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Sports Medicine: Common Musculoskeletal Conditions

and ConcussionsRusty McKune, MS, ATC

Sports Medicine Program DirectorNebraska Medicine

e-mail: rmckune@nebraskamed.comPhone: 402-552-3522

Declaration of Conflicts

I have no relevant:

Conflicts of Interest Financial Disclosures

To declare with regards to this presentation or any of the material contained within this presentation.

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Goals and Objectives

1. Identify the signs and symptoms that would help differentiate between a sprain, strain and possible fracture.

2. Identify the acute management for suspected sprains, strains and fractures.

3. Examine the clinical tools used to diagnose a suspected concussion.

4. Describe best practices in the management of concussion; to include return to learn and return to play guidelines.

5. Discuss the ancillary services available for patients who have sustained a concussion.

Musculoskeletal Injuries in Pediatric Athletes

Chronic /Overuse• Physeal Injuries

• Epiphysis• Little League Shoulder• Gymnast Wrist

• Apophysis• Osgood Schlatters• SLJ• Sever’s Disease• Little League Elbow• Pelvis/Low Back

• Tendonopathies• Inflammatory vs. Degenerative

• Fractures• Stress

• Spondylolysis

• Spondylolisthesis

Acute/Traumatic• Strains• Sprains• Fractures• Contusions

Journal of Paediatric and Child Health, 2016Sports Health, 2017

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Musculoskeletal Injuries-Sprains

Signs and Symptoms Vary with the degree of 

injury (eg‐ no joint instability vs. gross instability and “empty” feel with stress testing)

Inflammation Pain Swelling Ecchymosis 

(discoloration/bruising) Impaired Function

Differential Diagnosis Fractures Avulsion Fractures Muscle Strains

• Pain with Passive vs. Active ROM

Imaging X‐Ray to rule out associated 

bony injury and/or avulsion fractures

MRI to identify partial or complete tearing of the ligament

Special Tests Ligamentous Stress Tests to 

isolate and identify the ligaments that are injured and the extent to which they may be injured Ankle- Drawer Knee- Varus/Valgus,

Lachmans Elbow- Varus/Valgus

Prentice, 2009; Starkey, 2013

Musculoskeletal Injuries-Sprains

Immediate Management PRICE (Protect, Rest, Ice, 

Compress, Elevate)

POLICE (Protect, Optimal Loading, Ice, Compress, Elevate)

Protect and Rest• Crutches• Bracing and Taping• Cam Walkers

Referral For Athletes, essential to have a 

supervised and guided rehabilitation program• Physical Therapy • Athletic Trainer

Orthopaedics• Grade 2 Injuries that you are 

unsure of or unfamiliar with• Grade 3 Injuries that may 

require surgical intervention• Suspected Fractures or Avulsion 

Injuries that you are unsure of or unfamiliar with

• Injuries not responding to conservative care

• Salter‐Harris Fractures or Osteochondral Injuries

• If otherwise indicatedPrentice, 2009; Starkey, 2013

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Musculoskeletal Injuries-Strains

Signs and Symptoms Vary with the degree of 

injury (eg‐ no loss of motion/strength compared to complete disability)

Inflammation

Pain

Swelling

Ecchymosis (discoloration/bruising)

Impaired Function Differential Diagnosis

Avulsion Injuries

Muscle Sprains• Pain with Active vs. 

Passive ROM

Imaging X‐Ray to rule out associated 

bony injury and/or avulsion fractures (if suspected)

• Injuries to the muscle or tendon will not be visible on plain radiographs

MRI to identify partial or complete tearing of the muscle or tendon

Special Tests Joint ROM and Manual Muscle 

Testing to isolate the involved muscle and determine the extent to which it is injured

Prentice, 2009; Starkey, 2013

Musculoskeletal Injuries-Strains

Immediate Management PRICE/POLICE

Protect/Rest/Compress• Crutches• Compression Wraps

Special Considerations/ Complications Heterotopic Bony 

Formation• Ossification within 

the muscle secondary to trauma and hemorrhaging.

