le sports injuries

8/14/2019 LE Sports injuries

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:Treatment of Lower ExtremityTreatment of Lower Extremity

InjuriesInjuries

Gerard A. Malanga, MDGerard A. Malanga, MD

Director, Sports Medicine Mountainside HospitalDirector, Sports Medicine Mountainside HospitalMontclair, New JerseyMontclair, New Jersey

Associate Professor, Physical Medicine & Rehab.Associate Professor, Physical Medicine & Rehab.

UMDNJ- New Jersey Medical SchoolUMDNJ- New Jersey Medical School


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Basic Principles of FunctionalBasic Principles of Functional

RehabilitationRehabilitation

s Phase I: Decrease Pain and inflammation

PRICE ( Protection, Rest, Ice, Compression,Elevation)

s Phase II: Restore Normal/Symmetric Range ofMotion (ROM)

s Phase III: Restore Normal/Symmetric Strength

s Phase IV: Neuromuscular Control

(Proprioceptive) Re-trainings Phase V: Sport specific training


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Foot and Ankle InjuriesFoot and Ankle Injuries

s MTP sprain ( turf toe )MTP sprain ( turf toe )

s Mid-foot sprainMid-foot sprain

s

Plantar fasciitisPlantar fasciitiss Achilles tendinitisAchilles tendinitis

s Lateral ankle sprainsLateral ankle sprains

s

Deltoid ligament sprainsDeltoid ligament sprainss Syndesmosis ankle sprainSyndesmosis ankle sprain


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Foot and Ankle InjuriesFoot and Ankle InjuriesMTP Sprain (MTP Sprain ( Turf toe) Turf toe)

s History:History:

usually hyperdorsiflexion of the greatusually hyperdorsiflexion of the great

toetoe

pain with weight bearing, esp. push offpain with weight bearing, esp. push off

s Examination:Examination:

tendernesstenderness ++ swelling of the 1st MTPswelling of the 1st MTP

decreased ROM at the MTPdecreased ROM at the MTP

s Treatment:Treatment:

NSAID, ice, tape, long rigid shoeNSAID, ice, tape, long rigid shoe

orthoticorthotic


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Foot and Ankle InjuriesFoot and Ankle InjuriesMidfoot sprainMidfoot sprain

s Treatment:Treatment: x-rays to rule outx-rays to rule out

widening of the 1st andwidening of the 1st and2nd tarsometatarsal rays2nd tarsometatarsal rays

widening of greater thanwidening of greater than5 mm : surgery5 mm : surgery otherwise: castotherwise: cast

immobilization inimmobilization inplantarflexion andplantarflexion andsupination X 5-6 weekssupination X 5-6 weeks

mild sprains: crutchesmild sprains: crutchesWBAT, ice, ROMWBAT, ice, ROM


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Foot and Ankle InjuriesFoot and Ankle InjuriesPlantar fasciitisPlantar fasciitis

s History:History:

insidious onset of heel and plantarinsidious onset of heel and plantar

foot painfoot pain

increased pain on first standing inincreased pain on first standing in

AM or after a period of sittingAM or after a period of sittings Examination:Examination:

pain on palpation at the medialpain on palpation at the medial

calcaneuscalcaneus

increased pain with great toeincreased pain with great toe

dorsiflexion and palpationdorsiflexion and palpation

tight heel cord and plantar fasciatight heel cord and plantar fascia


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Foot and Ankle InjuriesFoot and Ankle InjuriesPlantar fasciitisPlantar fasciitis


pes planus or pes cavuspes planus or pes cavus


x-rays are not necessary !x-rays are not necessary !

stretching, icing, foot intrinsicstretching, icing, foot intrinsic

strengthening, orthotics forstrengthening, orthotics for

biomechanical foot abnormalitiesbiomechanical foot abnormalities

US/ phonoporesis usually not helpfulUS/ phonoporesis usually not helpful

night splintingnight splinting injection ???injection ???


