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The information below is not intended to replace numerous very good textbooks on the subject. It is intended for therapists and primary care physicians treating or are thinking about referring a sports injury. If you are managing the rehabilitation of a patient who has undergone surgery you may find the page on my recommended rehabilitation programs of use. These programs I have developed over 18 years of treating sports injuries. The many dedicated physiotherapists I have worked with have massively enhanced the content of these programs. Those who have expressed their opinions (both good or bad) on the recovering surgical patient have triggered regular revisions of these programs.

The most important contributors to these opinions on sports injuries and surgical recovery programs are the patients I’ve treated especially the less than totally satisfied ones.

Ligament

Diagnosis

Patients make the diagnosis through their description of the event of injury. For the interested listener clinical examination is required only to confirm what the patient has told you and to grade the injury and exclude commonly associated injuries. If I had to choose only one test for a ligament deficiency I would recommend the pivot shift test for ACL rupture. 1 For PCL injury I find the Quadriceps Active Test2 most useful.  MPFL deficiency almost always has a positive lateral displacement Apprehension Test3.

When examining knee ligament injuries we normally grade the injury from 1-3. Grade1 injuries can produce pain at the ligament origin or insertion site in the absence of laxity. It represents a sprain. Grade2 injuries (partial tear) will produce minor laxity but with a firm end point when stressing the ligament with techniques described above. Grade3 injuries (complete ligament tear) will demonstrate marked laxity with no end point on testing.

Isolated medial, lateral and posterior cruciate ligament injuries usually involve contact of some description whereas         ACL and combined ACL, MCL with or without posterolateral corner ruptures as well as MPFL (Medial Patellofemoral Ligament) injuries usually involve a non-contact injury. The latter can occur when a footballer lands from a jump or turning at speed (remember Michael Owen’s injury in the 2006 World Cup) 4

Natural History

Some knee ligament injuries such as MCL tears do very well with non-operative management. Nature does a very good job of repairing the injured MCL and lower grade injuries of the PCL and LCL.

ACL injuries do cause functional and structural instability for a long time and sometimes indefinitely whether the injury is partial or complete.  This is possibly because the ACL has so many nerve endings enabling the ACL to function as the “autopilot” of the knee. Allowing the owner to jump, turn and twist at speed while participating in another activity requiring their concentration.

There is some evidence that ACL reconstructions before any other structural damage to the knee occurs do much better in returning to a “normal knee” whereas ACL reconstructions done on the background of concurrent meniscal and cartilage injuries rarely allow the victim to predictably return to the previous level of activity. Strong evidence supports the length of time from injury to reconstruction with damage to other structures in the knee5.

Treatment

Grade1 ligament injuries (sprains) will recover without surgery. The recovery will be expedited by expert physiotherapy care.  Grade2 injuries of the MCL will more often than not recover in a similar fashion.

Grade 2 and 3 injuries of the other knee ligaments will normally produce a degree of mechanical instability and may require surgical intervention especially if more than one ligament has been damaged.

ACL and PCL tears lend themselves to arthroscopic reconstructions whereas significant injuries to the MCL, posterolateral corner and MPFL will require open surgery with incisions as small as possible and in some cases subcutaneous tunnelling.6

Osteotomy, with or without ligament reconstruction, has been rediscovered as a very potent surgical tool to treat instability especially if more than one ligament is involved.

Osteotomy of the proximal tibia or distal femur can change the way forces pass through the knee and compensate for ligament damage especially in patients who are naturally in varus or valgus posture. Osteotomy can change alignment in the coronal plane (varus or valgus) or in the sagittal plane (changing forces in flexion and extension).

Combined ACL and posterolateral corner instabilities can be treated with an Opening Wedge High Tibial Osteotomy that puts the knee into more valgus (to counteract the lateral thrust from the posterolateral corner injury). If the ACL injury is incomplete then reducing the sagittal tibial slope can restore stability. Equally increasing the natural 5-7° posterior sloping tibial plateau will restore competence in an incomplete PCL injury.

