Mgr. Alena Sedláková }Injuries of soft tissues (meaning ligaments, tendons and muscules) }Injuries of bones- fractures }Is a trauma to a joint that involves stretching or tearing the ligaments }Three degrees: } }GRADE 1 – MILD SPRAIN – there is some stretching or perhaps tearing of the ligamentous fibers with very little or no joint instability. Mild pain, little swelling and joint stiffness may be apparent }GRADE 2 – MODERATE SPRAIN – there is some tearing and separation of the ligamentous fibers and moderate instability of the joint. Moderate pain, swelling and joint stiffness. } }GRADE 3 – SEVERE SPRAIN – there is complete rupture of ligament with gross instability of the joint, severe swelling, inability to bear weight on the extremity } } }Is a less serious injury involving overstretching or tearing of muscle fibers }Muscle strains occur frequently in the hamstrings and quadriceps muscles in the athletes }PRICE principle – Protection, Rest, Ice, Compression, Elevation – can be applied to reduce swelling, relieve pain }Usually resulting from some strenuous physical activity to which we are unaccustomed }Muscle soreness may be best prevented by beginning a moderate level of activity and gradually progressing the intensity of the exercise over time }Treatment of sore muscles usually involves some type of stretching activity and ice application }Complete and incomplete fractures }Traumatic, fatigue (stress) and pathologic fractures }Closed or open fractures (the bone protrudes through an open wound in the skin) }Nondisplaced and displaced (translated, angulated, rotated, shortened) }Simple, multiple and comminuted fractures }Fracture pattern: linear, transverse, oblique, spiral, compression, impacted, avulsion }CONSERVATIVE - Closed reduction – is placing the bone back to its normal position without a surgical intervention and application of a cast to immobilize the injured bone. Non-operative treatmenet results in prolonged immobilization } }SURGICAL - Open reduction – involves surgery – } ORIF (open reduction/internal fixation) – intramedullary (insertion of nails, screws) and extramedullary (insertion of plats) } External fixator skenovat0020 }Complication when vessels and nerves are compressed by oedema or a plaster leading to increase pressure in the compartement }Symptoms – oedema, pain, sensory disturbances, motion disturbances }Intrafascial pressure over 60mm H2O – indication to emergency surgical correction - fasciotomy }If untreated, the lack of blood supply leads to permanent muscle and nerve damage and can result in the loss of function of the limb }TIBIA fractures (Tibial plateau fracture, Pilon fracture, Fractures of tibial diaphysis) }FIBULA fractures (Fractures of proximal aspect, of diaphysis and distal aspect) }Combined tibia and fibula fractures (Malleolar fractures) } skenovat0016 1)Proximal aspect 2)Diafysis 3)Distal aspect }Calcaneal fracture }Thalus fracture }Metatarsal fractures }Finger fractures } }A) CONSERVATIVE TREATMENT }Phase 1 – Acute Phase - during immobilization }Phase 2 – Rehabilitative Phase - after removing plaster } }B) SURGICAL TREATMENT }Phase 1 – Acute Phase – during committal }Phase 2 – Rehabilitative Phase – } in physiotherapy clinic } GOALS }Prevent oedema and compartment syndrome }Prevent deep vein trombosis }Prevent joint stiffness and muscle contractions or weakness of unaffected limbs }Prevent deconditioning }Gait training with assistive devices such as underarm or forearm crutches } } PHYSICAL THERAPY }Cryotherapy (application of ice reduces swelling), limb elevation }Circulatory exercises }Active range of motion and resistance trainning unaffected limbs }Isometric exercises affected limb }Exercises non-immobilizated parts of limb }Gait training – gait pattern (two/three/four point gait) – depands on full weight-bearing or non-weight-bearing (toe-touch weight-bearing, partial weight-bearing, weight-bearing as tolerated) – recommended by physicians } }Inpatient rehabilitation or physiotherapy clinic }After removing plaster there is often oedema, pain, limited movement, joint stiffness, lower muscle