Therapeutic Exercise - Midterm Review

Management During the Chronic Phase

*Maturation of Tissue*: There is an improvement in quality (orientation and tensile strength) of the collagen and reduction of wound size during this stage. The quantity of collagen stabilizes and there is a balance between synthesis and degradation. Healing may continue for 12-18 months. *Remodeling of Tissue*: Immature collagen can be easily remodeled with gentle and persistent treatment. This is possible for up to 10 weeks. If not properly stressed, the fibers adhere to surrounding tissue and form a restricting scar. As collagen changes its structure, this will become thick and resistant to remodeling. At 14 weeks, the scar tissue is unresponsive to remodeling. The AT's role during this phase is to design a progression of exercises that safely stresses the maturing connective tissue in terms of both flexibility and strength, so the patient can return to their functional activities. It is important to use controlled forces that replicate normal stresses on the tissue. *Patient Education*: Patient is more responsible for carrying out the exercises in the plan of treatment. Instruct them of safe progressions and how to self-monitor. Establish guidelines for what must be attained before they can return to sport. Re-examine them and modify exercises as needed. *Considerations for Progression of Exercises*: Free joint play within useful ROM is necessary to avoid joint trauma; rigorous joint mobilization can be used if no signs of increased irritation result; muscle strength should be at least 4 on a 5 point scale. Joint dynamics and muscle strength/flexibility should be balanced as the injured part is progressed to functional exercises. *Progression of Stretching*: Stretching should be specific to tissue involved using manual techniques (ie. joint mob, myofascial massage, PNF, passive stretching). Progress the intensity and duration of the stretching maneuvers so long as no signs of increased irritation persist beyond 24 hours. *Progression of Exercises for Muscle Performance: Developing Neuromuscular Control, Strength, and Endurance*: If patient isn't using some muscles because of inhibition, weakness, or dominance of substitute patterns, isolate the desired muscle action or use unidirectional motions to develop awareness of muscle activity and control of the movement. Progress exercises from isolated, unidirectional, simple movements to complex patterns and multidirectional movements requiring coordination with all muscles functioning. Progress strengthening exercises to stimulate specific demands including both weight-bearing and non and both eccentric and concentric contractions. Progress trunk stabilization, postural control, and balance exercises and combine with extremity motions for effective total body movement patterns. Teach safe body mechanics. *Return to High-Demand Activities*: Patients who are returning to activities with greater-than normal demand are progressed further to more intense exercises including plyometrics, agility training, and skill development. Develop exercise drills that stimulate the sport activities using a controlled environment with specific, progressive resistance and plyometric drills. Increase reps and speed as patient adapts. Change the environment and introduce surprise and uncontrolled events into the activity.

Where do we start with Therapeutic Exercise? What is the *logical progression*?

1. ROM 2. Flexibility 3. Strengthen individual muscle 4. Strengthen muscle group

Ankle Repair

2 most common repairs: achilles and ATF

Duration of Stretch

30 seconds has been shown to give a decent stretch (good to do on average) 3-4 sets is good but it depends on the person and where they're at. 2-3 times a day if you're starting out; as the athlete gets better, you can increase

How long does it take soft tissue to heal?

6-8 weeks

Prognosis (definition)

A *prediction of a patient's optimal level of function expected as the result of a plan for treatment* during an episode of care and the anticipated length of time needed to reach specified functional outcomes

Cardiopulmonary Fitness (definition)

Ability to perform moderate intensity, repetitive, total body movements (like walking, jogging, cycling, swimming) over an extended period of time.

Reversibility Principle

Adaptive changes in a body's systems, ie increased strength or exercise, in response to a resistance exercise program are transient unless training-induced improvements are regularly used for functional activities or unless an individual participates in a maintenance program of resistance exercises. Basically, if you stop your resistance training, you're going to lose your gains. This is why we want athletes to keep coming in to do rehab even after they return to play - so they don't lose all the work we put into them ("detraining").

Moderate Protection Stage

Also called the controlled motion stage. Where we start getting after it, increasing everything (strengthening, etc.) We should have full ROM, should have almost full flexibility (when compared bilaterally). This is where the bulk of the work happens but we need to bridge the two stages. Can do some agility.

Indications for Passive ROM

Areas where you have acute inflammation (that being said, if you have these areas and you do AROM, it will help reduce swelling...)

Balance with Hip Rehab

As soon as we are weight bearing, we are working proprioceptors. We might as well work on balance more now. This will also work our stabilizers.

Toe Region (Stress-Strain Curve)

Beginning part, where most functional activity comes in; involves stress on the body, some deformation of muscle fibers, but nothing damaging

Pronation

Combination of dorsiflexion, eversion and abduction

Supination

Combination of plantar flexion, inversion and adduction

Movement with Mobilization

Concurrent application of sustained accessory mobilization applied by you and an active physiological movement to end-range applied by the patient. Takes a lot of skill to do this.

Thrust Movement

Done at high velocity, short amplitude (depth); think of it as chiropractic (because they are trained to do it). If done wrong, you can really mess people up.

Volume

How many repetitions should we do? Research shows that we need to do 30 repetitions to get a gain (magic number; training effect) But it depends on what we're trying to do.

Meniscus

Improve the congruency of the articulating surfaces. Shock absorber

Intensity of Stretch

Intensity = how fast and how far you stretch; don't want to go too hard. We start off low and slow and ease into the stretch; low intensity stretching results in optimal rates of improvement in ROM without exposing tissues to excessive loads and potential injury.

Why do we tape an ankle in dorsiflexion?

It is the stable, closed-packed position of the ankle joint. Everything is "locked up" in that position, providing the most stability.

Why do we need to watch out for overtraining?

It means that our athletes aren't getting enough time to recover (so their muscles aren't getting stronger), or that we're progressing too quickly, or there may be a problem with their diet. Overtraining happens more quickly than overuse.

Hypomobility

Lack of movement; *decreased mobility* that you can get from too much exercise or lack of exercise. We see a lot of athletes with tight musculature (especially with spring sports); they aren't ready to do the work or they aren't in shape

How to set up a bike

Look for the knee to have a slight bend when the athlete pushes in extension

Talarnavicular Joint

Made up of the talus and navicular; this is what pushes and flattens the arch. If the posterior tibialis is weak and can't handle the force on it, pain is a result (usually in the shin area)

Ankle Joint

Made up of: distal fibula, distal tibia, and dome of the talus Ligaments: *deltoid ligament* (medial, four parts) and *lateral ligaments* (three parts - ATF, PTF, CF) ATF is the most commonly injured followed by the CF.

Muscle Spindle

Major sensory organ of muscle; sensitive to *quick and sustained (tonic) stretch* *Main function*: to receive and convey information about *changes in the length* of a muscle and the *velocity of the length changes*

Agility with Hip Rehab

Monster walks (after the athlete can complete a side to side squat) Lateral shuffles Side steps Can add bands to increase intensity. Figure eights - smaller the 8, harder it is (involves sharp turns).

Manual Resistance (Type of Resistance Exercise)

Most common type and easiest; but it takes up too much of our time so we try not to focus on it

Range of Motion

Movement of a joint through the fullest motion possible; affects all structures in the area (muscles, joint surfaces, capsules, ligaments, fascia, vessels, nerves)

Patellar Mobility

Patella has to be mobile. If we have a traumatic knee injury, we need to make sure the patella is mobile (if not, we need to mobilize by moving side/side, up/down).

What are the everters?

Peroneals Note: with inversion sprains, the person most likely strained their peroneals as well. It is possible that they didn't even sprain their ankle and they just strained the lateral muscles.

What is the loose-packed position of the ankle?

Plantarflexion (not stable)

Elastic Limit

Point beyond which the tissue does not return to its original shape and size. This is where injury happens.

What are Grades 3 & 4 used for?

Primarily used as stretching maneuvers

Where do we start with Ankle Rehab?

Range of motion -Ankle pumps -4 way -ABCs -Board (intensity depends on the ball size under the board - you can have the athlete seated if they can't weight bear) We can have the athlete do ROM on a bike too - pedal (slowly) as far forward as the range will allow and then reverse (we can also bring the seat down to force ROM) Note - it's hardest to get lateral movement back.

Overuse Syndromes, cumulative trauma disorders, repetitive strain injury

Repeated, submaximal overload and/or frictional wear to a muscle or tendon resulting in inflammation and pain

Evidence Based Practice

Researching the literature to verify your treatment procedures (big part of clinical-decision making)

What is the lumbopelvic rhythm?

Rhythm between the lumbar spine and the pelvis.

Cyclic/Intermittent Stretching

Shorter duration, more dynamic. Allows the athlete to get the stretch in a functional way

Hip Rehab

Similar to ankle and knee. The beginning stage is the only one that's very different. But remember keep it simple!

