LISFRANC INJURY

We have all heard about Cam Newton’s foot injury with speculation he is dealing with a Lisfranc injury.  If this is true, the most likely outcome will be season ending surgery.

A Lisfranc injury can be classified into three different categories including sprains, fractures, and dislocations.  The most severe form of the injury is a dislocation of the metatarsal bones from the tarsal bones especially at the 2nd tarsometatarsal joint.  This injury usually occurs as a result of combined external rotation and compressive force on the foot.  In football, the prime example is having an opponent step on the foot of another opponent while attempting to change direction.  This is typically more common in football, but can occur in soccer and basketball as well.

Often time Lisfranc injuries are categorized as a simple sprain of the foot especially if there are no radiographic changes present.  Conservative treatment focuses on decreasing pain and allowing the tissue and structures time to heal.  Time is usually the best prognostic factor for determining success with conservative treatment.  Often athletes, especially professional athletes, face a tough decision because they want to get back as soon as possible.  If you return too quickly and the foot is unable to tolerate the high levels of stress, re-injury is inevitable.

Rehab focuses on restoring the intrinsic foot muscles to help alleviate some of the strain on the Lisfranc ligament.  Check out @movementologist for foot intrinsic exercises. Once some weight bearing can be initiated without severe pain, any type of balance/proprioception training is warranted.  Then progressing to gentle plyometrics in double limb support before moving onto single leg plyometrics.

The final step in the rehabilitation process is the return to running in a straight line with progression to cutting and changing direction to restore full tolerance to all dynamic, weight bearing activities.  The one variable you cannot account for as a physical therapist is an opponent stepping on the athlete’s foot when attempting to change direction.  Sometimes no matter how much preparation and training an athlete puts in to minimize the chance of injury, a “true” contact can not be prevented.

PATELLAR DISLOCATIONS

During last Thursday’s NFL game, Patrick Mahomes suffered a dislocated patella during the second quarter from a quarterback sneak play. The patella was re-set immediately on the field which can correlate to immediate pain relief along with minimizing the detrimental effects of impaired quadriceps activation.

Once on the sidelines, Mahomes can be seen walking back to the locker room under his own power and without any assistive device.  All signs point to no true structural damage to the knee.

From a rehab perspective, the next 48 hours will probably be the worse in terms of pain and stiffening up.  Goals during those 48 hours will focus on maintaining range of motion, minimizing swelling, and restoring/maintaining quadriceps activation.  Even though there was no structural damage, there was still a traumatic event and the body will respond by trying to “protect” the knee.

Initiating several balance exercises will be key as well to restore proprioceptive and kinesthetic awareness of the knee.  This will aid in the progression towards more dynamic activities to minimize time away from the field.

As the acute phase of the healing process passes, gradual return to more strenuous weight bearing activities such as squatting, lunging, deadlifting, etc. can begin.  It is important to introduce low level plyometric drills to restore coordination of movement.  This can be performed in ways such as using an agility ladder or mini-hurdles.

Being able to return to the field will likely be anywhere from 3 to 6 weeks.  The ability to immediately have re-located the patella will aid in a quicker recovery along with Mahomes’ age and prior level of physical fitness.

Be sure to check out @jordandpt5 for exercises to assist with the recovery from a patellar dislocation.

 

 

 

UCL of the THUMB

When people hear about the UCL, or ulnar collateral ligament, injuries many immediately think about the elbow and possible Tommy John surgery.  But there is another UCL in the body and it happens to be in the thumb.

This is most likely the injury sustained by Drew Brees when his hand struck Aaron Donald during the Saints/Ram game earlier this year.  Significant injuries to the UCL usually require surgical intervention for proper recovery.

Now I know reports are coming out that Drew Brees will only miss 6 weeks but that time frame could be a little aggressive especially considering it is Drew’s throwing hand.  Having to grip a football repeatedly will challenge the healing tissue and since most tissue takes at least 8 weeks for full recovery, returning in 6 weeks will be a challenge.

Once healing is complete, beginning to increase load/stress tolerance is important.  Applying too much stress too soon can lead to lingering pain and this may be something Drew is willing to deal with throughout the rest of the season.

Exercises will focus on restoring range of motion, opposition, and gripping strength so Drew can repeatedly tolerate gripping and throwing a football.  Once some tolerance is built to withstanding repetitive load, the best therapy will be gripping and throwing a football.  No matter how many hand exercises you perform, there is no way to mimic the activity of throwing a football besides throwing a football.

Finally, don’t get caught up in these elaborate gimmicks to create something “new” or “mind-blowing.”  Understand the demands of the task and work to restore the body’s ability to tolerate those demands repeatedly.

