Rehab after an Ankle Sprain

Ankle Sprain Rehab

Ankle sprains are very common and occur across all sports and frankly, across all walks of life.  Almost 80% of ankle sprains are of the “inversion” nature.  Inversion is basically the motion when you “roll” your ankle.  We see people that roll their ankle off of a curb or out in the yard as much as we see athletes who land awkwardly from a rebound or struggle to plant correctly in a soccer game.  The expert sports physical therapists at SSOR are here to help you get back quickly and safely from an ankle sprain.  So let’s talk about the how’s and why’s of this injury.

What gets injured?

Depending on the severity of the sprain, the most common ligament injured is the anterior talo-fibular ligament.  With more severe sprains, the calcaneofibular ligament gets sprained as well.   It is worth noting that you can also suffer a “high ankle sprain” or syndesmotic sprain.  These are a little different that your typical rolled ankle and we’ll chat about them in a different post.

What is the cause of ankle sprains?

Most inversion ankle sprains occur when you “roll” the ankle some way, like we described above.  As a result, there is lots of pain and often an inability to walk without a limp.

Do you need X-rays after an ankle sprain?

Ankle sprains are an injury that get way too many X-rays.  Granted, it’s good to be cautious, but many people sit for hours in an emergency room waiting for an X-ray that many times is unnecessary.  The Ottawa Ankle Rules are a reliable method of determining if an X-ray is necessary.  In general, if you are able to walk, even if it’s a little painful, there is likely not a break.  Plus, there are specific bony spots that are exquisitely point tender that may indicate a fracture.  Try coming to see one of our physical therapists first before you sit in the ER for hours.  It’s great – in Kansas, you can see a physical therapist without a physician referral.

Should I use crutches?

Maybe.  If you are limping around, then you should.  Limping creates more problems and delays proper healing.  You may not need two crutches, one may do the trick.  The key is no limping.  FYI – if you use one crutch, it should go on the OPPOSITE side of your injury! Yes, it’s true.  Confusing?  Think of it this way – the door handle is always far away from the hinges.  Same concept.

Do I need rehab?

You may think we’re a little biased, but this is a resounding YES!  Without rehab, the ligament heals improperly, you won’t have your full strength and balance, and may not even get your full motion back.  Even a few visits to learn the best exercises are a good idea.  The problem is that 70% of people who have an ankle sprain develop chronic ankle instability.  Chronic ankle instability can really limit even daily activities, let alone recreational ones.  People with chronic ankle instability sometimes have trouble rolling their ankle randomly or even walking in the house.

Physical Therapy after an Ankle Sprain

Rehab after an ankle sprain depends on the severity.  Early on, you must control pain and swelling.  Therefore, compressive dressings, ice, rest, and elevation are a good starting point.  As stated above, you may need crutches/crutch/cane to help normalize your gait.  That said, here’s some critical things you need to make sure are addressed in physical therapy:

  1.  Range of motion exercises.  You should start with just dorsiflexion and plantarflexion first (pointing toes down/up).  Once that motion returns, then begin side-to-side.   Doing side to side motion too early may stretch out the healing ligament.
  2. Strengthening exercises for the ankle muscles.
  3. Hip strengthening.  Many physical therapists miss this critical aspect of ankle sprain rehab.  Multiple studies have shown a delay in muscle activation and weakness immediately after an ankle sprain.  You have to do exercises to strengthen the gluteals.
  4. Balance exercises.  Once a ligament is damaged, the proprioceptors on the ligament which tell your brain about balance, are impaired and need to be re-trained.
  5. Manual therapy/mobilizations to the ankle.  There are a few critical mobilizations that your physical therapist should do to restore ankle mobility.  Many fail to do this resulting in long-term deficits and recurrent sprains.
  6. Progression to functional activities.  At SSOR, we have a specific, detailed progression on return to impact and running activities.  Walking pain free is not enough.  You need to be progressed from activities that are front/back, side-to-side or lateral, then twisting motions and you should be taken through a functional testing progression as well to determine physical readiness.

Ankle sprains are painful and can severely restrict functional capabilities.  What is more, not properly treating them increases your risk of re-injury almost by 20x that of those that haven’t had one!  Physical therapy is critical, even for a few visits, after an ankle sprain to help avoid these from happening again.  Let the sports rehab experts at SSOR help you get back on your feet and back to life.  It would be a privilege to serve you and partner with you in your care.  We have locations in Overland Park and Prairie Village to serve you.

Pre-Operative Exercises for Knee Surgery

Should You Do Pre-Operative Rehab Before Knee Surgery?

