High Yield 7 Flashcards
Describe the decision based RTP model
Evaluation of health status (medical factors)
Pt demographics
S+S
PMH
Functional tests
Psychological state
Potential seriousness
Evaluation of participation risk
Type of sport
Position played
Limb dominance
Competition level
Ability to protect
Decision modification
Timing + season
Pressure from athlete
External pressure
Injury masking
Conflict of interest
Fear of litigation
Eligible impairment types in the Paralympics
Impaired muscle power (spinal cord injury, muscular dystrophy)
Impaired passive ROM (contracture, traumatic joint injury)
Limb deficiency
Leg length difference
Short stature
Hypertonia (CP, TBI, stroke)
Ataxia (CP, TBI, stroke, MS)
Athetosis (slow involuntary movements - CP, TBI, stroke)
Vision impairment
Intellectual impairment
What is autonomic dysreflexia?
Stimuli below level of lesion triggers a reflex of sympathetic overstimulation
Sx of autonomic dysreflexia
Usually pts w/ cord injury at or above T6 but as low as T10
Throbbing HA, profuse sweating, flushing, anxiety, blurred vision
Triggers for autonomic dysreflexia
ingrown toenail, kidney stones, pressure sores, bowel obstruction, constipation, bladder obstruction (blocked catheter), sitting on a pin, tightening straps, boosting (intentionally causing autonomic dysreflexia to induce bradycardia which increases performance)
Physical for autonomic dysreflexia
Bradycardia
HTN >200
Management of autonomic dysreflexia
Monitor BP q5 mins
Elevate head + lower legs
Loosen clothing inc removing abdo binders, compression stockings
Check bladder drainage equipment for kinks, clogging, overfull bag
Empty leg bag
If ?blocked, irrigate gently with 10ml NS
If still no urine flow, re-catheterise
Be aware of sudden hypotension if urine does start flowing
Fecal evacuation
Apply lignocaine gel around anal sphincter and into rectum
Leave for 5 mins
Insert finger to digitally evacuate stool
Monitor BP throughout - if BP increases, stop and give med before continuing
Meds - if BP >150 and no cause identified with above measures, start med
GTN spray 1 spray 400mcg (ensure no viagra in last 24hrs)
Captopril 25mg SL
Nifedipine 10mg
Nitropaste 2% 2.5cm - apply above level of lesion
Sodium nitroprusside
Complications of autonomic dysreflexia
Szs
MI
Retinal hemorrhage
Pulmonary edema
Cerebral hemorrhage
How does an episode of autonomic dysreflexia affect comp?
BP can be checked prior to comp, if >180, athlete removed but not sanctioned
Describe the issues with Thermoregulation in para athletes
Sweating is impaired below level of injury - important to hydrate + acclimatize appropriately, cooling + pre-cooling enhance endurance (ice packs, misting, ice baths, slurpees)
Reduced shivering response + lack of sensation causes inability to maintain warmth
Describe the issues with Osteopenia in para athletes
Immobility of paralysis promotes lower limb + spine osteoporotic changes
Increased risk of #s with minimal trauma
Describe the issues with Neurogenic bladder in para athletes
Increased frequency of UTIs d/t incomplete voiding, increased bladder pressure, catheter use
Often subtle findings of infection (reduced performance, fatigue, reduced appetite)
Prevent UTIs w/ hydration, cranberry juice, aseptic technique w/ catheters
Don’t treat asymptomatic bacteriuria
What are the uses of CT, US vs MRI
CT - useful adjunct for intra-articular fracture preoperative planning in larger joints, where the fractured bone is to be repaired rather than replaced, or complex areas, such as the carpal or tarsal regions
US - ideal inexpensive way of assessing superficial soft tissues for both trauma and masses. It has the distinct advantage of being dynamic, imaging the patient in real time as they move, and also being interactive with the patient, assessing their points of pain
MRI - useful method for assessing the soft tissues for injury or mass, the bones for occult injuries, and bone marrow changes
What imaging modality is useful, and what view are needed for fingers
XRs useful for trauma, FB, localized mass
Views: PA, oblique, lateral
US for radiolucent FB
MRI or US for mass or tendon lesion/ injury
What imaging modality is useful, and what view are needed for the thumb
XRs useful for trauma, FB, localized mass, UCL avulsion
Views: PA, lateral
US for radiolucent FB
MRI or US for mass, UCL injury or tendon lesion/ injury
What imaging modality is useful, and what view are needed for the hand
XRs useful for hand pain
Views: PA, oblique, lateral
MRI + US for soft tissue
What imaging modality is useful, and what view are needed for the wrist
XR useful for wrist pain
Nontraumatic views: PA, ulnar oblique, lateral
Traumatic views: PA, ulnar oblique, radial oblique, lateral wrist, navicular view, scaphoid views (oblique + ulnar deviation w/ cranial angulation), clenched fist AP (for scapholunate ligament disruption)
US useful for soft tissue + tendon
CT for occult scaphoid # or hook of hamate #
MRI good for AVN lunate or scaphoid, TFCC tears, intercarpal ligament injuries
What imaging modality is useful, and what view are needed for the forearm
XR useful for trauma, mass, FB, OM, abscess
Views: AP, lateral
US or MRI for soft tissue
What imaging modality is useful, and what view are needed for the elbow
XR good for chronic injuries, arthritis, FB, olecranon bursitis
Views: AP, lateral (good for olecranon bursitis + effusion)
Trauma views: AP, lateral, radial head
US or MRI for soft tissue
What imaging modality is useful, and what view are needed for the humerus + shoulder, ?hill sachs lesion, ?bony bankart lesion, ?dislocation, ?nerve impingement
XR good for trauma, infection, mass, FB
Views: AP/ external rotation, lateral/ internal rotation
Outlet view for subacromial nerve impingement
Stryker notch view for Hill-Sachs lesions
Westpoint view for bony Bankart lesions
Velpeau view for dislocation
Trauma views: AP scapula, lateral Y view, axillary view
US or MRI for rotator cuff
CT for pre-op planning before shoulder replacement or for Hill-Sachs or bony Bankart lesions
What imaging modality is useful, and what view are needed for the scapula
XR good for trauma, scapulothoracic syndrome
Views: AP, lateral
CT for trauma work up
What imaging modality is useful, and what view are needed for the AC joint
XR (bilateral) with and without weights to assess for separation
AP shoulder
What imaging modality is useful, and what view are needed for the clavicle
XR good for #
AP at 0 + 10 degree angle
CT for medial clavicle #
What imaging modality is useful, and what view are needed for toes
XR good for trauma, FB, mass
AP, medial oblique, lateral
US for radiolucent FB
MRI or US for soft tissue
What imaging modality is useful, and what view are needed for the foot
XR good, wt bearing for foot alignment, non wt bearing for FB, mass or ?osteomyelitis
AP (dorsoplantar), medial oblique, lateral
Sesamoid view (for sesamoid OA)
PA axial + lateral calcaneus (for heel pain)
US or MRI for morton’s neuroma, plantar fasciitis
MRI for occult # or mass
CT for Lisfranc injuries
What imaging modality is useful, and what view are needed for the ankle
XR (wt bearing for alignment, non wt bearing for trauma or mass)
AP, mortise, mediolateral lateral
Calcaneal or heel projections for heel pain
Broden view for posterior subtalar joint for intra-articular # or arthritis
Stress views (AP w/ varus stress) for ligamentous laxity (get bilateral)
CT for complex hindfoot #
MRI for tendons + ligaments + occult #
US for tendon injuries
What imaging modality is useful, and what view are needed for tib + fib
XR should include ankle + knee joints. Useful for trauma, FB, mass
AP, mediolateral lateral
MRI or bone scan for stress #
What imaging modality is useful, and what view are needed for the knee
XR good for arthritis
AP, mediolateral lateral
Trauma: AP, mediolateral lateral + lateromedial crosstable lateral
Merchants + sunrise view for patella alignment
MRI for internal derangement (less helpful when obvious OA on XR)
CT for occult tib plateau # + for surgically planning
What imaging modality is useful, and what view are needed for the femur
XR should include hip + knee
Nontraumatic: AP proximal + distal, mediolateral lateral to include knee, lateral frog leg hip
AP proximal + distal, cross table lateral femur, inferosuperior lateral to include proximal femur
What imaging modality is useful, and what view are needed for the pelvis + hips
XR for trauma
Nontrauma: AP pelvic, frog leg lateral
Trauma: AP pelvis, crosstable lateral, oblique pelvis
CT for full assessment of trauma
What imaging modality is useful, and what view are needed for the SI joints
XR good for screening for sacroiliitis
AP pelvis, AP oblique of each SI joint
MRI good for sacroiliitis
What imaging modality is useful, and what view are needed for the skull
XR not often used
PA, lateral, Townes
CT best
What imaging modality is useful, and what view are needed for the face
XR useful in facial trauma
Occipitofrontal, occipitomental, occipitomental w/ 30 degree cranial angulation, lateral face
Mandible views: Occipitofrontal, AP axial, inferosuperior oblique
Nose views: coned down occipitofacial, lateral
CT for further assessment of facial trauma
What imaging modality is useful, and what view are needed for C spine
XR
AP, lateral, AP odontoid, swimmers view (if C7-T1 not visualised on lateral view)
Flexion-extension series (to assess for stability, delay for 10 days after acute injury) - flexion + extension lateral, AP
CT for acute trauma
MRI or CT for chronic pain/ radiculopathy
What imaging modality is useful, and what view are needed for T spine
XR
AP, lateral
CT for any #
MRI in cases of long tract signs
What imaging modality is useful, and what view are needed for L spine
XR
AP pelvis, AP lumbar, lateral lumbar
What imaging modality is useful, and what view are needed coccydynia
XR
AP, AP caudal, lateral
What imaging modality is useful, and what view are needed for scoliosis
XR - scoliosis series
Used for measuring Cobb angle
PA + lateral wt bearing
What XR view is needed for ?rib #
PA erect chest
What imaging modality is best for sternoclavicular joint
CT
How to calculate sensitivity
True positive / (true positive + false negative)
How to calculate specificity + what is it?
