Classification and Management of Sports Injuries.pptx

describes sports injuries. their mechanism of injuries, classification and management.

1. Classification & Management of sports injuries MUJEEB UR RAHMAN ASSISTANT PROFESSOR IPM&R KMU.

2. Ways to classify sports injuries C ause of the injury Direct injury , indirect injury and overuse injury T he type of body tissue damaged S oft -tissue injury and hard-tissue injury.

3. Direct injury E xternal blow or force  collision S truck with an object Examples: Hematomas (‘corks’) and bruises , joint and ligament damage, dislocations and bone fractures.

4. Indirect injury An indirect injury can occur in two ways: The actual injury  some distance from the impact site. F alling on an outstretched hand  dislocated shoulder. The injury does not result from physical contact with an object or person  over -stretching, poor technique, fatigue and lack of fitness. Ligament sprains and muscle strains and tears.

5. Overuse injury Overuse injuries occur when excessive and repetitive force is placed on the bones and other connective tissues of the body. Little or no pain might be experienced The symptoms of overuse injury  increasing training frequency or intensity P oorly planned training programs  inc overuse injuries

6. Other causes of overuse injury are Poor technique and poor equipment. Poor backhand technique U se of a heavy racquet in tennis A nkle or knee pain from  running style or footwear. Examples: S tress fractures and tendonitis .

7. Classification according to tissue type Soft-tissue injury Skin injuries —abrasions, lacerations and blisters Muscle injuries —tears or strains of muscle fibers and contusions Tendon injuries —tears or strains of tendon fibers and inflammation ( tendonitis ) Ligament injuries —sprains and tears of ligament fibers. Soft-tissue injuries can result in internal bleeding and swelling. Prompt and effective management of this bleeding aids recovery.

8. Hard tissue injuries Damage to the bones of the skeleton. Fractures and joint dislocations  bruising of the bone. A direct force can bruise a bone and cause bleeding between the outer layer of the bone and the underlying compact bone. This is common in a bone such as the tibia (shin) where there is little muscle tissue over the bone to absorb the force. Bones have a blood supply and internal bleeding can result from a fracture. In major injuries, this internal bleeding in the bone, together with bleeding from surrounding damaged tissue, can lead to shock and serious circulatory complications

9. Secondary injury Athletes returning to activity are at risk of a secondary injury. An injury that occurs as a result of a previous injury being poorly treated or not being fully healed. Athletes risk recurrence of injuries if they commence playing before regaining full strength and ROM.

10. Soft -tissue injuries Three common soft-tissue injuries are: Strains D isruption of the fibers of a muscle or tendon. Microscopic (few fibers) or severe, involve larger fibers of muscles and tendons. Mechanism  Over -stretched or when a muscle contracts too quickly. Severity ranges from microscopic level (a strain) ,to a small number of fibers through to a complete rupture of all muscle fibers. A sprain is a tear of ligament fibers, muscles or tendon supporting the joint Mechanism  A joint extended beyond its normal ROM. I nvolve a small number of fibers through to a complete rupture . In extreme circumstances, the fibers of the ligament, muscle or tendon can remain intact and rip from the bone. A contusion or bruise is bleeding into the soft tissue. It is caused by a direct blow from another person, an implement or an object. A bruise can occur to any soft tissue of the body.

11. Skin abrasions, lacerations and blisters Very common in sport. They include: Minor wounds  A brasions (grazes), blisters and small lacerations. They also include bone fractures and more serious lacerations  suturing (stitches). Small skin abrasions, lacerations not requiring sutures and blisters are manageable conditions, and in most cases do not require referral to a doctor.

12. Abrasions  outer layer of skin is removed (scraping action). D irt or gravel, which should be removed. Extensive , deeper abrasions require medical attention. D epth and location of the laceration  S uturing ? Medical attention  E xpose tissues, such as fat, tendons or bone. S uperficial laceration will require suturing  IF??? Deep lacerations are usually accompanied by significant bleeding.

