Sport and Exercise Medicine Notes | Knowt (2024)

FUNDAMENTALS OF SPORT AND EXERCISE MEDICINE

• Sports medicine includes:

  • Injury prevention

  • Diagnosis

  • Treatment

  • Rehabilitation

• Warm up/cool down

• Recovery techniques

• Flexibility/stretching

• strength/power/endurance

• Appropriate training techniques

• Protective gear/footwear

• taping/bracing

• Musculoskeletal screening

• When an athlete sustains an injury, making an accurate diagnosis ASAP is important because:

  • The injured structure can be placed in an optimum healing environment

  • An appropriate rehabilitation program can be commenced or referred to an appropriate clinician for further treatment

  • Prevention of disuse atrophy

  • Maintain muscle/joint ROM

  • Gives the athlete/team an idea of timeframes/expectations for rehab/RTP

• Accurate history taking is the most crucial component to making an accurate diagnosis

• Awareness of red flags

• Strong anatomy knowledge

• Clinician aware of professional limits- when to refer

• Can include:

  • RICER

  • HARM

  • POLICE

  • TOTAPS

  • PEACE and LOVE

  • Stretching and strengthening

  • Proprioception and joint mobilisations

  • Orthopaedic intervention

  • Medication and massage

  • Taping and bandaging

  • Functional progressions e.g. plyometrics

• Clinician must:

  • Make an accurate diagnosis

  • Have a sound knowledge of anatomy

  • Be able to justify the treatment choice with current evidence-based treatment.

• Often the first point of contact after an on field injury is sustained

• Not their responsibility to completely diagnose the injury

• Important to be aware of potential provisional diagnoses

• Need to apply appropriate first aid until an accurate diagnosis can be made by the team doctor/physiotherapist

• Responsibilities:

  • Keep accurate records of injuries and the rehab process

  • Cooperation between athlete, coach, trainer and clinician is vital to maximize performance and health

  • Regular communications with all practitioners involved in rehab

  • Awareness of limitations and capabilities with respect to training/qualifications, medico-legal insurance and ethics.

• Life threatening injuries

  • Medical emergency

  • Emergency services must be contacted immediately

  • Includes spinal, hear, stroke, head injuries

• Musculoskeletal injuries

  • Hematoma

  • Contusion

  • Fractures

  • Dislocation

  • Subluxation

  • Sprain

  • strain/tear

  • Bursitis

  • Neuropraxia

  • Stress fractures

  • tendinopathy

• Specific injuries

  • Abrasion

  • Blisters

  • Lacerations

  • Chafing

  • Cramp

  • Fainting

  • Heat exhaustion

  • Nose bleed

• Acute:

  • Fracture

  • Periosteal contusion

• Overuse:

  • Stress fracture

  • boene strain

  • Osteitis

  • Periostitis

  • Apophysitis

• Acute

  • osteochondral/chondral fractures

• Chondral Lesions:

  • Grade 0: normal cartilage

  • Grade 1: cartilage with softening and swelling

  • Grade 2: partial thickness defect with fissures on the surface that do not reach the subchondral bone or <1.5cm in diameter

  • Grade 3: fissuring to the level of the subchondral bone in an area with a diameter >1.5cm

  • Grade 4: exposed subchondral cone

• Acute:

  • Dislocation

  • Subluxation

• Overuse

  • Synovitis

  • Osteoarthritis

• Acute

  • sprain/tear

  • Grade i-iii

• Overuse

  • Inflammation

• Grade 1:

  • Cause stretching of a ligament

  • Usually result in pain and swelling

  • Nil to mild increase in joint laxity

• Grade 2:

  • More severe partial tearing of ligament

  • Mild to moderate increase in joint laxity

  • Usually more significant pain, swelling and bruising

• Grade 3

  • Complete tear/rupture

  • Often reports snapping sensation

  • Sense of instability/give way

  • Often requires surgery

• Acute

  • strain/tear

  • contusion/cork

  • Cramp

  • Acute compartment syndrome

• Overuse

  • Chronic compartment syndrome

  • DOMS

  • Focal tissue thickening/fibrosis

• Grade 1:

  • involves a small number of fibres

  • Localised pain

  • normal/close to normal ROM

  • Normal MM strength

• Grade 2

  • Tearing of a significant number of fibres

  • More bleeding/bruising/swelling

  • Higher loss of strength and ROM

• Grade 3:

  • Complete tear, often at the MTJ

  • High levels of pain, swelling and bruising

  • Significant strength loss, no mm activation

  • Look for mm retractions i.e. torn achilles

  • Significant loss of joint ROM

  • Often requires surgery

• Acute

  • Tear - complete or partial

• Overuse

  • Tendinopathy

    • paratenonitis/tenosynovitis - injury of outer layer of tendon

    • Tendonosis

    • Tendonitis

• Acute

  • Traumatic bursitis - due to trauma

• Overuse

  • Bursitis - common in hip shoulder and knee

• Acute

  • Neuropraxia

• Chronic

  • Entrapment - repeated/long term compression of a nerve

  • Minor nerve injury/irritation

  • Altered neuromechanical sensitivity

INTRODUCTION TO INJURY PREVENTION AND PREVENTING REHAB WITH PREHAB

• Primary - for those who have never had an injury

  • Health promotion

  • Bracing

  • Footwear

• Secondary - early diagnosis and intervention to limit the development of further disability

  • RICER

• Tertiary - rehabilitation to reduce or correct an existing disability

  • Rehab following ankle sprain

    • Wobble board exercise

• This process enables

  • Identification of who is at risk

  • Establish why they are at risk

  • Understand how injuries occur in different sports

• Goal is to provide interventions that address risk factors with the aim of producing a meaningful reduction in injury incidence

• Systematic prevention

• Classic model - William van Mechelen 1992

  • Identify injuries in your cohort and all training and match exposure

  • Identify risk factors and mechanisms in your cohort

    • Intrinsic

    • Extrinsic

  • Introduce interventions to reduce incidence of injury

  • Evaluate effectiveness of interventions

• Injury mechanisms

• Differ for each sport

• Need to be familiar for sport specific literature

• Intrinsic:

  • Age

  • Gender

  • Genetic predisposition

  • Body composition

  • Fitness level

  • Biomechanics

• Extrinsic

  • Weather

  • Surface

  • Equipment

  • Training programs

• Modifiable:

  • Can be targeted with training programs

• Warm up

• Stretching

• Equipment

• Appropriate surfaces

• Appropriate training

• Taping and bracing

• Prehab

• Suggested to be beneficial for both physical and psychological preparation for sport

• Can include:

  • General exercise

  • Stretching

  • Skil specific activities

  • Prot activity warm down

• No data supporting intensity of warm ups

• Guide - produce mild sweating without fatigue

• Several studies have suggested that a structured warmup protocol designed to prevent injuries can reduce injury risk by 50% or more

• E.g. fifa 11+

• Static

  • Slow sustained hold at point of stretch typically 30-60s

• Ballistic/dynamic

  • Rapid limb movements aimed at rapidly moving muscles to end range length

• PNF

  • Alternating contraction and relaxation of both agonist and antagonist muscles

• No evidence pre exercise stretching reduces injury risk

• Can cause short term reduction in strength and power

• Outside of exercise regular stretching can reduce injuries by as much as 32%

• Running shoes

  • Key areas:

    • Heel counter

      • Hard shell that encases heel

      • Should be rigid

      • Test by squeezing between finger and thumb

      • Should not yield much

    • Midsole

    • Forefoot flexibility

    • Last construction

    • Last shape

    • All provide stability

• Football boots

  • Require all features of a good runningZ shoe

  • Must also have

    • Cleats placed to allow adequate forefoot stability

    • Slight gradient from rearfoot to forefoot

• Tennis racquet

  • Impact sport

  • Force depends on

    • Ball velocity

    • Racquet velocity

    • String tension

    • Grip size

    • Size of racquet face

    • Where the ball strikes the face

    • Stroke mechanics

  • To reduce the loads on the athlete consider:

    • Increase grip size

    • Decrease string tension

    • Increase racquet head size

    • Increase flexibility of racquet

• Protective equipment

  • Usually for high energy or contact sports

    • Football

    • Skateboarding

    • Motor racing

    • Road cycling

  • Pads

    • Shoulder

    • Shin

    • Thigh

    • Knee

  • Helmet

  • Mouthguards

• Surface interaction

  • Impact on shoe surface traction

    • Different types of grass - incidence if ACL injuries

    • Synthetic vs grass

  • Impact on impact

    • Hard surfaces result in the musculoskeletal system being subjected to higher loads

    • Loaded walking 2x

    • Running 3-4x

    • Jumping 5-12x

  • Hardness of surfaces should be considered because of its association with overuse injuries

    • Tendimptathy

    • Stress fractures

    • Shin pain

• SAID - specific adaptation to imposed demands

• Periodisation

• Specificity

• Overload

• Individuality

• Conditioning (preparation)

  • Aimed at building base aerobic or anaerobic condition, strength or power

  • Often a longer phase in which the athlete gradually builds the necessary foundations required to perform in their chosen sport

  • Is characterised by periods of heavier workloads over a 4-6 week period, broken with a week of active rest to allow the athlete to recover

  • Is also a tissue conditioning period

    • Increased bone density

    • Increased stiffness of tendons

    • Increased strength of muscles

• Transitional (pre-competition)

• Competition

• Specific adaptation to imposed demands

• Refers to the specific athletic traits or skills that are required for a given sport

• Train toward the traits you wish to improve

• Speed

• Endurance

• Explosive - jumping sports

• Skill based

• Power

• Strength

• Apply stress more than what is normally encountered

• Increase stress with adequate adaptation - supercompensation

• Can come in the form of:

  • Intensity

  • Frequency

  • Duration

• Coaches manipulate each of these variables to create an overload effect, imposing a demand on the body

• The response to this demand is an improvement in performance capacity - strength, endurance, speed etc.

