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Principles of Physiotherapy Interventions for

Common Sport Injuries

Tan Yee Siong Sport Physiotherapist TYS Physio On Wheel

Sport Injuries PT Mx

Nature of Healing and Repair

Injury Identification

Rehabilitation Principles

Overview

Nature of Soft Tissue Healing and Repair

Terms

• Wound – Damage/disruption of normal anatomical structure and functions

• Healing – A coordinated series of events in response to an

injury/wound resulting in partial or complete repair and regeneration of the lost part

• Repair - The process of synthesizing connective tissues and its

subsequent maturation into scar tissues • Regeneration – The exact replacement of the lost cells by cells of the

same type

• Connective Tissues – A group of wide variation cells that provide the structural framework, supports, transport and energy storage within the body

Connective Tissue Proper [Areolar Tissue] The Normal Healing Cascade

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Acute Inflammation Acute Inflammation

• Local tissue reactions to injury, sometimes known as the demolition phase/clean-up process.

• Preserve and restore homeostasis, ie returning normal

tissues condition and cells environment. • 4 cardinal signs: rubor, tumor, dolor, calor [Celsus AD35] +

loss of function described by Virchow • Suffix of –itis • Prerequisite for repair and regeneration

Possible Response after Injury Regeneration

• Seen in lower vertebrates eg earthworm up to complex organism eg human.

• Human’s organs /tissues regenerative powers varies

and limited. • Certain discrepancies between the amount of

regeneration and repair. • Epithelial, connective tissues (except cartilage),

smooth muscles tissues usually regenerate well. • Muscle and neural tissues regenerate poorly.

Rate of Healing

{ { Local

Disturbed demolition phase

Vascularity

Excess movements

Foreign material

Infection/irradiation

Systemic

Malnutrition

Corticosteroids

Jaundice

Factors Influencing Wound healing

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Stress-Strain Curve

Identification of Injury

Why Examination and Ax?

Excellent in the treatment and management of MS dysfunction can only be obtained as a result of the application of a logical, systematic, careful and intellectual examination and assessment strategy.

Petty & Moore 1999

I know that you believe you understand what I said, but I am not sure you realize that what you heard is not what I meant. Maitland 1986

Key Identification from the Subjective Ax

Always listen to what patient has to say.

What are the mechanisms of injury?

Which structures could be the source of the symptom/site of injury?

What is the nature of the injury/condition?

What others factors need to be examined?

Is the condition severe and/or irritable?

Key Points in Physical Examination

Systematic and goal-oriented.

Every piece of information gather is just a clue, not the truth by itself.

Do not test for the sake of testing. The value of examination/tests carried out must be weighted.

Keep and open-mind, think logically rather quickly jumping into conclusion.

Establish comparable sign.

Common MS Lesions

Strain

Sprain

Dislocation

Subluxation

Muscle/tendon rupture

Tendinoathy/Tendinosis

Synovitis

Hemarthrosis

Contusion

Bursitis

Synovitis

Ganglion

RSI

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Differential Dx of Soft Tissues Disorder Synovial Fluid Inspection

Synovial Fluid Quality

Time Lapse Colour Viscosity

2 weeks Bloody red Watery

5 weeks Apricot orange Loose salivary

4 months Clear light yellow Loose salivary

8 months Clear light yellow Thick salivary

1.5 – 2.0 years Clear light yellow Thick mucus

Cartilage Flakes

White colour fragmented debris suspended in the synovial fluid.

Degree of Injury Grade 1 Grade 2 Grade 3

Pain Mild Moderate Severe

Playability Able Unable Unable

Stress Response ERP ERP Nil

Structural Integrity Preserved

Joint play increased

Laxity/ Instability

Severity of Tissue Injury

Principles of Rehabilitation

The Initial Guide where Everything Started…

Return

to Sport

§Neuromuscular

relearning §Specific Sport Drills

Aerobic

& Endurance

§ROM

§Muscular Strength §Proprioception

LL Rehabilitation RoadMap

Sorts Specific Training

Plyometric and Agility

Neuromuscular Control 3

CR Capacity

Muscles Strength and Endurance

Neuromuscular Control 2

Protection and Healing

ROM and Muscle activation

Weight Bearing and Mobility

Neuromuscular Control 1

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Shoulder Rehabilitation RoadMap

