Transcript Concepts of Diagnosis of Sports Injuries

Concepts of Diagnosis of Sports Injuries
Site of
injury
Truism
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“If you hear hoof beats don’t think zebras”
You better eliminate the zebras first: Dolbin
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Priorities
 “The best things in life are not things”
 Harry Bertsch
 Hermy Bavier
 Ron Boris
 Amanda Driscoll
 Josh Bertsch
 Dad
Ron Boris
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Concepts of Diagnosis of Sports Injuries
Cause as it relates to exceeding the tensile strength of the tissue
Fracture dislocation
Dr.Jack Dolbin DC Session 2
Concepts of Diagnosis of Sports Injuries
Biomechanical
concepts of
causation
Motion deficits as major causative factor
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If dysfunction alters the efficiency of the musculoskeletal
system, there is an increase demand for energy. Not only for
increased activity but for normal activity.
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Increase demands on the cardiovascular system
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Observation
“Where observation is concerned, chance favors only the
prepared mind.” ~ Louis Pasteur
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Evaluation of the Kinetic Chain
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Lower limb: Ankles, Knees, and hips
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Upper limb: Core Stability, Endurance, Balance, Range of
Motion
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Scapula: Stability, Rhythm
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Shoulder: Clinical examination
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Concepts of inflammation and repair
Inflammation
Tissues respond to injury with a set of genetically
programmed mechanisms to replace the damaged
components and to restore normal function.
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Inflammation and Repair
Cardinal signs of inflammation
 Heat
 Swelling
 Pain
 Redness
 Loss of Function
Acute Inflammation
Two types of Inflammation:
 Acute
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Chronic
Chronic Inflammation
Inflammation and Repair
Acute Inflammation:
Characterized by the release of chemical mediators by mast
cells,platelets and basophils at the site of the injury.
Vasoactive mediators regulate the vascular response to the injury
and affect the recruitment of PMN’s from the vascular
component.
These in turn produce chemotactic factors that control the
damage and remove debris by phagocytosis.
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Granulation Tissue:
Lead to the restoration of the vascular supply and connective
tissue matrix.
Chronic Inflammation is the result of unresolved acute
inflammation
In the case of sports related injuries removal of the trauma and
successful management of the injury may result in the
reduction of fibrosis and restoration of normal function.
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Inflammation and Repair
Repair:
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The repair phase of healing ideally result in the restoration of normal
living tissue.
Repair by regeneration of injured tissue
Repair by second intention is characterized by the formation of scar
tissue at the site of the injury.
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Remodeling and Maturation
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Process begins about 6 days after the fibroblasts begin to lay
down collagen tissue.
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Collagen is laid down randomly initially
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Depends on the appropriate mechanical loading.
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The hallmark of remodeling is the orientation of new fibers
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Inflammation and Repair
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Immobilization of a healing wound has been shown to compromise
wound strength as a result of the failure of collagen to be oriented
along lines of stress.
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Mobilization and loading has been shown to result in stronger healed
tissue.
Time Frame of Healing:
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Inflammation Phase is relatively brief. 24-48 hours.
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Proliferative Phase: 3-7 days after the injury
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Repair Phase: Few days to a few weeks
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Remodeling Phase: Several months and may continue up to
12 months.
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Inflammation and Repair
Repair Mechanisms in Soft Tissue Injuries:
Muscle Tissue:
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Healing of skeletal muscle is dependent on the integrity of the
vascular system and nervous system
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Has considerable regenerative properties
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Both regeneration and repair by scar tissue.
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Capacity for regeneration is determined genetically but the success
is determined primarily by the extent and type of injury.
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Except for injuries in which the continuity of the muscle fiber is
preserved, and the innervation, vascularity and extracellular matrix
muscle will regenerate with a loss of normal tissue architecture and
function.
Most muscle injuries are a result of exceeding the tensile strength of
the tissue and are labeled indirect muscle injury.
Inflammation and Repair
Muscle Strain Injuries:
Consists of a partial or complete tear at or near the musculotendinous
junction.
When the force is sufficiently high the tendon has been shown to avulse
from the muscle with only a few fibers left intact.
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The greater the amount of injured tissue involved the more scar tissue
with be deposited at the sight of the wound.
Ischemia- Induced Muscle Damage:
Usually seen in compartment syndromes. Results from damage to vessels causing
ischemic injury.
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Seen in exhaustive endurance activities.
Extent of the injury is proportional to the duration of the pressure.
Nerve injury may result as a result of increase pressure.
Healing will be achieved with little or no damage if the damage is limited to
individual fibers and blood supply is restored without delay.
Can result in significant scar tissue formation if delayed resulting in excessive
cell death.
Concepts of treatment:
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Modalities
Cyriax
Joint Mobilizations
Muscle Energy
Laser therapy
Immobilization.
