1. Sports injuries in Knee and ankle

2. Contents • Common sports injuries in knee and ankle region • Differential Dx of anterior, medial, and lateral knee pain • Differential Dx of anterior, medial, lateral ankle and heel pain • Principles of Management

3. ANTERIOR KNEE PAIN

5. DIFFERENTIAL DIAGNOSIS OF ANTERIOR KNEE PAIN • PFJ PAIN SYNDROME • PLICAL AND FAT -PAD SYNDROME • PATELLAR SUBLUXATION • OVERUSE SYNDROME OF PATELLA TENDON • SINDING-LARSEN JOHANSSEN DISEASE • OSGOOD - SCHLATTER’S DISEASE • TRAUMA TO PATELLA • PREPATELLA BURSITIS • RSD

6. FUNCTIONAL STRESS

7. Tight lateral structures Back Abnormal lower biomechanics Patellar tracking dysfunction Hip and Thigh Ankle and Foot Weak medial structures

8. Sports activities Patella tracking dysfunction Excessive pressure on PF jt PF syndrome

9. CONTRIBUTING FACTORS TO PFJ PAIN SYNDROME • Patellar articular surface-related • Surface pathology fribillation • Trauma single or repetitive

10. PATELLAR TRACKING RELATED • Patella shape Accessory ossification centre • Patellar Position Patella Alta Increased Q Ass.with hyperextension • Muscular VMO

11. BACK Hip and Thighs Excessive lordosis/kyphosis Pelvic Tilt Femoral antersion Tight Hip flexors Tight Hamstrings Tight ITB Leg length discrepancy PROXIMAL SEGMENTS

12. Tibia Foot and Ankle Excessive internal torsion Genu varum or valgus Tight TA Hyperpronation Rigid cavus foot DISTAL SEGMENTS

13. MANAGEMENT • Control of inflammation and pain relieving • Correct alignment of patellar • Improvement of motor function • Soft tissue release • Knee brace • Correction of abnormal biomechanics

14. Correct alignment of patellar • Taping

15. Correction of rotation Correction of medial glide Correction of lateral tilt

16. Improvement of motor function • Muscle training (VMO) • Biofeedback • NMES • Start with sitting position • CKC • Hip control exercise

17. PATELLAR TENDINOPATHY

18. JUMPER’S KNEE • Related to repetitive extensor action of the knee with the generation of large eccentric forces • A typical functional overloading syndrome • Mostly in volleyball, basketball players, high and long jumpers

19. JUMPER’S KNEE CAUSATIVE FACTORS: EXTRINSIC: • TRAINING SESSIONS (DURATION, INTENSITY AND NUMBER) • PLAYING SURFACE • FOOTWEAR

20. JUMPER’S KNEE INTRINSIC FACTORS: • RESISTANCE, ELASTICITY AND EXTENSIBILITY OF THE TENDON • BIOMECHANCIAL VARIATION OF THE KNEE EXTENSOR MECHANISM, MUSCLE STRENGTH AND OVERALL LIMB ALIGNMENTS • HIP FLEXOR SHORTENING AND WEAKNESS OF ABDUCTOR

21. EXAMINATION AND INVESTIGATION

22. PRINCIPLES OF MANAGEMENT • Removal of triggering factors; • Biomechanical correction; • Estimate stage of injuries; • Control pain and inflammation; and • Appropriate tensile loading

23. TENDON HEALING • Inflammatory stage (6 days) • Fibroblastic/proliferative stage (5-21 days) • Remodelling/maturation stage (begins on day 20) • * the healing process for chronic tendinopathy may take a long time

24. CONTROL PAIN & INFLAMMATION • Physical Modalities • US • Laser • ES • Ice • Medication • NSAIDs • Steriods

25. APPROPRIATE TENSILE LOADING • Specificity: MTU • Maximal Loading • Progression of loading

26. ECCENTRIC EXERCISE PROGRAM • Warm-up • Flexibility • Specific exercise • Repeat flexibility exercises • Ice

27. Start with slow free active Pain Increase speed (moderate) Pain Pain Increase speed (Fast) Increase resistance Pain

28. PREVENTION • Pre-season strength training • Proper stretching and warm-up • Avoid triggering factors: • equipment modification • technique adjustment • environmental (running surfaces)

