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Course Submitted: PTH 646
Semester: Spring 2023
Date: April 23, 2023

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 PTH 646 Therapeutic Interventions I
Clinical Application Worksheet-KNEE, FOOT & ANKLE

Instructions: See Clinical App Worksheet Instructions.

16-year-old female presenting with signs and symptoms of patellofemoral syndrome (PFS) which began insidiously
about 2 months ago. Anterior/medial knee pain is rated a 0-5/10 at its worst with squatting, descending stairs,
prolonged sitting and sprinting at soccer practice.

1. Weakness/Poor proximal hip stability

Protection Phase/Rationale Minimum protection & maximum intensity phase. The timeline of this injury places it in the chronic state of
healing, and this patient’s pain is rated as no more than a 5/10 which means their pain level is no more than
moderate.

Intervention Glute bridge with red band around distal thigh

Brief Rationale/Intent This exercise will help strengthen the hip abductors & external rotators of the hip, which will reinforce a
more stable hip. By strengthening up the active stabilizers of the hip, this patient will have increased
proximal hip stability. These exercises are working to increase sarcomeres in parallel with each other &
therefore strength. We want these muscles to be able to work in endurance settings, as they are constantly
used during walking and maintaining a level pelvis in gait.
Mode/Dosage Endurance/strength exercise
60% intensity, 30 reps, 4 sets, 1x/day, 7x/wk
Reference Santos TR, Oliveira BA, Ocarino JM, Holt KG, Fonseca ST. Effectiveness of hip muscle strengthening in
patellofemoral pain syndrome patients: a systematic review. Braz J Phys Ther. 2015;19(3):167-176.
doi:10.1590/bjpt-rbf.2014.0089
Photo/Images

2. Knee extension/quadriceps weakness (HHD testing: Strength 73% of the uninvolved)

Intervention Open Kinetic Chain Resistance Exercise (Limited ROM: 90º to 45º flexion)
Brief Rationale/Intent Addressing muscular strength deficits in the quadriceps has been shown to improve outcomes in
patellofemoral syndrome.

A primary concern while strengthening quadricep musculature in the presence of patellofemoral pain is
reducing compressive stress in the patellofemoral joint. This requirement is significant enough that range of
motion for the prescribed exercise may be limited to angles with reduced stress across the patellofemoral
joint. In open kinetic chain exercise from a seated position, this range runs from 90º of flexion to 45º of
flexion. If pain is provoked before 45º of flexion, then the range of motion may be further restricted.

Replacing exercise intensity with volume or removing/reducing the concentric portion of the movement may
further reduce the stress placed across the affected structure. Reducing the concentric portion can be done
through the attachment of a strap to the machinery and assisting with the upper extremities. Recent research
indicates that muscular strength can be significantly increased by training close to failure at as low as 30%
of 1RM, although the patient may miss benefits through tendon development or neural adaptations. The
patient should be monitored for provocation of symptoms and instructed on these exercise modifications for
any home exercise programs.
Mode/Dosage Seated Single Leg Extensions
• 2 sets x10 reps with light resistance. Assess for provocation of symptoms and adjust ROM or
remove concentric load as needed.
• Once patient is warmed up and safe ROM is determined, build across 3 sets x30 reps, aiming for
failure on the last set (this will approximate 50% 1RM)
• Repeat 3x/week for 2 weeks
• Reassess pain-free ROM, increase ROM if possible, decrease volume, increase intensity

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 Reference Harvie D, O’Leary T, Kumar S. A systematic review of randomized controlled trials on exercise parameters
in the treatment of patellofemoral pain: what works? J Multidiscip Healthc. 2011;4:383-392.
doi:10.2147/JMDH.S24595

Sato S, Yoshida R, Murakoshi F, et al. Comparison between concentric-only, eccentric-only, and

concentric–eccentric resistance training of the elbow flexors for their effects on muscle strength and
hypertrophy. Eur J Appl Physiol. 2022;122(12):2607-2614. doi:10.1007/s00421-022-05035-w

Lacio M, Vieira JG, Trybulski R, et al. Effects of resistance training performed with different loads in
untrained and trained male adult individuals on maximal strength and muscle hypertrophy: A systematic
review. International Journal of Environmental Research and Public Health. 2021;18(21):11237.
doi:10.3390/ijerph182111237

Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports
Traumatol Arthrosc. 2014;22(10):2264-2274. doi:10.1007/s00167-013-2759-6
Photo/Images

71-year-old, 5 weeks s/p L total knee arthroplasty (TKA). Pain is 0-3/10 at worst and patient is ambulating with a
straight cane with decreased L knee flexion and excessive L pelvic elevation during swing phase. PMH is remarkable
for hypertension (HTN) and GERD.

