Rehabilitation program for the lower limb

INTRODUCTION — Physical therapy, manual therapy, and exercises for the lower limb serve to restore strength, improve posture, and alleviate pain and disability in patients with lower extremity problems. These measures should be used in conjunction with principles of joint protection for the lower limb. (See "Joint protection program for the lower limb").

COGNITIVE-BEHAVIORAL THERAPY — This type of therapy should be considered if the clinician or therapist observes poor coping strategies, patient fear of disability, lack of motivation, or other self-defeating behavior. Several controlled studies have shown the value of this type of psychological counseling [1-3].

PHYSICAL THERAPY — Physical therapy modalities include heat, cold, ultrasound, and diathermy. The purpose of these treatments is to allow the patient to perform an exercise program; they should therefore be performed prior to each exercise session.

PRICE program — Acute injury is best managed with the PRICE program: protection; rest; ice; compression; and elevation. Protection includes reduced weight bearing with forearm canes or crutches. Shoe modification should be individualized with either soft insert appliances or molded shoes. If a stress fracture of the foot is suspected, a fracture shoe can provide temporary protection until the diagnosis is secure. Ice packs include frozen gel packs and frozen bags of peas. If many areas are involved, dishtowels can be moistened and frozen, then applied as needed. Ice should be applied for up to 20 minutes, and repeated every few hours.

Heat — Heat increases local blood flow, and can be used after the first few days following injury. A heating pad over a layer of plastic separating it from warm moist towels can be applied as moist heat for 20 minutes preceding exercise. Diathermy has little advantage over hot packs or moist heat.

Joint aspiration and injection — If synovitis/synovial effusion is present, joint aspiration and injection may result in a more rapid response to physical therapy and joint protection.

Ultrasound — Ultrasound requires expertise. This technique uses sound waves directed at specific tissues. As the sound waves penetrate the tissue, local temperature increases and tissue extensibility is enhanced. Ultrasound is used for local tendinitis, bursitis, fasciitis, muscle pain, or spasm. It is usually performed two or three times per week for two to four weeks. Acute inflammation is a contraindication to the use of ultrasound due to the focal increase in tissue temperature. Despite its frequent use, evidence from well controlled studies is mixed and inconclusive regarding the effectiveness of ultrasound in relieving pain, contributing to overall functional outcomes, or reducing treatment time or cost [4,5].

Extracorporeal shock wave therapy (ESWT) — There are conflicting data regarding the effectiveness of ESWT. Three sham-treatment controlled studies with random assignment were favorable [6-8], while three other studies reported no significant difference between treatment and sham-controlled groups [9-11]. The technique does have soft tissue adverse side effects that include causing hematomas and microfractures. It is possible that efficacy depends upon the type of ESWT device and treatment protocols.

MANUAL THERAPY — Manual therapy includes many techniques that are totally operator-dependent. Thus, little hard data can be applied to individual situations. Experience and availability within a given community will determine preference.

Diathermy, massage, and ultrasound require a significant other person and therefore should be reserved for complex chronic problems. Massage techniques can be taught in the office to the patient and his or her significant other. Similar to physical therapy, an exercise program should follow manual therapy.

Magnets imbedded in orthotics were found to be no better than sham magnets in a controlled study of patients with plantar heel pain of at least 30 days duration [12].

EXERCISE THERAPY — Exercises that provide stretching and strengthening are important for pain management, strength restoration, and safety in patients with lower extremity problems. In general, the tissue should be stretched before strengthened.

A graded exercise program should be individualized, depending upon pain severity, limitation of movement, and current strength. A home exercise program should have clearly defined goals, easily understood instructions, and should not require more than about 30 minutes duration for each session. In most cases, we ask the patient to perform a twice daily regimen [4]. The value of exercise in different disorders has been assessed and the following are illustrative results: Efficacy for osteoarthritis is supported by three controlled studies of strength-training [13-15]. Pain, walking time, gait, safety, and strength improved significantly in all three studies. However, synovial effusion increased in one study [13]. Patients who develop osteoarthritis of the patellofemoral joint do not seem to be significantly helped by treatment with a combination of physical therapy, quadriceps strengthening exercises, and patellar taping [16]. Non-weight-bearing stretching exercises specific to the plantar fascia is superior to weight-bearing Achilles tendon-stretching exercises [17] (See exercise 10 below).

Isotonic exercise is suggested for initial strengthening in patients with exercise-induced knee pain, and subsequent isokinetic exercise is suggested for improving joint stability or walking endurance [18].

