Introduction To Evaluation And Management Of Athletic Injuries

Shoulder Anatomy Outline

A. Joints/Articulations*/Prominences
1. Glenohumeral - GH

2. Acromioclavicular AC
3. Sternoclavicular SC 4. Scapulothoracic - ST - no ligament attachment to

the thorax* 5. Bicipital Groove a. Lesser Tuberosity b. Greater Tuberosity

B. Ligaments/Supporting Structures
1. Capsule - surrounds the glenohumeral joint

2. AC Ligament
3. Coracoclavicular Ligament 4. Coracoacromial Ligament 5. SC Ligament 6. Glenoid Labrum

C. Muscle Function RE: Text D. Blood and Nerve Tissue 1. Subclavian artery 2. Brachial Plexus
E. Subdeltoid Bursa F. Scapulohumeral Rhythm : 2-1 ratio

G. Force or Depressor Couple Muscles

1. Subscapularis - Internal Rotator

2. Teres Minor - External Rotator

3. Infraspinatus - External Rotator

H. Rotator Cuff or SITS Muscles

1. Supraspinatus 2. Infraspinatus 3. Teres Minor 4. Subscapularis

I. Serratus Anterior - Importance of J. Axillary Lymph Nodes

K. Structures to palpate
1. Sternoclavicular Joint

2. Clavicle
3. Acromioclavicular joint 4. Deltoid muscle 5. Spine of the scapula 6. Inferior angle of the scapula 7. Biceps tendon (Long head) / Bicipital Groove 8. Rotator Cuff / Greater Tuberosity 9. Lesser Tuberosity

L. Shoulder Injuries
1. Muscular-Tendon Injuries

A. Rotator Cuff Strains/Tears i. Drop Am Test ii. Centinela Test or Empty Can Test iii. Palpation iv. Impingement Tests B. Biceps Tendon Strain i. Palpation ii. Yergason Test (Subluxing Tendon) iii. Speeds Test

 2. Ligamentous/Joint Injuries

a. AC Sprain separation
i. Palpation ii. Distraction iii. Piano Key Sign (Grade 3 this is actually a dislocation)

iv. Difficulty in abduction

v. Mechanics

a. Direct blow b. Landing on apex of shoulder, head on blocking c. Falling on hand as in falling backwards

 b. SternoClavicular Sprain
i. Palaption, swelling, possible deformity ii. Can be dangerous due to translocation so this

should be

put in a sling and refered

iii Mechanism a. Direct blow b. Force down the long axis of the arm

 3. Brachial Plexus Injury

a. Brachial Plexus Stretch Test b. Mechanism i. Direct blow Ii. Forced abduction

4. Thoracic Outlet Syndrome a. Allen Test b. Adson Test

 5. Bone /Joint Injuries

a. Dislocation of Glenohumeral Joint i. Apprehension Test ii. Sulcus Sign b. Clavicular Fractures c. Humeral Fractures - Shaft can affect or severe the radial nerve d. Epiphyseal Fractures 6. Synovitis and Bursitis a. Muscle Atrophy b. Pain on Abduction and Rotation

M. Elbow Structures
1. Olecranon Process

2. Lateral Epicondyle
3. Medial Epicondyle 4. Ulnar Groove/nerve 5. Biceps Tendon 6. Brachial Artery 7. Flexor Tendon Origins 8. Extensor Tendon Origins

N. Elbow Injuries
1. Medial Epicondylitis (Little League- Elbow)

2. Lateral Epicondylitis (Tennis Elbow)

extension test 3. Olecranon Bursiffs 4. Dislocations - Posterior Displacement of Ulna 5. Osteochondritis Dissecans 6. Ulnar Nerve Entrapment 7. Collateral Ligament Spasm Valgus and Varus Tests

O. Hand Anatomy
1. Phalanges 2. Metacarpals

3. Carpals
4. Carpal Tunnel median nerve goes through 5. Tunnel of Guyon can fracture

6. Thenar Eminence-fat pad &muscles (under thumb)

7. Hypothenar Eminence 8. Pisiform ulna side

9. Hook of Hamate
Scafoid/nevicular (snuff box-thumbs up)

base:radial & ulnar styloid

process

P. Injuries to the Hand, Wrist

1. Fractures a. "Snuffbox" or navicular b. Colle's Fracture c. Ulna or radius d. Hook of Hamate e . Smith Fracture f. Boxer's Fracture g. Bennetts Fracture

2. Soft Tissue Injuries a. Forearm Splints b. Nerve Entrapment. i. Ulnar Nerve - Tunnel Guyon ii. Median nerve - Carpal Tunnel Syndrome Phalen's Test iii. Bowlers thumb iv. Handlebar Palsy c. Tenosynovitis - Finkelstein Test d.Triangular Fibrocartilage Complex e. Subungual hemotoma

 3. Dislocations

a. Lunate (Kienbocks Disease) b. Proximal Interphalangeal Joint (PIP) c. Accompanying problems i. Volar Plate and collateral-ligament damage ii. Game keepers thumb - ulnar collateral ligament of the mcp joint of the thumb 4. Tendon Injuries a. Tendinitis b. Mallet Finger - distal extensor tendon c. Jersey Finger - distal flexor tendon d. Boutonniere Deformity - central slip or extensor tendon of the middle phalanx

Q. Rehabilitation for upper extremity

1. Deltoid Sets

2. Codman's & Sawing

3. T's 4. Wall ladder 5. Towel stretch / T bar 6. Shoulder Wheel 7. Dumbbells - shoulder flex/ext and int/ext

rotation 9. Surgical Tubing 10. Hand gripping/ball squeezing/ finger extensions

Introduction To Evaluation And Management Of Athletic Injuries

Lower Leg, Foot and Ankle

A. Anatomical Structures
1. Bony Structure

a. Talus b. Calcaneous c. Navicular, Cuboid & Cuneiform d. Tibia - weight bearing e. Fibula - non-weight bearing f. Sesamoids 2. Articulations a. Talo-Tibial or talocrural is the true ankle joint Plantarflexion & Dorsiflexion b. Talo-Calcaneal or sub - talar - Inversion & Eversion c. Mid Tarsal - Forefoot Abduction & Adduction d. Tarsometatarsal - slight flexion and extension; some rotation e. Metatarsal & Phalanges - Flexion & Extension

A. Anatomical Structures
3. Ligament & Tissue Support

a. Lateral Collaterals 1. Tibio-Fibular Ligament or Syndesmosis (High ankle sprain) 2. Anterior Talo-Fibular Ligament 3. Calcaneo-Fibular Ligament * The names identify the bones they connect b. Plantar Fascia c. Medial 1. Deltoid 2. Plantar Calcaneonavicular or spring ligament

A. Anatomical Structures
4. Arches of the Foot

a. Medial Longitudinal - Most significant b. Lateral Longitudinal c. Anterior Metatarsal d. Transverse 5. Arteries a. Dorsal Pedal b. Posterior Tibial 6. Nerves a. Posterior Tibia b. Superficial & Deep Peroneal Nerve

B. Movements
1. Dorsiflexion - Anterior Tibialis

2. Plantarflexion - Gastrocnemius (Power

muscle) & Soleus (anti-way while standing)

Flexed Knee vs. Extended Knee

3. Inversion - Posterior Tibialis 4. Eversion - Peroneal Longus & Brevis

5. Toe Flexors & Extensors

6. Pronation - eversion, dorsiflexion, and

abduction 7. Supination - inversion, plantarflexion, and

C. Deformities
1. Pes valgus - pronated

2. Pes Varus supinated

3. Pes Cavus - high arch 4. Pes planus - flat arch 5. Pes Calcaneus - toe off the ground 6. Pes Equinus - heel off the ground 7. Hallux Valgus - lateral deviation of the toe

(bunion)

D. Normal function during gait

1. Heel Strike

2. Mid Stance - foot pronates and becomes rigid

*Adaption to the surface takes place 3. Heel off - foot supinates; weight moves across metatarsal heads the big toe 4. Toe off; plantarfascia becomes tight along with strong flexion of the big toe

E. Common Injuries
1. Acute

a. Heel & Instep Bruise b. Inversion Sprain c. Plantar Fascia Strain d. Fractures 1. Base of the Fifth Metatarsal/Avulsion Fx 2. Medial Malleolus 3. Tibial Fractures 4. Fibular Fractures 5. Jones Fx e. Achilles Tendon Rupture f. Peroneal Dislocation/Subluxation g. Turf Toe h. Compartment Syndrome *Anterior Compartment i. Eversion sprain

