Athletic injuries 3336 Lectures

what is evidence based practice

• The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

• Incorporation of a clinician’s expertise and the best current research evidence with the patients values

• EBP = individual clinical expertise + best external evidence + patient values and expectations

why is evidence based practice important

• level of evidence varies greatly for the efficacy of much of what we do, much of it is based on perceived clinical success

• how do we accomplish this?

• 1. read all the scientific journals

• 2. more focused techniques (CAPs and CATs and infographics) critically appraised paper/topic

what are the steps in EBP (evidence based process) 1-6

1. ASSESS the patient: Start with the patient --a clinical problem or question arises from the care of the patient

2. ASK the question: Construct a well built clinical question derived from the case

3. ACQUIRE the evidence: Select the appropriate resource(s) and conduct a search

4. APPRAISE the evidence: Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)

5. APPLY: talk with the patient: Return to the patient --integrate that evidence with clinical expertise, patient preferences and apply it to practice

6. Self-evaluation: Evaluate your performance with this patient

grade practice recommendations

• A - strong recommendation

• B - recommendation

• C - option

• D - option

phases of healing

• Body goes through a predictable sequence of healing

• Our treatment choice will be dependent on the phase of healing

• We have minimal ability to speed up this process, but interfering with this sequence will slow both recovery and return to sport !

what are the 3 phases of healing

• inflammatory/destruction phase

• repair phase

• remodelling phase

inflammatory/destruction phase

• generally 1st 1-4 days

• cellular injury = altered metabolism + release of chemical mediators/proteins

• these cause the inflammation response?

• invasion by extrinsic cells

• phagocytosis (engulf bacteria, cellular debris)

primary damage

• damage at time of injury

• immediately irreversible

secondary damage

• Damage by released proteins

• Damage as a result of body processes swelling pinches off blood flow, without O2, cells die off

• Edema

• Damage due to decreased blood flow

• Decreased oxygen

• we want to drop metabolic rate of tissues: decreasing what they require can save them from dying

signs and symptoms of inflammation

• red

• swollen

• painful

• hot

• loss of function

repair (fibroblastic) phase

• 72 hours to 6 weeks

• proliferative and regenerative healing leading to formation of connective tissue scar (type 3 collagen)

• fibroplasia begins within first few days and inflammatory signs should be decreased

• growth of endothelial capillary buds into the wound is stimulated by lack of O2 (new growths allow increased O2 and BF)

• body lays down type 3 collagen (weak, delicate scar)

remodeling/maturation phase

• usually firm strong non-vascular scar by end of 3 weeks

• long term process - 3 weeks to years

• with increased stress and strain, the collagen changes to type 1 and begins realignment

wolfs law

• remodeling phase

• wolfs law - bone and soft tissue will respond to the physical demands placed on them, causing them to align along lines of tensile force progressively

• Critical that injured structures be exposed to progressively increasing loads

• Can work up to aggressive strengthening to facilitate remodeling and alignment

• Watch out for pain and swelling after exercise (dont want to do too much_

SOAP notes

• subjective

• objective

• analysis/assessment

• plan/program

subjective

• most important

• includes statements provided by patient regarding their symptoms

• from this history you develop assessment plan

subjective assessment: why

• most clinicians rate medical history as having greater diagnostic value than physical exam or results of lab

• interviewing one of hardest skills to master

subjective assessment: how

• used to develop a strat for further examination

• ask open ended questions

• active listening (eye contact, non verbal cues)

history- basic info needed

• primary complain

• history of injury

• MOI

• symptoms/pain profile

symptom

• organic manifestation which only patient is aware of, cant see symptoms

• immediate or delayed issues

• MSK injuries

• medical conditions

• red flags

what to ask for history

• What happened? When did it happen, Specific MOI

• Were you able to continue

• How did/does it feel

• Swelling –Yes, no, fast or slow? Fast (<4hrs) hemarthrosis, Slow (4-8 hrs) capsular swelling

• Describe your pain/other, Dull, Sharp, Shooting, bright, Numbness, tingling

objective

• signs - observable physical phenomenon indicative of a conditions presence

order of assessment

• subjective

• observation/visual inspection

• AROM

• PROM

• resisted

• neuro

• special tests

• palpation

observation/visual inspection

• We need to assess their general demeanor: Expression (pain, tired, angry) Tone of voice

