Clinical Orthopaedic Rehabilitation: A Team Approach, 4th Edition PDF

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Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at expertconsult.inkling.com and may not be transferred to another party by resale, lending, or other means. CLINICAL ORTHOPAEDIC REHABILITATION A Team Approach This page intentionally left blank Fourth Edition CLINICAL ORTHOPAEDIC REHABILITATION A Team Approach Charles E. Giangarra, MD Robert C. Manske, PT, DPT, MEd, Professor, Chief SCS, ATC, CSCS Division of Sports Medicine Professor and Chair Department of Orthopedic Surgery Department of Physical Therapy Marshall University Wichita State University Joan C. Edwards School of Medicine Via Christi Sports and Orthopedic Physical Huntington, West Virginia; Therapy Head, Team Physician Via Christi Sports Medicine, Department of Athletics Teaching Associate Marshall University, Department of Community Medicine Sciences Assistant Team Physician, Orthopaedic Consultant University of Kansas Medical Center Kentucky Christian University Via Christi Family Practice Sports Medicine Grayson, Kentucky Residency Program Wichita, Kansas; Teaching Associate Department of Rehabilitation Sciences University of Kansas Medical Center Kansas City, Kansas 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 CLINICAL ORTHOPAEDIC REHABILITATION: A TEAM APPROACH, ISBN: 978-0-323393706 FOURTH EDITION Copyright © 2018 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechani- cal, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2011, 2003, and 1996. Library of Congress Cataloging-in-Publication Data Names: Giangarra, Charles E., editor. | Manske, Robert C., editor. Title: Clinical orthopaedic rehabilitation : a team approach / [edited by] Charles E. Giangarra, Robert C. Manske. Description: Fourth edition. | Philadelphia, PA : Elsevier, | Includes bibliographical references and index. Identifiers: LCCN 2016049212| ISBN 9780323393706 (pbk. : alk. paper) | ISBN 9780323477901 (eBook) Subjects: | MESH: Orthopedic Procedures--methods | Musculoskeletal Diseases--rehabilitation | Musculoskeletal System--injuries | Wounds and Injuries--rehabilitation | Rehabilitation--standards | Evidence-Based Medicine--methods Classification: LCC RD797 | NLM WE 168 | DDC 616.7/06515--dc23 LC record available at https://lccn.loc.gov/2016049212 Executive Content Strategist: Dolores Meloni Content Development Specialist: Lisa Barnes Publishing Services Manager: Deepthi Unni Senior Project Manager: Beula Christopher Senior Book Designer: Margaret Reid Printed in United States of America. Last digit is the print number: 9 8 7 6 5 4 3 2 1 CONTRIBUTORS David W. Altchek, MD S. Brent Brotzman, MD Co-Chief, Sports Medicine and Shoulder Service, Assistant Clinical Professor Attending Orthopedic Surgeon Department of Orthopaedic Surgery Hospital for Special Surgery, University of Texas at San Antonio Health Sciences Center Professor of Clinical Orthopedic Surgery San Antonio, Texas; Weill Medical College, Assistant Professor Medical Director, New York Mets Department of Pediatrics New York, New York Texas A&M University System Health Sciences Center College Station, Texas; Michael Angeline, MD Former Division NCAA Team Physician Section of Orthopaedic Surgery Department of Athletics The University of Chicago Medical Center Texas A&M University–Corpus Christi Chicago, Illinois Corpus Christi, Texas; Section Chief Jeff Ashton, PT Department of Orthopaedic Surgery Staff Physical Therapist North Austin Medical Center, Cabell Huntington Hospital Private Practice Huntington, West Virginia North Austin Sports Medicine Medical Center Austin, Texas Jolene Bennett, PT, MA, OCS, ATC, Cert MDT Spectrum Health Rehabilitation and Sports Medicine Services Jason Brumitt, PT, PhD, ATC, CSCS Grand Rapids, Michigan Assistant Professor of Physical Therapy School of Physical Therapy Allan Besselink, PT, Dip MDT George Fox University Director, Smart Sport International, Newberg, Oregon Director, Smart Life Institute, Adjunct Assistant Professor David S. Butler, BPhty, MAppSc, EdD Physical Therapist Assistant Program Neuro Orthopaedic Institute Austin Community College University of South Australia Adelaide Austin, Texas South Australia Australia Sanjeev Bhatia, MD R. Matthew Camarillo, MD Naval Medical Center, San Diego Department of Orthopedics San Diego, California; University of Texas at Houston Department of Orthopaedic Surgery Houston, Texas Rush University Medical Center Chicago, Illinois Mark M. Casillas, MD The Foot and Ankle Center of South Texas Lori A. Bolgla, PT, PhD, MAcc, ATC San Antonio, Texas Associate Professor Department of Physical Therapy in the College of Allied Bridget Clark, PT, MSPT, DPT Health Sciences Athletic Performance Lab, LLC Department of Orthopaedic Surgery at the Medical College of Austin, Texas Georgia The Graduate School Alexander T. Caughran, MD Augusta University Chief Resident Augusta, Georgia Department of Orthopedic Surgery Marshall University Joan C. Edwards School of Medicine Huntington, West Virginia Michael D’Amato, MD HealthPartners Specialty Center Orthopaedic and Sports Medicine St. Paul, Minnesota v vi Contributors George J. Davies, DPT, MEd, PT, SCS, ATC, LAT, Charles E. Giangarra, MD CSCS, PES, FAPTA Professor, Chief Professor Division of Sports Medicine Department of Physical Therapy Department of Orthopedic Surgery Armstrong Atlantic State University Marshall University Savannah, Georgia Joan C. Edwards School of Medicine Huntington, West Virginia; Michael Duke, PT, CSCS Head, Team Physician North Austin Physical Therapy Department of Athletics Austin, Texas Marshall University, Assistant Team Physician, Orthopaedic Consultant Christopher J. Durall, PT, DPT, MS, SCS, LAT, CSCS Kentucky Christian University Director of Physical Therapy Unit Grayson, Kentucky Student Health Center University of Wisconsin, La Crosse Charles Andrew Gilliland, BS, MD La Crosse, Wisconsin Clinical Assistant Professor Department of Orthopedic Surgery Todd S. Ellenbecker, DPT, MS, SCS, OCS, CSCS Marshall University Group/Clinic Director Joan C. Edwards School of Medicine Physiotherapy Associates Scottsdale Sports Clinic, Huntington, West Virginia National Director of Clinical Research Physiotherapy Associates, John A. Guido, Jr., PT, MHS, SCS, ATC, CSCS Director, Sports Medicine–ATP Tour Clinical Director Scottsdale, Arizona TMI Sports Therapy Grand Prairie, Texas Brian K. Farr, MA, ATC, LAT, CSCS Director, Athletic Training Educational Program J. Allen Hardin, PT, MS, SCS, ATC, LAT, CSCS Department of Kinesiology and Health Education Intercollegiate Athletics The University of Texas at Austin The University of Texas at Austin Austin, Texas Austin, Texas Larry D. Field, MD Maureen A. Hardy, PT, MS, CHT Director, Upper Extremity Service Director Mississippi Sports Medicine and Orthopaedic Center, Rehabilitation Services St. Dominic Hospital Clinical Associate Professor Jackson, Mississippi Department of Orthopaedic Surgery University of Mississippi Medical School Timothy E. Hewett, PhD, FACSM Jackson, Mississippi Professor, Director of Biomechanics Sports Medicine Research and MST Core, Mayo Clinic G. Kelley Fitzgerald, PhD, PT Mayo Clinic Biomechanics Laboratories and Sports Medicine University of Pittsburgh Center School of Health and Rehabilitation Sciences Departments of Orthopedics, Physical Medicine and Pittsburgh, Pennsylvania Rehabilitation and Physiology and Biomedical Engineering Mayo Clinic Rachel M. Frank, BS Rochester and Minneapolis, Minnesota Department of Orthopaedic Surgery Rush University Medical Center Clayton F. Holmes, PT, EdD, MS, ATC Chicago, Illinois Professor and Founding Chair Department of Physical Therapy Tigran Garabekyan, MD University of North Texas Health Science Center at Fort Worth Assistant Professor Forth Worth, Texas Department of Orthopedic Surgery Marshall University Barbara J. Hoogenboom, EdD, PT, SCS, ATC Joan C. Edwards