Thanks, everyone, for joining us for this session. This session's going to be on rehab and kind of returning back to play. It's one of my favorite sessions because there's always great videos. And so we have a great session for you here, but we're going to start with some papers. The first paper is from Alex Meyer, who's going to talk to us about functional testing and return back to sport after shoulder stabilization. Thank you. We'll be talking about functional testing and return to sport after shoulder instability. We have no relevant disclosures, but they're available on the AOSSM website. We all know that shoulder instability is a major issue in our young athletic population, especially in our young males. And that does have a higher occurrence rate of potentially greater than 50% with non-operative treatment. Currently, we have very minimal literature on return to sport testing, with the most common return to sport criteria being time post-operatively before being cleared to play and don't have as good of metrics like we do with the ACL. Therefore, the aim of our study was to evaluate elements of return to sport battery for those undergoing arthroscopic band cart repair and determine which of these factors are associated with predicted failure or success of the repair. We did this by doing a retrospective case control study with a minimum of six months follow-up. All patients who participated in sport were eligible. This occurred over 18 months with a fellowship-trained orthopedic surgeon, and then were grouped into either being able to return to play or not yet being able to return to play or had recurrent instability or revision procedures. Here's our published algorithm from the same group. I'd like to draw your attention to this middle box here of our testing battery. It included psychological readiness tests, including WOSI scores, SIRSI scores, Carell and Jobe scores, and included strength testing, and then a couple other additional tests we'll go into shortly. We included additional testing for collision athletes, overhead athletes, and thrower athletes. One of the tests that we included was closed kinetic chain upper extremity stability tests where the athlete puts their hands 36 inches apart and then reaches across to touch their other hand. The goal is to have greater than 21 touches. The next one is posterior shoulder endurance tests where they hold a light weight out in the abducted position, in the prone position, and the goal is to be able to hold it within 90% of their non-affected side. Some additional tests, we also did traditional strength via handheld denometry, and then we used force plate for athletic shoulder tests to test the peak force and the rate of force development in the IT and Y position, again with the goal being greater than 90% compared to the contralateral side. We did standard demographic analysis, and then we reported the rate of passing the test with those predetermined markers and reported that as a percentage. In our results, we found we had five patients that did not return or had revision instability or procedures, and we had 16 patients that did return to sport at the same level or higher, and we found that there were a few specific tests that stood out. One was the closed chain kinetic upper extremities test. Those that were able to return to sport were able to pass this much higher rate than those that did not, as well as the athletic shoulder test with peak force in the Y and T positions and the rate of force development in the T position. If we compare that to the traditional strength testing, we did not see the noticeable differences. Even some of these had higher strength in the group that were not able to return to sport compared to those that were able to return to sport. In these patients specifically, this was part of a shared decision-making model when they were allowed to return to sport. A little discussion from the rest of the literature. Druman, Jr. et al., they used a similar return to sport testing battery, and they found that those that underwent their testing battery had a lower recurrence rate of 5% compared to 22% who did not undergo their battery. However, one thing that they did, they had to have passed all of their return to sport testing, and only 16% of those passed at six months, whereas the control group, all of them returned to sport at six months. In conclusion, closed chain kinetic upper extremities stability testing and athletic shoulder testing with peak force development and the rate of force development criteria were most associated with the ability to return to sport. Traditional strength testing did not demonstrate differences between the groups, and we would recommend closed chain testing and force plate testing to be incorporated as part of a functional test and can be incorporated as early as four months. Here's your references, and thank you. Thanks, Alex. We'll do questions after this next paper here. All right. Our next speaker is Mohan Khan, who's going to talk to us about cryocompression and opiate consumption after shoulder surgery. Discussing his multistandard randomized control trial. Thank you so much for the opportunity. It's my pleasure to present this on behalf of my co-authors. These are my disclosures. So we know that elective shoulder surgery is one of the most commonly performed orthopedic procedures and is increasing rapidly, and really the pain management following shoulder surgery involves pain medications in the form of opioid analgesics. And opioids certainly have received a lot of focus just given the opioid epidemic. And in North America, there has really been a substantially elevated number of opioid-related deaths and other harms, and it's in part fueled by excessive prescription of opioid medications. And certainly opioid-naive patients undergoing shoulder surgery are at an increased risk of long-term dependence. And so cryotherapy is commonly used in many surgeries, and particularly in shoulder surgery to decrease swelling and inflammation, and it also helps to alleviate post-operative pain. And the combination of cryotherapy and compression has been shown to be effective in knee surgery and spine surgery in reducing analgesic consumption and increasing recovery. But we wanted to look at how cryotherapy with compression really relates to shoulder surgery. So the question really was for this randomized control trial, what is the effectiveness of cryo-pneumatic compression on post-operative shoulder pain, narcotic use, and quality of life when compared to standard of care? So our main objectives really were to look at post-operative shoulder pain, post-operative narcotic use, and various health-related quality of life measures. And so how do we do this? This was a multi-center randomized control trial. There were five different hospitals in Ontario, Canada, and recruited 200 patients, 100 in each group. And really these were patients that were over the age of 18 that had open or arthroscopic primary or revision shoulder surgery, including arthroplasty procedures. And patients were randomized to either cryo-compression versus standard of care. And standard of care could include regular ice packs or cooling units, or just standard sling treatments. And so you can see here the breakdown of patients that were randomized. We used intention-to-treat analysis, and we followed up our results. So what was the intervention? Well, we compared patients from standard of care to the intervention, which was the game-ready ATX shoulder wrap. And this was applied to patients in the operating room at the conclusion of the surgical procedure. And it was used in the recovery room for 45 minutes to an hour. And post-operatively on days 1 and 2, they used it 30 minutes on and 60 minutes off throughout the day. And as needed overnight. And from days 3 onward, they used it to keep the shoulder as cold as comfortable on medium compression for a minimum of twice per day. And most people used it for about 2 weeks. And they received