KIN 140 Midterm AI
KIN140 - MIDTERM STUDY GUIDE
Review in Class:
Early phase of rehab strengthening exercise used:
Isometric exercises
Med used for steadiness and nervousness must be in control
Beta blockers
4 components for negligence suit
Duty
Breach of duty
Damages
Connection
What protects the privacy of students and gives parents certain rights with respect to their children’s school records?
FERPA = Family Educational Rights and Privacy Act
Open wound w/ smooth edges and easily sutured
Incision
Phase of healing w/ realignment or remodeling of permanent collagen (scar tissue)
Maturation
Sever’s disease is an apophysitis of the
Calcaneus
Malfeasance
Performing an action that is legally not theirs to do
Type of wound associated w/ risk of tetanus infection
Puncture
Which sprain grade involves total tearing of the ligament, which leads to gross instability of the joint
3
Organization responsible for helmet cert standards in football
NOCSAE - national operating committee on standards for athletic equipment
One bone in a joint forced completely out of normal and proper alignment
Dislocation
Type of fracture where attached tendon or ligament pulls small piece of bone to which it attaches away from the rest of the bone
Avulsion fracture
Which condition occurs when there is an apophysitis of the tibial tubercle in the knee:
Osgood Schlatter’s disease
Who is responsible for deciding when an injured athlete can return back to practice:
Team physician
SAID and how does it apply to conditioning/training?
Specific adaptation to imposed demands
Body will adapt depending on what you are training
Heat should be introduced within 72 hrs - t or f
False!
Length of muscle remains constant while tension dev towards max force against an immovable resistance
Isometric
What mechanisms cause transverse fracture?
Bending
4 mechanisms to heat gain or loss?
Evaporation
Radiation
Convection
Conduction
Incomplete break in a bone that has not completely ossified
Greenstick
Repeated blows to same area →
Myositis ossificans
Which condition is treated w/ metered dose inhaler (albuterol)?
Exercise induced asthma
If prone to asthmatic attacks:
Some sports are helpful
Humid enviro = swimming
POLICE and importance in managing acute musculoskeletal injury?
Protection
Optimal Loading
Some range of motion w/o hurting further
Ice
Compression
Elevation
Female athlete triad
Low energy availability
Disordered eating
Menstrual dysfunction
Osteoporosis or low bone mineral density
Notes from Class:
Chapter 1
Sports Medicine
Clinical application is on improving functional capacities
Focuses on areas of performance enhancement, injury care, prevention, and management
Organization goals
Code of ethics
Bring professionals together and work toward one purpose
National Athletic Trainers’ Association
To enhance the quality of healthcare for athletes and those engaged in physical activity, and to advance the profession of athletic training through education and research in the prevention, evaluation, management and rehabilitation of injuries
Employment Settings for the athletic trainer
Increasingly diverse
Dramatic transformation since 1950
Due largely to efforts of the NATA
Started out primarily in the collegiate setting, progressed to high schools and now 40% are found primarily in hospital and clinic settings
Athletic training profession evolution
Requires terminology changes
Patients and clients vs. athletes
Athletic training clinic or facility vs. athletic training room
Athletic trainers – NOT TRAINERS!!
Employment responsibilities of the athletic trainer
Work with athletes from time of injury to resolution
Directly responsible for all phases of health care in an athletic environment
May be employed in a variety of settings
How to become a certified athletic trainer
Must have extensive formal academic preparation and supervised practical experience
The Board of Certification sets academic coursework and clinical experience requirements
Upon meeting the educational guidelines applicants are eligible to sit for the BOC examination
Passing the certification examination = BOC certification as an athletic trainer
Credential of ATC
Roles & Responsibilities of athletic trainers
Injury prevention & health promotion
Ensure safe environment
Conduct pre-participation physicals
Develop training and conditioning programs
Select and fit protective equipment properly
Explaining important diet and lifestyle choices
Ensure appropriate medication use while discouraging substance abuse
Clinical evaluation & diagnosis
Recognize nature and extent of injury
Involves both on and off-field evaluation skills and techniques
Understand pathology of injuries and illnesses
Referring to medical care/Support Services
Acute care of injury & illness
Administration of appropriate first aid and emergency medical care (CPR, AED)
Activation of emergency action plans (EAP)
Psychosocial strategies & referrals
Recognize abnormal behaviors; recognize the role of mental health in injury/recovery and use of intervention strategies
Refer the patient to the appropriate medical personnel for intervention
Therapeutic intervention
Design preventative training systems
Rehabilitation program design
Supervising rehabilitation programs
Incorporation of therapeutic modalities and exercise
Healthcare administration
Budgeting, inventory, injury records, supervision of assistants, insurance, EAP development
Professional development & responsibility
Educating the public through seminars, research & providing good care
Coach’s Role
If no trainer, coach assumes responsibility
Must know their limits
Preventative conditioning program
Ensure quality and properly fit equipment
Maintain equipment
Be aware of causes of injuries in their sport and work to prevent them
Be certified in CPR/AED and 1st aid
Team physician’s role
Compile Medical History
Conduct Physical Examinations
Diagnose Injuries
Decide on Medical Disqualification
Absolute authority of health participation status
Attend Practices and Games
Family
Must also explain to and inform the parents about injury management and prevention
With minors, parents’ decisions regarding health care must be of primary consideration
Health Insurance plan (HMO, PPO) will affect the choice of health care
Athletic Trainer should maintain close contact with family regarding injuries
Athlete
All decisions of the physician, coach, and athletic trainer affect the athlete
Often caught in the middle between coaches and the medical staff
Should always be informed regarding their injury and rehabilitation
Hiring a certified athletic trainer in secondary schools
Problems can be prevented by this
According to NATA: “…all secondary schools should provide the services of a full-time, on-site, certified athletic trainer (ATC) to student athletes.”
American Academy of Pediatrics (1998) adopted a policy recommending employment of athletic trainers in the high school setting
Outreach contracts
External agencies like hospitals, physicians, or universities formalize contracts.
Pros
Wider pool of athletic trainers to utilize. If the athletic trainer is sick, easier to find replacement
Easily collaborate with other doctors in the contract
More cost effective as the school or district doesn't pay all the benefits and overhead costs like they would with a direct employee (social security, insurance benefits and retirement costs).
Cons
Less patient-centered care. The athletic trainer might not know the athletes as well as someone who is always at school, especially if the school athletic trainer is not always the same person but rather whoever is “on duty” for that day.
The athletic trainer might feel like an outsider and have less sense of belonging.
Direct employment
When the school system directly employs an athletic trainer, this comes with its own set of advantages but also has some things that the district needs to be aware of when utilizing this model.
Pros
Stronger bonds developed with everyone (student athletes, coaches/teachers, and administrators)
Better patient-centered care. When the athletic trainer gets to know each athlete's needs and preferences a better level of trust should develop, and this leads to improved outcomes.
When the athletic trainer is employed by the school or school district then they won’t be called away from their duty because of a conflicting event. This can happen occasionally with outreach contracts.
Cons
This model will be more costly for the school district. The district will be required to pay full benefits and other employee expenses (social security, insurance benefits and retirement costs).
The district must find the right fit. When hiring the best individual athletic trainer can take time and effort.
Often there are good athletic trainers and good school districts, and they aren’t a good match for each other for various reasons.
Independent contractors
In effect this is hiring a freelance athletic trainer. When the district hires an independent contractor, it offers a balance between the outreach and direct employment models.
Pros
Greater flexibility in this model
Fills short-term needs such as an absence of the staff athletic trainer or help to add additional staffing for busier times when multiple events are occurring simultaneously
More cost-effective
Like outreach contracts, the district will only pay for the service directly.
Avoids the costs typically associated with direct employment such as benefits.
Cons
It may be hard to find someone quickly for long absences as there may not be available people willing to step in and work.
Location of the school district can be a concern. In rural areas, finding qualified independent athletic trainers might be difficult.
