neuroplasticity

Can Your Brain Help Your Knee Pain? A Look at Graded Motor Imagery (GMI)

by Uncategorized

Knee osteoarthritis (OA) is one of the most common causes of knee pain in adults. It can lead to stiffness, weakness, and difficulty with everyday movements like walking, climbing stairs, or standing up from a chair. But managing knee OA isn’t just about treating the joint—it’s also about understanding the role your brain and nervous system play in pain and recovery.

When your knee hurts, your brain can actually interfere with how well your muscles work. This is called arthrogenic muscle inhibition—a protective response where the brain “turns down” the activity of muscles around a painful joint, even if they’re still strong. As a result, it becomes harder to move properly, which slows healing and makes pain worse.

That’s where Graded Motor Imagery (GMI) comes in.

🔗 Read the full study here

What Is GMI?

Graded Motor Imagery is a special therapy that helps retrain your brain and nervous system. Instead of focusing only on the painful joint, it targets how your brain processes movement and pain. GMI has three stages:

  1. Laterality Training – You look at images of knees (left and right) and quickly decide which side each belongs to. While this might seem simple, it re-engages the areas of your brain responsible for recognizing movement and body position—without triggering pain. This is often the first step in re-establishing healthy movement patterns and recoding pain signals in the brain.
  2. Motor Imagery – Next, you imagine moving your knee—walking, bending, climbing stairs, or performing rehab exercises. Research shows that simply visualizing movement can activate the same areas in the brain as actual movement, which can “prime” the muscles and nervous system for better function—without physical strain or risk of pain flare-ups.
  3. Mirror Therapy – Using a mirror placed between your legs, you move your healthy leg while watching its reflection, which looks like your painful leg is moving. This visual trick helps your brain reinterpret pain signals and reinforces pain-free movement patterns. Over time, this can reduce discomfort and improve muscle activation in the affected leg.

What the Research Says

A recent study looked at 46 adults with moderate knee OA. Half used GMI plus regular exercises for 8 weeks. The other half used a treatment called TENS (electrical stimulation) plus the same exercises.

Here’s what they found:

1. Pain Relief

  • Both groups had less pain during treatment.
  • Only the GMI group still had less pain six weeks later.

2. Range of Motion

  • Both groups improved how far their knees could bend.
  • The GMI group had more improvement in knee flexion.

3. Strength

  • Everyone got stronger, but the GMI group had better gains in quadriceps strength—and those gains lasted longer.

4. Function

  • On a timed walking test, both groups improved equally.
  • On a self-report questionnaire, the GMI group reported greater improvement in daily function.

What This Means for You

Pain isn’t just physical—it’s also neurological. When your brain learns to associate movement with pain, it can begin to “overprotect” the area, limiting your ability to move, even when structurally, everything is okay. GMI helps rewire those brain pathways, gently restoring the connection between brain and body.

By working from the inside out, GMI encourages your brain to “turn muscles back on” and change how it interprets movement and pain. Unlike tools like TENS, which help manage pain externally, GMI addresses the root of the dysfunction by targeting the central nervous system.

If you’re dealing with chronic knee pain, arthritis, or weakness—even if you’ve tried other treatments—Graded Motor Imagery could help unlock your body’s full potential. It’s safe, science-backed, and designed to help your brain support your healing.

Want to learn more about GMI and whether it’s right for your condition?

📞 Contact us today to schedule an appointment

📍 Or visit Threshold Physical Therapy and let’s start your path toward better movement, less pain, and a stronger you.

👉 Book an appointment with our team today and start your path to better movement.

Predicting Tendinopathy image

Can Ultrasound Help Predict Tendon Injuries in College Athletes?

by Uncategorized

A recent study in the British Journal of Sports Medicine looked at whether ultrasounds can help predict tendon injuries in elite athletes. The researchers focused on three common areas: the patellar tendon, Achilles tendon, and plantar fascia. These parts are often stressed in high-level sports like Division I college athletics.

🔗 Read the full study here

What Are Tendon Injuries?

Tendon injuries – tendinopathies – happen when tendons get inflamed or worn out. This usually comes from doing too much too fast, or not resting enough between workouts. Even everyday athletes can get them, but elite athletes are at greater risk because they push their bodies harder.

