sports injuries mikey bengzon, md, mbah 30 november 2010
TRANSCRIPT
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Sports Injuries
Mikey Bengzon, MD, MBAH
30 November 2010
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Specific Learning Objectives:
• Enumerate and define common acute and chronic orthopedic Sports injuries.
• Describe the anatomy and physiology of musculoskeletal structures.
• Review the ligamentous anatomy of the knee.• Analyze the pathology of Orthopedic sports
injuries.• Enumerate the methods of treatment of
Orthopedic sports injuries.
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Sports Injuries
Acute injuries• Ankle sprain• Muscle Strain• Contusion• rupture/dislocations
Chronic injuries• Tendinitis• Stress Fractures• Osgood Schlatter
Disease• Sever’s disease
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Orthopedic Sports Injuries
• S - Onset: Acute vs. Chronic;– MOI: Direct vs. Failure
• O - Location: Long bone vs. Periarticular; Structure: Osseous vs. Soft tissue
• A – Osseous or non osseous, Location
• P - ?
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Contusion
• Blunt injuries• Intra: Within the
compartment; more painful; swelling lasts longer; no obvious hematoma
• Inter muscular: less painful; swelling resolves sooner; obvious hematoma
• Grade 1 – 3 (tightness)
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Stress(?) Fracture
• Incomplete fracture• Overuse -> Fatigue• Force transfer from
muscle to bone• Rx: Rest vs IF
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Osgood Schlatter Disease
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Sever’s Disease
• Inflammation of the growth plate
• 8-13 year olds• Overuse injury in
running sports• Rx. Rest, control of
inflammation
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Mallet finger
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Rotator Cuff Tears
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
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Toe RegionLinear Region
Yield/ Failure
Strain
Stress
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Types of Muscle Contraction
• Concentric – Joint moves with a load and the muscle shortens (biceps contract)
• Eccentric – results in muscle lengthening while controlling a load during joint motion (biceps in elbow extension)
• Isometric – fixed load with no joint motion (quadriceps sets)
• Isokinetic – variable load with constant velocity (exercise bike)
• Isotonic contraction - tension rises and the skeletal muscle shortens
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Toe RegionLinear Region
Yield/ Failure
Strain
Stress
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2 types of Skeletal muscles
• Type I – Slow twitch, more for endurance and aerobic bc of the presence of mitochondria and myoglobulin
• Type II – fast twitch, for rapid generation of power but anaerobic so less able to sustain prolonged contraction – Type IIA vs Type IIB
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Factors affecting muscle properties
• Strength training – High force, low repetition: leads to an increase in muscle strength; increase muscle fiber size leads to an increase in contractile proteins
• Endurance training – (low tension, high repetition): Increases capillary density & mitochondria concentration resulting in VO2 max and improved fatigue resistance– MHR = 220 – Age– Increase VO2 max, HR must increase to 65-85% of
MHR
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Tendons
• Connects muscle to bone
• Collagen are more parallel and larger compared to ligaments
• Relatively avascular• 2 tendinous areas:
– Musculotendinous– Osteotendinous
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Functions of Tendons
• Length of tendon allows muscle belly to be at a distance from the joint
• Transmits force between muscle and bone– Tensile stresses are high
• Conservation of muscular energy during locomotion/ energy storage capacity– Satisfies kinematical and damping
requirements
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Mechanical Properties of Tendons
• Greater cross - sectional area– Larger loads can be applied prior to failure– Increased tissue strength– Increased stiffness
• Longer tissue fibers– Greater fiber elongation before failure– Decreased tissue stiffness– Unaltered tissue strength
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Strain
• Pertains to muscles• Overexertion• Grade 1 strength
maintained• Grade 2 – decrease
strength• Grade 3 – loss of
strength• Treatment – Similar to
sprains
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Toe RegionLinear Region
Yield/ Failure
Strain
Stress
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Tendinitis
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Lateral Epicondylitis
• Tennis elbow• Tendinitis at the
common extensor origin in the elbow
• Elbow and wrist extension
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Ligaments Tendons
% Collagen Less More
% Ground Substance
more less
Organization More random Organized
Orientation Weaving pattern
Long axis direction
Ligaments vs. Tendons
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COMPONENT LIGAMENT TENDON
Cellular Materials:
Fibroblasts 20% 20%
Extracellular:
Water 60-80% 60-80%
Solids 20-40% 20-40%
Collagen 70-80% Slightly higher
Type I 90% 95-99%
Type III 10% 1-5%
Ground substance 20-30% Slightly less
Elastin Up to 2X Collagen Scarce
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Dislocations/Subluxations
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Toe RegionLinear Region
Yield/ Failure
Strain
Stress
Mechanical Behavior of ligaments
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Sprain
• Pertains to ligaments• Ankle, knee & finger• Children vs adults• Grade 1- fxn
maintained• Grade 2 – partial
weight bearing• Grade 3 – unstable• Treatment: depends
on severity
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Ligaments
• Soft connective tissue composed of densely packed collagen fibers
• Mechanical properties depend on function and location
• Fibroblasts• Extracellular matrix
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Ligaments
• Functions:– Holds skeleton together– Transmit load bone to bone– Provides stability at joints– Limits freedom of movement
• Prevents excessive motion by being a static restraint• Occasionally acts as a positional bend/strain sensor• Mediate motions bw opposing fibrocartilage surfaces
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Ligaments
• No molecular bonds between fascicles– Free to slide relative to
each other
• Parallel or Branching/interwoven– Collateral vs Cruciates
• Smaller diameter than tendons
Simon, SR. Orthopaedic Basic Science. Ohio: American Academy of Orthopaedic Surgeons; 1994.