Summary
Sport Medicine- broad field of medical practice encompassing physical activity/sports
Professional Organizations establish professional standards (code of ethics) and exchange progressive ideas
Roles
Coaches- assume healthcare responsibility if no athletic trainer present, maintain equipment
Athletic Trainer- Prevention of Injury, Evaluation of immediate injuries and athlete referral when appropriate
Team Physician- Oversee all medical care of athletes, final authority on participation
Chapter 2
Legal and Ethical Concerns for Athletic Trainers
Be mindful to society as it relates to healthcare
Are held accountable for their patient care
Techniques and procedures can result in legal action from:
Liability
Negligence
Hiring in Secondary Schools
NATA: all secondary schools should have full time certified AT for athletes
American Academy of Pediatrics: 1998 policy recommending ATs in high school
Emergency Action Plan EAP
Plan must exist for accessing emergency personnel
Must include transportation of athlete to emergency facility
Must meet w/ outside personnel to determine roles/rules for athlete and equipment care
Example:
Record keeping:
Critical responsibility
Accurate, timely assessment and eval of all practices
Documents all practices to assure that responsibilities and expectations are being met
Medical records, injury reports, insurance info, injury eval, progress notes, equipment inventories, annual reports
Release of records:
CANNOT occur without:
If the athlete wants records released to college, professional organizations, insurance companies, news media…he and the parents must provide written consent
Waiver must specify what info is to be released
HIPAA Regulations - health insurance portability and accountability act
Regulates how any members of the sports medicine team can share health info concerning an athlete
Provides athletes w/ access to their med records and control over how their health info is used and disclosed
Athlete can provide blanket authorization for release of specified med info on a yearly basis
FERPA Regulations - family educational rights and privacy act
Protects privacy of student educational records
Provides parents certain rights w/ respect to inspection of kid’s educational records
School must have written permission to release info
Liability = state of being legally responsible for the harm one causes to another person
Standard of reasonable care
negligence: failure to use ordinary or reasonable care
Assumes that a person is of ordinary and reasonable prudence
Bring common sense approach to the situation
Must operate with the appropriate limitations of one’s educational background
Torts
Legal wrongs committed against a person
May emanate from:
Nonfeasance: fails to perform legal duty (ex: fail to refer)
Malfeasance: performs action that is not hers to legally perform (ex: perform advanced treatment leading to complications)
Misfeasance: performs an action incorrectly that she had the legal right to do
Proving Negligence
Caregiver does something a reasonably prudent person would not == commission
Caregiver fails to do something a reasonably prudent person would not == omission
For a negligence suit to be successful:
Must prove the AT had a duty to exercise reasonable care
The AT breached that duty
Damages occurred to patient
Establish a connection between the failure to use reasonable care and the injury suffered by the individual
Individual possessing higher level of training will possess higher level of competence
Once AT assumes duty of caring for athlete that person has an obligation to provide appropriate care
Obligation to provide services VS scope of employment
Ex: if there is an emergency in the stands…AT is responsible for the athletes and it would be outside their scope
AT at an institution has a duty to provide care to individuals at the institution
May be protected through sovereign immunity
Sovereign immunity
Individuals employed by govt can not be held liable for negligence
Varies state to state
Good samaritan law
Provides limited protection against legal liability to one that provides care should something go wrong
Statutes of limitations
Specific length of time one can sue for injury resulting from negligence
Varies by state usually 1-3 years
California 1-10 years
Clock begins at the time the negligent act results in suit or from the time the injury is discovered following negligent act
Minors usually have an extension
Time begins on 18th birthday
Assumption of risk
Individual is made aware of inherent risks involved in sport and voluntarily decides to keep playing
Expressed in written waiver or implied from conduct of athlete once participation begins
Can be used as defense against one’s negligence suit
Does not excuse overseers from exhibiting reasonable care and prudence regarding conduct of activities or foreseeing potential hazards
Many and varied interpretations (particularly with minors)
Often a waiver will stand in court except in incidents of fraud, misrepresentation or duress
Product liability
Liability of any of all parties involved in manufactured product for damages caused by product
Products with inherent defects are subject to liability suits
May be based on negligence, strict liability or breach of warranty
Equipment must not be modified and should be used for intended use to avoid liability issues
Manufacturer of equipment has duty to design and produce equipment that will not cause injury
Express warranty:
Manufacturer’s written guarantee - product safety
Equipment warning labels
Informs athlete of potential dangers inherent w/ product use
National operating committee on standards for athletic equipment NOCSAE
Minimum standards for equipment to ensure safety
Ex: size shin guards have to be
Ways to reduce litigation risk (risk of a lawsuit)
Practice within scope, document, maintain confidentiality, use common sense
Work to establish good working relationships w/ athletes, parents, pts and coworkers
Establish policies regarding athletic training facility and coverage
Dev emergency action plan
Become familiar w/ medical history of individuals under your care
Yearly required physical eval before cleared to play a sport
Maintain adequate records
Maintain confidentiality
Exercise caution w/ regards to medication distribution and modality use
Ensure safe equipment and facility
Allow injured pts to return following physician clearance
Follow doc orders esp w/ participation of athlete
Purchase liability insurance
Know scope of practice
Common sense!
Insurance considerations
Major changes in insurance have occurred in light of managed care
Major increases in the # of lawsuits and cost of insurance
Medical insurance is contract between company and policyholder
Company agrees to pay portion of medical bills following payment of deductible
HMO - health maintenance organization
Provide preventive measures and dictate where individual can receive care
Permission must be gained to see someone outside of the plan - except in emergencies
HMO pays 100% of costs if care rendered within HMO plan providers
Coaches, admin, ATs must have knowledge of HMO limits and restrictions
PPO - preferred provider organization
Provide discount healthcare and limit where treatment can be obtained
Must be aware of what facilities are approved for the program to have cost completely covered
May include other types of coverage
Physical therapy
PPO - pay on a fee for service basis
POS - Point of service
Combo of hmo and ppo
HMO model but allows for care outside of the plan
Flexibility allowed for certain conditions and circumstances
Insurance to protect the professional
Protect against damages that may arise from injuries occurring on school property
Covers against claims of negligence on part of individuals
Errors and omissions liability insurance have evolved to protect individuals against suit claiming malpractice, negligence, errors and omissions (each person should have personal liability insurance)
Insurance billing
Must file claims immediately and correctly
To facilitate, collect insurance info at the start of the academic year
Letters should be sent home to fully explain the coverage available and necessary procedures
Standard forms are the norm but accurate and thorough completion is critical
Filing a claim
Standard forms utilized
Complete and detailed
More accuracy & thoroughness = quick return and higher rate of reimbursement
Billing codes
Diagnostic code
Specifies injury/condition that is being treated
Procedural code
National provider identifier NPI
Govt issued ID # for individual health care providers and organizations
Covered healthcare providers health plans, and healthcare clearinghouses must use NPI in all admin and financial transactions according to HIPAA
As of 2007, all electronic transactions (claims, verifications, inquires) require use of this 10 digit #
Summary
Liability: legally responsible for the harm one causes to another person
Components to prove negligence:
Duty
Breach of duty
Damages
Connection
Statutes of limitations
Time frame for pt to enter negligence suit
Reduce litigation
Practice within scope, document, maintain confidentiality, use common sense
Types of insurance
HMO
PPO
POS
Chapter 3
Environmental Conditions
Heat stress
Extreme caution should be used when training in the heat (overexposure could result in heat illness)
Athletes that train under these extreme conditions are at risk
Physiologically the body will continue to function if body temp is maintained
Body must be able to dissipate heat to maintain homeostasis
The clinician must also consider that
The ability to dissipate heat may be limited due to the utilization of equipment and certain clothing
Heat stress = factor when competing in the cold if heat dissipation is limited and dehydration occurs
Metabolic heat production > evaporative heat loss = not good
Normal metabolic function results in production of heat (increases w/ intensity of exercise)
Conductive Heat exchange
Physical contact w/ objects resulting in heat loss or gain
Convective Heat exchange
Body heat can be lost or gained depending on circulation of medium
Radiant Heat exchange
Comes from sun and cause inc in temp
Evaporative Heat loss
Sweat glands allow water transport to surface
Evaporation of h20 takes heat with it
Air must be relatively water free for evaporation to occur
Humidity of 65% impairs evaporation
Humidity of 75% stops evaporation
Addressing heat illness
Gradual acclimation
Identify susceptible individuals
Uniform/clothing selection
Weight records
Hydration >
Gradual Acclimatization
Most effective method of avoiding heat stress
Involves becoming accustomed to heat and exercising in heat
Early pre season training and graded intensity changes are recommended w/ progressive exposure over 7-10 day period
Equipment restrictions may help athlete gradually acclimate
At risk / susceptible Individuals
Athletes w/ large muscle mass
Overweight
From increased metabolic rate
Poor fitness, history of heat illness, febrile condition, young, old peeps
Uniform / clothing Selection
Based on temp and humidity
Dress for the temp and weather
Avoid rubberized suits
Weight Records
Keep track of before/after measures for 1st two weeks
If inc in temp and humidity occurs during the season, weights should again be recorded
>2% loss of body weight = health threat and should be removed from practice until normal weight is achieved
Hydration
Consume fluids and stay cool
Start activity well hydrated
Urine should be light yellow
Dark urine = dehydration sign
Monitoring heat index
Monitor heat, sun, humidity closely
Wet bulb globe temp WBGT index provides objective measure for determining precautions concerning participation in hot
WBGT incorporates diff thermometer readings
Dry Bulb - standard mercury temp
Wet Bulb - thermometer w/ wet gauze
Black Bulb - black casing that measures radiant heat
HI (heat index) = 0.7W + 0.2D + 0.1B
*greater humidity = greater heat index
Heat Illness
Occurs on hot humid days
Heat cramps
Painful muscle spasms (calf, ab) from excessive water loss & electrolyte imbalance
Occurs in people in good shape that overexert themselves
Treat == fluids and light stretching w/ ice massage
Return to play unlikely due to continued cramping
Heat syncope / collapse
Associated w/ rapid fatigue and overexposure, standing in heat for a long time
Cause == peripheral vasodilation or pooling of blood in extremities, resulting in dizzy and fainting
Treat == cool enviro, fluids, lay down, elevate lower extremities
Exertional heat exhaustion
Unable to sustain adequate cardiac output
s/s == profuse sweating, pale skin, slightly elevated temp, dizzy, n/v/d, hyperventilation, muscle cramps, loss of coordination
core/rectal temp <104
Performance may decrease
Exertional heat stroke
Serious life threatening condition w/ unknown cause
s/s == sudden onset/collapse, LOC, CNS dysfunction, flushed hot skin, minimal sweating, shallow breathing, strong rapid pulse, core temp > 104
Breakdown of thermoregulatory mechanisms
Treatment:
Decrease body temp ASAP
Transport to hospital
Immerse in ice water or ice down
Best treatment
Chance of death dec if temp back to normal within 45 mins
Hyponatremia
Fluid electrolyte disorder = low sodium in blood, too much fluids
Cause = excessive sweat and excessive fluid intake
s/s == headache, n/v, lethargy, apathy, agitation, swelling of hands and feet
