WK8 - Stretching, Taping, Lower Limb Flashcards
Define Flexibility
ROM possible around specific joint/series of articulations
Flexibility commonly proposed as risk factor for injury in athletes. True or False?
TRUE!
* reduced joint ROM/flexibility is a risk factor
Provide two examples as to why flexibility is a proposed risk factor for injury in athletes.
- Eg. baseball pitchers –> reduced GH int rot is common, associated with POS shoulder capsular pain
- Greater risk of injury in pitchers with less GH INT ROT
- Eg. in junior basketball players –> Decreased mean ankle DF – developing patellar tendinopathy in 1yr study (dominant vs non-dominant side)
There is not a vast spectrum of low to extreme levels of flexibility. True or False
FALSE
Define joint specific flexibility
- varies between and within individuals
- varies between joint pairs e.g. dominant vs non-dominant arm
Define double-jointed
Generalised Joint Hypermobility
* commonly investigated as risk factor for injury
* can be associated with injury
Relate back to Beighton Scale (0-9)
0-3 = no GJH
4-6 = hypermobilie
7-9 extremely hypermobile
Evidence of being double associated with injury.
*Significantly greater percentage of knee injuries in extremely hypermobile and hypermobile athletes compared with no GJH
*No significant difference in % of ankle injuries across flexibility groups
*Consideration of different sports (contact, non-contact), athletes (age, sex), specific injuries (ACL, MCL, patellofemoral pain)
*Hypermobility increased odds ratio (4.69) of knee joint injury in contact sport
Consider Post-Injury. What are the acute and chronic factors that cause decreased ROM?
- pain
- swelling
- inelastic, dense scarring
- joint adhesions. e.g. after arm has been in fixed position in cast for long periods
- bony lesions
- restrict joint because of big lump of bone
e.g. femoroacetabular impingement restricting INT ROT –> dysfunction and pain
—–> increased risk of ACL injuries because of overcompensation at knee
Consider Post-Injury. What are the acute and chronic factors that cause increased ROM?
- lengthened ligaments
- stretched capsules
- vertebral slips
What factors constrain ROM?
- structural
- neural/functional
- injury
What are the %’s of structural constraints to ROM?
- 47% joint capsule and ligaments
- 41% passive muscle
- 10% tendons
- 2% skin
How do neural/functional factors constrain ROM?
- alpha and gamma activation of muscle
How does injury constrain ROM?
fear of movement (kinesiophobia) relating to feeling vulnerability due to pain
What to consider regarding factors that constrain ROM?
- multifaceted aspects to injury and flexibility
- interaction of both intrinsic and extrinsic factors
- modify to increase (stretching programs) or restrict ROM (strength training)
–> To decrease/increase flexibility for function/performance is entirely dependent on their sport and training goals
What is stretching?
Ubiquitous practice in athletes and exercising individuals
Clear evidence stretching has capacity to increase joint flexibility/ROM
What is the rationale for stretching?
- improve performance
- reduce risk of injury
- facilitate rehabilitation
- can performance and injury aspects conflict
List the types of stretching.
- static
- dynamic
- active
- passive (partner)
- PNF (proprioceptive neuromuscular facilitation)
- isometric
- plyometric
What has the study of lower limb soft tissue injuries and stretching found?
No difference for stretching programs on lower limb injury risk (RR 0.85, 15% risk reduction but confidence intervals 0.65-1.12, not statistically significant)
What has the study of shoulder injuries and stretching in baseball players found?
- decreased GH internal rotation is a injury risk
- Prospective study involving prevention program on incidence of shoulder and elbow injuries in 90 high school baseball pitchers
- Passive IR measured pre-season sleeper stretching, sleeper stretching & strengthening, no intervention
- Sleeper stretching after pitching significantly decreased baseball-related shoulder and elbow injuries
- Those who did not do the stretching regime, had significantly more injuries to shoulder (57% vs 25% who did)
- Current evidence allows us to conclude stretching itself does not reduce lower limb injuries in endurance type running
- Stretching reduces risk of shoulder and elbow injuries in baseball type sport movement
- In team sports, multi-component injury prevention programs show reduction in risk of lower limb injuries where these multi-component programs include proprioceptive and strength training along with stretching
- Problem with these programs is that we can’t tell which is the main factor causing the change (is it proprioception or stretching?)
