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Sports Med Lecture

Sports Med Lecture

by elisebaudille@gmail.com, Sep. 2011

Subjects: lecture med sports

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	Highest incidence of TBI ages:	15-24
	Annual incidence of sports related TBI:	300,000
	Highest risk for head injury per 100,000 (sport)	football, soccer, gymnastics, ice hockey
	Sports where concussions are common:	Rugby, football, MMA, gymnastics, equestrian sports
	Do the majority of sports-related concussions involve loss of consciousness?	No. Important because the athlete may not tell you their symptoms and the majority of concussion scales grade based on length of unconsciousness.
	Do athletes usually report concussion symptoms? What's the rate of report?	No; 15-45%
	What sport has the highest number of concussions? What percent of all injuries in this sport do concussions account for?	Football; 8-11% of all injuries
	___% of football players get concussions making a tackle; ___% get concussions getting tackled.	43; 23
	Is concussion incidence in football higher during practices or games?	games
	Players with one concussion are ___times more likely to sustain a second one.	3
	Higher incidence of concussion on artificial turf or real grass?	turf
	Do males or females sustain a higher percent of concussions during games?	Females
	Definitions of concussion:	A clinical syndrome characterized by the immediate and transient post-traumatic impairment of neural function such as alteration of consciousness, disturbance of vision or equilibrium etc. due to brainstem involvement. A trauma-induced alteration in mental status that may or may not involve lose of consciousness. A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
	What is the primary complaint after concussion in 81% of athletes?	headache
	Hallmarks of concussion:	confusion and amnesia
	MOI for concussion:	acceleration-deceleration injury
	Types of acceleration-deceleration injuries:	Linear (translational) acceleration Angular (rotational) acceleration Focal impact Combination
	Focal impact:	point at which head strikes hard object. Maximal stress at point of injury.
	Damage caused by focal impact:	Skull fracture Structural injury to brain parenchyma, vessels, or dura Injury to distal neural structures due to dissipation of force.
	Linear acceleration:	Vector perpendicular to skull. Tensile and compressive forces occur. Coup/contracoup injuries due to brain floating in CSF and brain acc/de relative to skull. Well tolerated.
	Tensile forces:	ability to resist deformation
	Compressive force:	pushing in until area fails
	Angular acceleration:	Rapid turning of head Shearing force w/in brain parenchyma. Poor prognosis
	Where is injury maximal for angular acceleration injuries?	Maximal where rotation is impaired. Falx cerebri and tentorium cerebelli. Increased force transmission to proximal structures. Brainstem and corpus callosum.
	Pathophysiology of concussion includes:	Decreased cerebral blood flow Metabolic disarray Glycolysis
	Concussion Pathophysiology- cerebral blood flow	Decreased flow 2 degrees to mild TBI. Cerebrovascular dysautoregulation Resultant ischemia & edema Concomitant brain stem capillary damage
	Concussion pathophys- metabolic disarray:	Membrane destabilization Rapid release of glutamate (1st degree excitatory NT) Neuronal depolarization Increased extracellular potassium Increased intracellular calcium leading to apoptosis Decreased brain intracellular and total magnesium (for ionic balance of injured cells)
	Concussion pathophys- glycolysis:	Attempt to resolve metabolic disarray. Activation of energy-dependent ionic pumps Increased energy demand Cerebral oxidative metabolism at baseline is already near maximum levels. Leads to acute hyperglycolysis and lactic acidosis
	S & S of concussion:	Confusion Loss of consciousness Post-traumatic or retrograde amnesia Disorientation Delayed verbal/motor response Inability to focus *Headache Nausea/vomiting Visual disturbance (photophobia, blurred vision, diploplia) Disequilibrium Vacant stare Emotional lability Dizziness Slurred/incoherent speech Excessive drowsiness
	Concussion AKA:	Mild TBI or MHI (mild head injury)
	Post-traumatic amnesia-	no recollection of what happened immediately after injury
	Retrograde amnesia-	can't remember what happened prior to event
	What is the key symptom in concussion?	headache as response to brain becoming hyperactive
	Photophobia-	sensitivity to light
	What are the image results typically for a concussion?	Typically normal.
	Indications for imaging w/ concussion:	Suspicion for intracranial/intracerebral lesion Prolonged disturbance of conscious state Focal neurological deficit Worsening sx Repeat concussion
	Second impact syndrome:	Loss of cerebrovascular autoregulation Vascular engorgement within cranium Markedly increased ICP Herniation of temporal lobe uncus or cerebellar tonsils Rapid brain stem failure
	Rapid brainstem failure results in:	Coma Ocular involvement Respiratory failure
	Second impact syndrome has ___% morbidity and ___% mortality.	100; 50
	Seizure is a complication of about ___% of TBI.	5
	Seizures and concussion:	Occur within first 7 days Associated with skull fx and cerebral contusion More likely to occur in adults
	Seizure risk factors:	recent seizure w/in 7 days of insult PTA greater than 12 hours Intracranial bleeding Persistent neuro deficit
	S & S of post-concussive syndrome:	Loss of intellectual capacity Poor recent memory Personality change Headache Dizziness Lack of concentration Poor attention Fatigue Irritability Phonophobia Photophobia Sleep disturbance Depressed mood Anxiety
	Post-concussive syndrome management:	Rest, prevention of further injury Behavioral modification Psychotherapy Biofeedback Medications- analgesics, B-blockers, anti-depressant
	Primary concussion assessment:	Neuro exam and interrogation
	Basic neuropsychological exam inclues what components?	Orientation- name city, opponent, day, score, quarter, etc Concentration (immediate)- repeat five words in correct sequence Presence of retrograde amnesia- recall events prior to play, score at time of injury, memory of injury, memory of events before injury Memory (recall 5 minutes later)- Repeat same five words in correct sequence Balance- ask to stand on one foot, evaluate tandem gait
	___% of athletic concussions do not involve loss of consciousness.	Greater than 90
	AAN system concussion grading scale:	1 (mild)-No LOC, sx less than 15 min. 2 (moderate)- No LOC, sx greater than 15 min 3 (severe)- any LOC
	Cantu system concussion grades:	Grade 1 (mild)- no LOC or PTA less than 30 min 2 (mod)- LOC <5 min, PTA 30 min-24 hrs 3- LOC >5 min, PTA>24 hrs
	Simple concussion ICCS system-	Progressively resolves w/o complication over 7-10 days No further intervention required Athlete resumes sport w/o problem Management: rest until resolution of sx
	Complex concussion ICCS system-	Prolonged LOC, prolonged cognitive impairment Persistent sx, specific sequelae Multiple concussions or repeated concussions w/ less impact force Formal neuropsychological testing or imaging
	What age group demonstrates prolonged memory impairment: high school or college?	high school
	RTP protocol should be:	modified for each individual patient More conservative for adolescent athletes
	RTP Contraindications:	Presence of post-concussive sx Permanent neuro deficit Hydrocephalus Spontaneous subarachnoid hemorrhage Symptomatic abnormality at foramen magnum
	Return to play protocol:	No activity, complete rest for 1st few days. Light aerobic exercise (walking or stationary cycling, no resistance training). Sport specific exercise (skating for hockey, running soccer, progressive resistance training) Non-contact training drills Full contact training RTP Supervised by physician, 24 hours for each step, no pharm agents
	If you 've had one concussion you're ___ x more likely to get a second.	3-6
	Universal agreements regarding management of athlete w/ concussion:	Remove from play to be observed and examined Serial assessments Complete resolution of sx at rest and w/ exertion Deteriorating condition Post-surgical acute subdural hematoma doesn't return to play
	___% of all concussions result in LOC or amnesia	<10
	Unconscious athlete w/ equipment:	Remove face mask immediately for airway. Supine position w/ immobilization Helmet and chinstrap maintained Helmet and shoulder pads are unit- head in neutral alignment; if removed as a unit at med facility ABCs
	ON field assessment of conscious athlete:	History of: injury, pain/tingling in neck or head, sensory or motor changes Exam: sensory or motor deficits, neck palpation, AROM
	Sideline assessment of conscious athlete:	History of headache, dizziness, visual changes, motor/sensory changes. Mental status exam Looking for deterioration of consciousness Neuro exam Balance Error Scoring system (BESS) Standardized Assessment of Concussion (SAC) Neuropsych Test Battery
	Mental Status Exam	Static memory Short term, PTA Immediate recall Info processing
	Neuro exam:	Strength, sensation Pupils Finger to nose
	Concussion outcome measurement tools:	Graded symptom checklist Postural testing- BESS SAC Neuropsych testing The last 3 should be done at baseline and post-concussion
	Graded symptom checklist:	Post-concussive sx Self-rated presence and severity of 17 sx Likert scale of 0 (no sx) to 6 (severe) per item Higher score- greater severity
	Postural stability assessment	BESS Double, single, and tandem stance on firm surface and foam Hands on hips, eyes closed 20 second trials Errors: hands off hips, open eyes, step, lift heel, outside test position >5s, hip >30 abd/flexion
	If postural stability doesn't return to baseline w/in 3 days, what difficulties are occuring?	sensory interaction difficulties
	Standardized Assessment of Concussion (SAC)	Standardized means of objectively documenting the presence and severity of neurocognitive impairment associated w/ concussion. Immediately provide info to medical/sideline personnel for clinical decision making regarding athlete's status. Assessing orientation, concentration, and memory. Score from 0-30, lower= more severe cognitive impairment.
