The physiotherapists are true magicians when it comes to their ability to relieve chronic MSK pain and disability,either from sports injuries or poor posture at work or from degenerative conditions. They have a wealth of knowledge and expertise and a lot of wonderful gadgets, that can accelerate the healing process. But their services are often sought late or not as frequently as it should. This could be because of 3 reasons ( to my mind ) 1) their capabilities are often underestimated by orthopedicians and GPs alike 2) their modalities of Rx ( and it's scope and applications / indications ), remain largely a mystery to the rest of the medical community 3) patien't want quick fixes, so they will prefer NSAIDS or steroids, than visits to the physiotherapist ( which could stretch for weeks ). It's up to us to educate our patients, that outside of surgery - there are no quick fixes and even surgery will require phased rehab ( running into weeks ). I will try and demystify all the modalities used in physiotherapy and specific injuries later in the thread. Suggestions are welcome, but pls. don't post any thank you or similar messages as it will break the flow of the thread.
General principles of physical therapy [TABLE] [TR] [TD="align: center"]General principles of physical therapy [/TD] [/TR] [/TABLE] The principle aim of the physical therapist working within sports medicine is to restore complete physical function in the injured athlete. The treatment prescribed should enhance the body's natural healing process and should maximize the patient's recovery within a safe context. In order to achieve this, various therapeutic modalities are employed. These include movement education, soft tissue and joint techniques, electrophysical therapies, and management advice. The treatment of foot and ankle injuries must involve a co-ordinated team approach with input not just from the physical therapist but also from a podiatrist (specializing in sports medicine) and the athletic trainer responsible for coaching the athlete. The athletic trainer and the athlete should liaise closely with the physical therapist in the development of treatment plans, but these must be followed by full co-operation and compliance from the athlete. Thorough assessmentand examination of the injury is essential prior to treatment in order to clarify the diagnosis and establish the etiology of the presenting dysfunction. Using clinical reasoning models, the therapist should establish the main structures involved in the injury and thus prescribe the necessary treatment. Assessment When assessing the foot and ankle, the physical therapist will employ a combination of standard orthopaedic testing together with gait analysis and biomechanical examination. The standard orthopaedic approach involves the following: Observation - Visual inspection of limb; examining for signs of inflammation, heat, swelling, deformity, and discoloration. Palpation - Locating the specific anatomical sites where damage has ocurred, whether superficial or deep-(if possible). Stress testing - Employment of specific reliable and valid teststo investigate tissue integrity; ligaments and tendons in particular, but also joint articulation/translation. Analysis of movement - Examination of gait analysis through observation of human motion; using video playback if equipment is available. The therapist needs to be skilled in the art of viewing movement and should have a thorough understanding of ideal, healthy and/or normal movement. This can be developed though painstaking research, observation, and study. Analysis should include: gait, running, jumping, lunging, squatting, climbing inclines/stairs, and twisting and cutting maneuvers. Alignment - Examination of the body's posture with the patient in a standing position, supine, prone, and whilst performing functional tasks. Any malalignment should be clarified as being either structural or postural. Hip rotation measured in the prone position can give an indication of malalignment deformities at the hip: medial rotationin excess of 60 degrees and lateral rotation less than 25 degrees is suggestive of hip antetorsion. Hip medial rotation is commonly greater than lateral rotation. (Average medial rotation is 50 to 60 degrees, average lateral rotation is 45 degrees). The angle of deformity of the tibia is also measured in prone with the knees at 90 degrees. This gives a measure of tibial rotation. The measurement is termed the thigh-foot angle. A thigh-foot angle between -5 to 30 degrees is considered normal. A mean of 10 degrees has been established in adults. The transmalleolar axis , believed to be a more accurate measure of tibial rotation, has a mean of 23 degrees in lateral rotation with a range between 0 and 40 degrees. The foot progression angle is measured in standing during the stance phase of walking and is characterized by in-toeing or out-toeing gait patterns. A mean of 10 degrees with a range of -3 to 20 degrees is considered normal.While confirmation of true structural torsion deformities requires radiological examination, clinical testing can be used to define joint related movement restrictions or excessive ranges. The clinician can use the measurements to plan treatment programs. Muscle strength and muscle length testing Muscle imbalance testing should be used to provide a