ER ASAP
Hypothermia
Dec body temp
s/s
mild : shivering, inc heart rate (tachycardia)
moderate : inc shivering, pale skin, blue lips, blue fingers/toes
severe : dec HR and BP, difficulty speaking, amnesia
Wind chill factor:
Air temp on exposed skin from wind
Measures the effect of wind on air temp
frostbite times determined by wind and temp
Lightning
110 deaths/year
Emergency action plan at every institution
Flash to bang: number of seconds divided by 5 = distance in miles
Count 30 (6 miles) inherent danger and monitor
Count 15 (3 miles) everyone should leave the field immediately for shelter
30 min pass before return to play
Summary
Heat considerations
Measure enviro: WBGT, heat index chart
Methods of heat exchange
Conduction, convection, radiation, evaporation
Heat illness
Heat cramps, exhaustion and heat stroke
s/s
Treatment
Hyponatremia
s/s
Cold
Wind chill factor & frostbite
Lightning
Flash to bang
Chapter 4: Preventing Injuries
Preventing Sudden Death in Sports:
Secondary School athletic population leads the nation in athletic-related deaths
Catastrophic Brain and Neck Injuries
Exertional Heat Stroke (EHS)
Sudden Cardiac Arrest
Exertional Sickling
Best Practices Recommendations Preventing Sudden Death:
All school athletic staff should Be CPR & AED certified
Educated on factors that contribute to sudden death and recognize life-threatening situations
Provide & or document competencies and continuing education specific to preventing sudden death in sport
Site specific EAP’s should be reviewed each sport by all athletic staff & updated as needed
Annual school-wide EAP rehearsal
No scheduled athletic activity w/o confirmation and documentation all athletic staff are fully familiar with EAP
Schools with contact and collision sports should employ an AT
Medical staff (MD / DO & AT) should complete an education module on appropriate medical management of concussion and neck injuries
Comprehensive medical management plan for head, neck and spine injuries AT & Treating physician of brain injured athletes must collaborate on gradual return to learn and return to play
Develop heat acclimatization plan preseason
Educate all athletic staff, administrators, coaches and athletes about common causes of EHS
Modify Activities Provide adequate fluids during practices & games
Monitor athlete’s weight loss
Athlete’s who exhibit CNS dysfunction during exercise in heat should be suspected to be suffering from EHS
loss of consciousness
altered consciousness
personality change
staggering gait
When combined with hyperthermia at time of collapse
Rectal temperature is the “Gold Standard” method to assess body temperature
Cold water immersion before EMS transport “Cool first, transport second”
If rectal temperature can’t be obtained cold water immersion should be done for at least 15 minutes
Exertional Sickling
Obtain Sickle Cell Trait (SCT) status from PPE
If SCT information isn’t available
SCT screening should be considered
SCT Positive Athletes shouldn’t be denied participation
Provide supplemental oxygen
Modify exercise especially in hot humid conditions
Allow longer rest and recovery time for patients with SCT
Preventing Injuries Through Physical Fitness:
Areas of concern:
Flexibility
Muscular strength, endurance, power
Cardiorespiratory endurance
Exercise related injuries can be reduced
Improved fitness = more resistant to fatigue and stress
Principles of Conditioning and Training:
Periodization Versus Year-Round Training:
Periods or Phases:
Transition period:
Follows last competition (early off-season)
Unstructured (escape rigors of training)
Preparatory period:
hypertrophy/endurance phase (Low intensity with high volume)
Allows for development of endurance base
Lasts several weeks to 2 months
Strength Phase
Power Phase (High intensity/ pre-season)
Competition period:
High intensity, low volume, skill training sessions
May incorporate weekly training cycles (1-7 days)
Designed to ensure peak on days of competition
Factors That Limit Flexibility:
Bony structures
Tissue approximation
Excessive fat
Muscle and tendon lengths
Connective tissue
Scarring and contractures
Skin
Range of Motion (ROM):
Active range of motion = dynamic flexibility
Ability to move a joint without assistance
Passive range of motion = static flexibility
Motion of joint when another person moves the joint (no muscle contraction)
Must be able to move through unrestricted range
Agonist vs. Antagonist Muscles:
Quadriceps will extend knee with contraction
Hamstrings will stretch during extension
Quads (muscle producing movement) referred to as agonist
Muscle undergoing stretch referred to as antagonist
Agonist and antagonist work together to produce smooth coordinated movements
Neurophysiological Basis of Stretching:
Stretch Reflex
Muscle is placed on stretch
Muscle spindles & Golgi tendon organs (GTO) fire relaying information to spinal cord
After 6 seconds GTO relays signal for muscle tension to decrease
Results in reflex relaxation of antagonist
Prevents injury - protective mechanism
With static stretching golgi tendons are able to override impulses from muscle spindle following initial reflex resistance
Static Stretching:
Passively stretching
Go to point of maximal stretch (end point resistance), back off slightly and hold for extended period
20-30 seconds (3 to 4 times)
Controlled, less chance of injury
Not dynamic
Should precede ballistic stretching
Stretching Techniques:
Dynamic stretching
Stretching technique of choice in athletic populations
Related to types of activity an athlete will engage in
Tend to be more functional in nature
Recommended prior to beginning an activity
Stretches that mimic components of athletic activity
Ballistic Stretching
Bouncing movement in which repetitive contractions of agonist work to stretch antagonist muscle
While effective in improving flexibility, caution should be exercised
Increased motion is achieved through a series of jerks on resistant tissue
Possible soreness may result if jerks are greater than tissue extensibility
Proprioceptive Neuromuscular Facilitation:
Using PNF = benefit greatly from these principles
Relaxation of antagonist during contraction = autogenic inhibition
Relaxation of antagonist during agonist contraction = reciprocal inhibition
Technique that involves combination of alternating contractions and relaxation of both agonist and antagonists
Core Stabilization Training:
The core is the lumbo-pelvic-hip complex
Center of gravity is located there
Core training works to improve
Dynamic postural control
Muscular balance
Functional strength
Neuromuscular efficiency
Body must be adequately stabilized
Allows muscles (prime movers) to generate strong, powerful, movements
“You can’t fire a cannon from a canoe”
Progressive Core Training:
Exercises must elicit maximal training response
Should be safe, challenging, stress multiple planes, and incorporate a variety of resistance equipment
Begin with activities where you are able to maintain stability and optimal neuromuscular control
“The best approach for developing the core muscles is through a variety of different exercises that involve a combination of stabilizing as well as dynamic functions”
Helmet Fitting:
NOCSAE develop standards for football helmet certification
Follow manufacturer’s directions
Must routinely check fit
Certification is of no avail if helmet is not fit and maintained
Key Points
Ear holes line up
Occipital protuberance - covers base of skull
2 fingers to eyebrow - open
3 finger “nose-to-mask” - open
Jaw covered
“Shake test”
Football Shoulder Pads:
Two types
Cantilevered - bulkier and used by those engaged in blocking and tackling
Non-cantilevered - do not restrict motion (quarterback and receivers)
Rules of fitting
Inside of pad should cover tip of shoulder in line with the lateral aspect of the shoulder (AC joint)
Epaulets and cups must cover deltoid (shoulder) and allow motion
Neck opening must allow athlete to raise arms over head w/o pads sliding forward and back
Front portion should cover the Xiphoid Process
Ice Hockey Helmets:
Helmets must be approved by Canadian Standards Association or the Hockey Equipment Certification Council
Thorax and Rib Protection:
Thorax protectors and rib belts
Protect against external forces
Air-inflated interconnected cylinders (jacket design)
Hips and Buttocks:
Required in collision and high-velocity sports
Boxing, snow skiers, equestrians, jockeys and water skiers
Girdle and belt types
Ankle Braces:
Alone or with tape -- they are increasingly popular
Significant debate over efficacy
Little or no impact on performance
Compared to tape, the device will not loosen significantly with use
Research also looking at impact on proprioceptive effects
Evidence to support use for prevention
Shin and Lower Leg:
Anterior aspect of leg is exposed to direct blows
Commercially marketed, hard molded shin guards are used in field hockey and soccer
Thigh and Upper Leg:
Necessary in collision sports
Pads slip into ready made uniform pockets
Customized pads may need to be held in place with tape and/or wraps
Neoprene sleeves can also be used for support of injuries
Knee Braces:
Used prophylactically to prevent injuries to MCL
AOSSM has expressed concerns to efficacy in doing so
May positively influence joint position sense
Types of Braces
Rehabilitative:
Widely used following surgery
Allows controlled progressive immobilization
Adjustable
Functional:
Used during and following rehab to provide functional support
Ready-made and customized
Neoprene (w/ medial and lateral support)
Used by those that have sustained collateral ligament injuries
Some are also used to provide support in those that have patellofemoral conditions
Elbow, Wrist and Hand Protection:
While the elbow is less commonly injured it is susceptible to instability, contusions, and muscle strain
Wrist, hand and finger injuries are often trivialized but can be functionally disabling
Susceptible to fracture, dislocation, ligament sprains and muscle strains
Gloves and splints are available for protection and immobilization
Construction of Protective and Supportive Devices:
An athletic trainer should be able to design and construct protective devices
A variety of hard and soft materials are available
Hard and soft materials
Gauze: versatile, can be used for protection or absorption
Cotton: cheapest and more widely used (absorbent, holds emollients and offers mild padding
Adhesive felt (moleskin, spongy rubber):
Felt: matted wool fibers, pressed in a variety of thicknesses
Construction of Protective and Supportive Devices:
Foam: many uses with many densities
Resilient, non-absorbent material that protects against compressive force
Non-yielding Materials
Thermomoldable plastics
Used in orthotics, braces, splints and for shielding body parts
Casting, support for foot, protect contusions
Casting Materials
Effective shell for splinting and padding
Summary:
Periodization- Intensity, volume, and specificity are manipulated to achieve peak levels of fitness while minimizing likelihood of injury.
Preparatory period- 3 phases
Hypertrophy phase
Strength Phase
Power phase
Stretching
Types of Stretching
Ballistic, Dynamic, Static
PNF- slow reversal hold relax, contract relax, hold relax
Core Stabilization
Equipment Fitting - key points
Helmet
shoulder pads
Chapter 5: Substance Abuse & Young Athletes
Performance Enhancing Drugs:
Drug use designed to improve performance is known as doping
Doping
“Administration or use of substances in any form alien to the body, or of physiological substances in abnormal amounts and with abnormal methods by healthy persons with the exclusive aim of attaining an artificial and unfair increase in performance in sports.”
Stimulants:
Used to increase alertness, reduce fatigue, increase competitiveness and hostility
Some respond with loss of judgment that may lead to personal injury or injury to others
Amphetamines
Extremely potent and dangerous
Most widely used for performance enhancement
Can produce euphoria w/ heightened mental status until fatigue sets in, accompanied by nervousness, insomnia, and anorexia
In high doses, will reduce mental activity and decrease performance
Athletes believe that it promotes quickness and endurance, delay fatigue, and increases confidence
Research indicates that it may increase the risk of injury, exhaustion and circulatory collapse
ADHD Medication
Amphetamines such as Ritalin & Adderall
Stimulants that decrease distractibility and facilitate focus
Reasons for abusing include improving attention, partying, reducing hyperactivity, and improving grades
Common signs and symptoms
Shakiness, rapid speech or movements
Difficulty sitting still, concentrating
Lack of appetite, sleep disturbance, and irritability
Caffeine
Found in coffee, tea, cocoa and cola
CNS stimulant, diuretic and stimulates gastric secretion
In moderation it will cause wakefulness and mental alertness
Large amounts will cause:
Elevated blood pressure, changes in heart rate
Increased plasma levels of epinephrine, norepinephrine and renin
Impacts coordination, sleep, mood, behavior and thinking processes
Additional:
Narcotic Analgesic Drugs
Morphine and codeine are examples
Used for management of moderate/severe pain
Risk physical and psychological dependency
Beta blockers
Primarily used for hypertension and heart disease.
