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TRANSCRIPT
12/15/2018
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Do it Yourself:
Home Exercise for Lower Extremity Problems
Kristin Mathews, MS, ATCHally Tappan, MA, ATCMichael Mayes, MS, ATC
Disclosures
▪ We have nothing to disclose.
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What is an Athletic Trainer (AT)?
▪ Unique health care professional who collaborate with physicians to optimize activity of physically active
▪ Provide preventative services, emergency care, clinical assessment, therapeutic intervention and rehabilitation of injuries and medical conditions
▪ AT improve functional outcomes and specialize in patient education to prevent injury and re-injury
▪ Employed in a variety of settings
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Athletic Training Domains
▪ Prevention▪ Evaluation▪ Immediate Care▪ Treatment, Rehabilitation & Reconditioning
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AT Clinical Responsibilities at UCSF
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Presentation Goals
▪ Provide basic instruction of LE acute injury care
▪ Understand the importance of acute injury care
▪ Understand the goals of early phases of rehab
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Goals of Acute Injury Care
▪ Minimize further damage
▪ Reduce hemorrhage and edema
▪ Relieve pain and spasm
▪ Promote healing
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(Baoge 2012)
Injury Process
▪ Inflammatory Phase
• 1-4 days post injury
▪ Proliferation Phase
• 2-4 days post injury
• Can last up to 6 weeks
▪ Remodeling Phase
• Starts after at least 3 weeks post injury
• Requires 12 months to become maximal
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(Baoge 2012)
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Inflammatory Phase Goals
▪ Protection
• Varies depending on injury/body part
▪ Rest
▪ Ice
▪ Compression
▪ Elevation
▪ Minimum 2-3 days post injury!
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Proliferation Phase Goals
▪ Improve/maintain range of motion
▪ Limit loss/maintain muscle strength and coordination
▪ Continue to promote an ideal healing environment
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Initial Rehab Exercises
▪ Goals of early intervention:
• Decrease swelling
• Decrease pain
• Restore range of motion
• Restore strength
• Restore neuromuscular control
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Thigh Injuries
▪ Muscle strain
• Quadriceps, hamstring, hip flexor
▪ Muscle contusion
▪ Differential diagnoses
• fracture, compartment syndrome,
radiculopathy, etc.
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PRICE▪ Protection
• Typically thigh injuries do not require any type of DME
▪ Rest
• Remove from activity. Consider assistive walking device
▪ Ice
• 15-20 min every hour
▪ Compression
▪ Elastic wrap. Consider adding a compression stocking if patient develops lower leg edema.
▪ Elevation
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Thigh Handout
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Stretching
▪ Early static stretching encourages elongation of maturing scar tissue (Kary 2010)
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Quadriceps StretchingHamstring Stretching
Strengthening
▪ Early muscle activation reduces strength losses (Slider 2013)
▪ Isometric → concentric → eccentric
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Hamstring Isometrics
Flex
Quadriceps Isometrics
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Thigh Injuries Wrap-Up
▪ Can become a chronic issue due to poor treatment and/or rehab
▪ Consider referral to physical therapy
▪ Educate patient to return to activity slowly
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Ankle Injuries
▪ Ankle sprains are one of the most common musculoskeletal injuries occurring in sports and sedentary persons. (Fong DT, 2008)
▪ The rate of ankle sprains can occur from 15-20% of all sports injuries. (Aiken, 2008)
▪ 77% of all ankle sprains are lateral ankle sprains.
▪ Most occur during ankle inversion and plantar flexion.