What is the aim of taping and bracing?
- prevent injury/reinjury
- reduce injury severity
- rehabilitation: support and reduce pain
Provide some evidence to taping and bracing.
-Meta-analyses show taping helps prevent ankle sprains
*Previous sprain – RR 0.33
- Prevents further injury by 67%
* Uninjured – RR 0.73
- Prevents new injury by 27%
-Ankle supports help prevent ankle sprains in young male and female basketballers, football and American footballers, military paratroopers
* Odds ratio 0.40, CI doesn’t cross 1
-Ankle supports are effective in preventing minor and more severe sprain
*G1 – RR 0.37 (63% lower risk)
*G2/3 – RR 0.57 (43% decreased risk)
-Ankle supports do not increase risk of other lower limb injuries
*Taping RR 1.02 (no increased risk of getting knee/hip injuries by taping)
-Multi-component injury prevention programs
What is the evidence of taping and patellofemoral pain?
-No statistically or clinically significant difference between taping and non-taping in pain (0-10 VAS) at end of treatment
-In short term, medial taping of patellar could help with pain but long-term, no difference
what is the evidence of taping and finger fractures?
-Majority of metacarpal fractures involve fifth metacarpal with boxer’s fracture affecting metacarpal neck
-Conservative management of boxer’s fracture include casting and buddy taping
-ROM and grip strength better at early follow-up with buddy taping (better to use buddy taping if you want your grip strength back earlier); no significant difference between cast and buddy taping at final follow-up
What is the evidence of joint bracing and injury prevention?
-Joint braces (guards) for injury prevention have insufficient evidence for knee injuries
-Supportive evidence for wrist and ankle injuries
*OR 0.25 – 75% decreased risk of injury if you wear a brace/guard
What are the finding of ankle braces on injury prevention?
Rovere et al.
* Retrospective analysis
*Braces 2.56 sprains/1000 injury exposures
*Taping 4.91 sprains/1000 injury exposures
What are the potential reasons for braces to outperform taping?
Easier to use – greater adherence
ack of skin reactions
Greater consistency in application
Greater capacity to re-tighten during sport
Greater use in training/games
Convenience during tournament play
Why are the mechanisms of bracing and taping not fully understood (joint position sense)?
*Meta-analyses show ankle taping and bracing reduce risk of ankle sprains, with greatest effects in athletes with previous injuries
*Evidence-based practice consistent with using ankle taping/bracing to reduce risk of injury
How to use preventative taping for LAS according to the Sports Med Aus Guidelines?
*Shave, clean, dry ankle region, cover wounds
*Apply 2 anchors around base of calf
*-3 stirrups (medial to lateral)
*2 figure 6/8s to counteract inversion
*Lock off with 2-3 tape strips to secure
What are the taping basics (consider preparation and removal)?
- pre-taping checks
- skin preparation
- tape application
- post-taping checks
- tape removal
What to do in pre-taping checks?
*24h prior to full taping, apply small tape strip for 10-20min for skin reaction
*Reaction to adhesives (methacrylate/acrylate) may be managed with low irritant tape or pre-wrap (possibly accelerate tape loosening)
-May be better to just brace
*Check for circulatory conditions
- Diabetes
What to do for skin preparation when taping?
*Shave area at least 12h prior to taping
*Clean, dry skin (no lotions or oils)
Can use spray adhesives
*Apply padding to areas needing protection
Cover cuts and blisters
*Resting skin temperature
Before warmup/sweating
What to consider for tape application when taping?
*Select appropriate tape size (eg. 35mm rigid)
*Don’t tape from roll, use strips, don’t apply excessively tightly
*Avoid continuous taping
*Overlap strips by ½ width tape
Tape sticks to skin well
*Avoid wrinkles or gaps
Can cause chafing and blistering
Sweat/moisture can get in through gaps loosening
*Just put a piece of tape over
*Be cautious of taping over superficial tendons
Eg tibialis anterior
What to do for post-taping checks?
