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11/21/2017 Do it Yourself: Home Exercise for Lower Extremity Problems Katie Elston ATC; Elise Hammond ATC; Derek Hirai, MS, ATC 1 Disclosures  We have nothing to disclose. 2 1

11/21/2017 What is an Athletic Trainer? 3 What is an Athletic Trainer (AT)?  Allied Health Care Professional  Domains • Prevention • Evaluation • Immediate Care • Treatment, Rehab, Reconditioning • Organization and Administration • Professional Responsibility 4 2

11/21/2017 AT Clinical Responsibilities at UCSF 5 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 6 3

11/21/2017 Goals of Acute Injury Care  Minimize further damage  Reduce hemorrhage and edema  Relieve pain and spasm  Promote healing (Baoge 2012) 7 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 (Baoge 2012) 8 4

11/21/2017 Inflammatory Phase  Immediate onset tissue death  Hematoma formation  Inflammatory cells • Leukocytes • Macrophages (Baoge 2012) 9 Proliferation Phase  New tissue laid down  Injury site contracts as new tissues are built  Blood vessels rebuilt 10 5

11/21/2017 Inflammatory Phase  P rotection  R est  I ce  C ompression  E levation  Minimum 2-3 days post injury! 11 Proliferation Phase  Improve/maintain range of motion  Limit loss/maintain muscle strength and coordination  Continue to promote an ideal healing environment 12 6

11/21/2017 Thigh Injuries  Muscle strain • Quadriceps, hamstring, hip flexor  Muscle contusion  Differential diagnoses 13 Thigh Muscle Strain  MOI = Eccentric loading of muscle fibers (Boublik 2013)  Causes tearing of muscle or tendon fibers  R/o muscle avulsion injury 14 7

11/21/2017 Sports Related Hamstring Strain 15 Thigh Muscle Contusion  “Charley Horse”  MOI = blunt force trauma (Kary 2010)  Causes tearing of muscle fibers  R/o fracture 16 8

11/21/2017 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 17 PRICE - Protection  Typically thigh injuries do not require any type of DME 18 9

11/21/2017 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 19 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 20 10

11/21/2017 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. 21 PRICE - Elevation  Elevate injured area above heart.  Combine elevation with compression and/or ice 22 11

11/21/2017 Initial Rehab Exercises  Goals of early intervention: • Decrease swelling • Decrease pain • Restore range of motion • Restore strength • Restore neuromuscular control 23 Stretching  Early static stretching encourages elongation of maturing scar tissue (Kary 2010) Hamstring Stretching Quadriceps Stretching 24 12

11/21/2017 Strengthening  Early muscle activation reduces strength losses (Slider2013)  Isometric  concentric  eccentric Flex Hamstring Isometrics Quadriceps Isometrics 25 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 26 13

11/21/2017 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. 27 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, 28 14

11/21/2017 Sports Related Ankle Sprain 29 Non-Sports Related Ankle Sprain 30 15

11/21/2017 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 31 Which one is fractured? 32 16

11/21/2017 Ottawa Ankle Rules 33 PRICE - Protection  Consider prescribing a brace or Air Cast 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 Walking Boot that some form of immobilization is necessary (NATA 2013, Lamb et al. 2009) 34 17

11/21/2017 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 35 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 36 18

11/21/2017 PRICE - Compression  Elastic wrap or compression stocking over the foot and ankle. 37 PRICE - Elevation  Elevate injured limb above heart  Combine elevation with compression and/or ice 38 19

11/21/2017 Initial Rehab Exercises  Goals of early intervention: • Decrease swelling • Decrease pain • Restore range of motion • Restore strength • Restore neuromuscular control 39 Range of Motion – Ankle Pumps  Goal: Restore and maintain ankle plantar flexion and dorsiflexion  Frequency: 2 sets 15, 3 times/day 40 20

11/21/2017 Range of Motion – ABC’s  Goal: Restore and maintain ankle motion  Frequency: 2 sets A-Z, 3 times/day 41 Range of Motion – ABC’s  Goal: Restore and maintain ankle motion  Frequency: 2 sets A-Z, 3 times/day 42 21

ACUTE ANKLE INJURY PROTOCOL For instructional videos of this protocol, visit sportsrehab.ucsf.edu BACKGROUND: Sw elling Reduction • Use an ACE WRAP to reduce swelling around your ankle. o Start at your toes and wrap half way up your lower leg. o 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. INCREASE RANGE–OF-MOTION: START NOW 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 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 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 FOOT STRENGTH 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 UCSF Orthopaedic Institute | 1500 Owens Street Ste 170 | San Francisco, CA 94158 | Phone: 415-353-2808 | Fax: 415-353-7593 | orthosurg.ucsf.edu