Q&A Spotlight: Robert Manske

 I'm excited to bring you insights from Robert Manske, a highly respected figure in physical therapy and sports rehabilitation. With over three decades of experience, Manske has made significant contributions to orthopedic and sports physical therapy through his lectures, research, and numerous publications covering topics like knee rehabilitation, shoulder injuries, and evidence-based practices in sports therapy.

For more of his expertise, you can follow Robert Manske on Twitter @Robptatcscs. Currently, he serves as Professor of the Doctor of Physical Therapy Program at Wichita State University, where he continues to mentor future physical therapists and advance rehabilitation science.

The questions begin by referencing his work on a common knee surgery (ACL reconstruction) before transitioning more into shoulder specific issues.

Below is a copy of our Q&A:

You were recently (a couple years ago) involved in a research group that looked at quad tendon bone (QTB) autograft patients, and how their strength recovered at 6 months and 12 months post-operatively. From my own personal experience, it can be challenging for these patients to regain equal strength when compared bilaterally, especially early in the recovery phase.

Q: Is this something that you have noticed in your work? What challenges do you notice between the different ACL approaches (QTB vs Patellar Tendon vs Hamstring vs Allograft)? Which is your preferred approach to rehab?

Great question.  All of the different graft choices have their own unique challenges.  All of the choices collectively have getting and obtaining early extension and obtaining a good quadriceps contraction early in their list of challenges.  Hamstring grafts due to being all soft tissue tend to have a little bit more laxity than other sources.  That is not always a problem, pending how much laxity is gained.  The BPTB sometimes have trouble getting quad strength back and a lot of them have issues kneeling.  The quad tendon grafts seem to get strength back a little slower than some of the other sources, but they tend to get it back in time.  And allografts are allografts.  Not as much problem with them regarding motion and strength, but a higher risk of re-rupture.  My favorite graft seems to change with times.  Right now I would say either BPTB or Quad tendon.  Never was much of an allograft fan.  And for a short time I was a fan of hamstrings.

Q: Piggy-backing off that question, what are some criteria or guidelines that you use to help determine readiness for return to sport/competition in someone recovering from ACL-R? What are some tools that you use or find beneficial in taking strong objective measures that help guide your decision-making process?

I use probably a lot of the same criteria that you and others use.  I want to have a knee that is no longer swollen, full ROM, and adequate strength.  We use isokinetic testing to determine their strength.  We test at 60 and 180 degrees per second.  We look at LSI and allometric scaling by body weight.  We also have a KT-1000 we check graft laxity with.  The functional tests we use are single leg hop, double leg jump and the LEFS test.  A lot of people lately question using these tests without a neurocognitive component.  But I have not seen the evidence yet that substantiates adding the NC component.  We would like to have them at around 70% LSI before jogging and 90%+ before RTS.  If they are close to these scores but not yet there I usually talk to the surgeon and ultimately let them make the call.  

Q: Switching gears to another commonly injured body part, the shoulder. This is one of my favorites because of the complexity of the joint and surrounding areas/muscle groups/ligaments. We’ll start with something that many people have heard of, the rotator cuff, as it is one of the most common surgeries in the U.S. (more than 500,000 per year!). A hot topic over the past couple of years was whether or not these patients should be in a sling. What are your thoughts on sling vs no sling? Does it depend on the size of the tear, or tissue quality, etc?

I would say that I am a fairly conservative guy in most cases.  Unless there is a reason not to sling, I think I would go with a sling.  I know the Tirefort study in JBJS showed that you may not need one for small tears.  I guess I would like to see a few more of these studies before throwing the baby out with the bathwater!  I am not even sure it matters to me about tear size.  I just think these repairs need a little protection early.   I have seen too many revisions that don’t end up near as good as a stable healed primary repair.  If it were me getting the surgery I would probably go with a sling for at least a while.  I am not saying no therapy or PROM early, but am saying still in favor of sling use for a short time. 

