacy consultation, and case management services are available as-
needed

For more information about the OSU Family Medicine Chronic Pain Rehabilitation Program, please speak
with your provider or contact Dr. Laurie Greco at (614) 366-8358

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Chronic Pain Rehabilitation Program
Education & ACT Topics STAFF

• Education: Bio-psycho-social model of pain, active Clinical Health Psychologist

Week vs. passive treatment, hurt vs. harm Resident Physician
1 • ACT: Nature of human suffering, Mindfulness

• Education: Spine health, posture, body mechanics Physical Therapist

Week • ACT: Let’s get clear about what’s NOT working; Clinical Health Psychologist
2 Control as the problem, not the solution Resident Physician

Week • Education: Healthy sleep habits Social Worker

3 • ACT: Let’s get clear about what’s NOT working; Clinical Health Psychologist
Control as the problem, not the solution Resident Physician

Week • Education: Activity management, pacing skills, and Physical Therapist

4 SELF-managing flare-ups Clinical Health Psychologist
• ACT: Methods for cultivating willingness Resident Physician

Week • Education: Pain medications Pharmacist

5 • ACT: Methods for cultivating willingness Clinical Health Psychologist
Resident Physician

Week • Education: Mindfulness, nutrition & wellness Dietitian

6 • ACT: Methods for cultivating willingness Clinical Health Psychologist
Resident Physician

Week • ACT: Values identification & clarification; Clinical Health Psychologist

7 Willingness in the service of values Resident Physician

• ACT: Barriers to living out values Clinical Health Psychologist

Week Making & keeping commitments Resident Physician
8 Follow up / booster session(s)

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Group Education / Acceptance & Commitment Therapy (ACT)

Acceptance and Commitment Therapy (“ACT”) is the treatment approach used in the CPRP program. ACT is a type
of behavior therapy or “talk therapy” that is used to treat chronic pain and conditions that often go along with pain, such
as anxiety, depression, and substance use problems. ACT is considered an evidence-based treatment for chronic
pain. Research has shown that ACT is an effective approach for people living with chronic pain and related conditions.
For more ACT, please visit the website: www.contextualscience.org.

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Table H:
Type of Pain
Peripheral Neuropathic Pain
(ex. Complex Regional Pain
Syndrome, Metabolic disorders,
Phantom limb)
Central Neuropathic Pain
(ex. Fibromyalgia, Parkinson’s
Disease, Multiple Sclerosis,
Post-stroke Pain, Myelopathies)
Musculoskeletal Pain
(ex. Arthritic joint pain,
Myofascial Pain Syndrome)
Inflammatory Pain
(ex. Rheumatoid Arthritis,
Infection, Post-op Pain, Tissue
Injury)
Evaluation
• Symptoms: abnormal
sensations or pain from
normally non-painful
stimuli, swelling, change
in skin temperature and
skin color, joint stiffness,
muscle spasms
• Exam: weakness,
decrease in functional
mobility/ROM, decrease
in sensation
• Imaging: X-ray, MRI,
bone scan
• Symptoms: abnormal
sensations, heightened
pain response
• Exam: decrease in
functional mobility/ROM,
weakness, spasticity
• Imaging: X-ray, MRI, CT
Scan
• Symptoms: muscle
aches, muscle spasms,
tender to palpation, joint
stiffness, pain with
movement or rest
• Exam: decrease in
functional mobility/ROM,
weakness, palpable
trigger points
• Imaging: X-ray, MRI
• Symptoms: increased
redness, warmth,
swelling, and pain
• Exam: decrease in
functional mobility/ROM,
weakness
• Imaging: X-ray, bone
scan
Treatment Recommendations
• Physical therapy
including appropriate
exercise, aquatic
therapy, GMI,
desensitization, CBT,
ACT, TENS,
biofeedback, pain
neuroscience education
• Interdisciplinary Chronic
Pain Program
• Physical therapy
including appropriate
exercise, GMI, CBT,
ACT, bracing, pain
neuroscience education
• Interdisciplinary Chronic
Pain Program if meets
all inclusion criteria
• Physical therapy
including appropriate
exercise, aquatic
therapy, yoga, Pilates,
GMI, CBT, ACT TENS,
biofeedback, pain
neuroscience education
• Interdisciplinary Chronic
Pain Program
• Physical therapy
including appropriate
exercise, aquatic
therapy, GMI, CBT,
ACT, pain neuroscience
education
• Interdisciplinary Chronic
Pain Program
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Table I:
LOCATION ADDRESS PHONE WEBSITE
NUMBER
ABS Pilates 238 South State Route 605 (614) 499-6770 www.a-b-spilates.com
(Pilates) Sunbury, OH 43230

Arthritis Foundation www.arthritis.org

Columbus Aquatic 1160 Hunter Ave, (614) 645-3129 www.columbus.gov

Center Columbus, OH 43201
Columbus Tai Chi 3436 Heritage Club Dr. (614) 517-6404 www.taichicolumbus.com
(Tai Chi) South, Hilliard, OH 43026
Exercise Is Medicine OSU Sports Medicine (614) 685-4348 www.wexnermedical.osu.edu/fitness/health
Healthy New Albany
150 W. Main Street New
Albany, OH 43054
Local Fitness Centers Located throughout *Ex. Lifetime Fitness, YMCA’s, Planet
Columbus and surrounding Fitness, L.A. Fitness, Community
suburbs Recreation Centers, Jewish Community
Center, etc.
Ohio State Center for 2050 Kenny Rd # 1010, (614) 293-2800 https://wexnermedical.osu.edu/locations-
Wellness and Columbus, OH 43221 and-parking/center-for-wellness-and-
Prevention prevention
Pilates Innovations 4245 N. High Street (614) 388-8939 www.pilatesinnovations.org
(Pilates) Columbus, OH 43214
Silver Sneakers Located throughout *Available through most Medicare
Columbus and surrounding Advantage plans at various gyms/fitness
suburbs centers (Ex. YMCA’s, Lifetime Fitness)
Shift Grandview (Tai 1520 West 1st Ave (614) 407-4668 www.shiftgrandview.com
Chi) Grandview Heights,
Columbus, OH 43212

The Pilates Studio 1700 W. Lane Ave, (614) 485-9145 www.thepilatesstud.io/upper-arlington

Columbus, OH 43221
Turning Point Fitness 5890 Chandler Ct. (614) 895-1433 www.turningpointfit.com
(Pilates) Westerville, OH 43082

Wesley Ridge 2225 Taylor Park Dr, (614) 902-3820 www.wesleyridge.com/harcum-fitness-and-

Aquatic Center Reynoldsburg, OH 43068 aquatic-center
Yoga Physical (614)-949-9930 http://stephaniecarterkelley.com/contact
Therapist- Stephanie
Carter Kelley, PhD

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The Journal of Pain. 2004; 5(2): 133-137.

Tekur, P, Nagarathna, R, Chametcha S, Hankey, A, Nagendra H. A comprehensive yoga program improves pain,
anxiety and depression in chronic low back pain patients more than exercise: An RCT. Complementary Therapies
in Medicine. 2012; 20: 107-118.

Pilates article 2014. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0100402

Lumbar stabilization greater than Pilates and dynamic strengthening for chronic LBP
https://www.e-sciencecentral.org/articles/SC000026761

Umit Dundar, MD, Ozlem Solak, MD, Ilknur Yigit, MD, Deniz Evcik, MD,and Vural Kavuncu, MD. Clinical
Effectiveness of Aquatic Exercise to Treat Chronic Low Back Pain, A Randomized Controlled Trial. Spine. 2009;
34(14): 1436-40.

Van Damme S, Crombez G, Bijttebier P, Goubert L, Van Houdenhove B. A confirmatory factor analysis of the
Pain Catastrophizing Scale: Invariant factor structure across clinical and non-clinical population. Pain. 2002;
96(3): 319-342.

vanMiddelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, vanTulder MW. Exercise therapy for
chronic nonspecific low-back pain. Best Prac Res Clin Rheumatol 2010:24 (2):193-204.

Veehof, M, Oskam, MJ, Schreurs, K, Bohlmeijer, E. Acceptance-based interventions for the treatment of chronic
pain: A systematic review and meta-analysis. Pain. 2011; 152: 533-42.

Vowles, K, Witkiewitz, K, Sowden, G. Acceptance and Commitment Therapy for Chronic Pain: Evidence of
Mediation and Clinically Significant Change Following an Abbreviated Interdisciplinary Program of Rehabilitation.
The Journal of Pain. January 2014; 15(1): 101-113.
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Waller, Benjamin, Lambeck Johan, Daly Daniel. Clinical Rehabilitation. Therapeutic aquatic exercise in the
treatment of low back pain: a systematic review. 2009; 23: 3-14.

Wetherell, J, Petkus, A, Alonso-Fernandez, M, Bower, E, Steiner, A, Afari, N. Age moderates response to

acceptance and commitment therapy vs. cognitive behavioral therapy for chronic pain. International Journal of
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INTERMEDIATE RETURN TO RUNNING

REHABILITATION GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

• Ideal for athletes with non-surgical injuries, post-surgical patients following Alter G or Deep Water Running
Progression and runners that average 20-40 miles per week
• This guideline is intended for end stage rehabilitation return to running and the clinician should use their
own clinical judgement when it is safe to return the athlete to plyometrics and running
• Supplement with Alter G and Deep Water Running Progression for post-surgical patients

Phase I: Walking and Plyometrics

Criteria to • Ability to walk 30 minutes pain-free
Start Phase I • Full joint range of motion
• At least 80% strength compared to the unaffected limb (specifically post-surgical
injuries)
• Trace to no edema present
Goals • Tolerate single leg impact activities
• Demonstrate proper lower extremity biomechanics
• Walking without limitations
• Demonstrate equal quality and power bilaterally
Guidelines • Double limb jumps progressed to Sample Functional Hop Progression
single limb hops
Double Leg Single Leg
• Unilateral to multi-directional plane
hops Hop in Place Hop in Place
Forward Hop Forward Hop
Backward Hop Backward Hop
Triple Hop Triple Hop
Side-to-Side Hop Side-to-Side Hop
Crossover Cross-over
Scissor Hops Dot Drills
Dot Drills Lateral Bounds/Skaters
180 Degree Hops 90 Degree Hops

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Phase II: Walk to Run Progression

Criteria to • Athlete is able to tolerate 200-250 foot contacts
Start Phase II o Athlete is able to tolerate number of foot contacts for ~1/3rd of a mile of running
• No symptoms reported by the patient and demonstrates adequate plyometric form with
minimal to no knee valgus, toe to heel landing, no trunk lean, and demonstrates soft
landing
• Ability to perform 15 heel taps with proper LE mechanics
Goals • Progression back to continuous running without aggravation of symptoms and antalgia

Guidelines • Prior to walk to run progression complete 5 minute dynamic warm-up (example at
wexnermedical.osu.edu/sports-medicine/treatments/endurance-medicine)
• Athlete must take at least one running off day in between each return to running
workout, non-impact cross training during off days
• Take at least one complete rest day a week
• If athlete develops pain, return of other symptoms, or cannot complete the phase they
remain at that phase until they are able to complete it without symptoms
• Complete only one phase per day

Intermediate
Walk to Run Warm-up Run:Walk Repetitions Cool down Total Days
Program
Phase 1 5-10 min 2 min:1-2 min 2-4 5-10 min 20-30 min 2
Phase 2 5-10 min 4 min:1-2 min 2-4 5-10 min 25-35 min 2
Phase 3 5-10 min 6 min:1-2 min 2-4 5-10 min 30-40 min 2
Phase 4 5-8 min 8 min:1-2 min 2-4 5-8 min 35-45 min 2

Phase III: Running Progression

Criteria to • Able to complete Phase II without pain or symptoms
Start Phase III • At least 90% strength and Limb Symmetry Index compared to the unaffected limb
(specifically post-surgical injuries)
• Ability to perform 12 inch hop downs from box with proper LE mechanics
Goals • Increase daily and weekly mileage gradually
• Return to normal running routine within 5 weeks
• No return of pain or symptoms
Guidelines • Athlete can cross train or rest on off days, but must take at least one rest day a week
• Prior to run progression complete 5 minute dynamic warm-up and 5-10 min walking
warm-up
• After run complete 5-10 min walking cool down and post-run stretch

Intermediate
Running Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Total
Progression Miles
Week 1 - 1 - 2 - 2 - 5
Week 2 - 2 - 3 - 4 - 9
Week 3 - 4 - 3 - 4 - 11
Week 4 5 - 4 3 - 5 - 17
Week 5 5 - 6 4 - 5 - 20

INTERMEDIATE RETURN TO RUNNING

PROGRAM (FOR PATIENTS)
Step 1: Walk to Run
• Only complete one phase per day, performing workout every other day
• On off days, either cross train or rest but must take one day of complete rest each week
• Stop running if you begin to experience pain, swelling, or altered running/walking pattern
• Complete each phase without symptoms before moving on to the next phase

Intermediate
Walk to Run Warm-up Run:Walk Repetitions Cool down Total Days
Program
Phase 1 5-10 min 2 min:1-2 min 2-4 5-10 min 20-30 min 2
Phase 2 5-10 min 4 min:1-2 min 2-4 5-10 min 25-35 min 2
Phase 3 5-10 min 6 min:1-2 min 2-4 5-10 min 30-40 min 2
Phase 4 5-8 min 8 min:1-2 min 2-4 5-8 min 35-45 min 2

Step 2: Running Progression

• On off days, either cross train or rest but must take one day of complete rest each week
• Avoid hill running until you have returned to your normal weekly mileage and pace
• Stop running if you begin to experience pain, swelling, or altered running pattern
• Work to increase speed before increasing distance

Intermediate
Running Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Total
Progression Miles
Week 1 - 1 - 2 - 2 - 5
Week 2 - 2 - 3 - 4 - 9
Week 3 - 4 - 3 - 4 - 11
Week 4 5 - 4 3 - 5 - 17
Week 5 5 - 6 4 - 5 - 20

Recommendations to Prevent Injuries in the Future

• Give yourself at least one rest day a week
• Continue with strengthening exercises from physical therapy at least 2-3 times a week
• Perform a dynamic warm-up prior to running and perform static stretching after your run (example at
wexnermedical.osu.edu/sports-medicine/treatments/endurance-medicine)
• Decrease mileage or stop running if your injured, slowly return to your normal routine
• Increased mileage increases your risk of injury, gradually increase mileage and intensity


References

Bates NA, Ford KR, Myer GD, Hewett TE. Impact differences in ground reaction force and center of mass
between the first and second landing phases of a drop vertical jump and their implications for injury risk
assessment. J Biomech. 2013;46(7):1237-41.
Brumitt J. A return to running program for the postpartum client: a case report. Physiotherapy Theory and Practice.
2009;25(4):310-325.
Fields KB, Sykes JC, Walker KM, Jackson JC. Prevention of running injuries. Current Sports Medicine Reports.
2010;9(3):176-182.
Fredericson M, Cookingham CL, Chaudhar AM, et al. Hip abductor weakness in distance runners with ITB. Cli. J.
Sport Med. 2000;10:169-175.
Gottschall JS, Kram R. Ground reaction forces during downhill and uphill running. Journal of Biomechanics.
2005;38:445-452.
Hreljac A. Etiology, prevention and early intervention of overuse injuries in runners: A biomechanical perspective.
Phys Med Rehabil Clin N Am. 2005;16:651-667.
Ryan ED, Everett KL, Smith DB, et al. Acute effects of difference volumes of dynamic stretching on vertical jump
performance, flexibility and muscular endurance. Clin Physiol Funct Imaging. 2014;34(6):485-492.
Ryan MB, Maclean ML, Taunton JE. A review of anthropometric, biomechanical and neuromuscular and training
related factors associate with injury in runners. International Sportmed Journal. 2006;7(2):120-137.
Sim AY, Dawson BT, Guelfi KJ, et al. Effects of static stretching in warm-up on repeated sprint performance.
Journal of Strength and Conditioning Research. 2009;23(7):2155-2162.
Stracciolini A, Meehan WP, d’Hemecourt PA. Sports rehabilitation of the injured athlete. Clin Ped Emerg Med.
2007;8:43-53.
Warden SJ, Davis IS, Fredericson M. Management and prevention or bone stress injuries in long-distance
runners. JOSPT. 2014;44(10):749-765.

PROXIMAL DEEP VEIN THROMBOSIS (PDVT)

CLINICAL DECISION RULE

Facts

Proximal • Affecting popliteal or femoral veins

• 5.1% fatality rate following anticoagulant therapy
• Studies indicate that physical therapist may underestimate the probability of the PDVT by as
much as 87%-64%

Distal • Calf veins

• Can dislodge and cause a PDVT and/or pulmonary embolism (PE)

Risk Factors
Strong Moderate Weak
• Fracture (pelvis, femur, • Arthroscopic knee surgery • Bed rest > 3 days
tibia) • Central venous lines • Immobility due to sitting
• Hip or knee replacement • Chemotherapy • Increasing age
• Major general surgery • Congestive heart or respirator failure • Laproscopic surgery
• Major trauma • Malignancy • Obesity
• Oral contraceptive therapy • Varicose veins
• Cerebrovascular accident
• Pregnancy/postpartum
• Previous venous thromboembolism

Conditions that may mimic PDVT

Category of Condition Specific Examples

Musculoskeletal Trauma, hematoma, myositis, tendonitis, baker’s cyst, synovitis, OA,
osteomyolitis, tumors, fractures
Neurological Sciatica, lower-limb paralysis
Venous Phlebitis, postthromboic syndrome, compressed veins
Arterial Acute arterial occlusions, a-v fistula
Generalized edema Cardiogenic, nephrogenic, dysprotinemic
Cutaneous Dermatitis, cellulites, lipoedema, panniculitis
Localized edema Pregnancy, oral contraceptives, limb immobilization

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a
Clinical Finding Score

Active cancer (within 6 months diagnosis or palliative care) 1

Paralysis, paresis, or recent plaster immobilizations of LE 1
Recently bedridden > 3 months or major surgery within 4 weeks of application of clinical decision rule 1
b
Localized tenderness along distribution of deep venous system 1
Entire lower extremity swelling 1
c
Calf swelling by > 3cm compared with asymptomatic lower extremity 1
Pitting edema (greater in symptomatic lower extremity) 1
Collateral superficial veins (nonvaricose) 1
d
Alternative diagnosis as likely or greater than that of deep vein thrombosis -2

a
Score interpretation: Greater than or equal 0 = probability of proximal lower extremity deep vein thrombosis (PDVT) of 3%
(95% confidence interval [CI] = 1.7%-5.9%), 1 or 2 = probability of PDVT of 17% (95% CI = 12- 23%), Greater than or equal to
3 = probability of PDVT of 75% (95% CI = 63-84%).
b
Tenderness along the deep venous system is assessed by firm palpation in the center of the posterior calf, the popliteal
space, and along the area of the femoral vein in the anterior thigh and groin.
c
Measured 10 cm below tibial tuberosity
d
Most common alternative diagnosis are cellulites, calf strain, and postoperative swelling

Ø Although the clinical diagnosis rule is a valid and reliable tool, all patients who are suspected of having
PDVT should have their physician contacted by the physical therapist and undergo formal diagnostic
testing even if the risk of PDVT is low.

References

Riddle DL, Wells PS. Diagnosis of lower-extremity deep vein thrombosis in outpatients. Physi
Ther. 84: 729-735, 2004.

Riddle DL, Hillner BE, Wells PS, et al. Diagnosis of lower-extremity deep vein thrombosis in
outpatients with musculoskeltal disorders: a national survey study of physical therapist. Phys Ther. 84; 7171-728.

STRENGTH / CONDITIONING CLINICAL PRACTICE
Chris Kolba, PT, PhD, MHS, CSCS
DISCLAIMER
Strength progression in rehabilitation is time and criterion based, dependent on tissue healing
timeframes, patient demographics and clinician evaluation.

BACKGROUND:
The outpatient and sports medicine clinician is responsible for returning their patients to the functional
activities they are unable to complete. If the clinician is unfamiliar with strength and power
progression they may be limited in optimizing the patient’s full recovery. This has been identified in a
few long term studies that reported even after 1-2 years people still lacked strength and power after
their injury /surgery and did not return to their activity at the previous level. (7) While many factors
may be identified, we should ask ourselves if we have progressed the patients strength and power to
its optimal level. This provides the patient with the confidence and reduces the risk of re-injury
associated with successful return to sports participation. (1)
This document will serve to provide rehab professionals with a frame work to progress strength
beyond the subacute phase. It will also serve to fill a gap in our education and clinical practice that
will significantly impact patients and their goal of returning to optimal function whether it be for life,
work or recreation.

SUMMARY OF RECOMMENDATIONS

Precautions /Contraindications
 Unhealed /inflamed tissue- healing tissue should not be overstressed.
 Contra-indicated movements per post-surgical guidelines. Ex: bench pressing after anterior shoulder
stabilization
 Diabetes, heart disease, osteoporosis – not contraindicated if stable
 Fever / flu like symptoms – not appropriate to lift /exercise
 Postural and technique considerations should be addressed
 Heavy weights in skeletally immature individuals
 Plyometric exercises need to be progressed appropriately and not used for conditioning and
endurance.
 See Appendix B

Criteria for progression:

 Pain free range of motion.
 No compensatory motion that would adversely affect performance of selected exercise.
 Appropriate ability to communicate and follow directions.
 Successful completion of previous phase. (Complete light weight exercises prior to moderate weight
exercises before progressing to heavy weight).
 No reactive pain or effusion.
 See Appendix A

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Phases of progression:
Periodization is the planned manipulation of both work and rest to maximize results and reduce injury.
Generally it would involve progressing strength and power training through the phases of general
conditioning, hypertrophy, strength and power (max strength).

Hypertrophy – working to increase the size of a muscle to prepare for the next phase
Intensity Reps Sets Frequency Rest between
sets
50-75% of 1 6-12 3-5 2-3x/wk. 30sec –
Rep max (RM) 1.5min

Strength - force production

Intensity Reps Sets Frequency Rest
80-90% of 1 4-8 3-5 2-3x/wk. 2-5 min
rep max

Power – The maximal force a muscle can generate

Intensity Reps Sets Frequency Rest
85-95% of 1 rep 1-4 3-5 2x/wk. 2-5min
max

*See Appendix A for linear and undulating models of periodization

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Plyometric / Power Purpose is to decrease amortization phase and increase explosiveness of
muscle. Increase rate of force development.
Key Points:
 High eccentric forces
 Higher risk for injury
 Not to be used as conditioning
 Typically performed in beginning of session
 Measure intensity by number of foot contacts for LE and UE contacts /throws

Plyometric Volumes & Frequency per NSCA

(Essentials of Strength Training and Conditioning 3rd Edition. 2008)
Plyometric Volume Frequency /week Rest
Experience (contacts/session)
Beginner (no 80-100 1-3 /WK Alt. linear & 45-60 sec
experience) multidirectional days between sets
1:5 – 1:10
work/rest
ratio
Intermediate (some 100-120 1-3/WK Alt. linear &
experience) multidirectional days
Advanced 120 - 140 1-3/WK Alt. linear &
(considerable multidirectional days
experience)

See Appendix B for example of Plyometric Progression

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APPENDIX A

Linear Model Periodization (Essentials of Strength Training and Conditioning. 3rd Edition. 2008)
Utilized when there is adequate time frame of training to complete the phases.
Multiple weeks spent on each phase – Traditionally 4-6 weeks starting in the hypertrophy phase and
progressing into strength and then power. This will assist in optimizing the patient’s progression to
more appropriately prepare them for return to sport and reduce their risk of re-injury.
Phase Intensity Reps Sets Frequency Duration
Hypertrophy 50-75% 10-25 3-5 2-3x/wk. 4-6wks
1RM

Strength 80-90 4-8 3-5 2-3x/wk. 4-6wks

1RM

Power 85-95% 1-4 3-5 2-3x/wk. 4-6wks

1RM

Hypertrophy Phase Practical Example Upper Body Exercises

Warm up: super set Y & T with serratus punches 2-3 x 15

Bench Press/Stand Band 3 sets 8-10 Rest 30 sec – 1.5 min

Press
1 Arm Cable Row (from 4 sets 8-10 30 sec – 1.5 min
mid position)
Shoulder Overhead Press 3 seta 8-10 30 sec – 1.5 min
B Cable Pull Down 4 sets 8-10 30 sec – 1.5min

Clinical Pearl: Super set Bench with cable row and shoulder press with cable pull down. (Push-Pull
super set)

Strength Phase Practical Example: Leg Exercises

Warm up: 2-3 rounds Body weight Lunge Walk superset with band or cable resisted side stepping

Barbell squat 4 sets 5 reps Rest 2-5 min

Barbell deadlift 4 sets 5 reps 2-5min
Leg Press 4 sets 5 reps 2-5min
Modified Deadlift 4 sets 5 reps 2-5min

Clinical Pearl: Superset each of above exercises with another balance or opposite muscle group to
get more work done in same amount of time.
Ex. Barbell Squat paired with feet on physio ball bridge or balance exercise.

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APPENDIX A Cont.

Undulating Model Periodization (2 examples)

 Varied intensity each work out throughout week
 Shown to be just as effective as linear model. May be more practical

Utilized for athlete training /competing year round or multi-sport athlete when 4-6 week time frames
are not available to follow linear model.

May be more appropriate for later phases of rehab. For example, in a later phase ACL patient
attending PT 2x/wk. you might work 1 day using 8 reps for your main exercises and for the second
visit of the week work in the 4 repetition range with your exercises. Alternatively, you could work in
the 6 or 8 rep range both days and change the exercises you are doing each day.

Example 1
Monday Strength 4-6 reps 3-5 sets

Wednesday Hypertrophy 6-15 reps 3-5 sets

Friday Power 1-4 reps 3-5 sets

Example 2
Monday Hypertrophy 6-15 reps 3-5 sets

Wednesday Strength 4-6 reps 3-5 sets

Friday Power 1-4 reps 3-5 sets

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Appendix B
Divide plyometric sessions into linear plyometrics (floor to box jumps / hurdle jumps / vertical jumps,
tuck jumps / anterior single legs hops) and multidirectional plyometrics ( alt. side-side hops -
skaters / lateral jumps over hurdle / single leg lateral hop)

Example of Plyometric Progression

(New Functional Training for Sports. 2nd edition. 2016.)

Phase 1
 Focus on mechanics w/ decreased eccentric forces / Quiet landings
 (2x/week 5 sets 5 -10 foot contacts = 50 to 100 contacts / week)
 Jump up onto box - SL hop up onto box 5x5-10 4-8in box
 Lateral hop up onto box / Alternating side to side hop w/ hold (Skater hops) 5x5-10

Phase 2
 Continue focus on form & technique. Increase eccentric forces by removing box
 (2x/week 5 sets 5-10 foot contacts /session)
 Vertical Jump and stick landing
 Lateral jump over hurdle and stick landing

Phase 3
 Add elastic response (2x/week 5 sets 5-10 foot contacts /session)
 Jump over hurdle to vertical jump & stick landing

Phase 4
 Plyometrics. Repetitive Jumps (2x/week 5 sets 5-10 foot contacts /session)
 Multiple jumps over hurdles – anterior and laterally. Progress to hops

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APPENDIX C
Common multi-joint exercises used in strength training

SQUAT

DEADLIFT

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SUMO DEADLIFT

BENCH PRESS

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APPENDIX D
Terminology

Periodization
Cycling of volume, intensity and duration to achieve desired goals, reduce injury and plateaus.

Volume
Total amount of weight lifted in a training session. Calculated: sets x reps x load

Intensity /Load
The amount of weight lifted

Duration /Frequency
How many reps or how often

Set
A group of repetitions sequentially performed before stopping to rest

Rep
The number of times a weight is lifted within a set.

Super Set
2 or more exercises working different muscle groups are performed in a row without rest between
them.

