one step ahead_knee and ankle injuries in little sports

Julio Martinez-Silvestrini, MDBoard Certified in Sports Medicine

Medical Director, Baystate Physical Medicine and RehabilitationMedical Director, Baystate Rehabilitation Care

Baystate Health, Springfield, MA

DisclosuresNoneTwitter User: @JulioMartinezMD

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

ObjectivesStudies the primary care

provider should order, and

When to refer to:Physical TherapyNon-surgical Sports

Medicine SpecialistTo Orthopedics

Knee

Common knee injuriesPatellofemoral pain syndromeJumper’s kneeOsgood-SchlatterAnterior Cruciate Ligament (ACL)

Patellofemoral pain syndromeInadequate patellofemoral glidingChief complaint (CC): Anterior knee painUsually a young female with:

Sensation of knee locking Pseudolocking

Mild swelling“Theater sign”

Patellofemoral pain syndromePain with retropatellar or condylar palpationInflexible

Quads and hip flexorsIliotibial band

WeakGluteus medius Vastus medialis

Pes planus

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

Jumper’s kneeChronic injury of the

patellar tendonExcessive stress

Sports the require repetitive jumping and runningVolleyballBasketballTennisTrack

Jumper’s kneeCC: Anterior knee

painBelow the patella

Older athlete (15 y/o+)Ask about anabolic

steroids useTender patellar tendonInflexible

Hip flexorsQuadsGastrocnemius

Jumper’s kneeRefer to physical

therapySurgery is rarely

neededHigh risk for tendon

tear if untreatedThis will require surgery

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

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

Tendinopathy severity stages

1: Only after activity2: During and after

activities; no performance limitation

3: Constant pain; progressive impairment

4: Complete rupture

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

Anterior Cruciate Ligament TearsCC: Knee is unstableUsually non-contact

injury“Pop” sensationBig joint swellingUnable to participate

post injury

Anterior Cruciate Ligament TearsKnee effusion

4 Causes for traumatic effusionACLMeniscusFracturePatellar dislocation

Anterior Cruciate Ligament TearsKnee effusionAnterior Drawer testLachman’s testPivot shift

Anterior Cruciate Ligament TearsRefer to surgeryMRI

Non-surgical Sports specialist

No PT referral

Foot/Ankle

Common ankle and foot injuriesLateral ankle sprainHigh ankle sprainSever’s diseaseLisfranc injury

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

Ankle sprainCC: Ankle swelling after

sprainWeak ankles

Inflexible Achilles tendon

No weaknessPoor balanceAnterior drawer test

Ottawa ankle rulesFibular head palpation

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

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

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

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

Sever’s diseaseBilateral foot x-rays

Calcaneal viewsIf not displaced, may be

treated conservativelySurgical referral for bigger

fragmentations or significant weakness

Sever’s disease

Sever’s disease

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

Principles of treatmentPRICE

Protection (Bracing, crutches)Rest (Modified activities) Ice (Ice packs, massage)Compression (Tubigrip, Neoprene, Ace)Elevation (Above heart level)

Principles of treatmentEarly rehabilitation

Modalities (Ice, heat, electrical stimulation) Symptom modification

Range of Motion (ROM, Stretching) Avoid contractures

Principles of treatmentEarly rehabilitation

Strengthening Restore muscle balance Eccentric biased (deceleration) Close kinetic chain (distal limb fixed)

Proprioception trainingReturn to normal activities

SummaryAnterior knee pain:

Usually atraumaticPatellofemoral pain:

FemalesOsgood-Schlatter: 12-16

years oldPatellar tendinopathy:

older adolescentsRefer to Rehabilitation

SummaryACL tears:

There is an eventUnable to play

afterwardsEffusionEarly surgical referral

Summary

Ankle sprainOttawa ankle rulesPalpate the fibular headEarly PT referral if no x-

rays abnormalitiesChronic ankle

instability can be avoided

SummaryApophysitis:

Osgood-Schlatter and Sever’s disease

Bilateral x-raysEarly PT referral if no x-

rays abnormalitiesEarly surgical referral if

x-rays abnormalities

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