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Lower limb pain
Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 135e152, 2007 doi:10.1016/j.berh.2006.10.007 available online at http://www.sciencedirect.com
9 Lower limb pain Karsten E. Dreinho¨fer*
MD
Deputy Head
Heiko Reichel
MD
Professor, Head of the Department
Wolfram Ka¨fer
MD
Consultant Department of Orthopaedics, Ulm University, Oberer Eselsberg 45, D-89081 Ulm, Germany
This article summarises lower limb pathology, which results in lower limb pain. It mainly addresses injuries and deliberately omits osteoarthritis and rheumatoid arthritis, since these entities are described in detail in other chapters in this volume. As major trauma is not a focal point for rheumatologists and repetitive strain injuries of the lower limb are rare, sports and leisure injuries are the main focus. Regarding lower limb pain, this chapter describes the most important problems and quantifies the size of the problem. Furthermore, it informs the reader about different treatment modalities, their goals and methods of measuring the effectiveness of the treatment. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence. Key words: lower limb pain; sports injuries; work-related lower extremity disorders; clinical manifestations; risk factors; prevention; treatment.
INTRODUCTION Lower limb pain is a common complaint with many possible causes. In the last 12 months, one in three people will have reported some pain in their lower extremities.
* Corresponding author. Tel.: þ49 731 177 1107; Fax: þ49 731 177 1118. E-mail address: [email protected] (K.E. Dreinho¨fer). 1521-6942/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved.
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While joint diseases and other disorders are discussed elsewhere, in this chapter the focus will be on sports and occupational injuries as a cause for lower limb pain. There is a wide spectrum of trauma and injuries that affect the musculoskeletal system in general, and the lower limb specifically, in terms of the cause, the structural damage and the outcome. For the purposes of this review, musculoskeletal trauma and injuries will be considered in the context of occupational and sports injuries only. This chapter will describe the most important pathologies and quantify the size of the problem. Furthermore, drawing on the European Action for Better Musculoskeletal Health report,53 it will provide information on different treatment modalities, their goals and methods for measuring their effectiveness. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence. WHAT ARE THE MOST IMPORTANT PROBLEMS? Many specific conditions may cause chronic or recurrent lower limb pain (see Table 1). The most common joint diseases (osteoarthritis (OA) and rheumatoid arthritis (RA)) have not been included in the table. The focus of this chapter is on musculoskeletal trauma and injuries. A wide spectrum of trauma and injuries affect the musculoskeletal system in terms of cause, structural damage and outcome. Trauma and injuries can be considered, for the purposes of this chapter, in the context of (a) major limb trauma, (b) occupational injuries and (c) sports injuries. The latter two causes will be primarily considered. Hip pain Self-reported hip pain is common. In a German health interview survey the prevalence over a 12 month period was 10% for those aged between 20 and 40 years, but more than 30% in patients aged over 60 years.1 Whilst most of the joint pain, especially in the elderly, would have been caused by degenerative joint disease, peri-articular pain and tight pain might indicate, especially in the younger participants, an injury-related problem. Knee pain In a British study, the lifetime prevalence for knee symptoms in adult men was 54%. Symptoms were strongly associated with meniscal lesions. Meniscal tear was strongly associated with participation in sports during the 12 months preceding the onset of symptoms; the risk was particularly high for soccer. Higher body mass index and occupational kneeling and squatting were associated with an increased risk of degenerative meniscal lesions, after adjustment for social class, joint laxity and sports participation.2,3 Musculoskeletal injuries The majority of sports injuries are similar to injuries that normally occur in nonathletes, but they have occurred during sporting activities. Many injuries are common to a variety of sports, but others are sport-specific. Injuries occurring in sports and
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physical activities are usually mild and many are never reported. More severe injuries may either be acute, chronic or overuse injuries. In this chapter we will only consider sports injuries to the musculoskeletal system that would require medical attention, either in a casualty department, or from a doctor or physiotherapist. They include strains, sprains, dislocations, fractures and lacerations. These injuries cause pain, loss of function and affect quality of life. They may result in loss of training or competition or absence from work. Lower extremity soft tissue injuries and overuse conditions are commonly encountered in athletes. Muscles are frequently strained or contused; tendons and bursae can become inflamed. Overuse injuries are the result of an excessive stress applied to normal tissue and the failure of normal adaptation. Tendons are the most common sites for such injuries; however, the joint, cartilage, bursae and bone can all be affected.4 Typical examples are anterior knee pain and Sever’s Disease, affecting the posterior aspect of the calcaneus where the Achilles tendon is fixed to the calcaneal apophyses.5,6 Stress fractures can result from normal stress applied to a weak or structurally deficient bone or from repetitive, excessive force applied to a normal bone.7
WHAT IS THE SIZE OF THE PROBLEM? Lower limb pain is common among adults across Europe, with one out of three men and one out of two women experiencing some pain in this region over a 12 month period.1 While there is a clear age-dependent increase in incidence, indicating that a large number of cases may be caused by underlying degenerative joint diseases, injuries are a common reason for lower limb pain. In Finland, 45% of schoolchildren aged 9e15 years reported moderate to severe disability attributed to lower limb pain during a three month period.8 About 9 million people in Germany (11.0% of the population), have an accident each year and injuries to the upper and lower limbs are found in more than 70% of these accidents. The incidence of trauma to an extremity depends on several factors such as sex, age and the cause of the accident. Home (32%) and leisure injuries (31%) accounted for most of the cases, followed by school (17%) and occupational injuries (15%). Traffic accidents accounted for about 5% of all injuries.9 Of the 5.4 million accidents at home or at leisure, 27% were sports injuries, with one in two of these affecting the lower limbs, while 13% of the home and leisure injuries required hospital treatment in 2000.9 Trauma is responsible for a huge socioeconomic burden, magnified by many years of lost productivity and lost income for the patient. Costs associated with trauma include the direct costs of the trauma system, hospital and physician, as well as the indirect costs for rehabilitation and lost productivity. In Germany, the direct costs (prevention, hospital care, rehabilitation) caused by trauma are estimated to be about V11 billion, representing 4.8% of the total health care costs.10 A significant portion of these costs is due to hospital treatment. In addition, trauma is one of the most important causes for disablement in Germany (1.1 million lost working years, equating to 20% of overall disablement). The loss of productivity is estimated to be V9 billion, equalling 0.5% of the gross national income.11 In the Netherlands in 1999, the total health care cost due to injury were V1.15 billion, or 3.7% of the total health care budget.12
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Table 1. Causes of lower limb pain. A. General B Overuse injuries B Stress fracture B Haematoma B Open wound B Bruises B. Hip pain - Children and adolescents B Acute transient synovitis B Slipped capital femoral epiphysis B Perthes disease B Congenital dysplasia of the hip B Strains or tendonitis (Mm. adductor longus, rectus femoris, iliopsoas) B Avulsion fracture B Tumours - Adults B Avascular necrosis B Transient osteoporosis B Fracture B Septic arthritis B Bursitis B Piriformis syndrome B Strains or tendonitis (Mm. adductor longus, rectus femoris, iliopsoas) B Tumors B Metastases C. Knee pain - Anterior B Patellofemoral syndrome B Osgood Schlatter disease B Osteochondritis dissecans B Chondromalacia patellae - Posterior B Baker cyst B Fabella syndrome B Gastrocnemius tendonitis B Hamstring tendonitis or chronic strain - Medial B Medial meniscal tear B Medial plica B Pes anserinus bursitis or tendonitis B Semimembranosus bursitis or tendonitis B Ganglion - Lateral B Lateral meniscus B Iliotibial band friction B Popliteus tendinitis - Others B Tumors (e.g. osteosarcoma, Ewing sarcoma, synovial sarcoma) B Systemic (connective tissue disease, sickle cell arthropathy, leukaemia) B Referred - Adolescent (slipped capital femoral epiphysis, Legg-Calve´-Perthes, spinal tumors) - Adult (osteoarthritis hip, spinal problems)
Lower limb pain 139 Table 1 (continued) BInfection BReflex sympathetic dystrophy D. Foot pain - Ankle pain B Sprained ankle ligaments B Impingement syndrome B Osteochondrosis dissecans - Heel pain B Sever’s disease B Achilles tendinitis B Enthesitis e AS B Haglunds deformity B Plantar fasciitis B Peroneal tendonitis or subluxation B Retrocalcaneal bursitis B Reflex sympathetic dystrophy B Tibialis posterior tendonitis - Midfoot pain B Plantar fibromatosis B Tarsal tunnel syndrome B Tarsal coalition B Posterior tibialis dysfunction B Tarsometatatarsal arthritis - Forefoot pain B MTP 1 pathology (Hallux valgus, Hallux rigidus) B Gout (podagra) B Plantar plate disruption B Sesamoiditis B Bursitis intermetatarsal B Morton’s neuroma B Ganglion B Stress fracture B Foreign body granulomas - Others B Tumors B Systemic (connective tissue disease, sickle cell arthropathy, leukaemia) B Infection B Reflex sympathetic dystrophy B Diabetic foot
Excluded B Osteoarthritis B Rheumatoid arthritis AS, Achilles tendon; MTP 1, metatarsophalangeal.
