Week 9: Abdomen, Thorax and Spine

Question 1

Palpation of the Abdomen

Answer 1

-Palpate the 4 quadrants
-Start superficial, gradually pressure

Question 2

Sports Hernias (Athletic Pubalgia)

Answer 2

-Fascial weakness in the abdominal wall, where the abdominals & adductors attach into pubic bone
-MOI: repetitive strain to the area
-Common in hockey, football, soccer, sprinters/hurdlers, rugby
-S&S: pain with sitting up, quick cutting, sprinting, coughing
-Don’t typically result in bulge (protruding intestines) like traditional inguinal hernias - can progress to that
-Special test: Resisted sit-up
-Acute management: PIER, adductor wrap?
-Conservative treatment 4-6wks
-Easily re-irritated → sequential RTP

Question 3

Visceral Structures Potentially Affected in Sport

Answer 3

-Kidney contusions
-Spleen rupture → mono?
-Lungs → pneumothorax
-Bladder rupture → empty bladder
-Testicular contusions → prevention!
(Need to stop spasm, control hemorrhage)
-Heart (typically congenital in origin)

Question 4

Abdominal Injuries

Answer 4

-MOI: direct blow, fall from height
-S&S: pain, rigidity in abdomen, feeling unwell, shock
-Cullen sign (umbilicus discoloration)
-Grey Turner Sign (flank discoloration)

Acute management:
-Quadrant palpation
-Call 911
-Rest comfortably (don’t move them)
-Treat for Shock
-Reassure

Question 5

Kidney Injuries

Answer 5

-MOI: blow to the back
-S&S: pain in low back, peeing blood (may not see it), feeling unwell, shock
-Refer

Question 6

Causes of Sudden Death in Athletes

Answer 6

-Usually due to cardiac disease
(Congenital abnormalities of coronary arteries, Hypertrophic cardiomyopathy)

Emerging causes of acquired heart disease in young athletes
-Anabolic steroids
-Peptide hormones e.g. growth hormone
-Stimulants e.g. energy drinks – high doses of caffeine & other stimulants

Question 7

Hypertrophic Cardiomyopathy

Answer 7

-Genetic condition causing thickening of heart muscle
-Leading cause of sudden death in athletes
-1 in every 200,000 high school athletes in U.S.
-Altered rhythm = reduced/blocked blood flow
-Warning signs (especially during activity):
-Fainting or seizure
-Dizziness or light-headedness
-Chest pain (even at rest)
-Palpitations – quick/fluttering/irregular/pounding heart beats
-Shortness of breath

Question 8

Blow to Solar Plexus “Wind Knocked Out of You”

Answer 8

-Spasm of the diaphragm muscle
-MOI: blow to abdomen or chest, fall on buttocks or back
-S&S: pain, difficulty breathing, panicky
-Acute management: bring athlete’s knees gently towards chest, guided breathing, diaphragmatic breathing
-Able to RTP once symptoms resolve (pending no other injury)

Question 9

Facet Joint Sprains

Answer 9

-MOI: forced rotation
-S&S: hear/feel pop, sharp localized pain, pain with motions that open the joint, muscle guarding
-Common in contact sports; unexpected hit
-Common in C-spine due to large ROM – ligaments taken beyond available length
-Special Test: Quadrant Test (+ve if pain on opposite side)
-Can be done on L/S & C/S
-Acute management: PIER, refer for treatment

Question 10

Facet Joint Effusion

Answer 10

-Irritation of the facet joint
-MOI: Sudden episode of extreme ROM, may have felt a click or sharp pain, localized pain, spasm around inflamed joint, nerve root can become irritated, closing joint will be painful
-Special Test: Quadrant Test (+ve if pain on same side)
-Acute Management: PIER, refer for treatment

Question 11

Disc Protrusions

Answer 11

-MOI: acute or chronic compression through disc, often in flexed position
-Results in a bulge in the disc (usually posterolateral) resulting in changes to myotomes & dermatomes
-S&S: Pain with repeat forward bending (for posterior protrusion), relief with extension, pain with cough/sneeze
-Refer for conservative treatment

Question 12

Dermatomes:

