Knee, Lower Leg, Ankle and Foot Injuries (Fundamentals of Physiotherapy Practice) PDF

Knee, Lower Leg, Ankle and Foot Injuries PTY-10086 Fundamentals of Physiotherapy Practice  Describe the mechanism Aims of and signs and symptoms of common lower limb (LL) injuries the Diagnose basic musculoskeletal session...

Knee, Lower Leg, Ankle and Foot Injuries PTY-10086 Fundamentals of Physiotherapy Practice  Describe the mechanism Aims of and signs and symptoms of common lower limb (LL) injuries the Diagnose basic musculoskeletal session injuries of the lower limb Discussion - Bone what Cartilage structures Muscle could be Tendon injured/source Ligament of pain in lower limb Bursa injuries in Joint MSK? Nerve Conditions / Injuries covered today Knee OA Tendon injuries of LL Muscle strains of LL Patellofemoral pain syndrome Iliotibial band syndrome Knee and ankle ligament injuries Patella instability Meniscal injury Bursitis Medial Tibial Stress Syndrome Plantar fasciitis Osgood Schlatters and Sinding-Larsen-Johansson Diseases  Osteoarthritis (OA) Osteoarthritis - joint pain accompanied by functional limitation and reduced quality of life. Primary OA – absence of a predisposing trauma or disease but is associated with the risk factors below. Secondary OA – due to previous joint abnormality, e.g., previous trauma, rheumatoid arthritis, Inflammatory arthritis, infectious arthritis Commonly seen at the hip and knee (most common) in LL, and IP joints and 1st MCP joint in the UL OA is a clinical diagnosis and can be diagnosed with confidence if the Risk factors for developing OA include age, female gender, obesity, anatomical following are present: factors, muscle weakness, and joint injury 1) Pain worse with activity and better with rest 2) Age > 45 years 3) Morning stiffness lasting less than 30 minutes 4) Bony joint enlargement 5) Limitation in range of motion Osteoarthritis | NICE impact arthritis | Reviewing the impact of our guidance | Measuring the use of NICE guidance | Into practice | What we do | About | NICE OA - Pathophysiology OA is characterised by: Degradation and loss of articular cartilage Hypertrophic bones changes and osteophyte formation Subchondral bone remodelling Chronic inflammation of synovium membrane  Knee OA Approx. 13% women, 10% of men >60 years have symptomatic knee OA Prevalence - females > males Radiographs – ~15% of patients with radiographic findings of knee OA are symptomatic Symptoms Gradual onset of symptoms Pain and stiffness in the knee joint NICE Guidelines Stiffness worse in the morning or after prolonged Adults aged 45 or over should be static positions – improves within 30 minutes diagnosed with osteoarthritis clinically Worse with prolonged activity, esp. bending, without investigations if they have stairs, and worse with inactivity activity-related joint pain and either no Better with rest morning joint-related stiffness or Knee stiffness, swelling, decreasing ambulatory morning stiffness that lasts no longer capacity Can report clicking, giving way and crepitus than 30 minutes. Knee OA Signs Observation – knee swelling, deformity Reduced knee ROM both actively and passively in most directions Restricted patella movement Gait – antalgic gait, asymmetrical..  Acute Injury – partial or full tear Overuse – tendinopathies Hamstrings – distal and proximal (taught with hip and thigh) Tendon Rectus Femoris – distal and proximal (taught with hip and thigh) Injuries Patella Tendon (AKA Patellar Ligament) Achilles Tendon Tibialis Posterior Flexor Hallucis Longus Peroneals LL Tendon Injuries - Clinical Presentation Subjective Hamstring Rectus Femoris History / Causes Gradual onset or acute Gradual onset or acute injury – running, sprinting, injury – running, sprinting, soccer, rugby weights Symptoms Distal hamstring Distal – sup. patella Posteromedial – semimembranosus, semitendinosus Posterolateral – biceps femoris Associated Tightness/stiffness in distal Tightness/stiffness in rectus Symptoms hamstring femoris Aggravating Knee flexion activities - Jumping, squatting, hill running, sprinting, kicking, walking, running, stepping stairs, sitting LL Tendon Injuries - Clinical Findings Objective Hamstring Rectus Femoris Observation Gait or functional Gait or functional movement movement abnormalities abnormalities Active Knee flexion Knee extension Passive - - Resisted Knee flexion Knee extension Special Hamstring length tests Modified Thomas Palpation Hamstring tendons – distal Rectus femoris - distal LL Tendon Injuries - Clinical