SPORTS INJURIES ASSESSMENT

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SPORTS INJURIESASSESSMENT MANAGEMENT
University of Pretoria Section Sports Medicine
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SPORTS INJURIESASSESSMENT MANAGEMENT

• Contents
• Classifications
• Principles of Injury Prevention
• Principles of Diagnosis
• Principles of Treatment
• Pearls of wisdom

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1. CLASSIFICATIONS
Acute vs Chronic
Overuse vs Overload
Sprains vs Strains
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1. CLASSIFICATIONS

• Acute vs. Overuse Injuries
• Predisposing factors to overuse injuries
• Grading
• Tendon
• Ligament
• Muscle

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Acute vs Overuse Injuries
SITE ACUTE INJURIES OVERUSE INJURIES
Bone Fracture Periosteal contusion Stress Fracture Bone strain, stress reaction Osteitis, Periostitis Apophysitis
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Acute vs Overuse Injuries
SITE ACUTE INJURIES OVERUSE INJURIES
Articular Cartilage Osteochondral/ Chondral fractures Minor osteochondral injury Chondropathy (e.g. softening, fibrillation, fissuring, chondromalacia)
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Acute vs Overuse Injuries
SITE ACUTE INJURIES OVERUSE INJURIES
Joint Dislocation Subluxation Synovitis Osteoarthritis
Ligament Sprain/tear (grades I-III) Inflammation
Bursa Traumatic bursitis Bursitis
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Acute vs Overuse Injuries
SITE ACUTE INJURIES OVERUSE INJURIES
Muscle Strain/tear (grades I-III) Contusion Cramps Acute compart-ment syndrome Chronic compart-ment syndrome Delayed onset muscle soreness Focal tissue thickening/fibrosis
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Acute vs Overuse Injuries
SITE ACUTE INJURIES OVERUSE INJURIES
Tendon Tear (complete or partial) Tendinopathy (includes paratenonitis, tenosynovitis, tendinosis, tendinitis)
Skin Laceration Abrasion Puncture wound Blister Callus
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Acute vs Overuse Injuries
SITE ACUTE INJURIES OVERUSE INJURIES
Nerve Neuropraxia Minor nerve injury/irritation Entrapment Adverse neural tension
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Predisposing factors to overuse injuries
EXTRINSIC INTRINSIC
Training errors Excessive volume Excessive intensity Rapid increase Sudden change in type Excessive fatigue Inadequate recovery Faulty technique Malalignment Pes planus/cavus Rearfoot varus Tibia vara Genu valgum/varum Patella alta Fem. neck anteversion Tibial torsion
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Predisposing factors to overuse injuries
EXTRINSIC INTRINSIC
Surfaces Hard, soft, cambered Leg length discrepancy Muscle imbalance Muscle weakness
Shoes Inappropriate, worn out Lack of flexibility Generalised muscle tightness Focal areas of muscle thickening Restricted joint ROM
Equipment Inappropriate Lack of flexibility Generalised muscle tightness Focal areas of muscle thickening Restricted joint ROM
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Predisposing factors to overuse injuries
EXTRINSIC INTRINSIC
Environmental Hot, cold, humid Sex, size, body composition
Psychological factors Inadequate nutrition Other Genetic factors, endocrine factors, metabolic conditions
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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

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Grading of ligament sprains

• Grade I
• Stretched fibers
• Normal ROM
• Grade II
• Considerable portion of the fibers involved
• Increased laxity but a definite endpoint

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Grading of ligament sprains

• Grade III
• Complete
• Excessive laxity with no firm endpoint

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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

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Grading of muscle strains

• Grade III
• Complete tear
• Mostly at musculotendinous junction

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2. PRINCIPLES OF INJURY PREVENTION

• Correct biomechanics
• Warm up
• Stretching
• - Static
• - Ballistic
• - PNF

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Does warm-up influence the mechanical properties
of the muscle?
Passive warm-up
Active warm-up
Increases peak stretch and peak force
Increases peak stretch but decreases peak force
Force (N)
Force (N)
Stretch (mm)
Stretch (mm)
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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

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PRINCIPLES OF INJURY PREVENTION

• 4. Taping and bracing
• 5. Protective equipment
• 6. Suitable equipment
• 7. Appropriate surfaces

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PRINCIPLES OF INJURY PREVENTION

• 8. Appropriate training
• Principles of training
• - Periodisation/Overload/Specificity/
• Individuality
• b) Training methods
• - Aerobic/Anaerobic/Strength/
• Flexiblility/Speed/Agility/Skill
• training/Cross-training

