Lower Extremity Sports Injuries Flashcards
What are 9 specific injuries to the pelvis, hip and thigh?
- pelvic apophysitis
- pelvic avulsion fractures
- snapping hip syndrome
- femoral stress fracture
- femoral acetabular impingement/labral tears
- muscle strains
traumatic hip dislocation - slipped capital femoral epiphysis
- Legg-Calve Perthes disease
What is the weakest point in the muscle-tendon unit of a growing athlete?
pelvic apophyses
Why do pelvic apophyses tend to occur?
bone growth exceeds the ability of the muscle tissue to sufficiently lengthen and stretch, thus increasing tensile forces which leads to microtrauma and progressive weakness and inflammation
What the 3 most common sites for pelvic apophysitis?
- ASIS
- AIIS
- ischial tuberosity
ASIS apophysitis occurs because what 2 muscles are pulling?
- Sartorius
- TFL
AIIS apophysitis occurs because what muscle is pulling?
rectus femoris
Between what ages do both the ASIS and AIIS apophyses ossify?
14-16
Ischial tuberosity apophysitis occurs because what muscle group is pulling?
hamstrings
Between what ages does the ischial tuberosity ossify?
21-25
What are 3 other less common apophysitis sites?
- lesser trochanter
- greater trochanter
- iliac crest
What are the symptoms of pelvic apophysitis?
well-localized, dull pain with activity at the involved location
What can be done to reproduce the athlete’s symptoms?
tensioning of the muscle
What is the treatment for pelvic apophysitis?
rest, WBAT as long as there is no antalgic gait.
Once pain is controlled focus on muscle flexibility, ROM, and strengthening of the lumbopelvic and LE musculature
Return to sport following pelvic apophysitis is dependent upon symptoms and may take up to _ weeks
6
When do pelvic avulsion fractures tend to occur?
with the progression of an unmanaged apophysitis in the pelvis
What ages do pelvic avulsion fractures tend to occur the most?
adolescents ages 14-25 years
What are the signs and symptoms of a pelvic avulsion fracture?
- sudden “pop”
- tenderness and swelling
- painful WB resulting in antalgic gait
- associated bruising
What determines the treatment of pelvic avulsion fractures?
the degree of widening and displacement of the apophysis:
- less than 2 cm = conservative
- greater than 2 cm = surgical ORIF
Describe conservative treatment for pelvic avulsion fractures
relative rest from activity for 3 weeks followed by focus on regaining ROM, short course of muscle strengthening, followed by return to sport activities around 6-8 weeks
What is snapping hip syndrome characterized by?
audible and/or palpable “popping” of the hip caused by tendons moving over bony prominences
In what type of athletes is snapping hip syndrome most frequently found?
- performing artists
- distance runners
- hurdlers
What are the 2 classifications of snapping hip?
- external
- internal
What causes external snapping hip syndrome?
the friction of the IT band and/or anterior aspect of the glute max passing over the greater trochanter
What are 2 other pathologies that may occur with repetitive external snapping?
- trochanteric bursitis
- damage to the glute med
What are the characteristics of external snapping hip syndrome?
- lateral hip pain and tenderness around greater trochanter
- snapping with a description of “hip dislocation”
True or False
True external snapping hip syndrome does not contribute to altered athletic performance
True
What causes internal snapping hip syndrome?
the iliposoas tendon chronically subluxes from lateral to medial while the hip is brought from a flexed, abducted, and ER position into extension with IR
What are the characteristics of internal snapping hip syndrome?
Deep, often painful and audible clunking sensation in the anterior groin
- May also report achiness in posterior buttock/SI region
What can help aid in the diagnosis of internal snapping hip syndrome?
direct pressure over the iliopsoas decreases snapping
What is the treatment of both external and internal snapping hip syndrome?
- soft tissue techniques and stretches
- exercises to improve trunk control, stability, and LE positioning
What are the 2 varieties of femoral stress fractures?
- compression stress along the medial aspect of the femoral neck
- tensioning along the lateral side
In what type of athlete do femoral stress fractures tend to occur?
long distance runners (females 4x more than males)
What causes femoral acetabular impingement (FAI)?
