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THE ROLE OFPHYSIOTHERAPY IN THE

MANAGEMENT OF SPORTSINJURIES

THE ROLE OFPHYSIOTHERAPY IN THE

MANAGEMENT OF SPORTSINJURIES

Mohd Asri AriffinMSc (Sports Science) Student

SSU (USM)

Supervisor: Dr Oleksandr Krasilschikov


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ContentContent Definition

Classification

Type of sports injuries Common sports injuries

Estimated relative risk

Physiotherapy management ofTennis Elbow

Physiotherapy management ofACL sprain

Physiotherapy management ofLateral Ankle sprain

Injury prevention

Criteria for return to sport Conclusion

Acknowledgement

References


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DefinitionDefinitionPhysiotherapy:

Physiotherapy is the treatment of

physical dysfunction or injury by the

use of therapeutic exercise and theapplication of modalities, intended torestore or facilitate normal function or

development.

http://www.thefreedictionary.com/physical+therapy
http://www.thefreedictionary.com/physical+therapyhttp://www.thefreedictionary.com/physical+therapy


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DefinitionDefinitionSports injuries:

Sports injuries result from acute trauma or

repetitive stress associated with athletic

activities. Sports injuries can affect bones,soft tissue (ligaments, muscles, tendons)or other organs.

http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp
http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsphttp://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp


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ClassificationClassification Acute injuries (traumatic)- Is typically the result of single event- Result in the immediate onset of pain- Associate with an obvious deformity with impaired function- Less than 72 hours

Chronic/ Sub-acute injuries (overuse)- Result from repetitive microtrauma to bone, ligament and

musculotendinous units- More than 72 hours


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Type of sports injuriesType of sports injuries

Sprains

Strains

Fractures

Cramps

Spinal cord injuries

Internal organ injuries Head injuries and concussions


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Common sports injuriesCommon sports injuries

Clavicle fracture

Shoulder dislocation

Rotator cuff injuries Ulnar collateral

ligament (UCL)

Sprain Acromioclavicular

sprain

Scaphoid StressFracture

Medial epicondylitis(Golfers elbow)

Lateral epicondylitis

(Tennis Elbow) Finger sprain

Low back injuries


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Common sports injuriescont.

Common sports injuriescont.

Adductors strain

Hamstring strain

Patello-femoral JointPain Syndrome

Stress fracture

Shin splintCompartmentSyndrome

Plantar Fascitis

Anterior cruciateligament sprain

Medial collateral

ligament sprains

Meniscus tear

Lateral ligament

sprain of ankle

Achilles tendontendinopathy


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Estimated Relatives RiskEstimated Relatives RiskAnatomicalregion

Head & Neck:Shoulder:

Elbow:

Wrist

Finger:Low BackPain:

Groin:

Thigh:Knees:

Legs:

Ankle & Foot:

%

0-2

5-10

5

5

5-10

15

5

5-10

10

20-25

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25

Games

Rugby, Gymnastics, Hockey,Badminton, Tennis, Volleyball

Bowling, Badminton, Gymnastics, Tennis

Wt Lifting, Diving, Gymnastics

Volley-Ball, Hockey, Cricket,Gymnastics, Badminton, Cycling,

Soccer, Hockey, Rugby

Athletics, Martial Arts, Soccer

Badminton, Athletics, Football, RugbyBadminton, Football, Hockey, volley-ball

Athletics, Martial Arts

Gymnastics, Athletics, Diving, basketball

Dr Aston Ngai, 6th ISSC 2006


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Tennis ElbowTennis Elbow

Excessive degree of pulling on the

common extensor tendon Pathology of repeated micro trauma,

small areas of tendon are torn awayfrom the periosteum producing anassociated inflammatory reaction thatinitially minor but progresses to become

recurrent

(Crowther, 1999)


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Tennis ElbowTennis Elbow Clinical features (C/F)

