Patellar Instability Or Maltracking

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Dynamic Tracking Patella
Fig. 134 Mal-tracking patellae, as shown by 3D CT scan

Fig. 135 Patella alta, as shown by 3D CT scan

Sagging Patella

Fig. 137 Genu recurvatum, often seen in players with general joint laxity

Fig. 136 Anatomic view of patellar mal-tracking

SYMPTOMS The knee feels unstable or weak, or gives way in association with recurrent pain around the anterior part of the knee, with or without preceding trauma. It is particularly common in young female athletes.

AETIOLOGY This condition can be caused by inherited conditions such as patella baja or alta, genu valgus or muscle imbalance around the knee. It can develop after a previous patella dislocation.

Fig. 137 Genu recurvatum, often seen in players with general joint laxity

CLINICAL FINDINGS Occasionally there is effusion but most commonly there are few clinical findings. An increased Q-angle and hyper-mobility can raise the suspicion of this diagnosis. INVESTIGATIONS Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. X-ray is valuable to rule out patella abnormalities. A three-dimensional CT scan taken at different knee angles can help measure the level of mal-tracking. MRI and arthroscopy may be important for evaluating alternative diagnoses. There is a high risk that cartilage on the kneecap as well as on the femur condyle will have been damaged if there was a previous dislocation. The combination of partial ACL rupture and patellar instability is not uncommon. TREATMENT An athlete with anterior knee pain and recurrent instability of the patella should be seen by an orthopaedic surgeon and a physiotherapist. Most cases can be treated without surgery and with physiotherapy, working in particular on muscle strength and control of the entire kinetic chain. In cases with an increased Q-angle of over 20 degrees, surgical treatment with anterior medialisation of the tuberositas tibia may be indicated if physiotherapy fails. REFERRALS Refer to orthopaedic surgeon for further investigations to verify the diagnosis. Physiotherapists should be involved in close collaboration with the surgeon.

EXERCISE PRESCRIPTION Cycling and water exercises are good alternatives to keep up general fitness. Valgus stress to the knee should be avoided so breast stroke is not recommended. Rehabilitation back to full sport usually takes around six months. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms and signs. Different functional knee scores for different sports are available to measure when the knee allows a return to full sport.

DIFFERENTIAL DIAGNOSES Meniscus tear, chondral injuries, OCD, medial plica syndrome, chondromalacia patellae, quadriceps insufficiency, Sinding-Larsen's syndrome, patellar tendon disorders, referred pain, secondary symptoms from ankle or back insufficiency, core instability and more.

PROGNOSIS Good-Fair. Appropriate treatment will allow a return to professional sport within three (non-operative) to six months (after surgery).

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17. PATELLAR TENDINOSIS

Fig. 138 Palpation test for patellar tendinosis

SYMPTOMS Gradual onset of diffuse exercise-induced pain or ache around the proximal part of the patellar tendon. It is common in middle-aged runners and recreational athletes in racket sports. AETIOLOGY Tendinosis is defined from histopatho-logical findings as a free tendon condition with altered collagen structure, thickening of the tendon, re-vascularisation and increased cellularity. It can be looked upon as an active halt in an early healing stage and is an ongoing process, not a degenerative condition. The condition may or may not be symptomatic. A majority of complete Achilles tendon and rotator cuff ruptures show these changes. It is most often localised at the proximal, central and posterior part of the patellar tendon. CLINICAL FINDINGS There is localised tenderness on palpation over the tendon, which often is thicker than the other side. There may be inflammatory signs with redness and increased temperature. Compare to the other side.

Fig. 139 Patellar tendinosis, as shown by MRI, in the most proximal and posterior part of the tendon insertion

INVESTIGATIONS Ultrasound or MRI will show typical intra-tendinous findings. TREATMENT This often chronic ailment may respond to conservative treatment in the early stages, including modification of training and muscle strengthening exercises that can be tried over three months. If this regime is not successful, surgery may be necessary to excise parts of the tendon. Cortisone injections should be administered only in rare exceptions, due to the high risk of later tendon rupture; indeed, NSAID and cortisone injection is one of the possible triggers of this ailment. Surgery is followed by a few weeks' partial immobilisation and a few months' rehabilitation before resuming sport. Weight bearing is usually allowed soon after surgery, avoiding plyometric activities. REFERRALS Refer to orthopaedic surgeon for consideration of surgery. Refer to physiotherapist for planning of a three to six months' return programme back to sport.

Fig. 140 Surgical excision of severe patellar tendinosis

EXERCISE PRESCRIPTION Cycling and water exercises (when the wound is healed) are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Note that the injured tendon will remain thicker than the non-injured. Calf muscle performance should be similar to the other side. Objective tests for quadriceps strength and for flexibility and proprioception, such as the one-leg hop test, are strongly recommended before resuming full sport. DIFFERENTIAL DIAGNOSES Tendinosis, tendinitis, bursitis, impingement from patella tip spur, meniscus tear, chondral injuries, OCD, medial plica syndrome, chondromalacia patellae, patellar instability or mal-tracking, quadriceps insufficiency, Sinding-Larsen's syndrome, fat pad syndrome, synovitis, referred pain, secondary symptoms from ankle or back insufficiency, core instability and more. PROGNOSIS Good-Poor; in some cases this condition can be the beginning of the end for an elite athlete.

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18. POPLITEUS TENOSYNOVITIS

Exercises For Plica Syndrome
Fig. 141 PopLiteus resistance test. Putting the Leg in a figure-of-4 position opens up the Lateral joint line for palpation

SYMPTOMS Gradual or acute onset of localised exercise-induced pain at the lateral posterior aspect of the knee with or without preceding trauma. It is most common in pivoting sports like football or rugby or in cross-country running. AETIOLOGY This is an inflammatory response around the popliteus tendon in the posterior lateral intra-articular part of the knee. This condition typically occurs as a result of sudden changes in training habits, such as an increase in intensity or amount of impact, or after a direct impact, such as a kick.