SPIN: Stands for “Specific test when Positive rules IN the disease”
proportion of people without a disease who test negative for it
True negative / (true negative + false positive)
How to calculate positive predictive value + what is it?
the probability that a person with a positive test result has a disease or condition
True positive / (true positive + false positive)
How to calculate negative predictive value + what is it?
the likelihood that a person with a negative test result does not have a disease or condition
True negative / (true negative + false negative)
What is sensitivity?
Probability of detection (true positive rate)
Highly sensitive test will have few false negatives
What is specificity?
Probability of healthy people measured as a negative test (true negative rate)
Highly specific test has few false positives
What is incidence?
The rate of new cases of a disease
Usually number of new cases in a given time frame
Equivalent to risk of getting disease
What is prevalence (+ point prevalence + period prevalence)?
Actual number of cases alive
Point prevalence = actual number of cases on a particular date in time
Period prevalence = actual number of cases during a given period
What is level I evidence?
Systematic review or meta analysis of all RCTs
What is level II evidence?
RCT
What is level III evidence?
Well designed, well controlled trial with no randomization
What is level IV evidence?
Case control or cohort study
What is level V evidence?
Systematic reviews of descriptive and qualitative studies
What is level VI evidence?
Single descriptive study (case report)
What is level VII evidence?
Opinions, expert committee reports
What is NNT?
Number of pts needed to treat to prevent 1 additional bad outcome
Inverse of absolute risk reduction
If a drug reduces the risk of a bad outcome from 50% to 40%, what is the ARR + NNT?
ARR = 0.5-0.4 = 0.1
NNT = 1/0.1 = 10
What is ARR?
The difference in event rates between the control and treatment groups
Control event rate (CER) - experimental event rate (EER)
The difference in risk between a treatment and control group. It tells us how much a treatment reduces risk compared to no treatment.
What is the NNH?
Indicates how many pts need to be exposed to a RF over a specific period to cause harm to one patient
Inverse of attributable risk
What is relative risk?
The ratio of risk between an exposed and unexposed group. It shows how many times more (or less) likely the outcome is in the exposed group.
Incidence with exposure / incidence without exposure
If 20% of smokers develop lung cancer and 1% of non-smokers do, then Smokers are 20 times more likely to develop lung cancer than non-smokers.
What is attributable risk?
The difference in risk between an exposed and unexposed group. It tells us how much of the disease risk is due to the exposure
Incidence with exposure - incidence without exposure
If 20% of smokers develop lung cancer and 1% of non-smokers do, then:
AR=20%−1%=19%
This means 19% of lung cancer cases in smokers are attributable to smoking.
What questions to think about when appraising a research paper
What is the research question? Is it concerned with impact of intervention, causality or determining magnitude of health problem? Is it a well stated research question?
What is the study type? Is the study type appropriate to the research question? How useful are the results produced by this type of study?
What are the outcome factors and how are they measured? Are all relevant outcomes assessed? Is there measurement error? How important are omitted outcomes?
What are the study factors and how are they measured? Is measurement error an important source of bias?
What important potential confounders are considered? Are potential confounders examined and controlled for? Is confounding an important source of bias?
What are the sample frame and sampling method? Is there selection bias? Does this threaten the external validity of the study?
In an experimental study, how were the subjects assigned to groups?
In a longitudinal study, how many reached follow up?
In a case control study, are the controls appropriate?
Are statistical tests considered? Were the tests appropriate for the data? Are CI given? Is the power given if a null result? Are results presented as absolute risk reduction + relative risk reduction?
Are the results significant? Was the sample size adequate? Is the study useful?
Are ethical issues considered? Does the paper have ethics approval?
What conclusions did the authors reach about the study question? Do the results apply to the population?
Types of articular osteochondroses and site
Perthe’s - femoral head
Kienbock’s - Lunate
Kohler’s - navicular
Freiburg - 2nd metatarsal
Osteochondritis dissecans - medial femoral condyle, capitellum, talar dome
Types of non-articular osteochondroses and site
Osgood schlatter - tibial tubercle
Sinding Larsen Johansson disease - inferior pole of patella
Sever’s - calcaneus
What is an osteochondroses?
Disruption of endochondral ossification at growth plates or articular cartilage
Due to mechanical stress, vascular compromise, genetic predisposition, and sometimes repetitive trauma, leading to bone necrosis, fragmentation, and eventual remodeling
Management of growth plate distal radius fracture
Cast immobilisation four weeks
Management of growth plate supracondylar # of elbow
Sling x3 wk
Management of growth plate distal fibula or tibial fracture
Cast non wt bearing x4-6 wks
What are growth plates?
Cartilage at end of long bones that grow to allow lengthening of bone
Solidify in teens
Describe the salter harris classification
Type 1 - # Straight across growth plate
Type 2 - # Above growth plate
Type 3 - # beLow the growth plate
Type 4 - # Through the growth plate
Type 5 - ERasure of growth plate
Describe MOI for different growth plate #s
Type 1, 2 + 3 = rotating/ twisting force
Type 4 + 5 = compression/ crushing force
Type 5 can also be caused by bone infection
Management of salter harris # based on type
Type 1-3 = closed reduction
Type 4+5 = open reduction
What is a greenstick # ?
Incomplete # that occur when bone is exposed to angulation + rotational bending forces
Bone fractures on tension side but not compression side
Most common in forearm
What do XRs show in greenstick #
show tearing of periosteum + cortex on the convex side of affected bone
Management of greenstick #
Ice
Splint
Reduce - May need to complete # to adequately reduce
Immobilize
NSAIDs
FU XRs at 2 + 6 wk post injury
Describe basic principles of acute # management
Controlling external bleeding
Assess for NVI
Pain control
Traction or reduction
Immobilisation
Elevation
Indications for joint injections
Diagnostic
LA providing temporary pain relief allows more accurate physical exam
Joint aspiration for dx of gout, pseudogout, septic arthritis, hemarthrosis
Therapeutic
Decrease pain
Increase ROM
Treatment of conditions
What conditions can be treated w/ joint injections?
Crystalline arthropathies
Osteoarthritis
Inflammatory arthritis
Bursitis
Tendonosis
Ganglion cysts
Nerve entrapments
Fasciitis
Trigger points
Absolute CI to joint injections
Infection (overlying cellulitis)
Lack of informed consent
Allergy to injection medications
Injection into weight-bearing tendons such as Achilles and patella due to high risk of rupture
Relative CI to joint injections
Brittle or uncontrolled diabetes
Coagulopathy (safe in patients with international normalized ratio [INR] <3.5)
Previous joint replacement/hardware
History of avascular necrosis
History of steroid or hyaluronic acid (HA) flare
Supplies needed for joint injection
Gloves
3-5ml syringe (unless aspiration is planned)
Needles:
18G for drawing up
18G for large aspiration or HA injection
22G 1.5” for medium to large joints
25G 1.5” for small joints
22G 3.5” for hip injections in large pts
Chlorhexadine swabs
Gauze
Band aids
LA
Lidocaine - onset in 3-5 mins, lasts 1-2hrs
Bupivacaine - onset 5 mins, lasts 3-4hrs
Viscosupplementation
Synvisc (sodium hyaluronate)
Complications of joint injection
bleeding, infection, tendon rupture, steroid flare, fat pad or soft tissue atrophy, and skin depigmentation
How do you treat a steroid flare after joint inj?
rest, ice, NSAIDs and usually resolves spontaneously after 24 to 36 hr.
