Flashcards: KNES 372

divide back and front (adduction and abduction)

divide top and bottom (rotation)

NO

B

A

Rotation: a kind of movement around a single point, away or towards midline

Circumduction: combination of movement to make circular movement

- Physician, Therapist, Strength and conditioning coach, Exercise physiologist, Sport psychologist, Biomechanist, Nutritionist, etc.

Diagnosing the athletes condition and prescribing the treatment

prevention, management, treatment and rehabilitation of injuries

Rehabilitation of more serious injuries/rehabilitation after surgery

Establishing and maintaining a strength and conditioning program

exercise prescription and testing

helping athletes to cope with competitive fears, mental skills, preparing for RTS, how to handle emotions after setbacks, etc.

biomechanical assessments to enhance performance and prevent injury

education of athletes and support staff on how nutrition can enhance performance, recovery and health

the scope of practice and standard of care.

describes the services that a qualified healthcare professional is deemed competent to perform and permitted to undertake

– in keeping with the terms of their professional license.

Medical treatment guideline.

It specifies appropriate treatment based on scientific evidence and collaboration between medical and/or psychological professionals involved in the treatment of a given condition.

Teamwork!

Communication between athlete and coach is extremely important

- 1st part of injury prevention lies with the coach

- coach is influenced by money, winning, etc. (must communicate well for mutual benefit)

SEM team should be there for the player's health and safety, but will also have a secondary goal of winning (NEVER at the athlete's expense)

- Injury/re-injury

- reduced team or individual performance

- career loss (player and staff)

- interpersonal conflicts

- broken trust (athlete or coach)

- mental health issues

- set-back in rehab

- medical-legal

- much less people apart of the team: parents, student volunteers, coaches

- if injured = parent/athlete are in charge of themselves

- go to your own physio/doctor (money barriers)

- much less communication

- everyone is involved even in minor injuries

- intense injuries require much more mental health support through fear of returning/contact (that is possible)

The process of identifying risks (assessment, evaluation, control)

1. Within/across sport: policies

2. Club/team level: train for risk prevention, equipment, training safety

3. Individual level: train to treat injuries

is a process of measurement/estimation of risks to teams and athletes

involves determining the significance and acceptability of the risks

is a process of identifying and implementing methods to control the risks and the consequences

- Injury surveillance

- Pre-season screening

- Monitor "at risk" team members

- Education

- Emergency Action Plan (EAP)

1. environment

2. equipment

3. athlete

- Field and surroundings

- Weather conditions

- EAP

- protective equipment

- special training equipment

- first aid kit

- AED

- medical issues

- previous injuries

- training history

- age

- sex

describe a possible change in behavior in an athlete when they use protective equipment.

- The theory is that the person will assess the level of risk, and if they assess that the protective equipment reduces that risk, they will simply undertake more extreme activities to return the risk to a level they are comfortable with.

- BE PREPARED!

- Emergency action plan is critical to facilitate a rapid and effect response to an emergency

- EAP should be prepared for practice and competition sites

• Charge person (designated for action and can ask for help = most capable for injuries)

• Call person

• Cell phone - Important phone numbers (EMS, facilitymanager)

- Instructions to EMS how to reach thefacility

• First Aid Kit

• Automated External Defibrillator (AED)

• Ambulation aid (crutches, wheelchair, spineboard)

1. Communication sheet (plasticized)

• Important phone numbers

• Address of facility, access(directions/map)

• Nearest hospital directions

2. Information where AED, spine board, etc. are located

3. Player/staff medical profile cards

• Name and emergency contact information

• Medical profile (e.g.,asthma, allergies)

• Is not breathing

• Does not have a pulse

• Is bleeding profusely

• Has impaired consciousness

• Has injured the back, neck or head

• Has a visible major trauma

• Cannot move arms or legs (or has lost feeling in them)

- EAP coordinator (charge person)

- Immediate AED access

- Trained personnel and annual practice

- Communication system

- Venue-specific EAP

- Medical timeout before each competition (between home and visiting team)

- Maintenance and monthly checks of AEDs (and document it! = prevent medical lawsuit)

Kinesiology A

• Main, Floor, across from Client Services Desk

• Main Floor, Aquatic Centre, next to change rooms

Kinesiology B

• Basement floor, Jack Simpson Gym entrance, next to emergency help phone

• 2nd floor, Jack Simpson Gym entrance, beside west elevator

• Main floor, near east main fire panel, MacEwan Hall link entrance

• Main floor, across from Sports Medicine

• Main floor, Racquet Centre, next to emergency help button

• Main floor, Human Performance Lab, outside B103

• 2nd floor, Human Performance Lab, outside B2225

Method of documentation

- standardized way to store medical info.

S (subjective information/history) = what player told you

O (objective information) = what you see, measurable

A (assessment) = what you conclude

P (plan) = what you do about it

*prevents medical lawsuits and helps SEM team

- happier

- play more

- common in sports = best you can

- burden on the healthcare system

17, 655

• 1 in every 3 youth (aged 11-18) in Canada seek medical attention for a sport-related injury every year

• Lower extremity injuries (60%) and concussions (20%)

- LE injuries: 60% knee and ankle

- Concussions: Hockey and rugby over 50%

• Highest burden –> hockey (10%), basketball (10%), soccer (10%)

• Participation in S&R (decrease)

• School/work attendance (decrease)

• Physical activity (decrease)

• Overweight/obesity + other health implications (increase)

• Osteoarthritis (ankle & knee joint injuries) (increase)

• Psychosocial consequences

• Health care and indirect costs are high

- Primary physio/doc appointment

- referral to sports med doc.

- imaging

- surgical consult

- pre-surgical physio

- surgery

- etc.

• Sport mastery and associated opportunities (U Sports, NCAA, Pro)

- 65% with ACL reconstruction for a total rupture played at the same level 3 years after (*in professional male Soccer).

