Prevention and Management of Exercise and Sports-related Injuries PDF

Prevention and Management of Exercise and Sports-related Injuries Prepared by: Mr. Aries I. Pasno I. Introduction to Injury Care and Legal Issues Sports medicine Athletic training Team Approach to the Delivery of Healthcare Legal Considerations Reducing Litigation Sport Medicin...

Prevention and Management of Exercise and Sports-related Injuries Prepared by: Mr. Aries I. Pasno I. Introduction to Injury Care and Legal Issues Sports medicine Athletic training Team Approach to the Delivery of Healthcare Legal Considerations Reducing Litigation Sport Medicine Sports medicine is a broad and complex branch of healthcare, encompassing several disciplines. Essentially, it is an area of healthcare and special services that applies medical and scientific knowledge to prevent, recognize, assess, manage, and rehabilitate injuries or illnesses related to sports, exercises, or recreational activities, and in doing so, it enhances the health fitness and performance of the participant Athletic Training According to the National Athletic Trainers' Association (NATA), athletic training is a discipline practiced by athletic trainers. Athletic trainers are allied healthcare professionals, who work in collaboration with physicians to “optimize activity and participation of clients.” Prevention The domain of prevention encompasses a broad spectrum of knowledge and skills that address the risks associated with participation in sports and physical activities. Such risks range in severity from minor to potentially catastrophic injuries or illnesses. In a similar manner, the strategies used to minimize such risks can vary from relatively simple to complex Clinical Evaluation and The domain of clinical evaluation and diagnosis addresses the Diagnosis responsibilities of the athletic trainer in using standardized clinical practices to make decisions regarding the nature and severity of an injury or illness. Evaluation, or assessment, can involve several scenarios, including on-field (or on-site) primary assessments, off-field initial assessments, and follow-up assessments Immediate Care The immediate-care domain identifies the role of the athletic trainer subsequent to determining the nature and extent of an injury or illness. The athletic trainer must be prepared to care for and prevent further harm for various conditions. As such, immediate care could range from the implementation of standard emergency care for a life-threatening condition Treatment, Rehabilitation, and Reconditioning The athletic trainer is responsible for the implementation of treatment, rehabilitation, and reconditioning programs appropriate to the diagnosis made during the evaluation and assessment phase. In consultation with a physician, a comprehensive treatment program is developed, including therapeutic goals and objectives, selection of appropriate therapeutic modalities and exercise, use of pharmacologic agents, methods to assess and document progress, and criteria for return to participation. Organization and The organization and administration domain describes the Administration responsibilities of the athletic trainer in developing and executing a series of plans, policies, and procedures to ensure responsive and efficient operation of the athletic training program. General areas that warrant attention in this domain include documentation and maintenance of the healthcare records, including those pertaining to health services TEAM APPROACH TO THE DELIVERY OF HEALTHCARE The team approach to the delivery of healthcare allows for a comprehensive prevention, assessment, and management of an injury or illness, as it taps the expertise of individual specialists working in conjunction with one another and the patient. By having healthcare professionals from different disciplines work collaboratively, a venue is in place for addressing an injury from different perspectives. Primary Care Physician In some settings, particularly outside the traditional athletic setting, the primary care physician or family physician assumes a key role in providing medical care to athletes and physically active individuals of all ages. The services provided by the primary care physician can vary with the background and expertise of the individual. Services performed by a primary care physician can range from completing a preparticipation examination for a young athlete to counseling a middle-aged patient with multiple risk factors for coronary artery diseases on the parameters for safely beginning an exercise program  Team Physician In organized sports, such as interscholastic, intercollegiate, or professional athletic programs, a team physician may be hired or may volunteer their services to direct the healthcare team. This individual supervises the various aspects of healthcare and is the final authority to determine the mental and physical fitness of athletes in organized programs.  The Coach, Physical Educator, Fitness Specialist, and Sport Supervisor These professionals are responsible for teaching various skills and/or strategies related to sports and physical activities. In many cases, these individuals are also responsible for administering and supervising activities or activity areas within an institution or health club facility. In both instances, these specialists are responsible for injury prevention, onsite assessment, and management of injuries, including reducing the potential for further injury or harm. Sport/Physical Activity Participant The participant must also play a role in efforts to maximize injury prevention. It is the responsibility of the participant to adhere to prescribed guidelines for their activity. Such responsibilities could include maintaining an appropriate level of fitness; performing within the rules or guidelines of an activity; and maintaining and wearing safety equipment.  Additional Professionals Involved in Healthcare of Physically Active Individuals Physical Therapist- provide a unique and valuable resource in the overall rehabilitation of an individual. Physical therapists often supervise the rehabilitation of injured participants in a hospital setting, an industrial clinic, or a sports medicine clinic. Exercise Physiologist - can provide information pertaining to the physiological mechanisms underlying physical activities. As such, the exercise physiologist can offer theoretical and practical suggestions regarding the analysis, improvement, and maintenance of health and fitness. Nutritionist - are primarily concerned with the role of proper dietary care in the prevention and treatment of illnesses. However, a nutritionist can provide valuable input regarding the specialized needs of athletes and physically active individuals Biomechanist- Applying basic laws of physics in performing mechanical analyses of human movement, a bio- mechanist can offer practical insight into improving human performance as well as preventing sport and physical activity related injuries.  Legal Considerations Standard of Care In defining standard of care, it is important to distinguish between reasonable person standard of care and professional standard of care. Reasonable person standard of care is a minimum standard that requires an individual to act as a reasonably prudent person.  Legal Considerations Duty of Care Duty of care, encompasses a variety of responsibilities, such as teaching proper and appropriate techniques for an age group, providing appropriate supervision of activities, providing quality safety equipment, ensuring a safe participation environment, and taking proper actions when an injury is sustained.  Legal Considerations Negligence Legal action involving the practice Type of Negligence of sport and physical activity injury Nonfeasance/ omission occurs when care is typically tried under tort law. an individual fails to perform a legal A tort is a civil wrong done to an duty of care. individual, whereby the injured Malfeasance/ commission occurs party seeks a remedy for damages when an individual commits an act that suffered. Such wrongs may be is not their responsibility to perform. attributed to negligence. Misfeasance occurs when an Negligence ca occur as a result of individual commits an act that is their an action or lack of an action by a responsibility to perform, but uses the professional who had a legal duty wrong procedure or perform the correct of care procedure in an improper manner Clearance for Reducing Litigation Participation performed by a licensed physician as a requirement for participation in a sports team or in a physical fitness program can be an effective strategy for ensuring an individual’s health and safety as it pertains to their participation in physical activity or sport  Reducing Litigation Assumption of Risk Participants and parents of minor Coaches should inform potential children should: participants of the risks for injury (1) understand that risk for injury during sport and physical activity exists, participation. Participants and (2) appreciate the nature of the risk, parents of minor children should and understand that the risk for injury (3) voluntarily accept the risk exists as well as the nature of that risk, so that informed judgments can be made about participation. Exculpatory Waiver Reducing Litigation An exculpatory waiver is a contract that releases the professional from any liability to the individual executing the release. Similar to an assumption of risk, in signing an exculpatory waiver, the participant acknowledges their understanding of the risks involved in their participation and their voluntary choice to participate in the face of those risks. Informed Consent Reducing Litigation Informed consent implies that an injured party has been reasonably informed of the needed treatment for the services that a coach may need to perform, possible alternative treatments, and advantages and disadvantages of each course of action. To be valid, consent can only be obtained from one who is competent to grant it, that is, an adult who is physically and mentally competent or the parent in the case of children under the age of 18.  Reducing Litigation Confidentiality A major concern affecting all healthcare providers is the individual’s right to privacy. Coaches have a duty of care to protect the constitutional rights of their participants by ensuring their right to confidentiality regarding medical information. If a coach releases any information, even accurate information, the coach could be liable for breach of duty of confidentiality to which the participant is entitled.  Reducing Litigation Foreseeability of Harm Foreseeability of harm exists when danger is apparent or should have been apparent, resulting in an unreasonably unsafe condition. This potential for injury can be identified during regular inspections of gymnasiums, field areas, swimming pools, safety equipment and athletic training facilities.  Reducing Litigation Instruction and Supervision It is essential that skill techniques, performance tactics, and rules be taught and continually reinforced by coaches in an effort to reduce the potential for injury. Coaches should present information in a manner that is both developmentally and instructionally appropriate Proper supervision of participants involved in sport and physical activity can help to reduce the rate of injuries. In the capacity of a supervisor, coaches must be alert and attentive.  