E. Common Injuries
2. Chronic Injuries

a. Sesamoiditis b. Calluses, blisters c. Achilles Tendinitis d. Medial Longitudinal Arch Strain e. Calcaneal Bursitis f. OS Trigonum g. Bunions h. Interdigital Norm i. Mortons Toe j. Severs Disease k. Plantarfascitis l. Cuboid Syndrome m. Shin Splints - Generic 1. Posterior Tibialis Inflammation/Strain 2. Anterior Tibialis Strain 3. Interosseous Membrane 4. Stress reaction/Fx to the tibia

F. Injury Management
1. Acute

a. Ice b. Compression c. Elevation d. Immobilization and Rest 2. Chronic a. Ice b. Reduced Activity c. Stretch & ROM Activities d. Anti-Inflammatories *Surgery could be indicated at any one point with some injuries

G. Ankle Stability Tests

1. Anterior Drawer 2. Talar Tilt

3. Thompson Test
4. Kleiger Test

H. Rehabilitation Techniques
1. Stretching

2. Strength Training
3. Proprioception

I. Return to Activity
1. Bilateral Strength 2. Bilateral Range of Motion

3. Functional Testing

Introduction To Evaluation And Management Of Athletic Injuries

Knee Anatomy and Related Injuries

A. Bone Structures
1. Femur

2. Tibia
3. Fibula 4. Patella

B. Articulations
1. Tibio - Femoral

2. Patello - Femoral

C. Stabilizing Structures
1. Medial Collateral Ligament

a. Superficial b. Deep Capsular 2. Lateral Collateral Ligament 3. Anterior Cruciate Ligament 4. Posterior Cruciate ligament 5. Joint Capsule

D. Cartilage tissue
1. Menisci

a. Lateral Meniscus b. Medial Meniscus 2. Hyaline Cartilage

E. Bursa
1. Suprapatellar

2. Prepatellar
3. Infrapatellar 4. Pretibial 5. Gastrocnemeus

F. Fat Pads
1. Infrapatellar

2. Suprapatellar
3. Popliteal

G. Movements
1. Extension

a. Rectus Femoris b. Vastus lateralis c. Vastus Intermedialis d. Vastus Medialis 2. Extenal Rotation - Biceps Femoris 3. Internal Rotation - Poptiteal 4. Flexion a. Biceps Femoris b. Semitendinosus c. Semimembranosus d. Gastocnemius - Small Role

H. Common Knee Injuries

1. Ligament Sprains/Tears

a. Medial Collateral b. Anterior Cruciate c. Posterior Cruciate d. Lateral Collateral 2. Bursitis a. Pes Anserine b. Pre-Patellar c. Housemaids Knee or Pre-tibial d. Popliteal 3. Quadriceps injuries a. Strains or tears b. Myositis ossificans 4. Cartilage or meniscal tears

H. Common Knee Injuries

5. Patellar Injuries

a. Fracture b. Tracking irregularities leading to PatelloFemoral Syndrome i. Irregular Patella ii. Weak oblique portion of vastus medialis iii. Increased Q angle iiii.Tight lateral Retinaculum iv. Foot pronation causing valgus displacement c. Dislocation

 6. Tendonitis a Patellar Tendon - Jumper's Knee b. Biceps Femoris c. Semitendinosus

 7. Muscle Strains a. Hamstrings b. Quadriceps c. Popliteus d. Gastrocnemius Heads 8. Joint mice & Loose Bodies 9. IliotibiaI Band Syndromes 10. Osgood - Schlatter Condition 11. Larson - Johansson Condition

I. Knee Structure
1. Stress-Tests

a. Valgus Stress Test - MCL b. Varus Stress Test - LCL c. Apley Distraction Test

J. Cruciate Ligament Tests

1. Anterior Drawer Test - ACL 2. PostenorDrawerTest- PCL 3. Lachman Test - AC

K. Cartilage Damage
1. McMurray

2. Joint Line Palpation

3. Apley Compression

L. Rehabilitation - Refer to lab manual

Introduction To Evaluation And Management Of Athletic Injuries

Hip, Low Back and Pelvis Anatomy

I. A. Important musculoskeletal anatomical points

1. Greater trochanter 2. Pubic symphysis 3. Anterior superior spine of ilium (ASIS) 4. Ilio femoral articulation 5. Sacroiliac articulation 6. Lumbosacral articulation 7. Posterior superior iliac spine 8. Iliac crest 9. Inguinal crease 10. Abdominals 11. Erector spinae 12. Ischial Tuberosity