Q: Another common shoulder issue that many have heard of or experienced themselves is the dreaded “frozen shoulder” or adhesive capsulitis. It seems there has been a bigger push for early diagnosis for these cases, as recent studies have shown that an injection early on in the process can significantly lessen a patient's limitation in their affected shoulder and help them return to previous levels of function sooner. Is this something that you have seen, as well? What are some good tips for readers to know if they are experiencing early signs of a frozen shoulder? Has your approach to treating frozen shoulders changed over the years?

I see a lot of these patients and have had this condition myself.  It is no fun at all.  I have seen injections work well in some.  I have also seen a steroid dose pack early will do wonders if you catch it soon enough.  Early signs of frozen shoulder include subacute onset, unilateral shoulder pain that limits both active and passive motion in all planes.  Usually, they have a component of night pain.  Initially it seems to mimic a small rotator cuff tear but progresses to the classical frozen shoulder symptoms.  My approach completely changed when I had it myself.  I treat it much less aggressively and much more slowly to patients’ tolerance.  I don’t feel now there is any need for torturing patients with overly aggressive ROM.  In most, in time, it will resolve.  More than likely whether they have treatment for it or not.  

Q: I enjoy working with overhead athletes. We can go down a long rabbit-hole on why working with athletes is both challenging but rewarding, as well. Something I’ve always tried to pay close attention to is scapular mobility, positioning, muscle recruitment, and stability, among other things. When you assess an overhead athlete, are there certain things you are looking for? How important is posture in your assessment? What are some common issues you find in an injured overhead athlete that maybe goes unnoticed or gets missed altogether by other healthcare professionals?

I certainly look at posture, but I think in a lot of cases it is hard to change posture.  I know there are studies that say you can, but I have found in real life it is difficult.  I think the key things you see in overhead athletes are cuff weakness, scapular muscle weakness, and either loss of GH motion or excessive GH motion and of course load management.  It really comes down to any order of those 4 potential things.  KISS principle.  And remember the basics.  They will never fail you.  A lot of the rest of things you see, biceps pain, deltoid insertion pain, OH pain, all resolve if you figure out what is wrong with that small list of things and provide treatment to help resolve those issues.  We try to make it much harder than it is.  It is pretty basic.  With good patient buy in and a hard working patient you can almost always get people back to their desired activity.

Q: Final question! You are very active in the research community and provide updated information through social media, sports journals, and other outlets all while teaching at a major University. Are there any current areas of research that you are currently working on? What are some things you do to “take a break” from the grind? What are some hobbies or interests you have away from your work?

We are starting some studies looking at BFR and the shoulder.  One study with students and training and another study we are just starting up, with actual patients following rotator cuff repairs and use of BFR.  My hobbies are just smoking meat, exercise, and family – not necessarily in that order.  However, some day I have a whole boatload of hobbies I want to start.  Too many to list here!

I'm very grateful  to Mr. Manske for taking time from his busy schedule and personal life to do this Q&A with me. I hope you found some good information in here! Look for more Q&A's like this in the near future!

Preventative Pain Series: Foot and Ankle (A Series)

I recently listened to a podcast about how important our feet are to our overall health and performance. Often, we don’t consider our feet to be the culprits behind hip or low back pain, when in reality, they could be the root cause!

In this post, we’ll explore effective strategies to help prevent foot pain and soreness. By improving foot and ankle mobility, reducing strain on our lower extremities, and increasing our tolerance to the demands of daily life, we may also enhance our overall movement quality in our dynamic world. Read on to learn more!

How Your Lack of Ankle Range of Motion is Causing You Pain

 Understanding the Ankle's Role

Your ankles, often overlooked in daily health routines, play a crucial role in supporting your entire body. They act as shock absorbers, absorbing the impact of every step and preventing excessive stress on the joints above (or below). When your ankles are stiff or restricted, this shock absorption becomes less effective, leading to a domino effect of problems throughout your body.