standardized post-operative medications and physical therapy as per the surgeon's normal protocols. In terms of control, standard methods of post-operative care, which were rest, ice, and regular compression using ice or standard cryotherapy or other such devices. And actually 40% of patients used some degree of ice machine, just no compression. And standard post-operative medications or physical therapy as per standard practices. So what did we look at? We looked at post-operative shoulder pain as evaluated from the numeric pain rating scale on a rating of 0 to 10. Post-operative narcotic use as measured by oral morphine milligram equivalents. And this was reported in a medication log. And we looked at various health-related quality of life measures. We looked at the various time points at 2 weeks, 6 weeks, and 12 weeks post-operatively. And we collected patients' medication scales. These are the various statistical analysis that we performed. In terms of baseline demographics, males and females, similar between groups. In terms of the actual procedures, again, baseline demographics were similar between both cryopneumatic compression or standard care. And really the main finding of this study was that using cryocompression, you were able to half the amount of opioid medication between standard care versus the intervention while maintaining the same amount of pain. So pain improved between both groups, but you were able to use half the pain medication in cryocompression versus standard of care. In terms of patient-reported outcomes, really the outcomes were very similar across groups. Otherwise, in terms of their SF36 physical outcome scores, mental outcome scores, certainly at 2 weeks, just because of the distributions, there was a statistical significance in SF36 function at 2 weeks. But otherwise, nothing else was found. In terms of adverse events, again, very similar between groups. So our main conclusions were there are no difference in patient-reported pain at any time point, but a significant decrease in narcotic medications that were consumed post-operatively in patients with cryocompression versus standard of care. And there was an improvement in SF36 at 2 weeks in comparison to standard of care. And otherwise, no difference in adverse events. Thank you so much. Okay. We have a few minutes for questions here. So we have about like 4 minutes for questions. So if anyone wants to come up to the mics, just let us know, but we'll start from questions. Kevin, did you have any questions? Dr. Khan, you said 2 weeks was the average that the subjects or the patients use the cryo. Is that the guidelines that you would suggest? Yeah, I think so. I think most of the time, by 2 weeks, patients are going to maximize their benefit from cryo. Less than 10% of patients ended up using after 3 weeks, but I think, you know, the first 2 weeks are where you're going to get the most bang for your buck. We have a question over here. Question to mine. Thank you. Excellent lecture. Excellent story. This question about were you able to differentiate, to distinguish between the different procedures of shoulder arthroscopy? Were there any difference between instability or rotator cuff tear repair? Were there data in the literature that demonstrate that rotator cuff tear repair is more painful than instability? Yeah, that's a great question, Emilio. We actually didn't do that analysis, but it certainly would be something interesting for us to go back and see how the pain difference is between those two. Yeah. I had a follow-up to that in terms of arthroscopic versus open. You said you included shoulder arthroplasty cases, obviously bigger incision, a little bit longer surgeries. Did you look at that and see any differences with those? We didn't, actually. I mean, regardless, their pain improved more in the cryo compression versus standard of care, but we didn't actually specifically break that down. Alex, I had a question for you as well. You mentioned a bunch of different tests there. How long does that take? Is that realistic for someone to do in their clinic, or how are you guys doing that over there? Yeah, so we are working with the physical therapists within our institution to standardize this at four months, and then six months, eight months, until they pass or return to play. And so it's worked into the scheduled physical therapy regimen. Probably takes around an hour to complete all the tests. Dr. Meyer, who was your subjects? I might have missed that. What type of subjects were there? Yeah, so they were any patients that participated in sports and underwent arthroscopic bank heart repair were eligible. I think our average age was around 19 or early 20s. Both groups were very similar in demographics. Was there any difference in sport? For the group that failed, they tended to over-add or think to be a sport? Yeah, so due to our relatively low number of participants that we have current data on, we weren't able to granulate the data into which type of sports, but that is something that we're going to want to look at and have included specific kind of testing for those types of athletes. But we don't have the data for that yet. And Emoen, I have one more question for you. You know, in this controlled study, in terms of right immediately post-op, having the cryo compression therapy is great. Are you still doing that now that your study is completed? And the question I ask for that is in terms of cost for that as well, in terms of insurance coverage. I know in our institution we have some issues of getting some of that stuff covered, but I'm interested in how you guys are incorporating that now that you've seen this evidence in your study. Yeah, so I didn't catch the first part of your question. But certainly for cost, I mean, as part of this study, the cryo compression was provided to patients, you know, as part of the study. But, you know, that's an important part of dealing with this. I mean, it has a significant improvement in narcotic use, and that should be something that we're looking into for cost. Yeah. I think it's really important to try whatever you do to decrease opioids. So thanks, you guys, for your presentation. Those are great papers. Next up. So next up, we have Scott Greenberg going to present and talk to us about blood flow restriction. Thanks so much. It's truly an honor to be here and speak in front of you guys today on a topic that's really, really something I'm passionate about. At the University of Florida, we were early adopters of this tool, I'll say, starting back in like 2014, but it's become more vogue of late. So we're going to talk about blood flow restriction training specifically. Maybe. So before we kind of move forward as to what blood flow restriction actually is and training is, we're going to set the foundation using this model that Al Vermeule first started with, and it was later kind of modified a little bit by Rob Panarella from a rehab perspective. And it really speaks to the hierarchy of athletic development. And it basically speaks to the fact that you can't really show speed unless you have a good foundation of reactive strength. And you can't have reactive strength unless you're explosive. And you can't be explosive without having some foundation of adequate strength. And that's really where blood flow restriction training has its merit, in actually the strength phase. So if we can really improve and become more efficient in getting our athletes stronger, we can hopefully get them back into the game quicker, which is basically the title of this whole session. So what is exactly blood flow restriction therapy and training? Well, you're basically inducing a response. And you're doing that by restricting completely venous return. And you're limiting arterial influx into an area. And what happens is that you put cuffs on either your proximal upper arm or your proximal thigh. And the limb occlusion pressure is determined. And then from there, you restrict based on a certain percentage