References

  1. http://www.wheelessonline.com/ortho/pivot_shift_test
  2. https://www.youtube.com/watch?v=7hCt_8fqX44
  3. https://www.youtube.com/watch?v=xXmjYVDkmVg
  4. https://www.youtube.com/watch?v=NyI_gXOE2bw
  5. Lorenzo Brambilla, MD et al. Prevalence of Associated Lesions in Anterior Cruciate Ligament Reconstruction: Correlation With Surgical Timing and With Patient Age, Sex, and Body Mass Index: Am J Sports Med December 2015 vol. 43 no. 12 2966-2973
  6. Panagopoulos A1, van Niekerk L, Triantafillopoulos IK. MPFL reconstruction for recurrent patella dislocation: a new surgical technique and review of the literature.  Int J Sports Med. 2008 May;29(5):359-65

Meniscus

Diagnosis

Meniscus tears are produced by natural aging meniscal tissue (very common) OR injury often in association with a ligament injury (rare). The age of the patient is therefore important as the most common meniscal tears present in adults in their late 30’s to mid 60’s. Although the patient often reports a slip, trip or twist this merely represents a final event in an already damaged meniscus. Only 10-20% of an adult meniscus has any nerves and blood vessels and these are located on the outer rim of the structure. The pain from a meniscal tear is therefore only felt when the already established tear reaches the outer edge.

Examination of the knee will produce tenderness to palpation over either the medial or lateral joint line. Traumatic tears (without degeneration or aging) of the meniscus which are more prevalent in adolescents and young adults after a significant twisting injury and is often associated with painful bleeding into the joint (haemarthrosis) within 20 minutes to an hour after the injury.

MRI scans are very sensitive (and specific) for tears of the meniscus and are used to confirm the diagnosis.

Natural History

Because of the peculiar blood and nerve supply of the meniscus only tears involving the outer 20% will produce pain. After a few days the body will attempt to heal the tear where it’s extended into neurovascular zone and this will result in a reduction and sometimes-temporary resolution of symptoms. The main body of the tear cannot however heal due to the poor blood supply of this structure and therefore on the next trivial twist of the knee the pain will return. This is the reason patients with degenerate tears of the meniscus reports a sporadic course in their symptoms.

Partial thickness tears of especially the lateral meniscus are known to heal/become asymptomatic without surgical intervention.1

The most serious of meniscus tears are those that involve the root. This is the bony attachment of the meniscus that helps to retain the shape and containment within the medial or lateral tibiofemoral compartment. Once the root has been compromised the meniscus will start migrating out of the joint. This will have 2 effects. First critical pressure on the articular cartilage of the tibia and femur will ensue with delamination or fragmentation of the articular cartilage. Secondly the medial or lateral knee compartment will loose its all-important ‘spacer’ causing the weight-bearing axis of the knee to shift to the damaged side. This will accelerate the osteoarthritic process and result in deformity (either varus or valgus).

Treatment

Arthroscopic part-resection is required only for symptomatic tears of the meniscus. It will not prevent or accelerate the further development of osteoarthritis in that compartment if the mode of failure is through aging tissue. Meniscal repair WILL NOT work in menisci that have torn though aging and degeneration.

Strong consideration for meniscus repair should be given to true traumatic tears especially if in association with a serious ligament injury

References

  1. Kyle R. Duchman et al.: The Fate of Meniscus Tears Left In Situ at the Time of Anterior Cruciate Ligament Reconstruction: A 6-Year Follow-up Study From the MOON Cohort. Am J Sports Med November 2015 43 2688-2695

Osteochondral Lesions

Diagnosis

Osteochondral lesions refer to injury of hyaline articular cartilage as well as the subchondral bone it lies on. Chondral injuries as the name suggests does not involve the bone. Articular cartilage has no blood, nerve or lymphatic supply. It is therefore a painless injury but one that is incapable of repairing itself. Articular cartilage that comes free within a synovial membrane does however cause a dramatic imbalance on the balance between production and absorption of synovial fluid that results an effusion within hours of the injury.

Should there be bone involvement of the injury concurrent bleeding into the joint (haemarthrosis) will occur with the joint swelling more immediate and dramatic than injury to the cartilage on it’s own.

Chondral injuries are normally graded on the Outerbridge Scale1. Grade 1: Very superficial damage with softening or swelling. When chronic the cartilage can have fibrillated appearance. Grade 2: Fissure or crack that does not reach the subchondral bone with a surface area < 1.5×1.5 cm2. Grade 3: Fragmentation or fissuring of cartilage (surface area > 1.5×1.5cm2 producing effusion. Grade4: Complete separation of cartilage from bone.

Grade 3 & 4 chondral injuries will produce activity related effusion and occasionally‘mechanical symptoms’ such as locking, clicking and pseudo-instability. Grade 1 & 2 lesions can often be asymptomatic but microscopic fragmentation of cartilage can often cause symptoms of synovial impingement without effusion. These patients often complain that they cannot sit in a confined space for any length of time and some have pain when going downstairs and walking downhill.

