Sports Medicine Specialists Rehabilitation Protocols

Achilles Tendinitis Rehabilitation Phase I

A. Ice massage before and after exercise and as often as possible between exercise sessions.

B. 1/4” - 3/8” heel lifts worn in shoes. Wear in all shoes.

C. Non-steroidal anti-inflammatory (NSAID) medication as prescribed by physician.

D. Ultrasound Achilles region while stretching Achilles Tendon.

E. Static Calf & Achilles Tendon stretching 5 - 8 times daily. Hold each stretch for 10 seconds and repeat 5 - 8 times per session.

F. Stationary bicycle or swimming are excellent rehabilitative and cardiovascular exercises. Build up to 30 minutes of continuous pain free activity.

Progress to Phase II when a 20 yard walk can be completed with little or no discomfort.

Phase II

A. Ice Massage before and after exercise

B. Continue stretching 5 - 8 times per day as described above.

C. Continue NSAIDs as prescribed by a physician.

D. Begin strengthening exercises:

Theraband® Exercises: Perform 3 sets of 10 repetitions in each direction. Progress by increasing repetitions to 3x15, then to 3x20. Theraband® can be attached to an immovable object or held by another person.

Inversion: Loop band over ball and instep of foot. Turn ankle & foot (not leg) inward as far as possible. Repeat 30 to 60 times one time daily.

Eversion: Loop band over outside edge of foot just below the toes. Turn ankle & foot (not leg) outward as far as possible. Repeat 30 to 60 times one time daily.

David Edell, LAT, ATC, CSCS

Cellular: 713.858.3802 • Fax: 281.341.3012 • E-Mail: [email protected]

The Sports Medicine Specialists RSH Physical Therapy 1601 Main Street # 602 Richmond, TX 77469 281.341.2874

Houston Orthopædics & Sports Medicine 1601 Main Street # 601 Richmond, TX 77469 281.565.8800

OakBend Medical Center 1705 Jackson Street Richmond, TX 77469 281.341.3000

Dorsiflexion: Loop band over top of foot at base of toes. Pull foot and toes up toward shin as far as possible. Repeat 30 to 60 times one time daily.

ABC’s: Loop band around ball and sole of foot while holding ends of the band. Write ABC’s with, moving only foot and ankle, as in #1. Perform 1 to 2 sets of the alphabet one time daily.

CALF RAISES: Stand with feet shoulder width apart and toes pointed forward. Left heels off of the floor as high as possible. Slowly lower heels to the floor and repeat as described below.

Progress to Phase III when 3x20 heel raises can be completed with little or no discomfort.

Phase III

A. Continue ice massage before and after exercise.

B. Continue NSAIDs as directed by physician.

C. Continue Ultrasound as directed by physician.

D. Continue calf and Achilles Tendon stretching.

E. Continue heel raises.

F. Begin light jogging on flat, smooth surface and progress in distance or time as pain allows.

G. Progress to normal activities when 3x20 one leg elevated heel raises and a 40 yd jog can be completed without pain within 24 hours after activity.

H. Continue rehabilitation activities for 1 - 3 months after returning to full activity.

Week 1 Week 2 Week 3 Week 4

Monday - Tuesday 3 x 10 3 x 10 3 x 10 3 x 10

Wednesday - Thursday 3 x 15 3 x 15 3 x 15 3 x 15

Friday - Saturday 3 x 20 3 x 20 3 x 20 3 x 20

Both Legs 2 Legs, Toes Elevated 1 Leg 1 Leg, Toes Elevated

Achilles Tendinitis, Pg. 2

Essential Ankle Rehabilitation Protocol General Treatment

1. ICE application for 20 minutes every 60 to 90 minutes the first two days after injury. Before and after exercise from that point forward.

2. COMPRESSION wrap or Aircast® stirrup brace applied to control swelling and motion.

3. ELEVATE the ankle above the knee as often as possible. 4. ANTI-INFLAMMATORY medication (Advil® or Aleve®) to reduce swelling in

accordance with package directions.

Exercises

1. ABC’s: Use big toe as a pencil, write letters of the alphabet moving ankle and foot only. Repeat as often as possible.

2. BALANCE: Stand on affected leg only, near an object that can be used to regain balance if you begin to fall. Perform this for 5 minutes. When it becomes easy, perform with eyes closed.

3. THERABAND: Using an this elastic band perform the following exercises to increase strength in the muscles of the affected ankle.

A. Inversion: Loop band over ball and instep of foot. Turn ankle & foot (not leg) inward as far as possible. Repeat 30 to 60 times one time daily. B. Eversion: Loop band over outside edge of foot just below the toes. Turn ankle & foot (not leg) outward as far as possible. Repeat 30 to 60 times one time daily. C. Dorsiflexion: Loop band over top of foot at base of toes. Pull foot and toes up toward shin as far as possible. Repeat 30 to 60 times one time daily. D. ABC’s: Loop band around ball and sole of foot while holding ends of the band. Write ABC’s with, moving only foot and ankle, as in #1. Perform 1 to 2 sets of the alphabet one time daily.

4. CALF RAISES: Stand with feet shoulder width apart and toes pointed forward. Left heels off of the floor as high as possible. Slowly lower heels to the floor and repeat as described below.

5. CALF STRETCHING: Stretch Calves, with the back knee bent and straight, 3 to 4 times daily.

Perform these exercises for 4 weeks to ensure a full return to participation!






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Anterior Cruciate Ligament (ACL) Hamstring Graft Rehabilitation Protocol

Pre-Op Instructions

1. Gait training instruction with crutches.

2. Instruction in immediate post-op exercises.

Post-Op: Day of surgery at home.

1. Hinged brace locked at 0° or straight leg brace.

2. Ice & elevation of knee. Compression wrap should be worn to control swelling.

3. Do not allow incisions to get wet while bathing.

4. Range of motion exercises:

a. Ankle range of motion (ABC’s),

b. Heel Slides, and

c. Passive Patellar Mobilization.

4. Begin strengthening exercises as tolerated:

a. Quadriceps and hamstring sets,

b. Straight Leg Raises (SLR): Supine, Abduction, Adduction, Prone,

c. Seated knee extension, hip flexion, and terminal knee extension,

d. Partial weight bearing to tolerance with crutches, and

e. Well body exercises.

f. No Active Hamstring Flexion Exercises for 4 weeks (Passive or Active-Assisted Only.)

5. Ice before and after exercise and 20 minutes every 2 hours while awake.

Post-Op: Day 1

1. Continue ice, elevation, and compression wrap.

2. Continue range of motion exercises 2 - 3 times per day and add:

a. Stationary bike riding with seat height as low as tolerable with low resistance.

3. Continue strengthening exercises and add:






ACL-Hamstring, Pg. 2

a. Heel raises with balance assistance, and

b. Partial squats with balance assistance.

4. Ice before and after exercises and 20 minutes every two hours while awake.

Post-Op: Day 2 - 7

1. Continue ice and elevation.

2. Discontinue crutches no later than day three.

3. Continue range of motion exercises.

4. Continue strengthening exercises by utilizing PRE principle and add:

a. Weight to all SLR’s, Knee Extension, Hip Flexion, and TKE, and

b. Side Step-Ups.

5. Ice before and after exercise and continue use of compression wrap.

6. Physician examination 6 - 8 days post-op for evaluation and suture removal.

Post-Op: Week 1 - 3

1. Continue ice and elevation as needed.

2. May shower or bathe after sutures have been removed.

3. Continue range of motion exercises (Full ROM allowed).


a. Gait training program on smooth, flat surface,

b. Squats progressing to Single-leg parallel squats,

c. Calf Raises progressing to Single-leg, then elevated heel raises,

d. Balance and proprioception activities, and

e. StairClimber exercises.

5. Ice before, if indicated, and after exercise.

Post-Op: Week 4 - 12

1. May apply lotion to incisions sites using heel of thumb and pressure as tolerated.

2. Continue range of motion exercises if needed.

3. Continue strengthening exercises utilizing PRE principles, add

a. Active Hamstring Curls,

b. Seated Leg Press 0° - 90°,

c. Squats in weight room with emphasis on form over weight,

d. Slide Board (week 6), and

e. Swimming with straight kicks only, after full wound healing.

4. Discontinue brace for daily living activities at 6 weeks post-op or as directed by physician.

5. Begin Jog program at 10 weeks post-op, with physician approval, on smooth flat surface, jog straight-a-ways only, walk curves. Slowly increasing time and/or distance. If painful or a limp is present, do not increase intensity until pain-free and gait is normal.

ACL-Hamstring, Pg. 3

Post-Op: Week 12 - 6 Months

1. Continue active exercises.

2. Begin functional activities after fitting of functional brace:

a. Light plyometrics,

b. Begin light cutting or agility activities, and

c. Begin sport specific non-contact drills.

3. Return to non-contact, non-competitive individual sports (running, swimming, biking) at 3 to 4 months if contralateral strength is 85% or more.

4. Return to competitive sports (4 - 12 months) when:

a. Contralateral strength is 85% or greater,

b. Range of motion is equal,

c. Girth measurements are equal, and

d. Knee is functionally stable.

Meniscal Repair Restrictions

If a meniscal repair is performed in conjunction with an ACL Reconstruction, the following limitations are added:

1. Non-weight bearing with crutches for 4 weeks.

2. Knee Flexion limited to 0° - 90° for 4 weeks.

3. Walk/Jog program instituted at week 12 post-op only if adequate strength, coordination, and range of motion has been regained.

Patients heal at different rates, possess various pre-operative deficiencies, and require specific attributes to perform normal function. Due to these factors, this protocol must be individualized to each patient to allow for optimal return to desired activities.

Low Back Program

1) Pelvic Tilt: Lie on your back with knees bent and feet flat. Tighten stomach muscles to flatten back against the floor. Hold for 5 seconds, then relax. Repeat 10 - 20 times.

2) Single Knee To Chest: Lie on your back with

knees bent and feet flat. Using both hands, grasp one leg, below the knee, and pull to chest. Hold 5 seconds and relax. Repeat with other leg. Perform 5 - 10 times for each leg.

3) Double Knee To Chest: Lie on back with knees

bent and feet flat. Using hands, bring one knee to chest, then the other. Hold for 5 seconds. Lower one leg at a time. Maintain Pelvic Tilt (see #1) while lowering leg. Repeat 5 - 10 times.

4) Partial Sit-Ups: Lie on back with knees bent and

feet flat. Assume Pelvic Tilt position. With arms out in front of you, tuck chin and curl upper body up to clear shoulder blades off of floor. Hold 5 seconds and relax. Begin with 10 repetitions, add 1 per day as strength improves.

5) Diagonal Sit-Up: Lie on back with knees bent and

feet flat. Assume the pelvic tilt position. Do a partial sit-up with the left had reaching for the right knee. Hold 5 seconds and relax. Repeat in the opposite direction. Begin with 10 repetitions to each side, add 1 per day to each side as strength improves.

