Orthopaedic Rehabilitation of the

Athlete: Getting Back in Game 1st

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 Contributors

Christopher S. Ahmad, MD Brian Armstrong, MPT

Professor of Orthopedic Surgery Physical Therapist/Clinic Director
Department of Orthopedics ATI Physical Therapy
New York Presbyterian/Columbia University Carmel, Indiana
Medical Center
New York, New York Michael J. Axe, MD
Board-Certified Orthopaedic Surgeon
Amy N. Alexander, PT, DPT First State Orthopaedics
Clinical Director of Rehabilitation Newark, Delaware
JAG Physical Therapy Union
JAG Physical Therapy Bernard R. Bach, Jr., MD
West Orange, New Jersey The Claude N. Lambert-Helen Susan
Thomson Professor
Brian K. Allen, DO Professor of Orthopaedic Surgery
Director of Student Health Director, Division of Sports Medicine
Student Health Center Director, Sports Medicine Fellowship
University of Wisconsin—La Crosse Midwest Orthopaedics at RUSH
La Crosse, Wisconsin Rush University Medical Center
Chicago, Illinois
David Altchek, MD
Professor of Clinical Orthopedic Surgery Abdo Bachoura, MD
Weill Medical College Orthopaedic Surgery Resident
Cochief, Sports Medicine and Shoulder Service Orthopaedics
Hospital for Special Surgery UPMC Hamot
Medical Director, New York Mets Erie, Pennsylvania
New York, New York
Geoffrey S. Baer, MD, PhD
Craig Alver, PT Assistant Professor
Senior Physical Therapist Department of Orthopedics and Rehabilitation
Orthopedic Associates Physical Therapy University of Wisconsin
Farmington, Connecticut Madison, Wisconsin

Annunziato Amendola, MD David S. Bailie, MD

Professor of Orthopedic Surgery and Rehabilitation Partner, Board member
Director of Sports Medicine The Orthopedic Clinic Association
Orthopedic Surgery PC Shoulder/Sports Medicine
University of Iowa Scottsdale, Arizona
Iowa City, Iowa
Champ L. Baker, Jr., MD
Kyle Anderson, MD Staff Physician
Orthopaedic Surgeon The Hughston Clinic
Fellowship Director Columbus, Georgia
Sports Medicine
William Beaumont Hospital Sue D. Barber-Westin, BS
Royal Oak, Michigan Director, Clinical and Applied Research
Noyes Knee Institute
John Apostolakos, BS Cincinnati, Ohio
Medical Student (MSII)
Department of Orthopaedic Surgery Michael J. Battaglia II, MD
University of Connecticut Private Practice
Farmington, Connecticut Bellevue, Washington

vii
viii CONTRIBUTORS

Steve Brian Behrens, MD Aaron Brock, MS, ATC, CSCS

Fellow, Orthopaedic Sports Medicine Director of Sports Medicine and Performance
Orthopaedic Surgery USA Volleyball
University of Pittsburgh Medical Center Anaheim, California
Pittsburgh, Pennsylvania
Jack Browne, OT, CHT
Knut Beitzel, MA, MD Naval Medical Center San Diego
Department of Sports Medicine Department of Occupational Therapy
Klinikum Rechts der Isar Hospital San Diego, California
Technical University of Munich
Munich, Germany Rick Burkholder, MS, ATC
Head Athletic Trainer
S. Josh Bell, MD Kansas City Chiefs
Orthopaedic Surgeon Kansas City, Missouri
The San Antonio Orthopaedic Group
San Antonio, Texas William E. Burns, Jr., DPT, OCS, SCS
Clinical Director
Neal M. Berger, MD Choice Physical Therapy
Orthopaedic Surgery Sports Medicine Fellow Westerly, Rhode Island
SOAR Orthopaedics
Redwood City, California Joseph S. Butler, MA, PhD, MRCSI
Specialist Registrar
Sanjeev Bhatia, MD Department of Trauma and Orthopedic Surgery
Sports Medicine and Hip Preservation Fellow Mater Misericordiae University Hospital
Orthopaedic Surgery Dublin, Ireland
The Steadman Clinic and Steadman Philippon
Research Institute Nathan L. Cafferky, MD
Vail, Colorado Orthopaedic Surgery Resident
Department of Orthopaedic Surgery
Nancy J. Bloom, PT, DPT, MSOT Geisinger Medical Center
Associate Professor in Physical Therapy and Danville, Pennsylvania
Orthopaedic Surgery
Washington University School of Medicine E. Lyle Cain, Jr., MD
Program in Physical Therapy Fellowship Director
Washington University School of Medicine American Sports Medicine Institute
Saint Louis, Missouri Founder
Andrews Sports Medicine and Orthopaedic Center
John Bojchuk, MS, ATCL Birmingham, Alabama
Division of Sports Medicine
Department of Orthopaedic Surgery Kaitlin M. Carroll, BS
Midwest Orthopaedics at Rush Orthopaedic Surgery
Rush University Medical Center Hospital for Special Surgery
Chicago, Illinois New York, New York

Robert J. Bradbury, BS, PT John T. Cavanaugh, PT, MEd, ATC, SCS

Physical Therapist Clinical Supervisor
Bellevue Bone and Joint Physicians Sports Rehabilitation and Performance Center
Bellevue, Washington Rehabilitation Department
Hospital for Special Surgery
James P. Bradley, MD New York, New York
Clinical Professor, Orthopaedic Surgery
Head Team Physician, Pittsburgh Steelers Theresa A. Chiaia, PT, DPT
Orthopaedic Surgery Section Manager
University of Pittsburgh Medical Center Sports Rehabilitation and Performance Center
Pittsburgh, Pennsylvania Hospital for Special Surgery
New York, New York
Kristen Fay Brinks, PT, DPT, LAT
Physical Therapist
Sports Medicine
Gunderson Health System
Onalaska, Wisconsin
 CONTRIBUTORS ix

Michael G. Ciccotti, MD Polly de Mille, RN, MA, RCEP, CSCS

Professor of Orthopaedics Clinical Supervisor
Chief, Division of Sports Medicine Sports Performance Center
Director, Sports Medicine Fellowship Hospital for Special Surgery
Rothman Institute New York, New York
Thomas Jefferson University
Head Team Physician, Philadelphia Phillies John DeWitt, PT, DPT, SCS, AT
Philadelphia, Pennsylvania Assistant Clinical Professor, Rehab Manager
OSU Sports Medicine
John C. Clohisy, MD Ohio State University Wexner Medical Center
Daniel C. and Betty B. Viehmann Distinguished Columbus, Ohio
Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery Roisin T. Dolan, MA, MD, MRCSI
Washington University School of Medicine Senior House Officer
St. Louis, Missouri Department of Plastic and Reconstructive Surgery
Mater Misericordiae University Hospital
Brian J. Cole, MD, MBA Dublin, Ireland
Department of Orthopaedics
Chairman, Department of Surgery Christopher J. Durall, PT, DPT, MS, SCS,
Rush Oak Park Hospital LAT, CSCS
Shoulder, Elbow and Knee Surgery Director of Physical Therapy Services
Section Head, Cartilage Restoration Center at Rush Student Health Center
Rush University Medical Center University of Wisconsin—La Crosse
Team Physician Chicago Bulls and Chicago White Sox La Crosse, Wisconsin
Chicago, Illinois
Thomas J.S. Durant, MPT
Danielle M. Cooper, DPT, NSCA-CPT Orthopaedic Surgery
Outpatient Physical Therapist University of Connecticut Health Center
Newton-Wellesley Hospital Farmington, Connecticut
Newton, Massachusetts
Bradley Kent Earnest, OTR/L, CHT
Mark P. Cote, PT, DPT, MS, CTR Senior Hand Therapist
Sports Medicine Clinical Outcomes Research Facilitator Missouri Physical Therapy
Department of Orthopaedic Surgery Missouri Orthopaedic Institute
New England Musculoskeletal Institute Columbia, Missouri
University of Connecticut Health Center
Farmington, Connecticut Mark E. Easley, MD
Associate Professor
Dana Curtis Covey Department of Orthopaedic Surgery
Clinical Professor Duke University Medical Center
Orthopaedic Surgery Durham, North Carolina
University of California–San Diego
San Diego, California LtCdr. Robert Shane Eberly, MD
Chief Resident
Nancy Craven, PT, DPT, OCS Orthopaedic Surgery
Physical Therapist II Naval Medical Center San Diego
Department of Rehabilitation San Diego, California
University of Connecticut Health Center
Farmington, Connecticut Craig J. Edson, MS, PT, ATC
Physical Therapist
Kimberly A. Cubeta-Gileau, PT, MSAH Department of Rehabilitation
Coordinator Geisinger Medical Center
Staff Development and Clinical Education Danville, Pennsylvania
Department of Rehabilitation and Sports Medicine
University of Connecticut Health Center Todd S. Ellenbecker, DPT, MS, SCS, OCS, CSCS
Farmington, Connecticut Clinic Director, Physiotherapy Associates Scottsdale
Sports Clinic
Demetris Delos, MD National Director of Clinical Research,
Orthopaedics Fellow Physiotherapy Associates
Sports Medicine and Shoulder Service Senior Director of Medical Services, ATP World Tour
Hospital for Special Surgery Scottsdale, Arizona
New York, New York
x CONTRIBUTORS

Scott A. Escher, BS, MD John A. Gallucci, Jr., ATC, PT, DPT

Adjunct Professor President, JAG Physical Therapy. Medical Coordinator,
University of Wisconsin—La Crosse Major League Soccer
Clinical Assistant Professor of Family Medicine JAG Physical Therapy
University of Wisconsin—Madison West Orange, New Jersey
Department of Family Medicine
Section of Sports Medicine Seth C. Gamradt, MD
Gundersen Health System Director of Orthopaedic Athletic Medicine
La Crosse, Wisconsin Associate Clinical Professor
Orthopaedic Surgery
Gregory C. Fanelli, MD Keck School of Medicine of USC
Orthopaedic Surgeon Los Angeles, California
Department of Orthopaedic Surgery
Geisinger Medical Center Trevor Ryan Gaskill, MD
Danville, Pennsylvania Assistant Professor of Surgery
Bone and Joint Sports Medicine Institute
Joanne Finn, GradDipPhys, MCSP Naval Medical Center Portsmouth
Senior Physiotherapist to Burns and Plastics Portsmouth, Virginia
Reconstructive Surgery
Department of Physiotherapy David Gendelberg, MD
St. James’s Hospital Resident
Dublin, Ireland Orthopaedics
Penn State Milton S. Hershey Medical Center
Donald C. Fithian, MD Hershey, Pennsylvania
Department of Orthopedics
Southern California Permanente Medical Group Thomas J. Gill IV, MD
San Diego, California Associate Professor of Orthopedic Surgery
Harvard Medical School
LtCdr. James H. Flint, MD, MC USN Director
Chief Resident Boston Sports Medicine and Research Institute
Orthopaedic Surgery Boston, Massachusetts
Walter Reed National Military Medical Center
Bethesda, Maryland Scott D. Gillogly, MD, FACS
Director, Orthopaedic Sports
Erick Fountain, MPT, OMPT Medicine and Cartilage Restoration Fellowship
Physical Therapist Atlanta, Georgia
Orthopaedic Edge PT
Shelby Township, Michigan Kahl Goldfarb, PT, DPT, OCS, OMT, CSCS
Adjunct Faculty
Heather E. Freeman, PT, DHS CEO of Water & Sports Physical Therapy, Inc.
Assistant Research Coordinator Doctor of Physical Therapy Program
Shelbourne Knee Center San Diego State University
Indianapolis, Indiana San Diego, California

