Beginning Exercises for the Wrist

In the early stages of a wrist injury, (whether it be a sprain, strain, tendonitis, TFCC injury, or after a cast is removed) therapeutic exercise is essential for a quick and complete recovery.  Targeted exercise can help to maintain/gain range of motion, improve swelling, decrease pain, and improve neuromuscular control (aka the nerve-muscle connection).

If the injury is still in the inflammatory stage (early on, still swollen) be sure to keep these exercises in a pain-free range. (Yup – I bolded this.  It’s a big deal).  If you push too hard to fast you run the risk or re-injury and can lose function and extend the return to sport.

If this is a more chronic (old, nagging) pain or you just came out of a cast, feel free to be a little more aggressive.  In this case getting the range of motion back may involve pushing past some mild discomfort (yep – discomfort, not pain).  The goals are a little different as you’re not trying to help with swelling or maintain range, rather you’re starting from a limitation and building back.

The Exercises:

1.  Wrist circles: With the hand in a relaxed fist, gently roll through the entire range of motion in a clockwise and counter clockwise direction.  The goal is to gain range of motion in all planes without irritation.  Perform 10-20 repetitions in each direction.   
2. Wrist AROM: flexion, extension, ulnar deviation, radial deviation, supination (turning the palm and forearm up), and pronation (turning the palm and forearm down): Gently move through each direction of motion (if you’re unsure of the term, check out the blog post on the “Anatomy of the Wrist.” The key with this exercise is to keep the hand open and relaxed while moving as far in each direction as you can.  Do 10-15 reps each direction.
   

   Ulnar Deviation (left hand)

   

   Radial Deviation (left hand)

   

   Wrist extension (right hand)

   

   Wrist flexion (right hand)

3. Towel (or putty squeeze): Grip a small towel (rolled up) or some rehab putty (play doh works too); squeeze and relax the hand in a motion that allows you to mash and form the putty.  The goal is not to make a distinct shape (sorry artsy folks) but to engage the flexors of the fingers and hand while encouraging the stabilizers of the wrist to work synergistically (together in a beneficial way) to keep the wrist fixed and stable.  Try to perform this for 1-3 minutes at a time with a rest break in between.
4. Finger extensions (with and without a rubber band): Simply stated, this involves opening and closing the fingers.  The goal is to keep them extended (straight) and to challenge the finger and wrist extensors.  Try and keep the wrist neutral throughout.  Do 10-15 reps, 1-2 times.  To increase the difficulty add a rubber band; to increase it further, add two.
5. Wrist stretches (with over pressure): flexion and extension;
   Flexion: With the fingers extended, pull the wrist and hand down (into flexion) until a stretch is felt on the top of the forearm and or wrist (in the extensor muscles).  Hold this for 30-45 seconds.  Be sure to avoid pain.  To increase the intensity, bend the fingers into a relaxed fist. Extension: With the fingers relaxed, grab the palm and pull the wrist and hand up (into extension) until a stretch is felt in the bottom of the forearm/wrist (in the flexor muscles).  Hold this for 30-45 seconds.  Be sure to avoid pain.  To increase the intensity, grab the fingers and pull (they will now be in an extended position thus putting more of a stretch on the flexor muscles).

Progression:

Once these exercises are easy (and pain-free) and your range of motion and flexibility on the affected wrist is equivalent to the other side, it is time to move to some strengthening exercises.  Check out “Intermediate Exercises for the Wrist.” – Coming soon!

Beginning Therapeutic Exercise for Inversion Ankle Sprains

With a grade 1 ankle sprain, you can begin gentle therapeutic exercise even while there is some swelling and pain (in standing/walking) that remain.  These exercises are designed to be very gentle – and it should be noted that they should be pain-free at all times.   All of them are non-weight bearing and designed to reduce swelling, regain motion, and begin re-training proprioception.

Beginning exercises for a grade 1 sprain (while there is still swelling/pain):

Ankle circles: With the leg supported (or elevated if there is still some swelling), make circles with foot at the ankle.  The goal is to make the largest circles possible, but it is essential that you stay within a pain-free range.  As the ankle continues to heal, you can make the circles larger and larger.  Do 15-20 times both clockwise and counter-clockwise.  This can be repeated 2-3 times a day.

Ankle Circles

Ankle plantar flexion/dorsiflexion: this is simply pointing and flexing the foot in a pain-free range.  With the leg supported (or elevated if there is still some swelling), focus on moving the foot without it twisting in or out.  The goal is smooth and controlled motion.  Do 15-20 times, 2-3 times a day.  Again, keep the motion in a pain-free range and progress when able.

