KIN281 Test 1

Phagocytosis

the process of ingesting material such as bacteria, dead cells, and other debris associated with disease, infection, or injury.

A patient sustained a grade 2 lateral ankle sprain 3 weeks ago. It was given proper immediate and follow up care. What repair has taken place during this time?

A grade 2 lateral ankle sprain implies that the joint capsule and ligaments are partially torn. At 3 weeks, the injury has been cleaned of debris and is undergoing the process of secondary healing. Granulation tissue fills the torn areas, and fibroblasts are beginning to form scar tissue.

Acute versus Chronic pain

Acute pain is less than six months in duration Chronic pain last longer than six months Chronic pain classified by International Association for the Study of Pain (IASP) as pain continuing beyond normal healing time

An 11-year-old soccer player fell on an outstretched hand during practice. There is obvious deformity in her right wrist. What is a possible complication with a fracture in this wrist?

An epiphyseal condition, such as an epiphyseal growth plate fracture, can occur in children and adolescents and needs to be considered with any musculoskeletal injury. These injuries can impair growth and further skeletal development.

Load

An external force acting on the body causing internal reactions within the tissues

Bone functions

Body support Organ protection Movement (through joints and levers) Calcium storage Formation of blood cells (hematopoiesis)

Tissues of the body

Bone - not classified as soft tissue 4 types of soft tissue Epithelial tissue Skin, vessel & organ linings Connective tissue Tendons, ligaments, cartilage, fat, blood, and bone Muscle tissue Skeletal, smooth, cardiac muscle Nerve tissue Brain, spinal cord & nerves

Nerve Healing

Cannot regenerate after injury Regeneration can take place within a nerve fiber Proximity of injury to nerve cell makes regeneration more difficult For regeneration, optimal environment is required Rate of healing occurs at 3-4 mm per day Injured central nervous system nerves do not heal as well as peripheral nerves

Muscle Strain Grade III

Complete rupture of muscle or musculotendinous junction, significant impairment, with initially a great deal of pain that diminishes due to nerve damage

Comminuted

Consists of three or more fragments at the fracture site

Bone Characteristics

Dense connective tissue matrix Outer compact tissue Inner porous cancellous bone including Haversian canals

Phase 2 of the healing process

Fibroblastic Repair phase Day 4 to week 6

Phase I: Inflammatory Response Phase

Healing begins immediately Injury results in altered metabolism and liberation of various materials Initial reaction by leukocytes and phagocytic cells Goal Protect Localize Decrease injurious agents Prepare for healing and repair

Microtrauma and Overuse Syndrome

Injuries as a result of abnormal and repetitive stress and microtraumas fall into a class with certain identifiable syndromes Frequently result in limitation or curtailment of sports involvement Often seen in running, jumping, and throwing activities Some of these injuries while small can be debilitating Repetitive overuse and stress injuries include Achilles tendinitis, shin splints, stress fx, Osgood-Schlatter's disease, runner's and jumper's knee, patellar chondromalacia and apophyseal avulsion

Tissue Properties

Load, Stiffness, Stress, Strain

Phase 3 of the healing process

Maturation-Remodeling Phase 3 weeks up to 3 years and beyond

Release of B-endorphins

Noxious stimuli can trigger endorphin release Stimulation of pain sensory fibers required Causes release from hypothalamus Strong analgesic effects

Tendon Healing

Requires dense fibrous union of separated ends Abundance of collagen is required for good tensile strength Too much = fibrosis - may interfere with gliding Initially injured tendon will adhere to surrounding tissues (week 2) Week 3 - tendon will gradually separate Tissue not strong enough until weeks 4-5

Pain Assessment

Self report is the best reflection of pain and discomfort Utilize multi- and uni-dimensional questionnaires Assessment techniques include: Visual analog scales (0-10, marked no pain to severe pain) Pain charts McGill Pain questionnaire Activity pain indicator profiles Numeric rating scale

Myofascial Pain

Trigger points or small hyperirritable areas within muscle resulting in bombardment of CNS Acute and chronic pain can be associated with myofascial points Often described as fibrositis, myositis, myalgia, myofascitis and muscular strain Active points cause obvious complaint Trigger points do not follow patterns Trigger point area referred to as reference zone which may or may not be proximal to the point of irritation

Vascular Response

Vasoconstriction and coagulation occur to seal blood vessels and chemical mediators are released Presses endothelial lining together to produce local anemia Followed by vasodilation of blood vessel 5-10 minutes later Initially increases blood flow (transitory) Vasodilation decreases blood flow, increased blood viscosity resulting in edema (swelling) WBC's able to adhere to walls Initial effusion of blood and plasma lasts 24-36 hours

Epiphysis

composed of cancellous bone and has hyaline cartilage covering provides areas for muscle  attachment

Traumatic

direct blow

Trauma

is defined as physical injury or wound, produced by internal or external force

Overuse

repetitive dynamic use over time

Muscle Strain Grade I

some fibers have been stretched or actually torn resulting in tenderness and pain on active ROM, movement painful but full range present

A basketball player steps on another player's foot and sustains a lateral ankle injury. What forces are applied, and what type of injury has been incurred?

