Sports Med Objectives Flashcards
Define concussion
A complex pathophysiology process affecting the brain inducing by biochemical forces.
Concussion presentation
Immediate:
- HA, dizziness, double vision
- Nausea, light/sound sensitivity
- Feeling foggy
- LOC, amnesia
- Behavioral changes
- Cognitive impairment
Later…
- Sleep disturbance
- Depression/anxiety
Concussion diagnosis
Based on clinical symptoms?? Not really sure what she’s looking for on this one.
Concussion management
- physical and cognitive rest until sx resolution
- avoid medications and let symptoms be your guide
- wear sunglasses if photophobia is present
- sleep in a dark room as much as possible for 2-3 days, then resume normal sleep/wake hours with 15-20 minute naps
- limit exposure to telephone, texting, music, tv
If you have a concussion, can you take meds for headache?
Yes, acetaminophen is ok but no NSAIDs
*can also take melatonin for HA and/or sleep
If a pt has concussion, should they be woken up during the night?
Nope! You don’t need to awaken throughout the night, just observe for normal breathing pattern.
Do helmets prevent concussion?
NO
Concussion prevention
Football helmets, for example, reduce impact force to head but not concussion incidence
AC sprain/separation
-Mechanism
“aka shoulder separation”
- impact to tip of shoulder
- fall on outstretched arm
AC sprain/separation
-S/Sx
- deformity at AC joint distal end of clavicle rides superiorly
- pain with movement and palpation
- (+) piano key sign
AC sprain/separation
-1st degree of injury
- no deformity
- pain with palpation & motion
- mild stretching of AC ligament
AC sprain/separation
-2nd degree of injury
- displacement of distal end of clavicle
- unable to abduct arm or bring it across body
- pain
AC sprain/separation
-3rd degree of injury
- compete rupture of AC and CC ligaments
- with dislocation of the distal end of clavicle
- severe pain
- LOM
- instability
AC sprain/separation
-general tx
- RICE
- Immobilization
- NSAIDs
AC sprain/separation
-tx based on separation grade (1-6)
- Grade 1 separation: RTP in 1-2 weeks
- Grade 2 separation: RTP in 3-4 weeks
- Grade 3 separation: RTP in 6-12 weeks; possible surgery
- Grade 4-6: surgery
Sternoclavicular (SC) sprain
-mechanism
- indirect force transmitted through the humerus, the shoulder joint and the clavicle
- direct impact to clavicle
Sternoclavicular (SC) sprain
-S/Sx
- may have deformity at sternal end
- swelling
- pain
- inability to abduct shoulder through full ROM
Sternoclavicular (SC) sprain
-1st degree separation
no deformity, pain w/ palpation & motion, mild stretching of SC ligament
Sternoclavicular (SC) sprain
-2nd degree separation
subluxation of the proximal end of clavicle
Sternoclavicular (SC) sprain
-3rd degree separation
complete rupture of SC and CC ligaments, with dislocation of the proximal end of clavicle
Sternoclavicular (SC) sprain
-general tx
- RICE
- Immobilization
- NSAIDs
*same as AC sprain
Sternoclavicular (SC) sprain
-tx based on grade of separation (1-3)
- Grade 1 separation: RTP in 1-2 weeks
- Grade 2 separation: RTP in 3-4 weeks
- Grade 3 separation: surgery
When is SC sprain a medical emergency?
any posterior subluxation or dislocation in an emergency due to potential cardiovascular compromise
What is the MC fracture around the elbow in children?
- supracondylar humerus fractures
- 95% are d/t extension-type injuries
Supracondylar humerus fractures
-mechanical factors
- occurs from a fall on an outstretched hand
- ligamentous laxity and hyperextension of the elbow are important mechanical factors
- may be associated with a distal radius or forearm fractures
Supracondylar humerus fractures
-classifications, type 1
- non-displaced (note posterior fat pad)
- in most cases, these can be treated with immobilization for approx. 3 weeks, at 90 degrees of flexion (unless significant swelling)
Supracondylar humerus fractures
-classifications, type 2
angulated/displaced fracture with intact posterior cortex
Supracondylar humerus fractures
-classifications, type 3
complete displacement, with no contact between fragments
Ulnar collateral ligament injuries at the elbow are usually d/t…
- chronic valgus stress placing ligament at risk for laxity or tearing
- pitchers are at highest risk
Ulnar collateral ligament
-evaluation
- medial pain during late cocking, acceleration or deceleration is hallmark
- pain with valgus testing more reliable than laxity
- laxity on valgus testing at 30 minimal unless tear is complete
What do you find on MRI for ulnar collateral ligament injury?