These exercises are used to control or improve low back pain. They should be done 3 - 5 times a day to provide maximum benefit. These exercises are best done on a firm surface such as a floor or firm bed. If any of these exercises aggravate your condition, they should be stopped for that session.






Low Back Program, Pg. 2

6) Bent Knee Roll: Lie on back with knees bent and feet flat. Gently roll knees to one side. Hold for 10 seconds. Return to starting position and roll to opposite side. Repeat 10 - 20 times to each side.

7) Bridging: Lie on back with knees bent and feet

flat. Lift buttocks off of floor, as high as tolerable, and hold for 5 seconds. Slowly lower and relax. Repeat 5 - 10 times.

8) Prone On Elbows: Lie on your stomach. Raise

up on your forearms and relax for 2 minutes. Allow back to sway. Increase time by 1 minute per day up to 10 minutes maximum.

9) Press Up: Lie on your stomach. Place hands flat

on table or floor at shoulder level. Push up while keeping hips on the floor or table, allowing back to sway. Hold for 5 seconds and relax. Repeat 5 - 10 times.

10) Prone Arm Lift: Lie on stomach with arms

reaching above and next to your head. Lift one arm off of the table or floor and hold for 5 seconds. Return to beginning position. Repeat with alternate arm. Repeat 10 times for each arm, adding 1 repetition per day as strength improves. Progress to lifting both arms together as strength improves.

11) Thoracic Extension: Lie on stomach with arms at

side. Keep chin tucked into chest, forehead resting of floor or table. Lift upper body off of floor, keeping chin tucked in. Hold 5 seconds and relax. Repeat 10 times, adding 1 repetition per day as strength improves.

12) Prone Leg Lift: Lie on Stomach. Raise leg, from

hip, with knee straight, 4 - 6 inches off of floor or table. Hold 5 seconds and relax. Repeat with opposite leg. Repeat 10 times, adding 1 repetition per day as strength improves.


13) Opposite Arm - Leg Lift: Lie on stomach with arms reaching above and next to your head. Lift the left arm as you lift your right leg. Hold them straight for 5 seconds and relax. Repeat with alternate arm and leg. Repeat 10 times for each arm, adding 1 repetition per day as strength improves.

14) Opposite Arm - Leg Life On Hands & Knees:

On hands and knees, lift left arm as you lift the right leg (straight) as a “Bird Dog on point.” Maintain a flat back and level hips. Repeat with alternate arm and leg. Repeat 10 times for each arm, adding 1 repetition per day as strength improves.

15) Cat - Horse: On hand and knees. Slowly arch

back up as far as tolerated while tucking chin to chest. Hold this position for 5 seconds. Slowly let back sink into a “sway back” position, while lifting head level with back. Hold this position for 5 seconds. Repeat 30 times.

16) Standing Side Bends: Standing up straight.

Bend to side as if sliding hand down outside of leg. Alternate to opposite side. Repeat 5 - 10 times each side.

17) Standing Back Bends: Sand upright with hands

on lower back. Bend backward as far as comfortable. Hold 5 seconds and relax. Repeat 5 - 10 times.

18) Wall Slides: Stand with your back to a wall, feet

shoulder width apart and 6 - 10 inches from the wall. Lean back against the wall. Slide down into a sitting position, flattening back against the wall. Hold sitting position for 10 seconds and return to standing position. Repeat 10 times, add 1 repetition per day as strength improves.


19) Fire Hydrant: On Hands and Knees. Lift right leg out to the side with knee bent. Hold for 5 seconds and repeat with opposite leg. Repeat 10 times for each leg, adding 1 repetition per day as strength improves.

Lower Body Stretching Exercises

20) Supine Hamstring: Lie on Back, raise leg to

chest by bending at the hip, grasping the back of your thigh with both hands just above the knee. Slowly straighten your knee until you feel a stretch in the hamstrings at the back of the thigh. Hold 10 seconds, and repeat on opposite leg. Repeat 3 - 5 times for each leg.

21) Seated Hamstring: In a sitting position, Slowly

lean forward to stretch leg. This can be performed with knees together or in a V-Leg position. Keep back flat while performing stretch. Hold 10 seconds, and repeat 3 - 5 times for each leg.

21) Standing Hamstring: Place one foot on a secure

table or object 6 - 12 inches tall. Slowly lean upper body forward, keeping leg straight and toes pointing up. Do not “hump” back and maintain curve in lower back. Hold 10 seconds, and repeat 3 - 5 times for each leg.

22) Hip Flexor: Lie on back on the edge of a bed or

table, hugging both knees. Lower one leg straight out, allowing it to hang over the edge of the table. Continue to hug opposite leg. Hold this position for 10 seconds. Return to the starting position and repeat on opposite side. Repeat 3 - 5 times each leg.

23) Piriformis (Figure 4): Lie flat on back with both

knees bend and feet flat on floor. Cross right ankle onto left knee. Grasp behind left knee and slowly pull towards your chest. Hold for 10 seconds and slowly lower to beginning position. Reverse position and repeat 3 - 5 times for each leg.


24) Piriformis (Trunk Twister): Sit on floor or table. Cross right leg over left thigh, placing right foot outside of the left knee. Place left elbow on outside of right knee. Gently stretch by pushing right elbow into left knee. Keep back straight while stretching. Hold for 10 seconds and repeat for opposite side. Repeat 3 - 5 times for each side.

25) Calf Stretch: Stand facing a wall, with one foot in

front of the other. Lean forward with your hands on the wall. Bend the front leg while keeping both heels on the floor. You should feel a gentile stretch in the back of your lower legs. Hold 10 seconds, repeat with the other leg forward. Repeat 3 - 5 times for both legs.

21) Standing IT Band Stretch: Strand, approximately

2 - 3 feet from a wall, with the involved side facing the wall. Place one hand on the wall and cross uninvolved leg over involved leg and lean into the wall. Place hand on uninvolved hip for overpressure. Hold for 10 seconds, repeat 3 - 5 times.

21) Table IT Band Stretch: Lie on back near edge of

table. Let leg stretch over edge of table so that there is a full stretch on outside of hip and side of leg. Bend leg being stretched to 90° angle at the hip and keep knee straight. Place arms out to the side to maintain balance. Hold for 30 seconds, repeat on other side. Repeat 3 - 5 times for each leg.

22) Quad Stretch: Stand with involved knee bent.

Gently pull heel toward buttocks, feeling a stretch in the front of the leg. Keep upper body straight, do not lean forward. To increase the stretch, pull with enough pressure to cause the involved knee to pass behind the uninvolved knee. Hold for 10 seconds, repeat 3 - 5 times.

Phase I

A. Ice Massage before and after exercise and as often as possible between exercise sessions.

1. Ice with knee extended and ankle dorsiflexed.

A. Mild Lower let & foot compression with wrap or compression hose for initial 48 - 72 hours.

B. Intermittent compression, if available, 2 - 3 times per day.

C. Non-steroidal anti-inflammatory medication (NSAID) as prescribed by physician.

D. Mild muscle relaxant medication as prescribed by physician.

E. Partial to full weight bearing as tolerated.

F. Static calf & Achilles tendon stretching 5 - 8 times per day. Hold stretch for 10 seconds and repeat 5 - 10 times per session.

Calf Stretch: Stand 12” - 18” away from a wall with trunk and knees straight. Slowly lean into wall, keeping knees locked and heels on the floor. Slowly move heels away from wall as stretch becomes easier.

Achilles Tendon Stretch: Assume the same position described above. Bend both knees slightly, keeping the heels flat on the floor, and lean into wall. The stretch should be in the region of the Achilles tendon.

Active Exercises:

Ankle ABC’s: Using the big toe like a pencil, write the letters of the alphabet moving only the foot and ankle. Make the letters as large as possible. Repeat as often as possible throughout the day.

Paper Pick-ups: Crumple several pieces of 3”x3” paper into balls about the size of marbles. Place the balls of paper on the floor, using the toes, grasp one ball at a time , pick up and place in opposite hand. Repeat 20 - 40 times.

Towel Push/Pull: Lay out a towel on a smooth, slick surface and position the foot at one end. Curl toes to pull the towel toward the body without moving the heel. When the end of the towel is reached, use toes to push the towel away from the body. Progress by increasing repetitions or by adding a weight to the end of the towel.

Calf Strain & Contusion Rehabilitation






Stationary Bicycling and Swimming are excellent rehabilitative and cardiovascular exercises. Build up to 30 minutes of continuous activity.

Progress to Phase II when Phase I can be completed with little or no discomfort.

Phase II: 2 - 7 Days After Injury

A. Continue Ice Massage before and after exercise.

B. Mild lower leg & foot compression with ace wrap or compression hose for weight bearing activities.

C. Continue intermittent compression as indicated.

D. Continue NSAIDs.

E. Discontinue muscle relaxant medication as directed by physician.

F. Begin ultrasound or electrical stimulation when danger of internal bleeding has passed (3 - 6 days).

G. Continue previous static calf & Achilles Tendon stretching. Progress stretch as pain allows.

H. Continue previous active exercises and add:

Balance: Stand on affected leg only, near an object that can be used to regain balance if you begin to fall. Perform this for 5 minutes. When it becomes easy, perform with eyes closed.

Theraband® Resistance Exercises: Perform 3 sets of 10 repetitions in each direction. Progress by increasing repetitions to 3x15, then to 3x20. Theraband® can be attached to an immovable object or held by another person.

Inversion: Loop band over ball and instep of foot. Turn ankle & foot (not leg) inward as far as possible. Repeat 30 to 60 times one time daily.

Eversion: Loop band over outside edge of foot just below the toes. Turn ankle & foot (not leg) outward as far as possible. Repeat 30 to 60 times one time daily.

Dorsiflexion: Loop band over top of foot at base of toes. Pull foot and toes up toward shin as far as possible. Repeat 30 to 60 times one time daily.

ABC’s: Loop band around ball and sole of foot while holding ends of the band. Write ABC’s with, moving only foot and ankle, as in #1. Perform 1 to 2 sets of the alphabet one time daily.

CALF RAISES: Stand with feet shoulder width apart and toes pointed forward. Left heels off of the floor as high as possible. Slowly lower heels to the floor and repeat as described below.

Calf Strain, Pg. 2






Begin stair climbing exercises as tolerated.

Progress to Phase III when 3x20 heel raises can be completed with little or no discomfort.

