Athletic Injuries Flashcards
What is primary prevention?
Preventing the situation from happenings all together
What is the most important role in injury prevention?
Minimize activity related injury
Aspects of primary prevention?
Athlete - technique, neuromuscular function
Surrounding - floor friction, playing rules
Equipment - shoe friction
What is secondary prevention?
Things to protect the athlete should a potentially dangerous situation arise
Aspects of secondary prevention?
Athlete - training status, falling techniques
Surrounding - safety nets
Equipment - tape/brace, protective equipment
What is tertiary prevention?
Reducing the consequences of injury
Aspects of tertiary prevention?
Athlete - rehabilitation
Surrounding - emergency medical coverage
Equipment - first aid equipment, ambulance
What are the four principles of athletic equipment?
Deflection
Dissipation
Deformation
Absorption
Principles of deflection?
Hard
Smooth
Round
Purposes of open cell foam?
Decreased density allows for more absorption at low force
Purposes of closed cell foam?
Increased density allows for greater resistance at high force
Components of sport specific equipment analysis
Biomechanics of body part
Individual activity level
Specific protection/performance demands
What are you trying to protect against
Purposes of a curved last shoe?
Neural for stability
Purposes of a straight last shoe?
Stability for motion control
For flat footed people (whose feet turn in)
Purposes of a slip lasted shoe?
Increased flexibility
For people with high arch
Purposes of a board lasted shoe?
Increased torsional resistance to pronation
For people with flat feet and an increased need for stability
Purposes of polyurethane?
For heavier runners
In heel of dual density midsoles
Purposes of EVA?
Lighter - increases durability when compressed
In toe in dual density midsoles
In whole midsole for single density midsoles
What type of shoe does a person with a rigid foot need?
Curve last with sufficient cushioning
Neutral cushioning shoes are best for… because they have…
Neutral foot
High arch
Single density midsoles
Mild torsional rigidity
Slip last
Curve last
Stability shoes are best for… Because they have…
Mild over pronators
Double density midsole
Moderate to extreme torsional rigidity
Curve last
Board last
Motion controlled shoes are best for… Because they have…
Severe over pronators
Triple density midsoles
Extreme torsional rigidity
Board last
Straight last
What is civil liability?
When a person engaged in conduct that results in harm to another private individual
What is criminal liability?
When a person contravenes social standards as expressed by criminal laws
What is a intention tort?
Harm was intended to another
What is an unintentional tort?
When a person ought to have foreseen that his or her actions would cause harm
What are the elements of negligence?
Duty of care
A breach of the standard of care
Damage or injury that results from the breach
Components of a EAP?
Event Dates Location Address Phone EMS access
What does the charge person do?
Decides when to activate EAP
Makes decisions if there is a spinal/life threatening condition
What does the control person do?
Keeps people back and assists the charge person
What does the call person do?
Contacts EMS
What is a traumatic injury?
Occur suddenly and have clearly defined cause or onset
What is a overuse injury?
Occur slowly over time secondary to the repetitive dynamics of the sport or movement in question
What is a isometric contraction? How much force is produced?
Muscle contraction in which length of muscle stays constant
Moderate force
What is a concentric contraction? How much force is produced?
Muscle shortens while contracting against resistance
Reduced force with increases speed
What is an eccentric contraction? How much force is produced?
Muscle lengthens while contracting against resistance
Maximal force
Increased force with increased speed
What types of muscle injuries are there?
Distentions
Direct trauma
What is a muscular distention injury?
Stains
Usually occur at musculotendinous junction
More common in 2 joint muscles
What is a grade 1 muscle strain?
Less than 10-20% of fibres torn or stretched
Near full ROM with some discomfort near the end
Good strength (4-5)
Slight pain and discomfort
What is a grade 2 muscle strain?
20-80% of fibres are torn Significantly decreased ROM (50%) with some discomfort near the end Poor strength (2-3) Significant pain and discomfort High bruising Can have palpable divot
What is a grade 3 muscle strain?
80-100% rupture of fibres
PROM only
Poor strength (0-1)
Variable pain
What is grade 5 muscle strength?
Normal
Full strength throughout the available range compared to the other side
What is grade 4 muscle strength?
Good
Near full strength through available range when compared to other side
What is grade 3 muscle strength?
Fair
Full ROM against gravity only (not against external resistance)
What is grade 2 muscle strength?
Poor
Can complete full ROM (with gravity eliminated)
What is grade 1 muscle strength?
Trace
Able to feel a muscle contraction but there is no movement at the joint
What is grade 0 muscle strength?
Nothing happens when the person tries to contract
What is a intramuscular injury?
No injury to fascia Blood trapped in muscle Longer healing time Increased compartmental pressure Chemical irritation (due to pooling of blood)
What is intermusclar injury?
Fascia is injured Blood flows out between the muscles Heals faster No increased pressure Blood can be absorbed
What are tendons made of?
Composed of 80-90% Type 1 collagen - arranged in parallel bundles of various sizes
What type of tendon injuries are there?
Traumatic
Overuse
What is tendinitis?
The inflammation of the tendon itself and is relatively rare
What is paratenonitis? How is it caused?
The inflammation, pain and crepitation of the paratenon as it slides over the structure
Acute irritation
Usually triggered by external factors: rubbing of bone or equiptment, external factors (“too much too soon”),
What are the characteristics of ligaments?
High content of elastic (higher than tendons)
Well innervated
Important for proprioception and rehabilitation
Built in wave like crimp to the ligament
What are the 3 types of ligaments?
Intra articular
Capsular
Extra capsular
What are the properties of an intra articular ligament? (Healing, blood supply) Example?
Inside a joint or joint capsule
Total rupture will not heal
Blood supply from ends, minimal to middle portion
ACL
What are the properties of a capsular ligament? (Healing, blood supply) Example?
Where ligament projects as a thickening of a joint capsule
Total rupture has excellent healing
Good blood supply
MCL
What are the properties of an extra articular ligament? (Healing, blood supply) Example?
Outside the joint capsule
Total rupture will not heal
Blood supply from ends, minimal to middle
LCL
Ligament injuries are closely correlated to _____?
Load deformation curve
What is phase 1 of the load deformation curve?
Toe region
Initial concave region
Represents normal physiological range of strain (3-4%) when the crimp in the ligament flattens out
Reversible
What is phase 2 of the load deformation curve?
Linear region
Pathological irreversible ligament elongation
Intramuscular and intermuscular cross links are broken until macroscopic failure is clinically evident
Early part = grade 1 sprain
Later part = grade 2 sprain
What is phase 3 in the load deformation curve?
Rupture region
Failure point is a 10% till complete rupture (90% of fibres torn)
Grade 3 sprain
What is a grade 1 sprain?
Full ROM
Slight pain on palpation
No joint laxity/good stability
What is a grade 2 sprain?
Significant loss of motion
Significant pain on palpaption
Joint laxity
What is a grade 3 sprain?
Loss of motion
Pain on palpation
Gross laxity
How can you tell the difference between a fracture and a bruise at the time of injury?
Indirect pressure will cause fracture pain.
What are the 3 phases of healing?
Inflammatory phase
Repair phase
Remodelling phase
How long does the inflammatory phase last?
3-4 days
How long does the repair phase last?
3 days - 6 weeks
How long does the remodelling phase last?
6 weeks - 1 year
What happens in the inflammatory phase?
Primary damage: damage at time of injury (immediately irreversible)
Secondary damage: damage by release of proteins and other body processes such as edema, decreased blood flow and oxygen.
Symptoms of inflammatory phase?
Redness Swelling Hot Pain Loss of function
What does the subcycle in the inflammatory phase include? What is its long term effect?
Pain, muscle spasm, ichemaia (decreased blood flow/oxygen to tissue)
Increases possibility of atrophy over time
What are the 6 steps of cell injury?
Injury to cell
Chemical mediators liberated - histamines, leukotrienes, cytokines
Vasoconstriction (10 mins) then vasodilation
Marination (neutrophils adhere to vascular wall)
Diapedesis (fluid through cell wall)
Phagocytosis
Clot formation
What happens in the repair phase?
Scar formation (fibroplasia) and repair of injured tissue Growth of epithelial capillary buds into the wound is stimulated by lack of oxygen Body lays down Type 3 collagen which is delicate and disarrayed
What happens in the remodeling phase?
Increased stress and strain causes the collagen to change from type 3 to type 1
There is normally a strong neurovascular scar by the end of 3 weeks
What is Wolf’s Law?