CLINICAL FINDINGS There is tenderness on palpation in the posterior and lateral joint line over the femur condyle that is aggravated by a resistance test.

INVESTIGATIONS X-ray is normal. MRI may show superficial sub-chondral oedema and can usually exclude a lateral meniscal tear. Ultrasound is also helpful in the diagnosis. Repeating the clinical test before and after 1 ml of local anaesthetic is injected

Fig. 142 Popliteus tenosynovitis, as shown by anthroscopy

into the most painful spot can usually help make the diagnosis clear.

TREATMENT This injury most often responds to conservative treatment, including modification of training and stretching exercises of the knee muscles. There is seldom an indication for surgery but in unclear situations, with effusion, arthroscopy may be needed to verify the diagnosis and administer a minor dose of cortisone.

REFERRALS Refer to physiotherapist for planning of a three months' return programme back to sport. Refer to orthopaedic surgeon if non-operative treatment fails.

EXERCISE PRESCRIPTION Most forms of exercise are allowed but temporary avoidance of jumping, twisting and pivoting activities may help.

EVALUATION OF TREATMENT OUTCOMES

Normal clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Stress fracture (MRI differentiates), lateral meniscal tear (MRI or arthroscopy differentiate), iliotibial band traction syndrome (clinical differentiation and no effusion). PROGNOSIS Excellent.

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19. POSTERIOR CRUCIATE LIGAMENT TEAR (PCL)

Fig. 143 Posterior sag of tibia indicates a PCL rupture

SYMPTOMS Immediate haemarthrosis and pain in the knee after a sudden hyper-flexion or hyperextension sprain or direct tackle. It is common in contact sports such as football and rugby and other high-intensity sports. AETIOLOGY The typical athlete suffers a hyperextension or valgus rotation sprain during sport or after a direct impact to the anterior proximal tibia while the knee is flexed ('dashboard' injury). The thick ligament can rupture partially or completely. In growing athletes or after highforce trauma, the posterior tibia bone insertion can be avulsed. Note! This injury is often associated with injuries to cartilage, menisci, capsule or other ligaments.

CLINICAL FINDINGS There is intra-articular bleeding (haemarthrosis) in most cases. If there is a capsule rupture, blood can penetrate from the joint and cause bruising. The posterior drawer test is positive if the rupture is complete. Since there are often associated injuries, examination must also include tests for collateral ligaments, menisci and cartilage.

INVESTIGATIONS Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. X-ray is valuable to rule out fractures, in particular in growing athletes or after high-impact trauma. MRI is valuable for evaluating associated injuries.

TREATMENT An athlete with haemarthrosis and suspected PCL tear should be seen by an orthopaedic surgeon to consider arthroscopy. This procedure can verify the diagnosis and deal with associated injuries that are often missed. An athlete with a complete PCL tear can usually return to full activity in most sports without surgical reconstruction. A PCL brace is very useful. However, individual considerations must be made. These injuries should be treated by a knee specialist. REFERRALS Refer to orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon. EXERCISE PRESCRIPTION After surgery, cycling and water exercises are good alternatives to keep up general fitness. Rehabilitation back to full sport usually takes around six months. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms and signs. Different functional knee scores for different sports are available to measure when the knee allows a return to full sport. Recurrent pain is more common than subjective instability after a PCL injury has been thoroughly rehabilitated.

DIFFERENTIAL DIAGNOSES ACL rupture (initial posterior sagging will give a sense of anterior translation of tibia during Lachman or anterior drawer test and mislead the examiner). PROGNOSIS Good-Fair. Surgery (PCL reconstruction) may be indicated in severe cases and will allow a return to professional sport within around six to nine months. Cartilage injuries and recurrent pain and effusion are common complications.

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20. POSTERIOR LATERAL CORNER INJURIES

Popliteus Tendinitis Symptoms
Fig. 144 A posterior lateral corner injury, reflected in the joint by separation of the popliteus tendon from lateral meniscus corner, as seen by arthroscopy

SYMPTOMS The symptoms are immediate haemarthrosis and pain in the posterior lateral corner of the knee. This injury is common in contact sports such as football and rugby. The diagnosis is often missed.

AETIOLOGY The typical athlete suffers a hyperextension and varus rotation sprain during sport. The posterior lateral corner structures involve the capsule, the popliteus tendon and the lateral collateral ligament and can rupture partially or completely. This injury is often associated with other injuries to cartilage, menisci, capsule or other ligaments.

CLINICAL FINDINGS There is intra-articular bleeding (haemarthrosis) in most cases. If there is a capsule rupture, blood can penetrate from the joint and cause bruising. Dyer's test is positive. Since there are often associated injuries, the examination must include tests for collateral ligaments and menisci.

Fig. 145 A PLC injury and consequential laxity can be demonstrated by an increased external rotation of the foot with the knee flexed around 30 degrees (Dyer's test)

INVESTIGATIONS Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. X-ray is valuable to rule out fractures. MRI is valuable for evaluating associated injuries. TREATMENT An athlete with haemarthrosis and suspected posterior lateral corner injury should be seen by an orthopaedic surgeon to consider arthroscopy. This procedure can verify the diagnosis and deal with associated injuries. Surgery is often indicated but has to be determined individually and by a knee specialist. Surgery (reconstruction) will allow a return to professional sport within around six months. The reconstruction will protect the knee from further meniscus or cartilage injuries and restore function but it is technically difficult and a good outcome cannot be guaranteed. This injury is often missed if combined with an ACL tear. When the ACL has been reconstructed, rotational instability will remain.

REFERRALS Refer to orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon. EXERCISE PRESCRIPTION Cycling and swimming (but not breaststroke) are good alternatives to keep up general fitness. Rehabilitation back to full sport usually takes around six months.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Different functional knee scores for different sports are available to measure when the knee allows a return to full sport.