• Posture: protective postures, guarding, stiff, etc. deformity asymmetry

• Obvious deformity/asymmetry

• Signs of inflammation: Swelling, redness, bruising

• quality of movement: How are they moving: Speed, Quality (smooth, jerky), Amount of movement

theory of selective tissue tension

• dr. James Cyriax developed

• method for locating and identifying a lesion by applying tensions selectively to each of the structures that might produce pain

• inert and contractile

• when tension is applied to an injures tissue, it will give rise to pain

inert

• ligaments

• bursa

• capsules

• fascia

• nerve roots

• dura mater

contractile tissues

• muscles

• tendons

• tenoperiosteal insertion

selective tissue tension: contractile tissue

• Increases in tension when the contracted tissue is both contracted or stretched

• Active motion in one direction and passive motion in the opposite

selective tissue tension: inert

• Increase in tension when they are stretched

• Will elicit pain on active and passive movement in one direction, only

AROM

• Movement assessment should begin with Active Range of motion (AROM)

• Active movements which cause pain do not specifically indicate either an inert or contractile lesion

• Muscle tension and joint movement causes contractile and inert tension to both occur!

• agonist contract

• antagonist stretch

• Inert tension in only one direction

what info does AROM give

• where they are sore

• willingness to move

• amount of movement

• available ROM

• give us clues on how we handle them

PROM: how

• patient must relax completely allowing therapist to move extremity

• look for limitation of ROM and presence of pain

• specific attention should be paid to how they feel at the end of ROM

• pain prior to end usually signifies inflammation or red flag

what info does PROM tell us

• Passive movements are used to detect lesions in inert tissues

• This stretching of the inert tissue will cause pain

• What is happening in surrounding contractile tissue during PROM?

• What does PROM alone tell us? Allows us to assess end feel

normal end feel

• soft tissue approximation - elbow knee flexion: soft spongy gradual painless stop when 2 muscle bellies meet

• bony: elbow extension - distinct abrupt endpoint/unyielding, painless

• capsular: hip rotation - abrupt firm endpoint with a little give, leathery feeling

abnormal end feel

• springy block - internal issue of joint - rebound at end or some point throughout ROM, bouncy

• spasm/stretch - hamstrings - involuntary contraction that prevents motion secondary to pain (guarding), more rubbery feel prior to expected end of range

• abnormal capsular - occurs prior to expected end of range

• empty - did not reach end feel - considerable pain is produced by movement, no mechanical resistance detected, significant soft tissue injury, bursitis, or neoplasm

what do we need for resisted testing

• Contraction of only target tissue stretch

• No stretch on antagonist (isometric movement, nothing on stretch)

• No movement through joint or stretch on surrounding inert tissues

info gained from resisted testing

• Will tell us about pain in a contractile tissue

• Will also give us an indication of how the nerve is working/how well it contracts

interpreting resisted movements

decision time

neurological testing

• reflexes

• sensation

• key muscles

reflexes

• biceps/brachioradialis: C5-C6

• triceps: C7-C8

• knee jerk: L3

• achilles: S1

sensation/dermatomes

• Cutaneous area receiving the greater part of its innervation from a single spinal nerve

myotomes

• A muscle receiving the greater part of its innervation from a single spinal nerve

• Isometric contraction held for at least 5 seconds

• fatigable weakness vs. no strength for peripheral nerve

special tests

• special tests hlp in the differential diagnosis of patients injury

• includes manual muscle testing, specific muscle (strength through ROM) and ligament test (laxity, end point, pain)

• these are an indication of how bad it is

• they allow us to grade the injury

• diff than isometric resistance because they move through ROM

manual muscle testing (oxford scale)

0 - Nothing happens

1 - Twitch or flicker only. No movement

2 - Able to move but not against gravity

3 - Able to move the joint fully against gravity

4 - Movement with some resistance

5 - Full movement with resistance equal to opposite side

analysis/assessment

• Hopefully at this point we have an idea if it is contractile, inert or both.

• After neuro, special tests and palpation, we should have a good idea of the degree of injury and contribution by each structure.

