Sports Medicine: Diagnosis and Treatment of Lower Extremity Injuries

Gerard A. Malanga, MD Director, Sports Medicine Mountainside Hospital Montclair, New Jersey Associate Professor, Physical Medicine & Rehab. UMDNJ- New Jersey Medical School

Basic Principles of Functional Rehabilitation
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Phase I: Decrease Pain and inflammation PRICE ( Protection, Rest, Ice, Compression, Elevation) Phase II: Restore Normal/Symmetric Range of Motion (ROM) Phase III: Restore Normal/Symmetric Strength Phase IV: Neuromuscular Control (Proprioceptive) Re-training Phase V: Sport specific training

Foot and Ankle Injuries
MTP sprain ( “ turf toe” ) s Mid-foot sprain s Plantar fasciitis s Achilles tendinitis s Lateral ankle sprains s Deltoid ligament sprains s Syndesmosis ankle sprain
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Foot and Ankle Injuries
MTP Sprain (“ Turf toe”)
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History: – usually hyperdorsiflexion of the great toe – pain with weight bearing, esp. push off Examination: – tenderness + swelling of the 1st MTP – decreased ROM at the MTP Treatment: – NSAID, ice, tape, long rigid shoe orthotic

Foot and Ankle Injuries
Midfoot sprain
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History: – awkward landing of the forefoot, usually in inversion – sudden pain difficulties walking/running Examination: – swelling, ecchymosis over dorsal medial foot – tenderness to palpation and stress of the forefoot – antalgic gait

Foot and Ankle Injuries
Midfoot sprain
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Treatment:

– x-rays to rule out widening of the 1st and 2nd tarsometatarsal rays – widening of greater than 5 mm : surgery – otherwise: cast immobilization in plantarflexion and supination X 5-6 weeks – mild sprains: crutches WBAT, ice, ROM

Foot and Ankle Injuries
Plantar fasciitis
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History: – insidious onset of heel and plantar foot pain – increased pain on first standing in AM or after a period of sitting Examination: – pain on palpation at the medial calcaneus – increased pain with great toe dorsiflexion and palpation – tight heel cord and plantar fascia

Foot and Ankle Injuries
Plantar fasciitis
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Examination: – pes planus or pes cavus Treatment: – x-rays are not necessary ! – stretching, icing, foot intrinsic strengthening, orthotics for biomechanical foot abnormalities – US/ phonoporesis usually not helpful – night splinting – injection ???

Foot and Ankle Injuries
Achilles tendinitis
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History: – insidious onset of posterior heel/leg pain – increase activity level: running, jumping, etc. Examination: – tenderness to palpation at distal Achilles tendon – occasionally swelling and nodularity of paratenon – antalgic gait

Foot and Ankle Injuries
Achilles tendinitis

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Treatment:
ice, NSAIDs, stretches heel lift ( temporarily ! ) strengthening the gastrocsoleus: concentric and eccentric – gradual increase in loading – – –

Foot and Ankle Injuries
Lateral ankle sprains
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History: – forceful ankle inversion, usually in a plantarflexed position – sudden pain, swelling difficulties walking Examination: – swelling, ecchymosis – pain on palpation: ATFL, CFL, PTFL – laxity testing: talar tilt, anterior draw

Foot and Ankle Injuries
Lateral ankle sprains
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Treatment: – PRICE – maintain heel cord flexibility – ankle everter strengthening – proprioceptive training – ankle bracing for Grades II and III

Foot and Ankle Injuries
Deltoid ligament sprains
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History: – forceful eversion, usually dorsiflexed ankle – difficulties ambulating Examination: – swelling, ecchymosis medially – tender to palpation – pain on passive eversion – pain with resisted external rotation – rule out fibular tenderness !

Foot and Ankle Injuries
Deltoid ligament sprains
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Treatment: – rule out syndesmosis – PRICE – crutches WBAT – airsplint – ROM, strengthening – ankle bracing

Foot and Ankle Injuries
Syndesmosis sprains
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History: – similar to deltoid ligament sprain – patient with more proximal pain Examination: – tender more proximally: Anterior tibiofibular ligament – positive “squeeze test” – rule out any proximal fibular tenderness

Foot and Ankle Injuries
Syndesmosis sprains
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Treatment:
– x-rays to rule out widening of the distal tib/fib – if there is widening then surgical treatment is recommended – otherwise treat as per medial deltoid ligament sprain – expect a long rehab course

Knee Injuries
Patellofemoral Syndrome s MCL/LCL Sprains s ACL/PCL Sprains s Meniscal tears
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Patellofemoral Syndrome
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Knee Injuries

History:
– insidious onset of anterior knee pain – increased pain with knee flexion e.g.... prolong sitting, up/down stairs – no swelling, occasional complaints of “clicking” and give way { must DDx from meniscal tears and ACL injuries )

Patellofemoral Syndrome Examination:

Knee Injuries

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– tenderness to palpation about the patella; usually medially or superior laterally – abnormal patellar tilt – atrophy/ poor activation of VMO – tight ITB, Quads, HS – increased Q angle
» check for pes planus

