Essentials of Athletic Injury Management Exam #3 St. Edward's University

Stress fracture

Various causes Overload d/u muscle contraction Altered stress distribution d/t muscle fatigue Change in surface Rhythmic repetitive stress vibrations Worsens over time Pain just with activity, pain after activity Early detection difficult Bone scan X-rays after several weeks Halt activity (14 days) Usually no casting needed

Anatomy of the pelvis

iliac crest, ilium, acetabulum, pubic bone, ischium

Neer's Test and Hawkins-Kennedy Test

used to assess impingement of soft tissue structures Positive test is indicated by pain and grimace

Motions of the rotator cuff muscles

Abduction, Forward flexions, Extension, Rotation

Special Tests

Active and Passive ROM Flexion & extension Abduction & adduction Internal & external rotation (IR/ER) Muscle Testing Shoulder and scapular stabilizing muscles Apprehension Test Neer's Test and Hawkins-Kennedy Test Empty Can Test Test for Sternoclavicular Stability Test for Acromioclavicular Stability

Injury types (causes, s/sx, treatment/management

Acute or Chronic

Hip Injuies in Adolescents:Osteitis Pubis

MOI Repetitive stress on pubic symphysis and adjacent muscles Ex: distance runners S/Sx Chronic pain and inflammation of groin TTP on pubic tubercle Pain w/ running, sit-ups and squats Tx Rest, NSAID's and gradual RTP

Valgus and Varus Stress Tests

Used to assess the integrity of the Medial collateral ligament (MCL) and Lateral collateral ligament (LCL) respectively Perform at 0 & 30 degrees of knee flexion

Neural

"Stinger" or "Burner" Neuropraxia Two common causes: compression or tension S/Sx: radiating pain, muscle weakness Acute or Chronic Examples? Sensory responses: hypoesthesia, hyperesthesia, paresthesia Ranges from minor severe life altering Neuritis: Chronic nerve problem d/t overuse or variety of forces Minor Severe problems Crushed/Severed Nerve Injury Life-long implications: paraplegia/quadriplegia could result Slow-healing structure 3-4 mm per day Depends if cell body is affected CNS vs. PNS repair

Tendinopathy

tendinitis and tendinosis

Dislocation

An injury that disrupts the alignment of bones at a joint, resulting in obvious deformity S/Sx: deformity, dysfunction, swelling, point tender Tx: Always treat as Fx until R/O (esp. 1st time)

Forearm contusions

Cause of Injury Ulnar side receives majority of blows due to arm blocks Acute or chronic Result of direct contact or blow Signs of Injury Pain, swelling and hematoma If repeated blows occur, heavy fibrosis and possibly bony callus could form Care Acute - RICE for at least one hour F/U w/ additional cryotherapy Protection is critical - full-length sponge rubber pad

Calluses

Caused by friction Pain ↑ as fatty layer loses elasticity/cushion Vulnerable to tears/cracks/blisters Tx: emery callus file, massage with lotion, sanding/pumicing (caution!) Prevention Shoe fitting One sock layer (at least) Petroleum jelly to reduce friction

Turf Toe

Caused by hyperextension of 1st MTP joint (single or repetitive trauma) S/Sx: Pain & swelling that ↑ w/ push off in walking, running, and jumping Tx: Rigid forefoot region of shoe (steel plate inserts) Taping to prevent great toe dorsiflexion Rest (discourage activity until pain-free) May take 3-4 weeks to subside

Metatarsal Arch Strain/Sprain

Caused by hypermobility of metatarsals d/t laxity of ligaments = excessive splay of foot Will appear to have fallen arch S/Sx: pain/cramping in metatarsal region, point tender, weakness, callus may form in area of pain Tx Pad to elevate metatarsals just behind ball of foot Strengthen intrinsic foot muscles Heel cord stretching

Ingrown Toenails

Caused by leading edge of nail growing into soft tissue Tx: Appropriate shoe width/length Soaking & packing w/ cotton to lift nail away from soft tissue Cutting "V" notch toward infected side allows nail to grow toward middle Prevention Correct nail trimming Too short penetrates skin as it grows out Too long irritated by shoes/socks

Corns

Caused by pressure from improperly fitting shoes Hard corns associated w/ hammer toes Soft corns narrow shoes & excessive foot sweating S/Sx: circular area of thickened, white macerated skin (b/w 4th & 5th toe is common) Tx: Shoe fitting & good foot hygiene Cotton/padding to separate toes Soaking in warm, soapy water softens

Blisters

Caused by shearing forces on skin fluid develops/accumulates between skin layers Prevention: appropriate footwear (socks & shoes) + lubricants may reduce friction Tx: Reduce friction (lubricant, tape, band aid, donut pad Careful with puncture infection May be necessary if pressure builds up causing excessive pain

Morton's Neuroma

Caused by thickening of nerve sheath (common - plantar nerve) where nerve divides into digital branches Common b/w 3rd & 4th met heads S/Sx: burning paresthesia & severe intermittent pain in forefoot, relief w/ NWB, toe hyperextension ↑ symptoms Tx: Teardrop pad b/w met heads = ↑ space & ↓ pressure on neuroma; shoes w/ wider toe box

Bunion (Hallux Valgus Deformity)

Caused by: Exostosis of 1st metatarsal head (assoc. w/ forefoot varus) Shoes too narrow, pointed, or short Bursa inflamed/thickened enlarges joint = lateral malalignment of great toe S/Sx: tenderness, swelling, enlarged joint, painful ambulation (as inflammation continues and angulation increases) Tx: Correct footwear, orthotics, pad 1st metatarsal head, tape/splint b/w 1st & 2nd toe; surgery in later stages

Longitudinal Arch Strain

Caused by: Increased stress on arch of foot Flattening of foot during mid-stance = strain on arch S/Sx: Pain below posterior tibialis tendon w/ running & jumping Pain & swelling May involve calcaneonavicular ligament sprain or flexor hallicus longus sprain Tx: RICE, reduce WB (pain-free WB ONLY), arch taping

Heel Bruise/Contusion

Caused by: Sudden starts/stops or changes of direction Irritation to fat pad S/Sx: severe heel pain, cannot WB Caution: progression to chronic bone covering inflammation Tx: PWB/NWB 24 hours, RICE, NSAIDs, Resume activity once pain subsides w/ protection Heel cup/doughnut pad w/ shock absorbent shoes Tape can generate "heel cup effect"

Diaphysis

Elongated shaft of a long bone

Shoulder Bursitis

Etiology Chronic inflammatory condition d/t trauma or overuse Direct impact or fall on tip of shoulder Signs of Injury Pain w/ motion TTP in subacromial space Positive impingement tests Management Cold packs and NSAID's to reduce inflammation Remove mechanisms precipitating condition Maintain full ROM to reduce chances of contractures and adhesions from forming

Syndesmotic "High Ankle" Sprain

Etiology Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament) Torn w/ increased external rotation or dorsiflexion In conjunction w/ medial and lateral ligaments May require extensive period of time for RTP

