ACL Considerations

Anterior Cruciate Ligament (ACL) injuries can be an excruciating ordeal to overcome. There are so many questions such as graft options, physicians, rehab protocols, etc.  We can help guide you at Rock and Armor, if you have suffered this injury.  Below are some key points nicely put together by one of our current students, Chris Edwards, SPT, from Eastern Washington University.

ACL Graft Options1

1. Bone-Patellar Tendon-Bone (BTB) autograft- Is considered the gold standard in ACL reconstruction. Requires the harvest of the central third of the patellar tendon with attached bone blocks from the patella and tibial tubercle. BTB is the graft of choice for active individuals especially under the age of 25.

Advantages- Bone to bone healing, ease of harvesting, good clinical outcomes, lower graft failure rates.

Disadvantages- Anterior knee pain, low risk of patella fracture and patellar tendon rupture.

2. Quadrupled Hamstring graft- Semitendinosus and Gracilis tendons are harvested from their pes anserine attachment and then folded to form a quadrupled construct.

Advantages- Decreased donor site morbidity and greater initial biomechanical strength.

Disadvantage- less reliable healing because it relies on bone growth into tendinous soft tissue opposed to bone to bone healing, also unable to stretch hamstrings for up to 6 weeks post-surgery.

3. Allografts- Include cadaveric patellar, quadriceps, hamstring, and achilles tendons.

Advantages- eliminates harvest site morbidity

Disadvantages- infection risk, increased failure rates in more active individuals (due to graft weakening from sterilization processes).
Technique2

Attachments: Tibial attachment- medial to the anterior horn of lateral meniscus, Femoral attachment- posterior lateral aspect of the intercondylar notch on lateral femoral condyle. Graft fixated with interference screws, Graft strongest and fixation weakest initially.
Incisions- Two 1 cm incisions around the patella tendon for the arthroscopy equipment. Small 2cm incision below the joint along the inside of you knee where the tunnels are drilled and the graft is obtained, small incision above and outside the knee where the fixation for the graft on the femur was placed.

Protocol3
Pre-Operative: increase range of motion (ROM), decrease swelling, decrease pain, restore normal strength for ADL’s and gait, prepare for surgery.

Post OP days 1-10: RICE medicine, early ROM exercises (passive extension exercises, seated AAROM for knee extension and flexion), quadriceps strengthening (quad sets, SLR in immobilizer), hamstring strengthening (heel slides, avoid until 4-6 weeks if hamstring graft used), 50% weight bearing use two crutches, suture removal, maintain passive extension, and return to desk job.

Days 10-14: Maintain full passive knee extension, achieve 100-120 degrees of knee flexion, develop muscle control to wean off knee immobilizer (able to perform SLR with no sag), early closed chain exercises (partial squats, calf raises), 50-75% weightbearing use 1 crutch (progress to no crutches if they can walk with no limp with a reciprocal gait pattern), and stationary bike (if 100 degrees of knee flexion).
Weeks 3-4: Full extension ROM, continue strengthening exercises, expected ROM 100-120 degrees of knee flexion (add wall slides), and start elliptical training.
Weeks 4-6: Push ROM exercises want 125 degrees of knee flexion (closing in on full flexion), strength building (Goal at week 6 is affected leg quad strength to be 60% of non-affected), add double leg balance activities (airex pad, tilt board).

Week 6-12: Week 6 want to maintain full extension and receive 135 degrees of knee flexion, can start hamstring curls if hamstring graft used, start flat treadmill, begin outdoor bike on flat road, strengthening exercises (week 8 goals are quadriceps and hamstrings of affected leg to be 80% of non-affected leg), add single leg balance activities if good knee control.
Week 12-20: Continue strengthening, introduce light jogging and running if can perform all ADLs and exercises without an increase in swelling, introduce agility.

24 weeks: Earliest you should plan to return to sport. Return to sport goals include quadricep and hamstring strength at least 80% of unaffected limb, full motion, no swelling, good stability and can complete a running program.
Return to Sport Tests4,5

Return to Sport tests include: Y balance, triple hop test, single hop distance test and isometric knee extension strength. Experts recommend not to return to sport until the Y Balance ANT has < 4 cm difference between affected and non-affected leg, be able to jump at least 90% the distance on the affected leg as the non-affected leg and to have at least 85% strength in the hamstrings and quadriceps on the affected side compared to the non-affected side.

