SPORTS INJURIES

ASSESSMENT & MANAGEMENT

University of Pretoria

Section Sports Medicine

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

Contusions Acute vs Chronic

Overuse vs Overload Tendinitis

vs.Tendinosis

Bursitis Sprains vs Strains

 1. CLASSIFICATIONS

• Acute vs. Overuse Injuries

• Predisposing factors to overuse injuries
• Grading
– Tendon
– Ligament
– Muscle
 Acute vs Overuse Injuries
SITE ACUTE OVERUSE
INJURIES INJURIES
Bone Fracture Stress Fracture
Periosteal ‘Bone strain’,
contusion ‘stress reaction’
Osteitis,
Periostitis
Apophysitis
 Acute vs Overuse Injuries

SITE ACUTE OVERUSE

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

Sprain/tear Inflammation
Ligament (grades I-III)

Traumatic Bursitis
Bursa bursitis
 Acute vs Overuse Injuries
SITE ACUTE OVERUSE
INJURIES INJURIES
Strain/tear Chronic compart-
(grades I-III) ment syndrome
Contusion
Delayed onset
Muscle muscle soreness
Cramps

Acute compart- Focal tissue

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

SITE ACUTE OVERUSE

INJURIES INJURIES
Neuropraxia Entrapment
Minor nerve Adverse neural
Nerve injury/irritation tension
 Predisposing factors to overuse injuries

EXTRINSIC INTRINSIC

Training errors Malalignment

Excessive volume Pes planus/cavus
Excessive intensity Rearfoot varus
Rapid increase Tibia vara
Sudden change in type Genu valgum/varum
Excessive fatigue Patella alta
Inadequate recovery Fem. neck anteversion
Faulty technique Tibial torsion
Predisposing factors to overuse injuries
EXTRINSIC INTRINSIC
Surfaces Leg length discrepancy
Hard, soft, cambered Muscle imbalance
Muscle weakness
Shoes Lack of flexibility
Inappropriate, worn Generalised muscle
out tightness
Equipment Focal areas of muscle
Inappropriate thickening
Restricted joint ROM
Predisposing factors to overuse injuries

EXTRINSIC INTRINSIC
Environmental Sex, size, body
Hot, cold, humid composition

Psychological factors Other

Inadequate nutrition Genetic factors,
endocrine factors,
metabolic conditions
 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
 Grading of ligament sprains
Grade I
• Stretched fibers
• Normal ROM
Grade II
• Considerable portion of the fibers involved
• Increased laxity but a definite endpoint
 Grading of ligament sprains
Grade III
• Complete
• Excessive laxity with no firm endpoint
 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
 Grading of muscle strains
Grade III
• Complete tear
• Mostly at musculotendinous junction
 2. PRINCIPLES OF INJURY
PREVENTION
1. Correct biomechanics
2. Warm up
3. Stretching
- Static
- Ballistic
- PNF
 Does warm-up influence the
mechanical properties of the muscle?
Passive warm-up Active warm-up
Increases peak stretch Increases peak stretch
but decreases peak force and peak force
Force (N)

Force (N)

Stretch (mm) Stretch (mm)

Stretching :practical points

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
 PRINCIPLES OF INJURY PREVENTION

4. Taping and bracing

5. Protective equipment
6. Suitable equipment
7. Appropriate surfaces
 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
 PRINCIPLES OF INJURY PREVENTION
9. Adequate recovery
- Warm down
- Whirlpools and spas
- Massage
- Rest and sleep
10. Psychological aspects
11. Nutritional aspects
 3. PRINCIPLES OF DIAGNOSIS
1. History
- Allow enough time
- Be a good listener
- Know the sport
- Discover the exact circumstances of
the injury
 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
 PRINCIPLES OF DIAGNOSIS
1. History (cont.)
- Training history
- Equipment
- Technique
- Overtraining
- Psychological factors
- Nutritional factors
- Level of participation
 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
 PRINCIPLES OF DIAGNOSIS
2. Examination
- Develop a routine
- Examine the other side, where
relevant
- Attempt to reproduce the
symptoms
- Assess local tissues
 PRINCIPLES OF DIAGNOSIS

2. Examination (cont.)
- Assess for referred pain
- Assess neural tension
- Biomechanical examination
 PRINCIPLES OF DIAGNOSIS
3. Investigations
- Understand the tests
- Know how soon changes can be
detected by investigations
- Only order investigations that will
influence management
 PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Be able to interpret tests
- Do not accept a poor quality
investigation
- Explain the investigations to the
patient
 PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Examples of investigations
Neurological (EMG/Nerve
conduction studies)
Muscular (compartment pressure/
dynamometry)
 PRINCIPLES OF DIAGNOSIS
3. Investigations (cont.)
- Examples of investigations
Cardiovascular (ECG/Echocardio-
graphy)
Pulmonary (Lung function tests)
Radiological (CXR/RT/MRI/US)
 XR Ultrasonography

Arthrography Imaging studies CT

MRI Bone scan
 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
 Physiology of soft tissue healing
Initially = prevent excess swelling and injury
w1-3 = collagen formation (protect from inversion)

>3w = collagen maturation

Inflammatory (controlled stress)

Phase
Repair
Phase
Remodelling
Phase
4-8w = full return to activity
 PRINCIPLES OF TREATMENT
Six principles of management (cont.)

4. Maintain or restore
- flexibility
- strength
- proprioception
- overall fitness
 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
 PRINCIPLES OF TREATMENT

Acute phase Long-term phase

P Pharmaceutical P Pharmaceutical
R Rest R Rehabilitation
I Ice E Exercise
C Compression P Prevention & Protection
E Elevation S Surgery
 PRINCIPLES OF TREATMENT
Types of treatment available:
1. Initial treatment
- RICE
2. Immobilise vs. mobilise
3. Heat vs. cold
 PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
4. Therapeutic drugs
- Analgesics
- NSAIDS
- Corticosteroids
- Hyaluronic acid
- Anti-depressants
 PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
5. Electro therapeutic modalities
- Ultrasound
- TENS
- Interferention
- Neuromuscular stimulators
- LASER
- Magnetic field therapy
 PRINCIPLES OF TREATMENT

Types of treatment available (cont.)

6. Manual therapy
- Joint mobilisation
- Joint manipulation
- Joint traction
- Massage therapy
- Neural stretching
 PRINCIPLES OF TREATMENT
Types of treatment available (cont.)
7. Acupuncture
8. Dry needling
9. Hyperbaric oxygen
10. Extracorporeal Shock Wave Therapy
11. Surgery
 PEARLS OF WISDOM
• When to refer a STI?
• Groin pain – HTAGP
• Look further than the obvious