	Neuropsych testing	Measures functions of memory, attention, speed, and flexibility of cognitive processing. Lower scores indicate greater impairment except for trail making test. Baseline testing preseason is essential. Determination of RTP
	Neuropsych tests for athletes include what subtests?	Hopkins verbal learning test (memory) Stroop color word test (mental flexibility) Trail making test B (cognitive processing) Symbol digit modalities test (cog processing) Controlled oral word association test (verbal fluency)
	Neurocognitive testing on field instruments	SAC, SCAT Exclude key components of cognition, limited sensitivity. Info processing speed Attention Concentration Reaction time Visual scanning and tracking Memory recall Problem solving
	Neurocognitive tests include:	CogSport Headminder ImPACT
	Computerized NCT ___ diagnostic accuracy.	increases
	Neurocognitive impairment often persists despite subjective symptom resolution. T/F?	T
	What's the only true articulation between shoulder girdle and axial skeleton?	SC joint
	What type of stability does the SC joint have?	Little bony stability but significant ligamentous support.
	Types of SC joint sprains:	Anterior and posterior
	What shoulder girdle motion produces anterior SC d/l?	excessive shoulder girdle retraction
	What shoulder girdle motion produces posterior SC d/l?	excessive shoulder girdle protraction
	What structures are at risk w/ SC joint sprains?	Brachiocephalic A and V Subclavian A and V Jugular V Carotid A Trachea Esophagus Lungs and pleurae Brachial plexus
	What complications may arise with posterior SC d/l and what percent of the time does this occur?	Compression/laceration of underlying structures 25% of all traumatic cases
	SC joint sprain MOI	Direct or indirect Most commonly lateral compression of the shoulder girdle. Forcible protraction or retraction w/ compression.
	SC sprain S&S	Well localized pain, swelling, and pain with shoulder girdle motion. Crepitus on motion (ensure no fx) Limited shoulder motion Palpable tenderness Varying degrees of disrupted anatomical alignment W/ posterior d/l S&S of damage to underlying structures.
	SC sprain diagnosis:	History S&S Positive squeeze test X-ray to rule out fx of clavicle or sternum
	MOI clavicle fx	Direct or indirect trauma Fall onto outstretched hand
	S&S of clavicle fx:	Snapping/cracking sensation at time of injury Immediate, well localized pain Rapid swelling Crepitus and increased pain on motion Fragments tend to override each other Limitation of motion Varying degrees of deformity
	Diagnosis of clavicle fx	History, S&S Confirm via x-ray Rule out injury to underlying structures esp laceration of subclavian A Figure of 8 wrap may increase comfort for transport to hospital
	AC sprains MOI	Direct blow to the superior aspect of the acromion which drives the scapula inferiorly. Falls on point of shoulder. Less common- direct blow to clavicle or indirectly a fall on the elbow or outstretched hand
	What are the ligaments of the AC joint?	AC ligament (across superior portion of joint; not very strong, prevents clavicle from riding up) Coracoclavicular ligament (coracoid process to clavicle; made of conoid and trapezoid running on either side of clavicle serving as a check ring to hold clavicle down.
	S&S of AC sprain	Point tenderness over AC joint Tenderness over coracoclavicular space (gr 2-3). Varying degrees of deformity. Increased pain with shoulder girdle motion. Gr 1- usually AC lig, 2- 2 ligs, 3- all three- tends to migrate superiorly or superiorly/posteriorly. Compare bilaterally.
	AC sprain diagnosis:	History, S&S x-ray Check alignment Rule out distal clavicle fx
	Anterior GH instability MOI	Classical- forced abduction and ER
	Anterior GH instability S&S	Considerable pain upon initial d/l Arm held in slight abducted, ER position, supported by uninjured arm. IR is painful and resisted by athlete. Loss of normal shoulder contour- prominent acromion process, indentation under acromion process (sulcus sign)
	What N is commonly damaged in anterior GH d/l, what is the incidence of this happening, and what is the most reliable clinical test?	33% incidence of axillary N damage. Isometric testing of anterior deltoid May check sensory function of axillary but not always reliable
	Anterior GH instability diagnosis:	History, S&S Positive apprehensive sign X-rays may be helpful pre reduction, but should always be done post-reduction.
	Job relocation test-	Pushing the humeral head posterior to see if you get a positive response. Done after positive apprehension test in GH instability.
	Recurrent GH s/l	Transient displacement of the humeral head w/ respect to the glenoid fossa, associated w/ momentary disruption of shoulder function.
	Recurrent GH s/l MOI	Acute or repetitive trauma- insufficiency of the dynamic or static stabilizers of the GH joint
	Recurrent GH s/l anterior instability caused by:	repetitive/forced abduction and ER
	Recurrent GH s/l posterior instability caused by:	repetitive/forced adduction and IR
	S&S of recurrent GH s/l	Pain, apprehension, instability w/ shoulder motion. Dead arm sensation- must r/o c-spine or BPI
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l W/ anterior instability-	Depression and protraction of shoulder girdle, limited ER, and change in normal scapulothoracic rhythm during abduction
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Recurrent GH s/l w/ posterior instability-	Decrease in IR, change in scapulothoracic rhythm during horizontal flexion, ER weakness, tenderness over the greater tuberosity, and positive impingement sign
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	Diagnosis of GH recurrent s/l	History, S&S Positive apprehension sign.
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Posterior GH instability MOI:	Posteriorly directed force to an adducted, IR arm w/ the arm below shoulder level Rare S/l more common- pull-through phase of freestyle swimming and backhand stroke in tennis
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	S&S of post GH instability	Inability to ER- arm locked in IR, inability to abduct shoulder May or may not have pain or awareness of trauma Change in performance
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	Post GH instability diagnosis-	History, S&S Positive apprehension test Positive or negative clunk test
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	Multidirectional GH instability-	Instability in more than one direction Typically anterior or posterior w/ inferior May present as global instability- anterior, posterior, and inferior
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	MOI of multidirectional instability-	May be traumatic, more commonly atraumatic or voluntary
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	S&S of multidirectional instability	May or may not have pain Insidious onset unless related to trauma Decreased function
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	Multidirectional instability diagnosis	History, S&S Positive apprehension and sulcus sign 3 finger inferior sulcus is substantial
	SLAP lesion	Described as an injury (tissue disruption or tear) located w/in the superior labrum extending from the anterior to posterior region.
	MOI SLAP lesion	Can be a single traumatic event ( GH d/l, falling on outstretched arm) or repetitive microtraumatic injuries (throwing). Peel-back mechanism- position of 90 ABD and max ER, a torsional force is produced at the proximal anchor of the long head biceps tendon (over time can lead to the peeling back of the superior aspect of the labrum)
	Type 1 SLAP clinical features	Positive speed test and supraspinatus tear significantly associated w/ type 1.