*Circulation/sensation
*Does tape feel too tight (pins and needles)
*Restricting intended movement
Inversion
*Actively move joint through full ROM to check desired movement limitations
Should not prevent other movements
What to do for tape removal?
*Don’t leave on for extended periods
Will be harder to get off Stickier and harder
*Use tape cutter or scissors with blunt nose
*Don’t tear against skin grain
Go with the skin (downwards)
*Pull tape back down on itself placing pressure on skin as close as possible to line of attachment with tape
What principles are considered in a holistic hamstring program?
- strength
- architectural adaptations
- ability to withstand high velocity actions observed within sporting actions
- using nordic curls?
Hamstring injuries are one of most common and debilitating injuries in many running-based sports. T or F
T!
Prevalence of hamstring injuries in professional soccer.
-In professional soccer, 57-72% of all hamstring injuries occurred during high-speed running, and in nearly all of these injuries the primary site was Biceps Femoris Long Head
which hamstring muscle is commonly injured?
biceps femoris long head at prox musculo-tendinous junction
*Bi-articular
*Strength determined by pennation angle and physiological cross-sectional area
*In pennate muscle, force from muscle fibers transmitted to tendon primarily via aponeurosis
Where does the semitendinosus and biceps femoris join together?
common tendon attached to ischial tuberosity
What is the pennation angle of the semitendinosus?
more insertion onto tendon compared to biceps
What happens when BFLH is most activated?
exceeds max. volume isometric contraction
-Amount of forces in running is more than you can manufacture by just isometrically contracting
-Relevant to eccentric capacity of muscle hamstring must be able to control large forces
-Maximum speed running or sprint acceleration
2 Large peaks in excitation, during late swing and early stance, exceeds 100% MVIC.
Late swing = 120d at hip flex, 140d knee flex
early stance = 140d hip flex, 150d knee flex
During maximum speed sprinting phase…
more ST than BFLH
Likely that BFLH activate in sprint acceleration more than ST
List characteristics of semitendinosus.
-Has long fibers that contain many sarcomeres
-Potential to contract quickly over long distances
-Nice architecture for eccentric load
-Considered more activated for controlling simultaneous knee extension and hip flexion during mid-swing phase of sprinting
-Nordic rehab – maybe helps ST work better and enhance architecture of BFLH
Why does BFLH get injured more?
maybe need balance between ST and BFLH recruitment
Characteristics of biceps femoris?
-Long proximal tendon attaching onto ischial tuberosity
-Short head has longer fascicles than the long head
*Better designed to cope with eccentric load
*ST also better designed to cope with eccentric load
*Maybe ^ is why long head is most injured in high speed running because it is not designed to cope with eccentric (swing)
-Maybe that’s why BFLH gets injured more commonly
Characteristics of sacro-tuberous ligament?
-Static restraint of SI joint
-biceps femoris part of self-bracing mechanism
*As leg moves through swing phase, allows for better structure to land on
RTP findings in BFLH?
-Substantial reduction in BFLH volume (4-5%) found in >50% of individuals with prior injury despite having returned to sport
-Architectural changes leaving people more prone to reinjury?
-Potential compensation
*Increase reflex
*Control
*Better recruitment
Effects of ischial tuberosity sitting almost sagittally over medial side of knee?
-Biomechanically well designed
-Biceps femoris on oblique angle, not as well aligned as medial side
*Potential reason for injury of lateral hamstring?
What happens to prior injury and migration of scar tissue altering mechanics of contraction, esp near site of previous injury?
-Won’t get nice contraction –> pathological contraction
^ Prior injury risk for re-injury
-Previous injury = architectural changes
What has the presence of scarring been shown to alter?
Alter vivo muscle contraction mechanics, generating localised regions of high tissue strains near site prior to injury of biceps femoris
Scar tissue adjacent to site of original injury has been observed as early as 6WKs and as late as 23months after injury
Diagnosis and management of hamstring injury?
- observation
- clutching of leg
What are other common hamstring injuries?
MED side –> semimembranosus
Distal MTJ of semimembranosus on contraction. L= contract (gap). R = relax (no gap)
Image provided on page 14 of WK8 document.
