pearls for foot injury rehabilitation & return to play...•recognize the importance of early...
TRANSCRIPT
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Pearls for Foot Injury Rehabilitation & Return to Play
DeDe Strama, PTKate Lutz, PT, DPT
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The presenters named in this presentation certify that they have no relevant financial or nonfinancial
relationships existent within the presentation today.
Declaration of Disclosure
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• Provide pearls of wisdom to optimize rehabilitation and return to play/work for foot and ankle injuries
Goal
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• Recognize the importance of early physical therapy referral for foot/ankle injuries
• Identify the necessity and value of including all parts of the body in foot/ankle rehabilitation
• Formulate return to play/work guidelines and functional testing with specific example of Lisfrancinjury including the importance of a healthcare TEAM approach
Objectives
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• Pearls = Important information for success of recovery – Recognize often overlooked aspects of rehabilitation– Immediate application to your clinical practice
• Kate– Division 2 collegiate athlete – Personal experience of rehab through 2 different ankle surgeries.
• DeDe– 33 years of professional experience and multiple CEU courses – Personal experience of her own Lisfranc injury.
Why pearls?
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• Value of Early Referral to Physical Therapy– Gait/Weight bearing (WB) status – Preventions of deconditioning – Optimize return to function
• Importance of addressing entire body to improve outcomes– Cardiovascular– Core– Hip– Foot/Ankle
Early Referral
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PEARL: Rethink traditional assistive devices and importance of normalizing gait pattern.
• Weight bearing status – Determined by provider
• Pros and cons of various assistive devices and gait patterns– Non‐weight bearing – Kneeling scooter – Hands free Assistive device – Touch weight bearing – CAM boot/Arch support – Equal leg length
Gait
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PEARL: Cardiovascular deconditioning is lost faster than musculoskeletal strength
• Prevention of Deconditioning – 2 months of CV gains are lost in 1 month of inactivity. – One study found endurance athletes with 4 weeks of inactivity= 20%
decrease in VO2 max
• Maintaining and Optimizing for return to play– Pool – Upper Body Ergometer – Uninvolved limb exercise – Bike‐ if approved by provider for WB restrictions
Cardiovascular System1,8
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PEARL: Core is the foundation for distal strength and skill.
• Educating patient on importance of core – Stabilization – Future injury prevention – Importance for return to more
skilled movements when appropriate– Safety for balance during use of
assistive device
Core
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PEARL: Early intervention for hips is key to recovery.
• Gluteus max/medius strength₋ Side‐lying Leg Raise‐ 81% EMG muscle activation
₋ Clam Shells‐ 30‐40% EMG muscle activation
₋ Progress to functional ex when able
• Psoas Major stretch ₋ Prone lying ₋ Prone on elbows ₋ Thomas Stretch₋ Half Kneeling
Hips6
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PEARL: Trying to prevent some atrophy will speed rehab
Focus strengthening on these major muscle groups:₋ Soleus/Gastroc (once able) ₋ Quadriceps₋ Hamstrings
• 4 Counter measures: ₋ 1) Antioxidants/anti‐inflammatory compounds, 2) Nutritional supplements, 3) Physical training and exercise2 4) neuromuscular e‐stim
₋ Exercise is still shown to be the most beneficial
• Slow twitch type 1 are more vulnerable and show more atrophy than type 22
Lower Extremity Strengthening
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PEARL: Importance of relationship of subtalar to midtarsal joint
• Pronation unlocks mid‐tarsal joint; Supination locks mid‐tarsal joint
• Measure dorsiflexion functionally in closed chain • Posterior Talar Glides
₋ Alleviate anterior ankle pain and increase dorsiflexion
• Propulsion Exercises ₋ Progression of calf strengthening
• Possible use of different taping techniques
Ankle Mobility & Strength
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PEARL: After limited weight bearing with any LE injury, foot intrinsic muscles need to be addressed