Eversion Ankle Sprains

Etiology Less common d/t bony protection and ligament strength Eversion force = damage to deltoid and possibly fx of the tibia Deltoid can also be impinged and contused with inversion sprains

ROM of the knee

Extension/Flexion, Internal/External Rotation, Gliding of patella in groove

Fracture (Open vs. Closed)

Extreme stress on a bone Dense connective tissue matrix Outer: compact tissue Inner: porous cancellous bone open-A fracture bone that pierces the skin. closed-broken bone with no open wound Load Characteristics Tension, compression, bending, twisting, shearing, or combo of stresses Amount of load impacts nature of fracture More force = more complex Fx Energy & force also absorbed by surrounding tissue Healing Fx Usually immobilize Approx. 6 weeks - arms & legs 3 weeks - hands & feet Osteoblasts - lay down bone & form callus After cast removal, normal stresses aid healing/remodeling Osteoclasts - re-shape bone in response to normal stress

Recognition & Management of Specific Injuries ch. 14 foot/lower leg

Foot problems are associated with: Improper footwear Poor hygiene Anatomical structural deviations Abnormal stresses Sports = stress on feet ATCs must be aware of potential problems of the foot... Identify, ameliorate, and/or prevent

Smiths' Fracture

Fracture of the distal radius with VOLAR (front of the hand) displacement. Caused by falling onto flexed wrists (less common)

Prophylactic knee bracing

Functional and Prophylactic Knee Braces Provide degree of support to unstable knee Can be custom molded and designed to control rotational forces and tibial translation

Injury classifications (e.g. Grade I vs. Grade III)

Grading System Grade I- Some pain & mild point tenderness Minimal loss of function/No abml motion Slight swelling & joint stiffness Grade II- Pain Moderate loss of function Swelling Some tearing of ligament fibers instability Grade III- Extreme pain Loss of function Severe instability & swelling Sometimes subluxed

Apley's Compression Test

Hard downward pressure is applied w/ rotation Pain indicates a meniscal injury Used to detect meniscus tear

Knee stability

Hinge joint w/ a rotational component Stability is due primarily to ligaments, joint capsule and muscles surrounding the joint

Foot Assessment (HOPS)

History: General - What? When? Where? How? Etc... Foot-specific Location of pain - heel, foot, toes, arches? Training surfaces? Changes in footwear? Changes in training, volume or type? Does footwear increase discomfort? Observations (Objective): Favoring a foot, limping, or is unable to bear weight? Does foot color change w/ weight bearing? Pes planus/cavus? How is foot alignment? Structural deformities? Wear pattern on the sole of the shoe? Symmetrical? Palpation: Bony anatomy first Deformities & tenderness Soft tissue (muscles and tendons) Point tenderness, swelling, muscle spasm or muscle guarding Circulation - dorsal pedal pulse Anterior surface of ankle and foot

Healing process/phases

Inflammatory Response Phase: begins immediately following injury Critically Important - w/o this phase others will not occur Phagocytosis - cleans injured area Chemical mediators released to facilitate healing S/Sx? (again, similar to infection) Lasts 2-4 days after injury Fibroblastic Repair Phase: occurs within initial hours of injury Proliferative & regenerative activity scar formation (fibroplasia) S/Sx of Inflammatory Phase decrease/subside Still some tenderness w/ motion pain decreases as scar develops Lasts up to 4-6 weeks Maturation-Remodeling Phase: long-term process Re-alignment of scar tissue based on tensile forces acting on tissue Maximum efficiency = parallel lines of tension Tissue gradually resumes nml appearance After 3 weeks firm, strong, contract, non-vascular scar exists Can take several years to be totally complete

Rotator cuff strains

Involves supraspinatus or rupture of other rotator cuff tendons Primary mechanism - acute trauma (high velocity rotation) Occurs near insertion on greater tuberosity Full thickness tears Athletes w/ a long history of impingement or instability (generally does not occur in athlete under age 40) Signs of Injury Present with pain with muscle contraction Tenderness on palpation and loss of strength due to pain Loss of function, swelling With complete tear impingement and empty can test are positive Care RICE for modulation of pain Progressive strengthening of rotator cuff Reduce frequency and level of activity initially with a gradual and progressive increase in intensity

Ankle Fractures/Dislocations

MOI Varies - often similar to those seen in ankle sprains S/Sx Swelling Pain may be extreme Possible deformity Tx Splint and refer to physician for X-ray and eval PRICE to control hemorrhaging and swelling Once swelling is reduced, a walking cast or brace may be applied w/ immobilization lasting 6-8 weeks Rehabilitation is similar to that of ankle sprains once ROM is normal

Bursitis of the Knee

MOI Acute, chronic or recurrent swelling Prepatellar = continued kneeling Infrapatellar = overuse of patellar tendon S/Sx Prepatellar bursitis may be localized swelling above knee that is ballotable Presents with cardinal signs of inflammation Swelling in popliteal fossa may indicate a Baker's cyst Tx Eliminate cause, PRICE and NSAID's Aspiration and steroid injection if chronic

Ganglion Cyst

round, cystic, nontender nodule overlying a tendon sheath or joint capsule, usually on dorsum of wrist. Flexion makes it more prominent. A common benign tumor; it does not become malignant.

Tendinosis

chronic tendon injury w/o inflammation Most common overuse problem in sports Pain likely occurred (was ignored) at initial injury stage improper healing

Jones Fracture

Base of 5th metatarsal (most common) Caused by: Inversion or high velocity rotational forces S/Sx: Immediate swelling Pain over 5th metatarsal May feel "pop" High nonunion rate; course of healing unpredictable Tx: Non-displaced: 6-8 weeks NWB in short leg cast Nonunion: internal fixation may be needed

Chronic Overuse Injuries

Bursitis, Tendinopathy, Tendinitis, Tenosynovitis, Tendinosis

Shoulder Anatomy

clavicle, ac joint, acronmion, coracoid process, glenoid, scapula, humerus, coracoacromial ligament, subcoracoid bursa, subscapularis tendon, bicep tendon, teres minor muscle, infraspinatus muscle, capsular ligaments, suprapinatus tendon, subacromial bursa, head of humerus

Names of fractures

greenstick, transverse, oblique, spiral, linear, comminuted

Special tests & what they assess

Use endpoint feel to determine stability Classification of Joint Instability Knee laxity includes both straight and rotary instability Translation (tibial translation) refers to the glide of tibial plateau relative to the femoral condyles As the damage to stabilization structures increases, laxity and translation also increase Valgus and Varus Stress Tests Lachman's Test Apley's Compression Test

Motions of the Elbow

Flexion,extension,rotation,pronation,supination

Epiphysis

End of a long bone

Metatarsal Stress Fractures

2nd metatarsal = "March Fx" Caused by: Changes in running pattern, mileage, hills, or hard surfaces Training errors (terrain, footwear, surfaces) Structural deformity of foot Associated w/ Morton's toe S/Sx: pain/tender along 2nd met., pain w/ running & walking, continued ache/pain when NWB Tx: find MOI, modified rest, training modifications (pool running, stationary bike) 2-4 weeks; GRADUAL (over 2-3 week period) RTP w/ good shoes

