CORES 全方位痛症治療中心

Lower Limb

Medial Collateral Ligament Injury (MCL Injury) 內側副韌帶創傷

Definition

Triangular fibrocartilage complex (TFCC) is a complex structure which is always described as wrist menisci, and located on the ulnar side of the wrist. TFCC is composed of a group of ligament and fibrocartilage. It has two main functions: firstly, to maintain wrist stability in rotational movement; secondly, to transmit and absorb the stress from hand. Acute injury or chronic overuse will cause TFCC injury.

Causes and Risk Factors

Quick and sudden wrist rotation when fall on outstretched arm is a common cause of acute injury, and may even leads to a wrist dislocation. Repetitive wrist and forearm rotation will cause chronic overuse, that creates stress to TFCC, causing tear or even degenerative changes. In addition, inadequate warm-up and poor flexibility of wrist and forearm, is risk factor of TFCC injury too. Sportsmen involved in weight-lifting and racket sports may lead to chronic injury.

Risk Factors

  • Nonunion of wrist fracture
  • Discrepancy between radius and ulna bone, too prominent of ulnar head
  • Always operate modalities (e.g. electrical drill) or athletes participating in sports with repetitive wrist compression (eg: tennis, gymnastics) creating repetitive microtrauma to TFCC

Common Symptoms

  • Pain and weakness on medial wrist joint
  • Rotational movement of forearm and wrist will aggravate the pain
  • Wrist swelling not prominent, but local tenderness in around medial wrist joint
  • When the wrist deviates to medial side, provotes more pain
  • Very few cases may lead to some wrist bone subluxation, causing prominent ulnar bone on dorsum, with reduced strength and range of movement

Management

If injury is not extensive with good joint stability, sports taping may be helpful to support the joint. Patient needs to apply ice therapy for 15-20 minutes for few times a day, and incorporates wrist strengthening in the later stage. NSAIDs or corticosteroid injection were shown efficient in controlling local inflammation, but not advise to do if symptoms are controllable. If the tear is severe, early arthroscopy of the wrist joint and immobilization provides promising results. If TFCC tear is not treated, in a long term wrist instability and loosen ligament may lead to overuse wrist arthritis, causing chronic pain and weakness.

Preventive Measures

  • Learning proper sporting techniques of racket sports
  • Sufficient warm-up of wrist and forearm
  • Strengthening the muscles surrounding wrist joint
  • Avoid from high risk wrist movement (e.g. carry heavy object in awkward angle)

Recommendations

Anterior Cruciate Ligament Injury (ACL injury) 前十字韌帶創傷

Definition

Anterior Cruciate Ligament (ACL) is the main stabilizing structure in knee for preventing the anterior translation of tibia. It works in conjunction with the posterior cruciate ligament (PCL) which cross-connects the femur and tibia to stabilize the knee. Excessive rotation or anterior translation of tibia creates high stress which may injure or even completely tear the ACL. Over 50% of ACL injury is combined with meniscal injury.

Causes and Risk Factors

The common injury mechanism is sudden twisting in the knee slightly bent and weight-bearing position or being collided in front of the thigh or the back of the lower leg.

Furthermore, sudden stop or jumping from high distances may also cause ACL injury as the lower leg need to slightly bend to disperse external force. If the quadriceps use large force at this moment, there will be excessive anterior translation of tibia, causing ACL injury.

Risk Factors

Sports like rugby, basketball, or football, which require a lot of lower limb turning may increase the injury risk.

Common Symptoms

  • “POP” sound of ligament tear will be heard during injury
  • Injured site will have pain and increase in temperature while swelling and redness usually occur after a few hours of injury
  • Knee instability when quick turning or sudden stop
  • May experience limited knee movement in end range

Management

Whether ACL reconstruction is needed depends on the severity of injury and the need for work and sports. If the knee instability severely affects the patient daily life, or if the patient is a professional athlete in contact sports, ACL reconstruction may help to improve knee stability. However, a very detailed rehabilitation plan after the surgery is essential for returning to sports.

Apart from electrophysical modalities, acupuncture, and scar management, post-surgical rehabilitation can be divided into four stages:

The first stage ( 1-2 weeks post-operation)
- Patient can do RICE: Rest, Ice, Compression and Elevation
- Practice walking normally with less support from walking aids
- Light Hamstrings strengthening exercise
- Restrict active knee pain-free range from 40-90 degree

The Second Stage (2-6 weeks post-operation)
- Walk unaided normally
- Gradually progress the hamstring and quadriceps active stretching in full range
- Start Close Kinetic Chain (CKC) strengthening exercise, but need to restrict the knee flexion angle according to the progress

The Third Stage (6-10 weeks post-operation)
- Gradually progress the strengthening exercise in a weight-bearing position, especially for hamstrings
- Involve knee stability and balance training on unstable surfaces (eg: wobble disc/trampoline)
- Incorporates cycling, stairs, or aquatic exercise

The Fourth Stage (10 weeks post-operation)
- Running training in a straight line and multi-angle, for endurance training first followed by speed
- Progressively includes agility training, such as quick turning, sideways hopping, shuttle run, trampoline, and figure of eight exercise

Preventive Measures

Motor control training and posture correction aiming to improve lower limb biomechanics are important. Sports taping, knee strengthening, and agility training can improve knee stability and reduce injury rate.

Recommendations

Meniscal Injury 半月板創傷

Definition

Menisci are semilunar-shaped fibrocartilage located inside the knee joint for reinforcing the knee stability and absorbing shock. However, menisci may wear and tear due to long-term impact or acutely injury during exercise. Pain and difficulty in movement will happen if the torn fragment of the meniscus is dislocated and stuck inside the knee joint.

Causes and Risk Factors

There are two types of meniscus injury: trauma or degenerative. Traumatic injury mainly occurs in adolescents during sports activities such as twisting and squatting, with impacted by an external force. ACL injury may be accompanied at the same time.

