Review

STAGES of INFLAMMATION and REPAIR

Acute Stage / Inflammatory Stage Subacute Stage / Repair Chronic stage / Remodelling

OTPT 130 : Medical Rehabilitation Lectures 2 University of the Philippines Manila , College of Allied Medical Professions

REHABILITATION of SOFT TISSUE and SPORTS INJURIES
MICHAEL D . MAGPANTAY , PTRP

moro

Physiotherapist Moro – Splash Foundation Inc ., Sports Clinic

SPORTS MEDICINE TEAM
Family physician Physiotherapist Sports physician Massage therapist Orthopedic surgeon Radiologist Podiatrist Dietician / Nutritionist Psychologist Sports Trainer / Athletic Trainer Other professionals such as Occupational Therapist, orthotist and nurses Coach

SPORTS MEDICINE TEAM
There may be a considerable amount of overlap between the different practitioner “Multiskilling” is particularly important if the practitioner is geographically isolated or is travelling with sports team

SPORTS MEDICINE MODEL
Trainer Physician Physiotherapist / OT

Dietician

Athlete - Coach

Massage Therapist

Psychologist Others

Podiatrist

SPORTS MEDICINE
The secret of success is to take a broad view of the patient and his or her problem Ask “Why has this injury / illness occurred Diagnosis and treatment

SPORTS MEDICINE
Diagnosis Precise anatomical and pathological cause of the presenting problem Presenting problem and cause of the problem History, physical examination and investigation

SPORTS MEDICINE
Treatment Treatment of presenting injury and treatment to correct the cause Combination of different forms of treatment will usually give the best result Evaluate effectiveness of treatment constantly

SPORTS MEDICINE
Meeting Individual Needs Every patient is a unique individual with specific needs Treatment depends on the patient’s situation, not purely on the diagnosis

SPORTS MEDICINE
“Love Thy Sport” It is essential to know and love the sport It is essential to be on site

SPORTS INJURY REHABILITATION
Primary goal is to enable the athlete to return to sports with full function in the shortest possible time Inadequate rehabilitation Prone to reinjury of the affected area Incapable of performing at pre-injury standard Predisposed to injuring other part of the body

SPORTS INJURY REHABILITATION
Keys to a successful rehabilitation Explanation Provide precise prescription Make the most of the available facilities Begin as soon as possible

SPORTS INJURY REHABILITATION
Components of Rehabilitation Muscle conditioning Flexibility Neuromuscular control, balance and propriception Functional exercises Sports skills Correction of abnormal biomechanics Maintence of CV fitness Psychology

Return to Sport

Skill Aquisition

Proprioception

Strength

Flexibility

Motor Re-education and Muscle Activation

SOFT TISSUES LESIONS
(Mechanism of Injury or Onset of Symptoms)

ACUTE INJURIES OVERUSE INJURIES

BONE ARTICULAR CARTILAGE JOINT (Site) LIGAMENT MUSCLE TENDON BURSA

SOFT TISSUES LESION

BONE

Acute Injuries

Overuse Injuries

Fracture

Stress Fracture ‘Bone Strain’, ‘Stress Reaction’

Perisosteal Contusion

Ostitis, Periostitis Apophysitis

ARTICULAR CARTILAGE
Acute Injuries

Overuse Injuries

Osteochondral / Chondral Fractures Minor Osteochondral Injury

Chondropathy Softening Fibrilation Fissuring Chondromalacia

JOINT

Acute Injuries

Overuse Injuries

Dislocation Sublaxation

Synovitis Osteoarthritis

LIGAMENT
Acute Injuries Overuse Injuries

Sprain / Tear

Inflammation

MUSCLE
Contusion Cramp

Acute Injuries

Overuse Injuries

Strain / Tear

Chronic Compartment Syndrome Delayed Onset Muscle Syndrome Focal Tissue Thickening / Fibrosis

Acute Compartment Syndrome

TENDON
Acute Injuries Overuse Injuries

Tear

Tendinopathy

BURSA
Acute Injuries Overuse Injuries

Traumatic Bursitis

Bursitis

JOINT Dislocation / Sublaxation
Dislocation occurs when trauma produces complete dissociation of articulating surfaces