- In elite athletes, at 2 years after ACLR surgery, 79.6% were still playing, 51% at the same level

Modifiable risk factors

• E.g., equipment, training, body weight, flexibility

Non-modifiable risk factors

• E.g., weather, growth, age, sex, previous injury

prevent injury before it even starts to occur (decrease injury chance)

detecting injury in early stages to prevent worsening

arresting the progression of injury and addressing the issues

• Training strategies

• Rule modification

• Equipment

• Training programs to improve fitness/movement quality (n=64)

• New or modified sport equipment (n=33)

• New or modified rules (n=19)

• Education (n=14)

• Training programs to improve psychological and/or cognitive skills (n=6)

• Policy change (n=5)

• Multi-component/multiple interventions (n=14)

Training programs to improve fitness/movement quality

- prevent injury

- improve skills, coordination and control

- increase reaction speed and power

- increase joint stability

- foundational movement

- warm up

- e.g. ACL is not fatigued based = neuromuscular

Regular neuromuscular training (NMT) can reduce injury rates up to 70%

Tissue loading = don't want to overload joints/ligaments = want to use proper muscles

Valgus, external rotation

- includes meniscus, MCL injury

- slow down in direction change

- bend knees for direction change

- avoid valgus position (use abductors/glutes)

- knees above toes = joint safety

- straight spine

- heels on ground

- head directly forward

- 90 degree angle

- slow lower

- maintain straight line (no pronation, no valgus)

Associations between injuries and:

• Rapid increases in training loads

• Insufficient practice vs. competition

• Too little variation in training load (monotony)

• Spikes in training load

*don't increase too quickly

*periodization = phases of training

External: work performed (quantifiable: intensity, duration, and frequency of exercise)

Internal: body's response (specific to the exercise type)

Sum of movement and structure specific loads (e.g. step, throw, jump, direction change)

- different between individuals

- strength capacity, injury history, biomechanics, size/weight

- Better to be multisport

- DONT early specialize

- increasing chance of injury

Athletes are classified as

• Low (score = 0-1)

• Moderate (score = 2), or : 2.61

• High (score = 3) specialization. :4.74

Injury may result from a clear acute mechanism (acute injury), clear repetitive mechanism (overuse injury), or from a combination of both mechanism.

• Acute injury → Sudden onset (single event)

• Overuse injury → Gradual onset (repetitive)

• Overuse injury → Sudden onset (single event / repetitive)

• Soft-tissue injuries → cartilage, muscle, tendon, ligament

• Skeletal injuries → bone

• Acute injuries → bleeding (hematoma)

• Articular cartilage: flexible cartilage, provides smooth surface for joint movement (end of bones)

• Fibrocartilage: a tough cartilage, able to absorb loads (e.g., discs of the spine,meniscus)

Tendon: muscle to bone

Enthesis: where a tendon or ligament attaches to bone

Ligament: bone to bone

Sprain: stretching or tearing of ligaments/joint capsule

Strain: stretching or tearing of muscle/tendons

Fracture: partial or complete break in a bone

Rupture: severe injury in which a part of your body (often internal) tears or bursts open

1. Hemostasis: Stop the leak

2. Inflammation: Clean Up!

3. Proliferation: Rebuild!

4. Remodeling: Increase tissue strength!

Stop bleeding (clot)

• Process to prevent and stop bleeding when injury occurs → Results in formation of a clot

• Steps:

a) Vascular spasm

b) Formation of platelet plug

c) Blood clotting (coagulation cascade)

d) Formation of the final clot

• Platelet release growth factors

*min/hrs

• Defensive response of tissues to a physical or chemical injury, or bacterial infection

• Recruitment of cells to destroy debris and bacteria:

a) Neutrophils – for the first 48 hours

b) Macrophages – peak around 48–72 hours

c) Lymphocytes – appear after 72 hours

• Indicated by redness, warmth, swelling, pain, and dysfunction

*days

Angiogenesis

• Formation of new blood vessels

• Restore blood flow

Fibroblast migration

• Fibroblasts produce collagen fibers and elastin

• Result = granulation tissue which replaces the clot

Epithelialization

• Epithelial cells cover denuded epithelial surface

Wound retraction

• Contraction of the wound

*weeks

• Granulation tissue matures into scar

• This stage may last several months-years (Important implications for return to sport!)

• Form & function of the scar tissue depend on loading during this stage

• Never achieve the same level of tissue strength than before injury! (~80%)

*months/years

- Bone & soft tissue respond to loading → remodel accordingly

- Healing structures need to be exposed to progressive loads.

• Nutrition

• Hypoxia

• Infection

• Immunosuppression

• Chronic disease

• Wound management

• Age

• Genetics

• Surgical technique

Goals:

• Limit bleeding (Too much bleeding slows healing)

• Limit swelling

• Relieve pain

- Improve conditions for subsequent treatment and healing

PEACE and LOVE

1. Protect

• Unload or restrict movement for 1-3 days

2. Elevate

• Elevate the limb higher than the heart

3. Avoid

• NSAIDs

• Ice

4. Compress

• Helps limit edema and hematoma

5. Educate

• Educate patients on the benefits of active approach to recovery

*EARLY

1. Load

- Active approach with movement and exercise benefits most patients

2. Optimism

- Optimistic patient expectations are associated with better outcomes

3. Vascularisation

- Cardiovascular activity is a cornerstone in the management of injuries

4. Exercise

- Exercises help to restore mobility, strength and proprioception early after injury

*Subsequent

1. Acute stage

- Days

• PEACE

• (PRICE, POLICE)

2. Subacute stage

- (Rehabilitation stage)

- Weeks

• LOVE

3. Chronic stage

- (Training stage)

- Months

• LOVE

• DO NO HARM!

• ESSENTIAL that treatment begins as soon as possible!

• In the 3 days following acute injury, avoid:

- Heat – hot baths, hot showers, saunas, heat packs

- Moderate-Vigorous-strenuous activity – e.g. walking briskly, running

- Massage

Can disrupt inflammation

- only used to help pain management

Injury may result from a clear acute mechanism (acute injury), clear repetitive mechanism (overuse injury), or from a combination of both mechanism.

