Physical Therapy for Sports Injury Nan-Ying Yu 2005 12 1

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Physical Therapy for Sports Injury

• Nan-Ying Yu
• 2005 12 12

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Mechanisms Characteristics of Sports Trauma
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Tissue Stresses Leading to Injury

• Tension - pulls or stretches tissue
• Stretching - pulls beyond elastic limit
• Compression - force that crushes tissue
• Shearing - force that moves across the parallel
  organization of the tissue
• Bending - force on a horizontal bone that places
  stress within the structure causing the bone to
  bend or strain

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Types of Tissues Injuries

• Epidermis and Dermis
• Muscle and Tendon (acute chronic)
• Synovial Joints (acute chronic)
• Bones
• Nerves

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Wound Classifications

• Blister - continuous friction or rubbing causing
  a collection of fluid within the epidermal or
  dermal layers
• Abrasion - scrape or strawberry resulting from an
  erosion of the epidermis / dermis
• exposes capillaries
• Laceration - tear of the epidermis with rough
  edges
• Incision - cut of the epidermis with smooth edges

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Wound Classifications

• Contusion bruise caused by a compressive force
• Avulsion - tear or rip that results in the
  involved tissue being completely ripped from its
  source
• Puncture penetration of the epidermis / dermis
  by a foreign object

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Skeletal Muscle Physiology

• Myofibril - muscle fiber
• Endomysium - surrounds each myofibril and
  provides capillary beds to muscle
• Fasciculi - bundles of muscle fibers
• Perimysium - surrounds each fascicula and
  provides network for arteries, veins, lymph
  vessels, and nerves
• Epimysium - surrounds each muscle

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Musculotendon Properties

• Muscle
• Attaches to bone via a tendon
• Tendon
• Attaches a muscle to bone
• Tends to be double the strength of muscle
• Injury can result from chronic elongation beyond
  its elastic limits
• Fibroblasts infiltrate initially, strengthening
  the tendon
• Constant tension weakens the tendon
• Especially prevalent in early periods of training
  and during immobilization

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Musculotendon Injuries

• Contusion
• extravasted blood forms a membrane encapsulated
  blood tumor
• deeper contusion more severe
• caused by an impact that results in p! and
  temporary paralysis due to pressure on sensory
  and motor nerves
• ecchymosis is common along with a palpable mass
• Strain
• stretch, tear, or rip in muscle, fascia, or
  tendon
• MOI
• forceful muscle contraction
• neuro-inefficiency of agonist / antagonist
  contractions
• strength imbalance b/w agonist / antagonist
  muscles
• fatigue producing metabolites in the muscle
• Grades
• 1 stretched or torn p! with AROM full ROM
• 2 torn p! with AROM loss of ROM palpable
  defect swelling discoloration
• 3 rupture intense p! initially no AROM
  palpable defect

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Musculotendon Injuries

• Cramps
• painful involuntary contraction
• usually due to dehydration and electrolyte loss
• Spasm
• reflex contraction caused by trauma to upper
  motor neuron or musculoskeletal system
• clonic - alternating, involuntary contractions
• tonic - rigid contraction that lasts for a long
  period
• can cause a muscle strain
• Guarding
• protective mechanism that causes an involuntary
  contraction following injury

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Musculotendon Injuries

• Muscle soreness
• acute-onset
• accompanies fatigue and occurs during and
  immediately after exercise
• delayed-onset
• onset is 12 hours post-exercise
• most intense 24 - 48 hours post-exercise
• relief within 3 - 4 days
• Muscle stiffness
• occurs when a group of muscles have been
  over-exerted for a prolonged period

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Chronic Musculotendon Injuries

• Myositis - inflammation of muscle tissue
• Fasciitis - inflammation of tissue separating
  muscle
• Tendinitis - inflammation of tendon
• Tenosynovitis - inflammation of synovial sheath
  surrounding tendon
• Ectopic calcification - accumulation of osteoid
  material in soft tissue
• Atrophy - muscle wasting
• Contracture - shortened muscle

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Synovial Joint Physiology

• Joint capsule
• cuff of fibrous tissue that functions to maintain
  a relative joint position
• When overstretched, muscle contraction is
  triggered
• Hiltons Law joint capsule, muscles, and skin
  have same nerve innervations
• Ligaments
• fibrous tissue that functions to connect bone to
  bone
• intrinsic - part of the thickened joint capsule
• extrinsic - independent of joint capsule

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Synovial Joint Physiology

• Ligaments
• strongest in the middle
• If torn in middle midsubstance tear
• Avulsions are more common, especially at extremes
  of age due to weakened bones
• Ligaments serve as protective backups for the
  joint static protection
• Ligaments can stretch a little due to their
  collagen arrangement
• Muscles are primary protection dynamic
  protection
• constant compression or tension causes collagen
  breakdown
• intermittent compression and tension increases
  strength, especially at bony attachment
• chronic inflammation causes collagen fiber
  shrinkage

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Synovial Joint Physiology

• Synovial membrane
• lines the joint capsule and secretes / absorbs
  synovial fluid
• Synovial fluid
• joint lubricant looks like egg whites
• changes viscosity with speed of movement
• Articular cartilage
• hyaline - nasal septum, larynx, trachea, bone
  ends
• fibrous - vertebral discs, symphysis pubis,
  menisci
• elastic - external ear, Eustachian tube

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Synovial Joint Physiology

• Hyaline Cartilage Functions
• Provides motion control
• Ex Knee menisci allow flex/control
• Ex Shoulder / Hip labrum allows circumduction
• Stability
• Ex Knee menisci deepen the naturally articular
  structure
• Load Transmission