Presentation Subjective Patella Achilles History / Overuse or acute injury - Overuse or acute injury – insertional, Causes associated with jumping and mid portion or proximal tendon injury change of direction – runners, sprinting, jumping sports, activities/sports (e.g. degenerative/age related basketball, volleyball, netball, soccer, ballet), weightlifting Risk Factors High load activities, e.g. Foot or LL abnormalities e.g. jumping, running, squatting excessive pronation or supination, training ‘errors’, poor footwear or change of footwear, tight and/or weak calves, type 2 diabetes, menopause Symptoms Anterior knee pain Local pain at insertion or mid portion Pain on activity of achilles Pain on activity Morning stiffness Aggravating Running, stairs, jumping, Walking, running, stairs, jumping squatting LL Tendon Injuries - Clinical Findings Objective Patella Achilles Observatio Poor Thickened or nodules on n biomechanics – tendon running, Poor LL biomechanics squatting… Active Knee extension Plantarflexion Passive - Dorsiflexion Resisted Knee extension Plantarflexion Special / Squatting Thompson test – Achilles Functional Single leg squats rupture Quads length Calf raises Calf length Palpation Tender over Tender over insertion, mid- patella tendon - portion or proximal tendon usual site is Achilles Tendon Rupture Usual site 3-6cm proximal to calcaneus - zone of circulation (poor circulation local degeneration) Common in sportspeople Mechanism – push off movement Reports being “kicked in the back of the leg” Risk factors o Age and gender - >35 years (males > females) o Sports o Steroid injection o Fluoroquinolone antibiotics, such as ciprofloxacin (Cipro) or levofloxacin (Levaquin) Achilles Tendon Rupture Signs Visible, palpable gap in tendon Marked swelling, bruising Excessive passive dorsiflexion Weakness on plantarflexion Thompsons or Squeeze test positive Lower Limb Tendinopathies Tibialis Posterior Flexor Hallucis Longus Peroneal Causes Excessive walking, running or Overuse of weight bearing Overuse of muscles – dancing, jumping PF activities, e.g. ballet basketball, volleyball Excessive pronation dancers, hill Excessive eversion – running on walking/running slopes or cambered surfaces Excessive pronation Chronic lateral ankle instability Clinical Medial ankle pain Medial ankle pain Lateral ankle/heel pain Features Tenderness along tendon Tenderness along tendon Tenderness along tendon Pain and weakness resisted Pain on toe-off or WB PF Painful resisted eversion ankle inversion Pain on resisted flexion of Pain on passive inversion Single heel raise – difficult to 1st toe Calf muscle tightness do and lacks hindfoot Pain on stretching FHL Excessive pronation inversion Muscle Strains Commonly injured in the lower limb Rectus Femoris Hamstrings Iliopsoas Adductor Longus Gastrocnemius* Acute hamstring strain one of the most common injuries in sport 15% of all injuries Muscle Strains - Clinical Presentation Subjective Gastrocs. Soleus History / Causes Mostly type I fast Mostly type II slow twitch fibres. twitch fibres. Sprinting, jumping, Running, hill walking bounding Symptoms Sudden, tearing pain Sudden pain, but – medial gastroc most common mostly affected increasing calf tightness Aggravating Running, jumping, Running, walking, stairs, calf raising hill walking, calf raises Muscle Strains - Clinical Findings Objective Gastrocs. Soleus Observation Depending on grade – swelling, Depending on grade – swelling, bruising, reduced WB. bruising, reduced WB. Active Plantarflexion Plantarflexion Passive Dorsiflexion Dorsiflexion Resisted Plantarflexion Plantarflexion Special Calf raises Calf raises (esp. bent knee) Gastroc length Knee to wall Palpation Tender over injured muscle – Tender over injured muscle – depends on which part of muscle depends on which part of (belly, MTJs) muscle (belly, MTJs) Depending on grade – palpable Depending on grade – palpable gap/dip in muscle gap/dip in muscle Patellofemoral Pain Syndrome (PFPS) Umbrella term for peri-patellar or retro-patellar pain A common MSK condition characterised by insidious onset of poorly defined anterior knee pain. Onset of symptoms can be slow or acutely develop and worse with LL loading activities Functional Anatomy of patella During knee flexion – patella moves inferiorly and medially to lie within intercondylar notch and patella articular surface comes in greater contact with the femur PFJ stress – 0.5 times BW walking; 7-8 times BW stair ascent Patella’s movement controlled by the VMO and VL PFPS