Sports Physiotherapy - SLKS

Injuries to the articular cartilage of the knee are common, posing an increasing public health problem, with multiple causes. Articular cartilage, different from meniscal cartilage, covers the bone ends of the femur and tibia, and allows the joint to slide-roll with low friction, absorbing the forces applied to the joint.

The pain of arthritis occurs when the articular cartilage of the knee loses its shape and function, deforms, thins, or disappears, with fibrillations and erosions, the appearance of osteophytes and bone remodeling. The 'chemical complex' articular cartilage contains chondrocytes cells synthesizing the matrix. The matrix, with 65-80% water, and not vascularized which does not facilitate healing, is composed of aggregates of proteoglycans (PG) linked to hyaluronic acid, and collagen fibers mainly of type II. The compliance and elasticity of the cartilage account for the role of proteoglycans. When the matrix of the cartilage is injured and breached, there is a decrease in PG, with an increase in cellular divisions of chondrocytes, therefore an increase in the synthesis of PG, and repair of the cartilage lesion:

Osteoarthritis worsens with age but with individual variations: the chondrocyte sees its capacity to restore the matrix decrease: by decreasing the synthesis of PG which are smaller and irregular. Furthermore, the more chondrocytes divide, as a consequence of the repetition of cartilage injuries, the faster they will be in senescence, with premature cellular aging. Chondropenia: it results from what precedes that repeated traumas and lesions, excessive joint use, accelerate cellular senescence (by increasing the divisions of chondrocytes), with loss of articular cartilage volume: this is chondropenia. While in the high-level athlete subjected to non-extreme training, the cartilage is thick, thickens, with high compliance and elasticity, the repetition of acute injuries, joint contact stresses, cartilage defects, meniscal and / or anterior cruciate ligament lesions, will lead to chondropenia, a loss of articular cartilage, gradually over time, in the aging athlete, an evolution towards knee osteoarthritis. These effects are potentiated with age, obesity, malalignment (varus-valgus) of the knee and / or patella, menopause.

The border between chondral defect and knee osteoarthritis is therefore moving, dependent on age, level of activity, presence of malalignment, obesity, instability (ACL), meniscal capital, muscle strength: good strength with a good ratio between quadriceps and hamstrings absorbs the constraints applied on the joint, and is favorable to the prevention of non-contact traumas of the type pivot of the knee (ACL, meniscus and cartilage).

The sprained ankle is the most common reason for consultation in common traumatology. It represents, approximately 20% of sports injuries.

A sprain is a traumatic ligamentous injury caused by an indirect mechanism and not resulting in permanent or temporary loss of normal relationships between joint surfaces. This distinguishes a sprain from a dislocation, where the joint loses its normal relationships permanently; it is an exceeding of physiological and joint barriers.

Ligaments are stays stretched from one bone to another around or in the middle of the joint. Their role is to allow the joint surfaces to remain well in contact during movements. They are an articulated restraint and, together with the joint capsule, constitute the passive stability system, allowing the joint to adapt to different gravitational constraints to ensure joint stability along with the active system, musculo-tendinous. The injury can range from a simple stretch (mild sprain) to total rupture (severe sprain), passing through the tearing of some bundles (moderate severity sprain).

A sprain follows a false movement of the foot, which causes a sudden torsion of the foot inward or outward. The most classic mechanism is the inversion mechanism. This inversion occurs during a jump landing, on a misstep, or while running and causes the foot to go beyond the physiological barrier on the outer edge, putting excessive tension on the lateral ligaments, which under mechanical stress can give way.

The ankle joint becomes overloaded, the ligaments stretch, and tiny tears occur. Small blood vessels can easily burst, causing the ankle to swell.

Classically, an ankle sprain corresponds to an injury to the external ligaments between the tibia, the talus, and the calcaneus.

Sometimes an ankle sprain can be accompanied by a fr

Each knee has two menisci: an internal meniscus and an external meniscus. The meniscus is a small fibrocartilage shaped like a "crescent moon" located between the femur and the tibia. It acts as a wedge, stabilizing the knee, and as a shock absorber, supporting 40% of the constraints exerted on the knee. An isolated meniscal lesion does not significantly affect the stability of the knee as long as the ligaments are intact, but it increases the risk of arthritis later.

Traumatic meniscal injuries occur following:

• a sudden twisting of the knee (sprain) that can occur in any circumstance: sports, fall, running, fast walking, sudden lifting from a squatting position...
• when the knee is overused without any obvious traumatic event.

Under these conditions, the meniscus, whether internal or external, can crack or even tear. This tear can cause knee pain (generally on the inner side of the knee if it is an internal meniscus and on the outer side in case of an external meniscus lesion). Swelling of the knee may occur following an effusion, and the knee may even lock and no longer extend normally.