Freddie H. Fu, MD LtCdr. Dominic Gomez-Leonardelli,

Distinguished Service Professor MD, MC USN
University of Pittsburgh Orthopedic/Hand Surgeon
David Silver Professor and Chairman United States Navy
Department of Orthopaedic Surgery Philadelphia, Pennsylvania
University of Pittsburgh School of Medicine
Head Team Physician Gregg Gomlinski, DPT, OCS, CSCS
University of Pittsburgh Department of Athletics Physical Therapist
Pittsburgh, Pennsylvania Rehabilitation
University of Connecticut Health Center
John Pryor Fulkerson, MD Farmington, Connecticut
Department of Orthopaedic Surgery
University of Connecticut School of Medicine
Farmington, Connecticut
 CONTRIBUTORS xi

Andreas H. Gomoll, MD Charles P. Hannon, BS

Assistant Professor of Orthopaedic Surgery Research Fellow
Harvard Medical School Foot and Ankle Service
Orthopaedic Surgery Hospital for Special Surgery
Brigham and Women’s Hospital New York, New York
Boston, Massachusetts
Marcie Harris-Hayes, PT, DPT, MSCI, OCS
Stephen Alexander Gould, MD, MPH Associate Professor
Resident Program in Physical Therapy
NYU Hospital For Joint Diseases Washington University School of Medicine
Department of Orthopedic Surgery St. Louis, Missouri
New York, New York
Richard J. Hawkins, MD
Stacie Christine Graves, MS, PA-C Professor of Clinical Orthopaedic Surgery
Physician Assistant University of South Carolina
Orthopaedic Surgery Team Physician, Denver Broncos
Division of Sports Medicine Team Physician, Colorado Rockies
William Beaumont Hospital Steadman Hawkins Clinic of the Carolinas
Royal Oak, Michigan Greenville, South Carolina

Deepti Gupta, MD Wendell M.R. Heard, MD

Internal Medicine Assistant Professor
Northwestern Memorial Hospital Orthopaedic Surgery
Chicago, Illinois Tulane University
New Orleans, Louisiana
Leslie C. Hair PT, DSc, OCS, FAAOMPT
Physical Therapist Timothy Peter Heckmann, PT, ATC
Physical Therapy Director of Rehabilitation
U.S. Navy Cincinnati Sportsmedicine & Orthopaedic Center
Chesapeake, Virginia Cincinnati, Ohio

Eric C. Hall, MS, ATC, CSCS Bryan C. Heiderscheit, PT, PhD

Clinical Athletic Trainer/Outreach Manager Professor
Methodist Sports Medicine Department of Orthopedics and Rehabilitation
Indianapolis, Indiana University of Wisconsin
Madison, Wisconsin
William G. Hamilton, MD, BSE, AAOS,
AOA, FACS Becky Heinert, MS, PT, SCS
Clinical Professor of Orthopedic Surgery, Columbia Sports Medicine
University Gundersen Health
College of Physicians and Surgeons, Senior Attending Winona, Minnesota
Surgeon, St Luke’s-Roosevelt Hospital
Orthopedic Consultant to The New York City Ballet Diego Herrera, MD
and American Ballet Theatre Orthopaedic Sports Medicine
Orthopedic Surgery Kaiser Permanente Orthopaedics
St Luje’s-Roosevelt Hospital San Diego, California
New York, New York
Nikolaus Hjelm, MD
Jo A. Hannafin, MD, PhD Jefferson Medical College
Attending Orthopaedic Surgeon and Director of Philadelphia, Pennsylvania
Orthopaedic Research,
Hospital for Special Surgery Sherwin SW Ho, MD
Orthopaedic Surgery Associate Professor of Orthopaedic Surgery
Hospital for Special Surgery Director, Sports Medicine Fellowship Program
New York, New York School of Medicine
The University of Chicago
Chicago, Illinois
xii CONTRIBUTORS

Todd R. Hooks, PT, ATC, OCS, SCS, MOMT, MTC, John G. Kennedy, MD, MCh, MMSc, FRCS
CSCS, N-REMT1, CMTPT, FAAOMPT Assistant Attending Orthopaedic Surgery
Champion Sports Medicine Foot and Ankle Surgery
Birmingham, Alabama Hospital for Special Surgery
New York, New York
Rob Hopkins, PT, SCS Nicholas I. Kennedy, BS
Director of Physical Therapy Steadman Philippon Research Institute
The Hughston Clinic Vail, Colorado
Columbus, Georgia
Christopher K. Kepler, MD, MBA
Darragh E. Hynes, MCh, FRCSI Assistant Professor
Consultant Orthopedic Surgeon Orthopedic Surgery
Department of Plastic & Reconstructive Surgery Thomas Jefferson University & Rothman Institute
Mater Misericordiae University Hospital Philadelphia, Pennsylvania
Dublin, Ireland
Stewart M. Kerr, MD
James J. Irrgang, PhD, PT, ATC, FAPTA Attending Orthopaedic and Spinal Surgeon
Professor, Department of Orthopedic Surgery and Departments of Orthopaedic Surgery and Neurosurgery
Director of Clinical Research Confluence Health Medical Center
Department of Orthopedic Surgery Wenatchee, Washington
Orthopedic Surgery
University of Pittsburgh Mohamed Khalid, MD, MCh, FRCS
Pittsburgh, Pennsylvania Senior Consultant in Hand and
Upper Extremity Surgery
Erin L. Ives, PT, MS, OCS, CertMDT Department of Surgery
Director of Rehabilitation Sultan Qaboos University Hospital
Hartford Healthcare Rehabilitation Network Muscat, Oman
Hartford Healthcare
Hartford, Connecticut Najeeb Khan, MD
Orthopaedic Surgeon
Sidney M. Jacoby, MD Department of Orthopedic Surgery
Assistant Professor of Orthopaedic Surgery Southern California Permanente Medical Group
Division of Hand Surgery San Marcos, California
Orthopaedic Surgery
Thomas Jefferson University Hospital Jason L. Koh, MD, FAAOS
Philadelphia, Pennsylvania Board of Directors Chair of Orthopaedic Surgery
Chairman, Department of Orthopaedic Surgery,
Jason M. Jennings, MD, DPT North Shore University Health System
Orthopaedics Director, NorthShore Orthopaedic Institute
Duke University Medical Center Clinical Associate Professor,
Durham, North Carolina Pritzker School of Medicine
University of Chicago
Lacy D. Jennings, DPT, SCS, MTC Evanston, Illinois
Physical Therapy
Duke Sports Medicine Physical Therapy Leo T. Kroonen, MD
Durham, North Carolina Orthopaedic Surgery
Naval Medical Center San Diego
Mark Allen Jordan, MD San Diego, California
Resident Physician
Department of Orthopaedics Robert F. LaPrade, MD, PhD
Grand Rapids Medical Education Program Complex Knee and Sports Medicine Surgery
Grand Rapids, Michigan The Steadman Clinic
Chief Medical Officer, Steadman Philippon
Christopher C. Kaeding, MD Research Institute
Judson Wilson Professor, Director OSU Sports Medicine Deputy Director, Sports Medicine Fellowship Program
Sports Medicine Center Director, International Scholar Program
The Ohio State University Wexner Medical Center Adjunct Professor
Columbus, Ohio Orthopaedic Surgery
University of Minnesota
Michael J. Keating, MS, ATC, CSCS Affiliate Faculty
Medical Director USA Rugby College of Veterinary Medicine and Biomedical Sciences
Sports Medicine Colorado State University
USA Rugby Vail, Colorado
Boulder, Colorado
 CONTRIBUTORS xiii

LtCdr. Lance E. LeClere, MD, MC USN Nathan A. Mall, MD

Assistant Professor Director
Department of Orthopaedic Surgery St. Louis Center for Cartilage Restoration and Repair
Naval Medical Center San Diego Regeneration Orthopedics
Uniformed Services University of the Health Sciences St. Louis, Missouri
Bethesda, Maryland
Philip J. Malloy, MS, PT, SCS
Andrew S. Lee, MD, MS Physical Therapist
Resident Exercise Science and Physical Therapy
Department of Orthopedics Marquette University
North Shore Long Island Jewish Medical Center Milwaukee, Wisconsin
Manhasset, New York
Robert C. Manske, DPT, SCS, MEd, SCS,
J. Martin Leland, MD ATC, CSCS
Orthopaedic Sports Medicine Surgeon Professor and Chair
Assistant Professor of Orthopaedic Surgery Department of Physical Therapy
Department of Orthopaedic Surgery and Wichita State University
Rehabilitation Medicine Staff Therapist
University of Chicago Sports and Orthopedic Physical Therapy
Chicago, Illinois Via Christi Health
Wichita, Kansas
Michael Levinson, PT, CSCS
Clinical Supervisor A. Simone Maybin, BS, NSCA-CPT
Department of Rehabilitation Medical Student
James M. Benson Sports Rehabilitation Center College of Medicine
Hospital for Special Surgery Medical University of South Carolina
Physical Therapist, New York Mets Charleston, South Carolina
New York, New York
Katelyn H McCormick, PT, DPT
David Logerstedt, PT, PhD, MPT, MA, SCS Physical and Occupational Therapy
Research Assistant Professor Naval Medical Center San Diego
Physical Therapy and Delaware Rehabilitation Institute San Diego, California
University of Delaware
Newark, Delaware Kate McDonald, BScPT, OCS, COMT
Director of Sports Rehabilitation
Robert M. Lucas, MD Physical Therapy
Orthopaedic Surgery Atlanta Sports Medicine and Orthopedic Center
University of California San Francisco Atlanta, Georgia
San Francisco, California
Brad McMahon, MPT
Laura M. Lundgren, PA-C, BS, MPAS Physical Therapy
Physician Assistant Peak Performance Physical Therapy and
Sports Medicine Sports Medicine
Sports Medicine Center Appleton, Wisconsin
Appleton, Wisconsin
Philip Malloy, MS PT, SCS
Travis G. Maak, MD Physical Therapist
Assistant Professor Exercise Science and Physical Therapy
Orthopaedic Surgery Marquette University
University of Utah Milwaukee, Wisconsin
Salt Lake City, Utah
Augustus D. Mazzocca, MS, MD
Leonard C Macrina, MSPT, SCS, CSCS Director, New England Musculoskeletal Institute
Physical Therapist Professor and Chairman, Orthopaedic Surgery
Champion Physical Therapy and Performance University of Connecticut Health Center
Waltham, Massachusetts Farmington, Connecticut