At Threshold Physical Therapy, we often help athletes recover from these injuries—and more importantly, we work to help prevent them through smart recovery and training strategies.

How Are These Injuries Usually Detected?

Physical therapists use different tests to check for tendon problems. These include:

  • Palpation
  • Strength tests
  • Sport-specific tests like single-leg single-hop or triple-hop tests

MRIs are often used to look at the tendon quality as well, and is often considered the gold-standard for tendinopathy diagnosis. However, even with these tools, it’s hard to predict when a tendon problem will happen.

What This Study Looked At

Researchers used ultrasound to scan the patellar tendon, Achilles tendon, and plantar fascia in NCAA college athletes from three schools. They looked for:

  • Hypoechogenicity (signs of swelling or tissue damage)
  • Tendon or fascia thickening
  • Neovascularity (new blood vessels that suggest healing or injury)

Then, they followed the athletes for a year to see who developed pain and had to miss practice or games.

What They Found

  • Good news: If the ultrasound looked normal, the athlete probably wouldn’t get a tendon injury. That means ultrasound might be a good way to rule out future problems.
  • Less helpful: If the ultrasound showed something unusual, it didn’t always mean the athlete would get hurt. Even the strongest link (neovascularity) still wasn’t a clear predictor.

Things to Keep in Mind

  • Few athletes got hurt: Only 4.8% had patellar tendon pain, 2.3% had Achilles pain, and 0.8% had plantar fascia pain.
  • Most came back fast: On average, injured athletes only missed one day of sports. But this might be due to the pressure to keep playing, even while in pain.
  • Only college athletes were studied: In general, division one athletes will have more resources for rehabilitation compared to the general population. More research is needed for a wider variety of athletes—like track, long-distance running, or recreational athletes with higher injury risks. 

What This Means for You

Ultrasound may not predict every tendon injury, but it can still be a helpful tool—especially when used alongside smart physical therapy care. If you are having these problems, considering ultrasound or other diagnostic imaging, we can help!

At Threshold Physical Therapy, we stay current on the latest research so we can give our athletes the best chance to stay healthy and on the field. Whether you’re a college athlete or just love to stay active, we can help you recover—and prevent injuries before they start.

👉 Ready to take the next step? Schedule your evaluation with one of our clinicians today!

Heavy lifting image

Heavy Lifting and Your Future Knees

by OrthopedicsPain And Its ManagementSport

Many people believe that lifting heavy weights now could hurt your knees later in life. That sounds like it makes sense—if we wear out our knees, they’ll hurt more later, right?

But new research says the opposite might be true. Lifting weights could actually help protect your knees as you get older.

🔗 Check out the full study here

What the Study Found

A research group called the Osteoarthritis Initiative looked at over 2,600 people. Out of those, 808 people had done regular heavy lifting during their lives. They answered questions about knee pain and got X-rays to check for signs of knee osteoarthritis (OA).

The results were surprising:

  • People who lifted weights had 17–23% lower odds of having knee pain or arthritis.
  • The more often they lifted weights, the better their knees looked and felt.

Why Does Lifting Help?

Here are a few reasons lifting weights contributes to protecting your knees:

✅ Better body movement – Lifting with good form builds muscle balance and stability. This helps you move well, both in and out of the gym.

✅ Fewer injuries – Strong muscles and tendons protect your joints. This can keep the bones and cartilage in your knees from getting hurt.

✅ Improved mobility – A good strength program helps you stay flexible and able to move easily. That can mean less knee pain, even if you already have arthritis.

✅ Healthy body composition– Keeping a healthy body weight while maintaining a good amount of muscle mass is important because extra unnecessary weight can increase stress on your knees. Weight lifting helps with that, too.

At Threshold Physical Therapy, we focus on safe strength training and smart recovery plans that support joint health. Whether you’re new to lifting or already experienced, our team can help you move better and feel stronger.

What If You Already Have Knee Arthritis?

There’s good news here, too.

