SOFT TISSUE INJURY

Soft Tissues
Pathophysiology and
Biomechanics
Type of insult and area of contact (blunt,
penetrating, crushed, etc);
Force applied;
Direction of force;
Area(s) of body affected;
Wound contamination;
General physical condition of the patient.
Types of Wounds
Type of force Type of injury
Sharp, pointed Stab wound
Blunt Contusion injury, cut
Extension, twist Laceration
Shear Degloving, wound defect, avulsions, abrasion

Combination of forces Wounds from blows, impaling, bites, and gunshot

Crushing Traumatic amputation, rupture, crush injury

Thermal Burns
 Closed Wounds
Soft tissue is damaged but
skin is not broken
Characteristic closed wound
is a contusion.
 Closed Wounds
If small blood vessels are
damaged, ecchymosis will
cover the area.
If large blood vessels are
torn, a hematoma will
appear.

Courtesy of Rhonda Beck

 Open Wounds

Characterized by disruption in the skin

Potentially more serious than closed wounds
Vulnerable to infection
Greater potential for serious blood loss
 Crush Injuries
An injury to the underlying
soft tissues and bones
Caused by a body part
being crushed between
two solid objects

Mark C. Ide
CONTUSION
CONTUSION
HEMATOMA
Soft Tissue
Injury
CLASSIFICATION
 Classification

Considers all essential factors and guides

treatment.
Effectively decreases complications by
preventing avoidable treatment errors.
Prognostic value.
Monitor and compare standardized treatment
protocols.
Gustilo classification
 Gustilo classification

Gustilo and Anderson developed their

classification on the basis of a retrospective and
prospective analysis of 1,025 open fractures.
They initially described three types.
 Type I

Fractures with a clean wound of less than 1 cm in

size
Little or no contamination
Wound results from an inside-out perforation
The fracture pattern is simple
 Type II

Skin laceration is longer than 1 cm

The surrounding tissues have minor or no signs of
contusion
No dead muscle present
The fracture instability is moderate to severe.
 Type III

Extensive soft-tissue damage

Frequently with compromised vascularity with or
without severe wound contamination
The fracture pattern is complex with marked
fracture instability.
Because of the many different
factors occurring in this group,
Gustilo proposed three
subtypes.
 Type IIIA

High-energy trauma
Adequate soft-tissue coverage of the fractured
bone, despite extensive soft-tissue laceration or
flaps
 Type IIIB

Extensive soft-tissue loss with periosteal stripping

and bone exposure
Usually associated with massive contamination
 Type IIIC

Any open fracture associated with arterial injury

requiring repair
Independent of the fracture type
 AO soft-tissue grading system

System identifies injuries to the different

anatomical structures and assigns them to
different severity groups
The grading of the skin lesion is done separately
for open or closed fractures
The letters O and C designate these two
categories
Each is divided into 5 severity groups
 Closed skin lesions (IC)

IC 1 No skin lesion

IC 2 No skin laceration, but contusion

IC 3 Circumscribed degloving

IC 4 Extensive, closed degloving

IC5 Necrosis from contusion

No Skin Lesion (IC 1)
 Open skin lesions (IO)

IO 1 Skin breakage from inside out

IO 2 Skin breakage from outside in < 5 cm, contused edges

IO 3 Skin breakage from outside in > 5 cm, increased

contusion, devitalized edges

IO 4 Considerable, full-thickness contusion, abrasion, extensive

open degloving, skin loss

IO5 Extensive degloving

 Muscle And Tendon Lesions (MT)

Although there may be considerable damage to

a muscle envelope, there is rarely an injury to
tendons except in severe injuries
The involvement of the neurovascular system
always indicates a most severe injury
Muscle and tendon injuries as well as
neurovascular injuries are of high prognostic value
for the fate of the extremity
 This system allows a comprehensive description of
the entire injury complex
A simple, closed spiral tibial midshaft fracture from
skiing with no injury of skin, muscles, tendons,
nerves, or vessels is graded: 42-A1.2/ic1-mt1-nv1
An open, complex, segmental tibial shaft fracture
with an open wound greater than 5 cm, muscle
defect, and tendon laceration. There is no nerve
injury but an injury of the peroneal artery. This
injury will be graded as 42-C2.3/io4-mt4-nv3.
Usage of classification systems
 Higher grades of the Gustilo classification of open
fractures and of the Tscherne classification of
closed fractures are most challenging from the
therapeutic point of view
These injuries have the highest complication rates
and can cause severe disability of the patient
 Objectives of classification systems

Facilitate communication;
Assist decision making;
Identify treatment options;
Anticipate problems;
Suggest treatment method;
Predict the outcome;
Enable comparison with similar cases;
Assist documentation and audit.
SPORTS INJURY
SPORT INJURIES are those
which occur in Athletic activities or
while exercising.

SPORT MEDICINE study and

research of injuries in sport in
order to prevent or reduce the
severity of injury.
 EPIDEMOLOGY
Kids ages 5-14 are most likely to hurt themselves on a
playground or engaged in "general exercise,

Ages 5-24, high school and college, team sports become

common-basketball, soccer, and football injuries make
their main appearance, especially for males.

