CONDITIONING

Proper conditioning means the development of strength, endurance, cardiovascular fitness, power, and flexibility. It also includes the development of proper body mechanics, form, and agility. The exact skill training depends on the specific sport involved, but lower extremity injuries can generally be lessened by strengthening exercises for individuals with loose joints to protect against ligament damage and stretching exercises for individuals with tight joints to avoid muscular strains. Staying in shape during the off-season may involve running stairs and jogging in place at home.

WARMING UP

Beginning any activity gradually reduces the incidence of injury, especially injury to the muscle–tendon unit. Stretching is especially important to avoid strain. Flexibility is often diminished after a long period of inactivity, and stretching is particularly important when resuming a sport. The heel cord, hamstrings, and quadriceps should have special attention (Fig. 15-1). Tissue stretches better when warm. Therefore, stretching is best performed after slow jogging or walking for 5 minutes. Two types of stretching exercises may be performed. Static stretching is a slow, gradual stretching through full movement and holding at the position of maximum stretch for 10 to 20 seconds before relaxing. A pulling sensation, not pain, should be felt. Ballistic stretching, which involves rapid, repetitive movements, is also occasionally used but is generally less effective and may even cause minor muscular tears. It is usually not recommended.

Fig. 15-1 Stretching exercises. These should be performed before vigorous exercise and after warming up for a few minutes by walking. The patient should be instructed not to “bounce” or cause strain. The stretch is held for several seconds and repeated several times, and then the legs are reversed. A, Quadriceps stretch. B, Heel cord stretch. C, Hamstring stretch. D, Hamstring and quadriceps stretch.

COOLING OFF

Proper habits after rigorous exercise permit muscles to cool off adequately and to dissipate heat. After running, it is usually advised not to simply stand still or lie supine, but to walk for 5 to 10 minutes and then rest in a sitting position. This may be especially important for the cardiac status of the individual. If the exercise is stopped abruptly, blood pooling can occur in the legs, causing syncope, hypotension, and arrhythymias.

MUSCULAR TEARS

Pain that develops acutely from violent activity is usually the result of a muscle tear. This may be partial or complete and may even involve the fascia. Muscles that cross two joints, such as the hamstrings, seem to be the most vulnerable. The diagnosis is usually not difficult, although it may not be easy to differentiate complete from incomplete ruptures. Sudden onset of pain, swelling, and marked local tenderness are characteristic. Pain is increased by stretching the affected muscle unit. Complete rupture may reveal a palpable defect on examination, but swelling often makes it difficult to diagnose a complete tear.

Ice (30 minutes every hour) should be applied immediately and the injured area elevated. There is probably little to be gained by attempting to aspirate the hematoma. A pressure bandage is always applied, and complete bed rest may even be necessary. After 24 to 48 hours, very gentle, active contraction of the muscle may be started. Ice should be continued when the exercises have begun. Heat and massage should be avoided, and the extremity should be protected against further injury. Weight bearing, passive stretching, or excessive muscular activity should also be avoided until swelling is under control and the limb can be actively moved through a full range with little pain. Crutches are often needed in lower extremity injuries. Cool whirlpool baths are often helpful at this stage. Gradually, a return to activity is allowed when motion is painless.

Although complete tears should theoretically be surgically repaired, many (if not most) surgeons do not support this concept. Immediate repair is often difficult because of the poor texture of the muscle and the difficulty in holding the sutures. The results are often poor. Late repair may occasionally be indicated, but the overall results are only fair. Therefore, unless surgery is contemplated, all acute muscular strains should be treated essentially the same.

Rehabilitation is often slow, and occasionally the functional capacity of the athlete never returns to normal. Stretching exercises should be continued as strength returns. An elastic wrap is occasionally helpful when activity is resumed. If the injury has been to a hamstring muscle, strains can often be prevented by being certain that the hamstrings are at least 60% to 70% as strong as the quadriceps. This 60:40 ratio of quadriceps to hamstring strength is important to prevent strain of the hamstrings because of their relative weakness as compared with the quadriceps. Athletes may return to regular activity when full, pain-free motion is present, muscle strength is restored, and tenderness and swelling have subsided.

MUSCLE CRAMPS AND SORENESS

Muscle cramps are common during exercise and are of unknown cause. They usually occur during the latter part of exercise and may be a result of the accumulation of waste products or electrolyte imbalance. Any muscle may be affected, but the most common are the thigh, calf, and foot. Treatment is primarily by static stretching through a full range of motion and local massage. Cramps may be prevented by proper stretching exercises and warm-up and by the maintenance of adequate oral fluid and electrolyte intake. It is inappropriate to ever have an athlete “run it out.”

