EXAM 2 - prevention and care

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Acute injury

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1

Acute injury

  • result of trauma

  • associated with specific MOI

  • recent onset

  • ex: fracture, sprain, strain, contusion, concussion, dislocation

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Chronic injury

  • repetitive/ overuse injury

  • gradual onset- develop overtime

  • no specific MOI - mechanism

  • ex: low back pain, shin splints, tendinitis, arthritis, stress fractures

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Periosteum

dense, white outer surface of the bone

  • contains blood vessels and osteoblasts

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Compact bone

middle layer

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spongy bone

inner cancellous tissue

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Diaphysis

hollow, cylindrical shaft of bone

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Epiphysis

distal and proximal ends of the bone

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epiphyseal plate

hyaline cartilage line at the ends of the bone

  • growth plate

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Acute fracture etiology

  • extreme stress and strain on a bone

  • stresses or loads can cause the bone to fail by tension, compression, bending, twisting and shearing

  • Greater force causes more complex fractures

  • subsequent forces that are not absorbed by the bone are absorbed by the adjacent soft tissues

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Fractures signs and symptoms

  • deformity

  • point tenderness

  • swelling

  • pain with AROM and PROM

  • muscle guarding

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treatment for fractures

  • immobilization

    • 6 weeks for bones and legs

    • 3 weeks for hands and feet

  • normal stresses and strains after cast removal will aid in healing and remodeling process

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muscle guarding

trying to protect the injury and minimize pain

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AROM

active range of motion

  • ex: knee contracting muscle to move it

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PROM

passive range of motion

  • physician moves joint for you

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Healing- fractures

  • osteoblasts will lay down bone and form callus

  • osteoclasts will assist in reshaping of the bone in response to normal stress

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16

Dislocation

  • at least one bone in a joint is forced completely out of normal and proper alignment

  • high level of incidence in fingers, elbow, and shoulder

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FOOSH - fractures, sprains

falling on outstretched hand

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Subluxation

  • partial dislocations causing incomplete separation of two bones

  • often occur in shoulder and females (patella)

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signs and symptoms for dislocations and subluxations

  • deformity

  • apprehension

  • loss of function

  • point tenderness

  • swelling

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Treatment for dislocation and subluxations

  • treat as fracture until further imaging can rule it out (avulsions/ growth plate)

  • RTP (return to play) determined by soft tissue damage

  • needs to be reduced as quickly as possible

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avulsion fracture

the tendon attachment or ligament attachment pulls off a piece of bone

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Ligament sprains etiology

  • damage (stretching or tearing) of a ligament

    • ligaments attach bone to bone

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Ligaments

are thick portions of the capsule or individual bands

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Grade 1 - ligament sprains

some pain, minimal loss of function, no abnormal motion and mild point tenderness, slight swelling and joint stiffness

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Grade 2- ligament sprains

pain, moderate loss of function, swelling, instability, some tearing of ligament fibers and joint instability

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grade 3 - ligament sprains

extremely painful, inevitable loss of function, severe instability and swelling but may also represent subluxation

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Signs and symptoms of ligament sprains

  • pain

  • swelling

  • heard a “pop”

  • ecchymosis - bruising or discoloration

  • limited range of motion

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treatment for ligament sprains

  • restoring joint stability is difficult after grades 1 and 2

  • original tension will not return and an inelastic scar will form

  • must strengthen surrounding musculature for support/ stability

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Contusion etiology

  • sudden, direct blow to body

  • hematomas can form due to blood and lymph flow in tissue

  • can be deep or superficial

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signs and symptoms of contusions

  • painful to the touch

  • discoloration

  • painful with movement

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treatment of contusions

  • ice on a stretch

  • massage

  • protect

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contusions

  • calcium deposits can form which may limit soft tissue mobility

  • protection is key and may allow for re absorption of calcium deposits

  • surgery may be needed to remove deposits if not re absorbed

  • quadriceps and biceps are both very susceptible to this condition

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Myositis Ossificans

can occur due to repeated blows

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Muscle strains etiology

  • stretching or tearing of muscle, tendon or adjacent tissue

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Signs and symptoms of muscle strains

  • muscle guarding

  • limited range of motion

  • point tenderness

    • ecchymosis (sometimes)

