Rehabilitation in Sports Injuries

1. SPORTS INJURIES
ASSESSMENT & MANAGEMENT

2. SPORTS INJURIES
ASSESSMENT & MANAGEMENT
Contents
1. Classifications
2. Principles of Injury Prevention
3. Principles of Diagnosis
4. Principles of Treatment
5. Pearls of wisdom

3. Acute vs Chronic
1. CLASSIFICATIONS
Overuse vs Overload
Sprains vs Strains
Tendinitis
vs.Tendinosis
Bursitis
Contusions

4. 1. CLASSIFICATIONS
• Acute vs. Overuse Injuries
• Predisposing factors to overuse injuries
• Grading
– Tendon
– Ligament
– Muscle

5. Acute vs Overuse Injuries
SITE ACUTE
INJURIES
OVERUSE
INJURIES
Bone Fracture
Periosteal
contusion
Stress Fracture
‘Bone strain’,
‘stress reaction’
Osteitis,
Periostitis
Apophysitis

6. Acute vs Overuse Injuries
SITE ACUTE
INJURIES
OVERUSE
INJURIES
Articular
Cartilage
Osteochondral/
Chondral
fractures
Minor
osteochondral
injury
Chondropathy
(e.g. softening,
fibrillation,
fissuring,
chondromalacia)

7. Acute vs Overuse Injuries
SITE ACUTE
INJURIES
OVERUSE
INJURIES
Joint
Dislocation
Subluxation
Synovitis
Osteoarthritis
Ligament
Sprain/tear
(grades I-III)
Inflammation
Bursa
Traumatic
bursitis
Bursitis

8. Acute vs Overuse Injuries
SITE ACUTE
INJURIES
OVERUSE
INJURIES
Muscle
Strain/tear
(grades I-III)
Contusion
Cramps
Acute compart-
ment syndrome
Chronic compart-
ment syndrome
Delayed onset
muscle soreness
Focal tissue
thickening/fibrosis

9. Acute vs Overuse Injuries
SITE ACUTE
INJURIES
OVERUSE
INJURIES
Tendon
Tear (complete
or partial)
Tendinopathy
(includes
paratenonitis,
tenosynovitis,
tendinosis,
tendinitis)
Skin
Laceration
Abrasion
Puncture wound
Blister
Callus

10. Acute vs Overuse Injuries
SITE ACUTE
INJURIES
OVERUSE
INJURIES
Nerve
Neuropraxia
Minor nerve
injury/irritation
Entrapment
Adverse neural
tension

11. Predisposing factors to overuse injuries
EXTRINSIC INTRINSIC
Training errors
Excessive volume
Excessive intensity
Rapid increase
Sudden change in type
Excessive fatigue
Inadequate recovery
Faulty technique
Malalignment
Pes planus/cavus
Rearfoot varus
Tibia vara
Genu valgum/varum
Patella alta
Fem. neck anteversion
Tibial torsion

12. Predisposing factors to overuse injuries
EXTRINSIC INTRINSIC
Surfaces
Hard, soft, cambered
Leg length discrepancy
Muscle imbalance
Muscle weakness
Shoes
Inappropriate, worn
out
Lack of flexibility
Generalised muscle
tightness
Focal areas of muscle
thickening
Restricted joint ROM
Equipment
Inappropriate

13. Predisposing factors to overuse injuries
EXTRINSIC INTRINSIC
Environmental
Hot, cold, humid
Sex, size, body
composition
Psychological factors
Inadequate nutrition
Other
Genetic factors,
endocrine factors,
metabolic conditions

14. Grading of symptoms of tendinopathy
• Mild
Pain only after activity/pain that disappears with
activity
• Moderate
Pain with sporting activity but not with activities
of daily living
• Severe
Pain during activities of daily living

15. Grading of ligament sprains
Grade I
• Stretched fibers
• Normal ROM
Grade II
• Considerable portion of the fibers involved
• Increased laxity but a definite endpoint

16. Grading of ligament sprains
Grade III
• Complete
• Excessive laxity with no firm endpoint

17. Grading of muscle strains
Grade I
• Small number of fibers
• Localised pain
• No loss of strength
Grade II
• Significant number of fibers
• Pain and swelling
• Strength reduced

18. Grading of muscle strains
Grade III
• Complete tear
• Mostly at musculotendinous junction

19. 2. PRINCIPLES OF INJURY
PREVENTION
1. Correct biomechanics
2. Warm up
3. Stretching
- Static
- Ballistic
- PNF

20. Passive warm-up
Force
(N)
Stretch (mm)
Active warm-up
Stretch (mm)
Force
(N)
Does warm-up influence the
mechanical properties of the muscle?
Increases peak stretch
and peak force
Increases peak stretch
but decreases peak force