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Synovial Joint Physiology

• Nerve supply
• mechanoreceptors provide info about the joint
  position
• located in capsule and ligaments
• myelinated fibers, unlike pain receptors
• Anatomical formation
• more movement less joint stability
• must rely on muscles and ligaments for support
• less movement more joint stability

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Synovial Joint Injuries

• Sprain
• traumatic joint twist that results in ligamentous
  / capsule tearing
• grade 1 p!, pt tender, no instability or loss
  of f(x), little swelling
• grade 2 p!, moderate instability and loss of
  f(x), swelling
• grade 3 extreme p!, instability and loss of
  f(x), possible subluxation, gross swelling
• Acute synovitis
• injured synovial membrane in conjunction with
  sprain
• Irritation of the membrane causes increased fluid
  production

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Synovial Joint Injuries

• Dislocations
• Luxation - complete disunion between two
  articulating bones
• Subluxation - partial separation between two
  articulating bones
• Diastasis
• disjoining of two parallel bones radius / ulna
• rupture of a solid joint symphysis pubis
• diastasis are usually accompanied by a fx

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Synovial Chronic Joint Injuries

• Osteochondrosis
• degenerative changes in the ossification centers
  of the bone ends (epiphysis)
• common in children during growth spurts
• Osteochondritis dissecans occurs within a joint
• Apophysitis occurs at a tubercle or tuberosity
• causes
• avascular necrosis
• trauma causing articular cartilage fx
• fissures subchondral bone

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Synovial Chronic Joint Injuries

• Osteoarthritis (OA)
• Degeneration of the articular or hyaline
  cartilage within a joint
• Degeneration results from repeated trauma (e.g.,
  direct blows, pressure from loads, or repetitive
  running/cycling)
• pain, muscle spasm, and crepitus
• weakened ligaments and loose bodies are possible
• Bursitis
• inflammed bursa due to constant pressure or
  trauma from overused muscles and/or tendons
• may lead to a calcific bursa

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Synovial Chronic Joint Injuries

• Capsulitis
• inflammation of capsule following repeated
  microtrauma
• associated with synovitis
• Synovitis
• joint congestion with edema
• synovial membrane becomes thickened and
  degenerative
• restricts movement

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Types of Bones

• Flat bones
• scapula, ribs, skull
• Irregular bones
• vertebrae and skull
• Short bones
• metacarpals and metatarsals
• Long bones
• femur, tibia, fibula, radius, ulna

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Bone Physiology

• Epiphysis
• Epiphyseal plate
• Diaphysis
• Periosteum
• Medullary canal
• Endosteum

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Long Bone Growth

• Ossification of epiphyseal plate occurs from
  epiphysis inward and diaphysis outward
• Osteoblasts lay down bone cells, replacing
  cartilage, and are followed by calcification
• osteoblasts build new bone on outside
• osteoclasts widen the medullary canal by breaking
  down bone inside
• process eventually balances in a mature bone
• offset by overtraining and hormonal disruptions
• Wolffs Law

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Bone Fractures

• Open vs. Closed
• Depressed
• mostly in flat bones (i.e. skull)
• indented fx caused by falling or striking an
  object
• Greenstick
• mostly in adolescent bones
• incomplete fx on the convex bone surface
• Impacted fx
• bone is impacted causing a shortening of bone
  that usually results from a fall from a height

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Bone Fractures

• Longitudinal
• bone splits along its length
• caused by jumping from a height or landing so to
  stress the longitude of the long bone
• Oblique
• fx line is diagonal to bone length
• created by a torsion force at one end with the
  other end fixed
• Serrated
• two fx ends are sharp and jagged
• caused by a direct blow

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Bone Fractures

• Spiral
• S-shaped fx site
• created by a torsion force at one end with the
  other end fixed
• Transverse
• fx line is at a right angle to length of bone
• caused by a direct blow creating a bending force
• Comminuted (poor healing disrupted blood)
• fx site has 3 or more bone fragments
• caused by a direct blow or fall in an awkward
  position

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Bone Fractures

• Countrecoup
• fx site on opposite side of impact
• Blowout
• inferior orbital wall is fractured trapping
  inferior eye muscle
• unable to look up
• Avulsion
• separation of bone fragment from its cortex at
  the attachment site of ligament or tendon
• caused by a sudden twist or torsion

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Bone Fractures

• Epiphyseal plate fx
• Defined by Salter-Harris criteria
• I complete separation of physis from metaphysis
  without fx
• II separation of physis and a small portion of
  metaphysis from shaft
• III fx of physis
• IV fx of portions of the physis and metaphysis
• V crush of physis without displacement

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Bone Fractures

• Stress
• Also referred to as march or fatigue fx
• MOI
• overtraining at the beginning of season (Wolffs
  Law)
• continuous muscle contraction
• altered stress distribution from fatigue
• change in ground reaction forces
• rhythmic repetitive stress leading to a vibratory
  summation point
• postural conditions
• flat feet, pronated feet, leg length discrepancy
• Bone scan can provide an early dx

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Bones Fractures

• Stress
• Four progressions of stress fx
• Focal microfracture
• Periosteal or endosteal response
• Linear fx
• Displaced fx
• Periosteal, endosteal, and linear fx are still
  considered stress fxs
• Stress fxs on the compression side of the bone
  heal more rapidly
• Stress fxs on the tension side of the bone tend
  to produce complete fxs

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Nerve Physiology

• Neuron
• Cell body
• Dendrite
• Axon
• Myelin

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Nerve Injuries

• Nerve injuries typically result from compression
  or tension forces
• Neuropraxia axontomesis -- neurotomesis
• compression nerve pinch causing muscle weakness
  and sharp, burning, radiating pain down muscle
• tension nerve stretch causing muscle weakness
  and sharp, burning, radiating pain down muscle