After age 25, those sports become less common and

people become more likely to hurt themselves generally
working out, running, biking.
Knee injuries(55%)>Shoulder> Ankle

The most common

injuries are

strains or sprains (41%),

broken bones (20%),
bruises or superficial
injuries (19%)
 SPRAIN VS STRAIN
Definitions of sprains and strains
Sprains:
characterized by the stretching or tearing of non-
contractile structures, such as the investing ligaments
or of the joint capsule itself.

strain :
characterized by stretching or severing along the
course of muscles or tendons.

*Both collateral ligament and cruciate ligament

sprains, as well as muscular strains, are relatively
common.
 GRADES OF SPRAINS AND STRAINS
Grade I sprain
Stretching but no tearing of the ligament, local tenderness, minimal
edema, no gross instability with stress testing, firm end point

Grade II sprain
Partial tears of the ligaments, moderate local tenderness, mild instability
with stress testing (but firm end point), moderately incapacitating

Grade III sprain

- Complete tear, discomfort with manipulation but less than expected for
degree of injury, variable amount of edema (ranging from negligible to
grossly conspicuous), clear instability with stress testing (expressing a
mushy end point), severe disability
knee ligaments
Of the all ligaments there are 4 ligaments which are
commonly injured , they can be classified as following
:

1-intra-articular
-anterior cruciate ligament ACL
-posterior cruciate ligament PCL

2-extra-articular
-medial (tibial ) collateral ligament MCL
-lateral (fibular) collateral ligament LCL
 ANTERIOR CRUCIATE LIGAMENT
The anterior cruciate ligament (ACL) , it resists the anterior translation
of the tibia relative to the femur.
-it originates on the anterior intercondylar area of the tibia and passes
upward backward and laterally to be inserts to posteromedial aspect of
the lateral condyle of the femur
- ACL includes two functional bundles:
1 anteromedial bundle, which tightens in flexion,
2 posterolateral bundle, which tightens in extension

-ACL prevents posterior displacement of the femur on the tibia

-with the knee joint flexed the ACL prevents the tibia from being pulled
anterior
-tight in hyperextension of the knee.
MECHANISM OF INJURY
The posterior cruciate ligament (PCL) resists against
posterior translation of tibia over femur .

It originates on the posterior intercondylar area of the tibia

and passes upward forward and medially and insert to the
anterolateral aspect of the medial femoral
condyle
-The PCL also is made up of two functional bundles.
1- anterior meniscofemoral
2- posterior meniscofemoral ligament originate from the
posterior horn of the lateral meniscus and contribute to the
function of the PCL.
- PCL prevent anterior displacement of femur on tibia -
with the knee joint flexed the PCL prevent the tibia
from being pulled posteriorly
- tight in hyperflexion
CLINICAL PICTURE
partial tear Complete tear

a partial tear the knee is painful. a complete tear the patient may
have little or no pain,

Swelling also is worse with partial Swelling is less with complete tear
tears

attempted movement is always Abnormal movement of a complete

painful tear is often painless or prevented
by spasm
 DIAGNOSIS

A- CLINICALLY ,by physical examination

ACL examination
 A. LACHMAN TEST

*position of the patient :

supine
*position of the examiner:
-he or she stand on the side of affected
limb
-the proximal hand attaches to the patient
femur and stabilizes it.
-the distal hand attaches to proximal part
of the tibia position it in 20 of flexion and
push it forward .
-not forget to examine the other limb for
comparison .

*results:
positive test indicated by noticing
abnormal ant displacement of the tibia
forward .
 B- PIVOT SHIFT TEST
*position of the patient:
supine
*position of examiner :
The examiner should lift the tested leg off the
table with the knee fully extended. Place the
heel of one hand behind the fibular head of the
patient. Use the other hand to grasp the tibia,
while palpating the medial joint line. While
maintaining a valgus force and internal rotation
of the tibia throughout the test, slowly flex the
patient's knee (note: the test starts by putting
the tibia in the abnormal position!).

*results:
if there is an anterior subluxation felt during
extension the test is positive for instability
 C-ANTERIOR DRAWER TEST

The patient lies supine on a plinth with

their hips flexed to 45degrees, his/her
knees flexed to 90degress and feet flat
on the plinth. The examiner sits on the
toes of the tested extremity to help
stabilize it. The examiner grasps the
proximal lower leg, just below the tibial
plateau or tibiofemoral joint line, and
attempts to translate the lower leg
anteriorly. The test is considered positive
if there is a lack of end feel or excessive
anterior translation relative to the
contralateral side.
2- PCL examination
 2-POSTERIOR DRAWER TEST
The patient lies supine on a plinth with their
hips flexed to 45degrees, his/her knees
flexed to 90degress and feet flat on the
plinth. The examiner sits on the toes of the
tested extremity to help stabilize it. The
examiner grasps the proximal lower leg,
just below the tibial plateau or tibiofemoral
joint line, and attempts to translate the
lower leg posteriorly . The test is
considered positive if there is a excessive
posterior translation relative to the
contralateral side.
 1-POSTERIOR SAG TEST
*position of the patient :
supine
*position of the examiner:
- the examiner stand on the side of the patient
and passively bring the hip and knee to 90 of
flexion ,and compare the level of tibial
tubersiteies of both knee.

