Sports injuries in Knee and ankle
Contents
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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
ANTERIOR KNEE PAIN
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
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FUNCTIONAL STRESS
Type of activities
PFJ force
Level walking
0.5 BW
Up and down stairs
3-4 BW
Squatting
7-8 BW
Back
Tight lateral structures
Hip and Thigh
Abnormal
lower biomechanics
Ankle and Foot
Weak medial structures
Patellar tracking
dysfunction
Sports activities
Patella tracking
dysfunction
Excessive pressure
on PF jt
PF syndrome
CONTRIBUTING FACTORS
TO PFJ PAIN SYNDROME
Patellar
articular surface-related
Surface pathology fribillation
Trauma single or repetitive
PATELLAR TRACKING
RELATED
 Patella
shape
 Patellar
Position
 Muscular
Accessory
ossification
centre
Patella Alta
Increased Q
Ass.with
hyperextension
VMO
PROXIMAL SEGMENTS
 BACK
 Excessive
 Hip
 Femoral
and
Thighs
lordosis/kyphosis
 Pelvic Tilt
antersion
 Tight Hip flexors
 Tight Hamstrings
 Tight ITB
 Leg length discrepancy
DISTAL SEGMENTS
 Excessive
 Tibia
 Foot
internal
torsion
 Genu varum or
valgus
and Ankle
 Tight TA
 Hyperpronation
 Rigid
cavus foot
MANAGEMENT
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Control of inflammation and pain relieving
Correct alignment of patellar
Improvement of motor function
Soft tissue release
Knee brace
Correction of abnormal biomechanics
Correct alignment of patellar
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Taping
Correction of
medial glide
Correction of
lateral tilt
Correction of
rotation
Improvement of motor function
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Muscle training (VMO)
Biofeedback
NMES
Start with sitting position
CKC
Hip control exercise
PATELLAR TENDINOPATHY
JUMPER’S KNEE
 Related
to repetitive extensor action of the
knee with the generation of large eccentric
forces
 A typical
 Mostly
functional overloading syndrome
in volleyball, basketball players,
high and long jumpers
JUMPER’S KNEE
CAUSATIVE FACTORS:
EXTRINSIC:
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TRAINING SESSIONS (DURATION,
INTENSITY AND NUMBER)
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PLAYING SURFACE
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FOOTWEAR
JUMPER’S KNEE
INTRINSIC FACTORS:
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RESISTANCE, ELASTICITY AND
EXTENSIBILITY OF THE TENDON
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BIOMECHANCIAL VARIATION OF THE KNEE
EXTENSOR MECHANISM, MUSCLE
STRENGTH AND OVERALL LIMB
ALIGNMENTS
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HIP FLEXOR SHORTENING AND
WEAKNESS OF ABDUCTOR
EXAMINATION AND
INVESTIGATION
PRINCIPLES OF MANAGEMENT
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Removal of triggering factors;
Biomechanical correction;
Estimate stage of injuries;
Control pain and inflammation; and
Appropriate tensile loading
TENDON HEALING
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Inflammatory stage (6 days)
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Fibroblastic/proliferative stage (5-21 days)
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Remodelling/maturation stage (begins on
day 20)
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* the healing process for chronic
tendinopathy may take a long time
CONTROL PAIN & INFLAMMATION
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Physical Modalities
 US
 Laser
 ES
 Ice
Medication
 NSAIDs
 Steriods
APPROPRIATE TENSILE LOADING
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Specificity: MTU
Maximal Loading
Progression of loading
ECCENTRIC EXERCISE
PROGRAM
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Warm-up
Flexibility
Specific exercise
Repeat flexibility exercises
Ice
Start with slow
free active
Pain
Increase speed
(moderate)
Pain
Increase speed
(Fast)
Pain
Increase resistance
Pain
PREVENTION
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Pre-season strength training
Proper stretching and warm-up
Avoid triggering factors:
 equipment modification
 technique adjustment
 environmental (running surfaces)
FAT PAD SYNDROME
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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
Principles of management
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Pain relieving &
Fat pad unloading by taping
Principle of taping for Fat Pad Syndrome
OTHER LESS COMMON
CONDITIONS
PLICAL SYNDROMES
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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.
