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Specific populations at high risk of primary PFPS include runners, bicyclists, basketball players, young athletes and females.
ITBS can result from one or more of the following: training habits, anatomical abnormalities, or muscular imbalances:
Training habits
- Spending long periods of time/regularly sitting in lotus posture in yoga. Esp beginners forcing the feet onto the top of the thighs
- Consistently running on a horizontally banked surface (such as the shoulder of a road or an indoor track) on which the downhill leg is bent slightly inward, causing extreme stretching of the band against the femur
- Inadequate warm-up or cool-down
- Excessive up-hill and down-hill running
- Positioning the feet "toed-in" to an excessive angle when cycling
- Running up and down stairs
- Hiking long distances
- Rowing
- Breaststroke
- Treading water
Abnormalities in leg/feet anatomy
- High or low arches
- Supination of the foot
- Excessive lower-leg rotation due to over-pronation
- Excessive foot-strike force
- Uneven leg lengths
- Bowlegs or tightness about the iliotibial band.
Muscle imbalance
- Weak hip abductor muscles
- Weak/non-firing multifidus muscle
- Uneven left-right stretching of the band, which could be caused by habits such as sitting cross-legged
The cause of snapping hip syndrome is not well understood, and confusion exists within the medical community regarding causation. Athletes appear to be at an enhanced risk for snapping hip syndrome due to repetitive and physically demanding movements.
In athletes such as ballet dancers, gymnasts, horse riders, track and field athletes and soccer players, military training, or any vigorous exerciser, repeated hip flexion leads to injury. In excessive weightlifting or running, the cause is usually attributed to extreme thickening of the tendons in the hip region. Snapping hip syndrome most often occurs in people who are 15 to 40 years old.
While ITBS pain can be acute, the iliotibial band can be rested, iced, compressed and elevated (RICE) to reduce pain and inflammation, followed by stretching. Massage therapy, and many of its modalities, can offer relief if symptoms arise.
Extra-articular snapping hip syndrome is commonly associated with leg length difference (usually the long side is symptomatic), tightness in the iliotibial band (ITB) on the involved side, weakness in hip abductors and external rotators, poor lumbopelvic stability and abnormal foot mechanics (overpronation). Popping occurs when the thickened posterior aspect of the ITB or the anterior gluteus maximus rubs over the greater trochanter as the hip is extended.
Because wear on the hip joint traces to the structures that support it (the posture of the legs, and ultimately, the feet), proper fitting shoes with adequate support are important to preventing GTPS. For someone who has flat feet, wearing proper orthotic inserts and replacing them as often as recommended are also important preventive measures.
Strength in the core and legs is also important to posture, so physical training also helps to prevent GTPS. But it is equally important to avoid exercises that damage the hip.
Isolated and combined posterolateral knee injuries are difficult to accurately diagnose in patients presenting with acute knee injuries. The incidence of isolated posterolateral corner injuries has been reported to be between 13% and 28%. Most PLC injuries accompany an ACL or PCL tear, and can contribute to ACL or PCL reconstruction graft failure if not recognized and treated. A study by LaPrade "et al." in 2007 showed the incidence of posterolateral knee injuries in patients presenting with acute knee injuries and hemarthrosis (blood in the knee joint) was 9.1%.
Rate in the United States have been estimated to occur among an at-risk population of 1,774,210,081 people each year. Incidence rates published in the American Journal of Sports Medicine for ages 10–17 were found to be about 29 per 100,000 persons per year, while the adult population average for this type of injury ranged between 5.8 and 7.0 per 100,000 persons per year. The highest rates of patellar dislocation were found in the youngest age groups, while the rates declined with increasing ages. Females are more susceptible to patellar dislocation. Race is a significant factor for this injury, where Hispanics, African-Americans and Caucasians had slightly higher rates of patellar dislocation due to the types of athletic activity involved in: basketball (18.2%), soccer (6.9%), and football (6.9%), according to Brian Waterman.
Lateral Patellar dislocation is common among the child population. Some studies suggest that the annual patellar dislocation rate in children is 43/100,000. The treatment of the skeletally immature is controversial due to the fact that they are so young and are still growing. Surgery is recommended by some experts in order to repair the medial structures early, while others recommend treating it non operatively with physical therapy. If re-dislocation occurs then reconstruction of the medial patellofemoral ligament (MPFL) is the recommended surgical option.
Dead arm syndrome starts with repetitive motion and forces on the posterior capsule of the shoulder. The posterior capsule is a band of fibrous tissue that interconnects with tendons of the rotator cuff of the shoulder. Four muscles and their tendons make up the rotator cuff. They cover the outside of the shoulder to hold, protect and move the joint.
