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Principles of athletic rehabilitation

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Power Point Presentation of the Priniciples of Athletic Rehabilitation

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Principles of athletic rehabilitation

  1. 1. Principles of Athletic Rehabilitation by Richard Blake, DPM San Francisco, California
  2. 2. Golden Rules to live or practice by These we do not ever want to break and they define our practices Like: Never Stretch Through Pain Hope this Talk either adds some or bolsters what you Know
  3. 3. Thank You!!! Greg Lawrence and His Committee OOLAB for their sponsorship
  4. 4. What do I want to present? 1. Crucial Phases of Rehabilitation 2. Maintaining the 0-2 Pain Level Throughout the Process 3. Three Types of Pain 4. What should be the basic aspects of your rehab? 5. KISS and Implied Need of the Injury 6. Correlation of Injury/Pain Syndrome to Biomechanics 7. Teamwork (Together Everyone Achieves More)
  5. 5. Important to learn Simple as well as Complex Treatments
  6. 6. Any Profession Tends to Throw Away Older Simpler and Get More Complex or Technical More Sophisticated or New does not always mean better I urge you to learn simple ways of treating something also as they will broaden your treatment options When to use OTC arch supports? When to tape, not brace? Developing good HEP over formal Physical Therapy?
  7. 7. Phases of Rehabilitation Phase I: Immobilization with Anti-Inflammatory Phase II: Re-Strengthening Phase III: Return to Activity Need to Create 0-2 Pain Level in Each Phase to Insure a Healing Environment In our attempt at 0-2, we get good at rehab!!
  8. 8. What does it mean to Immobilize? Unless you are dealing with a fragile system—torn tendons and ligaments or unstable fractures—Immobilization means creating that 0-2 pain level 24/7 by whatever skill set you have If you know how to modify boots, less time on crutches for example
  9. 9. Methods of Immobilization or Added Protection Crutches Canes Scooters Wheelchairs Removable Boots Off Loading Braces Activity Modification Taping Foot Orthotics Ankle Foot Orthotics Braces Padding Uber
  10. 10. Creating the Pain Free (0-2) Healing Environment This is how we learn what is needed and how to experiment This is how we decide if someone can get back to walking or running This is how we decide if a therapy is helpful For Student Athletes, with varying pain levels, it will be only if they limp that activities are curtailed
  11. 11. 3 Types of Pain being treated 1. Mechanical Pain—caused by mechanics, acute or overuse, and treated by mechanical changes 2. Inflammatory Pain—caused by poor mechanics, an injury, systemic, or combination, and treated with anti- inflammatory measures 3. Neuropathic Pain—caused by mechanics, chronic inflammation, or nerve injury, and treated with nerve treatments
  12. 12. What are mechanical changes that treat Mechanical Pain? 1. Immobilization 2. Off Weighting 3. Changing to a Better Position 4. Slow Down an Abnormal Motion 5. Strengthening the tissue at, above, and/or below 6. Stretching tight muscles in the area or those that effect the function
  13. 13. Example of Typical Mechanical Changes Utilized in Practice: Orthotics for Typical Plantar Fascial Heel Pain Orthotic Design: 1. Immobilize the Pull of the Plantar Fascia somewhat 2. Change the Position of the Pressure from the Painful Heel to the Arch 3. Slow Down the Motion of the Plantar Fascia which jerks the tissue at impact 4. Depending how pronated the foot, could also be changing into a better position of the heel to ankle alignment
  14. 14. What is the difference from treating Inflammation versus Irritated Nerves First of all, I consider Inflammation and Inflamed Nerves the same. The basic problem is inflammation. This is different from irritated or hypersensitive nerves. One third of these are numb, one third are painful and numb, and one third are just painful.
  15. 15. Treatment of Inflammation and Irritated Nerves can be somewhat the same or completely different. Inflammation is helped by prolonged icing 10-30 minutes, Irritated Nerves tolerate only 5 minutes of ice. Inflammation is helped by oral or topical NSAIDs, nerves normally not. Inflammation can be helped by deep tissue massage, irritated nerves like non-painful massage .
  16. 16. Inflammation tolerates prolonged stretching, irritated nerves like motion, and they do not like holding a stretch. Physical therapists tend to push through inflammation, but honor nerve pain.
  17. 17. Irritated nerves in general like warmth, motion, non-painful massage, Neuro-Eze, capsaicin, TENS, Quell, acupuncture, de-stress, meditation, hypnosis, biofeedback, Lyrica or other orals. In creating your 0-2 pain level for healing, this is how you learn what makes the patient feel better (do we get better results while we are treating with nerve or inflammatory treatments).
