SPORTS INJURIES PDF

LATERAL ANKLE SPRAIN What structures are involved? 2. What is the function of lig/tendon/muscle/bone/cartilage? The ligaments involved are the Anterior Talofibular ligament (ATFL), the Posterior Talofibular ligament (PTFL), the Calcaneofibular ligament (CFL) these are responsible for resisting against inversion and stabilizing the ankle. The main bones involved are the Talus, Fibula and Calcaneus. Other bones involved are the Tibia, Navicular, Cuboid and the Cuneiform bones. The main two muscles involved are the Peroneus brevis and Peroneus longus and their function is to evert the foot and plantarflex the ankle. The peroneus brevis originates from the distal lateral fibula and inserts onto the base of the 5th metatarsal. The peroneus longus originates on the head of the fibula and inserts onto the medial cuneiform. Also involved is the Gastrocnemius and Soleus they are the main plantar flexors of the foot. The gastrocnemius (a bi-articular muscle) originates at the epicondyles of the femur and inserts onto the calcaneus via the Achilles tendon. The soleus muscle originates at the posterior fibular head and tibial shaft and also inserts onto the calcaneus via the Achilles tendon. The tibialis posterior is another plantar flexor muscle that originates at the inner border of the fibula and attaches onto the navicular bone and tibialis anterior is a dorsiflexor muscle that originates at the lateral condyle of the tibia and inserts onto the medial cuneiform. The peroneal tendons are two tendons in the foot that run side-by-side behind the outer ankle bone. (lateral malleolus) Their function is to stabilize the foot and ankle. 3. How does the injury commonly happen? MOI or pathophysiology for chronic 4. Who does it normally happen to? Classification: General The most common mechanism of injury in lateral ankle sprains occurs with forced plantar flexion and inversion of the ankle as the body's center of gravity rolls over the ankle. The ATFL followed by the CFL are the most commonly injured ligaments. The CFL is injured more commonly in dorsiflexion and inversion. The posterior talofibular ligament is the strongest of the lateral complex and is rarely injured in an inversion sprain. A complete tear of all three ligaments is extremely rare and results in dislocation of the ankle. Grade 1 Sprain (Mild) Slight stretching and microscopic tearing of the ligament fibers Mild tenderness and swelling around the ankle Grade 2 Sprain (Moderate) Partial tearing of the ligament Moderate tenderness and swelling around the ankle Instability of the ankle when tested by your doctor Grade 3 Sprain (Severe) Complete tearing of the ligament Significant tenderness and swelling around the ankle Substantial instability of the ankle when tested by your doctor Lateral ankle injuries often occur in multidirectional sports especially if these take place on uneven surfaces, so they are very common in field sports. They also occur when a player jumps and lands on another player's foot making it a common injury for sports such as netball and basketball. 6. What are main Clinical Manifestations (S&S)? Pain mainly in the ATFL. Tenderness when touching the ankle Swelling Bruising Popping sensation or sound at the time of injury Restricted range of motion 7. Are there any complications? Risk of Reinjury Peroneii strain Base of 5th fracture Syndesmosis injury Malleolar fractures (fracture to the lowest part of the tibia) Talar dome lesions (an injury to the cartilage and underlying bone of the talus within the ankle joint) Navicular fractures Classification: General 8. What are the general treatment approaches? Regardless of the grade of injury we should follow the same treatment principles. The aims are to restore ROM, muscle strength and proprioception. Initially the injury will require RICE (Rest, Ice, Compression, and Elevation.). after a period of rest gradually increased weight bearing will help reduce the swelling and increase ankle motion. This can be done while still using crutches or by protecting the damaged joint with strapping or bracing. NSAIDS might be required however indications for the use of NSAIDS are unclear. Active strengthening exercises including plantarflexion, dorsiflexion, inversion and eversion should begin as soon as pain allows. Weight bearing exercises and wobble board exercises are encouraged as soon as pain permits. The patient should begin proprioceptive retraining early in rehab and these exercises should gradually progress in difficulty. Functional exercises can be commenced once an athlete is pain free, has full range of motion and adequate muscle strength and proprioception. Finally return to sport Is advised as long as functional exercises can be performed without pain during or after activity. → Grade 1 sprains are light sprains that usually allow return to sport in 2-3 weeks. → Grade 2 ankle sprains involve greater injury to the ligament and can take up 4-6 weeks to allow full return to sport. → Grade 3 injuries are more severe in nature and often involve full tearing of the ligament and possible bone fracture. The length of time to recover from grade 3 ankle sprains could be 3 months or more. All of these time frames are variable on case by case. Classification: General 2. ACHILLES TENDONAPATHY Achilles tendinitis is an overuse injury of the Achilles tendon, the band of tissue that connects calf muscles at the back of the lower leg to your heel bone. Achilles tendinitis most commonly occurs in runners who have suddenly increased the intensity or duration of their runs. 1. What structures are involved? 2. What is the function of lig/tendon/muscle/bone/cartilage? The bones involved are the Calcaneus, Femur, Tibia and fibula. The function of the Achilles tendon is to join both the gastrocnemius and soleus muscles to the posterior surface of the calcaneus to plantarflex the foot. The Achilles tendon is surrounded by a thin layer of tissue called the paratenon. The two muscles involved are the Gastrocnemius and Soleus they are the main plantar flexors of the foot. The gastrocnemius is a bi-articular muscle that originates at the epicondyles of the femur and inserts onto the calcaneus via the Achilles tendon. The soleus muscle originates at the posterior fibular head and tibial shaft and also inserts onto the calcaneus via the Achilles tendon. The plantaris tendon also fuses with the medial side of the Achilles tendon to aid with plantarflexion 3. How does the injury commonly happen? MOI or pathophysiology for chronic. 4. Who does it normally happen to? The Achilles tendon is susceptible to damage with repetitive use or overload. The Injury is classified as acute if symptoms have been present less than 3 weeks and it gradually becomes chronic if symptoms persist for 6 weeks. These types of injuries typically occur in athletes and are usually sports or exercise-related. Factors that increase the likelihood of Achilles tendinopathy include, a change of playing surface, a reintroduction to a high amount of running making it common in preseason, an introduction to a sport for example people who have never ran before and have just started to run often. Weak or tight calf muscles can lead to tissue injury. It is also very common if the tendon is abused, for example someone who is running a ridiculous amount of mileage each week. It is most common in males in their late 20s/30s. There has been a new strategy proposed when approaching tendon pain. Classification: General They propose there are 3 stages to this continuum. Being Reactive tendinopathy Tendon disrepair Degenerative tendinopathy. A reactive tendon is the 1st stage on the tendon continuum and is a non-inflammatory response. This is as a result of compressive or tensile overload Tendon disrepair- The progression of the reactive tendinopathy can occur if the tendon is not offloaded and allowed to regress back to the normal state. This phase of tendinopathy can be developed by frequently overloading the tendon in phase 1 of the continuum. Degenerative Tendinopathy -This is the final stage on the continuum and is suggested that at this stage there is a poor prognosis for the tendon and changes are now irreversible. 5. What are the stages of healing of the tissues? Stages of healing → Injury & immediate response → Inflammatory process → Repair → Remodeling Injury & immediate response When tissue is first injured, the small blood vessels in the damaged area constrict momentarily, a process called vasoconstriction. Following this, the blood vessels dilate (vasodilation), increasing blood flow into the area. The damaged cells release chemicals such as histamine that cause blood vessels to leak fluid into the tissues which causes swelling and localizes the injury response. Inflammatory process Cells release digestive enzymes to dissolve debris in damages tissue. Chemicals attract WBCs such as neutrophiles and monocytes. The most important feature of inflammation is the accumulation of white blood cells at the site of injury. Monocytes become macrophages once in tissue spaces. Macrophages can work at low O2 levels close to site of injury, engulfing cellular debris & clearing the area – phagocytosis. The timescale of this process depends on the size and extent of tissue damage, how the injury was dealt with and on the injured person themself. Normally lasts to 24hrs but can last up to 72hrs. Repair Capillary budding brings oxygen and nutrients to area. Tissue damage stimulates fibrocytes and induces the creation of fibroblasts. Fibroblasts fatten, multiply and move towards injury. They are involved in new tissue formation. By about day 5 fibroblasts begin to produce type III collage fibers (which will eventually mature into type I). Remodeling Classification: General May last up to 12/12 (12 months). Continual breakdown and replacement of collagen fibers. No more collagen fibers produced but tensile strength increases. If cross linkages are excessive or are badly aligned it could cause adhesions within the tissue. 6. What are main Clinical Manifestations (S&S)? 1. Pain- Insertional tendinopathy is painful where the tendon inserts onto the posterior surface of the calcaneus. Midportion tendinopathy is painful 2-3cm above the insertion point. (Most Common) 2. Stiffness in the first few steps in the morning. 3. swelling, tenderness and warmth of the Achilles tendon. 4. Palpable mass in the area. If the patient says that the pain is present at the beginning of training, eases off and then comes back worse afterwards. The duration of pain present increases as the injury gets worse. 