Lab 5: Lower Extremity Party 3 Group #1 Carlos Leon-Carlyle #0317752 Bruce Monkman #0310446 Loriana Costanzo #0308293 Mike Bois #0308171

Case Study #1 Chronic muscular tears to the hamstrings, calf, and Achilles tendon.

Supine Hamstring Stretch (Flexibility) The patient lies supine with the uninvolved extremity extended. The involved knee is brought toward the chest, and the hands are clasped behind the thigh. The knee is then actively extended as far as possible so that a stretch is felt behind the knee or in the thigh. Hold for 15-20 seconds. 2-3 sets. Rest 30 seconds in between sets. The opposite extremity is kept in extension to stabilize the pelvis so that the ischial tuberosity does not roll upward and reduce the effectiveness of the stretch on the hamstrings.

Standing Gastrocnemius Stretch (Flexibility) Patient is in a straddle position with the extremity to be stretched behind the opposite extremity. The patient places his or her body weight on the arms, which are supported on the wall and on the front foot while the back extremity remains extended at the knee. The heel should remain in contact with the floor; the hip should be forward of the knee; and the foot should be in a straight line or the toes slightly turned inward. Hold for 15-20 seconds. 2-3 sets. Rest 30 seconds in between sets. Common substitutions are allowing the midfoot to collapse by rotating the foot outward, lifting the heel off the floor, bending the knee, or moving the hips posteriorly.

Soleus Stretch (Flexibility) Uses similar position as Gastrocnemius stretch. With the involved extremity behind the uninvolved, he or she keeps the foot flat on the floor, with the foot turned slightly inward, and then slowly flexes the knee until stretch is felt in the calf. Hold for 15-20 seconds 2-3 sets Rest 30 seconds in between Common substitutions are outward rotation of the foot, knee valgus positioning, and posterior movement of the hip as the knee is flexed.

Calf raises (strengthening) The patient stands upright with the feet about shoulder width apart and raises up onto the toes as high as possible and slowly returns the feet to the starting position 10-15 reps 2-3 sets 30 seconds rest To increase difficulty, stand with toes on a raised surface such as a step.

Hamstring resistance (strengthening) Patient lies prone with a partner. With lower leg flexed at the knee joint, partner actively applies resistance to the flexion movement. Hold for 15-20 seconds 2-3 sets Rest one minute in between sets Adaptations include using an ankle weight, or attaching a theraband from the leg of the table to around the ankle.

Bent knee calf raise (strengthening) The patient stands upright with knees bent over the toes and feet shoulder width apart. The patient then raises up onto the toes as high as possible in a rocking motion, and slowly returns the feet to the starting position 10-15 reps 2-3 sets 30 seconds rest To increase difficulty, hold extra weight.

Pillow Standing (Stability) Patient stands upright on one foot on a pillow. Balance for as long as possible. Hold up to 1 minute. Perform exercise until 3 minutes of total balance time is attained. To increase difficulty, perform exercise with eyes closed. Can also be performed on a wobble board, or trampoline.

Raised Heel Pillow Stand Patient stands upright on both feet on a pillow. Raise heels so as to balance on toes. Balance for as long as possible. Hold up to 1 minute. Perform exercise until 3 minutes of total balance time is attained. To increase difficulty, perform exercise with eyes closed. Can also be performed on a wobble board, or trampoline.

Swiss Ball Stability Patient lies supine with legs flexed at the hip joint. Partner places Swiss ball in between feet. While patient attempts to balance the ball, partner repeatedly hits the ball with hand providing extra resistance Hold for 15-20 seconds 2-3 times Rest for 30 seconds in between sets For an alternative, perform the exercise while holding the weight of the partner on the feet. (superman/airplane

Running C’s (Plyometrics) In a forward motion, flex the leg at the knee, and forcefully drive the heel toward the buttocks as quickly as possible. 25 reps 3 sets Rest for 1 minute To increase intensity of exercise, apply weights to the ankle, or increase the amount of reps.

Multiple Vertical Jumps (Plyometrics) In an explosive action, start from an upright position, and rapidly jump maximally and repeats the jump without resting. Perform jumps for 20-30 seconds 2-3 sets Rest one minute in between sets. To increase intensity, hold weights across chest.

Climbing stairs (Functional Test) Request that athlete walk or run up stairs, and assess pain level. Exercise mechanics: A pause in between stairs, or climbing with flat feet may indicate difficulty.

Soccer drills (Functional Test) Since the patient is a soccer player, ask him to attempt at participating in a team warm up, and indicate pain level. Get the patient to perform a shuttle run (running to a line and pivoting into the opposite direction).

Case Study #2 28 year old student with a complete tear of the ACL, MCL, and lateral meniscus and has completed surgical repair using a patellar graft method. He requires strengthening of the muscle groups supporting the ACL. The meniscus and the collateral ligament are still weak.