In stepping on another player's foot, the basketball player produces an abnormal ankle torsion and lateral ankle tension, stretching and tearing ligaments.

While attempting to make an arm tackle, a football player injures his upper arm. What injury mechanism has occurred, and what injury might occur?

The football player has sustained a tension force to the long head of the biceps tendon, which caused a rupture or severe strain.

Capsulitis

Capsulitis is the result of repeated joint trauma

Three types of muscle

Cardiac Smooth Striated (skeletal)

Pain Sources

Cutaneous, deep somatic, visceral and psychogenic Cutaneous pain is sharp, bright and burning with fast and slow onset Deep somatic pain originates in tendons, muscles, joints, periosteum and blood vessels Visceral pain begins in organs and is diffused at first and may become localized Psychogenic pain is felt by the individual but is emotional rather than physical

Chemical Mediators

Derived from invading organisms, damaged tissue, plasma enzyme systems and white blood cells (WBC's) Histamine (from mast cells) Causes vasodilatation and changes cell permeability owing to swelling Leukotrienes & prostaglandins Impact margination (adherence along cell walls) Increase permeability locally for fluid and protein passage (diapedesis)

Tendinitis

Gradual onset, with diffuse tenderness due to repeated microtrauma and degenerative changes Obvious signs of swelling and pain Key to treatment is rest May require substitution of activity in order to maintain fitness without stressing injured structure Without proper healing condition may begin to degenerate and be referred to as tendinosis Less inflammation, more visibly swollen with stiffness and restricted motion Treatment involves stretching and strengthening

Phase 1 of the healing process

Inflammatory Response phase up to first 4 days

Phase III: Maturation & Remodeling

Long-term process Realignment of collagen relative to applied tensile forces Continued breakdown and synthesis of collagen = increased strength Tissue will gradually assume normal appearance May require several years to complete

Apophyseal Injuries

Young physically active individuals are susceptible Apophyses are traction epiphyses in contrast to pressure epiphyses. Serve as sites of origin and insertion for muscles Common avulsion conditions include Sever's disease and Osgood-Schlatter's disease

Contracture

an abnormal shortening of muscle where there is a great deal of resistance to passive stretch Generally the result of a muscle injury which impacts the joint, resulting in accumulation of scar tissue

Muscle Strain 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

Mechanical injury

results from force or mechanical energy that changes state of rest or uniform motion of matter

Diaphysis

shaft - hollow and cylindrical covered by compact bone medullary cavity contains yellow marrow and lined by endosteum

Linear

those in which the bone splits along its length

Atrophy

wasting away of muscle due to immobilization, inactivity, or loss of nerve functioning

Soft tissue healing (Cell structure/function)

All organisms composed of cells Properties of soft tissue derived from structure and function of cells Cells consist of nucleus surrounded by cytoplasm and encapsulated by phospholipid cell membrane Nucleus contains chromosomes (DNA) Functional elements of cells (organelles) include mitochondria, ribosomes, endoplasmic reticulum, Golgi apparatus & centrioles

The stress-strain curve represents the relationship between various tissue properties when a ligament is stretched. How does external stress lead to an ankle sprain in a patient who steps awkwardly off a curb?

An external tension load causes internal strain and deformation to the ligament. When the ligament can no longer respond elastically, the yield point has been exceeded and a ligament sprain occurs.

A second-semester college sophomore has decided that she is interested in becoming a certified athletic trainer. She happens to be in an institution that offers an advanced masters degree in athletic training yet does not offer an entry level CAATE- approved curriculum. How can this student most effectively achieve her goal of becoming a certified athletic trainer?

As of 2004, everyone must graduate from a CAATE-accredited program to take the BOC exam and become a certified athletic trainer. Therefore, she must transfer to an institution that enters entry-level CAATE-approved program, in which she must complete course work and directly supervised clinical experience.

Scar formation

Capillary buds form Formation of delicate connective tissue (granulation tissue) Consists of fibroblasts extracellular matrix Develop collagen, Elastin, ground substance, proteoglycans, glycosaminoglycans With proliferation of collagen scar tensile strength increases # of fibroblasts gradually diminishes Types of collagen 16 types; body is 80-90% Types I, II, & III Normal sequence = minimal scarring Persistent inflammation = extended fibroplasia

Sclerotomic and dermatomic pain

Deep pain with slow or fast characteristics May originate from sclerotomic, myotomic or dermatomic nerve irritation/injury Sclerotomic pain Transmitted by C fibers causing deep aching and poorly localized pain Can be projected to multiple areas of brain causing depression, anxiety, fear or anger Autonomic changes may result (vasomotor control, BP and sweating Dermatomic pain (irritation of A-delta fibers) is sharp and localized Projects to the thalamus and cortex directly

