OTPT 130 : Medical Rehabilitation Lectures 2 University of the Philippines Manila , College of Allied Medical Professions
REHABILITATION of SOFT TISSUE and SPORTS INJURIES
MICHAEL D . MAGPANTAY , PTRP
moro
Physiotherapist Moro – Splash Foundation Inc ., Sports Clinic
SPORTS MEDICINE TEAM
Family physician Physiotherapist Sports physician Massage therapist Orthopedic surgeon Radiologist Podiatrist Dietician / Nutritionist Psychologist Sports Trainer / Athletic Trainer Other professionals such as Occupational Therapist, orthotist and nurses Coach
SPORTS MEDICINE TEAM
There may be a considerable amount of overlap between the different practitioner “Multiskilling” is particularly important if the practitioner is geographically isolated or is travelling with sports team
SPORTS MEDICINE MODEL
Trainer Physician Physiotherapist / OT
Dietician
Athlete - Coach
Massage Therapist
Psychologist Others
Podiatrist
SPORTS MEDICINE
The secret of success is to take a broad view of the patient and his or her problem Ask “Why has this injury / illness occurred Diagnosis and treatment
SPORTS MEDICINE
Diagnosis Precise anatomical and pathological cause of the presenting problem Presenting problem and cause of the problem History, physical examination and investigation
SPORTS MEDICINE
Treatment Treatment of presenting injury and treatment to correct the cause Combination of different forms of treatment will usually give the best result Evaluate effectiveness of treatment constantly
SPORTS MEDICINE
Meeting Individual Needs Every patient is a unique individual with specific needs Treatment depends on the patient’s situation, not purely on the diagnosis
SPORTS MEDICINE
“Love Thy Sport” It is essential to know and love the sport It is essential to be on site
SPORTS INJURY REHABILITATION
Primary goal is to enable the athlete to return to sports with full function in the shortest possible time Inadequate rehabilitation Prone to reinjury of the affected area Incapable of performing at pre-injury standard Predisposed to injuring other part of the body
SPORTS INJURY REHABILITATION
Keys to a successful rehabilitation Explanation Provide precise prescription Make the most of the available facilities Begin as soon as possible
SPORTS INJURY REHABILITATION
Components of Rehabilitation Muscle conditioning Flexibility Neuromuscular control, balance and propriception Functional exercises Sports skills Correction of abnormal biomechanics Maintence of CV fitness Psychology
Return to Sport
Skill Aquisition
Proprioception
Strength
Flexibility
Motor Re-education and Muscle Activation
SOFT TISSUES LESIONS
(Mechanism of Injury or Onset of Symptoms)
ACUTE INJURIES OVERUSE INJURIES
BONE ARTICULAR CARTILAGE JOINT (Site) LIGAMENT MUSCLE TENDON BURSA
SOFT TISSUES LESION
BONE
Acute Injuries
Overuse Injuries
Fracture
Stress Fracture ‘Bone Strain’, ‘Stress Reaction’
Perisosteal Contusion
Ostitis, Periostitis Apophysitis
ARTICULAR CARTILAGE
Acute Injuries
Overuse Injuries
Osteochondral / Chondral Fractures Minor Osteochondral Injury
JOINT Dislocation / Sublaxation
Dislocation occurs when trauma produces complete dissociation of articulating surfaces
JOINT Dislocation / Sublaxation
Shoulder (Glenohumeral Joint) Dislocation - anterior dislocation results from the arm being force into excessive abduction and Supraspinatus - immobilized with elbow extended and shoulder external rotation
JOINT Dislocation / Sublaxation
Management: Protection Phase Protect healing tissue Activity restriction Avoidance of Abduction with external rotators
JOINT Dislocation / Sublaxation
Management: Controlled Phase. Provide Protection Increased Shoulder Mobility Increase Stability and Strength of Rotator Cuff and Scapulars
JOINT Dislocation / Sublaxation
Management: Return to Function Phase. Restore Functional Control Return to maximum function
LIGAMENT Sprain
Ankle – Anterior Talo Fibular Ligament Inversion
LIGAMENT Sprain Ottawa Ankle Rules
LIGAMENT Ankle Sprain
Management: Protection Phase Educate the Patient Decrease Inflammation Use Gentle Joint Mob to maintain joint integrity
LIGAMENT Ankle Sprain
Management: Controlled Motion Phase Attain Full range of motion Start Strengthening Balance and Propriception
LIGAMENT Ankle Sprain
Management: Controlled Motion Phase Progress strength training Progress Balance and propriception exercises Sports movement and skills
LIGAMENT Anterior Cruciate Ligament
Anterior cruciate ligament (ACL) injuries occur from both contact and noncontact mechanisms. blow to the lateral side of the knee resulting in a valgus force to the knee. rotational mechanism in which the tibia is externally rotated on the planted foot
LIGAMENT Medial Collateral Ligament
Result of valusstress on a semiflexed knee
Meniscectomy
Indication for Surgery
A symptomatic (pain and locking), displaced tear of the meniscus sustained by an older, inactive individual associated with pain and locking of the knee A tear extending into the central, less vascular third of the meniscus if not determined repairable when arthroscopically visualized and probed A tear localized to the inner, avascular third of the meniscus
Meniscectomy
Management: Protection Phase Educate the Patient Decrease Inflammation
Meniscectomy
Management: Controlled Motion Phase Attain Full range of motion Start Strengthening Balance and Propriception
Meniscectomy
Management: Controlled Motion Phase Progress strength training Progress Balance and propriception exercises Sports movement and skills
Tendinopathy
• Rotator cuff tendinopathy
• Primary
• Due to anatomic abnormalities
• Osteophytes • Type III Acromion process
• Secondary
• Excessive load on the shoulder due to
• impaired scapulohumeral rhythm • Joint instability • Muscle imbalance
Tendinopathy
• Rotator cuff tendinopathy • Clinical features • Pain with overhead activity or movement • Painful arc 60-120 degrees of abd. • Abduction less than 90 degrees are usually pain free • Pain and tenderness in the supraspinatus muscle particularly at the insertion • Pain with excessive shoulder flexion
Tendinopathy
Bicipital Tendinitis • Long head of the biceps susceptible to overuse injury • Occurs with individuals performing high volume of weight training • Referred pain and rotator cuff tendinopathy can produce pain in the biceps
• Symptoms
• Local tendernes s of the biceps tendon • Muscle tightness • Chronic intermusc ular and fascial thickening • Pain on
Tendinopathy
Acute
Subacute
Chronic
• • •
PRICEMEM PT: Taping Physical agents
• • •
• • •
Mobility/Strength
Low level functional activities
•Power •ADL in the pain free
range
Tendinopathy
Cumulative Trauma Disorders • Chronic Inflammation • repetitious movements over a prolonged period of time originating from the body part results in microtrauma of the area
•
Pain is the primary Manifestation •Characterized by increased collagen production and resorption of mature collagen •Efforts to stretch the inflamed tissue perpetuate the irritation
•
Tendinopathy
Tennis elbow
Typical Movements flexion and extension of the elbow
Tendinopathy
Tennis Elbow • Pain at the site radiating to the lateral epicondyle • ECRB + Supinator • ROM Complete • Weak grasp
Golfers Elbow • Pain at site reproduced by resisted wrist flexion, pronation, grasping
•
Tendinopathy
• Tennis and Golfers Elbow • Treatment is consistent with stages • Ergonomic modifications
Tendinopathy
De Quervains Disease • Stenosing tenosynovitis • APL and EPB tendon
•
•
Tendinopathy
De Quervain’s
Typical Movements Typical Job Activities combined forceful gripping and sawing use of pliers hand twisting “turning" control such as on a motorcycle inserting screws in holes forceful hand wringing
Primary Treatment: Ergonomics and Joint protection
Tendinopathy
Management Guidelines Acute • Control of inflammation • Focus on non-stressful activities / non-stressful intensities Subacute and Chronic • Exercise programs with controlled stress(until CT can withstand the stress) • Identify the cause of faulty muscle and joint mechanics
Tendinopathy
OT • Pallative treatment
Tendinopathy
ITB tendinitis • ITB Friction syndrome • Pain at insertion (Gerdys Tubercle) • Treatment consistent with stages
Tendinopathy
Patellar Tendinitis • “Jumpers knee” • Inferior pole of the patella Sinding Larsen Johansson • Osteochondritis of proximal attachment Osteochondritis Dissecans • Partial to complete avulsion of TT
•
Tendinopathy
Tib Post • Pain in the navicular bone • Resisted ankle inversion Achilles tendinitis • Pain in calcaneus • Plantarflexion Plantar fasciitis • Pain in plantar aspect • Rule out heel spurs
Bursitis
• Clinical Feature • Pain present in all motions • Leads to secondary complications (wekaness, LOM) • Continued use willl lead to erosion, rupture, adhesive pericapsulitis
ACHILLES TENDON REPAIR
Athletes in 30s or 40s Location of rupture is associated with the “watershed” area.
ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Maximum Protection Phase Protect the wound Prevention of early re-rupture Maintain strength of non immobilized joints Prevent reflex inhibition of immobilized muscle groups Specially Tibialis Posterior Prevent joint stiffness on operated ankle and foot Re-train proprioception Control swelling Maintain scar integrity Improve Gait pattern
ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Moderate Protection Phase Increase strength of hip and knee of operated extremity Improve proprioception and balance Attain Full Range of Motion on the operated ankle towards dorsiflexion Increase Strength of operated ankle and foot Maintain scar integrity No swelling Improve Cardiovascular Endurance
ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Moderate Protection Phase Progress strengthening on operated ankle Progress strengthening of hip and knee of operated extremity Maintain scar integrity Progress proprioception and balance Attain Full Range of Motion on the operated ankle towards plantarflexion Improve Cardiovascular Endurance Prepare for jogging
ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Minimun Protection Phase Progress strengthening of hip and knee of operated extremity Progress proprioception and balance Improve Cardiovascular Endurance Improve coordination Prepare for Sprints Improve agility Increase Power
ACHILLES TENDON REPAIR
Rehabilitation Guidelines: Return to Function Phase Progress strengthening on operated ankle Progress strengthening of hip and knee of operated extremity Progress proprioception and balance Improve Cardiovascular Endurance Improve Power Return to Sport
MUSCLE STRAINS
Maximum Protection Phase -No stretching -No strengthening -Protect healing muscle -Mobilize unimmobilized areas
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