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treatment

  • minimize pain

  • strengthen

  • stretching

  • generally a long process (hamstring 6-8 weeks)

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Muscle strains - grade 1

some fibers have been stretched or actually torn resulting in tenderness and pain on active ROM, movement painful but full range present

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Muscle strain - grade 2

number of fibers have been torn and active contraction is painful, usually a depression or divot is palpable, some swelling and discoloration result

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muscle strain - grade 3

complete rupture of muscle or musculotendinous junction, significant impairment, with initially a great deal of pain that diminishes due to nerve damage

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Nerve injuries etiology

  • compression or tension

  • can be acute or chronic

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signs and symptoms of nerve injuries

  • burning/ tingling

  • radiating pain

  • pinching pain

    • muscle weakness

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treatment for nerve injuries

  • slow healing process

  • CNS repair is rare and unlikely

  • PNS can regenerate

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43

Stress fracture etiology

overload due to muscle contraction, altered stress distribution due to muscle fatigue

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signs and symptoms of stress fracture

  • dull ache that progressively gets worse

  • pain with activity

    • swelling

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treatment for stress fracture

  • stop activity for 2 weeks

  • get imaging

    • can immobilize but casting is generally not required

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Tendonitis etiology

repeated microtrauma and degenerative changes

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signs and symptoms of tendonitis

  • gradual onset

  • pain

  • swelling

  • crepitus

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Treatment for tendonitis

  • rest

  • ice cup massage

  • strengthening programs to improve conditions

  • remove causal factors

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NSAID

non steroidal treatment

ex: ibuprofen, tylenol

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Tenosynovitis etiology

inflammation of synovial sheath due to injury, overuse or inflammatory diseases

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Signs and symptoms of tenosynovitis

  • pain

  • diffuse swelling

  • crepitus

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treatment for tenosynovitis

  • NSAIDS

  • rest

  • ice cup massage

  • strengthening programs to improve conditions

  • remove causal factors

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Bursitis etiology

can be acute or chronic. due to direct blow irritating or rupturing the bursa sac or overuse that irritates the sac

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Signs and symptoms of Bursitis

  • swelling (water balloon)

  • pain

  • loss of function/ ROM

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treatment of bursitis

  • keep the area clean

  • monitor for cuts/ abrasions

  • compression

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Inflammation

must occur to initiate healing

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signs and symptoms of inflammation

  • pain

  • redness

  • swelling

  • warmth

    • loss of function

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Treatment for inflammation

  • create an optimal healing enviornment - PRICE (protect, rest, ice, compression, elevation)

  • No heat for first 24-72 hrs

    • will only increase inflammation and swelling

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Healing process - inflammatory response phase

  • begins immediately after injury

  • damaged cells break open and leak their contents

  • in response to this, neurotransmitters and chemicals are sent to the injury site to begin the healing phases

  • Subsequent phases will follow but inflammation must happen first

    • acute inflammation phase typically lasts 2-4 days, post injury

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60

Foot can be divided into 3 areas

  • forefoot

  • midfoot

    • hindfoot

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61

forefoot

19 bones

phalanges: distal, middle and proximal (14)

Metatarsals (5)

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Midfoot

5 bones

cuboid, navicular (3), cuneiforms

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hindfoot

2 bones

calcaneus and talus

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Arches

  • longitudinal arch (medial and lateral)

  • transverse arch

  • metatarsal arch

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Plantar fascia

  • connective tissue

  • attaches on the heel

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Anterior compartment

  • tibialis anterior

  • extensor digitorum longus

  • extensor hallucis longus

  • peroneus tertius

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Lateral compartment

  • peroneus longus

  • peroneus brevis

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High arch

pes cavus

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69

Superficial posterior compartment

  • gastrocnemius

  • soleus

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70

Deep posterior compartment

  • tibialis posterior

  • flexor digitorum longus

  • flexor hallucis longus

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prevention of foot injuries

  • highly vulnerable area to variety of injuries

  • injuries best prevented by selecting appropriate footwear, correcting biomechanical structural deficiencies through orthotics

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Foot assessment

  • athletes should be preferred to qualified personnel for injury evaluation

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Foot assessment - history

  • Location of pain - heel, foot, toes, arches

  • training surfaces or changes in footwear

  • changes in training, volume, type

  • does footwear increase discomfort

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Palpation - foot assessment

  • should assess the bony anatomy first

    • checking for deformities and areas of tenderness

  • Assessment of soft tissue ( muscle and tendons) will allow for detection of point tenderness, swelling, muscle spasms or muscle guarding