Reducing Litigation Participant’s Responsibility It is the responsibility of the participant to adhere to prescribed guidelines for their activity. Such responsibilities could include maintaining an appropriate level of fitness; performing within the rules or guidelines of an activity; and maintaining and wearing safety equipment. Product Liability Reducing Litigation Implied warranty Manufacturers Participants, parents, and have a duty of care to design, coaches place a high degree manufacture, and package of faith in the quality and equipment that will not cause injury safety of equipment used in to an individual when used as sport and physical activity intended. participation. Expressed warranty is a written guarantee that the product is safe for use.  Reducing Litigation Good Samaritan Laws were developed to encourage bystanders to assist others in need of emergency care by granting them immunity from potential litigation.  Reducing Litigation Risk Management The duty of care for a coach includes reducing the risk of injury. As such, the coach is responsible for providing an environment that makes participation in an activity as safe as possible and minimizing opportunities for participants to sustain injury. However, responsibility for risk management cannot be the sole responsibility of the coach.  II. Injury Prevention Conditioning and Injury Prevention Proper Technique and Injury Prevention Protective Equipment and Injury Prevention  CONDITIONING AND INJURY PREVENTION Basic Principles of Conditioning In developing a physical conditioning program, several basic principles must be addressed. In efforts to develop a specific component of fitness (e.g., flexibility; strength; endurance; particular skill), the Specific Adaptation to Imposed Demands (SAID) principle or specificity must be followed. The SAID principle states that the body responds to a given demand with a specific and predictable adaptation.  CONDITIONING AND INJURY PREVENTION Basic Principles of Conditioning Overload states that physiologic improvements occur only when an individual physically demands more of the body than is normally required. If the demands are within appropriate physiological limits, the body will adapt and improve its function.  CONDITIONING AND INJURY PREVENTION Basic Principles of Conditioning Frequency Frequency refers to the number of exercise sessions per day or week. The number of days in which an individual should engage in a conditioning program will vary depending on various factors (e.g., goals; current fitness level). Basic Principles of Conditioning CONDITIONING AND INJURY PREVENTION Intensity Intensity reflects both the caloric cost of the work and the specific energy systems activated. It refers to the amount of work being done during an exercise. The level of intensity for any given activity should be based on the component being developed, the current performance level, and desired goals.  CONDITIONING AND INJURY PREVENTION Basic Principles of Conditioning Duration Duration refers to the length of a single exercise session. The recommended duration may be stated in terms of minutes (e.g., walking 45 minutes) or the number of repetitions and sets (e.g., muscular endurance training three sets of 12 to 15 repetitions).  CONDITIONING AND INJURY PREVENTION Flexibility Flexibility is the total range of motion (ROM) at a joint that occurs pain-free in each of the planes of motion. Joint flexibility is a combination of normal joint mechanics, mobility of soft tissues, and muscle extensibility.  CONDITIONINGMuscular AND INJURY Strength andPREVENTION Endurance Strength is the ability of a muscle or group of muscles to produce force in one maximal effort. Muscular strength influences the ability to execute normal activities of daily living and aids in reducing or preventing postural deformities. Muscular endurance is the ability of muscle tissue to exert repetitive tension over an extended period. The rate of muscle fatigue is related to the endurance level of the muscle (i.e., the more rapid the muscle fatigues, the less muscle endurance).  CONDITIONING AND INJURY PREVENTION Cardiorespiratory Endurance Cardiorespiratory endurance refers to the ability to sustain prolonged exercise. It involves activities that use the large muscle groups to engage in dynamic exercise at moderate or higher levels of intensity for an extended period of time  PROPER TECHNIQUE AND INJURY PREVENTION Proper technique is important with Instruction of proper techniques regard to efficient and effective skill requires knowledge of basic performance. It is also an important biomechanical principles (e.g., kinetics; factor in the prevention of injury. Use kinematics) to ensure that structures of improper techniques in executing within the body are not sustaining forces sport- specific skills has been that will cause soft or bony tissues to fail identified as a factor that can (i.e., rupture of soft tissue; fracture of contribute to injury.4 Subsequently, it bone) has been suggested that poor coaching can result in increased injuries. Specialized equipment, PROTECTIVE EQUIPMENTS AND INJURY when properly used, can protect a participant from PREVENTION Equipment Design Factors that Can accidental or routine injuries Reduce Potential Injury associated with a particular sport or Increase the impact area physical activity. However, there are Transfer or disperse the impact area to another body part limitations to the effectiveness of Limit the relative motion of a body part protective equipment. A natural Add mass to the body part to limit outcome of wearing protective deformation and displacement equipment is to feel more secure. Reduce friction between contacting surfaces Unfortunately, this often leads to more Absorb energy aggressive play, which can result in Resist the absorption of bacteria, fungus, and viruses injury to the participant or an opponent.  PREVENTION Liability and Equipment Standards Legal issues concerning protective equipment are a major concern for every organized sport or physical activity program. An organization’s duty to ensure the proper use of protective equipment is usually a shared responsibility among the members of the athletic staff.  PREVENTION Protective Equipment: Head and Face Many head and facial injuries can be prevented with regular use of properly fitted helmets and facial protective devices, such as face guards, eye wear, ear wear, mouthguards, and throat protectors. Helmets, in particular, are required in football, ice hockey, men’s lacrosse, baseball, softball, and bicycling, and must be fitted properly to disperse impact forces.  PREVENTION Football Helmets Footballs helmets consist of an outer shell constructed of plastic or a polycarbonate alloy, a material that is lightweight and impact-resistant. The inside of the helmet contains a single or double air bladder, closed-cell pads, or a combination of the two. The football helmet is designed to reduce the incidence and severity of head trauma.  PREVENTION Ice Hockey Helmets As with football helmets, ice hockey helmets reduce head injuries; however, they do not prevent neck injuries caused by axial loading. The use of head protection with a face mask seems to have given many players a sense of invulnerability to injury. Ice hockey helmet standards are monitored by the ASTM and the HECC and are required to carry the stamp of approval from the CSA. Helmets should be fitted and maintained in accordance with manufacturer’s guidelines.  PREVENTION Batting Helmets Batting helmets are now compulsory in baseball and softball and require the NOCSAE mark. Most batting helmets are open-faced with a double ear-flap design and can protect the majority of the superolateral cranium, but not the jaw or facial area. Although some studies claim that batting helmets fitted with face shields may prevent or reduce severity of facial injuries to children, there are no rigorous data to support such a claim  Other Helmets Lacrosse helmets are mandatoryPREVENTION in the men’s game, optional in the women’s game, and are also worn by field hockey goalies. bicycle helmet has a plastic or fiberglass rigid shell with a chin strap and an energy-absorbing foam liner. Face guards which vary in size and style, protect and shield the facial region from flying projectiles. Eye Wear- Eye injuries are relatively common and almost always preventable, if proper protective wear is worn. There are three types of protective eyewear: goggles, face shields, and spectacles Mouthguards- An intraoral readily visible mouthguard is required in all interscholastic and intercollegiate football, ice hockey, field hockey, and men’s and women’s lacrosse. Throat and Neck Protectors - The NCAA requires that catchers in baseball and softball wear a built-in or attachable throat guard on their mask. Helmets used in field hockey, lacrosse, and ice hockey also provide anterior neck protectors to protect this vulnerable area.  PREVENTION Protective Equipment: Upper Body In the upper body, special pads and braces are often used to protect the shoulder region, ribs, thorax, breasts, arms, elbows, wrists, and hands. Depending on the activity, special design modifications are needed to allow maximum protection, while providing maximal performance. Shoulder Protection PREVENTION Shoulder pads should protect the soft- and bony-tissue structures in the shoulder, upper back, and chest. The external shell is generally made of a lightweight, yet hard plastic. Football shoulder pads should be selected based on the player’s position, body type, and medical history. Linemen need more protection against constant contact and use larger cantilevers. Quarterbacks, offensive backs, and receivers require smaller shoulder cups and flaps to allow greater ROM in passing and catching. Elbow, Forearm, Wrist, and Hand Protection PREVENTION The use of a counterforce forearm brace may provide some relief for individuals with lateral and medial epicondylitis. These braces are designed to reduce tensile forces in the wrist flexors and extensors, particularly the extensor carpi radialis brevis. Although these braces may relieve pain on return to activity, debate continues about the effectiveness of counterforce fore-arm braces. These braces should not be used for other causes of elbow pain, such as growth plate problems in children and adolescents or medial elbow instability in adults.  PREVENTION Thorax, Rib, and Abdominal Protection Catchers in baseball and softball wear full thoracic and abdominal protectors to prevent high-speed blows from a bat or ball. Individuals in fencing, and goalies in many sports, also wear full thoracic protectors. Quarterbacks and wide receivers in football often wear rib protectors composed of air- inflated, interconnected cylinders to absorb impact forces caused during tackling. These protectors should be fitted according to the manufacturer’s instructions.  PREVENTION Lumbar/Sacral Protection Lumbar/sacral protection includes weight-training belts used during heavy weight lifting, abdominal binders, and other similar supportive devices. Each should support the abdominal contents, stabilize the trunk, and prevent spinal deformity or injury during heavy lifting.  