21. 1. Static stretching: 3 stretches held for 30
seconds
2. Stretch 3 times per day (high risk
inflexible areas)
3. Warm up and then stretch
4. Stretch a relaxed muscle
5. PNF stretching is preferred if ROM is
required in a very inflexible muscle
Stretching :practical points

22. PRINCIPLES OF INJURY PREVENTION
4. Taping and bracing
5. Protective equipment
6. Suitable equipment
7. Appropriate surfaces

23. PRINCIPLES OF INJURY PREVENTION
8. Appropriate training
a) Principles of training
- Periodisation/Overload/Specificity/
Individuality
b) Training methods
- Aerobic/Anaerobic/Strength/
Flexiblility/Speed/Agility/Skill
training/Cross-training

24. PRINCIPLES OF INJURY PREVENTION
9. Adequate recovery
- Warm down
- Whirlpools and spas
- Massage
- Rest and sleep
10. Psychological aspects
11. Nutritional aspects

25. 3. PRINCIPLES OF DIAGNOSIS
1. History
- Allow enough time
- Be a good listener
- Know the sport
- Discover the exact circumstances of
the injury

26. PRINCIPLES OF DIAGNOSIS
1. History (cont.)
- Obtain an accurate description of
symptoms e.g. pain/swelling/
instability/function
- Was there a previous similar injury
- Past injuries
- General health

27. PRINCIPLES OF DIAGNOSIS
1. History (cont.)
- Training history
- Equipment
- Technique
- Overtraining
- Psychological factors
- Nutritional factors
- Level of participation

28. ROLE OF AGE
• Weakest link in M/S system change according
to age
• General rule:
9-12 yr.  growth plate injuries of the heel
13-14 yr.  injuries upper tibial apophysis
15-18 yr.  avulsion injuries pelvis
19-30 yr.  muscle injuries
> 30 yr.  tendon injuries

29. PRINCIPLES OF DIAGNOSIS
2. Examination
- Develop a routine
- Examine the other side, where
relevant
- Attempt to reproduce the
symptoms
- Assess local tissues

30. PRINCIPLES OF DIAGNOSIS
2. Examination (cont.)
- Assess for referred pain
- Assess neural tension
- Biomechanical examination

31. PRINCIPLES OF DIAGNOSIS
3. Investigations
- Understand the tests
- Know how soon changes can be
detected by investigations
- Only order investigations that will
influence management

32. PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Be able to interpret tests
- Do not accept a poor quality
investigation
- Explain the investigations to the
patient

33. PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Examples of investigations
Neurological (EMG/Nerve
conduction studies)
Muscular (compartment pressure/
dynamometry)

34. PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Examples of investigations
Cardiovascular (ECG/Echocardio-
graphy)
Pulmonary (Lung function tests)
Radiological (CXR/RT/MRI/US)

35. Imaging studies
Ultrasonography
Arthrography
MRI
XR
CT
Bone scan

36. 4. PRINCIPLES OF TREATMENT
Six principles of management:
1. Minimize the extent of initial damage
2. Reduce associated pain and inflammation
3. Promote healing of damaged tissue

37. Physiology of soft tissue healing
Inflammatory
Phase
Repair
Phase
Remodelling
Phase
Initially = prevent excess swelling and injury
w1-3 = collagen formation (protect from inversion)
>3w = collagen maturation
(controlled stress)
4-8w = full return to activity

38. PRINCIPLES OF TREATMENT
Six principles of management (cont.)
4. Maintain or restore
- flexibility
- strength
- proprioception
- overall fitness

39. PRINCIPLES OF TREATMENT
Six principles of management (cont.)
5. Functionally rehabilitate the injured
athlete to enable return to sport
6. Assess and correct predisposing factors

40. PRINCIPLES OF TREATMENT
Pharmaceutical
Rest
Ice
Compression
Elevation
Pharmaceutical
Rehabilitation
Exercise
Prevention & Protection
Surgery
Acute phase Long-term phase
P
R
I
C
E
P
R
E
P
S

41. PRINCIPLES OF TREATMENT
Types of treatment available:
1. Initial treatment
- RICE
2. Immobilise vs. mobilise
3. Heat vs. cold

42. PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
4. Therapeutic drugs
- Analgesics
- NSAIDS
- Corticosteroids
- Hyaluronic acid
- Anti-depressants

43. PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
5. Electro therapeutic modalities
- Ultrasound
- TENS
- Interferention
- Neuromuscular stimulators
- LASER
- Magnetic field therapy

44. PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
6. Manual therapy
- Joint mobilisation
- Joint manipulation
- Joint traction
- Massage therapy
- Neural stretching

45. PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
7. Acupuncture
8. Dry needling
9. Hyperbaric oxygen
10. Extracorporeal Shock Wave Therapy
11. Surgery

46. PEARLS OF WISDOM
• When to refer a STI?
• Groin pain – HTAGP
• Look further than the obvious