School of Medicine Associate Professor Huntington, West Virginia Physical Therapy Associate Director Grand Valley State University Neil S. Ghodadra, MD Grand Rapids, Michigan Naval Medical Center, San Diego San Diego, California; James J. Irrgang, PhD, PT, ATC Department of Orthopaedic Surgery Director of Clinical Research Rush University Medical Center Department of Physical Therapy Chicago, Illinois University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Contributors vii Margaret Jacobs, PT Sameer Lodha, MD Momentum Physical Therapy and Sports Rehabilitation Department of Orthopaedic Surgery San Antonio, Texas Rush University Medical Center Chicago, Illinois R. Jason Jadgchew, ATC, CSCS Department of Orthopedic Surgery Janice K. Loudon, PT, PhD, SCS, ATC, CSCS Naval Medical Center Associate Professor San Diego, California Department of Physical Therapy Education Rockhurst University David A. James, PT, DPT, OCS, CSCS Kansas City, Missouri Associated Faculty Physical Therapy Program Adriaan Louw, PT, MAppSc (Physio), CSMT University of Colorado Instructor Denver, Colorado International Spine and Pain Institute, Instructor John J. Jasko, MD Neuro Orthopaedic Institute, Associate Professor Associate Instructor Department of Orthopedic Surgery Rockhurst University Marshall University Story City, Iowa Joan C. Edwards School of Medicine Huntington, West Virginia Joseph R. Lynch, MD Associate Professor Drew Jenk, PT, DPT Uniformed Services University of the Health Sciences Regional Clinical Director Bethesda, Maryland; Sports Physical Therapy of New York The Shoulder Clinic of Idaho Liverpool, New York Boise, Idaho W. Ben Kibler, MD Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS Medical Director Professor and Chair Shoulder Center of Kentucky Department of Physical Therapy Lexington, Kentucky Wichita State University Via Christi Sports and Orthopedic Physical Therapy Theresa M. Kidd, BA Via Christi Sports Medicine, North Austin Sports Medicine Teaching Associate Austin, Texas Department of Community Medicine Sciences University of Kansas Medical Center Kyle Kiesel, PT, PhD, ATC, CSCS Via Christi Family Practice Sports Medicine Residency Associate Professor of Physical Therapy Program University of Evansville Wichita, Kansas; Evansville, Indiana Teaching Associate Department of Rehabilitation Jonathan Yong Kim, CDR Sciences University of Kansas Medical Center University of San Diego Kansas City, Kansas San Diego, California Matthew J. Matava, MD Scott E. Lawrance, MS, PT, ATC, CSCS Washington University Assistant Professor Department of Orthopedic Surgery Department of Athletic Training St. Louis, Missouri University of Indianapolis Indianapolis, Indiana Sean Mazloom, MS Medical Student Michael Levinson, PT, CSCS Chicago Medical School Clinical Supervisor Chicago, Illinois Sports Rehabilitation and Performance Center, Rehabilitation Department John McMullen, MS, ATC Hospital for Special Surgery, Director of Orthopedics-Sports Medicine Physical Therapist Lexington Clinic/Shoulder Center of Kentucky New York Mets, Lexington, Kentucky Faculty Columbia University Physical Therapy School Morteza Meftah, MD New York, New York Ranawat Orthopaedic Center New York, New York viii Contributors Erik P. Meira, PT, SCS, CSCS Ryan T. Pitts, MD Clinical Director Metropolitan Orthopedics Black Diamond Physical Therapy St. Louis, Missouri Portland, Oregon Marisa Pontillo, PT, DPT, SCS Keith Meister, MD Penn Therapy and Fitness Weightman Hall Director, TMI Sports Medicine Philadelphia, Pennsylvania Head Team Physician, Texas Rangers Arlington, Texas Andrew S.T. Porter, DO, FAAFP Director Scott T. Miller, PT, MS, SCS, CSCS Sports Medicine Fellowship Program Agility Physical Therapy and Sports Performance, LLC University of Kansas School of Medicine- Wichita at Via Portage, Michigan Christi, Director Josef H. Moore, PT, PhD Osteopathic Family Medicine Residency Program Professor Kansas City University at Via Christi Army-Baylor DPT Program Wichita, Kansas Waco, Texas Christie C.P. Powell, PT, MSPT, STS, USSF “D” Donald Nguyen, PT, MSPT, ATC, LAT Co-Owner and Director ATEP Clinical Coordinator and Assistant Athletic Trainer CATZ Sports Performance and Physical Therapy, for Rowing Director of Physical Therapy University of Texas at Austin Lonestar Soccer Club, Austin, Texas Director of Physical Therapy Austin Huns Rugby Team Cullen M. Nigrini, MSPT, MEd, PT, ATC, LAT Austin, Texas Elite Athletic Therapy Austin, Texas Daniel Prohaska, MD Advanced Orthopedic Associates Steven R. Novotny, MD Wichita, Kansas Associate Professor Department of Orthopedic Surgery Matthew T. Provencher, MD, CDR, MC, USN Marshall University Associate Professor of Surgery Joan C. Edwards School of Medicine Uniformed Services University of the Health Sciences, Huntington, West Virginia Director of Orthopaedic Shoulder, Knee, and Sports Surgery Department of Orthopaedic Surgery Michael J. O’Brien, MD Naval Medical Center, San Diego Assistant Professor of Clinical Orthopaedics San Diego, California Division of Sports Medicine Department of Orthopaedics Emilio “Louie” Puentedura, PT, DPT, GDMT, Tulane University School of Medicine OCS, FAAOMPT New Orleans, Louisiana Assistant Professor Department of Physical Therapy Sinan Emre Ozgur, MD University of Nevada, Las Vegas Chief Resident Las Vegas, Nevada Department of Orthopedic Surgery Marshall University Amar S. Ranawat, MD Joan C. Edwards School of Medicine Associate Professor of Orthopaedic Surgery Huntington, West Virginia Weill Cornell Medical College, Associate Attending Orthopaedic Surgeon Mark V. Paterno, PhD, PT, MS, SCS, ATC New York-Presbyterian Hospital, Coordinator of Orthopaedic and Sports Physical Therapy Associate Attending Orthopaedic Surgeon Sports Medicine Biodynamics Center Hospital for Special Surgery Division of Occupational and Physical Therapy Ranawat Orthopaedic Center Cincinnati Children’s Hospital Medical Center, New York, New York Assistant Professor Division of Sports Medicine Department of Pediatrics University of Cincinnati Medical Center Cincinnati, Ohio Contributors ix Anil S. Ranawat, MD Michael D. Rosenthal, PT, DSc, SCS, ECS, Assistant Professor of Orthopaedic Surgery ATC, CSCS Weill Cornell Medical College, Assistant Professor Assistant Attending Orthopaedic Surgeon Doctor of Physical Therapy program New York-Presbyterian Hospital, San Diego State University Assistant Attending Orthopaedic Surgeon San Diego, California Hospital for Special Surgery Ranawat Orthopedic Center Felix H. Savoie III, MD New York, New York Lee C. Schlesinger Professor Department of Orthopaedics James T. Reagan, MD Tulane University School of Medicine Senior Resident New Orleans, Louisiana Department of Orthopedic Surgery Marshall University Suzanne Zadra Schroeder, PT, ATC Joan C. Edwards School of Medicine Physical Therapist Huntington, West Virginia Barnes Jewish West County Hospital STAR Center Bruce Reider, MD St. Louis, Missouri Professor Emeritus, Surgery Section of Orthopaedic Surgery and Rehabilitation Medicine Aaron Sciascia, MS, ATC, NASM-PES University of Chicago Coordinator Chicago, Illinois Shoulder Center of Kentucky Lexington, Kentucky Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS K. Donald Shelbourne, MD Assistant Professor Shelbourne Knee Center at Methodist Hospital Department of Orthopedic Surgery Indianapolis, Indiana Duke University Medical Center Durham, North Carolina Jace R. Smith, MD Senior Resident Amy G. Resler, DPT, CMP, CSCS Department of Orthopedic Surgery Department of Physical Therapy Marshall University Naval Medical Center, San Diego Joan C. Edwards School of Medicine San Diego, California Huntington, West Virginia Bryan Riemann, PhD, ATC, FNATA Damien Southard, MPT Associate Professor of Sports Medicine Staff Physical Therapist Coordinator Master of Science in Sports Medicine Cabell Huntington Hospital Director, Biodynamics and Human Performance Center Huntington, West Virginia