Bone and soft tissue will respond to the physical demands placed them, causing them to strengthen along lines of tensile force
What are pain receptors called?
Nocioceptors
What do nocioceptors respond to?
Mechanical stimulation
Thermal stimulation
Chemical stimulation
What type of fibres do nocioceptors transmit their information to?
Afferent fibres
In the gate control theory, what happens there is no stimulation?
Both large A and small C nerve fibres are quiet and the substantia gelatinosa (inibitory interneuron) blocks the signal in the T cel that connects to the brain.
The gate is closed
No pain
In the gate control theory, what happens with painful stimulation?
C fibres become active and bloack the inhibitory substantia gelatinosa and activate T cells.
The gate is open
Pain
In the gate control theory, what happens with non painful stimulation?
Large A Beta are active which activates the substantia gelatinosa which blocks the signal to the T cell
The gate is closed
No pain
What are the two pain signal carriers?
A delta
C fibres
What are the characteristics of A delta fibres?
Myelinated Fast Large diameter Respond to touch, pressure and temperature In skin
What are the characteristics of C fibres?
Unmyelinated Slow Respond to pain and temperature Located in skin and deep tissue Small WIll continue to fire for a long period after initial injury
Types of A beta input?
Pressure
Vibration (4 Hz x 10 mins)
Position finger
After 10 mins of the same stimulation, you will need to change the stimulation input to continue to block C fibre signals because A beta fibres will accomodate but C fibres will not
What area of the body responds best to cyrotherapy?
Joints, then muscle, then fat (based on fluid content)
What are the physiological responses to cryotherapy?
Breaks pain/spasm cycle
Decreases blood flow, capillary permeability, metabolic rate, collagen elasticity
Increases joint stiffness
Won’t reduce swelling that is present but will prevent more from accumulating
Decrease C fibre conduction rate
Physiological responses to thermotherapy?
Increases blood flow, capillary permeability, metabolic rate, collagen elasticity
Decreases joint stiffness, muscle spasm
Can flush swelling out - based on timing (NOT DURING inflammatory phase)
What are the goals for treating injuries in the inflammatory phase?
Decrease swelling, pain, inflammation
Optimize healing environment
How to treat injuries in the inflammatory phase?
Call da POLICE!
Protect Optimal loading Ice Compression Elevation
What is the best way to limit a hematoma?
Compression
Other than A beta fibres, how can you externally knock out C fibres?
Cooling by 4 degrees
What are the goals for treating injuries in the repair phase?
Protect from further damage
Increase blood flow and ROM
How to treat injuries in the repair phase?
Heat for 10-15 mins
Idealize ROM
Start low level strength and proprioception exercise?
Increase as able to weight bearing status
GENTLE and PAIN FREE
What is type 1 diabetes?
10% of diabetic population
Pancrease can’t produce enough insulin (can’t get sugar out of blood into the cells)
Dependence on exogenous insulin
What is type 2 diabetes?
90% of diabetic population
Not enough insulin produced and/or significant resistance at cellular level
What is hyperglycemia?
Sugar is present in blood stream but cant' get into tissues Body starts converting fat for energy Acidosis (fruity smell in breath) Frequent urination Possible coma
Treatment: bring to emergency medical practicioner
What is hypoglycemia?
Too much insulin in blood causing low levels of blood glucose
Decreased nutrients to the brain
Insulin shock/reaction
Treatment: give sugar
What are the signs and symptoms of hyperglycemia and hypoglycemia?
Altered level of consciousness - dizzy, drowsy, confused
Rapid breathing
Rapid pulse
Feeling ill
What is epilepsy?
The recurrence of unprovoked seizures
What are the 2 types of seizures?
Generalized - bilateral discharge involving entire cortex
Partial/focal - occurs in 1 part of brain
What are the types of generalized seizures?
Convulsive tonic clonic seizure - athlete falls to ground, goes through tonic chase of muscle stiffness, followed by clonic phase of muscle twitches
Non convulsive absences - sudden interruption of activity followed by a blank stare
What are the types of partial seizures?
Simple - without loss of awareness
Complex - alteration of awareness
What do you do when an athlete is having a seizure?
Do not restrain the athlete or place objects in their mouth
Protect the head
Remove closeby objects
Position in recovery position (on side) when done
What are the main causes of seizures?
Stress
Sleep deprivation
Fever/illness
Menses
What effect does exercise have on seizures?
Decreases seizure frequency
Increases seizure threshold
What is asthma?
Chronic inflammatory disorder of the airways
Excess mucus production and bronchial smooth muscle contraction
Maximal EXPIRATORY flow rate is reduced
What effect does exercise have on bronchiospasm?
Exercise triggers bronchoconstriction because it leads to dehydration of the lung’s airways
Symptoms peak 8-12 mins after exercise.
What are the objectives of a PPE?
Detect conditions that would restrict participation
Detect conditions that may be life threatening or disabling
Injury prevention evaluation
Meet legal and insurance requirements
Initiate and establish a rapport with athletes
Provide an opportunity for counselling
Establish a data base and record keeping system
When does a PPE occur?
4-6 weeks before the season
What are the different methods for evaluation?
Office based
Station based
What are the pros and cons of an office based evaluation for a PPE?
Get to meet with athletes more personally - athletes are able to tell Drs things in confidence
Time consuming, expensive
What are the pros and cons of station based evaluation for PPE?
Athetle meets more examiners (more than just Dr), fosters improved communication by the medical team itself, reduce staff burn out
Less personal
What are the components of a PPE?
Complete medical history MSK Medical evaluation form Visual acuity Quick mental processing form (SCAT3, McGill) Player status form
What is the strongest indpendent predictor of sports injury?
Previous injury!
Brought to attention by complete medical history
How long does a MSK take? What will it detect?
90 seconds
Will detect 90% of significant musculoskeletal injuries
What are the red flags for bone and soft tissue tumors?
Night pain, fever, loss of appetite, unwarranted fatigue, weight loss
What are the red flags for rheumatological conditions?
Morning stiffness, rashes, fingernail pitting, bowel disturbances, eye irritation, reports of a single or multiple swollen joints with no history or trauma or injury
What are the red flags for vascular conditions?
Tenderness on palpation of tissue, local heat, swollen, red/pale/blue
What are the red flags for infection?
Bone pain in children (at night or with activity), hot swollen (with no history of major trauma)
What questions would you want to ask for clearing athletes to play? (PPE)
Is there a problem that places the athlete at an increased risk of injury?
Is any other participant at risk of injury because of this problem?
Can the athlete safely participate with treatment of this problem?
Can limited participation be allowed while treatment is initiated?
If clearance is denied for certain activities, what other activities could the athlete participate in?
Is consultation with another health care provider necessary to answer any of the above questions?
The United States Preventative Services Task Force has 2 requirements for an effective screening process, what are they? Does the PPE satisfy these requirements?
Can detect target conditions earlier than without screening
Screening and treatment should improve likelihood of a favourable outcome
No, for the most part PPEs cannot satisfy these requirements, because:
No compelling evidence that PPE can accurately predict or prevent orthopaedic injury or cardiovascular sudden death
Advising students about rules and equipment may decrease mortality and morbidity more effectively than the PPE exam.
Can PPE identity medical adn orthopaedic problems of sufficient severity to place the athlete at risk for injury or illness?
No
Can the PPE identify correctable problems that may impair the athletes ability to perform?
Yes
Can the PPE help maintain the health and safety of the athlete?
Yes
Can the PPE assess fitness level for specific sports?
Yes
Can the PPE educate athletes and parents concerning sports, exercise, injuries, and other health related issues?
Yes
What is a concussion?
A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
What are the two types of concussions?
Linear and rotational
What is a linear concussion?
Injury at impact site; brain strikes skull on opposite side.
What is a rotational concussion?
Brain strikes skull on other side; brain rotates - stretching or tearing structures and vessels at it shears on itself.
What are the 4 types of symptoms of a concussion?
Somatic, emotionality, cognitive, sleep disturbance.
What are some somatic concussion symptoms?
Visual problems, dizziness, balance difficulties, headaches, light sensitivity, nausea
What are some emotional concussion symptoms?
More emotional thank usual, sadness, nervousness, irritability
What are some cognitive concussion symptoms?
Attention problems, memory dysfunction, fogginess, cognitive slowing
What are some sleep disturbance concussion symptoms?
Difficulty falling asleep, sleeping less than usual
What is the most common symptom of a concussion?