John Joseph Maguire, MBBS (QLD), FRACS Alexander K. Meininger, MD

(Orth), MSpMed, FA Orth A
Orthopedic Surgeon
Orthopaedics and Sports Medicine
Townsville Orthopaedics and Sports Surgery
Townsville, Queensland, Australia
Orthopaedic Surgeon and Sports Medicine Specialist
Steamboat Orthopaedic Associates
Steamboat Springs, Colorado
xiv CONTRIBUTORS

Erik P. Meira, PT, DPT, SCS, CSCS Frank R. Noyes, MD

Clinic Director CEO, Cincinnati Sports Medicine
Black Diamond Physical Therapy, Inc. and Orthopaedic Center
Portland, Oregon President, Noyes Knee Institute
Cincinnati, Ohio
Kellie K. Middleton, MD, MPH
Orthopaedic Surgery Resident Cheryl Kathleen Obregon, PT, DPT, FAAOMPT
University of Pittsburgh Medical Center Therapy Services Institute
Pittsburgh, Pennsylvania The San Antonio Orthopaedic Group
San Antonio, Texas
Bruce S. Miller, MD
Associate Professor Luke T. O’Brien, BPhty, GCertSportsPhty,
Department of Orthopaedic Surgery SCS, PES
University of Michigan Vice President, Clinical Physical Therapy
Ann Arbor, Michigan Howard Head of Sports Medicine
Vail Valley Medical Center
Joseph M. Miller, PT, DSc, OCS, SCS, CSCS Vail, Colorado
Officer in Charge
Robinson Health Clinic Physical Therapy Julie O’Connell, PT, DPT, OCS, ATC
Department of Rehabilitation Director of Performing Arts Rehabilitation
United States Army Athletico
Fort Bragg, North Carolina Chicago, Illinois

Marika E Molnar, PT, LAc Jamie Osmark, CSCS, USATF, CGFI-1

Director AthletiCo Sports Medicine and Physical Therapy
Physical Therapy Services for New York City Ballet and New York, New York
School of American Ballet
New York, New York A. Lee Osterman, MD
Professor of Hand and Orthopedic Surgery
Timothy S. Mologne, MD President Philadelphia Hand Center
Sports Medicine Center Department of Orthopedics
Appleton, Wisconsin Thomas Jefferson University
Philadelphia, Pennsylvania
Kenneth J. Mroczek, MD
Chief, Division of Foot and Ankle Surgery Brett D. Owens, MD
Orthopaedic Surgery Professor
New York University Hospital for Joint Diseases Orthopaedic Surgery
New York, New York Keller Army Hospital
West Point, New York
Bart Muller, MD
Orthopaedic Surgery Academic Medical Center, Kenny Patterson, MPT
Amsterdam Physical Therapy & Athletic Medicine
Amsterdam, NH, the Netherlands Milwaukee Brewers Baseball Club
University of Pittsburgh Medical Center Phoenix, Arizona
Pittsburgh, Pennsylvania
Christopher Peduzzi, MA, ATC
Christopher D. Murawski, BS Head Athletic Trainer
Research Fellow Athletic Training
Foot and Ankle Surgery Philadelphia Eagles
Hospital for Special Surgery Philadelphia, Pennsylvania
New York, New York
Alex J. Petruska, Jr., PT, SCS, LAT
Paul C. Murphy, MD Senior Physical Therapist
Orthopaedic Surgeon Sports Physical Therapy
Murphy Sportsmedicine Center Massachusetts General Hospital
San Diego, California Boston, Massachusetts

Stephanie Niño, PT, DPT, FAAOMPT, OCS

Orthopaedic Surgery/Physical Therapy
The San Antonio Orthopaedic Group
San Antonio, Texas
 CONTRIBUTORS xv

Marc J. Philippon, MD Smita Rao, PT, PhD

Director of Hip Research and Managing Partner Assistant Professor
The Steadman Philippon Research Institute and the Department of Physical Therapy
Steadman Clinic New York University
Vail, Colorado New York, New York

Casey M. Pierce, MD Mark F. Reinking, PT, PhD, SCS, ATC

Orthopaedic Surgery Resident PGY-2 Associate Professor
St. Joseph’s Regional Medical Center Department of Physical Therapy & Athletic Training
Seton Hall University School of Health Saint Louis University
and Medical Sciences St. Louis, Missouri
Paterson, New Jersey
Amy Resler, DPT, CMP, CSCS
Matthew A. Pifer, MD Physical Therapy
Orthopaedic Surgeon Naval Medical Center San Diego
Orthopaedic Surgery, Sports Medicine San Diego, California
Orthopaedic Specialists of Wilkes
North Wilkesboro, North Carolina Paul F. Reuteman, PT, DPT, MHS, OCS, ATC
Clinical Professor
Mike Pollzzie, PT, DPT, OMPT, CSCS Program of Physical Therapy
Physical Therapist University of Wisconsin—La Crosse
Orthopaedic Edge Physical Therapy Staff Physical Therapist
Shelby Township, Michigan Sports Medicine Physical Therapy
Gunderson Health System
Christopher M. Powers, PhD, PT La Crosse, Wisconsin
Associate Professor
Biokinesiolgy and Physical Therapy Paul F. Reuteman, PT, DPT, MHS, OCS, ATC
University of Southern California Clinical Associate Professor
Los Angeles, California Program of Physical Therapy
University of Wisconsin-La Crosse
Paul J. Pursley, PT, SCS CSCS Staff Physical Therapist
Rehabilitation Therapy Sports Medicine Physical Therapy
University of Iowa Hospitals and Clinics Gunderson Health System
Iowa City, Iowa La Crosse, Wisconsin

William G. Raasch, MD Beth E. Richardson, DPT

Professor of Orthopaedic Surgery Clinic Director
Director of Sports Medicine Clinical Instructor
Medical College of Wisconsin Team Rehabilitation Services, LLC
Head Team Physician—Milwaukee Brewers Troy, Michigan
Baseball Club
Milwaukee, Wisconsin Scott A. Rodeo, MD
Cochief and Attending Orthopaedic Surgeon
Stephen J. Rabuck, MD Sports Medicine and Shoulder Service
Assistant Professor Codirector
Orthopaedic Surgery Tissue Engineering, Regeneration, and Repair Program
University of Pittsburgh Medical Center The Hospital for Special Surgery
Pittsburgh, Pennsylvania Professor
Orthopaedic Surgery
Charles E. Rainey, PT, DSc, DPT, OCS, SCS, CSCS, Weill Medical College of Cornell University
FAAOMPT New York, New York
Physical Therapist
Naval Special Warfare Group ONE Mark Rogow, ATC, CSCS
San Diego, California Sports Medicine Program Manager
Naval Special Warfare Group ONE
Jeremiah Randall, PT, DPT, ATC, CSCS San Diego, California
Major League Physical Therapist/Assistant
Athletic Trainer
Pittsburgh Pirates
Pittsburgh, Pennsylvania
xvi CONTRIBUTORS

Richard L. Romeyn, MD Matthew Salzler, MD

Southeast Minnesota Sports Medicine and Orthopaedic Attending Orthopaedic Surgeon
Surgery Specialists Department of Orthopaedic Surgery
Adjunct Clinical Professor & Team Physician Tufts Medical Center
Winona State University Boston, Massachusetts
Medical Director
Winona Health Sports Medicine Steven Paul Sartori, B. Physio, FPCP
Winona, Minnesota Specialist Sports Physiotherapist
North Queensland Cowboys Rugby
Capt. Michael D. Rosenthal, PT, DSc, SCS, ECS, League Football
ATC, CSCS Townsville, Queensland, Australia
Department Head
Physical and Occupational Therapy Steven Michael Scher, MSPT, ATC, CSCS, PES
Naval Medical Center, San Diego Director/Owner
San Diego, California Team Rehabilitation
Team Physical Therapist
Michael J. Ross, MD Detroit Lions
Sports Medicine Physician Royal Oak. Michigan
Director, Performance Lab
Rothman Institute Emilie Schmidt, DPT, SCS, ATC, CSCS
Philadelphia, Pennsylvania Physical Therapist
MARSOC Human Performance Program
James R. Ross, MD Camp Lejeune, North Carolina
Attending Orthopaedic Surgeon
Broward Orthopedic Specialists Eric Schweitzer, DPT, OCS, MTC
Fort Lauderdale, Florida Owner
Premier Physical Therapy and Sports Performance
Cdr. John-Paul H. Rue, MD, MC USN Clearwater, Florida
Associate Professor of Surgery
Uniformed University of the Health Sciences Daphne R. Scott, PT, DSc, FAAOMPT, OCS
Bethesda Maryland Regional Manager/Director of Leadership Development
Head Team Physician, U.S. Naval Academy Athletico Physical Therapy
Department of Orthopaedic Surgery and Sports Chicago, Illinois
Medicine
Naval Health Clinic Annapolis Nadia Sefcovic, DPT, COMT
Annapolis, Maryland Senior Physical Therapist
Westside Dance Physical Therapy
Mark Andrew Ryan, MS, ATC, CSCS New York, New York
Rehabilitation Coordinator
Howard Head Sports Medicine Amee L. Seitz, PT, PhD, DPT, OCS
Vail Valley Medical Center Department of Physical Therapy and Human
Vail, Colorado Movement Sciences
Northwestern University
Nelson S. Saldua, MD Chicago, Illinois
Attending Orthopaedic Spine Surgeon
Department of Orthopaedic Surgery Jon K. Sekiya, MD
Naval Medical Center San Diego Professor, Larry Matthews Collegiate Professor of
San Diego, California Orthopaedic Surgery
MedSport
Peter Sallay, MD University of Michigan
Clinical Assistant Professor Ann Arbor, Michigan
Department of Orthoapedics
Methodist Sports Medicine Ellen Shanley, PhD, PT, OCS
Indianapolis, Indiana Proaxis Therapy
South Carolina Center for Rehabilitation and
Bryan M. Saltzman, MD Reconstruction Sciences, Inc.
Resident University of South Carolina
Department of Orthopaedic Surgery Greenville, South Carolina
Rush University Medical Center
Chicago, Illinois
 CONTRIBUTORS xvii