Empty Can Test

90 degrees of shoulder flexion, internal rotation and 30 degrees of horizontal adduction Downward pressure is applied Weakness and pain are assessed bilaterally

Subluxation

A partial or incomplete dislocation of a joint. S/Sx: deformity, dysfunction, swelling, point tender Tx: Always treat as Fx until R/O (esp. 1st time)

Sprain

An injury to a joint caused by the moving of the joint, such as an ankle or a knee, past its normal and safe end range of motion. With a sprain, ligaments are stretched forcefully, causing tears. Damage to a LIGAMENT (provide support to a joint) Traumatic jt. twist that stretches/tears connective tissue Synovial joint characteristics "Joint" = connection of 2 or more bones Capsule or ligament connected Capsule lined with synovial membrane Ligaments either thickened portion of capsule or separate bands Hyaline cartilage Joint cavity - synovial fluid Blood & nerve supply with muscles crossing the joint Mechanoreceptors in joint provide positional feedback Some joints have meniscus Thick fibrocartilage helping with shock absorption & stability Restoring joint stability is challenging for Grade I & II sprains Rely on other structures for stability Ex: Muscles surrounding joint Ligament stretched/torn (partially) = inelastic scar Ligament does not regain original tension Strength training (rehab) ↑ muscle tension = improve stability

Lachman's Test

At 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the femur Reduce hamstring involvement - "Relax" A positive test indicates damage to the anterior cruciate ligament (ACL)

Hip Injuies in Adolescents:Legg Calve'-Perthes Disease (Coxa Plana)

Cause of Condition Avascular necrosis of femoral head in children 4-10 y.o. Articular cartilage becomes necrotic and flattens S/Sx Pain in groin May refer to abdomen or knee Limping Varying onsets May exhibit limited ROM Tx Bed rest to ↓ chance of chronic condition Brace to avoid direct WB Early treatment head may reossify and revascularize Complication If not treated early, will result in ill-shaping and osteoarthritis in later life

Piriformis Syndrome

Cause of Condition Compression of sciatic nerve - irritation d/t tightness or spasm of muscle Similar to "sciatica" S/Sx Pain, numbness and tingling in butt May extend below knee and into foot Pain may ↑ following periods of sitting, climbing stairs, walking or running Tx Stretching and massage NSAIDs prescribed Avoid aggravating activities Corticosteroid injection Surgery

Collateral Ligament Sprains

Cause of Injury Axial force to the tip of the finger - produces the "jammed" effect Signs of Injury Severe point tenderness at the joint Collateral ligaments Lateral or medial joint instability Care Ice for the acute stage X-ray to rule out fracture and splint for support

Scaphoid Fracture

Cause of Injury Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones Signs of Injury Swelling, severe pain in anatomical snuff box Care Must be splinted and referred for X-ray prior to casting May be missed on initially Immobilization lasts 6 weeks and is followed by strengthening and protective tape Wrist requires protection against impact loading for 3 additional months Often fails to heal due to poor blood supply

Phalanx Fracture

Cause of Injury Crushed, hit by ball, twisted Multiple mechanisms of injury Signs of Injury Pain and swelling Tenderness at point of fracture Care Splint in slight flexion around gauze roll or curved splint - avoid full extension Relaxes flexor tendons Fx of distal phalanx is generally less complicated than fx of middle or proximal phalanx RICE, immobilize, splint, refer to physician

Metacarpal Fracture

Cause of Injury Direct axial force or compressive force Fractures of the 5th metacarpal are associated w/ boxing or martial arts (boxer's fracture) Signs of Injury Pain and swelling; possible angular or rotational deformity Palpable defect is possible When patient makes a fist the knuckle will be depressed or sunken Care RICE, refer to physician for reduction and immobilization Deformity is reduced, followed by splinting - 4 weeks

Acromioclavicular ("AC") Sprain

Cause of Injury Direct blow (from any direction), upward force from humerus, FOOSH Signs of Injury Grade 1 - point tenderness and pain w/ movement; no disruption of AC joint Grade 2 - tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction) Grade 3 - Rupture of AC and CC ligaments with dislocation of clavicle; gross deformity, pain, loss of function and instability Care Ice, stabilization, referral to physician Grades 1-3 (non-operative) will require 3-4 days (grade 1) and 2 weeks of immobilization ( grade 3) respectively Aggressive rehab is required w/ all grades Joint mobilizations, flexibility exercises, & strengthening should occur immediately Progress as athlete is able to tolerate w/out pain and swelling Padding and protection may be required until pain-free ROM returns

Elbow Sprains

Cause of Injury Elbow hyperextension or a valgus force Signs of Injury Pain along medial aspect of elbow Inability to grasp objects Point tenderness over the MCL Care Conservative treatment - PRICE elbow fixed at 90 degrees in a sling for at least 24 hours Gradual work on elbow ROM Athlete should modify activity Gradual throwing progression If unstable, MCL can be reconstructed Tommy John's procedure

Knee Plica

Cause of Injury Folds of synovial tissue (Infra-, supra-, mediopatellar plica) MOI Twisting knee with foot fixed; Sitting for long periods of time Signs of Injury May/may not have history of knee pain Pain with stairs, sensation of knee locking Care Rest, NSAIDs, heat Surgery if recurrent

Contusion of Upper Arm

Cause of Injury Direct blow Repeated trauma may myositis ossificans Signs of Injury Pain and tenderness Increased warmth Discoloration Limited ROM Management RICE for at least 24 hours Protect contused area to prevent repeated episodes that could cause myositis ossificans Maintain ROM

Shoulder Impingement Syndrome

Cause of Injury Mechanical compression of supraspinatus tendon, subacromial bursa and long head of biceps tendon d/t decreased space under coracoacromial arch Seen in over head repetitive activities Signs of Injury Diffuse pain TTP of subacromial space Decreased strength of external rotators compared to internal rotators; tightness in posterior and inferior capsule Positive impingement and empty can tests Care Restore normal biomechanics Strengthen RC & scapula stabilizing muscles Stretch posterior and inferior joint capsule Modify activity (control frequency and intensity)

Ulnar Nerve Injuries

Cause of Injury Pronounced cubital valgus = deep friction problem Ulnar nerve dislocation Traction injury from valgus force, irregularities w/ tunnel, subluxation of ulnar nerve due to lax impingement, or progressive compression of ligament on the nerve Signs of Injury Generally paresthesia in 4th and 5th fingers Care Conservative management - avoid aggravating condition Surgery may be necessary if stress on nerve can not be avoided

Lateral Epicondylitis ("Tennis Elbow")

Cause of Injury Repetitive microtrauma to insertion of extensor muscles of lateral epicondyle Signs of Injury Aching pain in region of lateral epicondyle after activity Pain worsens and weakness in wrist and hand develop Elbow has decreased ROM; pain w/ resistive wrist extension Care RICE, NSAIDs and analgesics Deep friction massage ROM exercises and PRE Hand grasping while in supination, avoidance of pronation motions Mobilization and stretching in pain free ranges Use of a counter force or neoprene sleeve Proper mechanics and equipment instruction