Strength
Force x distance

Power
Work divided by time

Jump
Double leg take off followed by double leg landing

Hop
Single leg take off, landing on same foot

Bound
Single leg take off, landing on opposite foot

Skip
Single leg take off with two foot contacts

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REFERENCES

Texts /Books
Baechle, TR., Earle, RW. NSCA Essentials of Strength Training and Conditioning 3 rd edition. 2008.
Boyle, M. New Functional Training for Sport 2nd edition. 2016.
Santana, JC. The Essence of Program Design. 2004
Starrett, K., Cordoza, G. Becoming a Supple Leopard. 2 nd edition. 2015.
Bompa, T., Buzzichelli, C. Periodization Training for Sports. 3 rd Edition. 2015.

Articles
1. Arden, CL, Webster KE, Taylor NF, et al. Return to sports following anterior cruciate ligament
reconstruction surgery: a systematic review and meta-analysis of the state of play. 2011; Vol. 7: 596-
606.
2. Cormie, P., McGuigan, M.R., Newton, R.U., et al. Developing neuromuscular power: part 2 -
training considerations for improving maximal power production. Sports Medicine (Auckland, N.Z.)
Feb 2011, 41(2):125-146.
3. R. Csapo, L. M. Alegre. Effects of resistance training with moderate vs heavy loads on muscle
mass and strength in the elderly: A meta-analysis. Scand J Med Sci Sports. 2016; 26: 995–1006.
4. Davies TB , Kuang K, Orr R, Halaki M, Hackett D. Effect of Movement Velocity During
Resistance Training on Dynamic Muscular Strength: A Systematic Review and Meta-Analysis. Sports
Medicine (Auckland, N.Z.). Aug 2017;47(8):1603-1617.
5. Gonzalez, A.M. Acute Anabolic Response and Muscular Adaption After Hypertrophy-Style and
Strength-Style Resistance Exercise. Journal of Strength and Conditioning Research. 20016; Volume
30, Number 10.
6. Grgic, J., Schoenfeld, B.J., Davies, T.B. et al. Effect of Resistance Training Frequency on Gains in
Muscular Strength: A Systematic Review and Meta-Analysis. Sports Medicine. May 2018; Volume
48, Issue 5, pp 1207–1220.
7. Larsen, JB, Farup, J., Lind, M., et al. Muscle strength and functional performance is markedly
impaired at the recommended time point for sport return after anterior cruciate ligament
reconstruction in recreational athletes. Hum Mov Sci. 2015; 39:73-87.
8. Ralston, GW., Kilgore, L., Wyatt, FB., Baker, JS. The Effect of Weekly Set Volume on Strength
Gain: A Meta-Analysis. Sports Med. 2017; 47:2585–2601.
9. Ratamess, NA., Alvar, BA., Evetoch, Tk. ACSM. Progression Models in Resistance Training for
Healthy Adults. Med Sci Sports Exerc. 2009; Vol. 41 (3), pp. 687-708
10. Rathleff, MS, Mølgaard, CM, Fredberg, U., et al. High‐load strength training improves outcome in
patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up. Scandinavian
Journal of Medicine and Science in Sports. 2015; Volume 25, Issue 3.
11. Silva, N.L., Oliveira, R.B., Fleck, S.J., et al. Influence of strength training variables on strength
gains in adults over 55 years-old: A meta-analysis of dose–response relationships. Journal of Science
and Medicine in Sport. 2014; ( 17) 337–344.
12. Schoenfeld, BJ. Is There a Minimum Intensity Threshold for Resistance Training-Induced
Hypertrophic Adaptations? Sports Med. 2013; 43:1279–1288.
13. Schoenfeld, BJ., Grgic, J., Ogborn, D., et al. Strength and Hypertrophy Adaptations Between
Low- vs. High-Load Resistance Training: A Systematic Review and Meta-analysis. Journal of
Strength and Conditioning Research. 2017; 31(12):3508-3523.

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14. Schoenfeld, BJ, Ogborn, DI, Krieger, JW. Effect of Repetition Duration During Resistance
Training on Muscle Hypertrophy: A Systematic Review and Meta-Analysis. Sports Medicine. 2015;
Volume 45, Issue 4, pp 577–585.
15. Suchomel, TJ, Nimphius, S., Bellon CR., et al. The Importance of Muscular Strength: Training
Considerations. Sports Medicine (Auckland, N.Z.) 2011,; 41(2):125-146.

Strength /Cond. Clinical Practice Guideline Author: Chris Kolba PT PhD MHS CCSCS. 2018
J Environ Res Public Health. 2017; 14(9).

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AN EVIDENCE-BASED GUIDELINE FOR PHYSICAL
THERAPY MANAGEMENT OF TEMPOROMANDIBULAR
JOINT DYSFUNCTION (TMD)
Physical therapists have an important role on the interpersonal team to provide care for people with temporomandibular
disorders (TMDs). The purpose of this guideline is to provide the clinician with a variety of evidence based methods to
effectively evaluate and manage TMD.

Patient reported outcome measures

• The recommended patient reported outcome measure is the TMD Disability Index
• The TMD Disability Index (also referred to as the Steigerwald Maher TMD Disability Index) was created in 1997
and involves 10 functionally related questions associated with TMD. The scale is a self-report, disease-specific
instrument with five possible selections for each question, each with increasing severity. (6)
• A study in 2015 at European School of Osteopathy, University of Greenwich suggests that the TMD Disability
Index offers sufficient external validity and could be integrated into practice life as a quick, accessible, and easy
tool to monitor patients’ progress and assess levels of inflammation, without the need for repetitive imaging. (6)

Dietary considerations

• Dietary considerations include soft foods to minimize over stretching of the mastication muscles such as beans,
steamed vegetables or fruits, cheese or cottage cheese, fish, fruit smoothies, oatmeal or other soft, hot breakfast
cereals, mashed potatoes, scrambled eggs, soup, or yogurt (3)
• Refrain from eating any foods that require one to open too wide, sticky or chewy items such as caramel apples or
candy bars, hard or crunchy foods, apples, pretzels, or raw carrots, crunchy cereals, or tough steak
• One can progress to foods that initially were painful or difficult to consume
• Once symptoms have decreased to a manageable level, harder foods can be periodically tested for provocation
and reintroduced when appropriate (3)

Considerations for manual therapy

• Consider implementation of joint mobilization (grade I or II) for pain including distraction, anterior glide, anterior
glide with pre-positioned mouth opening (5)
• medial/lateral glides, caudal-anterior-medial (CAM) glide and CAM with pre-positioned mouth opening (5)
• Joint mobilization should be applied when a movement restriction is evident but should be avoided if joint
hypermobility is suspected or verified unless a low-grade technique is utilized (5)
• Joint mobilization dosage should be guided by an informed decision that takes into account the patient’s irritability
level and can include cervical manual techniques
• Consider implementation of intraoral and extraoral soft tissue mobilization
• At a minimum, the temporalis, masseter, medial pterygoid, and lateral pterygoid muscles must be considered (8)
• Accessory muscles of mastication and cervical spine musculature may also require management through soft
tissue mobilization (8)
• Utilizing one digit or one reinforced digit to contact a myofascial trigger point or the general muscle belly can be
helpful
• Friction massage can be applied in a variety of directions and are easily applied to the masseter and temporalis
muscle bellies
• Intra-oral techniques directed at the medial and lateral pterygoid muscles are useful as well (consideration of
patient gag reflex is recommended) (9)

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 • Trigger Point Dry Needling could be considered when TMD associated muscle pain is related to trigger points
(must be sufficiently trained to implement) (5)

Considerations for therapeutic exercise

• Perhaps the most widely known exercise routine for TMD is the Rocabado 6 x 6 program which utilizes six
exercises six time per day (see table 1)
• The program has only been studied once for effectiveness and suggests the program adds no extra benefit to the
rehabilitation process
• Kraus’ temporomandibular joint exercises include those to inhibit excessive masticatory muscle activity, target
both neuro-muscular control of mandibular movement, and address joint clicking, muscle asymmetry, deviations
in active ROM patterns, and spasms that limit opening via isometrics (see table 2)

Patient education

• Patient education is a central component of TMD management and should include reducing parafunctional habits,
addressing psychosocial factors, and providing pain science education
• Functional habits are generally limited to caloric intake, breathing, and yawning
• Parafunctional habits can include bruxism and lip biting
• The clinician should educate the patient with regard to food consistency, laterality of chewing (ie chewing on both
sides if able to promote symmetry or unilaterally initially if chewing is too uncomfortable), symptom behavior, and
pain variables
• Harder, drier foods require an increased number of chewing cycles and longer times in the mouth before
swallowing
• Those with hypermobility may require education to avoid end range positions such as with yawning
• To avoid overstretching and irritating joint structures with yawning, the patient should be taught not to depress
their mandible farther than the position that permits the tip of the tongue to maintain contact with the hard palate
just posterior to the upper incisors
• Refrain from weight bearing through the joint (ie: resting the hand on the mandible if sitting at a desk)

Modalities

• Electrical stimulation has been recommended for the management of TMD

• Both interferential current and transcutaneous electrical nerve stimulation (TENS) have been show to produce an
analgesic effect in pain-free volunteers provoked by ischemic conditions
• In this study, stimulation was applied for 30 minutes, which may exceed dosage times commonly utilized in
clinical settings
• The utilization of biofeedback has also been recommended for the management of TMD during which surface
electrodes are typically placed over the masseter or anterior temporalis
• Iontophoresis with dexamethasone has been recommended for use in the management of TMD; however,
evidence supporting this approach is mixed
• Studies have shown that iontophoresis can deliver dexamethasone between eight and 17 mm deep and that long
duration (3 hours) application via low current is more effective than more traditional delivery by higher currents
over 10-30 minutes
• There an abundance of evidence suggesting little benefit from therapeutic ultrasound in managing TMD, and is
not recommended by the authors who conducted the studies (10)

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Multimodal approaches

• A series of studies demonstrated that over a minimum of five 30-minute sessions, multimodal management of
TMD including soft tissue mobilization, muscle stretching, gentle isometric tension exercises against resistance,
guided opening and closing, manual joint distraction, disc/condyle mobilization, postural corrections, and
relaxation techniques are helpful in reducing symptoms associated with TMD (4)

Cervical spine management

• The clinician should take care to address any cervical spine range deficits, accessory movement restrictions, and
altered muscle recruitment patterns

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Author:

Erik Phillips, PT, DPT, MBA, OCS

Reviewers:

Paul Tadak, PT, DPT, OCS

Damian Jankowski, PT, DPT, MBA

Completion date: 11/19/18

References:

1.) Wilk B, Stenback J, McCain J. Post arthroscopy Physical Therapy Management with Temporomandibular Joint
Dysfunction. JOSPT, Vol 18 September 1993
2.) Placzek J, Boyce B. Orthopaedic Physical Therapy Secrets 2nd ed. pp 496. Elsevier Inc, 2006.
3.) Shaffer S, Brismee J, Sizer P, Courtney C. Temporomandibular disorders. Part 1: Anatomy and
Examination/Diagnosis. Journal of Manual and Manipulative Therapy 2014 Vol 22.
4.) Shaffer S, Brismee J, Sizer P, Courtney C. Temporomandibular disorders. Part 2: Conservative Management- A
Systematic Review. Journal of Manual and Manipulative Therapy 2014 Vol 22.
5.) Effectiveness of Manual Therapy and Home Physical Therapy in Patients with Temporomandibular Disorders: A
Randomized Control Trial. Journal of Bodywork and Movement Therapies 2013.
6.) Johnston K, Bird L, Bright, P. Temporomandibular Joint Effusion and its Relationship with Perceived Disability
Assessed Using musculoskeletal Ultrasound and a Patient-reported Disability Index. Ultrasound 2015 May; 2
7.) Harrison A, Thorp J, Ritzline P. A Proposed Diagnostic Classification of Patients with Temporomandibular
Disorders: Implications for Physical Therapists. Journal of Orthopedic and Sports Physical Therapy March 2014
Vol 44
8.) Cook C. Orthopedic Manual Therapy: An Evidence-Based Approach. 2007 Pearson Education, Inc. pp 151-176.
9.) Cleland J. Orthopedic Clinical Examination: An Evidence-Based Approach for Physical Therapist. 2005 Icon
Learning Systems pp 141-199.
10.) Vander Windt, DA, vander Heijen GJ, Vanden Berg SG, Bouter LM. Ultrasound therapy for musculoskeletal
disorders: A Systematic Review. Pain. 1999; 81: 257-71.

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Appendix

Figure 1 Distraction of the temporomandibular joint (TMJ); large arrow: distraction force placed through the
ipsilateral lower molars and premolars with the first digit while the second and third digits provide a counterforce
on the inferior aspect of the ipsilateral and contralateral mandibular bodies, respectively; medium arrow:
posteriorly directed stabilization force applied through the ipsilateral aspect of the patient’s forehead; small
arrow: the examiner palpates the joint line to assess for movement of the mandibular condyle.

Figure 2 Anterior glide of the temporomandibular joint (TMJ); large arrow: anterior glide force with mild
caudal bias placed through the mandible via gripping the ipsilateral lower molars and premolars with the
first digit while the second and third digits provide a counterforce on the inferior aspect of the ipsilateral
and contralateral mandibular bodies, respectively; medium arrow: posteriorly directed stabilization
force applied through the ipsilateral aspect of the patient’s forehead; small arrow: the examiner
palpates the joint line to assess for movement of the mandibular condyle.

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Figure 3 Medial/lateral glide of the temporomandibular joint (TMJ); large arrow: medial glide force placed through the
mandibular condyle and/or mandibular ramus; small arrow: the contralateral hand provides a stabilizing force either
through the contralateral zygomatic arch of the temporal bone and/or the contralateral mandibular condyle, depending
on the patient’s experience.

Figure 4 Caudal-anterior-medial (CAM) glide of the temporo- mandibular joint (TMJ); large arrow: combined
caudal, anterior, and medial glide force placed through the mandibular condyle and/or mandibular ramus;
small arrow: the contralateral hand provides a stabilizing force either through the contralateral zygomatic arch
of the temporal bone and/or the contralateral mandibular condyle, depending on the patient’s experience.

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Figure 5 Caudal-anterior-medial (CAM) glide of the temporomandibular joint (TMJ) with pre-positioned mouth opening;
large arrow: medial glide force placed through the mandibular condyle and/or mandibular ramus; small arrow: the
contralateral hand provides a stabilizing force either through the contralateral zygomatic arch of the temporal bone and/or
the contralateral mandibular condyle, depending on the patient’s experience.

Figure 6 Self-mobilization of the temporomandibular joint (TMJ); large arrow: medial glide force placed through the
mandibular condyle and/or mandibular ramus; small arrow: the contralateral hand provides a stabilizing force either
through the contralateral zygomatic arch of the temporal bone and/or the contralateral mandibular condyle,
depending on the patient’s experience.

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Figure 7 Self-mobilization of the temporomandibular joint (TMJ) with pre-positioned mouth opening; large
arrow: medial glide force placed through the mandibular condyle and/or mandibular ramus; small arrow: the
contralateral hand provides a stabilizing force either through the contralateral zygomatic arch of the temporal
bone and/or the contralateral mandibular condyle, depending on the patient’s experience

Figure 8 Soft tissue mobilization of the temporalis muscle utilizing one digit for contact and one hand for
contralateral stabilization. Palpation of an MTrP or the general muscle belly by the tip of one digit (second digit
shown) to apply soft tissue mobilization to the temporalis muscle. Switching between different digits can be
helpful in prolonging technique application time before the onset of fatigue. Note that a contralateral hand provides
a counterforce to stabilize the head and prevent inadvertent head motion. In this instance, the therapist begins
at the anterior margin of the muscle and moves posteriorly while focusing on areas of the muscle that require
treatment.

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Figure 9 Bilateral soft tissue mobilization of the temporalis muscle utilizing reinforced digits for contact. Palpation
of an MTrP or the general muscle belly by the tips of the second digits with reinforcement by the third digits to
apply soft tissue mobilization to the temporalis muscles. Note that both hands provide simultaneous treatment
and therefore serve as both the treating and stabilizing forces. In this instance, the therapist begins at the
anterior margin of the muscles and moves posteriorly.

Figure 10 Soft tissue mobilization of the medial pterygoid muscle. Palpation of the muscle belly by the tip of the
second digit to apply soft tissue mobilization to the medial pterygoid muscle. For treatment purposes, having the
patient relax so that the mouth is not opened widely can be advantageous. The open mouth position is utilized
here for visualization purposes.

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Table 1 Rocabado’s 6x6 exercise program
Name
Rest position of the tongue
Control of TMJ rotation
Rhythmic stabilization technique
Axial extension of the neck
Shoulder posture
Stabilized head flexion
Exercise description/purpose
The anterior 1/3 of the tongue is placed at the palate with mild pressure, which
rests the tongue and jaw musculature and promotes diaphragmatic breathing
The jaw is repeatedly opened and closed with the
anterior 1/3 of the tongue on the palate, which
decreases initiating jaw movements (e.g. protrusive
movement in opening, talking, or chewing)
Gentle isometrics in the resting position are performed for jaw opening, closing,
and lateral deviation to promote muscular relaxation via reciprocal inhibition,
which promotes an improved resting position of the jaw through proprioceptive
input
Combined upper cervical flexion with lower cervical extension, allowing reduction
of tension in the cervical musculature
Shoulder girdle retraction and depression to
facilitate postural corrections
Upper cervical spine distraction via chin tuck (without
additional cervical flexion), during which it is
recommended that the fingers be laced behind the neck
to stabilize C2-7 while the head nods
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Table 2 Kraus’ temporomandibular joint exercises
Name
Tongue position at rest
Teeth apart
Nasal-diaphragmatic breathing
Tongue up and wiggle
Strengthening
Touch and bite
Neuro-muscular control
Isometric exercises
Exercise description/purpose
The patient is instructed to maintain a resting tongue position except during
function, which involves the tip of the tongue sitting on the palate with the tip
resting just posterior to the upper incisors
The patient is educated that maintaining the teeth apart
can be therapeutic, which facilitates the resting tongue
position
The patient is instructed in nasal breathing to facilitate function of the diaphragm,
which reinforces positioning of both the tongue and teeth
Patients who brace but whose teeth do not touch or grind while doing so are
instructed to routinely assume the resting position and gently oscillate the mandible
side-to-side to interrupt the bracing contractions. If clicking or popping occurs,
intensity is decreased
Resisted closing via self-manual resistance of lower
incisors: 5–10-second contractions, 10 repetitions,
3–56/day
Proprioceptive re-education: Lateral deviation – the patient
touches the contralateral maxillary canine with the fingertip
(with affected right lateral deviation touch left canine) and
then bites the finger, which requires lateral deviation toward
the finger. Protrusion – repeat with finger touching the outer
surface of maxillary incisors.
When excessive anterior movement of the mandibular condyle is noted, instruct
the patient to define end range opening by placing the tip of the tongue on the
anterior palate while the fingers gently palpate the chin and mandibular condyle.
Repeatedly open and close to that range.
Progression: incrementally remove feedback.
Reciprocal click: isometrics are performed immediately before
the closing click. Weakness or AROM deviations not believed to
be from a structural anomaly: isometrics are performed in any
position. Muscle inhibition to improve ROM: agonists or
antagonists can be contracted gently.
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TENDINOPATHY CLINICAL PRACTICE GUIDELINE

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Background
Tendinopathy is a common clinical condition characterized by painful mechanical loading of an involved tendon
associated with significant limitations in daily or sport activities. Etiology is multifactorial and typically includes
extrinsic and intrinsic factors. Tendinopathy has been described as a continuum of tissue pathology which can
1
include reactive or reactive-on-degenerative phases. A key determinant in rehab progression of tendinopathy is
whether or not a tendon reacts, or develops an increase in pain that does not return to baseline pain levels within
2
24 hours.

Progressive mechanical loading has been found to be an effective management strategy. Different modes of
strength training, including isometric, isotonic, isolated eccentric, and isokinetic, can be used to control pain,
improve motor control, and enhance function in pathological tissue. Although traditional rehabilitation approaches
have focused on isolated eccentric tissue loading, recent literature suggests that isolated eccentric exercise may
not be a superior choice to the other types of loading, particularly heavy-slow resistance (HSR) loading
3
(resistance performed up to an individual’s 6RM). In fact, eccentric-based exercise may contribute to worse
4
outcomes for an in-season athlete. Heavy-slow resistance loading is designed to target both concentric and
eccentric strength deficits, which both commonly present in cases of tendinopathy. HSR loading also has been
3
found to promote better collagen turnover than isolated eccentric loading. The selection and timing of the type of
load applied to the involved tendon may be critical to restoring function. For instance, isometrics have been found
4
to reduce pain while reducing cortical inhibition of muscles.

Tendinopathy can have profound negative effects on an individual’s function and ability to participate in and return
to their previous level of activity. Emerging research is indicating the presence of changes in central pain
5
processing, such as central sensitization, in some cases of tendinopathy. In such cases it would be beneficial to
6
consider the inclusion of cognitive-behavioral therapy and graded exposure. Generally, clinical management of
tendinopathy should include aspects of pain management and education, progressive mechanical loading,
treatment of kinetic chain deficits, and a graded return to activity. Adjunct treatments, such as joint mobilizations
and friction massage, can be used in combination with a progressive resistance program, especially if joint or
muscle dysfunction is contributing to altered movement patterns and abnormal tendon loading.

Definitions
• Strong level evidence: supported by systematic review, meta-analysis, or >5 RCT
• Moderate level evidence: supported by 3-4 RCT
• Low level evidence: supported in 1-2 RCT or clinical case series
• Expert opinion: supported by case studies, expert opinions or opinions of the authors

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Summary of Recommendations
Risk Factors • General overuse
• Repetitive tensile loading
• Combination of tensile, shear, and compressive forces
Differential • Partial to full tendon ruptures
Diagnosis • Muscle strain
• Stress reaction/fracture
• Nerve entrapment
Examination • Outcome Measure: VISA (Victorian Institute of Sport Assessment, body-part specific
measure
• Impairments and functional limitations
• Isolated muscle/kinetic chain deficits
Classification • Reactive
• Reactive-on-degenerative
Phases of • Pain Reduction and Load Management (isometric loading and avoiding positions of
Progression compression) – refer to appendix
• Isotonic Loading (Heavy- slow resistance through concentric-eccentric phases)
• Energy-Storage Loading (plyometric loading)
• Return to Activity/Sport
Interventions • Patient education
• Prolonged isometric contractions of moderate intensity (40-70%) with tendon in shortened
range throughout entirety of rehab
• Progressive muscle-tendon loading program
• Correction of kinetic chain deficits
• Joint/soft tissue mobilizations to adjacent areas
• Return to activity/sport progression
Criteria for • Full and symmetrical ROM and strength/power
Discharge • Pain-free high load resistance test to muscle-tendon unit
• Return to sport/activity without reactive pain
• Proper long-term maintenance program implemented for self-management of symptoms

Phase I: Pain Reduction and Load Management

Indications 1. Patient experiences reactive pain (More than 3/10 pain during or after activity/isotonic
loading that lasts greater than 24 hours). Range of acceptable pain levels may vary
dependent on patient tolerance and understanding of therapeutic ranges.
2. Unable to maintain current activity levels due to pain
3. Localized tenderness at tendon
Activity 1. Reduced loading, modified volume of activity, and avoidance of tendon in compressive
Modifications positions including end-range stretching
expert opinion 2. Patient Education: expected recovery progression, cognitive behavioral therapy if
indicated
Prolonged Perform with tendon in shortened/non-compressed position.
Isometric Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to 70%
Contractions maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily.
strong level
evidence
Treatment of Assessing and treating local and regional movement impairments
Kinetic Chain
Impairments
expert opinion
Criteria to 1. Can complete isotonic loading with minimal reactive pain (<3/10 pain or no increase in
Progress to baseline pain lasting longer than 24 hours)
Phase 2 2. Decreased pain with ADLs
expert opinion

Phase II: Isotonic Loading Progression

Indications 1. Strength deficits of the involved muscle-tendon unit

2. History of painful loading
Heavy, Slow Prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and
Resistance progressing to 6 repetitions, performed every other day.
Exercise (HSR)
strong level Initially, complete exercise in modified ROM to avoid compression of tendon then progress
evidence into full ROM as strength and pain levels allow.
Stretching Performed to address ROM deficits. Should not create reactive pain > 24 hours.
Exercises low
level evidence
Prolonged Perform with tendon in shortened/non-compressed/mid-range position.
Isometric Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to
Contractions 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily.
strong level
evidence
Cognitive Only indicated for cases of chronic pain or central sensitization.
Behavioral
Therapy/Graded
Exposure low
level evidence
Criteria to 1. Able to complete 3-4 sets of 6 repetitions throughout full ROM with minimal pain and no
Progress to increase in pain lasting greater than 24 hours (patients should be at about 7/10 on Borg
Phase 3 Rate of Perceived Exertion scale for strengthening purposes)
2. No pain with ADLs

Phase III: Energy Storage Loading Progression (Plyometrics)

Indications 1. Symmetrical strength bilaterally (recommended strength tests: 10 RM, Manual muscle
testing, and/or isokinetic testing)
2. Tolerates introduction of energy storage exercises with minimal pain
Sport or Progressing volume then intensity.
Activity-Specific Prescription: every third day, progressing to a volume required by the sport/activity
Movements
expert opinion
Heavy, Slow Prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and
Resistance progressing to 6 repetitions, performed every other day.
strong level
evidence Initially, complete exercise in modified ROM to avoid compression of tendon then progress
into full ROM as strength and pain levels allow.
Prolonged Perform with tendon in shortened/non-compressed/mid-range position. This is done as
Isometric needed at this phase for pain management.
Contractions
strong level Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to
evidence 70% maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily.
Criteria to Ability to complete energy storage exercises with minimal pain and at a volume that would
Progress to replicate the demands of the sport/activity
Phase 4
expert opinion

Phase IV: Return to Sport/Activity

Indications 1. Can complete introduction of sport/activity-specific exercise with minimal pain

Proper Warm- Gentle, dymanic movement relevant for the sport or activity
up Routine
expert opinion
Sport or Reintegration into competition (no greater than every three days initially)
Activity-
Specific Drills
expert opinion
Heavy, Slow Prescription: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and
Resistance progressing to 6 repetitions, performed at least twice per week.
strong level
evidence Initially, complete exercise in modified ROM to avoid compression of tendon then progress
into full ROM as strength and pain levels allow.
Prolonged Perform with tendon in shortened/non-compressed/mid-range position. This is done as
Isometric needed at this phase for pain management.
Contractions
strong level Prescription: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to 70%
evidence maximal voluntary contraction. 1-2 minute rest periods between contractions. Daily.
Criteria for 1. Full ROM and strength/power
Discharge 2. Pain-free high load resistance test, ensuring no pain in positions that normally compress
expert opinion the tendon
3. Full training with minimal pain

Appendix 1: Example of Initial Weekly Structure at Phases 3 and 4
Day 1 Plyometrics/Return to Play, Isometrics if needed
Day 2 Strengthening, Isometrics if needed
Day 3 Isometrics
Day 4 Rest
Day 5 Plyometrics/Return to Play, Isometrics if needed
Day 6 Strengthening, Isometrics if needed
Day 7 Isometrics

Appendix 2: Common Sites of Tendon Compression

Tendon Site of Compression Position of Compression Modification

Achilles
Superior calcaneus Ankle dorsiflexion Heel raise
Insertion
Tibialis
Medial malleolus Anatomically permanent pivot Orthotics and heel raise
Posterior
Long Head of
Bicipital groove Shoulder extension Modify resting shoulder positions
Biceps
Suprasinatus Greater tuberosity Shoulder adduction Modify resting shoulder positions

Pectoralis Humeral tuberosity External rotation Modify upper extremity activities

Proximal
Ischial tuberosity Hip flexion Limit sitting/ lunging
Hamstrings
Gluteus Medius
Greater trochanter Hip adduction Lumbopelvic control, sleep supine
and Minimus
Adductor
Longus/rectus Pubic ramus Hip abduction/ extension Limit loads in abduction/ extension
abdominus
Peroneal
Lateral malleolus Anatomically permanent pivot Heel raise
Tendons
Quadriceps Femoral condyle Deep knee flexion Limit loads in deep knee flexion
(Modified from Goom 2013)