*results:
a positive test is indicated when posterior
displacement of tibal tuberosity is more in the
affected limb .
 2- IMAGING
* knee x ray
Although x-rays do not show meniscal tears, they may show
other causes of knee pain, such osteoarthritis and
demonstrate bone avulsion if present .

*Magnetic resonance imaging (MRI)

This study can create better images of the soft tissues of
your knee joint, like a meniscus
Treatment
 TREATMENT
A- conservative
RICE. The RICE protocol is effective for most sports-related
injuries. RICE stands for Rest, Ice, Compression, and
Elevation.

Aspiration of hemartharosis to relive pain .

Exercises and physiotherapy must start since the

diagnosis is approved to prevent adhesion .

using knee brace until pain is disappear .

 B- SURGICAL TREATMENT
Unfortunately, the cruciate ligaments -- ACL and PCL
-- cannot be repaired.
Once they are completely torn or stretched beyond
their limits, The only option a reconstruction.
In this procedure, tendons are taken from other parts
of your leg or a cadaver to replace the torn ligament.
Collateral ligaments
Medial collateral ligament
Is flat band and attached above to the medial epicondyle of
the femur and below to the shift of the tibia it is firmly
attached to the edge of the medial meniscus

- (MCL) is the primary restraint to valgus stress.

*The MCL is the most commonly injured knee ligament.

 LATERAL COLLATERAL LIGAMENT
is cordlike and is attached above to the lateral condyle of
the femur and below to the head of fibula the tendon of the
popliteus muscle intervenes between the ligament and the
lateral meniscus
- (LCL) is the primary restraint to varus stress
 MECHANISM OF INJURY
Medial collateral ligament
tears often occur as a result of a direct blow to the
outside of the knee. This pushes the knee inwards
(toward the other knee).

lateral collateral ligament

tears often occur as a result of a direct Blows to the
inside of the knee that push the knee outwards.
MCL LCL
 CLINICAL PICTURE:
1.Pain at the sides of knee.
If there is an MCL injury, the pain is on the inside of the
knee;
an LCL injury may cause pain on the outside of the knee.
2.Swelling over the site of the injury
3.Instability : the feeling that your knee is giving way.
diagnosis
 A-BY PHYSICAL EXAMINATION
Valgus vs varus stress tests
*position of the patient: supine
*position of the patient leg :
hip is abducted and knee flexed with 20 degree

*position of the examiner:

-the examiner stands on the side of the affected leg
,with one hand on the medial and lateral (respectively for
LCL,MCL) line of the knee and the other hand on the
lateral aspect of the ankle .
1. a varus force pushing toward the Medline is applied to
the ankle for testing LCL injury
2. a valgus force pushing away from Medline is applied
through the ankle for testing MCL injury
 RESULTS OF THE TESTS
1- in MCL injury
pain and excessive gaping is positive indicator for the
injury
2- in LCL injury
pain and excessive gaping is positive indicator for the
injury
DIAGNOSIS
IMAGING
1-MCL ON MRI
2-LCL ON MRI
The menisci
 WHAT IS KNEE MENISCI ??

they are fibrocartilagenous structures

present In the intercondylar fossa between
femur and tibia condyles .
.
- functions:
1.disperse the Weight of the body
2.stabalization of knee joint
3.reduce friction between articular surfaces
of tibia and femur condyle.
4.shock absorber
CAUSES OF MENISCI TE AR
 CLINICAL PICTURE
1 severe pain
2 joint locking
3 limited movement of knee joint
4-swelling
5-inablity to stand on affected limb
6-popping or clicking within
knee
 DIAGNOSIS
A clinically by :
1-physical examination ,including the
following tests

a.muc Murray's test

b.Thessaly's test c- apleys test
 HOW TO INSURE UR DIAGNOSIS BY
EXAMINATION ??
1-muc Murray's test
* Position of the patient
supine
*position Of the examiner:
-stand on the side of the patient , the proximal
hand on knee joint and the distal one on the heel
of the same limb
- the knee should be fully flexed ,the examiner
passively rotate the tibia and extend the knee for
examining medial menisci , internal rotation and
extension of the tibia for examining the lateral
menisci

*results
a positive test indicated by hearing a crepitus
associated with pain .
 2-THESSALYS TEST
*position of the patient : stand on the affected
leg
*position of the examiner:
stand in front of the patient and provide his or her
hands for stability
*principle:
-knee is flexed 5 and femur is rotate medially and
laterally for 3 times
-the same step is repeated with knee flexed 20

*results :
a positive test is indicated if there is locking of
movement .
 3-APLEYS TEST
For this test, the patient is
positioned prone, with his or
her knee flexed. Compression
and external or internal
rotation may be painful,
showing that the medial or
the lateral meniscus are torn.
This test is always checked,
by performing rotation without
compression
 B- IMAGING
* knee x ray
Although x-rays do not show meniscal tears, they
may show other causes of knee pain, such
osteoarthritis.

