Sports Medicine: Diagnosis and

Treatment of Lower Extremity

Injuries

Gerard A. Malanga, MD
Director, Sports Medicine Mountainside Hospital
Montclair, New Jersey
Associate Professor, Physical Medicine & Rehab.
UMDNJ- New Jersey Medical School
 Basic Principles of Functional
Rehabilitation

■ Phase I: Decrease Pain and inflammation

PRICE ( Protection, Rest, Ice, Compression,
Elevation)
■ Phase II: Restore Normal/Symmetric Range of
Motion (ROM)
■ Phase III: Restore Normal/Symmetric Strength
■ Phase IV: Neuromuscular Control
(Proprioceptive) Re-training
■ Phase V: Sport specific training
 Foot and Ankle Injuries

■ MTP sprain ( “ turf toe” )

■ Mid-foot sprain
■ Plantar fasciitis
■ Achilles tendinitis
■ Lateral ankle sprains
■ Deltoid ligament sprains
■ Syndesmosis ankle sprain
 Foot and Ankle Injuries
MTP Sprain (“ Turf toe”)

■ History:
– usually hyperdorsiflexion of the great
toe
– pain with weight bearing, esp. push off
■ Examination:
– tenderness + swelling of the 1st MTP
– decreased ROM at the MTP
■ Treatment:
– NSAID, ice, tape, long rigid shoe
orthotic
 Foot and Ankle Injuries
Midfoot sprain

■ History:
– awkward landing of the forefoot,
usually in inversion
– sudden pain difficulties
walking/running
■ Examination:
– swelling, ecchymosis over dorsal
medial foot
– tenderness to palpation and stress
of the forefoot
– antalgic gait
 Foot and Ankle Injuries
Midfoot sprain

■ Treatment:
– x-rays to rule out
widening of the 1st and
2nd tarsometatarsal rays
– widening of greater than
5 mm : surgery
– otherwise: cast
immobilization in
plantarflexion and
supination X 5-6 weeks
– mild sprains: crutches
WBAT, ice, ROM
 Foot and Ankle Injuries
Plantar fasciitis

■ History:
– insidious onset of heel and plantar
foot pain
– increased pain on first standing in
AM or after a period of sitting
■ Examination:
– pain on palpation at the medial
calcaneus
– increased pain with great toe
dorsiflexion and palpation
– tight heel cord and plantar fascia
 Foot and Ankle Injuries
Plantar fasciitis

■ Examination:
– pes planus or pes cavus
■ Treatment:
– x-rays are not necessary !
– stretching, icing, foot intrinsic
strengthening, orthotics for
biomechanical foot abnormalities
– US/ phonoporesis usually not helpful
– night splinting
– injection ???
 Foot and Ankle Injuries
Achilles tendinitis

■ History:
– insidious onset of posterior
heel/leg pain
– increase activity level:
running, jumping, etc.
■ Examination:
– tenderness to palpation at
distal Achilles tendon
– occasionally swelling and
nodularity of paratenon
– antalgic gait
 Foot and Ankle Injuries
Achilles tendinitis

■ Treatment:
– ice, NSAIDs, stretches
– heel lift ( temporarily ! )
– strengthening the
gastrocsoleus: concentric
and eccentric
– gradual increase in
loading
 Foot and Ankle Injuries
Lateral ankle sprains

■ History:
– forceful ankle inversion, usually in a
plantarflexed position
– sudden pain, swelling difficulties
walking
■ Examination:
– swelling, ecchymosis
– pain on palpation: ATFL, CFL, PTFL
– laxity testing: talar tilt, anterior
draw
 Foot and Ankle Injuries
Lateral ankle sprains

■ Treatment:
– PRICE
– maintain heel cord
flexibility
– ankle everter
strengthening
– proprioceptive
training
– ankle bracing for
Grades II and III
 Foot and Ankle Injuries
Deltoid ligament sprains

■ History:
– forceful eversion, usually
dorsiflexed ankle
– difficulties ambulating
■ Examination:
– swelling, ecchymosis medially
– tender to palpation
– pain on passive eversion
– pain with resisted external
rotation
– rule out fibular tenderness !
 Foot and Ankle Injuries
Deltoid ligament sprains

■ Treatment:
– rule out
syndesmosis
– PRICE
– crutches WBAT
– airsplint
– ROM,
strengthening
– ankle bracing
 Foot and Ankle Injuries
Syndesmosis sprains

■ History:
– similar to deltoid ligament sprain
– patient with more proximal pain
■ Examination:
– tender more proximally: Anterior
tibiofibular ligament
– positive “squeeze test”
– rule out any proximal fibular
tenderness
 Foot and Ankle Injuries
Syndesmosis sprains

■ Treatment:
– x-rays to rule out widening of
the distal tib/fib
– if there is widening then
surgical treatment is
recommended
– otherwise treat as per medial
deltoid ligament sprain
– expect a long rehab course
 Knee Injuries

■ Patellofemoral Syndrome
■ MCL/LCL Sprains
■ ACL/PCL Sprains
■ Meniscal tears
 Knee Injuries
Patellofemoral Syndrome

■ History:
– insidious onset of anterior
knee pain
– increased pain with knee
flexion e.g.... prolong
sitting, up/down stairs
– no swelling, occasional
complaints of “clicking”
and give way { must DDx
from meniscal tears and
ACL injuries )
 Knee Injuries
Patellofemoral Syndrome