• Acute injury → Sudden onset (single event)

• Repetitive injury → Gradual onset (repetitive)

• Repetitive injury → Sudden onset (single event / repetitive)

repetitive injuries

- can be either gradual onset or sudden onset repetitive injuries'

- sudden onset occurs when they have a preexisting condition that causes the injury to occur right then

• It has been suggested that ice could disrupt the inflammation as well as the proliferation phases.

• Therefore, potentially, impairing tissue repair.

• BUT ice can effectively relieve pain

• Tissue never achieve the same level of tissue strength than before injury!

- It can reach up to 80% of it’s original strength.

• Form and function of the scar tissue depend on loading the tissue during this stage

– injured area needs proper loading!

• Don’t confuse the tissue strength of the injured area and function!

• Re-injury most often in the same location

• If the injury has gained enough strength, then the biomechanical weak-point becomes the interface between the scar tissue, and regenerating skeletal muscle fibre (weak point is the perimeters of scar tissue/where scar tissue meets regular tissue)

- Age; Sex

- Details of injury

- Training program & training history

- Diet

- History of previous injury General health

- Work/and leisure activities

- Other predisposing factors

- Inspection

- Palpation

- ROM testing

- Strength testing

- Ligament testing

- Neural testing

- Spinal examination

- Bio-mechanical examination

Active: patient moving on their own

Passive: clinician moving joint for the patient

*single leg squat is a good way to check biomechanics (look for valgus/over pronation)

X-ray (Radiography)CT (Computed Tomography)US (Ultrasound)MRI (Magnetic resonance imaging)

*imaging may overreport so its not 100% reliable

- what imaging finds may not be relevant to the patient

- delaying imaging may be more effective (less overreporting)

- this is why an effective SEM team is important

The healing process NOT time

1. Acute

2. Rehabilitation

3. Training

Acute injury:

• PEACE/PRICE/POLICE

Repetitive injury:

• Partial unloading of the injured structure

• The loading pattern must be altered!

*PPP may also be effective

1. Monitor pain and swelling

2. Ensure normal ROM

3. Ensure normal strength

4. Ensure normal neuromuscular function

5. Ensure normal aerobic capacity

- It is necessary to tolerate some pain

*Gradually increasing pain and/or swelling needs to be reduced

• Normal ROM is a prerequisite for returning the athlete to normal technique

• Reduced ROM limits ability to do strength and other training!

• Often Manual Muscle Test

– The Oxford Scale (0-5) (very subjective :()

• Consider, what is normal? (each person is unique)

• Sport, Limb Dominance etc.

• Strength v Endurance

• Equipment v No Equipment

• 10-15% often used as marker

• Painful conditions may result in reflex inhibitions → changes in movement patterns → unfavorable loading pattern → INCREASED RISK OF RE-INJURY

• Acute ligament injuries may also result in reduced joint position sense and coordination → INCREASED RISK OF RE-INJURY

• Proprioceptive training

• Progressive strength training (injured structures)

• Sport specific aerobic fitness

• Modifiable intrinsic risk factor for injury. . . Remember?

• Maintaining general strength and endurance

• Well performed alternative training will allow the athlete to return to sport sooner

• Training that affects the injured structures

• The amount, intensity, frequency, duration and exercises depend on the injury

• Highly repetitive training

• Weekly consultation with a physiotherapist

• Manual treatments: e.g., massage, manipulation, dry needling, vacuum cupping

• Taping, bracing

• Electrophysical agents: e.g., therapeutic ultrasound, laser, shockwave therapy

• Medication: e.g., NSAIDs, corticosteroids

• Dietary supplements: e.g., vitamin D, glucosamine

1. Gradual transition from controlled rehabilitation exercises to sport specific training

2. Functional and sport specific testing to determine whether an athlete can tolerate sport specific training loads

3. Necessery that at least 85-90% of original strength is regained before being allowed to compete again

- each RTS process should be defined according to sport and level of participation

- return to participate

- return to sport

- return to perform

• Functional and sport-specific conditioning tests play an important role in RTS decision-making

• Assessing readiness to RTS

• Tests assessing the athlete’s readiness to RTS should consider both closed (fixed environment) and open (less predictable) skills

• Psychological readiness is also an important element for optimal RTS

• RTS criteria: acute knee injuries, acute hamstring injuries, groin injury, Achilles tendon injuries, and shoulder injury

*RTS is a SHARED decision

*athletes often think they are further along in rehab than they truly are

low back pain occurs in ~10% of youth athletes

*spine extensions (back arch) puts pressure on spine and youth athletes are more likely to fracture

*pars interarticularis is the spine segment typically affected

1) Bone stress reaction (Posterior element overuse syndrome)

2) Fracture (Spondylolysis)

3) Slipping of vertebra (Spondylolisthesis)

- Excessive extension and rotation loads

- Improper technique

- Hyperlordosis

• History, physical and neurological examination

• Imaging: e.g., X-ray, MRI, single-photon emission computed tomography (SPECT)

• Pain management*

• Pain free activities – avoiding extension

• Physiotherapy: core strength, anti-lordotic exercises, hamstring and iliopsoas stretching

• Return to sport within 4-8 weeks

*early detection is essential (don't want it to become a stress factor)

- Week 1: short walks and stretching

- Weeks 2-9: static stabilization exercises (core)

- Weeks 6-12: dynamic strength exercises

- Weeks 9-12: low impact aerobic training

*RTS between 6 months and 1 year

• Recognition of risk factors

• In youth athletes → reduced training during rapid growth

• Proper techniques!

• Core strength

• Hamstring and hip flexor flexibility

Where the abdomen meets the lower limbs via pelvis

• Most common groin injury

• Pain during sprinting, direction changes, and kicking

• Pain in the insertion of the adductor longus

• History and physical examination (palpation and resisted adduction test)

• MRI is used to grade the injury extent from 0 to 3:

0 = no acute injury

1 = edema only

2 = structural disruption

3 = complete tear

• Exercise therapy programs

- Hölmich Exercise program (chronic groin pain)

- Progressive groin exercise program (acute groin injury)

Treatment of Chronic Adductor-Related Groin Pain

• Isometric and dynamic exercises to reactivate the adductor muscles (2 weeks)

• Heavier resistance training, balance and coordination (6-10 weeks)

• Jogging is allowed after 6 weeks (if pain free)

• No stretching of the adductor muscles during this period!

