THE ROLE OF PHYSIOTHERAPY IN THE MANAGEMENT OF SPORTS INJURIES

Mohd Asri Ariffin

MSc (Sports Science) Student SSU (USM)

Supervisor: Dr Oleksandr Krasilschikov

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Content
Definition Classification Type of sports injuries Common sports injuries Estimated relative risk Physiotherapy management of Tennis Elbow Physiotherapy management of ACL sprain Physiotherapy management of Lateral Ankle sprain Injury prevention Criteria for return to sport Conclusion Acknowledgement References

Definition
Physiotherapy:
Physiotherapy is the treatment of physical dysfunction or injury by the use of therapeutic exercise and the application of modalities, intended to restore or facilitate normal function or development.
http://www.thefreedictionary.com/physical+therapy

Definition
Sports injuries:
Sports injuries result from acute trauma or repetitive stress associated with athletic activities. Sports injuries can affect bones, soft tissue (ligaments, muscles, tendons) or other organs.
http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp

Classification
Acute injuries (traumatic) Is typically the result of single event Result in the immediate onset of pain Associate with an obvious deformity with impaired function Less than 72 hours Chronic/ Sub-acute injuries (overuse) Result from repetitive microtrauma to bone, ligament and musculotendinous units More than 72 hours

Type of sports injuries

Sprains Strains Fractures Cramps Spinal cord injuries Internal organ injuries Head injuries and concussions

Common sports injuries

Clavicle fracture Shoulder dislocation Rotator cuff injuries Ulnar collateral ligament (UCL) Sprain Acromioclavicular sprain Scaphoid Stress Fracture Medial epicondylitis (Golfers elbow) Lateral epicondylitis (Tennis Elbow) Finger sprain Low back injuries
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Common sports injuries cont.

Adductors strain Hamstring strain Patello-femoral Joint Pain Syndrome Stress fracture Shin splint Compartment Syndrome Plantar Fascitis Anterior cruciate ligament sprain Medial collateral ligament sprains Meniscus tear Lateral ligament sprain of ankle Achilles tendon tendinopathy
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Estimated Relatives Risk

Anatomical region Head & Neck: Shoulder: Elbow: Wrist Finger: Low Back Pain: Groin: Thigh: Knees: Legs: Ankle & Foot:

%
0-2 5-10 5 5 5-10 15 5 5-10 10 20-25 5-10 25

Games Rugby, Gymnastics, Hockey, Badminton, Tennis, Volleyball Bowling, Badminton, Gymnastics, Tennis Wt Lifting, Diving, Gymnastics Volley-Ball, Hockey, Cricket, Gymnastics, Badminton, Cycling, Soccer, Hockey, Rugby Athletics, Martial Arts, Soccer Badminton, Athletics, Football, Rugby Badminton, Football, Hockey, volley-ball Athletics, Martial Arts Gymnastics, Athletics, Diving, basketball
Dr Aston Ngai, 6th ISSC 2006

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Tennis Elbow
Excessive degree of pulling on the common extensor tendon Pathology of repeated micro trauma, small areas of tendon are torn away from the periosteum producing an associated inflammatory reaction that initially minor but progresses to become recurrent
(Crowther, 1999)

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Tennis Elbow
Clinical features (C/F) - tender lateral epicondyle; common extensor origin (ECRB) due to fibrosis, calcification & microtears Very common in racquet games such as badminton, tennis and squash

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Tennis Elbow
Assessment - pain during extension of the wrist - reduce grip power - loss of function Treatment a) Medical b) Physiotherapy treatment
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Physiotherapy treatment
Ultrasound Heat wrap therapy or Hot pack Soft tissue manipulation (massage) Stretching and strengthening exercises Advice Tennis Elbow brace
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Ultrasound (U/S)
Ultrasound is mechanical radiant energy derived from the application of an electric current on a crystal, which result in a vibratory motion Micro-massage and thermal effects Dosage: - Acute: 0.8w/cm square for 5 minutes, twice daily and 3 times per week - Chronic: up 2.0 w/cm square for 10 minutes and 3 times per week

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Literature Review
Falconer et al (1990) reviewed the literature to determine the effects of ultrasound on musculoskeletal condition, and suggested that ultrasound appears to be effective in relieving pain and increasing range of motion in acute periarticular inflammations condition, but not chronic periarticular inflammatory conditions According to Richardson and Iglarsh (1994), ultrasound assists in the resolution of inflammatory exudates by increasing the local blood flow. Leong et al (2005), in his study has found that u/s enhanced medial collateral ligament repair in rat.