Referral For Athletes, essential to have a 

supervised and guided rehabilitation program• Physical Therapy • Athletic Trainer

Orthopaedics• Grade 2 Injuries that you are 

unsure of or unfamiliar with• Grade 3 Injuries that may 

require surgical intervention• Suspected Avulsion Injuries 

that you are unfamiliar with• Injuries not responding to 

conservative care• Heterotopic Ossification• If otherwise indicated

Prentice, 2009; Starkey, 2013

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Musculoskeletal Injuries-Fractures

Description

Wide range of fractures‐ stress to open

Can represent a relatively simple management process to emergency surgical intervention

Clinical Management

History

Physical Examination

Radiographic Evaluation and Imaging

Referral (if necessary)

Rehabilitation

Musculoskeletal Injuries-Fractures

Physical Examination Key Findings (not exhaustive)

• Pain• Gross Deformity• Crepitation• Audible “snap,” “crack” or “pop” at the time of injury (from 

history)• Loss of Function• Swelling/Edema• Point Tenderness in one specific location• Pain with percussion, compression, or stress• Pain with extension/dorsiflexion, pronation/supination of wrist 

(Eyler, 2018)• Ottawa Ankle Rules• Ottawa Knee Rules

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Musculoskeletal Injuries-Fractures

Radiographic Evaluation and Imaging

X‐Rays may be all that are needed

MRI’s can help identify

• Associated soft tissue injury

• Loose bodies within the joint

• Stress Fractures

• Chondral Injuries

CT’s can help

• Confirm diagnosis

• Identify fractures involving the joint surface

Musculoskeletal Injuries-Fractures

Management

Identify the injury

Refer to orthopedist or other specialist if indicated or if you are unfamiliar with the injury

Protect

• Crutches

• Bracing

• Splinting

• Casting

PEARLs for Athletes Make sure that you understand the 

injury, the sport and the rules of the sport.• ie‐ can the player participate in a 

cast?   Athletes may want‐ and/or be able‐

to be more aggressive Surgical intervention will not increase 

the rate of the healing process but it may facilitate an accelerated rehabilitation program

Strict rest is not a desirable option‐work with the athlete and the rehab team to facilitate strengthening, cardiovascular conditioning and other skills that can be maintained in spite of the injury and limitations it may impose.

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Musculoskeletal Injuries in Pediatric Athletes

Chronic/Overuse• Physeal Injuries

• Epiphysis• Little League Shoulder• Gymnast Wrist

• Apophysis• Osgood Schlatters• SLJ• Sever’s Disease• Little League Elbow• Pelvis/Low Back

• Tendonopathies• Inflammatory vs. Degenerative

• Fractures• Stress• Spondylolysis• Spondylolisthesis

Acute/Traumatic• Strains• Sprains• Fractures• Contusions

Journal of Paediatric and Child Health, 2016Sports Health, 2017

Considerations for Overuse Injuries in Pediatric Athletes

Risk Factors Associated with Injury

Age

Physical Characteristics

Growth Patterns

Training Volume

Previous Injury

Biomechanics

Pediatric Annals, 2017Sports Health, 2017Journal of Athletic Training, 2019

The Impact of Early Sports Specialization…

Not Necessary (early on)

Not in the best interest of health. Impacts can be: Physical

Social

Emotional

Not Advised

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Managing Concussions

“Treat a Concussion, Don’t Grade It”

Ken Locker

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Characteristics of ConcussionsWe now know that….

• “Dings,” “bell-ringers” are concussions Significant Brain Injuries

• Concussions do not have to involve LOC 85% - 90% do not

• Young athletes are at increased risk for serious problems (CDC 2012) Less developed shoulder/cervical spine muscles Poor technique Brain is not as developed and less able to withstand

the insult associated with a concussive injury

How Do We Manage a Concussion?

Recognition relies on Education

Diagnosis relies on Recognition

Management relies on Diagnosis

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Recognition and Diagnosis

Recognition and Diagnosis• Diagnosis is a clinical decision.

• Evaluation should include: Medical AssessmentComprehensive historyClinical SymptomsDetailed neurological evaluation

Mental statusCognitive functioningSleep/Wake disturbanceOcular functionVestibular FunctionGaitBalance

Determination of clinical status Determination of the need for emergent neuroimaging to

exclude a more severe brain injury. (McCrory, 2017)

• When possible and available, compare with baseline performance.

