Education

 

THE PHYSIO PRO ACL ENHANCEMENT PROGRAM: A CRITERION-BASED APPROACH IN TRANSITIONING THE POSTOPERATIVE ACL SAFELY BACK TO IMPACT ACTIVITES AND COMPETITION

Nathan Lilley MPT, OCS, CSCS

Traditional rehabilitation following ACL reconstruction has always been an ever-evolving practice.  We have gone from immobilization to accelerated rehab and everywhere in between as far as our rehab progressions.  Traditional rehab protocols have often utilized a time based approach to treatment progression.  This “cookbook” approach has often caused clinicians to push their patients more aggressively than appropriate.  Although post-operative time often has a strong influence in progression, not all patients fall within the “norms” at a given point in time.  Co-morbidities, age, complications with surgery and even differences between doctors surgical techniques and philosophies all come into play with rehab progression. It is the responsibility of the clinician to constantly assess and reassess the objective status of the patient to ensure patients progress with their rehabilitation appropriately.

One of the most controversial and challenging dilemma to the  clinician is knowing when to safely progress a patient from standard rehab (ROM ,PRE, Proprioception training, Etc.)  into impact and more sport specific training.  The purpose of the following protocol is to take a research derived criterion-based approach to progressing a patient all the way back to their given sport.  Soft tissue healing, graft selection and incorporation, dynamic stability, range of motion, and patient confidence all have be taken into account.  Specific clinical “mile stones” have been outlined and must be met before progressing into the next phase of training.  Following such guidelines allows us to safely monitor and control the many variables that go into progressing rehab as safely and quickly as possible.  The patient should be carefully monitored throughout this progression with the clinician watching for any signs of abnormal joint stress, effusion or pain.

Over the last 10 years, a wealth of research has been focused on ACL injury prevention.  Prevention programs have been shown to drastically decrease the incidence of catastrophic knee injuries as well as improve athletic performance.  Physio Pro has taken this information into account and incorporated an “enhancement/return to impact” program consisting of progressive plyometrics beginning at about 8 weeks post-operatively extending to the 4-6 month mark.  Once an athlete has completed the protocol they are put through a comprehensive return to sport test.  This too is criterion based.  If the clinician, athlete and surgeon all agree that the clinical goals are met, then medical release can be considered.

The risk factors of ACL injury have been well documented over the last twenty years.

Intrinsic factors such as notch width, tibial slope, recurvatum, and hormonal influences and many other variables are thought to contribute to ACL injuries. These are variables that we cannot control as therapists.  As clinicians, we turn our  focus to the extrinsic variables that can be modified and adapted through training that have been shown to contribute to catastrophic knee  injuries.  It is the purpose of this protocol to identify and teach our patients such risk factors and how to modify activities to decrease these risks after ACL reconstruction.

It has been estimated that up to 90% of all ACL injuries occur from non-contact mechanisms. Clinical studies have indicated that such injuries usually occur during a landing from a jump or from deceleration prior to a change in direction.  Usually this involves an awkward movement or a need to unexpectedly change direction directly prior to the injury.  The same studies have shown there usually is an apparent valgus or dynamic valgus in the coronal plane prior to injury.  This vulnerable position or “the point of no return” for ACL injury has been defined as internal femoral rotation, knee valgus, external tibial rotation, with foot pronation.  Knee flexion angles of 45 degrees or less have shown an increase in anterior tibial shear as the quadriceps is contracting eccentrically to slow the landing  momentum.  Athletes that demonstrate these mechanics are termed ligament dominant and very susceptible to injury.  During all phases of the protocol, we are constantly instructing our patients to minimize these faulty movement patterns stressing that our athletes land with strong athletic positioning utilizing the quads, hamstrings and gluteals to absorb and control the amount of shear at the knee through co-contraction. This form of training is referred to as plyometric exercise.

Plyometric exercise can be defined as an activity in which an eccentric muscle contraction (lengthening) is quickly followed by a concentric muscle contraction (shortening) and is repeated for a given duration. This process of contract-lengthen, contract-shorten is often referred to as the stretch – shortening cycle. Almost all athletic movements involve this stretch-shortening cycle.  Most injury rehabilitation programs fail to realize that an eccentric muscle contraction can be up to three times more forceful than a concentric muscle contraction. This is why plyometric exercises are important in the final stage of rehabilitation, to condition the muscles to handle the added strain of eccentric contractions.

