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Chapter 15
INJURIES TO THE THIGH, LEG, AND KNEE
Anatomy Review. Many athletes experience injuries to their lower extremities. The leg bones
include the femur, patella, tibia, fibula, and those of the foot.
I. The femur is the longest, strongest, and heaviest bone in the body. Most blood vessels and nerves
of the thigh are well protected by muscles. The thigh muscles can be divided into three regions. The
anterior muscles of the thigh are called the quadriceps (refer to Figure 15.1 on page 224). The main
muscles in the medial aspect of the thigh include the adductor longus, adductor brevis, adductor
magnus, and gracilis. The third group of thigh muscles is commonly called the hamstrings. Time
Out 15.1 on page 225 lists thigh muscles and their actions and innervations.
II. The knee can be damaged by any number of accidents during sports participation. The patella is
a sesamoid bone, which means it is totally encased in a tendon and does not articulate with the tibia.
The four major ligaments of the joint are the tibial or medial collateral ligament, the fibular or
lateral collateral ligament, the anterior cruciate ligament, and the posterior cruciate ligament (refer
to Figure 15.2 on page 226).
A. The tibial collateral ligament and the fibular collateral ligament help limit motion and/or
disruption of the knee joint when the movement at the joint is side-to-side (valgus and
varus).
B. The cruciate ligaments are inside the knee joint. Their primary function is to reduce or
prevent anterior and posterior displacement of the femur or tibia.
C. The menisci are located within the space between the tibia and femur. These disks assist
with the lubrication and nourishment of the knee joint and aid in the distribution of stress
applied to joint surfaces. Injuries to these disks can end athletic careers.
D. Several bursae are between the tendons and bone.
III. Common Sports Injuries. Injuries to the thigh and knee can occur in almost any sport. Injuries
may result from overuse as well as trauma caused by an opponent or by the power and explosive
movements required in some sports.
A. Skeletal Injuries
1. Femoral Fractures. It requires a lot of force to fracture a femur; therefore, the
injury is uncommon in sports. If it does occur to the shaft of the bone, the injury will
be obvious because the athlete will be in much pain and unable to walk with the
affected leg.
a. The athlete should not attempt to walk or bear any weight on a femoral
fracture. The leg should be splinted, and the athlete taken immediately to a
medical facility.
b. Fractures of the neck of the femur occur more often in sports than fractures
of the bone’s shaft. Older children and teenagers are at greater risk of this
fracture because it can potentially occur at the sight of a growth plate.
i. The injury needs to be evaluated by a physician. A complication is
avascular necrosis of the femur, which is caused by a decrease in
blood supply to the area, resulting in tissue death.
c. Signs and symptoms include pain at the site of injury, difficulty walking on
the affected leg, and swelling and/or deformity. The athlete may report a
traumatic event as the cause of the injury and a severe pop or snap sensation
at the time the injury occurred.
d. First aid care includes treating the athlete for shock, if necessary; splint the
leg, preferably with a traction splint; apply sterile dressing to any open
wounds; and monitor vital signs and circulation to the lower leg.
i. Arrange for transport to a nearby medical facility.
2. Patellar Fractures. Patellar fractures do not occur often in sports. In most cases, the
patella is fractured by violent trauma and the athlete will be incapacitated for a short
time after the injury.
a. The major symptom is severe pain in the affected area.
b. The athlete needs to see a physician immediately.
3. Dislocation of the Tibiofemoral Joint. Dislocation of the knee or the tibiofemoral
joint can compromise blood flow to the lower leg. If there is a dislocation of the
tibiofemoral joint, it will be apparent, and the athlete will experience extreme pain.
a. The injury must be splinted and the athlete referred to the nearest medical
facility immediately to avoid compromising blood flow to the knee and lower
leg.
B. Soft Tissue Injuries to the Thigh. Most of the soft tissue injuries to the thigh are either the
result of direct contact with an opponent or a self-inflicted muscle strain that results from an
explosive movement. In some sports, protective padding can reduce injury.
1. Myositis Ossificans. When an athlete receives a blow to the quadriceps from an
opponent’s body, muscle contusion, bleeding, and damage often occur within the
muscle fibers. If the injury is not properly cared for, myositis ossificans may occur
in the area of the damage.
a. Signs and symptoms of a muscular contusion include the athlete’s report of
having sustained a forceful impact to the area and a feeling of tightness. The
affected area may be swollen, and the athlete is unable to contract the muscle
forcibly and has difficulty walking with the affected leg.
b. First aid care includes application of ice and compression immediately. If
the injury is severe, place the athlete on crutches. Have the athlete rest and
avoid any contact with the area.