Armstrong State University Savannah, Georgia Ken Stephenson, MD Orthopaedic Foot and Ankle Specialist, Toby Rogers, PhD, MPT Attending Surgeon Associate Professor of Sports Medicine Northstar Surgery Center, Coordinator Master of Science in Sports Medicine Associate Professor Director, Biodynamics and Human Performance Center Texas Tech Health Sciences Center Armstrong State University Lubbock, Texas Savannah, Georgia Faustin R. Stevens, MD Anthony A. Romeo, MD Orthopaedic Surgery Associate Professor and Director Texas Tech Health Sciences Center Section of Shoulder and Elbow Lubbock, Texas Department of Orthopaedic Surgery Rush University Medical Center Mark Stovak, MD, FACSM, FAAFP, CAQSM Chicago, Illinois Professor Department of Family and Community Medicine Richard Romeyn, MD University of Nevada, Reno School of Medicine Southeast Minnesota Sports Medicine and Orthopaedic Reno, Nevada Surgery Specialists Winona, Minnesota x Contributors Timothy F. Tyler, MS, PT, ATC Daniel Woods, MD Nicholas Institute of Sports Medicine and Athletic Trauma Senior Resident Lenox Hill Hospital Department Orthopaedic Surgery New York, New York Marshall University Joan C. Edwards School of Medicine Geoffrey S. Van Thiel, MD, MBA Huntington, West Virginia Division of Sports Medicine Rush University Medical Center Chicago, Illinois Mark Wagner, MD Orthopaedic Specialists, PC Portland, Oregon Reg B. Wilcox III, PT, DPT, MS, OCS Clinical Supervisor Outpatient Service Department of Rehabilitation Services Brigham and Women’s Hospital, Adjunct Clinical Assistant Professor Department of Physical Therapy School of Health and Rehabilitation Services MGH Institute of Health Professions Boston, Massachusetts FOREWORD BY GEORGE J. DAVIES It is indeed an honor and a privilege to be invited to write the as a clinician, teacher, professional, and administrator and has forward for the Fourth Edition of Clinical Orthopaedic Reha- edited or written seven textbooks that have made significant con- bilitation. For a book to be revised into a fourth edition is a tributions to the literature. Clinical Orthopaedic Rehabilitation is testimonial to the quality and longevity of the contribution to another example of Rob’s continued pursuit of excellence in con- the literature. Clinical Orthopaedic Rehabilitation is an excellent tributing to the literature and educating clinicians as to the opti- addition to the literature that provides current state of the art mum evidence-based rehabilitation for orthopedic conditions. information for rehabilitation. The quality of any book is predicated on the quality and I have personally had the opportunity to work with and conscientiousness of its editors. So, by combining the multiple had the opportunity to learn from both of the editors: Charles talents of these editors, the Fourth Edition of the book has main- “Chuck” Giangarra, MD, and Robert Manske, DPT. I had the tained its past format and updated approximately eight to ten privilege to work with Dr. Chuck and publish some other works new chapters to reflect the most current evidence and research. with him. Dr. Chuck did his fellowship at the Kerlan-Jobe Clinic The focus of the book is on examination, surgeries, and reha- and had the opportunity to work directly with Dr. Frank Jobe as bilitation of numerous orthopedic conditions to provide state of well as publish some research papers with Dr. Jobe. Dr. Chuck the art treatment protocols. This new edition also includes links is an experienced surgeon with 30 years of experience and is a to videos to reinforce the content within the book. This fourth tremendous physician. I had the opportunity to work with Dr. edition is an outstanding contribution to the literature and is a Chuck for approximately 5 years before he moved on to become must read for those who are interested in utilizing the best cur- the head team physician at Marshall University. Dr. Chuck rent evidence in rehabilitation for their patients. always had the patients’ interest foremost and understood the This book is highly recommended for physical therapists, importance of the team approach when patients had injuries or physical therapy assistants, athletic trainers, and physicians surgeries. He was always a strong proponent of the physicians involved in treatment of orthopedic conditions where rehabili- and rehabilitation specialists working closely together to pro- tation is a critical component of getting the patient safely and vide the optimum quality care for their patients. Consequently, effectively for performance enhancement back to activity. this book reinforces many examples of the team approach to treating patients and the importance of rehabilitation to return Respectfully, the patients to their optimum level of performance safely. George J. Davies, DPT, MEd, PT, SCS, ATC, LAT, I had the privilege to meet and work with Rob when he was CSCS, PES, FAPTA selected as the second resident at Gundersen Lutheran Sports Professor-Armstrong State University, 2004–present, Medicine (GLSM) (GLSM was the first APTA credential public Professor Emeritus, University of Wisconsin-LaCrosse, 2003, Sports Physical Therapy Residency program in the USA). Rob Founder and Co-Editor, 1979 was a hard worker and an accomplished clinician and earned his Journal of Orthopaedic and Sports Physical Therapy, SCS, ATC, and CSCS credentials during that year and the subse- Founder and Associate Editor, 2009 quent years. Rob has worked his way through academia from an Sports Health: A Multidisciplinary Approach, assistant professor to a full professor and chair at Wichita State Sports Physical Therapist: University. Since his residency program, Rob and I have col- Coastal Therapy, Savannah, GA, 2004–present, laborated on many articles, research projects, and presentations Gundersen Health System, LaCrosse, WI, 1991–present at numerous meetings during the last 20 years. Rob has excelled xi FOREWORD BY EDWARD G. MCFARLAND It is an honor to be asked to write a foreword to this incred- about rehabilitation techniques and another to have videos that ible book put together by two of the stars of the orthope- help a practitioner to get it right. Lastly, one of the best features dic community—Dr. Manske, a physical therapist, and Dr. for me as a practitioner is that I can use their rehabilitation Giangarra, an orthopedic surgeon. I have to admit that I was protocols in my orthopedic practice; they are a quick reference unfamiliar with this text until this invitation, and it was my to how the experts approach the rehabilitation of these impor- loss. This is an incredible book that has several attributes that tant orthopedic conditions. I plan to use these protocols in my make it a valuable addition to the practice of physical thera- practice. pists, hand therapists, and orthopedic practioners of any level: Drs. Manske and Giangarra not only bring their vast experi- student, resident, or surgeon in practice. One important qual- ence to this book, they also have recruited some of the leaders ity of this book is that for each area of the body it has a concise in each orthopedic topic discussed. This book has been written and informative summary of the most common conditions by the best and most visible leaders in the fields of orthopedic and injuries that affect that area. This assures that everyone in surgery and rehabilitation. The information has been updated the team treating the patient has as much knowledge as pos- and provides the latest and most up-to-date approach to clinical sible about the injury and the rationale for the treatment and orthopedic rehabilitation. I would recommend this textbook to rehabilitation. I am unaware of any other text that makes the all orthopedic practitioners. important link between the condition and the subsequent rehabilitation. Each chapter provides rehabilitation protocols for Edward G. McFarland, MD the injuries discussed in the chapter so that the rationale of the Wayne