We see many people before knee surgery for what we like to call “prehab,” or rehab exercises to prepare you for surgery.  There is evidence to support better outcomes in those that do physical therapy and/or exercises before knee surgeries like ACL reconstruction or total knee replacement.  Improving range of motion and increasing strength of the quadriceps and supporting hip muscles has been shown to help hasten recovery of both gait and function.  Unfortunately for many of our patients, they have limited insurance visits.  Therefore, we want to maximize the amount of time we can keep them and supervise their progress and assist them in return to activities.  As a result, we often only see people for a visit or two prior to surgery to show them a home program to do until surgery.  So what should we do about pre-operative exercises before knee surgery?

In the case of ACL reconstructions, a  classic 1995 study by Cosgarea et al in the American Journal of Sports Medicine tells us that basically 4 things should be achieved prior to having an ACL reconstruction.  There are other papers supporting pre-operative exercises here, and here, and one paper shows that it predicts function up to two years later.  The pre-operative exercises should achieve the following goals:

  1.  Minimal to no swelling.  You have to get the swelling out of there as much as possible.  The swelling is the principal reason why you should wait to have surgery – the knee is already “angry” from the injury and to make it more angry by operating can cause more pain and possibly more dysfunction from stiffness post-operatively.  Depending on the severity of the injury, there may be a point where you’ve maximized how much you’ll actually get out of it.  Ice, as much rest as possible, elevation, and compression are all ways to reduce swelling.
  2. Get at least 120° of knee flexion.  It’s hard to know for sure how much this actually is unless a physical therapist measures you, but basically get as much bending as possible.  Research has shown that if you achieve 120° of knee flexion pre-op, your risk of knee stiffness, known as arthrofibrosis, is much less.  Riding an exercise bike, deep water jogging in the pool, or heel slides (Figure 1) are all good ways to do this.
  3. Get your leg as straight as possible.  Much like knee bending, you want your knee to be as straight as possible.  If you have a meniscus tear or an ACL tear, the tear may restrict this and extension could be very very painful.  Do the best you can to get it straight.  Heel hangs are a great way to do this (Figure 2).
  4. Maximize your quadriceps function by being able to do a straight leg raise.  A straight leg raise (Figure 3) is a fundamental exercise post-op because if you can do it, you’ll be able to walk without a brace and you have “minimum” quad function.  You have to be picky with this though – it can’t be a “bent knee raise.”  We’re really particular about this exercise at SSOR, so check with us if you aren’t sure.  If you try and do one and can’t keep your knee straight, quad sets (Figure 4) are a good place to start. Roll a towel up and place it under your knee and just push the back of your knee into the towel roll.  A physical therapist can also put you on a muscle stimulator to help facilitate this.

Pre-Operative Exercises before Total Knee Replacement

Truthfully, the above are great guidelines for any knee surgery.   In the case of exercises before total knee replacement surgery, the evidence supports doing pre-operative exercises for those having a total knee replacement.  As this systematic review shows, pre-operative exercises may also reduce costs and length of hospital stay. However, there is evidence saying pre-operative exercises are not effective, but in our experience, improved motion and strength prior to surgery leaves you with a better starting point after your total knee replacement.   In addition to the goals stated above for pre-operative ACL surgery, other exercises may include hip strengthening, stretching, and balance activities.  The three main issues long-term after total knee replacement are declining quadriceps strength, loss of motion, and decreasing balance.  Those three items are heavily emphasized at SSOR both pre- and post-op to maximize function.

If you’re on track to have ACL reconstruction or a total knee replacement, it would be a privilege to partner with you in your care.  Give us a call if you need exercises before knee surgery to help maximize your outcome post-operatively and put yourself in the best position to succeed.  We have locations in Overland Park and Prairie Village to serve you.

Figure 1: Heel slides with sheet for range of motion

 

 

Figure 2: Heel Hangs

 

 

Figure 3: Straight Leg Raise

 

 

Figure 4: Quadriceps setting exercise

How to Squat Properly

Learn How to Squat Correctly

If there was one exercise that all people need to perfect is the squat – athletes or not.  We’re not necessarily talking about putting a bar on your back and doing maximal effort squats.  We’re alluding to simply performing sit to stand from a chair, or getting on/off the toilet with proper squat technique.  That said, so many compensatory patterns and muscle substitutions take place from the ankle to the trunk.  This is one of the first things we look at during a physical therapy evaluation, and you may not even know it, but we’re looking the minute we see you in the waiting room.  Watching you get up from the chair is the first clue as to how you are performing this activity.  We almost immediately have an opportunity to help you or your loved one before we’ve even talked!  There are many reasons that poor squat form can occur – lack of mobility in the hips, knees, or ankles or lack of stability in the core region. Figures 1 and 2 show some poor squat form because of these areas.  Figure 1 shows the subject leaning forward, and Figure 2 shows the heels elevated.  In figure 3, the subjects knees are collapsed in and the feet are turned out.  You may have one or all of these regions causing you to not perform a proper squat.   We can help you determine which areas are the sources of your dysfunction.  The purpose of this blog post is to talk about some ways to perform a proper squat movement to not only help improve function, young or old, but for the active patient, provide a foundation for more advanced leg strengthening.  The squat is not only a basic tenet of movement in general, but also part of a strengthening program.  The body weight squat should be perfected prior to adding external resistance.

