Lower Extremity Injuries Doc Borbon Flashcards
Lower Extremity Injuries
Doc Borbon
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Muscle Tendons Cartilage Ligaments Bone
• Muscle
o Limited ability to regenerate
o Often heals by dense scar formation
o Aging muscle demonstrates a decrease in size, number of muscle fibers (type II), and the number of motor units
o No decrease in metabolic potential for aerobic and anaerobic activities with aging
• Tendons
o Tendons subjected to large, repetitive stresses can tear, become inflamed, or degenerate
o increase in collagen cross-linkages, causing the fascia, ligaments, and tendons to be less distensible
o Activity promotes connective tissue hypertrophy, whereas inactivity leads to atrophy.
o Physical activity also enhances the rate of collagen turnover, which shortens its life span.
• Cartilage
o This helps maintain nutrition to the tissues.
o Cartilage rarely has a direct blood supply and derives most of its nutrition via diffusion.
o If deprived of bearing weight, the cartilage undergoes degeneration
o With repetitive overuse, cartilage can break down over time and lead to symptoms such as pain
• Ligaments
o Ligaments contain minimal blood supply, with most supplied by periarticular arterial plexuses
o The poor blood supply to ligaments explains the poor healing response in complete/partial injuries
• Bones
o dynamic tissue that remodels in response to external stress.
o In addition to failure of bone secondary to repetitive stress (i.e., stress fractures), bony malalignment
o will also predispose the athlete to injury
Non-functional Operative Rehabilitation ( 5 )
Phase I: Decrease Pain and Control Inflammation
Phase II: Restore Normal/Symmetric Range of Motion
Phase III: Restore Normal/Symmetric Strength
Phase IV: Neuromuscular Control (Proprioceptive) Retraining
Phase V: Return to Sport Activities
Phase I: Decrease Pain and Control Inflammation
▪ mediators involved in the inflammatory response are also important factors involved in the healing of soft-tissue injuries
▪ the goal is to control the inflammatory response – anti-inflammatory meds
▪ The PRICE (protection, rest, ice, compression, elevation) approach is well known to those who care for athletes.
▪ area can be protected either by splinting, bracing, or taping/wrapping
▪ Crutch ambulation (usually weight bearing as tolerated) for lower extremity injuries can be very helpful until a normal, pain-free gait pattern can be reestablished.
▪ Bracing should be limited to that which protects the specific area while allowing for full motion at other areas.
▪ Rest should be prescribed carefully – RELATIVE REST (affected area is rested, the remainder of the body is exercise)
▪ The affected areas should be generally iced 20 minutes four to five times a day, or more often if possible.
▪ Ice is used for its properties of vasoconstriction, which limits the edema as well the release of vasoactive and pain factors, such as bradykinins and leukotrienes.
▪ Ice also can decrease conduction along pain fibers and act as a counterirritant to assist in pain control and to reduce muscle spasm
▪ Compression is also used in an effort to limit the edema in the injured area
▪ Care must be taken to avoid excessive pressure over bony protuberances or superficial nerves.
▪ Compressive braces can also be effective
▪ The injured limb should be elevated above the level of the heart to optimally assist with venous and lymphatic drainage and therefore control edema
▪ Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) for a short period of time, if not contraindicated, and electrical stimulation
Phase II: Restore Normal/Symmetric Range of Motion
▪ Immobility will result in scar and contracture and therefore is not recommended.
▪ Range of motion (ROM) allows for controlled stress to a joint, which will stimulate proper collagen deposition.
▪ Motion provides sensory input to the central nervous system, which stimulates the proprioceptive system as well as modulates pain via the Gate theory
▪ In the early phase, pain-free movement of a joint and stretching that prevents contractures are encouraged as the motion that results in stress on the injured area is avoided.
▪ As the pain and inflammation subside, more aggressive stretching and mobilization continue until symmetric (to the unaffected limb) motion is achieved with normal movement patterns.
Phase III: Restore Normal/Symmetric Strength
▪ a stepwise approach toward strengthening must be used.
▪ In the early pos-tinjury phases, pain-free isometric contractions performed several times throughout the day are encouraged in an effort to retard muscular atrophy
▪ performed through multiple angles as the strengthening is specific to the manner and position in which a muscle is trained.
▪ there is no significant role for isokinetic strengthening
▪ Resistance training can be in the form of exercising against gravity, free weights machines, and resistance tubing
▪ The strengthening should be as functional as possible, attempting to match the demands of the sport
▪ the greatest tension with resistance occurs at the end ROM, where the muscle is usually weakest and the joint is most vulnerable
▪ the use of plyometric exercise should be included as the athlete is preparing to return to sport
Phase IV: Neuromuscular Control (Proprioceptive) Retraining
▪ adequate dynamic motor control
▪ the injured joint needs to be stabilized by synchronous activation of appropriate muscle groups so that the larger, more powerful muscles may safely produce the necessary force required in sports activity.
