Lower limb soft tissue injury

Question 1

Definition

Answer 1

Damage to muscles, ligaments and tendons throughout the body.
In the lower limb, this commonly involves sprains and strains of the:
- hip
- knee
- ankle
- foot
The injury often occurs when there is a sudden, unexpected movement or impact that places stress on the area beyond its functional capacity, causing overstretching or tearing of the tissues

Question 2

Types of sprains for ligamentous injury

Answer 2

Grade I (mild): minimal fibre damage, no loss of function
Grade II (mod): partial tear, some loss of function
Grade III (severe): complete tear, significant loss of function
Strains are muscular or tendinous injuries, similarly graded I-III based on severity

Question 3

Epidemiology

Answer 3

Young, active individuals
Sport: inadequate warm-up or poor conditioning
Inappropriate footwear
Previous history of soft tissue injury
Inflammatory conditions:
- Rheumatoid arthritis
- HLAB27
Fluoroquinolone Abx

Question 4

Greater trochanteric pain syndrome

Answer 4

AKA: Trochanteric bursitis
Type of mechanism of injury: Repetitive movement, trauma, inflammatory condition
S+S:
- Gradual onset lateral hip and buttock pain
- Worse on activity or prolonged standing or sitting
- Tenderness over the greater trochanter
- Trendelenburg gait

Question 5

ACL tear

Answer 5

Typical mechanism of injury: Twisting injury, often occurring due to sudden change in direction or deceleration
S+S:
- Popping sound with pain, swelling, instability and reduced range of movement
- Tenderness on palpation
- Positive anterior drawer and Lachnman tests

Question 6

Meniscal tear

Answer 6

Typical mechanism of injury:
- Twisting movement, typically when playing sport
S+S:
- Pain, swelling, reduced range of movment locking and instability
- Localised joint line tenderness on examination
- McMurray’s test positive

Question 7

Osgood Schlatter Disease

Answer 7

Typical mechanism of injury: Physical activity, resulting in multiple avulsion fractures of the tibial tuberosity where the patella ligament inserts
S+S:
- Unilateral anterior knee pain, common in adolescents
- Pain exacerbated by movement, particularly running, jumping and kneeling
- There may be a palpable lump on examination

Question 8

Achilles tendinopathy

Answer 8

Typical mechanism of injury:
- Repetitive movement,
- Quinolone Abx use,
- Diabetes
- Inflammatory conditions
S+S:
- Gradual onset heel pain, worse on activity
- Swelling and stiffness
- Tenderness of the Achilles tendon
- There may be nodularity

Question 9

Achilles tendon rupture

Answer 9

Typical mechanism of injury:
- Running/playing a sport
S+S:
- Sudden onset pain/snapping sensation
- Positive Simmond’s test
- Plantarflexion weakness

Question 10

Plantar Fasciitis

Answer 10

Typical mechanism of injury: Repetitive movement (e.g. running, obesity)
S+S:
- Inferior heel pain on pressure
- Tenderness on palpation

Question 11

Diagnosis

Answer 11

Often clinical
Consider:
- X-ray: to exclude fracture,
= for ankle injury, indicated by the Ottawa ankle rules
- Ultrasound: Achilles tendon rupture
- MRI: Not routine, imaging used if grade 3 rupture is suspected
Arthroscopy: GOLD STANDARD for meniscal and crutiate ligament tears.

Question 12

Treatment

Answer 12

FIRST LINE:
- RICE = Rest, Ice, Compression, Elevation = reduces pain and swelling
- Analgesia: titrated to pain and prescribed according to the WHO pain ladder.
= Paracetamol
= NDSAIDS
= Steroid injections
- Physio

Second line:
- Surgery: indicated for high grade injuries that fail conservative management or in elite athletes for whom optimal recovery is essential.

Question 13

Complications

Answer 13

• Chronic pain or instability
• Recurrence due to inadequate rest or rehabilitation
• Loss of function