Transcript No Slide Title

SPORTS INJURIES
ASSESSMENT & MANAGEMENT
University of Pretoria
Section Sports Medicine
SPORTS INJURIES
ASSESSMENT & MANAGEMENT
Contents
1. Classifications
2. Principles of Injury Prevention
3. Principles of Diagnosis
4. Principles of Treatment
5. Pearls of wisdom
1. CLASSIFICATIONS
Contusions
Acute vs Chronic
Overuse vs Overload
Bursitis
Tendinitis
vs.Tendinosis
Sprains vs Strains
1. CLASSIFICATIONS
• Acute vs. Overuse Injuries
• Predisposing factors to overuse injuries
• Grading
– Tendon
– Ligament
– Muscle
Acute vs Overuse Injuries
SITE
Bone
ACUTE
INJURIES
Fracture
Periosteal
contusion
OVERUSE
INJURIES
Stress Fracture
‘Bone strain’,
‘stress reaction’
Osteitis,
Periostitis
Apophysitis
Acute vs Overuse Injuries
SITE
Articular
Cartilage
ACUTE
INJURIES
Osteochondral/
Chondral
fractures
Minor
osteochondral
injury
OVERUSE
INJURIES
Chondropathy
(e.g. softening,
fibrillation,
fissuring,
chondromalacia)
Acute vs Overuse Injuries
SITE
Joint
ACUTE
INJURIES
Dislocation
Subluxation
OVERUSE
INJURIES
Synovitis
Osteoarthritis
Inflammation
Ligament
Sprain/tear
(grades I-III)
Bursitis
Bursa
Traumatic
bursitis
Acute vs Overuse Injuries
SITE
Muscle
ACUTE
INJURIES
Strain/tear
(grades I-III)
Contusion
Cramps
OVERUSE
INJURIES
Chronic compartment syndrome
Delayed onset
muscle soreness
Acute compart- Focal tissue
ment syndrome thickening/fibrosis
Acute vs Overuse Injuries
SITE
ACUTE
INJURIES
Tear (complete
or partial)
Tendon
Skin
Laceration
Abrasion
Puncture wound
OVERUSE
INJURIES
Tendinopathy
(includes
paratenonitis,
tenosynovitis,
tendinosis,
tendinitis)
Blister
Callus
Acute vs Overuse Injuries
SITE
Nerve
ACUTE
INJURIES
Neuropraxia
Minor nerve
injury/irritation
OVERUSE
INJURIES
Entrapment
Adverse neural
tension
Predisposing factors to overuse injuries
EXTRINSIC
Training errors
Excessive volume
Excessive intensity
Rapid increase
Sudden change in type
Excessive fatigue
Inadequate recovery
Faulty technique
INTRINSIC
Malalignment
Pes planus/cavus
Rearfoot varus
Tibia vara
Genu valgum/varum
Patella alta
Fem. neck anteversion
Tibial torsion
Predisposing factors to overuse injuries
EXTRINSIC
INTRINSIC
Surfaces
Leg length discrepancy
Hard, soft, cambered Muscle imbalance
Muscle weakness
Shoes
Lack of flexibility
Inappropriate, worn Generalised muscle
out
tightness
Focal areas of muscle
Equipment
thickening
Inappropriate
Restricted joint ROM
Predisposing factors to overuse injuries
EXTRINSIC
Environmental
Hot, cold, humid
INTRINSIC
Sex, size, body
composition
Psychological factors Other
Inadequate nutrition Genetic factors,
endocrine factors,
metabolic conditions
Grading of symptoms of tendinopathy
• Mild
Pain only after activity/pain that disappears with
activity
• Moderate
Pain with sporting activity but not with activities
of daily living
• Severe
Pain during activities of daily living
Grading of ligament sprains
Grade I
• Stretched fibers
• Normal ROM
Grade II
• Considerable portion of the fibers involved
• Increased laxity but a definite endpoint
Grading of ligament sprains
Grade III
• Complete
• Excessive laxity with no firm endpoint
Grading of muscle strains
Grade I
• Small number of fibers
• Localised pain
• No loss of strength
Grade II
• Significant number of fibers
• Pain and swelling
• Strength reduced
Grading of muscle strains
Grade III
• Complete tear
• Mostly at musculotendinous junction
2. PRINCIPLES OF INJURY
PREVENTION
1. Correct biomechanics
2. Warm up
3. Stretching
- Static
- Ballistic
- PNF
Does warm-up influence the
mechanical properties of the muscle?
