Rehabilitation of a Broken Femur
Congratulations! You have just broken your femur. They have inserted a titanium rod and released you from the hospital. You have a whole vague collection of rehab instructions. How do you keep track of them all? Here is my list of what I went through and why. Pay attention to the whys. They will help remind you of the importantance of each step. P.S. Yes, the nail is bent when the put it in. It is a bit of a shock to find out that the nail is curved!
- Drugs You will have several drugs to take. Their existance and dosage are there for a reason. Believe them. It may help to have someone at home remind you when to take each pill. It is also helpful to create a checklist. Write down all the dates and times for each prescription item and check them off as you go.
- Anitbiotics. You remain at high risk for an infection during the first week or so. You will have an antibiotic prescription that will be measured for the needed time period. For example 14 pills at twice a day, will last you one week. Take them all. Even if you feel great. Remember you are trying to prevent an infection from taking hold.
- Aspirin. I have a friend who had a blood clot get loose in his lung and it almost killed him. You are not taking these aspirin for pain. You are taking them as an anticoagulant. That means they are designed to keep blood clots from forming and getting loose in the blood stream. As your body heals there is lots of blood going lots of places doing a lot of different things. You have seen how blood clots when you scrape your skin. Something similar can happen inside you. If clot of blood gets loose it can block a vessel in your heart causing a heart attack, in your brain causing a stroke, or in your lungs preventing you from breathing. In my case I had aspirin therapy for 30 days. (60 tablets, two tablets each day, one in the morning, one in the evening.
- Pain Pills. I tried to limit mine because I like to understand my pain before I take pills. Some pain for example was a reminder that I needed a new mattress. In any case they will be there to take as needed. Your concern here is that you do not take too many of them. Also do not drive or operate heavy machinery after taking these pills. They induce drowsiness and other relaxed states.
- NutritionYou are healing several things. Each different item will require different nutrients at different points. Generally speaking a balanced diet will cover most things, but be sure you ask if you have special needs.
- Iron for Blood Healing. Did you lose a lot of blood in the accident? I lost a lot of blood during my surgery so I made sure I had more red meat (hamburger, steak) during the first week or two of my recovery. Since Vitamin C helps iron absorption I also made sure I had Vitamin C with that meat. That meant cooking the meat in tomato sauce or having a glass of orange juice with that meal.
- Calcium for bones. I think this might matter more about week four when you start laying down bone. However I do like milk and it is a great source of other vitamins so I drank a couple of glasses each day. Around week four and on the body will start using lots more calcium. It will take it from other bones in the body if it needs to. To reduce the risk of weakening other bones you should probably aim for double the RDA of calcium. You can do this with supplements, milk and dairy products or any of those many items that are now fortified with calcium, like certain orange juices. (WK:8 After the disappointing week seven x-rays I upped my calcium intake to about 200% of the RDA. Perhaps I should read my own advice. The calcium fortified orange juice has been my supplement of choice. Between that, the milk, the yogurt, and the cheese I may be getting enough calcium now.)
- Nutrient Density. Your body needs all the help it can get. Most of the time we can get away with lots of desserts and empty calories (chips, sodas) in our diet. This is not one of those times. Focus on putting as much healthy food in your body as possible. I always had juice or milk instead of sodas when I was thirsty. I ate fruit every day. I limited myself to one dessert item a day. By eliminating the usual sources of empty calories, by default I was eating a much healthier diet. Everything I ate had some value. Please note, this was after Christmas and I really had to pace myself with all the chocolate that was around the house.
- Range Of Motion This is the first thing you worry about. Strength will return when you are ready. However there is a two week window before scar tissue starts to harden. The more range of motion you can achieve during this window the less pain you will have later getting the scar tissue to align. Be sure you leave the hospital with an understanding how how you can stretch and improve your range of motion. It helps if you are working with a physical therapist as soon as possible. Make sure you leave the hospital with a prescription for the first couple of weeks of rehabilitation. In my case when I left the hospital I travelled to another state for the first few weeks of recovery. That meant I had to find a new doctor for a follow up and a physical therapy place to learn rehabilitation tricks. Each week there will be different stretches or exercises to do based on how well your recovery is progressing.
In my case two major muscle groups needed stretching, my hamstrings and my quadriceps. (Back of the thigh and front of the thigh) I found that they could not both be stretched at the same time. Stretching one way limited the range of motion the other day. I stretched four time a day. In the morning I would stretch the quads. An hour later I would stretch hamstrings. This would be repeated two hours before bedtime. I did hamstrings last because I had trouble sleeping because my leg would not straighten out. The steps were the same for both stretches.
