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
What are the 4 phases of healing following a lateral ankle sprain/ligamentous injury?
1 - Haemorrhage & Inflammation
2 - Fibroblastic Proliferation
3 - Collagen Protein Formation
4 - Collagen Maturation
Why is excessive NSAID use in the early stages of healing cautioned in patients with lateral ankle sprains?
The anti-inflammatory effect of NSAIDs can inhibit the second phase of healing: fibroblastic proliferation
What findings did Doherty et al report in their 2017 review of the available evidence on treatment and prevention of acute and chronic ankle sprains?
That exercise therapy and taping/bracing are effective in the management of acute/recurrent ankle sprains
However there is a lack of evidence to support the effectiveness of US therapy, acupuncture and manual therapy in the treatment of recurrent ankle sprains However
They also found evidence to suggest that women are more likely to have a lateral ankle sprain than men, and that sports that involve jumping and/or quick changes in direction are more likely to cause ankle sprains. A positive link was also made between the level of sport (i.e amateur, hobby, professional) and the risk of injury.
What are some DDX for lateral ankle sprains?
Foot & Ankle Fracture
Syndesmotic Injury (AKA ‘High ankle sprains’)
Osteochondral Lesion
Talar Bone Contusion
Deltoid Ligament Sprain (Medial ankle sprain)
Peroneal Tendon Strain or Tendinopathy
Achilles Tendon Strain or Tendinopathy
Epiphyseal Plate Injuries
What clinical assessments should you undertake when suspecting lateral ankle sprain?
Selective Tensioning:
Passive Movement - Invert and plantarflex the patient’s foot to see if pain is induced upon stretching of the lateral ankle ligaments. You can also palpate the ligaments while under tension to assess for tenderness
Active Movement - Ask patient to actively invert and plantarflex their foot, this can also illicit pain in inert structures such as the lateral ankle ligaments due to tensile stress.
Resisted Movement - Patient inverts and plantarflexes their foot against clinicians resistance with the joints held in midrange to prevent putting strain on inert structures. This assessment will usually not cause pain in lateral ankle injuries, but can help rule out injury to contractile structures such as peroneal tendon strain/ tendinopathy
Full Joint ROM: Ankle joint and STJ may be restricted and painful on assessment
Functional Tests: Ask patient to perform a lunge, stand on one limb and hop. Compare results between the pathological limb and non-pathological limb, a unilateral reduction in ankle joint function (i.e inability to hop, struggle to stand on one limb or perform a lunge with adequate stability) is indicative of ligamentous damage
Anterior Drawer Test: To assess the level of ligamentous instability present
Proprioception Assessment: Ask patient to stand single limb with eyes closed and assess for their ability to stay upright. Ankle sprains are associated with a reduction in proprioceptive ability
Ottawa Rules Test: To rule out fracture, referral for x-ray indicated in the presence of palpable tenderness 6cm above the medial or lateral malleoli, or around the base of the 5th metatarsal bone or navicular bone combined with an inability to weight bear.
External Rotation Stress Test and/or Calf Squeeze Test: Passively dorsiflex and externally rotate the patients ankle and/or squeeze the mid calf with both hands clasped together. If either induce pain this is more indicative of a Syndesmotic injury rather than a lateral ankle sprain
What differentials should you consider when a patient presents with anterior knee pain?
Patellar Tendinopathy
Patella-Femoral Pain Syndrome
Chondromalacia Patellae
Hoffa’s Fat Pad Syndrome
Iliotibial Band Friction Syndrome
Sinding-Larsen-Johansson Syndrome (exclusive to children and adolescents)
Knee OA
Osteochondral Lesions of the Knee
Medial Meniscus Tears
Medial Overload Syndrome
Popliteal Cyst (Baker’s Cyst)
ACL Tear
What is patellar tendinopathy?
A pathology of the patellar tendon caused by overuse or a sudden stress on the tendon (such as a heavy or awkward landing on the affected leg), this causes inflammation or tears in the tendon tissue.
It is commonly referred to as ‘Jumper’s Knee’ as its mechanism commonly involves repetitive overload related to jumping (or pivoting and quick changes in direction) e.g in sports such as… basketball, volleyball, athletic jump events, tennis, and football
There is also an association with tight quadriceps and/or hamstrings
What are the signs and symptoms of patellar tendinopathy?
Pain and tenderness localised to the inferior pole of the patella
Load related & dose dependant pain - Pain only on loading and the level of pain increases as load increases
Pain can reduce as the tendon ‘warms up’ but is increased the day after
Knee stiffness especially in the mornings
Some cases experience mild swelling at the site of the tendon
Positive Royal London Hospital Test for Patellar Tendinopathy - Palpate along the patellar tendon from the proximal to distal aspects with the knee in extension, once the tender spot is located the clinician passively flexes the patient’s knee, if the area is no longer tender this is indicative of patellar tendinopathy.
Assess the presence of dose related pain by asking the patient to perform exercises that load the patellar tendon e.g squatting and hopping. The deeper the squat and the higher the hop the sorer it will be for the patient, which is indicative of patellar tendinopathy.
What are the main causes of injury recurrence following a lateral ankle sprain?
Ligamentous weakness/ scar tissue
Ligaments have healed in a lengthened position
Peroneal muscle weakness
Distal tibiofibular instability
Inherent hypermobility
Loss of proprioception/ failure to adequately restore neuromuscular function
What is Patella-Femoral Pain Syndrome?
A condition characterised by diffuse pain at the anterior knee, with tenderness around the edges of the patella, that occurs due to abnormal contact and movement patterns of the patella onto the femur.
Also known as ‘Runner’s Knee’
One of the main causes involves patellar malalignment. The patella rests in a groove at the top of the femur known as the trochlear groove, when you flex or extend your knee, the patella moves back and forth inside the groove.
The patella may be pushed out to one side of the groove when the knee is flexed
Where there are alignment abnormalities such as:
Knee hypertension
Genu Valgum or Varus
Increased Q angle/ femoral anteversion
External tibial torsion
Increased STJ pronation
And/or muscular imbalances such as:
Quadricep weakness or tightness
Iliotibial band tightness
Gastrocnemius or Hamstring tightness
As tension from the quads pull the patella against the femur, if there is also malalignment present the patella is pulled laterally, and as such less of it is in contact with the femur. This causes a high amount of load to be exerted on a smaller surface area, which causes pain in the bone and soft tissues of the knee joint.
What are the signs and symptoms of PFP
Pain on knee flexion i.e in sitting, climbing stairs, jumping and/or squatting
Pain on activity with lower quadricep loads such as walking, running
Tenderness at the edges of the patella on palpation
Visual joint malalignment
Quadricep weakness or tightness
Positive Clarks sign/ Patellar grind test - Asking the patient while lying supine to further extend their knee with your hand placed at the anterior proximal aspect of the patella. Pain and/or an inability to contact their quads to further extend the leg is indicative of PFP (and also Chondromalacia patellae)
What are ‘Shin Splints’?
Shin splints is a term used to describe exercise induced lower leg pain, it accounts for 60% of all overuse injuries within the leg and has an incidence of 13.6 - 53% in runners/ As such, the term encompasses a range of pathology, including:
Tibial or fibular stress fractures
Periostitis (AKA Medial tibial stress syndrome)
Exertional compartment syndrome
Achilles, peroneal or tibialis posterior tendinopathy
Sural or superficial peroneal nerve entrapment
Popliteal artery entrapment
Intermittent claudication
Referred pain from spinal pathologies