7. Are there any complications? Risk of reinjury if correct rehab isn't completed. Tendon degenerates Achilles rupture Cellular matrix has changed so it technically never goes away it just becomes pain free. 8. What are the general treatment approaches? The aim of the treatment is to reduce strain on the tendon, prevent further injury and allow repair to get the patient back to the level that they were at before the → At the beginning it is crucial to avoid or severely limiting activities that may aggravate the condition, such as running. → Phase 1 is Isometric tendon loading has been found to have pain-relieving effects on tendons, while maintaining some baseline strength → Phase 2 is Isotonic loading through calf raises is introduced once pain level reduces, they can be performed with a gradual increase in loading. → Phase 3 is Energy Storage Loading through Plyometric Exercises These exercises include deformation of the tendon with jumping and hopping based exercises. These exercises help the tendon to regain its capacity to absorb and then release energy via the stretch-shortening cycle. Classification: General 3. SLAP LESION A SLAP tear is an injury to the labrum of the shoulder, which is the ring of cartilage that surrounds the socket of the shoulder joint. Superior labral anterior posterior (SLAP) 1. What structures are involved? 2. What is the function of lig/tendon/muscle/bone/cartilage? Glenohumeral joint is formed by the head of the humerus and the scapula's glenoid fossa. This joint is considered to be the most mobile and the least stable joint of the body. It is responsible for adduction, abduction, flexion, extension, internal and external rotation. The joint socket is shallow so it is deepened by the glenoid labrum. It is a fibro-cartilaginous rubbery structure which encircles the glenoid cavity deepening the socket to provide stability to the glenohumeral joint. The muscles of the rotator cuff act to reinforce the joint capsule. They are the supraspinatus, subscapularis, infraspinatus and teres minor. The Superior, middle and inferior Glenohumeral ligaments support the joint capsule. The biceps tendon attaches to the top of the labrum. The biceps tendon is a long cord-like structure which attaches the biceps muscle to the shoulder and helps to stabilize the joint. 3. How does the injury commonly happen? MOI or pathophysiology for chronic 4. Who does it normally happen to? ACUTE- A SLAP lesion is mainly caused by a fall on an outstretched arm where there is a superior compression on the labrum which causes a tear of the labrum. quickly lifting a heavy object or from a forceful, overhead arm motion during sports or work activity. CHRONIC - More often, however, they result from repetitive stress on the shoulder which, over time, wears down the shoulder labrum. SLAP tears are most common among people whose daily activities Classification: General require frequent upward arm movement, such as weightlifters, tennis players and factory or shipping workers. AGING- SLAP tears can simply happen as your labrum wears out over time. This tear is usually seen in people age 40 and older → Type I concerns degenerative fraying with no detachment of the biceps insertion. → Type II is the most common type and represents a detachment of the superior labrum and biceps from the glenoid rim. → Type III represents a bucket-handle tear of the labrum with an intact biceps tendon insertion to the bone. → Type IV lesions, the least common type represents an intra-substance tear of the biceps tendon with a bucket-handle tear of the superior aspect of the labrum. 6. What are main Clinical Manifestations (S&S)? → Shoulder pain that can be a persistent dull ache or a sharp pain deep in your shoulder. → Shoulder pain in certain positions, like raising your arm or stretching your arm behind your head. → Shoulder pain when you do certain things, like throwing a ball or reaching overhead. → Popping noises or a grinding feeling when you move your shoulder. → A feeling like your shoulder might pop out of your shoulder blade. 7. Are there any complications? Reoccurring shoulder instability Concomitant impingement Rotator cuff disease The superior labrum and biceps anchor could theoretically be gradually lifted off the glenoid loss of rotator cuff muscular strength and endurance. Athletes performing overhead movements, especially pitchers, may develop “dead arm” syndrome in which they have a painful shoulder with throwing and can no longer throw with pre-injury velocity. A loss of velocity and accuracy along with discomfort in the shoulder. Beside biceps tears, other problems, such as bursitis and rotator cuff tears, are often identified, in combination with SLAP lesions 8. What are the general treatment approaches? Classification: General Type I tears are usually asymptomatic and do not require treatment Type II tears require surgical reattachment Type III tears usually require resection of the bucket handle tear In the first step of conservative management, patients should abstain from aggravating activities in order to provide relief to the pain and inflammation. If necessary, NSAID’s and intra-articular can be applied. Strength, stability and motion are the components of shoulder function that should be focused on during rehabilitation. An introduction to specific exercises, with increasing low to moderate activity, can be applied in the early and intermediate phases of nonoperative and postoperative treatment for patients with SLAP lesions. This course of treatment should focus on restoring strength of the rotator cuff, shoulder girdle, trunk, core and scapular musculature, restoring normal shoulder motion, and training to improve dynamic joint stability. The patient is eventually advanced to a strengthening phase, which includes trunk, core, rotator cuff, and scapular musculature. In throwing athletes, a progressive throwing program that is directed toward the patients' specific sport and position can be initiated after 3 months. When conservative treatment fails, a surgical approach is in order. After surgery, for 3 to 4 weeks, the shoulder of the patient is placed in a sling, which immobilizes the shoulder in internal rotation and leads to general loss of motion and stiffness. 4 weeks post operative- Increase shoulder mobility by assisted and passive techniques. 4 – 8 weeks- internal and external rotation ROM exercises are progressively increased to 90° of shoulder abduction. 8 weeks – resistance training is slowly introduced. 4- 6 months – sport specific training dependent on type and intensity of sport. 4. Chronic Exertional Compartment Syndrome Chronic exertional compartment syndrome is an exercise-induced muscle and nerve condition that causes pain, swelling and sometimes disability in the affected muscles of the legs or arms. Classification: General 1. What structures are involved? There are four compartments in the lower leg. Anterior compartment- tibialis anterior, extensor digitorum longus, extensor hallux longus Lateral Compartment- peroneus brevis, peroneus longus Deep Posterior compartment- flexor digitorum longus, flexor hallux longus, popliteus, tibialis posterior Superficial posterior compartment- gastrocnemius, soleus, plantaris Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. 2. What is the function of lig/tendon/muscle/bone/cartilage? It usually occurs in the legs, feet, arms or hands, but can occur wherever there's an enclosed compartment inside the body. The anterior compartment of the leg is the most common location Anterior Compartment- Tibilias Anterior Origin - along the upper two-thirds of the lateral tibia Insertion - into the medial cuneiform and first metatarsal bones of the foot. Extensor Digitorum Longus Origin - Lateral tibial condyle Insertion - medial cuneiform Extensor Hallucis longus - Origin- Middle third of medial surface of fibula Insertion- base of hallux. Classification: General Fascia is a thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place Bones – Femur Tibia Fibula Patella Calcaneus 3. How does the injury commonly happen? MOI or pathophysiology for chronic The connective tissue forming a compartment is not pliable, so when bleeding or swelling occurs within the compartment, the intra-compartmental pressure rises. Normally a non-contracting muscle contains a pressure near zero. → If the pressure rises up to 30 mmHg (millimeter of mercury) , the vessels will be compressed, resulting in pain and a decrease in blood flow. → Lymphatic drainage will activate to prevent increasing interstitial fluid pressure. → Once the effects of lymphatic drainage have reached their maximum, the pressure within the compartments will cause physiological defects, such as a nerve dysfunction and deformation. → Hemorrhage or oedema causes the interstitial pressures within the soft tissues to increase, creating possible ischemia by loss of capillary refill → When a body part is not provided with blood for more than eight hours, the damage is irreversible and may lead to the death of the concerning tissues. 4. Who does it normally happen to? → Age. Although people of any age can develop chronic exertional compartment syndrome, the condition is most common in male and female athletes under age 30. → Type of exercise. Repetitive impact activity — such as running — increases your risk of developing the condition. Classification: General → Overtraining. Working out too intensely or too frequently also can raise your risk of chronic exertional compartment syndrome 6. What are main Clinical Manifestations (S&S)? → Pain and/or cramping in the involved limb that usually worsens with activity and lessens with rest. → Mild swelling. → Pain with stretching. → Numbness or tingling in the limb. → Weakness in the limb Pain caused by chronic exertional compartment syndrome typically follows this pattern: → Begins consistently after a certain time, distance or intensity of exertion after you start exercising the affected limb → Progressively worsens as you exercise → Becomes less intense or stops completely within 15 minutes of stopping the activity → Over time, recovery time after exercise may increase 7. Are there any complications? Ischemia – restricted blood flow Necrosis – death of tissue due to lack of blood flow Muscle damage Sensory abnormality's 8. What are the general treatment approaches? Range-of-Motion Exercises. Restrictions in the motion of your knee, foot, or ankle may be causing increased strain in the muscles housed within the compartments of your lower leg. Stretching techniques can be used to help restore motion in these joints to minimize undue muscle tension. Muscle Strengthening. Hip and core weakness can influence how your lower body moves, and can cause imbalanced forces through the lower-leg muscle groups that may contribute to compartment syndrome. Building core strength is important; a strong midsection allows greater stability through the body as the arms and legs perform different motions Manual Therapy. using hands on techniques to move and manipulate muscles and joints to improve motion and strength. Modalities. Use of modalities (such as ultrasound, heat and cold therapy) as a part of a rehabilitation program. These tools can help improve tissue mobility and flexibility, and enhance recovery. Classification: General If conservative measures fail, surgery may be an option. The operation is designed to open the fascia so there is more room for the muscles to swell. 