1. Overview of Lower Extremity Evia Nano November 19, 2004
Overuse Injuries
Overview of Lower Extremity
Evia Nano
November 19, 2004

2. Overuse injuries
Sports injuries are often associated with suddenly snapped bones and ripped tendons, but in non-contact sports, the vast majority of injuries come on gradually.
Stress that builds over time can cause aching kneecaps, stress fractures, shin splints, pulled muscles, tenderness in the Achilles tendon, or burning pain in the heel.
These problems strike most athletes at one time or another

3. Risk Factors That Contribute to Overuse Injuries
Intrinsic
Malalignment Muscle imbalance Inflexibility Muscle weakness Instability
Extrinsic
Training errors Equipment Environment Technique Sports-acquired deficiencies

4. Remember ACRONYMS P rotect R est I ce C ompression E levation H eat
A lcohol
R unning
M assage

5. TIPS ON AVOIDING INJURIES
Warm up and stretch before
Cool down after
The right exercise kit
Alternate types of exercises
Stop if it hurts
Caught a bug?

6. Evaluating and Examining the Athlete
Evaluation
The general evaluation of the injured athletes, independent of a specific evaluation of the site of injury, should include:
    Information related to training patterns
Running experience
Weekly mileage
    Inspection of shoe wear  Examination  
Musculoskeletal with an evaluation of the Athlete's gait and joint alignment, muscle strength, balance and flexibility, and palpation of the soft tissues

7. Lets Review the Foot

8. Turf Toe Syndrome
Turf toe can occur after a very vigorous upward bending of the big toe
Symptoms
Swelling and pain at the joint of the big toe and metatarsal bone in the foot.
Pain and tenderness on bending the toe or pulling (stretching) it upwards.

9. Turf Toe Syndrome Protect Rest Ice Compression Elevate
Avoid wt bearing 2-4d
Recovery (3-4 wks)

10. Hallux Limitus or Hallux Rigidus,
If Turf toe syndrome is ignored of partially treated
a reduction in how far the big toe can be pushed up (dorsoflexion).
pain in the big toe when it is dorsoflexed, or each time we take a step and "push off."
a "hard" bump or bone spur seen or felt on the top of the joint.
swelling around the joint by the end of the day, which may subside with rest.

11. Pes Cavus (Claw Foot)
is a genetic defect in the foot with a high arch.
This will often be associated with very tight calf muscles at the back of the lower leg.
Patient will not usually be any good at long distance running

12. Pes Cavus (Claw Foot) Pain in the feet during running.
Painful toes that are bent and cannot be straightened.
The abnormal shape can cause calluses or ulcers on the affected toes.
Do plenty of static stretching, especially of the calf muscles and the sole of the foot to avoid injuries
Fit orthotic devices.
Advise on the correct running shoes

13. Stress Fractures in the Foot
Can occur as a result of prolonged repeated loads on the legs.
Long distance runners are susceptible to this type of injury (in the calcaneus, navicular and metatarsal bones)
If the 2nd toe is longer than the big toe pt can be prone to this injury
A stress fracture of the 2nd or 3rd metatarsal bone is sometimes called a 'march fracture' because soldiers running in boots often get it!
An athlete who has a second toe which is longer than their big toe will be particularly prone to a fracture of the second metatarsal

14. Stress Fractures in the Foot
Symptoms
Pain in the forefoot worsened during activity or running
Tenderness and swelling at a point on the bone
Management
PRICE
X-ray the bone
Do a bone scan if x ray negative
Apply a plaster cast for weeks/non wt bearing
Ensure Physical therapy during this time
Athletes must ensure the muscles in the lower leg are stretched and supple before resuming exercise routine
Metatarsal stress fracture may not become apparent on x-rays until a few weeks after the injury. You may be able to return to gentle training three to four weeks after it is diagnosed
Be able to walk pain free before returning to running

15. Tarsal Tunnel Syndrome Entrapment of the Medial Calcaneal Nerve
Inflammation of medial and lateral plantar nerves.
More frequent in Athletes that over-pronate (foot rolls in)
Pain when standing for long periods of time or running
The flexor retinaculum constitutes the roof of the tarsal tunnel and is formed by the deep fascia of the leg and the deep transverse fascia (Richli, Roger, Carrasco, Charnsangavej, Rosenthal and Wallace, 1993).  The proximal and inferior borders of the tunnel are formed by inferior and superior margins of the flexor retinaculum (Holmes, 1994). The floor of the tunnel is formed by the superior aspect of the calcaneus, the medial wall of the talus, and the distal-medial aspect of the tibia (Holmes, 1994). The remaining fibro-osseus canal is termed the Richet’s or the  tibiocalcaneal tunnel (Holmes, 1994). The tendons of the flexor hallucis longus muscle, flexor digitorum longus muscle, tibialis posterior muscle, the posterior tibial nerve and the posterior tibial artery pass through the tarsal tunnel