  18. 18. Important!! In any presentation, all 3 types of pain may be present that need separate treatments
  19. 19. Everyone Blends the 3 Phases Should start Strengthening as soon as you injure an area Five Basic Types: Active Range of Motion Isometrics Progressive Resistive Isotonic Functional
  20. 20. Need to Know When to Back Up Re-flares typically are not placed back on the Immobilization Phase when they should be They are usually last 4 days or 2 weeks, longer if you do not immobilize They are frustrating, but typically you are not starting over
  21. 21. Why are Re-flares Always Part of the Process It is a constant balance between 0-2 Pain Level maintenance and Return to Activity Levels Your Team of Patient, You, Physical Therapist, etc., may think they are ready for something, but they were not We are always dealing with driving the pain down to level 2, then maintaining it at 0-2, while increasing strength, activity, range of motion, cardio Sometimes it is just life and vacations that get in the way!!
  22. 22. 5 Forms of Strengthening Crucial Injury Specific Strengthening (use our 5 types of individual strengthening exercises) But there is also: Leg and Core General Programs Cardio Fitness Programs Cross Training Programs Sport Specific Programs
  23. 23. If you want to strengthen something, I love to isolate it Best Example: Getting a patient with PTTD on posterior tibial tendon strengthening is hard, since the tendon is not being isolated in most activities since the ankle is not plantar flexed Ankle to Plantarflex and Invert to isolate Posterior Tibial Tendon
  24. 24. What are the General Principles of Stretching? 1. 30 seconds or 5 deep breathes 2. No bouncing 3. No Pain 4. Vary the Positions of the Stretch 5. Before and After Exercise 6. Twice Daily to maintain your improvement, 3 to gain 7. Be in a Stable Position (it is not a balancing exercise)
  25. 25. Summary of the Basic Aspects of Athletic Rehabilitation 1. Progress patients through the 3 Phases of Rehab with typically monthly appointments 2. Create 0-2 Pain Level quickly in the first month (if you can not, then the diagnosis is incorrect, or your treatment must be missing something) 3. Begin Strengthening the injured area on day one, and the lower leg with cardio as soon as possible 4. Define your team early—the patient, you, physical therapist, orthopod, pain specialist— and make sure all reports to you, or just add as you go
  26. 26. Summary of the Basic Aspects of Athletic Rehabilitation (cont.) 5. See if Your Implied Need matches with the patient (may take a visit or two) 6. Begin at the first visit, and continue each visit, to look at the cause(s) of the injury—think 3-5 typically (this is where podiatry rocks!!!!) 7. Begin to correlate injury with possible biomechanical causes—pronation, supination, short leg, shock issues, weak or tight muscles
  27. 27. Implied Need Concept KISS (Keep It Simple Stupid) means that you are stupid if you make things more complicated than needs to be Yet, the concept of Implied Need, based on the patient’s concern or your experience, can help us a lot and avoid frustrations In our rushed lives, at times the patient under estimates the problem, or you under- or over- estimate the problem
  28. 28. Implied Needs Part of the rehab, since it can greatly affect whatever protocol is in place by you or your staff Implied Need Error #1 —The patient has simple blister in arch, non painful, no urgency expressed, you however knowing the patient is a diabetic are worried of a fracture blister in Charcot foot (huge need to treat) You over treat in the patient’s eyes Have to err in treating the worse possible problem Implied Need Error #2 —The patient has unbearable pain (8-10) with no swelling (huge implied need to treat), you treat as simple pressure problem and tell them to get wider shoes (KISS missed CRPS). You under treat in the patient’s eyes
  29. 29. Rule of 3 Correlation of Injury to Possible Causes is Where Podiatry Rocks (not including overuse as a cause) Rule of 3: 3 Possible Causes should be looked for in every case For Example: Patient presents with posterior tibial shin splints along the medial border of the tibia—the 3 causes found over the next 5 visits were over- pronation helped with OTC inserts with varus wedges, low Vit D with normal bone density, and weak posterior tibial and soleus muscles which attach there.
  30. 30. Correlate Biomechanical Faults with Injuries/Pain Syndromes PRONATION SUPINATION SHORT LEG SYNDROME POOR SHOCK ABSORPTION TIGHT MUSCLES/TENDONS WEAK MUSCLES DEFORMITIES LIKE PLANTAR FLEXED FIRST RAY
  31. 31. TEAMWORK Share the fun and stress!!!
  32. 32. Thank You!!

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