	Type 2 SLAP clinical features	In patients younger than 40, Type 2 associated w/ Bankhart lesion Patients older than 40 type 2 were associated w/ supraspinatus tear and OA of humeral head
	Type 3-4 SLAP clinical features	Lesions associated w/ high-demand occupation and a Bankhart lesion
	Diagnostic tests for SLAP lesions	No single test specific enough, instead a cluster of tests should be used. Active compression (O'Brien's) Anterior apprehension Biceps load test (I&II) Crank test Clunk test Compression rotation test Resisted supination and ER Pain provocation MRI, x-ray
	What's the most common cause of chronic shoulder pain in athletes?	Shoulder impingment syndrome
	Most cases of impingement syndrome are due to:	Insufficiency of the rotator cuff mm
	Shoulder impingement syndrome MOI	Forced/repetitive abduction and external rotation (subscap impingement) Forced/repetitive adduction and IR (infra and teres minor) Resisted abduction or forced adduction (supra) Insufficiency of scapular stabilizers
	S&S of shoulder impingement syndrome	Deep, aching shoulder pain- lateral aspect of arm, delt insertion Progressive of sx Point tenderness over involved muscle tendon unit- pain on specific mmt Involvement of secondary structures- subacromial tenderness and positive impingement sign
	Bankhart lesion-	see when humeral head migrates anterior over anterior portion of glenoid rim taking with it portion of anterior labrum.
	Thoracic outlet syndromes:	Compression of the neurovascular bundle. Anterior scalene Pec minor Costoclavicular Cervical rib
	TOS- anterior scalene syndrome:	Posture related- forward head, increased kyphosis
	TOS- pec minor syndrome:	posture related- abducted scapula, protracted shoulder girdle
	TOS- costoclavicular syndrome:	Posture related- shoulder girdle depression
	TOS- cervical rib syndrome:	Posture related- forward head, depressed shoulder girdle Anatomical anomaly- supernumerary rib or elongated transverse process of C7
	S&S of TOS	Pain, numbness, and tingling Decreased radial pulse- cool, pale skin Sx made worse by fatigue
	TOS diagnosis	Positive differential test for involved structure- reproduction of sx (decreased radial pulse, increased numbness, pain, and tingling)
	Adson test/maneuver-	anterior scalene syndrome
	Wright test	Hyperabduction test Pec minor syndrome
	Costoclavicular test (military brace test)	Costoclavicular syndrome
	Halstead maneuver	cervical rib syndrome
	Posterior or posterolateral elbow d/l MOI	Fall onto outstretched hand w/ limb abducted and elbow extended- backward fall
	S&S of posterior/posterolateral elbow d/l	Severe musculoskeletal injury Snapping/cracking sensation at time of injury Immediate pain and swelling w/ limitation of motion Arm is held slightly flexed- supported, if possible, by uninvolved extremity May have tenting of skin- bony prominence pokes out tightening skin Characteristic deformity- prominent olecranon posteriorly or posterolaterally w/ skin tented and indented btween olecranon and arm.
	What must be ruled out in posterior/posterolateral elbow d/l?	R/O neurovascular involvement and medial epicondyle fx
	Olecranon bursitis MOI	AKA miner's or student's elbow Most common in wrestlers Direct trauma to the posterior aspect of the elbow. Repetitive pressure and friction (wrestling)
	S&S of olecranon bursitis	Discrete, variably tender mass over olecranon Variable swelling Elbow flexion limited w/ pain on overpressure May be signs of infection R/O septic bursitis
	Lateral epicondylitis (epicondylalgia)	Tennis elbow Common extensor tendinitis Most common cause of chronic elbow pain in athletes
	MOI for lateral epicondylitis	Multi-factorial Prolonged or repetitive use of the wrist extensors Sustained contraction as with grip Transmission of impact force Eccentric loading- most moderate-severe cases are due to eccentric loading of muscle/tendon complex
	S&S of lateral epicondylitis	Characteristic sx- lateral elbow pain related to use of the wrist extensors History of some change Progressive +/- crepitation-indicates chronicity of injury and laying down of scar tissue Change in routine is common. Point tenderness over lateral epicondyle Pain w/ resisted wrist extension and passive wrist flexion
	Lateral epicondylitis diagnosis:	History, S&S R/O cervical spine involvement especially c5 radiculopathy
	Medial epicondylitis MOI	AKA golfer's elbow Rapid deceleration of club head due to striking ground in front of ball. R/O UCL injury
	S&S of medial epicondylitis	Point tenderness over medial epicondyle Pain w/ resisted wrist flexion and passive wrist extension
	Medial tension/lateral compression syndromes:	Flexor/pronator tendinitis Medial epicondylitis Little leaguer's elbow Pitcher's elbow Capitellar osteochondrosis Elbow injuries caused by excessive valgus forces producing medial tension and lateral compression.
	Medial tension/lateral compression syndromes MOI (medial tension component)	Medial tension overload causing extra-articular injury Flexor/pronator strain or tendinitis UCL sprain Ulnar traction spurring (new bone laid down in response to excess tension) Ulnar neuritis
	Medial tension/lateral compression syndromes MOI of lateral compression component	Lateral compression overload-intra-articular injury Capitellar osteochondrosis Radial head deformity Loose body formation Degenerative joint disease
	Medial tension/lateral compression MOI	Common in throwers- mechanics of throwing and total amount of throwing Often develop secondary to shoulder problems
	S&S of medial tension/lateral compression syndromes	Medial elbow pain- use of wrist flexors and pronator teres; characteristic onset and progression of sx Pain, tingling, paresthesia- into hand, ulnar distribution Generalized pain, crepitation, swelling, and locking- lateral compression Point tenderness over medial epicondyle Pain- resisted flexion/pronation or passive wrist ext
	Posterior elbow impingement syndrome MOI	Repetitive, rapid, forceful extension of elbow. Throwing, punching, swinging a racquet/bat, doing a handstand. Repetitive valgus stress- impingement of medial aspect of olecranon against medial edge of olecranon fossa
	Posterior elbow impingement S&S	Onset early in season Sharp pain- active/passive elbow extension Pain well localized- posterior or posteromedial elbow Limitation of extension with stiffness, crepitation, and loose body sensation. Point tenderness over posterior/posteromedial olecranon. No pain w/ resisted elbow extension +/- palpable osteophyte formation over posteromedial olecranon MMT differentiates this from golfer's elbow
	Posterior elbow impingement syndrome diagnosis	Hist, S&S x-ray- extent of bony impingement w/ osteophyte formation and presence of loose bodies
	Pronator teres syndrome is associated with what N?	anterior interosseous N syndrome
	Pronator teres syndrome MOI	Compression of median N or anterior interosseous N- Swelling due to direct trauma or hypertrophy of pronator teres m
	S&S of anterior interosseous N syndrome	Weakness of flexor pollicis longus, flexor digitorum profundus to the index finger, and the pronator quadratus
	Pronator teres syndrome sx w/ median N involvement:	Weakness of flexor pollicis longus, flexor digitorum profundus to index finger, and pronator quadratus plus flexor carpi radialis, palmaris longus, and flexor digitorum superficialis. Sensory distribution of median N will be affected
	Diagnosis of pronator teres syndrome	Specific MMT of involved mm - Tinel sign S&S/history + pinch grip test
	Activity related neuropathies include:	carpal tunnel syndrome and cyclist's/handlebar palsy
	MOI carpal tunnel syndrome	overuse/hypertrophy of finger flexors
	MOI cyclist's palsy	repetitive trauma or weight bearing on palms of hands
	S&S of activity related neuropathies	Paresthesias in distribution of affected N Pain in distribution Specific motor weakness Decreased 2-point discrimination
	Activity related neuropathies diagnosis	History, S&S +Tinel sign + Phalen's test
	Scaphoid (carpal navicular) fx MOI	FOOH w/ wrist extended and radially deviated Striking an object/opponent w/ heel of hand
	Scaphiod fx S&S	Mimic wrist strain. Pain at base of thumb Exquisite tenderness to palpation in anatomical snuff box Impaired grip strength and general hand function Often don't show up on x-ray until healing starts to take place
	Hammate fx MOI	Fall on hand while holding implement such as tennis racket or relay baton.
