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COMMON ATHLETIC INJURIES PREVENTION AND

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COMMON ATHLETIC INJURIES PREVENTION AND Powered By Docstoc
					Sports injuries in Knee and ankle
Contents
n   Common sports injuries in knee and ankle
    region
n   Differential Dx of anterior, medial, and
    lateral knee pain
n   Differential Dx of anterior, medial, lateral
    ankle and heel pain
n   Principles of Management
ANTERIOR KNEE PAIN
DIFFERENTIAL DIAGNOSIS
OF ANTERIOR KNEE PAIN
n PFJ PAIN SYNDROME
n PLICAL AND FAT -PAD SYNDROME
n PATELLAR SUBLUXATION
n OVERUSE SYNDROME OF PATELLA
  TENDON
n SINDING-LARSEN JOHANSSEN DISEASE
n OSGOOD - SCHLATTER’S DISEASE
n TRAUMA TO PATELLA
n PREPATELLA BURSITIS
n RSD
  FUNCTIONAL STRESS
Type of activities   PFJ force

Level walking        0.5 BW

Up and down stairs   3-4 BW

Squatting            7-8 BW
                 Tight lateral structures
                 Tight lateral structures
    Back
    Back


                      Abnormal
                       Abnormal             Patellar tracking
                                            Patellar tracking
Hip and Thigh
Hip and Thigh     lower biomechanics          dysfunction
                   lower biomechanics          dysfunction



Ankle and Foot
Ankle and Foot   Weak medial structures
                 Weak medial structures
             Sports activities



Patella tracking        Excessive pressure
                        Excessive pressure
Patella tracking             on PF jt        PF syndrome
  dysfunction
   dysfunction                on PF jt       PF syndrome
CONTRIBUTING FACTORS
TO PFJ PAIN SYNDROME

nPatellararticular surface-related
nSurface pathology fribillation
nTrauma single or repetitive
PATELLAR TRACKING
RELATED
n Patella   shape       Accessory
                        ossification
                        centre
n Patellar   Position   Patella Alta
                        Increased Q
                        Ass.with
                        hyperextension
n Muscular              VMO
PROXIMAL SEGMENTS

n BACK     n Excessive
             lordosis/kyphosis
           n Pelvic Tilt


n Hipand   n Femoral antersion
 Thighs    n Tight Hip flexors
           n Tight Hamstrings
           n Tight ITB
           n Leg length discrepancy
DISTAL SEGMENTS
n Tibia              n Excessive   internal
                       torsion
                     n Genu varum or
                       valgus

                     n Tight TA
n Foot   and Ankle
                     n Hyperpronation
                     n Rigid cavus foot
MANAGEMENT

n   Control of inflammation and pain relieving
n   Correct alignment of patellar
n   Improvement of motor function
n   Soft tissue release
n   Knee brace
n   Correction of abnormal biomechanics
    Correct alignment of patellar
n    Taping
Correction of   Correction of   Correction of
medial glide    lateral tilt    rotation
Improvement of motor function
n   Muscle training (VMO)
n   Biofeedback
n   NMES
n   Start with sitting position
n   CKC
n   Hip control exercise
PATELLAR TENDINOPATHY
 JUMPER’S KNEE
n Relatedto repetitive extensor action of the
 knee with the generation of large eccentric
 forces

nA   typical functional overloading syndrome

n Mostlyin volleyball, basketball players,
 high and long jumpers
JUMPER’S KNEE
CAUSATIVE FACTORS:

EXTRINSIC:

n   TRAINING SESSIONS (DURATION,
    INTENSITY AND NUMBER)

n   PLAYING SURFACE

n   FOOTWEAR
JUMPER’S KNEE
INTRINSIC FACTORS:

n   RESISTANCE, ELASTICITY AND
    EXTENSIBILITY OF THE TENDON

n   BIOMECHANCIAL VARIATION OF THE
    KNEE EXTENSOR MECHANISM, MUSCLE
    STRENGTH AND OVERALL LIMB
    ALIGNMENTS

n   HIP FLEXOR SHORTENING AND
    WEAKNESS OF ABDUCTOR
EXAMINATION AND
INVESTIGATION
PRINCIPLES OF MANAGEMENT

n   Removal of triggering factors;
n   Biomechanical correction;
n   Estimate stage of injuries;
n   Control pain and inflammation; and
n   Appropriate tensile loading
TENDON HEALING
n   Inflammatory stage (6 days)