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Foot and Ankle InjuriesFoot and Ankle InjuriesAchilles tendinitisAchilles tendinitis

s History:History:

insidious onset of posteriorinsidious onset of posterior

heel/leg painheel/leg pain

increase activity level:increase activity level:

running, jumping, etc.running, jumping, etc.s Examination:Examination:

tenderness to palpation attenderness to palpation at

distal Achilles tendondistal Achilles tendon

occasionally swelling andoccasionally swelling and

nodularity of paratenonnodularity of paratenon

antalgic gaitantalgic gait


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Foot and Ankle InjuriesFoot and Ankle InjuriesAchilles tendinitisAchilles tendinitis

sTreatment:Treatment:

ice, NSAIDs, stretchesice, NSAIDs, stretches

heel lift ( temporarily ! )heel lift ( temporarily ! )

strengthening thestrengthening the

gastrocsoleus: concentricgastrocsoleus: concentric

and eccentricand eccentric

gradual increase ingradual increase in

loadingloading


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Foot and Ankle InjuriesFoot and Ankle InjuriesLateral ankle sprainsLateral ankle sprains

s History:History:

forceful ankle inversion, usually in aforceful ankle inversion, usually in a

plantarflexed positionplantarflexed position

sudden pain, swelling difficultiessudden pain, swelling difficulties

walkingwalkings Examination:Examination:

swelling, ecchymosisswelling, ecchymosis

pain on palpation: ATFL, CFL, PTFLpain on palpation: ATFL, CFL, PTFL

laxity testing: talar tilt, anteriorlaxity testing: talar tilt, anterior

drawdraw


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Foot and Ankle InjuriesFoot and Ankle InjuriesLateral ankle sprainsLateral ankle sprains


PRICEPRICE

maintain heel cordmaintain heel cord

flexibilityflexibility

ankle everterankle everter

strengtheningstrengthening

proprioceptiveproprioceptive

trainingtraining

ankle bracing forankle bracing forGrades II and IIIGrades II and III


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Foot and Ankle InjuriesFoot and Ankle InjuriesDeltoid ligament sprainsDeltoid ligament sprains

s History:History:

forceful eversion, usuallyforceful eversion, usually

dorsiflexed ankledorsiflexed ankle

difficulties ambulatingdifficulties ambulating

s

Examination:Examination: swelling, ecchymosis mediallyswelling, ecchymosis medially

tender to palpationtender to palpation

pain on passive eversionpain on passive eversion

pain with resisted externalpain with resisted external

rotationrotation rule out fibular tenderness !rule out fibular tenderness !


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Foot and Ankle InjuriesFoot and Ankle InjuriesDeltoid ligament sprainsDeltoid ligament sprains


rule outrule out

syndesmosissyndesmosis

PRICEPRICE

crutches WBATcrutches WBAT

airsplintairsplint

ROM,ROM,


ankle bracingankle bracing


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Foot and Ankle InjuriesFoot and Ankle InjuriesSyndesmosis sprainsSyndesmosis sprains

s History:History:

similar to deltoid ligament sprainsimilar to deltoid ligament sprain

patient with more proximal painpatient with more proximal pain


tender more proximally: Anteriortender more proximally: Anteriortibiofibular ligamenttibiofibular ligament

positive squeeze testpositive squeeze test

rule out any proximal fibularrule out any proximal fibular

tendernesstenderness


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Foot and Ankle InjuriesFoot and Ankle InjuriesSyndesmosis sprainsSyndesmosis sprains


x-rays to rule out widening ofx-rays to rule out widening of

the distal tib/fibthe distal tib/fib

if there is widening thenif there is widening then

surgical treatment issurgical treatment isrecommendedrecommended

otherwise treat as per medialotherwise treat as per medial

deltoid ligament spraindeltoid ligament sprain

expect a long rehab courseexpect a long rehab course


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Knee InjuriesKnee Injuries

s Patellofemoral SyndromePatellofemoral Syndrome

s MCL/LCL SprainsMCL/LCL Sprains

s ACL/PCL SprainsACL/PCL Sprainss Meniscal tearsMeniscal tears


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Knee InjuriesKnee InjuriesPatellofemoral SyndromePatellofemoral Syndrome

s History:History: insidious onset of anteriorinsidious onset of anterior

knee painknee pain

increased pain with kneeincreased pain with knee

flexion e.g.... prolongflexion e.g.... prolongsitting, up/down stairssitting, up/down stairs