PREVENTION Protective Equipment: Lower Body In the lower body, commercial braces are commonly used to protect the knee and ankle. In addition, special pads are used to protect bony and soft-tissue structures in the hip and thigh region. Depending on the sport/activity, special design modifications are needed to allow maxi- mum protection, while providing maximal performance.  PREVENTION Hip and Buttock Protection In collision and contact sports, the hip and buttock regions require special pads typically composed of hard polyethylene covered with layers of ensolite to protect the iliac crest, sacrum, coccyx, and genital region. A girdle with special pockets can effectively hold the pads in place. The male genital region is best protected by a protective cup placed in an athletic supporter.  PREVENTION Thigh Protection Thigh pads should be placed over the quadriceps muscle group, approximately 6 to 7 inches proximal to the patella. When using asymmetrical thigh pads, the larger flare should be placed on the lateral aspect of the thigh to avoid injury to the genitalia. In addition to thigh pads, neoprene sleeves can provide uniform compression, therapeutic warmth, and sup- port for a quadriceps or hamstring strain.  PREVENTION Knee and Patella Protection Knee pads can protect the area from impact during a collision or fall, and in wrestling, can protect the prepatellar and infrapatellar bursa from friction injuries. In football, knee pads reduce contusion and abrasions when falling on artificial turf.  PREVENTION Patellofemoral Protection Patella braces are designed to dissipate force, maintain patellar alignment, and improve patellar tracking. A horseshoe-type silicone or felt pad is sewn into an elastic or neoprene sleeve to relieve tension in recurring patellofemoral subluxation or dislocations. Lower Leg Protection PREVENTION Pads for the anterior tibia area should consist of a hard, deflective outer layer, and an inner layer of thin foam. Velcro straps and stirrups help stabilize the pad inside the sock. Many styles also incorporate padding or plastic shells over the ankle malleoli, which are often subject to repeated contusions. Several commercial designs are available.  PREVENTION Ankle and Foot Protection Commercial ankle braces can be used to prevent or support a postinjury ankle sprain and come in three categories: lace-up brace, semirigid orthosis, or air bladder brace. A lace-up brace can limit all ankle motions, whereas a semirigid orthosis and air bladder brace limit only inversion and eversion.  PREVENTION Foot Orthotics Orthotics are devices used in the treatment and prevention of foot and gait abnormalities and related conditions, such as plantar fasciitis, heel pain, shin splints, patellofemoral pain, and low back pain. III. Injury Mechanism and Classification of Injury ANATOMIC FOUNDATIONS Using correct terminology is crucial when communicating with members of the medical com- munity. Anatomic terms, such as superior and inferior, medial and lateral, or thoracic and abdominal, help pinpoint the exact location on which to focus. Combined with basic medical terms, one can describe the site and what motions are affected by an injury. ANATOMIC Anatomic Position FOUNDATIONS The human body is separated into two main segments: axial and appendicular. The axial segment relates to the head and trunk and includes the chest and abdomen. The appendicular segment relates to the extremities. Direction or position on the body is based on anatomic position ANATOMIC FOUNDATIONS Directional Terms Directional terms are used to describe the location of one body part relative to another. For example, the elbow is superior to the wrist, the chest is on the anterior thorax, and the big toe is on the medial side of the foot. These terms are always used relative to anatomic position, regardless of the body’s actual position. MECHANISMS OF INJURY The process by which an injury occurs is Injury is caused by an abnormal referred to as the mechanism of injury. force. Force is a push or pull acting Analyzing the mechanics of injuries to the on a body. A multitude of forces act human body is complicated by several on our bodies routinely during the factors. First, forces are applied to the day. The forces of gravity and friction body at different angles, over different enable us to move about in surface areas, and over different periods predictable ways when muscles of time. Second, the human body is produce internal forces. composed of many different types of tissue that respond differently to applied forces. Finally, injury to the human body is not an all-or-none phenomenon. MECHANISMS OF INJURY Axial loading that produces a squeezing or crushing effect is called compressive force or compression. Axial loading in the direction opposite to that of compression is called tensile force, or tension. Tension is a pulling force that stretches the object to which it is applied. Shear force tends to cause one part of the object to slide against, displace, or shear with another part of the object. SOFT Skin TISSUE INJURIES The integumentary system comprises the skin, hair, nails, and glands of the skin and is the largest organ in the body. It provides protection and sensation, regulates fluid balance and temperature, and produces vitamins (vitamin D) and immune system components. Skin Injury SOFT TISSUE INJURIES Abrasions are caused by shear when the skin is scraped Classification with sufficient force, usually in one direction, against a There are five rough surface such as the floor or the artificial playing common open surface wounds seen in Incisions are caused by a sharp, cutting object, such as sport and physical broken glass. activity: abrasions, Laceration is an irregular tear in the skin that typically incisions, results from a combination of tension and shear. lacerations, Avulsion is a severe laceration that results in complete separation of the skin from the underlying tissues avulsions, and punctures. Puncture wound is formed when a sharp object, such as a shoe spike or nail, penetrates the skin and underlying tissues with tensile loading. Muscle/Tendon Injury Contusions or bruises result from a SOFT TISSUE INJURIES Classification direct compressive force sustained from a heavy blow. Injuries to muscles and tendons are dependent upon the nature of Ecchymosis or tissue discoloration the causative force, the location of may be present if the hemorrhage is the force, and the properties of the superficial involved musculotendinous unit (e.g., cross-sectional area; training Hematoma formation of a hard mass composed of blood and dead tissue state). Injuries can be acute or chronic Strains are caused by indirect forces (i.e., abnormally high tensile forces) that produce rupturing of the tissue and subsequent hemorrhage and swelling. SOFT TISSUE INJURIES Joints A joint is the site at which two bones connect. Joints are classified by their structure or function. Structurally, they are grouped as fibrous, cartilaginous, or synovial joints  SOFT TISSUE INJURIES Joint Injury Classification Sprains are traumatic injury to ligaments. Abnormally high tensile forces produce a stretching or tearing of tissues that compromises the ability of the ligament to stabilize the joint. Dislocation is a traumatic injury that occurs when the bones that comprise a joint are forced beyond their normal position, resulting in the displacement of one joint surface on another. Osteoarthritis is a type of arthritis attributed to degeneration of the articular cartilage in a joint. Individuals with osteoarthritis experience pain and limited movement at the involved joint. Bursitis involves irritation of one or more bursae. It may be acute or chronic, depending on whether it is brought on by a single traumatic compression or repeated compressions associated with overuse of the joint.  Bone Injuries In keeping with its material constituents and structural organization, bone behaves predictably in response to stress. The composition and structure of bone make it strong for its relatively light weight.  Bone Injuries Anatomic Properties of Bone The primary constituents of bone are calcium carbonate, calcium phosphate, collagen, and water. The minerals, making up 60 to 70% of bone weight, provide stiffness and strength in resisting compression. Longitudinal bone growth continues only as long as the bone’s epiphyseal plates, or growth plates, continue to exist.  Bone Injuries Bone Injury Classification A fracture is a disruption in the continuity of a bone. Signs of fracture include rapid swelling, ecchymosis, deformity or shortening of the limb, precise point tenderness, grating or crepitus, and guarding or disability. Bone Injuries Epiphyseal Injury Bone Injuries Classification The bones of children and Type I: Complete separation of the epiphysis adolescents are vulnerable to from the metaphysis with no fracture to the bone Type II: Separation of the epiphysis and a small epiphyseal injuries, including portion of the metaphysis injuries to the cartilaginous Type III: Fracture of the epiphysis epiphyseal plate, articular Type IV: Fracture of a part of the epiphysis and cartilage, and apophysis. The the metaphysis apophyses are sites of tendon Type V: Compression of the epiphysis without attachments to bone, where fracture, resulting in compromised epiphyseal bone shape is influenced by the function tensile loads to which these sites are subjected. Epiphyseal Injury Classification  NERVE INJURIES The nervous system is divided into the central nervous system, consisting of the brain and the spinal cord, and the peripheral nervous system, which includes 12 pairs of cranial nerves and 31 pairs of spinal nerves, along with their branches  NERVE INJURIES Anatomic Properties of Nerves Each spinal nerve is formed from anterior and posterior roots on the spinal cord that unite at the intervertebral foramen. The posterior branches are the afferent (sensory) nerves that transmit information from sensory receptors in the skin, tendons, ligaments, and muscles to the central nervous system.  NERVE INJURIES Tensile or compressive forces most commonly injure nerves. Tensile injuries are more likely to occur during severe high-speed accidents, such as automobile accidents or impact collisions in contact sports Neurapraxia is a localized conduction block that causes temporary loss of sensation and/or motor function from selective demyelination of the axon sheath without true axonal disruption. Axonotmesis injuries that produce significant motor and mild sensory deficits that last at least 2 weeks.  PAIN The Neurological Basis of Pain Pain can originate from somatic, visceral, and psychogenic sources. Somatic pain originates in the skin as well as internal structures in the musculoskeletal system. Visceral pain, which is often diffuse or referred rather than localized to the problem site, originates from the internal organs. Psychogenic pain involves no apparent physical cause of the pain, although the sensation of pain is felt. Factors That Mediate Pain PAIN Some brain cells have the ability to produce narcotic- like, pain-killing compounds known as opioid peptides, including beta-endorphin and methionine enkephalin. A phenomenon called “runner’s high,” which is a feeling of euphoria that occurs among long distance runners, has been attributed to endorphin release. The brain stem and pituitary gland produce enkephalins. Enkephalins block pain neurotransmitters in the dorsal horn of the spinal cord.  