How do you treat a HA flare after joint inj?
rest, ice, NSAIDs and usually resolves spontaneously after several days. HA flare can be more drastic than steroid flare, and severe flares may require synovial aspiration and cultures to distinguish between pseudosepsis and true infection.
Aftercare after joint injection
Rest joint for several hours
Monitor for signs of infection
Ice for pain control
Resume activities after 3-5 days
How to do trigger point inj
Palpate tender nodule
Inject 1ml 1% lidocaine directly
Purpose, anatomy + approach for subacromial injection
For diagnosis + management of rotator cuff sprain or tear or impingement
Anatomy
The subacromial space is bordered superiorly by the coracoacromial ligament stretching between the coracoid process and acromion.
The contents of the subacromial space include the subacromial bursa, supraspinatus tendon, and tendon of the long head of the biceps.
Lateral approach:
Use
5-mL syringe with 22-gauge or 25-gauge 1½-inch needle
4-mL anesthetic (can combine 2 mL 1% lidocaine and 2 mL 0.25% bupivacaine [Marcaine])
1 mL (40 mg) Kenalog
The lateral edge of the acromion is palpated
The needle is inserted at the midpoint of the acromion and angled slightly upward under the acromion to full length (up to hub of needle)
Purpose, anatomy + approach for glenohumeral inj
Useful in OA, RA + adhesive capsulitis to improve ROM
Use when conservative therapy has failed
Anatomy
The glenohumeral joint is a ball and socket joint composed of the clavicle, scapula, and humerus.
The glenoid cavity is very shallow but contains a lip of fibrous tissue called the glenoid labrum, which deepens the glenoid and increases shoulder joint stability.
Posterior approach
Use
3-mL syringe with 22-gauge or 25-gauge 1½-inch needle
1 to 2 mL anesthetic
1 mL (40 mg) Kenalog
Posterior approach: The distal, lateral, and posterior edges of the acromion are palpated, and the soft spot 1 cm below the posterolateral corner is marked with the needle cap
The needle is inserted just inferior to the posterolateral edge of the acromion. The needle is directed anteriorly and may need to be walked into the joint.
Accuracy can be significantly improved with ultrasound guidance.
Purpose, anatomy + approach for AC joint inj
Indicated for shoulder pain d/t pathology of AC joint if conservative therapy has failed
Anatomy
The AC joint can be palpated as a narrow indentation at the distal end of the clavicle, about one thumb’s width medial to the lateral edge of the acromion.
The joint line runs obliquely medially at approximately a 20-degree angle.
Approach:
Use
3-mL syringe with 25-gauge 5/8- to 1-inch needle
½ mL 1% lidocaine
½ mL (20 mg) Kenalog
Palpate the depression of the AC joint at the distal clavicle and mark it with the needle cap
Insert the needle at a 15- to 20-degree angle (needle pointed more medially)
Avoid repetitive or heavy lifting afterwards
Purpose, anatomy + approach for elbow joint inj
Indicated for elbow pain d/t arthritis or trauma if conservative therapy has failed
Anatomy
The elbow joint is composed of the ulnohumeral, radiocapitellar, and proximal radioulnar joints.
The elbow joint can be approached via the triangle formed by the lateral olecranon, head of the radius, and lateral epicondyle.
Approach:
Use
3-mL syringe with 25-gauge 1-inch needle
5- to 10-mL syringe with 20-gauge or 22-gauge needle if aspirating
1 mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Place the patient’s arm on the table at a 45-degree angle.
Mark the soft depression in the center of the triangle formed by the lateral olecranon, head of the radius, and lateral epicondyle with the needle cap
The needle is inserted into the elbow joint between the lateral epicondyle and the radial head
Instruct the patient to perform flexion/extension ROM exercises to disperse the fluid within the joint.
Purpose, anatomy, medial + lateral approach + aftercare for epicondylitis inj + aftercare
Anatomy
The origin of the common extensor tendon is at the lateral epicondyle.
The origin of the common flexor tendon is at the medial epicondyle.
Use
3-mL syringe with 25-gauge 5/8- or 1-inch needle
½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Lateral epicondyle:
Place the patient’s arm on the table at a 45-degree angle with the lateral elbow facing up:
Palpate the area of most tenderness over the epicondyle and mark this with the cap of the needle.
The needle is inserted down to the bone of the lateral epicondyle
Medial epicondyle:
Medial epicondyle: Place the patient’s arm on the table at a 45-degree angle with the medial elbow facing up:
Palpate the area of most tenderness over the epicondyle and mark this with the cap of the needle.
The needle is inserted down to the bone of the medial epicondyle.
Take care not to inject the ulnar nerve because it traverses posterior to the medial epicondyle in the cubital tunnel. If the patient experiences pain or numbness in the ulnar nerve distribution while the needle is inserted, then back out and reposition the needle more anteriorly before injecting cortisone. At this time, doing this injection without ultrasound guidance increases the risks of injury to the ulnar nerve.
Aftercare
Consider an elbow extension splint to rest the elbow and/or wrist splint to avoid wrist flexion/extension for 1 to 2 wk to allow the injection to take effect.
The patient should avoid repetitive wrist extension or flexion.
Purpose, anatomy + approach for wrist inj + aftercare
Indicated for arthritis or trauma if conservative therapy has failed
Anatomy
The wrist joint capsule is not continuous but has septa, which makes the wrist injection sometimes difficult.
The radiocarpal joint can be palpated just distal to the distal radius in a depression near the scapholunate articulation.
Approach:
Use
3-mL syringe with 25-gauge 5/8- or 1-inch needle
5- to 10-mL syringe with 20-gauge or 22-gauge 5/8- or 1-inch needle for aspiration
½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Palpate the depression distal to the distal radius near the scapholunate articulation.
The needle is inserted into the wrist joint
If aspirating, withdraw fluid with 5- to 10-mL syringe, then stabilize needle and exchange 3-mL syringe containing steroid mixture and inject.
If injecting, use 3-mL syringe with 25-gauge 1-inch needle and inject fluid into joint.
Have patient perform wrist flexion and extension exercises to disperse the fluid through the wrist joint.
Consider wrist splint x1-2 wks
Anatomy + approach for de quervain tenosynovitis inj + aftercare
Anatomy
The dorsal wrist has six compartments containing tendons.
The 1st dorsal compartment contains the abductor pollicis longus and the extensor pollicis brevis tendons.
de Quervain tenosynovitis occurs when the tendon sheath becomes inflamed and thickened causing pain, swelling, and occasional triggering.
Approach
Use
3-mL syringe with 25-gauge 5/8- or 1-inch needle
½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Palpate the area of most tenderness over the 1st dorsal compartment and mark this with the needle cap.
The needle is inserted into the tendon sheath between the abductor pollicis longus and extensor pollicis brevis tendons at ~30-degree angle.
Ultrasound dramatically increases accuracy of this injection and improves outcomes.
An elliptical shaped bulge occurs with the injection of the bolus of fluid into the sheath.
Consider thumb spica wrist splint for 1-2 wks
Purpose, anatomy + approach for 1st CMC joint inj
Indicated d/t arthritis
Anatomy
The thumb CMC joint is composed of the saddle-shaped base of the 1st metacarpal as it articulates with the trapezium.
The thumb CMC joint can be approached on the extensor surface proximal to the 1st metacarpal, taking care to avoid the radial artery and extensor pollicis tendons.
Approach
Use
3-mL syringe with 25-gauge 1-inch needle for injection
½ mL 1% lidocaine without epinephrine (if using)
½ mL (20 mg) triamcinolone suspension (Kenalog)
Place the patient’s hand and forearm on the table palm down.
Palpate the CMC joint between the base of the 1st metacarpal and the wrist trapezium between the extensor pollicis longus and extensor pollicis brevis tendons.
Mark the depression at the base of the 1st metacarpal with needle cap.
To avoid the radial artery, the needle should enter on the ulnar side of the extensor pollicis brevis tendon. Distraction of the thumb can increase the space to get the needle into the joint.
Corticosteroid alone can be injected without anesthetic, given the small size of the CMC joint. Usually, not more than ½ mL volume will fit into the joint space.
