Principles of Physiotherapy Interventions for Common Sport Injuries Sport Injuries PT Mx Nature of Healing and Repair Injury Identification Rehabilitation Principles Tan Yee Siong Sport Physiotherapist TYS Physio On Wheel Overview Wound Damage/disruption of normal anatomical structure and functions Nature of Soft Tissue Healing and Repair 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 Terms Connective Tissue Proper [Areolar Tissue] The Normal Healing Cascade 1
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 Acute Inflammation Acute Inflammation 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. Possible Response after Injury Regeneration { Local { Disturbed demolition phase Vascularity Excess movements Foreign material Infection/irradiation Systemic Malnutrition Corticosteroids Jaundice Rate of Healing Factors Influencing Wound healing 2
Identification of Injury Stress-Strain Curve 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 Why Examination and 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 Identification from the Subjective Ax 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. Strain Sprain Dislocation Subluxation Muscle/tendon rupture Tendinoathy/Tendinosi s Synovitis Hemarthrosis Contusion Bursitis Synovitis Ganglion RSI Key Points in Physical Examination Common MS Lesions 3
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. Differential Dx of Soft Tissues Disorder Synovial Fluid Inspection Degree of Injury Grade 1 Grade 2 Grade 3 Pain Mild Moderate Severe Playability Able Unable Unable Stress Response Structural Integrity ERP ERP Nil Preserved Joint play increased Laxity/ Instability Principles of Rehabilitation Severity of Tissue Injury Return to Sport Sorts Specific Training Neuromuscular relearning Specific Sport Drills Plyometric and Agility Neuromuscular Control 3 Aerobic & Endurance ROM Muscular Strength Proprioception The Initial Guide where Everything Started CR Capacity Muscles Strength and Endurance Neuromuscular Control 2 Protection and Healing ROM and Muscle activation Weight Bearing and Mobility Neuromuscular Control 1 LL Rehabilitation RoadMap 4
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] Nature of Injury Healing Process Timing Wilhelm Roux Law of functional adaptation Mechanics (movement & position) Passive and Active Stability Associated Injuries Protection and Healing ROM 1 and Muscle activation [static isometric] Neuromuscular Control 1 [postural] Shoulder Rehabilitation RoadMap Governing Factors in Rehabilitation progression Acute Stage (Inflammatory Reaction) Management Guidelines Motor Tasks Taxonomy [Gentile 2000] 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. 5
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) 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. 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. 6
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. 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. 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. 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 Monitoring Signs Monitoring System Ensuring Safety Protect athlete from further harm/danger Keep the athlete calm Athlete Positioning Comfortable and injured part supported. For seriously injured athlete, only move unless is necessary Equipment Removal Only remove if it will not cause further injury, use proper cutter if needed Before Injury Assessment In The Field 7
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. In The Field Formula for Treatments? 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. 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? Questions to Ponder in Sports Rehab Questions to Ponder in Sports Rehab Kisner C, Colby LA (2007), Soft Tissue Injury, Repair and Management: Chapter 10, in Kisner C, Therapeutic Exercise Foundation and Techniques (5 th 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 (7 th Edition, pp. 118 137), USA, Pearson Cummings Spector TD, Axford JS (1999), Healing and Repair: Chapter 15, in An Introduction to General Pathology (4 th 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, (2 th 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 References 8