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Sports injuries in Knee and ankle. Contents. Common sports injuries in knee and ankle region Differential Dx of anterior, medial, and lateral knee pain Differential Dx of anterior, medial, lateral ankle and heel pain Principles of Management. ANTERIOR KNEE PAIN.

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contents
Contents
  • Common sports injuries in knee and ankle region
  • Differential Dx of anterior, medial, and lateral knee pain
  • Differential Dx of anterior, medial, lateral ankle and heel pain
  • Principles of Management
differential diagnosis of anterior knee pain
DIFFERENTIAL DIAGNOSIS OF ANTERIOR KNEE PAIN
  • PFJ PAIN SYNDROME
  • PLICAL AND FAT -PAD SYNDROME
  • PATELLAR SUBLUXATION
  • OVERUSE SYNDROME OF PATELLA TENDON
  • SINDING-LARSEN JOHANSSEN DISEASE
  • OSGOOD - SCHLATTER’S DISEASE
  • TRAUMA TO PATELLA
  • PREPATELLA BURSITIS
  • RSD
slide7

Tight lateral structures

Back

Abnormal

lower biomechanics

Patellar tracking

dysfunction

Hip and Thigh

Ankle and Foot

Weak medial structures

slide8

Sports activities

Patella tracking

dysfunction

Excessive pressure

on PF jt

PF syndrome

contributing factors to pfj pain syndrome
CONTRIBUTING FACTORS TO PFJ PAIN SYNDROME
  • Patellar articular surface-related
  • Surface pathology fribillation
  • Trauma single or repetitive
patellar tracking related
PATELLAR TRACKING RELATED
  • Patella shape Accessory ossification centre
  • Patellar Position Patella Alta

Increased Q

Ass.with hyperextension

  • Muscular VMO
proximal segments
BACK

Hip and Thighs

Excessive lordosis/kyphosis

Pelvic Tilt

Femoral antersion

Tight Hip flexors

Tight Hamstrings

Tight ITB

Leg length discrepancy

PROXIMAL SEGMENTS
distal segments
Tibia

Foot and Ankle

Excessive internal torsion

Genu varum or valgus

Tight TA

Hyperpronation

Rigid cavus foot

DISTAL SEGMENTS
management
MANAGEMENT
  • Control of inflammation and pain relieving
  • Correct alignment of patellar
  • Improvement of motor function
  • Soft tissue release
  • Knee brace
  • Correction of abnormal biomechanics
slide15

Correction of

rotation

Correction of

medial glide

Correction of

lateral tilt

improvement of motor function
Improvement of motor function
  • Muscle training (VMO)
  • Biofeedback
  • NMES
  • Start with sitting position
  • CKC
  • Hip control exercise
jumper s knee
JUMPER’S KNEE
  • Related to repetitive extensor action of the knee with the generation of large eccentric forces
  • A typical functional overloading syndrome
  • Mostly in volleyball, basketball players, high and long jumpers
jumper s knee19
JUMPER’S KNEE

CAUSATIVE FACTORS:

EXTRINSIC:

  • TRAINING SESSIONS (DURATION, INTENSITY AND NUMBER)
  • PLAYING SURFACE
  • FOOTWEAR
jumper s knee20
JUMPER’S KNEE

INTRINSIC FACTORS:

  • RESISTANCE, ELASTICITY AND EXTENSIBILITY OF THE TENDON
  • BIOMECHANCIAL VARIATION OF THE KNEE EXTENSOR MECHANISM, MUSCLE STRENGTH AND OVERALL LIMB ALIGNMENTS
  • HIP FLEXOR SHORTENING AND WEAKNESS OF ABDUCTOR
principles of management
PRINCIPLES OF MANAGEMENT
  • Removal of triggering factors;
  • Biomechanical correction;
  • Estimate stage of injuries;
  • Control pain and inflammation; and
  • Appropriate tensile loading
tendon healing
TENDON HEALING
  • Inflammatory stage (6 days)
  • Fibroblastic/proliferative stage (5-21 days)
  • Remodelling/maturation stage (begins on day 20)
  • * the healing process for chronic tendinopathy may take a long time
control pain inflammation
CONTROL PAIN & INFLAMMATION
  • Physical Modalities
      • US
      • Laser
      • ES
      • Ice
  • Medication
      • NSAIDs
      • Steriods
appropriate tensile loading
APPROPRIATE TENSILE LOADING
  • Specificity: MTU
  • Maximal Loading
  • Progression of loading
eccentric exercise program
ECCENTRIC EXERCISE PROGRAM
  • Warm-up
  • Flexibility
  • Specific exercise
  • Repeat flexibility exercises
  • Ice
slide27