n   Fibroblastic/proliferative stage (5-21 days)

n   Remodelling/maturation stage (begins on
    day 20)

n   * the healing process for chronic
    tendinopathy may take a long time
CONTROL PAIN & INFLAMMATION
 n   Physical Modalities
        n US

        n Laser

        n ES

        n Ice

 n   Medication
        n NSAIDs

        n Steriods
APPROPRIATE TENSILE LOADING

 n   Specificity: MTU
 n   Maximal Loading
 n   Progression of loading
ECCENTRIC EXERCISE
PROGRAM
n   Warm-up
n   Flexibility
n   Specific exercise
n   Repeat flexibility exercises
n   Ice
Start with slow
  free active         Pain



 Increase speed       Pain
   (moderate)



  Increase speed       Pain
      (Fast)



Increase resistance    Pain
PREVENTION
n   Pre-season strength training
n   Proper stretching and warm-up
n   Avoid triggering factors:
        n equipment modification

        n technique adjustment

        n environmental (running surfaces)
FAT PAD SYNDROME
n   Fat pad – a sensitive structure in the knee;
n   Chronic fat pad irritation is common;
n   Pain usually aggravated by extension
    maneuvers;
n   Localised tenderness and puffiness;
n   Often associated with hyperextension of
    knees and increased anterior pelvic tilt
Principles of management

n   Pain relieving &
n   Fat pad unloading by taping
Principle of taping for Fat Pad Syndrome
OTHER LESS COMMON
CONDITIONS
PLICAL SYNDROMES
n   Embryologically, fusion of 3 synovial
    compartments during fetal month
n   Plical - any portion of the embryonic
    synovial septa persist into adult life
n   Infrapatellar, suprapatellar and medial
    patella plica
n   Medial plica - a crescentic fold, running
    from the quadriceps into medial wall of jt.
    & ending in infrapatellar fat pad.
n   Pain might aggravate by squatting
n   Palpable thickened band under the medial
    border of patella
n   If conservative management fail,
    arthroscopic removal of plica
n   Osgood-Schlatter disease –
    osteochondrosis at tibial tuberosity
n   Excessive traction on the soft apophysis of
    the tibial tuberosity
n   Associated with high levels of activity in
    the growing phase adolescents
Principles of management
n   Usually self-limiting and settles at the time
    of bony fusion;
n   Might need activity modification; and
n   Symptomatic treatment (ice, EPT);
n   Stretch tight Quadriceps; and correction of
    biomechanical abnormality
Sinding-Larsen-Johansson syndrome

 n   Similar to Osgood Schlatter;
 n   Affects inferior pole of patella;
 n   Less common than Osgood Schlatter;
 n   Same management principles
LATERAL KNEE PAIN
Lateral knee pain
n   Iliotibial band friction syndrome (ITBFS);
n   Lateral meniscus problems;
n   Osteoarthritis of the lateral compartment of
    the knee;
n   Biceps femoris tendinopathy;
n   Superior tibiofibular joint sprain;
n   Synovitis of the knee joint;
n   Referred pain from lumber spine
ILIOTIBIAL BAND FRICTION SYNDROME

 n CAUSATIVE  FACTORS
 n TIGHTNESS OF ITB
 n MALALIGNMENT & LEG LENGTH
   DISCREPANCY
 n EXCESSIVE FOOT PRONATION
 n DOWNWARD CONTRALATERAL
   TILT OF PELVIC
ILIOTIBIAL BAND FRICTION SYNDROME

