Unit

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Unit 4Pathology of Injuries

• ILLNOIS WESLEYAN UNIV

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Mechanisms and Characteristics of Sports Trauma

• Chapter 9

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General Injury Mechanisms

• Primary Injury results directly from the stress
  of the sport
  
• Extrinsic
• Intrinsic
• Secondary Injury injury caused by a previous
  injury

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Mechanisms of Injury

• Tension a force that pulls (muscle)
• Strain
• Cramp
• Stretching the elongation of tissues
• Strain
• Sprain
• Compression a forceful blow to tissues
• Contusion
• Fracture

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Mechanism of Injury

• Shearing a force that moves parallel to the
  tissues
  
• Blisters
• Abrasions
• Vertebral disc injuries
• Bending a horizontal force causing the tissue to
  bend or strain
  
• Spiral fracture or Greenstick fracture

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Injury Forces To The Skin

• Friction
• Scraping
• Compression
• Tearing
• Cutting
• Penetrating

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Skin Wound Classification

• Friction Blister continuous rubbing on the skin
• Abrasion skin is scraped against a rough
  surface
  
• Bruise compression causes bleeding under the
  skin
  
• Laceration an irregular tear of the skin
• Avulsion skin is ripped off
• Incision a sharp cut
• Puncture penetration of the skin by a sharp
  object

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Treatments For Skin Wounds

• Powders drying agents
• Water drying agent
• Creams usually contain medications
• Tinactin
• Hydrocortizone cream
• Analgesic cream
• Ointments moistening agents
• bacitracin

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Treatments For Skin Wounds

• Lotions and Salves moistening agents
• Antipruritic agents control temperature
• Antihistamine drugs allergies
• Hydrogen Peroxide anticoagulant
• Isoprophyl alcohol drying and sterilizing agent
• Iodine antiseptic and germicide agent
• Dressings protection of the skin
• Gauze, bandaid, telfa pad
• Roller bandage, tape

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Skeletal Muscle Injuries

• Contusion an acute compression causing
  hemorrhage of the muscle tissue
  
• Strain is an acute stretch, tear, or rip in the
  muscle or tendon caused by an abnormal muscle
  contraction, tension, or stretch
  
• Grade 1 minimal tearing with tenderness and a
  decrease in strength
  
• Grade 2 moderate tearing with pain and impaired
  muscle function
  
• Grade 3 severe tearing with pain and loss of
  muscle function and a palpable deformity

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Skeletal Muscle Injuries

• Muscle Cramps an acute painful involuntary
  muscle contraction caused by dehydration or an
  electrolyte imbalance.
  
• Muscle Spasm a reflex reaction caused by acute
  trauma
  
• Clonic alternating involuntary contractions
• Tonic a rigid muscle contraction that lasts
• a period of time

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Skeletal Muscle Injuries

• Acute onset muscle soreness
• Delayed onset muscle soreness
• Muscle stiffness (swelling)
• Muscle cramps
• Myositis / Fasciitis
• Tendinitis
• Tenosynovitis
• Myositis ossificans
• Atrophy

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Synovial Joint Injury Classifications

• Acute Sprain stretching or tearing of the
  stabilizing connective tissues
  
• Grade 1 minimal pain and loss of function, mild
  point tenderness, little or no swelling, and no
  abnormal motion when tested.
  
• Grade 2 moderate pain and loss of function,
  swelling, moderate instability
  
• Grade 3 extremely painful with a major loss of
  function, severe instability tenderness and
  swelling

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Synovial Joint Injury Classifications

• Acute Synovitis inflammation of the synovial
  membrane.
  
• Dislocation a complete separation between two
  articulating bones.
  
• Subluxation an incomplete separation between two
  articulating bones.
  
• Separation / diastasis an increase in joint
  space between articulating surfaces.

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Synovial Joint Injury Classifications

• Osteochondrosis degenerative changes in the
  epiphysis or apophysis of bones.
  
• Osteochondritis dissecans occurs in the knee
• Apophysitis occurs to tendon-bone junctions
• Traumatic arthritis thickness of synovium of a
  joint causing creptitis and grating
  
• Bursitis
• Capsulitis

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Skeletal Injury Classification

• Acute Bone Fractures
• Depressed fractures (indent)
• Greenstick fractures
• Impacted fracture (compression)
• Longitudinal fracture (bone splits)
• Oblique fracture (diagonal)
• Serrated fracture (sawtooth sharp edged)
• Spiral fracture
• Transverse fracture (straight line)
• Comminuted fracture (fragments)

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Skeletal Injury Classification

• Acute Fractures
• Contrecoup fracture (skull)
• Blowout fracture (eye orbit)
• Avulsion fracture (bone chip)
• Stress fracture (from overload)
• Shin
• Metatarsal
• Calcaneus
• Pars interarticularis
• ribs

