Tips to Avoid Cast/Immobilization Problems

Tips to Avoid Cast/Immobilization Problems

Injuries can bring with them some form of casting to protect the area for a long enough time that the injured part has a great chance to heal. But as healing occurs to one area, other areas can be negatively impacted. The forms of casting available include permanent (plaster or fiberglass-type) and removable. All forms of casting cause a syndrome affectionately called “Cast Rot” or “Cast Disease”. This syndrome includes:

• Muscle/Tendon Atrophy or Weakness

• Muscle/Tendon Stiffness or Loss of Flexibility

• Proprioceptive Nerve Problems with Loss of Position Sense

• Cardiovascular Loss

• Weight Gain due to lessened activity

• Hip/Back Problems when the foot/ankle is immobilized due to height difference from cast side to good side

The permanent cast by far produces the most problems, but even the removable casts can be very destructive. In the rush of reviewing the x rays or MRIs, making the decision to cast, and orchestrating that the proper cast is applied, many simple suggestions are forgotten that can minimize some of the effects of cast disease. If you have a foot/ankle cast, or boot make sure the opposite foot is raised up evenly. A product called EvenUp® can be applied to the shoe on the opposite side to keep the knees, hips, pelvis, and spine level (as demonstrated in the photo above). Find out what cardio you can do to keep the heart/lungs strong (and remember the HDLs) and contain inevitable weight gain. Some walking is normally allowed with weight bearing casts as the soreness resolves, but stationary bikes on a daily basis can keep leg strength and adequate cardio.

Normally you can do pain free isometric strengthening exercises within the cast, but a physical therapist will have to show you how to do these. Normally, push painfree into the cast in all 4 directions, hold for 6 seconds, and repeat 10 times. Do these isometrics 3 times daily. Sometimes, it is appropriate to order a muscle stimulator. This can even be placed inside a permanent cast to begin strengthening as soon as possible. This is normally ordered and applied at the 2 week cast change.

As soon as the cast comes off, you may not be able to increase cardio, but you should be able to increase strength, flexibility, range of motion, and proprioception. Find out what exercise you can do as quickly as possible without risking harm. Keep pushing the doctor and/or therapist to move your rehabilitation along. A prescription for 3 physical therapy sessions (normally once every 2 weeks) can progressively build a home exercise program that you do daily.

Golden Rule of Foot: For every day you are in a cast,it takes 2 days to get back to normal. Your job, if you choose to accept it, is to move the rehabilitation along as quick as possible, without causing increased pain. Pain causes swelling, which causes more pain, which causes more swelling, and the cycle spins out of control. Be your own advocate, ask questions, make sure speedy rehabilitation is part of all those involved mindset for you. Tell them you want to soak to reduce swelling, you want to do exercises for strength, flexibility, range of motion, and proprioception. Tell them you need to get safe but effective cardio as soon as possible. Keep it moving! Another Golden Rule of Foot!!

Strengthening After An Injury: Email Advice

Dear Dr Blake

Re: Left leg fracture: Closed non-displaced lateral tibial plateau

I really need some help. I've been scanning the internet looking for advice and your's is the first site I've found that addresses by question. You see, I'm living temporarily in Thailand and it's almost impossible to advice from the doctor here, he just says - keep the leg still.

Two weeks ago I tripped over and caused this injury. I now have a full leg plaster which I will keep on for two months, maybe longer. It was only two days ago that I even began to consider atrophy, and now I realise this is a big problem.  I really wish to lessen the affects of atrophy as much as possible. You mention isometric strengthening exercises in your blog, but then say to consult my physio..  which I can't do.  I have started to use the exercise you described, but wondered if there anything else you can suggest? Is contracting and releasing the whole leg useful? I wiggle my toes up and down several times throughout the day (is that useful?)  I am an active and fit 57 year old woman (yoga and swimming) and wish to return to full fitness in the most efficient way. 

Your advice would be very much appreciated

Kind regards,

Jill (name changed)

Dr Blake's Response: 

Jill, I will try to get one of our physios to respond also, but I will also put a call out to any readers that have knowledge that can comment directly on the blog. Since I am a podiatrist, treating a fracture at the knee is not within my scope, but I sure talk to patients who have it. 

