Athletic Injuries Midterm PDF

Evidence Based Practice - the conscientious, explicit and judicious use of current evidence in making decisions about the care of individual patients - Incorporation of a clinicians expertise and the best current research evidence with the patients values - Level of evidence varies greatly...

Evidence Based Practice - the conscientious, explicit and judicious use of current evidence in making decisions about the care of individual patients - Incorporation of a clinicians expertise and the best current research evidence with the patients values - Level of evidence varies greatly and is mostly based on perceived clinical success - Read all scientific journals, critically appraised papers (CAPs) and critically appraised topics (CATs) - Steps: - Assess the patient (issues, problems, goals) - Ask the question (clinical question) - Acquire the evidence (select appropriate resources and conduct search) - Appraise the evidence (determine if evidence is valid and applicable) - Apply by speaking with patient (integrate evidence with expertise and patient preferences) - Self-evaluation (evaluate performance and effectiveness)   Phases of Healing - Our treatment choice will be dependant on the phase of healing the patient is in - We have minimal ability to speed up this process but interfering with the sequence will slow down recovery and return to sport   Inflammatory / destruction phase (up to 4 days) - Cellular injury alters metabolism and releases chemical mediators / proteins which cause inflammatory response - Primary - damage at time of injury - Immediately irreversible - Secondary - damage by released proteins and as a result of body processes - Edema, damage due to increased blood flow, decreased oxygen - Inflammatory response: redness, swelling, pain, local heat, loss of function   Repair phase (between 3 days and 6 weeks) - Proliferative and regenerative healing leading to formation of connective tissue scar and repair of injured tissue - Fibroplasia begins within the first few days and the inflammatory signs should be gone - Growth of endothelial capillary buds into the wound is stimulated by lack of oxygen and increases blood flow - Body lays down type 3 collagen which has weak tensile strength and is very delicate - Intense or aggressive exercise at this phase could lead to reinjury   Remodelling / maturation phase (between two weeks to 3 years) - Long term recovery process with gradually increased stress and strain - Collagen changes to type 1 (stronger) and begins fibre realignment - Wolf\'s law - bone and soft tissue will respond to the physical demands placed on them causing them to align along the lines of tensile force - Critical that injured structures are exposed to progressively increasing loads so fibres realign gradually - Can work up to aggressive strengthening to facilitate remodeling and realignment - Be aware of pain and swelling after exercise (small amount is okay)   SOAP Notes Subjective - Most important aspect of evaluation, includes statements provided by the patient regarding their symptoms and a medical history - Used to develop a strategy for further examination - Ask open ended questions and use active listening (eye contact, non-verbal cues) - History - Primary complaint - History of injury (specific MOI, symptoms, immediate or delayed issues) - Pertinent medical history (MSK injuries, medical conditions, red flags)   Objective - Signs (observable physical indications of a present condition) - Bruising, bleeding, AROM, PROM, strength, sensation, reflexes, tests, pain on palpation   1. Observation / visual inspection - Assess general demeanor as soon as patient walks in - Expression, tone of voice, protective postures - Obvious deformity or asymmetry - Signs of inflammation (red, hot, swollen, painful) - Quality of movement, speed, amount 2. Selective tissue tension testing - method for locating and identifying a lesion by applying tension to each of the structures that might produce pain - Contractile tissue = muscles, tendons, tenoperiosteal insertion - Increases in tension when tissue is stretched or contracted - Active motion in one direction and passive in opposite direction - Either direction will elicit pain if injured - Inert tissue = ligaments, bursa, capsules, fascia, nerve roots, dura mater - Increases in tension when stretched only - Will elicit pain on active and passive movement only in one direction - AROM (active range of motion) - Active movements that cause pain do not specifically indicate inert or contractile - Muscle tension and joint movement causes contractile and inert tension to occur - Agonist contract and antagonist stretch - Give us important information on pain location, willingness to move, quality of movement, available ROM