2. Golden Rules to live or practice by
These we do not ever want to break and they
define our practices
Like: Never Stretch Through Pain
Hope this Talk either adds some or bolsters what
you Know
4. What do I want to present?
1. Crucial Phases of Rehabilitation
2. Maintaining the 0-2 Pain Level Throughout the
Process
3. Three Types of Pain
4. What should be the basic aspects of your rehab?
5. KISS and Implied Need of the Injury
6. Correlation of Injury/Pain Syndrome to
Biomechanics
7. Teamwork (Together Everyone Achieves More)
6. Any Profession Tends to Throw Away
Older Simpler and Get More Complex
or Technical
More Sophisticated or New does not always mean
better
I urge you to learn simple ways of treating
something also as they will broaden your
treatment options
When to use OTC arch supports?
When to tape, not brace?
Developing good HEP over formal Physical Therapy?
7. Phases of Rehabilitation
Phase I: Immobilization with Anti-Inflammatory
Phase II: Re-Strengthening
Phase III: Return to Activity
Need to Create 0-2 Pain Level in Each Phase to
Insure a Healing Environment
In our attempt at 0-2, we get good at rehab!!
8. What does it mean to Immobilize?
Unless you are dealing with a fragile system—torn tendons and
ligaments or unstable fractures—Immobilization means creating
that 0-2 pain level 24/7 by whatever skill set you have
If you know how
to modify boots,
less time on
crutches for
example
9. Methods of Immobilization or Added
Protection
Crutches
Canes
Scooters
Wheelchairs
Removable Boots
Off Loading Braces
Activity Modification
Taping
Foot Orthotics
Ankle Foot Orthotics
Braces
Padding
Uber
10. Creating the Pain Free (0-2) Healing
Environment
This is how we learn what is needed and how to experiment
This is how we decide if someone can get back to walking or
running
This is how we decide if a therapy is helpful
For Student Athletes, with varying pain levels, it will be only if
they limp that activities are curtailed
11. 3 Types of Pain being treated
1. Mechanical Pain—caused by mechanics,
acute or overuse, and treated by mechanical
changes
2. Inflammatory Pain—caused by poor
mechanics, an injury, systemic, or
combination, and treated with anti-
inflammatory measures
3. Neuropathic Pain—caused by mechanics,
chronic inflammation, or nerve injury, and
treated with nerve treatments
12. What are mechanical changes that
treat Mechanical Pain?
1. Immobilization
2. Off Weighting
3. Changing to a Better Position
4. Slow Down an Abnormal Motion
5. Strengthening the tissue at, above, and/or
below
6. Stretching tight muscles in the area or those
that effect the function
13. Example of Typical Mechanical
Changes Utilized in Practice:
Orthotics for Typical Plantar Fascial
Heel Pain
Orthotic Design:
1. Immobilize the Pull of the Plantar Fascia somewhat
2. Change the Position of the Pressure from the Painful
Heel to the Arch
3. Slow Down the Motion of the Plantar Fascia which
jerks the tissue at impact
4. Depending how pronated the foot, could also be
changing into a better position of the heel to ankle
alignment
14. What is the difference from treating
Inflammation versus Irritated Nerves
First of all, I consider Inflammation and Inflamed
Nerves the same. The basic problem is
inflammation.
This is different from irritated or hypersensitive
nerves. One third of these are numb, one third
are painful and numb, and one third are just
painful.
15. Treatment of Inflammation and
Irritated Nerves can be somewhat the
same or completely different.
Inflammation is helped by prolonged icing 10-30
minutes, Irritated Nerves tolerate only 5
minutes of ice.
Inflammation is helped by oral or topical
NSAIDs, nerves normally not.
Inflammation can be helped by deep tissue
massage, irritated nerves like non-painful
massage .
16. Inflammation tolerates prolonged stretching,
irritated nerves like motion, and they do not
like holding a stretch.
Physical therapists tend to push through
inflammation, but honor nerve pain.
17. Irritated nerves in general like warmth, motion,
non-painful massage, Neuro-Eze, capsaicin, TENS,
Quell, acupuncture, de-stress, meditation,
hypnosis, biofeedback, Lyrica or other orals.
In creating your 0-2 pain level for healing, this is
how you learn what makes the patient feel better
(do we get better results while we are treating with
nerve or inflammatory treatments).