K. Donald Shelbourne, MD Lynn Snyder-Mackler, PT, ScD, SCS, ATC, FAPTA

Orthopaedic Surgeon Alumni Distinguished Professor
Shelbourne Knee Center Physical Therapy and Delaware Rehabilitation Institute
Indianapolis, Indiana University of Delaware
Newark, Delaware
Scott P. Sheridan, MS, PT, ATC, CSCS
Head Athletic Trainer J. Richard Steadman, MD
Philadelphia Phillies Chairman of the Board and Managing Partner
Philadelphia, Pennsylvania Steadman Philippon Research Institute and the
Steadman Clinic
Marc Sherry, DPT, LAT, CSCS, PES Vail, Colorado
Physical Therapist
Orthopedics and Rehabilitation, Division of Mark Stovak, MD, FACSM, FAAFP
Sports Medicine Program Director
University of Wisconsin Hospitals and Clinics Sports Medicine Fellowship and Family Medicine
Madison, Wisconsin Residency Programs
Via Christi Hospital
Alexander Y. Shin, MD Clinical Associate Professor
Professor and Consultant Department of Family and Community Medicine
Department of Orthopedic Surgery University of Kansas School of Medicine–Wichita
Division of Hand Surgery Wichita, Kansas
Mayo Clinic
Rochester, Minnesota Nicole A. Strick, MPT
Physical Therapy
Courtney A. Shinost, MS, CSCS, RSCC Peak Performance Physical Therapy and Sports
Senior Strength and Conditioning Coach Medicine
Human Performance Appleton, Wisconsin
1st Marine Special Operations Battalion
Camp Pendleton, California Charles Christopher Stroud, MD
Attending Physician
Paul A. Sibley, DO Department of Surgery
Orthopaedic Hand Surgery Fellow William Beaumont Hospital, Troy
Ohio University Troy, Michigan
Grandview Medical Center
Kettering Health Network Kari L. Sturtevant, DPT, OCS
Dayton, Ohio President, Physical Therapist
Peak Performance Physical Therapy and Sports
Gursukhman S. Sidhu, MBBS Medicine
Research Fellow Appleton, Wisconsin
Orthopedic Surgery
Thomas Jefferson University Jason A. Suda, MOTR/L
Philadelphia, Pennsylvania Occupational Therapy
Philadelphia Hand Center
Mark Simenson, Occupational Therapy Philadelphia, Pennsylvania
Occupational Therapist/Certified Hand Therapist
Missouri Orthopaedic Institute Therapy Services Kentaro Suzuki, MD
Missouri Orthopaedic Institute Orthopedic Surgeon
Columbia, Missouri Ventura Orthopedics
Ventura, California
Terri M. Skirven OTR/L, CHT
Certified Hand Therapist, Brian T. Swanson, PT, DSc, OCS, FAAOMPT
Director of Hand Therapy Assistant Professor
Philadelphia Hand Center School of Physical Therapy
Philadelphia, Pennsylvania Texas Woman’s University
Houston, Texas
Niall A. Smyth, MD
Resident Miho J. Tanaka, MD
Orthopaedic Surgery Orthopedic Surgeon
University of Miami/Jackson Memorial Hospital Regeneration Orthopedics
Miami, Florida Saint Louis, Missouri
xviii CONTRIBUTORS

Suzanne Tanner, MD Joseph J. Van Allen, MSPT, SCS, ATC, CSCS

Orthopaedic Surgeon Assistant Athletic Trainer/Director of
Sports Medicine/Orthopaedics Rehabilitation
Gundersen Health Sports Medicine New England Patriots
Onalaska, Wisconsin Foxbrough, Massachusetts

Chuck A. Thigpen, PhD, PT, ATC Geoffrey S. Van Thiel, MD/MBA

SC Center for Rehabilitation and Reconstruction Assistant Professor
Sciences Department of Orthopedic Surgery
Arnold School of Public Health Rush University Medical Center and Rockford
University of South Carolina Orthopedic Associates
Columbia, South Carolina Rockford, Illinois

Kristian Thorborg, PT, MSportsPhty, PhD Molly Van Zeeland, DPT

Associate Professor, Senior Researcher, Specialist in Physical Therapist
Sportsphysiotherapy Peak Performance Physical Therapy and
Sports Orthopedic Research Center—Copenhagen Sports Medicine
Copenhagen University Hospita Appleton, Wisconsin
Arthroscopic Centre Amager
Amager-Hvidovre University Hospital Sebastiano Vasta, MD
Copenhagen, Denmark Resident Orthopaedic and Trauma Surgery
Department of Orthopaedic and Trauma Surgery
Donald Torrey, PT Campus Bio-Medico University Hospital
Sacramento Knee and Sports Medicine Rome, Italy
Sacramento, California
Shane A. Vath, DSc, SCS
Catherine Gauthier Trahiotis, PT Director Clinical Support Services
Department or Orthopaedic Surgery Naval Hospital Camp Lejeune
Department of Rehabilitative Services Camp Lejeune, North Carolina
University of Connecticut Health Center
Farmington, Connecticut Nikhil N. Verma, MD
Associate Professor, Orthopedic Surgeon
Bruce Charles Twaddle, MD FRACS Department Of Orthopedics
Professor of Orthopaedics and Sports Medicine Section of Sports Medicine
Sports Medicine at Husky Stadium Rush University Medical Center
University of Washington Midwest Orthopaedics at Rush
Seattle, Washington Chicago, Illinois

Timothy F. Tyler, MS, PT, ATC L. Tyler Wadsworth, MD

Clinical Research Associate Adjunct Associate Professor
The Nicholas Institute of Sports Medicine Department of Family and Community Medicine
and Athletic Trauma Saint Louis University School of Medicine
Lenox Hill Hospital/LIJ St Louis, Missouri
New York, New York
Mark B. Wagner, MD
Alexander R. Vaccaro, MD, PhD Orthopaedic Surgeon
The Everett J. and Marion Gordon Professor of Orthopaedics
Orthopaedic Surgery Orthopaedics Northwest
Professor of Neurosurgery Tigard, Oregon
Codirector of the Delaware Valley Spinal Cord
Injury Center Bryan Warme, MD
Cochief Spine Surgery Iowa State Sports Medicine and Orthopaedic
Codirector Spine Surgery Consultant
Thomas Jefferson University and Orthopaedics
the Rothman Institute McFarland Clinic
Philadelphia, Pennsylvania Ames, Iowa

Jeremy Vail, PT, OCS, ATC Russell F. Warren, MD

Rehabilitation Director, Sports Medicine Professor of Orthopedics
Athletic Department Surgeon-in-Chief Emeritus
University of California—Los Angeles Hospital for Special Surgery
Los Angeles, California New York, New York

Stephen C. Weber, MD
Sacramento Knee and Sports Medicine
Sacramento, California
Lt. Bradley S. Wells, PT, DPT, CSCS
Physical Therapist, United States Navy
Physical and Occupational Therapy Department
Naval Medical Center San Diego
San Diego, California
Kathleen White, PT, DPT
Physical Therapist, Research Assistant
Biomechanics and Movement Science
University of Delaware
Newark, Delaware
David S. Wickenden, Dip Physiotherapy (NZ),
Master Manipulative Therapy (Australia),
FAAOMPT (USA)
Physical Therapist
Kiwi Physical Therapy
New York, New York
Reginald B. Wilcox III, PT, DPT, MS, OCS
Clinical Supervisor
Department of Rehabilitation Services
Brigham and Women’s Hospital
Boston, Massachusetts
Kevin E. Wilk, PT, DPT, FAPTA
Associate Clinical Director
Champion Sports Medicine
Birmingham, Alabama
Adjunct Associate Professor
Marquette University
Department of Physical Therapy
Milwaukee, Wisconsin
CONTRIBUTORS xix
Scott A. Wilkins, DPT, OCS
Physical Therapist
OSI Physical Therapy
Stillwater, Minnesota
Donna Williams, PT, MHS
Director of Rehabilitation
Physical and Occupational Therapy
Midwest Orthopedics at Rush
Chicago, Illinois
Karen E. Wojcik, DPT, OCS, ATC
Physical Therapist II
Department of Rehabilitation
University of Connecticut Health Center
Farmington, Connecticut
Scot A. Youngblood, MD
Department Chairman, Foot and Ankle
Orthopaedic Surgeon
Assistant Professor of Surgery
Uniformed Services University of the Health Sciences
Department of Orthopaedic Surgery
Naval Medical Center San Diego
San Diego, California
Biagio Zampogna, MD
Resident Orthopaedic and Trauma Surgery
Department of Orthopaedic and Trauma Surgery
Campus Bio-Medico University Hospital
Rome, Italy
Capt. Gregg Ziemke, PT, MS, MHA, OCS,
MSC USN
Head, Physical Therapy Department
Naval Medical Center, Portsmouth
Portsmouth, Virgina
This page intentionally left blank
 PREFACE