Thumb spica splint x1-2 wks
Anatomy + approach for carpal tunnel inj
Anatomy
The carpal tunnel is bounded by the carpal bones dorsally and the transverse carpal ligament (flexor retinaculum) ventrally.
The contents of the tunnel include the median nerve and flexor tendons of the hand.
Approach
Use
3-mL syringe with 25-gauge 1½-inch needle
1½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Have the patient lay the hand palm up on the table and make a fist with slight wrist flexion.
Observe the tendons of the palmaris longus (10% of the population will not have one) and the flexor carpi radialis.
Mark a spot with the needle cap 4 cm proximal to the distal palmar crease between the two tendons mentioned above.
With the fist clenched and the wrist slightly flexed, the needle is inserted at a shallow angle (~20 degrees) along the tendon sheath, aiming toward the ring finger. Have the patient slowly extend the wrist and fingers noticing the needle advance toward the carpal tunnel. This indicates proper needle placement
Ask the patient if they feel any increased pain or numbness. If they do, remove the needle because it may be in the median nerve.
DO NOT INJECT INTO THE MEDIAN NERVE.
Wrist splint x1-2 wks
Anatomy + approach for trigger finger inj + aftercare
Anatomy
Nodule or thickening occurs in the flexor tendon, which catches on the A-1 proximal pulley making finger extension difficult.
Approach
Use
3-mL syringe with 25-gauge 5/8- to 1-inch needle
½ mL 1% lidocaine
½ mL (20 mg) Kenalog
Palpate the tender nodule on the palm of the hand and mark with needle cap.
Injection site is either directly into the nodule or at the proximal interphalangeal digital crease.
Insert needle at a 45-degree angle—when you feel rubbery resistance, you are at the level of the tendon. Back needle out slowly until it is no longer in tendon and the fluid flows easily within the tendon sheath
Finger splint x1-2 wks
After 3 days, start extension exercises—hold finger in extension 10 sec × 10 times for one set. Complete three sets per day.
Avoid repetitive gripping or use padded gloves for any vibrating tools (i.e., jackhammers).
Anatomy + approach for ganglion cyst inj
Anatomy
Ganglion cysts are the most common soft tissue tumors of the hand and wrist, more commonly in women (3:1).
These thick mucin-filled cysts may out pouch from synovial or tendon sheaths from trauma or repetitive irritation.
Ganglion cysts are often connected to an underlying ligament or joint, most commonly at the scapholunate joint (60–70%), and next most frequently at the volar wrist (20–25%), and thirdly at the palmar flexor tendon sheath (10–12%).
Approach
Use
5- to 10-mL syringe with 18- to 22-gauge 1-inch needle if aspirating viscous cyst contents
3-mL syringe with 22-gauge 1-inch needle if injecting
½ to 1 mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Position the patient in sitting position with his or her arm on the table with the ganglion cyst facing upward.
Aspirate using the 18-gauge needle—the thick mucoid cyst contents may be difficult to aspirate and may actually be more effectively milked out of the puncture site after the needle is removed.
First, aspirate the cyst contents if possible and then stabilize the needle position with a hemostat, remove the aspiration syringe, secure the syringe with the steroid mixture, and inject.
Purpose, anatomy + approach for trochanteric bursitis inj
Indicated for bursitis, greater trochanteric pain syndrome
indicated if pain persists despite conservative therapy, including avoiding direct pressure and repetitive trauma, ice, NSAIDs, and stretching of the iliotibial band, tensor fascia lata, external hip rotators, hip flexors, and quadriceps.
Anatomy
The trochanteric bursa lies superficial to the greater trochanter of the femur, between the trochanteric process and the gluteus medius/iliotibial tract.
Tenderness to palpation over the trochanteric process is the classic finding for trochanteric bursitis.
Approach
Use
6-mL syringe with 21- to 22-gauge 1½- to 2-inch needle for thin patients
21- to 22-gauge 3.5-inch spinal needle may be needed for heavier patients.
5 mL 1% lidocaine without epinephrine and/or 0.25% bupivacaine
1 mL 40 mg/mL (40 mg) triamcinolone suspension (Kenalog)
Lay the patient in lateral recumbent position, with the affected side up.
Flex the patient’s hip at 50 degrees, and flex the knees 60 to 90 degrees.
Palpate the greater trochanteric process and identify the point of maximal tenderness, which usually corresponds well to the most superficial point of bony prominence. Mark this area with the needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Position the needle perpendicular to the skin and advance toward the site of maximal trochanteric tenderness.
Advance the needle until the tip reaches bone level to ensure delivery of the steroid below the tendon. Never inject under pressure, which may indicate placement within the tendon.
Withdraw the needle 2 to 3 mm to remain within the trochanteric bursa.
For acute bursitis, the 5 to 6 ml of corticosteroid and lidocaine can be directly injected into the bursa.
For chronic bursitis, a clockwise peppering motion may help break up scar tissue—each time, the needle should reach the level of bone and then inject.
Avoid pressure to area afterwards, rest x3 days
Repeat in 6-12 wks if pain relief was <50%
Purpose, anatomy + approach for olecranon bursa inj
Indicated for bursitis
Anatomy
The olecranon bursa overlies the olecranon process at the proximal ulna.
Olecranon bursitis is visible as posterior elbow swelling, often described as a golf ball or goose egg over the elbow tip.
Approach
Use
3-mL syringe with 25-gauge 1-inch needle if injecting
5- to 10-mL syringe with 18- to 22-gauge needle if aspirating
1 mL 1% lidocaine without epinephrine
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Place the patient’s arm on the table at maximal elbow flexion to accentuate the swelling.
Palpate over the olecranon bursa for fluctuance.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Aim the needle perpendicular to the olecranon bursa.
Aspirate bursa fluid until the bursa is flat.
If infection has been ruled out, inject steroid/lidocaine into bursa.
Compressive elbow sleeve may help fluid reaccumulation
Avoid direct pressure afterwards
Consider posterior splint or elbow pads for 1-2 wks
Purpose, anatomy + approach for prepatella burse inj
Indicated for chronic bursitis if not improving w/ conservative rx
Anatomy
Use
5- to 10-mL syringe with 18- to 22-gauge 1-inch needle if aspirating
1 mL 1% lidocaine without epinephrine (optional)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
The prepatellar bursa lies between the patella and the overlying skin.
Prepatellar bursitis is visible as a well-circumscribed region of swelling over the patella.
Approach
Position the patient in supine position with the knee flexed at 30 degrees on a pillow.
Position the affected leg with patella facing upward.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
The prepatellar bursa swelling should be clearly visible.
Aspirate by approaching from the side of the visible prepatellar swelling.
Pressure dressing after
Purpose, anatomy + approach for pes anserine bursa inj
For bursitis - can be done w/ conservative therapy
Anatomy
Use
3-mL syringe with 25-gauge 1-inch needle
1 mL 1% lidocaine without epinephrine
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
The pes anserine bursa lies between the conjoined tendon of the sartorius, gracilis, and semitendinosus muscles and the tibial insertion of the medial collateral ligament.
Diagnosis is made by tenderness to palpation over the anserine bursa, ~2 cm below the medial joint line at the proximal medial tibia.
Swelling is not usually visible with anserine bursitis.
Approach
Lay the patient in supine position.
Position the affected leg with the medial joint line accessible.
Identify the anserine bursa 1 to 2 cm below the middle of the medial joint line.
The point of maximal tenderness along the medial tibial plateau often serves to identify the ideal injection site—mark this site with the needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Insert the needle perpendicular to the skin.
Advance the needle to the level of bone to find the bursa space between the conjoined tendons and the tibia.
Inject the steroid/lidocaine mixture into the bursa—resistance to flow should be minimal.
Sleep w/ cushion between knees
Purpose, anatomy + approach + when to repeat for knee inj
Indications: dx of knee effusion, treatment of OA, crystalline dz, synovitis
Anatomy
The knee joint consists of the femoral–tibial and femoral–patellar joints, with stabilization from the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments.
Approach
Use
3-mL syringe with 25-gauge 1-inch needle for injection
20- to 60-mL syringe with 18- to 22-gauge 1½-inch needle if aspirating
5- to 10-mL syringe with 21- to 22-gauge 1½-inch needle for injecting
5 to 7 mL 1% lidocaine without epinephrine and or 0.25% bupivacaine (if using)
1 mL 40 mg/mL (40 mg) triamcinolone suspension (Kenalog)
For the supine medial or lateral midpatellar approach, position the patient’s knee either in full extension, which gives the most patellar mobility, or slightly flexed at 5 degrees with a rolled towel supporting underneath. The needle is advanced parallel to the floor directed straight toward the patellar midpole.