• Based on these findings we form a clinical opinion or diagnosis- this is your analysis/assessment

• make a problem list, (pain, decreased ROM), then make goals (decrease pain increase ROM)

the bodys response to hot and cold depends on":

• media being applied

• conductivity of area

• length of exposure time

hot and cold depends on media being applied

• ice, cold water immersion, sprays

• moist heat (better for deep tissues, dry heat (better tolerated), ultra sound (mechanical)

hot and cold depends on conductivity of the area

• High water content in tissue means > change

• Joints>muscle

• Decreased conductivity through fat

hot and cold depends on length of exposure time

• With ice, longer not always better prevents reflex vasodilation

• Bleakley et al (2006) Cold 10 on -10 off-10 on is superior to 20 min on. Less pain in first week no change after that

• With heat, the body will reach a peak heat in in 5-7 minutes and

physiological responses to hot and cold (chart)

the case for using ice

good for pain:

• C not myelinated!

• For every 10 drop in temp. you cool a nerve, you decrease conduction velocity.

• With a 4 degree cooling you knock out C fibers

when combined with exercise

• Demonstrated better ability to decrease heat vs. swelling

• Significant improvement in function vs. functional training

ice shown to maintain cell viability after injury

• ⇩chemical reactions +⇩ ATP demand= ⇩cellular collapse (anti-oxidant)

the case against using ice

The inflammatory or destruction phase of healing is a necessary stage

• We need the athlete to go through the stage, but not get stuck there.

There is evidence that one early ice one treatment may slow down the first 3-7 healing over days

• More necrosis in ice group at day 3 but equal at day 7

• Less neutrophils day 1 and more day 3 in ice group

• Less macrophages at day 1 and 3 with more at day 7 in ice group

what are the goals for inflammation/destruction phase goals

what is happening at the tissue level

• red, hot, swollen, painful

• tissue inflammation/destruction: primary and secondary

based on that, what are our immediate goals

• optimize healing environment

• palliate pain

• decrease swelling

PEACE and LOVE and POLICE

protection (PEACE and LOVE and POLICE)

• Protection and rest after injury are supported by interventions that shield, unload and/or prevent joint movement for various periods.

• Recent animal models show that short periods of unloading are required after acute soft tissue injury and that aggressive ambulation or exercise should be avoided.

• Remember our goal: control inflammation and prevent further injury

loading (PEACE and LOVE POLICE)

• Optimal loading means replacing rest with a balanced incremental rehabilitation program where early activity encourages early recovery

• This includes safe cardio, which will increase blood flow. - Vascularization

• Injuries vary, so there is no single one sized fits all strategy or dosage.

• Functional rehabilitation of ankle sprain, which involves early weight-bearing usually with an external support, is superior to cast immobilization for most types of sprain severity.

compression (PEACE and LOVE, POLICE)

• Compression has been shown to decrease local edema a pad

• Applying a pad or ice bag underneath will increase pressure over the injured area

• Helps disperse edema and makes it more available for absorption, by limiting the physical space is able to occupy it.

• An elastic bandage pulled tight can limit blood flow by up to 95% within a few seconds

elevation (POLICE and PEACE and LOVE)

• No reduction of blood flow until the injured area is at least 30 cm above the heart

• At 50 cm flow is 80% of normal

• At 70 cm flow is 65% of normal

• Think about what people usually do with their sprained ankle

optimism and education (PEACE and LOVE)

• Let them know:

• Why they are doing things

• How you will measure their progress goals

• Set goals with your patient and share their results

• By setting and achieving small goals you will condition their brain to be positive and confident

• This ”buy-in” will continue to pay dividends as they will work harder and stay motivated

• Teach them that rehabilitation is an active process

icing - clinical hack

Best cooling effect comes from ice mixed with water in plastic bag directly on skin

• Fill bag with ice chips or ice and cold water.

• Take air out of the bag, so the ice molds to the skin

• Mold ice bag to skin

Compression over top is best

• Use of towel, wet or dry compression bandage decreases conductivity

Explain to the athlete what they will feel

• CBAN

Timing- 10 on, 10 off, 10 on

repair/fibroblastic phase goals

What is happening at the tissue level? Based on that, what are our immediate goals?

• Protect the tissue and idealize healing environment increase blood flow

• increase blood flow**

• Before the end of this stage:

• Idealize ROM** (they feel better at this stage)

• Begin gentle strengthening **= helped by application of heat

heating - clinical hack

• Most clinics will use moist heat from hot packs kept in hydrocollators full of hot water 160° to 165°F (71°–74°C)

• 1. Remove hot pack with tongs and place in terrycloth slip-cover.