Sport injuries The increased involvement of people in sport at both recreational and professional levels has resulted in a greater incidence of sports injuries, a large proportion of which are preventable. The incidence and types of sports injuries vary greatly depending on the sport, the number of people participating and the hours played. In some sports,
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where high speeds and forces are encountered, there is a much higher risk of serious injury. The potential risks for injuries in sports seem to increase, for all levels of athletes, with increasing participation, intensity and demands, as well as with longer training periods. Statistics on the incidence of sports injuries are inadequate and difficult to compare. Many studies on the incidence of sports injuries in a particular sport or group of athletes use different definitions of incidence. These vary from (a) days lost from training and sport (the American National Athletic Injury Registration System (NAIRS), to (b) a definition that limits athletic participation for at least the day after the day of onset, to (c) the attendance at casualty or at a doctors surgery, to (d) an insurance claim. A definition that takes all these factors into consideration is: incidence ¼ (number of sports injuries/year)/(number of participants) (average hours of sports participation) (weeks of season/year).13 According to the EU Injury Database (IDB) sports injuries account for about 20% of all ‘‘home and leisure accidents’’ in 2002e2004. In Germany 2.0 million sports injuries require medical attention and cost 4 billion Euros annually.a In Europe, the overall sports injury incidence was found to vary between one and five per 1.000 hours spent playing or in a different perspective 10e15 per 100 personyears practising sports. About thirty per thousand of the total population or about sixty per thousand sports participants sustain per year a sports injury severe enough to require medical attention. Hospital admissions in Europe vary around five per thousand sports participants per year and represent around 5% of hospitalizations for all injuries.b Occupational injuries The third European Survey on Working Conditions (2000) has revealed that 33% of European workers have backache complaints, 23% have neck and shoulder pains, 13% upper limb pains and 12% lower limb pains.14 In Britain, almost 10 million working days are lost each year due to work-related musculoskeletal disorders. Of these, over 2 million lost days are caused by leg disorders. The UK estimate for the medical costs for work-related musculoskeletal disorders was between £84 and £254 million sterling, of which £17 to £55 million was spent on workrelated lower limb disorders. WHO IS MOST AT RISK? There are many risk factors for the occurrence of injuries (Table 2). Different factors are important depending on age, environment and main activities. In the young, risk factors in the home environment (toys, kitchen, animals, etc), games (playground, swimming, etc), traffic (bikes, cars, etc) and in the family (domestic violence, angry parent syndrome) dominate. In the adolescent, participation in sports, traffic-related and other dangerous activities are the main risks, aggravated by alcohol, recreational drugs and inappropriate self-control. a
https://webgate.cec.ei.int/idb/ Sports Injuries in the EU countries in view of the 2004 Olympics: Harvesting the information from existing databases (PHASE I), VS/1999/5311 (99CVF3-319), Athens 2001. b
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Table 2. Risk factors for the occurrence of trauma and injuries. Children
Youth
Working age
Old age
Unsafe homes (electricity, oven, etc) Unsafe playgrounds and swimming pools Participation in traffic-related situations
Contact sports (mismatched competitors) Unsafe sports facilities
Contact sports (mismatched competitors) Unsafe sports facilities
Late first-time participation in potentially dangerous activities Not-using protective gear correctly
Participation in dangerous activities (parachuting, hang gliding, boats, etc) Not-using protective gear correctly
Participation in dangerous activities (parachuting, hang gliding, boats, etc) Late first-time participation in potentially dangerous activities Unsafe workplace
Inappropriate and mismatched experience
Skateboards, rollerblades, bicycle Unsafe toys
Animals Inability to swim
Hyperactivity (ADHD) Clumsiness
Angry parent syndrome Domestic violence Low socioeconomic level
Inappropriate training and technique (inexperience, overuse, etc) Inadequate obeying of rules Inadequate enforcement of rules Inappropriate and mismatched experience Environmental factors (e.g. climate, weather, temperature) Clumsiness Hyperactivity (ADHD) Alcohol, recreational drugs, drugs Low socio-economic level
Not-using protective gear correctly Inappropriate training and technique (inexperience, overuse, etc) Inappropriate and mismatched experience Inadequate obeying of rules Inadequate enforcement of rules Alcohol, recreational drugs, drugs Stress
Inadequate obeying of rules
Environmental factors (e.g. climate, weather, temperature)
Alcohol, recreational drugs, drugs Medication
Reduced bone strength Concomitant diseases
Malnutrition (e.g. diabetes)
Low socio-economic level
ADHD, attention deficit hyperactivity disorder.
In the working age population, occupational risk factors (inappropriate protection, training, etc) supplement the risks in traffic, sports and leisure activities. In old age, reduced physical fitness, reduced bone mass, concomitant diseases and medication increase the risk for injuries at home (unsafe homes) or in public (traffic). In general, inappropriate risk awareness is the main problem. On a personal level, inappropriate training, experience and physical fitness, inadequate protection, inadequate obedience to rules are the key risk factors for the occurrence of trauma. The
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effects of alcohol and drugs decrease the internal control mechanisms and increase the risk for injuries. On a generic level, unsafe public or private environments might add further risk factors. Factors predisposing subjects to overuse injuries appear to be the intensity, volume and tempo of the activity. Such injuries are seen in the well-conditioned, as well as in the poorly conditioned, athlete. Following a traumatic event different determinants have an impact on the outcome of the injury (Table 3). In general, inadequate, delayed or inappropriate treatment and rehabilitation can lead to worse outcomes. On a personal level, age, overweight, comorbidities and complications as well as additional medication, drugs, alcohol and smoking all have an important influence on the final outcome. In addition socialeconomic factors (e.g. medico-legal compensation) play an important role. CAN LOWER LIMB PAIN BE PREVENTED AND/OR TREATED EFFECTIVELY? There is a wide spectrum of trauma and injuries that affect the musculoskeletal system in terms of the cause, the structural damage and the outcome. The nature of trauma differs from that of the other conditions considered in this volume, since interventions need to be adapted to the individual trauma phase. This chapter therefore follows a slightly different format. The populations that have been used to assess the evidence and form a basis for the recommendations and strategies are defined as: Normal: The whole population at all ages At risk: Children (0e16), especially those in the playground and household environments Youth (17e25), especially those involved in sports and in traffic situations Working age population (25e65), especially those involved in sports and high risk occupations Older people (65 plus), especially those at risk of falls In addition, any individuals with identified risk factors within the above age bands Early phase: Encompasses the acute phase of injury to the tissue healing and repair phase. Late phase: Encompasses chronic symptoms and disability attributable to injury.
Table 3. Risk factors and determinants for outcome of trauma and injuries. Severity of injuries Old age Overweight Co-morbidity Poor nutrition Immobility Infection Thrombosis/pulmonary embolism Alcohol Smoking
Medication Environmental factors Delayed therapy Transportation of victims Inadequate therapy Inadequate rehabilitation Inadequate compliance with medical advice Medicolegal compensation Socio-economic factors
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The targets for interventions are: 1. 2. 3. 4. 5.
To To To To To
prevent injuries related to trauma by preventing trauma. minimise injury following trauma. restore structure. reduce pain and other symptoms. reduce short and long term disability.