13. Hematoma: Definition and Mechanism of Hematoma A hematoma is a local accumulation of blood in a tissue, space or organ. In muscle it has 2 mechanisms of injury (Klein et al, 1990): 1. Direct : following direct impact or contusion 2. Indirect : following a tear or rupture of fibers of the muscle Contracted vs relaxed muscle trauma?

14. Types of Hematoma There are two types: Intramuscular Haematoma : T he muscle sheath and the fascia will remain intact. C onfining the bleed within the tissues  inc pressure  compression capillary beds and counteract the bleed) (Bird et al., 1997). S igns and symptoms will remain localised . C haracteristics include : Swelling (beyond 48 hours). This is because the contained blood causes an osmotic gradient and interstitial fluid is drawn into the muscle (Peterson and Renstrom , 2001). Pain and tenderness Decreased muscle function (reduced contraction and extensibility ) Prognosis …. B ad as compared to inter  mysositis ossificans & fibrosis.

15. Inter-muscular  Haematoma : F asica /sheath is torn. This allows communication of the fluid between muscles/compartments. D ramatic bruising and swelling  travels distally secondary to gravity. In Inter -muscular  hematomas the pain settles considerably following the first 24 hours (Smith et al., 2006 )… ???

16. Physical therapy management of hematoma (smith et al. 2006) Acute Phase Management (First 24 – 72 hours) REST : A period of relative rest is important. Whilst the pain should not be ignored but once the athlete can move the limb they should do so ( Renstrom , 2003). Early mobilisation is widely advocated (Smith et al., 1996). ICE :  Proposed in the acute stages   vasoconstriction. Ice is proposed to reduce: Blood Flow E dema Muscle Spasm Metabolism (and therefore secondary hypoxic damage) Pain Muscle Inhibition

17. COMPRESSION: No conclusive evidence. However , the physiological effects are undeniable. Thorsson et al. (1987) showed moderate compression was able to reduce intramuscular blood flow by up to 50% in healthy athletes. ELEVATION: No conclusive evidence can be drawn from the studies. T he decreased arterial pressure and increased venous return. The application of which is obvious in haematoma management.

18. Resolution Phase Management (72 hours +) HEAT : Giombini et al. (2001) showed that hyperthermia was superior to US for reduction of VAS and hematoma resolution following lower limb sports injuries. Such an improvement in hematoma resolution was mirrored by animal studies performed Lehmann et al. (1983). ULTRASOUND : There are some studies that examined the effects of US following muscle hematoma and their effects on haematoma absorption  present conflicting results . Some studies have shown increases in cellular activity (of unknown statistical significance),whilst others do not. Additionally , it is also possible that the positive effects reported by some studies are a result of the thermal effects of ultrasound. It is challenging to draw clear conclusions of the role of ultrasound in muscle haematoma management.

19. EXERCISE: AROM and isometric exercises are widely advocated (Smith et al., 2006). This is generally progressed to include resistance exercise (see table below). COMBINED PROGRAMS: “ Combined Program” which has included a 3 phase program (Smith et al., 1996; Ryan et al., 1991). However , it is challenging to draw any conclusions on the effectiveness of the programs as none include a control or non-intervention arm. The table below discusses the overall components of the combined programs.

20. No Evidence N o evidence/studies which examined the role of the following treatments. Additionally , they were not commonly proposed by a variety of sports medicine textbooks (Smith et al., 2006): Thermal Contrasts Massage Electrical Stimulation

21. Myositis Ossificans Myositis ossificans is a serious and relatively common (~10%) complication following muscle haematomas (Smith et al., 2006) . C haracteristics : Radiologically evident after 3 – 6 weeks Significant loss of ROM Significant tenderness and hardening on palpation More common in intramuscular hematomas R ehabilitation should include: Rest Gentle Rehabilitation

