Exercise Progression Strategies for the Knee & Shoulder · Rest: 30-90 seconds ... Tip: Add towel...

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Exercise Progression Strategies for the Knee & Shoulder: An Evidence-Based Approach

Eric J. Chaconas Morey J. Kolber

Exercise Progression Strategies

for the Knee & Shoulder

Eric J. Chaconas, PT, DPT, CSCS, FAAOMPT

Morey J. Kolber, PT, PhD, OCS,CSCS



Course Objectives

• Recall evidence-based implications for incorporating specific exercise strategies to the shoulder and knee in clinical practice.

• Discuss the principles of exercise dosing and prescription.

• Examine clinical and basic science research related to exercise progression at the shoulder and knee.

• Recognize appropriate rehabilitation exercises for the shoulder and knee.



Exercise• Load placed on the body in order to achieve a

physiological response

• Goal: functional movement pattern improvement

– Motor Control

– “Timing” “Activation”

– Strength: eccentric, concentric, isometric

– Hypertrophy

– Power

– Speed

– Endurance

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Eric J. Chaconas Morey J. Kolber 4

Other Benefits to Consider

• Reversing pathophysiology

• Stress/injury tolerance

• Desensitization

• Reduce fear of movement

• Reducing systemic disease risk factors



Treatment Progression

Mobility and Palliative Care

Motor Control, Strength, Proprioception

Endurance, Power, Functional



Considerations

• Patient goals

• Tissue healing

• Bio-psychosocial variables (coping skills)

• Limitations (i.e. number of treatment sessions)

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Exercise Order

• Complex movements first– Fatigue will impair movement patterns

– Warm up exercises should be very short in duration

• Exercise order example: ACL rehab 6 weeks post surgery– Squat 2 x 8

– Leg Press 3 x 15

– Single leg proprioception training 3 x 45 seconds

– Side stepping with resistance band 30 feet x 4

– Side plank 2 x 1 minute

– Straight leg raise 3 x 25



Intensity

• Inversely related to duration of rest period

• Can not increase intensity without sacrificing

some other parameter

– i.e. higher intensity = lower volume

• Intensity should be modified based upon

specific exercise goal



Frequency

• Most common parameter that is arbitrarily chosen

– i.e. 3 times per week, home exercise program every day

• Total session volume

• Frequency must match the goal of the exercise

program

– Reversing inhibition

– Motor control/movement re-learning

– Strength development

– Power development

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Dosing Strategies

• What are your goals?

–Timing or activation?

–Strength vs. endurance vs. power vs. hypertrophy?

– Is there atrophy?

–What muscle fiber type needs to be recruited?

–What about bioenergetics?

–How will you know you are dosing correctly?



Resistance Training Variables

Power Intensity:75-90% 1RM

Sets: 3-5

Repetitions: 1-5

Rest: 2-5 min

Strength Intensity:> 85%1RM

Sets: 2-6

Repetition: 6

Rest: 2-5 min

Hypertrophy Intensity:67-85%1RM

Sets: 3-6

Repetition: 6-12

Rest: 30-90 seconds

Endurance Intensity:< 67%1RM

Sets: 2-3

Repetition: 12

Rest: 30 sec

*Rest = between sets & exercises



Muscle Performance Impairments

Ideal goals for exercise selection:

•Maximal activation

•Maximal isolation

Reality:

• Exercises that maximally activate: perpetuate imbalances

Early rehabilitation needs:

• Exercises that activate (timing) key muscles

• Minimize undesirable recruitment

Late rehabilitation:

• Maximal activation

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Shoulder Complex

• Weakness/Impairment

– External rotators

– Serratus anterior

– Lower trapezius

• Imbalances

– Internal/External rotation

– Abduction/External rotation

– Upper/Lower trapezius

– Upper trapezius/Serratus anterior



Muscle Imbalances: Strength/Timing

Internal*/External RotationMacDermid et al, J Shoulder Elbow Surg, 2004; Marcondes et al, Rev Bras Fisioter, 2013;

Alderink et al, J Orthop Sports Phys Ther, 1986; Tata et al, J Orthop Sports Phys Ther, 1993

Abductor/External RotationReddy et al, J Shoulder Elbow Surg, 2000; Sharkey & Marder, Am J Sports Med, 1995

Upper Trapezius/Serratus AnteriorWadsworth, Int J Sports Med, 2007; Ludewig, Phys Ther, 2000

Upper/Lower TrapeziusChester, BMC Msculoskelet Disord, 2010; Cools et al, Scand J Med Sci Sports, 2007 ; Cools et

al, Am J Sports Med, 2003 ;Lin et al, Clin Rheumatol, 2005



Talking Point: Prone Scapular “Y”