 

THE PHYSIO PRO ACL ENHANCEMENT PROGRAM:

The first seven weeks of rehab are not outlined.  At Physio Pro we use our standard ACL-R protocol for the first seven weeks until the criteria to enter the impact protocol has been met.  Patients must meet the entry-level FTA criteria at a minimum of eight weeks.   We will not begin the program sooner 8 weeks post-op.   Progression of the program is at the discretion of the therapist/physician.   Sound clinical judgment is essential for safe progression.  If the criteria are not met then standard therapy will continue until objective measures are adequate.

There are a total of five phases of rehabilitation to complete before a safe return to competition can be considered.  Although estimated timeframes are outlined, not all patients will progress equally as there may be complicating factors that may hinder or expedite rehabilitation.  Below are the criteria for progression through the various phases of our protocol. Rehabilitation. Anticipated timelines and suggested interventions are found on the following pages.

Patients must commit themselves to a vigorous but safe 4 to 6 month rehab regime to insure safety and protection of their new ACL before returning to unrestricted activities.

Suggested Frequency of Training throughout the Impact Protocol: 3 days a week on non-consecutive days.

Exercise Dosage: Instead of sets and reps, Physio Pro uses time for almost all of our impact activities.  We usually start with 30 seconds and increase the time as indicated in 10-second increments.   As we begin to integrate patients back to impact activities, we need to “dose” the intensity, duration and amount of activity accordingly.  In the early phases of our protocol, we encourage clinicians to have their patients warm up adequately and start their program with the given Plyometric activities.  This is to prevent poor form secondary to muscular fatigue early in the protocol.  At the later stages we reverse this to challenge our patients while they are fatigued insisting they maintain good form throughout the activity   throughout the phases exercise duration will increase. The goal is to complete as many touches as possible using proper technique. If the athlete fatigues and loses proper technique, they should stop and rest until they can perform them properly again. At any point during the protocol if the patients loses form, or has joint pain the activity is stopped.

Resistance Training: We continue appropriate traditional progressive resistive exercise in conjunction with the impact protocol targeting muscle groups that display deficiencies.  Examples of traditional strength exercises extend far beyond the scope of this document.

Important Components to the Impact Protocol

1.      Choose you patients appropriately.  Not all patients need to reach this level of rehab. Know your patients and their ultimate goals.

2.      Follow functional testing criteria to assure safe participation/progression into the given phase of the program

3.      Know your physician.  Some surgeons want to prolong soft tissue healing times.  When in doubt, contact the doctor before progressing to more vigorous activity.

4.      Utilize Rest Breaks to restore short-burst creatine phosphate and fast glycolitic energy systems  Double or triple the time/duration for the desired exercise for its subsequent rest/recovery period.

5.      Encourage patients to be hydrated and properly nourished prior to vigorous exercise.

6.      Please consider proper footwear and use a firm but forgiving surface.

7.      Correct posture and body alignment is the focus for all phases.

8.      Utilize controlled quiet landings, landing in a toe → ball→ heel→ toe pattern for most jumps.(Activates the hamstring/quad co-contraction and minimizes joint reaction forces) Special situations requiring different landings will be discussed later in the program.

9.      Minimize amortization phase (landing of first jump should be the beginning of the next jump) This stresses good quick eccentric muscle control.

10.   Land with knees bent greater than 60 degrees of flexion.  After 60 degrees of flexion, the hamstrings and quadriceps work together through co-contraction.  The Quadriceps becomes an ACL agonist vs. antagonist.

11. Land with strong Athletic positioning with the feet shoulder width apart, the knees comfortably flexed, shoulders back, chest over the knees, and the center of balance over the balls of the feet.