If you need some guidance following ACL injury, please feel free to reach out to us at rockandarmor@yahoo.com, call 208-917-2660, or DM us on instagram or FB @rockandarmor

Reference List
1. Klinge SA, Sawyer GA, Hulstyn MJ. Essentials of Anterior Cruciate Ligament rupture management. Rhode Island Medical Journal. 2013;96(5):28-32.
2 Hosea, T. ACL reconstruction: techniques and avoiding pitfalls. University Orthopaedic Associates. 2015;1-38..
3. Evans, IK. ACL reconstruction rehabilitation protocol. Sports Medicine North Orthopedic Specialty Center. 2018; 1-23.
4. Teyhen DS, Robertson J. Return to sport: when should an athlete return to sport after an ACL surgery?. J Orthop Sports Phys Ther. (2011);41(6):388.
5. Garrison JC, Bothwell JM, Wolf G, Aryal S, Thigpen CA. Y balance test™ anterior reach symmetry at three months is related to single leg functional performance at time of return to sports following anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2015;10(5):602-11.

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Cooler Temps = A Great Time to Train Indoors At Rock and Armor

Fall and winter are great times to move your training indoors with out incredible team at Rock and Armor.  Whether you are looking for space for hitting/pitching on the weekends, or speed, strength, and agility training with one of our highly acclaimed Performance Coaches, Rock and Armor can help you and your team take their game to the next level. Whether you desire 1-on-1 training, team training, or want to join one of our existing classes, we can customize a routine to meet your needs and help you get bigger, faster, stronger, and stay ahead of the competition.  Visit our website at https://www.rockandarmor.com/class-schedule for a list of current classes.  Don’t see what you are looking for? Call 208-8917-2660 and we will meet to discuss goals and appropriate training this fall/winter.  We look forward to helping you reach your goals!

Scapular Dyskinesia

Scapular Dyskinesis

By Cody Suder, SPT, CSCS

• The scapula is a bone on the back side of your shoulder, commonly referred to as the shoulder blade. It serves as an attachment for many muscles that contribute to the shoulder, upper arm, thorax, neck, and chest.
• Scapular (shoulder blade)Dyskinesis appears to be a nonspecific response to shoulder dysfunction. With scapular dyskinesis, cases may be result of loss of muscular coordination, leading to abnormal scapulohumeral rhythm and various other shoulder pathologies as a result.
• Scapular dyskinesis can result in inhibition or disorganization of activation patterns in scapular stabilizing muscles.

Types of Scapular Diskenisis:

• Type I (Scapular tilt): Type I is characterized by prominence of the inferior medial scapular border.
• Type II (Scapular winging):is the prominence of just the medial border of the scapula.
• Type III (Scapular Shrugging): associated with shoulder impingement and rotator cuff injury and displays prominence of the superior medial border.

Muscles Involved:

• Scapular Upward Elevation: This movement occurs during arm elevation, such as moving the arm forward or to the side(flexion and abduction). Muscles involved include upper trapezius, lower trapezius, and serratus anterior.
• Scapular Downward Elevation: This movement occurs during lowering phase of elevated arm movements (adduction and extension). Muscles involved include levator scapulae, latissimus dorsi, pectoralis minor, and rhomboids.
• Scapular Protraction: This movement occurs during pushing activities, such as performing a push-up or closing your car door. The main scapular protractor is the serratus anterior.
• Scapular Retraction: This movement occurs while performing pulling activities, such as performing a row or closing a door. Scapular retractors include the trapezius(middle and lower fibers) and the rhomboids.

Is your scapular dyskinesis causing shoulder dysfunction? If so: what can you do on your own?

• Stretching muscles that attach to your scapula.
  • Pec Stretch (doorway stretch)
  • Posterior shoulder stretches (arm cross body)
  • Upper trapezius stretch (ear to shoulder)
• Strengthening muscles that attach to your scapula.
  • External rotation: keeping elbows at side and flexed to 90 degrees, rotate arms to the side.
  • Scapular retraction: pinching your scapula together as if to pin a tennis ball in the middle of your back.
  • Serratus Punches/ push-up plus: while lying on your back push your arm up to the sky as if to reach for something above you. OR, while performing a pushup, at the top of the motion try and push your back to the ceiling.
• What can your Physical Therapist do for you?
  • Provide manual mobilization (specific joint techniques) that allow for more efficient and normalized movement patterns.
  • Provide specific strengthening and stretching exercises to pinpoint your specific dysfunction and return to prior level of pain free functioning.
  • Implement modalities, such as electrical stimulation, ultrasound, heat and ice, that require skilled intervention to help relieve pain, normalize tissue, and speed recovery processes.
  • Provide you with home exercise programs that allow you to minimize future problems and provide you with your own self-care and independence.