-Looks like insertion type injury
-Bump is often misdiagnosed as bursa or cyst
* Quite a few bursas at back of leg
-Only seen on dynamic ultrasound and not on MRI
-Not total disruption, doesn’t require surgery
Where does biceps femoris attach?
fibula head and tib-fib joint - potentially tri-articular
Effects of distal biceps insertion injury?
-Athletes may report a sudden, immediate sensation of pain in posterolateral thigh (even without contact)
-Often accompanied by audible or palpable popping sensation with inability to RTP
- Sensation of being hit or kicked
-Tests
*Active hamstring curl (bring foot towards butt)
-can they recruit their hamstrings
*Resisted hamstring curl
- Isolation of point of pain
*Should be able to match both sides
Diagnostic test of hamstring injury?
Clinical evaluation 48h after injury
- measurement of AROM of knee on injured and uninjured side
- with AROM deficit of more than 30d
- recovery = >6wks
AROM - patient activated, brain wont let them hurt themselves more
What is a RTP test for hamstring injuries?
Askling H-Test
-Apprehension test, if there is any insecurity then extend rehab
-How well brain can react under speed
-Neurology aspect
Clinical exam - no signs of remaining injury
- knee brace to keep leg in EXT
- straps stabilising UB/contralateral leg
- perform SLR as fast as possible to highest point
- 3 trials per leg/uninjured leg first/no WU
- if experience any insecurity (VAS) - extended rehav
What are the potential hamstring injury risk factors for player load?
*Rapid increase in 2 week high speed running load was associated with HSI
*Any sudden increase in amount of running can be a risk factor
*With careful planning, running fast can potentially prevent HSI BUT running can also cause HSI
Gradually bringing up to greater than 85% speed leading up to the running event (competition)
*5-8 exposures
*Potentially in middle of the week
What exercises in the gym can mimic the movement and contraction of hamstrings at high speed?
*Sprinting is the only exercise that induces a sprint-specific hamstring muscles activation
*Impossible to replicate by usual strengthening exercises
Best way to get good at running is to run
What are the potential hamstring injury risk factors with gluteus medius activation?
not recruiting biceps fem enough, need to activae glute med to compensate
What are the potential hamstring injury risk factors?
- player load
- gluteus med activation
-Injury history
-Age
-Warm-up
-Lumbo-pelvic hip stability
-Motor patterning
-CV fitness
-Hamstring architecture
-Fatigue
-Hamstring function
-Flexibility/posture
-Psychosocial
-Recovery/nutrition
-Environmental factors
*Eg pitch type, surface
-Activation of other muscles
Define piriformis syndrome
-Sciatic nerve entrapment pain presenting as pain in hamstrings
-Not an acute injury/won’t be due to high-speed running
-Sciatic nerve path varies between individuals
*Sometimes goes through, sometimes goes above
-History can help distinguish between this and hamstring injury
What is ischiofemoral impingement?
-previous avulsion injury
-Reduction in size of gap between ischial tuberosity and lesser trochanter
-Internally rotate + extend hip
*Push nerve between bone and under QF
-Presents as hamstring pain
-May not see in MRI as there is no movement in an MRI and it is done in a prone position
-May see radiologically
What are the characteristics and mechanisms of complete hamstring avulsion?
-proximal insertion tear
-common in mature aged athletes
*Usually don’t take bone, just tendon disruption
-Difficult to completely avulse, usually partial
-Complete avulsion common in younger athletes (children, pediatric injury)
*Large piece of bone comes off
*Allow it heal by itself, bridging bone to callous
*Potential impingement syndrome later on
Mechanism:
*Slip and try to recover
*Falling
*Flexed and bent over (refer to pic)
What to look for in impingement test: Long-Stride Walking Test?
-No pain in normal walking but pain presents in long strides
-When hip is extended, pain is present
*Due to impingement
-When hip is abducted, pain goes away because alleviating the impingement
which nerve innervates the short head of biceps femoris?
common fibular, or peroneal, division of the sacral nerve (L5-S2)
which nerve innervates the long head of biceps femoris?
tibial portion of the sacral nerve (L5-S2)
What are the complications of potential scarring (at the SN area) due to previous injury? How to test for it?