Risk Factors

  • Participating in high impacts sports, such as: basketball, football or handball
  • Congenital abnormal shape of meniscus
  • Incorrect jumping, landing and changing direction movement

Common Symptoms

There may be a noticeable joint cracking sound during movement. In normal circumstances, the injured knee may not have immediate bruising and swelling, but it may be swollen up after 24-48 hours. After few weeks, the knee swelling may not be obvious, but tenderness along the joint line and the cracking and locking feeling may persist. “Locking mechanism” implies a come and go locking of the knee joint when walking, which can neither straighten nor bend the knee. A recurrent meniscal injury will lead to chronic knee pain and quadriceps muscle atrophy, which seriously affect knee functions.

Management

A mild meniscal injury can be treated by physiotherapy combined with adequate active rest. Immobilization devices or sports taping to prevent re-injury may be needed. If the meniscus fragment is stuck inside the joint, arthroscopic repairs or meniscectomy may be needed depending on the type and severity of the injury. Nevertheless, with or without surgery, patient requires a comprehensive rehabilitation program for knee strengthening and stability training to achieve normal knee functions.

Preventive Measures

Firstly, one should exercise within his tolerable capacity and intensity. Secondly, adequate warm-up is a must before exercise. Most importantly, maintain a regular exercise regime, especially for those aged 40 years old or more, because muscle intolerance to strenuous sporting activities easily leads to an injury and early degeneration.

Recommendations

Sciatica 坐骨神經痛

Definition

Many people may not know that sciatica is not a specific diagnosis for a physical disorder. The term "sciatica" usually describes a symptom (pain) along the sciatic nerve pathway. Some mean any pain starting in the lower back and going down the leg. The pain characteristically travels along the course of the affected nerves, but usually does not involve the sciatic nerve in real cases. The root cause may be due to spinal disc herniation, or the narrowing of the spinal canal which compressed the lumbar and sacral nerve root, causing ischemia or injury. It may be associated with neurological dysfunction, such as weakness, numbness or radiation from buttock to calf and foot.

Causes and Risk Factors

The causes of sciatica can be divided into two categories: primary and secondary. Primary type refers to internal infections, most of which arise from inflammation of other tissues in the body, but rarely occur clinically. The secondary type is much more common, usually due to the compression of the spinal nerve or sciatic nerve by nearby tissues, such as disc herniation, tumors, trauma, and improper posture.

Risk Factors

  • Poor sitting posture, including cross leg sitting or side-sitting
  • Pregnancy
  • People who need to sit or bend for a long time at work
  • History of back injury

Common Symptoms

Sciatica usually begins with buttock pain and spreads to the back of the thigh, if not the lower leg and foot, which is usually accompanied by lower back pain too. In the early stage, one may have backache and cannot stand upright. When the nerve becomes more squeezed, the pain will extend down to the back of the thigh or even to the foot. The pain may also cause "intermittent claudication". The patient needs to sit down and rest for few minutes after walking for a certain distance. For severe cases, one may have symptoms such as leg numbness, muscle atrophy and difficulty in moving the back. Prolonged sitting, sneezing, and coughing often aggravates the symptoms. Clinical examinations may reveal that the muscle strength innervated by the related nerve roots becomes worse, feels dull, and the leg reflexes are abnormal, which seriously affect daily life.

Management

Primarily sciatica should be treated by conservative therapy, that is physiotherapy, including manual therapy, lumbar traction, heat therapy, and interferential therapy, etc. These therapies aim at relaxing muscles and alleviating the symptoms of nerve compression. Therapeutic exercises aim at restoring normal spinal biomechanics and avoiding abnormal irritation of the spinal nerves. During the acute stage, the patient should bed rest for a few days, but it is not advisable to use a soft mattress, nor passively bed rest for more than a week. Those who are in serious condition can temporarily use a soft back brace for support but are advised to wind off as soon as possible to avoid spinal muscle atrophy. If the symptoms remain severe after a few months, it may be necessary to have a detailed assessment to consider the indication of surgical intervention for relieving the compression on the nerves or tissues, such as discectomy, or laminectomy or decompression, etc.

Preventive Measures

  • Maintain a good sitting posture, with both feet on the ground, back straight, or even add a lumbar support for maintaining normal spinal curvature
  • When tying shoelaces, raise your feet and avoid bending.
  • Avoid sitting or standing for too long; better to switch a position every hour.
  • Arrange regular breaks for proper spinal stretching and mobilizing exercises to relax muscles.
  • Before doing any exercises, one should do adequate warm-ups to reduce the chance of sprain injury

Recommendations

Hallux Valgus 拇指外翻

Definition

The big toe deviates outward, causing the toe and first metacarpal swelling, which is called hallux valgus. A prominent bone can sometimes swell like an abscess, causing severe tenderness. The severity can be assessed by measuring the angle of the big toe to the first metacarpal bone. In a normal population, the big toe should deviate less than 15 degrees outward when standing, and the first and second metacarpals should deviate less than 10 degrees. If the toe deforms more than the above degree, it can be diagnosed as hallux valgus. In addition, X-rays can assist assessing the bones contour, the extent of joint enlargement, and the presence of small bone displacement of the feet.

Causes and Risk Factors

There are multiple causes of hallux valgus. There are genetic factors and congenital foot abnormalities such as flat feet, too long big toe, etc. Apart from them, the most common factor is the habit of wearing shoes. Women who often wear tight or pointed high heels are prone to have abnormal toe compression. It is easy to cause inflammation or even permanent deformity, and resulting in hallux valgus.

Risk Factors

Inappropriate shoes wear, standing or walking too much, poor standing posture, inadequate rest, etc

Common Symptoms

  • Chronic pain and swelling in the great toe
  • Increased pain when wearing tight shoes
  • In severe cases, the big toe will deviate and cross above or below the second toe, which indirectly causes deformation of the second toe.

