Knee Arthroscopy Rehab Protocol - Phase 3

This phase of the rehab is the step prior to the final phase. The final phase is simply returning the athlete to play, and making sure they are comfortable enough to go out and perform closely to the level they performed prior to injury. This phase mainly consist of a lot of conditioning (sprints, running on the track), the introduction of plyometrics, power/explosive movements, mastering the exercises we've previously introduced and combining multiple exercises, and lastly, functional drills that would mimic basketball moves, or the athletes' respective sport. At this point, it is all about confidence, and regaining the athletes' trust in themselves. This is a tricky step, in the sense that every person is different in their exercise adaptation, however, keep in mind, that it is a slow process, and different people will progress at their own pace. Fortunately with collegiate athletes, you are allowed more time per session, but this is not always the case in other settings.

1. Step Down (3 x 12) - Depending on the conditioning level of your patient/athlete, this can be a tricky exercise. In this specific case, considering his knee, he was placed near a wall for concerns of him falling over, or needing extra support in the event he felt instability. The athlete starts with one leg over the side of the platform, and upon partially squatting with the affixed leg, the hanging leg is to touch the ground with the heel as the only part of the foot making contact. Concurrently, in this case, the athlete mimics a chest pass with a medicine ball (see picture). The addition of the upper body movement forces the lower extremity to work more towards balancing the whole body.




2. Step Ups (6 x 30 secs) - A commonly used exercise designed to build confidence, speed, coordination, and explosion. This can be progressed in variety of ways from changing the height of the steps, to increasing the duration of the exercise, and adding a combination of toe-touches alternating one foot, to two foot sets, etc. You will find with athletes, they love to be challenged and rewarded, so adding various contests may help them to strive.




3. Drag Squats (5 x each direction) - This is an original exercise performed in three planes; forward, laterally, and "open," which is similar to a reverse lunge, except there is 45 degree rotation in the hips along the vertical axis. Pictured below is an example of a lateral drag squat. Once the player is in start position, they are to lunge out as far as they can tolerate, and from there, drag their foot back to the beginning position. This can be performed with, or without, a medicine ball.



4. Alternate Dead Lifts (3 x 15) - This exercise is performed slowly with the athlete essentially placing the dumbbell on the ground, and then lifting it up, and switching to the other side. It is hard to perform without involving hip flexion, but the only movement should be occurring at the knee. Progress the exercise by adding heavier weight, increasing duration, reps/sets, etc.




5. Hill Climbers (6 x 30secs) - A familiar exercise among athletes who condition or strength train, this variation involves the use of the Dynadisc which secondarily works the upper body, and provides more of an overall challenge. Make sure to recognize if the athlete is driving their knees up and in, and not outward, and also are not bouncing their butts, meaning their back should be mostly flat.




6. Dynadisc Balance (6 x 30secs) - Although this may seem like a relatively easy exercise, it will be extremely difficult for someone with a lower extremity injury. There are various way to work with the Dynadisc, as well as, working with the progression in difficulty (one leg, no shoes, ball-toss, visual impairment, etc.) However, in this particular exercise with this athlete, whom really enjoyed challenges, the goal was for him to stand for :30 secs at a time without falling off. That's it! It's a great way to increase proprioception and balance. The position with the athletes' hip at 90 degrees is the correct position. Below, the athlete is intentionally holding a squat position.






7. Lateral Step Ups (6 x 30 secs) - This specific exercise is to increase the athletes' trust in their ability to shuffle sideways, and it is a great way to build confidence in basketball related moves. A great way to progress this exercise is to remove the visual angle, and instead of concentrating on the placement of their feet, have them look straight ahead of focus on another target. Use this technique only if the individual has mastered all other related exercises and you are confident they are prepared to progress.






8. Med Ball Squats (6 x 30 secs) - Similar to a wall squat, this exercise is performed while the athlete holds their squat position, with any type of ball between their legs proximal to the knee, and squeeze, or prevent the ball from falling. A variation of this exercise we utilized for progression is to add resistance to the object between their legs. In this case, we used a heavier ball. When our patient got really good, and showed good medial quad strength, I would apply pressure to the ball by hitting it from different angles, using varying amounts of strengths.