Abutment and approximation of the femoral head or neck with the acetabular ring
What are the 2 types of lesions FAI can result from?
- Cam lesion
- pincer lesion
What are Cam lesions a result of?
abnormally shaped femoral head repeatedly impinging on the acetabulum
Cam lesions result in lesions to what aspect of the acetabulum?
anterior superior
What are pincer lesions a result of?
excessive coverage of the acetabular rim, resulting in abutment of the femoral head and neck when the hip is flexed
Pincer lesions result in lesions to what aspect of the acetabulum?
posterior inferior
Cam lesions are more common in _____ whereas pincer lesions are more common in _____.
males
mature females
What are the main complaints in patients with FAI?
Deep hip and groin pain in the shape of a “C” that is aggravated with long periods of sitting as well as athletic activity
How is anterior hip impingement tested for?
hip flexion and IR
How is posteroinferior hip impingement tested for?
hip extension and ER
True or False
Labral tears most often need surgical repair
True
What exercises should be avoided in the early phases of labral repair rehab?
anterior hip
- SLR
- situps
- lunges
A torn labral early in life often times leads to earlier what in adults?
THA
Why are muscle strains not common in young athletes?
Because they tend to incur more apophyseal avulsion injuries instead
What are the 3 most common muscle strains to the hip and thigh?
- adductor
- flexor
- hamstring
What are the 3 classifications of muscle strains?
1) minimal muscle damage
2) moderate amount of microtears
3) complete muscle rupture
Describe the conservative treatment of muscle strains (1 and 2)
PRICE (protection, rest, ice, compression, elevation)
- avoid muscle stretching
- pain free ROM activities to the associated joint segments
- eccentric muscle training
True or False
Corticosteroid injections are used as a treatment intervention in the adolescent athlete with a muscle strain
False
In what direction do the majority of hip dislocations occur?
posterior
What is the protocol for traumatic hip disloctions?
splinting and prompt transport to a medical facility
How long after hip dislocation will an athlete be NWB?
6 weeks
How long after hip dislocation can an athlete begin hip mobility and strengthening?
12 weeks
What is Slipped capital femoral epiphysis (SCFE)?
Posterior slippage of the proximal epiphysis
In what patient population is SCFE most common?
boys around the age of 11 with a high BMI
What are the symptoms of SCFE?
insidious pain that was gradual in onset to the groin, thigh, or medial knee that increases with physical activity
What are 2 clinical signs that are indicative of SCFE?
- resting LE in extension, adduction, and ER
- significant limp
What is the treatment of SCFE?
surgery
How long is a child NWB following SCFE repair surgery?
8-12 weeks
What is the PT intervention strategy for SCFE?
maximize ROM, muscle strength and endurance, balance, and proprioception
What is Legg-Calve-Perthes disease?
Idiopathic osteonecrosis of the capital epiphysis of the femoral head presenting in males 4 to 8 years old
What are the clinical signs and symptoms of Legg-Calve-Perthes disease?
- insidious onset of limp usually without any associated pain
- limitations in hip IR and abduction
What are the primary goals of LCP treatment?
- maintenance of hip mobility
- decreased pain with WB
- containment of femoral epiphysis within acetabulum
What is the major difference between treatment approaches for SCFE and LCP?
SCFE = surgery Legg-Calve-Perthes = conservative
Describe the typical protocol following ACL repair
- open-chain knee extension within 40-90 degrees for the first 8-10 weeks
- progression to jogging and B jumping around 3-4 months
- Return to sport 6-12 months
Describe the 3 grades of MCL sprains
1) pain with stress testing without associated joint laxity
2) pain with stress testing with increased joint excursion; presence of distinct end point
3) complete ligament disruption with excessive excursion; no distinct end point
A return to sport can be expected to occur - weeks following a grade 1 MCL sprain, - weeks following grade 2, and - weeks in grade 3
1-3
4-6
9-12
Most meniscal injuries in children younger than age 10 occur in the setting of a congenital malformation known as what?