MRI scanners are somewhat variable in their ability to diagnose lesser chondral injury. The presence of ‘bone bruising’ (water displacement of marrowfat) seen as bright flecks or shadows on the back ground of the dark grey of marrowfat on the PD FS sequence of a MRI will be indicative of local trauma to the bone and it’s overlying cartilage. The pattern of bone bruising can also alert to associated ligament injuries. Bone bruising deep to the lateral tibial plateau indicates a ‘pivot shift injury’ such as occurs when the ACL is ruptured. Bone bruising on the lateral aspect of the lateral femoral together with bruising of the bone of the medial facet of the patella strongly indicates a recent patella dislocation with tearing of the MPFL.

Natural History

Absence of blood supply ensures that all cartilage injuries progress and deteriorate. Grade 1& 2 lesions at a much slower rate than 3 & 4. Progressive loss of cartilage leads to osteoarthritis.

Treatment

Grade 3 & 4 injuries are treated with arthroscopic debridement with subchondral abrasion or microfracture depending on the size of the lesion. Abrasion works very well on lesions < 1×1cm2. Microfracture is inexpensive and effective for lesions smaller than 2×2cm2  under ideal circumstances.

Cartilage transplantation whether grown from the patient’s own cells (cartilage or stem cells) or acquired from a donor is used under exceptional circumstances. Despite a lot of early promise on it’s emergence 15 years ago and a lot of research and development the results of these procedures have not really improved and it should be reserved for the young patients with very extensive cartilage loss from injury (not degeneration).

It is however imperative to correct any acquired limb malalignment and ligament instabilities to prevent early failure.

References

  1. http://www.kneeguru.co.uk/KNEEnotes/knee-dictionary/outerbridge-classification

Osteoarthritis

Diagnosis

Osteoarthritis produces pain with swelling. Other symptoms include locking, catching sensations and a feeling of grinding (also called crepitus)

In the past we used to divide osteoarthritis into idiopathic (that means we don’t know why) and post-traumatic types. We now know old age is not the only cause of what was called idiopathic osteoarthritis. Genetic factors on both a cellular and morphological level play the major role in the development of this type of arthritis.  I can highly commend the paper by Professor Michael Doherty on the subject that is available in full online. 1

The other factor that plays a powerful role in the development of premature ‘idiopathic osteoarthritis’ is the shape of the leg. Genu varus (bowed legs) and genu valgus (knocked knees) can both cause and accelerate wear changes in the medial- and lateral knee compartments respectively.

Natural History

Osteoarthritis is caused by the combination of biological failure of cartilage and meniscus on the one hand, and overload in one or more areas of the knee. The simple model of the knee in the erect patient has a medial and lateral compartment made up by cartilage and a medial and lateral meniscus supported by the bone of the femur and tibia. The menisci make the relatively flat surface of the tibia into a cupped or concave structure matching the convex shape of the femoral condyles.

The principle accelerator of osteoarthritis is overload. Magnitude of overload is dictated by the weight of the patient and alignment of the whole leg.

In osteoarthritis the meniscus and cartilage loose their relationship by the meniscus or the cartilage failing together or the one after the other. Once the meniscus fails it gets extruded from the joint causing all the weight bearing force to pass through either the medial (most common) or the lateral compartment producing either a varus or valgus deformity of the knee.

Cartilage is made up of:

  • Cells (chondrocytes)
  • Collagen
  • Proteoglycan
  • Water

Collagen and proteoglycan combined make up the matrix that the chondrocytes nest in. The cocooned chondrocyte is not very active and become less so as the patient gets older. The matrix behaves like steel reinforced concrete with the collagen being the ‘steel’ and the proteoglycan being the ‘concrete’.

Chondrocyte and proteoglycan quality is very similar in all patients. The big variable is the collagen. The main fibres (type II) are bound by crosslinks to their fellows by ‘lesser’ collagen molecules that are variable based on inheritance. When these ‘lesser’ collagen molecules are in short supply the main (type II) structure fails. The proteoglycan, imbedded in the collagen superstructure, is extremely hydrophilic (loves water) and cannot help itself from absorbing water to the point of literally bursting. Once free fluid gets into the blistered cartilage surface he damage is relentless.

Cartilage has no ability to repair, as it has no blood supply to allow an inflammatory response to initiate the repair process. It also has no nerve supply and therefore the initial phase of damage may not be noticed. The initial breakup of cartilage does however release inflammatory and pain producing enzymes (IL1 and TNF) that causes the synovial membrane to react. When this process moves from a microscopic to macroscopic level the synovium becomes ‘sick’ causing it to loose balance between synovial fluid production and absorption.  The knee now swells (develops effusion) in response to activity.