*Magnetic resonance imaging (MRI)

This study can create better images of the soft
tissues of your knee joint, like a meniscus.
 TREATMENT
Conservative Treatment

RICE. The RICE protocol is effective for most sports-

related injuries. RICE stands for Rest, Ice, Compression,
and Elevation.

If the joint is not locked, it is reasonable to hope that the

tear is peripheral and can therefore heal spontaneously.
After an acute episode, the joint is held straight in a
plaster backslab for 34 weeks; the patient uses crutches
and quadriceps exercises are encouraged .
 SURGICAL TREATMENT
by arthroscopy :

Meniscectomy
In this procedure, the damaged meniscal tissue is
trimmed away.

Meniscus repair. Some meniscal tears can be

repaired by suturing (stitching) the torn pieces
together
 RUPTURE OF QUADRICEPS TENDON

The four quadriceps muscles

meet just above the kneecap
(patella) to form the quadriceps
tendon. Tendons attach muscles
to bones. The quadriceps
tendon attaches the quadriceps
muscles to the patella. The
patella is attached to the
shinbone (tibia) by its tendon,
the patellar tendon.
Working together, the
quadriceps muscles, quadriceps
tendon and patellar tendon
straighten the knee.
 QUADRICEPS TENDON TEARS
Quadriceps tendon tears more common in people more
40 year , can be either partial or complete.

Partial tears. Many tears do not completely disrupt the

soft tissue. This is similar to a rope stretched so far that
some of the fibers are torn, but the rope is still in one
piece.
Complete tears. A complete tear will split the soft tissue
into two pieces.

When the quadriceps tendon completely tears, the muscle

is no longer anchored to the kneecap. Without this
attachment, the knee cannot straighten when the
quadriceps muscles contract.
Injury
Cause
A quadriceps tear often occurs when there is a heavy
load on the leg with the foot planted and the knee
partially bent. Think of an awkward landing from a
jump while playing basketball. The force of the
landing is too much for the tendon and it tears.
Tears can also be caused by falls, direct force to the
front of the knee, and lacerations (cuts).
Tendon Weakness
A weakened quadriceps tendon is more likely to tear.
 CLINICAL PICTURE
1-The typical injury is followed by tearing pain and
giving way of the knee.

3-There is bruising and local tenderness;

3-Active knee extension is either impossible

(suggesting a complete rupture) or weak (partial
rupture)
 BY EXAMINATION
SOMETIMES A GAP CAN BE FELT PROXIMAL TO
THE PATELLA.
 DIAGNOSIS
X-rays.
The kneecap moves out of place when the
quadriceps tendon tears. This is often very obvious
on a "sideways" X-ray view of the knee. Complete
tears can often be identified with these X-rays
alone.

MRI
diagnosis can be confirmed by MRI.
DIAGNOSIS
 TREATMENT
Partial tears
Non-operative treatment with plaster cylinder is
applied for 6 weeks, followed by physiotherapy that
concentrates on restoring knee.

Complete tears
Early operation is needed, End-to-end suturing can
be reinforced by turning down a partial-thickness
triangular flap of quadriceps tendon proximal to the
repair (Scuderi).
RUPTURE OF PATELLAR LIGAMENT
This is an uncommon injury; it is usually seen in
young athletes and the tear is almost always at the
proximal or distal attachment of the ligament.
 CLINICAL PICTURE
* The patient gives a history of :
1-sudden pain on forced extension of
the knee
2- bruising
3-swelling
4- tenderness at the lower edge of the
patella or more distally.
 DIAGNOSIS
X-rays
may show a high-riding patella (patella alta ) .
MRI
.
 TREATMENT
Partial tears : can be treated by applying a plaster cylinder.

Complete tears : need operative repair or reattachment to

bone, and keep the knee in extension position and use knee
immobilizer for 4-6 weeks Immobilizationin full extension
may precipitate stiffness after all, it is a joint injury
and it may be better to support the knee in a hinged brace
with limits to the amount of flexion permitted. This range can
be gradually increased after 6 weeks.
ANKLE SPRAIN
 Anatomy Review
The ankle complex includes three joints:
1.Talocrural (ankle) joint
o Synovial hinge joint between tibia, fibula, and talus
o Inferior tibiofibular joint unites tibia and fibula into
mortise

o Talus is tenon within mortise of tibia + fibula

o Motion: Hinge joint: Extension (dorsiflexion) and flexion
(plantar flexion)
 Anatomy Review
2. Subtalar joint:
o Synovial joint between talus and calcaneus
o divided into an anterior and posterior articulation separated
by the sinus tarsi
o Motion: Inversion, eversion, and anteroposterior gliding