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Indications (US)
Sprains and strains such as, Achilles tendon tendinitis, Medial Collateral Ligament sprains Chronic swelling- lateral ankle sprains Muscle tear- Hamstring tear Lateral epicondylitis (Tennis Elbow) Medial epicondylitis (Golfer Elbow)
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Ultrasound (Application)

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Physiotherapy treatment
ii) Heat wrap therapy or Hot pack dosage: 20 minutes, 3 times per week

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Heat Wrap Therapy (Hot Pack)

Superficial heating Heat wrap therapy consist of canvas or nylon cases, filled with a hydrophilic silicate or sand, stored in a thermostatically control cabinet in water at temperature between 70 degree Celsius and 75 degree celsius.
Low and Reed (1990)

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Literature review (Heat Wrap Therapy)

Clinically, hot pack appear to be used most often to help to reduce pain and muscle spasm, and to help improve tissue extensibility (Baker et al 1991, Lentell et al 1992) A clinical trial to evaluate the efficacy of continuous low-level heat wrap therapy for the treatment of various sources of wrist pain including strain and sprain (SS), tendinosis (T), osteoarthritis(OA), and carpal tunnel syndrome (CTS) has been carried out by Susan Michlovitz et al (2003). - In this study, the comparison is between heat wrap therapy group and the oral placebo group. - And, they found that continuous low-level heat wrap therapy was efficacious for the treatment of common conditions causing wrist pain and impairment.
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Indications (Heat Wrap Therapy)

Low back pain Muscle strain Muscle spasm Frozen shoulder Ligaments injuries- Anterior CL, MCL Cramps Tendon rupture- Achilles Tendon rupture Lateral epicondylitis (Tennis Elbow)
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Physiotherapy treatment
iii) Soft tissue manipulation (massage) - Deep transverse friction is effective for tendinitis, generally because of the mechanically induced hyperemia and its influence on tissue maturation
Richardson and Iglarsh (1994)

iv) Stretching

and strengthening - strengthening (Dumbell) - Stretching- into elbow extension, forearm pronation, ulnar deviation, wrist and finger flexion
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Physiotherapy treatment
v) Advice - taught on preventive measure, including proper technique and conditioning, limiting activity after the muscles begin to fatigue vi) Tennis Elbow brace
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Anterior Cruciate Ligament (ACL) Sprain

The ACL is the primary ligament stabilizer in the knee. The ACL prevents excessive rotation of the femur on the tibia and restricts anterior translation of the tibia relative to the femur.

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ACL Sprain
ACL sprains can occur from contact or non-contact forces. A football player who is tackled while standing on an extended knee or a skier who twists or hyperextends their knee can tear the ACL. An ACL sprain is commonly associated with a distinct pop in the knee followed by a sensation of the knee shifting or giving way
Anderson (2005)

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(ACL) Sprain

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ACL Sprain
Assessment - Reduce range of motion - Decrease muscle bulk - Reduce muscle power - swelling - pain - restricted movement - special test: Anterior drawer test and Lachman test - Radiagraphic: X-ray and MRI - Arthroscopy Surgical treatment: ACL reconstruction
- followed by extensive physiotherapy program
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Special Tests
Anterior drawer test Patient lying down; knee flexed 90 degrees; examiner stabilizes the foot and gently pull tibia forward Increased motion or indistinct end point indicates ACL injury

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Arthroscopy

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Physiotherapy Treatment
Treatment (Acute) i) Ice pack ii) compression bandage Treatment (Sub-acute) i) Heat treatment (heat wrap therapy or shortwave diathermy) ii) Therapeutic Exercise - mobilising - stretching - strengthening iii) Advance rehabilitation (field) iv) Advice on injuries prevention
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Physiotherapy treatment
Ice Therapy Immersion Massage Ice pack Cold gel