of that limb occlusion pressure. Typically, the pressures go anywhere from 50% to 80% occluded, and the lower extremity being probably more towards the 80%. And what this does, it sets up an environment. And that environment is similar to that that is created with traditional strength training. Traditional strength training, in order to get hypertrophy, you're looking at using weights that are somewhere between 65% and 85% of your warm-up max. And obviously, in the rehab world and in the injury world, oftentimes our tissue isn't capable of handling. And we wouldn't want to put that type of load through our tissues. So what blood flow restriction training allows us to do is use loads somewhere in the 20% to 30% of the one rep max range, and at the same time, still induce that same type of environment created by normal traditional loading. The other cool thing about blood flow restriction training is not only is there a local effect, which is definitely better than the systemic effect, there is a systemic effect as well. So in terms of the basic applications, obviously we're talking about this in the sports medicine world, whether it be rehabilitation, dealing with pain, or in acute management of injuries. There's also some components that are really, really beneficial for the performance side, whether it be during a deload week, if you're looking to improve aerobic capacity, or even people are starting to use it now in the world of recovery. This is my favorite slide in the whole presentation. I use it in all my BFR talks. It was first introduced in this fashion in 2021 by Baxter in his study, and it basically speaks to the fact that BFR works in several different ways. It creates an acute response, whether it be muscularly, metabolically, or cardiovascularly, and that acute response then leads to some training adaptations, and that's really what we're shooting for, those training adaptations. So from a muscular perspective, we're looking to increase strength or hypertrophy. Metabolically, there's going to be an increased buffering capacity, which will later have an effect on onset of blood lactate accumulation, increased capillary density. You'll see an increase in stroke volume, which has an effect, obviously, on VO2 max, as well as increased femoral artery diameter in the lower extremity. So again, it is very, very multifactorial in terms of how it works and the different implications it can have on your athletes depending on what you're striving for. Is there support? And the answer is absolutely yes, and it seems like every day I go on PubMed, there's another study that pops up as to its effect of use of blood flow restriction training. And you know, it's showing promise not only in the area of sports medicine, but also from an elderly adult population. So the applications of blood flow restriction, we're only scratching the surface right now, and the research that's coming out to date is really kind of focusing on more of the efficiency and the best ways of practice in which we can implement this type of tool. My favorite use cases. I think blood flow restriction training was basically born to treat Achilles tendon repairs. There are three main goals, at least the way I see it, with dealing with Achilles tendon repairs. Number one, first priority is wound healing. If you don't get adequate wound healing, you're in trouble. Second is throughout the course of your therapy, avoid tissue creep, right? You don't want that tissue to be stretched out. Lastly, and the thing that limits most return to sport is the actual atrophy of the calf. So if we can increase or improve the rate at which we increase the strength of the calf, I think we can work through that pyramid that we saw on the first slide a lot quicker. We can start by doing stuff. I usually start contralateral post-op day one, and I can use a lot of my larger muscle groups to try to elicit more of that systemic response. So I'll do a lot of leg extension work, a lot of hamstring work, even some calf work. As soon as I'm satisfied with the adequate tissue healing and the swelling is under control, I will use it on the involved side, doing just general movements, working from a non-weight bearing to a weight bearing status, from a double leg support to a single leg support. And then obviously you can progress the weight and resistance as tolerated as you move across. Another use case, Kevin's going to talk about it in a little bit, is probably the most common place in which it's used is ACL reconstruction and trying to get back that quad after the surgery. Obviously that's another important thing. Quad function is huge. Quad strength is huge. Again, it's the foundation for return to sport in a lot of these situations. The area that I tend to use it more that's more non-conventional, I'd say, would be foot and ankle strengthening. I tend to think that we traditionally, in normal therapy, don't adequately load the foot and ankle. I don't think TheraBand resistance is truly strong enough to create that hypertrophic response that we're looking for. It takes me all of one minute to put on a blood flow restriction cuff, and therefore why wouldn't I use it to ensure that I'm actually creating the environment to stimulate that response that I'm looking for. So I do it all the time for just general foot and ankle strength. You know, with our hands, we can easily grab weights and dumbbells. With our feet, it's a little bit more difficult to do so. So I find really the benefit of including blood flow restriction training for my general foot and ankle strengthening is key. Next question is, is blood flow restriction training safe? The answer is yes. There are numerous studies out there that support this, but that doesn't mean that it's safe for all situations. There are some basic contraindications. Obviously, any family history of clotting, clotting disorders, hemophilia, significant hypertension, any history of DVTs, or any type of thrombotic strokes. The area where you need to kind of take caution or that yellow light pops up are some of these other situations, such as, you know, smoking, any type of circulatory issue, they say travel is a possible yellow flag, history of synovitis being another one. It doesn't mean I don't do it in those situations, you just got to ask yourself the big question. I say this in my clinic all the time, is the juice worth the squeeze, right? Is the risk worth the reward? And for me, most cases it is, but obviously you just want to, you know, kind of tread with caution. If you are concerned about, you know, implementing blood flow restriction, you're always safer using a lower limb occlusion pressure. So maybe instead of starting at 80% occluded, you might want to start at maybe 60% occlusion and then work your way up and see how the athlete or patient tolerates it. So basically in summary, I can't say this enough. If you can load tissue, load tissue, okay? But there are situations where loading tissue isn't appropriate, and we want to get our athletes back as quick as we can, and doing nothing doesn't seem like a really valid solution to our problem. So blood flow restriction acts as a great tool that we can start this early process of trying to recover some of our strength to, again, get our athletes back in the game a little quicker. Thank you very much. Thank you. All right. Next up we have Kevin Welk, who's going to talk to us about how we get our ACL patients back quicker. Great. Yeah, I've got a topic that's a little bit controversial. It's accelerated rehab. So what I'd like to do is kind of walk you through maybe some circumstances and some things that may be the key as far as if we can accelerate somewhat or not. So hopefully we'll get... These are my faculty disclosures. They're on the AOSSM website. You know, when we talk about who we can accelerate and who we can't, obviously there's some circumstances where a person can go back relatively quickly, but we'll talk about what those circumstances are. Certainly meniscal