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Nerve Trauma Classifications

• Burner (stretched nerve cells)
• Neuritis (inflammation of nerve cells)
• Sciatica (stretch of sciatic nerve)
• Carpal Tunnel (compression of nerve cells)
• Mortons Neuroma (tumor of nerve cells)

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Common Injuries

• Sprained toe
• Sprained ankle
• Sprained knee
• Sprained finger (jammed finger)
• Sprained shoulder
• Sprained wrist
• Sprained elbow

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Common Injuries

• Strained achilles
• Strained quadriceps
• Strained hamstrings
• Strained rotator cuff
• Strained back
• Strained hip flexor

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Common Injuries

• Ruptured ACL
• Ruptured achilles
• Ruptured flexor tendon (jersey finger)
• Ruptured bicep tendon
• Bulging disc
• Herniated disc
• Torn meniscus (knee)
• Torn labrum (shoulder)
• Concussion

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Common Injuries

• Achilles tendinitis
• Patellar tendinitis
• Common flexor tendinitis (pitchers elbow)
• Common extensor tendinitis (tennis elbow)
• Rotator cuff tendinitis
• Medial tibial stress syndrome (shin splints)
• OTHERS

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Outline of Injury Presentation

• Choose an injury that occurs in your sport
• Name of the injury
• Mechanism of the injury
• Description of the injury
• Symptoms of the injury
• Treatment of the injury
• Presentation should include a picture of the
  injury
  
• Provide handouts for your peers

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CHAPTER 10

• TISSUE RESPONSE TO INJURY
• THE INFLAMMATORY RESPONSE AND THE HEALING PROCESS

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DEFINITION PURPOSE OF INFLAMMATION

• Definition The reaction of the body tissues to
  an irritant or injury which may be either acute
  or chronic. It is a protective mechanism,
  designed to?
• The purpose of inflammation is to rid the body
  of the irritant and to promote repair and
  healing of the damaged tissues.

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PURPOSE OF INFLAMMATION

• Is a protective mechanism designed to localize
  the irritant and rid body of the injurious agent
  in preparation for healing
  
• The major causes of inflammation are
• Trauma ( sprain, strain, contusion, etc.. )
• Chemical agents ( poisons, stings, etc. )
• Thermal extremes of heat or cold (burns)
• Pathogenic organisms ( infections )

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SIGNS AND SYMPTOMS OF INFLAMMATION

• The inflammatory response can be either acute or
  chronic, but the local reactions are described as
  the cardinal signs and symptoms of inflammation
  
• Typical signs and symptoms include
• Redness
• Heat (local)
• Swelling
• Pain
• Malfunction (loss of motion or use)

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INFLAMMATION

• In sports every injury is accompanied by some
  tissue damage. The seriousness of the injury
  will be determined by the type of tissue involved
  and the extent of the tissue damage.

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INFLAMMATION PHASES

• Acute Reactive Phase ( 24-48 hrs.)
• Bodys fundamental reaction designed to protect,
  localize, and fight the injurious agent, as well
  as prepare the area for healing and repair
  (Natures Way).
• Repair-Regeneration Phase(48hrs)
• Tissue repairs by resolution (granulation tissue)
  and regeneration .
  
• Repair depends on type of tissue amount of
  tissue damage.

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PHASES cont.

• Remodeling Phase (3wks. - 1 yr.)
• Remodeling depends on the type of tissue which is
  injured and the degree of damage to that tissue.
  
• Overlaps repair and regeneration phase
• Scar tissue forms in first 3-6 weeks
• Strength of the scar increases from 3 months to 2
  yrs after injury.
  
• Early mobilization promotes healing, but to early
  and the healing process is delayed.

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• RESPONSE FIRST HOUR
• Vasoconstriction, followed by vaso-dilation.
• Capillary hemorrhage
• Coagulation of broken vessels
• Release of chemical mediators
• Vasodilation

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ACUTE PHASE VASCULAR RESPONSE

• Vasoconstriction
• Coagulation begins to seal broken blood vessels
• Chemical mediators released
• Histamine the first chemical to appear and
  increases vasodilation and permeability
  
• Serotonin powerful vasoconstrictor
• Bradykinin increases permeability and causes
  pain
  
• Heparin temporarily prevents blood coagulation
• Vasodilation
• Permeability Changes
• Margination (pavementing) plasma exudate
  coagulates into a network of fibrin and localizes
  the injured area.
  
• Phagocytosis the process of ingesting material
  such as bacteria, dead cells, and other debris.

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SWELLING

• The amount of swelling present with any injury is
  highly dependent upon the extent of the tissue
  damage and the subsequent inflammatory response.
  Swelling basically comes from two sources (1)
  capillary bleeding, and (2) leakage of edema, and
  is sometimes referred to as EXUDATE.

