An overview of common lower extremity soft tissue injuries in athletes

S Lakkol, K Singisetti, S Anand

Department of Trauma and Orthopaedics,
University Hospital of North Tees, Stockton on Tees, UK

Correspondence to
Mr S Anand Department of Trauma and Orthopaedics,
University Hospital of North Tees, Stockton on Tees, UK
Email: s.anand@doctors.org.uk

Abstract
Lower limb soft tissue injuries are commonly encountered in sports medicine especially in athletes and long distance runners. Dilemmas can exist in identifying the correct aetiology as it can frequently be multifactorial. Management of such injuries in lower limbs is evolving as more people perform physical exercise and play sport. This article is an overview of common lower limb soft tissue injuries seen in athletes.

Lower extremity soft tissue injuries are common among athletes and non-athlete runners.1 Running injuries can be defined as pain or symptoms associated with running or starting within a specific time span from the beginning of a training programme, which forces the individual to stop training or decrease intensity.2 The knee is the commonest site involved comprising up to 44% of running injuries.2,3 This article outlines the natural history, pathophysiology, investigation and management of common conditions.

Patellofemoral Pain Syndrome (PFPS)

Patellofemoral Pain Syndrome (PFPS) is extremely common, especially in female athletes.2-4 PFPS can be defined as anterior knee pain without any definitive intra-articular and peri-articular pathology. Patient related risk factors contributing to PFPS include older age, below average height and recreational running.5 Controversy exists regarding the exact aetiology and many theories have been advocated by several authors including biomechanical, muscular and overuse. Patellar mal-tracking due to lateral deviation of the patella during flexion can generate anterior knee pain due to excessive pressure in the lateral portion of the patellofemoral joint (PFJ).6 Tight lateral stabilisers7 and bony mal-alignment between the patella and lateral femoral condyle predispose to mal-tracking. Imbalance in the Vastus Lateralis (VL) and Vastus Medialis (VM)/Vastus Medialis Oblique (VMO) could predispose to patellar mal tracking and thus PFPS.8 Biomechanical factors such as femoral ante-version, genu valgum and excessive foot pronation may also contribute towards generating excessive load on the lateral PFJ.

The main symptom is peripatellar or retropatellar pain aggravated by running or activities involving repeated forced flexion of the knee e.g. squatting. A further symptom is stiffness that may or may not be associated with pain. Patients may complain of knee instability and the sensation of the knee giving way. This is not true instability, rather likely a transient inhibition of quadriceps muscle function due to pain and/or deconditioning. Recent changes in physical activities and any previous injury sustained to the knee should be noted.

A mild to moderate effusion may be found. Any abnormal finding should ideally be confirmed by examining the normal side. A careful inspection of body posture and limb alignment would reveal genu valgum or excessive foot pronation. Atrophy/weakness in the VM/VMO and/or quadriceps should be assessed clinically and can be confirmed by electromyography. Patellar tilt test, patellar gliding test and patellar grinding are useful and positive results from these are consistent with the diagnosis of PFPS.9 The patellar position in relation to the lateral femoral condyle should be checked during flexion/extension and compared for weight bearing/non weight bearing. The tightness and extensibility of the Iliotibial band (ITB) and quadriceps and their effect on patellar excursion should be assessed. Though routine X-rays are not indicated, radiographs are helpful to rule out osteoarthritis in patients aged above 50 and bone tumors and osteochondritis dissecans in young skeletally immature individuals respectively.5 MRI may be useful to rule out other pathologies involving cartilage or ligaments.