 n   S/S:
 n   STINGING PAIN
 n   WORSE ON RUNNING
     DOWNHILL
 n   REPRODUCTION OF PAIN ON
     COMPRESSION OVER LATERAL
     FEMORAL CONDYLE WITH
     STRETCHED
 n   CREPITUS
Principles of management
n   Control of inflammation
n   Soft tissue release
n   Stretching of ITB
n   Strengthening of the lateral stabilizers of
    the hip
n   Correction of biomechanical factors
n   Corticosteroid injection or surgery if
    conservative management fails
Lateral meniscus abnormality
n   Degeneration of the lateral meniscus
n   Pain on distance running, more severe on
    uphill;
n   Tender along the joint line
n   McMurray’s test +ve
n   Confirmation by MRI
POPLITEUS TENDINITIS
Functions of popliteus
n Assists unlocking
  mechanisms of knee
n Prevents impingement of
  the posterior horn of the
  lateral meniscus
n Synergically with posterior
  cruciate preventing
  posterior glide of tibia
n Reinforces posterlateral
  capsule
POPLITEUS TENDINITIS
n   LOCAL TENDERNESS ANTERIOR TO
    THE SUPERIOR ATTACHMENT OF
    LCL

n   PAIN MAY BE REPRODUCED BY
    RESISTED KNEE FLEXION AND
    TIBIA HOLD IN EXT. ROTATION
    Biceps femoris tendinopathy

n   Might cause by excessive acceleration and
    deceleration activities;
n   Associated with tight hamstring and
    stiffness of lumber spine;
n   Pain reproduced with resisted flexion;
n   Same treatment principles of tendinopathy
Superior tibiofibular joint problems
n   Direct trauma or association with rotational
    knee or ankle injuries;
n   Tender on joint line;
n   Restricted or excessive gliding of superior
    T/F jt.
n   For stiff T/F jt : mobilization
n   EPT modalities for pain relieving
n   Biomechanical factors
MEDIAL KNEE PAIN
Medial knee pain

n   Patellofemoral syndrome
n   Medial meniscus abnormality
n   Pes Anserinus tendinopathy/bursitis
MENISCAL LESIONS
MECHANISM OF INJURY

n   ASSOCIATED WITH LGT. DISRUPTION
n   DEGENERATIVE CHANGES WITH AGE
n   REPETITIVE ABNORMAL STRESSES
    SECONDARY TO CHRONIC LGT. LAXITY
n   ISOLATED OR REPETITIVE ROTATIONAL
    STRESSES
n   ABNORMAL MENISCAL SHAPE OR
    ATTACHMENT
Medial Meniscus abnormality
n   Gradual degeneration of the medial
    meniscus
n   Over 35 years old
n   Complains of clicking and pain with
    twisting activities
n   Joint line tenderness
n   +ve McMurray’s test
MEDIAL CAPSULAR COMPLEX
n   During flexion the ant. fibres sup. med. lgt. are
    tense;
n   During partial extension the post. fib. & adj.
    posteromedial capsule take up the strain;
n   During full ext. the whole lt. is taut owing to
    asso. rotation
n   Quad. & Hamstring exp. lend dynamic support
n   Several bursa are asso. with lt and
    hamstring tend. & inflammation may
    mimic meniscal or lt. pathology
POSTEROMEDIAL CORNER OF KNEE

n   Deep medial collateral lgt. in association with
    medial meniscus;
n   Posterior superficial fibers blend with capsule
n   Expansions from semitendinosis also reinforce
    capsule
n   Combined structure called posterior oblique
    lt.
n   Torn with significant valgus or rotary stresses
Pes anserinus tendinopathy/bursitis
 n   Overuse syndrome;
 n   Common in swimmers (breaststrokers),
     cyclists and runners;
 n   Localised tenderness and swelling
 n   Pain reproduced on active contraction or
     stretching of hamstring
 n   Treatment principles same as tendionpathy
ANKLE AND FOOT
PROBLEMS
HEEL PAIN
n   MEDIAL
n   TIB. POST. TENDINITIS
n   FLEXOR HALLUCIS LOGNUS
    TENDINOPATHY
n   TARSAL TUNNEL SYNDROME
n   MEDIAL CALCANEAL NEURITIS

LATERAL
n PERONEAL TENDINOPATHY
n SINUS TARSI SYNDROME
n   PLANTAR
n   PLANTAR FASCIITIS
n   CALCANEAL SPUR
n   FAT PAD SYNDROME
n   CALCANEAL PERIOSTITIS