Headache (71%)
What are the most common symptoms of concussions within 3 days of injury?
Headache (71%), feeling slowed down (58%), difficulty concentrating (57%), dizziness (55%)
Is there any symptom that is always present after a concussion?
No
How can concussions be caused? (Give %)
60% - a direct blow to the head, face or neck
40% - elsewhere on the body with an impulsive force transmitted to the head
What is the minimum force needed to cause a concussion?
Force foes not factor in on symtom severity.
Will a mouth guard protect you from concussions?1
No
What are the grades of concussions?
There is no such thing as minor/severe/graded concussions.
How many symptoms need to be present to determine status at time of injury?
Cannot make prognosis at time of injury.
What is a factor at time of concussive injury that may modify management?
LOC for over 1 minute.
What does tonic posturing or convulsive movements tell us at time of concussive injury?
Nothing - they are usually benign and require no specific management.
What are some concussive modifiers?
Symptom duration over 10 days, LOC over 1 minute, frequency of concussive injuries, timing since last concussive injury or traumatic brain injury
Child and adolescent < 18 years old.
Migraine, depression or other mental health disorder, ADHD, learning disabilities, sleep disorders
What could be more important that the presence of amnesia alone? (Concussions)
Nature, burden and duration of clinical post concussive symptoms
How to check for mental status of concussed athlete?
(Child)SCAT3
Why does someone have to monitor concussed athletes after the injury? For how long?
For 4 hours someone needs to watch for presence/symptoms of hematomas (wake up every 2 hours if at night)
How are concussions in children different than concussions in adults?
The developing brain is more vulnerable to injury. Children never return to play on the same day.
How long does it take to recover from a concussion with 15 mins or less of on field symptoms?
7 days
What is the average amount of time required for high school students to return to baseline level of cognitive functioning after a concussion?
30 days
What is the average amount of time required for college students to return to baseline level of cognitive functioning after a concussion?
7 - 10 days
What is the average amount of time required for professional athletes to return to baseline level of cognitive functioning after a concussion?
3-5 days (based on career goals and not health)
How long does the period of vulnerability last?
14 days
What is the period of vulnerability?
Higher demand for glucose in the brain but dramatic decrease in metabolic rate and initial drop in blood flow.
When can athletes suffer from second impact syndrome? (Concussions)
In the period of vulnerability (14 days)
Who is most likely to have second impact syndrome? (Concussions)
Under 21 years old
What happens in second impact syndrome? (Concussions )
Catastrophic increase in intracranial pressure
What are the 5 stages of return to play after a concussion?
No activity, light aerobic exercise, sport specific exercise, non contact training and drills, full contact practice, return to play
Following return to play protocol after a concussion, what are the goals/plan for stage 1 - no activity?
Complete physical and cognitive rest. Goal: recovery
Following return to play protocol after a concussion, what are the goals/plan for stage 2 - light aerobic exercise?
Walking, swimming, biking. Keep intensity below 70% of max. (Talk test). Goal: increase heart rate
Following return to play protocol after a concussion, what are the goals/plan for stage 3 - sport specific exercise?
No head impact activities. Goal: add movement.
Following return to play protocol after a concussion, what are the goals/plan for stage 4 - non contact training drills?
Progression to more complex drills. Goal: coordination, cognitive load
Following return to play protocol after a concussion, what are the goals/plan for stage 5 - full contact practice?
Normal training. Goal: restore confidence, assess functional skills.
Following return to play protocol after a concussion, what are the goals/plan for stage 6 - return to play?
Normal game play
How long must you wait between stages after being symptom free - following return to play guidelines after a concussion?
24 hours
What happens if you experience symptoms while following the return to play guidelines after a concussion?
Go back to the last stage where you were symptom free.
What is the most common reason why athletes do not report a concussion?
Didn’t think it was a serious enough injury.
Following a possible c-spine injury, what 3 questions do you need to answer while on the field?
Is the athlete at risk?
Are they anatomically stable?
How to get the athlete off the field?
What are the 4 steps following a suspected neck injury?
Stabilize the c spine
Assure the athlete and tell them not to move
Get brief history and subjective report.
Begin palpation and assessment.
What is a stinger burner injury?
Traction or compression of BP trunks - roots C5 and C6
What are 3 ways a stinger burner injury can occur?
Forever neck extension and rotation to the injured side.
Shoulder distracted downward from head and neck (most common)
Blow to supraclavicular fossa.
How long does a stinger burner injury last?
Heals quickly - within minutes.
Symptoms of stinger burner injuries?
Unilateral symptoms:
Sensory changes for lateral arm over deltoid, radial side of arm and thumb
Motor changes for shoulder abduction and elbow flexion
What is the the return to play protocol following a stinger burner injury?
Same game if quick resolution to symptoms, full ROM and strength, mentally ready
What are the two mechanisms of injury of a c spine injury?
Axial load - vertical compression
Compression - flexion
What is a axial load c spine injury?
When neck is straight causing burrs fracture (usually) at C4-C5
What is a compression neck injury?
When the anterior portion compresses and the posterior portion elongates.
What are the immediate symptoms of a c spine injury?
Neck pain on central palpation of spinous processes
Bilateral neural findings
What do you need to palpate when assessing a c spine injury?
Upper back, neck, shoulder, clavicle and sternum
What is a dermatome?
Cutaneous area receiving the greater part of its innervation from a single spinal nerve?
What are myotomes?
A muscle receiving the greater part of its innervation from a single spinal nerve
What nerve root innervates muscles for neck flexion?
C2
What nerve root innervates muscles for side neck flexion?
C3
TWhat nerve root innervates muscles for shoulder shrug?
C4
What nerve root innervates muscles for shoulder abduction?
C5
What nerve root innervates muscles for elbow flexion?
C6
What nerve root innervates muscles for elbow extension?
C7
What nerve root innervates muscles for thumb extension?
C8
What nerve root innervates muscles for spreading fingers?
T1
What nerve root innervates muscles for hip flexion?
L1 and L2
What nerve root innervates muscles for knee extension?
L3
What nerve root innervates muscles for ankle dorsiflexion?
L4
What nerve root innervates muscles for 1st toe extension?
L5
What nerve root innervates muscles for plantar flexion?
S1
What nerve root innervates muscles for knee flexion?
S2
What nerve root innervates muscles for foot intrinsics?
S3
What are the 3 high risk factors that mandate a X-ray according to the Canadian c spine rules?
Over 65 years old, dangerous MOI, paresthesia in extremities
What are the low risk factors that allow for safe assessment of a c spine injury and do not require an x ray according to the Canadian c spine rules?
Simple rear end MVA, able to sit, delayed neck pain, absence of spinous process pain
What is the degree of rotation you must be able to actively complete following a c spine injury to not have an x ray according to the Canadian c spine rules?
45 degrees to each side
What are the commands for a log roll procedure?
“Prepare to roll”
“Roll”
In what position should the head be immobilized following a c spine injury? Why?
Neutral - because reduces spinal cord compromise, may facilitate airway management and application of immobilization devices.
What are the 3 general contradictions to moving the c spine to neutral?
If movement increases pain/symptoms, induces muscle spasm or compromises airway
If there is resistance
If the person is apprehensive
What is the best way (tools) to remove a helmet following a c spine injury?
Use a cordless screwdriver and scissors.
Never untie straps.
Should a hockey helmet be removed following a c spine injury?
No. Only on rare occasions.
Should a football helmet be removed following a c spine injury?
Only when also removing shoulder pads.
What are the reasons warranting helmet removal following a c spine injury?
If after a reasonable time the fade mask cannot be removed to gain access to airway.
If even after the face mask is removed you can’t access airway.
If helmet/chin straps do not hold head securely when immobilized.
If shoulder pads are removed.
What are the reasons warranting shoulder pad removal following a c spine injury?
Multiple injuries requiring access to shoulder
Ill fitting pads that do not immobilize spine
If CPR is necessary
If helmet is removed.
How many people does it take to do a vertical lift onto a spinal board?
8
How many people does it take to do a log role onto a spinal board?
Minimum 3
In what order should you strap someone onto a spinal board?
Thorax, head, lower limb
What does SOAP stand for?
Subjective
Objective
Analysis/ assessment
Plan
What is the most important aspect of evaluation?
Subjective
How much can you learn about someone’s injury from subjective assessment?
80-90%
What is a symptom?
Organic manifestation which only the patient is aware of.
What is a sign?
Observants of physical phenomenon indicative of a conditions presence.