• Important to understand each athlete

  • Psychology

  • Tolerance for work

  • Lifestyle

  • Nutritional intake

  • Goals

  • Genetics

• Programs must be shaped to meet each athletes profile

• Each athlete will respond differently so recipes can be a problem.

• Energy systems

  • Aerobic

  • Anaerobic

• Strength and power

  • Isotonic, isometric, isokinetic

  • Olympic lifting

  • Plyometrics

• Other

  • Speed

  • Agility

  • Skill

• ⅓ of all acute injuries

  • Gradual increase in severity

• Risk factors:

  • Eccentric phase most common

  • Age, previous injury

  • Reduced hip ROM - reduced hamstring flexion

  • Reduced hamstring strength - forces to resist knee flexion and initiate hip extension exceed muscular tendon unit

• Prevention programs

  • Standard stretching - mixed results

  • Increase strength

  • Nordics

  • Load management

• Most common injury in sports

  • 10 million in USA yearly

• Risk factors

  • Previous injury

  • Postural sway

  • Stability of joint and surrounding ligaments

• Prevention programs

  • Taping and bracing

  • Balance board to improve proprioceptive function

  • Neuromuscular training

• Most costly injury in sports

  • 9-12 months

• Risk factors

  • Sex

  • High friction shoes and surface

  • Strength around knee joint

• Prevention programs

  • Strength, balance, neuromuscular control

  • Increased core and lower limb stability

  • Raised awareness/alignment of knee position

• Restrict undesired motion, allow desired motion

  • Only evidence is in ankle sprains unless previous history of injury

• Rigid non stretch best

• Bracing:

  • Higher cost but lasts longer

  • Custom made

• Originally published in WWII

  • Improvement in physical and mental measures following pre-war rehab centres

• First sports med research in 1980s

• Theoretically sound

  • Enhancing functional capacity rto enable client to withstand a forthcoming stressor

• Current evidence is inconclusive

  • Small improvements to clinically insignificant findings in physiological and psychological parameters

• Attempts to decrease risk of injury by addressing concern or deficit identified

• Analysis:

  • Posture

  • joint alignment

  • Flexibility

  • Muscle control

  • Biomechanics

  • Core stability

  • Movement patterns

• Understand

  • Demands and risks of sport

• Considerations

  • Player

  • Position

  • Coach

  • Tactics

• Hypothesised improvements in:

  • Static and dynamic posture

  • Muscle length imbalance

  • Joint alignment

  • Flexibility

  • Core stability

  • Movement pattern efficiency

  • Proprioceptive

• Postural exercises which im at widening the space within a pair of joints

• Goals:

  • Create space

  • Decompress joint

  • Decrease pain

  • Reinforce stabilisers

• Injury prevention model

  • Extrinsic, intrinsic etc.

• Know components of warm up/stretching

• Be familiar with training methods and energy systems

  • Periodisation

  • Specificity

  • Overload

  • Individuality

  • SAID

• Injury mechanisms, risk factors and prevention programs

• Theoretical basis

• Potential benefits

• ELDOA

• Practical exam

  • Perform exercises specific to injury/sport

  • Correct technique/posture

  • Anatomical landmarks

Review of lower limb injuries, biomechanics and training prevention

• To assess gait and its contribution to injury, we require an understanding of:

  • Normal mechanics

  • Loading during the various phases of the gait cycle

  • Common biomechanical features that may contribute to injury

• Characterised by 2 phases

  • Stance or support

  • Swing or non support

• Can be divided further into 7 periods

• Walking has 2 double support periods

• Running has 2 float periods

• Kinematic features:

  • Float phase - no double stance phase

  • Decreased overall stance time, increased swing time

  • Increased anterior pelvic tilt

  • Increased range of the hip and knee in the sagittal and coronal planes

    • Flexion and extension hip and knee

    • Adduction hip - narrow base of support

• Kinetics

  • Increased vertical ground reaction force

  • Significantly higher eccentric muscle contractions

  • Jogging (recreational running)

    • Impac GRF (foot strike) = 1.5-2 x BW

    • Propulsive GRF (toe off: 2-3 x BW

  • Running (competitive running)

    • Impact GRF - very low

    • Propulsive GRF - almost 2-3 x BW (slightly less than jogging)

  • Shear ground reaction forces

    • Mediolateral shear

      • Increased propulsive medial shear force at toe off

    • Anterioposteriosr shear

      • Anterior (braking) shear from foot strike to mid support, followed by a posterior (propulsive shear) at toe off

      • Greater posterior propulsive shear in running compared to jogging due to reduced vertical GRFS

      • Novice runners ‘bounce’ whereas accomplished runners ‘glide’

• Heel

• Mid

• Forefoot

  • Strikes in slight PF

  • DF as heel lowers to ground

  • Foot more compliant → better absorption

  • basic theory regarding barefoot running

• Still need to consider habitual foot strike pattern

• Not all people are built or suit

  • Barefoot or forefoot running

  • Minimalist running footwear

• Changes in pattern requires

  • Changes in neuromuscular pattern

  • Significant adaptation of tissues to absorb GRFs

• Alignment

  • Flat foot or high arch

  • Leg length

  • Knock knee or bow

• Ankle lunge - DF range

• 1 leg squat

• Calf raise endurance

• Take off and landing technique

• Lower limb and foot posture

Examinations

• Observation

• Active movements

• Passive movements

• Resisted movements

• Functional tests

• Palpation

• Special tests

Preventing hamstring injuries

• Increasing hamstring strength:

  • Single leg HS catch

  • Single leg bridge catch

  • Single leg ball rollouts

  • Single leg slide outs

  • Nordic eccentric

  • Single leg reverse deadlift

• Increasing hamstring synergist strength

  • Barbell hip thrust f

  • Barbell hip thrust e

  • Squat

  • Deep lunge

(Glute max and adductor magnus)

Examinations

• Observation

• Active movements

• Passive movements

• Resisted movements

• Functional tests

• Palpation

• Special tests - effusion

• Special tests - MCL

• Special tests - LCL

• Special tests - Lachman's ACL

ACL also commonly results in injury to medial meniscus and MCL

• Increasing hamstring, gluteal and core

• Bridging

• Hip extension

• lunge/squat

• Proprioceptive

• Observation - standing and swelling

• Active movements

• Passive movements

• Resisted movements

• Functional tests

• Palpation

• Special tests - Anterior Drawer

• Special tests - Talar tilt

• Special tests - Proprioception

• Ottawa foot rule

  • xray required if pain tenderness on posterior tip of lateral/medial malleolus, base of 5th metatarsal, navicular or malleolar zone

Preventing ankle injuries

• Active strength exercises

  • PF, DF, inversion, eversion

• Weight bearing exercises

  • Wobble board/shuttle

• Proprioceptive exercises

  • ‘Functional’ balancing

Prevention

• Farmer walks

• Calf raises

• Plyo squats

• Standard stretching

• Downward dog

• Foam rolling

Examinations

• Rearfoot palpation

• Midfoot palpation

• Forefoot

Prevention

• Foot rolling

• Bosu

• Toe raises

• Bands

• Foot stretch to bear squat

CONCUSSION AND FACIAL INJURIES

• Subtype of head injury

• Complex pathophysiological process which affects the brain, induced by traumatic biomechanical forces

• Rapid onset of impaired neurological function

• Diagnosis and symptoms complicated

• Determine grade of concussion:

  • Grade 1 - no LOC, amnesia and post concussive symptoms <15min can RTP

  • Grade 2 - brief LOC, amnesia or post concussive symptoms lasting longer than 15 min - no RTP, review by doctor, gradual RTP when well

  • LOC >1 min or altered consciousness >2min. Post concussive signs lasting longer than 30min: transport to hospital with C/S precautions. Once asymptomatic for 1 week can gradually return to activity.

• Doctor or neurologist should clear for RTP for grades 2 and 3

• Repeated episodes of concussion (even if grade 1) during a season need a full neurological consult and consideration of no RTP that season

• Days to weeks after the impact, the player may experience

  • Sleep difficulty

  • Persistent low grade headache

  • Poor attention and concentration

  • sad/irritable/frustrated

  • Tired easily

  • Lethargic, low motivation

Cerebral function

• Where are we? Who are you playing? What is the score? - Orientation

• What happened? Can you remember walking off the field? - Tests anterograde amnesia

• What was last weeks score?/Who did you play last week? - Tests retrograde amnesia

• Does your head hurt?

• Is there any pain in your neck? Can you move your hands and feet normally? - Spinal cord

• Have you been knocked out before? - second impact syndrome

• Count backwards from 100 in 7s - test cognitive function

• Repeat 5 random words for the athlete to remember and ask later - test immediate and delayed recall

Cranial Nerve function

• Sense of smell

• Eye tracking

• Imitation of facial expressions

• Biting

• Balance

• Swallowing

• Tongue protrusion

Upper trap strength

Eye function

• Pupils equal and react to light

• Check for irregular or dilated pupils

• Blurred or double vision

Cerebellar function

• Coordination - finger to nose, heel to toe walk

• Balance - 2 leg stance, 1 leg stance, then with eyes closed

• Seek medical attention in the event of any of the following

  • Increased dizziness

  • Increased headaches

  • Loss of concentration

  • Loss of balance

  • Vomiting

  • Naurea

  • Blurred vision

• For next 48hrs

  • No alcohol

  • Rest

  • Monitored by responsible other

  • No drugs

  • Be woken at intervals to check no further deterioration

• Mild traumatic brain injury

• Symptoms that persist more than 2 weeks

• Physiological characteristics include:

  • Increased HR

  • Increased diastolic BP during exercise

  • Increased HR variability (parasympathetic response)

  • Increased cerebral blood flow during exercise

• 5-10% of concussions will persist for more than 6 weeks

• No known cause for persistent symptoms

• Prior history of concussions increases the likelihood of PCS

• The most common symptom is headache

• Experiencing dizziness is the most definitive predictor of poor outcomes long term

• “Rest is best” (no exercise)

• Direct trauma

• Profuse bleeding

• Possibility of neurological issues

Prevention:

• Faceguards

• Helmets

• Mouth guards

• Eyeglasses

SPINAL AND NECK INJURIES

• The spine consists of:

  • 7 cervical vertebrae

  • 12 thoracic vertebrae

  • 5 lumbar vertebrae

  • 5 fused sacral vertebrae (sacrum)

  • 4 fused coccygeal vertebrae (coccyx)

• Spinal cord:

  • Passes down from the midbrain at base of skull to the level of L1/2 in most adults

  • Protected by the vertebral column

  • Surrounded by fluid that acts to protect the nerves like tissue

  • Transmits signals to and from limbs, trunk and organs of the body

  • Spinal nerves/nerve roots

    • Nerves which come off the SC and pass out between the vertebrae to carry information to and from the spinal cord to the rest fo the body

• The cervical spine consists of:

  • 7 cervical vertebrae

  • 6 intervertebral discs

  • 8 pairs of exiting nerve roots

• Primary functions of cervical spine are mobility, support and protection of spinal canal.neural structures

• C1 (Atlas)

  • Uppermost cervical vertebrae

  • Serves as a ring/washer that the skull rests upon

  • Articulates in pivot joint with the dens or odontoid process of C2

  • The C0-C1 joint provides 50% of C/S flexion/extension - i.e. nodding

• C2 (Axis)

  • Second uppermost cervical vertebrae

  • Odotoid process forms the pivot for the C1 to rotate

  • The C1-C2 joint provides 50% of C/S rotation

• Vertebrae C3-7

  • More classic shaped vertebrae

  • Possess:

    • Vertebral body - IV discs sit on/between these, supports weight

    • Spinal canal - opening in the vertebrae that the spinal cord passes through

    • Pedicles - thick bony protrusions that connect the vertebral body to the spinous/transverse processes

    • Laminae - posterior bond that covers the spinal canal

    • Spinous processes - posterior bony protrusions - can be palpated

    • facet/zygapophyseal joints/Z joints - synovial joints, each vertebrae has 2 sets of facet joints

  • Smaller amounts of flexion/extension and rotation occur segmentally from C2-7

• Cervical nerves

  • 8 pairs of cervical nerves

  • Each nerve root exits the spinal canal superior to the vertebrae of its corresponding number

    • C1 nerve root exits between the Occiput (C0) and C1

    • C2 nerve root exits between C1-2

    • C8 nerve root exits between C7-T1

    • T1 nerve root exits between T1-2

• Lie between adjacent vertebrae from C2-3 to L5-S1

• Composed of

  • Nucleus pulposis - jelly like substance located in the middle part of the disc

    • High water content which reduces with ageing

  • Annulus fibrosus - tough outer layer of the disc which contains and protects the nucleus pulposis

  • Cartilage end plate - a thin layer of hyaline cartilage that separated the disc from the bone

• Can be acute or chronic

• Acute pain: usually a sudden onset and present for <3 months

• Most commonly idiopathic or whiplash associated disorder (WAD)

• Frequently persistent or recurrent

• Lifetime prevalence of neck pain in adults estimated to be between 50-80%

• Only 1-2/20 people with neck pain find it disabling

• Always apply DRSABCD/STOP/TOTAPS principles when dealing with c/s injury

• Allways assume a spinal injury if pt is unconscious/semiconscious until proven otherwise

• In the event of an acute suspected spinal injury - immobilise the neck/spine until qualified assistance arrives

• Know scope of qualifications

• Refer on to suitably qualified medical professional asap for further Ax/Mx

• An acceleration/deceleration mechanism of injury transferred to the neck usually as a result of MVA

• Symptoms can be immediate or delayed (open 24-48hrs)

• Most common symptom is pain/stiffness/spasm

  • Usually predominantly in c/s but also commonly found in arms, t/s and even l/s

  • Other symptoms include neurological symptoms (P+N, numbness), dizziness, headaches and various cognitive impairments

• Usually caused be MVS, especially collisions where impact is either head on or hit from behind

Classification

• Grade 0 - no complaint about C/S, no physical signs

• Grade 1 - complaint of neck pain, stiffness and tenderness only. No physical signs

• Grade 2 - neck complaining AND musculoskeletal signs - decreased ROM and point tenderness

• Grade 3 - neck complaining AND neurological signs - decreased/absent tendon reflexes, weakness and sensory deficits

• Grade 4 - neck complaint AND fracture or dislocation

Pathophysiology

• Evidence suggests:

  • Lesions to C/S structures, especially facet joints

  • Sensory disturbances indicative of augmented central pain processing mechanisms

  • Disturbed mm function in the form of morphological mm changes and disturbances in movement and neuromuscular control

  • Disturbed sensorimotor control including kinaesthetic deficits, loss of balance and loss of eye movement control - these are often associated with dizziness

Initial treatment

• Relative rest

• Ice - good for relieving pain acutely. Discontinue if this increases pain or mm spasm or if patient doesn't tolerate

  • If only moderate pain/stiffness, then heat may be more appropriate

• Avoid c/s collars

• See GP/hospital Xor C-ray and physio referrals - commence physio treatment ASAP

• GP will need to assess/document for any third party or insurance claims

• Early ROM within tolerated limits

• Gentle isometrics of deep neck flexors and pain levels begin to subside

• Prolonged poor posture

  • Chin protraction

  • Excessive c/s lordosis

• Results in damage to ligaments, mms and joints posturally

• OA may develop - esp in facet/Z joints

• headaches/pain referring into shoulder/arm may be associated with this condition

• Common in athletes who adopt prolonged postures - cyclists, baseball catchers, hockey players

• Sudden onset of sharp neck pain with deformity and limitation of movement

• Mechanism: sudden, unusual movement such as unexpected tracking, sustained unaccustomed postures (e.g Rock climbing, sleep on sofa) and waking with a stiff neck

Apophyseal Wry Neck

• More common in younger people up to early 30s

• Usually a sudden onset from a particular movement

• Pain reproduced when rotating/laterally flexing towards side of facet joint inflammation

Discogenic Wry Neck

• Can occur at all ages but more common in older people

• Usually a more gradual onset i.e. waking after sleeping in awkward posture

• Can often refer pain down the c/s and t/s

Initial management

• Rest

• Ice/heat - trial with ice if very painful. Use heat if ice not tolerated or if it increases mm spasm or pain

  • Start with heat if moderate pain/stiffness initially

• Pain medications - discuss with medical practitioner for patient suitability: paracetamol, NSAIDS

• Physio referral ASAP

• Common causes of herniated cervical docs include:

  • Aging

  • Trauma e.g. rugby tackle

  • Flexion injuries i.e. WAD

• Most common levels are:

  • C5/6

  • C6/7

• Symptoms include:

  • Usually an intense pain in the c/s, headaches - often describe pain as knife like

  • Can often report difficulty sleeping due to intense pain

  • Symptoms can often refer in to the shoulders and/or down the upper limbs

    • In addition to pain, these can include P+N, numbness and loss of strength/power in the upper limb

Initial management

• DRSABCD/STOP/TOTAPS

  • Know scope

• Relative rest

• See GP/hospital for:

  • X-ray referral - need to rule out red flags

  • Appropriate pain meds/ NSAIDS?

• ice /heat as tolerated

• AROM of C/S within tolerated limits initially

• Commence physio rehab ASAP

• 12 sets of ribs

• Articulate with thoracic vertebrae and sternum

• 7 pairs of true ribs - attach directly into sternum

• 5 pairs of false ribs consisting of:

  • 2 pairs of floating ribs - no sterna attachment, only spinal

  • 3 pairs attach to sternum via costochondral cartilage

1. Hypermobility of the intervertebral segments

2. Paraspinal mm strain

3. Costovertebral joint sprain

4. Rib trauma

5. Fracture - not to be missed

• Usually arises from a direct blow to the chest wall

• Can result in cruising, undisplaced/displaced rib fracture

• Symptoms: usually very painful and local tenderness, worse with coughing/deep breathing

  • Need to rule out pneumothorax or trauma to liver, kidney or spleen

• Ribs 5-10 most commonly fractured

• Rx: analgesia, encourage deep breathing exercises to prevent 2° lung conditions, taping may assist in controlling pain, thoracic spine mobility as tolerated, GP/physio review if not settling

• One of the most common causes of day to day t/s pain

• Patients typically report a gradual onset of pain and tightness in t/s

  • Symptoms can also be located in neck, shoulders or l/s

• Usually wake with no/minimal pain, but pain increases through the day following sustained poor structures

  • I.e. sitting at desk all day

Causes include:

• Weak core mms/postural mms

• Mm tightness - pecs, hip flexors, u.traps

• Poor workstation setup

• Joint stiffness

• Sedentary lifestyle/mm fatigue

• Occupation - sitting/standing lots

• Sport with sustained postures e.g. cycling

Treatment can include:

• massage/stretching of tight structures that are contributing to poor posture

  • I.e. pecs, upper fibres of traps etc.

