Midterm Flashcards
Roll Up Injury
MOI, possible injured structures
External rotation forced into dorsiflexion from a fall on the ankle from behind
Possible injured structures: deltoid lig, fractured fib, AITFL
- don’t all have to happen and can occur in different order
Healthy Ankle Injury
MOI, injured structures, tests
Eversion and external rotation (most commonly in hockey skate or ski boot)
Injured structures: fracture of fibula with no injury to deltoid lig.
Tests: squeeze test and external rotation (both indirect)
High Ankle Sprain
MOI types, injured structures, signs, tests
MOI:
1) Dorsiflexion and eversion
2) external rotation of foot w/ internal rotation of leg
3) Postulated to be external rotation and hyperdorsiflexion
Injured structures: AITFL and interosseous membrane
Signs: minimal swelling (noncapsular), toe to heel ambulation, negative ant. drawer and talar tilt, empty end feel in dorsiflexion
Tests: squeeze test, external rotation, length of pain on interosseous
Lower Leg Tendinitis/Paratenonitis
Signs/symptoms, treatment
Signs: pain/crepitation of acute onset, red and hot, ankle movement makes it worse, positive STTT
Treatment: POLICE, address training issues, gradual return
TOO MUCH TOO SOON
Retrocalcaneal Bursitis
Inflammation of bursa between tendon and calcaneus Usually chronic Structural irritants Pain above insertion of Achilles tendon Pain with squeeze from side
Achilles Bursitis
Easy to correct
Pain with palpation on posterior aspect of heel
Shoes too tight/excessive friction
Achilles Tendinosis
What is it?, Causes, predisposing factors,
Chronic pathological changes brought on my repetitive micro trauma
Inflammatory cells are absent + rice crispies
Changes in collagen fiber structure (disarray + fewer nuclei) and vascularity (neovascularization)
Can be brought on by neglect of tendinitis and worsens with little recovery time
Predisposing facts: years of running, excessive pronation, training in cold climate, improper footwear
Remodel w/ alfredson’s painful heel drops (eccentric)
Stages of Tendinopathies
Stage 1 - no pain prior, pain until warm during, after pain goes away with rest
Stage 2 - pain in AM, pain during, pain after
Stage 3 - slight pain before, pain limits activity, no inflammatory mediators but wider b/c it is fraying
Stage 4 - pain even at rest, unable to exercise, may rupture if untreated
Achilles Rupture
More common in males in 30-40s
Sports that require rapid change in direction
Reports snap/pop + pain rapidly subsides
Pain 1-2 inches above insertion
Can do double leg heel raise but not single
Divot on palpation
Unable to plantar flex
No pain on stretch because it is completely torn
Positive thompson test
Immobilize w/ 2 cm heel lift for 8 weeks with exercise below neutral for week 2-4
Compartment Syndrome (2 types, 4 Ps)
Traumatic/Acute: due to direct trauma, can result in devastating injury and is a medical emergency
Exertional/Chronic: starts following increase FITT, usualyl worsens during running/jumping, cease with rest
Pain (out of proportion)
Paresthesia
Paralysis (late finding)
Pulse (lack of)
How to evaluate compartment syndrome?
Test strength 10x - looking for weaker, slower, more painful
Stretch muscle - muscles working anaerobically will have pain on stretch
Palpate - firm is bad
Skin colour - pale turn red, dark turn darker
Anterior Compartment of Leg
pain, strength, stretch, nerve, sensory area
Pain: lateral tibia Strength test: dorsiflexion Stretch: plantar flexion Nerve: deep peroneal Sensory area: b/w 1st and 2nd toes
Lateral Compartment of Leg
Pain: lateral malleolus Strength test: eversion/plantar flexion Stretch: inversion/dorsiflexion Nerve: superficial peroneal Sensory area: dorsum of foot not near toes
Deep Posterior Compartment of Leg
Pain: lower 1/3 postero-medial tibia Strength test: inversion/plantar flexion Stretch: eversion/dorsiflexion Nerve: tibial Sensory area: plantar foot (not heel)
Treatment for Compartment Syndrome
Slow warm up before activity
Icing after
Stretch before and after
Modify the activity that causes it
What causes Medial Tibial Traction Periostitis (MTTP)
(AKA Medial Tibial Stress Syndrome) - true shin splints
Causes by over pronation (due to weak muscles, fatigue, or shoe) and training errors - both cause athlete to modify weight acceptance
Caused by soleus and flexor digitorum longus b/c they eccentrically limit pronation
MTTP - Signs and Treatment
Signs: pain on medial tibia that improves with warm up and is worse after, rough/rice crispies over medial tibial margin, minimal STTT signs (can’t produce as much force as running)
Treatment: POLICE, stretch, strengthen to prevent overpronation, correct training errors
Tibial Stress Fractures
cause, presentation, treatment
Can be caused by repetitive impact but also if there is muscular imbalance pulling on bone (decreases bone density)
Proximal and anterior stress fractures in the tibia are more resistant to treatment - “anterior is awful”
Presentation: cavus (no shock absorption) or planus (pronated foot - no absorption), gradual onset by exercise, pain all the time and at night
Treatment: decrease weight bearing, pneumatic brace , address training errors, slow return, train in water instead
Which types of muscles are most at risk for strain?