The evidence for different interventions will be considered in the context of the agreed targets for the prevention and treatment of musculoskeletal injuries and for the populations that the evidence applies to. Injuries range from major limb trauma to sprains and strains associated with occupation or sports. The evidence for these recommendations comes from selected and appraised guidelines, systematic reviews and major clinical studies and is presented below. INTERVENTIONS Lifestyle interventions Various lifestyle factors may increase the risk of sustaining trauma and lead to an increase in the associated pain and functional limitations. The field of trauma is vast and covers all ages and almost all activities. Therefore, the number of risk factors is great and the list below could be longer. Individual responsibility, as well as legislation and common rules, are needed to prevent and minimise injury. Injuries and their consequences can be prevented by either preventing trauma or by minimising injury following trauma.15e20 Trauma can be prevented by education to avoid risks and by removal of external risk. Avoidance includes education and training programs, obeying the rules and regulations, maintaining adequate physical fitness, using adequate and safe equipment and avoiding drugs and alcohol. Removal of external risks includes modification of the home and workplace environment, safe roads, safe sporting facilities and playgrounds, enforcement of rules and regulations and early identification of domestic violence. Injuries following trauma can be minimised by using protective equipment, by training in avoidance programs, as well as by maintaining adequate physical fitness and bone mass. Recommendations for lifestyle interventions To prevent injuries in childhood there is evidence (see Table 4) to recommend modification of the home environment with regard to the removal of external risks (e.g. safety sockets, stair gates and guards for kitchen appliances). Safe toys and appropriate safety measures for bicycles might prevent injuries. Early education in traffic awareness can reduce the risk of involvement in a traffic accident. Obeying the rules while participating in sports activities might protect the opponent and prevent self-inflicted injuries. To minimise the injury following trauma in childhood there is evidence for the use of protective equipment (child safety seats or booster seats). Early identification of children suffering from abuse might allow professionals to intervene at an early stage. To prevent injuries in youth the recommendations are focussed in particular on those involved in sports and those who drive cars and motorbikes. Special education and training programmes, as well as obeying the rules, seem to reduce the number of
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Table 4. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for lifestyle interventions on the target outcomes. Lifestyle interventions for those at risk
Prevent injuries
Minimise injury
Children Remove external risks Modification of home environment Use correct equipment Use protective equipment Educate to avoid risks Obey the rules Learn cycling, participating in traffic situations, etc Learn swimming Fence pools Nurse home visitation to prevent child abuse Identify children suffering from abuse
IIb þ Ia # IIb þ Ia þ III þ III þ IV þ IV þ III þ Ib þ IE
IIb þ Ia # IIb þ Ia þ III þ III þ IV þ IV þ III þ Ib þ III þ
Youth Remove external risks Encourage use of safety equipment Education & training programmes Maintain adequate physical activity Drugs e education & avoidance Alcohol e laws against consumption or access
Ia þ IIa þ III þ III þ IE III þ
Ia þ IIa þ III þ III þ IE III þ
Working age Remove external risks Modification of home environment Identify risks associated with occupation Safety equipment for sports, occupations, cars, etc. Post-license driver education Maintain adequate physical activity Drugs e education & avoidance Alcohol e laws against consumption or access Early identification of domestic violence
IIa þ Ia # IV þ IV þ Ia 0 III þ III þ III þ IV þ
IIa þ Ia # IV þ IV þ Ia 0 III þ III þ III þ IV þ
Older Removing external risks Modification of home environment Safety equipment Maintain adequate physical activity Falls prevention programme Brisk walking Hip protector Early identification of domestic violence
Ia 0 Ia # Ia þ Ib þ Ia þ Ib Ia # IV þ
Ia 0 Ia # Ia þ Ib þ Ia þ Ib Ia # IV þ
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence.
sports injuries, occupational and traffic-related injuries. Establishment and reinforcement of legal actions against access to and consumption of alcohol and other drugs will reduce the number of injuries. Speed control and avoidance of reckless behaviour is crucial for lowering the number of traffic accidents. To minimise the injury following trauma in youth encouragement of the use of protective equipment in sports and traffic-related activities is helpful. Fast and
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adequate first aid treatment is crucial to the extent and long-term prognosis of the injury. To prevent injuries in those of working age identification of risk factors associated with occupation is crucial. Appropriate safety equipment and adaptation of the work and home environment can reduce the number of accidents. Risk in traffic-related and sports activities needs to be addressed as described above. In this age group, it is especially important to maintain adequate physical activity. This will increase bone mass. Obeying rules and regulations prevents the risk of self-inflicted injuries and damage to others. Avoidance of alcohol and other drugs as well as appropriate participation in traffic-related or occupational activities when taking medication is advisable. To minimise the injury following trauma in those of working age the use of protective equipment is recommended in occupation and sports. Adequate early treatment is essential for the further progress of the injury. To prevent injuries in the older population multi-modal fall prevention programmes, in particular, might reduce the risk of falls. Together with adequate physical activity and bone mass and the removal of external risk factors in the home, these interventions will reduce the risk for fractures. Appropriate control and treatment of cardiovascular and neurological diseases, as well as visual impairment, will allow active participation at home and in public including traffic situations. Avoidance of excessive alcohol and medications can limit the risk for accidents. To minimise the injury following trauma in the older population protective equipment, including hip protectors, have shown to reduce the fracture risk in high-risk subgroups. Early detection of domestic violence might allow for appropriate intervention.
Pharmacological interventions Pharmacological interventions in trauma are mainly used for pain control and for the treatment of inflammation. In addition, prophylaxis against deep vein thrombosis (DVT) and infection should prevent further complications. There is no evidence that pharmacological interventions can prevent injuries.21e28 Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) can reduce pain, especially where the latter have an additional anti-inflammatory effect. Steroid injections and topical NSAIDs might also have a local analgesic and anti-inflammatory effect. There is no strong evidence that dietary supplements have any impact in patients with sports injuries. There is evidence that complications such as thrombosis (antithrombotics), infection (antibiotics) and heterotopic ossification (NSAIDs) can be prevented efficiently by pharmacological interventions. Recommendations for pharmacological interventions There are no recommendations for the use of pharmacological interventions as a preventative measure against trauma. To reduce the impact of pain caused by trauma there is evidence to support the use of analgesics, local and systemic NSAIDs and steroid injections (see Table 5). To reduce trauma-related restriction in activity and participation due to complications such as infection, thrombosis and heterotopic ossification, there is clear evidence that antibiotics can prevent post-injury infection, while antithrombotics can prevent thrombosis and pulmonary embolism and heterotopic bone formation is limited by NSAIDs.
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Table 5. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for pharmacological interventions on the target outcomes. Pharmacological interventions
Aims of intervention Function/structure Tissue damage
Symptom Analgesics NSAIDs
Activity & participation
Symptom pain Iaþ Iaþ
Iaþ Iaþ
Prevention of complications Antithrombotics Antibiotics NSAIDs
Iaþ Iaþ Iaþ
Iaþ Iaþ Iaþ
IVþ IVþ IVþ
Disease process Bone morphogenic protein
Ibþ
Ibþ
Ibþ
Local treatments Topical NSAIDs etc Steroid injections Fibrin Spray Skin substitutes
# þ/ IIaþ IIaþ
Ibþ Ibþ III III
III III III III
Supplements Calcium and vitamin D Glucosamine
Ib # Ib #
Ib #
III # III #
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence. NSAID, non-steroidal anti-inflammatory drugs.
Surgical interventions Surgical interventions for trauma victims can be used to restore structure, reduce pain and reduce both short and long-term disability caused by trauma injuries from accidents, participation in sports or participation in certain occupations.29e42 Reconstruction of soft tissue injury (e.g. cruciate ligaments, achilles tendon) restores structure and reduces long term disability. Reduction and stabilisation of fractures restores structure, reduces pain and improves short and long-term disability. Arthroscopic surgery, compared with open surgical treatment, can reduce short-term disability and allows tissue damage and pain to be reduced by removing the destroyed debris. Prosthetic replacements of severely damaged joints reduce pain and disability and can facilitate early and appropriate activity and participation. Autologous cartilage implantation for full thickness articular cartilage defects of the knee must currently be considered to be a technology under investigation whose effectiveness has yet to be determined in well designed and conducted clinical trials. Recommendations for surgical interventions There are no recommendations for surgical interventions that prevent trauma in the whole population.
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Table 6. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for surgical interventions on the target outcomes. Surgical interventions
Aims of intervention Function/structure
Activity & participation
Tissue damage
Symptom pain
III þ
III þ
III þ
IIa/III þ III þ III þ
IIa/III þ III þ III þ
IIa/III þ III þ III þ
Remove Amputation Foreign bodies Arthroscopic surgery
IV þ IIa þ
III þ IV IIa þ
III þ IV IIa þ
Replace Arthroplasty Bone transplantation Skin transplantation Cartilage transplantation
III þ III þ III #
III þ III þ III þ III #
III III III III
Repair Reconstruction of the tendon, capsule, muscle and ligament Stabilisation of fractures Replantation of limbs Plastic surgery
þ þ þ #
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence.