MRI with contrast – fluid leakage outside of joint represents complete tear
Ulnar collateral ligament
-tx
- rest
- physical therapy
- NSAIDs
- return to throwing when pain-free
- surgery
What is the surgical procedure for ulnar collateral ligament?
autologous tendon secured in tunnels in humerus and ulna in figure-of-eight fashion, ulnar N transposed
Aseptic olecranon bursitis etiology
- direct blow of fall (hemiarthrosis)
- gout
Septic olecranon bursitis etiology
- insect bite
- cut/abrasion
- hematogenous
Olecranon bursitis
-S/sx
- pain
- swelling
- erythema/febrile (septic)
Olecranon bursitis
-tx
- ice and compression
- aspirate (if serous/blood, give steroid injection; if pus, required I&D -ortho consult)
When does olecranon bursitis require surgery?
With recurrent aseptic bursitis
Define myositis ossificans traumatica
Where bone-like tissue grows in the muscles of the thigh (MC) or upper arm after an injury
Myositis ossificans traumatica
-etiology
- formation of ectopic bone
- MOI = repeated blunt trauma
- may be the result of improper thigh contusion treatment (too aggressive)
Myositis ossificans traumatica
-S/sx
-X-ray shows Ca2+ deposit 2 - 6 weeks post injury Sx: -pain -weakness -swelling -tissue tension -point tenderness -decreased ROM
Myositis ossificans traumatica
-management
- tx must be conservative
- may require surgical removal
Quadricep strain
-mechanism of injury
over-stretching or too forceful contraction
Quadricep strain
-S/sx
-Sx: pain, point tenderness, spasm, loss of function, and ecchymosis
NOTE: superficial strain results in fewer S&S than deeper strain
-complete tear results in deformity (athlete displays little disability and discomfort)
Quadricep strain
-management
- RICE, NSAIDs, analgesics
- manage swelling via compression and/or crutches
- stretching
- PRE strengthening exercises
- neoprene sleeve for added support
Hamstring strain
-etiology
- there are multiple theories of injury
- hamstrings and quadriceps contract together
- change from hip extender to knee flexor
- fatigue
- posture
- leg length discrepancy
- lack of flexibility
- strength imbalances
Hamstring strain
-S/sx
- pain in muscle belly or point of attachment
- capillary hemorrhage
- ecchymosis
Grade 1 hamstring strain
- pain with movement
- point tenderness
- < 20% of fibers torn
Grade 2 hamstring strain
- partial tear ( < 70% of fibers torn)
- sharp snap or tear
- severe pain
- loss of function
Grade 3 hamstring strain
- rupture of tendinous or muscular tissue ( > 70% muscle fiber tearing)
- severe hemorrhage
- disability
- edema
- loss of function
- ecchymosis
- palpable mass or gap
Hamstring strain
-general management
- RICE, NSAIDs, and analgesics
- Modalities
- PRE exercises
- when soreness is eliminated, focus on eccentrics strengthening
- recovery may require months to a full year
- scarring increases risk of injury recurrence
Hamstring strain
-grade 1 management
Do not resume full activity until complete function restored
Hamstring strain
-grade 2 and 3 management
- treat conservatively
- gradual return to stretching and strengthening in later stages of healing
Groin strain
-etiology
- injury usually occurs to the adductor longus
- others include iliopsoas, sartorius, gracilus
Groin strain
-mechanism of injury
MOI = running, jumping, or twisting with hip external rotation; over-stretching; or too forceful contraction
Groin strain
-S/sx
- sudden twinge or tearing during movement
- pain, weakness, and internal hemorrhaging
Groin strain
-management
- RICE, NSAIDs, and analgesics
- **rest is critical
- modalities: daily whirlpool and cryotherapy; ultrasound
- delay exercise until pain free
- restore normal ROM and strength
- provide support with elastic wrap
Define Legg-Calve-Perthes disease
Avascular necrosis of the femoral head in child ages 4-10
Perthes disease mechanism of injury
trauma
Perthes disease
-S/sx
- pain in groin: referred pain to the abdomen or knee
- limping
- may exhibit limited ROM
Slipped Capital Femoral Epiphysis (SCFE)
-etiology
- found mostly in overweight boys between ages 10-17
- may be growth hormone related
- MOI = trauma (accounts for 25% of cases)