There are also meniscal lesions that occur outside of any traumatic episode, often due to aging of the meniscus. This is a very common lesion. It should be considered in mature patients who present with progressive onset of internal knee pain. The evolution of pain is often cyclic with more or less long painful episodes that settle down for some time followed by the reappearance of identical symptoms. This is a difficult diagnosis that usually requires additional examinations such as radiography (arthrography) or MRI.

These meniscal lesions can sometimes be associated with cartilage wear at the level of the femur and the tibia, which is osteoarthritis. It is important to specify this cartilage damage as it can be responsible for residual pain, and it can potentially worsen following meniscus removal.

Knee pain due to meniscal lesions is treated by arthroscopy. One of the advantages of arthroscopy is that the surgeon can precisely target the procedure and perform the removal of the torn part of the meniscus (partial meniscectomy) while preserving the entire healthy portion. In some cases, arthroscopy also allows for the repair of a meniscus by performing a suture.

The knee is a frequently injured joint. The rupture of the ACL is on the rise, usually occurring during athletic activities. The knee is a vulnerable joint, the stability of the ligaments and menisci decreases during flexion. Techniques for preventing ACL ruptures in athletes are described, using, for example, selective strengthening of the hamstrings, plyometrics, and depending on the sport. The anterior cruciate ligament or ACL is made up of elastic fibers located in the middle of the knee and stretched between the femur and the tibia. The orientation of these fibers explains that its essential role is to prevent the tibia from moving forward relative to the femur as well as its rotation. It has a stabilizing role in the knee.

Knee ligament ruptures most commonly occur after a sports accident (football, skiing, jumping sports, combat sports…) but can also occur in any circumstance where the knee is subjected to a sudden sprain. The most commonly ruptured ligament is the anterior cruciate ligament (ACL), but other ligaments (lateral ligaments, posterior cruciate ligament) can also be injured. A rupture of the anterior cruciate ligament can cause effusion with knee swelling and, above all, knee instability that gives way during walking or sports practice. The patient can no longer use their knee with the same confidence as usual. Meniscal injuries can occur in association with a rupture of a knee cruciate ligament. Over time, anterior instability due to ACL rupture can lead to meniscal and cartilage injuries with an increased risk of knee osteoarthritis. In case of anterior cruciate ligament rupture, daily life is mostly normal, but the more physical or sports activity is important, the higher the risks of instability are (especially team and combat sports).

The posterior cruciate ligament (PCL) can also rupture during a knee sprain or during a violent impact on the front of the tibia. In this case, the knee can become unstable, but less frequently than during a rupture of the anterior cruciate ligament. However, the risk of osteoarthritis in the medium term is greater.

Ligament repair

Simple suturing of the anterior cruciate ligament does not yield good results because the ligament, once ruptured, becomes necrotic and loses its mechanical properties, even if the fragments are brought together and sutured. It is necessary to replace the ligament with an equivalent structure. It is necessary to use a natural tendon called an autologous graft or transplant taken from the patient's knee and used to replace the ruptured cruciate ligament: this is ligamentoplasty. Arthroscopy allows the reconstruction of a ruptured anterior cruciate ligament by performing an autograft.

1. Complete ACL rupture
2. Diagram of ACL location
3. ACL ligamentoplasty

The two most commonly used techniques today are:

• The KJ autograft technique according to Kenneth Jones

involves harvesting a 10 mm diameter strip of patellar tendon with two bone fragments through an incision on the front of the knee about 5 cm long. This graft is then replaced inside the knee by arthroscopy and positioned in place of the torn anterior cruciate ligament.

• The 4-bundle DIDT technique

involves using a transplant constructed using two tendons from the inner side of the thigh harvested through an incision of 2 to 3 cm on the inner side of the leg. This graft is also replaced in the knee by arthroscopy.
These transplants are very strong and especially have elasticity and characteristics very close to those of the normal anterior cruciate ligament. In the long term, the performance of the two methods is analogous. The assembly is solid and allows immediate rehabilitation.

They are caused by an intense and involuntary contraction of the muscle. It occurs suddenly and is accompanied by severe pain, which lasts only a few minutes, but nevertheless leaves a contracture in the days following its appearance. The cramp most often occurs during exertion but can also occur at rest. Treatment consists of stretching, followed by massages and the application of ice. Prevention involves hydration, the intake of minerals and stretching before and after sports practice.

Muscle soreness or delayed onset muscle soreness is also called DOMS (Delayed Onset Muscle Soreness). These are muscle pains occurring 12 to 48 hours after exertion. They usually disappear within 5 to 7 days. The pain is less severe and moreover affects groups of muscles. Although muscle soreness is included in the usual classification of an injury without anatomical lesions, it presents micro-lesions of the muscle fibers due to excessive eccentric contraction solicitations and/or non-adaptation to a level of training (muscle not adapted to the intensity of the training). The most severe muscle soreness is observed during downhill running, efforts against gravity or during the practice of maximal strength reinforcement. There is impairment of muscle function and is accompanied by an increase in the inability to produce maximal force and an increase in muscle stiffness, often observed during the first 4 days with muscle pain.