 

 

Figure 1:  Poor squat form, trunk leaned forward

 

Figure 2: Poor squat, heels off ground

Figure 3: Knees collapsed inward, toes pointed out

Reasons for Poor Squat Form

Are you Figure 1?  If you look more like figure 1 with a forward trunk lean and not so great depth, more than likely you have tight hips and/or core and hip weakness.  Both are easy fixes!

Are you Figure 2? You may have both of Figure 1 deficits, but if your heels are coming up, you may have tight calves or an ankle mobility restriction.  Perhaps you had a previous ankle/foot surgery and your mobility has been affected?  We can figure that out in an evaluation.

 

Are you Figure 3?  If you’re figure 3, more than likely you have some or all of the deficits in figures 1 and 2!

Key Aspects of a Proper Squat

First of all, see Figure 4 for good squat form.  The feet are slightly more than shoulder width apart, the trunk is leaned forward, the head is up, the trunk is parallel with the “shin” bones.  The curve in the low back is maintained.  Many people struggle with achieving these basic points.   Sometimes it’s a MOBILITY problem why we can’t get there.  Perhaps with arthritic aging joints or tightness in muscles from sitting in front of a computer all day, you may not be able to get in that position.  Conversely, you may have a STABILITY problem.  We know this by watching you squat by yourself, then having you repeat it while we hold your hands, supporting you.  If you increase your depth and your form improves, we know that you’re using us for stability.  Therefore, we know our targeted interventions here will focus on hip and core stability training.

Figure 4: Proper Squat Form

 

Exercises to Improve Your Squat

In figure 5, you’ll see the subject holding on to a cable attached to a weighted stack.  Basically, what this provides the subject is some stability as they descend.  Usually, people stop their descent with the squat because any lower, they will fall back.  You can confirm this by getting to the bottom of the squat and then letting go of the cable – if you fall backward, you are the ideal person to need this!  As you get better at this, you can release one hand, try and hold on less, or get to the bottom and pause without holding on.  If you don’t have a cable or are teaching this to a relative at home, any immovable object that the person can hold on to will work.  Exercises to strengthen your core and hip muscles should compliment this activity however.  One of our physical therapists can show you a comprehensive program to address this. Maintaining proper form and posture is paramount when you do this though.

Figure 5: Assisted squat, using a cable

In figure 6, you’ll see the subject’s feet are elevated.   This is actually a way to help someone squat with tight calves or lack of ankle mobility from joint or soft tissue restrictions.  Again, these issues can be addressed in physical therapy.   However, this method is also good because by virtue of shifting weight to the toes, the hips have to go backward – equal and opposite reaction.  As you improve, you can either lower the height your heels are elevated or use nothing at all.  The elevation of the heels effectively acts as a “buffer” or “buys you time” until ankle or soft tissue mobility is restored in physical therapy.  We don’t let people cheat, but this is a way to let you cheat until you have the mobility and control you need.

Figure 6: Assisted squat, heels elevated

Hopefully, these tips help you perform a proper squat.  You can use these tips to teach a child or an elderly relative how to perform a proper squat.  It would be a privilege to partner with you in your care.  Remember, you can see a physical therapist in Kansas without a physician referral.  Give us call!  We have locations in Overland Park and Prairie Village to serve you.

 

SSOR Serves Olathe, KS

Physical Therapy in Olathe, KS

SSOR has earned the confidence of both Overland Park and Prairie Village that we are the physical therapy provider of choice in these communities.  We are privileged to have patients come see us from as far as Topeka, KS and Warrensburg, MO too.  Did you know that we also serve the residents of Olathe, KS too?

SSOR in Overland Park is only about 5 miles from Olathe, KS!

 

The staff at the Overland Park location has many services including:

Check out what a recent patient from Olathe, KS had to say about her treatment at SSOR:

“This place is awesome !!! They have a highly knowledgeable and friendly staff that is down to earth and genuinely cares about you!

My first experience was working with them two years ago on a herniated disc in my lower back. I had worked with other trainers for about two month previously with no results and I don’t think I would have ever made much progress if I hadn’t came to these guys.