1. Significant limitations identified in knee flexion mobility

Protection Phase/Rationale Maximum protection & minimum intensity phase. The reason this patient is in this phase is due to his age as
well as his PMH being remarkable, as these are two factors that can slow the healing process. Another
reason he is in this phase is due to only being 5 weeks post-op, which is still early within the stages of
recovery from a TKA.

Intervention Sitting in chair pulling L leg into flexion on the ground

Brief Rationale/Intent This is a low intensity stretch that will allow the patient to choose how far to pull themselves into it before
they feel the muscle pull. It is also in a position that an older individual would more easily be able to get
into, rather than being supine with their legs up on a wall. The stretch will promote extensibility & lengthen
the quadriceps muscles that may be adaptively shortened by increasing the sarcomeres in series.
Mode/Dosage Flexibility/extensibility
30 sec hold, 3 sets, 4x/day, 7x/wk
Reference Oka T, Wada O, Asai T, Maruno H, Mizuno K. Importance of knee flexion range of motion during the acute
phase after total knee arthroplasty. Phys Ther Res. 2020;23(2):143-148. Published 2020 Aug 5.
doi:10.1298/ptr.E9996
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2. Significant quadriceps neuromuscular inhibition and weakness
Intervention Neuromuscular Re-education with combined NMES and voluntary contraction of affected quadriceps
Brief Rationale/Intent NMES allows strengthening of the affected musculature despite existing neuromuscular shortfalls. In a
population with intact neuromuscular function, resistance exercise alone would allow the patient to develop
the relevant musculature. However, a patient with neuromuscular inhibition may be unable to develop the
force necessary to trigger muscle protein synthesis. The additional stimulation provided by NMES may
produce enough mechanical tension to drive increases in muscle size and consequently strength in the
recruited motor units. We should measure a maximal voluntary contraction (MVC) with a hand
dynamometer and then match at least 50% of that MVC with the amplitude of the dosed stimulation.

Because NMES directly stimulates lower motor neurons, it often bypasses Henneman’s Size Principle and
recruits Type II fibers before the smaller Type I fibers. This will be particularly problematic in this
population and problem set, where the patient will need to develop precise control of Type I fibers for gait,
posture, and balance. To solve this shortfall, we will instruct the patient to volitionally contract the large
muscle being stimulated. This will induce mechanical tension in all the relevant motor units, leading to less
inequality of improvement in strength and size.

Because tendon and bone integrity may not be able to resist quick impulses in this population, we will use a
generous ramp up time. We also may use a gentler duty cycle to avoid excessive fatigue in a patient who is
unlikely to be familiar with strenuous exercise. Finally, we will keep the volume relatively low for the first
week to mitigate DOMS.
Mode/Dosage Burst-Modulated Alternating (Russian) NMES
Knee Extension from a Seated Position
Pulse Duration: 300 milliseconds
Frequency: 50 HZ
Amplitude: 50% MVC
Ramp: 5 second up, 2 second down
Duty Cycle: 10:50
• 2 sets x10 reps, 2 minutes of active recovery (i.e. gentle leg swings) between sets
• Repeat 3x/week for 1 week
• 3 sets x15 reps, increase amplitude to 70% MVC, 3 minutes of active recovery between sets
• Repeat 3x/week for 1 week
• 3 sets x18 reps, keep amplitude at 70% MVC, 3 minutes of active recovery between sets
• Tall glasses of cold milk. Big plates of scrambled eggs and potatoes. 9 hours of sleep.
Reference Dewansingh P, Melse-Boonstra A, Krijnen WP, van der Schans CP, Jager-Wittenaar H, van den Heuvel
EGHM. Supplemental protein from dairy products increases body weight and vitamin D improves physical
performance in older adults: a systematic review and meta-analysis. Nutrition Research. 2018;49:1-22.
doi:10.1016/j.nutres.2017.08.004

Manske RC, Reiman MP. Chapter 5 - Muscle Weakness. In: Cameron MH, Monroe LG, eds. Physical
Rehabilitation. W.B. Saunders; 2007:64-86. doi:10.1016/B978-072160361-2.50008-9