To reduce the impact of trauma-related pain, the removal of debris, bone, cartilage or meniscal fragments as well as foreign bodies is recommended (see Table 6). There is clear evidence that reconstruction and stabilisation of soft tissue injuries or bone fractures reduces pain. In advanced joint disease with pain, there is clear evidence that arthroplasties, especially hip and knee replacements, will allow for a major reduction of pain. To reduce the impact of trauma-related tissue damage there is evidence that repair of bone and soft tissue lesions by reconstruction of tendons and ligaments, capsules and bones is effective. To reduce the effect of trauma-related impact on activity and participation there is clear evidence that reconstruction, repair or replacement with an arthroplasty can clearly improve the functional status. Rehabilitative interventions Trauma is commonly associated with limited function, which can be improved with a wide variety of rehabilitative interventions aimed at the whole person and not just at the affected structure. The aims of rehabilitation are to manage pain, increase mobility and improve activity.43e49 Appropriate education and self-management, support services and social services as well as braces, aids and devices can prevent injuries or minimise tissue damage. In the acute phase there is clear evidence that PRICE (Protection, Rest, Ice, Compression, Elevation) can limit tissue damage, pain and loss of function. Immobilisation might prevent further tissue damage and pain. Function can be improved by
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Table 7. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for rehabilitative interventions on the target outcomes. Rehabilitation interventions
Aims of intervention Function/structure
Activity & participation
Tissue damage
Symptom pain
Ib þ
Ib þ
Ib þ
þ þ þ þ þ þ
Ib þ Ib þ
III þ
III þ
PRICE (Protection, Rest, Ice, Compression, Elevation) Joint mobilisation Joint-specific exercises Joint immobilisation Physical fitness Braces, aids and devices Support services, social interventions Education & self management
Ib III Ib III
þ þ þ þ
III þ
Ib Ib Ib III Ib III
III þ Ib þ III þ
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence.
a multi-disciplinary approach including joint mobilisation and specific exercises, education and support services as well as improved physical fitness. Recommendations for rehabilitative interventions To prevent trauma, the main recommendation is to maintain a level of physical fitness (see Table 7). Appropriate education and self-management (training in sports, driving lessons in traffic, education on the job) will decrease the number of accidents. To reduce the impact of trauma-related tissue damage and pain protection (braces, aids and devices) are helpful. In the early phase of trauma-related tissue damage and pain immobilisation and rest, ice, compression and elevation is of importance to limit the extent of the damage. In the later phase joint mobilisation, specific exercises and muscle techniques play an important role for protection from further tissue damage due to contractions, muscle weakness and lost proprioception. Functional limitations will be reduced and will allow for appropriate activity and participation. A multi-disciplinary approach to rehabilitation is recommended e.g. so that the patient can return to sport with the ability to enjoy it and prevent further injuries. Health system intervention In trauma, a key aspect that impacts on the outcome of a trauma incident is the structure and resourcing of the local health system. Early and appropriate treatment is the key factor in all of the different areas of injuries.50e52 In sports injuries, RICE (rest, ice, compression and elevation) prevents further tissue damage and allows fast recovery. In repetitive occupational injuries, early intervention can reduce the risk of chronicity. In life-threatening major trauma, appropriate medical treatment (intubation, oxygenation, stabilisation of fractures, fluid restitution) at the scene of the accident improves the chances for survival and long-term functional outcome. All three of the interventions mentioned above require appropriate education and training of the relevant people for early diagnosis and treatment: namely the
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trainers and physiotherapists in sport, superiors in the workplace and the general public for all kinds of accidents. This includes contacting the rescue services promptly in cases of major trauma so that expertise can be provided at the scene of the accident.
Practice points Sports and occupational injuries are a common cause of lower limb pain. The whole working population should be considered to be at risk for occupational musculoskeletal injuries, particularly those exposed to repetitive movements, high force, awkward joint posture, direct pressure, vibration, prolonged constrained posture or psychological factors such as psychological demand, stress, etc. The whole population that participates in physical activity or sport is at risk for sports injuries, particularly those who are physically unfit if they try to do too much, too quickly. As are participants in contact sports, with the wrong body type for the sport, or where the level of expertise and experience differs or where the rules of the sport are not observed. In the rehabilitation phase the risk for a new injury is increased. To prevent occupational injuries risk factors need to be identified and the workplace and organisation of work need to be adapted accordingly, supported by laws. In the early trauma phase accurate diagnosis and treatment including pain management are crucial. Partial work restriction and short-term immobilisation need to be considered, but early return to work is crucial. Based on an understanding of the mechanism of injury, future injuries can be prevent by considering adaptations in the workplace, by transferring the patient to another job or a by a distinct job modification. In addition, participation in accident awareness and prevention campaigns might be beneficial. This includes a multi-disciplinary approach to educate participants on: the importance of physical and psychological fitness the skills and techniques required by the particular work the nutritional requirements of the sports events correct clothing and protective equipment obeying the rules To prevent sports injuries it is important to maintain physical fitness, to be trained to use the correct technique under adequate supervision and in appropriate facilities. In addition the wearing of protective equipment and obeying the rules are key elements of the prevention strategy. In the early phase of a sports injury, the first step is to immediately remove the player from the field to prevent further injury. First treatment includes RICE (rest, ice, compression and elevation) and non-steroidal anti-inflammatory drugs (NSAIDs). An early, correct diagnosis has to be based on a competent clinical examination with, if indicated, imaging, and is crucial for prognosis.
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Operative reconstruction of the tendons, capsule and ligaments needs to be considered, as well as operative or non-operative stabilisation of fractures. A multi-disciplinary approach to the care of athletes should involve the coach, physiotherapist, physician, physiologist, psychologist, nutritionist, podiatrist and biomechanics specialist. In the late phase, prompt and adequate rehabilitation is necessary, in order to correct any predisposing problems. Before returning to practise, the individual must be pain free and have the muscle strength and skill required by the sport. Based on an understanding of the rules, the physiological stresses and the possible mechanisms for injury, adaptations to both training and technique need to be considered.
Research agenda Population-based studies and well designed prospective cohort studies are necessary to identify the true burden of occupational and sports injuries. More controlled trials are necessary to extend the already existing knowledge with regard to the aetiology, prevention and treatment of occupational and sports injuries of the lower extremities. When studying the effectiveness of prevention and treatment efforts, special emphasis should be given to a clear description of the characteristics of the disorder and study population and also to the content of the interventions.
REFERENCES 1. Public Use File BGS98 Bundes-Gesundheitssurvey 1998. Berlin: Robert Koch-Institut, 2000. 2. Baker P, Coggon D, Reading I et al. Sports injury, occupational physical activity, joint laxity, and meniscal damage. The Journal of Rheumatology 2002; 29(3): 557e563. 3. Baker P, Reading I, Cooper C & Coggon D. Knee disorders in the general population and their relation to occupation. Occupational and Environmental Medicine 2003; 60(10): 794e797. *4. Pleacher MD & Glazer JL. Lower extremity soft tissue conditions. Current Sports Medicine Reports 2005; 4(5): 255e261. 5. Mahieu NN, Witvrouw E, Stevens V et al. Intrinsic risk factors for the development of achilles tendon overuse injury: a prospective study. The American Journal of Sports Medicine 2006; 34(2): 226e235. 6. Krishna Sayana M & Maffulli N. Insertional Achilles tendinopathy. Foot and Ankle Clinics 2005; 10(2): 309e320. 7. Harmon KG. Lower extremity stress fractures. Clinical Journal of Sport Medicine 2003; 13(6): 358e364. 8. Vahasarja V. Prevalence of chronic knee pain in children and adolescents in northern Finland. Acta Paediatrica 1995; 84(7): 803e805. 9. Bundesanstalt fu¨r Arbeitsschutz und Arbeitsmedizin. Unfalltote und Unfallverletzte in Deutschland. Dortmund, 2006. 10. Statistisches Bundesamt (ed). Gesundheit e Ausgaben, Krankheitskosten und Personal 2004. Wiesbaden: Statistisches Bundesamt, 2006. 11. Bundesministerium fu¨r Arbeit und Soziales (ed). Sicherheit und Gesundheit bei der Arbeit 2004. Berlin: Bundesanstalt fu¨r Arbeitsschutz und Arbeitsmedizin, 2005.