What is the order of assessment?
Subjective Observation STTT: AROM, PROM, resisted movements Neuro sensation/reflex Special tests Palpation
Who developed the theory of selective tissue tension testing?
Dr James Cyriax
What tissues are inert?
Ligaments, bursa, capsules, fascia, nerve roots, dura mater
What tissues are contractile?
Muscles, tendons, tenoperiosteal insertion
What should the therapist be feeling for during PROM?
End of range
What does an end feel of soft tissue approximation tell us?
Normal for elbow and knee flexion
What does an end feel of bone-on-bone tell us?
Normal for elbow extension
What does an end feel of capsular tell us?
Normal for hip rotation
What does an end feel of springy block tell us?
Abnormal - like compressing a spring.
What does an end feel of spasm/stretch tell us?
Abnormal - involuntary contraction that prevents motion secondary to pain (guarding)
What does no end range tell us?
Grade 3 sprain
What position are the patients in during resisted movements?
Neutral - isometric contraction
When interpreting resisted movements, what does strong and painless mean?
Both muscle and nerve are normal.
When interpreting resisted movements, what does strong and painful mean?
Nerve is normal, minor problem with muscle
When interpreting resisted movements, what does weak and painless mean?
Possible nerve lesion, old/complete muscle rupture
When interpreting resisted movements, what does weak and painful mean?
Possible nerve lesion, significant acute muscle tear
At what point in the assessment do you do manual muscle testing?
Special tests
What is a grade 1 sprain?
Pain
Full ROM
Stable
What is a grade 2 sprain?
Significant loss of ROM
Significant pain
Slight instability and laxity
What is a grade 3 sprain?
Minimal pain
Minimal active ROM
Gross instability and laxity
What is the most important joint within the shoulder?
Scapulothroacic
How much if the shoulder is part of the upper extremity?
70%
Where does a shoulder separation occur?
Acromioclavicular joint and sternoclavicular joint
Where can a shouder fracture occur?
Humerus, clavicle, scapula
Where does a shoulder dislocation occur?
Glenohumeral joint
How much of the clavicles surface area is in contact with the manubrium?
25%
What is the most unstable shoulder joint?
Sternoclavicular
What is the movement of the clavicle when the arm moves through flexion and or abduction?
Retracts, elevated and rotates posteriorly
What are the most common causes of injury of the sternoclavicular joint?
MVA and sport injuries
How can an anterior dislocation of the sternoclavicular joint occur?
Direct trauma - rare
Indirect trauma - most common - when an anterolateral force is applied to the clavicle and the shoulder is rolled backward.
How can an posterior dislocation of the sternoclavicular joint occur?
Direct force to the anteromedial clavicle
Force to posterolateral shoulder causing it to roll forward.
How many grades of sternoclavicular joint dislocations are there?
3
What is a grade 1 sternoclavicular dislocation?
Slight pain and tenderness, no deformity
What is a grade 2 sternoclavicular dislocation?
Sublux with deformity, swelling and pain. Unable to abduct or bring arm across chest.
What is a grade 3 sternoclavicular dislocation?
Complete dislocation of clavicle
How to manage a posterior sternoclavicular dislocation?
Medical emergency - send to ER
How to manage an anterior sternoclavicular dislocation?
Reduce with lateral traction
POLI
When can the clavicle be fractured?
Any force that brings the shoulder to midline or direct force for superior or anterior direction.
What are the signs/symptoms of a clavicle fracture?
Mid 1/3 break with lateral fragment dropping down. (Most common)
Localized tenderness and swelling
Loss of function
Spasm of trapezius
What position does the injuries athlete hold their arm after a clavicle fracture?
Arm is held to body with shoulder elevated.
How to manage a clavicle fracture?
POLICE
Sling tube, figure 8 brace
Keep arm moving below 90 degrees
How long does it take a clavicle fracture to heal?
4-6 weeks
What provides vertical stability for the Acromioclavicular joint?
Coracoclavicular ligaments: conoid and trapezoid
What provides anterior/superior stability for the Acromioclavicular joint?
Acromioclavicular ligaments
What two ways can you have an Acromioclavicular separation?
Direct force when shoulder is adducted - most common
Indirect fall on outstretched hand
How many grades of acromioclavicular separations are there?
6
What is a grade 1 Acromioclavicular separation?
Small tear of capsule
No instability
Pain on palpation
Full ROM
What is a grade 2 Acromioclavicular separation?
Complete tear of capsule and coracoclavicular ligaments
Anterior posterior instability
45-90 degree abduction
What is a grade 3 Acromioclavicular separation?
Tear of capsule, Acromioclavicular ligaments and coracoclavicular ligaments
Step deformity at distal clavicle
Less than 45 degrees of abduction
No stability
What is a grade 4 Acromioclavicular separation?
All inert tissues torn
Posterior clavicle is pushed up and back
Possible tented trapezius
What is a grade 5 Acromioclavicular separation?
All inert tissues torn
Deltoid fascia stripped off
What is a type 6 Acromioclavicular separation?
All inert tissues torn
Downward displacement of clavicle pinching BP
How to treat types 4-6 Acromioclavicular separations?
Surgery
What two tests are used to test for Acromioclavicular injuries?
AC shear test
Cross flexion test
How big is the humerus compared to the glenoid?
Humerus is 3x bigger
What provides static support in the shoulder complex?
Labrum, capsule, Glenohumeral ligament
How far does the humerus have to move before the scapula begins to move too?
30 degrees
Once the humerus moves 30 degrees, how much will the scapula move compared to the humerus?
Scapula moves 1 degree for every 2 degrees the humerus moves
What are the three ligaments of the Glenohumeral joint?
Superior Glenohumeral ligament
Middle Glenohumeral ligament
Inferior Glenohumeral ligament
What ligament is strained/protects the shoulder most during abduction and external rotation?
Anterior inferior Glenohumeral ligament
Is the shoulder more supported anteriorly or posteriorly?
Posteriorly!
What supports the shoulder anteriorly?
Minimal bony support
Biceps brachii
Joint capsule
Ligaments
What provides dynamic support for the shoulder complex?
Rotator cuff
Scapular stabilizers
What muscles make up the rotator cuff?
Subscapularis
Ifraspinatus
Teres minor
Supraspinatus
What is TUBS?
Traumatic Unilateral lesion with Bankart requiring Surgery
How many shoulder dislocations occur anteriorly? Inferiorly? Posteriorly?
85% anteriorly
5% Inferiorly
10% posteriorly
What type of shoulder dislocation is most easily missed?
Posterior
How does an anterior shoulder dislocation occur?
Forced external rotation (FOOSH)
Signs and symptoms of an anterior shoulder dislocation?
Arm held slightly externally rotated and abducted
How does an inferior shoulder dislocation occur?
Arm is excessively abducted and a force is taken pushing head of humerus inferior
Signs and symptoms of an inferior shoulder dislocation?
Arm held slightly externally rotated and abducted
How does a posterior shoulder dislocation occur?
Seizures or electric shock
Arm is in flexion and adduction a force is taken on the hand
Signs and symptoms of a posterior shoulder dislocation?
Elbow is held at side with hand on stomach. Can’t externally rotate or abduct.
What is AMBRI?
Atraumatic, Multidirectional, frequently Bilateral, responds to Rehabilitation and rarely require an Inferior capsular shift.
Dead arm is a common symptom of what type of shoulder dislocation?
Atraumatic or acquired
What is dead arm?
Traction/impingement of neuromuscular structures causing transient weakness or numbness
What is a test for shoulder dislocations?
Apprehension test
What is GIRD?
Glenohumeral Internal Rotational Deficit
In what sport is GIRD most commonly seen?
Baseball
What measurement is used when assessing GIRD?
TRM (total rotational motion) = external rotation + internal rotation of left arm at 90 degrees should equal that of the right arm within 5 degrees.
What is the drop arm test used for?
Testing rotator cuff tears
How is a rotator cuff tear in children different than that in older adults?
Younger athlete is more like a true tear (rope cut)
Older athlete is more like a tendinosis (rope fraying)
What is shoulder impingement?
Weakness of the rotator cuff muscles reduces the effectiveness of the centralization of the humeral head. The humerus is pulled too far up and pinches the supraspinatus or sub acromial bursa.
What is the number one symptom of shoulder impingement?
Painful air between 70-120 degrees
Where do people with shoulder impingement feel pain?
Around acromion and over deltoid
What are shoulder impingement tests?
