dr.jack dolbin dc session 2 concepts of diagnosis of sports injuries site of injury truism “if you...
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Dr.Jack Dolbin DC Session 2
Concepts of Diagnosis of Sports Injuries
Site of injury
Truism “If you hear hoof beats don’t think zebras” You better eliminate the zebras first: Dolbin
Priorities
“The best things in life are not things” Harry Bertsch Hermy Bavier Ron Boris Amanda Driscoll Josh Bertsch Dad
Dr.Jack Dolbin DC Session 2
Ron Boris
Dr.Jack Dolbin DC Session 2
Concepts of Diagnosis of Sports Injuries Cause as it relates to exceeding the tensile
strength of the tissue
Fracture dislocation
Dr.Jack Dolbin DC Session 2
Concepts of Diagnosis of Sports Injuries
Biomechanical concepts of causation
Motion deficits as major causative factor If dysfunction alters the efficiency of the musculoskeletal
system, there is an increase demand for energy. Not only for increased activity but for normal activity.
Increase demands on the cardiovascular system
Observation “Where observation is concerned, chance favors only the
prepared mind.” ~ Louis Pasteur
Dr.Jack Dolbin DC Session 2
Evaluation of the Kinetic Chain Lower limb: Ankles, Knees, and hips
Upper limb: Core Stability, Endurance, Balance, Range of Motion
Scapula: Stability, Rhythm
Shoulder: Clinical examination
Dr.Jack Dolbin DC Session 2
Concepts of inflammation and repair
Inflammation
Tissues respond to injury with a set of genetically programmed mechanisms to replace the damaged components and to restore normal function.
Inflammation and RepairCardinal signs of inflammation Heat Swelling Pain Redness Loss of Function
Two types of Inflammation: Acute
Chronic
Acute Inflammation Chronic Inflammation
Dr.Jack Dolbin DC Session 2
Inflammation and Repair
Characterized by the release of chemical mediators by mast cells,platelets and basophils at the site of the injury.
Vasoactive mediators regulate the vascular response to the injury and affect the recruitment of PMN’s from the vascular component.
These in turn produce chemotactic factors that control the damage and remove debris by phagocytosis.
Acute Inflammation:
Granulation Tissue: Lead to the restoration of the vascular supply and connective
tissue matrix. Chronic Inflammation is the result of unresolved acute
inflammation
In the case of sports related injuries removal of the trauma and successful management of the injury may result in the reduction of fibrosis and restoration of normal function.
Dr.Jack Dolbin DC Session 2
Inflammation and Repair
Repair: The repair phase of healing ideally result in the restoration of normal
living tissue. Repair by regeneration of injured tissue Repair by second intention is characterized by the formation of scar
tissue at the site of the injury.
Remodeling and Maturation
Process begins about 6 days after the fibroblasts begin to lay down collagen tissue.
Collagen is laid down randomly initially
Depends on the appropriate mechanical loading.
The hallmark of remodeling is the orientation of new fibers
Dr.Jack Dolbin DC Session 2
Inflammation and Repair Immobilization of a healing wound has been shown to compromise
wound strength as a result of the failure of collagen to be oriented along lines of stress.
Mobilization and loading has been shown to result in stronger healed tissue.
Time Frame of Healing:
Inflammation Phase is relatively brief. 24-48 hours.
Proliferative Phase: 3-7 days after the injury
Repair Phase: Few days to a few weeks
Remodeling Phase: Several months and may continue up to 12 months.
Inflammation and RepairRepair Mechanisms in Soft Tissue Injuries:
Muscle Tissue: Healing of skeletal muscle is dependent on the integrity of the
vascular system and nervous system
Has considerable regenerative properties
Both regeneration and repair by scar tissue.
Capacity for regeneration is determined genetically but the success is determined primarily by the extent and type of injury.
Except for injuries in which the continuity of the muscle fiber is preserved, and the innervation, vascularity and extracellular matrix muscle will regenerate with a loss of normal tissue architecture and function.
Most muscle injuries are a result of exceeding the tensile strength of the tissue and are labeled indirect muscle injury.
Inflammation and RepairMuscle Strain Injuries:Consists of a partial or complete tear at or near the musculotendinous
junction.
When the force is sufficiently high the tendon has been shown to avulse from the muscle with only a few fibers left intact.
The greater the amount of injured tissue involved the more scar tissue with be deposited at the sight of the wound.
Ischemia- Induced Muscle Damage: Usually seen in compartment syndromes. Results from damage to vessels causing
ischemic injury.
Seen in exhaustive endurance activities. Extent of the injury is proportional to the duration of the pressure. Nerve injury may result as a result of increase pressure. Healing will be achieved with little or no damage if the damage is limited to
individual fibers and blood supply is restored without delay. Can result in significant scar tissue formation if delayed resulting in excessive
cell death.
