13/05/14. Lower Limb Injuries Below the Knee

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1 Lower Limb Injuries Below the Knee Dr Peter Friis Brisbane Orthopaedic & Sports Medicine Centre At least 1 previous injury or reduced lower limb funcjon score had a significant increased risk of sustaining a new injury of the same kind during the 8 month follow- up period. 1 in every 5 players sustain an injury every season, with hamstrings, ankle and knee by far the most common injuries Am J Sports Medicine 2008 Risk Factors for Lower Limb Injury in Youth Soccer At non elite level, there is a reported 18% increase risk for new injury Stats are not replicated at elite level and probably reflect less medical care available for youth teams Return to play often made by the coach/ player and or parents 1

2 Acute swollen ankle.. What to do next.. Based on Ottawa Ankle Scores Check around the knee following injuries to the Medial side of the ankle. 2

3 Acute Swollen Ankle History of trauma, N of force = potenjal OYawa Ankle Score = Xray Unable to bear weight = Xray Medial Tenderness =? Maisonneuve Fracture Ankle Joint Ligament Injuries Anterior talofibular lig., ATFL primary static restraint to plantarflexion and inversion Calcaneofibular lig. CFL. Floor of the peroneal sheath, main lateral ankle stabilizer.. 3

4 Anterior Draw Test Assessment Tips.. Ankle Sprain? Unable to bear weight, apply OYawa Rule If symptoms fail to show improvement a^er seven days, consider referral, MRI and or CT Consider forced plantar flexion injury and Os Trigonium, fractured Os, SJeda lesion Consider lateral process of the talus. Consider the anterior process of the calcaneus Consider the proximal 5 th metatarsal. Talar Dome Injuries Inversion with dorsiflexion Inversion with plantar flexion or atraumajc 4

5 Talus - Fracture of the trigonal process (lateral tubercle) Shepherd s Fracture Tenderness to deep palpajon anterior to the Achilles tendon over posterolateral talus. Plantar flexion may reproduce pain. Talus - Fracture of the trigonal process (lateral tubercle) Point tenderness over the lateral process (anterior and inferior to the lateral malleolus) Lateral Process Fracture often referred to as snowboarders ankle. Difficult to see on Xray Fracture Anterior Calcaneal Process Inversion with plantar flexion can lead to an avulsion fracture. Forced dorsiflexion compression fracture. Point tenderness over the calcanealcuboid joint (approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus) 5

6 Fracture of the fi^h metatarsal - Jones Fracture Avulsion Fracture 30% of cubo-metatarsal articulation with displacement? = surgical opinion Growth Plate Injury Medial Ankle ConsideraJons Anterior deltoid under max tension when plantar flexed Mid porjon of the deltoid tension when hyperpronated External rotajon = deep deltoid lig AbducJon/eversion = superficial deltoid lig Deltoid ligament injuries usually occur in combinajon Recalcitrant medial ankle pain??= OCD 6

7 Early Management Associated injuries and residual pain Post strain The AITFL which is intra- arjcular, can have an accessory slip which inserts at the extreme base of the fibula. BasseY s ligament can result in Talar irritajon. Associated injuries and residual pain Post strain Dislocation or Subluxation Fibula Peroneus Longus Peroneus Brevis 7

8 Associated injuries and residual pain Post strain SyndesmoJc Injury the Doc says it s a High Ankle Sprain. Distal Tibiofibular Syndesmosis A fibrous joint formed by two bones and four ligaments.. 8

9 Widening of the ankle mortise by 1mm DECREASES the contact area of the tibiotalar by 42% which could lead to instability and hence early osteoarthritis. Clinical Relevance The AITFL is the weakest of the 4 syndesmotic ligaments and first to yield to external rotation forces Bassett s Ligament can become inflamed and can be resected without compromising stability. SyndesmoJc Ligaments..Post. Lowest part= transverse ligament Injury can result in avulsion of the posterior malleolus with an intact PITFL 9

10 History of Injury.. Most Common Mechanism Ankle dorsiflexion, external rotation and pronation of the foot Physical ExaminaJon External Rotation Test Involves placing the knee at 90 with the ankle at neutral and applying an external rotation force 10

11 Physical ExaminaJon Squeeze Test Involves compressing the proximal tibia and fibula A positive test occurs at the level of the ankle joint. Pain more proximal should alert suspicion of proximal fracture of the fibula. Physical ExaminaJon Cross Over Test As illustrated with pressure applied to externally rotate the ankle. Clinical Case TIPS o Had to be assisted from the field, could not walk unaided to the change room. o Early swelling suggestive of high ankle sprain, positive cross over test, squeeze +. o Player complains of Achilles pain. o Xrays standard views reported normal. 11

12 Management..iniJal Clinical Case Dynamic Ultrasound Assessment Management Surgical 12

13 My ankle keeps giving way!!!! Have you had an Xray Examine and compare sides AP draw normal= think other pathologies Ankle locks = OCD, loose body Ankle snaps = peroneal dislocajon Ankle swells= synovijs due to? Check balance, Check hip/pelvic stability Think outside the square!!!! Lower Leg Pain Acute Compartment Syndrome Lower Leg Pain Exertional Compartment Syndrome Posterior Compartment Syndrome? 13

14 Lower Leg Pain Tibialis Anterior Syndrome Stress Fractures, not all the same! Medial Tibial Stress Syndrome Lower Leg Pain Beware the Anterior Cortical Stress Fracture. The dreaded black line Lower Leg - Posterior Pain Gastrocnemius muscle strain Soleus muscle strain Lateral compartment syndrome Fibula fracture and stress fracture 14

