Download conservative approaches to lower extremity sports injuries

CONSERVATIVE APPROACHES
TO
LOWER EXTREMITY
SPORTS INJURIES
Amy B. Harris, MSN, RN, OCNS-C
CNHS
Nurse Coordinator
[email protected]
CONFLICT OF INTEREST
I hereby certify that, to the best of my knowledge, no aspect of my current
personal or professional situation might reasonably be expected to affect
significantly my views on the subject on which I am presenting.
Sports Injuries
of the
Lower Extremity
OBJECTIVES
• List the various common lower extremity sports injuries
• Discuss prevention techniques aimed at reducing the
incidence / reoccurrence of lower extremity sports injuries
• Develop conservative treatment plans for athletes which focus on enhancing
function and reducing pain
LOWER EXTREMITY ATHLETIC INJURIES
SPORTS INJURIES
OVERUSE / CHRONIC
ACUTE TRAUMATIC
Kevin Ware - 2013
KEVIN
WARE
2016
P-RICE-MM Treatment for Acute Sports Injuries
Protection
• Stabilize Area
Rest
Ice
• 20 Minutes
Compression
• Ace Wrap
P-RICE-MM Treatment
For Acute Sports Injuries
Elevation
• ABOVE HEART LEVEL
Medication
• NSAIDs/
Analgesics
• Muscle Relaxants
Modalities
• Diagnostic Testing
• Physical Therapy
• Ultrasound / Electrical Stimulation
Iliotibial Band Syndrome (ITBS)
ILIOTIBIAL BAND
• Provides Lateral Stabilization to the Knee
Joint
OVERUSE SYNDROME
• From Excessive Friction
• Causes Lateral Leg / Knee pain
ITBS : Training Errors / Causes
 Consistently running on a horizontally banked surface
(such as the shoulder of a road or an indoor track on which the
downhill leg is bent slightly inward, causing extreme stretching of
the IT Band against the femur)
 Inadequate warm-up or cool-down
 Excessive up-hill and down-hill running
 Positioning the feet toed in to an excessive angle when cycling
 Running up and down stairs
 Hiking long distances
 Rowing
 Breaststroke
 Treading water
 Water Polo
ITBS Treatment
Conservative Treatment
• P-RICE-MM (Phonophoresis, Iontophoresis)
• Stretch Iliotibial Band
• Improve Hamstring Flexibility
• Strengthen Hip Abductors
• Strengthen Hip External Rotators
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•
•
•
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Aquatic Therapy – Water walking / Running
Cross Training
Many Athletes will need to utilize shoe inserts
Runners may need to adjust stride length
Cyclists should adjust seat height / foot position
Options if conservative treatment fails:
• Cortisone Injection
• Surgical Intervention (rarely necessary)
Iliotibial Band Stretch
 Purpose: To gain flexibility in the fibrous
band of tissue that is located along the
outside of the thigh and knee
 Start Position: Lying on your back with
a rope looped around the foot of the leg
to be stretched
 Action: Using the rope, pull the leg
across your body at an angle
approximately 20-30 degrees from the
floor
 Parameters: Hold stretch for 30
seconds, Repeat 3-5 times
 Tips: Stabilize the hip of the side being
stretched firmly to the ground so no
rotation of your trunk occurs
Knee: Normal A & P
The Lachman Test
Posterior Drawer Test
McMurray Test
Knee – Ligamentous Injuries
Function
• Attaches Bone to Bone
• Stabilizes Knee
Mechanism of Injury
• Torsional Injury Often with Direct Blow
Anterior Cruciate Ligament
Medial & Lateral Collateral Ligaments
• Grade 1
• Grade 2
• Grade 3
Conservative Treatment for Knee Injuries
• PRICE-MM
• Evaluation of QUAD and HAMSTRING strength along with a
full assessment to find any core muscle deficits
• Stationary Bicycle
• Active and Passive ROM Exercises
• Strengthening of Quads and Hamstrings
• Hamstring Curls (standing)
• Straight Leg Raises (supine and prone)
• Wall Slides
• Hip Abduction
• Balance Training Activities
Shin Splints / Stress Fractures
Overuse Syndrome
Micro Fractures Develop in Tibia
Diagnostic Testing
• X-Rays Rule Out Fracture
• MRI /Bone Scan
Conservative Treatment
• P-RICE-MM
• Nutritional Counseling
• Vitamin D3
• Orthotics
• Aquatic Therapy
• Prevention
Ankle Injuries
• The Ankle is a Hinged Joint
• Distal Tibia/Fibula
• Medial & Lateral Malleolus
• Talus
• 3 Planes of Motion
Dorsiflexion-Plantar Flexion
Inversion-Eversion
Abduction-Adduction