- 25% of cases are seen in both hips
- femoral head slippage on X-ray appears in posterior and inferior direction
SCFE S/Sx
- pain in groin that progresses over weeks or months
- hip and knee pain during passive and active motion
- limitations of hip abduction, flexion, and medial rotation
- limp
SCFE management
-minor vs. major slippage
- Minor slippage: rest and non-weight bearing may prevent further slippage
- Major slippage results in displacement: requires surgery
**If condition goes undetected or if surgery fails, severe problems will result!
Snapping hip
-etiology
- common in young female dancers, gymnasts, and hurdlers
- MOI = repetitive movement that leads to muscle imbalance
- related to narrow pelvis, increased hip abduction, and limited lateral rotation
- hip stability is compromised
Snapping hip
-S/sx
- pain while balancing on one leg
- possible inflammation
Snapping hip
-management
ROM exercises to increase flexibility:
- flexion and lateral rotation
- cryotherapy and ultrasound may be utilized
PRE exercises to strengthen weak muscles
Hip dislocation is a result of…
traumatic force directed along the long axis of the femur
Hip dislocation
-etiology
Posterior dislocation more common:
- Hip flexed, adducted, and internally rotated
- Knee flexed
*Rarely occurs in sport - MC in trauma such a MVA
Hip dislocation
-S/sx
- flexed, adducted, and internally rotated hip
- palpation reveals displaced femoral head
- medical emergency
- complications include soft tissue damage, neurological damage, and possible fracture
Hip dislocation
-management
- requires immediate medical care
- blood and nerve supply may be compromised
- contractures may further complicate reduction
- 2 weeks immobilization and crutch use for at least one month
Ankle sprains
-etiology
- MC athletic injury
- the medial malleolus is shorter than the lateral malleolus so there is naturally more inversion than eversion
- greater inversion increases the potential for over-stretching of the lateral ligaments
Which ligaments are sprained more/less often in the ankle?
- of the lateral ligaments, the ATFL is sprained the most often followed by the CFL
- Deltoid ligament is sprained less often (25% of ankle sprains)
Match the 3 special tests for the ankle to their ligament
- Anterior Drawer – ATFL
- Posterior Drawer – PTFL
- Talar Tilt – CFL
1st degree ankle sprain
- stretching of the ATFL
- little or no edema
- tenderness
- maintain function
2nd degree ankle sprain
- partial tear of the ATFL and/or CFL
- moderate edema
- some function loss
3rd degree ankle sprain
- complete tear ATFL, CFL, and/or PTFL
- total loss of function
- significant edema
An ankle sprain with no tendon tear, minimal loss of functional ability, minimal pain, minimal swelling, usually no ecchymosis, and no difficulty bearing weight is graded as…
Grade 1
An ankle sprain with partial tendon tear, some loss of function, moderate pain & swelling, frequent ecchymosis, and that usually includes difficulty bearing weight is graded as…
Grade 2
An ankle sprain with complete tendon tear, great loss of function, severe pain & swelling, ecchymosis, and that almost always includes difficulty bearing weight is graded as…
Grade 3
Ankle sprain tx
- RICE
- ice for 20 minutes on and 20 minutes off for the first two hours.
- after that, 20 min intervals over the next 48-72 hours,
- compression wrap with donut or horse shoes to fill in gaps around malleolus from 24-36 hours
- NSAIDS
- bracing – Lace-up vs. Stirrup vs. Boot
What is the mechanism of a syndesmosis injury?
- External rotation
- For example, a football player with direct posterior force on the leg of a down player whose foot is ER’d
- ER force at the knee with the foot firmly planted
Classification of syndesmosis injury
- AITFL (anterior inferior tibiofibular ligament) Sprain
- Grade I, II, III
Syndesmosis injury
-physical exam
- palpate IOL & fibula
- prox tib/fib joint dislocation
- squeeze test
- ER stress test
- direct eversion maneuver
- eversion/abduction force applied to foot as tibia stabilized
Syndesmosis injury tx
-grade I & III
- RICE
- weight bearing as tolerated (WBAT) after 48-72 hrs
- symptomatic tx: ROM, strengthening, proprioception, boot, taping
Syndesmosis injury tx
-grade III
*based on displacement & stability
Latent Injuries (normal XR but wide stress view)
- -NWB SLC or Moonboot
- -NWB 6-10 weeks
- -if osseous or ligamentous medial injury, then ORIF
Frank Injuries require ORIF
What are the 3 types of 5th metatarsal fractures?
