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BRUNKER SPORTS MEDICINE 5TH ED VOLUME I, BRUNKER SPORTS MEDICINE 5TH ED…
BRUNKER SPORTS MEDICINE 5TH ED VOLUME I
BRUNKER SPORTS MEDICINE 5TH ED VOLUME I
PART A FUNDAMENTAL PRINCIPLES
Sport and exercise medicine: the team approach
The SEM team
Multiskilling, roles, responsibilities and communication
The sport and exercise medicine model
The challenges of management
Diagnosis
Treatment
Meeting individual needs
The coach, the athlete and the clinician
'Love thy sport' (and physical activity!)
Integrating evidence into shared decision making with patients
What is evidence-based practice?
Why is the evidence-based practice concept controversial?
Challenges to EBP
Implementing EBP
Accessing research
Retrieving articles
Published appraisals
Interpreting research about treatment effects
Risk of bias
Research about other types of clinical questions
3.Sports injuries: acute
Pathophysiology and initial management
Bone
Hyaline cartilage
Fibrocartilage
Joint
Dislocation/subluxation
Ligament
Sprain/tear
Muscle
Strain/tear
Tendon
Tear/rupture
Fascia
Tear/rupture
Bursa
Nerve
Fat pad
skin
4.Sports injuries: overuse
Pathophysiology
Epidemiology
Risk factors
Diagnosis
Classification of bone stress injuries
Management
Articular cartilage
Joint
Ligament
Muscle
Tendon
Principles of rehabilitating lower limb tendinopathy
Bursa
Nerve
Skin
But it's not that simple
Pain: where is it coming from?
Masquerades
The kinetic chain
Pain: why and how does it hurt?
What is pain?
What is nociception? Clue-nociception is not pain!
Sensitisation of primary nociceptors ('peripheral sensitisation')
Sensitisation of spinal nociceptors ('central sensitisation')
The brain decides
The brain corrects the spinal cord
The brain is different in those with persistent pain
Treating someone in pain-a complex system requires a comprehensive approach
6.Pain: the clinical aspects
Pain and musculoskeletal tissues
Central sensitisation
Motor adaptation to pain
Treatment options for patients with pain
Language
Summary
Beware: conditions that masquerade as sports injuries
How to recognise a condition masquerading as a sports injury
Conditions masquerading as sports injuries
Summary
Introduction to clinical biomechanics
'Ideal' lower limb biomechanics-the basics
Lower limb joint motion
Ideal neutral stance position
'Ideal' biomechanics with movement-running
Loading (heel strike to foot flat)
Midstance (foot flat to heel off)
Propulsion (heel off to toe off)
Initial swing
Terminal swing
Angle and base of gait
Landing point relative to centre of mass
Influence of gait velocity
Comparing heel and forefoot strike patterns
Influence of fatigue on running biomechanics
Lower limb biomechanical assessment in the clinical setting
Structural ('static') biomechanical assessment
Functional lower limb tests
Dynamic movement assessment (e.g. running biomechanics)
Sport-specific assessment
Summary of the lower limb biomechanical assessment
Clinical assessment of footwear-the Footwear Assessment Tool
Conditions related to suboptimal lower limb biomechanics
Biofeedback and movement pattern retraining
Foot orthoses
Taping
Upper limb biomechanics
The biomechanics of throwing
The kinetic chain
Normal biomechanics of the scapula in throwing
Clinical significance of scapular biomechanics in shoulder injuries
Changes in throwing arm with repeated throwing
Biomechanical aspects of injury in specific sports
Cycling
Relationship between risk factors and loading
Cricket fast bowling
Golf
Rowing
Swimming
Tennis
Training programming and prescription
Principles of training
Periodisation
Overload
Specificity
Individualisation
Conditioning training
Endurance training
Speed training
Agility training
Resistance training
Flexibility training
Training load management for performance enhancement
11.Core stability
Introduction
Rationale for motor control training for lumbopelvic dysfunction
Motor control training to optimise core
stability-key principles and common misconceptions
Optimal motor control requires a balance between movement and stiffness
Optimal lumbopelvic control involves three main neural strategies
Optimal motor control requires a whole system, not a single muscle
Motor control training involves rehabilitation of whole system
Motor control training involves a motor learning approach
Interplay between motor control and biology of pain
Implications of the role of trunk muscles in respiration and bladder and bowel function
Is motor control training effective for everyone or is it more effective when targeted to specific individuals?
