Jamie Faison, a certified athletic trainer at the UCSF Sports Medicine Center for Young Athletes, discusses how the growing bodies and common injuries of sports-playing kids call for specialized, verified techniques in physical evaluation and rehab. He explains a common misconception about flexibility and youth, offers tips on rebuilding strength gradually, and describes specific exercises and tools for safe transitions out of that oft-prescribed device, the walking boot
and today we're gonna be talking about um progressing young athletes out of boot. Um One of the things that we work on a lot here um in my clinic I work at UCSF Benioff Children's Hospital at the Sports medicine Center for young athletes. And I work in the walnut Creek clinic again my name is Jamie, I'm a physical therapist assistant, a certified athletic trainer and a certified strength and conditioning specialist. And I work primarily in uh the walnut Creek Center. Today we're gonna work on describing what the Sports medicine Center for young athletes is. Review, review some physical therapy referrals, discuss therapeutic exercise progressions for out of the boot and outline basic exercises for eventual return to run and sport. Um This is gonna be a slide at the beginning and the end of the lecture. If you want to refer, if a patient wants to be referred to our center they can call 1877 you see child. We also have our outpatient facts numbers for Oakland and san Francisco. Um So if you want to refer a patient to our center here uh the sports medicine Center for young athletes um feel free to refer them over. And uh we'd love to see uh as many of your young athletes as we can. So like I said before we I work at the Sports medicine Center for young athletes. Um We actually have three clinics, we have one in Oakland, one in SAn Ramon and one in walnut Creek. Um The one in Oakland is located right behind the hospital. We have and that's where we started and we've branched out since then uh to to serve the East Bay community and the young athletes that work out in our area. Um The sports medicine Center for young athletes is built around comprehensive rehabilitation of sports injuries, physical therapy, sports training, injury risk risk assessment and injury prevention clinics. And we work specifically with pediatrics. Um so our main patient base is we will see kids, young people from three years old all the way up to about 25. So even in that post called the into that college area, but our main the lions serve our patients are 8 to 18 years old, young ambulatory young people. Um young people who have a orthopedic condition um, and um want to get back to being active again. Um, So we're the largest pediatric sports medicine facility in northern California. And our objective objective is to first and foremost to facilitate a child's quick and safe return to the enjoyment of sports through ongoing education and training. So what is physical therapy? We see a lot of referrals for physical therapy, but what actually is physical therapy in a nutshell. We help restore motion. So if I'm working with somebody who just had a knee surgery, maybe their knees feeling stiff, it's feeling sore is feeling a key. I'm gonna try and work with that young person on developing maybe doing massage, may be getting them on the stationary bike, getting it moving better if they're a swimmer and they have multidirectional shoulder instability, their shoulder feels like it's going to pop out all the time. I'm going to help restore normal range of motion by maybe doing more exercise, strengthening the rotator, cuff the scapular stabilizers, things like that. Um When you look at this is an older slide, but when you look at the rate of non fatal unintentional sports and recreation related injuries, we see a large spike between the ages of eight and 18. That's why we created our center to work with those young people because we we feel fundamentally that the young growing athlete is significantly different than the skeletal immature athlete that we would see if we're working with adults. Kids are not just little adults. Kids are physiologically different than adults and we created our center to service their needs. When we look at the growing athletic body, um we see a large spike in height gain and um uh peak high velocity for girls. It's a little bit younger than boys. But we see that and that's kind of what we specialize in is working with the the young athletic body as it changes and as they mature. Um This is one of the things I teach my students of course, we have to be mindful and aware of the growth plate. Um, a lot of the injuries that we're seeing are injuries at the growth plate and we need to be mindful and cognizant of the growth plate as we're developing a rehabilitation approach for treating those young athletes. Um When we're working with one of the the unique things about working with young athletes is when they're in the peak of that growth um growth curve. Um they're going to be tight. These young athletes are going to be um less flexible and it's not necessarily a indication on them being lazy. A lot of the time when I talk to football basketball coaches, they'll say um you know, these kids are just lazy, they're so tight because they never do their stretches well, part of the reason why they're not, they're inflexible is because the young growing athletic body, your bones are changing and your muscles need to accommodate a change in bony growth with muscular length. So muscles of especially the lower body, the quadriceps, the hamstrings, the gas rock, the hip muscles are going to be um they're going to be more inflexible due to the the the change in bone growth that's happening for that 10 to 17 year old young athlete, the limitations of that inflexibility of those muscle tissues will be imposed on the bone and as the bone is growing, that bony growth area is going to be soft and it's going to be um it's going where those areas where the bone is growing. We're going to see specific injuries at those bony growth sites. Things like also Osgood slaughters Severs disease, sending larsen Johansson um Avulsion fractures. These are the things that I'm seeing on a daily basis. Um, and the good news is young people are very adoptable and they can change their inflexibility patterns with a directed program and that's what I do on a daily basis. Okay. Getting into my main lecture here. Um, one of the things we see a lot is when we see a young athlete athlete with a really bad ankle spring or we see a young athlete who's had a ankle fracture, Even ankle surgery is eventually, the note