Lab 5 Lower Extremity Exercise Prescription Tyler Hyvarinen

Lab #5 – Lower Extremity Exercise Prescription Tyler Hyvarinen (0308368) Kelly Heikkila (0305975) Allison Pruys (0310660)

CASE STUDY #2 Flexibility Strength Stability Plyometrics Functional Activities

Flexibility exercise #1 Category Flexibility Exercise Description Standing Have the patient quadriceps flex one of their stretch knees and grasp it at the ankle. Holding onto a wall for support, the patient should pull towards the buttocks until they feel a stretch in their quadriceps muscle. Have the patient perform the exercise on both legs. If any pain emerges the exercise should be stopped. Repetitions Frequency Rest Exercise mechanics Exercise should be done two times each for both legs. Stretch should be held for 2030 seconds Ideally the stretch should be performed everyday, but 34 times a week is suitable. A rest of 15 -20 seconds should be done before going onto the second repetition for each leg. This stretch allows for lengthening of the quadriceps muscle group. This is essential for the ACL because it allows for the quads to have a more stable support for the knee.

Flexibility exercise #2 Category Flexibility Exercise Description Repetitions Frequency Rest Exercise mechanics Sitting Hamstring Stretch Have the patient sitting on the floor with one leg straight. The sole of the other foot should be placed on the inside of the outstretched leg. Have the patient lean slightly forward and try to touch their toes. Have the patient perform the exercise for both legs. If any pain emerges the exercise should be stopped. Exercise should be done two times each for both legs. Stretch should be held for 2030 seconds. Ideally the stretch should be performed everyday, but 3 -4 times a week is suitable. A rest of 15 -20 seconds should be done before going onto the second repetition for each leg. This stretch allows for elongation of the hamstrings muscles. Allows more flexibility and force during knee flexion, taking stress off the knee joint.

Flexibility exercise #3 Category Flexibility Exercise Calf Stretch Description Repetitions Frequency Rest Exercise mechanics Have the patient standing facing a wall. Have them place their hands on the wall and step back with one foot. Have them lean towards the wall until they feel a stretch in their calves. Make sure the patient is keeping their back heel on the ground. Have the patient perform the exercise for both legs. If any pain emerges the exercise should be stopped. Exercise should be done two times each for both legs. Stretch should be held for 2030 seconds. Ideally the stretch should be performed everyday, but 3 -4 times a week is suitable. A rest of 15 -20 seconds should be done before going onto the second repetition for each leg. This stretch allows for a stretch on the calf muscles as well as the posterior aspect of the knee. It loosens up the muscles and takes stress off the knee joint.

Strengthening exercise #1 Category Exercise Strengthening Straight leg raises Description Have the patient lie supine with the uninvolved knee flexed and the involved knee extended. The patient first contracts the quadriceps muscles and raises their heel about 20 cm off the table and hold the leg there for 5 seconds. Repetitions Exercise should be done in 2 sets of 10 raises. Frequency Rest Exercise mechanics Exercise should be done 3 -4 times a week. A rest of 30 seconds-1 minute should be taken between sets This is a hip extensor exercise, but because it requires the quads to hold the knee in extension it is essentially an isometric exercise for the quadriceps.

Strengthening exercise #2 Category Exercise Strengthening Seated leg lifts Description The patient sits in a chair or the edge of a table with their knee bent over the edge. The foot is lifted slowly upward to straighten the knee. Weight can be added to the foot to increase resistance. Repetitions Exercise should be done in 2 sets of 10 raises. Frequency Rest Exercise should A rest of 30 be done 3 -4 seconds-1 times a week. minute should be taken between sets Exercise mechanics This exercise strengthens the quadriceps muscle with the lifting of the leg from flexion. This exercise should be used with caution as it could cause pain to the ACL in the 0 -60 degree of flexion range.

Strengthening exercise #3 Category Exercise Strengthening Wall Squats Description The patient stand with their back against the wall. Have them squat down to either full knee flexion or as far as the patient can go. If any pain emerges the exercise should be stopped. Repetitions Exercise should be done in 2 sets of 10 squats. Frequency Rest Exercise mechanics Exercise should be done 3 -4 times a week. A rest of 30 seconds-1 minute should be taken between sets This exercise strengthens the quadriceps when returning up from flexion, but it also strengthens the hamstrings when holding the squat.

