Ankle Sprains: Muscle Function

Ankle Sprains and Muscle Function (Bullock-Saxton, 1994)

• Examines changes post-ankle injury by comparing patients with ankle injuries to a control group
• Increased joint pressure with capsule pinching decreases muscle activity
• Local sensory and proximal muscle changes correlate with severe ankle sprains
• Decreased vibration perception suggests ligament/capsular injury affects sensory receptor integrity on the injured side, potentially via direct damage
• Unilateral ACL injuries alter postural control compared to uninjured individuals
• The alterations might be due to central motor control adjustments
• Central adjustments involving delayed glute activation can occur post-ankle injuries
• Motor control impairments extend beyond the injured side
• Ankle joint injury diminishes the activity of hip extensors on both sides
• Reduced lower limb extensor activity can relate directly to the injury site and the opposite side of the body
• Gluteus maximus function during hip extension may remain compromised after ankle pain subsides, possibly from altered gait patterns during the injury period
• Rehabilitation should improve sensory functions given likely sensory function deficits associate with decreased muscle activity around other joints
• Muscles respond differently to peripheral injury, suggesting that the search for effects should extend to areas remote from the injury

Achilles Tendinopathy (Carcia et al., 2010)

• The Achilles tendon proximally is broad and flat, becoming more rounded distally
• Blood supply is greatest at the muscle-tendon junction and tendon-bone insertion, and least at the tendon's midpoint
• Risk factors include abnormal ankle dorsiflexion and subtalar joint ROM, decreased ankle plantar flexion strength, increased foot pronation, and abnormal tendon structure
• Medical conditions linked to Achilles tendinopathy include obesity, hypertension, hyperlipidemia, and diabetes
• Extrinsic risk factors encompass training errors, environmental factors, and faulty equipment
• Diagnosis involves self-reported localized pain and stiffness in the Achilles tendon following inactivity which lessens with activity
• Symptoms are frequently accompanied with Achilles tendon tenderness, a positive arc sign, and positive Royal London Hospital test
• Differentiate from other conditions if activity limitations or impairments of body function/structure don't align with this guideline
• Outcome measures should include validated functional assessments like Victorian Institute of Sport Assessment and Foot and Ankle Ability Measure
• When assessing functional limitations, measures can include walking ability, descending stairs, unilateral heel raises and the ability to hop
• One should consider measuring dorsiflexion range of motion, subtalar joint range of motion, plantar flexion strength and static arch height
• Eccentric loading should be used to decrease pain and improve function
• Low-level laser therapy can decrease pain and stiffness
• Iontophoresis with dexamethasone reduces pain and improves function
• Stretching exercises can be used to reduce pain and improve function
• Foot orthoses can reduce pain and modify ankle and foot kinematics during running
• Soft tissue mobilization as a manual therapy reduces pain and improves mobility and function
• Taping may be used to decrease strain on the Achilles tendon
• There's contradictory evidence regarding the use of heel lifts
• Night splints aren't more beneficial at reducing pain than eccentric exercises

The EdUReP Model for Tendinopathy (Davenport et al., 2005)

• EdUReP considers pathology at cellular, anatomical, and functional levels to reduce functional limitation/disability
  • tissue melioration
  • Educational Interventions, periods of tendon
  • Unloading and controlled
  • Reloading and implementation
  • Prevention strategies
• Tendon fascicles spiral from the myotendinous junction attaching to bone, increasing tendon strength during loading
  • Undifferentiated fibroblasts called "tenocytes'' are among the collagen fiber
• Tenocytes produce extracellular matrix components, like collagen, glycoproteins, and proteoglycans
• Tendinopathy symptoms may originate from a neurogenic process rather than active inflammation
  • High levels of tension or stress under chronic repetitive leads to sensory fiber stimulation and regional anoxia
  • Anoxia can trigger C-fiber activation, resulting in pain
• Goals of nonsurgical management
  • reverse disease progression
  • return the person to previous level of activity,
  • prevent disease recurrence
  • enable self-management
• Tendon Stage Scale
  • Healthy Tissue
    • Firm tendon, no pain to pressure, no swelling, normal temperature
  • Acute Tendinitis
    • Symptomatic degeneration with increased cellularity, vascular disruption, a minimal inflammatory repair response

