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Thoughts on lumbar fracture and knee pain.
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Thoughts on lumbar fracture and knee pain. - October 16, 2008 3:38:38 PM
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Kaden
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I have been treating a patient for medial knee pain for the past two weeks. The other day he fracture L1 transverse process in a work injury. He want to continue PT for the knee and his MD has okayed this.
Any thoughts on what is appropriate for the knee. I know some simple QS, range, etc will be okay but he has progressed well past this.
I am assuming any hamstring stretching (due to amout of hip flexion), SLR and squat activities would be out?
Any thoughts. What would you do for him.
Should I be seeing this guy for his knee or tell him to return when he has a stable fracture.
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RE: Thoughts on lumbar fracture and knee pain. - October 16, 2008 4:55:26 PM
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TexasOrtho
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Hi Kaden. Is he having problems related to the fracture? How is is function? My general approach is a gradual symptom limited progression of activity regardless of the specific structure involved, but it would depend on the individual.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Thoughts on lumbar fracture and knee pain. - October 16, 2008 5:05:13 PM
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Myostrain
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How old is he? Is he working still, with restrictions?
Was he seen by an ortho or primary physician? Given back support by the MD?
I would assume it is not a severe fx causing foraminal/n. comprise so they are letting it heal.
If no back support and pt. has been given the green light for working, what movements and stressors might he be doing on his own, I'm sure he is doing things that his body feels okay with and is avoiding or minimizing painfull positions/movements?
Be aware of pain medications he is on and beware of signs and symptoms of irritation, L1 regions, but it should be very workable to continue working on the knee.
Just more focus on slow/controlled/comfortable, no signs of neural irritation. More awareness for any glut max/hip ext/hip abd exercises to make sure those are done at a tolerated level, you can hypothosize that prone trunk stab-LE ext/abd or sidelying abd may cause greater rotator/PVM at that site and may be not appropriate but there are a lot of muscles and joints, small range movement and patient understanding of unwanted signs could make a few exercises go well but go according to what you think fits your patient.
Recumbent bike and treadmill should be doable.
Hamstring stretching may be okay but light; that high up the stress should not be too great with supine HS stretching.
I would work on what primary impairments are related to his medial knee pain and spend most of the treatment on those.
Maybe open chain ankle strength inv/ever/df/pf, ankle stretches, quad strengthening, hip abd-supine clamshell with bands, small range hip abd in standing-side step-ups or sideways walking depending on the tolerance to those positions and movements.
If you have just started and have a bit of time to go, why not do things you feel comfortable stresswise with for a week or two then ease back into others. Healing will take longer, but there are so many muscles and joints around there, it would probably take more than what you think to cause problems and it might not take too long to heal just enough to tolerate about everything you have in mind. Just keep in mind the anatomy and what primary movements happen there along with what muscles may exert tension in that area and what stressors come with each exercise position.
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RE: Thoughts on lumbar fracture and knee pain. - October 16, 2008 5:07:00 PM
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OrthoSam
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Hi Kaden,
Lumbar transverse process fractures are almost always stable as they have so much muscular and fascial support that you just have to be guided by pain. I just wouldn't do any running or jumping, but regular knee exercises should be fine.
Sam
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RE: Thoughts on lumbar fracture and knee pain. - October 16, 2008 6:29:18 PM
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Kaden
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Thanks,
I am not sure on exact function yet. I have only talked to him on the phone since the lumbar injury about him wanting to continue with therapy. At this time he is in thoracolumbar corset to restrict some motion. Hie is off work and okayed by his PCP to ambulate as tolerated.
He just figured why he is now off work due to the spine injury, if able, he should continue some therapy on the knee.
I think i will plan on letting pain be the guide and continue with some hamstring and other LE stretches, closed chain activities limiting lumbar motion and short arc quad type work.
I will probably plan to stay away from SLR type activities as these tend to create a longer lever on the spine. I just hesitate to do supine or prone SLR activity as in my head I imagine these causing a lot of stress to the spine, even if a stable fracture. Not sure if they are worth the risk.
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RE: Thoughts on lumbar fracture and knee pain. - October 16, 2008 6:47:24 PM
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bonez
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Since psoas attaches to the tvps he will have difficulty with any single leg weight bear activity either active(injured side) or reactive(bracing to support well leg work) Be aware that L1 sits high and behind lower ribs so the direct trauma to fracture it will have made rib contact too. This can make dynamic trunk bracing difficult too.