Many people worry that starting an exercise program—especially one involving weights—might make knee arthritis worse. But current research says otherwise. In fact, a recent systematic review found that strength training is not only safe for individuals with knee osteoarthritis but can actually reduce pain, improve mobility, and enhance quality of life.

The review, published in the journal Personalized Medicine, analyzed multiple studies involving patients with varying degrees of knee OA. It concluded that progressive resistance training—when properly guided and tailored to the individual—has significant benefits for joint health, functional ability, and even mental well-being.

🔗 Read the full review here

Key Findings:

  1. Pain Reduction: Strength training reduced reported pain levels in people with mild to moderate knee OA.
  1. Improved Joint Function: Participants showed better knee control, increased range of motion, and faster walking speeds.
  1. Muscle Support: Strengthening the muscles around the knee, particularly the quadriceps, helped offload pressure from the joint.
  1. Long-Term Benefits: With continued training, participants were better able to maintain mobility and independence.

Bottom Line

Lifting weights may be one of the best things you can do to protect your knees—both now and in the future.

When done correctly, strength training helps reinforce the muscles that stabilize your knee, reduces mechanical stress on the joint, and enhances your body’s ability to move confidently and pain-free. And for those already diagnosed with OA, it can slow progression and reduce symptoms.

Not Sure Where to Start?

If you’re dealing with knee pain or have been diagnosed with arthritis, you don’t have to navigate strength training alone. At Threshold Physical Therapy, we specialize in designing safe, effective, and personalized rehab programs for people with joint concerns.

Whether you’re completely new to exercise or returning after an injury, our team will help you:

Strengthen key muscle groups that support the knee

Avoid movements that aggravate symptoms

Improve balance, stability, and confidence

Build a sustainable routine for long-term joint health

✅ You don’t have to choose between movement and safety—you can have both.

📅 Book an appointment with our team today and take your first step toward stronger, healthier knees.

The Sleepy Athlete: Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis

The Sleepy Athlete

by OrthopedicsSport

Sleep and athletics. Athletics and sleep. We know that sleep is important. We know it is tied very closely to performance. We know that during sleep procedural memories are consolidated, immune responses are augmented, and anabolic metabolism is upregulated. There has even been a positive correlation with sleep duration and injury risk in adolescents…

The British Journal of Sports Medicine published an article (2018) looking at how the demands of competition and training affect sleep. 

Fifty-four studies were included (1997 – 2018) looking at sleep:

  • the night of competition,
  • the night before competition,
  • with the effects of training schedules,
  • with the effects of training load,
  • with the effects of hypoxia or altitude, 
  • with air travel
  • with the use of electronic devices

So, if we’re looking to achieve the highest attainable performance level when competing, we need to manage the factors that affect sleep and sleep quality as best we can. 

After a hard night of competition? Athletes rarely achieve total sleep time and/or sleep efficiency recommendations the night of competition. This is often attributed to a delay in bed time, as well as increased circulating cortisol, sympathetic hyperactivity, elevated core body temperature, muscle pain/soreness, and post competition arousal. 

Do the “nerves” get you? Regarding the night prior to competition, there was not consistent evidence from the systematic review to suggest sleep disturbances among athletes. It appears that there may be a subset who are more susceptible including individual athletes and those who compete in aesthetic sports.

Getting up early to train? Although athletes try to offset early morning training by going to bed earlier, this is rarely accomplished. Thus we see a reduction in total sleep time on nights prior to training when training commenced at or before 7:00am. The results indicate that most athletes go to bed about thirty minutes earlier, but get up about 90 minutes earlier resulting in a net sleep debt. 

Pouring on the coal? It was found that training load increases greater than 25% were correlated with decreases in total sleep time and sleep efficiency. This is thought to occur secondary to increased circulating cortisol and sympathetic activity which may prevent the normal down regulation of the human stress systems. 

Traveling high to compete? Exposure to high altitudes (over 2000m or 6500ft) and hypoxia had negative effects consistent with previous literature demonstrating lighter, more fragmented sleep. Interestingly, these are attributed to arterial desaturation (and thus a hyperventilatory response) and sympathetic hyperactivity. 

