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!
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