atep exam 2

Thermoregulation

Body prefers to operate between about 95-100 degrees F.

Below or Above that range implies thermoregulation is impaired.

Once impaired, performance declines, decision making is poor and risk of death occurs.

Heat Production

Exercise results in increased blood flow to deliver nutrients and energy to working muscles.

• The harder you exercise, the more heat you produce

• At high intensity, about 25% of this energy is used to perform your activity, while the other 75% of the energy is heat that the body has to dissipate (get rid of)

Heat Gain from Radiation

About 20% of heat gained is from the sun.

• Directly from the sun and reflectively off the ground

Heat Dissipation Mechanism

As the body heats up, blood vessels dilate to increase circulation.

• This stimulates the sweat glands to secret sweat (water taken from blood plasma)

• As the body heats up, blood vessels dilate (expand), to increase circulation and bring the warm blood closer to the surface of the skin

• This stimulates the sweat glands to secret sweat (water taken from blood plasma)

• Sweat cools the body through evaporation. This is the most effective type of cooling. We evaporate water off our skin and through respiration

  • Evaporation is affected by relative humidity – over 65%, will have a hard time evaporating

  • Also affected by wind speed – convection (circulating air) helps increase evaporation

  • Also affect by temperature – conduction (cooler temps speed evaporation)

• As water is taken out of blood plasma, blood volume begins to drop which leads to increased risk of heat illnesses (and why drinking water helps to mitigate risk)

Heat Rash

Red, raised bumps, prickling or tingling sensation; associated with unevaporated sweat.

Remove wet clothing, towel off often

Heat Syncope

Rapid fatigue during overexposure to heat.

• Peripheral vasodilation leads to dizziness, fainting and nausea

• Lay athlete down in cool area, replace fluids

Exertional Heat Cramps

Muscle spasms, mainly in legs, abs, arms, related to dehydration and electrolyte imbalance.

• Has been related to dehydration and electrolyte imbalance (especially low on sodium)

• Current thoughts are cramps more related to fatigue and muscle overload so they occur in muscles more stressed (calves, hams, quads, abs), less related to dehydration

• Ice massage, stretch, drink fluids – preferably a sports drink

Exertional Heat Exhaustion

Athlete becomes dehydrated to the point that they cannot continue intense exercise.Mildly elevated core temperature (below 105)

• NO CNS dysfunction

• Excessive thirst, profuse sweating, pale skin (?), stomach cramps with nausea, diarrhea, headache

• Remove from play, place in cool environment, replace fluids, elevate legs, may need an IV

• MONITOR VITAL SIGNS, should recover quickly

Exertional Heat Stroke

Thermoregulatory failure, core temperature 105°F or higher.

• Body loses ability to dissipate heat through sweating

• Can occur suddenly, without warning

• Altered consciousness, confusion, irritable, altered mental status

• Shallow, fast breathing, rapid/strong pulse, low BP, nausea, vomiting, headache, dizziness

• COOL BODY DOWN ASAP, immerse in COLD water, activate EMS system

• Cooling Options

  • Cool to 102F on the field BEFORE transporting via EMS

Acute Exertional Rhabdomyolysis

Intense exercise causes catabolic destruction of muscle tissue.

• Gradual onset of muscle weakness, swelling, pain, dark urine, renal dysfunction/failure, death

• Muscle pain without muscle cramping

• Sickle-cell trait increases risk

Hyponatremia

Abnormally low concentration of sodium in blood.

• Either not consuming enough sodium OR Dilution through drinking too much water

• Headache, nausea, vomiting, swelling of hands and feet, lethargy

• Associated with prolonged exercise bouts (greater than 3 hours)

• Prevention: include sodium in sports drinks

Hydration Loss During Exercise

• Lose ~1.5 liters of sweat per hour of exercise

• Sweat concentrations vary (salty vs. watery)

• 1-2% drop in body weight impairs cardiovascular performance and decision making, 3-5% drop impairs sport skills and power.

• Urine specific gravity – can be measured with a dip stick or a refractometer (light)

• Thirst is not a good indicator, urine color is

• Encourage water consumption before, during and after

Hydration Recommendations

• About 2 cups (17-20 oz) 2-3 hours before

• 8 oz about 20-30 min before

• 4-6 oz every 15-20 min during (will vary depending on weather and sweat rates)

• 20-24oz per pound lost post exercise

• Sports drinks vs. water? Salty sweat…..more sodium!

  • Water, carbohydrates, electrolytes (sodium)

  • How long is the training/competition session?

Wet Bulb Globe Temperature (WBGT)

Includes dry bulb temperature, wet bulb temperature, and globe temperature.