Muscle soreness may also develop 24 to 48 hours after exertion. The cause of this type of muscle pain is also not completely understood but may be caused by localized muscular spasm, swelling, and ischemia. It is treated by rest and stretching exercises. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful.

Nocturnal muscle cramps are also common in both adults and children. In adults, they are usually not in the athletic individual, whereas they are common in the physically active child. In the adult, these cramps may be quite severe and cause the development of a palpable muscular knot. The acute contraction is treated by static stretching and massage. Stretching exercises, especially calf stretching during the day, may prevent their development. Heavy blankets that keep the feet in the plantar-flexed position should be avoided. Sleeping with the feet over the edge of the bed may also prevent plantar flexion and allow more frequent changes in foot position during the night. Quinine tablets have been used before retiring, although their effectiveness is uncertain.

Children’s night cramps, sometimes referred to as a cause of “growing pains,” are usually not as severe as adults’ and do not cause contractions. They often occur late in the day or at night and may awaken the child. They usually occur in the thighs or calves and may be the result of fatigue. The child does not generally limp, and the physical examination is normal. The disorder is treated symptomatically by heat, massage, and acetominophen, and may be prevented by not allowing the child to become fatigued during play. Stretching exercises two to three times a day during play may also help.

CONTUSIONS

Muscular bruises are common in all athletic events, even in the so-called noncontact sports. They are differentiated from ruptures and strains because function remains after the injury, and the contusion usually results from direct trauma. The thigh and upper portion of the arm are most commonly involved. The diagnosis is usually not difficult. Tenderness is present at the site of injury, and there is usually ecchymosis, although it may not appear until later. Treatment is directed at avoiding the complications of myositis ossificans and contractures and returning the athlete to full, pain-free competitive activity. This is accomplished by the rapid application of ice to the affected area to control bleeding and the removal of the athlete from further competition. Crutches may be necessary for the lower extremity injury, and complete bed rest with elevation of the extremity may even be indicated to control swelling and pain. A compression wrapping is helpful in early stages. After 24 to 48 hours, gentle isometric muscle contractions may be started, and active gentle range of motion is gradually added at the patient’s tolerance. Passive range of motion should be avoided. Any increase in pain or swelling is an indication to resume complete rest and application of ice. Full strength and complete flexibility are gradually restored by exercise. Reinjury is avoided by allowing complete healing to occur before returning to activities and by appropriately protecting the injured site. A return to athletics should follow only complete recovery.

MYOSITIS OSSIFICANS (OSSIFYING HEMATOMA)

This condition is characterized by the formation of heterotopic bone in the soft tissues. It usually develops in muscle as the result of blunt trauma (myositis ossificans circumscripta). It also occurs in the lower extremities in conjunction with severe brain injuries. It may also follow major orthopedic surgery or spinal cord injuries with paralysis. A rare congenital form (myositis ossificans progressiva) may begin without trauma or shortly after birth. The common traumatic form usually follows a single injury. The mechanism of bone formation is unknown, but interstitial hemorrhage and cellular metaplasia are believed to play a role. Eventually, the hematoma becomes calcified and ossified.

The most common sites of localized development from trauma are the quadriceps, brachialis, deltoid, and hamstrings. After the injury, a large hematoma forms. The area becomes swollen and tender, and motion is restricted. Increased heat may even be present locally, and some patients have a mild febrile episode. The tenderness and heat may persist for several days. The erythrocyte sedimentation rate (ESR) is sometimes increased. As the swelling, pain, and heat subside, a firm mass becomes palpable in the involved area. Motion may continue to be restricted because of obstruction by the mass or from inelasticity of the muscle. A sympathetic knee effusion may develop in quadriceps lesions.

The roentgenographic diagnosis can usually be made 2 to 4 weeks after the contusion. Plain radiographs are usually sufficient. The initial appearance is that of a poorly defined opaque mass in the soft tissue adjacent to the bone (Fig. 15-2). As the mass matures, it becomes more clearly outlined and dense. The lesion usually stabilizes in 3 to 6 months and begins to resorb slowly, often without any disability. Eventually, it transforms itself into mature bone and is partially resorbed. Radiographic maturity is usually reached in about 6 months.

Fig. 15-2 Examples of myositis ossificans (ossifying hematoma). A, The typical early (2 ½ weeks) roentgenographic appearance. B, A more broad-based variety. C, Massive involvement in the hamstring area. D, The same case as C, after maturity. These injuries can occasionally be confused with malignant bone lesions, but in contrast to tumors, there is no involvement of the adjacent bone.