Management

Changing habits of wearing shoes is most important for controlling or improving symptoms. It is suggested to choose shoes with a larger toe-box and lower heels to reduce loading and provide enough space. Also, maintaining the big toe in a good position is very important. Using toe separation devices or splints at night or most of the time can improve symptoms.
Besides, some manual techniques, foot stretching and strengthening exercises can effectively relieve symptoms. If you need to do strenuous exercise, toes taping method may be needed to reduce the stress during exercise. If the pain is still severe, it may eventually need to be corrected by surgery. However, it is necessary to receiving post-operation rehabilitation for good results.

Preventive Measures

Choose shoes with more spacious toe-box and lower heels to prevent compressing on the protruding part of the metacarpal bones and pay attention to the walking posture.

Trochanteric Bursitis 股骨大轉子滑囊炎

Definition

The trochanteric bursa is located on the outer side of the hip, and its role is to reduce the friction and impact between the hip bone and muscle tendons. However, repeated stress often causes inflammation of the trochanteric bursa.

Causes and Risk Factors

Trochanteric bursitis mostly affects women, middle-aged people, and the elderly. Common causes include direct trauma, excessive use of the hip joint, standing or sitting for a long time, etc. When the bursa is rubbed too much, it will cause inflammation, swelling, and pain.

Risk Factors

  • Leg length discrepancy or scoliosis
  • Standing or limping for a long time
  • Participate in jumping or kung fu sports
  • Tight lateral hip muscles
  • People who have suffered a hip injury or surgery

Common Symptoms

  • Patients often cannot sleep on the painful side
  • Pain when bending hip
  • Pain in prolonged standing or sitting
  • Pain is usually most noticeable when wake up in the morning and will ease a bit after mobilizing the hip
  • Difficulty in climbing up and down stair

Management

Treatment aims at anti-inflammatory, pain relieve and improving hip function. The use of medication and physiotherapy can effectively improve the condition. Patients should reduce the activity of the affected area to avoid excessive stress. Physiotherapist may perform manual therapy to improve the joint mobility and release the tighten soft tissues with specific strengthening exercises for improving leg alignment. If therapy is not effective for cure the problems, one may consider consult doctor again for injection therapy or investigate any other underlying causes.

Preventive Measures

  • Avoid overweight and repeated high stress hip movements
  • Maintain good sitting posture and avoid from cross leg sitting or side-sitting
  • If patient suffered from leg length discrepancy, wear a tailor-made insole to correct alignment
  • Stretching and strengthening hip muscles and joints regime

脛骨及腓骨骨折 Tibia and Fibula Fractures

Definition

Tibia and fibula fracture are a very common type of fracture. In our calf, we have two bone connected together: tibia and fibula located in the lower leg. The tibia is the main bone that connects the femur (thigh bone) to bear weight, and the fibula is an important (non-weight bearing) bone attached to the calf muscles. Different injury mechanism contribute to different types of fractures. Moreover, the extent and speed of healing and the rehabilitation processes are different.

Causes and Risk Factors

Fracture occurs when a direct external or repetitive forces stress on the bone. There are open or closed fractures, and forms of direct and indirect external force. Indirect external force may cause a fracture occurs in places far away from external contact, that is, external force breaks at a distance from the point of force through conduction or torsion force, and it is most commonly caused by falling from a height, sprains or slips caused by running and jumping; fracture lines are often oblique type or spiral type. The other types of fractures included transverse, compression, stress and comminuted, etc.

Risk Factors

Contact sports like rugby, basketball or football, which require a lot of lower limb turning and direct insult may increase the injury risk.

Common Symptoms

  • Severe palpable pain and aches
  • The affected area will be hot, swollen and red
  • The pain worsens when the lower leg is moving, and the pain is more pronounced when the fracture is unstable.

Management

According to the severity of fractures, generally it can be divided into non-displaced fractures and displaced fractures.


1) Non-displaced fractures: The alignment of the bones and joints does not change a lot. For this type of fractures, generally only few weeks of immobilization period is needed (depends on types of fractures), followed by a stepwise physiotherapy. Most of the functions may be fully restored. When the bones is in healing stage, assistive protection devices and walking aids may be needed for walking.

2) Displaced fracture: It means that the position of the bone or joint has been displaced. Generally It may need surgical intervention to restore the normal alignment and fix the position with nails or plates. Most often this type of fractures are more serious and complicated, post-surgical rehabilitation requires a longer recovery time.

After operation, one usually feel very painful around the knee and ankle, which is often accompanied by swelling and stiffness. The angle of joint movement will be greatly reduced. In addition, the atrophy of the thigh and calf muscles are rapid and so the muscle strength and control weaken.

Physiotherapy aims to reduce pain, relieve oedema and stiffness, strengthen the muscles, and restore joint mobility. In fact, physiotherapy can be started just few days after surgery. In acute stage, electrophysical therapy, acupuncture and cryotherapy help to reduce pain and swelling. Physiotherapists will step by step use different types of manual therapy to restore a better angle and joints alignment. In later stage, gait training, knee and ankle strengthening, and sports conditioning training will be carried out according to stages of weight-bearing.

Preventive Measures

Sports taping, knee and ankle strengthening and agility training can improve knee and ankle stability and reduce injury rate.

Recommendations

Tibialis Posterior Injuries 脛骨後肌創傷

Definition

The tibialis posterior muscle is located at the medial ankle and runs along from the medial shin to the foot. When it is injured or not functioning well, the arch of the foot cannot be properly supported. It contributes to flatfoot and foot pronation. Combined with tight Achilles tendon, or frequent participating in activities like jumping or forefoot landing, it will cause inflammation of the tibialis posterior muscle.

Causes and Risk Factors

When the tibialis posterior muscle is overused for a long time, with frequent activities like standing, jumping or forefoot landing, small tears at the junction between the muscle and the tendon may occur with inflammation and pain. If it is not handled properly, the tibialis posterior muscle will eventually atrophy and become so weak that it cannot continue to support the function of the foot. As a result, patient may experience difficulty in walking and daily exercise, described as tibialis posterior dysfunction.