- tender lateral

epicondyle; commonextensor origin (ECRB)due to fibrosis,calcification &

microtears

Very common inracquet games such as

badminton, tennis andsquash


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Tennis ElbowTennis Elbow

Assessment

- pain during extension of the wrist

- reduce grip power

- loss of function

Treatment

a) Medical

b) Physiotherapy treatment


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Physiotherapy treatmentPhysiotherapy treatment Ultrasound

Heat wrap therapy or Hot pack

Soft tissue manipulation (massage)

Stretching and strengtheningexercises

Advice Tennis Elbow brace


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Ultrasound (U/S)Ultrasound (U/S) Ultrasound is mechanical

radiant energy derived

from the application ofan electric current on acrystal, which result in avibratory motion

Micro-massage and

thermal effects Dosage:

- Acute: 0.8w/cm squarefor 5 minutes, twice daily

and 3 times per week- Chronic: up 2.0 w/cmsquare for 10 minutesand 3 times per week


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Literature ReviewLiterature Review Falconer et al (1990) reviewed the literature to determine

the effects of ultrasound on musculoskeletal condition,

and suggested that ultrasound appears to be effective inrelieving pain and increasing range of motion in acuteperiarticular inflammations condition, but not chronicperiarticular inflammatory conditions

According to Richardson and Iglarsh (1994), ultrasoundassists in the resolution of inflammatory exudates byincreasing the local blood flow.

Leong et al (2005), in his study has found that u/senhanced medial collateral ligament repair in rat.


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Indications (US)Indications (US) Sprains and strains such as,

Achilles tendon tendinitis, MedialCollateral Ligament sprains

Chronic swelling- lateral anklesprains

Muscle tear- Hamstring tear

Lateral epicondylitis (Tennis Elbow)

Medial epicondylitis (Golfer Elbow)


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Ultrasound (Application)Ultrasound (Application)


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Physiotherapy treatmentPhysiotherapy treatment

ii) Heat wrap therapy or Hot pack

dosage: 20 minutes, 3 times perweek


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Heat Wrap Therapy(Hot Pack)

Heat Wrap Therapy(Hot Pack)

Superficial heating

Heat wrap therapyconsist of canvas ornylon cases, filled witha hydrophilic silicate or

sand, stored in athermostatically controlcabinet in water attemperature between

70 degree Celsius and75 degree celsius.

Low and Reed (1990)


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Literature review (Heat Wrap Therapy)Literature review (Heat Wrap Therapy) Clinically, hot pack appear to be used most often to

help to reduce pain and muscle spasm, and to helpimprove tissue extensibility (Baker et al 1991, Lentell etal 1992)

A clinical trial to evaluate the efficacy of continuouslow-level heat wrap therapy for the treatment of

various sources of wrist pain including strain and sprain(SS), tendinosis (T), osteoarthritis(OA), and carpaltunnel syndrome (CTS) has been carried out by SusanMichlovitz et al (2003).

- In this study, the comparison is between heat wraptherapy group and the oral placebo group.

- And, they found that continuous low-level heat wraptherapy was efficacious for the treatment of commonconditions causing wrist pain and impairment.


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Indications (Heat Wrap Therapy)Indications (Heat Wrap Therapy)

Low back pain Muscle strain

Muscle spasm

Frozen shoulder

Ligaments injuries- Anterior CL, MCL

Cramps Tendon rupture- Achilles Tendon rupture

Lateral epicondylitis (Tennis Elbow)


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Physiotherapy treatmentPhysiotherapy treatmentiii) Soft tissue manipulation (massage)

- Deep transverse friction is effective fortendinitis, generally because of themechanically induced hyperemia and itsinfluence on tissue maturation

Richardson and Iglarsh (1994)

iv) Stretching and strengthening

- strengthening (Dumbell)- Stretching- into elbow extension, forearmpronation, ulnar deviation, wrist and fingerflexion


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Physiotherapy treatmentPhysiotherapy treatmentv) Advice

- taught onpreventivemeasure, includingproper technique

and conditioning,limiting activity afterthe muscles beginto fatigue

vi) Tennis Elbowbrace


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Anterior Cruciate Ligament(ACL) Sprain

Anterior Cruciate Ligament(ACL) Sprain

The ACL is the primary ligamentstabilizer in the knee.