• Heat

• Postural education/retraining

• Ergonomic assessments - desk/chair setup

• Strengthening exercises of weak postural muscles - core, rhomboids/middle traps, extensors, deep C/S flexors

• Postural taping/bracing

• Physio review if not resolving

• Usually a flexion and/or rotation mechanism of the lumbar spine

  • E.g. lifting heavy box with flexed lumbar spine

• Can be acute or gradual onset

Symptoms

• Pain can be located in the lumbar spine and/or the lower limbs

  • Area of referred symptoms usually correlates with the dermatome for the nerve that is implicated with the disc injury

• Other symptoms include

  • Pins and needles, numbles, loss of strength in lower limbs

  • Distal symptoms can be present even in absence of lumbar spine pain

• True herniated disc patients usually present with one or more of the following clinical signs:

  • Significant restriction and pain in L/S flexion/extension

  • Positive neurodynamic tests (i.e. SLR test/prone knee bend/slump tested)

  • May have difficulty with sitting and standing postures

  • May have weakness on mm testing of the muscles innervated by affected nerves

  • Tightness In mms innervated by affected nerve

• Relative rest - avoid prolonged bed rest

• See GP for:

  • Advice in pain medications / ?NSAIDS

  • See GP for imaging - XR/CT/MRI scan if appropriate

• Heat

• Postural taping

• Hydrotherapy

• Isometric core activation exercises

• L/S and LL ROM exercises as tolerated - build into graded strengthening program

• Physio review ASAP

• Z joint (facet) injuries can arise during or after the following movements

  • Twisting

  • Lifting - heavy and/or repetitive loads

  • Lumbar extension

  • Lumbar flexion/lateral flexion

  • Prolonged sitting

• Patient often complains of following symptoms in L/S

  • Bi/unilateral pain/stiffness

  • Mm spasm on the affected side(s)

  • Pain may refer into buttocks/LL

• Symptoms can be reproduced with L/S movements that involve the affected joint level

• Treatment includes

  • Relative rest

  • Activity modification e.g. workstation review

  • Heat

  • Stretches - L/S, LLs

  • Hydrotherapy

  • Postural taping

  • Core activation

  • Graded strengthening program as tolerated

  • Physio referral if not resolving

• Stress fracture of the pars interticularis

  • Gradual onset of LBP

  • Microfracture in a bone

  • Results from repetitive physical loading of a bone at levels higher than its ‘failure threshold’

  • Diagnosed by X-ray, bone scan, MRI

• Mechanism:repeated L/S hyper extension and rotation

  • Pain usually reproduced with clinical testing of L/S extension, side flexion (towards painful side) and rotation (towards painful side)

  • Pain also reproduced wit combined L/S extn/side flexion and rotation

  • Common for pain to refer into the buttock(s)

• Cricket fast bowling, gymnastics, throwing sports, high jump etc.

• Pain usually found on opposite side to one performing activity

  • E.g .right arm bowler usually develop stress fracture on left side of L/S

• Anterior displacement of part or all of one vertebra on another

• Often associated with familial bilateral pars defects evident in early childhood

• Graded according to the degree of anterior displacement of the vertebrae

• Condition is aggravated by extension activities

• Prescription:

  • core / extensor stabilisation exercises, lumbopelvic mobility/stretching, antilordotic bracing/taping if appropriate

  • GIII/IV: avoid contact sports, spinal fusion ,may be indicated if displacement is progressing

UPPER LIMB INJURY EXAMINATION AND PREVENTION

• Examinations

• observation:

1. Active movements

2. Passive examination

3. Resisted examination

4. Special tests

• Jobe

• Hawkins

• Neer

• Apprehension

• Relocation

• Full can

• Increasing shoulder capacity

1. Rotator cuff exercises

2. Shoulder stability

3. Scapular muscle recruitment

4. improve UT/MT and UT/LT ratio

5. Improve UT/SA ratio

• Examinations

  • Observation

  • Active movements

  • Passive movements

  • Resisted movements

  • Palpation

  • Special tests

    • Periscapular soft tissues

• Preventing elbow and arm injuries

  • Active strength exercises

    • F,E of wrist, isometric, concentric, eccentric or functional

  • Coordination

    • supination/pronation with body blade

  • Weight bearing exercises

    • Forearm F, E

• Examinations

  • Observation

  • Active movements

  • Passive movements

  • Resisted movements

  • Palpation

  • Special tests

    • Straight leg raise

    • Prone knee bend/femoral slump

• Injury prevention

  • Posture and core stability

  • Lifting correctly

  • Overall health and wellbeing

  • Strengthening exercises

    • Bird dog

    • Wall sits

    • Knee to chest

    • Bridging

• Examinations

  • Observation

  • Active movements

  • Passive movements

  • Resisted movements

  • Palpation

  • Special tests

    • Watsons

    • Triangular fibrocartilage complex

    • Ulnar fovea sign

    • Press test

  • Injury prevention

    • F, E, Abd of joint

    • Be aware of imbalance

    • Don't have to isolate

    • Downward dog to wall

COMMON INJURIES OF THE HIP AND GROIN REGION

• Pain in the hip region can be often difficult to assess its origin

• Can include pain in the buttocks, lateral hip, anterior hip and groin

• Groin strains account for 5-15% of al football related injuries

  • 3rd most common in AFL

• Could be referred pain from L/S or SIJ

• Look at pain patterns and type/quality of pain, often can give clues to origin of pain source

• Hip joint; femoroacetabular joint

  • Tri planar synovial joint - need to consider all movements when assessing

    • F/E

    • Abd/Add

    • ER/IR

  • Formed by head of the femur articulating with acetabulum

• Acetabular labrum

  • Forms socket of hip joint

  • Ring of fibrocartilage attached to ring of acetabulum

  • Deepens the socket component of the hip joint, leading to greater joint stability

  • Distributes hip forces over a wider area, leading to protection for the hip joint chondral surfaces

• Ligaments of the hip

  • 5 ligaments

    • 4 extracapsular ligaments and 1 intracapsular - ligamentum teres

• Chondral surfaces

  • Both articular surfaces of the hip are lined with articular cartilage

• Possible to have referred pain in buttocks/hip region in the absence of L/S pain

• Common pain producing structures causing referred pain into the buttocks and hip region are:

  • IV discs

  • apophyseal /facet joints

  • Spondylolysis (stress fractures) and spondylolisthesis (slipping of one vertebra on another) can also refer pain into the hip/buttock region

  • Trigger points - i.e. piriformis and glutes

• Can either be acute or chronic

• Occurs at the origin near the ischial tuberosity (sitting bone)/lower gluteal region

• Often seen in athletes in running and jumping sports

• Gradual onset pain in hamstring origin and often be associated with the development of a proximal hamstring tendinopathy

Acute onset:

• If boney tenderness over ischial tuberosity, need to rule out avulsion # of hamstring tendon. Often associated with a pop or crack. Must not play on and seek further medical follow up/imaging

• Usually pain reproduced on field with

  • Palpation

  • AROM F/E?straight leg raise

  • Resisted knee flexion with hip in neutral and in 90° flexion

  • Resisted extension in neutral and 90°

  • PROM hip flexion/straight leg raise

Functional testing

• Bending forwards e.g. pick up ball

• Leg swings (front)

• Squats

  • Esp deep squats that load proximal hamstring

• Lunges

  See Also

  Brain–Periphery Interactions in Huntington’s Disease: Mediators and Lifestyle Interventions.

  • Esp deep

• hopping/jumping

• Kicking

• Running

  • Esp high knees

• Common in distance runners and women over 40

• Traditionally thought to be due to trochanteric bursitis, recent studies show that glute med/min tears, tendinopathies and trochanteric bursitis can all co exist

• New global term is Greater trochanter pain syndrome (GTPS)

• Common to experience pain at side of hip joint over greater trochanter

  • Commonly a gradual onset of pain due to tightness of overlying structures (ITB/TFL/Glute med) and overuse i.e. commencement of walking/gym program, prolonged standing one one extremity, overuse etc. ‘

  • In an acute onset, trauma to the lateral hip can lead to development of bursitis (i.e. landing on the lateral hip in a tackle)

  • Usually settles with soft tissue releases of tight overlying structures, hip strengthening (isometrics initially, then moving into graded loaded program), stretching

  • NSAIDS and ice

• Clinical diagnosis

  • Palpation - usually quite tender over greater trochanter - don't forget to rule out fractures of the femur or other serious pathologies e.g. Perthes and slipped femoral capital epiphysis.

  • Patients often report pain in side lying on affected side - as injury progresses these patients find sleeping on unaffected side painful too due to tight overlying structures compressing the bursa in that position or stretching of already irritated structures

  • FABER frequently positive

  • Pain with resisted hip ER and ABD

  • Analyse gait and SL squat - poor hip control on WB leg can often aid with diagnosis. If this is unclear, increase speed, work to fatigue or increase loading e.g. single leg hopping

• Flexion, Abduction, ER

• Ankle of affected leg placed across thigh og non affected leg

• Downward pressure applied to knee

• Lateral hip pain is indicative of superolateral and lateral FAI

• Groin pain can reflect iliopsoas pathology/psoas impingement against femoral heat or anterior capsule irritation

• Posterior pain can indicate SI joint pathology

• Also passive

• Thigh in 90° hip flexion, abduction and IR

• Positive when:

  • Anterior, anteromedial hip pain due to impingement of the anterior and anterolateral part of the femoral neck against the superior acetabular rim

• Common for pain in the groin region to be referred from hip region’

• Common sources of anterior hip pain

  • Synovitis

  • Labral tear

  • Chondropathy

  • OA/Femoro-acetabular impingement (FAI)

• Common sources of groin pain

  • Adductor pathology: mm tears/tendinopathy/tightness

  • Referred pain from abdominal wall (hernia?)