Orthopaedic Rehabilitation of the Athlete was designed to be a comprehensive, extensively illustrated textbook about
the rehabilitation of common musculoskeletal conditions that affect athletes—from the professional competitor to the
occasional participant. The textbook is the first of its kind to bring together surgeons, therapists, and athletic trainers
to address injuries from the cervical spine to the foot, and nearly everything in between.
Comprising 45 chapters and 242 internationally renowned authors, the content and organization of this work is
unique. All chapters have between three and nine parts (separate sections) with additional authors and experts that
tease out the most salient and clinically applicable features and scenarios for our patients. The fundamental issues in
the care of each major injury are first introduced in separate chapters. Next, treatment regimens for nonoperative care
are given, with guidelines describing the indications for surgical intervention. Each diagnostic section includes an
operative portion that explains, in a highly illustrative manner, the surgical technique and intraoperative variations,
so that the entire musculoskeletal care team can better understand how the details of surgery may affect the rehabilita-
tive portion of the athlete’s care.
For patients undergoing surgery, preoperative “pre-habilitation” and postoperative rehabilitation are described in
great detail. All physicians, physical therapists, and athletic trainers who work with competitive athletes face the chal-
lenge of returning the athlete to competition as quickly, safely, and completely as possible. In compiling this book, we
have emphasized the terminal and transitional phases of rehabilitation necessary to restore the athlete to competition.
This includes many chapters with detailed rehabilitation plans customized for sports in which the injuries commonly
occur. Many books that include rehabilitation do not emphasize this critical phase of the actual return to sport-specific
training and competition. Often there seems to be a gap between traditional rehabilitation programs and the intense
requirements of participation in specific sports. Much of this book is dedicated to this transitional phase of returning
the athlete back to sports safely, using sport-specific rehabilitation programs and progressive return to training, par-
ticipation, and competition. Detailed criteria are given to guide the clinician and facilitate the decision to discharge
the athlete from rehabilitation and return him or her back to sports.
The textbook was formatted with a post-injury and recover timeline that will facilitate progression through a reha-
bilitation plan. This original feature is formatted in a timeline “ribbon” of rehabilitation progressions. Simply reviewing
the ribbon will provide guidelines for the clinician to use when rehabilitating the patient following each specific injury.
The timeline is designed with the “stoplight” concept: The red area of the timeline signifies that extreme caution is
needed in the early stages, because of factors including pain, effusion, arthrogenic inhibition, soft tissue healing, and
kinesophobia. In the yellow area of the timeline, a moderate degree of caution is still required in the progression of
the patient. The green area of the timeline means that the patient can be accelerated and progress to the terminal and
transitional phases of the rehabilitation program.
We hope that therapists, athletic trainers, surgeons, students, residents, and fellows, as well as others with an inter-
est in the comprehensive care of the musculoskeletal system, will all find this book informative and useful for their
education and practice. To enhance post-injury care, both the print and online versions have dedicated rehabilitation
guidelines and exercise prescriptions that will enhance communication within musculoskeletal teams.
We are deeply indebted to our contributors. Without their incredible talent and expertise, this textbook would not
have been possible. We are very fortunate to have authors who are leaders in their fields. We would also like to thank
the Elsevier team of Ann Ruzycka Anderson, Don Scholz, and Jennifer Moore, who handled a complex and innovative
publishing product with the highest level of dedication and professionalism.

Bruce Reider
George J. Davies
Matthew T. Provencher

xxi
This page intentionally left blank
 CONTENTS
PART 1
Shoulder
SHOULDER INSTABILITY
1 Anterior Shoulder Instability 3 (SLAP/LONG HEAD BICEPS)
INTRODUCTION 3
Ellen Shanley, Charles A. Thigpen, and Richard J. Hawkins
NONOPERATIVE REHABILITATION FOLLOWING
ANTERIOR CAPSULOLABRAL INJURY 11
Charles A. Thigpen, Ellen Shanley, and Richard J. Hawkins
POSTOPERATIVE REHABILITATION AFTER
ARTHROSCOPIC ANTERIOR SHOULDER
STABILIZATION 24
Charles A. Thigpen, Ellen Shanley, and Richard J. Hawkins
POSTOPERATIVE REHABILITATION AFTER OPEN
ANTERIOR STABILIZATION OF THE SHOULDER WITH
OR WITHOUT BONE GRAFTING (ILIAC CREST GRAFT,
LATARJET PROCEDURE) 41
Amy Resler, Matthew T. Provencher, Emilie Schmidt,
and Courtney A. Shinost
2 Posterior Shoulder Instability 63
INTRODUCTION 63
Demetris Delos, Travis G. Maak, and Russell F. Warren
POSTOPERATIVE REHABILITATION AFTER OPEN
OR ARTHROSCOPIC POSTERIOR SHOULDER
STABILIZATION 71
Emilie Schmidt, Amy Resler, Michael D. Rosenthal,
and Matthew T. Provencher
BEYOND BASIC REHABILITATION:
RETURN TO FOOTBALL AFTER POSTERIOR
SHOULDER STABILIZATION 85
Travis G. Maak, and Russell F. Warren
3 Multidirectional Shoulder Instability
INTRODUCTION 91
Bryan Warme and Scott A. Rodeo
NONOPERATIVE REHABILITATION OF
MULTIDIRECTIONAL SHOULDER INSTABILITY 95
John T. Cavanaugh and Scott A. Rodeo
POSTOPERATIVE REHABILITATION AFTER
TREATMENT OF MULTIDIRECTIONAL
SHOULDER INSTABILITY 103
John T. Cavanaugh and Scott A. Rodeo
BEYOND BASIC REHABILITATION: RETURN TO
SWIMMING AFTER TREATMENT OF MULTIDIRECTIONAL
SHOULDER INSTABILITY 112
Polly de Mille, John T. Cavanaugh and Scott A. Rodeo
SUPERIOR LABRAL PATHOLOGY
4 Superior Labral Pathology
(SLAP/Long Head Biceps) 121
INTRODUCTION 121
Thomas J. Gill IV, Kaitlin M. Carroll, and Amee L. Seitz
NONOPERATIVE REHABILITATION OF SLAP TEARS 126
Amee L. Seitz, Alex J. Petruska, and Thomas J. Gill IV
POSTOPERATIVE REHABILITATION AFTER TREATMENT OF
SLAP TEARS 141
Amee L. Seitz and Thomas Gill IV
BEYOND BASIC REHABILITATION: RETURN TO PITCHING
AND THROWING AFTER SLAP TEAR REPAIR 156
Thomas J. Gill IV, Joseph J. Van Allen, and Jeremiah Randall
BEYOND BASIC REHABILITATION: RETURN TO
VOLLEYBALL AFTER LABRAL SURGERY (SLAP REPAIR
OR DEBRIDEMENT AND DECOMPRESSION OF
SPINOGLENOID NOTCH CYST) 167
Aaron Brock, Alexander K. Meininger, and Sherwin S.W. Ho
5 Biceps Tendon Disorders 183
INTRODUCTION 183
Brian Armstrong and Eric C. Hall
NONOPERATIVE REHABILITATION OF LONG HEAD OF
BICEPS TENDINITIS/TENDINOSIS 187
Brian Armstrong and Eric C. Hall
POSTOPERATIVE REHABILITATION AFTER BICEPS
TENOTOMY AND TENODESIS 195
Brian Armstrong, Eric C. Hall, and Peter Sallay
91
BEYOND BASIC REHABILITATION: RETURN TO
WEIGHTLIFTING AFTER BICEPS TENODESIS 207
Brian Armstrong and Eric C. Hall
ROTATOR CUFF INJURIES
6 Rotator Cuff Injuries 215
INTRODUCTION 215
Laura M. Lundgren and Timothy S. Mologne
xxiii
xxiv CONTENTS

NONOPERATIVE REHABILITATION OF ROTATOR CUFF BEYOND BASIC REHABILITATION: RETURN TO ICE

IMPINGEMENT SYNDROME 220 HOCKEY AFTER ACROMIOCLAVICULAR INJURY 371
Kari L. Sturtevant, Molly Van Zeeland, Laura M. Lundgren, and Amy Resler, Wendell M.R. Heard, Nathan A. Mall,
Timothy S. Mologne and Nikhil N. Verma

POSTOPERATIVE REHABILITATION AFTER SUBACROMIAL NONOPERATIVE REHABILITATION OF CLAVICLE

DECOMPRESSION 230 FRACTURES 377
Stephen C. Weber and Donald Torrey Theresa A. Chiaia, Miho J. Tanaka, and Christopher S. Ahmad

BEYOND BASIC REHABILITATION: POSTOPERATIVE REHABILITATION AFTER REPAIR OF

RETURN TO PITCHING AFTER SUBACROMIAL CLAVICLE FRACTURE 384
DECOMPRESSION 235 Miho J. Tanaka, Theresa A. Chiaia, and Christopher S. Ahmad
Michael G. Ciccotti and Scott P. Sheridan
BEYOND BASIC REHABILITATION: RETURN TO
NONOPERATIVE REHABILITATION OF INTERNAL MOTORCROSS AFTER CLAVICLE FRACTURE 393
IMPINGEMENT 246 Kahl Goldfarb and Paul C. Murphy
Mark Rogow and Charles E. Rainey

POSTOPERATIVE REHABILITATION AFTER TREATMENT OF SHOULDER CARTILAGE INJURIES,

INTERNAL IMPINGEMENT 260 ARTHRITIS, AND CAPSULITIS
Mark Rogow and Charles E. Rainey
8 Adhesive Capsulitis and Glenohumeral
POSTOPERATIVE REHABILITATION FOLLOWING Arthritis 402
ARTHROSCOPIC ROTATOR CUFF REPAIR 292
Todd S. Ellenbecker, and David S. Bailie INTRODUCTION 402
Jo A. Hannafin, Theresa A. Chiaia, and A. Simone Maybin
BEYOND BASIC REHABILITATION: RETURN TO TENNIS
AFTER ROTATOR CUFF REPAIR 304 NONOPERATIVE REHABILITATION OF ADHESIVE
Neal M. Berger, Jeremy Vail, and Seth C. Gamradt CAPSULITIS 406
Theresa A. Chiaia, Jo A. Hannafin, and A. Simone Maybin
BEYOND BASIC REHABILITATION: RETURN TO GOLF
AFTER ROTATOR CUFF REPAIR 315 POSTOPERATIVE REHABILITATION AFTER CAPSULAR
Seth C. Gamradt, Jeremy Vail, and Neal M. Berger RELEASE FOR GLENOHUMERAL ADHESIVE
CAPSULITIS 418
Theresa A. Chiaia, Jo A. Hannafin, and A. Simone Maybin

ACROMIOCLAVICULAR AND POSTOPERATIVE REHABILITATION AFTER ARTHROPLASTY

STERNOCLAVICULAR JOINT INJURIES (REPLACEMENT), HEMIARTHROPLASTY, TOTAL
SHOULDER OR JOINT RECONSTRUCTION 428
David S. Bailie and Todd S. Ellenbecker
7 Acromioclavicular Joint Injuries and
Sternoclavicular Joint Injuries 326 BEYOND BASIC REHABILITATION: RETURN TO GOLF,
SWIMMING, AND TENNIS AFTER SHOULDER
INTRODUCTION 326 ARTHROPLASTY 441
John Apostolakos, Mark P. Cote, Knut Beitzel, Todd S. Ellenbecker and David S. Bailie
and Augustus D. Mazzocca

NONOPERATIVE REHABILITATION OF PART 2

ACROMIOCLAVICULAR JOINT
SPRAIN/SEPARATION 333
Karen E. Wojcik, Mark P. Cote, Nancy Craven, Gregg Gomlinski,
Elbow and Forearm,
Brian T. Swanson, Catherine Gauthier Trahiotis, John Apostolakos, Wrist and Hand
and Augustus D. Mazzocca