ITB and lateral retinaculum stretching exercises are helpful in reducing excessive load on the lateral PFJ. Functional exercises aimed at strengthening, re-educating the VMO and quadriceps help to reduce mal-tracking and improve stability.10 Cambier et al have shown that there is no difference in long term functional outcome between open and closed kinetic chain programmes.11 Rigid adhesive tape applied to the anterior portion of knee with the view of correcting lateral gliding and/or tilting of patella can significantly improve symptoms. However physiotherapy in addition to adhesive tape has not shown any added benefit.12 Surgical options should be reserved for cases where conservative treatments have failed; these include release of tight lateral structures, proximal and distal realignment procedures.9

Iliotibial band syndrome (ITBS)

Iliotibial band syndrome (ITBS) is a common soft tissue injury involving the soft tissue around the knee resulting from thickening of the fascia lata.13 The flexion and extension of the knee while running will subject the ITB to move repeatedly over the lateral femoral condyle in an antero-posterior direction and this movement results in inflammation of the IT band.14 Friction typically occurs during the foot stance phase and downhill running.15 Overtraining, improper footwear and the running surface are common precipitants.

The commonest symptom is pain over the lateral aspect of the knee. This often radiates proximally and tenderness can be elicited over the lateral aspect of the joint, usually over the proximal attachment of the lateral collateral ligament (LCL). ITBS can mimic LCL injury and hence needs to be ruled out. Some patients have coexistent hip trochanteric tenderness due to rubbing of the ITB over a prominent greater trochanter. Hip abductors may be weak and their strength should be assessed.16 Ultrasound and MRI can be used to confirm thickening in the ITB or presence of bursa under the ITB near the knee.17

Adequate rest and anti-inflammatory drugs are helpful in the acute setting. Modifiable risk factors should be assessed and well fitted orthotics, alteration in the training regime and/or surface could help. Local steroid injection has been used successfully and should be reserved for chronic cases.18 Surgery is indicated when the conservative measures fail to relieve such symptoms.19 Surgical procedures include (1) resection of a triangular piece of iliotibial band at the lateral femoral epicondyle,20 (2) lengthening of iliotibial band by Z-plasty.21

Achilles tendonopathy

Neural inflammation around the Achilles tendon (TA) substance, degeneration affecting the tendon, failed tissue healing response to minor trauma and neovascularisation are believed to be the pathological processes leading to Achilles tendonopathy.22 Recurrent or persistent tendonitis can result in chronic tendonitis which may lead to focal degeneration in the TA substance and poses a risk of rupture under stress. Generally female runners are more frequently affected. Training errors such as an increase in mileage and/or intensity, uphill running and improper footwear/running surface are common modifiable predisposing factors.

Pain over the TA on exercise resolving after rest is the main symptom. Patients frequently complain of early morning stiffness around the ankle which generally gets better during day. Tenderness may be present diffusely over the entire tendon and in some cases nodules can be palpated. In the presence of a palpable nodule, peritendonitis or occult partial rupture of the TA needs to be ruled out. The clinical diagnosis is difficult and in such cases ultrasound scanning (USS) and MRI are useful tools to diagnose Achilles tendinopathy.23 However clinical assessment is crucial.24

Anti-inflammatory drugs, rest, orthotic treatment and physiotherapy (stretching exercises) are helpful in acute cases.25 Use of local steroid injections for pain relief is controversial and injecting into the tendon substance is best avoided. Steroid injection to the tissue space between tendon and paratenon has shown good results.26 Use of a sclerosing agent injection to decrease the neo-vascularisation process and associated pain has been tried and proved to be effective in relieving pain.27 Before returning to full exercise activity, graduated eccentric calf muscle strengthening exercises spanned over 12 weeks aimed at increasing tensile strength of tendon has been proposed.28 Laser therapy along with an eccentric exercise regime may speed up the healing process in chronic tendinopathies.29 Once all the conservative treatment options have failed, percutaneous tenotomy aimed to induce chemically mediated healing is an option.30

Medial Tibial Stress Syndrome:

Medial tibial stress syndrome commonly known as “shin splints” is a common condition with a reported incidence of between 4 to 35% in soldiers and athletes.31 Being female, excessive pronation of the foot, a sudden increase in training intensity, biomechanical factors, running surface and improper footwear are predisposing factors.32,33 Hubbard et al have shown that previous history of MTSS, tibial stress fracture and inadequate running experience increase the likelihood of developing MTSS.34 Stress reaction of bone at the muscle attachment site is believed to be a causative factor for pain.35 In such cases the involved periosteum may show extensive fibrous thickening, increased vascularity and signs of chronic inflammation.36

Most patients experience pain while exercising and feel tenderness over the medial aspect of the distal two-thirds of the tibia.37 Percussion on the distal tibia can incite pain. Passive stretching of the long toe flexor tendons, soleus and tibialis posterior may reproduce pain. Often simple radiography may not show any bony abnormality. Bone isotope scans frequently show a diffuse ‘tubular pattern’36 and are helpful in differentiating from stress fracture. Increased scintigraphic uptake and low bone mineral density at the affected site correlate well with clinical symptoms.38 In doubtful cases high resolution CT scans are valuable in diagnosing MTSS.39

Rest is the best treatment along with anti-inflammatory analgesics and local physiotherapy. Simple measures like shock-absorbing or pronation-control insoles and modification in running programmes have been effective in preventing MTSS.40 Individuals experiencing persistent pain despite addressing correctable malalignment are good candidates for surgical intervention. This involves the partial division of the deep posterior compartment fascia and soleus bridge. Yates et al, in their retrospective study involving forty six patients who underwent surgical intervention, have shown that despite good pain relief in 72% of patients only 41% of patients could return to their pre-injury exercise level.41
Chronic exertional compartment syndrome (CECS)
Chronic exertional compartment syndrome (CECS) is an often overlooked cause of pain in athletes who engage in repetitive physical activity. The anterior compartment of the leg is most commonly affected and the condition is frequently bilateral. Repetitive activity causes a rise in intra-compartmental pressure obliterating capillary circulation, leading to ischemic pain.42 Pain initiated by exercise and relieved by rest is the classical symptom. Initially symptoms are brought on by long duration training and/or high intensity training. However in chronic cases often the amount of activity required to reproduce these symptoms may be reduced. Patients often complain of tightness and a dull ache in the anterior compartment of the leg. Investigations such as radiographs and bone isotope scans are valuable in differentiating from shin splints and tibial stress fracture. CECS is a clinical diagnosis and intra compartmental pressure measurement is more objective way of diagnosing CECS but rarely done prior to surgical release by fasciotomy.43
In the initial stages rest will help to relieve pain. An assessment of training characteristics should be performed to address correctable precipitants. Reduction in the duration of training, lowering intensity training, proper orthotic support such as shock absorbing insoles and avoidance of hard training surfaces are important conservative measures. Decompressive fasciotomy is rarely needed and in such cases modification in the training programme is very important until symptoms have completely settled.44
Plantar fasciitis

Plantar fasciitis (PF) accounts for 10% of running injuries.45 Reduced ankle dorsiflexion, obesity, and work-related weight-bearing have been suggested as independent risk factors for PF in a case control study.46 Insidious onset of heel pain which is worse in the morning but gets better through the day is a typical presentation. Tenderness can be elicited mainly over the plantar fascia near the calcaneal attachment. X-ray may show a calcaneal spur. Ultrasound and MRI scans are useful in differentiating other painful conditions affecting the heel.

More than 90% patients respond well to conservative treatment.47 Biomechanical correction by use of orthoses and splints has been shown to be effective in the early stages.48 If pain is lasts for several weeks then a local anesthetic and steroid injection at the origin of the planar fascia can be used.49 Recently low-dose energy extracorporeal shock wave therapy (ESWT) has been tried and has shown good results in PF patients associated with a symptomatic calcaneal spur.50

References:

  1. Ballas MT, Tytko J, Cookson D. Common overuse running injuries: diagnosis and management. Am Fam Physician 1997; 55: 2473–84.
  2. Taunton J, Ryan M, Clement D, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002; 36 :95-101.
  3. Clement D, Taunton J, Smart G, et al. A survey of overuse injuries. Physician and Sports Medicine 1981; 9: 47–58.
  4. Arendt EA. Musculoskeletal injuries of the knee: are females at greater risk? Minn Med. 2007 Jun; 90(6): 38-40.
  5. Dixit S, DiFiori JP, Burton M, et al. Management of patellofemoral pain syndrome. Am Fam Physician. 2007; 75: 194-202.
  6. Kramer PG. Patella malalignment syndrome: rationale to reduce excessive lateral pressure. J Orthop Sports Phys Ther. 1986; 8(6): 301-9.
  7. Witvrouw E, Lysens R, Bellemans J, et al. Intrinsic risk factors for the development of anterior knee pain in an athletic population. Am J Sports Med 2000; 28: 480-9.
  8. Fox TA. Dysplasia of the quadriceps mechanism: hypoplasia of the vastus medialis muscle as related to the hypermobile patella syndrome. Surg Clin North Am. 1975 Feb; 55(1): 199-226.
  9. Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med 2002; 30: 447-56.
  10. Crossley K, Bennell K, Green S, et al. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med 2002; 30: 857-65.
  11. Cambier D. Open versus closed kinetic chain exercises in patellofemoral pain: Am J Sports Med 2004; 32: 1122.
  12. Whittingham M, Palmer S, Macmillan F. Effects of taping on pain and function in patellofemoral pain syndrome: J Orthop Sports Phys Ther 2004; 34: 504-10.
  13. Lucas CA. Iliotibial Band Friction Syndrome as Exhibited in Athletes. J Athl Train. 1992; 27(3): 250-252.
  14. Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: J Anat. 2006 Mar; 208(3): 309-16.
  15. Orchard JW, Fricker PA, Abud AT, et al. Biomechanics of iliotibial band friction syndrome in runners. Am J Sports Med. 1996 May-Jun; 24(3): 375-9. Review.
  16. Niemuth PE, Johnson RJ, Myers MJ, et al. Hip muscle weakness and overuse injuries in recreational runners. Clin J Sport Med. 2005 Jan; 15(1): 14-21.
  17. Nishimura G, Yamato M, Tamai K et al. MR findings in iliotibial band syndrome. Skeletal Radiol. 1997 Sep; 26(9): 533-7.
  18. Gunter P, Schwellnus MP. Local corticosteroid injection in iliotibial band friction syndrome in runners: Br J Sports Med. 2004 Jun; 38(3): 269-72; discussion 272.
  19. Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med. 2006 May; 16(3): 261-8.
  20. Drogset JO, Rossvoll I, Grøntvedt T. Surgical treatment of iliotibial band friction syndrome. Scand J Med Sci Sports. 1999 Oct; 9(5): 296-8.
  21. Richards DP, Alan Barber F, Troop RL. Iliotibial band Z-lengthening. Arthroscopy. 2003 Mar; 19(3): 326-9.
  22. Tan SC, Chan O. Achilles and patellar tendinopathy: Disabil Rehabil. 2008; 30(20-22): 1608-15.
  23. Campbell RSD, Grainger AJ. Current concepts in imaging in tendinopathy. Clin Radiol 2001; 56: 253–67.
  24. Khan KM, Forster BB, Robinson J, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? Br J Sports Med 2003; 37: 149–54.
  25. Kader D, Saxena A, Movin T, et al. Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 2002; 36: 239–49.
  26. Shrier I, Matheson G, Kohl G. Achilles tendinitis: are corticosteroid injections useful or harmful? Clin J Sport Med 1996; 6: 245–50.
  27. Alfredson H, Ohberg L. Sclerosing injections to areas of neovascularisation reduce pain in chronic Achilles tendinopathy: Knee Surg Sports Traumatol Arthrosc 2005; 13: 338–44.