Two joint muscles (gastrocs, rectus femoris, hamstrings) and muscles with more fast twitch fibers
Why does a muscle strain occur?
Forcible stretch of a passive or active muscle
The stretch must be past the resting length to cause damage
Commonly an eccentric contraction that causes it
Gastroc Strain
Sudden onset Medial head more susceptible AKA tennis leg Sports with quick starts and stop Foot planted and extension of knee
Soleus Strain
Slow onset Usually lateral Calf is tight Common in severe pronators Worse with walking and jogging than sprinting
Signs and symptoms of strain
Bruising, swelling, redness
Maybe palpable defect near MT junction
How to test for soleus vs gastroc strain?
Bent knee = soleus
Straight knee = gastrocs
How to treat a strain?
Same as other acute and subacute but use concentric and eccentric actions (alfredson’s)
Order of assessment
3 questions: life or limb, area stable, how to exit?
Subjective/History: MOI, pain, sounds, prior injury, continue?
Objective:
- clear above and below
- tests (ant. drawer, external rotation, squeeze)
- palpate important structures (ottawa ankle/knee rules)
- on sideline: AROM, PROM, resisted
*if there is a fracture - no more tests
What grade means it is not safe to remove athlete from field weight bearing?
Anything above grade 1
Grade 1 - weight bearing
Grade 2-3 - non weight bearing
even if it is grade 1 if the athlete does not feel comfortable - remove non weight bearing - better safe than sorry
What pain characteristics should you ask about in the clinical assessment?
Sharp = nerve
Localized and deep = bone
Dull and achy = muscle
Does it change? am/pm/sleep/activity
Why is it important if the joint is locking?
think about meniscus in the knee
Why is it important if the area feels like it is going to give way?
grade 3 injury
Difference between pain and discomfort
Pain changes the way you perform an activity, discomfort doesn’t
What is the sideline testing progression for the “minor injury”?
Straight - angle - cut - accelerate/decelerate - explosive - jump/kick/spin/strike
Aside from the formal rehab what must the athlete be working on for return to sport?
Maintaining their conditioning
Let the athlete know what they can do, not just what they can’t
What do you need to think about for sport specific skill progression?
speed, coordination, proprioception, cadence, quality, etc.
What are the three articulating surfaces in the knee?
1) Medial and 2) lateral tibiofemoral and 3) patellofemoral
Takes place between the bottom of the femur and the top of the menisci?
knee flexion and extension
Takes place between the bottom of the menisci and the tibia?
rotation/twisting
When does rotation of the knee occur and why? What is the difference between foot planted and femur fixed?
During the last few degrees of extension because the medial femoral condyle is larger than the lateral
Foot planted = femur rotates medially
Femur fixed = tibia rotates laterally
What muscle unlocks the knee?
Popliteus contracts to externally rotated the femur
Is the knee more stable in flexion or extension?
extension - poor bony fit in flexion
What muscles are the dynamic stabilizers of the knee?
hamstrings, quads, IT band, gastrocs
Is the MCL capsular or non capsular?
Capsular - slow capsular effusion
Is the ACL intracapsular or extracapsular?
