Injury Evaluation – Beyond Body Regions
Sports Trauma
Tissue Properties and Stresses
Properties
Load - outside forces or forces acting on tissue
Stress - internal reaction/response to the external load
Strain - deformation of tissue under loading
Viscoelastic - viscous and elastic properties which allow for the deformation; all human tissue has these properties
Anisotropic - tissue also has this property, dependent on the direction of load, the tissue will respond with greater or lesser strength
Yield point - elastic limit of tissue
Mechanical failure - what causes tissue to break but the limit being exceeded that the tissue can handle
Stresses
Tension - a force that pulls or stretches the tissue
Stretching - going beyond the yield pint can lead to rupture of soft tissue or fracture
Compression - when enough energy causes the tissue to not withstand the force
Shearing - force moving across parallel tissue
Bending - force on horizontal bone where the stress causes bending or strain
Trauma and Injury
Soft tissue trauma can be:
Inert (noncontractile) - skin, joint capsules, ligaments, fascia, cartilage, dura mater, and nerve roots
Contractile - muscle, tendon, or bony insertion
Skin injuries
Two-layer - epidermis and dermis
Can be caused by friction (blister), scraping, compression (bruise), tearing (laceration, avulsion), cutting, and/or penetrating (puncture)
Skeletal muscle injuries
Muscle fibers properties: contraction, irritability, conductivity, elasticity
Types: striated, cardiac, and smooth
Sarcoplasm (inner to outer), endomysium, perimysium (arteries, veins, lymph vessels, and nerve fibers), epimysium (capillaries)
Aponeurosis (fibrous wrapping) that attaches to other muscles
Types of injuries
Contusions
Strains
Tendon injuries
Muscle spasms
Overexertion muscle problems
Muscle guarding
Myofascial trigger points
Chronic musculotendinous injuries
Myositis
Fasciitis
Tendonitis
Tenosynovitis
Ectopic Calcification
Atrophy
Contracture
Synovial Joints
Joints
Cartilage and fibrous connective tissue
Classification:
Synarthrotic = immovable
Amphiarthrotic = slightly movable
Diarthrotic = freely movable
Joint capsule - strong, the cuff of fibrous tissue consisting of collagen and helps to maintain relative joint position
Ligaments
Collagen fibers that connect two bones
Intrinsic - where the articular capsule is thickened
Extrinsic - outside of joint
Contain elastic and collagen fibers - wavy, irregular, spiral
Strongest in middle; weakest at ends
Avulsion fractures
Injury factors
Constant compression or tension leads to deterioration
Intermittent compression or tension increases strength
Chronic inflammation shrinks collagen fibers leading to acute injuries
Joint protection
Capsules and ligaments provide protection
Roux's law of function adaptation - an organ will adapt itself structurally to an altercation, quantitative or qualitative, of function
Synovial membrane and synovial fluid
Connective tissue with flattened cells and villi
Fluid secreted and absorbed acts as a lubricant
Articular cartilage
No direct blood flow or nerve supply
Three types:
Hyaline (articular) - nasal septum, larynx, trachea, bronchi, articular ends of bones -
Provides static and dynamic stability; no direct blood supply
Motion control, stability, and load transmission
Fibrous - vertebral disks, pubic symphysis, menisci
The elastic - external ear, Eustachian tube
Additional synovial joint structures
Fat pads - knee and elbow
Fibrocartilage - disks connected to the capsule
Nerve supply
Mechanoreceptors provide information about the relative position of the joint; myelinated
Types of synovial joints
Ball and socket - glenohumeral, hip joint
Hinge - elbow
Pivot - cervical atlas and axis, proximal ends of radius and ulna
Ellipsoidal - wrist
Saddle - carpometacarpal joint of the thumb
Gliding - joints between the carpal and tarsal bones, intervertebral joints
Synovial joint stabilization
Hilton's law - the joint capsule, the muscles moving the joint, and the skin on top have the same nerve supply
Muscles help stabilize
Shunt muscles - muscles that attach directly to articular cartilage
Articular capsule and ligaments
Ligaments are strongest in middle, weakest at the ends
Quick response than muscles
Synovial joint trauma
Capsule
Acute - tension, compression --> sprains, dislocation, subluxation, synovial swelling
Chronic - tension, compression, shearing --> capsulitis, synovitis, bursitis
Hyaline cartilage
Chronic - compression, shearing --> osteochondrosis, traumatic arthritis
Acute joint injuries
Joint sprains ( Grade I, Grade II, Grade III )
Acute synovitis
Subluxation
Dislocation
Diastasis
Chronic joint injuries
Osteochondrosis
Osteoarthritis
Bursitis
Capsulitis
Synovitis
Bone Injury
