What are the 4 phases of tissue healing?
Four Phases of Tissue Healing
- Remodeling (takes the longest, weeks to months)
What are the 3 phases of tendon healing?
- Reactive (inflammatory)
- Reparative or proliferative (scar)
- "Normal" elastic type 1 collagen fibers replaced with weaker (type 3)
- Remodeling (slow)
Describe the healing process of bone.
- Fracture & Inflammation
- Disruption of osteocytes & haversion canals
- Repair: osteoblast, fibroblast and vascular progenitor vs. "modifies" (osteoclasts)
- Remodeling: long slow road to adaptation and healing
What are the affects of aging on MSK tissue?
- Collagen/connective tissue (particularly type I & type II, ligaments and tendons) decrease water content, become more rigid and brittle & become less flexible and adaptive
- Sarcopenia (muscle "thinning") occurs: both amount of muscle tissue and the number and size of muscle fibers decrease
- Fast twitch (type II) muscle fibers are more signifcantly affected
- The result is a gradual loss of muscle mass and muscle trength; this degenerative affect on MSK tissue can be minimized with regular exercise (stressing) of the various tissue types
Describe the grading of overuse injuries in athletes:
Grading of Overuse Injuries in Athletes
Grade 1: No pain with activity, but some discomfort afterward (1-2 days)
Grade 2: Some discomfort with activity but does not interfere with performance (1-2 wks)
Grade 3: Discomfort with activity; interferes with performance (4-6 wks)
Grade 4: Discomfort so intense that activity cannot be performed at all (ill defined)
An elite marathoner presents to your clinic. She complains of "shin splints" that have become so uncomfortable she has started to miss training. How would you grade her injury? What is the management for this type of injury?
This athlete's discomfort has become so intesne that the activity cannot be performed at all. This is a grade 4 overuse injury.
Management of Overuse Injuries
- Identify offending stress & contributing intrinsic or extrinsic factors
- Reduce the stress on the tissue until symptoms have subsided, avoid immobiliazation
- Rehabilitate the injured area
- Graduated and progressive return to activity suach as the walk-run program to allow the tissue to adapt to stress
- Don't STOP, CHANGE (active rehab)
A 30 yr old male presents the the clinic with a CC of knee pain. He describes an achy and stiff pain in both knees. The patient mentions that a couple of months ago he started a new job laying hardwood floor. What is the most likely diagnosis?
- Traumatic, septic, or inflammatory etiologies ex. inflammatory arthritis such as rheumatoid arthritis, gout, and infection
- Knee bursitis is often seen in brick layers (leaning on the joint for long periods of time)
- Bursitis is an inflammation or degeneration of the sac-like structures that protect the soft tissues from underlying bony prominences 
- Septic bursitis refers to inflammation of the bursa that is due to infection, typically resulting from bacterial inoculation that is direct (eg, puncture wound), spread from nearby soft tissues (eg, cellulitis), or hematogenous (eg, bacterial endocarditis).
Define the following:
Tendinitis: inflammation of tendon (can't ACTUALLY know that this is happening without a pathology report)
Tendinopathy: "diseased" tendon
Tendinosis: focal are of intratendinous degeneration
Tenosynovitis: inflammation in the tendon sheath (peritendinitis)
Enthesopathy: tendon disease at insertion (bone-tendon interface)
Genie Bouchard presents to your clinic complaining of elbow pain. She has recently been working on her back hand. On physical exam the elbow appears to have mild swelling and is tender on palpation. What is the most likely diagnosis? What is the treatment?
Tendonitis (Tennis Elbow = Lateral Epicondylitis)
- Common tendinopathies: achilles, patella, rotator cuff, elbow
- RICE (Rest, Ice, Compression, Elevation)
- Braces & splints
- Eccentric exercise to strengthen muscles around the tendon (proceed with caution)
A pt. presents to the ER with a L tibial shaft fracture. The patient complains of excrutiating pain, more painful than what is usually described for a fracture. The patient also appears pale on physical exam. The L lower extremity is swollen. What is the treatment?
This patient likely has acute compartment syndrome. This is a surgical emergency (urgent fasciotomy)!
Acute Compartment Syndrome
- Results from acute trauma (fracture, crush, contusion with hematoma)
- Rapid increase in pressure compresses blood vessels in compartment and results in loss of blood flow to the muscle and eventual myonecrosis
A 23 yr old Dinos soccer player presents to the clinic complaining of 10/10 pain in her lower legs (specifically in her 'calf' muscles). She says that the pain tends to develop shortly after warm up, in their first drill and persists throughout practice. After practice, by the time she drives home the pain tends to subside. What is the diagnosis and treatment?
This pt. likely has chronic (exertional) compartment syndrome.
Chronic Compartment Syndrome
- Overuse history: may be insidious onset or after one or more signifcant overuse events
- Most commonly affects lower leg
- Pain begins at certain time into activity, disappears with cessation of activity
- R/O neurogenic and vascular claudication
- Treatment: activity modification or surgical decompression (fasciotomy)
A 24 yr old female med student and runner presents to the clinic complaining of knee pain. She says that it occurs with running and worsens when descending hills. She also finds that the pain returns when sitting in lecture for long hours in the day. What is the diagnosis?
Patellofemoral Pain Syndrome
- Variety of names: runner's knee, anterior knee pain and chondromalacia patellae
- Most common "knee pain" presentation
- Exact cause unknown: muscle imbalance, biomechanical, chondral architecture and mechanics, patellofemoral instability
- Retropatellar or peripatellar pain
- Typically occurs with activity and often worsens when descending steps or hills
- It can also be triggered by prolonged sitting (the theatre sign_)
- Multiple causes, multiple treamtents but don't do nothing
Describe the 3 degrees of muscle strains.