Ankle alphabets: With the leg supported (or elevated if there is still some swelling), write the alphabet with the foot by moving at the ankle.  Be sure to keep the leg still and move slowly and in a pain-free range.  Start with 1-2 times through, from A to Z, and do this 2-3 times a day.

Ankle alphabets: draw the alphabet (upper or lowercase doesn’t matter)

Beginning exercises for a grade 1 ankle sprain (after the pain had subsided):

Once you no longer have pain in the ankle with walking and the swelling is beginning to subside, you can progress to some more advanced exercises.  The goal of this phase of rehab is to continue to restore motion, strengthen the affected muscles, and begin re-training proprioception (in closed chain  – aka in weight bearing).

First, begin by doing all of the exercise listed above for 1 set as the “warm-up.”  Then also include the exercises listed below:

Ankle PREs (progressive resistive exercises): Done with the therapy band, these movements strengthen the muscles of the lower leg that help to externally stabilize the ankle.  The key to these exercises is to only move the foot/ankle and keep the lower leg still.  Be sure to have the leg supported.  Do 10-15 reps for 1-2 sets, only once per day.  Choose a band that is mildly to moderately difficult, but not painful or hard.  You can tie the band to anchor it, have a partner help you, or can use the other foot to anchor it.  (see the therapeutic resistance bands link under “rehab modalities for more info on band difficulty/progression)

Ankle PREs (includes all 4 directions – not sure about the eye guard, but it can’t hurt)

Single Leg Stand (SLS):This exercise is designed to retrain balance and proprioception.  Be sure to start with the hands on or near a cabinet for protection in case you lose your balance.   Try and balance on the foot for 30-45 seconds without using your hands/stepping down.  Do this 2-3 times, once a day.  Keep the heel flat (do not rise onto the toe).

SLS

Gastroc & Soleus Stretches: (calf stretching): In an ankle sprain, especially if there was some immobilization, the calf muscles will likely tighten.  It is essential to stretch them out to allow the right amount of dorsiflexion on a landing (so that the anterior ankle structure are not over-stressed and re-injured).  There are two main muscles that attach into the achilles, the gastroc (short for gastrocnemius) and the soleus.

The gastroc stretch is the traditional calf stretch.  Start with the affected leg behind you, toes forward, heel flat.  Then lean forward until a stretch is felt in the upper portion of the calf.  Hold for 30 seconds.  Do 4 repetitions, 1-2 times a day.

Gastroc Stretch (the back leg is straight; the front leg carries the weight.  The stretch should be felt high up in the calf muscle.)

The soleus stretch is similar to the traditional calf stretch, but the back leg is bent. This focuses the stretch on the soleus muscle (which lies deep to the gastroc).  This will likely be felt lower down in the leg (more along the achilles tendon).  Hold for 30 seconds. Do 4 repetitions, 1-2 times a day.

Soleus stretch (notice that the back leg is bent; the weight should be over the front leg)

Once these exercises become easy and your form is consistent (no loss of balance, no pain, and no “shaking” with movement), you can consider progressing to the next block of exercises.  In most cases, it will take about 1-3 weeks to progress through these exercises.  Be sure to take your time and don’t rush – if the ankle is not appropriately retrained, there is a VERY high risk of re-injury.

Remember, a grade 2 sprain is more severe, and should be checked out by a medical professional prior to the initiation of any self-rehabilitation.  That said, once the ankle has healed > 4 weeks, (ligamentous injury takes 4-6 weeks), you can try the grade 1 exercises and progress through as if it were a grade 1 injury.  It is even more important to rehab the grade 2 ankle sprain carefully and fully as there was more ligamentous and nerve injury than in a grade 1 sprain.

(And because I know you need reminding, be sure to ice after these exercises if they make the ankle sore or if any swelling remains.  72 hours is not the “limit” and rather ice should be used any time the healing joint is painful or swollen.)

 

Use of the foam roll for self myofascial release

Often times pain is caused by tight fascia and muscle.  The myofascial junction (the point where the muscle and the fascia meet) is often an area of tenderness and increased tone (resting tightness).  While stretching is important in injury prevention, it alone cannot address this area. In conditions like patellar tendonitis, IT band tendonitis, or with simple delayed onset muscle soreness (DOMS) myofascial release can be essential in eliminating pain.