Active warm-up
Increases peak stretch
but decreases peak force
Increases peak stretch
and peak force
Force (N)
Force (N)
Passive warm-up
Stretch (mm)
Stretch (mm)
Stretching :practical points
1. Static stretching: 3 stretches held for 30
seconds
2. Stretch 3 times per day (high risk
inflexible areas)
3. Warm up and then stretch
4. Stretch a relaxed muscle
5. PNF stretching is preferred if ROM is
required in a very inflexible muscle
PRINCIPLES OF INJURY PREVENTION
4.
5.
6.
7.
Taping and bracing
Protective equipment
Suitable equipment
Appropriate surfaces
PRINCIPLES OF INJURY PREVENTION
8. Appropriate training
a) Principles of training
- Periodisation/Overload/Specificity/
Individuality
b) Training methods
- Aerobic/Anaerobic/Strength/
Flexiblility/Speed/Agility/Skill
training/Cross-training
PRINCIPLES OF INJURY PREVENTION
9. Adequate recovery
- Warm down
- Whirlpools and spas
- Massage
- Rest and sleep
10. Psychological aspects
11. Nutritional aspects
3. PRINCIPLES OF DIAGNOSIS
1. History
- Allow enough time
- Be a good listener
- Know the sport
- Discover the exact circumstances of
the injury
PRINCIPLES OF DIAGNOSIS
1. History (cont.)
- Obtain an accurate description of
symptoms e.g. pain/swelling/
instability/function
- Was there a previous similar injury
- Past injuries
- General health
PRINCIPLES OF DIAGNOSIS
1. History (cont.)
- Training history
- Equipment
- Technique
- Overtraining
- Psychological factors
- Nutritional factors
- Level of participation
ROLE OF AGE
• Weakest link in M/S system change according
to age
• General rule:
9-12 yr.  growth plate injuries of the heel
13-14 yr.  injuries upper tibial apophysis
15-18 yr.  avulsion injuries pelvis
19-30 yr.  muscle injuries
> 30 yr.  tendon injuries
PRINCIPLES OF DIAGNOSIS
2. Examination
- Develop a routine
- Examine the other side, where
relevant
- Attempt to reproduce the
symptoms
- Assess local tissues
PRINCIPLES OF DIAGNOSIS
2. Examination (cont.)
- Assess for referred pain
- Assess neural tension
- Biomechanical examination
PRINCIPLES OF DIAGNOSIS
3. Investigations
- Understand the tests
- Know how soon changes can be
detected by investigations
- Only order investigations that will
influence management
PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Be able to interpret tests
- Do not accept a poor quality
investigation
- Explain the investigations to the
patient
PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Examples of investigations
Neurological (EMG/Nerve
conduction studies)
Muscular (compartment pressure/
dynamometry)
PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Examples of investigations
Cardiovascular (ECG/Echocardiography)
Pulmonary (Lung function tests)
Radiological (CXR/RT/MRI/US)
XR
Arthrography
MRI
Ultrasonography
Imaging studies
Bone scan
CT
4. PRINCIPLES OF TREATMENT
Six principles of management:
1. Minimize the extent of initial damage
2. Reduce associated pain and inflammation
3. Promote healing of damaged tissue
Physiology of soft tissue healing
Initially = prevent excess swelling and injury
w1-3 = collagen formation (protect from inversion)
>3w = collagen maturation
(controlled stress)
Inflammatory
Phase
Repair
Phase
Remodelling
Phase
4-8w = full return to activity
PRINCIPLES OF TREATMENT
Six principles of management (cont.)
4. Maintain or restore
- flexibility
- strength
- proprioception
- overall fitness
PRINCIPLES OF TREATMENT
Six principles of management (cont.)
5. Functionally rehabilitate the injured
athlete to enable return to sport
6. Assess and correct predisposing factors
PRINCIPLES OF TREATMENT
Long-term phase
Acute phase
P
R
I
C
E
Pharmaceutical
Rest
Ice
Compression
Elevation
P
R
E
P
S
Pharmaceutical
Rehabilitation
Exercise
Prevention & Protection
Surgery
PRINCIPLES OF TREATMENT
Types of treatment available:
1. Initial treatment
- RICE
2. Immobilise vs. mobilise
3. Heat vs. cold
PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
4. Therapeutic drugs
- Analgesics
- NSAIDS
- Corticosteroids
- Hyaluronic acid
- Anti-depressants
PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
5. Electro therapeutic modalities
- Ultrasound
- TENS
- Interferention
- Neuromuscular stimulators
- LASER
- Magnetic field therapy
PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
6. Manual therapy
- Joint mobilisation
- Joint manipulation
- Joint traction
- Massage therapy
- Neural stretching
PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
7. Acupuncture
8. Dry needling
9. Hyperbaric oxygen
10. Extracorporeal Shock Wave Therapy
11. Surgery
PEARLS OF WISDOM
• When to refer a STI?
• Groin pain – HTAGP
• Look further than the obvious