discoid meniscus
Do discoid menisci tend to occur most commonly in the medial or lateral menisci?
lateral
Describe the rehab process following repair of the meniscus in a child
- NWB or PWB for 4-6 weeks with the use of a hinged brace to limited knee ROM to 0-90 degrees
- address deficits in strength, coordination, and limb control
- return to sport 3-4 months post-op
What is an OCD lesion of the knee?
a condition in which damage to the subchondral bone causes secondary damage to the overlying articular cartilage
What is the most commonly affected site within the knee?
lateral aspect of the medial femoral condyle
What is the major complaint of a knee OCD lesion?
anterior knee pain
Describe conservative treatment for a stable OCD lesion
NWB with the knee immobilized for 6-8 weeks
Return to sport around 3 months
Return to sport is expected at - months following surgery to repair an unstable OCD lesion
6-9
What are 3 differentials for an OCD lesion?
- patellofemoral pain
- chondromalacia
- plica syndrome
What are most acute patellar dislocations and associated osteochondral fractures caused by?
planting or twisting maneuvers
Describe treatment if there is no osteochondral damage noted
immobilization for 4 weeks followed by progressive ROM and rehab
Where do osteochondral fractures typically occur with an acute patella dislocation?
medial patella facet and/or lateral femoral condyle
Describe treatment if there is no osteochondral damage noted
Surgery followed by a period of protective WB (dependent upon damage) and a return to sport within 4-6 months
What are 5 commonly encountered diagnoses that cuase anterior knee pain due to overuse?
- patellofemoral pain syndrome
- Osgood-Schlatter disease
- Sinding-Larsen-Johansson disease
- inflamed synovial plica
- patella tendinopathy
What is the most common cause of all knee overuse injuries?
patellofemoral pain syndrome
What causes patellofemoral pain syndrome?
biomechanical alterations in LE function resulting in abnormal stress across the patellofemoral joint and tissue overload
What is the main complaint of PFPS?
Dull ache from underneath or around the patella that increases with squatting, stairs, running, and prolonged sitting
What is the major proximal factor that may contributes to PFPS that should be part of the focus of treatment?
glute med and max strength and neuromuscular control during CKC
What are 2 distal factors that may contribute to PFPS that should be part of the focus of treatment?
- excessive foot pronation
- limited ankle dorsiflexion
Where does Osgood-Schlatter disease represent injury at?
tibial tubercle
Where does Sinding-Larsen-Johansson disease represent injury at?
inferior pole of the patella
What is the focus of treatment for both Osgood-Schlatter and Sinding-Larsen-Johansson disease?
- rest
- NSAIDs
- normalizing LE flexibility (esp quads and hamstrings)
- strengthing of quads, adductors, and ERs
In what patient population does patellar tendinopathy develop?
Older adolescents with fused growth plates
What is patellar tendinopathy aka?
jumper’s knee
Describe treatment for patellar tendinopathy
- rest
- eccentric strengthening
- stretching of quads and hamstrings
What are plicae?
bands of tissue in the synovial lining of the knee that arise from remnants of embryologic knee development
When does a plica become symptomatic?
when it rubs across the medial femoral condyle
What plica is most commonly symptomatic?
medial
What is the plica usually felt as?
A painful, taught band, running from the medial patella to the medial femoral condyle
Describe treatment for plica syndrome
- activity modification
- inflammation control
- flexibility restoration
- pain free strengthening
- dynamic limb control
What is the generic term to describe pain to the lower leg?
shin splints
What are 3 differential diagnoses for lower leg pain?
- medial tibial stress syndrome
- tibial stress fracture
- compartment syndrome
What is medial tibial stress syndrome characterized by?
pain and inflammation along the anteromedial plane of the distal to central 1/3 of the tibia with running and jumping activities
What causes medial tibial stress syndrome?
high, repetitive loads and rapid foot pronation
What are 7 contributing factors to MTSS?