12. Avoid Dynamic Valgus Moment or knock-knees positioning with landing

 

ESTIMATED WEEKS 8-10 IMPACT PHASE A : Entry Level Plyometrics

 

ROM	0-0-125
Effusion	Minimal to none, no joint line tenderness
Strength	65% quad
	50% HS/Quad Ratio
Special Testing	Satisfactory Lachman/Drawer
Functional Score	>6 score on Cinti Knee Rating System
Functional Testing	1 Minute Step Test > 60%,  Satisfactory squat test,   step-down tes

 

 

 

 

 

 

•   Shuttle-bilateral   (3x 20)
•  Shuttle-alternating (3 x20)
•  Lateral bounding in place (3x 30”)
• Slide Board (3 x 30”)
• Jog in place  (second week) (3 x 30”)
• High knees in place (second week)   (3x 30”)
• Gluteal kicks in place (second week)  (3x 30”)

ESTIMATED WEEKS 10-12 IMPACT PHASE B:  Transitional Plyometrics /Phase- Level I Agility

ROM	0-0-130
Effusion	Minimal to none, no joint line tenderness
Strength	70% quad
	60% HS/Quad Ratio
Special Testing	Satisfactory Lachman/Drawer
Functional Score	>6 score on Cinti Knee Rating System
Functional Testing	none

1.     Shuttle-bilateral grid jumps  (1x 20 CW, 1x 20 CCW)

2.     Shuttle-alternating  (2×20)

3.     Shuttle unilateral grid hops  (1x 20 CW, 1x 20 CCW)

4.     Lateral bounding in place – 3 point  (3×40”)

5.     Lateral bounding with rotation  (1 x 30” R,  1×30” L)

6.     Step work: Quick feet (second week)  (1 x 30”)

7.     Step work: Ali shuffle  (second week) (1 x 30”)

8.     Step work: Lateral quick feet  (second week) (1 x 30”)

9.     Step work: Lateral skaters (second week) (1 x 30”)

10.  Return to jogging program (treadmill)  (second week)  (3W-1J-1W-3J-3W-5J- 1W progression)

ESTIMATED WEEKS 12-14 IMPACT PHASE C:  Level II Agility, Sport Specific  Movement

ROM	0-0-135
Effusion	Minimal to none, no joint line tenderness
Strength	75% quad
	60-65% HS/Quad Ratio
Special Testing	Satisfactory Lachman/Drawer
Functional Score	>7 score on Cinti Knee Rating System
Functional Testing	No pain, gait deviation with 10 min TM jog

Continue jogging program on treadmill 2-3 days a week on non-protocol days

1.     Jump Rope: Bilateral  (1 x 1’)

2.     Jump Rope: Alternating ( 1’ R, 1’ L)

3.     Step work: Quick feet  (2x 30”)

4.     Step work: Lateral quick feet  (2 x30”)

5.     Step work: Ali shuffle  (2×30”)

6.     Step work: Lateral skaters  (2×30”)

7.     Lateral Bounding with Rotation- 3 point  (2 x 30” R, 2 x 30”L)

8.     Sport cord: Forward   (1/2 speed) (2 x 20)

9.     Sport Cord: Backwards (1/2 speed) (2 x20)

10.  Sport Cord: 3 point Lateral Bounding (2x 30” R, 2 x 30”L)

11.  Dynamic Sports routine (second week) (1x)

12.  Agility Ladder: “High Knees” (second week) (3x)

13.  Agility Ladder: Lateral “High Knees” (second week) (3x)

14.  Agility Ladder: Lateral Quick Feet “Ins and Outs” (front lead) (second week) (3x)

15.  Agility Ladder: Lateral  Quick Feet “Ins and Outs “(back lead) (second week)(3x)

16.  Agility Ladder: “Ali Shuffle” (second week) (3x)

17.  Agility Ladder: “Icky Shuffle” (second week) (3x)

ESTIMATED WEEKS 14-16 IMPACT PHASE D:  Level III Agility, High Level Sport Specific Movement

ROM	Within 90% contralateral limb
Effusion	Minimalto none, no joint line tenderness
Strength	75  to 80% quad
	65-70% HS/Quad Ratio
Special Testing	Satisfactory Lachman/Drawer
Functional Score	>7 score on Cinti Knee Rating System
Functional Testing	SL hop 50% ,  Broad Jump with sound mechanics

Continue Jogging program and transition to outdoors.