Phase III: Sport Specific Activities (5 - 21 days post injury)

A. Continue ice massage before and after exercise.

B. Continue NSAIDs as directed by physician.

C. Continue ultrasound/electrical stimulation as directed by physician.

D. Continue Achilles Tendon & calf stretching.

E. Continue Theraband® exercises.

F. Progress difficulty of heel raises as previously outlined.

G. Progress to normal activities:

H. Begin walk or jog program as pain allows.

I. Begin agility activities, such as carioca and zig-zag running as pain allows.

Calf Strain, Pg. 3

A good preventative for injuries remains adequate conditioning. This should include aerobic training and strength training that ensures a balance in strength and endurance. The flexibility of the muscles is also a major factor in preventing hamstring injuries. Having proper muscle flexibility will make the athlete perform at a higher competitive level. Proper stretching before and after exercise will: decrease injuries, enhance performance, improve joint range of motion, and decrease post-exercise soreness. Flexibility improvement and maintenance is often overlooked when an exercise program is instituted. Muscle flexibility is important to everyone due to its relationship to health and the body's working capacity. Poor flexibility of joints and muscles can cause injuries, or make daily living painful. The best examples of this are seen in the shoulder and lower back. Proper stretching should include both upper and lower extremities and the back for any competitive activity or training. Remember do not bounce when stretching, this can, in some cases, result in injury. Stretching should be performed following a gentle warm-up, such as 5 - 10 minutes of cycling or walking. Muscles will respond better to flexibility training when warm and pliable. The "core" stretches for all people should include: hamstrings, quadriceps, calves, gluteals, and shoulders. Volleyball and basketball players should add more specific shoulder stretches, while sprinters should add more specific lower extremity stretches. Hold each stretch for 10 - 30 seconds, repeat the stretch 3 to 5 times for each body part, and stretch 3 - 5 times daily.

Basic Stretches for Active Individuals Calf Streth:Stand faciong a wall, with one foot in front of the other. Lean forward with your hands on the wall. Bend front leg, leaving the rear leg straight and keeping both heels on the floor. Continue until a gentile stretch is felt in the calf. Hold 10 seconds, then repeat with other leg forward. A second stretch is performed in the same manner, but with a slight bend in the knee of the back leg. This stretch will be felt lower in the calf, near the Achillies Tendon. Repeat each stretch 3 times, with a 10 sec hold.

Quadriceps Stretch: Stand with the knee bent , foot held in hand, gently pull foot towards buttocks. The stretch is felt in the front of the thigh. Do not bend over at the waist, this will make the stretch less effective. Hold 10 seconds and repeat 3 times for each leg.

Groin (Butterfly) Stretch: Sit on floor, bend knees so that soles of feet are touching. Gently draw feet towards the groin. Relax, and let the weight of the legs allow knees to move towards the floor. If a stronger stretch is desired, use the elbows to gently push the knees to the floor. Hold for 10 seconds and repeat 3 times.

Flexibility Training






Hamstring Stretch: Sit on floor, with legs straight out in front, toes pointing up. Gently lean forward, causing a stretch in backs of legs. Do not allow the back to “hump” as you reach for your toes. Hold for 10 seconds and repeat 3 times. (For variation, try this with the legs spread apart. Stretch to the left leg, middle, and right leg. Hold 10 seconds each, and repeat 3 times.) Trunk Twister: Sit on floor. Cross leg over thigh at the knee and place opposite elbow on outside of bent knee. Gently stretch back and buttock muscles by pushing bent knee across body while looking in the opposite direction. Reverse arm and leg position for opposite side. Hold for 10 seconds, and repeat 3 times.

Advanced Back Stretch: Lay on back, bend knees and lift legs over head. Straighten knees, causing a gentile stretch in backs of legs, buttock, and back muscles. Hold for 10 seconds, relax, and repeat 3 times.

Horizontal adduction stretch (left): Grasp elbow of arm to be stretched with opposite hand. Gently pull arm across front of chest, just below the throat. Hold for 10 seconds, relax and repeat 3 times for each arm.

Tricep Stretch (right): Lift arm to be stretched so that elbow is next to ear, allow elbow to bend. Grasp bent elbow with opposite hand and gently pull arm behind head. Hold for 10 seconds, relax, and repeat 3 times for each arm.

Biceps/Chest Stretch: Stand grasping door frame with both arms at shoulder level. Slowly lean away from door, gently stretching chest and shoulder muscles. Hold for 10 seconds, relax, and repeat 3 times.

Wrist Flexion (left): With elbow straight and palm facing down, grasp back of hand, and gently pull hand back, stretching forearm. Hold for 10 seconds, and repeat 3 times. Wrist Extensi on (right): With elbow straight and palm facing up, grasp palm of hand, and gently pull hand back, stretching forearm. Hold for 10 seconds, and repeat 3 times.

Additional stretches can be found on the next two pages.

Flexibility Training, Pg. 2



Groin Strain Rehabilitation

Phase I A. Ice massage with hip abducted and externally rotated as far as possible. Perform before and

after exercise and as often as possible between exercise sessions. B. Mild hip spica compression wrap for initial 48 - 72 hours. C. Non-steroidal anti-inflammatory (NSAID) medication as prescribed by physician. D. Mild muscle relaxant medication as prescribed by physician. E. Static groin stretching exercises as tolerated 4 - 5 times daily. Each stretch should be held for

15 - 30 seconds. DO NOT BOUNCE. F. Stationary Bicycle riding with seat as low as possible at a low to moderate intensity.

Supine Groin Stretch: While lying on back with knees bend and soles of feet together, relax and allow gravity to stretch groin area. Sitting Groin Stretch: Sitting on floor, put soles of feet together with hand and pull heels towards body. Gently pull upper body forward until a stretch is felt in the groin area. You may also push down on the knees with elbows to intensify stretch. Wall Stretch: Start with legs elevated and close together against a wall. Slowly separate legs with heels in contact with the wall until an easy stretch is felt. Slowly squeeze legs together . Repeat. Sit and Reach: Sit on floor with legs straight and spread shoulder width apart or greater. With a flat back reach across body with leg hand to right foot to feel a comfortable stretch. Alternate and repeat to left side. Lunge Stretch: Kneel on left knee with foot turned to inside. The right knee should be bent to 90° angle. Put hand on floor to inside of upper body. Move hips downward to stretch inside of right groin. Alternate and repeat.






Groin Strain, Pg. 2

Advanced Groin Stretch: Place one leg on edge of a table with opposite leg spread as far as possible and on ground. Slowly lean upper body to side of the leg on the ground. Hold and repeat to other side. Quad Stretch: While standing, grasp top of right foot with left hand and gently pull heel with left hand toward buttocks. Hold and repeat with other leg. PNF (Facilitated stretching): A partner will help by gently pressing the knees outward. Be careful to not overstretch.

PHASE II A. Begin moist heat application before exercise after danger of internal bleeding has passed (2 - 4

days). B. Begin physician prescribed ultrasound with or without electrical muscle stimulation before

exercise when danger of internal bleeding has passed. C. Continue NSAIDs and muscle relaxants as prescribed by a physician. D. Continue stretching. E. Begin Groin Strengthening Exercises: 1) Straight Leg Raises: a) Adduction b) Abduction c) Supine d) Prone 2) Hip Flexion: Sit on edge of table with feet resting on floor. Lift involved leg towards chest. Hold and slowly lower to beginning position. Repeat 30 times, increasing repetitions as strength improves. 3) Hip Internal/External Rotation: Sit on edge of firm surface with feet suspended above floor. Rotate thigh about the axis of the hip, turning lower leg slowly inside as far as possible then turn to outside slowly. Repeat 30 times, increasing repetitions as strength improves.

Groin Strain, Pg. 3

4) Ball Squeeze: Sit on edge of chair, place 8” - 10” ball between knees. Slowly contract groin muscles, squeezing ball as tightly as possible and hld for 5 - 10 seconds. Relax and repeat 30 times. 5) Slide Board: 6) Front Step-Ups: Stand directly behind a 4” - 6” box or step. Step up on box with involved leg followed by uninvolved leg. Step down with involved leg followed by uninvolved leg. Repeat. Progress by increasing repetitions then step height. F. Begin interval work on stationary bicycle. G. Begin light jogging on smooth, straight surface. H. Begin stair climbing exercises, increasing step height as tolerated. I. Ice massage after exercises. J. Progress to Phase III when Phase II can be completed with little or no discomfort. Note: During all exertional acti vities a hip spica compression wrap should be worn. Progression for weighted activities (# 1 - 3 above)

Phase III A. Continue all activities from Phase II B. Progress strengthening exercises as tolerated. C. Begin functional activities to tolerance: 1) Carioca, 2) High Knee Running, 3) Backward Running, 4) Bounding Drills, 5) Vertical leaps progressing to horizontal jumping, and 6) Sprinting with running starts and coast-through stops. D. Return to full activities as tolerated when Phase III can be completed with little or no discomfort

and bilateral groin strength is equal.

3 x 10 Day off 3 x 15 Day off 3 x 20 Day off

Add 1 - 2#

Phase I A. Ice massage with knee extended and hip flexed as far as possible. Perform before and after

exercise and as often as possible between exercise sessions. B. Mild full leg compression wrap for initial 48 - 72 hours. C. Non-steroidal anti-inflammatory (NSAID) medication as prescribed by physician. D. Mild muscle relaxant medication as prescribed by physician. E. Static hamstring stretching exercises as tolerated 4 - 5 times daily. Each stretch should be held

for 15 - 30 seconds. DO NOT BOUNCE. F. PNF hamstring stretching as tolerated 2 - 3 times daily. G. Stationary Bicycle riding with seat as low as possible at a low to moderate intensity. H. Progress to Phase II when a set of 10 prone leg raises can be completed with little or no

discomfort.

Hamstring Strain Rehabilitation






Phase II (2 - 7 days post injury) A. Begin moist heat applications before exercise after danger of internal bleeding has passed (2 -

4 days) B. Begin ultrasound or electrical muscle stimulation, as prescribed by physician, when danger of

internal bleeding has passed, preferably prior to exercise. C. Continue NSAID and muscle relaxant medications as prescribed by physician. D. Continue previous static and PNF stretching. E. Begin hamstring strengthening exercises using light weight and high repetitions: 1) Straight Leg Raises a. Prone b. Abduction c. Adduction 2) Standing knee flexion 3) Bent over hip extension 4) Ball squeeze 5) Partial squats 6) Forward step-ups 7) Seated leg press 8) Chair walk F. Begin interval work on stationary bicycle. G. Begin light jogging on smooth, straight surface. H. Begin stair climbing exercises, increasing step height as tolerated. I. Ice massage after exercise. J. Progress to Phase III when Phase II can be completed with little or no discomfort. Phase III A. Continue moist heat before exercise. B. Continue ultrasound/EMS, preferably before exercise. C. Continue NSAIDs as prescribed by physician. D. Continue static and PNF stretching. E. Progress strengthening exercises as tolerated. F. Begin functional activities to tolerance. 1) High knee running, 2) Backward running, 3) Vertical leaps progressing to horizontal jumping, and 4) Sprints with running starts and coast-through stops. G. Return to full activities as tolerated when Phase III can be completed with little or no discomfort

and: 1) Bilateral hamstring strength is equal, and 2) Quadriceps to hamstring ratio is 60 - 80%.

