HSS Cavanaugh I

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HSS Cavanaugh I
2012-10-18 17:08:39
HSS Cavanaugh

HSS Cavanaugh I
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  1. disciplines on the sports therapy team
    PTs, athletic trainers, PAs, massage therapist, orthopedic surgeons, MDs, exercise physiologists, chiropractors
  2. Cavanaugh's 3 rules of rehab
    • #1 create a safe env: have a sound understanding of bsic sciences, be aware of physiological heating restraints, etc
    • #2 don't hurt the pt: unless it's really necessary for ROM, don't push pt into pain, and instruct the pt to not put self in pain at home
    • #3 be aggressive w/o breaking rules 1 and 2
  3. functional progression
    ordered sequence of activities enabling the acquisition or reacquisition of skills required for the safe, effective performance of athletic endeavors
  4. SAID
    specific adaptations to imposed demands = specificity / replicate in therapy what the pt will be facing in sport or life
  5. "every step is therapy" - Cavanaugh's intent
    use walking as learning and healing, so don't rush to get pt off crutches. Getting off them too early may hurt the wound. Staying on them a little longer can help pt learn better and more safely to walk. (too many MDs will say a pt can get rid of crutche w/o first watching the pt walk)
  6. "throw out the cookbook" - what Cavanaugh means
    Don't follow a protocol. Look at guidelines, yes, but then make each treatment personalize to the pt' strength, ROM, prior level of activity, specifics of the surgery, etc.
  7. "treatment base on evaluation"
    "keep modalities in their place"
    • don't just treat based on the name of the surgery and the number of days post-op
    • don't over-rely on modalities like e-stim
  8. main mechanism of muscle strain injury
  9. which muscles are most prone to strains?
    2-joint muscles when they're elongated during a quick, powerful stretch
  10. injury grading
    • I, II, III - III is the worst. w II and III you'll feel a  palpable divot at site of injury
    • tx is based on grade
  11. RICE, and an extra bit on I
    rest, ice, compression, elevation

