le sports injuries
TRANSCRIPT
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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
s Examination:Examination:
pes planus or pes cavuspes planus or pes cavus
s Treatment:Treatment:
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
s Treatment:Treatment:
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
s Treatment:Treatment:
rule outrule out
syndesmosissyndesmosis
PRICEPRICE
crutches WBATcrutches WBAT
airsplintairsplint
ROM,ROM,
strengtheningstrengthening
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
s Examination:Examination:
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
s Treatment:Treatment:
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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Knee InjuriesKnee InjuriesPatellofemoral SyndromePatellofemoral Syndrome
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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Knee InjuriesKnee InjuriesPatellofemoral SyndromePatellofemoral Syndrome
s Treatment:Treatment:
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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Knee InjuriesKnee InjuriesMCL/LCL SprainsMCL/LCL Sprains
s Examination:Examination:
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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Knee InjuriesKnee InjuriesMCL/LCL SprainsMCL/LCL Sprains
s Treatment:Treatment: PRICEPRICE
crutches WBATcrutches WBAT
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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Knee InjuriesKnee InjuriesACL SprainsACL Sprains
sTreatment:Treatment: PRICEPRICE
crutches WBATcrutches WBAT
restore full ROMrestore full ROM CKC strengthening; HSCKC strengthening; HS
biased strengtheningbiased strengthening
Proprioceptive trainingProprioceptive training
bracing for high demandbracing for high demandsportssports
Knee InjuriesKnee Injuries
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Knee InjuriesKnee InjuriesACL SprainsACL Sprains
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
Knee InjuriesKnee Injuries
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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
s Examination:Examination:
posterior sag signposterior sag sign Posterior drawPosterior draw
Knee InjuriesKnee Injuries
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Knee InjuriesKnee InjuriesPCL SprainsPCL Sprains
sTreatment:Treatment:
PRICE as neededPRICE as needed
ROMROM
CKC strengthening;CKC strengthening;Quadriceps biasedQuadriceps biased
generally no needgenerally no need
for bracingfor bracing
Knee InjuriesKnee Injuries
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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
Knee InjuriesKnee Injuries
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Knee InjuriesKnee InjuriesMeniscal tearsMeniscal tears
s Examination:Examination:
effusioneffusion
decreased flexiondecreased flexion
pain on hyperflexionpain on hyperflexionjoint line tendernessjoint line tenderness
McMurrays: veryMcMurrays: very
specific but poorspecific but poor
sensitivitysensitivity
Knee InjuriesKnee Injuries
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Knee InjuriesKnee InjuriesMeniscal tearsMeniscal tears
s Treatment:Treatment:
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 Injuries
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Hip InjuriesHip InjuriesHip flexor strainHip flexor strain
s Treatment:Treatment:
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
Hip InjuriesHip Injuries
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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
s Examination:Examination:
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
Hip InjuriesHip Injuries
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Hip InjuriesHip InjuriesGreater trochanteric bursitisGreater trochanteric bursitis
sTreatment:Treatment:
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
Hip InjuriesHip Injuries
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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
s Examination:Examination:
anatalgic gaitanatalgic gait
pain, ecchymosis posterior thighpain, ecchymosis posterior thigh
Hip InjuriesHip Injuries
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Hip InjuriesHip InjuriesHamstring strainHamstring strain
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
Hip InjuriesHip Injuries
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Hip InjuriesHip InjuriesHamstring strainHamstring strain
sTreatment (cont):Treatment (cont):
strengtheningstrengthening
should includeshould include
CKC, eccentric,CKC, eccentric,
and plyometricand plyometrictrainingtraining
return to sportreturn to sport
when strength iswhen strength is
symmetricsymmetric
Hip InjuriesHip Injuries
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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
s Examination:Examination:
pain on palpation and stretch ofpain on palpation and stretch of
the involved musclethe involved muscle
s Treatment:Treatment:
functional rehabilitation: vastfunctional rehabilitation: vastmajority do wellmajority do well
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Thank youThank you