Friday Lecture Notes

2019 Spring Sports Symposium Friday, March 22, 2019 Lafayette, Louisiana

High Ankle Sprains Dr. Michael Hartman

Current Concepts in Rehabilitation of Femoroacetabular Impingement Steve Levins, PT, DPT, OCS

SLAP Lesions and Biceps Tendon Injuries Dr. Brian Etier

LPTA Professionalism LPTA President Joe Shine (All are invited and encouraged to attend) Table of Contents

Welcome 1

Exhibitors 2

Important Dates 3

High Ankle Sprains 4

Current Concepts in Rehabilitation of Femoroacetabular Impingement 8

SLAP Lesions and Biceps Tendon Injuries 34

LPTA Professionalism 66 Welcome to the 2019 LPTA Spring Sports Symposium!

We appreciate your participation and want to welcome you to the LPTA ! If you need assistance, the Meeting Staff can be identified by their purple name badges. They will be happy to help you in whatever way is appropriate. Spring Sports Symposium EXHIBITS ARE OPEN FROM :00 PM TO :30 PM FRIDAY AND 7:00 AM TO 1 : AM SATURDAY 6 7 For entry to the Exhibit Hall, you must wear y1our00 meeting name badge. Please make a point of visiting all of our exhibitors, thereby qualifying for the exhibitor prize drawings that will be held at 10: a.m. at the break on Saturday morning. Please wear your name badge to ALL eeting functions. It45 identifies you as an authorized participant in the eeting activities and amenities. Name badges are in several colors: m m LPTA Members White Non-Members Yellow Spouse/Guests Blue Exhibitors Green LPTA Staff Purple

NOTE: Lunch is provided for all meeting registrants at the Saturday Business Meeting. Non-registrant members are invited to attend, but should make other luncheon plans outside of the meeting room, or purchase a luncheon ticket for $30.00. Please do not bring any food or beverages into the Business Meeting with you. Download the 2019 Spring Symposium Lecture Notes

Scan the following QR Code: Type in your browser LPTA Meeting Notes webpage:

https://lpta.org/2019springmeetingnotesSpring Save the Date! 2019 Fall Meeting Crowne Plaza August 23-25, 2019 Baton Rouge, LA Welcome to the 2019 LPTA Spring Sports Symposium!

1 Exhibitors

Lafayette General Health

Louisiana Physical Therapy Board

Mor Physical Therapy

Ochsner Health Systems

Partners in Physical Therapy

Physical Therapy Provider Network

Quantum Rehab

Synergy Care, Inc.

Willis-Knighton Health System

2 Important Dates

May 9, 2019 Day at the Capital Baton Rouge, LA

June 12-15, 2019 NEXT Conference Chicago, IL

August 23-25, 2019 LPTA Fall Meeting Baton Rouge, LA

October 31- November 2, 2019 National Student Conclave Albuquerque, NM

3 High Ankle Sprains

Dr. Michael Hartman

4 Notes

______

______5 Notes

______

______6 Notes

______

______7 Current Concepts in Rehabilitation of Femoroacetabular Impingement

Steve Levins, PT, DPT, OCS

8 Management of Non –Operative FAI in the Athlete

About Me

[email protected]

What is FAI ?

9 Femoroacetabular impingement (FAI) is a condition in which extra bone grows along one or both of the bones that form the hip joint — giving the bones an irregular shape. Because they do not fit together perfectly, the bones rub against each other during movement.

Flashback……

Corbett Hall Edmonton, Alberta, Canada

Trends in Publications for hip arthroscopy and Hip Impingement

Kassarjian, Ara. "Hip Hype: FAI Syndrome, Amara's Law, and the Hype Cycle." Seminars in musculoskeletal radiology. Thieme Medical Publishers, 2019.

10 Increase in publications on surgical outcomes for FAI in 13 year 2600 % period (2004‐2016)

Reiman MP, Peters S, Sylvain J, Hagymasi S, Ayeni OR. Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review. Arthroscopy. 2018 Apr;34(4):1319‐1328

Hype Cycle Gartner Hype Cycle – From Kassarjian, Ara (2019)

Hip Hype Look familiar to PTs…?