Repeat injection can be done after 3 mo if the steroid injection afforded adequate pain relief—average duration of effect for joint steroid injections is 4 wk.
Purpose, anatomy + medial + lateral approach + when to repeat for ankle inj
Indicated to dx ankle effusions or to treat OA, crystalline dz, synovitis
Anatomy
The ankle joint consists of the articulation of the tibiotalar and talofibular joints.
The ankle joint space can be approached either medially or laterally.
Use
3-mL syringe with 25-gauge 1-inch needle for injection
Extra 3- to 5-mL syringes if needed for aspiration of effusion
½ to 1 mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Medial approach
Identify the soft spot between the anterior tip of the medial malleolus and the medial edge of the tibialis anterior tendon:
Palpate down to feel the tibiotalar joint line—mark this site with the needle cap.
Advance the needle in a posterolateral direction and inject.
Having an assistant apply mild eversion/plantarflexion pressure may help to open the joint.
Lateral approach
Identify the triangular depression between the lateral tibia, fibula, and the talus:
Palpate down to feel the tibiotalar joint line—mark this site with the needle cap.
Advance the needle in a posteromedial direction.
If aspirating, remove as much fluid as possible and then stabilize the needle in the joint with a hemostat and switch between the aspiration and therapeutic syringes. Keep the needle hub and syringe tips sterile.
After securing the therapeutic syringe, inject the steroid/lidocaine mixture.
Repeat injection can be done after 3 mo if the steroid injection afforded adequate pain relief—average duration of effect for joint steroid injections is 4 wk.
Purpose, anatomy + approach for plantar fascia inj
2nd line after conservative therapy failed
Anatomy
The plantar fascia supports the medial longitudinal arch of the foot and stretches between the base of the phalanges and the medial tuberosity of the calcaneus.
The plantar fascia lies deep to the fat layer of the heel.
On physical exam, the plantar fascia insertion point on the calcaneus is usually markedly tender to palpation.
Approach
Use
3-mL syringe with 25-gauge 1.5-inch needle for injection
½ mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Position the patient in the lateral recumbent position with the painful side down.
Position the affected foot medial side up.
Palpate the maximal point of tenderness at the plantar fascia insertion on the calcaneus, usually in the middle of the heel—this gives the injection target depth along the width of the heel.
Find the medial edge of the calcaneus and mark with needle cap—this marks the injection point along the length of the foot.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Apply ethyl chloride for topical cooling.
Inject perpendicular to the medial foot, aiming just distal to the calcaneal edge in order to avoid the heel fat pad.
If the calcaneus is reached with the needle tip, walk the needle off the bony edge and then down to the depth of the point of maximal tenderness.
Inject the steroid/lidocaine mixture.
Purpose, anatomy + approach for morton neuroma inj
Indicated if conservative therapy has failed
Anatomy
Morton neuroma usually develops between the 2nd and 3rd or between the 3rd and 4th metatarsal heads.
Tenderness to palpation between the metatarsal heads usually confirms the diagnosis.
Approach
Use:
3-mL syringe with 25-gauge 1-inch needle for injection
½ mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Lay the patient in a supine position with a bent knee and the foot flat on the table.
Identify the point of maximal tenderness between the metatarsal heads on the dorsal foot—mark entry site with needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Apply ethyl chloride for topical cooling.
Advance the needle at a 45-degree angle proximally toward the point of maximal tenderness or nodule—aim toward the heel and stop at the level of the interdigital fullness.
Do not inject at the level of the plantar fat pad to avoid fat pad atrophy.
Purpose, anatomy + approach for 1st MTP inj
Indicated for dx of gout or for treatment of OA, RA, gout
Approach
Use:
3-mL syringe with 25-gauge 5/8- to 1-inch needle
1 mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog or equivalent
Lay the patient in a supine position with a bent knee and the foot flat on the table.
Flex and extend the 1st MTP joint to identify the joint line and mark with needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Distal traction may help open the joint space.
Aim the needle distally toward the toe and enter at a 60-degree angle to match the joint slope.
The joint lies fairly superficially, and the injection solution should flow freely within the joint.
What are the individual, relational and organisational forms of violence that threaten athletes?
Individual:
Injury, depression, self harm, eating disorders
Relational:
Sexual harassment, sexual abuse, physical abuse, forced physical exertion, emotional abuse, neglect, bullying, doping
Organisational:
Abuse from spectators, discrimination, unhealthy training programs, hazing, medical mismanagement, age cheating
Signs and symptoms of athlete maltreatment
Unexplained or unwarranted injuries
Decline in performance Nightmares, avoidance
Aggressive behaviour or intense anger
Acting out sexually
Self-destructive behaviour
Appearing sad or withdrawn Difficulty forming new relationships or trusting others
Drug or alcohol use
Change behaviour patterns
Fear of certain adults
How should you manage athlete disclosure of allegations of harassment or abuse?
Actively listen to athlete, provide empathy, acknowledge courage in speaking out, assure athlete experiences not their fault, encourage disclosure, do not denigrate the perpetrator, keep accurate records, ensure athlete safety, stop the abuse (report disclosure to authorities including police and sporting organisation), support teammates and family members, encourage whistleblowing culture
What are the risks to mental health from elite sport participation?
Mental burnout, overtraining, conflict with coaches or teammates, school or work issues due to increased time demands
Concussion, debilitating injury illness
Eating disorders, violence, or harassment
How to manage someone in a mental health crisis
Provide timely access to support
Provide services in the least restrictive manner
Ensure support is available
Spend adequate time with the individual in crisis
Ensure that people intervening have appropriate training and competence
Help the individual to regain a sense of control
Attend to issues of culture, gender, race, age, sexual orientation and communication needs
Insure services trauma informed
Take measure to reduce the likely of future emergencies
Classification of ligament injuries
Grade 1: disruption of some collagen fibres
Localised tenderness, minimal inflammation, normal range and end fill on ligament stress test but maybe painful, little functional deficit
Grade 2: disruption of considerable proportion of collagen fibres
Significant tenderness, considerable swelling, increased ligament laxity but definite endpoint, moderate functional deficit
Grade 3: complete disruption of collagen fibres
Audible pop, immediately painful but may become pain-free, considerable swelling, significantly increased ligament laxity with no designable endpoint, significant functional deficits
What are the classifications of tendinopathy?
Stage 1 = reactive tendinopathy - tendon cells activate + proliferate, occurs w/ trauma + acute overload
Stage 2 = tendon disrepair - increased matrix breakdown, myofibroblasts appear, cells more rounded (chondrocytic). Collagen separates which allows ingrowth of vessels. Seen in overloaded tendons in young (but can occur at any age)
Stage 3 = degenerative tendinopathy - end stage overuse progression of cell changes to point of apoptosis. Large areas of disordered matrix w/ ingrown vessels, heterogenous on pathology
What is an apophysis?
Normal bony outgrowth that arises from a separate ossification centre + fuses w/ bone
Site of tendon or ligament attachment
Weakest link of the muscle - tendon unit in the skeletally immature
What is apophysitis?
Traction injury - repeated microavulsion of apophysis caused by disproportionate growth of bone in relation to associated myotendonous units
How does apophysitis present?
Pain during + after activity, insidious onset
Localised tendnerness + swelling, pain w/ resisted activation + passive stretching
What do you see on an XR of apophysitis?
Hypertrophied, fragmented or separated apophysis - XR can also be normal
Rx inc RTP for apophysitis
Relative rest from activities that cause pain (inadequate protection can lead to avulsion #), ice, NSAIDs, stretching, PT, 4 wks pain free then gradual RTP
Describe the physiological response to physical activity?
Increase liver glucose output mainly from glycogenolysis, also gluconeogenesis.
Increased adipose tissue lipolysis.
Increased whole body oxygen uptake
Increased heart rate and cardiac output
Increased ventilation
Increased ATP turnover in muscle, creased glucose uptake and lipolysis in the muscle increased oxygen neutralisation, CO2 and heat production and increased blood flow
Release of myokines
What are the benefits of warming up?
Prepares the body by increasing your heart rate and breathing, vasodilation.
Increases muscle temperature, which improves flexibility
Reduces risk of injury
Improves performance
Helps with mental preparation
Warming up slowly increases your heart rate, which helps reduce stress on your heart.
Approach to injury prevention
Identify type and severity of injuries
Identify risk factors and injury mechanisms
Introduce measures to reduce future risk or severity of injuries
What risk factors for injury are modifiable?