strength of affected area }GOALS - decrease oedema, relieve pain, improve ROM, improve muscle strenght }GOALS – improve or maintain physical fittness, improve balance, improve coordination, enable ambulation } PHYSICAL THERAPY }Modalities – cryotherapy, magnet therapy (promotes fracture healing), hydrotherapy – whirpool (reduces swelling a relieves pain) }Soft tissues mobilization (PIR, balling) – to release contracted muscles, tendons and fascia }Joint mobilization – to restore joint play }PROM – passive range of motion exercises, AAROM – active assisted range of motion, AROM – active range of motion } }Resistance exersice to improve muscle strength }Sensorimotor training – to improve balance skills and joint stability (includes simple exercises such as toe-standing, standing hip flexion, standing side leg raise following modifications doing exercise with eyes closed; balance training aids such as balance discs, unstable platform) }Gait training without assistive devices, gait pattern correction }Posture correction }Apropriate sports - stacionary bike, cycling, swimming, walking, jogging } GOALS }Prevent oedema and compartment syndrome }Prevent deep vein trombosis }Prevent respiratory complications }Prevent joint stiffness and muscle contractions or weakness of unaffected limbs }Prevent deconditioning }Improve bed mobility }Gait training with assistive devices such as walker, underarm or forearm crutches } } PHYSICAL THERAPY }Cryotherapy (application of ice reduces swelling), limb elevation, balling free parts }Circulatory exercises }Respiratory rehabilitation }Active range of motion exercise and resistance exercise unaffected limbs (upper and lower limbs) }Isometric exercises affected limb }PROM or AAROM exercise of operated limb } }Functional mobility training – includes bed mobility and transfer training such as bridging, rolling to the sides, moving up or down the bed -scooting, transitions from lying to sitting in bed or on the edge of bed, from sitting to standing transfers from bed to chair/wheelchair }Gait training with assistive devices such as walker, underarm or forearm crutches – it depands on patient condition }Stair climbing } } }Full weight-bearing or non-weight-bearing (toe-touch weight-bearing, partial weight-bearing 25/50/75%, weight-bearing as tolerated) – recommended by physicians }ADL training (washing, dressing) }Scare care – after stitches extraction }Instruction patient to follow exercise at home } }Full weight bearing stadium approx. after 6-8 weeks } GOALS }decrease oedema }relieve pain }improve ROM }improve muscle strenght }improve or maintain physical fittness }improve balance, improve coordination }enable ambulation } } } PHYSICAL THERAPY }Modalities – cryotherapy, magnet therapy (promotes fracture healing), hydrotherapy – whirpool (reduces swelling a relieves pain) }Soft tissues mobilization (PIR, balling) – to release contracted muscles, tendons and fascia }Joint mobilization – to restore joint play }Scare care } }PROM – passive range of motion exercises, AAROM – active assisted range of motion, AROM – active range of motion }Resistance exersice to improve muscle strenght }Sensorimotor training – to improve balance skills and joint stability (includes simple exercises such as toe-standing, standing hip flexion, standing side leg raise following modifications doing exercise with eyes closed; balance training aids such as balance discs, unstable platform) } }Gait training without assistive devices, gait pattern correction }Posture correction }Aquatic exercises }Apropriate sports - stacionary bike, cycling, swimming, walking, jogging }Instruction patient to follow exercise at home } } }Ankle sprains }Ankle fractures }Grade 1 – mild ankle sprain – a stretch of the ligament with no macroscopic tear, little swelling or tenderness, minimal or no functional impairment, and no joint instability }Grade 2 – moderate ankle sprain – involves a partial tear of the ligament with moderate swelling and tenderness, some loss of joint function, mild joint instability }Grade 3 – severe ankle sprain – a complete tear of the ligaments (ATFL, CFL) with severe swelling and tenderness, inabilty to bear weight on the extremity and mechanical joint instability } Phase 1: Acute Phase }Timing }Grade 1 sprain: 1-3 days }Grade 2 sprain: 2-4 days }Grade 3 sprain: 3- 7 days }Goals }Decrease swelling }Decrease pain }Protect from reinjury }Maintain appropriate weight-bearing status }Protection Options }Taping }Functional bracing }Removable cast boot (some grade 2 and most grade 3sprains) }Rest (crutches to promote ambulation without gait deviation) } }Ice }Cryocuff ice machine }Ice bags }Light Compression }Elastic wrap }Elevation }Above the heart (combined with ankle pumps) } } Phase 2: Subacute Phase }Timing }Grade 1 sprain: 2-4 days }Grade 2 sprain: 3-5 days }Grade 3 sprain: 4-8 days }Goals }Decrease swelling }Decrease pain }Increase pain-free ROM }Begin strengthening }Begin non-weight-bearing proprioceptive training }Provide protective support as needed }Modalities to Decrease Pain and Swelling }Ice or contrast baths }Electrical stimulation (high-voltage galvanic or interferential) }Ultrasound }Weight-bearing }Progress weight-bearing as symptoms permit }Partial weight-bearing to full weight-bearing if no signs of antalgic gait are present }Therapeutic Exercises }Active ROM exercises – Dorsiflexion, Inversion, Foot circles, Plantar flexion, Eversion }Strength exercises - Isometric in pain-free range, Toe curls with towel, Pick up objects with toes (tissue, marbles) }Proprioceptive training }Stretching - Passive ROM-only dorsiflexion and plantar flexion in pain free range, not eversion or inversion, Achilles tendon stretch, Joint mobilizations } Phase 3 – Rehabilitative Phase }Timing }Grade 1 sprain: 1 wk }Grade 2 sprain: 2 wk }Grade 3 sprain: 3 wk }Goals }Increase pain-free ROM }Progress strenghtening }Progress proprioceptive training }Increase pain-free activities of daily living }Pain-free full weight-bearing and uncompensated gait }Therapeutic exercise }Stretching – Gastrocnemius and Soleus with increased intensity, Joint mobilization }Strengthening – Weight-bearing exercises (heel raises, toe raises, stair steps, quarter squats), Eccentric/concetric and isotonics (with Theraband inversion, eversion, plantar flexion, dorsiflexion) }Proprioceptive training – single-leg balance activities stable to unstable surfaces (balance disc, trampoline) }Continue modalities as needed }Supportive taping, bracing or orthotics used as needed }Phase 4 – Return to Activity or Functional Phase }Timing }Grade 1: 1-2 wk }Grade 2: 2-3 wk }Grade 3: 3-6 wk }Goals }Regain full strength }Normal biomechanics }Return to participation }Protection and strengthening of any mild residual joint instability }Therapeutic exercise }Continue progression of ROM and strengthening exercises }Appropriate sports/activities: jogging, running, cycling, swimming } }Phase 5: Prophylactic Phase }Goal }Prevent injury }Therapeutic Exercises }Functional drills }Multidirectional balance board activities }Prophylactic strengthening (emphasis on peroneal eversion) }Prophylactic protective support as needed }CONSERVATIVE – only simple undisplaced fractures, immobilization for 6wk, first 3 wk without weight-bearing, then partial weight-bearing recommended by physician, removing plaster and inititation of physical therapy after 6 wk } } PHYSICAL THERAPY }Modalities – cryotherapy, magnet therapy (promotes fracture healing), hydrotherapy – whirpool (reduces swelling and relieves pain) }Soft tissues mobilization (PIR, balling) – to release contracted muscles, tendons and fascia }Joint mobilization – to restore joint play }PROM – passive range of motion exercises, AAROM – active assisted range of motion, AROM – active range of motion } }Resistance exersice to improve muscle strength }Sensorimotor training – to improve balance skills and joint stability (includes simple exercises such as toe-standing, standing hip flexion, standing side leg raise following modifications doing exercise with eyes closed; balance training aids such as balance discs, unstable platform) }Gait training without assistive devices, gait pattern correction }Posture correction }Apropriate sports - stacionary bike, cycling, swimming, walking, jogging } } }SURGICAL – displaced fractures, post-operative cast immobilization for 3-4wk without weight-bearing } } PHYSICAL THERAPY – Acute Phase }Cryotherapy (application of ice reduces swelling), limb elevation, balling free parts }Circulatory exercises }Respiratory rehabilitation }Active range of motion exercise and resistance exercise unaffected limbs (upper and lower limbs) }Isometric exercises affected limb }PROM or AAROM exercise of operated limb } }Functional mobility trainig – includes bed mobility and transfer trainig such as bridging, rolling to the sides, moving up or down the bed -scooting, transitions from lying to sitting in bed or on the edge of bed, from sitting to standing, transfers from bed to chair/wheelchair }Gait training with assistive devices such as walker, underarm or forearm crutches – it depands on patient condition }Stair climbing }Weight-bearing (toe-touch weight-bearing, partial weight-bearing 25/50/75%, weight-bearing as tolerated) – recommended by physicians }ADL trainig (washing, dressing) }Scare care – after stitches extraction }Instruction patient to follow exercise at home } } } PHYSICAL THERAPY – Rehabilitative Phase }Modalities – cryotherapy, magnet therapy (promotes fracture healing), hydrotherapy – whirpool (reduces swelling a relieves pain) }Soft tissues mobilization (PIR, balling) – to release contracted muscles, tendons and fascia }Joint mobilization – to restore joint play }Scare care }PROM – passive range of motion exercises, AAROM – active assisted range of motion, AROM – active range of motion }Resistance exersice to improve muscle strength }Sensorimotor training – to improve balance skills and joint stability (includes simple exercises such as toe-standing, standing hip flexion, standing side leg raise following modifications doing exercise with eyes closed; balance training aids such as balance discs, unstable platform) }Gait training without assistive devices, correction of gait pattern }Posture correction }Aquatic exercises }Apropriate sports - stacionary bike, cycling, swimming, walking, jogging }Instruction patient to follow exercise at home }Occurs most often in a degeneratively altered tendon, approximately 2-5 from its insertion (there is minimal vascular supply) }Most common in middle age men }Occurs during athletic activity involving a sudden acceleration, sudden change in direction of movement }Typical sports include tennis, squash, volleyball, basketball }Clinical presentation: loud pop is heard, sharp pain, able to bear weight, but unable to stand on toes on affected limb }Objective findings: edema, hematoma, a defect can be palpated, +Thompson‘s test (https://www.youtube.com/watch?v=wCdOoTSm3Vg) }Well-padded 20-degrees of plantar flexion splint with plaster postoperative }Non-weight-bearing with crutches for 4 wk. }Progress to partial weight-bearing with crutch-assisted ambulation in a short-leg fiberglass cast }For High-level Compliant Athletes }Initially use cam boot with 15-20 degrees of equinus (plantar flexion) dialed in, using a heel lift and ankle angle boot setting of 20 degrees of plantar flexion }Active non-weight-bearing ROM exercises can be started as early as 7 days after surgery. Incision must be well healed before inititation of exercises }Initial exercise consists of very gentle passive plantar flexion and active dorsiflexion limited to 20 degrees, two sets of five, three times a day }Use walking boot for 6-8 wk, then make the transition to normal shoes when using the smaller heel lifts }Stationary bicycling (no resistance) and swimming initiated at 6 wk }For lower-demand Athletes }Use a short-leg non-weight-bearing gravity equinus cast for 6-8 wk followed by l-cm heel lift in a removable boot for 1 mo. }Progressive non-weight-bearing resistance exercises are started at 8- 10 wk. }Stationary bicycling and swimming at approximately 8 wk. }Return to some athletic activity (light running) at 5-6 mo if strength is 70% of uninvolved leg }Generally, return to full level takes 1 yr, can take up to 18 mo. }