and clues on how to proceed - PROM (passive range of motion) - Patient must relax completely and allow therapist to move extremity (important because do not want contraction of agonist muscle) - Look for ROM limitation and presence of pain - Pay attention to how they feel at end of ROM - Passive movements are used to detect lesions in inert tissue (stretch = pain) and allows us to assess end feel - Normal end feel - Soft tissue approximation - soft spongey gradual painless endpoint when two muscle bellies meet (elbow flexion) - Bone to bone - distinct abrupt painless endpoint (elbow extension) - Capsular - abrupt firm endpoint with little give (shoulder rotation) - Abnormal end feel - Springy block - internal issue of joint, rebound at some point through ROM - Spasm - involuntary contraction that prevents motion, rubbery feel prior to expected end of ROM - Abnormal capsular - prior to end of ROM - Empty - did not reach end feel, considerable pain produced by movement, no mechanical resistance detected, significant soft tissue injury - Resisted movements - Contraction of only agonist muscle (no stretch on antagonist) - No movement through joint or stretch on inert tissues - Isometric and midrange, position yourself to maximise mechanical advantage - Indicates pain in contractile tissue and indicates nerve function - Strong painless = normal nerve and muscle - Strong painful = minor muscle problem - Weak painless = nerve lesion and complete rupture - Weak painful = nerve lesion and significant muscle tear 3. Neurological testing - Reflexes - C5-C6 = biceps and brachioradialis - C7-C8 = triceps - L3 = knee jerk - S1 = Achilles - Dermatomes - cutaneous area receiving the greater part of it innervation from a spinal nerve - Myotomes - muscle receiving innervation from a spinal nerve - Isometric contraction to identify weakness   C2 neck flexion L1 hip flexion ----------------------------------- ----------------------- C3 neck side flexion L2 hip flexion C4 shoulder shrug L3 knee extension C5 shoulder abduction L4 ankle dorsiflexion C6 elbow flexion, wrist extension L5 1st toe extension C7 elbow extension, wrist flexion S1 plantar flexion C8 thumb extension S2 knee flexion T1 spread fingers S3 intrinsics of foot   1. Special tests - Assist in differential diagnosis of patient\'s injury - Includes manual muscle testing, specific muscle and ligament tests - Allow us to grade the injury   Oxford scale (manual muscle testing) -------------------------------------- 0 - nothing happens 1 - muscle twitch, no movement 2 - move but not against gravity 3 - move against gravity 4 - move with some resistance 5 - full movement with resistance   1. Palpation - This is done last to avoid inflicting more pain on the individual from the very beginning   Analysis / Plan - We now know if the injury is contractile, inert or both and have an idea of the degree of injury to each structure - Based on these findings we form a clinical opinion or diagnosis Factors for Hot/Cold Response 1. Media that is being applied - Ice, cold immersion, sprays - Moist heat (better for deep tissues), dry heat (better tolerated), ultrasound 2. Conductivity of the area - High water content mean more responsive to temperature change - Joints contain synovial fluid so they will respond better to temp change compared to muscle - Decreased conductivity through body fat 3. Length of time of exposure - Ice = 10 on, 10 off, 10 on - Heat = peak in 5-7 minutes then level off   Physiological responses to Heat - Increase blood flow, capillary permeability, metabolic rate, collagen elasticity, edema - Decrease muscle guarding, joint stiffness and pain   Physiological Response to Cold - Increase joint stiffness - Decrease muscle guarding, blood flow, capillary permeability, metabolic rate, collagen elasticity, edema and pain   Ice = Good - Knock out C fibers by decreasing conduction velocity which reduces pain perception - Decreases swelling and significant improvement in function - Maintain cell viability after injury (decrease secondary cell death)   Ice = Bad - Evidence that early ice treatment may slow down healing over the first 3-7 days - More necrosis, less neutrophils and macrophages in the first few days   Immediate Goals during Inflammation Phase - Optimize healing environment - Palliate / manage pain - Decrease swelling   Treatment Strategies - Protection - Interventions that shield and prevent joint movement - Short periods of unloading are required after acute soft tissue injury - Goal is to control inflammation and prevent further injury - Loading - Balanced incremental rehabilitation - Early activity encourages early recovery because increased blood flow - No one size fits all strategy - Compression - Decrease local edema - Applying pad or ice bag will increase