Athlete fitness
Human factors
Protective equipment
Sports equipment
Environment
How to prevent hamstring strains
Increase hamstring strength and increased hip range of motion
Preventing ankle sprains
Taping or bracing for one after an ankle sprain
Balance board training program
How to prevent acute knee injuries
Structured warm up targeting strength, balance and neuromuscular control (eg FIFA 11)
How to prevent overuse injuries
Structured training program
Technique modification
Nutritional strategies to prevent stress fractures
Modifying risk factors such as shoes and sporting equipment
Managing the rate of load increase
What should be included in recovery?
Active recovery (low intensity work after exercise)
Massage within 2 hrs
Neuromuscular electrical stimulation ASAP
Stretching
Cold water immersion ASAP, max 10 mins, temp 10-15 degrees
Compression clothing ASAP for min 60 mins
Nutrition - replacing fluids (1.5x weighed fluid loss) + fuel (carbs) + repair (protein)
Optimal sleep
Types of manual treatment
Joint mobilisation and manipulation
Soft tissue therapy
Dry needling
Taping
Therapeutic ultrasound
Transcutaneous electrical nerve stimulation (TENS)
Neuromuscular stimulators
Laser
Electromagnetic therapy
Shockwave therapy
Benefits of dry needling
Treating intramuscular trigger points for pain relief
Benefits of taping
Restriction of range of motion
Altering anatomical alignment
Cutaneous stimulation for pain relief
Improved proprioception
What conditions is taping useful for?
Patellofemoral pain
Ankle sprain
de Quervains tenosynovitis
Plantar fasciitis
Shoulder pain
Benefits of therapeutic ultrasound
Increased blood flow, metabolic activity
Treatment of acute bone fractures
Benefits of TENS
Short term pain relief
Benefits of neuro muscular stimulators
Enhance recovery, improved performance, reduced muscle soreness
Benefits of laser
Pain relief
Benefits of shockwave therapy
Treatment of tendinopathy
What are the primary phases of tissue healing, and what is the approximate timeline for each phase?
Inflammation Phase (0–3 days): Characterized by redness, swelling, heat, and pain. The goal is to remove debris and prepare for repair.
Proliferation Phase (4–21 days): Fibroblasts produce collagen, and new blood vessels form to support tissue repair.
Remodeling Phase (21 days to months): Collagen is reorganized to increase tensile strength, and the tissue matures.
Explain the concept of VO₂ max. What factors influence it, and how can it be improved through training?
VO₂ max is the maximum rate of oxygen uptake during intense exercise. It reflects aerobic capacity and is influenced by:
* Cardiac output: Heart rate × stroke volume.
* Muscle efficiency: Oxygen extraction by working muscles.
* Lung function: Oxygen exchange efficiency.
How to improve it:
* Endurance training: Interval training and long-distance running are effective.
* High-intensity interval training (HIIT) can boost VO₂ max rapidly.
How to document shoulder ROM
180/30/L1, referring to forward flexion/ ext rotation / int rotation.
How to document knee ROM
0 = neutral, so if the knee passes through neutral from hyperextension to full flexion, it will be the middle number. If there is a loss of full extension, the 0 precedes the degree of full extension.
Documenting Knee Range of Motion:
If a person has 10 degrees of knee hyperextension and 130 degrees of knee flexion, it would be documented as 10-0-130.
If a person has a 10 degree contracture and loss of full knee extension with 130 degrees of knee flexion, it would be documented as 0-10-130.
What specific movements does the PCL resist?
PCL resists posterior translation of the tibia + hyeprflexion of the knee
What is lactate threshold?
The lactate threshold is the exercise intensity at which blood lactate begins to accumulate faster than it can be cleared. This marks the transition from predominantly aerobic metabolism to significant anaerobic metabolism.
Expressed as a percentage of VO₂ max (e.g., 60–90% of VO₂ max in well-trained athletes).
What is piriformis syndrome?
Piriformis muscle in the buttock irritates or compresses the sciatic nerve
Sx of piriformis syndrome
Pain or tenderness in the buttocks, especially after prolonged sitting or activity.
Sciatic-like symptoms, such as pain radiating down the back of the thigh and into the leg.
Worsening pain with certain movements, such as sitting, climbing stairs, or squatting
Physical for piriformis syndrome
FADDIR might be positive
Ix for piriformis syndrome
not necessarily needed, MRI if so
Causes of piriformis syndrome
Overuse or injury of the piriformis muscle (e.g., from running, cycling, or prolonged sitting).
Trauma
Management of piriformis syndrome
Conservative Management:
Stretching and strengthening exercises, particularly for the piriformis and surrounding muscles.
Avoiding aggravating activities and maintaining good posture.
Non-steroidal anti-inflammatory drugs (NSAIDs) or muscle relaxants.
Physical therapy, including manual therapy or dry needling.
Advanced Treatments:
Corticosteroid injections around the piriformis muscle for persistent cases.
Botox injections to relax the muscle.
Surgery: Rarely needed and reserved for severe, refractory cases.
DDx of piriformis syndrome
Lumbar disc herniation or radiculopathy.
Sacroiliac joint dysfunction.
Gluteal tendinopathy.
What are the recommendations for minimizing effect of pollution on health?
1) monitoring concentrations using trusted source of ozone, nitrous oxide + particulate matter
2) exercising in the morning or in locations when seasonal events are less likely
- When ambient air pollution concentrations are high, it may be favourable to relocate an
exercise bout indoors after considering the indoor air quality and potential co-exposures (e.g.,
indoor temperatures).
● Indoor air quality can also be improved by controlling indoor sources of air pollution, optimizing
ventilation, and using portable air cleaners fitted with HEPA filters.
3) minimizing pre-exercise and intra-transport exposures:
Minimize exposure to air pollution during transportation to exercise facilities by closing vehicle
windows, turning on air conditioning, and using cabin air filters.
4) wearing face masks in areas of high particulate matter
5) optimizing antioxidant consumption.
For at least one week prior to exercising in an environment with high O3 levels, athletes may
consider consuming 250-650 mg of vitamin C and 75-100 mg of vitamin E, and 25 mg of βcarotene.
6) Athletes with asthma and/or EIB should continue to use medications as prescribed by their physicians.
7) Consecutive multi-day exposures to ozone prior to competition may also attenuate the pulmonary effects of ozone pollution.
8) During exercise, athletes should aim to minimize the total inhaled dose of air pollution and maximize distances from significant sources of air pollution (e.g., major traffic arteries).
What to do if you suspect a case of maltreatment but you’re not sure?
Look for presentations
H+P with athlete to explore (do you feel safe? Etc)
Report to MCFD if a child, encourage adult to report to authorities, report to sport dispute resolution centre of Canada for all cases
What can you do in your role to protect athletes from maltreatment?
Maintain focus on well being of athlete
Educate athletes, coaches, staff, parents
Ensure organizations have policies for athlete protection (codes of practice, education, training, complaint reporting, support mechanisms)
Know duty to report
What can you do to protect yourself from allegations?
Respect professional boundaries
Understand and follow universal code of conduct
Ensure organization has policies + codes of conduct in place that you follow
Accurate + timely record keeping
Recommendations for preventing ACL injuries in young athletes
- All Canadian youth soccer players should engage in exercise programs that incorporate neuromuscular, proprioceptive, agility, and strength training in their routine practice and warm-ups
- These NMT programs should be commenced at least by the early teenage years
- During the performance of the ACL injury prevention program in training, the coaches and trainers should give effective feedback on the performance of the drills, and players should learn from watching each other perform the tasks
- National and provincial soccer governing bodies should develop age-specific ACL injury prevention programs and monitor these programs for effectiveness
- Soccer teams should collaborate with a qualified health or physical education professional in the institution of an ACL injury prevention program for the team’s training sessions
- Professionals can lead by educating teams
- Ongoing research needed
- Ongoing understanding, development, and refinement of implementation strategies are needed to improve compliance and uptake of the prevention programs
What is the FIFA 11?
Group of exercises to prevent injury
Performance considerations at altitude
Reduced oxygen availability at altitude can impair endurance performance.
Acclimatization strategies are essential to mitigate performance decrements.
Individual responses to altitude vary; personalized plans are recommended.
Training strategies at altitude
Live High–Train Low (LHTL): Living at high altitude to stimulate physiological adaptations while training at lower altitudes to maintain training intensity.
Live High–Train High (LHTH): Both living and training at high altitude; may lead to reduced training intensity due to hypoxia.
Live Low–Train High (LLTH): Living at low altitude and performing high-intensity training sessions at high altitude; less common due to logistical challenges.