POSTOPERATIVE REHABILITATION AFTER DISTAL ELBOW AND FOREARM INJURIES

CLAVICULAR RESECTION (MUMFORD) 342
Brian T. Swanson, Karen E. Wojcik, Kimberly Cubeta-Gileau, 9 Epicondylitis 451
Thomas J.S. Durant, John Apostolakos, Mark P. Cote,
and Augustus D. Mazzocca INTRODUCTION 451
Michael Levinson and David Altchek
NONOPERATIVE REHABILITATION OF
STERNOCLAVICULAR JOINT SPRAINS 349 NONOPERATIVE REHABILITATION OF LATERAL
Richard L. Romeyn and Becky Heinert EPICONDYLITIS (TENNIS ELBOW) 454
Michael Levinson and David Altchek
POSTOPERATIVE REHABILITATION AFTER JOINT
RECONSTRUCTION OF ACROMIOCLAVICULAR POSTOPERATIVE REHABILITATION AFTER OPEN
SEPARATIONS 358 OR ARTHROSCOPIC SURGERY FOR LATERAL
Nathan A. Mall, Amy Resler, Wendell M.R. Heard, EPICONDYLITIS 459
and Nikhil N. Verma Michael Levinson and David Altchek

BEYOND BASIC REHABILITATION: RETURN TO TENNIS
AFTER TREATMENT FOR LATERAL EPICONDYLITIS 467
Jamie Osmark, Michael Levinson, and David Altchek
NONOPERATIVE REHABILITATION OF
GOLFER’S ELBOW 475
Steven Michael Scher, Stacie Christine Graves, Beth E. Richardson,
and Kyle Anderson
BEYOND BASIC RECOVERY: RETURN TO GOLF
AFTER TREATMENT FOR MEDIAL EPICONDYLITIS
(GOLFER’S ELBOW) 484
Steven Michael Scher, Stacie Christine Graves, Beth E. Richardson,
and Kyle Anderson
10 Epiphyseolysis and Osteochodritis
INTRODUCTION 494
Rob Hopkins and Champ L. Baker, Jr.
NONOPERATIVE REHABILITATION OF
EPIPHYSIOLYSIS OF THE MEDIAL EPICONDYLE
(LITTLE LEAGUE ELBOW) 498
Rob Hopkins and Champ L. Baker, Jr.
POSTOPERATIVE REHABILITATION AFTER TREATMENT
OF OSTEOCHONDRITIS DISSECANS OF THE
CAPITULUM 503
Rob Hopkins and Champ L. Baker, Jr.
BEYOND BASIC REHABILITATION: RETURN TO PITCHING
AFTER OSTEOCHONDRITIS DISSECANS OF
THE CAPITULUM 508
Rob Hopkins and Champ L. Baker, Jr.
11 Ulnar Collateral Ligament Injuries
INTRODUCTION 511
E. Lyle Cain, Jr.
NONOPERATIVE REHABILITATION OF ULNAR COLLATERAL
LIGAMENT INJURIES 515
E. Lyle Cain, Jr., Kevin E. Wilk, and Todd R. Hooks
POSTOPERATIVE REHABILITATION AFTER ULNAR
COLLATERAL LIGAMENT RECONSTRUCTION 523
E. Lyle Cain, Jr., Kevin E. Wilk, and Todd R. Hooks
BEYOND BASIC REHABILITATION: RETURN TO
PITCHING AFTER ULNAR COLLATERAL LIGAMENT
RECONSTRUCTION 544
E. Lyle Cain, Jr., Kevin E. Wilk, and Todd R. Hooks
12 Elbow Stiffness 557
INTRODUCTION 557
Michael Levinson and David Altchek
POSTOPERATIVE REHABILITATION AFTER ELBOW
CAPSULAR RELEASE 561
Michael Levinson and David Altchek
13 Forearm Nerve Entrapments 573
INTRODUCTION 573
Robert C. Manske and Mark Stovak
CONTENTS xxv
NONOPERATIVE REHABILITATION FOR FOREARM
NERVE ENTRAPMENTS 577
Robert C. Manske and Mark Stovak
14 Forearm Tendinitis 583
INTRODUCTION 583
Robert C. Manske and Mark Stovak
NONOPERATIVE REHABILITATION FOR
FOREARM TENDINITIS 588
Robert C. Manske and Mark Stovak
WRIST AND HAND INJURIES
494
15 Triangular Fibrocartilage
Complex Injuries 594
INTRODUCTION 594
Sidney M. Jacoby, Paul A. Sibley, and Leo T. Kroonen
NONOPERATIVE REHABILITATION OF WRIST SPRAINS AND
TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES 602
Roisin T. Dolan, Joseph S. Butler, Joanne Finn, Darragh E. Hynes,
and Alexander Y. Shin
POSTOPERATIVE REHABILITATION AFTER TRIANGULAR
FIBROCARTILAGE COMPLEX REPAIR/DEBRIDEMENT AND
WRIST LIGAMENT REPAIR/WRIST ARTHROSCOPY 610
Dominic Gomez-Leonardelli, Jack Browne, and Leo T. Kroonen
16 Jersey Finger and Mallet Finger 619
INTRODUCTION 619
511
A. Lee Osterman, Abdo Bachoura, Sidney M. Jacoby,
Terri M. Skirven, and Jason A. Suda
NONOPERATIVE REHABILITATION FOR
MALLET FINGER 626
A. Lee Osterman, Abdo Bachoura, Sidney M. Jacoby,
Terri M. Skirven, and Jason A. Suda
POSTOPERATIVE REHABILITATION FOR MALLET FINGER
AND JERSEY FINGER 630
A. Lee Osterman, Abdo Bachoura, Sidney M. Jacoby,
Terri M. Skirven, and Jason A. Suda
17 Thumb Ulnar Collateral
Ligament Injuries 639
INTRODUCTION 639
Mohamed Khalid
NONOPERATIVE REHABILITATION OF THUMB ULNAR
COLLATERAL LIGAMENT INJURIES 643
Mohamed Khalid, Bradley Kent Earnest, and Mark Simenson
POSTOPERATIVE REHABILITATION OF THUMB ULNAR
COLLATERAL LIGAMENT INJURIES 646
Mohamed Khalid, Bradley Kent Earnest, and Mark Simenson
BEYOND BASIC REHABILITATION: RETURN TO SKIING
AFTER NONOPERATIVE OR OPERATIVE TREATMENT OF
THUMB ULNAR COLLATERAL LIGAMENT INJURIES 652
Mohamed Khalid
xxvi CONTENTS

PART 3 CERVICAL SPINE INJURIES

Lumbar, Thoracic, 22 Cervical Spine Strains, Sprains,
and Cervical Spine and Burners 749
LUMBAR SPINE INJURIES INTRODUCTION 749
Nelson S. Saldua
18 Lumbar Spine Strains and Sprains 663
NONOPERATIVE REHABILITATION OF CERVICAL SPINE
INTRODUCTION 663 STRAINS, SPRAINS, AND BURNERS 753
Christopher J. Durall and Brian K. Allen Bradley S. Wells

NONOPERATIVE REHABILITATION OF LUMBAR

SPINE STRAINS AND SPRAINS 667
23 Cervical Spine Disc Injuries 757
Christopher J. Durall and Brian K. Allen INTRODUCTION 757
Christopher K. Kepler, Nikolaus S. Hjelm,
Gursukhmandeep S. Sidhu, David Gendelberg,
19 Herniated Lumbar Disc 677 and Alexander R. Vaccaro
INTRODUCTION 677
NONOPERATIVE REHABILITATION OF CERVICAL SPINE
S. Josh Bell, Stephanie Niño, and Cheryl Kathleen Obregon
DISC INJURIES 761
Christopher K. Kepler, Michael J. Ross, Christopher Peduzzi,
NONOPERATIVE REHABILITATION OF
Rick Burkholder, and Alexander R. Vaccaro
HERNIATED LUMBAR DISC 680
S. Josh Bell, Stephanie Niño, and Cheryl Kathleen Obregon BEYOND BASIC REHABILITATION: RETURN TO
CONTACT SPORTS AFTER CERVICAL
POSTOPERATIVE REHABILITATION AFTER LUMBAR SPINE INJURY 767
DISC HERNIATION SURGERY 687
Christopher K. Kepler, Michael J. Ross, Christopher Peduzzi,
S. Josh Bell, Stephanie Niño, and Cheryl Kathleen Obregon Rick Burkholder, and Alexander R. Vaccaro

BEYOND BASIC REHABILITATION: RETURN TO GOLF

AFTER LUMBAR DISC HERNIATION 698 PART 4
S. Josh Bell, Stephanie Niño, and Cheryl Kathleen Obregon
Hip and Thigh
20 Spondylolysis 703
HIP/THIGH MUSCLE STRAINS
INTRODUCTION 703
Gregg Ziemke, Stewart M. Kerr, Leslie C. Hair, and 24 Muscle Strains about the Hip
Charles E. Rainey and Thigh 775
NONOPERATIVE REHABILITATION OF INTRODUCTION 775
SPONDYLOLYSIS 708 Timothy F. Tyler and Stephen J. Nicholas
Gregg Ziemke, Leslie C. Hair, Charles E. Rainey,
and Stewart M. Kerr NONOPERATIVE REHABILITATION OF ADDUCTOR AND
HIP JOINT STRAINS 778
POSTOPERATIVE REHABILITATION AFTER REPAIR OF
Timothy F. Tyler and Stephen J. Nicholas
SPONDYLOLYSIS 713
Charles E. Rainey, Stewart M. Kerr, Gregg Ziemke, and Leslie C. Hair BEYOND BASIC REHABILITATION: RETURN TO HOCKEY
AFTER ADDUCTOR STRAIN 785
BEYOND BASIC REHABILITATION: RETURN TO
Timothy F. Tyler and Stephen J. Nicholas
GYMNASTICS AFTER OPERATIVE REPAIR OF
SPONDYLOLYSIS 727 NONOPERATIVE REHABILITATION OF HAMSTRING
Charles E. Rainey, Stewart M. Kerr, Gregg Ziemke, and Leslie C. Hair STRAINS AND CONTUSIONS 790
Marc Sherry, Bryan C. Heiderscheit, and William Clancy

THORACIC SPINE INJURIES BEYOND BASIC REHABILITATION: RETURN TO SPRINTING

ACTIVITIES AFTER HAMSTRING STRAIN 803
21 Musculoskeletal Thoracic Bryan C. Heiderscheit, Marc Sherry, and William Clancy
and Chest Injuries 736
POSTOPERATIVE REHABILITATION AFTER REPAIR OF
INTRODUCTION 736 PROXIMAL HAMSTRING AVULSION 810
Paul F. Reuteman and Scott A. Escher Matthew Salzler, Steve Brian Behrens, and James P. Bradley

