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Functional Rehab for Lower Extremity Injuries

Jaime Holt, PT, MPT, SCS, CSCSHolt Physical Therapy & Performance Training

jaimeholtpt@gmail.comTwitter: @HOLTPT1

Biography

❖ East Carolina University

❖ BS Exercise Physiology 1995

❖ MS Adapted Physical Education 1997

❖ MPT Physical Therapy 1999

Provider Disclaimer• Allied Health Education and the presenter of this webinar

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• There was no commercial support for this presentation.

• The views expressed in this presentation are the views and opinions of the presenter.

• Participants must use discretion when using the information contained in this presentation.

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Biography

APTA Sports Certified Specialist

NSCA Certified Strength and Conditioning Specialist

Owner and Sports Orthopaedic PT at Holt Physical Therapy & Performance Training

PT Consultant NHL Carolina Hurricanes (2007 – 2014)

Mentors❖ Pete Friesen

❖ Doug Geiger

❖ Gary Gray

❖ Walt Jenkins

❖ Kevin Wilk

❖ Bill Moore

❖ Co-workers

❖ Patients

Outline

❖ Etiology and Incidence of Knee Injuries

❖ Hip and Knee Anatomy

❖ Common Knee Injuries

❖ Patellofemoral Pain

❖ Knee OA

❖ IT Band Syndrome

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Outline

❖ Hip Flexor Pathology

❖ Patellar Tendonitis

❖ Meniscus Pathology

❖ MCL Injuries

❖ ACL Injuries

❖ Restoring Immediate ROM and Strength

Outline

❖ Early LE Muscle Activation Exercises

❖ Dynamic Warm Up

❖ Proprioceptive Training

❖ Hip Activation Exercises

❖ Maintaining Tissue Mobility

❖ Total Knee Rehab for the Athlete

❖ Return to Sport Training

Etiology and Incidence of Knee Injuries

❖ Approx 15 million visits a year are made to MD offices for knee pain

❖ 500,000 total knee replacements last year

❖ By 2030 projected to be 3.48 million/year due to agin baby boomers and obesity

❖ 150,000 ACL injuries per year

❖ Costing US Healthcare more than $500 million/year

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Bony Knee Anatomy

Knee Musculature

Hip Anatomy

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Q angle

❖ Q angle can be increased by:

❖ excessive femoral anteversion

❖ external tibial torsion

❖ genu valgum

❖ subtalar hyperpronation

Hip Musculature

❖ Hip External Rotators

❖ Gluteus Maximus and Medius

❖ Piriformis

❖ Obturator muscles

❖ Gemellus muscles

Common Knee Injuries

❖ Patellofemoral Pain

❖ Knee OA

❖ IT Band Syndrome

❖ Hip Flexor Pathology

❖ Patellar Tendonitis

❖ Meniscus Pathology

❖ Ligament Injuries

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Patellofemoral Biomechanics

❖ PF Force transmission

❖ CKC 0-20 deg: pressure is primarily on patellar tendon

❖ In mini squat, as flexion angle increases, quad accepts more load

❖ 45 deg and beyond; more quad force than patellar tendon force

Clinical Applications

❖ Patellar tendon: squat 45-120 deg

❖ PF arthritis: CKC 0-30 deg

❖ PF Instability: 40-90 deg

Patellofemoral Pain

❖ s/s: global knee pain; sharp at times; click?

❖ Picture of PF joint

❖ Causes of patella mal-tracking

❖ What can we actually change?

❖ Pressures on patella at different angles

❖ The knee is stuck between the foot/ground and hip

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Classification SystemKevin Wilk

❖ Compression

❖ Tension

❖ Instability

❖ Friction

Patella and Trochlear Groove Contact

❖ As flexion angle increases, the contact area moves from proximal to distal on the femur and from distal to proximal on the patella

❖ Femoral rotation creates increased PF contact pressures on the contralateral patellar facets

❖ Tibial rotation creates increased PF contact pressures on the ipsilateral patellar facets

Patellofemoral Biomechanics

❖ PF contact areas

❖ 0 degrees: patella above trochlea

❖ 10 deg: initial contact

❖ 90 deg: Increase contact from inferior pole towards superior pole

❖ 135 deg: “odd” facet contact

❖ any imbalance of contact and compression increases articular degeneration

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Trochlear Groove

Tight Gastroc Soleus

❖ If inflexible, may not allow for full ankle DF

❖ Results in compensatory increase in subtalar pronation

❖ Encouraging lateral tracking of the patella

PFP Treatment

❖ Improve flexibility in HS, hip flexors and IT Band

❖ Increase strength in glutes, hip rotators

❖ Balance and proprioceptive training

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Knee OA

❖ s/s: painful crepitus, deeper achy pain, edema

❖ stat on incidence of knee OA

❖ current medical treatments ie carticel, microfracture, hyalgen

❖ meds to assist

❖ when is it time to have TKA?