*Sport specific training progressively after the program

- Nine groin exercises

- Alternate days 3 times a week

- No groin pain allowed during the exercises

• Three milestones:

1. Clinically pain free

2. Controlled sports training

3. Full team training → RTS

• Athletes with an MRI grade 0-2 adductor injury

- Usually return to full team training after 3 weeks

• Athletes with an MRI grade 3 adductor injury

- Usually return to full team training within 3 months

• Dense bands of collagen tissue

• Collagen, elastin, proteoglycan, and other proteins

• Vary in size, shape, orientation and location

• Connect one bone to another → Passive stabilization of the joints

• Ligaments can creep

• Serve important proprioceptive function

• Healing follows the constant pattern

• Ligament scars have inferior creep properties

• Ligament injury → decreased proprioception

the interaction between the passive, active and neural subsystems

consists of non-contractile connective tissues (ligaments, bones, cartillage)

controlled by the neural subsystem to provide dynamic joint stability (tendon and muscle) (dynamic joint stability)

1. Intra-articular ligaments (within joint) e.g. cruciate ligaments of the knee

2. Extra-articular ligaments (additional support structure) e.g. calcaneofibular ligament

3. Capsular ligaments (thickening of joint capsule) e.g. anterior talofibular ligament

Best: capsular ligament

Worst: Extra-articular ligament

1. Adapt slowly to increased loading, but weaken very rapidly as a result of immobilisation

2. Adapt to loading by increasing the cross-sectional area3. Normal everyday activity is sufficient to maintain mechanical properties4. Systematic training can increase ligament strength by 10-20%

*TYPICALLY INJURED BECAUSE OF ACUTE TRAUMA

- REPETITIVE INJURIES RARE, BUT CAN OCCUR AS THE LIGAMENT IS GRADUALLY STRETCHED OUT

e.g. UCL repetitive pitching injury

SUDDEN OVERLOAD → LIGAMENT IS STRETCHED (JOINT IN AN EXTREME POSITION)

Grade 1• Mild• Structural damage on the microscopic level• No instabilityGrade 2• Moderate• Partial tear• Swelling & Pain• No/limited instability

*LaxityGrade 3• Severe• Full rupture• Significant swelling• Instability

Joint play, implies movement, but ligament is still intact

Implication: Patellar dislocation/subluxation

Implication: MCL +/- ACL

Implication: ACL +/- MCL +/- lateral meniscus +/- bone bruise

Implication: PCL

Implication: ACL

Implication: Degenerative Meniscal tear

1. Did you feel or hear a rip, pop or tear?

2. Did something come out of place?

3. Knee or Knee-cap?

4. Where is the pain?

When did the swelling occur? Min? Hours?

• ACL injury• MCL sprain• Lateral dislocation of patella• Meniscus injury• Lateral tibial plateau fracture or bone bruise

bleeding into the joint

Do: ACL tear; Peripheral meniscus tear; Osteochondral injuries; Fractures

Don't: MCL tear; Central meniscus tear; PCL tear; Cartilage injury

1. Anteromedial bundle resists tibial anterior translation2. Posterolateral bundle resists tibial rotation• No pain fibers, but has proprioceptive fibers (usually traumatic e.g. bone bruise which makes it painful)

Pivot shift test!

- or an MRI, but they often are only used with a locked knee (torn fibrocartilage in the meniscus)

- Osteochondral injury- ACL injury and Meniscus tear- Osteoarthritis in 15-20 years- Unhappy Triad (MCL, ACL, lateral meniscus)

causes a locked knee

- 20% of repairs fail

To prevent subsequent injuries, such as osteochondral injuries and meniscus injuries

• Modification of activity (no twisting activity)• Bracing for light twisting activity• ACL reconstruction (although functional – never normal)

- the graft is weakest at 3-6 months

- high re-injury rates over 2 years after reconstruction

*can use hamstring tendon or patellar tendon

hamstring tendon = skiing (patellar tendon is used lots when skiing and is much more invasive)

*doesn't use bone = has a higher chance of being lax :(

patellar tendon

*more invasive surgery

Simple decision rules

Returning to Level 1 sport after ACL reconstruction leads to a more than 4-fold increase in reinjury rates over 2 years

- pelvis larger

- flexible

- strength

- biomechanical

- hormones

- training (modifiable)

• Weak hip abductors an external rotators• Increased knee abduction moments during cutting and landing

• Adolescent female soccer players (n=4600)• 64% reduction in the rate of ACL injury was seen in the intervention group

- Although current ACL injury prevention training programs have been successful in reducing injuries in controlled research settings, the real-world ACL injury rate remains high, and even continues to increase- The ACL injury rate for girls/women has not changed in over 20 years, and they remain up to 6 times more likely to experience injury compared with boys/men- In addition, as many as 40% sustain a recurrent ACL injury in the same knee or new ACL injury in the contralateral knee

Due to poor athlete and coach buy-in!

