Transcript Sports Medicine 2013

Sports Medicine
2013
Jacqui McCord-Uys
Sports Physiotherapist
Who am I ?
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Practising since 1989
Sports injuries since 1990
Beijing Olympics team
Common Wealth teams (Snr & Jnr)
All Africa Games
SA Schools Rugby, Women's Rugby
Falcons Rugby Team (4 yrs)
SuperSport United Football Club Medical Team Leader &
Physio (16yrs)
• Course presenter in India 2011 & 2012
• Conference Presentations 2008,2010,2011,
• ETC…….
Sports Medicine
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Why the need for specialization?
GP orthopaedic surgeon not sufficient?
Work opportunities?
Qualifications needed?
– MSc Sports Medicine Degree(TUKS, Wits, UCT &
Bloemfontein)
– College of medicine & HPCSA approved Specialist
rating awaiting Government approval.
Sport Injuries
• Acute
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Bone
Articular Cartilage
Joint
Ligament
Muscle
Tendon
Bursa
Nerve
Skin
Sports Injuries
• Chronic ie overuse
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Bone stress
Osteitis & Periostitis
Articular cartilage
Joint
Ligament
Muscle
Tendon
Nerve
Bursa
Skin
AND the unknown……
Sports Injury principals
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Diagnosis
Treatment
Recovery
Rehabilitation
Return to Play
Diagnosis
There is no more difficult art to acquire than the art of
observation. (William Osler)
• Clinical assessment:
 NB to make an accurate pathological Dx.
 Too often broad terms like “swimmers shoulder”
or “Runners 'knee” are used
 Enables better explanation to sportsman of way
forward.
 Enables optimum treatment
 Enables optimum rehabilitation.
Diagnosis
• Special Investigations
– Should be a tool confirm or exclude a diagnosis not
a replacement of a thorough physical examination.
– Old saying by James M Hunter “Treat the patient and
not the X-Ray”
– Radiological Investigations
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X-ray
CT scan
MRI
Ultrasound
Radio isotopic Bone scan
Special Investigations
• Neurological Investigations
 EMG
 Nerve conductivity
 Neuropsychological testing (head injuries)
• Muscle assessments
 Compartment pressure testing
• Cardiovascular Investigations
• Respiratory Investigations
 Pulmonary function tests
Treatment
• Randomized controlled trial evidence for all
treatments given?
• Eg Parachute
• We must take note of evidence that is around
but never forget our craft remains much an
art as science.
• Standard principals
– Acute management RICE
RICE
• Rest: First 48hrs Sportsman
• Ice: Reduce tissue metabolism
– Reduced hematoma, inflammation & tissue necrosis
– Accelerated early regeneration in Muscle tissue
– 20min every 2hrs
• Compression:
– Co-adhesive bandage or Compression sleeves
• Elevation
– Decrease in hydrostatic pressure Reduces accumulation of
interstitial fluid
Immobilization
• Earlier better
• Too lengthy leads stiffness degeneration,
osteopenia, muscle atrophy etc.
• Braces, POP, Crutches
• CPM (Forms part of in hospital post
operative rehabilitation)
Therapeutic drugs
• Analgesics : Relieve patients pain immediately post
injury
• Corticosteroids: Concern regarding the effects on tissue
healing
– Considered a bridge treatment i.e. providing immediate
symptomatic relief but underlying cause of problems must
be addressed
• NSAID’s : Debatable effects
– Avoided in first 48hrs
– Long term use (more than 5 days) should be avoided.
Reassess & diagnose
– Be aware of gastrointestinal problems.
Acute or Chronic
Musculoskeletal Injuries
Are antiinflammatory
signs &
symptoms
present ?
Previous
History adverse
effect
Non-NSAID’s
Analgesic
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NSAID’s combined
with protective
agent
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No
NSAID’s for max
of 7 days
NSAID’s not
indicated
Additional Treatments
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Electrotherapy
Extracorporeal Shock therapy
Manual therapy
Acupuncture/ dry needling
Hyperbaric Oxygen therapy
Surgery
Rehabilitation
RETURN TO SPORT
Skill Acquisition
Proprioception
Strength
Flexibility
Motor re-education &
Muscle activation
Correct Motor control
• Poor pelvic control i.e. weak Gluteus medius
can cause anterior knee pain
• Poor scapular control can be cause of ant
shoulder tilting causing impingement
• Exercise in open or closed chain (more
functional)
• Remember agonist and antagonist
Flexibility
• Pre Event Active warm-up
• Post event Passive cool down stretch
• Tight muscles may be associated with injuries
– Psoas :Lumbral apophyseal joints and Hamstring
– Soleus : Achilles tendinopathy
– Vastus Lateralis ITB : Patellofemoral syndrome
Therapy progression
Parameters to monitor
• Pain & tenderness
• ROM
• Swelling
• Heat & redness
• Ability to perform exercises
• Number of sets and reps
Psychology
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Athlete must understand injury full extend
Long term goal
Short term goal
Listen to Athlete
Give alternate active rest exercise
Refer if needed
Recovery
Common methods (Research needed)
• Warm Down
• Ice baths (5min 10 – 15 degrees)
• Massage
• Compression garments
• Lifestyle factors
• Nutrition
• Psychology
Most Common Injury summaries
1. Head - Concussions
• Direct blow to head
• Rapid onset of short lived impairment of
neurological function
• Good clinical judgement must prevail over
guidelines and coach and player insistence.
