sports medicine pfn: somool09 - jsomtcmyositis ossificans communicate the signs and symptoms,...

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Slide 1JSOMTC, SWMG(A)

Sports MedicinePFN: SOMOOL09

Hours: 5.0


Terminal Learning Objective

Action: Communicate knowledge of “Sports Medicine”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


References

Wilderness Medicine (6th edition; 2012; Auerbach)

Current Diagnosis and Treatment (55rd

edition; 2016)

The Merck Manual (19th edition; 2011)

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References

Patient Instructions for Sports Injuries (2012, Marc Zafran)

Special Operations Forces Medical Handbook (2008 edition; Farr)

Fixing Your Feet (1997, John VonHof)

Netter’s Sports Medicine (2010)


Reason

As SOF Medics, you will encounter a myriad of orthopedic problems resulting from either recreational, military training, or combat‐related, sports‐medicine injuries and disorders. Proper diagnosis and management of these injuries and disorders will ensure team effectiveness helping result in mission success.


Agenda

Identify predictors of injuries and ways to lessen the chance of incurring an injury

Identify the keys to injury prevention

Identify how to employ different stretching methods

Communicate how to utilize fluid and nutrients with exercise and activity

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Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of contusions

Communicate the signs and symptoms, mechanism of onset, and prevention of myositis ossificans

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of sports hernias


Agenda

Communicate nerve injuries and the muscles involved with brachial plexus injuries

Communicate evaluation techniques of head injuries without loss of consciousness (LOC) and the return to activity status

Communicate the signs and symptoms and physical exam techniques of SLAP injuries


Agenda

Communicate rehabilitation instructions for a patient with a shoulder injury

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of thoracic outlet syndrome

Communicate the patient education to lessen the development of hand and foot blisters

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Agenda

Communicate intrinsic and extrinsic causes leading to running injuries

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of stress fractures versus MTSS versus exertional compartment syndrome


Predictors of Injury and Ways to Lessen the Chance of

Incurring an Injury


Sports Medicine

The application of professional training to the understanding, prevention, care, and rehabilitation of sports‐related problems

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Predictors of Injury

Two best predictors

If you have been injured before

Number of consecutive days of training


Injuries

Occurs due to

Improper training

Overtraining

Violent collisions

Others


Keys to Injury Prevention

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Prevention of Injuries

Physical examination

Screening for muscle imbalances

Flexibility

Cardio

Pulmonary


“Know” Your Team Members

Simple example

To assess for muscle imbalance one needs to combine flexibility tests

• Hamstrings and rectus femoris are the two main mobilizer muscles around the hip joint

• Gluteals are the key stabilizer muscles around the hip joint


“Know Your Units”

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Different Stretching Methods


Stretching Methods

Dynamic ‐ Beginning

Static ‐ Cool down

Ballistic ‐ Increase flexibility


Stretching: Compare and Contrast

Dynamic Stretching Static Stretching

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Utilizing Fluid and Nutrition with Exercise and Activity


Solutions and Carbohydrates

2hrs before exercise

During exercise

Exercise < 1hr

Exercise > 1hr

500mL (about 17 oz’s)

Start drinking early, replace fluid lost through sweating

Plain water adequate

Carbohydrates* be ingested at a rate of 30 to 60 g/hr

*Solutions containing 4% to 8% carbohydrates


Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Contusions

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Contusions

Results from direct trauma

Differentiate from ruptures and strains

Function remains after the injury

Two types

Intramuscular

Intermuscular


Hematoma

A collection of pooled blood within a relatively restricted area


Quad Contusion

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Hand Contusion


Hip Pointer


Signs and Symptoms, Mechanism of Onset, and Prevention of

Myositis Ossificans

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Myositis Ossificans

Characterized by the formation of heterotopic bone in the soft tissues

Usually develops in muscle as the result of trauma (myositis ossificans circumscripta)


Myositis Ossificans


Myositis Ossificans

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Myositis Ossificans

Plan

Graded according to severity

May result in long‐term disability

R.I.C.E

Maintain range‐of‐motion

Complications

•Myositis ossificans

• Compartment syndrome

• Fascial herniation


Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Sports Hernias


Hernias

Abdominal

Inguinal

Femoral

Sports

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Common Hernia Locations

A. Epigastric HerniaOccur in the upper abdomen at the midline

B. Incisional HerniaOccur at the site of a previous surgical incision

C. Umbilical HerniaOccur at the navel

D. Direct Inguinal HerniaOccur in the groin near the opening of the inguinal canal

E. Indirect Inguinal Hernia Occur in the groin at the opening of the inguinal canal

F. Femoral HerniaOccur in the femoral canal


Sports Hernia

History

High speed twisting, turning, jumping, running and cutting

Symptoms

Pinching pain

Swelling in the groin, lower abdominal region

Pain with sudden movements (running, jumping, kicking, going up/down stairs, sneezing or coughing)


Nerve Injuries and the Muscles Involved with Brachial Plexus

Injuries

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Peripheral Nerve Injury Types

Contusion

Neuropraxia (nū′rō‐prak′sē‐ă) (Class 1)