Phase V: Return to Sport Activities
▪ This occurs as the athlete successfully meets the challenges of the previous phases.
▪ The athlete then is put through activities that replicate the demands of the sport
HIP INJURIES
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HIP INJURIES ( 11 )
- either from direct trauma or musculotendinous overload
- often greatly impaired in sport participation as a result of significant alterations in gait.
Hip Pointer Hip Flexor Strain Greater Trochanter Bursitis Osteonecrosis of Femoral Head Legg-Calves-Pethes Disease Coxa Vara Slipped Capital Femoral Epiphysis Chondrolysis Protrusio Acetabuli Transient Synovitis of the hip Snapping Hip
Hip pointer
o direct blow to the pelvic brim or hip region, which results in a contusion to the soft tissues and often the underlying bone
o common in sports such as football and hockey, where there are many collisions (both player to player as well as contact between the player and the field or arena
o Common areas include the greater trochanter and iliac crest.
o The contact can result in hematoma formation, but often there is little visible swelling or ecchymosis.
o There is, however, a significant amount of pain and focal tenderness that is due to bony contusion and periosteal irritation
o has difficulty with quick bursts of running and with any contact to the area.
o Diagnosis:
▪ by the above history or on field observation.
▪ On examination, it is important to note full ROM of the hip and the knee.
▪ If there is a great deal of pain with passive ROM, then x-rays should be obtained to rule out any significant bony pathology.
▪ For most injuries, imaging studies are not necessary. In cases of significant soft tissue swelling, additional imaging such as CT or MRI may be indicated.
o Treatment
▪ requires frequent and repeated icing, active ROM and a period of rest until gait can be normalized.
▪ In a very painful hip, crutches with weight bearing as tolerated may be necessary for pain control and to unload the hip.
▪ NSAIDs can be helpful in the very early period to assist with pain control and inflammation but can generally be discontinued in less than a week
▪ Appropriate padding over the area is important to protect the area from recurrent injury
Hip Flexor Strain
o are commonly seen in sprinting as well as in other sports, such as soccer, baseball, and football.
o They occur as a result of an eccentric overload of the psoas muscle or as the athlete attempts to flex the fully extended hip, such as in hurdling.
o Most athletes are unable to continue to run
o Diagnosis:
▪ tenderness to palpation over the area and with resisted hip flexion and passive hip extension.
▪ ROM may also be painful.
▪ the majority of these injuries require plain x-rays of the hip (usually an anteroposterior and frog-leg lateral view) to exclude bony injury.
▪ This is particularly important in the adolescent or skeletally immature athlete, as injury to the apophyseal plate can commonly occur.
o Treatment:
▪ protected weight bearing when there is a significantly antalgic gait, aggressive icing, and gentle active ROM as soon as possible.
▪ Strengthening exercises of the lower extremities should be avoided until the gait is nonantalgic and ROM is full and pain free.
▪ Then the athlete should be progressed through an aggressive strengthening consisting of both open and closed kinetic exercises.
▪ Eccentric and plyometric training should be added when the athlete is ready and can be invaluable in preventing recurrent injuries that are common
Greater Trochanter Bursitis
o generally occurs secondary to repeated irritation of the bursa, or less commonly from direct trauma.
o Traumatic inflammation of the bursa is seen in collision sports, such as football and hockey, and at times in soccer and baseball after sliding hard into a base or hitting the ground after diving for a ball.
o Repeated irritation usually occurs secondary to other biomechanical abnormalities such as a tight iliotibial band (ITB) and/or weakness of the hip abductors
o Diagnosis:
▪ an aching pain along the lateral aspect of the hip that is worse with running and jumping and any contact on the area, including laying on the affected side at night.
▪ Physical examination will demonstrate relative weakness of the hip abductors on the affected side, a tight ITB on Ober testing
▪ significant pain with direct palpation over the bursa
o Treatment:
▪ icing, NSAIDs, and stretching of the ITB and strengthening of the hip musculature with attention to the hip abductors.
▪ In refractory cases, injection of a corticosteroid into the bursa can be very helpful in progressing the rehabilitation process.
Osteonecrosis of Femoral Head
o Causes: Fracture of the neck of the femur, Tearing of retinacular vessels (20-30%), traumatic dislocation of the hip , forceful manipulation or wringing out of the joint capsule by fixing hip in ER position, forced manipulation of slipped under upper femoral epiphysis, microfractures of the trabeculae bone of femoral head associated severe osteoporosis or osteomalacia.
o Infarction results in death of marrow elements (fat elements).
o Death of cancellous bone as manifested by degeneration and disappearance of osteocytes from the lacunae within bone trabeculae .
o Necrosis results in marked hyperaemia of the tissues adjacent the infarction
o Diagnosis:
▪ a limp and slight spasm in the hip, followed by pain present on weight bearing and often referred to the thigh.