POSTERIOR
n RETROCALCANEAL BURSITIS
n CALCANEAL APOPHYSITIS


DIFFUSE
n CALCANEAL STRESS FRACTURE
TIBIALIS POSTERIOR SYNDROME
n   Common in middle distance runner

n   Essential for the eccentric control of foot pronation in
    Heel strike phase

n   Frequently associated with excessive subtalar pronation

n   Pain on palpation along tendon

n   Passive eversion and resisted inversion
FLEXOR HALLUCIS LONGUS
TENDINOPATHY
 n   Integral part of the smooth take-off phase of
     walking and running

 n   Tenosynovitis occurs secondary to overload

 n   High jumper and dancing sports (ballet dancer)

 n   Pain on resisted flexion and full dorsiflexion of
     hallux
MANAGEMENT
n   Rest
n   Stretching exercise
n   Tape in slightly plantar-flexed position
n   Check sport shoes
n   Check subtalar joint
n   Check excessive pronation
    Tarsal Tunnel Syndrome
n   Entrapment of the posterior tibial nerve
n   Overuse associated with excessive pronation
n   Result of trauma

S/S
n Sharp pain radiating into the arch of the foot, heel,
   and occasionally the toes
n Prolonged standing, walking or running aggravates
   pain
n +ve Tinel’s sign
n May accompany with altered sensation
Principles of management

n   Correct excessive pronation
n   Corticosteriod injection
n   Decompression release
Medial Calcaneal neuritis
n   Pain over the inferomedial aspect of
    calcaneus
n   May radiates into the arch of the foot
n   Tenderness over medial calcaneus
n   +ve Tinel’s sign

n   Treatment principle same as Tarsal tunnel
    syndrome
LATERAL ANKLE PAIN
PERONEAL TENDINOPATHY
n   Excessive action of the peroneals:
n   Excessive eversion caused by hill running or road
    running
n   Ball games (basketball, volleyball)
n   Tight plantarflexors might cause excessive load
    on the peroneals

n   Local tenderness
n   Swelling and crepitus
n   Passive inversion and resisted eversion: pain+
n   Check for eccentric loading
Principles of management

n   Rest from aggravating activities
n   EPT modalities
n   Stretching and strengthening
n   Mobilisation of subtalar, midtarsal joints
n   Correction of biomechanical abnormalities
    SINUS TARSI SYNDROME
n   A small osseous canal running from an opening
    anterior and inferior to the lateral malleolus
n   Part of the subtalar joint with subtalar lgts, fat and
    connective tissue
n   Excessive pronation
n   Repeated forced eversion
n   Result of ankle sprain
n   Pain locate at anterior to lat malleolus
n   Pain+ on running on curve
n   Stiffness of subtalar joint
n   Pain+ on forced eversion and/or inversion
n   Relief with lignocaine injection
Principles of management
n   Rest
n   Ice
n   EPT
n   Mobilisation of subtalar joint
n   NASID
n   Contricosteriod injection
PLANTAR HEEL PAIN
FAT PAD SYNDROME
CONTRIBUTING FACTORS:

n   THINNING OF FAT PAD WITH AGE
n   EXCESSIVE BODY WT.
n   POORLY CUSHIONED OR WORN-OUT
    SHOES
n   SINGLE SIGNIFICANT CONTUSION
n   SUDDEN INCREASE IN TRAINING
n   SWITCH TO UNEVEN AND HARD TERRAIN
n   REPETITIVE HILL WORK OR STEEP
    INCLINES
Tibialis Anterior Tendinopathy

n   Overuse of ankle dorsiflexors
n   Too infrequent downhill running
n   Excessive tightness of strapping or
    shoelaces
n   Treatment principles same as tendinopathy
ANTERIOR ANKLE PAIN
n   Anterior Impingement of the ankle
    n   Caused by forced dorisflexion in activities
    n   Footballers’ ankle
    n   Also commonly seen in ballent dancers
    n   Exotoses develop on the anterior of the upper
        surface of neck of talus
    n   +ve anterior impingement test
n   Management
    n   NASIDs
    n   AP glide of talocrual joint
    n   Surgical excision for promient exostoses
Recommended reading:

n   Brukner P., Khan K. 2001 Clinical Sports
    Medicine 2nd edition, The McGraw Hill
    Co. Chapter 24, 25 and 30

				
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