Therapeutic Exercise HPER 4860
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Date Created: 09/30/15
3rd Degree Aeromioelavieular Sprain Rehabilitation Protocol Brad Toepper Andy Bliz Rotate cu d Made Of Acromion Process ofthe Scapula Lateral End of the Clavicle Acromioclavicular Ligament AC Coracoclavicular Ligament CC Provides the ONLY Articulation to the Body a 39 Part ofthe Shoulder Girdle quot 9 mum Magee 2008 1 lubmaling sac i2tcir39tnxw is n13 r39i39i 221325 r EE Fi E rih rig491 153 j n 2009 Mechanism of Injury How does it happen a Three Primary MOl s in Hockey l Typically Injured by Player Contact Other Contact or NO contact Agel Dompier Dick amp Marshall 2007 Easily Injured by a Direct Blow to the AC Fall on Point of Shoulder Axial Load Through Long Axis of Humerus during FOOSH Anderson Hall amp Martin 2005 Anylmpact That Forces Acromion Process I Inferior Posterior Medially While the Clavicle is Pushed Against Rib Cage Most Commonly Seen in Contact Sports Prentice 2004 Grades of Injury Six Grades of Injury Grades 13 are Most Common 1 Grade1 Sprain to the AC Ligaments Grade 2 Tearing of AC Ligaments amp Sprain ofthe r Coracoclavicular Ligament n Grade 3 Complete Tear of Both the AC and Coracoclavicular Ligaments r um mm m Anderson Hall amp Martin 2005 gJwwvveorthonocicontinuouspatient education6 rrnoo avioular loin oeoerationh m nl 2009 Grades of Injury 39 ulcernth itquot http www 39 39 I Grades 46 Anderson Hall amp Martin 2005 Most Severe Grades Less Common Dependent on How Much MuscleSkin is Tom Same MOI and Result as Grade 3 bagesThe Shoulder Sprain 2009 Deltoid and Trapezius are Affected at Insertion on Distal Clavicle Signs amp Symptoms 3rd Degree What are You Looking For httQwwwcsmfoundationorgEducational Upger E Xtremityhtm 2009 Prominent Elevation of Clavicle Severe Swelling Pain on PalpationDepression of Acromion amp clavicle Sometimes No Pain When Ligaments Are Completely Torn No Neural Connection So No Pain Palpable amp visual Step Deformity ROM Restricted Through AbductionHorizontal Adduction AC Shear Apley Scratch Piano Key Sign Anderson Hall amp Martin 2005 SOAP Note I Subjective Hearing a pop after MOI May or may not have previous history AROM esp AbductionHorizontal Adduction is limited due to pain Complains of pain over AC joint SOAP Note Objective Affected arm will often be at athletes side or held up by good arm n Extreme difficulty removing jerseypads u Obvious step deformity and swelling over AC Neck may be laterally flexed to affected side Palpable pain and tenderness over affected AC Apley Scratch for decreased ROM AC Shear and Piano Key Sign SOAP Note I Assessment Put together everything from you evaluation and come to a conclusion on what you believe the injury to be I 3rd Degree AC Sprain SOAP Note I Plan I Ice u Immobilize in Sling I Refer to Orthopedic for Confirmation and rule out fracture ATC LS LT I Avoid I Movements Above 90 Abduction I Movements Behind Back I Lifting Anything Away From the Body I WeightBearing Through Axis of Arm I Pain I Compression on Joint ie Backpack I Timing I Healing Processes and the Timing of Each Stage I Increasing lntensity Too Quickly I Each Athlete Reacts Differently ATC LS LT Compliance Keep Athlete Coming Back NewCreative Exercises Will Encourage Return Athletes are Naturally Competitive Creating Competition Makes Athlete Feel at Home Athletes are Goal Oriented lndividualization Each Athlete is Different How They Respond to Tx and Rehabs is Different Too Each Athlete is Different Just Because One Progressed to Weight Bearing in Week 2 Doesn t Mean Everyone Will Specific Sequencing Follow the Healing Process Ride the Roller Coaster Be Aggressive but Not Too Aggressive ATC LS LT Intensity Should Become More Intense as Athlete Progresses Through Rehab Program I Should not Cause Pain PostExercise Should not Cause Edema to Remain or Return I Should not Cause a Backward Step Total Patient All Athletes are Individuals Athletes Have Names and are Known by Their Names not Their Injury Must Consider Athletes Psyche Does Injury Affect ADLs Treatment Options I Grades 1 amp 2 I Treated Conservativer with ROM and Strengthening Exercises I Grades 46 I Treated with Surgery to Repair Surrounding Soft Tissue I Grade 3 ll Treatment is Controversial