Hamstring Strain, Pg. 2

Iliotibial Band Syndrome Rehabilitation Phase I

A. Ice massage before and after exercise and as often as possible between exercise sessions. B. Non-steroidal anti-inflammatory (NSAID) medication as prescribed by a physician. C. Phonophoresis or Iontophoresis with knee in slight flexion as prescribed by physician. D. Stretching exercises to be performed 2 - 3 times a day. Hold each stretch for 10 - 30

seconds, repeat 3 - 5 times per session.

1. Cross injured leg behind uninjured leg. Keeping knees straight, lean body towards un injured side.

2. Place injured leg in same position as above. Rotate trunk and reach toward the back of the uninjured leg.

3. Lie on a bed or table on uninjured side. Straighten injured leg back behind you and let it hang over the side of the bed or table.

4. Lie on injured side, keeping trunk, hips and knees in a straight line. Keeping legs in this position, push up to a sitting (sideways) position. It may be necessary to cross injured leg over for balance.

5. Sit on floor or table. Cross right leg over left thigh, placing right foot outside of the left knee. Place left elbow on outside of right knee. Gently stretch by pushing right elbow into left knee. Keep back straight while stretching. Hold for 10 seconds and repeat for opposite side. Repeat 3 - 5 times for each side.

1.

4.

3.

2.

5.

Phase II

Upon return to full activity the athlete will need to:

1. Perform all stretches. 2. Attempt activity until tightness (not discomfort) is felt on the outside of the knee. 3. Once the tightness is felt on the outside of the knee, stop activity and perform stretches. Do

not attempt any more activity that day. 4. Each day, do the stretches and try to activities until tightness is felt. Goal is to finish full work-

out without tightness. 5. Ice massage after activities.






KNEE EXERCISE PROGRAM 1 ANKLE ABC’s: Using the big toe as an imaginary pencil, write the letters of

the alphabet moving only the ankle and foot. Try to make the letters as large as possible. Repeat as often as possible throughout the day.

2 PATELLA MOBILIZATION: With leg straight and muscles relaxed, place two fingers on either side of the kneecap and gently move kneecap side-to-side for 1 - 2 minutes. Repeat, moving the kneecap up and down for 1 - 2 minutes. Repeat as often as possible

3 HEEL SLIDES: While sitting on a smooth surface, pull heel of injured leg toward buttocks, flexing knee as much as tolerable. Hold and straighten leg by sliding heel downward. Use hands to put pressure on leg above kneecap, trying to make the knee as straight as possible. Repeat 30 times, 2 - 3 times daily.

4 PASSIVE KNEE FLEXION: While seated in chair or table, gently push involved foot back as far as tolerable with opposite leg. Hold for 5 seconds and slowly relax. Repeat 30 times, 2 - 3 times daily.

5 QUAD SETS: With leg as straight as possible, tighten thigh muscles, trying to pull kneecap toward hip. Hold for 10 seconds contracting the muscles as tight as possible. Relax and rest 2 seconds. Repeat as often as possible.

6 HAMSTRING STRETCH: While seated with legs straight and heels resting on a book or rolled up towel, slowly lean over involved leg touching toes with hands and nose to knee. Hold for 10 - 30 seconds and slowly return to start position. DO NOT BOUNCE! Repeat as often as possible.

7 PROGRESSIVE RESISTANCE EXERCISE (PRE): Begin all PRE’s doing 3 sets of 10 repetitions. Upon completion of 3x10 with little difficulty, progress to 3x15 for the next session, then 3x20. When 3x20 can be completed with little difficulty, add 1 - 2 lbs. of resistance and return to 3x10. Work back up to 3x20 add another 1 - 2 lbs, and repeat cycle.

8 STRAIGHT LEG RAISES (SLR) — SUPINE: While lying on back or sitting with hips flexed less than 90 degrees, flex ankle to 90 degrees. Tighten thigh muscles and raise leg upward, keeping knee straight. Lift leg 12” - 18” off of floor and hold 1 second. Slowly lower leg to floor. Repeat and progress as detailed under PRE (#7).






9 STRAIGHT LEG RAISES — ABDUCTION: Repeat process used for Supine SLR while lying on uninvolved side and raise injured leg 10 - 18” off floor. Repeat and progress as detailed under PRE(#7).

10 STRAIGHT LEG RAISES — ADDUCTION: Repeat process used for Supine SLR while lying on involved side and raise injured leg 6 - 12” off floor. Repeat and progress as detailed under PRE(#7).

11 STRAIGHT LEG RAISES — PRONE: Repeat process used for Supine SLR while lying on stomach and raise injured leg 6 - 12” off floor. Repeat and progress as detailed under PRE(#7).

12 PRONE FLEXION: Lay on stomach and flex knee, bringing heel toward buttocks. Hold and slowly lower leg. Repeat and progress as detailed under PRE (#7).

13 STANDING FLEXION: Standing, using an object for balance, flex knee, bringing heel up to buttocks. Keep thighs parallel. Hold and slowly lower leg. Repeat and progress as detailed under PRE (#7).

14 SEATED EXTENSION: In sitting position, slowly extend lower leg until straight. Hold, contracting thigh muscles as tight as possible, and slowly lower. Repeat and progress as detailed in PRE (#7).

15 90 - 45 DEGREE EXTENSION: In sitting position, slowly extend lower leg to a 45 degree. angle. This can be seen when the shin is in line with the kneecap. Hold and slowly lower leg. Repeat and progress as detailed under PRE (#7).

16 SEATED CORD EXTENSION: In sitting position with Sport Cord placed under ball of involved foot, extend knee against cord pushing down and away, to -5 degree. of full extension. Repeat 3x10, 3x15, 3x20 then progress by increasing cord density and returning to 3x10.

17 HIP FLEXION: Sit on edge of firm surface with feet resting on floor. Lift involved knee toward chest, while keeping knee comfortably bent. Hold and slowly lower. Repeat and progress as detailed in PRE (#7).

18 TERMINAL KNEE EXTENSION: Place a coffee or paint can under involved knee, allowing knee to bend about 30 degree. Slowly extend lower leg until it is straight and contract thigh muscles as tight as possible for 3 seconds. Slowly lower heel to floor. Repeat and progress as detailed in PRE (#7)

KNEE EXERCISE PROGRAM Page 2

19 STANDING TERMINAL KNEE EXTENSION: While standing with Sport Cord placed just above the joint line on back of involved knee. Slowly straighten knee (without locking knee) against Sport Cord. Repeat and progress as detailed in PRE (#7)

20 PARTIAL SQUATS: Standing with feet shoulder width apart and toes pointing slight outward, bend knees and slowly squat down. Maintain upright posture and do not allow thighs to go below parallel to floor. Hold and slowly return to start position and repeat. Progress by increasing reps to 3x20 then begin one-leg squats.

21 SPORT CORD SQUATS: Stand with heels on Sport Cord. Squat down and grasp Sport Cord handles stretching cord snugly. Slowly stand erect pulling on cord. Slowly return to squat position against cord. Repeat as directed and progress as for Seated Cord Extensions (#16).

22 ONE LEG SQUATS: Using chair or table for balance assistance, slowly squat down on involved leg as far as possible — not to exceed 90 degree. of knee flexion. Then slowly raise up to start position and repeat as directed.

23 SIDE STEP UPS: Stand sideways with involved leg next to 3 - 6” step. Place involved foot on step and slowly lift body weight with involved leg. Slowly lower body back to start position, gently touching heel on ground, then repeat by slowly lifting body with involved leg. Repeat as by increasing repetitions for 3 x 10 to 3 x 15 to 3 x 20, increase step height 2 - 3” begin with 3 x 10 reps, i ncreasing to 3 x 20.

24 FRONT STEP UPS: Stand directly behind 4 - 6” step or box. Step up on box with involved leg followed by uninvolved leg. Step back down with involved leg followed by uninvolved leg. Repeat as directed, increasing reps and box height as directed in Side Step Ups (#22)

25 BALL SQUEEZE: Seated on edge of chair, place an 8 - 10” rubber ball between knees. Slowly contract inner thigh muscles, squeezing ball as tightly as possible, hold for 5 - 10 seconds. Relax and repeat as directed.

26 HEEL RAISES: Stand with feet shoulder width apart and toes pointed forward. Raise up on toes, lifting heels off floor as high as possible. Hold for one second and slowly lower to start position. Progress by increasing reps, placing balls of feet on 2 - 4” board (elevated), then progressing to one-leg calf/heel raises.


27 CHAIR WALK: Sit on a rolling chair or stool. Reach out in front of body as far as possible with involved heel. Slowly pull body and chair toward heel and repeat with opposite leg. Fully extend leg on each cycle and DO NOT EXCEED 90 DEGREES OF KNEE FLEXION. Repeat as directed.

28 SLIDE BOARD: Begin at one end of slide board with knees bent and one foot pressed against block. Maintaining a squatting position, use outside leg to push body sideways across board, sliding to opposite side. Bring both feet together when opposite block is reached and repeat.

29 STATIONARY BICYCLING: Adjust seat height so that legs are almost straight at the bottom pedal position. Tension should provide low to moderate resistance. Ride for 10 - 20 minutes. Progress by lowering seat height as tolerable and increasing resistance and time.

30 SWIMMING/RUNNING/STAIRCLIMBER: These activities may be beneficial to your knee rehabilitation. Please consult your therapist or doctor to determine if these forms of exercise are recommended for your condition.

32 ICE: Apply ice to the involved area before and after exercise to reduce swelling, pain, and reduce the chances of aggravating the condition. Ice massage is preferable if there are no open wounds. Massage the affected area with ice cup until it becomes numb, this may take between 4 to 10 minutes. Ice bags may be used when placed over a wash cloth, and the treatment time is 15 - 20 minutes.


1) Supine Hamstring: Lie on Back, raise leg to

chest by bending at the hip, grasping the back of your thigh with both hands just above the knee. Slowly straighten your knee until you feel a stretch in the hamstrings at the back of the thigh. Hold 10 seconds, and repeat on opposite leg. Repeat 3 - 5 times for each leg.

2) Seated Hamstring: In a sitting position, Slowly

lean forward to stretch leg. This can be performed with knees together or in a V-Leg position. Keep back flat while performing stretch. Hold 10 seconds, and repeat 3 - 5 times for each leg.

3) Standing Hamstring: Place one foot on a secure

table or object 6 - 12 inches tall. Slowly lean upper body forward, keeping leg straight and toes pointing up. Do not “hump” back and maintain curve in lower back. Hold 10 seconds, and repeat 3 - 5 times for each leg.