Osteocytes (bone cells) fixed in intracellular matric
Outer bone - compact tissue; inner bone - cancellous bone which is more porous - tunnled by marrow cavity
Haversian system - canals of blood vessels and lymphatic vessles
Periosteum - outside bone that contains blood supply
Functions
Body support
Organ protection
Movement
Calcium storage
Hematopoiesis
Types of bone
Flat bones - skull, ribs, scapulae
Irregular bones - vertebral column and skull
Short bones - wrist and ankle
Long bones - humerus, ulnar, femur, tibia, fibula, phalanges
Structures of bones
Diaphysis - main shaft of long bone
Epiphysis - at the ends of long bones
Articular cartilage - covers ends of long bones
Periosteum - fibrous membrane that covers long bones
Medullary (marrow) cavity - hollow tube in long bone diaphysis containing marrow
Calcium salt - make bone hard
Osteocyte - found in lacunae
Haversian system - haversian canal with alternating layers of intercellular matrix
Compact bone - interspersed lamellae fill spaces between haversian system
Cancellous bone - numerous open spaces located between trabeculae
Volkmann’s canal - blood circulation connects periosteum and haversian canal
Bone growth
Osteoblasts synthesize matrix --> calcification of matrix
Ossification begins in the diaphysis and in both epiphyses
Growth plate - layers of cartilage cells in different stages of maturity
Osteoblasts build new bone on outside of bone; at same time
Osteoclasts increase medullary cavity
Bone’s functional adaptation - Wolff’s law
Bone injuries --> Anatomical weak point and load characteristics
Periostitis
Depressed fracture
Greenstick fracture
Impacted fracture
Longitudinal fracture
Spiral fracture
Oblique fracture
Serrated fracture
Transverse fracture
Comminuted fracture
Contrecoup fracture
Blowout fracture
Avulsion fracture
Stress Fracture
Salter-Harris Classification: (Type 1 - Type 5)
Apophyseal injuries - Sever’s disease, Osgood-Schlatter’s disease
Nerve Injury
Neuron-cell body dendrites, axon
Large axons in peripheral nerves enclosed in neurilemmal sheaths
Schwann cells, Satellite cells)
CNS - neuroglial cells - astrocytes, oligodendrocytes, ependymal cells, microglia - work together to bind neurons and provide support for nervous tissue
Injuries - compression, tension
Neuritis
Referred pain
Microtrauma and overuse --> injury
Patho-mechanics - poor mechanic of movement
Many sports are unilateral --> imbalance
Tissue Response to Injury
The Healing Process - Inflammatory Response Phase
Inflammatory response phase
4 days
Cellular injury = altered metabolism and release of the substances that initiate this process
Signs and symptoms
Redness
Swelling
Tenderness
Pain
Warmth (increased temperature)
Loss of function
Leukocytes, phagocytic cells, exudates --> injured tissue
Phagocytosis = dispose of injury byproducts, i.e. blood, damaged celled
Vascular reaction
Immediate vasoconstriction (within minutes)
Vascular dilation
Initial effusion lasting about 24-36 hours
Chemical mediators
Histamine
Leukotaxin - margination --> diapedesis
Necrotic
Leukocytes release - bradykinin and prostaglandin
Formation of clot
Starts at 12 hours post-injury --> finish within 48 hours
Due to injury to a vessel
Blood coagulation
Thromboplastin release --> prothrombin changed to thrombin --> thrombin converts fibrinogen
Phagocytosis
PMN's (polymorphonuclear neutrophils) - kills bacteria
Mononuclear phagocytes/macrophages
Debris removed --> blood coagulates --> epithelial cells migrate
Chronic inflammation
Replaces leukocytes with macrophages, lymphocytes and plasma cells
The Healing Process - Fibroblastic Repair phase
Fibroblastic repair phase
Day 4 - 6 weeks
Fibroplasias - scar formation
Revascularization
Capillary buds grow into wounds by way of decreased oxygen
Fibroblasts lay granulation tissue (fibroblasts, collagen, capillaries)
Wound contraction
Extracellular matrix - collagen, elastin, ground substance - start at the margins of the wound and work their way towards the center of the wound
Types of repair
Resolution = back to normal
Granulation tissue = initial is type III collagen but changes to type I within two weeks leading the tensile strength to begin low
Regeneration = new cells of the same type are made and can still perform the function of previous cells
The Healing Process - Maturation/Remodeling Phase
Maturation/remodeling phase
6 weeks - 2-3 years
Realignment and remodeling of collagen fibers depend on the tensile forces that are put on the scar tissue
Fibers should realign parallel to lines of that tensions
After about 3 weeks, a scar exists
Wolff's law = "bone and soft tissue will respond to the physical demands placed on them, causing them to remodel or realign along lines of tensile force."