I Most Treated Conservativer w 90100 Return to Play or Activities of Daily Life I Others are Treated with Surgery Anderson Hall amp Martin 2005 Phase 1 In ammatory Response 04 Days Occurs immediately following MOI to any injury and lasts as long as 4 days Once surrounding cells are injured the body responds with a change in metabolism this change in metabolism is what initiates the inflammatory response The inflammatory process can be considered a protective and necessary physiological response Inflammatory response is started when various phagocytic cells specifically leukocytes travel through the body to the site of injury Their general function is to localize and clean up byproducts ofthe injury The cleaning and localization ofthe injury sets the injured area up forthe healing process to begin I 5 Cardinal Signs of Inflammation Redness Swelling Pain Increased Temperature Loss of Function Prentice 2004 Phase 1 Goals I Decrease Inflammation and Swelling I Decrease Pain I Increase PROM amp AROM I Work on Neuromuscular Control I Allow Necessary Healing to Occur Phase 1 Exercises amp Treatments Edema Control I Cryotherapy Skeletal Muscle Pump ACE Wrap Pain Management Cryotherapy Electrical Stimulation IFC Acetaminophen Grade 1 Joint Mobilizations Cardiovascular Fitness I seated Pedal Blke htt wwwbiosbccnetb100cardioindexhtm 2009 Avond Exercnse that Causes Excessnve Motion of Arm quotFe in Phase 1 Exercises amp Treatments I All movement should remain below 90 of flexion amp abduction 39 it 39 v ll I Active Range of Motion amp Flexibility I Codman s Exercises Right I Passive Scapular Movements I Assisted ROM wHockey Stick I Wall Walks I Proprioception amp Strengthening I Isometric Contractions at Varying Angles for All Planes of Motion l Joint Repositioning Exercises at Varying Angles for All Planes of Motion Phase 2 Fibroblastic Repair 228 days Once the inflammatory response phase has completed its task the fibroblastic repairphase can begin Fibroplasia scar formation and repair begins shortly after the injury occurs and can last several weeks n The 5 cardinal signs of inflammation begin to subside during this phase Growth of endothelial capillary buds occur this process allows the injury to heal aerobically I Leads to an increase in nutrition delivery these nutrients are essential for healing of the injury Granulation tissue a form of connective tissue is composed of fibroblasts collagen and capillaries Fibroblasts align themselves parallel to capillaries These fibroblasts produce collagen the collagen gives strength to the wound As strength increases the number of fibroblasts begins to diminish Prentice 2004 Phase 2 Goals I Control Pain Continue Increasing ROM Begin to Stress and Stretch Soft Tissue Around AC Increase Strength Improve Neuromuscular Control Improve Scapulohumeral Rhythm Gait Analysis Remove from Immobilizing Sling Scapulohumeral Rhythm Clavicular Rhythm Shoulder Symmetry Cervical Alignment Phase 2 Exercises amp Treatments Edema Control Thermotherapy Pre Skeletal Muscle Pump Exercise Ultrasound NSAIDS Pain Control Electrical Stimulation NSAIDs Ice PostExercise Grade 1 amp 2 Joint Mobilization Active ROM Codman s Circles w Increased Circumference BAPS Board Increase Hockey Stick Motions Past 90 FIexionAbduction Wall Walks Past 90 Grade 3 amp 4 Joint Mobilization Humerus Scapula Clavicle Phase 2 Exercises Proprioception and Strengthening Red Theraband As Tolerated Flexion Extension Abduction Adduction IRER arm side Swiss Ball Compression Against Wall Serratus Anterior Punches Rhythmic stabilization Phase 2 Exercises I Cardiovascular Maintenance I Upper Extremity UBE I Elliptical I Stairmaster I Stationary Bike I Incorporate Athlete into Team Conditioning Drills Phase 3 MaturationRemodeling Phase 21365 days I This is a long term process and is dependent upon severity of injury Begins as fibroblasts leave the injury site and focuses on realignment and remodeling of scar tissue according to the stresses applied A continuing cycle of break down and formation of new more efficient collagen occurs This more efficient collagen causes tensile strength of the injury to increase I The stresses applied cause the more efficient collagen fibers to align parallel to lines of tension on the joint I 3 