repair, certainly LEDs, certainly different types of grafts will certainly play into this, whether or not you can accelerate or not. Should we go slow or should we go fast? Right now the gauntlet is swinging toward a little bit slower rehabilitation, as you're all familiar with. So one of the things that we have to control immediately post-op is swelling and pain and long-term knee preservation. So we don't want to accelerate someone and sacrifice their knee 10 years later or 15 years later. The other issue is, and it seems to be a bigger issue nowadays even than previous years, is motion. We have more and more individuals with slight flexion contractures, and we struggle to get extension. And some of it, I think, is people are just a little bit quicker, the patients as far as walking and ambulating and things of that nature. And obviously we're trying to avoid arthrofibrosis, which is a big problem, which is the gentleman that you have on the right-hand side. So we want an asymptomatic knee 5, 10, 15 years later. And this is actually a young lady who wound up playing for the U.S. soccer team at about nine weeks, 10 weeks post-op, believe it or not, back in 96. And just talked to her about maybe about a month ago, see how she was doing, maybe three weeks ago. And she's still relatively asymptomatic on that ACL side. So quite frankly, we got lucky. I mean, that's the bottom line. We got lucky with her. These are our program. This is our phases, if you will. And you can see that it's not exactly an accelerated program. We're talking nine months to go back to sports. So what are some important factors? First, we have to start slow to go fast. And as I mentioned before, starting slow is immediately post-op, calming the knee down, get your swelling down, get your extension, get quad activation in particular. These are the 10 key points. Pre-op is critical to calm the knee down. We've learned the hard way that if you don't have good motion prior to surgery or you have a quiet knee, you have a higher risk of knee loss of motion, arthrofibrosis, classic article by Shelbourne several years ago. Also an interesting study out of Delaware actually showed that if you delay your pre-op phase longer, even two years later, your outcome has a higher score. And so that's relatively interesting as well. As we talk about being accelerating, maybe we need to calm it down first before we accelerate. What about post-op? Well, we've talked about this already. We need full extension, whatever that means to you, looking at the opposite side or some degree of extension. So I like a little bit of hyperextension. If they have that on the opposite side, I think that allows the knee to block out. Shelbourne showed that even a loss of five, three degrees of extension compared to the opposite side leads to early osteoarthritic changes to the knee. So range of motion is still the name of the game. We do different devices. These are devices that will create overpressure. So we do low load, long duration type stretching to get our extension. Calm the knee down first. I've mentioned this several times before, but the key is really activating the quad as well. So we use a lot of cold. It was great to see the study on the shoulder as well as decreasing the need for narcotics. So we use cold, compression, and a big advocate as well. If you're able to contract but you can't contract very well, we do biofeedback, EMG to your quads so you can see your threshold, give you goals so you can activate to a higher degree. If you use the biofeedback, many times I use muscle stim at the same time to augment a better contraction and even some muscle education. But again, the key is that you have muscle activation and that's why we use the biofeedback. The real problem is the people who can't contract, that post-op patient who just cannot contract their quads and you use muscle stim or something like that, they're able to contract but they come back two days later and they still can't contract. We'll talk about those individuals shortly. So that's the problem. So what do we do for those individuals? We think there's some neuroplasticity that's going on. That's why they can't activate their quads. They have inhibition from their central nervous system. And so we do visual reactive types of movements like this with these lights where they have to hit the target color while they do an exercise like knee extension. Here's a 67-year-old, 68-year-old ACL reconstruction with a hamstring graft and you notice the difference when one moved versus the other. This gentleman's a little bit slower in his reaction time because of age. We also can do closed chain exercises, terminal knee extensions here with a resistance band and he's, again, has visual input. That visual input will override in many cases the neuroplasticity that's happening in central nervous system. It's all about milestones. We have to hit the milestones regarding range, muscle activation to be able to progress. But there are speed limits as well. Flexion, long-term we want to heal the glute flexibility. There's three things that decreases anterior knee pain with patellar tendon grafts. Patellar mobility, full knee extension, full knee flexion. Those are the keys in our mind. And we talked about this range of motion progression as well. Restoring patellar mobility, especially with a patellar tendon graft or even a quad tendon graft for that matter. Quad tendon grafts rehab differently than patellar tendon grafts and hamstrings as well. Kinesiophobia. One of the keys that we see with ACL patients, if you have high degrees of confidence in your knee and your recovery along that process, you tend to, I don't want to say accelerate, but you tend to rehab easier than somebody who's very apprehensive. So how can we override this kinesiophobia? I feel very strongly about this. One of the keys is neuromuscular training. So we do perturbation training. We do a lot of neuromuscular dynamic stabilization, standing on foam. Things that you didn't think you were able to do, we actually ask you to do in a very controlled graduated fashion. It builds limb confidence, but it also creates dynamic stabilization of quads and hamstrings. Perturbation training is what you see here. It's a postural disturbance. They're on an even board. I come up behind and I simply tap the board. This is life. Life is full of perturbations where the person is walking down the street and missteps, or they're running on a trail and they step in a hole. Can you right that? Can you correct? So we try to do this fairly early in the rehab, and it's all graduated. In the beginning, you'd be with your foot just on the floor. Then you might go on foam, then a rocker board. So everything is a progression, building confidence, dynamic stabilization, and proper muscle activation. We start this early. As you can see here, there's a gentleman patellar tending graph on the right side. And one thing to notice about neuroplasticity, or to note, is it happens bilaterally. So if you tear your ACL on the right side, you have changes that are occurring on the left side. You have quads that are decreasing in strength, proprioception is decreasing as well. So we start these exercises on the uninvolved side, immediately post-op, and then we go on the involved side as well. Scott did a great job on BFR. We believe in BFR. We've used it for several years, to say the least. I think it's a game changer as far as quads. This is one system here that we use. We're generally between 60% and 70% occlusion. There is some variability based on comfort as well. And we do higher reps. That's one of the keys, right, with BFR is you want high reps, 25 reps in a set for the first set. Then the gradation is 15-15, something like that. You have to pick the best quad exercise. I'm all about the hips with ACLs. I'm all about glutes. I'm all about foot and ankle. But every study, when you look at outcomes, it correlates quads to outcome. So we need quads back. And so you have to pick carefully as far