Athletic Rehabiliation Interns



5/13/13Having had Bryan Bourcier as my physical therapist through two anterior cruciate ligament reconstructions, I am so privileged to be beginning today. He and I began discussing how his style varies from many because he is really an aggressive researcher and always looking for a better way. I can already tell how dynamic and impacting his style is. The athletes coming in to the Parkview Sports Medicine clinic share the same trusting excited view of their experience as I did when I came to see him at Indiana Physical Therapy. I am excited to be one of the first interns at this young facility. I can quickly see myself being able to meet all my goals and have a great example to observe. Today we had an orientation meeting where I learned I will be alongside two other interns in the rehabilitation area, but also about four others will be at AWP in the sport performance area. We will all be able to work together and have each other as a reference if Bryan becomes busy or is in another part of the facility. 5/14/13Already I have learned that one of the first ways Bryan begins back or lower extremity issues is check their alignment. Bryan chooses to use three primary ways to check, but some I am not qualified to use. However, they are producing great results in the clinic for patients complaining of pain. Some of the people who I find need it have:SI problems/back pain“muscle tightness” especially in the thoracic spine areaHip painIT band issuesThe 3 techniques are: 1) shotgun: paitent lis supine with the knees bent and feet together, clinician place are between knees and patient squeezes 2)5/15/13Before beginning here, I did not realize how important the posterior tibialis is. It was a muscle I never gave a second thought to, and basically I just knew it was a lower extremity muscle. Looking back, that was a terrible approach because every single muscle and part of the body is crucial to understanding the true underlying injury. 5/16/13Already through this experience I am gaining so much shoulder information. The shoulder always seem a bit testy as it is so complicated, but seeing it all come together here makes so much sense. Stretching and warming it up are always key parts of this and any other rehabilitation program—which is awesome. Now I feel like I have a lot to work with as much of the shoulder exercises overlap and apply to so much because the overlap.5/20/13:All of the interns are beginning to start taking detailed notes over the exercises. In the end we will use these to compile a take home program for his patients. Here are some shoulder exercises I learned with some important information: *(I will use this type of information for many of my daily notes) General stretches— doorway: if patient feels it pop out, step toward and don’t lean; pulley: do it for about 10 minutes straight; pendulums: use body momentum, don’t swing the shoulder; towel slides: can be done seated on table or standing facing a wall and reach upBicep stretch: grab on a doorway with the arm extended, reach up as high and back as you can and turn away5/21/13I have never really had experience working specifically with my own shoulder-injury patient, so learning the basic isometrics even is a helpful experience. This is where I know everyone should start beyond stretches:Isometrics:ER: stand with wrist braced against the wall and try to externally rotate; have a ? roll under armABD: stand with entire forearm braced against a wall and try and lift arm up and out; have a ? roll under armGH Flexion: stand facing the corner of a wall. Have arm straight with fist against the wall (thumb up)GH Extension: have hand in a fist with arm extended against a wall (facing away)For the elbow can also do these but add a seated curl up underneath the side of a table5/22/13We are still hammering out the shoulder information. There are so many simple exercises that can be done with little equipment used besides a weight or small medicine ball. This is great for me if I end up working in a high school!Scapular retractionWall pinches: do about 30 for 10 second holdsBand work: ER/IR with it in door and use ? roll; Rows with scapular retractionProne external rotation: Lie on a table with the arm off, start in 90 degrees of abduction and 90 degrees of elbow flexion. Externally rotate the shoulder holding a weight (1-5 lbs usually); hold for 5 secondsSidelying external rotation: use ? roll and raise arm to ER just past neutral (~45 degrees)Medicine ball design: circle, star square—arm at 90 degrees of shoulder flexionI, T, Y’s: patient lies prone with involved arm off of a tableI— extend arm backT—arm straight