Appendix 3: Isometric/Isotonic loading suggested positions (initial setup to be progressed)
Isometric: 5 repetitions of 45-60 seconds, 2-3 times per day, progressing from 40% to 70% maximal voluntary
contraction.
Isotonic: 3-4 sets of concentric-eccentric exercise starting at 15 repetitions and progressing to 6 repetitions, performed
every other day

Rotator Cuff • Resisted ER/IR

Tendinopathy • Scapular stabilization
• Closed kinetic chain resistance including proprioceptive-enriched
exercise like Bosu push-ups

Lateral • Wrist extension in full Medial • Wrist flexion in full

Epicondylosis elbow extension Epicondylosis elbow extension
• Wrist extension at 90 • Wrist flexion at 90
degrees elbow flexion degrees elbow flexion
• Wrist neutral pronated • Wrist neutral
curls supinated curls

Proximal • Physioball hamstring Gluteal • Physioball glute Quad / Patellar • Quad extension
Hamstring curls Tendinopathy bridges Tendinopathy • Slant board
Tendinopathy • Glute bridges • Monster walks / single leg squats
• Nordic curls band squats • Leg extension
• Askling’s glide • Lumbopelvic stability
• Prone/seated leg training
curls

Midsubstance • Traditional Alfredson Insertional • Modified Alfredson Plantar • Foot intrinsic

Achilles heel drop Achilles heel drop (stopping fasciopathy (Seated relevé)
Tendinopathy Tendinopathy at neutral) • Calf raises

Author: J.J. Kuczynski, PT, DPT
Reviewers: Matt Longfellow, PT, DPT; Thomas Best, MD, PhD; Stephanie Di Stasi Roewer, PhD, PT; Daniel Chelette,
PT, DPT; Sarah Miller, PT, DPT; Chelseana Davis, PT, DPT; Michael Baria, MD; John DeWitt, PT, DPT, AT
Updated: May 19, 2017

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2. Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for
challenging case presentations. JOSPT. 2015;45:887-897.
3. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes: a
systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med.
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4. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar
tendinopathy. Br J Sports Med. 2015;49(19):1277-83.
5. Plinsinga ML, Brink MS, Vicenzino B, Van Wilgen CP. Evidence of nervous system sensitization in commonly
presenting and persistent painful tendinopathies: a systematic review. JOSPT. 2015;45:864-875.
6. Rundell SD, Davenport TE. Patient education based on principles of cognitive behavioral therapy for a patient with
persistent low back pain: a case report. JOSPT. 2010;40:494-501.
7. Fredburg U, Bolvig L, Andersen NT. Prophylactic training in asymptomatic soccer players with ultrasonographic
abnormalities in Achilles and patellar tendons: the Danish Super League Study. Am J Sports Med. 2008;36:451-
460.
8. van Ark M, et al. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-
season? A randomized clinical trial. J Sci Med Sport; 2015 Dec 7. pii: S1440-2440(15)00231-5. doi:
10.1016/j.jsams.2015.11.006. [Epub ahead of print] PMID:26707957.
9. Goom TSH, Malliaras P, Reiman MP, Purdam CR. Proximal hamstring tendinopathy: clinical aspects of
assessment and management. JOSPT. 2016;46:483-493.
10. Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of
Physiotherapy. 2014;60:122-129.
11. Silbernagel KG, Crossley KM. A proposed return-to-sport program for patients with midportion Achilles
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Yang of tissue homeostasis. Br J Sports Med. 2012;46:696-698.
13. Scott A, Docking S, Vicenzino B, et al. Sports and exercise-related tendinopathies: a review of selected topical
issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012. Br J
Sports Med. 2013;00:1-12.
14. Scott A, Backman LJ. Speed C. Tendinopathy: Update on Pathophysiology. JOSPT. 2015;45:833-841.
15. Couppe C, Svensson RB, Silbernagel KG, Langberg H, Magnusson SP. Eccentric or concentric exercises for the
treatment of tendinopathies? JOSPT. 2015;45:853-863.
16. Michener LA, Kulig K. Not all tendons are created equal: implications for differing treatment approaches. JOSPT.
2015;45:829-832.
17. Vicenzino B. Tendinopathy: evidence-informed physical therapy clinical reasoning. JOSPT. 2015;45:816-818.
18. Morrissey D. Guidelines and pathways for clinical practice in tendinopathy: their role and development. JOSPT.
2015; 45:819-822.
19. Docking SI, Ooi CC, Connell D. Tendinopathy: is imaging telling us the entire story. JOSPT; 2015:842-852.
20. Ryan M, Bisset L, Newsham-West R. Should we care about tendon structure? The disconnect between structure
and symptoms in tendinopathy. JOSPT. 2015;45:823-825.
21. Naugle KM, Fillingim RB, Riley III JL. A meta-analytic review of the hypoalgesic effects of exercise. J Pain.
2012;13:1139-1150.
22. Malliaris P. Managing tendons does not need to be complex: Achilles tendon example. Tendinopathy Rehabilitation.
2016 April (Accessed 10 August 2016). Available at: http://tendinopathyrehab.com/freelesson/?platform=hootsuite.
23. Goom T. Tendinopathy rehab progression – part 1. RunningPhysio. 2013 June (Accessed 10 August 2016).
Available at: http://www.running-physio.com/tendinopathy1/.
24. Littlewood C et al. The central nervous system – an additional consideration in ‘rotator cuff tendinopathy’ and a
potential bias for understanding response to loaded therapeutic exercise. Man Ther. 2013;18:468-472.
25. Dejaco B, Habets B, van Loon C, van Grinsven S, van Cingel R. Eccentric versus conventional exercise therapy in
patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial. Knee Surg Sports Traumatol
Arthrosc. 2016. DOI 10.1007/s00167-016-4223-x
26. Nefeli T, van Dieën JH, Coppieters MW. Central pain processing is altered in people with Achilles tendinopathy. Br
J Sports Med. 2016;50:1004–1007.
27. Allison K, Wrigley TV, Vicenzino B et al. Kinematics and kinetics during walking in individuals with gluteal
tendinopathy. Clinical Biomechanics. 2016;32:56-63.

ADHESIVE CAPSULITIS/FROZEN SHOULDER
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and clinician
evaluation. Contact Ohio State Sports Medicine Physical Therapy at 614-293-2385 if questions arise.

Background
Adhesive capsulitis is characterized by a painful, gradual loss of both active and passive glenohumeral motion in
multiple planes resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule.
Primary adhesive capsulitis is reported to affect 2% to 5.3% of the general population. The prevalence of
secondary adhesive capsulitis related to diabetes mellitus and thyroid disease is reported to be between 4.3%
and 38%.

Clinical Course
Stage 1: Painful/Pre-Adhesive Stage (3 months)
• Sharp pain at end ROM, achy pain at rest, sleep disturbance, early loss of ER ROM.
• Diffuse synovial reaction without adhesion or contracture.

Stage 2: Freezing/Adhesive Stage (3-9 months)

• Gradual loss of motion in all directions due to pain.
• Aggressive synovitis and angiogenesis, loss of motion under anesthesia.

Stage 3: Frozen/Fibrotic Stage (9-15 months)

• Characterized by pain and loss of motion.
• Progressive capsulo-ligamentous fibrosis results in the loss of the axillary fold and ROM.

Stage 4: Thawing Stage (15-24 months)

• Pain begins to resolve, but significant stiffness persists.
• Capsulo-ligamentous complex fibrosis, receding synovial involvement.

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Technology Commercialization Office at https://tco.osu.edu.

Summary of Recommendations
Risk Factors • Age: 40-65 years old
• Autoimmune Disease
• Diabetes Mellitus
• Gender: Female
• Myocardial Infarction
• Prolonged Immobilization
• Thyroid Disease
• Trauma
Exam • Measure pain, postural alignment, shoulder AROM/PROM, strength, functional
elevation, key impairments of body function, translational glide of GH joint
• Outcome Measure
• quickDash, DASH, SPADI, ASES
• Activity Limitation
• Pain during sleep
• Pain & difficulty with grooming & dressing
• Pain & difficulty with reaching activities: to the shoulder level, behind the back, and
overhead
• Impairment
• Decreased active and passive shoulder ROM
• Loss of glenohumeral joint accessory motion
Diagnosis/ Primary Adhesive Capsulitis Secondary Adhesive Capsulitis
Classification idiopathic, not associated with history of related to history of injury, disease or
injury or systemic condition pathology

Interventions Corticosteroid injections – reduce inflammation and pain

Patent Education – Essential to lessen fear and prevent self-immobilization, encourage
activity modification and emphasize functional ROM
Modalities – Heat /E-stim/Ice can have a positive benefit on pain and assist with other
interventions
Stretching Exercises – When matched to irritability can improve ROM & pain. Optimal
dosage remains unclear.
Joint Mobilization – Match force to tissue irritability
Manipulation – When unresponsive to PT
Differential Acute calcific tendonitis/bursitis Labral lesions
Diagnosis Arthritis: Rheumatoid, Pyogenic Neoplasm
Arthrosis/bursitis of the shoulder OA of AC or …GH joint/cervical spine
Avascular necrosis Osteoporosis-pathological fracture
Cervicalgia, cervical disc disorder Pain in thoracic spine
Cervico-brachial syndrome Radiculopathy
Contusion of shoulder/upper arm Rotator cuff syndrome
Fibromyalgia Sprain/strain AC/SC/GH joints
Fracture-clavicle/scapula/humerus Tendinopathy-supra/infra/biceps
Impingement syndrome
Criteria for • Independent pain management & home exercise program
Discharge • Normal postural alignment
• Increased ROM to match unaffected side
• Improved muscle performance, strength & endurance
• Functional use of affected UE
• Normal GH and scapulo-thoracic biomechanics


Phase I: Painful/Pre-Adhesive Stage (3 months)

Content • Modalities: Heat/Ice/E-Stim PRN
• Postural correction exercises/Scapular retraction
• PROM/AAROM Therapeutic Ex: Codman’s, table/wall slides, cane
• End range GH joint stretching, 5-10 second hold as tolerated
• GH mobilization, long axis distraction to maximize ROM
• Daily Home Exercise and Icing Program
Criteria to • Tolerance of 10 second end-range stretches
Progress • Full AROM of extension/adduction
• Improving AROM of flexion, abduction, ER, IR

Phase 2: Freezing/Adhesive State (3-9 months)

Content • Modalities: Heat/Ice/E-Stim PRN
• Postural correction exercises/Scapular retraction
• PROM/AAROM Therapeutic Ex: Codman’s, table/wall slides, cane
• End range GH joint stretching, 15-20 second hold as tolerated
• GH mobilization, long axis distraction to maximize ROM
• Daily Home Exercise and Icing Program
Criteria to • Tolerance of 20 second end-range stretches
Progress • Full AROM of extension/adduction/IR/abduction
• Improving AROM of flexion, ER

Phase 3: Frozen/Fibrotic State (9-15 months)

Content • Modalities: Heat/Ice/E-Stim PRN
• Postural correction exercises/Scapular retraction
• PROM/AAROM Therapeutic Ex: Codman’s, table/wall slides, cane
• End range GH joint stretching, 20-30 second hold as tolerated
• GH mobilization, long axis distraction to maximize ROM
• Gravity Resisted Strength Work: Scapular, Rotator Cuff, Deltoid
• Daily Home Exercise and Icing Program
Criteria to • Tolerance of 30 second end-range stretches
Progress • Full PROM flexion/ER
• Gravity resisted strength work to 1x30 repetitions each


Phase 4: Thawing Stage (15-24 months)

Content • Modalities: Heat/Ice/E-Stim PRN
• Postural correction exercises/Scapular retraction
• AAROM/AROM Ther Ex: Supine/side-lying/standing postures
• Resisted Strength Work: Scapular, Rotator Cuff, Deltoid
• Resisted Strength Work: Free Weights, Theraband, PNF
Scapular, Rotator Cuff, Deltoid, Biceps, Triceps, Closed Chain
• Daily Home Exercise and Icing Program
Criteria to • Independent pain management and home exercise program
Progress • Normal postural alignment
• Increased ROM to match unaffected side
• Improved muscle performance, strength & endurance
• Functional use of affected UE
• Normal GH and scapula-thoracic biomechanics

Author: Amy Davison, PT

Reviewer: John DeWitt, PT, DPT, SCS
Completion Date: 3/30/17

References
Martin KJ, et al. Shoulder pain and mobility deficits: adhesive capsulitis. Kelley MJ, Shaffer MA, Kuhn JE,
Michener LA, Seitz AL, Uhl TL, Godges JJ, McClure PW. J Orthop Sports Phys Ther. 2013 May;43(5):A1-31.
Neviaser AS, Hannafin JA. Adhesive Capsulitis: A Review of Current Treatment.Am J Sports Med. 2010
Nov;38(11):2346-56


ARTHROSCOPIC SLAP REPAIR

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Background
SLAP (superior labral anterior to posterior) tears can begin as a result of a traumatic injury such as a FOOSH or
an atraumatic, degenerative injury as a result of repeated activity. SLAP tears are common in overhead athletes
and overhead workers. SLAP tears are classified based on the type of tear as well as the portion of the labrum
that is affected. Surgical intervention may include reattachment of the labrum, debridement, or a combination.
Consultation with the surgeon as well as a review of the operative report should be completed prior to initiation of
rehabilitation.

Summary of Recommendations
Risk Factors • Repeated overhead activity
• Falling on out stretched arm
• Contact sports
• Poor shoulder strength
• Poor scapular stability
• Limited trunk mobility
• Faulty mechanics
Corrective • Therapeutic exercise to improve shoulder and scapular strength, endurance, stability, and
Interventions mobility
• Therapeutic activity to improve ADLs
• Neuromuscular reeducation to improve joint stability and proprioception

Precautions • Excessive external rotation above guideline recommendations

• Excessive loading of biceps
• Cross body motion
• Shoulder extension with elbow extension
• Failure to return sport/position/job without appropriate external range of motion
Outcome • Disability of Arm Shoulder and Hand (DASH) or Kerlan-Jobe Orthopaedic Clinic (KJOC)
Testing questionnaires.
• Strength testing for quality, endurance, and IR/ER strength ratios vs uninvolved and based
on sport
• ROM appropriate for job/sport
• Isokinetic strength assessment if available
Manual • Soft tissue mobilization as appropriate
Therapy • Joint mobilizations: initially to decrease pain, to improve ROM when appropriate
Criteria for • ROM within appropriate ranges based on patient specific needs
discharge • Full muscle strength and endurance of shoulder and periscapular strength
• Consistently low pain scores
• MCID on functional outcome measure

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Phase I: Protection Weeks 1-2

PROM • Elevation to 75º in the scapular plane
• ER in scapular plane up to 15º
• IR in scapular plane up to 45º
• Posterior joint mobilizations (grades I-II)
• Elbow ROM – may be AROM/PROM – no resistance
• Full hand/wrist ROM
• Pendulum Exercises
Strength • Scapular stabilization (scapular clock and manual resisted scapular PNF patterns)
• Submaximal isometrics in neutral for shoulder and elbow– no elbow flexion

Goals to 1. Control pain and inflammation

Progress to 2. Gradual increase in ROM
Next Phase 3. Promote healing of tissue
4. Initiate muscle contraction

Phase I: Protection Weeks 3-4

PROM • Elevation to 90° in the scapular plane
• Abduction to 80°
• ER in scapular plane up to 30°
• IR in scapular plane up to 55°
• Pendulum Exercises
AAROM • May begin with same restrictions as PROM
Strength • Continue scapular stabilization
• Rhythmic stabilization
o Side-lying neutral
o Hand on ball within ROM limitations
o No strong ER contractions
• Continue isometrics
Goals to 1. Achieve full PROM goals
Progress to 2. Reduce inflammation and pain
Next Phase 3. Tolerate basic strengthening
4. Postural awareness

Phase I: Weeks 5-6

PROM and • Elevation to 145°
AAROM • ER at 45° abduction to 50°
• IR at 45° abduction to 60°
• Gentle IR and ER stretch at 90° abduction

AROM • Full can WITHOUT weight

• Abduction as tolerated


Strength • Initiate IR/ER at neutral (0º of abduction) with tubing
• Towel roll placed under arm
• Prone exercises WITHOUT weight
• Row
• Horizontal abduction
• Extension to neutral
• Supine punches with light resistance
• Scapular PNF Patterns
• UBE with light resistance

Goals to 1. Achieve PROM and AAROM limitations

Progress to 2. No exacerbations of pain
Next Phase 3. Independent with HEP

Phase II: Weeks 7-9
PROM and • Full flexion
AAROM • Full abduction
• ER in neutral and 90° abduction: up to 90°
• IR in neutral and 90° abduction: up to 70°
• Towel and side-lying internal rotation stretch
• Continue posterior and initiate inferior Grade III-IV mobilization at GH joint
AROM • May begin AROM biceps at 8 weeks
• Continue to progress elevation and abduction AROM
Strength • Initiate biceps strengthening at 8 weeks with elbow flexed and neutral abduction
• Continue isotonic strengthening
• Initiate Thrower’s 10 Program
• PNF patterns with tubing
• Progress rhythmic stabilization
Goals to 1. Achieve full AROM by 9 weeks except ER if thrower
Progress to 2. NO substitution patterns
Next Phase 3. Low pain scores

Phase II: Weeks 10-12

PROM and • Full in all planes
AAROM • May progress throwers to beyond 90° ER

AROM • Continue as necessary to sport and ADL demands

Strength • Continue isotonic and scapular strengthening
• Begin ER/IR at 90° abduction
• Advance Thrower’s 10 and CKC exercise as tolerated
o Progress biceps strengthening
Goals to 1. Maintain full AROM in all planes (beyond 90 ER if overhead athlete)
Progress to 2. 4+/5 shoulder strength in all planes
Next Phase 3. No reported pain
4. Verbal confidence in initiation of return to sport progression

Phase III: Weeks 12-16

ROM • Continue to progress AROM, PROM as needed for ADL and sport demands
• Ensure thoracic and cervical mobility
Strength • May begin resisted biceps and forearm supination
• Muscular endurance exercise
• Light plyometrics
o Begin with two hands and progress to one
o Wall ball dribbles/free throws with single hand
• Light tossing – Single knee throwing 15 feet with emphasis on proper throwing mechanics
and follow through. (Only if ROM has been normalized in all planes)
• Progress eccentric strengthening of posterior cuff and scapular musculature
• Begin throwing progression at 4 months
• Restricted sport activity (light swimming, half golf swings, sport specific activities)
• No contact sports
Goal to 1. Full throwing status at 6-8 months with successful completion of throwing program
Progress to
Return to
Sport Phase

Phase IV: Return to Sport/Activity Weeks 16-20

ROM • Terminal end ROM stretching
• Teach long term home stretching and mobility
Strength • Advance plyometrics to sport specific
• Begin throwing program or other sport specific program is all goals met and physician has
provided clearance
• Progress shoulder strengthening to include return regular gym/team strengthening
Return to 1. ROM appropriate for sport or activity
Sport 2. Strength or shoulder and scapular musculature tested at 5/5 MMT or isokinetics vs
Criteria uninvolved
3. Completion of closed chain functional measurement such as Closed Kinetic Chain Upper
Extremity Strength Test CKCUEST
4. MCID for functional outcome measure
5. Completion of progressive return to sport/throwing program
6. No pain with activity

Reviewers: Katherine Sullivan, Joann Walker

ANTERIOR SHOULDER STABILIZATION

CLINICAL PRACTICE GUIDELINE

Background
Ohio State’s Anterior Shoulder Stabilization Rehabilitation Guideline is to be utilized following open or
arthroscopic anterior shoulder stabilization procedures. Included surgical interventions include Bankart,
Remplissage and Latarjet. The guideline is based on Bankart repair, but includes specific considerations based
on additional techniques utilized. It is intended to be used in conjunction with the therapist and surgeon’s
collaborative input.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Summary of Recommendations
Risk Factors • Excessive joint laxity
• Exceeding guideline ROM recommendations/goals
• History of instability
• Comorbidities including, but not limited to, connective tissue disorders

Precautions • Limited to 30 degrees external rotation for 6 weeks

• Progression of ROM should not be forced and is per patient’s tolerance
• Return to jogging should be not initiated until 10-12 weeks depending on patient presentation
and physician clearance
• Return to sport 5-6 months; minimum of 6 months for contact sports and climbing
• Initiation of throwing program at month 4 with goal of return to game at 9 months
• Refer back to surgeon with any positive apprehension testing
• No Olympic lifting or bar bench press until 6 months
Manual • Passive ROM not to exceed guideline
Therapy • Soft tissue mobilization per clinical judgment
• Joint mobilizations per guideline to reduce pain and improve mobility

Corrective • Therapeutic exercises to optimize rotator cuff and periscapular strength

Interventions • Neuromuscular re-education to improve joint stability and proprioception
• Therapeutic activity to improve ADL and leisure activities
• Manual (PROM, AAROM, AROM) to restore normal ROM per guidelines
• Modalities to control pain and swelling

Outcome • Disability of Arm Shoulder and Hand (DASH) Questionnaire

Testing • Kerlan-Jobe Orthopaedic Clinic (KJOC) Questionnaire

Criteria for • Full AROM appropriate for patient

discharge with • 5/5 MMT shoulder and scapular strength
return to sport • No substitution patterns
(9-24 months) • Independent with home exercise program per patient needs
• Low pain scores
• Return to full abilities with ADLs
• Initiation and guidance with return to sport phase

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Technology Commercialization Office at https://tco.osu.edu.

Remplissage Considerations
Remplissage (French for “fill in”) is an arthroscopic procedure that insets the posterior shoulder capsule and
infraspinatus tendon into the Hill-Sachs defect, converting the intra-articular location of the defect to an extra-
articular one
• Most often used in conjunction with Bankart repair
• No active external rotation strengthening for 12 weeks
• No internal rotation or cross body stretching for 12 weeks
• No pushing motions
• No Grade 3 or 4 posterior joint mobilizations for 12 weeks
• Treat like posterior rotator cuff repair

Latarjet Considerations
The Latarjet operation is a surgical procedure used to treat recurrent shoulder dislocations typically caused by
bone loss or a fracture of the glenoid.
• Open procedure: See Subscapularis Precautions
• Review surgical report to determine if subscapularis was taken down or split
• Joint mobilizations above grade 1 begin at Week 6
• No anterior mobilizations
• No cross body stretching until Week 12

Subscapularis Precautions
Repair of the subscpaularis following disruption due to traumatic or forces external rotation and abduction.
• No ER past 30 degrees
• No cross body adduction
• No active IR or IR behind the back
• No supporting of body weight with affected side (ie. pushing self up from a chair)

Phase I: Protection (Post-Anterior Shoulder Stabilization – 0-6 weeks)

Post Operative Goals
to 6 weeks • Max protection of surgical repair (capsule, ligaments, labrum, sutures)
• Achieve staged ROM goals - do not significantly exceed
• Patient education on post-op restrictions and maintaining appropriate posture
• Minimize shoulder pain and inflammatory response
• Ensure adequate scapular function

Post Operative Protection

to 3 weeks • Sling usage 4-6 weeks (discuss with physician) including while sleeping
ROM Goals by week 3
• Forward elevation to 90 degrees
• ER in scapular plane to 20 degrees (no ER at 90 degrees abduction)
• No abduction or internal rotation
• Elbow/wrist/hand ROM as tolerated

Weeks 4 to 6 ROM Goals by week 6

PROM
• Forward elevation limited to 135 degrees
• IR to 50 degrees
• Abduction to 115 degrees
• ER in the scapular plane to 30 degrees
• ER at 90 degrees abduction to 30 degrees
Start AAROM
• Cane and wall walks with limitations to 135 degrees
• Pendulum exercises
AROM
• Begin at week 4 within limitations to 115 degrees flexion
May begin elbow AROM

• Strengthening
• Begin submaximal isometrics (ER, Abduction, Flexion, Extension)
• Scapular stabilization (scapular clocks)
• IR/ER with light theraband at 0 degrees of abduction (within ROM restrictions)

Goals to 1. Appropriate healing of surgical repair by adhering to precautions and immobilization guidelines
Progress to 2. Staged ROM goals achieved but not significantly exceeded
Next Phase 3. Minimal to no pain with ROM

Phase II: Intermediate Phase

Weeks 7 to 12 Goals
• Achieve staged ROM goals to normalize PROM and AROM – do not significantly exceed
• Minimize shoulder pain
• Begin to increase strength and endurance
• Increase functional activities
Weeks 7 to 9 ROM Goals by week 9
PROM
• May perform joint mobilizations (emphasis on posterior mobility)
• Forward elevation 155 degrees
• IR at 90 degrees of abduction to 60 degrees by week 8-9
• ER at 20 degrees ABD to 60 degrees
• ER at 90 degrees ABD to 75 degrees
AROM
• Elevation to 145 degrees
Strengthening
• Begin light UBE
• PRE’s for scapular stabilizers (rows, shoulder extension, scapular retraction)
• Initiate Thrower’s 10 Program
• Dynamic resistance with PNF patterns and manual techniques
• Elbow flexion/extension strengthening
• Begin CKC exercise with table/wall weight shifts
Weeks 10 to 12 • Initiation of jogging with physician clearance

ROM Goals by week 12

PROM
• WNL all planes
AROM
• Elevation WNL

• Strengthening
• Progress PREs in all planes
• Rhythmic stabilization ie. Prone medicine ball eccentric drops, free throws, ball taps, etc
• Progress CKC exercises
Goals to 1. Staged AROM goals achieved with minimal to no pain and without substitution patterns
Progress to 2. Appropriate scapular posture at rest and dynamic scapular control during ROM and
Next Phase strengthening exercises
3. Strengthening activities completed with minimal to no pain


Phase III: Advanced Activity Phase
Weeks 12-20 Goals
• Normalize strength, endurance, neuromuscular control, and power
• Gradual and planned build up of stress to anterior capsulolabral tissues
• Gradual return to full ADLs, work, and recreational activities

Weeks 12 to 16
• ROM
• Terminal ER stretches at 12 weeks
• Self capsular stretches, AROM, and passive stretching as needed
• Strengthening
• Advanced isotonics
• Initiate plyometrics (2-handed drills) i.e. chest pass
• Ball catch/toss at 90 degrees abduction position
• Begin dumbbell pec exercises


Phase IV: Return to Sport/Activity
Weeks 16-20 • ROM
• May begin more aggressive stretching techniques
• Strengthening
• Begin overhead PRE’s
• Begin light toss or volley (refer to return to throwing program)
• Continue with specific training program
• Return to full activity
• Bench Press with bar at 6 months

Goals to 1. Progress functional activities towards return activity or sport

Progress to 2. Enhance neuro-muscular control
Return to Sport 3. Improve strength, power, and endurance
4. Muscular strength no less than 80% of contralateral side
5. Full functional ROM
6. 5/5 scapular and rotator cuff strength

Authors: Mitch Salsbery, PT, DPT, SCS

Reviewers: Mitch Salsbery, PT, DPT, SCS; Chelseana Davis, PT, DPT, SCS; Katherine Sullivan, PT, DPT, SCS,
ATC; Joann Walker, PT, SCS
Completion date: April 14, 2016

References
Hayes K, Callanan M, Walton J, Paxinos A, Murrell GA. Shoulder Instability: Management and Rehabilitation:
JOSPT. 2002; 32:1-13.
Lebar RD, Alexander AH: Multidirectional Shoulder instability. Clinical results of inferior capsular shift in an
active-duty population. AM J Sports Med 1992 Mar-April; 20 (2): 193-198.
Wilk KE, Reinold MM, Dugas JR, Andrews JR. Rehabilitation Following Thermal-Assisted Capsular Shrinkage of
the Glenohumeral Joint: Current Concepts. JOSPT. 2002;32: 268-292.
Gaunt BW, Shaffer MS, Sauers EL, Michener LA, McCluskey GM, Thigpen CA. The american society of shoulder
and elbow therapists’ consensus rehabilitaation guideline for arthroscopic anterior capsulolabral repair of the
shoulder. JOSPT. 2010 40(3): 155-168

BICEPS TENODESIS
CLINICAL PRACTICE GUIDELINE

Background
Indications for tenodesis include partial tears >25%, tendon subluxation, recalcitrant tendinopathy, chronic tendon
atrophy, and impingement, SLAP, or rotator cuff treatment. The normal attachment of the long head of the biceps
is surgically cut and reattached to the humerus with either a soft tissue or hardware fixation technique.
Rehabilitation following tenodesis will progress more slowly over the first 6 weeks to protect healing biceps tendon.
Consultation with the surgeon as well as a review of the operative report should be completed prior to initiation of
rehabilitation.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Summary of Recommendations
Risk Factors • Limit shoulder ER to 40° and no extension or horizontal extension for 4 to 6 weeks
• Concomitant surgeries
Precautions • Use sling for 6 weeks
• No excessive biceps loading for 8 weeks
• Initiate soft tissue mobilization at 2 weeks (avoid or cross friction massage for 6 weeks)
• No isolated biceps activation with elbow flexion or straight arm resisted flexion/ supination for 8
weeks

Manual • PROM exercises and GH joint mobilizations (phase I & II)

Therapy • Scar massage is appropriate in phase II

Corrective • Cryotherapy for pain and inflammation

Interventions • Manual Therapy

Functional • Disability of Arm Shoulder and Hand (DASH) Questionnaire

Outcome • Kerlan-Jobe Orthopaedic Clinic (KJOC) Questionnaire
Measures
Criteria for • >90% with patient-reported outcome
Discharge • Full AROM, strength, and able to demonstrate pain-free, sports specific movements without
compensatory movements

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.