9. Floor Squats (3 x 12) - Having a relatively easy exercise is a huge benefit for the athlete's psyche, and physically, gives them a break from the more intense exercises. Typically, this exercise is performed after a few more rigorous ones. In the beginning, I like to have the athlete perform the squats in front of a mirror for visual feedback. Once they become good enough, I take away the visual aid, and then, the target becomes (as you can see in the picture) the inner soles of his shoes.



Plyometrics (3 x 15) - Plyometrics are an easy form of exercises to train athletes, and also, they are great for patients who are further along in their respective program. With our athlete being a basketball player, naturally, he wanted to get back to jumping, so this was an obvious drill. We simply used a jump rope and set it at a specific height. Here, he is jumping laterally, but this can be progressed by having them jump in different directions.





Jump Twist - Here, our patient is performing an exercise that will increase confidence using his knee, and help in regaining the specific level of athletic performance that he was used to. The important element here is landing. We want to focus on a controlled landing in which he does not wobble, or come down too hard, all the while working accessory and stabilizing muscles.





Exercise Ball Squats - This is an exercise that focuses on generating power and maintaining stability.





Reverse Total Gym (3 x 15) - This is the only exercise performed with a machine.




All the above exercises are advanced level exercises, in other words, are not recommended for acute injuries, or injuries still in the beginning stages of healing. A thorough evaluation should completed upon initial exercise prescription, also before progressing to more difficult exercises.

Really?..."the best day of your life?"

Dang, that's a small picture? But the news is still BIG...

How many people can honestly say they remember the "best day in their life?" I believe this is mine. If you haven't heard, I passed the Board of Certification (BOC) Exam today. If you're even reading this blog, then I'm pretty sure you already know what I'm talking about, since becoming a Certified Athletic Trainer was the very premise of this whole thing in the first place!

Now that I am reflecting back on it, I am so glad I did this! My mother would occasionally ask me, "do you have any regrets?" in which she'd be referring to the major I chose to study, and the school I chose to attend, etc., and every time, I would respond with a stern "No, I don't have any regrets." However, when she would ask me this, I would sometimes slip into a daydream where I would fantasize about what my life would have been like had I chose a different path.

I always wanted to study music, or be involved with the musical artist/writer scene in some way, and I think those that know me see how that reflects in my personality. I've always said if I couldn't do music, or science, I would love being a Director. Not so much music videos or anything, but more along the lines of short films or documentaries. I think that shows with my sort of love for photography. Why I never pursued these things? Well, I did -- or, I do! I still do all of the things I love to do, which is why my favorite saying is "only boring people get bored." My particular needs are always met. There is never a moment when there is not something I can be doing. Call me "too busy" if you want, but I call it just having fun. Just being me.

When I took the exam back on April 7, 2010, I was nervous as all hell. Admittedly. It is natural to be nervous, as this will potentially decide the course of your future. At least in the short term. Prior to taking the test, the biggest motivation for me was Sean, AJ, and Eric, whom all passed on their first attempts. For the last two years, we've been hearing nothing but how hard the test is, and how the test is set up to weed out the weak, and how it is intentionally designed to trick you, etc. But, I remember the morning when hearing the news that these three guys passed, and I immediately thought, "Hey, I know every bit as much as they do," in the notion that we were taught by the same instructors, read from the same books, exposed to pretty much the same things, etc. It was not so much of me comparing myself to them, it was moreso a cohort that was able to overcome what most people assumed to be the truth about a "test." So, I cracked open the books!

I stuck to a study schedule of 2hrs of straight study, and 1hr of a break, which was mainly video games. Then, 2hrs of some more studying, and yet again, another 1hr of break-time. I kept this schedule during Spring Break -- while most people were on the beach, I was in between the sheets -- of the textbooks, that is! I sacrificed a lot over the last two years. Went through a lot of stuff that many people, except those involved, don't even know about. Not even those closest to me. And I am suddenly overjoyed with such elation, now that I have passed the test. Nice!