Lower limb pain 151 *12. Meerding WJ, Mulder S & van Beeck EF. Incidence and costs of injuries in The Netherlands. European Journal of Public Health 2006; 16(3): 272e278. 13. van Mechelen WI. Incidence and severity of sports injuries. In Renstrom P (ed). Sports Injuries: Basic Principles of Prevention and Care. London: Blackwell Publishing, 1993, pp. 3e15. *14. European Commission. European social statistics: Accidents at work and work-related health problems. Luxembourg: European Communities, 2002. Available at: http://ec.europa.eu/employment_social/ health_safety/docs/social_statistics_1994_2000_en.pdf#search¼%22Accidents%20at%20work%20 and%20work-related%20health%20problems%22. 15. Bass JL, Christoffel KK, Widome M et al. Childhood injury prevention counselling in primary care settings: a critical review of literature. Paediatrics 1993; 92: 544e550. 16. McNamee R, Kemmlert K, Lundholm L et al. Injuries after falls at work in the United Kingdom and Sweden with special reference to fractures in women over 45. Occupational and Environmental Medicine 1997; 54: 785e792. *17. Speller V, Mulligan JA, Jaw C & Foot B. Preventing Injury in Children and Young People: A Review of the Literature and Current Practice. Winchester: Wessex Institute of Public Health Medicine, 1995, pp. 1e61. 18. Lyons RA, Sander LV, Weightman AL et al. Modification of the home environment for the reduction of injuries (Cochrane Review). In The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons, Ltd., 2004. 19. DiScala C, Lescohier I, Barthel M & Li G. Injuries to children with attention hyperactivity disorder. Pediatrics 1998; 102(6): 15e21. 20. Handoll HHG, Rowe BH, Quinn KM & de Bie R. Interventions for preventing ankle ligament injuries (Cochrane Review). In The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons, Ltd., 2004. 21. Neal B, Rodgers A, Dunn L & Fransen M. Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty (Cochrane Review). In The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons, Ltd., 2004. 22. Gillespie WJ & Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures (Cochrane Review). In The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons, Ltd., 2004. 23. Cohen SP, Christo PJ & Moroz L. Pain management in trauma patients. American Journal of Physical Medicine & Rehabilitation 2004; 83(2): 142e161. 24. Bolin DJ. Transdermal approaches to pain in sports injury management. Current Sports Medicine Reports 2003; 2(6): 303e309. 25. Maughan RJ, King DS & Lea T. Dietary supplements. Journal of Sports Sciences 2004; 22(1): 95e113. 26. Powers SK, DeRuisseau KC, Quindry J & Hamilton KL. Dietary antioxidants and exercise. Journal of Sports Sciences 2004; 22(1): 81e94. 27. Fillmore CM, Bartoli L, Bach R & Park Y. Nutrition and dietary supplements. Physical Medicine and Rehabilitation Clinics of North America 1999; 10(3): 673e703. 28. Moore RA, Tramer MR, Carroll D et al. Quantitative systematic review of topically applied non-steroidal anti-inflammatory drugs. British Medical Journal 1998; 316(7128): 333e338. 29. Allen CR, Griffin JR & Harner CD. Revison anterior cruciate ligament reconstruction. The Orthopedic Clinics of North America 2003; 34(1): 79e98. 30. Blyth MJ, Gosal HS, Peake WM & Bartlett RJ. Anterior cruciate ligament reonstruction in patients over the age of 50 years: 2- to 8-year follow-up. Knee Surgery, Sports Traumatology, Arthroscopy 2003; 11(4): 204e211. 31. Brittberg M, Lindahl A, Homminga G et al. A critical analysis of cartilage repair. Acta Orthopaedica Scandinavica 1997; 68(2): 186e191. 32. Chartain F, Adeleine P, Chambat P & Neyret P. Societe Francaise d’Artroscopie. A comparative study of medial versus lateral arthroscopic partial medniscectomy on stable knees: a 10-year minimum followup. Arthroscopy 2003; 19(8): 842e849. 33. Gobbi A, Majahan S, Zanazzo M & Tuy B. Patellar tendon versus quadrupled bone-semitendinosus anterior cruciate ligament reconstruction. Arthroscopy 2003; 19(6): 592e601. 34. Lo IK, Kirkley A, Nonweiler B & Kumbhare DA. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review. Clinical Journal of Sport Medicine 1997; 7(3): 207e211. 35. Messner K & Gillquist J. Cartilage repair. A critical review. Acta Orthopaedica Scandinavica 1996; 67(5): 523e529.
152 K. E. Dreinho¨fer et al 36. Neumeister MW, Brown RE. Mutilating hand injuries: principles and management. Hand Clinics Feb; 19(1): 1e15. 37. Rauh PB, Papoutsikakis A, Vlachonikolisi IG & Craig DM. Revision arthroscopic partial meniscectomy of the knee. A retrospective review. Acta Orthopaedica Belgica 2003; 69(2): 168e174. 38. Schaefer DJ, Klemt C, Zhang XH & Stark GB. Tissue engineering with mesenchymal stem cells for cartilage and bone regeneration. Der Chirurg; Zeitschrift fu¨r alle Gebiete der operativen Medizen 2000; 71(9): 1001e1008 [In German]. 39. Shea KG, Apel PJ & Pfeiffer RP. Anterior cruciate ligament injury in paediatric and adolescent patients: a review of basic science and clinical research. Sports Medicine (Auckland, N.Z.) 2003; 33(6): 455e471. 40. Su EP & Healy JH. Salvage reconstruction for lateral ankle instability using a tendon graft. Clinical Orthopaedics 2003; 415: 232e238. 41. Wasiak J & Villanueva E. Autologous cartilage implantation for full thickness articular cartilage defects of the knee (Cochrane Review). In The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons, Ltd., 2004. 42. Wilhelmi BJ, Lee WP, Pagensteert GI & May Jr JW. Replanation of the mutilated hand. Hand Clinics 2003; 19(1): 89e120. 43. Dogra AS & Rangan A. Early mobilisation versus immobilisation of surgically treated ankle fractures. Prospective randomised control trial. Injury 1999; 30(6): 417e419. 44. Kerkhoffs GMMJ, Handoll HHG, de Bie R et al. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults (Cochrane Review). In The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons, Ltd., 2004. 45. Kerkhoffs GMMJ, Struijs PAA, Marti RK et al. Different functional treatment strategies for acute lateral ankle ligament injuries in adults (Cochrane Review). In The Cochrane Library, Issue 1. Chichester, UK: John Wiley & Sons, Ltd., 2004. 46. Kartus J, Stener S, Kohler K et al. Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow up of 78 consecutive patients rehabilitated with or without a brace. Knee Surgery, Sports Traumatology, Arthroscopy 1997; 5: 157e161. 47. Kannus P. Types of injury prevention and care, Encyclopedia of Sports Medicine. Oxford: Book Science, 1993. *48. Kinch M. Principles of Rehabilitation. In Bruckner P (ed). Clinical Sports Medicine. 2 edn. McGraw-Hill Publishing Co, 2001. *49. Garrett Jr. WE, Speer KP & Kirkendale DT. Principles and Practice of Orthopaedic Sports Medicine. Philadelphia: Lippincott, Williams and Wilkins, 2000. *50. Best T & MacAuley D. Evidence-based Sports Medicine. London: Blackwell BMJ Books, 2002. *51. European Agency for Safety and Health at Work. Good Practice. Accident Prevention. Available at: http://europe.osha.eu.int/good_practice/risks/accident_prevention/index_html. *52. Bundesa¨rztekammer. Verletzungen und deren Folgen e Pra¨vention als a¨rztliche Aufgabe. Texte und Materialien der Bundesa¨rztekammer zu Fortbildung und Weiterbildung, Band 23, 2001. 53. European Action Towards Better Musculoskeletal Health: A Public Health Strategy to Reduce the Burden of Musculoskeletal Conditions. A Bone and Joint Decade Report, 2004. The European Bone and Joint Health Strategies Project. The Bone and Joint Decade, Lund, Sweden. Available at: http://ec.europa.eu/health/ph_projects/2000/promotion/fp_promotion_2000_frep_15_en.pdf.
9 Lower limb pain Karsten E. Dreinho¨fer*
MD
Deputy Head
Heiko Reichel
MD
Professor, Head of the Department
Wolfram Ka¨fer
MD
Consultant Department of Orthopaedics, Ulm University, Oberer Eselsberg 45, D-89081 Ulm, Germany
This article summarises lower limb pathology, which results in lower limb pain. It mainly addresses injuries and deliberately omits osteoarthritis and rheumatoid arthritis, since these entities are described in detail in other chapters in this volume. As major trauma is not a focal point for rheumatologists and repetitive strain injuries of the lower limb are rare, sports and leisure injuries are the main focus. Regarding lower limb pain, this chapter describes the most important problems and quantifies the size of the problem. Furthermore, it informs the reader about different treatment modalities, their goals and methods of measuring the effectiveness of the treatment. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence. Key words: lower limb pain; sports injuries; work-related lower extremity disorders; clinical manifestations; risk factors; prevention; treatment.