The full leg plaster casts will certainly cause tremendous atrophy and will take 6-12 months to regain strength and motion. So, your question is perfectly timed. Any area of your lower leg that you can move, you should move. The simpliest, but still powerful, form of muscle strengthening is active range of motion. The exercises can not put stress on your injury, or any other body part. Simply taking the hip muscles 3 times through their range of motion will be very helpful. The hip moves in 6 planes (front, back, in, out and inward rotation and outward rotation). If the ankle is out of the cast, do the same (up, down, in, and out) with it's 4 directions. Try to do these motions every few hours and it should take less than 5 minutes.

The knee muscles to strengthen are the hamstrings and quads. The hamstrings pull the lower leg backward and the quads pull the leg straight. To perform an isometic exercise you attempt to move the body part in the desired direction (for the quad you are trying to straighten your knee). The cast will not allow you to move, so you push against the cast for a count of 6, rest 4 seconds, and then repeat 10 times. You try to do this every 2-3 hours. 

If you are doing the exercises, the area of the fracture can not hurt. 

Please ask the doctor, if you promise to completely stay off the leg, how much faster can you get out the the cast!! I sure hope this helps. Rich

Another response from Dr Blake:

Jill, I talked to our orthopedist Dr Susan Lewis. She says that this fracture can be very unstable, even if nondisplaced, and should be immobilized for minimum of 8 weeks. She did not like the idea of you getting out of the cast early, so sorry!! Best to overprotect it now, and then rehab the leg after. The exercises however are still fine. Rich

Tips to Avoid Cast/Immobilization Problems

Injuries can bring with them some form of casting to protect the area for a long enough time that the injured part has a great chance to heal. But as healing occurs to one area, other areas can be negatively impacted. The forms of casting available include permanent (plaster or fiberglass-type) and removable. All forms of casting cause a syndrome affectionately called “Cast Rot” or “Cast Disease”. This syndrome includes:

• Muscle/Tendon Atrophy or Weakness
• Muscle/Tendon Stiffness or Loss of Flexibility
• Proprioceptive Nerve Problems with Loss of Position Sense
• Cardiovascular Loss
• Weight Gain due to lessened activity
• Hip/Back Problems when the foot/ankle is immobilized due to height difference from cast side to good side

The permanent cast by far produces the most problems, but even the removable casts can be very destructive.

In the rush of reviewing the x rays or MRIs, making the decision to cast, and orchestrating that the proper cast is applied, many simple suggestions are forgotten that can minimize some of the effects of cast disease. If you have a foot/ankle cast, make sure the opposite foot is raised up evenly. A product called EvenUp® can be applied to the shoe on the opposite side to keep the knees, hips, pelvis, and spine level (as demonstrated in the photo above). Find out what cardio you can do to keep the heart/lungs strong (and remember the HDLs) and contain weight. Some walking is normally allowed with weight bearing casts as the soreness resolves, but stationary bikes on a daily basis can keep leg strength and adequate cardio. Normally you can do pain free isometric strengthening exercises within the cast, but a physical therapist will have to show you how to do these. Normally, push painfree into the cast in all 4 directions, hold for 6 seconds, and repeat 10 times. Do these isometrics 3 times daily. Sometimes, it is appropriate to order a muscle stimulator. This can even be placed on inside a permanent cast to begin strengthening as soon as possible. This is normally ordered and applied at the 2 week cast change.

As soon as the cast comes off, you may not be able to increase cardio, but you should be able to increase strength, flexibility, range or motion, and proprioception. Find out what exercise you can do as quickly as possible without risking harm. Keep pushing the doctor and/or therapist to move your rehabilitation along. A prescription for 3 physical therapy sessions (normally once every 2 weeks) can progressively build a home exercise program that you do daily.

Golden Rule of Foot: For every day you are in a cast,it takes 2 days to get back to normal. Your job, if you choose to accept it, is to move the rehabilitation along as quick as possible, without causing increased pain. Pain causes swelling, which causes more pain, which causes more pain, and the cycle spins out of control. Be your own advocate, ask questions, make sure speedy rehabilitation is part of all those involved mindset for you. Tell them you want to soak to reduce swelling, you want to do exercises for strength, flexibility, range of motion, and proprioception. Tell them you need to get safe but effective cardio as soon as possible. Keep it moving! Another Golden Rule of Foot!!