Early treatment of muscle contusions is important to prevent the disorder. Ice, elevation, and rest will control swelling and prevent additional bleeding. Although usually not practical, early aspiration of large, well-localized hematomas could prevent heterotopic bone formation. Once bone formation has developed, rest of the affected part is indicated. Gentle exercise may be helpful to prevent stiffness, but early vigorous physical therapy only leads to more disability. If the heterotopic bone is locally painful or disabling, it may be removed, but excision is contraindicated until complete maturity of the bony mass is reached. This may take several months. Premature removal could result in a recurrence more extensive than the original mass. It is generally recommended that athletes not resume their physical activity until the bone has completely matured, which may take 3 to 6 months. The injured area should then be protected by padding. With time, the mass becomes well demarcated and decreases in volume, often resolving completely. Residual muscle deficits are unusual.

FASCIAL HERNIAS

These hernias often develop as a result of a simple contusion or small puncture wound that causes a rent to develop in the fascia and aponeurosis that envelops all muscle. Often, however, there is no history of trauma. The defect may vary in size, the smallest being 1 cm. Hernias may also develop in weak fascial areas in patients with chronic compartmental syndromes as a result of increased pressure in the compartment. They are also seen where nerves emerge from the fascia. Examination will reveal a palpable “tumor” mass, especially when the muscle is relaxed (Fig. 15-3). Muscle contraction may cause the mass to disappear, and direct pressure also “reduces” the mass. There may be numbness in the foot if the hernia protrudes through a neural foramen.

Fig. 15-3 Fascial hernia. A, The clinical appearance. B, The lesion at surgery.

Treatment is usually unnecessary. Good elastic support stockings may be advised if symptoms of pain or fatigue are present. If pain persists, surgical referral is indicated. Usually, the hole is simply enlarged.

BIOMECHANICS

The running gait pattern is a repetitive movement that consists of a support phase, when the foot is on the ground, and a nonsupport phase. It is during the support phase that most injuries develop. Distance runners usually begin this phase by landing on the heel (sprinters usually land on the forefoot). As weight is taken on the heel, the calcaneus will begin to roll laterally (pronate, evert) under the talus at the subtalar joint (Fig. 15-4). This allows the heel to absorb shock and adapt to the underlying surface. The forefoot follows this motion by pronating, and at the same time, the tibia begins to rotate internally in proportion to the amount of heel pronation. As the weight moves forward, the calcaneus begins to supinate (invert) or roll back medially under the talus, and the tibia begins to externally rotate. This allows the foot to become more rigid and gives the heel cord a strong lever on which to act and transfer power. There are also a number of other coordinated motions that occur in the pelvis, hip, and other joints throughout the gait cycle, but understanding the subtalar joint mechanics is the most important.

Fig. 15-4 Movements of the subtalar joint. A, Eversion (pronation) allows for shock absorption upon impact. B, Inversion (supination) converts the hindfoot to a more powerful lever for push-off.

HISTORY

An accurate history, especially of the training program, is extremely important in evaluating injuries to runners, because only 40% will actually have an anatomic problem causing their disorder. The remaining 60% can usually be traced to errors in training. The history begins by determining whether the individual was ever treated for any childhood malalignment problem. It should be ascertained whether the individual has had any other significant past musculoskeletal diseases. An accurate running history is then taken:

EXAMINATION

The examination should consist of a complete evaluation of the lower extremities to determine whether any anatomic problems of extremity alignment are present as well as a local examination of the injured part. There is obviously a proper position or alignment for the foot and leg in which it functions most efficiently. This is the neutral, or straightforward, position. Minor deviations from this alignment may not cause problems with normal walking or running, but because of the great accumulation of repetitive stresses applied to the lower extremities in long-distance running, subtle malalignment problems may translate into major disturbances for the runner. This may even cause abnormal compensatory motions to develop in other joints and cause them to break down. To determine whether a problem with alignment exists, a complete examination of the lower extremities is necessary. The most important aspects of the examination can be ascertained with the patient standing, lying supine, and kneeling. With the patient standing, any gross abnormalities, such as torsion, varus, or valgus of the legs, laterally directed patellae, or obvious foot deformities, such as high or low arches, should be noted. Any eversion of the heels as visualized from behind is especially important.

In the supine position, the true leg lengths are measured between the anterior superior iliac spines and the medial malleoli. Discrepancies of 0.5 to 1.0 cm may be significant in the runner and require correction by a shoe lift. The range of motion of the hips is then determined. Internal and external rotation should be within 30 degrees of each other. Marked external rotation may cause an out-toed gait. The knee is closely examined, especially if patellar pain is present, and the Q angle is determined (Fig. 15-5). Patients with high Q angles may develop knee pain with running. The range of motion of the ankle is then determined with the knee extended. Fifteen degrees of dorsiflexion is normal. Any tightness of the heel cord is noted.