	S&S of hamate fx	Pain in hypothenar emminence +/- pain and paresthesia- ulnar N involvement
	Diagnosis of hamate fx	History, S&S, x-ray negative x-rays don't rule out scaphoid fx
	Scaphoid and hamate fx complications:	delayed union, non-union, aseptic necrosis
	Thumb UCL sprain AKA	UCL is a Y shaped ligament AKA gamekeeper's thumb, skier's thumb
	MOI of thumb UCL sprain	Forcible abduction and extension of the thumb- FOOH, catching thumb in opponent's clothing/equipment, fall while holding a ski pole (most common)
	S&S of thumb UCL sprain	Pain in dorsoulnar aspect of MCP joint. Decreased grip and pinch strength Increased pain/laxity- valgus (abduction and/or extension) stress to joint x-ray to r/o avulsion fx Thumb to finger is very diagnostic- if this motion is too painful or thumb gaps it's most likely sprained.
	MOI to IP joints	Direct blow to fingertip- hyperflexioN of DIP, disruption of extensor mechanism, malet finger. Directblow hyperextension of PIP- volar plate injury Hyperextension of DIP or PIP- posterior d/l
	S&S of IP injury	Pain, swelling, ecchymosis Associated deformity Point tenderness x-ray to R/O avulsion fx
	Patellar tendon rupture MOI	Usually a deceleration force- landing off balance from jump. May be related to tendon pathology
	S&S of patellar tendon rupture	Inability to extend knee Significant swelling High riding patella R/O patellar d/l or fx
	Patellar tendon rupture diagnosis:	Hist, S&S Differentiate between quadriceps tendon
	Patellar/quadriceps tendinitis AKA/MOI	Jumper's knee Microtrauma from repetitive eccentric loading
	S&S of patellar/quad tendinitis	Pain w/ deceleration Quad weakness- usually due to inhibition from pain. Chronically may see atrophy due to disuse Palpable tenderness History is key- when is pain most severe- Doesn't hurt when I jump, just when I come down.
	MOI pre-patellar bursitis-	direct trauma; repetitive friction
	S&S of pre-patellar bursitis	Pain w/ palpation Focal swelling- r/o septic bursitis
	Chronic anterior knee pain (patellofemoral pain syndrome) MOI	New activity Incomplete rehab- VMO weakness- VMO is an important stabilizer to prevent patella from gliding laterally HS tightness Extensor mechanism restriction- Often portal sites develop adherence post-surgery Abnormal biomechanis- look at feet- STJ over pronation increases valgus force at knee and increases q angle Structural abnormalities- May have anteversion/torsion at hip
	Predisposing factors to chronic anterior knee pain	VMO atrophy Increased q angle? Patella alta- High riding patella- measure patellar tendon if it's greater than or equal to 1.5 x greater than length of patella. Causes abnormal gliding/stress. HS tightness- limits knee extension during gait b/c quads must overcome HS resistance increasing compressive forces Anteversion/torsion of hip- alters quad pull Glut med weakness- abductor need to control IR during swing. If land in adduction it increases lateral pull of quads
	S&S of chronic anterior knee pain	Diffuse pain, increased with resisted extension Knee stiffness-+ movie house sign (sit for long periods w/o extending knee increase pain) Variable swelling +/- Clarke's sign (PTF grinding test. Flex about 5 degrees, put tension on superior aspect of capsule and draw away so doesn't pinch, maintain pressure on quads and contract allowing patella to glide under web of hand.
	Chondromalacia patellae degrees	Softening of articular cartilage 1st degree- slight swelling on specific point of patella 2- disruption of articular cartilage begins. Full thickness involvement, doesn't include bone. Articular cartilage is both aneural and avascular so doesn't hurt. 3- larger diffuse area of involvement and down to subchondral bone, which does have pain fibers so this is when you begin to feel pain.
	What type of x-ray view is required to view articular cartilage of the patella?	sunrise view
	MCL MOI	Valgus force w/ foot fixed Valgus, external tibial rotation force (skiing)
	LCL MOI	Varus force w/ foot fixed
	S&S of collateral ligament injuries	Pain along course of ligament- palpate lig above, below, and at joint line Variable joint laxity Swelling- min to mod +valgus/varus stress test at 0 and 30 degrees. As flex knee you test primary static stabilizers. If positive put in terminal extension where secondary stabilizers also work. If positive in full extension, this is a more severe injury.
	Grade 1 collateral lig sprain	less than .5 cm
	Grade 2 collateral lig sprain	.5-1 cm
	Grade 3 collateral lig sprain	greater than 1 cm
	Name the anterior lateral static stabilizers of the knee	ITB
	Posterolateral static stabilizers of the knee	LCL, popliteus tendon, and popliteus-arcuate complex (thickening of capsule)
	Posteromedial static stabilizers of the knee	Semimembranosus corner- semimembranosus doesn't have well defined tendon Posterior oblique ligament MCL
	Anteromedial static stabilizers of knee	MCL
	Anterior dynamic stabilizer of knee	Patellar tendon (quads)
	Anterolateral dynamic stabilizer	ITB
	Posterolateral dynamic stabilizer	biceps femoris gastroc lateral head
	Posteromedial dynamic stabilizers	Gastroc medial head Semitendinosus Semimembranosus Gracilis Sartorius
	Pes anserine group includes:	Semimembranosus Gracilis Sartorius
	Medial knee stabilizers:	MCL Posterior oblique ligament PM capsule ACL PCL Medial patellar retinaculum Semimembranosis Pes anserine Medial gastroc
	Lateral knee stabilizers:	LCL PL capsule Popliteus Arcuate ligament complex PCL ACL Lateral gastroc Biceps femoris
	ACL is ___-articular and ____-capsular	intra-articular, but extracapsular ACL sits between the 2 bones, but synovial sheath of capsule surrounds ACL so ligament is never bathed in synovial fluid. When someone tears ACL they usually also tear synovial sheath. Ligament isn't highly vascular, but sheath is so will have bleeding into capsule- hallmark sign of ACL tear is hemarthrosis.
	ACL MOI:	Hyperextension Plant and cut to same or opposite side (opposite more common). Force to posterior tibia w/ knee flexed. Rapid deceleration
	What motion does the ACL resist?	Anterior tibial translation on femur
	S&S of ACL injury	Pop Usually not associated w/ external trauma Rapid effusion- hemarthrosis Anterior joint line laxity: + Lachman's test +/- anterior drawer +/- pivot shift- rotatory instability at knee
	PCL MOI	Anterior force w/ knee flexed- fall w/ ankle dorsiflexed Hyperflexion Severe hyperextension
	S&S of PCL injury	Vague knee pain b/c deep in joint Posterior joint line laxity? Variable swelling + posterior drawer test Posterior rotatory instability Tibial sag sign Difficult to diagnose
	Anterior knee stabilizers	ACL PL capsule PM capsule MCL ITB Posterior oblique ligament Arcuate ligament complex
	Posterior knee stabilizers	PCL Arcuate ligament complex Posterior oblique ligament ACL
	Rotatory instability is defined by	the ligamentous complex involved allowing tibial s/l. Define by the direction the tibia is s/ling.
	Anterior-lateral rotatory instability means that the tibia rotates what direction?	medially
	Anteriomedial rotatory instability the tibia is rotated what direction?	laterally
	Posteromedial rotatory instability the tibia is rotated what direction?	medially
	Posterolateral rotatory instability the tibia is rotated in what direction?	laterally
	Anteriormedial rotatory instability can be related to what stabilizing structures?	MCL Medial capsular ligament Posterior oblique ligament PM capsule ACL
	Anterolateral rotatory stabilizers	ACL PL capsule Arcuate ligament complex LCL ITB
	Posteromedial rotatory stabilizers	PCL Posterior oblique ligament MCL Medial capsular ligament Semimembranosus PM capsule ACL
	Posterolateral rotatory stabilizers	PCL Arcuate ligament complex LCL Biceps femoris PL capsule ACL
	___ meniscus is more C shaped, ___ is more circular and has a stronger attachment to the inner third of the articular surface.	Medial; lateral
	Functions of the meniscus:	shock absorber Deepens articular surface. If have had partial menisectomy, individual has lost some joint stability. Wedge shape limits translation of femur on tibial plateau. Reduce stresses on ACL They force synovial fluid into articular cartilage (helping to nourish the white zone) during compression.