With the loss of cartilage and meniscus in either the medial or lateral knee compartment the distance between bone of the femoral condyle and tibial plateau gets less. The leg starts deforming. This results in the mechanical axis (line of force passing from hip to ankle) shifting from the middle of the knee into the compartment where the cartilage is breaking down. The process of cartilage fragmentation is thus accelerated and the forces passing to the supporting bone is increased (compartment overload).

Bone in the human body is unique in its response to load. In accordance with Volkmann’s Law it actually grows to become thicker and stiffer to resist the load increase. The circulation through this thicker bone is slower than through bone with normal density and as with most body tissue oedema ensues as water leaks from the sinusoids (vascular channels in bone). This is called bone oedema that can be clearly seen on a MRI scan. It also results in the dull gnawing rest pain of osteoarthritis.

Summary:

  • Pain sources in OA are torn menisci, synovial inflammation and bone oedema.
  • Joint space loss produces deformity (varus, valgus or fixed flexion) that alters the mechanical axis of the limb resulting in overload in one or more areas of the knee.

Treatment

Treatment efforts therefore can only be successful if focussed on treating pain and compartment overload.

Painkillers:  The use of analgesia in combination with Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) is fairly straightforward and algorithms for escalation in primary care are well established. The natural history of the disease will however dictate that with disease progression analgesia will become less effective. Therefore when the end stage of the disease is reached and the ‘pills don’t work anymore’, internal amputation of the knee joint (more commonly referred to as Total Knee Replacement) is required.

Physiotherapy: Deformity, in the early stages, will be very minor and can be counteracted by addressing overall body posture as well as improving muscle strength and balance. Core strength and proprioception will aid in postural control. Hip abductor strength rapidly diminishes especially when joint space is lost in the medial knee compartment. One only has to observe the Trendelenburg body posture of a patient with varus knees trying to walk fast to realise what a crucial role the strength and control the hip abductors play in the treatment of very early forms of medial compartment OA. The involvement of an interested and able physiotherapist is therefore crucial in the treatment of early knee arthritis.

Braces and insoles: When deformity has exceeded what the patient and therapist can achieve though exercise, deformity control/correction can be achieved through external bracing or support. Physics dictate that the more remote such a brace or support is from the deformity it’s trying to correct the less effective it’ll be. Shoe insoles may therefore have a limited role to play in the very early form of the disease.

The length of the lever and surface area over which the brace is working can reduce the forces required by an external brace to control deformity. To that end I prefer to use a brace such as the Össur Unloader brace that has a good lever length and silicone thigh and calf lining over a big surface area.

Surgery: Arthroscopy will not help the pain of arthritis. It may have a role to play if the patient’s main complaint is that of locking or catching of the knee.

The only other surgery for arthritis is osteotomy and knee replacement surgery. I don’t offer knee replacement surgery as it falls outwith the scope of my practice of joint reconstruction in younger patients prior to the requirement for total joint replacement.

Osteotomy changes leg alignment to shift the mechanical axis (the line where the load from the hip to the ankle passes through the knee) from an arthritic part of the knee to a healthy part. Tibial osteotomy is conventionally done for medial compartment OA (varus knee) and femoral osteotomy for lateral compartment OA (valgus knee).

Weight loss: Neither non-operative nor operative management of osteoarthritis will succeed in the presence of obesity. A Body Mass Index (BMI=Weight in kg/Height2) in excess of 30 will cause knee pain even in the absence of pathology. In the presence of meniscus tear or cartilage damage obesity will accelerate disease progression. Non-operative treatments will be less successful and complication rates with operative treatments will be higher.

Summary:

  • Weight loss together with shifting load from the site of maximum damage is the most effective way of treating OA of the knee.
  • Painkillers and NSAID may be required during this process to achieve objectives.

References

  1. https://www.jrheum.com/subscribers/04/70/22.html

Coming soon...

Sprains and Ligament Tears

Ankle Instability

Chronic ankle instability is a condition characterized by a recurring giving way of the outer (lateral) side of the ankle. This condition often develops after repeated ankle sprains. Usually, the giving way occurs while walking or doing other activities especially on uneven surfaces. Many athletes, as well sedentary individuals, suffer from chronic ankle instability.