16. Tarsal Tunnel Syndrome Entrapment of the Medial Calcaneal Nerve
Symptoms
Pain (possibly sharp) radiating into the arch of the foot, heal and sometimes the toes.
Pins and needles or numbness may be felt in the sole of the foot.
Diagnosis
Tapping the nerve (just behind the medial malleolus) reproduces pain. This is known as Tinel's Test.

17. Tarsal Tunnel Syndrome Entrapment of the Medial Calcaneal Nerve
Treatment
PRICE
Rehabilitation program.
If the athlete is over pronating should have orthotics fitted.

18. Inflammation of the Extensor tendons (extensor tendinitis)
The tendons which straighten the toes run along the top of the foot and are known as the Extensor tendons.
These tendons can become inflamed causing pain and swelling

19. Inflammation of the Extensor tendons (extensor tendinitis)
What causes it?
Overuse
Badly fitting shoes / shoes that are laced far too tightly
Change in training methods or running terrain, particularly hill running.
Running on icy or slippery surfaces can also be a cause.
Management
PRICE
Alter shoes or get shoes that fit properly!
Pad the shoe in the forefoot to take the pressure off.
Follow a rehabilitation programme for strengthening of the extensor muscles and stretching the calf muscles at the back of the lower leg
NSAIDS
If it is a long term problem a steroid injection may be given

20. Inflammation or rupture of the tendon of the Peroneus Brevis muscle.
The Peroneus Brevis muscle (does plantar flexion) and also pulls the outside of the foot upwards (eversion).
Tendon attaches to the fifth metatarsal on the outside of the foot.
This muscle can get very tight in runners especially those who run a lot on roads.
MRI currently is the diagnostic tool of choice

21. Inflammation or rupture of the tendon of the Peroneus Brevis muscle
The symptoms
Pain at the point of attachment to the outside of foot
Pain with toe walking or cutting laterally while playing on a field
Management
PRICE
Gently stretch the muscle if this does not produce pain
NSAIDS
Apply a cast if necessary
Grade 4 and sometimes 3 require surgery
Sobel Classification
Grade 1 - Flattened tendon
Grade 2 - Partial-thickness split less than 1 cm
Grade 3 - Full-thickness split less than 2 cm
Grade 4 - Full-thickness split more than 2 cm

22. Morton's Syndrome / Morton's Neuroma
Lat plantar N, combines with part of the Med plantar N
nerve lies above the fat pad of the foot, close to A and V
deep transverse metatarsal ligament creates the ceiling of nerve compartment
part of the lateral plantar nerve combines with part of the medial plantar nerve here. When the two nerves combine, they are typically larger in diameter than those going to the other toes. Also, the nerve lies in subcutaneous tissue, just above the fat pad of the foot, close to an artery and vein. Above the nerve is a structure called the deep transverse metatarsal ligament. This ligament is very strong, holds the metatarsal bones together, and creates the ceiling of the nerve compartment. The ground pushes up on the enlarged nerve with each step and the deep transverse metatarsal ligament pushes down. This causes compression in a confined space.

23. Morton's Syndrome / Morton's Neuroma
The condition is made worse by athletes who spin on the ball of their foot such as golfers and tennis players.
Pain when you squeeze the foot.
Pain if you press the end of a pen between the bones
part of the lateral plantar nerve combines with part of the medial plantar nerve here. When the two nerves combine, they are typically larger in diameter than those going to the other toes. Also, the nerve lies in subcutaneous tissue, just above the fat pad of the foot, close to an artery and vein. Above the nerve is a structure called the deep transverse metatarsal ligament. This ligament is very strong, holds the metatarsal bones together, and creates the ceiling of the nerve compartment. The ground pushes up on the enlarged nerve with each step and the deep transverse metatarsal ligament pushes down. This causes compression in a confined space.

24. Morton's Syndrome / Morton's Neuroma
Management
PRICE
Fit orthotics and avoid tight shoes or high heels
NSAIDS
Give exercises to strengthen the arch of the foot.
Corticosteroid and Anesthetic injection
Operate.