ACHILLES REHAB – PHASE 4

Now we are getting into some enjoyment for the athlete.  The initial phases are about setting up the foundation and many times that leads to limitations in overall activity.  This can be frustrating for an athlete who is used to going 100% all the time.  Educating them about the process and keeping them focused and encouraged will go a long way to the overall perceived success of rehab.

Build a rapport with your athlete and BE A HUMAN BEING.

Phase 4 in my books is about restoring tolerance to dynamic activities in preparation for running.  If you are as lucky as I am and have an AlterG at your disposal, you can start having the athlete run sooner rather than later.  The AlterG allows you as the therapist to decrease the amount of body weight the athlete has to control under load and minimize the chance of creating abnormal running patterns.

If you don’t have an AlterG, laying the foundation for strength and stability in single limb is important.  Without the AlterG, I used standards of performing single leg squats and calf raises as the measure to returning to running unassisted.  Running is nothing but repetitive single leg movement and if you can’t control yourself during single leg squats and don’t have the strength for single leg calf raises, you will eventually breakdown and that usually leads to compensation.  Try to have the repetitions and quality equal to the uninvolved side.  Understanding and building a relationship with your athlete will help you determine if full effort is being given on the uninvolved side to have a true gauge of function.

I begin my progression towards running with gentle plyometrics.  Some may feel this is too advanced but if you can’t control yourself jumping and landing with 2 feet, how will you ever control yourself on 1 foot.

Doing a variety of box jumps from double limb support is how I initiate the process.  As the tolerance builds, I will begin to introduce the ladder to help with coordination of movement between the upper and lower body.  Not building agility!!! (that’s for another blog)

During this time of progressing towards more dynamic activities, we have been laying the foundation for squatting, lunging, and deadlifting to restore strength.  I am just highlighting some of the other components of the rehab process.  If the athlete is not exhibiting the pre-requisites to transition to these higher phases, then we stay at the current level until those markers are met.  This is where building a relationship with the athlete is important because you can be honest about the progress and know whether the appropriate amount of effort is being given outside of the facility.

Sometimes the hardest part about the rehab process is calling out an athlete who isn’t giving the effort needed to achieve the goals they lined out at the beginning of the rehab process.  Do you have the gumption to be honest with an athlete?

Photo by 冬城

 

 

FOOT REHAB

As the football season is upon us, several big names are already being hit by the injury bug.  This blog will focus on foot rehab to coincide with Derwin James who suffered a stress fracture to the 5th metatarsal resulting in surgical intervention.

One of the more common fractures of the 5th metatarsal is called a Jones fracture.  A Jones fracture is a fracture of the 5th metatarsal bone that leads to the pinky toe, between the diaphysis and metaphysis.  Diaphysis is the shaft of the 5th metatarsal and metaphysis is the base of the 5th metatarsal (seen below).  This type of fracture usually occurs when increased force is placed on the lateral aspect of the foot while in plantar flexion.  Jones fractures are usually seen in sports where cutting and pivoting are a prime component of the sport (basketball and soccer). It can also occur because of sudden deceleration with the foot in plantar flexion and inversion.

This type of fracture can be improperly diagnosed because many times any fracture of the 5th metatarsal, especially near the base, will be diagnosed as an avulsion fracture.  An avulsion fracture is where a portion of the bone tears away from the main bone mass and occurs where tendons attach to the ends of bones.

Now as reported, Mr. James suffered a stress fracture of the 5th metatarsal.  Out of the 3 types of fractures to the 5th metatarsal, a stress fracture is more likely to require surgery and usually takes at least 3 months to heal.  Since a portion of the time after surgery will be non-weight bearing, maintaining a level of conditioning for the athlete is necessary.  There are a variety of ways to increase heart rate and blood flow so get creative as long as you are not compromising the healing process.

Once weight bearing restrictions are cleared, gradually returning the athlete to load tolerance for dynamic activity is key.  Significantly more force is placed upon the foot when transitioning from walking to running to sprinting and without gradual return, consistent pain or re-injury is possible.

All in all neither the athlete or the physical therapist should drive the rehab process solo.  This needs to be a collaborative effort to help the athlete return to the level of performance they desire.

 

 

 

 

ACHILLES REHAB – PHASE 3

Now we are starting to spend more time out of the boot while in physical therapy.  The athlete may still be required to be in the boot during the first portion of phase 3 secondary to usually still being only 12 to 14 weeks out of surgery.

Photo by Ashim D’Silva

The focus in rehab now is about normalizing gait without the boot or other assistive device.  The athlete can begin exercises such as semi-weight bearing calf raises in the seated position without external load, squats or leg presses, and focusing on balance.