• Dry bulb temperature (air temp)

• Wet bulb temperature (humidity, wind)

• Globe temperature (solar and wind)

• Temperature, humidity, wind, sun intensity

Hypothermia

Body's heat loss to environment exceeds heat production resulting in impaired neuromuscular response.Small drop in core temp. (below 95F) induces impairment, fatigue (which slows heat production.

• Contributing factors:

  • wind, dampness, cold

  • sport does not require heavy protective clothing

  • warm-up, stand around

  • 65% heat loss through radiation, mostly around head and neck (wear a hat and scarf)

  • 20% heat loss through evaporation (skin and respiratory tract)

• Preventing Hypothermia

  • Appropriate clothing

    • Fabrics (wool, wicking, layers)

  • Proper warm-up

  • Conditioning

  • Fluids

  • Monitor the weather

Frostnip

Firm, cold, red, tingling skin, tips of nose, ears, chin, fingers, toes (painful).

Frostbite

Superficial and Deep; both present as pale, hard, cold, waxy skin; deep involves deeper tissue layers.

Lightning deaths

24,000 deaths/year (global), only ~20 deaths/year (USA), 240,000 injuries/year.

Lightning

• 69% of lightning survivors have some degree of transient lower extremity paralysis.

• 72% survivors have LOC, 86% report confusion and amnesia

• Trauma due to high temp of the strike (up to 50,0000F – direct strike)

• Injury from electromechanical forces

• Electrical storms routinely produce 2,000 to 200,000 Amps

  • .75 mA to 50 mA will cause ventricular fibrillation

  • Larger currents may cause transient asystole

• Appear cold, clammy, and pulseless

Types of lightning strikes

Direct, Side strike (flash or splash), Ground.

Direct strike

Person is primary point of contact (most fatal).

• Increase your odds when in contact with metal (golf club, umbrella, metal bleachers)

Side strike

Hits another person or object and then the victim.

Ground strike

Hits ground and travels along ground or through puddles to victim(s).

Flash to Bang Theory

Time in seconds from visual sighting of lightning until thunder is heard; divide by 5 to calculate miles away.

• Watch closely if count is 30, leave immediately if count is 15 or less

  • Imminent danger if hair stands on ends

  • Wait 30 min. after last sound of thunder before resuming play

JMU Weather system

SINGLE 15-second air horn blast - RED ALERT (7 miles away), THREE 5-second air horn blasts - ALL CLEAR.

Altitude effects on performance

Challenges athlete's oxygen transport system; at altitude, air has decreased oxygen saturation.

Acute Mountain Sickness

Headache, nausea, vomiting, sleep disturbances, disequilibrium; most common.

High Altitude Pulmonary Edema

Severe form of AMS; swelling in and around lungs.

High Altitude Cerebral Edema

Swelling around brain.

Sickle Cell Trait Reaction

Decreased oxygen causes red blood cells to 'sickle'; trait has no health consequences at normal oxygen saturation.

Air Pollution effects

Ozone, Nitrogen Dioxide, Sulfur Dioxide, Particulate Matter impact respiratory tract by decreasing functional capacity and increasing risk of infections.

Jet Lag

Travel disrupts natural patterns of metabolism, sleep, hormones (immune system).

• Circadian Dysrhythmia

• Results in fatigue, headache, digestive problems (bowel habits), HR and hormones 

• Easier to go east to west

Mechanism of Injury

The cause of an injury or disease; Acute - has a known mechanism, Overuse - may not have a known mechanism– often called chronic (long onset OR long duration)

Pathology

Structural and functional changes that result from the injury process.

Symptom

Patient's perception of change in body or function - often subjective.

Sign

Objective finding from an examination, more definitive finding of the injury.

Diagnosis

Name of a specific condition; differential diagnosis is a list of possible injuries.

Prognosis

A prediction of the course of the condition, what to expect as it heals.

Sequela

A condition following or resulting from an injury (or disease), complication.

Syndrome

A group of symptoms and signs that combined indicate an injury or disease.

HOPS

Overview - 4 general steps: History, Observation, Palpation, Special Tests.

Palpation

• Palpation = feeling with the fingers and hands during an evaluation

• What are you palpating for?

  • Pain, skin temp., abnormalities (compared to other side), sensation, swelling

• Must KNOW ANATOMY

• SYSTEMATIC APPROACH:

  • Start away from the injured site working towards

  • Start with light pressure, gradually increasing

  • Bony structures followed by soft tissue (or vice versa)?