DIFFERENTIAL DIAGNOSES ACL or PCL rupture. PROGNOSIS Good-Poor. This is an injury that can halt a professional career.

21. POSTERIOR MEDIAL CORNER INJURIES

Septated Ovarian Cyst
Fig. 146 A posterior medial corner injury, reflected in the joint by the capsule rupture, as seen by arthroscopy

SYMPTOMS The symptoms are acute posterior and medial knee pain and haemarthrosis, which is caused by bleeding from the ruptured posterior medial capsule. Since the capsule ruptures, the extent of bleeding is often underestimated. This injury is fairly uncommon but occurs in contact sports such as football, rugby and others. AETIOLOGY The typical athlete suffers a hyperextension and valgus rotation sprain. The capsule can rupture partially or completely. This injury is often associated with other injuries to the medial meniscus, cartilage or other ligaments, in particular the medial collateral ligament. CLINICAL FINDINGS There is haemarthrosis in most cases. The capsule rupture will make blood penetrate from the joint and cause bruising. With the foot in internal rotation the posterior drawer test shows increased laxity if the rupture is complete but this injury is often missed clinically and found only during arthroscopy or MRI. Since there are often associated injuries, examination must also include tests for other ligaments, menisci and cartilage.

INVESTIGATIONS Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. MRI can verify a capsule tear in most cases but this injury is often noted first on arthroscopy. TREATMENT An athlete with haemarthrosis and suspected posterior medial capsule tear should be seen by an orthopaedic surgeon to consider arthroscopy. This procedure can verify the diagnosis and deal with associated injuries that are often missed. This injury may require early open or arthro-scopic surgery or bracing over six to twelve weeks. REFERRALS Refer to orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon. EXERCISE PRESCRIPTION Cycling and swimming (but not breaststroke) are good alternatives to keep up general fitness. Rehabilitation back to full sport usually takes around six months. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms and signs. Different functional knee scores for different sports are available to measure when the knee allows a return to full sport.

DIFFERENTIAL DIAGNOSES PCL rupture. PROGNOSIS There is very little data regarding the outcome of this particular injury.

Burst Prepatellar Bursa
Fig. 147 Typical appearance of prepatellar bursitis

SYMPTOMS There is gradual or acute onset of localised swelling and inflammatory signs over the patella.

AETIOLOGY The bursitis can develop from a direct trauma and bleeding or from repetitive stress, when synovial fluid fills the bursa (housemaid's knee) or when pus from infected superficial skin wounds penetrates the bursa.

CLINICAL FINDINGS There is a localised tender and fluctuating swelling anterior to the patella but no effusion on the knee.

INVESTIGATIONS X-ray is normal. MRI or ultrasound will confirm.

TREATMENT If the swelling is caused by bleeding or temporary over-use (kneeling on hard ground) this injury responds to conservative treatment including cold and compression and avoidance of direct impact to the knee. There is seldom an indication for surgery. If it is caused by infection, antibiotics and open drainage of the bursa should be considered. REFERRALS Refer to orthopaedic surgeon to determine the cause of the bursitis and treatment. EXERCISE PRESCRIPTION Rest if the cause is infection. Otherwise most sports could be allowed, but avoid direct impact on the knee. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Soft tissue tumour (rare). Septic bursitis can develop into a much more dangerous septic arthritis by penetration of bacteria into the knee joint via the blood. PROGNOSIS Good-Fair. Once the bursa has been affected, it will be more sensitive to further knocks and the bursitis can therefore recur independent of the initial cause.

23. RUPTURE OF THE QUADRICEPS OR HAMSTRING MUSCLES

Septic Bursitis Thigh
Fig. 148 Clinical view of quadriceps rupture in right leg

Fig. 150 Resisted strength test of rectus femoris hip flexion function

Fig. 149 Haematoma after a quadriceps muscle rupture. Note the mark of the football on the thigh. Apply ice and compression!

Fig. 150 Resisted strength test of rectus femoris hip flexion function

SYMPTOMS Sudden sharp pain most commonly affecting the quadriceps or hamstring muscles during activity. Often the athlete falls in the middle of a stride and cannot continue. AETIOLOGY The tear can be partial (Grade I-II) or complete (Grade III-IV), often close to a musculo-tendinous junction and occasionally at the origins. The muscle can tear from sudden excessive strain, often during an eccentric contraction such as landing from a jump or push-off in sprinting.

Resisted Knee Extension
Fig. 151 Resisted strength test of quadriceps knee extension function

CLINICAL FINDINGS There is tenderness on palpation around the rupture; sometimes there is a palpable gap in the muscle. Contraction of the muscle during a resistance test is painful and there is obvious weakness.

Aetiology For Hamstring Injury
Fig. 152 Resisted strength test of hamstring muscles

INVESTIGATIONS Clinical examination is the most important tool for diagnosis and should also include tests for all ligaments and other structures in the knee. Ultrasound and MRI can be valuable to determine whether the tear is intra- or intermuscular, which is important for treatment and prognosis.

TREATMENT Most muscle ruptures can be treated without surgery with immediate compression and ice, followed by gradual mobilisation and increased activity, guided by a rehabilitation programme, over three months. If the rupture is complete, surgery may be required. Also if the rupture and bleeding occur within its fascia, intra-muscular, surgical evacuation of the haematoma may be necessary. REFERRALS Refer to orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon. EXERCISE PRESCRIPTION Cycling and swimming are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Monitor clinical symptoms and signs. Muscle strength and flexibility must be up to the same standard as the non-injured leg before allowing a return to full sport. An objective test in an iso-kinetic machine is recommended. DIFFERENTIAL DIAGNOSES Tendon rupture, avulsion fracture of the origin or insertion. PROGNOSIS A majority of these injuries will not cause long-term problems, subject to correct initial handling to reduce bleeding, and thorough rehabilitation. In rare cases, the bleeding may turn into calcification (myositis ossificans) and fibrosis, which may trap nerves or cause other local symptoms.