1.     Dynamic Sports routine (warmup)

2.     Sport cord: Forward   (3/4 speed) (2x 20)

3.     Sport Cord: Backwards (3/4 speed) (2 x20)

4.     Sport Cord: Lateral Shuffles (1 x 20 R, 1x 20 L)

5.     Sport Cord:  3 Point Lateral Bounding with Rotation (2x 30”R, 2 x30”L)

6.     Sport Cord: 3 Point Drill Forward(second week) (20x)

7.     Sport Cord: 3 Point Drill Backward(second week) (20x)

8.     Agility Ladder: “High Knees”  (4x)

9.     Agility Ladder: Lateral “High Knees” (4x)

10.  Agility Ladder: Lateral Quick Feet “Ins and Outs”(front lead) (4x)

11.  Agility Ladder: Lateral  Quick Feet “Ins and Outs” (back lead) (4x)

12.  Agility Ladder: “Ali Shuffle “ (4x)

13.  Agility Ladder: “Icky Shuffle”  (4x)

IMPACT PHASE E:  Physio Pro Jump Program ESTIMATED WEEKS 16-22  (Minimum Criteria to Enter Full Plyometric Program)

6 days a week X 6 weeks           ( 3 Days Plyometrics / 3 Days Functional Strengthening)

ROM	Within 90% contralateral limb
Effusion	Minimal to none, no joint line tenderness
Strength	75  to 80% quad
	65-70% HS/Quad Ratio
Special Testing	Satisfactory Lachman/Drawer
Functional Score	>7 score on Cinti Knee Rating System
Functional Testing	SL hop 60% ,  Broad Jump with sound mechanicsGood form with eccentric step-down test

Dynamic Sports Routine Warm Up (All 6 Weeks)

Functional Strengthening (All 6 Weeks, Every Other Day, Non-Jump Days)

1.     Hip Hinges:  Sustained Isometric Squat

2.     Cook Hip Lift

3.     Fire Hydrants

4.     Split Leg Squat/Chair Dip

5.     Plank x 4

6.     Multidirectional Lunge

7.     Unilateral Straight Leg Dead Lift

8.     Straight Leg Abduction with External Rotation

9.     Lunge Walk

Plyometrics Phase I: 2 Weeks, 3x a week

1.     Wall/Block Jump

2.     Broad Jump

3.     Squat/Vertical Jump

4.     180/Half Spin Jump

5.     Lateral Bounding In Place

6.     Scissors/Rudder Jump

7.     Richochets- Bilateral- Side to Side

8.     Richochets- Bilateral- Back to Front

Plyometrics Phase II:  2 Weeks, 3x a week         (continue dynamic warm-up and functional strengthening)

1.     Wall/Block Jump

2.     Tuck Jump

3.     Jump, Jump, Jump, Vertical Jump

4.     Squat/Vertical Jump

5.     Lateral Bounding for Distance

6.     Scissors/Rudder Jump

7.     Richochets- Bilateral- Side to Side

8.     Richochets- Bilateral- Back to Front

9.     Richochets- Unilateral- Side to Side

10.  Richochets- Unilateral- Back to Front

11.  Hop, Hop, Hop Stick

Plyometrics Phase III: 2 Weeks,  3x a week              (continue dynamic warm-up and functional strengthening)

1.     Squat/Vertical Jump

2.     Jump Up, Jump Down, Vertical Jump

3.     Tuck Jump

4.     Scissors/Rudder Jump

5.     Jump Into Bounding for Distance

6.     Richochets- Bilateral- Side to Side

7.     Richochets- Bilateral- Back to Front

8.     Richochets- Unilateral- Side to Side

9.     Richochets- Unilateral- Back to Front

10.  Single Leg hop and Stick

4-6 Months Post-Op (Return to Competition Criteria)

ROM	Within 90% contralateral limb
Effusion	Trace to none, no JLT
Strength	80 to 85% quad or greater
	70-75% HS/Quad Ratio
Special Testing	Satisfactory Lachman/Drawer
Functional Score	> 8 score on Cinti Knee Rating System
Functional Testing	SL hop >85%, Pass RTC criteria
Physician Clearance	Must have prior to release

 

When a group of cells are damaged with surgery, injury or repetitive stress, proper nutrition has a profound effect on the speed of their recovery. Every cell in the human body requires proper nutrition to grow, divide and function properly. Our bodies are constantly replacing our cells as we live our lives.  It is estimated that muscle cells are completely replaced with new muscle cells about every six months.  This also occurs with bone, blood and other soft tissues.  Without proper nutrition, this cycle does not function properly.

