Sport Inj Test 1

What are the steps in the healing process?

• inflammation

• repair or proliferative

• remodelling or maturation

What is inflammation?

generic response to tissue threat

sounding alarm to let the immune system know the body is experiencing some kind of threat

What does Inflammation release?

Release Biochemical Mediators

How long can acute inflammation last?

last up to 72 hours

Where are biochemical mediators released from?

• Mast cells

• Local blood vessels near inflammation

What are the biochemical mediators?

• histamine

• prostaglandin

• bradykinin

What do biochemical mediators do?

• potent vasodilators

• increase vascular permeability

• make nerve endings more sensitive to threatening stimuli

  • injured and non injured area

What does SHARP stand for?

• S= Swelling

• H= Heat

• A = Altered function

• R = Redness

• P = Pain

Is inflammation swelling?

NO

inflammation is a process, NOT SWELLING

What is edema?

fluid leaks from vessels into tissues

can be localized or wide spread

What is hematoma?

collection of blood that escapes the vessels and sometimes can present as a bruise

what is hemarthrosis?

blood into a joint cavity

what is joint effusion?

when the synovial membrane inside a joint creates an excessive amount of synovial fluid

What is Swelling?

• collection of fluid

• can remain present after the inflammation process is done

what is Heat and Redness?

when the injury area produces heat and some colour discolouration can occur

What is Altered Function?

• Negative impact on ability to walk or support own body weight or play sport

• related to pain, lack of stability in joint, altered motor patterns

What is pain?

product of chemicals coming in and stimulating nociceptors, making them more sensitive

What is the repair/proliferative stage?

clean up any debris, such as dead tissue leftover from injury

build a foundation that will temporarily close the gap between the injured ends of muscle, ligaments, or bone

when does the repair stage begin?

starts around 2 days post injury while inflammatory stage is slowing down

what are Macrophages?

big eaters who clean up the injury area

what the process done by Macrophages called?

phagocytosis

What are Fibroblasts?

• build a new foundation

• create and lay down new collagen

  • tends to be weaker, less organized form, some structural integrity but not a lot

• build new fragile blood vessels

What is Granulation Tissue?

Underneath scab are fragile new collagen and blood vessels

How does the repair/proliferative stage present clinically?

• patient feels they improved but the underlying structure is weak and will easily fail again

• can feel better gain structural integrity, and feel ready for activity, but the tissue is not fully confident yet

What is the remodelling or maturation stage?

• Primary goal to develop end product

• what to progressively challenge the tissue so they build into the shape and strength needed

when does the remodelling/maturation stage begin?

3 weeks post injury and can last up to 2 years

what is the physiology story of the remodelling/maturation stage?

• no net gain in collagen content because balance between new high-quality well organized collagen and the breakdown of the original foundation

• blood vessels more stable, new growth comes to a stop

how does the remodelling/maturation stage present clinically?

progressively introduce more challenging and sport-specific skills as musculature becomes stronger and develops more endurance

What are the steps in the injury assessment process?

1. History

2. Observation

3. ROM

4. Resistance

5. Special Tests

6. Palpation

What are the steps in the History portion of injury assessment?

1. Introduction

2. Injury Story

3. Clinical Presentation

4. Facts and details of the person

What do you want to focus on during the introduction of the History Step?

Introduce yourself, ask the person their name and then guide them to tell you about the incident

What do you want to focus on during the Injury Story of the History Step?

• Focus on HOW mechanics of story

• understand the timeline of injury

• want to determine if acute or chronic

What do you want to focus on during the Clinical Presentation of the History Step?

• focus on the consequences of injury

• Ask about signs and symptoms, and functional impacts

What do you want to focus on during the Person of the History Step?

• focus on previous history, general health, current PA demands, including sport and daily life activity

• ask questions about future ideal state

• look backwards to find factors that could contribute to current issue

What are the steps in the Observation portion of injury assessment?

• consent

• qualitative and bilateral

  • test both sides, injured vs non injured

• swelling

• deformity

• discolouration

  • bruising, lack of blood, pale, etc

What type of tests do you run during ROM of injury assessment?