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Ankle Sprain Classifications
▪ Grade 1
• Mild stretching of ligament complex w/o joint instability, weight bearing, no hemorrhaging
▪ Grade 2
• Partial rupture of the ligament complex with mild instability, hemorrhaging, tender to palpate, some loss of function
▪ Grade 3
• Complete rupture of the ligament complex with joint instability, hemorrhaging, great loss of normal function
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Differential Diagnosis▪ Syndesmosis sprain = high ankle sprain
• Occurs in 1-24% of ankle sprains
• If disrupted, may need surgical intervention
▪ Fracture
• Medial or lateral malleolus, base of 5th metatarsal, or navicular
• Refer to Ottawa Ankle Rules
▪ Lis Franc fracture/dislocation
• Disruption of the TMT ligaments at the TMT joint
▪ Osteochondral lesion of talus
• Persistent pain and swelling
▪ Achilles rupture
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Ottawa Ankle Rules Types of X-Rays
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• In ortho clinics, WB XR are preferred because it shows:
‒ Alignment/Joint space narrowing
‒ Signs of instability
‒ Severity of displacement
WB Views NWB Views
PRICE - Protection▪ Consider prescribing a brace or
walking boot
▪ Grade I and II lateral ankle sprains
• Decreased pain/swelling (Kerkhoff et al. 2001)
• Reduced time off from work/sport compared to using elastic wrap (Beynnon et al. 2006)
▪ Grade III lateral ankle sprains
• Clinical consensus suggests that some form of immobilization is necessary (NATA 2013, Lamb et al. 2009)
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Air Cast
ASO Brace
Cam Walker
PRICE▪ Protection
• Varies depending on severity of ankle injury
▪ Rest
• Remove from activity. Consider assistive walking device
▪ Ice
• 15-20 min every hour
▪ Compression
▪ Elastic wrap. Consider adding a compression
stocking if patient develops lower leg edema
▪ Elevation
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Ankle Handout
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Range of MotionExercise Goal Frequency Photo
Ankle Pump Restore and maintain ankle dorsiflexion and plantarflexion
2 x 15reps3x/day
ABC's Restore and maintain ankle motion
2 sets A-Z3x/day
Calf Stretch Restore and maintain ankle dorsiflexion
3 sets 2min3x/day
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Strengthening – Towel Toe Pulls
▪ Goal: Increase strength of toe/foot flexors
▪ Frequency: 1 sets 5 pulls, 3 times/day
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Strengthening – Toe Pick-Ups
▪ Goal: Increase strength of toe/foot flexors
▪ Frequency: 2-3 sets, 3 times/day
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Strengthening – Toe Taps
▪ Goal: Increase strength of tibialis anterior muscle
▪ Frequency: 1 set to fatigue, 3 times/day
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Strengthening – Windshield Wipers
▪ Goal: Increase strength of peroneal and posterior tibialis muscles
▪ Frequency: 1 set to fatigue, 3 times/day
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Strengthening – Calf Raises
▪ Goal: Increase strength of calf muscles
▪ Frequency: 2 set 10-12 reps, 3 times/day
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Strengthening– Gait Training
▪ Goal: Ensure proper walking gait
▪ Frequency: Repeat until perfect throughout the day
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▪ Can become a chronic issue due to poor treatment and/or rehab
▪ Consider referral to physical therapy to work strengthening, neuromuscular control, and proprioception.
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Ankle Injuries Wrap-Up Knee Injuries
▪ Most commonly injured joint in adolescent athletes (Gage et al 2012)
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(Nicholl et al 1991)11%
PRICE - Protection
▪ Consider prescribing a hinged knee brace or T-scope brace instead of a knee immobilizer.
• More functional, allows for protected ROM, better ambulation.
• T-scope brace commonly used after knee surgery.
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T-Scope Brace
• Ligament injury• Meniscus injury• Patella dislocation
Hinged Knee Brace
• Mild ligament injury
PRICE – Protection (cont.)
▪ Knee Immobilizer (Gravlee, Van Durme 2007)
• Quadriceps tendon rupture
• Patella tendon rupture
• Patella fracture or dislocation
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PRICE▪ Protection
• Varies depending on severity of knee injury
▪ Rest
• Remove from activity. Consider assistive walking device
▪ Ice
• 15-20 min every hour
▪ Compression
▪ Elastic wrap. Consider adding a compression stocking if patient develops lower leg edema.
▪ Elevation
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Specific Goals of Acute Knee Exercises
▪ Within 2 weeks post injury:
• Full knee ROM
• Good quad muscle activation
• Restore normal gait pattern
▪ Discontinue use of crutches:
• Normal gait pattern achieved
• Ability to ascend/descend stairs w/o significant pain
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Knee Handout
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Range of Motion
Exercise Goal Frequency Photo
Knee ExtensionBridges
Restore and maintain full knee extension
10-15min3x/day
Towel Slides Restore and maintainfull knee flexion
3 x 10reps3x/day
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Strengthening
Exercise Goal Frequency Photo
Quad Sets Increase strengthof quadricep muscle
3 x 10reps3x/day
Straight Leg Raises
Increase strength of quadricep muscle
3 x 10reps3x/day
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Flex
Refer to Ortho Specialist
▪ Initiate PRICE
▪ Order appropriate DME
▪ Order MRI
▪ Begin acute rehab exercises
▪ Primary goals:
• Minimize swelling
• Improve range of motion
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Acute Injury Timeline
▪ Example:
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Day 1 Patient is injured on the weekend
Day 2-3 Patient makes appt to see PCP
Day 4-5 Patient is seen by PCP and an MRI is ordered
Day 6-10 Patient has MRI done and is referred to ortho specialist
Day 11-20 Patient is seen by ortho specialist
Up to 15 days before an intervention is prescribed.Consider recommending acute injury exercises.
Conclusion
▪ Acute injury care is time sensitive
▪ Early intervention accelerates recovery
▪ Follow the PRICE principle
▪ Provide patients with basic instruction of acute rehab exercises
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Thank you!