Myofascial Trigger Points

Discrete, hypersensitive nodule within tight band of muscle or fascia Classified as latent or active Develop as the result of mechanical stress Either acute trauma or microtrauma May lead to development of stress on muscle fiber = formation of trigger points Latent trigger point Does not cause spontaneous pain May restrict movement or cause muscle weakness Become aware of presence when pressure is applied Active trigger point Causes pain at rest Applying pressure = pain = jump sign Tender to palpation with referred pain Tender point vs. trigger point Found most commonly in muscles involved in postural support

Management Concepts

Drug utilization Anti-prostaglandin agents used to combat inflammation Non-steroidal anti-inflammatory agents (NSAID's) Medications will work to decrease vasodilatation and capillary permeability Therapeutic Modalities Thermal agents are utilized Heat facilitates acute inflammation Cold is utilized to slow inflammatory process Electrical modalities Treatment of inflammation Ultrasound, microwave, electrical stimulation (includes transcutaneous electrical muscle stimulation and electrical muscle stimulation) Therapeutic Exercise Major aim involves pain free movement, full strength, power, and full extensibility of associated muscles Immobilization, while sometimes necessary, can have a negative impact on an injury Adverse biochemical changes can occur in collagen Early mobilization (that is controlled) may enhance healing

A long jumper experiences a sudden, sharp pain in the region of the left ischial tuberosity during a jump. What injuries are possible through this mechanism?

During the jump, a powerful stretch of the biceps femoris could cause a serious strain or an avulsion fracture in the region of the ischial tuberosity.

Factors that impede Healing

Extent of injury Edema Hemorrhage Poor Vascular Supply Separation of Tissue Muscle Spasm Atrophy Corticosteroids Keloids and Hypertrophic Scars Infection Humidity, Climate, Oxygen Tension Health, Age, and Nutrition

Fast versus Slow pain

Fast pain localized and carried through A-delta axons Slow pain is perceived as aching, throbbing, or burning (transmitted through C fibers)

Muscle Guarding

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 Not spasm which would indicate increased tone due to upper motor neuron lesion in the brain

Bone Healing

Follows same three phases of soft tissue healing Less complex process Acute fractures have 5 stages Hematoma formation Cellular proliferation Callus formation Ossification Remodeling

Ligament Healing

Follows similar healing course as other vascular tissues Proper care will result in acute, repair, and remodeling phases in same time required by other vascular tissues Repair phase will involve random laying down of collagen which, as scar forms, will mature and realign in reaction to joint stresses and strain Full healing may require 12 months Factors affecting healing Surgically repaired ligaments tend to be stronger due to decreased scar formation With intra-articular tears synovial fluid will dilute hematoma and prevent clotting and spontaneous healing Exercised ligaments are stronger Exercise vs. Immobilization Muscles must be strengthened to reinforce the joint Increased tension will increase joint stability

Skeletal Muscle Healing

Initial bleeding followed by proliferation of ground substance and fibroblast Myoblastic cells form = regeneration of new myofibrils Collagen will mature and orient along lines of tension Healing could last 6-8 weeks depending on muscle injured

Role of Progressive Mobilization

Initially must maintain some immobilization in order to allow for initial healing As healing moves into repair phase controlled activity should be added Work towards regaining normal flexibility and strength Protective bracing should also be incorporated During remodeling aggressive ROM and strength exercises should be incorporated Facilitates remodeling and realignment Must be aware of pain and other clinical signs - may be too much too soon

A wrestler receives a sudden twist to his right shoulder, causing a grade 2 strain to the teres minor muscle. What hemodynamic changes occur in the first hour of this acute injury?

Initially, a transitory vasoconstriction with the start of blood coagulation of the broken blood vessels occur. Dilation of the vessels in the region of injury follows, along with the activation of chemical mediators via key cells.

Strain

Internal change in tissue (i.e. length) resulting in deformation

Stress

Internal resistance to a load

A patient was in a car accident in which a close friend was seriously injured. He has had difficulty sleeping and is beginning to have nightmares, which further compound hos insomnia. What might the athletic trainer suspect is affecting this individual?

It is likely that the emotional distress caused by the accident is triggering post-traumatic stress disorder. Group therapy with others who have had similar experiences may be helpful.

Cartilage Healing

Limited capacity to heal Little or no direct blood supply Chondrocyte and matrix disruption result in variable healing Articular cartilage that fails to clot and has no perichondrium heals very slowly If area involves subchondral bone (enhanced blood supply) granulation tissue is present and healing proceeds normally

A volleyball player has sprained her ankle just 2 days prior to the beginning of the conference tournament. The athlete, her parents, and her coach are extremely concerned that she is going to miss the tournament and want to know if anything can be done to help her get well more quickly. What can the athletic trainer tell this patient about the healing process?

Little can be done to speed up the healing process physiologically. This athlete must realize that certain physiological events must occur during each phase of the healing process. Any interference with this healing process during a rehabilitation program will likely slow return to full activity. The healing process must have an opportunity to accomplish what it is supposed to.