24. TIBIAL SPINE AVULSION FRACTURE

SYMPTOMS This injury is caused by a sprain and prevents continuation of sport in a young growing athlete usually below or just above 15 years of age. The symptoms are immediate haemarthrosis, which is caused by bleeding from the bone, and pain. This is an injury that is not uncommon in contact sports such as football or rugby and other high-intensity sports such as downhill skiing. AETIOLOGY The typical athlete suffers a hyperextension or valgus rotation sprain during sport. In some cases however it is a non-contact injury where the player loses their balance and twists the knee. The ACL avulses its insertion at the tibia spine since the bone is weaker than the ligament. Grade I injuries are not displaced; Grade II are but with the fragment still attached; Grade III is a displaced loose bony fragment. This injury is often associated with other injuries to cartilage, menisci, capsule or other ligaments. CLINICAL FINDINGS There is haemarthrosis in most cases. If there is a capsule rupture, blood can penetrate from the joint and cause bruising. The Lachman test is positive in Grade III injuries but can be falsely negative in Grade I and II injuries. Since there are often associated injuries, examination must also include tests for collateral ligaments, menisci and cartilage. The compression rotation test is often positive due to the loose bony fragment. INVESTIGATIONS Clinical examination is the most important tool for diagnosis and should include tests for all ligaments and other structures in the knee. X-ray is essential in growing athletes with a suspected ACL injury, to rule out this type of fracture. MRI or CT scans can be useful in unclear cases.

Fig. 153 X-ray showing avulsion of the tibia spine where the ACL is inserted

TREATMENT An athlete with haemarthrosis and suspected ACL tear should be seen by an orthopaedic surgeon to consider arthroscopy. This procedure can verify the diagnosis and deal with associated injuries that are often missed. In Grade III and in some Grade II injuries, the bone fragment can be re-fixated with a screw. Grade I injuries can be treated without surgery by being kept braced in extension for four to six weeks, followed by progressive rehabilitation.

Fig. 154 Arthroscopic view of refixated ACL insertion and tibia spine

REFERRALS Refer to orthopaedic surgeon for further investigations to verify the extent of the injury. Physiotherapists will be involved in close collaboration with the surgeon. EXERCISE PRESCRIPTION Cycling and water exercises are good alternatives to keep up general fitness. Rehabilitation back to full sport usually takes around six months. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms and signs. Different functional knee scores for different sports are available to measure when the knee allows a return to full sport.

DIFFERENTIAL DIAGNOSES ACL rupture. PROGNOSIS Surgery will allow a return to sport within around six months. The risk of re-rupture is low. Note! If the bony Grade II-III injury is missed, it will lead to chronic increased laxity and most often to the inability to perform pivoting sports due to functional instability.

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EXERCISE ON PRESCRIPTION DURING INJURY TO THE KNEE

This table provides advice on forms of exercise that may or may not be recommended for athletes with different injuries. The advice must be related to the severity and stage of healing and take the individual's situation into account.

This activity is harmful or risky.

This activity can be done but with care and with specific advice.

This activity can safely be recommended.

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OSTEOCHONDRITIS DISSECANS

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PATELLA DISLOCATION

PATELLA TENDON RUPTURE

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PATELLAR INSTABILITY

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PATELLAR TENDINOSIS

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POPLITEUS TENOSYNOVITIS

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PCL TEAR

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POSTERIOR LATERAL CORNER INJURIES

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POSTERIOR MEDIAL CORNER INJURIES

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PREPATELLAR BURSITIS

RUPTURE OF THE QUADRICEPS OR HAMSTRING MUSCLES

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TIBIA SPINE AVULSION FRACTURE

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The figures below show the anatomical appearances of the groin and thigh from different angles with arrows indicating the locations of symptoms of particular injuries.

Patients with thigh and groin pain are usually not straightforward to diagnose and treat. In acute muscle rupture or trauma, it is of course easier. The patient's history is very important, since myriad conditions can cause pain in this region, ranging from referred pain from the lower back, vascular or neurological disorders, intra-pelvic or abdominal disorders such as gynaecological

Fig. 155 The groin area is very complex and groin pain can be caused by a variety of injuries

Fig. 156 Striking a ball repeatedly is a common cause of groin pain

v THIGH AND GROIN INJURIES

problems, bowel ailments, prostatitis or hernias, muscle ruptures and tendon disorders or functional problems arising from poor core stability, to give just a few examples. A thorough clinical examination, followed by a systematic approach to the use of investigating tools such as ultrasound or MRI is essential for successful outcomes. These patients can travel between different health providers and become confused by the different advice and treatments given.

I must stress that in this book I deal only with musculo-skeletal causes of groin and thigh pain; if none of these causes fits with the symptoms, specialist advice should be sought. It is important to be systematic. In many of these conditions, associated or secondary problems from unilateral injuries are common. Many core stability problems cause tenderness at the insertion of the adductor longus muscles and around the symphysis so it is important to rule out whether these symptoms are primary or secondary. For example, a left knee injury, which causes limping or pain around that knee, may often result in contra-lateral right groin pain, due to the suddenly increased stress on that leg.

