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Notes on Sports Medicine_Punita V. Solanki

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Notes on Sports Medicine_Punita V. Solanki

  1. 1. Disclaimer The occupational therapy undergraduate notes have been prepared by Ms. Punita V. Solanki (Ex- Assistant Professor, Occupational Therapy School and Centre, Seth G. S. Medical College and King Edward VII Memorial Hospital, during her teaching tenure) as per the Maharashtra University of Health Sciences University curriculum requirements, between the years 2001 and 2012 and the references of the textbooks have been listed at the beginning or the end of each topics. Occupational therapy students are directed to refer the latest editions of the listed references or additional references to upgrade the latest information for the concerned topics and keep up-to-date with the latest evidence-based practice literature. However, these notes will be useful guide for preparing updated notes as per the latest syllabus requirements set by the concerned university. For further information may contact Ms. Punita V. Solanki. MSc (OT); Fellow ACOT, ADCR (Mumbai) ֍ www.orthorehab.in
  2. 2. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 1 of 10 Advances in Occupational Therapy and Rehabilitation Medicine: Course Content: (Revised Syllabus): No. 10: Introduction to sports medicine - common sports injuries, assistive, adaptive equipment, splints & adaptation methods, and role of occupational therapist in return to sports & athletic activities. (8 hrs) References: 1. Clinical Sports Medicine by Peter Brukner & Karim Khan. Third Edition. 2007. The McGraw-Hill Companies. 2. Therapeutic Exercises ~ John V. Basmajian. Fifth Edition.1990. Williams & Wilkins. Chapter 16: Exercise in Sports Medicine by Terry R. Malone. Page 323-332 3. Rehabilitation Medicine: Principles and Practice by Joel A. DeLisa, Bruce M. Gans. Third Edition. 1998. Lippincott-Raven Publishers. Chapter 63: The Physiatric Approach to Sports Medicine by Jeffrey L. Young et.al. Page No.1599 to1625 4. Krusen’s Handbook of Physical Medicine & Rehabilitation by Frederic J. Kottke. Fourth Edition. 1990. Published by W. B. Saunders Company. Chapter 54: Physiatry in Sports Medicine by James C. Agre. Page No. 1140 to 1153 5. Therapeutic Exercise: Foundations and Techniques ~ Carolyn Kisner, Lynn Allen Colby. Fifth Edition. Jaypee Brothers. 6. Orthopedic Taping, Wrapping, Bracing & Padding by Joel W. Beam. F. A. Davis Company. Indian Reprint by Jaypee Brothers. First Indian Edition 2007 7. Indian Association of Sports Medicine: http://www.iasm.co.in/index.html
  3. 3. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 2 of 10 Introduction to Sports Medicine: Sports medicine is a much greater entity than sport plus medicine. Sports medicine is the holistic care of the athlete during the pursuit of an active life style. “Sports” and “Sports Medicine” are far from 20th century terms. Evidence of development of the sport of wrestling dates as far back as 2500 B.C. and most ancient civilizations had some forms of loosely organized recreational activities. The first Olympic games featured wrestling, chariot racing, boxing, pentathlon and running events. America’s introduction to sports medicine occurred in the 19th century. Edward Hitchcock, an instructor in physical education at Amherst College is considered America’s first sports physician. At that time sports physicians were professionals who interacted with athletes but who did not have a significant scientific basis of their injury management. Analysis of exercise performance and the physiological makeup of elite athletes were implemented by Dr. D. B. Hill and his associates at Harvard in the 1920s. Following the Second World War sports and recreation became an important factor in the rehabilitation of injured soldiers as well. In 1954 the American College of Sports Medicine, a multidisciplinary organization of basic scientists and clinicians dedicated to sports medicine was formed. The American Orthopaedic Society for Sports Medicine was formed by the American Academy of Orthopaedic Surgery in 1972. Indian Association of Sports Medicine (IASM) was established in 1971 at National Institute of Sports, Patiala. The headquarter of IASM is situated at J.N. Stadium, New Delhi. The aim of IASM is to have a better interaction between different categories of sports scientists. Sports Musculoskeletal Injuries are not uncommon and the causes are multifactorial. Some are benign and self-limiting and little is required besides routine medical care and advice; others become chronic and present complex therapeutic challenges. Optimal management, especially for patients with associated comorbidities, requires a multidisciplinary team to simultaneously address the physical condition, the underlying psychological processes and the social milieu of the athlete. The most appropriate sports medicine multidisciplinary team depends on the setting. The sports medicine team may consist of a family physician, sports physician, orthopaedic surgeon, radiologist, physical therapists, occupational therapists and other rehabilitation specialists such as nurse, orthotist, osteopaths, chiropractors, biomechanists, optometrists etc, podiatrist, sports nutritionists, sports psychologists, exercise physiologists, sports trainer or an athletic trainer, coach and a fitness advisor.