Principles of the clinical application of motor Managing load to prevent injury control training
Assessment of motor control for core stability
Training of motor control for core stability
Training of motor control for core stability for prevention of pain and injury 164 Monitoring athletes' response to load-the
Considerations for training of motor control for core stability in athletes
Conclusion
12 Preventing injury
A conceptual approach to injury prevention
The inciting event
Risk management: applying prevention models to your team
Reviewing the literature-risk identification and assessment
Developing an injury surveillance program within the team
Season analysis-risk profiling the training and competition program
The periodic medical assessment-mapping current problems and intrinsic risk factors
Developing and initiating a targeted prevention program
Preventing hamstring strains
Injury mechanisms
Risk factors
Prevention programs
Preventing ankle sprains
Injury mechanisms
Risk factors
Prevention programs
Preventing acute knee injuries
Injury mechanisms
Risk factors
Prevention programs
Preventing overuse injuries
Stretching
Structured training programs
Technique modification
Nutritional strategies to prevent stress fractures
Modification of extrinsic risk factors
The relationship between load and injury
Monitoring the rate of load increase
Monitoring the acute: chronic load ratio
Monitoring athletes' response to load-the traffic-light approach
Protective equipment
Appropriate surfaces
Natural grass versus artificial turf
Recovery
Assessing recovery
Active recovery
After high-intensity short-duration exercise
After longer-duration exercise-active recovery and metabolite clearance
Psychological effects of active recovery
Massage
Massage and blood flow
Massage, muscle tone and viscoelasticity
Cellular and structural effects of massage
Psychological effects of massage
Neuromuscular electrical stimulation
NMES and blood flow
NMES and performance
NMES and muscle soreness
Stretching
Sleep
Water immersion
Compression
Nutrition
Replacing fluids
Replacing fuel
Repair
Pulling the different threads together-practical considerations for the clinician
Summary
Clinical assessment: moving from rote to rigorous
Why is differential diagnosis important?
Differential diagnosis: a three-step process
How to calculate an accurate diagnosis
Reliability
Sensitivity and specificity
Positive and negative predictive values
Likelihood ratio
Clinical utility
The formal diagnostic assessment
The role of bias in influencing diagnostic metrics
Challenges to making a diagnosis
Final thoughts and guidance
Patient-reported outcome measures in sports medicine
What are PROMs?
Why is it important to use appropriate PROMs in sports medicine?
Considerations for what constitutes a 'good'
PROM for use in sports medicine
Is the PROM easy to use in a sports medicine setting?
Does the PROM evaluate dimensions that are relevant for the patient?
Do all items within a PROM measure the same construct?
Can the PROM be trusted to detect true change in the patient and be free from error?
Is the PROM sensitive enough to detect real change in the patient's condition?
Summary
Principles of sports injury rehabilitation
General principles
An essential element-effective planning
Goal setting and targeted interventions
Phases of rehabilitation
Phase 1: Acute
Phase 2: Restore activities of daily living
Phase 3: Returning to sports activities
Phase 4: Prevention of re-injury
When rehabilitation doesn't go according to plan
17.Treatment of sports injuries
Therapeutic exercise
Stimulation of repair and remodelling: Develop a routine
Mechanotherapy
Altering biomechanics: motor-control training
Acute injury management
Protection
Optimal loading
Ice
Compression
Elevation
Do no HARM!
Manual treatments
Joint techniques: mobilisation and manipulation
Soft tissue therapy
Dry needling
Neurodynamic techniques
Taping
Proposed mechanisms of taping
Evidence of efficacy
Practical considerations
Electrophysical agents
Therapeutic ultrasound
Transcutaneous electrical nerve stimulation
Neuromuscular stimulators
lnterferential stimulation
Laser
Electromagnetic therapy
Extracorporeal shockwave therapy
Therapeutic medication in musculoskeletal injury
Analgesics
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Traumeel
Actovegin
Sclerosant
Prolotherapy
Medications for neuropathic pain and central sensitisation
Local anaesthetic injections
Mechanical and high-volume injections
Hyaluronic acid
Corticosteroids
Other medications
Nutraceuticals in injury management
Glucosamine, chondroitin and omega-3 fatty acids
Vitamin D
Green tea/polyphenols
Autologous blood, blood products and cell therapy
Autologous blood injections
Platelet-rich plasma
Cell therapy
Surgery
Arthroscopic surgery
Open surgery
15.How to make the diagnosis
Does 'diagnosis' mean 'tissue diagnosis'?