Knee OA Treatment

❖ need to find pain free ranges form strengthening

❖ tough patients as they are easy to flare up

❖ NSAIDs, hyalgen injections

❖ Activity modification

❖ Isometric Strengthening

❖ Assess footwear

IT Band Syndrome

❖ s/s: pain in lateral knee, thigh and/or hip

❖ Comes off the Tensor Fascia Latae

❖ attaches on Gerdy’s tubercle

❖ what is the role of the ITB?

❖ assess pelvic alignment

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Function of the IT Band

❖ As the knee flexes 30 degrees, its function changes from an extensor to a flexor

❖ The iliotibial tract helps prevent the pivot-shift

❖ In combination of the pelvic deltoid muscles, the ITB assists with LE postural control during gait

Thomas Test❖ easiest way to assess for IT Band tightness

ITB Syndrome Treatment

❖ stretching of restricted tissues

❖ medial patellar glides and tilts

❖ cross friction to distal and central ITB

❖ Quad strengthening and McConnell taping

❖ modalities: US, ionto with dexamethasone

❖ AIS rope stretches

❖ Foam Roller

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Hip Flexor Pathology

❖ s/s: anterior hip pain, groin pain, lower back pain

❖ beginning to think plays a huge roll in many lower quarter injuries

❖ hip flexor tightness puts increased strain on lower back and groin structures

❖ common in patients that sit a great deal at work or in car, golfers, hockey players, cyclists

❖ Origin: lateral surface of vertebral bodies T12 to L5

❖ Insertion: lesser trochanter

Thomas Test for Hip Flexor

❖ Iliopsoas vs Rectus Femoris

❖ If rectus, knee will be extended more

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Hip Flexor Treatment

❖ Check SI alignment

❖ #1 thing you can do is release the iliopsoas!!

❖ AIS stretches

❖ Foam Roller

Iliopsoas Release

Patellar Tendonitis

❖ s/s: anterior knee pain; tenderness to palpation of patellar tendon

❖ “Runner’s Knee” or “Jumper’s Knee”

❖ more chronic it is, the harder it is to treat

❖ can be very painful

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Patellar Tendonitis Treatment

❖ modalities: ice, US, ionto with dexamethasone

❖ cross friction massage

❖ Cho-pat strap

❖ biomechanical training (orthotics?)

❖ PRP injection ??

Meniscus Pathology

❖ s/s: catching or locking in the knee; joint line pain

❖ one of the only pathologies where I push for surgery

❖ loss of “brake pads”

❖ acute vs degenerative

❖ carry 50-60% of compressive load across the knee

❖ At 90 deg of flexion, load increases to 85%

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Meniscus Pathology❖ Medial meniscus is most oftenly injured because of its

adherence to the MCL

❖ With the foot planted, any direct blow to the lateral aspect of the knee can injure the MCL and medial meniscus

❖ Medial compartment takes greater weight bearing loads during gait which lends to having increased degeneration over time

Debridement vs. Repair

❖ If debrided, much quicker recovery but now patient is functioning on less than 100% brake pads.

❖ MUST let debridement heal up, scar over and get LE strength as maximal as possible.

❖ If repaired, what are the guidelines in regards to weight bearing? ROM?

❖ Prefer repair long term although return to activity is delayed

Debridement vs Repair

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Meniscus Injury Treatment

❖ Whether it is a meniscectomy or repair, be aware of the depth of squats!

❖ At 90 degrees of knee flexion, meniscus carries 85% of body weight

MCL Injuries

❖ s/s: pain over medial compartment, feeling of instability with valgus movement

❖ very rarely operated on!

❖ how many more times larger than LCL or ACL/PCL?

❖ a lot of times occurs in conjunction with other pathology

Grading Ligament Injuries

❖ Grade 1: <5-mm joint line opening with stress

❖ Grade 2: 5 to 10mm joint line opening with stress

❖ Grade 3: >10-mm joint line opening with stress

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MCL Injury Treatment

❖ #1: Protect the healing fibers!