2. Inferior tibiofibular joint:

o distal parts of the fibula and tibia articulate to form fibrous
Inferior tibiofibular joint (tibiofibular syndesmosis).
 Anatomy Review
Ligaments:
3 sets of ligaments stabilize ankle complex:
1. lateral collateral ligaments
2. Medial collateral ligaments (deltoid ligaments)
3. Distal tibiofibular syndesmotic complex

lateral collateral ligaments: Stabilize ankle against inversion and

anterior, posterior subluxation
o Anterior talofibular ligament (ATFL): it is the main talar stabiliser.
Stabilizes talus against anterior displacement, internal rotation, and
inversion
o Calcaneofibular ligament (CFL): secondary lateral restraint of subtalar
joint
o Posterior talofibular ligament (PTFL)
o Lateral talocalcaneal ligament (LTCL)
 Anatomy Review
Medial collateral ligaments (deltoid ligament):
o Divided into superficial and deep components
o Superficial: From superficial margin of medial malleolus. provide
rotational stability
o Deep: Posterior and anterior tibiotalar ligaments. prevent joint eversion

Tibiofibular syndesmotic ligaments:

o Maintain width of ankle mortise, stabilize against eversion
o Anterior and posterior inferior tibiofibular ligaments
o Inferior transverse ligament: Distal to main posterior tibiofibular
ligament
o Interosseous ligament: Distal thickening of syndesmotic membrane
 Anatomy Review

RANGE OF MOTION:

Primary plane motions include:

o Sagittal plane motion: dorsiflexion (15- 25) and plantarfiexion (50-55)
o Frontal plane motion is inversion (35) and eversion (20)
o Transverse plane motion is abduction (10) and adduction (20)

Triplanar motions occurring about oblique axes defined:

o Pronation (20) is a combination of dorsiflexion, eversion, and abduction.
o Supination (35) is a combination of plantarfiexion, inversion, and adduction.
 Introduction
Fong DT et al. A systematic review on ankle injury and ankle sprain in sports.
Sports Med. 2007;37(1):73-94.
 Introduction
28,000 ankle sprains occur daily in the US (Kaminski 2013)
Ankle is the 2nd most commonly injured body site. (Ferran
2006)
Ankle sprains are the most common type of ankle injury.
(Ferran 2006)
A sprained ankle can happen to athletes and non-athletes,
children and adults.
Inversion injury most common mechanism (Ferran 2006)
Only risk factor is previous ankle sprain (Ferran 2006)
Sex , generalized joint laxity or anatomical foot types are
not risk factors. (Beynnon et al. 2002 )
 Introduction
It is estimated that 80% to 85% of ankle sprains occur to the
lateral ligaments (Ryan et al., 1986)
It is generally accepted that an eversion ankle sprain is more
severe, with greater instability. however, an inversion ankle
sprain is more common, with the lateral ligaments being
involved in 80% to 85% of all ankle sprains. (Ryan et al., 1986)
ATFL is most common injured ligament
High rate of recurrence (20%-40%)(Verhagen 2010)
Chronic ankle instability (20-50%) (Verhagen 2000)
 Classification

Ankle sprain classified in to:

1. Low ankle sprain:

I. Lateral ankle sprain classic sprain 80% to 85%
II. Medial ankle sprain 5% to 10%

2. High ankle sprain (Syndesmotic sprain) 5% to 10%

 Low ankle sprain

Lateral ankle sprain:

oThe most common mechanism of ankle injury is

inversion of the plantar-flexed foot.
oThe anterior talofibular ligament is the first or only ligament to be
injured in the majority of ankle sprains. Stronger forces lead to
combined ruptures of the anterior talofibular ligament and the
calcaneofibular ligament
 Low ankle sprain

Medial ankle sprain

oThe medial deltoid ligament complex is the strongest of the ankle

ligaments and is infrequently injured.
oForced eversion of the ankle can cause damage to this structure but
more commonly results in an avulsion fracture of the medial malleolus
because of the strength of the deltoid ligament.
 High ankle sprain
High ankle sprain (Syndesmotic sprain):
oDorsiflexion and/or eversion of the ankle may cause sprain
of the syndesmotic structures.
oThere generally tends to be less swelling with a high ankle
sprain, however there tends to be pain that is more severe and
longer lasting.
oSyndesmotic ligament injuries contribute to chronic ankle
instability and are more likely to result in recurrent ankle
sprain and the formation of heterotopic ossification.
 Grading & symptoms

I. Grade I sprain:

It results from mild stretching of a ligament with microscopic

tears.
Patients have mild swelling and tenderness.
There is no joint instability on examination, and the patient is
able to bear weight and ambulate with minimal pain
 Grading & symptoms

II. Grade II sprain

Is more severe injury involving an incomplete tear of a ligament.

Patients have moderate pain, swelling, tenderness, and
ecchymosis.
There is mild to moderate joint instability on exam with some
restriction of the range of motion and loss of function.
Weight bearing and ambulation are painful
 Grading & symptoms

III. Grade III sprain

involves a complete tear of a ligament.