Phase I: Protection to PROM (0-2 weeks)
Decrease Pain
and
Inflammation
Restore
Passive
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Range of
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Begin Home
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Program
Criterion to
Progress to
Phase II
Phase II: PROM to AROM (2-6 weeks)
Minimize Pain
and
Inflammation
Post-op Weeks •
2-4 • PROM-AAROM for all planes to tolerance
• Scar massage, no
Post-op Weeks •
4-6 • Increase AAROMH;>78?B?J7J?ED
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joint tendon. Regardless of the surgical
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lesions. Currently, the best evidence for
Progress to
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used as an outline to guide the rehabili-
tation process (7FF;D:?9;I87D:9). The
protocols are divided into 3 phases. Ad-
justments are made depending on the
presentation of the individual patient.
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pertinent patient history, mechanism
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l of Orthopaedic & Sports Physical Therapy®
patient. Decisions to advance through
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Manual therapy treatments, such as
• Education: No extremity AROM, incisions clean and dry, ace wrap or lymphatic drainage taught
for upper extremity swelling control
• Initiate passive pendulums as warm-up
• Modalities including vasopneumatic device or E-stim
• No friction massage
• Sleep with sling, place towel under elbow to prevent extension
• Limit shoulder ER to 40° for 4 weeks
• No extension or horizontal extension for 4 weeks
• Posture education
• Arm immobilized seated scapular retractions
• Scapular clocks progressed to scapular isometrics
• PROM elbow flexion/ extension & forearm supination/ pronation
• AROM wrist/ hand & ball squeezes
• No computer activity: 4wks
• Full passive shoulder range of motion
• Full passive elbow flexion/extension
• Full passive forearm supination/pronation
• No bicep tension for 6 weeks
• Continue sling use for 6 weeks
NO ER>40deg and Limit shoulder extension in frontal and sagittal planes (4weeks)
[ CLINICALand
COMMENTARY ] at shoulder, wrist, and elbow
within limits
jointcross friction
tendon. Regardless of the surgical
procedure, there will likely be alterations
in shoulder proprioception and function
that will have to be addressed during
rehabilitation.
Initiation of shoulder submaximal-isometrics: IR, ER, ABD, & ADD
FEIJEF;H7J?L;
– AROM muscle endurance from supine to standing for waist level function,
COMMENTARY
maintaining proper] scapular kinematics (ex. Lawn chair progression). See inset:
El[hl_[m
J
here is minimal research spec-
ifically relating to the rehabilita-
tion of the long head of the biceps.
In the latest Cochrane review33 of physi-
cal therapy for shoulder pain there were
no studies specific to long head of biceps
Downloaded from www.jospt.org at on June 18, 2015. For personal use only. No other uses without permission.
lesions. Currently, the best evidence for
postoperative rehabilitation is surgeon
and physical therapist experience. Our
clinic has developed protocols that are
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
used as an outline to guide the rehabili-
tation process (7FF;D:?9;I87D:9). The
protocols are divided into 3 phases. Ad-
justments are made depending on the
presentation of the individual patient.
Krupp RJ, JOSPT, 2009 It is important to take into account
<?=KH;,$Lawn chair active range-of-motion progression from supine to sitting. The patient is progressed through
increasingly upright positions to gradually increase the effect of gravity on the shoulder.
pertinent patient history, mechanism
of injury, and patient goals when plan- F^Wi[' tion. During this phase, nothing super-
• Pain-free, full shoulder AROM Rehabilitation begins 1 day postopera- sedes the importance of protecting the ning the course of treatment for the
Journal of Orthopaedic & Sports Physical Therapy®
tively. A standard sling is used as needed healing tissue. patient. Decisions to advance through
• Pain-free, full AROM elbow flexion and extension
for comfort. An elastic wrap is placed Particular attention is placed on
over the upper arm to provide support rhythmic stabilization and scapular sta-
the phases of rehabilitation are based
on protecting the healing tissue, apply-
• Pain-free, full AROM forearm and supination
to the healing biceps. A transcutane- bilization exercises during phase 1. Iso-
ous electrical nerve stimulation unit is lated scapular retraction, with the arm
ing controlled loads to the healing tis-
sue, and monitoring patient response to
• Proper static posture and dynamic scapular control with AROM
applied in the recovery room and sent immobilized, has been shown to produce
home with the patient for pain manage- low levels of biceps activity. Therefore,
treatment in terms of changes in pain
and swelling. 68
ment. The goals for phase 1 are to de- scapular retraction exercises are initiated
CWdkWbJ^[hWfoJh[Wjc[dj
crease pain and swelling, initiate gentle early in phase 1 to improve neuromus-
<?=KH;,$Lawn chair active range-of-motion progression from Manual
supine totherapy
sitting. Thetreatments,
patient is progressed as rhythmic stabilization exercises, initiate
suchthrough cular control. This sets the stage for the
increasingly upright positions to gradually increase the effectrange-of-motion exercises and gle- scapular stabilization exercises, and re-
of gravity on the shoulder. scapular stabilization and rhythmic sta-
nohumeral joint mobilizations, are most store full passive shoulder range of mo- bilization exercises performed in phases
F^Wi[' tion. Duringduring
appropriate this phase,
phasesnothing
1 and 2 super-
(AP- tion. Passive shoulder external rotation 2 and 3. Gentle rhythmic stabilization
Rehabilitation begins 1 day postopera- sedes F;D:?9;Ithe8 importance of protecting
7D: 9). Particular attentionthe is often painful, and placing half of a exercises are initiated with the patient
tively. A standard sling is used as needed healing is focused on the posterior and inferior foam roll under the patient’s arm during
tissue. supine, the arm at 0° of shoulder flexion,
for comfort. An elastic wrap is placed capsule. Tightness
Particular of these is
attention placed ison supine exercises helps to relieve some of
structures and half of a foam roll supporting the el-
over the upper arm to provide support rhythmic linked to impingement. 27,37,48
stabilization and scapular sta- the discomfort. Full passive motion is ex-
Soft tissue bow, then progressed to 90° of forward
mobilizations
to the healing biceps. A transcutane- bilization exercises during phase are utilized to 1. Iso- pected 1 to 2 weeks postoperatively, with
decrease elevation.
pain and spasms of the biceps or other patients posttenotomy typically achieving At our clinic, to advance the patient
ous electrical nerve stimulation unit is lated scapular retraction, with the arm
shoulder muscles. As patient range of full motion slightly ahead of those post- from phase 1 to phase 2, patients should
applied in the recovery room and sent immobilized, has been shown to produce
motion increases, manual interven- tenodesis. Manual therapy treatments be able to perform passive range of mo-
home with the patient for pain manage- low levels of biceps activity.68 Therefore,
tions are decreased in favor of active and modalities are utilized as needed to tion to 80% or greater of the uninvolved
ment. The goals for phase 1 are to de- scapular retraction exercises are initiated
exercises. decrease pain and improve range of mo- shoulder, 1 minute of rhythmic stabiliza-
crease pain and swelling, initiate gentle early in phase 1 to improve neuromus-
rhythmic stabilization exercises, initiate cular control. This sets the stage for the

Phase III: Strength Phase (6-12 weeks)
Pain-free, • No pain, inflammation or strengthening in plane until ROM in almost full
Progressive • Avoid long lever arm resistance for elbow supination and flexion
Restoration of • Normalize strength, endurance, neuromuscular control starting below chest level, working up to
AROM and overheard functional activities
Strength
Post-op Weeks • Continue PROM to AROM of shoulder and elbow, gaining muscle endurance with high reps, low
6-8 resistance
• Isotonic IR and ER light resistance resisted movement with wrist in neutral (no supination)
• Supine ABC & SA punches with high reps, low resistance
• Week 7 begin prone scapular stability program

Post-op Weeks • Slowly progress resisted biceps curl, supination, & pronation
8-12 • Progress prone Scap 6 to Supine 5
• Resisted IR and ER at 30° ABD progressing to 90°
• Resisted SA punch & bear hugs, standing
• Resisted low row, prone 30°/45°/90° to standing
• Push-up plus: wall, counter, knees on the floor, & floor
• Rhythmic stabilization: ER & IR in scapular plane; flexion, extension, ABD & ADD at various
angles of elevation
• Supine to standing diagonal patterns: D1 & D2
• Begin closed chain stabilization exercises

Return to • Running, biking, & Stairmaster

Activity After • Golf with proper kinematics
Week 8
Criterion to • Pain-free, full AROM of shoulder and elbow with normal scapulohumeral rhythm
Progress to • 5/5 MMT scores for RTC at 90° ABD in scapular plane
Phase IV • 5/5 MMT for scapulothoracic musculature

Phase IV: Return to Sport/Activity (weeks 12-16)

Aim to return to sport at 4 month at earliest

Goals • Maintain full non-painful AROM

• Progress strength and power without compensatory strategies
• Avoid excessive anterior capsule stress (NO military press, upright row, or wide grip bench)
• Return to sports progression: throwing/ swimming
• Analysis of sports specific movements

Exercises 12+ • Initiate plyometric training below shoulder to overhead: begin with both arms and progress to a
single arm
• Low to higher velocity strengthening and plyometric activities: ball drops in prone to D2 reverse
throws

Criterion to • Pain-free, stability & control with higher velocity movements including sports specific patterns
Return to Sport and change of direction movements
Activity, Weeks • Proper kinematic control transfer from the hip & core to the shoulder with dynamic movement
12+

Authors: Josh Pintar, PT, DPT,SCS

Reviewers: Mitch Salsbery, PT, DPT, SCS; John DeWitt, PT, DPT, SCS, AT
Completion date: April 8, 2016

References
Gregory JM, Harwood DP, Gochanour E, Sherman SL, Romeo AA. Clinical outcomes of revision biceps tenodesis.
International Journal of Shoulder Surgery. 2012;6(2):45-50. doi:10.4103/0973-6042.96993
Krupp RJ, Kevern MA, Gaines MD, Kotara S, Singleton SB. Long head of the biceps tendon pain: differential
diagnosis and treatment. J Orthop Sports Phys Ther. 2009 Feb;39(2):55-70. doi: 10.2519/jospt.2009.2802
Ryu JH, Pedowitz RA. Rehabilitation of biceps tendon disorders in athletes. Clin Sports Med. 2010 Apr;29(2):229-
46, vii-viii. doi: 10.1016/j.csm.2009.12.003
Wittstein JR, Queen R, Abbey A, Toth A, Moorman CT 3rd. Isokinetic strength, endurance, and subjective
outcomes after biceps tenotomy versus tenodesis: a
postoperative study. Am J Sports Med. 2011 Apr;39(4):857-65. doi: 10.1177/0363546510387512
Galasso, O., Gasparini, G., De Benedetto, M., Familiari, F., & Castricini, R. (2012). Tenotomy versus Tenodesis in
the treatment of the long head of biceps brachii tendon lesions. BMC Musculoskeletal Disorders, 13, 2005.
doi:10.1186/1471-2474-13-205

DISTAL BICEPS REPAIR

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and
clinician evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Phase I: Weeks 0-6

Dr. Jones • Patient to be immobilized in 90 degrees flexion with forearm supinated

for 2 weeks post-op. After 2 weeks until 5-6 weeks, patient is allowed to
unlock hinged brace three times a day for PROM exercises. PROM can
be increased by 20 degrees extension every 4-5 days until full 0 degree
extension is gained.
Dr. Bishop • Patient is to perform no PROM until after first post-op visit. No bracing is
used subsequently, so only PROM is to be performed until 6 weeks post-
op
• Patient can perform ball squeezes for edema control
At 2 Weeks • PROM elbow per physician guidelines above, pronation and supination
• PROM shoulder flexion, abduction, ER- avoid extension
• Maintain active scapular stabilizers: retraction, clocks, PNF
• Shoulder isometrics: extension, abduction, ER, IR, submaximal flexion
Goals 1. Protect repair
2. Minimal to no edema

Phase II: Weeks 4-6

• PROM elbow flexion, supination

• PROM shoulder flexion
• AAROM shoulder abduction, ER, IR, extension progressing to AROM as
tolerated by end of 6th week
• Initiate scar tissue mobilizations as needed
• Putty or finger web for grip strength
Goals 1. At least 75% elbow PROM
2. Tolerate increases in elbow extension
3. No edema or exacerbation with bicep isometrics and ROM

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Phase III: Weeks 6-8

• Discontinue brace at 6 weeks

• Continue to gain elbow extension ROM
• AAROM elbow flexion, supination
• AAROM shoulder flexion
• Initiate UBE forward direction, using vertical handholds
• Prone scapular stabilizing exercises- retraction, ext, rows, Ts
o Avoid loading the biceps with a weight during rows
• Initiate submaximal elbow flexion and supination isometrics
• Rhythmic stabilization- supine, multiangle
• Side lying or Theraband ER/IR strengthening
• Triceps and posterior deltoid strengthening
Goals 1. Tolerate forearm hanging dependently and extended out of sling
2. AAROM of elbow from extension to full flexion

Phase IV: Weeks 8-12

• AROM elbow flexion, supination- start gravity assisted, progress to

antigravity
• AROM shoulder flexion
• If lacking extension range, begin to push stretching into extension
• Biceps PRE’s initiated submaximally
• Shoulder flexion PRE’s initiated
• Progress scapular stability
• UE weight shifts on table
Goals 1. 5/5 shoulder flexion, abduction, ER, IR strength
2. Full ROM of elbow in supination and extension
3. No reactive effusion/exacerbation with biceps PRE’s

Phase V: Weeks 12-20

• Continue to strengthen biceps and surrounding musculature

• Progress both WB and NWB strengthening activities
o Integrate functional strengthening
• Initiate light plyometrics- chest pass to rebounder, impulse

Goals 1. Demonstrate 5/5 with biceps strength testing

2. No reactive effusion with unrestricted ADLs


Phase VI: Weeks 20-24

• If ROM is full and pain free, and patient tolerates PRE’s, may begin free
throwing and ballistic activities as well as unrestricted lifting
Criteria to • Good functional ROM and strength
begin • 65% ER/IR isokinetic strength ratio
throwing
• No less than 15% difference in functional testing compared
bilaterally
• Single arm hop- Patient in single arm push-up position. Hops
with that one UE to small step and then returns to starting
position. This is performed 5 times as quickly as possible.
• Line test- Patient in push-up position with each hand on piece
of tape. Upon start of test, patient removes one hand from
tape, touches the opposite line, and then returns to starting
piece of tape. This is performed with alternating hand touches.
One test is maximal touches in 15 seconds.
• Biodex/ Isokinetic testing for supination-pronation or elbow flexion-
extension within 15% of uninvolved upper extremity

References

Bisson LJ, Gurske de Perio JG, Weber AE, Ehrensberger MT, Buyea C. Is it safe to perform
aggressive rehabilitation after distal biceps tendon repair using the modified 2-incision
approach? The American Journal of Sports Medicine. 2007; 35(12): 2045-2050.

Mazzocca AD, et al. Biomechanical evaluation of 4 techniques of distal biceps brachii tendon
repair. The American Journal of Sports Medicine. 2007; 35(2): 252-258.

Ramsey ML. Distal Biceps Tendon Injuries: Diagnosis and Management. Journal of the
American Academy of Orthopedic Surgeons. 1999; 7: 199-207.

Hurov JR. Controlled active mobilization following surgical repair of the avulsed radial
attachment of the biceps brachii muscle: a case report. Journal of Orthopaedic and Sports
Physical Therapy. 1996; 23(6): 382-387.


DISTAL TRICEPS REPAIR

CLINICAL PRACTICE GUIDELINE
Background
Indications for distal triceps repair include partial or complete tendon ruptures. Repair is preferably performed
within the first three weeks for the best outcomes. Rehabilitation following distal triceps repair will progress more
slowly over the first 6 weeks to protect the healing triceps tendon. Consultation with the surgeon as well as a
review of the operative report should be completed prior to initiation of rehabilitation.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Summary of Recommendations
Risk Factors • Subsequent surgeries
• Lack of adherence to surgical precautions
• Secondary comorbidities

Precautions
• No aggressive stretching of the triceps
• Splint for first two weeks
• Light soft tissue mobilization, not directly on the scar, to improve blood flow and reduce
edema
• Limit passive shoulder flexion to <90 degrees for 6 weeks
• No isolated triceps contraction with elbow extension or shoulder extension for 6 weeks
• No resisted elbow extension or shoulder extensions/rows for 12 weeks
• No weight bearing through the surgical extremity (pushing open a door, pushing up from a chair)
for 12 weeks

Manual • PROM exercises and GH joint mobilizations (phase I & II)

Therapy • Scar massage is appropriate in phase III

Corrective • Cryotherapy for pain and inflammation

Interventions • Manual Therapy

Functional • Disability of Arm Shoulder and Hand (DASH) Questionnaire

Outcome • Kerlan-Jobe Orthopaedic Clinic (KJOC) Questionnaire
Measures
Criteria for • >90% with patient-reported outcome
discharge • Full AROM, strength, and able to demonstrate pain-free, sports specific movements without
compensatory movements

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Phase I: Protection to PROM (0-2 weeks)
Pain and • Education: No elbow AROM, incisions clean and dry, hinged brace per physician instructions
Edema • Vaso and E-stim for pain and edema control
Management • No soft tissue mobilization or cross friction massage directly on the scar
• No weight bearing through surgical extremity for 12 weeks

Restore • Limit shoulder flexion to 90° for 4 weeks

Passive • Elbow flexion limited to 20 degrees in brace
Shoulder and • Gentle shoulder PROM (pulleys, self-passive ranging with uninvolved extremity, table slides)
Elbow ROM
• Gentle elbow PROM (therapist guided ranging, self-passive ranging with uninvolved extremity)

Home Exercise • Posture education

Program • Arm immobilized per physician instructions
• Scapular control exercises (sidelying clocks, seated retractions, scapular PNF)
• PROM elbow flexion locked at 20 degrees in hinged brace
• Able to progress elbow flexion 15 degrees every 5 days (3 sets of 30 minutes per day)
• No active elbow extension
• AROM wrist/ hand (gripping, wrist curl, pronation/supination)

Criterion to • Protect the repair

Progress to • Minimal to no edema
Phase II

Phase II: PROM progression to AROM (2-6 weeks)

Pain and • No soft tissue mobilization or cross friction massage directly on the scar for 6 weeks
Edema • No active elbow extension for 6 weeks
Management • Vaso and E-stim for pain and edema control

Post-op Weeks • No shoulder flexion >90 degrees for 4 weeks

2-4 • Do not PUSH elbow flexion ROM unitl 6 weeks
• PROM-AAROM within limits at shoulder and elbow (therapist guided ranging, self-passive
ranging with uninvolved extremity)
• Gentle soft tissue mobilization, not on the surgical scar, for improved blood flow and reduced
edema

Post-op Weeks • Do not PUSH elbow flexion ROM until 6 weeks

4-6 • Initiation of shoulder submaximal-isometrics (initiate at 25%-50% effort, pain-free): except
shoulder extension
• Progress shoulder AAROM-AROM (Pulleys, wand, self-passive ranging with uninvolved
extremity)

Criterion to • Pain-free, full shoulder AROM with good scapular control

Progress to • Pain-free, full PROM elbow flexion (do not push ROM)
Phase III • Minimal to no edema


Phase III: Initiation of Elbow AROM and Strength (6-12 weeks)
Introduction to • No pain or reactive edema with initiation of active elbow extension
AROM • Avoid resisted elbow extension and shoulder extensions/rows for 12 weeks

Post-op Weeks • Continue progressing AROM of shoulder, gaining muscle endurance with high reps, low
6-8 resistance
• Initiate active, concentric elbow extension (no resistance)
• NO eccentric triceps activity (use uninvolved extremity to aid in eccentric phase of triceps
activity)
• Isotonic IR and ER light resistance resisted movement (at neutral)
• Supine ABC & SA punches with high reps, low resistance
• Gentle soft tissue mobilization (light scar massage of hypomobile)

Post-op Weeks • Initiate prone scapular series at week 8

8-12 • Initiate light, sub-maximal triceps isometrics (25%-50% effort, pain-free) at week 9
• Gradual progression of biceps strengthening
• Resisted IR and ER at 30° ABD progressing to 90° abduction
• Resisted SA punch & bear hugs, standing
• Rhythmic stabilization for shoulder (supine progressing to various positions)
• No pressing activity (bench press, overhead press) for 12 weeks

Return to Stationary bike and light jogging

Activity After
Week 10
Criterion to • Pain-free, full AROM of shoulder and elbow
Progress to • 5/5 MMT for shoulder /rotator cuff strength
Phase IV • 5/5 MMT for scapulothoracic musculature

Phase IV: Return to Sport/Recreational Activity (weeks 12-16)

• Goal: Return to sport at 5-6 months at earliest

Goals • Maintain full, non-painful AROM

• Progress isotonic strength of the triceps (including eccentrics) and surrounding musculature
• Introduce light pressing activity (pushups progression, bench press, overhead press)
• Return to sports progression: throwing/ swimming/lifting
• Analysis of sports specific movements

Exercises 12+ • Progress triceps strengthening (concentric) with light resistance

• CKC UE weight bearing (start with 25% weight bearing, wide hand position, 0-10 degrees of
elbow flexion to limit stress on triceps): wall weight shifts, quadruped rocking at week 12
• Gentle, short duration UBE (2-3 minutes initially, progressing as pain allows)
• Introduce pushup progression (limiting amount of elbow flexion to 45 degrees initially) at week
14
• Initiate plyometric training below shoulder height with progressing to overhead: begin with both
arms and progress to a single arm (16 weeks)
• PNF/Diagonal pattern strengthening

Criterion to • 5/5 MMT for triceps strength

Return to Sport • Pain-free, stability & control with higher velocity movements including sports specific patterns
Activity, Weeks and change of direction movements
12+ • Proper kinematic control transfer from the hip & core to the shoulder with dynamic movement

Authors: Greg Hock, PT, DPT

Reviewers: Mitch Salsbery, PT, DPT, SCS
Completion Date: March 2018

References
Blackmore SM, Jander RM, Culp RW. Management of distal biceps and triceps ruptures. Journal of Hand
Therapy. 2006; 19(2): 154-169. Doi: 10.1197/j.jht.2006.02.001

Demirhan M, Ersen A. Distal triceps ruptures. EFORT Open Rev. 2016;(1):255-259. DOI:10.1302/2058-
5241.1.000038.

Dunn JC, Kusnezov N, Fares A, Rubin S, Orr J, Friedman D, Kilcoyne K. Triceps tendon ruptures: a systematic
review. Hand. 2017;12(5): 431-438. Doi:10.1177?1558944716677338

Giannicola G., Bullitta G., Sacchetti F.M., Scacchi M., Merolla G., Porcellini G. (2016) Triceps Repair. In:
Pederzini L., Eygendaal D., Denti M. (eds) Elbow and Sport. Springer, Berlin, Heidelberg

Keener JD, Sethi PM. Distal Triceps Tendon Injuries. Hand Clin. 2015; (31): 641-650.
Doi:10.1177/155894471667733810.1016/j.hcl.2015.06.010
Kocialkowski C, Carter R, Peach C.Shoulder & Elbow. 2018;10(1): 62-65. Doi:10.1177/1758573217706358

Redler LH, Dines JS. Elbow Trauma in the Athlete. Hand Clin. 2015;31(4): 663-681.
Doi:10.1016/j.hcl.2015.07.002

OPEN LATARJET FOR ANTERIOR STABILIZATION

CLINICAL PRACTICE GUIDELINE

Background
Ohio State’s Latarjet Anterior Shoulder Stabilization Rehabilitation Guideline is to be utilized following open
anterior shoulder stabilization procedures. During the procedure the anterior coracoid is harvested and attached
to the deficient portion of the anterior glenoid to improve stability. It is intended to be used in conjunction with the
therapist and surgeon’s collaborative input. Therapists should obtain the operative note to ensure an
understanding of the procedure performed.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Summary of Recommendations
Risk Factors • Excessive joint laxity
• Exceeding guideline ROM recommendations/goals
• History of instability
• Comorbidities including, but not limited to, connective tissue disorders

Precautions • Limited to 30 degrees external rotation for 6 weeks

• Limit active biceps AROM for first 6-8 weeks due to detachment of coracobrachialis and short
head of the biceps
• Avoid extension behind the body for 6 weeks
• Avoid heavy bicep exercises for 12 weeks
• Progression of ROM should not be forced and is per patient’s tolerance
• Return to jogging should be not initiated until 10-12 weeks depending on patient presentation
and physician clearance
• Return to non-contact sport 5-6 months; minimum of 6 months for contact sports and climbing
• Initiation of throwing program around month 4 with goal of return to game at 9 months
• Refer back to surgeon with any positive apprehension testing
• No Olympic lifting or bar bench press until 6 months
Manual • Passive ROM not to exceed guideline
Therapy • Soft tissue mobilization per clinical judgment
• Joint mobilizations per guideline to reduce pain and improve mobility
Corrective • Therapeutic exercises to optimize rotator cuff and periscapular strength
Interventions • Neuromuscular re-education to improve joint stability and proprioception
• Therapeutic activity to improve ADL and leisure activities
• Manual (PROM, AAROM, AROM) to restore normal ROM per guidelines
• Modalities to control pain and swelling

Outcome • Disability of Arm Shoulder and Hand (DASH) Questionnaire

Testing • Kerlan-Jobe Orthopaedic Clinic (KJOC) Questionnaire

Criteria for • Full AROM appropriate for patient

discharge with • 5/5 MMT shoulder and scapular strength
return to sport • No substitution patterns
(9-24 months) • Independent with home exercise program per patient needs
• Low pain scores
• Return to full abilities with ADLs
• Initiation and guidance with return to sport phase

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During surgery the subscapularis will be either split or taken down and repaired. It is imperative that the treating
therapist understands which technique was utilized in surgery. Please consult referring surgeon for operative note.