❖ Road Runner Brace

❖ Strengthen quad/hamstrings/glutes

❖ Balance and proprioceptive training

❖ Limit valgus movements early on

❖ get controlled ROM early on

ACL Injuries❖ s/s: general knee pain; feeling of instability or giving way

with activities such as descending steps, running or walking

❖ operative vs non-operative treatment

❖ initial goals are to control edema, quad activation and restore normal knee ROM

ACL TreatmentNon-operative

❖ eliminate edema

❖ quad activation

❖ restore normal knee ROM

❖ Proprioceptive exercises

❖ Quad dominant knees can sometimes get away without an ACL depending on level of activity

❖ Need to be careful of potential arthritic changes

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ACL Surgery Options

ACL Reconstruction

❖ Hamstring Autograft

❖ Patellar autograft (ipsilateral/contralateral)

❖ Hamstring Allografts

❖ Patellar Tendon Allografts

❖ Achilles Tendon Allografts

❖ Single bundle vs Double Bundle

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Double Bundle ACL Reconstruction

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• Origin: Posterior medial aspect of the lateral

femoral condyle.

• Insertion: Anterior middle aspect of the tibial

plateau & anterior to the intercondylar

eminence.

• Action: Limits anterior translation and

internal rotation of the tibia in relation to the

femur.

The knee – Anterior Cruciate Ligament

Picture 1

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• An athletic or non-athletic related activity in

which the knee is forced into hyperextension and/or internal rotation may

result in an ACL tear.

Structure of the ACL

Picture 11

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• The ACL is referred to as one ligament

consisting of two bundles.

• Anteromedial Bundle – AM

• Posterolateral Bundle – PL

Structure of the ACL

Picture 12

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• Antromedial Bundle – AM

• Origin: Originates more anteriorly on the

tibia.

• Insertion: Inserts more medially on the

femur.

• Posterolateral Bundle – PL

• Origin: Posterior of the AM bundle on the tibia.

• Insertion: Inserts lateral of AM bundle on

the femor.

Structure of the ACL

Picture 13

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• Function of Bundles

• Extension

• Anteromedial Bundle – AM: Works in conjunction with PL bundle to resist anterior

displacement of tibia on the femur.

• Posterolateral Bundle – PL: Works in conjunction with AM bundle to resist

anterior displacement of tibia on the femur.

Structure of the ACL

Picture 14

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• Function of Bundles

• Flexion – Bundles cross in knee

flexion.

• Anteromedial Bundle – AM: Resists anterior

displacement of tibia on femur.

• Posterolateral Bundle – PL: Becomes loose in knee flexion to allow for rotation of the

knee.

Structure of the ACL

Picture 14

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• Double-Bundle Technique

1. Definition of the ACL as a ligament with two

functional bundles.

2. Anteromedial (AM) bundle accounts for

forward movement of the tibia under the

femur, while the postrolateral bundle controls rotational stability of the knee.

3. Identifies two origin and insertion sites of

the ACL with the DB surgery duplicating both sites.

Single-Bundle Technique

1.Definition of the ACL as a single ligament.

•ACL accounts to forward movement of the tibia under the femur, but does not fully

address complete rotational stability of the

knee.

•Identifies single origin and insertion site and

performs the surgery accordingly.

Surgical Procedures

Double-bundle vs single-bundle technique

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• Double-Bundle Technique

4. Reproduces an individual’s native anatomy.5. Patients report less pain and more stability

following DB surgery.

6. Decreased occurrence of arthritis.

7. More knee stability reported.

8. Normal range of motion.

Single-Bundle Technique

4.Does not reproduce an individual’s native anatomy.

•More patients report pain and less stability

following SB surgery.

•Increased occurrence of arthritis.

•Less knee stability reported.

•Range of motion can be compromised.

Surgical Procedures

Double-bundle vs single-bundle technique

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• The most popular ACL surgery in the United

Sates is the Single-Bundle Technique.

• The Single-Bundle Technique does not replicate the individual’s normal or “native” anatomy.

Surgical Procedures

surgery & graft sites

Single-Bundle Technique on the left. Double-

Bundle technique on the right.

