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Do it Yourself: Home Exercise for Lower Extremity Problems

Katie Elston ATC; Elise Hammond ATC; Derek Hirai, MS, ATC

Disclosures

We have nothing to disclose.

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What is an Athletic Trainer?

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What is an Athletic Trainer (AT)?

Allied Health Care Professional
Domains
Prevention
Evaluation
Immediate Care
Treatment, Rehab, Reconditioning
Organization and Administration
Professional Responsibility

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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

Immediate onset tissue death
Hematoma formation
Inflammatory cells
Leukocytes
Macrophages

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(Baoge 2012)

Proliferation Phase

New tissue laid down
Injury site contracts as new tissues are built
Blood vessels rebuilt

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Inflammatory Phase

Protection
Rest
Ice
Compression
Elevation
Minimum 2-3 days post injury!

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Proliferation Phase

Improve/maintain range of motion
Limit loss/maintain muscle strength and coordination
Continue to promote an ideal healing environment

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Thigh Injuries

Muscle strain
Quadriceps, hamstring, hip flexor
Muscle contusion
Differential diagnoses

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Thigh Muscle Strain

MOI = Eccentric loading of

muscle fibers (Boublik 2013)

Causes tearing of muscle
r tendon fibers
R/o muscle avulsion injury

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Sports Related Hamstring Strain

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Thigh Muscle Contusion

“Charley Horse”
MOI = blunt force trauma (Kary 2010)
Causes tearing of muscle fibers
R/o fracture

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Differential Diagnoses

Compartment Syndrome
Direct trauma
Life/limb threatening (Burns 2004)
Osteochondritis Dissecans
Acute Fracture
Direct trauma
Avulsion fracture during eccentric loading (adolescent athletes)
Muscle Cramp
Radiculopathy

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PRICE - Protection

Typically thigh injuries do not require any type of DME

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PRICE - Rest

Remove from activity to prevent further injury
Consider assistive walking devices to limit pain, improve mobility,

prevent secondary injury, decrease risk of falling

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PRICE - Ice

Ice for 15-20 minutes every

1-2 hours

Always use a towel or thin

barrier to protect skin

Never sleep with ice applied

to the body

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PRICE - Compression

Elastic wrap over the injured area.
For muscle contusions, use foam pad with elastic wrap to minimize

hematoma development.

Consider adding a compression stocking if patient develops lower

leg edema.

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PRICE - Elevation

Elevate injured area above heart.
Combine elevation with compression and/or ice

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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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Stretching

Early static stretching encourages elongation of maturing scar

tissue (Kary 2010)

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Quadriceps Stretching Hamstring Stretching

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Strengthening

Early muscle activation reduces strength losses (Slider2013)
Isometric  concentric  eccentric

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Hamstring Isometrics Flex Quadriceps Isometrics

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

ccurring in sports and sedentary
persons. (Fong DT, 2008)
The rate of ankle sprains can
ccur 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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Sports Related Ankle Sprain

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Non-Sports Related Ankle Sprain

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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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Which one is fractured?

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Ottawa Ankle Rules 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 Walking Boot

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PRICE - Rest

Remove from activity to prevent further injury
Consider assistive walking devices to limit pain, improve mobility,

prevent secondary injury, decrease risk of falling

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PRICE - Ice

Ice for 15-20 minutes every 1-2 hours
Always use a towel or thin barrier to protect skin
Never sleep with ice applied to the body

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PRICE - Compression

Elastic wrap or compression stocking over the foot and ankle.

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PRICE - Elevation

Elevate injured limb above heart
Combine elevation with compression and/or ice

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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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Range of Motion – Ankle Pumps

Goal: Restore and maintain ankle plantar flexion and dorsiflexion
Frequency: 2 sets 15, 3 times/day

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Range of Motion – ABC’s

Goal: Restore and maintain ankle motion
Frequency: 2 sets A-Z, 3 times/day

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Range of Motion – ABC’s

Goal: Restore and maintain ankle motion
Frequency: 2 sets A-Z, 3 times/day

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For instructional videos of this protocol, visit sportsrehab.ucsf.edu

ACUTE ANKLE INJURY PROTOCOL

BACKGROUND: INCREASE RANGE–OF-MOTION: START NOW

Sw elling Reduction

Use an ACE WRAP to reduce swelling around your ankle.
Start at your toes and wrap half way up your lower leg.
Tension should be tighter around your toes and loose on your leg.
Wear your wrap 24/7.
Remember to elevate you ankle above your heart to encourage a

decrease in swelling Cold Therapy

Ice injured ankle 15 min every 2 hours.
Ice packs should be combined with elevation of the ankle.
Place a hand towel or cloth napkin between the skin and the ice.
Continue Ice Therapy until swelling resolves.

Ankle Alphabet Imagine your big toe as a pencil. Trace the capital letters of the alphabet. Use big, loopy, motions. Frequency: 2 sets, A-Z. 3 times per day. Goal: Increase All Motions of the Ankle Ankle Pumps Point foot away from body, curl toes. Pull foot toward body, extend toes. Speed doesn’t matter. Slow steady pace. Frequency: 2 sets x 15reps 3 times per day. Goal: Increase Plantar/Dorsi Flexion of the Ankle Tow el Toe Pulls Use a medium sized towel. Place a 1 lb weight at the end. Use toes to grab towel and pull it toward you. Repeat FIVE Times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Toe/Foot Flexors

FOOT STRENGTH

Calf Stretching Start in a seated position Place towel over ball of the foot Gentle pull ankle back to stretch calf Frequency: 3 sets x 2 min. 3 times per day. Goal: Increase All Motions of the Ankle

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ACUTE ANKLE INJURY PROTOCOL

ANKLE STRENGTH EXERCISES: START WHEN PAIN DECREASES:

Toe Taps Seated in chair, feet shoulder width apart. Keep heels on ground, lift toes up. Repeat until fatigue. Steady pace. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Tibialis Anterior Muscle Gait Training “Heel to Toe Walking”. Practice proper walking gait. Heel strike. Midstance, Toe Off. Avoid “Flat Foot Walk”. Frequency: Repeat until perfect. Throughout the day. Goal:

Ensure a Proper Walking Gait (Walking Normally)

Windshield Wipers Seated in chair, feet shoulder width apart. Keep heels on ground, lift toes to the right.