Used for sports requiring steadiness
Relax blood vessels, slows heart rate and decreases cardiac output
Diuretics
Used for variety of cardiovascular and respiratory conditions
In sports, misused for weight loss or to decrease a drug's concentration in urine
Certain classes banned for ethical and health grounds
Blood Reinjection (Blood doping):
Endurance, acclimatization and altitude make increased metabolic demands for the body, requiring increased blood volume and RBCs
Can replicate physiological responses by removing 900 ml of blood and re-infusing after 6 weeks (allows time to replenish supply)
Can significantly improve performance
While unethical, it can also prove to be dangerous
Anabolic Steroids:
Synthetic chemical (structure resembles sex hormone, testosterone)
Androgenic effects
Growth, development and maintenance of reproductive tissues, masculinization
Anabolic effects
Promote nitrogen retention leading to protein synthesis - causing increased muscle mass and weight, general growth and bone maturation
Goal is to maximize this effect
Can have deleterious and irreversible effects causing major threats to health
Androstenedione
Weak androgen produced primarily in testes and in lesser amounts by adrenal cortex and ovaries
Increases testosterone in men and particularly women
Effects last a few hours
No scientific evidence to support or rebuke efficacy or safety of using this ergogenic aid
DEA regulated substance
Banned by IOC, NFL, NCAA, and minor league baseball
Contains steroid hormones
May result in breast enlargement, testicular shrinkage (males) or facial/body hair, voice deepening, and clitoral enlargement (females)
Drug Testing in Athletics:
NCAA and USOC have established banned substances lists and testing programs
Banned substances list have not been set at the high school level
Choice is left up to the individual schools
Testing at the high school level is on the rise
NCAA Banned Substances:
The NCAA bans the following classes of drugs:
a. Stimulants
b. Anabolic Agents
c. Alcohol and Beta Blockers (banned for rifle only)
d. Diuretics and Other Masking Agents
e. Street Drugs
f. Peptide Hormones and Analogues
g. Anti-estrogens
h. Beta-2 Agonists
i. Blood Doping
j. Marijuana
k. Local Anesthetics
Common Overuse Injuries in Young Athletes:
Causes of Common Overuse Injuries:
Repetitive Stress w/o adequate recovery
Training errors
Improper technique
Excessive sports training
Inadequate rest
Muscle weakness
Muscle imbalance
Common Overuse Injuries:
Apophysitis bone stress injury (stress fx)
Epiphysiolysis (abnormal/excessive bone growth)
Tendinopathy
Patellofemoral pain syndrome
Osteochrondritis dessicans
Factors that may influence risk of overuse injury:
Nutrition, anatomy, age, BMI, sleep, prior injury, insufficient caloric intake, and low vitamin D levels
Growth plate fractures:
Growth plate
Region at the end of long bones where bone growth occurs
Determines length and shape of bone
Trauma could be single acute incident or chronic, overuse, stress related
Suspected fracture should be referred to a physician immediately
Determine severity and form of treatment/immobilization
Must be carefully monitored
Bone will either not get longer or end up with stimulated growth with injured leg becoming longer than uninjured
Complicated fractures must be followed up with until skeletal maturity is reached
Apophysitis:
Apophysis
Specialized area of cartilage within growth plate
Repetitive stress results in inflammatory response
Osgood-Schlatter’s and Sever’s Disease (tibia and calcaneus bones, respectively)
Not serious (with conservative treatment) and will typically resolve over time
Treatment is directed toward reducing symptoms
Prevention of Pediatric Overuse Injuries:
Preventing Overuse Injuries in Young Athletes
“Requires identifying and addressing factors that lead to an imbalance between stress and recovery”
Only increase training loads 10% - 20% per week
Develop individualized programs to address mechanical factors that may have led to prior injuries
Optimize nutrition, hydration & sleep
Work to improve psychosocial factors for all athletes
Play one overhead sport at a time
Playing multiple sports provides wider skill development
Athletes should 2 – 3 months off from each sport per year
Avoid specialization and repetitive sport activity at a young age
Chapter 6
Infectious Diseases
Caused by invasion or infection of a host (a person or animal) by microorganisms called pathogens
Pathogens cause diseases by either disrupting a vital body process or stimulating the immune system to mount a defensive reaction.
Immune response against a pathogen includes high fever, inflammation, and other associated symptoms.
Can be more devastating than the direct damage caused by the pathogen itself.
Most common pathogens are microorganisms.
Examples: Viruses, bacteria, parasites, and fungi.
Characteristics:
Can live harmlessly in a host without causing infection.
Can become a pathogen in a new host.
Can enter the body through the respiratory system, skin, digestive system, or reproductive system.
Preventing the spread of infectious disease
WHO and CDC recommend the following
Wash hands
Face mask
Avoid close contact with sick people
Get tested after coming in contact with infected people
Avoid crowds and indoor places that have poor ventilation
Wash hands often with soap and water for at least 20 seconds, or use an alc based hand sanitizer that contains at least 60% alcohol
Cover mouth when cough or sneeze
Avoid sharing dishes, glasses, towels, bedding
Clean and disinfect high touch surfaces
Stay home if sick unless going to get medical care
Must be diligent
Most effective=washing hands
Immunizations up to date
Educate patients on inability of antibodies to impact viruses, and need to take antibiotics as directed
Encourage healthy lifestyle habits
Bloodborne pathogens
Pathogenic organisms, present in human blood and other fluids (cerebrospinal fluid, semen, vaginal secretion and synovial fluid) that can potentially cause disease
Most significant pathogens are Hep B, C, HIV
Healthcare facility must be maintained as clean and sterile
The immune system
Mechanical defenses
Separates the internal body from the external environment
Skin, mucous membranes, nasal hairs, cilia lined airways
Cellular System (Immune system)
Eliminates microorganisms, foreign proteins and antigens
Consists of T-cells and B-cells
Located in bloodstream lymphatic tissues and interstitial fluid
Hepatitis B and C
Major cause of viral infection, resulting in swelling, soreness, loss of normal liver function-indication for liver transplant
S&S
Flu-like symptoms like fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice
Possible that individual will not exhibit signs and symptoms -- antigen always present
Can be unknowingly transferred
Prevention
Good personal hygiene and avoiding high risk activities
Be cautious as HBV can survive in blood and fluids, in dried blood and on contaminated surfaces for at least 1 week
Management (HBV)
Vaccination against HBV should be provided by employer to those who may be exposed
Athletic trainers and allied health professionals should be vaccinated
Post-exposure vaccination is also available after coming into contact with blood or fluids
Management (HCV)
No vaccine for HCV
HIV
Virus has potential to destroy immune system
According to World Health Organization 37.6 million people were living with HIV/AIDS in 2020
Symptoms and Signs
Transmitted by infected blood or other fluids
Fatigue, weight loss, muscle or joint pain, painful or swollen glands, night sweats and fever
May go for 8-10 years before S&S develop
Most that acquire HIV will develop acquired immunodeficiency syndrome (AIDS)
AIDS (acquired immunodeficiency syndrome)
Collection of signs and symptoms that are recognized as the effects of an infection
No protection against the simplest infection
Positive test for HIV cannot predict when the individual will show symptoms of AIDS
50% develop AIDS w/in 10 years of HIV infection
After contracting AIDS, people generally die w/in 2 years of symptoms developing
HIV and athlete participation
No definitive answer as to whether asymptomatic HIV carriers should participate in sport
American with Disabilities Act: says athletes infected cannot be discriminated against and may only be excluded with medically sound basis
Must be based on objective medical evidence
Also, must take into consideration risk to patient and other participants and means to reduce risk
Bodily fluid contact should be avoided
Chance of transmitting HIV among athletes is low
Minimal risk of on-field transmission
Some sports have potentially higher risk for transmission because of close contact and exposure to bodily fluids
________ (list of close contact sports?)
Avoid exhaustive exercise that may lead to susceptibility to infection
Universal precautions
Aimed to prevent spread of bloodborne pathogens
Occupational safety and health administration (OSHA) established standards for employer to follow that govern occupational exposure to blood-borne pathogens
Developed to protect healthcare provider and patient
All sports programs should have exposure control plan
Include counseling, education, volunteer testing, and management of bodily fluids
Preparing the athlete
All open wounds and lesions should be covered with dressing that will not allow for transmission
Occlusive dressing lessens chance of cross-contamination
Hydrocolloid dressing reduces chance that wound will reopen, maintains moist and pliable wound
When bleeding occurs
Athletes must be deemed safe
Bloody uniforms must be removed or cleaned, it can sometimes be removed with hydrogen peroxide.
Disinfectants
Contaminated surfaces should be cleaned immediately with a solution of one part bleach to ten parts water or with a disinfectant approved by the Environmental Protection Agency.
Contaminated towels or other linens should be bagged and separated from other laundry.
Soiled linen is to be transported in red or orange containers or bags that prevent soaking or leaking and are labeled with the biohazard warning labels.
Contaminated laundry should be washed in hot water (160°F for 25 minutes) using a detergent that deactivates the virus.
Personal precautions
Use appropriate equipment
Latex gloves, gowns, aprons, masks and shields, eye protection, disposable mouthpieces for resuscitation
Extreme care must be used with glove removal
Hands and skin surfaces coming into contact with blood and fluids should be washed immediately with soap and water (anti-germicidal agent)
Sharps
Needles, razorblades, and scalpels
Use extreme care in handling and disposing all sharps
Do not recap, bend needles or remove from syringe
Scissors and tweezers should be sterilized and disinfected regularly
Types of open wounds
Abrasions
Skin scraped against rough surface
Top layer of skin wears away exposing numerous capillaries
Often involves exposure to dirt and foreign materials = increased risk for infection
Laceration
Blunt force delivered over a sharp bone or a bone that is poorly padded results in wound with jagged edges
May also result in tissue avulsion
Puncture Wounds
Can easily occur during activity and can be fatal
Penetration of tissue can result in introduction of tetanus bacillus to bloodstream
Avulsion Wounds
Skin is torn from body = major bleeding
Place avulsed tissue in moist gauze (saline), plastic bag and immerse in cold water
Take to hospital for reattachment
Incisions
Wounds with smooth edges
Consider causes from razor blades, glass, etc.
Immediate care
Should be cared for immediately
All wounds should be treated as though they have been contaminated with microorganisms
To minimize infection clean wound with copious amounts of soap, water and sterile solution (Hibiclens)
Avoid hydrogen peroxide initially
Dressing
Sterile dressing should be applied to keep fresh wounds clean.
Occlusive dressings provide a complete barrier around and over a wound and are air-tight and water-tight.
