Lower Limb Sports Injuries Flashcards
What are the two categories of lower limb sports injury?
Acute & Overuse
What are some signs of an acute lower limb injury?
Sudden, severe pain
Swelling
Inability to place weight on a lower limb
Extreme tenderness
Inability to move a joint through full range of motion
Extreme limb weakness
Visible dislocation / break of a bone
What are some signs of a chronic overuse lower limb injury?
Pain aggravated by activity
A dull ache when at rest
Localised swelling
Potential history of an acute injury that has since become chronic
What are some examples of acute lower limb injuries?
Bone - Acute fracture
Joint - Joint dislocation or subluxation
Ligamentous - Ligament sprain/ tear
Muscular - Muscle strain/ tear, contusion (bruising/damage to the muscle fibres from a blunt direct impact to the area), cramp, acute compartment syndrome (increased pressure within a muscle compartment that restricts blood flow)
Tendinous - Tendon tear/rupture
Bursa - Traumatic bursitis (Inflammation of a bursa due to trauma, often has a rapid onset and presents with marked swelling, can occur at knee (prepatellar, infrapaterllar, suprapatellar, pes anserine or semimembranosus bursae), ankle (retrocalcaneal (anatomical) or subcutaneous)
Epidermal - Skin abrasions, puncture wounds, lacerations
What are some examples of chronic overuse lower limb injuries?
Bone - Stress fracture, periostitis (inflammation of the periosteum), bone stress response, OLT
Joint - Synovitis, OA
Ligamentous - Ligament inflammation
Muscular - Chronic exertional compartment syndrome (increased presssure within a muscle compartment causing bilateral leg swelling and pain due to overexertion/over exercise), delayed onset muscle soreness (muscle pain the day after exercise, usually caused by eccentric contraction)
Tendinous - Tendinopathy
Bursa - Development of an adventitious bursa or bursitis
Epidermal - Blisters, callous
What are some extrinsic factors that contribute to the development of an overuse injury?
Inadequate Training Progression - Failing to progressively increase training intensity/difficulty (ideally by about 5-10% each training session), either by under-training or increasing the difficulty too suddenly resulting in tissue overload. Interruptions in training or a sporadic training schedule also inhibit progression and increase injury risk
Improper Technique - Incorrect form can cause you to not be loading/strengthening the tissues you are intending to, possibly overloading other tissues that are being loaded inadvertently due to poor form and increasing the risk of injury.
Footwear - Wearing improper footwear when participating in sport that requires specific footwear or changing your footwear can cause increased load on your tissues
Surfaces - Training on harder surfaces such as concrete or surfaces that are designed to have some resistance such as astroturf can increase tissue load and thus the risk of injury
Weather - Training in wet, snowy, windy or icy weather conditions increases tissue loading as your tissues must work harder to prevent you from slipping/falling
What are some intrinsic factors that can contribute to the development of an overuse injury?
Age - Children/young athletes experience periods of rapid growth which cause their bones to lengthen quickly, their ligaments and tendons must stretch overtime to accommodate this, as their bones are not fully ossified and become slightly soft during these periods of growth, children can experience osseous pathologies such as stress fractures, OCD etc. Advanced age is associated with reduced collagen formation and remodelling, meaning that tissue capacity and ability to heal from injuries reduces as we get older
Anatomical Variation - LLDs, coxa valgum & varum, Genu valgum and varum, spine malalignments etc
Biomechanical Abnormalities - Gait abnormalities, joint restrictions, joint hypermobility, ligamentous laxity, muscle weakness/tightness can all contribute to repetitive overload of certain tissues
Body Weight - Increased body weight or a sudden increase in body weight can increase tissue loading and thus the risk of injury
Physical Fitness/Skill Level - Poor physical fitness and associated low tissue capacity and poor neuromuscular control can lead to overuse injuries if training is not adequately progressed.