Intracapsular - fast swelling (hemarthrosis)
Is the PCL intracapsular or extracapsular?
extracapsular
is the LCL capsular or extracapsular?
extracapsular
The lateral aspect of the knee is mainly support by___
Muscles
Biceps femoris IT band Popliteus tendon Capsular ligaments Lateral collateral ligament
Lateral knee injuries occur due to a ___. Isolated LCL tears are common/uncommon
varus force
Isolated LCL tears are uncommon
Characteristics of the LCL
lateral epicondyle of femur to fibular head
extracapsular - minimal swelling
primary STATIC restraint to varus force
Takes load at 25-30 degrees because muscles change angle of pull
The medial aspect of the knee is supported by?
MCL is primary stabilizer (at 25-30 degrees)
ACL/PCL
Muscles - medial hamstrings, medial gastroc, quads
boney structure
Characteristics of the MCL
capsular - slow swelling
connects directly to MCL - likely injured together
Medial femoral epicondyle to tibia
has superficial and deep components
With a knee injury that has damaged the MCL, medial meniscus, what else is likely to be injured?
ACL
then PCL
Structure of the ACL
goes from anterior tibia to lateral femoral condyle
has 3 bands - two of which are major: anteromedial (controls forward and back) and posterolateral (medial rotation)
primary restraint for anterior tibial translation (greatest at 30 degrees)
Which cruciate ligament is stronger?
PCL
What does the ACL do?
restrict posterior translation of femur during weight bearing
restrict anterior translation of tibia during non-weight bearing
The anteromedial band of the ACL tighten in __
the posterolateral band of the ACL tightens in __
flexion
extension
Structure of the PCL
medial condyle of femur to posterior tibia
has anterolateral and posteromedial bands (opposite to ACL)
What does the PCL do?
restrict anterior translation of femur during weight bearing
restrict posterior translation of the tibia during non weight bearing
The anterolateral band of the PCL tightens in___
The posteromedial band of the PCL tightens in __
flexion
extension
General ligament principles:
Lateral rotation makes the __ tight
Medial rotation makes the __ tight
lateral rotation - collateral
medial rotation - cruciate
What is the purpose of the menisci?
distribute nutrients on compression
stabilize knee by increasing concavity
Shock absorption (greatest at 90 degrees knee flexion)
Characteristics of the medial meniscus?
C shaped
greater radius of curvature
tight connection with MCL and capsule
Poor mobility
Characteristics of the lateral meniscus?
O shaped
smaller radius of curvature
Attached loosely to capsule
Increased mobility
Each meniscus has three zones, what are they and what is the implication?
red-red - heals well
red-white
white-white
What are the Ottawa Knee Rules?
What should you be suspicious of?
Xray when one of the following is present:
Age greater than 55 or less than 18
Tender over fibular head or patella
Inability to flex to 90 degrees (swelling/fracture)
Inability to walk 4 steps
Be suspicious of: MVA, young patients who could have avulsed a bone, clinically loose people
Important questions to ask people with knee injuries?
MOI - foot planted or not, contact or non contact, pop/crack
were you able to continue? If not, how did you get of the field?
Locking or giving way since?
MCL injury MOI
valgus force with or without external rotation
can occur in isolation
LCL injury MOI
less common but more complicated
varus with or without hyperextension
What is something done differently with knee injuries during the acute stage?
instead of restricting ROM, we want to maintain gentle flexion/extension and dynamic stabilizers (quads/hams)
ACL injury MOI
occurs with contact or non contact
during cutting or single leg landing
1) deceleration/internal rotation
2) quads active - anterior tibia translation (main mechanism)
3) valgus after MCL
can occur in isolation or with other structures
NOT through hyperextension (protected in notch)
MAY SEE LATERAL JOINT LINE BRUISE - DO NOT CONFUSE WITH LCL
Why are there more ACL injuries in females than males?