Patellofemoral Syndrome
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Knee Injuries

Treatment:
– – – – Ice Stretches: ITB, HS, Quads Strengthening: VMO, CKC EMG biofeedback if VMO is not activating – Mc Connell taping; bracing – shoe orthotics for pes planus

Knee Injuries
MCL/LCL Sprains
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History:
– sudden valgus or varus force to the knee – occasional “pop” will be heard – immediate pain difficulties cutting – usually little or no swelling if isolated injury

Knee Injuries
MCL/LCL Sprains
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Examination: – pain on end ROM usually flexion – tenderness to palpation; usually midsubstance – Grade II : laxity with firm end point @ 30 degrees – Grade III: laxity with soft end point @ 30 degrees – rule out laxity at 0 degrees

Knee Injuries
MCL/LCL Sprains
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Treatment: – PRICE – crutches WBAT – rarely: Knee immobilizer – early pain free ROM – return to play: no pain, full pain-free ROM, no pain on palpation, no pain or laxity on stress testing – bracing for remainder of season for Grade III

Knee Injuries
ACL Sprains
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History: – twisting injury after planting and pivoting – hyperextension – valgus force to the knee – sudden pain, “pop”, sense of instability of knee – rapid swelling

Knee Injuries
ACL Sprains
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Examination
– acutely: effusion, decreased ROM – Anterior draw, Lachman – rule out other injuries: MCL , MM, LM
» O’Donahue’s triad: ACL, MCL, MM

Knee Injuries
ACL Sprains
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Treatment:
– – – – PRICE crutches WBAT restore full ROM CKC strengthening; HS biased strengthening – Proprioceptive training – bracing for high demand sports

Knee Injuries
ACL Sprains
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Treatment:

– operative treatment : young, high-demand activity; unwilling to modify activity level; failed nonoperative treatment – post-operative treatment similar to nonoperative treatment – encourage early ROM, CKC strengthening, protect graft from stress

Knee Injuries
PCL Sprains
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History:
– fall on a flexed knee; dashboard injury – usually minimal swelling, mild discomfort

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Examination:
– posterior sag sign – Posterior draw

Knee Injuries
PCL Sprains
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Treatment:
– PRICE as needed – ROM – CKC strengthening; Quadriceps biased – generally no need for bracing

Knee Injuries
Meniscal tears
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History: – acute tears: twisting injury; usually with some flexion – chronic degenerative tears: insidious, at time after a period of prolong knee flexion – swelling; usually more gradual than after ACL injury – clicking, catching, locking; pain with knee flexion

Knee Injuries
Meniscal tears
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Examination:
– – – – – effusion decreased flexion pain on hyperflexion joint line tenderness McMurray’s: very specific but poor sensitivity

Knee Injuries
Meniscal tears
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Treatment: – PRICE; tubigrip compression; NSAID – WBAT – decrease weight bearing activities – LE strengthening; isometrics initially – aspiration if not responding – surgery for locked knees; patients not responding to treatment with mechanical Sx after 3 months

Hip Injuries
Hip flexor strain s Greater trochanteric bursitis s Hamstring strain s Apophysitis/avulsions
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Hip Injuries
Hip flexor strain
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History: – sudden extension of hip – groin pain; increased with hip flexion Examination: – pain on palpation of the psoas tendon – pain with resisted hip flexion and passive extension – mild pain with PROM of the hip

Hip Injuries
Hip flexor strain
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Treatment: – x-rays: r/o hip joint pathology/avulsion – PRICE; crutches if limping – early stretching after a warm up – limited weight bearing activities until the pain decreases

Greater trochanteric bursitis
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Hip Injuries

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History: – usually insidious onset of lateral hip pain – can occurs after direct trauma – increased pain with walking and running Examination: – tenderness to palpation over greater trochanter – look for: hip abductor weakness, tightness of the ITB as biomechanical causes

Greater trochanteric bursitis

Hip Injuries

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Treatment:
– – – – – ICE ! strectch ITB, HS, Quads strengthen hip abductors injection if not responding US only to facilitate ITB stretching

Hip Injuries
Hamstring strain
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History: – sudden posterior thigh pain – usually runner or sprinter during knee extension – eccentric overload Examination: – anatalgic gait – pain, ecchymosis posterior thigh

Hip Injuries
Hamstring strain
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Examination (cont.): – pain on palpation – tightness and pain with passive stretching Treatment: – PRICE – encourage AROM, gentle stretching – crutches as needed – strengthening when no pain, improved ROM

Hip Injuries
Hamstring strain
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Treatment (cont):
– strengthening should include CKC, eccentric, and plyometric training – return to sport when strength is symmetric

Apophysitis/Avulsions
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Hip Injuries

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History: – muscle overload in skeletally immature athlete – present like muscle strains in the adult Examination: – pain on palpation and stretch of the involved muscle Treatment: – functional rehabilitation: vast majority do well

Thank you