People with chronic ankle instability often complain of:

  • A repeated turning of the ankle, especially on uneven surfaces or when participating in sports
  • Persistent discomfort and swelling
  • Pain or tenderness
  • The ankle feeling wobbly or unstable

Causes

Chronic ankle instability usually develops following an ankle sprain that has not adequately healed or was not rehabilitated completely. When you sprain your ankle, the ligaments are stretched or torn. The ability to balance is affected. Rehabilitation is needed to strengthen the muscles around the ankle and retrain the tissues within the ankle that affect balance. Failure to do so may result in repeated ankle sprains.

Repeated ankle sprains often cause chronic ankle instability. Each subsequent sprain leads to further or stretching of the ligaments, resulting in greater instability and the likelihood of developing additional problems in the ankle.

Diagnosis

In assessing, the surgeon will ask you about any previous ankle injuries. The surgeon will examine your ankle to check for tender areas, signs of swelling and instability of your ankle. X-rays or other imaging studies may be helpful in further evaluating the ankle.

 

Nonsurgical Treatment

Treatment for chronic ankle instability is based on the results of the examination and tests, as well as on your level of activity.

Nonsurgical treatment may include:

  • Physiotherapy. Physical therapy involves various treatments and exercises to strengthen the ankle, improve balance and range of motion and retrain your muscles. In later rehabilitation, you will receive training that relates specifically to your activities or sport.
  • Bracing. Some patients wear an ankle brace to gain support for the ankle and keep the ankle from turning.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be prescribed to reduce pain and inflammation.

When Is Surgery Needed?

In some cases, the surgeon will recommend surgery based on the degree of instability or lack of response to nonsurgical treatment. Surgery usually involves repair or reconstruction of the damaged ligament(s). The surgeon will select the surgical procedure best suited for your case based on the severity of the instability and your activity level. The length of the recovery period will vary, depending on the procedure or procedures performed.

After surgery

The ankle is usually placed in a below knee plaster cast. More often than not you will have to stay in hospital for that night. The next day you will leave the hospital on crutches but taking some weight through the plaster cast.

After two weeks the plaster cast is removed. The sutures are removed and you are supplied with an Aircast boot. You will normally use the Aircast boot for approximately four weeks. You can usually take full weight through the ankle if the wound is satisfactory and in the absence of pain. If you feel a bit unsteady there is nothing wrong with continuing the use of the crutches.

Once you are mobile in the Aircast boot and the wound is satisfactory you can commence physiotherapy and range of motion exercises. It is important to bring the ankle up towards the direction of your head under its own power as well as with passive means. This may include the use of a small hand towel that is slung around the front of your foot while your knee is in the bent position.

You may return to driving when you are confident that you can control your vehicle. Please note:  you cannot and should not drive with the Aircast boot in place. You will need to keep an ordinary driving shoe in your car to swap into before setting off.

Osteochondral Lesions

Ankle pain is often due to an ankle sprain but can also be caused by ankle instability, arthritis, gout, tendonitis, fracture, nerve compression (tarsal tunnel syndrome), infection and poor structural alignment of the leg or foot. Ankle pain can be associated with swelling, stiffness, redness and warmth in the involved area. The pain is often described as an intense dull ache that occurs upon weightbearing and ankle motion.

Initial treatment may consist of rest, ice, elevation and immobilization but may also include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, physiotherapy and corticosteroid injection. A surgeon can best determine the cause of the ankle pain and appropriate treatment options after a consultation, examination and an MRI scan with or without an x-ray of the ankle. Occasionally in arthritic conditions weight-bearing x-rays of the ankle and leg need to be obtained to see how the ankle behaves and a load.

For more information on ankle pain, see these topics below:

  • Achilles Tendinopathy
  • Ankle Arthritis (Osteoarthritis)
  • Gout
  • Peroneal Tendon Injuries
  • Posterior Tibialis Tendon Dysfunction
  • Talar Dome Cartilage and Bone Lesions
  • Tarsal Tunnel Syndrome (Nerve Compression)

Achilles Tendinopathy/Disorders

The Achilles tendon is a band of tissue that connects a muscle to a bone. It runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the heel cord, the achilles tendon facilitates walking by helping to raise the heel off the ground.

 

Achilles tendinopathy A common disorder that occur in the heel cord is achilles tendinopathy. It is characterised by alternating episodes of tendon breakdown and inflammation. Tendon breakdown occurs when the tendon loses its organized structure and develops microscopic tears. Sometimes the degeneration involves the site where the achilles tendon attaches to the heel bone but mostly it occurs between five and 7 cm from its insertion to the heel bone. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.

