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Sports injuries in Knee and ankle

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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 ... – PowerPoint PPT presentation

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Title: Sports injuries in Knee and ankle


1
Sports injuries in Knee and ankle
2
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

3
ANTERIOR KNEE PAIN
4
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5
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 - SCHLATTERS DISEASE
  • TRAUMA TO PATELLA
  • PREPATELLA BURSITIS
  • RSD

6
FUNCTIONAL STRESS
Type of activities PFJ force
Level walking 0.5 BW
Up and down stairs 3-4 BW
Squatting 7-8 BW
7
Tight lateral structures
Back
Abnormal lower biomechanics
Patellar tracking dysfunction
Hip and Thigh
Ankle and Foot
Weak medial structures
8
Sports activities
Patella tracking dysfunction
Excessive pressure on PF jt
PF syndrome
9
CONTRIBUTING FACTORS TO PFJ PAIN SYNDROME
  • Patellar articular surface-related
  • Surface pathology fribillation
  • Trauma single or repetitive

10
PATELLAR TRACKING RELATED
  • Patella shape Accessory ossification
    centre
  • Patellar Position Patella Alta
  • Increased Q
  • Ass.with hyperextension
  • Muscular VMO

11
PROXIMAL SEGMENTS
  • BACK
  • Hip and Thighs
  • Excessive lordosis/kyphosis
  • Pelvic Tilt
  • Femoral antersion
  • Tight Hip flexors
  • Tight Hamstrings
  • Tight ITB
  • Leg length discrepancy

12
DISTAL SEGMENTS
  • Tibia
  • Foot and Ankle
  • Excessive internal torsion
  • Genu varum or valgus
  • Tight TA
  • Hyperpronation
  • Rigid cavus foot

13
MANAGEMENT
  • Control of inflammation and pain relieving
  • Correct alignment of patellar
  • Improvement of motor function
  • Soft tissue release
  • Knee brace
  • Correction of abnormal biomechanics

14
Correct alignment of patellar
  • Taping

15
Correction of rotation
Correction of medial glide
Correction of lateral tilt
16
Improvement of motor function
  • Muscle training (VMO)
  • Biofeedback
  • NMES
  • Start with sitting position
  • CKC
  • Hip control exercise

17
PATELLAR TENDINOPATHY
18
JUMPERS 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

19
JUMPERS KNEE
  • CAUSATIVE FACTORS
  • EXTRINSIC
  • TRAINING SESSIONS (DURATION, INTENSITY AND
    NUMBER)
  • PLAYING SURFACE
  • FOOTWEAR

20
JUMPERS 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

21
EXAMINATION AND INVESTIGATION
22
PRINCIPLES OF MANAGEMENT
  • Removal of triggering factors
  • Biomechanical correction
  • Estimate stage of injuries
  • Control pain and inflammation and
  • Appropriate tensile loading

23
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

24
CONTROL PAIN INFLAMMATION
  • Physical Modalities
  • US
  • Laser
  • ES
  • Ice
  • Medication
  • NSAIDs
  • Steriods

25
APPROPRIATE TENSILE LOADING
  • Specificity MTU
  • Maximal Loading
  • Progression of loading

26
ECCENTRIC EXERCISE PROGRAM
  • Warm-up
  • Flexibility
  • Specific exercise
  • Repeat flexibility exercises
  • Ice

27
Start with slow free active
Pain
Increase speed (moderate)
Pain
Pain
Increase speed (Fast)
Increase resistance
Pain
28
PREVENTION
  • Pre-season strength training
  • Proper stretching and warm-up
  • Avoid triggering factors
  • equipment modification
  • technique adjustment
  • environmental (running surfaces)

29
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

30
Principles of management
  • Pain relieving
  • Fat pad unloading by taping

31
Principle of taping for Fat Pad Syndrome
32
OTHER LESS COMMON CONDITIONS
33
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.