Klika AK, Yakubek G, Piuzzi N, Calabrese G, Barsoum WK, Higuera CA. Neuromuscular Electrical
stimulation use after total knee arthroplasty improves early return to function: A randomized trial. J Knee
Surg. 2022;35(1):104-111. doi:10.1055/s-0040-1713420
3.
Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Early neuromuscular electrical
stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled
trial. Phys Ther. 2012;92(2):210-226. doi:10.2522/ptj.20110124
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3. Diminished L lower extremity proprioception
Intervention Single leg stance on firm surface with eyes open and light perturbations
Brief Rationale/Intent This is a safe way to start initiating proprioception for ankle strategy, which is your first reactive balance
strategy to kick in and is most used. Since this patient is still in the acute phases of recovery, we want to be
conscious of how long they can weight bear on the injured leg without pain or compensation, so starting out
in single leg stance on a firm surface is a better option than introducing an uneven surface. This stimulates
the mechanoreceptors at both the ankle as well as the knee, working on their anticipatory control since their
eyes will be open.
Mode/Dosage 30 sec perturbations, 3 sets, 1x/day, 3x/wk
Reference Piva SR, Gil AB, Almeida GJ, DiGioia AM 3rd, Levison TJ, Fitzgerald GK. A balance exercise program
appears to improve function for patients with total knee arthroplasty: a randomized clinical trial. Phys Ther.
2010;90(6):880-894. doi:10.2522/ptj.20090150
Photo/Images

46-year-old with a lateral ankle sprain that occurred during a pick-up basketball game 6 days ago. Radiographs were
(-). Patient is ambulating with a mildly antalgic gait pattern and is not using an assistive device. Pain rated a 3-7/10 over
the lateral ankle.

1. Ankle evertor (FL/FB) neuromuscular inhibition and weakness

Protection Phase/Rationale Maximum protection & minimum intensity. Negative radiographs indicate a lack of bone injury. Sprain
diagnosis indicates compromise of the passive stabilizers of the ankle. Ligamentous injuries must first be
protected then compensated for by developing active systems. Therapeutic interventions should challenge
these active systems without exacerbating the ligamentous injuries.

Intervention Open Kinetic Chain Exercise of Contralateral Limb in Single Leg Stance
Brief Rationale/Intent The diagnosis of neuromuscular inhibition indicates that not only is the specified musculature weak, it is
ineffective at a critical role of contributing to balance along the mediolateral axis. Without reintegrating
proprioception at the affected joint into the motor patterns associated with balance, gait, and posture, the
patient is at high risk of fall and/or reinjury especially without an assistive device in this early phase.

This risk of fall and/or reinjury is also present during therapy, but by using safety devices, such as parallel
bars, we can challenge the affected musculature in single leg stances. This will allow integration of
proprioception at the joint with compensatory motor patterns and strengthen this vital musculature to
accelerate recovery and mitigate risk. If the patient is unable to maintain their balance and posture,

In single leg stance, resisted abduction of the opposite leg requires eversion of the supporting leg to produce
lateral force/medial ground reaction forces and maintain balance. By oscillating the opposite leg between
adduction and abduction we can simulate the perturbations associated with athletic movements and reteach
the compensatory movements at the foot and ankle. Slower oscillations will allow greater development and
duration of mechanical tension and produce greater gains in muscular size and strength.

Although patients with chronic ankle instability typically manifest the condition in a single limb following
an acute injury, it is possible that bilateral deficits are present, and the injured limb simply happened to be
first in line. We will administer the intervention to the patient bilaterally. In the best case scenario, this will
be preventative for an injury on the unaffected limb. In the worst case scenario, we keep the athlete from
getting bored during his rest periods.
Mode/Dosage While standing on affected foot between the parallel bars
• 10 slow large amplitude abduction/adduction oscillations with unaffected limb. Observe for
deficits in balance.

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 • 10 rapid small amplitude abduction/adduction oscillations with unaffected limb. Observe for
deficits in balance.
Adding a looped band around the unaffected limb resisting adduction
• 10 rapid small amplitude adduction/abduction oscillations with unaffected limb. Observe for
deficits in balance.
• 3 sets x30 rapid small amplitude adduction/abduction oscillations. Alternate between unaffected
and affected limb.
• 2 sets x15 slow medium amplitude adduction/abduction oscillations. Alternate between
unaffected and affected limb.
Reference Hertel J, Corbett RO. An Updated Model of Chronic Ankle Instability. Journal of Athletic Training.
2019;54(6):572-588. doi:10.4085/1062-6050-344-18

