Team physican manual

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Introduction
Musculoskeletal Injuries:
Diagnosis, Treatment, and
Rehabilitation
Christer G. ROLF, MD
Angela D. SMITH, MD
Introduction
Musculoskeletal Injuries: Diagnosis,
Treatment, and Rehabilitation
Christer G. ROLF
Angela D. SMITH
These sections summarize international consensus for managing muscu-
loskeletal injuries. The guidelines herein are intended for use by physi-
cians everywhere, including team physicians in developing countries,
who are the primary audience for whom this text was conceived.
Appropriate management depends on a proper diagnosis, which in
most cases starts with a proper history and a thorough clinical examina-
tion. As a team physician your specialty and competence may vary. If
you are not an orthopedic specialist but feel confident to handle these
injuries by yourself, your main task is to handle the acute situation, dis-
tinguish “emergencies” from “benign” conditions and to determine
where, when, and to whom the athlete should be referred for proper
treatment. You will most likely be asked by the athlete when and how
training can be resumed. This chapter therefore concerns itself with ad-
dressing such issues, keeping in mind that competence and regimen may
vary significantly among different countries and sports.
The approach to managing most sports injuries includes several com-
ponents in addition to the treatment of the injured anatomic region.
Immobilization should be minimized to decrease the severity of disuse
atrophy and general deconditioning. The athlete should perform cross-
training activities if possible, to maintain cardiopulmonary fitness and
the strength and flexibility of uninjured regions. Even among some rela-
tively elite athletes, strength of the core (trunk) muscles may be inade-
quate, or weakness may have resulted from decreased activity during
the early phases of injury healing, so core strengthening is an important
part of rehabilitation of almost all sports injuries. The athlete should
strengthen not only the core muscles, but the entire kinetic chain for the
injured region. For example, a pitcher with an injured elbow should
obtain full strength, flexibility, and endurance of the entire upper ex-
tremity, as well as normal scapulothoracic, trunk, and supporting lower
extremity function.
 Introduction
Musculoskeletal injuries: diagnosis, treatment, and rehabilitation 239
Athletes are often able to resume some aspects of training before their
injuries have healed completely. One set of guidelines for playing while
injured is known by the acronym “PLAY.” It is applicable to most situ-
ations, and has the aim of returning the athlete to play as rapidly as is
safely possible.
•P
ain may be present at the end of activity, but must be gone by the
next morning, indicating that the amount of tissue injury is probably
not exceeding tissue healing.
•L
imping, or favoring the injured limb, means it is too risky to partici-
pate in activities where you are not in control of the situation. If you
continue in an activity where collision or slipping is likely—and the
muscles about the knee (for example) are not firing in a normal, coor-
dinated manner—then serious, permanent injury could occur.
•A
bility to complete the prescribed exercise program effectively, 6 days
a week, is necessary. If you have so much discomfort following the
sport activities that you cannot do the strengthening exercises prop-
erly, then you should either decrease the amount of sport activity or
perform the strengthening exercises in the morning.
•Y
ou should not use pain-masking drugs or ice application before sport
activity, so that you can monitor your body’s signals of pain.
GENERAL OBJECTIVES
The focus of these sections, wherever possible, is to describe how to eval-
uate the athlete’s history; how to conduct an initial clinical examination;
how to provide first aid; where to refer the athlete if he/she needs advice
for further investigations and treatment; and what advice to give regard-
ing continuation of training until definitive treatment is done. The mate-
rial will give a theoretical basis for proper management and hands-on
training of clinical examination techniques for diagnosing common
injuries.
SPECIFIC OBJECTIVES
With respect to common orthopedic injuries, these sections will aim to
teach:
• how to take a typical history and recognize a clinical presentation;
• how to conduct a proper clinical examination;
• how to provide on-field first aid treatment of acute injuries;
 240
F.I.M.S. Team Physician Manual
• why and to whom to refer for further treatment; and
• how to advise the athlete during recovery.
GENERAL CLINICAL APPROACH TO ATHLETES PRESENTING WITH INJURY/PAIN
History
Consider age, gender, physical appearance, training status, and previous injury.
How did the current symptoms occur? Let the athlete demonstrate. How does the
athlete describe the symptoms, ie, duration, intensity, and location?
Principles of clinical examination
• Always compare injured to non-injured side.
• Inspection and palpation: ecchymosis/laceration, swelling, muscle symmetry,
focal tenderness, neurovascular status.
• Range of Motion: any restrictions? Is the limiting factor intra-articular pathology?
• Muscle function: muscle pathology or muscle guarding?
• Special tests: joint stability, tests for intra-articular disorders, provocative tests
Imaging
• Plain x-ray
• Ultrasound
• Magnetic resonance imaging (MRI)
• Computed tomography (CT) scan
• Special imaging indications to be discussed in coverage of specific injuries
When to refer
Whenever not comfortable with confirming specific diagnosis/treatment plan, in-
cluding rehabilitation and return to action
Treatment
• Emergency or on-field treatment
• Non-operative/functional treatment
• Surgical treatment
Return to action
• Formulating rehabilitation plan or program
• Return to action criteria
Copyright © 2001 International Federation of Sports Medicine
All rights reserved. This book is protected by copyright. No part of this book may be repro-
duced in any form or by any means, including photocopying, or utilized by any information
storage and retrieval system without written permission from the copyright owner.
Care has been taken to confirm the accuracy of the information presented and to describe gen-
erally accepted practices. However, the authors, editors, and publisher are not responsible for
errors or omissions or for any consequences from application of the information in this book
and make no warranty, expressed or implied, with respect to the currency, completeness, or
accuracy of the contents of the publication. Application of this information in a particular sit-
uation remains the professional responsibility of the practitioner.
ISBN 962-356-029-X
Printed in Hong Kong
First Edition, 2001
Production:
Lippincott Williams & Wilkins Asia Ltd
Suite 907-910, New T&T Centre
Harbour City, 7 Canton Road
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Tel: (852) 2610 2339
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Corporate website: www.lww.com
Photos on the cover supplied coutesy of the National Athletic Trainers Association, 2952 Stem-
mons Hwy., Dallas, TX, 75247.
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