KNES 372 - Midterm Review

What are the 4 anatomical planes?

• median → plane that runs through the midline of the body, splitting into left + right portions

• sagittal → plane splitting the body into left + right portions

• frontal → plane dividing the body into anterior and posterior portions

• transverse → plane dividing the body into superior + inferior portions

What is valgus? What is varus?

valgus → lateral angling of the distal part of a bone or joint (knock knees)

varus → medial angling of the distal part of a bone or joint (bow legs)

What is hyper lordosis? What is kyphosis?

hyper lordosis → excessive curvature of the lower back

kyphosis → dorsally excessive curvature of the thoracic, lumbar or cervical spine

What is the difference between rotation + circumduction?

rotation → bone or limb turning around its own axis

circumduction → movement of a body part in a circular pattern by combining flexion, extension, adduction + abduction

Inversion and eversion vs. supination and pronation?

inversion → tilting the sole of the foot inward (toward midline)

eversion → tilting the sole of the foot outward (away from midline)

supination → combination of inversion, adduction, plantarflexion

pronation → combination of eversion, abduction, dorsiflexion 

What is SEM team? What is another name for it? What is the purpose of it?

sport and exercise medicine team aka integrated support team (IST)

• multi-disciplinary team of sport science, sport medicine + sport performance professionals

• goal is to ensure athletes are healthy, fit + mentally ready for optimal performance

What are some examples of the members of an SEM team?

• physician

• therapist (physio, chiro, athletic)

• strength + conditioning coach

• exercise physiologist

• sport psychologist

• biomechanist

• nutritionist

What are the roles of each of the members of an SEM team?

• physician → diagnose, prescribe, X-rays, MRI’s, big picture (1st assessment)

• therapist (physio, chiro) → taping, rehab exercises, manual therapy

• strength + conditioning coach → skills + fitness, injury prevention

• exercise physiologist → testing, limit determination

• sport psychologist → mental readiness (after injury, before competitions)

• biomechanist → ergonomics, equipment

• nutritionist → food to optimize health + performance, education

SEM specialists must follow the __________ and standard of care. 

scope of practice

What is scope of practice?

the procedures + actions that a qualified practitioner is allowed to do

What is standard of care?

medical treatment guideline

It specifies appropriate treatment based on scientific evidence + collaboration between medical and/or psychological professionals involved in the treatment of a given condition

What are the different levels of identifying risks in sport?

• within/across sport

• club/team level

• individual level

What is the process of identifying risks in sport?

1) assessment → process of measurement/estimation of risks to teams + athletes

2) evaluation → involves determining the significance + acceptability of the risks

3) control → process of identifying + implementing methods to control the risks + consequences

What are the components of an effective risk management system for a team?

• injury surveillance → recording/reporting injuries

• season analysis → risks, travelling, timing

• preseason screening → baseline testing, injury history, strengths/weaknesses

• monitoring “at risk” team members → risk factors for future injuries

• return to sport → facilitating safe return to sport

• education → of all members

• equipment + facilities → safe, up to date

• emergency action plan (EAP)

When should an EAP (emergency action plan) be activated immediately?

if the person:

• is not breathing

• does not have a pulse

• is bleeding profusely

• has impaired consciousness

• has injured the back, neck or head

• has a visible major trauma

• cannot move arms or legs (has lost feeling in them)

What is a SOAP note?

method of documentation → standardized way to store medical information

S: subjective 

O: objective

A: assessment

P: plan

What direction of travel has the most jet lag? The least?

most: west → east

least: east → west

What is neuromuscular training? What are the components of NMT?

focuses on performing exercises that train the nerves + muscles to react + communicate, a specialized form of physical training that focuses on improving the coordination + function of the nervous + muscular systems, designed to enhance movement control, stability of movements, movement technique + skills, strength, power and speed

components: balance + proprioception, plyometrics, strength + stability, agility + coordination, acceleration + deceleration, reactive perturbation

What are the aims of NMT?

• to improve neuromuscular control + stability

• to improve movement skills + technique

• to enhance performance

• to reduce the risk of injury

What is the leading cause of injury in youth in Canada?

sport-related injury

What sports have the highest burden for sport-related injuries?

hockey, basketball, soccer

What type of sport accounts for 44% of all hospital treated sport injuries in the EU?

team ball sports

What is the leading risk for injury in sport?

previous injury

What is Van Mechelen’s 4 step sequence of injury prevention?