-Scarring in SN area could cause nerve tethering in sub gluteal space
-Sciatic nerve gets tethered as it wraps around the corner
-Gives rise to symptoms in butt then hamstring region
Test:
*Ultrasound –> Flex hip then move around
*Nerve should move freely, if not it may be tethered in sub-gluteal space
*Introducing fluid into this space may free up fibrous scarring and relieve symptoms
How to test for nerve issues in a straight leg raise?
-At extreme, loss of lumbar lordosis and presence of pelvic tilt
-Sciatic nerve experiences increased strain
-Wrap-around phenomenon
-Neural component to their hamstring pain
-Pelvic tilt could be affecting the sciatic nerve
What is the “wrap-around” phenomenon?
During SLR, SN (sciatic nerve) experiences an average of increased strain at 26%
What are other issues in POS region around hip and thigh?
sacroiliac pain
bursitis diagnosis
From SUP to INF (refer to page 21 image of hip)
sacroiliac pain
iliac crest contusion (hip-pointer)
lumbosacral spine pain (dermatomal)
greater trochanteric bursitis
sciatica
Define sacroiliac pain and how to test for it.
-movement or irregularities of SIJ
-Pain towards butt
-Only ~4 of movement of SIJ, hardly likely to be implicated in pains unless you have sacroiliitis
Tests
* Flex
* Stand
What is bursitis?
-Presents as hip pain
-lack of glute strength pelvic tilt, TFL rubbing on greater trochanter bursa
-Consider other diagnoses
*Potentially tendons of Glute med/glute min?
similar to rotator cuff irritation
*Encourage other investigations
*What protective stuff can we do
-Especially in older athletes
*Bursitis is due to something else, it is not the main issue
Is glute med/min in working order?
HX IS VERY IMPORTANT!
What are the characteristics of the rectus femoris?
-Indirect and direct head
*Vastus muscles attached to femur but rectus femoris is bi-articular, attaches above hip as well
*‘double responsibility’
*Direct – AIIS but variable
*Indirect – Above acetabulum of hip but also variable
-Hip movement and knee movement
What does the direct head of the rectus femoris mean?
flat aponeurosis by the time it’s joining with the indirection.
- changes cross-sectionally
attaches to the AIIS
Cross-sectional image of the rectus femoris (L+R)
^ L (on the right of picture), oedema around central tendon (white)
-Referred to as bulls eye sign
-Central tendon damage
-Takes a lot longer for athlete to recover if there is central tendon damage
The oedema in the image = more centrally preserved
(small circle) - oedema more on the outside, centrally preserved.
Explain the structural components of the rectus femoris and how they change with depth.
deep - bipennate
superficial - unipennate
central tendon in middle
Define Intramuscular degloving injuring.
indirect myotendinous complex of RF – inner bipennate muscle belly separates and dissociates from superficial unipennate muscle
^ muscle within muscle damage + damage to tendon
Type of injury dictates how long it takes athlete to recover
^ MRI may be useful for depth and type of injury
List some common ANT thigh and quadriceps injuries in young athletes.
-AIIS secondary ossification
-Traction apophysitis
*Continuous pulling of tendons of rectus femoris on bone which has not fully fused
-Avulsion injury instead of central tendon/target lesion/degloving
-Presents as groin pain, symptoms related to RF
-Diagnosis using x-ray, may need MRI
-Can be left alone to heal
-Potential impingement area at hip
List the hip flexor muscles, their characteristics and injury risk.
Iliopsoas –> Psoas + iliacus
-Activated more when rectus femoris does not have biomechanical advantage (in fully extended position)
-Rec fem is compromised in full hip extension, cannot be recruited, will predominantly be using iliopsoas
Injuries –> can be traction apophysitis (of lesser trochanter?), acute injury, lesions (muscle within muscle from above)
Characteristics, causes and complications of impact injuries to the thigh (cork/hematomas)?