The history taken from the patient must include a description of the onset, type and location of the pain, details of previous injuries to the lower limbs and medical details about bowel or urinary diseases, neurological, gynaecological or back problems. If there is any suspicion that the symptoms may be caused by non-orthopaedic ailments, ask a relevant specialist for their advice. The type of pain and its triggers must be noted in detail. Note that secondary tightness of the muscles around the pelvis and hip is almost always associated. The clinical examination should include a functional provocation of the symptoms if possible. Ask the patient to demonstrate what causes most pain. The lower back must be examined from an orthopaedic and neurological perspective. Hip joint mobility, muscle flexibility tests and palpation of tender spots in the groin and thigh must be performed. X-rays are sometimes indicated but

Joint Mobility Test Knee
Fig. 157 Hip joint mobility test with external rotation. Fig. 158 Hip joint mobility test with internal rotation. Compare with the other side Compare with the other side
Hip Joint Test
Fig. 159 Hip joint mobility test with compression can reveal injuries to the hip joint

must have a clear and relevant purpose such as suspected stress fracture or osteoarthritis, to avoid unnecessary or excessive exposure to radiation. MRI can be helpful but because of the complexity of the anatomy around the hip and groin, specific questions must guide the radiologist. Herniogram, hip arthroscopy and other sophisticated investigations may follow but again must be directed by logic.

Besides acute injuries, which are often relatively straightforward to handle, chronic groin pain can be handled as follows:

• Less than one month's duration: advice on modification of training, core g stability tests and training if deemed necessary, NSAID if required, most con- N ditions heal. G

• More than one month's duration: refer to relevant specialist (orthopaedic z surgeon, urologist, gynaecologist, general surgeon, physician) for advice and | ask a physiotherapist for a functional evaluation. X-ray of the hip joints or relevant structures may be indicated.

• More than two months' duration: MRI or other specialist investigations may follow, guided by symptoms and signs and progression. Refer to relevant specialist for further investigation. Obviously professional athletes will not wait for two months.

• More than three months' duration: such patients are difficult to diagnose and require specialist treatment. Whatever the diagnosis, the absence from ,_

high-level sport is usually very long.

TRAINING OF THE CORE MUSCLES AND CORE STABILITY

This training requires a progressive programme, guided by a physiotherapist, since it includes a variety of complex manoeuvres, which often involve compensatory mechanisms. Slide boards, balls, wobble boards and other instruments may be used in parallel with functional sport-specific exercises such as dancing and martial arts. Strength training, stretching and functional exercises of specific muscle groups aim to restore a right-left leg balance and core stability that lasts. Limping, and injuries that move around the pelvic region, are signs of poor core stability. Recurrent pain in different locations, such as pain moving from the left groin, to the right groin, to the trochanter region and radiating down the hamstring muscles are other typical symptoms of poor core stability. The hip adductors and abductors and rotators are vital for core stability and their strength and flexibility can be trained in various ways. The iliopsoas muscles are the most important hip flexors and stabilisers of the lower back. Insufficiency or left-right imbalances of this

Pelvics And Hip Stability Exercises
Fig. 160 Core stability exercises including martial arts Fig. 161 Test of pelvic control can be tested by slow are very important sit-ups and return to supine position

Fig. 163 Flexibility test and stretching of iliopsoas can be achieved effectively as demonstrated in this photo

Fig. 162 The 'Charlie Chaplin' test provokes the lower lumbar vertebrae and the iliopsoas insertions muscle group can cause groin pain as well as lower back pain. A 'Charlie Chaplin' test is a simple test of iliopsoas muscle strength and screens for problems in the lower back. A disc prolapse or sciatica will

Fig. 163 Flexibility test and stretching of iliopsoas can be achieved effectively as demonstrated in this photo make this test impossible but weak iliopsoas muscles will be identified. The flexibility of this muscle group can be improved with stretching.

The Groing Flexbilitytest
Fig. 164 Origin of the long adductor

SYMPTOMS Gradual onset of diffuse or localised exercise-induced pain at the insertion of the adductor longus around the symphysis. It can be associated with a slip, strain or split on a slippery football pitch. It is common in footballers, who usually complain of an inability to strike the ball with full power.

AETIOLOGY This is usually caused by excessive stress reaction or strain from jumping, twisting and plyometric or running exercises. Partial ruptures have also been discussed as a potential cause. The left and right leg anatomy can vary substantially in the same individual; therefore the symptoms may vary.

CLINICAL FINDINGS There is distinct tenderness on palpation over the most proximal part of the adductor longus tendon and its insertion, aggravated by contraction against resistance. INVESTIGATIONS X-ray is normal. MRI may show intra-tendinous hyper-intensity and sub-chondral oedema. Ultrasound may show signs of tendinosis.

TREATMENT If it is the primary cause for the symptoms, this injury will most often respond to conservative treatment, including modification of training and stretching exercises. There is seldom any indication for immobilisation or surgery. The main clue to success is to realise whether the symptoms from the tendon are secondary to impaired core stability caused by another injury or the primary root of the symptoms.

Patellar Maltracking Exercises

Fig. 165 Test of flexibility and strength of long adductor muscles can be evaluated whilst palpating the insertion

Patellar Maltracking Exercises

Fig. 165 Test of flexibility and strength of long adductor muscles can be evaluated whilst palpating the insertion

1. ADDUCTOR TENDONITIS/TENDINOSIS Cont.

REFERRALS Refer to physiotherapist for symptomatic treatment and planning of a three months' return programme back to sport. Refer to orthopaedic surgeon if non-operative treatment fails. IXIRCISI PRESCRIPTION Cycling and other low-impact activities are usually good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Normal clinical symptoms and signs. DIFFERENTIAL DIAGNOSES It is important to be aware that myriad different conditions can cause these symptoms.

PROGNOSIS Excellent-Poor, depending on the cause.

Patellar Maltracking Exercises

Fig. 167 Hip joint compression/rotation test

Fig. 166 Hip joint labrum

Fig. 167 Hip joint compression/rotation test

SYMPTOMS There is gradual onset of diffuse exercise-induced pain in the groin. Occasionally the patient experiences, and may be able to demonstrate, clicking from the groin in rotational movement. The hip joint is usually stiff and more painful in the morning than in the afternoon and rotational movements are most difficult. In severe cases there is pain during rest as well. There are periods of better and worse symptoms. Secondary muscular symptoms are very common around the glutei and trochanter regions. This injury is most common in relatively young and middle-aged footballers and rugby players. AETIOLOGY Labral tears can be secondary to previous trauma. This diagnosis is one of many to be considered when a young, fit footballer has groin pain after intensive pre-season training or a tough game.