pressure - Limit space it is able to occupy - Can improve quality of life by allowing functionality - Elevation - Area must be at least 30 cm above the heart - Optimism and education - Educate the athlete and let them know why they are doing things - Set small goals and share achievements to maintain positive attitude and confidence - Teach them rehabilitation is an active and ongoing process - Icing - Best cooling is ice mixed with water in plastic bag directly on skin - Compression over top is best - Explain what athlete will feel (CBAN - cold, burning, aching, numbness) - Repair phase - Protect the tissue and idealize healing environment - Increase blood flow, idealize ROM and begin gentle strengthening - Heat - Increases elasticity and reduces muscle stiffness - Use moist heat from hot packs with 6-8 layers of towel underneath - It will take a few minutes to feel heat (do not remove any of the towels - Keep on for 10-20 mins   Ankle Sprains - 85% lateral, 10% medial and 5% syndesmosis (high ankle) - Lateral sprains are most common because there is less bony protection on the lateral side to prevent inversion injury   Bones of the Ankle - Talocrural joint (ankle) - Ankle mortice is a u shaped structure making up the top of talocrural joint - Inferior end of tibia - Medial malleolus (tibia) - Lateral malleolus (fibula) - longer and more posterior - No muscle attachments - Trochlear surface (top) is wider anteriorly than posteriorly and with dorsiflexion this portion will move between the malleoli which increases stability - Dorsiflexion - Fibula externally rotates and moves superiorly - External rotation of fibula increase tension in AITFL, PITFL and ITFL   Passive stabilizers - Fibrous capsule is thin and weak anteriorly / posteriorly to allow complex movements - ATFL - intracapsular, weakest ligament, increased strain in plantarflexion and inversion - CFL - extracapsular, lateral stability in neutral / dorsiflexion, much stronger ligament - PTFL - support in dorsiflexion, injury not isolated - Deltoid - anterior part is tight in plantar flexion, middle portion in neutral, posterior portion in dorsiflexion, stability in eversion   Ligament Sprains - 0-4% strain is normal physiological range - Microtears in ligament occur after 4% where fibers partially rupture - Grade 1 = \ 1. Rule out fracture - Ottawa ankle rules - bone tenderness at any of the landmarks or inability to bear weight on ankle - External rotation test (fibular fracture) - hand medial by knee and rotate foot laterally (pain = positive fib fracture) 2. Assessing and grading - Normal ROM for ankle - Plantar flexion = 50 deg - Dorsiflexion = 20 deg - Inversion = 30-35 deg - Eversion = 15-20 deg - Anterior drawer test (ATFL injury) - slight plantarflexion, positive if foot slides forward or makes clunk sound as it reaches endpoint - Talar tilt test (CFL and deltoid injury) - pain or excessive motion when moving calcaneus into inversion (CFL) or eversion (deltoid) - Manual muscle testing (oxford scale) - Grade 1 = 4-5 on scale - Grade 2 = 2-3 on scale - Grade 3 = 0-1 on scale 3. Rule out based on assessment findings - ATFL sprain (most common) - MOI inversion and plantar flexion - CFL sprain - MOI inversion and dorsiflexion - Deltoid sprain (least common) - MOI eversion 4. Prognostic indicators - Higher age, poor weightbearing status, higher grade injury at baseline - Not achieving full ROM within weeks indicates accompanying injury - Medial pain on palpation and with dorsiflexion are associated with poorer function Retrocalcaneal Bursitis - bursa in the recess between the anterior inferior side of the Achillies tendon and the posterosuperior aspect of the calcaneus - Sometimes seen with insertional tendinopathy - Structural irritants (tight / pokey) - Pain just above insertion of Achillies (test by squeezing from sides)   Achillies Bursitis - superficial calcaneal bursitis - Bursa located between calcaneal prominence, Achillies tendon and skin - Pain posterior aspect of heel with solid swelling - Often due to friction - Palpate directly on bursa to identify pain   Tendinitis / Paratenonitis - Tendons are mechanically responsible for transmitting muscle forces to bone and in doing so permit locomotion and enhance joint stability - Tendons are structured to withstand stretch - No synovial sheath but vascular tendons are surrounded by paratenon - Tendinitis - inflammation of the tendon itself (relatively rare) - Paratenonitis - inflammation, pain and crepitation of paratenon as it slides over structure - MOI = acute irritation (too much, too soon) - Symptoms and signs - Pain / crepitation of acute onset - Red and hot over involved structure - Usually precipitated by movement around ankle joint - Local swelling location - STTT - Lateral side - peroneus