Muscle % MVIC

Lower trap 97

Middle trap 100+

Upper trap 79

Serratus ant 43

Lat delt 90

Post delt 88-100+

Infraspinatus Up to 85

Supraspinatus 65-82Boettcher et al, Med Sci Sports Exerc, 2009; Ekstrom et al, J Orthop Sports Phys Ther, 2003

Reinold et al, J Orthop Sports Phys Ther, 2004; Blackburn et al, Athl Train, 1990

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Impairment: External Rotator Weakness



External Rotator Muscle Performance

ER at side:

Teres minor 84% MVIC

Infraspinatus 46-73% MVIC

Supraspinatus 20-51% MVIC

Lower trapezius 48% MVIC

Lateral deltoid 8-21% MVIC

Posterior deltoid 31% MVIC

Myers et, J Athl Train, 2005; Hintermeister, Am J Sports Med, 1998 Dark et al, Phys Ther, 2007 Andersen et al, Phys Ther, 2010

Tip: Add towel roll & consider EMS



External Rotator Muscle Performance

ER at 90°:

Teres minor 89% MVIC

Infraspinatus 51% MVIC

Supraspinatus 50% MVIC

Lower trapezius 88% MVIC

Lateral deltoid 50% MVIC


Myers et, J Athl Train, 2005; Hintermeister, Am J Sports Med, 1998 Dark et al, Phys Ther, 2007 Andersen et al, Phys Ther, 2010

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External Rotation: Sidelying

Infraspinatus 62-85% MVIC

Lat. deltoid < 40% MVIC


Supraspinatus 51% MVIC

Teres minor 67-80% MVIC Reinold et al, J Orthop Sports Phys Ther, 2004; Townsend et al, Am J Sports Med, 1991

*De Mey et al, J Orthop Sports Phys Ther, 2013; Andersen et al, Phys Ther, 2010

Consideration:

-Conscious scapular correction

leads to ↑ LT activity (13%)*



External Rotation: Prone

Muscle % MVIC

Infra Up to130

Supra 68

Low Trap 79

Up Trap 20

Serratus Ant 57

Post Delt 79

Lat Delt 49

Reinold et al, J Orthop Sports Phys Ther, 2009; Ekstrom et al,J Orthop Sports Phys Ther, 2003



Impairment: Lower Trapezius Weakness

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Lower Trapezius: Modified Cobra

Arlotta et al, J Electromyogr Kinesiol, 2011



Lower Trapezius: Modified Cobra



Lower Trapezius: Prone “Y”

Muscle % MVIC

Lower trap 97

Middle trap 100+

Upper trap 79

Serratus ant 43

Lat delt 90

Post delt 88-100+

Infraspinatus Up to 85

Supraspinatus 65-82

Disadvantage: upper trapezius

& lateral deltoid recruitment

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Impairment: Serratus Anterior Weakness



Serratus Anterior

•Punches:50-80% MVIC

*UT activation 7% MVICDecker et al, Am J Sports Med, 2003

Myers et al, J Athl Train, 2005

Ekstrom et al, J Orthop Sports Phys Ther, 2003

•Push up plus:73-80% MVIC

* UT activation 8-19% MVIC

Ludewig et al, Am J Sports Med, 2004

Moseley et al, Am J Sports Med, 1992



Serratus Anterior

Scaption above 120°

Ludewig et al, Am J Sports Med, 2004; Moseley et al, Am J Sports Med, 1992Ekstrom et al, J Orthop Sports Phys Ther, 2003

Serratus ant. MVIC 96%Upper trap MVIC 79%

Upper Cut

Serratus ant. MVIC 100%Upper trap MVIC 66%

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Additional Exercise Considerations

• Scapular retraction

• Empty-Full can

• Return to gym



Scapular Retraction with Elastic Tubing

Rhomboids: 59% MVIC

Lower trapezius: 51%

Subscapularis: 74% MVIC

Infraspinatus: 31% MVIC

Teres minor: 101% MVIC

Hintermeister et al, Am J Sports Med, 1998; Myers et al, J Athl Train, 2005



Supraspinatus: Empty Can

0-60º recommended angle for empty can

*Townsend et al, Am J Sports Med, 1991 *Ballantyne et al, Phys Ther, 1993

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Supraspinatus: Full Can

*Improved isolation

compared to empty can

*Potentially less activation

than empty can

*Possibly Anterior

scapular tilting compared

to empty can

*↓ concern over improper

form

Kelly et al, Am J Sports Med, 1996



Supraspinatus Considerations–Empty can: possible AHD - anterior tilt - poor form (SIS)

–Full can: alternative to empty can

–Empty & full can both have significant deltoid recruitment

• Both may perpetuate imbalance of force couples & impingement

–Prone scapular Y activates supraspinatus (> 65% MVIC) although significantly activates lateral deltoid (90% MVIC) & upper trap

