1. © 2010 McGraw-Hill Higher Education. All rights reserved. Chapter 13: Recognizing Different Sports Injuries

2. © 2010 McGraw-Hill Higher Education. All rights reserved. Injuries No matter how much time is spent on injury prevention sooner or later an injury occurs No matter how much time is spent on injury prevention sooner or later an injury occurs Either acute or chronic in nature Either acute or chronic in nature Acute injuries Acute injuries Result of macrotrauma Result of macrotrauma Athlete knows when injury occurred Athlete knows when injury occurred Chronic Chronic Caused by repetitive, overuse activities Caused by repetitive, overuse activities Multiple microtraumas Multiple microtraumas

3. © 2010 McGraw-Hill Higher Education. All rights reserved. Fractures Result of extreme stress and strain on bone Result of extreme stress and strain on bone Anatomical Characteristics Anatomical Characteristics Dense connective tissue matrix Dense connective tissue matrix Outer compact tissue Outer compact tissue Inner porous cancellous bone including Haversian canals Inner porous cancellous bone including Haversian canals

4. © 2010 McGraw-Hill Higher Education. All rights reserved. Bone Structure Diaphysis Diaphysis shaft - hollow and cylindrical shaft - hollow and cylindrical covered by compact bone covered by compact bone Epiphysis Epiphysis composed of cancellous bone composed of cancellous bone has hyaline cartilage covering has hyaline cartilage covering Periosteum Periosteum dense, white fibrous covering which penetrates bone via Sharpey’s fibers dense, white fibrous covering which penetrates bone via Sharpey’s fibers contains blood vessels and osteoblasts contains blood vessels and osteoblasts

5. © 2010 McGraw-Hill Higher Education. All rights reserved. Acute Fractures Partial or complete disruption that can be either closed or open (through skin) Partial or complete disruption that can be either closed or open (through skin) Serious musculoskeletal condition Serious musculoskeletal condition Presents with deformity, point tenderness, swelling and pain on active and passive motion Presents with deformity, point tenderness, swelling and pain on active and passive motion

6. © 2010 McGraw-Hill Higher Education. All rights reserved. Load Characteristics of Fractures Bones can be stressed or loaded to fail by tension, compression, bending, twisting and shearing Bones can be stressed or loaded to fail by tension, compression, bending, twisting and shearing Either occur singularly or in combination Either occur singularly or in combination Amount of load also impacts the nature of the fracture Amount of load also impacts the nature of the fracture More force results in a more complex fracture More force results in a more complex fracture While force goes into fracturing the bone, energy and force is also absorbed by adjacent soft tissues While force goes into fracturing the bone, energy and force is also absorbed by adjacent soft tissues Some bones will require more force than others Some bones will require more force than others

7. © 2010 McGraw-Hill Higher Education. All rights reserved. Healing of Fractures Generally require immobilization for some period Generally require immobilization for some period Approx. 6 weeks for bones of arms and legs Approx. 6 weeks for bones of arms and legs 3 weeks for bones of hands and feet 3 weeks for bones of hands and feet Fracture healing requires osteoblast activity to lay down bone and form callus Fracture healing requires osteoblast activity to lay down bone and form callus Following cast removal, normal stresses and strains will aid in healing and remodeling process Following cast removal, normal stresses and strains will aid in healing and remodeling process Osteoclasts will be called on to assist in re-shaping of bone in response to normal stress Osteoclasts will be called on to assist in re-shaping of bone in response to normal stress

8. © 2010 McGraw-Hill Higher Education. All rights reserved. Stress Fractures No specific cause but with a number of possible causes No specific cause but with a number of possible causes Overload due to muscle contraction, altered stress distribution due to muscle fatigue, changes in surface, rhythmic repetitive stress vibrations Overload due to muscle contraction, altered stress distribution due to muscle fatigue, changes in surface, rhythmic repetitive stress vibrations Begins with a dull ache and progressively becomes worse over time Begins with a dull ache and progressively becomes worse over time Initially pain during activity and then progresses to pain following activity Initially pain during activity and then progresses to pain following activity Early detection is difficult, bone scan is useful, x-ray is effective after several weeks Early detection is difficult, bone scan is useful, x-ray is effective after several weeks Due to osteoblastic activity Due to osteoblastic activity If suspected – stop activity for 14 days If suspected – stop activity for 14 days Generally do not require casting Generally do not require casting