29. FAT PAD SYNDROME • Fat pad – a sensitive structure in the knee; • Chronic fat pad irritation is common; • Pain usually aggravated by extension maneuvers; • Localised tenderness and puffiness; • Often associated with hyperextension of knees and increased anterior pelvic tilt

30. Principles of management • Pain relieving & • Fat pad unloading by taping

31. Principle of taping for Fat Pad Syndrome

32. OTHER LESS COMMON CONDITIONS

33. PLICAL SYNDROMES • Embryologically, fusion of 3 synovial compartments during fetal month • Plical - any portion of the embryonic synovial septa persist into adult life • Infrapatellar, suprapatellar and medial patella plica • Medial plica - a crescentic fold, running from the quadriceps into medial wall of jt. & ending in infrapatellar fat pad.

34. Pain might aggravate by squatting • Palpable thickened band under the medial border of patella • If conservative management fail, arthroscopic removal of plica

35. Osgood-Schlatter disease – osteochondrosis at tibial tuberosity • Excessive traction on the soft apophysis of the tibial tuberosity • Associated with high levels of activity in the growing phase adolescents

36. Principles of management • Usually self-limiting and settles at the time of bony fusion; • Might need activity modification; and • Symptomatic treatment (ice, EPT); • Stretch tight Quadriceps; and correction of biomechanical abnormality

37. Sinding-Larsen-Johansson syndrome • Similar to Osgood Schlatter; • Affects inferior pole of patella; • Less common than Osgood Schlatter; • Same management principles

38. LATERAL KNEE PAIN

40. Lateral knee pain • Iliotibial band friction syndrome (ITBFS); • Lateral meniscus problems; • Osteoarthritis of the lateral compartment of the knee; • Biceps femoris tendinopathy; • Superior tibiofibular joint sprain; • Synovitis of the knee joint; • Referred pain from lumber spine

41. ILIOTIBIAL BAND FRICTION SYNDROME • CAUSATIVE FACTORS • TIGHTNESS OF ITB • MALALIGNMENT & LEG LENGTH DISCREPANCY • EXCESSIVE FOOT PRONATION • DOWNWARD CONTRALATERAL TILT OF PELVIC

42. ILIOTIBIAL BAND FRICTION SYNDROME • S/S: • STINGING PAIN • WORSE ON RUNNING DOWNHILL • REPRODUCTION OF PAIN ON COMPRESSION OVER LATERAL FEMORAL CONDYLE WITH STRETCHED • CREPITUS

43. Principles of management • Control of inflammation • Soft tissue release • Stretching of ITB • Strengthening of the lateral stabilizers of the hip • Correction of biomechanical factors • Corticosteroid injection or surgery if conservative management fails

44. Lateral meniscus abnormality • Degeneration of the lateral meniscus • Pain on distance running, more severe on uphill; • Tender along the joint line • McMurray’s test +ve • Confirmation by MRI

45. POPLITEUS TENDINITIS Functions of popliteus • Assists unlocking mechanisms of knee • Prevents impingement of the posterior horn of the lateral meniscus • Synergically with posterior cruciate preventing posterior glide of tibia • Reinforces posterlateral capsule

46. POPLITEUS TENDINITIS • LOCAL TENDERNESS ANTERIOR TO THE SUPERIOR ATTACHMENT OF LCL • PAIN MAY BE REPRODUCED BY RESISTED KNEE FLEXION AND TIBIA HOLD IN EXT. ROTATION

47. Biceps femoris tendinopathy • Might cause by excessive acceleration and deceleration activities; • Associated with tight hamstring and stiffness of lumber spine; • Pain reproduced with resisted flexion; • Same treatment principles of tendinopathy

48. Superior tibiofibular joint problems • Direct trauma or association with rotational knee or ankle injuries; • Tender on joint line; • Restricted or excessive gliding of superior T/F jt. • For stiff T/F jt : mobilization • EPT modalities for pain relieving • Biomechanical factors

49. MEDIAL KNEE PAIN