H. Lewis Professor of Orthopaedic and Shoulder Surgery protocol is provided and readily available. These rehabilitation Professor, Department of Orthopaedic Surgery protocols are excellent and I wish I’d had access to them many Johns Hopkins University years ago. Another strength of this book is the ability to access Baltimore, Maryland videos of the rehabilitation techniques. It is one thing to read xii PREFACE Our goal in preparing the 4th edition of Clinical Orthopaedic information provided within the pages of this comprehensive Rehabilitation: A Team Approach was to continue to widen the text. Dr. Giangarra and I have continued this forward momen- breadth of the content and orthopedic and sports information to tum with the 4th edition. Updated and new evidence-based lit- mimic that of the everyday practicing surgeon, physician, physi- erature covering sound examination techniques, classification cal therapist, and athletic trainer who work in orthopedics. In systems, differential diagnosis, treatment options, and updated increasing the breadth of content we have made this text more criteria-based rehabilitation protocols have been included. Vid- useful to clinicians and student clinicians. Several areas of con- eos of some of the most commonly used exercises are included tent that are rarely seen in orthopedics except very rare special within the text. New all-color images have been included to cases have been removed and other more pertinent pathologies update the over 800 images to help the visual learner better see have been included. For example, several chapters have been and appreciate injuries and exercises used to treat those injuries. included in the expanded shoulder, elbow, knee, and hip sec- The treatment of orthopedic conditions is not static. The pro- tions. Dr. Charles Giangarra, a well-published author, already cess of treating conditions of the muscles, bones, and nerves is has brought a wealth of knowledge to many sections of the 4th and has always been dynamic. Textbooks about examination, edition. We have done our best to use a team approach so often evaluation, prognosis, and treatment of these conditions must seen and needed between physicians and rehabilitation special- be just as dynamic and ever changing. We hope that the readers ists. The chapter authors are an exceptional group of clinicians of this text continue to feel that Clinical Orthopaedic Rehabili- who have presented the best available evidence regarding con- tation is the definitive reference for achieving success with the temporary rehabilitation of orthopedic conditions. This dedi- management of orthopedic conditions. cated multidisciplinary team of authors has added an incredible value to the foundation of this already strong book. Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS In the third edition Dr. Brotzman and I took tremendous Charles E. Giangarra, MD steps forward to improve the overall quality and content of the xiii ACKNOWLEDGMENTS To my fabulous wife, Jean, and my three wonderful children, To Dr. Brent Brotzman and Dr. Charles E. Giangarra. Nick, Jenna, and Cristen, who I am so very proud of and who Dr. Brotzman, I want to personally thank you for taking the put up with me and made the best of my multiple moves across chance by allowing me to work with you on COR3. It was an the country until I found the right opportunity. I could not have incredible experience and I am forever indebted to you for your made it this far without their love and support and for that I am partnership. It is such a great resource for all health care pro- eternally grateful. fessionals in rehabilitation and will go down as one of the best To my mentor, chairman, and friend, Dr. Oliashirazi, who orthopedic textbooks of the last several decades. believed in me and has encouraged me to excel more times than Dr. Chuck, I appreciate your willingness to jump on this fast- I can count. moving train we call COR4 and take over for Dr. Brotzman. To the orthopedic residents of Marshall University who Your insight, mentorship, guidance, and willingness to always have revitalized not only my career but my enthusiasm for lend a hand have been an invaluable gift to me throughout the learning. last 20 years. I would have never thought that when we first met I would also like to thank Ashley Belmaggio MA, Meagan back in LaCrosse in 1998 that either of us would end up with Bevins ATC, Tom Garton MPT, and Michael Bonar PTA for such a great project that will impact so many great rehabilitation their help with this project especially in preparing many of the professionals in a positive way. new photographs for publication. I could not have done it with- Lastly a special thanks to B.J. Lehecka for reviewing and out them. editing the spinal chapter section of this text. His insight was extremely valuable in this addition. Charles E. Giangarra, MD Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS xiv CONTENTS SECTION 1 Hand and Wrist Injuries 14 Medial Collateral Ligament and Ulnar Nerve Injury at the Elbow 66 1 Flexor Tendon Injuries 2 MICHAEL LEVINSON, PT, CSCS | DAVID W. ALTCHEK, MD S. BRENT BROTZMAN, MD | STEVEN R. NOVOTNY, MD 15 Treating Flexion Contracture (Loss of 2 Flexor Digitorum Profundus Avulsion (“Jersey Extension) in Throwing Athletes 71 TIGRAN GARABEKYAN, MD | CHARLES E. GIANGARRA, MD Finger”) 9 S. BRENT BROTZMAN, MD | STEVEN R. NOVOTNY, MD 16 Post-Traumatic Elbow Stiffness 74 3 Extensor Tendon Injuries 12 DANIEL WOODS, MD | CHARLES E. GIANGARRA, MD S. BRENT BROTZMAN, MD | THERESA M. KIDD, BA 17 Treatment and Rehabilitation of Elbow 4 Fractures and Dislocations of the Hand 19 Dislocations 77 MAUREEN A. HARDY, PT, MS, CHT | S. BRENT BROTZMAN, MD | MICHAEL J. O’BRIEN, MD | FELIX H. SAVOIE III, MD STEVEN R. NOVOTNY, MD 18 Lateral and Medial Humeral Epicondylitis 81 5 Fifth Metacarpal Neck Fracture (Boxer’s TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS | GEORGE J. DAVIES, DPT, MEd, PT, SCS, ATC, LAT, CSCS, PES, FAPTA Fracture) 24 S. BRENT BROTZMAN, MD | THERESA M. KIDD, BA | MAUREEN A. HARDY PT, MS, CHT | STEVEN R. NOVOTNY, MD 19 Forearm Upper Extremity Nerve Entrapment Injuries 89 6 Injuries to the Ulnar Collateral Ligament STEVEN R. NOVOTNY, MD of the Thumb Metacarpophalangeal Joint (Gamekeeper’s Thumb) 29 S. BRENT BROTZMAN, MD | STEVEN R. NOVOTNY, MD SECTION 3 Shoulder Injuries 7 Nerve Compression Syndromes 32 20 General Principles of Shoulder S. BRENT BROTZMAN, MD | STEVEN R. NOVOTNY, MD Rehabilitation 94 ROBERT C. MANSKE, PT, DPT, MEd, SCS, ATC, CSCS 8 Scaphoid Fractures 42 S. BRENT BROTZMAN, MD | STEVEN R. NOVOTNY, MD Shoulder Rehabilitation 98 MARISA PONTILLO, PT, DPT, SCS 9 Triangular Fibrocartilage Complex Injury 45 FELIX H. SAVOIE III, MD | MICHAEL J. O’BRIEN, MD | 21 Importance of the History in the Diagnosis of LARRY D. FIELD, MD Shoulder Pathology 100 RICHARD ROMEYN, MD | ROBERT C. MANSKE, PT, DPT, MEd, SCS, 10 Metacarpal Phalangeal Joint Arthroplasty 51 ATC, CSCS STEVEN R. NOVOTNY, MD 22 Rotator Cuff Tendinitis in the Overhead Athlete 110 2 Rehabilitation After Total MICHAEL J. O’BRIEN, MD | FELIX H. SAVOIE III, MD SECTION Elbow Arthroplasty 23 Rotator Cuff Repair 117 ROBERT C. MANSKE, PT, DPT, MEd, SCS, ATC, CSCS 11 The Total Elbow 54 SINAN EMRE OZGUR, MD | CHARLES E. GIANGARRA, MD 24 Shoulder Instability Treatment and Rehabilitation 130 12 Rehabilitation After Fractures of the Forearm SAMEER LODHA, MD | SEAN MAZLOOM, MS | AMY G. RESLER, DPT, CMP, CSCS | RACHEL M. FRANK, BS | and Elbow 57 NEIL S. GHODADRA, MD | ANTHONY A. ROMEO, MD | SINAN EMRE OZGUR, MD | CHARLES E. GIANGARRA, MD JONATHAN YONG KIM, CDR | R. JASON JADGCHEW, ATC, CSCS | MATTHEW T. PROVENCHER, MD, CDR, MC, USN 13 Pediatric Elbow Injuries in the Throwing Athlete: Emphasis on Prevention 63 25 Adhesive Capsulitis (Frozen Shoulder) 158 ROBERT C. MANSKE, PT, DPT, SCS, MEd, SCS, ATC, CSCS | CHRISTOPHER J. DURALL, PT, DPT, MS, SCS, LAT, CSCS MARK STOVAK, MD, FACSM, FAAFP, CAQSM