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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!