• Muscle, tendon, bone, ligament

special tests- Range of Motion Assessment (ROM)

• Range of Motion Assessment

  • AROM – movement is performed by the patient contracting their muscles – assess contractile tissue

  • PROM- movement performed by the examiner with the patient completely relaxed

•  Looking for smooth, equal movement on both sides, WNL

• Goniometry measurements, inclinometer

special tests- Strength Assessment

• Strength Assessment (Manual Muscle Testing, Resisted ROM)

  • KNOW muscle function

  • MMT – 2 methods

    • Isometric (break) test is performed typically in mid-range and assesses patients ability to contract the muscle

    • Isotonic (ROM) testing assesses strength as the patient is moving through the ROM from start to finish

  • Only evaluates about 60% of functional capacity – functional strength tests also important

• Other ways to measure strength? Power?

special tests- Joints and Tendons

• Knowledge of anatomy and function is critical

  • Ligaments attach bone to bone and provide stability for a joint

    • Stress the ligament to makes sure it is still intact

    • Congenital or generalize laxity may be present (Ehlers-Danlos syndrome)

  • Tendons attach muscle to bone and assist with movement of joint

  • Meniscus and Labrum are soft tissue around a joint to either cushion (meniscus) or help to add depth and stability to a joint – they don’t like to be compressed (grind)

• Stress the tissue to see if it does it’s job or fails. Could be looking for laxity (movement in tissue that isn’t supposed to move), pain, grinding, function.

special tests- Function

• Functional Performance – Can they continue???

  • Determines full strength to perform sport/activity

  • Are the FUNCTIONALLY able to continue participation?

  • Proceed from minimal stress activities (light jog) to high stress activities (single leg hop, twist in air, controlled landing)

  • Simulate the sport or activity (run, jump, cut, start, stop, throw, hit, twirl, spin) at half, ¾, and full speed

special tests- Situational

• Posture assessment

• Gait assessment

• Cranial Nerves, dermatomes (senory) and myotomes (muscle activation)

• Anthropometric (body comp)

• Imaging:

  • X-rays - bones

  • MRI – soft tissue and bones

  • CT scans – soft tissue and bones 

  • Bone scans – bones injected with dye

• Cardiology, nerve conduction, blood work, urinalysis, etc….

End Goals of Assessment

• Determine:

  • Type, severity and structure injured

  • What is the athlete’s playing status?

  • What needs to be done for first aid/immediate care?

  • What is the need for further evaluation (and by whom)?

  • Initial treatment and rehabilitation – what is our plan (prognosis)?

SOAP notes

• Subjective: what the patient said, felt, thought

• Objective: what the clinician found (ROM, strength, special tests)

• Assessment: differential diagnosis

• Plan: what you did, what you are going to do, instructions given to patient

Bones

Hardest, strongest tissue

• Hardest, strongest tissue

• Provide structure and protection

Joints

Formed by two or more bones connecting

Varying types and levels of mobility

Fibrocartilage

• Semi-rigid disc within joints 

• Shock absorption and increase joint stability between bones

• Ex. meniscus, labrum, intervertebral discs

Articular Cartilage

• Thin, specialized tissues that that covers the ends of bones within joints 

• reduce friction & shock absorption between bones

Muscles

Contractile & conductive (electricity) tissues that connect to bones via tendons

produce movement, stability,& protection

Elastic Region

Tissue deformed, but no damage occurs = normal physiologic range

Plastic Region

• tissue deformed beyond it’s limit, and micro- to moderate-damage occurs

• Damage depends on magnitude & repetition of the loads 

Failure

Complete tear or fracture of tissue

Compression

Coming together

Tension

Pulling apart

Shearing

Opposing forces sliding past each other

Bending

One side is receiving compression and one side is receiving tension

Torsion

Opposing forces twisting

Complete Fx

Bone damaged into 2+ pieces

Incomplete Fx

Bone partially damaged, but still connected

Displaced Fx

Bone out of alignment

Non-displaced Fx

Bone in alignment

Open Fx

Bone breaks through the skin (Infection Risk!)

Closed Fx

Bone does not break skin

Avulsion Fracture

Fx occurs where a tendon or ligament attaches

Greenstick

Incomplete fractures in skeletally immature patients, like a 'green stick'

Comminuted

Three or more fragments at the fracture site

Linear

Splits along the length, often from jumping/landing

Transverse

Straight line more or less a right angle to bone shaft

Oblique

On a diagonal

Spiral

S-shaped, rotation mechanism

Impacted

Compression along the long axis of a bone

Stress Fx

Chronic breakdown of bone tissue due to repetitive loading – bone regrowth can’t keep up with breakdown

• Overtraining, Malnutrition, Hormone-imbalance

• Often don’t show up on x-ray

Salter-Harris Fx

Fx through the epiphyseal ('growth') plate

• Adolescent Populations

• Concerns for bone growth

Metatarsal Stress Fracture- foot

• Mechanism: Overuse, poor foot mechanics, change in footwear

• S&S: pain with weight bearing, tender to palpate

5th Metatarsal Fractures- foot

lots of mechanisms

• Jones’ Fracture– inversion mechanism, looks like an ankle sprain

  • S&S: tender to palpate, unable to bear weight, swelling/bruising

  • Part of bone that has poor blood supply, often needs to be pinned

• Avulsion fracture – same mechanism and presentation, often heals without pinni

lower leg fracture

• Tibia (larger bone) and Fibular (smaller, lateral bone)