Sorts Specific Training

Strength 3 [task specific]

Neuromuscular Control 3 [closed-chain stabilization]

Functional 2 [Eccentric-plyo, Total body]

ROM 2

Strength and Endurance [dynamic]

Neuromuscular Control 2 [ST and GH]

Functional 1 [ADL]

Protection and Healing

ROM 1 and Muscle activation [static– isometric]

Neuromuscular Control 1 [postural]

Nature of Injury

Healing Process – Timing

Wilhelm Roux – Law of functional adaptation

Mechanics (movement & position)

Passive and Active Stability

Associated Injuries

Governing Factors in Rehabilitation progression

Motor Tasks Taxonomy [Gentile 2000]

Acute Stage (Inflammatory Reaction) Management Guidelines

Characteristic (< 7days unless insult is perpetuated)

Vascular reaction

Exudation of cells and chemicals

Clot formation

Phagocytic, neutralization of irritants

Early fibroblastic activity

Goals

Provide reassurance and understanding

Control the effects of inflammation

Maintain soft tissue and joint integrity

Maintain function of associated areas (ROM, Muscle performance, Circulation, Function)

The initial inflammatory response is critical to the entire healing process. If this response does not accomplish what it is suppose to or if it does not subside, normal healing cannot take place.

Any movement tolerated at this stage is beneficial, but it must not increase the inflammation or pain.

Stretching and resistance exercises should not be performed over the lesion site. Active movement is usually contraindicated.

In an injured structure that is not rested and is subjected to unnecessary external stress and strains, the healing process will never really get a chance to begin.

Clinical Reminders

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Subacute Stage (Repair and Healing) Management Guidelines

Characteristics (2 – 3 weeks after injury, up to 6 weeks in tissue with limited circulation)

Decreasing or absent of inflammation

Removal of noxious stimuli

Angiogenesis

Exudate replacement by collagen formation

Tissue granulation

Myofibroblastic activity

Goals

Encourage patient to return to normal activities that do not exacerbate the symptoms. Help them to adapt to their work and recreational activities.

Monitor healing tissue response to exercise

Restore soft tissue, muscle and joint mobility and flexibility

Develop neuromuscular control, strength and endurance (including proper mechanics)

Clinical Reminders

Wound closure takes 5 to 8 days in muscle and skin and up to 6 weeks in tendons and ligaments.

Exercises and activities should be within the tolerance of the healing tissues. (non-destructive motion)

Criteria for initiating active exercises and stretching include decreased swelling, intermittent pain and pain that are not exacerbated by motion in the available range.

During this stage, the immature connective tissue is thin and unorganized. Yet proper growth and alignment can be stimulated by appropriate tensile loading in the line of normal stress of the tissue.

Clinical Reminders

Patient response is the best guide to how quickly or vigorously to progress. Any abnormal response might be the sign of chronic inflammation and intensity of exercises should be tuned-down.

Muscle weakness will set in even in the absence of muscle pathology because of restricted use of the injured region.

Be certain patient is using the correct motor pattern without substitution.

Chronic Stage (Maturation and Remodeling) Management Guidelines

Characteristic (up to 6 months and continues…)

No inflammatory sign

Balance between synthesis and degradation of collagen

Collagen oriented and increase in tensile strength in response to stresses placed on them

Adhesions and contractures

Goals

Instruct patient in biomechanically safe progression of resistance and stretching exs and how to monitor for signs of excessive stress.

Increase soft tissue, muscle and joint mobility including joint play.

Improve neuromuscular control, strength and endurance.

Improve cardiovascular endurance.

Progress functional activities.

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Clinical Reminders

Immature collagen molecules are held together with hydrogen bonding and can be easily remodeled in response to the stresses placed for up to 10 weeks with gentle but persistent treatment.

At 14 weeks, the scar tissue has changed to covalent bonding and is unresponsive to remodeling. Treatment under these conditions requires either adaptive lengthening in the tissue surrounding the scar or surgical release.