Stability exercise #1 Category Stability Exercise Description Standing Have the patient on one leg stand on one leg and support their entire body weight. The non-weight bearing leg can be manipulates to force the weight bearing leg to support different types of movement. Exercise can be done on a trampoline or foam rollers to add complexity. Repetitions Frequency Rest Exercise mechanics This should be held for at least 2530 seconds. This exercise should be done twice in one session. This activity should be done 4 -5 times a week once the patient is comfortable enough for such an activity. A rest of 30 seconds-1 minute should be taken between sets This exercise allows for the injured knee to get used to weight bearing activities as well as function is stabilizing the knee when different forces are applied to it from different directions.

Stability exercise #2 Category Stability Exercise Single leg squat Description Repetitions Frequency Have the patient Exercise This activity stand on one leg should be done and bend in like a done 5 -10 3 -5 times a squat. The patient times week once the should try to bend depending patient is the leg as much as on the comfortable possible without patients enough for losing their balance. comfort level. such an activity. Rest Exercise mechanics A rest of 30 seconds-1 minute should be taken between sets This exercise allows for strengthen of the quadriceps muscle while stabilizing the knee joint during the flexion.

Stability exercise #3 Category Stability Exercise Lunge Description Have the patient step forward with one leg and bend at the knees and hips. Keeping the torso erect try to get the back knee as close to the floor as possible. To add complexity weight can be place in the patients hands, or the arms can be held out of the sides. Repetitions Exercise should be done 5 -10 times depending on the patients comfort level Frequency Rest Exercise mechanics This activity should be done 3 -5 times a week once the patient is comfortable enough for such an activity. A rest of 30 seconds-1 minute should be taken between sets This exercise allows for the knee to support weight while stabilizing the upper body. Exercise will increase muscle strength as well as force the knee to stabilize the movement of the torso.

Plyometric Exercise #1 Category Exercise Description Plyometric Hip-Twist Patient begins Ankle Hop exercise with the feet shoulder width apart and knees bent to 90°. They will jump into the air, and turn 90° to the left (twisting at the hips). The patient will land bend knees to 90°, then jump again from the same knee bend position, turning to face forwards. The motion is repeated to the right. Repetitions Frequency Rest Exercise mechanics The exercise should be repeated 10 times to the left, and 10 to the right with a forward facing jump in between. One to two sets (depending on comfort level) This activity should be done 3 -5 times a week once the patient is comfortable enough for such an activity. A rest of 2 to 3 minutes should be taken between sets This exercise will be ideal for stabilization and strengthening of the knee joint (particularly the ACL, meniscus and collateral ligaments) because it involves landing and jumping quickly in a rotated position. This is to be done once the patient has been through treatment and the range of motion has increased.

Plyometric Exercise #2 Category Exercise Plyometric Lateral Jump to Box Description Repetitions Frequency Rest Exercise mechanics The patient will lower their body into a semi-squat position and jump up onto box (which is to their side). They will be instructed to not hold a squat position before jumping up and keep the time between dipping down and jumping up to a minimum. The patient steps down from the box. The exercise should be repeated 10 times to the left, and 10 to the right. One to two sets (depending on comfort level) This activity should be done 3 -5 times a week once the patient is comfortable enough for such an activity. A rest of 2 to 3 minutes should be taken between sets The exercise increases stability and strength within the knee, especially the lateral and medial collateral ligaments because it involves lateral jumping and landing with an incline. This is to be done once the patient has been through treatment and the range of motion has increased.

Functional Activity #1 Description Walking The patient will be encouraged to work on walking without the use of crutches. Repetitions Frequency Starting with short distances (down a hallway) and building to longer distances (around a track). Daily, building further distance with practice and as the joint allows. Rest Dependant on pain level. Exercise Mechanics Walking requires a range of motion of 0° extension to 60° flexion. Also, an average of 13° of tibial rotation is needed. Due to the ranges of motion required for gait, weight bearing may be difficult for the patient at first. However with increased distances, the muscles surrounding the knee will become more stable, allowing the patient to return to normal activities sooner.

Functional Activity #2 Description Repetitions Frequency Rest Exercise Mechanics Stairs Once the patient has been able to walk without the use of crutches, they should be able to advance to climbing and descending stairs. The patient should begin with a small stair case (maximum of three). They should be able to ascend and descend these with minimal pain before moving to larger stair cases. Repeat daily as stairs are present during daily activities (ie school, work, home) Daily, building further distance with practice and as the joint allows. Dependant on pain level. (Use an elevator or crutches if needed) Normal Range of Motion for the knee is from 0° of extension to 135° of flexion. The maximum knee flexion needed for this movement is between 83° and 105° to ascend and 86° to 107° to descend the stairs. Many muscles surrounding the knee are engaged, including the hamstrings, quadriceps, collateral ligaments and meniscus.