Risk Factors

Many adults with pronated feet, flat feet, high arched feet or heel valgus often have this symptom due to biomechanical abnormalities. It is especially common in women who often wear high heels or people who have high exercise intensity.

Common Symptoms

The pain extends to the medial ankle and may even cause heel pain, arch pain, plantar fasciitis or bone spur formation. Patients with inflammation of the tibialis posterior muscle can feel pain when weight bearing especially during the starting or accelerated running.

Management

Firstly, the pain and swelling can be controlled by resting and reducing the activity. It will take time for tissue healing and recover. Choosing shoes with heel with good cushioning material and arch support, which can reduce the traction force of the tibialis posterior tendon and plantar fascia. In addition, changing the exercise mode and walking posture can reduce repetitive stimulation of the tibialis posterior muscle. Anti-inflammatory drugs, physiotherapy such as acupuncture, ultrasound, and ice help reduce inflammation and swelling. Appropriate manual therapy can also improve the position and degree of foot pressure. Muscle training can be added to support the foot arch later. Severe cases require special sports taping methods or orthotics to support the affected area to exercise, so that the tibialis posterior muscle can function properly again.

Preventive Measures

  • Stretching and strengthening of the tibialis posterior muscle
  • You should choose shoes with a firm heel to reduce the excessive strain on the tibialis posterior muscle. You should also avoid wearing unsupported shoes such as sandals and cloth shoes
  • Avoid wearing high heels

Recommendations

脛骨痛症 Shin Splints

Definition

The tibia is the main weight-bearing bone of the lower leg. The middle to the lower end of the tibia bears a lot of stress, so most symptoms will occur in this region, collectively known as shin splints. It can be roughly divided into three types:

  • Medial tibial stress syndrome
    Muscle and skeletal tissues are irritated due to long-term overuse. Pain is usually concentrated on the medial border of the tibia and is the most common condition.

  • Compartment syndrome
    When exercising, the pressure in the muscles increases, or severe swelling is caused by direct contusion, which hinders blood circulation in the compartments. Symptoms ease after rest or reduce swelling. Rarely in severe cases, the nerve inside the compartment is acutely compressed to cause numbness and sudden loss of muscle power. One should be sent to the hospital immediately for acute management to avoid permanent injury to the nerve.

  • Stress fracture
    When the shin muscles are too tight or fatigued, the stress of muscle contraction can stretch the periosteum excessively. Initially, there will be some small fine cracks on the tibia that are not visible. If you do not get proper recovery and continue to overuse, it will become a stress fracture. The patient's tibia will have obvious tender points. Symptoms will initially appear during strenuous exercise, and will eventually become painful even at rest.

Causes and Risk Factors

Tight calf muscles can cause excessive stress on the periosteum of the tibia. Some lower limb structural abnormalities (such as knee valgus and flat feet) are also the main causes of medial tibial stress syndrome. High flexibilty of foor, flat foot, increased foot pronation, or excessive adduction of lower limbs greatly increase the stress of the tibialis posterior muscle. If the tibialis posterior muscle is not strong enough to withstand additional pulling force, chronic inflammation will occur.

Conversely, high arches can also cause problems because high arches are less effective in absorbing shock, which increase the stress on the tibia. In addition, wrong running posture of the forefoot landing may cause tibial pain due to the increased stress of the lower limbs.

Risk Factors

Too high intensity of training, too many running mileage, progression of speed and slope training in a short time can cause problems. Coupled with insufficient warm-up and tense calf muscles. Other factors include wearing sneakers with low shock absorption, hard training ground, and obesity causing excessive stress on the lower limbs.

Common Symptoms

  • Deep pain in medial tibia
  • Inflamed calf on medial side
  • Tibia with bulge
  • The pain is more severe at the beginning of a run, but reduces when the muscles relax after warmup, but the pain increases again when the running time goes on

Management

Physiotherapists will have some manual therapy and soft tissue release techniques to relieve muscle tension, and acupuncture on tibial muscles are also very effective. However, if the symptoms are severe and chronic, the patient must take a period of rest to avoid painful activities. Jogging in the water or cycling are considered as safe activity to continue. Do more leg stretching and strengthening can reduce the stress on the periosteum. In addition, ice can have analgesic and anti-inflammatory effects. If there is abnormality in the structure of the lower limbs, an orthopedic insole can be worn to reduce the tibial stress.

Preventive Measures

Practice more calf stretching exercises and soft tissue release techniques to promote recovery.

Recommendations

Popliteus Injury 膕肌創傷

Definition

Popliteus Injury is a common sports injury that occurs in athletes and runners who are associated with downhill running or other deceleration activities. Popliteus is a small muscle, located in the back of the knee, which attaches from the lateral distal femur to the posterior part of the tibia. It acts as a primary internal rotator of the tibia and helps with the initial flexion of the knee from an extended position (“unlock” the knee). In addition, the popliteus assists the quadriceps and posterior cruciate ligament to maintain normal tibial and femoral orientation.

Causes and Risk Factors

Common causes are either a direct varus force, while the tibia is externally rotated, or a sudden forced knee hyperextension with the tibia internally rotated.

Risk Factors

  • Overuse of popliteus, especially when athletes who run or are trained on hills or inclined surfaces, and require downhills running or deceleration activities
  • Some researchers suggest that fatigue or overuse of quadriceps may lead to inflammation of the popliteus for overwhelming the popliteus muscle. On the other hand, over-pronation provides post-lateral stress to the popliteus tendon.

Common Symptoms

Pain, swelling in the posterolateral corner of the knee; Able to run for short distances, but with continuous running, posterolateral knee pain develops; Sports that require frequent deceleration or downhill running exacerbate the symptoms; When the knee is flexed in 90 degrees, resisted external rotation of the tibia will provoke pain

Management

Most of the popliteus injuries do not require surgical intervention. Popliteus injury can be managed by “RICE” -- Rest, Ice, Compression bandage, and Elevation, combined with NSAIDs and physiotherapy for swelling and pain control. Most patients respond quickly and recover in a few weeks. Ultrasound, acupuncture, specific soft tissue release techniques, and shockwave are effective in reducing swelling, pain, tightness, and inflammation of the popliteus.