11 FAI and post hip Arthroscopy is an increasingly common condition walking into the clinic and you need to know what to do with it

Transverse acetabular ligament, acetabular labrum, and ligamentum teres (resected). © McGraw‐Hill Education Australia, 2012.

12 CAM and PINCER

Mosler, A et al, J Orthop Sports Phys Ther, 2018;48(4):250‐259

CAM IMPINGEMENT : PINCER IMPINGEMENT: Cam effect caused by non‐spherical excessive prominence of femoral head rotating in anterolateral rim of acetabulum acetabulum

overgrowth of anterior ‐ can be sequela of sliped edge capital femoral epiphysis

‐theory that intense retroversion of physical activity at young acetabulum age leads to closure of capital physis at early age

13 Prevalence

14 • “Groin Pain “ : incidence of 0.44%. Of these patients, 17% were radiologically diagnosed with FAI. Another 30% of these patients had a high clinical suspicion for FAI.

• 15.9% of the patients had cam type, 10.6% had pincer type, 3.1% had combined type FAI • 29.6 % of those with hip / groin pain • general population

• Roling 2016 PREVALENCE

• 2017 study – Trauma Patients over 1 year • prevalence of radiological FAI findings in asymptomatic adult population was 29.6% in Turkey. • asymptomatic FAI is significantly more in males (46%) in comparison to females (17%) Van Klij, Pim, et al. "The p revalence of cam and pincer morphology and its association with development of hip osteoarthritis." journal of orthopaedic & sports physical therapy 48.4 (2018): 230‐238. •

15 • • Prevalence had more than one sign” or pincer impingement, and 77% hips had at least one sign of cam “Ninety‐five percent of the 134 • Van Klij, Pim, et al. "The prevalence of cam and pincer 1):14‐20. resonance imaging study with clin impingement morphology in asympt CR. Prevalence of femoroacetab B, Galia AK, Abreu M, Germani Yépez

• morphology and its association with development of hip

Joint Surg Am. 2011;93(19)(1–10):e111 football players: AAOS Exhibit Selection. J Bone impingement in collegiate of femoroacetabular Petron DJ, Toth R, et al. Radiographic prevalence AL, Anderson AE, Aoki SK, Phillips LG, Kapron osteoarthritis." journal of orthopaedic & sports physical PREVALANCE therapy 48.4 (2018): 230‐238. ical correlation. Rev Bras Ort omatic youth soccer players: ma op. 2017;52(Suppl gnetic ular 16 Prevalence

• Young , active , military population • Examined individuals with c/o hip pain • At least one finding of FAI was found in 135 of the 155 patients (87%). Ochoa‐ 2010

• What is FAI syndrome? • FAI syndrome is a motion‐ related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. • It represents symptomatic premature contact between the proximal femur and the acetabulum.

Warwick Agreement

FAI Triad

17 Triad

Imaging Symptoms

Clinical signs

Imaging

• An anteroposterior radiograph of the pelvis and a lateral femoral neck view of the symptomatic hip should initially be performed to obtain an overview of the hips, identify cam or pincer morphologies, and identify other causes of hip pain. • Where further assessment of hip morphology and associated cartilage and labral lesions is desired, cross‐sectional imaging is appropriate.

Triad

Symptoms Imaging

Clinical signs

18 Symptoms

• The primary symptom of FAI syndrome is motion‐related or position‐related pain in the hip or groin. Pain may also be felt in the back, buttock or thigh. In addition to pain, patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way.

Triad

Imaging Symptoms

Clinical signs

Clinical Signs

• Diagnosis of FAI syndrome does not depend on a single clinical sign; many have been described and are used in clinical practice. Hip impingement tests usually reproduce the patient’s typical pain; the most commonly used test, flexion adduction internal rotation (FADIR), is sensitive but not specific. There is often a limited range of hip motion, typically restricted internal rotation in flexion.