as the exercise. As I mentioned, as I kind of come down the finish line, it's not an isolated injury, unfortunately. That things are happening bilateral. That high school female soccer player, when she tears her ACL, unfortunately, she's super high susceptible for the contralateral side, unfortunately. The male is more likely to tear the same side, ipsilateral. Neuroplasticity. In years past, we thought you tore your ACL, proprioception was altered on that ACL side because of a localized effect. But it didn't explain what was going on with the opposite side. And now we've learned that what's happening is where you're interpreting that information and processing and reacting is different in your central nervous system in your brain. So doing a simple knee extension here with a person in an MR device, and you look at the brain activity with people with neuroplasticity, they're using various centers of their brain where in reality, they should be using one particular area. And this is some work from Dustin Grooms from Ohio University. So neuroplasticity now is about recognizing a joint position, processing it, reacting properly. And that's why we use the lights. To give you an idea, here's an ACL high school football player. He's going to count backwards by sevens from 100 while he does an agility ladder drill. I'm going to also throw a ball to him, so he's got to count backwards by seven, catch a ball. I tell him the direction to go in and the drill to do. So a lot going on at the same time. It's not just that you're able to do it, but you're able to do it proficiently and normal. We do these lights with players of various sports. This is a perturbation treadmill. So this gentleman, I'll start that over for a second. He's walking on the treadmill and the treadmill actually moves laterally and he has to correct to it. And we use a harness because, unfortunately, it's quite a bit of a perturbation. We'll do things visually. And again, a lot of input, a lot of the correction seems to be visual in nature. So here's a high school basketball player, ACL on the right side, Patel or Tenegraff. We throw a hextech to her. We call the color out that she has to catch the limb while she's dribbling a basketball and stabilizing on a rocker board. This is one of the last things I'll mention. This is a neurocognitive exercise where this gentleman, another basketball player, he's on a rocker board. We're tapping it. He's got to solve math equations while he's doing this. So by doing those types of activity, it overrides the neuroplasticity that's occurring. Hip really critical. Hip to control that valgus moment. Also, we want to gradually increase the loads on the joints. We like pool, unloading treadmills, things of that nature. Last couple of things to mention, return to play. Return to play has changed dramatically, right? So we wrote a paper on this in the International Journal of Sports, PT, great journal if you don't get it. It's free access. You want to access it online. It was written last year where we said we need to change our return to play. A run test like this is fantastic, but he knows the direction he's going in and it's an anticipated movement. What I'd rather do is point to the direction that this person has to go to. So he runs to that cone, either the lights light up, almost like a stop sign, which way to go, or my hands. He has to react. I see how he moves. Last one to mention is a hop test. Great work by Dr. Noyes, but here I'm actually calling out the foot that I want him to land on. So I'll say, ready, go left, or ready, go right. So when they push off in the air, they have to process that information and land on the foot. In this case, it's landing on what side of the tape? So I'll say left, left, meaning left foot, left side. Force plates, great. Look at how this girl lands. She thinks she's ready to go back to field hockey. She even said when she landed and we showed her the video, I'm not ready, compared to this gentleman who seems ready. So with that, I'll end there in the interest of time, and thank you very much for your kind attention. Thanks, Kevin, for showing those videos. It makes me remind myself that I'm definitely a former athlete. I don't think I could ever get back to that. So next up, let me just make sure we have this pulled up here. We have Chuck, who's going to talk to us about what we need to include into shore stabilization rehab. Thanks a lot. Thanks a lot. I appreciate the opportunity to speak to you today. Dr. Meyer set us up well. You would have thought we coordinated, which is impressive since I went to Chapel Hill. I have no disclosures relative to this talk. I do want to think much of this is really reflective of the team that we have. You can find the protocols and a lot of the principles we'll discuss here are actually in the Orthopedic Rehabilitation of the Athlete, published a few years ago, as well as in the American Society of Shoulder and Elbow Therapists consensus statement. I really want to talk to you about three things. One is, and try to simplify it a little bit, of how to communicate with your team and around this. And I think with shoulder instability, it's really these three things that kind of guide how I think about and educate and communicate. First is to avoid distractions. We want to establish expectations and then match load to capacity. For me, shoulder instability is my favorite thing to rehab. And part of it is because there's so much that can be going on. And I apologize, I don't have a cape or anything like Dr. Provencher and Tokus had earlier today if you got to see their debate. But I think it's clear up front with these patients, we have to establish their patient goals in the context of what's going on. And I think when you think about that, it allows you to define what winning looks like. Are we just trying to get the shoulder not to come out again? Are we trying to get them back to a certain level of function? Or are we trying to get them back to sport? Or all three? And I think those things really guide how we think about setting expectations that we'll talk about. And I think it's really important up front to document where they start. I'm a fan of the saying, and just simply, where are you scale of zero to 100? Where are you today before you have surgery? And I think it really begins to set an expectation of what that baseline is. What we've seen, the lower you are, the longer it takes you to get back because you're starting from a different spot. And then what are the barriers to winning? You know, are they able to be in the clinic and commit to the rehabilitation it's going to take? Do they have compressed timelines? Kevin talked about accelerated return. They may not have a choice. I think that the UFC folks are over in the Sheraton. They have a different set of guidelines that they're returning to, and so what does that mean? That then allows us to set the expectations, and I think the two critical things for instability is, one, what is their expected active range of motion at six weeks? You're going to be a variable in your sling use and exactly how aggressive you're going to be communicating to your patient and your rehab team of what do you want that patient to look like at six weeks. That allows you then to gauge how much they need to be moved and are they on target. That then sets you up, Kevin, you know, it's amazing to me the correlation between ACL and instability, they really parallel. It's about mobility. You've got to get that first, but that sets you up in what are the criteria to return to sport and clearly stating from day one, in order for you to return to sport, this is what I expect, and I think that allows the surgeon, the rehab team, and the patient to all be on the same place. And so when you think about range of motion, it varies by sport. There's really good normative data that are in the literature to look at what do we expect side to side for this individual athlete, and how does that fit in the context of what they're