When the pain and swelling subsided, a supervised physiotherapy program focusing on eccentric strengthening of quadriceps and popliteus is essential for returning to play. When the strength of the popliteus and quadriceps resume, athletes can return to play. However, due to the different severity of injuries, the rehabilitation time frame is different. If the patients do not respond to conservative treatment, patients may receive corticosteroid or PRP injections.

*Photo description: Step forward and backward in each position 3 times, and return to the starting position (Figure 1), after finishing all positions, change to another leg. Please exercise under proper supervision.

Preventive Measures

  • Adequate and correct warm-up before exercise
  • Static stretching exercises before and after the training to improve the flexibility of lower limbs
  • Improve the strength and endurance of quadriceps muscle, to prevent excessive overloading of the popliteus
  • Improve the knee stability
  • Correct shoewear to fix the hyperpronation of the foot

Knee Osteoarthritis 膝關節退化

Definition

A young, healthy knee joint is infiltrated with joint fluid. However, with the increase of age, the joint fluid decreases, and the femur and tibia continue to have tissue proliferation, which makes the space of the knee joint smaller, and the cartilage of the articular surface is not fully protected, which increases its friction and degeneration. When the knee joint is worn to an irreversible degree and cannot move smoothly, X-ray also shows degenerative changes and degradation of the cartilage of the knee joint. This joint pain and chronic inflammation are collectively referred to as knee osteoarthritis, which often mix up with the terms of "rheumatic" condition by patients.

Causes and Risk Factors

Joint degeneration is what we will experience in life, but the knee joint bears the largest load, and it is most likely to have obvious symptoms after the age of 40.

Risk Factors

  • Previous knee joint injuries
  • Obesity overloads joints and may accelerate cartilage degeneration
  • Repeated knee joint activities, such as carrying heavy objects, participating in long-distance running, track and field, gymnastics and dance, etc., often squatting, jumping up and down stairs, etc.
  • Structural abnormalities, such as varus and valgus knees, causing uneven stress on the knee joints

Common Symptoms

  • Knee joint swelling and redness with deep joint pain
  • Reduced knee range and feel weakness, increased pain during flexion and extension
  • After a break, or when getting up from sleep, the knee joint is particularly stiff, and even lasts for more than half an hour, called morning stiffness
  • There is sounds or frictions in knee joints during movements
  • In late stage, it can cause joint deformation and difficult in walking

Management

In the acute stage, patients can reduce inflammation in the affected area by applying ice and taking non-steroidal anti-inflammatory drugs (NSAID). Patients with chronic pain can reduce pain through hotpad and joint mobilization exercises. The use of insoles matching the shape of the feet can mildly correct the abnormal mechanical structure and reduce the load on the knee joint. In addition, because joints will bear less weight than normal after degeneration, patients should strengthen the quadriceps, vastus medialis, gluteus etc. in order to share and maintain the loading capacity of the knee joint and alleviate the impact of the knee cartilage.

Preventive Measures

If a patient starts to have signs of knee osteoarthritis, the protection of the knee joint should be emphasized and highly loading activity of knee joint should be minimized, such as running stairs, squatting, dancing, sitting on a low chair etc. Those with severe degenerative and painful conditions should stop and take rest between walking, and using handrails when going up and down stairs to reduce the load on knee joint.

Recommendations

Patellofemoral Pain Syndrome 髕股關節綜合症

Definition

Patellofemoral pain syndrome, characterised by anterior knee pain, is a common knee injury, accounting for around 25% of knee pain. Women suffer from patellofemoral pain syndrome twice as often as men, but men and women athletes have the same rate of suffering this syndrome.

Causes and Risk Factors

In recent studies, it has been shown that patella mal-tracking will cause cartilage underneath the knee repetitively and chronic compressed. When the knee is bent repeatedly, the greater the degree of flexion, the greater the patellofemoral pressure. The pressure on the patellofemoral joint of walking on flat roads is 0.5 times the weight, and it increases to 3 to 4 times the weight when going up the stairs, and 7 to 8 times the pressure when squatting. High muscle tension or congenital abnormalities in the lower extremities will further increase patellofemoral pressure and cause pain. Common physiological structural problems, including knee valgus, flat feet, excessively tight soft tissue on the outside of the knee, and imbalance of the knee muscles, can easily lead to patella mal-tracking.

臏股關節綜合症 Patellofemoral Pain Syndrome_膝痛物理治療1

Risk Factors

Long-distance running, track and field, gymnastics and dance and other sports, because the legs have been impacted repetitively, so the chance of suffering from this disease is higher.

Common Symptoms

  • Diffuse pain in the base of the patella and its joint
  • Pain in large degree of knee flexion and repeated flexion and extension
  • Tenderness of the medial patella
  • Knee joint swelling and redness
  • The affected area may sometimes produce sounds in movement or weakness of legs
  • Pain can be aggravated when downstairs and downslope
  • Immediate standing after prolonged sitting can cause discomfort
  • In severe cases, it can cause quadriceps atrophy and joint overuse, degeneration and deformation.

Management

Patients can achieve anti-inflammatory and reduce pain through rest, ice and electrophysical therapy. Passive knee mobilization techniques can also be used to improve the patella mal-tracking. Appropriate and adequate stretching exercises for warm-up and post-exercise adjustments can also increase the flexibility of the taut tissue, and non-stretchable tape can also be used to improve the position of the patella. Patients should do more quadriceps, vastus medialis, gluteus medius and maximus and adductor muscle strengthening to relieve the pressure of the knee cartilage. The use of insoles that match the shape of the feet can correct the abnormal mechanical structure and improve the pain. If the pain persists, the patient should use swimming, running or cycling under the water instead of the original training. In addition, patients should also reduce the excessive load on the knee joint, such as squatting, sprinting, running downhills and stairs walking.