• When in doubt refer.
• Assessment forms: 1.FIFA (SCAT2)
www.bjsm.bmj.com (pocket edition)
– 2. SA Rugby Bok Smart program: Concussion
Management
2.Shoulder Injuries
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Rotator cuff
Instability
Labral injury
Stiffness
AC Joint Pathology
Referred Pain
Rotator cuff Muscles and Tendons
• Acute or Chronic
• Acute on Chronic ie. An acute tendon tear on a
degenerative tendon
• Symptoms: Shoulder pain
– Overhead activity problems
• Investigations: MRI
• Treatment: Full thickness tear - repair
– Tendons NSAID’s at first
– Correct abnormalities: Muscle weakness, Glenohumeral rhythm etc….
Shoulder instability
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On field dislocations Reduce ASAP
Damage to Capsule and Labrum (Ant, Post, Sup)
Periscapular Muscle weakness
Changes to passive structures ie lig, capsule or
labrum
• Ant Dislocations damage the labrum (Bankart
lesion)
• Symptoms
– Pain, unstable, Weakness, Stiffness
• Treatment
– Non surgical – Rehabilitation and analgesic Rx
– Surgical – Post operative rehab program
Labral Injury
• Overuse or acute
• Intervention: Surgical since Conservative
usually unsuccessful
• Symptoms:
– Impingement or Joint pain
– May be unstable
– History is NB on mechanism of injury
– Common traction on Biceps tendon
Shoulder Stiffness
• May be secondary to trauma
• Adhesive capsulitis or Frozen Shoulder
• Possible injury to cervical nerve roots or
brachial plexus
• Treatment:
– Conservative Rehabilitation
– Manipulation
Soft Tissue Acute Injuries
eg. Post Thigh
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Sudden onset like a puncture!
Return to sport 8 -25 days
High re-occurance rate
Key = correct Dx
Anatomy
History
Strong incident ie sprinting (eccentric) or
overstretching (ballet)
 None consider referred pain
 Special investigations : confirm grade of tear
Ultrasound, MRI
Management
 First 48hrs – RICE, early pain free M contractions
 Following:
Stretching: Hamstring & Antagonists (Quads
Iliopsoas)
Neural Mobilization
Soft tissue Rx
Strengthening
Sport specific drills esp. Agility and motor control
3.Anterior Knee conditions
7. ITB
1.OA Knee
6. Lat Lig.
2. Med Lig
5.General knee
effusion
3. Pes Anserine
bursitis
4. Patellar tendon /
Osgood-Schlatters /
Runners knee
Knee injuries
Medial
menisci tear
Patellar tendon
rupture
# Tibial Plateau
MCL Sprain
Quadriceps
tendon tear
Avulsion # tibial
spine
ACL
sprain/rupture
Acute patella
femoral
contusion
Osteochondritis
dissecans
Knee Injuries
Lateral
Menisci tear
LCL sprain
Osteochondritis
dissecans
PCL
Acute fat pad
impingement
Regional Pain
Syndrome
Patellar
dislocation
Avulsion biceps
femoris tendon
Quadriceps
rupture
Acute knee injury pricipals
Is the injury significant ie fast intervention
History to consider:
Mechanism of injury
Amount of pain
Swelling & timing of onset
Degree of disability
Previous injuries
Diagnosis knee injury
Assessment:
? Damaged structures
Extent of damage
Degree of joint limb disability to provide safe
and timely management
Hints
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Symptom of ‘give way’ (ACL)
Location of pain – Cruciate poorly localized
Collaterals fairly well localized
Severity of pain not always in corralation with injury
severity
 Intra articular swelling obvious within 2 hrs damage
 - ACL,PCL
 - Pateller dislocation
 - Osteochondral #
 - Medial menisci peripheral tear
Hints
 Effusion develops after a few hours
Reactive synovitis ie. meniscal or chondral
injuries
 Little effusion with collateral injuries
 Pop or snap or tear : ACL
 Locking : Loose body or displaced meniscal
tear
Lower leg Injuries
• ‘Shin splints’
• Deep compartment muscle strains
• Gastrocnemius / Soleus strains /
tears
• Achilles tendinosis or ruptures
• ‘Severs’ disease
Tibialis Anterior
Tibialis Posterior
FDL
Gastrocnemius /Soleus & Achilles
Sport specific injuries
• Always consider the type of sport
played
• Level of sport ie international, national
or local
• Is sport the players income?
• Surface where injury occurred
• Gear involved
• Training regime
Rugby injuries
Are you Listening?
• Your patient is the answer to your diagnosis
• Your Diagnosis is the answer to your
successful treatment
• So Listen
Sources
• Clinical Sports Medicine Fourth edition
Brukner & Khan
[email protected]
0123466909
Complete Physio
Brooklyn Pretoria