dr.jack dolbin dc session 2 concepts of diagnosis of sports injuries site of injury truism “if you...

Dr.Jack Dolbin DC Session 2

Concepts of Diagnosis of Sports Injuries

Site of injury

Truism “If you hear hoof beats don’t think zebras” You better eliminate the zebras first: Dolbin

Priorities

“The best things in life are not things” Harry Bertsch Hermy Bavier Ron Boris Amanda Driscoll Josh Bertsch Dad


Ron Boris


Concepts of Diagnosis of Sports Injuries Cause as it relates to exceeding the tensile

strength of the tissue

Fracture dislocation


Concepts of Diagnosis of Sports Injuries

Biomechanical concepts of causation

Motion deficits as major causative factor If dysfunction alters the efficiency of the musculoskeletal

system, there is an increase demand for energy. Not only for increased activity but for normal activity.

Increase demands on the cardiovascular system

Observation “Where observation is concerned, chance favors only the

prepared mind.” ~ Louis Pasteur


Evaluation of the Kinetic Chain Lower limb: Ankles, Knees, and hips

Upper limb: Core Stability, Endurance, Balance, Range of Motion

Scapula: Stability, Rhythm

Shoulder: Clinical examination


Concepts of inflammation and repair

Inflammation

Tissues respond to injury with a set of genetically programmed mechanisms to replace the damaged components and to restore normal function.

Inflammation and RepairCardinal signs of inflammation Heat Swelling Pain Redness Loss of Function

Two types of Inflammation: Acute

Chronic

Acute Inflammation Chronic Inflammation


Inflammation and Repair

Characterized by the release of chemical mediators by mast cells,platelets and basophils at the site of the injury.

Vasoactive mediators regulate the vascular response to the injury and affect the recruitment of PMN’s from the vascular component.

These in turn produce chemotactic factors that control the damage and remove debris by phagocytosis.

Acute Inflammation:

Granulation Tissue: Lead to the restoration of the vascular supply and connective

tissue matrix. Chronic Inflammation is the result of unresolved acute

inflammation

In the case of sports related injuries removal of the trauma and successful management of the injury may result in the reduction of fibrosis and restoration of normal function.


Inflammation and Repair

Repair: The repair phase of healing ideally result in the restoration of normal

living tissue. Repair by regeneration of injured tissue Repair by second intention is characterized by the formation of scar

tissue at the site of the injury.

Remodeling and Maturation

Process begins about 6 days after the fibroblasts begin to lay down collagen tissue.

Collagen is laid down randomly initially

Depends on the appropriate mechanical loading.

The hallmark of remodeling is the orientation of new fibers


Inflammation and Repair Immobilization of a healing wound has been shown to compromise

wound strength as a result of the failure of collagen to be oriented along lines of stress.

Mobilization and loading has been shown to result in stronger healed tissue.

Time Frame of Healing:

Inflammation Phase is relatively brief. 24-48 hours.

Proliferative Phase: 3-7 days after the injury

Repair Phase: Few days to a few weeks

Remodeling Phase: Several months and may continue up to 12 months.

Inflammation and RepairRepair Mechanisms in Soft Tissue Injuries:

Muscle Tissue: Healing of skeletal muscle is dependent on the integrity of the

vascular system and nervous system

Has considerable regenerative properties

Both regeneration and repair by scar tissue.

Capacity for regeneration is determined genetically but the success is determined primarily by the extent and type of injury.

Except for injuries in which the continuity of the muscle fiber is preserved, and the innervation, vascularity and extracellular matrix muscle will regenerate with a loss of normal tissue architecture and function.

Most muscle injuries are a result of exceeding the tensile strength of the tissue and are labeled indirect muscle injury.

Inflammation and RepairMuscle Strain Injuries:Consists of a partial or complete tear at or near the musculotendinous

junction.

When the force is sufficiently high the tendon has been shown to avulse from the muscle with only a few fibers left intact.

The greater the amount of injured tissue involved the more scar tissue with be deposited at the sight of the wound.

Ischemia- Induced Muscle Damage: Usually seen in compartment syndromes. Results from damage to vessels causing

ischemic injury.

Seen in exhaustive endurance activities. Extent of the injury is proportional to the duration of the pressure. Nerve injury may result as a result of increase pressure. Healing will be achieved with little or no damage if the damage is limited to

individual fibers and blood supply is restored without delay. Can result in significant scar tissue formation if delayed resulting in excessive

cell death.