The ACL prevents excessive rotation ofthe femur on the tibia and restricts

anterior translation of the tibia relative to

the femur.


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ACL SprainACL Sprain ACL sprains can occur from contact or

non-contact forces. A football player whois tackled while standing on an extendedknee or a skier who twists or hyper-

extends their knee can tear the ACL. An ACL sprain is commonly associated

with a distinct pop in the knee followed by

a sensation of the knee shifting or giving

wayAnderson (2005)


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(ACL) Sprain(ACL) Sprain

www.whyfiles.org


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ACL SprainACL Sprain Assessment

- Reduce range of motion

- Decrease muscle bulk- Reduce muscle power- swelling

- pain- restricted movement- special test: Anterior drawer test and Lachmantest

- Radiagraphic: X-ray and MRI- Arthroscopy

Surgical treatment: ACL reconstruction

- followed by extensive physiotherapy program


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Special TestsSpecial TestsAnterior drawer test Patient lying down; knee flexed 90

degrees; examiner stabilizes the

foot and gently pull tibia forward Increased motion or indistinct end

point indicates ACL injury


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ArthroscopyArthroscopy


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Physiotherapy TreatmentPhysiotherapy Treatment Treatment (Acute)

i) Ice packii) compression bandage

Treatment (Sub-acute)i) Heat treatment (heat wrap therapy or

shortwave diathermy)ii) Therapeutic Exercise

- mobilising

- stretching- strengtheningiii) Advance rehabilitation (field)iv) Advice on injuries prevention


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Physiotherapy treatmentPhysiotherapy treatment Ice Therapy

- Immersion- Massage

- Ice pack

- Cold gel


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Physiotherapy treatmentPhysiotherapy treatment Ice Therapy

Is recommended for the first 24-48 hours

Rationale:

- Less fluid filtration into the interstitial tissue, due tovasoconstriction

- Less inflammation and less pain- Decrease metabolic rate

Michlovitz (1996)

According to Knight (1985), efficacy of cold for the

care of acute injuries is because of the reduction in

metabolism and, thus, a decrease in secondary

hypoxia injury


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ii) compression bandage- If still swollen

This is the most effective means of

stopping hemorrhage, but to effective,compression must be selective

- For example, for ankle joint, padding must

be applied to ensure the evencompression to the affected area

Garrick and webb, 1999


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Sub acute stage

- Heat treatment (heat wrap therapy or shortwavediathermy)

Isometric contraction- Static quadriceps and static

hamstring

When Swelling and pain subsided- Therapeutic Exercise

i) mobilisingii) stretchingiii) strengthening


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Physiotherapy treatmentPhysiotherapy treatment1. Short-wave diathermy (SWD)

Medium frequency current 27.12 MHz is commonly used Can penetrate the body Beneficial effects

- increase in blood flow due tovasodilation

- improvement in tissueoxigenation

- increase capillary pressure

and cell membrane permeability- relief muscle spasm- decreased tension of the

collagenous tissueShankar and Randall (2002)


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Literature ReviewLiterature ReviewThere are mixed results

Acute ankle sprain have been treated by thismodality with marked benefit (Wilson, 1974),some benefit (Pasila et al, 1978) and no effect

(McGill, 1989) Chronic back pain has been successfully treated

with SWD (Wagstaff et al, 1986)


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SWDSWD Indications

- Knee injuries- Muscle spasm

- Low back pain

- Rotator cuff injury- Neck an shoulder

injuries

- Prolapseintervertebral disc(PID)