There are many ways to perform self myofascial release.  In the context of this article, I’ll focus on the use of a foam roll.  This is a relatively mild-moderate tool and may not alleviate small points of tightness in the muscle/fascia.  If you feel that it it not “reaching that spot” you might want to progress to a tennis or lacrosse ball (to be discussed in a later post).  There are different levels of “firmness” available and this is often described as density.  I’d recommend a moderate density and you don’t need to invest in any of the rolls with odd patterns/edges – these are more gimmick than they are based in research.  Keep it simple and you’ll see progress.

Basic foam roll, 6″ in diameter and 36″ long.  Available online from many companies.  Look for a price under $20 before tax/shipping. Most running stores also sell them in shorted lengths if transport is an issue (12-24″ long).

You can roll over any muscle/connective tissue in the body.  The keys to remember for safety are to avoid rolling across joints or areas of skin damage (bruises, open cuts, rashes) as this can cause harm.  Traditionally, you should roll across the length of the muscle, and focus over sore spots.  The duration of the treatment can vary, but about 1-3 minutes is usually sufficient to cause significant relaxation and lengthening in the muscle/fascia.  Try to roll after a good warm-up so that you have enough circulation to the muscles.  It can also be done after a workout to decrease the amount of soreness.  (In other words, just don’t roll when you’re “cold” and have been sitting)

Listed below are the links to YouTube videos that I’ve posted on several muscles in the body.  If you need more of a description, drop me an email and I’d be happy to elaborate!

• Hamstrings: http://www.youtube.com/watch?v=aUC9mVQWDxQ
• Quadriceps: http://www.youtube.com/watch?v=BRMbTr5HX6k
• Latissimus Dorsi: http://www.youtube.com/watch?v=OwtQwDgr_II
• Gluteal/Piriformis: http://www.youtube.com/watch?v=OxkuKMhS_p8
• ITB (illiotibial band): http://www.youtube.com/watch?v=LeEqGuT2ue4

More muscles to come!  For the Gymkana members reading this, I’ve donated 4 foam rolls to the team (located in the study lounge).  Please take care of them and use them often after practice!

Beginning Therapeutic Exercise for the Rotator Cuff

Doorway Stretch:

Standing in a doorway, place your arms on the frame (the shown positions A, B, C all stretch as different portion of the pectorals so try them all). With one leg in front, step through while keeping your head and chest up. You should feel a stretch across your chest and into the front of your arms. Hold for 30 seconds. Perform 3-4 times a day.

Posterior Capsule Stretch:

Grab the back of the arm and pull it across the chest until a stretch is felt in the back of the shoulder. Hold for 30 seconds. Do 3-4 times a day.

Posterior Shoulder Rolls:

Shrug the shoulders up and backward and then relax down and forward.  The goal is a backward circling motion. Do 10-20 times, 1-2 times a day.

Shoulder extension stretch:

Standing, slowly bring the arms back and squeeze the shoulder blades together. You should feel a stretch across the chest and muscle contraction between the shoulder blades (postural strengthening). Hold for 10-15 seconds. Do 5-10 times, 1-2 times a day.

Shoulder PREs: (with therapy resistance bands)

Using the resistance band (choose a color that allows you to complete the full sets with mild-moderate difficulty). Perform 2 sets of 10-15 repetitions in a PAIN-FREE range of motion. Do these 3 times a week (and never before practice – always on off days or after).

External Rotation: Stand facing to the side with the arm across the stomach.  Keeping the elbow still and at your side (think of it as the hinge on a door) pull the band out by twisting the arm out.  Be sure to keep the elbow bent to 90 degrees throughout (so only go as far out as you can without breaking form).  Return the arm to the starting position slowly.

Abduction: Stand facing the side with the band anchored across the body.  With the elbow bent, raise the arm out to the side.  If more of a challenge is needed, perform with the arm straight (this puts greater torque on the rotator cuff). Only go as high as shoulder level.  Return slowly.

Rows (labeled extension): Stand facing the anchor-point of the band.  With the arms bent, pull the hands STRAIGHT back against your sides as you pinch your shoulder blades together.  (Think of sliding your hands across a level table).

Internal Rotation: Stand with the band to your side, elbow bent to 90 degrees.  Pull the arm in to your stomach.  Again, keep the elbow in one place (think of it as the hinge on a door) and rotate the arm around it.  Return slowly to the starting position.

Beginning Therapeutic Exercise for Shin Splints

Strengthening:

So, now that you know the importance of it, how do you strengthen to prevent or treat shin splints?  There are a variety of ways and which you choose will depend on:

1. the severity of your shin splints
2. the intensity of the rebound apparatus (impact activities) you’re involved in and
3. your baseline strength level.

