FACULTY OF SPORT AND PHYSICAL EDUCATION Foundation Degree in Science in Sports Therapy Student ID Number: 9900543251 Module Code: Introduction to Assessment and Treatment EXCE1156 Module Leader: Tammy Emmins Submission Date: 29/11/2024 Table of Contents Table of Contents i List of Tables and Figures ii Abbreviations iii Introduction 1 Types, Common Sign and Symptoms of a Sport Injury 1 Lateral Ankle Sprain Injury 4 Ankle Sprain Grades, Signs and Symptoms 5 Cryotherapy, Thermotherapy and Its Applications 6 Common Risk Factors for a Range of Sport Injuries 7 The Relation between Common Risk factors and Mechanisms of an Injury 11 References 12 i List of Tables and Figures Figure 1, Classification of sporting injuries Brukner et al., (2017, pp. 14) 2 Figure 2, Classification of Contact as a Mechanism for Sudden-Onset Injuries (The International Olympic Committee Injury and Illness Epidemiology Consensus Group et al., 2020). 3 Figure 3, Signs and Symptoms of acute and chronic sports injuries (Babarinde et al., 2017) 3 Figure 4, A close-up of a foot and ankle (Cork, 2016) 4 Figure 5, Ankle Fundamental ROM (BMJ, 2021) 5 Figure 6, Ligaments injury grades of a lateral ankle sprain (Sportnova Team, 2019) 6 Figure 7, Intrinsic factors related to the risk of injury in athletes reported by the participants. (Saragiotto et al., 2014) 9 Figure 8, Extrinsic factors related to the risk of injury in athletes reported by the participants. (Saragiotto et al., 2014) 10 Figure 9. Comprehensive model for injury causation. (Bahr & Krosshaug, 2005) 11 ii Abbreviations ACL Anterior Cruciate Ligament ATFL Anterior Talofibular Ligament BMI Body Mass Index CFL Calcaneofibular Ligament Cm Centimetre/s COD Change of Direction DOMS Delay Onset Muscle Soreness MSK Musculoskeletal OA Osteoarthritis PTFL Posterior Talofibular Ligament ROM Range of Movement iii Introduction In sports medicine, sports injury and its definition has been discussed by Timpka et al., (2014), regard the lack of common resources and records of health issues, developed by athletes in sports participation. The authors suggest sports injury as a subdivision of sports impairment, denoted as “the loss of bodily function or structure that would be observed in a clinical examination” (Timpka et al., 2014). Micheo & Sanchez, (2018) defined sports injury as a pathological process, in which an athlete may require time off from training or competition, in order to seek medical attention due to trauma. Both the authors agreed, from different perspective, that sports injury is related to the disfunction or impairment an athlete incur, during sport participation, resulting in medical or therapy intervention. Through the years, there has been an incremental impact of sport-related injuries due to the greater involvement in recreational activity, which has resulted in substantial and almost inevitable incidents, in needs of trustworthy preventive measure (Hopkins et al., 2016; Dreinhöfer et al., 2007). Despite the acknowledgement of musculoskeletal injuries raise, specific statistic of sport-related injury, are inadequate and difficult to compare; there are a range of many injuries that are common to a variety of sports, however, the same injury can differ between individuals, by the mechanism and activity performed while occurred, including factors related to the single or multiple individuals pre and during the injury event (Werner et al., 2023; Dreinhöfer et al., 2007). Types, Common Sign and Symptoms of a Sport Injury Brukner et al., (2017, pp. 13-15, 29-34) defined the musculoskeletal sports injury of an athlete, as the damaged occurred to tissues, while competing or training, of which may be categorised as acute or overuse, based on the mechanism of injury and rapidity of the onset symptoms (Fig.1). The International Olympic Committee Injury and Illness Epidemiology Consensus Group et al., (2020) described, an acute episode, as a sudden injury derived from a specific, identifiable event, due from a transfer of kinetic energy, for example, an unwanted inversion of the foot, while performing a change of direction (COD) when walking or running, due to a collision between players (Halabchi, F., & Hassabi, M., 2020); conversely, the overused episode, is defined by the authors as a gradual onset injury that lack from a well-defined traumatic event and is caused from a progressive accumulation of loading over time, for example, a reoccurring ankle sprain from foot misplacement while jumping, due to laxity, looseness at the joint with increased unstable ROM, of which, the patient may describe as the ankle “giving way” (Mugno et al., 2023). It is worth mention that, in their article, the authors 1 consider a third onset injury, combining acute and overused mechanisms; an example would be, an athlete who developed a tendinopathy due to their overtraining regime, resulting in weakness, sustaining a tendon rapture, due to a collision or jump. Figure 1. Classification of sporting injuries Brukner et al., (2017, pp. 14) The relation between the categorisation of an injury, as Bruce et al., (2015) suggested, includes the mechanisms of an injury, which involve the transmission of force directly or indirectly the injured body part. The International Olympic Committee Injury and Illness Epidemiology Consensus Group et al., (2020) created and published a helpful table (Fig. 2), classifying the mechanism of an acute injury. 