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Review

STAGES of
INFLAMMATION and REPAIR
Acute Stage / Inflammatory Stage
Subacute Stage / Repair
Chronic stage / Remodelling
OTPT 130 : Medical Rehabilitation Lectures 2
University of the Philippines Manila , College of
Allied Medical Professions

REHABILITATION of
SOFT TISSUE and
SPORTS INJURIES
MICHAEL D . MAGPANTAY ,
PTRP
Physiotherapist
Moro – Splash Foundation Inc .,
moro Sports Clinic
SPORTS MEDICINE TEAM
Family physician
Physiotherapist
Sports physician
Massage therapist
Orthopedic surgeon
Radiologist
Podiatrist
Dietician / Nutritionist
Psychologist
Sports Trainer / Athletic Trainer
Other professionals such as
Occupational Therapist, orthotist
and nurses
Coach
SPORTS MEDICINE TEAM
There may be a
considerable amount
of overlap between the
different practitioner

“Multiskilling” is
particularly important if
the practitioner is
geographically isolated
or is travelling with
sports team
SPORTS MEDICINE MODEL
Trainer

Physician Physiotherapist / OT

Dietician Athlete - Coach Massage Therapist

Psychologist Podiatrist
Others
SPORTS MEDICINE
The secret of success
is to take a broad view
of the patient and his or
her problem

Ask “Why has this


injury / illness occurred

Diagnosis and
treatment
SPORTS MEDICINE
Diagnosis

Precise anatomical and


pathological cause of the
presenting problem

Presenting problem and


cause of the problem

History, physical
examination and
investigation
SPORTS MEDICINE
Treatment

Treatment of presenting
injury and treatment to
correct the cause

Combination of different
forms of treatment will
usually give the best result

Evaluate effectiveness of
treatment constantly
SPORTS MEDICINE
Meeting Individual Needs

Every patient is a unique


individual with specific
needs

Treatment depends on the


patient’s situation, not
purely on the diagnosis
SPORTS MEDICINE

“Love Thy Sport”

It is essential to know
and love the sport

It is essential to be on
site
SPORTS INJURY REHABILITATION
Primary goal is to enable the
athlete to return to sports with
full function in the shortest
possible time

Inadequate rehabilitation
Prone to reinjury of the
affected area
Incapable of performing at
pre-injury standard
Predisposed to injuring other
part of the body
SPORTS INJURY REHABILITATION
Keys to a successful rehabilitation

Explanation
Provide precise prescription
Make the most of the available
facilities
Begin as soon as possible
SPORTS INJURY REHABILITATION
Components of Rehabilitation

Muscle conditioning
Flexibility
Neuromuscular control,
balance and propriception
Functional exercises
Sports skills
Correction of abnormal
biomechanics
Maintence of CV fitness
Psychology
Return to
Sport

Skill Aquisition

Proprio-
Strength Flexibility
ception

Motor Re-education
and
Muscle Activation
SOFT TISSUES LESIONS
(Mechanism of Injury or Onset of Symptoms)

ACUTE INJURIES OVERUSE INJURIES


BONE

ARTICULAR CARTILAGE

JOINT

SOFT TISSUES LESION LIGAMENT


(Site)

MUSCLE

TENDON

BURSA
BONE
Acute Injuries Overuse Injuries
Fracture Stress Fracture

‘Bone Strain’,
‘Stress Reaction’
Perisosteal Ostitis,
Contusion Periostitis
Apophysitis
ARTICULAR CARTILAGE
Acute Injuries Overuse Injuries
Osteochondral / Chondropathy
Chondral Softening

Fractures Fibrilation

Fissuring

Chondromalacia

Minor
Osteochondral
Injury
JOINT
Acute Injuries Overuse Injuries
Dislocation Synovitis

Sublaxation Osteoarthritis
LIGAMENT
Acute Injuries Overuse Injuries
Sprain / Tear Inflammation
MUSCLE
Acute Injuries Overuse Injuries
Strain / Tear Chronic Compartment
Syndrome
Contusion Delayed Onset
Muscle Syndrome
Cramp Focal Tissue
Thickening /
Fibrosis
Acute Compartment
Syndrome
TENDON
Acute Injuries Overuse Injuries
Tear Tendinopathy
BURSA
Acute Injuries Overuse Injuries
Traumatic Bursitis
Bursitis
JOINT
Dislocation / Sublaxation

Dislocation occurs when trauma


produces complete dissociation of
articulating surfaces
JOINT
Dislocation / Sublaxation

Shoulder (Glenohumeral Joint) Dislocation


- anterior dislocation results from the
arm being force into excessive abduction
and Supraspinatus
- immobilized with elbow extended and
shoulder external rotation
JOINT
Dislocation / Sublaxation

Management:
Protection Phase

Protect healing tissue


Activity restriction
Avoidance of
Abduction with
external rotators
JOINT
Dislocation / Sublaxation
Management:
Controlled Phase.