-Direct force Muscles pushed against bone
-Bone tears muscle instead of the impact
-Tensing before impact occurs may protect bone
*Resists load against bone but is not something that can always be trained for
-Direct trauma can cause bleeding to occur
*Within intramuscular
*Extramuscular
*Potential compartment syndrome
- If bleeding continues but is contained
- Can tolerate a fair bit of blood but there is a threshold
Why should a physical examination record degrees of knee FLEX on both legs?
- If cannot FLEX >45d, indicates major injury
- 2ndary problems like calcification within hematoma
- knee can be maintained in 120d FLEX with elastic wrap/adjustable ROM brace set (primary care management strategy)
–> could RTP earlier if you put them in positions of greater FLEX earlier on
What should a physical examination record?
- degrees of knee FLEX on both legs
- firmness rating of injured muscle
- circumference of thigh at suprapatellar border of thigh
What is involved in primary care after injury?
-Knee maintained 120 flexion
-Patient will need to use crutches and maintain flexed position for 24h
-NSAIDs can be administered for first 48-72h only (explanation below)
What are your thoughts on NSAIDs?
administered for first 48-72h only but consult else first
What are the tissue repair phases?
- bleeding
- inflammation
- proliferation
- remodelling
What happens at point of injury?
lot of necrosis, damaged tissue, want to build new mscle
What happens when the complement system is activated?
*Activates neutrophils to remove dead tissue
*New neutrophils in area –> pro-inflammatory cytokines (back to top, red)
*Mast cell degranulation causes inflammation
*Macrophages come in – for inflammation but now is then used for anti-inflammatory purposes
*Inflammation is necessary for clearing of the site, allowing macrophages to come in and decrease inflammation, thus we don’t want anti-inflammatory drugs for too long
*These natural processes are under influence of Cox enzymes
–>Anti-inflammatories are cox inhibitors
–>Anti-inflammation good for the initial phase with a lot of inflammation
–>But in 2nd and 3rd wave, you want macrophages to come in and help with anti-inflammation, don’t want to inhibit that
Anti-inflammatory could cause fibrosis scarring instead of natural healing – muscle that heals with fibrosis wont heal well. T or F?
TRUE!
NSAIDs may cause more fibrotic scarring compared to natural healing.
NSAIDs have paradoxical effect. T or F and why?
TRUE!
-Early signs of improvement but subsequent late impairment in functional capacity and histology
-First 3 days doesn’t have detrimental effect but continued use appears to affect natural healing negatively
-Promotion of fibrosis and inhibition of both early and later stages of muscle cell regeneration
-Good for chronic things but will affect natural healing process
Define myositis ossificans
bone deposition instead of healing muscle
- similar to hetertrophic bone ossification which is a complication of orthopedic surgery
- occurs typically where it is very vascular - lots of blood supply and hematoma
What is the incidence of myositis ossificans after muscle contusion?
9-17%
those with early ROM after injury are less likely to have MO
Pre-calcified stage can cause diagnostic problems as it is not always connected to recent trauma and can resemble sarcoma
How to treat MO?
long term NSAIDs
- inhibit bone formation, so not good for healing bone fractures
When does faint periosteal bone formation occur?
7-14days, mature bone after 4-6months
- process of bone formation occurs over many months
- don’t operate on it until it is fully mature (could be ~12months)
- manage well but DON’T overdo it on NSAIDs
Provide examples of common groin injuries.
- athletic pubalgia
- osteitis pubic
Where are the potential areas causing pain for athletic pubalgia?
- inguinal ligament
- pubic symphysis
- rectus abdominis
- superficial inguinal ring
- add longus
What implications does athletic pubalgia have on the inguinal ligament? Consider location and what it is.
implications of potential hernia
- goes backwards through POS wall, may not be obvious
- 40% undiagnosed in some cohort
located in testes to scrotum, canal seals off but may leave a space
Ballooning out of material which presents as a lump
- more obvious when strained
pain when coughing/sneezing?
- increases intra-abdominal pressure
- if pain present, likely a hernia
What does osteitis pubis mean when considering athletic pubalgia?
- indicates area of pain but not the underlying cause
- does not tell us how to manage better
What are the mechanisms of osteitis pubis?