Sex - Certain overuse injuries are more prevalent in women (such as lateral ankle sprains, Syndesmotic injury, chronic ankle instability) and some are more commonly seen in men
Is ‘abnormal’ foot posture a risk factor for lower limb overuse injuries?
There is debate over the significance of foot posture as a risk factor for lower limb overuse injuries within the literature. As historically, theories of podiatric biomechanics has focused on identifying pathology in foot posture (i.e Root et al), we tend to believe that it plays a role in the development of chronic overuse injuries. However, recent systematic reviews into the subject have found very little evidence to support this.
Neal et al (2014), performed a systematic review to determine is foot posture is a risk factor for the development of overuse injuries, and found that there was strong evidence relating pronated foot posture to the development of medial tibial stress syndrome, but not enough evidence to support this as a factor for other overuse pathologies
Another systematic review (Dowling et al, 2016) looked at dynamic foot function as a risk factor for lower limb overuse injuries and concluded that there was very little evidence to support this. However this may be due to the fact that dynamic foot function is very difficult to assess accurately and quantifiably, so quantity of high quality studies in this field are very limited.
What is a lateral ankle sprain?
A strain is defined as the stretching or tearing of ligaments. In the case of a lateral ankle sprain, the ankle is excessively inverted (and potentially plantarflexed) in an acute incidence of trauma, this puts tensile stress on the lateral ligament complex of the ankle.
They are the most common type of ankle sprain, with their incidence being highest in men ages 10-19, however women over 30 experience a higher incidence than their male counterparts. Only 3-5% of ankle injuries are eversion sprains as they are uncommon.
They can be graded based on the severity of the injury and have a high rate of recurrence due to the development of secondary ligamentous laxity following injury.
What are the three ligaments of the lateral ankle complex?
The Anterior Talofibular Ligament (ATFL) - The ligament most commonly affected in lateral ankle sprains as it is the weakest of the complex.
The Calcaneocuboidal Ligament - Also commonly damaged in the context of lateral ankle sprains
The Posterior Talofibular Ligament - Can be affected by lateral ankle sprains but is rather rare as it is not strained by inversion
Describe the 3 grades of ankle sprains
Signs & Symptoms Pathophysiology
Grade 1 - Minimal tenderness. Some fibres torn w/
& swelling Minimal haemorrhage
No laxity or instability
Full ligamentous
Function and strength
Maintained
Grade 2 - Moderate tenderness. Incomplete tear of ligament
& swelling
Decreased ankle
ROM w/ mild
Laxity and instability
Slight reduction in function,
Strength & proprioception
Grade 3 - Significant tenderness Complete disruption of ligament
& swelling
Gross instability & laxity
Potential for complete loss of function,
Strength and proprioception
What assessments would you perform in a suspected lateral ankle injury?
Observation/Visual Assessment of Lateral Ankle - Looking for swelling, potentially bruising or observable deformity
Active Movement - Ask patient to move their ankle through, dorsiflexion, plantarflexion, eversion and inversion. In a LAS, pain should be elicited by active inversion and potentially plantarflexion
Passive Movement - Assess ankle and ST joint range of motion, inversion/plantarflexion may be reduced in grades 2 and 3, and will most likely be painful in all grades. You can also palpate the ligaments with the ankle/STJ in maximal supination, this will cause pain in a LAS
Resisted Movement - Assess patients ability to actively invert, evert, plantarflex and dorsiflex the ankle and STJ against resistance with the ankle joint held in midrange. Active inversion may be painful but usually damage to inert structures does not cause impairment in muscle power or pain as the tissues do not contract. This may help rule out differentials involving contractile soft tissues such as peroneal tendinopathy however.
Anterior Drawer Test - The competency of ATFL to stabilise the lateral ankle joint is assessed with this test. Stabilise the distal leg with one hand while the other grabs the calcaneus, with the foot in 20 degrees of plantar flexion, pull the calcaneum upwards/ dorsally. More than 1 cm of translation of the foot compared to the uninjured leg suggests ligamentous laxity