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Advanced ImagingNot necessary for diagnosis of concussionUsed to rule out:

Skull Fractures

Structural Injuries Hematoma Hemorrhage

Consider for: GCS less than 15

Deteriorating Mental Status

Focal Neurologic Deficits

Abnormal fundoscopic exam/papilledema

Progressive Symptoms(Moffatt, 2017)

Clinical Tools to Help Identify and Concussions

Clinical Symptoms Graded Symptom Check List 

Neurologic Status Glasgow Coma Scale

Cranial Nerve Assessment

Neurocognitive Deficits SAC

Computerized Testing ImPACT ANAM CogSport XLNTBrain

Formal Neuropsychological Evaluation (not required for all athletes)

Postural Stability BESS

Sway Balance (ios mobile devices)

C3 (Cleveland Clinic Concussion System) (I‐Pad App)

SCAT5Clinical utility decreases after 3‐5 days

SCAT5 (ages 13 and up) http://bjsm.bmj.com/content/bjsports/early/2017/04

/26/bjsports-2017-097506SCAT5.full.pdf

Child SCAT5 (ages 5‐12) http://bjsm.bmj.com/content/bjsports/early/2017/04/26

/bjsports-2017-097492childscat5.full.pdf

IncludesGlasgow Coma ScaleMaddocks ScoreGraded Symptom

Evaluation SAC BESSCoordination

ACE (CDC)https://www.cdc.gov/headsup/pdfs/providers/ace-a.pdf

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Symptom Categories“What They Tell Us”

Physical Symptoms• Headache • Fatigue• Dizziness• Sensitivity to Light and/or

noise• Nausea• Balance Problems

Emotional Symptoms• Irritability

• Sadness

• Feeling more emotional

• Nervousness

Cognitive Symptoms• Difficulty remembering

• Difficulty concentrating

• Feeling slowed down

• Feeling like they are “in a fog”

Sleep Symptoms• Drowsiness

• Sleeping more than usual

• Sleeping less than usual

• Trouble falling asleep

Berlin, 2017

Signs of Concussion

• Memory Deficits (Repeatedly asks the same questions, Can’t remember events prior to injury, can’t remember events after the injury)

• Gross incoordination (can’t walk a straight line)

• Emotions out of proportion to the situation

• Loss of Consciousness

• Seizures• Nystagmus

• Vacant Stare• Slow to Answer

Questions or Follow Instructions

• Easily Distracted• Disoriented; can’t

focus attention• Disoriented; unaware

of time, date, and place

• Slurred or incoherent speech

• Photophobia

“What We See/Observe”

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Beyond the field of play

• Academic/School Concentration/Focus

Remembering Assignments

Tolerance of Environment

Fatigue

Drop in Grades, Attendance

• Personal/Home

Reduced Play/Activity

Difficulty completing chores

Depression

Irritability:• Parents• Siblings• Boyfriends/Girlfriends

Management

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Immediate Management Considerations

1. Make sure that they understand the injury.2. Outline expectations

a. Yours….1. Avoid Re-injury2. Communication from them about increases in symptoms.

b. Theirs…1. No sports or activities until cleared and as directed by

health care professional Light, non-contact cardiovascular activity is

encouraged…IF it does not result in a significant increase in symptoms

2. How long will they be out? Each injury is different Adults- 10-14 days…approximately Children- 4 weeks…approximately

3. Children Should be in school (see next slide)

4. Return to activity should follow a medically directed gradual increase and return to full activities.

Managing Concussions Current cornerstone of concussion management is

physical and cognitive rest until acute symptoms resolve. Cognitive rest may ease discomfort during acute stages Minimize brain injury demands following concussion (McCrory,

2017)

Current evidence regarding the amount of rest is limited and evolving. The exact amount of rest is not yet well defined (Berlin, 2017).

Initial rest period of 24-48 hours may be beneficial (McCrory, 2013)

Strict rest for 5 days following injury offers no additional benefit over the usual 1-2 day rest. (Thomas 2015)

Berlin, 2017 After brief period of rest, encourage gradual and

progressive increase in activities that do not result in an increase in physical or cognitive symptoms.

