Pearls for Foot Injury Rehabilitation & Return to Play. DeDe Strama, PT Kate Lutz, PT, DPT

Transcription

1 Pearls for Foot Injury Rehabilitation & Return to Play DeDe Strama, PT Kate Lutz, PT, DPT

2 Declaration of Disclosure The presenters named in this presentation certify that they have no relevant financial or nonfinancial relationships existent within the presentation today. 2

3 Goal Provide pearls of wisdom to optimize rehabilitation and return to play/work for foot and ankle injuries 3

4 Objectives 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 Lisfranc injury including the importance of a healthcare TEAM approach 4

5 Why pearls? 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. 5

6 Early Referral 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 6

7 Gait 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 7

8 Cardiovascular System 1,8 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 8

9 Core 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 9

10 Hips 6 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 10

11 Lower Extremity Strengthening 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 exercise 2 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

12 Ankle Mobility & Strength PEARL: Importance of relationship of subtalar to midtarsal joint Pronation unlocks mid tarsal joint; Supination locks midtarsal 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 12

13 Foot Intrinsic Strength 3 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 13

14 General Guidelines of Lisfranc Injury 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 weeks Grade 2 3 Lisfranc Injury Typically surgical Weight bearing status determined by surgeon (typically NWB). Return to sport with surgery between weeks Grade 2 and Grade 3 is season ending typically and much longer recovery 14

15 Case Study Lisfranc Injury 5 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 15

16 Case Study: Rehab progression/return to sport 5 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 16

17 Case Study: Return to Sport/Functional Testing 5 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 17

18 Key Pearls of Wisdom 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 18

19 References 1. Bogdanis GC. Effects of physical activity and inactivity on muscle fatigue. Front Physiol May; 142(3): doi: Gao Y, Arfat Y, Wang H, Goswami N. Muscle atrophy induced by mechanical unloading: mechanisms and potential countermeasures. Front Physiol Mar; 235(9): doi: Gooding TM, Feger MA, Hart JM, Hertel J. Intrinsic foot muscle activation during specific exercises: A T2 time magnetic re sonance imaging study. J Athl Train Aug; 52(8): doi: / 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 Sept; 44(9):

20 References Continued 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): 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 Jul; 53(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 Oct; 25(3): doi: Rich H. How fast do you fall out of shape? Allina Health. id= Published 6/16/16. Accessed 12/20/18. 20

21 QUESTIONS? 21