PAIN Referred Pain and Radiating Pain Referred pain is perceived at a location remote from the site of the tissues actually causing the pain. A proposed explanation for referred pain begins with the fact that neurons carrying pain impulses split into several branches within the spinal cord. Radiating pain, which is pain that is felt both at its source and along a nerve. Pinching of the sciatic nerve at its root may cause pain that radiates along the nerve’s course down the posterior aspect of the leg. IV. The Healing Process Soft Tissue Healing Bony Tissue Healing Nerve Tissue Healing Factors That Delay Healing  SOFT TISSUE HEALING Trauma or physical damage results in the destruction of tissues. Necrosis is the death of living cells. It is due to disruption of the oxygen supply (hypoxia) to the involved area. The extent or amount of necrosis depends on the cause of the trauma and contributing factors. The healing of destroyed soft tissues is a three-phase process involving inflammation, proliferation, and maturation. Inflammatory Phase (0 to 6 days) The familiar symptoms of inflammation An acute inflammatory response is have long been recognized as rubor relatively brief and involves the creation of (redness), calor (local heat), tumor exudate, a plasma like fluid that exudes (swelling), dolor (pain), and in severe out of tissues or its capillaries and is cases, loss of function. Although composed of protein and granular inflammation can be produced by leukocytes (white blood cells) adverse response to chemical, thermal, and infectious agents, the focus of this A chronic inflammatory response, explanation is on the characteristic alternatively, is prolonged and course of the inflammatory response is characterized by nongranular leukocytes following injury. and the production of scar tissues The Proliferative Phase (3 to 21 days) The proliferative phase involves repair and regeneration of the injured tissue. This phase takes place from approximately 3 days after the injury through the next 3 to 6 weeks, overlapping the later part of the inflammatory phase. The proliferative processes include the development of new blood vessels (angiogenesis), the process of fibrous tissue formation, the generation of new epithelial tissue, and wound contraction. Maturation Phase (up to 1+ year) The final phase of soft tissue wound repair is the maturation, or remodeling, phase. This phase involves the maturation of the newly formed tissue into a scar tissue. The associated characteristics include decreased fibroblast activity, increased organization of the extracellular matrix, decreased tissue water content, reduced vascularity, and a return to normal histochemical activity.. MUSCLES, TENDONDS, AND LIGAMENTS Muscle injury can result in scarring or the formation of adhesions within the muscle, which inhibits the potential for fiber regeneration from the reserve cells. Consequently, following severe injury, muscle may regain only about 50% of its pre-injury strength. Tendons and ligaments have few reparative cells, healing of these structures is a slow process that can take more than a year. Regeneration is enhanced by proximity to other soft tis- sues that can assist with supply of the chemical mediators and building blocks required. BONY TISSUE HEALING During repair and regeneration, osteoclasts resorb damaged bone tissues, whereas osteoblasts build new bone. Between the fractured bone ends, a fibrous, vascularized tissue known as a callus is formed. The callus contains weak, immature bone tissues that strengthen with time through bone remodeling. The process of callus formation is known as enchondral bone healing. An alternative process, known as direct bone healing, can occur when the fractured bone ends are immobilized in direct contact with one another. NERVE TISSUE HEALING When a nerve is completely severed, healing does not occur and loss of function is typically permanent. Unless such injuries are surgically repaired, random regrowth of the nerve occurs, resulting in the formation of a neuroma or nerve tumor. When nerve fibers are ruptured in a tensile injury, but the surrounding myelin sheath remains intact, it is sometimes possible for a nerve to regenerate along the pathway provided by the sheath. However, such regeneration is relatively slow proceeding at a rate of less than 1 mm per day or about 2.5 cm per month.  FACTORS THAT DELAY HEALING A variety of factors can delay or inhibit the healing of a wound. In general, these factors can be characterized as systemic or local. Local factors occur at the site of the Systemic conditions can affect wound. Local factors that delay healing multiple organs, systems, or the entire include: body. Systemic conditions that can Extent (size) of the injury impede wound healing include: Extent (amount) of hemorrhage and Poor nutrition edema Vascular insufficiencies Muscle spasm Age Inflammation Infection Infection Metabolic disorders Poor blood supply Prolonged immobilization; excessive motion or repeated adverse stress V. Injury Management Determination of Findings The Emergency/Accident Plan Soft Tissue Wound Care Management Bone Injury Management DETERMINATION OF FINDINGS Following completion of an In general, the options available to the coach in on-site assessment, the managing an acute injury would include: coach must analyze the Standard acute care (i.e., cold, compression, information obtained and elevation, protected rest, as appropriate) make decisions on the best Standard acute care with physician referral way to manage the situation. prior to return to activity It is especially important to Standard acute care with immediate physician determine whether the referral (i.e., emergency care facility) situation can be handled on- Summon emergency medical services (EMS) site or if referral to a physician Regardless of the severity of injury, a written plan is warranted. should be in place to direct the coach through the implementation of each option. THE EMERGENCY/ACCIDENT PLAN An emergency/action plan is a well-developed written process that defines the policies and procedures to be used in the management of an acute injury to a participant. The plan should provide direction to those individuals who will have responsibilities in managing the condition.  THE EMERGENCY/ACCIDENT. PLAN Developing the Emergency Plan In developing the emergency plan, several The development of an emergency plan areas must be addressed, including the: should be recognized as a significant Population being served endeavor that requires input from several Potential injuries/conditions sources. It should be developed with input Personnel from the personnel at the facility, higher Availability of medical/first aid equipment, authorities to which the institution reports. Facility access Communication Documentation SOFT TISSUE WOUND CARE MANAGEMENT Soft tissue injuries may involve: Open wounds Abrasions Blisters Lacerations Puncture wounds Closed wounds Contusions Strains Sprains SOFT TISSUE WOUND CARE MANAGEMENT Open Wound Injury Care In general, management of open wounds involves controlling bleeding, evaluating the wound to determine whether emergency treatment is necessary, cleansing the wound, and dressing the wound. In addition, care of open wounds includes following universal precautions to reduce the risk of transmission of bloodborne pathogens. SOFT TISSUE WOUND CARE MANAGEMENT Closed Soft Tissue Injury Care Closed wound care focuses on immediately reducing inflammation, pain and secondary hypoxia. The process for providing immediate management for an acute closed soft tissue injury includes several components, commonly referred to as the PRICE principle: Protected, Rest, Ice, Compression, and Elevation) SOFT TISSUE WOUND CARE MANAGEMENT Application of Cold The extent of a soft tissue injury can be significantly affected by altering the temperature of the injured tissues. Within minutes of an injury, the application of cold can lead to vasoconstriction at the cellular level and decreased tissue metabolism  BONE INJURY MANAGEMENT A fracture can range in severity from a minor injury to a life- threatening emergency. As such, the immediate management of a fracture must take into consideration the nature and severity of the fracture. In all instances, medical attention is required.  BONE INJURY MANAGEMENT In situations considered a medical emergency, it is best to avoid moving or transporting the individual. Because movement could aggravate the condition, the individual should remain in the position found and the paramedics should handle transport. While waiting for medical assistance to arrive, the following actions should be considered in managing the condition: Controlling any bleeding (e.g., application of gentle pressure) Immobilizing the injured area in the position in which it was found Applying cold to the area If shock is suspected, then providing treatment for shock VI. Injury Assessment The Injury Evaluation Process Disposition  The Injury Evaluation Process When evaluating any injury or condition, Examples of these subjective diagnostic signs and symptoms are obtained feelings include: and interpreted to determine the type and Blurred vision extent of injury. A diagnostic sign is an Ringing in the ears objective, measurable physical finding Fatigue regarding an individual’s condition. Dizziness Nausea A sign is what the evaluator hears, feels, sees, Headache or smells when assessing the patient. A Pain symptom is information provided by the Weakness injured individual regarding their perception of Inability to move a body the problem. part.  The HOPS Format—An HOPS Overview History Observation Palpation Special testing The HOPS format uses both subjective information (i.e., history of the injury) and objective information (i.e., observation and inspection, palpation, and special testing) to recognize and identify problems contributing to the condition.  The HOPS Format—An History Overview A complete history includes information on the primary complaint; cause or mechanism of injury; characteristics of the symptoms; and related medical history that may have a bearing on the specific condition. This information can provide potential reasons for the symptoms and identify injured structures prior to initiating the physical examination.  The HOPS Format—An History Overview Primary Complaint The primary complaint focuses on the injured individual’s perception of the current injury. As such, the individual is asked questions that permit responses that describe the current nature, location, and onset of the condition. Mechanism of Injury The mechanism of injury is the physical cause or circumstance under which the injury occurred. For example, a mechanism could be a hit in the head by a thrown ball that results in an acceleration force involving the brain.  The HOPS Format—An History Overview The individual’s pain perception can indicate which structures may be injured. There are two categories of pain: somatic and visceral. Somatic pain arises from the skin, ligaments, muscles, bones, and joints, and is the most common type of pain encountered in musculoskeletal injuries. Visceral pain results from disease or injury to an organ in the thoracic or abdominal cavity, such as compression, tension, or distention of the viscera. Similar to deep somatic pain, it is perceived as deeply located, nagging, and pressing, and it is often accompanied by nausea and vomiting.  