Chiropractic Adjustments
Concepts of rehabilitation:
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Goals
Necessary training
Necessary equipment
Isotonic exercise
Repetitive motion
Stability ball
Rehabilitation of most common athletic
injuries
 Rehabilitation concepts:
a. Injury prevention vs. Injury causation.
Rehabilitation and return to competition:
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Daily Function
Demands of the Sport
Incidence of injury according to the
American Journal of Sports Medicine
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Football players in a 5 year program at the Div. 1 level have a
100% chance of being inured
High School: 50-80%
Swimming: 50% men 70% women will develop shoulder
problems.
Jogging, running: 60%
Tennis: 60% Musculotendinous overload injuries
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Duration of Injury
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Tri-athlete: 30 days
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Cyclists: 2 weeks
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Swimming: 2 weeks
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Runners: 40 days
Predictor of Injury
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No previous injury: 40 % chance
of experiencing a sports related
injury
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Previous Injury: 65% chance of a
re-injury in the Kinetic chain
a. Mostly due to incomplete
rehabilitation
b. Rehab stopped at symptom
reduction.
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Goals of
Rehabilitation:
Return to Function
Allows for proper healing
Maintaining the other components of athletic fitness
Return to Normal Competition
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4.
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Return to Function is the key not simply symptom reduction
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Establish an accurate diagnosis
Minimize the local effects of acute injury
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Effects of Immobilization:
For each week of immobilization there is a 20% loss of strength in joint.
Effects of Immobilization
Percent Strength Loss
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100
80
60
40
20
0
1
2
3
Weeks Immobile
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Type 1 fibers are most affected
Cartilage deterioration, bone and ligament strength loss and
increased stiffness.
Rehabilitation can counteract these changes by introducing
motion with protection and loading.
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Goals of Rehabilitation:
2.
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Allows for proper healing
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Protects Tissue
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Use of Physical Treatment Modalities:
 Cold, Heat, Electricity, Laser
Use predicated on accurate diagnosis
Understanding of the biophysics of the modality
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Maintaining the other components of athletic fitness
a.
Strength
b.
Flexibility
c.
Aerobic Conditioning
4.
Return to Normal Competition
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Baseline established in Preseason Physical
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Begin graded return if no baseline established
Increase volume and intensity incrementally
What are we Rehabilitating?
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Dx. more than the site of the injury!
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Kinetic Chain
Classification of Injury
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Acute Injury: Normal anatomy and normal physiology
followed by abnormal anatomy and abnormal physiology.
a. One-Time microtrauma.
Chronic Injury: Building up for a period of time.
a. Represents the tip of the iceberg of entire derangement
of physiology
Repetitive microtrauma overload:
a. Rotator Cuff Tendonitis
b. Plantar fascitisc.
c. Achilles Tendonitis
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Adaptation
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Body adapts over a period of time to chronic injuries. The Dx must
look for these adaptations:
– Weakness and tightness in gastrocnemius in Achilles tendonitis
– Elbow tendonitis : tightness of wrist extensors
– Rotator Cuff tendonitis: Infexibility in posterior RJC muscles and
weakness in scapular stabilizers and post cuff muscles.
Note: Entire Kinetic Chain must be searched and evaluated
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Acute exacerbation of a chronic injury: Result from symptomatic
treatment leading to return to athletic activity. Results in a
recurrence of previous symptoms or new symptoms as a result of
acute injury in kenetic chain.
1. Ankle Sprain
- return to competition- Groin strain
2. Rotator Cuff tendonitis
- return to competition- lateral epicondylitis
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Adaptation
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Injections cause very poor
healing and a return of
symptoms with activity
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Chronic Adaptations
1. No overt symptoms
2. Pattern of abnormalities that lead to decreased function and
performance
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Negative Feedback Vicious Cycle
Tissue
Overload
Complex
Sub-clinical
Adaptation
Complex
Functional
Biomechanical
Deficit
Complex
Tissue
Injury
Complex
Clinical
Symptom
Complex
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Negative Feedback Vicious Cycle
1. Tissue overload complex
a. Failure of Tensile strength
b. Subject to microtrauma
2. Tissue Injury complex
a. Disrupted
b. Producing Symptoms
3. Clinical Symptom Complex
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Pain
4. Functional Biomechanical Deficit Complex
a. Decreased flexibility
b. Decreased Strength
c. Muscle imbalances
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Negative Feedback Vicious Cycle
5. Sub-clinical adaptation complex
a. Activities the athlete uses to compensate for altered mechanics.
1. Running on the outside of foot to compensate for heel
pain.
2. Over reaching in swimming to compensate for
decreased ROM in the low back
1. Tissue overload complex
Cycle begins again