Al-Mohrej OA, Al-Kenani NS. Chronic ankle instability: Current perspectives. Avicenna J Med.
2016;6(4):103-108. doi:10.4103/2231-0770.191446

Luan L, Adams R, Witchalls J, Ganderton C, Han J. Does Strength Training for Chronic Ankle Instability
Improve Balance and Patient-Reported Outcomes and by Clinically Detectable Amounts? A Systematic
Review and Meta-Analysis. Physical Therapy. 2021;101(7):pzab046. doi:10.1093/ptj/pzab046

Wang H, Yu H, Kim YH, Kan W. Comparison of the Effect of Resistance and Balance Training on
Isokinetic Eversion Strength, Dynamic Balance, Hop Test, and Ankle Score in Ankle Sprain. Life.
2021;11(4):307. doi:10.3390/life11040307
Photo/Images

2. Gastrocnemius mm adaptive shortening

Intervention Long sitting with belt around forefoot pulling into dorsiflexion
Brief Rationale/Intent By having the knee extended & dorsiflexing the foot, the gastrocnemius is being maximally elongated. Due
to the acuteness of the injury, you want to prevent adaptive muscle shortening but also don’t want to place
all weight on the foot quite yet, so performing this stretch allows the patient to control how much of a stretch
they will get. They will be instructed to pull the belt back until a stretch is felt in their calf, but it shouldn’t
be increasing their pain in their ankle more than a 3/10.
Mode/Dosage Flexibility/extensibility
30 sec hold, 3 sets, 4x/day, 7x/wk
Reference Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010;29(1):157-167.
doi:10.1016/j.csm.2009.09.006
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A 51-year-old with the insidious onset of plantar foot/calcaneal region pain. His/her primary care physician diagnosed
plantar fasciitis. Patient complains of brief, sharp pain “on bottom of foot near heel” when getting out of bed in the
morning and the 1st few steps after prolonged sitting at his desk at work.

1. Plantar fascia fibrosis and adaptive shortening

Protection Phase/Rationale Minimum protection & maximum intensity. Plantar Fasciitis is a degenerative disease, so no inflammation
is present by definition. The degenerative processes can either be reversed or compensated through
therapeutic interventions. In this phase, increasing the extensibility of the plantar fascia in terms of length
and structural robustness is secondary to protection.

Intervention High Load Brief Stretch combined with Soft Tissue Massage
Brief Rationale/Intent Plantar fasciitis can be reliably treated with therapies designed to control pain and develop more robust
material qualities.

Consistent high load brief stretching can have both pain-relieving properties and lengthen the connective
tissue of the plantar fascia. Soft tissue massage of fibrotic tissue may improve the orientation of the
structural proteins, improving their ability to bear longitudinal tension or compression. The combination of
these adaptations represents a reversal of the degenerative processes contributing to plantar fasciitis.
Mode/Dosage Repeat 2x on each side every morning immediately upon waking
• 2 sets x 45 seconds triceps surae strap stretch
• 2 sets x 45 seconds plantar fascia stretch
• 2 sets x 45 seconds soft tissue mobilization with round surface
Reference Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel pain. The Foot. 2018;34:11-16.
doi:10.1016/j.foot.2017.08.001

Rompe J, Cacchio A, Weil L, et al. Plantar Fascia-Specific Stretching Versus Radial Shock-Wave Therapy
as Initial Treatment of Plantar Fasciopathy. The Journal of bone and joint surgery American volume.
2010;92:2514-2522. doi:10.2106/JBJS.I.01651

Siriphorn A, Eksakulkla S. Calf stretching and plantar fascia-specific stretching for plantar fasciitis: A
systematic review and meta-analysis. Journal of Bodywork and Movement Therapies. 2020;24(4):222-232.
doi:10.1016/j.jbmt.2020.06.013
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2. Improve dynamic longitudinal medial arch stability
Intervention Forefoot slides on a towel with a 5lb weight
Brief Rationale/Intent This will help strengthen tibialis posterior, which is an active stabilizer of the medial longitudinal arch that
helps in elevating the arch. By strengthening the active stabilizers of the medial longitudinal arch, it places
less stress on the passive stabilizers (such as the plantar fascia) to maintain arch stability.
Mode/Dosage Resistive strengthening exercise
80%, 10 reps, 3 sets, 2x/day, 3x/wk
Reference Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical
practice. J Athl Train. 2004;39(1):77-82.
Photo/Images