Orthopedic Tx 400 (Strains & Sprains -- 5 & 6) Flashcards
myositis ossificans risk factors
Not appropriately resting muscle after a bruise or muscle strain, thus causing repetitive injury to the injured muscle.
Not taking measures to reduce inflammation and swelling in the injured muscle, including not icing or applying compression.
who is myositis ossificans most common in?
Myositis ossificans is most common in young, active people and athletes of all levels. It is also more likely to occur in people who are paralyzed from the waist down (paraplegia), even if they haven’t had an injury that started the symptoms.
again, why?
While the exact cause of this reaction is unknown, athletes who subject the area to repetitive trauma before it is able to fully heal are more likely to have calcification and bony formation in the injured muscle.
Additionally, not taking measures to reduce inflammation in the muscle after the initial injury also leads to in an increased risk of developing myositis ossificans.
how long does it take to take place?
Calcification typically occurs 2-4 weeks after the initial muscle injury and the bone fully matures by 3-6 months.
myositis ossificans most common with
Trauma –> acute trauma
Far less likely with repetitive use –> E.g. strains
other risk factors (myositis ossificans)
Intensive stretching, therapy, or massage after an injury are thought to increase bleeding into the muscle and inhibit healing, thus leading to myositis ossificans.
Premature return to sport.
Re-injury to the same area as a previous injury.
Don’t friction ____?
calcified tissue in mm (via myositis ossificans)
note ROM testing — sprain vs strain
contractiel vs non-contratile tissue
strain most commonly occurs @
weakest area of musculotendinous unit
grade 1, mild, 1st degree STRAIN
Minor stretch and tear.
Minimal loss of strength.
Can continue with activity with mild discomfort.
0-20% tissue damage.
Grade 2, Moderate, or 2nd Degree STRAIN
Tearing occurs-varies from several fibers to many.
Snapping sensation or sound.
Palpable gap at injury site.
Difficulty continuing with activity due to pain and weakness.
20-70% tissue damage.
Grade 3, Severe, or 3rd Degree
Complete rupture or avulsion fracture.
Snapping sensation or sound.
Palpable & often visible gap
Cannot continue activity due to pain & weakness.
70 – 100% tissue damage.
MOI?
differentiate acute trauma vs RSI
onset?
stage of healing
can they continue with ADLs?
can speculate about grade
medication?
pain perception
no inflammatory response
—> I.e. watch out for pressure, or intense techniques like frictions and TrP ischemic compressions
what does strain look like in acute phase (esp grade 2-3)
Antalgic gait/posture. Support. Edema. Hematoma. Redness. Bruising is Red, black, purple.
what does strain look like in sub-acute phase?
Antalgic gait/posture & edema diminishes. May be supported. Bruising changes from purple & black in early to brown, yellow, & green in late.
whta does strain look like in chronic phase?
Habituated antalgic gait/posture. Grade 2-3 may have support with activity that stresses. May have residual edema. Fascial distortions may be noted. Scar will be present if surgically repaired.
what does acute strain feel like
Heat, tenderness, firm edema. Gap with grade 2 or 3. Protective mm spasms.
whta does sub acute strian feel like
Temp diminishes, tenderness present, edema less firm, gap, spasm in early change to HT in late. TP’s present.
what does chronic strain feel like?
Local ischemia, point tenderness, adhesions present and possible crepitus, gap with 2 or 3, HT, TP’s, disuse atrophy may be present.
some common acute vs sub-acute (RSI) pathologies for weightlifters
The pathology of shoulder pain with lifting also varies greatly.
Sub-acute injuries include rotator cuff tendinopathies, long head bicep tendinopathy, glenohumeral joint instability, and distal clavicle osteolysis.
Acute injuries include biceps and pectoralis tendon ruptures and shoulder dislocations.
movement testing & strains (acute)
AROM is decreased.
Other testing is contraindicated in acute if grade 2 or 3 suspected.