Overuse can lead to a buildup of tissue around the posterior capsule called hypertrophy. The next step is tightness of the posterior capsule called posterior capsular contracture. This type of problem reduces the amount the shoulder can rotate inwardly.
Over time, with enough force, a tear may develop in the labrum. The labrum is a rim of cartilage around the shoulder socket to help hold the head of the humerus (upper arm) in the joint. This condition is called a superior labrum anterior posterior (SLAP) lesion. The final outcome in all these steps is the dead arm phenomenon.
The shoulder is unstable and dislocation may come next. Dead arm syndrome will not go away on its own with rest—it must be treated. If there is a SLAP lesion, then surgery is needed to repair the problem. If the injury is caught before a SLAP tear, then physical therapy with stretching and exercise can restore it.
It is common among baseball pitchers as they age, and it can also occur with quarterbacks in football and handball players also as they age.
Future research into posterolateral injuries will focus on both the treatment and diagnosis of these types of injuries to improve PLC injury outcomes. Studies are needed to correlate injury patterns and mechanisms with clinical measures of knee instability and laxity.
In most patients with PFPS an examination of their history will highlight a precipitating event that caused the injury. Changes in activity patterns such as excessive increases in running mileage, repetitions such as running up steps and the addition of strength exercises that affect the patellofemoral joint are commonly associated with symptom onset. Excessively worn or poorly fitted footwear may be a contributing factor. To prevent recurrence the causal behaviour should be identified and managed correctly.
The medical cause of PFPS is thought to be increased pressure on the patellofemoral joint. There are several theorized mechanisms relating to how this increased pressure occurs:
- Increased levels of physical activity
- Malalignment of the patella as it moves through the femoral groove
- Quadriceps muscle imbalance
- Tight anatomical structures, e.g. retinaculum or iliotibial band.
The cause of pain and dysfunction often results from either abnormal forces (e.g. increased pull of the lateral quadriceps retinaculum with acute or chronic lateral PF subluxation/dislocation) or prolonged repetitive compressive or shearing forces (running or jumping) on the PF joint. The result is synovial irritation and inflammation and subchondral bony changes in the distal femur or patella known as "bone bruises". Secondary causes of PF Syndrome are fractures, internal knee derangement, osteoarthritis of the knee and bony tumors in or around the knee.
Greater trochanteric pain syndrome (GTPS), also known as trochanteric bursitis, is inflammation of the trochanteric bursa, a part of the hip.
This bursa is at the top, outer side of the femur, between the insertion of the gluteus medius and gluteus minimus muscles into the greater trochanter of the femur and the femoral shaft. It has the function, in common with other bursae, of working as a shock absorber and as a lubricant for the movement of the muscles adjacent to it.
Occasionally, this bursa can become inflamed and clinically painful and tender. This condition can be a manifestation of an injury (often resulting from a twisting motion or from overuse), but sometimes arises for no obviously definable cause. The symptoms are pain in the hip region on walking, and tenderness over the upper part of the femur, which may result in the inability to lie in comfort on the affected side.
More often the lateral hip pain is caused by disease of the gluteal tendons that secondarily inflames the bursa. This is most common in middle-aged women and is associated with a chronic and debilitating pain which does not respond to conservative treatment. Other causes of trochanteric bursitis include uneven leg length, iliotibial band syndrome, and weakness of the hip abductor muscles.
Greater trochanteric pain syndrome can remain incorrectly diagnosed for years, because it shares the same pattern of pain with many other musculoskeletal conditions. Thus people with this condition may be labeled malingerers, or may undergo many ineffective treatments due to misdiagnosis. It may also coexist with low back pain, arthritis, and obesity.
Chondromalacia patellae (also known as CMP) is inflammation of the underside of the patella and softening of the cartilage.
The cartilage under the kneecap is a natural shock absorber, and overuse, injury, and many other factors can cause increased deterioration and breakdown of the cartilage. The cartilage is no longer smooth and therefore movement and use is painful. While it often affects young individuals engaged in active sports, it also afflicts older adults who overwork their knees.
"Chondromalacia patellae" is sometimes used synonymously with patellofemoral pain syndrome. However, there is general consensus that "patellofemoral pain syndrome" applies only to individuals without cartilage damage.
The condition may result from acute injury to the patella or chronic friction between the patella and a groove in the femur through which it passes during knee flexion. Possible causes include a tight iliotibial band, neuromas, bursitis, overuse, malalignment, core instability, and patellar maltracking.