Overuse, gradual onset injury – increase in PFJ loading activities, e.g. stairs, running, squats, lunges.. Pain aggravated by stairs, squatting, running, prolonged sitting Causative and contributing factors - multifactorial: o Training factors / errors o Malalignment of the leg – static and dynamic o Patella maltracking o Pronated foot type o Inadequate flexibility o Muscle imbalance – between VL and VMO o Reduced hip abductor and external rotation strength Pathophysiology unclear o May be due to inflamed synovial lining and fat pad tissues, irritation of the retinacula changes, cartilage and/or and increased osseous metabolic activity of the patella. PFPS – Clinical Presentation Signs Abnormal patella movement / mal-tracking observed Altered LL alignment and biomechanics o Knee valgus, excessive foot pronation o Poor pelvic and LL control under load, e.g. squat, single leg squat Reduced VMO activation – abnormal VL/VMO activation Tight ITB, hamstrings, quadriceps Reduced hip abductor, external rotation strength Pain on resisted knee extension through range Tender on palpation around patella +/- swelling Pain on patella compression Pain and restriction on patella mobilisations  Iliotibial Band Syndrome (ITBS) Common cause of lateral knee pain Overuse injury – in individuals that do sports with repetitive knee flexion and extension - runners , cyclists, military recruits. ITB - dense connective tissue - unlikely to stretch it. o Provides insertion for Glute Max and TFL o Proximally TFL exerts tension on ITB o Distally ITB crosses lateral joint line acts like a ligamentous support to lateral knee Pathophysiology remain controversial o Most likely theory is pain is due to irritation of the richly innervated fat pad underneath the ITB, and connective tissue separating ITB and lateral femoral epicondyle  ITBS – Clinical Presentation Gradual, insidious onset – due to overuse Pain, dull ache on lateral aspect of knee or lower ⅓ of ITB Aggravated by cycling, running (esp. downhill running) Causes multifactorial: o Training factors / errors o Altered LL alignment and biomechanics: o Increase femoral internal rotation/add and tibial internal rotation, knee valgus, excessive foot pronation o Poor pelvic and LL control, e.g., single leg squat, running, lunges o Strength – reduced hip abductor and external rotation strength Special tests - reduced Obers test Tender over lateral epicondyle of femur or ⅓ of ITB distally Medial Collateral Ligament (MCL) Caused by a valgus force Tears are classed according to degree of injury Medial Collateral Ligament (MCL) Mechanism of injury may involve: o Abrupt turning, cutting, or twisting o Direct blows to the lateral knee that cause an extreme valgus stress Graded on severity o Grade 1 – may be able to continue playing o Grade 2 and 3 – may hear a ‘pop’, difficulty walking, complaints of knee instability Grade I - Mild Local tenderness on MCL No swelling Pain on stress of MCL, but no laxity Grade II - Marked tenderness, swelling Moderate Pain on valgus stress, some laxity Knee is stable in full extension despite the laxity Grade III - Tenderness over MCL Severe Swelling Gross laxity on valgus stress test without a distinct end point Can be associated with ACL and medial meniscus injury – ‘Unhappy triad) Lateral Collateral Ligament (LCL) Much less common than MCL injuries Due to severe, high-energy, direct varus stress on the knee Complete tears associated with other instability, e.g. PCL = posterolateral instability  Anterior Cruciate Ligament (ALC) Injury Classic injury will involve a twisting mechanism - pivoting movement and often non-contact Sports - soccer, basketball, netball, downhill skiing, rugby, gymnastics Sudden pain +/- audible ‘pop’, ‘feeling of something going’ Unable to continue playing Complains of knee ‘giving way’ Usually, immediate effusion will occur 5 minutes to one hour post injury with large haemoarthrosis Often associated with meniscal tears, articular cartilage injuries, MCL injuries Investigations o X-ray – exclude any fractures o MRI – detects ACL and associated injuries ACL Injury Signs Examination difficult in first few days due to swelling Altered weightbearing – often on crutches Restricted knee ROM Knee joint tenderness Special tests - Lachman’s and Anterior Drawer tests Widespread tenderness around the knee  Posterior Cruciate Ligament Mechanism – direct blow to anterior tibia with knee in flexed position, e.g. dashboard in car, contact from opponent or equipment, fall onto hyper- flexed knee Often