Start with slow

free active

Pain

Increase speed

(moderate)

Pain

Pain

Increase speed

(Fast)

Increase resistance

Pain

prevention
PREVENTION
  • Pre-season strength training
  • Proper stretching and warm-up
  • Avoid triggering factors:
      • equipment modification
      • technique adjustment
      • environmental (running surfaces)
fat pad syndrome
FAT PAD SYNDROME
  • Fat pad – a sensitive structure in the knee;
  • Chronic fat pad irritation is common;
  • Pain usually aggravated by extension maneuvers;
  • Localised tenderness and puffiness;
  • Often associated with hyperextension of knees and increased anterior pelvic tilt
principles of management30
Principles of management
  • Pain relieving &
  • Fat pad unloading by taping
plical syndromes
PLICAL SYNDROMES
  • Embryologically, fusion of 3 synovial compartments during fetal month
  • Plical - any portion of the embryonic synovial septa persist into adult life
  • Infrapatellar, suprapatellar and medial patella plica
  • Medial plica - a crescentic fold, running from the quadriceps into medial wall of jt. & ending in infrapatellar fat pad.
slide34
Pain might aggravate by squatting
  • Palpable thickened band under the medial border of patella
  • If conservative management fail, arthroscopic removal of plica
slide35
Osgood-Schlatter disease – osteochondrosis at tibial tuberosity
  • Excessive traction on the soft apophysis of the tibial tuberosity
  • Associated with high levels of activity in the growing phase adolescents
principles of management36
Principles of management
  • Usually self-limiting and settles at the time of bony fusion;
  • Might need activity modification; and
  • Symptomatic treatment (ice, EPT);
  • Stretch tight Quadriceps; and correction of biomechanical abnormality
sinding larsen johansson syndrome
Sinding-Larsen-Johansson syndrome
  • Similar to Osgood Schlatter;
  • Affects inferior pole of patella;
  • Less common than Osgood Schlatter;
  • Same management principles
lateral knee pain40
Lateral knee pain
  • Iliotibial band friction syndrome (ITBFS);
  • Lateral meniscus problems;
  • Osteoarthritis of the lateral compartment of the knee;
  • Biceps femoris tendinopathy;
  • Superior tibiofibular joint sprain;
  • Synovitis of the knee joint;
  • Referred pain from lumber spine
iliotibial band friction syndrome
ILIOTIBIAL BAND FRICTION SYNDROME
  • CAUSATIVE FACTORS
  • TIGHTNESS OF ITB
  • MALALIGNMENT & LEG LENGTH DISCREPANCY
  • EXCESSIVE FOOT PRONATION
  • DOWNWARD CONTRALATERAL TILT OF PELVIC
iliotibial band friction syndrome42
ILIOTIBIAL BAND FRICTION SYNDROME
  • S/S:
  • STINGING PAIN
  • WORSE ON RUNNING DOWNHILL
  • REPRODUCTION OF PAIN ON COMPRESSION OVER LATERAL FEMORAL CONDYLE WITH STRETCHED
  • CREPITUS
principles of management43
Principles of management
  • Control of inflammation
  • Soft tissue release
  • Stretching of ITB
  • Strengthening of the lateral stabilizers of the hip
  • Correction of biomechanical factors
  • Corticosteroid injection or surgery if conservative management fails
lateral meniscus abnormality
Lateral meniscus abnormality
  • Degeneration of the lateral meniscus
  • Pain on distance running, more severe on uphill;
  • Tender along the joint line
  • McMurray’s test +ve
  • Confirmation by MRI
popliteus tendinitis
POPLITEUS TENDINITIS