looking to achieve. And then as we think about, especially in patients with bony loss, with adjunctive procedures like Latter-day and Rheplisage, they're going to change those expectations. So how are we going to adjust that individual? And in particular, I'm not going to dwell on overhead athletes, but that's the really tough one, right? We want, if I can't get back into my layback position, if you will, for a thrower or overhead for a volleyball player, I can't compete at sport. On the other hand, that's the most risky thing to do for this instability procedure. And so we have to set those expectations, and I think it's really important that we clearly communicate that I'm looking for extensibility. And what I mean by that is, I want you to be able to actively move through the range you need for the function required. And that's as opposed to be, I don't necessarily care that you're flexible, which is passive range of motion, in particular in this population. And in the early phases rehab, I would actually say, I don't want to see this stuff. I don't think that's the right application, because if someone's getting neuro- driven tightness, it's likely because they're not strong enough. And in particular in this population, taking away protective muscle guarding, especially early, is a really good way to have a patient dislocated night. Don't ask me how I know. And so for me, really starting at the base and restoring force coupling with really basic exercises, it's the fundamentals, and if you will, the blocking of tackling of shoulder rehab is where we want to start. And it's kind of crazy to think that you would take an athlete and put them in the same kind of lawn chair program for a rotator cuff. What I found is, if I do that, I don't ever have to fight this. I don't ever have to come back and clean this up. If I start them supine and gradually bring them up, if I start them with the base exercises, and one of the things that I really try to emphasize is how hard with this. And I think Scott hit on it, we tend to under load and under dose our patients, in particular in the early post-operative period. And for an instability patient, within the safe range that I'm good, unless I'm protecting subscap, or infraspinatus with Latter Jay, or remplissage, otherwise, that's the one thing I can do. Like, hey, I can really load up your shoulder. I'm going to make you sweat, and we're going to work. So giving them guides, and this is the OmniRes, it's just super simple how hard with that. I want you up into that yellow pretty early for your cuff exercises. And then that allows us to gradually load the shoulder, and this is actually from a JSES article where Bryce Kahn did a really nice job summarizing the EMG literature. It's not changed a lot in 10 years, and it really allows us to see, wrong way, allows us to see that gradually loading that shoulder. And so for shoulder instability, I can start in phase two in general, right? I can start to ramp up my load pretty quick in phase two and phase three exercises earlier for instability, as opposed to rotator cuff where I want to wait to introduce those. And then ultimately, as I get to the end range. So if we think about, not only is there normative values for range of motion, there is for sport and side-to-side differences. And so as we start to set up our objective criteria, I think the one thing that's a little different for overhead athletes compared to other sports is you're going to have a side-to-side difference, and we expect a certain balance of posterior to anterior musculature. So Alex did, Dr. Meier did a really nice job describing the upper extremity closed kinetic chain test, or TAP test as I call it, Dr. Davies, because that's a lot to say in a short time. But really using the systematic isometric test and scapular test, and then really what's become a favorite of mine is this prone horizontal abduction test. And if you were to say, hey, you only get one thing to do if time really becomes a crunch and you can't take through the whole battery, this is a single test, gives me the ability to capture posterior endurance. The one way we do it more traditionally is more re-described when she was at the University of Kentucky is we look for reps. And what we typically see, if you can get 25 reps on your involved side with weight relative to your body weight, typically you're in a pretty good spot. If you can't get above 20, that seems to be the cutoff, and that's completely anecdotal, but seems to be the spot. And I think what's telling, as you saw in Dr. Meyer's presentation as well as this one out of Penn a couple of years ago, most patients have deficits and instability. And I think as opposed to ACL, where I think we've come a long way and we at least do some sort of physical testing, we're not very good at instability. We're still kind of back in the 90s. When I started, it was like, oh, are you four or five months? All right, you're good. Surely it's all back together. You'll be fine. And I think what we see is usually you are until you're not. And so I think really having a systematic approach that ensures the correct, the expected range of motion we have, what's our overhead elevation required for sport, what's our strength ratios isometrically, and then our posterior endurance. And that really sets us up now to begin the functional testing required and really think about how do we gradually walk this patient back into sport, which really leads to the last point. We have to match the sport demand and athlete capacity. And this Bern Consistence Statement, if you haven't read it, is outstanding. That really helps us think about what is the demand of the athlete and what's the capacity required to get there. So if you think about our journey, returning to sport, I mean, Kevin hit it great. Like, you got to start at the beginning. Like, it actually starts before surgery starts return to sport. I think we get in our mind, oh, return to sports at six months or five months or whatever. That's just actually the process of going through return to play, return to sport, and return to performance, and being able to set expectations with the athlete and consistently looking at our markers of rehabilitation, including pain and range of motion and strength as we incorporate kinetic change, psychological readiness, and then our sport-specific maneuvers. One of the biggest changes we've made to our criteria over the last two or three years has been based on the work out of Australia by Margie Olds, which really shows that this dynamic testing, and it's a wonderful paper where she really lays out this series of movements that allow you to dynamically challenge the shoulder. And so we've been doing some of the similar work that Dr. Meyer presented. But what's really interesting, we've asked the athletes before and after testing, and similar to them, it's about an hour, what you're saying before you start and what is it after. And all of them are exactly what Kevin said to the girl that jumped on the force plate, I'm ready, let's go. And then you take them through a strenuous pattern, and they're like, oh, I'm not as good as I thought I was. And so I think that port really sets us up, gives us a chance for success to achieve that. And just as a reminder, you can only prevent the recurrence one time. And I think we're, you know, it's always saying about, Champ Baker always said, best time to prevent shoulder dislocations before the second occurs, right? So I just think about that every time I do this presentation. Thank you, guys. Thanks for that talk. We have one more. We'll have the question and answer session. So Milo Calvo is going to come talk to us about whether to move or not move our rotator cuff patients. Thank you, good afternoon. It's a real pleasure to share with you this interesting topic. And thank you to the OSSM for inviting me to this session. This is a difficult topic, should we mobilize or immobilize our patients after rotator cuff repair? These are my