1) establish the extent/severity of the injury problem

2) find the mechanisms + risk factors

3) introduce a preventative measure

4) evaluate the effectiveness of the intervention

What is the injury mechanism composed of?

• events leading to injury situation

• injury situation

• whole body biomechanics

• joint biomechanics

What are intrinsic + extrinsic risk factors?

intrinsic → physical characteristics, psychological + psychosocial characteristics, etc. (internal)

extrinsic → exposure, environment, equipment (external)

What are modifiable risk factors?

balance, flexibility, strength, aerobic fitness, training load

What are non-modifiable risk factors?

age, sex, previous injury

What are the different levels of injury prevention?

primary prevention → reduce occurrence in those who don’t yet have an injury

secondary prevention → early diagnosis

tertiary prevention → minimize consequences (stop worsening of injury + minimize future issues)

What are some strategies used in sport injury prevention?

• training programs to improve fitness/movement quality

• new or modified sport equipment

• new or modified rules

• education

______________ and _______________ are key factors in injury occurrence.

Biomechanics, mechanical loads/forces

ACL rupture occurs ___________ after initial foot contact.

30-40 ms

What mechanism causes the most ACL injuries?

non-contact

• bodyweight on one leg

• small knee flexion angle

• knee valgus + internal rotation

• high impact force

What are the 3 types of modes of onset for sport injuries? What is an example of each?

1) acute, sudden onset injury (ankle sprain)

2) repetitive, gradual onset injury (overuse, pain increases over time)

3) repetitive, sudden onset injury (stress fracture overuse injury, pain is sudden but tissue damage has been happening for a while)

What are the classifications of contact as a mechanism for acute injuries?

1) direct contact injury (contact with injured area) with another athlete or object

2) indirect contact injury (no direct contact to injured area, contact doesn’t occur at exact time of injury)

3) noncontact injury (no other athlete or object involved)

What do soft-tissue injuries involve? Skeletal injuries? Acute (traumatic) injuries?

1) cartilage, ligaments, tendons, muscle

2) bone fractures

3) bleeding (hematoma)

What is the difference between articular cartilage and fibrocartilage?

articular → flexible, provides smooth surface for joint movement (end of bones)

fibrocartilage → tough, able to absorb loads (discs of the spine, meniscus)

What is a tendon, enthesis, and a ligament?

tendon → connects muscle to bone

enthesis → the junction between a tendon and a bone

ligament → connects bone to bone

What structures can a tear involve? A sprain? A strain? A fracture? A rupture?

tear → ligaments, muscle, tendon, cartilage

sprain → ligaments, joints

strain → tendons + muscles 

fracture → bone 

rupture → muscle, tendons, ligaments, internal organs

Describe the stress-strain curve. What is stiffness? What is the yield point? What is creep?

stiffness → ability of a tissue to resist a load

yield point → indicates the limit of elastic behaviour + the beginning of plastic behaviour

creep → deformation in the shape/properties of a tissue that occurs under the influence of persistent mechanical stress

What is hemostasis?

process to stop bleeding when injury occurs → results in formation of a clot

What are the steps of hemostasis?

• vascular spasm

• formation of a platelet plug

• blood clotting (coagulation cascade)

• formation of the final clot

platelets release growth factors 

What is the purpose of inflammation?

• defensive response of tissues to a physical or chemical injury, or bacterial infection

• growth factors recruit inflammatory cells to destroy debris + bacteria 

  • neutrophils → first 48 hours

  • macrophages → peak around 48-72 hours

  • lymphocytes → appear after 72 hours

• indicated by redness, warmth, swelling, pain, and dysfunction

What is proliferation?

rebuild stage

What is angiogenesis?

component of proliferation: formation of new blood vessels, restoration of blood flow

What is fibroblast migration?

component of proliferation: fibroblasts produce collagen fibers + elastin, results in granulation tissue which replaces the clot

What is epithelialization?

component of proliferation: epithelial cells cover the exposed surface

What is wound retraction?

component of proliferation: contraction of the wound (healing + closing of the wound)

What is the purpose of remodelling?

to increase tissue strength

• may last months/years

• granulation tissue matures into scar

• form + function of the scar tissue depend on loading during this stage

• same level of tissue strength before the injury is never achieved!

