Unit #4

Pathology of
Injuries
ILLNOIS WESLEYAN UNIV

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 Mechanisms and
Characteristics of Sports
Trauma
Chapter 9

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 General Injury
Mechanisms
 Primary Injury: results directly from the stress of
the sport
 Extrinsic
 Intrinsic

 Secondary Injury: injury caused by a previous

injury

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 Mechanisms of Injury
 Tension: a force that pulls (muscle)
 Strain
 Cramp
 Stretching: the elongation of tissues
 Strain
 Sprain
 Compression: a forceful blow to tissues
 Contusion
 Fracture

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 Mechanism of Injury
 Shearing: a force that moves parallel to the
tissues
 Blisters
 Abrasions

 Vertebral disc injuries

 Bending: a horizontal force causing the tissue to

bend or strain
 Spiral fracture or Greenstick fracture

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 Injury Forces To The
Skin
 Friction
 Scraping
 Compression
 Tearing
 Cutting
 Penetrating

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 Skin Wound
Classification
 Friction Blister: continuous rubbing on the skin
 Abrasion: skin is scraped against a rough
surface
 Bruise: compression causes bleeding under the
skin
 Laceration: an irregular tear of the skin
 Avulsion: skin is ripped off
 Incision: a sharp cut
 Puncture: penetration of the skin by a sharp
object
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 Treatments For Skin
Wounds
 Powders: drying agents
 Water: drying agent
 Creams: usually contain medications
 Tinactin
 Hydrocortizone cream

 Analgesic cream

 Ointments: moistening agents

 bacitracin

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 Treatments For Skin
Wounds
 Lotions and Salves: moistening agents
 Antipruritic agents: control temperature
 Antihistamine drugs: allergies
 Hydrogen Peroxide: anticoagulant
 Isoprophyl alcohol: drying and sterilizing agent
 Iodine: antiseptic and germicide agent
 Dressings: protection of the skin
 Gauze, bandaid, telfa pad
 Roller bandage, tape
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 Skeletal Muscle
Injuries
 Contusion: an acute compression causing
hemorrhage of the muscle tissue
 Strain: is an acute stretch, tear, or rip in the muscle
or tendon caused by an abnormal muscle
contraction, tension, or stretch
 Grade 1: minimal tearing with tenderness and a decrease
in strength
 Grade 2: moderate tearing with pain and impaired muscle

function
 Grade 3: severe tearing with pain and loss of muscle
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 Skeletal Muscle
Injuries
 Muscle Cramps: an acute painful involuntary
muscle contraction caused by dehydration or an
electrolyte imbalance.
 Muscle Spasm: a reflex reaction caused by acute
trauma
 Clonic: alternating involuntary contractions
 Tonic: a rigid muscle contraction that lasts

a period of time

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 Skeletal Muscle Injuries
 Acute onset muscle soreness
 Delayed onset muscle soreness

 Muscle stiffness (swelling)

 Muscle cramps

 Myositis / Fasciitis

 Tendinitis

 Tenosynovitis

 Myositis ossificans

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
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 Synovial Joint Injury
Classifications
 Acute Sprain: stretching or tearing of the stabilizing
connective tissues
 Grade 1: minimal pain and loss of function, mild point
tenderness, little or no swelling, and no abnormal
motion when tested.
 Grade 2: moderate pain and loss of function, swelling,

moderate instability
 Grade 3: extremely painful with a major loss of

function, severe instability tenderness and swelling

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 Synovial Joint Injury
Classifications
 Acute Synovitis: inflammation of the synovial
membrane.
 Dislocation: a complete separation between
two articulating bones.
 Subluxation: an incomplete separation
between two articulating bones.
 Separation / diastasis: an increase in joint
space between articulating surfaces.

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 Synovial Joint Injury
Classifications
 Osteochondrosis: degenerative changes in the
epiphysis or apophysis of bones.
 Osteochondritis dissecans: occurs in the knee
 Apophysitis: occurs to tendon-bone junctions

 Traumatic arthritis: thickness of synovium of a joint

causing creptitis and grating
 Bursitis
 Capsulitis

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 Skeletal Injury
Classification
Acute Bone Fractures
 Depressed fractures (indent)
 Greenstick fractures

 Impacted fracture (compression)

 Longitudinal fracture (bone splits)

 Oblique fracture (diagonal)

 Serrated fracture (sawtooth sharp edged)

 Spiral fracture

 Transverse fracture (straight line)

 Comminuted fracture (fragments)

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 Skeletal Injury
Classification
 Acute Fractures
 Contrecoup fracture (skull)
 Blowout fracture (eye orbit)

 Avulsion fracture (bone chip)

 Stress fracture (from overload)