disclosures. You know very well what the problem is. If we try to protect our rotator cuff, we take the risk of having stiffness after surgery. But if we do a too accelerated program of rehabilitation, the risk is return, which is also a major concern. And in this difficult scenario, we know that the world we live in and patients' compliance is different. And our patients want to be ready for daily activities and even for sports as soon as possible. So rotator cuff repair is a challenging situation. And trying to adapt the rehabilitation protocol to the tear is difficult. And this is the reason why probably there's not many consent, there's not a very important consensus among surgeons on how to proceed with these patients. You see in this paper that although the majority of surgeons recommend to keep immobilization up to the fourth or sixth postoperative week, there's no clear consensus as a very important variability among surgeons. This is a paper we published last year recently, and we could see that the more experienced the surgeon was, the less the time of immobilization was. So probably there's a relation between surgeon experience and immobilization length. But what are the purposes of immobilization after rotator cuff repair? First, we must ensure tendon healing, which is difficult sometimes. It's very important to try to control pain after surgery by patients. We should try to speed up recovery as much as possible, but also to ensure tendon healing. And in the end, our main purpose should be to obtain satisfactory clinical outcomes. Let's address first the tendon healing process. We know according to basic science that there's several phases in any tendon to be healed, from an inflammatory phase to proliferative phase. And in this proliferative phase, the fibers are already strong enough to start mobilization of the shoulder. And this takes place from the sixth to the eighth week after surgery. So we should try to keep our shoulders immobilized for about six to eight weeks after surgery. Theoretically, because if we analyze the rotator cuff tear healing process, it is a mechanosensitive process. So we know that tendons should be subjected to some kind of tension and stress to obtain a good healing compared to a complete immobilization. None of this, there are some data on the literature that immobilization creates fatty atrophy of the tendon. So we should protect tendon healing, but complete immobilization is not as good as we could think initially. How about clinical outcomes? There are several prospective randomized control studies in literature comparing early versus delayed mobilization after rotator cuff tear repair. And we can see there are no very, very important difference. It seems that it's the same at the end of six months. The final outcomes are the same comparing early versus delayed immobilization. But if we go deeper to this data, we can see that the majority of these studies analyze only small to medium-sized tears of rotator cuff tears. So probably this conclusion stands for small tears, but not for large tears. Moreover, there's no data about how to manage postoperatively suprascapular tears. No data in the literature how to do particularly these specific types of tears. So how about large tears? This is a paper by Lee that demonstrate that the larger the tear, the higher the risk of tear if we immobilize too soon the shoulder. Krasinski went even deeper to this analysis, and he could see that three centimeters were the cutoff point. Tears with less than three centimeters in diameter could be treated more aggressively and be immobilized earlier after surgery, but those tears with a diameter over three centimeters should be more conservatively treated and should be kept at least six weeks immobilized after surgery. So what kind of type of brace should we use? Should we do a Vagra brace? Should we do an abduction brace? An external rotation brace? There's not many data in literature. Most of these studies recommend, they show that there's no differences, but there is a paper coming from Mario Conti from Italy that shows that external rotation braces with slight abduction are better for controlling postoperative pain. And this is something that I've seen in my patients. If we use a sling with slight abductions, the degree of pain in the first week after surgery is lower than a conventional sling. How about patient factors? We try to treat the patient the same way, no matter how they are, but probably there are some patient factors that play an important role in how to manage this patient. Probably patients with rhetoric of atrophy, smokers, hypercholesterolemic patients, patients with diabetes or osteoporosis should be managed in a more conservative way. But not only patient factors, there are also important repair factors that can play a role. We know that patients with rhetoric of tear reduction with repairs under tension and not stable repairs, they should be managed more conservatively. So this is my protocol approach for this rhetoric of tear repair. I follow a hybrid protocol. So in small to medium-sized, stable-sized tears, I do immediate passive pulmonization. But if I'm dealing with a large, unstable tear with a difficult repair, I try to be more conservative and I delay therapy for six weeks. So I follow a conventional approach from phase one, one to six weeks postoperatively. I try to do passive range of movement. From six weeks, I try to regain strength and regain active range of movement. And 12 weeks after I start the strengthening and return to pain program. So thank you very much. I kindly invite you to attend the 4th Madrid Shoulder Meeting in November this year. Thank you. We have about five minutes for questions, so if anyone has questions, please feel free to come up to the microphones here. Kevin, did you want to start with any questions? So, the first question I have for Scott, you mentioned in terms of BFR and the benefits of it, is it too early to do one, or is it ever a time when it's too late to try an add-on? Is it too early to start BFR post-op? So, like I said, I like to do it. I will do a day one post-op on the contralateral side. So, I'm really striving for that systemic effect. How strong that is, it may vary, again, depending on the muscle that you're kind of stimulating and how much of those hormones can get released. I think if you're going to do it on the involved side, you just got to be mindful of, like I said with the Achilles stuff, wound healing. You don't want to open up, especially in Achilles repair, you don't want to open that wound up. In the case of an ACL, same type of thing. I don't think it's too early, as long as, like you said, you're getting good blood flow in and out of the tissue. Like, let's say you have an ACL and you're able to kind of bring the effusion down, and then it comes back a little bit more the next day, and there's some fluctuation in that, as opposed to just a knee that's totally effused all the time. Those are the ones where I'd be a little bit more cautious with. But if blood is flowing in and out, I think you're safe to kind of go there, as long as the incision is closed. And then, Kevin, you talked about, like, the importance of the pre-op motion, which I think we all can agree with, and there's a lot of data to support that. Now, a lot of us take care of elite athletes who have access to a lot of resources post-operatively and get a lot of attention early. Do you treat them any differently in terms of, do they have to get a certain amount of motion, and you're like, you know what, I know you're going to get three times a day rehab afterwards. Is it okay to go a little bit earlier? Is it okay to go earlier on surgery without less motion? Yeah, I mean, you know, that's a physician call and a patient call. You know, when I worked with Dr. Andrews for a lot of years, the pro athletes that would come in, I would say probably 70% of the patients I saw were having surgery within 7 to 10 days from the injury, and their knee was