Healing structures need to be exposed to ________________ to remodel because bone + tissue respond to _____________ + remodel accordingly. 

progressive loads, loading

What time frame is each stage of wound healing occurring at?

1) hemostasis → minutes/hours

2) inflammation → days

3) proliferation → weeks

4) remodeling → months/years

What are the goals of early treatment of acute soft tissue injuries?

• limit bleeding (too much bleeding slows healing)

• limit swelling

• relieve pain

• improve conditions for subsequent treatment + healing

What are the new acronyms for acute injury management + what does each letter stand for?

PEACE and LOVE

P - protection (unload/restrict movement for 1-3 days)

E - elevation (higher than the heart)

A - avoid anti-inflammatories + ice
C - compression (helps limit edema + hematoma)

E - education (educate patients on benefits of active approach to recovery)

L - load (appropriate movement + exercise for healing stage)

O - optimism (associated with better outcomes)

V - vascularization (cardiovascular activity helps manage injuries)

E - exercise (to help restore mobility, strength + proprioception early after injury)

What does the acronym POLICE stand for?

protect, optimal loading, ice, compression, elevation

What injuries are X-rays used for?

fractures, dislocations (anything with bones)

What injuries are CT (computed tomography) used for?

cross-sectional areas, bone injuries that are complex (wrist, spine)

What injuries is U (ultra-sound) used for?

ligaments, tendons, other soft tissues

What injuries are MRI’s (magnetic resonance imaging) used for?

brain, detailed soft tissue images

What are the 3 stages of treatment + rehabilitation?

1) acute stage

2) rehabilitation stage

3) training stage

What is the difference in treatment during the acute stage for acute injuries and overuse injuries?

acute: PEACE/PRICE/POLICE

overuse: partial unloading of the injured structure, loading pattern must be altered

What occurs during the rehabilitation stage?

• monitor pain + swelling

• ensure normal ROM

• ensure normal strength

• ensure normal neuromuscular function

• ensure normal aerobic capacity

______________ is a pre-requisite for returning the athlete to normal technique because reduced ____________ limits the ability to do strength + other training.

Normal ROM, ROM

What is alternative training? Why is it important during the rehabilitation stage?

• maintaining general strength + endurance

• well performed alternative training will allow the athlete to return to sport sooner

What is the specific training part of the rehabilitation stage?

• training that affects the injured structures

• amount, intensity, frequency, duration + exercises depend on the injury

• highly repetitive training

• weekly consultation with a physiotherapist

Why is neuromuscular training important in the rehabilitation stage?

• painful conditions may result in reflex inhibitions → changes in movement patterns → unfavorable loading pattern → increased risk of reinjury

• acute ligament injuries may also result in reduced joint position sense + coordination → increased risk of reinjury 

• proprioceptive training + progressive strength training will improve this 

How much of an athlete’s original strength must be regained before being allowed to compete again?

85-90%

What occurs in the training stage?

• gradual transition from controlled rehabilitation exercises to sport specific training

• functional + sport specific testing to determine whether an athlete can tolerate sport specific training loads

What are the 3 elements of the return to sport continuum?

1. return to participation

2. return to sport

3. return to performance

What is the StARRT framework? What are the 3 steps of this framework?

strategic assessment of risk and risk tolerance

1) evaluation of health status

2) evaluation of participant risk

3) decision modification

What is the biopsychosocial model?

theoretical return to sport model that addresses the best interests of the athlete by looking at social/contextual, physical and psychological factors

What is the most common groin injury?

adductor related groin pain/injury

What is the structure of ligaments?

• dense bands of collagen tissue (collagen, elastin, proteoglycan, other proteins)

• vary in size, shape, orientation + location

What are the functions of ligaments?

• connect one bone to another (passive stabilization of joints)

• creep (stretching or deforming over time in response to sustained or repetitive stress)

• proprioceptive function

What is the response of ligaments to injury?

• ligament scars from healing have poor viscoelastic properties (reinjury risk = very high)

• decreased proprioception

If force causes more than a ______ change of length, permanent elongation starts (microdamage begins)

4%

What are the 3 types of ligaments?