Keys to accurate diagnosis
History
Allow enough time
Be a good listener
Know the sport
Discover the exact circumstances of the injury
Obtain an accurate description of symptoms, both at the time of injury and at the initial
consultation
History of a previous similar injury
Other injuries
General health
Work and leisure activities
Consider why the problem has occurred
Training/activity history
Equipment
Technique
Psychological factors
Nutritional factors
Drugs: prescription and others
History of exercise-induced anaphylaxis
Determine the importance of the sport to the athlete
Differential diagnosis
Physical examination
Develop a routine
Where relevant, examine the other side
Consider possible causes of the injury
Attempt to reproduce the patient's symptoms
Assess local tissues
Assess for referred pain
Assess neural mechanosensitivity
Examine the spine
Biomechanical examination
Functional testing
The examination routine
Differential diagnosis
Diagnostic imaging
The five imaging-related habits of highly effective sports medicine clinicians
Specific imaging modalities
Conventional radiography
MRI: massive blessing for active patients
Ultrasound scan (for diagnosis)
CT scanning
Radioisotopic bone scan
Return to play
Strategic Assessment of Risk and Risk Tolerance framework for RTP decision making
Step 1: Tissue health
Step 2: Tissue stresses
Step 3: Risk tolerance modifiers
Return-to-play decision making-beyond risk for injury
Applying the StARRT framework
Assessing across outcomes probabilities
Additional perspectives
Who should be the decision maker?
Clinicians
Athletes
The coach
Family, friends, agents
Management
A multidisciplinary approach
Summary
PART B
20.Sports concussion
Definition
Prevention of concussion
The initial impact: applied pathophysiology
Management of the concussed athlete
On-field management
Confirming the diagnosis
Determining when the player can return safely to competition
The risk of premature return to play and concussion sequelae
Clinical assessment
Treatment
21.Headache
Headache in sports
Clinical approach to the patient with headache
History
Clinical measurement of headache
Examination
Primary headache
Migraine
Primary exercise headache
Secondary headache
Cervicogenic headache
Post-traumatic headache
Post-traumatic migraine
External compression headache
High-altitude headache
Hypercapnia headache
22.Face, eyes and teeth
Functional anatomy
Clinical assessment
immediate management of lacerations
Management of larger lacerations
Additional considerations
Nose
Ear
Eyes
Assessment of the injured eye
Prevention of eye injuries
Teeth
Nature of injuries
Emergency management
Dental management and follow-up
Prevention
Prevention of facial injuries
23.Neck pain
Anatomical considerations
Clinical perspective
History
Patient-reported outcome measures
Imaging
Physical examination
Performance-based outcome measures
Management of mechanical neck pain
Sport and functional modifications
Education
Pain management
Manual therapy
Neural tissue mobilisation
Training motor function
Training sensorimotor control
Maintenance program
Cervicogenic headache
Conclusion
24.Shoulder pain
Functional anatomy and biomechanics
Static stabilisers
Dynamic stabilisers
The role of the scapula in normal shoulder function
Causes of shoulder pain-overview
Impingement
Clinical approach
History
Physical examination
Special tests-diagnostic testing and symptom modification tests
Screening of the kinetic chain
Key outcome measures
Investigations
Radiography
Arthrography
Ultrasound
Magnetic resonance imaging
Diagnostic arthroscopy
General treatment and rehabilitation guidelines for the most common shoulder injuries in athletes
Rehabilitation guidelines for shoulder
instability-overview
Pathomechanics of biceps-related
Clinical features
Pathomechanics of GIRD
Treatment of GIRD
Rehabilitation of scapular dyskinesis-a scapular rehabilitation algorithm
Special note-immature skeleton
Less common causes of shoulder pain
Other muscle tears around the shoulder
Less common fractures around the shoulder
Special considerations for the overhead athlete
Kinetic chain integration
The thrower's program
Return to play following shoulder injury
25.Elbow and arm pain
Anatomy
Muscles
History
Examination
Investigations
Other causes of lateral elbow pain
Fractures