B. Alignment
1. Pelvic tilt

2. Pelvic obliquity a. Leg length discrepancy b. Coxa Vera/Valga c. Muscle weakness e.g. Gluteus Medius 3. Anteversion and retroversion

II. A. Hip and Pelvis Sprains- not very

common
1. Sacroiliac - acute pain over the joint

Test: Pelvic Rock / Compression 2. Pubic Symphysis- acute pain over the joint Test: Contracting Abdominals / sit-ups are painful or impossible 3. Iliofemoral - acute pain throughout hip region Test: Inability to circumduct

B. Low Back Pain

1. Disc related 2. Soft tissue compression/nerve root compression

a. excessive lordosis b. weak abdominals / poor posture c. overweight d. tight hip flexors - Thomas test e. tight hamstring - Straight leg raising test 3. Structural abnormalities a. spina bifida b. spondylolysis / Spondylolisthesis c. leg length discrepancies d. Scoliosis e. Scheuermann's Disease (Condition)

C. Groin Strains- abrupt stretching or

twisting
1. Hip adductors - most frequent of all groin

strains 2. Hip flexors - rectus femoris and iliopsoas

Must be resolved immediately or the injury

will haunt the athlete for the season.

D. I.T. Band Syndrome/Tensor Fascia Lata Tightness: Pain over lateral femoral
condyle
1. Ober Test

2. Nobel Test / Renee Test

E. Snapping Hip Syndrome - I.T.

Band "Snaps" over greater trochanter

F. Blows/contusions to the back and hip

1. Posterior Crest/Erector Spinae

2. Transverse and Spinous process fractures

3. Lateral/Anterior crest or Hip Pointer

G. Quadriceps Strain - abrupt stretching or

sudden contraction
1. Lack of range depending on degree 2. Point tenderness 3. Swelling could be evident

H. Hamstring Strain (Highest incidence of thigh muscle strains); usually injured while running during
the transition from "stabilizer to hip extender. 1. Lack of flexion ROM 2. Point tenderness 3. Possible swelling and/or defect

I. Iliofemoral Pathology
1. Legg - Calves - Perthes Disease 2. Slipped capital femoral epiphysis 3. Groin strains 4. Hernia a. Inguinal b. femoral 5. Posterior hip dislocation a. avascular necrosis b. sciatic nerve damage c. accompanying fracture 6. Anterior hip dislocation a. femoral artery damage b. accompanying fracture 7. Lymph inflammation

J. Low back rehabilitation

1. Williams flexion exercises - used for non-disc

related pathology 2. McKenzie extension exercises - used for disc related pathology 3. Herzog patterning both 4. Combinations - either / trial and error

McKenzie Low Back Exercises:

Prone Position

Individual extremities were extended one at a

time Contralateral extremitites extended simultaneously Trunk extended while pushing off floor Trunk only extended Legs/hips only extended Trunk, legs/hips extended simultaneously Standing back extensions

Cat Arch Patterning:

All fours position, hands under shoulders and

knees under hips Abdominals contracted and back is arched Each extremity extended individually Contralateral Extremity extended simultaneously

Williams Flexion 1. Pelvic Tilt 2. Knees to chest 3. Partial sit-ups 4. Single leg raises

Introduction To Evaluation And Management Of Athletic Injuries

Spinal Injuries

A. Immature Athlete and Related Injuries

1. Scoliosis - idiopathological condition of the spine which results in lateral

curvature. Early evaluation and treatment essential. Long term results in excessive rotation of the thorax.
2. Spina Bifida - defective closure of the vertebral arches of the spinal

column. Asymptomatic or neurological impairment from that vertebral level down. Low back pain, tight or weakened hamstrings Refer for orthopedic evaluation
3. Spondylos

a. Spondylolysis - fracture of the pars interarticularis (Scotty Dog Fracture) low back pain that does not resolve, tight hamstrings. Seen in gymnasts, football players, dancers and other athletes who repeatedly hyperextend the back b. Spondylolisthesis - bilateral Fx resulting in a potential for vertebral subluxation. Referral is necessary
4. Scheuermanns Condition - osteochondrosis of the spine or

degeneration of the epiphyseal endplates; increased kyphotic curve with

B. Things not to do with suspected spinal injuries

1. Never move the athlete until extent of injury is

determined 2. Never remove the football helmet 3. Never use ammonia capsules

C. Things to do with suspected spinal injuries

1. Stabilize head and then spine board 2. Call EMS 3. Never let go of the head 4. Provide access for CPR/Rescue breathing 5. Make a secondary survey of the athlete