Patients have severe pain, swelling, tenderness, and ecchymosis.
There is significant mechanical instability on exam and significant
loss of function and motion. Patients are unable to bear weight or
ambulate
 Grading & symptoms
Sign/symptom Grade I Grade II Grade III
Ligament tear None Partial Complete

Loss of functional Minimal Minimal Some Moderate Great Severe

ability Pain
Minimal Usually Moderate Severe Yes
Swelling
not None Common Usual Almost always
Ecchymosis

Difficulty bearing
weight
 physical examination

o There is swelling, ecchymosis, and tenderness over affected site.

o The degree of swelling or ecchymosis is proportional to the likelihood
of fracture.
o Palpation should include bony landmarks such as the lateral
malleolus, the medial malleolus, the fibula, the fifth metatarsal, and,
the physis in skeletally immature patients.
o Achilles tendon, peroneal tendons, and posterior tibial tendon should
also be palpated.
o Tenderness over the anterior joint line or syndesmosis may indicate a
sprain of the interosseous membrane.
 physical examination

o Recurrent sprains often have very little swelling.

o An individual with an ankle sprain can almost always walk on the foot
carefully with pain.
o Grade III ankle sprains often include an audible snap followed by pain
and swelling
o A careful neurologic examination is essential to rule out loss of
sensation or motor weakness, as peroneal nerve and tibial nerve
injuries are sometimes seen with severe lateral ankle sprains.
 Special Tests
Anterior Draw Test

Purpose:
To test for ligamentous laxity or
instability in the ankle. This test
primarily assesses the strength of
the Anterior Talofibular
Ligament.

Diagnostic Accuracy:
Sensitivity: 71%
Specificity: 33 %
 Special Tests
Talar Tilt test

Purpose:
The talar tilt test detects excessive ankle
inversion. If the ligamentous tear extends
posteriorly into the calcaneofibular portion
of the lateral ligament, the lateral ankle is
unstable and talar tilt occurs.

Diagnostic Accuracy:
Sensitivity: 67%
Specificity: 75%
 Special Tests
External Rotation Stress
Test

Purpose:
To help identify a tibiofibular
Syndesmotic injury (high ankle
sprain).

Diagnostic Accuracy:
Sensitivity: 20%
Specificity: 84.5%
 Special Tests
Squeeze (Hopkin's) Test

Purpose:
To help identify inferior
tibiofibular Syndesmotic injury.
consisting of compression of the
fibula against the tibia at the mid-
calf level producing pain in the
syndesmosis.
 Imaging
o The Ottawa ankle rules are a set of guidelines
for clinicians to help decide if a patient with foot
or ankle pain should be offered X-rays to
diagnose a possible bone fracture.
o Sensitivity: 98.5%

o MRIs, CT scans, Bone scans, and arthrograms all

have diagnostic utility for specific injuries
(fractures; avulsions; talar dome fracture) but
have little role in the initial evaluation of ankle
sprains.
 Imaging
The rules are as follows :
An ankle series is only indicated for patients who have pain in
the malleolar zone AND
Have bone tenderness at the posterior edge or tip of the lateral or medial
malleolus OR
Are unable to bear weight both immediately after the injury and for
four steps in the emergency department or doctor's office.
A foot series is only indicated for patients who have pain in the
midfoot zone AND
Have bone tenderness at the base of the fifth metatarsal or at the
navicular OR
Are unable to bear weight both immediately after the injury and for four
steps in the emergency department or doctor's office.
 Imaging
o weight-bearing AP, lateral, and mortise
radiographs of the injured ankle to rule out
fracture
o If a high ankle sprain is suspected, the
radiograph should include the upper leg to
assess for bony injury or gross syndesmotic
disruption.
stress view
o stress views are performed by applying
external rotation and lateral displacement
stresses If a high ankle sprain is suspected.
o These should be compared to the contralateral
uninjured ankle since there is variability in soft
tissue laxity between patients.
 Imaging
Abnormal findings includes:

1. decreased tibiofibular overlap

normal >6 mm on AP view
normal >1 mm on mortise view 1 2
2. increased medial clear space
normal less than or equal to 4 mm
3. increased tibiofibular clear space
normal <6 mm on both AP and mortise
views

3
 Management
Conservative Management
Initial Management:
o The initial management of ankle sprain requires the PRICER regimen;
P= Protection . crutches, splint or brace
R= Rest .
I= Ice . 20 minutes every 2 hours
C= Compression .
E= Elevation .
R= Rehabilitation .
oThis is probably (the single-most important factor in treatment,
particularly with grade I and grade II injuries).
oPain and swelling can be reduced with the use of electrotherapeutic
modalities
oAnalgesics (NSAID) may be required.
 Management
Conservative Management
Restoring of Full Range of Motion:

oThe patient may be non-weight-bearing on crutches for the first 24

hours but should then commence partial weight-bearing in normal
heel-toe gait.
oIt will be necessary from this stage to protect the damaged joint with
strapping or bracing.
oAs soon as pain allows, active range of motion exercises can be
commenced.
 Management
Conservative Management
Muscle Conditioning:
oStrengthening exercises should be commenced as soon as pain allows.
oActive exercises should be performed initially with gradually
increasing resistance
oExercises should include plantarflexion and dorsiflexion, inversion
and eversion.