Causes It is usually caused by a sudden increase of a repetitive activity involving the Achilles tendon. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibres. Due to this ongoing stress on the tendon, the body is unable to repair the injured tissue. In its attempt to heal the injured tissue the body produces an inflammatory reaction to bring in cells that normally repair and heal. The structure of the tendon is then altered, resulting in repetitive inflammation episodes with the resulting pain.

At risk groups

  • Athletes are at high risk for developing disorders of the Achilles tendon.
  • Achilles tendinopathy also common in individuals whose work puts stress on their ankles and feet, such as laborers, as well as in “weekend warriors”—those who are less conditioned and participate in athletics only on weekends or infrequently.
  • People with excessive pronation (flattening of the arch) have a tendency to develop achilles tendinopathy due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their overpronation could further aggravate the Achilles tendon.

Symptoms

  • Pain—aching, stiffness, soreness or tenderness—within the tendon. This may occur anywhere along the tendon’s path, beginning with the tendon’s attachment directly above the heel upward to the region just below the calf muscle. Pain often appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
  • Tenderness, or sometimes intense pain, when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.
  • When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.

Diagnosis In diagnosing achilles tendinopathy, the surgeon will examine the patient’s foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with ultrasound and magnetic resonance imaging (MRI).

Treatment: Treatment approaches for achilles tendinopathy are selected on the basis of how long the injury has been present and the degree of damage to the tendon. In the early stage, when there is sudden (acute) inflammation, one or more of the following options may be recommended:

  • Immobilization may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon and promote healing. 
  • To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of four or five times a day. Do not put ice directly against the skin.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation in the early stage of the condition.
  • Orthotics for those with overpronation or gait abnormalities, custom orthotic devices may be prescribed.
  • Night splints help to maintain a stretch in the Achilles tendon during sleep.
  • Physiotherapy. This may include strengthening exercises, soft-tissue massage/mobilization, gait and running re-education, stretching and ultrasound therapy.
  • Low frequency shockwave therapy. Where a wave of sound is focused on the degenerative tissue to break up scar tissue and encourage a healing response internally.
  • High-volume injections. This is where saline (salt water) with local anaesthetic is injected in the interval between the Achilles and the surrounding membrane to stretch the membrane or paratenon (that is often the source of pain) away from the tendon. This procedure is done under ultrasound control by a qualified radiologist.

Surgery: If nonsurgical approaches fail to restore the tendon to its normal condition, surgery may be appropriate. The surgeon will select the best procedure for the damaged and degenerative parts of the tendon, based on the extent of the injury, the patient’s age and activity level.

Prevention: To prevent Achilles tendinopathy from recurring after surgical or nonsurgical treatment, the surgeon may recommend strengthening and stretching of the calf muscles through daily exercises. Wearing proper shoes for the foot type and activity is also important in preventing recurrence of the condition.

Occult Fractures and Accessory Bones

Ankle pain is often due to an ankle sprain but can also be caused by ankle instability, arthritis, gout, tendonitis, fracture, nerve compression (tarsal tunnel syndrome), infection and poor structural alignment of the leg or foot. Ankle pain can be associated with swelling, stiffness, redness and warmth in the involved area. The pain is often described as an intense dull ache that occurs upon weightbearing and ankle motion.

Initial treatment may consist of rest, ice, elevation and immobilization but may also include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, physiotherapy and corticosteroid injection. A surgeon can best determine the cause of the ankle pain and appropriate treatment options after a consultation, examination and an MRI scan with or without an x-ray of the ankle. Occasionally in arthritic conditions weight-bearing x-rays of the ankle and leg need to be obtained to see how the ankle behaves and a load.

For more information on ankle pain, see these topics below:

  • Achilles Tendinopathy
  • Ankle Arthritis (Osteoarthritis)
  • Gout
  • Peroneal Tendon Injuries
  • Posterior Tibialis Tendon Dysfunction
  • Talar Dome Cartilage and Bone Lesions
  • Tarsal Tunnel Syndrome (Nerve Compression)

Achilles Tendinopathy/Disorders

The Achilles tendon is a band of tissue that connects a muscle to a bone. It runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the heel cord, the achilles tendon facilitates walking by helping to raise the heel off the ground.

 

Achilles tendinopathy A common disorder that occur in the heel cord is achilles tendinopathy. It is characterised by alternating episodes of tendon breakdown and inflammation. Tendon breakdown occurs when the tendon loses its organized structure and develops microscopic tears. Sometimes the degeneration involves the site where the achilles tendon attaches to the heel bone but mostly it occurs between five and 7 cm from its insertion to the heel bone. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.