▪ In adult, pain on groin (first symptom), spasm about the hip (early sign). In late stages, muscle atrophy and restriction of abduction and internal rotation may be noticeable
▪ X-ray films - Resorption may be extensive at the periphery of the infarct, weakening the cartilage support and resulting in fracture in subchondral area, which produces: “crescent sign”
▪ The process of removal of dead bone and its replacement of new bone is referred as creeping substitution
Legg-Calves-Pethes Disease
o Osteonecrosis of the femoral head/flattening of the femoral head
o ETIOLOGY: ischemia of head due to increase intrarticular pressure or trauma that occlude the retinacular vessel
o PATHOPHYSIOLOGY: 1. disruption of the epiphyseal plate with subsequent growth disturbance and collapse of the head may occur during the resorptive phase, producing characteristic flattening.
o Diagnosis:
▪ Manifested by pain, muscle spasm, limitation of movement
▪ X-ray for diagnosis
Coxa Vara
o decrease on the neck shaft angle (angle of torsion)
o congenital; acquired; chronic disability such as severe paralytic disorder; secondary deformity in congenital dislocation of the hip
o PATHOPHYSIOLOGY: demarcation of a triangular area of bone in lower side of the femoral head close to the neck
o seen after interthrochanteric fx; slipping of the capital femoral epiphysis; and fx of the head of the femur
o Diagnosis:
▪ (unilateral)painless and wadlling gait; bilateral (lurching)
▪ X-rays
Slipped Capital Femoral Epiphysis
o ETIOLOGY: unknown; but may due to trauma or strain
o common in children between 10 and 16 years of age ; more common in boys; in girls its occur 2 years earlier (after menarche
o PATHOPHYSIOLOGY: periosteum becomes thinner in the adolescent and may yield to shear forces associated with increase body weight and a more vertical slope of growth plate
o Diagnosis
▪ aching fatigue and feeling of stiffness; after standing or walking ;limp
▪ X-ray for diagnosis
Chondrolysis
o Cartilage necrosis
o progressive narrowing of the joint space due to loss of cartilage from acetabular and femoral surfaces ETIOLOGY: unknown
o PATHOPHYSIOLOGY: matrix loss and degeneration of articular cartilages and mild inflammatory changes in the synovial membrane; elevation of the synovial fluid and serum immunoglobulins and c3 component
o Diagnosis
▪ hip pain with progressive loss of mobility; hip flexion and adduction contractures; osteoporosis of the femoral head and acetabulum; fibrous ankylosis
▪ X-ray
o Treatment
▪ rest; restrictions of activities; use of crutches; gentle active exercise; salicylates; NSAIDs; surgery; arthrodesis; arthroplasty
Protrusio Acetabuli
o deepening or inward protrusion of the acetabulum
o ETIOLOGY: unknown; congenital or acquired
o PATHOPHYSIOLOGY: thinning of the wall of the acetabulum but ocassionaly there is evidenced of increase bone formation; there may be narrowing of the cartilage space
o Diagnosis:
▪ discomfort; limitation of motion (abduction and rotation); pain until osteoarhtritic changes is superimposed
o Treatment
▪ rest; night traction; crutches; arthroplasty
Transient Synovitis of the hip
o transient inflammation of the synovium of the hip
o ETIOLOGY: trauma or low grade, short lived infection that subsides after 1 or 2 wks PATHOPHYSIOLOGY: distension of the joint capsule
o commonly seen in boys between age of 4 and 10;
o unilateral involvement; pain on hip,, thigh or knee; tenderness over the hip joint;
o restriction of passive hip mobility due to spasm;
o limp;
o hips often flexed and abducted position; infection is slight or absent
o rest; hot application; traction
Snapping Hip
o clicking sound upon movement that is heard over the hip
o ETIOLOGY: slipping to and fro over the greater throcahanter of the tibial band
o PATHOPHYSIOLOGY: fibrous thickening on the deep surface of the gluteus maximus
o Clicking sound on the hip - HARMLESS
KNEE
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KNEE ( 25 )
- common in almost all sports, particularly those that require running, jumping and pivoting, and cutting.