5.Femoral Acetabular Impingement Mechanical process in which morphological abnormalities of the acetabulum and/or femur, combined with vigorous hip motion can damage the soft tissue structures within the hip itself. 1. What structures are involved? 2. What is the function of lig/tendon/muscle/bone/cartilage? The femoral acetabular joint is a ball-and-socket joint. The hip joint has two bony structures: the acetabulum and the femoral head. The acetabulum has a ring of fibrocartilage called the Labrum that deepens the acetabulum and improves the stability of the hip joint. Ligaments involved are the iliofemoral ligament - prevents excess extension Pubofemoral ligament. - prevents excess abduction and extension Ischiofemoral ligament is also a main ligament in the area Movements of the FA joint include Flexion/extension, abduction/adduction and medial/lateral rotation. The muscles typically affected by FAI include the adductors, abductors, hamstrings, iliopsoas, and hip flexors. There are five bursae in the hip joint. Their primary role is to reduce friction between the bony components of the joint and the surrounding muscles. 3. How does the injury commonly happen? MOI or pathophysiology for chronic FAI syndrome is associated with three variations in the morphology of the hip joint: cam, pincer and the combination of cam and pincer. Pincer morphology describes "over coverage" of the femoral head by the acetabulum in which the acetabular rim is extended beyond the typical amount. The Cam form describes the femoral head and neck relationship as not perfectly round. This loss of roundness contributes to abnormal contact between the head and socket as the hip goes through a range of motion. Classification: General Cam and pincer morphology can lead to damage of the articular cartilage and the Labrum due to impingement between the acetabular rim and the femoral head during movement, which causes the symptoms of FAI syndrome. 4. Who does it normally happen to? FAI is common in high level athletes, but also occurs in active individuals. While either type of impingement can occur in men or women at any age, most frequently the Cam type of impingement tends to affect young (20s) male athletes, while Pincer tends to occur more commonly in women in their 30s and 40s who are athletically active. Sports associated with FAI include martial arts, ballet, cycling, rowing, golf, tennis, soccer, football, ice hockey, baseball, lacrosse, field hockey, rugby, water polo, and deep squatting activities such as power lifting. 6. What are main Clinical Manifestations (S&S)? The primary symptoms reported with this condition are: → Moderate to marked hip or groin pain related to certain movements or positions → Pain reported in the thigh, back or buttock → Stiffness → Restricted hip range of motion → Clicking and/or catching → Locking or giving way → Decreased ability to perform activities of daily living and sports. 7. Are there any complications? Cartilage damage which can lead to arthritis or painful joint deterioration. Joint wear and tear Hip replacement Labral tear - particularly for men. This is a common problem that can cause pain, stiffness, and locking or catching in the hip joint 8. What are the general treatment approaches? Classification: General The underlying problem with FAI is a bony abnormality. This bony shape will not change with physical therapy or rest Improving the neuromuscular function of the hip should be a goal of conservative protocols for FAI syndrome due to weakness of deep hip musculature and an expected subsequent reduction in dynamic stability of the hip joint. → Hip-specific and functional lower limb strengthening: deep hip external rotators, abductors and flexors in the transverse, frontal and sagittal planes for improvement of dynamic stability → Core stability → Postural balance exercises 6.Articular Cartilage Lesions in Knee Articular cartilage lesions are an injury where the articular cartilage of the knee joint is affected. Articular cartilage lesions in weight-bearing joints often fail to heal on their own and may be associated with pain, loss of function and long-term complications such as osteoarthritis. 1. What structures are involved? 2. What is the function of lig/tendon/muscle/bone/cartilage? Articular Cartilage lines the surface of bone regions forming synovial joints. It provides a smooth, lubricated surface allowing for low friction gliding and possesses unique viscoelastic properties which facilitate the absorption and distribution of loads to the underlying subchondral bone. The tibia, femur and patella are covered in articular cartilage. The normal function of the knee joint depends upon this. The knee joint consists of 3 articulations: The tibiofemoral articulation located between the convex femoral condyles and the concave tibial condyles. The patellofemoral articulation where the patella lies in the intercondylar groove of the femur. The Tibiofibular articulation located between the tibia and fibula. Bones: Classification: General Femur Tibia Fibula Patella Muscles involved around the knee. Knee extensors → Rectus femoris → Vastus medialis → Vastus lateralis → Vastus Intermedius Knee flexors and internal rotators → Semimembranosus → Semitendinosus → Gracilis → Sartorius → Popliteus → Popliteus- prevents the femur from slipping forwards on the tibia during squatting Biceps femoris- knee flexion and external rotation. Plantaris - works with the Achilles to plantarflex the ankle and knee joint Gastrocnemius- Week knee flexor and internal + external rotator of the knee. Strong plantar flexor of ankle. Ligaments Anterior cruciate ligament (ACL) is to prevent anterior translation of the tibia in relation to the femur. Position- Medial aspect of lateral femoral condyle, travels medially inferiorly and anteriorly to tibial plateau. Posterior cruciate ligament (PCL) to prevent posterior translation of the tibia to the femur. Position - Medial aspect of medial femoral travels laterally, inferiorly and posteriorly to tibial plateau. Classification: General Medial collateral ligament (MCL) role is to stabilize the knee against valgus stress Position - Medial condyle of femur to anterior medial aspect of tibial condyle deep fibers attach to the medial meniscus broad and flat can be 8-9cm long. Lateral collateral ligament (LCL) stabilizes the knee against varus forces position is the lateral separate from joint capsule a rounded cord that can be 5cm long. Tendons The function of hamstring tendon is to flex your knee, extend the thigh at your hip and rotate your lower leg from side-to-side while your knee is bend. Origin of the hamstring tendon is the ischial tuberosity and the insertion is the medial surface of tibia. The function of the quadriceps tendon is to attaches the quadricep muscles to the patella. The quadriceps tendon originated in the anterior surface of the femoral shaft and the insertion is the tibial tuberosity (via patellar ligament ligament), patella (lateral condyle of tibia). The function of the patellar tendon is to help straighten your leg. The origin of the patellar tendon is from the anterior aspect of the distal end of the patella coursing anterior to the knee joint, the insertion is on the tibial tuberosity. 3. How does the injury commonly happen? MOI or pathophysiology for chronic Articular Cartilage damage may occur as an isolated condition in which chondral or subchondral damage is the primary pathology or in association with other injuries, such as ligamentous instability resulting from MCL, ACL or PCL injuries or patella dislocations. It may also be seen in association with meniscal injury. Articular cartilage injuries can result from a number of causes, including: Forceful impacts to the joint as a result of sports injuries or a fall Repetitive smaller impacts to the joint Twisting the joint while it bears weight, for instance twisting the knee while the foot is planted Progressive degeneration due to wear and tear, usually over several decades of use Poor alignment of joints due to a congenital (meaning “at-birth”) abnormality or previous injury In many cases, the damage is limited to the thin layer of articular cartilage at the end of a bone, which is referred to as a chondral injury or chondral defect. (Chondral simply means “relating to cartilage.”) Chondral injuries typically don’t heal well on their own, in part, because articular cartilage does not have a blood supply, which promotes healing. 4. Who does it normally happen to? - Cartilage damage is most frequently seen between the ages of 15-30 years or above the age of 50. Classification: General When the cartilage is damaged the underlying bone has no protection from the normal wear and tear of daily living and begins to break down can lead to osteoarthritis more common in older clients. - People who are overweight/ obese- this is because of the extra weight there is a heaver load on the knees. This may cause damage to the knees and or weaken them. - high-level competitive sports, In the healthy athlete a positive, linear dose-response relationship exists for repetitive loading activities and articular cartilage function. However, studies indicate that this dose- response curve reaches a threshold and that activity beyond this threshold can result in maladaptation and injury of articular cartilage 6- what is the main clinical manifestations Pain and/or swelling in the joint A “catching” feeling when bending or moving the joint A crackling, grating, or popping sound and sensation that occurs when bending or moving the joint Joint locking (an inability to fully extend or bend the joint) Feeling that the joint may give way or is unstable Stiffness Reduced range of motion 7- Are there any complications? Osteoarthritis due to the lack of the shock absorption. Chondromalacia which is the softening and breakdown of the tissue/ cartilage on the underside of the kneecap. Knee instability Osteochondritis dissecans- can be from either repeated micro trauma. This is where a well-demarcated small area of cartilage and underlying bone loses its blood supply, dies and eventually fragments and separates into the joint. Axial malalignment of the knee can also cause articular cartilage defects. In severe cases, a piece of cartilage can break off, and the joint can become locked. This can lead to hemarthrosis (bleeding in the joint) the area may become blotchy and may have a bruised appearance. Rheumatoid arthritis can be a long-term effect which causes progressive joint erosion and polyarchic stricken which can also be genetic disorder. 