South African Haemophilia Foundation (SAHF) Medical and Scientific Advisory Council (MASAC) Treatment Guidelines - Treatment of Bleeding Episodes

Bleeds in the Lower Limbs (Legs)

This guide is intended for people with haemophilia and healthcare personnel who may not be familiar with particular physiotherapy protocols pertaining to haemophilia management. A pdf version can be downloaded here.

If you are uncertain about anything, please contact Mrs Ethelwyn Remmers on +27 72 247 7352 or your nearest Haemophilia Treatment Centre to be referred to a Haemophilia Physiotherapist.

HIPS AND PSOAS MUSCLE
The ilio-psoas muscle is the hip flexor muscle. For these bleeds, the only good form of immobilisation is bed rest with the hip as straight as possible. It may be necessary to use a pillow to support the leg in the very acute stage, but as soon as possible this must be removed. It is advisable to lie on the stomach (prone lying) for periods of the day – this is to stretch the hip muscles. After a hip bleed/psoas bleed it is advisable to also do quadriceps exercises.

HIP FLEXION (PSOAS MUSCLE) AND EXTENSION

Free hip extension
Stretching ilio-psoas muscle with assistance
Stretching ilio-psoas muscle
Hip flexion against gravity
Hip flexion against resistance (weights)
Free hip abduction (away from the centre)
Hip abduction against gravity
KNEE JOINT, QUADRICEPS AND HAMSTRING MUSCLES
These are the muscles that straighten and bend the knee. The medial (inner) part of the quadriceps muscle helps to “lock” the knee when straightening it. This muscle needs to be strengthened as soon as possible to reduce the risk of re-bleeds when walking or running.

QUADRICEPS (EXTENSION MUSCLE)

Static contractions of quadriceps muscle (knee extension muscle)
Knee extension against gravity with a small range of movement
Knee extension against gravity with a greater range of movement
Knee extension against resistance (weights) with a small range of movement
Knee extension against resistance (weights) with a greater range of movement

HAMSTRINGS (FLEXION MUSCLE)

Free knee flexion
Knee flexion against gravity
Knee flexion against resistance (weights)
ANKLE JOINT AND CALF MUSCLE
A bleed in the calf muscle would affect knee and ankle movement. Position the ankle in mid-position, and the knee as straight as possible. The same applies for an ankle bleed.

ANKLE AND CALF MUSCLE

Free ankle plantarflexion (foot down) and dorsiflexion (foot up)
BALANCING AND STRETCHING EXERCISES (Following a muscle bleed)
Weight bearing for ankles
Walking on toes or heels balancing exercise
Exercise on a ‘wobble board’ balancing exercise
Stretching of hamstring muscle
Weight bearing exercise for calf muscles
2 x Stretching exercises for calf muscle