Dynamic Balance

Stabilizes the body when the support surface is moving (ie. standing on a bosu ball) or when the body is moving on a stable surface, such as walking.

What do we need to work in the state of New Jersey?

State Licensure, BOC certification, department of education certification for athletic training in NJ

Functional Strength

Strength required to do daily activities (the ability of the neuromuscular system to produce, reduce, or control forces, contemplated or imposed, during functional activities in a smooth, coordinated manner.)

Gentile's Taxonomy of Motor Tasks

System for analyzing functional activities and a framework for understanding the conditions under which simple to complex motor tasks can be performed

How can we work the VMO?

TKE, seated knee extension, bike

Stability (definition)

The ability of the neuromuscular system through synergistic muscle actions to hold a proximal or distal body segment in a stationary position or to control a stable base during superimposed movement. Joint stability is the maintenance of proper alignment of bony partners of a joint by means of passive and dynamic components.

Flexibility (definition)

The ability to move freely, without restriction; used interchangeably with mobility elasticity of the musculature around a joint which allow for unrestricted, pain-free ROM

Intensity (of exercise)

The amount of resistance (weight) imposed on the contracting muscle during each repetition of an exercise. We want to start low (sub-maximal loads to start). As the athlete gets better, we can increase the intensity.

What does hip hiking look like?

The body will always find a way to move. So if the person refuses to bend their knee, the body will compensate by lifting the entire hip up and swinging the leg forward.

What happens to someone's balance when they are sick/congested?

Their balance control will be impaired to some degree (so maybe don't have the athlete work on balance)

Tibiofibular Joints

There are two - superior tibiofibular and inferior tibiofibular joints. *Superior* Tib-Fib Joint*: plane synovial joint, made up of the femoral head and a facet on the posterolateral aspect of the rim of the tibial condyle; reinforced by anterior & posterior superior tibiofibular ligaments. *Inferior* Tib-Fib Joint*: syndesmosis with strong articulation between the bones; supported by the anterior and posterior interior tibiofibular ligaments

Muscle Fiber

These fibers make up individual muscles; lie parallel to one another Made up of many myofibrils

What are some ways we can tell if the athlete is ready to progress to the next level of rehab?

They don't shake anymore while they do their exercises Their pain is gone They can complete a body weight squat. They can complete side-step squats Etc.

Minimum Protection/Return to Function Stage

This is the end. We've already gotten strength back but now we can push harder, push more sports specific stuff. The athlete should be close to RTP at this stage.

What are Grades 1 & 2 used for?

Treating joints limited by pain or muscle guarding. These may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brain stem level. Help move synovial fluid to improve nutrition to the cartilage.

How often should we do strength training with our athletes?

Try for at least three times a week. But the situation may dictate how often. You can do more as long as you incorporate recovery time (so maybe mix up your strength training with cardio, flexibility work, etc)

Postural control, postural stability, and equilibrium

Used interchangeably with static or dynamic balance

Sustained Joint Play

Varying levels of distraction at the joint

Why is *recovery* important?

When you do resistive exercises, you're not actually getting stronger. You're body makes adaptations during recovery that increases your strength. The only way to get stronger is to allow your body to recover. We hurt the athlete more by not letting them recover because their muscles will eventually break down.

Active Assistive ROM

assistance is provided manually or mechanically by an outside force because the prime mover muscles need assistance to complete the motion Have the athlete contract while an outside force assists them (like us or a machine)

Short-Duration Stretches

cyclic, intermittent, ballistic stretching

Long-Duration Stretches

static, sustained, maintained, and prolonged stretching

*Power*

the ability of a muscle group to produce maximal force in as short amount of time as possible (defined as the amount of work performed per unit of time)

*Endurance*

the ability of a muscle or muscle group to exert force to overcome resistance many times

*Strength*

the ability of a muscle or muscle group to exert force to overcome the most resistance in one effort.

Strength

*Ability of contractile tissue to create tension/force based on the demands placed on the muscle* If you want to build strength, you have to place increasing demands on the muscle

Mobility (definition)

*Ability of structures or segments of the body to move or be moved* in order to allow the occurrence of ROM for functional activities (functional ROM). *Passive mobility* is dependent on soft tissue (contractile and noncontractile) extensibility. *Active mobility* requires neuromuscular activation.

Adhesion (clinical condition resulting from trauma)

*Abnormal adherence of collagen fibers to surrounding structures during immobilization*, after trauma, or as a complication of surgery, which *restricts normal elasticity and gliding* of the structures involved. Happens a lot around joints and you get scar tissue; also need to be broken up and limits ROM

Manipulation of objects - absent or present

*Absent*: When a task is performed without manipulating an object; less complex (walking with nothing in your hands) *Present*: more complex skill, like walking with a cup of coffee in your hand

Dynamic Flexibility

*Active mobility*; degree to which an active muscle contraction moves a body segment through the available ROM of a joint. This is done later with injured athletes because you need ROM and a degree of strength to be able to do it. Ex. High knees, butt kicks, arm crosses, etc

Contracture (clinical condition resulting from trauma)

*Adaptive shortening of skin, fascia, muscle, or a joint capsule that prevents normal mobility or flexibility of that structure* Usually happens to muscle and limits ROM; can be caused by immobility (like a non-weight bearing ankle injury where the patient gets contracture in the *gastroc* - common); hurts to break up

What movements should we be aware of at the pelvis?

*Anterior Pelvic Tilt*: ASIS gets pulled closer to the head of the femur; it moves the pelvis anteriorly and inferiorly causing hip flexion and lumbar extension. *Posterior Pelvic Tilt*: PSIS moves posteriorly and inferiorly. We get hip extension and lumber flexion. *Lateral Pelvic Tilt*: Quadratus lumborum on the side of the elevated pelvis and reverse muscle pull of the gluteus medius on the side of the lowered pelvis cause this.

Body stable or body transport

*Body stable* - maintaining an upright posture - considered simple tasks, especially when performed under closed environmental conditions *Body transport* - when the task requirements involve the patient moving from one place to another; ex. performing a transfer, walking, jumping, climbing - more complex.

What is used Post-Surgical to help regain ROM?

*CPM Machines*. They may help out immediately after surgery. They allow the athlete to get ROM back quickly because the body part isn't actively contracting. However, you're not actively contracting (so it's not as great as it seems - not moving swelling, preventing atrophy, etc). In some cases, you can tell the athlete to actively contract with the CPM machine to help activate the muscle.

Muscle Performance (definition)

*Capacity of muscle to produce tension and do physical work*. This encompasses strength, power, and muscular endurance.

Closed or Open Environment

*Closed Environment* is one in which objects around the patient and the surface on which the task is performed do not move. This way, the patient's complete attention is focused on performing the task, and the task is self paced. Ex. drinking or eating while sitting straight in a chair, standing at a sink and washing your hands or combing your hair. *Open Environment* is one in which the object or other people are in motion or the support surface is unstable during the task. The movement that occurs is not under the control of the patient. Ex. maintaining sitting or standing balance on a BOSU ball, standing on a moving train or bus, ascending or descending stairs in a crowded stair well, etc. During these tasks, the patient must predict the speed and directions of movement of people or objects in the environment and must anticipate the need to make postural changes or balance adjustments.

Closed Chain vs Open Chain

*Closed chain*: easy exercise, environment is stable/fixed; ex. standing *Open chain*: harder exercises, like walking, running, jumping; more dynamic

Stages of Motor Learning

*Cognitive*: when the patient first figures out what to do - learn the goal or purpose and the requirements of the exercise or functional task; patient needs to think about each component or sequencing of the movement; because patient's attention is often directed to the correct performance of the motor task, distractions may interfere initially with learning; mistakes are common but the patient gradually learns to differentiate correct from incorrect *Associative*: patient makes infrequent errors and concentrates on fine-tuning the skill; refines timing of skill; patient uses problem-solving to self-correct; requires infrequent feedback, begins to anticipate necessary adjustments and make corrections before error occurs *Autonomous*: movements are automatic; patient doesn't have to pay attention (can multitask); easily adapts to variations; little instruction occurs here

Noncontractile Parts of Muscle

*Collagen Fibers* - gives *strength and stiffness to muscle* and *resists tensile deformation*; tissue with greater proportion of collagen provides greater stability *Elastin Fibers* - *provide extensibility/elasticity* to muscle; show a great deal of elongation with small loads and fail abruptly without deformation at higher loads; tissues with greater amounts of elastin have greater flexibility *Reticulum Fibers* - gives muscle it's "bulk" *Ground Substance* - viscous fluid that fills the spaces; reduces friction between fibers, transports nutrients and metabolites (also, when you have scar tissue, there is a lack of ground substance in that area)

Forms of PNF Stretching

*Contract-Relax*: works well for the hamstrings and pretty well for the quads; patient performs a *pre-stretch, end-range, isometric contraction* (about 5-seconds) followed by *voluntary* relaxation of the range-limiting target muscle; the limb is then passively moved into a new range as the range-limiting muscle is elongated. *Agonist Contraction*: in this case, the "agonist" describes the muscle opposite the ROM-limiting target muscle; so if the hip flexors are the ROM-limiting target muscle group, the patient is going to perform an end-range, prone leg lift by contracting the hip extensors concentrically; this contraction is held for several seconds; after a brief rest period the patient repeats the procedure (so instead of contracting/relaxing the hip flexors which are the problem, we are contracting the hip extensors on the opposite side; this allows us to get a good stretch of the hip flexors as the leg is extended). *Contract-relax with agonist contraction*: combination of the two

Sarcomeres

*Contractile unit of the myofibril*; composed of overlapping myofilaments of *actin and myosin* that form cross-bridges. *Gives the muscle it's ability to contract and relax*. When a motor unit stimulates a muscle to contract, the actin-myosin filaments slide together, and the muscle actively shortens. When the muscle relaxes, the cross-bridges slide apart slightly and the muscle returns to its resting length.