D. Tests for neurological impingement

1. Compression

2. Distraction
3. Lateral bending

E. Things not to do with suspected spinal injuries

1. Never move the athlete until extent of injury is

determined 2. Never remove the football helmet 3. Never use ammonia capsules

F. Neck Excercises
Manual Resistance

Athlete is positioned supine

Resistance is applied during flexion Resistance is applied during extension Resistance is applied during lateral flexion

Introduction To Evaluation And Management Of Athletic Injuries

Head and Face

A. Bone Anatomy
1. Parietal Bone 2. Occipital Bone 3. Temporal Bone 4. Frontal Bone 5. Maxilla

6. Mandible
7. Mastoid Process 8. Zygomatic Arch

9. Orbit
10. Nasal Complex

B. Soft Tissue Anatomy

1. Auricle

2. Nasal Septum
3. Gum Line

C. Facial Injuries
1. Fractures

a. Nose - most frequent - alot of blood b. Mandibular Fracture - second most frequent direct blow c. Zygomatic Bone - third most frequent - visual problems may occur d. Maxilla - fourth most frequent - severe blow such as a hockey puck e. Floor of the orbit - also visual problems 2. Mandibular Dislocations 3. TMJ Syndrome 4. Lacerations - very bloody due to large number of capillaries in the face and scalp

D. Dental Injuries
1. Fractured Tooth

2. Dislocated Tooth

E. Ear Injuries
1. Hematoma Auris 2. Object in the ear 3. Pressure Injuries

F. Eye Injuries : 2% of all sports injuries

1. Orbital Hematoma ( p. 814)

2. Foreign body in the eye (p. 815)

3. Corneal Abrasion (p. 816) 4. Hyphema (p.816) 5. Blowout or trap door fracture (p. 815) 6. Retinal detachment (p. 817) 7. Conjunctivitis (p. 817) 8. Hordeolum sty or blepharitis (p. 817)

RE: page 700 for serious eye injury symptoms

General management of eye injuries

1. When to transport:
A. Any of the previously mentioned injuries B. Decreasing vision C. Loss of visual/peripheral field D. Poor pupil reaction/adaptation

E. Double vision
F. Laceration G. Impaired lid function.

1. How to transport
A. Recumbent position

B. Both eyes should be covered

C. Apply no pressure D. Possible cold application E. Monitor for concussion or other developing

issues RE: P. 814 for Eye management supplies

G. Concussion
1. Grades - categorize severity

2. Glasgow Coma Scale

H. Intracranial hemorrhaging
1. Epidural - arterial 2. Subdural venous 3. Intracranial - within the brain

I. Cerebral Contusion J. Skull Fracture K. Post-concussion Syndrome L. Second - Impact Syndrome M. Treatment/Assessment
NOTE:

1. Do Not Use Ammonia Caps !

2. Do Not Remove Helmet !

Refer to appropriate pages in the text.

Introduction To Evaluation And Management Of Athletic Injuries

Abdomen and Thorax

A. General Anatomy
1. Musculoskeletal

a. Sternum b. Xiphoid Process c. Ribs i. True ribs # 1 - 7 separate attachment ii. False Ribs # 8 - 12 common cartilage attachment iii. Floating Ribs # 11 & 12 no attachment d. Clavicle e. Abdominals f. Pectoral muscle g. Latissimus Dorsi h. Trapezius i. Diaphram 2. Organ a. Spleen b. Stomach c. Liver d. Bladder e. Appendix f. Kidneys g. Intestinal Tract h. Heart

B. Athletic Injuries
1. Thoracic Region

a. Rib Contusion b. Fractures: rib, sternal, clavicular c. Costocondal Separation/dislocation d. Intramuscular Strain: intercostals pectorals, abdomen, lats, traps e. Hemothorax and Pneumothorax f. Breast Injuries i. Coopers ligament ii. Runners nipple 2. Organ Injuries a. Spleen Rupture b. Kidney contusion c. Testicular Injuries i. contusion; hydrocele ii. spermatic cord torsion d. Bladder rupture; runners bladder e. Appendicitis 3. Soft tissue/systemic a. Hernia b. Solar Plexus Injuries c. Stitch in the side d. Hyperventilation e. Sudden Death Syndrome