INTRODUCTION Lower limb pain is a common complaint with many possible causes. In the last 12 months, one in three people will have reported some pain in their lower extremities.
* Corresponding author. Tel.: þ49 731 177 1107; Fax: þ49 731 177 1118. E-mail address: [email protected] (K.E. Dreinho¨fer). 1521-6942/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved.
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While joint diseases and other disorders are discussed elsewhere, in this chapter the focus will be on sports and occupational injuries as a cause for lower limb pain. There is a wide spectrum of trauma and injuries that affect the musculoskeletal system in general, and the lower limb specifically, in terms of the cause, the structural damage and the outcome. For the purposes of this review, musculoskeletal trauma and injuries will be considered in the context of occupational and sports injuries only. This chapter will describe the most important pathologies and quantify the size of the problem. Furthermore, drawing on the European Action for Better Musculoskeletal Health report,53 it will provide information on different treatment modalities, their goals and methods for measuring their effectiveness. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence. WHAT ARE THE MOST IMPORTANT PROBLEMS? Many specific conditions may cause chronic or recurrent lower limb pain (see Table 1). The most common joint diseases (osteoarthritis (OA) and rheumatoid arthritis (RA)) have not been included in the table. The focus of this chapter is on musculoskeletal trauma and injuries. A wide spectrum of trauma and injuries affect the musculoskeletal system in terms of cause, structural damage and outcome. Trauma and injuries can be considered, for the purposes of this chapter, in the context of (a) major limb trauma, (b) occupational injuries and (c) sports injuries. The latter two causes will be primarily considered. Hip pain Self-reported hip pain is common. In a German health interview survey the prevalence over a 12 month period was 10% for those aged between 20 and 40 years, but more than 30% in patients aged over 60 years.1 Whilst most of the joint pain, especially in the elderly, would have been caused by degenerative joint disease, peri-articular pain and tight pain might indicate, especially in the younger participants, an injury-related problem. Knee pain In a British study, the lifetime prevalence for knee symptoms in adult men was 54%. Symptoms were strongly associated with meniscal lesions. Meniscal tear was strongly associated with participation in sports during the 12 months preceding the onset of symptoms; the risk was particularly high for soccer. Higher body mass index and occupational kneeling and squatting were associated with an increased risk of degenerative meniscal lesions, after adjustment for social class, joint laxity and sports participation.2,3 Musculoskeletal injuries The majority of sports injuries are similar to injuries that normally occur in nonathletes, but they have occurred during sporting activities. Many injuries are common to a variety of sports, but others are sport-specific. Injuries occurring in sports and
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physical activities are usually mild and many are never reported. More severe injuries may either be acute, chronic or overuse injuries. In this chapter we will only consider sports injuries to the musculoskeletal system that would require medical attention, either in a casualty department, or from a doctor or physiotherapist. They include strains, sprains, dislocations, fractures and lacerations. These injuries cause pain, loss of function and affect quality of life. They may result in loss of training or competition or absence from work. Lower extremity soft tissue injuries and overuse conditions are commonly encountered in athletes. Muscles are frequently strained or contused; tendons and bursae can become inflamed. Overuse injuries are the result of an excessive stress applied to normal tissue and the failure of normal adaptation. Tendons are the most common sites for such injuries; however, the joint, cartilage, bursae and bone can all be affected.4 Typical examples are anterior knee pain and Sever’s Disease, affecting the posterior aspect of the calcaneus where the Achilles tendon is fixed to the calcaneal apophyses.5,6 Stress fractures can result from normal stress applied to a weak or structurally deficient bone or from repetitive, excessive force applied to a normal bone.7
WHAT IS THE SIZE OF THE PROBLEM? Lower limb pain is common among adults across Europe, with one out of three men and one out of two women experiencing some pain in this region over a 12 month period.1 While there is a clear age-dependent increase in incidence, indicating that a large number of cases may be caused by underlying degenerative joint diseases, injuries are a common reason for lower limb pain. In Finland, 45% of schoolchildren aged 9e15 years reported moderate to severe disability attributed to lower limb pain during a three month period.8 About 9 million people in Germany (11.0% of the population), have an accident each year and injuries to the upper and lower limbs are found in more than 70% of these accidents. The incidence of trauma to an extremity depends on several factors such as sex, age and the cause of the accident. Home (32%) and leisure injuries (31%) accounted for most of the cases, followed by school (17%) and occupational injuries (15%). Traffic accidents accounted for about 5% of all injuries.9 Of the 5.4 million accidents at home or at leisure, 27% were sports injuries, with one in two of these affecting the lower limbs, while 13% of the home and leisure injuries required hospital treatment in 2000.9 Trauma is responsible for a huge socioeconomic burden, magnified by many years of lost productivity and lost income for the patient. Costs associated with trauma include the direct costs of the trauma system, hospital and physician, as well as the indirect costs for rehabilitation and lost productivity. In Germany, the direct costs (prevention, hospital care, rehabilitation) caused by trauma are estimated to be about V11 billion, representing 4.8% of the total health care costs.10 A significant portion of these costs is due to hospital treatment. In addition, trauma is one of the most important causes for disablement in Germany (1.1 million lost working years, equating to 20% of overall disablement). The loss of productivity is estimated to be V9 billion, equalling 0.5% of the gross national income.11 In the Netherlands in 1999, the total health care cost due to injury were V1.15 billion, or 3.7% of the total health care budget.12
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Table 1. Causes of lower limb pain. A. General B Overuse injuries B Stress fracture B Haematoma B Open wound B Bruises B. Hip pain - Children and adolescents B Acute transient synovitis B Slipped capital femoral epiphysis B Perthes disease B Congenital dysplasia of the hip B Strains or tendonitis (Mm. adductor longus, rectus femoris, iliopsoas) B Avulsion fracture B Tumours - Adults B Avascular necrosis B Transient osteoporosis B Fracture B Septic arthritis B Bursitis B Piriformis syndrome B Strains or tendonitis (Mm. adductor longus, rectus femoris, iliopsoas) B Tumors B Metastases C. Knee pain - Anterior B Patellofemoral syndrome B Osgood Schlatter disease B Osteochondritis dissecans B Chondromalacia patellae - Posterior B Baker cyst B Fabella syndrome B Gastrocnemius tendonitis B Hamstring tendonitis or chronic strain - Medial B Medial meniscal tear B Medial plica B Pes anserinus bursitis or tendonitis B Semimembranosus bursitis or tendonitis B Ganglion - Lateral B Lateral meniscus B Iliotibial band friction B Popliteus tendinitis - Others B Tumors (e.g. osteosarcoma, Ewing sarcoma, synovial sarcoma) B Systemic (connective tissue disease, sickle cell arthropathy, leukaemia) B Referred - Adolescent (slipped capital femoral epiphysis, Legg-Calve´-Perthes, spinal tumors) - Adult (osteoarthritis hip, spinal problems)
Lower limb pain 139 Table 1 (continued) BInfection BReflex sympathetic dystrophy D. Foot pain - Ankle pain B Sprained ankle ligaments B Impingement syndrome B Osteochondrosis dissecans - Heel pain B Sever’s disease B Achilles tendinitis B Enthesitis e AS B Haglunds deformity B Plantar fasciitis B Peroneal tendonitis or subluxation B Retrocalcaneal bursitis B Reflex sympathetic dystrophy B Tibialis posterior tendonitis - Midfoot pain B Plantar fibromatosis B Tarsal tunnel syndrome B Tarsal coalition B Posterior tibialis dysfunction B Tarsometatatarsal arthritis - Forefoot pain B MTP 1 pathology (Hallux valgus, Hallux rigidus) B Gout (podagra) B Plantar plate disruption B Sesamoiditis B Bursitis intermetatarsal B Morton’s neuroma B Ganglion B Stress fracture B Foreign body granulomas - Others B Tumors B Systemic (connective tissue disease, sickle cell arthropathy, leukaemia) B Infection B Reflex sympathetic dystrophy B Diabetic foot
Excluded B Osteoarthritis B Rheumatoid arthritis AS, Achilles tendon; MTP 1, metatarsophalangeal.