Medial Collateral Ligament (MCL) Sprain

Cause of Injury Result of severe valgus blow or outward twist Signs of Injury - Grade I Little fiber tearing or stretching Stable valgus test Little or no joint effusion Some joint stiffness and point tenderness Relatively normal ROMSigns of Injury (Grade II) Complete tear of deep capsular ligament and partial tear of superficial layer of MCL No gross instability; slight laxity Slight swelling Moderate to severe joint tightness w/ decreased ROM Pain along medial aspect of knee Signs of Injury (Grade III) Complete tear of supporting ligaments Complete loss of medial stability, meniscus disruption Minimum to moderate swelling Immediate pain followed by ache Loss of motion due to effusion and hamstring guarding Positive valgus stress test Tx RICE for at least 24 hours Crutches if necessary Knee immobilizer Isometrics and STLR exercises to bicycle riding and isokinetics Conservative non-operative approach for isolated grade 2 and 3 injuries Limited immobilization (w/ a brace); progressive weight bearing for 2 weeks Follow with 2-3 week period of protection with functional hinge brace When normal range, strength, power, flexibility, endurance and coordination are regained athlete can return Some additional bracing and taping may be required

Boutonniere deformity

Cause of Injury Rupture of extensor tendon dorsal to the middle phalanxForces DIP joint into extension and PIP into flexion Signs of Injury Severe pain, obvious deformity and inability to extend DIP joint Swelling, point tenderness Care Cold application, followed by splinting of PIP Splinting must be continued for 5-8 weeks Athlete is encouraged to flex distal phalanx

Fractures of the Humerus

Cause of Injury Shaft fx- direct blow or FOOSH Proximal fx - direct blow, dislocation, FOOSH Signs of Injury Pain, swelling, point tenderness, decreased ROM X-ray is positive for fracture Care Immediate application of splint Treat for shock and refer Out of competition for 2-6 months depending on location and severity of injury

Wrist Ganglion

Cause of Injury Synovial cyst (herniation of joint capsule or synovial sheath of tendon) Generally appears following wrist strain or repeated forced hyperextension Signs of Injury Appear on back of wrist generally Occasional pain w/ lump at site Pain increases w/ use May feel soft, rubbery or very hard Care Old method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healing New approach includes aspiration, chemical cauterization w/ subsequent pressure from pad Surgical removal is most effective way

Dislocation of Phalanges

Cause of Injury Blow to the tip of the finger (directed upward from palmar side Forces 1st or 2nd joint dorsally Results in tearing of supporting capsular tissue and hemorrhaging Possible rupture of flexor or extensor tendon(s) and/or chip fractures may also occur May be closed or open Care Reduction should be performed by physician X-ray to rule out fractures Splint for 3 weeks in 30 degrees of flexion Inadequate immobilization may lead to instability or excessive scar tissue accumulation Buddy-tape for support upon return Special consideration must be given for thumb dislocations and MCP dislocations MCP joint of thumb dislocation occurs with thumb forced into hyperextension Any MCP dislocation will require immediate care by a physician

Mallet finger

Cause of Injury Caused by a blow that contacts tip of finger avulsing extensor tendon from insertion Signs of Injury Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx Unable to extend distal end of finger (carrying at 30 degree angle) Point tenderness at sight of injury Care RICE and splinting (in extension) for 6-8 weeks

Forearm Shaft Fractures

Cause of Injury Common in youth - due to falls and direct blows Fracturing ulna or radius singularly is rarer than simultaneous fractures to both Signs of Injury Audible pop or crack followed by moderate to severe pain, swelling, and disability Edema, ecchymosis w/ possible crepitus Older athlete may experience extensive damage to soft tissue structures Care RICE, splint, immobilize and refer to physician Athlete is usually incapacitated for 8 weeks

Carpal Tunnel Syndrome

Cause of Injury Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel Result of repeated wrist flexion or direct trauma to anterior aspect of wrist Signs of Injury Sensory and motor deficits (tingling, numbness and paresthesia); weakness in thumb Care Conservative treatment Rest, immobilization, NSAID's If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament

Subungual Hematoma

Cause of Injury Contusion of distal finger causing blood accumulation in the nail bed Signs of Injury Produces extreme pain due to pressure - nail loss will ultimately occur Discoloration - bluish-purple Slight pressure on nail will exacerbate condition Care Ice pack for pain and swelling reduction Drill nail within 12-24 hours to relieve pressure Perform under sterile conditions May be required to drill a second time due to additional blood accumulation

Clavicular Fractures

Cause of Injury FOOSH, fall on tip of shoulder or direct impact Primarily middle third Greenstick fracture often occurs in young athletes Signs of Injury Supporting/guarding arm Head tilted towards injured side w/ chin turned away Clavicle may appear lower Palpation reveals pain, swelling, deformity and point tenderness Care Closed reduction - sling and swathe, immobilize w/ figure 8 brace for 6-8 weeks Removal of brace should be followed w/ joint mobes, isometrics and use of a sling for 3-4 weeks Occasionally requires operative management

Fractures of the Elbow

Cause of Injury Fall on flexed elbow or direct blow FOOSH often fractures humerus above condyles or between condyles Signs of Injury May or may not result in visual deformity Hemorrhaging, swelling, muscle spasm Care Ice and sling for support Refer to physician

Forearm Splints and Other Strains

Cause of Injury Forearm strain - most come from severe static contraction Cause of splints - repeated static contractions Creates minute tears in connective tissues of forearm Signs of Injury Dull ache between extensors Weakness and pain w/ contraction Point tenderness in interosseus membrane Care Treat symptomatically Strengthen forearm Utilize cryotherapy, thermotherapy & wraps for support and protection

Glenohumeral Dislocations

Cause of Injury Head of humerus is forced out of the joint Anterior dislocation is the result of an anterior force on the shoulder, forced abduction, extension and external rotation Occasionally the dislocation will occur inferiorly Signs of Injury Flattened deltoid, prominent humeral head in axilla; arm carried in slight abduction and external rotation; moderate pain and disability Care RICE, immobilization and reduction by a physician Begin muscle re-conditioning ASAP Use of sling should continue for at least 1 week Progress to resistance exercises as pain allows

Dislocation of the Elbow

Cause of Injury High incidence in sports caused by FOOSH w/ elbow extended or severe twist while flexed Signs of Injury Swelling, severe pain, disability May be displaced backwards, forward, or laterally Complications w/ median & radial nerves/blood vessels Often rupture/tear stabilizing ligaments Care Immobilize and refer to physician for reduction Following reduction, elbow should remain splinted in flexion for 3 weeks

Elbow Osteochondritis Dissecans

Cause of Injury Impairment of blood supply to anterior surface resulting in degeneration of articular cartilage, and bone creating loose bodies within the joint Signs of Injury Sudden pain, locking; range usually returns in a few days Swelling, pain and crepitation may also occur Care If repeated locking occurs, loose bodies may be removed surgically Without removal, arthritis may develop