Concepts of treatment: Modalities Cyriax Joint Mobilizations Muscle Energy Laser therapy Immobilization. Chiropractic Adjustments
Concepts of rehabilitation: Goals Necessary training Necessary equipment Isotonic exercise Repetitive motion Stability ball
Rehabilitation of most common athletic injuries Rehabilitation concepts:a. Injury prevention vs. Injury causation.
Dr.Jack Dolbin DC Session 2
Rehabilitation and return to competition: Daily Function Demands of the Sport
Incidence of injury according to the American Journal of Sports Medicine
Football players in a 5 year program at the Div. 1 level have a 100% chance of being inured
High School: 50-80% Swimming: 50% men 70% women will develop shoulder
problems. Jogging, running: 60% Tennis: 60% Musculotendinous overload injuries
Dr.Jack Dolbin DC Session 2
Duration of Injury Tri-athlete: 30 days
Cyclists: 2 weeks
Swimming: 2 weeks
Runners: 40 days
Predictor of Injury No previous injury: 40 % chance
of experiencing a sports related injury
Previous Injury: 65% chance of a re-injury in the Kinetic chain
a. Mostly due to incomplete rehabilitation
b. Rehab stopped at
symptom reduction.
Dr.Jack Dolbin DC Session 2
1. Return to Function is the key not simply symptom reduction
– Establish an accurate diagnosis– Minimize the local effects of acute injury
Goals of Rehabilitation:
1. Return to Function
2. Allows for proper healing
3. Maintaining the other components of athletic fitness
4. Return to Normal Competition
Dr.Jack Dolbin DC Session 2
Effects of Immobilization: For each week of immobilization there is a 20% loss of strength in joint.
Effects of Immobilization
0
20
40
60
80
100
1 2 3
Weeks Immobile
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Type 1 fibers are most affected Cartilage deterioration, bone and ligament strength loss and
increased stiffness. Rehabilitation can counteract these changes by introducing
motion with protection and loading.
Goals of Rehabilitation:2. Allows for proper healing
Protects Tissue Use of Physical Treatment Modalities:
Cold, Heat, Electricity, Laser Use predicated on accurate diagnosis Understanding of the biophysics of the modality
3. Maintaining the other components of athletic fitness
a. Strength
b. Flexibility
c. Aerobic Conditioning
4. Return to Normal Competition Baseline established in Preseason Physical
1. Begin graded return if no baseline established
2. Increase volume and intensity incrementally
Dr.Jack Dolbin DC Session 2
What are we Rehabilitating? Dx. more than the site of the injury!
Kinetic Chain
Classification of Injury 1. Acute Injury: Normal anatomy and normal physiology
followed by abnormal anatomy and abnormal physiology.
a. One-Time microtrauma.
2. Chronic Injury: Building up for a period of time.
a. Represents the tip of the iceberg of entire derangement of physiology
3. Repetitive microtrauma overload:
a. Rotator Cuff Tendonitis
b. Plantar fascitisc.
c. Achilles Tendonitis
Dr.Jack Dolbin DC Session 2
Adaptation Body adapts over a period of time to chronic injuries. The Dx must
look for these adaptations:– Weakness and tightness in gastrocnemius in Achilles tendonitis– Elbow tendonitis : tightness of wrist extensors– Rotator Cuff tendonitis: Infexibility in posterior RJC muscles and
weakness in scapular stabilizers and post cuff muscles.
Note: Entire Kinetic Chain must be searched and evaluated
Acute exacerbation of a chronic injury: Result from symptomatic treatment leading to return to athletic activity. Results in a recurrence of previous symptoms or new symptoms as a result of acute injury in kenetic chain.
1. Ankle Sprain
- return to competition- Groin strain
2. Rotator Cuff tendonitis
- return to competition- lateral epicondylitis
Dr.Jack Dolbin DC Session 2
Adaptation
Injections cause very poor healing and a return of symptoms with activity
Chronic Adaptations
1. No overt symptoms
2. Pattern of abnormalities that lead to decreased function and performance
Dr.Jack Dolbin DC Session 2
Negative Feedback Vicious Cycle
Functional Biomechanical
Deficit Complex
Tissue Injury
Complex
Clinical Symptom Complex
Tissue Overload Complex
Sub-clinical Adaptation Complex
Dr.Jack Dolbin DC Session 2
1. Tissue overload complex
a. Failure of Tensile strength
b. Subject to microtrauma
2. Tissue Injury complex
a. Disrupted
b. Producing Symptoms
Negative Feedback Vicious Cycle
3. Clinical Symptom Complex
Pain
4. Functional Biomechanical Deficit Complexa. Decreased flexibilityb. Decreased Strengthc. Muscle imbalances
Negative Feedback Vicious Cycle
5. Sub-clinical adaptation complex a. Activities the athlete uses to compensate for altered mechanics.
1. Running on the outside of foot to compensate for heel pain.
2. Over reaching in swimming to compensate for decreased ROM in the low back
1. Tissue overload complex
Cycle begins again