Damaged cells affected by an injury become hypoxic or lacking oxygen secondary to swelling in the surrounding tissues of that cell.  Without oxygen the cell will die and need to be replaced.  The new cells health will depend on your specific nutritional status at that time. Poor nutrition has also been linked to extended inflammatory processes in the body.

Carbohydrates, proteins, fats, vitamins and mineral as well as water must be balanced correctly for optimum healing to take place.  Each meal should contain 30% from Proteins, 30% from healthy fats, and 40% from complex carbohydrates.  The daily caloric needs vary from person to person.

During the waking hours the body needs food about every four hours to maintain adequate glucose levels.  It is recommended to eat 5 to 6 small meals a day.  This is to prevent insulin surges, as they will disrupt the steady intake of nutrients to the healing tissues.  Eating frequently and watching your protein to carb ratios can achieve this.  (3 parts protein to 4 parts carbs are recommended)

Staying hydrated is another important component of providing a healthy environment for healing tissues.  Muscle function is decreased by 30% with dehydration.  If exercising over one hour, sports drinks such as Gatorade may be beneficial to replace lost electrolytes.

Healing Foods:  “The Good”

• Whole Grains: wheat, corn, buckwheat, rye, millet, barley, whole grain breads, cereals, pancakes, muffins, brown rice, wheat germ or bran
• Legumes, Nuts, and Seeds:  soybeans or soy products (tofu), black-eyed peas, lima beans, pinto beans, sesame seeds, pumpkin seeds, sunflower seeds, macadamia nuts, almonds, chestnuts, walnuts
• Vegetables: spinach, collard greens, arugula lettuce, kale, watercress, Brussels sprouts, broccoli, cauliflower, yams, carrots, onions, garlic, cabbage, winter squash
• Vegetable oils: extra virgin olive oil
• Fruits: all fresh fruits, dried figs, raisons, dates, prunes and apricots.
• Dairy: skim or low-fat milk
• Animal Proteins:  fish (cold water preferred), salmon, mackerel, sardines, non-processed chicken, turkey and eggs
• Sweetener: Honey

Foods to Avoid:  “The Bad”

• Red and Processed Meats: These release bad prostaglandins which can elevate the inflammatory process
• Cheese, Butter, Ice Cream, Whipped Cream, Hydrogenated vegetable oils, White flour products
• High Fructose Corn Syrups: Avoid all processed or refined sugars as they can cause abrupt insulin surges.  Use honey instead.
• Caffeine: Simulates muscle tension and is a diuretic which can cause us to urinate important nutrients before the body can use them
• Alcohol: Dehydrates our system, limit to two drinks per day, Red wine is better 

Vitamins and Minerals In Rehabilitation

Healing cells also require various minerals and vitamins to develop quickly and perform at an optimum level.  It is best to get these nutrients through a healthy diet, but when the body is healing from a surgery or injury, supplemental vitamins can expedite the process.  Like food, the body can only absorb nutrients at a specific rate.  If not absorbed, the remaining minerals will be filtered and passed through the urinary system. Do not drink caffeine within thirty minutes of taking a supplement or they will not be absorbed and passed through the urinary system. To maximize uptake from the body, it is recommended to take no more than 500-600mg of one vitamin or supplement at one time.  It is better to spread them out through the day.  Thus, a one-time daily multivitamin may not fulfill your body’s daily needs.

Vitamin C: (Muscle and Tendon strains) Best to get through fruits and vegetables, essential for soft tissue healing    Recommended dose of 1-3 grams (1000 through 3000mg per day)

B-Complex Vitamins: B6 Prevents muscle cramps, improves nerve function, and regulates fluid levels.  No limit on dosage.

Calcium: (Fractures, Rotator Cuff Repairs, ACL reconstruction, Total joint replacements, muscle and tendon injuries) Important for mm, nerve, and bone function. Recommended dosages: 1500 mg/per day for females, 1200 mg/per day for males or females on hormone replacement therapy.