Sternoclavicular ("SC") Sprain

Cause of Injury Indirect force, blunt trauma Signs of Injury Grade 1 - pain and slight disability Grade 2 - pain, subluxation w/ deformity, swelling and point tenderness and decreased ROM Grade 3 - gross deformity (dislocation), pain, swelling, decreased ROM Possibly life-threatening if dislocates posteriorly Care PRICE, immobilization Immobilize for 3-5 weeks followed by graded reconditioning

Wrist Sprains

Cause of Injury Most common wrist injury Arises from any abnormal, forced movement Falling on hyperextended wrist, violent flexion or torsion Signs of Injury Pain, swelling and difficulty w/ movement Care Refer to physician for X-ray if severe RICE, splint and analgesics Have athlete begin strengthening soon after injury Tape for support can benefit healing and prevent further injury

Hamate Fracture

Cause of Injury Occurs as a result of a fall or more commonly from contact while athlete is holding an implement Signs of Injury Wrist pain and weakness (5th digit due to ulnar nerve compression), along w/ point tenderness Care Casting wrist and thumb is treatment of choice Hook of hamate can be protected w/ doughnut pad to take pressure off area

Colles' Fracture

Cause of Injury Occurs in lower end of radius or ulna MOI is fall on extended wrist, forcing radius and ulna into hyperextension Displacement occurs posteriorly A Smith fx involves falling on flexed wrist Less common Displacement occurs anteriorly Signs of Injury Visible deformity (silver fork deformity) When no deformity is present, injury may be passed off as bad sprain Extensive bleeding and swelling Tendons may be torn/avulsed and there may be median nerve damage Care Cold compress, splint wrist and refer to physician X-ray and immobilization Without complications a Colles' fracture will keep an athlete out for 1-2 months

Wrist Tendinitis

Cause of Injury Primary cause is overuse of the wrist Repetitive wrist accelerations and decelerations Signs of Injury Pain on active use or passive stretching Tenderness and swelling over involved tendon Care Acute pain and inflammation treated w/ ice massage 4x daily for first 48-72 hours, NSAID's and rest Use of wrist splint may protect injured tendon PRE can be instituted once swelling and pain subsided (high rep, low resistance)

Medial Epicondylitis ("Pitcher's Elbow")

Cause of Injury Repeated forceful flexion of wrist and extreme valgus torque of elbow Signs of Injury Pain w/ forceful flexion or extension Point tenderness and mild swelling PROM at wrist seldom elicits pain, but active mvmt does Care Sling, rest, cryotherapy Ultrasound Analgesic and NSAIDs Curvilinear brace to reduce elbow stressing Severe cases may require splinting and complete rest for 7-10 days

Bicipital Tenosynovitis

Cause of Injury Repetitive overhead athlete - ballistic activity that involves repeated stretching of biceps tendon causing irritation to the tendon and sheath Signs of Injury Tenderness over bicipital groove Swelling & crepitus d/t inflammation Pain when performing overhead activities Care Rest and ice to treat inflammation NSAID's Gradual program of strengthening and stretching

Jersey finger

Cause of Injury Rupture of flexor digitorum profundus tendon from insertion on distal phalanx Often occurs w/ ring finger when athlete tries to grab a jersey Signs of Injury DIP can not be flexed, finger remains extended Pain and point tenderness over distal phalanx Care Must be surgically repaired Rehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re-rupture

Gamekeeper's finger

Cause of Injury Sprain of UCL of MCP joint of the thumb Mechanism is forceful abduction of proximal phalanx occasionally combined w/ hyperextension Signs of Injury Pain over UCL in addition to weak and painful pinch Tenderness and swelling over medial aspect of thumb Care Immediate follow-up must occur If instability exists, athlete should be referred to orthopedist If stable, X-ray should be performed to rule out fracture Thumb splint should be applied for protection for 3 weeks or until pain free

Plantar Fasciitis

Caused by: ↑ stress on fascia Change in footwear (rigid/supportive soft/flexible) Poor running technique Change training surface Leg length discrepancy Excessive pronation (pes planus) Inflexible longitudinal arch Tight gastroc-soleus complex S/Sx: Ant. medial heel pain (along long. arch); worse in AM, loosens after first few steps, pain w/ forefoot dorsiflexion Extended Tx required (8-12 weeks) Orthotics (soft w/ deep heel cup) Arch taping Night splint Vigorous stretching (heel cord) Exercises to ↑ great toe dorsiflexion NSAIDs Steroid injection (occasionally)

Subungual Hematoma

Caused by: Direct pressure\Dropping object on toe Repetitive shear forces to toenail S/Sx: blood accumulation under toenail, extreme pain, nail loss (sometimes) Tx: RICE for pain/swelling Relieve pressure w/in 12-24 hours Lance/drill nail (Caution - infection)

Retrocalcaneal Bursitis ("Haglund's Deformity")

Caused by: Inflammation of bursa under Achilles tendon Pressure/rubbing of shoe heel counter Chronic condition (longer resolution) Exostosis ("pump bump") may occur DDx - Sever's disease S/Sx: inflammation, TTP (sup. & ant. Achilles insertion), "bump" on calcaneus, swelling both sides of heel cord Tx: stretch Achilles, heel lift (reduce stress), donut pad (reduce pressure), change footwear (change height of heel counter)

Metatarsal Fractures

Caused by: direct force or torsional/twisting stress on bone DDx difficult Fx vs. Sprain X-ray necessary S/Sx: Swelling, pain, point tender, deformity (?) Tx: Symptomatic RICE for swelling Short leg walking cast once swelling subsides 3-6 weeks

Fractures & Dislocations of the Phalanges

Caused by: kicking unyielding object, stubbing toe, being stepped on S/Sx: Immediate/intense pain Swelling & discoloration Obvious deformity (if dislocated) Tx: Dislocation reduced by physician Casting may occur with great toe (or stiff soled shoe) Buddy tape generally sufficient Shoe may need larger toe box

Bony anatomy of foot

Consists of 26 bone, 5 phalanges make up toes Metatarsal bones tarsal bones Medial structures- first metatarsal, medial cuniform, intermediate cuniform, lateral cuniform navicular, talus Lateral structures - Distal phalanx, middle phalanx, proximal phalanx, fifth metatarsal cuboid, calcaneus

Gross Anatomy of the bone

Diaphysis - shaft Hollow, cylindrical, covered with compact bone Epiphysis - ends of long bone ("growth area") Covered with articular cartilage (protection/cushion) Periosteum - covers outer layer of long bones (except ends) Dense, white, fibrous Contains blood vessels (nutrition) & osteoblasts (growth/repair)

Types of fractures

Degree:Simple (closed), compound (open), greenstick (splintering of inner bone surface),Patterns: transverse ( fracture line perpendicular to long axis of bone), spiral (fracture line encircling bone), oblique (Fracture line at an angle to long axis of bone), Linear (parallel to the long axis of the bone Character: Comminuted (multiple bone frags), compression (fracture wedged or squeezed together on one side of bone) Impacted (fracture frags pushed into each other)