Torsion

Loads caused by twisting in opposite directions from opposite ends Shear stress encountered will be perpendicular and parallel to the loads

Patients who are injured must deal with both the physiological and the psychological aspects of injury. What stages of psychological reaction does the patient typically go through following injury?

Many patients experience five stages of psychological reaction, beginning with denial that they are injured, followed by anger, bargaining, depression, and finally acceptance.

Soft tissue Adaptations

Metaplasia - transformation of tissue from one type to another that is not normal for that tissue Dysplasia - abnormal development of tissue Hyperplasia- excessive proliferation of normal cells in normal tissue arrangement Atrophy- a decrease in the size of tissue due to cell death and re-absorption or decreased cell proliferation Hypertrophy - an increase in the size of tissue without necessarily changing the number of cells

Treating Pain

Modalities Must have clear rationale for use Used to relieve pain and control other signs and symptoms of injury/surgery Must use in conjunction with exercise Induced analgesia Introduce thermal agents for pain control Utilize electrical modalities to reduce pain TENS, superficial heat/cold, massage used to target Gate Theory Acupuncture, electrical stimulation, deep massage used to stimulate endorphin release Pharmacological Agents Oral, injectable medications Commonly analgesics and anti-inflammatory agents Important to work with referring physician or pharmacist to ensure patient is taking appropriate medications

Chronic Inflamation

Occurs when acute inflammatory response does not eliminate injuring agent Tissue not restored to normal physiologic state Involves replacement of leukocytes with macrophages, lymphocytes and plasma cells As inflammation persists necrosis and fibrosis prolong healing process Granulation and fibrotic tissue continue to develop within highly vascular and loose connective tissue. Cause for shift from acute to chronic is unknown Typically associated with overuse, overload, cumulative microtrauma

Psychological Aspects of Pain

Pain can be subjective and psychological Pain thresholds vary per individual Pain is often worse at night due to solitude and absence of external distractions Personality differences can also have an impact A number of theories relative to pain exist Physiological and psychological components Patients, through conditioning, are often able to endure pain and block sensations of minor injuries

Nociception

Pain receptors -free nerve endings sensitive to extreme mechanical, thermal and chemical energy Located in meninges, periosteum, skin, teeth, and some organs Pain information transmitted to spinal cord via myelinated C fibers and A delta fibers (first-order afferent fibers) Nociceptor stimulation results in release of substance P

Referred Pain

Pain which occurs away from actual site of injury/irritation Unique to each individual and case May elicit motor and/or sensory response A-alpha fibers are sensitive to pressure and can produce paresthesia Three types of referred pain include: myofascial, sclerotomic, and dermatomic

Clot Formation

Platelets adhere to exposed collagen leading to formation of plug (clot) Clots obstruct lymphatic fluid drainage and aid in localizing injury Requires conversion of fibrinogen to fibrin Initial stage: thromboplastin is formed Second stage: Prothrombin is converted to thrombin due to interaction with thromboplastin Third stage: thrombin changes from soluble fibrinogen to insoluble fibrin coagulating into a network localizing the injury

Yield point

Point at which elasticity is almost exceeded is the yield point If deformation persists, following release of load permanent or plastic changes result When yield point is far exceeded mechanical failure occurs resulting in damage

Cardinal Signs of Inflamation

Rubor (redness) Tumor (swelling) Color (heat) Dolor (pain) Functio laesa (loss of function)

Phase II: Fibroblastic Repair Phase

Scar formation through 3 phases Resolution (little tissue damage and normal restoration) Restoration (if resolution is delayed) Regeneration (replacement of tissue by same tissue) Referred to as fibroplasia Complaints of pain and tenderness gradually subside during this period

Gate Theory

Sensory information from cutaneous receptors enters A-Beta afferents to dorsal horn of spinal cord Pain simultaneously travels along A-delta and c-fibers Sensory information overrides pain information, closing gate Pain message never received Gate control occurs at the level of the spinal cord

Second order afferent fibers

Sensory message from dorsal horn to brain (nociceptive specific) Receive input from A- beta, delta and C-fibers Overlapping receptive field Nociceptive-specific second order afferents receive input only from A-delta and C-fibers All of these neurons synapse with third order neurons Transmit information to brain centers via ascending spinal tracts Information is integrated, interpreted and acted upon

Central Biasing

Stimulation of descending pathways used to inhibit A-delta and C-fiber pain transmission Involves release of enkephalin and norepinephrine release in dorsal horn blocking and inhibiting synaptic transmission

Hematoma Formation

Trauma to the periosteum and surrounding soft tissue occurs due to the initial bone trauma During the first 48 hours a hematoma within the medullary cavity and the surrounding tissue develops Blood supply is disrupted by clotting vessels and cellular debris Soft callus is a random network of woven bone Osteoblasts fill the internal and external calluses to immobilize the site Calluses are formed by bone fragments that bridge the fracture gap The internal callus creates a rigid immobilization early Hard callus becomes more well-formed as osteoblasts lay down cancellous bone, replacing cartilage With crystallization of callus remodeling begins Less than ideal immobilization produces a cartilaginous union instead of a bony union Ossification is complete when bone has been laid down and the excess callus has been resorbed by osteoclasts Bone continually adapts to applied stresses Balance between osteoblast and osteoclast activity Time required is dependent on various factors Severity and site of fracture Age and extent of trauma Time will range from 3-8 weeks

A field hockey player falls and sustains an acute fracture of the left humerus. What are the healing events typical of this acute bone fracture?