Sport injuries The increased involvement of people in sport at both recreational and professional levels has resulted in a greater incidence of sports injuries, a large proportion of which are preventable. The incidence and types of sports injuries vary greatly depending on the sport, the number of people participating and the hours played. In some sports,
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where high speeds and forces are encountered, there is a much higher risk of serious injury. The potential risks for injuries in sports seem to increase, for all levels of athletes, with increasing participation, intensity and demands, as well as with longer training periods. Statistics on the incidence of sports injuries are inadequate and difficult to compare. Many studies on the incidence of sports injuries in a particular sport or group of athletes use different definitions of incidence. These vary from (a) days lost from training and sport (the American National Athletic Injury Registration System (NAIRS), to (b) a definition that limits athletic participation for at least the day after the day of onset, to (c) the attendance at casualty or at a doctors surgery, to (d) an insurance claim. A definition that takes all these factors into consideration is: incidence ¼ (number of sports injuries/year)/(number of participants) (average hours of sports participation) (weeks of season/year).13 According to the EU Injury Database (IDB) sports injuries account for about 20% of all ‘‘home and leisure accidents’’ in 2002e2004. In Germany 2.0 million sports injuries require medical attention and cost 4 billion Euros annually.a In Europe, the overall sports injury incidence was found to vary between one and five per 1.000 hours spent playing or in a different perspective 10e15 per 100 personyears practising sports. About thirty per thousand of the total population or about sixty per thousand sports participants sustain per year a sports injury severe enough to require medical attention. Hospital admissions in Europe vary around five per thousand sports participants per year and represent around 5% of hospitalizations for all injuries.b Occupational injuries The third European Survey on Working Conditions (2000) has revealed that 33% of European workers have backache complaints, 23% have neck and shoulder pains, 13% upper limb pains and 12% lower limb pains.14 In Britain, almost 10 million working days are lost each year due to work-related musculoskeletal disorders. Of these, over 2 million lost days are caused by leg disorders. The UK estimate for the medical costs for work-related musculoskeletal disorders was between £84 and £254 million sterling, of which £17 to £55 million was spent on workrelated lower limb disorders. WHO IS MOST AT RISK? There are many risk factors for the occurrence of injuries (Table 2). Different factors are important depending on age, environment and main activities. In the young, risk factors in the home environment (toys, kitchen, animals, etc), games (playground, swimming, etc), traffic (bikes, cars, etc) and in the family (domestic violence, angry parent syndrome) dominate. In the adolescent, participation in sports, traffic-related and other dangerous activities are the main risks, aggravated by alcohol, recreational drugs and inappropriate self-control. a
https://webgate.cec.ei.int/idb/ Sports Injuries in the EU countries in view of the 2004 Olympics: Harvesting the information from existing databases (PHASE I), VS/1999/5311 (99CVF3-319), Athens 2001. b
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Table 2. Risk factors for the occurrence of trauma and injuries. Children
Youth
Working age
Old age
Unsafe homes (electricity, oven, etc) Unsafe playgrounds and swimming pools Participation in traffic-related situations
Contact sports (mismatched competitors) Unsafe sports facilities
Contact sports (mismatched competitors) Unsafe sports facilities
Late first-time participation in potentially dangerous activities Not-using protective gear correctly
Participation in dangerous activities (parachuting, hang gliding, boats, etc) Not-using protective gear correctly
Participation in dangerous activities (parachuting, hang gliding, boats, etc) Late first-time participation in potentially dangerous activities Unsafe workplace
Inappropriate and mismatched experience
Skateboards, rollerblades, bicycle Unsafe toys
Animals Inability to swim
Hyperactivity (ADHD) Clumsiness
Angry parent syndrome Domestic violence Low socioeconomic level
Inappropriate training and technique (inexperience, overuse, etc) Inadequate obeying of rules Inadequate enforcement of rules Inappropriate and mismatched experience Environmental factors (e.g. climate, weather, temperature) Clumsiness Hyperactivity (ADHD) Alcohol, recreational drugs, drugs Low socio-economic level
Not-using protective gear correctly Inappropriate training and technique (inexperience, overuse, etc) Inappropriate and mismatched experience Inadequate obeying of rules Inadequate enforcement of rules Alcohol, recreational drugs, drugs Stress
Inadequate obeying of rules
Environmental factors (e.g. climate, weather, temperature)
Alcohol, recreational drugs, drugs Medication
Reduced bone strength Concomitant diseases
Malnutrition (e.g. diabetes)
Low socio-economic level
ADHD, attention deficit hyperactivity disorder.
In the working age population, occupational risk factors (inappropriate protection, training, etc) supplement the risks in traffic, sports and leisure activities. In old age, reduced physical fitness, reduced bone mass, concomitant diseases and medication increase the risk for injuries at home (unsafe homes) or in public (traffic). In general, inappropriate risk awareness is the main problem. On a personal level, inappropriate training, experience and physical fitness, inadequate protection, inadequate obedience to rules are the key risk factors for the occurrence of trauma. The
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effects of alcohol and drugs decrease the internal control mechanisms and increase the risk for injuries. On a generic level, unsafe public or private environments might add further risk factors. Factors predisposing subjects to overuse injuries appear to be the intensity, volume and tempo of the activity. Such injuries are seen in the well-conditioned, as well as in the poorly conditioned, athlete. Following a traumatic event different determinants have an impact on the outcome of the injury (Table 3). In general, inadequate, delayed or inappropriate treatment and rehabilitation can lead to worse outcomes. On a personal level, age, overweight, comorbidities and complications as well as additional medication, drugs, alcohol and smoking all have an important influence on the final outcome. In addition socialeconomic factors (e.g. medico-legal compensation) play an important role. CAN LOWER LIMB PAIN BE PREVENTED AND/OR TREATED EFFECTIVELY? There is a wide spectrum of trauma and injuries that affect the musculoskeletal system in terms of the cause, the structural damage and the outcome. The nature of trauma differs from that of the other conditions considered in this volume, since interventions need to be adapted to the individual trauma phase. This chapter therefore follows a slightly different format. The populations that have been used to assess the evidence and form a basis for the recommendations and strategies are defined as: Normal: The whole population at all ages At risk: Children (0e16), especially those in the playground and household environments Youth (17e25), especially those involved in sports and in traffic situations Working age population (25e65), especially those involved in sports and high risk occupations Older people (65 plus), especially those at risk of falls In addition, any individuals with identified risk factors within the above age bands Early phase: Encompasses the acute phase of injury to the tissue healing and repair phase. Late phase: Encompasses chronic symptoms and disability attributable to injury.
Table 3. Risk factors and determinants for outcome of trauma and injuries. Severity of injuries Old age Overweight Co-morbidity Poor nutrition Immobility Infection Thrombosis/pulmonary embolism Alcohol Smoking
Medication Environmental factors Delayed therapy Transportation of victims Inadequate therapy Inadequate rehabilitation Inadequate compliance with medical advice Medicolegal compensation Socio-economic factors
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The targets for interventions are: 1. 2. 3. 4. 5.
To To To To To
prevent injuries related to trauma by preventing trauma. minimise injury following trauma. restore structure. reduce pain and other symptoms. reduce short and long term disability.