9. © 2010 McGraw-Hill Higher Education. All rights reserved. Dislocations and Subluxations Dislocation Dislocation At least one bone in a joint is forced completely out of normal and proper alignment At least one bone in a joint is forced completely out of normal and proper alignment High level of incidence in fingers, elbow and shoulder High level of incidence in fingers, elbow and shoulder Subluxation Subluxation Partial dislocations causing incomplete separation of two bones Partial dislocations causing incomplete separation of two bones Often occur in shoulder and patella Often occur in shoulder and patella

10. © 2010 McGraw-Hill Higher Education. All rights reserved. Dislocations and Subluxations (cont’d.) S&S of dislocations S&S of dislocations Deformity – almost always present Deformity – almost always present Occasionally obscured by heavy musculature = requires palpation to determine normal contours Occasionally obscured by heavy musculature = requires palpation to determine normal contours Other factors associated with dislocations - 1) loss of limb function, 2) swelling and point tenderness Other factors associated with dislocations - 1) loss of limb function, 2) swelling and point tenderness Additional concerns Additional concerns Avulsion fractures Avulsion fractures Growth plate separation Growth plate separation “Once a dislocation, always a dislocation” “Once a dislocation, always a dislocation” Treatment Treatment Dislocations (particularly first time) should always be considered and treated as a fracture until ruled out Dislocations (particularly first time) should always be considered and treated as a fracture until ruled out X-ray is the only absolute diagnostic technique X-ray is the only absolute diagnostic technique Return to play often determined by extent of soft tissue damage Return to play often determined by extent of soft tissue damage

11. © 2010 McGraw-Hill Higher Education. All rights reserved. Sprains Damage to a ligament Damage to a ligament Ligaments provide support to a joint (connect bone to bone) Ligaments provide support to a joint (connect bone to bone) Synovial joint characteristics Synovial joint characteristics 2 or more bones 2 or more bones Capsule or ligaments Capsule or ligaments Capsule is lined with synovial membrane Capsule is lined with synovial membrane Hyaline cartilage Hyaline cartilage Joint cavity with synovial fluid Joint cavity with synovial fluid Blood and nerve supply with muscles crossing joint Blood and nerve supply with muscles crossing joint Mechanoreceptors within joint structures provide feedback relative to position Mechanoreceptors within joint structures provide feedback relative to position

12. © 2010 McGraw-Hill Higher Education. All rights reserved. Sprains (cont’d.) Some joints will have meniscus (thick fibrocartilage) for shock absorption and stability Some joints will have meniscus (thick fibrocartilage) for shock absorption and stability Ligaments Ligaments Thickened portions of the capsule or totally separate bands Thickened portions of the capsule or totally separate bands Plays some role in the motions the joint Plays some role in the motions the joint

13. © 2010 McGraw-Hill Higher Education. All rights reserved. Sprains (cont’d.) Result of traumatic joint twist that causes stretching or tearing of connective tissue Result of traumatic joint twist that causes stretching or tearing of connective tissue Graded based on the severity of injury Graded based on the severity of injury Grading System Grading System Grade I - some pain, minimal loss of function, no abnormal motion, and mild point tenderness, slight swelling and joint stiffness Grade I - some pain, minimal loss of function, no abnormal motion, and mild point tenderness, slight swelling and joint stiffness Grade II - pain, moderate loss of function, swelling, and instability, some tearing of ligament fibers and joint instability Grade II - pain, moderate loss of function, swelling, and instability, some tearing of ligament fibers and joint instability Grade III - extremely painful, inevitable loss of function, severe instability and swelling, and may also represent subluxation Grade III - extremely painful, inevitable loss of function, severe instability and swelling, and may also represent subluxation

14. © 2010 McGraw-Hill Higher Education. All rights reserved.