Posterior dislocation
Tendon ruptures
26.Wrist pain
Clinical approach
History
Physical examination
Key outcome measures
Investigations
General tendinopathies around the wrist
Surgery for wrist conditions
Wrist rehabilitation
Wrist splinting
Post-immobilisation wrist rehabilitation
27.Hand and finger injuries
Clinical approach
History
Physical examination
Key outcome measures
Investigations
Principles of treatment
Oedema control
Exercises
Taping and splinting
Surgical referrals following hand injury Exercises for the hand
Exercises for the hand
28.Thoracic and chest pain
Assessment
Clinical assessment
Conclusion
29.Low back pain
Epidemiology
The multidimensional nature of low back pain
Triage
Serious pathology
Specific pathoanatomical diagnoses
Factors contributing to low back pain
Physical factors
Lifestyle factors
Psychosocial factors
Neurophysiological factors
Individual considerations
Clinical approach
History
Physical examination
Investigations
Clinical approach
Rehabilitation following low back pain
Sporting technique
Optimal motor control
Flexibility
Conclusion
30.Buttock pain
Clinical approach
History
Physical examination
Investigations
Examination
Treatment of myofascial buttock pain
Referred pain from lumbar spine
Examination
Treatment
Functional anatomy
Examination
Treatment
Functional anatomy
Clinical features
Treatment
Less common causes of buttock pain
Conditions not to be missed
35.Acute knee injuries
Functional anatomy
Clinical approach
'Does this patient have a significant knee injury?'
History
Physical examination
Key outcome measures
Investigations
Clinical features
Treatment
Rehabilitation after meniscal surgery
Treatment
Anatomy of the ACL
Mechanism of ACL injury
Clinical features
Surgical or conservative treatment of the torn ACL?
Surgical treatment
Combined injuries
Rehabilitation after ACL injury
Problems encountered during rehabilitation
Outcomes after ACL treatment
Prevention of ACL injuries
Clinical features
Treatment
Epidemiology
Management
Less common causes
31.Hip pain
Epidemiology
Functional anatomy and biomechanics
Morphology
Acetabular labrum
Ligaments of the hip
Chondral surfaces
Muscle function
Clinical approach
History
Physical examination
Key outcome measures
Investigations
Predisposing factors for pain
Local factors
Remote factors
Systemic factors
Prevalence of FAI
Aetiology
Association with pain and pathology
pathology
Treatment of hip impairments
Principles of rehabilitation of the injured hip
Nine principles of rehabilitation for hip pain patients
Surgical management of the injured hip
Examination of the patient with lateral hip pain
Treatment of the patient with lateral hip pain
32.Groin pain
Anatomy
Pubic symphysis
Hip adductors
Hip flexors
Inguinal region
Summary of anatomy
Epidemiology
Incidence-soccer
Incidence-elite sports other than soccer
Prevalence
Distribution of acute injuries
Risk factors
Terminology and definitions
Classification
Clinical overview
History
Clinical examination
Imaging
Diagnosis
Less common injuries
Other nerve entrapments
Prevention of groin injuries
Possible prevention strategies
33.Anterior thigh pain
Epidemiology
Functional anatomy and biomechanics
Clinical approach
History
Physical examination
Key outcome measures
Investigations
Treatment of quadriceps contusion
Complications related to contusion
Less common causes
Referred pain
34.Posterior thigh pain
Functional anatomy
Clinical approach
History
Physical examination
Investigations
Integrating the clinical assessment and investigation to make a diagnosis
Epidemiology
Prognosis of hamstring injuries
Management of hamstring injuries
Risk factors for acute hamstring strain
Intrinsic risk factors
Extrinsic risk factors
Prevention of hamstring strains
Eccentric hamstring strength training
Balance exercises/proprioception training
Sport-specific training
A promising clinical approach for the high-risk athlete
Trigger points
Lumbar spine
Sacroiliac complex
Other hamstring injuries
Less common causes
36.Anterior knee pain
Clinical approach
History
Physical examination
Patient-reported outcome measures
Investigations
What is patellofemoral pain?
Functional anatomy
Factors that may contribute to patellofemoral pain
Treatment of PFP
Nomenclature
Clinical features
Investigations
Management: is the athlete still competing?