19. Everyone Blends the 3 Phases
Should start Strengthening as soon as you injure an area
Five Basic Types:
Active Range of Motion
Isometrics
Progressive Resistive
Isotonic
Functional
20. Need to Know When to Back Up
Re-flares typically are not placed back on the Immobilization Phase
when they should be
They are usually last 4 days or 2 weeks, longer if you do not immobilize
They are frustrating, but typically you are not starting over
21. Why are Re-flares Always Part of the
Process
It is a constant balance between 0-2 Pain Level maintenance
and Return to Activity Levels
Your Team of Patient, You, Physical Therapist, etc., may think
they are ready for something, but they were not
We are always dealing with driving the pain down to level 2,
then maintaining it at 0-2, while increasing strength,
activity, range of motion, cardio
Sometimes it is just life and vacations that get in the way!!
22. 5 Forms of Strengthening Crucial
Injury Specific Strengthening (use our 5 types of
individual strengthening exercises)
But there is also:
Leg and Core General Programs
Cardio Fitness Programs
Cross Training Programs
Sport Specific Programs
23. If you want to strengthen something, I
love to isolate it
Best Example: Getting a patient with PTTD on posterior tibial tendon
strengthening is hard, since the tendon is not being isolated in most
activities since the ankle is not plantar flexed
Ankle to Plantarflex and
Invert to isolate Posterior
Tibial Tendon
24. What are the General Principles of
Stretching?
1. 30 seconds or 5 deep breathes
2. No bouncing
3. No Pain
4. Vary the Positions of the Stretch
5. Before and After Exercise
6. Twice Daily to maintain your improvement, 3 to
gain
7. Be in a Stable Position (it is not a balancing
exercise)
25.
26. Summary of the Basic Aspects of
Athletic Rehabilitation
1. Progress patients through the 3 Phases of Rehab
with typically monthly appointments
2. Create 0-2 Pain Level quickly in the first month
(if you can not, then the diagnosis is incorrect,
or your treatment must be missing something)
3. Begin Strengthening the injured area on day
one, and the lower leg with cardio as soon as
possible
4. Define your team early—the patient, you,
physical therapist, orthopod, pain specialist—
and make sure all reports to you, or just add as
you go
27. Summary of the Basic Aspects of
Athletic Rehabilitation (cont.)
5. See if Your Implied Need matches with the
patient (may take a visit or two)
6. Begin at the first visit, and continue each visit,
to look at the cause(s) of the injury—think 3-5
typically (this is where podiatry rocks!!!!)
7. Begin to correlate injury with possible
biomechanical causes—pronation, supination,
short leg, shock issues, weak or tight muscles
28. Implied Need Concept
KISS (Keep It Simple Stupid) means that you are
stupid if you make things more complicated than
needs to be
Yet, the concept of Implied Need, based on the
patient’s concern or your experience, can help us
a lot and avoid frustrations
In our rushed lives, at times the patient under
estimates the problem, or you under- or over-
estimate the problem
29. Implied Needs
Part of the rehab, since it can greatly affect whatever protocol is in
place by you or your staff
Implied Need Error #1 —The patient has simple blister in arch, non
painful, no urgency expressed, you however knowing the patient is
a diabetic are worried of a fracture blister in Charcot foot (huge
need to treat)
You over treat in the patient’s eyes
Have to err in treating the worse possible problem
Implied Need Error #2 —The patient has unbearable pain (8-10) with
no swelling (huge implied need to treat), you treat as simple
pressure problem and tell them to get wider shoes (KISS missed
CRPS).
You under treat in the patient’s eyes
30. Rule of 3
Correlation of Injury to Possible Causes is Where Podiatry
Rocks (not including overuse as a cause)
Rule of 3: 3 Possible Causes should be looked for in every
case
For Example: Patient presents with posterior tibial shin
splints along the medial border of the tibia—the 3
causes found over the next 5 visits were over-
pronation helped with OTC inserts with varus wedges,
low Vit D with normal bone density, and weak
posterior tibial and soleus muscles which attach there.
31. Correlate Biomechanical Faults with
Injuries/Pain Syndromes
PRONATION
SUPINATION
SHORT LEG SYNDROME
POOR SHOCK ABSORPTION
TIGHT MUSCLES/TENDONS
WEAK MUSCLES
DEFORMITIES LIKE PLANTAR FLEXED FIRST RAY