Uncomplicated acute bone healing goes through five stages: hematoma formation, cellular proliferation, callus formation, ossification, and remodeling.

Transverse

occur in a straight line, more or less at right angles to the bone shaft

Subluxation

Partial dislocations causing incomplete separation of two bones Bones come back together in alignment

Muscle Spasms

A reflex reaction caused by trauma Two types Clonic - alternating involuntary muscular contractions and relaxations in quick succession Tonic - rigid contraction that lasts a period of time May lead to muscle or tendon injuries

A young woman training for a marathon is complaining of pain in the lower leg. She consults with her physician, who determines that she has a stress fracture. She is confused about how a stress fracture is different from a normal fracture. How should the athletic trainer explain the difference between the two, and what is the course of management?

A stress fracture is not an actual break of the bone; it is simply an irritation of the bone. Treatment of a stress fracture requires about 2 to 4 weeks of rest. However, the athletic trainer should point out that a stress fracture can become a true fracture if it is not rested; if that happens, 4 to 6 weeks of immobilization in a cast is necessary. Thus, it is critical that this athlete rest for the required amount of time.

Stiffness

Ability of a tissue to resist a load Greater stiffness = greater magnitude load can resist

Nerve Trauma

Abnormal nerve responses can be attributed to injury or athletic participation The most frequent injury is neuropraxia produced by direct trauma Lacerations of nerves as well as compression of nerves as a result of fractures and dislocations can impact nerve function

Osteochondrosis

Also known as osteochondritis dissecans and apophysitis (if located at a tubercle/tuberosity) Causes not well understood Degenerative changes to epiphyses of bone during rapid child growth Possible cause includes 1)aseptic necrosis (disrupted circulation to epiphysis, 2) fractures in cartilage causing fissures to subchondral bone, 3) trauma to a joint that results in cartilage fragmentation resulting in swelling, pain and locking With the apophysis, an avulsion fracture may be involved, including pain, swelling and disability

All-American High school is considering hiring an athletic trainer instead of using an emergency medical technician. However, the administrators do not completely understand why an athletic trainer may be more beneficial for their athletes. A group of area athletic trainers will be holding a meeting to discuss the potential change. What reason should the athletic trainers use to persuade the administrators to hire an athletic trainer?

Although emergency medical technicians are qualified to handle emergency situations, an athletic trainer is able to provide comprehensive health care to the All-American High School athletes. An athletic trainer is responsible for the prevention of athletic injuries; the recognition, evaluation, and assessment of injuries; and the treatment and rehabilitation of athletic injuries.

In general, athletes are highly motivated individuals. What can the athletic trainer do to motivate an injured patient to become more compliant with the rehabilitation program?

Athletes tend to be goal-oriented individuals. They are used to having goals set for them and striving to meet them. The athletic trainer can motivate the athlete by setting an ultimate goal and devising a series of short term goals that should be met sequentially to achieve the long term goal.

Tenosynovitis

Inflammation of synovial sheath In acute case - rapid onset, crepitus, and diffuse swelling Chronic cases result in thickening of tendon with pain and crepitus Often occurs in long flexor tendon of the digits and the biceps tendon Due to nature of injury anti-inflammatory agents may be helpful

A cross country runner sustains a stress fracture of her left tibia. Her left leg is 3/4 inch shorter than her right leg. What is a possible cause of this injury?

Because it is shorter, the left leg has the greater stress during running. This stress creates increased tension on the tibia's concave side, causing an increase in osteoclastic activity.

Bursitis

Bursa are fluid filled sacs that develop in areas of friction Sudden irritation can cause acute bursitis, while overuse and constant external compression can cause chronic bursitis Signs and symptoms include swelling, pain, and some loss of function Repeated trauma can lead to calcification and degeneration of internal bursa linings

An alpine skier catches his right ski tip and severely twists his lower leg. What type of serious injury could be created by this mechanism?

Catching the ski tip produces a torsional force that could cause a boot-top spiral fracture.