Muscle Weakness (clinical condition resulting from trauma)

*Decrease in the strength of muscle contraction*. Muscle weakness may be the *result of a systemic, chemical, or local lesion of a nerve* of the CNS or PNS or the myoneural junction. May be result of *direct insult to muscle or simply due to inactivity*

2 Forms of Stabilization

*External*: can be applied manually by the AT or with equipment (belt, straps, table, chair, etc) *Internal*: achieved by an isometric contraction of an adjacent muscle group that does not enter into the movement pattern but holds the body segment of the proximal attachment of the muscle being strengthened firmly in place (ex. when your abs tighten up to hold your pelvis in place so you can do a SLR)

After hip ROM, what comes next?

*Flexibility/Stretching* Quad stretch (with green band) Hip Flexor (prone with the green band - extend the hip straight up - not at an angle; we can also have them lying on the table with their butt cheek and leg hanging off - having gravity do the job of stretching hip flexors; can do a lunge on the ground where we tilt our pelvis to get the stretch) Hamstring (sit and reach with head down, chest to knees) Glute stretch (figure four and lift, grabbing the under leg around the tibia) Glute/Hamstring stretch (put foot on a relatively high chair and lean forward) Groin (butterfly stretch - elbows can push on the sides to make it harder; can bring feet closer to butt to make it more difficult) Can do a warrior/lunge stretch with the toes pointing in the direction that you are looking to stretch?

Grading Sustained Joint Play

*Grade 1*: (loosen) small-amplitude distraction is applied when no stress is placed on the capsule *Grade 2*: (tighten) enough distraction or glide is applied to tighten the tissues around the joint *Grade 3*: (stretch) distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures

Grading Joint Mobilization: Non-Thrust Oscillation Techniques

*Grade 1*: Small-amplitude, rapid rhythmic oscillations; performed at the beginning of the range *Grade 2*: large-amplitude, working within range but not to the limit (a little slower but going deeper) *Grade 3*: large-amplitude, still slow; performed up to the limit of available range and we have some tissue resistance *Grade 4*: rapid, small amplitude; performed at the limit of the available motion and stressed into tissue resistance *Grade 5*: thrust maneuver, fast and hard thrust to break adhesions (we don't do this)

Indications for Sustained Joint Play

*Grade 1*: used with all gliding motions and may be used for relief of pain *Grade 2*: used for the initial treatment to determine the sensitivity of the joint *Grade 3*: used to stretch the joint structures and thus increase joint play

Parts of the Foot

*Hindfoot*: calcaneus and talus (where most of the ankle motion comes from; when we tape, we want to lock in the subtalar joint here) *Midfoot*: cuneiforms, navicular, cuboid *Rearfoot*: metatarsals and phalanges

Neuromuscular Control (definition)

*Interaction of the sensory and motor systems* that enables synergists, agonists, and antagonists, as well as stabilizers and neutralizers to *anticipate or respond to proprioceptive and kinesthetic information* and, subsequently, to work in correct sequence to *create coordinated movement*.

Intrinsic & Augmented Feedback

*Intrinsic* feedback: feedback from yourself, your body; important at all stages, provides ongoing information about the quality of movement during a task and information about the outcomes of a task (ex. The athlete tells you that she has pain in her knee during a SLR) *Augmented/Extrinsic* feedback: feedback that another person gives; information about the performance or results of a task that is supplemental to intrinsic feedback; as ATs, we are in control of the type, timing, and frequency of this feedback; this is when we provide instruction about form and encourage the athletes

Three Types of Exercises

*Isometric*: static exercise; muscle contracts and produces force without an appreciable change in the length of the muscle and without visible joint motion; lowest available level; ex. quad sets, rhythmic stabilization (trying to hold a body part steady while someone else tries to move it) *Isotonic*: start getting appreciable shortening of muscle tissue; ex. band work, weight machines, free weights *Isokinetic*: all about velocity; "form of dynamic exercise in which the velocity of muscle shortening or lengthening and the angular limb velocity is predetermined and held constant by a rate-limiting device; machines are expensive but it allows your athlete to work at a set speed; the *lower the speed, the more emphasis on strength*

Muscle Endurance

*Local endurance* Ability of a muscle to contract repeatedly against a load (resistance), generate and sustain tension, and resist fatigue over an extended period of time We build muscle endurance with reps (low intensity at first, then increase the intensity). Repetitions build strength and muscular endurance.

Types of Stretching (that Mac wants us to know)

*Manual Stretching* - you do the stretch for the athlete; we apply an end-range stretch force to elongate a shortened muscle past the available ROM *Self-Stretching* - what we want to teach our athletes so we aren't held up for too long *PNF Stretching* - proprioceptive neuromuscular facilitation stretching (3 types, will mention later) *Muscle Energy* - manipulative procedure designed to lengthen muscle and fascia and to mobilize joints; employs voluntary muscle contractions against a counterforce (Ashley does this a lot when she's trying to realign an athlete's pelvis after a long-sit test) *Joint Mobilization* - manual therapy intervention used to modulate pain & possibly stretch the capsule

3 Stages of Rehab Management

*Maximum Protection Stage* *Moderate Protection Stage* *Minimum Protection/Return to Function Stage*

Joint Dysfunction (clinical condition resulting from trauma)

*Mechanical loss of normal joint play in synovial joints*; commonly causes loss of function and pain. Precipitating factors may be trauma, immobilization, disuse, aging, or a serious pathological condition

Inter-trial variability - absent or present

*No Inter-trial Variability* - when the environment in which a task occurs is constant (unchanging) from one performance of a task to the next. The environmental conditions for the task are predictable and little attention to the task is required (allows patient to perform two tasks at once). *With Inter-trial Variability* - when the demands change from one attempt or repetition of a task to the next. Here, the patient must continually monitor the changing demands of the environment and adapt to the new circumstances by using a variety of movement strategies to complete the task. Ex. lifting and carrying objects of different sizes and weight, climbing stairs of different heights, or walking over varying terrain.

Passive Flexibility

*Passive mobility*, when someone else/something else stretches you out (outside force moves the muscle until you feel tension). Most common type used (ie. sit-and-reach, static stretching; can use a table/wall to stretch)

Factors that Influence Adherence to an Exercise Program

*Patient Related*: understanding the health condition, impairments, or exercise program; level of motivation, self-discipline, attentiveness, memory, and willingness and receptivity to change; degree of fatigue or stress; availability of time to devote to exercise program, etc *Factors related to health condition or impairments*: acuity, chronicity, severity, stability of the primary health condition and related impairments; pain, etc *Program-Related variables*: complexity and necessary duration of exercise program; adequacy of instruction, supervision and feedback; whether the patient has input in the plan of care; etc

What nerve should we know in the foot/ankle?

*Peroneal Nerve* We need to be careful with this nerve because it wraps around the fibular head. It's superficial and therefore can be a problem if the athlete gets hit in that area.

Motions of the Foot/Ankle

*Plantar flexion & dorsiflexion, inversion & eversion, pronation & supination* With pronation/supination, we are looking at the movement of the talus.

Reflex Muscle Guarding (clinical condition resulting from trauma)

*Prolonged contraction of a muscle in response to a painful stimulus*. Primary pain-causing lesion may be in nearby or underlying tissue, or it may be a referred pain source. When not referred, the contracting muscle functionally splints the injured tissue against movement (ie. hamstrings after you tear your ACL) *Guarding ceases when painful stimulus is relieved* (in class, Mac said this sometimes happens with athletes who lack self-confidence and it usually goes away when the confidence comes back)

Intrinsic Muscle Spasm (clinical condition resulting from trauma)

*Prolonged contraction* of a muscle *in response to the local circulatory and metabolic changes* that occur when a muscle is in a continued state of contraction. Pain is a result of the altered circulatory and metabolic environment, so the *muscle contraction becomes self-perpetuating* regardless of whether the primary lesion that caused the initial guarding is still irritable.