Picture 35

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Surgical Procedures

Superior aspects of Double-bundle technique

Table 1

Post Operative ACL Protocol(no meniscus involvement)

Visit #1-2

Post op bandages removed

Patella Mobility

NMES Quad 15mins.

Heel slides ( disregard if HS graft is used)

SLR ( if able) without extensor lag

Standing weight shifts

Calf raises

TKE ( if able)

Cryotherapy

Goals: ROM 0-90 degrees

Gait with one crutch/no crutch by 2 weeks

Full extension in brace x 2 weeks.

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FYI-At this stage, edema is the biggest problem.

-Athlete needs to ice frequently and elevate knee.

-Continue with ankle pumps and quad sets for HEP.

-Extension is critical from the beginning, don’t focus too much on flexion at this point.

Weeks 2 & 3

NMES quad sets ( If needed)

Patella mobs (if needed)

Passive seated knee flexion ( NO ACTIVE knee extension)

Bike for ROM 10mins

Ankle PNF

TKE’s 2 x 20 4 Way SLR 2 x 10

Rebounder 2 x 30

Step up with TKE

Wall sit 2:30min (See Hurricane Series)

Sustained lunge ( See Hurricane Series)

Gait Training

Goals: ROM 0-110 degrees

No Crutch use

Unlock brace to appropriate ROM/ possible short runner

brace

Must be able to complete with correct form 4inch

anterior step down

FYI

-Gait Mechanics must be correct ( Locker Room

Walk)

-Use scales if necessary to monitor weight

distribution during wall sit.

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Weeks 4-7

Bike for exercise

Dynamic Warm-up ( see attachment)

Rebounder 3 way ( progress to Airex pad)

Complete Hurricane Isometric Series ( see attachment)

Hip Mini band ( See attachment)

BOSU step ups anterior/lateral

BOSU lunges anterior only

Medial step downs

Kettlebell Single leg RDL’s Kettlebell Plie Squats

Core strengthening( Plank, situps, crunches with a med ball….) AIS stretching ( hamstring, hip adduction)

Cross Friction massage to ITB ( if needed)

Prone passive knee flexion

Y balance testing ( week 6/7)

Goals: ROM 0-120 degrees

Normalized Gait

NO measurable edema

D/C brace by week 6 (MUST be able to complete 8” anterior stepdown)

FYIMonitor technique and compensatory patterns

during mini band exercises.

Challenge on bike for cardio exercise (3mile

bike test, 5 mile bike)

Monitor anterior knee pain.

May need to adjust mechanics for possible

tendonitis development.

Weeks 8-11

*****DANGER ZONE***** the highest incidence of re-tears occurs during

this time frame. At this point, the graft is at its weakest. Concurrently the

athlete feels secure with their knee and can sometimes do ill advised activities

that can compromise the integrity of the graft.

Continue previous exercises

Anterior sustained lunge on BOSU with up/downs :30hold/15lunges/:30 hold

Hurricane series with BW movements after isometric hold.

Walking DB lunges

Goblet squats

Friesen Squat Series ( See attachment)

Vertimax( if available)

TRX single leg strengthening ( see youtube video)

Interval bike sprints for cardio

Functional Movement Screen (FMS)

Goals: Full knee ROM

Comparable proprioception/balance btw L/R

Obtain Girth measurement 10cm/20cm above suprapatellar pole.

(<10% difference)

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FYINO running before 12 weeks.

This is a very frustrating time for both clinician

and athlete due to lack of progression.

However, this is the most important time to

continue strengthening, balance, proprioception

and core training.

Challenge core, cardio and upper body strength.

Weeks 12-16

Continue strengthening exercises increasing weight, reps, sets

Consider consult with Sport Psych if needed

Incorporate Metabolic workouts (High intensity circuit training)

EASY straight ahead jogging ( Treadmill ok)

Re-test Y-balance

Agility

oLateral slides

oCarioca

oLadder drills

oResisted Bungee drills

Plymetric Training

oDepth jumps

oBox jumps

oAlternating single leg deceleration lunges

oSquat jumps

oSkiers

FYI

Monitor closely varus/valgus movement during

plyometric training.

If girth measurement differences were > 10%,

alter training to incorporate lower reps/heavier

weight to encourage hypertrophy.

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Weeks 16+

Re-test FMS

Sport specific training

oComplete training in the setting of the

sport ( basketball court, soccer field)

OKC vs CKC for ACL

❖ during open chain active knee extension, the maximum stress on the ACL occurs at 20 degrees

❖ recent studies have stated that it is ok to do OKC strengthening for post op ACLs early on but......