	Menisci forced ___ in flexion and ___ in extension	posteriorly; anteriorly
	What part of the menisci have blood supply?	Peripheral blood supply so tears in the outer third (red zone) are at times capable of repair/healing. Further towards center (towards white zone) there's less blood supply. Inner 2/3 of menisci are avascular.
	Meniscal MOI	Plant and cut to opposite side Rapid extension w/ foot fixed- restricts screw home mechanism Weight bearing w/ hyperflexion Injury to related structures- ACL or MCL When knee flexes, weight shifts to posterior aspect of joint. Posterior horn of medial meniscus doesn't shift so many tears occur here during flexion.
	Types of meniscal tears:	Vertical Radial Horizontal Degenerate Complex- tears in multiple directions Horn A loss of any part of the meniscus causes uneven weight distribution and can lead to early wear of knee.
	Bucket handle meniscal tear-	Along entire part and tends to move into joint causing locking
	Discoid meniscus-	Congenital deformity in which meniscus is no longer wedge shaped, but relatively flat.
	Meniscal injuries occur in ___% of ACL injuries	15
	___% of patients w/ a history of ACL tears will likely tear their meniscus w/ incidences of instability of the knee	80
	___% of meniscal injuries are to the medial meniscus	70- has strong peripheral attachment so doesn't move and is more likely to be injured
	Almost all meniscal injuries ages 20 and under were related to what activities?	sports related
	In acute knee injuries w/ ACL intact, what type of injury is likely	Medial meniscal injury more likely than lateral.
	In acute knee injuries w/ ACL ruptured, what structure is more likely to be involved?	lateral meniscus
	What structure is more likely to be injured in repetitive deep squatting?	medial meniscus (20:1)
	S&S of meniscal injury	Sudden locking Localized joint line pain- often posterior/medial End-feel- rubbery/cartilaginous Mild/moderate effusion- intraarticular injury Transitory pain- aspatient flexes knee will move posteriorly, as extend pain moves centrally or anteriorly Pain on hyperflexion Loss of full knee extension Baker's cyst
	Thessaly test	Done with patient standing, first on normal leg. Flex knee 5 degrees, rotate body on fixed leg back and forth 3 times, holding examiner's hands for stability Flex further to 20 degrees and repeat. Repeat on affected leg. +test- pain at joint line or feeling of locking or catching
	Baker's cyst-	Herniation of posterior capsule through semimembranosis fascia Pathognomonic for medial meniscus injury. Doesn't always indicate meniscus tear, but does raise degree of suspicion.
	A synovial plica is..	Thickening of synovial membrane. A normal anatomical variant that may become symptomatic due to overuse or trauma.
	MOI synovial plica	Overuse Direct trauma Biomechanical abnormalities such as STJ overpronation
	S&S of synovial plica	Anterior knee pain Tenderness along the medial femoral condyle Clicking, popping, locking (pseudo), focal swelling + Hughston plica test r/o medial meniscal injury- Won't have joint line tenderness
	Function of the popliteus	Unlocks knee at initiation of flexion Dynamic stabilizer- assists PCL Originates at LCL and inserts into psteriomedial tibia. Resists posterior shear.
	MOI popliteus tendinitis	Downhill running or backpacking. Fatigue is a predisposing factor.
	S&S of popliteus tendinitis	Vice-like/stabbing posterolateral knee pain Activity related, increased going downhill
	Osteochondral fx and osteochondritis dissecans MOI	Internal vs. external trauma- location dependent Internal trauma- plant and cut to opposite side. Intercondylar eminence impacts posterolateral corner of medial femoral condyle. Direct blow- external trauma- fall w/ knee flexed; injury to WB surface of femoral condyle
	S&S of osteochondral fx and osteochondritis dissecans	Localized tenderness Pain esp w/ weight bearing Swelling/hemarthrosis + Wilson's test- if fx is in intercondylar notch
	Ostechondritis dessicans is-	Loose body in joint- joint mouse
	S&S of osteochondritis dissecans	Mild/mod effusion Episodes of locking Bony or hard end-feel
	ITB friction syndrome MOI	Overuse Tightness of TFL/ITB Running on uneven surfaces- crown of road Faulty biomechanics of STJ
	ITB friction syndrome S&S	Pain over lateral femoral epicondyle Crepitus Localized swelling + ober's test + Noble compression test
	Patellar s/l or d/l MOI	Usually non-contact Cutting maneuver- valgus stress w/ strong quad contraction Anatomical predisposition- increased Q angle, bony anomalies May tear retinaculum which assists in stabilizing patella, this puts them at further risk.
	S&S of patellar s/l or d/l	Sensation of knee going out Intense pain with effusion Inability to actively flex knee- laterally displaced patella. Significant soft tissue damage + patellar apprehension- try to glide patella laterally quads fire
	What must be ruled out in patellar s/l or d/l?	Osteochondral fx and knee d/l
	Ottawa Knee Rules	1. Age 55 or older 2. Point tenderness at patella (no bone tenderness of knee other than patella) 3. Tenderness at head of fibula 4. Knee can't be flexed to 90 5. Patient is unable to bear weight for four steps immediately and in the emergency department/office.
	Potential benefits of Ottawa knee rules	Reduction in proportion of patients referred for knee radiography. Sensitivity and reliability of the rule for detecting knee fx. Reduction in waiting time for patients and health care costs.
	Majority of hip flexor strains involve...	2 joint mm- rectus femoris is most commonly involved
	MOI of hip flexor strain	Maximum contraction before muscle is ready (concentric) Force generated exceeds muscle's ability to withstand such a force (eccentric)
	S&S of hip flexor strain	Pain w/ resisted knee extension and passive stretch. Knee flexion w/ hip extension. Swelling- may be localized Location- commonly at MT junction, but can occur at m belly Defect
	Hip adductor strain MOI	Quick change of direction (football/soccer) Sudden propulsion (hockey)
	S&S of hip adductor strain	More severe occur near mm attachment to pelvis
	Hip pointer-	Contusion to the iliac crest or ASIS
	MOI of hip pointer	direct blow
	S&S of hip pointer	Very painful to touch Inability to stand erect (trunk flexed forward and toward side of injury) May be unable to take deep breath or cough due to pain Occasional ecchymosis and swelling at site of injury
	Hip pointer diagnosis:	Must r/o intra-abdominal injury (rebound tenderness) History Palpation S&S
	Snapping hip syndrome-	Slipping of ITB over greater trochanter May be associated w/ trochanteric bursitis Usually no MOI Seen more frequently in women esp those w/ hypermobile joints
	S&S of snapping hip syndrome	Snapping sensation on lateral aspect of thigh During swing phase of gait and prior to heel strike- slips from post to ant
	Snapping hip diagnosis-	History Resisted motion from hip ADD/IR to hip ABD/ER will reproduce popping.
	Medial (internal) snapping hip syndrome	Iliopsoas slipping over lesser trochanter or iliopectineal eminence of pelvis S/l of hip joint Suction phenomenon in joint- pistoning of femoral head and acetabulum causing joint to pop in and out of place. If muscular may be painful b/c can develop tendonitis. S/l is often not all that painful unless it's frequent causing synovitis.