2. Muscular Strains to the Thigh. Compared to other thigh muscles, the hamstrings
and adductor muscles are most likely to sustain strains. Strains of the adductor
muscles are commonly called groin pulls. Strains can occur as a result of
overstretching the muscle or a miscommunication between agonistic muscles and
antagonistic muscles, which is the case in many strains involving the hamstrings.
a. If a muscle is stretched too far, the muscle fibers are damaged and bleeding
occurs. The result is loss of contractibility, stiffness, and impaired movement.
Hamstrings are usually weaker and more susceptible to strains than the
quadriceps.
b. Adductor muscles in the groin region of the thigh are critical for speed and
changing direction movements and are not easy to warm up and stretch. It is
important for athletes to prepare these muscles for sports participation.
c. Groin injuries can be debilitating if not immediately cared for properly.
i. These muscles take a long time to heal. Stretching must be an
integral part of the recovery program.
d. Signs and symptoms of muscle strains to the thigh include a sharp pain in
the affected muscle, swelling and redness in the immediate area, muscle
weakness, and inability to contract the muscle forcibly. After a few days,
there may be discoloration of the area. In severe cases, a visible defect is
noted in the muscle (refer to Figure 15.4 on page 229).
e. First aid care involves the application of ice and compression
immediately. The athlete needs to rest and if necessary, use crutches.
i. Have the athlete evaluated by a member of the medical team.
C. Patellofemoral Joint Injuries. Chronic and acute injuries can affect the patellofemoral
joint. Such injuries can be debilitating and must be treated if the athlete is to return to sports
participation.
1. Osteochondritis Dissecans. Osteochondritis dissecans (OCD) or “joint mice” can
occur when small pieces of bone are dislodged or chipped from the joint and float
within the joint capsule. In some cases, a bone fragment blocks or locks the joint.
Additionally, a small bone fragment may remain attached to the original bone,
causing painful movements. The damage to the joint surfaces that results can be
serious.
a. Signs and symptoms include chronic knee pain with exertion that is
generalized; chronic swelling may be present; the knee may lock; the
quadriceps may atrophy; and one or both femoral condyles may be tender to
palpation when the knee is flexed.
b. First aid care includes application of ice and compression. If the athlete
has difficulty walking, have him or her use crutches.
i. Refer the athlete to a physician.
2. Inflamed Bursa. A bursa is a small fluid-filled sac that assists in the prevention of
friction between bony surfaces, tendons, muscles, or skin. There are numerous
bursae in the knee joint. Bursae may become inflamed due to trauma, infection, or
overuse. The prepatellar bursa, for example, is susceptible to direct trauma (refer to
Figure 15.6 on page 230).
a. Most of the other bursae in the knee are susceptible to chronic injury.
b. Signs and symptoms of an inflamed bursa include swelling and tenderness
at the site and pain when increased external pressure is applied. The athlete
may report direct trauma to the knee or a chronic buildup of swelling in the
area.
c. First aid care includes the application of ice and compression, reduced
activity for a short time, and in chronic cases, anti-inflammatory agents may
be helpful.
3. Patellar Dislocation/Subluxation. This injury can occur when an athlete makes a
quick cutting motion and a great deal of abnormal force is generated within the knee.
Instead of moving superiorly and inferiorly as it normally does, the patella moves
laterally and may dislocate. The patella may return to its normal position
spontaneously, but if it does not, the athlete will be aware of the injury.
a. Signs and symptoms include severe pain and abnormal movement of the
patella when the injury occurred and swelling. Additionally, the knee and
patella will be extremely tender, especially the medial aspect.
b. First aid care includes applying ice immediately; compression and
elevation are also helpful. Splint the entire leg and transport the athlete to the
nearest medical facility. If not treated properly, this injury can become
chronic.
4. Osgood-Schlatter Disease and Jumper’s Knee. The attachment of the patellar
tendon at the tibial tubercle can be the site of Osgood-Schlatter disease and
jumper’s knee. Athletes who do a great deal of jumping are more prone to these
conditions than athletes who do not do much jumping. The main difference of these
conditions is the location of the injury.
a. Osgood-Schlatter disease is usually a problem at the junction of the patellar
tendon and the tibial tuberosity in the adolescent athlete. Jumper’s knee can
occur at multiple sites within the patellar tendon down to the tibial tuberosity
attachment. Excessive jumping creates a pull on the patellar tendon and its
attachment at the tibia, causing inflammation and swelling to occur below the
patella.
i. Signs and symptoms include pain and tenderness about the patellar
tendon complex, swelling in the area, and decreased ability to use the
quadriceps. If the inflammation continues, the area over the tibial
tuberosity may become solid when palpated. Symptoms seem to
worsen with activity.
ii. First aid care includes application of ice and compression to the
area. Refer the athlete to a physician. Until the inflammation subsides,
rest is important.
b. Jumper’s knee is also an irritation of the patellar tendon complex between
its attachments. Typically the athlete will experience pain over the superior or
inferior pole of the patella or at the tibial tuberosity that is associated with
jumping.
i. Signs and symptoms include pain and tenderness about the patellar
tendon complex and swelling in the area that may spread from the
patella to the tibial tuberosity.
ii. The athlete has a decreased ability to use the quadriceps for
running or jumping.
iii. Symptoms seem to worsen with activity.
iv. First aid care includes application of ice and compression to the
area. Refer the athlete to a physician for possible anti-inflammatory
medications. Rest will be helpful.
