How the Principles of Massage and remedial exercise were used successfully for the rehabilitation of a fractured leg – Lee Kalpin RMT
On Saturday, January 31, 2005, I fractured the fibula of my left leg. I wish I could tell my readers that I was doing something exciting and daring, but in fact the accident occurred, as most accidents do, in my own home.
mechanism of injury
Most fractures of the fibula occur as a result of forced inversion or eversion of the ankle and it is usually the lateral maleolus that is broken. In my case the action was very different and the shaft of the fibula was fractured just proximal to the maleolus. The action was extreme flexion of the knee so that my heel was touching the buttock, and forced plantar-flexion of the ankle. I then slid down several steps with my full body weight on the shin.
Fortunately, this was a simple fracture and did not require reduction or pins - just a cast. It was very interesting for me to note that absolutely no information was given at the hospital regarding elevation of the limb, use of hydrotherapy, or exercise. I realized that I was on my own with this injury, and was determined to make a full recovery as quickly as possible.
definitions of disablement
In order to have a good understanding of goals and outcomes in remedial exercise, it is necessary to define some basic terms.
Pathology – the illness or injury that causes the symptoms
Impairment – the symptoms as they affect the body systems; the limitations in movement and/or function that are caused by the pathology
Disability – the changes and limitations to daily life and function that result from the impairments
Handicap – the barriers presented by the client’s environment
protocol for a pre-acute injury
The pre-acute stage is identified as that short time before inflammation begins. Inflammation can be limited by prompt intervention. Massage therapists do not usually have an opportunity to treat immediately after an injury unless they are working with athletes during training and competition.
Immediately after the accident, I hobbled to my bed, elevated my leg, wrapped it in a tensor bandage and applied ice. This strategy limited the inflammation, pain and bruising.
I palpated the painful structures, which were the fibularis longus and soleus, as well as the flexor and extensor muscles of the big toe. I discovered point tenderness on the lateral aspect of the fibula about two inches proximal to the lateral maleolus. Xrays at the emergency department confirmed a fracture of the fibula and a fiberglass cast was applied. The doctor advised that my leg would likely be in a cast for eight weeks. I was provided with crutches and instructed on their use. I was given a prescription for analgesic medication and sent home. I did not fill the prescription since the prompt use of ice had limited the pain. Also, I live alone and did not think I could manage on crutches if my balance was impaired by strong medication.
protocol for an injury in the acute or protection stage
Rest from function
Mobilize joints of unaffected limb. Stretch muscles of unaffected limb
Mobilize joints of affected limb proximal and distal to the injury. Maintain movement to decrease risk of thrombus formation.
application of protocol
The leg was rested from function as no weight-bearing was permitted on the cast.
It is possible to ice a limb in a cast by wrapping the cast in plastic and applying ice packs for extended periods of time. However, this was not necessary as I did not have excessive swelling. I did apply heat packs to the inguinal area to encourage venous and lymphatic return
Compression was not necessary because of the cast
I kept the leg well elevated for many hours per day, and slept with it elevated.
I performed mobility and stretching exercises for the unaffected (right) leg several times a day while lying supine. The unaffected leg takes the full weight of the body when using crutches. Quadriceps and hamstrings are overused when raising and lowering the body from chairs and cars, using only one leg .
I moved the toes of the affected leg frequently. This is necessary to make sure that circulation and nerve supply are normal, and also provides a pumping action to prevent thrombus formation. I also performed mobility and stretching exercises for the knee and hip to keep those joints moving.
I did experience “transitional swelling” in the foot of the left (affected) leg during the time the cast was on. This occurred if the leg was lowered for any length of time. The foot became very swollen and discoloured (purple). When the limb was elevated, the swelling subsided.
impairments were swelling, and lack of ability to weight-bear on the injured leg
disability included difficulty in performing household tasks, lack of ability to bathe or shower independently, inability to drive my car (which is a standard shift), inability to navigate stairs on crutches, difficulty in walking outside with crutches due to icy conditions, inability to shop for food. It was necessary to obtain a wheelchair because performing household tasks while balancing on crutches was just too hazardous.
handicap – the stairs in my house, and my standard car provided barriers to normal functioning. Icy conditions provided an additional handicap.
protocol for an injury in sub-acute or limited motion stage
Elevate if swelling is present.
perform gentle mobility in all ranges except the direction of the injury
perform isometric strength exercises
maintain mobility of the unaffected limb
maintain mobility and strength of the joints proximal and distal to the injury
After two weeks the fiberglass cast was removed, my leg was xrayed again, and I was given a boot cast (or walking cast). The doctor advised that this cast must be worn constantly and removed only to shower, and that I could not weight-bear on the cast.
Homecare application of protocol
I continued to experience transitional swelling, and therefore elevated my leg whenever possible.