How about traveling by plane? Both late night and early morning flights were found to negatively affect sleep. Interestingly, eastward travel found decreased total sleep time while westward travel provided increased total sleep time upon arrival. Eastward travel appears to be more disruptive to sleep.

What about the devices?? We know blue light can cause sleep disturbances and delayed bed time and reductions in total sleep time was been associated with electronic device use. However, a study looking to reduce electronic media use after 10:00pm did not improve sleep habits in high school athletes. 

When we’re looking to promote of every possible advantage in competition, good sleep is an irrefutable component to focus upon. Knowing what factors may contribute to performance and how to modify these for success can be crucial. 

Thanks for reading!

Throwing Athlete - Return to Sport as an Outcome Measure for Shoulder Instability

Shoulder Instability: Surprising Findings in Nonoperative Management in a High School Athlete Population

by OrthopedicsSport

I speak from personal experience when I say that there is nothing like the experience of dislocating a joint. It’s as if your body knows something is really, really not ok followed by a certain nausea deep in the pit of your stomach. Having been through over 100 dislocations and two shoulder surgeries, I feel a deeper connection and sympathy for those experiencing shoulder issues and pathology. Being such a complex joint, there is also a deeper understanding of the complexity and individualized nature…

When considering high school athletes (…and where my shoulder and Physical Therapy journey started), The American Journal of Sports Medicine published a recent article looking at conservative versus surgical treatment for shoulder instability and return to sport.

Shanley et. al. (2019) looked at 129 scholastic athletes over 4 years. Interestingly, 85% of the nonoperatively treated and 72% of the operatively treated athletes successfully returned to the same sport without injury for at least 1 full season! Those within the nonoperative group that failed, 11 of 15 individuals, went on to operative care with 82% of the athletes successfully returning to sport by the next season.

Consider, more of those treated nonoperatively returned than those who were treated operatively. AND, if the nonoperative didn’t work – the athlete could still have the surgical intervention afterwards!! If this doesn’t speak to physical therapy first, I’m not sure what does!

Keep in mind that the athlete was run through a high-quality, multi-disciplinary rehabilitation program with a stringent return-to-sport clearance. Return-to-sport criteria included: absence of pain at rest, with training, or during activity; the absence of an apprehension sign; symmetrical shoulder range of motion (90% of unaffected side); a 67% external:internal rotation ratio within the affected extremity; and the ability to load upper extremity body weight during functional movement without apprehension.

Thanks for reading!

Dry Needling vs Corticosteroid Injection for Plantar Fasciitis Threshold Physical Therapy and Performance

Dry Needling vs Corticosteroid Injection for Plantar Fasciitis?

by OrthopedicsPain And Its ManagementSport

It’s there again… That pain in the bottom of the foot at the heel. Standing up in the morning is pure agony, like a hot butter knife cutting into the bottom of your foot. Maybe it’s better to just stay in bed? Too bad someone can’t just roll you into work today…

Everything was fine until you picked up that spring club sport again. It just seemed like a good idea at the time with the weather being so nice. At least the pain will calm down after a bit of limping around here this morning. What was it called? Plantar something-or-other…

What to do? What to do??

Plantar fasciitis (acutely) or plantar fasciosis (chronically) is a fairly common problem. Often reported as a stabbing or tearing pain in the bottom of the foot (plantar surface) and is worse with the first few steps of walking when getting up in the morning. It can also flare with longer bouts of standing, or when raising after sitting for longer periods. Often it is worse after exercises, as opposed to during. 

Treatments for such symptoms and a diagnoses have been noted to include calf and plantar fascia stretching exercises, local injections of corticosteroids and botulinum toxin, extracorporeal shock wave therapy, ultrasound scanning, radiofrequency ablation, cryopreserved human amniotic membrane injection, taping, and endoscopic release. All that being said, optimal treatment continues to be debated.

A recent (2019) study by Esat et. al. in The Journal of Foot and Ankle Surgery compared corticosteroid injection versus dry needling with some interesting results.

Wait, so they might stick a needle into the bottom of my foot?? Frankely, it’s not as bad as it sounds, and this is a case where size does matter… Dry needling needles are smaller!