8- what are the general treatment approaches? RICE- rest, ice, compression, and elevation. Classification: General Or PEACE & LOVE- protection, elevation, avoid anti-inflammatories, compression, and education & load, optimism, vascularization and exercise. If symptoms are severe or do not improve after a few days. You may need professional treatment example sport therapist, physiotherapist or a general practitioner if very serious possibly surgery which would be to promote the growth of new cartilage by drilling small holes in nearby bone, replacing the damaged cartilage with healthy cartilage taken from another part of the joint, replacing the entire joint with an artificial one, such as a knee replacement, this is only necessary in most severe cases. In the case when overloading the joint with people overweight their treatment will be losing weight and or doing exercise to strengthen the knee and mobility. The pain and stiffness of arthritis can often be managed with over-the-counter anti-inflammatories (NSAIDs) a range injection therapies and exercises that focus on mobility and flexibility such as yoga. Surgery is only recommended if the damage to your cartilage is severe enough for it to debilitating or having a negative effect on your lifestyle. Surgery may be necessary if you are a professional athlete or dancer, or if a traumatic/ acute injury to your knee that has affected other parts of the joint. 7. Metatarsal Stress Fracture A metatarsal stress fracture – The metatarsal bones are the long bones in your foot that connect your ankle to your toes. A stress fracture is a break in the bone that happens with repeated injury or stress. Metatarsal stress fractures are caused by overly stressing the foot when using it in the same way repeatedly. 1. What are the structures involved? Stress fractures can occur anywhere there is overuse, but they’re most commonly found in the lower extremity as a result of impact and weight bearing activities. The most common bone is the shin bone or tibia (20% to 75% of all stress fractures — often running injuries). Stress fractures can also occur in the foot. The foot is made up of several small bones. The bones running to the toes are called metatarsals. The metatarsals are the long bones in the foot which connect the tarsal bones in the ankle to the phalanges bones of the toes. There are five metatarsals in each foot. It is most common for a stress fracture to happen in the second and third metatarsals. Stress fractures can also be seen in the heel (calcaneus), hip (proximal femur) and even the lower back. 2. What is the function of lig/tendon/muscle/bone/cartilage? Classification: General The function of the metatarsal bones are an essential structure for the origin and insertion of many muscles of the lower limb and foot and contribute to the proximal half of the metatarsophalangeal joints. The toe flexors (flexor digitorium longus) help to prevent excessive stress onto the metatarsal bones when running and help to distribute forces through the foot. The function of ligaments – these are crucial as ligaments hold the metatarsal bases rigidly in place, keeping the arch of the foot and anchoring the metatarsals to the rest of the body. Proximal metatarsal stress fractures are normally caused by direct blows (may result from falling forward over a plantar-flexed foot). The interosseous metatarsal ligaments are ligaments in the foot their function is to maintain the integrity of the forefoot. 3. How does the injury commonly happen? MOI pathophysiology for chronic A metatarsal stress fracture most likely involves the second, third or fourth metatarsal bones. They are the second most common location for a stress fracture in sport, after tibia stress fracture (shin). It is also more common for those feet to roll in too much or flatten (overpronate). This is because the first metatarsal bone is in a dorsiflexed (foot pointing upwards) position. As a result, this places a greater load on the 2nd metatarsal. Stress fractures in the other metatarsals are less common, although they do occur. The main causes are: -Overuse - They are common in army recruits (often called a march fracture), runners, ballet dancers, and gymnasts. Repetitive strain on the bone eventually results in a stress fracture. -Overpronation – where your foot rolls in too much, or flattens. -Over supination – where your foot has a particularly high arch and rolls outwards. This means it is rigid and does not pronate enough to absorb forces from running. The most common mechanism of injury in fifth metatarsal fractures involves a fall from standing height or an ankle twist with the forefoot fixed 4. Who does it normally happen to? Age – older athletes may have underlying bone density issues such as osteoporosis (thin/weak bones). Already weakened bone will develop a stress reaction and/or fracture sooner than a healthy bone. Sex – females at higher risk than men if they have irregular menstrual periods or no periods Athletes- athletes who put a lot of pressure on their feet such as dancers, runners and basketballers Athletes, individuals who are obese, and individuals with osteoporosis or rheumatoid arthritis or diabetes have an increased risk of developing metatarsal fractures. Classification: General 6. What are the main clinical manifestations (S&S) Signs and Symptoms include; Pain in the forefoot that develops gradually over time Pain is normally located towards the middle, or front of the foot Symptoms are made worse with weight bearing activities such as running and walking Foot will be tender to touch, possibly a specific spot on the bone where fracture is located Weakness – normal performance may be diminished Bruising Area may be swollen and very sore to pinpoint 7. Are there any complications? If treated correctly metatarsal stress fractures should heal without long-term consequences. If not treated properly some of the below problems can occur; Can become gradually worse if repeated stress to the bone continues. It can eventually become a full-thickness metatarsal fracture. A fracture of the first metatarsal bone can lead to later arthritis of the big toe joint. A full-thickness fracture which is displaced and not ‘put back’ into line can heal ‘out of shape’ leading to deformity of the foot (making shoe fitting difficult). The foot may be painful A fracture at the base of the fifth metatarsal bone is often mistaken for an ankle sprain and therefore not rested or supported enough. This may lead to problems in healing and continuing pain. Acute metatarsal stress fractures can also lead to ‘nonunion’, which is when the two ends of broken bone stop trying to heal due to the movement between them makes this impossible. This can lead to reduced ability of the foot. MTP joint synovitis. 8. What are the general treatment approaches? Treatment of a metatarsal stress fracture requires a period of rest from the individual's activity, usually at least 3-4 weeks. If there is pain with daily activities, crutches may possibly be need for a short period until the individual can walk comfortably alone. The use of a CAM boot for 1-2 weeks if patient is required to be on foot excessively. The initial period of rest is followed by gradual return to activity over the next 2-4 weeks. Depending on the individuals risk factors, the individual may be advised to have a change in footwear, inserts for shoes and begin a course of therapy to correct any imbalances in muscle strength and flexibility. Most metatarsal stress fracture heal completely with a non-operative treatment. Classification: General PEACE AND LOVE or RICE are also both methods taken into consideration with metatarsal stress fractures. Initial therapy exercises focus on little to no weight-bearing on the affected limb as the bones continue to calcify and heal properly. Therapists will introduce manual therapy around the ankle and plantar of the foot to minimize inflammation and pain while also promoting increased ROM within the smaller metatarsal and tarsal joints. Ice needs to be applied to reduce swelling and inflammation. The physical therapist could perform soft tissue massage, joint mobilizations, electrotherapy, hydrotherapy and later on exercises to increase strength, flexibility and balance. Medial Tibial Stress Fracture Syndrome Medial Stress fracture syndrome is a common overuse injury of the lower extremity. It presents as exercise-induced pain over the anterior tibia and is an early stress injury in the continuum of tibial stress fractures. This injury can also be known as “shin splints” 1. What are the structures involved? The lower leg is made up of 2 bones, the tibia and the fibula. In medial tibial stress fracture syndrome, the periosteum on the inner part of the tibia is affected. The periosteum is the outer layer of the bone in which muscles attach. Inflammation and pain occur due to repetitive pulling of the muscles on the periosteum. The most common muscles involved are the tibialis posterior flexor digitorium and soleus muscles (all of which are primary muscles to help stabilize the leg). Another muscle commonly involved is the tibialis anterior muscle (helps DF the foot). 2. What is the function of lig/tendon/muscle/bone/cartilage? Muscles – metatarsal stress fracture syndrome is a traction periostitis that results from the sheering stresses of the muscles in the posterior compartment on the posterior medial border of the tibia. The soleus muscle, the flexor digitorium longus muscle, and the deep crural fascia all originate along the medial aspect of the tibia. Tibialis posterior O; inner border of the fibula I: navicular Action; DF Classification: General Flexor digitorum longus ; ACTION: flex the digits O: posterior surface of tibia I: Bases of distal phalanges of digits 2-5 Soleus: ACTION: plantarflexor ORIGIN:posterior fibular head and tibial shaft INSERTION: calcaneus via the Achilles tendon tibialis anterior ACTION: DF ORIGIN: lateral condyle of the tibia INSERTION:medial cuneiform Perisoteum- The periosteum is the medical definition for the membrane of blood vessels and nerves that wraps around most of your bones. It's what delivers bones their blood supply and gives them their sense of feeling 3. How does the injury commonly happen? MOI pathophysiology for chronic This injury commonly results from repetitive forceful pronation and plantar flexion of the foot leading to periosteal inflammation along the tibia at the insertion of the soleus muscle. Commonly occurs with running or others sports-related activities which may lead to overuse. Medial tibial stress fracture syndrome develops when there is irritation where the calf muscles attach to the shin bone. It also commonly happens when running on a slanted surface or downhill, or when someone participates in a sport with frequent starts and stops. 