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Capillary Bleeding

• Capillary bleeding occurs when the small blood
  vessels (capillaries, arterioles, venules) are
  injured, and results in the initial, primary
  swelling.
• Primary swelling is the result of immediate
  hemorrhage which may cause some tissue cell death
  and swelling until coagulation occurs.

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Leakage of Edema

• Edema come from the leakage of blood plasma thru
  the intact vessels in the area of the injury.
  
• Secondary swelling is delayed swelling, caused by
  the release of chemical mediators as a result of
  the inflammatory response following injury
  
• Permeability changes caused by brakykinin

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PERMEABILITY CHANGES

• Permeability changes are going to be very limited
  in minor injuries where there has been little
  tissue damage. However, in more severe injuries,
  there may be a delayed response with delayed
  swelling which may not appear for many hours.

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CHEMICAL MEDIATORS

• Histamine causes vasodilation and permeability
  changes.
  
• Serotonin is a powerful vasoconstrictor.
• Bradykinin increases permeability and causes
  pain.
  
• Heparin anticoagulant
• Prostaglandins both encourage and inhibit
  inflammation, depending on the need.

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PHASE II REPAIR AND REGENERATION

• Repair is synonymous with healing
• Regeneration refers to the restoration of
  destroyed or lost tissue
  
• Granulation or scar tissue is that tissue which
  has been repaired or regenerated, and is the scab
  which forms on wounded tissues as they heal.
  With time this scar tissue will become more like
  the original tissue.

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SCAR TISSUE

• Immature scar is less viable, not as strong and
  less elastic than the original tissue, and is
  highly vascular.
  
• Mature scar eventually forms ( can take as long
  as 3wks. to 6 months to occur )
  
• Healing occurs in two ways ( types )
• Primary healing
• Secondary healing

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REGENERATION

• Regeneration in man (unlike the salamander or
  earthworm) is limited to certain tissues.
  
• Type of tissue, amount of tissue damage, age,
  nutrition, etc., can all be factors which limit
  regeneration of tissues .
  
• Generally connective tissue can regenerate and
  repair itself.

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REGENERATION, REPAIR, HEALING STAGES

• Elimination of the tissue debris at site of the
  wound must occur before repair and regeneration
  can occur (elim. Swelling)
  
• Regeneration of endothelial cells occurs
• Production of fibroblasts (which compose
  connective tissue throughout the body) takes
  place, and is the basis for scar tissue
  formation
• New blood vessels form around wound

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PHASE III REMODELING

• Remodeling overlaps the repair and regeneration
  phase. Generally the first 3-6 weeks are
  characterized by the production of scar tissue
  and strengthening of its fibers. Strengthening
  of the scar tissue continues for 3 - 6 months
  following injury, and may take as long as a year
  to be completely healed (if in fact it ever does).

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Critical Thinking Exercise

• An athlete has sustained a grade 2 lateral ankle
  sprain 3 weeks ago. It was given proper
  immediate and follow-up care. What repair has
  taken place in the ankle during this time? What
  kind of sports performance would you expect from
  this athlete?

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SUBACUTE OR CHRONIC INFLAMMATION

• Book defines subacute as an acute inflammation
  failing to resolve in 1 month. Chronic is
  defined as lasting for months or years.
  Proliferation and degeneration of tissue is
  characteristic of chronic inflammation.

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SIGNS SYMPTOMS OF CHRONIC INFLAMMATION

• Develops gradually over period of time, (versus
  immediate onset - acute), and may last for months
  or even years.
  
• Caused by repeated acute injury, repeated
  microtrauma, or tissue disease or degeneration
  (ex.,aging, ).
  
• Usually little or no swelling. Swelling may come
  and go with activity level, as does pain and
  ROM.

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Critical Thinking Exercise

• A basketball player complains of a swollen ankle
  that never became completely resolved since a
  sprain was sustained 9 months ago. What is the
  reason for this chronic swelling? What
  background information would you need to know
  (what questions would you ask)?

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TREATMENT CARE POINTS TO REMEMBER

• HEALING IS UNIQUE TO EACH ATHLETE
• TISSUES HEAL DIFFERENTLY
• AGE AND MOTIVATION PLAY A ROLE
• ORGANIC DISORDERS (ie., diabetes) CAN DELAY
  HEALING
  
• HEREDITY CAN BE A FACTOR
• PSYCHOLOGICAL CONSIDERATIONS?

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Potential for Healing of Various Types of Soft
Tissues

• Cartilage- limited, primarily because of its
  little if any blood supply.
  
• Ligaments- as good as other tissues with a
  vascular supply gradually a scar is formed (may
  take as long as 1 year)
  
• Skeletal Muscle- regeneration of myofibers is
  minimal, otherwise heal the same as other
  vascular tissues.
  