The HOPS Format—An Overview Related Medical History In many scenarios involving acute conditions, obtaining information regarding other problems or conditions that may affect the current condition is also advantageous. For example, awareness of a previous history of exercise-induced bronchospasm (EIB) or determining no previous history of EIB may offer insight into the individual’s response to the condition and, ultimately, influence the ongoing assessment and immediate management.  The HOPS Format—An Overview Observation It is initiated the moment the injured person is seen and continues throughout the assessment. The initial observation focuses on the individual’s state of consciousness and body language, which may indicate pain, disability, fracture, dislocation, or other conditions. Valuable information is also obtained by noting the individual’s general posture, willingness and ability to move, ease in motion, and general overall attitude.  The HOPS Format—An Overview Palpation Palpation involves the healthcare provider physically touching and feeling the body of the injured individual. Palpation begins with gentle, circular pressure followed by gradual, deeper pressure. It is initiated on structures away from the injury site and progresses toward the injured area. Palpating the most painful area avoids any carryover of pain into non-injured areas.  The HOPS Format—An TestingOverview Testing includes Once fractures and/or Functional tests dislocations have been ruled Stress tests, out, soft tissue structures, Special tests, such as muscles, ligaments, Neurologic testing, and the joint capsules, and Sport or activity-specific functional bursae, are assessed using a testing. variety of tests.  The HOPS Format—An Overview Functional Tests Functional tests identify the patient’s ability to move a body part through the range of motion (ROM) actively, passively, and against resistance. Active range of motion (AROM) is joint motion performed voluntarily by the individual through muscular contraction. Stress Tests Stress tests occur in a single plane and are graded according to severity. Specifically, sprains of ligamentous tissue are generally rated on a three- degree scale after a specific stress is applied to a ligament to test its laxity.  The HOPS Format—An SpecialOverview Tests Special tests have been developed for specific body parts or areas as a means for detecting injury or related pathology. In general, special tests occur across planes and are not graded. Neurologic Testing A segmental nerve is the portion of a nerve that originates in the spinal cord and is referred to as a nerve root. The motor component of a segmental nerve is tested using a myotome, a group of muscles primarily innervated by a single nerve root. The sensory component is tested using a dermatome, an area of skin supplied by a single nerve root. The HOPS Format—An Overview Activity-specific tests involve the performance of active movements typical of the movements executed by the individual during sport or activity participation. These movements should assess strength, agility, flexibility, joint stability, endurance, coordination, balance, and activity-specific skill performance.  Injury Assessment and the Coach The coach should be prepared to assess a range of acute conditions as the first respondent. It is not within the duty of care of a coach to assess and manage post-acute, chronic, or stress-related injuries. Rather, it is the responsibility of the coach to refer those injuries to healthcare professionals.  Injury Assessment and the The primaryCoach survey determines the level of responsiveness and assesses airway, breathing, and circulation (ABCs). The primary survey begins as the coach approaches the individual by observing their body language (e.g., movement; absence of movement) and observing any talking (e.g., absence of any talking or sounds; screams or statements attributed to pain).  Injury Assessment and the Coach If at any time during the assessment, conditions exist that are an immediate threat to life or “red flags” are noted the assessment process should be terminated and the emergency medical plan activated  Injury Assessment and the Coach Secondary Survey Once it has been determined that a life- threatening condition does not exist, a secondary survey is performed to identify the type and extent of any injury, and the immediate disposition of the condition. Decisions must be made regarding the on- site management of the injury.  DISPOSITION Information gathered during the Other conditions that are not necessarily assessment must be analyzed life-threatening, but serious enough to and decisions made based on warrant referral to a physician for the best interests of the injured immediate care, include individual. It is especially Eye injuries important to determine whether Dental injuries in which a tooth has been the situation can be handled knocked loose or knocked out on-site or referral to a physician Minor or simple fractures is warranted. Lacerations that might require suturing Injuries in which a functional deficit is noticeable Loss of normal sensation Noticeable muscular weakness in the extremities VII. Emergency Conditions Obstructed Airway Cardiopulmonary Emergencies Unconscious Individual Shock Anaphylaxis Hemorrhage  OBSTRUCTED AIRWAY The airway can become partially or totally blocked by a solid foreign object, swelling in the throat caused by allergic reactions, or, more commonly, the back of the tongue. An obstructed airway prevents adequate oxygen from being exchanged in the lungs and can lead to cyanosis and death.  OBSTRUCTED AIRWAY Partial Airway Obstruction When a person has a partial airway obstruction, there is still some air exchange in the lungs. Signs and Symptoms The individual is able to cough. The individual typically grasps the throat in the universal distress signal for choking. Management If the individual is able to cough forcefully, there should be no action taken by the coach other than to encourage the individual to continue coughing in an attempt to dislodge the obstruction. An ineffective cough or a high-pitched noise during breathing indicates poor air exchange and should be treated as a total airway obstruction.  OBSTRUCTED AIRWAY Total Airway Obstruction In a total airway obstruction, no air is passing through the vocal cords. Signs and Symptoms The individual is unable to speak, breathe, or cough. In a conscious person, the universal distress signal is usually apparent. Management The Heimlich maneuver is used to dislodge the foreign object so breathing may resume. How- ever, if the individual becomes unconscious, the coach must react quickly to clear the airway and stimulate the breathing process.  CARDIOPULMONARY EMERGENCIES Cardiac arrest can result from strenuous physical activity in a dehydrated state, direct trauma, electrical shock, excessive alcohol or other chemical substance abuse, suffocation, drowning, or heart anomalies. Sudden cardiac death (SCD) has been termed the “silent killer.” It is defined as an unexpected death, owing to sudden cardiac arrest within 6 hours of an otherwise normal clinical healthy state. CARDIOPULMONARY EMERGENCIES Management The emergency plan should be activated, including summoning of EMS. While waiting for EMS to arrive, the coach should monitor the individual’s airway, breathing, and circulation. As necessary, the coach should perform rescue breathing and CPR.  UNCONSCIOUS INDIVIDUAL While unconsciousness can be attributed to a variety of causes (e.g., medication overdose; diabetic coma; seizure), head injuries are the leading cause of loss of consciousness in sport activity Signs and Symptoms Unconsciousness identifies an individual who lacks conscious awareness and is unable to respond to superficial sensory stimuli. Management The coach must proceed on the basis that an unconscious individual has a life-threatening condition that requires an immediate primary survey and, as appropriate, continue with an assessment of vital signs  SHOCK Shock occurs if the heart is unable to exert adequate pressure to circulate enough oxygenated blood to the vital organs. This condition may result from a damaged heart that fails to pump properly, low blood volume from blood loss or dehydration, or dilation of blood vessels that leads to blood pooling in larger vessels away from vital areas. Management The emergency action plan should be activated, including summoning EMS. While waiting for EMS to arrive, the coach should maintain the airway, control any bleeding, and maintain normal body temperature. If a head or neck injury is not suspected, the feet and legs should be elevated 8 to 12 inches.  ANAPHYLAXI Anaphylaxis is a severe S allergic reaction that affects the entire body. Commonly known substances that cause anaphylaxis in hypersensitive individuals include Medications Food and food additives Insect stings Management Inhaled substances Monitor the individual’s airway, breathing, and Radiographic dyes circulation and perform rescue breathing and CPR, as necessary. If the individual has medication, such as a self-administered epinephrine device (EpiPen), it should be administered immediately.  HEMORRHAG E Severe hemorrhage causes a decrease in blood volume and blood pressure. In an attempt to compensate for this factor, the heart’s pumping action must increase. Because there is less blood in the system, the strength of the pumping action is weakened, resulting in a characteristic rapid, weak pulse.  HEMORRHAG Signs and Symptoms E Arterial bleeding from an oxygen-rich vessel is characterized by a spurting, bright red color. Major arteries, when completely severed, often constrict and seal themselves for a short period. Management External bleeding is best controlled with direct pressure and elevation. Using universal safety precautions Pressure is applied directly over the wound with a sterile gauze pad, compressing the region against the underlying bone. Elevation uses gravity to reduce blood pressure, and in doing so, aids blood clotting. VIII. Cranial, Facial and Spinal Conditions Facial Anatomy Head Anatomy Nerves of the Head and Face Blood Vessels of the Head and Face Protective Equipment for the Head and Face Head Injuries Facial Injuries Anatomy of the Spine Kinematics and Major Actions of the Spine Anatomical Variations Predisposing Individuals to Spinal Conditions Prevention of Spinal Conditions Cervical Spine Conditions Brachial Plexus Injury Thoracic Spine Injuries Lumbar Spine Conditions Sacrum and Coccyx Conditions The Coach and On-Site Assessment of an Acute Spinal Condition HEAD ANATOMY This review of anatomy focuses on the bones of the skull, the brain and its coverings, the 12 cranial nerves that emerge from the brain stem, and the arterial blood vessels that nourish the skull. A basic understanding of this anatomy can help the coach understand the reasons for particular signs and symptoms occurring with damage to specific anatomic structures of the region. HEAD ANATOMY The skull is primarily composed of flat bones that interlock at immovable joints called sutures. The bones that form the portion of the skull known as the cranium protect the brain. The facial bones provide the structure of the face and form the sinuses, orbits of the eyes, nasal cavity, and mouth. The large opening at the base of the skull that sits atop the spinal column is called the foramen magnum. HEAD ANATOMY The Scalp The scalp is the outermost anatomical structure of the cranium. The scalp is composed of three layers: the skin, subcutaneous connective tissue, and pericranium. The protective function of these tissues is enhanced by the hair and looseness of the scalp, which enables some dissipation of force when the head sustains a glancing blow. HEAD ANATOMY The Brain The four major regions of the brain are the cerebral hemispheres, diencephalon, brainstem, and cerebellum. The entire brain and spinal cord are enclosed in three layers of protective tissue collectively known as the meninges. The outermost membrane is the dura mater, a thick, fibrous tissue containing dural sinuses that act as veins to transport blood from the brain to the jugular veins of the neck.  