Less common causes of anterior knee pain
37.Lateral, medial and posterior knee pain
Clinical approach
Less common causes of lateral knee pain
Less common causes of medial knee pain
Clinical evaluation
Other causes of posterior knee pain
38.Leg pain
Clinical approach
Role of biomechanics
History
Physical examination
Key outcome measures
Investigations
Assessment
Treatment
Prevention of recurrence
Treatment
Risk factors
Treatment
Pathogenesis
Clinical features
Outcomes of exertional compartment syndrome surgery
Rehabilitation following compartment syndrome surgery
Less common causes
Referred pain
Developmental issues
39.Calf pain
Anatomy
Clinical approach
History
Physical examination
Key outcome measures
Investigations
Vascular causes
Less common causes
Neuromyofascial causes
Conditions not to be missed
40.Pain in the Achilles region
Clinical perspective
History
Physical examination
Key outcome measures (PROMs)
Investigations
Pathology
Predisposing factors for Achilles tendinopathy
Treatment of midportion Achilles tendinopathy
Medications
Electrophysical agents
Surgical treatment
Anatomy and the key role of compression
Clinical assessment
Treatment
Other causes of pain in the Achilles region (gradual onset)
Referred pain
Clinical approach
History
Physical examination
Key outcome measures
Investigations
Rehabilitation of Achilles tendon ruptures
41.Acute ankle injuries
Functional anatomy
Clinical perspective
History
Examination
Investigations
Treatment and rehabilitation of lateral ligament injuries
Initial management
Treatment of grade Ill injuries
Less common causes
Significant ankle fractures
Clinical approach to the difficult ankle
Other fractures
Other causes of the difficult ankle
42.Ankle pain
History
Examination
Key outcome measures
Investigations
Other causes of medial ankle pain
Examination
Referred pain
43.Foot pain
History
Examination
Investigations
Patient-reported outcome measures
Clinical approach to midfoot pain
Investigations
Less common causes of midfoot pain
Clinical perspective
Corns and calluses
Less common causes of forefoot pain
PART C
44.The younger athlete
The young athlete is unique
Nonlinearity of growth
Maturity-associated variation
Unique response to skeletal injury
Management of musculoskeletal conditions
45.Military personnel
Special military culture
Epidemiology of military injuries
Injury prevention in the military
Injury surveillance
Sex as a risk factor for injury
Body composition
Previous injury
Weekly running distance
Running experience
Competitive behaviours
Warm-up/stretching
Conclusion
Periodic medical assessment of athletes
Why perform the medical assessment?
Identification of medical conditions that contraindicate participation in sport
Assessment of known injuries and illnesses
Review of current medications and supplements
Education
Baseline testing
Development of athlete
Screening
Who is being assessed?
Sport and position
Geographical location
Age
Sex
Available resources
When to perform a PMA
What to include in the template
Other issues to consider
Consent
Clearance or restriction from play
Who should perform the PMA?
Pre-employment medical assessment
Insurance medical assessment
Action points from the PMA
Summary
47.Working and travelling with teams
The medical support team
Key attributes of a successful medical team
Medical indemnity and trauma training
Where does the medical team work?
Medical equipment
Team care throughout the season
Core principles providing care for a team
Emergency action plans
Preparing to travel
1 . Before travel
During travel
On arrival
Journey home
Air travel and jet lag
Pathophysiology
Prevention of jet lag
Symptomatic treatment for jet lag
48.Career development
Development of sport and exercise medicine
The adoption of exercise medicine in the sports medicine movement
Increased resources in sport
Proficiency in a second or third language
Widening the scope of practice-dual qualifications and subspecialist courses
Quotation sources
Sports therapy, sports and exercise science and sports rehabilitation
Men and women have a place in sport and exercise medicine
Key behaviours for a successful and interesting career
Lessons from around the world
Ummukulthoum Bakare-football medicine enthusiast and sports injury prevention strategist, West Africa
Dr Liam West-the rookie doctor, Northern Europe and Australia
Hans-Wilhelm MUiier-Wohifahrt-the team and celebrity doctor, Bavaria, Central Europe
Rod Whiteley-sports physiotherapist who has moved across continents for his career, Middle East via Australasia and Major League Baseball
Roald Bahr-Professor of Sports Medicine, the Nordic country