Plantar Fasciitis and Heel Pain

• Plantar medial heel pain is most noticeable with initial steps after rest
• Heel pain worsens following prolonged weight bearing
• Heel pain precipitated by a recent increase in weight-bearing
• Pain with palpation/provocation plantar fascia insertion Positive windlass
• Negative testing for tarsal tunnel and peripheral nerve entrapment
• Negative testing suggests lumbopelvic, provocation of lumbar structures of the lower limb
• The Foot and Ankle Ability Measure is a useful self-report outcome
• Visual analog scale assesses pain with initial steps after inactivity
• Assess Active and passive talocrural dorsiflexion
• Test foot posture, lower-quarter musculoskeletal and biomechanical elements of gait via the following - First metatarsophalangeal joint range to 65° of extension at preswing - Rearfoot/talocalcaneal 4° to 6° of eversion at loading response - Tibialis posterior strength and movement coordination motion control at loading response - Fibularis longus strength and control motion at terminal stance - Talocrural dorsiflexion , accessory mobility, and gastrocnemius/soleus
• Therapeutic exercises
  • Plantar fascia and gastrocnemius/soleus stretching
• Manual therapy
  • Joint mobilization to improve LE, with an emphasis on improving TCJ DF
  • Soft tissue mobilization of the plantar fascia
  • Myofascial release
• Taping should include antipronation taping
• Pt Education
• Foot orthoses should provide medial arch support
  • Excessive pronation, demonstrate lower-quarter strength, respond to orthosis taping
    • Use an over-the-counter heel that provides cushion + strategies that incorporate heel cushioning
      • excessive supination and/or coexisting deficits
  • If appropriate night splints may be useful for 1-3 months
  • Physical agents - Application of iontophoresis and laser procedures where acute pain and other interventions are tolerated
• Targeted exercise
• Soft mobilization stretching Strength exercises, hip adduction, and lower limb rotation

Randomized Trial of Orthoses and Exercise for Tendon Dysfunction

• Subjects consisted of 36 adults w stage or II Tib.Post. Tendinopathy assigned to 12-week program of:
• Orthoses & stretching group
• Orthoses stretching & concentric assisted group
• orthoses stretching & eccentric assistive group
• Found Functional Index decreased in all groups after intervention OE subgroup improved in each subcategory and tolerated greater loading with less pain
• Individuals benefited from orthoses and stretching + resistive eccentric exercises increased endurance -Tendinopathy can be staged as:
  • Stage I mild swelling, medial ankle pain
  • Stage II progressive flattening of the arch/foot w ankle deformity
  • Stage 3 all stage 2 symptoms fixed tendon
• Stage 4 valgus tilt occurs from tibia degeneration
• Eccentric training may be useful to promote loading adaptation resistance loading performed within limits of pain and endurance
• Gastroc/Soleus stretching 3x/30sec via slant board
• horizontal adduction with plantarflexion (3x15 reps)
• Acute Lateral Sprain: Clinicians should recognize risk in individuals who have had sprains, not using external support, or warming up etc
• Following sprain, ankle instability develops in patients/w increased curvature and didn't perform balance exercises
• Acute Sprain diagnosed via level of laxity joint motion hemorrhaging
• Acute motion guidelines suggest the utilization of assistance along with progressive bearing on the affected area
• immobilizations reduce the risk for further pain for an immobilized area for recovery
  • After being stable one can use soft tissue mobility
• Cryo can reduce the need of pain/inflammation and medication post splint
• Rehabilitation programs should include specific exercises for severe lateral sprains

Knee Injury Prevention Tactics (Arundale et al., 2018)

• Clinicians should recommend use of exercise-based knee injury prevention programs in athletes for the prevention of knee and ACL injuries
• Use exercise-based programs that can be adapted to work for specific groups of athletes/coaches/parents
• Women used programs should incorporate multiple components to address strength and control during movements - Clinicians, coaches, parents, and athletes should encourage implementation w/ other coaches, medical, and practitioners

Exercise-Based Knee & ACL Prevention Programs

• To optimize numbers and prevent ACL or joint issues implementation of strategies should be implemented in ages 12-25 - Exercises led by trainers or coaches can reduce further joint or ACL risks and encourage a team

Knee Ligament Sprains and Early Motion

• Early mobilization, cryotherapy, and supervised rehab indicate the importance of early recovery from tears and pains - A therapist will implement ranges and exercises that will help you strengthen along side neuromuscular endurance