25. Lisfranc Injury of the Foot
Lisfranc joint fracture dislocations and sprains result from high-energy force such as motor vehicle crashes, falls from heights, athletic trauma
Early recognition and treatment lessen the possibility of post-traumatic arthrosis.
The Lisfranc joint, or tarsometatarsal articulation of the foot, is named for Jacques Lisfranc ( ), a field surgeon in Napoleon's army. Lisfranc described an amputation performed through this joint because of gangrene that developed after an injury incurred when a soldier fell off a horse with his foot caught in the stirrup.1,2

26. Lisfranc Injury of the Foot
Nonoperative Mgmnt Treatment with a short-leg walking cast, 4-6 weeks or until symptoms have resolved.
Operative Treatment it should be done within the first 12 to 24 hours after the injury. Or after 7 to 10 days to allow the reduction of swelling
Dorsal dislocation of the proximal base of the second metatarsal (small arrow) when the foot is placed in extreme plantar flexion with an axial load (large arrow).
closed fixation with percutaneous K-wires
open reduction and internal fixation with AO screw fixation

27. Weight-bearing anteroposterior and lateral views for Lisfrank injury
Anteroposterior non­weight-bearing radiograph of the left foot of the patient in the illustrative case. Note that this view shows no evidence of malalignment or any other joint disruption.

28. Plantar Fasciitis (Heel Spur)
The Plantar Fascia or arch ligament is a band that runs from under the heel to the front of the foot.
A rupture can sometimes occur at the origin of the arch ligament and result in inflammation and heel pain, Fasciitis.
This is more common in sports where jumping is important
increase in activities, no arch support, lack of flexibility in the calf muscles, being overweight, a sudden injury, using shoes with little cushion on hard surfaces, using shoes that do not easily bend under the ball of the foot, or spending too much time on the feet
If the athlete over pronates then they may be prone to this injury because as the foot rolls in, the arch ligament is stretched more, putting more strain on it.

29. Plantar Fasciitis (Heel Spur)
Symptoms
Heel pain if standing on tip toes,
Tenderness and swelling on heel,
numbness along the outside of the sole of the foot.
Pain worse first in the morning.
Worsens again during the day especially if walking a lot.
Heel pain at the origin of the arch ligament when weight is put on the foot, pain at this point if standing on tip toes, tenderness and swelling under the heel, numbness along the outside of the sole of the foot.
Pain is usually worse first thing in the morning. After a few minutes it eases as the foot gets warmed up, but can get worse again during the day especially if walking a lot.
If the athlete over pronates then they may be prone to this injury because as the foot rolls in, the arch ligament is stretched more, putting more strain on it.

30. Plantar Fasciitis (Heel Spur)
Management
PRICE
A good taping technique can help the foot get the rest it needs by supporting the plantar fascia.
NSAIDS
Prescribe orthotics
Streching and rehabilitation
X ray to see if there is any bone growth (calcification)
Operate if there is calcification.

31. Inflammation of the flexor tendons of the toes (flexor tendinitis)
Symptoms
Tenderness along the course of the tendons.
Pain when the big toe is bent against resistance.
Pain on the inside back of the ankle.
Pain in the arch of the foot.
Management
PRICE
NSAIDS
Orthotics and Rehab
The tendons which bend the toes originate from two muscles of the lower leg; the Flexor digitorum longus and the Flexor hallucis longus muscles

32. Bruised Heel / Heel Pain
Inflammation of the fat pad
Management
PRICE
Pad the heel of shoes with a shock absorbing insole.
Replace running shoes if they are old (more than 400 miles of running) or the soles are weakened through use.
If caught early – recovery within few days
If you catch this injury early and rest then it should recover quite quickly - within a few days. If you ignore the warning signs (heel pain) and the fat pad gets damaged beyond easy repair then this is a very difficult injury to treat. Rest means rest. There is no point you stopping running for a week if you put up scaffolding for a living and are on your feet every day. If you have to be on your feet then ensure you put a shock absorbing and cushioning heel insert into your shoes.