Relaxation exercise can be performed when anxiety, tension, or pain limit exercise performance. These techniques include Yoga, breathing, audio tapes, and guided imagery. Self-help books are readily available.

A series of 11 exercises are presented here to stretch and strengthen the muscles of the lower extremity. The choice of exercise for individual patients is dependent upon the condition that is being treated. These exercises were selected for their ease of application and the author's experience. The snapping hip syndrome may be treated with the standing iliotibial band stretch (show picture 1). Fascia lata fasciitis may be treated with the sidelying iliotibial band stretch (show picture 2). Hamstring injuries may be treated with the posterior leg stretch-wall (show picture 3), posterior leg stretch-doorway (show picture 4), or supine leg stretch (show picture 5) (See "Evaluation of the adult patient with knee pain"). Myofascial knee pain may be treated with the hip flexor stretch (show picture 6). Quadriceps disuse atrophy, knee injuries, and the piriformis pain syndrome may be treated with resistive quadriceps strengthening (show picture 7). Sport centers often combine this with leg curls to strengthen the hamstring muscle group. Popliteal tendinitis (tennis leg) may be treated with the posterior leg stretch-wall (show picture 3). Plantar fasciitis may be treated with the calf-plantar fascia stretch (show picture 10) and toe curls (show picture 8). (See "Plantar fasciitis and other causes of heel and sole pain"). Running injuries may be treated with different exercises depending upon the area affected: a general exercise is the posterior leg stretch-wall (show picture 3); resistive quadriceps strengthening is used for knee injuries (show picture 7); foot/ankle circles are used for ankle sprains (show picture 9). Leg cramps may be treated with the posterior leg stretch-wall (show picture 3). (See "Nocturnal leg cramps, night starts, and nocturnal myoclonus"). Ankle tendinitis may be treated with foot/ankle circles (show picture 9), and the posterior leg stretch-wall (show picture 3). (See "Posterior ankle tendinopathies"). Achilles disorders may be treated with the posterior leg stretch-wall (show picture 3) and the calf-plantar fascia stretch (show picture 10). Metatarsalgia may be treated with toe curls (show picture 7), and toe towel curls (show picture 11). Adhesive capsulitis of the ankle, and plantar fasciitis may be treated with the calf-plantar fascia stretch (show picture 10).

SHOE MODIFICATION — Patients with metatarsalgia may benefit from adding rocker bars to the sole or from an orthotic. Structural disorders including pes planus, plantar fasciitis, bunions, and osteoarthritis of the midfoot may also improve with shoe modification. Patients who live or work on concrete flooring should change to running shoes, extra-depth shoes (see below), heat moldable shoes, or custom-made shoes. For dorsal exostoses, I teach the patient to mark the exostosis with lipstick, put on the shoe, then construct a bridge by applying adhesive-backed foam rubber strips (1/4 inch wide by 1 inch long) on either side of the lipstick mark inside the shoe or tongue. Elastic shoelaces should be used.

Extra-depth shoe — The extra-depth shoe is prescribed with the additional feature of the enlarged toe box. This shoe is helpful for patients with metatarsal and metatarsophalangeal joint difficulties, hammer toe, and rheumatoid or other inflammatory arthritides with forefoot deformity. Occupational therapists, orthopedists, or podiatrists are skilled in making the mold.

Running shoes — A running shoe has microcellular foam and a rigid forefoot. These are important differences from other sport shoes.

Orthoses — Orthoses can be used for a variety of purposes: to correct a leg length discrepancy; to correct foot/floor contact as in pronation/supination disorders; and to redistribute weightbearing patterns. Orthoses may be obtained over-the-counter or can be custom made.

RESOURCES — Resources for the professional include:

Carolyn Kisner, Lynn Allen Colby:Therapeutic Exercise: Foundations and Techniques. F A Davis Co; 4th edition, 2002.

William E Prentice, William Prentice: Rehabilitation Techniques for Sports Medicine and Athletic Training with Laboratory Manual and eSims Password Card. McGraw-Hill Humanities/Social Sciences/Languages; 4th edition; 2003

Steven B. Brotzman, Kevin E. Wilk: Clinical Orthopaedic Rehabilitation. Elsevier Science 2003

Anderson, BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd ed, WB Saunders Company, Philadelphia 1999.

Banwell, B, Hoehing, P. Physical interventions, exercise, and rehabilitation. In: Soft Tissue Rheumatic Pain: Recognition, Management, Prevention, 3rd ed, Sheon, RP, Moskowitz, RW, Goldberg, VM (Eds), Williams & Wilkins, Baltimore, 1996.


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