longus, peroneus brevis - Medial side - tibialis posterior, flexor digitorum longus, flexor hallucis longus, tibialis anterior - Rehabilitation - Inflammatory / destructive phase - police peace and love, heel lift, donut pad, tape - Repair - address training issues to avoid reinjury, heat, idealize ROM   Tendinosis - Collagen fiber disarray, loss of parallel bundles and fewer cell nuclei - Hypervascularity and increased number of poor quality blood vessels (not evenly spaced) - Predisposing factors - Years of running - Excessive pronation - Poor flexibility - Cold climate - Improper footwear - May be brough on due to neglect of acute tendonitis - Common stages for signs and symptoms - Stage 1 - no pain prior to activity, pain during activity, pain following activity disappears after rest - Stage 2 - pain prior to activity in morning, pain throughout activity but does not restrict, pain and tightness after activity - Stage 3 - pain and stiffness before, pain limits quality and quantity of activity, very painful after - Stage 4 - severe pain, unable to exercise, may lead to rupture if untreated - Diagnosis - Midsubstance is easier to treat than insertional - History of increased FITT of training, pain, swelling and tenderness over tendon - Excessive pronation - Pain with plantar and dorsiflexion - Rehabilitation - No acute / inflammatory because long term injury - Repair - tissue healing, palliate pain, correct risk factors, stretch and strengthen - Remodeling - restore symptom free ROM, improve paratenon gliding, eccentric exercises   Achillies Rupture - Increased risk for males, steroid users, prior rupture on contralateral side - Patient reports pop or snap like someone kicked them, immediate pain that subsides - Occurs usually 1-2 inches above insertion - Diagnosis - Foot hangs straight down (no plantar flexion) - Palpable divot above insertion - Positive Thompson\'s test (squeeze calf no movement) - Treatment - Immobilize in air cast with heel lift and crutches - Exercise below neutral to avoid any tension - Remove heel lift 6-8 weeks - Remove boot 8-12 weeks   Compartment Syndrome - Traumatic (acute) - Secondary to direct trauma - May occur after fracture, muscle injury or acute overload - Considered medical emergency (call 911) - Symptoms - Pain that is out of proportion with injury - Pain aggravated by stretching muscle group within compartment - Paresthesia - altered sensations / pins and needles - Exertional (chronic) - Following increased activity levels - Repetitive overuse leads to fibrosis and decreased elasticity of fascia - Chronic symptoms arise during running and jumping movements and cease with rest - Injury mechanism - Increased volume demands in compartment due to noxious stimulus - Increased pressure in compartment as it fills with blood - Compromise of capillary profusion (arteries open but pressure collapses veins so blood cannot leave) - Muscle swells and dumps fluid (traumatic = fluid must be released with fasciotomy) - Clinical compartment evaluation - Weak, slow (fatigable weakness) and painful - Muscles working anaerobically will have pain with stretch - Palpate for firmness (firm = bad)   Anterior Compartment - Pain - lateral tibia - Strength test - dorsiflexion - Stretch - plantarflexion - Nerve - deep peroneal - Sensory area - between first and second toes   Lateral Compartment - Pain - near lateral malleolus - Strength test - eversion / plantarflexion - Stretch - dorsiflexion / inversion - Nerve - superficial peroneal - Sensory area - top of foot   Deep Posterior Compartment - Pain - lower third posterior medial tibia - Strength test - invertors (plantarflexion) - Stretch - eversion / dorsiflexion - Nerve - tibial - Sensory area - plantar foot not near heel   General Treatment Guidelines for Compartment Syndrome - Acute = medical emergency - Chronic - Modification of activity - Gradual motion before activity - Icing after activity to decrease secondary cell death - Soft tissue release - Stretching / strengthening   Medial Tibial Stress Syndrome (MTSS) - Most commonly occurring chronic overuse injury (running or jumping) - Contributing factors - Over pronation - Muscular dysfunction - Fatigue - Shoe design - Training errors (FITT) - Initially tibialis posterior what thought to be the sole source of pain because it works eccentrically to slow down the internal rotation of the leg on the foot during pronation - More recently soleus and flexor digitorum longus have been implicated - Diagnosis - Diffuse pain medial border of tibia - Pain that improves slightly with warm up and worsens after exercise again (may progress to pain during exercise the incapacitating) - Palpation over medial tibial margin (pain / rough) - Minimal STTT signs unless advanced - Hop test for diffuse pain - Treatment - Police peace and love - Correct training errors - Gradual loading with pain below 2 Vas - Stretching and strengthening - Taping arch and shins   Medial Tibial Traction Periostitis (MTTP) - Periostitis = inflammation of the outer covering of the bone - Pronation provides shock absorption and medial soleus is strongest plantar flexor / invertor because it eccentrically resists pronation - Excessive pronation to pes planus or overuse with repetitive load creates chronic traction over its insertion on the periosteum (this decreases bone mineral density)   Tibial Stress Fractures - Impact absorbed by shoes, muscles, bones - Too strong of a muscle pull on one side of the bone ill affect bone mineral density - Up to 50% stress fractures occur in lower leg - 90% will be posteromedial - Proximal and anterior are more resistant to treatment (anterior is awful) - Usual presentation - Cavus or pronated foot - Gradual onset aggravated by exercise - Pain walking, rest and night - Localized tenderness (single point or small area) - Treatment - Decrease weight bearing and use pneumatic brace - Address training errors - Slow return to pain free activity       Activity pain Muscle strength Repeated muscle contractions Sensory changes Night pain ----------------- --------------------------------------------- ------------------------------------------------------------------ ----------------------------------- ------------------------------------------------ ------------------ MTTP Pain onset, reduced warm up, pain following No change No effect No change None CS Pain escalate as activity continues Stretching muscle within affected compartment will increase pain Slowing and weakening contraction Potential changes corresponding to compartment None Stress Fracture Pain before, same during and after No change No effect No change Deep aching pain Tibiofemoral joint - Articulating surfaces between the medial and lateral condyles of the femur and tibia - Allows transmission of body weight from the femur to the tibia while providing hinge-like sagittal plane joint rotation and a small degree of tibial rotation (screw home mechanism)   Patellofemoral joint - Articulation between patella (largest sesamoid bone in body) and femur - Extensor mechanism and works eccentrically during gait   Capsule of the Knee - Knee is surrounded by a capsule - Anteriorly to suprapatellar pouch and inferior to infrapatellar fat pad / bursa - Medially it communicates with deep fibers of MCL - Posteriorly covers femoral condyles - Lined by synovial membranes except posteriorly where it passes in front of cruciates   Knee Stability - More stable in extension with help from dynamic stabilizers - Knees have relatively poor bony fit when flexed - Strong fibrous joint capsule - Inert stabilizers - MCL (protects from valgus 20-30 deg) - LCL (protects from varus 20-30 deg) - ACL (prevents anterior tibial translation) - PCL (prevents posterior tibial translation   Lateral Support Complex 1. Superficial - IT band and biceps femoris 2. Middle - patellofemoral ligaments and retinaculum 3. Deep - LCL, popliteus tendon, capsule, other ligaments   - Lateral aspect of the knee is significantly supported by muscles and MOI is a varus load - LCL surface anatomy - Round fibrous cord about the size of pencil - Extends from lateral epicondyle of femur to lateral fibular head - Figure 4 position trace a line from fibular head to femur - Primary static restraint to varus   Medial Support Complex 1. Superficial - sartorius and fascia 2. Middle - superficial MCL and semimembranosus 3. Deep - deep MCL and capsule   - MOI is valgus load (ACL and PCL provide secondary help vs valgus) - Muscles help in full extension - Medial hamstrings - Medial head of gastrocs - Quad muscles - MCL surface anatomy - To palpate find the medial joint line then move posteriorly (it is wide and flat) - Deep component connects directly to medial meniscus - Superficial component runs from medial femoral epicondyle to superomedial surface of tibia - Most active when resisting valgus loading at 25-30 deg knee flexion   Anterior Cruciate Ligament - Runs from anterior aspect of tibial plateau to the posterior medial aspect of lateral femoral condyle - 2 major bundles: anteromedial (tight in flexion) and posterolateral (tight in extension) - Greatest translocation occurs at 20-30 deg - Functions to restrict posterior translation of the femur relative to the tibia during weight bearing and anterior translation of the tibia during non weight bearing - Limits rotation and is secondary support for valgus and varus with collateral ligament damage - MOI - Valgus after MCL (contact) - Deceleration and internal rotation (non contact) - Hyperextension but not in isolation - Quads active - anterior tibial translation   