irritated, their knee was lost of motion. You can do it, it's just rehab is harder, you know, and everybody needs to be in sync. But to do that in a high-level athlete where there's trainers involved and PTs, I think, you know, you've got a better chance of success. But if you're dealing with a high school kid with limited visits or, you know, life events, you know, you have somebody who's a worker in the workforce, that's where you get into trouble with these patients, I think, by rushing the surgery. Yeah, I definitely agree with that. I think the resources and understanding where they're at and how much resources they have is important. And then you also mentioned, obviously, the importance of motion postoperatively. How soon should they have full motion? What would you say is a good target for people to have? Yeah, I mean, that's a great question. You know, a lot has to do with the individual and if there's meniscal pathology, repairs. Certainly, when you start talking about root tears that are repaired, ramps, that influences our range of motion quite a bit, particularly active range of motion. So, for me, with a patellar tending graph, I mean, full extension, you know, day one, people will talk about getting it on day one, but the reality is their knee is too irritated, in my mind. So, usually by day three, day four, we're emphasizing that quite a bit as far as extension. And we gradually get flexion. We've learned the hard way that we can get flexion later. If we push it early, we end up with a big effused knee in a lot of cases. Quad tendons, for me, are a lot more difficult to get hyperflexion with. And also, LETs with any type of graph is usually a little harder to get hyperflexion. So, that may not happen until 10 weeks, 12 weeks to get healed of glute flexibility. Yeah. I was saying earlier on my page that I noticed that LETs are a little bit slower to get that flexion. There's a question here. So there's definitely some pain mitigation aspects of blood flow restriction therapy. So if you're looking to maybe decrease pain a little bit, I think there is a use case for that. I think there's also a use case for maybe getting some increased activation. You can get through the type 1 into the type 2 fibers a little quicker using blood flow restriction. You're not going to, the goal is to fatigue the muscle. You're not going to get the same amount of delayed onset muscle soreness that you would with say traditional loading. However, I would be real, real mindful of how many reps and sets you're doing if you are doing blood flow restriction pre-activity, let's say. But there is a debate that goes back and forth, you know, should you start your treatment session with blood flow or should you end it, use it as a finisher? I think I've used it in both cases depending on what my goal is, right? So if my goal is to try to activate as many muscle units as I possibly can early in the treatment session, I'll use it first. If I want to make sure that that patient leaves the clinic and they're totally fatigued out, I'll end with it. So I think you just got to be mindful of what you're trying to do and what your goals are with regards to the activity. Yeah, we don't, I typically don't use it that way. I'm not seeing my patients before they run on the field or anything along those lines. So I would not use it, and I have not used it that way. But again, if you are trying to maybe activate some tissue a little bit more aggressively early on, I could see a use case for it. But again, I'd be very, very mindful of how many exercises, how long you're occluded for, those type of things. So it wouldn't be my first choice. We have a question over here. Yeah. So in a post-operative setting, what is your indication to move to like conventional loading? I've heard six weeks, like based on tissue healing timelines. And I've also heard like 40, 50 percent pre-injury, one rep max. So what do you usually typically as your indicator for moving out of BFR and to traditional loading? That's a great question. I think when they can handle load, they can handle load. Right. So I think if you progress through your BFR, adding resistance as you go, messing with the limb occlusion pressure, the pressures that you're using, I think all of those are guides to help you make that decision. I think time, depending on the injury, is obviously something that's going to be a factor, like, you know, an Achilles repair is obviously going to be a little bit different, say, than maybe an ACL reconstruction, depending on open chain, closed chain, you know, open chain, leg extension, squat. You know, that's going to play a little bit of a factor of it, too. Just like anything else, I think strengthening, it's just about progressively adding load. Right. So if you add load, they tolerate, you add a little bit more. They tolerate it. So you can do that with BFR as well, you know. So there are some studies out there that show, you know, even though you're using 80% occlusion pressure, you can still go more than 20 to 30% of the one rep max and get more benefit. So I think that's part of it, too. So the blood flow restriction is just a tool to aid in that, creating that fatigued environment. But like I said, also, there's no substitute for loading. So if you can load the tissue, load the tissue. The injury itself is going to play a factor. I use a lot with hamstring strains because, again, that's one situation where you got to be careful as to loading them too aggressively, too early on. And I use the BFR as a way to kind of stimulate the hamstring, let's say, but still at the same time protect it as much as I can. Awesome. Thanks. Chuck, I have a question for you. I think your battery is really important. I think what you're saying in terms of we need to catch up in the shoulders and stability compared to ACLs. Now, you listed all those different targets. Do they need to meet all those targets to progress or is there like seven out of ten need to be met? How are you and does that change by sport? Yeah. So I think probably the one thing that's quite different in the ACL versus shoulders depends what you're going back to, right? What I'm going to ask a contact athlete to do versus an overhead thrower versus somebody in maybe less contact is going to vary. I think the basic piece, if you will, in terms of the required range of motion, isometric test, posterior endurance and close kinetic chain test. That's everyone. And then I think the last part's really sports specific. And the more contact and the more overload, you've got to have more capacity and it takes longer to get there. And I think for me, at least, that's I think about wrestlers and there's a MMA fighting center in Greenville. And so we get all kinds of crazy contact athletes. Like, it's a different level of expectation that they have to demonstrate before I'm going to let them go back in. Yeah, makes sense. And then, Emilio, I got the last question for you. So you mentioned in your studies that or in your review there that small tears, you get moving right away passively. When should they start doing active motion and when do you expect them to have full motion? That's a very good question. So they should be allowed to move passively from the beginning, small tears. But I'm starting now allowing them to move actively when they have no pain. This means they start actively to movement two to three weeks after surgery. And I cannot give you data, but it seems it is not harmful for the healing process. Well, I think that's what we're at time here. So thanks, everyone. And enjoy the rest of the conference.

Brian C. Lau, MD

Kevin Wilk, PT, DPT

Alex Meyer, MD

Moin Khan, MD, MSc., FRCSC

Troy Blackburn, PhD, MS, BA

Scott Greenberg, PT, DPT, MBA, CSCS

Charles A. Thigpen, PhD, PT, ATC

Emilio Calvo, MD, PhD

rehabilitation

shoulder injuries

rotator cuff repairs

functional testing

cryotherapy

blood flow restriction

ACL injuries

neurocognitive exercises

shoulder instability

personalized protocols