Ankle Sprain – Severity Guide
GRADE I
GRADE II
GRADE III
Mild
Moderate
Severe
Some Tearing of Some Tearing of
Ligamentous
Ligamentous
Fibers
Fibers & Loss of
Function
Complete
Rupture of
Ligaments. Loss
of Function &
Instability of the
Joint
Ankle Sprain – Severity Guide
Ankle Sprains
Mechanism of Injury
• Twisting of ankle most commonly
affecting the lateral side
Clinical Presentation
• Athlete reports tearing sensation
at time of injury
• Unable to bear weight on
affected ankle
• Swelling/Stiffness (early)
Ecchymosis (later)
• Instability
Ankle Sprains
Diagnostic Testing
• X-Rays to rule out fracture
• R/O possible associated
Avulsion Fracture of Fibula
ANKLE SPRAINS
Conservative Treatment
• P-RICE-MM
• Initial Immobilization
• Posterior Splint with Ace Wrap
• Air Cast
• Short Leg Cast or Walking Boot
Achilles Tendinitis
Achilles Tendon - Poor Capacity to
Repair
Common Overuse Syndrome
Direct Trauma Can Lead to Rupture
Clinical Presentation
• Pain and Stiffness
Conservative Treatment
• P-RICE-MM
• Daily Stretching
• Orthotics / Heel Lifts
THOMPSON TEST:
Squeezing the Gastruc
should cause plantar flexion
Achilles Tendon Rupture
Achilles Rupture - Sonography
PLANTAR FASCIITIS
• THE most common cause of heel pain in adults
ETIOLOGY
A degenerative tear of part of the fascial origin from the calcaneus,
followed by a tendonosis-type reaction
• Chronic degenerative changes in the
fibers of the plantar fascia occur
• Affects women 2x more often than men
• More common in overweight adults
• NOT associated with a particular foot type
(pes planus, pes cavus)
PLANTAR FASCIITIS
Clinical Symptoms:
• Focal pain and tenderness over the medial calcaneal tuberosity
• Tenderness 1 – 2 cm distal to that, along the plantar fascia
• Pain more intense in the morning or when rising from sitting position
• Increased pain with prolonged standing and walking
• Tightness in the Achilles tendon
Diagnostic Tests:
• Not necessary initially
• Lateral Weight-bearing X-Ray prior to cortisone injection or after 6-8 weeks of
conservative treatment
• Heel Spur – develops in the Flexor Brevis muscle just superior to the Plantar Fascia in
approx. 50 % of patients
PLANTAR FASCIITIS
Treatment
95 % of patients do well with conservative treatment
HOWEVER – Symptoms may take 6-12 months to resolve
• Silicone Gel Heel Pad
• P.T. / Home program of stretching exercises
• Contrast baths
• Ice
• NSAID’s
• Shoes with shock absorbing sole
• Night Splinting
• Cortisone Injection
Surgical Treatment – Partial release of the plantar fascia
Case Study
• 59 y/o Dragon Boat Team member
• Training schedule – laps on hard surface 30 minutes weekdays x one month
• Anterior tibia pain x 5 months without relief of symptoms despite P.T.
H and P
X-Rays
Treatment Plan
Exercise Regimen
Case Study
•
•
•
•
•
•
58 y/o Lawn Tennis player
Twice a week informal games with weekly competitive matches
Traveled to Australia to compete
Initial injury – Left Achilles Tendon Tear Treatment: Surgical Repair, Casting, P.T.
Upon full recovery – returned to Lawn Tennis
Sustained Right Achilles Tendon Tear
H and P
X-Rays
Treatment Plan
Exercise Regimen
CASE STUDY
• 72 YEAR OLD TRI-UMPH TRIATHLETE COMPLAINS OF HEEL PAIN
• PAIN IS PARTICULARLY INTENSE IN THE MORNING
• HE DOESN’T RECALL ANY SPECIFIC INJURY
History and Physical
X-Rays ?
Treatment Plan
Exercise Regimen
Tom Brady
New
England
Patriots
DOB 8/3/77
38 y/o
Zdeno Chara
Boston
Bruins
DOB 3/18/77
39 y/o
David Ortiz
(Big Papi)
Boston Red Sox
DOB 11/18/75
40 y/o
Paul Pierce
Boston Celtics
(1998-2013)
Current team:
L.A. Clippers
DOB 10/13/77
38 y/o
REFERENCES
National Association of Orthopaedic Nurses Core Curriculum for Orthopaedic Nursing (7th Edition) 2013.
Armstrong, April D. and Hubbard, Mark C. (Ed.) Essentials of Musculoskeletal Care (5th Edition) 2015.
Magee, David J. Orthopaedic Physical Assessment, (6th Edition) 2013.
National Association of Orthopaedic Nurses / www.orthonurse.org
Orthopaedic Nursing (Journal) /www.orthopaedicnursing.com
American Academy of Orthopaedic Surgeons /www.aaos.org
www.orthoinfo.aaos.org Patient Education Materials
www.summitmedicalgroup.com Exercise Programs