As you can tell, I am in a really great mood! Like AJ says, "Life's good," and yes, it feels great to be me right about now. I wish everyone can get a chance to experience the type of unbelievable emotion that I felt once I found out the results. But, before I get too sentimental, I have to gloat a little (as if I wasn't already) and smash on one particular person. I'm not the type to hold grudges, but this moment is especially bitter for none other than USF Professor Gary Stevens, who once advised me to change my major after not performing well on an Anatomy exam. I have heard of things like that happening to other people, maybe in the movies, but I never thought it would happen to me. I couldn't believe this person would say something like that. Until this point, I have never revealed these details, but I held it in just for this moment! And all I have to say to him is, HOW GREAT AM I?

I am certainly proud of where I come from, proud of what I have developed into, proud of what I am; education is truly a gift that no one can ever take from you, and is truly able to lift communities to higher levels. The knowledge I have amassed over the last two years is unmatched and I will never forget the people I've met along the journey, especially my lifetime bros. (and sis) from the c/0 2010. The ride has come to an end, but the fun is just getting started. I hope and pray that I can continue to live as fulfilling of a life as I have been living, especially leading up to this point.

Now in regards to celebration, where is the cake?

-The Dreamer, ATC

Knee Arthroscopy Rehab Protocol - Phase 2

A few of the new exercises added to the knee rehab program. The other exercises have since been progressed, or discontinued, depending upon evaluation, and largely the level at which the patient completes them.

Multi-Hip - An exercise typically seen performed on machines, but can be changed if a machine isn't available. Most exercises are that way; can be modified as such to perform the actions you are trying to accomplish. The tubing is of moderate resistance and is affixed to his uninvolved leg. The involved leg then becomes the stabilizer, thus improving his proprioception, strength, and balance. In early stages, using a stick or some type of device is helpful in preventing your patient from falling.

Working hip abductors

Working hip adductors, primarily

Working hip flexors

Lateral Cup Slides - Being a basketball player, sliding from side-to-side is important for defensive stances, as well as getting your body low. This exercise replicates those movements. At this stage, only 4 cups were used; mainly as distance markers for him to meet.

For the last set, we incorporated an additional cup for him to pick up, and then place back down, in order to add more knee flexion; making sure to watch for all bending motions to come from the knee, and not so much at the hip.

Modified Squat - There is added resistance with the use of his arms, which are forced in a downward (palms down) swinging motion while squatting, and an upward motion (palms up) while returning to start position.

Downward motion

Upward motion

Jogging - For a patient that is 6'10" you can imagine this would be somewhat difficult for such a small hot tub.

Marching - Marching was actually more difficult than light jog. In the picture, the patient is shown with his knee somewhat out of the water, but this is only for demonstration purposes, as this is a practice we do not want to make a habit of. The patients' knee should be submerged under water at all time. They can bring their knee up as close to the surface as possible, but avoid lifting it any further.

If the patient is not tired by the end of the workout/exercises, think to increase the level of intensity, or volume, depending on the stage of their rehab. Dealing with Div. I athletes, one would expect them to be in top physical form, but that is not always the case, so it is always important to treat every case with specificity and be careful not generalize. Usually we will end most exercises with a 15 minute bike ride, or a minimum of 5 minutes out on the track, then finally, end with cryotherapy. Some individuals like to be challenged more than others and it is great working with those types, but also understand not everyone heals the same, so different people will be at different stages after certain amounts of time.

Knee Arthroscopy Rehab Protocol - Phase 1

Patient Profile: 19 year old basketball player suffered what was initially thought to be an ACL partial tear, and combination tears in the posterior horn of the medial and lateral meniscus of his left knee. On April 2, 2010, once the Docs went in to scope his knee, they found the ACL to still be intact, also minimal damage to the meniscus; at which point they just cleaned up and any scarring that took place along the ligamentous attachment sites. Below are a few of the exercises we are working on in order to restore the patients' full range of motion, strength, and confidence in the use his knee.