19 FAI DIAGNOSIS

Diagnostic Symptoms Additional Injections cross to confirm sectional hip as imaging source of ( CT / MRI) pain Clinical Imaging signs

Advanced Imaging

• Gold Standard = MRA

• Edwards 1995 • 23 patients had MRI followed by arthoscopy • MRI without contrast failed to identify chondral defects < 1cm, loose bodies, labral tears • MRI with contrast helped find labral tears but not labral fraying / degeneration

Physio

DIAGNOSIS Conservative Care

Options Surgery Treatment

20 DIAGNOSIS • Guides vigor ofobjective vigor Guides • Irritability • 3 primary components 3 primary • Timeto settle for symptoms required of symptoms • Intensity on • symptomsbring to activityof Amount

Evaluation Treatment

Subjective Options exam and initial treatment and exam Conservative Care Surgery Physio 21 Aggravating Factor Easing Factor

Pain

Aggravating Factor Easing Factor

Pain

Typical S&S

50% insidious onset Persistent deep groin, lateral hip or buttock pain Increases with prolonged standing , sitting and with hip flexion Decreased hip ROM (Samora 2011)

“ C‐ sign”

• Hip ROM • End feel, capsular pattern • Lumbar • Objective Eval r/o contribution • AROM / overpressure • Quadrant test • SLR / Slump • PA s

22 • Thomas Test • FABERS Special • Quadrant Test Testing • Fitzgerald • Impingement Test ( FADDIRS)

Thomas Test Take out lumbar flexion Watch add / abd

FABERS

• Stabilize pelvis !

• Objective measure : knee to mat

23 Quadrant Test

• 70 to 140 degrees • Compression • In slight adduction and slight abduction

Anterior Flex / ER / Ext / IR / Labrum Abd Add Fitzgerald Test

Posterior Flex / Add Ext / ER / Labrum / IR Abd

Impingement / FADDIRS

24 Posterior Relocation Testing

• Mass, R et al., Posterior hip instability relocation testing: A resident’s case report Journal of Manual & Manipulative Therapy, Vol. 25, No4, 215‐220, 2017

•Opposite of provocation tests – FADDIR with post pressure to stress posterior structures •Similar to Relocation test of shoulder

Treatment Strategies

25 Exercise Prescription for Non Op FAI

26 Hip Hinge

Hinge Faults

Sarah Haran

arrowptseattle

TFL Downtraining

27 Psoas Banded Eccentric

28 Tight …. Or weak ????

Zach Long, DPT

Eccentric Control

29 30 Basic Glute Strength

Abduction & Adduction

31 https://redefiningstrength.com

Progressions

Core Strength

32 Adductor Strength

Plyometrics

Thank You

33 SLAP Lesions and Biceps Tendon Injuries

Dr. Brian Etier

34 BICEPS TENDON BRIAN ETIER, MD

LafayetteGeneral.com

Outline Anatomy Function Physical Exam Imaging Pathology Treatment Therapy

35 Anatomy

• 5‐6 mm diameter • 9 cm length • Anterior Circumflex Humeral Artery • Net‐like pattern of sensory and sympathetic innervation greatest at anchor

Elser F et al “Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon” Arthroscopy 2011.

Anatomy

Dual Attachment: 1. Superior Labrum 2. Supraglenoid Tubercle

Vangsness CT, Jorgenson, SS, Watson T, Johnson DL “The Origin of the Long Head of the Biceps from the Scapula and Glenoid Labrum” JBJS (Br) 1994

Anatomy

55%

36 Anatomy

Soft tissue sling stabilizes the LHB: Biceps Reflection Pulley CH Ligament SGHL Subscapularis Tendon Elser F et al “Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon” Arthroscopy 2011.