If the subscapularis was taken down and repair, the following precautions must be taken for 6 weeks:
• No ER past 30 degrees
• No cross body adduction
• No active IR or IR behind the back
• No supporting of body weight with affected side (i.e. pushing self up from a chair)

If the subscapularis was split, the precautions above should be followed except: resisted IR may begin at 4 weeks

Phase I: Protection (Post Surgical– 0-6 weeks)

Post Operative Goals
to 6 weeks • Max protection of surgical repair (capsule, ligaments, labrum, sutures)
• Achieve staged ROM goals - do not significantly exceed
• Patient education on post-op restrictions and maintaining appropriate posture
• Minimize shoulder pain and inflammatory response
• Ensure adequate scapular function

Post Operative Protection

to 3 weeks • Sling usage 6 weeks (discuss with physician) including while sleeping
ROM Goals by week 3
• All ROM is to first end feel only
• Forward elevation to 90 degrees
• ER in scapular plane to 20 degrees (no ER at 90 degrees abduction)
• No abduction or internal rotation
• Elbow/wrist/hand ROM as tolerated
Weeks 4 to 6 ROM Goals by week 6
PROM
• Forward elevation limited to 135 degrees
• IR to 50 degrees
• Abduction to 115 degrees
• ER in the scapular plane to 30 degrees
• ER at 90 degrees abduction to 30 degrees
Start AAROM
• Cane and wall walks with limitations to 135 degrees
• Pendulum exercises
AROM
• Begin at week 4 within limitations to 115 degrees flexion
May begin elbow AROM

• Strengthening
• Begin submaximal isometrics (ER, Abduction, Flexion, Extension to hip only)
• Scapular stabilization (scapular clocks)
• ER with light, non-fatiguing theraband at 30 degrees of abduction (open pack position) - within
ROM restrictions

Goals to 1. Appropriate healing of surgical repair by adhering to precautions and immobilization guidelines
Progress to 2. Staged ROM goals achieved but not significantly exceeded
Next Phase 3. Minimal to no pain with ROM


Phase II: Intermediate Phase
Weeks 7 to 12 Goals
• Achieve staged ROM goals to normalize PROM and AROM – do not significantly exceed
• Minimize shoulder pain
• Begin to increase strength and endurance
• Increase functional activities
Weeks 7 to 9 ROM Goals by week 9
PROM
• May perform joint mobilizations (emphasis on posterior mobility)
• Forward elevation 155 degrees
• IR at 90 degrees of abduction to 60 degrees by week 8-9
• ER at 20 degrees ABD to 60 degrees
• ER at 90 degrees ABD to 75 degrees
AROM
• Elevation to 145 degrees
Strengthening
• Begin light UBE
• PRE’s for scapular stabilizers (rows, shoulder extension, scapular retraction) utilizing low load,
high repetition of 12-15 repetitions
• Dynamic resistance with PNF patterns and manual techniques
• Elbow extension strengthening using light weight/high reps
• Begin CKC exercise with table/wall weight shifts while keeping hands shoulder width or closer

Weeks 10 to 12 • Initiation of jogging with physician clearance

ROM Goals by week 12

PROM
• WNL all planes
AROM
• Elevation WNL

• Strengthening
• Progress PREs in all planes using progressive weight and high repetitions
• Rhythmic stabilization i.e. prone medicine ball eccentric drops, free throws, ball taps, etc.
• Progress CKC exercises while keeping hands shoulder width or closer

Goals to 1. Staged AROM goals achieved with minimal to no pain and without substitution patterns
Progress to 2. Appropriate scapular posture at rest and dynamic scapular control during ROM and
Next Phase strengthening exercises
3. Strengthening activities completed with minimal to no pain


Phase III: Advanced Activity Phase
Weeks 12-20 Goals
• Normalize strength, endurance, neuromuscular control, and power
• Gradual and planned build up of stress to anterior capsulolabral tissues
• Gradual return to full ADLs, work, and recreational activities

Weeks 12 to 16
• ROM
• Terminal ER stretches at 12 weeks
• Self capsular stretches, AROM, and passive stretching as needed
• Strengthening
• Advanced isotonics
• Begin elbow flexion strengthening
• Initiate plyometrics (2-handed drills) i.e. chest pass
• Ball catch/toss at 90 degrees abduction position
• Begin dumbbell pec exercises with reduced motion in horizontal abduction to 45 degrees
• Begin light resitance training except: military press, pull ups, behind head pull-downs, overhead
tricep extensions.
• Elbow should stay at or in front of midline of the body to recude anterior shoulder stress

Phase IV: Return to Sport/Activity
Weeks 16-20 • ROM
• May begin more aggressive stretching techniques
• Strengthening
• Begin overhead PRE’s – never behind midline of body
• Begin light toss or volley (refer to return to throwing program)
• Continue with specific training program
• Return to full activity
• Bench Press with bar at 6 months

Goals to 1. Progress functional activities towards return activity or sport

Progress to 2. Enhance neuro-muscular control
Return to Sport 3. Improve strength, power, and endurance
4. Muscular strength no less than 80% of contralateral side
5. Full functional ROM
6. 5/5 scapular and rotator cuff strength

Authors: Mitch Salsbery, PT, DPT, SCS

Reviewers: Mitch Salsbery, PT, DPT, SCS; Chelseana Davis, PT, DPT, SCS; Katherine Sullivan, PT, DPT, SCS,
ATC; Joann Walker, PT, SCS
Completion date: January 2017

References
Hayes K, Callanan M, Walton J, Paxinos A, Murrell GA. Shoulder Instability: Management and Rehabilitation:
JOSPT. 2002; 32:1-13.
Lebar RD, Alexander AH: Multidirectional Shoulder instability. Clinical results of inferior capsular shift in an
active-duty population. AM J Sports Med 1992 Mar-April; 20 (2): 193-198.
Wilk KE, Reinold MM, Dugas JR, Andrews JR. Rehabilitation Following Thermal-Assisted Capsular Shrinkage of
the Glenohumeral Joint: Current Concepts. JOSPT. 2002;32: 268-292.
Gaunt BW, Shaffer MS, Sauers EL, Michener LA, McCluskey GM, Thigpen CA. The american society of shoulder
and elbow therapists’ consensus rehabilitaation guideline for arthroscopic anterior capsulolabral repair of the
shoulder. JOSPT. 2010 40(3): 155-168

Medial Epicondyle ORIF
CLINICAL PRACTICE GUIDELINE
Background
Medial epicondyle fractures account for a significant portion of all elbow fractures, both acute and chronic, in the
adolescent population. Indication for a medial epicondyle ORIF is a fracture with a large displacement (typically >5 mm) of
the bone. Rehabilitation following an ORIF will progress more slowly over the first 6 weeks to allow bone healing.
Consultation with the surgeon as well as a review of the operative report should be completed prior to initiation of
rehabilitation.

Disclaimer
Progression is time and criterion-based, dependent on bone and soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Summary of Recommendations

Risk Factors • Subsequent surgeries

• Lack of adherence to surgical precautions
• Secondary comorbidities
Precautions • Brace and ROM limitations
• Splint for 10-14 days at 90 degrees of elbow flexion
• Light soft tissue mobilization, not directly on the scar, to improve blood flow and reduce
edema
• No elbow joint mobilizations for 6 weeks
• No wrist flexor or pronator strengthening for 6 weeks
• No aggressive wrist flexor or pronator stretching for 6 weeks
• No valgus stress to the medial elbow for 6 weeks (consider with PROM and strengthening
of shoulder
• No lifting >5 lbs for 8 weeks (could be longer if other surgical interventions performed)

Potential • Nonunion
Complications • Nerve palsy
• Joint stiffness
Corrective • Cryotherapy for pain and inflammation
Interventions • Manual Therapy

Functional • Disability of Arm Shoulder and Hand (DASH) Questionnaire

Outcome • Kerlan-Jobe Orthopaedic Clinic (KJOC) Questionnaire
Measures
Criteria for • >90% with patient-reported outcome
discharge • Full AROM, strength, and able to demonstrate pain-free, sports specific movements without
compensatory movements

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Phase I: Immediate Post-Op (0-2 weeks)

Goals • Protection of incision

• Allow for bone healing
• Decrease pain and inflammation
• Patient education: bone healing time, activity modification, swelling management, HEP
• No elbow AROM, incisions clean and dry, immobilization per physician instructions

Restore • Splint for 10-14 days at 90 degrees of elbow flexion

Passive • Gradual, pain-free elbow PROM
Shoulder and
• Shoulder strengthening (sub-maximal isometrics EXCEPT flexion due to closed fist/gripping
Elbow ROM
and ER)
• Scapular retraction or clocks in S/L
• Trunk ROM/core strengthening (No weight bearing on elbow or carrying/lifting)
• Lower extremity strengthening and balance
- Squats, lunges, heel taps, single leg stance, shuttle presses, side stepping
• Vaso for pain and swelling control

Home Exercise • Posture education

Program • Elbow immobilized per physician instructions
• Scapular control exercises (side lying clocks, seated retractions, scapular PNF)
• No active elbow OR wrist extension, flexion, pronation, supination
Criterion to • Protect the repair/incision site
Progress to • Minimal pain
Phase II • Minimal to no edema

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Phase II: PROM progression to AROM (2-6 weeks)

Goals • Slow progression of elbow extension and flexion ROM (Do not push aggressively)
• Manage pain and inflammation
• Promote tissue and bone healing
• No soft tissue mobilization or cross friction massage directly on the scar for 6 weeks
• No elbow joint mobilizations for 6 weeks
• No wrist flexion or pronator strengthening for 6 weeks
• No wrist flexor or pronator stretching for 6 weeks
• No valgus stress to elbow for 6 weeks
• Vaso and E-stim for pain and edema control
Interventions • Hinged brace from weeks 2-6
• Gentle PROM of elbow and wrist (Do not push ROM into pain)
Muscular end feel: traditional stretching
Capsular/firm end feel: low load, long duration
• Progress to elbow AROM at 4 weeks
• Ulnar nerve mobility if needed (avoid valgus stress to elbow with nerve glide)
• Shoulder strengthening (wrist weights for S/L ER and prone scap series)
• Light rhythmic stabilizations proximal to elbow
• Continue trunk/core strengthening, LE strengthening, and balance (no holding medicine
balls/weight OR weight bearing with involved arm)
• Shoulder PROM (Do Not Apply Pressure Distal To Elbow For ER/IR; Use Humerus)
• Vaso for pain and swelling control

Criterion to • Full PROM of elbow (Refer back to physician if not achieved)

Progress to • Shoulder total arc of motion (ER+IR at 90 degrees of abduction) dominant = non-dominant
Phase III
• Pain free with all exercises
• No swelling

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Phase III: Intermediate Phase (6-12 weeks)

Goals • Gradual increase to WNL elbow and forearm ROM in all planes
• Pain free with all exercises
• NO swelling
• Initiate light strengthening of wrist and elbow musculature
• Promote proper scapular control and mobility
• Improve overall conditioning and strength

Post-op Weeks • Unlock brace to full motion at 6 weeks

6-8 • Wean from brace at 8 weeks
• Focus on elbow extension and flexion AROM
• Initiate pain-free wrist and elbow strengthening at 6 weeks
**Delay if flexor-pronator mass is repaired (check with surgeon)
• Continue balance, lower extremity strengthening, and core strengthening (<5 lbs of weight)
• Continue shoulder ROM and strengthening (no valgus stress on the elbow)
- Ex: s/l ER, rows, rhythmic stabilizations, horizontal abduction
• Scapular stability and control exercises (side-lying, prone)
• Criteria to progress to next phase:
- Pain free with all exercises
- Full AROM of elbow
- Symmetrical hip ROM
- 5/5 lower extremity strength (MMT)
- 50 degrees of seated thoracic rotation each direction
- Shoulder total arc of motion dominant = non-dominant
- 4/5-5/5 MMT of involved shoulder musculature
Post-op Weeks • Wean from brace at week 8
8-12 • Plyometric progression can be initiated at week 10 (1 week double arm, 1 week single arm)
• Example interventions
- Prone 90/90 ER, prone quick drops
- Rhythmic stabilization
- PNF patterns
- Double arm plyometrics: Medicine ball chest pass, chops
- Single arm plyometrics: 90/90 ball on wall/tramp, manual plyo’s
• Throwing mechanics/Towel drills initiated same week as single arm plyometrics (need to be
pain-free)
• Weight bearing on involved arm at week 8
• Running at week 8

Criterion to • Pain-free, full AROM of shoulder and elbow

Progress to • 5/5 MMT or within 10% of uninvolved side with HHD for shoulder /rotator cuff strength
Phase IV • 5/5 MMT or within 10% of uninvolved side with HHD for scapulothoracic musculature

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Phase IV: Return to Sport Activity (weeks 12+)

Goals • Progress back to sport level conditioning

Exercises 12+ • Continue lower extremity and core interventions as needed

• Continue plyometrics and towel drills as necessary
• Criteria for return to throwing program
- Physician clearance
- 5/5 MMT or within 10% of uninvolved with HHD
- Full AROM
- Pain-free towel drills and plyometric drills
• Initiate return to throwing program
- Light throw into wall for mechanics
- Educate on return to throwing progression (give print-out from sports medicine
website: https://wexnermedical.osu.edu/sports-medicine/education/medical-
professionals/rehabilitation-protocols)
- Highlights: therapist monitor mechanics, start at 50% effort, crow hop when reaching
distance of 90 ft or more

Authors: Greg Hock, PT, DPT; Dan Himmerick, PT, DPT; Matt Schultz, PTA
Reviewers: Mitch Salsbery, PT, DPT, SCS; Adam Ingle, PT, DPT, SCS
Completion date: January 2019

References
Kamath AF, Cody SR, Hosalkar HS. Open reduction of medial epicondyle fractures: operative tips for technical ease. J
Child Orthop. 2009;3(4):331-6.
Huleatt JB, Nissen CW, Milewski MD. Pediatric Sports Medicine Injuries: Common Problems and Solutions. Clin Sports
Med. 2018;37(2):351-362.

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PECTORALIS MAJOR TENDON REPAIR

CLINICAL PRACTICE GUIDELINE

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Phase I: • Immobilize in sling per physician (Typically 6-8 weeks)

• Pendulums
Weeks 1-4 • Wrist and elbow ROM
• Avoid active movement in all directions

Goals to 1. Decrease pain

Progress to 2. Minimal to no edema
Next Phase

Phase II: • Begin PROM: avoiding abduction, ER

• Scapular clocks, retraction, depression, protraction
Weeks 4-6 • Scapular PNF
• Scapular mobility
• Begin table weight shifts for weight bearing through UEs
• Grades I-II (anterior, posterior, distraction) oscillatory joint mobilizations
• Stationary bike with immobilizer

Goals to 1. 75-100% PROM, except ER- keep to no more than 30-40 degrees
Progress to 2. Sleeping through the night
Next Phase

th
Phase III: • Initiate AAROM-progress to AROM as tolerated toward 8 week
Weeks 6-8 • Can push PROM ER beyond 40 degrees
• Grade III sustained joint mobilizations for capsular restriction
• Isometrics-flexion, extension, abduction, ER, horizontal abduction
• Progress scapular strengthening
• Can progress weight bearing to quadruped, tripod (1UE +2LE)
• Avoid active adduction, horizontal adduction, IR

Goals to 1. 75-100% full AAROM without pain

Progress to 2. AAROM flexion, abduction, ER, IR without scapular or upper trap substitution
Next Phase 3. Tolerate PRE’s for scapular stabilizers and shoulder complex
4. No reactive effusion

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Phase IV: • Gain full ROM through stretching and grade III mobilizations
• Active flexion, abduction, adduction strengthening -avoid IR/flexion/horizontal adduction
Weeks 8-12 • Progress scapular strengthening and progress rotator cuff strengthening avoiding IR
• Begin submax pectoralis strengthening
• Wall pushups progressing to table pushups, uneven surfaces
• Dynamic stabilization, perturbations, weight bearing planks on hands
• Active ER, horizontal abduction- not to end range

Goals to 1. Full AROM

Progress to 2. Increased strength/ proprioception with exercise without an increase in symptoms
Next Phase

Phase V: • Progress scapular and rotator cuff strengthening- including IR

• Single arm pectoralis major strengthening- therabands then progress to dumbbell bench
Weeks 12- press with light weight/ high reps, avoiding a wide grasp, and end range ER/ABD.
24 • Pushups- avoiding humeral abduction beyond frontal plane
• Progress into UE plyometrics- eg. wall taps, chest pass (bilateral)
• PNF D1, D2
Goals to 1. Tolerate high level of strengthening and plyometrics without an increase in symptoms
Progress to 2. Tolerate/progress single arm strengthening of pec
Next Phase 3. No pain with any strengthening activities

Phase VI: • Discourage 1RM for bench press

• Prepare for return to sport
Months 6-9 o Use of One-Arm Hop Test as outcome measure for return to sport- reliable for
comparing performance in injured and contralateral uninjured UEs

Goals to 1. Sufficient score on functional test- isokinetic or one arm hop test- to allow safe return to
Progress to sport
Return to Sport

References

Petilon J, Carr DR, Sekiya JK, Unger DV. Pectoralis major muscle injuries: evaluation and management. Journal of the
American Academy of Orthopaedic Surgeons. 2005; 13:59-68.

Shepsis AA, Grafe MW, Jones HP, Lemos MJ. Rupture of the pectoralis major muscle outcome after repair of acute and
chronic injuries. American Journal of Sports Medicine. 2000; 28(1):9-15.

Uhl TL, Carver TJ, Mattacola CG, Mair SD, Nitz AJ. Shoulder musculature activation during upper extremity weight bearing
exercise. Journal of Orthopaedic and Sports Physical Therapy. 2003; 33:109-117.

Hintermeister RA, Lange GW, Schultheis JM, Bey MJ, Hawkins RJ. Electromyographic activity and applied load during
shoulder rehabilitation exercises using elastic resistance. American Journal of Sports Medicine. 1998; 26(2): 210-220.

Fees M, Decker T, Snyder-Mackler L, Axe MJ. Upper extremity weight training modifications for the injured athlete: a clinical
perspective. American Journal of Sports Medicine. 1998; 26(5):732-742.

Falsone SA, Gross MT, Guskiewisc KM, Schneider RA. One-arm hop test: reliability and effects of arm dominance. Journal of
Orthopaedic and Sports Physical Therapy. 2002; 32:98-103.

POSTERIOR SHOULDER STABILIZATION

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Rehabilitation Precautions
• Strict sling use for 6 weeks after procedure, proper use with shoulder in neutral rotation, not across belly.
• Sling removal for exercises, hygiene, dressing and elbow support activities such as writing or typing.
• Avoid any positions of horizontal adduction or internal rotation so as to not stress posterior capsule and
labrum.
• Neither horizontal adduction nor internal rotation stretches until 10-12 weeks.
• Avoid any weightbearing thru the involved UE for 10-12 weeks.
• Isotonic strengthening at 8 weeks.
• Progression is time and criterion-based, dependent on soft tissue healing, patient demographics, and
clinician evaluation

Phase I: Weeks 0-6

ROM • Education in performance of pendulums.
• Initiate PROM ER in neutral in supine.
• Initiate wand ER in supine.
• Limit wand supine FE to 90° for first 4 weeks
• Progress wand supine FE to 120° at weeks 4-6

Strength • No isometric or isotonic strengthening

Goals to 1. Proper sling use

Progress to 2. Pain controlled
Next Phase 3. Physician clearance for sling discharge at 6 weeks

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Phase II: Weeks 7-10
ROM • Progress FE in supine to 180° as tolerated
• Progress ER at 90° of abduction
• AROM as tolerated without upper trapezius substitution.
• Continue avoidance of horizontal adduction and internal rotation movements or stress
• Avoidance of UE weight bearing exercises or positions
Strength • Neuromuscular re-education for RC and Scapular Stabilizers
o Rhythmic Stabilization in non provocative positions (90° FE, 120° FE and ER)
o Scapular PNF with manual resistance
• Initiate dynamic isometrics with band
• Initiate light band exercises for ER and IR at neutral
• Initiate light band exercises for scapular stabilization (Row, Extension, Depression,
Horizontal Abduction)
• Initiate standing scapular retraction to isolate middle traps

Goals to 1. Functional AROM without upper trap compensation or pain.

Progress to 2. No increased pain or soreness with initial isotonic exercises.
Next Phase

Phase III: Weeks 10-12

ROM • Continue terminal PROM stretches in all directions except horizontal adduction and internal
rotation
• Initiate gentle stretching into horizontal adduction and internal rotation

Strength • Continue progression of Neuromuscular re-education for RC and Scapular Stabilizers

• Progress ER and IR strengthening to 45° of abduction.

Initiate band/weight strengthening into FE and Abduction

Goals to 1. Full AROM and PROM

Progress to 2. Normalized arthrokinematics with daily activities
Next Phase


Phase IV: Weeks 12-17
ROM • Initiate inferior GH mobilizations to improve abduction if appropriate.
•
Strength • Initiate gentle CKC UE weightbearing exercises on wall
• Initiate Throwers 10 program (T, Y, Extensions, Row)
• Progress all endurance and neuromuscular exercises
• Initiate PNF diagonals with band and manual resistance
• Initiate Plyometric medicine ball program
Goals to 1. No increased pain or compensations with addition of horizontal adduction and internal
Progress to rotation stretches.
Return to Next
Phase

Phase V: Weeks 18+

ROM • PROM as needed
• Progress all terminal stretches if needed

Strength • Initiate prone CKC UE weightbearing exercises

• Initiate supine bench press and military press
• Initiate lat pull down
• Initiate prone push-ups at 5-6 months.
• Initiate controlled falls onto therapy ball or ground, emphasis on landing with elbows flexed to
absorb impact.
• Initiate and progress all sport specific drills specific to sport.
Initiate throwing program or gradual return to sport if appropriate.

Goals to 1. Physician clearance at 6 month check up for contact sports

Progress to
Sport

References

Andrews JR, Harrelson G, Wilk KE; Physical Rehabilitation of the Injured Athlete, 3rd Ed. Philadelphia, PA,
Saunders, 2004.

Eckenrode BJ, Logerstedt DS, Sennett BJ. Rehabilitation and Functional Outcomes in Collegiate Wrestelers
Following Posterior Shoulder Stabilization Procedure. JOSPT, July 2009.

REVERSE TOTAL SHOULDER ARTHROPLASTY

CLINICAL PRACTICE GUIDELINES
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Rehabilitation Precautions
• Sling use for 6 weeks
• No internal rotation, cross body adduction, or extension x 12 weeks
• Forward elevation in SCAPTION only
• No stretching into pain
• Caution with end range motion – Do NOT push hard into end ranges
• No supporting of body weight by hand on involved side (for example, pushing up from a chair) x 12 weeks
• No driving for six weeks
• Jogging may begin at 12 weeks
• Long Term:
o No push ups or bench press
o 15lb limit below shoulder height
o 10lb limit above shoulder height
Check with surgeon’s office if posterior instability precautions are indicated on referral or operative report

Phase I: Post-operative – 2 weeks

• Continue home program including wrist/hand, pendulums, and shoulder blade squeezes

Phase II: Weeks 2-4

ROM • Continue all exercises as above
• Frequent cryotherapy application – 4-5 times a day for 15 to 20 minutes
• NO SHOULDER IR, ADDUCTION, EXTENSION OR CROSS BODY
MOVEMENT
Strengthening • Begin submaximal pain-free deltoid isometrics in scapular plane (avoid
shoulder extension when isolating posterior deltoid)

Goals to 1. Enhance PROM

Progress to 2. Restore active range of motion (AROM) of elbow/wrist/hand
Next Phase 3. Independent with activities of daily living (ADLs) with modifications

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Phase III: Weeks 4-6

ROM • Progress PROM

• Forward scaption in supine to 120°
• ER in scapular plane to tolerance, respecting soft tissue constraints (30-45°)
• Continue frequent cryotherapy
• NO SHOULDER IR, ADDUCTION OR CROSS BODY MOVEMENT
Strength • Gentle resisted exercise of elbow, wrist, and hand
• Discontinue use of sling at six weeks

Goals to 1. Patient tolerates shoulder PROM as outlined above

Progress to 2. Patient tolerates elbow, wrist and hand AROM
Next Phase 3. Patient demonstrates the ability to isometrically activate all components of the
deltoid and periscapular musculature in the scapular plane

Phase IV: Weeks 6-10

Precautions • Continue to avoid shoulder hyperextension

• In the presence of poor shoulder mechanics avoid repetitive shoulder AROM
exercises/activity
• Restrict lifting of objects to no heavier than a coffee cup
• No supporting of body weight by involved upper extremity
ROM • Begin shoulder active assisted ROM/AROM progressing from supine to seated
as tolerated in scaption, and ER in the scapular plane
• Gentle glenohumeral and scapulothoracic joint mobilizations as indicated
(Grades I and II)
• Patient may begin to use hand of involved extremity for feeding and light ADLs
• Continue use of cryotherapy as needed
• NO SHOULDER IR, ADDUCTION, EXTENSION OR CROSS BODY
MOVEMENT
Strength • Progress strengthening of elbow, wrist, and hand
• Begin gentle glenohumeral ER submaximal pain-free isometrics
• Initiate gentle scapulothoracic rhythmic stabilization and alternating isometrics
in supine as appropriate.
• Begin gentle periscapular and deltoid submaximal pain-free isotonic
strengthening exercises, typically toward the end of the eighth week

Goals to 1. Continue progression of PROM (full PROM is not expected)

Progress to 2. Gradually restore AROM
Next Phase 3. Control pain and inflammation
4. Re-establish dynamic shoulder stability


Phase V: Weeks 10-12

ROM • Continue with above exercises and functional activity progression

• NO SHOULDER IR, ADDUCTION OR CROSS BODY MOVEMENT
Strength • Begin supine forward flexion scaption with light weights of 1-3 pounds at
varying degrees of trunk elevation as appropriate (ie, supine to sitting/standing)
• Progress to gentle glenohumeral ER isotonic strengthening exercises

Goals to 1. Improving function of shoulder

Progress to 2. Patient demonstrates the ability to isotonically activate all components of the
Next Phase deltoid and periscapular musculature and is gaining strength

Phase VI: Weeks 12+

Precautions • No lifting of objects heavier than six pounds with the operative upper extremity
• No sudden lifting or pushing activities

ROM • Continue to maintain gains

• Begin progressing IR as tolerated

Strength • Continue with the previous program as indicated

• Progress to gentle resisted flexion, elevation in standing as appropriate
• Typically the patient is on a HEP at this stage, to be performed 3-4 times per
week, with the focus on:
o Continued strength gains
o Continued progression toward a return to functional and recreational
activities within limits, as identified by progress made during
rehabilitation and outlined by surgeon and physical therapist
Criteria for 1. Patient is able to maintain pain-free shoulder AROM (typically 80°-120° of
Discharge elevation, with functional ER of about 30°)
from Physical 2. Patient demonstrates proper shoulder mechanics
Therapy

References
Bourdreau S, Bourdreau E, Higgins LD, and Wilcox RB. Reahabilitation Following Reverse Total Shoulder
Arthropoplasty. Journal of Orthopaedic and Sports Physical Therapy. 2007; 37:12 (734-743).