So what do we know now that we didn’t know prior to this study? Well, with patients suffering from plantar fasciitis being assessed at three weeks and six months post-treatment, the differences might be surprising. Interestingly, the corticosteroid injection group showed a significant loss of efficacy at 6 months. However, in the dry needling group, there were no significant differences in results between the third week and sixth month. 

Dry needling was as effective as the corticosteroid injection at three weeks without the risks of the steroid (plantar fascia rupture, local infection, and fat pad atrophy) for pain, disability, and activity limitations. Not only that, but it outlasted the medication with better outcomes at six months! 

The authors note that this study should lead physicians to consider needling and further research should look at whether the key point in treating plantar fasciitis is peppering into the fascia or the induction of microbleeding.

For those that want to geek out just a bit more:

  • Although corticosteroid injection has antiinflammatory effects on tissues, dry needling can reduce pain by affecting substance P, beta-endorphin, and local blood flow levels
  • Dry needling has been shown to be effective against tendinitis
  • In this study, the most common adverse effects of dry needling were pain (38%) at the needling site and subcutaneous bleeding (12%).
    • Those were the unwanted effects of needling during the process and did not last very long

Reach out to your local providers to see if dry needling might be appropriate for your symptoms! Thanks for reading!! 

Threshold Physical Therapy and Performance Pain Recommendations

Eleven Consistent Recommendations for Musculoskeletal Pain

by Pain And Its Management

There is an interesting phenomenon in the realm of neuroscience and memory where each time you recall the past your brain networks change in a way that can alter the later recall of the past. 

Why bring this up in a musculoskeletal pain post?

I would argue that as often as we want to believe we are correct about something, it may be important to review what we think we know and (especially with regards to medical research) look to see if something has changed over the past year … or two … or five … or ten … or twenty…

A 2019 systematic review by Lin et. al. in the British Journal of Sports Medicine reviewed 44 clinical practice guidelines finding eleven consistent guidelines for best practice care of musculoskeletal pain.

Two things worth noting before we get into the eleven guidelines.

  1. Clinical practice guidelines (or CPGs) are a synopsis of, typically, high-quality and current evidence to help — wait for it — guide clinical practice for more efficient and effective care. As it can be challenging to balance busy clinical care and keeping up with the thousands of medical research articles that are published every year, these CPGs can help to streamline the literature to practitioner flow… Ultimately, they have been found to result in better patient outcomes and lower costs.
  2. What is musculoskeletal pain and why is it a problem?
    • Musculoskeletal pain conditions are the biggest cause of disability internationally and include pain that arises from the muscular and/or skeletal systems. 
    • Worth noting from the background of the Lin et. al. article:
      • There is an overuse of medical imaging with between 25% and 42% of those with low back pain receiving this despite its routine use being discouraged secondary to the associated harms.
      • There is an overuse of surgery where, for example, arthroscopy for knee osteoarthritis is not recommended yet has an increased rate of use in the US from 2006 to 2010, and we see an increased rate of subacromial decompression at the shoulder despite comparable outcomes with exercise-based rehabilitation and sham surgery. Yes, you read that correctly, the real and fake surgery have comparable outcomes…
      • There is an overuse of opioids despite questionable efficacy of opioids for musculoskeletal pain (both chronic and acute), evidence for poorer outcomes with individuals suffering from low back pain, and notable opioid-related harms. 
      • Lastly, these is a failure to provide appropriate education and advice where only 20% of individuals have been found to receive education in the primary care setting. This is considered the cornerstone of managing musculoskeletal pain conditions. 

Ok, referring back to the portion above – do we know what we think we know? And, if we know it, are we doing the best things?

