Lecture 5,6 And 7 Flashcards
Elements of diagnosis
-history
-physical examination
- neural testing
-spinal examination
Elaborate on how history is an element of diagnosis and what are the elements within history
-can diagnose an injury just based on the elements of history
- age and sex
- details of injury
- training history
- diet
- injury history
- general health
- work and leisure activities
- other predisposing factors
Elaborate on age as a part of history
- it is important to distinguish since young and adult athletes have different common injuries
- jumpers knee aka tendinopathy is common in adult athletes
Elaborate on the details of an injury as part of the history
- mechanism symptoms and type of pain help provide context
An example of how the training history in diagnosing an injury can be utilized
- evaluate the equipment used and potentially change equipment, related to overuse injury
What are example of other predisposing factors
- family history, musculoskeletal injuries and genetics
What is involved in physical examination
- inspection
- palpation
- ROM testing
- ligament testing
- strength testing
- neural testing
- spinal examination
- biomechanical examination
Does inspection include accessing the posture of an athlete and how they walk
Yes
Examples of neural testing
- nerve root compression
- peripheral nerve compression
- other MSK disorders
What is the purpose of neural testing
- assess nerve mobility
- assess nerve sensitivity
- differentiate sources of pain (MSK Vs neural)
What are the key components of neural testing
- questions (what are the symptoms) and inspection (posture)
- reflex testing (clinician tap on major tendons)
- sensory testing (test feeling)
- motor testing (can they pick something)
- neural tension tests; ulnar, radial,median which all correspond to specific body part, and any affect to these areas would be indicative with damage to respective nerves
Spinal examination
Posture and ROM testing as well as functional assessments, neural testing and manual examination
Example of a bio mechanical examination
Knee lift test; measures how well hip abductors work to stabilize pelvic muscles
Is single leg squat a bio mechanical examination and when is it used
Yes it is used when there is anterior or unclear knee pain done to monitor proper lower limb alignment
Vertical drop jump when is it used
Related with knee overuse injuries with valgus mechanism
What are the different types of imaging and when are they used
- X-ray; info on fractures
-CT; cross sectional image between muscle and bone
-US; investigate tendon muscle and soft tissue
-MRI; structures of joint,muscle, brain, SC and internal organs
Principles of treatment and rehabilitation include what stages
- Acute stage (last a few days)
- Rehabilitation stage (last several weeks)
- Training stage (weeks-months depending on severity)
Acute stage
Involved with acute injury and overuse injury
Within acute injury (which is due to mechanism and improper technique)
Treated with PEACE, POLICE AND PRICE
Within overuse injury
-protect area by partial unloading of the injured structure
Crucial to alter loading pattern
What is involved in the rehabilitation stage
-prepare athlete to train normally, prevent rein-jury and return to optimal performance
In the rehabilitation stage you monitor—— and ensure what 4 things (goals of rehabilitation stage)
- monitor pain and swelling
- ensure normal ROM
- ensure normal strength
- ensure normal neuromuscular function
- ensure normal aerobic capacity
In rehabilitation stage its important to know when pain starts increasing you must
Gauge loading
Within the Rehabilitation stage is normal ROM a prerequisite for returning the athlete to a normal technique
Yes
Reduced ROM limits ——-
Ability to do strength training
Rehabilitation stage
- Maintaining general strength
- well performed alternative training will allow the athlete to return to sport sooner
Rehabilitation stage
- Training that affects the injured structures
- the amount, the intensity, frequency, duration and exercises depend on the injury
- highly repetitive training
- weekly consultation with a physiotherapist
Rehabilitation stage (what is vital)
-NMT
Painful conditions may result in reflex —— leading to changes in ——- which then leads to ———— and an increased risk of rein-jury
Inhibitions leading to changes in movement patterns which then leads to unfavourable loading patterns which leads to an increased risk of re-injury
Acute ligament injuries may also result in reduced joint position sense and ———— which leads to
Coordination which leads to increased risk of re injury
What types of training is involved in rehabilitation stage
Proprioceptive and progressive strength training of injured structures
What are other therapies involved in rehabilitation
-manual treatments exp massage, manipulation, dry needling, vacuum cupping, taping and bracing
-electro physical agents known as therapeutic ultrasound laser, shockwave therapy (done to relieve pain)
-medication; NSAIDS and corticosteroids
-dietary supplements exp vitamin D
Training stage (sport specific training)
1.gradual transition from controlled rehabilitation exercises to sport specific training