  28. Maffulli N, Walley G, Sayana MK, et al. Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Disabil Rehabil. 2008; 30(20-22): 1677-84.
  29. Stergioulas A, Stergioula M, Aarskog R, et al. Effects of low-level laser therapy and eccentric exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Am J Sports Med. 2008 May; 36(5): 881-7.
  30. Testa V, Capasso G, Maffulli N, et al. Ultrasound guided percutaneous longitudinal tenotomy for the management of patellar tendinopathy. Med Sci Sports Exerc 1999; 31: 1509–15.
  31. Moen MH, Tol JL, Weir A, et al. Medial tibial stress syndrome: a critical review. Sports Med. 2009; 39(7): 523-46.
  32. Yates B, White S. The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med. 2004; 32(3): 772–780.
  33. Reinking MF, Hayes AM. Intrinsic factors associated with exercise related leg pain in collegiate cross-country runners. Clin J Sport Med. 2006; 16(1): 10–14.
  34. Hubbard TJ, Carpenter EM, Cordova ML.Contributing factors to medial tibial stress syndrome: a prospective investigation. Med Sci Sports Exerc. 2009 Mar; 41(3): 490-6.
  35. Tweed JL, Avil SJ, Campbell JA, et al. Etiologic factors in the development of medial tibial stress syndrome: J Am Podiatr Med Assoc. 2008 Mar-Apr; 98(2): 107-11.
  36. R Bhatt, I Lauder, D B Finlay,et al.Correlation of bone scintigraphy and histological findings in medial tibial syndrome Br. J. Sports Med., Feb 2000; 34: 49-53.
  37. Mubarak, S. J., Gould, R. N., Yu Fon Lee, et al. "The medial tibial stress syndrome". Am.J.Sports Med.10; 41: 201-205.
  38. Magnusson HI, Ahlborg HG, Karlsson C, et al..Low regional tibial bone density in athletes with medial tibial stress syndrome normalizes after recovery from symptoms. Am J Sports Med. 2003 Jul-Aug; 31(4): 596-600.
  39. Gaeta, M., Minutoli, F., Vinci, S., et al. High-resolution CT grading of tibial stress reactions in distance runners. Am. J. Roentgenol 187: 789-793.
  40. Debbie I. Craig, ATC Medial Tibial Stress Syndrome: Journal of Athletic Training 2008; 43(3): 316–318.
  41. Yates B, Allen MJ, Barnes MR. Outcome of surgical treatment of medial tibial stress syndrome. JBJS Am. 2003 Oct; 85-A(10):1974-80.
  42. Bong MR, Polatsch DB, Jazrawi LM, et al. Chronic exertional compartment syndrome: diagnosis and management. Bull Hosp Jt Dis. 2005; 62(3-4): 77-84. Review.
  43. Cebesoy O, Kose K. Is the diagnosis as simple as the treatment? Diagnostic pitfalls in chronic exertional compartment syndrome? Knee Surg Sports Traumatol Arthrosc. 2007 Jan;15(1):109
  44. Mouhsine E, Garofalo R, Moretti B, et al. Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc. 2006 Feb; 14(2):193-7.
  45. Filippou DK, Kalliakmanis A, Triga A, et al. Sport related plantar fasciitis. Current diagnostic and therapeutic advances. 2004; 46(3): 56-60.
  46. Riddle DL, Pulisic M, Pidcoe P, et al. Risk factors for Plantar fasciitis: a matched case-control study. JBJS Am. 2003 May; 85-A(5): 872-7.
  47. Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int. 1998 Dec; 19(12): 803-11.
  48. Pfeffer G, Bacchetti P, Deland J, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999 Apr; 20(4): 214-21.
  49. Crawford F, Atkins D, Young P, et al. Steroid injection for heel pain: evidence of short-term effectiveness. Rheumatology (Oxford). 1999 ct; 38(10): 974-7.
  50. Thomson CE, Crawford F, Murray GD. The effectiveness of extra corporeal shock wave therapy for plantar heel pain: BMC Musculoskelet Disord. 2005 Apr 22; 6:19. Review.