- decreased hip IR ROM
- excessive PF ROM
- excessive midfoot mobility
- poor shock attenuation
- rapid changes in exercise intensity
- weakness or imbalance about the lower leg
- high BMI
What is the suggested treatment for MTSS?
- active rest (low impact activities)
- ice
- compression/taping
- NSAIDs
- flexibility and strengthening of lower leg musculature (focus on gastrocsoleus complex)
How long is the return to sport following MTSS?
6-8 weeks
What causes tibial stress fractures?
repetitive bony overload and the inability to meet the demands of the levels of force
What are 5 contributing factors to tibial stress fractures?
- improper training regimens
- poor bone health
- high BMI
- abnormally high or low arches
- excessive foot pronation
What running characteristics lead to a high incidence of tibial stress fractures?
- high vertical loading rates
- heel striking at ground contact
- increased step length
- decreased cadence
- high tibial acceleration
What are the signs and symptoms of tibial stress fractures?
localized, acute, and sharp pain on the tibial surface along with palpable thickening usually along the central to upper 1/3 of the tibia
What is the treatment option for acute compartment syndrome?
fasciotomy
In what patient population is chronic exertional compartment syndrome or exercise-induced compartment syndrome common in?
long distance runners
Why does exercise induced compartment syndrome occur?
Because the containing fascia is unable to expand, thereby constricting blood flow resulting in ischemia
What compartments of the leg are most commonly affected by compartment syndrome?
anterior and lateral
What are the signs and symptoms in an athlete with chronic exertional compartment syndrome (CECS)?
aching pain, tightness, and squeezing sensations about the lower leg in the distribution of the affected compartment
What is the treatment for CECS?
alteration of running mechanics along with pain relief strategies
The ankle is the most common site for athletic injuries, accounting for __-__% of all musculoskeletal injuries
20-30
What motions occur at the talocrural joint?
DF and PF
What motions occur at the subtalar joint?
inversion and eversion
Ankle supination is a combination of what motions?
PF, inversion, and adduction
Ankle pronation is a combination of what motions?
DF, eversion, and abduction
85% of ankle pathology is due to what?
acute ankle sprain (lateral most often)
What is a high ankle sprain aka?
syndesmotic sprain
What causes a high ankle sprain?
forced eversion and ER of the ankle causing widening of the distal tib-fib joint
What are the signs and symptoms of an ankle sprain?
- patient reports a distinct injury with a sudden “pop”
- unable to continue activity
- pain, swelling, and ecchymosis throughout the ankle and into the foot and toes
- limited and painful WB
What is treatment for an ankle sprain?
PRICE (protection, rest, ice, compression, and elevation)
- a few days of rest and immobilization due to pain
- early joint mobility and weight bearing has been shown to be more favorable for functional return (begin DF and PF movements first followed by inversion and eversion movements)
When do ankle fractures in sports tend to occur?
with deceleration or rotational forces about a fixed foot
In children under 12 years with an immature skeletal system, a physeal fracture of the distal fibula is highly probable with what type of injury?
lateral ankle sprain
What are the signs of a ankle fracture?
pain on palpation over the physeal growth plate (1 finger width above distal portion of lateral malleolus)
Ottawa Ankle Rules
- bone tenderness at posterior edge or tip of lateral malleolus
- bone tenderness at posterior edge or tip of medial malleolus
- inability to bear weight both immediately and in ER
What is the treatment for an ankle fracture?
cast immobilization for 3 weeks followed by rehab similar to that of a lateral ankle sprain
Ottawa ankle rules have been shown to be sensitive in detecting fractures to the foot in children over 5 years of age, what are they?
- bone tenderness at posterior edge or tip of lateral malleolus
- bone tenderness at posterior edge or tip of medial malleolus
- inability to bear weight both immediately and in ER
What is a triplane fracture?
an ankle fracture that occurs in older children ages 15-17 in 3 planes (coronal, sagittal, and transverse) due to partially closed growth plates
What is a Tillaux fracture?
a Salter-Harris type III fracture of the unfused anterolateral segment of the distal tibia epiphysis caused by avulsion of the epiphyseal segment of the AFTL
Where is pain experienced in a Tillaux fracture?
anterior lateral aspect of the foot
What is the treatment protocol following a triplane of Tillaux fracture?