Hawkins Kennedy test
Neer test
Speeds test
Fowler reduction test (positive = no pain)
When treating a rotator cuff injuried patient, what are the steps of treatment?
POLICE Maintain ROM Strengthen scapular stabilizers Strengthen rotator cuff Reinforce proper movement patterns
What is kyphosis?
Increased thoracic curve
Protracted scapula
What is lordosis?
Increased lumbar curve
Increased anterior pelvic tilt
What is sway back?
Anterior shift of entire pelvis
Thoracic segments shift posteriorly causing flexion of thorax
Decrease in lordosis and increase kyphosis
What is flat back?
Decrease lordosis
Infested posterior pelvic tilt
Appears stooped forward
What is scoliosis?
Lateral curve of spine with Cobb angle greater than 10 degrees
What percent of the child population has scoliosis?
2-4%
With small curves, what gender is most likely to have scoliosis?
Same
With large curves, what gender is more likely to have scoliosis?
Girls are 10x more likely
What is a hallmark sign for curves greater than 10 degrees?
Rib hump (on side of curve apex)
What is the most common type of curve?
Right thoracic curve
What are possible causes of left thoracic curves?
Chiari malformations
Spinal cord tumors
Neuromuscular disorders
What is the difference between structural and non structural scoliosis?
Structural scoliosis has a bony deformity that will not disappear on forward flexion. Structural scoliosis may be progressive. Has rib hump.
Non structural scoliosis can be caused by tight muscles, bad posture, leg length discrepancy
What is Adams forward bend test used for?
Checking to see if scoliosis and rib hump disappear when flexed forward.
How are over use injuries caused?
Extrinsic and intrinsic factors lead to joint loads which leads to overuse injuries
What is a Q angle?
Angle formed by the femur and tibia
A large Q angle pulls the patella…
Laterally
At what point does the Q angle increase the risk of instability of the patella femoral joint?
20 degrees
Which gender has a greater Q angle?
Females
What are the three characteristics of medial collapse mechanism?
Hip adduction
Femoral internal rotation
Knee valgus
What problem could arise form genu valgus stance?
Patellofemoral syndrome
What problem could arise from genu varus stance?
IT band friction syndrome
What is the screw home mechanism?
Rotation that occurs during the last few degrees of knee extension because the medial femoral condyle is larger
If foot is planted: femur rotates medially
If foot is not planted: tibia rotates laterally
The plantar calcaneonavicular ligament = spring ligament supports what arch of the foot?
Longitudinal arches
What supports the longitudinal arches of the foot?
Tibialis posterior
Calcaneonavicular (spring) ligament
What is the purpose of the transverse arch in the foot?
Gives protection to soft tissue and increase the foots mobility
What are the characteristics of pes planus?
Decreased medial longitudinal arch
Excessive pronation
What are the characteristics of pes cavus?
Excessive medial longitudinal arch
Supination
What is the windlass mechanism?
When foot is flat on the ground, extension of toes causes tightening of plantar fascia raising the longitudinal arch.
What is the origin and insertion of plantar fascia?
Medial tubercle of the plantar surface of calcaneus to metatarsal heads
What is the purpose of the plantar fascia?
Supports the foot against downward forces and and shock absorption.
Transfers the weight from the medial to lateral sides of the foot during the gait cycle.
How much time is spent on a single leg during the gist cycle?
40% of the the time
60% in stance
What are the three movements of supination of the foot?
Inversion
Adduction
Plantar flexion
What are the three movements of pronation of the foot?
Eversion
Abduction
Dorsiflexion
How does the foot move upon impact while walking?
Tibia rotates internally with calcaneus and talus and acts to convert the torque - this unlocks the foot to distribute forces.
In what position are the mid-tarsal joints locked?
Supination
How it stability acheived during push off phase of gait?
Cuboid pulley for peroneus longus - while supinated
80% of runners have what type of heel stike?
Lateral
What type of heel strike do elite runners have?
Mid foot strike
What effect does excessive pronation cause?
Internal rotation of tibia and delayed re supination causing tibia not to externally rotate. Therefore the femur must internally rotate more to get to extension so that the tibia can be in lateral external rotation for the screw home mechanism.
What is the most common condition in the foot?
Plantar fasciitis
How many people will have plantar fasciitis?
1 in 10
Where is most of the pain felt for plantar fasciitis?
Plantar tubercle of calcaneus
Does plantar fasciitis come on slowly or quickly?
Sudden onset
What is the hallmark sign of plantar fasciitis?
Pain in first few steps after sleeping or after sitting for long periods of time
What is the most common cause for plantar fasciitis?
Changes FITT, overloading
What causes heel spurs?
Bleeding of attachment side of planar fascia to calcaneus.
Calcium deposit secondary to excessive tissue strain and repetitive trauma.
How should you treat plantar fasciitis?
Treat like -osis Manual therapy Stretching Taping Orthotics Night splints
Muscles that dorsiflex and evert?
Peroneus tertius
Extensor digitorum longus
Extensor hallicus longus
Muscles that dorsi flex and invert?
Tibialis anterior
Muscles that plantar flex and evert?
Peroneus longus
Peroneus brevis
Muscles that plantar flex and invert?
Flexor hallicus longus
Flexor digitorum longus
Tibialis posterior
Where is the problem located to Morton’s neuroma?
Issue with transverse arch between the 3rd and 4th metatarsal heads where nerve is thickest
What are the signs and symptoms of Morton’s neuroma?
Severe intermittent pain and parenthesia radiating from distal metatarsal heads to the tips of toes
Pain is relieved when not weight bearing
Treatment of Morton’s neuroma?
Metatarsal pad
Strengthen dynamic stabilizers of intrinsic foot muscles
What is the the purpose of the sesamoid bones in the big toe?
Protect flexor hallicus longus from being crushed
What causes sesamoiditis?
Often caused by repetitive hyperextension of the great toe
Signs and symptoms of sesamoiditis?
Swelling
Pain
Palpable tenderness under first metatarsal head
Warm to touch
What causes turf toe?
Forced hyperextension of the great toe (over 100 degrees)
What is turf toe?
Tearing of cause and ligaments around the 1st metatarsal head
Different signs and symptoms between turf toe and sesamoiditis?
Turf toe hurts hurts with PROM beside joint is unstable.
What is a subungual hematoma?
Bleeding underneath toe nails
How to prevent a sunungual hematoma?
Pad the forefoot under the tongue to prevent sliding in the shoe
Management of a subungual hematoma?
Heat paper clip, press into nail to release pressure and blood.
Apply sterile padding.
What causes an ingrown toenail?
Lateral pressure of poorly fitting shoes, improper trimming or repeated trauma
What is an ingrown toe nail?
Nail grows into the lateral nail fold causing it to be irritated.
Treatment of ingrown toe nail?
Soak with warm water, tease back skin from nail with q tip. Roll cotton ball and insert along border of nail.
Allow nail to grow just beyond toe and cut a small V in middle of nail.
What shape should you cut toe nails in?
Straight across
How many people get ankle sprains in the general population each year?
3.7%
What is the most common sport injury?
Ankle sprain
How many sports injuries are ankle sprains?
23%
What are the three types of ankle sprains? How many of each occur?
85% lateral
10% high (syndemosis)
5% medial
What are the three categories that provide ankle stability?
Shape of bones
Capsule and ligaments
Strength of muscles
What is the mortise? What is it made of?
Talocrucal joint
Made of lower end of tibia, lateral malleolus, medial malleolus
Why is the ankle more stable when in dorsi flexion?
The trochlear surface of the talus is wider anteriorly than posteriorly
What are the three ankle ligaments?
Anterior talofibular ligament (ATFL)
Calcaneofibular ligament (CFL)
Posterior talofibular ligament (PTFL)
Which ligament of the ankle is injuried most often?
ATFL
When is the ATFL strained?
Plantar flexion and inversion
What type of ligament is the ATFL?
Capsular
What type of ligament is the CFL?
Extra capsular
When is the CFL strained?
Adduction/medial tilt from neutral to dorsiflexion
What is the strongest lateral ankle ligament?
PTFL
When is the deltoid ligament strained?
Anterior part is tight in plantar flexion and eversion
Middle part is tight in neutral
Posterior part is tight in dorsiflexion
Limits talar abduction/ lateral tilt
What are the two ankle stability test?
Anterior drawer test and talar tilt test
When is the ankle anterior drawer test used?
Testing ATFL
When is the talar tilt test used?