Fig. 15-5 The Q angle, formed by the intersection of a line from the anterior superior iliac spine (ASIS) through the midpatella and a line from the midpatella to the tibial tubercle. The normal angle is 15 to 20 degrees. Higher angles, by causing a bowstringing effect and lateral tracking, may cause peripatellar pain.

The patient then kneels on the examining table, and leg–heel and heel–forefoot alignments are determined. First, the neutral position of the subtalar joint is found by everting and inverting the foot and finding the point where the head of the talus is placed in the navicular and is no longer palpable (Fig. 15-6). This may require a little practice and is often only a rough estimate. Next, leg–heel alignment is determined by drawing lines posteriorly that bisect the lower portion of the leg and calcaneus (Fig. 15-7). The lines should be parallel or have no more than 2 to 3 degrees of varus. Heel–forefoot alignment is estimated by observing the relationship of the calcaneal line to the plane of the metatarsal heads. Normally, these lines should be perpendicular.

Fig. 15-6 A, The neutral position of the foot. B, Inversion. C, Eversion.

Fig.15-7 Leg–heel A, and heel–forefoot B, alignment. The foot and subtalar joint are held in the neutral position.

If the alignment of the leg is not satisfactory, the knee and the foot are the most commonly affected areas. The foot may be adversely affected by too little pronation or a heel that is in too much inversion. This will not allow force to be absorbed during weight bearing. Excessive pronation may lead to strain on the medial side of the foot and ankle. This also prevents the heel from completely returning to the stable position before push-off.

The knee may also be secondarily affected, because as the heel pronates, the tibia normally internally rotates, and the femur externally rotates. If heel pronation is excessive, internal tibial rotation may increase and require that the knee absorb more rotation during this support phase. This may lead to knee pain.

A common example of a malalignment problem is what James (1978) calls “malicious malalignment syndrome.” The patient with this disorder usually has a broad pelvis, femoral anteversion, genu valgum, a high Q angle, external tibial torsion, and pronated feet.

BACK, HIP, AND THIGH PAIN

Back, hip, and thigh pain is relatively uncommon in long-distance runners. Back pain is especially rare, but may be caused by disc disease with or without radicular symptoms. Congenital or developmental problems, such as spondylolisthesis, may also become symptomatic under the conditions of long-distance running. The usual early course of treatment is symptomatic, but long-distance running may aggravate the condition under treatment, and a decision may have to be made not to return to the sport.

Trochanteric bursitis is occasionally seen in runners and may be associated with tendinitis of the gluteus medius. The pain often radiates down the iliotibial band of the lateral aspect of the thigh and thus may be confused with disc herniation. Point tenderness is usually present. The condition may develop when the patient runs on banked surfaces or has a leg length inequality. The treatment is heat, anti-inflammatory medication, and a local cortisone injection. A lift in the running shoe may help compensate for a leg length inequality. The runner is advised to switch sides of the road from time to time.

Stress fractures occasionally occur in the pelvis and femur of the distance runner (Fig. 15-8). They should be ruled out in all cases of chronic pain that fail to respond to routine symptomatic management. The appropriate roentgenographic study should include a bone scan if the diagnosis is uncertain. As with other stress fractures, reduction of activity is usually curative, but fractures of the femoral neck may require internal fixation.

Fig. 15-8 Stress fracture of the femur (arrow). A, Plain anteroposterior (AP) roentgenogram. B, Bone scan.

Hamstring strains are a less common cause of disability in the distance runner than in the sprinter. They are treated as previously described. Stretching exercises are important not only because they can prevent local injuries but also because tight hamstrings may cause excessive lumbar lordosis that adds strain to the back when running. Rather than strain the hamstring, the sprinter whose apophyses are not closed may occasionally avulse the ischial tuberosity instead. If there is delay in assessment, the avulsed fragment may enlarge as it heals, causing a palpable fullness on clinical examination and bony enlargement on radiographic evaluation (Fig. 15-9). Unless the injury is acute and the athlete is highly competitive, treatment is symptomatic only. The fragment usually shrinks over time, but some of it may persist indefinitely.

Fig. 15-9 AP radiograph of the pelvis revealing a large bony mass (arrow), which represents exhuberant bone reaction from an avulsion fracture of the ischial apophysis several weeks earlier in a teenager. The patient thought it was a simple hamstring strain.