When inflammatory symptoms decrease --> controlled mobilization
ROM and strengthening should be done during this phase and depending on the pain
Healing
Factors that impede healing
Extent of injury
Edema
Hemorrhage
Decrease vascular supply
Separation of tissue
Muscle spasm
Corticosteroids
Keloids
Infection
Environmental factors (humidity, climate, oxygen tension)
Biological factors (health, age, nutrition)
Soft tissue healing
Epithelial tissue - skin, organ lining
Connective tissue - tendons, ligaments
Muscle - skeletal, cardiac
Nervous tissue - brain, nerves
Soft tissue adaptation
Metaplasia
Dysplasia
Hyperplasia
Atrophy
Hypertrophy
Cartilage healing
Limited healing capacity
Ligament healing
First 72 hours - blood loss and inflammatory cells
Vascular proliferation --> fibrin clot
Maturation = up to 12 months
Factors that affects ligament healing : Surgery, active exercise vs immobilization and the strength of the muscles that surround the injured site
Muscle healing
Hemorrhage --> edema -- > phagocytosis
Fibroblasts --> fibrosis --> scarring
Long rehab period
Tendon healing
Dense fibrous connectivity --> need a lot of collagen
By the 2nd week - healing tendon connect with tissue that surrounds it
By the 3rd week - tendon starts to separate from tissue
Nerve healing
Regeneration (3-4mm per day) of nerve is impossible unless the cell body is unaffected
Axon that is distal to injury degenerates and breaks down
Regeneration process begins - nerve cell body
Myelin portion of Schwann cells also degenerates
Myelin phagocytized
PNS nerves have possibility of generated better than CNS nerve
Modifying soft-tissue healing
Anti-inflammatory medications may interfere with inflammatory process
Therapeutic modalities
Therapeutic exercise
Immobilization is not always the best
Bone healing
Affected by torsion, bending and compression
Damage to blood vessels and periosteum
First week
Fibroblasts lay down fibrous collagen
Chondroblast --> form callus
Osteoblasts --> form cancellous bone trabeculae which replaces cartilage
Callus (external and internal) crystallizes --> bone and remodeling phase starts
Osteoclasts - to clean up debris
Remodeling - Wolff's law
Weeks - 3-8 - Immobilization
2-3 years - osteoblasts and osteoclasts still work
Acute fractures
Full immobilization
Factors that affect healing
Poor blood supply
Poor immobilization
Infection
Soft tissue impingement
Stress fractures
Cyclic forces that load bone, pull on muscles
Healing = restore balance between osteoclast and osteoblast activity
Better treated is noticed early
Pain
Types of pain
Acute - lasting less than 6 months
Chronic
Referred - pain is not necessarily at the site of injury
Nociceptors and neural transmission
Nociceptors - pain receptors; sensitive to mechanical, thermal, and chemical factors
First-order afferents
Transmit impulses from nociceptor
A-alpha and A-beta = large-diameter
A-delta (fast-skin) and C (slow-skin and deeper) - small diameter
Pain and temperature
Second-order afferents
Carry sensory messages from the dorsal horn to the brain
Receive input from A-betas, A-deltas, and Cs
Third-order afferents
Carry information to the brain for interpretation
Facilitators and inhibitors
Serotonin-descending pathways
Norepinephrine - inhibits pain transmission between first and second-order
Substance P - in first order
Enkephalins - in descending pathways
Beta-endorphins - CNS
Mechanisms of pain control
Level 1 = Gate Control Theory
Level 2 = Central Biasing
Level 3 = Release of Beta-Endorphins
On and Off Field Emergencies
On Field Emergencies
Primary survey
Life-threatening injuries
Check ABC's
Do not remove helmet until clearing neck/spine injury
Supine (not breathing) check ABCs
Supine (breathing) wait for consciousness
Prone (not breathing) logroll to supine, check ABC's
Print (breathing) wait for consciousness
Check, call, care!