Functional Exercise:
oFunctional exercises (e.g. jumping, hopping, twisting, figure-of-eight
running) should be commenced when the athlete is pain-free, has full
range of motion and adequate muscle strength and proprioception.
 Management
Conservative Management
Treatment of grade III injuries:

oTreatment of grade III ankle injuries requires initial conservative

management over a six-week period.
oIf the patient continues to make good progress and is able to perform
sporting activities with the aid of taping or bracing and without
persistent problems during or following activity, surgery may not be
required.
oIf, however, despite appropriate rehabilitation and protection, the
patient complains of recurrent episodes of instability or persistent pain,
then surgical reconstruction is indicated.
 Management
Max. protection Mod. Protection Min. protection Return to activity
phase phase phase
1-3 Days 4-10 Days 11-21 Days 3-8 weeks
PRICE formula Non weight Weight bearing as Weight bearing as
Protection with a bearing AROM tolerated tolerated
splint Cross-fiber Initiate Eccentric ex. Agility drills.
Icing every 2hours massage Toe walks Adv. Exercises
during 1st 48hours Grade 2 joint Subtalar Staticdynamic
Elevation to reduce mobilization mobilization Isokinetic resistance
swelling Toa curls Tape or Brace for training
Gentle mobilization Seated calf sports or other Specific sport training
to inhibit pain stretches strenuous activities Protective bracing for
Partial WB with Endurance training Proprioception/ participation into a
crutches strengthening balance board ex sports
Muscle-setting exercises of
Techniques intrinsic foot
muscles

Caroline, Kysner, and Colby Lyn Allen. "Therapeutic Exercise Foundation and Techniques." FA.
Davis, Philadelphia (1988).
 Management

Conservative Management
o Medial ankle sprain and high ankle sprain can be treated
conservatively as lateral ankle sprain by PRICER protocol but time of
full recovery and return to function may extend to twice that of classic
ankle sprain.
 Management

Operative Management
Indication of operation in low ankle sprain:
1. pain and instability despite extensive nonoperative management
2. large bony avulsions
3. severe ligamentous damage on the medial and the lateral sides of the
ankle
4. severe recurrent injuries
 Management

Operative Management
Techniques of operation in low ankle sprain:
Arthroscopic reconstruction
Gould modification of Brostrom anatomic reconstruction
o an anatomic shortening and reinsertion of the ATFL and CFL
Tendon transfer and tenodesis
 Management

Operative Management
Indication of operation in high ankle sprain:
1.syndesmotic sprain (without fracture) with instability on stress
radiographs
2.syndesmotic sprain refractory to conservative treatment
3.syndesmotic injury with associated fracture that remains unstable
after fixation of fracture
 Management

Operative Management
Techniques of operation in high ankle sprain:
syndesmosis screw fixation
syndesmosis fixation with suture button
o fiberwire suture with two buttons tensioned around
the syndesmosis +/- syndesmosis screw.
Muscle Injury
Inflammation
Repair
 Introduction--- Types of injuries

Primary Injury
Injury from acute or chronic trauma
Secondary Injury
Inflammatory response to primary injury
 3 Phases of Tissue Healing

Inflammatory response phase

Fibroblastic-repair phase

Maturation-remodeling phase
Healing process is a continuum and phases
overlap one another with no definitive beginning or
end points
 Inflammatory-Response Phase

After injury, healing process begins

immediately
Destruction of tissue produces direct injury to
cells of various soft tissue
Characterized by redness, swelling, tenderness
and increased temperature
Critical to entire healing process
 Inflammatory-Response Phase

Leukocytes and other phagocytic cells

delivered to injured tissue
Dispose of injury by-products through
phagocytosis
 Inflammatory-Response Phase

Vascular reaction Chemical mediators

Blood coagulation Released from damaged
tissue, white blood cells and
and growth of
plasma
fibrous tissue
Histamine, leukotrienes and
occurs cytokines assist in limiting
First 5-10 minutes exudate/swelling
vasoconstriction Amt of swelling directly
occurs related to extent of vessel
damage
Best time to
evaluate
Followed by
vasodilation
Effusion of blood
and plasma last 24
 Inflammatory Response Cont
Formation of Clot
Platelets adhere to
collagen fibers and create
sticky matrix
Platelets and leukocytes
adhere to matrix to form
plug
Clot formation occurs 12
hours after injury and is
complete w/in 48 hrs
Set stage for fibroblastic
phase
Chronic inflammation
Acute phase dos not
respond sufficiently to
eliminate injury agent and
restore tissue to normal
physiologic state
Damage occurs to
connective tissue and
prolongs healing and repair
process
Response to overuse and
overload
 Inflammatory Response Cont

Entire phase last 2-4 days

Greater tissue damage longer
inflammatory phase

NSAIDS may inhibit inflammatory

response thus delaying healing process
Will assist with pain and swelling
 Fibroblastic-Repair Phase

Proliferative and regenerative activity leads to

scar formation
Begins w/in 1st few hours after injury and can last
as long as 4-6 weeks
Signs and Symptoms of inflammatory phase
subside
Increased O2 and blood flow deliver nutrients
essential for tissue regeneration
 Fibroblastic-Repair Phase