1. coracoacromial ligament

2. coracohumeral ligament

3. glenohumaral ligaments

*stability formed from the rotator cuff

complete separation of articulating bones

partial dislocation of articulating bones

- Direct blow to the posterior aspect of the shoulder

- Landing on outstretched arm• Anterior dislocation• Fracture dislocation

1. History & Physical examination2. Imaging3. Reduction of the shoulder (after confirmed diagnosis)4. Protection from re-injury5. Rehabilitation period prior return to sport

- 50-90% depending the type of sport and shoulder dominance- Surgical management (in high-risk population)- Rehabilitation of the shoulder is critical to long-term function

- strength

**Neuromuscular control

• Collagen tissue• Connects muscle to bone• Transfer force from muscles into skeletal system• Excellent tensile properties

1. Tendon

2. Tertiary fiber bundle

3. Fascicle

4. Subfascicle

5. Collagen fiber

6. Collagen fibril

• Junction between a tendon and a bone• Fibrocartilage• Enthesopathy (disorder)

• Connection between tendon and muscle• Susceptible for injury

• Relationship between stress and deformation of tendons is the same as for ligaments

- Tendons adapt to training by increasing cross-sectional area- Tendon loading every 2-3 days- Compared to muscles, it takes longer time to gain tendon strength

Repetitive tendon injuries

• Tendons are most often affected by repetitive injuriesAcute tendon injuries• Direct trauma• Rupture

Umbrella term used for tendon problems

• Repetitive tensile (or compressive) loading (e.g., sprinting, jumping, changing direction) → repetitive microtraumas• Inadequate recovery between loadings

1. Reactive tendinopathy• Non-inflammatory, structural changes & thickening of stressed tendon area2. Tendon disrepair• Worsening tendon pathology, tendon structure becomes disorganized3. Degenerative tendinopathy• Chronic stage

• Can't recover

***Need to catch EARLY

- adiposity

- pre-existing conditions (e.g. diabetes)

- age

- menopause

- previous injuries

- extra weight (loading)

- uneven ground

- type of sport

- periods of deconditioning (e.g. covid)

History: Symptoms often progress (start low)• First pain after exercise• Then pain at the start of an activity• Finally pain both during and after activity

Physical Examination• Palpation – tenderness

Imaging: US, MRI (not very usuful)

- Education of patients (long time to recover, pathology may still exist in the absence of pain)- Load monitoring - Pain monitoring (will still have)- Exercise based progressive rehabilitation program

****DO NOT REST for tendon injury (except acute)

Stage 1: Isometric exercises (joint doesn't move, allogenic in nature/pain relief)

Stage 2: Isotonic & Heavy slow resistance exercises (movement with contraction. Concentric (muscle shortens) or eccentric (muscle lengthens))

Stage 3: Increase in speed and energy storage exercises (if pain = decrease level)

Stage 4: Energy storage and release & Sport specific exercises

• Shock wave therapy, laser, and ultrasound• Medications (e.g. anti-inflammatory)• Injectable therapies (can be bad for tendon cells)• Passive treatments• Experimental treatments (e.g. STEM cell)• Surgery

*Conservative treatment

• Acute rupture of a normal and healthy tendon is rare• Commonly occur in athletes and recreational exercisers aged 30-50 years

Eccentric force generation:

•Mid-tendon area•Bone-tendon junction

Achilles tendon, Supraspinatus tendon:

•Partial rupture•Complete rupture

- Active mid-aged recreational athletes- High risk of injury: rapid direction changes, jumps- Usually occur without warning (degenerative changes)

Strong contracture of the lower leg musculature, with simultaneous extension• ECCENTRIC LOADING of the tendon

- Acute, intense pain

- Audible ‘SNAP’

- Reduced power in plantar flexion

- ‘Gap’ in the tendon tissue

- Bruise and swelling

- Ultrasound/MRI

- Conservative vs. Surgical repair (end-to-end suture)- Cast- Rehabilitation- Return to Sport

takes pressure off, so that tendon heals in the shortest position (still elastic after recovery)

61.3% of NFL players were able to successfully RTS at a mean 11.90 months following a primary AT rupture.

- neuromuscular training

*Proper loading

Generate power

- muscle cells (fibers)

muscle shortens to overcome resistance

(concentric and eccentric)

- rapid response to training

- neural and muscular factors (neural 1st)

- muscle fibers increase their cross-sectional area (hypertrophy)

1. Direct trauma

• Contusion• Muscular laceration

2. Distension ruptures

• Muscle strain

3. Other

• DOMS• Myositis ossificans (calcification of muscle tissue, caused from trauma)• Muscle cramps

- Muscle bruise- External force- Contact sports, team ball sports- Most common site is the quadriceps

- Tensile forces- Usually close to MTJ- Hamstrings, quadriceps, gastrocnemius- Pop, bump, swelling*Pain on active contraction and passive stretch, reduced contraction strength, decreased ROM and loss of function

Grade 1 – Mild• ‘Few fiber’ injury, minimal loss of strength and motionGrade 2 – Moderate• Tissue damage, decreased ability to contract and decreased ROM (large spectrum)Grade 3 – Severe• Complete tear, complete loss of muscle function

• Type I – Sprinting-related hamstring strain (biceps femoris)• Type II – Stretching-related hamstring strain (semimembranosus)

• History & Physical examination- Mechanism- Palpation• Imaging- MRI

• History & Physical examination- Mechanism- Palpation• Imaging- MRI

**Higher up

• Destructive Phase (Hemostasis & Inflammation)• Repair Phase (Proliferation)• Maturation Phase (Remodeling)

1. Mobilization2. Progressive strengthening (concentric)3. Functional exercises (e.g., running program)4. Other body regions (other muscles help do tasks, want to work effectively)

High reinjury = decrease by doing lengthening (eccentric) during rehab = more beneficial compared to concentric

**No evidence stretching helps

- LOADING

- no evidence on stretching

*eccentric training (new and recurrent prevention)

• Protects our internal organs• Provides the body its basic shape• Facilitates movement• Provides a framework for support

• Traumatic fracture (e.g., accidents and sports) - major trauma

• Pathological fracture (e.g., osteoporosis and cancer) - 2nd to disease

• Fatigue fracture (e.g., stress fracture and atypical femoral fracture) - stress

1. long bone

2. short bone

3. flat bone

4. irregular bone

these bones do not have a definite shape like the previous three types.

e.g. vertebra, pelvis

In MEDULLARY CAVITY

- Yellow: fat storage

- Red: create RBCs

• Lamellar bone– Slowly formed, highly organized– Parallel layers of anisotropic matrix of mineral crystals and collagen fibers• Woven bone– Quickly formed, poorly organized– Randomly arranged mineral and collagen fibers– Sites of fracture healing, tendon/ligament attachments