CLINICAL FINDINGS This depends on the severity. The patient's history and a systematic and thorough approach in the clinical examination are crucial for successful outcomes. Tests of core stability, proprioception, muscle strength and balance, flexibility and kinetic chain function must be thoroughly evaluated. Hip rotation and compression tests may provoke the symptoms. INVESTIGATIONS X-ray is normal. MRI can occasionally indicate a labral tear. Arthrogram may be more successful in finding a leak from the joint that indicates a labral tear but carries a small risk of complications. Arthroscopy, also risky, is the best method to find and treat this condition. TREATMENT A range of symptomatic treatments is available, from physiotherapy and exercise modification to NSAID, arthroscopic debridement and excision of loose bodies. REFERRALS These patients are very much helped by being evaluated clinically by their physician, surgeon and physiotherapist in close collaboration. If this diagnosis is suspected, the patient should be referred to an experienced hip arthroscopist.

2. HIP JOINT LABRAL TEARS Cont.

EXERCISE PRESCRIPTION Cycling, walking, water exercises and low-impact sports like golf are good alternatives to keep up general fitness. EVALUATION OF TREATMENT OUTCOMES

Monitoring of clinical symptoms and signs, and X-ray.

DIFFERENTIAL DIAGNOSES It is important to be aware that different conditions can cause these symptoms.

PROGNOSIS Excellent-Poor depending on severity. Even if successfully operated, associated cartilage injuries can lead to osteoarthritis.

Hip Joint Stabilization

Fig. 168 Hip joint osteoarthritis, anatomic view

Fig. 168 Hip joint osteoarthritis, anatomic view

Fig. 169 X-ray of moderate hip joint osteoarthritis

SYMPTOMS There is gradual onset of diffuse exercise-induced pain in the groin. The hip joint is usually stiff and more painful in the morning than in the afternoon and rotational movements are most difficult. In severe cases, there is pain during rest. There are periods of better and worse symptoms. Secondary muscular symptoms are very common around the glutei and trochanter regions. AETIOLOGY Osteoarthritis is a major problem for the general population and affects most weight-bearing joints. It can be secondary to previous trauma, and this is more common in footballers, ballet dancers and manual workers. Primary osteoarthritis is usually bilateral and hereditary. In the hip, this is a progressive disease affecting the soft tissues as well as the cartilage of the hip joint. For the cartilage, hip osteoarthritis is graded from 0-4 in a radiological score. CLINICAL FINDINGS There is usually a restriction in rotation that when tested causes discomfort at the end range. Compare with the other side. Findings depend on the severity. If no structural pathological signs can be found, the problem may be functional, perhaps induced by poor core stability or referred from the back. The patient's history and a systematic and thorough approach in the clinical examination is crucial for a successful outcome. Tests of core stability, proprioception, muscle strength and balance, flexibility and so on must be thoroughly evaluated.

INVESTIGATIONS X-ray can help to grade the severity but there could be major cartilage damage before X-ray will show a decreased joint space, sclerosis and osteophytes. Since this is a gradual disorder, many patients seek medical advice in situations where the groin pain is particularly bad. TREATMENT There is presently no cure for this condition. However there is a range of symptomatic treatments available, from physiotherapy and exercise modification to NSAID, arthroscopic debridement, excision of loose bodies and various forms of hip joint replacement. A replaced hip joint will last for 15-25 years before a replacement is required.

3. HIP JOINT OSTEOARTHRITIS Cont.

lu REFERRALS These patients are very much

= helped by being evaluated clinically by their

^ physician, surgeon and physiotherapist in close o collaboration.

® EXERCISE PRESCRIPTION With appropriate

< advice and exercise the time until replacement x

® can be significantly delayed. Cycling, walking,

^ water exercises and low-impact sports like golf are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Monitoring of clinical symptoms and signs and X-ray.

DIFFERENTIAL DIAGNOSES It is important to be aware that myriad different conditions can cause these symptoms.

PROGNOSIS Fair-Poor. Due to the progressive development of symptoms this condition often leads to so much restriction in mobility and pain that a hip joint replacement is required.

Patellar Maltracking Exercises

Fig. 170 Stretching of iliopsoas

Fig. 170 Stretching of iliopsoas

Fig. 171 Iliopsoas flexibility test

SYMPTOMS Gradual onset of diffuse or localised exercise-induced groin pain and occasionally lower back pain. A runner often complains that he cannot produce enough force in the stride forwards and a footballer cannot strike a ball properly. This condition can also present as low back pain. AETIOLOGY This is secondary pain in the groin caused by a tight or cramping iliopsoas muscle, which blocks normal movements of the hip joint. The pain can be severe and radiate to the posterior thigh or medial femur. This condition typically occurs as a result of sudden changes in training habits, such as an increase in intensity or amount of impact in preseason training, or as secondary to low back injuries. CLINICAL FINDINGS There is tenderness on palpation over many structures around the groin area. Flexibility around the hip joint is decreased in all directions, in particular in extension. Iliopsoas flexibility is decreased and stretching of the iliopsoas may relieve or decrease the symptoms dramatically. INVESTIGATIONS X-ray, MRI and other investigations are normal.

TREATMENT This problem responds to conservative treatment including modification of training and stretching exercises. Occasionally the player walks into the clinic in agony and leaves free of pain. However, if the symptoms are chronic the core stability has been affected and a long re-training period will be required. Furthermore, any underlying disc prolapse or instability must be addressed. REFERRALS Refer to physiotherapist for functional rehabilitation. EXERCISE PRESCRIPTION Stretching and strengthening exercises and core stability training are required. Otherwise full training can be resumed as soon as the symptoms subside. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs. Similar flexibility in hip joint movement should be achieved on both legs.