LARGE-MASSIVE ROTATOR CUFF

REPAIR GUIDELINE
Background
The rotator cuff is responsible for stabilization and active movement of the glenohumeral joint. An acute
or overuse injury may cause the rotator cuff to be injured and varying widths of tears may cause
increased pain and dysfunction of the shoulder joint. A large size rotator cuff tear is defined as a tear 3-
5cm, massive >5cm. Rotator cuff repair is performed, either arthroscopically or via mini-open procedure,
by suturing the torn tendon to the humerus.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and
clinician evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Superior Capsule Reconstruction Considerations

• Follow protocol timeframes Ÿ Limit lifting to 5 lbs for 6 months

Summary of Recommendations
Risk Factors • Low preoperative functional level • Lower education level
• Poorer preoperative active ER • Workman’s comp claims
• Younger age
Precautions • Sling use for 6 weeks Subscapularis Repair (12 weeks)
• No PROM into pain • No ER past 30 degrees
• Start physical therapy at 4-6 weeks • No cross body adduction
• • No active IR or IR behind back
• • No supporting of body weight on
affected side (i.e. pushing up from
chair)
Manual • Week 0-4: continue post-operative home exercises (wrist and hand, pendulums,
Therapy scap squeeze)
• Week 4-6: posterior and caudal GH mobilizations, soft tissue mobilization as
appropriate
• Week >6: PROM, soft tissue and joint mobilization as appropriate
Corrective • Pain and edema control modalities
Interventions • Manual for glenohumeral and scapular mobility and shoulder ROM
• Therapeutic exercise and neuromuscular re-education for UE strength, control and
postural stability
• Therapeutic activity for return to work simulations to increase strength and
endurance
• Sport-specific activity training
Outcome • Disability of Arm, Shoulder, Hand (DASH)
Testing • Quick DASH

Criteria for • Full AROM with no scapular substitution

Discharge • 5/5 MMT RTC strength
• 65-70% IR/ER isokinetic testing

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Phase 1: Protection

WEEK ROM • Continue PROM

4-6 § Begin PROM in flexion and external rotation only
§ Do NOT push into pain
• Shoulder joint mobilizations (grade II-III) – posterior and caudal
• Scapular mobilization
• Pectoralis minor flexibility
§ Supine postural stretch
§ Passive therapist overpressure
• Begin wand exercises in a seated position
§ Shoulder external rotation
§ Shoulder flexion with physician’s authorization
Strengthening • Begin isotonic scapular retraction/protraction
§ Serratus punches
§ PNF patterns in sidelying (scapular clock)
§ Sitting retraction
• Begin manual resistance scapular stabilization (sitting, side lying)
§ Rows, pulldowns – light resistance
Modalities • Ice and pain modalities as indicated
Goals for 1. Decrease pain
Progression 2. Full PROM supine
to Next Phase 3. Sleeping through the night
4. Normal posture


Phase 2

WEEK D/C sling per physician

6-8
ROM • AAROM per patient tolerance - adding abduction, horizontal abduction (maintain
subscapularis precautions)
• Ball on wall, UE swiss ball mobility –IR/ER
• Towel wipes on table – any direction
Strengthening • Closed-chain stability – elbow extension with hand on ball performing
oscillations
• Progress scapular neuromuscular strengthening
• Initiate SUB-MAX/50% effort strengthening
• Isometric flexion, extension, abduction, ER, IR
• Isometric lower trap

WEEK ROM § AROM per patient tolerance; avoid scapular substitution

8-10
Strengthening • UBE light resistance
• Begin prone exercise program no weight, below shoulder level
• Row
• Shoulder extension
• Continue scapular strengthening progression
• Begin closed chain UE activities
§ Towel wipes on wall – horizontal, diagonal and vertical
§ Quadruped weight-shifts

WEEK ROM § Continue AROM per patient tolerance

10-12 § Add gentle IR stretching
Strengthening • UBE moderate resistance
• Continue isometric strengthening
• Dynamic isometric walk-outs
• Progress prone exercise program no weight
• Row
• Shoulder extension
• Progress closed chain UE activities
• Seated press-up
• Serratus punches
• Proprioceptive exercises
• Ball on wall
• Supine ABC’s
Goals for 1. Full AROM with no scapular substitution
Progression 2. No reactive inflammation with strengthening
to Next Phase 3. Return to full ADLs pain free


Phase 3

WEEK Strengthening • T-band exercises

12-16 • Shoulder IR/ER
• Horizontal abduction/adduction
• Diagonal patterns
• Begin Prone exercise program with weight
• Row
• Shoulder extension
• Horizontal abduction – T exercise position
• Lower trapezius – Y exercise position
• Begin rhythmic stabilization exercises supine, starting at balance point position
(90-100 degrees of elevation); progress to side lying, prone, standing
• Functional eccentric strengthening
• Decelerations
• Progress closed chain UE strengthening
• Push up with a plus
• Swiss ball activities
• Plank BOSU weight shifts
• Trunk and lower extremity strengthening
Goals for 1. Full AROM with no scapular substitution between weeks 10-12
Progession to 2. 5/5 rotator cuff strength
Next Phase 3. 65-70% IR/ER isokinetic testing

Phase 4 – Return to Sport / Activity

Goal is to return to sport at 6 months

4-6 ROM • Emphasis on posterior capsule stretching

MONTHS • General stretching/flexibility program
Strengthening • Progress T-band exercises
• Progress Dumbbell Program with weight
• Scaption
• Diagonal patterns
• Bent row
• Prone Retraction with ER
• Functional eccentric strengthening
• Progress closed chain UE strengthening
• Push up with a plus
• Swiss ball activities
• Continuation of trunk and lower-extremity strengthening
• Initiation of throwing progression (See OSU Sports Med Throwing Program)
• Begin short toss and overhead endurance activities per physician release
• Continuation of functional UE/LE strengthening and endurance activity
Goals to • Completion of throwing progression
Return to • No reactive effusion, pain and/or instability
Sport • 65-70% IR/ER isokinetic testing
• Full functional mobility and strength


Authors: Mitch Salsbery, PT, DPT, SCS and Adam Ingle PT, DPT, SCS
Reviewers: Grant Jones, MD and Julie Bishop, MD
Completion date: December 2017

References
Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone
Joint Surg Am. 2012;94:227-233.
Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary
McCann PD, Wooten ME, Kadaba MP, Bigliani LU. A kinematic and elctromyographic study of shoulder
rehabilitation exercises. Clin Orthop Rel Res. 1993;288:178-188.
Ellsworth AA, Mullaney M, Tyler TF, McHugh M, Nicholas S. Electromyography of selected shoulder
musculature during un-weighted and weight pendulum exercises. N Am J Sports Phys Ther. 2006;1:73-
79.
Kibler WB, Livingston B, Bruce R. Current concepts in shoulder rehabilitation. In: Stauffer RN, Erlich MG.
Advances in Operative Orthopaedics. Vol 3. St. Louis, MO: Mosby; 1995: 249-297
Park MC, Idjadi JA, Elattrache NS, Tibone JE, McGarry MH, Lee TQ. The effects of dynamic external
rotation comparing 2 footprint-restoring rotator cuff repair techniques. Am J Sports Med. 2008;36(5): 893-
900.
Slabaugh MA, Nho SJ, Grumet RC, Wilson JB, Seroyer ST, Frank RM, Romeo AA, Provencher MT,
Verma NN. Does the literature confirm superior clinical results in radiographically healed rotator cuffs after
rotator cuff repair? Arthroscopy. 2010 Mar;26(3):393-403. Epub 2010 Jan 15
Jost B, Zumstein M, Pfirrmann CW, Gerber C. Long-term outcome after structural failure of rotator cuff
repairs. J Bone Joint Surg Am. 2006 Mar;88(3):472-9.
Paxton ES, Teefey SA, Dahiya N, Keener JD, Yamaguchi K, Galatz LM. Clinical and radiographic
outcomes of failed repairs of large or massive rotator cuff tears: minimum ten year follow-up. J Bone Joint
Surg Am. 2013 Apr 3;95(7):627-32.


SMALL-MEDIUM ROTATOR CUFF

CLINICAL REPAIR GUIDELINE
Background
The rotator cuff is responsible for stabilization and active movement of the glenohumeral joint. An acute or
overuse injury may cause the rotator cuff to be injured and varying widths of tears may cause increased pain and
dysfunction of the shoulder joint. A small size rotator cuff tear is defined as a tear <1cm, medium 1-3cm. Rotator
cuff repair is performed, either arthroscopically or via mini-open procedure, by suturing the torn tendon to the
humerus.

Disclaimer
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Summary of Recommendations
• Do not perform PROM into pain
• Physical Therapy will be initiated between weeks 2-4 based on physician preference

Risk Factors • Avoid AROM before 6 weeks

• Correct scapular substitution with AA/AROM
• Smoking
• Postural considerations should be addressed
Precautions • Sling use for 6 weeks
• Start physical therapy Week 2-4
• Continue post-operative home exercises until starting physical therapy
• No behind back stretching x 12 weeks
• Subscapularis Repair (12 weeks)
• No ER past 30 degrees
• No cross body adduction
• No active IR or IR behind back
• No supporting of body weight on affected side (i.e. pushing up from chair)
Manual • Week 2-4: caudal GH mobilizations, PROM flexion and external rotation only, soft tissue
Therapy mobilization as appropriate, hand/wrist/elbow ROM exercises
• Week >4: PROM (flexion, external rotation, internal rotation, abduction), soft tissue and
joint mobilization as appropriate
Corrective • Pain and edema control modalities
Interventions • Manual for glenohumeral and scapular mobility and shoulder ROM
• Therapeutic exercise and neuromuscular re-education for UE strength, control and postural
stability
• Therapeutic activity for return to work simulations to increase strength and endurance
• Sport-specific activity training
Outcome • Disability of Arm, Shoulder, Hand (DASH)
Testing • Quick DASH

Criteria for • Full AROM with no scapular substitution

Discharge • 5/5 RTC strength
• 65-70% IR/ER isokinetic testing

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Technology Commercialization Office at https://tco.osu.edu.

Phase 1: Protection
WEEK ROM • Continue PROM
2-6 • Begin PROM in abduction per patient tolerance
• Shoulder joint mobilizations (grade II-III) – posterior and caudal
• Scapular mobilizations
• Pectoralis minor flexibility
• Supine postural stretch
• Begin wand exercises in a seated position
• Shoulder external rotation
• Shoulder flexion if not contraindicated
Strengthening • Begin isotonic scapular retraction/protraction
• Supine serratus punches
• PNF patterns in sidelying (scapular clock)
• Sitting retraction
• Begin manual resistance scapular stabilization (late phase)
• Scap Squeezes, extension with light resistance
Modalities • Ice and pain modalities as indicated
Goals for 1. Decrease pain
Progression 2. Full PROM supine
to Next Phase 3. Sleeping through the night
4. Normal posture

Phase 2
WEEK D/C sling at 6 weeks
6-8
ROM • AAROM per patient tolerance - all motions, adding abduction, IR, horizontal
abduction (maintain subscapularis precautions)
• Ball on wall, UE swiss ball mobility –IR/ER
• Towel wipes on table – any direction
Strengthening • Initiate sub-max/50% effort strengthening
o Isometric flexion, extension, abduction, ER, IR
o Isometric lower trap
o Dynamic isometric walk-outs
• Closed-chain stability – elbow extension with hand on ball performing
oscillations
• Progress scapular neuromuscular strengthening
WEEK ROM § AROM per patient tolerance; avoid scapular substitution
8-10 Strengthening • UBE light resistance
• Begin prone exercise program below shoulder level
• Extension, rows
• Begin closed chain UE activities
• Towel wipes on wall – horizontal, diagonal and vertical
• Serratus punches
• Quadruped weight-shifts
• Proprioception exercise
• Supine ABC’s
• Ball on wall
Goals for 1. Full AROM with no scapular substitution
Progression 2. No reactive inflammation with strengthening
to Next Phase 3. Return to full ADLs pain free

Phase 3
WEEK Strengthening • UBE moderate resistance
10-12 • Light T-band exercises
• Shoulder IR/ER
• Horizontal abduction/adduction
• Diagonal patterns
• Progress prone exercise program
• Row
• Shoulder Extension
• Horizontal Abduction – T exercise position
• Lower Trap – Y exercise position
• Begin rhythmic stabilization exercises supine, starting at balance point position
(90-100 degrees of elevation); progress to side lying, prone, standing
Goals for 1. Full active ROM
Progression 2. No trapezius substitution
to Next Phase 3. No reactive inflammation with strengthening

WEEK Strengthening • Progress prone exercise program

12-16 • Progressive Dumbbell Program – emphasis on high reps/low weight
§ Scaption
§ Diagonal patterns
§ Bent row
§ Prone Retraction with ER
• Functional strengthening
• Functional positions with eccentrics loads
• Progress closed chain UE strengthening
§ Push up with a plus
§ Swiss ball activities
§ Plank BOSU weight shifts
• Trunk and lower extremity strengthening
• Begin short toss and overhead endurance activities per physician release
Goals for 1. Full AROM with no scapular substitution between weeks 10-12
Progression 2. 5/5 rotator cuff strength
to Next Phase 3. 65-70% IR/ER isokinetic testing

Phase 4 – Return to Sport / Activity
Goal is to return to sport at 6 months

4-6 ROM • Emphasis on posterior capsule stretching

MONTHS • General stretching/flexibility program (pectorals, biceps, upper trapezius, etc.)
Strengthening • Progress T-band exercises
• Begin Diagonal Patterns
• Progress prone exercise program with weight
• Row
• Shoulder Extension
• Horizontal Abduction – T exercise position
• Lower Trap – Y exercise position
• Progress Dumbbell Program with weight
• Scaption
• Diagonal patterns
• Bent row
• Prone Retraction with ER
• Functional eccentric strengthening
• Progress closed chain UE strengthening
• Push up with a plus
• Swiss ball activities
• Trunk and lower-extremity strengthening
• Initiation of throwing progression (See OSU Sports Med Throwing Program)
• Continuation of functional UE/LE strengthening and endurance activity
Goals to • Completion of throwing progression
Return to • No reactive effusion, pain and/or instability
Sport • 65-70% IR/ER isokinetic testing

Authors: Mitch Salsbery, PT, DPT, SCS and Adam Ingle PT, DPT, SCS
Reviewers: Grant Jones, MD and Julie Bishop, MD
Completion date: December 2017

References
Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint
Surg Am. 2012;94:227-233.
Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary
McCann PD, Wooten ME, Kadaba MP, Bigliani LU. A kinematic and elctromyographic study of shoulder
rehabilitation exercises. Clin Orthop Rel Res. 1993;288:178-188.
Ellsworth AA, Mullaney M, Tyler TF, McHugh M, Nicholas S. Electromyography of selected shoulder musculature
during un-weighted and weight pendulum exercises. N Am J Sports Phys Ther. 2006;1:73-79.
Kibler WB, Livingston B, Bruce R. Current concepts in shoulder rehabilitation. In: Stauffer RN, Erlich MG.
Advances in Operative Orthopaedics. Vol 3. St. Louis, MO: Mosby; 1995: 249-297
Park MC, Idjadi JA, Elattrache NS, Tibone JE, McGarry MH, Lee TQ. The effects of dynamic external rotation
comparing 2 footprint-restoring rotator cuff repair techniques. Am J Sports Med. 2008;36(5): 893-900.


THROWING PROGRESSION
Call Ohio State Sports Medicine at 614-293-2385 with any questions

WORKOUT WARM-UP THROWING THROWS REPEAT?

#1 to 45’ 45’-25
#2 to 45’ 45’-25 Rest 10 min and repeat
#3 to 45’ 45’-25 Rest 10 min and repeat two times
#4 to 60’ 60’-25
#5 to 60’ 60’-25 Rest 10 min and repeat
#6 to 60’ 60’-25 Rest 10 min and repeat two times
#7 to 90’ 90’-25
#8 to 90’ 90’-25 Rest 10 min and repeat
#9 to 90’ 90’-25 Rest 10 min and repeat two times
#10 to 120’ 120’-25
#11 to 120’ 120’-25 Rest 10 min and repeat
#12 to 120’ 120’-25 Rest 10 min and repeat two times
#13 to 150’ 150’-25
#14 to 150’ 150’-25 Rest 10 min and repeat
#15 to 150’ 150’-25 Rest 10 min and repeat two times

MOUND WORK
MOUND DAY WARM-UP THROWING TO 120’ USING PROPER MECHANICS AND CROW-HOP
#1 20 pitches @ ½ speed
#2 30 pitches @ ½ speed (15, rest 5 min, 15)
#3 45 pitches @ ½ speed (15, rest 5 min, 15, rest 5 min, 15, rest 5 min)
#4 10 pitches @ ½ speed 15 pitches @ ¾ speed 10 pitches @ ½ speed
#5 10 pitches @ ½ speed 30 pitches @ ¾ speed (15, rest 5 min, 15) 10 pitches @ ½ speed
#6 10 pitches @ ½ speed 45 pitches @ ¾ speed (15, rest 5 min, 15, 10 pitches @ ½ speed
rest 5 min, 15, rest 5 min)
#7 10 pitches @ ¾ speed 15 pitches @ full speed 10 pitches @ ¾ speed
#8 10 pitches @ ¾ speed 30 pitches @ full speed (15, rest 5 min, 15) 10 pitches @ ¾ speed
#9 10 pitches @ ¾ speed 45 pitches @ full speed (15, rest 5 min, 15, 10 pitches @ ¾ speed
rest 5 min, 15, rest 5 min)

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Technology Commercialization Office at https://tco.osu.edu.




RETURN TO THROWING GUIDELINES

Ohio State Sports Medicine’s return to throwing program is designed to guide athletes through a progressive plan
to safely return them to sport. The program includes gradual increases in throwing distance and volume while
utilizing the best research available to optimize athlete safety and success. The program should be completed
under the supervision of the medical team (physician, physical therapist, athletic trainer).

In order to begin the program, athletes must meet the following requirements:
• Clearance from physician
• Pain free
• Full range of motion of shoulder and elbow
• Completion of strengthening program for upper body, lower body and core

Throughout the program, the following must be observed:

GENERAL • Minimum of 1 rest day between throwing sessions – per rehab professionals discretion
• Athletes must warm up prior to each session
• Throwing distances and volumes are non-negotiable and not be exceeded without
clearance by medical team member
• Proper mechanics must be utilized at all times
• If an athlete becomes fatigued prior to completion of a session they should immediately
stop throwing that day
• If an athlete notices pain during a session they should immediately stop and contact a
member of the medical team
• Normal, diffuse muscle soreness after a throwing session is acceptable and to be
expected
• A resistance-training program must supplement the return to throwing program. This
should never be completed prior to throwing.
WARM-UP Athletes should jog until they begin to slightly sweat. This ensures that the body is warm
and prepared to throw. An active warm-up may accompany jogging.
STRETCHING Shoulder, elbow, trunk, and lower extremity stretches should be completed after jogging.
Consult your physical therapist or athletic trainer for an individualized stretching program.
BAND WARM-UP One set or 15 repetitions of 3-4 shoulder exercises using a medium resistance band
should be completed to fully prepare the shoulder for throwing. These exercises should
not be fatiguing.
THROWING • Athletes must complete all throws in the session utilizing a crow-hop.
• Throws should be on a line (slight arch) and hit partner in the chest
• Following through after each throw is critical to shoulder health
• If pain occurs during the session, the athlete must immediately stop for the day
• The athlete will rest a minimum of 1 day and until all pain is gone
• The next session will be the step before the last, painful session (ex: if session 10 was
painful, rest, and attempt session 9 next time)
• No breaking balls until completion of all mound work


Sample Warm-Up Exercises

SOFTBALL THROWING PROGRESSION

Call Ohio State Sports Medicine at 614-293-2385 with any questions

WORKOUT WARM-UP THROWING THROWS REPEAT?

#1 to 30’ 30’-25
#2 to 30’ 30’-25 Rest 10 min and repeat
#3 to 30’ 30’-25 Rest 10 min and repeat two times
#4 to 45’ 45’-25
#5 to 45’ 45’-25 Rest 10 min and repeat
#6 to 45’ 45’-25 Rest 10 min and repeat two times
#7 to 60’ 60’-25
#8 to 60’ 60’-25 Rest 10 min and repeat
#9 to 60’ 60’-25 Rest 10 min and repeat two times
#10 to 80’ 80’-25
#11 to 80’ 80’-25 Rest 10 min and repeat
#12 to 80’ 80’-25 Rest 10 min and repeat two times
#13 to 100’ 100’-25
#14 to 100’ 100’-25 Rest 10 min and repeat
#15 to 100’ 100’-25 Rest 10 min and repeat two times

BULLPEN PITCHING WORK

MOUND DAY WARM-UP THROWING TO 60’
#1 25 pitches @ ½ speed
#2 40 pitches @ ½ speed
#3 50 pitches @ ½ speed
#4 10 pitches @ ½ speed
#5 10 pitches @ ½ speed
#6 10 pitches @ ½ speed
#7 10 pitches @ ¾ speed
#8 10 pitches @ ¾ speed
#9 10 pitches @ ¾ speed
15 pitches @ ¾ speed 10 pitches @ ½ speed
30 pitches @ ¾ speed 10 pitches @ ½ speed
30 pitches @ ¾ speed 10 pitches @ ½ speed
15 pitches @ full speed 10 pitches @ ¾ speed
30 pitches @ full speed 10 pitches @ ¾ speed
45 pitches @ full speed 10 pitches @ ¾ speed

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Technology Commercialization Office at https://tco.osu.edu.




TOTAL SHOULDER ARTHROPLASTY

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Joint Specific Outcome Measure

Upon the start of postoperative care the patient and therapist will complete the Simple Shoulder Test and the
American Shoulder and Elbow Surgeon’s Shoulder Evaluation Short Form during their first ambulatory visit (see
Appendix 1 and 2). These assessment measures are then completed every 30 days and upon discharge from
physical therapy, in conjunction with routine re-evaluations to assist in assessing progress.

***Range of Motion after surgery will likely be similar to range of motion before surgery***

Rehabilitation Precautions
• Sling use for 6 weeks
• No internal rotation (IR) x 12 weeks
o IR behind back should NEVER be pushed
• No cross chest adduction x 12 weeks
• Forward elevation in SCAPTION only
• No stretching into pain
• Avoid arm extension in all positions
• No supporting of body weight by hand on involved side (for example, pushing up from a chair) x 12 weeks
• No driving for six weeks
Check with surgeon’s office if posterior instability precautions are indicated on referral or operative report

Phase I: Post-operative – 2 weeks

• Continue home program including wrist/hand, pendulums, and shoulder blade squeezes

Phase II: Weeks 2-4

ROM • Begin PROM in scaption and external rotation only
• NO SHOULDER IR, ADDUCTION OR CROSS BODY MOVEMENT

Strengthening • Progress active distal extremity exercise to strengthening as appropriate

Goals to 1. Tolerates PROM program

Progress to 2. Achieves at least 90° PROM flexion
Next Phase 3. Achieves at least 90° PROM abduction
4. 4. Achieves at least 45° PROM ER in plane of scapula

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Phase III: Weeks 4-6

Rehabilitation • In supine, a small pillow or towel should be placed behind the elbow to avoid
Precautions shoulder hyperextension/anterior capsule stretch
• In the presence of poor shoulder mechanics avoid repetitive shoulder AROM
exercises/activity against gravity in standing
• No heavy lifting of objects (no heavier than coffee cup)
• No supporting of body weight by hand on involved side
• No sudden jerking motions
ROM • Continue with PROM, active assisted range of motion (AAROM)
• Begin at week 4 - AAROM pulleys in scaption as long patient has greater than
90° of PROM
• Gentle glenohumeral and scapulothoracic joint mobilizations as indicated
• Continue use of cryotherapy for pain and inflammation
• NO SHOULDER IR, ADDUCTION OR CROSS BODY MOVEMENT
Strength • Begin shoulder submaximal pain-free shoulder isometrics in neutral EXCEPT
IR
• Progress distal extremity exercises with light resistance as appropriate
• Initiate glenohumeral and scapulothoracic rhythmic stabilization
Goals to 1. Tolerates PROM/AAROM, isometric program
Progress to 2. Achieves at least 140° PROM flexion
Next Phase 3. Achieves at least 120° PROM abduction
4. Achieves at least 60° PROM ER in plane of scapula
5. Able to actively elevate shoulder against gravity with good mechanics to 100°

Phase IV: Weeks 6-8

Rehabilitation • No heavy lifting of objects (no heavier than coffee cup)

Precautions • No sudden lifting or pushing activities
• No sudden jerking motions

ROM • Begin AROM exercise/activity as appropriate – use reclined position

• Advance PROM to stretching as appropriate – minimal pain
• NO SHOULDER IR, ADDUCTION OR CROSS BODY MOVEMENT
Strength • Begin light functional activities
• Wean from sling completely
• Continue isometrics
• Scapular rows, extensions, and sidelying or light band external rotation

Goals to 1. Gradual restoration of shoulder strength, power, and endurance

Progress to 2. Optimize neuromuscular control
Next Phase 3. Gradual return to functional activities with involved upper extremity


Phase V: Weeks 8-10

ROM • Progress AROM as tolerated.

• Continue AAROM as necessary
• Minimize shoulder substitution patterns
• NO SHOULDER IR, ADDUCTION OR CROSS BODY MOVEMENT
Strength • Resisted flexion, abduction, extension (Therabands)
• Continue progressing ER strength

Goals to 1. Tolerates AAROM/AROM/strengthening

Progress to 2. Achieves at least 120° AROM flexion
Next Phase 3. Achieves at least 100° AROM abduction
4. Achieves at least 50° AROM ER in plane of scapula supine
Note: If above ROM are not met, then patient is ready to progress when the
patient’s ROM is consistent with outcomes for patients with the given underlying
pathology.

Phase VI: Weeks 10-12

Precautions • Avoid exercise and functional activities that put stress on the anterior capsule
and surrounding structures (eg, no combined ER and abduction above 80° of
abduction)
• Bench press and push ups are contraindicated long-term
• No aggressive IR behind back
ROM • Maintain nonpainful AROM
• NO SHOULDER IR, ADDUCTION OR CROSS BODY MOVEMENT

Strength • May initiate IR strengthening at the 12 week postop mark

• Continue to progress AROM scaption and abduction as tolerated
• Gradually progress strengthening program to improve muscular strength,
power, and endurance
• Gradual return to more advanced functional activities
• Progress weight-bearing exercises as appropriate
• Typically patient is on a home exercise program by this point, to be performed
3 to 4 times per week
• Return to recreational hobbies, gardening, sports, golf, doubles tennis
Criteria for 1. Patient able to maintain nonpainful AROM
Discharge 2. Maximized functional use of upper extremity
from Physical 3. Maximized muscular strength, power, and endurance
Therapy 4. Patient has returned to advanced functional activities

Appendix 1: Simple Shoulder Test

Circle Yes or No
1. Is your shoulder comfortable with your arm at rest by your side? Yes / No
2. Does your shoulder allow you to sleep comfortably? Yes / No
3. Can you reach the small of your back to tuck in your shirt with your hand? Yes / No
4. Can you place your hand behind your head with the elbow straight out to the side? Yes / No
5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow? Yes / No
6. Can you lift 1 lb (a full pint container) to the level of your shoulder
without bending your elbow? Yes / No
7. Can you lift 8 lb (a full gallon container) to the level of the top of your head
without bending your elbow? Yes / No
8. Can you carry 20 lb (a bag of potatoes) at your side with the affected extremity? Yes / No
9. Do you think you can toss a softball underhand 10 yards with the affected extremity? Yes / No
10. Do you think you can throw a softball overhand 20 yards with the affected extremity? Yes / No
11. Can you wash the back of your opposite shoulder with the affected extremity? Yes / No
12. Would your shoulder allow you to work full-time at your regular job? Yes / No

Appendix 2: American Shoulder and Elbow Surgeons

Standardized Assessment Form
Pain: How bad is your pain today? (mark along the line)

__________________________________________________________________________________________
No Pain Pain is as bad as it can be

Function: Circle the number that indicates your ability to do the following activities. (0=Unable to do, 1=Very
difficult to do, 2=Somewhat difficult, 3=Not difficult)

Activity Right Arm Left Arm

1. Put on a coat 0123 0123
2. Sleep on your painful side 0123 0123
3. Wash back / do up bra in back 0123 0123
4. Manage toileting 0123 0123
5. Comb hair 0123 0123
6. Reach a high shelf 0123 0123
7. Lift 10 pounds above the shoulder 0123 0123
8. Throw a ball overhand 0123 0123
9. Do usual work (list) _____________ 0123 0123
10. Do usual sport (list) _____________ 0123 0123

References
Wilcox RB, Arslanian LE, and Millet PJ. Rehabilitation Following Total Shoulder Arthroplasty. Journal of
Orthopaedic and Sports Physical Therapy. 2005; 35:12 (821-836).
Michener LA, McCluer PW, and Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder
Assessment Form, Patient Self-Report Section: Reliability, Validity, and Responsiveness. Journal of Shoulder and
Elbow Surgery. 2002; 11: 587-594.