1. TKE (Terminal Knee Extensions) 2 x 15 - I am actually on the opposite end providing the resistance. This can modified in a number of ways. Some like to affix the end to an attachment wall, or via pulley-system. But since I did not have those items available to me at the time, one must get creative

(START position)

(END position)

2. Cup Walking 10x - This is also another exercise that can be highly modified. Some are more comfortable with using larger cones, but for the purposes of this rehab, I use a stack of cups (again, resources available) because partially, this is only Day 2, and your patient may not be as comfortable with that much hip flexion at this point. So, a 4" obstacle vs. a 8" obstacle makes a huge difference.

3. Total Gym mini squat - Patient performs a partial squat in a limited range that is to be predetermined in your evaluation. In this particular case, the patient was able to actively flex his knee to about 45 degrees without pain. Allowing pain to be his guide, we asked the patient flex his knee to his end point, and from there, flex it slightly beyond the point of pain, but no further than that.

4. Calf raise 2 x 15 - This is a great exercise I like to do because not only does it incorporate gastroc strengthening, but it provides physical and tactile feedback to the body about its positioning in space. From the initial evaluation, the patient complained of placing as low as 35% of weight on the involved leg. So this is a great exercise to address both strengthening and confidence concerns.

(START position) Patient stands close to a stable, depending on stability, and raises up off the floor to the metatarsal heads, or the ball of the foot. For patients with patellar grafts, or any one who has undergone a procedure involving the patellar tendon, raising to their toes may provide an unwanted strain on the tendon at this point in the rehab.

(END position) Simply return to the flat-foot position

5. Quad Sets 10 x 10 secs - A standard exercise in most knee rehabs, patient actively contracts their quadriceps muscle group while playing close attention to the firing order of each muscle. Most importantly, we want to focus on the neuromuscular control of the vastus medialis oblique; allowing it to contract first, while the others follow. Having the patient place their hand over each muscle is an easy way to determine if this is being accomplished.

6. Straight Leg Raise (5 way) - The SLR is also a common exercise found in many rehab protocols. It is an excellent way to build strength and range of motion, especially during the early phases of rehab. Pictured below is the patient performing SLR's with a 2lb. weight, which he progressed to after exhibiting good technique and control with no weight attached. Many reading this already know the 4-way direction in which the hip moves, but may ask about the "5th direction?" Nope, it is not "rotation," it resembles a 90-90 hip extension that T. Solley coined the "donkey kick," which sorry to say, is not pictured. It is patent-protected ;-)

Overall, we have had good success with these rather simple exercises. They are easily progressed for difficulty and easily modified for future phases. Within one week, the patient has shown tremendous improvement, going from 11o degrees of knee flexion, to 130 degrees in essentially 5 days. His uninvolved side was last measured at 148 degrees, so there is 18 degrees to go. Although his swelling has subsided significantly, it is still noticeable, which is why every session is completed with 5-10 mins on the bike in order to flush out any remnant substances from the workout, and a cryotherapy treatment for residual swelling.

Osteochondral Fracture

The procedure that took place this morning was the removal of an osteochondral defect of the left lateral femoral condyle; and it was a rather large piece! The patient, 56 male, initially reported a feeling of "locking," and "intense pain" along the medial and lateral joint line, also with stiffness deep from within the knee joint, and some "instability." Upon evaluation of radiographs, the Doctor felt there may be a presence of loose bodies, commonly referred to as 'joint mice,' or technically termed osteochondral defects.

However, while the knee was being scoped, the Doctor noticed a particularly large piece on the monitor. It took some time for him to grab a hold of it, even at one point, losing sight of it and having to reconfigure himself and enter from a different angle. Once he got a decent view of the object, he realized how large of a piece it was. He struggled for next few minutes to finally get a hold of the piece and remove it.

Once removed, he looked around the condyles and any other structures to get an idea where such a large piece may have come from. There was no definitive answer. At this point, they decided to have the knee x-rayed and maybe that could help them discover where it came from, also, if there were any other pieces around they did not get.