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Risk Factors for Protracted Recovery• Adults…>10-14 days• Children…> 4 weeks• Number 1 predictor of slower recovery is the severity of the persons

initial symptoms on the first day, to a few days following injury (McCrory,

2017)

Pre-Morbid (Pre-Existing)Prior History of ConcussionMigraineDiagnosed ADHD/ Learning DisabilityGender (Female>Male)Age- Younger > Older

Post-InjuryPost Traumatic MigraineDizziness (immediate)FogginessDifficulty ConcentratingHeadacheImbalanceNausea/VomittingPhoto/PhonosensitivityIncreased Physical/ Cognitive ActivityVisual Abnormalities

Iverson et al (2006)Mucha and Steinhaufel (2014)

Changing the Culture of Concussions

• Nebraska’s Concussion Awareness Act Effective Date July 1, 2012

• Contains the three tenets of model legislation1. Education‐ Coaches, Parents and Student Athletes;

2. Removal from Play‐ if a concussion is reasonably suspected;

3. Clearance by a licensed Health Care Provider;

PLUS…..4. Return to Learn Protocol

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Prior to the Concussion Awareness Act (and others like it across the country), concussion management and return to 

play had primarily been:

Return to Activity=

Return to Play Asymptomatic Normal NCT Completed RTP

Progression

Remember….

• In a pediatric patient, not all students are athletes but

ALL ATHLETES ARE STUDENTS.

THEREFORE….

• We can’t just focus on athletics we need to include academics.

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Cultural Shift….

Return to Activity=

Return to Learn

Cognitive RestPhysical Rest

Return to PlayAsymptomaticNormal NCTCompleted RTP ProgressionNormal Balance*Normal Vision*

Changing the Culture of Concussion

• Return to Learn must precede Return to Play.

• We can’t thoroughly treat the athlete unless we first treat the student. If a student-athlete continues to receive academic

adjustments due to the presence of any symptoms, they should still be considered symptomatic and not be allowed to resume physical activity. (McAvoy, April, 2011)

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Team Based Return to Learn Models for Student‐Athletes

NE Department of Education:                 Bridging the Gap… AAP and REAP Team Model

Advocates the formation of a team to collaborate in caring for the student.

Family Team

Medical Team

School Academic Team

School Physical Team

Student

Family

Medical

School

Coaches

Halstead et al, 2013McAvoy, 2018

Return to Learn ProgressionStage Objective Activity Goal

1 Daily activities at home that do not give child symptoms

Typical activities of daily living (ie. Reading, texting, screen time).  Start with 5‐15 min. at a time and gradually build up

Gradually return to typical activities

2 School Activities Homework, reading, or other cognitive activities outside the classroom

Increase tolerance to cognitive work

3 Return to School Part-Time

Gradual introduction to schoolwork. May need to attend ½ days, alternating days

Increase academic activities

4 Return to School Full-Time

Progress activities until a full day can be tolerated Return to full academic 

activities and catch up on missed work

McCrory P, et al. Br J Sports Med 2017; 51:838‐847.

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Return to Play Progression

McCrory P, et al. Br J Sports Med 2017; 51:838-847.

Step Aim Activity Goal

1 Symptom Limited Activity

Daily activities that do not provoke symptoms

Gradual reintroduction of work/school activities

2 Light Aerobic Exercise

Walking or stationary cycling at a slow to medium pace. No resistance training.

Increase heart rate in a controlled environment

3 Moderate Aerobic Exercise

Running or agility drills: NO head impact activities.

Add functional movement

Return to Play Progression

McCrory P, et al. Br J Sports Med 2017; 51:838-847.

Step Aim Activity Goal

4 Non-contact training drills

Increase intensity of activities; passing drills, re-introduce resistance training.

Exercise, coordination, and increased thinking during activity.

5 Full Contact Practice

Following Medical Clearance; participate in full activities

Restore confidence and assess functional skills

6 Return to Sport Normal Game Play

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After all that…When can an Athlete Return to Play?

No academic adjustments/accommodations in place +Resolution of clinical symptoms + resolution of

neurocognitive deficits + normal balance/postural stability =

Begin the Graduated Return to Play Protocol

NO SAME DAY RETURN TO PLAY

In athletes that have been diagnosed with a concussion.

Medical Team Expanded: The medical professionals 

involved in the interdisciplinary management of concussion.

