Sports Inuries Flashcards
Medial ligament of the anlkle role and attachments
Deltoid ligament.
Navicular, talus, calcaneus.
Resists eversion.
Lateral ligament of the ankle role and attachments
ant and post talofibular and fibulocalcaneal.
Resists inversion.
What is the sequence of prevention?
Measures to prevent sports injuries. Firstly the extent of the promblem must be identified and described. Secondly the factors and mechanisms identified. Thirdly introduce measures based on aetiological factors and mechanisms. Evaluate through repeating first step.
What is a sports injury
Any physical complaint sustained by practising or competing in a sport that causes a reduction in future training/ competition or an athelet to seek medical attention
Broad classification of sports injury
Time loss injury or medical attention injury
Some potention consequences of sport injury
Pain, Financial
Repetitive muscle straign, osteoarthritis, bone fracture, lig reupture, tendonopathy
What is epidemiology
The study of disease in relation to populations
What is incidence
The number of new cases per 1000 people within a set population in a set time period.
What factors could cause variation in studys?
Definition of sports injury Variation of methods to count injuries Variation of populations The way incidence is expressed MEthod used t establish the population at risk Representativeness of sample.
Why is prospective better than retrospective
Can measure many exposures Count number of episodes No Recall bias Single standard of diagnosis. Can prove temporal sequence
What is a stress fracture
Hariline fractures that cant be imaged via Xray
Variate in how you measure the nature of a sports injury
Acute (traumatic) vs chronic (overuse)
Tendonitis vs tendopathy. Failure to heal.
Difference between contusion vs laceration
Skin cut vs un cut
How is severity measured? 6 criteria
Time loss (working or sport), medical/ economic cost, nature of injury, nature of treatment, permanent damage.
How is severity measure in terms of days lost?
<7 minor
8-21 moderate
>21 severe
Describe the spectrum of tissue regenrates
Fastest to slowest
Bone, muscle, tendon, ligament, meniscus, cartilage
Costs of sports injuris
Direct (medical) and indirect
Difference between systematic review and meta analysis
Synthetic output of one value, not all included
Describe intinsic factors
Know as capacity (as increases, risk of injury decreases)
Includes psych - A (competitive and self critical) and C personalities (struggle expressing emotion e.g. always nice)
Whats the difference between relative risk and odds ratio
Relative risk = (exposure case/ Total exposure)/ (non exposure case/ Total non exposure)
= exposure risk/ non exposure risk
OR =
(exposure case/ Exposure non case)/ (non exposure case/ non exposure non case)
If disease is rare then OR= RR as is normally the case.
Why is a association not always causal
unknown factor may cause both
Confounder
Also an unknow factor may cause one thing that causes another
RFs for sports injuries
Loads
Describe the causation model
Intrinsic factors predispose an athlete. Exposure to extrinic factors result in a susceptible adult.
An inciting event/ mechanism of injury causes an injury
Difference between mechanism and diagnossi
Mechanism- Process of how an injury occured, macro (being tackled from behind) or micro e.g. hyperextension of a joint, inversion.
Diagnosis - Outcome of mechanism e.g. straign, rupture, break
What does the injury incidence assessment depend on?
Definition of the sport injury in question
Method using to establish pop at risk (how to define exposure group)
Method used to count injuries (e.g. diagnosis)
Representativeness of sample
The way incidence is expressed e.g. hours/years
What is the sequence of prevention? What factors should be ascertained?
Prevalence/ extent WHAT
Aetiology - RFs and mechanism WHO WHY HOW
Preventative measure based on factors/ mechanisms introduced
Evaluate through repeating first step.
Measures
How many Nature - acute vs chronic Where Type Who Severity Situation - trianing/comp Process (mechanism) - contact vs non contact
First step of sequence of prevention. Best practice
Comparable measure e.g. 1000 hours of sport participation (variable measure)
Can be retro or prospective. Bare in mind the representativeness of sample.
Second step of sequence of prevention from Van Mechelen 1992 (review of concepts)
often uses an epidemiological model.