❖ do we want single muscle firing or prefer closed chain for more functional strengthening??

Plasma Rich Platelet Injections

❖ More long term studies needed but PRP injections are promising in early studies

❖ Uses red blood cells from platelets that release growth factors

❖ Could help the body heal itself at a faster rate

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Restoring Immediate ROM and Strength

❖ Focus on restoring full knee extension asap

❖ Prevents scar tissue from forming and causing an extension block

❖ Edema can cause up to 20% deficit in quad activation

Restoring Immediate ROM and Strength

❖ Knee extension mobs

❖ Patellar Mobs

❖ Quad sets with NMES

❖ Resisted Ankle PNF

❖ Isometric Strengthening

Early LE Muscle Activation Exercises

❖ Quad sets with NMES

❖ Isometric Wall Sit

❖ Isometric Anterior Lunge

❖ Isometric Split Lunge

❖ Isometric Calf Raise

❖ Sidelying Hip Exercises

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Isometric Wall Sit

❖ up to 2:30 hold

Isometric Anterior Lunge

❖ 1:15 hold ea leg

Isometric Split Lunge

❖ :45 sec hold ea

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Isometric Calf Raise

❖ 2:00 hold

Sidelying Hip Exercises video

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Dynamic Warm Up

❖ Have to prepare the muscles, joints, ligaments, GTO’s for athletic movements.

❖ Static stretches just don’t get it and actually decrease power/speed output and effect athletic performance

❖ Maintain good posture and tightened core throughout

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Knee Hugs

Butt Kicks

Straight Leg March

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Leg Cradle

Inverted Toe Touch

Lunge with Overhead Reach

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Lunge with Opposite Reach

Lunge with Same Side Reach

Proprioceptive Training

❖ Critical for return to athletic movements

❖ Need to get all the muscles firing at the right time by stimulating the muscle spindles

❖ Stable vs Unstable Surface

❖ Eyes Open/Closed

❖ External Forces

❖ Vibration training

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LE Proprioceptive Exercises

❖ Single leg stance

❖ Star reaches

❖ Airex pads

❖ BOSU balls

❖ I joy

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Hip Activation Exercises

❖ Can hip weakness contribute to knee pain?

❖ From initial contact to midstance, the hip rotates internally

❖ External rotators must control this eccentrically

❖ If they are weak, will have excessive hip IR which functionally increases the Q-angle

Hip Activation Exercises

❖ Important to get the hip musculature activated prior to athletic participation

❖ Also important in assisting with control of the LE when moving in space

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Cowboy Walks

Lateral Slides

Charleston Video

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Standing Hip 3 Way

Bowler’s

Maintaining Tissue Mobility

❖ Whether there is a pathological injury or if due to excessive training, for efficient athletic movements you have to maintain normal tissue mobility

❖ Massage, foam roller, stick are all effective ways to accomplish this

❖ Sx of soft tissue adhesions include: decreased ROM, muscle weakness and pain, compensatory patterns and paresthesia.

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Massage

❖ Good for improving tissue mobility

❖ Improves edema flow

❖ Improves blood flow

Foam Roller IT Band

Foam Roller Quad/Hip Flexor

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Foam Roller Piriformis

Stick

Total Knee Rehab for the Athlete

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Mobile Bearing Knee

Rehab for the Total Knee Athlete

❖ As with all knees, emphasize edema control, patellar mobility, IT Band mobility, quad activation and extension ROM

❖ Once you get to the 8 week mark and all bony damage is healed up, you can turn up the intensity

❖ Need strong hip IR and ER and proprioception so the knee does not take the torsional stress

Return to Sport Training

❖ critical to train in all 3 planes to mimic return to sport

❖ reps, reps, reps

❖ footwork!

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Ladder Drills (video)

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Squat Series❖ 4-6 rounds with or without weight vest

❖ Sumo squats x 20

❖ Narrow Squats x 20

❖ Anterior Lunges x 10 ea

❖ Posterior Lunges x 10 ea

❖ Rotational Lunges x 10 ea

❖ RDLs x 10 ea

❖ Squat Jumps x 20

❖ Bowlers x 10 ea

❖ Step Ups x 10 ea

❖ Superman’s x 20

❖ 1:00 break

Advanced Exercises Videos

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questions?

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