xv xvi Contents 26 Rehabilitation for Biceps Tendon Disorders 39 Ankle Sprains 255 and SLAP Lesions 164 BRIAN K. FARR, MA, ATC, LAT, CSCS | DONALD NGUYEN, PT, MSPT, ATC, LAT | KEN STEPHENSON, MD | TOBY ROGERS, PhD, GEOFFREY S. VAN THIEL, MD, MBA | SANJEEV BHATIA, MD | MPT | FAUSTIN R. STEVENS, MD | JOHN J. JASKO, MD NEIL S. GHODADRA, MD | JONATHAN YONG KIM, CDR | MATTHEW T. PROVENCHER, MD, CDR, MC, USN 40 Ankle-Specific Perturbation Training 273 27 Scapular Dyskinesis 174 MICHAEL DUKE, PT, CSCS | S. BRENT BROTZMAN, MD W. BEN KIBLER, MD | AARON SCIASCIA, MS, ATC, NASM-PES | JOHN MCMULLEN, MS, ATC 41 Chronic Ankle Instability 275 S. BRENT BROTZMAN, MD | JOHN J. JASKO, MD 28 Rehabilitation Following Total Shoulder and Reverse Total Shoulder Arthroplasty 181 42 Syndesmotic Injuries 278 TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS | S. BRENT BROTZMAN, MD | JOHN J. JASKO, MD REG B. WILCOX III, PT, DPT, MS, OCS 29 Upper Extremity Interval Throwing 43 Inferior Heel Pain (Plantar Fasciitis) 281 S. BRENT BROTZMAN, MD | JOHN J. JASKO, MD Progressions 189 TIMOTHY F. TYLER, MS, PT, ATC | DREW JENK, PT, DPT 44 Achilles Tendinopathy 290 S. BRENT BROTZMAN, MD 30 Shoulder Exercises for Injury Prevention in the Throwing Athlete 196 JOHN A. GUIDO, JR., PT, MHS, SCS, ATC, CSCS | KEITH MEISTER, MD 45 Achilles Tendon Rupture 299 JOHN J. JASKO, MD | S. BRENT BROTZMAN, MD | CHARLES E. GIANGARRA, MD 31 Glenohumeral Internal Rotation Deficiency: Evaluation and Treatment 203 46 First Metatarsophalangeal Joint Sprain TODD S. ELLENBECKER, DPT, MS, SCS, OCS, CSCS | W. BEN KIBLER, MD | GEORGE J. DAVIES, DPT, MEd, PT, SCS, ATC, LAT, CSCS, PES, FAPTA (Turf Toe) 303 MARK M. CASILLAS, MD | MARGARET JACOBS, PT 32 Postural Consideration for the Female Athlete’s Shoulder 207 JANICE K. LOUDON, PT, PhD, SCS, ATC, CSCS SECTION 5 Knee Injuries 33 Impingement Syndrome 210 47 Anterior Cruciate Ligament Injuries 308 MICHAEL D. ROSENTHAL, PT, DSc, SCS, ECS, ATC, CSCS | S. BRENT BROTZMAN, MD JOSEF H. MOORE, PT, PhD | JOSEPH R. LYNCH, MD 48 Perturbation Training for Postoperative 34 Pectoralis Major Rupture Repair 221 ACL Reconstruction and Patients Who ROBERT C. MANSKE, PT, DPT, MEd, SCS, ATC, CSCS | DANIEL PROHASKA, MD Were Nonoperatively Treated and ACL Deficient 322 MICHAEL DUKE, PT, CSCS | S. BRENT BROTZMAN, MD 35 Thoracic Outlet Syndrome in the Overhead Athlete 226 ROBERT C. MANSKE, PT, DPT, MEd, SCS, ATC, CSCS 49 Gender Issues in ACL Injury 326 LORI A. BOLGLA, PT, PhD, MAcc, ATC 36 Proximal Humeral and Humeral Shaft 50 Functional Testing, Functional Training, Fractures 233 CHARLES E. GIANGARRA, MD | JACE R. SMITH, MD and Criteria for Return to Play After ACL Reconstruction 334 MARK V. PATERNO, PhD, PT, MS, SCS, ATC | TIMOTHY E. HEWETT, 37 The Use of a Functional Testing Algorithm PhD, FACSM (FTA) to Make Qualitative and Quantitative Decisions to Return Athletes Back to Sports 51 Functional Performance Measures and Following Shoulder Injuries 237 Sports-Specific Rehabilitation for Lower GEORGE J. DAVIES, DPT, MEd, PT, SCS, ATC, LAT, CSCS, PES, FAPTA | BRYAN RIEMANN, PhD, ATC, FNATA Extremity Injuries: A Guide for a Safe Return to Sports 341 CHRISTIE C.P. POWELL, PT, MSPT, STS, USSF “D” SECTION 4 Foot and Ankle Injuries 52 Treatment and Rehabilitation of Arthrofibrosis of the Knee 353 38 Foot and Ankle Fractures 246 SCOTT E. LAWRANCE, MS, PT, ATC, CSCS | JAMES T. REAGAN, MD | CHARLES E. GIANGARRA, MD | K. DONALD SHELBOURNE, MD JOHN J. JASKO, MD Contents xvii 53 Posterior Cruciate Ligament Injuries 359 68 Hamstring Muscle Injuries in Athletes 447 MICHAEL D’AMATO, MD | S. BRENT BROTZMAN, MD J. ALLEN HARDIN, PT, MS, SCS, ATC, LAT, CSCS | CLAYTON F. HOLMES, PT, EdD, MS, ATC 54 Medial Collateral Ligament Injuries 367 MICHAEL ANGELINE, MD | BRUCE REIDER, MD 69 Athletic Pubalgia 462 CHARLES ANDREW GILLILAND, BS, MD 55 Meniscal Injuries 372 MICHAEL D’AMATO, MD | S. BRENT BROTZMAN, MD | THERESA M. 70 Femoro-acetabular Impingement: Labral KIDD, BA Repair and Reconstruction 466 TIGRAN GARABEKYAN, MD | DAMIEN SOUTHARD, MPT | JEFF 56 Patellofemoral Disorders 376 ASHTON, PT S. BRENT BROTZMAN, MD 57 Medial Patellofemoral Ligament SECTION 7 Spinal Disorders Reconstruction 389 CHARLES E. GIANGARRA, MD | JACE R. SMITH, MD 71 Whiplash Injury: Treatment and Rehabilitation 479 58 Hip Strength and Kinematics in Patellofemoral ADRIAAN LOUW, PT, MAppSc (Physio), CSMT Syndrome 393 LORI A. BOLGLA, PT, PhD, ATC 72 Therapeutic Exercise for the Cervical Spine 487 59 Overuse Syndromes of the Knee 397 CHRISTOPHER J. DURALL, PT, DPT, MS, SCS, LAT, CSCS S. BRENT BROTZMAN, MD 73 Treatment-Based Classification of Low Back 60 Patellar Tendon Ruptures 400 Pain 496 MATTHEW J. MATAVA, MD | RYAN T. PITTS, MD | SUZANNE ZADRA MICHAEL P. REIMAN, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS SCHROEDER, PT, ATC 74 Core Stabilization Training 498 61 Articular Cartilage Procedures of the BARBARA J. HOOGENBOOM, EdD, PT, SCS, ATC | Knee 405 KYLE KIESEL, PT, PhD, ATC, CSCS G. KELLEY FITZGERALD, PhD, PT | JAMES J. IRRGANG, PhD, PT, ATC 75 McKenzie Approach to Low Back Pain 514 62 The Arthritic Knee 411 BARBARA J. HOOGENBOOM, EdD, PT, SCS, ATC | DAVID A. JAMES, PT, DPT, OCS, CSCS | CULLEN M. NIGRINI, MSPT, JOLENE BENNETT, PT, MA, OCS, ATC, Cert MDT MEd, PT, ATC, LAT | ROBERT C. MANSKE, PT, DPT, MEd, SCS, ATC, CSCS | ALEXANDER T. CAUGHRAN, MD 76 Rehabilitation Following Lumbar Disc Surgery 523 63 Total Knee Replacement Protocol 417 ADRIAAN LOUW, PT, MAppSc (Physio), CSMT DAVID A. JAMES, PT, DPT, OCS, CSCS | CULLEN M. NIGRINI, MSPT, MEd, PT, ATC, LAT 77 Chronic Back Pain and Pain Science 532 ADRIAAN LOUW, PT, MAppSc (Physio), CSMT | DAVID S. BUTLER, BPHTY, MAppSc, EdD SECTION 6 Hip Injuries 78 Spinal Manipulation 541 64 Hip Injuries 422 EMILIO “LOUIE” PUENTEDURA, PT, DPT, GDMT, OCS, FAAOMPT ERIK P. MEIRA, PT, SCS, CSCS | MARK WAGNER, MD | JASON BRUMITT, PT, PhD, ATC, CSCS 79 Neurodynamics 553 EMILIO “LOUIE” PUENTEDURA, PT, DPT, GDMT, OCS, FAAOMPT 65 The Arthritic Hip 432 ALEXANDER T. CAUGHRAN, MD | CHARLES E. GIANGARRA, MD 80 Spondylolisthesis 563 ANDREW S.T. PORTER, DO, FAAFP 66 Total Hip Replacement Rehabilitation: Progression and Restrictions 436 81 Lumbar Spine Microdiscectomy Surgical MORTEZA MEFTAH, MD | AMAR S. RANAWAT, MD | ANIL S. RANAWAT, MD | ALEXANDER T. CAUGHRAN, MD Rehabilitation 571 CULLEN M. NIGRINI, MSPT, MEd, PT, ATC, LAT | R. MATTHEW CAMARILLO, MD 67 Groin Pain 443 MICHAEL P. REIMAN, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS | S. BRENT BROTZMAN, MD xviii Contents SECTION 8 Special Topics 84 Tendinopathy 601 ROBERT C. MANSKE, PT, DPT, MEd, SCS, ATC, CSCS 82 Running Injuries: Etiology and Recovery-Based Treatment 577 Index 605 ALLAN BESSELINK, PT, DPT, Dip MDT | BRIDGET CLARK, PT, MSPT, DPT 83 Running Injuries: Shoes, Orthotics, and Return- to-Running Program 588 SCOTT T. MILLER, PT, MS, SCS, CSCS | JANICE K. LOUDON, PT, PhD, SCS, ATC, CSCS VIDEO CONTENTS Chapter 18 Chapter 40 Video 18-1 Rowing Motions Low Middle High 640 Video 40-1 Bosu Squats 640 Video 18-2 Wall Push Up Plus 640 Video 40-2 Seated With Perturbations 640 Video 18-3 Side-lying Er 640 Video 18-4 External Rotation Tubing With Retraction 640 Chapter 47 Video 18-5 Wrist Isotonic Extension 640 Video 47-1 Bridging With Side 640 Video 18-6 Wrist Isotonic Flexion 640 Video 47-2 Level Ground Squats Bilateral 640 Video 18-7 Wrist Flips Flexors And Extensors 640 Video 47-3 Lunge Anterior 640 Video 47-4 Single Leg Balance Foam Pad 640 Chapter 22 Video 47-5 Single Leg Balance Level Ground 640 Video 22-1 Posterior Glide 45 640 Video 47-6 Single Leg Balance Perturbations 640 Video 22-2 Posterior Glide 90 640 Video 22-3 Single Theraband External Rotation 640 Chapter 49 Video 22-4 Single Theraband Internal Rotation 640 Video 49-1 Side-lying Clam 640 Video 22-5 2 Handed Chop 640 Video 22-6 2 Handed Overhead 640 Chapter 50 Video 50-1 Swiss Ball Progression Is Ys Ts 640 Chapter 26 Video 26-1 Rotator Cuff Isometrics Rhythmic Chapter 51 