  4. 4. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 3 of 10 Multiskilling: The sports medicine team practitioners have each developed skills in a particular area of sports medicine but the practitioner should be encouraged to increase their knowledge and skills in areas other than the one in which they received their basic training. This Multiskilling is particularly important if the practitioner is geographically isolated or is travelling with the sporting teams. All sports medicine practitioners should have a solid understanding of anatomy, biomechanics, exercise physiology and a firm grasp of the physiological and musculoskeletal demands that various sports place on the athlete’s body. The sports medicine model: In the traditional medical model the physician is the primary contact practitioner with subsequent referral to other medical and paramedical practitioners but the sports medicine model is different. The athlete’s primary medical contact may be with a physician or may be a trainer, physical therapist or the massage therapist. Because the athlete usually present to the practitioner with whom they have the best relationship or are more accustomed to meeting, it is essential that all practitioners in the sports medicine team understand their own strengths and limitations as well as are aware of other team member’s role, thus offering timely referral and management of the athlete. Sports medicine is the delivery of comprehensive health services to individuals for whom vocational or avocational physical activity is an important component of life. It includes evaluation and treatment of competitive and recreational athletes, from young to elderly, the able bodied and disabled. It includes providing medical coverage by all the professionals at the athletic events, pre-participation physical examination screening for the presence of conditions that jeopardizes safe participation in athletic event and educational programs geared towards injury prevention. The sports therapist bridges the gap from the clinic to the practice field and the performance arena. Sports therapy requires attention to detail and the demands of activity. Prevention and performance enhancement are just as critical to the sports therapists, as the normal return of functional levels following injury. The athletic care can be best summated by the mnemonic “SAID” i.e. Specific Adaptation to Imposed Demands. Love thy sport: To be a successful sports medicine practitioner it is essential to know and love sport and to be an advocate of physical activity. A good understanding of a sport and exercise confers two advantages. Firstly if the practitioner understands a particular sport, then it will improve his/her understanding of possible causes of injury and also facilitate development of sports specific rehabilitation programs. Secondly it will result in the athlete having increased confidence in the practitioner. The best way to understand the sport is to attend both training and competition or to actually participate in the sport.
  5. 5. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 4 of 10 Classification of Common Sporting Injuries: SNo Site Acute Injuries Overuse Injuries 1. Bone Fractures, Periosteal contusion Stress fractures, bone strain, stress reaction, osteitis, periostitis, apophysitis e.g. Osgood Schlatter’s Disease, Sever’s Disease 2. Articular Cartilage Osteochondral fractures, Chondral fractures, minor Osteochondral injury Chondropathy e.g. softening, fibrillation, fissuring, chondromalacia 3. Joint Dislocation, Subluxation Synovitis, Osteoarthritis 4. Ligament Sprain/Tear Grades I to III Inflammation 5. Muscle Strain/Tear Grades I to III, Contusion, Cramp commonly seen of calf and thigh muscles, Acute compartment syndrome Chronic compartment syndrome, delayed onset muscle soreness (DOMS), focal tissue thickening/fibrosis 6. Tendon Tear; complete or partial Tendinopathy; paratenonitis, tenosynovitis, tendinosis, tendinitis, chronic tears 7. Bursa Traumatic bursitis Activity induced overuse bursitis 8. Nerve Neuropraxia Entrapment, Minor nerve injury/irritation, adverse neural tension 9. Skin Lacerations, Abrasions, Puncture wounds Blisters, Calluses Acute Injuries: may be due to extrinsic causes such as a direct blow either as a result of contact with another player or equipment, indirect twisting injury or axial loading, suboptimal sporting surfaces or protective equipments etc or intrinsic causes such as ligament laxity or muscle weakness or tightness, faulty technique etc Overuse Injuries: commonly result from sports activities, especially of the endurance type and may account for half of all sports injuries. The common etiologic factor of all overuse injuries is repetitive microtrauma that
  6. 6. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 5 of 10 exceeds the tissue’s ability to repair itself. Factors leading to overuse injuries have been divided into intrinsic and extrinsic categories by Renstrom and Johnson. Intrinsic factors: are malalignment e.g. excessive pronation of foot, pes planus, pes cavus, rear foot varus, tibia vara, tibial torsion, genu valgum or varum, patella alta, excessive femoral neck anteversion, due to some other structural orthopaedic causes etc, leg length discrepancy, muscular imbalance, muscular weakness, poor flexibility, inappropriate participation with respect to gender, age, size and body composition, poor technique, health factors such as genetic or metabolic or endocrine conditions. Poor technique is not an uncommon cause of injury often seen in running or swimming. For instance in breast strokers improper technique for the whip kick have been reported to cause medial knee pain. Extrinsic factors: are training errors e.g. rapid increases in time, overdistance, sudden change in the type of sports, repetitions/excessive volume, excessive intensity, hills, faulty technique, excessive fatigue, inadequate recovery etc, Surfaces such as hard, soft, canted/cambered, inappropriate footwear and equipment, suboptimal environmental conditions, psychological factors, inadequate nutrition. For instance Running injuries often occur due to increasing the time spent running, increasing the distance of the run, or the intensity of the run. Changing the surface upon which one runs or running on a slanted surface may also lead to overuse injuries by increasing the ground reactive forces or altering the biomechanics. Relationship of technique faults in various sports leading to injuries: S.No Sport Technique fault Injury 1. Tennis Excessive wrist action with backhand stroke Service contact made too far back i.e. ball toss not in front Extensor Tendinopathy (lateral epicondylitis) of elbow, Flexor Tendinopathy (medial epicondylitis) of elbow 2. Swimming Insufficient body roll, Low elbow on recovery, insufficient external rotation of the shoulder Rotator cuff tendinopathy 3. Diving Shooting at the water too early (backward dives) Lumbar spine injuries 4. Cycling Incorrect handlebar and seat height, Toe-in/Toe-out n cleats Thoracic/Lumbar spine injuries Iliotibial band/patellofemoral syndrome
  7. 7. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 6 of 10 5. Weightlifting (Olympic) Bar position too far in front of the body in clean phase/jerk phase Lumbar spine injuries Sacroiliac joint injury 6. Weightlifting (Power lifting) Grip too wide on bar in bench press Toes pointing forward on squatting Pectoralis major tendinopathy Patellofemoral syndrome/medial meniscus injury 7. Javelin Elbow dropped Poor hip drive Medial elbow pain Thoracic/Lumbar spine dysfunction 8. Triple jump Blocking on step phase Sacroiliac/Lumbar spine injuries, patellar tendinopathy, sinus tarsi syndrome 9. High jump Incorrect foot plant Patellar tendinopathy Sinus tarsi syndrome Fibular stress fracture 10. Pole vault Too close on take off Late plant Lumbar spine injuries e.g. spondylolysis Ankle impingement, Talar stress fracture, shoulder impingement 11. Running Anterior pelvic tilt Poor lateral pelvic control Hamstring injuries Iliotibial band friction syndrome 12. Cricket bowling Mixed side-on/front-on action Stress fracture pars interarticularis 13. Baseball pitching Opening up too soon Dropped elbow ‘hanging’ Anterior shoulder instability, Medial collateral ligament sprains of elbow, Osteochondritis radiocapitellar joint Rotator cuff tendinopathy 14. Gymnastics Excessive hyperextension on landing Tumble too short (not enough rotation) Stress fracture pars interarticularis Anterior ankle impingement 15. Rowing Change from bow side to stroke side Stress fracture ribs
  8. 8. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 7 of 10 16. Ballet Poor turnout Sickling en pointe Hip injuries, Medial knee pain Stress fracture second metatarsal Evaluation and management plan: The focus of evaluation is to identify the injury, grade its severity and formulate a multidisciplinary management plan to return the athlete to the sporting activity as soon as possible. Therapists approach towards an athlete’s rehabilitation is based on various models or frames of references such as biomechanical, ergonomic, rehabilitation, behavioral, learning, occupational adaptation, sensory motor etc. Evaluations are done prior to injury for fitness level assessment for injury prevention and after injury for injury management. Evaluations are done of the athlete, other athletes and the environment • Identifying the injury and the cause of injury involves taking a careful history which includes chronology of the injury, mechanism of injury, nature of pain, injury inventory, age consideration, exercise habits, equipment used, exercise environment, review of systems and coping skills, performing a thorough general and local clinical examination including injury specific and region specific specialized tests and examinations and conducting relevant investigations. • Grading the injury involves assessing the level of disability in relation to the athlete’s ability to return to sporting activity, as well as his or her occupation and role in the community. • A multidisciplinary management plan is developed with the athlete, sports physician, physical therapist, exercise physiologist, sports psychologist, occupational therapist, nurse, sports nutritionist, podiatrist and orthotist and other sports medicine team members as and when required. Management plan has two components: Treatment of the presenting injury and treatment to correct the cause of injury whilst meeting the specific needs of the athlete. A template for analysis and rehabilitation of musculo-tendinous overload injuries: Step 1: Establish an accurate diagnosis: a. Tissue injury complex: the area of actual tissue disruption b. Clinical symptom complex: the symptoms associated with the dysfunction and injury c. Tissue overload complex: the tissue group being subjected to tensile overload d. Functional biomechanical deficit: inflexibilities and/or muscle strength imbalances that create altered mechanics e. Subclinical adaptation complex: functional substitutions used by the patient in order to try to maintain activity. Step 2: Acute Management based on PRICER principle
  9. 9. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 8 of 10 Step 3: Initial Treatment Step 4: Correction of Imbalances Step 5: Rehabilitation for return to normal functions Principles of injury prevention: An important role for the sports medicine practitioner is to minimize activity related injury, that is, to improve the benefit: risk ratio associated with the physical activity and sport. Sports injury prevention can be characterized as being primary, secondary and tertiary. Often Prevention in sports is synonymously used with what is technically known as Primary Prevention. Primary prevention includes health promotion and injury prevention e.g. ankle braces being worn by an entire team, even those without previous ankle sprain. Secondary Prevention can be defined as early diagnosis or reduce the risk of reinjures, in sports it is referred as Treatment e.g. RICE treatment of an ankle sprain. Tertiary Prevention is the focus on Rehabilitation to reduce and/or correct an existing disability attributed to an underlying disease e.g. wobble board exercise for an ankle sprain for graduated return to sport after the initial treatment of sprain. Factors that may assist in the prevention of injury are: (Primary Prevention) 1. Warm up for preparing the body for active sports training or participation 2. Stretching to develop optimal flexibility required for sports participation 3. Taping and Bracing for protection and restricting undesired motion, correcting/restoring the biomechanics of static/dynamic postures 4. Protective equipment such as helmets, mouth guards, shoulder pads, elbow pads, wrist guards, knee pads etc to shield various body parts against injury without interfering with sporting activity. 5. Suitable equipment with respect to age, gender, techniques, type & level of sports participation e.g. running shoes, football boots, ski boots, tennis racquets etc 6. Appropriate surfaces to offer optimal ground reaction forces and shoe surface friction 7. Appropriate training based on correct biomechanics of sports, appropriate training methods and principles of training such as periodization, specificity, overload, individuality, reversibility etc 8. Adequate recovery to minimize DOMS and prevent overuse injuries 9. Psychology: Mental imagery techniques for better participation and motivation, adequate arousal, concentration and attention, reaction time etc 10. Optimal/Adequate nutrition with respect to age, gender and sports requirements and the timing of sporting or training phases.
  10. 10. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 9 of 10 Role of an occupational therapist & other sports medicine team professionals in return to sports & athletic activities; as a team approach: Phases of Rehabilitation: 1. Acute or Initial Treatment Phase (Secondary Prevention) 2. Subacute or Intermediate Treatment Phase (Secondary Prevention) 3. Supervised Progressive Exercise and Rehabilitation or Advanced Phase (Tertiary Prevention) 4. Return to Atheletic Activity & Competition Acute or Initial Treatment Phase: The goals of this treatment phase are reducing pain, preventing further injury and minimizing hemorrhage and edema formation. The most important time in the treatment of acute soft tissue injuries is in the 24 hours immediately following injury. When soft tissue is injured, blood vessels are usually damaged too. Thus blood accumulates around damaged tissue and compresses adjoining tissues, which causes secondary hypoxic injury and further tissue damage. Consequently every effort should be made to reduce bleeding at the site of injury. The most appropriate method of doing this by a. PRICER principle: (Protect from further damage, Relative/Active Rest, Icing, Compression, Elevation and Referral to the concerned team member of sports medicine team) b. Immobilization by splints, orthotics and early protected mobilization involving gentle active and active assisted movements with dynamic splints, continuous passive motion machines. c. Therapeutic drugs such as analgesics (topical or oral) e.g. NSAIDs, Corticosteroids, and other agents including glyceryl trinitrate, sclerosing therapy, glucosamine and chondroitin sulfate, prolotherapy, hyaluronic acid therapy, local anesthetic injections etc d. Cryotherapy. Subacute or Intermediate Treatment Phase: The promotion of the reparative processes is the goal of this phase of treatment whilst great care is taken to avoid further damage to the injured tissues. This phase includes gradual & careful mobilization which is very essential in the athlete’s treatment program. The use of protected mobilization/therapeutic exercises facilitates the healing process whereas lack of exercise may lead to permanent disability. The optimal conditions for healing depend on a balance between activity and protection of injury from stress. The therapy must be kept subalgenic at all times. Other methods of treatment included in this phase are as follows: a. Electrotherapeutic modalities and Heat Therapy b. Extracorporeal shock wave therapy indicated for non unions of fractures and tendinopathy
  11. 11. © Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for Fourth BOTh. Revised Syllabus Page 10 of 10 c. Manual therapy: joint mobilization, manipulation, traction, muscle energy techniques, myofascial release, neural stretching techniques etc d. Acupuncture e. Dry needling f. Hyperbaric oxygen therapy g. Surgery: Arthroscopic Versus Open Surgery and Post Surgical Rehabilitation. The timing of surgery post injury and type of surgery depends on the type & the extent of injury. Supervised Progressive Exercise and Rehabilitation or Advanced Phase: The goals of this phase of rehabilitation are to achieve complete return in flexibility, muscular strength and endurance, muscular speed and power, core strengthening, neuromuscular control including coordination, proprioception and balance or postural control, movement patterns and agility, sports specific skills and plyometric training, cardiorespiratory fitness, correction of abnormal biomechanics of sports and sports psychological training. This phase of progressive exercise program is known as sports conditioning phase wherein all aspects of fitness are taken care of before sports participation or pre competition activity. If the rehabilitation is inadequate the athlete is a. Prone to reinjury of the affected area b. Incapable of performing at pre injury standard c. Predisposed to injuring another part of the body. And the key to successful rehabilitation program includes a. Explanation/ Athlete Education b. Precise Exercise prescription based of exercise principles and athletic demands c. Making the most of the available facilities d. Beginning the rehabilitation program as soon as possible. Return to Atheletic Activity & Competition: This phase of the rehabilitation program begins when the athlete returns to competition. Return to competition is not initiated until the athlete has achieved complete recovery by sports conditioning program. This phase includes functional and biomechanical fitness testing of the athlete by standardized methods and equipments or testing machines and maintaining a high level of training to maintain the gains made in the earlier phase and reduce the risk of future injury. This phase involves work hardening based on ergonomic and biomechanical principles. Continuing the training and follow up assessment even after return to competition is mandatory for successful participation and continuing commitments to athletic activities. Only serious injuries may prevent the athlete from sports participation at competitive level.

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