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Mobilising Exercise

- usually cycling for20 minutes eachsession

Stretching Exercise

- quadriceps

- Hamstring


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Strengthening exercise

- Quadriceps- Hamstring

Quads bench


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TreadmillTreadmill Before progress

to field training Re-evaluation


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Advice on injuriesprevention

- warming up and

cooling down- knee brace


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Lateral Ankle SprainLateral Ankle Sprain

Lateral ankle sprains are commonin running, jumping, pivoting, andcutting sports. Sprains occur when

the ankle inverts past the pointwhere bony architecture and

ligaments can stabilize the joint.C.N. van Dijk (1997)


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Lateral Ankle SprainLateral Ankle Sprain Most common injury in sports

Immediately feel the pain and swelling


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Classification of Lateral AnkleSprains

Classification of Lateral AnkleSprainsGrade I:

minor tear of ATFL/CFL. Mildtenderness & swellingSlight / no functional loss

Grade II:Partial ATFL/CFL tear, ++functional impairment.

++ pain & swelling, +/++ bruising& instability;

motion and function;Grade III:

ATFL/CFL/PTFL Completely torn,+++ swelling (more than 4 cmabout the fibula) +++bruising, Loss of function & motion (i.e.,

patient is unable to bear weight orambulate) ++/+++ instability

Adapted from Lateral ankle pain. Park Ridge,Ill.:

American College of Foot &

Ankle Surgeons, 1997: preferred practice guideline

no. 1/97


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Lateral Ankle SprainLateral Ankle Sprain Assessment

- pain especially on inversion- swelling- limping gait

- range of motion

Treatment

- medical- physiotherapy- traditional massage


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Physiotherapy treatmentPhysiotherapy treatment Acute phase

- RICE

Sub-acute phase

- Wax Therapy

- U/S

-Therapeutic Exercise

- mobilising

- stretching

- strengthening

Proprioceptive training

Ankle tapping


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Wax TherapyWax Therapy


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Literature ReviewLiterature Review Hayes (1993) reported

that an increased intra-

articular temperaturemight initially heighteninflammatory activity,further increases intemperature might slow

it down

Hensley (1992) claimedthat there is an

increased range ofmotion following heatingof a joint by paraffin wax


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Wax TherapyWax Therapy Using paraffin wax

- it has low melting point (54 degreeCelsius)

- has low specific heat, whichmeans that it does not feel as hotas water of the same temperature,

therefore, there is less risk of burn

Michlovitz (1996)


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Indication (Wax Therapy)Indication (Wax Therapy) Plantar Fascitis

Achilles Tendon Tendinitis Rheumatoid Arthritis

Finger sprain

Fracture metacarpal and phalanges Fracture metatarsal and toes

Carpal tunnel syndrome

Trigger finger

Ankle sprain


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Physiotherapy TreatmentPhysiotherapy Treatment Therapeutic

Exercise- mobilising

- stretching

- strengthening

Proprioceptive

training- wobble board

Ankle tapping
http://images.google.com.my/imgres?imgurl=http://www.fitter1.com/media/wb20.jpg&imgrefurl=http://www.fitter1.com/wooble-board-20.html&h=204&w=260&sz=17&hl=en&start=2&tbnid=62acj03nwDP5PM:&tbnh=88&tbnw=112&prev=/images%3Fq%3Dwobble%2Bboard%26svnum%3D10%26hl%3Den%26lr%3D


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Injury PreventionInjury Prevention Warm up and cooling down

Gradual training program Tapping

Proper technique Appropriate shoes


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Return to SportsReturn to Sports Review by sports physician &

physiotherapist Normal full functional activity

Tested with sports-specific agility

skills by sports science specialist Completion of rehabilitation program


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ConclusionConclusion Lack of data in the prevalence of

sports injuries in Malaysia,therefore more studies should becarried out in the future.

More research on theeffectiveness of physiotherapy

modalities is required in exercise& sports.