D. Patellofemoral Conditions. Athletes may complain of pain behind the patella that may be
due to an increased Q angle. This angle is the difference between a straight line drawn from
the anterior superior iliac spine and the center of the patella compared to one drawn from the
center of the patella through the center of the tibial tuberosity (refer to Figure 15.7 on page
232).
1. The larger the Q angle, the greater the likelihood that the patella can be pulled too
far laterally when the knee is extended. Although highly individual, an angle of 15°
to 20° is acceptable. Females typically have higher Q angles due to the width of their
pelvis.
2. Idiopathic retropatellar pain can occur if there is abnormal patellofemoral
configuration. This can occur in athletes who perform a great deal of repetitive
movements. If the problem continues, chondromalacia, the softening and wearing
out of the posterior cartilage surface of the patella, can result. Chondromalacia can
interfere with performance and cause pain and tenderness with movement.
a. Athletes with retropatellar pain will complain about the chronic
discomfort. There is no immediate first aid, but the athlete may find RICE
and nonsteroidal anti-inflammatories helpful.
b. Athletes with abnormally large Q angles should consult a physician.
E. Menisci Injuries. The menisci are commonly torn when the athlete makes a quick, sharp,
cutting movement when the foot is stabilized and does not turn with the rest of the body.
This movement and others that cause excessive stress in abnormal planes will tear the
meniscus at different points. Some athletes can function with a torn meniscus; others will
not be able to extend the leg at the knee joint because the injury causes a blocking or locking
effect.
1. Signs and symptoms include the athlete’s report of hearing a pop or snap when the
knee was twisted, possible swelling, little or no complaints of pain, loss of ROM,
possibility of continued participation, and a feeling of the knee “giving out” at times.
2. First aid care includes the application of ice and compression, use of crutches for
walking, and encouragement to see a physician as soon as possible.
F. Knee Ligament Injuries. The most commonly injured knee ligaments are the medial
collateral ligament, the lateral collateral ligament, and the anterior and posterior cruciate
ligaments. The knee can be injured by all types of forces, both internal and external.
1. Collateral Ligament Injuries. In sports, a sprain to the medial collateral ligament is
a common knee injury. Figure 15.9 on page 234 illustrates the mechanism for this
type of injury (valgus stress). If the opposite mechanism occurs (varus stress), a
sprain of the lateral collateral ligament can occur.
a. Both injuries render the knee unstable in side-to-side movements. As the
severity of the injury increases, the knee becomes more unstable during
movement and activity.
2. Cruciate Ligament Injuries.
a. The anterior cruciate ligament (ACL) can be injured when the tibia moves
forcefully in an anterior direction, such as when an athlete gets hit in the
lower leg from behind, or when the femur gets pushed backward while the
tibia is held in place. If the opposite occurs and the tibia is forced posteriorly,
the posterior cruciate ligament can be disrupted and injured.
i. Quick rotational movements can also injure the ACL.
ii. The stronger the activation during eccentric contraction, the greater
the likelihood of ACL damage, especially in female athletes. The
interaction between the athlete’s shoe and the playing surface appears
to play a role in ACL injuries, but more research is needed.
iii. Signs and symptoms include the athlete’s report of the knee being
forced beyond its normal range or pain at the site of injury. Swelling
may occur in and around the knee, the knee may feel unstable, and the
athlete may report the sensation of a pop, tear, or snap when the injury
occurred.
iv. First aid care includes the immediate application of ice and
compression; crutches for walking, if the knee is unstable; and referral
to a physician.
v. “Terrible triad” injury occurs when a blow to the lateral side injures
the medial collateral and anterior cruciate ligaments along with the
medical meniscus. This injury creates a very unstable knee, and the
athlete should seek proper medical care.
3. A large majority of ACL injuries are from non-contact mechanisms. Over the
years, there has been a great deal of research into the basis for these non-contact
ACL injuries. Most of the research has focused on the sport of soccer, and
specifically the female athlete. It appears that female soccer players are at a much
higher risk of non-contact ACL injury when compared to males and players in other
sports. The increased risk and the incidence of non-contact ACL injuries in females
are confusing to many researchers. There appear to be many different reasons why
female athletes are more prone to ACL injury and some doctors and researchers
believe that there are multiple factors contributing to this problem.