weeks postinjury a strong efficient scar exists Prentice 2004 Phase 3 GoalsGait Analysis Goals I Gait Analysis I Full Functional ROM Perform While Skating Pain Free ROM and On Ice Exercises Look for Favoring of Increase Injured Shoulder StrengthPower amp Apprehension to Use Endurance of Shoulder Injured ShOUIder Compex Leaning Towards I 39 quot i39 dSh ld I Begin Functional Activity lure ou er Phase 3 Exercises amp Treatments Edema Control Pain Control Pain Should Be Vary Minimal This Stage Electrical Stimulation Should Be Absent This Stage Thermotherapy Pre Exercise Using a Heat Pack 39 0 Ultrasound I Grade 1 amp 2 Joint Skeletal Muscle Pump MObilization Exercises Should Not I Cryotherapy Post Cause Edema Exercise Cut Back Intensity if Edema Does Occur Phase 3 Exercises amp Treatments I ROM amp Flexibility I Cardiovascular I Grade 3 amp 4 Joint lVI intent mCe Mobilization Aquatic Therapy u Measured Every 3 Days Stationary Bike wGoniometer I Upper Extremity UBE WallWaIks Past 90 Elliptical I StaticDynamic l Stalrmaster Stretching of Soft FullTime Participation in Tissues Team Conditioning Phase 3 Proprioception Phase 3 Strengthening Exercises Jump I M115 Phase 4 Return To Play I Occurs immediately following the maturation phase The timing of this phase is totally dependent on the athlete and is different for each athlete Prentice 2004 Goals Full Functional ROM Bilateral Strength Measurements are 80 Meets Cardiovascular Demands of Sport Passes Functional Tests O Donoghue 2008 Phase 4 Exercises amp Treatments I Gait Analysis I Edema Control Perform While Skating I Thermotherapy lore Exercise on Ice LOOK for Upper Extremity UBE Favoring of Injured Therabands Shoulder Light Dynamic Exercise Apprehension to Use Cryotherapy Post Injured Shoulder ExerCiSG Leaning Towards I Pain Control Injured Shoulder Should Be NonExistent If Needed IFC and Cryotherapy Joint Mobilizations Grade 2 Phase 4 Exercises amp Treatments ROM amp Flexibility A r Grade3amp4Joint 39 card39OVaSCUIar Mobilization Maintenance u StaticDynamic Stretching I Treadmill I ProprioceptionStrength in Team Weight Training 39 Upper EXtremltY UBE Program W Some Stationary Bike Modification Depending on the Individuals tolerance to l Skating DFIHS pain Team Conditioning Core Strengthening At appropriate intensity for athlete ll Plyometric Drills UE Plyoboxes amp medicine ball Phase 4 Return to Play Injury Prevention Donut Padding Over AC Joint To protect from compressive forces Shoulder Spica of Affected Shoulder AC Taping httowwwruobvshoobeDroductview117en 2009 Summary I AC Joint Sprains are very common in contact and collision sports I An AC Sprain can hinder sports performance and activities of daily living I All though initially debilitating the overall prognosis is a quick and efficient rehabilitation I Through ROM proprioceptive and strengthening exercises the athlete can have a full efficient and speedy recovery References I Agel J Dompier T Dick R amp Marshall S 2007 Descriptive epidemiology of collegiate men39s ice hockey injuries national collegiate athletic association injury surveillance system 19881989 through 20032004 Electronic Version Journal of Athletic Training 422 241 248 I Anderson M Hall S amp Martin M 2005 Foundations of athletic training prevention assessment and management 3rd ed Lippincott Williams amp Wilkins I Magee D 2008 Orthopedic Physical Assessment 5th ed Saunders I O Donoghue J 2009 spring semester Chapter 18 Rehabilitation of shoulder injuries Therapeutic Exercise HPER 4860 Class lecture presented at Western Michigan University I Prentice W 2004 Rehabilitation techniques for sports medicine and athletic training 4th ed NewYork McGraw Hill I httpAMWdrraghuveercomarthroscopvhtm Retrieved April 10 2009 I httpAmWeorthopodcompublicpatient education6525acromioclavicular ioint separationhtml Retrieved April 10 2009 httpWVWVconguestchroniclescompagesT he Shoulder Sprain Retrieved April 10 2009 httpvavcsmfoundationorgEducational Upper Extremityhtml Retrieved April 10 2009 httpjoestrainingroomblogspotcom2008l lcjointLmloadinghtml Retrieved April 10 2009 11thIWNW1 L12bVShODbeDIOdIlCtVlGWl l7en Retrieved April 10 2009 I 331121wyvvbjgslgpp pg OOcardioindex htm Retrieved April 15 2009
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