4) Hip Flexor: Lie on back on the edge of a bed or

table, hugging both knees. Lower one leg straight out, allowing it to hang over the edge of the table. Continue to hug opposite leg. Hold this position for 10 seconds. Return to the starting position and repeat on opposite side. Repeat 3 - 5 times each leg.

5) Piriformis (Figure 4): Lie flat on back with both

knees bend and feet flat on floor. Cross right ankle onto left knee. Grasp behind left knee and slowly pull towards your chest. Hold for 10 seconds and slowly lower to beginning position. Reverse position and repeat 3 - 5 times for each leg.

Lower Extremity Stretching






6) Piriformis (Trunk Twister): Sit on floor or table. Cross right leg over left thigh, placing right foot outside of the left knee. Place left elbow on outside of right knee. Gently stretch by pushing right elbow into left knee. Keep back straight while stretching. Hold for 10 seconds and repeat for opposite side. Repeat 3 - 5 times for each side.

7) Calf Stretch: Stand facing a wall, with one foot in

front of the other. Lean forward with your hands on the wall. Bend the front leg while keeping both heels on the floor. You should feel a gentile stretch in the back of your lower legs. Hold 10 seconds, repeat with the other leg forward. Repeat 3 - 5 times for both legs.

8) Standing IT Band Stretch: Strand, approximately

2 - 3 feet from a wall, with the involved side facing the wall. Place one hand on the wall and cross uninvolved leg over involved leg and lean into the wall. Place hand on uninvolved hip for overpressure. Hold for 10 seconds, repeat 3 - 5 times.

9) Table IT Band Stretch: Lie on back near edge of

table. Let leg stretch over edge of table so that there is a full stretch on outside of hip and side of leg. Bend leg being stretched to 90° angle at the hip and keep knee straight. Place arms out to the side to maintain balance. Hold for 30 seconds, repeat on other side. Repeat 3 - 5 times for each leg.

10) Quad Stretch: Stand with involved knee bent.

Gently pull heel toward buttocks, feeling a stretch in the front of the leg. Keep upper body straight, do not lean forward. To increase the stretch, pull with enough pressure to cause the involved knee to pass behind the uninvolved knee. Hold for 10 seconds, repeat 3 - 5 times.

Lower Body Stretching, Pg. 2

Isolated Medial Collateral Ligament (MCL) Sprain Rehabilitation Protocol

PHASE I

1. Ice, preferably, ice massage, as often as possible, before and after exercise sessions.

2. Hinged brace allowing for non-painful range of motion, if indicated.

3. Partial to full weight bearing in brace with crutches as tolerated.

4. Non-steroidal anti-inflammatory medications (NSAID’s) as prescribed by physician.

5. Range of motion exercises performed 3 times daily.

a. Heel Slices,

b. Quadriceps Sets,

c. Ankle ABC’s

6. Strengthening exercises performed 3 times daily.

a. Straight Leg Raises: prone, supine, abduction (NO ADDUCTION),

b. Standing Knee Flexion, Knee Extension, Hip Flexion, and Terminal Knee Extension (TKE),

c. Seated Isometric Ball Squeezes,

d. Heel Raises with balance assistance,

e. Partial Squats with balance assistance

7. Stationary bicycle riding with seat as low as tolerated

8. Progress to Phase II when Phase I can be completed with little or no discomfort, increase in swelling, or point tenderness.

PHASE II

1. Continue all activities in Phase I as indicated.

2. Continue all strengthening exercises using PRE Principle

3. Begin Side Step-Ups with 1 1/2” - 3” step.

4. Begin StairClimber activities.

5. Begin static stretching as tolerable.

6. Progress to Phase III when Phase II can be completed with:

a. No increase in pain or swelling,

b. Normal Gait, and

c. Normal knee stability.






, Pg. 2

PHASE III

1. Continue ice after exercise sessions if pain and/or swelling is present.

2. Discontinue use of brace for daily activities with physician approval

3. Continue SLR PRE’s and add:

a. Standing sport cord TKE’s,

b. Leg Press 90° - 0° as tolerated, and

c. Slide Board.

4. Begin walk/jog program on flat, smooth surface

5. Progress to Phase IV when 50 yard jog can be completed with little or no limping and/or pain.

PHASE IV

Continue PRE’s.

1. Progress walk/jog program to include sprints and agility drills

a. Figure 8’s,

b. Carioca, and

c. Zig-Zag Drills.

2. Return to desired activity when:

a. Phase IV can be completed without pain, swelling, or limp,

b. Bilateral girth and range of motion measurements are equal,

c. Strength measurements are 85% of contralateral side, and

d. Clearance from physician.

Patients heal at different rates, possess various pre-operative deficiencies, and require specific attributes to perform normal function. Due to these factors, this protocol must be individualized to each patient to a llow for optimal return to desired activities.

Meniscus Repair Rehabilitation Protocol Pre-Op Instructions







a. Ankle range of motion (ABC’s), and

b. Heel Slides (Do Not Flex Past 90° for 4 weeks)



b. Straight Leg Raises (SLR): supine, Abduction, Adduction, Prone, and

c. Seated knee extension, hip flexion, standing knee flexion, and Terminal Knee Extensions.


6. Non-weight bearing with crutches for 4 weeks.

Post-Op: Day 1




4. Continue strengthening exercises.


Post-Op: Day 2 - 7




a. Weight to all SLR’s, Knee Extension, Knee Flexion, Hip Flexion, and TKE’s.







Menisectomy/Plica, Pg. 2


Post-Op: Week 1 - 3



3. Continue range of motion exercises to 90° of flexion limitation.



Post-Op: Week 4 - 8


2. Continue range of motion exercises progressing past 90° to achieve full motion.

3. Continue strengthening exercises, and add:

a. Heel raises with balance assistance,

1. Progressing to elevated or one-leg heel raises.

b. Partial squats with balance assistance,

1. Progressing depth as tolerated, and

2. Progressing to single leg squats.

c. Side Step-Ups,

d. StairClimber exercises, and

d. Begin Walk-Jog program on smooth, flat surface, walking curves as tolerated at 6 weeks.

4. Return to full activities when:

a. Range of motion and girth measurements are bilaterally equal,

b. Bilateral strength measurements are 85% or better, and

c. Clearance by treating physician.


Menisectomy /Plica Resection Rehabilitation Protocol

Pre-Op Instructions








b. Heel Slides.



b. Straight Leg Raises (SLR): supine, Abduction, Adduction, Prone,

c. Seated knee extension, hip flexion, standing knee flexion, and terminal knee extension,



Post-Op: Day 1














Post-Op: Day 2 - 7





a. Weight to all SLR’s, Knee Extension, Knee Flexion, Hip Flexion, and TKE, and

b. Side Step-Ups.



Post-Op: Week 1 - 3





a. Walk-Jog program on smooth, flat surface, walking curves,

b. Single-leg parallel squats,

c. Single-leg, then elevated heel raises, and

d. StairClimber exercises.


Post-Op: Week 3 - 6









Mini Rotator Cuff Repair Rehabilitation Protocol

Post-Op: 1 - 10

1. Arm in sling - out for exercises only. 2. Do not allow wounds to get wet while bathing or showering. 3. Ice before and after exercise sessions and as often as possible throughout the day. 4. Active Exercises, performed 2 - 3 times daily: a. Codman’s Pendulum Swings, b. Gripping Exercises, c. Wrist Flexion/Extension, d. Isometric Towel Squeezes, and e. Elbow Flexion Exercises. 5. Passive Exercises: use involved hand to lift involved arm through a pain-free range of motion,

performed 2 - 3 times per day. a. Bent-Arm Flexion, b. Bent-Arm Abduction, c. Bent-Arm Extension, d. Seated Internal/External Rotation with arm adducted and elbow flexed to 90°. 6. Physician examination at 7 - 10 days post-op.

Post-Op: Day 10 - Week 3

1. Sling off except when in crowds, you become fatigued, or in stressful situations. 2. May shower when sutures have been removed and wounds have sealed. 3. Continue to ice before and after exercise sessions, and during the day as needed. 4. Continue previous Active Exercises and add: a. Supine Triceps Extensions, b. Shoulder Shrugs, and c. Bent-Over Rows. 5. Progress Passive Exercises to Active-Assisted Exercises using a T-Bar or Pulley apparatus.

Performed 3 - 4 times daily. a. Straight-Arm Flexion, b. Straight-Arm Abduction, c. Straight-Arm Extension, d. Supine Internal/External Rotation with arm adducted and elbow bent to 90°, and e. Wall Ladder Climbs for Shoulder Flexion and Abduction.






Mini Rotator Cuff Repair, Pg. 2

Post-Op: Week 3 - 6

1. Discontinue Sling Use. 2. Ice before and after exercise sessions. 3. Stretch before and after exercise as tolerated: a. Horizontal Adduction Stretch, b. Triceps/Inferior Cuff Stretch, c. Internal Rotation with shoulder abducted and elbow bent 90°, and d. External Rotation with shoulder abducted and elbow bent 90°. 4. Continue previous Active-Assisted exercises 4 - 5 times weekly, and add: a. Progress towel squeezes to shoulder adduction using sport cord, and b. Upper Body ergometer as tolerated with low resistance and low RPM. 5. Progress Active-Assisted Exercises to Active Exercises, as tolerated, 3 - 4 times weekly and add: a. Prone Horizontal Abduction, b. Prone Extension with internal rotation of shoulder, and c. Supine dumbbell press (with no weight). 6. Full Active-Assisted Range of Motion is expected by 6 weeks post-op. 7. Physician examination at week 6.


1. Continue previous stretching exercises before and after exercise sessions as part of a general warm-up and cool-down.

2. Continue previous Active Exercises and add: a. Biceps Curls, b. Triceps Extensions, c. Supraspinatus (Empty Can), d. Parallel Dips, e. Bench Press, f. Push-Ups, g. Bent-Over Rows, h. Lat Pulldowns, i. Behind the neck overhead press, and j. Internal/External Rotation with shoulder abducted and elbow flexed to 90°. 3. Full return to athletic activities is expected at 3 - 4 months post-op.


Moderate Rotator Cuff Repair Rehabilitation Protocol

Post-Op: Day 1 - 10

1. Arm in sling - out for exercises only. 2. Do not allow wounds to get wet while bathing or showering. 3. Ice before and after exercise sessions and as often as possible throughout the day. 4. Active Exercises, performed 2 - 3 times daily: a. Codman’s Pendulum Swings, b. Gripping Exercises, c. Wrist Flexion/Extension, and d. Elbow Flexion Exercises. 5. Passive Exercises: use involved hand to lift involved arm through a pain-free range of motion,

performed 2 - 3 times per day. a. Bent-Arm Flexion, b. Bent-Arm Abduction, c. Bent-Arm Extension, d. Seated Internal/External Rotation with arm adducted and elbow flexed to 90°. 6. Physician examination at 7 - 10 days post-op.