Antibacterial ointments are effective in limiting surface bacterial growth and prevent the dressing from sticking to the wound.
Saline solution is recommended for cleaning wounds repeatedly.
Are sutures necessary?
Deep lacerations, incisions and occasionally punctures will require some form of manual closure
Decision should be made by a physician
No specific timeline, sutures should be used within 12 hours
Area of injury and limitations of blood supply for healing will determine materials used for closure
Physician may decide wound does not require sutures and utilize steri-strips or butterfly bandages
Signs of wound infection
Same as those for inflammation.
Pain, heat, redness, swelling, and disordered function.
Pus may form due to accumulation of white blood cells.
Fever may occur as the immune system fights bacterial infection.
Most wound infections can be treated with antibiotics.
Some strains of Staphylococcus aureus have become resistant to some antibiotics.
Bacteria is known as methicillin-resistant Staphylococcus aureus (MRSA) and is more difficult to treat.
Infections tend to become more severe than they may otherwise have been if the cause of the infection is not diagnosed early, and antibiotics that are given at first may not work.
Tetanus
Bacterial infection that may cause fever and convulsions.
Occurs most often with a puncture wound.
Tonic spasm of skeletal muscles is always a possibility for any non immunized athlete.
Tetanus bacillus enters the wound as a spore and acts on the motor end plate of the central nervous system (CNS).
After initial childhood immunization with a tetanus vaccine, boosters should be given every 10 years.
Athletes who are not immunized should receive tetanus immune globulin (Hyper-Tet) immediately following a skin wound.
Methicillin Resistant Staphylococcus Aureus (MRSA)
Cause
Strain of bacteria that is resistant to methicillin and other antibiotics
Often times occurs in patients in hospital that are already ill, have open cuts or wounds
Can also infect people outside the hospital
Symptoms
Broad range
Typically, redness, tenderness, and swelling
Injury reports
Injury reports serve as future reference
Reports can shed light on events that may be hazy following an incident
Necessary in case of litigation for up to three years after the injury
All reports should be filed in the athletic health care facility and in the athlete’s medical record
SOAP format
Subjective – information that the patient / athlete tells the athletic trainer about the injury (what happened, what they felt or heard)
Objective – information such range of motion, strength levels, visually obvious information (deformity, color, swelling
Assessment – the professional opinion of the athletic trainer based on the subjective and objective information
Plan – the plan of treatment and how the injury will be managed with short- and long-term goals for care and rehabilitation
Summary
Universal Precautions- aimed to prevent spread of bloodborne pathogens
Hepatitis B, Hepatitis C, HIV
Types of Open Wounds
Policies regarding bloodborne pathogens
Use appropriate methods to dispose infectious materials
Biohazard waste baskets
Sharps containers
Considerations for sutures
SOAP Notes
Chapter 7
Emergency action plan
Primary concern is maintaining cardiovascular and CNS functioning
Key to emergency aid is the initial evaluation of the injured athlete
Establish equipment and helmet removal policies and procedures
Availability of phones and access to 911
Must be aware of wireless phone calling area issues
All staff should be familiar with community based emergency health care delivery plan
Be aware of communication, transportation, treatment policies
Emergency Action Plans
Separate plans should be developed for each facility
Outline personnel and role
Identify necessary equipment
Everyone should know AED location
Cooperation between emergency care providers
Cooperation and professionalism is a must
Athletic trainer generally first to arrive on scene
ATC generally has more experience moving injured players than physician
When AT or physician unavailable, rescue squad should be called
Paramedic has final say in transportation
To avoid problems, all individuals involved in plan should practice to familiarize themselves with all procedures
Including equipment management
Principles of assessment
Primary survey
Performed initially to establish presence of life threatening condition
Airway, breathing, circulation, shock and severe bleeding
Life threatening injuries take precedents
Life threatening injuries include
Injuries requiring CPR
F Profuse bleeding
Shock
Rescue squad should always be contacted in these situations
Secondary survey
Assess vital signs and perform more detailed evaluation of conditions that do not pose life-threatening consequences
Used to identify additional problems in h other parts of the body not necessarily associated with the injury
The unconscious athlete
Provides great dilemma relative to treatment
When acting alone, contact EMS first
Must be considered to have life threatening condition
Note body position and level of consciousness (AVPU)
Active-actively responds
Verbal- responds to verbal instructions
Pain-responds to pain stimulus
Unconscious
Check and establish airway, breathing, circulation
Assume neck and spine injury
Protective equipment such as helmets, face masks, and shoulder pads should be removed to expose the airway as soon as possible.
If the athlete is supine and breathing, monitor closely until consciousness returns.
Emergency CPR
Individuals associated with competitive or recreational sports program should be certified in CPR, AED, and first aid by the American Heart Association, the American Red Cross, or the National Safety Council.
All individuals who provide emergency medical care need to be aware of the Good Samaritan Laws.
Provide legal protection to individuals voluntarily providing emergency care.
American Heart Association simplified CPR for those who are not certified.
Hands only CPR
Requires rescuer to call 911 and then perform 100 to 120 uninterrupted chest compressions per minute until paramedics take over or arrives or an AED is available to restore normal heart rhythm.
Should be used for adults who unexpectedly collapse and stop breathing or are unresponsive.
Administering CPR to an adult
Establish unresponsiveness.
Activate emergency response system, dial 911.
If an AED is available, deliver one shock if instructed by the device and begin CPR.
If no AED, check for definite pulse within 10 seconds.
If there is a definite pulse give 1 breath every 30 seconds
If no pulse, begin cycles of 30 compressions and 2 breaths.
For rescuers who are certified in CPR, the American Heart Association uses the acronym C A B.
Circulation, airway, breathing
Administering CPR to children (ages 1-8) or an infant (<1 year)
Establish unresponsiveness and then call 911
If no AED, check for pulse within 10 seconds
If there is a definite pulse give 1 breath every 30 seconds
If no pulse, for one rescuer begin cycles of 30 compressions and 2 breaths, for two rescuers begin cycles of 15 compressions and 2 breaths
As soon as AED comes, use it, and immediately check rhythm
If shockable, give 1 shock, then resume CPR immediately for 2 minutes.
If not shockable, resume CPR immediately for 2 minutes.
Managing external bleeding
Direct pressure
Firm pressure (hand and sterile gauze) placed directly over site of injury against the bone (if not fractured
Recommended primary technique
Elevation
Reduces blood pressure and facilitates venous and lymphatic drainage
Pressure points
Eleven points on either side of body where direct pressure is applied to slow bleeding (brachial, femoral, etc.)
Managing shock
Generally occurs with severe bleeding, fracture, or internal injuries
Shock occurs when there is not enough blood for the circulatory system
Movement of blood cells slows, decreasing oxygen transport to the body
S&S
Moist, pale, cold, clammy skin
Weak rapid pulse
Inc shallow respirations
Dec BP
Urinary retention and fecal incontinence (severe cases)
Disinterest in surroundings, irritability, restlessness, or excitement
Extreme thirst
Management
Dial 911
Maintain core body temp
Elevate feet and legs 8-12” above heart
Modify positioning if needed due to injury
Keep athlete calm
Conducting a secondary survey
Begin once athlete is stable
Vital signs
HR and breathing rate
BP
Temp
Skin color
Pupils
Movement
Presence of pain
Level of consciousness
On field injury inspection
Decisions can be made with regard to:
Seriousness of injury
Type of first aid and immobilization
Whether condition requires immediate referral to physician for further assessment
Manner of transportation from injury site to sidelines, athletic training room or hospital
Individual performing initial assessments should document findings of exam and actions taken
Once the mechanism has been determined, specific information can be gathered concerning the affected area
Brief history and visual observations
Gently palpate to aid in determining nature of injury
Determine extent of point tenderness, irritation and deformity
Off field assessment
Performed by athletic trainer, physical therapist or physician once athlete has been removed from site of injury
Divided into 4 segments (HOPS)
History
Obtain information about injury
Listen to athlete and how questions are answered
Observation
Compare injured and non-injured areas
Look for gross deformity, swelling, skin discoloration
Physical examination/Palpation
Assess bony and soft tissue structures
Systematic evaluation beginning with light pressure and progressing to deeper palpation – begin away from injured area
Special tests
Designed for every body region for detecting specific pathologies
Used to substantiate findings from other testing
Immediate treatment following acute injury
Primary goal: limit swelling and extent of hemorrhaging
If controlled initially, rehabilitation time will be reduced
Control via PRICE
Protection
Rest
Ice
Compression
Elevation
More recently, POLICE
Protection
Prevents further injury
Immobilization and appropriate forms of transportation will help in protecting an injury from further damage
Optimal loading
Determining and subsequently incorporating the appropriate progression.
Ranges from protecting the tissue to prevent exacerbation of the injury, to mechanically loading the tissue to facilitate healing.
Ice
Initial treatment of acute injuries
Used for strains, sprains, contusions, and inflammatory conditions
Used to decrease pain, promote vasoconstriction
Lowers metabolism, tissue demand for oxygen and hypoxia
Compression
Decreases space allowed for swelling to accumulate
Important adjunct to elevation and cryotherapy and may be most important component
A number of means of compression can be utilized (Ace wraps, foam cut to fit specific areas for focal compression)
Elevation
Reduces internal bleeding due to forces of gravity
Prevents pooling of blood and aids in drainage
Greater elevation = more effective reduction in swelling
Emergency splinting
Should always splint a suspected fracture before moving
Without proper immobilization increased damage and hemorrhage can occur (potentially death if handled improperly)
Two rules
Splint 1 joint above and below fx
Splint injury in position found
Rapid from immobilizer = angulated
Styrofoam chips sealed in airtight sleeve
Moldable with Velcro straps to secure
Air can be removed to make splint rigid
SAM splint
Made with a thin sheet of soft, pliable aluminum covered by padding.
Material can be cut with a pair of taping scissors.
When shaped into structural curves, the aluminum core becomes rigid.
Same sheet of splint material to be reused as many times as desired
Suspected cervical spinal injury
Dial 911 immediately
Work closely with EMS to transport the athlete
Requires extreme care and is best left to paramedics, EMTs, or athletic trainers
Ensure spinal motor restriction to prevent further harm
Maintain head and neck neutral with long axis of body
Stabilization methods
Trap squeeze technique
Head squeeze technique
Equipment considerations
Protective equipment may complicate lifesaving procedures
If appropriate, prior to transporting athlete
Executive summary from the inter-association task force changed language to “when appropriate, protective equipment may be removed prior to transport.”