CPR
While someone else calls 911
Control bleeding
External - direct pressure with sterile gauze and elevation
Internal - 911
Shock
Reduced blood for the circulatory system
Fatigue, dehydration, illness, low blood pressure, rapid and weak pulse, shallow and rapid breathing
Maintain body temperature, elevate feet and legs
Secondary survey
Pulse - average 80-100 bpm - rapid and weak
Respiration - average 12-20 breaths per minute
Blood pressure - average 120/80 mm Hg
Temperature - hot and dry or cool and clammy
Skin color - red; pale; cyanotic
Pupils - dilated
Level of consciousness - alert, unresponsive
Movement - deficits
Abnormal nerve response - numbness, lack of pain
Musculoskeletal assessment
History
Visual observation - compared bilaterally
Palpation - point of tenderness
Assessment - seriousness, treatment/immobilization, immediate referral
Immediate treatment - RICE
Emergency splinting - vacuum splint, air splint
Lower body - splint above and below joint
Upper body - sling, splint
Spine/pelvis - spine board
Transportation of injured athlete
Spine board
Maintain head and neck alignment
Determine breathing and pulse
Prone - logroll
Supine - lift and slide
Pool
Where is an injured person in the pool
Edge - rescue tube
Deeper - get in the water
Crutch and Cane Fitting
Tip 6 inches anterior, 2 inches lateral
Underarm brace 2-3 finger width
Arm flexion of 30 deg
Crutch-walking
Crutch 12-15 inches ahead and swing through
One crutch
Hold crutch on uninjured side and move crutch simultaneously with an injured leg
Emergency Action Plan (EAP)
Requirements
Personnel and corresponding roles
Emergency equipment
Procedures for removal of equipment
Phone numbers
Emergency call info
Type of emergency
Type of injury
Present condition of injured person
Current assistance i.e. CPR
Location of call
Exact location of emergency
Gate keys accessible
Sports medicine team aware of EAP --> assign roles,
Always have contact information for athletes
EAP for spectators as well
Good relationship with local EMTs
Consent from parents of minor athlete
Off Field Emergencies
Diagnosis - what disease, injury, or syndrome a person is believed to have
Evaluation vs. Diagnosis --> AT needs to stay within the scope
Differential diagnosis - method of diagnosing an injury/illness
Working diagnosis - most likely cause
Etiology - cause of injury or disease
Mechanism - mechanical description
Pathology - structural and functional changes
Symptom - functions that indicate injury or disease
Sign - objective and obvious indications for a specific conditions
Prognosis - predicted outcome
Sequel - condition following or resulting from a disease or injury
Syndrome - a group of symptoms indicating a certain condition or disease
Normal anatomy
Surface anatomy
Key surface landmarks
Planes - sagittal (anteroposterior), transverse (cross-sectional), coronal/frontal (mediolateral)
Anatomical directions - distal/proximal, anterior/posterior, medial/lateral, inferior/superior
Quadrants
Right hypochondriac region --> epigastric region --> left hypochondriac region
Right lateral abdominal region --> umbilical region --> left lateral abdominal region
Right inguinal region --> hypogastric region --> left inguinal region
Musculoskeletal
Joints, bony structure, skeletal muscle, neural anatomy
Abduction/adduction, eversion/inversion, extension/flexion, internal rotation/external rotation, pronation/supination, valgus/varus
Biomechanics
Biomechanics = application of mechanical forces to living organisms
Pathomechanics = mechanical forces that are applied to living organisms and adversely change the body's structure and function
Understand biomechanics and kinesiological aspects of each sport
Evaluation
History
Observation
Palpation
Special tests
AROM, PROM, RROM (strong and painless - all muscles painful)
MMT (0-5)
Neurological
Cerebral function - general effect, loss of consciousness, emotional status, language
Cranial nerves
Cerebellar function - coordinated movements (finger to nose, heel to walk)
Sensory testing - dermatomes and myotomes
Reflexes (0-4 / absence of reflex - hyperactive)
Babinski's
Chaddock's
Oppenheim's
Clonus
Superficial reflexes
Motor testing
Referred pain
Joint stability
Accessory motions
Functional performance
Posture
Measurements
Progress evaluations
Comparing to the previous day, previous treatment, etc.
History
Observation
Special tests
Documentation
SOAP Notes
Subjective
Statements from the injured athletes
Objective
AT's findings but observation, testing, special tests, assessment
Assessment
Judgment on impression and nature of the injury
Plan
Immediate steps (treatment, referral) and/or plans for further treatment, rehab with goals
Progress notes
Written often
Treatment, responses to treatment, progress towards goals, and next steps
Diagnostic testing
X-ray (plain film radiography) - fractures, bony abnormalities
Arthrography - x-ray after injection with dye into joint space to observe joint
Arthroscopy - a surgical procedure is done through a small incision
Myelography - assessment of spinal canal with dye to flow through the spinal cord to detect tumors, disk issues, etc.