My second experience was with rehabbing a labral tear in my shoulder this spring. I had been discouraged about whether or not I could see any results from consultation from other athletic trainers but, these guys encouraged me, got me back on track, and got me back on to workouts on my own in a very timely manner.

Overall they aren’t going to try to get you to come in more than you need to or hit you with any hidden or extra charges. From my experience they want to get you better and back out as quick as healthily possible.

I give a special thanks to Curtis and the rest of the Staff. Keep doing great work and thanks for all the help.”

-Wyatt Melton, Olathe

 

It would be a privilege to serve you and partner with you in your care.  Remember, you can see a PT in Kansas without a physician referral.  Give us a call, we welcome the opportunity to help you achieve your goals.

Did you know SSOR serves Mission, KS too?

Physical Therapy in Mission, KS

SSOR has worked very hard to earn a solid reputation as the physical therapy provider of choice in Overland Park and Prairie Village.  We draw from several other communities as well however.  Did you know that SSOR Prairie Village is just minutes away from Mission, KS?

The staff at the Prairie Village location has many services including:

Our newest location is just 5 miles away from Mission, KS!

 

Check out what a recent patient from Mission, KS had to say about her treatment at SSOR:

Jamie Martens of  Mission, KS writes: ” I started seeing John Smith at SSORKC in November of 2013 after battling back, hip, and leg pain for over a year. A radiologist’s read of a hip MRI conducted in December 2012 indicated no structural damage. I am very active and participate in softball, flag football, basketball, running, and cycling. I had just finished competing at the National Duathlon Championships and qualified for Worlds 2014 but finally admitted I needed help with the pain. John worked with me for over 8 weeks and recognized that something wasn’t right and urged me to see a hip specialist. After consulting with 3 orthopedic surgeons, John’s suspicion was confirmed – torn labrum of the right hip (radiologist missed that in the December 2012 MRI). Surgery was scheduled for January 24, 2014 and John continued working with me right up to surgery. Five days after surgery, I resumed seeing John with the goal of competing at the National Duathlon Championships on July 19 in order to hopefully qualify for Wolds 2015 since I had to miss the Worlds in 2014. Plus, John knows that I want to return to all my other sports and tailored my physical therapy toward those goals. I recently had a 4-month post-op evaluation with John and because of the personal training program he provided, I passed with flying colors! I would highly recommend John Smith and SSORKC. Their personal attention is invaluable and has me back to doing the things I love.”

 

As you can see, our patients expect and demand results quickly.  We have a very goal-oriented population at SSOR.  Whether you want to compete in multi-sport events like the testimonial above or just being able to play with your grandkids without pain, the physical therapists at SSOR can help.  It would be a privilege to partner with you in your care.  Give us a call!  Remember, you can see a physical therapist in Kansas without a physician referral.

Things We Learned in 2015

Top 6 Things We Learned in the Clinic This Year

As 2015 comes to a close, we reflected on what we’ve learned this year or how our practice has evolved or changed. Physical therapy is such an awesome profession because it is constantly changing. New research modifies or changes what we do, new treatments surface that provide new “tools” for us to use, and as always, we go home on any given day learning something new from our patients. Our treatment philosophy is derived from Dr. David Sackett, the father of evidence-based medicine. He advocated the best clinical practice being a combination of using the best available evidence in the literature, clinical experience/expertise, and patient values to formulate the optimal treatment plan. With that in mind, in no particular order, here’s some things we learned in 2015 that stuck out to the PT staff here at SSOR:

top-5-things-we-learned-this-week-300x194

1. Two patients can present with the same diagnosis, but have a very different treatment approach. This one is almost a given almost every year. Shoot, almost everyday! Our patients are not “cookie cutters.” Every patient has different needs, interests, past medical histories, comorbidities, etc that make them unique. As a result, an individualized approach must be taken. We believe this not only gets a good physical therapy outcome, but also makes our patients most happy because their needs and interests are most important.

2. There’s something to dry needling. Our staff took the Level 1 course this past August and we’re about to take Level 2 in January. We made a promise to each other that we wouldn’t be just randomly sticking people with no rhyme or reason to it. While there isn’t a lot of research yet on it and we’re not entirely sure what the mechanism is, for the right patient, it’s a nice adjunct to our normal approach. Like anything else, dry needling is a tool. It is not the only thing we do nor is it central to our approach. However, it clearly is helping specific populations. Dry needling is definitely one of those treatments that fits the “clinical experience/expertise” facet of the three-pronged approach mentioned above. It will be interesting to see what the research shows us in the coming years.