So what ‘should’ we be doing? Per the Lin et. al. (2019) article: 

  1. Care should be patient centered.
    • This includes care that responds to the individual context of the patient, employs effective communication and uses shared decision-making processes.
  2. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions.
    • Examples included suspicion of infection, malignancy, fracture, inflammatory causes of pain, severe and progressive neurological deficit (including cauda equina syndrome) and serious conditions that masquerade as musculoskeletal pain, for example, aortic aneurysm
  3. Assess psychosocial factors.
    • These factors included ‘yellow flags’, mood/emotions (depression and anxiety), fear/kinesiophobia and recovery expectations.
  4. Radiological imaging is discouraged unless:
    • i. Serious pathology is suspected.
    • ii. There has been an unsatisfactory response to conservative care or unexplained progression of signs and symptoms.
    • iii. It is likely to change management.
  5. Undertake a physical examination, which could include neurological screening tests, assessment of mobility and/or muscle strength.
    • “the repercussions of not performing an examination would lead to dissatisfaction and unwarranted demand for tests or further referrals”
  6. Patient progress should be evaluated including the use of outcome measures.
  7. Provide patients with education/information about their condition and management options.
  8. Provide management addressing physical activity and/or exercise.
  9. Apply manual therapy only as an adjunct to other evidence-based treatments.
    • Manual therapy was consistently recommended as a component of multimodal care, in conjunction with other management strategies, including exercise, psychological therapy, information/education, and activity advice rather than a stand-alone treatment
  10. Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery.
    • There is literally an army of conservative practitioners ready and willing…
  11. Facilitate continuation or resumption of work. 

As a quick aside and to reiterate #1, it’s important to keep in mind that what may be appropriate for any given individual is specific for that individual. This is why Google is not good at diagnostics and why your doctors hold a doctoral degree. Just important things to keep in mind…

With regards to more specific recommendations within a single pain condition:

  • Osteoarthritis (OA)
    • Offer self-management programmes.
    • Provide interventions targeting weight loss to people with OA who are overweight or obese.
    • Do not use glucosamine or chondroitin for disease modification.
    • Do not undertake knee arthroscopic lavage and debridement unless there is a rationale (such as mechanical knee locking).
  • Low back pain
    • Do not offer paracetamol as a single medication.
    • Do not offer opioids for chronic LBP.
    • Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants or anticonvulsants for LBP.
    • Do not offer rocker shoes or foot orthotics.
    • Do not offer disc replacement.
    • Only offer spinal fusion if part of a randomised controlled trial.
    • Spinal injections (eg, facet joint injections, medial branch blocks, intradiscal injections, prolotherapy and trigger point injections) should not be used for LBP.
  • Neck pain
    • Neck pain disorders should be classified as grades I–IV.

So, as a clinician, are you using best evidence to care for your patients? AND, as a client or patient are you asking for and getting what is best for your care? 

Thanks for reading!

Threshold Physical Therapy and Performance #beatthecopay

ACL Reconstruction: What to use???

by OrthopedicsSport

Imagine… You’ve had a really bad day…

A friend called asking if you wanted to meet for a pick up game. It seemed like a good idea at the time! But, then you pivoted to intercept that pass, heard the knee ‘pop’, and collapsed in pain. The crazy bad swelling set in crazy fast. The physician at the urgent care place says it’s probably your ACL (anterior cruciate ligament) and you should schedule a consultation with an orthopedic surgeon, and (just maybe) they are progressive enough to also recommend some prehab with physical therapy to speed the recovery. 

So, you get home and decide to hop on Google to do a little research. Of course, the Google results diagnose you with death. It’s probably the black plague from your neighbors sickly pet…

Over the course of your research you decide to watch a youtube video on the ALC surgical procedure. You’ve had better ideas and now, not only does your knee feel sore and unstable, you’re feeling a little queasy. It is here that you realize that several types of tissue grafts can be used to reconstruct the ACL.

Wait. Wait. Wait. They are going to take a strip of tissue from somewhere else in your body to make your new ACL? Yep, it’s called an autograft and (more than likely) it’ll work out better than taking it from some dead individual (called an allograft), or a pig (yea, the domesticated omnivore). 

So, what can they take? What should they take? The optimal graft source remains a topic of controversy…

We’ve got the bone-patellar tendon-bone (BPTP), but there are well-documented issues including pain at the anterior/front of the knee, difficulty kneeling, increased incidence of mid- and long-term osteoarthritis, and possible kneecap fracture or rupture of the tendon. Yep, that last part is probably as bad as it sounds, but BPTP is an option on the table…

Then, we’ve got a hamstring tendon graft. Talk about a pain in the … well, you know. Again though, we’re seeing issues including weakness in hip extension and terminal knee flexion, higher infection rate, graft laxity (especially in females over time), and variable graft size and length. 