• 2. Add one folded towel and apply to patient (Terrycloth slip-cover is equal to 4-6 layers of towel. If not available add 6-8 layers of towel under the hot pack)

• 3. Place on patient and let them know that it will take a few minutes to feel the heat.

• 4. Direct them: • Not to remove towels at this time • That they need to let you know if it feels too hot

• 5. Check back in 5 minutes and add or remove layers as needed

• Total time 10-20 minutes depending on depth

ankle injuries

• fractures

• sprains

• strains

ankle sprains

• most common injury in sports

• 85% lateral

• 5% syndesmosis

• 10% medial

ankle stability comes from (1-3)

1. shape of bones

2. passive stabilizers (capsules and ligaments)

3. dynamic stabilizers (muscles that cross the joint)

the bones of the ankle (talocrural joint)

• The ankle mortice is a U-shaped structure making up the top of the talocrural joint

• Made up of:

• Lower end of tibia

• Medial malleolus (Tibia)

• Lateral malleolus (Fibula)

• Lateral malleolus longer and more posterior than medial

the bones of the ankle ( the talus)

• Has no muscles that attach to it

• Very extensive articular surface

• Convex on top and concave on the sides

• Allows it to better articulate with the Tibia and Fibula anteriorly

• Trochlear surface (top) is wider anteriorly than posteriorly

• With dorsiflexion the wider portion lies between the malleoli (Tibia and Fibula) might have more fratcures or high ankle sprains in dorsiflexion

• What could that mean for stability? more stable in dorsiflexion

bones of the ankle (fibula)

with dorsiflexion

• Fibula externally rotates and it moves superiorly

• External rotation of fibula increases the tension in the structures that hold the tibia and fibula together

• Opposite happens in plantar flexion

passive stabilizers - capsule and ligaments

Ankle is surrounded by fibrous capsule

• thin and weak anteriorly and posteriorly to allow movement (dorsiflexion and plantarflexion)

• Talocrural joint is further strengthened medially and laterally by ligaments

• Some communicate (ATFL, PTFL , deep Deltoid) with the capsule, while others do not. more swelling with capsula

passive stabilizers - lateral ankle

ATFL

• Communicates with/is within capsule (Increase swelling)

• Considered the weakest of the lateral ligaments plantarflexion

• Increased strain in plantarflexion and inversion

CFL

• Extracapsular capsular ligament

• Provides stability to the lateral talocrural joint as neutral/dorsiflexion it moves into neutral/dorsiflexion

• Up to 3.5 x stronger than the ATFL

PTFL

• Primarily supports talocrural joint in • May provide secondary support to the talocrural joint throughout range

surface anatomy hacks: how to find ATFL, CFL, PTFL

ATFL

• slide anteriorly and medially off of the distal tip of the lateral malleolus

CFL

• slide inferiorly and slightly posteriorly off of the lateral malleolus

PTFL

• slide posteriorly off of the posterior aspect of the distal tip

passive stabilizers of ankle: deltoid ligament

Deltoid ligament- limits talar/subtalar abduction or eversion

• Very broad from front to back

• Deep portion communicates with capsule

• Described as up to 6 bands with considerable variability anatomically

• Anterior part is tight in plantar flexion

• Middle portion in neutral

• Posterior portion tight in Dorsiflexion

Surface Anatomy Hack- Slide off of the medial malleolus with your thumb and finger. Notice how the separate. This is the broad Deltoid ligament

ligament sprains (percentages of range)

• 0-4 % strain is physiological range

• Pathological irreversible ligament elongation occurs after 4% strain

• As this continues intra and inter- molecular cross-links are disrupted until macroscopic failure is clinically evident

• Early part = mild/ grade 1 < 50 %

• 2nd part= grade 2 50-80% fiber disruption

• Obvious clinical laxity 3rd part=Grade 3. Rupture zone 80-100%

dynamic stabilizers of ankle

assessment tips

what does an ankle sprain look and sound like

• MOI: inversion or eversion, plantarflexed or dorsiflexed

• were you able to continue (make sure it isnt fractured)

• did you hear or feel a pop or crack (fracture/significant ligament injury)

observation: ankle sprain (what are we looking for)

• swelling

• obvious deformity (lower leg, ankle, foot)

• weight bearing (static - equal pressure on front and back or side to side, dynamic - guarded/painful movement)