	Hamstring strain MOI	Sudden maximal contraction (concentric)- sprinter's push leg out of blocks, jumper's plant leg Rapid eccentric contraction to decelerate limb- sprinter in full stride
	Most commonly strained HS	short head of biceps femoris Biceps femoris- dual innervation: tibial division of sciatic and peroneal division of sciatic Timing problems w/ long head or quads- co-contraction prob causing strain
	S&S of HS strain	Location important- rule of thumb: higher the strain, longer the rehab b/c less blood supply. Pain w/ resisted knee flexion and passive stretch Palpable tenderness +/- defect
	Myositis ossificans	Heterotopic bone growth w/in muscle. Most commonly occurring in anterior thigh (quads)- usually results as a complication to a contusion
	Myositis ossificans MOI	Initial deep contusion followed subsequent reinjury (second trauma, vigorous massage, or passive stretching) Repetitive minor traumas to same area- ex blocker's nodules in linemen's forearms next to ulna
	S&S myositis ossificans	Related to initial contusion and hematoma formation Instantly disabling or disabling after the athlete has stood or sat for a few minuts- quads spasm w/ limited knee flexion Rapid and significant swelling (hematoma formation) Impaired quad function- knee held in extension Active/passive knee flexion resisted and painful May be due to periosteal response which thinks there's been a fx.
	What may give a general estmate of the severity and likelihood of developing myositis ossificans?	Measuring painless knee flexion 24 hours post-injury Greater limit of knee flexion, greater risk of developing MO
	In MO, prone, passive knee flexion <45 degrees=	serious contusion and significant potential for developing MO
	MO passive knee flexion 45-90	Moderate injury and risk
	Painless flexion >90 for MO	Mild injury, minimal risk
	Examinatino 2-4 weeks post injury w/ MO present:	Thigh tender to deep palpation, thickened swelling Grows like coral, sharp spicules of bone. Movement around this causes further bleeding. End-feel may feel bony in nature or like scar. Less painful than acute Significant quad atrophy Firm limitation to knee flexion
	Diagnosis of MO-	Radiographic evidence of bone formation: As early as 3 weeks Fluffy calcification which becomes clearer as bone matures. Bone scans used to assess maturity of lesion (hot scan- immature lesion) May use bone scan to diagnose lesion before radiographic evidence of lesion is present.
	Gastroc strain AKA tennis leg	Strain of the MT junction of the medial head of the gastroc. Older than 30 usually Women more than men Rarely ever have strain of lateral head of gastroc. Tearing sensation generally occurs in the medial head.
	Gastroc strain MOI	Forceful PF (propulsion) as w/ jump or sudden start. Often associated with fatigue May begin w/ mild strain followed by complete rupture of medial head.
	S&S of gastroc strain	Pop in medial upper aspect of calf. Spasm of calf- PF of foot w/ inability to put heel on ground but unable to bear weight on toes. Significant swelling and ecchymosis 24-48 hours post-injury
	Gastroc strain diagnosis	Exquisite point tenderness- medial side of junction of the middle and proximal thirds of the calf Hist, S&S
	Achilles tendon strain/rupture MOI	Forceful PF from a fully DFed position while extending the knee.
	S&S of achilles tendon strain/rupture	Sensation of being struck in the tendon. Audible pop or snap + Thompson test Loss of PF strength Loss of tendon continuity Substantial swelling and ecchymosis Antalgic gait w/ loss of push off
	Acute compartment syndromes:	tissues within an osteofascial compartment are compromised by increasing pressure within that compartment
	4 compartments in leg:	anterior, lateral/peroneal, superficial, deep Anterior is most commonly involved
	Acute compartment syndrome MOI	Any microtrauma or macrotrauma- associated with bleeding or swelling within an osteofascial compartment Acute injury- a tightly applied circumferential cast or bandage can cause a compartment syndrome
	S&S of acute compartment syndrome	Classic sign- severe pain disproportionate to the apparent severity of injury +/- paresthesia Swelling and tenderness- early signs Pain exacerbated by specific compartmental muscle testing (ant compartment- ant tib) Paresis, pallor, pulselessness- late and ominous signs- at risk for losing leg
	Diagnosis of acute compartment syndrome	Hist, S&S Direct measurement of intercompartmental pressure Only way to relieve pressure is fasciotomy
	Achilles tendinitis MOI	Intrinsic vs extrinsic Activity change- initiation, intensity, duration. Overuse or unprepared Direct compression such as excess pressure from back of shoe
	Achilles tendinitis S&S	Pain and stiffness (initial complaints) Tenderness to palpation Minimal swelling- compare bilaterally. May be thickening of tendon at this area upon palpation Chronic tendonitis increases rupture risk.
	In chronic anterior leg pain (shin splints)	Stress fx- pes cavus is more likely to have stress fx b/c don't pronate to absorb shock and supinated foot is rigid. Chronic exertional compartment syndrome- repetitive activity that causes localized m hypertrophy, increased volume due to increased blood flow. When stop exercise sx tend to diminish. Periostitis- develop inflammation of periosteum of bone due to repetitive irritation. Anterior or posterior tib tendinitis
	Chronic anterior leg pain (shin splint) MOI	Unaccustomed activity or overuse Change in mileage, terrain, or shoes Specific activity- vaulting, jumps, or runs Better athletes, less change required to produce symptoms. Biomechanical abnormalities may/may not predispose athlete to pain
	Chronic anterior leg pain S&S: pain	Primary sx is pain- initially following activity, later with activity, ultimately preceding activity. Late stages- pain w/ ADLS.
	Chronic anterior leg pain S&S: location	Distal lateral aspect of leg- fibular stress fx Entire anterolateral aspect of leg- chronic compartment syndrome or ant tib tendinitis Anterior surface of tibia (midleg)- tibial stress fx Medial pain in distal third of leg- post tib tendinitis or tibial stress fx
	Chronic anterior leg pain S&S: timing	Pain early in workout that disappears w/ continued activity and reappears following workout- ant/post tib tendinitis Pain that occurs at the same time or mileage during a workout- chronic compartment syndrome
	Chronic anterior leg pain S&S: swelling	Localized- more indicative of stress fx Diffuse or fascial hernias- compartment syndrome
	Chronic anterior leg pain S&S: paresthesia or hypesthesia-	compartment syndrome
	Chronic anterior leg pain diagnosis	Must try and precisely locate area of maximal tenderness- tenderness localized to an area less than 1.5 inches is suggestive of stress fx. Tenderness over distal third of medial border of tibia- post tib tendinitis. MMT helpful- resisted dorsiflexion- compartment syndrome or anterior tib tendinitis. Resisted PF and inversion- post tib tendinitis.
	Lateral ankle sprain MOI	Inversion often accompanied by PF. Running on uneven surfaces Cutting Landing on an uneven surface from a fall or jump.
	S&S of lateral ankle sprain	Cracking/popping sensation at time of injury Discrete swelling laterally Tenderness localized over anterior talofibular and/or calcaneofibular ligaments Late diffuse swelling- echymossis of heel and forefoot Variable instability
	Diagnosis of lateral ankle sprain	Hist, S&S Positive anterior drawer test and or + talar tilt test
	Ottawa ankle rules	X-ray required if: Bone tenderness at posterior edge or tip of lateral malleolus. Bone tenderness at posterior edge or tip of medial malleolus. Bone tenderness at the base of the fifth metatarsal. Bone tenderness at navicular. Inability to bear weight both immediately and in emergency department.
	Peroneus brevis strain/avulsion fx of base of 5th metatarsal MOI	Inversion stress Often accompanies lateral ankle sprain
	Peroneus brevis strain/avulsion fx of base of 5th metatarsal S&S	Swelling and tenderness localized over peroneus brevis tendon proximal to its insertion on the base of the fifth metatarsal.
	Peroneus brevis strain/avulsion fx of base of 5th metatarsal diagnosis:	Radiographic examination r/o Jones fx (fx of proximal diaphysis) and stress fx (typically in metaphysis)
	Medial (deltoid) ligament sprain MOI	Excessive pronation (abduction, eversion, and DF)
	S&S of deltoid ligament sprain	Same as lateral except medially. R/O concomitant fx of tibia and fibula. Palpate medial malleolus and shaft of fibula.