Periosteum

Double-layered connective tissue that covers and nourishes the bone. covers outer layer of long bones

Osgood-Schlatter Disease and Larsen-Johansson Disease

MOI An apophysitis occurring at the tibial tubercle D/T repeated pulling by tendon Cartilagenous bony callus, enlarging the tubercle Larson-Johansson disease involves inferior pole of patella Resolves w/ aging S/Sx Swelling, hemorrhaging & gradual degeneration of the apophysis d/t impaired circulation Pain with activity and tenderness Conservative Care Reduce stressful activity until union occurs (6-12 months) Padding may be necessary for protection Possible casting Ice before and after activity Isometrics

Joint Contusions

MOI Blow to the muscles crossing the joint S/Sx Present as knee sprain: severe pain, loss of movement and acute inflammation Swelling, discoloration Tx PRICE Gradual progression to normal activity following return of ROM and padding for protection If swelling does not resolve w/in a week a chronic condition (synovitis or bursitis) may exist requiring more rest

Stress Fracture of Tibia or Fibula

MOI Common overuse condition, esp. athletes w/ structural and biomechanical insufficiencies Repetitive loading during training S/Sx Pain with activity Pain more intense after exercise than before Point tenderness Difficult to discern bone and soft tissue pain Bone scan results Tx Eliminate offending activity Discontinue stress inducing activity 14 days Use crutch for walking WB when pain subsides After pain free for 2 weeks athlete can gradually return to activity Biomechanics must be addressed

Acute Patella Subluxation or Dislocation

MOI Deceleration w/ simultaneous cutting in opposite direction (valgus force at knee) Quad pulls the patella out of alignment Some athletes predisposed to injury Repetitive subluxation weaken medial restraints Female > Males S/Sx Subluxation: pain and swelling, restricted ROM, palpable tenderness over adductor tubercle Dislocations: total loss of function First time dislocation = assume fx Tx Immobilize and refer to physician for reduction Ice around the joint Following reduction, immobilization for at least 4 weeks w/ use of crutches After immobilization period, horseshoe pad w/ elastic wrap used to support patella Muscle rehab focusing on muscle around the knee, thigh and hip are key STLR's are optimal for the knee

Groin Strain

MOI Difficult to diagnose Often in early season d/t poor strength & flexibility Running, jumping, twisting w/ hip external rotation or severe stretch Signs of Injury Sudden twinge or tearing during active movement Produce pain, weakness, and internal hemorrhaging Tx PRICE, NSAID's and analgesics for 48-72 hours Determine exact muscle or muscles involved Rest! Restore normal ROM and strength -- provide support w/ wrap Refer to physician if severe groin pain is experienced

Hip Injuies in Adolescents:Acute Fracture of Pelvis

MOI Direct blow or blunt trauma S/Sx Severe pain Loss of function Shock Tx Immediately treat for shock Refer to physician Seriousness of injury dependent on extent of shock and possibility of internal injury

Hip Injuies in Adolescents:Iliac Crest Contusion ("hip pointer")

MOI Direct blow to iliac crest or abdominal musculature S/Sx Pain, spasm, and transitory paralysis of soft structures ↓ rotation of trunk or thigh/hip flexion d/t pain Tx PRICE for at least 48 hours NSAIDs, Bed rest 1-2 days in severe cases Referral for X-ray Padding used upon RTP to minimize chance of added injury

Shin Contusion

MOI Direct blow to lower leg (impacting periosteum anteriorly) S/Sx Intense pain Rapidly forming hematoma w/ jelly like consistency Increased warmth Tx PRICE, NSAIDs and analgesics PRN Maintain compression for hematoma May need to aspirate Doughnut pad and orthoplast shell for protection

Fracture of Patella

MOI Direct or indirect trauma (severe pull of tendon) Forcible contraction, falling, jumping or running S/Sx Hemorrhaging and joint effusion w/ swelling Indirect fractures may cause capsular tearing, separation of bone fragments and quadriceps tendon tearing Little bone separation w/ direct injury Management X-ray necessary for confirmation of findings PRICE and splinting if fracture suspected Refer and immobilize for 2-3 months

Quadriceps Contusions

MOI Exposure to traumatic blows S/Sx Pain ↓ function Immediate bleeding of affected muscles Early detection & avoidance of internal bleeding ↑ recovery rate and prevents muscle scarring Tx PRICE and NSAIDs Crutches for severe cases Isometric quadriceps contractions as soon as tolerated Heat, massage and ultrasound to prevent myositis ossificans Padding for additional protection upon RTP

Achilles Tendinitis

MOI Inflammatory condition involving tendon, sheath or paratenon Tendon is overloaded d/t extensive stress Gradual onset and worsens w/ continued use Decreased flexibility exacerbates condition S/Sx Generalized pain and stiffness, localized proximal to calcaneal insertion Warmth and pain w/ palpation Thickened cord May progress to morning stiffness Tx Resistant to quick resolution due to slow healing nature of tendon Reduce stress on tendon address structural faults (orthotics, mechanics, flexibility) Aggressive stretching and use of heel lift may be beneficial NSAIDs

Patellar Tendinosis (Jumper's Knee)

MOI Jumping or kicking - placing tremendous stress and strain on patellar or quadriceps tendon Sudden or repetitive extension may lead to inflammatory process S/Sx Pain and tenderness at inferior pole of patella and on posterior aspect of patella with activity Tx Avoid aggravating activities Ice, rest, NSAID's Patellar tendon bracing Transverse friction massage

Meniscus Injuries

MOI Medial meniscus is more commonly injured d/t ligamentous attachments and ↓ mobility Rotary force w/ knee flexed or extended while weight bearing is most common S/Sx Effusion developing over 48-72 hour period Joint line pain and loss of motion Intermittent locking and giving way Pain w/ squatting Tx Immediate care = PRICE If the knee is not locked, but indications of a tear are present further diagnostic testing may be required Treatment should follow that of MCL injury If locking occurs, anesthesia may be necessary to unlock the joint w/ possible arthroscopic surgery follow-up W/ surgery all efforts are made to preserve the meniscus -- with full healing being dependent on location Menisectomy vs. Meniscal repair

Femoral Fractures

MOI More common in auto accidents (significant force) Less common in sports S/Sx Shock, pain, swelling, deformity Be aware of bone displacement and gross deformity Loss of function Tx Treat for shock Verify neurovascular status Splint before moving Reduce following X-ray Activate EMS

Posterior Cruciate Ligament (PCL) Sprain

MOI Most at risk during 90 degrees of flexion Fall on bent knee is most common mechanism Can also be damaged as a result of a rotational force S/Sx Feel a "pop" in the back of the knee Tenderness and swelling in the popliteal fossa Laxity w/ posterior sag test Tx RICE Non-operative rehab of grade I & II injuries should focus on quad strength Surgical versus non-operative care