associated with meniscal and chondral injury Up to 60% involve disruption of posterolateral structures (LCL, popliteus complex) = posterolateral instability Poorly defined pain, mainly posterior Minimal swelling Special tests – Posterior drawer test X-ray – to exclude bony avulsion MRI – diagnose PCL and other structures  Patella Instability Patellar instability, by definition, is a condition where the patella bone pathologically disarticulates out from the patellofemoral joint, either subluxing or complete dislocation laterally Traumatic – traumatic force (twisting or jumping) followed by hemarthrosis / severe effusion Atraumatic – due to ligament laxity/hypermobility – no significant trauma Disruption to medial patellofemoral ligament (MPFL) (primary stabiliser) = passive instability Patella Instability - Clinical Presentation Anterior knee pain and swelling Reports of instability or “popping out” Patella usually relocates naturally on knee extension Tenderness over medial border of patella Special tests - patella lateral apprehension test X-ray – to exclude # Meniscal Injury Two types – traumatic or degenerative Menisci Lie on the periphery of the tibial plateaus, following the basic outlines of the tibial plateaus Important biomechanical function: o Load transmission – transmit between 50-95% of loads of the knee o Shock absorption o Joint stability o Spreads stress over the joint surface and decreasing cartilage wear Traumatic Meniscal Tears Most common mechanism of injury is a twisting movement on a slightly flexed knee with the foot anchored on the ground, e.g., change of direction sports (football, basketball, rugby). The medial meniscus attaches into the medial joint capsule and MCL which decreases its mobility and makes it more at risk for injury compared with the more mobile lateral meniscus. Sudden immediate pain and ‘?audible pop’. Swelling occurs several hours after the injury, gradually resolves with rest and returns with or after activity Can have locking or giving way Degenerative Meniscal Tears Occur in older populations - with age, the menisci become more brittle Common to have radiographic evidence of degenerative meniscal tears in the older population o Note - poor correlation between radiological findings and pain Pain can occur with or without and inciting event - insidious onset of knee pain Medial meniscus > lateral meniscus​ Can have locking or giving way Meniscal Injury – Clinical Presentation Reduced ROM or pain at end of ranges Pain on loading activities, e.g. squatting, stairs, run, twisting movements Locking - a fragment of the meniscus becomes displaced and trapped between the tibial and femoral condyles, preventing full extension - knee will often unlock with a “clunk” May produce catching or clicking on movement Knee may give way – reflex inhibition of the quadriceps muscles due to pain Localised knee joint line tenderness on palpation Joint effusion may be present Special tests - McMurry, Thessaly test, Apley’s test  Menisci Typically, avascular structure with the primary blood supply limited to the periphery Only the peripheral 10% to 25% of the meniscus is vascularised by geniculate arteries = more likely to heal Meniscus damaged in the central portion – reduced normal healing process Knee Pain - Younger Patient Osgood-Schlatter Disease (more common) Osteochondrosis or traction apophysitis of the tibial tuberosity Sinding-Larsen-Johansson Disease Osteochondrosis or traction apophysitis of patella tendon at inferior pole of patella Typically seen in: Males – aged 10-14 years Have gone through growth spurt Play sports - running, football, basketball… Objectively - tenderness over tibial tuberosity or inferior pole of patella and pain with, poor quadriceps and hamstring flexibility, may get pain with resisted knee extension, and pain with jumping and squatting activities. Bursitis Bursitis - swelling or inflammation of a bursa Pain occurs when movement against or compression on the bursa Two types – acute and chronic Many causes - including overuse injury, infectious disease, trauma, and inflammatory disorders. Acute bursitis - typically arises from trauma, infection, or crystalline joint disease (e.g. gout) Chronic bursitis - result of inflammatory arthropathies, repetitive pressure or friction. Imaging X-ray - considered in cases where there is a history of trauma or concern for a foreign body or fracture causing swelling or pain. MRI - for investigating deep bursa Ultrasound – for superficial bursa Bursiti s Common bursitis