NONOPERATIVE REHABILITATION OF MUSCULOSKELETAL BEYOND BASIC REHABILITATION: RETURN TO RUGBY

THORACIC SPINE AND CHEST INJURIES 743 AFTER REPAIR OF HAMSTRING AVULSION 819
Paul F. Reuteman James R Ross, Michael J. Keating, and Bruce S. Miller
 CONTENTS xxvii

25 Groin Injury 826 PART 5

INTRODUCTION 826 Knee
Bruce Charles Twaddle and Kristian Thorborg
EXTENSOR MECHANISM INJURIES
NONOPERATIVE REHABILITATION OF LONGSTANDING
GROIN INJURY 836 28 Patellar Instability 927
Kristian Thorborg and Bruce Charles Twaddle
INTRODUCTION 927
POSTOPERATIVE REHABILITATION AFTER Diego Herrera, Najeeb Khan, Donald C. Fithian,
ADDUCTOR RELEASE 841 and Christopher M. Powers
Bruce Charles Twaddle and Kristian Thorborg
NONOPERATIVE REHABILITATION OF PATELLAR
BEYOND BASIC REHABILITATION: RETURN TO INSTABILITY 931
FOOTBALL (SOCCER) AFTER TREATMENT OF Najeeb Khan, Donald C. Fithian, and Christopher M. Powers
ACUTE GROIN INJURY 849
Kristian Thorborg and Bruce Charles Twaddle POSTOPERATIVE REHABILITATION AFTER
PROXIMAL REALIGNMENT PROCEDURES AND
MEDIAL PATELLOFEMORAL LIGAMENT (MPFL)
FEMOROACETABULAR IMPINGEMENT RECONSTRUCTION 934
Kentaro Suzuki, Matthew Pifer, Najeeb Khan, Donald C. Fithian,
and Christopher M. Powers
26 Femoroacetabular Impingement
and Labral Injuries 856 POSTOPERATIVE REHABILITATION AFTER
ANTEROMEDIALIZATION OF THE TIBIAL TUBERCLE 940
INTRODUCTION 856 John Pryor Fulkerson, Craig Alver, and Erin L. Ives
John C. Clohisy

NONOPERATIVE REHABILITATION OF 29 Patellar and Quadriceps

HIP STIFFNESS AND HIP IMPINGEMENT Tendinopathy 951
(CAM/PINCER LESIONS) 860
Erik P. Meira and Mark B. Wagner INTRODUCTION 951
Christopher C. Kaeding
POSTOPERATIVE REHABILITATION AFTER
FEMOROACETABULAR IMPINGEMENT TREATMENT, NONOPERATIVE REHABILITATION OF PATELLAR
LABRAL REPAIR, AND LABRAL DEBRIDEMENT 868 TENDINOPATHY 955
Nancy J. Bloom, John C. Clohisy, and Marcie Harris-Hayes John Dewitt and Christopher C. Kaeding

BEYOND BASIC REHABILITATION: RETURN POSTOPERATIVE REHABILITATION AFTER PATELLAR

TO BASEBALL AFTER OPERATIVE TREATMENT OF TENDINOPATHY DEBRIDEMENT 964
FEMOROACETABULAR IMPINGEMENT 894 John Dewitt and Christopher C. Kaeding
Trevor Ryan Gaskill, Mark Andrew Ryan,
and Marc J. Philippon BEYOND BASIC REHABILITATION: RETURN TO
BASKETBALL AFTER OPERATIVE TREATMENT FOR
BEYOND BASIC REHABILITATION: PATELLAR TENDINOPATHY 972
RETURN TO GOLF AFTER OPERATIVE John Dewitt and Christopher C. Kaeding
TREATMENT OF FEMOROACETABULAR
IMPINGEMENT 901 POSTOPERATIVE REHABILITATION AFTER REPAIR OF
Trevor Ryan Gaskill, Mark Andrew Ryan, PATELLAR AND QUADRICEPS TENDON 976
and Marc J. Philippon J. Martin Leland and Phillip J. Malloy

27 Stress Fractures of the Femoral

Neck/Shaft 907 MENISCUS INJURIES
INTRODUCTION 907 30 Meniscus Injuries 991
Bryan C. Heiderscheit and Geoffrey S. Baer
INTRODUCTION 991
NONOPERATIVE REHABILITATION OF Frank R. Noyes
STRESS FRACTURE OF THE FEMORAL
NECK AND SHAFT 911 NONOPERATIVE REHABILITATION OF
Bryan C. Heiderscheit and Geoffrey S. Baer MENISCUS INJURIES 998
K. Donald Shelbourne and Heather E. Freeman
BEYOND BASIC REHABILITATION:
RETURN TO RUNNING AFTER OPERATIVE POSTOPERATIVE REHABILITATION AFTER
TREATMENT OF A STRESS FRACTURE OF MENISCUS REPAIR 1004
THE FEMORAL NECK 916 Frank R. Noyes, Timothy P. Heckmann,
Bryan C. Heiderscheit and Geoffrey S. Baer and Sue D. Barber-Westin
xxviii CONTENTS
POSTOPERATIVE REHABILITATION AFTER MENISCUS
REPAIR AND PRIMARY ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION 1014
Frank R. Noyes, Timothy P. Heckmann,
and Sue D. Barber-Westin
BEYOND BASIC REHABILITATION: RETURN TO CATCHING
AFTER MENISCAL REPAIR 1024
Kenny Patterson and William G. Raasch
ARTICULAR CARTILAGE INJURIES
31 Articular Cartilage Injury (Including
Osteochondritis Dissecans) in the Young
Athletic Knee 1048
INTRODUCTION 1048
Nathan A. Mall, Bryan M. Saltzman, Andrew S. Lee,
and Brian J. Cole
NONOPERATIVE REHABILITATION OF ARTICULAR
CARTILAGE INJURIES 1059
Andreas H. Gomoll and Reginald B. Wilcox III
POSTOPERATIVE REHABILITATION AFTER
FEMORAL CONDYLE OR TROCHLEAR GROOVE
MICROFRACTURE 1071
Luke T. O’Brien and J. Richard Steadman
POSTOPERATIVE REHABILITATION AFTER AUTOLOGOUS
CHONDROCYTE IMPLANTATION FOR CARTILAGE
RESTORATION 1082
Scott D. Gillogly and Kate McDonald
POSTOPERATIVE REHABILITATION AFTER
OSTEOCHONDRAL ALLOGRAFT/AUTOGRAFT TRANSFER
FOR CARTILAGE RESTORATION 1097
Scott D. Gillogly and Kate McDonald
BEYOND BASIC REHABILITATION:
RETURN TO BASKETBALL AFTER
OSTEOCHONDRAL ALLOGRAFT
TRANSPLANTATION 1110
Daphne R. Scott, Wendell M.R. Heard, Andrew S. Lee,
Bryan M. Saltzman, and Brian J. Cole
LIGAMENT INJURIES
32 Anterior Cruciate Ligament Injuries
INTRODUCTION 1118
J. Martin Leland
NONOPERATIVE AND PREOPERATIVE
REHABILITATION OF ANTERIOR CRUCIATE
LIGAMENT INJURIES 1123
David Logerstedt, Kathleen White, Michael J. Axe,
and Lynn Synder-Mackler
POSTOPERATIVE REHABILITATION AFTER
BONE-PATELLAR TENDON-BONE ANTERIOR CRUCIATE
LIGAMENT RECONSTRUCTION (AUTOGRAFT AND
ALLOGRAFT) 1134
Donna Williams, Mark Allen Jordan,
and Geoffrey S. Van Thiel
BEYOND BASIC REHABILITATION: RETURN TO
SKIING AFTER ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION 1145
Nicole A. Strick and Timothy S. Mologne
POSTOPERATIVE REHABILITATION AFTER SOFT TISSUE
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
(AUTOGRAFT AND ALLOGRAFT) 1153
Sanjeev Bhatia, Geoff S. Van Thiel, John Bojchuk,
and Bernard R. Bach, Jr.
BEYOND BASIC REHABILITATION: RETURN TO
SOCCER AFTER ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION 1163
Jason L. Koh and Julie O’Connell
POSTOPERATIVE REHABILITATION AFTER
ANATOMIC ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION 1173
Kellie K. Middleton, Bart Muller, Stephen J. Rabuck,
James J. Irrgang, and Freddie H. Fu
33 Posterior Cruciate Ligament Injuries 1193
INTRODUCTION 1193
Robert F. LaPrade, Casey M. Pierce, and Scott A. Wilkins
NONOPERATIVE REHABILITATION OF POSTERIOR
CRUCIATE LIGAMENT INJURIES 1203
Robert F. LaPrade, Casey M. Pierce, and Scott A. Wilkins
POSTOPERATIVE REHABILITATION AFTER POSTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION 1221
Ernest M. Muntean and Jon K. Sekiya
BEYOND BASIC REHABILITATION: RETURN TO FOOTBALL
AFTER POSTERIOR CRUCIATE LIGAMENT INJURY 1231
Robert F. LaPrade, Casey M. Pierce, and Scott A. Wilkins
BEYOND BASIC REHABILITATION: RETURN TO JOGGING
AFTER MULTILIGAMENT KNEE RECONSTRUCTION 1241
Nathan L. Cafferky, Gregory C. Fanelli, and Craig J. Edson
34 Medial Collateral Ligament Injuries 1254
INTRODUCTION 1254
Michael J. Battaglia II
NONOPERATIVE REHABILITATION OF MEDIAL
COLLATERAL LIGAMENT INJURIES 1259
Robert J. Bradbury and Michael J. Battaglia II
1118
POSTOPERATIVE REHABILITATION AFTER REPAIR OR
RECONSTRUCTION OF THE MEDIAL COLLATERAL
LIGAMENT 1268
Timothy S. Mologne and Molly Van Zeeland
BEYOND BASIC REHABILITATION: RETURN TO FOOTBALL
AFTER MEDIAL COLLATERAL LIGAMENT SURGERY 1279
Luke O’Brien, Nicholas Kennedy, and Robert F. LaPrade
35 Lateral Collateral Ligament and
Posterolateral Ligament Injuries 1291
ISOLATED LATERAL COLLATERAL LIGAMENT INJURIES:
INTRODUCTION 1291
William G. Clancy, Jr.
 CONTENTS xxix