Stress/ capcity model (must be inbalance) intrinsic effects capacity and stress (extrinsic) also mechanism needs to be addressed.
Another model = relationships between factors and determinants of sports behaviour e.g. athlete manipulates stress and alters capacity and risk of injury. Factors include load, personal equipment, physical and human factors and intrinsic factors - all lead to sports behaviour.
Only 1st talked about in lecture
Findings from Taimela et al 1990 - intrinsic RFs
Intrinsic factors
Aged 15-16 and Senior but sport dependent
Men more at risk - due to more vig exercise?
Certain lesions recur e.g. sprain, dislocation
Individuals at higher risk or injury a cause
Height and weight being high
lack of fitness
muscle weakness, joint looseness, poor flexibility
Reaction times
Life stress
Loqwer IQ
Can decrease by Coaching anatomical considerations motor performance requirements Psychological factors Avoid stress treatment and rehab to avoid recurrence
Findings from Bahr & Holme (2003) Metholodical sport injuries
For moderate to strong associations 20-50 cases are needed, small to moderate need 200 injured subects. Lots are too small to detect moderate associaions.
Prospective cohort the best.
Findings from Bahr, R., & Krosshaug, T. (2005). Understanding injury mechanisms: a key component of preventing injuries in sport. British Journal of Sports Medicine, 39(6), 324-329.The importance of the mechanism (not just intrinsic and extrinisic factors). Including a description of whole body and joint biomechanics at the time of injury.
Ability to design specific prevention programmes is limited by lack of knowledge of cause. Needs a multifactoral approach to understand all the factors involved in this
The importance of a comprehensive model which accounts for all events leading to injury including mechanism (not just intrinsic and extrinisic factors, also situation, player and opponent behaviour). Including a description of whole body and joint biomechanics at the time of injury.
Explain common problems with SEM in the army
Many fail to improve with physio and then there is no evidence for the next step e.g. PRP- platelet rich plasma
Many injuries
Most downgraded (get worse)
Difference between origin and insertion
Origin close and insertion distal.
Does a tendon lengthen or schorten during muscle contraction?
Stay the same
Why can running in boots be an RF for achillies tendinopathy?
Compression of tendon is a RF
Describe the microstructure of a tendon
Covered in epitenon (surrounded by peratenon)
Tertiary fibre bundle
Fascicle (secondary fibre bundle) - covered in endotenon
Subfascilcle (primary fibre bundle) - endotenon
Fibre
Fibril
High alligned collagen composed of the above
Initiates movement of joints and stabalises joints
Movement that precipitates achillies tendon rupture
repetition and overuse,
eccentric activities, and quick cutting motions that
involve rapid acceleration / deceleration
These injuries upset the balance between mobility
and stability and results in abnormal loading that
could damage other soft tissues and cause pain
and osteoarthritis in long run.
Cause of subacromial impingement (painful arc)
Posture causing tendon (rotator cuff) impingement
Describe tendinopathy pain
Morning stifness/ pain (shortening) Pain commencing and after activity. Eases with warm up Pain on palpation Pain at specific site Insidious onsett
Causitive factors of tendinopathy intrinsic (achillies) (RFs)
Giat
Heavy heel strike
Double heel lift
Motor patterning
BMI
Previous injury
Age
Posture/Allignment
DM/ dyslipidaemia
Causitive factors for tendinopathy extrinsic
Training errors
Frequency
Intensity
Energy storage activities
Footware
Exercise
Medication e.g. fluroquinolones or steroid
Describe the continuum model
Replaced the inflammatory tendinities model.
excessive load leads to reactive tendinopathy.
Optimised load leads to gradual strengthening and adaptation with normal tendon.
Lack of load leads to stress shielded (normal load may then cause this to become reactive).
Further load causes tensdon dysrepair.
Further load cuases degenerative tendinopathy
The further from normal tendon means the harder it is to return so treament revolves around modified load.
What does disrepair look like?
Increased cellularity and ground substance (occurs initially).
Focal area of disorganised collagen.
Neurovascular ingrowth (cause of pain?)