My recommendation is that everyone begin with the exercises listed below (on the attached PDF).  These exercises are dosed for daily use – this means they aren’t designed to strengthen by adding bulk.  Rather the goal is to build endurance and retrain the neuromuscular system (basically make these muscles faster and more efficient).  This is why it’s okay to do them everyday.  That said, do them AFTER you practice or workout – not before.  Since they are designed to fatigue, if you do them before practice/exercise, it’s likely your performance will suffer and you might actually increase your risk of injury!

Introductory Therex (Stage 1):

* Note: the dosage is on the attached PDF – the descriptions below are just to help clarify!

Shin splints – introductory therapeutic exercise

Breakdown of the exercises on the sheet:

(see the section in the “rehab modalities” category for the levels of resistance bands)

Page 1:  PREs (progressive resistive exercises)

These exercises are done with resistance bands.  As mentioned before, the muscles that control the ankle are located along the tibia/fibula in the lower leg and are the same muscles that contribute to shin splints.  At the ankle, there are four directions of movement: dorsiflexion (ankle/foot flexion), plantarflexion (ankle/toe point), inversion (tilting the ankle in), and eversion (tilting the ankle out).

1. Theraband resisted dorsiflexion: Hook the band around the ball of your foot while it is pointed (with the heel free to move – either rest the back of the ankle on a towel roll or on the edge of the table) and slowly pull the toes and foot up to a flexed position.  The key to this is a SLOW motion both in the exercise and the return to the starting position.  This will require a partner to hold the band OR you can tie it to a chair/doorknob and do it yourself.
2. Theraband resisted plantarflexion: The exact opposite of the above exercise.  Start with the foot flexed, loop the band around the ball of your foot and point the toes.  You can hold the band yourself with this one, but again – focus on a slow and controlled motion.
3. Theraband resisted inversion: (this is when you pull the ankle INWARDS).  Cross the other leg on top to provide a fulcrum for the band (or have a friend hold it for you).  Wrap the band around the ball of your foot and then loop the length of the band around the other foot.  Without turning the leg, twist the ankle and foot inwards against resistance.
4. Theraband resisted eversion: This is the exact opposite of the last one (this is where you pull the ankle OUTWARDS). Start seated, with your legs about a foot apart.  Wrap the band around the ball of the foot and anchor it around the other foot so you can pull the ankle out (of have a friend hold it for you).

Page 2:

1. Calf stretch (on the step): Stand on a step and hang one heel off the back.  Keeping the leg straight, drop the heel off the step until a stretch is felt in the back of the calf/heel and perhaps into the foot.  Be sure to keep the stretch gentle and have the other foot firmly on the step – it can also be beneficial to have something to hold onto so you aren’t balancing yourself too (this takes away from the stretch).  The ideal hold time is 30 seconds (it takes 20 seconds for the muscle to even begin to stretch).
   Why stretch? Well, if the calf is tight, the gastroc/soleus (main calf muscles) will put additional stress/strain on the anterior lower leg muscles (by overpowering them during activity) which leads to increased force along the periosteum and the interosseus membrane.  As mentioned in the article on shin splints, this overwhelming of forces is a main cause of the associated pain.
   
2. Single leg balance: This trains isometric contraction (meaning contracting without changing muscle length) in the lower leg muscles.  It also improved balance and makes your landings safer and less jarring on the shin.  To make the exercise more challenging, try closing your eyes or standing on a wobbly surface (an 8-inch mat or a pillow work great).
3. Heel raises: Seems simple enough right? Wrong – doing these right involves a SLOW up and down without the ankles rolling out (twisting) and without you moving you feet.  If it feels easy, you’re doing them too fast.  Focus on a slow controlled motion and be sure to tighten all the muscles in your core throughout.
4. Ankle alphabets: Sitting with the ankle free, write the alphabet with your foot and ankle (be sure to keep the lower leg still).  Make BIG, CLEAR letters and go SLOW!

Page 3:

1. Toe curls: (aka towel scrunches) Sitting in a chair, lay a towel out on the floor.  Using the toes and foot, scrunch up the towel.  You can do a certain number of reps (as listed on the PDF) or do it for a set amount of time – I recommend about 3-5 minutes.
2. Seated ankle dorsiflexion: (against gravity with a weight):  Wrap a cuff weight (between 2-5 lbs) around the foot.  Slowly lift the foot up from a pointed to a flexed position and then return.  You should feel this along the length of the shin, but be sure to keep the weight in a comfortable range – you don’t want the “burn” to be more intense than a 3-5 out of 10.

If you have any questions, drop a comment below and I’ll get back to you!  And be certain to ICE afterwards!