Answer 12

-Sensory areas of the skin that are innervated by specific nerve roots (afferent nerve fibers)
-Sensations can include pain, tingling, numbness, pressure

Question 13

Special Test: Myotome Testing Cervical Nerve Root Involvement

Answer 13

Resisted tests are performed 5x bilaterally (look for weakening)

C1- cervical flexion
C2- cervical rotation
C3- cervical side bending
C4- shoulder elevation (shrug)
C5- shoulder abduction
C6- elbow flexion
C7- elbow extension
C8- thumb extension
T1- hand intrinsics (spread fingers)

Question 14

Special Test: Myotome Testing Lumbosacral Nerve Root Involvement

Answer 14

Resisted tests are performed 5x bilaterally (look for weakening)

L1, L2- hip flexion (in high sitting)
L3- knee extension
L4- foot dorsiflexion and inversion
L5- hallux extension
S1, S2- plantarflexion in standing (toe raises)
S1- knee flexion
S2- hallux flexion

Question 15

Reflexes

Answer 15

The following reflexes will be dampened if there is pressure on the associated nerve roots:

C5- Biceps
C6- Brachioradialis
C7- Triceps
L3, L4- Patellar tendon
S1- Achilles tendon

Question 16

Muscle Strains of the Neck and Back

Answer 16

-MOI: overstretch or eccentric load (loading the muscle while forward bending), rotation at high velocity, may have external force
-Tennis, golf, baseball
-S&S: abrupt “pull”, pain, protective spasm, divot (large strains)
-Even minor strains can become quite limiting d/t stability role
-Acute management: PIER (but never to anterior neck d/t major vessels), altered activity

Pain-> Spasm -> Pain -> Spasm *need to break the pain-spasm cycle (find the cause and treat the cause!)

Question 17

Rib and Scapula Fractures

Answer 17

-MOI: Direct blow, compression (ribs)
-Ribs: pain with deep breath (therefore may see shallow breathing), pain with compression, & TOP area of fracture
-Scapula: TOP, pain with movement of shoulder
-Acute Management: stabilize the segments with padding & tensor (if tolerated), tube sling for scapula fracture, send for imaging

Question 18

Spinal Fractures

Answer 18

-MOI: axial load, compression through spine
-S&S: central pain, tingling, numbness, unwillingness to move, spasm
-Displacement of segments can put pressure on spinal cord or nerve roots resulting in paralysis
-C-spine = paraplegia; T-spine, L-spine = quadriplegia
-Acute management: stabilize, call 911

Question 19

Importance of Palpation

Answer 19

-Palpation is very important to help identify injuries of the abdomen, thorax and spine
-Take your time practicing to locate key structures

Question 20

Palpation of Bony Structures

Answer 20

-Spinous processes
-Ribs
-Costal cartilages
-Sternum (ulnar side of hand)
-Scapula

Question 21

Rule out Pelvis Fracture

Answer 21

-Compress both sides of ileum together
-Compress ASIS down towards table

Question 22

Posterior Palpation of Kidneys

Answer 22

-There’s only 1 thing shaped like a kidney!
-Cup the back in the area shown
-Tenderness could indicate injury
-Athlete should watch for blood in urine
-Refer

Question 23

Special Test: Rib Compression

Answer 23

-Compress ribs gently
-Positive Test: pain at suspected fracture site
-Pain with inspiration or cough can also indicate a fracture
-Do not perform the test with obvious rib fractures

Question 24

Special Test: Quadrant Test of Lumbar Spine Joint Effusion vs Ligament Sprain

Answer 24

-Athlete in standing
-Have athlete extend backwards, side bend, & rotate in same direction
-Pain on same side = facet joint effusion/irritation
-Pain on opposite side = facet sprain on opposite side
-Repeat on other side
-A.K.A. Lumbar Quadrant Test (Kemp’s Test)

Question 25

Special Test: Stork Stance Spondylolysis or Spondylolythesis

Answer 25

-Have athlete stand on one leg on side of pain & extend backward through lumbar spine
-Positive test = pain localized to affected segment
-Positive test coupled with history of repeat backbending (gymnasts, figure skaters, cheerleaders) may indicate a spondylolysis or spondylolythesis