 

 

Help my child’s heel pain

Sever’s Disease

What is it?

Sever’s disease is a painful bone disorder that results from inflammation of the growth plate in the heel. It is a common cause of heel pain in growing kids. It occurs during adolescence: Age 8-13 for female, 10-15 for males. It rarely occurs in older teens because the back of the heel usually finishes growing by the age of 15.

Why?

During the growth spurt of early puberty, the heel bone/calcaneus sometimes grows faster than the leg muscles and tendons. This can cause the muscles and tendons to become very tight and overstretched, making the heel less flexible and putting pressure on the growth plate. Over time, repeated stress on the already tight Achilles tendon damages the growth plate, causing the swelling, tenderness, and pain of Sever’s disease.

* A child is more at risk if they have pronated feet, flat or high arches, short leg syndrome, or if they are overweight.

Symptoms

Most common and most obvious is pain or tenderness in one or both heels-usually at the back. The pain might also radiate to the sides and bottom of the heel.

-swelling and redness in the heel

-difficulty walking

-discomfort in the feet in the morning

-discomfort when the heel is squeezed on both sides

-unusual gait- limping or on tiptoes to avoid putting pressure on the heel.

Diagnosis

Most doctors are able to diagnose sever’s disease based on the symptoms. They may have an x-ray taken to rule out any fractures, but you cannot see sever’s disease on a x-ray.

Treatment

Goal: pain relief!! Because the pain usually increases with activity, they will need to rest to relieve pressure on the heel bone, which will decrease pain.

-foot and leg exercises to stretch and strengthen the leg muscles and tendons

-ice to reduce swelling

-compression stocking for swelling

-Tylenol/ibuprofen

—Severe cases the doctor could place a cast from 2-12 weeks to immobilize the foot so that it can heal.

With proper care, it will go away within 2 weeks-2 months and doesn’t cause problems later on in life.

-Proper shoes(shock-absorbent soles, maybe shoes with open back to relieve pressure on the heel. No heavy or high heels

If your child is suffering from heel pain, call Rock and Armor at 208-917-2660 to get them headed in the right direction.

 

O’Brien, K. B. (Ed.). (2013, June). Sever’s Disease. Retrieved April 16, 2018, from https://kidshealth.org/en/parents/severs-disease.html

Carpal Tunnel Syndrome-Rock and Armor

Carpal Tunnel Syndrome

 By Mikayla Andersen, SPTA

Carpal tunnel syndrome is a peripheral nerve entrapment injury that occurs as a result of compression of the median nerve where it passes through the carpal tunnel. The carpal tunnel is created by the transverse carpal ligament, scaphoid tuberosity and trapezium, hook of the hamate and pisiform, and the volar radiocarpal ligament. The median nerve, FDP, FDS, FPL pass through the carpal tunnel.

Etiology: Unclear, however associated conditions that contribute to CTS include repetitive use, rheumatoid arthritis, pregnancy, diabetes, cumulative trauma disorders, tumor, hypothyroidism, and wrist sprain or fracture.

Signs and Symptoms: Sensory changes and paresthesia along the median nerve distribution in the hand. It can also radiate into the upper extremity, shoulder, and neck. Some symptoms you may have are: night pain, weakness of the hand, muscle

atrophy, decreased grip strength, clumsiness, and decreased wrist mobility. 

Diagnosis: Electromyography and electroneurographic studies can be used to diagnose a motor conduction delay along the median nerve within the carpal tunnel. MRI’s are also used to identify inflammation of the nerve, altered tendon or nerve positioning within the tunnel or thickening of the tendon sheath. Tinel’s sign, and phalen’s test can be used to assist when confirming the diagnosis.

Treatment: No universally accepted treatment, however, patients will initially receive conservative management including splinting, ergonomic measures, local corticosteroid injections, and physical therapy management.  In physical therapy, patients can expect to receive carpal mobilization, and gentle stretching. Severe cases may require surgical release of the carpal tunnel. Post surgical physical therapy intervention should include the use of moist heat with electrical stimulation, iontophoresis, cryotherapy, gentle massage, desensitization of the scar, tendon gliding exercises, and AROM. Patients should initially avoid wrist flexion and a forceful grasp. Patients should see improvement of symptoms within four to six weeks. If they have to do surgery, rehab may last six to eight weeks.