Anatomy

Bicipital Groove Sling Roof: CH Ligament SGHL Subscapularis Tendon

Attach Lateral to Bicipital Groove

Werner et al. “The Stabilizing Sling for the Long head of the Biceps Tendon…” AJSM 2000

Anatomy

Nho SJ et al ”Long Head of the Biceps Tendon: Diagnosis and Management” JAAOS 2010

37 Outline Anatomy Function Physical Exam Imaging Pathology Treatment Therapy

Function – Superior Stability

No LHB LHB

Warner JJP and McMahon PJ “The Role of the Long Head of the Biceps Brachii in Superior Stability of the Glenohumeral Joint” JBJS 1995

Function – Anterior Stability

TLB Resists Anterior/Inferior Instability:

1. Resists torsional forces in ABD/ER

2.Decrease stress IGHL Rodosky, Harner, and Fu. “The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder.” AJSM 1994; 22(1): 121‐130.

38 Function – Superior Stability

5 Patients who underwent unilateral subpec biceps tenodesis Biplane flouro to evaluate GH motion

Giphart JE, et al “The Long Head of the Biceps Tendon has Minimal Effect on GH Kinematics: A Biplane Flouroscopy Study” AJSM 2011

Function – Superior Stability

The effect of biceps tenodesis on mean glenohumeral positi in vivo was less than 1.0 mm

Giphart JE, et al “The Long Head of the Biceps Tendon has Minimal Effect on GH Kinematics: A Biplane Flouroscopy Study” AJSM 2011

Outline Anatomy Function Physical Exam Imaging Pathology Treatment Therapy

39 Physical Exam

Point Tenderness in the Bicipital Groove Popeye sign LHB Tendon Test: TTP with resisted IR

Physical Exam

• Yergason Test: +Pain with resisted supination Elbow @ 90 • Speed Test: + Resisted FF FA Supinated, Shoulder 90 FF, Elbow @ 0, • O'Brien's Test: + Resisted downward force FA max IR, Shoulder 90 FF, 10 Add, Elbow @0 • Loss of 10‐20 degrees terminal FF Entrapped or “hour glass” biceps

Outline Anatomy Function Physical Exam Imaging Pathology Treatment Therapy

40 Radiographs

Cross Sectional Imaging

Nho SJ “LHB Tendinopathy” JAAOS 2011

Cross Sectional Imaging

Walch et al “LHB Subluxation” JSES 1998

41 Cross Sectional Imaging

Walch et al “LHB Subluxation” JSES 1998

Cross Sectional Imaging

Fraying of the deep layer of the tendon of the LHB is the best sign to suspect subluxation. Walch et al “LHB Subluxation” JSES 1998

Outline Anatomy Function Physical Exam Imaging Pathology Treatment Therapy

42 Biceps Pathology

• SLAP tear • Biceps tendinopathy • Partial tear • Subluxation / dislocation

Biceps Pathology

SLAP tear

SLAP Tear

• 73 Throwing Athletes • Electrically Stimulated the Biceps Brachii • Biceps tendon became “quite taut and actually raised the superior labrum off the glenoid” AJSM 1985

43 SLAP Tear – BLOOD SUPPLY

• Capsular and Periosteal Blood Supply • Meniscus like – inner portion avascular • Posterior/Inferior > Superior

Keener, JD and Brophy RH. “Superior Labral Tears of the Shoulder: Pathogenesis…” JAAOS 2009.

SLAP Tear ‐ Pathogenesis

Burkhart SS, et al. “The disabled throwing shoulder: Spectrum of pathology…” Arthroscopy 2003.

SLAP Tear ‐ Pathogenesis

• Internal impingement • Contracted PIGHL $ • Posterior Shift in COR • Anterior Pseudolaxity • Hyperexternal Rotation

Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404‐420

44 SLAP Tear ‐ Pathogenesis

Late Cocking

Vertical Posterior Twist

Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404‐420

SLAP Tear ‐ Pathogenesis

Resting Abduction, External Rotator Burkhart SS, Morgan CD: The peel‐back mechanism: Its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14: 637‐640.