First Step of Hip Rehab

*ROM* Heel slides (for flexion and extension) Note - when we range someone, hip extension is not usually an issue. Just getting them flat on a table is good. Not much more we can do for hip ROM. We could do heel slides off to the side for abduction and back for adduction, but not necessary unless those are problem areas.

Knee Rehab - where to start?

*Range of Motion* Heel slides (works flexion/extension - make sure to bend the other knee to take pressure off the low back, head is down, body in alignment and stabilized) Bike (works flexion/extension; have the athlete go as far forward as they can, hold for five seconds, then go in reverse as far as they can, and hold for 5 seconds) Prone Hang (for extension, but watch for the quad - make sure it's stabilized on the table just above the patella; we can also put a cuff weight around the ankle) Manual Flexion/Extension (we can get fairly aggressive with this) Quad sets into a towel (active extension) Force flexion (have the athlete bring their knee into flexion, take a deep breath, and then manual force them farther as they exhale; this can help them get ROM back faster)

What is the difference between Range of Motion and Flexibility?

*Range of Motion* is the movement of a *joint* through the fullest motion possible. *Flexibility* is the *extensibility of soft tissues (muscles)* that cross or surround a joint which are necessary for unrestricted ROM.

Clinical Decision-Making (definition)

*Refers to a dynamic, complex process of reasoning and analytical (critical) thinking that involves making judgments and determinations* in the context of patient care. To make effective decisions, one must merge clarification and understanding with critical and creative thinking. As a young athletic trainer, we should err on the side of caution (we are there to protect the athlete, first and foremost). -Can the athlete move? If no, they're not playing -Can they move but not perform functional tests? They're probably not playing. (Occurs when the athletic trainer has to determine the selection, implementation, and modification of a therapeutic exercise program)

Ballistic Stretching

*Rhythmic Stretching* Slow going down, slow coming up, and each time you go down you try to stretch a bit further. Problem: if done wrong, it will cause injury. Not meant to be quick/hard; a little more functional stretch

Types of Joint Mobilization

*Self-Mobilization* *Mobilization with Movement* *Physiological Movements* *Accessory Movement* *Component Movements* (part of accessory movement) *Joint Play* (part of accessory movement)

SAID Principle

*Specific Adaption to Imposed Demands* "A framework of specificity is a necessary foundation on which exercise programs should be built." *Basic Rehab Principle* - Exercise has to be specific to what you want the intended outcome to be; you need to tailor your rehab program to what the athlete wants to get back to doing (this is why a football player and a soccer player have different rehabs)

Types of Balance Control

*Static Balance* *Dynamic Balance* *Automatic Postural Reaction*

What are the two things that protect every joint in your body?

*Strength and Flexibility* of that joint protect the joint Note: this is what we do, no matter what the injury is. If we're rehab-ing or doing preventative stuff, we need to build up strength and work on flexibility. The bigger the person is, the more they need to work on their flexibility.

After flexibility, what's next for hip rehab?

*Strengthening Individual Muscles/Muscle Groups* Quad Sets Prone Hamstring Curl (can add weight to make it harder) SLR (3-4 directions, with good form; can add weight) Knees to Chest while seated (then add weights - for iliopsoas; make sure back is straight) Ball Squeeze (for groin) Ball squats - bodyweight squats - sumo squats, etc. Straight leg hip extension - standing with band/cuff weight Lunges (involves balance and good strength - so may need to wait)

Types of Motion

*Swing*: movement of the bony lever; described as flexion, extension, abduction, adduction, and rotation *Roll*: results in angular motion of the bone (swing); always in the same direction as the swinging bone motion whether the surface is convex; when it occurs alone, causes compression of the bone surfaces (bad) *Slide/Translation*: involved in the convex-concave rule where one bone slides or translates on another bone; pure sliding does not occur in joints because the surfaces are not completely congruent *Spin*: rotation of a segment about a stationary mechanical axis; occurs when the shoulder flexes/extends, hip flexes/extends, and the radiohumeral joint with pronation/supination ^motion of the bone surfaces in the joint is a variable combination of rolling, sliding, and spinning.

Tendinopathy/Tendinous Lesion

*Tendinopathy* = general term that refers to chronic tendon pathology *Tenosynovitis* = inflammation of the synovial membrane covering a tendon *Tendinitis* = inflammation of a tendon; there may be resulting scarring or calcium deposits *Tenovaginitis* = inflammation with thickening of a tendon sheath *Tendinosis* = degeneration of the tendon due to repetitive microtrauma

3 Types of Stress Put On Muscle

*Tension*: stretching force (example of an injury involving tension force = strain) *Compression*: compression force (example of injury = fracture) *Shear*: force applied parallel to cross-sectional area of the tissue (ex. abrasions of the skin)

Cardiovascular or Cardiopulmonary Endurance

*Total body endurance* Associated with repetitive, dynamic motor activities, such as walking, cycling, swimming, or upper extremity ergometry, which involve use of the large muscles of the body Important for all athletes, regardless of sport

What is the main problem/cause of shin splints?

*Weakness of the posterior tibialis*; this is where we get the medial pain If they have anterior shin pain, it's more of an anterior muscle problem. Lateral pain --> lateral muscular problem (ie peroneals or flexors) Note: Posterior tibialis requires more work to get better (need to work on both inversion AND plantarflexion)

Contractile Elements of a Muscle

-*Muscle fiber* -*Myofibrils* -*Sarcomeres*

Precautions of Stretching

-Don't push the athlete too far -Feel the tension in their muscles with your hand -If they tell you it feels tight, don't push it (there's no reason to) -Don't start off too fast -Watch your time (there's no point in holding a stretch for 10 seconds; if you aren't having the athlete stretch long enough, don't bother)

Contraindications for Joint Mobilization

-Hypermobility -Joint effusion -Inflammation (make a judgment call - how bad is it?)

Contributing Factors to Chronic Recurring Pain

-Imbalance between length and strength of the muscles around the joint -Rapid or excessive repeated eccentric demand placed on muscles not prepared for it -Muscle weakness or inability to respond to excessive strength demands that results in muscle fatigue with decreased contractility and shock-absorbing capabilities -Bone malalignment or weak structural support (causes faulty joint mechanics) -Change in usual intensity or demands of activity -Returning to an activity too soon after an injury -Sustained awkward postures or motions -Environmental factors (excessive cold, continued vibration, inappropriate weight-bearing surface) -Age-related factors -Training errors -A combination of several contributing factors

*Goals for PROM*

-Maintain joint and connective tissue mobility -Minimize effects of formation of contractures -Maintain mechanical elasticity of muscle -Assist circulation

Indications for Joint Mobilization

-Muscle guarding -Muscle spasm -Pain within reason (use your judgment) -Hypomobile joints

Requirements for Skilled Clinical Decision-Making During Patient Management

-Prior clinical experience with similar problems -Ability to integrate new and prior knowledge -Ability to recognize clinical patterns -Understanding of patient's values and goals

Strategies for Balance Control

1. *Ankle Strategy*: sensory receptors in the ankle joints and ligaments, as well as muscle spindles, provide important information for a balance reaction; used in balance control during perturbation 2. *Weight Shift*: disturbance causes a weight shift in your legs so you avoid falling over 3. *Hip Strategy*: disturbance is so much that your hip muscles have to fire to provide stability 4. *Stepping Strategy*: caused by an even greater disturbance than the hip can correct - helps us regain balance by taking a step

Important to Remember with ROM

1. *Stabilize* the body part 2. *Align* the body part ex. With Ankle ROM - have the athlete on the table with the leg supported and only the ankle over the edge (supports proximal, allows you to move distal; no barrier in the way; *no unnecessary muscle contraction holding the body in place because it is already stabilized*) ^*Allows for freedom of movement*

Four Main Task Dimensions Addressed in Gentile's Taxonomy

1. Environment in which the task is performed (is it open or closed?) 2. Inter-trial variability of the environment that is imposed on a task (variability or no?) 3. Need for a person's body to remain stationary or to move during the task (body stable or body in motion?) 4. Presence or absence of manipulation of objects during the task (object being manipulated or not?)