■ Examination:
– tenderness to palpation
about the patella;
usually medially or
superior laterally
– abnormal patellar tilt
– atrophy/ poor activation
of VMO
– tight ITB, Quads, HS
– increased Q angle
» check for pes planus
 Knee Injuries
Patellofemoral Syndrome

■ Treatment:
– Ice
– Stretches: ITB, HS, Quads
– Strengthening: VMO, CKC
– EMG biofeedback if VMO
is not activating
– Mc Connell taping; bracing
– shoe orthotics for pes
planus
 Knee Injuries
MCL/LCL Sprains

■ History:
– sudden valgus or
varus force to the
knee
– occasional “pop”
will be heard
– immediate pain
difficulties
cutting
– usually little or
no swelling if
isolated injury
 Knee Injuries
MCL/LCL Sprains

■ Examination:
– pain on end ROM usually
flexion
– tenderness to palpation;
usually midsubstance
– Grade II : laxity with firm
end point @ 30 degrees
– Grade III: laxity with soft end
point @ 30 degrees
– rule out laxity at 0 degrees
 Knee Injuries
MCL/LCL Sprains

■ Treatment:
– PRICE
– crutches WBAT
– rarely: Knee immobilizer
– early pain free ROM
– return to play: no pain, full
pain-free ROM, no pain on
palpation, no pain or laxity
on stress testing
– bracing for remainder of
season for Grade III
 Knee Injuries
ACL Sprains

■ History:
– twisting injury after
planting and pivoting
– hyperextension
– valgus force to the knee
– sudden pain, “pop”, sense
of instability of knee
– rapid swelling
 Knee Injuries
ACL Sprains

■ Examination
– acutely: effusion,
decreased ROM
– Anterior draw, Lachman
– rule out other injuries:
MCL , MM, LM
» O’Donahue’s triad: ACL,
MCL, MM
 Knee Injuries
ACL Sprains

■ Treatment:
– PRICE
– crutches WBAT
– restore full ROM
– CKC strengthening; HS
biased strengthening
– Proprioceptive training
– bracing for high demand
sports
 Knee Injuries
ACL Sprains

■ Treatment:
– operative treatment :
young, high-demand
activity; unwilling to
modify activity level; failed
nonoperative treatment
– post-operative treatment
similar to nonoperative
treatment
– encourage early ROM, CKC
strengthening, protect
graft from stress
 Knee Injuries
PCL Sprains

■ History:
– fall on a flexed knee;
dashboard injury
– usually minimal
swelling, mild
discomfort
■ Examination:
– posterior sag sign
– Posterior draw
 Knee Injuries
PCL Sprains

■ Treatment:
– PRICE as needed
– ROM
– CKC strengthening;
Quadriceps biased
– generally no need
for bracing
 Knee Injuries
Meniscal tears

■ History:
– acute tears: twisting injury; usually
with some flexion
– chronic degenerative tears:
insidious, at time after a period of
prolong knee flexion
– swelling; usually more gradual than
after ACL injury
– clicking, catching, locking; pain
with knee flexion
 Knee Injuries
Meniscal tears

■ Examination:
– effusion
– decreased flexion
– pain on hyperflexion
– joint line tenderness
– McMurray’s: very
specific but poor
sensitivity
 Knee Injuries
Meniscal tears

■ Treatment:
– PRICE; tubigrip compression; NSAID
– WBAT
– decrease weight bearing activities
– LE strengthening; isometrics initially
– aspiration if not responding
– surgery for locked knees; patients not
responding to treatment with mechanical
Sx after 3 months
 Hip Injuries

■ Hip flexor strain

■ Greater trochanteric bursitis
■ Hamstring strain
■ Apophysitis/avulsions
 Hip Injuries
Hip flexor strain

■ History:
– sudden extension of hip
– groin pain; increased with hip
flexion
■ Examination:
– pain on palpation of the psoas
tendon
– pain with resisted hip flexion
and passive extension
– mild pain with PROM of the hip
 Hip Injuries
Hip flexor strain

■ Treatment:
– x-rays: r/o hip joint
pathology/avulsion
– PRICE; crutches if
limping
– early stretching after a
warm up
– limited weight bearing
activities until the pain
decreases
 Hip Injuries
Greater trochanteric bursitis

■ History:
– usually insidious onset of lateral
hip pain
– can occurs after direct trauma
– increased pain with walking and
running
■ Examination:
– tenderness to palpation over
greater trochanter
– look for: hip abductor weakness,
tightness of the ITB as
biomechanical causes
 Hip Injuries
Greater trochanteric bursitis

■ Treatment:
– ICE !
– strectch ITB, HS, Quads
– strengthen hip abductors
– injection if not responding
– US only to facilitate ITB
stretching
 Hip Injuries
Hamstring strain

■ History:
– sudden posterior thigh pain
– usually runner or sprinter during
knee extension
– eccentric overload
■ Examination:
– anatalgic gait
– pain, ecchymosis posterior thigh
 Hip Injuries
Hamstring strain

■ Examination (cont.):
– pain on palpation
– tightness and pain with
passive stretching
■ Treatment:
– PRICE
– encourage AROM, gentle
stretching
– crutches as needed
– strengthening when no pain,
improved ROM
 Hip Injuries
Hamstring strain

■ Treatment (cont):
– strengthening
should include
CKC, eccentric,
and plyometric
training
– return to sport
when strength is
symmetric
 Hip Injuries
Apophysitis/Avulsions

■ History:
– muscle overload in skeletally
immature athlete
– present like muscle strains in the
adult
■ Examination:
– pain on palpation and stretch of
the involved muscle
■ Treatment:
– functional rehabilitation: vast
majority do well
Thank you