15 Lower Leg q Direct trauma to the lateral calf. q Initial Xrays normal. q Torsional stress aggravates periosteal damage. q Serial radiology may be necessary. q Early rest, for long term gain. Achilles Tendon Rupture Complete Rupture Anatomical considerations Natural history (degenerative change) Symptoms of rupture Signs of rupture (Thompsen s Test - see next slide) Partial Rupture Conservative management Operative management Achilles Tendon Rupture 15

16 Achilles Tendon Rupture Achilles Tendinopathy Acute Tendonitis : History Symptoms and Signs Anti-inflammatory measures Preventative measures Further Investigations Chronic Achilles Tendinosis Thickening Achilles Bursitis Superficial Bursitis Retrocalcaneal Bursitis Role of Xrays and Ultrasound Haglund s Syndrome Management Options 16

17 Sever s Disease. Active individuals (age from 8 to 15 years) Symptoms of heel pain Role of Xrays Treatment options Midfoot Pain Navicular stress fractures can present with vague midfoot, medial arch pain. Midfoot Pain Accessory Navicular 17

18 Midfoot Pain.. Tarso- metatarsal Midfoot Pain.. Tarso- metatarsal ü Swelling not a good indicator of severity. ü Palpation tenderness at the tarso-metatarsal junction on the 1 st and 2 nd metatarsal. ü Tenderness and inability to do single heel raise. ü Xrays need to be weight bearing AP with comparison of opposite foot. ü Strain without subluxation= Lis Franc arthritis. Heel Pain Initial Xray NAD Extensive bone oedema T2 MRI Xray evidence late 18

19 Heel Pain Start-up pain.. If not significant think alternative diagnosis. Bilateral heel pain and associated other joints, consider referral for blood tests HLA B27 and trial of NSAIDs. Consider running history and hallmarks for stress fracture then check with the squeeze test. Entrapment of FBLPN difficult to call on NCS Neural L/S spine? Degenerative plantar fasciosis usually occurs in degenerative bodies True fasciitis may occur from training errors. This should become your return to sport barometer. 19

20 19/05/14 Overuse Knee Injuries Dr. Peter Friis Anterior Knee Pain Consider! Patella Patellar Tendon Other Structures Commonest complaint Pain on hills stairs Behind knee cap Crepitus Tests Grind 1

21 19/05/14 Crepitus Hip Femoral anteversion, weak gluts, tight ITB/Hamstrings Knee Q angle, J track, valgus, tight or hypermobile patella, VMO Below knee Pronation, tight calves 2

22 19/05/14 Are the knee caps squinting? Increased Internal Rotation Patellofemoral Malalignment Syndrome Unstable Patellofemoral Joint Hypermobility Syndrome 3

23 19/05/14 Hypermobility Syndrome XR +/- MRI Relative rest Will take time Not likely to need surgery Patellar Tendinopathy Jumper s Knee basketball, high jump, ballet, climbing stairs Painful overuse injury Successful management remains major clinical challenge 4

24 19/05/14 Patellar Tendinopathy Clinical Features tendinosis anterior knee pain aggravated by jumping, changing directions pain at inferior pole of patella (tender on palpation) thickening of tendon (rarely effusion) Crepitus (sign of PFJ pain not tendinopathy) Grade Blazina Score for Patellar Tendon pathology Relationship of symptoms to activity Guidelines for activity I Pain after activity only Receive treatment Continue activity Ice after activity II Pain before and after exercise Pain gradually lessens during exercise Receive treatment Modify activity III Pain with activity causing restriction Receive treatment Rest from of activity aggravating activity IV Pain during everyday activities (pain worsening or progressing) Rest for significant period Long rehabilitation program (minimum 3 months) Surgery may be required if no improvement with rehabilitation 5

25 19/05/14 Patellar Tendinopathy First presentation: 3-6 month recovery Longstanding history: month recovery Generalized quadriceps wasting Patellar Tendinopathy Clinical Features Weakness of lower limb musculature Shortening of quads Squatting / hopping reproduces pain Patellar Tendinopathy Investigations Ultrasound Examination with Doppler (vascularity) MRI 6

26 19/05/14 Patellar Tendinopathy Treatment Multifaceted approach Relative load reduction Reduce amount of jumping Muscle strengthening / correct biomechanics Forefoot landing generate lower forces Increased hip / knee flexion reduces loading Underwater Treadmill Alter G Treadmill 7

27 19/05/14 Patellar Tendinopathy Treatment Biomechanical correction Limited ankle dorsiflexion Hamstring inflexibility decreased sit and reach associated with patellar tendinopathy Gluteal weakness Brufen, doxycycline, green tea Nitrate patches Polidocanol Autologous blood injections Prolotherapy Shock wave therapy Must have consistent rehab Patellar Tendinopathy Treatment Soft tissue therapy limited success Surgery not a quick fix after failed conservative management 8

28 19/05/ yr, inc girls, 25-30% bilateral Running/jumping Pain and tender tib tubercle Mechanics as previous All about activity modification Common-sense Cut out unnecessary activity Physio trial strap Endurance runners Knee flexion angles Lateral pain +ve Obers, ITBFS test +ve Anti inflamm Stretch, mechanics return Ober s Test for ITB and Hip Extension Pathology 9

29 19/05/14 Was there a training error? 10