25% water, 32% organic matrix (collagen), 43% apatite mineral

• Bone is a dynamic tissue• Constantly remodeling in response to its mechanical environment• Adapts to best resist the loads experience during habitual activity• Mechanical stimuli = bone strain (or some consequence thereof)

Load causes bone to develop cortical bone and withstand pressure

1. Driven by dynamic, rather than static, loading2. Only a short duration of loading is necessary; extended loading durations have diminishing adaptive returns3. Bone cells accommodate to customary loading making them less responsive to routine loading signals

• Traumatic fracture – caused by acute high energy trauma

• Pathologic fracture – caused by minimal trauma in a weak, diseased, or fragile bone

• Fatigue fracture – caused by accumulation of microtrauma associated with repetitive loads

* Traumatic and pathological fracture when the applied load exceeds the bone’s strength* Fatigue fracture when number of repetitive loads exceeds the bone’s fatigue life

biomechanical

• Closed fracture – bone does not break through skin• Open fracture/Compound fracture – bone breaks through skin. These carry high risk of infection

Transverse: straight across

Linear: in the middle

Oblique non-displaced: angle attached

Oblique displaced: angle detached

Spiral: from rotational force

Greenstick: side

Comminuted: shattered

Fluctuating loads are MORE detrimental than monotonic loads

Human cortical bone– Monotonic load failure = 190 MPa– Cyclic load failure = <30 MPa (107 cycles)

*increasing magnitude of stress, greatly decreases the number of cycles to failure

1. Inflammatory phase2. Reparative phase3. Remodeling phase

*overlap

• Immobilizes the fractured bone and activates cells for repair• Hematoma formation• Vasodilation and serum exudation• Infiltration of inflammatory cells• 3-7 days

• Primary callus response• Inflammation triggers cell division and growth of new blood vessels• Chondrocytes secrete collagen and proteoglycans to form fibrocartilage• 2 weeks

• Endochondral ossification• Direct bone formation by osteoblasts• Soft callus turns to hard callus made of woven bone• 2 weeks

• Modeling and remodeling of fracture site• Gradually restores original shape and internal structure• Woven bone replaced by secondary lamellar bone• Can last for many years

• Pain and tenderness• Swelling and bruising• Deformity and loss of motion/function• Protruding bone

*Reduction and Immobilization• Splinting and bracing• Plaster or fiberglass casting• Bandages and orthoses

When conservative treatment fails or fracture is highly displaced or unstable– Intramedullary rods– Locking and stabilizing plates

Internal: placed inside the bone, or on the outside of the bone

External: outside of the skin holding bone on the inside

• Bone grafts

• Stem cell therapy

• Mechanical stimulation

– Ultrasound

– Electricity and magnetic fields

*Not tested

*Efficacy?

rheumatoid arthritis

– Arthro – joint– -itis – inflammation– Rheuma - fluid

– Fluctuating joint pain and swelling– Morning stiffness, usually > 1 hour, better with moving and heat.– Systemic symptoms (weight loss, fatigue)– Joints affected MCP + wrist > PIP + MTP > knees + shoulders + ankles > elbows + hips >> other

- Rheumatoid nodules

- May start as a monoarthritis, but often evolves into a small joint, symmetrical, polyarthritis.- 90 % of all affected joints will be affected in the first year.

a. Weight loss.b. Fevers .c. Night sweats.d. Morning stiffness.e. Fatigue

a. Subcutaneous nodules in 20 %.b. Pulmonary involvement in 50 %.c. Cardiac involvement in 5 %.d. Eye involvement in up to 35 %.e. Neurologic, rare to common findings.f. Renal, rare.g. Muscular, disuse atrophy very common.h. Rheumatoid vasculitis, rare.

autoimmune

– Refers to diseases in which the patient’s own immune system is at the centre of the disease process– The immune system is stimulated to act against ‘self’– When the immune system is stimulated it can produce antibodies to self antigens, and inflammatory mediators which cause tissue damage

– Infections• Viruses eg. Cytomegalovirus, Herpes virus, Rubella, EBV• Bacteria eg. Staph, Strep, Borelia (Lyme disease)• Mycoplasma– Autoantigens-Type 2 collagen- Proteoglycans- Chondrocyte- Immunoglobulins (IgG)

• Genetic factors are responsible for 50-60% of the risk associated with RA, HLA-DRB1 and HLA-DR4 genes are associated with an increased risk of RA or more severe disease.• Environmental factors such as smoking and sex hormones also play a role

1. To prevent or control joint damage.2. To preserve or prevent loss of function.3. To decrease pain and swelling.

– Non-pharmacological– Pharmacological– Surgical– Alternative

– Lifestyle adjustments– Physiotherapy– Occupational therapy

• Rest• Smoking cessation ( risk of RA in smokers)• Reduced stress• Healthy eating (?anti-inflammatory diets, fish oils).• Education– patient needs to learn about their illness and needs to play arole in its management

• Decreases joint pain and stiffness.• Improves ability to carry out activities of daily living.• Enables better sleep and relaxation.• Strengthens muscles and tendons to take stress off of joints.

• Helps to maintain a healthy weight, obese patients have worse RA than non-obese patients.• Improves sense of well being.• Decreases likelihood of medical complications.• Enables participation in “fun” activities with friends and family

• Range of motion.• Endurance/aerobic exercise.• Strengthening exercise.

- Performed at least once a day– Gentle assisted movement through the joint’s normal range, to prevent contracture– Isometric “static muscle contraction” exercises to maintain muscle tone without increasing inflammation– These exercises should not be pushed into pain & any discomfort felt after exercising should settle within one hour– Build up new exercises gradually so that you can differentiate between the ‘normal’ amount of pain you get and pain from overusing a joint– The acute phase is when joints are most vulnerable to damage, so adjust the number of exercises or how far you move each joint for how you feel that day

– Can progress the above exercises to include use of light resistance– Postural / core stability exercises/ swimming / walking / cycling to maintain cardiovascular fitness– Gentle stretches for areas that can become tight, such as knees & calves – try to regain any lost range of motion

Therapeutic modalities1. Heat2. Parraffin – wax baths3. Cold4. TENS machines

Joint protection *benefits of joint protection include less pain and greater ease in doing tasks.• 4 main techniques for joint protection:» Pacing» Positioning» Using assistive devices» Weight Control

means using your joints in ways to avoid excess stress, it includes:– Avoiding repetitive activities that will damage joints.– Using a brace or splint to protect the joint and provide more stability.– Using a cane or walking stick to unload the joint.