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Physiotherapy treatment
Ice Therapy Is recommended for the first 24-48 hours Rationale: - Less fluid filtration into the interstitial tissue, due to vasoconstriction - Less inflammation and less pain - Decrease metabolic rate
Michlovitz (1996)

According to Knight (1985), efficacy of cold for the care of acute injuries is because of the reduction in metabolism and, thus, a decrease in secondary hypoxia injury
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Physiotherapy treatment
ii) compression bandage - If still swollen This is the most effective means of stopping hemorrhage, but to effective, compression must be selective - For example, for ankle joint, padding must be applied to ensure the even compression to the affected area
Garrick and webb, 1999

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Physiotherapy treatment
Sub acute stage - Heat treatment (heat wrap therapy or shortwave diathermy) Isometric contraction- Static quadriceps and static hamstring When Swelling and pain subsided - Therapeutic Exercise i) mobilising ii) stretching iii) strengthening

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Physiotherapy treatment
1. Short-wave diathermy (SWD) Medium frequency current 27.12 MHz is commonly used Can penetrate the body Beneficial effects - increase in blood flow due to vasodilation - improvement in tissue oxigenation - increase capillary pressure and cell membrane permeability - relief muscle spasm - decreased tension of the collagenous tissue
Shankar and Randall (2002)

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Literature Review
There are mixed results Acute ankle sprain have been treated by this modality with marked benefit (Wilson, 1974), some benefit (Pasila et al, 1978) and no effect (McGill, 1989) Chronic back pain has been successfully treated with SWD (Wagstaff et al, 1986)

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SWD
Indications
Knee injuries Muscle spasm Low back pain Rotator cuff injury Neck an shoulder injuries - Prolapse intervertebral disc (PID)
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Physiotherapy treatment
Mobilising Exercise - usually cycling for 20 minutes each session Stretching Exercise - quadriceps - Hamstring

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Physiotherapy treatment

Strengthening exercise - Quadriceps - Hamstring Quads bench

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Treadmill
Before progress to field training Re-evaluation

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Physiotherapy treatment
Advice on injuries prevention - warming up and cooling down - knee brace

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Lateral Ankle Sprain

Lateral ankle sprains are common in running, jumping, pivoting, and cutting sports. Sprains occur when the ankle inverts past the point where bony architecture and ligaments can stabilize the joint.
C.N. van Dijk (1997)

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Lateral Ankle Sprain

Most common injury in sports Immediately feel the pain and swelling

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Classification of Lateral Ankle Sprains Grade I:

minor tear of ATFL/CFL. Mild tenderness & swelling Slight / no functional loss Grade II: Partial ATFL/CFL tear, ++ functional impairment. ++ pain & swelling, +/++ bruising & instability; motion and function; Grade III: ATFL/CFL/PTFL Completely torn, +++ swelling (more than 4 cm about the fibula) +++bruising, Loss of function & motion (i.e., patient is unable to bear weight or ambulate) ++/+++ instability
Adapted from Lateral ankle pain. Park Ridge,Ill.: American College of Foot & Ankle Surgeons, 1997: preferred practice guideline no. 1/97

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Lateral Ankle Sprain

Assessment - pain especially on inversion - swelling - limping gait - range of motion Treatment - medical - physiotherapy - traditional massage
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Physiotherapy treatment
Acute phase - RICE Sub-acute phase - Wax Therapy - U/S -Therapeutic Exercise - mobilising - stretching - strengthening Proprioceptive training Ankle tapping
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Wax Therapy

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Literature Review
Hayes (1993) reported that an increased intraarticular temperature might initially heighten inflammatory activity, further increases in temperature might slow it down Hensley (1992) claimed that there is an increased range of motion following heating of a joint by paraffin wax

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Wax Therapy
Using paraffin wax - it has low melting point (54 degree Celsius) - has low specific heat, which means that it does not feel as hot as water of the same temperature, therefore, there is less risk of burn
Michlovitz (1996)

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Indication (Wax Therapy)

Plantar Fascitis Achilles Tendon Tendinitis Rheumatoid Arthritis Finger sprain Fracture metacarpal and phalanges Fracture metatarsal and toes Carpal tunnel syndrome Trigger finger Ankle sprain
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Physiotherapy Treatment
Therapeutic Exercise - mobilising - stretching - strengthening Proprioceptive training - wobble board Ankle tapping
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Injury Prevention
Warm up and cooling down Gradual training program Tapping Proper technique Appropriate shoes