Quadriceps Stretch (Flexibility) Patient is standing near a table or wall to use as support. The patient grabs the foot behind the back and pulls it towards the buttocks. The body should remain in an upright position with the hips forward to include the rectus femoris in the stretch. Hold for 15-20 seconds. 2-3 sets. Rest 30 seconds in between sets. If the patient is unable to reach the foot because of insufficient flexibility, they can use a chair or table to hook their foot on.

Standing Gastrocnemius Stretch (Flexibility) Patient is in a straddle position with the extremity to be stretched behind the opposite extremity. The patient places his or her body weight on the arms, which are supported on the wall and on the front foot while the back extremity remains extended at the knee. The heel should remain in contact with the floor; the hip should be forward of the knee; and the foot should be in a straight line or the toes slightly turned inward. Hold for 15-20 seconds. 2-3 sets. Rest 30 seconds in between sets. Common substitutions are allowing the midfoot to collapse by rotating the foot outward, lifting the heel off the floor, bending the knee, or moving the hips posteriorly.

Supine Hamstring Stretch (Flexibility) The patient lies supine with the uninvolved extremity extended. The involved knee is brought toward the chest, and the hands are clasped behind the thigh. The knee is then actively extended as far as possible so that a stretch is felt behind the knee or in the thigh. Hold for 15-20 seconds. 2-3 sets. Rest 30 seconds in between sets. The opposite extremity is kept in extension to stabilize the pelvis so that the ischial tuberosity does not roll upward and reduce the effectiveness of the stretch on the hamstrings.

Lunges (strengthening) The patient stands with the feet in a forward-backward stance with the involved extremity in front. The quadriceps and buttocks are tightened, and the weight is shifted to the front extremity as the patient bends the knee. The knee should remain in line with the second toe, and the arch should be lifted as weight is placed on the extremity. Hold for 30 seconds 2-3 sets 30 seconds rest Do not allow the arch to fall and the knee to move into a valgus position. The knee should not move forward ahead of the foot. The leg should remain at an angle no more than perpendicular to the floor.

Hamstring resistance (strengthening) Patient lies prone with a partner. With lower leg flexed at the knee joint, partner actively applies resistance to the flexion movement. Hold for 15-20 seconds 2-3 sets Rest one minute in between sets Can also be performed standing. Adaptations include using an ankle weight, or attaching a Theraband from the leg of the table to around the ankle.

Short-Arc Quad Exercise (strengthening) A towel is placed under the knee to position the knee in partial flexion. The patient is supine to utilize the rectus femoris or sitting to increase the difficulty of the exercise. With the uninvolved knee flexed, the involved knee is straightened, held in full extension, and then returned to the starting position. Hold for 5-10 seconds. 2-3 sets 15 seconds rest To increase difficulty, apply extra weight to the ankle.

Pillow Standing (Stability) Patient stands upright on one foot on a pillow. Balance for as long as possible. Hold up to 1 minute. Perform exercise until 3 minutes of total balance time is attained. To increase difficulty, perform exercise with eyes closed. Can also be performed on a wobble board, or trampoline.

Raised Heel Pillow Stand Patient stands upright on both feet on a pillow. Raise heels so as to balance on toes. Balance for as long as possible. Hold up to 1 minute. Perform exercise until 3 minutes of total balance time is attained. To increase difficulty, perform exercise with eyes closed. Can also be performed on a wobble board, or trampoline.

Swiss Ball Stability Patient lies supine with legs flexed at the hip joint. Partner places Swiss ball in between feet. While patient attempts to balance the ball, partner repeatedly hits the ball with hand providing extra resistance Hold for 15-20 seconds 2-3 times Rest for 30 seconds in between sets For an alternative, perform the exercise while holding the weight of the partner on the feet. (superman/airplane)

Tony Bauer Two-Step (Plyometrics) Have the patient lift the right leg with the knee bent 90 degrees while also lifting the left arm with the elbow bent 90 degrees. Then the patient should alternate with opposite extremities. 25 reps 3 sets Rest for 1 minute To increase intensity of exercise, apply weights to the ankle, or increase the amount of reps.

Pylon Lateral Jumps (Plyometrics) In an explosive action, start from an upright position, and rapidly jump laterally up and over the pylon. Repeat the jump without resting. Perform jumps for 20-30 seconds 2-3 sets Rest one minute in between sets. To increase intensity,use ankle weights or hold light weights in hands.

Object Pickup Task (Functional Test) Patient uses a 80-90 degree flexion squat to pick up an object placed on a chair and then the floor. Change the heights of pickup such as table, chair, floor. Change the weight of objects.

Running (Functional Test) Have the patient run at a light pace for 40 meters. This distance can be increased as the patient becomes more comfortable and as their rehab program progresses.