COMBINED LATERAL COLLATERAL LIGAMENT

AND POSTEROLATERAL LIGAMENTOUS INJURIES: ACHILLES TENDON INJURIES
INTRODUCTION 1294
William G. Clancy, Jr. 38 Achilles Tendinopathy and Rupture 1385
NONOPERATIVE REHABILITATION OF LATERAL INTRODUCTION 1385
COLLATERAL LIGAMENT SPRAINS 1297 James H. Flint, Michael D. Rosenthal, and Jean-Paul H. Rue
William Clancy, Jr., Kevin E. Wilk, and Leonard C. Macrina
NONOPERATIVE REHABILITATION OF ACHILLES
POSTOPERATIVE REHABILITATION AFTER TENDINOPATHY 1390
POSTEROLATERAL CORNER REPAIR OR Leslie C. Hair, Michael D. Rosenthal, James H. Flint,
RECONSTRUCTION 1304 and John-Paul H. Rue
William G. Clancy, Jr., Kevin E. Wilk, and Leonard C. Macrina
POSTOPERATIVE REHABILITATION OF ACHILLES
BEYOND BASIC REHABILITATION: RETURN TO RUGBY TENDINOPATHY 1397
LEAGUE AFTER POSTEROLATERAL CORNER KNEE James H. Flint, Michael D. Rosenthal, Charles E. Rainey,
RECONSTRUCTION WITH AUTOGRAFT 1316 and John-Paul H. Rue
John Maguire and Steven Sartori
NONOPERATIVE REHABILITATION OF ACHILLES
TENDON RUPTURE 1403
Bradley Wells, Michael D. Rosenthal, James H. Flint,
and John-Paul H. Rue
PART 6
POSTOPERATIVE REHABILITATION OF ACHILLES TENDON
Leg, Ankle, and Foot RUPTURE 1409
James H. Flint, Michael D. Rosenthal, Charles E. Rainey,
LOWER LEG CONDITIONS and John-Paul H. Rue

BEYOND BASIC REHABILITATION: RETURN TO

36 Leg Pain in the Athlete: Stress Fractures, BASKETBALL AFTER TREATMENT OF ACHILLES TENDON
Medial Tibial Stress Syndrome, and External RUPTURE 1417
Compartment Syndromes 1329 Bradley Wells, Michael D. Rosenthal, James H. Flint,
and John-Paul H. Rue
INTRODUCTION 1329
Timothy S. Mologne and Kari Sturtevant

NONOPERATIVE REHABILITATION OF MEDIAL TIBIAL ANKLE INJURIES

STRESS SYNDROME 1332
Mark F. Reinking and L. Tyler Wadsworth 39 Ankle Sprains, Fractures,
and Chondral Injuries 1426
NONOPERATIVE REHABILITATION OF TIBIAL STRESS
FRACTURE 1337 INTRODUCTION 1426
Mark F. Reinking and L. Tyler Wadsworth Annunziato Amendola, Sebastiano Vasta,
and Biagio Zampogna
POSTOPERATIVE REHABILITATION AFTER TREATMENT OF
EXERTIONAL COMPARTMENT SYNDROMES 1342 NONOPERATIVE REHABILITATION OF LATERAL AND
Dana Curtis Covey and Shane A. Vath SYNDESMOTIC SPRAINS 1432
Paul J. Pursley and Annunziato Amendola
BEYOND BASIC REHABILITATION: RETURN TO RUNNING
AFTER STRESS FRACTURE OF THE TIBIA 1350 POSTOPERATIVE REHABILITATION AFTER LATERAL ANKLE
Kari Sturtevant, Danielle Cooper and Timothy S. Mologne LIGAMENT REPAIR/RECONSTRUCTION 1438
Scot A. Youngblood and William E. Burns, Jr.

37 Tibial Shaft Fractures 1360 POSTOPERATIVE REHABILITATION AFTER TREATMENT OF

INTRODUCTION 1360
Lance E. LeClere and Robert M. Lucas
NONOPERATIVE REHABILITATION OF TIBIAL SHAFT
FRACTURES 1364
Katelyn H. McCormick and Lance E. LeClere
POSTOPERATIVE REHABILITATION AFTER TIBIAL SHAFT
FRACTURE 1370
Katelyn H. McCormick Robert S. Eberly, and Lance E. LeClere 40
BEYOND BASIC REHABILITATION: RETURN TO SKIING
AFTER TREATMENT OF TIBIAL SHAFT FRACTURE 1379
Katelyn H. McCormick
LATERAL AND MEDIAL ANKLE FRACTURES 1449
Joseph M. Miller and Brett D. Owens
POSTOPERATIVE REHABILITATION AFTER TREATMENT OF
MICROFRACTURE OR CHONDRAL INJURIES OF
THE ANKLE 1463
Charles P. Hannon, David Wickenden, Niall A. Smyth,
Christopher D. Murawski, and John G. Kennedy
Ankle Impingement 1477
INTRODUCTION 1477
Charles P. Hannon, Niall A. Smyth, Christopher D. Murawski,
and John G. Kennedy
xxx CONTENTS

BEYOND BASIC REHABILITATION: RETURN TO SOCCER

AFTER SURGICAL TREATMENT OF POSTERIOR ANKLE 44 Fifth Metatarsal Fractures 1552
IMPINGEMENT 1482
John Gallucci, Jr., Amy N. Alexander, Niall A. Smyth, INTRODUCTION 1552
and John G. Kennedy Timothy S. Mologne

NONOPERATIVE REHABILITATION OF FIFTH METATARSAL

41 Flexor Hallucis Longus Tendinopathy
INTRODUCTION 1492
William G. Hamilton, Marika Molnar, and Nadia Sefcovic
BEYOND BASIC REHABILITATION: RETURN TO BALLET
AFTER TREATMENT FOR FLEXOR HALLUCIS LONGUS
TENDINOPATHY AND POSTERIOR IMPINGEMENT 1496
William G. Hamilton, Marika Molnar, and Nadia Sefcovic
FOOT INJURIES
1492 FRACTURES (INCLUDING JONES FRACTURE) 1556
Brad McMahon, Laura Lundgren, and Timothy S. Mologne
POSTOPERATIVE REHABILITATION AFTER INTERNAL
FIXATION OF FIFTH METATARSAL FRACTURES 1560
Timothy S. Mologne, Laura Lundgren, and Brad McMahon
BEYOND BASIC REHABILITATION: RETURN TO FOOTBALL
AFTER OPEN REDUCTION AND INTERNAL FIXATION OF
JONES FRACTURE 1566
Brad McMahon and Timothy S. Mologne

42 Plantar Fasciitis 1511 45 First Metatarsophalangeal Joint Sprain

(Turf Toe) 1571
INTRODUCTION 1511
Charles Christopher Stroud, Erick Fountain, and Mike Pollzzie INTRODUCTION 1571
Stephen Gould and Kenneth J. Mroczek
NONOPERATIVE REHABILITATION OF
PLANTAR FASCIITIS 1515 NONOPERATIVE REHABILITATION OF FIRST
Charles Christopher Stroud, Erick Fountain, and Mike Pollzzie METATARSOPHALANGEAL SPRAIN (TURF TOE) 1576
Smita Rao and Kenneth J. Mroczek
POSTOPERATIVE REHABILITATION AFTER PLANTAR
FASCIITIS SURGERY 1521
Charles Christopher Stroud, Erick Fountain, and Mike Pollzzie

43 Midfoot Sprains and Strains

and Lisfranc Injuries 1531
INTRODUCTION 1531
Jason M. Jennings and Mark E. Easley

NONOPERATIVE REHABILITATION OF MIDFOOT SPRAINS

(STAGE I LIGAMENTOUS LISFRANC INJURIES) 1536
Eric R. Schweitzer, Lacy D. Jennings, Mark E. Easley,
and Jason M. Jennings

POSTOPERATIVE REHABILITATION OF MIDFOOT SPRAINS

(STAGE II-III LIGAMENTOUS LISFRANC INJURIES) 1543
Eric R. Schweitzer, Lacy D. Jennings, Mark E. Easley,
and Jason M. Jennings
PART 1

Shoulder
This page intentionally left blank
 SHOULDER INSTABILITY
Chapter 1
Anterior Shoulder Instability
INTRODUCTION
Ellen Shanley, PhD, PT, OCS, Charles A. Thigpen, PhD, PT, ATC, and Richard J. Hawkins, MD
Epidemiology
Overall Incidence
• Estimates of the initial incidence of anterior glenohu-
meral instability in the general population range from
8.2 occurrences per 100,000 person years1 in the rural
United States to as high as 24 occurrences per 100,000
person years in Scandinavian countries.2,3
• In NCAA athletes the instability incidence at the gle-
nohumeral joint was calculated as 0.12 injuries per
1000 athletic exposures (AE).4
• The frequency of instability episodes in a military pop-
ulation over 1 year was calculated as 2.8%.5
• The overall injury rate, including both initial and recur-
rent episodes of shoulder instability, has been docu-
mented to significantly increase the total number of
episodes.1,4
Age
• Owens et al. reported that 80% of shoulder disloca-
tions occur in younger patients.5 Forty seven percent
of patients presenting to U.S. emergency departments
with traumatic dislocations were between the age of 15
and 29.6 A Scandinavian population study reported
that the overall peak incidence of shoulder dislocations
in males occurred between the ages 21 and 30 and in
females between the ages of 61 and 80.2 Recurrent
instability has been reported at highest frequencies in
patients younger than 20 years old (66% to 94%).7,8
Gender
• Male collegiate athletes (0.15/1000 AE) were 2.7 times
more likely to sustain a shoulder instability episode
than female (0.06/ 1000 AE) collegiate athletes.4 In the
military, male cadets had a slightly higher frequency
of shoulder instability than their female counterparts
with 2.9% and 2.5% documented over a 1-year study
period, respectively.5
Sport
• In collegiate athletes, the rate of shoulder instability was
greatest in Spring football at 0.40/1000 AE followed
by wrestling (0.21/1000 AE), women’s ice hockey
(0.18/1000 AE) and fall football (0.18/1000 AEs).4
• In high school athletes, dislocations were reported to
be higher in male sports (38%) than female sports
(29%).9 However, female basketball players sustained
more shoulder dislocations than male basketball players
(proportion ratio = 2.7).9,10
• Injuries were sustained more in games (0.31/1000 AE)
than practices (0.09/1000 AE) and NCAA athletes
were 3.5 times more likely to sustain an injury in games
than in practice.4
Position
• In football, linebackers, wide receivers, and running
backs most frequently sustained dislocations.9
• Outside hitters reported the highest percentage of
shoulder dislocation amongst volleyball players 9
Pathophysiology
Intrinsic Factors
• Several anatomic factors have been theorized to in-
crease the potential for anterior instability of the
3
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN