Basic Principles in Treating Athletic Injuries

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Basic Principles in Treating Athletic Injuries
1. Acute Phase
2. Healing Phase
3. Rehabilitation Phase
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• Acute Inflammation ( 24-48 hours )
• Chronic Inflammation ( 3-7 days )
• Healing ( 3-6 WEEKS )
• Rehabilitation ( up to a year ) Min 3 months

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Innate ?

• Tissues respond to injury through a set of
  genetically programmed mechanisms to replace the
  damaged components and restore normal function

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Einstein on Insanity

• Doing the same thing over and over expecting a
  different result.
• Dog lady

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Evidence based Practice

• A method of integrating clinical expertise with
  the best available evidence from clinical
  research to make decisions about the care of
  individual patients

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Process of EBP

• Defining the question
• Searching the literature
• Evaluating the evidence
• Applying the results to the patient
• Evaluating the outcome

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Levels of EBP

• Research report or original research with
  systemic reviews
• Case-control studies or reports
• Expert opinions leads to clinical commentary
• Application Therapeutic Value

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Treating Athletic Injuries

• Acute Phase
• Control tissue injury complex
• Enforce rest of injured area with protection
• Maintain conditioning anaerobic-aerobic
• 2. Treat Inflammation
• Pain meds.
• Nasaids
• Modalities

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Treating Athletic Injuries

• Acute Phase (Cont.)
• 3. If not overt signs of inflammation no meds or
  modalities necessary
• 4. When healing allows
• Protected ROM
• Isometric activity
• Resisted short arc isotonic contractions

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Treating Athletic Injuries

• Acute Phase (Cont.)
• 4. Goals
• a. Reduced Swelling
• b. Decrease Pain
• c. Tissue Healing
• d. Improved ROM

When achieved - Proceed to healing phase.
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Treatment Protocols

• Exercise is not an adjunctive therapy, exercise
  is the therapy
• Ken Hutchins.

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Ardnt-Schultz Law

• Weak stimuli increases physiological activity and
  very strong stimuli inhibits or abolishes
  physiological activity.

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Law of Least Action

• Maupertius The quantity of action necessary to
  effect any change is the least possible, the
  decisive amount is always the minimal, the
  infintesimal.

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Treatment Protocols

• Phase 1 Acute Inflammatory Phase
• Question Does inflammation cause pain or does
  pain cause inflammation?
• For a long time pain has been summarily dismissed
  as the outcome of direct stimulation of sensory
  nerve endings by injury and the pressure of
  inflammation exudates. This opinion completely
  neglects the observation that pain often
  initiates the inflammatory response and may
  become less severe as that process gains speed.
  Robbins pg.44
• Goal is to control the pain and inflammation
• PRICE
• Protection
• Rest
• Ice
• Compression
• Elevation

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Treatment Protocols

• Ice 15-30 minutes of cryotherapy reduces
  temperature 3-7 degrees C.
• Method of delivery
• Ice Pack
• Ice Massage
• Versacooler Adds compression to the TX.
• Immersion
• Cryotherapy to the point of cold vasodilation is
  counter productive. Hunter Reaction is the bodies
  reaction to excessive cryotherapy causing
  increase hemorrhage and inflammation.

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Treatment Protocols

• ICE Suggested Protocol
• 10 minutes C-Spine, wrist, elbow, ankle shin
• 15 minutes T-Spine, knee, shoulder
• 20 minutes, L-Spine, pelvis, thigh.
• Frequency 2-4 times/day,
• Maximum hourly 15/45

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Treatment Protocols

• ICE vs HEAT
• Ice
  Heat
• Grade 2 Sprain-strain Within 24
  hours After 24 hours
• 
  6 days 11 days
  15 days
• Grade 3
  13 days 30 days
  33 days
• Sensory Fiber Analgesia 4-5 minutes with
  cryotherapy which lasts for 30 minutes.
• Cryotherapy gives comparable relief
• to local anaesthesia and morphine.

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Treatment Protocols

• Electrotherapy Used for edema reduction and pain
  control
• High Volt
• Low volt
• Interferential
• Faradic
• Galvanic Iontophoresis

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Treatment Protocols

• Ultrasound
• Promotes healing of soft tissue.
• Continuous
• Pulsed
• Phonophoresis

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Physiological Effects of Ultrasound

• Heat
• Mechanical action
• Micromassage
• Tissue alterations
• Chemical effects
• Clearing agent
• Microdestruction
• Analgesia

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Heat

• Increase peripheral blood flow
• Increase local metabolic rate
• Increases membrane permeability
• Blocks peripheral nerve impulses
• Alters spinal reflexes
• Relax muscle spasm

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Mechanical action

• Softens tissue
• Softens scar
• Breaks down collagen fibrils

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Chemical Action

• Increased gaseous exchange
• Liquifaction of cellular gels
• Increased oxygenation

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Clearing agent

• Causes exudates and precipitates to be absorbed.
• Pulsed US especially effective in acute stages of
  injury

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Microdestruction

• Disrupts tissue deposits
• Breaks down calcium deposits ( action not
  conclusive)
• Calcified hematomos

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Analgesia

• Ultrasound triggers enkephalin formation

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Hands Free Ultra Sound

• Low intensity
• Longer treatment time
• Stationary
• Results Stress Fractures, Soft Tissue Injuries

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Low Level Pulsed Ultrasound

• Reduced healing time in fracture repair by 30-38
• When applied to non union fractures it stimulated
  union in 86 of cases
• Potential for use in tendon, ligament, muscle and
  cartilage injuries
• Conclusion may have a beneficial effect in
  treating sports injuries accelerated healing

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Treatment Protocols

• Joint mobilization Tissue must heal in the
  presence of motion.
• Cyriax Cross Fiber
• Laser
• Exercise

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Joint mobilization

• Activates mechanoreceptors
• Breaks down adhesions
• Decrease congestion in joint
• Relieves compressive forces on articular capsular
  and cartilagenous structures
• Relieves contracture of connective tissue
  transversing joint

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Mobilization

• The strength of healed tendons is superior to
  that of controls where mobilization was delayed.
• An augmentation of extrasynovial tendon healing
  by continuous passive motion has been
  demonstrated in the rabbit model

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Mobilization

• Mobilization stimulates the intrinsic tendon
  healing response, specifically the fibroblasts,
  resulting in healing with minimal scar formation.
• . Early passive mobilization reduces adhesions

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Transverse FM

• Transverse friction massage of the injured tendon
  in chronic tendonitis is thought to be beneficial
  in breaking down adhesions,
• Tissue mobilizations maybe beneficial in tendon
  healing by the transport of nutrients to the area.

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Cyriax Crossfiber

• Mobilize scar tissue
• Reduce adhesions
• Activates phagocytes
• Neurological component
• Should be preceeded by ice massage
• Followed by PNF stretches

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James Cyriax MD
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Muscle Energy
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Muscle energy
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Laser/Light

• Tissue heals relative to the reversal of
  glycolytic damage.
• Oxygen utilization major key to healing
• Laser is directed at mitochondrial activity
• Increases cellular metabolism

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Laser v Light Therapy
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Light v Laser
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Physics

• UV light lt 400nm lt infrared
• 600-750 nm Red
• 750 lt Infra Red- not visible
• Depth of penetration NM Wave Length

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Physics ( Cont )

• Depth of Penetration
• 400 nm 2-3 mm
• 600-750 10 mm
• 880 nm 30-40 mm
• Dose sec x power/ area JCm2

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LLLT Effect on Inflamation
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LLLT ( cont )
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LLLT ( cont )
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LLLT effect on pain
Cell membrane changes Ca, Na, K ion changes
Endorphin increase C-fiber depolar block
Nitric Oxide Production Increased action potential
Decreased Bradykinin Levels Increased acetylcholine
Pain reduction ?
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LLLT effect on healing time
Increased leukocytic activity Increased macrophage activity
Increased vascular regeneration Increased fibroblast proliferation
Early cell regeneration Enhanced cell differentiation
Increased tensile strength Accelerated wound healing
Reduced healing time ?
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Application
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Electrotherapy

• Low Frequency
• High Volt
• Interferential Current

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Low volt currents

• Galvanic current
• Sine wave
• Electrical muscle stimulation
• Combination therapies
• TENS

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Galvanic current

• Direct, unidirectional, waveless, low volt
  current
• Various electrochemical effects
• Use today is almost totally limited to
  iontophoresis

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Tens

• Transcutaneous electrical nerve stimulation
• Based on the Melzack-Wall theory ( 1965)
• Sensory only
• Pad placement, dermatomal.
• Wave form widths 40-500ms
• Frequency 70-150 pps

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Sine Wave

• Used primarily for muscle stimulation
• Restricted joint motion
• Adhesions
• Muscle atrophy
• Passive exercise
• Trigger points

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High Volt Therapy

• High voltage monophasic pulsed stimulation
• Advantage is primarily depth of penetration
• No danger of burning patient

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General Settings for High Volt Therapy

• 1-10 pps. Muscle stimulation or pain modulation,
  small diameter electrode
• 10-15 pps, Muscle exercise, twitching
• 15 lt Tetanize
• 20-80 pps muscle tetany without fatigue
• 70-110 enkephalin production for pain control
• polarity acute polarity chronic

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Interferential

• Two or more oscillations applied simultaneously
• 4000-4250 hz.
• Modulation
• 40-90 hz increases circulation
• 90-130 hz increased enkephalin production

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Exercise

• Early transition from passive to active care
• Key to restoration of function
• Effects on the somatic system
• Effects on nervous system
• Should be initiated as soon as pain free motion
  is established.

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Kerri Welsh
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Kinesiotaping
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Theraband
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Theraband
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Treating Athletic Injuries

• Recovery Phase Rehabilitation
• Begin tissue overload
• Functional biomechanics
• Deficit Complexes
• Nsaids and modalities less appropriate during
  recovery phase.
• b. Focus on loading of bone, muscle, tendons.
• c. Begin at the base of the kinetic chain.

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Treating Athletic Injuries

• Maintenance Phase
• Absence of pain
• Normal ROM
• No residual tissue damage
• Strength at 75 of normal
• Smooth function of entire kinetic chain

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Treating Athletic Injuries

• Maintenance Phase (Cont.)

Begin with return to play Continues through
athletes sport activity Subclinical Adaptation
Complex a. Technique b. Maintain Strength c.
Maintain ROM
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Treating Athletic Injuries

• Nirschl mentions three concepts to initiate a
  healing stimulus
• Enhancement of peripheral aerobics. (Oxygenation,
  nutrition, adequate peripheral circulation)
• Collagen induction, strengthening, and alignment
• Enhancement of biochemical changes associated
  with endurance training.