- unclear
- sports involving pivoting on a single leg or sudden change of direction at high speed are most commonly associated with athletic pubalgia
Correlation between osteitis pubic and early maturing boys?
-Pigeon-holed into specializing early which could help with skill development
*But maybe skeletally/muscularly not ready
*Can’t keep up, don’t have the same movement patterns
-Early maturers have a greater probability of sustaining a groin/hip injury
*Use their bulk instead of developing skill
*Specialize too early, don’t learn the game properly
*Those who matured later more likely to be successful later
What are non-modifiable risk factors for athletic pubalgia?
History of previous injury
*Deficits in physical conditioning, scar tissue formation, inadequate rehabilitation, reduced proprioception, altered movement patterns, premature early return to play after initial injury
What are modifiable risk factors for athletic pubalgia?
-Body mass
-Relative Weak hip adductor muscles (WHAM)
*Adductor to abductor strength ratio of less than 80%
*17% more likely to sustain groin injury
*Decreased hip rotation ROM
-Internal rotation
-ROM
*No association between ROM/flexibility and groin injury
Summary of groin pain…
-Hip strength testing provides a good indication of ability of athlete to generate maximum forces
-Adductors are important for specific athletic skills such as kicking, accelerating, decelerating, cutting movement, HSR
-When athlete can generate sufficient hip adduction forces comparable to that of healthy side and/or to abductors under following conditions, then more strenuous sports-specific athletic activities and return to play test batteries can be commenced
*Isometrically and eccentrically
*Without or with only minimal pain
If you wait until they have no pain at all they may never return
How to test for groin pain?
Copenhagen Test
- functional testing for RTP
- doing copenhagens
What is the Copenhagen test?
Copahagen 5s squeeze test
- place one arm between the ankels of the player, instructing the player ot isometrically and continuously swueeze as hard as possible for 5s and subsequently rate the pain experienced in groin during this manoeuvre on a 0-10 numerical rating scale (NRS)
0-2 = safe
3-5 = acceptable
6-10 = high risk
Where does the rectus abdominis insert onto?
pubic tubercle
What does the squeeze test tell you?
- superior pubic pain may be related to RA
- LAT pain may be related to insertion of inguinal ligament
ADL squeeze test tests more than just ADL - testing whether whole pelvis can cope
What could be the reason for hip pain?
triangle structures
What is located within the femoral triangle?
- femoral artery
- femoral vein
ADD longus muscle
What body position is good for testing hip pain?
standing on one leg
- lot of forces going through hip joint - 3x body weight
What is the Trendelenburg Sign?
stand patient on one leg, should be able ot tilt pelvis up to balance on one leg
- sagging indicates Trendelenburg +ve, possible weakness in muscles (ADD) or bad hip
- running and falling into this position will stretch TFL and ITB
What does moving the knee like a windshield wiper tell us?
-Compare sides and detect discomfort
-Checking for difference in internal rotation between sides
-Potential osteoarthritis or other issues with hip
-Patients may present with thigh and knee pain but movement in this position causes pain at hip
What to consider with overuse hip injuries in athletes?
-Positive internal rotation + positive hop test with groin pain send them off for further evaluation
*Possible stress fractures on femoral neck
- likely osteopenia
What is femoro-acetabular impingement (FAI)?
Congruency at hip joint
- can’t tolerate many things going wrong
List the types of femoro-acetabular impingement.
- normal
- Cam (usually in young athletes, seen in femoral neck)
- Pincer (usually for older athletes, seen in joint capsule)
- Mixed
What kind of pain indicates Labral Tears of the hip?
-Pain with crossing legs
-Pain with end ROM
-Pinching, catching, grating feeling inside hip
-Pain with combined flexion, adduction and IR (knee across chest) [FADIR]
-Pain with combine flexion, abduction and ER (knee bent and resting out to side) [FABER]
-Pain with resisted straight leg raise (raising leg against resistance) [rSLRT]
What is the McCarthy Hip extension sign?