Crush

Axonotmesis (ak′son‐ot‐mē′sis) (Class 2)

Complete division

Neurotmesis (nū′rot‐mē′sis) (Class 3)


Brachial Plexus “Stingers”


Rucksack Palsy

Predisposing factors

Pack used without waist support

Prior anomaly or injury: cervical rib; vertebral anomaly

Increased weight

Longer duration of load

Full syndrome may be preceded by transient weakness

Upper and middle trunks + occasional individual nerves

Lateral shoulder and upper arm

Shoulder: deltoid; supraspinatus; infraspinatus; serratus anterior

Other: triceps; biceps; wrist extensors

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Brachial PlexusNerve Injury Results

Suprascapular

Innvervates the supraspinatous and infraspinatous



Long thoracic

Innervates the serratus anterior



Axillary

Innervates the deltoid

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Evaluation Techniques of Head Injuries without Loss of

Consciousness (LOC) and the Return to Activity Status


But first…

Definitions

Concussion

• A non‐specific term, no universally agreed‐upon definition

•Most common: history of head injury and an alteration in mental status

mTBI (mild traumatic brain injury)

• Synonymous with “concussion,” but no the preferred term to use with patients or their family/friends due to stigma attached to term


Head Injuries without LOC or Unsure if LOC Occurred

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Head Injuries

Injury classifications

Mild

Moderate

Severe


Head Injuries

Risk

Grade 1: Low

Grade 2: Moderate

Grade 3: High


Head Injuries

RED FLAGS

Neurological

•Witnessed loss of consciousness

• Amnesia/memory problems

• Unusual behavior/combative

• Seizures

•Worsening headache

• Cannot recognize people

• Disoriented to time and/or place

• Abnormal speech

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Head Injuries

RED FLAGS (cont.)

Eyes

• Double Vision

General

• 2 or more blast exposures within 72 hours

• Repeated vomiting

•Weakness

• Unsteady on feet


Head Injuries

Management

TMEPs (q.v., mTBI, MACE)

ImPACT (within 24 to 72 hours)

“Rest” the brain

[email protected]


Head Injuries

Disposition

RED FLAGS: Consider Urgent evacuation

Consider Priority evacuation in the presence of MACE <25 and persistent symptoms despite appropriate treatment

Consider Routine evacuation if MACE <25 OR MACE >25 and persistent symptoms despite appropriate treatment

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Signs and Symptoms and Physical Exam Techniques of SLAP* Injuries


Shoulder


Disorders of the Rotator Cuff

Impingement

Repetitive activity

Strains

Repetitive activity with overload

Tears

Sudden or chronic activity

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SLAP Injuries

Superior Labrum Anterior Posterior (SLAP)

Deep dull, throbbing, ache; worse with throwing activities or when reaching overhead

Shoulder may also click or snap with movement and may feel like being dislocated


SLAP Injuries

Objective: physical exam and diagnostics

O’Brien and Crank tests

MRI

Arthroscope

Treatment

NSAID

Physical therapy

CAM


Rehabilitation Instructions for a Patient with a Shoulder Injury

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Shoulder RehabilitationBeginner

Hanging circumduction

Shoulder weakness

Recent post‐op

Wall crawl

Frozen shoulder

Those that c/o pain upon lifting arm


Shoulder RehabilitationIntermediate to Advanced

Rear monkey grip

Grip hands from behind

Start with towel to improve flexibility


Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Thoracic Outlet

Syndrome

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Thoracic Outlet Syndrome (TOS)

Symptoms

Pain, numbness, tingling in the middle, ring, and little fingers and inner forearm

Pain and tingling in the neck and shoulders (carrying heavy load may worsen pain)


Thoracic Outlet Syndrome (TOS)

Symptoms (cont.)

Poor circulation in the hand or forearm

Weakness of the muscles in the hand

Headache may occur in a minority of patients


Thoracic Outlet Syndrome

Tests

Roos or “hands up”1

“Adson’s” or Scalene maneuver2

Wright’s3

Costoclavicular maneuver

Traction

3

2

1

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Thoracic Outlet Syndrome

Management

Heat

Stretching

• Scalene stretch1

• Scapular squeeze2

• Pectoralis stretch3

• Thoracic extension

NSAID

Referral• Transaxillary first rib resection (TAR)

1 2

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Patient Education to Lessen the Development of Hand and Foot

Blisters


Hand Blisters

Prevention

Wear gloves

Talcum powder hands before putting on gloves

Bandage (adhesive) areas prone to blister

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Hand Blisters

Management

Preserve blister if possible

Drain with sterile #11 blade

Moleskin protection

Antiseptic for open lesions


Foot Blisters

Prevention

Comfortable shoes; broken‐in

Frequent synthetic sock changes

Vegetable based lubricants • Avoid petroleum products which heat up with friction

Antiperspirant (spray) agents


Foot Blisters

Treatment ‐ Tactical

Intact (sealed) vesicles

• Disinfect with alcohol swab

• Puncture vesicle wall close to the base

• Express fluid

Deroofed or torn vesicles

• Cleansed as above

• Remove loose dermis

• Irrigate the blister base with normal saline

• 1/8" thick DuoDerm, same size as the eroded cavity

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Intrinsic and Extrinsic Causes Leading to Running Injuries