Achilles Tendon Rupture

MOI Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension Commonly seen in athletes > 30 years old Generally patient has history of chronic inflammation S/Sx Sudden snap ("kick in the leg") w/ immediate pain that rapidly subsides Point tenderness, swelling, discoloration, decreased ROM Obvious deformity & positive Thompson test Tx Usually surgical repair for serious injuries Non-operative treatment: PRICE, NSAIDs, analgesics, & non-weight bearing cast for 6 weeks Regain normal ROM gradual and progressive strengthening program

Muscle Strains

MOI Quadriceps Strain Sudden stretch when athlete falls on bent knee or experiences sudden contraction Associated with weakened or over constricted muscle Hamstring Strain (various theories) Hamstring and quad contract together Change in role from hip extender to knee flexor Fatigue, posture, leg length discrepancy, lack of flexibility, strength imbalances, etc... S/Sx Pain, point tenderness, spasm, ↓ function, discoloration Peripheral tear = fewer symptoms than deeper tear Complete tear often = little disability and discomfort but some deformity Tx - Determine extent of injury early PRICE to control internal bleeding Neoprene sleeve may provide some added support Ballistic stretching and explosive sprinting avoided initially

Compartment Syndrome

MOI Rare acute traumatic syndrome due to direct blow or excessive exercise May be classified as acute, acute exertional or chronic S/Sx Excessive swelling compresses muscles, blood supply and nerves Deep aching pain and tightness Weakness with foot and toe extension Occasionally numbness in dorsal region of foot Tx May present as medical emergency requiring surgery to reduce pressure or release fascia PRICE, NSAIDs and analgesics PRN Avoid use of compression wrap = increased pressure Surgical release is generally used in recurrent conditions May require 2-4 month recovery (post surgery) Conservative management requires activity modification, icing and stretching Surgery is required if conservative management fails

Myositis Ossificans

MOI Repeated blunt trauma S/Sx X-ray shows calcium deposit 2-6 weeks post-injury Pain, weakness, swelling, decreased ROM Tissue tension and point tenderness Tx Conservative Surgical removal required if too painful and restricts motion May return if removed too early Recurrent condition may indicate problem with blood clotting

Hip Injuies in Adolescents:Stress Fractures

MOI Repetitive abnormal overused forces S/Sx Groin pain w/ aching sensation in thigh Discomfort ↑ w/ activity and ↓ w/ rest Tx Refer to physician X-ray Rest for 2-5 months

Medial Tibial Stress Syndrome ("Shin Splints")

MOI Repetitive microtrauma Strain of posterior tibilalis muscle and fascial sheath attachment to periosteum of distal tibia during running Stress fractures, muscle strains, chronic anterior compartment syndrome, periosteum irritation Weak muscles Improper footwear Training errors Varus foot, hypermobile or pronated feet, and forefoot supination Tight heel cord Signs of Injury Diffuse pain on disto-medial aspect of lower leg As condition worsens ambulation may be painful, w/ ↑ morning pain and stiffness Can progress to stress fracture if not treated Tx Physician referral for X-rays and bone scan Activity modification Correction of abnormal biomechanics Arch taping and orthotics Ice massage to reduce pain and inflammation Flexibility program for gastroc-soleus complex

Hip Labral Tears

MOI Repetitive overuse (e.g. running or pivoting) Acute trauma (e.g. dislocation) S/Sx Often present as asymptomatic Causes clicking, locking, or catching Pain in the groin; stiffness; limited ROM Tx Exercises to maintain ROM, strength & stability Avoid aggravating activities NSAIDs, corticosteroids Surgical repair

Iliotibial Band Friction Syndrome (Runner's Knee)

MOI Repetitive/overuse conditions attributed to mal-alignment and structural asymmetries Result of repeated knee flexion & extension S/Sx Irritation at ITB insertion Tenderness, warmth, swelling, and redness over lateral femoral condyle Pain with activity Tx Correction of mal-alignments Ice before and after activity, proper warm-up and stretching; NSAID's Avoidance of aggravating activities

Tibial and Fibular Fractures

MOI Result of direct blow or indirect trauma S/Sx Pain, swelling, soft tissue insult Leg will appear hard and swollen (Volkman's contracture) Deformity - may be open or closed Tx Immediate treatment should include splinting, ice, and medical referral Restricted WB for weeks/months depending on severity

Loose Bodies in the Knee

MOI Result of repeated trauma Possibly stems from osteochondritis dissecans, meniscal fragments, synovial tissue or cruciate ligaments S/Sx May become lodged, causing locking or popping Pain and sensation of instability Tx If not surgically removed it can lead to conditions causing joint degeneration

Ankle Tendinosis

MOI Singular cause or collection of mechanisms Footwear, mechanics, trauma, overuse, limited flexibility S/Sx Pain & inflammation Crepitus Pain with AROM & PROM Tx Rest, NSAIDs, modalities Orthotics

Chondromalacia patella

MOI Softening and deterioration of the articular cartilage Abnormal patellar tracking Bony alignment Quadriceps weakness Pelvis width S/Sx Pain w/ walking, running, stairs and squatting Possible recurrent swelling, grating sensation w/ flexion and extension Tx Conservative measures PRICE, NSAID's, isometrics for strengthening Avoid aggravating activities Surgical possibilities

Lateral Collateral Ligament (LCL) Sprain

MOI Varus force, generally w/ the tibia internally rotated Direct blow is rare S/Sx LCL pain and tenderness Swelling and effusion Joint laxity w/ varus testing Tx Following management of MCL injuries depending on severity

Sprains of the Hip Joint

MOI Violent twist due to forceful contact Force from opponent/object or trunk forced over planted foot in opposite direction S/Sx Acute injury w/ inability to circumduct hip Pain in hip region, w/ hip rotation increasing pain Tx X-rays or MRI performed to r/o fx PRICE, NSAIDs and analgesics Crutches may be required if severe ROM and PRE once hip is pain-free

Anterior Cruciate Ligament (ACL) Sprain

MOI Deceleration with foot planted and turn in the direction of the planted foot forcing tibia into internal rotation May be linked to inability to decelerate valgus and rotational stresses - landing strategies Females > Males Much research re: impact of femoral notch, ACL size and laxity, malalignments (Q-angle), & faulty biomechanics Extrinsic factors may include: conditioning, skill acquisition, playing style, equipment, preparation time Can involve damage to PCL, meniscus, capsule, MCL "Unhappy Triad"? S/Sx Experience "pop" w/ severe pain and disability Rapid swelling at the joint line Positive anterior drawer and Lachman's Care RICE; use of crutches MRI, Arthroscopy may be necessary to determine extent of injury Could lead to major instability w/ high performance W/o surgery joint degeneration may result Age and activity may factor into surgical option Surgery may involve joint reconstruction w/ grafts (transplantation of external structures, i.e. tendon) Will require brief hospital stay and 3-5 weeks of a brace Also requires 4-6 months of rehab

Hip Injuies in Adolescents:Avulsion Fractures

MOI Pulling of tendon away & off of bony insertion Sports w/ sudden accelerations and decelerations Common sites: ASIS (sartorius) AIIS (rectus femoris attachment) Ischial tuberosity (hamstring) S/Sx Sudden localized pain w/ limited movement Pain, swelling, point tenderness Tx Rest Limited activity Graduated exercise