CT scan (computed tomography) - view of tissues from many angles, cross-sectional views
Bone scan - evaluate things like stress fractures using a radioactive tracer
MRI (magnetic resonance imaging) - electromagnetic machine to help view clear images
Ultrasonography - ultrasound to view organ or tissue damage
Echocardiography - ultrasound to view cardiac structures
Arteriogram - catheter inserted into a blood vessel with contrast and x-rays to evaluate
Venogram - veins filled with contrast, x-ray to evaluate
Doppler ultrasonography - ultrasound to examine blood flow in major arteries and veins (blood clots)
ECG (electrocardiography) - electrical activity of the heart
EEG (electroencephalography) - electrical waves in the brain
EMG (electromyography) - records muscle contraction
Nerve conduction velocity - speed at which a muscle action occurs
Synovial fluid analysis - detects infection in joint
Blood testing - various tests, CBC = complete blood count (RBCs, WBCs, hemoglobin, hematocrit, etc.)
Urinalysis - evaluation of urine, specific gravity, pH, ketones, protein, electrolytes, etc.
Bloodborne Pathogens
Virus reproduction
A submicroscopic parasitic organism that depends on living cells -- > alters cell activity to create more virus
Bloodborne pathogens
Transmission - human blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluids
Hepatitis B (HBV)
Swelling, soreness, and loss of normal liver function
Hepatitis C (HCV)
Can cause acute and chronic liver disease
Most common bloodborne infection in the US
Jaundice
Hepatitis A, D, E - not bloodborne pathogens
HAV - liver inflammation but does not lead to chronic liver disease (fecal or oral)
HDV - liver inflammation - only affects those that have HBC
HEV - liver inflammation, rare in the USA
HIV
Retrovirus changes cells' RNA
Transmitted by exposure to infected blood or other bodily fluids
Can develops into AIDS
In athletics
The probability of transmitting HIV among athletes is low but some sports might have a higher risk of transmission (wrestling, boxing)
OSHA guidelines and education important
HIV
Americans with Disabilities Act (1991) - athletes infected with HIV cannot be discriminated against and maybe excluded on a medical basis
Many states have laws that protect the confidentiality of someone with HIV
Athletes might be encouraged to do voluntary anonymous testing
Universal precautions
1991 - OSHA standards
If an athlete has open wounds, they should be completely covered with appropriate barrier
When bleeding does happen, an athlete must be removed from the sport, cleaned, and covered; any uniform that has blood will likely need to be treated and removed
Personal precautions - gloves (double gloving for heavy bleeding), gowns, masks, eye protection, wash with soap and water
Be conscious of latex allergy
Supplies and equipment
Disinfectants
Surfaces - 10% bleach
Soiled towels and linens - washed separate from other laundry in hot water and detergent that deactivates the virus
Sharps
Red biohazard bin
Protection from exposure
Institution responsible for ensuring the safety of coach, athletic trainer; follow policies
Athlete - shower after activity; use mouthpieces
Postexposure - medical evaluation, if required
Psychosocial Response to InjuryTissue Response to Injury
Responses to Injury
Psychological
Psychological barriers to rehabilitation
Depression/grief
Anxiety
Anger/aggression
Denial
Sleep disturbances
Psychosocial isolation
Substance abuse
Length of rehabilitation vs reactions
<4 weeks (short) - reaction: shock, relief; reaction to rehab: impatience, optimism; reaction to return to sport: eagerness, anticipation
>4 weeks (long) - reaction: fear, anger; reaction to rehab: loss of vigor, irrational thoughts, alienation; reaction to return to sport: acknowledgment
Chronic - reaction: anger, frustration; reaction to rehab: dependence or independence, apprehension; reaction to return to sport: confidence or skepticism
career-ending - reaction: isolation, grief; reaction to rehab: loss of athletic identity; reaction to return to sport: closure, renewal
Sociological
Long-term rehab - athletes might feel that coaches and/or teammates do not want to be with them and that their social life depends on their rehab
Support level from coaches and/or teammates
Injured athletes might feel like they are not able to keep the same relationships they had prior to injury with teammates --> athletic identification
