24 Jun Lower limb injury assessment
The first step in any injury assessment is what previous injuries do you have. The biggest predictor of future injury lies in your injury history. As a result looking into your injury history will play an important roll in deciding on what needs to be done. If you have previously injured your ankle, knee or hip these are areas we need to investigate in the injury assessment. We do this becasue of the scale of the impact they have on the way you move. Two of the more important things that we are looking out for in the clinic are asymmetries and pain.When we are assessing movement we are looking to see both how good it is and does it cause pain.
If there is any pain in a movement it needs to be addressed but not simply because in means there is an injury, often there isn’t, but rather because it would suggest that there me have been an incomplete recovery from a previous injury. If you don’t go through a full graded exposure that helps to desensitise the injured area there is always the possibility that it will be reactive to certain positions or loads that make it seem like it has been re-injured. There is also the very real possibility that it isn’t going to be strong enough to cope with the demands of returning to running and as such genuine re-injury is a possibility.
With the quality of the movement, we are looking at how “clean” it is, how much there is and is it symmetrical. With running it is only really at higher speeds that we need to be able to express larger ranges of movement but even here we aren’t going into full range hip flexion or worrying about end range external rotation. What we are really looking for is that there is both enough movement and that it is symmetrical.
One of the important movements we need to have good quality, symmetrical range of movment is dorsi flexion. This is hugely important to how well we move and when we are looking to avoid or assess lower limb/ankle injuries one of the first areas we want to ensure is ok is the range of movement the the ankle, as assessed by the knee to wall test. As I noted last week we ideally we want this to be around 10 cm, probably between 10-15 cm, and there to be little difference between the two legs, +/- 2 cm. If this isn’t the case in terms of ROM but the difference is within tolerance then there is no need to panic since the range that could be considered normal is large, 5-20 cm, and as it is an even measurement it may simply be that it is completely normal for you.
If the range is less than we would like and you are asymptomatic in terms of having an achilles issue or other lower limb injury then as noted above it is generally ok. But if you are symptomatic then we need to assess why this is the case as the range of movement is a symptom of the over all why and not simply a bi-product of the pain.
Sticking with the lower leg we know that strengthening soleus is beneficial in achilles and plantar fasciopathy as well as a way to help address the constant tightness some runners feel but it is only one part of the puzzle. We need to be able to both produce and absorb force through the whole posterior leg and hip with the muscles working in synergy
We need to know if you can perform a number of hops on one leg and stick the final one. If you can’t perform a series of hops, usually 3, and plant the last one holding it for a least 3 seconds. The ability to perform this with the pause lets us that the calf muscles, hamstrings and glutes are working well in synergy with one another. If you can’t do it then it obviously lets us know the opposite is the case. If you are symptomatic then we aren’t going to do this and so we can use the reverse plank with the twist that you do it whilst pressing your toes against a wall.
When this synergy is lacking we tend to see what you can consider as slack in the system and some areas needing to take up a greater share of the work as they take up the slack. This can result in extra work for the lower leg and greater stress on the achilles tendon and result in tendanopathy, tension in the higher part of the hamstring or a softer than ideal knee positions than we want that might cause ITB syndrome.
One of the first steps we use in restoring this posterior knee stability is this exercise. It is a very gentle exercise where you are pressing at about 20% max of what could press. The pressure should start at the hip and push down through the fore/midfoot. Whilst it is a simple and very low level exercise don’t be too surprised if you get cramp or pain the foot, calf or hamstring when you try it. The exercise is to teach you to push gently through the the front of the foot so if you are experiencing any cramping or such like then simply go lighter. It is a great tool to start rebuilding the synergy between the posterior leg and hip I was talking about above.
Going further into the rehab process we want to create the ability to take slack out of the system. To do this we add in a variety of progressions that include arm reaches and move onto single leg work. One of the the later stage exercises we use are modified reverse planks. The normal revers plank the legs are straight and you are pushing down through the heel. In our variation you use a bent knee and press the toes into the wall. In doing this we require co-contractions of the gastroc and hamstring in a similar manner to how you might use them when running. Once this is mastered we can confidently move through the more demanding bounding and hopping progressions.
These exercises are from of our hamstring rehab we tend to find they are useful in most leg injuries. The reason for this is that most injuries tend to come from over use and poor mechanics. Addressing the gastroc/hamstring relationship and their ability to stabilise the knee is very important in running. The ability to do this dissipate forces well through the leg is fundamental to a robust return to running program.