Apply a rigid cervical collar at the earliest time
Placing athlete on spine board
Initially place the patient on a long spine board, scoop stretcher, or vacuum mattress for extraction from the field or court.
If the patient is supine, utilize a six-plus lift and use a lift and slide technique.
If the patient is prone, logroll him or her onto his or her back.
Once on the spine board, secure the patient using spider straps applied across the chest, hips, thighs, and lower leg.
Secure the head with lateral restraint pads and then secure to the spine board with straps or tape over the chin and forehead.
Equipment considerations
Removal of helmet and shoulder pads appropriate when:
Trained personnel indicate removal
Helmet is not preventing independent movement of the head anymore
Prevents neutral alignment of spine
Prevent airway or chest access
Summary
Emergency Action Plan (EAP) - designates personnel, supplies, and communication in an emergency event
All staff must be aware of procedures within EAP
Controlling bleeding
Direct pressure
Elevation
Pressure points (brachial and femoral)
Shock
S&S
Treatment
Suspected neck/spine injury
POLICE
Splint considerations
Chapter 8: Basics of Injury Response / Rehab
Healing stages cycle
Inflammatory response Phase
***preceded by bleeding that kick starts this cycle
Injury to 3 days
May be longer if surgery
s/s
Redness, swelling, heat, pain, loss of function
Goals
Dec inflammation = ice
Reduce secondary injury
Healthy cell die off - hypoxia
Dec pain
Maintain ROM
Immobilization w/ controlled ROM
Maintain strength
Examples
Cold dec hypoxia injury
Compression encourage lymphatic function
Immobilization limits ROM
Stim reduces pain, restores muscle function
Proliferation (collagenization / fibroblastic) Repair phase
3 days to 3 weeks
s/s
Scar formation
Type I weak collagen
Pain tenderness subsides
Temporary fix
Goals
Deliver o2 and nutrients to repair injured tissue
Remove waste accomplished by increase blood flow to and from injured tissue
Increase ROM
Increase strength
Facilitate neuromuscular control
Davis Law: tissue growth and orientation is response to forces or tension applied
Maturation Phase
3 weeks to 1 year
s/s
Type III strong collagen fibers
Correct orientation
Tissue still remodeling to form strong perm repair
Goals
Increase tissue extensibility
Control post exercise inflammation
Progress functional strength and endurance
Proprioception and somatosensory function
Dynamic and sport specific exercise
Rehab program
Provide correct and immediate first aid to control swelling
Control pain
Restore full ROM
Restore core stability
Restore and inc strength, endurance and power
Reestablish neuromuscular control and balance
Maintain levels of cardiorespiratory fitness
Initial care & controlling swelling:
Primary strategy during inflammatory phase
Initial management has significant impact on course of rehab process
Immobilization while sometimes necessary, can be negative
Early controlled mobilization may enhance healing
Protection: crutches, immobilization in slung, brace or cast
Optimal loading: stimulates healing process of muscle, bone, tendons, ligaments
Load applied to structures that maximizes physiological adaptation
Ice: dec muscle spasm, dec circulation, dec temp, dec inflammation, dec pain
Compression: dec space allowed for swelling to accumulate
Elevation: dec swelling and pooling due to gravity
Controlling pain:
Pain dependent on severity of injury, athlete’s response, perception of pain and circumstances
Pain can interfere w/ rehab, must be addressed
Reduce:
Ice
Heat
Use after inflammatory phase
Electrical stimulation
Gate control theory
Sensory information from cutaneous receptors enters a-beta (thick and myelinated) afferents to dorsal horn of spinal cord
Pain simultaneously travels along a-delta and c-fibers (thin and unmyelinated)
Sensory info overrides pain info, closing gate
Pain message never received
Gate control occurs at the level of spinal cord
Treating pain
Must have clear rationale for use
Induced analgesia
Introduce thermal agents to control pain
Electric to reduce pain
TENS, superficial heat/cold, massage used to target gate theory
Acupuncture, electrical stimulation, deep massage to stimulate endorphin release
Therapeutic modalities
electrical stimulation
Treat inflammation and pain
Ultrasound, microwave, electrical stimulation (transcutaneous electrical muscle stimulation and electrical muscle stimulation)
Ice vs heat
Ice immediately after injury
For at least 72 hrs or until inflammatory phase is over
Not warm to the touch
Heat after inflammatory phase
Too soon increases the chance of more swelling
Used to inc blood flow
Safe to switch from ice to heat when:
Little or no chance of additional swelling
Injury not tender to touch
Any discoloration is starting to dissipate
Restore full ROM
Static Stretching
Passively stretching
Controlled, less chance of injury
Golgi tendon organ
Dynamic Stretching
Related to types of activity for an athlete
Tend to be more functional
Rec prior activity
Ballistic Stretching
Mimics components of athletic activity
Bouncing movement - repetitive contractions of agonist work to stretch antagonist muscle
Muscle spindle: stretch reflex
Proprioceptive neuromuscular facilitation PNF
Involves combo of alternating contractions and relaxation of both agonist and antagonist to increase ROM
Reestablish core stability
Essential to dev functional strength
Core strength and power emphasized early in strength training program
Consider role of breathing
Core training aims to improve:
Dynamic postural control
Functional strength
Neuromuscular efficiency
Body must be stabilized
Allows muscles to generate strong powerful movements
Restoring muscle strength, endurance and power
isometric: exercise minimal joint movement to maintain strength and reduce atrophy (muscle pump)
Progressive resistance Exercise (concentric (lifting) eccentric (lowering) exercise)
Open and closed chain exercises
Isokinetics: Machine with fixed speed provides resistance throughout ROM
How It Works (specialized machine):
The user sits in the machine with their legs secured behind a padded bar.
The machine is programmed to allow movement at a set speed (e.g., 60 degrees per second).
As the user extends their legs, the machine automatically adjusts the resistance so that no matter how much force is applied, the movement speed remains constant.
The same control occurs during the lowering phase, ensuring that both the concentric (lifting) and eccentric (lowering) phases occur at the pre-set speed.
Plyometrics: Quick stretch of the muscle followed by a concentric contraction
Major goal == full and pain free ROM
Reestablishing neuromuscular control
Reestablishing proprioception and kinesthesia should be of primary concern
proprioception: joint position sense (determine position of joint in space)
Kinesthesia: ability to detect movement
Mediated by mechanoreceptors in muscles and joints and cutaneous, visual and vestibular input
Reestablishing neuromuscular control requires repetition of same movement until it is automatic = muscle memory
Regain balance & maintain postural stability
Dynamic joint stability: result of neuromuscular control and proprioception
Postural control: result in integrated visual, vestibular and proprioceptive inputs
Postural control: involves controlling body’s position in space for the dual purpose of stability (balance) and orientation (maintain appropriate relationship between body segments and between the body and enviro for a task)
Maintain postural stability involves complex integration of muscular forces, neurological sensory info from mechanoreceptors and biomechanical info
Even motionless body is undergoing constant postural sway w/ reflexive muscle contractions which correct and maintain dynamic equilibrium in upright posture
Maintain cardiorespiratory fitness
After injury, reduced physical activity unless training to maintain it
Alternative activity to maintain as early as possible
Incorporating functional progressions
Series of gradually progressive activities designed to prepare the individual to prepare the individual for return to sport
If no pain or swelling, advance the activity
Incorporate sport specific skills into rehab program
Running
Increase sport specificity
Latter stages of functional progression activities done at sports practice
Integrate athlete w/ team, coaches
Program will minimize anxiety and apprehension experienced by the athlete upon returning to sport
Optimal functional progression would be designed to allow opportunity for practice of every skill that is required for sport
Functional testing
Use functional progression skills to assess athlete’s ability to perform an activity
Entails single maximal effort to gauge how close the athlete is to full return
If preseason testing was completed, performance can be compared to preseason results to determine if athlete is ready to return to full activity
Tests:
Shuttle runs
Agility runs
Hopping ro distance
Figure 8s
Vertical jumps
1.5 mile run
Criteria to return to full activity
Rehab plan must determine what is meant by full recovery
Athlete fully reconditioned
Full ROM, strength, neuromuscular control, cardiovascular fitness and sport specific skills
Athlete is mentally prepared
Return to play
Athlete fulfilled rehab plan
Sports medicine team decision, physician ultimately responsible
Chapter 9: General Medical Conditions
Types of infection
Viral
Small organism that can live only in a cell
Triggers a disease (or stays dormant) upon entering
Can damage host cell by blocking normal function and using metabolism for self reproduction
Destroys the cell
Ex:
Herpes
Herpes simplex: viral infection in mucous membranes
Type i - cold sore
Type ii - genital
Herpes zoster
Specific pattern on body innervated by nerve root
Reappearance of chicken pox virus
s/s
Early: tingling/ hypersensitivity in infected area 24 hrs before appearance of lesions
Local swelling followed by vesicles
Heal in 10-14 days
Care
If outbreak, they should _______ due to contagious nature
Verruca virus and warts
Forms
Verruca plana - flat wart
Verruca plantaris - plantar wart
Condyloma acimnatum - venereal
Wart enters through lesion in skin
s/s
Small round, elevated lesions with rough dry surfaces
Painful if pressure
Secondary bacterial infection
Care
Protect until treated
Freezing kits
Mononucleosis
Epstein barr virus incubation period of 4-6 weeks
Transmitted through saliva
s/s
3-5 days: severe fatigue, headache, loss of appetite, myalgia
5-15 days: fever, swollen lymph nodes, sore throat, enlarged spleen
Jaundice, rash, puffy eyelids
Care
Symptomatic treatment
Acetaminophen
Resume training after 3 weeks if spleen not enlarged / painful, no fever, liver function normal, pharyngitis resolved
Contact sports wait 1 month so spleen returns to normal size
Fungal
Cause
Ringworm fungi - tinea
Cause of most skin, nail and hair fungal
Care
Non prescription meds
Failure to respond to meds indicates non fungal problem (bacteria)
Topical meds, oral,
Topical antifungal cream, good foot hygiene
Tinea corporis: topical med
Ex
Tinea cruris
Jock itch: bilateral brown red lesion resembling the outline of butterfly in groin
Tinea pedis
Athletes foot
Extreme itching in soles of feet and between toes
Rash w/ small pimples exuding yellow
Scratching → tissue inflamed and infected (red white or gray scaling)
Bacterial
Single celled microorganisms
Bacterial pathogen enters host, growth of bacteria and production of toxic substances occurs and host attempts to fight infection
Types
Staphylococcus
Streptococcus
Methicillin resistant staph aureus MRSA
Cause
In pts in hospital w/ open wounds
s/s
Broad range
Redness, tender, swelling
Small red bumps look like pimple
Turns into painful boil or abscess → life threatening
Care
Cover and hcp
Antibiotics IV
Surgically drained
Hypertension high blood pressure
Primary hypertension accounts for 90% of all cases with no other disease association
Secondary hypertension is associated with kidney disorder, overactive adrenal glands, hormone-producing tumor, narrowing of aorta, pregnancy and medications
s/s
Primary == asymptomatic until complications
Dizzy, flushed, headache, fatigue, epistaxis, nervous
Management
Thorough examination to determine type of hypertension and extent of hypertension
Medication is not recommended for those with pre-hypertension (120-139/80-89) unless linked with other conditions
Individuals with stage 1 and 2 hypertension should be medicated
Risk of heart disease and stroke double for each 20/10 increase
Normal 120/80
Pre htn >139/89
Stage 1 >159/99
Stage 2 > 160/100
Prognosis / return to participation
Mild htn: participate in all sports if no organ damage or heart disease
Severe htn: restrict from strenuous exercise, dynamic physical activity discouraged
GI
4 quadrants
RUQ: liver, gallbladder, duodenum, R adrenal gland, portions of R kidney
LUQ: spleen, stomach, body of pancreas, L adrenal gland, portion of L kidney
RLQ: Appendix, ascending colon, bladder, ovary, R spermatic cord, R ureter
LLQ: Sigmoid colon, descending colon, bladder, ovary, L spermatic cord, L ureter
Red flags for ad pain = immediate referral
Vomiting bright red blood or black material reminiscent of coffee grounds
Fever of 101⁰ F or more, accompanied by severe abdominal pain
Persistent vomiting, such that the person is unable to keep any fluids down for more than 24-36 hrs.