Preventive Measures

Focus on muscle strengthening, stretching and adequate rest. Pay attention to whether the exercise posture is correct and reduce unnecessary overloaded exercise of the knee joint.

Recommendations

Patellar Tendinitis & Fat pad syndrome臏骨腱炎及脂肪體綜合症

Definition

A fat pad is located underneath the patella. When there are inflammation and swelling in the fat pad, it will be considered fat pad syndrome. Patella tendinitis may be accompanied in the later stage.

Causes and Risk Factors

Excessive knee motion or injury will lead to hyperemia, thickening, or inflammation of the patellar tendon and fat pad. After recurrent and repeated inflammation, there will be swelling and even bleeding in the fat pad causing the surrounding soft tissues to lose flexibility and become stiff and tight.

Risk Factors

Abnormal biomechanics such as wide pelvic, large Q-angle (the angle between quadriceps and patellar tendon), or hyperextended knee will increase the chance of having patella tendinitis and fat pad impingement.

Common Symptoms

  • Painful when knee fully extended
  • Tenderness underneath patella
  • Swelling in patellar tendon, even worsen in prolonged standing
  • Soreness especially in night time, Stiff and swollen knee in the morning

Management

Cryotherapy and electrophysical therapy can be used to relieve the pain and desensitized the soft tissue surrounding the patella. Besides, patients can use appropriate bandaging or taping to reduce the pressure in the knee. Patellar mobilization and manual therapy can help to reduce the swelling of the fat pad.

Hyperextended knee increases the pressure of the fat pad and patellar tendon.

Patients should do more calf muscle stretching to prevent hyperextended knees due to tight calf muscle. When patients experience less pain, knee strengthening focusing on medial quadriceps (VMO) and gluteus medius can help correct the biomechanics of lower limbs, while isometric and closed kinetic chain exercise help to reduce pressure in training.

Preventive Measures

Emphasizes quadriceps strengthening and stretching to prevent hyperextended knee in standing. Prolonged crouching or directly impinge on the fat pad should be avoided.

Recommendations

Plantar Fasciitis 足底筋膜炎

Definition

Plantar fascia is a thick fibrous tissue that extends from the heel to the forefoot. It is responsible for supporting the joints, bones, and muscles of the soles when walking. Plantar fasciitis means inflammation of the plantar fascia. The longer the inflammation lasts, the greater the chance of causing calcaneal bone spurs. However, calcaneal bone spur itself may not have any symptoms.

Causes and Risk Factors

There are many causes of inflammation, for example, overuse, overweight, prolonged standing, too much walking, too high jogging mileage, or structural defects, etc. Flat feet, high foot arch, shorten Achilles tendon can also cause abnormal tension on the plantar fascia.

Risk Factors

Studies have shown that plantar fasciitis may be triggered by training errors, such as sudden increase in mileage or training frequency or vigorous upslope training. Too hard or too soft ground surface (concrete, grass, sand etc.), insufficient recovery time and running on uneven surface lead to the painful condition as well. Improper choice of running shoe (too soft, too tight, too hard insole, insufficient arch support, lack of shock absorption etc.) also strain the plantar fascia. Because the plantar fascia connects to calf muscles insertion, tight calf muscles pull to increase fascia tension excessively. It thickens and reduces the flexibility of the fascia.

Common Symptoms

  • Significant heel pain, may radiate to the arch of the inner foot
  • Feel pain when first landing after wake up and even walk with difficulties
  • Relieve pain in the early stages after warming up
  • Standing or exercising too long will elicit the pain again

Management

Do more calf and plantar fascia stretching to reduce pain. Patient should rest as much as possible and apply ice and electrical modalities to reduce pain and inflammation. Also, one can do soft tissue massage and release to painful areas. Applying transverse friction massage to the plantar fascia can reduce tension, improve blood circulation and promote recovery. Patient should choose soft and comfortable shoes, avoid high-heeled, too tight or too hard shoes. If the condition persists for few months, one can try shockwave or injection therapy.
Use non-stretchable sports taping or arch support pads to maintain foot arch and reduce irritation. To resume training, you must have fewer miles than before, reduce intensity, and the training surface should not be too hard. "10% rule" is always a safe training guideline, which means that you cannot increase your mileage or intensity by more than 10% weekly to reduce the chance of relapse.

Preventive Measures

If you need to stand for a long time at work, you should try to take breaks as much as possible. People who are overweight must try weight management. Runners should not increase the training volume too quickly and should stop when plantar fascia are still inflamed. One should choose suitable running shoes to protect their feet. Avoid excessive stimulation of the plantar fascia, which makes the inflammation worse.

Recommendations

Sprain Ankle 足踝扭傷

Definition

The ankle is mainly fixated by four ligaments. The lateral ligaments are anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). As inverted ankle sprain accounts for 80% of ankle sprain, these ligaments are commonly injured. The medial ligament is the deltoid ligament. According to the severity of the injury, it can be divided into the following 3 grades:
1) Minor sprain or tear of the ligament, no joint instability
2) One or more of the ligaments are partially torn, and the joints are slightly unstable.
3) Completely torn. There may be fracture, and the joints are unstable

Causes and Risk Factors

It is usually injured when landing or by a quick turn. If the ankle joint is too loose (congenital instability or previously injured), it is more likely to be sprained. It is generally believed that an ankle sprain is fully recovered if the pain disappears, so the swelling control and the stability training of the ankle joint will be overlooked. In fact, when the ligaments are not fully recovered, the proprioception (the sense of joints) will be diminished, and they will often produce inappropriate response and are easy to be re-injured again.

Risk Factors

Insufficient rehabilitation after previous sprain; Ankle weakness; Lack of recovery after training; The training field is uneven or has many obstacles; Old sports shoes or high heel

Common Symptoms

  • Redness, swelling, warmth and pain in the affected area
  • Difficulty in walking; the pain becomes noticeable when turning; in severe cases, severe pain will elicit even one only put weight on his ankle during standing
  • Joint instability when seriously injured

Management

When injured, one should stop moving the affected area immediately. If it is a grade 1 or 2 tear, one should use sports tapes to support and control the swelling as soon as possible and apply ice for around 20 minutes to reduce pain and swelling. When resting, elevate the feet helps alleviate the swelling. Manual therapy and electrophysical therapy can promote the healing of soft tissues.

