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Unit #4 Pathology of Injuries. ILLNOIS WESLEYAN UNIV. Mechanisms and Characteristics of Sports Trauma. Chapter 9. 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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unit 4 pathology of injuries

Unit #4Pathology of Injuries

ILLNOIS WESLEYAN UNIV

general injury mechanisms
General Injury Mechanisms
  • Primary Injury: results directly from the stress of the sport
    • Extrinsic
    • Intrinsic
  • Secondary Injury: injury caused by a previous injury
mechanisms of injury
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
mechanism of injury
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
injury forces to the skin
Injury Forces To The Skin
  • Friction
  • Scraping
  • Compression
  • Tearing
  • Cutting
  • Penetrating
skin wound classification
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
treatments for skin wounds
Treatments For Skin Wounds
  • Powders: drying agents
  • Water: drying agent
  • Creams: usually contain medications
    • Tinactin
    • Hydrocortizone cream
    • Analgesic cream
  • Ointments: moistening agents
    • bacitracin
treatments for skin wounds9
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
skeletal muscle injuries
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
skeletal muscle injuries11
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

skeletal muscle injuries12
Skeletal Muscle Injuries
  • Acute onset muscle soreness
  • Delayed onset muscle soreness
  • Muscle stiffness (swelling)
  • Muscle cramps
  • Myositis / Fasciitis
  • Tendinitis
  • Tenosynovitis
  • Myositis ossificans
  • Atrophy
synovial joint injury classifications
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
synovial joint injury classifications14
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.
synovial joint injury classifications15
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
skeletal injury classification
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)
skeletal injury classification17
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
nerve trauma classifications
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)
common injuries
Common Injuries
  • Sprained toe
  • Sprained ankle
  • Sprained knee
  • Sprained finger (jammed finger)
  • Sprained shoulder
  • Sprained wrist
  • Sprained elbow
common injuries20
Common Injuries
  • Strained achilles
  • Strained quadriceps
  • Strained hamstrings
  • Strained rotator cuff
  • Strained back
  • Strained hip flexor
common injuries21
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
common injuries22
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………
outline of injury presentation
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
chapter 10

CHAPTER 10

TISSUE RESPONSE TO INJURY

THE INFLAMMATORY RESPONSE AND THE HEALING PROCESS

definition purpose of inflammation
DEFINITION & PURPOSE OF INFLAMMATION
  • Definition: The reaction of the body tissues to anirritant or injury; which may be either acute or chronic. It is a protective mechanism, designed to?
  • Thepurpose of inflammation is to: rid the body of the irritant and to promote repair and healing of the damaged tissues.
purpose of inflammation
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 )
signs and symptoms of inflammation
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)
inflammation
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.
inflammation phases
INFLAMMATION PHASES
  • Acute Reactive Phase ( 24-48 hrs.)
    • Body’s fundamental reaction designed to protect, localize, and fight the injurious agent, as well as prepare the area for healing and repair (Nature’s Way).
  • Repair-Regeneration Phase(48hrs>)
    • Tissue repairs by resolution (granulation tissue) and regeneration .
    • Repair depends on type of tissue & amountof tissue damage.
phases cont
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.
slide31
RESPONSE: FIRST HOUR
  • Vasoconstriction, followed by vaso-dilation.
    • Capillary hemorrhage
    • Coagulation of broken vessels
    • Release of chemical mediators
    • Vasodilation
acute phase vascular response
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.
swelling
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.

capillary bleeding
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.
leakage of edema
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
permeability changes

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.

chemical mediators
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.

phase ii repair and regeneration
PHASE II: REPAIR ANDREGENERATION
  • 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.
scar tissue
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
regeneration
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 .
  • Generallyconnective tissue can regenerate and repair itself.
regeneration repair healing stages
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
phase iii remodeling
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 tissuecontinues for 3 - 6 months followinginjury, and may take as long as a year to be completely healed (if infact it ever does).

critical thinking exercise
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?

subacute or chronic inflammation
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.
signs symptoms of chronic inflammation
SIGNS & SYMPTOMS OFCHRONIC 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.
critical thinking exercise46
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 thereason for this chronic swelling? What background information would you need to know (what questions would you ask)?

treatment care points to remember
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?
potential for healing of various types of soft tissues
Potential for Healing of VariousTypes 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.
management concepts
MANAGEMENT CONCEPTS
  • DRUGS
  • SUPERFICIAL HEAT AND COLD Tx
  • PHYSICAL MODALITIES
  • MASSAGE
  • EXERCISE REHABILITATION
  • OTHERS
confuscius say
Confuscius say……….

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

inflammation implications for immediate care
Inflammation: Implications forImmediate 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
inflammation implications for follow up care
Inflammation: Implications forFollow-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?

inflammation implications for follow up care53
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

Inflammation: Implications forFollow-up Care?
inflammation implications for therapeutic exercise
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 body’s response to injury:

  • When should therapeutic exercise begin?
  • How much exercise should be allowed?
  • Does the type of exercise make a difference.
fracture healing
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.
fracture care
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
healing of stress fractures
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…”

slide58
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
acute vs chronic pain
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”
referred pain
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
pain sensitivity
PAIN SENSITIVITY
  • Pain tolerance can be a learned response, and is both physiological andpsychological in nature
  • Pain is a feeling
  • Pain is subjective……but we try to get objective data to make our decisions. Unfortunately the so-called “objective tests” that we often use are often unreliable.
pain assessment
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.
pain treatment
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?
psychological aspects of pain
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
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