G. Prevention. The quest to prevent knee injuries continues for athletes, coaches, and
athletic trainers. Research will continue to outline techniques that will hopefully prevent the
various knee injuries. Proper warm-up and stretching may decrease muscle strains in certain
athletes. Prophylactic knee bracing, much like stretching, should be an individual choice for
the athlete. The newest trend in prevention of ACL injuries is using jump and landing
training techniques. These programs are designed to enhance the dynamic function of the leg
musculature that will assist the function of the ACL during activity. Athletes, especially
females, may benefit from this type of training and reduce the chances of an ACL tear. It is
worth looking into some of these programs as this area is quite promising.
H. Knee Bracing. The general consensus regarding prophylactic knee braces indicates that
they do not prevent knee ligament injuries. Specialized proprioceptive training may decrease
ACL injuries. Functional braces tend to work better than prophylactic braces for assisting
the athlete after reconstructive knee surgery.
1. Athletes need to be monitored to make sure they wear their knee braces during
participation and continue to use them until released by a physician.
REVIEW QUESTIONS
1. List the bones that comprise the knee joint.
Answer: The femur, tibia, and patella.
Page: 224
2. Give the common name for the muscles located on the anterior portion of the thigh.
Answer: Quadriceps
Page: 224
3. Give the common name for the muscles of the posterior thigh region.
Answer: Hamstrings
Page: 224
4. Give the common name for the muscles located on the medial aspect of the thigh.
Answer: Adductor longus, adductor brevis, adductor magnus, and the gracilis.
Page: 224
5. Where do the quadriceps attach on the lower leg?
Answer: See explanation on page 224.
Page: 224
6. Define a sesamoid bone using the patella as an example.
Answer: A sesamoid bone is one that is totally enclosed within a tendon. In the case of the patella it
is located within the quadriceps tendon.
Page: 224
7. Explain the articulation of the knee joint, including the involvement of the patella.
Answer: The femur and the tibia articulate with each other here (tibiofemoral joint) and the patella
and femur also have an articulation (patellofemoral joint).
Page: 224
8. List and explain the attachments of the four main ligaments of the knee.
Answer:
1. Tibial collateral ligament: extends from medial epicondyle of the femur down to the
medial condyle of the tibia.
2. Fibular collateral ligament: begins at the lateral epicondyle of the femur and extends to
the head of the fibula.
3. Anterior cruciate ligament: attaches on the anterior portion of the intercondylar area of the
tibia and runs superiorly and posteriorly to the internal aspect of the lateral femoral condyle.
4. The posterior cruciate ligament: attaches on the posterior aspect of the intercondylar area
of the tibia and runs superiorly and anteriorly, passing the anterior cruciate ligament on the
medial side and attaching to the internal aspect of the medial femoral condyle.
Pages: 224–225
9. True or False: There are two menisci located within the knee joint.
Answer: True. The Menisci are located within the space between the tibia and femur.
Page: 225
10. Explain the first aid care for a severe contusion of the thigh.
Answer:
1. Apply ice and compression immediately.
2. If the injury is severe, place the athlete on crutches.
3. Have the athlete rest and avoid any contact with the area.
Page: 228
11. Explain which muscles of the thigh can experience strains through athletic participation.
Answer: Almost any of the muscles in the thigh region are susceptible to strains. Most of the strains
to athletes, however, are to the hamstrings and adductor muscles.
Page: 228
12. True or False: If the patella dislocated, it will not return to its proper position without surgical
intervention.
Answer: False. In many cases, if the athlete is a chronic subluxor the patella will reduce without
intervention.
Page: 231
13. Define joint mice.
Answer: Small pieces of bone that have been dislodged or chipped from the joint are floating within
the joint capsule.
Page: 229
14. What age group is most susceptible to Osgood-Schlatter disease?
Answer: This condition is unique to children and adolescents.
Page: 231
15. Describe how to care for an athlete with jumper’s knee.
Answer:
1. Apply ice and compression to the area.
2. Have the athlete see a physician for possible anti-inflammatory medications.
3. Rest will be helpful to the ailing athlete.
Page: 232
16. What population is more susceptible to Q-angle alignment problems?
Answer: This typically occurs in athletes such as runners or gymnasts.
Page: 232
17. True or False: An athlete with a torn meniscus will always have a great deal of swelling in the
knee joint itself after the injury.
Answer: False. The athlete may not have any swelling, depending on the structures involved in the
injury.
Page: 233
18. Explain the mechanism by which the medial and lateral collateral ligaments are damaged.
Answer: See explanation on pages 233–234
Pages: 233–234
19. Define and list the structures damaged if an athlete experiences a terrible-triad injury.
Answer: Medial collateral ligament, medial meniscus, and anterior cruciate ligament
Page: 234
20. Explain why an athlete should or should not choose to use a prophylactic knee brace.
Answer: Refer to pages 236–238.
Page: 236–238