4. Who does is normally happen to? Commonly seen in; Classification: General Runners – especially those who run long distance and/or run-on uneven surfaces. Also, a sudden increase in their running program. Athletes – whom play high impact sports that put stress on legs/ run on uneven surfaces e.g. hills or concrete Individuals who have flat feet, high arches. In this situation, the clients' muscles and bones may not absorb or distribute force from impact and loading activities as well. 6. What are the main clinical manifestations? (S&S) Signs and Symptoms; Pain along the ‘shin bone’ Pain can range from dull ache to a sharp, intense pain Pain usually located along the inside border of the shin bone (middle or lower third) Pain may be present with early activity and subside with continued exercise but can also be persistent throughout the activity Tenderness and soreness Mild swelling in lower leg Pain is worse after activity 7. Are there any complications? Acute complications for athletes include pain leading to decreased performance and/or time away from training/participation. May progress to a tibial stress fracture 8. What are the general treatment approaches? The treatment should aim to modify training conditions and to address eventual biomechanical abnormalities. Change of training conditions could be decreased running distance, intensity and frequency by 50%. It is advised to avoid hills and uneven surfaces. During the rehabilitation period the client can do low impact and cross-training exercises. After a few weeks athletes may slowly increase training intensity and duration and add sport-specific activities, and drills such as hill running to their rehabilitation programme as long as they remain pain free. A stretching and strengthening (eccentric) calf exercise program can be introduced to prevent muscle fatigue. Clients may also benefit from strengthening core hip muscles. Developing core stability with Classification: General strong abdominal, gluteal and hip muscles can improve running mechanics and prevent lower-extremity overuse injuries. Proprioceptive balance training is crucial also. This can be completed with a one-legged stand or balance board. Improved proprioception will increase efficiency of joint and postural- stabilizing muscles. 8.Hamstring strains 1 - What structures are involved? The semitendinosus, semimembranosus and bicep femoris muscles comprise the hamstring muscle group. Beginning at the pelvis and running posteriorly along the length of the femur, the majority of muscles within the hamstring complex cross both the femoroacetabular and tibiofemoral joint. Semitendinosus Action -Hip extension, knee flexion, internal rotation Origin - Ischial tuberosity Insertion - medial tibial condyle Semimembranosus Action- hip extension, knee flexion, internal rotation Origin - Ischial tuberosity Insertion -the medial tibial condyle Biceps femoris * short head and long head Action -hip extension, knee flexion and external rotation Origin – long- ischial tuberosity and short- Linea aspera Insertion - the lateral tibial condyle Bones- femur, tibia, fibula 2- What is the function of ligaments/ tendon / muscles/ bone / cartilage Classification: General The function of the hamstrings as a group is to flex the knee joint and extend the hip - activities such as walking, running and climbing. -help rotate your lower leg. -play an essential role as a dynamic stabilizer of the knee joint. -due to their insertion location, they act together with the collateral ligaments to stabilize the knee joint. The hamstrings are inactive when the body weight is equally distributed between both lower limbs in a standing position. However, when a person starts tilting forward, these muscles counteract the tilting movement in order to stabilize the hip joint and prevent falling. 3-How does the injury commonly happen? 4-Who does it normally happen to? A pulled hamstring can occur when the muscle becomes overloaded beyond its limits, this may occur if the hamstring sustains a sudden load that overstretches the muscle. During sudden powerful movements such as sprinting or jumping that overstretches your tendons or muscles. Bicep femoris – most commonly injured, usually during maximal acceleration and deceleration in sprinting Semimembranosus is second most common and also heals slower than biceps femorus injury Can occur when eccentrically lengthening the muscle At point of failure due to fatigue. Usually occurs at myotendinous junction (the interface between the muscle and the tendon) Athletic injuries- most torn hamstrings are caused by extreme stretching or overload during a sport. The injury often happens to people who play soccer, rugby and football. Repetitive kicking such as goal keepers, free takers Hamstring injuries happen most often at the swing phase of running, just before the outstretched leg is put to the ground. At this point, the hamstring muscles have to suddenly shorten/ contract to bend the knee. Past hamstring injury-biggest cause! Returning to play too quick. Incorrect rehab. Decrease in strength is common at 23 post injury due to degeneration in spine. Overtraining- training too hard can overload your hamstrings and cause tears. Poor flexibility- if you have limited flexibility, certain movements may stretch your muscle imbalance, it can also happen if the athlete has poor core stability. Lumbar pelvis stability- If we have anterior pelvic tilt, ischial tuberosity is risen and hamstrings are stretched. So commonly injured Classification: General Hamstrings are fast twitch muscles meaning they fatigue quickly meaning hamstring injuries are a lot more common in 2nd half of games It can also happen if exercise is increased dramatically an example would pre-season training as the athletes go from doing no exercise to doing extreme training. 6-What are the main clinical manifestations (S&S) The symptoms of a torn hamstring depend on the severity of your injury. You may feel; Sudden, sharp pain a ‘popping’ sensation at the time of injury Localized pain to were damage is Myotendinous junction is common pain location tenderness -swelling within the first few hours bruising within the first few hours partial or complete weakness in legs inability to place weight on your leg Grade 1 (mild): just a few fibres of the muscle are damaged or have ruptured. This rarely influences the muscle's power and endurance. Pain and sensitivity usually happen the day after the injury (depends from person to person). Normal patient complaints are stiffness. Patients can walk fine. There can be a small swelling, but the knee can still bend normally Grade 1 hamstring strains should be rested from sporting activity for about three weeks Grade 2 (medium): approximately half of the fibres are torn. ) are usually more painful and tender. There may also be some swelling and bruising at the back of your thigh and you may have lost some strength in your leg. The walk of the patient will be influenced. Grade 2 injuries for a minimum of four to eight weeks. Grade 3 (severe) is the most severe hamstring tear. It occurs when the hamstring muscle rips completely or tears off the bone. A tear that pulls the muscle off the bone is called an avulsion. If you have a grade 3 tear you likely heard a ‘popping’ sound or sensation when you got the injury. The back of your thigh will also be extremely painful and swollen. Because this is so severe, you may not be able to put weight on the injured leg. 75% plus Grade 3 the muscle may have to be repaired surgically and the rehabilitation to follow will take about three months Classification: General 7-Are there any complications? Returning to strenuous activities before your hamstring's muscles are completely healed might cause an injury recurrence. Be aware that you can injury yourself further if you do your stretches and exercises too fast. Chronic hamstring pain Hamstring syndrome- scar formation and impingement on the sciatic nerve. neuropraxia (injury to the sciatic nerve) Restless leg syndrome Cramps in the affected area causing discomfort Discomfort when sitting High prevalence of injury reoccurrence 35% chance after injury 8-What are the general treatment approaches? Recovery time can vary greatly it depends on various factors including; 1) grade of tear 2) history of the torn hamstring 3) age 4) overall health. Recovery can take at least 4-8 weeks if you have partial tear. During this time, you’ll need regular physiotherapy and lots of rest. If you have a complete tear recovery can take about 3 months. It might take slightly longer if you get surgery. During the first 2 or 3 days, you should care for your injury using RICE- rest, ice, compression and elevation. Do gentle range of motion exercise to maintain flexibility once inflammation has gone down. If walking is too painful such as non-weight being or partial weight bearing a knee brace or crutches can be used. Going to a physiotherapist, or a sports therapist once the pain has subsided, you’ll go to physical therapy. The therapist will plan a regimen that’s designed to improve your flexibility and range of movement. Surgery is rare, and only needed if your hamstring is pulled away from your bone, if the treatments above don’t heal a partial tear, or if you have a complete tear, you may need surgery to repair it. Classification: General There are 4 stages of healing: the injury and immediate response stage, the inflammatory process stage, the repair stage, and the remodeling stage The injury and immediate response stage The healing process begins as soon as the injury occurs In this initial stage the blood vessels are disrupted Vasoconstriction of local arterioles begins in order to slow blood flow and prevent excess blood loss Platelets travel to the area and create a sticky matrix for the white blood cells to attach to and a plug is formed In this stage, a number of different white blood cells travel to the area to begin the healing process The Neutrophils are the fastest responders, which engulf pathogens and release oxidants which act like antibiotics Eosinophils release enzymes and are involved in phagocytosis Basophils