• Active range tests

• Passive range tests

What is an Active range tests?

person with injury does all the work

they actively contract muscles to show the ROM they have

What is a Passive range test?

the tester takes the individuals joint through ROMs

no muscle activity required

what do you want to focus on during the ROM portion of the injury assessment?

want to see if ROM is…

• limited

• excessive

• painful

What 2 questions do we want to ask when interpreting ROM assessments?

1. Does that motion tear apart or pull part an injured structure? [could be ligament, muscle or tendon]

2. The test performed, is it asking an injured structure to contract? [only a muscle]

What is the Resistance portion of injury assessment?

• Resistance ISOMETRIC tests

• mostly done during mid-range, don’t do anything end range b/c muscle strongest during mid-range

What are the categories of the Resistance test?

Categories go from Level 0 to level 5

What is Level 0 of the resistance test?

• cannot contract at all

• doesn’t happen most of the time

• would show up if had significant neurological injury

What is Level 1 of the resistance test?

• flicker of contraction but not enough to create any motion at the joint

What is Level 2 of the resistance test?

• enough muscle activation for joint to move but not enough to actually overcome gravity

What is Level 3 of the resistance test?

• can overcome gravity

• max effort is can hold against gravity

What is Level 4 of the resistance test?

• can meet some resistance and overcome gravity

• has A LOT of variability

  • injured side may be somewhat weaker than the uninjured side, could be a lot or little difference

What is Level 5 of the resistance test?

• Strength is equal to uninjured side

• no limitations at all

What are the Special Tests and Palpation portion of injury assessment?

• Narrow down to index of suspicion [IOS]

• reproduce mechanism of injury [MOI]

• reproduce symptoms

• no test is perfect

• know your anatomy

What is the MOI of Lateral Ankle Sprain?

Excessive inversion of the foot

What is the sound or sensation associated with Lateral Ankle Sprain?

Felt or heard a pop

tissue may have failed

Where is the pain distributed for Lateral Ankle Sprain?

a bit Distal to Lateral malleolus

What is the swelling and bruising distribution for Lateral Ankle Sprain?

• Bruising could happen due to broken blood vessels or damage to something with blood supply

• Swelling could move down the foot due to gravity pulling it down

What structures could be injured in a Lateral Ankle sprain?

• ATF [anterior talo-fibular ligament]

• CF [calcanofibular ligament]

• PTF [posterior talo-fibular ligament]

• Peroneus longus tendon

What happens if you overload a ligament?

load the ligament fast and hard enough with enough stress applied, it will go OVER its capacity to stop you

What is the plastic region for ligaments?

the region when change the shape of collagen, deform the ligament permanently

How many grades are there for ligament sprins?

• Grade 1

• Grade 2

• Grade 3

What is a Grade 1 ligament sprain?

• hasn’t popped or failed

• everything intact

• maybe some deformity or stretched out a bit

• a FEW tore ligament fibres

What is a Grade 2 ligament sprain?

• Some collagens tore

• when tested, might feel there is still some resistance

• might see some bruising

• More Severe PARTIAL tear of the ligament

What is a Grade 3 Ligament Sprain?

• every price or vary nearly every piece of collagen tore

• bruising for sure

• COMPLETE tear of the ligament

What is the MOI for High Ankle Sprain?

heavy loaded dorsiflexion and external rotation, opens up the joint and sprains the ligaments of support

Why does heavy loaded dorsiflexion and rotation cause a High Ankle Sprain?

With heavy dorsiflexion, it puts the widest part of the talus into the mortis [seat], and the external rotation forces the fibula away from the tibia

What is the pain distribution for a High Ankle Sprain?

Around the front of the lateral malleolus, front of the ankle but feels deep

What is the swelling distribution for a High Ankle Sprain?

can be broad, but can also be localized to area

what are the weight bearing status for High Ankle Sprain?

• NWB [none]

• PWB [partial]

• FWB [full]

What structures can be injured in a High Ankle Sprain?

• AiTFL [anterior tibiofibular ligament] - PRIMARY]

• PiTFL [posterior tibiofibular ligament]

• TTF [transverse tibiofibular ligament]

• Extensor Digitorium Longus[EDL]?