PROM grade 1 reduced. Painful mm spasm end feel. RROM minimal loss of strength with grade 1. Contract to Pain only.
movement testing & strains (sub-acute)
AROM decreased due to pain. PROM decreased, painful end feel. RROM contract to pain only. Grade 1: min. loss of strength. Grade 2: mod loss and pain. Grade 3: significant loss and pain.
movement testing & strains (chronic)
AROM may be limited. PROM mild pain with a tissue stretch end feel. RROM decreased strength.
CI’s – strain
In acute stage, only pain free AROM testing with grade 2 or 3 to prevent further injury.
Distal circulation techniques CI’d in acute and early sub-acute to avoid congestion.
No heat in acute/early subacute stages(?) grade 2/3 strain
Avoid MOI such as stretching the affected tissue in acute/early subacute gr2/3 strain
do not work on area in acute/early subacute stages
Avoid contracting or load the affected tissue in acute/early subacute stages gr2/3 strain
Tx – strains
Acute: RICE, reduce edema (nodal pumping, DB), Reduce mm spasm, no on-site tx’s.
Early sub-acute: Ice (or contrast ?). Reduce edema, spasm, & TP’s. On-site work only with grade 1.
Late sub-acute: Prevent excessive scar tissue formation (skin rolling, separations, MRF, frictions, rom, stretch all pain free) TPR. Reduce chronic edema if present. Cold/hot contrasts.
Chronic: Heat. Client presentation. Possible surgeries, complications, habitual gate/protective/ guarding ?
homecare – Strains
Hydrotherapy: Acute/Early Subacute(?) - cold , Late Subacute-heat/cold aka contrast.
chronic = heat
Remedial exercise is dependant on the stage of healing and severity of the strain. To avoid repeated strain or rupture, training programs for strength or fitness should be gradual. This applies to stretching also. It is important in the acute and sub-acute stages to work to the onset of pain only. In this way, contractile tissue can withstand incrementally heavier workloads or increasing stretches without injury.
return to activity (post-strain)
Grade 1: The client can return to activity with support such as an elastic bandage after 2 days.
Grade 2: The client can resume activity several days to several weeks after injury.
Grade 3: Immobilization is generally removed after four to eight weeks. Return to activity may be delayed from disuse atrophy.
cross fibre frictions area of application:
Muscles, tendons, ligaments
cross-fibre frictions can be performed in which stage?
Late subacute to Chronic stage of orthopedic injury
IMPORTANT CONTRAINDICATIONS TO FRICITONS
Not used over peripheral nerves.
Acute/early subacute injury.
Corticosteroid, anti-inflammatory, anti-coagulant medications
*
Calcification and ossification of soft tissue.
Psoriasis, ulcers, blisters, hematoma, edema, open wound, skin sensitivity
Client’s apprehension and an increase in symptoms (ex. Pain)
SPRAINS
**
strain bruising is
more
(more vascular)
healing time
ligaments less vascular
longer healing
sprain ROM
laxity
instability
remember to
remember to use CHATGPT for random case studies
“give me a case study for orthopedic treatment for massage therapy. E.g. sprain case study.”
sprain is
overstretch injury to a ligament
ligaments are composed of
flexible, non-contractile connective tissue
what do ligaments do?
add stabiity to joint capsule
ligaments and vascularization
moderately vascularized
= slower healing than mm
ligament scar tissue formation time
Scar tissue here will take 6 weeks to develop, but take 6 months to mature and provide maximum strength.
sprian cause
They are caused by a trauma related sudden twist or wrench of a joint beyond its normal range of motion.
contributing factors/ risk factors – sprains
congenital ligament laxity, a history of previous sprains to the same joint, altered biomechanics that place stress on the ligament and joint, and connective tissue pathologies, like rheumatoid arthritis.
–> also Ehler-Danlos, Marfan’s
classificaitons of sprains
grade 1, 2, 3
mild, moderate, severe
grade 1 sprain
This is a minor stretch and tear to the ligament.
There is no instability on passive relaxed testing.
They can continue with activity with some discomfort.
grade 2 sprain
The degree of fiber tearing is variable, from several fibers to the majority.
There is a snapping sound at the time of the injury, and the joint gives way.
The joint is hypermobile yet stable on passive relaxed testing.