Posterior Cruciate Ligament - Originates on lateral aspect of the medial femoral condyle and inserts posteriorly to intercondylar area of tibia - 2 major bindles: anterolateral (tight in flexion) and posteromedial (tight in extension) - Greatest translocation occurs at 20-30 deg - Functions to restrict anterior translation of femur relative to tibia during weight bearing and posterior translation of the tibia during no weight bearing - Secondary support for valgus and varus with collateral ligament damage - MOI - Direct blow to the upper portion of tibia (fall on flexed knee or MVA) - Hyperflexion - increase tension in anterior segment, impinged between posterior tibia and intercondylar notch roof - Hyperextension   Medial and lateral Meniscus - Serve essential roles in maintaining knee function (stabilize knee by increasing concavity of tibia and provide shock absorption) - Full extension 45-50% of load - 90 deg flexion 85% of load - Compression facilitates distribution of nutrients - Medial meniscus - C shaped - Larger radius of curvature - Tight connection with capsule and MCL (poor mobility) - Injured more often - Lateral meniscus - O shaped - Small radius of curvature - Attaches loosely to capsule and popliteal tendon (increased mobility) - Meniscal blood flow - divided into three zones - Red zone: outer 1/3 with good blood supply (most likely to heal on its own) - Pink zone: middle 1/3 minimal blood supply - White zone: inner 1/3 no blood supply (will not heal on its own if injured)   Subjective Knee Injury - MOI - varus, valgus, rotation, anterior, posterior translation etc. - Pop or crack could indicate injury to ligament or bone - Pain and disability at time of injury speaks to initial severity and level of function - Presence and timing / onset of swelling - Indicates bleeding in the joint - Swelling 2-6 hours post injury \75% ACL tear - Patellar dislocation next most common followed by fracture and meniscal tears - Pediatrics suspect patellar dislocation   Observation Knee Injury - Swelling, obvious deformity, ROM, weight bearing - Tap test and wipe test to asses swelling - Ottawa knee rules - Older than 55 - Isolated tenderness of patella or head of fibula - Cannot flex to 90 deg - Unable to bear weight   Assessing and Grading structures - Normal ROM for the knee - Knee flexion 0-140 deg - Extension 0-10 deg - Special tests for knee - Patellar apprehension test - Valgus and varus (collateral ligaments) - Anterior drawer or Lachman\'s (ACL) - Lachman\'s is better because hamstrings are not as active - Posterior drawer or sag test (PCL) - McMurray\'s or hyperflexion (meniscus) - Patellar apprehension test - apply lateral force to patella look for visible apprehension and / or pain - Manual muscle testing and grade using oxford scale   Collateral ligament sprain - 40% of knee injuries involve MCL, LCL injuries less common and rarely occur in isolation - MCL - valgus MOI, pain over medial knee, localized swelling, pain with valgus stress - LCL - varus MOI, pain over lateral side, minimal swelling, pain with varus stress   ACL ligament sprain - Secondary support, 70-75% hemarthrosis, 80% bone bruise on lateral joint line, 75% meniscal injury - MOI - cutting, landing, quads active - Pop or crack, fast swelling, unable to continue because of instability - Significant swelling, restricted movement, lateral joint tenderness - Positive anterior drawer or Lachman\'s   PCL ligament sprain - Not very commonly injured, 60% include injuries to other structures - MOI - dashboard, hyperflexion or hyperextension - Pop in posterior knee and poorly defined pain - Minimal swelling - Positive posterior drawer and sag test   Meniscal Injuries - Acute occur when combined shear forces generated by flexion, compression and rotation exceeded the meniscal collagen\'s resistance - Medical meniscus is most likely injured - MOI - twist under load - Medial or lateral joint line pain, locking with movement - Swelling differs depending on what layer of meniscus is injured - Springy end feel, possible decrease in ROM, pain on squatting   Acute Patellar Dislocation - MOI - forceful knee rotation or quads contraction, knee near full extension, laterally directed force - Severe pain until reduced (slightly flex hip and slowly extend knee) - Loss of knee function, tenderness over medial border of patella, positive lateral apprehension test   Patellofemoral pain - Characterized by pain in peripatellar / retro patellar area that is aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee - Walking down stairs, squatting, sitting for long periods, running, jumping - 10-25% of all PT visits - Primary focus is evaluating overuse injuries of the knee and identify factors that may contribute to condition - Strive for equal pressure distribution across