What is the MOI of Turf Toe?

hyper extension at MTP joint of toe caused by axial loading of heel in dorsiflexion

what factors can increase risk of Turf Toe?

• Artificial turf

• Flexible shoes

How can flexible shoes affect turf toe?

wearing flexible shoes allows the foot to go into different ROM

what is the pain, swelling and bruising location for Turf Toe?

Toe really sore at MTP joint… pain, swelling, bruising at that joint

What structure can be injured during Turf Toe?

Flexor Hallucis Longus [FHL], MTP joint

What order of foot/ankle injuries is most difficult to weight bear in?

1. High ankle sprain

2. Turf Toe

3. Lateral Ankle sprain

What are the four ROM should you test when evaluating an ankle injury?

• DF

• PF

• INV

• EV

what are the four ROM you should test when evaluating a toe injury?

• Toe flex

• Toe ext

• DF

• PF

When is pain most likely to show up?

• when injured muscle contracts

• when injured muscle pulls apart

• when injured joint surface is compressed

which ROM test are most likely to be painful for an ATFL sprain?

Active and Passive plantar-flexion and inversion

why would resisted test be less likely to be painful than active and passive tests?

when muscle is in mid-length that when it is the strongest

which tests are most likely to be painful for a high ankle sprain?

active and passive dorsiflexion

which active tests are most likely to be painful for peroneus longus strain?

plantarflexion and eversion

Which passive test are most likely to be painful for peroneus longus strain

Dorsiflexion and inversion

which resisted tests are most likely to be painful for a peroneus longus strain?

plantarflexion and eversion

What does PEACE stand for?

• P = Protect

• E = Elevate

• A = Avoid anti-inflammatory meds

• C = Compress

• E = Elevate

Who is likely to have Plantar Fasciopathy?

• Distance Runners

• Sedentary, middle age individuals with a high BMI

Where is the localized pain for Plantar Fasciopathy?

• Primarily on the heel but leans heavily on the medial side on the calcaneus

• has the capacity to spread into the medial arch of foot

What is the pain timing of Plantar Fasciopathy?

• terrible first thing in the morning

• also bad when you are seated or sedentary for extended periods of time and then load the plantar fascia

What happens and when does plantar fasciopathy occur?

• doesnt just happen one day

• could be happening on and off for weeks or months

What is the Windlass Mechanism ?

Plantar fascia passively lifts the arch, supinated the foot to create rigid lever when pushing off whenever toe goes into extension [i.e. running]

What are potential factors/MOI of Plantar Fasciopathy?

• Excessive foot pronation [flat foot]

• BMI > 30 KG/m² [obese range]

• Plantar flexor tightness tightness

• < 0 degree Dorsiflexion [limited DF range due to tight plantarflexors]

What does MTSS stand for?

Medial Tibial Stress Syndrome

[AKA Shin Splints]

Who is likely to have MTSS?

• Someone who has to absorb energy on impact in some way, has to do a lot of energy absorption

• Runners, jumper type sports, etc

When does MTSS occur?

• has insidious onset

• sneaks in overtime, a little sore don’t notice it all the time until it is constant

is MTSS exercised induced?

YES

during the sport or training, will notice it and will bother you [have to be jumping or landing]

In what area is the focus of pain for MTSS?

• Distal posteromedial tibial border, > 5cm [at least 5 cm]

  • posterior side of the medial malleolus

What are some signs and symptoms you should watch out for MTSS?

• Cramping, burning, pressure

• Neurological symptoms

  • pins, needles, numbness

• vascular dysfunction

  • pale, discolouration (red, blue, white)

• Compartment Syndrome

What is Compartment Syndrome?

When fascia surrounding muscle group squeezes down on the muscles and builds excessive pressure

What are the two hypotheses of MTSS?

• Periostitis

• Bone Stress

What is Periostitis?

• inflammation that is occurring in the periosteum of the tibia

what is periosteum?

• layer of connective tissue that wraps the bone,

• sensitive thin membrane

What causes Periostitis?

• caused due to soft tissues in the area pulling on the periosteum when running, jumping, landing, etc

What is bone stress?

response related to impact loading and bony integrity

• type of impact load the tibia is taking when you land on the ground and how is the bone is reacting