2.functional and sport specific testing to determine whether can tolerate sport specific training loads
3.necessary that at least 85-90% of the original strength is regained before being allowed to compete again
Define RTS
- according to the sport and the level of participation
- rts success means different things to different people
- contextual factors influence the expectations and risk tolerance
- shared decision making process
Contains the practicing of closed and open skills
What are the 3 elements of RTS
- Return to participation
- Return to Sport
- Return to performance
True or false RTS is different between individuals
True
What evidence do we have to inform the clinicians contribution to the shared RTS decision
- functional and sport specific conditioning tests
- assessing readiness to RTS by conducting tests that consider both closed and open skills psychological readiness taken into consideration as well as
What is RTS criteria
- acute knee injuries, acute hamstring injuries, groin injuries, Achilles tendon injury and shoulder injury
Groin pain (adductor)
-most common groin injury
-pain in sprinting, direction change and kicking
-pain in the insertion of the adductor longus
-longstanding groin pain can start gradually or suddenly
-involved in high risk sports
Diagnosis of groin pain
-history and physical examination
-MRI used to grade the injury extent from 0-3
-exercise therapy programs
-holmich program (chronic pain)
-progressive groin program (acute injury)
Holmich exercise program
-isometric and dynamic exercise to reactivate the adductor muscles (2 weeks)
-heavier resistance training, balance and coordination (6-10 weeks)
-jogging (allowed after 6 weeks if no pain)
NO STRETCHING OF ADDUCTOR MUSCLES
In the holmich exercise program can sport specific training resume
Yes progressively after the training is over
What is grades of injury
- 0 no acute injury
- 1 edema only
- 2 structural disruption
- 3 complete tear
Progressive groin exercise program
- nine groin exercises
-alternate days 3 times a week
-no groin pain allowed during the exercise
Three milestones in RTS progression
- clinically pain free
- Controlled sports training
- Full team training to RTS
When do athletes with an MRI grade 0-2 adductor injury return to full team training
After 3 weeks
Athletes with an MRI grade 3 adductor injury is returning to full team training..
Within 3 months
Primary prevention of groin injury
-adductor strength and flexibility training
Glenohumeral joint
-coracocromial ligament
2. Coracohumeral ligament
3. Glenohumeral ligaments
Subluxation
Partial dislocation of articulating bones
Dislocation
Complete separation of articulating bones
Mechanism shoulder dislocation
- direct blow to the shoulder
- landing on outstretched arms
Different type of dislocation
Anterior dislocation
Fracture dislocation
Labrum injury
- History and physical examination
- Imaging
- Reduction of the shoulder (after confirmed diagnosis)
- Protection from re-injury
- Rehabilitation period prior return to sport
High risk of recurrence
- 50-90% depending the type of sport and shoulder dominance
- surgical management (in high risk population)
- rehabilitation of the shoulder is critical to the long term function
Ligament structure
dense bands of
collagen tissue
• Collagen, elastin,
proteoglycan, and
other proteins
• Vary in size, shape,
orientation and
location
Ligament function
function- Connect one bone to
another → Passive
stabilization of the joints
• Ligaments can creep
• Serve important
proprioceptive function
Ligament response to injury
response to injury- Healing follows the
constant pattern
• Ligament scars have
weaker tensile strength
& poor viscoelastic
properties→ re-injury
risk is very high!
• Ligament injury →
decreased
proprioception
if force causes more
than a 4% change of
length, the collagen
fibers will start to
rupture (stress strain curve) TRUE or FALSE
if force causes more
than a 4% change of
length, the collagen
fibers will start to
rupture
Types of Ligaments
Intra-articular ligaments
e.g., Cruciate ligaments of the knee
Extra-articular ligaments
e.g., Calcaneofibular ligament
Capsular ligaments
e.g., Anterior talofibular ligament
Adaptation to Training ligament injury
Adapt slowly to increased loading, but weaken very
rapidly as a result of immobilization
Adapt to loading by increasing the cross-sectional
area
Normal everyday activity is sufficient to maintain
mechanical properties
Systematic training can increase ligament strength
by 10-20%
Joint Stability
Depends on the interaction between the passive, active
and neural subsystems
Passive subsystem consists of non-contractile connective
tissues
Active subsystem is controlled by the neural subsystem to
provide dynamic joint stability
Mechanisms of Ligament Injuries
Typically injured
because of acute
trauma
Sudden overload →
ligament is stretched
out (joint in an
extreme position)
Overuse injuries rare,
but can occur as the
ligament is gradually
stretched out
Most common injury
most common injury in sport-lateral ankle sprain
2nd most common injury
2nd most common injury- knee ligament injury
Why are knee and ankle joints sensitive?