release granules which contain heparin, histamine, and serotonin Lymphocytes contain B-cells which destroy bacteria, T-cells which attack foreign cells trying to enter the body, for example, fungi, and natural killer cells which attack infectious microbes Monocytes destroy microbes and clean up cell debris through phagocytosis This can last a few minutes to a few days depending on the amount of damage and initial treatment The inflammatory process stage Cells release enzymes to dissolve debris in damaged tissues Chemicals attract white blood cells –chemotaxis- (especially neutrophils & monocytes) Histamine & serotonin are secreted from basophils, which help with vasodilation Monocytes become macrophages once in tissue spaces Macrophages can work at low O2 levels close to site of injury, engulfing cellular debris & clearing the area –phagocytosis This normally lasts 0-36 hours but can last up to 72 hours This again can depend on the extent of the injury, initial treatment, and the patient’s physical status The repair stage Classification: General White blood cells migrate and escape to damaged tissue area for phagocytosis There is now very low levels of oxygen Capillary budding brings oxygen and nutrients to area Tissue damage stimulates fibrocytes and induces the creation of fibroblasts. Fibroblasts, attracted by chemicals, fatten, multiply and move towards injury Fibroblasts make collagens, glycosaminoglycans, reticular and elastic fibers, glycoproteins found in the extracellular matrix, and cytokine, meaning they are involved in new tissue formation (angiogenesis) Angiogenesis starts about day 2 Highly permeable walls continue to allow fluid, plasma proteins and cells to leak out Allows oxygen to diffuse out into local tissue By about day 5 fibroblasts begin to produce type III collagen fibres initially (matures eventually to type I) Orientation of fibers is influenced by application of local tensile stresses Tensile strength of wound begins to increase Mitosis, cellular division, and fibroblast proliferation begins within the first 12-24 hours Collagen production begins at day 3 and can last up to 21 days, the maximum rate of production happens around day 16-21 Collagen fibers organize into bundles at around 3-4 weeks The remodeling stage Breakdown and replacement of collagen fibers continues No more collagen fibers produced but tensile strength increases because of cross linkages In this stage, increasing tissue strength and mobility to return injured area back to previous levels should be focused on May last up to 12 months Classification: General 9. ACL Strain Rupture Structures Involved: BONES Femur Patella Tibia Fibula The bones provide attachment sites for the ligament LIGAMENTS Anterior cruciate ligament - is a band of dense connective tissue which courses from the femur to the tibia. It is considered as a key structure in the knee joint and prevents anterior translation of the tibia in relation to the femur. The ACL provides nearly 90% stability to anterior translation. Also involved in providing stability with rotation. The ACL arises from the medial aspect of the lateral femoral condyle in the and inserted anterior to the tibia, blending with the anterior horn of the medial meniscus. The ACL courses anteriorly, medially, and distally across the joint as it passes from the femur to the tibia. As it does, it turns on itself in a slight outward (lateral) spiral. This is due to the orientation of its bony attachments. The orientation of the femoral attachment of the ACL, with regard to the joint position (flexion/extension), is also responsible for the relative tension of the ligament throughout the range of motion MOI or Pathophysiogly Common in unpredictable and multi directional sports, especially if involved with pivoting and sudden deceleration. Tibia rotates internally as a result of valgus stress ACL sprains typical occur in positions a player has frequently placed themselves into. However, in any one instance external factors such as Being off balance Being pushed or held by an opponent Trying to avoid collision Adopting an unusually wide foot position Fatigue and loss of concentration may lead to inadequate muscle protection and/or poor muscular control. When landing if knee falls in medially Usually, associated with foot being planted in the ground Classification: General Uneven Foot surface Usually not due to human contact Common in Skiing Higher in females than males due to the Q angle, females have wider pelvis than males which causes additional stress on the knees, natural valgus weakness. Males typically have stronger quadriceps to support the knee. The female hormones Eostrogen and relaxin affect ligaments negatively (although good for tendons) as it creates ligament laxity. Clinical features Audible noise, pop crack, sensation in knee Feel that their leg goes out and then popped back into place Usually associated with extreme pain or pain at the time that it happens, followed by no pain Swelling minimal at initial injury so testing can be done straight away. Maximal swelling 2-4hrs post injury. ROM is altered due to swelling ROM will increase after a couple of days again. Pain is very generalized or no pain as rupture causes nerve endings to alter. If you don’t test for the first hour then don’t test for 72 hours. Joint line tenderness To confirm an ACL injury, you can perform both the anterior drawer test and the Lachmann's test Grade I TEAR The fibers of the ligament are stretched, but there is no tear. There is a little tenderness and swelling. The knee does not feel unstable or give out during activity. No increased laxity and there are a firm end feel. Grade 1 ACL tears are treated with methods such as bracing, nonsteroidal anti-inflammatories (NSAIDs) for pain, and RICE (rest, ice, compression, and elevation). When these precautions are taken, general healing time is about 2-4 weeks. Grade II TEAR The fibers of the ligament are partially torn or incomplete tear with hemorrhage. (Bleeding from a damaged blood vessel) There is a little tenderness and moderate swelling with some loss of function. The joint may feel unstable or give out during activity. Increased anterior translation yet there is still a firm end point. Painful and pain increase with Lachman's and anterior drawer stress tests. Classification: General Weightbearing on the leg will not be possible without significant amounts of pain. Because of the severity in damage and associated symptoms, Grade 2 tears require longer periods of recovery of about 6-8 weeks and may even require surgical repair of the ACL. The decision of whether or not to operate can be made between patient and surgeon and will depend on factors such as age and activity level. Grade III TEAR The fibers of the ligament are completely torn (ruptured); the ligament itself is torn completely into two parts. There is tenderness, but limited pain, especially when compared to the seriousness of the injury. There may be a little swelling or a lot of swelling. The ligament cannot control knee movements. The knee feels unstable or gives out at certain times. There is also rotational instability as indicated by a positive pivot shift test. No end point is evident. Haemarthrosis occurs within 1-2 hours. (Hemarthrosis happens when something causes bleeding that leaks into your synovial membrane or the cavity inside one of your joints. It will cause swelling, and might make it hard to use your joint.) Surgery followed by rehab – 9-12 months post-surgery. Surgery to reconstruct a torn ACL is done with a graft of a tendon. Reinjury rate is lower with a patella graph than a hamstring graph. Taking patella graph can lead to quad injury. Taking hamstring graph can lead to hamstring injury Return to preinjury level is really high post-surgery and rehab. Complications ACL injury's usually come with with meniscus injury and vice versa. Over 50% of ruptures have associated meniscal Injuries MCL injury is associated. Post-surgery; high reinjury rate, first 12 months Reinjury rate is lower with a patella graph than a hamstring graph Taking patella graph can lead to quad injury Taking hamstring graph can lead to hamstring injury If ACL injury is seen in combination with a medial meniscus tear and an MCL Injury, it is termed O’Donohue’s Triad which has 3 components: 1. Anterior Cruciate Ligament (ACL) Tear 2. Medial Collateral Ligament (MCL) Tear 3. Meniscal Tear Classification: General Stiffness in the knee is common post-surgery, but physical therapy can help it. This can be avoided by performing rehabilitation to regain all of your motion before surgery. People who experience an ACL injury have a higher risk of developing osteoarthritis in the knee. Arthritis may occur even if you have surgery to reconstruct the ligament Treatment Depending on the grade of tear. Surgery followed by rehab – 9-12 months post-surgery Reinjury rate is lower with a patella graph than a hamstring graph Taking patella graph can lead to quad injury Taking hamstring graph can lead to hamstring injury Return to preinjury level is really high now. 10. Meniscal injuries Structures involved Femur Tibia Fibula Patella The soft tissue structure in the knee includes 2 menisci, the medial meniscus (located on the inside of the knee) and lateral meniscus (located on the outside of the knee). Menisci are crescent-shaped pads of fibrocartilage that sit on the end of the tibia bone (tibial condyles) and form a concave surface for the rounded ends of the femur bone (femoral condyles) to rest on. They cover approximately 2/3 of the tibia surface (this surface is flat) and are thicker on the outside and thinner on the inside appearing triangular in cross section. The 2 menisci fill the space between the leg bones and cushion the femur so it doesn't slide off or rub against the tibia. They help stabilize the knees when in motion, reduce friction within the joint, and lubricate and protect the articular cartilage surrounding the tips of the bones from damage due to wear and tear. Classification: General They work like shock absorbers, supporting the load by compressing and spreading the weight evenly within the knee Fibrocartilage - Menisci are composed of tissue called fibrocartilage which is tougher and contains more fiber than other types of cartilage in the body. Fibrocartilage collagen fibers are woven into dense tissue that is resistant to stretching and extending in various directions. This makes fibrocartilage an excellent material for cushioning the knee joint - a joint that is required to move multi-directionally. The amount of blood vessels in the fibrocartilage throughout the meniscus varies. The outer one-third of the meniscus is vascular, which means there