If you think you may have carpal tunnel syndrome, or would like to try non-surgical treatment options for your symptoms, call Rock and Armor at 209-917-2660 or visit www.rockandarmor.com

Hip Impingement-Rock and Armor Physical Therapy and Sports Performance

Femoral Acetabular Impingement (FAI) occurs when bony aspects of the femur and acetabulum of the hip pinch together during certain movements of the leg. The acetabulum is the socket of the hip joint that the head (ball) of the femur sits inside.  FAI can be divided into either cam impingement or pincer impingement subtypes.  Cam impingement occurs with a thickening of the femoral neck.  Pincer impingement occurs with osteophyte growth on the acetabular rim.

FAI often causes hip pain during sitting and activities that involve hip flexion and internal rotation.  It can limit range in these motions and people often notice these limitations before they ever have pain.  FAI generally occurs in middle-aged adults with cam impingement much more likely in males (14:1), and pincer impingement more likely in females (3:1).  This condition can result in damage to articular cartilage and the labrum over time.  Physical therapy has been show to have similar results to surgical intervention in people with FAI.  Unfortunately, many people still report pain after surgical intervention.

Physical therapy program for FAI often includes a combination of much of the following:

• Manual Therapy: Hip Extension in Standing MWM, Hip Distraction during Internal Rotation MWM, Loaded Lateral Hip Distraction MWM, Loaded Internal Rotation, Lateral Glide in External Rotation, Long Axis Hip Distraction
• Motor Control Exercises: Reverse Lunge with Front Ball Tap, Isolateral Romanian Deadlift with Dowel, Lateral Step-Down with Heel Hover, Side Plank, Seated Isometric Hip Flexion, Supine Hip Flexion with Theraband.
• Mobility Exercises: Kneeling Internal Rotation Self-Mobilization with Lateral Distraction, Half-Kneel FABER Self-Mobilization, Quadruped Rock Self-Mobilization with Lateral Distraction, Prone Figure-4 Self-Mobilization, ITB Soft Tissue Self-Mobilization on Foam Roll, Quadriceps Soft Tissue Self-Mobilization on Foam Roll, Piriformis/Glut Min Self Myofascial Release on Ball, Standing Figure-4 Stretch, Kneeling Tri-Planar Mobilizations

If you think you have Femoracetabular Impingement Syndrome and could benefit from treatment for this  condition, visit http://www.rockandarmor.com/contact.html or call 208-917-2660 to schedule an appointment.

Mansell et al (2018)

 

 

Squatting

Hip Mobility and Recruitment for an improved squat

I. Functional Assessment

• Perform non-cued squat

• Perform full deep squat

 

II. Functional Movement Presentation

• Knee Valgus

• Tibial External Rotation

• Lumbar flexion/posterior pelvic tilt

• Lumbar reversal fault (butt wink)

• Forward trunk

• Knees forward

• Decreased hip mobility

• Decreased ankle mobility

 

III. Problem List

• Weak/tight hip external rotators

• Tight hip adductors

• Weak Lumbar extensors

• Weak hip flexors

• Tight hamstrings

 

IV. Corrective Squat Biomechanics

• Feet placement: shoulder width apart/slightly outside

• Toe alignment: neutral/5-12 degrees ER if necessary

• Spinal alignment: braced in neutral (two-hand rule)

• Femoral ER torsion force

• Supinated/stable foot

• Knees outside of feet movement

• Upright/vertical trunk movement

 

V. Stretches

• ER Table stretch

• Pigeon stretch

• Warrior stretch

• Goalie stretch

• Hip opening band stretch (supine against wall)

• Executive hip stretch

 

VI. Exercises

• Squat rack barbell squat

• Wall squat

• Box squat

• ER theraband

 

I. Other Considerations

• Heel lift

• Load position

• Low-bar back, high-bar back, front, overhead

If you think you could improve your squat mechanics, visit www.rockandarmor.com or call 208-917-2660 to schedule an appointment with a skilled physical therapist today.

References

Starrett K. Cordoza G. Becoming a Supple Leopard: The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance. Victory Belt Publishing Inc. Las Vegas. 2015.

SCHOENFELD BJ. Squatting kinematics and kinetics and their application to exercise performance. Journal of Strength & Conditioning Research (Lippincott Williams & Wilkins). 2010;24(12):3497-3506.

Todoroff M. Dynamic deep squat: Lower-body kinematics and considerations regarding squat technique, load position, and heel height