2 Figure 2. Classification of Contact as a Mechanism for Sudden-Onset Injuries (The International Olympic Committee Injury and Illness Epidemiology Consensus Group et al., 2020). Different Injuries may be identified by common signs and symptoms, related to the stage the injury is presented, the tissue affected and how far in time the event occurred; pain, swelling, bruising, stiffness, instability as difficulty to bear weight, and limited range of motion (ROM) are common in ankles, knees and shoulders injuries involving tissue strains and sprains (Dalton & Schweinle, 2006; Hare et al., 2017; Caroline et al., 2005); headache, dizziness, confusion, nausea, vomiting and sensitivity, might be seen in musculoskeletal (MSK) injuries, however, these signs and symptoms are commonly related to sport-related concussion (McCrory et al., 2016). ☓ Figure 3. Signs and Symptoms of acute and chronic sports injuries (Babarinde et al., 2017) 3 Lateral Ankle Sprain Injury Fong et al., (2007) rates, the ankle injury across different sports, such as track and field, basketball, tennis, hockey, football, volleyball, and gymnastic, the highest and most common issue between athletes, with a 45% ratio, of all athletic injuries encountered. The 75% of the injuries in sports, which involve the ankle, are lateral sprains from inversion and plantar flexion of the foot, caused by a misplacement, while changing direction, walking, running, or jumping (Ferran & Maffulli, 2006). In a more recent study, Van Middelkoop et al., (2012) retrieved enough data, to affirm the requirement of more than one year for over 50% of the athletes in the case study, to fully recover from long-term disability, and eventually regain optimal performance, led from an ankle sprain; the author linked the injury, to an increased risk of osteoarthritis (OA) and articular degeneration, underlying particular concerns. Figure 4. A close-up of a foot and ankle (Cork, 2016) Anatomically, the foot can be subdivided into three main areas, the hindfoot, also referred as the rear foot including tibia, talus, and calcaneus bones, the midfoot, comprise of navicular, cuboid, and cuneiforms), and the forefoot, toes and metatarsals (Dutton, 2016). The lateral complex, situated in the hindfoot, are the predominant ligaments that suffer from an ankle inversion sprain, formed by the anterior talofibular (ATFL), the posterior talofibular (PTFL), and the calcaneofibular (CFL), respectively connecting fibula with talus and calcaneus (Dutton, 2016; Zulak et al., 2018). Despite the anatomical complexity of the ankle and foot, Halabchi, F., & Hassabi, M., (2020), recognised and stated the ligaments involvement rate, as high as 4 85% of all ankle injuries, of which, 65% of the cases, isolate the ATFL, 20% includes both the ATFL and CFL, and a smaller percentage involve the PTFL. Ankle Sprain Grades, Signs and Symptoms Brukner et al., (2017, pp. 19-27) graded the damage of the tissue by the severity, pain and ROM the articulation possesses as grade one, two or three. Grade one is defined by mild stretching of the tissue, with light tears and instability (<20% of full rupture), oedema and ecchymosis might be present, influencing the ROM and function of the ankle joint, which could partially impact the ability to bear weight, the patient might be restricted from activity for no longer than one week, with full return to participation between two to three weeks (Glascoe, Allen, Awtry, & Yack, 1999); grade 2 would show a tear or partial rupture of a tissue, with mild oedema and ecchymosis (20% to 80% of full rupture), the patient can experience difficulties to bear weight, and instability with mild functional loss at the articulation suggesting the stop of activity for two to three weeks, with return to play between four to six weeks (Glascoe, Allen, Awtry, & Yack, 1999); grade 3 appears as full disruption of the ligament or tendon (>80%), with hard instability and impossibility to bear weight. It shows immediate oedema and ecchymosis with great loss in functionality and stability of the joint (Mugno et al., 2023). The recovery time can vary widely depending on the treatment provided, indicatively, from six weeks to three or more months before the patient would be able to return to participation (Konradsen, Holmer, & Sondergaard, 1991). x Figure 5. Ankle Fundamental ROM (BMJ, 2021) 5 Figure 6, Ligaments injury grades of a lateral ankle sprain (Sportnova Team, 2019). Cryotherapy, Thermotherapy and Its Applications Nadler et al., (2004), define cryotherapy and thermotherapy as techniques used on acute and chronic injuries in response to pain, reducing the action of its transmission, through signal sent by nociceptors to the brain, which are specific sensory neurons that detect damaged tissues and harmful stimuli all over the body. The author specify cryotherapy, “as the therapeutic application of any substance to the body that removes heat from the body, resulting in decreased tissue temperature.” The effects of cryotherapy on the body are pathophysiological, and further than act as “psychological pain reduction”, it decreases blood flow, by causing vasoconstriction to a depth of 2 to 4 centimetres (Cm), reduces tissue metabolism, oxygen utilization, inflammation, and muscle spasm (Nadler, Weingand, & Kruse, 2004; Nadler, 6 Weingand, & Stitik, 2001). It is interesting how Nadler et al., (2004), in his article concluded positively to continuous cold-water treatment, and intermitting compression, as extremely effective technique