I no longer feel team camaraderie
Keep athlete involved in sports to feel less isolated and guilty about being away from the team and ability to help the team
Social support
Support groups
The supportive relationship between athlete and athletic trainer
Functional exercises to keep them engaged in sports
Athletic Trainer's Role
Good listening
Be conscious of body language
Caring image
Get to the root of the problem
Educate and explain the injury to the athlete
Help manage stress
Return to competition
Predictors of Injury
Injury-prone
Risk takers
Usually, try to reduce anxiety by being more aggressive or playing through injury
Stress
Positive and negative forces can disrupt the body's equilibrium
Negative stress decreases focus and increases muscle tension --> decreased flexibility, problems with coordination, and decreases movement efficiency
Physical response: increased cortisol
Emotional: performance declines and changes in personality; an athletic trainer can help
Overtraining
The imbalance between physical load and coping capacity
Staleness
Training too hard and long without adequate recovery, emotional problems, anxiety, outside stressors
Decreased performance, sleep disturbances, loss of appetite, difficulty concentrating, nausea, illness, anxiety
Burnout
Physical and emotional exhaustion leads to negative outcomes
Headaches, GI problems, sleep issues, chronic fatigue
Psychological Side of Injury and Rehabilitation
Athletic trainer response
Calm, reassuring, allow and encourage athletes to talk about how they are feeling, empathy
DO NOT tell the athlete they are not acting normal, pity, or be too abrupt
Catastrophic injury
Must evaluate the psychological side of the trauma and how the athlete is coping during treatment
How injury affects the athletic trainer
Athletic trainers are affected by their athlete's injury, both emotionally and psychologically
Relationship with team and athlete
Do not let emotions affect decision making
Rehabilitation process
Build rapport with athletes - trust is very important
Cooperation
Use rehab for education
Improve confidence
Difference phases of rehab
Immediately post-injury
Fear, denial, pain
Full evaluation of an athlete with the education of injury, treatment, plan, and process is important
Early preop
Explain the healing process and plan
Maintain some level of exercise for a non-injured body part
Postop/rehab
Continue to maintain some level of exercise of a non-injured body part
Increase athlete's confidence with milestones and positive reinforcement
Reassurance they will return to sport and be successful
Return to full play
Increased anxiety can lead to injury
Make sure athlete is vocal about how they are feeling
Baby steps
Goal setting
Short term goals are important
Goal setting --> motivation
Challenging but not unachievable
Positive reinforcement
Time management
Support
Mental Training and Barriers
Techniques
Anxiety
Meditation - focusing on a constant mental stimulus, turning away outside thoughts
Progressive relaxation - tense each muscle group for 5-7 seconds --> relax for 20-30 second, contraction gradually decreased --> mentally willing tension to zero
Cognitive
Refuting irrational thoughts - confronting irritation dialogue
Thought stopping - focus on unwanted thoughts and stop them with "stop."
Imagery - using a sense to create an experience in your mind
Coping with pain
Tension reduction - relaxation to reduce muscle tension, decreasing pain
Attention diversion - mental problem solving to divert pain
Altering pain sensation - turning from negative to positive imagination can counteract stress and help in wellness
Educated athletes on the physiological process of healing
Mood disorders
Depression - most common type of mood disorder; feeling normal to helplessness, loss of energy, guilt, changes in eating and sleeping
Bipolar/manic depression - excessive happiness/energy --> extreme depression
Seasonal affective disorder (SAD) - mood disorder surrounding certain seasons of the year; more likely to occur in winter because of less sunlight; fatigue, decreased concentration, more common in women
Anxiety disorders
Panic attacks - Unexpected; terror and fear --> behavior modification, medication
Phobias - persistent and irrational fear of something, an object, etc --> behavior modification, medication, desensitization
Personality disorder
Paranoia - unrealistic and unfounded fears of a person or thing