There were a few moments that took me by surprise; a "whoa" moment, if you will. There was a point where the surgical table was too high, and he asked for it to be lowered, and apparently the table was being lowered, but the technician didn't know how to stop it, so the patient was being lowered while there were surgical tools still inside him. It may not have been much of a deal, but I was certainly taken away at the time. The other thing that happened, which gave me more insight into the risks with surgery, was the patient was bleeding more than normal, and the doctor requested the tourniquet's pressure be increased. Again, one of the tech's was unsure on how to do this, or maybe just wasn't familiar with the equipment or could not locate the proper tool to, etc., I am not sure, but the Doctor sure was upset. And I am guessing, the last thing you want, as a patient, is to have an angry Doctor performing your surgery.

TheraLase Presentation Summary

I thoroughly enjoyed the presentation given this morning on Thera Lase, which is a new product of low level laser therapy, typically used for chronic pain, wounds, and tissue recovery. The presentation was very well done, professionally given, easy to follow, and did an excellent job of explaining its use.

One of the most surprising claims the presenter made that really caught my attention was its effects on fungal infections similar to eczema, or like tinea versicolor, which is a skin condition I have had for 13 years. This was surprising to me at the time, and although I did not follow up with a question, I did my own research on the companies' website.

Upon navigating their website, there is a section on Anti-Aging Treatments, which is the closest category I could find to skin conditions. There, they talk about reducing lines and wrinkles, crows feet, blemishes, acne, scars, etc., no mention of treatment of fungal conditions. All the text says are relative to surface layer treatments and conditions whereas tinea versicolor is treated more on an internal level.

After a little more searching, I steered over to the clinical practitioner section of the website, where I discovered a little more of the information I was seeking. Although for most part, it says the same thing as the patient section, however, it gives a little more scientific background mentioning that its use increases local vascularity and capillary formation, which in turn, brings more oxygen and nutrients to the area, in order to stimulate collagen growth. There is also a list of treatable conditions that include; herpes simplex, psoriasis, rosacea, keloids, stretch marks, and others I mentioned above; but I noticed how none of those conditions are caused by a fungus. So, it is still unclear what they meant as to what skin conditions are treated with the laser. The only other explanation would be if I mistakenly heard one word for another.

Total Hip Replacement

The procedure I observed this morning was a right total hip replacement, in which the patient was a 79 year old woman, whom had her left hip replaced five years prior. The surgery was scheduled to begin at 7:00 AM, however, the first incisions were not made until 8:45AM. Other than the Doc being slightly late, there was a staggering amount of preparation that went into this surgery, which may have contributed to the delay. The technicians scrubbed the patients' entire leg for a good ten minutes before wrapping it in the necessary materials to prepare for the surgery.

The patient was unquestionably a larger woman which proved to be no obstacle for the Doctor, as he navigated his way through skin, adipose tissue, and muscle to locate the greater trochanter, and eventually the femoral head which was subsequently sawed off. Unfortunately, the pictures I took during the procedure were all on my phone, which was recently destroyed, otherwise I would show a few great shots of the incisions and the sawed-off femoral head.

The procedure itself was pretty straight forward. There wasn't too many interesting things that took place while in the surgery room. Every now and then, the Physician Assistant would toss a quiz question my way, and since there was another high school student in attendance, the Physician Assistant allowed me to answer some questions, however, he shot most of the questions to the high school student, because "he hadn't already had anatomy," and I have, so he expected me to know all the answers to his questions.

Other interesting things that happened during the surgery was one of the technicians apparently became uneasy during the surgery and needed to be helped out of the room. She did not pass out, per se, but from the looks of it, she was well on her way to taking a dive into the operating rooms' floor.

There were a few moments during the middle of the procedure where the Physician Assistant had to shift and adjust the patients' leg positing, which was 1) so the Doctor could get a better view, and 2) so they can observe the way the newly added hardware would work with the patients' existing bony structures, in which they simply simulated all the motions of the hip. There was one time when the Physician Assistant joked, "I will give anyone in here $20 if they could position their leg like this," and I saw just exactly how he was holding the leg, and there is no one alive who could do that. The leg was placed into hip adduction, internal rotation, knee flexion, and and horizontally adducted to where the involved foot could reach the opposite side (right ASIS) and then bend upwards. It was certainly a freakish sight to see and very unnatural, of course.

Needless to say, the environment in their operating room was very relaxed and inviting. There were several times when the Doctor and the Physician Assistant allowed us to get closer looks and really, truly allowed us the opportunity to learn.