• Alternatives:–Sidelying external rotation • Significantly anterior & lateral deltoid (< 40% MVIC) activity• Supraspinatus activity: 51% MVIC (Empty/Full/Y 64-85%)

–Prone external rotation• Significantly anterior & lateral deltoid (49% MVIC) activity• Supraspinatus activity: 68% MVIC

Dark et al, Phys Ther, 2007; Boettcher et al, Med Sci Sports Exerc, 2009



Exercise Program Design

List key exercises for each muscle in a 3-stage progression

Acute Sub-acute Sport Return

Subscapularis Stand IR T-band Push-up plus Rebounder

Infraspinatus

Serratus Ant

Lower Trap

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Exercise Program Design

• Secondary Impingement with supra/infra tendinosis

• Patient does not play sports or exercise

List 5 key exercises for muscle performance

First week Discharge

1.

2.

3.

4.



Return to Gym and/or Sport

• Considerations: Gym

•Adjustment/advancement of volume & load

• Atrophy is common…..consider………

• Rehabilitation vs. Post rehabilitation volume & load

• Rest between sets?

•Gym/exercises: require consideration of biomechanics

•Rotator cuff disorders

•Anterior instability



Weight-Training Injuries

– Descriptive epidemiological reports comprise majority of literature

pertaining to WT injuries

– Injury surveillance (NEISS) ER

• 35% injury rate in past two decades

• Males comprise > 80% injuries Jones et al, Phys Sportsmed, 2000

– Injury surveillance (NEISS) ER 1990 -2007

• Males > 80% with “48.4% from 1996 to 2006”

Kerr et al, Am J Sports Med, 2010

– Primary site of injury: Shoulder complex

Goertzen et al, Sportverletz Sportschaden,1989; Raske & Norlin, Am J Sports Med,

2002; Van der Wall, Clin Nucl Med, 1999; Koegh et al, J Strength Cond Res, 2006

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Shoulder Pain During Weight Training

N =110Kolber et al, NSCA, 2010



Relationship Between Exercise Selection

& Shoulder Pain During WT

Exercise (N = 110)

Frequency (%)

Pain Reported During WT

3 days 6-mos 1-year

K K K

Rear lat pull-downs (52) 0.40 0.71 0.76

Military press (58)

Behind the neck

0.57 0.87 0.71

External rotation (52) -0.40 -0.54 -0.58

Kolber et al, J Strength Cond Res, 2013



Pectoral StretchingModifications: Anterior Instability

Avoid High-Five

PositionKolber et al, Strength Cond J, 2010


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Seated Barbell Press: Deltoids (A &L)Modification: Anterior Instability

What we know: Both behind the neck pull-downs & military press

have a significant association with shoulder pain & clinical symptoms

of anterior shoulder instability Kolber et al, J Strength Cond Res, 2013



Machine Chest Fly: Pectorals Modification: Anterior Instability



Seated Dumbbell Press: Deltoids (A&L) Modification: Anterior Instability & SIS

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Chest Fly: PectoralsModification: Anterior Instability

Dumbbell Chest Fly Dumbbell Chest Press



Shoulder Press: Deltoids (A/L)Modifications: Anterior Instability & SIS



Bench Press: Pectorals & TricepsModifications: Anterior Instability & AC Disorder

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Seated Bench Press: Pectoral & TricepsModification: Anterior Instability & AC Disorders



Latissimus Pull-Downs: Posterior Musculature

Modifications: Anterior Instability

Considerations:

1. Wide grip to front instead of rear

-Increase activation of latissimus

Lehman et al, Dyn Med, 2004

Signorile et al, J Strength Cond Res, 2002

-↓ propensity for anterior instability/pain


2. Add scapular depression to ↑ LT activity



Consideration:

-Scapular retraction may mildy* middle trap, lats & rhomboid activity

Lehman et al, Dyn Med, 2004

Seated Rows: Posterior Musculature

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Lateral Deltoid Raise: Lateral DeltoidModifications: Impingement Syndrome

Kolber et al, NSCA, 2013



Schoenfeld et al, Strength Cond J, 2011; Kolber et al, NSCA, 2012

Upright Row: Upper Trapezius/Lat. DeltoidModifications: Impingement Syndrome



Overhead Triceps Extension: TricepsModification: Biomechanics at End-Range

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KNEE

“You can’t control the knee at the knee”

• Weakness Impairment

– Hip external rotators and extensors

– Gluteus maximus and medius

– Quadriceps

• Applicable diagnoses

– PFPS (anterior knee pain)

– Knee osteoarthritis, ligament injury, patella

tendinopathy



Step Down Test



Step Down Trunk Control

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Drop Jump



Glute Amnesia

• Common problem is

poor control of the

glutes with

overcompensation from

adjacent muscles

• Glute medius to tensor

fascia latae (TFL)

• Gluteus maximus to

hamstrings ratio



Early Hip Control Principle

• Maximize abduction, external rotation and

extension motor control

• Optimize glute to TFL and glute to hamstring

ratio

• Minimize dynamic valgus

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What doesn’t work?