- avulsion
- jones
- stress fracture
What are the general causes of 5th metatarsal fractures?
- acute inversion injury
- overuse/stress on a metatarsal
- abnormal foot structure or mechanics (e.g. flatfoot, over inversion)
Describe styloid avulsion fractures
- type of injury
- healing potential
- tx
- Acute inversion injury
- TTP base of 5th metatarsal
- good healing potential
- treat with Fracture Shoe/Boot for 4-6 weeks, may WBAT (weight bear as tolerated)
Describe Jones fractures
- type of injury
- healing potential
- tx
- Acute inversion injury
- TTP base of 5th metatarsal
- fair healing potential
- treat with Cast/Boot for 6 weeks NWB
- -then WB in Cast/Boot for 4-6 weeks
- consider surgical screw for sooner RTP
Describe diaphyseal stress fractures
- type of injury
- healing potential
- tx
- overuse injury
- TTP proximal to mid 5th metatarsal
- poor healing potential
- treat with Cast/Boot for 10-16 weeks NWB
- -then WB in Cast/Boot for 4-6 weeks
- consider surgical screw for non-Athlete
- surgical screw fixation for Athlete
What is the MC ruptured tendon in the LE?
Achilles tendon
Describe a complete Achilles tendon rupture
- complete ruptures are due to eccentric loading during abrupt stopping, landing from a jump
- usually a popping sound is heard with a complete tear
- there may or may not be an obvious gap 2 to 6 cm from the calcaneus attachment
Exam and tx of Achilles tendon rupture
Exam:
- “Hatchet deformity”
- significant ecchymosis and edema
- inability to actively plantar flex the foot
- pain with passive dorsiflexion of ankle
- (+) Thompson Squeeze Test
Tx may or may not include surgery, but both require immobilized for 3 months
Where is the plantar fascia?
the plantar fascia runs from the calcaneus to the metatarsals - it acts like a bow string to maintain the arch of the foot
Define plantar fasciitis
- refers to an inflammation of the plantar fascia
- inflammation is usually due to repeated trauma to where the tissue attaches to the calcaneus.
- the trauma results in microscopic tears at the calcaneus attachment site.
- this may produce heal spurs
*pain is worse in the morning or after a period of inactivity
Causes of plantar fasciitis
- high arch
- excessive pronation
- footwear (worn out, stiff)
- increase in intensity
Plantar fasciitis tx
- stretch***
- Ice Massage (Frozen water bottle)
- NSAIDs, Arch Supports, Night Splint/Boot
- Steroid Injection, PT, Surgery
Define “turf toe”
-when does it occur
- sprain that occurs at the base of the big toe at the first metatarsal phalangeal joint.
- it usually occurs when the toe is jammed forcibly into the ground or, more commonly, when the toe is bent backward too far (hyperextended)
- it causes significant pain and swelling at the base of the big toe and can be a significant problem because players use the toe when they run and plant and push off
Class I turf toe
-tx
attenuation, swelling, minimal ecchymosis
Tx: non-Surgical: taping, early rehabilitation
Class II turf toe
-tx
partial tear, moderate swelling, restricted ROM
Tx: Non-Surgical: 2 weeks rest, taping; “turf-toe” or carbon-fiber orthosis to prevent MTP extension
Class III turf toe
-tx
complete disruption, FH weakness, instability
Tx:
- Non-Surgical: Immobilization 10-16 weeks
- Surgical: open repair of capsule
Define TMT (Lisfranc) injury
- an injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus
- axial loading mechanism that is often missed
- often ligamentous, subtle clinical and radiographic findings
Dx of Lisfranc injury
- “pop” in midfoot, rapid onset pain.
- tender on midfoot compression, pronation, supination, stressing
Imaging of Lisfranc injury
Xray:
- B/L WB AP, 30° Oblique, Lateral
- > 2mm between 1st and 2nd metatarsal bases, fleck sign
- stress views if plain radiographs equivocal
MRI: not indicated if diastasis seen on plain film
Tx of Lisfranc injury
-sprain
- Non-displaced, stable midfoot on stress radiographs
- Non-Surgical Management
- Non-weight bearing 3-4 weeks in boot/cast
- Protected weight bearing 3-4 weeks and rehab
Tx of Lisfranc injury
-rupture/avulsion
- diastasis > 2mm (compared to other foot) on stress XR
- Principle: Obtain and maintain anatomical reduction of the midfoot
- Treatment - Surgical