  • Hip joint pathology

  • Osteitis pubis/pubic symphysis misalignment/dysfunction

• Common in sports requiring sudden changes of direction

• Clinical diagnosis

  • Tender over sire of strain, bruising

  • Pain with resisted adduction - knees flexed or extended

  • Pain with PROM hip abduction - knees flexed or extended

  • Difficulty walking - esp when increasing stride length

• Palpation - often biggest hint to find pain source

• Active movements

  • Hip F/E, Add/Abd - can do adductor squeeze test, IR/ER neutral and 90°

• Passive movements

  • Adductor stretch (knee in extension)

  • FABERS

  • IR/ER

  • Hip F/E

  • Thomas test

  • Cough test

  • Resisted abdominals

• Can help identify tightness in the following MM groups

  • Iliopsoas:

    • knee of lower leg not sitting lower than the line of the greater trochanter

  • TFL/ITB

    • These are tight if the pelvis (once corrected) has the lower leg in an abducted position away from the midline

  • Rectus femoris

    • I the ankle of the lower leg is not sitting below the line of the knee, this can be due to a tight rec fem (unless the client is not actively switching this mm off - often need to prompt patient to relax)

KNEE INJURIES

• Consists of 3 joints

  • Tibiofemoral

  • Patellofemoral

  • Proximal tibiofibular

• The tibial surface is covered by fibrocartilaginous menisci

• They:

  • Enhance the joint stability of the tibiofemoral joint by deepening the contact surface area

  • Aid with shock absorption by transmitting ½ of weight bearing load in full knee extension and some in flexion

  • Protect the articular cartilage

  • Distribute load across knee joint

    • 2-4x body weight walking

    • 6-8x body weight running

    • Contact area in joint reduces 50% when menisci are absent

• Structure

  • Vascular supply good on the most peripheral 20% of the fibres

    • Supplied by the geniculate arteries

  • Inner ⅓ of the ring is avascular

    • Relatively thin

    • Nourished through synovial fluid

  • Middle ⅓ is combination

• In acute knee injuries with ACL intact, medial meniscus injury is 5 times more likely than lateral

• In acute knee injuries with ACL ruptured, common for medial meniscus and MCL to also be involved

  • Unhappy triad, O’Donoghue’s triad

• In repetitive deep squatting, medial meniscus most likely to be injured (20:1)

• Twisting on planted foot

  • Inertial forces or external forces

• Acute effusion and pain in acute injury

• Difficulty WB, particularly on walking

• Medial or lateral joint line tenderness

• Often report clicking, catching or pop at time of injury

• Intermittent effusion with chronic injury

• Pain usually most common at end of range knee extension and knee flexion - often find patients most comfortable position is knee fixed insight flexion (10-15°)

• The knee is comprised of 4 major ligaments which contribute to the stability of the knee

  • ACL prevents forward displacement of the tibia relative to the femur

  • PCL prevents posterior displacement of the tibia

  • MCL or tibial collateral prevents valgus stresses

  • LCL or fibular collateral prevents varus stresses

• Mechanisms:

  • Usually non contact

  • Change direction

  • stop/jump

  • Audible pop

  • Significant pain but can occasionally subside relatively quickly - need to look at all symptoms

  • Instability - feeling of giving way

  • swelling/effusion

• Acute diagnosis:

  • Lachman's test

    • Can be difficult to test accurately

    • Need patient to completely relax

    • Feel for length relative to uninjured side and end feel

    • Absence of end feel indicates ACL rupture

• The MCL is usually damaged after the athlete experiences and external valgus force to the knee

• Common mechanism is getting hit from the side in a rugby tackle

• Results in instant pain and often swelling if a more significant tear (minor sprains generally do not result in swelling) and/or damage to other structures (i.e. medial meniscus, ACL)

• Diagnosis

  • Valgus stress test

  • In both 30° flexion and full knee extension

  • If it reproduces pain and there is laxity, seek further medical review

• Treatment

  • The injured MCL usually heals predictably without repair regardless of its grade

  • Non-operative management of all MCL tears is considered standard practice

  • If a patient has damaged the MCL and ruptured the ACL, they will generally stay in an ROM brace to rehabilitate the MCL prior to reconstructing the ACL

Grade I and II MCL

• Non surgical treatment

  • Crutches until symptoms improve

  • WB as tolerated

  • ROM

  • Control swelling - RICE

  • NSAIDS as prescribed

  • Hinged knee brace - see treating physio for appropriate settings

Grade III MCL

• Again a non surgical approach for isolated MCL ruptures

• Brief period of immobilisation - knee brace generally locked for 2-3 weeks before opening up the permitted ROM

• May need a longer period of protected WB

• Risk of developing PFPS due to prolonged period of knee remaining fixed in flexion

• Result from varus force to the knee

  • A blow to the medial aspect resulting in disruption of the LCL

• Same testing procedure as MCL except varus force

• Rehab similar to MCL

• Mechanisms:

  • Falling onto tibia/knee

  • Dashboard injuries i.e. car accidents

  • Hyperextension or hyperflexion of knee

• Posterior pain (not always)

• Minimal pain and dysfunction initially due to dynamic stabilisation of knee by quads

• Often non operative approach to rehab

• Usually requires extensive rehab/quad strengthening to prevent secondary injuries

• Diagnosis:

  • Posterior drawer test

    • Increase posterior translation = positive test

• The patella dislocates when it is displaced laterally, leaving the trochlear groove of the femoral condyle

• Can either be traumatic (i.e. rotating mechanism on a fixed foot) or atraumatic (i.e. ligamentous laxity in young girls)

• Medial patellofemoral ligament provides 54-67% of medial stability of PF joint

• Re dislocation rates after primary dislocation are 15-44%

• DO NOT MISS ACL RUPTURE even if the patient reports dislocated/subluxed patella - always check the ACL

Diagnosis:

• TOP over medial joint line and medial PF ligament

• Gross effusion. Swelling

• Positive apprehension test - where examiner aims to gently move the relaxed patella laterally, resulting in patient resisting with quad contraction or visible discomfort

Initial management:

• Knee generally most comfortable in full extension - aim to immobilise in this position

• RICE and non WB

• VMO activation exercises

• Refer on for further medical review

  • Will require zimmer splint to be fitted - keeps knee locked in full extension

  • Require XR if patella has dislocated or subluxed to rule out fracture

• PFPS most common source of knee pain

• Anterior knee pain behind and around PF joint lines

• Usually gradual pain onset

• Aggravated by up/down stairs, lunges / squats, kneeling, jumping, running (esp hills) or prolonged sitting / sit to stand

• Pain often eased by knee extension or mobility

Common presenting features

• Usually a gradual onset due to any of the following

  • Weak hip stabilisers (glute med)

  • Weak VMO/decreased VMO activation

  • Abnormal lower limb biomechanics (i.e. tibial torsion)

  • Tight lateral structures (i.e. ITB/TFL)

  • Tight posterior structures i.e. H/S, calf

  • Fall onto flexed knee/direct blow

  • Poor/inappropriate footwear

• Prolonged sitting increases pain - often improves when up and moving

• Reports of clicking, grinding or aching can be a sign of degenerative changes

• Common in running, jumping sports or occupations that require long periods of sitting/driving or squatting/stairs

• Much more common in females than males

  • Increased Q angle

  • Decreased glute control

• Often symptoms improve rapidly with McConnell taping in conjunction with a comprehensive rehab program that targets contributing factors such as mm tightness, mm weakness etc.

COMMON INJURIES OF THE LOWER LIMB

• Mms cross 2 joints

  • Hip extension, knee flexion

• Undergoes large eccentric contractile forces

• High proportion of fast twitch fibres

• Represent 15% of all injuries in running based sports and football codes (approx 6 players per AFL team per season)

  • Very prone to injury

  • High recurrence rate

    • High correlation with previous H/S tears

    • Common eccentric weakness in previously injured leg

• Most common presentation

• Occur during sprinting

• Usually occur at the end or running swing phase

• Most often involves biceps femoris

• Usually occur more distally than type 2 strains

• More common in sports requiring large amplitude movements of the lower limb

  • Ballet, gymnastics, dancing, high kicking (martial arts)

• Most common mechanism is excessive hip flexion

• Usually located more proximal (closer to ischial tuberosity) than type 1

• Most commonly involve semimembranosus

• Rehab time frame usually longer for more proximal (type 2) strains

• Limit passive stretching and heavy loading with type 2 strains - appear to further aggravate injury

• Predict likelihood of recurrence of G1 hamstrings

• Predict approx rehab timeframes

• All MRI (-) recovered within 2 weeks

  • More than half within 1

• No MRI (+) recovered within 2 weeks

  • All between 2-5 weeks

  • Depends on size of strain

• 84% affected biceps fem

  • 11% semimembranosus

  • 5% semi tend

  • 16% re injury

    • All involved biceps fem

• In conjunction with thorough assessment

• acute/elite amateur athletes

• If the patient is in 2nd/3rd week of rehab

  • Still troubled by unresolving anterior thigh pain/dysfunction

  • Need to ? bulls eye lesion and should be carefully rehabilitated

• For remote quad tears (>8wks) troubled by chronic pain/dysfunction

  • ? bulls eye lesion, myositis ossificans etc.

• Most commonly located at the MTJ of the medial head of gastrocnemius

• Common in sports that require rapid deceleration and COD

• Mechanism is a rapid concentric contraction - especially if this directly follows an eccentric contraction

• Often reported as a one off tear or pop sensation

• Can often be misdiagnosed as a cramp or often can be referred pain from L/S - pain tends to be more intermittent

• DO NOT MISS ACHILLES RUPTURES

  • Importance of accurate history

• Common sire of DOMS - especially after heavy session of eccentric loading (plyometrics)

• Localised TOP usually over the site of tear

• Pain reproduced with contraction of the calf (calf raise)

• Pain reproduced with stretching of the gastroc/soleus

• Can differentiate between gastroc/soleus with knee position (F/E)

• Often find it difficult to heel strike during end swing phase - look for ‘toe walkers’ when assessing gait

• Approximate RTP timeframes

  • G1: 10-12 days

  • G2: 16-21 days

  • G3: 6-9 months (post op)

• The achilles tendon can either partially tear or completely rupture

• Most common in men aged 30-50 (avg 40)

• Sudden onset, often with a popping or snapping sound.

