Athletic Injuries

Introduction to Sports Medicine Lesson 1:

Introduction to Sports Medicine

Objectives: At the completion of this lesson the student will be able to explain and understand the concepts of the “funnel theory” of Sports Medicine. They will also understand the theory of the “Spider” in relationship to a Sports Medicine Team. The student will understand the 4 Tier Sports Medicine Rehabilitation Program. The student will understand the rolls of the head trainer, associate trainers, Team Orthopedist, Team Physician, Team Chiropractor, Team Dentist and Team Physical Therapist.

  1. The Funnel Theory of Sports Medicine
  2. Your Stratification into the Funnel
  3. Your participation on the Sports Medicine Team depends upon
  4. The level or profile of your sport
  5. Your expertise as it relates to the program
  6. Your education and credentials
  7. The Athletes confidence in you
  8. The Team Physicians Confidence in you
  9. High profile athletes
  10. Down time treatment
  11. Increase Functional Parameters
  12. Reimbursement for Services
  13. Primary and secondary income
  14. Fee for service, insurance Billing
  15. Direct or indirect income
  16. Program Billing
  17. Must weigh the cost and return
  18. Idea of non displaced revenue
  19. The idea of the Spider
  20. The “Web I spin is the Web you Eat off”
  21. The 4 aspects of a Sports Medicine Delivery System
  22. Stability
  23. Soft Tissue Flexibility
  24. Range of motion
  25. Segmental
  26. Global
  27. Exercise prescription
  28. Violation of any aspect of the Sports Medicine Delivery System
  29. Sports Medicine Job Description
  30. Head Trainer
  31. Budgetary concerns
  32. Staffing concerns for Team Sports
  33. Logistics and travel
  34. Injury Update to Local Sports Marketing System
  35. Injury Review with Athletic Director, Head Coaches
  36. Head Sports Trainer
  37. Sports specific
  38. Reports equipment needs to Head Trainer
  39. Travel and Logistics to Head Trainer
  40. All Injury reports to Head Trainer before Team Physicians
  41. Hierarchy for injury reporting
  42. Films, MRI, Ct, Neurological evaluation

vi. on field responsibilities

  1. Graduate Assistants
  2. Gator aide / power aide
  3. Pack trunks
  4. Taping cutting boards
  5. Majority of taping procedures
  6. On field Watering
  7. Team Physician
  8. Colds, Flu, General Health Care
  9. Medications – pain and inflammatory
  10. Med Kit and Log
  11. Never out of his sight..
  12. NCAA reporting and testing
  13. Concussion and Neurological evaluation
  14. General Sutures
  15. General Lacerations
  16. Team Orthopedist
  17. Team Surgeon
  18. Evaluate functional Level of play
  19. Makes decision as to orthopedic problems and return to play
  20. On Field Responsibilities
  21. Team Dentist
  22. Handles all sutures in the mouth, lips and nose.
  23. Mouth guards
  24. Salvage Teeth
  25. Team Chiropractor
  26. Team with the fewest mechanical defects Wins……
  27. Team Physical Therapist
  28. Assist in Functional restoration following surgical intervention
  29. Measures return to play function capacity

Athletic Injuries Lesson 2:

Legal Aspects of Sports Medicine

Objectives: At the conclusion of this lesson the student will understand the concepts of torts, implied consent, informed consent, product liability, surface (event) liability, personal liability, shared liability and negligent assignment.

1. Understanding Tort Law:

  1. Nonfeasance (act of omission) you did not do something
  2. Malfeasance (act of commission) you did something
  3. Misfeasance: (improper treatment your trained to do)

2. Negligence 2 types:

a. Do something a reasonable prudent person would not do

  1. Would you adjust on the sidelines?
  2. Gynecologist on the field of a football game?
  3. EMT pushing a claustrophobic Rodeo athlete down on the gurney

b. Fails to do something that a reasonable prudent person would do under

circumstances similar to those shown by the evidence.

  1. Fail to administer CPR to a unconscious non breathing athlete
  2. Could you not perform a manipulation and as a result increase

the probability of further injury?

c. Standard of care

d. Cannot have athlete "sign away your negligence"

i. Case of Chiropractor who does not treat disease.

3. Negligent assignment

  1. Back pain with return to lifting and strength coach
  2. Limited cervical ROM with return to baseball hitting practice
  3. Knee injury with sliding practice
  4. Walking the Rodeo Arena prior to Rodeo

4. Statute of Limitations

  1. Driven by state statutes
  2. Usually 1-3 years

5. Assumption of Risk

  1. Age related
  2. Interpretations varied by the courts

6. Product Liability

  1. Vitamin company and allergic reaction
  2. L - screen to high or low with baseball hitting practice

7. Personal Liability

a. Does your Malpractice Carrier know you are a Team Physician

8. Event Liability

  1. What happens if your table slides or slips on a slick floor?
  2. What happens if your table collapses?

i. 350 pound lineman

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Athletic Injuries

9. Shared Liability (deep pocket ratification)

  1. Shot gun approach in filling a law suit
  2. Process of discovery weeds out the "small fish" with limited exposure

i. Concepts of good will towards

10. Informed consent

a. Minor children a concern

  1. Blanket exposure risk not secured by signing initial form at beginning of the season

ii. Must notify parents with trauma

1. High School football player death

11. Implied Consent

  1. Symptoms Survey forms
  2. Keep records in Day Planner

12. Travel to Treat Laws

a. Notify your Malpractice carrier

13. Documentation

a. MNOPQR - If it's not in the record it didn't happen......

Athletic Injuries Lesson 3 Sports Injury and Wound Care

Objectives: At the conclusion of this lesson the student should understand the Healing Process and it’s dependence upon the inflammatory process. The student will review the mechanism of injury and the path of clinical reasoning in applying physical modalities in the handling of acute and chronic injury. The student will also understand wound management.

  1. Mechanism of Injury
  2. Compressive forces (toward)
  3. Bruises, contusion, hematoma,
  4. Tensile forces (away)
  5. Pulling apart, sprains, ligament avulsions
  6. Open field tackling
  7. Shear forces
  8. Against the plane of tissue
  9. Surface area and force applied
  10. Smaller the surface area impacted the greater the impact for tissue injury
  11. Review of the inflammatory Process
  12. Inflammatory Phase:
  13. Acute Injury 0-6 days:
  14. Signs and symptoms:
  15. Redness, swelling, tenderness, increased temperature, loss of function
  16. Cellular Response:
  17. Cells rupture from trauma
  18. Produce plasma like fluid: protein, granular leukocytes (WBC), phagocytes
  19. Building a brace, protective in nature, get rid of cell debris setting stage for tissue repair
  20. Vascular Response:
  21. Immediate response to damage is vasoconstriction last 5-10 minutes
  22. Brings endothelial wall torn apart together
  23. Blood viscosity increases (thicker) slows blood down allowing for platelet adherence
  24. Mast cells dump histamine (vasodilatation), leucotaxin (margination of cells), necrosin (phagocytic)
  25. Causes local anemia and hypoxia
  26. Ends in platelet plug
  27. Localized tissue hypoxia drives the switch to vasodilatation
  28. Blood continues and forms a hematoma
  29. Hematoma and dead cells from hypoxia and cell rupture create a primary zone of injury
  30. Modalities to be used during this phase
  31. RICE
  32. No cold whirlpool because of gravity dependency
  33. Intermittent compression
  34. Non thermal ultrasound
  35. Proliferation / Fibroblastic Repair Phase:
  36. Leads to scar formation
  37. Initial symptoms reduce
  38. Scar becomes more red - vascular budding because of lack of O2
  39. Wound now heals aerobically
  40. Gray anaerobic fibrosis plug fills in gaps
  41. Excessive fibrogenesis leads to irreversible tissue damage – adhesive capsulitis, extra articular adhesions
  42. Mature scar is devoid of physiologic function
  43. Less tensile strength
  44. Wolfe’s law
  45. Bracing and motion
  46. Maturation Phase:
  47. Long term process, inelastic, non vascular, less strong
  48. Wound shrinks, due to water loss, vasoconstriction
  49. Fibrogenesis begins to cease, if proliferates then disease
  50. Return to prior activity level
  51. Modalities
  52. Designed to remodel scar formation?
  53. Line up fibroblastic repair
  54. Cold laser, Magnetism, Poultice,
  55. Concept of Bioelectromagnetic Modalities
  56. Bone scan, cold laser
  57. Tissue responds in a manner similar to that which it normally grows in
  58. However, danger exists as density increases
  59. Above certain densities, tissue destruction occurs with all energy forms
  60. 4 levels of electrical intervention
  61. Cellular
  62. Tissue
  63. Segmental
  64. Systematic
  65. Modalities at the Injury site are used for
  66. Increasing joint mobility
  67. Muscle pumping action to change circulation and lymphatic
  68. Alteration of microvascular system not associated with muscle pumping
  69. Increased movement of charged proteins into the lymphatic channels with subsequent oncotic force bringing increase in fluid to the lymph system; lymphatic contraction increases as a result and more fluid is moved centrally
  70. Most connective tissue generates a tissue based electrical potential in response to strain of tissue. Tension on surfaces or distraction of surface will cause changes in electrical current.
  71. Strain related potentials (electricity of injury)
  72. Compression potentials are negative
  73. Stretch or tension they are positive
  74. Normal Bioelectric fields
  75. Head is positive, Feet is negative
  76. Can be measured
  77. Skin is always negative in comparison to dermis
  78. Long bone = mid point is positive in relationship to distal negative points
  79. Bioelectrical Field changes in Response to Injury
  80. Fields reverse when a injury occurs
  81. With laceration a steady currently will move from the relative positively charged dermis into the wound area and reenter just below the stratum corneum.
  82. Wound creates a lateral potential difference forming a lateral potential difference
  83. With wound closure the gradients return to normal
  84. If wound dries the currents also drop off because of increased resistance to electrical flow
  85. Bioelectrical effects in Reponses to Injury
  86. Bioelectrical effects reverses immediately with injury
  87. Salamander (Becker’s) leg amputed –10me at amputation +20 me
  88. Limb regeneration occurred the current returned to baseline
  89. Becker’s current of injury stimulate tissue healing
  90. Three ingredients to tissue regeneration
  91. Powerful initial current of injury
  92. High tissue innervation’s density
  93. Presence of peripheral nerves in he wound area
  94. Magnetic field generation
  95. Iontophoresis
  96. Positive currents
  97. Zinc: open lesions, healing tensions, ligaments
  98. Magnesium: muscle relaxant, vasodilator, mild analgesic
  99. Copper: fungicide, astringent, sinusitis, (athletes foot),
  100. Calcium: snappy fingers, snappy hip, effective with muscle spasm
  101. Negative currents
  102. Chlorine: (sodium chloride) sclerolytic agent, scar tissue, keloids
  103. Iodine: sclerolytic agent, bactericidal (adhesive capsulitis)
  104. Phonophoresis
  105. Open Wound Care Management
  106. Laceration: fall on a 9.0 pitch
  107. Incision: Ice Skates across the face
  108. Abrasion: bicycle race
  109. Puncture: Fish hook in the lip
  110. Avulsion: handle bars across the forehead

11. Field Strategy

  1. Always glove up, glasses, goggles, sun glasses
  2. Hemostat in kit, understand pressure points
  3. Glove up with topical cleaner
  4. Wash wound from center out, circular pattern
  5. Apply non stick compression gauze
  6. Dress bandage to play with “H” bandage
  7. Vet wrap, conform, best
  8. Ointments are optional
  9. Change bandage often when sweat weakens tape
  1. Super glue vs. steri strip
  2. Glue is faster and maintains better with sweaty environments
  3. Most teams will glue to return to play and then tape after the shower
  4. To apply steri strips the area needs to be cleaned with prep kit and then dried with air. Steri strip pattern is close middle out.
  5. Be careful with glue - do not glue your lips shut with cap
  6. Do not spill onto sides or glue you to patient
  7. Muscle Injury Classification Strains
  8. Grade 1, Grade 2, Grade 3
  9. 0-30%, 30-60%, 60-90%
  10. Weakness
  11. Muscle spasm
  12. Loss of function
  13. Swelling
  14. Palpable defect
  15. Pain on contraction
  16. Pain with stretching
  17. Range of motion
  18. Muscular / Tendon Strains depends upon cross sectional area of tendon
  19. What would you expect more tendonitis at radial head or hip flexors?
  20. Progressions of injury if left untreated
  21. Myositis / fasciitis
  22. Tendonitis, tenosynovitis (natural aging of tendons)
  23. Bursitis
  24. Arthritis
  25. Joint Injury Classification Sprain
  26. Grade 1, Grade 2, Grade 3
  27. Ligaments undergo high tensile trauma producing rupture of tissue and subsequent hemorrhage and swelling
  28. Treat with intermittent traction and compression.
  29. Constant compression or tension causes ligaments to deteriorate
  30. Paraplegic - Mike Riggel (son)
  31. Subluxation: “partial displacement of joint surfaces, torn but not completely ruptured.” Every grade 1, and grade 2 sprain therefore has a subluxation.
  32. Dislocation is a grade 3 sprain

Athletic Injuries Lesson #4: Taping procedures lower and upper extrmeninities

Dr. Laney Nelson

Objectives: The purpose of this section is not to make you tape like an ATC. It is to make you think like a physician. Tape is a great adjunct to your private practice because it can help you differentiate between diagnostic pathways. Help establish the need for ordering functional bracing and orthotics, and teach your patients that you are responsible for their care. This is also an important avenue in which you can begin dialogue with sports medicine centers if you wish to pursue that avenue in your private practice. The main concept of our taping approach will be to stabilize pathology by either taping the pathology or recommending changes to current ATC taping procedures.

  1. Introduction to the types of tape:
  2. White tape
  3. Ultra light
  4. Elastikon
  5. Leuco tape
  6. Sizes: Ankle dependent 1”, 1 ½”, 2” 3” 4”
  7. Depends upon the size
  8. Ultra light is more forgiving
  9. Under warp
  10. Hold lace pads in place
  11. Usually only used around the heel and arch
  12. Made of light foam and is 2 ¾ inch wide
  13. Tuff skin
  14. Used to keep the pre wrap in place prior to tape
  15. Watch for tape allergies
  16. Help prevent tape slippage
  17. Heel and lace Pads
  18. Prevent tape pinching and blisters
  19. Have skin lube on the underneath side

Standard Ankle Tape Applications Step by Step

Step 1: Spay ankle: tough skin or some other tape adhesive

Step 2: Apply heel and lace pads

Step 3: Roll on pre wrap: (high or low tape procedure)

  1. roll wrap from under side of roll
  2. Pull until it “glistens”
  3. Try not to cover repeatedly, more does not make more padding makes the tape slip
  4. Most Universities like pre wrap confined to a small area.

Step 4: Place white tape anchors: (basketball vs. football)

  1. Always follow contour of muscles
  2. White tape is less expansive and cannot be used in large muscular areas. A better anchor in a large fleshly area would be Elastikon or ultra light
  3. A must when taping as a physician is to remember Anchor-Pathology-Anchor. This is apparent as you begin to explore taping and correction of biomechanics and mechanical dysfunction.
  4. Place Anchors around tissue landmarks: base of the 5th metarsal and posterior muscle tendon junction of soleus and gastroc

Step 5: Place Stirrups: medial to lateral / lateral to medical (depending upon pathology)

Step 6: Place medical and lateral heel locks

a. Once accomplished, you can begin to spin the tape

b. Do not create tape bunch

c. only overlap 1/3 of previous tape run

Step 7: Close the tape with small strips from the back of the anatomy pulled to the front. Always try to keep the tape in front of you. Always keep the seam of the torn tape in front of you. Always compress the tape w3hen finished. If socks are going over some trainer like baby powder sprinkled over the tape to help it slide better.

Special Procedures: “H” tape from Elastikon for special procedures involving positional joint correction. Turf toe, plantar fasciitis, inter digit neuroma, halux valgus, Achilles tendonitis, fat pad compression, all can be addressed with taping. You can also use white tape slowing down or speeding up the pronation sequence in your differential diagnosis. Correction of pes planus, pes cavus, inversion or eversion sprains correcting rear foot valgus and varus deformities also can be addressed with taping procedures. . Achilles bursitis, tarsal tunnel syndromes, shin splints, peroneal stain and fibular head dysfunction and be supported and treated.

Standard Tape Procedure Knee

Step 1: Place Heel on tape roll or book to get 15 degrees forward flexion

Step 2: Spray knee

Step 2: Apply lace pads (behind popliteal fossa)

Step 3: Apply pre wrap around sensitive areas

Step 4: Apply Anchors (remember large fleshly areas Elastikon, ultralight)

Step 5: Pathology:

a. Spiral Elastikon or ultralight medical to lateral and lateral to medical for ACL / PCL

b. Use white tape “fanning procedure” for MCL / LCL

c. “H” tape for patellar tracking

d. Osgood - Chock Pat taping

Step 6: Anchor applied over pathology strips

Step 7: Close with ultra light or ace wraps

Special Procedures: Using Elastikon and ace wraps you can wrap groin injuries and hip flexor strains. You can apply padding and extra compression using foam, felt or plastic such as in a thigh contusion. You can also control the speed of internal and external rotation of the femur as it relates to the tibia. This may help you differentiate between a knee problem and a hip problem.

Standard Taping Procedure Shoulder

Step #1: Shave the area, there is no functional way to use pre-wrap on the shoulder.

Step #2: Spray the area with tough skin

Step #3: Asses stability of AC joint anterior to posterior

Step #4: Lift the elbow with white tape to approximate the AC joint if separated.

a. One end of strap is on distal olecranon and the other proximal to the AC joint. Palpate the AC joint as you lift the shoulder

Step #5: Place Anchors with leuco tape or Elastikon around upper humerus and on mid clavicular line on top of supraspinatus

Step #6: Construct fan on or off patient

Step #7: Use Elastikon “H” procedure to provide functional lift to shoulder

Step #8: Cut away white tape lifting straps

Standard Taping Procedures Elbow

Step #1: Spray skin before application of pre wrap

Step #2: apply anchors above and below muscle mass

  1. Make sure they are anatomical correct in regards to cinching down when extension is applied to the elbow.
  2. Should be above the bicep bubble and cone shaped on the lower forearm

Step #3: Create fan of white tape off patient or use Elastikon “H” tape procedure to create hyperextension brace (both ends of the Elastikon become anchors)