the back of patellae to ensure proper nutrition - Hypo pressure - cartilage degeneration from inside out due to mal nutrition - Hyper pressure - cartilage rub and fibrillation - Structural issues - Excessive pronation - Causes internal rotation of tibia and delayed resupination - Affects screw home mechanism and causes lateral pull on patella - Lower chain alignment - Q angle - axis formed by femur and tibia - Causes lateral pull on patella - Occurs in varus or valgus - Tissue length issues - Rectus femoris - increase compression of PF joint - Hamstrings - greater force production from quads to overcome hamstring stiffness - ITB - lateral influence in patella - Gastrocs / soleus - limited ROM compensated by excessive rotation and increase valgus stress on knee - Line of pull - Quadriceps - Sum of quads is offset into valgus - Weak muscles not able to maintain alignment which can cause abnormal pull on patella - Poor multi plane lumbopelvic femoral control - Medial collapse mechanism - Hip adduction, femoral internal rotation and knee valgus - Decrease joint contact area and increase joint stress Normal ROM for Hip / Pelvis - Flexion - 120 - Extension - 30 - Abduction - 45 - Adduction - 30 - Internal rotation - 45 - External rotation - 45   Femoral Acetabular Impingement (FAI) - One of the most common intra-articular causes of hip pain - Cam = result of abnormal morphology at the femoral head-neck junction (build up of bone on femoral head) - Pincer = result of an abnormal morphology of acetabulum (build up of bone on acetabulum)   FAI Clinical Presentation - Symptoms include pain at groin or hip, clicking, popping, or stiffness - Patients often describe a deep anterior groin-related pain - Flexion, adduction, internal rotation test (FADIR) or flexion, adduction, external rotation test (FADER)   Labrum - Triangular fibrocartilage that deepens acetabulum against femoral head translation - Fluid filled central compartment to lubricate joint and even the distribution of contact forces - Tears are common secondary to trauma and impingement (FAI) - Main symptom is anterior hip pain, groin pain and sometimes clicking - Positive c sign and hip scour test   Hip Pointer - Iliac crest contusion and contusion of abdominal musculature - Very disabling due to pain - Crush of soft tissue between hard object and iliac crest - Symptoms and signs - Immediate pain / spasm - Quick decline in level of function, may have STTT for hip movements and trunk rotation - Check pain through pelvic ring (pressure through ring without pushing on injured area) - In rare circumstances pelvic crest can be fractured - Treatment - Police and palliate pain - Slow rehab secondary to pain - Pad for return to sport   Hip Flexor / Groin Strains - Can include iliopsoas, rectus femoris, and adductor group - Difficult to diagnose because usually combination of MOIs - Adductors often acute injury, iliopsoas often more chronic - Adductor longus most common site of injury (may be from resisted adduction, forced extension or hip contraction)   Adductor Strain - common in sports utilizing sudden change of direction - Athlete recalls sudden intense pain - Usually acute onset that is well localized to belly of adductor longus or proximal MT junction - Signs and Symptoms - Pain on resisted adduction or flexion and adduction - Pain on passive hip abduction - Swelling or bruising - Rule out avulsion by palpating attachment site - Treatment - Control bleeding and swelling - Gentle strengthening (do not want to stretch too early) - Focus on muscular imbalances   Hip Flexor Strain - Forced extension / excessive contraction of hip flexors - Rectus femoris - near origin and acute - 2 joint muscle meaning higher risk - Explosive hip flexion and knee extension - Tenderness 8-10 cm below ASIS - 27 days average rehab - Pain with stretch and active knee extension - Positive Thomas test - Iliopsoas - chronic - Usually from repetitive and excessive hip flexion - Poor localized ache deep on one side of anterior hip / groin - Pain on stretch, and resisted hip flexion - Positive Thomas test   Groin Strain - Abduction, extension, external rotation - Combination of hip flexor and adductor strain - Large eccentric component - Pain at extremes of movement (changeover) - Pain with stretch into extension, abduction or external rotation - Pain on resisted flexion, adduction and internal rotation - Treatment - Can be acute or chronic - Pay close attention to muscle imbalance, movement style etc.   