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PRINCIPLES OF INJURY PREVENTION

• Adequate recovery
• - Warm down
• - Whirlpools and spas
• - Massage
• - Rest and sleep
• 10. Psychological aspects
• 11. Nutritional aspects

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3. PRINCIPLES OF DIAGNOSIS

• History
• - Allow enough time
• - Be a good listener
• - Know the sport
• - Discover the exact circumstances of
• the injury

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PRINCIPLES OF DIAGNOSIS

• History (cont.)
• - Obtain an accurate description of
• symptoms e.g. pain/swelling/
• instability/function
• - Was there a previous similar injury
• - Past injuries
• - General health

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PRINCIPLES OF DIAGNOSIS

• History (cont.)
• - Training history
• - Equipment
• - Technique
• - Overtraining
• - Psychological factors
• - Nutritional factors
• - Level of participation

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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
• gt 30 yr. ? tendon injuries

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PRINCIPLES OF DIAGNOSIS

• Examination
• - Develop a routine
• - Examine the other side, where
• relevant
• - Attempt to reproduce the
• symptoms
• - Assess local tissues

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PRINCIPLES OF DIAGNOSIS

• 2. Examination (cont.)
• - Assess for referred pain
• - Assess neural tension
• - Biomechanical examination

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PRINCIPLES OF DIAGNOSIS

• 3. Investigations
• - Understand the tests
• - Know how soon changes can be
• detected by investigations
• - Only order investigations that will
• influence management

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PRINCIPLES OF DIAGNOSIS

• 3. Investigations (cont.)
• - Be able to interpret tests
• - Do not accept a poor quality
• investigation
• - Explain the investigations to the
• patient

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PRINCIPLES OF DIAGNOSIS

• Investigations (cont.)
• - Examples of investigations
• Neurological (EMG/Nerve
• conduction studies)
• Muscular (compartment pressure/
• dynamometry)

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PRINCIPLES OF DIAGNOSIS

• Investigations (cont.)
• - Examples of investigations
• Cardiovascular (ECG/Echocardio-
• graphy)
• Pulmonary (Lung function tests)
• Radiological (CXR/RT/MRI/US)

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Ultrasonography
XR
Imaging studies
Arthrography
CT
Bone scan
MRI
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4. PRINCIPLES OF TREATMENT

• Six principles of management
• Minimize the extent of initial damage
• Reduce associated pain and inflammation
• Promote healing of damaged tissue

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Physiology of soft tissue healing
Initially prevent excess swelling and
injury w1-3 collagen formation (protect from
inversion)
Inflammatory Phase
gt3w collagen maturation (controlled stress)
Repair Phase
Remodelling Phase
4-8w full return to activity
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PRINCIPLES OF TREATMENT

• Six principles of management (cont.)
• Maintain or restore
• - flexibility
• - strength
• - proprioception
• - overall fitness

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PRINCIPLES OF TREATMENT

• Six principles of management (cont.)
• Functionally rehabilitate the injured
• athlete to enable return to sport
• 6. Assess and correct predisposing factors

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PRINCIPLES OF TREATMENT
Long-term phase
Acute phase
P R E P S
P R I C E

• Pharmaceutical
• Rest
• Ice
• Compression
• Elevation

• Pharmaceutical
• Rehabilitation
• Exercise
• Prevention Protection
• Surgery

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PRINCIPLES OF TREATMENT

• Types of treatment available
• Initial treatment
• - RICE
• Immobilise vs. mobilise
• Heat vs. cold

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PRINCIPLES OF TREATMENT

• Types of treatment available (cont.)
• Therapeutic drugs
• - Analgesics
• - NSAIDS
• - Corticosteroids
• - Hyaluronic acid
• - Anti-depressants

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PRINCIPLES OF TREATMENT

• Types of treatment available (cont.)
• Electro therapeutic modalities
• - Ultrasound
• - TENS
• - Interferention
• - Neuromuscular stimulators
• - LASER
• - Magnetic field therapy

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PRINCIPLES OF TREATMENT

• Types of treatment available (cont.)
• Manual therapy
• - Joint mobilisation
• - Joint manipulation
• - Joint traction
• - Massage therapy
• - Neural stretching

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PRINCIPLES OF TREATMENT

• Types of treatment available (cont.)
• Acupuncture
• Dry needling
• Hyperbaric oxygen
• Extracorporeal Shock Wave Therapy
• Surgery

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PEARLS OF WISDOM

• When to refer a STI?
• Groin pain HTAGP
• Look further than the obvious