Stabilization 640 Video 51-1 Single Leg Squat 640 Chapter30 Chapter 56 Video 30-1 Cross Arm Stretch Seated Patient 640 Video 56-1 Squatting 640 Video 30-2 Cross Arm Stretch Supine Patient 640 Video 56-2 Squatting With Therapist Tapping 640 Video 30-3 Cross Arm Stretch Supine Therapist Assist 640 Video 30-4 Cross Arm Stretch Supine Therapist Chapter 64 Stabilized 640 Video 64-1 Hip Abduction Side-lying 640 Video 30-5 Scapuular Plane Elevation 640 Video 64-2 Hip Extension 640 Video 30-6 Seated Press Up Plus 640 Video 64-3 Isometric Hip Abduction Wall 640 Video 64-4 Single Leg Balance Hip Rotation 640 Chapter 34 Video 64-5 Standing Hip Abduction 640 Video 34-1 Side-lying Scapular Isometrics 640 Chapter 68 Chapter 39 Video 68-1 Prone Eccentric Hamstrings Manual Video 39-1 Hold Patterns Injured Limb On Tilt Board 640 Resistance 640 Video 39-2 Hold Patterns Uninjured Limb On Tilt Board 640 Video 68-2 Supine Hamstring Curl 640 xix This page intentionally left blank SECTION 1 Hand and Wrist Injuries SECTION OUTLINE 1 Flexor Tendon Injuries 2 Flexor Digitorum Profundus Avulsion (“Jersey Finger”) 3 Extensor Tendon Injuries 4 Fractures and Dislocations of the Hand 5 Fifth Metacarpal Neck Fracture (Boxer’s Fracture) 6 Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint (Gamekeeper’s Thumb) 7 Nerve Compression Syndromes 8 Scaphoid Fractures 9 Triangular Fibrocartilage Complex Injury 10 Metacarpal Phalangeal Joint Arthroplasty 1 1 Flexor Tendon Injuries S. Brent Brotzman, MD | Steven R. Novotny, MD IMPORTANT POINTS FOR Immediate (primary) repair is contraindicated in patients REHABILITATION AFTER FLEXOR with any of the following: Severe multiple tissue injuries to the fingers or palm TENDON LACERATION AND REPAIR Wound contamination The goal of the tendon repair is to coapt the severed ends Significant skin loss over the flexor tendons without bunching or leaving a gap (Fig. 1.1). Repaired tendons subjected to appropriate early motion REHABILITATION RATIONALE AND stress will increase in strength more rapidly and develop fewer adhesions than immobilized repairs. BASIC PRINCIPLES OF TREATMENT Flexor rehabilitation protocols must take into account the AFTER FLEXOR TENDON REPAIR typical tensile stresses on normally repaired flexor tendon Timing tendons (Bezuhly et al. 2007). Passive motion: 500–750 g (4.9–13 N) The timing of flexor tendon repair influences the rehabilitation Light grip: 1500–2250 g (14.7–22 N) and outcome of flexor tendon injuries. Strong grip: 5000–7500 g (49–73.5 N) Primary repair is done within the first 12 to 24 hours after injury. Tip pinch, index flexor digitorum profundus (FDP): 9000– Delayed primary repair is done within the first 10 days after 13,500 g (88.2–132.3 N) injury. Initially rather strong, the flexor tendon repair strength If primary repair is not done, delayed primary repair should decreases significantly between days 5 and 21 (Bezuhly et al. be done as soon as there is evidence of wound healing without 2007). infection. The tendon is weakest during this time period because of Secondary repair is done 10 and 14 days after injury. minimal tensile strength. Strength increases quickly when Late secondary repair is done more than 4 weeks after injury. controlled stress is applied in proportion to increasing tensile After 4 weeks it is extremely difficult to deliver the flexor ten- strength. Stressed tendons heal faster, gain strength faster, don through the digital sheath, which usually becomes exten- and have fewer adhesions. Tensile strength generally begins sively scarred. However, clinical situations in which the tendon gradually increasing at 3 weeks. Generally, blocking exer- repair is of secondary importance often make late repair neces- cises are initiated 1 week after active range of motion (ROM) sary, especially for patients with massive crush injuries, inad- excursion (5 weeks postoperative) (Baskies 2008). equate soft tissue coverage, grossly contaminated or infected The A2 and A4 pulleys are the most important to the me- wounds, multiple fractures, or untreated injuries. If the sheath chanical function of the finger. Loss of a substantial portion is not scarred or destroyed, single-stage tendon grafting, direct of either may diminish digital motion and power or lead to repair, or tendon transfer can be done. If extensive disturbance flexion contractures of the interphalangeal (IP) joints. and scarring have occurred, two-stage tendon grafting with a The flexor digitorum superficialis (FDS) tendons lie on the silicone (Hunter) rod should be performed. palmar side of the FDP until they enter the A1 entrance of the Before tendons can be secondarily repaired, these require- digital sheath. The FDS then splits (at Champer’s chiasma) and ments must be met: terminates into the proximal half of the middle phalanx. Joints must be supple and have useful passive range of mo- Flexor tendon excursion of as much as 9 cm is required to tion (PROM) (Boyes grade 1 or 2, Table 1.1). Restoration of produce composite wrist and digital flexion. Excursion of PROM is aggressively obtained with rehabilitation before only 2.5 cm is required for full digital flexion when the wrist secondary repair is done. is stabilized in the neutral position. Skin coverage must be adequate. Tendons in the hand have both intrinsic and extrinsic capa- The surrounding tissue in which the tendon is expected to bilities for healing. glide must be relatively free of scar tissue. Factors that influence the formation of excursion-restricting Wound erythema and swelling must be minimal or absent. adhesions around repaired flexor tendons include the Fractures must have been securely fixed or healed with ad- following: equate alignment. Amount of initial trauma to the tendon and its sheath Sensation in the involved digit must be undamaged or re- Tendon ischemia stored, or it should be possible to repair damaged nerves at Tendon immobilization the time of tendon repair directly or with nerve grafts. Gapping at the repair site The critical A2 and A4 pulleys must be present or have been Disruption of the vincula (blood supply), which decreases reconstructed. Secondary repair is delayed until these are re- the recovery of the tendon (Fig. 1.2) constructed. During reconstruction, Hunter (silicone) rods Delayed primary repair results (within the first 10 days) are are useful to maintain the lumen of the tendon sheath while equal to or better than immediate repair of the flexor tendon. the grafted pulleys are healing. 2 1 Flexor Tendon Injuries 3 Extending skin Passive DIP incision line joint flexion Distal FDS/FDP stumps Cruciate-synovial sheath flap Approximation Proximal FDS/FDP of distal and Tendon repair stumps proximal stumps Laceration of zone ll Skin flaps Wound Tube repair attachment A B C D Fig. 1.1 Author’s technique of flexor tendon repair in zone 2. A, Knife laceration through zone 2 with the digit in full flexion. The distal stumps retract distal to the skin incision with digital extension. B, Radial and ulnar extending incisions are used to allow wide exposure of the flexor tendon system. Note appearance of the flexor tendon system of the involved fingers after the reflection of skin flaps. The laceration occurred through the C1 cruciate area. Note the proximal and distal position of the flexor tendon stumps. Reflection of small flaps (“windows”) in the cruciate-synovial sheath allows the distal flexor tendon stumps to be delivered into the wound by passive flexion of the distal interphalangeal (DIP) joint. The profundus and the superficialis stumps are retrieved proximal to the wound by passive flexion of the DIP joint. The profundus and superficialis stumps are retrieved proximal to the sheath by the use of a small catheter or infant feeding gastrostomy tube. C, The proximal flexor tendon stumps are maintained at the repair site by means of a transversely placed small-gauge hypodermic needle, allowing repair of the FDS slips without extension. D, Completed