Preventive Measures

Do not neglect the training of joint stability and flexibility, especially in the rehabilitation training after the first injury. It can effectively prevent re-injury. Besides, after complete recovery, excessive reliance on protective taping should be avoided, although preventive sports taping is still necessary for high-risk sports (such as dancing, gymnastics, orienteering, rugby etc.).

Recommendations

跟腱發炎、勞損退化或撕裂 Achilles Tendinopathy

Definition

The Achilles tendon is a very thick tendon that connects the calf muscle on the back of the lower leg (gastrocnemius and soleus) to the heel. It bears a very large pulling force and performs plantar flexion of the foot. Acute overloading of this tendon will cause the Achilles tendon to inflame. In recent studies, prolonged overuse of the Achilles tendon will cause early degeneration of it and induce insidious pain in the heel. When suddenly overstretched, there are chances to tear or break it completely. In many cases, surgery is needed to repair the torn tissues. Well-organizing physiotherapy rehabilitation is needed to achieve full recovery.

Causes and Risk Factors

Excessive or repetitive pulling can cause inflammation or degenerative changes of the Achilles tendon. Especially if the training intensity is too high, the training intensity increased in a short period, or training on a steep surface will cause acute or chronic inflammation due to the excessive tension in the Achilles tendon. Besides, severe Achilles tendon strains or tears are commonly associated with powerful starts of a race, jumps, sudden stops, or changing directions. Some rare conditions of calf muscle injuries are caused by direct impact.

跟腱發炎、勞損退化或撕裂 (Achilles Tendinopathy)_腳痛成因物理治療1
跟腱發炎、勞損退化或撕裂 (Achilles Tendinopathy)_腳痛成因物理治療

Risk Factors

Highly repetitive foot movements which bear weight tend to overuse the Achilles tendon excessively. The soft tissue itself will gradually grow thicker and lose flexibility. The rate of self-recovery will slow down as well. The tendon will eventually become weaker due to early degeneration and will be more susceptible to have inflammation and pain. In addition, abnormal mechanical structures of the lower limbs (such as valgus knees and flat feet) can cause the Achilles tendon to bear excessive tension.

Common Symptoms

Acute Phase
- Redness, swelling, warmth, and local tender spots
- Pain in Achilles tendon when moving the ankle
- Pain increases with activity and decreases with rest

Chronic Phase
- No obvious painful spots, scattered across the entire Achilles tendon and calf muscles
- When resting (e.g. sitting) for a long time or getting up in the morning, the ankle and Achilles tendon tends to feel very tight.
- Lumps or thickening of the Achilles tendon
- Ankle muscle weakness and reduces weight bearing on the affected side

Management

The principle of treatment is to reduce the stress of the inflamed area. Other than choosing appropriate sports shoes and insoles to support the foot, ice or gentle soft tissue release also help. More stretching exercises of the calf are necessary. The gastrocnemius and soleus muscles need to be stretched separately to achieve better results. Sports taping can reduce the direct stress on the Achilles tendon, therefore, prevent re-injury. Studies have shown that in the later stages of rehabilitation, gradual eccentric training effectively strengthens tendons and reduces the effects of tendon degeneration.

Preventive Measures

Perform calf stretching before and after the activities to prevent the achilles tendon from over-pulling and overuse.

Recommendations

Metatarsalgia蹠骨痛

Definition

The metatarsal head is located on the front part of the sole of the foot. If the pain occurs here, it is generally called metatarsalgia. When standing, the bodyweight will gradually press on the first to second metatarsals, and when running, it will withstand up to three times the weight of the ground impact. Therefore, as long as the pressure on the lower extremities or sole is unevenly distributed, metatarsalgia is prone to occur.

Causes and Risk Factors

Forefoot pain is caused by long-term abnormal foot stress. The most common cause is high impact, excessive use of the foot, or improper gait posture. Metatarsalgia is a general term to describe the area of pain. Besides the injury to the metatarsal bone, there may also involve sesamoid bone, ligament, neuroma or tendinitis, etc.

Risk Factors

  • The most common factors are wearing inappropriate shoes, poor standing posture, inadequate rest, etc.
  • Genetic factors and congenital foot structure abnormalities (such as flat feet)

Common Symptoms

  • Long-term compression of the metatarsal area will produce thick calluses
  • Severe pain when the metatarsophalangeal joint is flexed
  • For severe cases. even standing for a short period can trigger forefoot pain and swelling. One may need to rest immediately to relieve the pain.

Management

Changing habits of wearing shoes is important for controlling or improving symptoms. It is suggested that choose your shoes with a larger toe-box and lower heels to reduce loading and provide enough space.
Also, some manual techniques, foot stretching, and strengthening exercises can effectively relieve symptoms. Electrophysical therapy, acupuncture, and joint mobilization can reduce the pain as well. If you need to do strenuous exercise, you can learn some foot arch taping methods to reduce stress during exercise.

Preventive Measures

Choose shoes with more spacious toe-box and lower heels to prevent compressing on the protruding part of the metacarpal bones and pay attention to the walking posture.

Recommendations

Cuboid Syndrome 骰骨綜合症

Definition

The Cuboid bone is a dice-like small bone on the lateral side of the foot, connected to the muscles and tendons on the lateral side of the lower leg. Cuboid Syndrome is caused by subluxation or dislocation of the cuboid bone. Patients usually experience pain and limited joint movements. It may cause inflammation of the surrounding tissues such as the joint capsule and ligaments.

Causes and Risk Factors

During ankle sprain, the foot is turned inward pulling the lateral tendons vigorously. This may tear the nearby ligaments Subluxation is resulted as the integrity of the soft tissue connecting the cuboid bone was affected. Apart from acute sprains, long-term overuse, such as long-distance runners on uneven roads or hard grounds especially when sudden mileage increase, are more likely to develop this disease.