- not much support on knee joint, bony anatomy, doesnt provide much
support, not much passive support
situations where these injuries occur
Quick direction changes, causing knee misalignment
Mechanisms of Acute Knee Joint Injury
- Patellar dislocation/subluxation
- Hit from lateral side - valgus MCL +/- ACL
- Valgus/external rotation - with or without contact ACL +/- MCL +/- lateral meniscus +/- bone bruise
- Direct blow to anterior tibia PCL
- Hyperextension injury ACL
- Minor twist in older individual Degenerative Meniscular tear
valgus mechanism of injury results in
- ACL rupture
• MCL rupture
• Lateral dislocation of patella
• Lateral meniscus injury
• Lateral tibial plateau fracture or bone bruise
valgus mechanism of injury results in
- ACL rupture
• MCL rupture
• Lateral dislocation of patella
• Lateral meniscus injury
• Lateral tibial plateau fracture or bone bruise
What is hemarthosis, Injuries that cause Hemarthrosis and what injuries don’t
Bleeding into the joint
• ACL tear; Peripheral meniscus tear; Osteochondral injuries; Fractures
Injuries that cause hemarthrosis
Don’t cause
• MCL tear; Central meniscus tear; PCL tear; Cartilage injury
ACL
Anterior
Cruciate
Ligament
(ACL) • ACL – 2 bundles
• Anteromedial bundle resists tibial anterior translation
• Posterolateral bundle resists tibial rotation
• No pain fibers, but has proprioceptive fibers
(seperate)
physical examination for ACL injury
- anterior drawer test of the knee 90 degrees 2. lachman test 20-30 degree flex externally rotated 3. Pivot shift test (mimics injury mechanism itself clinician applies valgus force used for acl injuries as well as if it is complete or partial tear)
what imaging is needed for ligament injury
- mri is rarely needed
- only used when injuries are more severe ore stuctures that are daaged/ dislocation/bone damage
ACL Complications
Osteochondral injury
ACL injury and Meniscus tear
Unhappy triad, MCL, ACL LCL
Osteoarthritis in 15-20 years
ACL Treatment – Goals and Options
Goal is to prevent recurrent
giving way
• To prevent subsequent
injuries, such as
osteochondral injuries and
meniscus injuries
Three options (as for any
unstable joint):
• Modification of activity (no
twisting activity)
• Bracing for light twisting
activity
• ACL reconstruction (ACLR)
• Although functional –never normal
ACL
Reconstruction
• The graft is weakest at
3 to 6 months!
• High re-injury rates
over 2 years after
reconstruction
cross bracing protocol
- The patient’s knee is in brace set at a fixed
angle of 90-degrees (4 weeks, 24/7)
Increased extension: 10-15 degrees each
week (weeks 5-12)
Why are females
more prone to ACL
injuries than males?
Anatomical factors
Biomechanical factors
Neuromuscular factors
Hormonal factors
Training related factors
Traditional sex-based approach does not
take into account the growing recognition
of how sex and gender (a social construct)
are ’entangled’ and influence each other. TRUE OR FALSE
TRUE
Prevention of ACL Injuries
• Modifiable risk factors
• Weak hip abductors an external
rotators
• Increased knee abduction moments
during cutting and landing
• Knee Control training program
• Adolescent female soccer players (n=4600)
• 64% reduction in the rate of ACL injury
was seen in the intervention group
Mechanism of ACL injury can be gradual TRUE OR FALSE
TRUE
Two types of bone tissue
- Trabecular spongy bone (cuboidal bones, flat bones at the ends of bones)
- 75-95% porosity, found inside bones - Cortical compact bone (forms the outer shell of long bones, its function is strength and protection, low porosity 5-10%
Long bone anatomy
- periosteum membrane covering bone
- marrow; both red and yellow marrow
- cortical hard bone
- trabecular spongy bone
- epiphyseal plate
Bone marrow two types? In adults? Children?