Explains why NSAIDs may not help
Describe the pathology of acute/ reactive tendinopathy
Increase in small proteoglycans and ground substnace (NSAIDs)
Non inflam response secondary to acute tensile or compressive overload - too much too soon
Tenocyte proliferation (become more chondroid)
No neovascularisation
Some collagen disruption from water
Describe the cause of pain in acute tendinopathy
Hypoxic - increased tissue fluid
Hypersensitivity of tenocytes
Describe how long acute tendinopathy may last for
a few days
Describe pathology of dysrepair tendinopathy
Focus of holes of collagen disorganisation
More ground substance
Upregulation of neo vascularisation factors e.g. VEG F
Myofibroblasts
MOre chondrocytic cells
causes of Pain in dysrepair tendinopathy
new vessels with nerves (more factors e.g. glutamate and substance P) Pain centralisation (thinks it's more important than it is)/ neuronal sesnitivity
Degenerative tendinopathy pathology
Significant matrix disorganisation cell death - apoptosis - hypoxia due to more cells Increased type III. Hyaline degeneration Tenocyte echaustion Very disorganised Little reversibility older people
Difference in swelling in types of tendinopathy
Fusiform in reactive and dysrepair possible (and in reactive on degenerative).
Nodular in degen
Response to load in different types
sensitive in acute
less sensitive in dysrepair
Occasional grumbles in degen
Treatment for reactive
Rest/ unload (stress shielding)
Use ice
Adress compressive loads (concentric) and positions
What does rehabilitation address?
ROM
Pain
Contractile deficits
Movement patterns
Describe some outcome measures used in achillies.
Victoria Institute of sport A/P/H (VISA A)
Not good for less than 6 weeks
Achillies tendinopathy measure
VAS, NRS (numerical rating scale
Daily symptom report
General pain
Pain on walking
pain on activity
FAA (army) - occupational score
Causes of pain in degenerative
hypoxic
Centralisation
Neural
Describe the appearence of denerative on ultrasound and H&E
Hypoechoic areas and los of textured appearence on US
BV lumens visible
Doppler and BVs
Also in dysrepair but larger areas and more vessels with focal swelling in degenerative
Describe a progressive loading stage 1
Isometric contraction e.g. sitting or standing
Stimulate collagen synth and adress deficits.
30-60secs 4-5 times a day 4-5 secs
Avoid pain and compression
Describe a progressive loading stage 2
Concentric or eccentric medium load
Open and close chain if possible (fixed joint vs unfixed distal)
Stage 1 on days off
Describe a progressive loading stage 3 and options
HSL - Heavy slow resistance- through entire range. often less frequent option and more useful between dys and degen. Often increase %of 1RM working at but always till failure/ bad form
Eccentric training (Alftedson programme)
Describe a progressive loading stage 4
Pliometrics
Ensure no pain
Controlled intro to sport (can quikcly overloda)
Energy storage loading (jumping)
Minimal pain during/after high load tests
Started When single leg strength is equivalent
Summarise total program
Progressively add stages but add sparsely at first and increase frequency
May add ESWT.
Return to sport on high load days but continue monitoring
Other things considered in treatment other than load
Biomechanics Flexibility Lumbar spine Neural mobility Associated injury
Ensure
coontinued education, maintain strength and gradula intro of novel activity
Other less conventional treatments
Steroid injection
LA injection (p
Dextrose injection
PRP/ autologous blood injection
Describe the functions of ligaments
Keep articulating surfaces together (limit mobility)
Minimise unwanted joint movement
Provide joint stability
What is viscoelasticity? how is this clinically relevant?
Can stretch slowly under tension but return to original shape.
Rapid strectching however can rupture e.g. grass
What is the Beighton score? genetic variation in stretching?
Degree of hypermobility assessed.
Natural stretchiness not from stretches e.c.t.
Less flexible with age.
1) Hands on floor
2) Elbows extent backwards
3) Knee that bends backwards
4) Thumb that touches forarm when bent backwards
5) little finger 90 deg when bent backwards
What is the cut off score for Beighton?