CASE STUDY #3 Flexibility Strength Stability Plyometrics Functional Activities

Flexibility Exercise #1 Description Repetitions Achilles Stretch This exercise is to be performed as a prolonged stretch. The patients stands with the back to the wall. The feet are placed on the edge of a book with the heel no more than 2. 5 cm from the wall. A towel roll is placed between the posterior knees and the wall to prevent knee hyperextension. The patient stands in this position for a prolonged period. 1 repetition. Stretch is held for at least 5 minutes and up to 20 minutes if tolerable. Frequency Daily Rest Exercise Mechanics Few hours to a days worth of rest. This stretch applies tension to the Achilles tendon over a prolonged period and thus tension is experienced in the gastronemius and soleus muscles. Once the stretch is released, the patient commonly feels stiffness in the posterior calf or ankle area, but this should subside quickly. Common substitutions are standing with the feet in pronation, standing too far away from the wall, and hyperextension of the knees.

Flexibility Exercise #2 Description Repetitions Gastrocnemius Stretch (sitting position) With the patient sitting position, as stretch strap or towel is hooked around the forefoot. Keeping the knee straight, the patient pulls on the strap to dorsiflex the ankle. Additional stretch can be applied with active contraction of the ankle dorsiflexors. 3 repetitions each repetition is held for 1520 seconds. Frequency Daily Rest Patient rests 1530 seconds in between repetitions. Exercise Mechanics Because the gastrocnemius extends from above the knee to the calcaneus, both the knee and ankle joints must be placed on stretch to effectively stretch the muscle. Common substitutions in this exercise are hip rotation and foot pronation.

Flexibility Exercise #3 Description Repetitions Dorsiflexor Stretch Beginning on hands and knees with dorsum of foot and anterior portion of lower legs flat on a mat. The patient leans forward on the hands and pushes the hips back toward the heels as tolerated. 3 repetitions each repetition is held for 1520 seconds. Frequency Daily Rest Patient rests 1530 seconds in between repetitions. Exercise Mechanics Ankles lacking full plantar flexion can be stretched with the patient sitting on the heels. Once full range is achieved, he or she should be able to sit fully on the ankles. This stretch puts considerable tension on the knees and should not be performed if the patient has a history of knee problems. The main muscle under stretch in the lower extremity is the tibialis anterior.

Strength Exercise #1 Description Rubber Tubing Dorsiflexion The patient sits with the tubing around the forefoot and anchored to a table, which the patient faces. The patient pulls the foot toward the shin, dorsiflexing the foot. The foot is lowered to its original position and then brought through dorsiflexion once again. Repetitions 10 -15 repetitions Frequency 3 -5 times per week. Rest Exercise Mechanics 30 seconds rest in between sets. This exercise strengthens the ankle dorsiflexors, primarily the tibialis anterior. The most common substitution in this exercise is knee flexion.

Strength Exercise #2 Description Rubber Tubing Plantar Flexion The patient sits on a table in a long-sitting position with the tubing around the plantar foot and grasped in both hands. Maintaining a firm tension on the tubing and starting with the foot in full dorsiflexion, the patient pushes the foot against the tubing to move the ankle into plantar flexion. The ankle is returned to its original position and the movement is repeated. Repetitions 10 -15 repetitions Frequency 3 -5 times per week. Rest Exercise Mechanics 30 seconds rest in between sets. This exercise can be used to strengthen the plantar flexors of the ankle: gastrocnemeus, soleus, peroneus longus (to a lesser extent). This exercise is especially useful if the patient is non-weight bearing. This exercise can be modified to be performed with the knee in flexion and the patient sitting on a table with their extremity hanging off the table. In this position, plantar-flexion motion isolates and strengthens the soleus muscle.

Strength Exercise #3 Description Heel Raises With the feet shoulder-width apart, the patient rises up on the toes as high as possible and then returns to a position with feet flat on the floor. This exercise can be performed on an incline or the edge of a stair to increase the difficulty. Repetitions 10 -15 repetitions Frequency 3 -5 times per week. Rest Exercise Mechanics 30 seconds rest in between sets. This exercise strengthens the posterior aspect of the lower leg, mainly the gastrocnemeus and the soleus. Common substitutions include using the hamstrings by flexing the knees during the heel raise, moving the body forward or rocking rather than moving straight upward, and placing most of the body weight on the uninvolved extremity rather than equally distributing the weight over both extremities.