  •  Mechanisms: Can be acute (bending, twisting) or overuse (stress)

    • IF overuse: have to consider biomechanics, strength, flexibility, bone density, etc…

  • Management: depends on type, severity and location of injury

    • May need to have stabilized with rod (tibia) and/or plates/pins (often fibula)

Femur Mid-Shaft fracture

• not common, longest and strongest bone in body

• Would require significant force to cause fracture (skiing, X-Games), often a spiral fracture

• Considered a medical emergency (pain, swelling, bruising, unable to bear weight)

• Almost always requires surgical pinning/repair

Clavicle fracture

• most common in middle 1/3, often a greenstick type in youth

• Mechanism: FOOSH, direct hit

• S&S: pain, deformity, discomfort moving arm, head often tilted toward side of injury

• Manage: Depends on severity. Splint or sling for non-displaced, surgical for displaced)

Colles Fracture- wrist

• distal radius fracture that displaces backward

• Mechanism: FOOSH

• S&S: deformity (Dinner Fork), pain, swelling

• Manage: re-set the bones (manually or surgically), casting 6-8 weeks

Scaphoid fracture- wrist

• carpal bone in wrist

• Mechanism: FOOSH

• S&S: pain in the anatomical snuff box, radial deviation

• Manage: has poor blood supply, often needs surgical pinning

Contusions

• anywhere on the body

• Mechanism: Compression of soft tissue between an external force and a bone (internal) causing blood vessels to rupture and spill into soft tissue.

• May form a hematoma.

  • S&S: tender to touch, bruising (ecchymosis)

  • Manage: maintain ROM, ice (pain)

    • Potential complication: myositis ossificans –formation of bone in soft tissue following a contusion

Hip Pointer

Contusion on iliac crest (top of hip)

Dislocation

• when two bones are no longer “together”

• May damage ligaments, joint capsule, labrum, bones, cartilage

• Subluxation – did not come “fully” out or went out and slipped back in on it’s own

• Patient will tell you “it’s out” – very painful

• Once dislocated, common for it to reoccur…why?

Sprain

• partial or completely torn Ligament

• Degrees (1st, 2nd, 3rd) or (mild, moderate, severe)

  • Mild – few fibers torn, no instability, minimal swelling/pain

  • Moderate – more fibers torn, some instability, moderate swelling/pain

  • Severe – most fibers torn, instability,

Turf Toe

• ligaments/capsule of big toe are “sprained”

• From a forced big toe hyperextension mechanism

• Results in pain, swelling and difficulty pushing off big toe when walking

• Management: protect with tape, rigid shoes

  • May need surgical repair

Lateral Ankle Sprain

• Most common, 3 smaller ligaments 

• Inversion mechanism, tension

• Associated injuries to muscle/tendon

Medial Ankle Sprain

• bigger ligament, harder to tear

• Eversion mechanism, tension

Syndesmosis (High) Sprain

• igaments holding tib/fib together

• Forced dorsiflexion with rotation (usually eversion)

• Longer healing time – often tightrope surgery

Ottawa Ankle Rules

Used to determine if X-ray is needed based on 4 areas of pain with palpation and inability to take 5 steps.

MCL Sprain- knee

Valgus injury mechanism, keeps knee from opening up on medial side.

LCL Sprain

Varus injury mechanism, keeps knee from opening up on lateral side.

ACL Sprain

• ACL ligament keep the tibia from sliding anteriorly on the femur

• Mechanism: foot planted, knee twists inward

• Can be from contact or non-contact

• Women more likely than men

  • neuromuscular timing issue

  • Hormone cycles

• Typically requires surgery to repair – fully torn

  • Surgical graft options, patellar tendon, hamstrings, quad tendon

  • Rehabilitation takes 9-12 months

Meniscus Tear

• Meniscus is the “cushion” between femur and tibia

• When loaded and rotation occurs, can be torn

• Also common with repeated deep squats

• Lots of different types of tears

  • Surgical debridement vs. repair

Patellar Dislocation

Patella slides laterally outside groove it sits in.

Reduce (put back in place) – recovery/rehabilitation

Labrum- hip

• Can be torn with repeated flexion/IR mechanism

  • Also abnormal bone growth on socket and/or ball 

• Pain in the groin, anterior deep hip

• Imaging does not correlate to injury

• Dislocation is rare

  • Usually goes into a posterior direction

  • Likelihood of avascular necrosis