Concepts of treatment: Modalities Cyriax Joint Mobilizations Muscle Energy Laser therapy Immobilization. Chiropractic Adjustments

Concepts of rehabilitation: Goals Necessary training Necessary equipment Isotonic exercise Repetitive motion Stability ball

Rehabilitation of most common athletic injuries Rehabilitation concepts:a. Injury prevention vs. Injury causation.


Rehabilitation and return to competition: Daily Function Demands of the Sport

Incidence of injury according to the American Journal of Sports Medicine

Football players in a 5 year program at the Div. 1 level have a 100% chance of being inured

High School: 50-80% Swimming: 50% men 70% women will develop shoulder

problems. Jogging, running: 60% Tennis: 60% Musculotendinous overload injuries


Duration of Injury Tri-athlete: 30 days

Cyclists: 2 weeks

Swimming: 2 weeks

Runners: 40 days

Predictor of Injury No previous injury: 40 % chance

of experiencing a sports related injury

Previous Injury: 65% chance of a re-injury in the Kinetic chain

a. Mostly due to incomplete rehabilitation

b. Rehab stopped at

symptom reduction.


1. Return to Function is the key not simply symptom reduction

– Establish an accurate diagnosis– Minimize the local effects of acute injury

Goals of Rehabilitation:

1. Return to Function

2. Allows for proper healing

3. Maintaining the other components of athletic fitness

4. Return to Normal Competition


Effects of Immobilization: For each week of immobilization there is a 20% loss of strength in joint.

Effects of Immobilization

0

20

40

60

80

100

1 2 3

Weeks Immobile

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Type 1 fibers are most affected Cartilage deterioration, bone and ligament strength loss and

increased stiffness. Rehabilitation can counteract these changes by introducing

motion with protection and loading.

Goals of Rehabilitation:2. Allows for proper healing

Protects Tissue Use of Physical Treatment Modalities:

Cold, Heat, Electricity, Laser Use predicated on accurate diagnosis Understanding of the biophysics of the modality

3. Maintaining the other components of athletic fitness

a. Strength

b. Flexibility

c. Aerobic Conditioning

4. Return to Normal Competition Baseline established in Preseason Physical

1. Begin graded return if no baseline established

2. Increase volume and intensity incrementally


What are we Rehabilitating? Dx. more than the site of the injury!

Kinetic Chain

Classification of Injury 1. Acute Injury: Normal anatomy and normal physiology

followed by abnormal anatomy and abnormal physiology.

a. One-Time microtrauma.

2. Chronic Injury: Building up for a period of time.

a. Represents the tip of the iceberg of entire derangement of physiology

3. Repetitive microtrauma overload:

a. Rotator Cuff Tendonitis

b. Plantar fascitisc.

c. Achilles Tendonitis


Adaptation Body adapts over a period of time to chronic injuries. The Dx must

look for these adaptations:– Weakness and tightness in gastrocnemius in Achilles tendonitis– Elbow tendonitis : tightness of wrist extensors– Rotator Cuff tendonitis: Infexibility in posterior RJC muscles and

weakness in scapular stabilizers and post cuff muscles.

Note: Entire Kinetic Chain must be searched and evaluated

Acute exacerbation of a chronic injury: Result from symptomatic treatment leading to return to athletic activity. Results in a recurrence of previous symptoms or new symptoms as a result of acute injury in kenetic chain.

1. Ankle Sprain

- return to competition- Groin strain

2. Rotator Cuff tendonitis

- return to competition- lateral epicondylitis


Adaptation

Injections cause very poor healing and a return of symptoms with activity

Chronic Adaptations

1. No overt symptoms

2. Pattern of abnormalities that lead to decreased function and performance


Negative Feedback Vicious Cycle

Functional Biomechanical

Deficit Complex

Tissue Injury

Complex

Clinical Symptom Complex

Tissue Overload Complex

Sub-clinical Adaptation Complex


1. Tissue overload complex

a. Failure of Tensile strength

b. Subject to microtrauma

2. Tissue Injury complex

a. Disrupted

b. Producing Symptoms


3. Clinical Symptom Complex

Pain

4. Functional Biomechanical Deficit Complexa. Decreased flexibilityb. Decreased Strengthc. Muscle imbalances


5. Sub-clinical adaptation complex a. Activities the athlete uses to compensate for altered mechanics.

1. Running on the outside of foot to compensate for heel pain.

2. Over reaching in swimming to compensate for decreased ROM in the low back

1. Tissue overload complex

Cycle begins again

dr.jack dolbin dc session 2 concepts of diagnosis of sports injuries site of injury truism “if you...

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jack dolbin dc session

concepts of inflammation

repair repair

repair inflammation

types of inflammation

repair immobilization

collagen tissue