out to side, knuckles downY—at 30 degrees, thumbs upStanding scaption, abduction, and bicep flexion (with a weight)Scaption—thumbs up, keep shoulders even and raise (about 30 degrees of shoulder adduction)Abduction—palms downBicep flexion—have arm extended, hold weight, raise with palm up, and hold 5 seconds (moves form 0-90 degrees of flexion); may do unilateral or bilateralSlide board Box step up: can do in push up position or kneelingBosu ball stabilitiy: in plank postion, with the black side up, do the following: circles, touch laterally both sides, touch forward and backRebounder ball exercisesSerratus punches or hugs: hugs can be single arm; can add weight; do a 3 second pause at topPush up stabilization: on the table have a 30 degree bend in elbow and begin with knees bent, progress to plankSingle arm stabilization: begin with just leaning, then do on the table then pushup position5/23/13The toughest part of rehab for me is progressions—knowing when and what to do. For the shoulder, what I have noticed exercise-wise is generally that it goes from isometrics, to band, to ITY with weights, to medicine ball designs and on to more dynamic stuff and body weight bearing activities. Another thing I tried to watch for is which types of exercises were used for different injuries. For example here is what was used primarily for two different injuries/conditions:Bicep tendinitis: bicep stretch, doorway stretch, ITY, sidelying ERFracture of a GH growth plate (interesting injury): pulleys, towel slides, doorway stretch, sidelying ER, band exercises in door, serratus punches, push up stabilizationGranted, this is only a snap shot. These will progress even more. It is just to help me get an idea and remember what he did. 5/27/13I have had some slideboard experience, but I really like some that Bryan is using for different patients.Shoulder: patient is kneeling on all fours or in plank position next to the slide board. Reach up with arm, reach out at 30 degrees on slide board, reach straight out, reach backHamstring: place uninjured leg in the sock on the board behind. Pull leg forward while keep foot on the surface using the hamstring of the leg on the turf. Quadricep/Hip Flexor: uninjured leg goes in the sock; place socked foot ahead of body on the board; pull get on the board back using the stable leg’s hip flexor5/28/13The neck is another thing that always seems scary but I really enjoy some of the stretches he gave us. Trapezius stretch: tilt head laterally and away and look back and up; can do seated against a wall and lean on a towel and pull for extra stretch. Basically is just lean to side and look upLevator scapulae: sit on edge of table, laterally flex the head and look down and in pocketSerratus: Laterally flex head bringing the ear to the shoulder; pull on table and lean for moreSome other neck exercises are the serratus punches and hugs, chin tucks, or the neck stretches with traction using a towel to save clinician energy5/29/13Another awesome part about being an intern at AWP is that I get to observe whenever I want and watch some of the sport performance classes. I really like some of the unique stretches they do. They have sheets with lists of different activities the kids can do. Here are some for Hip flexibility/Mobility: Fire hydrants (lateral/forward/backward); Bird dogs; Scorpion (posterior/anterior); 90/90 leg lifts; knee to chest (flexion/extension); hip rotations (internal/external); roll throughs (apart, together, butterfly—continuous); pigeon stretches (upright/forward/across); spiderman’s (stationary/with rotation); glute stretch6/3/13A huge part of almost every lower extremity rehab, particularly hip, knee or core, requires bridging and glute activation. Most commonly we do single leg bridging. The patient is supine, with the knees bent, activate core, tighten glutes and tighten the leg and raise parallel to the bent thigh. Lift the bottom off table without dropping legs and keep them level. Hold for 10 seconds and do it 10 times on both sidesHere are some variations we use:Normal (double leg)Single leg (SL)SL/SL with flexionSL/SL with flexion/Rotation—continuous Foam roll between and bridgeBridge inchers6/4/13We work with a lot of female injuries revolving around hip weakness. I love all the exercises we are using! Here are some of the stretches we use for our patients. Everyone seems to do these!IT band stretch: stand about two feet from a wall with your unaffected side toward it. Cross the unaffected leg over the affected and lean away from it with arms overhead towards the wallPiriformis stretch: lay on back and bend both knees, pull knee to the middle of your chest, *or try