EXAM 2 - prevention and care

Acute injury

* result of trauma
* associated with specific MOI
* recent onset
* ex: fracture, sprain, strain, contusion, concussion, dislocation

Chronic injury

* repetitive/ overuse injury
* gradual onset- develop overtime
* no specific MOI - mechanism
* ex: low back pain, shin splints, tendinitis, arthritis, stress fractures

Periosteum

dense, white outer surface of the bone

* contains blood vessels and osteoblasts

Compact bone

middle layer

spongy bone

inner cancellous tissue

Diaphysis

hollow, cylindrical shaft of bone

Epiphysis

distal and proximal ends of the bone

epiphyseal plate

hyaline cartilage line at the ends of the bone

* growth plate

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**

Fractures signs and symptoms

* deformity
* point tenderness
* swelling
* pain with AROM and PROM
* muscle guarding

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

muscle guarding

trying to protect the injury and minimize pain

AROM

active range of motion

* ex: knee contracting muscle to move it

PROM

passive range of motion

* physician moves joint for you

Healing- fractures

* osteoblasts will lay down bone and form callus
* osteoclasts will assist in reshaping of the bone in response to normal stress

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

FOOSH - fractures, sprains

falling on outstretched hand

Subluxation

* partial dislocations causing **incomplete separation** of two bones
* often occur in shoulder and females (patella)

signs and symptoms for dislocations and subluxations

* deformity
* apprehension
* loss of function
* point tenderness
* swelling

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

avulsion fracture

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

Ligament sprains etiology

* damage (stretching or tearing) of a **ligament**
* ligaments attach bone to bone

Ligaments

are thick portions of the capsule or individual bands

Grade 1 - ligament sprains

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

Grade 2- ligament sprains

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

grade 3 - ligament sprains

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

Signs and symptoms of ligament sprains

* pain
* swelling
* heard a “pop”
* ecchymosis - bruising or discoloration
* limited range of motion

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

Contusion etiology

* sudden, direct blow to body
* hematomas can form due to blood and lymph flow in tissue
* can be deep or superficial

signs and symptoms of contusions

* painful to the touch
* discoloration
* painful with movement

treatment of contusions

* ice on a stretch
* massage
* protect

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

Myositis Ossificans

can occur due to repeated blows

Muscle strains etiology

* stretching or tearing of muscle, tendon or adjacent tissue

Signs and symptoms of muscle strains

* muscle guarding
* limited range of motion
* point tenderness
* ecchymosis (sometimes)

treatment

* minimize pain
* strengthen
* stretching
* generally a long process (hamstring 6-8 weeks)

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

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

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

Nerve injuries etiology

* compression or tension
* can be acute or chronic

signs and symptoms of nerve injuries

* burning/ tingling
* radiating pain
* pinching pain
* muscle weakness

treatment for nerve injuries

* slow healing process
* CNS repair is rare and unlikely
* PNS can regenerate

Stress fracture etiology

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

signs and symptoms of stress fracture

* dull ache that progressively gets worse
* pain with activity
* swelling

treatment for stress fracture

* stop activity for 2 weeks
* get imaging
* can immobilize but casting is generally not required

Tendonitis etiology

repeated microtrauma and degenerative changes

signs and symptoms of tendonitis

* gradual onset


* pain
* swelling
* crepitus

Treatment for tendonitis

* rest


* ice cup massage
* strengthening programs to improve conditions
* remove causal factors

NSAID

non steroidal treatment

ex: ibuprofen, tylenol

Tenosynovitis etiology

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

Signs and symptoms of tenosynovitis

* pain
* diffuse swelling
* crepitus

treatment for tenosynovitis

* NSAIDS
* rest
* ice cup massage
* strengthening programs to improve conditions
* remove causal factors

Bursitis etiology

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

Signs and symptoms of Bursitis

* swelling (water balloon)
* pain
* loss of function/ ROM

treatment of bursitis

* keep the area clean
* monitor for cuts/ abrasions
* compression

Inflammation

must occur to initiate healing

signs and symptoms of inflammation

* pain
* redness
* swelling
* warmth
* loss of function

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

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

Foot can be divided into 3 areas

* forefoot
* midfoot
* hindfoot

forefoot

19 bones

phalanges: distal, middle and proximal (14)

Metatarsals (5)

Midfoot

5 bones

cuboid, navicular (3), cuneiforms

hindfoot

2 bones

calcaneus and talus

Arches

* longitudinal arch (medial and lateral)
* transverse arch
* metatarsal arch

Plantar fascia

* connective tissue
* attaches on the heel

Anterior compartment

* tibialis anterior
* extensor digitorum longus
* extensor hallucis longus
* peroneus tertius

Lateral compartment

* peroneus longus
* peroneus brevis

High arch

pes cavus

Superficial posterior compartment

* gastrocnemius
* soleus

Deep posterior compartment

* tibialis posterior
* flexor digitorum longus
* flexor hallucis longus

prevention of foot injuries

* highly vulnerable area to variety of injuries


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

Foot assessment

* athletes should be preferred to qualified personnel for injury evaluation

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

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**__

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

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

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

Calcaneus fracture

* usually from direct blow
* ex: landing from tall height such as ladder

Heel bruise causes

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

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

sever’s disease

growth plate injury in heel found in young adolescents

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

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

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

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

itis

chronic

Lateral ankle ligaments

* anterior talofibular ligament
* Calcaneofibular ligament
* Posterior talofibular ligament

Medial ligaments

* deltoid ligament
* calcaneonavicular ligament

Anterior ligament

Anterior inferior tibiofibular ligament

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

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

Strength training

* static and dynamic joint stability is important in preventing injury
* develop a balance in strength throughout the range

Neuromuscular control training

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

Footwear - ankle injuries

* can be important factor in reducing injury
* shoes should not be used in activities they were not made for

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

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

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

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

Percussion

bump

Compression

squeeze