Familiar face?

Came across this article on Huffpost and couldn't help but recognize the face in the background -- is that you Father Privett, President of my alma mater?

An amazing tale of heroism

...or just another day in the life of an Athletic Trainer!

This afternoon while attending Ben's usual Sunday soccer game (he participates in a Mexican League), we witnessed a pretty nasty injury to one of the opposing players. In the late second half, the score was 3-2 so both teams are battling; one team to tie the game, the other to win the game. Lauren P. (also another emergency responder) and I are sitting in upper part of the stands when these two teammates both go for the ball. I'm presuming they didn't see one another. One teammate goes to kick the ball, but instead, kicks his own guy along the side of his lower leg. The teammate then proceeds to fly about 4ft. in the air, inverts head-over-heel, and lands on his back. However, while in the air, the kids' foot points outwards, as if it was broken in half -- just dangling there, prior to him slamming back into the ground. Lauren and I both have an "Oh S__t!" moment. Well, her's was more like a "Oh my!," but still we both had sudden reactions from the sight of the grossly deformed foot.

At that moment I run onto the field to check on the athlete. He is visibly hurt and in pain, yet calm. Some of the players begin to surround the scene. I survey the athlete and his foot does not appear to be in any unnatural position. In fact, it is pointed straight and not out to the side, like it was when upon initial contact. The player is on his side, as pictured below, and reaches down to grab for his leg. Upon closer inspection, there appears to be a bulge along the lateral malleous, or outside ankle, apparently the site of injury.

There were over 300+ Spanish speaking individuals (a language which I do not speak fluently) so I motioned to one of the persons standing by for his shirt, or jacket, to cover up the foot, for fear that the player would see it and go into shock. It was just a precautionary measure, but luckily, the player was very calm. He squirmed and groaned occasionally, but overall, he was very calm.

By now, Ben and I are both at the scene, some 1.5 minutes into the ordeal, and the the players' cousin, is dialing 911, but no one (out of the 300+ people out there) knew exactly where we were!

Meanwhile, Ben begins to palpate the players ankle and lower leg feeling for deformities. I report to him what I saw, and he continues his inspection. By now, everything has stopped (on both fields) and everyone has gathered around, so I step back and try to restore control, making space for Ben to work and creating a path for the ambulance. The cousin on the phone finally communicates to the authorities that we are at a park off the loop, that when I say "Near the expo center," which would hopefully give them a better idea of our location.

Ben is busy checking for breaks in continuity, checking pulses, and making sure everything is intact, while we wait for the ambulance to arrive. He is also asking questions about relevant sounds and sensation, all through the cousin who is translating every word. At this point, the only thing we could do is manage the scene, keep the athlete as comfortable as possible (placing a rolled jacket underneath his head), monitor his consciousness making sure he's not slipping into shock (he said he didn't want the jacket we offered to keep him warm), and wait for the Emergency Personnel to arrive.

It was at this point where I pulled out my phone and began to take pictures, and Ben instructs one of the persons standing by to flag down the ambulance once it arrives. They got there quickly in under 12-13 minutes.

Emergency personnel working to remove the shoe.

Ben (blue white stripes) assisting with the care of the athlete. A closer look reveals the position of the splinted foot, wrapped in what appears to be a rigid "L" shape splint that covers the foot posteriorly, with a soft cushion material protecting it anteriorly and laterally, which had the appearance of an Ace bandage.

Once the players shoe was removed, he was lifted and boarded onto the stretcher and placed into the ambulance. And 5 minutes later, the game resumed. Ben's team ended up losing 3-2.

Video of Ben's inspection and communicating with the cousin, right before the ambulance arrives.

My impressions of what happened, and over reflection with Ben, is that the guy suffered a left leg distal fibular fracture, evidenced by the 90 degree angulation his foot presented with while he was in the air, but possibly upon impact with the ground, his foot shifted to its normal position, although by normal, I mean it was no longer pointed outwards. During Ben's inspection he noticed some discontinuity over the lower fibular shaft, and noticeable deformity, but it was a closed-fracture, or there was no skin breakage.