Many times I will utilize a leg press machine, if available, for range of motion.  It’s useful as the athlete can use a light load and have their feet slightly lower on the foot platform while maintaining heel contact.  Emphasizing a return to the bottom position without allowing the heels to pop off the platform is important as it will aid in restoring ankle dorsiflexion range of motion.

The athlete can then begin restoring movement patterns and weight bearing tolerance for squatting, lunging, and deadlifting in preparation for external load.

Photo by Ben Hershey

Finally, balance is crucial to restoring tolerance to single leg support.  I usually do not perform any static balance activities.  I would rather start in double limb support and add medicine ball throws, balancing on inverted BOSU, or any other dual task to make the exercise more engaging.  I tend to stay away from static balance because there is rarely going to be an instant where an athlete is standing on a single leg without movement.

With that being said, make sure you still check the athlete in a static position.  Sometimes athletes can mask balance deficiencies when an activity is given to them.  Just because I may lean one way versus the other does not mean it is an absolute end all, be all.  Make sure you are doing your due diligence when rehabbing anyone.

Be sure to check out @jordandpt5 for exercises in phase 3 of Achilles rehab.

ANKLE REHAB

As football season is around the corner, fantasy talks have definitely started.  There are probably several people out there developing draft boards and determining the next steal of the draft right now.

If you have been paying attention to the start of training camps, you have definitely heard about AJ Green’s ankle injury and subsequent surgical intervention.  Since surgery was warranted, Green most likely tore his anterior talofibular ligament or ATFL for short.  ATFL is responsible for resisting inversion of the ankle and minimizing the anterior translation of the talus in the ankle mortise.

Rehab will consist of allowing the healing process to occur while minimizing the effects of deconditioning secondary to the level of performance the athlete will need to return to.  Performing battle ropes in a seated position can be a great way to maintain some level of conditioning especially when someone cannot bear weight initially.

The early stages of rehab will work on restoring range of motion and improving intrinsic foot activation.  This can be a great time to work on some of the finer details to improve overall function that are often overlooked when training to get ready for the season.

Once allowed to bear weight, the rehab process will move towards normalizing gait and initiating balance to restore weight acceptance and proprioception.  This is a great time to start seated calf raises as well as with resistance.  It’s crucial to begin building the stress tolerance of the soleus since the athlete is returning the football and will need to return to cutting, changing direction, and decelerating on a dime.  The soleus has more of a role especially in cutting sports because there is rarely, if ever, an instance when an athlete is running or changing direction and their knees are straight.  The knee maintains a slightly flexed position, thus the soleus has more of a role when performing these dynamic movements.

Once cleared for more contact, the focus of rehab should be all about load management when progressing towards a return to the field.  One of the most important aspects when returning athletes to their full potential is to gradually progress their activity and avoid going from 0 to 100%.  Gradual return will lead to future success and minimize the chance of a nagging injury throughout the season.

Have questions about phases of the rehab process? Reach out through instagram @jordandpt5 or email at joshua.jordan87@gmail.com.

 

 

ACL REHAB

NBA finals provided a good springboard into the new theme for this blog.  First KD’s Achilles rupture and then Klay’s ACL tear.

ACL rehab starts very similar to Achilles rehab with education about nutrition, sleep, and everything in between.  Depending on the time between the initial tear and surgical reconstruction, continued strength training can occur prior to surgery to maintain a good level of strength.  This will help minimize the effects of disuse atrophy.  Also, it’s important to make sure the athlete has full knee flexion and extension prior to surgical intervention, but especially extension.

Knee extension is pivotal for restoring normal gait mechanics and has a greater impact on function than some limitation in knee flexion.

For most athletes, this will be the first time going in for a surgical procedure especially one of this magnitude.  Be sure you spend the time educating the athlete and their parents/support system about the overall surgical and recovery process.  One of the biggest complaints I believe we get throughout the healthcare world is lack of transparency and people feeling surprised about the process.

Educating athletes about this generally being a year-long process at minimum helps eliminate confusion later on when the athlete really wants to return to their sport.  It’s not beneficial to anyone if the physician says one thing while the physical therapist is saying something completely different.  We need to stop rushing these athletes back to competitive play, especially if the athlete is not showing the progression adequate enough to return to their sport at the highest level.

Nowadays, athletes are usually seen two days after surgery and goals are to control swelling, initiate quad activation, restore patellar mobility, initiate range of motion, and decrease pain.  One of the most important things is restoring quadriceps activation and this can be achieved in a variety of ways.  Couple gems I picked up over the years are knee extension isometrics in 90/90 and seated leg press into a ball.  Check out @jordandpt5for videos of these exercises.