Environment considerations at altitude
Increased ultraviolet radiation at altitude necessitates skin and eye protection.
Cold temperatures require appropriate clothing to prevent hypothermia.
What are the most common injuries sustained on home trampolines?
Fractures, sprains + strains, upper >lower limb
What are the CASEM recommendations for trampoline use?
Trampolines should not be used for recreational purposes at home (including cottages and temporary summer residences) by children or adolescents.
Health care professionals, including family physicians and pediatricians, should warn parents of the dangers of trampolines as a recreational toy at routine health care visits.
Parents should be advised to avoid the purchase of trampolines for the home, as enclosures and adequate supervision are no guarantee against injury.
Trampolines should not be regarded as play equipment and should not be part of outdoor playgrounds.
Physicians should advocate for legislation to require warnings of trampoline dangers to be put on product labels.
More research on trampoline injuries sustained in supervised settings, such as schools, gym clubs, and training programs, should be conducted to assess the risk of injury in these settings.
Benefits of exercise in kids with JIA
- Encourages range of motion, strength, and fitness, especially with aquatic exercises.
- Improves aerobic fitness, muscle strength, disease activity, quality of life, and reduces pain and medication use.
- Sports participation does not exacerbate the disease.
Risks of exercise in kids with JIA
- Potential for joint strain, muscle atrophy, fractures, and cardiovascular complications.
- Children with cervical arthritis are at higher risk for spinal injuries during contact sports.
Recommendations for exercise in kids with JIA
- Safe participation in moderate fitness, strengthening, and flexibility exercises.
- Gradual return to full activity after flare-ups.
- Screen for C1-C2 instability before contact sports, use mouthguards for jaw issues, and eye protection as needed.
Benefits of exercise in kids with hemophilia
- Regular exercise reduces bleeding episodes, strengthens muscles around joints, and increases joint stability.
- Aerobic and weight-bearing exercises improve bone health, coagulation, and overall fitness.
Risks of exercise in kids with hemophilia
- Reduced fitness, muscle strength, and anaerobic power due to hemophilia.
- Participation in contact sports poses risks of bleeding and injury.
Recommendations for exercise in kids with hemophilia
- Children should receive appropriate factor prophylaxis and undergo joint function assessments.
- Avoid high-risk contact sports without medical clearance.
- Use protective equipment and physical therapy, and have a clear plan for managing acute bleeds.
Benefits of exercise in kids with asthma
- Regular exercise improves fitness and may reduce exercise-induced bronchospasm (EIB) severity.
- Swimming is particularly beneficial due to lower EIB triggers.
- Exercise can enhance exercise capacity and quality of life.
Recommendations for exercise in kids with asthma
- Children can participate in any activity if symptoms are well-controlled.
- Use inhaled beta2-agonists 15-30 minutes before exercise.
- Avoid scuba diving if asthma symptoms persist or spirometry is abnormal.
Risks of exercise in kids with asthma
- High-intensity exercise may trigger EIB, especially in dry or cold environments.
- Endurance sports may increase bronchial hyperresponsiveness.
Benefits of exercise in kids with CF
- Exercise improves aerobic fitness, lung function, and survival rates.
- Activities like swimming, walking, and jogging strengthen respiratory muscles.
- Strength training improves muscle mass, FEV1, and weight gain.
Risks of exercise in kids with CF + sports to avoid
- Exercise may trigger coughing, oxygen desaturation, and fatigue due to lung disease.
- Potential for pneumothorax during scuba diving and dehydration during prolonged exercise.
- Avoid contact sports for those with liver dysfunction or enlarged spleen.
Recommendations for exercise in kids with CF
- Encourage physical activity with individualized programs.
- Avoid scuba diving and monitor hydration, especially for those with diabetes or liver complications.
What are the 7 tests + treatments to question in SEM?
1) Don’t order an MRI for suspected degenerative meniscal tears or osteoarthritis
2) Don’t prescribe opioids as first line treatment for acute or chronic non-cancer musculoskeletal pain
3) Don’t order orthotics for asymptomatic children with pes planus (flat feet)
4) Don’t order an MRI as an initial investigation for suspected rotator cuff tendinopathy
5) Don’t immobilize ankle inversion sprains with no evidence of bony or syndesmotic injury
6) Don’t use single-use vials of anesthetic agents such as xylocaine to prepare injections for patients
7) Don’t recommend strict rest until symptom resolution after an acute sports-related concussion
8 tests + treatments to question in paediatric SEM
1) Don’t order knee radiographs to diagnose Osgood Schlatter Disease in children
2) Don’t order ultrasound as an initial investigation for shoulder/knee injuries in children
3) Don’t order scoliosis radiographic series for back pain
4) Don’t order thoracic spine radiographs if there is clinical concern about scoliosis
5) Don’t order oblique radiographic views for investigation of spondylolysis
6) Don’t order a head CT scan for minor head injuries/concussion
7) Don’t immobilize a joint with suspected amplified pain syndrome (complex regional pain syndrom
8) Don’t order follow-up radiographs for buckle fractures of the distal radius if there are no clinical symptoms at the time of follow-up
What are the recommendations regarding mental health management in RFP/ RTP decisions?
Mental health challenges do not always disable athletes; they may still participate in training/competition.
RFP and RTP decisions should be based on symptom severity, stability, and functional impairment.
Sports psychiatrists should be involved in assessment and management.
Limited research on RFP/RTP for primary mental health issues compared to concussion.
Athletes may continue competing without proper assessment or return prematurely without adequate support.
The study calls for more global data and better mechanisms for supporting mental health recovery in athletes.
What are the possible causes of a change in motor or sensory function in disabled athletes?
Spinal cord- syrinx or syringomyelia, compressive myelopathy (neck or thorax),
Brain- stroke, tumor, hemorrhage (subdural etc), infection.
Nerve root – disc herniation,
Brachial plexus – trauma or traction
Peripheral nerve – compression, fracture.
If a disabled athlete has a change in motor or sensory function, what questions would elicit whether there are bulbar symptoms? If present, what could this mean?
Dysphagia, dysarthria, diplopia, dysmetria (reduced coordination) – as these symptoms could signify a problem in the brainstem
What physical would you do for a disabled athlete with a change in motor or sensory function?
Dematome + myotome assessment
CN exam
Rectal tone, perianal sensation
Ability to bear down
What ix would you do for a disabled athlete with a change in motor or sensory function?
MRI spine
What is the management of a syrinx?
refer to neurosurg, often observed with serial imaging, can be decompressed
What are the possible causes of a change in spasticity in disabled athletes?
Any noxious or painful stimulus from the skin, abdominal organs, bones, joints etc can amplify the muscle stretch response and worsen spasticity. An increase in spasticity can be a sign of infection or injury in athletes with a spinal cord injury or other conditions of the central nervous system.
What questions would you ask in a change in spasticity in disabled athletes?
Neurological- has there been any change in the strength or sensation? - suggests a new problem with the spinal cord- syrinx, compression
Do you have a Baclofen pump?
Genitourinary - change in bladder pattern? New incontinence, frequency of catheterizations, blockage of catheter, change in color of urine (pyuria or hematuria)
Gastrointestinal - Change in bowel function (constipated, diarrhea, nausea, vomiting, blood in stool), intraabdominal injury or infection?
Skin – any new sores, ingrown toe nails
Musculoskeletal – any trauma or swelling of extremities
Vascular – change in color or swelling of a leg or arm?
Infectious- look for infection! Fever, chills, rigors, malaise etc
What physical would you do for a disabled athlete with a change in spasticity?
Check vitals – BP/HR/ Temp
* Check for change in strength and sensation if suspicious for problem with spinal cord. * Check each system Genitourinary – urine, check genitals for infection or injury, Gastrointestinal- bowel for constipation, abdominal exam (may not have pain so need to have high index of suspicion for problem), * Skin – look for new sores; check nails, MSK- check for new injuries, fractures, joint injuries, or infection. Need to look at legs, and spine particularly carefully, Vascular - any signs of ischemia or deep vein thrombosis, Infection- look for signs
What complications can arise from fractures in a disabled athlete?
- neurovascular compromise
- autonomic dysreflexia
- fat emboli with large long bone fractures / increased DVT risk post-injury
- pressure sores from immobility or attempts at casting (should be avoided)
- further patient disability: loss of independence with mobility / transfers
- Inquire about the functional implications of the fracture (just because they don’t walk on it doesn’t mean they don’t use it)
What are the possible causes of a swollen limb in an athlete with a neurological impairment?
Fracture
DVT
heterotopic ossification (HO)
infection
impending pressure sore.
