Lower Limb Injuries

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Knee Problems

The knee joint owes it stability significantly to the strong ligaments that surround it – the medial and lateral ligaments (MCL and LCL)  and the anterior and posterior cruciate ligaments  (ACL and PCL). The joint surface is protected and its movement enhanced through pads of cartilage between the bones which spread load – the menisci. All these structures are not uncommonly injured through the trauma of contact sport such as football and rugby.  It is not uncommon for these injuries to be overlooked in a busy A&E department but their diagnosis and treatment is no less important than a break to a bone.

There are also a number of soft tissue structures around the knee which can be equally troublesome but more challenging to diagnose and treat without resorting to surgery.

Patellar tendinopathy

The quadriceps tendon attaches to the patella (knee cap) which then forms the patella tendon which joins onto the shin bone (tibia). This is a troublesome area, particularly in runners who can experience an inflammation close to the patella. This is initially best managed through a system of gradual loading called eccentric loading exercises. Once again relative rest is likely to improve the condition.

Ilio-tibial band (ITB) friction syndrome

A thick band runs down the leg to insert on the outer part of the knee known as the ITB. Repetitive trauma can occur in the area where it runs over the outer part of the knee, particularly when the structure is tight or bio-mechanical issues are present. IT responds well to Physiotherapy and local corticosteroid injection.

Pes Anserine Bursitis

This is another runners’ overuse injury where a fluid-filled bursa becomes inflamed as tendons on the inner part of the knee rub over it. It is a feature common with overuse, a rapid increase in training or bio-mechanical abnormalities in gait. It once again responds well to physiotherapy and occasionally steroid injection.

Lower Leg, Ankle and Foot Problems

Shin Pain

The term ‘shin splints’ is a commonly used term to describe a host of potential problems of lower limb discomfort commonly bought on by exercise. Medial tibial stress syndrome (MTSS) is the medical term for a pain that arises on the medial (inner) border of the tibia (shin bone) when the bone and soft tissue are overloaded. This may be due to the level of exercise but may be due to excessive loads bought on by abnormal bio-mechanics (the way we walk and run).

By analysing and treating these abnormalities MTSS can often resolve but if left unchecked may reflect the start of a more significant stress injury or stress fracture of the tibia. This is really important to rule out especially in endurance runners or those who might have poor bone health. (Some runners can become underweight due to poor dietary habits resulting in a form of osteoporosis – in women this can be associated with reduced or absent periods – the so called ‘female athlete triad’.)

Sometimes shin or calf pain can be due to a myriad of other causes from tendon inflammation, muscle injury or nerve entrapment. One particular problem that can affect athletes is where a muscle becomes too tight within its muscle sheath. As the athlete runs, the pressure from the increased blood feeding the muscle becomes too great, eventually overcoming the ability of the body to supply the muscle and leading to ‘exertional lower limb pain or ‘compartment syndrome’.

Once again abnormal bio-mechanics may play a role and it is important to establish this diagnosis and cause to enable the most appropriate treatment.

Ankle sprains

The ankle is one of the most common joints to be injured. Patients are commonly advised to rest for an indeterminate time and then return to sport. The importance of working out how badly injured the ankle is and planning a proper program of rehabilitation is perhaps one of the most valuable interventions a sports doctor can do to reduce re-injury or chronic discomfort in the ankle.

The outer/lateral ligament is the commonest structure to be injured and most people eventually return to a reasonable level of sport without problems but when problems continue to be there, it is important to ensure other structures within the joint, surrounding tendons and nerves or the bone itself have not been injured. Poor rehabilitation practices is by far the main reason for failure to return safely to sport and this is reasonably easy to rectify with the right advice!

Achilles tendinopathy

This is often an issue for those who load the ankle repetitively such as endurance runners. The Achilles tendon undergoes a degenerative process and weakens, thickens and becomes painful. Relative rest and progressive loading through eccentric loading exercises can hep to reduce symptoms, however the condition can be quite troublesome to manage. Where the inflammation is at the insertion point we will often look out for other inflammatory responses in the body such as an inflammatory arthropathy.

Foot issues

A lot of discomfort in the ankles, feet, knees, hips and back are laid at the door of poor foot posture such as an overpronating gait where the arches are classically dropped. Whilst this is a really important aspect to consider when looking further up the leg, all ills are not cured by corrective footwear or insoles. Indeed, foot alignment if often significantly influenced by the ability of the hip and pelvic muscles to control the ‘kinetic chain’ and though a complex chain of bio-mechanics and rotation result in overpronation. Having said that, it can be an issue and working with experienced bio-mechanists can help to sort significant issues.

One of the simple ways to avoid significant foot pain and bio-mechanical issues is to ensure that running footwear is appropriately fitted and not too old or worn.

Excessive stresses within the foot, particularly in runners can lead to some potentially troublesome issues such as stress fractures of the metatarsals – March fracture, or the navicular and other carpal bones.

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