will say, there are, the doctor's instructions, will say progress out of boot or win out of boot. So, um, you know that idea that like you go right from a boot to a shoe and then you just learn how to walk normally. Um, some kids can pick that up pretty quickly, I'm sure um, there's a bunch of kids who go to doctor's offices and they'll start in a boot and they'll just, you know, hey, in two weeks, take off your boots and you're going to be completely fine. We like to use a little bit more of a structured approach to how we get young people out of the boot, especially when the doctor's instructions are up to uh, physical therapy to progress them out of the boot. We want to make sure that our young people are safe and that they're healthy and that they're progressing upward and outward out of a boot or um some kind of split and make sure that it's safe and that we're we have a progression that is sound to make sure that they don't have a re injury or cause some kind of compensation that could cause further injury down the line. Um One of the things, well the young person is in a boot because we're gonna check the range of motion of course. Um The main range of motion that I'm looking for for young people as they're when they're in a boot is dorsal flexion typically. Um And this is generally there's difference um there's different range of motion requirements depending on different age ranges and different activity levels. But typically with the knee straight. I like to get young people's ankle Dorsey flexion to be 10 to 12 degrees uh In a knee extended position and then between 15 and 20 degrees. With the knee flex you can do this measure in um non weight bearing or in a weight bearing position. We do what's called the wall test sometimes but instead of trying to measure that awkward angle that's really down towards the floor will scoot the foot progressively back and see can you tap with your heel down? Can you tap your need to the wall and that will give us an indication of what your ankle doors reflection like in a closed chain position. So um if someone is long sitting and we're looking at their ankle range of motion. we want them to be able to move their ankle in an open chain position. Uh Dorsey flexion, plantar flexion inversion E version. But also it may be important to measure that in a closed chain position. So we are always mindful and cognizant of um closed chain and open chain. But typically I want to get my young athletes to have a knee extended ankle, dorsal flexion 10 degrees and knee flexed, Ankle dorsal flexion measure of 15°. otherwise I see compensation later on down the line if we don't address those basic range of motion benchmarks um when we see someone who's in an ankle boot, especially if they're non weight bearing or they're in a boot. Um What we'll do is we'll initially we'll start um doing some strengthening in that open chain position. So we're not going to be doing loaded exercises until we get the description back from or the instruction back from the doctor to progress, weight bearing tolerance or progress amount of the boot. So some of the things we'll work on is the top kind of image there is ankle pumps, long sitting, just ankle Dorsey flexion, plantar flexion. Um The ankle alphabet is kind of old school but we do that one still as well if someone's in the boot and there certainly if they're non weight bearing um We'll have them take off the boot and start you initiate um writing the alphabet with your big toe in the air just to get those all those range of motion um requirements in that open chain position. It also gives the kid and the parents something to work on because sometimes being in the boot, it means you're not able to do anything. We want to always teach young peop that exercises are good for you, exercise is healthy and that exercise is um what part of physical therapy is we're going to help teach you how to exercise correctly and build exercise into your day. Um four way ankle band here in the bottom, we have ankle plantar flexion with the thorough band, which is really important exercise in a open chain position. Um if they're not cleared to do weight bearing, we can start initiating a little bit of ankle Dorsey flexion. Um and then of course you can do straight leg raise and side lake raise things like that. Um you know, open chain position where your non weight bearing, but you're kind of working the lake more generally. And those are all non weight bearing, open kinetic chain exercises. So of course, then the next kind of goal for the next kind of um thing we have to progress towards is close chain. And this is when we start thinking about, okay, how are we going to get people people out of the boot? So these are what I call my kitchen sink exercises. Typically I'll have young people start when we start transitioning out of the boot. First thing they have to do is bring two shoes in because if you're wearing a boot, that means oftentimes you're only wearing one shoe when you are when you're arriving in our clinic, whether you're on crutches or you're not. Um So we want kids to bring to shoes, make sure they get comfortable wearing shoes again. My top three exercises that I do all the time. I give these out all the time. And actually when I have when I um when I work with residents, students or when I talk with pediatricians, these out of boot exercises I give all the time. So standing at the kitchen sink or the bath, the kitchen counter or the bathroom sink. I have kids so they have a nice little handhold there. Hi March is a little tiny heel toe raise and then standing late standing side lake lift. Uh These three exercises I do all the time. Um I give them out as part of an initial salvo of exercises that we're going to build up from. Of course this is very basic exercises, but often times like this gentleman, the picture on the bottom right, he's standing by a chair and oftentimes chairs will move around. So I don't really like my kids, the kids that I'm treating on a daily basis using a chair and certainly not a rolling chair for their exercises. I like something sturdy. Um the kitchen counter isn't going to move on you, the bathroom, bathroom sink isn't gonna move around on you. And um Uh these are exercises that kids can do at home with no equipment necessary, they can stand up um right when they're done brushing their teeth for the night, stay standing at the bathroom sink and we're gonna do 10 high marches on each side, just like the lady on the, on the bottom left. He'll raise toe raise 10 times each direction and then a standing side leg raise or side leg lift 10 