Bone fractures

Classified as either closed or open Closed fractures are those where there is little movement or displacement Open fractures involve displacement of the fractured ends and breaking through the surrounding tissue Serious condition if not managed properly Signs & symptoms Deformity, pain, point tenderness, swelling, pain on active and passive movements Possible crepitus X-ray will be necessary for definitive diagnosis

Structures of the Bone

Diaphysis Epiphysis Periosteum

Synovial Joint

Each joint has both hyaline or articular cartilage and a fibrous connective tissue capsule Additional synovial joint characteristics Capsule and ligaments for support Capsule is lined with synovial membrane Hyaline cartilage Joint cavity with synovial fluid Blood and nerve supply with muscles crossing joint Menisci (fibrocartilage)

Shearing

Force that moves across the parallel organization of tissue

Tension

Force that pulls and stretches tissue

Compression

Force that results in tissue crush - two forces applied towards one another

Dislocation

High level of incidence in fingers and shoulder Occurs when at least one bone in a joint is forced out of alignment and must be manually or surgically reduced Gross deformity is typically apparent with bilateral comparison revealing asymmetry Stabilizing structures of the joint are disrupted Joint often becomes susceptible to subsequent dislocations X-ray is the only absolute diagnostic technique (able to see bone fragments from possible avulsion fractures, disruption of growth plates or connective tissue) Dislocations (particularly first time) should always be considered and treated as a fracture until ruled out "Once a dislocation, always a dislocation"

Most athletic trainers do not have academic training as counselors or psychologists. If an injured patient is not responding psychologically to the efforts of the athletic trainer to rehabilitate and return that individual to full activity, what options does the athletic trainer have for referring this patient for additional help?

If the athletic trainer needs help with the psychological aspects of a rehabilitation program, the patient can be referred to a physician, a sport psychologist, a clinical psychologist, a psychiatrist, a school guidance counselor, or a social worker.

A football player sustains a grade 2 medial collateral ligament sprain in his left knee. The athlete expresses concern with prolonged immobilization because he does not want to lose strength. What method can be used to prevent atrophy from occurring but still allow healing to take place?

Immobilization during the inflammatory process may be beneficial; however, controlled mobilization helps this tissue decrease atrophy and enhance the healing process. Controlled mobilization allows the athlete to perform progressive strengthening exercises in a timely manner.

A patient complains of a swollen ankle that never became completely resolved since he sustained a sprain 9 months ago. What is the reason for the chronic swelling?

In its acute phase, the injury was not allowed to heal properly. As a result, the injury became chronic, with a proliferation of scar tissue, lymphocytes, plasma cells, and macrophages.

Neuropraxia

Interruption in conduction through nerve fiber Brought about via compression or blunt trauma Impact motor more than sensory function Temporary loss of function

Stress fractures

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 Bone becomes susceptible early in training due to increased muscular forces and initial remodeling and resorption of bone Progression involves, focal microfractures, periosteal or endosteal response (stress fx) linear fractures and displaced fractures Early detection is difficult, bone scan is useful, x-ray is effective after several weeks Typical causes include Coming back to competition too soon after injury Changing events without proper conditioning Starting initial training too quickly Changing training habits (surfaces, shoes....etc) Variety of postural and foot conditions Signs and symptoms Focal tenderness and pain, (early stages) Pain with activity, (later stages) with pain becoming constant and more intense, particularly at night, (exhibit a positive percussion tap test) Common sites involve tibia, fibula, metatarsal shaft, calcaneus, femur, pars interarticularis, ribs, and humerus Management varies between individuals, injury site and extent of injury

Bone Growth

Ossification occurs from synthesis of bones organic matrix (work of osteoblasts and osteoclasts) Involves growth of diaphysis and the epiphyseal growth plates (towards one another) As cartilage matures, immature osteoblasts replace to ultimately form solid bone Deforming forces, premature injury and growth plate dislocation can alter growth patterns and/or result in deformity of bone Bone diameter increases via the activity of osteoblasts adding to the exterior while osteoclasts break down bone in medullary cavity At full size, bone maintains state of balance between osteoblastic and -clastic activity Changes in activity and hormonal levels can alter balance Bone loss begins to exceed external bone growth overtime As thickness decreases, bones are less resistant to forces --osteoporosis Bone's functional adaptation to stresses follows Wolff's Law --every change in form and function or in its function alone is followed by changes in architectural design

Muscle Soreness

Overexertion in strenuous exercise resulting in muscular pain Generally occurs following participation in activity that individual is unaccustomed Two types of soreness 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) Potentially caused by slight microtrauma to muscle or connective tissue structures Prevent soreness through gradual build-up of intensity

Muscle Cramps

Painful involuntary skeletal muscle contraction Occurs in well-developed individuals when muscle is in shortened position Experienced at night or at rest

Anatomical Characteristics of nerves

Provides sensitivity and communication from the CNS to muscles, sense organs and various systems in the periphery Neuron cell body has a large nucleus with branched dendrites which respond to neurotransmitter substances Each nerve cell has an axon that conducts nerve impulse Axons are encased in neurilemmal sheaths (Schwann and satellite cells) Various neurological cells in CNS help to form framework for nervous tissue

A football player who plays wide receiver sustains repeated blows to his left quadriceps muscle. What type of injury could be sustained from repeated compressible forces to the quadriceps muscle?