Vitamin D: Aids in calcium uptake in the body.  Recommended dosage: 1200 mg/day

Other Beneficial Supplements for Rehabilitation

Dietary supplements have become a multi-million dollar business in the USA.  Many of them have little to no scientific support to back them.  The following list has had the most research regarding their potential use for therapeutic benefit.

Glucosamine and Chondroitin:  (Osteoarthritis and Osteochondral Injuries) In theory, glucosamine helps to prevent the breakdown of cartilage as they produce cartilage-building proteins.  Chondroitin is thought to aid in fighting inflammation and in inhibiting the production of cartilage destroying enzymes.  Consumer Reports recommends Kirkland Signature (Costco), Spring Valley (Wal-Mart) and Target Triple Strength brands.  Expensive brands bought at nutrition stores often add other supplements to their products that have little to no medical backing.  These should not be taken with shellfish allergies or if you have a clotting disorder.

Avocado/Soybean Oils: These may reduce the needs for painkillers to treat osteoarthritis in the hips but not the knees.  The oils have protected joint cartilage in animal research.

Ginger: May have pain-relieving and anti-inflammatory properties.

MSM: A compound containing sulfur.  May decrease pain and swelling as well as improve joint function.

References:

Repetitive Strain Injuries: The Complete Guide to Alternative Treatment and Prevention Jameson,Timothy J, 1998

Consumer Reports, June 2006

*****These are nutritional guidelines.  Physio Pro, P.C. are not registered dieticians.  Please consult your physician before changing or beginning a new diet. *****

What Is Osteoarthritis?

Osteoarthritis (OA) is the leading cause of disability in the USA. It is estimated that 1 out of 3 adults will suffer from arthritis. By definition osteoarthritis or degenerative joint disease (DJD) is a progressive disorder involving inflammation and degradation of the articular or hyaline cartilage on the ends of bones in various joints of the body. The affected cartilage usually develops small tears in the joint surfaces that begin to progress into larger more substantial areas of wear. In normal joints, articular cartilage is capable of repairing minor wear through chondrocyte production which are cells that form new cartilage. When the damage rate becomes too significant and continuous, these cells can no longer repair the affected area. When this happens the process of degenerative joint disease begins. As this disease progresses, eventually the cartilage will wear out to a point where the underlying bone becomes exposed. When this happens in a joint, the bones connecting the joint rub together resulting in pain and joint inflammation. This is where the term “bone on bone” comes from. Although it is primarily found in weight bearing joints (knees and hips), it also occurs in non-weight bearing joints such as the shoulder.

DJD symptoms usually begin as stiffness (especially in the AM), pain with prolonged weight-bearing or immediately following activity, swelling, crepitus (audible grinding or ratcheting) and loss of motion. Symptoms vary from person to person and joint to joint.

The knee joint is one of the sites most commonly to be associated with OA. The knee joint is a hinge joint, which connects the large upper leg bone (femur) to the lower leg bone (tibia). In the knee, there are two unique structures called the menisci. One is on the inside weight bearing surface of the tibia (medial meniscus) and one is on the outside of the tibia. The meniscus is a spongy type of cartilage known as fibrocartilage which functions to cushion the knee much like the shocks on a car. These structures act as cushions for the ends of the bone and to protect the hyaline or articular cartilage on the ends of the bones. In addition, the meniscus is concave in shape to accommodate the convex shape of the femur. This shape allows the weight of the body to evenly be distributed to the femur and allow the amount of contact pressure of the femur to be diminished. When the meniscus is damaged, the contact pressures on the femur increase. In young and active individuals, meniscal injuries usually happen from trauma from sports or other high level activities. In older adults, the meniscus can begin to fray and degenerate without specific trauma. Over time, if the process continues the meniscus will fray, continue to tear and eventually fail exposing the articular cartilage to the increased contact pressures. This exposure can lead to an osteochondral defect (OCD) in the articular cartilage which resembles a “pothole” on the weight bearing surface of the joint. An OCD is uncapable of healing itself. Once an OCD is present it will expose the underlying bone. This bone has a rich nerve supply which unlike the articular cartilage is painful with compression such as weight bearing. Overtime, the OCD will continue to wear and begin to get larger and larger until the majority or all the articular cartilage is worn down to the bone. In end stage OA, a visible joint deformity is often noted. This is do to loss of space from the degradation of the meniscus. On X-rays, the bones will appear to be “kissing”.

