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Concepts of Diagnosis of Sports Injuries

Concepts of Diagnosis of Sports Injuries. Site of injury. Truism. “If you hear hoof beats don’t think zebras” You better eliminate the zebras first: Dolbin. Priorities. “ The best things in life are not things” Harry Bertsch Hermy Bavier Ron Boris Amanda Driscoll Josh Bertsch Dad.

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Concepts of Diagnosis of Sports Injuries

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  1. Concepts of Diagnosis of Sports Injuries Site of injury Truism • “If you hear hoof beats don’t think zebras” • You better eliminate the zebras first: Dolbin Dr.Jack Dolbin DC Session 2

  2. Priorities • “The best things in life are not things” • Harry Bertsch • Hermy Bavier • Ron Boris • Amanda Driscoll • Josh Bertsch • Dad Ron Boris Dr.Jack Dolbin DC Session 2

  3. Concepts of Diagnosis of Sports Injuries Cause as it relates to exceeding the tensile strength of the tissue Fracture dislocation Dr.Jack Dolbin DC Session 2

  4. Concepts of Diagnosis of Sports Injuries Biomechanical concepts of causation Motion deficits as major causative factor • If dysfunction alters the efficiency of the musculoskeletal system, there is an increase demand for energy. Not only for increased activity but for normal activity. • Increase demands on the cardiovascular system Dr.Jack Dolbin DC Session 2

  5. Observation Evaluation of the Kinetic Chain • Lower limb: Ankles, Knees, and hips • Upper limb: Core Stability, Endurance, Balance, Range of Motion • Scapula: Stability, Rhythm • Shoulder: Clinical examination • “Where observation is concerned, chance favors only the prepared mind.” ~ Louis Pasteur Dr.Jack Dolbin DC Session 2

  6. Concepts of inflammation and repair Inflammation Tissues respond to injury with a set of genetically programmed mechanisms to replace the damaged components and to restore normal function. Dr.Jack Dolbin DC Session 2

  7. Inflammation and Repair Two types of Inflammation: • Acute • Chronic Cardinal signs of inflammation • Heat • Swelling • Pain • Redness • Loss of Function Chronic Inflammation Acute Inflammation

  8. Acute Inflammation: Inflammation and Repair Characterized by the release of chemical mediators by mast cells,platelets and basophils at the site of the injury. Vasoactive mediators regulate the vascular response to the injury and affect the recruitment of PMN’s from the vascular component. These in turn produce chemotactic factors that control the damage and remove debris by phagocytosis. • Granulation Tissue: • Lead to the restoration of the vascular supply and connective tissue matrix. • Chronic Inflammation is the result of unresolved acute inflammation In the case of sports related injuries removal of the trauma and successful management of the injury may result in the reduction of fibrosis and restoration of normal function. Dr.Jack Dolbin DC Session 2

  9. Inflammation and Repair Repair: • The repair phase of healing ideally result in the restoration of normal living tissue. • Repair by regeneration of injured tissue • Repair by second intention is characterized by the formation of scar tissue at the site of the injury. • Remodeling and Maturation • Process begins about 6 days after the fibroblasts begin to lay down collagen tissue. • Collagen is laid down randomly initially • Depends on the appropriate mechanical loading. • The hallmark of remodeling is the orientation of new fibers Dr.Jack Dolbin DC Session 2

  10. Inflammation and Repair • Immobilization of a healing wound has been shown to compromise wound strength as a result of the failure of collagen to be oriented along lines of stress. • Mobilization and loading has been shown to result in stronger healed tissue. Time Frame of Healing: • Inflammation Phase is relatively brief. 24-48 hours. • Proliferative Phase: 3-7 days after the injury • Repair Phase: Few days to a few weeks • Remodeling Phase: Several months and may continue up to 12 months. Dr.Jack Dolbin DC Session 2

  11. Inflammation and Repair Repair Mechanisms in Soft Tissue Injuries: Muscle Tissue: • Healing of skeletal muscle is dependent on the integrity of the vascular system and nervous system • Has considerable regenerative properties • Both regeneration and repair by scar tissue. • Capacity for regeneration is determined genetically but the success is determined primarily by the extent and type of injury. • Except for injuries in which the continuity of the muscle fiber is preserved, and the innervation, vascularity and extracellular matrix muscle will regenerate with a loss of normal tissue architecture and function. • Most muscle injuries are a result of exceeding the tensile strength of the tissue and are labeled indirect muscle injury.

  12. Inflammation and Repair Muscle Strain Injuries: Consists of a partial or complete tear at or near the musculotendinous junction. When the force is sufficiently high the tendon has been shown to avulse from the muscle with only a few fibers left intact. • The greater the amount of injured tissue involved the more scar tissue with be deposited at the sight of the wound. Ischemia- Induced Muscle Damage: Usually seen in compartment syndromes. Results from damage to vessels causing ischemic injury. • Seen in exhaustive endurance activities. • Extent of the injury is proportional to the duration of the pressure. • Nerve injury may result as a result of increase pressure. • Healing will be achieved with little or no damage if the damage is limited to individual fibers and blood supply is restored without delay. • Can result in significant scar tissue formation if delayed resulting in excessive cell death.