FACIAL ANATOMY The Bones of the Face In addition to protecting the brain, the facial skeleton provides the bony framework and protection for the eyes, nose, mouth, and ears. The primary bones of the face are the mandible, maxilla, frontal bone, nasal bones, and zygoma.  FACIAL ANATOMY The Eyes The eye is a hollow sphere, approximately 2.5 cm (1 in.) in diameter in adults. The anterior eye surface receives protection from the eyelids, eyelashes, and the attached conjunctiva. The conjunctiva lines the eyelids and the external surface of the eye, and secretes mucus to lubricate the external eye.  FACIAL ANATOMY The Nose The nose is composed of bone and hyaline cartilage. The roof is formed by the cribriform plate of the ethmoid bone. The nasal bones form the bridge of the nose. The nasal cavity is separated into right and left halves by the nasal septum, which is made of cartilage.  FACIAL ANATOMY The Ear The ear is divided into three major areas: the outer ear (auricle and external auditory canal), middle ear (tympanic membrane), and inner ear (labyrinth). Assisting the middle and inner ear in the process of hearing and equalizing pressure between the two areas is the eustachian tube, a canal that links the nose and middle ear.  FACIAL ANATOMY The Teeth The 20 primary teeth seen in children are replaced between the ages of 6 and 14 with 32 permanent teeth. The visible part of the tooth is the crown. It lies almost entirely above the exposed gum line. The nonvisible root serves to anchor the tooth into the bone.  NERVES OF THE HEAD AND FACE Twelve pairs of cranial nerves emerge from the brain, some with motor functions, some with sensory function, and some with both. Knowledge of their function is important in assessing a cranial injury. The cranial nerves are numbered and named according to their functions  BLOOD VESSELS OF THE HEAD AND FACE The major vessels supplying the head and face are the common carotid and vertebral arteries. The common carotid artery ascends through the neck on either side to divide into the external and internal carotid artery just below the level of the jaw. The external carotid arteries and their branches supply most regions of the head external to the brain. PROTECTIVE EQUIPMENT FOR THE HEAD AND FACE Protective equipment, when used properly, can protect the head and facial area from accidental or routine injuries. It is important to recognize that protective equipment cannot prevent all injuries. Protective equipment may include a Helmet Face guard Mouth guard Eye wear Ear wear Throat protector.  HEAD INJURIES Scalp Injury As the outermost anatomical structure of the cranium, the scalp is the first area of contact in trauma. The scalp is highly vascular and bleeds freely, making it a frequent site for abrasions, lacerations, contusions, or hematomas between the layers of tissue. The primary concerns with any scalp laceration are to control bleeding, prevent contamination, and assess for a possible skull fracture.  HEAD Skull Fracture INJURIES A fracture or intracranial injury of the skull depends on the material properties of the skull, thickness of the skull in the specific area of impact, magnitude and direction of the sustained force, and size of the impact area. The bone deforms and bends inward, placing the inner border of the skull under tensile strain, whereas the outer border is placed in compression.  CEREBRAL INJURIES The impact can cause a shock wave to pass through the skull to the brain, causing acceleration. This acceleration can lead to shear, tensile, and compression strains within the brain substance. Shear is the most serious type of strain.  CEREBRAL Focal Cerebral InjuriesINJURIES Hematomas are classified as Focal cerebral injuries usually result in a localized collection of Epidural (outside the dura mater) blood or hematoma because the skull has no room for additional Subdural (deep to the dura mater) accumulation of blood or fluid, any additional foreign matter Cerebral contusion there is no within the cranial cavity mass-occupying lesion increases pressure on the brain, associated with this condition. leading to significant alterations in neurologic function.  CEREBRAL INJURIES Epidural Hematoma An epidural hematoma is very rare in sport or recreational physical activity. Typically, the condition is caused by a direct blow to the side of the head and is almost always associated with a skull fracture.  CEREBRAL INJURIES Subdural Hematoma A subdural hematoma is approximately three times more frequent than an epidural hematoma, and is the leading cause of catastrophic death in football players. Hemorrhaging occurs when the bridging veins between the brain and the dura mater are torn  CEREBRAL INJURIES Cerebral Contusion A cerebral contusion is a focal injury, but a mass-occupying lesion is not present. Instead, micro hemorrhaging, cerebral infarction, necrosis, and edema of the brain occur. Cerebral contusions occur most often from an acceleration-deceleration mechanism from the inward deformation of the skull at the impact site.  Diffuse Cerebral Conditions Diffuse cerebral injuries Common diffuse cerebral injuries involve trauma to widespread include areas of the brain rather than Concussion, one specific site. The range of Posttraumatic headaches, these injuries can vary from Post concussion syndrome, mild to severe, involving impairment of neural function, Second-impact syndrome structural damage, or both.  Diffuse Cerebral Conditions What is a Concussion? A concussion is a disturbance in brain function caused by a direct blow to the head or an indirect force that produces a violent jarring of the brain. The injury may cause an immediate and transient impairment of neural function, such as alteration of consciousness and disturbance of vision and equilibrium.  Diffuse Cerebral Posttraumatic Conditions headaches can be confused with a simple concussion or post concussive headache. A vascular headache is a result of vasospasm and does not usually occur with impact but, rather, develops shortly afterward. Post concussion syndrome may develop after any concussion. Cognitive impairments may extend from the time of injury to 48 hours after trauma and last for several weeks to months. Second impact syndrome occurs when an individual who has sustained an initial head injury, usually a concussion, sustains a second head injury before the symptoms associated with the previous one have totally resolved.  The Coach and Concussion The primary responsibility of the coach is to recognize potential signs and symptoms of a concussion. It is not the responsibility of the coach to determine the level of a concussion, but rather to note the presence of any signs and/or symptoms that could be indicative of a concussion. The initial assessment should take place immediately following the trauma and should be repeated at regular intervals (i.e., 5 to 10 minutes) until the symptoms have resolved or the individual is released to the care of someone else.  FACIAL INJURIES Eye Injuries The eyes are exposed daily to potential trauma and injury. Trauma can range in severity from mild to severe with complications. The coach should be able to recognize “red flags” that indicate a potentially serious injury that warrants immediate referral to an appropriate healthcare provider  FACIAL INJURIES Nasal Injuries The nose can be vulnerable to injury during sports and physical activity that involve contact and do not require facial protection.  FACIAL INJURIES Facial Injuries Injuries to the cheek, nose, lips, and jaw are common in sports and physical activities with moving projectiles e.g., racquets, bats, or balls), in contact sports (e.g., football, rugby, or ice hockey), or in sports involving collisions with objects (e.g., diving, skiing, hockey, or swimming).  FACIAL INJURIES Oral and Dental Injuries Any force great enough to cause a tooth fracture or loose teeth can also cause a jaw fracture or even a concussion. Therefore, an assessment of the individual’s overall condition should be conducted to ensure that one is only dealing with an isolated tooth injury.  FACIAL INJURIES Ear Injuries Several conditions can affect the ear. Except for boxing, wrestling, and water polo, specialized ear protection is uncommon.  ANATOMY OF THE SPINE Vertebral Column The five regions of the spine— namely, the cervical, thoracic, lumbar, sacral, and coccygeal regions—are structurally and functionally distinct.  ANATOMY OF THE SPINE Intervertebral Discs Fibrocartilaginous discs provide cushioning between the articulating vertebral bodies. In the intervertebral disc, a thick ring of fibrous cartilage, the annulus fibrosus, surrounds a gelatinous mate- rial known as the nucleus pulposus. The discs have a dual function: they serve as shock absorbers and allow the spine to bend  Ligaments Some ligaments (e.g., anterior and posterior longitudinal ligaments) connect the vertebral bodies of the motion segments; whereas, the supraspinous ligament attaches to the spinous processes throughout the length of the spine. The lumbar spine also contains several ligaments (e.g., iliolumbar ligaments, posterior SI ligament) that are responsible for maintaining its articulation with the sacrum.  Muscles The muscles of the neck and trunk are paired, with one on the left and one on the right side of the body. These muscles produce lateral flexion and/or rotation of the trunk when they act unilaterally and trunk flexion or extension when they act bilaterally.  Spinal Cord and Spinal Nerves The spinal cord serves as the A bundle of spinal nerves major neural pathway for extends downward through the conducting sensory impulses to vertebral canal from the end of the brain and motor impulses from the spinal cord at the L1 to L2 the brain. It also provides direct level. This nerve bundle is known connections between sensory and collectively as the cauda equina. motor nerves inside the cord, enabling reflex activity.  Blood Vessels The largest blood vessels coursing through the neck are the common carotid arteries. The common carotid arteries divide into external and internal carotid arteries, which provide the major blood supply to the brain, head, and face. The vertebral arteries, which are located in the posterior neck, are a source of blood supply for the spinal cord.  