Functions of popliteus

  • Assists unlocking mechanisms of knee
  • Prevents impingement of the posterior horn of the lateral meniscus
  • Synergically with posterior cruciate preventing posterior glide of tibia
  • Reinforces posterlateral capsule
popliteus tendinitis46
POPLITEUS TENDINITIS
  • LOCAL TENDERNESS ANTERIOR TO THE SUPERIOR ATTACHMENT OF LCL
  • PAIN MAY BE REPRODUCED BY RESISTED KNEE FLEXION AND TIBIA HOLD IN EXT. ROTATION
biceps femoris tendinopathy
Biceps femoris tendinopathy
  • Might cause by excessive acceleration and deceleration activities;
  • Associated with tight hamstring and stiffness of lumber spine;
  • Pain reproduced with resisted flexion;
  • Same treatment principles of tendinopathy
superior tibiofibular joint problems
Superior tibiofibular joint problems
  • Direct trauma or association with rotational knee or ankle injuries;
  • Tender on joint line;
  • Restricted or excessive gliding of superior T/F jt.
  • For stiff T/F jt : mobilization
  • EPT modalities for pain relieving
  • Biomechanical factors
medial knee pain51
Medial knee pain
  • Patellofemoral syndrome
  • Medial meniscus abnormality
  • Pes Anserinus tendinopathy/bursitis
meniscal lesions
MENISCAL LESIONS

MECHANISM OF INJURY

  • ASSOCIATED WITH LGT. DISRUPTION
  • DEGENERATIVE CHANGES WITH AGE
  • REPETITIVE ABNORMAL STRESSES SECONDARY TO CHRONIC LGT. LAXITY
  • ISOLATED OR REPETITIVE ROTATIONAL STRESSES
  • ABNORMAL MENISCAL SHAPE OR ATTACHMENT
medial meniscus abnormality
Medial Meniscus abnormality
  • Gradual degeneration of the medial meniscus
  • Over 35 years old
  • Complains of clicking and pain with twisting activities
  • Joint line tenderness
  • +ve McMurray’s test
medial capsular complex
MEDIAL CAPSULAR COMPLEX
  • During flexion the ant. fibres sup. med. lgt. are tense;
  • During partial extension the post. fib. & adj. posteromedial capsule take up the strain;
  • During full ext. the whole lt. is taut owing to asso. rotation
  • Quad. & Hamstring exp. lend dynamic support
  • Several bursa are asso. with lt and hamstring tend. & inflammation may mimic meniscal or lt. pathology
posteromedial corner of knee
POSTEROMEDIAL CORNER OF KNEE
  • Deep medial collateral lgt. in association with medial meniscus;
  • Posterior superficial fibers blend with capsule
  • Expansions from semitendinosis also reinforce capsule
  • Combined structure called posterior oblique lt.
  • Torn with significant valgus or rotary stresses
pes anserinus tendinopathy bursitis
Pes anserinus tendinopathy/bursitis
  • Overuse syndrome;
  • Common in swimmers (breaststrokers), cyclists and runners;
  • Localised tenderness and swelling
  • Pain reproduced on active contraction or stretching of hamstring
  • Treatment principles same as tendionpathy
heel pain
HEEL PAIN
  • MEDIAL
  • TIB. POST. TENDINITIS
  • FLEXOR HALLUCIS LOGNUS TENDINOPATHY
  • TARSAL TUNNEL SYNDROME
  • MEDIAL CALCANEAL NEURITIS

LATERAL

  • PERONEAL TENDINOPATHY
  • SINUS TARSI SYNDROME
slide59
PLANTAR
  • PLANTAR FASCIITIS
  • CALCANEAL SPUR
  • FAT PAD SYNDROME
  • CALCANEAL PERIOSTITIS

