one step ahead_knee and ankle injuries in little sports
TRANSCRIPT
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Julio Martinez-Silvestrini, MDBoard Certified in Sports Medicine
Medical Director, Baystate Physical Medicine and RehabilitationMedical Director, Baystate Rehabilitation Care
Baystate Health, Springfield, MA
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DisclosuresNoneTwitter User: @JulioMartinezMD
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ObjectivesWe will discuss common
sports and exercise related injuries involving the knee and ankle
We will focus on:The mechanism of
injurySymptoms Physical examination
findings
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ObjectivesStudies the primary care
provider should order, and
When to refer to:Physical TherapyNon-surgical Sports
Medicine SpecialistTo Orthopedics
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Knee
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Common knee injuriesPatellofemoral pain syndromeJumper’s kneeOsgood-SchlatterAnterior Cruciate Ligament (ACL)
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Patellofemoral pain syndromeInadequate patellofemoral glidingChief complaint (CC): Anterior knee painUsually a young female with:
Sensation of knee locking Pseudolocking
Mild swelling“Theater sign”
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Patellofemoral pain syndromePain with retropatellar or condylar palpationInflexible
Quads and hip flexorsIliotibial band
WeakGluteus medius Vastus medialis
Pes planus
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ReferralsIt takes long time for full recovery
Consider referral to non-surgical sports specialistConsider X-rays including “sun-rise view”Early referral to PT is appropriate Surgery is rarely needed
Lateral patellar releaseOsteotomy
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Jumper’s kneeChronic injury of the
patellar tendonExcessive stress
Sports the require repetitive jumping and runningVolleyballBasketballTennisTrack
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Jumper’s kneeCC: Anterior knee
painBelow the patella
Older athlete (15 y/o+)Ask about anabolic
steroids useTender patellar tendonInflexible
Hip flexorsQuadsGastrocnemius
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Jumper’s kneeRefer to physical
therapySurgery is rarely
neededHigh risk for tendon
tear if untreatedThis will require surgery
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ApophysitisThe weakest point at the insertion of a muscle is the
traction epiphysis Not contributes to longitudinal growthMay cause cosmetic deformity or non-unions if not
treated
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Osgood-SchlatterCC: Anterior knee
painInferior to the patellar
tendonAge: 12-16 years oldSimilar exam to
patellar tendinopathyTender at the tendon
insertionIf at tendon origin
Sinding-Larsen
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Tendinopathy severity stages
1: Only after activity2: During and after
activities; no performance limitation
3: Constant pain; progressive impairment
4: Complete rupture
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Osgood-SchlatterBilateral knee x-raysIf not displaced, may be
treated conservativelySmall fragmentation
cannot be reducedLess than 1 cm
Surgical referral for bigger fragmentations or significant weakness
Mild deformity may occur
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Anterior Cruciate Ligament TearsCC: Knee is unstableUsually non-contact
injury“Pop” sensationBig joint swellingUnable to participate
post injury
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Anterior Cruciate Ligament TearsKnee effusion
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4 Causes for traumatic effusionACLMeniscusFracturePatellar dislocation
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Anterior Cruciate Ligament TearsKnee effusionAnterior Drawer testLachman’s testPivot shift
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Anterior Cruciate Ligament TearsRefer to surgeryMRI
Non-surgical Sports specialist
No PT referral
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Foot/Ankle
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Common ankle and foot injuriesLateral ankle sprainHigh ankle sprainSever’s diseaseLisfranc injury
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Ankle sprain90% are Inversion
sprainWhile jumping the
forefoot functions as a lever arm Ankle joint is unstable
The lateral malleolus is longer Promotes eversion
stability
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Ankle sprainCC: Ankle swelling after
sprainWeak ankles
Inflexible Achilles tendon
No weaknessPoor balanceAnterior drawer test
Ottawa ankle rulesFibular head palpation
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Ligamentous Sprain SeverityFirst degree
Minor TraumaFew ligamentous fibers injuredNo instability
Second degreeModerate trauma/ Fiber injury
50-90% fibers Some laxity
Third degreeFull thickness ligamentous tear
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High ankle sprainEversion injuryMay be associated with a medial malleolar or
proximal fibular fractureCC: Similar to lateral ankle sprainOttawa ankle rules“Squeeze” testPalpate fibular head
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Ankle sprain managementAP, lateral and mortise ankle x-raysTibio-fibular x-rays AP and lateral if fibular pain
Early referral to orthopedics if x-rays abnormalitiesCrutchesPT referralIf no recovery in 2 weeks or history of recurrent
sprains, referral to non-surgical sports specialist
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Sever’s diseaseCC: Heel pain when
jumping or landingHeel swelling
12-16 years oldTight Achilles tendonTender lateral and
medial heel Similar management to
Osgood-Schlatter
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Sever’s diseaseBilateral foot x-rays
Calcaneal viewsIf not displaced, may be
treated conservativelySurgical referral for bigger
fragmentations or significant weakness
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Sever’s disease
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Sever’s disease
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Lisfranc InjuryAxial loading to the footRupture of the Lisfranc
ligamentFrom the medial cuneiform to
the second metatarsal baseDorsal mid-foot pain Swelling dorsum footX-rays:
Weight-bearing AP, lateral and oblique views
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Principles of treatmentPRICE
Protection (Bracing, crutches)Rest (Modified activities) Ice (Ice packs, massage)Compression (Tubigrip, Neoprene, Ace)Elevation (Above heart level)
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Principles of treatmentEarly rehabilitation
Modalities (Ice, heat, electrical stimulation) Symptom modification
Range of Motion (ROM, Stretching) Avoid contractures
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Principles of treatmentEarly rehabilitation
Strengthening Restore muscle balance Eccentric biased (deceleration) Close kinetic chain (distal limb fixed)
Proprioception trainingReturn to normal activities
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SummaryAnterior knee pain:
Usually atraumaticPatellofemoral pain:
FemalesOsgood-Schlatter: 12-16
years oldPatellar tendinopathy:
older adolescentsRefer to Rehabilitation
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SummaryACL tears:
There is an eventUnable to play
afterwardsEffusionEarly surgical referral
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Summary
Ankle sprainOttawa ankle rulesPalpate the fibular headEarly PT referral if no x-
rays abnormalitiesChronic ankle
instability can be avoided
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SummaryApophysitis:
Osgood-Schlatter and Sever’s disease
Bilateral x-raysEarly PT referral if no x-
rays abnormalitiesEarly surgical referral if
x-rays abnormalities
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Contact InformationSports Medicine Clinic360 Birnie Ave.Springfield, MA01199(413) 794-1600
@JulioMartinezMD
Sports Medicine, Adult Musculoskeletal Care and PM&R
294 N. Main St. Suite 202East Longmeadow, MA
01028(413) 794-1150
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