Findings
The presentation may or may not be with lumbar
pain, but pain may refer onto the anterior thigh, shn and the top of the foot,
which may have pins and needles”, numbness and hyperaesthesia. There may be
painful, fixed, lumbar flexion and back movements that provoke leg pain.
Femoral stretch and prone lying knee flexion are positive. The knee jerk may be
absent and the quadriceps weak, but this is not a pain-induced weakness. Hip
rotation, tested in the sitting position so as not to involve the back, is
pain-free. There is no history of trauma, swelling of bruising.
Cause
L3/4 disc or lateral canal entrapment of the
L3/4 root; L2/3 is referred more to the groin.
Reffered pain: Hip
Findings
When the back is tested with the patient
sitting on the couch then little mechanical pressure is applied to the hip.
When the hip is involved then lumbar movements are pain-free, but hip
rotations, flexion, abduction and adduction are painful and refer pain through
to the knee.
Trauma to the quadriceps
There is a history of an acute episode of
direct trauma or blocked quadriceps muscle action. Swelling of the thigh may
occur, and, if the bleeding is extrafascicular, the bruising will track down, under
gravity, towards the knee. This early bruising is indicative that the injury
will heal fairly rapidly, whereas swelling with no bruising is indicative of a
central tear or haemathoma, which heal much more slowly. There is pain on
testing resisted quadriceps, and the pain is worse on the stairs, with squats,
straightening the knee and kicking. Stretch and movements in quadriceps are
limited.
Cause
There has been direct trauma to quadriceps,
especially whilst contracting the muscle. Blocking of a fast quadriceps
movement, such as a kick blocked by a tackle, tears the muscle.
Treatment
b)
In the
early stages, aspirate any haemathoma, under ultrasound control.
c)
Electrotherapeutic
modalities to encourage healing and removal of tissue debris, such as
ultrasound.
d)
Massage to
remove tissue debris and realign healing fibroblasts.
e)
Electrotherapeutic
modalities, such as interferential, to encourage early muscle contraction
within the pain-free range.
f)
Stretch
the quadriceps to prevent scar contraction.
g)
Isometric
exercises followed by isotonic exercises.
i)
Myositis
ossificians may develop in 15% of athletes with severe injury, so be warn about
development.
Sports
Occurs in sports where a quadriceps movement
may be interrupted or blocked extrinsically, or direct trauma can occur.
Early management of this lesion has to be
observed for the suspected onset of myositis ossificans. If this is shown as
true, then active treatment has to be stopped and rest instituted.
Torn rectus femoris muscle
Findings
There is an acute or chronic history, with pain
in the upper mid-quadriceps, which is worse on running, kicking, squats and
stairs. Sometimes the history is not so much of pain, but a weakness or
incoordination during the above movements. The lesion is locally tender with
two gaps, invariably palpable, about 6cm apart in the upper mid-thigh. Resisted
knee extension with the hip flexed may be pain-free, but supine lying, resisted
straight raise is weak or painful, and the modified Thomas test is tight.
Cause
Sometimes from a blocked quadriceps action, but
the lesion can develop insidiously, presumably from microtears. Kicking and
sprinting are often causative, as this muscle exhibits Lombard ’s
paradoxical movement.
Treatment
a)
The
chronic phase is difficult to manage and the lesion slow to heal, but
maintaining quadriceps stretching, the quadriceps ladders for training, and
playing within tolerance helps. Sometimes rest from sport, but maintaining
stretch and quadriceps rehabilitation, is required.
b)
The acute
tear is treated with pressure, RICE and then as for a quadriceps tear.
Sports
No specific sport is responsible for this
injury, but a weak psoas is often found when this lesion is present.
The chronic phase seems to niggle on without
getting totally better, but then if the tear gets worse, and completes, the
pain eases and the muscle heals to normal function, but with the indentations
from the tears still palpable.
Ruptured quadriceps
Findings
Total separation of a muscle produces a
painless muscle contraction on resisted muscle testing, but this is unusual in
the quadriceps where a partial tear occurs, and resisted quadriceps is painful,
even producing inhibition. There is bruising and swelling, which may also be around
the knee in the acute phase, with a deformed quadriceps on contraction.
Cause
Partial or complete rupture of the quadriceps,
often close to the patella insertion.
Treatment
b)
Electrotherapeutic
modalities to settle inflammation and remove tissue debris.
c)
Isometric
exercises to organize scar tissue and build muscle strength.
d)
Stretching
to prevent scar contraction.
e)
Closed
chain exercises to maintain proprioceptive control and to strengthen the
muscle.
g)
Total
ruptures heal well without surgery; possible surgical repair.
Sports
The injury occurs in sports that can block
quadriceps movement, or overload can occur with weightlifting – when steroid
abuse must also be considered.
Surgical repair can be benefit if injury is
located close to the insertion into the patella.
Meralgia paraesthetica
Findings
Pain and numbness over the front to the lateral
side of the thigh, but the focal point of tenderness may range from the
anterior superior iliac spine to the upper one-third of the thigh.
Cause
Compression of the lateral cutaneous nerve of
the thigh, usually as it passes from deep to superficial through the
subcutaneous fascia.
Treatment
Relieve the cause of pressure, and if required inject
cortisone around the tender focal compression area of the nerve. Surgery to
release the nerve from the stenotic fascia is required if the problem fails to
settle.
A prime cause in sports players is compression
of the nerve by the tight elastic around the top of the leg, from pants to
shorts, and the tender spot may be palpated under the compression band left in
the skin by the elastic. Alteration of the elastic compression cures most!
Stress fracture of the femur
Findings
A history of pain in the hip, thigh or knee
that is worse with activity, which is invariably running or marching. Onset of
non-traumatic pain in the hip or the thigh, worse with running or walking, that
is not clinically diagnosable must be treated as a potential stress lesion. The
patient should be given crutches if a potential diagnosis of a tension stress
fracture of the hip is made. Femoral shaft stress lesions usually have pain
with hopping on the affected leg and with transaxial stress across the femur.
An athlete sits on the couch with the legs hanging over the side. The examiner
places one arm under the thigh as the fulcrum and the other presses the knee
towards the floor. When the fulcral arm is under, or near the stress lesion,
the patient experiences pain. This is sometimes called the fulcrum test.
Cause
Overload during running. Stress fractures in
the femur occur at the subtrochanteric level and along the shaft of the femur,
where it is an uncommon lesion.
Treatment
Non-weight-bearing on crutches, followed by a
gradual introduction of weight-bearing and repeat testing, but, beware, the
subtrochanteric and tension femoral neck lesion can fracture.
Sports
A possibility in all impact sports, but running
and power walking are particularly noted for this injury. Beware the
amenorrhoeic athlete.
The femoral shaft stress fracture is not
common. Why at times the stress occurs in the subtrochanteric region as opposed
to the femoral neck is not understood, but I wonder if power walking and a
hamstring-pull style of running might be causative.
"Concise
guide to sports injuries, 2nd edition",Churchill Livingstone,
Malcolm T.F. Read, foreword by Bryan English
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