 Shin

 Metatarsal

 Calcaneus

 Pars interarticularis

 ribs

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 Nerve Trauma
Classifications
 Burner (stretched nerve cells)
 Neuritis (inflammation of nerve cells)
 Sciatica (stretch of sciatic nerve)
 Carpal Tunnel (compression of nerve cells)
 Mortons Neuroma (tumor of nerve cells)

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 Common Injuries
 Sprained toe
 Sprained ankle
 Sprained knee
 Sprained finger (jammed finger)
 Sprained shoulder
 Sprained wrist
 Sprained elbow

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 Common Injuries
 Strained achilles
 Strained quadriceps
 Strained hamstrings
 Strained rotator cuff
 Strained back
 Strained hip flexor

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 Common Injuries
 Ruptured ACL
 Ruptured achilles
 Ruptured flexor tendon (jersey finger)
 Ruptured bicep tendon
 Bulging disc
 Herniated disc
 Torn meniscus (knee)
 Torn labrum (shoulder)
 Concussion
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 Common Injuries
 Achilles tendinitis
 Patellar tendinitis
 Common flexor tendinitis (pitchers elbow)
 Common extensor tendinitis (tennis elbow)
 Rotator cuff tendinitis
 Medial tibial stress syndrome (shin splints)
 OTHERS………

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 Outline of Injury
Presentation
 Choose an injury that occurs in your sport
 Name of the injury
 Mechanism of the injury

 Description of the injury

 Symptoms of the injury

 Treatment of the injury

 Presentation should include a picture of the injury

 Provide handouts for your peers

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 CHAPTER 10
TISSUE RESPONSE TO INJURY

THE INFLAMMATORY RESPONSE AND

THE HEALING PROCESS

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 DEFINITION & PURPOSE
OF INFLAMMATION
 Definition: The reaction of the body tissues to
an irritant or injury; which may be either acute
or chronic. It is a protective mechanism,
designed to?

 The purpose of inflammation is to: rid the

body of the irritant and to promote repair and
healing of the damaged tissues.

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 PURPOSE OF
INFLAMMATION
 Is a protective mechanism designed to localize
the irritant and rid body of the injurious agent in
preparation for healing
 The major causes of inflammation are:
 Trauma ( sprain, strain, contusion, etc.. )
 Chemical agents ( poisons, stings, etc. )

 Thermal extremes of heat or cold (burns)

 Pathogenic organisms ( infections )

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 SIGNS AND SYMPTOMS OF
INFLAMMATION
 The inflammatory response can be either acute
or chronic, but the local reactions are described
as the cardinal signs and symptoms of
inflammation:
 Typical signs and symptoms include:
 Redness
 Heat (local)

 Swelling

 Pain

 Malfunction (loss of motion or use)

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 INFLAMMATION
 In sports every injury is accompanied by
some tissue damage. The seriousness of
the injury will be determined by the type of
tissue involved and the extent of the
tissue damage.

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 INFLAMMATION PHASES
 Acute Reactive Phase ( 24-48 hrs.)
 Body’s fundamental reaction designed to protect,
localize, and fight the injurious agent, as well as
prepare the area for healing and repair (Nature’s
Way).
 Repair-Regeneration Phase(48hrs>)
 Tissue repairs by resolution (granulation tissue) and
regeneration .
 Repair depends on type of tissue & amount of

tissue damage.
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 PHASES cont.
 Remodeling Phase (3wks. - 1 yr.)
 Remodeling depends on the type of tissue which is
injured and the degree of damage to that tissue.
 Overlaps repair and regeneration phase

 Scar tissue forms in first 3-6 weeks

 Strength of the scar increases from 3 months to 2 yrs

after injury.
 Early mobilization promotes healing, but to early and

the healing process is delayed.

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  RESPONSE: FIRST
HOUR
 Vasoconstriction,
followed by vaso-
dilation.
 Capillary
hemorrhage
 Coagulation of
broken vessels
 Release of
chemical
mediators
 Vasodilation

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 ACUTE PHASE VASCULAR
RESPONSE
 Vasoconstriction
 Coagulation begins to seal broken blood vessels
 Chemical mediators released
 Histamine: the first chemical to appear and increases
vasodilation and permeability
 Serotonin: powerful vasoconstrictor
 Bradykinin: increases permeability and causes pain
 Heparin: temporarily prevents blood coagulation
 Vasodilation
 Permeability Changes
 Margination (pavementing): plasma exudate coagulates
into a network of fibrin and localizes the injured area.
 Phagocytosis: the process of ingesting material such as
bacteria, dead cells, and other debris.
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 SWELLING

The amount of swelling present with any injury is

highly dependent upon the extent of the tissue
damage and the subsequent inflammatory
response. Swelling basically comes from two
sources: (1) capillary bleeding, and (2) leakage
of edema, and is sometimes referred to as
EXUDATE.

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 Capillary Bleeding
 Capillary bleeding occurs when the small blood
vessels (capillaries, arterioles, & venules) are
injured, and results in the initial, primary swelling.
 Primary swelling is the result of immediate
hemorrhage which may cause some tissue cell
death and swelling until coagulation occurs.

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 Leakage of Edema
 Edema come from the leakage of blood plasma
thru the intact vessels in the area of the injury.
 Secondary swelling is delayed swelling, caused
by the release of chemical mediators as a result of
the inflammatory response following injury:
 Permeability changes caused by brakykinin

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 PERMEABILITY
CHANGES
Permeability changes are going to be very limited in minor
injuries where there has been little tissue damage.
However, in more severe injuries, there may be a delayed
response with delayed swelling which may not appear for
many hours.

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 CHEMICAL MEDIATORS
Histamine causes vasodilation and
permeability changes.
Serotonin is a powerful vasoconstrictor.
Bradykinin increases permeability and
causes pain.
Heparin: anticoagulant
Prostaglandins both encourage and inhibit
inflammation, depending on the need.

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 PHASE II: REPAIR AND
REGENERATION
 Repair is synonymous with healing
 Regeneration refers to the restoration of destroyed
or lost tissue
 Granulation or scar tissue is that tissue which has
been repaired or regenerated, and is the scab which
forms on wounded tissues as they heal. With time
this scar tissue will become more like the original
tissue.

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 SCAR TISSUE
 Immature scar is less viable, not as strong and less
elastic than the original tissue, and is highly
vascular.
 Mature scar eventually forms ( can take as long as
3wks. to 6 months to occur )
 Healing occurs in two ways ( types ):
 Primary healing
 Secondary healing

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 REGENERATION
 Regeneration in man (unlike the salamander or
earthworm) is limited to certain tissues.
 Type of tissue, amount of tissue damage, age,
nutrition, etc., can all be factors which limit
regeneration of tissues .
 Generally connective tissue can regenerate and
repair itself.

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REGENERATION, REPAIR, &
HEALING STAGES:
 Elimination of the tissue debris at site of the wound
must occur before repair and regeneration can
occur (elim. Swelling)
 Regeneration of endothelial cells occurs
 Production of fibroblasts (which compose
connective tissue throughout the body) takes
place, and is the basis for scar tissue formation
 New blood vessels form around wound

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 PHASE III REMODELING
Remodeling overlaps the repair and regeneration
phase. Generally the first 3-6 weeks are
characterized by the production of scar tissue and
strengthening of its fibers. Strengthening of the
scar tissue continues for 3 - 6 months
following injury, and may take as long as a
year to be completely healed (if in fact it ever
does).

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 Critical Thinking Exercise

An athlete has sustained a grade 2 lateral ankle

sprain 3 weeks ago. It was given proper
immediate and follow-up care. What repair has
taken place in the ankle during this time? What
kind of sports performance would you expect from
this athlete?

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 SUBACUTE OR CHRONIC
INFLAMMATION

 Book defines subacute as an acute inflammation

failing to resolve in 1 month. Chronic is defined
as lasting for months or years. Proliferation and
degeneration of tissue is characteristic of chronic
inflammation.

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 SIGNS & SYMPTOMS OF
CHRONIC INFLAMMATION
 Develops gradually over period of time, (versus
immediate onset - acute), and may last for months
or even years.
 Caused by repeated acute injury, repeated
microtrauma, or tissue disease or degeneration
(ex.,aging, ).
 Usually little or no swelling. Swelling may come
and go with ^ activity level, as does pain and
ROM.
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 Critical Thinking Exercise

A basketball player complains of a swollen ankle

that never became completely resolved since a
sprain was sustained 9 months ago. What is the
reason for this chronic swelling? What
background information would you need to know
(what questions would you ask)?

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 TREATMENT & CARE:
POINTS TO REMEMBER
 HEALING IS UNIQUE TO EACH ATHLETE
 TISSUES HEAL DIFFERENTLY
 AGE AND MOTIVATION PLAY A ROLE
 ORGANIC DISORDERS (ie., diabetes) CAN
DELAY HEALING
 HEREDITY CAN BE A FACTOR
 PSYCHOLOGICAL CONSIDERATIONS?

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 Potential for Healing of
Various Types of Soft

Tissues
Cartilage- limited, primarily because of its little
if any blood supply.
 Ligaments- as good as other tissues with a
vascular supply; gradually a scar is formed
(may take as long as 1 year)
 Skeletal Muscle- regeneration of myofibers is
minimal, otherwise heal the same as other
vascular tissues.
 Nerve- CNS nerves are poor healers;
peripheral nerves are fair.
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 MANAGEMENT CONCEPTS
 DRUGS
 SUPERFICIAL HEAT AND COLD Tx
 PHYSICAL MODALITIES
 MASSAGE
 EXERCISE REHABILITATION
 OTHERS

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 Confuscius say……
….
“…..if all you have is a hammer, then everything
looks like a nail “.

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 Inflammation: Implications
for Immediate Care ?
 R.I.C.E. ?
 Rest - what effect does rest have upon the
physiological changes resulting from the injury
and subsequent inflammatory response?
 Ice - ?

 Compression - ?

 Elevation - ?

 Other ? – immobilize, NSAIDS

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 Inflammation: Implications
for Follow-up Care?
Regardless of which method of follow-up therapy
you choose, what would your knowledge of the
inflammatory process tell you about the purpose
of your treatment?
What treatment methods might be contraindicated?
Acute vs. Chronic inflammation?

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 Inflammation: Implications
for Follow-up Care?
 Moist heat packs  Ice bag
 Whirlpool (110 deg)  Ice massage
 Analgesics  Cold whirlpool (55 deg)
 Ultrasound  Vapocoolant sprays
 Massage  Phonophoresis
 Paraffin bath  Iontophoresis
 Fluidotherapy  EMS
 Diathermy  Alternative therapy
(electromagnetic)
 Low Power Laser

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 Inflammation: Implications
for Therapeutic Exercise
Deciding when to begin therapeutic exercise,
reconditioning, and/or a return to activity, is
always a difficult decision. Based upon what you
have learned about the inflammatory process and
the body’s response to injury:
 When should therapeutic exercise begin?
 How much exercise should be allowed?

 Does the type of exercise make a difference.

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 FRACTURE HEALING
 TIME is a major concern as bone healing goes
thru the various phases of healing, but generally
4-6 weeks.
 Acute Phase: first 3-4 days
 Repair Phase: hematoma formation, organization
of scar, and fibrous junction between bone ends
(soft callus - hard callus)
 Remodeling Phase: May take years.

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 FRACTURE CARE
 Immobilization until hard callus has formed,
usually 4-6 weeks, but can last several months
depending on the nature, extent, & site of the
fracture.
 Conditions which can delay healing
 poor blood supply to fracture area
 poor immobilization

 infection or disease

 age and/or osteoporosis

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 Healing of Stress
Fractures
…”if the osteoclastic activity is greater than the
osteoblastic activity, the bone becomes
increasingly susceptible to stress fracture.”

…”decrease in activity and elimination of other

factors in training that cause stress will allow
bone remolding…”

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 PAIN
 CAUSES OF PAIN
 released CHEMICAL SUBSTANCES
 PRESSURE ON NERVE ENDINGS

 ISCHEMIA IN THE AREA

 PAIN, SPASM,SWELLING, PAIN CYCLE

 TYPES OF PAIN
 SHARP (EXCRUCIATING), DULL, ACHE,
CONSTANT, OFF\ON, THROBBING,NIGHT

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 Acute vs Chronic Pain
 Acute Pain
 Less than 6 days in duration
 Specific cause or mechanism of injury

 Generally of short duration

 Usually a specific area of origin

 Chronic Pain
 Gradual onset and/or long duration
 “that which continues beyond the usual normal

healing time”
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 Referred Pain
 Pain is common in sports
 Types of pain by location
 Away from the actual site of irritation
 May be motor, sensory or both

 May produce paresthesia

 Three types common to athletics:

 Myofacialpain at trigger points
 sclerotomic is deep pain

 dermatomic pain is sharp and well organized

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 PAIN SENSITIVITY
 Pain tolerance can be a learned response, and
is both physiological and psychological in
nature
 Pain is a feeling
 Pain is subjective……but we try to get objective
data to make our decisions. Unfortunately the
so-called “objective tests” that we often use are
often unreliable.

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 Pain Assessment
 Methods for Pain Assessment
 Numeric value scale
1 to 10 with 1 representing the least
 Verbal descriptors as assessment, such as ‘none’,
‘slight, ‘mild’, ‘moderate’, and ‘severe’
 Palpation

 Response to activity,weight bearing, etc.

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 Pain Treatment
 Management methods can be used separately or
in combination
 Break the pain-spasm-pain cycle thru a variety of
methods, such as:
 heat or cold
 electrical stim and ultra sound

 phonophoresis & iontophoresis

 pharmacological agents(analgesics)
 topical counterirritants

 others?

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 Psychological Aspects of
Pain
 Pain can cause serious emotional changes in an
athlete, including depression and irritability
 Pain is a physiological and psychological
phenomenon, unique to each athletic
 Through conditioning, athletes can learn pain
tolerance

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