bringing your ankle to your opposite shoulderHip Flexor stretch: place foot on stool, brace self with the table, tuck pelvis, keep the core engaged, and clench and dip into a stretch6/6/13The hip seems to be at the center of everything that people are having issues with. Here are some of the exercises people with hip issues have in their program that I have noticed:IT, piriformis, & hip flexor stretchBridgesClamshells: 10 second holds, bilateralProne hip extension with gluteSidelying straight leg raises (glute med): straighten leg on bottom, keep everything stacked, brace and draw in core, tighten glutes, sweep leg up and back. Hold for 10 seconds.Monster series with a band (do at a 45 degree angle and come together, stay wide, and lateral)Up quick down slow on varied box levelStadiumsVertamaxSquatsSquat jumpsQuick jumps (rebounds/sets on toes)Single leg hip flexion explosion6/10/13Having been through two knee surgeries, I particularly enjoy working with these patients. I spend a lot of time teaching the same rehab exercises I had to do, and I find it simply awesome. Here is what I do with most of my patients for the knee:Calf stretch on the slant boardKnee extension stretch for Hamstrings (with rope)Knee to butt (quadriceps stretch)Sidelying straight leg raisesBridging (tighten core/glutes, straighten leg, lift toe of bent knee, raise from the butt) watch for too much hamstring activationSL bosu balance (hold for 10 seconds)Quadriceps isometrics at 90: sit at the end of the table with belt around ankle kick for 5 seconds, rest for 5Kick out with band to 70 degrees1-2 stick: in the 3 hoops, focus on quick stabs, powerful movement coming from the legsWeight room: Hamstring curl: down with both up with 1Leg press: both, then up with both, down with one, SLHeel taps: stand on affected leg, straighten other legMonster series:Lateral: don’t lose tension, keep trail leg strong, don’t cave45 degree angle: step and come togetherWide: push knees outStep, load, explode: power hop to a SL squat and touch toe with opposite handRunning formUp quick, down slowHamstring curl on physio ballQuick feet on a boxSide squat along tableWeight shiftHamstring curls into a band6/12/13Today I did some more observations in the sport performance area and finally got the warm up exercises all jotted down. These would be great for any team to use! I will have to rember these for later use.Hamstring walks, same backSweeps and backFrankenstein kick with a catchLateral lunge and forward lungeExplosive lungeInchers then spiderman backStationary spiderman (6 each way)Interior roation (10 yards, control it and keep body squareSumo squats (extend all the way up/hips through)Lunge with a twist (10 each side)“A” walks (land on balls of feet, lift heel up, knee will follow)Heel pullsA skips (hips up, chest up, eyes up)Power skips (ground contact, force knee up)Low heels, high heels (put together)Fast leg series (3 steps and snap up)Up tall and fallKnee starts6/13/13I really am enjoying watching some of the other interns teach the youth classes. They do some really dynamic and challenging drills that help them learn better techniques. Here are some exercises I liked:Switch/switch on the vertamax: both ankles hooked up to it for better heel recovery. Eyes stay up, head up, and on the balls of their feet. T drill: sprint forward, lateral to side cones, and sprint backX-drill: sprint to middle, sink hips, sprint back-wards, lateral shuffle and sprint againAlso, I learned different running techniques. For example, for the first 10 yards they drive at 45 degrees body slant. Then 25-30 years more upright. The heel is always lifted toward the butt. Geoff King works as the speed specialist, and he helped me analyze one of the patients running issues. It was a little over my head, but I understood what he was saying. 6/17/13In general these are some of the things to do for a hamstring issue I have noticed lately:Curls on a machineProne Curls with a band on the tableBosu Ball curlsSlide boardClamshellsSL/DL bridging6/18/13I learned a fun fact that there is nothing in the first 6 weeks for ACL and Tommy John surgery rehab that can be done to speed up the process. We also got to watch part of the patients Tommy John (anterior ulnar collateral ligament) reconstruction on a DVD he brought in. It is very cool too to see how to adjust his brace and work with the parent that comes in with some many questions. 