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Physician

Athletic Trainer

Physical Therapist

Occupational Therapist

Medical Professionals on the Concussion Management 

Team

Audiologist

Psychologist

Neuro‐psychologist

Neuro‐optometrist/ 

ophthalmologist

Speech and Language Pathologist

Health Care Providers Roles and Functions throughout the Management of Sports 

Related ConcussionProvider Function Phase

Physician E, SM, RH/T P, DM, RTLP

Neuropsychologist E, RH/T DM, RTLP

Athletic Trainer E, SM, RH/T, EP P, DM, RTLP, PCM

Psychologist E, RH/T DM, RTLP, PCM

Neuro‐Optometrist E, RH/T DM, PCM

Audiologist E, RH/T DM, RTLP, PCM

SLP E, RH/T DM, RTLP, PCM

Occupational Therapist E, RH/T DM, RTLP, PCM

Physical Therapist E, RH/T DM, RTLP, PCM

Function:  Evaluation (E), Exercise Prescription (EP), Sideline Management (SM), Rehabilitation/Treatment(RH/T), Phases‐ Prevention (P), Diagnosis and Management (DM), Return to Learn and Play (RTLP), Post Concussion Monitoring (PCM).  

Adapted from Pabian et al, 2017, p. 126.

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Closing Thoughts We know a lot about concussions, but the hurrider-we-

go, the behinder-we-get. Concerns with concussions:

→It may not as much be the cause of the injury, but rather the management that we continue to focus our efforts on at this time.

→2nd Impact SyndromeMorbidity Rate = 100% (Martineau, 2007)

Mortality Rate = 50% (Martineau, 2007)

Fortunately, if we can educate and get people to communicate, it is also (almost) completely preventable.

→CTE and other long-term neurodegenerative diseases “Whether repetitive head impact and multiple concussions

sustained in youth lead to long-term neurodegenerative diseases, such as CTE and Alzheimers, remains unclear.” (IOM, 2013 pg. 189)

THANK YOU!

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References1. Arnold, A et al. Overuse Physeal Injuries in Youth Athletes: Risk Factors, Prevention and

Treatment Strategies. Sports Health. 2017:9(2) 139-147.2. The Center on Brain Injury Research and Training. Max’s Law: Concussion Management

Implementation Guide. Retrieved from http://www.cbirt.org3. Brain Injury Association of Nebraska. Retrieved from www.biane.org4. Brenner, J et al. The Psychosocial Implications of Sports Specialization in Pediatric Athletes.

Journal of Athletic Training. 2019: 54(10).5. Brenner, J. Sports Specialization and Intensive Training in Young Athletes. American Academy

of Pediatrics. 2016:138(3)6. Broglio, SP et al. National Athletic Trainers Position statement: Management of Sport

Concussion. Journal of Athletic Training. 2014:49(2)7. Collins, M et al (2003). On-field Predictors of Neuropsychological and Symptom Deficit

Following Sports Related Concussion. CJSM. 13:222-229.8. Collins, M et al(2014) A comprehensive, targeted approach to the clinical care of athletes

following sport-related concussion. Knee Surg Sports Traumatol Arthrosc 22(2):235-146.9. Eyler, Y et al. The evaluation of the sensitivity and specificity of wrist examination findings for

predicting fractures. American Journal of Emergency Medicine 36(3): 425-429.10. Gessel, LM et al. Concussions Among United States High School and Collegiate Athletes.

Journal of Athletic Training. 2007; 42(4) : 495-503.11. Giza C, Hova, D. The Neurometabolic Cascade of Concussion. Journal of Athletic Training.

2001; 36(3): 228-235.12. Giza C, Kutcher J, et al. Summary of evidence-based guideline update: Evaluation and

management of concussion in sports. Neurology, 2013; 10.1212/WNL.0b013e31828d57dd.13. Harmon, KG, et al. American Medical Society for Sports Medicine position statement:

concussion in sport. Br J Sports Med. 2013; 47:15-26.14. ImPACT Training Workshop, July 25-26, 2013

References15. Institute of Medicine and National Research Council of the National Academies.

Sports-Related Concussions in Youth. National Academies Press. 2013.16. Kontos AP et al (2013) A revised factor structure for the post concussion symptom

scale (PCSS): baseline and post-concussion factors. Am J Sports Med 40(10):2375-2384.