Received several massage therapy treatments, including lymph drainage, muscle work on both the affected and unaffected leg, and passive stretching of quads on the affected leg.
I observed that there was some muscle atrophy in gastrocnemius and soleus, as well as the quadriceps muscles in the affected leg. There was a noticeable difference in size between my injured and uninjured leg.
At this time I started to perform isometric exercises with the injured ankle, moving it into plantar-flexion and dorsi-flexion, using the cast as resistance. I also performed knee extensions from a seated position using the weight of the rather heavy boot-cast as resistance to build up the quadriceps muscles.
Flexibility exercises for the unaffected leg were continued.
In spite of doctor’s advice, I did start to weight-bear with the boot cast after about two weeks.
I found that I could not sleep with the boot-cast on. The first night I woke in terrible pain, which seemed to be either ischemic or nerve related, and I had to remove the cast. After that time I removed the boot-cast whenever I was resting and elevated the leg, propped between pillows to limit movement. When speaking to other people who had experienced fractures, they told me that they also removed the boot-cast to sleep. I wonder if orthopedic specialists know this?
Impairment – lack of ability to weight-bear and walk normally
Disability– walking with crutches on stairs or snow continued to be a challenge but became easier as I could weight-bear on the boot-cast. I was able to trade cars with my brother and driving an automatic car increased my mobility and independence.
I was not able to perform massage treatments, but did continue teaching throughout this time, missing only one class session!
protocol for return to function stage
stretches to affected limb to return normal range of motion
strengthening exercises to affected limb
balance (proprioception) exercises when a lower limb is affected
conscious effect to normalize gait when a lower limb is affected
Six weeks from the date of the fracture, my leg was xrayed again and I was advised that the fracture was healed, and that I could discard the boot cast and walk in a shoe with goodsupport. The doctor told me that my injured leg would be weaker and that swelling of the foot would continue for a year. With good remedial exercise, this prognosis is not accurate.
I was given only one exercise to perform; that was a proprioception exercise of standing on one foot and balancing. No muscle testing was performed.
home care application of protocol
Quadriceps had returned to normal size as a result of exercise during the sub-acute stage.
I immediately focused on normal gait, making an effort to “roll-through” from heel to toe when walking and to avoid limping. I found it beneficial to walk barefoot to build muscle strength and balance.
I increased stretching of the ankle to obtain normal range of motion. Walking up and down stairs normally requires good range of motion of the ankle. Within one week I was able to walk stairs properly without the one-step-at-a time “baby-step” motion.
Increased strengthening exercises for gastrocs and soleus with weight-bearing toe-raises.
Balancing on one foot proved to be challenging. We do not realize how many muscles come into play when balancing. It took about one week to achieve balance on the affected leg.
Two weeks after the cast was removed, I reclaimed my car and began using my injured leg to work the clutch. This helped to build strength in the plantar-flexors.
Cycling has been my major exercise activity as it builds all the muscles of the leg, and encourages equal use of both legs, without excessive weight-bearing. I cycle ten kilometers a day, when weather permits.
I performed my first massage therapy treatment on April 1st– two months after the injury and two weeks after cast removal.
Two months after cast removal I accompanied a grade eight trip to Ottawa, where we did a terrific amount of walking, some of it over rough ground in the La Fleche Park caves. This was my test for the recovery of function in my leg, and I was well able to keep up with all the activities. And I had a lot of fun too!
pathology - Post-fracture/ muscle strain injury. Pre-existing osteoarthritis in the metatarsal-phalangeal joint of the big toe was exacerbated, particularly in the right (uninjured) foot. This is a result of taking the entire body weight on the right foot for several weeks. The injury to the muscles, andt he arthritis are more of a challenge than the fracture.
impairment - All ranges of motion of the ankle are normal. Pain is felt on forced plantar-flexion of the ankle when kneeling with the weight of the buttocks on the heel. Some pain in both feet after extensive walking due to arthritis. There is palpable scarring in the plantar fascia and the tendon of the flexor muscles in the affected foot. I perform aggressive self-massage on these areas, including muscle stripping, trigger-point release, and frictions..
disability - There is no functional disability. I am able to perform all tasks and functions without pain. I am working on improving my general conditioning.
The principles of hydrotherapy, remedial exercise and massage are extremely effective in the return to function of a fracture injury. Massage therapists can play an important role in rehabilitation.
I had believed that hospitals and medical staff provided adequate support and advice. My experience taught me that very little support is actually provided. There is a real concern that some clients, particularly those who are older, might never make a complete recovery from their injuries without proper care. There is a real need for massage therapists to provide treatment for clients with fractures by providing massage, in addition to advice on hydrotherapy and remedial exercise. A progressive remedial exercise program which begins in the early stages of healing is crucial to achieving a satisfactory outcome.