POSTERIOR

  • RETROCALCANEAL BURSITIS
  • CALCANEAL APOPHYSITIS

DIFFUSE

  • CALCANEAL STRESS FRACTURE
tibialis posterior syndrome
TIBIALIS POSTERIOR SYNDROME
  • Common in middle distance runner
  • Essential for the eccentric control of foot pronation in Heel strike phase
  • Frequently associated with excessive subtalar pronation
  • Pain on palpation along tendon
  • Passive eversion and resisted inversion
flexor hallucis longus tendinopathy
FLEXOR HALLUCIS LONGUS TENDINOPATHY
  • Integral part of the smooth take-off phase of walking and running
  • Tenosynovitis occurs secondary to overload
  • High jumper and dancing sports (ballet dancer)
  • Pain on resisted flexion and full dorsiflexion of hallux
slide63
MANAGEMENT
  • Rest
  • Stretching exercise
  • Tape in slightly plantar-flexed position
  • Check sport shoes
  • Check subtalar joint
  • Check excessive pronation
tarsal tunnel syndrome
Tarsal Tunnel Syndrome
  • Entrapment of the posterior tibial nerve
  • Overuse associated with excessive pronation
  • Result of trauma

S/S

  • Sharp pain radiating into the arch of the foot, heel, and occasionally the toes
  • Prolonged standing, walking or running aggravates pain
  • +ve Tinel’s sign
  • May accompany with altered sensation
principles of management65
Principles of management
  • Correct excessive pronation
  • Corticosteriod injection
  • Decompression release
medial calcaneal neuritis
Medial Calcaneal neuritis
  • Pain over the inferomedial aspect of calcaneus
  • May radiates into the arch of the foot
  • Tenderness over medial calcaneus
  • +ve Tinel’s sign
  • Treatment principle same as Tarsal tunnel syndrome
peroneal tendinopathy
PERONEAL TENDINOPATHY
  • Excessive action of the peroneals:
  • Excessive eversion caused by hill running or road running
  • Ball games (basketball, volleyball)
  • Tight plantarflexors might cause excessive load on the peroneals
  • Local tenderness
  • Swelling and crepitus
  • Passive inversion and resisted eversion: pain+
  • Check for eccentric loading
principles of management70
Principles of management
  • Rest from aggravating activities
  • EPT modalities
  • Stretching and strengthening
  • Mobilisation of subtalar, midtarsal joints
  • Correction of biomechanical abnormalities
sinus tarsi syndrome
SINUS TARSI SYNDROME
  • A small osseous canal running from an opening anterior and inferior to the lateral malleolus
  • Part of the subtalar joint with subtalar lgts, fat and connective tissue
  • Excessive pronation
  • Repeated forced eversion
  • Result of ankle sprain
  • Pain locate at anterior to lat malleolus
  • Pain+ on running on curve
  • Stiffness of subtalar joint
  • Pain+ on forced eversion and/or inversion
  • Relief with lignocaine injection
principles of management72
Principles of management
  • Rest
  • Ice
  • EPT
  • Mobilisation of subtalar joint
  • NASID
  • Contricosteriod injection
fat pad syndrome74
FAT PAD SYNDROME

CONTRIBUTING FACTORS:

  • THINNING OF FAT PAD WITH AGE
  • EXCESSIVE BODY WT.
  • POORLY CUSHIONED OR WORN-OUT SHOES
  • SINGLE SIGNIFICANT CONTUSION
  • SUDDEN INCREASE IN TRAINING
  • SWITCH TO UNEVEN AND HARD TERRAIN
  • REPETITIVE HILL WORK OR STEEP INCLINES
tibialis anterior tendinopathy
Tibialis Anterior Tendinopathy
  • Overuse of ankle dorsiflexors
  • Too infrequent downhill running
  • Excessive tightness of strapping or shoelaces
  • Treatment principles same as tendinopathy
anterior ankle pain
ANTERIOR ANKLE PAIN
  • Anterior Impingement of the ankle
    • Caused by forced dorisflexion in activities
    • Footballers’ ankle
    • Also commonly seen in ballent dancers
    • Exotoses develop on the anterior of the upper surface of neck of talus
    • +ve anterior impingement test
  • Management
    • NASIDs
    • AP glide of talocrual joint
    • Surgical excision for promient exostoses
recommended reading
Recommended reading:
  • Brukner P., Khan K. 2001 Clinical Sports Medicine 2nd edition, The McGraw Hill Co. Chapter 24, 25 and 30