The Domino Effect: How Ankle Immobility Impacts Other Joints

• Knee Pain: As the ankles struggle to absorb shock, the knees are forced to compensate. This can lead to conditions associated with increased prolonged stress at the knee/tendonitis.
• Hip Pain: When the knees are under stress, the hips are also affected. Hip flexor tightness, labral tears, and even hip bursitis can be linked to restricted ankle mobility.
• Low Back Pain: The strain on the hips can travel further up the body, leading to low back pain. Tight hamstrings and weak core muscles can also contribute to this issue.
• Foot Pain: Plantar fasciitis, a common condition causing heel pain, can be exacerbated by limited ankle mobility.

Your foot may try to compensate for restricted ankle mobility by decreasing/increasing the height of your arch. High arches limit hip internal rotation. Flat feet limit hip external rotation. You can see how that lack of hip mobility can negatively impact your other joint above or below (and this is without going into significant detail on your thoracic spine, scapula, shoulders, neck, etc).

The Importance of Proper Gait

Ankle mobility is essential for maintaining a proper gait. When your ankles are stiff, your walking pattern can become altered, leading to increased stress on the joints and muscles. This can contribute to conditions like shin splints, Achilles tendonitis, and even stress fractures.

How to Improve Ankle Mobility

• Regular Stretching: Incorporate ankle stretches into your daily routine. Simple exercises like calf raises, seated ankle circles, and towel stretches can help improve flexibility.
• Strengthening Exercises: Target the muscles around the ankle, such as the calf muscles and shin muscles. Exercises like toe raises, heel walks, and balance exercises can help.
• Footwear: Consider your footwear. Shoes that are too tight or offer inadequate support can contribute to ankle stiffness.
• Rest and Recovery: If you've experienced an ankle injury or have chronic ankle issues, ensure you get enough rest and recovery time.

Fun Fact: The human ankle can support approximately four times our body weight! This is important for running, jumping, and other high impact activities.

Conclusion

By prioritizing ankle mobility, you can not only reduce pain and discomfort but also improve your overall balance, coordination, and athletic performance. So, next time you're stretching, don't forget to give your ankles some love!

Sources:

• "Association between unilateral functional ankle instability, limited ankle dorsiflexion range of motion and low back pain": https://revistas.um.es/sportk/article/download/526661/337951/2048081
• "The effect of ankle dorsiflexion range of motion on the occurrence of low back pain": https://pubmed.ncbi.nlm.nih.gov/21214345/
• "The influence of ankle joint range of motion and muscle strength on low back pain": https://journals.lww.com/nsca-jscr/fulltext/2012/08000/effect_of_range_of_motion_on_muscle_strength_and.17.aspx

Preventative Pain Series: Shoulders (A Series)

 Disclaimer: This post is about different strategies/techniques to help reduce the risk of general shoulder issues/soreness and not necessarily meant to prevent higher level sport-specific injuries. I do have a plan to add a post addressing those issues in the future.

Shoulder Stability: The Key to Pain-Free Adventures

Our shoulders, workhorses of our upper body, play a vital role in countless daily activities, from lifting groceries to reaching for overhead shelves. But neglecting shoulder health can lead to pain, stiffness, and limited mobility. By incorporating a few simple strategies into your routine, you can keep your shoulders strong, stable, and ready for any challenge.

The Startling Stats on Shoulder Pain

Shoulder pain is a common complaint, affecting millions of people worldwide. A study published in the Journal of Orthopaedic & Sports Physical Therapy found that shoulder pain is one of the most frequent reasons for seeking physical therapy [1]. A study by the American Academy of Orthopaedic Surgeons found that over 3 million people in the United States visit a doctor each year with complaints of shoulder pain.

With a proactive approach, you can significantly reduce your risk of shoulder problems and maintain a pain-free lifestyle.