Pain at the front or inner side of the knee is common in both young adults and those of more advanced years, especially when engaging in soccer, gymnastics, cycling, rowing, tennis, ballet, basketball, horseback riding, volleyball, running, combat sports, figure skating, snowboarding, skateboarding and even swimming. The pain is typically felt after prolonged sitting. Skateboarders most commonly experience this injury in their non-dominant foot due to the constant kicking and twisting required of it. Swimmers acquire it doing the breaststroke, which demands an unusual motion of the knee. People who are involved in an active life style with high impact on the knees are at greatest risk. Proper management of physical activity may help prevent worsening of the condition. Athletes are advised to talk to a physician for further medical diagnosis as symptoms may be similar to more serious problems within the knee. Tests are not necessarily needed for diagnosis, but in some situations it may confirm diagnosis or rule out other causes for pain. Commonly used tests are blood tests, MRI scans, and arthroscopy.
While the term "chondromalacia" sometimes refers to abnormal-appearing cartilage anywhere in the body, it most commonly denotes irritation of the underside of the kneecap (or "patella"). The patella's posterior surface is covered with a layer of smooth cartilage, which the base of the femur normally glides effortlessly against when the knee is bent. However, in some individuals the kneecap tends to rub against one side of the knee joint, irritating the cartilage and causing knee pain.
Running is a form of exercise and described as the one of the world's most accessible sport. However, its high-impact nature can lead to injury. Approximately 50% of runners are affected by some form of running injuries or running-related injuries (RRI) annually, and some estimates suggest an even higher frequency. The frequency of various RRI depend on the type of running, as runners vary significantly in factors such as speed and mileage. RRI can be both acute and chronic. Many of the common injuries that plague runners are chronic, developing over a longer period of time, as opposed to injury caused by sudden trauma, such as strains. These are often the result of overuse. Common overuse injuries include stress fractures, Achilles tendinitis, Iliotibial band syndrome, Patellofemoral pain (runners knee), and plantar fasciitis.
Proper running form is important in injury prevention. A major aspect of running form is foot strike pattern. The way in which the foot makes contact with the ground determines how the force of the impact is distributed throughout the body. Different types of modern running shoes are created to manipulate foot strike pattern in an effort to reduce the risk of injury. In recent years, barefoot running has increased in popularity in many western countries, because of claims that it reduces the risk of injury. However, this has not been proven and is still debated.
There are few good estimates of prevalence for pes cavus in the general community. While pes cavus has been reported in between 2 and 29% of the adult population, there are several limitations of the prevalence data reported in these studies. Population-based studies suggest the prevalence of the cavus foot is approximately 10%.
An effective rehabilitation program reduces the chances of reinjury and of other knee-related problems such as patellofemoral pain syndrome and osteoarthritis. Rehabilitation focuses on maintaining strength and range of motion to reduce pain and maintain the health of the muscles and tissues around the knee joint.
Pes cavus may be hereditary or acquired, and the underlying cause may be neurological, orthopedic, or neuromuscular. Pes cavus is sometimes—but not always—connected through Hereditary Motor and Sensory Neuropathy Type 1 (Charcot-Marie-Tooth disease) and Friedreich's Ataxia; many other cases of pes cavus are natural.
The cause and deforming mechanism underlying pes cavus is complex and not well understood. Factors considered influential in the development of pes cavus include muscle weakness and imbalance in neuromuscular disease, residual effects of congenital clubfoot, post-traumatic bone malformation, contracture of the plantar fascia, and shortening of the Achilles tendon.
Among the cases of neuromuscular pes cavus, 50% have been attributed to Charcot-Marie-Tooth disease, which is the most common type of inherited neuropathy with an incidence of 1 per 2,500 persons affected. Also known as Hereditary Motor and Sensory Neuropathy (HMSN), it is genetically heterogeneous and usually presents in the first decade of life with delayed motor milestones, distal muscle weakness, clumsiness, and frequent falls. By adulthood, Charcot-Marie-Tooth disease can cause painful foot deformities such as pes cavus. Although it is a relatively common disorder affecting the foot and ankle, little is known about the distribution of muscle weakness, severity of orthopaedic deformities, or types of foot pain experienced. There are no cures or effective courses of treatment to halt the progression of any form of Charcot-Marie-Tooth disease.
