ANTERIOR KNEE PAIN

ed hyperextension of the knee, for example with swimming or fast bowling Presentation: The pain will occur as a result of a specific incident eg. a kick to the knee, or a gradual onset of pain and swelling fol- lowing activity. The inferior aspect of the patella is swollen with- out any knee joint effusion. The pain is aggravated by prolonged standing and often downhill running and descending stairs. The patient may also complain of being unable to fully extend the knee Assessment: The chronic patient will often stand with hyper- extended locked back knees and show poor control of knee exten- sion during running and walking, with the knee flicking into hyperextension. The infra-patella fat pad will be swollen and often tender on palpation. The knee in all but the acute situation will have good range of movement, full flexion with only pain on pas- sive over-pressure of extension. Resisted straight leg raise may also illicit pain Treatment/rehabilitation: Electrotherapeutic modalities may help in the initial stages to reduce swelling. Taping to offload the fat pad or to act as a check to over extension of the knee can allow function without the irritation of the fat pad. Careful analy- sis and correction of the aggravating activity is essential. Straight leg raising and inner range quadriceps exercises must be avoided, as should downhill running in the early rehabilitation stages

5 TRACTION APOPHYSITIS Definition: Inflammation of the apophyseal growth plate. Cause: An overuse injury caused by repetitive traction on the apophyseal plate imparted by the quadriceps via the patella ten- don Presentation: Active, usually male, rapidly growing adolescents (10-15 year olds) present with pain and tenderness either over the tibial tubercle (Osgood Schlatter’s disease) or the inferior pole of the patella (Sinding Larsen Johansson disease). This is aggra- vated by activity especially of increasing intensity, squatting, resisted quadriceps and stairs and improved with rest Assessment: In Osgood Schlatter’s disease the tibial tubercle will be prominent. In both conditions localised swelling may occur. Intense pain on palpation over either the inferior pole of the patella (Sinding Larsen Johansson disease) or tibial tubercle (Osgood Schlatter’s disease) will occur in all cases. Short tight muscles (hamstrings, rectus femoris, iliotibial band, gastrocne- muis/soleus) and features of biomechanical mal-alignment are always present. X-ray may show separation of the apophyseal plate Treatment/rehabilitation: This is essentially a self-limiting con- dition and will stop when the apophyseal plates fuse. Rehabilitation involves activity modification (as opposed to com- plete rest) with a graduated return to full activities.

In the early stages activities should be avoided which increase knee (quadriceps) forces such as jumping, landing, sprinting, and activities on hard surfaces. Shock absorbing footwear may prove useful. Correction of the biomechanical faults and muscle stretch- ing are essential

6 ILIOTIBIAL BAND FRICTION SYNDROME Definition: Chronic inflammation of the iliotibial band (ITB) at the lateral epicondyle of the femur or Gerdy’s tubercle of the tibia Cause: Repetitive friction of the distal portion of the ITB as it

28 SportEX

Bony abnormalities

Soft tissue length

Lower limb alignment

Foot posture

Muscle strength imbalances

Figure 2: Factors affecting lower limb alignment

traverses across the lateral femoral condyle or Gerdy’s tubercle of the lateral tibial condyle during knee flexion and extension. It is a chronic overuse injury always associated with some form of bio- mechanical alignment problem Presentation: It has been reported to account for 21% of chron- ic knee injuries in runners. Patient presents with lateral knee pain, most often building up during activity. Going up stairs and hills, increasing pace of running and running on a camber, aggra- vates this pain Assessment: Patient will present with poorly controlled lower limb rotation during running, either excessive/late pronation or excessive hip internal rotation/lateral pelvic displacement. Varus (adduction) stressing of the knee in extension may illicit pain. The ITB will be tender either over the lateral femoral condyle or Gerdy’s tubercle. A short ITB will be present often accompanied by a weak Gluteus medius Treatment/rehabilitation: Electrotherapeutic modalities may help the local pain and inflammation. Lengthening of the ITB and strengthening of the gluteus medius must take place. Correction of any biomechanical fault present is also of paramount impor- tance.

Lower limb alignment Much has been written over the years about the importance of the role of correct lower limb alignment and the prevention of injuries. Likewise, incorrect alignment or mal-alignment of the lower limb during functional activities has the potential to generate micro-trauma and injury. The injury of any tissue represents a failure of that structure’s adaptation to the load it is exposed too. Under normal circumstances the tissues of the lower limb can accept high levels of tensile and compressive load and with training adapt to further increases in loads. The problems occur when torsional (rotary) or shear (translatory) forces are

Q angle

Figure 3a: Normal alignment during a single leg squat