KINEMATICS AND MAJOR ACTIONS OF THE SPINE Kinematics is the study of spatial and temporal aspects of motion, which translates to movement, form, or technique. Evaluation of the kinematics of a particular movement can provide information about timing and sequencing of movement, which can then yield important clues for injury prevention. KINEMATICS AND MAJOR ACTIONS OF THE SPINE Flexion, Extension, and Hyperextension Spinal flexion is anterior bending of the spine in the sagittal plane, Extension being the return to anatomical position from a position of flexion. When the spine is extended backward past anatomical position in the sagittal plane, the motion is termed hyperextension. KINEMATICS AND MAJOR ACTIONS OF THE SPINE Movement of the spine away Rotation, which is from anatomical position in a movement around the lateral direction in the frontal longitudinal axis, plane is termed lateral flexion. produces a turning of the spine to the side (right or left).  ANATOMICAL VARIATIONS PREDISPOSING INDIVIDUALS TO SPINAL CONDITIONS Excessive spinal curvatures can be congenital or acquired. Regardless of their cause, these conditions can be predisposing factors in the development of injuries or conditions related to the spine. Injuries or conditions related to the spine. Kyphosis Scoliosis Lordosis  ANATOMICAL VARIATIONS PREDISPOSING INDIVIDUALS TO SPINAL CONDITIONS Kyphosis Accentuation of the thoracic curve is called kyphosis. The cause of kyphosis can be congenital, idiopathic (unknown), or secondary to osteoporosis. Congenital kyphosis arises from deficits in the formation of either the vertebral bodies or the anterior and posterior vertebral elements.  ANATOMICAL VARIATIONS PREDISPOSING INDIVIDUALS TO SPINAL CONDITIONS Scoliosis Lateral curvature of the spine is known as scoliosis. The lateral deformity, coupled with rotational deformity of the involved vertebrae, may range from mild to severe. Scoliosis may appear as either a “C” or an “S” curve involving the thoracic spine, lumbar spine, or both.  ANATOMICAL VARIATIONS PREDISPOSING INDIVIDUALS TO SPINAL CONDITIONS Lordosis Abnormal exaggeration of the lumbar curve, or lordosis, is often associated with weakened abdominal muscles in combination with tight muscles, especially the hip flexors, tensor fasciae latae, and deep lumbar extensors  PREVENTION OF SPINAL CONDITIONS Although most of the load on the spine is borne by the vertebral bodies and discs, the facet joints assist with some load bearing. Protective equipment can prevent some injuries to the cervical and thoracic regions. However, physical conditioning plays a more important role in preventing injuries to the overall region. PREVENTION OF SPINAL CONDITIONS Physical Conditioning Protective Equipment Proper Skill Technique  PREVENTION OF SPINAL CONDITIONS Physical Conditioning Strengthening of the back muscles is imperative to stabilize the spinal column. Strengthening exercises for the cervical region may involve isometric contractions, manual resistance, or weight training with free weights or specialized machines.  PREVENTION OF SPINAL CONDITIONS Protective Equipment Several pieces of equipment can be used to protect the spine. In the cervical region, a neck roll or posterolateral pad made of a high, thick, and stiff material can be attached to shoulder pads to limit excessive motion of the cervical spine, and has been shown to reduce the incidence of repetitive burners and stingers.  PREVENTION OF SPINAL CONDITIONS Proper Skill Technique Proper skill technique is vital in preventing spinal injuries. Helmets are designed to protect the cranial region from injury, but do not prevent axial loading on the cervical spine. It is critical that proper techniques be taught and reinforced in an effort to reduce the potential for injury.  CERVICAL SPINE CONDITIONS The relatively small size of the cervical vertebrae, combined with the nearly horizontal orientation of the cervical facet joints, makes the cervical spine the most mobile region of the spinal column. As such, this area is especially vulnerable to injury. The major concern with cervical injuries is the potential involvement of the spinal cord and nerve roots. Cervical Injures Includes: Acute Torticollis Cervical Strains Cervical Sprains Cervical Fractures and Dislocations  CERVICAL SPINE CONDITIONS Acute torticollis, commonly referred to as “wry neck,” as a result of a muscular strain often follows exposure to cold air currents or occasionally sleeping with the neck in an abnormal position, which leads to painful tender cervical muscles. However, any trauma involving the cervical spine can present with torticollis.  CERVICAL SPINE CONDITIONS Cervical strains usually involve the sternocleidomastoid or upper trapezius, although other muscles may be involved. Strains can occur as a result of direct or indirect trauma associated with a tension force.  CERVICAL SPINE CONDITIONS Cervical Sprains The same mechanisms that cause cervical strains also lead to cervical sprains. However, the mechanism for a sprain tends to be more violent in nature. Injury can occur to any of the major ligaments traversing the cervical spine, as well as to the capsular ligaments surrounding the facet joints. It should be noted that a cervical sprain and strain can occur simultaneously.  CERVICAL SPINE CONDITIONS Cervical fractures and dislocations can result from the axial loading and violent neck flexion. This mechanism can be seen in unsafe practices, such as diving into shallow water, spearing in football, or landing on the posterior neck during gymnastics or trampoline activities.  BRACHIAL PLEXUS INJURY The brachial plexus is typically damaged in two ways. A “stretch injury” can occur when the head is forced laterally away from the shoulder while the shoulder is simultaneously forced downward, such as when an individual is tackled and subsequently rolls onto the shoulder with the head turned to the opposite side. A stretch injury can also occur when the arm is forced into excessive external rotation, abduction, and extension.  BRACHIAL PLEXUS INJURY Acute symptoms involve an immediate, severe, burning pain that radiates from the clavicular area down the arm into the hand, hence the nickname “burner” or “stinger.” Pain is usually transient and subsides in 5 to 10 minutes, but tenderness over the supraclavicular area and shoulder weakness may persist for hours or days after the injury. The individual often tries to shake the arm to “get the feeling back.” Muscle weakness is evident in shoulder abduction and external rotation Management When weakness is present, the individual should be removed from activity. If strength and function return completely in 1 to 2 minutes, the individual can return to play. If any neurologic symptoms persist after this time, the individual should not be allowed to return to play until evaluated by a physician.  THORACIC SPINE INJURIES The protective rib cage serves to limit movement in the thoracic motion segments. However, the thoracolumbar junction is a region of potentially high stress during flexion-extension movements of the trunk. Injuries to this area may include Contusions Strains Sprains Fractures and Apophysitis  THORACIC SPINE INJURIES Contusions Direct blows to the back during contact sports frequently yield contusions to the muscles in the thoracic region. Contusions can range in severity but are generally characterized by pain, ecchymosis, spasm, and limited swelling.  THORACIC SPINE INJURIES Thoracic Strains and Sprains Thoracic sprains and strains result from either overloading or overstretching muscles in the region through violent or sustained muscle contractions. Painful spasms of the back muscles serve as a protective mechanism to immobilize the injured area, and they may develop as a sympathetic response to a sprain.  THORACIC SPINE INJURIES Thoracic Spinal Fractures and Apophysitis Thoracic fractures tend to be concentrated at the lower end of the thoracic spine in the transition region between the thoracic and lumbar curvatures. Large com- pressive loads, such as those sustained during heavy weight lifting, head-on contact in football or rugby, or landing on the buttock area during a fall, can fracture the vertebral end plates or lead to a wedge fracture, named after the shape of the deformed vertebral body.  LUMBAR SPINE CONDITIONS Lumbar Strains and Sprains An estimated 75 to 80% of the population experiences Low back pain stemming from mechanical injury to muscles, ligaments, or connective tissue. Although Low Back Pain typically strikes adults, nearly 30% of children experience Low back pain, up to the age of 16.  LUMBAR SPINE CONDITIONS Low Back Pain in Runners Many runners develop muscle tightness in the hip flexors and hamstrings. Tight hip flexors tend to produce a forward body lean, leading to anterior pelvic tilt and hyperlordosis of the lumbar spine. Because the lumbar muscles develop tension to counteract the forward bending moment of the entire trunk when the trunk is in flexion, these muscles are particularly susceptible to strain.  LUMBAR SPINE CONDITIONS Sciatica is not considered a condition in and of itself, but rather a set of symptoms attributed to a condition that compresses or irritates the sciatic nerve. Possible conditions include a herniated disc, annular tear, muscle-related disease, spinal stenosis, facet joint disease, and piriformis syndrome.  LUMBAR SPINE CONDITIONS Disc Injuries Prolonged mechanical loading of the spine can lead to micro ruptures in the annulus fibrosus, resulting in degeneration of the disc. Bulging or protruded discs refer to some eccentric accumulation of the nucleus with slight deformity of the annulus.  LUMBAR SPINE CONDITIONS Lumbar Fractures and Dislocations Transverse or spinous process fractures result from extreme tension from the attached muscles or from a direct blow to the low back during participation in contact sports, such as football, rugby, soccer, basketball, hockey, and lacrosse. These fractures often lead to additional injury to surrounding soft tissues, but are not as serious as compression fractures.  SACRUM AND COCCYX CONDITIONS Because the sacrum and coccyx are essentially immobile, the potential for mechanical injury to these regions is dramatically reduced. In many cases, injuries result from direct blows and stress on the Sacroiliac joint.  SACRUM AND COCCYX CONDITIONS Sacroiliac Joint Sprain Sprains of the Sacroiliac Joint may result from a single traumatic episode involving bending and/or twisting, repetitive stress from lifting, a fall on the buttocks, excessive side-to-side or up-and- down motion during running and jogging. The injury may irritate or stretch the sacrotuberous or sacrospinous ligament, or may lead to an anterior or posterior rotation of one side of the pelvis relative to the  SACRUM AND COCCYX CONDITIONS Coccygeal Conditions Direct blows to the region can produce contusions and fractures of the coccyx. Injury to the coccyx results in localized pain and tenderness to the area. The pain typically increases as a result of sitting, especially for prolonged periods of time, or when direct pressure is applied to the area. Pain resulting from a fracture may last for several months.  