17. Kucera, KL et al Annual Survey of Football Injury Research 1931-2016. 2017.18. Langlois JA, et al. Traumatic Brain Injury in the United States: Emergency

Department Visits, Hospitilizations, and Deaths. CDC, National Center for Injury Prevention and Control; 2004.

19. Langlois JA, et al. The epidemiology and impact of traumatic brain injury: a brief overview. Journal of Head Trauma Rehabilitation. 2006 Sept-Oct; 21 (5): 375-378.

20. Lau B et al. On-field markers that predict protracted recovery. AJMS. 39(11):2311-18. 2011

21. Lau B et al. Which subacute symptoms predict protracted recover? CJSM. 2009 (3):216-21.

22. McAvoy, K. (2011). Returning to Learning: Going Back to School Following a Concussion. Communique Online. April.

23. McAvoy, K. (2018). REAP the benefits of good concussion management. Centennial, CO: Rocky Mountain Sports Medicine Institute Center.

24. Martineau, C (2007). Guidelines for treatment of sport-related concussions. JAAPA 20(5): 22-28.

22. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus Statement on Concussion in Sport: the 4th International Conference on Concussion in Sport. Br J Sports Med. 2013; 47: 250-258

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References23. McCrory et al. Consensus statement on concussion in sport- the 5th international

conference on concussion. British Journal of Sports Medicine. 2017. 51:838-847)24. McCrea, M. et al. Unreported Concussion in High School Football Players:

Implications for Prevention. Clinical Journal of Sports Medicine. Jan. 2004, 14(1): 13-17.

25. Mucha, A, Steinhaufel, N. Neurovisual and Vestibular Presentation. September 2014.26. Mueller FO, Colgate B. Annual Survey of Football Injury Research: 1931-2009.

Chapel Hill, NC: National Center for Catastrophic Sport Injury Reasearch; 2010. 27. Prentice, WE. Arnheims Principles of Athletic Training. A Competency Based

Approach 13th Edition. McGraw-Hill. 200928. NE Department of Education. Bridging the Gap from Concussion to Classroom. 2014.29. NE DHHS. LB 260 Follow-up Survey. 2013.30. Orcas (2011). Brain Injury 101: Concussion Management. Policy and Resource

Handbook. Retrieved from http://brain101orcasinc.com31. Pabian et al. Interprofessional management of concussion in sport. Physical Therapy

in Sport. 2017; 23: 123-132.32. Starkey, C. Athletic Training and Sports Medicine. An Integrated Approach. Jones and

Bartlett Learning. 2013.33. Stracciolini, A et al. Injury Prevention in Youth Sports. Pediatric Annals. 2017:46(3). 34. Thomas, DG et al. Benefits of Strict Rest After Acute Concussion: A Randomized

Controlled Trial. Pediatrics. 2015. 135(2): 1-11.

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Musculoskeletal Injuries-Sprains

Definition

Injury to ligaments‐ non‐contractile soft tissue that connects bone to bone

Disruption to the integrity of a ligament caused by trauma resulting in tensile and/or shear forces being delivered to a joint  

Typically 3 degrees of injury

1. Grade 1‐ Stretching of the ligament with minimal to no joint instability

2. Grade 2‐ Partial tearing of the ligament with moderate joint instability

3. Grade 3‐ Complete disruption (rupture) of the ligament with gross joint instability 

Prentice, 2009; Starkey, 2013

Musculoskeletal Injuries-Strains

Definition Injury to muscles or tendons (contractile tissues that connect 

muscle to bone)

Damage of the muscle or tendon occurs secondary to overstretching or a forced contraction against overwhelming resistance  • Typically occurs in the muscle at the musculotendinous junction

Typically 3 degrees of injury1. Grade 1‐ Stretching of the muscle or tendon; typically full Range 

of Motion that is comparatively strong but may be painful.2. Grade 2‐ Partial tearing of the muscle or tendon; typically 

limited Range of Motion that is comparatively weak and painful.  May exhibit a divot or defect in the muscle or tendon.  

3. Grade 3‐ Complete disruption (rupture) of the muscle or  tendon; typically significant impairment and dysfunction      during attempts to actively contract the muscle.  

Prentice, 2009; Starkey, 2013

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