The progressively increasing in tensile quality may continue for 12 to 18 months. It is important to use controlled forces that duplicate the normal stresses on the tissue.

Clinical Reminders

Joint motion without adequate muscle support causes trauma to the joint as proposed by Zohn and Mennell, who recommended a muscle test grade of 4 in LL musculature before discontinuing use of assistive devices for ambulation.

Joint dynamics, muscle strength and flexibility should be balanced.

Monitoring Signs

Soreness that does not decrease after 4 hours and is not resolved after 24 hours.

Pain that comes on earlier or is increased over the previous session.

Progressive stiffness and decrease in ROM.

Inflammatory signs.

Progressive weakness.

Decreased in functional usage.

Monitoring System

McKenzie Traffic Light Procedure

If symptom increase – RED Light – STOP

If symptom unclear but not worse – AMBER Light – Try a little bit further

If symptom improve – GREEN Light – Move On

Before Injury Assessment

Equipment Removal

Only remove if it will not cause further injury, use proper cutter if needed

Athlete Positioning Comfortable and injured part supported.

For seriously injured athlete, only move unless is necessary

Ensuring Safety Protect athlete from further

harm/danger Keep the athlete calm

In The Field

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In The Field Formula for Treatments?

R.I.C.E, P.R.I.C.E, P.O.L.I.C.E, P.R.I.C.E.M.M.

Only 5% level 1 evidence.

Based on expert opinion and clinical reasoning.

Questions to Ponder in Sports Rehab

High cost incur for ACL injuries in overseas.

Only 53% of the patient return back to sport post trauma 3 – 4 years (Kvist 2005)

94% of football players went back to sport within a year.

Probable reasons for the above rehab / conditioning lack: Failure to mimic the complexity of the sport movements

during rehab.

Condition in rehabilitation is over controlled.

Gap between the rehab knowledge and athletic expertise

Outcome measures are not up to the athletic level.

Questions to Ponder in Sports Rehab

What is the nature of the sport?

How would you judge the current level of practice / training in compare to the pre-injury level?

How appropriate with the outcome measures used in relation to the sport before discharging from training / conditioning / rehab?

How do you feel during the first practice / competition and why so?

Has the rehabilitation brought patient back to the normal practice routine?

References

Kisner C, Colby LA (2007), Soft Tissue Injury, Repair and Management: Chapter 10, in Kisner C, Therapeutic Exercise – Foundation and Techniques (5th Edition, pp. 295 – 307), USA, F.A. Davis Company

Robert FD, Melissa CE (2004), Wound Healing: An Overview of Acute, Fibrotic and Delayed Healing. Frontiers in Bioscience (9), pp 283 – 289, Virginia US

Martini FH (2006), The Tissue Level of Organization: Chapter 4, in Fundamentals of Anatomy and physiology (7th Edition, pp. 118 – 137), USA, Pearson Cummings

Spector TD, Axford JS (1999), Healing and Repair: Chapter 15, in An Introduction to General Pathology (4th Edition, pp. 141 – 156), Churchill Livingstone

Bleakley CM (2013), Acute Soft Tissue Injury Management: Past, resent and Future. Physical Therapy in Sort 14 (2013), 73 – 74, Elsevier UK

Suun A et al (2010), Introduction to Sort Injuries Management: Chapter 1, in Sorts Injuries, pp 1 – 6, Open University Malaysia, Meteor Doc

PEtty NJ, Moore AP (2001), Subjective and Physical Examination: Chapter 2 – 3, in Neuromusculoskeletal Examination nd Assessment – A Handbook for Therapist, (2th Edition, pp. 5 – 107), Churchill Livingstone

Dr Arshad Puji, Sport Physician, ASIU, Orthopedic Institute HKL Dr Goh Siew Li, Sport Physician, ASIU, Orthopedic Institute HKL Dr Siti Hawa, Orthopedic Surgeon ASIU, Orthopedic Institute HKL Dr Bazam, Orthopedic Surgeon, ASIU, Orthopedic Institute HKL Mr Zahari Afandi, Sport Physiotherapist, Physiotherapy Department HKL