Management During the Acute Stage

AT's role during this phase is to control the effects of inflamm, facilitate wound healing, maintain normal function in unaffected tissues/body regions. *Patient Education*: inform them of expected duration (4-6 days), what they can do during this stage, precautions/contraindications, what to expect when symptoms lessen. Reassure them that these symptoms are usually short-lived *Protection of Injured Tissue*: Protection is necessary during first 24-48 hrs; usually provided by rest, cold, compression, and elevation. Massage may be beneficial to control swelling. *Prevention of Adverse Effects of Immobility*: Limit continuous immobilization; begin treatment during acute stage, when tolerated, with controlled passive movements - as long as it doesn't increase inflam or pain. *Specific Interventions and Dosages*: PROM, low-dosage joint mobilization, muscle setting (gentle isometric contractions), massage (to move fluid and prevent adhesions). *Interventions for Associated Areas*: We want to maintain as normal a physiological state as possible in related areas. Techniques include ROM (active or passive, depending on proximity to/effect on injured tissue), Resistance Exercise (applied to muscles not directly related to injury to prepare patient for use of assistive devices), and Functional Activities.

Contracture

Adaptive shortening of soft-tissue (skin, fascia, muscle, joint capsule); causes lack of full ROM

What are the dorsiflexors?

Anterior tibialis (primary) Note: don't get hung up on dorsiflexion; work it if it's a problem but if the athlete can walk or stand, they have dorsiflexion.

ACL and PCL provide what kind of stability to the knee?

Anteroposterior stability

What about agility work involving the ankle in rehab?

As strength improves, you have to include some type of lateral movement (because no sport is done straight ahead); lateral motion is the last thing an athlete gets back. We can start this once the athlete is capable of squatting or taking a side-step while in a squat or even as soon as they can walk with some strength - start doing side steps slowly. After agility work is completed, we can move on to more sport-specific exercises.

Maximum Protection Stage of Rehab Management

Beginning stage of rehab. We've gotten the OK to work with someone but we still want to be careful. We do ROM exercises, flexibility, and some beginning isometrics.

Hemarthrosis

Bleeding into a joint, usually due to severe trauma

Q Angle

Bony landmarks = ASIS, mid-patella, tibial tuberosity. 10-15 degrees is normal. Greater than that can cause problems. Women usually have a greater q-angle. Can't change the Q angle because it's based on bony landmarks!

What makes up the subtalar joint?

Calcaneus and talus

How do we know when to transition to different exercise or difficulty level?

Can base it on the athlete's pain level, maybe when they don't shake anymore while doing the exercise; if we're doing knee/hip stuff, maybe once they can complete a bodyweight squat, they can be pushed to do more. Need to be able to explain a measurable way to tell when someone is ready to move on.

Soreness (note from class)

Can be cured with active movement. Warm the muscle up to get it moving and stress the importance of a cool down after workouts (to help prevent soreness).

Cardio with Hip Rehab

Can start when they have full ROM and are able to walk. Start on bike, then walking on treadmill, then jogging, then running. Can use a stairmaster at the end of rehab to increase intensity and test to see if they are ready to return to sport.

Indications for Active ROM

Can use at any point, swollen or not; it's all subjective (what are *you* comfortable with?) When we want to limit swelling, start building strength, and it can help ROM as well. *Note*: AROM does not really increase strength; but it does give us the ability to start doing strengthening exercises.

With Knee Rehab, when can we start working balance?

Can use it as a transition off the table. Once the athlete can walk, start working on balance (may take a little time for it to be pain free) Start with a stable surface - single leg with eyes open, then eyes closed; then eyes open with ball manipulation, then unstable surface. Note: balance work will lessen the time it takes for the athlete to master harder tasks

Chronic Recurring Pain - Causes

Connective tissue is repeatedly stressed beyond the ability to repair itself and the inflammatory process is perpetuated. *Causes*: Overuse, cumulative trauma, repetitive strain (can result in structural weakening, fatigue breakdown, etc), trauma (that is followed by repetitive trauma), reinjury of an "old scar", contractures or poor mobility.

Things to be aware of with the hip.

Decreased flexibility causes a lot of problems. If we have tight hip extensors, it usually causes increase in lumbar flexion when the hip is flexed. We don't want this lumbar movement. If hip flexors are tight, we get increase in lumbar extension when the hip is extended (BAD). Hip musculature is supposed to take the weight (shock absorber). If they don't, the stress is translated to the lumbar spine (which causes bigger problems). Tight hip abductors/adductors --> cause lateral tilt

Special Considerations for Post Surgical Ankle People

Do NOT do anything until you get doctor approval (probably 4+ weeks). Once you get approval, start with ROM (ankle pumps, ABCs). This make take up to 4 weeks and it's going to hurt. We have to use our judgment to decide how hard to push them. (*Note*: if the sutures are still in, that is an open wound and you have to treat it as such. Once the stitches are out, it's still an open wound for a day or two.) The gastroc is going to be really tight and the athlete might not have enough motion in the ankle to actually stretch the gastroc. An achilles needs to be stretched very slowly - don't want to re-tear it because it's going to be crazy tight. Note: Inversion/eversion take a little longer to get back with ankle ligament repair because that's what was involved in the tear. As you start doing ROM work, you can start with simple isometrics and work with what you have. As this gets easier (ie. no pain, more reps before fatigue hits, stuff we can measure), they are ready to move on. (*note*: if they are shaking during an exercise, they are WEAK) Once we get ROM/Flexibility back, we can strengthen!

Injury Severity

Don't have use the grading system for injuries. You can look at them in terms of functionality (ie. can someone play with a grade one injury? It depends on the athlete. This is where functional testing may come in. If they can do the tests, the answer may be yes. Can someone with a grade two play? It also depends, but we know that with grade 2, there's been tearing in the fibers - so maybe we err on the side of caution)

Balance

Dynamic process by which the body's position is maintained in equilibrium (postural stability) Balance is greatest when the body's center of mass (COM) or center of gravity (COG) is maintained over its base of support (BOS)

Alignment - it's importance with stretching

Essential element of effective stretching. Proper alignment/positioning of the patient is necessary for patient comfort and stability during stretching. Alignment influences the amount of tension present in soft tissue and consequently affects the ROM available in a joint (so, if the patient's body isn't in full alignment, they won't be able to get the full ROM at that joint - which defeats the purpose of stretching that joint)

What's after ROM in the knee?

Flexibility (want to stretch quads and hamstring and gastroc) We can use the green band for a good quad stretch (stretches and helps with ROM - so if someone still has a flexion issue, put them on their stomach, have them put the band around their foot to get a quad stretch but also help with hamstring ROM) Toe Reach (for the hamstrings - as long as the athlete bends from the waist and not the back; make sure they keep the leg straight, no bouncing, chest down, head up to avoid low-back stress; if you're using a strap for this, make sure the athlete climbs down the strap and doesn't pull against it or else they're stretching the wrong muscle; also make sure the strap is low on the foot) Bike (dynamic stretching) Gastroc (can use a strap to pull into dorsiflexion, slant board, etc.)

What's after ROM for Ankle Rehab?

Flexibility. Here, we want to focus on the gastrocnemius. We can use a slant board and adjust the height (the higher the board, the harder/deeper the stretch). We can also use a pro-stretch or use a band to pull the foot into dorsiflexion. Can have them on the total gym with their legs straight and half the foot on the bar - then have them dip their heels down to stretch the gastroc.

When will my athlete be ready to return to practice? What do I need to see before they can return to practice?

Full ROM and flexibility (when compared bilaterally); pain free with strengthening exercises, lunges are performed correctly and pain free, quick and tight agility drills completed pain free, able to complete long-duration cardio pain free (run a mile, complete 30 suicides, etc), sports specific drills completed quickly with no pain.

What are the plantarflexors?

Gastrocnemius (2-joint muscle, second strongest in the body), soleus (1-joint muscle) Note: you don't have to go crazy working the soleus over the gastroc - you will get a degree of it with gastroc strengthening

*Patient Management Model*

Governs just about everything we do in rehab (What are we doing? How are we going about doing it?) *STEPS* 1. *Take a history* 2. *Evaluation* (six parts; even if the athlete had been seeing a PT, you should still do your own evaluation to find out for yourself; reevaluation - typically each time you see them, doesn't haven't be long, just ask a few questions and get feedback) 3. *Diagnosis* (what do you think the problem is?) 4. *Prognosis/Plan of Care* (what do you want to do? what do you think is going on? also includes *goal setting* - need some short-term goals, little/achievable goals, as well as the ultimate goal of getting back to play) 5. *Interventions* (what you're doing to help them get back, what exercises are you giving them to do?) 6. *Outcomes/Results* (did you get it done? how close did you get to the ultimate goal? is the patient more comfortable? do you need to refer them out?)

What should we also be aware of when working with young athletes?

Growth plate injuries (possible to fracture and don't want this to go undiagnosed).

Overload Principle

Guiding principle of exercise; one of the foundations on which the use of resistance exercise to improve muscle performance is based. *If muscle performance is to improve, a load that exceeds the metabolic capacity of the muscle must be applied - that is, the muscle must be challenged to perform at a level greater than that to which it is accustomed.*

How can you figure out how strong someone is?