on each side. So we're starting to build that closed kinetic chain ankle strength from the ground up. Um With and they have a nice hand hold. This is something I give out all the time. These are just basic little exercises and it helps bridge like out between take off your boot and just go for a walk. I also get a chance when I'm teaching these exercise to determine. Are the kids confident enough to stand on their injured leg? Are they are they strong enough or do they have major compensation? And at any time I could always regress the exercises back to the table. Um If they are not feeling comfortable with their um with how their ankle is feeling when they're out of the boot. Sometimes I'll get a kid who's standing um at the edge of the table or at the at that we have a little counter in our clinic, stand on the clinic on the at the counter and we initiate high marches and they don't want to do it, They don't want to raise their foot up so that they could very easily bring them back to the table. Maybe we'll do another session or two of the non weight bearing exercises to determine. Are they okay to progress onward and upward? So these out of boot exercises are very basic. But this is something that I give out all the time, especially when the doctor's prescription where the doctor's instructions are progress athletes or pro progress patient out of boot or progress out of boot. P. R. N. Or D. C. Boot in two weeks something like that. And of course then the next thing we have to think about so we get the young person out of the boot we have to look at walking so we're then transitioning off of crutches. Um This is just a general slide about uh stance phase and swing phase of gait but we need to look at each individual aspect of swing phase of gait, stance phase of gait I should say. Um And of course and mid stance of gate. We're standing in that high march position anyway so I'm able to assess um stance, phase stability and then swing phase toe clearance to make sure that the young people that I work with are getting back walking as safely as possible. All right and then the next progression. So we're getting people walking. We're getting them doing exercises in the clinic and then the next phase for almost all my patients is okay when can I start running? So running um is challenging to teach for young people. What we like to do in my clinic is break the running uh motion down into its component parts. So we're working on how do we differentiate, how do we build up and make sure that people are safe to return to run? Um The exercise that we look at in specific is um single leg mini squad being able to stand on your injured side and do um single leg mini squat single leg calf raise and then we do a small hop and stick. Um That can help us um get people back running safely. Um And utilizing a specific measurable progressive exercise program can help get these young athletes back running safely. Which of course is the key is getting young athletes running safely. Um In our clinic we also use an alter G. Treadmill. An alter G. Treadmill is an anti gravity treadmill. Um Where you put on these fancy shorts and you can get in the treadmill and you can go for a jog um at less than your body weight. So getting young athletes uh to walk and eventually run and at less than their body weight a gives us a chance to assess what their pain is with weight bearing activities or impact activities. It can also help us decrease or catch any compensation or limping that's going on when they're running. And um I can look in those in those. This is actually one of the clinicians that I work with talking with one of her former patients as she's running in the alter G. Treadmill. You can look in those glass windows or those plastic windows on the side and look at the specific running motion and make sure that they're not doing anything that's um any any compensation or olympic. I can also coach the athlete on stride length cadence and all those things in a good safe supported manner. Not just say hey your ankle feels good. Go and pound pavement outside. We want to be as specific as possible And make sure that we're getting kids back to doing the things that they want to do safely. Um So we'll typically start the alter G. Treadmill. Um After of course we get clearance from the doctor. Um We're gonna start the alter G. Treadmill training at 50% body weight. And depending on the patient tolerance and the injury history will typically go up 5% body weight a week until we get up to 80%. And in addition to increasing the body weight percentage when we're running we can also progress speed and uh Uh speed as a function of intensity and duration of running. Maybe we'll start with a 1-1 where you walk for a minute dog for a minute that 50% well the next session we will have them come in and we'll do 50 5% walk for a minute and jog for two minutes. And we can be very specific in our intervention for how we build young athletes back to doing the things that they want to do safely and hopefully pain free. Typically if a young athlete can run or or they can jog in the alter G. At 80% body weight for 10 minutes, then we will typically clear them to start running on their own. And of course I'll be coaching them the entire way in addition to motion analysis or to the alter g treadmill. We also provide motion analysis and run retraining at our clinic. We do video running analysis where we have a young athlete on the treadmill and we'll video we'll do video um to view video analysis and we will actually track how they look um joint specific angle starting at the foot, in the ankle, knee, hip pelvis, low back, shoulder, head and neck. And we also have um a um force plate and jump retraining program where we can do video and I use a kinetic and force plate data to make sure that young athletes of course are getting back safely to doing the things that they want to do. Uh This is one of the things that we do in at our one Creek clinic. All right. Uh So we talked about this earlier. We have we want uh as many of your young people as possible um to come on out to our clinic here in walnut Creek. We have um you know, we treat we treat kids all day long. Each one of us, all of our our patient care in walnut Creek, Oakland san ramon. Each physical therapy session is 45 minutes long and it's one on one with the patients. So we're not doing multiple patients of one's. Each patient gets individualized care for their individualized injury needs. And um we're getting people working with young kids, giving back, doing the things that they want to do in a safe and healthy manner.