  13. Concepts of treatment: • Modalities • Cyriax • Joint Mobilizations • Muscle Energy • Laser therapy • Immobilization. • Chiropractic Adjustments Concepts of rehabilitation: • Goals • Necessary training • Necessary equipment • Isotonic exercise • Repetitive motion • Stability ball Rehabilitation of most common athletic injuries • Rehabilitation concepts: a. Injury prevention vs. Injury causation.

  14. Rehabilitation and return to competition: Incidence of injury according to the American Journal of Sports Medicine • Daily Function • Demands of the Sport • Football players in a 5 year program at the Div. 1 level have a 100% chance of being inured • High School: 50-80% • Swimming: 50% men 70% women will develop shoulder problems. • Jogging, running: 60% • Tennis: 60% Musculotendinous overload injuries Dr.Jack Dolbin DC Session 2

  15. Predictor of Injury Duration of Injury • No previous injury: 40 % chance of experiencing a sports related injury • Previous Injury: 65% chance of a re-injury in the Kinetic chain a. Mostly due to incomplete rehabilitation b. Rehab stopped at symptom reduction. • Tri-athlete: 30 days • Cyclists: 2 weeks • Swimming: 2 weeks • Runners: 40 days Dr.Jack Dolbin DC Session 2

  16. Goals of Rehabilitation: • Return to Function • Allows for proper healing • Maintaining the other components of athletic fitness • Return to Normal Competition • Return to Function is the key not simply symptom reduction • Establish an accurate diagnosis • Minimize the local effects of acute injury Dr.Jack Dolbin DC Session 2

  17. Effects of Immobilization: • For each week of immobilization there is a 20% loss of strength in joint. • Type 1 fibers are most affected • Cartilage deterioration, bone and ligament strength loss and increased stiffness. • Rehabilitation can counteract these changes by introducing motion with protection and loading. Dr.Jack Dolbin DC Session 2

  18. Goals of Rehabilitation: • Allows for proper healing • Protects Tissue • Use of Physical Treatment Modalities: • Cold, Heat, Electricity, Laser • Use predicated on accurate diagnosis • Understanding of the biophysics of the modality • Maintaining the other components of athletic fitness • Strength • Flexibility • Aerobic Conditioning • Return to Normal Competition • Baseline established in Preseason Physical • Begin graded return if no baseline established • Increase volume and intensity incrementally

  19. What are we Rehabilitating? Classification of Injury • Acute Injury: Normal anatomy and normal physiology followed by abnormal anatomy and abnormal physiology. a. One-Time microtrauma. • Chronic Injury: Building up for a period of time. a. Represents the tip of the iceberg of entire derangement of physiology • Repetitive microtrauma overload: a. Rotator Cuff Tendonitis b. Plantar fascitisc. c. Achilles Tendonitis • Dx. more than the site of the injury! • Kinetic Chain Dr.Jack Dolbin DC Session 2

  20. Adaptation • Body adapts over a period of time to chronic injuries. The Dx must look for these adaptations: • Weakness and tightness in gastrocnemius in Achilles tendonitis • Elbow tendonitis : tightness of wrist extensors • Rotator Cuff tendonitis: Infexibility in posterior RJC muscles and weakness in scapular stabilizers and post cuff muscles. Note: Entire Kinetic Chain must be searched and evaluated • Acute exacerbation of a chronic injury: Result from symptomatic treatment leading to return to athletic activity. Results in a recurrence of previous symptoms or new symptoms as a result of acute injury in kenetic chain. 1. Ankle Sprain - return to competition- Groin strain 2. Rotator Cuff tendonitis - return to competition- lateral epicondylitis Dr.Jack Dolbin DC Session 2

  21. Adaptation • Injections cause very poor healing and a return of symptoms with activity • Chronic Adaptations 1. No overt symptoms 2. Pattern of abnormalities that lead to decreased function and performance Dr.Jack Dolbin DC Session 2

  22. Negative Feedback Vicious Cycle Tissue Overload Complex Sub-clinical Adaptation Complex Tissue Injury Complex Functional Biomechanical Deficit Complex Clinical Symptom Complex Dr.Jack Dolbin DC Session 2

  23. Negative Feedback Vicious Cycle 1. Tissue overload complex a. Failure of Tensile strength b. Subject to microtrauma 2. Tissue Injury complex a. Disrupted b. Producing Symptoms 3. Clinical Symptom Complex • Pain 4. Functional Biomechanical Deficit Complex a. Decreased flexibility b. Decreased Strength c. Muscle imbalances Dr.Jack Dolbin DC Session 2

  24. Negative Feedback Vicious Cycle 5. Sub-clinical adaptation complex a. Activities the athlete uses to compensate for altered mechanics. 1. Running on the outside of foot to compensate for heel pain. 2. Over reaching in swimming to compensate for decreased ROM in the low back 1. Tissue overload complex Cycle begins again

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