1) anatomical - smaller intracondylar notch, wider pelvis, ligament laxity
2) hormonal - estrogen (not well proven)
3) neuromuscular - increased quad activation between 10 and 30 degrees, activate quads before hams, cut and land differently
Knees should be bent on landing because __
the line of pull in flexion is more backwards vs in standing it is vertical
Findings on an ACL injury
Restricted movement in extension Lateral joint tenderness (bone bruise - do not mistake for LCL) Positive lachmans (better because in 20-30 flexion when ligaments are loose and hamstrings don't contribute as much) and anterior drawer (90 degrees)
During grade 3 ACL injuries what do we do in the acute stage?
prepare for surgery
POLICE
maintain quads/hams strength - required for surgery
PCL Injury MOI
Sports or MVA (dashboard injury)
commonly due to hyperflexion
valgus after MCL and ACL
varus after LCL and ACL
Presentation of PCL injury
pop in posterior knee
poorly defined pain in back of knee
minimal swelling - extracapsular
posterior drawer test and sag test positive
With ACL injury we want to strengthen __
With PCL injury we want to strengthen __
ACL - strengthen hamstrings
PCL - strengthen quads
Acute meniscal injuries usually occur in (young/old) adults through combination of flexion, compression and rotation. In full flexion they accept __% of the laod
usually young adults
85% of load at 90 degrees
Medial meniscus is __x more likely to be injured and MOI is?
5x more likely
MOI - internal femoral rotation and possible varus
Lateral meniscus MOI
hyper flexion or external rotation
Presentation of meniscus injuries
pain on squatting
restricted ROM - locking
quicker swelling if lateral (red-red)
medial meniscus has less swelling
positive mcmurrays (heel is pointed to side we are testing)
distraction test should have no pain (pulling surfaces apart)
Factors indicating surgery for meniscus
locked knee
severe twisting
positive mcmurrays - pretty bad
With ankle injuries in acute stage we __ ROM and with knee injuries we ___ ROM
ankle - restrict
knee - maintain
Patella subluxation or dislocation MOI
moves out of groove laterally MOI: tibia ER and femur IR foot planted lateral/varus force knee usually in extension
Predisposing factors for patellar instability
patella alta (high riding)
shallow LFC or flat patella
mechanical dysfunction with excessive femoral internal rotation
lax bodies
Symptoms/Signs of Patellar Dislocation
knee pop out pain until reduced fast swelling - hemarthrosis loss of knee function if still dislocated tender of MEDIAL border positive lateral apprehension
What injury has similar presentation to patellar dislocation?
ACL - because of the fast swelling and loss of knee function
to tell them apart: ACL will hurt on lateral joint bruise and Patella has pain medially
To relocate patella:
slightly flex hip and slowly extend the knee
If it does not, do NOT force it because there be other injured structures - send for xray
How to treat someone who has dislocated their patella?
PROTECT
POLICE
maintain ROM
strengthen associated structures
Why should we be cautious of the painful then suddenly not painful injury?
grade 3
What should you do on the primary survey?
U responsiveness (alert, verbal, pain, unresponsive)
Airway
breathing
circulation
spinal injury, deformation, bleeding, shock (if any of these activate EAP and go)
if not then secondary assessment
Why do we clear above and below when doing onfield assessment?
to rule out injuries to other areas and assess athlete’s tolerance to handling
Palpate the knee for:
ottawa knee rules (patella and fibular head)
MCL, LCL, hamstrings, ITB, joint lines
Knee tests:
patellar apprehension lachmans anterior and posterior drawer mcmurrays (meniscus) valgus/varus stress (MCL and LCL)
Hamstring strains are the most common and have high reoccurrence, what muscle is usually injured ?
biceps femoris
active in terminal swing to initial stance
often injured in terminal swing before heel strike (eccentric)
Intrinsic and extrinsic factors contributing to hamstring strain are:
intrinsic: age (over 23), previous injury, strength (quads more than hams), flexibility, lumbopelvic stability
extrinsic: warm up, fatigue (muscles absorb less and change in coordination), training (increase in FITT)
Symptoms and signs for hamstring strain
sudden onset
spasm (grade 1) or tear (grade 2-3)
difficulty moving
pain near head of biceps (MT junction)
Bruising
positive STTT
palpable gap
Grade 1 strain
slight tightness
4-5/5 strength
fewer than 20% torn
Grade 2 strain
pop or tearing sensation
can’t extend knee
2-3/5 strength
70-80% torn
Grade 3 strain
pop or tearing
can’t extend knee
0-1/5 strength
more than 80% torn
Quadriceps Strain MOI
sudden forceful contraction of hip and knee
most common in rectus femoris (2 joint)
unlike hamstrings the tear is near distal MT junction, if they are proximal they are harder to rehab (bull-eye lesion)
similar presentation to hamstring train
For strains it is important to ___
compression because it prevents blood from localizing
During the remodelling stage of strains it is important to work____
eccentrically and concentrically
Thigh contusion (AKA \_\_\_) MOI
AKA charlie horse
usually result of impact to relaxed thigh
intra or intermuscular
Signs and Symptoms of thigh contusion
may be able to continue sudden decrease of ROM following bruising STTT contraction may have palpable mass (do NOT massage out)
How to test for inter vs intramuscular contusion
prone knee bend
if knee bend is less than 90 degrees after 24-48 hours it is most likely intramuscular
Grade 1 quad contusion (mild)
greater than 90 degrees flexion
may not remember
sore after
minimal strength lost
Grade 2 quad contusion (moderate)
45 to 90 degrees flexion
tender to touch but finishes game
loss of strength to pain
Grade 3 quad contusion (severe)
less than 45 degrees flexion
rapid onset - may not finish game
functional loss of strength
Key points with quad contusions
risk to rebleed in first 7-10 days
hands OFF (nothing until after 48 hours to promote lymphatic drainage)
no aggressive stretch past pain
How to treat a quad contusion in first 24 hours?
