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Concepts of Diagnosis of Sports Injuries


Concepts of Diagnosis of Sports Injuries Site of injury Truism If you hear hoof beats don t think zebras You better eliminate the zebras first: Dolbin – PowerPoint PPT presentation

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Title: Concepts of Diagnosis of Sports Injuries

Concepts of Diagnosis of Sports Injuries
Site of injury
  • If you hear hoof beats dont think zebras
  • You better eliminate the zebras first Dolbin

  • The best things in life are not things
  • Harry Bertsch
  • Hermy Bavier
  • Ron Boris
  • Amanda Driscoll
  • Josh Bertsch
  • Dad

Ron Boris
Concepts of Diagnosis of Sports Injuries
Cause as it relates to exceeding the tensile
strength of the tissue
Fracture dislocation
Concepts of Diagnosis of Sports Injuries
Biomechanical concepts of causation
Motion deficits as major causative factor
  • 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.
  • Increase demands on the cardiovascular system

  • Where observation is concerned, chance favors
    only the prepared mind. Louis Pasteur

Evaluation of the Kinetic Chain
  • Lower limb Ankles, Knees, and hips
  • Upper limb Core Stability, Endurance, Balance,
    Range of Motion
  • Scapula Stability, Rhythm
  • Shoulder Clinical examination

Concepts of inflammation and repair
Tissues respond to injury with a set of
genetically programmed mechanisms to replace the
damaged components and to restore normal function.
Inflammation and Repair
  • Cardinal signs of inflammation
  • Heat
  • Swelling
  • Pain
  • Redness
  • Loss of Function
  • Two types of Inflammation
  • Acute
  • Chronic

Chronic Inflammation
Acute 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 PMNs from the vascular component.
  • These in turn produce chemotactic factors that
    control the damage and remove debris by
  • 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.
Inflammation and Repair
  • Repair
  • 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
  • Remodeling and Maturation
  • Process begins about 6 days after the fibroblasts
    begin to lay down collagen tissue.
  • Collagen is laid down randomly initially
  • Depends on the appropriate mechanical loading.
  • The hallmark of remodeling is the orientation of
    new fibers

Inflammation and Repair
  • 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
  • Mobilization and loading has been shown to result
    in stronger healed tissue.
  • Time Frame of Healing
  • Inflammation Phase is relatively brief. 24-48
  • Proliferative Phase 3-7 days after the injury
  • Repair Phase Few days to a few weeks
  • Remodeling Phase Several months and may continue
    up to 12 months.

Inflammation and Repair
  • Repair Mechanisms in Soft Tissue Injuries
  • Muscle Tissue
  • Healing of skeletal muscle is dependent on the
    integrity of the vascular system and nervous
  • Has considerable regenerative properties
  • Both regeneration and repair by scar tissue.
  • Capacity for regeneration is determined
    genetically but the success is determined
    primarily by the extent and type of injury.
  • 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.
  • 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.
  • 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
  • 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
  • Modalities
  • Cyriax
  • Joint Mobilizations
  • Muscle Energy
  • Laser therapy
  • Immobilization.
  • Chiropractic Adjustments

Concepts of rehabilitation
  • 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
  • Daily Function
  • Demands of the Sport

Incidence of injury according to the American
Journal of Sports Medicine
  • 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
  • Jogging, running 60
  • Tennis 60 Musculotendinous overload injuries

Duration of Injury
Predictor of Injury
  • Tri-athlete 30 days
  • Cyclists 2 weeks
  • Swimming 2 weeks
  • Runners 40 days
  • No previous injury 40 chance of experiencing a
    sports related injury
  • Previous Injury 65 chance of a re-injury in the
    Kinetic chain
  • a. Mostly due to incomplete rehabilitation
  • b. Rehab stopped at symptom reduction.

Goals of Rehabilitation
  1. Return to Function
  2. Allows for proper healing
  3. Maintaining the other components of athletic
  4. Return to Normal Competition
  • Return to Function is the key not simply symptom
  • Establish an accurate diagnosis
  • Minimize the local effects of acute injury

Effects of Immobilization
  • For each week of immobilization there is a 20
    loss of strength in joint.
  • 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.

Goals of Rehabilitation
  • Allows for proper healing
  • Protects Tissue
  • Use of Physical Treatment Modalities
  • Cold, Heat, Electricity, Laser
  • Use predicated on accurate diagnosis
  • Understanding of the biophysics of the modality
  • Maintaining the other components of athletic
  • Strength
  • Flexibility
  • Aerobic Conditioning
  • Return to Normal Competition
  • Baseline established in Preseason Physical
  • Begin graded return if no baseline established
  • Increase volume and intensity incrementally

What are we Rehabilitating?
  • Dx. more than the site of the injury!
  • Kinetic Chain

Classification of Injury
  • 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

  • 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
  • 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

  • Injections cause very poor healing and a return
    of symptoms with activity
  • Chronic Adaptations
  • 1. No overt symptoms
  • 2. Pattern of abnormalities that lead to
    decreased function and performance

Negative Feedback Vicious Cycle
Tissue Overload Complex
Sub-clinical Adaptation Complex
Tissue Injury Complex
Functional Biomechanical Deficit Complex
Clinical Symptom Complex
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
  • Pain
  • 4. Functional Biomechanical Deficit Complex
  • a. Decreased flexibility
  • b. Decreased Strength
  • c. Muscle imbalances

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