3. We continue to get great results with instrument-assisted soft tissue work. We have lots of instruments at our disposal here. Most people refer to them all as “Graston” as it has become the “trade name” that most people refer to. However, the concepts are still the same regardless of what brand or device we use. The instruments are used to break up adhesions and improve soft tissue quality. They just do a better job than our fingertips and hands can sometimes. Again, we’re not entirely sure what the actual mechanism is, but these tools are enhancing our ability to help our patients reduce pain and move better.

4. Educating patients about their pain and how pain works is very important. We took a course on teaching patients about pain a couple of years ago. Pain is really the main reason people come to see us, regardless of body part. We spend a lot of time with each patient teaching them how pain works, what is “good” vs. “bad” pain, and how our bodies and brains interpret pain. We have found that educating patients about this has not only reduced anxiety about physical therapy, but also significantly impacted their daily lives by understanding how pain works.

5. We’re realizing more and more how important it is to treat the whole person. While this sounds intuitive, we continue to learn how vital it is to talk to patients about their sleep patterns, how pain works, how to manage stress, how to modify activities to stay active and work around their conditions, and how to best make it through their day with as little pain and discomfort as possible. Everyone has work-related and/or family stress, anxiety, and worry about their prognosis and future. Addressing all of these things to the best of our knowledge and ability truly encompasses the most comprehensive and well-rounded approach to maximize our patients outcomes.

6. Patient self-referral continues to be highly utilized, and patients love it! A significant percentage of our patients come to our facility “off the street.” People like how fast we get them in and get them going on a treatment plan to get them back to the activities they enjoy. They appreciate how up front we are about results here – we know what we’re doing, so if you’re not significantly better in 2-4 visits, we’re going to send you to the doctor or adjust our treatment plan accordingly. Getting PT for 3 months with no results is just not in our vernacular here. Plus, people are tired of getting medications and potentially needless X-rays and MRI’s. They want solutions, not band-aids. Physical therapists can provide those solutions and we’re doing it very effectively.

We’re fired up for 2016 to keep growing as professionals and to keep learning from our patients and each other. No doubt, we’re blessed to be physical therapists and have the privilege of helping people live their lives to their best ability. Physical therapy is the greatest profession out there. We look forward to serving our patients in 2016 and partnering with them in their care. Thanks 2015 for all you taught us, and 2016, we can’t wait to learn what you’ll teach us!

“Home Gym” for Senior Citizens

Home Fitness Equipment for Seniors

Mom and/or Dad needs a home gym.  What should I buy?

We had some questions recently about what “home gym” equipment people might get for an elderly parent, grandparent, or relative.  Whether it’s to stay in shape and active or to prevent physical decline, there’s lots of stuff you can get.  Many of the common things that most people use or purchase just aren’t necessary or aren’t safe for older folks though.  Here’s a short list of some things you might consider getting them set up with. Of course, some of this is determined by your space and budget needs.

First of all, it’s important to talk about the main things that affect older adults.  As we age, we tend to get weaker, stiffer/tighter, lose balance, and lose cardiovascular conditioning.  Therefore, our home gym should focus on those things.

Home Gym for Older Relatives

  1. Bike or recumbent stepper. A bike is a great way to keep old joints moving and keep up the cardio without the impact loading of treadmills, upright steppers, ellipticals, etc.  A stepper might be a good idea for a relative with osteoporosis because it allows some weight-bearing to help facilitate bone growth.  There’s lots of refurbished or used equipment out there if budget is a concern.  Choosing an upright or a recumbent or upright bike is a personal preference, but if safety is a concern, recumbent bike is the choice for you.  With all of these, there is a wide array of prices with assorted “bells and whistles.”  Truth be told, most of that stuff just isn’t necessary.  Need an “On” button, some resistance, and a timer.  Good to go!! stepper
  2. Ankle weights and a set of light dumbbells. There are lots of choices of dumbbells and these “space saver” cuff weights.  We suggest getting a set of 1-10 lbs.  Grandma and grandpa have the ability to get stronger just like the rest of us, it just takes more time to do it.  Can’t be afraid to lift an extra pound or two provided they have good form while performing the exercises.  For most exercises, these are better choices than elastic bands are because the resistance with the bands is highest at the end ranges of motion.  At this position, their muscles are at risk for injury. With cuff weights and dumbbells, the resistance is consistent.  However, bands are consistent and are great tools that can be taken anywhere.  Just start with the lightest resistance you can get and work up from there.
  3. A stretch strap. This is an easy way for your older relative to do some stretching without having someone help them.  There are lots of stretching exercises you can find online with this strap. Keep in mind, not all of them are appropriate.  Might want to review these with a physical therapist. Don’t like that idea? Get a video on Yoga poses for older adults or Tai Chi exercises. stretch
  4. A mat if they can get on/off the floor safely OR a table of some kind. Mats are cheap, but getting on/off the floor can be trouble for an older person.  A bed or a couch isn’t a great choice because it’s not a firm surface to push from.  A treatment table used in physical therapy can be about 4-500$, or if you have more money to invest, a mat table is a good choice.  You can get away with a used massage table too.  table