Meniscal Cartlidge

• Cartlidge rehabilitation/exercises require proper stimulation to have the recovery needed to have optimal pain reductions - Exercises can improve core movement and give confidence

Revision Notes on knee

• Knee function needs to be high and balanced/regulated limb functions
• Exercises can then start with hip adduction - Strength may be applied to all areas of the knee via function and weight adjustments
• Neuromuscular functions help knee mobility
• One should assess for injuries with balance, mobility and ligament conditions to help improve joint strength and reduce impairments

Knee Cartilage Care

• One should assess function, strength, and abilities over the course of care following knee rehabilitation - It also improves over time especially with exercise with knee and hip strength adjustments
• Following recovery, an emphasis on weight-bearing activity and range can improve function and balance with exercises
  • Early rehab can include early range activity
• Return to activity may include more exercises depending on the surgeon and recovery
• Clinicians can provide guidance based exercise and education to promote improvements with neuromuscular coordination and more

Exercise and Muscle Function

Exercise is more dominant vs TFL for rehabilitation,

TFL muscle is easier when the glut muscle needs more adjustments

• These tests are a way to assess for glut control

Health Care Considerations

• PFM contractions aide vaginally as it provides control and aide with better muscle contractions
• Pain assessment should guide outcome methods with assessment with questionnaires
• Belts can support the rehabilitation but exercises are needed for better management
• Assessments during sessions can help diagnose conditions and recommend better treatments
• PT can limit patients from overworking/pushing their bodies to the extent that recovery is limited

TR Protocol

One suggestion mentions that patients can directly access a PT without the need for a referral to see a specialist who is already booked out 4-6 weeks ahead of time. This can save time for patients as they don't need to wait to be seen by a specialist and can get started with physical therapy right away improving their outcomes and saving them time and money on medical procedures down the line. The key in making his work is that they can provide assistance in 72 hours after a direct contact call for a therapist/physician. The ultimate goal is to promote physician/therapy communication.

Managing Back Pain

One should consider that the cost of care and health reform has shifted, this means that value is more prioritized versus volume. It also indicates early access to treatment may reduce health care costs for back pain which is indicated

Yellow flags: Psych, Social, and Environmental

• Cleveland Clinic - Yellow Flag - STarT Back Screening (SBST) SBST - Patient scores indicate that the patient is at high value for prolonged treatment

One should screen and consider whether the patient has red or blue flags to assist in the course of treatment

• Flexion, Extension, Lateral
  • Mobility
  • Wellness etc

Pain is acute, subacute, less, or may reoccur

• Treat to limit current and future pain that may be associated
• Treat or refer out to avoid psychological pathology

Goal is to maintain activity level and pain assessment with some mobility

• Utilize manipulation and reduce disability + pain

Back Problems and Exercise

• Early Treatment in 72 hours shows more positive improvement versus just education Strength can be obtained with proper exercise and balance

• Early treatments can include = Mobilization manipulations = Strengthen = Traction = Directional preferences

• Moderate intensity is preferred versus low

Managing Back Pain in Terms of Activity

One should consider that the patient's symptoms are not resolving with impairments after treatment

• Validated assessments can help limit symptoms
• Routine is important to have a great affect
• It should be known that manual procedures reduce pain
• trunk cord strength improves recovery for disability and chronic pain in the body
• It is very important to set proper goals and educate the patient of the treatment and recovery process

Managing Fear with Back Injuries

• One should indicate the need for a patient's understanding of back strength and what activities can reduce pain
• Patients may have success and better outcomes when they feel they have a voice of approach to pain
• One is able to increase mobility and exercise with better coping mechanisms

Assessing PT Effectiveness

One idea explains whether receiving PT is more effective than usual routines. This states if you have acute LBP the therapy may assist however the progress may be limited to some regard. The goals with this program will be spinal manipulation and trunk to help assist with exercises

• Manipulation improves recovery for psychosocial factors that can relate to positive recovery success

Improving Pain Relief & PT

Treatment may improve pain relief for pt compared to other treatment plans One can measure is opioid prescriptions are filled and ER assistance received "PT shows reduction from early treatment

• Spontaneous recoveries occur with herniated disc after time with the aid of PT

Early treatment leads to proper mobilization and improvement

• Acute patients have less pain with early treatments
• Mobilization provides leg function and coordination