	Deltoid ligament sprain diagnosis	Hist, S&S + medial stress test and/or +kleiger test (helpful to eval rotatory instability. ATF injured talus will be more mobile laterally. Deltoid injury anterior drawer will be more prominent on medial side) x-ray to r/o fx
	Anterior (talotibial) impingement syndrome MOI	Repetitive, forced DF- gymnasts, dancers, baseball, basketball, or tennis players
	S&S of anterior (talotibial) impingement syndrome	Pain in front of the ankle initially during physical activity w/ DF and later w/ ADLs. Tenderness over anterior joint line, limited DF Forced passive DF produces pain Osteophyte formation- anterior tib and talus Radiographic examination
	Posterior (talotibial) impingement syndrome MOI	Repetitive forced PF- karate, dance, gymnastics, diving.
	Posterior talotibial impingement syndrome S&s	Posterior ankle pain during physical activity w/ PF and later w/ ADLs. Tenderness anterior to the achilles tendon (tendon not tender to palpation) Limited PF Forced passive pF produces pain Osteophyte formation of post tib and talus Radiographic exam
	Osteochondritis dissecans of the talus	Small area of medial or lateral WB portion of the talus loses its blood supply
	MOI of osteochondritis dissecans of talus	Medial or lateral ankle sprain- tilted talus comes in contact w/ malleoli Or idiopathic
	S&S of osteochondritis dissecans of talus	Hist, S&S Confirmed w/ radiographic exam
	Bifurcated ligament sprain-	Y shaped ligament that goes from calcaneus to navicular and from calcaneus to cuboid.
	Bifurcated ligament sprain MOI S&S	Inversion of foot- may be associated w/ lateral ankle sprain Pain w/ forced inversion of foot and palpation Minimal, localized swelling
	Turf toe-	Sprain of 1st MTP joint
	Turf toe MOI	Forced hyperextension Repeated maneuvers requiring push-off form the extended great toe (seen on synthetic surface) Forced hyperflexion
	Turf toe S&S	Pain, swelling, and tenderness around joint Painful active or passive extension/flexion of great toe. Flatfoot gait in an attempt to avoid pushoff
	Morton's neuroma-	focal enlargement of plantar digital N. Usually between 3-4 metatarsals.
	Morton's neuroma MOI	Footwear tight across forefoot. Aggravated by propulsion activities (sprinting or running uphill) which extend toes
	Osteochondritis dissecans of the talus	Small area of medial or lateral WB portion of the talus loses its blood supply
	Osteochondritis dissecans of the talus	Small area of medial or lateral WB portion of the talus loses its blood supply
	MOI of osteochondritis dissecans of talus	Medial or lateral ankle sprain- tilted talus comes in contact w/ malleoli Or idiopathic
	S&S of osteochondritis dissecans of talus	Hist, S&S Confirmed w/ radiographic exam
	MOI of osteochondritis dissecans of talus	Medial or lateral ankle sprain- tilted talus comes in contact w/ malleoli Or idiopathic
	S&S of osteochondritis dissecans of talus	Hist, S&S Confirmed w/ radiographic exam
	Osteochondritis dissecans of the talus	Small area of medial or lateral WB portion of the talus loses its blood supply
	Bifurcated ligament sprain-	Y shaped ligament that goes from calcaneus to navicular and from calcaneus to cuboid.
	Osteochondritis dissecans of the talus	Small area of medial or lateral WB portion of the talus loses its blood supply
	MOI of osteochondritis dissecans of talus	Medial or lateral ankle sprain- tilted talus comes in contact w/ malleoli Or idiopathic
	Bifurcated ligament sprain-	Y shaped ligament that goes from calcaneus to navicular and from calcaneus to cuboid.
	MOI of osteochondritis dissecans of talus	Medial or lateral ankle sprain- tilted talus comes in contact w/ malleoli Or idiopathic
	Bifurcated ligament sprain MOI S&S	Inversion of foot- may be associated w/ lateral ankle sprain Pain w/ forced inversion of foot and palpation Minimal, localized swelling
	Turf toe-	Sprain of 1st MTP joint
	S&S of osteochondritis dissecans of talus	Hist, S&S Confirmed w/ radiographic exam
	S&S of osteochondritis dissecans of talus	Hist, S&S Confirmed w/ radiographic exam
	Bifurcated ligament sprain MOI S&S	Inversion of foot- may be associated w/ lateral ankle sprain Pain w/ forced inversion of foot and palpation Minimal, localized swelling
	Turf toe-	Sprain of 1st MTP joint
	Turf toe MOI	Forced hyperextension Repeated maneuvers requiring push-off form the extended great toe (seen on synthetic surface) Forced hyperflexion
	Bifurcated ligament sprain-	Y shaped ligament that goes from calcaneus to navicular and from calcaneus to cuboid.
	Turf toe MOI	Forced hyperextension Repeated maneuvers requiring push-off form the extended great toe (seen on synthetic surface) Forced hyperflexion
	Bifurcated ligament sprain MOI S&S	Inversion of foot- may be associated w/ lateral ankle sprain Pain w/ forced inversion of foot and palpation Minimal, localized swelling
	Turf toe S&S	Pain, swelling, and tenderness around joint Painful active or passive extension/flexion of great toe. Flatfoot gait in an attempt to avoid pushoff
	Bifurcated ligament sprain-	Y shaped ligament that goes from calcaneus to navicular and from calcaneus to cuboid.
	Turf toe S&S	Pain, swelling, and tenderness around joint Painful active or passive extension/flexion of great toe. Flatfoot gait in an attempt to avoid pushoff
	Bifurcated ligament sprain MOI S&S	Inversion of foot- may be associated w/ lateral ankle sprain Pain w/ forced inversion of foot and palpation Minimal, localized swelling
	Turf toe-	Sprain of 1st MTP joint
	Morton's neuroma-	focal enlargement of plantar digital N. Usually between 3-4 metatarsals.
	Morton's neuroma-	focal enlargement of plantar digital N. Usually between 3-4 metatarsals.
	Turf toe MOI	Forced hyperextension Repeated maneuvers requiring push-off form the extended great toe (seen on synthetic surface) Forced hyperflexion
	Turf toe-	Sprain of 1st MTP joint
	Morton's neuroma MOI	Footwear tight across forefoot. Aggravated by propulsion activities (sprinting or running uphill) which extend toes
	Morton's neuroma MOI	Footwear tight across forefoot. Aggravated by propulsion activities (sprinting or running uphill) which extend toes
	Turf toe MOI	Forced hyperextension Repeated maneuvers requiring push-off form the extended great toe (seen on synthetic surface) Forced hyperflexion
	Turf toe S&S	Pain, swelling, and tenderness around joint Painful active or passive extension/flexion of great toe. Flatfoot gait in an attempt to avoid pushoff
	Turf toe S&S	Pain, swelling, and tenderness around joint Painful active or passive extension/flexion of great toe. Flatfoot gait in an attempt to avoid pushoff
	Morton's neuroma-	focal enlargement of plantar digital N. Usually between 3-4 metatarsals.
	Morton's neuroma MOI	Footwear tight across forefoot. Aggravated by propulsion activities (sprinting or running uphill) which extend toes
	Morton's neuroma-	focal enlargement of plantar digital N. Usually between 3-4 metatarsals.
	Morton's neuroma MOI	Footwear tight across forefoot. Aggravated by propulsion activities (sprinting or running uphill) which extend toes
	Causes of stress fx	Overuse Bone absorption exceeds bone remodeling
	Most common sites for stress fx and causes	2-5 metatarsals- endurance athletes Base of 2nd metatarsal- ballet Proximal third of 5th metatarsal- sports that require running and rapid direction change. Tarsal navicular- jumping activities like basketball
	S&s of stress fx	Palpable tenderness Occassional swelling- shafts of mets
	Stress fx diagnosis	bone scan Follow-up x-ray: 2-4 weeks for evidence of fx healing
	Plantar fasciitis MOI	Overuse, training errors Incomplete rehab following ankle sprain- weak posterior tibialis failing to support arch. Abnormal pronation High arched pes cavus foot- put excess stress on fascia
	S&S of plantar fasciitis	Pain of gradual onset- along the entire medial border of the fascia. Localized- anteriomedial aspect (medial tubercle) of calcaneus. Pain worse w/ extension of great toe. Pain is worse in the morning (initial WB upon getting out of bed) Palpable tenderness over medial tubercle of calcaneus
	Diagnosis of plantar fasciitis	H, S&S Radiographic exam- presence of bone spurs at insertion of fascia on calcaneus. Not necessary for diagnosis
	Progression through rehab program:	Phase in- phase out Goal-oriented approach SAID principle (specific adaptation to imposed demand)
	Acute phase of tissue healing:	24-72 hours Catabolic state- tissue breakdown, not going to build tissue during this time. Hallmark: inflammation- redness, swelling, heat, pain/tenderness, loss of function Rx: minimize effects of inflammation Optimum healing environment
	Sub acute phase of tissue healing:	3-21 days Anabolic state- tissue building. NOt normal tissue, but scar tissue. Hallmark- proliferation of scar tissue Rx: restoration of motion and strength Graded stress.