- red marrow; produces blood cells
Children; in most bones
Adults; flat bones, vertebrae and long bones
-yellow marrow; stores fat
Adults; long bones
Function of bone
• Bone serves a mechanical purpose
• Protects our internal organs
• Provides the body its basic shape
• Facilitates movement
• Provides a framework for support
• Mineral storage (calcium & phosphate)
• Blood cell production
• Fat storage
• Hormone regulation (osteocalcin)
Bone injury adaptation to training
Physical training increases bone mass (bone mineral density) Training related increases in bone strength are site specific Driven by dynamic, rather than static loading Only a short duration of loading is necessary
Peak strength and density typically between the ages of 25 and 30
Osteoclasts
remove bone
Osteoblasts
produce bone
Stress-Strain Curve for bones
• Typical stress–strain
curves of compact and
spongy bones
• The last point of the
stress–strain curve is the
failure point
Stress strain curve where is the yield point
The point where the graph starts to flatten
Bone Injury Types
Traumatic fracture (closed or open)
Pathological fracture (e.g., osteoporosis and
cancer)
Stress fracture (fatigue fracture)
Bone contusion (acute traumatic bone injury
without fracture)
Osteitis (inflammation of bone)
Periostitis (inflammation of periosteum
Traumatic fracture
Acute sudden onset; high energy trauma
(Closed or open)
Pathological fracture
-exp cancer or osteoporosis
-acute sudden onset injury, due to weak brittle bones, low energy
Stress fracture
Fatigue fracture
Repetitive loading and micro traumas
Bone contusion
Acute traumatic , bone injury , without fracture
Osteitis
Inflammation of bone (overuse)
Periostitis
Inflammation of periosteum after blunt trauma
Open fracture
- compound fracture, bone breaks through skin
Closed fracture
- bone does not break through skin
Fracture patterns
- the pattern indicates the cause/mechanism
What does a transverse fraction indicate
Injury due to tension
What does a oblique fracture indicate
Compression injury
What does a butterfly fracture indicate
Bending load on bone
Spiral fracture pattern indicates
Torsion
Diagnosis of bone injury
- history
- physical examination, inspection,palpation and ROM testing and neuromuscular assessment
- imaging; x ray, ct scan, mri
MRI is good for early stage fractures T or F
True
What is the number 1 treatment for fracture treatment
- conservative treatment
• Conservative treatment of fractures
• Splinting and bracing
• Plaster or fiberglass casting
• Bandages and orthoses
Surgery
• When conservative treatment fails, or fracture is highly
displaced or unstable
• Intramedullary rods
• Locking and stabilizing plates
The stages of fracture healing are:
- Blood clotting and inflammation (3-7 days)
- Soft callus formation (2 weeks)
- Hard callus formation (2 weeks)
- Bone remodelling (can last for many years)
These stages may overlap with each other [1]. During the healing process, two types of bone are formed:
- Woven bone
- Lamellar bone
What are the 2 types of bones formed during healing process
- Woven bone: Quickly formed, poorly organized bone that appears during the soft callus stage
- Lamellar bone: Slowly formed, highly organized bone that replaces woven bone during the hard callus and remodeling stages [2]
Other
Treatments
For fractures
Efficacy is
questionable
Bone grafts
Stem cell therapy
Ultrasound
Electrical stimulation
Healing Time bone fracture
Lower limb takes the ingest 3-6 months healing for femoral neck injury, femur injury and tibia injury
Complications of fractures
- Infection
(open fractures) - Delayed union (slowed healing), mal-union( healing in the wrong position) , non-union (not healing)
- Acute compartment syndrome, sudden increase in pressure inside the bone
- Osteonecrosis; bone death due to improper blood flow
- Nerve injury overstretch of peripheral nerve
- Vascular injury
- Osteoarthritis
- Deep vein thrombosis & Pulmonary embolism
Stress fractures is associated in what sports
stress fractures in sport is involved high risk sport, figure skating, football, weight lifting, wresting
Continuum of stress fractures
• 1) Bone stress reaction (Posterior element overuse syndrome)
• 2) Fracture (Spondylolysis), when we overload spine w extension and flexion leads to immediate stress response; fracture
• 3) Slipping of vertebra (Spondylolisthesis),
Risk Factors for
Spondylolysis &
Spondylolisthesis
- Excessive extension and
rotation loads - Improper technique
- Hyperlordosis
Diagnosis and Treatment:
Posterior Element Overuse Syndrome
• History, physical examination
• Imaging: e.g., X-ray, MRI
• Pain management: ice and NSAIDs
• Pain free activities: avoid extension!
• Physiotherapy: core strength, anti-lordotic exercises, stretching (hip flexors)
• Return to sport within 4-8 weeks
Diagnosis and Treatment: Spondylolysis and Spondylolisthesis after surgery
- Week 1: short walks
and stretching - Weeks 2-9: static
stabilization exercises
(core) - Weeks 6-12: dynamic
strength exercises - Weeks 9-12: low impact
aerobic training
RTS between 6 months
and 1 year
Medial Tibial Stress
Syndrome (MTSS)
• Running and jumping
• Repetitive loading leads to periosteal
inflammation along the tibia
• Pain and inflammation along middle-
distal third of posteromedial aspect of
tibia
• Diffuse pain
MTSS is aka as shin splints T or F
T
MTSS: Diagnosis and Treatment
- History and physical examination (palpation)
- Alternative training; change loading pattern
- Correction of malalignment (valgus movement) & training problems (monotone)
- Exercise therapy: strength and flexibility
- Prognosis is good if treated early!
Tibial Stress Fracture
• Running and jumping
• Significant pain during running, often
disappears during rest, returns when
athlete starts running again
• Focal pain
Tibial Stress Fracture: Diagnosis and Treatment
- History and physical examination (Palpation & hop test)
- X-ray; MRI
- Crutches & Brace & Alternative training
- When pain free → Progressive training
How long does stress fractures take to heal
12 weeks to heal
The prevention of stress fracture
The prevention of stress fracture is by changing activity techniques, calcium supplements, proper recivery , hormonal levels take into account as well