Finally remember after any surgical intervention, the main goal is to promote the natural healing process of the body.  Being too aggressive early on usually leads to prolonged pain throughout the rehab process.  Be patient and allow the athlete the opportunity to recover.

 

 

 

 

 

 

ACHILLES REHAB – PHASE 2

Phase 2 of the rehab process usually starts about 4 weeks after surgery, while non-weight bearing restrictions are still in place.

This phase focuses on improving range of motion (ROM), decreasing swelling, improving scar mobility, initiating muscle activation, and improving overall joint mobility.

Exercises include plantarflexion isometrics with foot in neutral, toe yoga, active range of motion (AROM) in all planes, arch lifts, seated ankle dorsiflexion, and continued upper body and lower body strengthening without impacting the healing process or compromising the weight bearing restrictions.  If the restrictions are lifted, generally athletes are then transitioned to weight bearing as tolerated for balance activities.

Photo by Jon Tyson

One thing I stay away from is stretching the calf in any fashion.  Educating the athlete about not stretching the calf so the repair is not compromised secondary to having too much length is vital.  It’s more beneficial and less risk to gain dorsiflexion through improving muscle activation rather than stretching the posterior lower leg (gastrocnemius and soleus).

Once weight bearing is allowed, starting with simple weight shifts in a variety of stances is mandatory.  Many times physical therapist will by-pass some of the easier exercise because it may be hard to justify the purpose to an athlete.  By-passing these early steps can set the athlete up for a longer overall recovery process.  Don’t be afraid to slow the athlete down and make sure they develop a sound foundation to build upon.

Another big component of phase 2 is initiating gait even in the boot to restore the reciprocal pattern.  I have the athletes stay with crutches or a single crutch until able to walk without compensation.  Once walking a majority of time without crutches, I will still encourage athletes to have a crutch handy especially if spending several hours on their feet.  It’s important to minimize fatigue which can alter the athlete’s walking pattern as this may lead to future complications.

Photo by Volkan Olmez

Finally, phase 1 and 2 are still about protecting the healing process and allowing the body’s natural ability to heal itself work.  Everything we do as physical therapists should be done to assist the body’s natural ability to heal.  At times we may push an athlete too far and we must be able to recognize those instances and not be afraid to admit the mistake.  It happens and recognizing those mistakes will help you improve the rehab process in the future.

Be sure to check out @jordandpt5 for videos of some of the exercises I utilize.  Phase 3 is just around the corner!!!

ACHILLES REHAB

What a better way to start off the transition than by highlighting the rehabilitation process following Achilles rupture status post repair. This coincides with Kevin Durant’s injury during the NBA finals.

Rehab starts immediately with proper nutrition, hydration, and sleep.  Educating athletes, especially young athletes, about the benefits of recovery from proper nutrition, hydration, and sleep is vital to success.  A couple examples include educating athletes about possibly needing more calories following surgery and consuming gelatin with vitamin C to help promote tendon and ligament health.

All athletes following surgical intervention will have a decrease in overall activity level which in turn causes many athletes to decrease how much they eat.  This decrease in their calorie intake can be too drastic and have an impact on overall healing.  Athletes need to be educated about being smart on the food choices they make.  Young athletes are used to eating whatever they want since they tend to burn it off easily.  Even though calories can be maintained, the type of calories an athlete is consuming becomes even more important.  This can be a barrier for a lot of athletes.

Following surgery, the athlete is placed in a CAM boot and usually non-weight bearing for up to 8 weeks.  During this time the athlete may use crutches or a knee scooter for ambulation.  Initial rehab will focus on minimizing disuse atrophy throughout the entire body without compromising the healing process.

Some examples of exercises include sidelying hip abduction with band, bridging, knee extensions, leg curls, modified lateral plank, and any upper body exercises not perform in standing.  To see examples of these exercise, check out my instagram @jordandpt5.

Another intervention I have the luxury of utilizing is blood flow restriction training or BFR for short.  If you do not know about blood flow restriction training, please check out Owens Recovery Science for more information.

All in all, the initial phase of rehab is about promoting the healing process and minimizing the effects of disuse atrophy to help the athlete maintain a certain level of overall strength and conditioning.  Be on the look-out for phase 2 of the rehab process.

References:

Knappenberger, K. (July 2018). Nutrition for Injury Recovery and Rehabilitation: How to make sure your patients are receiving optimal fueling. Retrieved from https://www.nata.org/sites/default/files/nutrition-for-injury-recovery-and-rehabilitation.pdf