Have them perform a 1 rep max (measurable way to determine how strong someone is)

Active ROM

Ideal, movement caused by the contraction of the musculature (movement of a segment within the unrestricted ROM that is produced by active contraction of the *muscles* crossing that joint)

Note about Menisectomy

If the meniscus is removed, there's nothing to heal. Within a week, the athlete should be able to walk decently without crutches. It will probably take 2 months to get back to activity (so we can strengthen and let the body heal from having instruments inside it). If the meniscus is repaired, it will probably take 6-8 weeks of healing/non-weight bearing.

Note about stretching & balance

If you are trying to have someone stretch while maintaining their balance, you won't get as good of a stretch. You want the athlete to do an effective stretch but you are putting them in a position that may require muscle contraction on the side you are trying to stretch (which means they are more concerned about maintaining balance than focusing on the stretch).

Wolff's Law

If you strengthen the muscle around a bone, the bone will be stronger because it has to handle the increased stress.

Why do we need to be careful about overstretching?

If you want to truly loosen a body part up, it takes two weeks of doing it 4-5 times a day every day. But we need to be careful because people stretch too much. If your athlete has a strain and they stretch it too soon, they are just pulling the muscle farther apart. It's important that we allow the tissue to heal before we push it to stretch. Or we may just make the strain/issue worse.

What 3 bones make up the pelvis?

Ilium, ishium, pubis Together, they work as a unit. They join at the pubic symphysis anteriorly. Posteriorly, they attach at the sacrum (SI joint) where the spine and lower extremity meet.

Stress-Strain Curve

Illustrates how much stress you can put on the muscle fiber before you do damage *parts of the stress-strain curve*: toe region, elastin phase, and elastic limit (don't worry about the rest)

Hypertrophy

Increase in the size (bulk) of an individual muscle fiber As you get hypertrophy in the muscle fibers, the tensile strength of the tendon has to get stronger as well

Plan of Care (definition)

Integral component of the prognosis, delineates: -Anticipated goals -Expected functional outcomes that are meaningful, utilitarian, sustainable, and measurable -Extent of improvement predicted and length of time necessary to reach that level -Specific interventions -Proposed frequency and duration of interventions -Specific discharge plans Requires collaboration and negotiation between patient and provider. Also indicates the "optimal level of improvement" that will be reflected by the functional outcomes as well as how those outcomes will be measured.

What is important to remember about the head of the femur?

It moves opposite the direction of motion.

What are some agility exercises?

Lateral movement is key. We want lateral shuffles, karaokes, can do ladder drills (two steps in each box across and back - facing the same direction), monster walks, side-step squats. We want to make sure to include movement in both directions (to see if one motion is more painful than the other, like pushing/pulling - usually pulling is harder). *What else is important with agility?* We want to make sure the athlete can do tight cuts (figure eights - start off with a big eight than make it smaller and tighter to put more stress on the body). Angular running in a small area is good.

Automatic Postural Reactions

Maintain balance in response to unexpected external perturbations, such as standing on a bus that suddenly accelerates forward. (Allows the body to react when something unexpected happens)

Myofibrils

Make up a muscle fiber; composed of even smaller structures called sarcomeres which lie in series within a myofibril

Chronic Inflammation

May occur if injured tissue is continually stressed beyond its ability to repair. Patient will have symptoms of increased pain, swelling, and muscle guarding that last more than several hours after activity. Increased feelings of stiffness after rest, loss of ROM 24 hrs after activity, and progressively greater stiffness of the tissue as long as irritation persists.

MCL and LCL provide what kind of stability to the knee?

Mediolateral stability

Subluxed Patella

Most likely subluxes in the lateral direction because the lateral structures are tight. When the knee is in extension, we sublux our patella when the patella moves superiorly because it is no longer sitting comfortably between the condyles. Therefore, it's more likely to move in the direction of the strongest pull (laterally). ^This is why we work the VMO (helps resist the lateral pull)

Component Movements

Motions that accompany normal active motion but are not under voluntary control. *Ex. motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion, and rotation of the fibula, which occurs with ankle motions, are component motions*. (Needed for normal ROM but you can't control it)

Joint Play

Motions that occur between the joints surfaces and also the distensibility or *"give" in the joint capsule, which allows the bones to move*. *Necessary for normal joint functioning* through the ROM and can be demonstrated passively, but they *cannot be performed actively by the patient*. *Movements include distraction, sliding, compression, rolling, and spinning of the joint surfaces*. (Every joint has a degree of play to it; we try to take advantage of this when we do joint mobilization...ex. shoulder - looser joint, it can move even with just a gentle pull on the humerus)

Accessory Movements

Movements in the joint and surrounding tissues that are *necessary for normal ROM but that cannot be actively performed by the patient* (joint play and component movements are considered accessory movements) (Movement every joint needs to get through normal ROM)

Physiological Movements

Movements the patient can do voluntarily (classic or traditional movements, like flexion, abduction and rotation)

After strengthening individual muscles in the ankle, what's next?

Muscle group strength. We can have the athlete do calf raises while holding onto a table - so we get strengthening without worrying about balance. To make it more difficult, we can put the athlete on a total gym and have them do single leg calf raises. We can have the athlete do squats - starting off with ball squats (these take pressure off the ankle and involve more stabilizers). Then the athlete can hold the table and squat, then let go of the table and squat, then do body weight squats, then weighted squats, and maybe eventually do bosu squats.

Chronic Stage (Maturation and Remodeling)

No signs of inflammation during this stage. May have contractures or adhesions that limit range, and maybe muscle weakness limiting normal function. Connective tissue continues to strengthen and remodel in response to stresses. A stretch pain may be felt when testing tight structures at the end of their available range. Function may be limited by muscle weakness, poor endurance, or poor neuromuscular control. Functional exercises and specificity drills are very important to help the athlete develop functional independence.

Note to Remember from Class (about rehab vs actually playing in a sport)

Nothing replicates playing in a game. You can work an athlete as hard as you want with rehab, but they will still need to adjust to actual playing conditions, which means they're going to swell again and might be in a little pain. It's just because their body needs to adjust to the newer, harder rigors that come with playing in an actual game.

Vestibular System

Occurs in our *ears*. Provides information about the position and movement of the head with respect to gravity and inertial forces. Detects angular acceleration of the head, changes in direction

Joint Mobilization

Passive manual therapy technique applied to the joints/surrounding tissues for therapeutic purposes. Good at the beginning when the athlete has issues with movement. Done at varying speeds and amplitudes (depths) depending on your goal for the treatment

Static Stretching

Passive stretch, long duration. ex. Sit-and-reach. Good to do at the beginning of rehab

What are some post-surgical considerations we need to be aware of?

Patellar mobilization will be important post-surgery. We will also have to mobilize scar tissue (lotion the area, massage/move the scar around and break it up)

Scenario: A 14 year old basketball player comes in complaining of knee pain. What should we be thinking?

Patellar tendon issue. There's a lot of jumping and running involved in basketball. Then, you can check out the feet and hips to see where the pain is really coming from.

Management During the Subacute Phase

Patient feels better during this stage because pain isn't constant and active movement can begin. The key is to initiate and progress nondestructive exercises and activities (within the tolerance of healing tissues). *Patient Education*: Inform them on what to expect, time frame for healing, and S/S they should look out for incase they push themselves beyond tissue tolerance. Encourage them to return to normal activities that don't exacerbate symptoms, but caution against returning to detrimental activities. Teach them exercises for home and help them become an active participant in the recovery process. *Management of Pain/Inflamm*: Initiate active exercises and stretching when swelling decreases, pain is no long constant, and pain is not exacerbated by motion in the available range. Monitor patient response as new exercises are introduced. *Initiation of Active Exercises*: Submaximal isometric exercises are used during early subacute stage to initiate control and strengthening of muscles in involved region. Intensity and angles for resistance are determined by absence of pain. AROM exercises are used to develop control of the motion. Initially, use isolated, single plane motions. Muscular endurance exercises are emphasized here because slow-twitch muscle fibers are first to atrophy. Partial weight-bearing may be used to load the region in a controlled manner and stimulate stabilizing co-contractions in the muscles. *Initiation and Progression of Stretching*: Restricted motion during the acute stage and adherence of the developing scar usually cause decreased flexibility in the healing tissue and related structures. To increase mobility and stimulate proper alignment of the scar, initiate stretching that is specific to the tissues involved. Also, warm the tissue (modalities or active ROM), use muscle relaxation techniques, joint mobilization/manipulation, stretching techniques, massage, and use of the new range. *Correction of Contributing Factors*: Continue to maintain/develop as normal a state as possible in related areas of the body. Address postural/biomechanical impairments, resume low-intensity functional activities as tolerated, and continue to re-assess patient's progress.

Center of Mass

Point that corresponds to the center of the total body mass and is the point at which the body is in perfect equilibrium. Determined by finding the weighted average of the COM of each body segment.

