11/1/2016. Michael Schuk, PT, DPT, ATC Assistant Athletic Trainer/Physical Therapist New York Yankees
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1 Michael Schuk, PT, DPT, ATC Assistant Athletic Trainer/Physical Therapist New York Yankees Surgery Techniques Graft Selection Palmaris Longus Immediate ROM Avoid aggressive stretching x 2 wks Gracilis graft Avoid stretch x 2 3 wks Avoid isolated hamstring for 3 4 wks Bike ok 2 4 wks Isotonics at 6 wks Phase 1: Immediate Post Op (1 3) Phase 2: Intermediate (4 7) Phase 3: Advanced Strengthening (8 13) Phase 4: Return to Activity (14+) ITP (initiated b/w wks) Flat Ground / Long Toss Mound BP/Sim Game Game 1
2 Protect the graft/healing tissue Pain / Inflammation Control Reestablish Non painful ROM Retard Muscular Atrophy Protect the graft/healing tissue Pain / Inflammation Control Reestablish Non painful ROM Retard Muscular Atrophy 2
3 Protect the graft: Infection control Suture Removal: 7 10 days post op Avoid Valgus Stress Avoid ER Post Splint Week 1: Immobilized first 7 days Posterior splint at 90 elbow flexion Hinged Brace (Weeks 2 6/8) Week 2: Week 3: Protect the graft/healing tissue Pain / Inflammation Control Reestablish Non painful ROM Retard Muscular Atrophy Control Pain / Inflammation: Nutrition MEDS (anti inflam) Hivamat Laser ROM E stim Hi volt, IFC Cryotherapy Elbow Joint + Graft Site Compression Sleeve Kinesiotape Lymph drainage Retrograde Massage Scar Mobs (week 2+) 3
4 Protect the graft/healing tissue Pain / Inflammation Control Reestablish Non painful ROM Retard Muscular Atrophy Reestablish NON PAINFUL ROM Pre op # s vs ND side # s Week 1: Wrist AROM (ext/flex) FP detach = no wrist ext x 6 wk mm split = ext ok Knee ROM (if involved) Week 2: Elbow: P/AAROM: Humero ulnar jt (FLEX/EXT) Humero radial + Radio ulnar jt (SUP/PRO) Reestablish NON PAINFUL ROM: Week 3: Wrist/Hand: AROM Elbow: AROM: Flex/Ext Shoulder: AROM Avoid ER (valgus stress) Full Can Lateral raises Scaption Scap: PROM Cervical ROM/Stretch 4
5 Protect the graft/healing tissue Pain / Inflammation Control Reestablish Non painful ROM Retard Muscular Atrophy Retard Muscular Atrophy: E stim: NMES (scap/rtc) Gripping: week 1 Isometrics Submax Wrist Iso s: week 2 Elbow flex/ext: Week 2 (biceps) Shoulder: Avoid ER Scap: squeezes BFR Shoulder/Scap/Wrist & Forearm Other topics for Phase 1: Cardio Bike: week 3 (No LE Graft) Avoid running/jumping = no treadmill 5
6 Promote Healing of Repaired Tissue Gradual Increase to Full ROM Regain and Improve Muscular Strength Restore Full Function of Graft Site Promote Healing of Repaired Tissue Gradual Increase to Full ROM Regain and Improve Muscular Strength Restore Full Function of Graft Site 6
7 Promote Healing of Repaired Tissue Hivamat Soft Tissue / Fascial mobility Scar mobility Promote Healing of Repaired Tissue Gradual Increase to Full ROM Regain and Improve Muscular Strength Restore Full Function of Graft Site Gradual Increase to Full ROM Week 4: Functional Brace set Week 5: Functional Brace set Week 6: 0 145/Full (AROM) Functional Brace set D/C Brace (wk 6 8) PRE TX: Warm Whirlpool/MHP/UBE 7
8 Trouble shooting ROM: Acute (5 6 wks) vs Chronic Tear (6 8 wks) Ideally FULL ROM by week 6 Don t force in early phases!! If still having trouble MEDS (prevent HTO) LLLD 4 x 15 / day produce creep = tissue elongation no pain/mm spasm (low load) Manual Therapy MET s/pnf (Contract/Relax) Joint Mobs G I & II : stimulate type 1 & 2 articular receptors Promote Healing of Repaired Tissue Gradual Increase to Full ROM Regain and Improve Muscular Strength Restore Full Function of Graft Site Regain and Improve Muscular Strength: Week 4: Begin light resistance isotonics (1 lb) + 1 lb per week Wrist: Flex/Ext/Pro/Sup Elbow: Flex/Ext Shoulder: emphasize RTC IR exc permitted thru full ROM ER: limited arc of motion (until 6 wk) Scapular Manuals 8