- In addition, contact and collision sports often place the knee joint at risk for injury
Patellofemoral Syndrome Patellofemoral insufficiency MCL and LCL Sprain ACL and PCL Ligaments ACL Tear PCL Management Meniscal Tears Menisci Lesions Degenerative Meniscal Tear Pelligrini-Steida Disease Loose Bones Synovial Chondromatosis Osteochondritis Dissecans Myositis Ossifican and Quadriceps Contusion Osgood-Schlatter Disease Recurrent Dislocation and Subluxation of the Patella Chondromalacia Patellae Patellar Tendinitis Bursitis Genu Varum Genu Valgum Tibia Vara/ Blount’s Disease Leg Length Discrepancy
Patellofemoral Syndrome
o Anterior knee pain
o Failure of energy absorption by the articular cartilage causing increased patellar subchondral bone pressure
o lateral malalignment causing hyperpressure of the lateral patellofemoral compartment and hypopressure on the medial patellofemoral joint
o Abnormal lateral tracking of the patella
Patellofemoral insufficiency
o Vastus medialis obliquus (VMO) insufficiency - help maintain proper patella tracking during extension of the knee. It is the only dynamic medial stabilizer and, if weak, it allows lateral tracking.
o functional increase in the Q-angle - which results in abnormal kinematics which affect patellar tracking, resulting in patellofemoral pain due from tightness of the soft tissues
o ITB tightness is felt to result in abnormal patellar tracking - as its distal-most fibers insert on the lateral patella, exerting a lateral pull during knee flexion
o Hamstring tightness - it increases the patellofemoral joint reaction force in stance
o Gastrocnemius tightness causes a decrease in ankle dorsiflexion, with a resultant compensatory pronation of the foot, via the subtalar joint - increase in the Q-angle and lateral patellar deviation.
o Hyperpronation results in internal rotation of the leg and femur- increasing the Q-angle, and malalignment of the patella.
o pain control is addressed with ice, NSAIDs, and occasionally, electrical stimulation
o Avoiding activities such as kneeling, excessive stair climbing, and prolonged sitting.
o appropriate shoe orthotics if hyperpronation
o Proper stretching of gastrocnemius, hamstrings, and ITB is essential in treatment.
o McConnell taping can be done to improve the positioning and tracking of the patella and to facilitate an aggressive stretching and strengthening program.
MCL and LCL Sprain
o Medial collateral ligament – most commonly injured in sports
o occurs from a valgus force to the knee joint that stretches or tears the ligament
o Although isolated LCL sprains are less common, but necessary to rule out other injuries
o VALGUS TESTING
o Isolated, complete tears of the MCL can be successfully managed nonoperatively at all levels of sport participation and should be considered the state-of-theart treatment for this injury
o The knee should be protected by a double upright hinged knee brace, which initially can be used in conjunction with crutches until a normal gait pattern is established.
o important to promote active ROM of the knee.
o Strengthening
o Once again, with a complete MCL tear, knee bracing would be recommended for 6 to 9 months
ACL and PCL Ligaments
o providing predominantly anterior and posterior stability, along with lateral rotatory stability to the knee joint
o most commonly occur following a hyperextension injury or from a significant valgus force of blow to the knee
o Unhappy triad/O’ Donohue’s triad: ACL, MCL, medial meniscus
o In general do not heal
ACL Tear
o patients often describe hearing or feeling a “pop” with an unstable sensation of the knee.
o If chronic, giveway episodes of the knee are common with rotatory activity, such as pivoting
o An effusion (hemarthrosis) usually develops
o a positive anterior drawer and Lachman test should be noted.
o MRI for diagnosis
PCL
o occur with a posterior force to a bent knee, such as after being tackled or receiving a blow with the knee in 90 degrees of flexion as can occur with a dashboard injury during a motor vehicle accident
o there is a positive posterior drawer sign
o Minimal swelling
Management
o those who attempt a nonoperative treatment course, the results can be favorable, particularly if there is a strong focus on the later stages of strengthening and proprioceptive training with some type of functional bracing.
o For a high demand athlete – ACL reconstruction
o Isolated PCL injuries have been found to do quite well. A functional stepwise approach works very well with a bias toward greater quadriceps strength and closed kinetic training.
Meniscal Tears
o serve as shock absorbers and force dissipaters to protect the knee joint
o from either a direct blow to the knee or a twisting type injury, as the menisci are susceptible to compression/rotation forces
o swelling or “tightness” within the knee from the associated synovitis that occurs, and bleeding in the younger athlete if there is injury to the vascular portion of the meniscus.
o There can be mechanical symptoms such as catching or locking with an associated or intermittent clicking.
o Symptoms are generally increased with knee flexion and are often localized to the joint line
o usually a small to moderate effusion, with pain on flexion and on palpation of the joint line over the side of the injured meniscus
o Many meniscal tears can be treated conservatively with a combination of relative rest, vigorous icing, and NSAIDs
o Followed by a course of physical therapy with restoration of motion and an aggressive strengthening program stressing closed kinetic-type exercises
o aspiration and injection with a corticosteroid can be very helpful in decreasing the reactive inflammatory response – if persistent effusion
o arthroscopic treatment with either resection of the unstable portion or repair (if possible) – if unresponsive