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Crimping: – orientation of collagen in ligaments– Allows elongation of fibers before tensile stresses are
experienced
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Viscoelastic Response
• Viscous – resists strain; Elastic – returns to original state• Dependent on
– Magnitude of load – Duration of load– Prior loading
• Affected by movement of water– Resistance to compressive forces due to water trapped in
proteoglycans– Contributes to sustained or cyclic responses to stress
• Types of responses– Creep – Stress relaxation– Hysteresis
http://www.tendinosis.org/injury.htm
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Creep • Time dependent elongation when subjected to a constant stress– Tendons: in an isometric
contraction, the tendon will lengthen slightly and more muscle fibers will be recruited in order to maintain the position of the limb
– Ligaments: Joints will loosen with time, decreasing the possibility of injury
• Ex. Maintaining posterior pressure of the knee in extension
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthconntiss.htm
http://ttb.eng.wayne.edu/~grimm/ME518/L5A3.html
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Stress - Relaxation• Time dependent
decrease in applied stress required to maintain a constant elongation– Tendons: in an isotonic
contraction, the stress will decrease with time
– Ligaments: joints will loosen with time decreasing the possibility of injury
• Ex. Biceps curls x 2 reps
http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthconntiss.htm http://ttb.eng.wayne.edu/~grimm/ME518/L5A3.html
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Hysteresis
• Energy lost within the tissue between loading and unloading– Response of tissue
becomes more repeatable
– Subsequent use of the same force results in greater deformation
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Knee Injuries
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Knee Injuries
• Medial Collateral Ligament (MCL) strains
• Anterior Cruciate Ligament (ACL) tears
• Meniscal Tears
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Examination of the Knee
• Bone
• Soft tissue
• Ligaments
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Anterior Cruciate Ligament
• Located between the femur & tibia at the center of the knee– Origin: Medial Surface of the Lateral Femoral
condyle– Insertion: anterior tibial plateau– Intracapsular; extrasynovial
• 2 bundles: AM & PL*• + Lachman’s & Anterior drawer’s test
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ACL
• Anterior Drawer’s test
• Lachman’s test
• Pivot Shift
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KT 2000
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ACL MRI
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Posterior Cruciate ligament
• Origin: Medial Femoral Condyle• Insertion: Posterior Cortical
surface of the tibia in the sagittal midline
• Covered by synovium (intimately associated with the posterior capsule)
• Blood supply from the middle geniculate artery
• + sag sign, Posterior drawer’s test
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Medial Collateral Ligament
• Primary stabilizer to valgus
• Origin: MFC at the adductor tubercle
• Insertion: Medial aspect of the proximal tibia
• Superficial and Deep layer
• + Valgus Stress test
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Lateral Collateral Ligament
• Origin: Lateral Femoral condyle
• Insertion: fibular head
• Resists Varus stress
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Meniscal tear
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Inflammation
regeneration
Fibrosis
Weeks
Stages of Healing
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R.I.C.E.
• REST – avoid painful movements but use as tolerated
• Ice – 20 minutes at a time x 24-48 hours
• Compression
• Elevation
• Address main pathology
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Issues in Treatment
• Temperature: – Negative Effects of Ice, Dr. Ho, University of Hawaii –
Decreases blood flow and metabolism– 1980 AOS & AJSM – nerve palsies
• Motion – immobilization affects overall health of the joint (scar tissue, cartilage necrosis, ligament weaknening)
• Medications– NSAIDS: inhibit fibroblastic growth processes
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Post Surgery
• Range of Motion
• Strengthening
• Endurance
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