Understanding Your Shoulder's Complexities

The shoulder joint, also known as the glenohumeral joint, is a ball-and-socket joint formed by the head of the humerus (upper arm bone) and the glenoid cavity of the scapula (shoulder blade) [2]. Surrounding muscles, tendons, and ligaments provide stability and allow for a wide range of motion [2].

Key structures include:

• Rotator cuff muscles: These four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) help stabilize the shoulder joint and allow for smooth movement [3].
• Deltoid muscle: The large, triangular muscle covering the shoulder joint provides strength and power.
• Biceps brachii: This muscle assists in shoulder flexion and helps stabilize the shoulder joint.
• Triceps brachii: Located on the back of the upper arm, it extends (straightens) the elbow and contributes to shoulder stability.

Building Shoulder Strength: Your Key to Stability

Stronger shoulder muscles can help prevent injuries and reduce pain. Here are some effective exercises to incorporate into your routine:

• Rows: This exercise targets the muscles in your back, which help stabilize the shoulder joint. Use dumbbells or a resistance band to perform rows, focusing on maintaining good posture and avoiding shrugging your shoulders [4].
• Sidelying External Rotation: This exercise targets the rotator cuff muscles, which help stabilize the shoulder joint. Lie on your side with your arm bent at a 90-degree angle. Keeping your elbow close to your body (ideally with a rolled towel between your arm and body), slowly rotate your arm outward, rotating the hand towards the ceiling.
• Banded Internal Rotation: This exercise also targets the rotator cuff muscles. Use a resistance band anchored to a door handle or a sturdy object. Stand facing away from the anchor point and hold the band with your affected arm. Keeping your elbow close to your body, rotate your arm inward, moving the band towards your body. (You could also do external rotation this way, with same rules as above).

Don't Forget Flexibility: Your Shoulder's Secret Weapon

Tight muscles can contribute to shoulder pain and stiffness. Regular stretching helps improve flexibility and range of motion. Here are some key stretches to include:

• Arm Circles: Stand tall with your arms extended out to the sides at shoulder height. Gently rotate your arms in a circular motion, gradually increasing the size of the circles. Repeat 10 times in each direction [7].
• Doorway Stretch: Stand facing a doorway and place your hands on the doorframe at shoulder height. Step forward until you feel a stretch in the front of your shoulder. Hold for 15-30 seconds and repeat on the other side [8].
• Behind-the-Back Stretch: Stand tall with your arms extended down to your sides. Reach behind your back with one hand, then try to touch your hand to the opposite shoulder. Hold for 15-30 seconds and repeat on the other side [9].

Bonus Tip: Listen to Your Body!

If you experience shoulder pain during activity, take a break and rest. For persistent pain, consult a healthcare professional for proper diagnosis and treatment.

By following these simple strategies, you may be able to keep your shoulders strong, stable, and ready for life's next adventure!

References:

[1] Journal of Orthopaedic & Sports Physical Therapy: https://biddefordpt.com/try-pt-for-these-5-common-causes-of-shoulder-pain/ 
[2] Cleveland Clinic: https://my.clevelandclinic.org/health/body/24780-shoulder-joint
[3] American Academy of Orthopaedic Surgeons: OrthoInfo - Rotator Cuff Tears
[4] American Council on Exercise: https://www.acefitness.org/resources/everyone/exercise-library/12/bent-over-row/
[5] American Council on Exercise: https://www.acefitness.org/resources/everyone/exercise-library/43/seated-shoulder-press/
[6] American Council on Exercise: https://www.acefitness.org/resources/everyone/exercise-library/295/lateral-shoulder-raise/
[7] Mayo Clinic: https://www.youtube.com/watch?v=P-DbBfHZHC8
[8] American Academy of Orthopaedic Surgeons: OrthoInfo - Shoulder Conditions
[9] American Council on Exercise: https://ace-pt.org/shoulder-exercises-for-strength-and-flexibility/

Stay Tuned!