- Warm up the muscles, either with hot water in the shower or with a heating pad. 10 minutes of heat worked for me.
- Massage with an Aloe Vera moisturizing lotion. This was part lubricant and part healing agent. Five minutes of massage helped. The trick was to massage across the grain. The muscles run the long way on your leg. By massaging perpendicular to that you could break up the scar tissue that was not aligned. After scar tissue sets it bonds tissue to bone or other tissue. Scar tissue aligned with muscles will not limit range of motion as much as scar tissue bonding at right angles to muscle direction.
- Gentle stretching. Do not go past pain level 3 on a 1-10 scale. You will find that you may need to get into some interesting positions to get the best stretch. Of course if you can get into a heated whirlpool or spa you will find that best. As you stretch the four factors will limit you. Swelling, Scar tissue in muscles, scar tissues in joints, and a stretch reflex. As you stretch a muscle the muscle on the opposite side tightens to protect you from hurting yourself. To keep this reflex from kicking in too strongly you want to move slowly. Any time you can get gravity to help you you may be able to get a better stretch.
Best Quad Stretches: Sit on a flat surface, like a chair or bed, that will allow you leg to hang over the edge without touching the floor. Early on you will not be to let your leg just hang. You will not be able to bend 90 degrees at the knee. What you can to is use your good leg to control the lowering of the injured leg. The more advanced version of this stretch is to lie on your back near a wall. You should be positioned so that you can rest your good leg on the wall at a 90 degree angle.
You will have a show on the good leg and just a sock on the bad leg. Lift the bad leg up high on the wall. Use the good leg underneath the bad leg to control how far down the wall the leg will slide.
Best Hamstring stretches: Sitting up on a smooth, flat surface extend your leg. You may have difficulty lowering the knee all the way down. Gently tightening the quadriceps muscles to press the leg down should provide a very good stretch.
- Stretches to not do!
- Stretches to do.
- Positions to rest in.
- Muscle Tone This is the first thing you will work on. My whole leg felt like a big heavy log that I could not control. Rolling over in bed was almost impossible. Regaining muscle tone will help this. Muscle tone requires simple muscle contractions. Tighten a muscle group and hold it for five seconds. You will do several sets of those at regular intervals. Questions for your doctor or physical therapist include: When do I start these exercises? How often do I do them? In my case I worked up to doing sets hourly. Every hour, for each muscle group I was doing 20 repetitions of 5 second contractions. Muscle groups I found needed work were:
- Quadriceps - Simply contract the quadriceps muscles.
- Hamstrings - It helps if your leg is slightly bent and you can think about pulling yoru heel back or digging your heel into the bed or carpet.
- Calves - Not because they were injured, but because they were not getting to work out and they would get sore from lying around or sleeping. Because of how this muscle will rest while you are sleeping you will probably need to stretch this muscle regularly as well.
- Gluteals - Sit on your tail all day and all night and this is one muscle that gets no work. I had one sore muscle back there that caused more pain than the fracture did. All this because it was getting no exercise at all. To contract this muscle it helps to be standing up or lying face down.
- Muscle Strength These exercises will probably start about 5-7 days after you start getting some sense of muscle tone. You will want to procedue with caution. Anything that causes pain should be stopped. You should be working with a physical therapist at this point. They will explain things in greater detail and be charting your progress. Based on how you are doing with whatever your current sets are they will recommend what to add next. The basics though, are as follows. All of these exercises are usually done in two sets of 10-20 reps, twice a day. Each exercise will have two variations. The first one is done for 5-7 days. The second one will be a slightly harder version and you will commence it after sufficient strength has developed to be able to do the exercise without pain.
- Level 1: The initial exercise is best done standing. In one reasonably fluid motion lift your knee up and then extend your lower leg forward.
- Level 2: For this exercise perform a straight leg lift. Lying on your back, with your shoulders propped up o your elbows, lift your leg off the bed or floor and hold for 5 seconds then lower it back down.
- Level 1: Standing Leg Curls: Keeping your kneecaps lined up gently curl the affected leg up behind you. Because of limited strength and range of motion you may only be able to moved your leg a few inches. Have patience! As you gain strength and range of motion you will be able to move your leg over greater distances. Don't try to do too much too fast.
- Level 2: Here you lie face down and repeat the same exercise. Again have patience if you can only move your leg a few inches. Strength and range of motion return over time.