Obsessive-compulsive disorder (OCD) - emotional and behavioral symptoms --> recurrent feelings, impulses, thoughts
Post-traumatic stress disorder (PTSD) - re-experiencing traumatic events --> insomnia, increased aggression --> group therapy can be helpful
End Feel and Laxity
Normal End Feels
Soft = soft-tissue approximation
Contact between soft tissue
Example: elbow flexion
Firm
Muscular stretch
Passive muscle stretch
Example: hip flexion
Capsular stretch
Passive stretch
Example: external rotation of shoulder, anterior glenohumeral joint capsule
Ligamentous stretch
Tension
Example: forearm supination
Hard = bone-to-bone
Contact between two structures
Example: elbow extension
Abnormal End Feels
Soft
When it occurs sooner or later in the ROM than usual
When it occurs in a joint that normally has a firm or hard end feel
Example: ligamentous tear
Firm
When it occurs sooner or later in ROM than usual
When it occurs in a joint that is normally has a soft or hard end feel
Example: muscular shortening
Hard
When it occurs sooner or later in ROM than usual
When it occurs in a joint that normally has a soft or firm end feel
When a bony block is felt
Example: chondromalacia, osteoarthritis
Empty
No end feel
Pain limits ROM
Muscle guarding
Example: fracture, bursitis
Ligamentous Laxity
Grade I - firm
Slight stretching of the ligament
Little or no tearing of fibers
Pain
Stability equal bilaterally
Grade II - soft
Partial tearing of fibers
Joint line opens more when compared bilaterally
Grade III - empty
Complete tearing of ligament
Restricted motion by other joint structures
Reflexes
Superficial Reflexes
Upper abdominal
Umbilicus moves up and toward area being stroked
T7-T9
Lower abdominal
Umbilicus moves down and toward area being stroked
T11-T1
Cremasteric
Scrotum elevates
T12, L1
Plantar
Flexion of toes
S1
Gluteal
Skin tenses in the gluteal area
L4-L5, S1-S2
Anal
Anal sphincter muscle contract
S2-S4
Pathologic Reflexes
Babinski's
Stroke lateral aspect of sole of foot
Positive response = Big toe extension, fanning of four small toes
Pathology = pyramidal tract lesion
Chaddock's
Stroke lateral side of food beneath lateral malleolus
Positive response = Big toe extension, fanning of four small toes
Pathology = Organic hemiplegia
Oppenheim's
Stroke anteromedial tibial surface
Positive response = Big toe extension, fanning of four small toes
Pathology = Pyramidal tract lesion
Gordon's
Squeeze calf muscle firmly
Positive response = Big toe extension, fanning of four small toes
Pathology = Pyramidal tract lesion
Brudzinski's
Passive flexion of one lower limb
Positive response = Similar movement occurs in opposite limb
Pathology = Meningitis
Hoffman's
Flicking of terminal phalanx of index, middle, or ring finger
Positive response = Reflex flexion of distal phalanx of thumb and of distal phalanx of index or middle finger
Pathology = Increased irritability of sensory nerve in tetany ; pyramidal tract lesion
Deep Tendon Reflexes
Jaw
Mandible
Mouth closes
Cranial nerve V
Biceps
Biceps tendon
Biceps contraction
C5-C6
Brachioradialis
Brachioradialis tendon - distal to the musculotendinous junction
Elbow flexion and/or forearm pronations
C5-C6
Triceps
Distal triceps tendon - superior to olecranon process
Elbow extension/muscle contraction
C7-C8
Patella
Patellar tendon
Leg extension
L3-L4
Medial hamstrings
Semimembranosus tendon
Knee flexion/muscle contraction
L5-S1
Lateral hamstrings
Biceps femoris tendon
Knee flexion/muscle contraction
S1-S2
Tibialis posterior
Tibialis posterior tendon - behind medial malleolus
Plantar flexion with inversion
L4-L5
Achilles
Achilles tendon
Plantar flexion
S1-S2
Abnormal Vital Signs
Pulse
Rapid, weak
Shock
Internal hemorrhage
Hypoglycemia
Heat exhaustion
Hyperventilation
Rapid, bounding
Heat stroke
Fright
Fever
Hypertension
Apprehension
Hyperglycemia
Normal exertion
Slow, bounding
Skull fracture
Stroke
Drug use (barbiturates, narcotics)
Some cardiac problems
Some poisons
No pulse
Blocked artery
Low blood pressure
Cardiac arrest
Respiratory Rate
Shallow breathing
Shock
Heat exhaustion
Insulin shock
Chest injury
Cardiac problems
Irregular breathing
Airway obstruction
Chest injury
Diabetic coma
Asthma
Cardiac problems
Rapid, deep
Diabetic coma
Hyperventilation
Some lung diseases
Frothy blood
Lung damage (for example, puncture wound to the lung from a fractured rib)
Slowed breathing
Stroke
Head injury
Chest injury
Use of certain drugs
Wheezing
Asthma
Crowing