22. Prognosis There have been a wide range of recovery periods following muscle haematoma . Intramuscular haematomas have a worse prognosis than intermuscular haematomas (Smith et al., 2006). Other poor diagnostic indicators include reduced distal pulses and paraesthesias . Ryan et al. (1991) evaluated the use of combined program (see above) following quadriceps contusions and found the following results. The average time to recovery was Mild Injuries (knee ROM at 12 - 24hrs > 90 degrees): 13 days Moderate Injuries (knee ROM at 12 - 24hrs 45 – 90 degrees): 19 days Severe Injuries (knee ROM at 12 - 24hrs < 45 degrees): 21 days

23. Inflammatory response The initial stage of repair of body tissue is the acute inflammatory phase 24 to 72 hours after injury. Immediate response of the body  increase the flow of blood and other fluids to the injured site . If blood vessels damaged there  direct bleeding into the surrounding tissue  an increase in tissue pressure , pain. All these changes produce inflammation . R edness , heat, swelling, pain and loss of function . U nchecked inflammation  severe scar tissue . Prevention of scar tissue formation directly proportional to the time required for rehab and return of function to pre-injury level.

24. To be continued 

25. Managing soft-tissue injuries Effective management of soft-tissue injuries  RICER procedure Immediate management of soft-tissue injuries (acute phase)  S uccessful rehabilitation The aims of immediate treatment are to : P revent further tissue damage Minimize swelling E ase pain R educe the formation of scar tissue R educe the time needed for rehabilitation .

26. These aims are achieved through the application of the RICER procedure . R •  first 48–72 hours  severity of the injury . I •  20–30 minutes every 2 hours for the first 48–72 hours. C •  fluid build-up & protection E •  S eated or lying down R •  for Referral. Actions to be avoided…?

27. Immediate treatment of skin injuries The aims of the immediate management :  P revention of infection for both the victim and the first aider,  Minimization of blood loss and tissue damage, and  P romotion of healing in order to reduce recovery time. For most skin injuries the common management steps that should be followed are: 1 Reduce the dangers of infection ? 2 Control bleeding with rest, pressure and elevation 3 Assess the severity of the wound 4 Clean the wound using clean water, saline solution or a diluted antiseptic 5 Apply an antiseptic to the wound 6 Dress the wound with a sterile pad and bandage. 7 If necessary, refer Skin injuries that should be referred to medical attention include  ?

28. Hard-tissue injuries Types of hard-tissue injuries F ractures and dislocations. A fracture is a break in a bone. Direct force, A n indirect force or R epetitive smaller impacts (stress fracture). If the skin over a fractured bone is intact, the fracture is? If the skin is broken, the fracture is ? The skin might be broken either by the force of the injury that caused the fracture or by a piece of broken bone protruding through the skin. A fracture is described as ‘?’ if nearby tissues and/or organs are damaged. In some cases, a simple fracture can be difficult to detect. The signs and symptoms of a fracture include: pain at the site of the injury inability to move the injured part unnatural movement of the injured part deformity of the injured part swelling and discoloration grating of bones .

29. Dislocations Dislocations are injuries to joints where one bone is displaced from another. O ften accompanied by considerable damage to the surrounding connective tissue. Dislocations occur as a result of the joint being pushed past its normal range of movement. Common sites of the body where dislocations occur are the finger, shoulder and patella. Signs and symptoms of dislocation include: loss of movement at the joint obvious deformity swelling and tenderness pain at the injured site.

30. Managing hard-tissue injuries Medical treatment Because hard-tissue injuries can be accompanied by significant damage to muscle, blood vessels, surrounding organs and nerves, immediate medical treatment is required. For serious hard-tissue injuries, the person should not be moved, and an ambulance should be called. Immediate management: Immobilize and support  splint or sling. Check for impaired circulation and other possible complications . Arrange for transport to hospital and professional medical assessment. Implement the RICER procedure—if it does not cause pain.