They have difficulty continuing with activity due to pain.
grade 3 sprain
There is either a complete rupture or avulsion fracture.
There is a snapping sound and the joint gives way.
Significant instability with no end point on passive relaxed testing.
They cannot continue with activity due to pain and instability.
Pain is present in acute. A chronic sprain will be painless but hypermobile.
May need surgical intervention.
sprain – SSx
Joint effusion: Occurs when the injury is severe enough to inflame the synovium, increasing the production of synovial fluid, and is intracapsular.
Hemarthrosis: is bleeding into the synovial space and can occur.
SSx – Acute grade 1-3
Grade 1: Pain is mild & local, at rest & w/ activity. Minimal local edema, heat, bruising.
Grade 2: Pain is moderate at rest & w/ activity. Moderate local edema, heat and bruising, hypermobility.
Grade 3: Pain may be intense or mild at rest. Marked local edema, heat, bruising. Joint effusions or hemarthrosis may occur, instability
in all grades bruising is
In all grades bruising is red, black, and blue. Decreased ROM from protective mm spasm, edema and pain.
SSx – early subacute grade 1-3
Grade 1 Grade 2 Grade 3- Pain, edema & inflammation should be lessened.
Adhesions are developing.
ROM reduced.
Loss of proprioception in the joint.
TrP’s in mm crossing the joint that replace mm spasms.
late subacute (sprains)
Bruising is yellow, green, and brown.
Pain, edema, & inflammation are diminishing.
ROM is reduced.
Loss of proprioception in the joint.
Protective mm spasms replaced by increased tone in mm crossing the joint.
SSx – Chronic sprain
Pain local only if stressed. Bruising has resolved.
Adhesions have matured.
Full ROM is restricted.
HT & TrP’s present in mm crossing the joint.
A pocket of chronic edema may be present.
Tissue may be ischemic.
Loss of proprioception.
observations – acute sprain
Antalgic gait/face, taping/support, edema (possibly distal),
local hyperemia
red black and purple bruising
observations – subacute sprain
Antalgic gait/face,
edema diminishes,
bruising changes to brown yellow and green,
scars if repaired.
observaitons – chronic sprain
Residual chronic edema,
habituated antalgic gait,
scars if repaired,
support during activity.
palpation – acute sprain
Heat, tenderness, firm edema, protective mm spasms.
palpation – subacute sprain
Temp. diminishes, tenderness remains, edema less firm, adhesions form.
palpation – chronic sprain
May be cool, point tender, remaining pocket of chronic edema (can be boggy, even jelly-like), crepitus may be present.
testing – acute sprain
AROM-will be limited due to pain. Other testing is CI’d at this stage.
testing – sub-acute sprain
AROM-limited due to pain but less than acute.
PROM-test injury direction last, reduced range from pain, spasm end feel.
Ligamentous stress test.
note which direction is done last for PROM (or even AROM)?
PROM-test injury direction last
testing – chronic sprain
AROM-may be limited.
PROM-test injury direction last, pain and possible hypermobility.
RROM-assess loss of strength from atrophy or injury. Ligamentous stress test positive and possible hypermobility with grade 2 and 3.
CONTRAINDICAITONS – Acute/Early Subacute:
Gr1,2,3:
No heat on the site of the injury;
no distal circulatory effleurage towards the injury;
do not place the affected joint into direction of MOI;
do not stretch the mm crossing the joint;
no deep massage at the site of the injury;
no jt mobilization at the affected jt
CONTRAINDICAITONS – late subacute
Tx approach/Rehabilitation exercises should be applied gradually and conservatively in the beginning
(remember principles of Mx? ) in all grades of the sprain;
CI – grade 2-3
Do not mobilize the joint into the direction of the injury; Increasing ROM shouldn’t be your primary goal in a majority of cases;
Do not stretch the structures supporting the affected joint (ex: ligaments; muscles crossing the jt)
CI – chronic ?
Chronic: It all depends on client presentation(note: be aware of possible surgical innervation)
Tx goals – acute & early subacute (sprain)
Tx goals – late subacute (sprain)
Tx – Chronic (sprain)
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