Brian Schiff’s Blog

The tensor fascia lata (TFL) is a problematic muscle for many clients. In many cases, it is synergistically dominant over the gluteus medius and often contributes to tightness associated with the IT band. Its actions are primarily hip flexion and abduction, and it tends to be tight in many runners and athletes I see. Performing targeted soft tissue mobilization can help resolve myofascial tightness as well as promote better activation and preferential recruitment of the gluteus medius.

Many people argue the effectiveness of foam rolling the IT band itself. While I am not inclined to ignore it altogether, I do believe that foam rolling probably has a far greater impact on the length/tension of the soft tissue beneath and associated with the IT band (e.g. glutes, quads, hamstrings and TFL). The TFL is often full of trigger points.

Below is a video I created for my Functionally Fit column for PFP Magazine. Employing some routine soft tissue mobilization will help reduce hip flexor tightness and help reset the neuromuscular system and set the stage for enhancing preferential gluteus medius activation during training exercises.

SLAP tears are a common problem for overhead athletes among others today. There is no consensus per se in how to treat them and results following primary repair are mixed. Common complaints following a repair are persistent pain and stiffness. In the past, I have writtne about SLAP tears as well as outcomes for elite pitchers.

In addition, I have discussed outcomes for type 2 SLAP tear revision surgery on this blog.  What always concerns me (and more importantly patients who undergo surgery is how to achieve predictable pain relief and recover shoulder function.  In the April 2014 edition of the American Journal of Sports Medicine, there is a level 4 prospective study by McCormick et al. looking at the efficacy of subpectoral biceps tenodesis as a viable solution for failed primary SLAP repairs.  The study took place from 2006-2010 and all procedures were performed by 2 fellowship trained surgeons at a tertiary military facility.

Subjects: Active-duty men and women b/w 18 and 50 years old who had arthroscopically confirmed type 2 SLAP lesions and who then underwent arthroscopic repair and were subsequently unable to return to duty(follow-up period was 2-6 yeaers with mean follow-up of 3.5 years).  They also had to consent to a biceps tenodesis to address the failed repair.  All told, 42 of 46 patients completed the study.  The mean age was 39.2, while 85% of the subjects were male.

Criteria to be included in the study: inability to return to active duty within a minimum 6 months of surgery, ASES score less than 75 at 1 year follow-up from the primary procedure, or patient electing to undergo revision surgery due to dissatisfaction with the primary results.

Procedure: Biceps tendon was released and the remaining stump was debrided so the superior labrum was confluent with the remaining labral tissue.  All sutures and loose anchors were removed.  If the rotator cuff interval was inflamed, debridement with a 4.o mm shaver was used and/or radiofrequency wand was used.  Next, a 2 cm incision was made in the axillary skin crease at the inferior border of the pec major.  The biceps tendon was anchored 1 cm proximal to the musculotendinous junction using a nonabsorbable suture and 8 x 12 interference anchor fixation.

Rehab protocol: Patients were in a sling for 4 weeks with no active biceps use for 6 weeks.  They all underwent graded supervised physical therapy consisting of an initial 6-week phase of passive ROM exercise in addition to scapular and core strengthening. This was followed by progressive strengthening at 6 weeks and return to-duty-evaluation at 3 months post-op.

Results

• 34 patients (81%) returned to active duty
• Clinically significant improvement across all outcome measures after revision surgery as follows:

1. Pre-op ASES = 68 and post-op ASES = 89
2. Pre-op SANE = 64 and post-op SANE = 84
3. Pre-op WOSI = 65 and post-op WOSI = 81
4. Pre-op shoulder flexion = 135 and post-op shoulder flexion = 155
5. Pre-op shoulder abduction = 125 and post-op shoulder abduction = 155

Summary

Currently, there is no standard of care for failed SLAP repairs.  One previous case control study by Boileau et al. found higher satisfaction in those undergoing biceps tenodesis compared to arthroscopic repair in the management of an isolated SLAP tear. Further, in the Boileau study there were no failed tenodesis procedures and those opting for that as revision had a full return to previous sports activity.  This prospective study by McCormick et al. resulted in similarly high rates of return to previous activity and clinically significant improvements in outcome scores and ROM.

There are several reasons why primary SLAP repairs may fail including: postoperative stiffness as a result inadvertent restriction of physiological biceps excursion or nonanatomic biceps anchor reduction, suture anchor pullout, suture granuloma formation, suture pullout, synovitis, glenoid osteochondrolysis from prominent hardware, a suprascapular nerve injury (due to prominent mendial hardware placement), and a delaminated long head of the biceps.

It is also important to keep in mind the anterior-superior labrum and glenoid are poorly vascularized, and this is thought to limit the healing process.  Persistent pain may manifest after surgery in light of the fact the proximal intra-articular portion of the long head of biceps tendon contains sensory and sympathetic fibers associated with shoulder pain.  The authors’ findings at the revision procedure in this study suggest a consistent constellation of multifactorial complicating factors including: synovitis of the rotator cuff interval, loose knots, and a lack of healing at the glenoid interface.

Key takeaways

• Outcomes following primary SLAP repairs are inconsistent and patients often continue to c/o persistent pain and stiffness
• Military personnel (an extremely active population) had excellent results with a tenodesis procedure
• The results of this study cannot be generalized to the general public nor overhead athletes per se
• This study did not employ randomization nor did it compare the tenodesis to another procedure/modality so further research should be done on this
• Biceps tenodesis seems to provide a safe and effective treatment option for failed SLAP repairs at a  minimum of a 2 year follow-up in active individuals

References

Boileua et al. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. 2009;37(5):929-936.

McCormick et al. The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs. Am J Sports Med. 2014;(42):820-825.

Many athletes and clients struggle with hamstring muscle activation.  A normal quad to hamstring ratio would be 3:2, but studies often find that subjects tend to be closer to 2:1 (especially females).  This diminished ratio can increase knee injury risk (non-contact ACL) with jumping and cutting sports.  Some people struggle with proximal hamstring tendinopathy related to overuse.  Incorporating eccentric hamstring exercises in your training can markedly improve hamstring strength and activation patterns.

Quad/Ham dynamic relationship

I must admit that I am always looking for new ways or tools to enhance my practice and work as a sports physical therapist. I recently completed the necessary hours of training to perform dry needling in the state of North Carolina. I trained with Myopain Seminars and have nothing but great things to say about their courses.

For those unfamiliar with trigger point dry needling (TDN), it is a treatment gaining traction in the therapy world. Dry needling is a treatment that involves a very thin needle being pushed through the skin to stimulate a trigger point. Dry needling may release the tight muscle bands associated with trigger points and lead to decreased pain and improved function for those suffering from pain related to muscular dysfunction.

Trigger points may ultimately refer pain to other sites, and research indicates that TDN can reduce acidity in the muscle and clear out pain propagating chemicals. The picture below is an example of me performing trigger point dry needling to the upper trapezius of a 16 y/o female.

This particular client had been suffering from an inability to lift the arm above shoulder height and marked shoulder pain since September 2013.  She also mentioned having headaches at school.  Clinically, she was diagnosed with multi-directional instability and scapular dyskinesis by the referring MD. We began working on a scapular stabilizer and rotator cuff strengthening program in late November that was helping to diminish pain and increase function. However, she continued to c/o pain in school, stiffness and headaches.

Continue reading…

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