33. Calcaneal Stress Fractures
Symptoms
Insidious, gradual onset heel pain.
Pain is made worse by weight bearing
Pain is reproduced by squeezing the back of the heel from both sides
Management
PRICE
Rest, non ft wt bearing 6 to 8 weeks
X-ray the bone.
Bone scan if X ray neg
Apply a plaster cast for 2-6wk

34. Calcaneal Stress Fractures
Often an X-ray of the injured bone will not show any sign of fracture until the fracture has actually started to heal (2-3 weeks later). It is also possible that a stress fracture will not appear on an X-ray at all

35. Sprained or Twisted ankle
The most common type of ankle injury is a sprain. A sprain is stretching and tearing of talo-fibula ligament
Degrees of sprain
First degree:
Some stretching or perhaps tearing of the ligament.
Little or no joint instability.
Second degree:
Some tearing of the ligament fibres
Moderate instability of the joint
Third degree:
Total rupture of a ligament
Gross instability of the joint

36. Sprained or Twisted ankle
Management
PRICE
NSAIDS
Rehabilitation exercises
Use ultrasound and laser treatment.

37. Tibialis Posterior Syndrome
Inflammation around medial malleolus
Athletes involved in skating or running on tight bends are more prone to this injury
Assessment of the tendon asking the patient to resist an abductory force applied to the forefoot whilst the foot is in a plantar flexed and adducted position
MRI only of benefit is assessing the extent of structural changes, not in the actual diagnosis
tibialis posterior muscle comes from behind the tibia and runs into medial malleolus.

38. Tibialis Posterior Syndrome
Symptoms
Pain over the attachment of the tendon to the navicular bone in the foot.
Swelling around the medial malleolus
Management
PRICE
NSAIDS
Injection into the tendon sheath
Plaster cast for 3 weeks
Rehabilitation exercises
Surgery if the tendon is completely ruptured

39. Peroneal Tendonitis and Disloaction
The injury is common in athletes with unstable ankles
Symptoms
Pain or tenderness behind the lateral malleolus
Swelling and bruising
Diagnosis
Assessment of the tendon asking the patient to resist an adductory force applied to the forefoot whilst the foot is in a plantar flexed and abducted position
Management
The same as per other Tendonitis
The peroneal tendon runs behind the lateral malleolus

40. Achilles Tendinitis
The Achilles tendon is the large tendon at the back of the ankle. It connects Gastrocnemius and Soleus to calcaneus
This tendon can become inflammed through overuse
It is estimated that 11% of all running injuries can be due to Achilles tendinitis
The Achilles tendon has a poor blood supply which is why it is slow to heal.

41. Achilles Tendinitis Symptoms : Pain on the tendon during exercise.
Swelling over the Achilles tendon.
Redness over the skin.
You can sometimes feel a creaking when you press your fingers into the tendon and move the foot.

42. Achilles Tendinitis Management PRICE NSAIDS
Identify the causes and prescribe orthotics or a change in training methods.
Apply a plaster cast
ultrasound treatment
Apply sports massage techniques.
Rehabilitation programme.
Steroid injection controversial, can increase the risk of a total rupture
If you look after this injury early enough you should make a good recovery. It is important you rehabilitate the tendon properly after it has recovered or the injury will return. If you ignore the early warning signs and do not look after this injury then it may become chronic which is very difficult to treat

43. Achilles Bursitis (Retrocalcaneal bursitis)
This is a common condition in athletes, particularly runners. It can often be mistaken for Achilles tendinitis or can also occur in conjunction with Achilles tendinitis (Haglund’s syndrome)
Symptoms
Pain at the back of the heel when running uphill
Tenderness and swelling which might make it difficult to wear certain shoes.
When pressing fingers in both sides of the heel a spongy resistance may be felt.
The retrocalcaneal bursa lies between the Achilles tendon and the calcaneus (heel bone). With repeated trauma the bursa can become inflammed

44. Achilles Bursitis (Retrocalcaneal bursitis)
Management
PRICE
NSAIDS
Identify the causes and prescribe orthotics or a change in training methods.
Apply a plaster cast
ultrasound treatment
Apply sports massage techniques.
Rehabilitation programme.
Steroid injection controversial, can increase the risk of a total rupture

45. Apophysitis Calcanei (Sever's disease)
This condition occurs mainly in active children aged 8 to 15 y/o
The site at which the Achilles tendon attaches to the heel becomes inflammed and the bone starts to crumble It is often associated with a rapid growth spurt.
As the bones get longer, the muscles and tendons become tighter.
This is the second most common injury of this type in youngsters after Osgood Schlatter's of the knee and very simmilar