Provide Protection
Increased Shoulder
Mobility
Increase Stability
and Strength of
Rotator Cuff and
Scapulars

JOINT
Dislocation / Sublaxation
Management: Return
to Function Phase.

Restore Functional
Control
Return to maximum
function
LIGAMENT
Sprain
Ankle – Anterior
Talo Fibular
Ligament

Inversion
LIGAMENT
Sprain
Ottawa Ankle Rules
LIGAMENT
Ankle Sprain

Management:

Protection Phase
Educate the Patient
Decrease Inflammation
Use Gentle Joint Mob to maintain joint
integrity
LIGAMENT
Ankle Sprain

Management:

Controlled Motion Phase


Attain Full range of motion
Start Strengthening
Balance and Propriception
LIGAMENT
Ankle Sprain

Management:

Controlled Motion Phase


Progress strength training
Progress Balance and propriception
exercises
Sports movement and skills
LIGAMENT
Anterior Cruciate Ligament
Anterior cruciate ligament (ACL)
injuries occur from both contact
and noncontact mechanisms.

blow to the lateral side of the


knee resulting in a valgus force
to the knee.

rotational mechanism in which


the tibia is externally rotated on
the planted foot
LIGAMENT
Medial Collateral Ligament
Result of valusstress on a semiflexed knee
Meniscectomy

Indication for Surgery


A symptomatic (pain and locking),
displaced tear of the
meniscus sustained by an older,
inactive individual associated
with pain and locking of the knee
A tear extending into the central, less
vascular third
of the meniscus if not determined
repairable when
arthroscopically visualized and probed
A tear localized to the inner, avascular
third of the meniscus
Meniscectomy

Management:

Protection Phase
Educate the Patient
Decrease Inflammation
Meniscectomy

Management:

Controlled Motion Phase


Attain Full range of motion
Start Strengthening
Balance and Propriception
Meniscectomy

Management:

Controlled Motion Phase


Progress strength training
Progress Balance and
propriception exercises
Sports movement and skills
Tendinopathy
• Rotator cuff tendinopathy
• Supraspinatus tendinitis
• Bicipital tendinitis
• Cumulative trauma disorder
• ITB tendinitis
• Patellar tendinitis
• Tibialis posterior tendinitis
• Plantar fasciitis

Tendinopathy
• Rotator cuff tendinopathy
• Primary
• Due to anatomic abnormalities
• Osteophytes
• Type III Acromion process
• Secondary
• Excessive load on the shoulder due
to
• impaired scapulohumeral
rhythm
• Joint instability
• Muscle imbalance

Tendinopathy
• Rotator cuff tendinopathy
• Clinical features
• Pain with overhead activity or
movement
• Painful arc 60-120 degrees of abd.
• Abduction less than 90 degrees are
usually pain free
• Pain and tenderness in the
supraspinatus muscle particularly
at the insertion
• Pain with excessive shoulder flexion
Tendinopathy
Bicipital Tendinitis

• Symptoms
• Long head of the • Local
biceps tendernes
susceptible to
overuse injury s of the
biceps
• Occurs with
individuals tendon
performing high • Muscle
volume of tightness
weight training • Chronic
• Referred pain and intermusc
rotator cuff ular and
tendinopathy fascial
can produce
pain in the thickening
biceps • Pain on
Tendinopathy

 Acute Subacute Chronic


• PRICEMEM
• PT: Taping
• Physical agents •




 • •Power
Mobility/Strength
•ADL in the pain free
Low level functional
range
activities
Tendinopathy

Cumulative Trauma Disorders


• Chronic Inflammation
• repetitious movements over a prolonged period of
time originating from the body part results in micro-
trauma of the area
• Pain is the primary
Manifestation

•Characterized by increased
 collagen production and
resorption of mature collagen
 •Efforts to stretch the inflamed

tissue perpetuate the irritation


Tendinopathy

Tennis elbow
Typical Movements Typical Job Activities
flexion and extension small parts assembly

of the elbow hammering

 meat cutting

playing tennis

bowling

Golfers Elbow
•Rare

Tendinopathy
Tennis Elbow
 Golfers Elbow

• Pain at the site • Pain at site


radiating to reproduced by
resisted wrist
the lateral flexion,
epicondyle pronation,
• ECRB + grasping
Supinator
• ROM Complete
• Weak grasp