DIFFERENTIAL DIAGNOSES It is important to be aware that different conditions can cause these symptoms.

PROGNOSIS Excellent.

5. NERVE ENTRAPMENT CAUSING GROIN PAIN

Functional Maltracking Patella
Fig. 172 Nerve distribution in the groin

SYMPTOMS Sharp, often radiating, pain in the groin, aggravated by stretching and exercise. AETIOLOGY This pain is caused by entrapment of one of the nerves that branch to the groin: for example, the inguinal nerve. Since the left and right groins of an individual can vary substantially, from an anatomical point of view, symptoms can vary as well. CLINICAL FINDINGS There is sometimes tenderness on palpation around the groin area but very few other clinical findings. If the affected nerve is found, Tinel's sign is positive (radiating pain is felt).

INVESTIGATIONS Most investigations are negative. MRI may in some cases show scar formations or neuromas that have caused the entrapment. Nerve conduction test may be valuable. Diagnostic blocking of the nerve with an injection of local anaesthetic may be useful to confirm the diagnosis. TREATMENT If the duration of symptoms is less than one month, try symptomatic physiotherapy with stretching and local anti-inflammatory treatment.

REFERRALS Refer to physiotherapist for symptomatic treatment. Refer to surgeon if non-operative treatment fails, for consideration of further investigations or surgical nerve release. EXERCISE PRESCRIPTION Maintain a normal training regime. There is no need to rest. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs. DIFFERENTIAL DIAGNOSES It is important to be aware that different conditions can cause these symptoms.

PROGNOSIS Excellent-Good, but the duration of symptoms may be very long even after successful surgical release.

Patellar Instability

Fig. 173 Rectus femoris muscle, anatomic view

Fig. 174 Test against resistance causes pain and weakness

Fig. 173 Rectus femoris muscle, anatomic view

Fig. 174 Test against resistance causes pain and weakness

SYMPTOMS There is an acute onset of sharp tearing pain in the proximal anterior thigh or towards the anterior iliac crest during activity. This injury often occurs during intense activity in sports like tennis, squash or other sprinting and jumping sports. AETIOLOGY This is usually a partial rupture of the insertion or proximal muscle bulk of the rectus femoris after excessive hip extension or eccentric contraction from push-off or landing. CLINICAL FINDINGS There is tenderness on palpation over a localised area of the insertion of the muscle bulk. Resistance testing of the muscle in question will cause further pain. Jumping and landing on the forefoot with a straight knee is painful and hip flexion with straight knee against resistance and starting from maximal hip extension is very painful. INVESTIGATIONS This diagnosis is made from the patient's history and clinical findings. Ultrasound or MRI can demonstrate the rupture and haematoma. These investigations are important if the initial diagnosis has been missed and can grade the rupture, which is important for rehabilitation and length of absence from sport.

TREATMENT In the acute situation, RICE. This injury most often responds to conservative treatment including modification of training and strength exercises over three months, which is the usual healing time. Partial weight bearing is usually allowed earlier.

REFERRALS Refer to physiotherapist for planning of a three to six months' return programme back to sport. EXERCISE PRESCRIPTION Cycling, water exercises and other low-impact activities are good alternatives to keep up general fitness. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms and signs. Strength and flexibility must be monitored objectively to be complete at the end of rehabilitation when compared with the other leg. The risk is otherwise high that the weaker muscle will re-rupture. DIFFERENTIAL DIAGNOSES This is usually a straightforward diagnosis but still often missed. LONG-TERM PROGNOSIS Excellent but re-ruptures are common due to a too-early return to sport and insufficient rehabilitation.

7. STRESS FRACTURE OF THE FEMUR NECK

Femoral Neck Stress Response
Fig. 175 X-ray of tension side stress fracture of the femur neck

SYMPTOMS Gradual or acute onset of diffuse or localised exercise-induced pain in the groin. AETIOLOGY Stress reaction from excessive jumping or running exercises. Stress fractures in the femur neck are not as typical in osteoporotic or osteopenic patients as pelvic fractures. The location and type of fracture is important for the outcome: tension-side fractures may displace and cause major damage to the hip, leading to hip replacement in young athletes. CLINICAL FINDINGS The athlete limps. There is pain on hip rotation and compression. Jumping and running on hard surfaces aggravates the symptoms. Secondary muscular symptoms around the groin are common.

INVESTIGATIONS This injury is often initially missed. If it is suspected, an X-ray may show the fracture. MRI will show localised bone oedema. CT can show the fracture line. TREATMENT This injury must be treated with utmost care and the patient should not bear weight until the fracture is healed. Tension-side fractures should be operated on.

REFERRALS Refer to orthopaedic surgeon for consideration of surgery. If no surgery is indicated or after surgery, refer to physiotherapist for planning of a three to six months' return programme back to full sport.

EXERCISE PRESCRIPTION Cycling and water exercises are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Normal clinical symptoms and signs and healing on X-ray.

DIFFERENTIAL DIAGNOSES It is important to be aware that different conditions can cause these symptoms.

PROGNOSIS Excellent-Good if the diagnosis is made early and if it is a side compression fracture, but poor if it is missed or if it is a tension-side fracture. Many tension-side fractures lead to displacement and, later, hip replacement.

Lc1 Pelvic Ring Fracture Ray
Fig. 176 X-ray showing stress fracture of the pelvic ring

SYMPTOMS There is gradual onset of diffuse or localised exercise-induced pain in the groin or pelvic area in a young anorexic athlete (often a female long-distance runner) or in elderly athletes with osteoporosis.