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Pain might aggravate by squatting
Palpable thickened band under the medial
border of patella
If conservative management fail,
arthroscopic removal of plica
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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
Principles of management
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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
Sinding-Larsen-Johansson syndrome
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Similar to Osgood Schlatter;
Affects inferior pole of patella;
Less common than Osgood Schlatter;
Same management principles
LATERAL KNEE PAIN
Lateral knee pain
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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
ILIOTIBIAL BAND FRICTION SYNDROME
 CAUSATIVE
FACTORS
 TIGHTNESS OF ITB
 MALALIGNMENT & LEG LENGTH
DISCREPANCY
 EXCESSIVE FOOT PRONATION
 DOWNWARD CONTRALATERAL
TILT OF PELVIC
ILIOTIBIAL BAND FRICTION SYNDROME
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S/S:
STINGING PAIN
WORSE ON RUNNING
DOWNHILL
REPRODUCTION OF PAIN ON
COMPRESSION OVER LATERAL
FEMORAL CONDYLE WITH
STRETCHED
CREPITUS
Principles of management
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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
Lateral meniscus abnormality
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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
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
POPLITEUS TENDINITIS
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LOCAL TENDERNESS ANTERIOR TO
THE SUPERIOR ATTACHMENT OF
LCL
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PAIN MAY BE REPRODUCED BY
RESISTED KNEE FLEXION AND TIBIA
HOLD IN EXT. ROTATION
Biceps femoris tendinopathy
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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
Superior tibiofibular joint problems
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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
MEDIAL KNEE PAIN
Medial knee pain
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Patellofemoral syndrome
Medial meniscus abnormality
Pes Anserinus tendinopathy/bursitis
MENISCAL LESIONS
MECHANISM OF INJURY
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ASSOCIATED WITH LGT. DISRUPTION
DEGENERATIVE CHANGES WITH AGE
REPETITIVE ABNORMAL STRESSES
SECONDARY TO CHRONIC LGT. LAXITY
ISOLATED OR REPETITIVE ROTATIONAL
STRESSES
ABNORMAL MENISCAL SHAPE OR
ATTACHMENT
Medial Meniscus abnormality
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Gradual degeneration of the medial
meniscus
Over 35 years old
Complains of clicking and pain with
twisting activities
Joint line tenderness
+ve McMurray’s test
MEDIAL CAPSULAR COMPLEX
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During flexion the ant. fibres sup. med. lgt. are
tense;
During partial extension the post. fib. & adj.
posteromedial capsule take up the strain;
During full ext. the whole lt. is taut owing to
asso. rotation
Quad. & Hamstring exp. lend dynamic support
Several bursa are asso. with lt and
hamstring tend. & inflammation may
mimic meniscal or lt. pathology
POSTEROMEDIAL CORNER OF KNEE
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Deep medial collateral lgt. in association with
medial meniscus;
Posterior superficial fibers blend with capsule
Expansions from semitendinosis also reinforce
capsule
Combined structure called posterior oblique
lt.