Testing CFL or deltoid ligament
What are the 5 components of the Ottawa ankle rules?
Pain on posterior edge or tip of lateral malleolus (6cm)
Pain on posterior edge or tip of medial malleolus (6cm)
Pain on base of 5th metatarsal
Pain on navicular
Can’t walk 4 steps
What is a “healthy” ankle?
Eversion and external rotation of the ankle without deltoid ligament tear - bone trauma to tibia and fibula
How to test for “healthy” ankle injury?
Squeeze test
How to test for lower leg fracture?
Gentle external rotation
What is significant about true tendon pain that helps to differentiate it?
True tendon pain is confined to the tendon itself.
Pain on stress and press
What is retrocalcaneal bursitis?
Inflammation of the bursa that is between the tendon and the calcaneus
Where is pain felt with retrocalcaneal bursitis? How to test?
Pain just above the insertion of the Achilles.
Pain with squeeze from side.
What is Achilles bursitis?
Pain on posterior aspect of heel over calcaneus which is often due to excessive friction.
What is the thickest and strongest part of the body?
Achilles’ tendon
What is tendinitis?
Inflammation of the tendon itself and is relatively rare
What is paratenonitis?
Inflammation, pain and crepitation of the paratenon as it slides over the structure.
What are the predisposing factors of Achilles tendinosis?
Years of running Excessive pronation Poor flexibility Training in cold climate Improper footwear
Signs and symptoms of an Achilles rupture?
Hears a pop or snap. Pain may be immediate the rapidly subsides. Pain only at site of tear.
Usually 1-2 inches above insertion.
What test do you use for testing an Achilles rupture?
Thompsons test
What can cause overuse injuries of the knee?
Lower chain alignment: valgus or varus Excessive pronation Medial collapse mechanism Shortened muscles that cross the knee Pull of quads - vastus medialis dysfunction
What is vastus medialis dysfunction?
Weak vastus medialis cannot maintain alignment against pull of other 3 quads.
What happens to the soft tissue when the patella moves laterally?
Hyper pressure on lateral side resulting in cartilage run and fibrillation
Hypo pressure on medial side resulting in cartilage degeneration from inside out.
What is knee locking a sign of?
Meniscus damage
What is hemarthrosis?
Bleeding into the joint. Typically occurs more quickly than synovial effusion. Within 4 hours of injury.
What is the most common acute knee injury in adults?
72% are ACL tears
What is the second most common acute knee injury in adults?
Patellar dislocation
What is the number one acute knee injury in children?
Patellar dislocation
What are the 5 components of the Ottawa knee rules?
Age greater than 55 or less than 18 Tender over fibular head Tender over patella Inability to flex 90* Inability to walk 4 steps
What happens in an acute patellar dislocation?
The patella moves out of its groove laterally onto/over femoral condyle
Mechanism of injury for a patellar dislocation?
Forceful knee external rotation of tibia
Foot planted
Knee usually near full extension
Signs and symptoms of an acute patellar dislocation?
Hemarthrosis
Loss of knee function until replaced
Fever ness over medial border of patella
What test is used for a lateral patellar dislcoation?
Lateral apprehension test
What do you do if the patella is dislocated?
Slightly flex the hip and slowly extend the knee
If the patella does not go back on its own after a dislocation, what should you do?
Do not force it - need to get X-rays!
What supports the knee laterally?
LCL: lateral collateral ligament
Muscles: biceps femoris, IT band, popliteus
What supports the knee medially?
MCL
Muscles (if in full extension)
Bony structure
When does LCL damage occur?
Varus loading possibly with hyperextension
How often does a LCL injury occur?
1/4 knee injuries
At what degree of flexion does LCL contribute most to stability?
20-30 degrees of flexion
At what degree of flexion does MCL contribute most to stability?
20-30 degrees of flexion
How often does a MCL injury occur?
40% of knee injuries
When does a MCL tear occur?
Valgus force with or without rotation
How to get for MCL tear?
Valgus stress
How to test for a LCL tear?
Varus stress
How are signs different for MCL tear vs. LCL tear?
LCL tear has less swelling.
What movements dresses collateral ligaments?
Tibial lateral rotation
What movement stresses cruciate ligaments?
Tibial medial rotation
How many ACL injuries during contact or non contact MOI?
60-80% non contact
What other injuries are common to occur at the same time as a ACL tear?
75% meniscus injury
80% have lateral bone bruise
What gender is more likely to tear their ACL?
Females injure their ACL 2-8x more often
What is the MOI of ACL tears?
Valgus (ACL will tear after MCL tear) during contact
Deceleration and internal rotation - non contact
Does hemarthrosis always occur with an ACL tear?
Only 75% of time
What are ACL tests?
Anterior drawer test
Lockmans test - better because pull of hamstrings affects anterior drawer test giving false positive
How much more likely is a ACL injury vs. PCL injury?
Only 1/10 cruciate injuries involved the PCL
What is the most common MOI of a PCL tear?
MVA
How does the PCL tear?
Impinged between posterior tibia and Intra condylar notch roof
Signs and symptoms of a PCL injury?
Poorly defined pain in back of knee
Minimal selling at time of injury
What tests are used for PCL tear?
Posterior drawer test
Sag test
What results in more fatalities than any other sports injury?
Head traumas
What is the purpose of CSF? (In relation to head traumas)
Acts to covert a focal force into compressive stress dissipated ovr the brains full surface area
Signs and symptoms of a skull fracture?
Severe headache and nausea Palpation may reveal divot/defect in skull Blood in middle ear, eye, nose Raccoon eyes and or battle signs Halo sign
What is ‘raccoon eyes’? When does it occur?
Peri orbital ecchymosis
Late finding - 24-48 hours post injury
What is ‘battle signs’? When does it occur?
Periauricular ecchymosis
Late finding - 24-48 hours post injury
What is the halo sign?
CSF will leak away from blood when placed on gauze - indicating a skull fracture
What is the acronym for normal pupil reaction? What does it stand for?
PEARL: pupils equal and responsive to light
What does equal, dilated and unresponsive pupils indicate?
Cardiac arrest, CNS injury
What does equal, constricted and unresponsive pupils indicate?
CNS injury or disease, narcotic drug use (heroine, morphine)
What does unequal, one dilated, unresponsive pupils indicate?
Cerebrovascular accident (stroke), head injury, direct trauma to eye
What is a epidural hematoma?
Blow to head causes tearing of meningeal arteries. Blood pressure increases, blood accumulation and creation of hematoma occur rapidly.
What are the signs and symptoms of an epidural hematoma?
LOC followed by a period of lucidity - showing few signs of a serious head injury.
Gradual progression of symptoms: head pains, dizziness, nausea, dilation of 1 pupil (aka anascoria), depression of pulse and respiration, convulsion
What is the care procedure for an epidural hematoma?
Urgent neurosurgical care
Must relieve pressure to avoid disability or death
What is a subdural hematoma?
Acceleration or deceleration forces cause tearing of veins that bridge he dura mater and brain
What are the signs and symptoms of a subdural hematoma?
LOC within seconds to minutes. Dilation of one pupil. Headache, dizziness, nausea, sleepiness.
What is the care procedure for a subdural hematoma?
Immediate medical attention
CT or MRI is necessary to determine the extent of injury
What is the leading cause of catastrophic death?
Subdural hematoma
How to care for a scalp laceration?
Clean with antiseptic soap and water. Apply firm pressure.
Wounds larger than 1/2 inch should be referred.
How long after a head trauma should the athlete be monitored for?
4-6 hours
What are the steps for a physical exam for fascial injuries?
Identify active bleeding
Look for signs of orbital blowout fracture
Palpation of facial bones
Evaluation of eye movements
Where is the most common place for a mandibular fracture?
Frontal angle
What are the signs and symptoms of mandibular fractures?
Pain with biting Deformity - palpate inferior borders and mandibular condyle Loss of occlusion Bleeding around teeth Lower lip anaesthesia
How to care for a mandibular fracture?
Temporary immobilization with elastic wrap
Emergency medical referral
What are the signs and symptoms for a zygomatic complex fracture?
Deformity and bony discrepancy
Palpable step offs in the upper later orbital rim and inferior orbital rim
Cheek numbness
Upper lip and ipilateral teeth numbness
Nose bleed on side of injury
Diplopia (double vision) and possible restricted eye movements
Subconjectival hemorrhage and peri orbital ecchymosis
What is the maximum amount of time after an injury for an athlete to be sutured?