Risk Factors

  • Runners wearing shoes with poor support
  • Excessive pronation and flat feet
  • Prolonged tip-toeing ( e.g. Ballet ) which create micro-trauma to foot ligament.

Common Symptoms

  • Pain will increase when walking or weight-bearing.
  • Tenderness when pressing the cuboid bone, sometimes with pain radiated to the medial arch, fourth and fifth toes.
  • Abnormal changes in the appearance of the bone around the lateral arch, with swelling or muscle atrophy

Management

The most direct way of treatment is to rectify the misaligned joints through reduction by manual therapy, but it relies on an accurate diagnosis. There are other methods including the use of insoles to correct excessive pronation, ultrasound, and acupuncture. However, the effect is less than manual therapy. Before performing reduction, one can relax the extensor muscles through massage or using a hot pad or ice. After reduction, applying sports taping on the dislocated bones to prevent dislocation again.

Preventive Measures

  • Choosing shoes with better support
  • Using suitable insoles for correcting foot pronation or flat feet
  • Strengthen the medial muscle group of the foot

Recommendations

Iliotibial Band Friction Syndrome (ITB Syndrome) 髂脛束磨擦綜合症

Definition

Iliotibial Band Friction Syndrome (ITB Syndrome) is the most common type of lateral knee pain. The iliotibial band is a very thick soft tissue on the lateral side of the thigh, which extends from the lateral side of hip to the outer and lower sides of the knee and the patella. When its flexibility is low, repeated movements of the knee may cause the ITB to rub with the femur, causing inflammation and pain, which is called ITB Syndrome. If the inflammation persists, it may hinder the normal movement of the patella and induce pain over knee area.

Causes and Risk Factors

Most people think that this is a phenomenon of excessive fatigue or inevitable degeneration, but the causes are complicated. In addition to the low flexibility of the ITB, abnormal body structures such as pronated feet and flat feet are prone to increase friction between the ITB and its surrounding tissues. Besides, from the perspective of sports biomechanics, the weakness of the medial knee muscles or unbalanced lower limb muscle strength will aggravate the poor running postures (such as habitual internal rotation).

髂脛束磨擦綜合症 ITB Iliotibial Band Friction Syndrome_膝痛成因物理治療2

Risk Factors

Studies have found that sports with repetitive movements (such as long-run) are more likely to cause inflammation than sports with changing orientation or at a fast speed (such as basketball, short-run, etc.). In Hong Kong, the long-distance race includes more stair steps, such as the mountain races. Participants need to go down the mountain or take the stair road on a hard surface, which is more likely to induce this disease. Besides, Asians tend to have flat feet and less preparation and training before the race due to busy life pace. All these factors make Hong Kong sports enthusiasts more vulnerable to this pain.

Common Symptoms

  • Insidious pain in the thigh or the lateral side of the knee during sports activities.
  • Redness, increased temperature, swelling, and pain over the knee area
  • Difficulty in knee flexion and extension
  • Pain intensifies when going down the mountain or stairs
  • Pain during daily life or at rest in severe cases

Management

Ice, electrophysical therapy and anti-inflammatory drugs can effectively relieve inflammation, but reducing the friction and pressure of the ITB is the ultimate cure. The effect of ITB stretching is less ideal. Proper soft tissue release to loosen the ITB is more effective.

Since quadriceps have many adhesions with the ITB, stretching the quadriceps can help to relax the ITB. In addition, insoles that fit the foot and sports shoes can help correct abnormal biomechanics. Rigid tapes can correct the abnormal mechanical structures and reduce compression of the affected area.

Preventive Measures

The endurance training of the quadriceps, vastus medialis, gluteus maximus, and medius muscles can effectively correct the fatigue induced poor running posture (habitual internal rotation, etc.) When first returning to training, athletes should increase the number of miles with respect to pain. For some serious patients or elite athletes, specific training for lower limb strength, knee flexion, landing technique, frequency, and duration is important, in order to gradually return to the previous level of performance.

Recommendations

Hip Osteoarthritis 髖骨關節炎

Definition

The hip joint is composed of a ball (femoral head) and a socket (acetabulum), surrounded by powerful joint capsules, muscle and ligaments. Hip osteoarthritis means that after long-term wear and tear of the cartilage of this joint, the surface is no longer smooth, and the normally smooth cartilage is gradually worn away, causing inflammation and pain.

Causes and Risk Factors

  • Usually over age 50
  • Common in overweight people
  • Failure of hip joint development in childhood
  • Insufficient blood supply to bones in childhood, resulting in permanent damage to the hip

Risk Factors

  • Leg length discrepancy or scoliosis
  • Standing or limping for a long time
  • Participate in jumping or kung fu sports
  • People who have suffered a hip injury or surgery

Common Symptoms

  • Hip joint pain. The pain is triggered when the affected hip joint bears weight, such as prolonged walking or sitting
  • Swelling and deformation of the hip joint
  • Physical activities are restricted, which may make it difficult for the patient to perform certain activities, such as sitting and getting up on a low chair, getting in and out of the vehicles, going to the toilet
  • Difficulty in walking, or limping gait

Management

The most direct way of treatment is to rectify the misaligned joints through reduction by manual therapy, but it relies on an accurate diagnosis. There are other methods including the use of insoles to correct excessive pronation, ultrasound, and acupuncture. However, the effect is less than manual therapy. Before performing reduction, one can relax the extensor muscles through massage or using a hot pad or ice. After reduction, applying sports taping on the dislocated bones to prevent dislocation again.

Preventive Measures

  • Avoid overweight and repeated high stress hip movements
  • Maintain good sitting posture and avoid from cross leg sitting or side-sitting
  • If patient suffered from leg length discrepancy, wear a tailor-made insole to correct alignment
    Stretching and strengthening hip muscles and joints regime

Recommendations

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