15. Sprains (cont’d.) Restoration of joint stability is difficult with grade I and II injuries Restoration of joint stability is difficult with grade I and II injuries Must rely on other structures around the joint Must rely on other structures around the joint Rely heavily on muscles surrounding joint Rely heavily on muscles surrounding joint Ligament has been stretched/partially torn causing development of inelastic scar Ligament has been stretched/partially torn causing development of inelastic scar Ligament will not regain original tension Ligament will not regain original tension Increased muscle tension due to strength training will improve joint stability Increased muscle tension due to strength training will improve joint stability

16. © 2010 McGraw-Hill Higher Education. All rights reserved. Contusions Often referred to as “bruise” Often referred to as “bruise” Result of sudden blow to body Result of sudden blow to body Can be deep or superficial Can be deep or superficial Hematoma results from blood and lymph flow into surrounding tissue Hematoma results from blood and lymph flow into surrounding tissue Minor bleeding results in discoloration of skin Minor bleeding results in discoloration of skin May be painful to the touch and with active movement May be painful to the touch and with active movement Must be cautious and aware of more severe injuries associated with repeated blows Must be cautious and aware of more severe injuries associated with repeated blows Calcium deposits may form with fibers of soft tissue Calcium deposits may form with fibers of soft tissue Myositis ossificans Myositis ossificans

17. © 2010 McGraw-Hill Higher Education. All rights reserved. Contusions (cont’d.) Prevention relies on protection and padding Prevention relies on protection and padding Particularly when dealing with myositis ossificans Particularly when dealing with myositis ossificans Protection and rest may allow for calcium re- absorption Protection and rest may allow for calcium re- absorption Surgery would not be necessary to remove Surgery would not be necessary to remove Quadriceps and biceps are very susceptible to developing myositis ossificans Quadriceps and biceps are very susceptible to developing myositis ossificans

18. © 2010 McGraw-Hill Higher Education. All rights reserved. Muscle Strains and Injuries Causes Causes Stretch, tear or rip to muscle or adjacent tissue (tendon) Stretch, tear or rip to muscle or adjacent tissue (tendon) Muscle Strain Grades Muscle Strain Grades Grade I - some fibers have been stretched or actually torn resulting in tenderness and pain on active ROM, movement painful but full range present Grade I - some fibers have been stretched or actually torn resulting in tenderness and pain on active ROM, movement painful but full range present Grade II - number of fibers have been torn and active contraction is painful, usually a depression or divot is palpable, some swelling and discoloration result Grade II - number of fibers have been torn and active contraction is painful, usually a depression or divot is palpable, some swelling and discoloration result Grade III- Complete rupture of muscle or musculotendinous junction, significant impairment, with initially a great deal of pain that diminishes due to nerve damage Grade III- Complete rupture of muscle or musculotendinous junction, significant impairment, with initially a great deal of pain that diminishes due to nerve damage

19. © 2010 McGraw-Hill Higher Education. All rights reserved. Treatment/Rehab of Strains Large tendon ruptures will require surgery Large tendon ruptures will require surgery Rehabilitation Rehabilitation Lengthy process regardless of severity Lengthy process regardless of severity Will generally require 6-8 weeks Will generally require 6-8 weeks Return to activity too soon may result in re-injury Return to activity too soon may result in re-injury

20. © 2010 McGraw-Hill Higher Education. All rights reserved. Muscle Guarding and Cramps Muscle Guarding Muscle Guarding Following injury, muscles within an effected area contract to splint the area in an effort to minimize pain through limitation of motion Following injury, muscles within an effected area contract to splint the area in an effort to minimize pain through limitation of motion Involuntary muscle contraction in response to pain following injury Involuntary muscle contraction in response to pain following injury Not spasm which would indicate increased tone due to upper motor neuron lesion in the brain Not spasm which would indicate increased tone due to upper motor neuron lesion in the brain Muscle Cramps Muscle Cramps Painful involuntary contraction Painful involuntary contraction Attributed to dehydration/electrolyte imbalance Attributed to dehydration/electrolyte imbalance May lead to muscle or tendon injuries May lead to muscle or tendon injuries

21. © 2010 McGraw-Hill Higher Education. All rights reserved. Muscle Soreness Overexertion in strenuous exercise results in muscular pain Overexertion in strenuous exercise results in muscular pain Generally occurs following participation in activity to which individual is unaccustomed Generally occurs following participation in activity to which individual is unaccustomed Two types of soreness Two types of soreness Acute-onset muscle soreness - accompanies fatigue, and is transient muscle pain experienced immediately after exercise Acute-onset muscle soreness - accompanies fatigue, and is transient muscle pain experienced immediately after exercise Delayed-onset muscle soreness (DOMS) - pain that occurs 24-48 hours following activity that gradually subsides (pain free 3-4 days later) Delayed-onset muscle soreness (DOMS) - pain that occurs 24-48 hours following activity that gradually subsides (pain free 3-4 days later) Potentially caused by slight microtraumas to muscle or connective tissue structures Potentially caused by slight microtraumas to muscle or connective tissue structures Also associated with lactic acid build up Also associated with lactic acid build up Prevent muscle soreness through gradual build-up of intensity Prevent muscle soreness through gradual build-up of intensity Treat with static or PNF stretching and ice application within 48- 72 hours of insult Treat with static or PNF stretching and ice application within 48- 72 hours of insult

