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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
Note 
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