Repeated contusion of any muscle may lead to the development of myositis ossificans. The key to treating myositis ossificans is prevention. An initial contusion to any muscle should be immediately protected with padding to prevent re-injury.

Contusion

Result of sudden blow to body Can be both deep and superficial Hematoma results from blood and lymph flow into surrounding tissue Localization of extravasated blood into clot, encapsulated by connective tissue Speed of healing dependent on the extent of damage Chronically inflamed and contused tissue may result in generation of calcium deposits (myositis ossificans) Prevention through protection of contused area with padding

Ligament Sprains

Result of traumatic joint twist that causes stretching or tearing of connective tissue Graded based on the severity of injury Grade I - some pain, minimal loss of function, no abnormal motion, and mild point tenderness Grade II - pain, moderate loss of function, swelling, and instability with tearing and separation of ligament fibers Grade III - extremely painful, inevitable loss of function, severe instability and swelling, and may also represent subluxation Can result in joint effusion and swelling, local temperature increase, pain and point tenderness, ecchymosis (change in skin color) and possibly an avulsion fracture Greatest difficulty with grade 1 & 2 sprains is restoring stability due to stretched tissue and inelastic scar tissue which forms To regain joint stability strengthening of muscles around the joint is critical

Muscle Strain

Stretch, tear or rip to muscle or adjacent tissue Cause is often obscure Abnormal muscle contraction is the result of 1)failure in reciprocal coordination of agonist and antagonist, 2) electrolyte imbalance due to profuse sweating or 3) strength imbalance May range from minute separation of connective tissue to complete tendinous avulsion or muscle rupture

Synovitis

Synovitis can occur acutely but will also develop following mistreatment of joint injury Chronic synovitis can result in edema, thickening of the synovial lining, exudation can occur and a fibrous underlying develops Motion may become restricted and joint noises may develop

A patient is just beginning a rehabilitation program following injury. What specific things can the athletic trainer do to provide social support to the patient?

The athletic trainer can be a good listener, find out what the problem is, be aware of his or her body language, project a caring image, explain the injury to the patient, help manage the stress of injury, and prepare the athlete physically and psychologically to return to competition.

A patient has been rehabilitating a surgically repaired knee for 6 months. Physically, she is capable of returning to activity but seems hesitant to engage in an activity where there is potential contact. Should the athletic trainer push her back into activity despite her apprehension?

The athletic trainer must appreciate that, even though she is physically ready to return, she is not psychologically prepared and has not yet realized that she can compete physically. The athletic trainer should have her engage in practice activities that will progressively expose her to more chance of physical risk until she is totally confident that she is ready to return.

Some athletes seem to get injured more often than others. What factors should the athletic trainer look for that might make the possibility of injury more likely in certain athletes?

The athletic trainer should look for athletes who have personality characteristics that make them more prone to injury, athletes who are under stress, and athletes who are over training and exhibiting signs of staleness and/or burnout.

A secondary school athletic trainer is concerned about the number of anterior cruciate ligament injuries that are occurring in the female athletes in all sports. She wants to find out whether incorporating a jump-landing training program will have any effect on reducing the number of ACL injuries. How should she go about answering the clinical question?

The athletic trainer should make use of an evidence based practice approach to find an answer to her clinical question "Can incoporating a jump-landing training program reduce the number of ACL injuries in female athletes?" The next step is to search the literature to find the best evidence and then evaluate the strength of that evidence. She needs to apply the evidence that she finds in the literature and use her clinical experience to address the specific goal of reducing the incidence of ACL tears. Finally she needs to assess the outcome or effectiveness of having integrated this jump-landing training program in reducing ACL injuries in her female athletes

An athlete who has experienced several different injuries throughout the season is anxious about performing at his usual level. What can the athletic trainer recommend to help the patient before a game?

The athletic trainer should recommend and lead the athlete through meditation and/or progressive relaxation techniques in a quiet environment that will allow the athlete to relax mentally and focus on his abilities to perform at a high level

A wrestler complains of pain, swelling, and warmth around the knee that always seems to be worse after practice. What should an athletic trainer suspect is wrong with the knee, and how should it be treated?

The athletic trainer should suspect that the wrestler has developed bursitis from constantly kneeling on the mat. Inflammation may best be treated by rest, ice, antiinflamitory medication, and protective padding of the knee.

A certified athletic trainer moves to a different state to take a new job. She discovers that in that state the ATC must be licensed to practice athletic training. Because she was registered as an athletic trainer in the other state, must she go through the process of licensure in her new state?

The laws regarding regulation of the certified athletic trainer vary from state to state. It is likely that she will have to apply for a license through the academic training licensing board in her new state to get a license to practice in that state. It is not likely that there is reciprocity between the two states.

A tennis player with a pronounced single-handed topspin style of hitting a backhand stroke sustains a painful elbow injury. What are the forces and type of elbow injury sustained by the tennis player, and what are ways to prevent this problem?