is an abundance of blood vessels to allow blood to the area. The central part of each meniscus has fewer blood vessels and the inner third does not contain any. As a result, a tear on the outer peripheral of the meniscus can heal faster than one on the inner portion. Tears in the innermost part of the meniscus may not heal completely due to the lack of blood supply. MOI OR PATHOPHYSIOLOGY A meniscus can be torn or can be completely ruptured. There are partial or total ruptures of a lateral or medial meniscus. Medial tears are reported more commonly than lateral tears. Meniscal injuries are more common in males, because they are more involved in aggressive sporting. Men are more likely to have bucket-handle lesions than women, bucket handle lesions are related to trauma The most common mechanism of menisci injury is a twisting injury with the foot anchor on the ground, often by another player's body. A slow twisting force may also cause the tear as the bones grind on the meniscus. Damage to the meniscus is due to rotational forces directed to a flexed knee (as may occur with twisting sports) is the usual underlying mechanism of injury. Forceful blows to the knee occur most frequently during multidirectional sports when you twist your knee, or slow down too quickly. The most common mechanism of menisci injury is a twisting injury with the foot anchor on the ground, often by another player's body. Regarding the medial meniscus, young athletes are more likely to suffer a medial meniscus tear combined with a medial collateral ligament (MCL) injury. Regarding the lateral meniscus, young athletes are more likely to suffer a lateral meniscus tear along with an anterior cruciate ligament (ACL) injury. Flexion + rotation The most common causes of meniscus injuries in young people is acute trauma to the knee whereas degeneration of the knee joint tissue is the most common cause in seniors. Classification: General As we age the meniscal tissue weakens and becomes less flexible, more brittle and develops small cracks much like those seen in an old car tire (fibrocartilage). Once a meniscus is degenerated significantly, the weak meniscus can become injured with only slight trauma, such as getting down into a squat. Sometimes there is no one event that can be blamed for the cause of a meniscus tear due to degeneration. Unfortunately, the blood supply to the menisci decreases by 20% by the age of 40 and the body's ability to heal itself becomes reduced. As a result, it is more difficult to heal a tear caused by deterioration than an acute trauma that occurs earlier in life. Approximately 60% of people over 65 years of age will experience some form of degenerative meniscus tear Who suffers: Anyone can suffer from a meniscus injury but those that are at greater risk are: athletes who play contact sports such as football, rugby, hockey and other multi directional sports athletes that have highly repetitive activities that stress the knee (such as running and skiing) frequent activities where a lot of time is spent in a squatting position (i.e. construction labor, carpet-laying, warehouse worker, gardening Elderly people as meniscus degenerates. SIGNS AND SYMPTOMS Tearing sensation in the knee Causes pain at the time and then nothing until swelling kicks in 24hrs – 48hrs is pain at maximal A popping sensation Swelling or stiffness Pain, especially when twisting or rotating your knee Difficulty straightening your knee fully Feeling as though your knee is locked in place when you try to move it Feeling of your knee giving way Reduced ROM A partial meniscus tear BUCKET OR FLAP TEAR (partial thickness in depth - meniscus still remain attached) tends to be smaller and more stable because it stays connected to the front and back of your knee and doesn't move about freely. Depending on the location, a partial tear can heal well with non-invasive methods. A complete meniscus tear - RADIAL TEAR (full thickness - tissue separates from your meniscus and tear goes all the way through) tends to be larger and less stable because it hangs by a thread of cartilage. The torn part moves about in your joint which can lead to further complications and damage if not treated. Classification: General Degenerative meniscus tears have frayed edges on the inner rim, where the meniscus is thinnest, which can eventually tear in multiple directions and can lead to a completely degenerated meniscus. A piece in the body of the meniscus often moves about in your joint Complications Once you have a meniscus tear, you have an increased risk of developing knee arthritis because these shock absorbers are weakened it leads to general loss of function of the knee. Likely hood of meniscal Injury's healing on their own is very unlikely. Can lead to neurovascular complications Knee stiffness Increased risk of other knee injuries such as an ACL tear Moving around with a torn meniscus could pull fragments of the cartilage in the joint causing larger knee issues which will require more significant surgery. It can extend to lower back, hip and glute pain Treatment Rehab area to improve function Build up strength in structures around the knee If possible, avoiding surgery is typically the best option. However, in some some cases meniscal repair or even a meniscectomy is advised. Surgical removal of a meniscus (a procedure called a meniscectomy) may be necessary if the meniscus is worn down too much and/or is damaged beyond repair. If knee is locking it is a big sign for need of surgery They go in and remove the flap which decreases the size of your meniscus which can lead to knee osteoarthritis and general loss of function of the knee. Full recovery from surgery may take 4 to 6 weeks, depending on the type of procedure performed as well as other factors. But keep in mind that people also heal at different rates. In most cases physical therapy is used after surgery to minimize complications and speed recovery. 11 Supraspinatus Tendinopathy Supraspinatus tendinopathy is a common source of shoulder pain in athletes that participate in overhead sports (handball, volleyball, tennis, baseball). This tendinopathy is in Classification: General most cases caused by an impingement of the supraspinatus tendon on the acromion as it passes between the acromion and the humeral head Q. What structures are involved? The shoulder joint is made up of three bones: the humerus, scapula and clavicle. The head of the humerus and the glenoid of the scapula form a ball-and-socket joint called the glenohumeral joint. The shoulder allows for a large range of motion due to the spheroid shape of the glenohumeral joint but this (i.e., a large ball in a small socket) renders it prone to dislocation and other injuries. Movements available at the shoulder joint include adduction, abduction, flexion, extension, internal and external rotation. The Supraspinatus is one of the rotator cuffs muscles along with the infraspinatus, teres minor and subscapularis muscles. It originates from the posterior aspect of the scapula and inserts on the greater tuberosity of the humerus, blending partially with the tendon of the infraspinatus muscle. The function of the supraspinatus is to stabilize the shoulder, externally rotate and help to abduct the arm, by initiating the abduction of the humerus on the scapula. The Rotator cuff functions to compress the head of the humerus into the glenoid fossa of the scapula. Collagen is the major matrix protein of supraspinatus tendons, consisting of > 95% type I collagen, with lesser amounts of other collagens including collagen type III Q. How does the injury commonly happen? When there is a damage or injury to the supraspinatus tendon, it is referred to as supraspinatus tendinopathy. Supraspinatus tendinopathy is a common cause of shoulder pain and weakness. This tendinopathy is in most cases caused by an impingement of the supraspinatus tendon on the acromion as it passes between the acromion and the humeral head. It becomes degenerated most often as a result of repetitive stresses and overloading during sports or occupational activities. Commonly happens in sports that involve throwing and overhead motions It can also happen due to: Classification: General Weakness of the muscles that make up your rotator cuff Age-related changes in the structures that make up your shoulder joint Acute changes such as an injury, muscle sprain or strain Tendon impingement is a big cause of supraspinatus tendinopathy. Q. Who does it normally happen to? The average age of onset of this complication is in one’s 50s due to degeneration during the normal process of aging when all of the tendons of the rotator cuff start to become weak as the muscle becomes weaker. Diabetic patients are more prone to the condition. - If you have chronically high blood sugar levels, sugar molecules may attach to collagen. Collagen is a major protein that makes up the connective tissue that holds your joints together. When the sugar attaches to the collagen, it gets sticky, so movement becomes restricted and your shoulder starts to stiffen It is also a common cause of shoulder pain in athletes whose sports involve throwing and overhead motions (tennis or badminton as it involves raising the arms frequently and repetitively above shoulder level). Q. What are the main signs and symptoms Pain increases with reaching. Pain is felt after frequent repetitive activity involving the shoulder. Patient feels weakness of resisted abduction and forward flexion, especially with pushing and overhead movements. Patient has difficulty sleeping at night due to pain, especially when lying on the affected shoulder. Patient has difficulties with simple movements, such as brushing hair, putting on a shirt or jacket, or reaching the arm above shoulder height. Patient has a limited range of motion in the shoulder. Patient had a former shoulder trauma. Q. Are there any complications. Complications of supraspinatus tendonitis include progression to a rotator cuff tear. Progressive weakening of the tendon fibers and internal tendon damage may result in partial or complete tendon failure. Frozen shoulder, also called adhesive capsulitis, involves stiffness and pain in the shoulder joint. Classification: General Surgery is required for tears involving greater than 50% thickness. Can eventually cause weakness and disability of the shoulder Q. What are the general treatment approaches? If recognized early, it might be treated successfully in as little as six weeks. Chronic cases often take three to six months to heal completely, and sometimes longer The main goal in the acute phase (initial phase) is to alleviate pain, inflammation, prevent aggravation of pain. A period of rest should be considered in order to avoid further aggravation and shoulder discomfort. Modalities such as ultrasound, cryotherapy and electrical muscle stimulation can provide temporary relief in acute phase. Strengthening exercises such as isometric exercises should be considered in order to work out the shoulder girdle musculatures. Once pain has been reduced, joint mobilizations, massages, muscle stretches, active-assisted and active exercises are needed to improve the ROM again. Strengthening exercises should work on the external rotators, internal rotators, biceps, deltoid, and scapular stabilizers. Strengthening these muscles will keep the shoulder joint more stable and prevent further injuries. Eccentric exercises will also be more effective than concentric exercises. 