Pathological process is often under way for a period of time before the athlete notices symptoms

*gradual and sudden onset

•Gradual onset injury•Chronic injury•Overuse syndrome•Sports disease•Cumulative trauma disorder•Repetitive strain injury•Overuse injury

Bone stress reaction, Stress fracture, Osteitis, Apophysitis, Enthesopathy

Sever's disease: an irritation of the back of the calcaneus, on the growth plate (inflammed)

Achilles Tendon Enthesopathy: irritation of the tendon which attaches to the calcaneus bone, pulling on the growth plate.

*ALWAYS in adolesence

*During growth

Inflammation and pain at the growth plates of bones

- e.g. OSD

- adolescents, pubertal growth (overload the apophysis (growth plate))

junction between tendon and bone

- fibrocartilage

- enthesopathy = inflammation, compression, autoimmune, etc.

- largely in adolescents

- load through spine with too much extension (repetitive)

- can lead to fracture

- pain, affects nervous system

tendinopathy

Umbrella term used for tendon problems

- Mechanism:• Repetitive tensile (or compressive) loading (e.g., sprinting, jumping, changing direction) → repetitive microtraumas• Inadequate recovery between loadings

- Reactive tendinopathy• Non-inflammatory, structural changes & thickening of stressed tendon area- Tendon disrepair• Worsening tendon pathology, tendon structure becomes disorganized- Degenerative tendinopathy• Chronic stage

Labrum repetitive (overuse) injury, Ligament degeneration, Synovitis, Chondropathy

Synovitis: inflammation of the synovial membrane, necessary for joint lubrication

Chondromalacia patella: "runner's knee" softening and degeneration of the cartilage on the underside of the patella

- biomechanical reasons

DOMS, Fasciitis, Chronic compartment syndrome

• Exercise induced condition of muscle- Repetitive impact activity (e.g., running), overloading- Swelling and increased pressure causing reduced blood flow and pain• Most commonly in the lower legs- The lower leg has four compartments, and any one or all of them can be affected• Aching, burning, tightness, numbness, weakness• Typically treated conservatively

bursitis

- repetitive compression of nerve = inflamed

- bursa: fluid filled sac = cushion = decrease friction

Altered neuromechanical sensitivity

Intrinsic factors• Previous injury• Biomechanics• Leg length discrepancy• Muscle imbalance• Muscle weakness• Lack of flexibility• Sex• Body composition• Genetic factors

Extrinsic factors• Training load errors• Surfaces• Shoes• Equipment• Environmental conditions• Inadequate nutrition

- Treatment is not only managing the injury.- Essential to address the factors that have contributed to the development of injury!

*EDUCATE: just because symptoms are gone = don't ignore

- Gradually increase training load

- Cross-training- Strength training for the major muscle groups- Correct form & technique- Nutrition- Sleep Rest days- Proper equipment

- Exercise regularly

• Running and jumping sports• Risk factors (female, increase BMI, too quickly increase loads)• Pain and inflammation along middle-distal third of posteromedial aspect of tibia• Diffuse pain

1. History and physical examination (palpation)2. Alternative training3. Correction of malalignment & training problems4. Exercise therapy: strength and flexibility5. Prognosis is good if treated early!

• Running and jumping sports• Risk factors (female, decrease nutrients)• Significant pain during running, often disappears during rest, returns when athlete starts running again• Focal pain

- History and physical examination (Palpation & hop test)- X-ray; MRI- Crutches & Brace & Alternative training- When pain free –> Progressive training- Prognosis is good if diagnosed early!

Lifetime prevalence 85%→ Up to 20-30% can become persistent

Lifetime prevalence 1-94%→ Time-loss from sport, limitations to performance, decreased quality of life, high costs of treatment

• Non-specific low back pain• Complex combination of intrinsic and extrinsic risk factors

• Previous back injury• Family history of LBP• Anatomical structure of the spine• Improper technique• Sleep deficits• Nicotine use• Overloading the structures of the spine• Stress

• Heavy stress to the spine• Intervertebral disc degenerates→ pain and other symptoms

• History, physical and neurological examination• Imaging (e.g., x-ray, MRI)• Conservative treatment = physiotherapy (exercise therapy, e.g., core strength, flexibility)

- Most common sporting injury- Around 80% of ankle injuries are ligamentous caused by sudden inversion/supination

Lateral structures put under stress• Anterior talofibular (ATF) ligament• Posterior talofibular (PTF) ligament• Calcaneofibular (CF) ligament• Peroneal tendons

• Grade I: partial rupture of ATF, PTF or CF• Grade II: total rupture of one of the three ligaments or partial rupture of two ligaments• Grade III: total rupture of two ligaments

• Sudden excessive supination• Sudden excessive inversion• 130 – 180 ms after initial foot contact

• History and physical examination (Palpation)• X-ray• Weight bearing after 24-48 hours (using crutches or brace)• Grade I and II: brace, taping• Grade III: immobilization• Early functional treatment• Progressive exercise therapy

Medial structures put under stress• Deltoid ligament• Sometimes combination with malleolar fractures or syndesmosis injury• Tibialis posterior and toe flexor tendons

excessive eversion

- History and physical examination (palpation)- X-ray

- Brace, sometimes medial arch support- Functional treatment in the same manner that for lateral ankle - ligament injuries- Prognosis is good, but healing takes about twice as long (or more) than for lateral ankle sprains

Braces?