Problems with score?
2 means hypermobility of joints likely Often in studies >=4 (7-15% have >=4) Higher score - higher risk of hypermobility and risk of injury -dose. Binary score so score or don't
Describe the hypermobility questionnaire? Cut off
1) Hands on floor
2) Bend thumbs to touch forarms
3) As a child contort or do splits
4) As a child shoulder or knee dislocate more than once?
5) Consider yourself double jointed?
How do scores relate to hypermobility syndrome?
Don’t necessarly as asymptomatic often
Difference between structure of tendon and ligament
Ligaments have a more wavey appearence and slightly less parallel than tendons allowing lengthening (spring) fibroblasts les parallel.
Grades of ligamnet tear
1- Stain or streched but still competent and able to stabilise a joint
2- Partially torn and partially able to stabalise - healing is possible and promising
3 - complete tear, no stability
Treatment of ATFL tear?
Conservative
train muscle, strenght, speed, proprioception
Why might women be more prone to ACL injury?
More hypermobile, more valgus positon??
Where is the pain in tendonopathy?
Normally at attachment but achillies can be in the centre
Pathology of underloading and tendon
Hyalin degen Matrix disorganisation Angiofibroblastic hyperplasia Angiofibroblastic hyperplasia. Mostly reversible in animals
Treatment for reactive… drugs?
3 days for peak body response
De-load
but can load without energy storage and release e.g. cycling, strength based weights training.
NSAIDs good for pain but may delay healing as inhibit tenocyte prolif. Ibuprofen favoured
Treatment for late tendon dysrepair/degeneration?
Stim cell activity and protein production via massage (friction) ESWT, US, Surgery??, Prolotherapy (blood and glucose??), injection itself may bemefit, Polidocinol sim to placebol,
Aptotinin - acollegenase inhibitor no evidence
Sclerosing agenets
GTN for pain
4-6weeks eccentric will change pain
Pain in exercse ok - wont affect outcome
General points about dislocation
Xray for fracture May need diazepam or GA to relocate Early protection Early mobilization Muscle strengthening
Grade 3 tear and pain?
May be none as sensory fibres can be divied
MCL injury mechanism
Valgus force on partially flexed knee
MCL symptoms
1 - no swelling
Pain - localised tenderness to medial condyle/ tibial plateu
Pain but no laxity on test
2 - swelling possible (capsule tear)
Some laxity but distinct endpoint
3 - Instability, gross laxity without endpoint, lack of full extension, ACL tear often, swelling
MCL treatment
Conservative. Hinged brace (immobilisation is bad) Rehab - ROM, strengthening, proprioception, graded exposure to sport 2-4week for mild, 6-10 for severe. Other: Cryo Electrotherapy Manual Gait re-education Patient education
PCL function
Resists posterior draw of tibia and external rotation
Stronger than ACL
Often underdiagnosed
PCL damage associated injuries
LCL/ popliteus
1/4 have meniscal damage
PCL features
History
skiier
Poorly defined back of knee or calf
No swelling as extrasynovial
Exam
Posterior draw test
Posterior sag
PCL mechanism
Direct blow to anterior tibia when flexed
PCL investigation
Xray - avulsion
MRI if posteriolater cornal damage is suspected
Treatment of PCL
Conserve
Rebab - quad heacy
immobalise for 2-3 weeks if complete rupture
Good functional result
Surg
Sig posterolateral damage
Medial ligament incidence and treatment
Stronger than lateral and inversion rarer.
