W8 Flashcards
Treatment planning depends on what
findings from patient interview & physical examination
identification of Impairment(s), functional limitation(s), participation restriction(s)
BUT ALSO need to consider:
* Psychosocial (contextual) factors
* Patient’s goals
diagnosis is still important – WHY?
Need to be aware of pathology & stage
Aims of Physiotherapy Management
Return to function/sport
Functional activity progression
Neuromuscular control
Muscle conditioning
Muscle flexibility, joint ROM
Localised Tissue healing
Intervention(s) - options PEMAT
Advice & education
Therapeutic Exercise
Manual therapy eg PAM, massage
Physical devices eg tape
Electrophysical agents eg ice heat
Advice & Education
- Rest / load modification to allow adequate
healing/recovery and settle acute symptoms - Use of P.O.L.I.C.E.
- Role of external devices/walking aids to de-load and protect affected structures to allow healing
Treatment aim: Tissue healing
External devices – immobilisation & protection
- Stress #
- NWB until ‘clinically stable’: minimal or no palpable pain at # site, minimal or no pain with activities in brace
- Generally 6-8wks
- If poor response, surgery may be required (e.g. navicular)
- Lis franc (6-8 weeks)
- High ankle sprain (4-6 weeks)
- only if separation of syndesmosis
Treatment aim: Tissue healing
External devices – taping & bracing
De-loading/protection of injured structures e.g.
* ankle ligament sprain
* Tendinopathies (tibialis anterior, tibialis posterior, soleus, plantar fasciopathy)
Treatment aim: Tissue healing
External device
De-loading/protection of injured structures
e.g. heel cup for fat pad contusion, heel spur
e.g. heel raise (30-50mm) for:
* Calf strain
* Achilles Tendinopathy
E.g. temporary adhesive felt for Morton’s neuroma (disc shape or donut)
Treatment aim: Tissue healing
Electrophysical agents- cold
❖Minimise extent of damage (POLICE)
* Cryotherapy, IFT
* When- Acute injuries, Acute swelling, Inflammation, Muscle spasm
Treatment aim: Tissue healing
Electrophysical agents- heat
❖Stimulate tissue healing & blood flow
* Ultrasound (Pulsed), IFT, Laser, Heat, ESWT
When- Localised inflammation, Superficial injuries, e.g. muscle strains, ligament sprains, tendon injuries (PF, AT, Glut Med)
Treatment aim: Improve Joint ROM
Manual Therapy & Therapeutic Exercise
- Mobilisation
- Joints (PAMs, PPMs)
- Soft tissue (massage)
- Neural structures (neurodynamics)
- Stretching (muscle length)
- Early, pain-free AROM should be encouraged
Treatment aim: Improve Joint ROM- DORSIFLEXION when would uou do it and what techniques
- Anterior impingement
- Post-immobilisation
- Post-ankle sprain
tech= AP talar glide WB / NWB)
Treatment aim: Improve Joint ROM- plantarFLEXION when would uou do it and what techniques
When- Rigid foot, Post-immobilisation, Post-ankle sprain
Which technique(s)?
* S-T joint transverse mobilisation
* Medial glide to improve eversion
* Lateral glide to improve inversion
Treatment aim: Improve Joint ROM- ankle ROM
- Particularly if pain key feature post ankle sprain a useful technique is AP fibula MWM
- Consider replicating with taping
Also shown to be useful in improving ankle position in landing from a jump
Treatment aim: Improve Joint ROM- ankle PAMs when would uou do it and what techniques and why
When?- Capsular tightness, Anterior or posterior impingement, OA
Which technique(s)- T-C or S-T joint distraction +/- MWM
Why- To de-load joint surfaces, To stretch surrounding soft tissue
Treatment aim: Improve Joint ROM- midfoot and forefoot PAMs when would uou do it and what techniques
When?- Post immobilisation, Post ankle sprain, Rigid foot
Which technique(s)?- Intertarsal glides (AP/PA), Tarsometatarsal glides (AP/PA)
Treatment aim: Improve Joint ROMof dorsiflexion restrictions when would uou do it and what techniques
Soft tissue tightness – common culprits:
* Gastrocnemius/soleus
* Plantar fascia
* Deep flexors & TP
Which exercises/techniques?
* Massage & stretching
* Foam roller and trigger ball
* Dry needling
Treatment aim: Muscle conditioning
Consider the patient’s impairments
* voluntary activation (& co-ordination)
* muscle strength
* muscle endurance
* muscle reaction and timing
* postural control
Treatment aim: Muscle conditioning
Therapeutic Exercise for the foot
Example: Medial Long. arch
* Intrinsic foot muscles
* Tibialis posterior in the excessive pronator
* Can be done NWB and FWB
Treatment aim: Muscle conditioning
Electrophysical Agents
Muscle stimulation
* Intrinsic foot muscles
* Can be done NWB and FWB
Four (4) Stage Program
More recent Tendinopathy Protocol for Mid Portion Achilles Tendinopathy
Stage 1: Isometrics for pain relief
Stage 2: Isotonic strength endurance
Stage 3: Energy storage exercises
Stage 4: Energy storage & release
Stage 1: Isometrics for pain relief
indications, implementation and cosideration
indications= reactive tendionopathy, reactive or degenerative tendionopathy
implemtation= isometric heel raises 5 sets 45 seconds several times a day
considerations= different ankle ROM for mid-portion v insertional tendionpathy, treat plantaris like insertional tendionopathy, dont forget soleus, no tendon bouncing avoid compression of tendons
Stage 2: Isotonic strength endurance
indications, implementation and cosideration
indications= pain is stable on morning test, pain has settled from peak
implemtation= 4 sets 6-8 reps 2 times a week slow and heavy isotonic heel raises
considerations= avoid compression of tendon, avoid tendon speed, encourage implementation in the evening to avoid calf fatigue during the day, dont forget rest of the kinetic chain
Stage 3: Energy storage exercises
indications, implementation and cosideration
indication= pain is stable on morning test, symmetry in muscle bulk, good strength eg 1.5x body weight, kinestic chain deficits addressed
implemetation= every 2-3 days & assess response, may keep strength going, consider equal emphasis on neural reprogramming and muscle tendon function eg stair running, split squats, skipping
considerations= add or change only one thing at a time, exercise also include energy release- but done slower than a grade 4