While some treatments seem to alleviate DOMS, none of them have yet demonstrated their real effectiveness, particularly in accelerating muscle regeneration. Treatment consists of alternating hot/cold baths and a moderate resumption of activity. The severity of symptoms related to muscle soreness could be limited by: maintaining good muscle flexibility, especially that of the muscle groups involved in the targeted physical activity, pre-conditioning the main muscle groups with a few high-intensity eccentric contractions one or two weeks before scheduling difficult sessions, using specific warm-up exercises for the main muscle groups.

As the name suggests, contracture comes from the exaggerated contraction of part of the muscle. The pain is first felt at the end of the exercise, during the rest phases. If the effort is continued, the muscle "stiffens" more and more; the pain becomes noticeable during the exercise and then very uncomfortable at the end of it. The athlete distinctly perceives a troublesome area. On examination, we generally find only one muscle, or even a single muscle bundle, indurated and painful. The ultrasound will reveal no abnormality. The contracture lasts for 5 to 10 days. The contracture may come from a reflex contraction aimed at protecting the muscle and the joint(s) involved following a significant stretch. The origin may also be significant muscle fatigue leading to disorders of certain molecules at the cellular level (calcium, potassium, magnesium). This pathology can finally be favored by a recent muscle injury (strain, tear, contusion...) which makes the muscle fiber not fully functional.

Treatment consists of the use of ice packs, muscle relaxants and massages, physiotherapy and functional rehabilitation.

Unlike the previous pathologies, contusion is a traumatology due to a direct impact on the muscle. (Fall on a barrier, blow to the muscle, the crutch...). Following the trauma, the muscle may be more or less injured, the muscle fibers more or less damaged (crushing, tearing). A slight internal bleeding (intramuscular hematoma) or subcutaneous swelling may occur. The consequences can be relatively minor if the impact was light. Most often they do not prevent physical practice. On the other hand, in case of a severe blow, the muscle fibers may have suffered a significant tearing equivalent to a tear, or even a muscle rupture. The pain is sudden and exquisite, causing a stop in activity. The important thing is to treat the hematoma in order to prevent it from preventing muscle healing and/or calcifying, which in both cases weakens the muscle fiber.

These are micro-tears in the muscle bundle, sometimes associated with simple fraying of myofibrils. They are caused by excessive demands on the muscle working at the limit of stretching. They are recognized by a sudden but moderate pain, poorly localized, causing relatively minor discomfort. The athlete has little pain when asked to perform movements alone, on the other hand, stretching is painful, as is isometric contraction (during a resisted movement). Finally, note the absence of visible bruising. Palpation reveals an indurated cord. Ultrasound shows an elongated hypoechoic area.

Treatment must be immediate and allows recovery within 10 to 15 days thanks to containment such as elastoplast (tape), ice packs, rest, local anti-inflammatories as well as other specific methods of physiotherapy.

This time, it is tears of fibers, or even entire muscle bundles.

They are caused by two factors:

• Either by a too violent and too rapid contraction (type of start)
• Or by an impact on a contracted muscle

They are recognized by a sudden and well-localized pain associated with a total inability to move. The muscle strain occurs during exertion and causes its immediate stop.

Of course, in this case, one would not even attempt any stretching or other maneuver as the injury is too serious. The muscle strain is mainly seen in the hamstrings and the inner gemellus.

Moreover, a hematoma does not take long to appear. If the injury is superficial or interstitial, a bruise appears within a few days. It constitutes an element of good prognosis. If the injury is deep, intramuscular, the hematoma does not spread, the bruise is lacking and the ultrasound shows it very well and can guide us towards a possible puncture. The treatment lasts from 21 to 30 days. It is also urgent to immediately apply a compressive containment completed by a splint, and to apply icing which can be prolonged for 21 days relayed by more specific methods of physiotherapy.

Unfortunately, these are the same problems, in the first case, the muscle is completely torn in its fleshy part, in the other case the tear occurs in its osteo-ligamentous insertion. Often there is a noise of added cracking. They are caused by the same mechanisms as before: too violent and too brief effort or direct impact. The pain can go up to loss of consciousness, the injured person is totally impotent and a hematoma or swelling appears within a few hours which can mask the palpable notch of the fibers. The ultrasound confirms the true "fracture" of the muscle. The treatment lasts from 45 to 60 days during which strict immobilization must be respected (21 days) then a surgical opinion is systematically requested.