The mechanism of this elbow injury is repeated tension to the extensor tendons attached to the lateral epicondyle, causing micro traumas. Stress to this area can be reduced by increasing the grip circumference and flattening the back hand stroke.

A butterfly swimmer has been experiencing low back pain for more than 6 months. The pain is described as aching and throbbing. What type of pain is this athlete experiencing?

The pain is considered to be chronic, deep somatic pain stemming from the low back muscles. It is conducted primarily by the C-type nerve fibers.

An athlete has a chronic back injury. How can the athletic trainer help the athlete deal with chronic pain?

The patient can be taught to inhibit pain by reducing tension and stress using the Benson and Jacobson techniques; by diverting attention from the chronic pain by engaging in problem solving' or by imagining or visualizing pleasant thoughts.

A gymnast is receiving electrical stimulation for chronic low back pain. What is the purpose of administering electrical stimulation for the chronic pain?

The purpose is to stimulate the large, rapidly conducting nerve fibers to inhibit the smaller and slower nerves that carry pain impulses.

Epiphyseal Conditions

Three types can be sustained by adolescents (injury to growth plate, articular epiphysis, and apophyseal injuries) Occur most often in children ages 10-16 years old Classified by Salter-Harris into five types (see illustration on next slide)

A young athletic trainer has taken his first job at All-American High School. The school administrators are extremely concerned about the number of athletes who get hurt playing various sports. They have charged the athletic trainer with the task of developing an athletic training program that can effectively help prevent the occurrence of injury to athletes in all sports at the school. What actions can the athletic trainer take to reduce the number of injuries and to minimize the risk of injury in the competitive athletes at the high school?

To help prevent injury, the athletic trainer should 1) arrange for physical examinations and preparticipation screenings to identify conditions that predispose an athlete to injury; 2) ensure appropriate training and conditioning of the athletes; 3) monitor environmental conditions to ensure safe participation; 4) select and maintain properly fitting protective equipment; and 5) educate parents, coaches, and athletes about the risks inherent in sport participation.

An athletic trainer has taken a job at a sports medicine clinic that has 4 physical therapists and two physical therapy assistants. This clinic has never employed an athletic trainer before, and there is some uncertainty among the physical therapists as to exactly what role the athletic trainer will play in the function of the clinic. How does the role of the athletic trainer working in the clinic differ from the responsibilities of the athletic trainer working in the university setting?

To some extent, the role of the clinical athletic trainer is dictated by the state's regulation of the practice of athletic training. Certainly, the clinical and academic preparation of athletic trainers should enable them to effectively evaluate an injured patient and guide that patient through a rehabilitative program. The athletic trainer should treat only those individuals who have sustained injury related to physical activity and not patients with neurological or orthopedic conditions. The athletic trainer may work part-time in the clinic and then cover one or several high schools around the area. The athletic trainer and physical therapist should work as a team to maximize the effectiveness of patient care.

Bending

Two force pairs act at opposite ends of a structure (4 points) Three forces cause bending (3 points) Already bowed structures encounter axial loading

A high-school basketball player suffers a grade 2 ankle sprain during mid season of the competitive schedule. After a 3-week course of rehabilitation, most of the pain and swelling have been eliminated. The athlete is anxious to get back into practice and competitive games as soon as possible, and subsequent injuries to other players have put pressure on the coach to force the athlete's return. Unfortunately, the athlete is still unable to perform the functional tasks (cutting and jumping) essential in basketball. Who is responsible for making the decision regarding when the athlete can fully return to practice and game situations?

Ultimately, the team physician is responsible for making that decision. However, that decision must be made based on the collective input from the athletic trainer, the coach, and the athlete. Remember that everyone on the sports medicine team has the same ultimate goal- to return the athlete to full competitive levels as quickly and safely as possible.

Tendons

Wavy parallel collagenous fibers organized in bundles - upon loading Can produce and maintain 8,700- 18,000 lbs/in2 Collagen straightens during loading but will return to shape after loading Breaking point occurs at 6-8% of increased length Tears generally occur in muscle and not tendon

Osteoarthritis

Wearing away of hyaline cartilage as a result of normal use Changes in joint mechanics lead to joint degeneration Commonly affects weight bearing joints but can also impact shoulders and cervical spine Symptoms include pain (as the result of friction), stiffness, prominent morning pain, localized tenderness, creaking, grating Either generalized joint pain or localized to one side of the join

Impacted

can result from a fall from a height, which causes the long bone to receive, directly on its long axis, a force of such magnitude that the osseous tissue is compressed

Periosteum

dense, white fibrous covering  which penetrates bone via  Sharpey' fibers contains blood vessels and  osteoblasts

Spiral

have an S-shaped separation

Greenstick

incomplete breaks in bones that have not completely ossified

Depressed

occur most often in flat bones.

Contrecoup

occur on the side opposite the point at which trauma was initiated

Oblique

occur when one end of the bone receives sudden torsion or twisting while the other end is fixed