Torn with significant valgus or rotary stresses
Pes anserinus tendinopathy/bursitis
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Overuse syndrome;
Common in swimmers (breaststrokers),
cyclists and runners;
Localised tenderness and swelling
Pain reproduced on active contraction or
stretching of hamstring
Treatment principles same as tendionpathy
ANKLE AND FOOT
PROBLEMS
HEEL PAIN
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MEDIAL
TIB. POST. TENDINITIS
FLEXOR HALLUCIS LOGNUS
TENDINOPATHY
TARSAL TUNNEL SYNDROME
MEDIAL CALCANEAL NEURITIS
LATERAL
 PERONEAL TENDINOPATHY
 SINUS TARSI SYNDROME
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PLANTAR
PLANTAR FASCIITIS
CALCANEAL SPUR
FAT PAD SYNDROME
CALCANEAL PERIOSTITIS
POSTERIOR
 RETROCALCANEAL BURSITIS
 CALCANEAL APOPHYSITIS
DIFFUSE
 CALCANEAL STRESS FRACTURE
TIBIALIS POSTERIOR SYNDROME
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Common in middle distance runner
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Essential for the eccentric control of foot pronation in
Heel strike phase
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Frequently associated with excessive subtalar pronation
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Pain on palpation along tendon
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Passive eversion and resisted inversion
FLEXOR HALLUCIS LONGUS
TENDINOPATHY
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Integral part of the smooth take-off phase of
walking and running
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Tenosynovitis occurs secondary to overload
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High jumper and dancing sports (ballet dancer)
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Pain on resisted flexion and full dorsiflexion of
hallux
MANAGEMENT
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Rest
Stretching exercise
Tape in slightly plantar-flexed position
Check sport shoes
Check subtalar joint
Check excessive pronation
Tarsal Tunnel Syndrome
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Entrapment of the posterior tibial nerve
Overuse associated with excessive pronation
Result of trauma
S/S
 Sharp pain radiating into the arch of the foot, heel,
and occasionally the toes
 Prolonged standing, walking or running aggravates
pain
 +ve Tinel’s sign
 May accompany with altered sensation
Principles of management
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Correct excessive pronation
Corticosteriod injection
Decompression release
Medial Calcaneal neuritis
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Pain over the inferomedial aspect of
calcaneus
May radiates into the arch of the foot
Tenderness over medial calcaneus
+ve Tinel’s sign
Treatment principle same as Tarsal tunnel
syndrome
LATERAL ANKLE PAIN
PERONEAL TENDINOPATHY
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Excessive action of the peroneals:
Excessive eversion caused by hill running or road
running
Ball games (basketball, volleyball)
Tight plantarflexors might cause excessive load
on the peroneals
Local tenderness
Swelling and crepitus
Passive inversion and resisted eversion: pain+
Check for eccentric loading
Principles of management
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Rest from aggravating activities
EPT modalities
Stretching and strengthening
Mobilisation of subtalar, midtarsal joints
Correction of biomechanical abnormalities
SINUS TARSI SYNDROME
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A small osseous canal running from an opening
anterior and inferior to the lateral malleolus
Part of the subtalar joint with subtalar lgts, fat and
connective tissue
Excessive pronation
Repeated forced eversion
Result of ankle sprain
Pain locate at anterior to lat malleolus
Pain+ on running on curve
Stiffness of subtalar joint
Pain+ on forced eversion and/or inversion
Relief with lignocaine injection
Principles of management
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Rest
Ice
EPT
Mobilisation of subtalar joint
NASID
Contricosteriod injection
PLANTAR HEEL PAIN
FAT PAD SYNDROME
CONTRIBUTING FACTORS:
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THINNING OF FAT PAD WITH AGE
EXCESSIVE BODY WT.
POORLY CUSHIONED OR WORN-OUT
SHOES
SINGLE SIGNIFICANT CONTUSION
SUDDEN INCREASE IN TRAINING
SWITCH TO UNEVEN AND HARD TERRAIN
REPETITIVE HILL WORK OR STEEP
INCLINES
Tibialis Anterior Tendinopathy
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Overuse of ankle dorsiflexors
Too infrequent downhill running
Excessive tightness of strapping or
shoelaces
Treatment principles same as tendinopathy
ANTERIOR ANKLE PAIN
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Anterior Impingement of the ankle
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Caused by forced dorisflexion in activities
Footballers’ ankle
Also commonly seen in ballent dancers
Exotoses develop on the anterior of the upper
surface of neck of talus
+ve anterior impingement test
Management
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NASIDs
AP glide of talocrual joint
Surgical excision for promient exostoses
Recommended reading:

Brukner P., Khan K. 2001 Clinical Sports
Medicine 2nd edition, The McGraw Hill Co.
Chapter 24, 25 and 30