22. © 2010 McGraw-Hill Higher Education. All rights reserved. Nerve Injuries Two main causes of injury Two main causes of injury Compression Compression Tension Tension Resulting in radiating pain & muscle weakness Resulting in radiating pain & muscle weakness Stinger or burner Stinger or burner May be acute or chronic May be acute or chronic Causes pain and can result in a host of sensory responses (pinch, burn, tingle, muscle weakness, radiating pain) Causes pain and can result in a host of sensory responses (pinch, burn, tingle, muscle weakness, radiating pain)

23. © 2010 McGraw-Hill Higher Education. All rights reserved. Nerve Injuries (cont’d.) Injuries can range from minor to severe and life altering Injuries can range from minor to severe and life altering Neuritis Neuritis Chronic nerve problem caused by overuse or a variety of forces Chronic nerve problem caused by overuse or a variety of forces Results in minor to severe problems Results in minor to severe problems Crushing or severed nerve injury Crushing or severed nerve injury Life long implications Life long implications Paraplegia/quadriplegia could result Paraplegia/quadriplegia could result Healing process is very slow and long term Healing process is very slow and long term Optimal environment is critical Optimal environment is critical CNS vs. PNS repair CNS vs. PNS repair

24. © 2010 McGraw-Hill Higher Education. All rights reserved. Chronic Overuse Injuries Inflammation is an essential part of healing process Inflammation is an essential part of healing process Must occur following tissue damage to initiate healing Must occur following tissue damage to initiate healing Signs and Symptoms Signs and Symptoms Pain, redness, swelling, loss of function and warmth Pain, redness, swelling, loss of function and warmth If source of irritation is not removed then inflammatory process becomes chronic If source of irritation is not removed then inflammatory process becomes chronic

25. © 2010 McGraw-Hill Higher Education. All rights reserved. Tendinitis Most common overuse problem in sports Most common overuse problem in sports Gradual onset, with diffuse tenderness due to repeated microtrauma and degenerative changes Gradual onset, with diffuse tenderness due to repeated microtrauma and degenerative changes Obvious signs of swelling and pain Obvious signs of swelling and pain May also experience crepitus (due to chemical products of inflammation) May also experience crepitus (due to chemical products of inflammation) Key for treatment is rest and removal of causal factors Key for treatment is rest and removal of causal factors Work to maintain fitness but avoid activities that aggravate condition Work to maintain fitness but avoid activities that aggravate condition

26. © 2010 McGraw-Hill Higher Education. All rights reserved. Tenosynovitis Inflammation of synovial sheath Inflammation of synovial sheath In acute case - rapid onset, crepitus, and diffuse swelling In acute case - rapid onset, crepitus, and diffuse swelling Chronic cases result in thickening of tendon with pain and crepitus Chronic cases result in thickening of tendon with pain and crepitus Often develops in long flexor tendons of fingers Often develops in long flexor tendons of fingers Treatment is similar to that of tendinitis Treatment is similar to that of tendinitis NSAID’s may also be of some assistance NSAID’s may also be of some assistance

27. © 2010 McGraw-Hill Higher Education. All rights reserved. Bursitis Bursa Bursa Fluid filled sac that develops in area of friction Fluid filled sac that develops in area of friction Sudden irritation can cause acute bursitis, while overuse and constant external compression can cause chronic bursitis Sudden irritation can cause acute bursitis, while overuse and constant external compression can cause chronic bursitis Results in increased fluid production, causing increases in pressure due to limited space around anatomical structures Results in increased fluid production, causing increases in pressure due to limited space around anatomical structures Signs and symptoms include swelling, pain, and some loss of function Signs and symptoms include swelling, pain, and some loss of function Three most commonly irritated Three most commonly irritated Subacromial, olecranon, and prepatellar bursa Subacromial, olecranon, and prepatellar bursa