6/18/13For the calf, I have not been able to collect too many distinct exercises. It is incorporated into many of the other exercises. Here is what I have as some components to a calf program:Slantboard stretchesRunning form: bend knee, reach forward, like a single leg squatSL balance on BOSU into a calf raise; hold both for 10 secondsDown and in with a theraband; seated and leg is extended to be able to pull toe down6/20/13As I continue to do more with the calf, I realize that he incorporates anterior tibialis strengthening with it. This makes sense then they work in opposition on the lower leg. I also learned that stretching with toes out on the slant board can help with shin splints. Here is what I have for those exercises:Anterior tibialis stretch: seated in figure 4, pull foot down and inInversion/Eversion seated on a stool with a bandDorsiflexion: on the table, leg extended, band attached to table leg, band on footSL dorsiflexion standing6/24/13Today, we spent most of the day at the computer checking patient files and codes. It was very insightful as I got to learn the billing side of rehabilitation. It is a very complicated process. We will be finishing up these files over the next few days whenever we have down time. 6/25/13The ankle is one of the most common injuries I will likely see in my profession. I am glad that we finally have a patient in that is rehabilitating an ankle sprain. We have these exercises outlined for him to do:Calf stretch on slant board (5x30 seconds)Anterior tib stretchBand exercises seated:Inv/Eversion: knee at 90/90Up and out: for peroneal brevis, start with a little plantar flexion; seated also at 90/90Down and in: for posterior tib, sit with leg extendedDorsiflexion on the table with leg extendedCalf raises (heel lift) SL/DLStanding dorsiflexion (toe raises SL/DL)SL balance on airex/bosu, progress to a calf raise on it as well (*may need to maintain arch)Wall falls: feet together and flat on the floorLine jumps: stay on balls of feet6/26/13We have been working a lot with the bands anchored to the wall this whole time. It is really functional for rehabilitation and challenges the demands on the body. Today we went over some cues like this for running straight out and coming back slow:Run out, sink, reach back with a 2 second pause for each stepArms at 90/90, ear to pocketToe to heelReach back, chest up***any change in motion = stop and sink the hipsFor these, we generally do at least 15 of each. For a football player with a PCL rehab program, we also implemented running routes with it. Some other variations for this include lateral running/lunge back and sprint back wards7/1/13I already know how important the core is, but I find it interesting to see how weak everyone is. A couple people (low-back pain/GH stress fx) are doing plank progressions. They are very challenging. The ones that Bryan recommends are bring the knee up, bring it across to the opposite shoulder, and then bring it around and up from the outside toward the shoulder7/2/13Back pain always seems to scare me. We have a lot of patients that come in and need realigned, but then they also do some vigorous rehabilitation programs.Piriformis stretchSidelying lumbar rotation: lying supine on side, flex top hip to 90/90 and leg under with knee flexed to 90; keep shoulders down on tableHip flexor stretchBracing: draw in belly button, abs tight, knees bent, flatten backProne, extend hip and raise opposite arm – 10 oscillationsSide step with a band (don’t let feet touch)Bridging: supine, knees bent, close to butt, toes up, belly tight (brace); clench and lift, push through butt;Should have butt, knees, shoulder in a straight lineClamshellsSidelying straight leg raiseSL balance (brace 1st and do a mini squat)Thoracic Oscillations 10 for 10 seconds7/8/13The glute medius seems to be weak on everyone. It is hard to get patients to do the exercises without cheating. I have had to work really hard on how I deliver my cues. Here is what I have come up with:Connect a line from the greater trochanter to PSIS (imagine it), keep stomach tight (exaggerate), back straight, sweep leg back and up and maintain correct posture of the rest of the body. Try not to hold on.7/9/13Bryan is a great role model. I am learning so much about how I want to be and what type of health professional I envision myself. He is so motivated and well-learned that it makes me consider going to graduate school for physical therapy. I was very excited today when he told me I reason like a physical therapist. I felt very accomplished. It feels good to be recognized when I do something on my own based on what I have learned. He is inspires me to be a better student!7/10/13We finally got our shirts in! They are for the patients once they successfully complete rehab and are released. We are also getting ready to go and recruit individuals to come to AWP and the Parkview Sports medicine facility. This