    ice can help keep local cells from dying hypoxic deaths

    also, work on protection - unload pt, get her on crutches, put a heel lift in both shoes to get her in flexion, etc - whatever will help take pt out of pain
  12. a reason strengthening, not just basic healing, is so important
    The injury prob happened bc muscle wasn't strong enough to meet the demands placed on it. Got to strengthen it after injury to meet sport's needs
  13. 5 general principles/steps for treating athletes
    • RICE
    • protection
    • AROM
    • flexibility
    • strengthening
  14. thigh contusion - etiology, immediate tx, protective tx when pt returns to play
    • direct blow to thigh
    • ice in flexion, w ice held to flexed knee by an ace bandage wrapping around the knee and calf, holding calf in tight
    • the flexion, bandage, and ice all provide pressure which limits hematoma and limits ROM loss
    • later, put a protective pad on pt's thigh to distribute force of any new blow
  15. myositis ossificans
    old blood from a thigh contusion gets stagnated under a new wound, and the old blood starts turning to heterotopic bone --> permanently reduced ROM --> reduced running speed
  16. heterotopic ossification
    process by which bone tissue forms outside of the skeleton
  17. 4 overuse injuries
    • patella tendonitis
    • ITB synderome
    • PFPS - patellofemoral pain syndrome
    • plantar fascitis
  18. 7 elements of tx
    • eval - determine cause
    • activity modification - get pt to take some rest, or at least switch to a less harmful activity
    • NSAIDS
    • therapeutic modalities
    • flexibility
    • strength
    • return to sport progression
  19. lig most commonly injured in sports, and who gets it more
    • ACL, females (4:1 in basketball, 6:1 in soccer)
    • women have wider pelvis, increased flexibility, less developed musculature, narrower femoral notch, more genu valgum
  20. a few mechanisms for ACL injuy
    • hyper ext
    • varus/valgus force
    • rotation
    • unhappy triad
    • "hanom foot" for skiers
    • most ACL injurie are non-contact injuries
  21. unhappy triad
    ACL, MCL, and med meniscus all go at once
  22. 3 surgeries for ACL replacement
    • bone-tendon-bone operation (taking pieces from pt's body)
    • hamstrings (spaghetti strings from pt's own)
    • allograft - cadaver lig
  23.  functions of ACL
    • prevents foward translation of ibia on femur
    • checks IR
    • checks hyperext
  24. surgery vs conservative tx depends on...
    • age of pt
    • activity level(you can do a triathalon w/o an ACL, but if you want to do decellatory or rotational sports you need one)
    • laxity (objective finding) / instability (subjective complaint)
  25. 4 aspects of old fashioned post-op ACL life
    • prolonged immobilization/bracing
    • limited ROM
    • NWB
    • "strict protocols" - like a year to recover
  26. goals for pre-op PT for an ACL
    • get full ext
    • normal gait
    • 125 degrees flex
    • strength for ascending stairs
    • quads firing
  27. 5 things to address in a pre-op PT consult for the ACL
    • pt edu (what to expect, how to don/doff brace, how to walk w brace)
    • KT1000 knee ligament arthrometer
    • amb training
    • brace management
    • therapeutic exercise
  28. hospital stay for ACL surgery, then and now
    • was: ~3 days
    • now: ~3 hours
  29. first concern post op
    asap, must get knee straight - put a towel under the ankle, not knee
  30. post-op goals for ACL
    • quad control (SLR w/o knee quivering or pain)
    • ROM - full ext and flex
    • normal gait pattern w/o crutches
    • ascend stairs w normal pattern w/o pain
    • descend stairs
    • running
    • activites for sport - cutting, plyometrics, etc
  31. 3 early post-op goals after ACL surgery
    • full ext
    • effusion control (cryocuff)
    • quads re-edu (use estim to get them firing -- the body, sensing the knee is hurt, wants to turn off the quads)
  32. OKC leg raises, at what angles does it impact ACL?
    • 90-70 degrees flex it's not ACL
    • 0-70 it's ACL
  33. CKC squat and OKC flex, when are these straining the ACL
    never - they hit the PCL
  34. ACL rehab activity for early mob (starting day 1)
    calves off table, contralat leg pushes hurt one into ext, supports it on the way down into flex, then dangle, then try unilat to pus back into flexion. Repeat, and occasionally have contralat leg help push into flexion
  35. wt bearing status immed post ACL op
    PWB - this helps promote ext
  36. CKC squats - benefits when compared to OKC
    loads joint, provides stbility, less shear, less load on ligs, less pattelo-femoral joint reaction force
  37. which has more influence over functional outcomes, neuromuscular control mechanisms or joint laxity?
    neuromuscular control mech > joint lax
  38. 6 eval techniques for initial eval of ACL pt 
    • Incision site – look for sin quality, infection, etc
    • Edema – palpate and measure
    • Quad strength – is it firing?
    • Strength at hip and ankle joints
    • Gait – deviations, how’s the wt bearing Is pt in full extension?
  39. 6 things to do on first treatment for an ACL pt
    • Work on quad setting (put heel on table, towel under knee to press down against)
    • Put pt on short crank bike
    • Dangle legs off edge of table w contralat leg helping w flex and ext
    • Gait training w crutches
    • E-stim on quad to help it fire
    • Calf stretch for gastroc
  40. 6 Short term (6 week) goals for ACL pt
    • Full knee ext
    • Flex to 120 degrees
    • Ascend 6” step w recip pattern
    • Normalized gait
    • SLR w/o lag (demonstrates quad control)
    • Single limb stance eyes closed 10 sec
  41. 5 Long term (7 month) goals for ACL pt
    • Descend 8” step w control
    • Treadmill running program
    • Accomplishing sport-specific goals
    • Perform X jumps over Y distance without apprehension
    • 5/5 muscle strength
  42. 6 Treatment interventions for ACL pt at POD 6
    • Mobilize patella
    • Stretch hamstrings
    • Bridging – for core strength
    • Walking in water
    • SLRs in all 4 directions
    • Proprioceptive – as soon as 50% wt bearing, get pt on uneven surface, close eyes, reestablish neuro pathways
  43. Steps in a jumping program
    • Jump up and land softly
    • Later, jump both up and down
    • Jump rope, jump around a target on the ground or over obstacles
  44. PCL – when to do surgery, when to do non-op w rehab
  45. Depends a lot on pt’s age, goals, and the laxity, but also….
    • If it’s an isolated injury à non-op. If it’s combined w MCL, LCL, or PLC, à surgery
  46. Patello-femoral joint is at risk of getting more pressure if __ lig is gone
  47. PCL 3 jobs
    • Restrain posterior tibial displacement
    • Restrain ER
    • Restrain varus-valgus rotation
  48. Biomechanics of PCL
    • Average ultimate failure strength < 2x ACL
    • Increased forces w hamstring loading 12-100 degrees
  49. Mechanisms of injury for PCL
    • A/P force on a flexed knee w/wo rotary force (ex – knee hitting the dashboard in a car accident)
    • Rotary force w varus or valgus force
    • Hyperextension
  50. ACL works w PCL to determine the blend of …?
    Gliding/sliding btwn tib/fib
  51. Non-op management of PCL injury/loss includes…?
    • Quads strengthening
    • Protect patella
    • Restore normal ROM
    • Proprioception training
    • Functional progression
    • Avoid strengthening at deep flexion angles (no deep squats, leg presses, hamstring curls)
    • No OKC hamstring strengthening
  52. Post-op rehab guidelines after PCL reconstruction
    • Work on motion and wt bearing, but less aggressively than for ACL
    • Patella mob
    • Quads re-edu
    • No OKC hamstring strengthening
    • Make sure knee is at 90 degrees flex by 6 weeks
  53. How is OKC at any point surrounding a PCL wound?
    Don’t do it!!
  54. MCL  is good for what?
    • Primary restraint to valgus force
    • Restraint to ER
  55. Biomechanics of MCL
    Taut thru ROMIncreased tautness as knee approaches full ext
  56. Mechanisms of injury to MCL
    • Valgus or valgus/rotation force w leg fixed
    • Injury common in football bc players get tackled at knees from the side
  57. Management of MCL injury
    • Surgery unlikely for isolated injry (they generally scab down and heal well enough, even grade III)
    • Immobilization / Rehab – based on eval
    • Consider physiological healing restraints!
  58. MCL injuries grades I, II, III – how they’ll appear, and when return to play
    • I – pain but no gap – might could return to play next week
    • II – hinge w/ an end feel
    • III – no end feel – needs a brace, usually season ending
  59. Biomechanics of ACL injury
    • Increased anterior translation w active knee extension (OKC) esp 60-0 degrees
    • Increased stress (ACL) w increased tibial rotation