no swelling, occasionalno swelling, occasionalcomplaints of clickingcomplaints of clickingand give way { must DDxand give way { must DDx

from meniscal tears andfrom meniscal tears andACL injuries )ACL injuries )

j i


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s Examination:Examination: tenderness to palpationtenderness to palpation

about the patella;about the patella;usually medially orusually medially or

superior laterallysuperior laterally abnormal patellar tiltabnormal patellar tilt atrophy/ poor activationatrophy/ poor activation

of VMOof VMO tight ITB, Quads, HStight ITB, Quads, HS

increased Q angleincreased Q angle check for pes planuscheck for pes planus

K I j i


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IceIce

Stretches: ITB, HS, QuadsStretches: ITB, HS, Quads

Strengthening: VMO, CKCStrengthening: VMO, CKC EMG biofeedback if VMOEMG biofeedback if VMO

is not activatingis not activating

Mc Connell taping; bracingMc Connell taping; bracing

shoe orthotics for pesshoe orthotics for pes

planusplanus

j iK I j i


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Knee InjuriesKnee InjuriesMCL/LCL SprainsMCL/LCL Sprains

s History:History: sudden valgus orsudden valgus or

varus force to thevarus force to thekneeknee

occasional popoccasional popwill be heardwill be heard

immediate painimmediate paindifficultiesdifficultiescuttingcutting

usually little orusually little orno swelling ifno swelling ifisolated injuryisolated injury

K I j iK I j i


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pain on end ROM usuallypain on end ROM usually

flexionflexion

tenderness to palpation;tenderness to palpation;

usually midsubstanceusually midsubstance

Grade II : laxity with firmGrade II : laxity with firm

end point @ 30 degreesend point @ 30 degrees

Grade III: laxity with soft endGrade III: laxity with soft end

point @ 30 degreespoint @ 30 degrees

rule out laxity at 0 degreesrule out laxity at 0 degrees

K I j iK I j i


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s Treatment:Treatment: PRICEPRICE


rarely: Knee immobilizerrarely: Knee immobilizer

early pain free ROMearly pain free ROM return to play: no pain, fullreturn to play: no pain, full

pain-free ROM, no pain onpain-free ROM, no pain on

palpation, no pain or laxitypalpation, no pain or laxity

on stress testingon stress testing

bracing for remainder ofbracing for remainder of

season for Grade IIIseason for Grade III


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K I j iK I j i


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Knee InjuriesKnee InjuriesACL SprainsACL Sprains

s ExaminationExamination

acutely: effusion,acutely: effusion,

decreased ROMdecreased ROM

Anterior draw, LachmanAnterior draw, Lachman rule out other injuries:rule out other injuries:

MCL , MM, LMMCL , MM, LM

ODonahues triad: ACL,ODonahues triad: ACL,

MCL, MMMCL, MM

K I j iKnee Injuries


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sTreatment:Treatment: PRICEPRICE


restore full ROMrestore full ROM CKC strengthening; HSCKC strengthening; HS

biased strengtheningbiased strengthening

Proprioceptive trainingProprioceptive training

bracing for high demandbracing for high demandsportssports



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s Treatment:Treatment: operative treatment :operative treatment :

young, high-demandyoung, high-demandactivity; unwilling toactivity; unwilling tomodify activity level; failedmodify activity level; failed

nonoperative treatmentnonoperative treatment post-operative treatmentpost-operative treatment

similar to nonoperativesimilar to nonoperativetreatmenttreatment

encourage early ROM, CKCencourage early ROM, CKCstrengthening, protectstrengthening, protect

graft from stressgraft from stress



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Knee InjuriesKnee InjuriesPCL SprainsPCL Sprains

s History:History: fall on a flexed knee;fall on a flexed knee;

dashboard injurydashboard injury

usually minimalusually minimalswelling, mildswelling, milddiscomfortdiscomfort


posterior sag signposterior sag sign Posterior drawPosterior draw



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Knee InjuriesKnee InjuriesPCL SprainsPCL Sprains