The development of the cavus foot structure seen in Charcot-Marie-Tooth disease has been previously linked to an imbalance of muscle strength around the foot and ankle. A hypothetical model proposed by various authors describes a relationship whereby weak evertor muscles are overpowered by stronger invertor muscles, causing an adducted forefoot and inverted rearfoot. Similarly, weak dorsiflexors are overpowered by stronger plantarflexors, causing a plantarflexed first metatarsal and anterior pes cavus.
Pes cavus is also evident in people without neuropathy or other neurological deficit. In the absence of neurological, congenital, or traumatic causes of pes cavus, the remaining cases are classified as being ‘idiopathic’ because their aetiology is unknown.
Originally described by Dr. Paul Segond in 1879 after a series of cadaveric experiments, the Segond fracture occurs in association with tears of the anterior cruciate ligament (ACL) (75–100%) and injury to the medial meniscus (66–75%), lateral capsular ligament (now known as the Anterolateral ligament, or ALL), as well as injury to the structures behind the knee.
A rare, mirror image of the Segond fracture has also been described. The so-called "reverse Segond fracture" can occur after an avulsion fracture of the tibial component of the medial collateral ligament (MCL) in association with posterior cruciate ligament (PCL) and medial meniscal tears.
Segond fracture is typically the result of abnormal varus, or "bowing", stress to the knee, combined with internal rotation of the tibia. Reverse Segond fracture, as its name suggests, is caused by abnormal valgus, or "knock-knee", stress and external rotation.
Originally thought to be a result of avulsion of the medial third of the lateral collateral ligament, the Segond fracture has been shown by more recent research to relate also to the insertion of the iliotibial tract (ITT) and the anterior oblique band (AOB), a ligamentous attachment of the fibular collateral ligament (FCL), to the midportion of the lateral tibia and to be associated with avulsion by the anterolateral ligament (ALL). (Roberts CC, Towers JD, Spangehl MJ et-al. Advanced MR imaging of the cruciate ligaments. Radiol. Clin. North Am. 2007;45 (6): 1003-16, vi-vii.)"
In general, overuse injuries are the result of repetitive impact between the foot and the ground. With improper running form, the force of the impact can be distributed abnormally throughout the feet and legs. Running form tends to worsen with fatigue. When moving at a constant pace, a symmetrical gait is considered to be normal. Asymmetry is considered to be a risk factor for injury. One study attempted to quantify the change in running form between a rested and fatigued state by measuring asymmetrical running gait in the lower limbs. The results showed that "knee internal rotation and knee stiffness became more asymmetrical with fatigue, increasing by 14% and 5.3%, respectively". These findings suggest that focusing on proper running form, particularly when fatigued, could reduce the risk of running related injuries. Running in worn out shoes may also increase the risk of injury and altering the footwear might be helpful. These injuries can also arise due to a sudden increase in the intensity or amount of exercise.
The Segond fracture is a type of avulsion fracture (soft tissue structures tearing off bits of their bony attachment) of the lateral tibial condyle of the knee, immediately beyond the surface which articulates with the femur.
The Rolando fracture is less common than the Bennett's fracture, and is associated with a worse prognosis.
The reported incidence of constriction ring syndrome varies from 1/1200 and 1/15000 live births. The prevalence is equally in male and female.
Fetomaternal factors like prematurity, maternal illnes, low birth weight and maternal drug exposure are predisposing factors for the constriction ring syndrome.
No positive relationship between CRS and genetic inheritance has been reported.
There are several proposed methods of treatment. Interestingly the quality of reduction does not correlate with late symptoms and osteoarthritic changes. Despite this fact, the joint surface should be restored as close to its anatomical position as possible.
Some advocate fixation with Kirschner wires, or plate and screw constructions.
Another accepted treatment is an external fixator accompanied by the tension band wiring technique.
Tension band wiring is a technique in which the bone fragments are transfixed by Kirschner wires, which are then also used as an anchor for a loop of flexible wire. As the loop is tightened the bone fragments are compressed together.
The prognosis depends on the location and severity of the constricting bands. Every case is different and multiple bands may be entangled around the fetus.
Bands which wrap around fingers and toes can result in syndactyly or amputations of the digits. In other instances, bands can wrap around limbs causing restriction of movement resulting in clubbed feet. In more severe cases, the bands can constrict the limb causing decreased blood supply and amputation. Amniotic bands can also sometimes attach to the face or neck causing deformities such as cleft lip and palate. If the bands become wrapped around the head or umbilical cord it can be life-threatening for the fetus.
The number of cases of miscarriage that can be attributed to ABS is unknown, although it has been reported that it may be the cause of 178 in 10,000 miscarriages.