 I've been working on lining up some Q&A's to add to the blog from some well-respected people in the exercise, sport-performance, coaching realm in the near future. I'm excited about adding this type of content to the blog.

Currently, I've got four different individuals lined up to provide some new information to the blog. If there is anything in particular that you would like to see/read about, let me know and I'll try to make it happen!

Beyond Stuffiness: The Science Behind Your Dominant Nostril

(NOTE: A recent conversation with a family member this past weekend was the inspiration for this blog post. Thanks, Jason!)

Ever wondered why one nostril seems stuffier than the other sometimes? It turns out there's more to nostril dominance than just a passing annoyance. Your breath and your nervous system are connected in a fascinating way, and which nostril is on top can actually influence how calm or energized you feel.

Preventative Pain Series: Knees (A Series)

 

Knees Over Toes: Keeping Your Adventures Going Strong

Our knees are the ultimate adventurers. They propel us through life's journeys, from conquering mountain peaks to simply walking the dog. But like any trusty companion, they need a little TLC to stay strong and happy. The good news? Keeping your knees healthy doesn't require scaling back your active lifestyle.

In this post, we'll explore some data-driven strategies and easy-to-understand tips to prevent knee pain and keep your adventures going.

What to Expect When You're Expecting: A Rotator Cuff Surgery

 

Facing rotator cuff surgery can feel daunting, but with preparation and a positive attitude, you can navigate the recovery process smoothly. In the next of our "What to Expect When You're Expecting" Series, we will guide you through what to expect before, during, and after your surgery, so you can focus on healing and regaining shoulder strength.

Updated Blog Post: The Powerful Effects of Music on Your Mind and Body

 

I've been going through some of my older blog posts that were very popular (in terms of clicks/views) and have been updating them with new information that has come about in the years since. This one focuses on my second most popular post, looking at the affects music can have on your brain/body. Check it out!

Gas Pedal or Brake? Understanding Your Body's Response to Stress

 Have you ever been walking down the street, minding your own business, when suddenly a car screeches by, horn blaring? Your heart jumps, your breathing quickens, and your stomach clenches. That's your body's fight-or-flight response kicking in, a built-in survival mechanism controlled by your sympathetic nervous system.

But what if that car wasn't actually a threat? What if you just need to unwind after a long day? That's where your parasympathetic nervous system comes in. Imagine these two systems as partners in a dance, constantly working together to keep your body in a state of equilibrium.

Guest Presenters

 Hey All!

I'm currently working on getting a few guests to join the blog and/or record some podcasts.

I'm curious if anyone has some recommendations or requests of folks I can reach out to. My plan is to invite people of all different expertise and fields to talk about their thoughts/opinions on all aspects relating to health. This can include almost anything, ranging from physical and mental health, to financial, all the way to sport-specific training/education.

Reach out to me on social media (like some of you already have), email, or comment in the section below.

I'd be interested in seeing who the readers would like to hear from!

Thanks!

-Robbie

What to Expect When You're Expecting: Total Knee Replacement

 

What to Expect When You're Expecting: Total Knee Replacement

In my 12 years of working in the outpatient physical therapy world, I've treated hundreds of people following a total knee replacement. I would venture to guess that 90%, or more, are surprised by how difficult the first couple weeks post-operative can be. Millions of people undergo this procedure each year to relieve chronic knee pain and regain mobility. While the thought of surgery might be a bit nerve-wracking, understanding what to expect throughout the process can prepare you for a successful outcome.

Reader Request: Exercises/Stretches As We Age?

 

Move with Ease: Age-Specific Mobility Exercises for a Lifetime of Activity

Our bodies are meant to move! But as we age, our natural flexibility can decline, leading to stiffness, aches, and even limitations in daily activities. The good news? Regular mobility exercises can help us stay active and independent well into our golden years.

This post explores some key mobility exercises and stretches tailored for different age groups, helping you maintain a healthy range of motion throughout your life's journey.