• Why should we avoid ball between the knees?

• What is wrong with side lying hip abduction?



Hip Movement Pattern Strategies

• Foundational motor control

• Tactile instruction

• Visual/cognitive

Exercise Gluteal to TFL Activation Index

Clam 115

Sidestep 64

Quadruped Hip Extension 50

Sidelying Hip Abduction 38

Step-up 32

Selkowitz 2013



Clam

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Clam Plus



Early Phase Gluteus Medius

• Side bridge (side plank)

– Endurance holds

• Side step progression



Slow Eccentric

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Early Phase Gluteus Maximus

• Bridge with abduction

of hips to improve

glute/hamstring ratio

• Add resistance

• Unilateral

Kang 2013



Extension Diagonals



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Boudreau 2009



Side Bridge Progression



Side Step Progression

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Single Leg Squat



Single Leg Squat



Single Leg Deadlift

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Squat Progression



Step Up/Down



Quadriceps

• Quadriceps inhibition in the presence of knee

pain

– Knee osteoarthritis

– Ligament Injury

– Knee joint effusion

– Patella femoral pain syndrome

– Most knee surgical procedures

• Does quadriceps weakness cause knee pain?

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Quadriceps Rehabilitation

• Open kinetic chain: straight leg raise, knee

extension

• Closed kinetic chain: Deeper knee flexion

angle = greater quadriceps activation



Quadriceps

• NMES is effective

• Consider

– Electrode size

– Motor point

– Max intensity tolerated

• Diagnoses

– Total knee Stevens-Lapsley 2012

– Knee OA Vaz 2013

– ACL Kim 2010



Home Program

• Patient adherence is the #1 concern

• Less is more

• Instruction: video, patient smartphone

• Adherence to an exercise program directly

associated with level of Self-determination

theory

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Self-determination Continuum

Lonsdale, 2012



5 A’s to Maximize Patient Self-

Determination

• Ask: Open ended questions, paraphrase, empathize– Gauge patient readiness to accept advice

• Advise: Provide rationale, request patient input and use autonomy focused phrases

– “Here are some things that will help you overcome”

• Agree: Active participation in goal setting, decide on objective, measurable and time based goals

• Assist: Identify barriers, identify solutions

• Arrange: Provide patient with a rehabilitation diary, follow up appointment and contact information for questions



References (Lower Quarter)• Boudreau, S.N., M.K. Dwyer, C.G. Mattacola, C. Lattermann, T.L. Uhl, and J.M. McKeon: Hip-muscle activation during

the lunge, single-leg squat, and step-up-and-over exercises. J Sport Rehabil 2009;18(1)91-103.

• Cambridge, E.D., N. Sidorkewicz, D.M. Ikeda, and S.M. McGill: Progressive hip rehabilitation: the effects of resistance band placement on gluteal activation during two common exercises. Clin Biomech 2012;27(7)719-724.

• Kang SY, Jeon HS, Kwon O, Cynn HS, Choi B. Activation of the gluteus maximus and hamstring muscles during prone hip extension with knee flexion in three hip abduction positions. Man Ther 2013 Jan 8. [Epub ahead of print]

• Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. J Orthop Sports Phys Ther. 2010;40:383-391.

• McBeth, J.M., J.E. Earl-Boehm, S.C. Cobb, and W.E. Huddleston: Hip muscle activity during 3 side-lying hip-strengthening exercises in distance runners. J Athl Train 2012;47(1)15-23.

• McCurdy, K., E. O'Kelley, M. Kutz, G. Langford, J. Ernest, and M. Torres: Comparison of lower extremity EMG between the 2-leg squat and modified single-leg squat in female athletes. J Sport Rehabil 2010;19(1)57-70.

• Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus mediusactivation during rehabilitation exercises. Physiother Theory Pract 2012;28(4)257-268.

• Selkowitz, D.M., G.J. Beneck, and C.M. Powers: Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther201243(2):54-64.

• Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Phys Ther 2012;92(2):210-26.

• Vaz MA, Baroni BM, Geremia JM, Lanferdini FJ, Mayer A, Arampatzis A, Herzog W. Neuromuscular electrical stimulation (NMES) reduces structural and functional losses of quadriceps muscle and improves health status in patients with knee osteoarthritis. J Orthop Res 2013;31(4):511-6.

Exercise Progression Strategies for the Knee & Shoulder · Rest: 30-90 seconds ... Tip: Add towel...

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