ULNAR COLLATERAL LIGAMENT

RECONSTRUCTION GUIDELINE
Functional Outcome Measure
KJOC (Appendix 1) should be completed at initial evaluation and at all identified times through guideline,

Phase 1 – Immediate Post-Op Phase

Goals
1) Protect healing tissue
2) Decrease pain/inflammation
3) Limit muscle atrophy

WEEK 1 Wound Care Sterile gauze used at incision site. Check brace for rubbing or irritation.
DAYS 1-7 Compression garment at elbow to be used with physician’s authorization
Posterior Splint At 90 Degrees
ROM Wrist AROM ext/flex
Hamstring flexibility if gracilis tendon graft utilized.
Shoulder Strength Gripping
Shoulder Isometrics EXCEPT Internal Rotation AND External Rotation
Scapular Clocks with manual resistance
Trunk/Core Thoracic Extension
Side lying Thoracic Rotation
Pelvic Tilts – supine, seated, standing, single leg stance as able
Lower Extremity Hamstring Strength – eccentrics
Hip Abduction – side steps, SL abduction, clamshells
Hip Extension – glute sets, bridges, hip extension
Breathing Teach proper breathing patterns- no accessory breathing
Exercises Progress from supine to functional positions
Balance Progressive, safe exercises in kneeling, half kneeling, and single leg
Posture Education on proper posture throughout each session
Modalities Cryotherapy and E-stim for swelling control at elbow and graft site.
Lower Extremity Stationary bike without upper body support

WEEK 2 Brace 30-90 degrees

ROM Elbow- 5 – 125 degrees. May progress if no pain or pinch is reported.
Strength Light rhythmic stabilization at end range of elbow extension
T-Band – Scapular retraction exercise
Trunk/Core Continue previous exercises/mobility
Progress as able without weight bearing or stress on elbow
No holding med balls/weights
Lower Extremity Continue previous activities with safe progressions
Modalities Cryotherapy and light compression

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WEEK 3 Brace 10-120 degrees

ROM Elbow- 5 – 125 degrees. May progress if no pain or pinch is reported.
Strength Light rhythmic stabilization at end range of elbow extension
T-Band – Scapular retraction exercise
Conditioning Begin light cycling- avoid gracilis graft irritation.
Core strengthening avoiding any upper extremity stress.
May begin lower extremity strengthening (hold if gracilis graft used)

Criteria to progress to Phase 2

1) Meet ROM guidelines
2) Low, controlled pain
3) Consistently low swelling

Phase 2 – Intermediate Phase

Goals
1) Control pain and inflammation
2) Gradual increase in ROM to WNL
3) Promote healing of tissue
4) Good scapular control with exercises
5) 5/5 shoulder strength with MMT or dominant = non-dominant with HHD
6) Progress general conditioning, including lower extremity strength work

WEEKS Brace 10-110 degrees

4-5 Low load long duration stretch, maintaining forearm in a neutral position, if
elbow extension is lacking.
Shoulder internal rotation flexibility as indicated
Strength Use ankle weights around wrist vs dumbbells/bands if able
Initiate light resistance exercises
Wrist dumb bells – flexion/ extension/ pronation/ supination.
Elbow dumb bells and light T-band - flexion and extension.
Over pressure and rhythmic stabilization to be utilized with end range
elbow extension strengthening.
Shoulder program for rotator cuff strengthening – use ankle weights
§ Prone Series – row/ extension/ flexion/ horizontal abduction
§ Standing - flexion/ abduction/ scaption
§ IR and ER ISOMETRICS in neutral
§ Protraction supine – manual resistance proximal to the elbow
§ UBE – low resistance
§ Hand/gripping exercises to be continued.
Manual Therapy Scar massage
Conditioning Initiate Elliptical and /or stepper for aerobics
Begin leg press and mini lunges (gracilis graft)
Continue Core strengthening program – no planks
No upper body resistance training
No lifting plate weights or holding dumbbells in hands

WEEKS ROM Full AROM/PROM – discharge brace

6-7 Joint mobilizations as needed at end range with distraction
Shoulder Total Arc of Motion (IR+ER at 90): dominant = non dominant
Strength Elbow PRE’s – dumb bells and manual resistance
Push up plus on Swiss ball, elbows remain straight
Side lying External Rotation with dumbbells/ankle weights
Thera band exercises - Shoulder internal rotation/ external rotation/ horizontal
abduction. – AVOID VALGUS STRESS TO THE ELBOW
Manual resistance exercises (concentric and eccentric) Prone row/horizontal
abduction in neutral/ external rotation/ internal rotation/ flexion at 105 deg.
thumb up position.
PNF- D2 pattern (hold at elbow) rhythmic stabilization at multiple angles.
Aerobics Running may be initiated on safe surfaces. (hold if gracilis graft used)

WEEK 8 Strength Seated row and lat pull

Prone row with external rotation
Prone quick drops – flexion/ external rotation/ horizontal abduction
Thera-band at 90/90- external rotation/ internal rotation (perform slowly
avoiding valgus stress at the elbow)
Rhythmic Stabilization - 90/90 position and D2 PNF- holding at elbow
Begin hamstring open chain exercises (gracilis graft used)
Thera Band at 0 degrees shoulder abduction – IR and ER

Criteria to advance to Phase 3

1) Full Elbow AROM
2) Total Arc of Motion: uninvolved = involved
3) 5/5 MMT strength OR Hand Held Dynamometer of involved shoulder
a. Shoulder external rotation in neutral
b. Shoulder internal rotation in neutral
c. Shoulder horizontal abduction
d. Shoulder flexion
e. Shoulder full can/scaption
f. Shoulder extension
g. Shoulder overhead flexion
4) Ext Rotation/Int Rotation to 67% ratio
5) Lower Extremity Strength 5/5 or HHD dominant=non dominant
a. Hips all planes
b. Knee all planes
c. Ankle all planes
6) Ankle Dorsiflexion
a. Equal bilaterally (ideal 10 degrees)
7) Thoracic Spine AROM
a. 50 degrees rotation bilaterally in seated position


Phase 3 – Advanced Strengthening Phase
Goals
1) Full elbow ROM maintained
2) Progression of UE strength without exacerbation
3) Good muscular control with manual exercises
4) General conditioning progression tolerated

WEEK 9 ROM Normalize elbow ROM- external rotation of humerus to facilitate elbow
extension- do not press at wrist (avoid valgus stress at elbow)
Strength Elbow – initiate eccentric flexion/ extension exercises and continue concentric
strengthening progression
Shoulder – continue concentric strengthening program
Manual resistance D2 PNF pattern with resistance proximal to the elbow.
Impulse – 90/90 position external rotation and horizontal abduction.
Body blade – 90/90 position external rotation/ internal rotation/ and through the
throwing motion.
Rhythmic Stabilization – at 90/90 position and through the D2 PNF pattern.
Core Prone pike stabilization with forearms held in a neutral position.
Strengthening May begin jogging on flat ground (gracilis graft used)
Continue lower extremity strengthening progression

WEEKS Strength Continue strengthening as above.

10-16 Weight training program to be progressed (avoid pec fly’s and push ups)



WEEK 10 Bodyblade internal/external rotation at 0 degrees shoulder abduction
flexion and scaption at 90 degrees shoulder abduction
Impulse internal/external rotation at 0 degrees shoulder abduction
Plyometrics Double arm ball toss – start at chest height 2-3kg ball



WEEK 11 Plyometrics Continue double arm plyometrics
Overhead Soccer Throw
Wall dribbles – semi circle
Ball chops
Free throws- 3kg ball (100-200 reps) against a wall


WEEK 12 Strength Single arm plyometrics
Initiate over-the-shoulder deceleration exercise with 1kg ball
Begin closed chain shoulder stability exercises


WEEK 13 Plyometrics T-band ER/IR quick contractions.
90/90 wall dribbles



WEEK 14 Functional 15 ft baseball throws into wall for mechanics
Exercise Elbow elevation above the shoulder for over the top throwing mechanics.
Finish throw with ample deceleration ROM from the shoulder back and trunk


WEEK 16 Strength Continue UE strengthening program
Continue core strengthening
Plyometrics Continue progression of UE plyometric activities
Isokinetic Testing IR/ER testing to be performed at 90, 180 and 300 deg./sec.



Phase 4 – Functional Activity Phase
Goals
1) Continuation of strengthening program
2) Full UE ROM maintained
3) Acceptable Isokinetic test results for external/internal rotators
a. Shoulder non-dominant to dominant side strength to be 90%
b. Shoulder external rotators to be 65% of internal rotators.

WEEK 18 Functional Begin throwing progression with monitored mechanics avoiding medial elbow
Activities stress. – Requires physician clearance to initiate
• Maintain elbow elevation above shoulder height.
• Curl hop to be used when initiating throws of 90 ft and greater.
• Deceleration to include good back and trunk flexion ROM

UNSTABLE SHOULDER:
NON-SURGICAL MANAGEMENT
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and
clinician evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Phase 1: Weeks 0-2

ROM • AAROM to AROM (avoid ER and ABD)

Strength • RTC
o ER at 0o abduction: side lying to standing
• Periscapular musculature
o PNF, scapular retraction
Neuromuscular • ER/IR rhythmic isometrics
Stability
Goals to 1. Reduce pain
Progress to 2. Increase ROM
Next Phase

Phase 2: Weeks 2-6

ROM • Stretch posterior cuff
o Sleeper stretch
o Caution with posterior joint mobilization (do not stretch attenuated
structures)
Strengthening • RTC/Scapular Strengthening
o Progress strengthening and stability exercise towards position of
instability
o ER to 45o abduction
o Prone exercises
o Scaption, abduction and extension
o PNF (manual and T-band) and functional strengthening
o Perturbations with all exercise (Progress proximal to distal)
• Trunk and LE strengthening
o Utilize unstable surface to engage trunk and lower extremity
Neuromuscular • RTC/Scapular Stabilizers
Stability o WB and NWB ex
o Proximal to Distal Perturbations
o PNF and functional strengthening
o Progress from stable to unstable surface (BOSU, Dynadiscs)
§ Plyometrics (0, 45 degrees)
Goals to 1. Normalize movement
Progress to 2. Strengthen and stabilize RTC and scapular stabilizers
Next Phase 3. Correct glenohumeral and scapulothoracic mechanics

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Phase 3: Weeks 6-12

ROM • Maintain normal osteo and arthrokinematic movement
• Stretching (warm-up prior to stretching)
• Internal rotators, posterior capsule

Strength • RTC and Scapular Strengthening

o Thrower’s Ten Exercise
o ER at 90o abduction
o Emphasis on eccentric control
• Continue and progress trunk and LE strengthening

Stability • WB Plyometrics
• NWB Plyometrics at 90º abduction
o With perturbations
o Increase speed and change accuracy of tosses
o Increase reps to improve endurance
Goals to 1. Increased dynamic functional strength
Progress to 2. Improved neuromuscular control at multiple angles towards unstable
Next Phase position
3. No signs of instability or biomechanical impingement

Phase 4: Months 2-6 Sports Specific Training

Initiate • Full functional ROM
Throwing • 5/5 strength with RTC testing
Program • Isokinetic ER/IR ratios: 66-75%
• Emphasis on good mechanics

References
Andrews, JR, Harrelson G, Wilk, K: Physical Rehabilitation of the Injured Athlete, Saunders, 2004

Hayes K, Callanan, M, Walton, J, Paxinos, A, Murrell, G: Shoulder Instability: management and

Rehabilitation. J Ortho Sports Phys The, 2002


ACHILLES TENDON MID-SUBSTANCE

ULTRASOUND GUIDED
PERCUTANEOUS TENOTOMY
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Avoid 1 week before and 1 month after your procedure.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might reduce the beneficial effects of the procedure.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• Crutches
• Boot
• Peel away heel lift (Wear this in your boot and shoe at all times; you will gradually decrease use as directed
by your care team.)
• Therapy appointment times
• Follow-up times (approximately 2 weeks and 6 weeks after your procedure)

Post-procedure Care
Day of your • Plan to have a family member or friend drive you home after your procedure.
procedure • Bring your crutches / scooter / boot to your appointment if they were given to you.
• Weight-bearing: No weight bearing on treated leg; use crutches / scooter and boot to get
around.
• Activity & Rehab: Protect ankle by resting and keeping it elevated to reduce swelling.
Days 2-3 • Weight-bearing: No weight bearing; use crutches / scooter and boot to get around.
• Activity & Rehab: Elevate at least 3 times a day to control swelling. Begin gentle ankle
range of motion exercises 3 times per day.

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Weight Bearing Activity and Rehab

Progression 1 • Transition to partial weight- • Continue ankle range of motion and add ankle
bearing using crutches & boot. isometrics 3 times per day.
If you were given a foot • Manual Therapy: May use soft tissue mobilizations
orthotic, wear it in your boot. around incision, avoiding direct pressure throughout
See ‘bracing’ section below. progressions.
Some discomfort is normal.
The “rule of thumb” is that
discomfort should calm down
by the next morning.
• If you use a scooter, begin
partial weight bearing by
placing untreated leg on
scooter and bearing some
weight on the treated foot in
your boot.
Progression 2 • Under the supervision of your • Continue ankle range of motion 3 times per day.
therapist, discontinue the use Continue isometric strengthening. Begin non-impact
of the boot. Continue partial aerobic exercise with a stationary bike. You can start
weight bearing with the gentle swimming and pool exercise when the wound
crutches in your home and is healed.
community.
Progression 3 • Under the direction of your • Continue ankle range of motion and add gentle
therapist, begin weaning off Achilles tendon stretching. Continue isometric
the crutches. First, walk strengthening. Progress ankle strengthening with
without crutches in your home. resistance bands. Begin balance exercises like
In the community, continue single-leg stance.
partial weight bearing with
crutches. The “rule of thumb” is
that discomfort should calm
down by the next morning.
Progression 4 • Under the direction of your • Progress ankle strengthening by using heavier
therapist, walk normally in your resistance bands.
home and community. Start
with shorter community
distances and increase as
tolerated. Place the peel-away
heel lift in your shoe and
gradually peel away layers as
tolerated.
Progression 5 • Once you are walking normally in your home and
community, use an elliptical machine (begin with no
incline and low resistance) and increase walking pace
for exercise. Begin using a leg press, first for
quadriceps strengthening and then progress to low
resistance calf raises. Advance at the discretion of
your care team.
Progression 6 • Increase the intensity of biking, swimming, elliptical,
fast walking and weight machines. Once you are
working hard at these without pain, progress to higher
impact activities (like jogging, running, sprinting &
jumping) as directed by your care team.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily. If you are concerned about your pain, please
contact your care team.

Dressing
• Remove dressing after 24-48 hours. Replace with simple bandage.
• Keep ACE wrap or compression sleeve on ankle for 2 days. It should be snug, but not tight. If you see
swelling in your toes, the compression is too tight.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep bandages and
procedure area clean and dry.

Bathing
Do not soak/submerge the ankle in water for 1 week. Showering is OK.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine. Otherwise, seek care at your local emergency room.

ACHILLES TENDON ULTRASOUND GUIDED

PERCUTANEOUS TENOTOMY
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Avoid 1 week before and 1 month after your procedure.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might reduce the beneficial effects of the procedure.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• Crutches
• Boot
• Peel away heel lift (Wear this in your boot and shoe at all times. You will gradually decrease the use of the
heel lift as directed by your care team.)
• Therapy appointment times
• Follow-up times (approximately 2 weeks and 6 weeks after your procedure)

Post-procedure Care
Day of your • Plan to have a family member or friend drive you home after your procedure.
procedure • Bring crutches / scooter / boot to your procedure appointment if they were given to you.
• Weight-bearing: No weight bearing on treated leg; use crutches / scooter and boot to get
around.
• Activity & Rehab: Protect ankle by resting and keeping it elevated to reduce swelling.
Days 2-7 • Weight-bearing: No weight bearing; use crutches / scooter and boot to get around.
• Activity & Rehab: Elevate at least 3 times a day to control swelling. Begin gentle ankle
range of motion exercises 3 times per day (plantarflexion, inversion & eversion only). Avoid
stretching your tendon past neutral (no stretching in dorsiflexion).
Week 2 • Weight-bearing: Transition to partial weight-bearing using crutches & boot. If you were
(Days 8-14) given a heel lift, wear it in your boot. See ‘bracing’ section below. Some discomfort is
normal. The “rule of thumb” is that the discomfort should calm down by the next morning.
• If you use a scooter, begin partial weight bearing by placing untreated leg on scooter and
bearing some weight on the treated foot in your boot.
• Activity & Rehab: Continue ankle range of motion described above.

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Weight Bearing
Progression 1 • Under the supervision of your
therapist, begin weaning the
boot. Continue partial weight
bearing in your home using
crutches only. Use crutches
and boot for community
distances.
• *Note that dorsiflexion is permitted for gentle stretching, but should be avoided for all
subsequent strength exercises*
• Manual Therapy: May use soft tissue mobilizations around incision, avoiding direct pressure
throughout progressions.
Progression 2 • Under the supervision of your
therapist, begin walking
normally in your home.
Continue partial weight bearing
using only crutches in the
community.
Progression 3 • Under the direction of your
therapist, walk normally in your
home and in the community.
Start with shorter community
trips and increase as tolerated.
Place peel-away heel lift in
your shoe and gradually peel
away layers as tolerated.
Progression 4
Progression 5
Progression 6
Progression 7
Activity and Rehab
• Continue ankle range of motion and add gentle
Achilles tendon stretching. Begin isometric ankle
strengthening.
• Continue isometric strengthening. Begin non-impact
aerobic exercise with a stationary bike without the
boot. You can start swimming and pool exercise when
the wound is healed.
• Progress ankle strengthening using resistance bands.
Begin balance exercises like single-leg stance.
• Progress ankle strengthening with heavier resistance
bands and continue balance exercises as described
above. Once you are walking normally in your home
and community, begin using an elliptical machine (no
incline and low resistance at first) and increase
walking pace for exercise.
• Gradually increase the intensity of the elliptical
machine and walking as tolerated. Begin using a leg
press, first for quadriceps strengthening and then
progress to low resistance calf strengthening.
Advance at the discretion of your care team.
• Increase the intensity of biking, swimming, walking
and weight machines. Increase the resistance and
incline on the elliptical machine.
• Once you are working hard at the activities above
without pain, progress to higher impact activities (like
jogging, running, sprinting & jumping) as directed by
your care team.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily. If you are concerned about your pain, please
contact your care team.

Dressing
• Remove dressing after 24-48 hours. Replace with simple bandage.
• Keep ACE wrap or compression sleeve on ankle for 2 days. It should be snug, but not tight. If you see
swelling in your toes, the compression is too tight.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep bandages and
procedure area clean and dry.

Bathing
Do not soak/submerge the ankle in water for 1 week. Showering is OK.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine. Otherwise, seek care at your local emergency room.

ELBOW ULTRASOUND GUIDED PERCUTANEOUS

TENOTOMY/PRP INJECTION
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Make every effort to avoid these medications before and after your procedure.
They may impair your ability to heal and may increase risk of bleeding.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician or health care provider about stopping. These products
impair your ability to heal and might reduce the beneficial effects of the procedure.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• A sling
• Therapy appointment times
• Follow-up visit times

Post-Operative Elbow Care Timeline

Day of your • Plan to have a family member or friend drive you home after your procedure.
procedure • Bring sling to your appointment.
• Activity restrictions: Rest today.
• Protect your elbow by resting and keeping it elevated to reduce swelling.
Days 2-3 • Keep arm in sling.
• Keep compression wrap on. It should be snug, but not tight.
• Come out of sling three times per day for gentle range of motion.
Days 4-7 • Discontinue sling.
• Activity restrictions: You may lift up to 5 lbs. Begin use of elbow and hand for activities of
daily living (like using it to groom, dress, eat and drive short distances). No sustained
gripping like opening a jar.
• Rehab: Continue elbow and wrist range of motion exercises and perform 3-5 times per
day.

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Activity Rehab
Restrictions
Week 2 You may lift Continue range of motion exercises. Perform isometric wrist and elbow
up to 10 lbs strengthening 1-2 times per day.

Week 3 Progress as Continue range of motion exercises. Perform wrist and elbow isotonic
tolerated strengthening with dumbbell wrist extension and flexion (start with 2 lb
dumbbell and progress as tolerated) 1-2 times per day.
Week 4 None Increase intensity of isotonic strengthening under the supervision of your care
team. Begin joint integrated strengthening like chest press, rows and hammer
curls. Be sure to maintain a neutral wrist position with these exercises.
Week 5 None Continue to increase intensity of strengthening exercise and begin sport /
activity specific training under the supervision of your care team.
Week 6 None You may resume high impact sports like golf and tennis under the supervision
of your care team.

Orthotics/Braces
You do not need to sleep in the sling. Do not drive while wearing the sling.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily. If you are concerned about your pain, please
contact your care team.

Bandage
• If a bandage / dressing was applied, remove dressing after 24-48 hours. Replace with simple bandage.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep procedure area
clean and dry for 1 week after the procedure until your doctor has seen you for your wound check.

Bathing
Do not soak/submerge the elbow in water for 1 week. Showering is OK, but keep incision site covered for the first
week.

Follow-Up Appointment
You will be scheduled for follow-up appointments approximately 1 week, 1 month and 3 months after your
procedure.

When to call your Provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine (614-293-3600) during normal clinic hours. Otherwise seek care at your
local emergency room.

For Therapists Only

All strength work should be performed every other day, 2-3 sets of each exercise to fatigue without reactive pain
Manual work may begin 2 weeks after the procedure date.

Last reviewed August 2017

GLUTEAL TENDON ULTRASOUND GUIDED

PERCUTANEOUS TENOTOMY/PRP INJECTION
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Make every effort to avoid these medications before and after your procedure.
They may impair your ability to heal and may increase risk of bleeding.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might prevent you from getting better.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• Crutches or scooter
• Therapy appointment times
• Follow-up times

Post-procedure Care
• Plan to have a family member or friend drive you home after your procedure.
• Bring your crutches to your procedure if they were given to you.

Weight Bearing Activity and Rehab

Days 1-3 • Toe-touch weight bearing • Rest

with crutches.
Days 4-7 • Transition to partial weight-
bearing using crutches,
placing 50% of your body
weight on your treated leg.
Week 2 • Under the direction of your •
therapist, begin weaning off
the crutches as tolerated.
• Begin gentle hip range of motion. Begin isometric
strengthening with quad sets and glute squeezes 3 times
per day.
Continue increasing hip range of motion. Perform
straight leg raises, hip abduction exercises like clam
shells and core stability exercises like planks 1-2 times
per day.
• You can start swimming and pool exercise when the
wound is healed.



Weight Bearing Activity and Rehab

Week 3 • You should be walking • Continue hip range of motion. Progress hip abduction
normally in your home strengthening and begin body-weight mini-squats 1-2 times
and in the community. per day.
• Begin using a stationary bike for exercise.
Week 4 • Increase the intensity of strengthening exercises and begin
more complex movements like squats, hip bridges and
bridge walk outs.
• Begin balance exercises like single-leg stance.
• You may begin low impact aerobic exercise (e.g., walking,
elliptical machine) with no incline and low resistance.
• Progress as you can tolerate under the guidance of your care
team.
Week 5 • Progress intensity of strengthening exercises and balance
exercises.
• Increase intensity of low impact aerobic exercise (eg, biking,
swimming, elliptical, walking).
Week 6 • Progress strength exercises as directed by your care team.
• Continue to increase intensity of low impact aerobic exercise,
but no running.
Week 7 • Once you are working hard at the activities above without
pain, progress to higher impact activities (like jogging,
running, sprinting and jumping) as directed by your care
team. For runners, begin using the anti-gravity treadmill.
Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily. If you are concerned about your pain, please
contact your care team.

Dressing
• Remove dressing after 24-48 hours. Replace with simple bandage.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep bandages and
procedure area clean and dry.

Bathing
Do not soak/submerge hip in water for 1 week. Showering is OK, but keep incision dry until you see your doctor
for your wound check.

Follow-up Appointment
You will be scheduled for follow-up appointments approximately 1 week, 1 month and 3 months after your
procedure.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine (614-293-3600) during normal clinic hours. Otherwise seek care at your
local emergency room.

For Therapists Only

All strength work should be performed every other day, 2-3 sets of each exercise to fatigue without reactive pain.
Manual work may begin 2 weeks after the procedure date.

Last reviewed August 2017

HAMSTRING TENDON ULTRASOUND GUIDED

PERCUTANEOUS TENOTOMY
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Avoid 1 week before and 1 month after your procedure.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might prevent you from getting better.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• Crutches
• Therapy appointment times
• Follow-up times (approximately 2 weeks and 6 weeks after your procedure)

Post-procedure Care
Days 1-3 • Plan to have a family member or friend drive you home after your procedure.
• Bring your crutches to your procedure if they were given to you.
• Weight-bearing: Toe-touch weight bearing with crutches.
• Activity & Rehab: Rest to minimize tendon irritation.

Weight Bearing Activity and Rehab

Progression 1 • Transition to partial weight-
bearing using crutches. Some
discomfort is normal. The “rule
of thumb” is that discomfort
should calm down by the next
morning.
• Begin gentle range of motion to increase hip flexion.
Begin isometric strengthening with quad sets and
glute squeezes 3 times per day.
• Manual Therapy: May use soft tissue mobilizations
around incision, avoiding direct pressure throughout
progressions.

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.



Weight Bearing Activity and Rehab

Progression 2 • Under the direction of your
therapist, begin weaning off the
crutches. First, walk without
crutches in your home. In the
community, continue partial
weight bearing with crutches.
The “rule of thumb” is that
discomfort should calm down
by the next morning.
Progression 3 • Under the direction of your
therapist, walk normally in your
home and community.
Progression 4
Progression 5
Progression 6
Progression 7
• Continue increasing hip flexion. Continue quad sets
and begin straight leg raises, reverse straight leg
raises and heel slides. Incorporate core stability
exercises like planks.
• You can start swimming & pool exercise when the
wound is healed.
• Continue hip range of motion and add gentle
hamstring stretching. Begin active knee flexion and
hip extension strengthening (first just using the
weight of your leg, then add resistance as tolerated).
Begin balance exercises like single-leg stance.
• Continue hip range of motion and stretching.
Increase the intensity of strengthening exercises and
begin more complex movements like double and
single leg hip bridge and bridge walk outs. You may
begin low impact aerobic exercise (e.g., walking,
elliptical machine) with no incline and low resistance
at first.
• Progress intensity of strengthening exercises. Begin
exercises like split squats and single leg deadlifts.
Perform hip bridges on a physioball. Gradually
increase intensity of low impact aerobic exercise
(e.g., biking, swimming, elliptical, walking).
• Progress strength exercises as directed by your care
team. Continue to increase intensity of low impact
aerobic exercise, but no running.
• Once you are working hard at the activities above
without pain, progress to higher impact activities (like
jogging, running, sprinting & jumping) as directed by
your care team.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily.

Dressing
• If a dressing was placed by the care team, remove dressing after 24-48 hours. Replace with simple bandage.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep bandages and
procedure area clean and dry.

Bathing
Do not soak/submerge hip in water for 1 week. Showering is OK.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine. Otherwise, seek care at your local emergency room.