Dislocated Hip

MOI Rarely occurs in sport Traumatic force directed along the long axis of femur S/Sx Flexed, adducted and internally rotated hip Palpation reveals posteriorly displaced femoral head Serious pathology Soft tissue, neurological damage and possible fx Tx Immediate medical care! Reduction - contractures may complicate 2 weeks immobilization Crutch use for at least one month

Contusions

MOI: sudden blow to body Deep or superficial Hematoma (blood & lymph flow into surrounding tissue) Minor bleeding = discoloration of skin (bruising) TTP w/ active mvmt. More severe injuries if repeated blows sustained Ex: calcium deposits within soft tissue Myositis ossificans (protection & rest = calcium reabsorption) Quads & biceps very susceptible Prevention: protective padding

ankle sprain Treatment

Manage pain and swelling Horseshoe-shaped foam pad for focal compression Apply wet compression wrap to facilitate passage of cold from ice packs surrounding ankle Apply ice for 20 minutes and repeat every hour for 24 hours Continue over the course of the next 3 days Keep foot elevated as much as possible Avoid WB for at least 24 hours Begin WB as soon as tolerated RTP should be gradual and dictated by healing process

Hip Injuies in Adolescents:Slipped Capital Femoral Epiphysis

Management W/ minor slippage: rest and NWB may prevent further slippage Major displacement requires surgery If undetected or surgery fails severe problems will result

MOI

Mechanism of Injury

Foot anatomy

Metatarsal arch Transverse arch Medial longitudinal arch, lateral longitudinal arch Plantar Fascia

Soreness (e.g. DOMS)

Muscle Soreness - pain from overexertion in strenuous exercise Usually after activity someone is not accustomed to Acute-onset: transient muscle pain immediately after exercise Accompanies fatigue Delayed-Onset Muscle Soreness (DOMS): pain occurring 24-48 hours after activity Gradually subsides (pain free 3-4 days later) Potentially d/t microtrauma to muscle/connective tissue Prevention: progression/build-up into activity Tx: static/PNF stretching, cryotherapy (ice) within 48-72 hours

Injury prevention - hamstring: quad ratio

Physical Conditioning and Rehabilitation Total body conditioning is required Strength, flexibility, cardiovascular and muscular endurance, agility, speed and balance Muscles around the hip and knee must be conditioned to maximize stability Shoe Type Use of cleats that allow for foot control but that do not fix foot to the ground

Ankle anatomy

Posterior talofibular ligament, calcaneofibular ligament, anterior talo fibular ligament, fibula, tibia, ant/post tibiofibular ligaments, deltoid ligaments

Test for Sternoclavicular Stability

Pressure applied superiorly, inferiorly & anteriorly to assess for pain and stability

Test for Acromioclavicular Stability

Pressure applied to distal end of clavicle in 4 directions

Recognition & Management of Specific Injuries Ch. 15 The Ankle and Lower Leg

Preventing Injury in the Lower Leg and Ankle Achilles Tendon Stretching Tight heel cord may limit dorsiflexion Before and after practice Performed with knee extended and flexed 15-30 degrees Strength Training Static and dynamic joint stability Develop balance & strength throughout the range Neuromuscular Control Training Controlled uneven surfaces balance board Appropriate Footwear Can reduce injury Shoes worn for intended use only Preventative Taping and Orthoses Tape may provide prophylactic protection Can disrupt normal biomechanical function and cause injury if improperly applied Lace-up braces may also be effective in controlling ankle motion

Prevention of shoulder injuries

Proper physical conditioning Strengthen through FROM Rotator cuff muscles in all planes of motion Incorporate scapula stabilizing muscles Enhances base of function for glenohumeral joint Warm-up before explosive arm movements Proper instruction on falling Protective equipment Throwing mechanics

Functional testing & RTP

RTP when all areas have returned to normal Continued bracing may be required

Graded Ankle Sprains

Signs of Injury Grade 1 Mild pain and disability; WB is minimally impaired; point tenderness over ligaments and no laxity Grade 2 Feel or hear pop or snap; moderate pain w/ difficulty bearing weight; tenderness and edema Positive talar tilt and anterior drawer tests Possible tearing of the anterior talofibular and calcaneofibular ligaments Grade 3 Severe pain, swelling, hemarthrosis, discoloration Unable to bear weight Positive talar tilt and anterior drawer tests Instability d/t complete ligamentous rupture

Ankle Ligament Injuries

Sprains Single most common injury in athletics Sudden inversion or eversion moments Severity of sprains is graded (1-3) Inversion Sprains Most common injury to the lateral ligaments Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus

Strain

Strain = stretch, tear, or rip to muscle Grading System Grade I - some fibers stretched/torn Pain & tenderness w/ AROM FROM present Grade II - # of fibers torn Active contraction painful Palpable divot usually Some swelling & discoloration Grade III - complete rupture of muscle/musculotendinous junction Significant impairment Intense pain initially diminishes d/t nerve damage Large tendon ruptures require surgery

Commonly injured bursa

Subacromial bursa. This bursa is located between the arch of the acromion above and the humerus below.

Olecranon Bursitis

Superficial location = susceptible to injury (acute or chronic) Cause of Injury Direct blow Signs of Injury Pain, swelling, and point tenderness Swelling will appear almost spontaneously and w/o usual pain and heat Care In acute conditions, ice Chronic cases require protective therapy If swelling fails to resolve, aspiration may be necessary Can be padded in order to return to competition

Avulsion fracture

Tendon or ligament pulls bone away at site of attachment

Special tests The Thigh, Hip, Groin, and Pelvis

Thomas Test- Test for hip contractures Assesses hip flexor tightness Iliopsoas Rectus femoris Straight Leg Raise- Test for hip extensor tightness May also be used to assess low back, SI joint dysfunction, sciatic nerve pain

Apprehension Test

Used to assess anterior glenohumeral instability This motion should not be forced

Throwing Mechanics Phases

Windup Phase First movement until ball leaves gloved hand Lead leg strides forward while both shoulders abduct, externally rotate and horizontally abduct Cocking Phase Hands separate (achieve max. external rotation) while lead foot comes in contact w/ ground Acceleration Max external rotation until ball release (humerus adducts, horizontally adducts and internally rotates) Scapula elevates and abducts and rotates upward Deceleration Phase Ball release until max shoulder internal rotation Eccentric contraction of ext. rotators to decelerate humerus while rhomboids decelerate scapula Follow-Through Phase End of motion when athlete is in a balanced position

Bursitis

inflammation of bursa Bursa - fluid-filled sac in area of friction Acute or Chronic (sudden vs. repetitive external compression/irritation) ↑ fluid production, pressure S/Sx: swelling, pain, dysfunction Most common: subacromial, olecranon, & prepatellar

Tenosynovitis

inflammation of synovial sheath Acute - rapid onset, crepitus, & diffuse swelling Chronic - thickening of tendon w/ pain & crepitus Common in long flexor tendons of fingers Tx: similar to tendinitis NSAIDs may help

Tendinitis

inflammation of the tendon