Contractures of the hip joint also add strain to the back and should be treated by static stretching exercises. Inflammation may also develop in the piriformis, adductor, and iliopsoas tendons and in the ischial and iliopsoas bursae. Inflammation of the symphysis pubis (osteitis pubis) and sacroiliac joints may also develop because of the repetitive shearing forces applied to these areas. The treatment for these disorders is also symptomatic.

KNEE PAIN

OVERUSE SYNDROMES

Major injuries of the meniscus or ligaments are uncommon in the knees of runners. More frequent are overuse disorders that develop because of the repetitive nature of running (Fig. 15-10). Several areas are commonly affected:

1 Tenosynovitis of the popliteus tendon may develop near its insertion just above the lateral joint line and anterior to the lateral collateral ligament. This insertion is deep to the iliotibial band. The inflammation may be caused by excessive downhill running.

2 The iliotibial band friction syndrome is an inflammation of the band as it rubs over the lateral femoral condyle. A snapping sensation may be present during flexion and extension.

3 Anserine bursitis causes pain beneath the anserine tendons over the medial flare of the tibia. A stress fracture of the upper portion of the tibia should be ruled out in resistant cases.

4 Jumper’s knee is a tendinitis of the patellar tendon, usually where it attaches to the patella. As the name implies, it is also seen in athletes whose events require jumping.

5 Tendinitis of the quadriceps mechanism may also occur over its wide insertion or over the medial or lateral retinaculum that helps support the patella.

6 Synovitis. Chronic inflammation of the joint may also develop from overuse. An effusion is usually the only physical finding, and the history does not reveal any apparent cause for the swelling, except occasionally a history of increased mileage. Oral anti-inflammatory medication and a period of decreased mileage may be curative, but complete rest for 6 to 8 weeks may be necessary. An occasional steroid injection may be tried if all other treatments fail, but repeated injections are probably not advisable.

Fig. 15-10 Common areas of tendinitis of the knee. The most common areas of involvement are the quadriceps tendon and its medial (M) and lateral (L) expansions. ITB, Iliotibial band.

ANTERIOR KNEE PAIN SYNDROME (PATELLOFEMORAL PAIN SYNDROME)

This is a condition in which pain develops beneath or, more commonly, around the patella (see Chapter 11). It is sometimes seen in conjunction with varying amounts of fibrillation and degeneration of its articular cartilage (chondromalacia), although the relationship of this to symptoms has not been established. The diagnosis is usually one of exclusion (e.g., meniscus injury, jumper’s knee). Anything that adversely affects the normal “tracking” of the patella in its femoral groove may lead to pain, often on the lateral side. The causes are frequently multifactorial: (1) an increased Q angle with a bowstringing effect; (2) tightness of the lateral retinaculum with relative weakness of the vastus medialis muscle; (3) patellofemoral malalignment, sometimes with subluxation; (4) direct trauma; (5) simple overuse; and (6) malalignment of the extremity (Fig. 15-11).

Fig. 15-11 External tibial torsion. A, With the patella pointing straight forward, the feet are externally rotated. This may cause peripatellar pain with excessive use because of abnormal pressure. Note the high Q angles. B, The knees face inward with the feet pointing straight ahead.

Clinically, patellar or peripatellar pain and discomfort are present and are usually aggravated when stress is applied to the extensor mechanism by stair walking or running up and down hilly terrain. Crepitus may be present, although this finding is of debatable significance. Sitting with the knee flexed for any excessive period of time may cause a stiff feeling to develop that is usually relieved by knee extension. An effusion is rarely present, and palpation of the undersurface of the patella may be painful. A Q angle of more than 20 degrees or other physical findings of malalignment may be present. Roentgenograms are usually not helpful unless subluxation is present.

The wide variety of treatments used to manage this condition attests to the difficulty in curing it. Conservative measures such as rest, anti-inflammatory medication, local heat, stretching exercises, quadriceps exercises in extension, and avoiding the offending activity are useful. Many patients benefit from a referral to a physical therapist. Patellar straps or braces seem to be of only limited benefit. Although arthroscopically shaving the fibrillated articular cartilage has been a common surgical intervention, the results are often inconsistent, probably because the changes in the articular cartilage are not the source of pain. If a distal malalignment problem is present, an orthotic device in the shoe may occasionally be advised to help correct the tracking problem, mainly on empiric grounds. As a last resort, a surgical procedure to realign the patella sometimes eliminates the symptoms, but it would seem difficult to justify such a major operation simply to allow continued running. Despite the frustrating nature of the condition, however, most patients do well with a home exercise program.

LOWER LEGPAIN

MEDIAL TIBIAL STRESS SYNDROME

A common cause of leg pain is what is sometimes referred to as the shin splint,

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