repair of both FDS and FDP tendons is shown with the DIP joint in full flexion. Extension of the DIP joint delivers the repair under the intact distal flexor tendon sheath. Wound repair is done at the conclusion of the procedure. Proper palmar digital artery TABLE 1.1 Boyes’ Preoperative Classification Grade Preoperative Condition 1 Good: minimal scar with mobile joints and no trophic changes VBP VLP VBS VLS 2 Cicatrix: heavy skin scarring from injury or Superficialis tendon previous surgery; deep scarring from failed Profundus tendon primary repair or infection Fig. 1.2 Blood supply to the flexor tendons within the digital sheath. The 3 Joint damage: injury to the joint with restricted segmental vascular supply to the flexor tendons is by means of the long range of motion and short vincular connections. The vinculum brevis superficialis (VBS) and 4 Nerve damage: injury to the digital nerves resulting the vinculum brevis profundus (VBP) consist of small triangular mesenteries in trophic changes in the finger near the insertion of the FDS and FDP tendons, respectively. The vinculum 5 Multiple damage: involvement of multiple fingers longum to the superficialis tendon (VLS) arises from the floor of the digital with a combination of the above problems sheath of the proximal phalanx. The vinculum longum to the profundus tendon (VLP) arises from the superficialis at the level of the proximal interphalangeal (PIP) joint. The cut-away view depicts the relative avascularity of the palmar side of the flexor tendons in zones 1 and 2 as compared with the richer blood supply on the dorsal side, which connects with the vincula. Zone 3—“area of lumbrical origin”: from the beginning of the pulleys (A1) to the distal margin of the transverse carpal Anatomy ligament Zone 4—area covered by the transverse carpal ligament The anatomic zone of injury of the flexor tendons influences Zone 5—area proximal to the transverse carpal ligament the outcome and rehabilitation of these injuries. The hand is As a rule, repairs to tendons injured outside the flexor sheath divided into five distinct flexor zones (Fig. 1.3): have much better results than repairs to tendons injured inside the Zone 1—from the insertion of the profundus tendon at the sheath (zone 2). distal phalanx to just distal to the insertion of the sublimus It is essential that the A2 and A4 pulleys (Fig. 1.4) be pre- Zone 2—Bunnell’s “no-man’s land”: the critical area of served to prevent bowstringing. In the thumb, the A1 and pulleys between the insertion of the sublimus and the distal oblique pulleys are the most important. The thumb lacks vin- palmar crease cula for blood supply. 4 SECTION 1 Hand and Wrist Injuries Distal to FDS tendon also prevents the tendon from gliding. Intrinsic healing relies l on synovial fluid for nutrition and occurs only between the l tendon ends. l Flexor tendons in the distal sheath have a dual source of nutrition via the vincular system and synovial diffusion. Diffu- l sion appears to be more important than perfusion in the digital ll sheath (Green 1993). No man’s land Several factors have been reported to affect tendon healing: l ll Age—The number of vincula (blood supply) decreases with age. ll General health—Cigarettes, caffeine, and poor general health Lumbrical origin delay healing. The patient should refrain from ingesting caf- lll lll feine and smoking cigarettes during the first 4 to 6 weeks lV after repair. lV Carpal tunnel Scar formation—The remodeling phase is not as effective in patients who produce heavy keloid or scar. V Muscle-tendon V Motivation and compliance—Motivation and the ability to junction follow the postoperative rehabilitation regimen are critical factors in outcome. Level of injury—Zone 2 injuries are more apt to form lim- Fig. 1.3 The flexor system has been divided into five zones or levels iting adhesions from the tendon to the surrounding tissue. for the purpose of discussion and treatment. Zone 2, which lies within In zone 4, where the flexor tendons lie in close proximity to the fibro-osseous sheath, has been called “no man’s land” because it each other, injuries tend to form tendon-to-tendon adhe- was once believed that primary repair should not be done in this zone. sions, limiting differential glide. Trauma and extent of injury—Crushing or blunt injuries promote more scar formation and cause more vascular trauma, impairing function and healing. Infection also impedes the healing process. Pulley integrity—Pulley repair is important in restoring me- chanical advantage (especially A2 and A4) and maintaining A5 tendon nutrition through synovial diffusion. C3 Distal transverse Surgical technique—Improper handling of tissues (such as A4 digital artery forceps marks on the tendon) and excessive postoperative hematoma formation trigger adhesion formation. Intermediate transverse C2 digital artery The two most frequent causes for failure of primary tendon repairs A3 are formation of adhesions and rupture of the repaired tendon. Proximal transverse Through experimental and clinical observation, Duran and C1 digital artery Houser (1975) determined that tendon glide of 3 to 5 mm is suf- ficient to prevent motion-limiting tendon adhesions. Exercises A2 Branch to are thus designed to achieve this motion. viniculum longus Proper palmar digital artery Treatment of Flexor Tendon A1 Lacerations Common Partial laceration involving less than 25% of the tendon sub- digital artery stance can be treated by beveling the cut edges. Lacerations between 25% and 50% can be repaired with 6-0 running nylon Flexor tendon suture in the epitenon. Lacerations involving more than 50% should be considered complete and should be repaired with a core suture and an epitenon suture. No level 1 studies have determined superiority of one suture Fig. 1.4 The fibrous retinacular sheath starts at the neck of the meta- method or material, although a number of studies have com- carpal and ends at the distal phalanx. Condensations of the sheath form pared different suture configurations and materials. Most stud- the flexor pulleys, which can be identified as five heavier annular bands ies indicate that the number of strands crossing the repair site and three filmy cruciform ligaments (see text). and the number of locking loops directly affect the strength of the repair, with six- and eight-strand repairs generally shown to be stronger than four-strand or two-strand repairs; however, the Tendon Healing increased number of strands also increases bulk and resistance The exact mechanism of tendon healing is still unknown. Heal- to glide. Several four-strand repair techniques appear to provide ing probably occurs through a combination of extrinsic and adequate strength for early motion. intrinsic processes. Extrinsic healing depends on the formation The following discussion is mainly for zone 2 flexor ten- of adhesions between the tendon and the surrounding tissue, don lacrations. The other zones are repaired similarly, but the providing a blood supply and fibroblasts, but unfortunately it peculiarities of zone 2 tendon repairs will be emphasized. I still 1 Flexor Tendon Injuries 5 prefer a standard Brunner type incision instead of a midaxial. should not be advanced more than 1 cm to avoid the quadregia My exposure and opening of the tendon sheath depends on effect (a complication of a single digit with limited motion causing the location of its laceration and the quality of the traumatized limitation of excursion and, thus, the motion of the uninvolved sheath. If the laceration is through the A2 pulley, I will make digits). Citing complications in 15 of 23 patients with pull-out controlled sheath incisions distal or proximal to the pulley. If wire (button-over-nail) repairs, 10 of which were directly related the pulley is cut asymmetrically, I have vented the pulley for to the technique, Kang et al. (2008) questioned its continued a better exposure. I prefer to work through distally