Same treatment as alteral but takes twice as long
Pott’s fracture symptoms, management and treatment
One or more malleoli (local pain)
May be pain at distal attachment of ligs
Xray needed
Conserve - cast immobilisation for 6 weeks
Surg- repair mortise via internal fixation
Maisonneuve fracture
Fracture of proximal fib with complete rupture of AFTL and interosseus membrane High impact sports Xray often misses Can reduce spontaneously Refer to ortho
4 zones of lig to bone
Lig Fibrocartilage Mineralised fibro Bone Superficial fibres to periosteum Depp directly to bone at acute angles
3 stages of lig repair
Heamatoma formation
Reparative phase - fibroblast prolif and matrix
Remodelling - reallignment of collagen over years
Future treatments of ligs
Growth factors - PDGF in mice
Gene transfer to reduce undesired proteins
Cell therapy - mesenchymal stem cells
Mechanical factors e.g. allignment with strethc
Scaffolding materials e.g. alginates and collagen
Many disciplins that need to work together e.g. histology, clinicians, biomechaics, molecular bio, immunology
Describe valgus/ varus
Valgus is knee in toe out - lateral force (external rotation)
Varus is medial force
What is the mechanism of ACL damage
Valgus (abduction) or varus (adduction) force, contact or non contact
Valgus load
MCL stretched and lateral meniscus compression
Contraction of hamstring pulls lateral femoral condyle posteriorly and tibial internal rotation.
ACL ruptures at 4ms
Without this there is no resistance to extrenal rotation and this occurs until 170ms
Function of ACL
Stability
Reist anterior translocation
Resist internal rotation
Symptoms/ sings of ACL injury
ASymptomatic
Popping sound or feel
Sudden sharp pain
Loss of full extension or flexion (contracture)/ locking of joint
Swelling (haemarthrosis) within hrs (menisucs days) as more vascular
Stiffness
Anterior tibial translation
Potential injured structures from ‘knee in toe out’
ACL, LM, MCL
Potential injured structures from ‘knee out toe in’
ACL, MM, LCL
What is distraction/ compression
Into or away from - cause of knee damage but rare
Describe biomechanics of what happens in ACL injury
(Valus force causes) neutral abduction to 10-13 deg with external rotation at 5 degree at IC.
Rotated internally 8 degree during first 40ms then external fotation of 17.
High peak verticle ground reaction force is associated.
Likely injury occurs at 40ms.
Knee felxion and minimal valgus loading could prevent this. (study of 10 handball/ basketball players)
How do we know about biomechs of ACL injury?
From model based image matching (MBIM) motion analysis technique - skeleton matched frame by fram using animation software
What is genus valgum and varum
Posture that is naturally in or out - feet appear closer or more separate
What is the lachman test? Limitation?
knee plexed to 30 deg
hold thigh and with other hand apply anterior force to tibia.
Muscles need to be relaxed so ask patient to look away
Cant do if swelling/ immediately as wont be positive
What is the anterior draw test? Looking for? cause of false neg?
Knee flexed to 90 degee Apply anterior force to tibia Signs of anterior subluxation False negative - injured and tibia already forward (like anterior sag) Note if end point
Describe the pivot shift test. limitations?
Hip flexed to 30
internally rotate tibia to 20 deg then apply valgus force - feel for subluxation by flexing
Reduction of a subluxeed tibia with further flexion as the IT band goes from extensor to flexor
How is ACL diagnosed?
Clinically or via MRI - solid black band - torn then ligher in coler +/- disorganisation or breakage
Arthroscopy
Aims of ACL treatment
Return to normal joint staboloty, ROM, muscle function, physical activity levels
Describe surgical techniques to repair torn ACL
Wait until no swelling Uses graft - drill 2 holes, one in femur and tibia Pass graft through holes Fix with screws Autograft - patella or hams Allograft - infection, cost, but lower OA, decreased morbidity? No RCTs, only if no visible autograft Xenograft Arthroscopy or arthotomy No evidence of prosthesis
Describe petalla graft
PBP Central third used 140% of strength Bone to bone healing better Worse scan Can damage nerves around patella
Describe hamstring graft
70% of strength Double or single bundle semitendinosis +/- gracillis Scar is only a hole treat as a pulled hamstring. 4 stand much better, same clinical outcome as BPB
Describe bone to tendon healing
Progressive mineralisation of interface
Many cells acutely due to recruitment of healing cells
after 6 weeks incorporation - bone grows into outer tedon
Decreased cellularity due to matrix remodeeling and reestablishment of collagen fibres