• Intrinsic weakness could be a source of pain and potential cause of re‐injury
• Exercise Ideas₋ HEP2GO look under Toe Yoga₋ Recommended 3 second holds progressing up to 40 reps each • Second to fourth toe extension (4‐
4‐toe salute)• Toe splaying • First Toe Extension • Short‐foot progression
Foot Intrinsic Strength3
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PEARL: Realistic expectations for recovery (typically prolonged)
• Grade 1 Lisfranc Injury‐ less then 2mm diastasis and no arch height loss. Only grade normally managed conservatively with physical therapy₋ Weight bearing status ranges from NWB for 6 weeks to full WB with orthotic
₋ Return to sport between 11‐18 weeks
• Grade 2‐3 Lisfranc Injury‐ Typically surgical ₋ Weight bearing status determined by surgeon (typically NWB). ₋ Return to sport with surgery between 12‐20 weeks Grade 2 and Grade 3 is season ending typically and much longer recovery
General Guidelines of Lisfranc Injury
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Timeline:• December Wrestling Injury – 1 month misdiagnosed due to not having WB radiographs
• January Surgery Grade 3 (5mm separation) • NWB 8 weeks then PWB Crutches with CAM boot 6 more weeks
• April Rehabilitation begins at 14 weeks₋ Lacks push off during gait ₋ Compensated Trendelenburg (4/5 side‐lying gluteus medius strength with psoas major dominance)
₋ Plantar flexor weakness
Case Study Lisfranc Injury5
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• Gluteus max/med strength • LE stretching program
‐ Psoas, calf, hamstrings, quadriceps • Posterior talar glides were valuable for dorsiflexion (DF)motion‐ Star excursion test to determine functional DF
• After pain free heel raise (approximately 3 weeks) progressed to low impact exercise on mini trampoline‐ Two legged jump‐ Jump with turns ‐ Single leg jumps ‐ Jog in place
Case Study: Rehab progression/return to sport5
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• Progress toward single leg hopping and agility ladder‐ A/P, M/L, Diagonals
• When one‐legged hops on the involved leg were pain free could return to jogging
• Incline treadmill at 10% incline to promote push off• Jogging forward and backward was pain free added in 45 degree cuts then 90 degree cuts
• Functional Tests ‐ Hop tests for return to play
₋ SL hop ₋ Triple hop ₋ 6 meter timed hop
Case Study: Return to Sport/Functional Testing5
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• Accurate diagnosis • Early referral to Physical Therapy to prevent deconditioning
• Weight bearing and assistive device options • Full body approach • Address foot intrinsic muscles • Functional testing prior to return to sports
Key Pearls of Wisdom
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1. Bogdanis GC. Effects of physical activity and inactivity on muscle fatigue. Front Physiol. 2012 May; 142(3): 1‐15. doi:10.3389.
2. Gao Y, Arfat Y, Wang H, Goswami N. Muscle atrophy induced by mechanical unloading: mechanisms and potential countermeasures. Front Physiol. 2018 Mar; 235(9): 1‐17. doi: 10.3389.
3. Gooding TM, Feger MA, Hart JM, Hertel J. Intrinsic foot muscle activation during specific exercises: A T2 time magnetic resonance imaging study. J Athl Train. 2016 Aug; 52(8): 644‐650. doi: 10.4085/1062‐51.10.07.
4. Keene DH, Williamson E, Bruce J, Willett K, Lamb SE. Early ankle movement versus immobilization in the postoperative management of ankle fracture in adults: a systematic review and meta‐analysis. J. Orthop. Sports Phys. Ther. 2014 Sept; 44(9):690‐700.
References
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5. Lorenz DS, Beauchamp C. Functional progression and return to sport criteria for a high school football player following surgery for a lisfranc injury. Int J Sports Phys Ther. 2013; 8(2):162‐71.
6. McCann, RS, Bolding, BA, Terada M, Kosik KB, Crossett ID, Gribble PA. Isometric hip strength and dynamic stability of individuals with chronic ankle instability. J Athl Train. 2018 Jul; 53(7): 672‐678.
7. Yamauchi K, Yoshiko A, Suzuki S, Kato C, Akima H, Kato T, Ishida K. Muscle atrophy and recovery of individual thigh muscles as measured by magnetic resonance imaging scan during treatment with cast for ankle or foot fracture. J. Orthop. Surg. 2017 Oct; 25(3): 1‐10. doi: 10.1177.
8. Rich H. How fast do you fall out of shape? Allina Health. https://www.allinahealth.org/HealthySetGo/SingleArticle.aspx?id=36507235773. Published 6/16/16. Accessed 12/20/18.
References Continued
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QUESTIONS?