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RE: Thoughts on lumbar fracture and knee pain. - October 17, 2008 7:45:08 AM
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Shill
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Did I miss what his diagnosis is for the knee pain? This would likely direct what you would want to do at the knee, and then give us some ideas as to whether it would bother the spine. I think Rod said it best and first. Careful symptom related progression, making sure he is not over stressing the spine while at home "resting" from the injury.
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RE: Thoughts on lumbar fracture and knee pain. - October 17, 2008 2:32:59 PM
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Kaden
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Thanks for the advice.
In doing some more reading I found this case study. http://www.pfats.com/research/pubs/articles/multi_level_transv_proc_fx.cfm
This approach seems to be very aggressive while I have seen other references waiting 6-8 weeks to do any dynamic lumbar core work or trunk motion.
So needless to say I will be doing some more reading and contacting the MD for some guidance.
I spoke to the patient today and the MD said he could start therapy in one more week (2 weeks post injury) and the script called for core strengthening. Core strengthening is obviously and broad statement...dynamic versus isometic, etc. So I will contact the MD.
I tend to dislike fracture care and I think it is b/c of all the variability in treatment progression from physician to physician.....frustrating.
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RE: Thoughts on lumbar fracture and knee pain. - October 17, 2008 7:42:39 PM
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jma
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See what the functiional impairments are and then discuss your treatment plan with the MD before you start therapy. If there is agreement, document it, and go from there. You are covered that way.
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RE: Thoughts on lumbar fracture and knee pain. - October 20, 2008 11:22:48 AM
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Kaden
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Thanks for the info folks.
Now if we are talking more about rehabilitation of the TP fracture itself. When would you start stabilization trainining. I have seen large variability here. Obviously some TrA and MF work isometrically would be no problem, but what about common trunk stability exercises. Would you simply be guided by pain or is there a time frame out from injury you would wait prior to initiating dynamic work.
Thanks again
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RE: Thoughts on lumbar fracture and knee pain. - October 21, 2008 12:23:13 AM
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bonez
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quote:
ORIGINAL: Kaden
Thanks for the info folks.
Now if we are talking more about rehabilitation of the TP fracture itself. When would you start stabilization trainining. I have seen large variability here. Obviously some TrA and MF work isometrically would be no problem, but what about common trunk stability exercises. Would you simply be guided by pain or is there a time frame out from injury you would wait prior to initiating dynamic work.
Thanks again
If you think about the structures here and all that is damaged is a single tvp then the non function of one does not comprimise stability here so I personally think individual pain levels should be your guide. If adequate time has passed for primary recovery you should be fairly safe. Combine this with a full explanation to the patient chart it and make your progression logical.
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RE: Thoughts on lumbar fracture and knee pain. - October 21, 2008 9:45:25 AM
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Kaden
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Thanks bonez
That is what I have seen with more research. It sounds like pain free stability training and even some light range activities for the spine and lower extremities are fine.
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RE: Thoughts on lumbar fracture and knee pain. - October 22, 2008 7:43:16 PM
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jma
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Agree with that as well.
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RE: Thoughts on lumbar fracture and knee pain. - October 23, 2008 8:29:18 AM
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rwillcott
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Kaden,
I think a safe approach to 'core' training would be to begin with the Australian approach (TrA and MF) with addition of arm and leg movements in crook lying. Sahrmann has a nice progression that is in supine as well. Once adequate healing takes place then I would progress to some of McGill's exercises and more weight bearing movements.
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RE: Thoughts on lumbar fracture and knee pain. - October 23, 2008 9:49:06 AM
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Kaden
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I was planning to start with TrA and MF in crooklying as you suggest Rwillcot. When you say McGill exercises, what types of activities are you specifically referring to. I have read some of his work but are your referring to a specific series of exercises.
After crooklying exercises I will plan on progressing to prone work and quadruped work as pain dictates. I know this is more challenging to the spine but ultimately it is the posterior mm. that needs retrained.
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RE: Thoughts on lumbar fracture and knee pain. - October 23, 2008 10:39:03 AM
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jma
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Does Sahrman have a textbook out or are the exercises in an article?
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