of the lower limb Pre-patellar Pes anserine bursitis Retrocalcaneal bursitis Prepatellar bursitis Generally, bursa is tender on palpation – especially acute cases ROM of involved joint is reduced and painful especially if actively using overlying tendon or movement compresses the bursa Signs of inflammation - redness, heat, swelling, pain, reduced function Medial tibial stress syndrome (MTSS) AKA “shin splints” Overuse injury - long distance runners, endurance athletes, military o Pain – likely bone stress reaction, periosteal inflammation – attachments into tibia of soleus, deep crural fascia, FDL, Tib. Post Causes and contributing factors: o Training factors / errors o Female > male o Previous history of MTSS o Lower bone mineral density, fatigue o >BMI o Excessive pronation, pes planus Diffuse pain along medial border of tibia (distal 2/3) Worse with activity, or warms up and returns following activity Tenderness posteromedial muscular tenderness X-rays – typically negative MRI or bone scan – show bone reaction Plantar Fasciitis Plantar fascia - important role in the foot biomechanically - provides static and dynamic stability, propulsion and important for dynamic shock absorption Overuse injury – caused by repeated overload – micro- trauma - Common in activities with plantarflexion and toe extension, e.g. dancing, running, excessive walking Pain on medial side of foot and heel Changes similar to tendinopathy – collagen breakdown, fibrocyte cell changes, matrix degradation, vascular ingrowth Pain worse with: o First steps in morning or after period of rest o Sustained loading, e.g. standing, walking, running o In more severe cases, walking aggravates, and pain increases during the day Plantar Fasciitis Associated with: High BMI Excessive pronation (and supination) – static and dynamic Pes planus (low arches) or pes cavus (high arches) Prolonged standing occupations, running, excessive walking, dancing Inadequate footwear Reduced hamstring and calf flexibility Signs Acute tenderness to palpation along medial plantar aspect of foot and insertion into calcaneus Dorsiflexion of ankle and extension of toes may cause pain (Windlass test) Reduced ankle DF and first MTP extension ROM Decreased strength plantar flexors and toe flexors Reduced ankle and calf flexibility Excessive foot pronation or supination (van Leewan et al., 2016) Ankle Sprains Lateral Ligament Injuries Inversion sprain Anterior talofibular lig – forced inversion and plantarflexion Calcaneofibular ligament – forced inversion Posterior talofibular - rarely injured Complete tear of all ligaments – associated with dislocations and fractures Medial (Deltoid) Ligament Injury Eversion sprain Less common than lateral injuries, but twice as long to heal Ankle Sprains - Diagnosis History is critical – mechanism? audible snap? Could they immediately weight bear? Pain, swelling, tenderness, bruising Pain on stretching or compressing ligament, e.g. ankle inversion or eversion Ligament stress tests - anterior drawer, talar tilts Used to determine grade Compare both sides as large inter-individual variability ? X-ray to rule out # - Ottawa ankle rules Lateral ligament sprain One of the most common injuries in sport Inversion injuries x4 more likely than eversion ATFL most injured Sudden pain, felt over lateral aspect of ankle following forced inversion movement Complaint of ‘pop’, ‘snap’, crack, tear Swelling Reduced ability to weight bear Degree of pain, swelling, ROM reduction and weight bearing difficulty help diagnose severity Often a recurring injury if not fully rehabilitated Complains of pain on weight-bearing activities, change of direction activities Lateral Ligament Sprains Signs Pain on plantarflexion and inversion Reduced ankle ROM Tenderness over lateral ankle ligaments Possible bruising and swelling at lateral malleolus or into foot Pain on stress of lateral ankle ligaments +/- laxity – Anterior drawer test, talar tilt test Antalgic gait Pain on weight bearing activities Decreased proprioception, e.g. balance - single leg stand Resources Brukner & Khan’s clinical sports medicine – books in the library References Petersen et al. (2014) Patellofemoral Pain Syndrome. Knee Surg Sports Traumatol Arthrosc. 22:2264–2274 van Leeuwen, K., Rogers, J., Winzenberg, T., & van Middelkoop, M. (2016). Higher body mass index is associated with plantar fasciopathy/'plantar fasciitis': systematic review and meta-analysis of various clinical and imaging risk factors. British Journal of Sports Medicine, 50, 972-981