- NWB for 3-4 weeks
- short leg cast for 3-4 weeks
- PT to restore normal strength and mobility
When should you suspect a osteochondral fracture of the talar dome?
when there is persisten pain following a sprain with continued edema and intermittent clicking or locking
What are the treatment methods of an osteochondral fracture of the talar dome?
- conservative:
casting and orthotic intervention - surgery to remove loose body
Ankle _____ can be the source of anterior, antereolateral, or posterior ankle pain
impingement
What causes ankle impingement?
the formation of an osteophyte on the distal tibia due to abnormal ankle mechanics
What are the symptoms of ankle impingement?
Pain between the fibula and the lateral talus, within the sinus tarsi, or AFTL
What is the treatment of ankle impingement?
- rest
- NSAIDs
- bracing
- joint mobilization
- possible arthroscopic debridement
What 2 overuse foot injures are often more frequent in the skeletally mature athlete?
tendonitis and plantar fasciitis
In the skeletally immature athlete, atraumatic pain along the posterior calcaneus is likely due to what?
Sever’s Disease
Describe what Sever’s disease is
a traction apophysitis of the calcaneus at the site of the attachment of the Achilles tendon, plantar fascia, and intrinsic muscles of the foot
What are the symptoms of Sever’s disease?
- pain along the heel that increase during sports such as soccer, gymnastics, and basketball with repetitive running and jumping (pain is usually bilateral)
- muscles length restrictions to triceps surae muscle complex
- excessive foot pronation
- possible swelling
What is the treatment for Sever’s disease?
- pain control modalities
- continuation of sports activities if tolerable
- restore flexibility and length to impaired musculature
- strengthening of calf and foot muscles
- gel heel lift to unload Achilles
What is Iselin’s disease?
A traction apophysitis to the proximal fifth metatarsal (insertion of peroneus brevis muscle)
What are the symptoms of Iselin’s disease?
- pain and swelling over the proximal 5th metatarsal
- pain with WB
- pain with resisted eversion
What is the treatment for Iselin’s disease?
Rest and flexibility activities to the evertors and PFs
A Lisfranc injury is an injury to what joint?
Tarsometatarsal joint
What causes a Lisfranc injury in sports?
a low-energy axial load on a plantarflexed foot with the knee anchored on the ground
What are the symptoms of a Lisfranc injury?
- pain on the dorsum of the foot
- forefoot edema and bruising along the plantar arch
- weightbearing is painful and increases when asked to stand on tiptoes
- tenderness upon palpation along the tarsometatarsal joints
- gapping between the hallux and 2nd toe
How are Lisfranc injuries treated?
conservatively with the athlete immobilized with a CAM walking boot for 6-10 weeks and allowed to WB according to pain tolerance
How long does complete recovery take in a Lisfranc injury?
4 months, and some may not be able to return to sport
What is tarsal coalition?
a congenital malformation where two or more tarsal bones are fused
What are the symptoms of tarsal coalition?
- restricted midfoot mobility
- pain with cutting, pivoting, running
- history of recurrent, chronic ankle sprains
What is the treatment for tarsal coalition?
directed at controlling foot motion to decrease stresses about the fusing joints
What is an os navicular secundum?
a congenital formation of a small ossicle next to the navicular or within the tibialis posterior tendon
What metatarsal is the most commonly fractured in children?
5th
What are the Ottawa foot rules?
- bone tenderness at the base of the 5th metatarsal
- bone tenderness at the navicular
- inability to bear weight both immediately an in ER
What is a Jones fracture?
a fracture of the proximal diaphysis of the fifth metatarsal
What is turf toe?
Hyperextension injury to the first MTP, resulting in damage to the plantar capsuloligamentous structures
What are the symptoms of turf toe?
pain along the plantar surface of the toe along with possible bruising and swelling
- pain is replicated with active or passive great tow extension
What is the treatment for turf toe?
PRICE
- early mobility is key to avoid hallux rigidus