Running Injuries

MTSS

Stress fracture

Exertional compartment syndrome

Turf toe


Running InjuriesBiomechanics

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Foot for Thought

Anatomy

Age

Running shoe

Type of running

Running surface

Recent injuries

Prior injuries

Recurrent injuries


Running Injuries

Causes by anatomical location

Feet ‐ Over pronation, pes cavus, loss of transverse arch

Ankles ‐ Laxity

Legs ‐ Unequal leg length, weak posterior tibialis

Knees ‐ Genu valgus, genu verum

Hips ‐ Q angle

Back ‐ Increased lordosis

Muscles ‐ Unequal muscle strength


Turf Toe

First metatarsophalangeal joint sprain

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Turf Toe

Introduction

Sprain of the first metatarsophalangeal (MPJ)

Most commonly occurs with hyperextension

Occur with any forced ROM

Term derived from injuries while using artificial turf athletic fields


Turf Toe

Subjective findings

First MP joint

• Tenderness

• Swelling

• Limited motion

Patient cannot continue activity or walk normally


Turf Toe

Objective findings

Swelling

Ecchymosis

Painful ROM great toe

Painful walking

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Turf Toe

Diagnostic studies

Radiographs to detect

• Avulsion fractures

• Evaluate joint congruity

• R/O arthritic changes

Bone scan or MRI

• R/O sesamoid or metatarsal fractures


Turf Toe

Plan

R.I.C.E.

Protected weight bearing (crutches)

Immobilization 1 to 2 weeks

Consultation


Signs and Symptoms, Physical Exam Findings, Diagnostic Tests, and Management of Stress Fractures versus MTSS versus Exertional

Compartment Syndrome

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Stress Fractures vs. MTSS vs. Exertional Compartment Syndrome

Subjective findings

Too far, too fast, too soon

Increased pain with activity

Decreased pain with rest (initially)



High index of suspicion

Repetitive loading of a specific area of bone



Objective findings

Point tenderness

Tuning fork finding

If available:

• Radiographs negative first 1 to 14 days

• Bone scan, CT, or MRI if results needed sooner

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Stress Fractures Femoral Neck


R/O Femoral Neck Stress Fracture


Navicular Stress Fracture

Clinical presentation

Vague, aching pain in the dorsal midfoot

Physical examination

Tenderness over the navicular area

No ecchymosis or deformity and usually no swelling

Patients generally exhibit increased pain with hopping and standing on their toes in the equinus position (on toes)

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Radiologic tests

Plain radiographs

Bone Scan

CT scanning, MRI

Management

6 weeks in a well molded, non‐weight bearing cast results in healing


Positive Results

Bone Scan CT MRI

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Metatarsal Stress Fracture

Common

Involves 2nd and 3rd

metatarsalsPeriostium Reaction


Metatarsal Stress Fracture

Plan

Displaced fractures

Usually involves multiple fractures and may require open reduction, internal fixation (ORIF)

Non‐displaced fractures

• P.R.I.C.E. (protection, rest, ice, compression, and elevation)


Shin Splint versus Stress Fracture

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Medial Tibial Stress Syndrome“Shin Splints”


Posterior Tibial Tendonitis


Exertional Compartment Syndrome

Pain onset usually 8 to 12 minutes into exercise

Outer part of leg

Resolves after approximately 30 minutes of rest

Weekend athlete

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Rehabilitation Steps

PT (both types)

Alternative training

Maintain aerobic fitness

Avoid weight gain

Progressive training

Major concern is avoiding training too hard or too soon

Return to full training

Patient education: healing time for ligaments and tendons versus muscle


Questions?


Terminal Learning Objective

Action: Communicate knowledge of “Sports Medicine”

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards

35


Agenda

Identify predictors of injuries and ways to lessen the chance of incurring an injury

Identify the keys to injury prevention

Identify how to employ different stretching methods

Communicate how to utilize fluid and nutrients with exercise and activity


Agenda

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of contusions

Communicate the signs and symptoms, mechanism of onset, and prevention of myositis ossificans

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of sports hernias


Agenda

Communicate nerve injuries and the muscles involved with brachial plexus injuries

Communicate evaluation techniques of head injuries without loss of consciousness (LOC) and the return to activity status

Communicate the signs and symptoms and physical exam techniques of SLAP injuries

36


Agenda

Communicate rehabilitation instructions for a patient with a shoulder injury

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of thoracic outlet syndrome

Communicate the patient education to lessen the development of hand and foot blisters


Agenda

Communicate intrinsic and extrinsic causes leading to running injuries

Communicate the signs and symptoms, physical exam findings, diagnostic tests, and management of stress fractures versus MTSS versus exertional compartment syndrome


Reason

As SOF Medics, you will encounter a myriad of orthopedic problems resulting from either recreational, military training, or combat‐related, sports‐medicine injuries and disorders. Proper diagnosis and management of these injuries and disorders will ensure team effectiveness helping result in mission success.

37


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