And functional treatment of the LE

Transcription

1 And functional treatment of the LE

2 Function: Mobility and support for almost all functional activities of the lower limb ROM norms Flexion : Most ADLs require 115 Increased needs with sport and squatting Extension 0-10 hyperextension Lack of normal motion will inevitably lead to dysfunction and pain Increased compressive forces or patella and cartilage Decreased quad force production (leads to compensation) How can this affect function up/down the chain?

3 Gait/Ambulation: 60 Stairs and Sit - Stand: Getting up from toilet: 115 In/out of bathtub: 135

4 Knee extension Quads: RF=2jt Vasti=1jt TFL/ITB: Can help stabilize terminal knee ext. Knee Flexion Semimebranosus, Semitendinosus, Biceps femoris, Sartorius, Gracilis, Gastroc Knee is a simple joint: It s happy when it can flex/extend in the sagittal plane We need to train stability against forces in frontal/transverse planes Where does rotational stability come from?

5 Need to understand what tissues are causing pain Patient education/expectations/responsibility Patient specific treatment Important to help guide treatment Precautions for specific Dx. Meniscus no twisting, focus on rotational stability Tendinopathy gradual increase in tendon loading OA joint specific treatment, disperse forces Do you see how cookie cutter rehab may not always be effective?

6 Diagnosis Patellar Tendonitis Meniscal Tear PF Syndrome Knee OA Aggravating Factors Active and passive Rom, eccentric loading, worse with increased load and time. Twisting and compressive activities, stairs Pop/lock of jt, instability. Stairs, sitting *with knees bent, typically due to motor control that irritates soft tissue Stiff/painful, worse in AM and prolonged inactivity. Pain at endranges. Special Tests Pain with palpation, resisted ext and passive flexion. Thessely, mcmurray, joint line tenderness Pain at PROM endranges Correlation of signs/sympto m reproduction. Functional tests. Pain at endrange, ROM limits. Chronic = compensation up/down the chain.

7 Quad set/slr Inhibited by swelling Literature: less than 20cc can shut down quad Important for post surgical patients! Biofeedback and NMES supported by literature If it s not done right, it s not worth doing. What compensations do you see in the clinic? Knee extension ROM Functional tests/special tests (if indicated/appropriate) to guide where we focus treatment. Irritability determines extent of testing day 1

8 Hip/pelvis Decreased hip extension leads to weak glutes and overactive hip flexors Pelvic drop (trendelenberg vs. reverse tr.) Adduction/IR likely due to poor lateral hip control All can translate excessive force to knee joints Knee Lack of knee ROM Decreased knee ext rom may be caused by tonic HS Quad whip Varus/valgus

9 Foot/ankle Poor push off Compensated with overactive ant. Tibialis or toe extensors Weak plantar flexors vs. learned compensation Lack of DF may cause knee to hyperextend Normal supination/pronation? Pronation is NORMAL! Not always a bad thing if controlled Medial heel whip? Could be result of excessive IR into the LE Having this info day 1 helps to prioritize impairments.

10 Need to prioritize impairments to effectively progress through stages of rehabilitation Always driven by functional deficits and impairments What is the goal of exercise/modality/ manual treatment? Don t forget about the pyramid! Strength Function AROM PROM Edema, Pain Control

11 Manual RX: STM: quad/hs/itb/fat pad/patellar tendon Joint mobs: patella, tib/fib jt, femoral/tibial Exercises: Pain free ROM, Exercises in elevated position Focus on issues away from irritated tissue (hip/ankle) Activation exercises: QS, glute ladders, Core breathing Relaxation techniques: breathing, phasic activation Taping: V-tape: fat pad off-loading Tilt/glide: patellar positioning X-tape: facilitate glutes, inhibit hyperextension Pinch/tent taping: off-load tendon/ ligament/ mm belly Kinesiotaping: web tape to increase lymph flow

12 Manual Rx: Knee flexion MWM Anterior tibial glides (prone) More than jt and mm limiting ROM Neural, swelling, pain inhibition/guarding Exercises More effective if addressing tissue length AND motor control: patients need specific instruction Heelslides: focus on hip control as well as stretch Prone hangs: may strengthens HS and shorten muscle Need to focus on multiplanar stability Poor control will lead to increased tissue irritation Exercises should not reproduce symtpoms Muslce soreness is NOT a symtpom Pain does NOT always = gain

13 Exercise must meet life/work demands Once AROM is pain-free we must incorporate it into functional tasks Basic skills of LE SLB Squat Step Lunge Must master SLB before other single leg exercise Includes step up, lunge, sidesteps...

14 One of the most basic functional movements Basic building block for all single limb activities Steps, side steps, lunge, throwing, layup, putting on pants. Consider using Mirrors: help increase feedback (initially) UE assist: help bypass other strength limits Progress to unstable surfaces, UE/LE movements Get functional sooner than later!

15 Most appropriate when patient able to move through functional ROM without pain and normal patterns. Adding weight/resistance to any abnormal movement pattern will promote abnormal patterns Many types of strength Endurance needs vs. maximal force needs Stability needs vs. mobility needs Eccentric vs. concentric Train multiplanar movements when appropriate

16 It s common to see faulty mechanics with knee pain Hip adduction/ir (valgus) with steps/slb Femoral IR with knee extension Quad dominant activation increases stress at knee joint and to surrounding tissues Squat with increased anterior tibial translation Quad whip with ambulation Need to find painful and functional tests (asterisk) The tests help determine what needs to be treated The tests become the exercises

17 Function Dysfuntion? Restricted? Weak? Sit-stand SLB Step Up Squat

18 Knee treatment is about the hips. Khayambashi K, et al. and Dolak, KL et al. strengthen hip effective for females with pfs Powers, C 2010 importance of hip mechanics Hips role in knee function Stabilization reduces unnecessary forces at joint Proper control can decrease muscle imbalances that lead to pain

19 Focus on control of entire chain Hip and pelvic control very important (chris powers) Rehab needs to include proprioceptive/sensorimotor control of the entire chain SLB, varying surfaces to increase neural control, progressing towards multiplanar/functional movement Exercises need to be task specific Bridges increase strength and improve performance of doing a bridge, NOT stairs/sit-stand/walking If you want to improve something, train it functionally!

20 Depends on the GOAL of rehab High MVIC% for strength? Activation to recruit proper firing of muscle? Easier exercises for highly irritable patients To help dampen down compensations Functional?

21 Boren et al Gluteus Medius Side plank abd (103% leg down- 88% leg up) SL squat 82% Hip clam #4 76% Sidelying ABD 62% Gluteus Maximus Front plank hip ext 106% Glute squeeze 80% (are you as shocked as I was?) SL squat 70% Unilateral wall squat 86% (Ayotte et al.2007)

22 The good: we can assume these are great for muscle strengthening Rehab concerns: Is it controlled? May be too advanced for some patients Do they have the available ROM? Does exercise increase pain? (correct recruitment?)

23 Good Clam 115 Not so good Lunge 18 Sidestep 64 Hip hike 28 Unilateral bridge 59 Squat 28 Quadraped hip ext 50 No dif for knee position Sidelying hip abd 38 All of these preferentially targets glutes over TFL Maybe not best choice to turn down TFL, but very functional!

24 Glute med Quad hip ext (non dom) 22% Glute squeeze 43% Quad hip ext (dom) 46% Glute max Hip clam #2: 12% Quad hip ext (non dom) 21% Dom = 59% Dynamic leg swing 33% Glute med Prone bridge 27% Bridge 28% Lunge 29% Glute max Prone bridge 9% Bridge 25% Boren et. al 2011 Ekstrom et al. 2007

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