31. Immobilisation Management of hard-tissue injuries aims  minimize movement This is achieved by immobilizing the joints ? and ? the injury site. If the injury site is the shaft of a long bone (for example, the femur or humerus ), the injury can be supported with a sling or splint. A supporting splint should be long enough to extend beyond the nearest joints of the injured site . The correct application of the splint is essential. When correctly applied, a splint is secured at all these six points: above the joint above the fracture below the joint below the fracture at the joint above the fracture at the joint below the fracture just above the fracture just below the fracture

32. In some cases of fracture, a rigid splint is unnecessary. In these cases, a sling or bandaging of the injured limb to the other limb is adequate. With dislocation, immobilization is also the immediate aim. Under no circumstances should the first aider attempt to relocate the dislocation. As a result of the dislocation there can be associated damage to the bones and to the ligaments of the joint. In most cases, an X-ray is needed before relocation. Any rushed attempt by the first-aider to relocate the dislocation might result in further damage to the joint.

33. Assessment of injuries It is important to follow correct assessment procedures when assisting an injured athlete. TOTAPS When attending to an injured athlete  unconscious  DRABCD If the athlete is conscious  TOTAPS method of injury assessment. P rovide information about the extent of the injury, and will indicate whether the person should be permitted to continue the game/performance or should be given professional medical help.

34. DRABCD stands for danger , response, airway , breathing , compressions and defibrillation .

35. TOTAPS stands for: T • Talk O • Observe T • Touch A • Active movement P • Passive movement S • Skills Test . It is important to note that the control of bleeding takes priority over TOTAPS.

36. Talk cause , nature and site of the injury info. For example: How did the injury happen? Where does it hurt? Did you hear any snaps or cracks? Do you have any ‘pins and needles’? Is the pain sharp or dull? Did you continue to play for any time? For suspected concussion  athlete’s alertness and level of consciousness. If the athlete shows signs of serious injury the person should be immobilized and professional help should be sought immediately. The first aider might also seek information on the injury history of the athlete (for example, previous injuries to the body part) and might talk to witnesses who saw the injury occur. Observe After questioning the athlete, visually examine the site of the injury . Look for deformity, swelling and redness. If the injury is to a limb, compare.? If there is obvious deformity, there is likely to be a fracture or serious ligament/tendon damage, and medical assistance is needed  no deformity ‘ touch ’.

37. Touch If there is no obvious deformity and the athlete is not especially distressed, feel the site of the injury. Using your hands and fingers, gently touch the site without moving it. If possible, feel the corresponding site on the other side of the body and compare. Note any differences. Observe the athlete’s level of distress as you touch the injury. If touching the injury causes the athlete intense pain, the injury might be serious and medical diagnosis is necessary. If touching the injury causes only slight pain  ‘ active movement ’. If there is evidence of a fracture or dislocation, the procedure is stopped at this point. Specific management for a fracture should begin .

38. Touch

39. Active movement Observe the degree of pain. O bserve the extent or range of movement that is achieved by the athlete. Compare. As the athlete moves, feel the injured site for any clicking or grating. If the athlete cannot move the injured site, or has only minimal range of movement  RICER procedure is used, and medical assistance. If the athlete can move without intense discomfort, proceed to the passive moment .

40. Passive movement R eached the passive movement stage  not serious. A decision needs to be made as to whether or not the athlete should continue to play . The ‘passive movement’ stage requires the first aider to move the athlete’s injured body part and determine how much pain-free movement is possible. If the athlete cannot have the injured part manipulated through the normal range of movement without pain, the first aider should not continue. RICER treatment should be administered. If the range of movement is normal, the athlete should be asked to stand.

41. Skills test If the athlete can stand  pressure on the injured site by performing movements For example, the athlete could run, hop, jump and push. If these actions can be completed  ? For example, in the case of a football player being assessed for an ankle injury, you would ask the player to  ?

42. Thank You 