• very debilitating p the athlete often reports that they felt like they were kicked in the back of the leg

• Most likely to occur in sports requiring sudden acceleration/deceleration

• Common in middle aged athletes who have not been training or doing relatively little training

• Thompson test

  • Positive if no movement of foot

• If suspecting rupture

  • Positive thompson test

    • Often accompanied by significant pain/swelling/bruising

    • minimal/no PF strength (could still be able to PF through tib posterior/FHL

    • Very tentative to move foot into DF

    • Apply RICE ASAP

    • Crutches and non WB

    • Must seek immediate medical follow up (ED) as most ruptures require surgical intervention

INJURIES OF THE SHOULDER AND UPPER LIMB

• Age

• Hand dominance

• Occupation

• sports/hobbies

• Medical history (esp diabetes)

• Previous shoulder problems/ops

• Mechanism

  • Fall onto outstretched arm

  • Was arm forced into abd/ER

  • Was arm forced into add/IR

• Location of pain

• Night pain

• What precipitates pain

• Weakness

• Loss of motion

• clicking/catching

• instability/dead arm

• Special consideration

  • Rest pain

  • Constant pain

  • neck/scapula pain

  • Paraesthesia

• Under 30 years

  • Impingement

  • Instability

• 30-50 years

  • Impingement

  • Biceps tendonitis

  • Arthritis AC joint

  • Calcific tendonitis

• Over 50 years

  • Rotator cuff tears

  • Adhesive capsulitis

  • Arthritis

• Diarthrodial joint (freely moveable joints held together by joint capsule) between the acromion and distal clavicle

• Stability provided by coracoclavicular ligaments (most important, acromioclavicular ligaments, joint capsule

• Mechanisms:

  • Fall onto point of unprotected shoulder

    • I.e. landing on shoulder in rugby tackle

  • Fall onto outstretched hand

  • Downward force onto acromion from above

    • I.e. heavy hit with top of shoulder whilst attempting rugby tackle

Grades:

• Mild sprains typically affect

• AC joint capsule and AC joint first before affecting coracoclavicular ligaments

• Type III and IV injuries consist of complete tears of the coracoclavicular ligaments - associated with marked and visible step deformity

Diagnostic tests:

• Palpation

• Horizontal adduction test

• AC shear test

  • Squeeze scapula and clavicle together

Initial management

• Apply RICE initially

• Sling for pain relief and to take injured structures off stretch - 3 days - 6wks

• Taping useful

• Isometrics once pain has settled

• X-ray referral when step deformity or bony tenderness present

• Surgery for types IV, V and VI or if failing to respond to conservative management

• Restore normal scapula mechanics

• Majority of GH dislocations are anterior >95%

  • Arm forced into abd/ER

• Posterior dislocations occur <5% of the time

  • Arm forced into IR/add

• True inferior GH dislocations <1%

• Day to day, non traumatic dislocation (i.e. party trick shoulder) may present as multidirectional discoloration due to generalised ligament laxity, usually pain free.

GJH anatomy

• Glenoid cavity is very small relative to size of humeral head - like gold ball on tee

• Labrum is like ring on top of tee that makes it concave so ball doesn't fall off

• Highly mobile therefore very susceptible to dislocation

Complications of anterior GH dislocations

• Bankart lesion

  • Injury of anterior glenoid labrum

  • Increases chances of future anterior dislocations

  • Can be accompanied by avulsion fracture of anterior inferior glenoid cavity

• Hill-Sachs lesions

  • Cortical depression/flattening of the posterolateral head of the humerus

  • Result of forceful impact between the humeral head and anterior inferior glenoid rim during anterior shoulder dislocation

  • Can be be seen in up to 92% of recurrent dislocations

• Early:

• Neurovascular injury (rare)

• Axillary nerve injury

• Fracture of neck of humerus or greater/lesser tuberosities

• Late

  • Avascular necrosis

    • Can be seen in head of humerus (increased risk with delayed reduction)

    • Heterotopic calcification/myositis ossificans

    • Recurrent dislocation

Clinical picture

• Patient is in pain++

• Holds the injured limb with other hand close to trunk

• Loss of normal shoulder contour

• Loss of contour may appear as ‘step’

• Anterior bulge of head of humerus may be visible or palpable

• Gap can be palpated above dislocated head of humerus

Clinical tests for GH instability

• Positient

  • Supine, elbow 90°, shoulder abd to 90°

• Apprehension test

  • Passively taken into ER

  • + if reproduces pain/apprehension

• Relocation test

  • Apply pressure to GH joint whilst taking through PROM as per apprehension test

  • + if pain decreased or increased ROM until onset of pain

Management of anterior GH dislocation

• It is an emergency

• Should be reduced in less than 25 hours or may result in avascular necrosis of humeral head

• Shoulder X-ray essential following reduction, even if pain free

• Sling vs no sling

  • Recent studies advocating 30° ER brace

  • Other studies show no sig difference between bracing or no bracing

• Swimmers shoulder or throwers shoulder

• Supraspinatus tendon, biceps tendon or subacromial bursa being impinged (pinched/jammed) between the humeral head and the underside surface of the acromion as it passes through the shoulder joint

• Terminology debated as compression mechanism less frequent than initially thought

• Exercise therapy priority, manual therapy - short term pain reduction

Subacromial bursa

• Decreases friction

• Thickens with degeneration and general wear and tear

• Can be site of acute irritation or secondary inflammatory response to primary degenerative pathology

Causes of SAI

• Activities include

  • Racket sports - tennis/squash

  • Swimming and throwing sports

• Can also be caused by painting, carpentry, construction work or other jobs involving overhead work or repetitive use (i.e. cleaning)

• Even After years of normal use, older people may develop an impingement syndrome

Symptoms of SAI

• Usually gradual onset of pain

• Usually anterior and/or lateral aspect of shoulder (badge sign) - can often feel like it moves down the outside of the arm towards the mid humerus

• Pain with overhead movements

• Night pain - especially when side-lying on affected side

• Painful arc (70-120°)

• Impingement signs

  • Neers test

  • Hawkins and Kennedy test

Diagnosing a SAI

• Ultrasound imaging only 40% accurate

• Clinical tests/signs more accurate than imaging

• X-ray useful to identify shape of acromion - is it a bony protrusion that is causing impingement?

Neers test

• Arms in IR, guide through abduction in scapula plane

• Stabilise scapula with opposite hand

• Sensitivity - 72%

• Specificity = 60%

Hawkins and Kennedy test

• Arm in 90° forward flexion. Elbow bent 90°

• Humerus supported at waist, upper limb moved into IR

• Sensitivity = 74%

• Specificity = 57%

ROM

• Scapulohumeral dysfunction

• Compare scapula motion through ROM on both sides

• Increase loading or repeat movements into fatigue to exaggerate symptoms

  • Wall push ups

• Symmetrical

• Smooth

• No winging of scapula

Strength testing

• IR

  • Subscapularis, pec

• Arms by side with elbows at 90°

• IR against ISM resistance

• Subscapularis lift off test

• Supraspinatus

  • Empty can test

  • Jobes test

  • Attempt to isolate from deltoid

  • Sitting, arms straight, elbows locked, thumbs down, arm at 30° in scapular plane, elevate arms against resistance

Treatment of SAI

• Identify cause before implementing treatment plan

• Need to restore scapulohumeral rhythm

  • stretching/releasing tight structures that contribute to symptoms

    • Usually pecs, upper traps, subscap and even ERs

  • Restore strength in scapula stabilisers

    • Particularly shoulder ERs and retractors that pull the head of the humerus inferiorly/posteriorly

• Partial thickness tear

• Full (complete) thickness tear

• May be due to

  • Impingement

  • Degeneration

  • Overuse

  • Trauma

• Partial tears

  • Conservative

• Complete tears

  • Surgery

Drop-Arm test

• Abducted arm slowly lowered

  • May be able to lower arm slowly to 90° (deltoid function)

  • Arm will then drop to side if rotator cuff tear

• Positive test

  • Patient unable to lower arm further with control

  • If able to hold at 90°, pressure on wrist will cause arm to fall

RC tear diagnosis

• Pain and weakness (when comparing ISM tests from side to side) can often give a hint as to which mm may be involved

• HHD can be useful for detecting subtle variances in ISM strength measures

• Pain or limitation into a particular ROM may hin as to which structure has been torn (i.e. if painful or tight in IR range, infraspinatus/teres minor could be implicated as they are being stretched in this movement)

• Usually accompanied by positive impingement test, full/empty can tests and drop arm tests

• Rotator cuff pathology and/or subacromial impingement

• Dysfunctional scapula position

  • Significant symptom relief and improvement of ROM from scap repositioning

• Post cortisone - not usually for approx 72hrs

• Stiff shoulder

• Frozen shoulder/adhesive capsulitis

  • Especially stages II and III when pain has decreased and shoulder is stiff. Physio essential to restore ROM and function. Also a role with education and prevention of secondary problems in stage I.

• hypermobile/unstable shoulder

• Pre and post shoulder surgery

• Unclear diagnosis

  • I.e. pins and needles, multiple pathologies, referring pain into arm, unusual.abnormal pain patterns, headaches etc.

• Recurrent dislocations/subluxations

  • Should be checked after first dislocation if planning to return to contact sports

• Rotator cuff tears over 2cm, multiple tears of RC mms, full thickness tears, partial thickness tears over 50% thickness

• Frozen shoulder stage 1

• If conservative management is not progressing within expected time frames

• Unclear diagnosis

ELBOW INJURIES

• Biceps brachii

• Brachialis

• Brachoradialis

• Triceps brachii

• Pronator teres, supinator

• Wrist flexors - pronator teres, flexor carpi radialis, flexor carpi ulnaris

• Palmaris longus

• Flexor digitorum superficialis, extensor digitorum

• Wrist extensors - extensor carpi radialis longus/brevis, extensor carpi ulnaris

• Pathologic condition of the common extensor muscles at their origin on the lateral humeral condyle

• Epicondylitis suggests an inflammation at one of the epicondyles

• Generally occurs in adults between 35-50

• Affects 1-3% of the population

• Typically overuse

• Occupations or sports that involve repetitive grasping with the wrist in extension place the elbow at risk because the wrist extensors must contract during grasping activities to stabilise the wrist

• Leads to tendonitis of the origin of the extensor carpi radialis brevis tendon

• 9x more common than medial

• Diffuse achiness

• Morning stiffness

• Occasional night pain

• Dropping of objects/weak grip strength

• Pain with palpation of lateral epicondyle

• Pain with active or resisted wrist extension

• Pain with grasping objects with the affected hand

• Patient sits with examiner stabilising affected elbow while palpating lateral epicondyle

• With a closed fist, patient pronates and radially deviates the forearm and extends the wrist against examiners resistance

• Positive result if pain along lateral epicondyle or objective muscle weakness

• Rest, ice, NSAIDS if no contraindications

• flexibility/ROM exercises of wrist flexors and extensors

• stretching/massage of extensors (not over tendon)

• Active assistive and resistive exercises

• Train entire kinetic chain (don't overlook shoulder

• Taping / bracing

• Golfers elbow

• Less common than lateral

• Affects medial epicondyle

• Irritation of common flexor tendon that inserts into medial epicondyle

• Similar diagnostic and treatment principles to lateral.