Other “home remedies” to use:

  1. A chair to do squats with.province-active-gardening-chair-squat
  2. Steps to do step-up exercise for leg strengthening.
  3. Can’t afford dumbbells? Cans of soup work pretty well! soup cans
  4. A closed door or a wall to do push-ups from.wall_push_up

It would be a privilege to help your loved one get back on their feet after an injury or to help them avoid physical decline.  We know how to be progressive, but safe at the same time. Give us a call! We have locations in Overland Park and Prairie Village to serve you.

“Must Do’s” After ACL Surgery

ACL Surgery and ACL Rehab

It’s hard to watch a sporting event anymore without seeing or hearing an athlete tore his or her ACL.  U.S. Women’s National soccer player Megan Rapinoe is one of late that tore her ACL.  Rehab after anterior cruciate ligament (ACL) surgery is a long, arduous process that takes several months.   Unfortunately, the internet is a sea of misinformation on what to do/not to do.  It’s littered with various experts, horror stories, and various pundits who all have a different take, which adds to confusion.  Complicating matters further is that everyone seems to want to base outcomes on a professional athlete’s outcomes, or be married to the idea that it has to be a specific time frame, commonly 6 months, prior to return to sport after ACL surgery.  Your ACL rehab should be a collaboration with you, your operating surgeon, and your sports physical therapist.  The purpose of this blog is to emphasize a list of 10 things that must be addressed in your ACL rehab.

ACL tear

Rehab after ACL Surgery:

  1.  Get your knee as straight as possible as soon as possible.  This is critical for proper muscle function as well as normal walking, and for you athletes, running eventually.  Studies have found as little as a 3° loss of extension adversely affects function, so make sure this is a priority.  Furthermore, Paulos et al showed us in the 80’s in a study in the American Journal of Sports Medicine that scar tissue can form in the joint if you don’t get it straight quickly.
  2. Get your quad muscle working.  In order to walk, it is imperative that your quads work correctly.  These are the muscles on the front of your thigh.   These are the muscles you contract when you stretch in the morning and extend your knees.  As soon as you are able after surgery, you should start “setting” the muscle with brief contractions to get it firing. Think of it almost like a heart beating.  A nice tool to help with this is a muscle stimulation.  Multiple studies have shown that muscle stimulation on the quads helps subjects improve gait and quad functioning than those that don’t.
  3. Maximize your bending as much as your physician allows.  Try not to let that knee get too stiff.  Doing either heel slides, sitting at the edge of the bed, or using a bike for range of motion only are some ways you could do it.  Your doctor may get you a Continuous Passive Motion (CPM) machine but studies show it is not required.
  4. Use crutches until you are walking completely normal!  This one is huge.  Amazingly, many physicians tell people to ditch the crutches and then watch them walk out of the office limping.  This may be my biggest pet peeve with physicians.  All eliminating the crutches does is keep your knee swollen, inhibit your quad, and delay your recovery.  Even if you don’t need two crutches, use one on the opposite side of the surgery (yes, the OPPOSITE side) or even a cane until you are walking completely normal.  Trust us – you’ll thank us later.
  5. Focus on single-leg emphasized training.  Several studies have shown that after ACL reconstruction, subjects unconsciously unload their involved leg up to a year after surgery doing squats on both legs (Neitzel et al, Clin Biomech 2002).  Furthermore, they even unload their leg two years after surgery when landing from a box to floor jump (Paterno et al, JOSPT; Chmielewski et al, JOSPT).  So, even though you think you’re symmetrically distributing weight, you are really not.  Therefore, you should focus your training on single leg movements for most of your rehab.  Lunges, step ups, step downs, leg press, and single leg squats should be the focus of your training.  Once you transition to plyometrics/jumping activities, the focus there should also be on single leg movements.  Eventually, to maximize strength, you’ll need to transition to double-leg activities, but only after your sports physical therapist has determined your readiness.
  6.  You must get your thigh muscle mass no more than 1 cm difference than your non-injured leg.  Many people who have chronic trouble with their involved leg long after surgery is often due to not getting their quad mass back.  Persistent pain, swelling, and dysfunction ultimately affect their function.  Many physical therapists fail to actually measure thigh mass throughout the course of rehab.  An analogy is having no shocks on a car, or having half inflated tires.  What do you think would happen with either of these scenarios?  The car would break down faster and have problems.  Well, your knee is no different.  This may take a year or so after surgery to get back, but someone should keep checking.
  7. What you do in front, you need to do in back.  In real estate circles, people talk about “curb appeal.”  Make the house look nice in front – new paint, trimmed bushes, a nice freshly cut lawn.  Then you look at the backyard.  May be a disaster.  The focus on making the thigh muscle bigger neglects the critical hamstrings.  For the recovering athlete with an ACL reconstruction, your hamstrings are your best friend.  They are the “brakes” that limit the risk of the ACL being torn.  Therefore, make sure you do lots of stiff leg deadlifts, exercise ball bridges, ball curls, leg curls, and eccentric hamstring lowers.
  8. You have two legs, balance training needs to be on both legs.  Humans are a bipedal species – we walk and run on both feet.  Balance after an ACL reconstruction is impaired and needs to be a focus of your rehab.  Further, once you have one ACL tear, you are at risk to do the other.  Why on earth would you only do balance work on one leg?  The other one will get jealous for one, and two, why would you possibly set up your “good” one to be a “bad” one and risk a tear in it by not working on balance for that leg too. Therefore, what you do on one, do on the other.  Speaking of balance, if the only balance exercise you do is throwing a ball at a mini-trampoline while standing on unstable surfaces, it’s time to look for a new physical therapist.
  9. Get your heel to your butt!   This is critical for people that want to play sports again.  When you run, your heel needs to get all the way to your glutes to sprint correctly.  Many athletes get their “active” range of motion back (what they can do), but lack the “passive” range.  The passive range is the “extra” range when you pull.  This is illustrated when you stretch your quads.  If you lift your heel up to try and touch your glute, it can’t get all the way up.   That’s the active range.  When you grab your foot and pull it up to your glute, that’s the passive part – the “leftover” slack.  You have to have that to run right.  If not, you won’t be as fast, and you’re at risk for hamstring strains.  There are many techniques to get this back, and it’s more than just cranking on it till it gets there.   You should wait several months (about 4 months post-op) before you aggressively stretch.
  10. Make sure you get tested before you get “cleared.”  The biggest mistake doctors make is telling patients they’re “cleared” without explaining the difference between being “medically” cleared and “physically” cleared.  Unfortunately, it puts the idea in the patient’s head that he’s good to go.  The doctor clears you medically.  They tell you that your new ACL is healed and you have no infections or any reason to stop training/progressing.  However, physical readiness is totally different.  It shocks me how many people get “cleared” to practice/play when no one has ever watched them cut, sprint, or jump on one leg.  At a very minimum, you should perform a series of single leg functional tests to make sure that your involved leg is at least 90% of your uninvolved one before getting released.  Once you do that, then you are “physically” cleared to begin return to play progressions.

Rehab after an ACL surgery is a long process that requires perseverance, dedication, and a lot of hard work.  Maybe more than you have ever done.  While many factors contribute to the outcome and this list is not exhaustive, the things mentioned in this blog should help you maximize your outcome.

It would be a privilege to serve you and partner with you in your care after ACL surgery.  The physical therapists at SSOR have the most comprehensive and thorough treatments and return to play assessments in the Kansas City metro.  Give us a call, we welcome the opportunity to show you! We have offices in Overland Park and Prairie Village to serve you.

Jimmy Graham Injury Rehab

Patellar Tendon Rupture Rehabilitation

Seattle Seahawks Tight End Jimmy Graham ruptured his patellar tendon a couple of weeks ago.  This is a tough injury for any athlete.  It’s a season-ending one, much like an ACL or Achilles rupture is.  Athletes can definitely return from this, but the rehab process is a long one.  So what will Jimmy Graham’s rehab look like?

Jimmy Graham

Function of the Patellar Tendon

The quadriceps muscles converge to form the patellar tendon and it attaches on the tibial tuberosity below the knee.  Basically, the quad muscles lost their anchor. Without that, the knee cannot function. It really is as simple as that.

Patella-Tendon-Rupture

How long is the recovery?