1) intra-articular ligaments (inside joint capsule, e.g. cruciate ligaments of the knee)

2) extra-articular ligaments (outside of joint, e.g. calcaneofibular ligament)

3) capsular ligaments (surrounds a joint + has great healing potential, e.g. glenohumeral ligament)

How do ligaments adapt to training?

• adapt slowly to increased loading, but weaken very rapidly when immobilized 

• adapt to loading by increasing cross-sectional area

• normal everyday activity is sufficient to maintain mechanical properties

• systematic ligament training can increase ligament strength by 10-20%

Joint stability depends on the interaction between the ___________, ____________ and ____________ subsystems. 

passive, active, neural

What are the passive, active + neural subsystems in joint stability?

passive → consists of non-contractile connective tissues

active → controlled by the neural sub-system to provide dynamic joint stability

Mechanisms of ligament injuries?

acute → sudden overload, ligament is rapidly stretched out

overuse → repetitive loading, ligament is gradually stretched out 

What is hemarthrosis? What injuries usually cause hemarthrosis?

bleeding into the joint, ACL tear, peripheral meniscus tear, osteochondral injuries, fractures

The ACL has two bundles. What are they and what are their respective functions? Does the ACL have pain fibers?

• anteromedial bundle → resists tibial anterior translation

• posterolateral bundle → resists tibial rotation

• no pain fibers, but has proprioceptive fibers

What is the ACL injury mechanism?

heel strike (lots of force), then valgus knee movement (knee caves in)

What tests can be used to assess the ACL?

• anterior drawer test

• Lachman test

What are some ACL complications?

• osteochondral injury → articular cartilage + underlying bone are damaged in a joint

• ACL injury, meniscus tear

• unhappy triad (ACL, MCL, medial meniscus)

• osteoarthritis

What are some modifiable risk factors for ACL injuries?

• weak hip abductors + external rotators

• increased knee abduction moments during cutting + landing

What is a labrum injury?

injury to the fibrocartilage rim of a joint

What are the 2 types of bone tissue?

1) trabecular (spongy) bone → high porosity, cuboidal bones, flat bones, ends of long bones

2) cortical (compact) bone → low porosity, forms outer shell of long bones

How do bones adapt to training?

• physical training increases bone mass (bone mineral density) and is site specific

• bone mass increases are driven by dynamic rather than static loading (fast, impactful)

• only a short duration of loading is necessary

What is the difference in function between osteoclasts and osteoblasts?

osteoclasts → remove bone

osteoblasts → produce bone

What are the bone injury types? (7)

• traumatic fracture → closed or open

• pathological fracture → break due to weakness from osteoporosis or cancer)

• stress fracture → fatigue fracture

• bone contusion → acute traumatic bone injury without fracture

• osteitis → inflammation of bone

• periostitis → inflammation of periosteum

• osteochondral injury → articular cartilage + underlying bone

What is the difference between woven bone + lamellar bone?

woven (soft callus stage): 

• quickly formed, poorly organized

• first bone formed during the healing process

lamellar (hard callus + remodeling stages:

• slowly formed, highly organized

• replaces woven bone during the later stages of healing

What are some possible complications from fractures?

• infection (open fractures)

• delayed union, malunion, non-union

• acute compartment syndrome (pressure inside muscle compartment)

• osteonecrosis

• nerve injury

• vascular injury 

• osteoarthritis

• deep vein thrombosis + pulmonary embolism

What are the common mechanisms for bone stress injuries?

• high impulse forces

• repetitive bone loading

• high training volumes

What bones do bone stress injuries usually occur in?

highly loaded bones

• tibia, tarsals, lumbar spine, humerus, ulna

What is the difference between spondylolysis and spondylolisthesis?

fracture and slipping of vertebra, respectively

What is the continuum for spine injuries? What are the risk factors?

1) bone stress reaction (posterior element overuse syndrome)

2) fracture (spondylolysis)

3) slipping of vertebra (spondylolisthesis)

one can lead to the next (progressively worse) if not treated early or properly

• excessive extension + rotation loads

• improper technique

• hyperlordosis

What is medial tibial stress syndrome (MTSS)?

repetitive loading leads to periosteal inflammation along the tibia (diffuse pain)

What is a tibial stress fracture caused by?

running + jumping, focal pain

What is the myotendinous junction?

connection between tendon and muscle that is susceptible to injury