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Return to Sports
Review by sports physician & physiotherapist Normal full functional activity Tested with sports-specific agility skills by sports science specialist Completion of rehabilitation program

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Conclusion
Lack of data in the prevalence of sports injuries in Malaysia, therefore more studies should be carried out in the future. More research on the effectiveness of physiotherapy modalities is required in exercise & sports.
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References
1. 2. 3. 4. T.J. Noonan and W.E. Garrett, Muscle strain injuries, J Am Acad Orthop Surg (1999), pp. 262269. Garrick JG and Webb DR (1999) Sports Injuries Diagnosis and Management. C.J. Couture and K.A. Karlson, Tibial stress injuries, Phys Sports Med 30 (2002) (6), pp. 2936. C.N. van Dijk, L.S. Lim, P.M. Bossuyt and R.K. Marti, Physical examination is sufficient for the diagnosis of sprained ankles, J Bone Joint Surg Br 79 (1997) (6), pp. 10391040. Michlovitz MS (1996) Thermal Agents in Rehabilitation, F.A. Davis Company: Philadelphia Anderson SJ (2205) Disease a Month. Volume 51, Issues 8-9 . Dr Aston Ngai. 6th ISSC 2006. Crowther CL (1999) Primary Orthopaedic Care. Mosby, St Louis.

5. 6 7. 8.

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References
9. Knight KL (1985) Cry therapy, Theory, Technique, Physiology. Chattanoga Corp.Chattanoga, TN, p 154 10. 11. Low J and Reed A (1990) Electrotherapy Explained: Principle and Practice. Butterworth-Heinemann, Oxford Leung CP, Ng YF and Yip KK (2005) Therapeutic ultrasound enhances medialcollateral ligament repair in rats Ultrasound in Medicine & Biology Volume 32, Issue 3, March 2006, Pages 449-452 12. 13. 14. Baker RJ and Bell GW (1991) The effect of therapeutic modalities on blood flow in the human calf. Journal Orthopaedic Sports Physical Therapy 13 (23). Richardson JK and Iglarsh ZA (1994) Clinical Orthopaedic Physical Therapy.WB Saunder Company. London. Michlovitz S , Hun L, Erasala GM, Hengehold DA and Weingand KW (2003) Continuous low-level heat wrap therapy is effective for treating wrist pain. Arch Phys Med Rehabil 2004;85:140916.

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References
15. Hayes KW (1993) Heat and cold in the management of rheumatoid arthritis. Arthritis Care and Research 6), pp. 156166 Hensley S (1992) Comparison of tolerance to high and low temperature paraffin in children with arthritis and related diseases, Arthritis Care and Research 5 (1992), p. S8. Shanker K and Randall KD (2002) Therapeutic Physical Modalities . Hanley and Belfus Inc. Philadelphia. Falconer J, Hayes KW, Chang RW (1990) Therapeutic Ultrasound in the treatment of musculoskeletal condition. Arthritis Care Res. 3 (2): 85. Wilson DH (1974) Comparison of Shortwave Diathermy and pulsed electromagnetic energy in treatment of soft tissue injuries. Physiotherapy, 60, 309-10. Wagstaff P, Wagstaff S, Downey M (1986) A pilot study to compare the efficacy of continuous and pulsed magnetic (SWD) on the relief of low back pain. Physiotherapy, 72, 563-6 58 16.

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References
21. McGill SN (1989) The effects of pulsed Shortwave therapy on lateral ligament sprain of the ankle . New Zealand Journal of Physiotherapy, 16, 21-4 Pasila M, Visuri T, Sundholm A (1978) Pulsating shortwave diathermy: value in treatment of ankle and foot sprains. Arch Phys Med Rehabil, 59, 283-6. http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp 22.

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Acknowledgement
I would like to express my gratitude to My Supervisor Dr. Oleks Unit Head Dr. Chen Chee Keong Ass. Prof Dr. Asok Academic Advisor Dr. Jolly All my classmates
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Thank you for your attention

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