based tri- use. Complications of the pull-out wire technique included nail angular openings if possible, believing the repaired sheath deformities, fixed flexion deformities of the distal interphalan- apex will allow enhanced gliding for the tendon anastomosis, geal (DIP) joint, infection, and prolonged hypersensitivity. as opposed to the transversely sutured sheath flap. Rectangular A more recent technique for FDP lacerations is the use of flaps for larger exposure are sometimes needed. When retriev- braided polyester/monofilament polyethylene composite (Fiber- ing a tendon from the palm, I have no qualms about excising the Wire, Arthrex, Naples, FL) and suture anchors rather than pull- A1 pulley for enhanced visualization. I place my core sutures out wires (Matsuzaki et al. 2008; McCallister et al. 2006). Reports approximately 1 cm from the laceration (Cao et al. 2006). The of outcomes currently are too few to determine if this technique proximal core sutures are captured with a 26-gauge looped steel will allow earlier active motion than standard techniques. wire as a passer, causing minimal trauma to the native sheath. I try not to use hypodermic needles, Keith needles, or a Bloodless Surgery manufactured tendon approximator unless needed, to mini- mize epitendon trauma. A skilled assistant can often tension the A current topic of interest is bloodless awake surgery for more proximal stump with traction on one set of core sutures. The complex hand problems. I refer the reader to a recent publica- core sutures should be placed dorsal as opposed to volar (Aoki tion by Lalonde and Martin (2013). I firmly believe in the sci- et al. 1996), the running epitendon suture must have reasonable ence and employ it when appropriate. However, some patients depth (Daio et al. 1996), and I repair the sheath whenever pos- refuse to proceed under local anesthesia. Vasculopaths, such sible (Tang and Xie 2001). as those with Buerger’s disease, may not be appropriate candi- Tendons lacerated sharply without need of débridement are dates. Lastly, repairing extensor tendons, an easier proposition, repaired as described in Pike, Boyer and Gelberman’s 2010 pub- can still be challenging when the patient involuntarily contracts lication. Not surprisingly, many patients have significantly trau- muscles as the proximal tendon stump is pulled distally for matized tendon edges in need of débridement. I use the ASSI repair. A posterior interosseous nerve block is easy to perform Peripheral Nerve and Tendon Cutting Set (ASSI, Westbury, NY) to prevent inadvertent muscle pull; a proximal median nerve to restore quality tendon edges. In this scenario I am more likely to block in the antecubital fossa is a little different. Gaining the use basic science principles (Zhao et al. 2002; Paillard et al. 2002; skill to use an ultrasound or having an anesthesiologist perform Xu and Tang 2003) and débride one slip of the superficialis tendon. the block if needed could be difficult. Teno Fix Repair Rehabilitation After Flexor Tendon Repair A stainless-steel tendon repair device (Teno Fix, Ortheon Med- The rehabilitation protocol chosen (Rehabilitation Protocols 1.1 ical, Columbus, OH) was reported to result in lower flexor ten- and 1.2) depends on the timing of the repair (delayed primary or don rupture rates after repair and similar functional outcomes secondary), the location of the injury (zones 1 through 5), and when compared with conventional repair in a randomized, the compliance of the patient (early mobilization for patients multicenter study, particularly in patients who were noncom- who are compliant and delayed mobilization for patients who pliant with the rehabilitation protocol (Su et al. 2005, 2006). are noncompliant and children younger than 7 years of age). A Active flexion was allowed at 4 weeks postoperatively. Solomon survey of 80 patients with flexor and extensor tendon repairs et al. (unpublished research) developed an “accelerated active” determined that two thirds were nonadherent to their splint- rehabilitation program to be used after Teno Fix repairs: Active ing regimen, removing their splints for bathing and dressing digital flexion and extension maximum-attainable to the palm (Sandford et al. 2008). are started on the first day with the goal of full flexion at 2 In a comparison of early active mobilization and standard weeks postoperatively. The anticipated risks with this protocol Kleinert splintage, Yen et al. 2008 found at an average 4-month are forced passive extension, especially of the wrist and finger follow-up (3 to 7 months) that those in the early active mobili- (e.g., fall on outstretched hand), and resisted flexion, potentially zation group had 90% of normal grip strength, pinch, and range causing gapping or rupture of the repair. of motion compared to 50%, 40%, and 40%, respectively, in The possibility of a more rapid return of function, or at least those with Kleinert splinting. being more forgiving of rehabilitation mistakes, adds some Sueoka and LaStayo (2008) devised an algorithm for zone potential attractiveness to the use of Teno Fix for flexor ten- 2 flexor tendon rehabilitation that uses a single clinical sign— don repairs. At least one research group (Wolfe 2007) noted no the lag sign—to determine the progression of therapy and the benefit of using the Teno Fix system compared to the sutures need to modify existing protocols for individual patients. They techniques they used. What one doesn’t know is the cost to the defined “lag” as PROM—AROM (active ROM) ≥15 degrees consumer of the product. Is the product cost worth the ben- and consider it a sign of tendon adherence and impairment efit? Kubat (2010) describes a case report with multiple tendon of gliding. Rehabilitation begins with an established passive involvement and proposes that, at least with his patient, the ROM Protocol (Duran), which is followed for 3.5 weeks before savings of operative time and its associated expense may make the presence or absence of a lag is evaluated. The presence or using this product more palatable. absence of lag is then evaluated at the patient’s weekly or twice- FDP lacerations can be repaired directly or advanced and weekly visits, and progression of therapy is modified if a lag sign reinserted into the distal phalanx with a pull-out wire, but they is present (Rehabilitation Protocol 1.3). 6 SECTION 1 Hand and Wrist Injuries REHABILITATION PROTOCOL 1.1 Rehabilitation Protocol After Immediate or Delayed Primary Repair of Flexor Tendon Injury: Modified Duran Protocol Marissa Pontillo, PT, DPT, SCS Postoperative Day 1 to Week 4.5 Active wrist extension to neutral only Keep dressing on until Day 5 postoperative. Functional electrical stimulation (FES) with the splint on At Day 5: replace with light dressing and edema control prn. 5.5 Weeks Patient is fitted with dorsal blocking splint (DBS) fashioned in: 20 degrees wrist flexion. Continue passive exercises. 45 degrees MCP flexion. Discontinue use of DBS. Full PIP, DIP in neutral Exercises are performed hourly: 12 repetitions of PIP blocking Hood of splint extends to fingertips 12 repetitions of DIP blocking Controlled passive motion twice daily within constraints of splint: 12 repetitions of composite active flexion and extension 8 repetitions of passive flexion and active extension of the PIP May start PROM into flexion with overpressure joint A B Passive flexion and extension exercises of the proximal interphalangeal (PIP) joint in a dorsal blocking splint (DBS). A, Passive flexion of PIP joint. B, The finger being extended from flexed position. 8 repetitions of passive flexion and active extension of the 6 Weeks DIP joint Initiate passive extension for the wrist and digits. 8 repetitions of active composite flexion and extension of the DIP and PIP joints with the wrist and MCP joints supported 8 Weeks in flexion Initiate gentle strengthening.

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