What are the inverters?

Posterior tibialis is the most important

Somatosensory System

Provides information about the position and motion of the body and body parts relative to each other and the support surface.

What are the three main muscles involving the knee?

Quad, hamstrings, gastroc/calf ^These are what we work during rehab (but we can't forget about the adductors)

Foot Rehab

ROM work is hard - can scrunch toes, marble pick-ups, towel crunches with/without weight. If there's a foot injury, figure out how much the ankle is involved and you can work the ankle a bit. With a foot problem, we want to move the tendon (flexion, extension, etc.) *Plantar fasciitis*: roll the foot on a hard ball (freeze water bottle and do the same); manage pain and swelling is the most important thing (common in women especially those wearing heels; runners who run on their toes); *to test*, push the athlete's toes back and the person should have pain running up the plantar fascia Not much else we can do. Foot injuries suck and they need time to get better.

Self-mobilization

Refers to self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule. Ex. pulley swings (for the shoulder)

Center of Gravity

Refers to the vertical projection of the center of mass to the ground. In the anatomical position, the COG of most adult humans is located around the waist/midsection

Note about ACL reconstruction

Rehab goes in stages. We can't push the athlete until the doctor clears them. We can work ROM and start flexibility but not much else. Mac usually doesn't let these athletes back to practice for 7-9 months.

Power

Related to strength and speed of movement; *the work (force x distance) produced by a muscle per unit of time*; in other words, it is the *rate at which a muscle contracts and produces a resultant force and the relationship of force and velocity are factors that affect muscle power*. Power can be enhanced by either increasing the work a muscle must perform during a specified period of time or reducing the amount of time required to produce a given force. The *greater the intensity of the exercise and the shorter the time period taken to generate force, the greater the muscle power*. Football players need power training, people who do field events in track, baseball batters, lacrosse players, basketball, etc If done correctly, Olympic lifts are good for power training (deadlifts, cleans, squats, overhead jerk, etc) Box jumps are good too (because you can raise the box to increase intensity)

What's the main nerve we need to know in the hip?

Sciatic Nerve. Can shoot pain from low back down to foot. Biggest cause --> nerve being compressed against the ischial tuberosity (so we'd need to loosen the hamstrings, piriformis, etc).

Golgi Tendon Organ (GTO)

Sensory organ; *located in the tendon*; *sensitive to even slight changes in tension* on a muscle-tendon unit as the result of passive stretch of a muscle or with active muscle contractions during normal movement *Function*: to monitor changes in tension of muscle-tendon units. When tension develops in a muscle, the GTO fires, inhibits alpha motorneuron activity, and decreases tension in the muscle-tendon unit being stretched. GTO has a low threshold for firing (fires easily) so it can continuously monitor and adjust the force of active muscle contractions during movement or the tension in muscle during passive stretch. However, if you move too quickly, the GTO won't be able to fire in time and you can pull a muscle.

Acute Stage of Inflammation and Repair (Inflammatory Reaction)

Signs of inflammation are present: *swelling, redness, heat, pain at rest, and loss of function*. There are vascular changes, exudation of cells and chemicals, clot formation, phagocytosis, neutralization of irritants, early fibroblastic activity, etc. It is possible to do rehab at this stage, but it depends on patient pain level, ROM, and swelling. What does the injury look like? What's their function? How well do they move/walk? During this stage, here's where we want the injury to calm down - especially the swelling. Simple movements can help squeeze the swelling out. Nondestructive movement is good as well as ice, rest, compression and elevation.

Subacute Stage (Proliferation, Repair, and Healing)

Signs of inflammation progressively decrease and go away. There is removal of noxious stimuli, growth of capillary beds into area, collagen formation, granulation tissue, and the tissue is very fragile and easily injured. When testing ROM, patient may experience pain synchronous with encountering tissue resistance at the end of available ROM. Pain occurs when new tissue is stressed beyond its tolerance or when tight tissue is stressed. Muscles may test weak, function is limited as a result. The injury is calming down and tissue is healing itself. During this stage, we can work ROM, flexibility, prevent contractures/adhesions, controlled motions. This is where the bulk of rehab comes in. Selective stretching, mobilization/manipulation of restricted tissue is good, as well as nondestructive active, resistive, open- and closed-chain stabilization, muscular endurance, and cardiopulmonary endurance exercises, carefully progressed in intensity and range.

What are some balance exercises we can do with ankle rehab?

Single leg stance on a stable surface with eyes open, then involving ball manipulation, then maybe with eyes closed. If we want to make it harder, we can put them on an unstable surface with these variations. We can also have them do a single-leg deadlift of sorts where they pick something up off the ground while maintaining balance. We can also have them work on a bosu ball (standing, single-leg, squats, etc)

After working on knee flexibility, what's next?

Strengthen Individual Muscles Isometrics of all muscles (quad - ie quad sets, hamstring, gastroc) Quad Sets - contract the quad, hold for 5 seconds while the athlete is supported on the table and lying flat with the other leg bent and a towel under the knee TKE (band around the knee, start with the heel off the ground and knee bent, push into full extension; the heel-up allows for a fuller range of motion) SLR (other knee is bent, make sure the athlete is contracting their quad before lifting; also make sure the foot is dorsiflexed to take some pressure off the quad) Side leg raises with bottom leg (make sure the athlete is fully on their side - not their back; make sure the leg/spine is in alignment - even if it's not as comfortable; opposite leg bent over straight leg; not as much movement in this direction) Side leg raises with top leg (make sure athlete in alignment, bottom leg bent, works inner and outer thigh - so you work other muscles around the knee) Ball Squeezes (put a ball in between their knees and have them squeeze - isometric contraction of groin muscles) Hamstring Curls (start with no weight to make sure they can do it, then add weight right above the knee so it's easy, then lower it to make it harder - can be prone or standing)

After strengthening individual muscles in the knee, what's next?

Strengthen Muscle Group First, we want to make sure the patella is mobile (this allows the knee to work properly). So take it side-to-side, up and down, while the knee is straight. Don't push the patella too far but move it to loosen it up. Leg extension (short arc knee extension) - you can have the athlete lying down with the knee bent, and then have them extend. Can use a stool - so the heel starts of the stool with the leg bent, and then they bring the knee into extension, then bend back (if the athlete can tolerate this, move up to the full arc; you can also add weight/resistance, then move on to a machine and go from double leg to single leg extension) Squats - ball squats first to stabilize the body without thinking (allows you to strengthen through full ROM), then normal bodyweight squats, then weighted squats Lunges (can be added once you are done with bands and have started ball squats/body squats or leg press - because they are a tougher movement and most athletes perform it wrong) Monster walks Walking side squat with/without band

After getting ankle flexibility, what's next?

Strengthening individual muscles. We can do isometric exercises (4-5 second holds) - this involves pushing the foot against a solid surface while sitting (can do eversion, inversion, plantarflexion, and dorsiflexion). We can use therabands (yellow, then red, then green, blue, black) for *eversion and inversion* but we have to make sure to stabilize the athlete so they don't rotate their shin. Note: inverters and everters need to be worked directly. Once we have the athlete weight bearing, we are already working muscle groups.

Strength Training

Systematic procedure of a muscle or muscle group lifting, lowering, or controlling heavy loads (resistance) for a relatively low number of repetitions or over a short period of time. (program for developing muscle strength) Most common adaptation to heavy resistance exercise is an increase in the maximum force-producing capacity of muscle - ie. increase in muscle strength (and an increase in muscle fiber size)

What do shin splints tell us?

That we have pain somewhere between the ankle and knee, but it doesn't tell us anything until we figure out what's causing it.

Balance (definition)

The *ability to align body segments against gravity to maintain or move the body (center of mass) within the available base of support without falling*; the ability to move the body in equilibrium with gravity via *interaction of the sensory and motor systems*

Coordination (definition)

The *correct timing and sequencing of muscle firing* combined with the appropriate intensity of muscular contraction *leading to the effective initiation, guiding, and grading of movement*. This is the *basis of smooth, accurate, efficient movement* and occurs at a conscious or automatic level.

Therapeutic Exercise (definition)

The *systematic, planned performance of bodily movements, postures, or physical activities* intended to provide a patient/client with the means to: 1. Remediate or prevent impairments 2. Improve, restore, or enhance physical function 3. Prevent or reduce health-related risk factors 4. Optimize overall health status, fitness, or sense of well-being

Flexibility

The extensibility of soft tissues (muscles) that cross or surround a joint which are necessary for unrestricted ROM; ability to move a joint smoothly through unrestricted ROM by working the musculature around the joint

Why is hip balance strategy important?

The hips are involved so much in balance. They have the biggest/strongest muscles and the center of gravity is around our midsection.

