Manual Therapy and Therapeutic Exercise for Common Orthopedic Conditions and Functional Mobility: Summary 53
Inversion Ankle Sprains These represent the most common lower extremity injury in athletes, with 40-50% of patients experiencing persistent symptoms or recurrence. Lack of dorsiflexion and weakness in the peroneal muscles are common after ankle sprains and in the case of chronic ankle instability. Evidence supports exercise as the main intervention, with manual therapy to improve dorsiflexion enhancing outcomes. Manual Therapy for Ankle Sprains Common manual therapy techniques include: talocrural distraction, anterior to posterior talocrural glides, and soft tissue massage/lymphatic drainage. Adding mobilization with movement (MWM) significantly improves pain, dorsiflexion range, and dynamic balance. Exercise for Ankle Sprains Exercise is the main component of treatment for ankle sprains, with focus in the following areas: • Range of motion-limited inversion/eversion until tenderness is decreased • Stretching of the heel cord • Strengthening: isometric to isotonic exercises (focus on peroneals) ○ Include core and proximal muscles • Neuromuscular and proprioceptive training ACHILLES TENDINOPATHY Treatment approaches include: • Manual Therapy : Limited evidence as a primary intervention but may be beneficial as an adjunct. The goal is commonly to increase ankle DF • Therapeutic Exercise : ○ Eccentric gastrocnemius-soleus strengthening (Alfredson's protocol: 180 repetitions daily for 12 weeks) ○ Progressive tendon loading program with graded mechanical load ○ Seated heel raise → squat → DL standing heel raise → low step down → SL standing heel raise → walking → running → SL hopping • Rehabilitation Phases : 1. Symptom management and load reduction (weeks 1-2): ■ AROM DF/PF, standing DL/SL heel raise on floor, eccentric heel lowering 2. Recovery phase with strengthening (weeks 2-5): ■ DL/SL heel raise on edge of step, eccentric heel lowering, quick heel raises 3. Rebuilding phase with increased intensity (weeks 3-12): ■ Adding weight to heel raises, eccentric heel lowering, plyometrics 4. Sport-specific rehabilitation
○ Week 5: Marching with variations, lateral step downs ○ Week 6: Directional changes while walking, tip toe walking PATELLOFEMORAL PAIN SYNDROME (PFPS) PFPS is characterized by anterior knee pain during activities that load the patellofemoral joint. LEARNING TIP! Treatment focuses on: • Strengthening hip abductors and external rotators to decrease dynamic valgus
• Short foot exercises: Strengthens the intrinsic muscles of the foot, improves the longitudinal and transverse arches, and strengthens the abductor hallucis muscle. Overall improved pronation control leads to reduced tibial internal rotation and hip ADD • Addressing biomechanical factors that increase patellofemoral joint stress
Patellar Tendinopathy Also known as "Jumper's Knee," this condition is common in jumping sports. Rehabilitation focuses on progressive load tolerance development using a three- tier progression: • Tier I : Walking, low step exercises, basic squats (60 deg), low step down, high step up, SL squat (60 deg), DL squat (full) • Tier II : Lunges, jumping exercises, run/stop, SL squat (full), running • Tier III : Advanced hopping (SL), SL decline squat, cutting, and sport-specific movements ANKLE JOINT: BIOMECHANICS AND CONDITIONS Ankle Mechanics The ankle joint is formed by the articulation between the mortise (tibia and fibula), which is concave, and the trochlea of the talus, which is convex. Motion is triplanar but primarily occurs in the sagittal plane (dorsiflexion/ plantarflexion). A normal range includes 10-20° of dorsiflexion and 34-50° of plantarflexion There are accessory motions in both OKC and CKC conditions. CKC ankle dorsiflexion is functionally necessary for walking, running, stairs, and transfers, with limitations linked to various injuries. During closed kinetic chain (CKC) dorsiflexion, the mortise rolls and glides anteriorly. In OKC dorsiflexion, the convex talus rolls anteriorly but glides posteriorly.
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