WRIST INJURIES

• Overuse injury of extensor Pollicus brevis tendon and/or abductor pollicus longus tendon

• Usually overuse, precipitated by repetitive wrist/thumb motions (typing/mouse movements are common causes)

• Often tender to palpate over the first extensor compartment particularly at radial styloid

• Can often see swelling of this compartment or through the distal forearm when the condition is advanced

• Finkelstein’s test - thumb placed in a fist and wrist taken into ulnar deviation

• Pain = positive test

• rest/removal from pain provocative activities

• Regular ice application

• splinting/taping/brace

• Physio modalities for pain relief

• Referral to specialist/sports physician if symptoms are not settling as predicted

TREATMENT OF ACUTE INJURIES

• Involves an acute loading situation in which the load exceeds the ultimate tolerance of the tissue involved

• Can be either

  • Extrinsic - direct blow or collision

  • Intrinsic - internally generated forces such as a sprain, strain or tear of soft tissue

• Age

• Poor blood supply

• Drugs

  • Steroids and non-steroidal anti inflammatory - NSAIDS

  • Excessive or early loading/movement

• Minimise initial damage

• Reduce associated pain and inflammation

• Provide environment to promote healing of damaged tissue

• Restore flexibility, ROM, strength and proprioception

  • Sports specific goals in each of these categories

• Maintain cardiorespiratory condition during the healing phase

• Identify and manage any predisposing factors to injury

• Interventions should, by first principle be aimed at stimulating of promoting normal events, not avoiding or changing them

• You must respect the physiological process and its required time frame

• Factors impacting this:

  • Age

  • Severity

  • Tissue

  • Drugs

• Interventions available

  • Acute management - PRICER, HARM

  • Immbilisation v early mobilisation

  • Exercise - strengthening, stretching and control

  • Pharmacological agents - paracetamol

  • Blood products - PRP

  • Manual therapy - massage

  • acupuncture/dry needling

  • Electrotherapy

  • surgery

• Protect the athlete from further harm

  • On field - stop athlete, stop play

  • Off field - brace, splint or tape, crutches

• Rest or relative rest

  • Reduce rest or reduce activity

  • Decreases load on tissues

  • Decreases blood flow to injury site

  • Contain or limit acute response

• Ice

  • Vasoconstriction

  • Reduces blood volume to injury site

  • Reduces metabolic demand of tissues

  • Lowers O2 requirement of tissues

  • Reduces waste production

  • Limit tissue death

• Compression

  • Contains bleeding and swelling

• Elevation

  • Reduces hydrostatic pressure at injury site

  • Reduces swelling and bleeding

  • Improves fluid clearance from the injury site

    • Lymphatic and venous return

• Referral/Rehab

  • Know your scope

  • Refer to HP

  • Plan rehab

  • Coordinate between Hps

• HARM

  • Heat

  • Alcohol

  • Running

  • Massage

• Has benefits for early repair phase and is crucial for fractures

• Muscle injuries immobilisation generally less than 1 week

  • Allows scar formation

  • No adverse effects in this time frame

• Too much has detrimental effects

  • Joint stiffness

  • Degenerative changes - cartilage

  • Muscle atrophy - weakness

  • Osteopenia

Out of scope

• NSAIDS

  • Neurofen

  • Voltaren

  • Naprosyn

  • Celebrex

• Analgesic properties no better than paracetamol

• NSAIDS have adverse effects

  • Irritate GIT

  • Raise BP

  • Increase irritability of airways - asthmatics

  • Can inhibit connective tissue healing

• Paracetamol is analgesic of choice

  • Promote normal pathways dont change them

• Non opioid medications

  • Easily obtained

  • More active role in changing chemical pain responses in pNF

  • No addiction

  • Upper limit of pain relief (taking more doesn't work)

  • Potential side effects over long periods

• Opioid (narcotic medication)

  • Stronger analgesics for when pain is too high for non opioid

  • Moderate to high pain

  • Target receptors in CNS, decrease brains awareness of pain

  • Prolonged use can lead to addiction or tolerance

  • Side effects include dizziness, nausea, constipation, mental clouding

  • Usually prescription only issued by qualified medical personnel

OVERUSE INJURIES

• Can be thought of as a gradual failure or fatigue failure of tissues that are subjected to higher volume cyclical loading

• Not acute failure

• Loads do not exceed the ultimate load tolerance of the tissues in one loading cycle

• They present 3 challenges to sports personnel

  • Diagnosis

  • Mechanisms

  • treatment

• Can be addressed while in a period of relative de-loading

• Predisposing factors typically divided into 2 categories

  • Extrinsic

    • External to the athlete

      • Training errors

      • Surface

      • Shoes

      • Equipment

      • environment

  • Intrinsic

    • Relate to athletes physical characteristics

      • Alignment

      • Muscle length

      • Muscle strength

      • Muscle imbalance

      • Genetic factors

      • Gender, size and composition

• 

• Period of relative de-loading

• Address intrinsic and extrinsic mechanisms in play

• Soft tissue massage - connective tissue characteristics

• Pharmacological agents if necessary

• Does not necessarily mean no loading - usually a reduction.

  • Can be complete rest in severe cases

• Allows tissues to heal/catch up

• Time frame can vary depending on several factors

• Typically 3-12 weeks

  • Tissue type - bone vs tendon

  • Severity

• Always take measures, flexibility, endurance, strength etc.

• Set goals, progress as they are met

• Maintain motivation and compliance

• Improved measure reflects improved tissue function and capacity

• Gives objective data to base rehab on

• Be aware of latent symptoms

• Symptoms that occur some time after a bout of loading. Commonly pm or next am

• May suggest tissues are not coping with loading they are being subjected to

• Return to running

  • Min 20 SL calf raises

  • Competent sl squat to 90° under load x8

  • Good pelvic hip control

  • Walking a given time frame e.g 45 mins

  • All with no symptoms, immediate or latent

LOWER LIMB EXERCISE REHAB

• Type 1 (running)

  • Most common

  • Occur during sprinting

  • End of running swing phase

  • Usually biceps fem

  • Usually more distal than type 2

• Type 2 (dancers)

  • More common in sports requiring large amplitude movements of the lower limb

    • Ballet, gymnastics, dancing, martial arts

  • Most common mechanism is excessive hip flexion

  • Usually more proximal than type 1

  • Usually involve semimembranosus

  • Rehab usually longer for more proximal strains

  • Limit passive stretching and heavy loading - appear to further aggravate

• Work within parameters of healing

  • How is the athlete achieving hip extension

    • Is glute max overactive or hamstring underactive

  • Consider relationship between hamstring and surrounding mms (glutes, quads, hip flexors)

  • Remember hamstring is 2 joint mm

    • Considerall movements and incorporate entire kinetic chain

    • Include lumbar spine: ROM/Strength/Neural mobility

  • Progression - consider long term hamstring weakness - need to develop hamstring strength eccentrically (is program sports specific?)

  • Limited research regarding effectiveness of static stretching

    • Emphasis on dynamic flexibility and strength development

• Minimise VMO atrophy ASAP

• Consider potential of RF-CT injury - implications for pushing too hard too early

• Incorporate entire kinetic chain

  • Include mms that work with quads in function movements

  • Gutes, hamstrings, hip flexors, lumbar spine

• Exercises need to become functional prior to clearance for RTP.

• Patellofemoral pain

• Patella tendinopathy

Less common

• Referred pain from hip

• Fat pad impingement

• Infrapatellar bursitis

• Age related conditions

  • Osgood Schlatters

• Synovial, gliding joint

• Sesamoid bone in the quadricep tendon and the femoral condyle

• Relies on static and dynamic stabilising structures to maintain joint congruency

• Static

  • Lateral faucet of the trochlear and the femoral condyle

  • Increased congruence with greater than 20° flexion

• Dynamic

  • Balance of muscle activity between VL and VMO

  • Less than 20° flexion dynamic stability maintains congruency

  • PFJ is subject ot high compressive forces ascending stairs (2.5 x BW) and squatting (7 x BW)

• PFPS is the most common source of knee pain

• Anterior knee pain behind and around PF join lines

• Usually gradual onset

• Pain aggravated by activities such as up/down stairs, lunges/squats, kneeling, jumping, running (esp hills) or prolonged sitting/sit to stand

• Pain often eased by knee extension or mobility

• Skeletal structure

  • Shallow groove, small patella, femoral anteversion, increased tibial torsion, large Q angle, poor foot biomechanics

• Muscle imbalances

  • Tight lateral structures (ITB, lateral retinaculum), decreased VMO, decreased pelvic control (decreased strength of gluteals)

• Usually gradual onset due to any of the following

  • Weak hip stabilisers i.e. glute med

  • Weak VMO/decreased VMo activation

  • Abnormal lower limb biomechanics (tibial torsion)

  • Tight lateral structures (ITB, TFL)

  • Tight posterior structures (H/S, Calf)

  • Fall onto flexed knee/direct blow

  • poor/inappropriate footwear

• Much more common in females

  • Increased Q angle

  • Decreased pelvic/hip control

1. Direction of body movement - horizontal less stressful than vertical

2. Weight of the athlete - the heavier the athlete = higher demands on body

3. Speed of execution - higher speed = higher demands

4. External load - external loads significantly increase demand on body, don't raise the load to a level that significantly slows the speed of the movement

5. Intensity - the amount of effort exerted, always start bilateral and progress to unilateral, simple to complex

6. Volume - usually measured by the amount of foot contacts. Start beginners with volume of 75-100 foot contacts/session, increasing to 200-250 of low to moderate intensity

7. Frequency - need 48-72 hrs rest between sessions

8. Age - if younger/less time involved in the sport: reduce demands of a plyometric program and progress as tolerated

9. Recovery - rest time between sets. For power, work rest ratio 1:3 of 1:4 (higher anaerobic component therefore requires longer rest b/w sets. For endurance training, 1:1 or 1:2 recommended.