Sensory System

The main sense that helps with balance = *vision* Our eyes provide information regarding (1) the position of the head relative to the environment; (2) orientation of the head to maintain *level gaze*; and (3) the direction and speed of head movements, because as your head moves, surrounding objects move in the opposite direction. Our eyes allow us to *orient ourselves*

Base of Support

The perimeter of the contact area between the body and its support surface; foot placement alters the BOS and changes a person's postural stability. A wide stance, as seen with elderly individuals, increases stability. A narrow stance, such as tandem stance or walking, reduces stability. As long as a person maintains the COG within the limits of the BOS, they will not fall.

What should we put at the center of efforts to prevent or halt the progression of disability?

The person, not solely the disease or disorder. This is why we *employ interventions that improve a patient's functional abilities while simultaneously reducing or eliminating the causes of disability.*

What should we also look at if someone has a knee problem?

Their feet and hip musculature. Both of these have referred pain in the knee. So if someone comes in with knee pain and can't describe an MOI, it's possible the problem is somewhere else in the kinetic chain.

Note about the 3 Stages of Rehab Management

These stages blend together. We have to look for something that tells us they are ready for the next stage. For example, Mac with ankle injuries. As soon as he gets someone weight bearing, he progresses to strengthening. From maximum to moderate - can blend as soon as strengthening starts; from moderate to minimum, can blend into the other as soon as agility starts?

What do we know if someone is limping?

They are WEAK. The body wants to move and so it will use other muscle groups to try and cover the weakness. This is when we need to teach the athlete how to walk again. Have them slow down (which puts less stress on the foot/ankle) - it will help break the limp quickly. Have them focus on heel strike and take a better step. Breaking the limp is difficult - don't let the limp go on for long.

Static Balance

This is what we start with - maintaining a stable anti-gravity position while at rest, such as standing or sitting. ex. standing at first, then single leg stance with eyes open; then with eyes closed to make it harder; then you can throw objects at them before moving to an unstable surface

Arthokinematics of the Knee

Tibial plateau moves in the same direction as tibial movement. Femoral condyles move in the opposite direction (to allow for movement at the knee)

Elastic Phase

Tissue is taken to its end-range of motion and a stretch is applied. When you put so much tension on the tissue, this is where you start having some breakdown. You can still get the tissue back to its normal length, but you need to rest. At this point, you've started to do too much/go too far.

Does the order to our exercises matter?

To a degree. *Basic Order* 1. Warm Up 2. Stretch 3. Our rehab program 4. Cool down Note: Stretch/ROM heats our tissues - one of the by-products of exercise is heat so you can get the muscle warm by having them do low-level stretching/cardio

Stabilization - also important with stretching

To achieve an effective stretch of a specific muscle or muscle group and associated periarticular structures, it is imperative to stabilize (fixate) either the proximal or distal attachment site of the muscle-tendon unit being elongated. Stabilization of multiple segments of a patient's body also helps maintain the proper alignment necessary for an effective stretch. Sources of stabilization include: manual contacts, body weight, or a firm surface (table, wall, floor)

Where do we see a lot of SI issues?

Track people (constant running), football players, field hockey, etc. If the SI locks up, it's not necessarily going to refer pain to the back, it may refer to hip/legs.

Balance Control

Two main systems work together to maintain balance - *muscular system and nervous system* The *nervous system* provides sensory processing for perception of body orientation in space and sensorimotor integration essential for linking sensation to motor responses and for adaptive and anticipatory aspects of postural control. Also provides motor strategies for planning, programming, and executing balance responses. The *musculoskeletal system* provides for postural alignment, musculoskeletal flexibility such as ROM, muscle performance, and sensation. *Sensory Motor Integration*: you have a nerve impulse and it generates a motor response

Speed of Stretch

Want to start off slow - to minimize muscle activation during stretching and reduce the risk of injury to tissues and post-stretch muscle soreness. A slowly applied stress is less likely to increase tensile stresses on connective tissues.

How about cardio with ankle rehab?

We can have them begin on a bike (as a non-weight bearing option). Then progress to walking on a treadmill when they are okay with weight bearing. Then, we can have them jog, run, and eventually get them doing that on normal ground.

How long do we have to wait after an injury to start working on cardiovascular endurance?

We need some degree of physical strength before we start but not much. We can start cardio pretty quickly - it's just a question of where to start in order to reach our end goal. For example, if we have a basketball player with an ankle injury - once we get ROM and flexibility, we can stick them on the bike to get some movement in a non-weight bearing, low-intensity way to get them started.

Patellofemoral Joint Rehab (these notes were taken after the previous knee notes so I'll just include them here)

We need to strengthen quads, hamstring, gastroc (get the athlete warmed up on a bike - can also do ROM, heel slides, prone hang off table, quad sets, forced flexion, etc.) Quad sets to straight leg raises (at least 3 way is good; flexion/abduction/adduction; can do extension SLR but it's better if you do hamstring curls) When doing weighted SLR, put the weight on the quad first, because it's easiest; then move the weight distally as they get stronger. After SLR - work gastroc (heel raises if they can, or start with ankle pumps, add bands, heel raises without weight, then add weights). Then - hamstrings (prone curl, standing curl - can add weights to both when ready) Then move to squats (ball squats, regular bodyweight, then weighted). BALANCE - double leg stance, single leg, eyes closed; throw object at them, move to unstable surface CARDIO - once they can walk, progress them to jogging on treadmill, then running on treadmill, then have them on solid ground. Can have them on a bike as well - as a non-weight bearing option to start. Other strengthening - Leg presses, hamstring curl, seated hamstring with band, with cuff weight, chair pulls (more advanced), can do machine hamstring curls. Also, we can throw lunges in at the end because we need stability, balance, and strength (good way to see where the athlete is at before starting sport-specific drills or even before they return to play). *^Good basic progression* AGILITY - want to start when WE are comfortable with it. So if the athlete can do a weighted squat with no pain, they can do straight ahead sprinting with no pain/gait issues. Mac usually waits until inflammation is gone, the athlete has full ROM, and they can do some squats/lunges. I would say once the athlete has full ROM/flexibility and starts strengthening muscles, we can start doing side-steps. Then progress to lateral shuffles, side squats with bands, monster walks, etc).

What is functional hamstring ROM?

We want 90 degrees. The lower that number is, the more susceptible they are to getting hurt.

Important to remember about feedback

We want to be careful and not overload the athlete with feedback because it could set them back. But we also have to be aware of the timing of our feedback - if it comes at the right time, it could help the athlete out of a slump.

Gait Training

When someone walks, if they don't have hip flexors, their trunk is going to take over and you will see an obvious swing (where they throw their leg to the side to be able to take a step). If you lose hip extensors, you'll see a posterior lurch. It's not easy to see but the person will complain of glute pain, ITB pain, upper thigh problems.

Passive Angular Stretching

When the *bony lever is used to stretch a tight joint capsule*; may cause increased pain or joint trauma because the *use of a lever magnifies the force at the joint and the force causes compression of the joint surfaces* in the direction of the rolling bone. The roll without a slide doesn't replicate normal joint mechanics either. ^*Note: this is very bad*. May cause increased pain or joint trauma and there is way to much force involved when stretching the capsule.

With Knee Rehab, when can we start cardio?

When the athlete has some form of measurable strength (like they can walk with no pain, etc). Once we get the athlete off the table (ie. weight bearing), we can start them with light cardio and increase intensity over time

Joint Glide Stretching

When the translatoric slide component of the joint function is used to stretch a tight capsule; safer and more selective because the force is applied close to the joint surface and controlled at an intensity compatible with the pathology. The *direction of the force also replicates the sliding component of the joint mechanics and does not compress the cartilage*. Finally, the *amplitude of the motion is small yet specific* to the restricted or adherent portion of the capsule or ligaments - thus the forces are selectively applied to the desired tissue. (*Force applied close to the joint, where we control the intensity and direction; much safer*)

Note about Sarcomeres

When you put tension on a muscle, the cross bridges of the sarcomeres start to lengthen. If you hold a stretch for a good duration and you stretch frequently, these sarcomeres will retain their new length - giving you increased flexibility.

Accessory Motions of the Foot/Ankle/Leg

With dorsiflexion and plantarflexion, there are slight accessory movements of the fibula. The movement is necessary to allow full range of the talus in the mortise during ankle dorsiflexion (tibia and fibula have to separate to make room).

Endurance

ability of a muscle to *perform low intensity movements, repetitive, or sustained activities over a prolonged period of time*; this is a hallmark of what we do *More important than strength* (think about how long most sporting events are - we need our athletes to be able to last)

Passive ROM

movement of a segment within the unrestricted ROM that is produced entirely by an *external force*; involves little to no voluntary muscle contraction. External force can be from machine, gravity, athletic trainer, etc. Can be done on any body part; but it takes up a lot of our time as clinicians; may be a good place to start depending on the stage of injury