upcoming Thursday we are going to Parkview field for the Tincaps baseball game and work a booth. Our goal is to get full sheets of new sign ups. 7/16/13I am a firm believer in ASTYM! Bryan used it on me for breaking up tissues and such during my knee rehabilitation. It seems to work better than Graston or Sastm in my opinion. This is just a clear plastic tool that can get to tissues that regular massaging cannot. ?Astym regenerates healthy soft tissues like muscles and tendons, and removes unwanted scar tissue that may be causing pain or movement restrictions. Everyone calls it “scraping”. After about 2 or 3 times of this patients really notice results. I talked to Bryan and he said I don’t have to be certified to use it, but I will have to research it more. 7/17/13We are working on finishing our home exercise program for Bryan. It is really difficult to capture the essence of a movement in a picture. I know that this will help him out a lot so I am very glad we are doing this for him. Plus, it’s a way for us to leave our mark. 7/18/13Yesterday, a female patient came in that had been rehabbing for shin splints. She had finally just returned to play, but was to be limited in going full out. She reported that she hurt herself in the game after planting to kick. Her pain was over her knee when she squatted down. She had torn her ACL before, but Bryan seemed to think it initially looked like a patellar tracking issue and didn’t want to assume the worst. Based off of my own experience, I had her try and stand on that leg completely straightened. She said it felt like it was giving out, and this is exactly how I felt both times before my ACL tear was confirmed. Yesterday in my mind, I was suspecting another ACL tear. Although I am bummed for her, I am excited to know that I was correct in my judgment as we found out she re-tore it. 7/22/13Bryan does not seem to do a ton of mobilizations as I have noticed. He really leans initially toward stretching and Astym. Today he showed us how patients can perform hip self-mobilizations. This will be included in our home exercise program. You simply prop the lower leg up on a table with the rest of the body in a standing position. Then you perform your own oscillations by pushing inferiorly with both hands on the thigh. Bryan also does two other mobilizations: the sacral and anterior-posterior spine mobilization. The sacral mobilization I had to perform for him on a high school female basketball player with discomfort sitting and on with her tailbone. It is a very intense procedure, but it yielded amazing results. The other one I have never mentioned is the latter of the two in which he digs into the mid torso to reach and touch the spine. He pushes it posteriorly. He does this a lot for patients with spondy issues7/23/13I absolutely love working with the vertamax. It is so easy to get sport specific, but they’re very expensive. This is my first time working with one, but it challenges athletes at the level they need. Looking back, I have worked most closely with two different rehabilitation patients on this:Female semi-professional basketball player with a knee injury: she did squats and jump squats. We could add a ball toss for the jump squat or she did mini jumps to resemble a rebound. We did not incorporate fakes and moves, but that could have easily been doneFemale collegiate volleyball player with a fibular stress fracture: she also did squats and squat jumps but we would add a block move at the top. She also did mini jumps but did tips or sets. 7/24/23Today I self-diagnosed and treated myself. I believe I have the potential to develop carpal tunnel. Bryan concurred with my reasoning after checking. It was fun to get to work on myself, and I actually felt so much better. We did some scraping, stretches, and cold-tubbed it. I love it here. 7/25/13This has been an amazing learning experience. Bryan ordered us food today and we had a celebration. I am very sad to leave, and I really hope to stop in when I am home and observe some more. Bryan and I will always be in touch, and I am so grateful for all his guidance. It is crazy to think that I met him through my injuries which were devastating to me at the time. Looking back it is so easy to see that that was just part of the plan to lead me to such a mentor. I will be able to apply so many skills when I return back to campus this fall. Parkview Sports MedicineAthletic Rehabiliation InternsSummer 2013809625232410Left: Bree Fuller, Trine University. Center: Mandy Toney, Manchester College. Right: Morgan Uhen, Indiana University.41814751762125 ................
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