Creating A More Explosive Wind-Up (Softball-Style)

 

Dial Up the Heat: Mastering the Modern Softball Pitcher's Windup for Maximum Velocity

Remember that blog post I wrote years back about the intricacies of a softball pitcher's windup? Well, buckle up, because the game – and the science behind throwing heat – has evolved! Let's revisit the challenges pitchers face and explore modern techniques to craft a more explosive windup for blazing fastballs.

Preventative Pain: Low Back (A Series)

 

Fight Back Pain, Not Your Age: Simple Exercises for a Strong and Healthy Lower Back

If you've been around me much in the physical therapy world, you've heard me tell clients that back pain and toothaches are similar in that there is no quick fix and are often time debilitating. Low back pain is a common complaint, and as we age, it can become more frequent and frustrating. But don't resign yourself to a life of backaches! Here's the good news: many cases of low back pain are preventable through simple exercises that strengthen your core and improve your flexibility.

In this post, we'll explore some easy-to-do exercises you can incorporate into your daily routine to keep your lower back strong and healthy:

Reader Request: Difference Between Mobility and Flexibility

 

Move It or Lose It: Understanding Mobility vs. Flexibility for Peak Performance

Have you ever reached for that high shelf in the grocery store and felt a twinge in your shoulder? Or maybe that killer jump shot you used to have just doesn't feel quite the same anymore. Flexibility and mobility, often used interchangeably, are actually two distinct concepts that play crucial roles in athletic performance and overall well-being. 

Click on to read more!

Wearable Technology: Is it right for you?

Wearable Tech: Your Powerful Ally on the Road to Wellness

Wearable technology has exploded in popularity in recent years. From fitness trackers to smartwatches, these gadgets can be a powerful tool to help you monitor your health, reach your fitness goals, and improve your overall well-being.

In this post, we'll delve into the exciting world of wearable tech and explore how it can benefit your life:

Management of Shin Splints

Shin Splints: Outrunning the Pain

Ah, shin splints. Those pesky aches and pains that can sideline even the most dedicated runner. I've recently began doing some increased running, myself, and have noticed some mild aches, leading to the motivation for this post. Shin splints are a common complaint, but they're definitely not a reason to hang up your sneakers for good. In this post, we'll tackle everything you need to know about shin splints, from managing the discomfort to preventing them altogether.

The Vestibulo-ocular Reflex (VOR): Your Inner Ear's Secret Weapon for Steady Vision

Have you ever noticed how you can still read a book while walking, or keep your gaze fixed on a friend's face as you chat while turning your head? It's all thanks to a clever little reflex in your inner ear called the Vestibulo-ocular reflex, or VOR for short.

I recently had a patient come in for VOR-related symptoms so I thought that this would be a good time to give a brief but informative post on what VOR even is.

How Best to Utilize BFR? (Part 3 of 3)

 

Part 3: Blood Flow Restriction Training - Putting it into Practice

Now that you understand the science behind BFR training, let's explore its practical application. Here, we'll delve into proper BFR technique, exercise selection, and safety considerations.

How Does Blood Flow Restriction (BFR) Work? (Part 2 of 3)

 Part 2: Blood Flow Restriction Training - How Does It Work?

In part one, we explored the concept of Blood Flow Restriction (BFR) training and its origins. Now, let's delve deeper into the fascinating science behind it. BFR utilizes a unique approach to achieve muscle growth and strength gains, even with lighter weights. But how exactly does restricting blood flow benefit your workout?

What is Blood Flow Restriction? (Part 1 of 3)

Building Muscle Smarter, Not Harder: All About Blood Flow Restriction Training

Ever wished you could get those gym gains without lifting all that weight? Blood Flow Restriction (BFR) training might be your answer. This technique has been gaining popularity in recent years, and for good reason. Let's break down what BFR is, how it became a thing, and how it works it's magic.