28. © 2010 McGraw-Hill Higher Education. All rights reserved. Osteoarthritis Wearing away of hyaline cartilage as a result of normal use Wearing away of hyaline cartilage as a result of normal use Changes in joint mechanics lead joint degeneration (the result of repeated trauma to tissue involved) Changes in joint mechanics lead joint degeneration (the result of repeated trauma to tissue involved) May be the result of direct blow, pressure of carrying and lifting heavy loads, or repeated trauma from an activity such as running or cycling May be the result of direct blow, pressure of carrying and lifting heavy loads, or repeated trauma from an activity such as running or cycling Commonly affects weight bearing joints but can also impact shoulders and cervical spine Commonly affects weight bearing joints but can also impact shoulders and cervical spine

29. © 2010 McGraw-Hill Higher Education. All rights reserved. Osteoarthritis (cont’d.) Symptoms include pain (as the result of friction), stiffness, prominent uprising in the morning, localized tenderness, creaking, grating, and often is localized to one side of the joint or generalized joint pain Symptoms include pain (as the result of friction), stiffness, prominent uprising in the morning, localized tenderness, creaking, grating, and often is localized to one side of the joint or generalized joint pain

30. © 2010 McGraw-Hill Higher Education. All rights reserved. Myofascial Trigger Points Develop due to mechanical stress Develop due to mechanical stress Either acute strain or static postural positions producing constant tension in muscle Either acute strain or static postural positions producing constant tension in muscle Typically occur in neck, upper and lower back Typically occur in neck, upper and lower back Signs and Symptoms Signs and Symptoms Pain with palpation, with predictable pattern of referred pain which may also limit motion Pain with palpation, with predictable pattern of referred pain which may also limit motion Pain may increase with active and passive motion of involved muscle Pain may increase with active and passive motion of involved muscle

31. © 2010 McGraw-Hill Higher Education. All rights reserved. Importance of the Healing Process Following Injury Essential to possess understanding of both sequence and time frame for various phases of healing process Essential to possess understanding of both sequence and time frame for various phases of healing process Interference with healing process will delay return to full activity Interference with healing process will delay return to full activity Work to create optimal healing environment Work to create optimal healing environment Little can be done to speed the process, while much can be done to impede it Little can be done to speed the process, while much can be done to impede it

32. © 2010 McGraw-Hill Higher Education. All rights reserved.

33. Inflammatory Response Phase Begins immediately following injury – critically important Begins immediately following injury – critically important Without the inflammatory phase the other phases will not occur Without the inflammatory phase the other phases will not occur Phagocytosis occurs to clean the injured area Phagocytosis occurs to clean the injured area Chemical mediators are released to facilitate healing Chemical mediators are released to facilitate healing Symptomatically presents with redness, swelling, warmth, tenderness and loss of function Symptomatically presents with redness, swelling, warmth, tenderness and loss of function Stage lasts 2-4 days following injury Stage lasts 2-4 days following injury

34. © 2010 McGraw-Hill Higher Education. All rights reserved. Fibroblastic Repair Phase Proliferative and regenerative activity occurs resulting in scar formation (fibroplasia) Proliferative and regenerative activity occurs resulting in scar formation (fibroplasia) Occurs within initial hours of injury and continues up to 4-6 weeks Occurs within initial hours of injury and continues up to 4-6 weeks S&S of inflammatory phase subside S&S of inflammatory phase subside Athlete will still experience some tenderness and pain with motion Athlete will still experience some tenderness and pain with motion With increasing development of the scar complaints of pain and tenderness will decrease With increasing development of the scar complaints of pain and tenderness will decrease

35. © 2010 McGraw-Hill Higher Education. All rights reserved. Maturation-Remodeling Phase Long-term process Long-term process Re-alignment of scar tissue according to tensile forces acting on tissue Re-alignment of scar tissue according to tensile forces acting on tissue Re-align to position of maximum efficiency (parallel to lines of tension) Re-align to position of maximum efficiency (parallel to lines of tension) Tissue gradually resumes normal appearance and function Tissue gradually resumes normal appearance and function After 3 weeks, firm, strong, contracted, nonvascular scar exists After 3 weeks, firm, strong, contracted, nonvascular scar exists Maturation may take several years to be totally complete Maturation may take several years to be totally complete

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