Causes It is usually caused by a sudden increase of a repetitive activity involving the Achilles tendon. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibres. Due to this ongoing stress on the tendon, the body is unable to repair the injured tissue. In its attempt to heal the injured tissue the body produces an inflammatory reaction to bring in cells that normally repair and heal. The structure of the tendon is then altered, resulting in repetitive inflammation episodes with the resulting pain.

At risk groups

  • Athletes are at high risk for developing disorders of the Achilles tendon.
  • Achilles tendinopathy also common in individuals whose work puts stress on their ankles and feet, such as laborers, as well as in “weekend warriors”—those who are less conditioned and participate in athletics only on weekends or infrequently.
  • People with excessive pronation (flattening of the arch) have a tendency to develop achilles tendinopathy due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their overpronation could further aggravate the Achilles tendon.

Symptoms

  • Pain—aching, stiffness, soreness or tenderness—within the tendon. This may occur anywhere along the tendon’s path, beginning with the tendon’s attachment directly above the heel upward to the region just below the calf muscle. Pain often appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
  • Tenderness, or sometimes intense pain, when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.
  • When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.

Diagnosis In diagnosing achilles tendinopathy, the surgeon will examine the patient’s foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with ultrasound and magnetic resonance imaging (MRI).

Treatment: Treatment approaches for achilles tendinopathy are selected on the basis of how long the injury has been present and the degree of damage to the tendon. In the early stage, when there is sudden (acute) inflammation, one or more of the following options may be recommended:

  • Immobilization may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon and promote healing. 
  • To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of four or five times a day. Do not put ice directly against the skin.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation in the early stage of the condition.
  • Orthotics for those with overpronation or gait abnormalities, custom orthotic devices may be prescribed.
  • Night splints help to maintain a stretch in the Achilles tendon during sleep.
  • Physiotherapy. This may include strengthening exercises, soft-tissue massage/mobilization, gait and running re-education, stretching and ultrasound therapy.
  • Low frequency shockwave therapy. Where a wave of sound is focused on the degenerative tissue to break up scar tissue and encourage a healing response internally.
  • High-volume injections. This is where saline (salt water) with local anaesthetic is injected in the interval between the Achilles and the surrounding membrane to stretch the membrane or paratenon (that is often the source of pain) away from the tendon. This procedure is done under ultrasound control by a qualified radiologist.

Surgery: If nonsurgical approaches fail to restore the tendon to its normal condition, surgery may be appropriate. The surgeon will select the best procedure for the damaged and degenerative parts of the tendon, based on the extent of the injury, the patient’s age and activity level.

Prevention: To prevent Achilles tendinopathy from recurring after surgical or nonsurgical treatment, the surgeon may recommend strengthening and stretching of the calf muscles through daily exercises. Wearing proper shoes for the foot type and activity is also important in preventing recurrence of the condition.

Achilles Tendon Injuries

Ankle pain is often due to an ankle sprain but can also be caused by ankle instability, arthritis, gout, tendonitis, fracture, nerve compression (tarsal tunnel syndrome), infection and poor structural alignment of the leg or foot. Ankle pain can be associated with swelling, stiffness, redness and warmth in the involved area. The pain is often described as an intense dull ache that occurs upon weightbearing and ankle motion.

Initial treatment may consist of rest, ice, elevation and immobilization but may also include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, physiotherapy and corticosteroid injection. A surgeon can best determine the cause of the ankle pain and appropriate treatment options after a consultation, examination and an MRI scan with or without an x-ray of the ankle. Occasionally in arthritic conditions weight-bearing x-rays of the ankle and leg need to be obtained to see how the ankle behaves and a load.

For more information on ankle pain, see these topics below:

  • Achilles Tendinopathy
  • Ankle Arthritis (Osteoarthritis)
  • Gout
  • Peroneal Tendon Injuries
  • Posterior Tibialis Tendon Dysfunction
  • Talar Dome Cartilage and Bone Lesions
  • Tarsal Tunnel Syndrome (Nerve Compression)

Achilles Tendinopathy/Disorders

The Achilles tendon is a band of tissue that connects a muscle to a bone. It runs down the back of the lower leg and connects the calf muscle to the heel bone. Also called the heel cord, the achilles tendon facilitates walking by helping to raise the heel off the ground.