34
  • Pain might aggravate by squatting
  • Palpable thickened band under the medial border
    of patella
  • If conservative management fail, arthroscopic
    removal of plica

35
  • 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

36
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

37
Sinding-Larsen-Johansson syndrome
  • Similar to Osgood Schlatter
  • Affects inferior pole of patella
  • Less common than Osgood Schlatter
  • Same management principles

38
LATERAL KNEE PAIN
39
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40
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

41
ILIOTIBIAL BAND FRICTION SYNDROME
  • CAUSATIVE FACTORS
  • TIGHTNESS OF ITB
  • MALALIGNMENT LEG LENGTH DISCREPANCY
  • EXCESSIVE FOOT PRONATION
  • DOWNWARD CONTRALATERAL TILT OF PELVIC

42
ILIOTIBIAL BAND FRICTION SYNDROME
  • S/S
  • STINGING PAIN
  • WORSE ON RUNNING DOWNHILL
  • REPRODUCTION OF PAIN ON COMPRESSION OVER LATERAL
    FEMORAL CONDYLE WITH STRETCHED
  • CREPITUS

43
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

44
Lateral meniscus abnormality
  • Degeneration of the lateral meniscus
  • Pain on distance running, more severe on uphill
  • Tender along the joint line
  • McMurrays test ve
  • Confirmation by MRI

45
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

46
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

47
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

48
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

49
MEDIAL KNEE PAIN
50
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51
Medial knee pain
  • Patellofemoral syndrome
  • Medial meniscus abnormality
  • Pes Anserinus tendinopathy/bursitis

52
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

53
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 McMurrays test

54
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

55
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

56
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

57
ANKLE AND FOOT PROBLEMS
58
HEEL PAIN
  • MEDIAL
  • TIB. POST. TENDINITIS
  • FLEXOR HALLUCIS LOGNUS TENDINOPATHY
  • TARSAL TUNNEL SYNDROME
  • MEDIAL CALCANEAL NEURITIS
  • LATERAL
  • PERONEAL TENDINOPATHY
  • SINUS TARSI SYNDROME

59
  • PLANTAR
  • PLANTAR FASCIITIS
  • CALCANEAL SPUR
  • FAT PAD SYNDROME
  • CALCANEAL PERIOSTITIS
  • POSTERIOR
  • RETROCALCANEAL BURSITIS
  • CALCANEAL APOPHYSITIS
  • DIFFUSE
  • CALCANEAL STRESS FRACTURE

60
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61
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

62
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

63
  • MANAGEMENT
  • Rest
  • Stretching exercise
  • Tape in slightly plantar-flexed position
  • Check sport shoes
  • Check subtalar joint
  • Check excessive pronation

64
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 Tinels sign
  • May accompany with altered sensation

65
Principles of management
  • Correct excessive pronation
  • Corticosteriod injection
  • Decompression release

66
Medial Calcaneal neuritis
  • Pain over the inferomedial aspect of calcaneus
  • May radiates into the arch of the foot
  • Tenderness over medial calcaneus
  • ve Tinels sign
  • Treatment principle same as Tarsal tunnel syndrome

67
LATERAL ANKLE PAIN
68
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69
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

70
Principles of management
  • Rest from aggravating activities
  • EPT modalities
  • Stretching and strengthening
  • Mobilisation of subtalar, midtarsal joints
  • Correction of biomechanical abnormalities

71
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

72
Principles of management
  • Rest
  • Ice
  • EPT
  • Mobilisation of subtalar joint
  • NASID
  • Contricosteriod injection

73
PLANTAR HEEL PAIN
74
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

75
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76
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77
Tibialis Anterior Tendinopathy
  • Overuse of ankle dorsiflexors
  • Too infrequent downhill running
  • Excessive tightness of strapping or shoelaces
  • Treatment principles same as tendinopathy

78
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

79
Recommended reading
  • Brukner P., Khan K. 2001 Clinical Sports Medicine
    2nd edition, The McGraw Hill Co. Chapter 24, 25
    and 30
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