Break down of fibrin clot forms connective

tissue called granulation tissue
Consist of fibroblast, collagen and capillaries
Fills gap during healing process
Unorganized tissue/fibers form scar
Fibroblast synthesize extracellular matrix consisting
of protein fibers (Collagen and Elastin)
Day 6 7 collagen fibers are formed throughout scar
Increase in tensile strength increases with rate of
collagen synthesis
 Fibroblastic-Repair Phase

Importance of Collagen
Major structural protein that forms strong, flexible
inelastic structure
Type I, II & III
Type I found more in fibroblastic repair phase
Holds connective tissue together and enables tissue
to resist mechanical forces and deformation
Direction of orientation of collagen fibers is along lines of tensile
strength
 Fibroblastic-Repair Phase

Importance of Collagen
Mechanical properties
Elasticity
Capability to recover normal length after elongation
Viscoelasticity
Allows slow return to normal length and shape after
deformation
Plasticity
Allows permanent change and deformation
 Maturation-Remodeling Phase

Long term process that involves realignment of

collagen fibers that make up scar
Increased stress and strain causes collagen fibers to
realign to position of maximum efficiency
Parallel to lines of tension
Gradually assumes normal appearance and function
Usually after 3 weeks a firm, contracted, nonvascular
scar exist
Total maturation phase may take years to be totally
complete
 Maturation-Remodeling Phase

Wolfs law
Bone and soft tissue will respond to physical
demands placed on them
Remodel or realign along lines of tensile force
Critical that injured structures are exposed to
progressively increasing loads throughout rehab
process
As remodeling phase begins aggressive active range of
motion and strengthening
Use pain and tissue response as a guide to progression
 Maturation-Remodeling Phase

Controlled mobilization vs. immobilization

Animal studies show Controlled mob. Superior to
Immobilization for scar formation
However, some injuries may require brief period of
immob. During inflammatory phase to facilitate
healing process
 Factors that impede healing

Extent of injury Hemorrhage

Bleeding causes same
Microtears vs. neg. effect as edema
macrotears Poor vascular supply
Edema Tissues with poor vascular
supply heal at a slower rate
Increased pressure
Failure to deliver
causes separation phagocytic cells and
of tissue, inhibits fibroblasts for scar formation
neuro-muscular
control, impedes
nutrition,
neurological
changes
 Factors that impede healing

Separation of tissue Corticosteroids

How tissue is torn In early stages
will effect healing shown to inhibit
Smooth vs. jagged healing
Traction on torn Keloids or
tissue, separating 2
ends hypertrophic scars
Ischemia from Infection
spasm spasm Health, Age and
Atrophy nutrition
 Role of Physician

Diagnosis and
Treatment

Team Leader
Decision Maker
Return to Play

Educator, Advisor
Advocate & Confidant
 PREVENTION

Primary Secondary Tertiary

Avoidanc Early Rehabilita
e of diagnosis tion- to
injury ( and reduce
eg- treatment and
safety once the correct
helmets) injury has any
occurred deformity
 PRIMARY
Warm up
PREVENTION-
Stretching
Taping and
Bracing
Protective
Equipment
Suitable
Equipment
Environmental
factors
Appropriate
Training
Psychology
 Injury prevention program
focus on
Balance
Eccentric Strength
Proper Mechanics
Flexibility

overall reduction of severe ACL injuries

from 72 89%.
 Treatment
Assessment of
injuries
ABC
TOTAPS
Treatment of
injuries
PRICER
No HARM
 ABC
Airway
Breathing
Circulation
 TOTAPS
Talk
Observe
Touch
Active
Passive
Skills
 Initial treatment of
injuries PRICER
Protection
Rest
Ice
Compression
Elevation
Referral
Protection
Take player away from field to avoid further injury
as soon as possible
 Rest
Remove player from
field

Rest injured area

Immobilize area
Why?
Reduces further tissue
damage
Reduces blood flow
Allows for full
assessment of injury
Ice
Ice bag, pack
Ice water bath
15 mins/ 5 times a day

Why?
Cool the area which constricts blood vessels, reduces
blood flow and fluid leakage, less swelling, pressures
and pain
 Compression
Compress injured area with
Elastic bandage
Cohesive bandage
Move distal to proximal
Why?
External pressure reduces fluid leakage and
bleeding into tissues
Provide support the area
 Elevation
Elevate area above height
Why?
Reduces bleeding as blood has to
flow up hill
Gravity helps swelling to move
towards lymph nodes
 No HEAT
Includes
Hot packs
Spas
Saunas

Why?
Increases blood flow to area therefore
increases swelling
 No ALCOHOL
Includes most things adults enjoy after a
game of sports

Why?
Thins blood which increases
swelling
Less pain felt therefore more
damage caused
Adds toxins to already injured
area
 No RUNNING
Includes running as well as any exercise
that is painful

Why?
Increases in tissue damage
Overload to other area as
compensation
 No MASSAGE

Rub down
Massage
Mobilizations

Why?
May increases tissue damage
Increases blood circulation to the
injured area
 Summary
Diverse range of causes

Understanding cause may influence treatment and

prevention

No simple way to identify what the relative mix of

causes is for one particular injury

In clinical practice, think about the range of options

and treat
THANK YOU