Evaluation:
History
Pain: onset, duration, quality, radiation
Other symptoms: nausea, vomiting, diarrhea, constipation, fever
Medications, appetite, and bowel habits
Observation
Shape and symmetry
Assessment of skin and scars
Auscultation- Do BEFORE percussion and palpation of abdomen
Bowel sounds
Percussion
Four Quadrants
Liver span and spleen
Palpation
Light palpation prior to deep palpation
Palpate spleen, liver, kidneys, and McBurney’s point
Viral gastroenteritis
Watery diarrhea, nausea, and fever
Pay attention to dehydration as needed
Referral needed if over the counter medicine is not effective or if symptoms exceed 48 hrs
Return to participation:
When s/s resolve in 2-3 days, hydration adequate
Bacterial diarrhea = food poisoning suspected if multiple people get sick
More severe and longer than viral gastroenteritis
High fever, abdominal cramps, vomiting
Onset may occur 4-6 hrs. after meal or even 3-10 days later dependent on bacteria
Prognosis
Over the counter medicines for viral gastroenteritis
Return to play as symptoms resolve and hydration is normal
Appendicitis
Cause = acute obstruction and inflammation of appendix
s/s
Discomfort may begin near umbilicus and will progress to RLQ
Pain localizes and maximal tenderness @mcburneys point
Low grade Fever and Nausea or vomiting
Prognosis
Refer immediately due to surgical emergency
Immediate surgery is warranted with the symptoms; even normal appendixes are removed in surgery if the appendicitis was expected
Timing for return is given by the surgeon. Varies by sport, type of surgery, and other complications
Diabetes
Imbalance between blood sugar and insulin
Affects 24 million people, 5.7 are unaware they have disease.
Diabetics are active with little to no restriction in sports, as long athletes are able to properly manage blood sugar concentrations
Measured via “glucometer”; Range for glucose level is prescribed by endocrinologist
Type I - insulin dependent
typically occurs in individuals under age 35
Autoimmune beta cells in Islets of Langerhans are attacked
Type ii - non insulin dependent
Becoming increasingly prevalent in younger individuals due to childhood obesity; body’s inability to use insulin effectively.
s/s
Type I - sudden symptoms of frequent urination, constant thirst, weight loss, constant hunger, weight loss, tiredness, weakness, itchy dry skin and blurred vision
Diagnosed through measurements of blood glucose levels
Type 2- Usually a prolonged symptom free period (years) of hyperglycemia
Treat
Goal is to have normal blood sugar level and prevent multiple complications if elevated levels persist
Use of Insulin via insulin pump or direct injections in combination of a proper diet
Regular use of glucometer to measure levels after meals, prior to activity, and post activity
Have extra glucometer, insulin, and glucose in kit if needed
Return to activity
Knowledge of disease, medication, and dietary habits are necessary to control blood sugar levels
Wound healing is more difficult and extensive in diabetics; ALL wounds need to be effectively cared for
Emergencies
Hyperglycemia
Etiology
Loss of sodium, potassium and ketone bodies through excessive urination (ketoacidosis)
s/s
Labored breathing (Kussmaul), fruity smelling breath (due to acetone), nausea, vomiting, thirst, dry mucous membranes, flushed skin, mental confusion or unconsciousness followed by coma
Management
Early detection is critical as this is a life-threatening condition
Monitor blood glucose levels
Insulin injections may help to prevent coma
Insulin shock / hypoglycemia
Etiology
Occurs when the body has too much insulin and too little blood sugar
s/s
Tingling in mouth, hands, or other parts of the body, physical weakness, headaches, abdominal pain, blurred vision
Normal or shallow respiration, rapid heart rate, tremors along with irritability and drowsiness
Management
Adhere to a carefully planned diet including snacks before exercise
Emergency Tx: readily digestible carbohydrates
Difference:
Hyperglycemia
Labored breathing (Kussmaul) and gasping for air
Fruity-smelling breath
Extreme thirst, dry mouth, flushed skin
blood glucose >180
tx- assist insulin injection
Risk: Diabetic Coma
Hypoglycemia
Physical weakness
Normal or shallow respirations
Blurred vision
blood glucose <70
tx- give sugar
Risk: Insulin Shock
Sickle cell anemia
Etiology
Hereditary hemolytic anemia - RBCs are sickle or crescent shaped (irregular hemoglobin)
35% of Black population have the sickle cell trait
Less ability to carry oxygen, limited ability to pass through vessels, causing clustering and clogging of vessels (thrombi)
Severe cases can result in death if embolism develops and travels to lungs
Can be brought on by high altitudes
Exercise factors causing sickle cell anemia:
Acidosis
Hyperthermia
Dehydration
Severe hypoxemia
Signs and Symptoms
Fever, pallor, muscle weakness, pain in limbs
Headaches and convulsions are also possible
Early preseason workouts in hot humid enviros lead to attacks.
W/ sickling, working muscles become weak and wobbly and can no longer hold up patient
Referral and Diagnostic Tests
Sickle cell trait collapse requires emergency transport to a hospital
Athlete may go into shock and experience multisystem organ failure.
Treatment, Prognosis, and Return to Participation
ABC’s and hospital arrival are required to decrease likelihood of acute renal failure
Provide anticoagulants and analgesics for pain
Management
Build slowly to training with progressions and longer rests
Encourage participation in offseason conditioning and activities
Cease activity w/ onset of symptoms
Testing for trait (required for NCAA division i)
Bronchial asthma
Common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm
Produced from a number of stressors, but exact cause is unclear
s/s
Difficulty breathing, may cause hyperventilation resulting in dizziness, coughing, wheezing, shortness of breath and fatigue
Tight chest, breathlessness, coughing, wheezing, nausea, hypertension, fatigue, headache, and redness of skin
Release of copious amounts of mucus
Management
Regular exercise, appropriate warm-up and cool down, w/ intensity graduated
Using a mask or scarf may be beneficial in avoiding cold, dry, air
Consider exercise in warm humid enviro (i.e., swimming) >>
Conditioning tends to reduce bouts of asthma
Avoid exercising in high levels of pollution or high pollen counts
Inhaled bronchodilators may be useful
Beta agonist - albuterol
Salmeterol – provides prophylaxis for up to 12 hours
Exercise induced asthma
Bronchial asthma triggered by exercise
Brought on by exercise w/ exact cause unknown
Loss of heat and water, sinusitis can also trigger
*Higher likelihood in cold/dry climate
Symptoms
Swelling of the face, palms, and soles of the feet; chest tightness; shortness of breath; coughing; nausea; hypertension; diarrhea; fatigue; itching; respiratory stridor; headaches; and redness of the skin
Care
Regular exercise, gradual warm-up and cool-down, and gradual increase in intensity.
Use of metered-dose inhalers and bronchodilators.
Athletes are reminded to have inhalers with them at all times.
Iron deficiency anemia
Causes
Inadequate dietary intake of iron.
Gastrointestinal (GI) losses are common in runners because of bowel ischemia.
Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) may cause GI blood loss.
Among women: Menstruation and lack of iron in diet.
Symptoms of condition.
First stage of deficiency: Athlete’s performance declines.
Feeling of tiredness and lethargy.
Muscle fatigue and nausea.
Care
Refer to a physician to determine hemoglobin levels.
Eat a proper diet including more red meat or dark chicken.
Avoid coffee or tea.
Consume vitamin C.
Take iron supplements.
Menstrual cycle irregularities
Strenuous training may alter cycle (25-38 day long cycles)
Oligomenorrhea: diminished flow (refers to fewer than 3-6 cycles per year)
Dysmenorrhea: painful menstruation cycle
Etiology
Painful menstruation prevalent in active women
May be caused by hormonal imbalance, ischemia of the pelvic organs, endometriosis
Sign and Symptoms
Cramps, nausea, lower abdominal pain, headache, occasionally emotional variability
Management
Mild to vigorous exercise that help to ameliorate dysmenorrhea are usually prescribed
Continued activity as long as performance levels do not drop
Amenorrhea: is the complete cessation of the cycle
Ovulation is seldom or not at all due to low levels of estrogen circulation
•Etiology
Primary
Female has not had menstrual periods by age 16
Secondary
Occurs when menstrual periods stop for 3-6 months
General population (2-5%); women engaging in intense exercise (up to 40%)
Sign and Symptoms
Complete cessation of menstrual cycle
Depending on the cause, female may also experience headache, vision changes, hair loss, excess facial hair, milky nipple discharge
Management
Thorough medical examination, nutritional counseling, reduction of exercise intensity and emotional stress
Estrogen replacement may be considered
Female athletic triad
More common in female athletes who participate in sports that emphasize leanness or weight restrictions, such as gymnastics, ballet, and figure skating.