This can take 6-8 months for sure to recover from, especially for an athlete at that level.  The two most significant limiting factors after this surgery are that the range of motion (ROM) is restricted for the first 6 weeks to allow the repair to heal and the other is regaining the quadriceps strength lost from the injury and subsequent period of protected mobilization.  You just cannot run, jump, cut or frankly, walk or ambulate the stairs without strong quadriceps.   Because of the strength and power needed, especially for him, this injury can take a really long time to get the strength back to perform at a high level.

repair

Rehab after the Jimmy Graham Injury

Usually, ROM is restricted for the first 6 weeks or so.  People are often locked in extension for a week or so, then a graded progression of ROM is allowed – 30°, then 60°, then 90° by 6 weeks post-op.  During this time, the patient should have soft tissue work done on the lower body, strengthening of the hips and lower legs, and for athletes, cardiovascular activity can be accomplished with an arm bike.  Quadriceps strengthening can be initiated with some basic exercises and can be enhanced by muscle stimulation to the quadriceps.  Numerous studies have advocated the use of muscle stimulation after knee surgery to facilitate quadriceps strength both in the short and long-term.  Unfortunately, the first 6 weeks is a waiting game for healing to take place.   Another concern along those lines is that the incision is rather long as the surgeon has to “open up” the knee.  Therefore, a proper healing environment has to be facilitated, but patients will also need extensive soft tissue work to break up any scar tissue from the incision.

Once the patient gets the “green light” from the doctor to begin strengthening, the process really kicks into high gear.  Weight-bearing exercises like squats, step ups, and leg press are initiated. Again, these are initiated in graded ranges so as to not stress the repair too much.  Loading increases over time.  Progress is measured by standardized strength testing as well as measurement of the muscle mass.  We like to tell our patients that their “tires need full inflation” before we release them to sports.  If the quadriceps muscles are smaller, athletes are at risk for a host of injuries.  Hopefully, that makes sense.

The other issue after this surgery is getting ROM back, especially end-range flexion.  Most of the time, surgical procedures are the ultimate “catch-22” – you need protected ROM to allow healing, but as a result, patients often battle getting the last bit of ROM due to stiffness/tightness.  Numerous techniques exist to maximize ROM gains, but the bottom line is that you need a physical therapist that provides hands-on treatment to get it.  Ultimately, athletes (and really all patients, but athletes especially), need to be able to get their heel to their glutes.  If not, a whole myriad of issues can surface.

Once adequate strength is restored, impact activities begin.  Athletes need to develop not only power, but neuromuscular control to tolerate landing from jumps as well as cutting during change of direction maneuvers.  Athletes especially have to demonstrate willingness to load the limb during these activities.  An astute sports physical therapist (like the ones at SSOR!) will be meticulous in their evaluation of the performance of these activities to maximize their return-to-play ability.

Will Jimmy Graham come back the same or better after this injury?

We bet he will.  Most athletes have every resource at their disposal to heal and get their bodies right.  It’s just a war of attrition – will he have the resolve to persist and keep working to get back? Only he will decide that.  Like we said above, expect a 6-8 month recover after this one.

SSOR has a goal-oriented population that demands results quickly.  Our staff understands post-operative protocols and more importantly, how to safely yet effectively progress you back to the activities you want to do.  It would be a privilege to partner with you in your care.  Give us a call! We have locations in Prairie Village and Overland Park to serve you.

Can You Do This Critical Movement After Knee Surgery?

Key Clinical Milestone After Knee Surgery

We see lots of people after knee surgery at SSOR – knee “scopes,” meniscus repairs, anterior cruciate ligament (ACL) reconstructions, and total knee replacements.  We also see lots of people as the “last resort” physical therapy place due to having persistent trouble after knee surgery and just not getting where they want to be.   Whether they have persistent swelling, pain, weakness, or poor range of motion, people come to us after knee surgery frustrated and searching for answers.  One of the first things we look at and one of our principle post-operative goals is to obtain full knee extension range of motion.  Previous studies have found that even a 3° loss of extension leads to a decline in function (Shelbourne & Gray, AJSM 2009).  It is critical that that the knee gets fully extended after surgery.  First of all, it is needed for proper walking gait.  When you are in the stance phase of gait (all your weight on one leg, the other swinging), the stance leg needs to be straight at that point.  Otherwise, you effectively walk with a shorter knee and you will have a quadriceps muscle that can’t best do its job.  Plus, if you can’t get straight, your quadriceps can’t stabilize your knee enough – it can lead to “buckling” during walking and instability.  The other key problem with lack of extension is that scar tissue can form in the front or anterior part of the knee, known as an infrapatellar contracture syndrome (Paulos et al, AJSM 1987).  If scar tissue forms there, it is very difficult for the knee to function properly.

Once your knee is fully extended, the hard part is getting the quadriceps muscles to work correctly.  Check out this video to learn more about how the quadriceps should work after knee surgery.

It would be a privilege to serve you and partner with you in your care.  Please understand that there IS a difference in quality of physical therapy, just like any other business.  We are confident you will be thrilled with our approach and your outcome.  Give us a call! We have locations in Overland Park and Prairie Village to serve you.