Stability Exercise #1 Description Stork Stand The patient stands on the involved extremity while attempting to maintain balance. Repetitions 3 repetitions each held for 30 sec. Frequency Daily Rest Exercise Mechanics 30 seconds rest between each set. Posture and balance are important in maintaining ankle stability. Once this exercise is accomplished, the patient can perform the exercise with eyes closed to eliminate visual balance. The stork stand can also be performed on an unstable surface such as a trampoline or a foam roller.

Stability Exercise #2 Description Ankle Motion Exercise (Swiss Ball) The patient stands in pelvic neutral with the uninjured foot on top of the ball. The patient then writes the alphabet with the uninjured foot, using the ball as a base off support. Repetitions 3 repetitions Frequency Daily Rest Exercise Mechanics 30 seconds rest in between each set This is a balance exercise for the lower extremity. By using the uninjured foot to perform motion, the injured foot is forced to maintain balance and thus stability is the point of focus for the exercise. The patient should not feel any significant pain or discomfort, and repetitions can be adjusted to compensate for particular contraindications.

Stability Exercise #3 Description Bridging (Swiss Ball) The patient is positioned supine on the ball so that the scapulae are on the ball and the feet are on the floor about shoulder-width apart. The pelvis is in neutral and the abdominals are tight as the patient lifts the buttocks and extends the hips. The movement is initiated at the buttocks, and the pelvis is kept in neutral throughout. Heels remain flat on the floor. Repetitions 3 sets of 10 repetitions. Frequency Daily Rest Exercise Mechanics 30 seconds rest in between sets This exercise strengthens the back extensors and may assist in rehabilitating the patients lower back pain. Stability is referred to the ankles which are flat on the floor as well as the abdominals. The exercise is more challenging if the patient marches in place while maintaining pelvic neutral.

Plyometric Exercise #1 Category Exercise Plyometric Skipping Description Repetitions Frequency Rest Exercise mechanics The patient will begin skipping with a rope, using both feet and only jumping approximately 2 inches off the ground. They should be reminded to bend their knees to absorb the shock of landing. The pace of skipping can be determined by the patient, increasing as they get stronger. The exercise can be repeated for about 2 minutes, depending on the patients comfort and pain levels. Two to three sets can be performed. This activity should be done 3 -5 times a week once the patient is comfortable enough for such an activity. A rest of 2 to 3 minutes should be taken between sets. This exercise involves short, quick bursts from many muscles, including the gastrocnemeius, soleus, plantaris and especially the Achilles Tendon. The exercise will help to strengthen and stabilize these structures while also increasing cardiovascular fitness. This is to be done once the patient has been through treatment and the range of motion has increased.

Plyometric Exercise #2 Category Exercise Description Plyometric Ankle The patients Plyometrics knees are kept in a slightly flexed position throughout the exercise. The patient will jump repeatedly as high as they can by using a forceful plantar flexor force. Repetitions Frequency Rest Exercise mechanics This exercise should be repeated 20 times, with two sets, depending on the patients comfort level and progression in therapy. This activity should be done 3 -5 times a week once the patient is comfortable enough for such an activity. A rest of 2 to 3 minutes should be taken between sets. The patient will focus on jumping by plantar flexor forces (gastrocnemius, soleus, achilles tendon). These muscles will become strengthened and will assist in having the patient return to dynamic activities, such as squash. This is to be done once the patient has been through treatment and the range of motion has increased.

Functional Activity #1 Description Repetitions Frequency Rest Exercise Mechanics Driving Simulation The patient will sit on a chair with a spongy ball (or rolled up socks) under their toes on one foot. He is asked to push down on the ball as if he is driving a car. If the injury is in the right ankle (or the patient drives a manual car), this exercise can be performed whenever they need to drive somewhere. Daily, building further distance with practice and as the joint allows. Dependant on pain level – whenever they are not in a car. The normal range of plantar flexion is about 50’. Flattening the ball completely requires about 45’, and driving will need slightly more range. If they have injured their right foot, they can perform this activity while watching TV, eating dinner, at work, etc.

Functional Activity #2 Description Repetitions Frequency Calf Raises This activity can be done while brushing your teeth, putting a book on a shelf or doing the dishes. The patient simply raises their heels off the ground and then lowers them back down. This exercise should be repeated a minimum of 10 times, depending on pain levels. Daily, two to three times a day as the opportunity arises. Rest Dependant on pain level. Exercise Mechanics This exercise will strengthen the muscles of the calf (gastrocnemius and soleus) as well as the Achilles Tendon. The exercise should be done using correct posture, so the lower back will also be stabilized.