More recently, a graft from the quadriceps tendon (from the muscles at the front of the thigh down to the kneecap) has been looked at with serious potential. Even though it’s 2019, this method was advocated for back in 1979 and 1984. A recent ahead-of-print article in the American Journal of Sports Medicine published a systematic review looking at outcomes for quadriceps tendon vs bone-patellar tendon-bone, and hamstring-tendon autografts for ACL reconstruction. The good news – you have options!

What does the research say? In short, and when looking at the clinical and functional outcomes, the results for the quadriceps tendon were comparable to the hamstring tendon and bone-patellar tendon-bone. Additionally, the quadriceps autograft had less harvest site pain when compared to the bone-patellar tendon-bone, and better functional scores when compared to the hamstring-tendon graft. 

If we want to dive a little deeper into the literature findings from the review for quadriceps tendon ACL reconstruction:

  • Knee stability outcome and graft survival rates were comparable to patellar and hamstring tendon
  • Anterior knee pain was reported in only 6.1% of the cases
  • Graft failure (possibly worst case scenario) was shown in only 2.1% of the cases
  • Earlier return to activity and higher patient satisfaction
  • It doesn’t seem to be detrimental to the extensor mechanism with equivalent level muscle recovery at 1 year
  • Harvesting the central quadriceps free tendon leaves a stronger extensor mechanism when compared to harvesting of a patellar tendon graft 
  • Less analgesic consumption and less pain immediately postoperatively 
  • Earlier complete knee extension
  • Improved maturity of the graft at 6 months

The authors note some limitations in the study including differences in surgical techniques, quadriceps with or without bone block, hamstring with different muscular components and strand count, different fixation methods, and a lack of standardized rehabilitation protocols.

Despite the unfortunate injury, you’ll be on your game when you speak with the orthopedic surgeon discussing what might be best for you as an individual, and with regards to what is best functionally for recovery. Thanks for reading!

Threshold Physical Therapy and Performance Blood Flow Restriction

Blood Flow Restriction: Proximal, Distal, and Contralateral Effects

by OrthopedicsSport

Blood flow restriction (BFR) as been shown to promote greater increases in strength, hypertrophy, and endurance, when compared to low-load training alone, in healthy study subjects. Previously, significant gains have been shown in muscle fiber recruitment, hypertrophy, muscle circumference, and endurance. These then translated, functionally, into improvements in overall strength. Worth additional note, the technique has been shown to limit muscular atrophy that commonly occurs after an injury or surgery when considering a rehabilitation augmentation perspective. 

A recent 2019, ahead of print article in the multidisciplinary journal Sports Health, looked at the clinical efficacy of BFR training on muscle groups proximal, distal, and contralateral (non-BFR limb) to the tourniquet placement. Their study showed some interesting results…

First though, let’s consider what BFR training is, as well as how it is thought to be effective. BFR training typically consists of low-load exercises performed while wearing an inflatable tourniquet about the proximal aspect of the limb. This, as the authors note, results in partial restriction of the arterial flow and venous return which ultimately increases overall strength with effects similar to high-load training. It is thought that the increased metabolic stress from the restriction may upregulate various cellular signaling pathways in the hypoxic (decreased oxygen) environment resulting in adrenergic and hormonal changes resulting in muscular adaptation. These changes appear to include increased muscle protein synthesis, gene regulation of muscular satellite cells, fiber recruitment, hypertrophy, and endurance.

Interestingly the authors, Bowman et. al. (2019), reinforced much of the prior literature with regards to what has been previously found. Low-level BFR training produces substantially greater increases in strength both proximal and distal to the tourniquet placement. Also interesting, there were some changes contralaterally (at the non-BFR limb), but the authors note that a larger study cohort may be necessary to fully detect these smaller changes.

Worth noting, the most common complaints with BFR training are pain and discomfort which generally improve with treatment, and resolve when the treatment is stopped. A previous study also found complications including: bruising (13%), localized numbness or cold feeling (1.3%), light-headedness (0.28%), deep vein thrombosis (0.06%), pulmonary embolism (0.008%), rhabdomyolysis (0.008%), and worsening ischemic heart disease (0.02%).

