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17. 2. 2012.

Anterior thigh injuries


Reffered pain: lumbar nerve root L3/4

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

      a)   Pressure and RICE
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.
h)      Quadriceps ladders - will be discussed in one of later chapters
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

      a)    RICE
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.
f)       Quadriceps ladders, plus knee(kicking) ladder - if required.
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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