8-10 hours
How to test for facial nerve damage?
Facial asymmetry
Assess opening and closing mouth
Difficulty wrinkling brow, showing teeth, frowning, closing the eyes tightly
What are the three types of tooth damage?
Uncomplicated fractures: produce fragments without bleeding
Complicated fractures: produce bleeding with the tooth chamber being exposed - very painful
Root fractures: difficult to determine-need X-ray
How to care for a uncomplicated and complicated tooth fracture?
Do not require immediate attention - can wait 24-48 hours
Place fractured piece in milk or save a tooth solution
Control bleeding with gauze
How to care for a root fracture?
Athlete can finish game but must follow up immediately after.
What is a subluxed tooth? How to care for it?
Tooth may be loose within socket with little or no pain. Referral within 48 hours.
What is a luxed tooth? How to care for it?
Tooth displacement without a fracture. Reposition should be attempted along with immediate follow up.
What is a tooth avulsion? How to care for it?
Tooth is completely knocked out of oral cavity. Clean and cover tooth with prophylactic antibiotics. Reposition tooth if athlete is conscious or store in moist environment (save a tooth solution, cold milk, cold saline, athletes cheek, cold water).
Only have 2 hours to replace tooth!
Signs and symptoms of nasal fractures and chondral separation?
Possible deviation of tip or dorsum of nose
Palpat for crepitus, step deformity or bony adymmetries
How to care for nasal fractures or chondral seperation?
Secure airway if needed.
Control bleeding by external pressure and internal packing if needed.
Refer to physician
Cause of deviated septum?
Compression or lateral trauma
Signs and symptoms of a deviated septum?
Bleeding and possibly a septal hematoma
Athlete will complain of nasal pain
Care for a deviated septum?
Compression (MD should drain), wick is inserted, packing
What happens if a septal hematoma is neglected?
A neglected hematoma will result in formation of an abscess along with bone and cartilage loss and deformity.
What is an epistaxis?
Nose bleed
Signs of an epistaxis?
Bleeding from anterior aspect of septum.
Care for an epistaxis?
Sit upright with cold compres over nose. Apply pressure to affected nostril.
Gauze between gum and upper lip will limit blood supply.
What is the nickname of an auricular hematoma?
Cauliflower ear
Cause of injury for an auricular hematoma?
Either from compression or shearing force to the ear (single or repeated) causing subcutaneous bleeding.
What are the signs of an auricular hematoma?
Haemorrhaging and fluid accumulation - appears elevated, white, rounded, nodular and firm = like a cauliflower
What happens if an auricular hematoma is left untreated?
Coagulation, organization and fibrosis
How to care for an auricular hematoma?
Physical aspiration, packing, pressure
Keloid removal if necessary
What can cause a rupture to the tympanic membrane?
Fall or slap to the unprotected ear
Sudden underwater variation
Signs and symptoms of a ruptured tympanic membrane?
Complain of loud pop then pain
Nausea, vomiting, dizziness
Hearing loss and visible rupture
What is otitis media?
Middle ear infection
What are signs of a middle ear infection?
Intense pain in ear, fluid drainage from ear canal, transient hearing loss
Signs of infection (fever, headache, irritability, loss of appetite, nausea)
How long does a middle ear infection normally last?
24 hours. Pain may last 72 hours.
How many ocular injuries occur in sport each year?
Over 100’000
What is a blow out fracture?
When pressure on the eye causes the suborbital bone to fracture
Signs of a orbital fracture?
Diplopia
Restricted eye movement
Downward displacement of eye
Soft tissue swelling and haemorrhaging: sub conjunctival haemorrhaging, peri orbital ecchymosis
Unilateral epistaxis
Numbness: infra orbital nerve impingement
How to care for a orbital fracture?
Ice
Do not blow nose!
Need x ray
What is a orbital hematoma?
Black eye
How to care of a orbital hematoma?
Cold application for at least 30 minutes
24 hours rest if there is distorted vision
Do not blow nose
What are signs and symptoms of corneal abrasions?
Watering of eye
Photophobia
Decreased focusing ability
Spasm of orbicular muscles of eyelid
How to care for a corneal abrasion?
Patch eye
Refer to physician
What is hyphema?
Blood pooling in the lens/iris
How do you get hyphema?
Direct blow to eye.
What are the signs and symptoms of hyphema?
Visible reddish tinge in anterior chamber of eye (blood may turn pea green)
Vision is partially or completely blocked
How to care for a hyphema?
Immediate referral to opthamologist.
Best rest and elevation.
Both eyes patched.
Medication to reduce anterior chamber pressure.
What is a retinal detachment?
Blow to the eye can partially or completely separate the retina from underlying retinal pigment epithelium
What are the signs and symptoms of retinal detachment?
Flash of bright light then fall of curtain
Seeing specks of light
Blurred vision
How to care for someone with retinal detachment?
Refer to opthamologist
Best rest
Patch both eyes
What is acute conjunctivitis?
Pink eye
What is the cause of pink eye?
Bacterial or viral infection
Allergies
What are the he signs and symptoms of pink eye?
Eyelid swelling with purulent discharge
Burning or itching
Pinkish tinge
If there is a chemical eye injury, how long do you flush the eye for? At what stage of the assessment does this occur?
30 mins before the assessment
What are the 4 stages of a eye assessment?
History
Check vision with newspaper 16” away
Physical examination of pupil, cornea, conjuntivia (penlight exam, foreign bodies)
Eye movements
How is a minor injury to the larynx dangerous?
Can go into spasm up to hours later - blocking airway
Signs and symptoms of larynx following trauma?
Hoarseness, loss of prominence in anterior neck, difficulty breathing, pain with swallowing, subcutaneous emphysema, hematoma/hemaptysis
What is hemaptysis?
When blood mixes with air causing you to cough up pink frothy blood.
What percent of athletic injuries affect the abdomen?
10%
What are the signs and symptoms of rib contusions?
Blow to front or side causing localized pain during inspiration and with palpation.
What ribs are most commonly fractured?
5-9
What is the weakest point of the ribs? (Where they are normally fractured)
Posterior angle
What are the signs and symptoms of rib fractures?
Athlete is trying to split themselves - bent forward holding chest.
With coughing and deep inspiration.
Trunk movements increase pain
What is a costochondral injury?
Compression of the anterolateral ribs causes a separation of the cartilage and rib
What are the signs and symptoms of costochondral injuries?
Local swelling and tenderness
Hematoma
Step off deformity
What is the most commonly strained thoracic muscle?
Intercostal
How to thoracic muscle strains occur?
Usually violent external forces or trauma
Over stretching via rotation
What is the difference between a pneumothroax and a tension pneumothroax?
Pneumothroax is a partial lung collapse
Tension pneumothorax is a full collapse.
What happens in a pneumothroax? What are the signs and symptoms?
Pleural cavity filled with air through opening in chest.
What happens in a tension pneumothroax?
Pleural sac fills with air. Displacement of heart to the other side. Trachea may deviate. Other lung may collapse.
What is a hemothorax? What are the signs and symptoms?
Presence of blood in the plural cavity.
Difficulty breathing, shortness of breath and cyanosis
Hemaptysis - coughing up frothy blood
What is commotio cordis?
When the heart receives blunt trauma when it is depolarizing.
What does commotio cordis result in?
Cardiac arrest
How is more susceptible to commotio cordis?
Young athletes because they have a more pliable chest wall.
What is the survival rate of commotio cordis?
50% (depends on when the defibrillation is delivered)
For every minute after the heart stops, how much does the persons survival rate drop?
10% per minute
How can you tell the difference between an abdominal muscular contusion and internal bleeding?
With internal bleeding the abdominal wall will not relax - will feel firm.
What is the most commonly strained abdominal muscle?
Rectus abdominus at lower rib insertion or pubic rami insertion
What causes an abdominal muscle strain?
Sudden violent contraction or recurrent micro trauma
What are the signs and symptoms of an abdominal muscle strain?
Localized pain and spasm at site of injury.
STTT positive
What is osteitis pubis?
Too much pull through rectus abdominus may cause unequal force through the pelvic ring or injury to the periosteum.
What activities would you be doing to notice pain with osteitis pubis?
Running, sit-ups, squats
What is another name for the celiac plexus?
Solar plexus
What could cause trauma/injury to the celiac plexus?
Trauma to relaxed abdominal wall or through back
What would trauma to the celiac plexus effect?
Temporary paralysis of her diaphragm (wind knocked out)
What type of breathing should people with a injury to the celiac trunk do?