Post-Op: Day 10 - Week 4

1. Sling off except when in crowds, you become fatigued, or in stressful situations. 2. May shower when sutures have been removed and wounds have sealed. 3. Continue to ice before and after exercise sessions, and during the day as needed. 4. Continue previous Active Exercises and add: a. Supine Triceps Extensions (no weight), b. Shoulder Shrugs, and c. Isometric Towel Squeezes. 5. Progress Passive Exercises to Active -Assisted Exercises using a T-Bar or Pulley apparatus.

Performed 3 - 4 times daily. a. Straight-Arm Flexion, b. Straight-Arm Abduction, c. Straight-Arm Extension, and e. Wall Ladder Climbs for Shoulder Flexion and Abduction.






Moderate Rotator Cuff Repair, Pg. 2

Post-Op: Week 4 - 8

1. Continue Sling Use in crowds or stressful situations. 2. Ice before and after exercise sessions. 3. Continue previous Active-Assisted exercises 4 - 5 times weekly, and add: a. Supine Triceps Extensions with light weight, b. Upper Body ergometer as tolerated with low resistance and low RPM. 4. Progress Active-Assisted Exercises to Active Exercises, as tolerated, 3 - 4 times weekly and add: a. Supine Internal/External Rotations with arm adducted and elbow flexed to 90°. 5. Full Active-Assisted Range of Motion is expected by 6 weeks post-op. 6. Physician examination at week 6.


1. Stretch before and after exercise as tolerated: a. Horizontal Adduction Stretch, b. Triceps/Inferior Cuff Stretch, c. Internal Rotation with shoulder abducted and elbow bent to 90°, and d. External Rotation with shoulder abducted and elbow bent to 90°. 2. Continue previous Active Exercises and add: a. Progress towel squeezes to shoulder adduction using sport cord, b. Bent-Over Rows, c. Prone Horizontal Abduction, d. Prone Extension with forearm internally rotated, e. Supine dumbbell press with no weight, and f. Supine Internal/External Rotation with arm abducted and elbow flexed to 90°.


1. Continue previous stretching exercises before and after exercise as part of a general warm-up and cool-down.

2. Full Active ROM is expected at end of Week 16. 3. Active exercises as tolerated (Low Weight, High Repetitions) a. Biceps Curls, b. Triceps Extensions, c. Supraspinatus (Empty Can), d. Bench Press, e. Progressive Push-ups, f. Bent-Over Rows, g. Lat. Pulldowns, and h. Supine Internal/External Rotation with arm abducted and elbow flexed to 90°. 4. Progress to normal athletic activities by 4 to 6 post-op with physician clearance.


Plantar Fasciitis Rehabilitation A. Ice Massage over entire arch and heel area until numb (5 - 8 minutes) as often as possible

and before and after exercise sessions.

B. Friction massage over affected area for 5 minutes, pressing as hard as tolerable. Repeat 3 - 5 times daily.

C. Non-steroidal anti-inflammatory (NSAID) medications as prescribed by physician.

D. Heel lifts or heel cups worn in shoes as prescribed.

E. Iontophoresis or ultrasound, if available, as prescribed by physician.

F. Golf Ball Roll: Roll a frozen golf ball under the affected heel and arch, pressing down as hard as tolerable for 5 minutes at a time. Repeat as often as possible throughout the day.

G. Arch taping: Tape arch to add stability to affected structures. The treating physician may opt for prescription orthotics application.

H. Metatarsal Phalangeal Joint Stretching: Place toes on wall 3 - 6 inches above the floor, slowly slide foot down wall, eliciting a stretch in the great toe and arch. Hold each stretch for 10 - 30 seconds, repeat 5 - 10 times, 5 - 10 times daily.

I. Calf & Achilles Tendon Stretching: Stand 12” - 18” away from a wall with trunk and knees straight. Slowly lean into wall, keeping knees locked and heels on the floor. Slowly move heels away from wall as stretch becomes easier. Perform with knees straight and knees bent. Hold each stretch for 10 - 30 seconds, repeat 5 - 10 times, 5 - 10 times daily.

J. Paper Pick-Up: Crumple several pieces of 3”x3” paper into balls about the size of marbles. Place the balls of paper on the floor, using the toes, grasp one ball at a time , pick up and place in opposite hand. Repeat 20 - 40 times.

K. Towel Crunches: Lay out a towel on a smooth, slick surface and position the foot at one end. Curl toes to pull the towel toward the body without moving the heel. When the end of the towel is reached, use toes to push the towel away from the body. Progress by increasing repetitions or by adding a weight to the end of the towel.






Menisectomy /Plica Resection Rehabilitation Protocol

Pre-Op Instructions








b. Heel Slides.



b. Straight Leg Raises (SLR): supine, Abduction, Adduction, Prone,

c. Seated knee extension, hip flexion, standing knee flexion, and terminal knee extension,



Post-Op: Day 1














Post-Op: Day 2 - 7





a. Weight to all SLR’s, Knee Extension, Knee Flexion, Hip Flexion, and TKE, and

b. Side Step-Ups.



Post-Op: Week 1 - 3





a. Walk-Jog program on smooth, flat surface, walking curves,

b. Single-leg parallel squats,

c. Single-leg, then elevated heel raises, and

d. StairClimber exercises.


Post-Op: Week 3 - 6









Quadriceps Strain & Contusion Rehabilitation Phase I

A. Ice Massage with hip extended and knee flexed as much as tolerable. Before and after exercises and as often as possible between exercise sessions.

B. Mild full-leg compression wrap for initial 48 hours.

C. Non-steroidal anti-inflammatory (NSAID) medications as prescribed by physician.

D. Mild muscle relaxant medication as prescribed by physician.

E. Static Quadriceps Stretching: Stretch as tolerated 2 - 3 times daily. Hold each stretch for 10 - 30 seconds, repeat 5 - 10 times per session. Perform with hip flexed and hip extended as shown in the graphic.

F. Proprioceptive Neuromuscular Facilitation: Perform 2 - 3 times daily as directed by Athletic Trainer. Perform with hip flexion, neutral hip extension, and with hip hyperextension.

G. Stationary Bicycle: Ride with seat as high as tolerable and light to moderate resistance to maintain quadriceps muscle function.

H. Straight Leg Raises (SLR): Perform with light weight and high repetitions in all 4 planes: Supine, Abduction, Adduction, and Prone.

I. Progress to Phase II: When 10 supine SLR’s can be completed with little or no discomfort.

Phase II (2 - 7 days post-injury)

A. Continue with Phase I activities unless otherwise instructed.

B. Begin ultrasound and or electrical stimulation, as directed by physician, when swelling has been controlled and the chance of further internal bleeding has passed.

C. Continue quadriceps strengthening (SLR) exercises utilizing Progressive Resistance Principles (PRE) and add:

PRE 3 x 10 Day off 3 x 15 Day off 3 x 20 Day off

Add 1 - 2#






Quad Strain/Contusion, Pg. 2

D. Hip Flexion: Sit on the edge of a firm surface with feet resting on floor. Lift involved knee toward chest. Hold and slowly lower to beginning position. Progress under PRE guidelines.

E. Seated Knee Extension: In sitting position, slowly extend lower leg until knee is straight. Hold, contracting thigh muscles as tightly as possible, and slowly lower to starting position.

F. Partial Squats: Stand with feet shoulder width apart and toes slightly turned out. Bend knees and slowly squat down, keeping knees from going in front of toes. Squat as low as tolerable, pause at lowest depth and raise to beginning position. Do not allow thighs to go lower than parallel to the floor.

G. Side Step-Ups: Stand sideways with involved leg next to 3 - 6” step. Place involved foot on step and slowly lift body weight with involved leg. Slowly lower body back to start position, gently touching heel on ground, then repeat by slowly lifting body with involved leg. Repeat as by increasing repetitions for 3 x 10 to 3 x 15 to 3 x 20, increase step height 2 - 3” begin with 3 x 10 reps, increasing to 3 x 20.

H. Begin interval training on stationary bicycle.

I. Begin light jogging on smooth, straight surface. No sudden starts and stops.

J. Progress to Phase III when Phase II exercises can be performed with little or no discomfort.

Phase III

A. Continue Phase I and II activities as directed.

B. Begin functional activities as tolerated: 1. High Knee Jogging, 2. Running: start sprint running with coast-through stops, 3. Cariocas, 4. Bounding drills, and 5. Vertical leaps progressing to horizontal jumps.

C. Return to full activities as tolerated when Phase III can be completed with little or no discomfort and:

1. Bilateral quadriceps strength is equal and 2. Quad to Hamstring strength ration is 60 - 80&.

Shin Splints Protocol A. Ice massage for 10 - 15 minutes before and after any exercise and whenever pain is present.

B. Non-steroidal anti-inflammatory (NSAID) medication as prescribed by physician.

C. Professionally fitted orthotic or arch supports used for any weight bearing activity.

D. Wear proper shoes for the activity. Old, poorly fitted or inappropriate types of shoes will increase the stress placed on the lower leg bones and muscles.

E. Reduce the intensity and/or duration of activities that produce pain. Begin by decreasing the activity level by half and slowly progress or regress as pain level dictates.

F. Change the location or type of surface where activities are performed. Avoid very soft or hard surfaces and change direction or course to decrease lower leg stress.

G. Stretch the muscles of the lower leg 4 - 8 times daily, holding each stretch for 10 - 30 seconds, repeat each stretch 3 - 5 times per session.

H. Strengthening Exercises performed 1 - 3 times daily:

1. Dorsiflexion: Stand 12” - 18” away from a wall with trunk and knees straight. Slowly lean into wall, keeping knees locked and heels on the floor. Slowly move heels away from wall as stretch becomes easier.

2. Plantarflexion: Point toes down as far as possible with knees straight. Progress by placing palm of opposite hand over the base of the toes and applying slow downward pressure on the foot.

3. Inversion: Turn ankle/foot inward as far as possible without moving lower leg. Progress by standing on outside edge of foot.

4. Eversion: Turn ankle/foot outward as far as possible without moving lower leg. Progress by standing on inside edge of foot.

1. Paper Pick-ups: Crumple several pieces of 3”x3” paper into balls about the size of marbles. Place the balls of paper on the floor, using the toes, grasp one ball at a time , pick up and place in opposite hand. Repeat 20 - 40 times.

2. Towel Push/Pull: Lay out a towel on a smooth, slick surface and position the foot at one end. Curl toes to pull the towel toward the body without moving the heel. When the end of the towel is reached, use toes to push the towel away from the body. Progress by increasing repetitions or by adding a weight to the end of the towel.






, Pg. 2

I. Continue this program for 2 weeks. If improvement is not experienced during that time, consult your physician, therapist, or Athletic Trainer. If the symptoms are becoming less severe, continue the program for 2 weeks after all symptoms have ceased in order to reduce the chance of recurrence.