Caused by the pressure to excel in her chosen sport and to meet a specific athletic image to attain goals.
Low energy availability
Disordered eating, anorexia nervosa, bulimia nervosa, or restrictive eating patterns.
Menstrual dysfunction
Amenorrhea (absence of the menstrual cycle for more than 6 months)
Osteoporosis or low bone mineral density(BMD)
Premature bone loss in young women, and inadequate bone development.
Care
Returning to normal exercise and eating patterns allow for return of normal menstrual periods
Testicular torsion
Event when testicle is twisted or rotated, this can lead to arterial ischemia of the testicle. Highest incidence among males 12-18 y.o.
Signs and Symptoms
Sudden onset of unilateral scrotum P, scrotal swelling, nausea and vomiting
Tender and painful testicle, may be horizontal in position, elevation of testicle provides no relief
Referral, Treatment, and Return to Participation
Immediate urological emergency and requires fast referral
Treatment in less than 6 hrs. Will have 80-100% salvage of testicle, 0% by 12 hrs.
Physician may manually place testicle back by turning “externally” 180⁰
If not effective, surgery is warranted
Return to participation based on physician clearance
Chapter 10 - Recognizing Sport Injuries
Injury Occurrence Models
Physical Stress Theory
Low → atrophy
Normal → maintenance
Moderate → hypertrophy
High → injury
Extreme → death
Acute Vs Chronic Injury
Trauma is defined as a physical injury or wound that is produced by an external or internal force.
Acute injuries, also referred to as macrotrauma, are caused by trauma.
Chronic injuries, also called microtrauma, can result from overuse such as the injuries that occur with the repetitive dynamics of running, throwing, or jumping.
Acute
Some sort of trauma
Ex: Ankle Sprain, Shoulder Dislocation
Chronic
Overuse
Ex: Patellar & Achilles tendinitis
Fractures
Breaks or cracks in bone
Result of extreme stress and strain on bone
Serious musculoskeletal condition
Signs and Symptoms
Obvious deformity
Point tenderness/Pain on AROM and PROM
Swelling/Crepitus
Opened (through the skin) vs closed (does NOT penetrate through skin)
Types of Fractures
Greenstick – Incomplete break in bone, more common in with children
Comminuted – Three or more fragments
Transverse– Straight line across the bone
Linear – Bone splits along its length
Spiral – Diagonal separation
Oblique – Rotational angle across the bone, similar to spiral
Greenstick
Incomplete break in a bone that has not completely ossified (young child)
Name derived from similarity of fractures to a green twig taken from a tree
Comminuted
Consists of 3 or more fragments at the fracture site
Difficult healing situation
soft- tissues interposed between bone fagments may cause incomplete healing
Transverse
Occurs in a straight line at right angles to the bone shaft
Mechanism: Bending (3-points)
Linear
Occur along the bone’s length
Often result of jumping from a height
Spiral
Have a S-Shaped separation
Fairly common in football and skiing, which foot is firmly planted and body is suddenly rotated
Oblique
Similar to the spiral fractures
caused by axial compression, bending, and torsion
Avulsion
Tendon pulls and removes portion of bone from insertion point.
Fracture Healing
Bone healing following a fracture
Hematoma formation
New blood vessels and ‘soft’ callus
Bony callus formation
Bone remodeling
Fracture healing
Fractures of the long bones of the arm and leg require 6 weeks of casting.
Fractures of the bones in the hands and feet require 3 to 4 weeks of either casting or splinting
Wolff’s Law - Bones adapt to the forces placed on them. This means that bones can remodel themselves to become stronger or weaker in response to stress
Dislocation vs Subluxation
Dislocation
At least one bone in a joint is forced completely out of normal and proper alignment
Must be manually or surgically put back into place or reduced
High level of incidence in fingers, elbow and shoulder
OUT & STAYS OUT
Subluxation
Partial dislocations causing incomplete separation of two bones
Often occur in shoulder and females (patella)
OUT & IN
S&S of dislocations
Deformity – almost always present
Loss of function
Swelling, point tenderness
Dislocations/Subluxations
Additional concerns
Avulsion fractures
“Once a dislocation, always a dislocation”
Treatment
Dislocations (particularly first time) should be considered and treated as a fracture until ruled out
X-ray is the only absolute diagnostic technique
Return to play often determined by extent of soft tissue damage
*Sprain vs Strain
Sprain → Injury to a ligament or joint capsule
Strain → A stretch, tear or rip in muscle or tendon
Ligament Sprains
Damage to a ligament or joint capsule
Result of traumatic joint twist that causes stretching or tearing of connective tissue
Graded based on the severity of injury
Grading System
Grade I, mild- some pain, minimal loss of function, no abnormal motion, and mild point tenderness, slight swelling and joint stiffness
Grade II, moderate- pain, moderate loss of function, swelling, and instability, some tearing of ligament fibers and joint instability
Grade III, severe- extremely painful (initially- followed by minimal/no pain due to no nerve connection), inevitable loss of function, severe instability and swelling, and may also represent subluxation
Common ligamentous sprains in athletics
MCL (Medial Collateral Ligament of the Knee)
ACL (Anterior Cruciate Ligament of the Knee)
Lateral Ankle (Ant. Talofibular Ligament)
AC Joint “Shoulder Separation”
UCL (Ulnar Collateral Ligament of the Elbow)
Muscle Strains
Stretch, tear or rip to muscle or adjacent tissue
Muscle Strain Grades
Grade I - some fibers have been stretched or actually torn resulting in tenderness and pain on active ROM, movement painful but full range present
Grade II - number of fibers have been torn and active contraction is painful, usually a depression or divot is palpable, some swelling and discoloration result
Grade III- Complete rupture of muscle or musculotendinous junction, significant impairment, with initially a great deal of pain that diminishes due to nerve damage
Tendon ruptures
Large tendon ruptures will require surgery
Muscle Strains
Rehabilitation Lengthy process regardless of severity Will generally require 6-8 wks. Return to activity too soon may result in re-injury
Common Muscles: Hamstrings, Quadriceps, Biceps, Rotator Cuff, Calf, etc.
Muscle Guarding and Cramps
Muscle Guarding
Muscles within an effected area contract to splint the area in an effort to minimize pain through limitation of motion
Voluntary muscle contractions occurring in response to pain after musculoskeletal injury
Not spasm (Involuntary muscle contraction) which would indicate increased tone due to upper motor neuron lesion in the brain
Muscle Cramps
Painful involuntary contraction
Attributed to dehydration/electrolyte imbalance
May lead to muscle or tendon injuries
Contusions
= Bruise
Result of sudden blow to body
Can be both deep and superficial
Hematoma results from blood and lymph flow into surrounding tissue
May be painful to the touch and with active movement
Must be cautious and aware of more severe injuries associated with repeated blows
Myositis Ossificans
Myositis Ossificans:
Calcium deposits from repeated trauma in muscle
Quadriceps and biceps are very susceptible to developing myositis ossificans
Causes:
One significant hit
Repeated hits
Improper treatment
Attempting to ‘run off’ a quadricep contusion
Too vigorous treatment (e.g., massage and heat after injury)
Quad Contusion Treatment
Prevention relies on protection and padding
Protection and rest may allow for calcium re-absorption
Long duration stretching a passive exercises
Ice in a stretched position
Nerve Injuries
Two main causes of nerve injury
Compression and tension
Resulting in radiating pain & muscle weakness
Stinger or burner
May be acute or chronic
Causes pain and can result in a host of sensory responses
Hypoesthesia = less
Hyperesthesia = more
Paresthesia = tingling
Nerve Injuries
Return to Play
Patient/athlete exhibits full ROM (AROM, PROM)
Full strength
Neuromuscular control
May benefit from additional protective equipment
Chronic Overuse Injuries
Importance of Inflammation in Healing
Essential part of healing process
Must occur following tissue damage to initiate healing
Signs and Symptoms
Pain, redness, swelling, loss of function and warmth
If source of irritation is not removed then inflammatory process becomes chronic
Examples of Chronic Injuries
Stress Fracture
Tendinosis/Tendinitis
Tenosynovitis
Bursitis
Osteoarthritis
Stress Fractures
Most common fracture results from chronic overuse
Number of possible causes
Overload due to muscle contraction
Altered stress distribution due to muscle fatigue
Changes in surface or training routine
Progressively becomes worse over time
Common sites include weight bearing bones of the leg or foot
Pain is most severe during activity
Biggest issue is fracture is often not present on X-ray until osteoblasts begin laying down new bone
Tendinosis and Tendinitis
Tendinosis
Chronic tendon injury without inflammation
Most common overuse problem in sports
Likely that pain occurred with initial stages of injury without proper tendon healing
Tendinitis
Inflammation of the tendon
Crepitus
Crackling sound caused by “sticking” of tendon when sliding
Sticking occurs due to chemical products of inflammation
Tenosynovitis
Inflammation of synovial sheath
In acute case - rapid onset, crepitus, and diffuse swelling
Chronic cases result in thickening of tendon with pain and crepitus
Often develops in long flexor tendons of fingers
Management
Key for treatment is rest and removal of causal factors
Work to maintain cardiovascular fitness using means that don't irritate inflamed tendon
Gradual strengthening program as Sx resolve
Bursitis
Bursa are pieces of synovial membrane that contain a small amount of fluid
Becomes pathological when bursae produce large amounts of synovial fluid due to irritation or inflammation
Both acute (sudden irritation) and chronic (overuse and constant external compression) causes
Results in increased fluid production, causing increase in pressure due to limited space around anatomical structures
Three most commonly irritated
Subacromial
Prepatellar bursa
Olecranon
Osteoarthritis
Wearing away of hyaline cartilage as a result of normal use
Changes in joint mechanics lead joint degeneration (the result of repeated trauma to tissue involved)
Commonly affects weight bearing joints but can also impact shoulders and cervical spine
Summary
Types of acute fractures
greenstick, comminuted, transverse, linear, spiral, oblique
Stress fractures
Dislocations/subluxations
Contusions
Myositis ossificans
Sprains vs Strains
Nerve Injuries
Chronic Injuries-
Tendinitis/tenosynovitis
Bursitis
Osteoarthritis