THE COACH AND ON-SITE ASSESSMENT OF AN ACUTE SPINAL CONDITION As such, the coach should begin with the As with other on-site injury following questions: assessments, it begins as the What happened? coach is approaching the Where is your pain? individual. The focus should be on observing the individual’s Are you experiencing any neck or back pain? overall presentation and attitude, with a particular focus Are you having any difficulty breathing or swallowing? on their willingness or ability to move. It may also be necessary Are you experiencing any unusual sensations in your arms or legs? for the coach to control any Can you wiggle your fingers? scene around the individual. Can you gently squeeze my hand? Can you gently push your foot against my hand?  Anatomy IX. Throat,ReviewThorax, of the Throatand Visceral Conditions Anatomy Review of the Thorax Anatomy Review of the Visceral Region Prevention of Injuries to the Throat, Thorax, and Viscera Throat Conditions Thoracic Conditions Internal Complications Abdominal Wall Conditions Intra-Abdominal Conditions The Coach and On-Site Assessment of the Throat, Thorax, and Abdominal Regions  ANATOMY REVIEW OF THE THROAT The throat includes the pharynx, larynx, trachea, esophagus, a number of glands, and several major blood vessels. Injuries to the throat are of particular concern because of the life-sustaining functions of the trachea and carotid arteries.  Pharynx, Larynx, and Esophagus The pharynx, commonly known as the throat, connects the nasal cavity and mouth to the larynx and esophagus. larynx is known as the “Adam’s apple.” A specialized spoon-shaped cartilage, the epiglottis, covers the superior opening of the larynx during swallowing to prevent food and liquids from entering. The esophagus carries food and liquids from the throat to the stomach. It is a muscle- walled tube that originates from the pharynx in the mid-neck and follows the anterior side of the spine  Trachea The trachea extends inferiorly from the larynx through the neck into the midthorax, where it divides into the two right and left bronchial tubes. The tracheal tube is formed by C- shaped rings of hyaline cartilage joined by fibroelastic connective tissue.  Blood Vessels of the Throat The largest blood vessels coursing through the neck are the common carotid arteries. The common carotid arteries, which provide the major blood supply to the brain, head, and face, divide into external and internal carotid arteries at the level of the “Adam’s apple.”  ANATOMY REVIEW OF THE THORAX The thoracic cavity, or chest cavity, lies anterior to the spinal column and extends from the level of the clavicle down to the diaphragm. The bones of the thorax, including the sternum, ribs and costal cartilages, and thoracic vertebrae form a protective cage around the heart and lungs  ANATOMY REVIEW OF THE VISCERAL REGION The visceral region includes the organs and vessels between the diaphragm and pelvic floor. The region contains both solid and hollow organs. The solid organs include the spleen, liver, pancreas, kidneys, and adrenal glands. The hollow organs include the stomach, gall bladder, small and large intestines, bladder, and ureters. The pelvic girdle protect the lower abdominal organs.  ANATOMY REVIEW OF THE VISCERAL REGION Visceral Organs The stomach is a J-shaped bag positioned between the esophagus and small intestine. Food is stored in the stomach for approximately 4 hours, during which time it is broken down by hydrochloric acid secreted in the stomach into a paste-like substance known as chyme. The chyme moves into the small intestine where it is progressively absorbed.  ANATOMY REVIEW OF THE VISCERAL Muscles of the Trunk REGION As is the case throughout the neck and trunk, muscles in the pelvic region are named in pairs, with one located on the left and the other on the right side of the body. These muscles cause lateral flexion or rotation when they contract unilaterally, but contribute to spinal flexion or extension when bilateral contractions occur ANATOMY REVIEW OF THE VISCERAL REGION Blood Vessels of the Trunk The major blood vessel of the trunk is the aorta, with its numerous branches. The left and right coronary arteries branch from the ascending aorta to supply the heart muscle.  PREVENTION OF INJURIES TO THE THROAT, THORAX, AND VISCERA Injuries to the throat, thorax, and abdomen occur in nearly every sport, yet few sports require protective equipment for all players. In sports where high-velocity projectiles are present, throat and chest protectors are required only for specific players’ positions (i.e., a catcher or goalie). As with other body regions, protective equipment, in combination with a well-rounded physical conditioning program, can reduce the risk of injury. Although proper skill technique can prevent some injuries, this is not a major factor in this region.  PREVENTION OF INJURIES TO THE THROAT, THORAX, AND VISCERA Protective Equipment Face masks with throat protectors are required for participants in some sports (e.g., baseball/softball catchers, field hockey, ice hockey, and lacrosse goalies). In many cases, an extended pad is attached to the mask to protect the throat region. PREVENTION OF INJURIES TO THE THROAT, THORAX, AND VISCERA Physical Conditioning Flexibility and strengthening of the torso muscles should not be an isolated program, but should include a well-rounded conditioning program for the back, shoulder, abdomen, and hip regions. Range of motion (ROM) and strengthening exercises should include both open and closed kinetic chain activities  THROAT CONDITIONS Neck Lacerations Although uncommon, lacerations to the neck can occur. If the trauma is sufficiently deep, it can damage the jugular vein or carotid artery on the lateral side of the neck. Immediate control of hemorrhage is imperative. In addition to blood loss, air may be sucked into the vein and carried to the heart as an air embolism. Such an embolism can be fatal.  THROAT CONDITIONS Contusions and Fractures Contusions and fractures to the trachea, larynx, and hyoid bone can occur during hyperextension of the neck. In this position, the thyroid cartilage (Adam’s apple) becomes prominent and vulnerable to direct impact forces. In rare instances, these injuries can be fatal as a result of the extravasation of blood into the laryngeal tissues leading to airway edema and asphyxia resulting from obstruction.  THORACIC CONDITIONS THORACIC CONDITIONS Thoracic injuries are frequently caused by sudden deceleration and impact, which can lead to compression and subsequent deformation of the rib cage. The extent of damage depends on the direction, magnitude of force, and point of impact Stitch in the Side THORACIC CONDITIONS A “stitch in the side” refers to a sharp pain or spasm in the chest wall, usually on the lower right side, during exertion Breast Conditions Excessive breast motion during activity can lead to soreness, contusions, and nipple irritation. Although breast conditions are usually associated with females, men may also experience these conditions. Strain of the Pectoralis Major Muscle Pectoralis major muscle strains can occur in a variety of activities, including power lifting, particularly while bench pressing, boxing, wrestling. The mechanism of injury is usually indirect, resulting from extreme muscle tension.  THORACIC CONDITIONS Costochondral Injury Costochondritis and costochondral sprains may occur during a collision with another object or as a result of a severe twisting motion of the thorax, such as during the sweep motion in rowing. Sternal Fractures The sternum is rarely fractured in sports, but may occur as a result of rapid deceleration and high impact into an object, or acute flexion that causes the upper fragment to displace anteriorly over the lower fragment. Rib Fractures Stress fractures to the ribs can result from an indirect force, such as a violent muscle contraction. They typically occur at the rib’s weakest point (i.e., where it changes direction or has the smallest diameter).  INTERNAL COMPLICATIONS Hyperventilation Hyperventilation is often linked to pain, stress, or trauma in sport participation. The respiratory rate increases during activity. Pneumothorax, Hemothorax, and Tension Pneumothorax Three lung conditions—pneumothorax, hemothorax, and tension pneumothorax— can lead to a life-threatening situation. In pneumothorax, a fractured rib is the leading cause. When lung tissue is lacerated, air escapes into the pleural cavity with each inhalation and prevents the lung from fully expanding In hemothorax the fractured rib tears lung tissue and blood vessels in the chest or chest cavity. In tension pneumothrax, air progressively accumulates in the pleural space around the injured lung during inspiration and cannot escape on expiration.  INTERNAL COMPLICATIONS Heart Injuries Blunt chest trauma can compress the heart between the sternum and spine, leading to blunt cardiac injury (formally called myocardial contusion). Red blood cells and fluid leak into the sur- rounding tissues and, in doing so, decreases circulation to the heart muscle. Sudden Death in Athletes Sudden death is defined as an event that is nontraumatic, unexpected, and occurs instantaneously or within minutes of an abrupt change in an individual’s previous clinical state. While hypertrophic cardiomyopathy is the most common cause of sudden cardiac death  ABDOMINAL WALL CONDITIONS The muscles of the abdominal wall are strong and powerful, yet flexible enough to absorb impact. Consequently, injuries to the abdominal wall usually are minor. However, other conditions, such as a contusion to the solar plexus and hernias, can affect sport participation.  ABDOMINAL WALL CONDITIONS Muscle Strains Muscle strains are caused by sudden twisting or sudden hyperextension of the spine. The rectus abdominis is the most commonly injured muscle. Complications arise when the epigastric artery or intramuscular vessels are damaged, leading to a rectus sheath hematoma.  ABDOMINAL WALL CONDITIONS Solar Plexus Contusion (“Wind Knocked Out”) A blow to the abdomen with the muscles relaxed is referred to as a “solar plexus punch ” Although the true cause of the breathing difficulty is unknown, it is thought to be caused by diaphragmatic spasm and transient contusion to the sympathetic celiac plexus.  ABDOMINAL WALL CONDITIONS Hernia A hernia is a protrusion of abdominal viscera through a weakened portion of the abdominal wall and typically occurs in or just above the groin  INTRA-ABDOMINAL CONDITIONS Trauma to the abdomen can lead to severe internal hemorrhage if organs or major blood vessels are lacerated or ruptured. Injuries can be open or closed, with closed injuries typically caused by blunt trauma.  INTRA-ABDOMINAL CONDITIONS Splenic Rupture Although rarely injured in sport participation, certain systemic disorders, such as infectious mononucleosis, can enlarge the spleen, making it vulnerable to injury. The spleen is the most commonly injured abdominal organ and is the most frequent cause of death from abdominal blunt trauma in sport.  INTRA-ABDOMINAL CONDITIONS Liver Contusion and Rupture A direct blow to the upper right quadrant can contuse the liver. As with the spleen, systemic diseases, such as hepatitis, can enlarge the liver, making it more susceptible to injury. An individual with an enlarged liver (i.e., hepatomegaly) should avoid contact sports until the liver has returned to its normal size or is nonpalpable.  THE COACH AND ON-SITE ASSESSMENT OF THE THROAT, THORAX, AND ABDOMINAL Injury assessment should focus on the primary survey, history of the injury, and assessment of vitalREGIONS signs. Chest or abdominal trauma, although initially