  • circulation must also be monitored using the dorsal pedal pulse

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75

Retrocalcaneal bursitis (pump bump)

  • caused by inflammation of bursa beneath achilles tendon

  • Result of pressure and rubbing of shoe heel counter of a shoe

  • Chronic condition that develops over time and may take extensive time to resolve, exocytosis (pump bump) may develop

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Signs and symptoms of retrocalcaneal bursitis

  • Signs of inflammation

  • Tender, palpable bump on calcaneous

  • Pain w/ palpation superior and anterior to Achilles insertion, swelling on both sides of the heel cord

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Care for retrocalcaneal bursitis

  • routine stretching of achilles, heel lifts to reduce stress, donut pad to reduce pressure

  • Select different footwear that results in increasing or decreasing height of heel counter

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78

Calcaneus fracture

  • usually from direct blow

  • ex: landing from tall height such as ladder

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79

Heel bruise causes

caused by sudden starts, stops or changes in direction, irritation of fat pad

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80

Signs of injury - heel bruise

  • severe pain in heel and is unable to withstand stress of weight bearing

  • may progress to chronic inflammation of bone covering

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81

sever’s disease

growth plate injury in heel found in young adolescents

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Care of heel bruise

  • reduce weight bearing for 24 hours, RICE and NSAIDS

  • resume activity with heel cup or doughnut pad after pain has subsided

  • Applying tape can also be effective in generating a heel cup

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Plantar Fasciitis - cause

  • increased stress on fascia

  • change from rigid supportive footwear to flexible footwear

  • poor running technique

  • leg length discrepancy, excessive pronation, inflexible longitudinal arch, tight gastroc soleus complex

    • Running on soft surfaces, shoes with poor support

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Signs and symptoms - plantar Fasciitis

  • pain in anterior medial heel, along medial longitudinal arch

  • increased pain in morning, loosens after first few steps, pain in forefoot dorsiflexion

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Care - plantar fasciitis

  • extended treatment (8-12 weeks) is required

  • orthotic therapy is very useful (soft orthotic with deep heel cup)

  • Simple arch taping, use of a night splint to stretch

  • vigorous heel cord stretching and exercises that increase great toe dorsiflexion

  • NSAIDS and occasionally steroidal injection if symptoms don’t improve with conservative treatment

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86

itis

chronic

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87

Lateral ankle ligaments

  • anterior talofibular ligament

  • Calcaneofibular ligament

  • Posterior talofibular ligament

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Medial ligaments

  • deltoid ligament

  • calcaneonavicular ligament

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Anterior ligament

Anterior inferior tibiofibular ligament

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90

avulsion fracture

occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone

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91

Achilles tendon stretching

  • a tight heel cord may limit dorsiflexion and may predispose athlete to ankle injury

  • should routinely stretch before and after practice

  • Stretching should be performed with knee extended and flexed 15-30 degrees

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92

Strength training

  • static and dynamic joint stability is important in preventing injury

  • develop a balance in strength throughout the range

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Neuromuscular control training

can be enhanced by training in controlled activities on uneven surfaces or a balance board

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94

Footwear - ankle injuries

  • can be important factor in reducing injury

  • shoes should not be used in activities they were not made for

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Preventive taping and orthoses

  • tape can provide some prophylactic protection

  • however, improperly applied tape can disrupt normal biomechanical function and cause injury

  • lace up braces have even been found to be effective in controlling ankle motion

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Assessing the ankle and lower leg - history

  • past history

  • mechanism of injury

  • when does it hurt

  • type of quality or duration of pain

  • sounds or feelings

  • how long were you disables

  • swelling

  • previous treatments

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Assessing the ankle and lower leg - observations

  • postural deviations

  • genu valgum or genu varum

  • is there difficulty with walking

  • deformities, asymmetries or swelling

  • Color and texture of skin

  • patient in obvious pain

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98

Assessing the ankle and lower leg - palpation

  • begin with body landmarks and progress to soft tissue

  • Attempt to locate areas of deformity, swelling and localized tenderness

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99

Percussion

bump

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Compression

squeeze

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