9 Regain and Improve Muscular Strength: Week 5: Progress exercises Week 6/7: Progress exercises Add/Progress SHOULDER ER Strengthening ER walkouts (iso s) Initiate Thrower s 10 Progress above exercises Increase weight Neuromuscular Drills: Initiate PNF diagonal patterns Proprioception drills/rhythmic stabs (Swiss ball in CKC) RS at mid/end range Promote Healing of Repaired Tissue Gradual Increase to Full ROM Regain and Improve Muscular Strength Restore Full Function of Graft Site Restore Full Function of Graft Site: Wrist: ROM/Strength Thigh: ROM, Gait, Strength 9
10 Increase Strength, Power, Endurance Maintain Full Elbow ROM Gradually Initiate Sporting Activities Increase Strength, Power, Endurance Maintain Full Elbow ROM Gradually Initiate Sporting Activities 10
11 Increase Strength, Power and Endurance Weeks 8 11: Continue Isotonics Wrist/Forearm/Shoulder Initiate eccentric elbow flex/ext Manual resistance diagonal PNF patterns Body Blade Emphasize scap, core, lower body + balance Week 12 13: Initiate isotonic machines (if desired) Bench press (seated) Lat pulldowns (front) Increase Strength, Power and Endurance Initiate 2 Hand Plyo s (week 12) Close to body Chest Pass Side throw (hands close to body) Increase Strength, Power, Endurance Maintain Full Elbow ROM Gradually Initiate Sporting Activities 11
12 Maintain Full Elbow ROM Continue Warm Whirlpool and Contrast Baths LLLD (if necessary) Stretching and Soft Tissue Mob as needed Fascial Mobility Joint Mobs Stretch Increase Strength, Power, Endurance Maintain Full Elbow ROM Gradually Initiate Sporting Activities Gradually Introduce/Inc. Sporting Activities Surgeon Follow Up Week 12: Initiate golf/swimming Initiate interval hitting program (if position player) 12
13 Continue: Increase Strength, Power, Endurance Gradual Return to Sport Activities Continue: Increase Strength, Power, Endurance Gradual Return to Sport Activities 13
14 Continue to Increase Strength, Power & Endurance Week 14: Initiate 1 hand plyo s (stationary) Progress away from body Side to Side Soccer Throw Side Wrist flips / extension grips Week 15: Initiate 1 hand wall dribble Continue strengthening program Emphasis on elbow/wrist strengthening and flexibility ex Continue: Increase Strength, Power, Endurance Gradual Return to Sport Activities Gradual Return to Sport Activities Week 16 20: Initiate ITP: Phase 1 Week 34 38: Progress ITP: Phase 2 Months 8 9 of ITP: Progress to Competitive Throwing/Sports 14
15 Criteria to initiate ITP: Physician Approval / Pass Clinical Exam Full Pain Free ROM Elbow Stability Appropriate time frame Tissue has healed Objective/Goals Build tolerance to incr. demands/stress on elbow Start at 50% intensity and slowly build to 75% 100% Pain Free Take breaks as needed Get the ball there Proper warm up and cool down Jog/Cycle (sweat); Stretch, Activate Provide feedback Amount per week: 3d x/wk Amount per session (time or throws) Phase 1: Initiate ITP Week 16 / 20 (4 5 mo post op) Flat Ground/Long Toss 18 weeks Phase 2: Progress ITP Weeks: 34 / 38 Mound/BP weeks (reliever vs starter) Phase 3: Progress to Competitive Throwing Month 8 9 of ITP Sim Game Game 15
16 Flat Ground Week 1 2: 60 x 25 throws Week 3 6: 60 x 50 throws Week 7 10: x 25 throws + PFP (no throws) Week 11 14: 90 x 50 throws Week 15 18: x 25 throws DOWNLOAD WEEKS: Week 6 Week 12 Week 18 16
17 Mound Week 19 20: ½ mound Side 25 FB Week 21 22: reg mound Side 25 FB Week 23 24: Side 30 FB/CH Week 25 26: Side 35 ALL Week 27 28: Side 45 ALL Week 29: 1 / 20 (BP) Week 30: 2 / 35 (BP) DOWNLOAD WEEK: Week 24 Relievers: Progress to hitters after 35 ALL (week 2) Starters: Progress to hitters after 45 ALL (week 29) M T W R F Sa Su LT Side OFF LT Side OFF x x x x Wk Wk Add CH (flat ground) CH (flat ground) Wk Start Flat Ground Spin Flat Ground Spin Sim Game: Week 31: 1 / Inc intensity Take away L Screen Add defense Offense players are running Game situation Hitters don t know what pitch is coming Game Ready! Starter (2/35) Reliever (1/20) 17
18 Standard for return to competition 12 mo 14 mo 16 mo Down time from throwing (flat ground) Down time from mound progression Velocity based programs Radar Long Toss to 200 ft? 150 or < for 1 st year post op Kevin Wilk Matt Holland NYY Sports Medicine Staff Dr. Chris Ahmad Steve Donohue Tim Lentych Mark Littlefield David Colvin Jeremy Maddox 18
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