46. Chronic Posterior Deep,Lateral, Anterior Compartment Syndrome
Muscle compartments —
The anterior tibial compartment
(tibialis anterior and the extensor hallucis longus)
The deep posterior compartment
(tibialis posterior, the flexor digitorum longus, and the flexor hallucis longus)
The lateral compartment
(peroneus) longus and peroneus brevis muscles.
The superficial posterior compartment (soleus muscle and the two heads of the gastrocnemius)

47. Chronic Posterior Deep, Lateral, Anterior Compartment Syndromes
Physiology
Over use and over developing the muscle through training.
At rest the blood vessels are not at capacity. During exercise these blood vessels fill up much more and expand putting pressure on the sheath
Symptoms
Aching or cramping of the leg in the anatomic distribution of the compartment within 10 to 30 minutes of exercise. There is usually a return to normal function between episodes
Diagnosis
Measure intracompartment
pressure

48. Chronic Posterior Deep, Lateral, Anterior Compartment Syndromes
Management
PRICE
NSAIDS
Identify the cause and change training methods.
ultrasound treatment
Apply sports massage techniques.
Surgery may be needed to decompress the compartment but is usually not an emergency in chronic compartment

49. Periostitis (Shin splints)
Caused by running on hard surfaces or running on tip toes, jumping,over pronation
Tenderness over the inside of the shin and erythema
Lumps and bumps over the bone.
A redness over the inside of the shin

50. Stress Fracture of the Fibula, Tibia
A stress fracture is a small fracture or hairline crack in the bone
Pain on weight bearing
PRICE
NSAIDS
CAST
Return to training very gradually.
Stretch the muscles of the lower leg.

51. Inflammation of the Illiotibial band Runners Knee
The Illio-tibial band runs down the outside of the thigh. If this becomes tight the tendon starts to rub on the bone at the knee. Eventually this will become inflamed until running becomes very painful. If you rest, the inflammation dies down but reappears when you start to run again.

52. Patellar Tendinitis Inflammation can result from overuse.
It affects athletes involved in jumping or throwing,weight lifters, Tennis and Badminton players
Pain at the bottom of the kneecap when pressing
Aching and stiffness after exertion.
Pain when you contract the quadriceps muscles

53. Bakers Cyst (Popliteal Cyst)
Overuse of the knee causes the synovial fluid within the knee joint to increase. This then spills into the bursa at the back of the knee causing it to increase in size
A rounded swelling the size of a golf ball, shining light through the lump can see a red glow .
Pressure in the back of the joint
Difficulties in bending the joint.
Aching and tenderness after exercise
Differential Diagnosis:
r/o tumor or an aneurysm
40% chance of the Cyst returning if surgical correction
Therapy is favored as method

54. Epicondylitis difficulty holding onto, pinching, or gripping objects
pain, stiffness, or insufficient elbow and hand movement
forearm muscle tightness
insufficient forearm functional strength
point tenderness at or near the insertion sites of the muscles of the lateral or medial elbow
Epicondylitis
Lateral (Tennis Elbow)
Medial (Golfers Elbow)

55. Tennis elbow / Lateral epicondylitis
Management
PRICE
Streching/strengthening exercises
Bracing
Equipment modifications

56. Myositis Ossificans (Heterotopic Bone Formation)
A bad muscle strain or contusion that is neglected. It is usually as a result of impact which causes damage to the sheath that surrounds a bone (periostium) as well as to the muscle. Bone will grow within the muscle (called calcification). The bone will grow 2 to 4 weeks after the injury and be mature bone within 3 to 6 months.

57. Tips for preventing overuse injuries:
Don't push through pain.
Increase your workouts gradually.
Increase running by10 percent per week/ Don't run more than 45 miles per week.
Run on soft, flat surfaces. Alternate hard training days with easy days.
Get new running shoes every 500 miles.
Women should make sure they're getting enough calcium, whether from their diet or from supplements. Stress fractures are 10 times more common in women than in men.
Ankle sprains may be the most common sports injury not caused by overuse.
Usage of some ankle strengthening or lace-up stabilizers, can help you avoid injury (see below). High-top shoes didn't lower the risk of ankle sprains.

58. References
Techdjian, MO. Clinical Pediatric Orthopedics. Appleton and Lange, Stamford, CT 1997.
Reid, DC. Sports Injury Assessment and Rehabilitation, 1st ed. Churchill Livingstone, New York 1992.
Morrisey, RT, Weinstein, SL. Lovell and Winter's Pediatric Orthopedics, 5th ed. Lippincott Williams and Wilkins, Philadelphia.
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