related to post traumatic oedema, rather than cool packs. However, the authors also referred to ice packs and ice message therapy as preferable, when a quick recovery is needed, for example at side pitch. It is worth mention how in a most recent study, Alharbi, (2020) agreed and reinforce the use of cold therapy treatment as injury approach, to reduce the pain perceived from an individual. Nadler et al., (2004) describes thermotherapy as “the therapeutic application of any substance that adds heat to the body, resulting in increased tissue temperature”. Thermotherapy works as analgesic over pain, however, the physiological effects are opposite; the increment in blood flow, facilitates tissue healing by supplying fresh nutrients, oxygen, and proteins to the affected body part, while the raised metabolism, given from the higher tissue’s temperature, aids the waste and repair process, of the injury. Multiple studies have been conducted of the use of thermotherapy and its application; demonstrating that continuous low-level heat therapy applied directly on the skin, would be therapeutically effective in treating musculoskeletal disorders like tendinopathy, joint contractures, muscle spasms and osteoarthritis, acute muscular pain, menstrual pain, and DOMS (Nadler, Weingand, & Kruse, 2004). In case of a lateral ankle sprain, following the studies provided by the authors, a first application of intermittent cryotherapy, and compression, is indicated to reduce oedema and ecchymosis in the affected area. The cold therapy should be applied as close as possible to the traumatic event, cold packs, gels or ice are ideal at first, however, on the long term, lowlevel cold, for example a cold towel wrapped around the ankle, or a cold whirlpool, would be beneficial to reduce pain and swelling. Thermotherapy also can be applied as soon the inflammation ends; the vascularisation would help the damaged tissue to receive fresh blood flow, carrying nutrients useful to the restoring process. It is indicated to use cryotherapy and thermotherapy depending on the specificity and severity of the injury, and the condition and sensitivity, of each individual, whether in needs of immediate action, post-surgery, or delay onset muscle soreness (DOMS) varying the duration of the therapy case by case. Common Risk Factors for a Range of Sport Injuries Drawer & Fuller, (2002) stated the relation between sports injuries and osteoarthritis (OA) as long-term result, an unacceptable burden for the healthcare settings and costs, in the early 2000s. Wiggins et al., (2017), reported an increment in sports incidence rate, between 15- and 7 25-years old athletes, noting that, major injuries and case studies referred to the lower limbs, as part of the body majorly stress. Both the authors included in the research, the aim to categorize and understand common risk factors that would influence the event of injury, identifying high practice hours, absence or improper warm up routine, inadequate sports facilities, and the younger age, especially 14 to 17 years old, as common risk factors. Recent analysis by Al-Qahtani et al., (2023) reviewed, and confirmed the aforementioned risks factors, including body mass index (BMI), physical activity patterns, age, gender, sport type, previous injuries, and training practice. In an in-depth study, Saragiotto et.al (2014) interviewed 30 members of the medical and technical department who participated in the Pan American Games of Guadalajara in 2011, questioning what could have been the main causes of injury in the athletes who took part of the event, and what they would have done, in order to prevent them. The conclusion generated from the study, again, reinforce as main risk factors the above cited overtraining, athlete’s skills, fitness and behaviours, and incorrect sports technique and facilities (Fig. 7; Fig. 8). It is interesting how all the authors in their studies, concluded emphasizing the needs to target injury prevention strategies and detail of the mechanisms of injuries, related to intrinsic and extrinsic risk factors. 8 An example list, with potential data related to intrinsic risk factors. Figure 7. Intrinsic factors related to the risk of injury in athletes reported by the participants. (Saragiotto et al., 2014) 9 An example list, with potential data related to extrinsic risk factors. Figure 8, Extrinsic factors related to the risk of injury in athletes reported by the participants. (Saragiotto et al., 2014) 10 The Relation between Common Risk factors and Mechanisms of an Injury In their article, Bahr & Krosshaug, (2005), emphasise a comprehensive multifactorial model approach to injury, based on Meeuwisse (1994) research, by deeply looking into the caused of internal and external risk factors and inciting event as mechanisms of injury (Fig 9). This models and study have been used since, in order to understand and perfection sports injury prevention strategies. The authors accentuated the importance of the description of every detail, in order to recreate the factorial line causing the inciting event. The model illustrated is a concise confrontation of the traditional biomechanical approach of an injury event, to a more targeted and descriptive mechanism, which involve the particular type of injury, in a specific sport, considering all the key factors and, possible adaptations during the event itself (Bahr & Krosshaug, 2005). Figure 9. 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