-Patient supine with both hips flexed
-Examiner extends one hip down with lateral then medial rotation
-Test repeated on other hip
-Will get a ‘clunk’ but pain is better indication than this clunk
*Due to iliopsoas bursa, iliopsoas tendon running across bursa as it runs over iliopectineal line, position of lesser trochanter changes based on positioning
-Positive test when pain is reproduced, not the clunk
-MR arthrogram – injecting dye into hip joint, scanning
-MRI
Characteristics of Bursitis?
-Bursa present to protect bone from tendons
-‘Deflated balloons’
-Greater Trochanteric Bursitis from ITB rubbing on greater trochanter
*Pain at side, thumb can generate pain by palpation
-Older athletes may have tendinopathy
*Cause of pain instead of bursa
-Iliopsoas bursa/bursitis – pain in internal groin
What to consider for paediatrics with hip pain?
-Thigh and knee pain can be from hip
-Don’t miss opportunity to get on the pain early on
-May not fit pattern similar to adults
Define slipped upper femoral epiphysis (SUFE), prevalence and risk factors.
-Displacement of capital femoral epiphysis from femoral neck
*Like an ice cream falling off the cone
*Femoral head breaks off into acetabulum because metaphysis has moved up/head slipped downwards
*Similar to cam lesion – developmental
-Typical patient is adolescent obese male
-Aged 10-15y
-Bilateral in 30-60% of cases
-Obesity and endocrine problems are often a risk factor
How does SUFE present?
-Limp and hip pain
-Limited hip movement in all directions
-Trendelenburg positive test
-In supine position, leg is externally rotated
How to test for SUFE
-C-sign –> Hip pathology
-Triangulate, can’t pinpoint hip pathology
-Jam fingers into femoral artery hip pathology
-Drooping hip hip pathology or inadequate muscular strength
What did a study of 147 athletes with COVID-19 find?
-57% fatigue
-50% dry cough
-46% headache
-40% fever
-30% myalgia
-14% dyspnoea
-2% chest pain
Mild self-limiting illness
Lower respiratory tract features (dyspnoea, SOB and dry cough)
-3x risk of prolonged illness
2x risk of delayed RTP
What did a study of 147 athletes with COVID-19 find on symptom duration?
-10 days median (6-17)
-Prolonged symptoms
*14% reported >28 days of symptoms
What did a study of 147 athletes with COVID-19 find on time lost?
-Median 18 days (12-30)
-Prolonged
*27% not fully available >28 days
-Comparison to normal respiratory infection – mean 6 days/prolonged 4%
-Prediction prolonged recovery
*Dyspnoea +/- chest pain +/- cough +/- fever
*Chest pain only
What did a study of 571 competitive junior athletes with covid-19 find?
- (age 14.3 +/- 2.5y)
-50% mildly symptomatic
Symptoms
*Average duration 4+/-1 days
*Small pericardial effusion (2.6%) – fluid in sac that heart sits in
*Moderate pericardial effusion (0.2%)
*Pericarditis (0.4%) – inflammation of heart’s sac, can cause chest pain
*No myocarditis or arrhythmias
What was the management of COVID-19 in these 571 young athletes?
-Pericarditis and moderate pericardial effusion
- Remove from sport, cease exercise until symptoms resolve
- Allow gradual return once complete clinical resolution
Provide a summary of findings of the impact of COVID-19 on athletes vs competitive junior athletes.
-Asymptomatic or mild covid-19 infection
-Cardiac involvement low risk
-Management based on symptoms
-Echocardiographic screening not recommended
-Minimal long term consequences
What is the incidence of transmission during sport (study on soccer players)?
-Training/matches
-Professional, youth or amateur
-Potentially infectious players: PCR or symptoms
-Transmission-relevant contacts: video
-Identified 1247 football matches/training
-165 potentially infectious players
Consider transmission during sport. What to do in professional levels?
- follow up PCR test of 44 players
- no transmission
Consider transmission during sport. What to do in Youth and Amateur leagues?
- Partial PCR (31/60)
-Symptom monitoring for 14 days (46/60)
-2/60 matches had infections occur
-Attributed to non-football activities
*Soccer has some contact but maybe not enough to transmit covid
Provide a summary on transmission in sport findings.
-Little evidence that transmission during training
-Sport is relatively same in terms of transmission
-Likely they caught covid from other activities than actual training