Tendinopathy
• Tennis and Golfers Elbow
• Treatment is consistent with stages
• Ergonomic modifications
Tendinopathy

De Quervains Disease

• Stenosing tenosynovitis
• APL and EPB tendon



Tendinopathy
De Quervain’s
Typical Movements Typical Job Activities
combined forceful gripping and sawing
hand twisting use of pliers

 “turning" control such as on

a motorcycle
inserting screws in holes

forceful hand wringing

Primary Treatment: Ergonomics and Joint protection


Tendinopathy
Management Guidelines
Acute

• Control of inflammation
• Focus on non-stressful activities /
non-stressful intensities
Subacute and Chronic

• Exercise programs with controlled


stress(until CT can withstand the
stress)
• Identify the cause of faulty muscle
and joint mechanics
Tendinopathy
OT

• Pallative treatment
Tendinopathy
ITB tendinitis
• ITB Friction syndrome
• Pain at insertion (Gerdys
Tubercle)
• Treatment
 consistent with stages
Tendinopathy
Patellar Tendinitis
• “Jumpers knee”
• Inferior pole of the patella
Sinding Larsen Johansson

• Osteochondritis of proximal
attachment
Osteochondritis Dissecans

• Partial to complete avulsion of TT



Tendinopathy
Tib Post
• Pain in the navicular bone
• Resisted ankle inversion
Achilles tendinitis

• Pain in calcaneus
• Plantarflexion
Plantar fasciitis

• Pain in plantar aspect


• Rule out heel spurs

Tendinopathy
Acute Chronic
Treatment

Tib Post

Achilles
Tendinitis

Plantar
Fasciitis
Bursitis

Subacromial /
Ischiogluteal bursitis Subdeltoid bursae
“Weavers bottom”

Prepatellar bursitis Olecranon


“Housemaids knee” Bursitis
“Miners Elbow”

Superficial infrapatellar
bursitis Pes anserine bursitis
“Nun’s Knee”
Bursitis
• Clinical Feature
• Pain present in all motions
• Leads to secondary complications
(wekaness, LOM)
• Continued use willl lead to erosion,
rupture, adhesive pericapsulitis
ACHILLES TENDON REPAIR
Athletes in 30s or 40s

Location of rupture is
associated with the
“watershed” area.
ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Maximum Protection Phase

Protect the wound


Prevention of early re-rupture
Maintain strength of non immobilized joints
Prevent reflex inhibition of immobilized muscle groups
Specially Tibialis Posterior
Prevent joint stiffness on operated ankle and foot
Re-train proprioception
Control swelling
Maintain scar integrity
Improve Gait pattern
ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Moderate Protection
Phase

Increase strength of hip and knee of operated


extremity
Improve proprioception and balance
Attain Full Range of Motion on the operated
ankle towards dorsiflexion
Increase Strength of operated ankle and foot
Maintain scar integrity
No swelling
Improve Cardiovascular Endurance
ACHILLES TENDON REPAIR

Rehabilitation Guidelines: Moderate


Protection Phase

Progress strengthening on operated ankle


Progress strengthening of hip and knee of
operated extremity
Maintain scar integrity
Progress proprioception and balance
Attain Full Range of Motion on the operated
ankle towards plantarflexion
Improve Cardiovascular Endurance
Prepare for jogging
ACHILLES TENDON REPAIR

Rehabilitation Guidelines: Minimun Protection


Phase

Progress strengthening of hip and knee of


operated extremity
Progress proprioception and balance
Improve Cardiovascular Endurance
Improve coordination
Prepare for Sprints
Improve agility
Increase Power
ACHILLES TENDON REPAIR

Rehabilitation Guidelines: Return to Function


Phase

Progress strengthening on operated ankle


Progress strengthening of hip and knee of
operated extremity
Progress proprioception and balance
Improve Cardiovascular Endurance
Improve Power
Return to Sport
MUSCLE STRAINS
Maximum Protection Phase
-No stretching
-No strengthening
-Protect healing muscle
-Mobilize unimmobilized areas
-

Moderate Protection Phase


-Strengthening
-Isometrics  as tolerated isotonic
-Core
-Start stretching, massage
-
Minimum Protection Phase
Strengthening
isotonic  eccentrics
Stretching calf, hamstrings and quads

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