detailed analysis of the appropriate supporting structures in the foot and ankle. Muscle strength should be graded according to the Oxford scale and areas of weakness should be identified. It is also important that co-ordination and timing of muscle activity is analyzed: this can be done by observing muscle action during tests of strength and movement. Inappropriate muscle activity can be identified as delayed joint motion or disorganized patterns of movement. Balance and proprioception testing This involves the examination of the patient after their base of support and stability of surface has been reduced. The tools used as standard are wobble boards or foam surfaces . The patient is tested whilst standing on two legs, on one leg, with the eyes open, and with the eyes closed. The therapist observes for body sway (at each joint, from the trunk to the big toe), any loss of balance, and the amount of time spent upright. Substitute patterns of muscle activity should be monitored together with excessive or restricted joint motion at the trunk, hip, knee, tibia, ankle, subtalar, midfoot, forefoot, and toes. The patient should be able to dissociate and localize joint and muscle movement to the specific joints tested. An inability to do this could indicate muscle weakness, tightness, joint hyper/hypomobility, poor neuromuscular co-ordination and timing, psychological apprehension or fear, structural tissue damage, and/or peripheral or central pain inhibition. I will cover rehab under 2 broad headings a) Modalities other than exercise and will include: - immediate treatments - electrotherapy - manual therapy ( include joint mobilization, soft tissue techniques, muscle energy techniques, and neuromeningeal mobilizations ) b) Rehab Exercises - isotonic exercise - muscle balance ( faulty movement patterns will be discussed here - proprioception - aerobic and anerobic conditioning Please Note : Most of the assessment techniques and exercises used during rehab, will also prevent the injuries from happening. ex - the rotator cuff strengthenig exercises, prescribed during rehab from rotator cuff injuries can also be used to prevent injuries in athletes who are engaged in sports that subject their shoulders to excessive stresses.
Immediate treatment of soft tissue injury (PRICE) Immediate treatment of soft tissue injury (PRICE) Immediately following injury to a ligament, tendon, or muscle attached to the knee, there will be an inflammatory reaction of varying degrees depending on the severity of the injury. In a strain, sprain, or rupture of the soft tissues, blood vessels can be damaged and bleeding may occur. The accumulated blood and inflammatory exudate produces pain and swelling of the surrounding tissues. If left untreated, the swelling may inhibit healing of the damaged tissues and lead to spasm of the surrounding muscles. The immediate aim following injury is to reduce the amount of bleeding at the site of injury and to prevent further damage. Treatment must be applied as soon as possible and the most effective way of doing this is to follow the principles of PRICE ( Kerr et al., 1998 ). P P rotection R R est I I ce C C ompression E E levation Protection Protection should be applied for at least three days and may include, for example: 1. The use of crutches to allow non weight bearing following a severe sprain of the medial collateral ligament. 2. A patellar brace for a dislocation of the patella. 3. An extension splint following rupture of the posterior cruciate ligament. Rest Rest should occur immediately following injury, as stress may cause further damage and subsequent bleeding. A mild (first degree) injury may require only 24 hours rest. A moderate (second degree) injury may require 3-5 days rest. A severe (third degree) injury may require at least one week's rest. Isometric contractions of the quadriceps, hamstrings, and calf muscles can be performed within the limits of pain. Ice Ice should be applied immediately following injury in the form of crushed ice, cold packs, or a Cryo-cuff for the knee (image) . (If ice is used, a damp towel should be first applied against the skin to avoid an ice burn. (not applicable for Cryo-cuff). The recommended time for ice application is for 20 to 30 minutes every 2 hours. 30 minutes is the maximum recommended time to avoid tissue damage. The cooling effect of ice decreases tissue temperature and brings about vasoconstriction. This in turn reduces the swelling associated with bleeding and inflammation. Metabolism is decreased as well as pain and muscle spasm. Ice is inexpensive, easy to use and effective. Compression A compression bandage should be applied six inches below the knee, moving from distal to proximal and finishing six inches above the knee. The bandage should be applied firmly in a spiral fashion with each layer overlapping the underlying layer by at least one-half. The bandage must not be so tight as to cause pain and must remain in place for the first 72 hours following injury when standing. Elevation Elevation of the leg above the level of the heart reduces the blood flow to the injury and encourages the return of venous blood and lymph flow. Elevation should occur as soon as possible after injury and be maintained for the first 72 h