	Chronic phase of tissue healing	21+ days Slowed healing rate Hallmark- tissue maturation Rx: restoration of function. SAID principle If eccentrically biased injury ensure exercise works on this. Adapt athlete to kinds of stresses he/she will be putting on their body.
	Acute rehab	Modalities- ice, pressure support, crutches/orthoses, Iontophoresis, E-stim ROM- PROM, AAROM, Gr 1 mobs
	Subacute rehab	Modalities- ice, whirlpool, contrast, hot packs, US, massage ROM- AROM, gr 2-3 mobs, static stretching and later subacute balistic and PNF stretching Strengthening- Single joint OC, isometric, Concentric isotonic, Concentric isokinetic (fast to slow), multiple joint pNF and CC. Later Isotonic eccentric, isokinetic eccentric (slow to fast). Cardio- add later in subacute Proprioception/kiesthesia- gait, bi/unilateral static exercise, bi/unilateral dynamic exercise. Functional retraining
	Chronic rehab	Add taping/bracing, sport specific drills, and return to sport
	Criteria for return to sport:	ROM, strength, CV endurance, functional performance, sports performance
	Clinical goals-	impairment based- decreased pain, swelling, increased ROM/strength. Attainment of full, pain-free strength and ROM doesn't ensure the athlete is ready to return to sports activities.
	Functional goals are based on:	sports and/or position specific demands
	Functional rehab step program	Muscular strength Flexibility CV endurance Proprioception Power Speed Agility RTS
	Analysis of imposed demands: strength	Muscle groups Types of m action- con, ecc, isom Energy system used- stability mm vs mm that produce movement have different fiber types/functions and should be trained accordingly. Predominant fiber type How strength is used- submax/max; single effort/repetitive; power vs endurance
	Analysis of imposed demands: Flexibility	Muscle groups Type of flexibility- static, dynamic, resistive (ability to move part through range while experiencing resistance) Amount- not what's normal, but what's functional How flexibility is used: submax/max, single effort/repetitive, slow/fast
	Analysis of imposed demands: CV endurance	energy system used anaerobic vs aerobic
	Analysis of imposed demands: Proprioception	Injury to any structure crossing a joint will reduce that joint's proprioceptive input Activity specific- increased risk for reinjury
	Analysis of imposed demands: power, speed, and agility	all functional applications of strength, flexibility, CV endurance, and proprioception
	Specificity-	once you know the demands being placed on the athlete, you should be able to plan a specific rehab program to help athlete meet those demands.
	Progression parameters-	Limited range to functional range- dynamic functional strength and stability. Slow to fast (or fast to slow?) Submaximal to maximal Stable to unstable- w/ and w/o perturbation Known to unknown Strengthen in position they need to use it. Go fast to slow when in an eccentric pathology
	Injuries most likely to result in litigation:	Head and neck, heat related, knee
	Your role as sports med provider:	Minimize risk Manage injuries appropriately Document accurate
	Scope of practice-	Range of duties/ skills PT is allowed and expected to perform when necessary.
	How is scope of practice determined?	Legal, ethical, and medical guidelines
	Standard of care-	level of care provided that would normally be provided by a person w/ similar training or experience in a similar situation. Criterion established for extent and quality of care. Perform to "minimally accepted" standard.
	How is standard of care determined?	Practice act, code of conduct, and local laws/customs
	Duty to act-	when on duty, the sports pT has a duty to provide emergency care to injured athletes. Determined by case law, statute, or job description.
	What about times not on duty?	Moral vs legal obligation Once care has begun- legal obligation to continue
	Competence	Injured athlete's ability to understand questions and implications of decisions made regarding health care. Must obtain permission from competent individual to begin care/treatment- consent
	Informed consent (preseason)	Requires that the athlete (or parents for minors) know that sports participation involves a risk that the athlete might be seriously hurt or even killed. Must be written and signed by an adult.
	Consent during games	Injured athletes have the right to decide if they want to be treated for an injury- must obtain consent. Expressed, informed, or actual consent.
	To obtain consent you must:	ID yourself and level of training Explain what you observe and plan to do
	Expressed consent-	written or verbal informed
	Implied consent-	When a person gives consent to something in general then it is mplied that consent is given to the individual things involved.
	Presumed consent-	When a person is unable to give consent of their own accord, but it is reasonable to believe they would consent if able. Unconscious, confused, impaired, or seriously injured/ill athlete may not be able to give expressed consent. Applies to minors in need of emergency (life-threatening) assistance in absence of guardian.
	Refusal of care-	Injured athlete may refuse care, even if he/she is seriously injured Try and convince athlete need for care. Is athlete competent to make decision based on seriousness of injury?- presumed content or battery?
	Battery-	Unlawful touching of an injured person w/o his/her consent. A parent can consent for a minor to be touched even if child says no. OK doesn't have emancipated minor statute.
	Sexual battery-	Unauthorized touching of another w/ sexual intent. Not likely to occur on field/during game, but think about training room.
	Prevention of sexual battery	Don't be alone w/ opposite gender athlete. Explain the need to touch under clothing to athlete/parents before beginning Avoid joking- your attempt to lighten the atmosphere might cause your words to be misconstrued
	Abandonment-	Once care has begun in an emergency situation, you're legally obligated to continue that care until you're relieved by a person of equal or higher level of training, you're physically unable to continue, or injured person refuses continued care. Stopping care before that time is abandonment
	LIability-	State of being legally responsible for the harm one causes another person. Assumes you would function/act as any "reasonably prudent" individual would function/act in a comparable situation.
	Tort-	legal wrong committed against the person or property of another. Act of omission Act of commision
	Tort liability-	liability for personal injury that is alleged to be the result of the defendant's negligence
	Negligence-	Failure to act a sa prudent individual would act under similar circumstances, thereby causing or contributing to injury or damage of another. 4 elements must be present to prove negligence
	4 elements of negligence	Individual had a duty to act to avoid unreasonable risk to others. Individual failed to observe that duty. Failure to observe that duty was the proximate cause of damage. Actual damage or injury did occur.
	Good samaritan law-	Designed to protect volunteers in an emergency situation. Varies state to state in OK- voluntarily, w/o compensation, no prior contractual agreement.
	Confidentiality	Respect for injured athlete's privacy- news media, friends/acquaintances, coaches/scouts/recruiters, fans, beware of casual conversation.
	Avoiding a lawsuit-	Follow established guidelines Establish communication Work w/ a team; ID responsibilities of each person. Preseason screening- baseline info and fit of equipment. good clinical judgement Early, proper care Informed consent Documentation Confidentiality
	Conflicts in sports med:	Role of health care provider vs role of fan Welfare of athlete vs welfare of team Welfare of athlete vs wishes of athlete Welfare of athlete vs wishes of family
	Avoiding conflicts of interest in sports med:	Clarify the nature of the relationship between you and others involved w/ athlete at onset of that relationship: athlete, coaches, parents, school admin, team owners. Insist on professional autonomy over all medical decisions (w/ assistance of other sports med team members). Anticipate, ID, and insulate yourself from all possible coercive pressures. Communicate personal principles and guidelines under which you intend to deliver care and make med decisions before you accept the role of sports med provider. Recognize and eliminate/minimize any personal biases you might have that might adversely affect your function as sports med provider.

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