INJURIES TO SPECIAL POPULATIONS

• Will suffer many of the same injuries as adults

• Will sustain different types of injuries due to anatomical differences between age groups

• May have the same injury as an older athlete but may have different effects and must be treated differently

• Articular cartilage of growing bone is of greater depth and is able to remodel

• The epiphyseal plate is vulnerable to disruption

• Tendon attachment sites (apophysis) are weak

• Long bones are more resilient and elastic - incomplete fractures (greenstick)

• During rapid growth phases, bone lengthens before mms and tendons have stretched/strengthened

• Bones in children/adolescents have a higher water content and lower mineral content

  • Less brittle than adult bone

  • Thick periosteum

  • Rich blood supply in bone

• The epiphyseal plate (growth plate)

  • Cartilaginous structure that is weaker than bone

  • Predisposed to injury

• Ligaments in children functionally stronger than bone

• Younger athlete more likely to injure cartilage, bone, avulsion fracture than to have a significant ligament sprain

• E.g. 9 year old with high grade ATFL sprain and swelling over lateral malleolus, avulsion fracture of the fibula must be considered/ruled out

• Approx 20% of children/adolescents who are participating in organised sport sustain an injury

  • Approx ¼ are considered serious

• Greatest injury risk to children that have just started a new sport

• 2:1 ratio boys to girls in sports related injuries

  • Potentially due to rough play/high relative-risk behaviours

• Fractures

• Postural abnormalities

• Osteochondroses

• Common in forearm and lower leg

• Where bone bends/partially breaks - incomplete fracture where the break is on the opposite side to the bend

• More common in children/adolescents where bones are more flexible - adult bones more brittle and tend to break under the same injury mechanisms/relative loads

• Mechanisms of injury similar to typical fractures

• Like trying to snap a green tree branch

• If no growth plate damage, simple immobilisation for 3-6 weeks

  • Must see GP/ED for review

• Standard fractures of long bones where the fracture involves the epiphyseal plate

• These account for ⅕ of major long bone fractures and ⅓ of hand fractures in children and adolescents

• Salter harris scale

  • High correlation with potential growth complications

  • 5 types

• Type i-ii: usually heal well, but may be associated with local growth plate closure and osseous bridging

• Type iii-iv: usually associates with high complication rates/growth disturbances

• Type v: uncommon compression injury to the end of the bone, resulting in compression of the epiphyseal plate - usually a poor prognosis/significant growth deficits

• If there is joint involvement, thai increases the complication rates (very high)

• Need to suspect epiphyseal plate injury if high force/shear/rotation with associated TOP and loss of function

• Need to see GP/orthopaedic specialise asap regardless of classification

• May occur in older children, esp 12-15 years

• Similar to salter-harris type 1

• Common in overweight boys

• Symptoms may present suddenly or gradually over time

• Often presents with a limp and pain in the hip or knee

  • If presenting with knee pain, reinforces importance of clearing the hip

• Clinical signs:

  • Noticeable limp during gait - often for no known cause

  • Decreased hip abduction and internal rotation

  • X-ray - widening of growth plate and line fro superior surface of neck of femur does not intersect growth plate

• Commonly seen in attachment sites of ligaments and larger tendons to bone

  • Sartorius/ASIS

  • Rectus femoris/AIIS

  • Hamstring/ischial tuberosity

  • Iliopsoas/lesser trochanter of femur

• Similar injury mechanisms for typical ligament sprains or muscle strains

• Need to be highly suspicious when boney TOP present (X-ray?)

• Management rarely surgical - similar to that of a grade iii tear of mm/ligament

  • Control pain/swelling

  • Restore full PROM - gentle stretching/massage

    • Increase into AROM as symptoms settle

  • Graduated strengthening program

  • Work Closely with GP/physio

  • Reattachment of avulsed fragment rarely necessary

• Causes of back pain similar to those in adults

• Ended to consider other biomechanical factors such as leg length discrepancy, pelvic instability, excessive pronation

• Minor complaints usually respond well to reduction in activity

• Back pain in children under 18 is always pathologic until proven otherwise

• Osteochondrosis of the spine - affects growth plates

• Males more than females

• Excessive T/S kyphosis typically in teenagers

• Cannot consciously correct posture

• Associated wit acute pain and stiffness in T/S

• Symptoms most prevalent during periods of rapid growth

• May develop compensatory lordosis

• Usually diagnosed on X-ray

• Positive if there is >5° wedging of more than 3 adjacent vertebrae

• Treatment aimed at preventing progression of condition

  • Postural exercises

    • Strengthening

    • Stretching

  • maddaga/physio

  • Avoiding pain-provoking activities

  • Heat packs

  • Postural braces can be worn

  • Further medical review if curvature >50° or any signs of spinal cord irritation

• Abnormal curvature of the spine

• Affects more boys than girls

• 0-5° curvature is common

• Often resolve with bone growth

• >15° may brace

• Clinical signs:

  • Uneven shoulder height

  • Notable pelvic asymmetry/tilt

  • Large scoliosis may be observable from behind

  • Forward flexion test

    • Becomes more visible as client bends

  • Usually confirmed by basic spine X-ray

• Treatment

  • Varies on following factors:

    • Underlying cause

    • Location and size of curvature

    • Is client still growing?

      • May recommend brace ig still growing

  • May benefit from traditional core stabilisation and restoration of ROM exercises

  • GP review

• Osteochondritis that occurs at the growth plate of the tibial tuberosity

• Repeated quadricep contractions under load may cause softening/partial avulsion

• Extremely common in adolescents during growth spurts, esp 11-15 years

• Usually associated with forced knee extension, esp in sports involving running and jumping

• Clinical signs

  • TOP++ over tibial tuberosity

  • May have an observable bump/swelling at tibial tuberosity

  • Pain on resisted knee extension

  • Tight quads

  • Pain with lunges, squats and functional tests such as hopping or jumping

• Treatment

  • Activity modification - relative rest, avoid aggravating activities - or when not possible, stopping aggravating activity prior to the onset of pain

  • ice/modalities

  • stretching/massage/foam roller

  • taping/bracing of patella tendon

  • Graded strengthening program as tolerated

  • Address any factors which also may be contributing

    • I.e. landing technique from jump

  • GP review

• Similar to osgood schlatter’s but less common

• Affects inferior pole of patella at superior attachment of patella tendon

• Treatment principles sams as for OS

• Osteochondritis affecting the femoral head

• Presents as limp or low grade ache in thigh, groin or knee

• Restrictions into internal rotation and abduction, FABER

• Typically affects children aged 4-10

• More common in males

• Reduced blood flow to the joint

• X-ray finding may show femoral head disfigurement, flattening or collapse

• Management:

  • Aim to minimise further progression of condition - degenerative arthritis

  • Relative rest/unloading from aggravating activities

  • ROM exercises: esp to maintain abduction and hipIR

  • Swimming and cycling are good exercise options

  • Children under 6 generally have a good prognosis

  • Use of bracing can assist with more severe cases

  • Must see GP for review and Hip x-ray

  • Referral to orthopaedic specialise

• Most common cause of heel pain in 10-14 year olds, particularly during growth spurts

• pain/TOP in the calcaneus/achilles insertion which is activity related

• Common in sports that involve running and jumping

• Clinical signs:

  • overuse/gradual onset

  • Positive squeeze test

  • TOp achilles insertion into calcaneus

  • restricted/decreased ankle DF ROM (knee to wall less than 10cm)

  • Tight gastroc/soleus

  • May have visible bump in advanced stages over insertion of achilles into calcaneus

• Treatment

  • Relative rest, avoid aggravating these activities prior to symptom onset

  • Ice

  • Calf stretches/massage/foam roller

  • Heel wedges/silicone heel cups

  • Calf strengthening

  • Orthotics if presenting with biomechanical abnormalities

  • Gp review -X-ray

• Bone and associated cartilage lose blood supply

• Can be insidious onset or following trauma

• Common at knee and elbow

• Boys 9-18 most common

• Symptoms include:

  • Localised joint pain

  • Stiffness

  • Locking of the joint

  • Swelling

• If suspected, requires orthopaedic review for assessment and imaging

• Traction stress at humeral physis

• Commonly affects 11-13 year olds

• Symptoms include pain in shoulder during and/or after throwing

• May have loss of shoulder ROM

• TOP humeral Physis

• Rest for 8-12 weeks

• Must be symptom free before loading

• RC strengthening/ROM

• prevention/pre season conditioning

• Part time graded throwing program monitor symptoms during and after

• Acceleration phase of throwing

• Repetitive valgus overload

• Traction injury of MCL (anterior band)

• Medial epicondyle apophysitis

• Common symptoms:

  • Pain

  • Loss of elbow ROM

  • Localised medial elbow pain, esp over medial epicondyle - reproduced with valgus stress test?

  • Swelling

  • Needs XR

• High frequency of Rotator cuff tears in acute onset shoulder pain

  • Many elderly patients have a rotator cuiff tear but are asymptomatic

• Any falls - must assume fracture until proven otherwise

  • Gp/hospital review ASAP

  • High frequency of wrist/hip fractures - often require surgical intervention

  • Need to consider underlying bone density problems/osteoporosis

  • Good research behind effectiveness of falls prevention programs in the elderly

• Osteoarthritis

• One of the most common underlying causes of insidious onset pain in older patients

• Most common areas found include the spine, hips and knees

• Generally respond well to heat, mobility (low impact exercise) strengthening and stretching of the affected area(s)

CONCUSSION

• Concussion - impaired consciousness less than 1 hr, no neuronal damage

• Contusio cerebri - impaired consciousness over 1 hour, substantial brain damage.

• Second trauma to brain without prior full reconstitution of first one

• Children and young adults particularly prone

• Neurological symptoms

• Pain

• Balance problems’

• Psychological and psychosocial problems

• Decrease in symptoms

  • 40-50% remain over first weeks

  • 30% over first months

  • 15-120% over first year