Slow expiration
Short inspiration
What organs are in the right upper quadrant of the abdomen?
Liver Right kidney Gall bladder Colon Pancreas
What organs are in the left upper quadrant of the abdomen?
Stomach Kidney Spleen Colon Pancreas
What organs are in the right lower quadrant of the abdomen?
Appendix
Colon
Small intestine
What organs are in the left lower quadrant of the abdomen?
Colon
Small intestine
Half of bladder
Where is pain felt after a liver/gallbladder injury?
Over liver and gall bladder on front
Small area over liver at back
Over right shoulder (trapezius area)
Where is pain felt after a stomach injury?
Semi-large area at the midline (at stomach height) on front and back
Where is pain felt after a pancreas injury?
Small area to the left of the pain of the stomach (left of midline) on front and back
Where is pain felt after an injury to theft and spleen?
Over left chest and down the inside/ulnar side of arm till mid forearm
Where is pain felt after a kidney injury?
“Loin to groin”
Larger area at front than back
Where is pain felt after an appendix injury?
Small area between ASIS and umbilicus (McBurneys point)
Where is pain felt after a bladder injury?
Over bladder on front over rectum in back
What should you do if there is a penetrating Intra-abdominal injury?
Leave the object in place unless bleeding is compromised
Focus on controlling the bleeding
What is the most common athletic trauma?
Blunt trauma to abdomen
What does the loss of bowel sounds indicate?
Acute abdominal injury
Why does the spleen have referred pain in the shoulder?
Diaphragmatic irritation
Why does an injuried spleen have slow onset of symptoms?
Symptoms are secondary to bleeding
If there is a contusion to the liver, what signs and symptoms should you look for?
Occasional nausea and vomiting
If there is a laceration on the liver, what signs and symptoms should you look for?
Abdominal rigidity
Guarding
Referred pain
Loss of bowel sounds
What is the most commonly injured abdominal organ?
Kidneys
What could be the MOI for an injured kidney?
Blunt trauma to flank or abdomen
Repetitive micro trauma (jostling)
What are the signs and symptoms of kidney injuries?
Flank pain, tenderness, ecchymosis and hematuria
What is hematuria?
Blood in urine
At what temperature does the body absorb heat from the environment?
27C = 80F
How can the body loose heat when it is hotter than 27*C outside?
Evaporation only
When the humidex is below 29, what danger are you in? What symptoms can you experience?
Have caution
Little discomfort. Fatigue possible with prolonged exposure and or physical activity
When the humidex is between 30-39, what danger are you in? What symptoms can you experience?
Have extreme caution
Some discomfort. Heatstroke and heat exhaustion possible with prolonged exposure and or physical activity.
When the humidex is between 40-54, what danger are you in? What symptoms can you experience?
Danger
Great discomfort. Avoid exertion. Seek a cool shady place. Heat exhaustion likely. Heat stoke possible with continued exposure or physical activity
When the humidex is above 55, what danger are you in? What symptoms can you experience?
Extreme danger
Heatstroke imminent with continued exposure
What is the modern hypothesis to heat cramps?
Alternations in the spinal cord reflex are secondary to fatigue
What is the modern hypothesis to heat syncope?
Due to blood pooling and poor venous return
What is exertional heat stroke?
The patient had exertion-related hyperthermia (core body temperature above 40*C) and associated central nervous system disturbance or organ damage.
What are are the signs and symptoms of exertional heat stroke?
Dizziness, weakness, nausea, fast pulse and respiration, confusion
Collapse, sudden LOC
Stop sweating - hot dry skin
What are the signs and symptoms of heat exhaustion?
Heavy sweating with pale, moist, cool skin
Headache, weakness, dizziness, nausea, chills/goosebumps, rapid respiration
What is heat exhaustion?
An inability to continue functioning in the t without evidence supporting the diagnosis of heat stroke (core temp less than 40 degrees)
How to care for patients with mild exertional heat innesses?
Care on sideline for up to 1 hour with 2L of fluids
Frequent vital signs check and mental assessment
How to care for patients with moderate-severe exertional heat illnesses?
Ice water submersion, fanning, rehydration, frequent vital signs and mental status check
Arrange for quick evacuation to hospital
What are the 5 concepts to combatting heat illnesses?
Get an accurate temperature Keep/ get the cool Allow time to acclimatize Train athletes and coaches to recognize signs of heat illnesses Keep hydrated
What is the most accurate way to measure core body temperature?
Rectal thermometer
Most EHS deaths occur among non acclimatized players during the first ___ days if practice?
3
How long does it take conditioned athletes to acclimatize to new hot environment?
4-7 progressive exercise sessions 1-4 hours total duration over a period of 1-2 weeks
What is the physiological definition of dehydration?
Loosing 2% of body mass from water deficit
For every 1% or body weigh loss from fluid, how much does the cord body temperature increase?
0.15-0.2 *C
How much dehydration causes decreased muscular strength?
5%
How much dehydration cause decreased max aerobic power?
3%
What and when you should drink before exercise?
500-600 ml of 6% CHO drink 2 hours before exercise
200-300 ml 10-20 mins before exercise
What and when should you during exercise?
Drink when thirsty
If longer than 50 mins or excessively sweating have 6% CHO drink
What and when should you drink after exercise?
Drink enough to replace fluid loss within 2 hours
Should have water, CHO and electrolyte
Have another 50% for urine loss within 4-6 hours
What should you increase your intake of during acclimatization?
Sodium
How much weaker is the epiphyseal plate compared to the rest of the bone?
2-5x
How many childhood fractures occur at the growth plate?
15-30%
What is the metsphysis?
Area of bone surrounding the epiphyseal plate
What is apophysis?
Growth plate surrounding/on site of tendon attachment
What type of forces are growth plates most resistant to?
Tension (not rotational)
What is little league shoulder?
Stress fracture of the proximal epiphyseal plate of the humerus?
What age group is most susceptible to little league shoulder?
11-16 year olds
What is the care procedure for little league shoulder?
Abstinence from throwing for 4-6 weeks
Do not need to immobilize
What is a slipped capital epiphysis?
Femoral head maintains position while femoral neck slips upward
Who is most susceptible to slipped capital epiphysis?
12-15 year olds
Overweight males
What are the signs and symptoms of a slipped capital epiphysis?
Decreased hip adduction and internal rotation
Shortening of leg and held externally rotated
Caffe procedure for a slipped capital epiphysis?
Emergency surgery
What is little league elbow?
Medial epicondylar apophysitis
What causes little league elbow?
Traction on the medial side and compression of the lateral side
Signs and symptoms of little league elbow?
Medial elbow pain - over medial epicondyle
Pain with resisted wrist flexion and pronation
Valgus stress on elbow
Tenderness on lateral side from bone on bone compression
What is the care procedure for little league elbow?
Complete rest for 4-6 weeks
Start 8 week gradual throwing program
Where can hip avulsions occur? Where is most common?
ASIS - most common
AIIS
What is different in the symptoms of a ASIS hip avulsion vs a AIIS hip avulsion?
AIIS has poorly localized groin pain; will be sore with knee extension
ASIS will displace inferiorly over the AIIS
What are the signs and symptoms of a green stick fracture?
Tender on palpation of mid shaft
Swelling
May have decreased ROM or pain with weight bearing
May have hump from bend in bone
What is the care procedure for a green stick fracture?
Immobilization for 3-4 weeks
After a fracture, what is most important to regain first? (ROM or strength)
ROM first
What is osgoods-schlatter’s disease?
Continuous contraction or stretch of quads causing softening or partial avulsion of the apophysis at the tibial tuberosity
What is shinding-Larsen-johansson disease?
Continuous contraction or stretch of quads causing softening or partial avulsion of the apophysis at the inferior pole of patella
What are the signs and symptoms of OS disease or SLJ syndrome?
Slow onset tenderness over tibial tuberosity or inferior patella
Tightness of surrounding muscles
Possible excessive pronation
How to care for OS disease or SLJ syndrome?
Activity modification - don’t run or jump
Ice
Strengthen/stretch muscles
What is severes disease?
Calcaneal apophysitis of the insertion of the Achilles
Who is most likely to have severs disease?
7-10 year olds
Management of severs disease?
Insert heel raise to decrease pain
Stretch plantar flexors
Strengthen plantar flexors and dynamic stabilizers when pain free
Correct over pronation
How long does it take to recover from severs disease?
6-12 months (max 2 years)
