Week 4 Lecture 2

Acute: Soft tissue -Muscle tears -Capsulo/ligamentous sprains -Contusions Articular -Osteochondral lesions/fractures Bone -Fractures Chronic/non-acute: Lower limb overuse tendinopathies Achilles Patella Tibialis posterior Upper hamstring Upper limb overuse tendinopathies -Rotator cuff -Lateral epicondylagia -Medial epicondylagia Fasciopathies/other non-contractile tissue disorders - Plantar fasciopathy - Retinacular and ligamentous stress reactions Chronic exertional (exercise =-related) syndroms Bony disorders Bony stress reactions OCDosteochondritisdissecans) Bone stress injuries Stress fractures Joint disorders Articular stress reactions Degenerative joint disorders Inflammatory diseases RA, spondylopathies Infections Congenital lesions, deformities

Muscles: Functional muscle injury – acute indirect muscle disorder, no macroscopic evidence (in MRI) of muscular tear. Associated with increase of muscle tone Structural muscle injury – any acute indirect muscle injury with macroscopic evidence Classically labeled as a ‘strain’ injury Ligaments: Grade I, II, III, IV (III plus avulsion) Indicates severity Joint surfaces: Isolated OC lesion Associated lesion Classfication: Matrix and AC cell injuries (micro-trauma to joint surface) Chondral injury- Cartilage disruption (macroscopitc injury, variable patterns: fissure, flap, tear) osteochondral injury (Cartilage + bone disruption) • also classified with grades 1-4 Tendon: Reactive/proliferative Hx of acute overload De-trained athlete returning to training Tendon disrepair Hx of repeated or chronic overload Degenerative tendinopathy Long term (mal)adaptive changes Fascia:

INDIRECT vs DIRECT Indirect: Structural vs Functional Stage: (acute, subacute, chronic) Grade: severity of injury Associated injuries

Indirect: Inability to tolerate forces transferred to or generated within a tissue structure Direct injury: Contusion or impact injury

INDIRECT Type 1 overexertion related (functional) -Ia Fatigue induced -Ib DOMS Type II Neuromuscular disorder( functional) • IIa Spine related muscle disorder • IIB Muscle related muscle disorder Type III Partial muscle tear (Structural) • IIa minor partial tear • IIb moderate partial tear Type IV (sub) total muscle tear(Structural) DIRECT- contusion -laceration

Over exertion related disorder IA Fatigue induced mms disorder Circumscribed longitudinal increase in mms tone due to overexertion (change of playing surface, change in training patterns) Aching mms firmness, can provoke pain at rest, during or after activity Dull diffuse tolerabel pain in involved mms Circumscribed increase in tone, mms tightness MRI: neg

OVEREXERTION RELATED DISORDER DOMS Generalised muscle pain following unaccustomed eccentric deceleration movements Acute inflammatory pain. Pain at rest hours after activity Odematous swelling, stiff mms, limited ROM, pain on isometric contraction Stretching leads to releif MRI: Neg or odema only

NEUROMUSCULAR DISORDER Spine related neuromuscular disorder Circumscribed longitudinal increase in mms tone due to functional or structural disorder Aching mms firmness. Increases with continued activity No pain at rest Discreet odema b/n mms & fascia occasional skin sensitivity. Defensiver reaction on muscle stretching. Pressure pain. MRI: neg or odema

NEUROMUSCULAR DISORDER Muscle related neuromuscular disorder Circumscribed (spindle shaped) area of mms tone Results from dysfunctional neuromuscular control aching gradually increases mms firmness Cramp like pain Odematous swelling, theraputic stretching> releif Pressure pain MRI: neg or odema

PARTIAL MUSCLE TEAR Minor partial muscle tear Tear with max diameter less than muscle fascicle/bundle Sharp needle like stabbing pain at time of injury Well defined localised pain Palpable defect in fibre structure within a firm muscle band Stretch induced pain aggravation MRI: pos for fibre disruption. intramuscular hematoma

PARTIAL MUSCLE TEAR Moderate partial muscle tear Tear with diameter greater than fasicle/bundle Sharp stabbing pain @ time of injury Well defined localised pain Palpable defect in muscle structure often hematoma fascial injury Stretch induced pain aggragation MRI: pos for sig fibres disruption & retraction Intramuscular hematoma Fascial injury

Sub total muscle tear/tendinous avulsion Tear involving subtotal/complete muscle diameter Tendinous injury involving bone tendon junction Dull pain @ time of injury Noticable tearing ‘snap’ followed by sudden onset of localised pain Large defectin in muscle Hematoma Muscle retraction Pain with movement Loss of function MRI: subtotal/complete discontinuity of muscle

Direct mms trauma caused by blunt external force Leads to diffuse or circumscribed hematoma within muscle causing pain and loss of motion Dull pain @ time of injury Increased due to hematoma Dull diffuse pain Hematoma Pain on mvmnt Swelling Decreased ROM, TOP

Muscle: Ultrasound MRI Clinical diagnosis usually adequate Ligaments: Abnormal end-feel Joint surfaces: CT scan MRI HORRIBLE ANSWER

Challenged wisdom to mobilise aggressively post ankle-sprain: Resulted to severe, acute ankle sprain injuries Found superior results with a period of immediate complete immovilisation versus early, aggressive mobilization at 10 days post But same outcomes at 6/12 CLINICAL BOTTOM LINE: Limited period of joint protection with a graduated return to FWB is indicated – including some relatively mild cases

GRADE 1 4-10% deformation A few fibres torn, capsule intact, joint stable Painful on stress testing Increased range/laxity on testing End feel may be slightly softer GRADE 2 10-20 % deformation <50% fibres torn +- capsule tear, joint stable Painfull on stress testing Significantly increased range/laxity on testing End feel markedly soft GRADE 3 >20% deformation \+- capsule tear, joint unstable may or may not be painful if complete rupture marked abnormal laxity on testing Hollow end feel GRADE 4 Grade 3 + avulsion

MATRIX INJURIES • variable pain response • low grade effusion & synovitis • undetectable on imaging • some cell proliferation, generally reversible CHONDRAL INJURIES( cartilage destruction) Pain & intolerance of joint loading Synovitis & effusion more marked Mechanical symptoms more common *synovial macrophages ingest particles & release catabolic substances * some attempt to repair at margins(chondrocytes unable to migrate to to lack of inflam response) * increased matrix synthesis at margins but deficit not repaired OSTOCHONDRAL INJURIES(cartilage+subchondral bone Grade 4 or greater -Hemmorage clotting with associated inflam response -Clot fills bone defect -Platelets release growth factors -Chondrocytes produce hyaline cartilage in defect (2 weeks post) -Immature bone & fibrous osseous tissue fills osseous defect -Chondral repair (6-8) weeks repair breaks down within (1-2) years Defect leaves subchondral bone exposed

Grade 0 = normal 1 Chondral softening & blistering 2 Partial thickness AC injury less than 50% depth 3 Deeper partial thickness AC injury > 50% depth 4 Full thickness cartilage loss with exposure of subchondral bone Clinical features Effusion on MRI Bone scan. Increased BF in synovial lining XRay only detects ostochondral lesions