1st degree: microtearing, mild pain, swelling, spasm
2nd degree: partial tear, moderate symptoms with some loss of function
3rd degree: complete tear, severe symptoms with significant functional loss
At shot put practice, a 22 yr old male dropped the ball on his thigh. He suffered a contusion-hematoma. What complication(s) might he be at risk for?
- Contusion-hematoma: crush injury of muscle tissue with bleeding
- Usually from direct blow
- Quadricep contusion/hematoma "charley horse"
- Beware of NSAID usage, less sticky platelets may result in ++ bleeding
Complication - Myositis Ossificans
- Myositis ossificans is the heterotropic ossification occurring in muscle tissue after moderate or severe contusion-hematoma
- Clinically, it presents with increasing pain and reduced ROM following a muscle contusion
- Most common in quadriceps and biceps but can occur in any muscle
- Diagnosis: awareness, x-ray positive for calcification at 2-3 wks, bone scan 1 wk earlier
An 18 yr old elite basketball player jumped up for a rebound when he experienced pain in his lower leg. He described the pain as feeling like someone had shot him in the leg. Upon physical examination you note a positive Thompson's test. What is your diagnosis? What is the treatment?
- Force exceeds tensile strength
- Usually sudden eccentric load
- Predisposing factors include diabetes, arthritis, fluoroquinolones, anabolic steroids
- +/- antecedant pain indicating tendon disease
- Treatment: longer recovery whether surgical or non-surgical (tissue perfusion), dependent on rehab (avoid stretching, and emphasize cellular nutrition & progressive strengthening)
This pt. likely has an achilles tendon rupture.
- Pt. describes feeling like someone hit them or shot them in the leg
- Positive Thompson's test and palpable gap
- Dorsiflexed foot
- Early diagnosis is crucial
- Treatment: most often managed non-operatively if treatment provided early, surgery in special circumstances (gap has formed)
Describe the grading of ligament injuries (I, II, III).
Ligament Injury Grading
Grade I: mild, the ligament is stretched, but only a few fibers are disrupted
Grade II: moderate, where the ligament is partially disrupted
Grade III: severe, the ligament is totally disrupted
A AA female soccer player presents to the sports medicine clinic with a L knee injury. She describes a popping sound as she changed directions with the ball, which was when the injury occurred. On PE you notice that her L knee is swollen in comparison to her R. She has a positive Lachman test. What is the diagnosis and treatment?
This athlete has likely torn her ACL. The treatment may be surgical or non-surgical (physio., bracing, activity modification).
- More often non-contact injuries, common in twisting, pivoting, jumping sports
- VERPS: Valgus force, External Rotation, Pop, Swell
- Common in female soccer players: neuromuscular, alignment, hormonal
- Treatment: non operative (physio., bracing, avoid high risk activities), surgery (quality of life questionnaire is helpful)
ACL Pivot Shift Injury
- ACL tear: the anterior tibial translation +/- pivot
- Posterolateral tibia impacts lateral femoral condyle
- Bone bruise, meniscus tear, chondral injury, osteochondral injury, fracture
What is the treatment for a patellar dislocation?
- Typical MOI involves external rotation with valgus force
- Often dislocates laterally
- Severey pain and swelling
- Patella can spontaneously reduce or require bystander/physician reduction
- Common cause of knee instability in adolescent females (mutli-factorial)
- Treatment: PRICE (Protection/stabilize, Rest, Ice, Compression, Elevation), extensive physiotherapy, brace (controversial), chronic patellar instability may require surgical intervention (associated injuries)
What is the grading for a lateral ankle sprain?
Lateral Ankle Sprain Grading
Grade I: stretching of ligament(s) without significant tearing
Grade II: ligaments are partially torn
Grade III: ligaments are completely torn
You are on the medical service for a trail marathon. A runner is brought to the medical tent after rolling his ankle. The runner says that his foot rolled inside while running on a heavily rooted path. Any weight bearing causes significant pain to the pt. and you notice bruising and swelling on the exam. What exam do you complete to to determin if an x-ray is needed? What is the most likely diagnosis?
This pt. likely has a lateral ankle sprain.
- Common injury which results from an inversion (rolling) MOI of the ankle
- Involves injury to the lateral ankle ligaments which provide stability to the talotibial joint
- Often there is pain with attempted wt. bearing, significant bruising and swelling (grade 2 and 3 sprains)
- Ottawa Ankle Rules provide guideline on when to x-ray the ankle
You are on the medical service for a trail marathon. A runner is brought to the medical tent after rolling his ankle. The runner says that his foot rolled inside while running on a heavily rooted path. Any weight bearing causes significant pain to the pt. and you notice bruising and swelling on the exam. What is the management for this pt.?
Management of Lateral Ankle Sprains
- Rehab is key to avoiding chronic pain and dysfunction after ankle sprain
- May initially require crutches, immobilization (avoid if possible)
- Proprioceptive (position sense) retraining is crucial to rehab
- Often 6-12 wks before able to return to play
- Key is to restore function
What injury results in this deformity?
Long Head of Biceps Tendon Rupture
What structures are contained within the carpal tunnel?
Flexor digitorum profundus (4 tendons)
Flexor digitorum superficialis (4 tendons)
Flexor pollicis longus (1 tendon)
Flexor carpi radialis (1 tendon)