Patients with a spinal cord injury (SCI) are at highest risk for a DVT in the months immediately following the injury.
Heterotopic ossification is the formation of bone in ectopic sites. It has been reported to occur in 16-35% of persons with SCI. The bone formation can lead to severe joint restriction.
What is baclofen withdrawal syndrome?
BWS is a potentially life-threatening syndrome that appears to be reversible if sufficient dosages of GABAergic drugs are given in time.
abrupt change in mental status
increased spasticity
pruritis
hyperthermia
myoclonus or seizure
instigated by a sudden cessation of Baclofen.
How do you treat baclofen withdrawal syndrome?
Restart baclofen, benzos
ABCs
Potential causes of fever in a disabled athlete
impaired thermoregulation due to impaired reflex vasodilation + inability to dissipate excess heat predictably.
UTI
Resp infections
Infected pressure uclers
DVT
heterotopic ossification
What are clinical problems related to amputation?
1) residual limb pain d/t neuroma, bone overgrowth (including pediatric bony overgrowth, heterotopic ossification & bone spurs), poor prosthetic fit, skin lesions
2) phantom pain
3) residual limb skin problems - friction or pressure ulcers, abraisions
4) contralateral limb overuse injury
What are common clinical issues in pts with spinal cord injuries?
Spasticity
mechanical and neuropathic pain
pressure sores
autonomic instability (autonomic dysreflexia, orthostatic hypotension, impaired thermoregulation)
urinary tract infections
insufficiency fractures
contractures.
What is the American Spinal Injury Association (ASIA) Impairment Scale + what factors influence someone’s rating?
assigns a neurological level and degree of distal preservation of:
sensory and motor function
rectal sensation
voluntary anal contraction
Typically expressed as C, T or L and numeric assignment for neurologic level followed by impairment severity rating A, B, C, D or E. i.e. “C5 ASIA A spinal injury”
Describe the ASIA impairment rating
A - Complete: no sensory or motor function is preserved
B - Sensory Incomplete: sensory but no motor function is preserved
C - Motor Incomplete: motor preservation below the neurologic level, and more than half of key muscles below last normal level have a muscle grade ≤3. Must have some spared sensation or motor S4/5.
D - Motor Incomplete: motor function preserved below the neurologic level, and at least half of key muscles below last normal level have muscle grade >3. Must have some spared sensation or motor S4/5.
E - Normal: sensory and motor function are normal. May have reflex abnormalities
What are the categories of vision loss?
- best corrected visual acuity of less than 20/60, or significant central field defect,
- significant peripheral field defect
- reduced peak contrast sensitivity
What are the 3 classes of visual classification?
B 1: From no light perception to inability to recognize a hand
B 2: From ability to recognize a hand up to visual acuity of 2 / 60 OR a visual field <5 degrees
B 3: From visual acuity above 2/60 to visual acuity of 6/60 OR a visual field of 5-20 degrees
What are common clinical problems in pts with cerebral palsy, as a baby + as an adult?
As a baby:
hypotonia, poor feeding and motor delay.
Persistence of primitive reflexes beyond 4-7mo eg persistence of the asymmetric tonic neck reflex (fencer pose) and Moro (startle) reflex beyond 6 months
As an adult:
Abnormal gait patterns
poor walking efficiency and speed
kyphosis scoliosis
rotational deformities
hip subluxation and contractures. This leads to long term issues with pain, abnormal bone growth and early OA.
Retinopathy of prematurity
strabismus
esotropism + exotropism
visual field deficits
Hearing impairments
Urinary symptoms including frequency, incontinence, and difficulty urinating
Seizure disorders
Osteoporosis and increased risk of pathological fracture
What are the 3 categories of spina bifida?
Spina bifida occulta
meningocele
myelomeningocele
What are common clinical issues that are found with TBI?
Post traumatic seizure disorder and need for anti-seizure medications
Hydrocephalus – may have ventriculo-peritoneal shunt
Spasticity
Ataxia
Aphasia
Dysarthria
Visual Field Deficits
Cognitive impairments
Behavioral impairments
What are common causes of shoulder pain in a wheelchair athlete?
rotator cuff and impingement problems
* Bicipital Tendonopathy
* Glenohumeral Instability+/- 2* impingement
* Osteolysis of the distal clavicle
* Labral injuries
* Osteoarthritis of the Glenohumeral Joint
* Osteoarthritis of the Acromioclavicular joint
* Myofascial Pain Syndrome
* Suprascapular Neuropathy
* Cervical Pathology (Facet Joint, Cervical Root, Deg Disc Disease, Syringomyelia/Syrinx)
What extra supplies would you consider carrying in a paralympic medical bag?
Equipment repair kit (allen key, multitool, duct tape)
Foley catheter
Glycerin suppositories
Leg bag
Captopril 25mg SL
Lidocaine jelly
Gabapentin + baclofen
What are the indications of a steroid joint injection?
Osteoarthritis (OA) of large joints (e.g., knee, hip, shoulder)
Inflammatory arthritis (e.g., rheumatoid arthritis, gout, psoriatic arthritis)
Bursitis, tendinitis, or synovitis
Rotator cuff impingement
Plantar fasciitis
What are the indications of a viscosupplement joint injection?
Symptomatic knee osteoarthritis (moderate evidence)
May be considered for other large joints (e.g., hip, shoulder) in certain cases.
What are the indications of PRP?
Mild-to-moderate osteoarthritis (especially knee and hip OA)
Chronic tendinopathies (e.g., lateral epicondylitis, patellar tendinitis, Achilles tendinopathy)
Rotator cuff tears
Ligament sprains or partial tears
Early cartilage damage
What are the indications of prolotherapy?
Chronic musculoskeletal pain (e.g., low back pain, neck pain)
Ligament or tendon laxity
Osteoarthritis in specific joints (e.g., knee, sacroiliac joint)
What are the indications of a stem cell joint injection?
Early osteoarthritis
Cartilage defects or degeneration
Experimental use in sports injuries and degenerative joint disease
What are the benefits of a steroid joint injection? How long does it last?
Potent anti-inflammatory effect
Rapid pain relief, often within 1-3 days
Can improve joint mobility and function
Useful for acute flares of arthritis or severe pain
Variable; typically 4-8 weeks but can be shorter in advanced osteoarthritis.
Not a long-term solution; recommended to limit to 3-4 injections per joint per year.
What are the risks of a steroid joint injection?
Post-injection flare (transient increase in pain)
Joint infection (rare but serious, <0.1%)
Skin or subcutaneous fat atrophy at the injection site
Depigmentation of the skin at the injection site
Tendon rupture if injected near tendons
Accelerated cartilage degeneration with repeated use in weight-bearing joints
What are the benefits of a viscosupplementation joint injection? How long does it last?
Provides lubrication and shock absorption to the joint
May reduce pain and improve function, particularly in early-to-moderate OA
Delays the need for surgical intervention in some cases
Typically 6-12 months, though some patients report relief up to 1 year.
Effectiveness is variable and may take several weeks to notice
What are the risks of a viscosupplementation joint injection?
Local joint swelling, pain, or stiffness post-injection
Rare systemic allergic reaction
Joint infection (rare)
Limited evidence for benefit in severe OA
What are the benefits of a PRP? How long does it last?
Promotes tissue repair and regeneration by delivering growth factors
May provide longer-lasting pain relief compared to steroids
Minimal systemic side effects (autologous blood product)
Some evidence suggests delaying progression of OA
Variable; typically 6 months to 1 year or more for OA.
May require multiple injections (e.g., 2-3 spaced weeks apart).
What are the risks of PRP?
Pain, swelling, or stiffness at the injection site
Risk of infection (rare)
Limited evidence for effectiveness in advanced OA
Expense (not typically covered by insurance in Canada)
What are the benefits of prolotherapy? How long does it last?
Stimulates local healing response by injecting irritant solutions (e.g., dextrose, saline)
Evidence for pain reduction and improved function in some studies
Non-steroidal alternative for chronic joint or ligament pain
Varies; typically requires multiple injections (e.g., 3-6 sessions) over weeks to months.
What are the risks of prolotherapy?
Injection site pain or irritation
Risk of local infection (rare)
Transient inflammation
Limited high-quality evidence for efficacy in large-scale studies
What are the benefits of stem cell injections? How long does it last? What are the risks?
Potential for cartilage regeneration and joint repair
Pain reduction and possible delay of disease progression
Experimental but promising for OA
Expense (not covered by insurance)
Limited high-quality evidence for widespread use
Risk of infection or inflammatory reaction
Highly variable; data suggests effects may last 1-2 years in some cases.