Ottawa ankle rules

what test is sued to rule out an ankle fracture

• external rotation test for fibular fracture

• pry open mortis putting pressure on lateral side of ankle

• send for leg xray if pain

• this is an INDIRECT test for fracture

what is considered normal ankle range for movements

• Plantar flexion- 50 degrees

• Dorsiflexion- 20 degrees

• Inversion- 30-35 degrees

• Eversion- 15-20 degrees

what are the special tests for ankle ligaments

• anterior drawer

• talar tilt

• external rotation (already done and was positive

• ottawa ankle rules (already done and was positive)

anterior drawer test for ankle

• Used to determine damage to Anterior Talofibular Ligament, primarily

• Tested in slight plantarflexion

• A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point

• Grade ligaments by assessing pain, laxity and endpoint

talar tilt test

• Performed to determine extent of injury to the calcaneofibular ligament (inversion) or Deltoid ligament (eversion )

• With foot at 90 degrees, the calcaneus is inverted . Pain and excessive motion indicates injury to Calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments

• If the calcaneus is everted deltoid , the deltoid ligament is tested

special tests for contractile tissue does what

• allows us to grade injury

• manual muscle testing (oxford scale)

• resisted tells us if a contracted tissue is injured

• manual muscle testing tells us how bad it is

symptoms and signs of ATFL sprain

most common sprain

symptoms

• inversion in plantar flexion MOI

• Pain on the lateral side of the ankle, anterior to malleolus

• May report instability with high grade sprain

signs

• Significant swelling

• Pain with active and passive inversion in plantar flexion

• Pain, laxity, endpoint? Findings with Anterior Draw Test

• Possible pain with resisted eversion (dynamic stabilizers)

• Pain on palpation over the Anterior Talofibular ligament

symptoms and signs of CFL sprain

3.5x stronger than ATFL

symptoms

• Inversion mechanism of injury in neutral to slight dorsiflexion

• Pain on the lateral side of the ankle inferior to the malleolus

• May report instability with high grade sprain

signs

• May not have significant swelling if injured in isolation

• Pain with active and passive inversion in neutral to slight dorsiflexion

• Pain, laxity, endpoint? Findings with talar tilt (inversion)

• Possible pain with resisted eversion (dynamic stabilizers)

• Pain on palpation over the CFL ligament

symptoms and signs of deltoid ligament sprain

least common sprain

Stability of the medial ankle depends upon the Deltoid Ligament and supported by lateral malleolus.

symptoms

• eversion MOI

• Pain on the medial side of the ankle

• May report instability with high grade sprain

signs

• Pain with active and passive eversion

• Pain, laxity, endpoint? Findings with Talar tilt (eversion)

• Possible pain with resisted inversion (dynamic stabilizers)

• May have increased pronation - Navicular dropped?

• Pain on palpation over the deltoid ligament

ankle sprain prognostic indicators

• Higher age, poor weightbearing status and higher grade of injury at baseline are associated with poorer outcomes.

• Not achieving full ROM within 2 weeks may be a sign of accompanying injury.

• Medial pain on palpation (bone bruise) and pain with dorsiflexion at week 4 were prognostic of poorer function at 4 months

ankle sprain treatment in acute phase

• NSAIDs to reduce pain and enhance self-reported function in conjunction with ice, compression, and elevation early in the rehabilitation process.

• Early return to motion over immobilization

• protect injured tissue

• maintain ROM to uninjured tissue

• Ice, compression, elevation

• protected gait (crutches)

ankle sprain treatment in subacute repair phase

• Strong evidence for using exercise to prevent future sprains • Including balance and coordination training as soon as weight bearing can be tolerated.

• Proprioceptive and neuromuscular interventions after ankle injuries can be effective for the prevention of recurrent injuries.

• Limited evidence for use of manual therapy

• Strong evidence for use of external support for return to activity

• heat

• Begin ROM ex. and idealize by 2 weeks

• Maintain strength of uninjured tissue.

• Begin gentle strengthening of injured tissue, once ROM is achieved

• increase weight bearing

• Begin proprioception exercise

ankle sprain treatment in late repair/remodeling

• idealize strength of dynamic stabilizers through full range

• Continue with balance and coordination training

• Repetition in practice helps develop effective movement solutions

• Aids in avoidance of reinjury as the cognitive load decreases and we “tune” perception and action

• This will allow for improved agility and power

• Jumping, cutting, push-off, etc

• Decide on return to play taping or bracing x 1 year