3. Theraband: Using an this elastic band perform the following exercises to increase strength in the muscles of the affected ankle. Repeat 30 to 60 times one time daily.

4. Calf Raises: Stand with feet shoulder width apart and toes pointed forward. Left heels off of the floor as high as possible. Slowly lower heels to the floor and repeat as described below.

5. Backward Running: Run backward raising knees up as high as possible and pushing o ff with the toes. Run 25 - 50 yards as tolerated. Emphasis should be on form, not speed.

a. Inversion: Loop band over ball and instep of foot. Turn ankle & foot (not leg) inward as far as possible.

b. Eversion: Loop band over outside edge of foot just below the toes. Turn ankle & foot (not leg) outward as far as possible.

c. Dorsiflexion: Loop band over top of foot at base of toes. Pull foot and toes up toward shin as far as possible.

d. ABC’s: Loop band around ball and sole of foot while holding ends of the band. Write ABC’s with, moving only foot and ankle, as in #1. Perform 1 to 2 sets of the alphabet one time daily.






Shoulder Exercise Program 1. Codman’s Pendulum Swings: Lean over table, supporting body with

uninvolved arm. Let involved arm hang straight down in a relaxed position. Gently swing arm in circles clockwise and counterclockwise; then in a pendulum motion forward-backward and side-to-side. Repeat 30 times in each direction.

2. Wall Ladder: Stand next to wall ladder, brick wall, or louvered doors and use fingers of involved hand to “walk” up the ladder as high as possible and hold. “Walk” down ladder and repeat 3 - 5 times. Perform this exercise by facing ladder and also by standing next to ladder.

3. Supine Flexion: Lie on back and hold T-bar or broom stick with both hands at waist level, preferably with hands close together. Lift arms up over head as far as possible and hold for 5 - 10 seconds and return to start position. Repeat as directed. Weight may be added to T-bar.

4. Bent Arm Flexion: Rest involved arm in palm of uninvolved hand and slowly and gently lift involved arm forward and upward as far as possible. Hold and slowly return to start. Relax involved arm and shoulder as much as possible and lift with uninvolved arm. Repeat 30 times.

5. T-Bar Flexion: Loosely grasp end of T-bar or broom stick with involved hand and hold longer end with uninvolved hand. Use uninvolved hand to lift involved arm upward in front of body as high as possible, hold, and slowly lower. Involved arm may assists pain allows. Repeat 30 times.

6. Active Flexion: Stand with elbow straight and thumb pointing forward. Raise involved arm upward in front of body as high as tolerable, hold, and slowly lower. Repeat as directed.

7. Bent Arm Extension: Rest involved arm in palm of uninvolved hand and slowly and gently push involved arm backward as far as tolerable. Hold, then slowly return to start. Repeat 30 times.






Shoulder Program , Pg. 2

8. T-Bar Extension: Loosely grasp end of T-bar with involved hand and hold longer end with uninvolved hand. Use uninvolved hand to lift involved arm backward behind body as far as tolerable, hold, then slowly return to start. Repeat 30 times.

9. Prone Extension: Lie on table on stomach with involved arm hanging toward floor. With thumb and arm rotated outward as far as possible, raise arm straight back toward hip. Do not go past parallel to floor. Hold, then slowly lower to start and repeat as directed.

10. Bent Arm Abduction: Rest involved arm in palm of uninvolved hand and slowly and gently lift involved arm outward to side of body as high as tolerable. Hold and slowly return to start. Relax involved arm and shoulder as much as possible and lift with uninvolved arm. Repeat 30 times.

11. T-Bar Abduction: Loosely grasp end of T-bar with involved hand and hold longer end with uninvolved hand. Use uninvolved hand to lift involved arm outward to side of body as far as tolerable, hold, then slowly return to start. Repeat 30 times.

12. Active Abduction: Stand with elbow straight and thumb pointing outward.. Raise involved arm outward to side of body as high as tolerable, hold, and slowly lower. Repeat as directed.

13. Prone Horizontal Abduction: Lie prone on table. Rotate arm and thumb outward as far as possible. Raise arm out to the side. Do not raise higher than paralle l to the floor. Hold, slowly return to start and repeat as directed.

14. Adducted Internal/External Rotation: With involved arm resting at side, flex elbow to 90°. Slowly rotate arm bringing hand across and in front of body to stomach as far as tolerable. Hold, then slowly rotate arm outward taking hand toward side of body as directed. Hold, then slowly return to start and repeat 30 times.

15. Side Lying Internal Rotation: Lying on involved side with elbow at side and flexed to 90°, slowly raise hand to somtach. Hold, then slowly return to start and repeat as directed.

16. Side Lying External Rotation: Lying on uninvolved side withelbow resting on chest and flexed to 90°, slowly raise hand up and away from body as far as possible, or as directed. Hold, then slowly lower and repeat as directed.

Shoulder Program, Pg. 3

17. Supine Internal/External Rotation: Lie supine on table or floor with shoulder abducted to 90° with arm supported on table and elbow flexed. Slowly raise hand up and forward as far as possible. Hold for 1 - 2 seconds and slowly return to start. Attempt to place back of hand on table in “up” position and palm on table in “down” position. Repeat as directed.

18. Supraspinatus: Stand with elbow straight and arm rotated inward with thumb pointing down. Raise hand to eye level at 30° angle to body. Do not allow the hand to go above eye level! Hold, then slowly lower to start and repeat as directed.

19. Shrugs: Standing with arms at sides. Lift shoulders up toward ears and hold, then pull shoulders back, pinching shoulder blades together. Hold and relax. Repeat as directed.

20. Towel Squeeze: Fold a towel into eighths and place between chest and involved elbow. Slowly squeeze arm against towel and chest with forearm crossing in front of body at 45° angle. Hold isometric contraction for 5 - 10 seconds and relax. Repeat as directed.

21. Supine Triceps Extension: Lying flat on back with involved elbow bent near head. Rest involved hand on uninvolved shoulder. Slowly extend elbow as straight as possible without moving upper arm. Slowly return to start and repeat as directed.

22. Standing Triceps Press: Raise involved arm/elbow overhead with hand resting on shoulder. Provide support at elbow with opposite hand. Slowly straighten arm overhead, hold, and slowly return to start. Repeat as directed.

23. Seated Dips: Sit on edge of table or chair gripping sides of table with hands. Slowly straighten arms, lifting buttocks off of seat. Hold for 3 - 5 seconds and slowly lower to table. Repeat as directed.

24. Chair Dips: Place hands behind body on front edge of chair with legs out in front of body. Slowly lower body toward floor until upper arms are parallel to floor and no further. Lift body up, carefully arms, and hold. Slowly return to start and repeat as directed.

25. Biceps Curls: With arm straight and at side with palm facing forward, slowly flex elbow bringing hand up toward shoulder as far as possible. Hold, then slowly relax to beginning position. Repeat as directed.

26. Supine Press: Lie on back with elbows next to chest and flexed to 90°. Slowly raise and extend arm straight upward. Hold, then slowly return to start. Repeat as directed.

27. Progressive Push-Ups: Grip sides of sturdy stable or countertop with feet together about 3 - 4 feet from table. Slowly lower chest toward edge of table by bending elbows and without allowing chest to touch table. Slowly return to start position and repeat as directed. Progress by moving to shorter tables and eventually to floor.

28. Bent Over Rows: While bent over with back parallel to floor and arms hanging to floor, slowly pull arms up, bringing hands up to chest level. This motion is similar to using a cross-cut saw. Slowly lower arms to start and repeat as directed.

29. Ice: Apply ice to involved shoulder for 15 - 20 minutes before and after exercise to reduce swelling, pain, and the chance of aggravating the condition. This can be accomplished by use of ice bags, CryoCuffs, or ice massage. Ice massage is preferable if there are no open wounds and will take about 5 - 12 minutes.

Shoulder Program, Pg. 4

Shoulder Impingement Rehabilitation Phase 1

A. Avoid pain producing activities. B. Physician prescribed non-steroidal anti-inflammatory medication (NSAID) C. Iontophoresis with shoulder in mild flexion and mild abduction. D. Ice, preferably ice massage, before and after range of motion and strength exercises and following any activity

which produces pain.

Range of Motion Exercises: Through pain free movements, performed 2 - 3 times per day. 1. Codman’s Pendulum Swings: Lean over table, supporting

body with uninvolved arm. Let involved arm hang straight down in a relaxed position. Gently swing arm in circles clockwise and counterclockwise; then in a pendulum motion forward-backward and side-to-side. Repeat 30 times in each direction.

2. Horizontal Adduction Stretch: Grasp elbow of involved arm with opposite hand and gently pull involved arm across front of chest just below chin. Hold 5 - 7 seconds and relax. Repeat 5 - 10 times.

3. Triceps Stretch: With elbow of involved arm bent and raised, grasp elbow and gently pull involved arm down behind head with uninvolved hand. Hold 5 - 7 seconds and relax. Repeat 5 - 10 times.

4. Corner Stretch: Standing and facing corner, abduct shoulders and flex elbows to 90° and slowly lean into corner, stretching chest and front of shoulders. Hold 5 - 7 seconds and relax. Re-peat 5 - 10 times.

5. Standing Adduction Stretch: While standing, place involved hand behind body. Gently grasp elbow across back with unin-volved hand and slowly pull. Hold 5 - 7 seconds and relax. Re-peat 5 - 10 times.

Horizontal Adduction

Triceps

Corner

Adduction

Codman’s






6. Chicken: Place both hands behind head and slowly push elbows straight back. Hold 5 - 7 seconds and relax. Repeat 5 - 10 times.

7. Biceps/Chest: Stand and grasp a door frame with both arms at shoulder level. Slowly lean away from door, stretching chest and shoulder muscles. Hold 5 - 7 seconds and relax. Repeat 5 - 10 times.

8. Internal Rotation: While standing with shoulder abducted to 90°, place T-bar or broom stick behind upper arm and grasp lower bar with involved hand. With uninvolved hand, slowly and gently pull upper bar down, forcing involved arm back and up. Hold 5 - 7 seconds and relax. Repeat 5 - 10 times.

9. External Rotation: While standing with shoulder abducted to 90° and elbow flexed to 90°, place T-bar or broomstick behind upper arm and grasp upper bar with involved hand. With uninvolved hand, slowly pull lower bar forward and up, forcing involved arm back and down. Hold 5 - 7 sec-onds and relax. Repeat 5 - 10 times.

Chicken

Phase 2 Strength Enhancing Exercises: Perform 3 times per week using the schedule of sets x repetitions outlines to the right. Do not exceed 7 pounds for weighted exercises. Complete range of motion stretching exercises prior to and following strengthening exercises. Active Flexion: Stand with elbow straight and thumb facing forward. Raise involved arm upward in front of body as high as tolerable, hold and slowly lower. Repeat as directed.