45 SLAP Tear ‐ Imaging

• Non‐contrast MRI has low sensitivity (38%) for SLAP tears • MR Arthrogram increases accuracy

Connolly KP, et al. “Sensitivity and specificity of non contrast magnetic resonance…” JBJS 2013 Amin MR, Youssef AO. “The diagnostic value of magnetic resonance…” Eur J Radiology 2012.

SLAP Tear ‐ Types

Debride

Repair

Mileski RA and Snyder SJ. “Superior Labral Lesions in the Shoulder…” JAAOS 1998.

SLAP Tear ‐ Types

Debride

Repair

Mileski RA and Snyder SJ. “Superior Labral Lesions in the Shoulder...” JAAOS 1998.

46 SLAP Tear – Normal Variant

3.3% 8.6%

1.5%

Repair = ER

Mileski RA and Snyder SJ. “Superior Labral Lesions in the Shoulder: Pathoanatomy and Surgical Management. JAAOS 1998. Rao AG et al “Anatomical Varients in anteriosuperior glenoid labrum” JBJS 2003

Biceps Pathology • SLAP tear • Biceps tendinopathy

Biceps Pathology

• SLAP tear • Biceps tendinopathy • Partial tear

47 Biceps Pathology

• SLAP tear • Biceps tendinopathy • Partial tear • Subluxation / dislocation

Biceps Pathology

Subluxation / dislocation

Walch et al “LHB Subluxation” JSES 1998

Outline Anatomy Function Physical Exam Imaging Pathology Treatment Therapy

48 SLAP I, III – Debride SLAP Repair SLAP II, IV – Repair

JBJS 2009

SLAP Repair ‐ Failures

Why? Offending Agent Blood Supply

SLAP Repair ‐ Failures

Who? • AGE

• Concomitant RTC Tear

Franceschi F, et al. “No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion…”. AJSM 2008 Provencher MT, et al. “A prospective analysis of 179 type 2 superior labrum anterior and pos‐ terior repairs..” AJSM 2013..

49 SLAP Repair ‐ ASPBT

AJSM 2009

SLAP Repair ‐ OSPBT

AJSM 2014

Biceps Tenotomy

Indications:  Older patients (~65yo)  Low Demand  Isolated Biceps Problem  Severe tendon degeneration

50 Biceps Tenotomy

• Pros: • Simple • Tried and true • Tolerated well by most • Rapid recovery • Cons • Popeye deformity 40 – 70% (Slenker, Arthroscopy 2012; Kelly AJSM, 2005) • Fatigue discomfort 38% (Kelly etal, AJSM 2005) • Spasm

• Patient Preference***

Biceps Tenodesis

Why? When? How?  Pain Relief  Preserve Biceps Anatomy Musculotendinous unit  Limit fatigue, cramping  Prevent cosmetic deformity  Limit weakness

Biceps Tenodesis ‐ Subpec

• Technique well described • Modified incision • Know Anatomic Landmarks • Fixation Options • Tenodesis Screw  Better biomechanically

51 Biceps Tenodesis ‐ Subpec

Biceps Tenodesis ‐ Subpec

52 Biceps Tenodesis ‐ Subpec

Biceps Tenodesis ‐ Subpec

53 Biceps Tenodesis ‐ Subpec

Biceps Tenodesis ‐ Subpec

Dickens etal., AJSM 2012:

 Musculocutaneous Nerve BT site: 10.1mm (6 – 18mm) Medial retractor: (1 ‐ 6mm)

 Radial Nerve Medial retractor: (2 – 12mm)

 Deep Brachial Artery Medial retractor: (1 – 10mm)

Biceps Tenodesis ‐ Subpec

Denard etal., Arthroscopy 2012

54 Biceps Tenodesis ‐ Subpec

Pros: Minimally open Reproducible technique Robust fixation Outcomes well reported Cons NV risk Very low, ? length/tension Challenging in “larger” patients Fracture risk

Biceps Tenodesis ‐ Arthroscopic

•Beach chair •Arm positioner •Subdeltoid space •Hemostasis •Biceps “accessory” portal •Tensioning

55 Biceps Tenodesis ‐ Arthroscopic

Biceps Tenodesis ‐ Arthroscopic

 Tendon Sizing •Can be variable •Remove all investing tissue, synovitis  Tendon Wrapping •Less with “single dunk” •Maintain consistent angle  Establishing accurate tension •Possible to under and over tension

56 Subpec vs Arthroscopic

• Risk of significant over‐tensioning of the biceps with current arthroscopic techniques.