AETIOLOGY Stress reaction from excessive jumping or running exercises in fragile athletes. Stress fractures in the flat bones such as the pelvis are typical in osteoporotic or osteopenic patients. CLINICAL FINDINGS Tenderness on palpation over affected bone. Eccentric jumping and running on hard surfaces aggravates the symptoms. INVESTIGATIONS X-ray may be false-normal until callus formation, which in osteoporotic athletes may take a long time. MRI will show localised bone oedema.

TREATMENT This injury always responds to conservative treatment including modification of training until the fracture is healed. REFERRALS If the athlete shows signs of anorexia or osteoporosis, bone density tests and referral to specialist should be made; the fracture reflects a multi-factorial disease. If this is a one-off injury, caused by sudden increase in training, refer to a physiotherapist for planning of a three months' return programme back to full sport. EXERCISE PRESCRIPTION Cycling and water exercises are good alternatives to keep up general fitness. If osteoporosis or anorexia is causing the injury, specialist treatment is required and training must be substantially modified. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs and X-ray. DIFFERENTIAL DIAGNOSES It is important to be aware that these symptoms can be caused by myriad different conditions. Bone tumours and intra-pelvic ailments must be excluded. PROGNOSIS Excellent-Good but the duration of symptoms may be very long. If anorexia is the cause, the prognosis is usually poor from a sporting point of view and the athlete should be told to abandon any attempts to reach elite level until the condition has improved.

9. SYMPHYSITIS

Patellar Instability
Fig. 177 X-ray showing irregularities and sclerosis of the symphysis

SYMPTOMS There is gradual onset of diffuse or localised exercise-induced pain in both the groin and around the symphysis. The symptoms are often vague and secondary muscular symptoms are very common, misleading the examiner. AETIOLOGY This condition is thought to be a stress reaction from excessive jumping or running exercises but the exact aetiology is unknown. It typically presents as a result of sudden changes in training habits, such as an increase in intensity or amount of impact.

CLINICAL FINDINGS There is tenderness on palpation over the symphysis. However, this area is often tender in normal athletes, in particular footballers and other contact sport athletes. Pain can be provoked by repetitive jumping and attempts to strike a football hard with a straight leg. INVESTIGATIONS X-ray may show fragmentation of the symphysis but this is also a common finding in asymptomatic players. MRI may show bone oedema but again this can be seen in asymptomatic players during the season. A bone scintigram may show localised increased uptake. Usually it takes a long time to reach this diagnosis. TREATMENT This injury often responds to conservative treatment including modification of training and stretching exercises combined with core stability training.

REFERRALS Refer to a physiotherapist for planning of a six months' return programme back to sport. Seek advice from a urologist or gynaecologist if the symptoms are vague. EXERCISE PRESCRIPTION Cycling and water exercises are good alternatives to keep up general fitness.

EVALUATION OF TREATMENT OUTCOMES

Normal clinical symptoms and signs. DIFFERENTIAL DIAGNOSES This is an unusual condition but one often suggested in referrals. Most pain in this area is secondary to core stability problems.

PROGNOSIS Good-Fair,but the symptoms can be very long-lasting.

EXERCISE ON PRESCRIPTION DURING INJURY TO THE THIGH AND GROIN

This table provides advice on forms of exercise that may or may not be recommended for athletes with different injuries. The advice must be related to the severity and stage of healing and take the individual's situation into account.

This activity is harmful or risky.

This activity can be done but with care and with specific advice.

This activity can safely be recommended.

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vi WRIST AND HAND INJURIES

The figures below show the anatomical appearances of the hand and wrist from different angles with arrows indicating the locations of symptoms from the injuries.

Wrist and hand injuries are common in sports such as boxing, martial arts, snowboarding, skateboarding, tennis, ice hockey, hockey, handball, volleyball and similar sports. The importance of hand function is reflected in the

Fig. 178

Stress fracture of the radial epiphysis

Scaphoid fracture

Baseball mallet finger *

Stress fracture of the radial epiphysis

Scaphoid fracture

Baseball mallet finger *

Bowler Thumb Cure

Bowler's thumb

De Quervains tenosynovitis

Bowler's thumb jjj——^^Dislocation of ^ringer joint

Fig. 178

Fig. 179

existence of specialist hand surgeons and specially trained hand therapists who treat such injuries. The injuries listed below are just some of those that can affect the hand and wrist. If in any doubt, always consult a hand surgeon or other specialist.

1. BASEBALL MALLET FINGER

Bowler Thumb Treatment
Fig. 181 MaLLet finger - this bandage is simple but effective. It should be used for six weeks

SYMPTOMS There is localised pain and swelling around the distal inter-phalangeal (DIP) joint, which is difficult or impossible to extend fully. In chronic cases, pain and swelling may be absent but the inability to extend the distal phalanx remains.

AETIOLOGY This injury is a rupture of the most distal insertion of the extensor digitorum tendon at the DIP joint, often after a direct trauma to the tip of the finger from, for example, a basketball or volleyball.

CLINICAL FINDINGS There is tenderness on palpation over the DIP joint. The patient cannot actively extend the distal phalanx and cannot hold it extended against resistance.

Fig. 182 Inability to extend distal phalang signifies a positive mallet test

INVESTIGATIONS X-ray may show a small avulsion fracture of the dorsal plate that corresponds to the tendon insertion. MRI or ultrasound may show the tendon rupture and haematoma. TREATMENT If there is no fracture this injury usually heals by immobilising the distal phalanx in a 'mallet bandage'. If there is a fracture, re-fixing surgery is usually required.

REFERRALS Refer to hand specialist if there is a fracture on X-ray or if the diagnosis is unclear. A mallet bandage should be available to be applied on the field by the team medic. EXERCISE PRESCRIPTION Usually the two or three adjacent fingers can be strapped together and normal activities may be continued throughout healing in some sports. However, in sports like boxing, martial arts and similar ones, six to eight weeks' absence may be

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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Responses

  • GREGORIO
    Does maltracking of knee = instability?
    11 months ago

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