Lower. Lift toes to the left. No movement at the knees.

Repeat until fatigue. Steady pace. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Peroneal & Tibialis Posterior Muscles Calf Raises Start with two feet, progress to single foot. Rise up on your toes. Hold ONE sec, slowly lower. Repeat. Frequency: 2 sets x 10-12 reps. 3 times per day. Goal: Increase Strength of Calf Muscles Toe Pick-Ups Cut 20 1” x 1” foam squares. Pick up one-by-one with toes. Drop into a cup. Repeat. Frequency: 2-3 sets. 3 times per day. Goal: Increase Strength of Toe/Foot Flexors START NOW

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For instructional videos of this protocol, visit sportsrehab.ucsf.edu

ACUTE KNEE INJURY PROTOCOL

BACKGROUND: INCREASE RANGE–OF-MOTION: Limit Pain and Sw elling P: PROTECTION (Brace or Crutches) can add stability and decrease pain. R: REST (limit walking/activity) your knee when possible. I: ICE your knee as frequently as possible (20 minutes every 2-3 hours). C: COMPRESSION (ACE) wraps can help limit/manage your swelling. E: ELEVATE your knee above the level of your heart. Pain: Take Tylenol (acetaminophen) for pain control. Compression: Start at your foot and wrap up above the knee. The wrap should be snug, but not too tight as to cause numbness of the toes. Extension Bridging Seated or lying on a table. Place towel under heel of injured leg. Keep knee in full extension and off of the ground. Gentle pressure can be applied to the thigh if needed. Frequency: 10-15 min. 3 times per day. Goal: Restore and Maintain Full Knee Extension Heel Slides Back against a wall, in a seated position. Bend your knee, sliding your heel toward your buttock/ Use towel to assist if necessary. Slow steady pace. Frequency: 3 sets x 10 reps. 3 times per day. Goal: Restore and Maintain Full Knee Extension

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For instructional videos of this protocol, visit sportsrehab.ucsf.edu

ACUTE KNEE INJURY PROTOCOL

INCREASE STRENGTH: Quad / Thigh Contractions Sit on table or ground, keep knee in full extension. Contract your quadriceps muscle (squeeze your thigh). Hold 10 seconds. Relax. Repeat TEN times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Quadriceps Muscle Straight Leg Raises Sit on table or ground, keep knee in full extension. Contract your quadriceps muscle (squeeze your thigh). Raise leg ≈ 24 in, Hold 2 sec, Slowly lower to ground under control. Relax Quad. Repeat TEN times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Quadriceps Muscle * Do not perform if you cannot fully straighten you knee.

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For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Thigh Injury PROTOCOL

`

BACKGROUND: QUADRICEP EXERCISES:

Description
Commonly occur during

sprinting/agility activities.

Pain increased with activity.
Common Signs and Symptoms
Pain
Bruising/ecchymosis.
Mild swelling.
Treatment
Rest.
Activity modification.
Stretching exercises.
Progressive strengthening

exercises. Quadriceps Stretches Kick back leg and slowly pull heel towards buttock. Try to keep knees close to each other and abdominals contracted. Frequency: 3 sets of 60 seconds 2-3 times per day. Goal: Increase Quadriceps Flexibility Straight Leg Raise Begin in a seated position, resting back on hands. Flex quad muscles. Slowly raise leg up 24 inches and hold 5 sec. Slowly lower down. Frequency: 3 sets of 15 reps. 3 times per week. Goal: Improve Strength of Quadriceps Quad / Thigh Contractions Sit on table or ground, keep knee in full extension. Contract your quadriceps muscle (squeeze your thigh). Hold 10 seconds. Relax. Repeat TEN times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Quadriceps

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For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Thigh Injury PROTOCOL

=

Hamstring Stretching 1 Patient lies flat on their back with one leg through the door jam. One leg is placed up against the wall. Slowly move the body closer to the wall until a stretch is felt. Continue to move closer as flexibility improves. Frequency: 1 set 3-5 min. 2-3 times per day. Goal: Increase Hamstring Flexibility Hamstring Stretching 2 Patient lies on flat on their back. With a towel wrapped around the foot, slowly raise leg. Continue until a stretch is felt and hold. Try to keep opposite leg flat on the ground. Frequency: 3 sets of 60 secs. 2-3 times per day. Goal: Increase Hamstring Flexibility

HAMSTRING EXERCISES:

Hamstring Isometrics Sit on a stationary chair or stool. Extend injured leg slightly more than 90 degrees. Gently contract hamstrings by digging heel into ground, and as if to pull it back towards you. Hold 5 sec Note: Your leg and body should not move at all. Frequency: 3 sets of 15 reps. 3 times per week. Goal: Increase Strength of Hamstring Hamstring Curls Beginner: Stand in front of chair and draw heel back towards buttock. Hold 5 sec. Frequency: 3 sets of 15 reps, 3 times per week Intermediate: Place resistance band around ankle and leg of chair. Draw heel back towards buttock. Hold 5 sec and slowly leg to start position. Frequency: 3 sets of 15 reps. 3 times/wk. Goal: Increase Strength of Hamstring