R f


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ReferencesReferences

1. T.J. Noonan and W.E. Garrett, Muscle strain injuries, J Am Acad Orthop Surg(1999), pp. 262269.

2. Garrick JG and Webb DR (1999) Sports Injuries Diagnosis and Management.

3. C.J. Couture and K.A. Karlson, Tibial stress injuries, Phys Sports Med30 (2002)(6), pp. 2936.

4. C.N. van Dijk, L.S. Lim, P.M. Bossuyt and R.K. Marti, Physical examination is

sufficient for the diagnosis of sprained ankles, J Bone Joint Surg Br79 (1997)(6), pp. 10391040.

5. Michlovitz MS (1996) Thermal Agents in Rehabilitation, F.A. Davis Company:Philadelphia

6 Anderson SJ (2205) Disease a Month. Volume 51, Issues 8-9.

7. Dr Aston Ngai. 6th ISSC 2006.

8. Crowther CL (1999) Primary Orthopaedic Care. Mosby, St Louis.
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ReferencesReferences9. Knight KL (1985) Cry therapy, Theory, Technique, Physiology. Chattanoga

Corp.Chattanoga, TN, p 154

10. Low J and Reed A (1990) Electrotherapy Explained: Principle and Practice.Butterworth-Heinemann, Oxford

11. Leung CP, Ng YF and Yip KK (2005) Therapeutic ultrasound enhances media-

lcollateral ligament repair in rats Ultrasound in Medicine & Biology Volume 32,

Issue 3, March 2006, Pages 449-452

12. Baker RJ and Bell GW (1991) The effect of therapeutic modalities on blood flow inthe human calf. Journal Orthopaedic Sports Physical Therapy 13 (23).

13. Richardson JK and Iglarsh ZA (1994) Clinical Orthopaedic Physical Therapy.WBSaunder Company. London.

14. Michlovitz S , Hun L, Erasala GM, Hengehold DA and Weingand KW (2003)Continuous low-level heat wrap therapy is effective for treating wrist pain. ArchPhys Med Rehabil 2004;85:140916.

ReferencesReferences


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ReferencesReferences15. Hayes KW (1993) Heat and cold in the management of rheumatoid arthritis.

Arthritis Care and Research6), pp. 156166

16. Hensley S (1992) Comparison of tolerance to high and low temperature paraffin

in children with arthritis and related diseases, Arthritis Care and Research5(1992), p. S8.

17. Shanker K and Randall KD (2002) Therapeutic Physical Modalities. Hanleyand Belfus Inc. Philadelphia.

18. Falconer J, Hayes KW, Chang RW (1990) Therapeutic Ultrasound in thetreatment of musculoskeletal condition. Arthritis Care Res. 3 (2): 85.

19. Wilson DH (1974) Comparison of Shortwave Diathermy and pulsed

electromagnetic energy in treatment of soft tissue injuries. Physiotherapy, 60,309-10.

20. Wagstaff P, Wagstaff S, Downey M (1986) A pilot study to compare the efficacyof continuous and pulsed magnetic (SWD) on the relief of low back pain.

Physiotherapy, 72, 563-6
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ReferencesReferences21. McGill SN (1989) The effects of pulsed Shortwave therapy on lateral ligament

sprain of the ankle . New Zealand Journal of Physiotherapy, 16, 21-4

22. Pasila M, Visuri T, Sundholm A (1978) Pulsating shortwave diathermy: value intreatment of ankle and foot sprains. Arch Phys Med Rehabil, 59, 283-6.

23. http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp

24. http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp
http://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsphttp://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsphttp://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsphttp://www.healthatoz.com/healthatoz/Atoz/ency/sports_injuries.jsp


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AcknowledgementAcknowledgement

I would like to express my gratitude to My Supervisor Dr. Oleks

Unit Head Dr. Chen Chee Keong

Ass. Prof Dr. Asok

Academic Advisor Dr. Jolly

All my classmates


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Thank you forThank you foryour attentionyour attention

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