JOINT Dislocation / Sublaxation
Shoulder (Glenohumeral Joint) Dislocation - anterior dislocation results from the arm being force into excessive abduction and Supraspinatus - immobilized with elbow extended and shoulder external rotation

JOINT Dislocation / Sublaxation
Management: Protection Phase Protect healing tissue Activity restriction Avoidance of Abduction with external rotators

JOINT Dislocation / Sublaxation
Management: Controlled Phase.  Provide Protection Increased Shoulder Mobility Increase Stability and Strength of Rotator Cuff and Scapulars 

JOINT Dislocation / Sublaxation
Management: Return to Function Phase. Restore Functional Control Return to maximum function

LIGAMENT Sprain
Ankle – Anterior Talo Fibular Ligament Inversion

LIGAMENT Sprain Ottawa Ankle Rules

LIGAMENT Ankle Sprain
Management: Protection Phase Educate the Patient Decrease Inflammation Use Gentle Joint Mob to maintain joint integrity

LIGAMENT Ankle Sprain
Management: Controlled Motion Phase Attain Full range of motion Start Strengthening Balance and Propriception

LIGAMENT Ankle Sprain
Management: Controlled Motion Phase Progress strength training Progress Balance and propriception exercises Sports movement and skills

LIGAMENT Anterior Cruciate Ligament
Anterior cruciate ligament (ACL) injuries occur from both contact and noncontact mechanisms. blow to the lateral side of the knee resulting in a valgus force to the knee. rotational mechanism in which the tibia is externally rotated on the planted foot

LIGAMENT Medial Collateral Ligament
Result of valusstress on a semiflexed knee

Meniscectomy
Indication for Surgery
A symptomatic (pain and locking), displaced tear of the meniscus sustained by an older, inactive individual associated with pain and locking of the knee A tear extending into the central, less vascular third of the meniscus if not determined repairable when arthroscopically visualized and probed A tear localized to the inner, avascular third of the meniscus

Meniscectomy
Management: Protection Phase Educate the Patient Decrease Inflammation

Meniscectomy

Management: Controlled Motion Phase Attain Full range of motion Start Strengthening Balance and Propriception

Meniscectomy

Management: Controlled Motion Phase Progress strength training Progress Balance and propriception exercises Sports movement and skills

Tendinopathy
• • • • • • • • • Rotator cuff tendinopathy Supraspinatus tendinitis Bicipital tendinitis Cumulative trauma disorder ITB tendinitis Patellar tendinitis Tibialis posterior tendinitis Plantar fasciitis

Tendinopathy
• Rotator cuff tendinopathy
• Primary
• Due to anatomic abnormalities
• Osteophytes • Type III Acromion process

• Secondary
• Excessive load on the shoulder due to
• impaired scapulohumeral rhythm • Joint instability • Muscle imbalance

Tendinopathy
• Rotator cuff tendinopathy • Clinical features • Pain with overhead activity or movement • Painful arc 60-120 degrees of abd. • Abduction less than 90 degrees are usually pain free • Pain and tenderness in the supraspinatus muscle particularly at the insertion • Pain with excessive shoulder flexion

Tendinopathy
Bicipital Tendinitis • Long head of the biceps susceptible to overuse injury • Occurs with individuals performing high volume of weight training • Referred pain and rotator cuff tendinopathy can produce pain in the biceps

• Symptoms
• Local tendernes s of the biceps tendon • Muscle tightness • Chronic intermusc ular and fascial thickening • Pain on

Tendinopathy

Acute

Subacute

Chronic

• • •

PRICEMEM PT: Taping Physical agents

• • •

• • •
Mobility/Strength

Low level functional activities

•Power •ADL in the pain free
range

Tendinopathy
Cumulative Trauma Disorders • Chronic Inflammation • repetitious movements over a prolonged period of time originating from the body part results in microtrauma of the area


    

Pain is the primary Manifestation •Characterized by increased collagen production and resorption of mature collagen •Efforts to stretch the inflamed tissue perpetuate the irritation

Tendinopathy
Tennis elbow
Typical Movements flexion and extension of the elbow

Typical Job Activities small parts assembly hammering meat cutting playing tennis bowling