• Currently available arthroscopic tenodesis implants may be prone to pull‐out failure at lower loads when compared to those used in open tenodesis.

Subpec vs Arthroscopic

Werner, BC, et al “Arthroscopic Suprapectoral and Open Subpectoral Biceps…” AJSM 2014

Subpec vs Arthroscopic

•In the early postoperative period, 9.4% of ASPBT patients and 6.0% of OSPBT patients had postoperative stiffness requiring further management: Further rehabilitation Intra‐articular corticosteroid injection •No deformity or known failures

Werner, BC, et al “Arthroscopic Suprapectoral and Open Subpectoral Biceps…” AJSM 2014

57 Arthroscopic Stiffness

• ~ 250 open and arthroscopic biceps tenodesis • 18% Stiffness ASPBT • Female • Smokers • 6% Stiffness OSPBT • Female

Werner, BC, et al. AOSSM Specialty Day 2014

Arthroscopic Stiffness

Average Location: Non‐stiff: 50.34 (± 7.8) mm Stiff: 32.44 (± 7.8) mm p < 0.0001

Werner, BC, et al. AOSSM Specialty Day 2014

Current Practice

Tenotomy: Low demand Isolated biceps pathology Arthroscopic Suprapectoral BT: ~85% of cases Concomitant ARCR, etc. Open Subpectoral BT: Select patients Young, very high demand, overhead athlete, ?able compliance, concern for postop ROM

58 Outline Anatomy Function Physical Exam Imaging Pathology Treatment Therapy

PREVENTATIVE Therapy

Prospective Measure 1. Internal Rotation 2. Horizontal Adduction

PREVENTATIVE Therapy

Horizontal Adduction Side to Side > 15o = 4x Injury Rate

59 Preoperative Therapy

• Does it work? Sometimes

• 39 Patients with documented SLAP lesion • PT (avg 18 visits) • Capsular stretching • Core strengthening • Periscapular strengthening • RTC strengthening • 51% of patients went on to surgical intervention AJSM 2010

Preoperative Therapy

AJSM 2010

Capsular Stretching

• 54 asymptomatic patients • 24 side to side IR < 10 degrees • 20 side to side IR > 10 degrees  Randomized

Mclure et al. “A Randomized Controlled Comparison of Stretching Procedures for Posterior Shoulder Tightness” Journal of Orthopedic and Sports PT 2007

60 Capsular Stretching

CROSS BODY STRETCH

Mclure et al. “A Randomized Controlled Comparison of Stretching Procedures for Posterior Shoulder TightnessJournal of Orthopedic and Sports PT 2007

Capsular Stretching

Sports Health 2010

Capsular Stretching

Sports Health 2010

61 Post Op Therapy

Post Op Therapy

GUIDELINES: • Individualized approach • Mechanism of Injury • Compression Injury – Avoid WB exercises • Traction Injury – Avoid Resisted/Eccentric Biceps • Peal Back Lesions – Avoid Shoulder ER

Post Op Therapy

GUIDELINES: • Phases 1. Protection 2. Motion 3. Strength 4. Endurance 5. Sport Specific

62 Post Op Therapy ‐ Protection

Post Op Therapy ‐ Protection

Post Op Therapy ‐ Motion

63 Post Op Therapy ‐ Strength

Post Op Therapy ‐ Endurance

Post Op Therapy ‐ Sports

64 65 LPTA Professionalism

LPTA President Joe Shine

66 Notes

______

______67 Notes

______

______68 Notes

______

______69