Electrotherapy [TABLE] [TR] [TD="align: center"]Electrotherapy [/TD] [/TR] [/TABLE] Ultrasound therapy The use of high frequency acoustic energy is widespread in sports. Ultrasound is a mechanical vibration, which oscillates biological tissues to stimulate healing. The waveform helps accelerate tissue healing by stimulating cellular activity within the inflammatory, proliferation, and remodeling phases. Ultrasound stimulates growth factors within macrophages and mast cells (white blood cells) to clear tissue debris accumulated after injury. Pulsed ultrasound is non-thermal, has an analgesic effect, and is recommended as a form of therapy for acute injuries. Continuous ultrasound produces heat and is used for chronic injuries. The frequency and intensity of ultrasound is varied according to the stage of the injury. Interferential stimulation Two medium frequency currents are used, which cross to produce a 'beat frequency'. A low frequency current is produced within tissues, with low skin impedance. The interferential current improves the permeability of muscle and nerve tissue and stimulates the healing process. In acute injuries currents from 0 to 100 Hz are used to stimulate widespread motor, sympathetic, and sensory fibers to aid tissue/fluid mobility reducing swelling. For pain relief, currents 80 to 130 Hz stimulate sensory fibers and provide pain relief (using principle of pain gate theory). Muscle tissue can be stimulated using currents between 0 to 50 hertz. Pulsed short wave Pulsed short waveuses magnetic field energy to stimulate cellular activity at the surface of the membrane. This enhances fluid flow across the cell, aiding the resolution of inflammatory exudate. It can be used immediately following injury at power ranges 0 to 0.5w. It is thought that cellular mitosis is enhanced by the use of pulsed magnetic energy. Iontophoresis Iontophoresis is the therapeutic process by which pharmacological agents (non-steroidal anti-inflammatories) are transported through the skin into the tissues using electrical currents. This technique is used to help penetration of the anti-inflammatory medicine deep into the injured soft tissues or joint and can help make the application of the anti-inflammatory medication more effective for the deep tissues. Combination therapy Combination therapy consists of a mixture of interferential stimulation and ultrasound to provide cellular stimulation and tissue fluid flow at lower intensity outputs. It is particularly useful for acute ankle injuries. Ultrasound can stimulate healing of the ligament while interferential stimulation reduces general capsular swelling. Neuromuscular electrical stimulators Muscle stimulators occur in various forms from Faradic to Russian. All muscle stimulators work between frequencies of 0 to 50 Hz. The aim is to stimulate weak and atrophied muscles that the patient is unable to activate. In acute injuries or post-surgery, muscle stimulation can maintain muscle activity whilst avoiding excessive stress through the joint. In chronic or overuse injuries, muscle stimulators provide a trigger to inhibited and disused muscles. This can be useful for recurrent ankle injuries to the peroneal muscles. Electrical biofeedback Surface electromyography is an increasingly useful tool to aid the re-education of pain inhibited muscles. Surface electrodes are applied to the muscle belly of selective muscles and subsequent muscle activity is recorded. The information is converted into visual and auditory signals meaning that the patient is able to alter muscle activity appropriately. In chronic overuse injuries, muscles initially inhibited by pain may remain dysfunctional after the pathology has resolved (despite gym exercises). In recurrent ankle injuries, the peroneals can develop a delayed response time. Research on healthy individuals has established that the peroneus longus muscle is active prior to impact in cutting movements. This is believed to provide muscular stability to the subtalar joint and protection against excessive supination.Effective biofeedback trainingcan re-educate muscle response timing, selective to specific sporting movements including standing on one leg, twisting, cutting, jumping, and running. TENS (Transcutaneous electrical nerve stimulation) TENS is regularly used to aid pain relief, it is used on acupuncture or trigger points to stimulate biological analgesics, pain gate, and opiates etc. TENS machines set at high frequency (80 to 130hz) and high pulse rates per second (60 to 80 pulses) stimulate large diameter nerves in the spinal cord and thus inhibit the information transmitted to the spinal column by the small diameter pain fibers. The pain gate theory postulates that pain is transmitted via the spinal cord by small diameter a-delta and c fibers. Stimulation of large diameter nerve fibers reduces the perception of pain by closing the gate to pain fibers at the spinal cord level. Low frequency stimulation of nerve fibers helps to stimulate the release of the body's own pain relieving substances (endorphins or endogenous opioids). Opioids work on the central nervous system to stimulate control of pain transmission and also influence the spinal cord, inhibiting the transmission of messages of tissue damage to the brain. The TENS machine is set at frequencies below 80 Hz with a pulse rate below 4 pulses per second. This can produce a low intensity muscle twitch.