Active Abduction: Stand with elbow straight and thumb pointing out. Raise involved arm outward to side of body as high as tolerable. Hold, then slowly lower to start. Repeat as directed.

Prone Extension: Lie prone on stomach with involved arm hanging toward floor. Rotate arm and thumb outward as far as possible. Raise arm toward hip. Do not raise higher than parallel to the floor. Hold, then slowly lower to start and repeat as directed.

Prone Horizontal Abduction: Lie prone on table. Rotate arm and thumb outward as far as possible. Raise arm out to the side. Do not raise higher than parallel to the floor. Hold, slowly return to start and repeat as directed.

Chest

External Rotation

Internal Rotation

Impingement, Pg. 2

3 x 10 Day off 3 x 15 Day off 3 x 20 Day off

Add 1 - 2#

Abduction

Flexion

Prone Horizontal Abduction

Prone Horizontal Extension

Shrugs

Triceps

Bent Over Rows

Biceps Curls

Empty Can

Internal & External Rotation

Seated Dips

Supine Press

Towel Squeeze

Supine Internal/External Rotation: Lie supine on table or floor with shoulder abducted to 90° with arm supported on table and elbow flexed. Slowly raise hand up and forward as far as possible. Hold for 1 - 2 seconds and slowly return to start. Attempt to place back of hand on table in “up” position and palm on table in “down” position. Repeat as directed.

Supine Triceps Extension: Lying flat on back with involved elbow bent near head. Rest involved hand on uninvolved shoulder. Slowly extend elbow as straight as possible without moving upper arm. Slowly return to start and repeat as directed.

Supine Press: Lie on back with elbows next to chest and flexed to 90°. Slowly raise and extend arm straight upward. Hold, then slowly return to start. Repeat as directed.

Seated Dips: Sit on edge of table or chair gripping sides of table with hands. Slowly straighten arms, lifting buttocks off of seat. Hold for 3 - 5 seconds and slowly lower to table. Repeat as directed.

Towel Squeeze: Fold a towel into eighths and place between chest and involved elbow. Slowly squeeze arm against towel and chest with forearm crossing in front of body at 45° angle. Hold isometric contraction for 5 - 10 seconds and relax. Repeat as directed.

Shrugs: Standing with arms at sides. Lift shoulders up toward ears and hold, then pull shoulders back, pinching shoulder blades together. Hold and relax. Repeat as directed.

Biceps Curls: With arm straight and at side with palm facing forward, slowly flex elbow bringing hand up toward shoulder as far as possible. Hold, then slowly relax to beginning position. Repeat as directed.

Bent Over Rows: While bent over with back parallel to floor and arms hanging to floor, slowly pull arms up, bringing hands up to chest level. This motion is similar to using a cross-cut saw. Slowly lower arms to start and repeat as directed.

Supraspinatus (Empty Can): Stand with elbow straight and arm rotated inward with thumb pointing down. Raise hand to eye level at 30° angle to body. Do not allow the hand to go above eye level! Hold, then slowly lower to start and repeat as directed.

It is not uncommon for your pain level to slightly increase during the first week of exercising. Continue the program for a minimum of 4 weeks. At the end of 4 weeks, if you do not notice improvement in your condition consult your physician or therapist. If your pain is diminishing, continue the program for 2 - 3 weeks after your symptoms have ceased to ensure the condition does not return.

Impingement, Pg. 3

1. Warm up sufficiently to break a sweat.

2. Complete the required stretching routine.

3. Make a few lazy throws at a distance of about 10 - 15 feet using proper throwing mechanics.

4. Perform *LONG TOSS* from deep center field throwing to second base. Throw continuously for 5 minutes, paying strict attention to proper body mechanics.

5. Perform #SHORT TOSS# for 5 minutes, paying particular attention to proper mechanics. DO NOT throw any breaking pitches.

6. Repeat stretching exercises.

7. Ice massage for 15 - 20 minutes (until shoulder is numb).

8. Perform this program 3 - 5 times per week. The program may be done twice daily.

9. Advance to the next stage every 1 - 2 weeks as allowed by pain. If pain is experienced, regress one stage.





Polly Ryon Hospital 1705 Jackson Street Richmond, TX 77469 281.341.3000

Long Toss - Short Toss Program

*LONG TOSS* #SHORT TOSS#

Stage I Ball just rolls into 2nd base. 1/2 speed at 30 feet.

Stage II Ball gets to 2nd base on 4 - 5 bounces. 1/2 speed at 60 feet.

Stage III Ball gets to 2nd base on 1 bounce. 3/4 speed at 60 feet.

Stage IV Ball gets to 2nd base on the fly. Full speed at 60 feet.

Stage V Ball gets to 2nd base on the fly. Return to respective position.

Acromioplasty/Decompression Rehabilitation Protocol

Post-Op: Day 1 - 3

1. Do not allow wounds to get wet while bathing or showering.

2. Ice before and after exercise and as often as possilble between exercise sessions.

3. Range of motion exercises to be performed 2 - 3 times daily, as tolerated, using T-Bar, Pulleys or similar device:

a. Codman’s Pendulum Exercises,

b. Gripping Exercises,

c. Shoulder Flexion,

d. Shoulder Abduction, and

e. Shoulder Extension.

f. Seated Internal/External Rotation with arm adducted and elbow flexed to 90°.

4. Strengthening exercises to be performed one time a day, without weight, as tolerated:

a. Shoulder Flexion,

b. Shoulder Abduction,

c. Prone Shoulder Extension,

d. Isometric Towel Squeezes,

e. Elbow Flexion & Extension,

f. Wrist Flexion & Extension, and

g. Shoulder Shrugs.

Post-Op: Day 3 - 7

1. Do not allow wounds to get wet.

2. Ice before and after exercise and as often as possible between exercise sessions.

3. Continue range of motion exercises 2 - 3 times daily as tolerated.

4. Begin flexibility exercises 2 - 3 times daily as tolerated:

a. Horizontal Adduction Stretch,

b. Inferior Cuff Stretch,

c. Internal Rotation with shoulder abducted to 90° and elbow flexed to 90° stretch, and

d. External Rotation with shoulder abducted to 90° and elbow flexed to 90° stretch.

5. Continue previous strengthening exercises and add:






Acromioplasty/Decompression, Pg. 2

a. Prone Horizontal Abduction with arm externally rotated,

b. Supine Internal/External Rotation with arm and elbow flexed to 90°,

c. Supraspinatus (Empty Can) Exercise, and

d. Supine Press

6. Physician examination at 7 - 10 days post-op. Suture removal at this time.

Post-Op: Week 1 - 3

1. May shower/bathe after sutures are removed and all wounds have sealed.

2. Ice, preferably ice massage, before and after exercises.

3. Continue range of motion exercises if indicated.

a. Full range of motion no later than 3 weeks post-op.

4. Continue flexibility exercises as tolerated.

5. Continue strengthening exercises, with weight, as tolerated 3 - 4 times per week and add:

a. Shoulder adduction with sport cord,

b. Progressive push-ups,

c. Bent-over rows, and

d. Weighted shoulder shrugs.

6. Physician examination at 3 - 4 weeks post-op.

Post-Op: Week 3 - 6

1. Ice after exercise.

2. Continue flexibility exercises.

3. Progress strengthening exercises, utilizing PRE principles, as tolerated and add:

Seated Dips.

4. Physician examination at 6 weeks post-op.

Post-Op: Week 6 - On

1. Ice after exercise.

2. Continue flexibility exercises.

3. Progress previous strengthining exercises and add:

a. Push-ups,

b. Bench Press,

c. Behind the Neck Overhead Press,

d. Parallel Dips, and

e. Lat Pulldowns.


Tennis Elbow Rehabilitation

1) Avoid pain producing activities. 2) Physician prescribed non-steroidal anti-inflammatory medication. 3) Iontophoresis or Phonophoresis as prescribed by a physician 4) Deep transverse friction massage across affected area for 5 minutes, 3 - 5 times daily. 5) Gripping exercises using a gripper, small rubber pall, putty, washcloth, etc. as often as possible. 6) Ice massage after exercise and as often as possible between exercise sessions.

Range of Motion Exercises

Complete through a pain free range of motion. Hold each stretch for 10 seconds and repeat 3 - 5 times per session. Repeat 3 - 5 times daily. 1) Wrist Flexion: With elbow straight and palm facing down, grasp

back of hand and slowly pull hand back.

2) Wrist Extension: With elbow straight and palm facing up, grasp fingers and slowly pull hand back.

1)

2)

Strength Enhancing Exercises To be performed 3 times per week, with one day of rest between exercise sessions. Begin with 3 sets of 10 repetitions, advancing up to 5 sets of 10 as strength improves. When 5 sets of 10 can be performed, add weight or increase weight being used. 1) Pronation / Supination: With elbow straight and forearm supported by table, hold

a stick with the heavier end up. Slowly lower stick as far as possible to the right and hold for 2 seconds. Slowly raise the stick back to the start position and then lower as far as possible to the left and hold for 2 seconds. Return to starting position and repeat.

2) Radial / Ulnar Deviation: With elbow straight and forearm supported by table, hold a stick with the heavier end up. Slowly lower stick forward as far as possible and hold for 2 seconds. Return stick to the starting position and then slowly lower stick over shoulder as far as possible and hold for 2 seconds. Return to starting position and repeat.

3) Wrist Curls (Flexion): With forearm supported on table and hand off of edge, palm facing up, lower hand as far as possible. Slowly lift hand as far as possible, return to starting position and repeat.

4) Wrist Curls (Extension): With forearm supported on table and hand off of edge, palm facing down, lower hand as far as possible. Slowly lift hand as far as possible, return to starting position and repeat.






Tennis Elbow, Pg. 2

5) Biceps Curls: With arm straight and at your side, palm facing forward, slowly flex elbow bringing hand up toward shoulder as far as possible. Hold, then slowly relax returning to full extension.

6) Supine Triceps Extension: Lying flat on back with involved elbow bent near your head. Rest involved hand on uninvolved shoulder. Slowly extend elbow as straight as possible without moving upper arm. Slowly return to start and repeat.

7) Wrist Roller: Use a 12 - 18 inch broom handle with 2 - 3 feet of cord attached in the middle, hand a weight from the end of the cord. Grip stick on either side of the cord with palms facing down. Wind cord by turning stick toward body, causing weight to rise. When weight reaches sitck, lower weight by slowly unwinding cord. Repeat with palms facing upward.

Continue this program for 2 - 3 weeks AFTER all symptoms have ceased. It is common for symptoms to worsen the first week of this program. To help prevent recurrence, continue the stretching exercises (Wrist Flexion & Extension) before doing any repetitive activities.

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Sports Medicine Specialists Rehabilitation Protocols

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