Golfers Elbow •Rare •

Tendinopathy
Tennis Elbow • Pain at the site radiating to the lateral epicondyle • ECRB + Supinator • ROM Complete • Weak grasp
 

Golfers Elbow • Pain at site reproduced by resisted wrist flexion, pronation, grasping

Tendinopathy
• Tennis and Golfers Elbow • Treatment is consistent with stages • Ergonomic modifications

Tendinopathy
De Quervains Disease • Stenosing tenosynovitis • APL and EPB tendon
  

Tendinopathy
De Quervain’s
Typical Movements Typical Job Activities combined forceful gripping and sawing use of pliers hand twisting  “turning" control such as on a motorcycle inserting screws in holes forceful hand wringing

Primary Treatment: Ergonomics and Joint protection

Tendinopathy
Management Guidelines Acute • Control of inflammation • Focus on non-stressful activities / non-stressful intensities Subacute and Chronic • Exercise programs with controlled stress(until CT can withstand the stress) • Identify the cause of faulty muscle and joint mechanics

Tendinopathy
OT • Pallative treatment

Tendinopathy
ITB tendinitis • ITB Friction syndrome • Pain at insertion (Gerdys Tubercle) • Treatment  consistent with stages

Tendinopathy
Patellar Tendinitis • “Jumpers knee” • Inferior pole of the patella Sinding Larsen Johansson • Osteochondritis of proximal attachment Osteochondritis Dissecans • Partial to complete avulsion of TT
 

Tendinopathy
Tib Post • Pain in the navicular bone • Resisted ankle inversion Achilles tendinitis • Pain in calcaneus • Plantarflexion Plantar fasciitis • Pain in plantar aspect • Rule out heel spurs
 

Tendinopathy
   

Treatment Tib Post

Acute

Chronic

Achilles Tendinitis
 

Plantar Fasciitis

Bursitis
Ischiogluteal bursitis “Weavers bottom” Prepatellar bursitis “Housemaids knee” Subacromial / Subdeltoid bursae Olecranon Bursitis “Miners Elbow”

Superficial infrapatellar bursitis “Nun’s Knee”

Pes anserine bursitis

Bursitis
• Clinical Feature • Pain present in all motions • Leads to secondary complications (wekaness, LOM) • Continued use willl lead to erosion, rupture, adhesive pericapsulitis

ACHILLES TENDON REPAIR
Athletes in 30s or 40s Location of rupture is associated with the “watershed” area.

ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Maximum Protection Phase Protect the wound Prevention of early re-rupture Maintain strength of non immobilized joints Prevent reflex inhibition of immobilized muscle groups Specially Tibialis Posterior Prevent joint stiffness on operated ankle and foot Re-train proprioception Control swelling Maintain scar integrity Improve Gait pattern

ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Moderate Protection Phase Increase strength of hip and knee of operated extremity Improve proprioception and balance Attain Full Range of Motion on the operated ankle towards dorsiflexion Increase Strength of operated ankle and foot Maintain scar integrity No swelling Improve Cardiovascular Endurance

ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Moderate Protection Phase Progress strengthening on operated ankle Progress strengthening of hip and knee of operated extremity Maintain scar integrity Progress proprioception and balance Attain Full Range of Motion on the operated ankle towards plantarflexion Improve Cardiovascular Endurance Prepare for jogging

ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Minimun Protection Phase Progress strengthening of hip and knee of operated extremity Progress proprioception and balance Improve Cardiovascular Endurance Improve coordination Prepare for Sprints Improve agility Increase Power

ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Return to Function Phase Progress strengthening on operated ankle Progress strengthening of hip and knee of operated extremity Progress proprioception and balance Improve Cardiovascular Endurance Improve Power Return to Sport

MUSCLE STRAINS
Maximum Protection Phase -No stretching -No strengthening -Protect healing muscle -Mobilize unimmobilized areas
-

Moderate Protection Phase -Strengthening -Isometrics  as tolerated isotonic -Core -Start stretching, massage Minimum Protection Phase Strengthening isotonic  eccentrics Stretching calf, hamstrings and quads

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