Larynx spasms
Apnea
Hypoxia
Congestive heart failure
Head injury
No breathing
Cardiac arrest
Poisoning
Drug abuse
Drowning
Head injury
Other injuries that are life threatening
Blood Pressure
Systolic = 100mm
Hypotension caused by:
Shock
Hemorrhage
Heart attack
Internal injury
Poor nutrition
Systolic = 140mm
Hypertension cause by:
Certain medical conditions
Oral contraceptives
Anabolic steroids
Amphetamines
Chronic alcohol use
Obesity
Skin Temperature
Dry, cool
Exposure to cold
Cervical, thoracic or lumbar spine injury
Cool, clammy
Shock
Internal hemorrhage
Trauma
Anxiety
Heat exhaustion
Hot, dry
Disease
Infection
High fever
Heat stroke
Overexposure to environmental heat
Hot, moist
High fever
Isolated hot spot
Localized infection
Cold appendage
Circulatory problem
"Goose pimples"
Chills
Communicable disease
Exposure to cold
Pain
Fear
Skin Color
Red
Embarrassment
Fever
Hypertension
Heat stroke
Carbon monoxide poisoning
Diabetic coma
Alcohol abuse
Infectious disease
Inflammation
Allergy
White or ashen
Emotional stress
Anemia
Shock
Heart attack
Hypotension
Heat exhaustion
Insulin shock
Insufficient circulation
Blue or cyanotic
Heart failure
Some severe respiratory disorders
Some poisoning
Bluish cast can also be seen in the mucous membranes of the mouth, tongue, inner eyelids, lips and nail beds
Yellow
Liver disease
Jaundice
Pupils
Constricted
Opiate-based drug use
Ingested poison
Unequal
Head injury
Stroke
Dilated
Shock
Hemorrhage
Heat stroke
Use of a stimulant drug
Coma
Cardiac arrest
Death
Skin
Anatomy
Epidermis
Barrier against invaders, foreign items, chemicals, and UV rays
Stratum corneum - stratum granulosum - stratum spinosum - stratum basale
Melanocytes - block solar radiation
Langerhans cells - recognize foreign substances and present to lymphocytes
Dermis
Connective tissue
Mechanical support to the epidermis
Houses blood vessels, nerves, sweat glands, hair follicles, sebaceous glands
Adnexal structures
Hair, sebaceous glands (secrete sebum), eccrine glands
Sweat glands
Responsible for cooling surface and internal organs
Nails
Sensory nerve endings
Sensation and recognize temperatures changes in pain
Subcutis - subcutaneous fat
Skin lesions
Cafe au lait spots - increase melanin
Cellulitis - infectious inflammation
Primary lesions
Macules
Papules
Plaques
Nodules
Tumors
Cysts
Wheals
Vesicles
Bullae
Pustules
Secondary lesions
Excoriations
Skin Trauma and Injuries
Friction/pressure
Hyperkeratosis - epidermal skin layer thickens from constant pressure
Blisters - raised skin filled with fluid due to friction
Soft corns and hard corns
Hyperhidrosis - excessive perspiration
Changing
Xerotic skin - dry skin
Ingrown toenails
Wounds
Abrasions - the top layer of skin
Punctures - tetanus bacillus
Lacerations - sharp object that disrupts tissues
Incisions - smooth cut
Avulsions - skin is torn away from the body
Bruises - ecchymosis
Allergic reactions
Contact dermatitis - allergy to irritant
Miliaria - prickly heat
Chilblains - Perino - from cold
Burns
Sunburn
Psoriasis
Chronic itching
Pityriasis rosea
Skin rash with no origin
Infections
Bacterial
Staphylococcus - gram-positive bacteria, seen in clumps
Streptococcus - gram-positive bacteria, seen in long chains
Impetigo - from streptococci
Furunculosis - boils
Carbuncles - early stages of furunculosis
Folliculitis - inflammation of hair follicle
Hidradenitis suppurative - inflammation of apocrine glands
Acne vulgaris - inflammation of hair follicles and sebaceous glands
Paronychia and onychia - infection of proximal/lateral nail folds
Tetanus infections
Fungal
Ringworm
Tinea capitis - scalp
Tinea corporis - body
Tinea unguium/onychomycosis - nail
Tinea cruris - "jock itch"
Tinea pedis - athlete's foot
Tinea versicolor - yeast
Herpes simplex labialis, gladiatorum, herpes zoster
Type 1 - extragenital
Type 2 - genital
Gladiatorum - face, neck, shoulders - wrestlers
Verruca virus and warts
Common wart - verruca vulgaris and plana - hands of children
Plantar warts - soles of feet; can spread
Molluscum contagiosum - pox virus; very contagious
Infestations and bites
Scabies - mites (Sarcoptes scabiei)
Lice - pediculosis
Pediculus humanus capitis - head lice
Phthirus pubis - pubic lice
Pediculus humanus corporis - body lice
Fleas
Ticks - parasitic insect --> Rocky Mountain spotted fever and Lyme disease
Mosquitoes
Stinging insects - bees, wasps, hornets, yellow jackets
Spider bite
Black widow and brown recluse cause most problems