HIP ARTHROSCOPY
CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise

Phase I – Initial Exercise

Goals • Protect integrity of repaired tissue

• Restore ROM within restrictions
• Diminish pain and inflammation
• Prevent muscular inhibition
ROM • Passive hip circumduction (first post-op visit until gait is normal and pain free)
o 5 min clockwise/counterclockwise each at slight flexion (10 total min.)
o 5 min clockwise/counterclockwise each at 30 degrees flexion (10 total min)
• “Belly time” – lie prone BID for 20 min
• Stationary bicycle with minimal to no resistance
• Aquatic ambulation-emphasize neutral ambulation to avoid capsular stretch at week 3
• Standing pendulum swings
• Active-assistive range in all directions
• Prone prop hip flexor stretch initially and progress to half kneeling hip flexor stretch at week3
• Posterior capsule stretching-quadruped rocks
Manual • Iliopsoas release
Therapy
Education • Use crutches and weight bearing as tolerated.
o Move crutch(es) forward along with operated leg to help reduce stress on hip.
o Use crutches 5 to 7 days after surgery and progress to full weight bearing without
discomfort.
• “Belly Time”- Lay on your stomach twice a day for 20 minutes each time.
• 1-2 days after surgery begin with exercises (See Below).
• Apply ice to front or side of hip for 15 minutes, 3-5 times per day.
• You should be seeing a physical therapist by 5-7 days after surgery.
• Perform gluteal squeezes throughout the day.
• When sitting, try to sit with the hips at 90 degrees. Sitting with the knees closer to the chest
might produce pain or pinching at the hip.
Precautions • Limit prolonged standing and walking up to four weeks after surgery to avoid hip discomfort.
• Avoid deep squatting or heavy lifting up to six weeks after surgery.
• Avoid sleeping on the operated hip. Sleeping on your back or unaffected leg (with a pillow
between the legs) will be more comfortable.
Contra- • DO NOT move hip in direction that causes • DO NOT perform straight leg raises
indications pain, irritation or “pinching” in the hip.
• DO NOT push through pain.
• DO NOT perform sit-ups or sit-up like
motion.
• DO NOT perform the elliptical machine or
impact activities, such as running, without
clearance from your physician or physical
therapist.

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Starting 1-2 Days After Surgery

• All exercises should be performed pain free. If painful, contact your physician or physical therapist.
• Please perform exercises 5 days per week that you are not in physical therapy.
• Perform the following exercises until you are off crutches and walking pain-free.

Isometric Squeeze buttock muscles.

Gluteal Hold for 5 seconds, repeat 20 times, and perform 3
Exercises times per day.

Isometric Lying on back or sitting up with legs straight out in

Quadriceps front, straighten knee down into supporting surface.
Hold for 5 seconds, repeat 20 times, and perform
each exercise 3 times per day.

Isometric Bend knee and dig heel into the floor or surface.
Hamstrings Hold for 5 seconds, repeat 20 times, and perform
each exercise 3 times per day.

Isometric During “belly time,” bend both knees up with pillow or

External rolled towel between feet and squeeze feet together.
Rotation Hold for 5 seconds, repeat 20 times, and perform
each exercise 3 times per day.

Isometric During “belly time,” bend both knees up, with

Internal resistance band or belt placed around ankles. Begin
Rotation to separate feet. Belt or band will provide resistance
and not allow for movement to occur.
Hold for 5 seconds, repeat 20 times, and perform
each exercise 3 times per day.

Ankle Pumps Bring toes up and then point them down.

Repeat 30 times, 3 times per day.

Self Standing Standing supported on non-operative leg on stair or

Hip stool (4-8 inches off the ground) allow opposite leg to
Circumduction remain off stool and slowly move leg in circular,
pendulum type motion.
Perform 20 circles clockwise and counterclockwise
each, 3 times per day.


Cat and Positioned on all fours, lower stomach and roll hips
Camel forward then roll hips backward and arch back up.
Repeat 10 times, 3 times per day.

Abdominal Draw in stomach down towards spine and up

Isometrics towards the lower ribs. Be sure that there is no
movement occurring through the hips with this
particular exercise.
Hold for 5 seconds; repeat 10 times, 3 times per day.

Posterior Draw in stomach as instructed above and roll hips

Pelvic Tilts back until lower back is flat on supporting surface.
Hold for 5 seconds; repeat 10 times, 3 times per day.

Terminal During “belly time,” position foot on toes, as shown in

Knee picture, or use a rolled up towel under the shin (see
Extension in picture for placement) and straighten knee.
Prone Hold for 5 seconds; repeat 10 times, 3 times per day.

Passive Hip Lie on your back and have partner support leg with
Circumduction knee straight and hip slightly bent, AVOID ANY
PINCHING, and move leg in circles, both clockwise
and counterclockwise. Perform each direction for 5
minutes, 2 times per day for 20 minutes total.

Soft Tissue Proximal and distal ITB.

Mobilization Perform for 8-10 minutes.


1 Week After Surgery
• Once approved by your physical therapist, perform stationary bike 10-20 minutes per day (no resistance,
no recumbent bike and no use of foot straps on the pedals). Raise seat height to a comfortable position to
avoid hip pain or discomfort.
• Add the following exercises in addition to the exercises prescribed above.

Rocking on Position yourself on your hands and knees and shift

All Fours your weight forward through your arms and then
back through your knees as tolerated.
Perform 10 repetitions, 2-3 sets, 3 times per day.

Isometric Hip With resistance band or belt around knees, attempt

Abduction to separate knees without movement occurring.
Hold 5 seconds; repeat 10 times, 3 times per day.

Isometric Hip Place pillow between knees and squeeze together.

Adduction Hold 5 seconds; repeat 10 times, 3 times per day.

Double Leg Squeeze buttocks and lift waist up off of supporting

Bridges surface. Once you have reached position as in
picture, slowly lower down to table and repeat.
Repeat 10 times, 3 times per day.

Standing Lift heels off floor and rise up onto toes.

Heel Raises Repeat 30 times, 3 times per day.


Single Limb Stand on one foot without arm support and maintain
Balance balance.
Hold for 30 seconds, 3 times per day.

Supine Hip Lying on back, move leg to side comfortably.

Abduction Repeat 10 times, 3 times per day.
Slides

Supine Heel Dig heel into surface, slide foot toward your buttocks
Slides comfortably and then slide leg back to straight
position. Avoid any irritation or pinching at hip.
Repeat 10 times, 3 times per day.

2-4 Weeks After Surgery

Prone Hip Lay supine, with torso prone on table/physio ball,
Extension and feet on the ground.
Repeat 10 times, 3 times per day

Straight Leg Repeat 10 times, 3 times per day

Raise
Extension
Straight Leg Repeat 10 times, 3 times per day
Raise
Abduction/
Adduction
Leg Start with hip/knees at 90 degree flexion and push
Press/Shuttle up until hips/knees are extended. Use low
resistance.
Repeat 10 times, 3 times per day

Standing In standing position, loop band around leg behind

Terminal knee. With band pulling knee into slight knee
Knee flexion-straighten knee while resisted by band.
Extension

Clamshells With resistance band or belt around knees, attempt

(sidelying to separate knees with movement occurring.
and supine) Repeat until fatigue, 3 times per day.

Criteria for • Decrease edema

Progression • Minimal pain with above exercises
to Next Phase • Normalized gait
• ROM ≥75% of uninvolved side
• Proper muscle firing for initial exercises


4-6 Weeks After Surgery
ROM • Continue with stationary bike
• Continue with mobility exercise
• Manual Therapy (long axis distraction and A/P mobilizations)
o Grade III multi-angle joint mobilizations with and without movement
o Iliopsoas release

Strengthening (Below) • Functional weight bearing

• Double leg mini squats strengthening
• Progressive trunk and lumbopelvic • Leg Press/Shuttle progression to
strengthening single leg strengthening
o Bridging with swiss ball
o Side abdominal bridge
• TKEs
Double Leg Perform 10 repetitions, perform 3 sets
Mini Squats

Bridging with Perform 10 repetitions, perform 3 sets

Swiss ball

Side Perform until fatigue or loss of good form, perform 3

Abdominal sets
Bridge/Plank

Terminal Perform 20 repetitions, perform 3 sets

Knee
Extensions

Criteria for • Able to perform single-leg stance

Progression • Normalized gait without assistive device
to Next Phase • No pain with above exercises
• Full range of motion


Phase II – Intermediate Phase (Weeks 6-8)

Goals • Protect integrity of repaired tissue

• Restore ROM
• Progressively increase muscle strength and propioceptive retraining
• Emphasis on rotational strength and stability
ROM • Continue with stationary bike
• Stair-climber/upright elliptical for ROM and endurance

Partial Range Step with involved LE and drop hips down towards
Lunges ground, keeping knee from coming forward over
toes.

Single Leg Balance on involved LE with soft knee and hips

Balance on level, progress to increased difficulty on unstable
Unstable surfaces
Surfaces

Step Downs Start on 4 inch step or box, keeping hips level, drop
bottom down by b

Single Leg Balance on involved LE, hips level and slight bend
Cord in knee, keeping core activated, pull band across
Rotations body maintaining stability through entire motion.


Mini Squats Stand with legs shoulder width apart and balanced
on BOSU on BOSU, drop back into a small squat.

Side Shuffles
with
Resistance
Band

Criteria for • Improve functional strength and endurance without exacerbation of symptoms
Progression • Full pain-free ROM
to Next Phase • Hip flexion strength >60% of uninvolved
• Hip add, abd, ext, IR, ER strength >70% of uninvolved

Phase III – Advanced Rehabilitation (Weeks 8-12)

Goals • Restoration of muscular strength/endurance
• Restoration of cardiovascular endurance
• Optimize neuromuscular control/balance/proprioception
ROM • Continue with above and stretching
Strengthening • Progress single limb balance on unstable balance
• Progression of LE and trunk strengthening on stable to unstable surface (include
rotational components)

Squat Progression
Chops and Lifts (Half
Kneeling, Tall
Kneeling, Lunge)

• Landing mechanics with emphasis on proper alignment

o NO KNEE VALGUS
o Soft, quiet landings with equal distribution of force through ankle, knee, and hip.
• Sport cord jogging
• Begin with shuttle plyometrics
o Progress bilateral to single LE
o Progress straight plane to rotational component
• Initiate walking-jogging progression
• Swimming (Avoid rotational kicks)
Criteria for • Plyometrics without exacerbation of symptoms
Progression to Next
Phase


Weeks 12-18
ROM • Continue per tolerance and pre-exercise warm-up
Strengthening • Continued neuromuscular strengthening with emphasis on hip and pelvic stability
• Continue jogging progression
• FWB plyometrics
• Begin multi-directional agility drills and sport specific drills

Criteria for • Ability to perform sport-specific drills at moderate speed without pain
Progression to Next • Hip flexion strength >70% of uninvolved
Phase • Hip abd, add, ext. IR, ER strength >80% of uninvolved
• Complete functional sport test
o 3 cross-over hop test for distance (within 15% of uninvolved limb)
• Demonstrate initial agility drills with proper technique

3-6 Months
Sport-Specific • Sport specific drills
Training • Caircoas, Z-cuts, W-cuts, etc.
• Functional Testing
Criteria for Full • Physician clearance at last check-up
Return to Sport • Hip strength >85% compared to uninvolved
• Passing score on Functional Movement Screen
• Demonstrate significant change with outcome questionnaire
• Ability to perform sport-specific drills at maximum speed without pain

References

Enseki KR, Martin RL, Draovitch R, Kelly BT, Philippon MJ, Schenker ML. The hip joint: arthroscopic procedures
and postoperative rehabilitation. JOSPT. 2006;36:516-525.

Green DM, Noble PC, Bocell JR, Ahuero JS, Poteet BA, Birdsall HH. Effect of early full weigh-bearing after joint
injury on inflammation and cartilage degradation. J Bone Joint Surg Am. 2006;88:2201-2209.

Griffin KM, Henry CO, Byrd JW. Rehabilitation after hip arthroscopy. J Sport Rehabil. 2000;9:604-606.

Kelly BT, Williams RJ, Phillipon MJ. Hip arthroscopy: current indications, treatment options, and management
issues. Am J Sports Med. 2003;31:1020-1037

Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006:86:110-121.

Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and debridement
in young adults. J Bone Joint Surg Am. 2006;88:1735-1741.

Phillipon MJ, Stubbs AJ, Schenker ML, Maxwell RB, Ganz R, Leunig M. Arthroscopic management of
femoroacetabular impingement: osteoplasty technique and literature review. Am J Sports Med. 2007;35:1571-
1580.

Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;25:337-357.

LABRAL REPAIR WITH CAPSULAR SHIFT

CLINICAL PRACTICE GUIDELINE
Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Rehabilitation Precautions
Weight Bearing • Weight bearing as tolerated
• Discontinue assistive device initial 2-3 weeks as gait mechanics normalize
Range of • Flexion within pain-free range and no anterior impingement
Motion • Anterior Repair:
o Extension and external rotation within pain-free range and no overpressure
• Posterior Repair:
o Flexion, adduction, and internal rotation within pain-free range and limit
overpressure
• Utilize both weight-bearing and non weight bearing mobility techniques
• Chondroplasty procedure follow same parameters
Bracing • No post-operative bracing unless indicated by surgeon
Other • Don’t push through hip flexor pain/inflammation
• No ballistic stretching or forced stretching

Phase I - Initial Exercise

Goals • Protect integrity of repaired tissue
• Restore ROM within restrictions
• Diminish pain and inflammation
• Prevent muscular inhibition
Weeks 0-4
ROM • Passive hip circumduction (first post-op visit until gait is normally and pain free)
• 5 min clockwise/counterclockwise each at slight flexion (10 total min.)
• 5 min clockwise/counterclockwise each at 30 degrees flexion (10 total min)
• “Belly time” – lie prone BID for 20 min
• Stationary bicycle with minimal to no resistance
• Aquatic ambulation-emphasize neutral ambulation to avoid capsular stretch at week 3
• Standing pendulum swings
• Active-assistive range in all directions
• Prone prop hip flexor stretch initially and progress to half kneeling hip flexor stretch at
week3
• Posterior capsule stretching-quadruped rocks
Manual • Iliopsoas release
Therapy

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Technology Commercialization Office at https://tco.osu.edu.



Strengthening • Glute activation exercise: Prone hip extension over ball/pillows (cues to isolate glute and
limit hamstring dominance; no knee flexion)
• Isometric contraction of quadriceps, gluteals, transverse abdominis, hamstrings
• Isometric contraction of hip abduction and adduction and prone IR and ER
• SLR in extension, abduction, and adduction at week 2-3
• Supine bridging (with or without theraband)
• Clamshells (supine and sidelying) at week 3
• Leg Press/Shuttle with low resistance
Criteria for 1. Decrease edema
Progression to 2. Minimal pain with above exercises
Next Phase 3. Normalized gait
4. ROM ≥75% of uninvolved side
5. Proper muscle firing for initial exercises

Weeks 4-6
ROM • Continue with stationary bike
• Continue with mobility exercise
• Manual Therapy (long axis distraction and A/P mobilizations)
Manual • Iliopsoas release
Therapy • Grade III multi-angle joint mobilizations with and without movement
Strengthening • Double leg mini squats
• Progressive trunk and lumbopelvic strengthening
• Bridging with swiss ball
• Side abdominal bridge
• Functional weightbearing strengthening
• Leg Press/Shuttle progression to single leg strengthening
• TKEs
Criteria for 1. Able to perform single-leg stance
Progression to 2. Normalized gait without assistive device
Next Phase 3. No pain with above exercises
4. Full range of motion


Phase II – Intermediate Phase (Weeks 6-8)
Goals • Protect integrity of repaired tissue
• Restore ROM
• Progressively increase muscle strength and propioceptive retraining
• Emphasis on rotational strength and stability
ROM • Continue with stationary bike
• Stair-climber/upright elliptical for ROM and endurance

Strengthening • Partial range lunges

• Single leg balance exercise
• Sidestepping with resistance
• Step downs (heel touch)
• Single knee bends
• Single leg cord rotations
• Single limb balance on dynadisc
• Mini-squats on BOSU
Criteria for 1. Improve functional strength and endurance without exacerbation of symptoms
Progression to 2. Full pain-free ROM
Next Phase 3. Hip flexion strength >60% of uninvolved
4. Hip add, abd, ext, IR, ER strength >70% of uninvolved

Phase III – Advanced Rehabilitation

Goals • Restoration of muscular strength/endurance
• Restoration of cardiovascular endurance.
• Optimize neuromuscular control/balance/propioception
Weeks 8-12
ROM • Continue with above and stretching

Strengthening • Progress single limb balance on unstable balance

• Progression of LE and trunk strengthening on stable to unstable surface(include rotational
components)
o Squat progression (double leg to single leg)
o Chops and lifts (half kneeling, tall kneeling, lunge)
• Landing mechanics with emphasis on proper alignment
• Sport cord jogging
• Begin with shuttle plyometrics
o Progress bilateral to single LE
o Progress straight plane to rotational component
• Initiate walking-jogging progression
• Swimming (Avoid rotational kicks)
Criteria for 1. Plyometrics without exacerbation of symptoms
Progression to
Next Phase


Weeks 12-18
ROM • Continue per tolerance and pre-exercise warm-up

Strengthening • Continued neuromuscular strengthening with emphasis on hip and pelvic stability
• Continue jogging progression
• FWB plyometrics
• Begin multi-directional agility drills and sport specific drills
Criteria for • Ability to perform sport-specific drills at moderate speed without pain
Progression to • Hip flexion strength >70% of uninvolved
Next Phase • Hip abd, add, ext. IR, ER strength >80% of uninvolved
• Complete functional sport test
o 3 cross-over hop test for distance (within 15% of uninvolved limb)
• Demonstrate initial agility drills with proper technique
3-6 Months
Sport Specific • Sport specific drills
Training • Caircoas, Z-cuts, W-cuts, Ghiardelli’s, etc.
• Functional Testing

Criteria for Full 1. Physician clearance at last check-up

Return to Sport 2. Hip strength >85% compared to uninvolved
3. Demonstrate significant change with outcome questionnaire
4. Ability to perform sport-specific drills at maximum speed without pain

References

Enseki KR, Martin RL, Draovitch R, Kelly BT, Philippon MJ, Schenker ML. The hip joint: arthroscopic procedures
and postoperative rehabilitation. JOSPT. 2006;36:516-525.

Green DM, Noble PC, Bocell JR, Ahuero JS, Poteet BA, Birdsall HH. Effect of early full weigh-bearing after joint
injury on inflammation and cartilage degradation. J Bone Joint Surg Am. 2006;88:2201-2209.

Griffin KM, Henry CO, Byrd JW. Rehabilitation after hip arthroscopy. J Sport Rehabil. 2000;9:604-606.

Kelly BT, Williams RJ, Phillipon MJ. Hip arthroscopy: current indications, treatment options, and management
issues. Am J Sports Med. 2003;31:1020-1037

Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006:86:110-121.

Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and debridement
in young adults. J Bone Joint Surg Am. 2006;88:1735-1741.

Phillipon MJ, Stubbs AJ, Schenker ML, Maxwell RB, Ganz R, Leunig M. Arthroscopic management of
femoroacetabular impingement: osteoplasty technique and literature review. Am J Sports Med. 2007;35:1571-
1580.

Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;25:337-357.

PATELLAR / QUADRICEPS TENDON ULTRASOUND

GUIDED PERCUTANEOUS TENOTOMY
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Avoid 1 week before and 1 month after your procedure.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might prevent you from getting better.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• Crutches
• Knee brace, if deemed necessary
• Therapy appointment times
• Follow-up times (approximately 2 weeks and 6 weeks after your procedure)

Post-procedure Care
Days 1-3 • Plan to have a family member or friend drive you home after your procedure.
• Bring your crutches and brace to your procedure if they were given to you.
• Weight-bearing: Toe-touch weight bearing with crutches. If you were given a brace, wear
it to protect the tendon.
• Activity & Rehab: Rest and keep leg elevated to reduce swelling.

Weight Bearing Activity and Rehab

Progression 1 • Transition to partial weight-bearing
using crutches and discontinue
using the brace. Some discomfort
is normal. The “rule of thumb” is
that discomfort should calm down
by the next morning.
• Begin gentle range of motion to increase knee
flexion. Begin heel slides and isometric
strengthening with quad sets 3 times per day.
• Manual Therapy: May use soft tissue
mobilizations around incision, avoiding direct
pressure throughout progressions.

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Technology Commercialization Office at https://tco.osu.edu.


Progression 2 • Under the direction of your
therapist, begin weaning off the
crutches. First, walk without
crutches in your home. In the
community, continue partial weight
bearing with crutches. The “rule of
thumb” is that discomfort should
calm down by the next morning.
Progression 3 • Under the direction of your
therapist, walk normally in your
home and community.
Progression 4 .
Progression 5
Progression 6
Progression 7
• Continue increasing knee flexion and begin using
a stationary bike to improve range of motion; use
your untreated leg to pedal and let the treated leg
go along for the ride. Continue quad sets and
begin straight leg raises.
• You can start swimming & pool exercise when
the wound is healed.
• Continue knee range of motion and add gentle
quadriceps stretching. Begin active, unweighted
knee extensions. Begin balance exercises like
single-leg stance.
• Continue knee range of motion and stretching.
Progress strengthening exercises, using a leg
press first then add body weight mini-squats.
Increase intensity of the stationary bike to build
strength, pedaling equally with both legs
• Progress intensity of strengthening exercises as
directed by your care team. Once you are
walking normally in your home and community,
you may use an elliptical machine (no incline and
low resistance at first) and increase walking pace
for aerobic exercise.
• Continue to progress strengthening exercises as
directed by your care team. Gradually increase
the intensity of biking, swimming, elliptical or
fast/incline walking.
• Once you are working hard at the activities
above without pain, progress to higher impact
activities (like jogging, running, sprinting &
jumping) as directed by your care team.

Bracing
If your care team gave you a knee brace, wear it for the first 3 days after your procedure.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily. In some circumstances your care team may
prescribe pain medicine.

Dressing
• Remove dressing after 24-48 hours. Replace with simple bandage.
• Keep compression sleeve on for 2 days. It should be snug, but not tight.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep bandages and
procedure area clean and dry.

Bathing
Do not soak/submerge knee in water for 1 week. Showering is OK.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine. Otherwise, seek care at your local emergency room.

PLANTAR FASCIA ULTRASOUND GUIDED

PERCUTANEOUS FASCIOTOMY
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Make every effort to avoid these medications before and after your procedure.
They may impair your ability to heal and may increase risk of bleeding.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might reduce the beneficial effects of the procedure.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• Crutches
• Walking boot
• Therapy appointment times
• Follow-up times

Post-procedure Care
• Plan to have a family member or friend drive you home after your procedure.
• Bring your crutches / scooter / boot to your procedure appointment.

Weight Bearing Activity and Rehab

Day 1 (day of • No weight bearing on treated • Protect your foot by resting and keeping it elevated to
your foot; use crutches/scooter and reduce swelling.
procedure) boot to get around.

Days 2-3 • Begin light partial weight
bearing, placing your foot on
the ground for balance; use
crutches/scooter and boot to
get around.
• Elevate at least 3 times a day to control swelling.
Begin gentle ankle range of motion exercises 3 times
per day.

For OSUWMC USE ONLY. To license, please contact the OSU

Technology Commercialization Office at https://tco.osu.edu.


Days 4-7 • Discontinue crutches. Begin
walking using the boot only.
• If you use a scooter, begin
partial weight bearing by
placing untreated leg on
scooter and bearing some
weight on the treated foot in
your boot.
Week 2 • Discontinue the use of the
boot / scooter. Begin walking
normally in your home and
then in the community as you
are able.
Week 3-4
Week 5
Week 6
• Continue ankle range of motion. Perform isometric
ankle strengthening and toe crunches 1-2 times per
day.
• Continue ankle range of motion 3 times per day.
Perform isotonic ankle strengthening, toe crunches
and foot intrinsic strengthening 1-2 times per day.
Begin non-impact aerobic exercise with a stationary
bike without the boot. You can start gentle swimming
and pool exercise when the wound is healed.
• Advance strengthening by adding more resistance.
Continue ankle range of motion. Begin balance
exercises like single-leg stance.
• Begin using an elliptical machine (begin with no
incline and low resistance) and increase walking pace
for exercise. Advance lower body strengthening as
tolerated at the discretion of your care team.
• Increase the intensity of biking, swimming, elliptical,
fast walking and resistance exercises. Once you are
working hard at these without pain, progress to higher
impact activities (like jogging, running, sprinting and
jumping) as directed by your care team. For running,
consider using an anti-gravity treadmill to start.

Orthotics/Braces
You do not need to sleep in boot. Do not drive while you are wearing the boot. If you have an orthosis, wear this
in your boot/shoe as you normally would.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily. If you are concerned about your pain, please
contact your care team.

Bandage
• If a bandage/dressing was applied, remove dressing after 24-48 hours. Replace with simple bandage.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep procedure area
clean and dry for 1 week after the procedure until your doctor has seen you for your wound check.

Bathing
Do not soak/submerge the foot in water for 1 week. Showering is OK, but keep incision site covered for the first
week.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine (614-293-3600) during normal clinic hours. Otherwise seek care at your
local emergency room.

For Therapists Only

All strength work should be performed every other day, 2-3 sets of each exercise to fatigue without reactive pain.
Manual work may begin 2 weeks after the procedure date.
Last reviewed August 2017

ROTATOR CUFF ULTRASOUND GUIDED

PERCUTANEOUS TENOTOMY
CLINICAL PRACTICE GUIDELINE
The ultrasound guided percutaneous tenotomy allows what was once major surgery to be performed quickly
through a small incision. Although post-procedure care will be tailored to fit your individual needs, the following
guidelines are designed to help you and your physical therapist after the procedure.

Progression is time and criterion-based, dependent on soft tissue healing, patient demographics and clinician
evaluation. Contact Ohio State Sports Medicine at 614-293-2385 if questions arise.

Things to Avoid Before and After Your Procedure

• Over-the-counter pain medicine like ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Naprosyn™) and
acetaminophen (Tylenol™): Avoid 1 week before and 1 month after your procedure.
• Alcohol: Avoid 48 hours before your procedure. Do not consume alcohol while you are taking prescription
pain medication.
• Tobacco & nicotine: Consider talking to your physician about stopping. These products impair your ability to
heal and might reduce the beneficial effects of the procedure.
• Diet: There is no need to fast before the procedure. You may eat normal meals before your procedure and
resume your regular diet when you feel able.

Make sure your medical team provides you with the following before or
at your procedure:
• A sling
• Therapy appointment times
• Follow-up times (approximately 2 weeks and 6 weeks after your procedure)

Post-procedure Care
Day of your • Plan to have a family member or friend drive you home after your procedure.
procedure • If you were given a sling, bring it to your appointment.
• Activity restrictions: No lifting today.
• Rehab: Protect your shoulder by resting it.
Days 2-7 • Activity restrictions: You may lift up to 1 lb. As you are comfortable, you may begin non-
repetitive use of elbow and hand (like using it to groom, dress, eat and drive short
distances). You can stop wearing the sling after 3-5 days as you are comfortable. No
sustained gripping like opening a jar.
• Rehab: Start shoulder range of motion with pendulums and table slides as tolerated 3-5
times per day. Begin strengthening with scapular pinch.

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Activity Restrictions Rehab

Progression 1 • You may lift up to 5 lbs. • Continue range of motion with pendulum and table
slides. Continue strengthening with scapular pinch.
You may begin isometric strengthening of your
rotator cuff.
• Manual Therapy: May use soft tissue mobilizations
around incision, avoiding direct pressure throughout
progressions.
Progression 2 • Progress as tolerated. • Continue range of motion exercises. Progress to
isotonic scaption, internal and external rotation
strengthening (start with 2 lb. dumbbell and progress
as tolerated)
Progression 3 • None • Increase intensity of isotonic strengthening under the
supervision of your care team. Begin joint integrated
strengthening like chest press and rows.
Progression 4 • Continue to increase intensity of strengthening
exercise and begin sport / activity specific training
under the supervision of your care team.
Progression 5 • You may resume high impact sports like golf and
tennis under the supervision of your care team.

Orthotics/Braces
If you were given a sling, you can wear it for the first 3-5 days for comfort. You should come out of the sling 3-5
times per day for range of motion exercises. You do not need to sleep in the sling. Do not drive while wearing the
sling.

Discomfort
Some pain after your procedure is expected for the first few weeks. Use an ice pack on the painful area for 15
minutes as needed; in the first 2-3 days consider icing 3 times daily.

Dressing
• If a dressing was placed on you, remove it after 24-48 hours. Replace with simple bandage.
• Sterile strip bandages can be removed when they begin peeling off or after 7 days. Keep bandages and
procedure area clean and dry.

Bathing
Do not soak/submerge the shoulder in water for 1 week. Showering is OK.

When to call your provider

If you notice increasing redness, warmth, pain, fever, drainage from the wound or other problems that concern
you, call Ohio State Sports Medicine. Otherwise, seek care at your local emergency room.