Hamstrings Injury - Majority occurs in biceps femoris at proximal MT junction (eccentric to slow leg swing and concentric to pull leg towards) - Can also have stretch injuries at ischial tuberosity (longer healing time) - Intrinsic Predisposing factors - Age over 23 due to decreased mm size and denervation - Previous injury = reduced strength - Quads to hamstrings strength ratio (problem is quads are much stronger) - Flexibility - Lumbopelvic stability - Extrinsic Predisposing Factors - Inadequate warm up - Fatigue changes time and coordination - Abrupt increase in FITT - Signs and symptoms - Sudden onset, spasm like sensation, difficulty walking or running - Bruising - Positive STTT - Palpable gap or tenderness on palpation - Grade 1 = slight tension, good strength, fewer than 20% fibers torn - Grade 2 = feel pop or tear, unable to extend knee, significant pain and weakness, 70-80% fibers torn - Grade 3 = palpable defect or tear, greater than 80% fibers torn, may be painless if complete tear - Treatment - Acute - police, compression, gentle knee movement - Sub acute - idealize ROM and stretch end range - Remodeling - increase stress through injured tissues, work concentrically and eccentrically   Quadriceps Strain - Sudden forceful contraction of hip and knee - Most common in rectus femoris because crosses two joints - Usually in distal MT junction (but rec fem takes slightly longer to heal) - Strains of proximal muscle are more difficult to rehab because strain on central tendon causes shearing - Symptoms and signs - Sudden onset - Site of pain usually rectus femoris distal MT junction - Watch out for proximal pain as may indicate longer recovery - Bruising, positive STTT, decreased ROM, palpable gap if high grade - Treatment is exact same as hamstrings   Thigh Contusions - Most common acute thigh injury in sport (result of high impact on relaxed thigh) - Intermuscular = blood escapes through fascia and is distributed between compartments in the thigh - Intramuscular = confined to a single muscle compartment (more painful and restrictive) - Increased volume and pressure and decreased ROM - Symptoms and signs - Sudden onset of decreased ROM following impact - Bruising, STTT contractile, palpable mass (if it is intramuscular), tenderness on palpation at injury site, decreased ROM - Passive knee flexion after 24 hours is indicator of severity - Prone knee bend = if performed 24-48 hours post injury ROM less than 90 suggests intramuscular bleed and is prognostic of long recovery - Grading Quads Contusion - Mild = greater than 90 flexion - Can continue activity - Minimal strength loss - Moderate = 45-90 flexion - Tender to touch - Loss of strength due to pain - Severe = less than 45 flexion - Rapid swelling and bleeding - Difficulty weight bearing - Functional loss of strength - Treatment - Significant risk of rebleed in 7-10 days - DO NOT use soft tissue therapy for at least 48 hours - No aggressive passive stretch past pain - US navy protocol = flexion as soon as possible for 24 hours - Passively and painlessly flex knee to 120 deg and wrap - Keep wrapped for 24 hours, add ice when needed - Goal is pain free AROM equal to other side, active pain free stretching and isometric strength   Myositis Ossificans - Muscle inflammation and formation of blood from bone - Periosteal - connected to normal bone - Heterotopic - within muscle belly - Osteoblasts replace some of the fibroblasts in the healing hematoma 1 week after injury (stops growing at 6-7 weeks) then slow reabsorption of bone - Risk factors - Inappropriate treatment - vigorous therapy - Flexion less than 45 deg 2-3 days post injury   Acute Compartment Syndrome of Thigh - Fairly uncommon but does occur in contact sports - 24-48 hours post injury - Compartment pressure as high as 80-100 mmHg (normal is 20 mmHg) - Usually treated conservatively in quads but may require surgery   Genital Injuries - Male genitalia more susceptible to blunt trauma or straddle fall injuries (majority are self limiting injuries) - Female - Often result of straddle fall or laceration due to water injection - Most common injury is labial or vulvar contusion - Anatomy is comprised of loose fatty tissue that is well vascularized and innervated - Significant pain and bleeding - Contusion produces edema and hematomas (need to ensure blood does not organize and create a mass) - Compress, ice and refer to physician - Male - Testes and scrotum are commonly injured from blunt trauma - Instinctive cremasteric muscle contraction recoil serves as protective function - Difficult to differentiate mild from significant injuries - Most common groin injury - Early excruciating pain followed by fairly rapid recovery - Hemorrhage or effusion - Testicular torsion - Occurs when a testicle rotates on the spermatic cord which provides blood flow to the testicle - Common in 12-18 year olds - Unilateral scrotal pain and swelling - Testicular swelling, nausea, vomiting - Medical emergency - If increasing or unresolved pain after 15-20 minutes refer to physician - Prevention = wear protective equipment