The hip joint is a little different than the knee. This joint is a ball and socket joint and is the most stable joint in the body. In hip arthritis, the two affected joint surfaces are the femoral head and the hip socket known as the acetabulum. The disease progression is very similar in nature to that of the knee.

Symptoms of OA in the hip are commonly groin pain with occasional buttock or lateral hip pain. Stiffness with rotating the leg in and out as well a stiffness going from the seated to standing position are also common

The shoulder joint is also a ball and socket joint. Opposite to that of the hip, it is the most mobile joint in the body. OA is less common due to the fact that the shoulder is a non-weightbearing joint. The two affected joint surfaces are the humeral head and the shoulder socket known as the glenoid fossa. Many times, progressive rotator cuff disease and ultimate cuff failure (rotator cuff arthropathy) begin the degeneration of the articular cartilage in the shoulder. Symptoms of OA in the shoulder are commonly lateral arm pain with the inability to move the arm through its full range of motion. In the later stages, “catching”, “ratcheting” and “popping” as very common with progressive loss of are motion and significant pain to follow.

A step-by-step approach is the common treatment for OA. This progression begins with conservative care and progresses to total joint replacement at end stage OA.

• Anti-inflammatory drugs: Your doctor will often prescribe a trial of NSAID’s (non-steroidal anti-flamatory drugs) such as Aleve, ibuprofen, Celebrex, Mobic, Advil, Naprosyn, etc.
• Physical Therapy: A trial of physical therapy is often prescribed at the same time as NSAIDS. Therapy will address joint restrictions, loss of strength, and flexibility as well as pain modulation. Many times, physical therapy will deter the progression of DJD. Generalized deconditioning is very common with arthritic joints. Skilled physical therapists will identify muscular imbalances and specific joint restrictions, which will improve joint function and overall strength and conditioning. Various therapeutic modalities in PT are helpful for pain modulation. Since OA is a progressive and chronic disorder, our clinic utilizes moist heat in conjunction with inferential electrical stimulation (IFC) or transcutaneus electrical nerve stimulation (TENS). Ice is only encouraged with an acute arthritic flare-up. The main-stay of conservative care for OA, are joint-sparing progressive resistive exercise as well as manual therapy for promotion of motion and joint lubrication. The phrase “Motion is Lotion” is the key for arthritic joints. The right exercise is essential to slow the progression of DJD and promote joint and overall health.
• Glucosamine and Chondroitin Supplementation: In theory, glucosamine helps to prevent the breakdown of cartilage as they produce cartilage-building proteins. Chondroitin is thought to aid in fighting inflammation and in inhibiting the production of cartilage destroying enzymes. Consumer Reports recommends Kirkland Signature (Costco), Spring Valley (Wal-Mart) and Target Triple Strength brands. Expensive brands bought at nutrition stores often add other supplements to their products that have little to no medical backing. Should not be taken with shellfish allergies or if you have a clotting disorder.
• Cortisone injections: Your doctor may recogmend a steroid injection which can decrease some of the inflammatory properties of OA. This has been a classic treatment option for management of OA.
• Viscosupplementation injections: Another option your doctor may discuss with you are a new type of injection which involves injecting hyaluronic acid (HA)in order to improve lubrication and to thereby reduce the inflammation of the joint. Hyaluronic acid is a nature substance in the fluid within the knee. As the OA progression occurs, the body stops producing HA in its normal amount. There are currently five different companies offering products for viscosupplementation. A series of three to five injections spaced one week apart are the current protocol at this time. Anywhere from 50 to 75% of patients express relief with this treatment.
• Surgical Intervention: The last and final treatment for end stage OA would be total joint arthroplasty. (TJA) This should be the last option to consider. Before considering a TJA, a patient should be in constant pain the significantly limits their capacity for activities of daily living or occupational duties.