passively and painlessly flex knee to 120 degrees and wrap
ice
crutches
every couple hours unwrap and pump to prevent blood clot
How to treat quad contusion after 24 hours?
idealize ROM
idealize quad girth and firmness
regain mobility
donut pad for return to sport
Myositis Ossificans (types)
Periosteal - connected to bone
Heterotopic - within muscle belly
osteoblasts replace fibroblasts and form bone
stops at 6-7 weeks w/ bone reabsorption
muscles can’t function properly
Risk factors leading to myositis ossificans from contusion
didn’t control bleeding aggressively enough
too vigorous therapy: massage, heat, stretch
knee flexion less than 45 degrees 2-3 days post
Symptoms of myositis ossificans
increasing morning pain, activity pain, night pain
Loss in ROM
woody on palpation
Acute compartment syndrome of the thigh
What is the normal pressure, what can it get to?
normal 20 mmHg
can get to 80-100 mmHg
What muscles can be affected with hip and groin strains?
iliopsoas
rectus femoris
adductors (gracilis, pectineus, longus, brevis and magnus)
Adductors are usually ___
Iliopsoas is usually ___
acute
chronic
Adductor strain
MOI and signs
sudden change of direction acute and well localized - belly of adductor longus pain with resisted adduction pain of passive hip abduction bruising
Treatment of adductor strain
control bleeding and swelling in first 48
after 48 - focus on muscular imbalances, concentric and eccentric, rapid change of direction, exercise progression
Groin Strain - Hip Flexor MOI
forced extension and/or excessive contraction of flexors
can be:
rectus femoris (acute)- tenderness 8-10 cm below ASIS
iliopsoas (chronic) - repetitive hip flexion, poorly localized deep pain
How to tell the difference between rectus femoris and iliopsoas for groin strain?
rectus - pain with flexed knee stretch, pain with active knee extension, positive elys (ipsilateral) and two joint with bent knee
iliopsoas - pain with hip flexion stretch (straight knee), pain with resisted hip flexion with extended knee, positive thomas (contralateral) test and two joint straight knee
How to treat a groin strain?
POLICE
concentric and eccentric
address muscular imbalances
wrap with hip spica
Groin Strain - Abduction, extension and external rotation MOI
combination of previous two (adductor and groin strain)
largely due to eccentric movement
common in hockey (skating)
pain on resisted flexion, adduction and internal rotation
look at: muscle imbalances, shooting style, flex of equipment
Hip Pointer injury MOI
iliac crest contusion and abdominal contusion
disabling - crushing of soft tissue between hard objects
common with improper equipment/placement
immediate pain, decline in hip function, check pain through pelvic ring - pelvic crest can be fractured
Female genital injuries
straddle fall most common
labial/vulvar contusion, perineal tearing, vaginal laceration
contusion can cause hematomas that we must apply pressure to so it doesn’t form a mass
Male genital injuries
Most common due to blunt trauma
can be:
- testicular/scrotal contusion (immediate excruciating that improves w/ cremasteric muscle spasm)
-testicular torsion (testicle rotates on spermatacord) - due to forceful cremasteric contraction - medical emergency
unilateral pain and testicle may not be vertical anymore