• Nerve- CNS nerves are poor healers peripheral
  nerves are fair.

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MANAGEMENT CONCEPTS

• DRUGS
• SUPERFICIAL HEAT AND COLD Tx
• PHYSICAL MODALITIES
• MASSAGE
• EXERCISE REHABILITATION
• OTHERS

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Confuscius say.

• ..if all you have is a hammer, then everything
  looks like a nail .

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Inflammation Implications for Immediate Care ?

• R.I.C.E. ?
• Rest - what effect does rest have upon the
  physiological changes resulting from the injury
  and subsequent inflammatory response?
  
• Ice - ?
• Compression - ?
• Elevation - ?
• Other ? immobilize, NSAIDS

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Inflammation Implications for Follow-up Care?

• Regardless of which method of follow-up therapy
  you choose, what would your knowledge of the
  inflammatory process tell you about the purpose
  of your treatment?
• What treatment methods might be contraindicated?
• Acute vs. Chronic inflammation?

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Inflammation Implications for Follow-up Care?

• Moist heat packs
• Whirlpool (110 deg)
• Analgesics
• Ultrasound
• Massage
• Paraffin bath
• Fluidotherapy
• Diathermy (electromagnetic)
• Low Power Laser

• Ice bag
• Ice massage
• Cold whirlpool (55 deg)
• Vapocoolant sprays
• Phonophoresis
• Iontophoresis
• EMS
• Alternative therapy

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Inflammation Implications for Therapeutic
Exercise

• Deciding when to begin therapeutic exercise,
  reconditioning, and/or a return to activity, is
  always a difficult decision. Based upon what you
  have learned about the inflammatory process and
  the bodys response to injury
• When should therapeutic exercise begin?
• How much exercise should be allowed?
• Does the type of exercise make a difference.

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FRACTURE HEALING

• TIME is a major concern as bone healing goes thru
  the various phases of healing, but generally 4-6
  weeks.
  
• Acute Phase first 3-4 days
• Repair Phase hematoma formation, organization
  of scar, and fibrous junction between bone ends
  (soft callus - hard callus)
  
• Remodeling Phase May take years.

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FRACTURE CARE

• Immobilization until hard callus has formed,
  usually 4-6 weeks, but can last several months
  depending on the nature, extent, site of the
  fracture.
• Conditions which can delay healing
• poor blood supply to fracture area
• poor immobilization
• infection or disease
• age and/or osteoporosis

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Healing of Stress Fractures

• if the osteoclastic activity is greater than
  the osteoblastic activity, the bone becomes
  increasingly susceptible to stress fracture.
  
• decrease in activity and elimination of other
  factors in training that cause stress will allow
  bone remolding

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PAIN

• CAUSES OF PAIN
• released CHEMICAL SUBSTANCES
• PRESSURE ON NERVE ENDINGS
• ISCHEMIA IN THE AREA
• PAIN, SPASM,SWELLING, PAIN CYCLE
• TYPES OF PAIN
• SHARP (EXCRUCIATING), DULL, ACHE, CONSTANT,
  OFF\ON, THROBBING,NIGHT

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Acute vs Chronic Pain

• Acute Pain
• Less than 6 days in duration
• Specific cause or mechanism of injury
• Generally of short duration
• Usually a specific area of origin
• Chronic Pain
• Gradual onset and/or long duration
• that which continues beyond the usual normal
  healing time
  

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Referred Pain

• Pain is common in sports
• Types of pain by location
• Away from the actual site of irritation
• May be motor, sensory or both
• May produce paresthesia
• Three types common to athletics
• Myofacial pain at trigger points
• sclerotomic is deep pain
• dermatomic pain is sharp and well organized

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PAIN SENSITIVITY

• Pain tolerance can be a learned response, and is
  both physiological and psychological in nature
  
• Pain is a feeling
• Pain is subjectivebut we try to get objective
  data to make our decisions. Unfortunately the
  so-called objective tests that we often use are
  often unreliable.

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Pain Assessment

• Methods for Pain Assessment
• Numeric value scale
• 1 to 10 with 1 representing the least
• Verbal descriptors as assessment, such as none,
  slight, mild, moderate, and severe
  
• Palpation
• Response to activity,weight bearing, etc.

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Pain Treatment

• Management methods can be used separately or in
  combination
  
• Break the pain-spasm-pain cycle thru a variety of
  methods, such as
  
• heat or cold
• electrical stim and ultra sound
• phonophoresis iontophoresis
• pharmacological agents(analgesics)
• topical counterirritants
• others?

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Psychological Aspects of Pain

• Pain can cause serious emotional changes in an
  athlete, including depression and irritability
  
• Pain is a physiological and psychological
  phenomenon, unique to each athletic
  
• Through conditioning, athletes can learn pain
  tolerance