If you’re looking to nerd out just a bit more on the science, some of the effects of BFR training include:

  • Improvements in aerobic exercise with increased stroke volume and VO2 max at a decreased heart rate
  • Hypertrophy of both types 1 and 2 skeletal muscle, as well as increased glycogen stores
  • Increases in growth hormone, cortisol, insulin-like growth factor 1, catecholamines, lactate dehydrogenase, nitric oxide synthase, vascular endothelial growth factor mRNA, hypoxia-inducible factor 1-alpha, and various heat shock proteins
  • Proliferation of myogenic stem cells

Blood flow restriction training continues to gain literary support in both the performance and rehabilitation arenas. Is it something that may be beneficial for you? Thanks for reading!

Threshold Physical Therapy and Performance Field Youth Concussion

Exercise As Medicine: Youth Concussion

by Sport

It has been found that individuals aged 14 to 25 years are disproportionately affected by concussion and, after suffering the injury, take longer to recover when compared to adults. A 2018 article, published in the Journal of Neurologic Physical Therapy, looked at some of the current concussion-related brain changes, recent research on the effects of exercise and physical activity, and the authors provide a potential progression after concussion.

The concussion injury results in a range of pathophysiological changes that may occur, and sets into motion a complex cascade of metabolic and neurochemical events. Additionally, it has been found that roughly 20% individuals who have suffered even one concussion present with persistent, clinically significant, physical and cognitive symptoms years afterwards. The diversity of external factors (location of injury, severity, and individual response), as well as the evolving secondary changes can result in unique and dramatic alterations in brain structure and function. For example, microscopic tears in the white matter of the brain and global changes in functional brain networks, where adolescence itself is a unique period of white matter development.

The current guidelines for returning to activity after a concussion injury include a brief period (about 3 days) of physical and cognitive rest. At the same time, appropriate exercise and activity levels continue to be supported in the literature for positive changes in brain neurophysiology. As an example, after moderate to severe brain injuries, fitness training has been shown to influence depression, physical symptoms, and self-reported health status positively. In fact, it is now recognized that prolonged rest (greater than 3 days) and activity restriction is not beneficial for recovery. Interestingly, although youth who have suffered a concussive injury do take longer to recover, there is no evidence that they require more time to rest. 

To support this, the authors noted both a retrospective and prospective study. In the retrospective, youth athletes who engaged in low to moderate physical activity and cognitive tasks experienced fewer symptoms and better neurocognitive test performance when compared to those who engaged in no physical activity as well as those who engaged in high levels of activity. Prospectively, youth with concussion who participated in moderate physical activity within 7 days of their injury had significantly fewer symptoms than those who were restricted. 

The authors proposed a progression of engagement, consistent with guidelines, for return to physical activity, exercise, and sport. They do note that it is a framework and would benefit from being experimentally tested, and should be used in conjunction with clinical judgement as well as consultation with the youth, family, and an interdisciplinary team.

Threshold Physical Therapy and Performance JNPT Screen Shot

It should also be noted that it is possible that vigorous exercise in the acute phase of recovery after concussion may be associated with disrupted brain dynamics and increased symptoms. Until more research is done, we don’t necessarily know the immediate and long-term neurophysiological responses of this type of exercise. 

We know that engagement in structured physical activity is a key element in concussion intervention. This follows the knowledge that there are clear benefits for neuroplasticity and recovery (brain health) after physical activity and exercise. Worth noting regarding youth concussion, implementation of exercise as daily therapy should involve a scheduled routine and incorporate peer networks for compliance. Additionally, and of significant importance, the activity after concussion should be limited to activities that do not put the individual at risk for another concussive injury. Also, encouraging social activities and allowing moderate use of social media can promote recovery and minimise the risk of post-concussive symptoms. 

Are you or someone you know recovering from a concussion? Working with your local physical therapist to find, and progress, appropriate levels of physical activity and exercise will be significantly beneficial! Thanks for reading!!