12 Lateral Elbow Pain Tennis elbow is a condition that causes pain around the outside of the elbow. It's clinically known as lateral epicondylitis. It often happens after overuse or repeated action of the muscles of the forearm, near the elbow joint. It is the most common overuse syndrome in the elbow. It is a tendinopathy injury involving the extensor muscles of the forearm. Other causes of lateral elbow pain can include: Referred pain from the Cx or upper Tx spine. Less common: Synovitis of the radiohumeral joint, radiohumeral bursitis, or posterior interosseus nerve entrapment in the radial tunnel Not to be missed: osteochondritis dissecans (in adolescents) Structures Involved: Classification: General The elbow joint is made up of three bones: the humerus, the radius and ulna. At the distal end of the humerus there are two epicondyles, one lateral and one medial. Main muscle: the extensor carpi radialis brevis O: Lateral epicondyle of humerus I: base of 3rd metacarpal bone Action; hand extension and abduction Other muscles: extensor digitorum O; Lateral epicondyle of humerus I: Extensor expansions of digits 2-5 Action: finger extension extensor carpi radialis longus O; Lateral supracondylar ridge of humerus I; base of 2nd metacarpal bone Action: hand extension and abduction extensor carpi ulnaris O; Lateral epicondyle of humerus I; Base of 5th metacarpal bone the extensor tendon- The extensor tendons are strong smooth cords that straighten the fingers by connecting the muscles of the forearm and hand to the bones in the fingers and thumb. Q. How does the injury commonly happen? Contractile overloads that chronically stress the tendon near the attachment on the humerus are the primary cause of lateral elbow pain. It occurs often in repetitive upper extremity activities such as computer use, heavy lifting, forceful forearm pronation and supination, and repetitive vibration. Classification: General Despite the name, you will also commonly see this chronic condition in other sports such as squash, badminton, baseball, swimming and field throwing events. People with repetitive one-sided movements in their jobs such as electricians, carpenters, gardeners, desk bound jobs also commonly present with this condition. Overuse of the muscles and tendons of the forearm and elbow together with repetitive contractions or manual tasks can put too much strain on the elbow tendons. These contractions or manual tasks require manipulation of the hand that causes maladaptations in tendon structure that lead to pain over the lateral epicondyle. Lateral elbow pain is equally common in both sexes. Between the ages of 30-50 years the disease is most prevalent. Other risk factors are overuse, repetitive movements, training errors, misalignments, flexibility problems, ageing, poor circulation, strength deficits or muscle imbalance and psychological factors. Twenty percent of cases persist for more than a year. Q. What are the main signs and symptoms The symptoms of tennis elbow develop gradually. In most cases, the pain begins as mild and slowly worsens over weeks and months. There is usually no specific injury associated with the start of symptoms. Common signs and symptoms of tennis elbow include: Pain or burning on the outer part of your elbow Weak grip strength Sometimes, pain at night The symptoms are often worsened with forearm activity, such as holding a racquet, turning a wrench, or shaking hands. Your dominant arm is most often affected; however, both arms can be affected. Q. Are there any complications. Bursitis Osteo Arthritis Rheumatoid arthritis Sprains Stress factors Classification: General osteochondritis dissecans (in adolescents) Q. Treatment; Non-operative medical treatment of Lateral elbow pain is the first-line management. It is initially based on the following principles: relieving pain and controlling inflammation If non-operative management fails for more than 6 months., surgical treatment may be indicated. Most surgical procedures for this condition involve removing diseased muscle and reattaching healthy muscle back to bone. Classification: General Part B Discuss the function and usefulness of the following sections of the E&A – - Observation or Quick touch - 3 from: Active mvts, Passive mvts, Resisted mvts, Muscle tests, Ligament tests, Palpation, Joints above and below SOAP RECAP A structured format ensures consistency of assessment for every athlete Provides background information about the presenting injury Standardised routine for assessing joints of the body Legal requirement / protection for you Forms the basis of treatment / rehab plan  Observation  Quick touch  Active movements  Passive movements  Resisted movements  Muscle tests  Ligament tests  Palpation  Joints above and below  Special tests/ Functional Tests Observation Looking for: General Appearance Postural Abnormalities Symmetry/ Asymmetry & Alignment Muscle Wastage / Bulk Changes in colour of the skin Cuts, bruises, signs of operations Classification: General Adequately Expose View from all angles Be systematic ANATOMICAL vs FUNCTIONAL Anatomical zero – Used for measuring joint angles, location of bony landmarks etc. Functional stance – Normal standing, most comfortable / natural position Quick Touch Dorsum (back) of hand Why? Temperature & texture: Temp - hot? / cold? Texture - sweaty? / dry & scaly? What would this mean? Movements – Active What the patient can do; how far they can take the joint; uses their muscle forces Shows physiological end of range Looking for: Quality – Movement pattern? How easy? Quantity – How far? Any pain, if so, where? Limiting factors may be pain, joint or muscle stiffness AROM – PRINCIPLES Classification: General → Bilateral comparison: uninjured/injured → Check where you need to be standing for the best view of each movement → Full ROM - e.g., DF starts at full active PF → Explain to athlete what you would like them to do - clearly and in lay terms → Demonstrate if appropriate - but demonstration must be precise → Try and quantify the ROM PASSIVE ROM What the therapist does; gently taking the joint further with overpressure Shows anatomical end of range Looking / feeling for: “End Feel” Symptoms – reproduce or new Restrictions may be: swelling, joint stiffness, bony block May go much further due to ligament laxity NORMAL END FEELS Type of End Feel Description Example Soft tissue approximation Soft and spongy, a gradual Elbow flexion painless stop Capsular An abrupt, hard, firm Shoulder rotation endpoint with only a little give Bone to Bone A distinct and abrupt end- Elbow extension point where two hard surfaces come into contact with one another Page Break ABNORMAL END FEELS Classification: General Type of End Feel Description Indicative of Empty Movement definitely beyond Ligament rupture the anatomical limit Spasm Involuntary muscle Joint Instability contraction that prevents normal ROM secondary to pain Loose Extreme but unexpected Joint instability hypermobility Springy block A rebound at the end- point Loose body formation e.g. meniscal tear PROM – Continued → Bilateral comparison: uninjured/injured → Explain - you are doing not them → You take joint through full ROM & then apply overpressure at end of range → Overpressure should be applied gradually and released gradually → NO BOUNCING! Support injured joint → What may a difference between A & PROM represent? RESISTED ROM → Therapist applies resistance at the end of the active range → Shows athlete’s ability to control the joint at the end of their available active range → Safety for sport participation → Limiting factors – pain, stiffness, muscle weakness → Testing the joints ability at end range RROM – Continued → Bilateral comparison: uninjured/injured → Ask athlete to take to their full AROM → Explain: “You are going to TRY to take further & you want them to stop you taking further” → YOU apply gradual pressure at EROM to TRY to take further but you DO NOT take past physiological EROM Classification: General MUSCLE TESTS Bilateral comparison: uninjured / injured Mid-Inner Range– strongest portion of muscle Isometric testing Can also be assessed through ROM Attempting to isolate specific muscle Remember: To say then do Athlete may be stronger than you! Gradual onset & release of pressure - not a fight! OXFORD GRADING SCALE GRAD MUSCLE ACTIVITY E 0 No contraction 1 Flicker/ Trace contraction 2 Active Movement with gravity eliminated 3 Active Movement against gravity 4 Active Movement against gravity and resistance 5 Normal Power LIGAMENT TESTING → Bilateral comparison: uninjured / injured → Testing integrity of ligament – “stress” tests → Asking / looking / feeling for : Pain Joint opening / laxity Distinct ‘end feel’ → Bilateral comparison: uninjured/injured Classification: General → Explain - you are doing not them → Hands as close to joint line as possible but not over the ligament you are testing → Take joint into position where ligament under tension → Stress: applied & released gradually → NO BOUNCING! Support injured joint PALPATION “To examine by the sense of touch” (Shorter Oxford English Dictionary) Requires interpretation of what is felt Important diagnostic tool precision is vital to differentiate between structures (bone, muscle, ligament, scar tissue) JOINTS ABOVE & BELOW Active movements only Looking for: Referred pain - from proximal joints / spine Biomechanical effects / compensations What is the joint above the shoulder? Hip? Wrist? SPECIAL TESTS Targets specific anatomical structures / functions Variety / battery of tests for all anatomical areas Used as differential diagnostic tests to help confirm/deny the working hypothesis Never 100% accurate FUNCTIONAL TESTS Sports specific/functional tests performed (e.g., pain only after 20 mins run) To pinpoint possible underlying cause of problem Perform action / activities which reproduce the symptoms Classification: General Classification: General

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