- Level 1: Standing up raise your leg straight up behind you. You may lean slightly forward to increase the range of motion. Still your leg may only travel about a foot or two. Anything more is not needed and may risk hurting your lower back. (WK 8: This exercise does not work if the muscle is completely on vacation as mine was. You will need to do the muscle tone tensing exercises to wake up the muscle before these exercises will work. The test here is whether or not the muscle is being used during the exercise. In my case my hamstrings were doing all the work during this exercise. Rest your hand on the muscle you think you are working and see if you feel it tensing up at all. If not see if other muscles are over compensating. You will learn anatomy eventually.)
- Level 2: The advanced version is to lie face down and perform the same exercise. Lying face down you will probably only have a range of about six inches, even with full strength.
- Level 1: For this you will need a length of theraband. In the absence of theraband you can use a towel. Wrap the towel around the ball of your foot. Pulling back on the towel or supporting the theraband for resistance pull your toes up towards your knee. Against resistance point your toes. Repeat this motion 20 times.
- Level 2: I have not reached level 2 yet, so you'll have to wait for an update.
- IT Band/Side of Leg
- Level 1: Standing upright, lift your leg out to the side.
You need only move your leg about a foot. After a week or so you should be able to do the advanced verion.
- Level 2: Lying on your side with the injured leg on top, lift the leg about four inches in the air. Hold for a 5 count then lower the leg down. If you feel pain greater than 3 on a scale of 1-10 return to level one for a couple more days. My IT band was cut into and was extremely weak. I learned a little trick that helped make a little more progress. Yoru muscles can lower more weight than they can lift. This is called negative work. If you cannot lift the leg as is, but can help it into the air, you may be able to hold it there and lower it. In my case I was able to use my hand to help the leg get about 4-6 inches in the air. I could then hold it for a three count and then lower it. At first I could only do about 6 reps. Every day or two I could add another couple of reps. Work your way up to twenty and then try lifting the leg.
- Crutches Some thoughtful soul will give you a pair of crutches to help you get around. If you are lucky enough to travel on dry, flat surfaces you will have no problem. What little instruction you get for walking will serve you well. The rest of you have some serious worries ahead. You might get instruction, but I suspect it will not help you in two situations, slippery surfaces and steps. The things you need to know about crutches are that you have no use of your hands and your are limited in where you can put your feet down.
- Steps: This is less of a problem going up, but going down it is an extreme danger. The crutches will support your arms and upper body at a certain height. As you lean forward your leg can only land at a certain place in front of you. Unfortunately if you are at the top of a flight of steps that place does not exist. This can be 20 steps in a house or three steps getting off a bus. If you shift your weight forward your body will be carried into space and down the steps you will go. For this reason I recomend removing the crutches from under your arms long before you get to the steps. Shift them to one hand and use them like a cane. Then make sure you use the railing for support and control and the crutches like a cane to help you down the stairs. With one hand on the railing you can at least prevent your self from falling all the way down the stairs.
- Slippery Surfaces: Again you have the problem of being propped up with your hands occupied. You put either the good leg or the bad leg forward and it keeps going. Instant splits and lots of torn groin muscles. There is another way to go down on slippery surfaces. You put one crutch out to the side or forward and it hits a slippery spot, ice, water on tiles, an object on a slippery surface. You will find yourself falling with no way to catch yourself.
In either case the lesson is that you always need to focus on where your next steps are going to be and where you are putting your feet or your crutches. You will find that you cannot pay any attention to the wonders of life unless you are at a complete stop. The rest of the time you will always have to look where you are going and plan your steps ahead.
- Cane At some point in the 3-6 week range you will want to shift from crutches to a cane. The important thing here is that the cane goes in the hand opposite the injured leg. It moves in tandem with the injured leg. The cane and injured leg move forward and plant then the good leg follows through with the next step. Studies show that the cane helps support 40% of the body weight. This means the the injured leg only has to support 60% of the body weight. Following a good physical therapy routine and with normal healing the injured leg will have regained enough strength to support 60% of the body weight about 3-6 weeks. In my case it was just after four weeks that I was able to take short steps. I was thrilled to be able to make the 12 foot trip into the kitchen and return. With crutches or a walker both hands are occupied. With a cane I have a free hand to hold a plate. As with all other steps if it hurts too much (more than three on a scale of 1-10) then discontinue the action until more healing has occurred.
- Range of Motion - Update see the Week 19 notes on the main page for more stretching ideas.
- Leg Strength - Update see the Week 19 notes on the main page for more exercise ideas. These are exercises I wished I had learned about and tried. I took the doctor's emphasis on weight bearing literally. Walking is the easiest activity to undertake when recovering. If you have access to weights there may be a better way. A lot may depend on how much muscle you lost. I sat for a week before really moving and then spent too much time sitting the following three weeks. That set me back a lot and forced me into a different recovery regimen than most.