EXERCISE (proprioception, strength)

- Balance training programs 36% in ankle injuries- NMT programs 50%

• High ankle sprain• External rotational trauma• Sprain of syndesmotic ligaments that connectthe tibia and fibula- Partial or complete rupture of syndesmosis- Sometimes rupture of anterior tibiofibular ligament

• Forced external rotation• High-risk sports: Downhill skiing, football, rugby

• Diagnosis: History & Physical examination (palpation); X- ray, MRI• Partial rupture – Walking cast/boot (2 weeks or more)• Complete rupture – surgery, cast/boot (6 weeks)• Progression of rehabilitation when near pain free

*pain in the front and external rotation = HAI

- Increased risk for recurrent injuries- An unstable joint (chronic ankle instability)- Ankle joint osteoarthritis- Persistent pain

• Instability from repeated inversion trauma• Feeling that the ankle is ‘giving way’ on the lateral side• Treatment- Brace- Balance and strength- Surgery

*usually conservative treatment

• Usually occur in association with ankle sprains

• Recurrent pain, stiffness and or locking

• MRI• Cast/brace (6-8 weeks) and rehabilitation

• Surgery

• May progress to ankle joint

- osteoarthritis

- Degeneration of articular cartilage in synovial joints

- Disease of the whole joint (cartilage, bone, ligaments, tendons, synovium and meniscus)

*pain, stiffness, decrease mobility, joint failure

*bone thickens, osteoformation (extra bone), degeneration of ligament

- OA is the most common arthritis- Found in Hip, knee and ankle- More common in females than males- Prevalence increases with age- Popping/cracking, stiffness, loss of flexibility, pain, swelling, bone spurs- Disability, inactivity, comorbidities, poor quality of life, mortality- There is no cure for OA

OA is a multifactorial disease

**Aging and trauma are the main risk factors

Other contributing factors:

- genetics

- obeisity

- sex/hormones

- environment

intraarticular injuries are on the rise.

- The number of total hip & knee replacements is increasing → severe challenge to healthcare system (costs)- In Canada, from 2010 to 2031 the total direct costs of OA is estimated to increase from $2.9 Billion to $7.6 Billion – 2.6-fold increase !

• Hospitalization cost $2.9 billion• Outpatient services $1.2 billion• Rehabilitation after surgery $0.7 billion• Drugs & Side-effects of drugs $1.6 billion• Physiotherapy & complementary $1.2 billion care

- History & Physical examination- Clinical criteria: pain, stiffness, crepitus, bony tenderness and bony enlargement- X-ray (MRI)

Few: surgery

Some: Pharmacological pain relief, orthoses/aids, and passive treatments given by a therapist

All: Education, exercise and weight loss

Exercise (only treatment to show moderate effect)

**Exercise Therapy is Evidence-based OA Treatment !!!

- helps health care system and patient

- less pain and functional disability at 1yr

- is cost-effective and can delay surgery

- Also called offloading/unloading bracing- Is used to reduce symptoms such as inflammation and pain in the knee joint

Components• 2-day course for clinicians• 8-week exercise and education program for patients• Data registry

*increase in QOL, decrease pain (27%), 30% increase in PA

Pain: 28% knee, 26% hip

Physical activity: 20% knee, 22% hip

Sick leaves: 42% knee, 21% hip

Neuromuscular exercises which focus on the muscles controlling the joint as it moves• 10min warm-up & Four exercise stations (two exercises at each station):- Leg strength- Core strength- Functional exercises- Positional exercises (Alignment)• Program is different for each person

NO!

• Knee joint loading exercise seems to not be harmful for articular cartilage in people at increased risk of, or with, knee OA (proper loading is critical)• More studies needed

- Only a few with OA have tried exercise therapy & education prior to surgery- Treatment guidelines and best evidence are not sufficiently applied- WHY ?

• surgeon guidelines

• pain while exercising

• its a buisness

- Relieves pain in 8/10 patients- 1/10 experience a severe adverse event- Current 90-day care cost for total knee replacement is about $12,000 CAD (Ontario)

*don't last forever = deteriorate = revisal surgery

*muscles surrounding the knee have to support knee joint and stabilize it

Exercise first approach can delay or avoid surgery

- build muscle strength to support knee before surgery

- knees are worse than hips

- surgery only lasts about 10yrs

- Acute ligament strain- Chronic ligamentous instability- ACL rupture- Meniscus injury- Fracture- Cartilage damageor a combination of these

• Eight years after an ACL injury, 50% of patients display radiological signs of OA• After 15 years, 80% of patients display radiological signs of OA• Within 20 years, nearly all patients display radiological signs of OA• Prevalence of OA does not seem to depend on whether an ACL reconstruction was performed or not

- intra-articular injury, re-injury

- early return to sport

- obesity

- physical inactivity

- poor diet

- muscle weakness

- inaccurate beliefs

- joint dysplasia

- Pain management- Increasing physical activity- Reducing the risk of comorbidities- Improving strength- Improving alignment and gait

Prior to injury (primary prevention): prevent joint injuries in susceptible populations

Injury to PTOA (secondary prevention): identify and slow down PTOA onset after joint injury

PTOA (tertiary prevention): slow progression and improve function in those with PTOA

• Injury prevention is not happening (Primary prevention)!- Injury prevention training programs (strength & technique) can reduce the riskof severe acute knee joint injuries by 50%- Only 3% of coaches apply these programs• Most with ACL injury have immediate surgery

- Only a few with OA have tried exercise therapy & education prior to surgery• Current treatment is to wait until the joint is destroyed and replace it with metal and plastic

- OA is characterized by degeneration of articular cartilage in synovial joints. Disease of the whole joint.- Symptoms and outcomes: Pain, disability, poor quality of life, comorbidities, mortality- Risk factors: Intra-articular injury, early RTS, obesity, physical inactivity, muscleweakness, fear of movement, poor diet, unrealistic expectations,insufficient exercise therapy, joint dysplasia- Treatment: Education, exercise, weight loss, pharmacotherapy, orthosis, surgery- Role of exercise: Method for reducing pain and comorbidities; exercise can improvestrength, physical activity, alignment and gait