 

Achilles tendinopathy A common disorder that occur in the heel cord is achilles tendinopathy. It is characterised by alternating episodes of tendon breakdown and inflammation. Tendon breakdown occurs when the tendon loses its organized structure and develops microscopic tears. Sometimes the degeneration involves the site where the achilles tendon attaches to the heel bone but mostly it occurs between five and 7 cm from its insertion to the heel bone. In rare cases, chronic degeneration with or without pain may result in rupture of the tendon.

Causes It is usually caused by a sudden increase of a repetitive activity involving the Achilles tendon. Such activity puts too much stress on the tendon too quickly, leading to micro-injury of the tendon fibres. Due to this ongoing stress on the tendon, the body is unable to repair the injured tissue. In its attempt to heal the injured tissue the body produces an inflammatory reaction to bring in cells that normally repair and heal. The structure of the tendon is then altered, resulting in repetitive inflammation episodes with the resulting pain.

At risk groups

  • Athletes are at high risk for developing disorders of the Achilles tendon.
  • Achilles tendinopathy also common in individuals whose work puts stress on their ankles and feet, such as laborers, as well as in “weekend warriors”—those who are less conditioned and participate in athletics only on weekends or infrequently.
  • People with excessive pronation (flattening of the arch) have a tendency to develop achilles tendinopathy due to the greater demands placed on the tendon when walking. If these individuals wear shoes without adequate stability, their overpronation could further aggravate the Achilles tendon.

Symptoms

  • Pain—aching, stiffness, soreness or tenderness—within the tendon. This may occur anywhere along the tendon’s path, beginning with the tendon’s attachment directly above the heel upward to the region just below the calf muscle. Pain often appears upon arising in the morning or after periods of rest, then improves somewhat with motion but later worsens with increased activity.
  • Tenderness, or sometimes intense pain, when the sides of the tendon are squeezed. There is less tenderness, however, when pressing directly on the back of the tendon.
  • When the disorder progresses to degeneration, the tendon may become enlarged and may develop nodules in the area where the tissue is damaged.

Diagnosis In diagnosing achilles tendinopathy, the surgeon will examine the patient’s foot and ankle and evaluate the range of motion and condition of the tendon. The extent of the condition can be further assessed with ultrasound and magnetic resonance imaging (MRI).

Treatment: Treatment approaches for achilles tendinopathy are selected on the basis of how long the injury has been present and the degree of damage to the tendon. In the early stage, when there is sudden (acute) inflammation, one or more of the following options may be recommended:

  • Immobilization may involve the use of a cast or removable walking boot to reduce forces through the Achilles tendon and promote healing. 
  • To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the affected area for 20 minutes of four or five times a day. Do not put ice directly against the skin.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be helpful in reducing the pain and inflammation in the early stage of the condition.
  • Orthotics for those with overpronation or gait abnormalities, custom orthotic devices may be prescribed.
  • Night splints help to maintain a stretch in the Achilles tendon during sleep.
  • Physiotherapy. This may include strengthening exercises, soft-tissue massage/mobilization, gait and running re-education, stretching and ultrasound therapy.
  • Low frequency shockwave therapy. Where a wave of sound is focused on the degenerative tissue to break up scar tissue and encourage a healing response internally.
  • High-volume injections. This is where saline (salt water) with local anaesthetic is injected in the interval between the Achilles and the surrounding membrane to stretch the membrane or paratenon (that is often the source of pain) away from the tendon. This procedure is done under ultrasound control by a qualified radiologist.

Surgery: If nonsurgical approaches fail to restore the tendon to its normal condition, surgery may be appropriate. The surgeon will select the best procedure for the damaged and degenerative parts of the tendon, based on the extent of the injury, the patient’s age and activity level.

Prevention: To prevent Achilles tendinopathy from recurring after surgical or nonsurgical treatment, the surgeon may recommend strengthening and stretching of the calf muscles through daily exercises. Wearing proper shoes for the foot type and activity is also important in preventing recurrence of the condition.

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When should the patient drive after knee or ankle surgery?

The responsibility to decide when to return to driving after an operation is entirely the patient's.  I do not recommend that you drive at all for two days after any operation.  It may be possible to return to driving after forty-eight hours if surgery was on the left knee / ankle.  That is to say that if the knee or ankle is not restricted by dressings, a brace or a plaster cast.

If your patient had any surgery to your right knee / ankle then they should discuss to return to driving with their physiotherapist.  The general advice would be that the right knee / ankle should be free from dressings, braces or any other restriction and that the patient is confident that they can perform an emergency stop and be in full control of their motor vehicle.

Rehabilitation Programmes

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