Manual therapy [TABLE] [TR] [TD="align: center"][FONT=Arial,Helvetica,Sans-Serif]Manual therapy [/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT] [/TD] [/TR] [/TABLE] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Manual therapy is an umbrella term used to describe treatment techniques that aim to restore normal physiological motion to soft tissue and joints. They include joint mobilization, soft tissue techniques, muscle energy techniques, and neuromeningeal mobilizations. These treatment methods are all passive movement techniques. [/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Joint mobilization [/FONT] [FONT=Arial,Helvetica,Sans-Serif][/FONT][FONT=Arial,Helvetica,Sans-Serif] Joint mobilization at the foot and ankle helps to restore full range of motion at the talocrural joints and the midtarsal joints.[/FONT][FONT=Arial,Helvetica,Sans-Serif] Stiffness in these joints can cause various problems: a stiff segment at the midtarsal for example, can prevent the shock absorption capacity of the foot and a stiff talocrural joint, reducing ankle dorsiflexion, can lead to excessive motion at the subtalar or midtarsal joints. This compensation may cause excessive pronation, abduction, and eversion, which can then lead to a flat longitudinal arch. Restricted metatarsalphalangeal (MTP) motion will prevent the amount of forefoot dorsiflexion needed for sprinting (for runners) and pointe work (for ballet dancers). [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] NB: dorsiflexion of the MTP joint above 70 degrees is the normal range in ballet dancers. Any reduction in ankle joint flexibility is often correlated with new injuries. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] Joints described as hypo-mobile or restricted (with a firm end feel) with less than expected range of movement require Grade III, IV or V manipulations. A grading system for joint mobilizations has been developed to guide the therapist.[/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] The therapist assesses the relative mobility between several joints and records the end feel once joint motion has stopped. End feels are frequently described as firm to hard to describe very restricted mobility, empty to describe excessive mobility, and rubbery to describe tightness at less than expected range. The therapist then selects the depth and type of technique to use on the joints. Grade I to II techniques are joint mobilizations at less than the full physiological mobility of the joint. These techniques are chosen for pain relief. Minimal controlled motion to the joint helps to provide a mechanical counter irritant to painful chemical stimuli. Grade III to IV techniques are mobilizations to the end of the physiological mobility of the joint. These techniques are used to correct restrictions to joint motion. The therapist needs to reason the cause of joint restrictions before applying any technique. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] The most common reason for restricted joint movement is reduced soft tissue extensibility due to dense scar tissue formation. Intra-articular degenerative joint changes may also reduce the articular gliding between joint surfaces. The safe application of a technique requires the exclusion of any contraindications to joint movement and an understanding of normal joint mechanics. Manipulations are grade V techniques, small amplitude thrusts that aim to restore joint alignment, and blocks to segmental mobility. The [/FONT][FONT=Arial,Helvetica,Sans-Serif] talocrural [/FONT][FONT=Arial,Helvetica,Sans-Serif]and [/FONT][FONT=Arial,Helvetica,Sans-Serif] cuboid [/FONT][FONT=Arial,Helvetica,Sans-Serif] joints are manipulated if the joints becomes subluxed or grossly stiff. Specific pressure applied direct to the joint at the motion barrier, followed by a sudden sharp thrust helps to restore normal motion. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] Soft tissue techniques [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Massage[/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] Massage of the foot and ankle is important as it helps reduce swelling, breaks down scar tissue (adhesions), and improves circulation to facilitate healing. [/FONT][FONT=Arial,Helvetica,Sans-Serif] Techniques such as [/FONT][FONT=Arial,Helvetica,Sans-Serif] stroking[/FONT][FONT=Arial,Helvetica,Sans-Serif], [/FONT][FONT=Arial,Helvetica,Sans-Serif] kneading [/FONT][FONT=Arial,Helvetica,Sans-Serif] , and effleurage, all aid fluid flow after acute injuries. Massage helps to prevent the stagnation of inflammatory exudate. This in turn prevents excessive fibrin formation, which can lead to excessive scar tissue and eventually fibrinous adhesions. If this occurs in a synovial joint, such as the ankle, the capsule can become contracted and immobile. The result would be a stiff weak joint. Techniques such as kneading mobilize the soft tissues to aid lymphatic and venous circulation. Kneading involves using a gentle lumbrical grip around the muscles to pick up squeeze. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Acute injury management [/FONT] [FONT=Arial,Helvetica,Sans-Serif][/FONT][FONT=Arial,Helvetica,Sans-Serif] Massage is applied with gentle pressure to avoid further tissue damage. It: [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] 1. Promotes local circulation, to remove inflammatory exudate. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] 2. Provides pain relief. Gentle pressure stimulates [/FONT][FONT=Arial,Helvetica,Sans-Serif] pain gating [/FONT][FONT=Arial,Helvetica,Sans-Serif] at the spinal cord level. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Chronic injury management [/FONT] [FONT=Arial,Helvetica,Sans-Serif][/FONT][FONT=Arial,Helvetica,Sans-Serif] Massage can be applied more aggressively to encourage tissue mobility. It: 1. Breaks down scar tissue adhesions, which restricts normal joint movement. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] 2. Promotes correct scar tissue formation in healing soft tissue injuries. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] 3. Encourages relaxation. [/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] Massage techniques [/FONT] [FONT=Arial,Helvetica,Sans-Serif] Kneading[/FONT][FONT=Arial,Helvetica,Sans-Serif] - Circular pressure is applied to the deep tissues of the lower leg. Deep pressure is applied for half the circular motion and superficial pressure completes the other half of the circle. The aim of the massage is to encourage local circulation and reduce any soft tissue thickening. Alternate deep and superficial pressurehelps to relax the patient.[/FONT][FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Effleurage[/FONT][FONT=Arial,Helvetica,Sans-Serif] - Pressure is applied distal to proximal from the foot to the knee or hip to encourage lymphatic and venous fluid flow. The aim is to encourage pumping of fluid to prevent dependent edema settling in the foot after injury. The therapist uses a light but firm lumbrical grip to the foot and applies pressure proximal to a lymphatic nodule. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Stroking - [/FONT][FONT=Arial,Helvetica,Sans-Serif]is the application of gentle and superficial pressure is applied to help relax the patient prior to using deeper techniques. The direction of the strokes is variable. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Percussive techniques[/FONT][FONT=Arial,Helvetica,Sans-Serif] - Clapping or hacking stimulates circulation and reflex responses on the skin. These techniques are useful prior to sporting events to increase the responsiveness of the soft tissues to movement. In effect they 'wake up' the tissues. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT][FONT=Arial,Helvetica,Sans-Serif] Transverse frictions [/FONT][FONT=Arial,Helvetica,Sans-Serif]- Pressure is applied in the direction of the fibers of the muscle or ligament fibers. The depth and force of pressure is varied according to the type of injury. For an acute injury, gentle pressure is applied for very short periods, to stimulate blood circulation.[/FONT][FONT=Arial,Helvetica,Sans-Serif] For chronic injuries, [/FONT][FONT=Arial,Helvetica,Sans-Serif] deeper pressure [/FONT][FONT=Arial,Helvetica,Sans-Serif]can be applied for up to twenty minutes, to mechanically breakdown adhesions or tethering. Deep pressure should be avoided for the first few weeks of an injury. [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] [/FONT] [FONT=Arial,Helvetica,Sans-Serif] The therapist can use many different techniques to mobilize to soft tissues of the foot and ankle. [/FONT]