PRICE as neededPRICE as needed

ROMROM

CKC strengthening;CKC strengthening;Quadriceps biasedQuadriceps biased

generally no needgenerally no need

for bracingfor bracing



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Knee InjuriesKnee InjuriesMeniscal tearsMeniscal tears

s History:History:

acute tears: twisting injury; usuallyacute tears: twisting injury; usually

with some flexionwith some flexion

chronic degenerative tears:chronic degenerative tears:

insidious, at time after a period ofinsidious, at time after a period of

prolong knee flexionprolong knee flexion swelling; usually more gradual thanswelling; usually more gradual than

after ACL injuryafter ACL injury

clicking, catching, locking; painclicking, catching, locking; pain

with knee flexionwith knee flexion



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effusioneffusion

decreased flexiondecreased flexion

pain on hyperflexionpain on hyperflexionjoint line tendernessjoint line tenderness

McMurrays: veryMcMurrays: very

specific but poorspecific but poor

sensitivitysensitivity



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PRICE; tubigrip compression; NSAIDPRICE; tubigrip compression; NSAID

WBATWBAT

decrease weight bearing activitiesdecrease weight bearing activities

LE strengthening; isometrics initiallyLE strengthening; isometrics initially

aspiration if not respondingaspiration if not responding

surgery for locked knees; patients notsurgery for locked knees; patients not

responding to treatment with mechanicalresponding to treatment with mechanical

Sx after 3 monthsSx after 3 months


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Hip InjuriesHip Injuries

s Hip flexor strainHip flexor strain

s Greater trochanteric bursitisGreater trochanteric bursitis

s Hamstring strainHamstring strains Apophysitis/avulsionsApophysitis/avulsions


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Hip InjuriesHip InjuriesHip flexor strainHip flexor strain


x-rays: r/o hip jointx-rays: r/o hip joint

pathology/avulsionpathology/avulsion

PRICE; crutches ifPRICE; crutches if

limpinglimping early stretching after aearly stretching after a

warm upwarm up

limited weight bearinglimited weight bearing

activities until the painactivities until the pain

decreasesdecreases



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Hip InjuriesHip InjuriesGreater trochanteric bursitisGreater trochanteric bursitis

s History:History:

usually insidious onset of lateralusually insidious onset of lateral

hip painhip pain

can occurs after direct traumacan occurs after direct trauma

increased pain with walking andincreased pain with walking andrunningrunning


tenderness to palpation overtenderness to palpation over

greater trochantergreater trochanter

look for: hip abductor weakness,look for: hip abductor weakness,

tightness of the ITB astightness of the ITB as

biomechanical causesbiomechanical causes



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Hip InjuriesHip InjuriesGreater trochanteric bursitisGreater trochanteric bursitis


ICE !ICE !

strectch ITB, HS, Quadsstrectch ITB, HS, Quads

strengthen hip abductorsstrengthen hip abductors injection if not respondinginjection if not responding

US only to facilitate ITBUS only to facilitate ITB

stretchingstretching



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Hip InjuriesHip InjuriesHamstring strainHamstring strain

s History:History:

sudden posterior thigh painsudden posterior thigh pain

usually runner or sprinter duringusually runner or sprinter during

knee extensionknee extension

eccentric overloadeccentric overload


anatalgic gaitanatalgic gait

pain, ecchymosis posterior thighpain, ecchymosis posterior thigh



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s Examination (cont.):Examination (cont.):

pain on palpationpain on palpation

tightness and pain withtightness and pain with

passive stretchingpassive stretching

s

Treatment:Treatment: PRICEPRICE

encourage AROM, gentleencourage AROM, gentle

stretchingstretching

crutches as neededcrutches as needed

strengthening when no pain,strengthening when no pain,improved ROMimproved ROM



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sTreatment (cont):Treatment (cont):


should includeshould include

CKC, eccentric,CKC, eccentric,

and plyometricand plyometrictrainingtraining

return to sportreturn to sport

when strength iswhen strength is

symmetricsymmetric



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Hip InjuriesHip InjuriesApophysitis/AvulsionsApophysitis/Avulsions

s History:History:

muscle overload in skeletallymuscle overload in skeletally

immature athleteimmature athlete

present like muscle strains in thepresent like muscle strains in the

adultadult


pain on palpation and stretch ofpain on palpation and stretch of

the involved musclethe involved muscle


functional rehabilitation: vastfunctional rehabilitation: vastmajority do wellmajority do well


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Thank youThank you

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