The evidence for different interventions will be considered in the context of the agreed targets for the prevention and treatment of musculoskeletal injuries and for the populations that the evidence applies to. Injuries range from major limb trauma to sprains and strains associated with occupation or sports. The evidence for these recommendations comes from selected and appraised guidelines, systematic reviews and major clinical studies and is presented below. INTERVENTIONS Lifestyle interventions Various lifestyle factors may increase the risk of sustaining trauma and lead to an increase in the associated pain and functional limitations. The field of trauma is vast and covers all ages and almost all activities. Therefore, the number of risk factors is great and the list below could be longer. Individual responsibility, as well as legislation and common rules, are needed to prevent and minimise injury. Injuries and their consequences can be prevented by either preventing trauma or by minimising injury following trauma.15e20 Trauma can be prevented by education to avoid risks and by removal of external risk. Avoidance includes education and training programs, obeying the rules and regulations, maintaining adequate physical fitness, using adequate and safe equipment and avoiding drugs and alcohol. Removal of external risks includes modification of the home and workplace environment, safe roads, safe sporting facilities and playgrounds, enforcement of rules and regulations and early identification of domestic violence. Injuries following trauma can be minimised by using protective equipment, by training in avoidance programs, as well as by maintaining adequate physical fitness and bone mass. Recommendations for lifestyle interventions To prevent injuries in childhood there is evidence (see Table 4) to recommend modification of the home environment with regard to the removal of external risks (e.g. safety sockets, stair gates and guards for kitchen appliances). Safe toys and appropriate safety measures for bicycles might prevent injuries. Early education in traffic awareness can reduce the risk of involvement in a traffic accident. Obeying the rules while participating in sports activities might protect the opponent and prevent self-inflicted injuries. To minimise the injury following trauma in childhood there is evidence for the use of protective equipment (child safety seats or booster seats). Early identification of children suffering from abuse might allow professionals to intervene at an early stage. To prevent injuries in youth the recommendations are focussed in particular on those involved in sports and those who drive cars and motorbikes. Special education and training programmes, as well as obeying the rules, seem to reduce the number of
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Table 4. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for lifestyle interventions on the target outcomes. Lifestyle interventions for those at risk
Prevent injuries
Minimise injury
Children Remove external risks Modification of home environment Use correct equipment Use protective equipment Educate to avoid risks Obey the rules Learn cycling, participating in traffic situations, etc Learn swimming Fence pools Nurse home visitation to prevent child abuse Identify children suffering from abuse
IIb þ Ia # IIb þ Ia þ III þ III þ IV þ IV þ III þ Ib þ IE
IIb þ Ia # IIb þ Ia þ III þ III þ IV þ IV þ III þ Ib þ III þ
Youth Remove external risks Encourage use of safety equipment Education & training programmes Maintain adequate physical activity Drugs e education & avoidance Alcohol e laws against consumption or access
Ia þ IIa þ III þ III þ IE III þ
Ia þ IIa þ III þ III þ IE III þ
Working age Remove external risks Modification of home environment Identify risks associated with occupation Safety equipment for sports, occupations, cars, etc. Post-license driver education Maintain adequate physical activity Drugs e education & avoidance Alcohol e laws against consumption or access Early identification of domestic violence
IIa þ Ia # IV þ IV þ Ia 0 III þ III þ III þ IV þ
IIa þ Ia # IV þ IV þ Ia 0 III þ III þ III þ IV þ
Older Removing external risks Modification of home environment Safety equipment Maintain adequate physical activity Falls prevention programme Brisk walking Hip protector Early identification of domestic violence
Ia 0 Ia # Ia þ Ib þ Ia þ Ib Ia # IV þ
Ia 0 Ia # Ia þ Ib þ Ia þ Ib Ia # IV þ
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence.
sports injuries, occupational and traffic-related injuries. Establishment and reinforcement of legal actions against access to and consumption of alcohol and other drugs will reduce the number of injuries. Speed control and avoidance of reckless behaviour is crucial for lowering the number of traffic accidents. To minimise the injury following trauma in youth encouragement of the use of protective equipment in sports and traffic-related activities is helpful. Fast and
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adequate first aid treatment is crucial to the extent and long-term prognosis of the injury. To prevent injuries in those of working age identification of risk factors associated with occupation is crucial. Appropriate safety equipment and adaptation of the work and home environment can reduce the number of accidents. Risk in traffic-related and sports activities needs to be addressed as described above. In this age group, it is especially important to maintain adequate physical activity. This will increase bone mass. Obeying rules and regulations prevents the risk of self-inflicted injuries and damage to others. Avoidance of alcohol and other drugs as well as appropriate participation in traffic-related or occupational activities when taking medication is advisable. To minimise the injury following trauma in those of working age the use of protective equipment is recommended in occupation and sports. Adequate early treatment is essential for the further progress of the injury. To prevent injuries in the older population multi-modal fall prevention programmes, in particular, might reduce the risk of falls. Together with adequate physical activity and bone mass and the removal of external risk factors in the home, these interventions will reduce the risk for fractures. Appropriate control and treatment of cardiovascular and neurological diseases, as well as visual impairment, will allow active participation at home and in public including traffic situations. Avoidance of excessive alcohol and medications can limit the risk for accidents. To minimise the injury following trauma in the older population protective equipment, including hip protectors, have shown to reduce the fracture risk in high-risk subgroups. Early detection of domestic violence might allow for appropriate intervention.
Pharmacological interventions Pharmacological interventions in trauma are mainly used for pain control and for the treatment of inflammation. In addition, prophylaxis against deep vein thrombosis (DVT) and infection should prevent further complications. There is no evidence that pharmacological interventions can prevent injuries.21e28 Analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) can reduce pain, especially where the latter have an additional anti-inflammatory effect. Steroid injections and topical NSAIDs might also have a local analgesic and anti-inflammatory effect. There is no strong evidence that dietary supplements have any impact in patients with sports injuries. There is evidence that complications such as thrombosis (antithrombotics), infection (antibiotics) and heterotopic ossification (NSAIDs) can be prevented efficiently by pharmacological interventions. Recommendations for pharmacological interventions There are no recommendations for the use of pharmacological interventions as a preventative measure against trauma. To reduce the impact of pain caused by trauma there is evidence to support the use of analgesics, local and systemic NSAIDs and steroid injections (see Table 5). To reduce trauma-related restriction in activity and participation due to complications such as infection, thrombosis and heterotopic ossification, there is clear evidence that antibiotics can prevent post-injury infection, while antithrombotics can prevent thrombosis and pulmonary embolism and heterotopic bone formation is limited by NSAIDs.
146 K. E. Dreinho¨fer et al
Table 5. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for pharmacological interventions on the target outcomes. Pharmacological interventions
Aims of intervention Function/structure Tissue damage
Symptom Analgesics NSAIDs
Activity & participation
Symptom pain Iaþ Iaþ
Iaþ Iaþ
Prevention of complications Antithrombotics Antibiotics NSAIDs
Iaþ Iaþ Iaþ
Iaþ Iaþ Iaþ
IVþ IVþ IVþ
Disease process Bone morphogenic protein
Ibþ
Ibþ
Ibþ
Local treatments Topical NSAIDs etc Steroid injections Fibrin Spray Skin substitutes
# þ/ IIaþ IIaþ
Ibþ Ibþ III III
III III III III
Supplements Calcium and vitamin D Glucosamine
Ib # Ib #
Ib #
III # III #
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence. NSAID, non-steroidal anti-inflammatory drugs.
Surgical interventions Surgical interventions for trauma victims can be used to restore structure, reduce pain and reduce both short and long-term disability caused by trauma injuries from accidents, participation in sports or participation in certain occupations.29e42 Reconstruction of soft tissue injury (e.g. cruciate ligaments, achilles tendon) restores structure and reduces long term disability. Reduction and stabilisation of fractures restores structure, reduces pain and improves short and long-term disability. Arthroscopic surgery, compared with open surgical treatment, can reduce short-term disability and allows tissue damage and pain to be reduced by removing the destroyed debris. Prosthetic replacements of severely damaged joints reduce pain and disability and can facilitate early and appropriate activity and participation. Autologous cartilage implantation for full thickness articular cartilage defects of the knee must currently be considered to be a technology under investigation whose effectiveness has yet to be determined in well designed and conducted clinical trials. Recommendations for surgical interventions There are no recommendations for surgical interventions that prevent trauma in the whole population.
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Table 6. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for surgical interventions on the target outcomes. Surgical interventions
Aims of intervention Function/structure
Activity & participation
Tissue damage
Symptom pain
III þ
III þ
III þ
IIa/III þ III þ III þ
IIa/III þ III þ III þ
IIa/III þ III þ III þ
Remove Amputation Foreign bodies Arthroscopic surgery
IV þ IIa þ
III þ IV IIa þ
III þ IV IIa þ
Replace Arthroplasty Bone transplantation Skin transplantation Cartilage transplantation
III þ III þ III #
III þ III þ III þ III #
III III III III
Repair Reconstruction of the tendon, capsule, muscle and ligament Stabilisation of fractures Replantation of limbs Plastic surgery
þ þ þ #
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence.
To reduce the impact of trauma-related pain, the removal of debris, bone, cartilage or meniscal fragments as well as foreign bodies is recommended (see Table 6). There is clear evidence that reconstruction and stabilisation of soft tissue injuries or bone fractures reduces pain. In advanced joint disease with pain, there is clear evidence that arthroplasties, especially hip and knee replacements, will allow for a major reduction of pain. To reduce the impact of trauma-related tissue damage there is evidence that repair of bone and soft tissue lesions by reconstruction of tendons and ligaments, capsules and bones is effective. To reduce the effect of trauma-related impact on activity and participation there is clear evidence that reconstruction, repair or replacement with an arthroplasty can clearly improve the functional status. Rehabilitative interventions Trauma is commonly associated with limited function, which can be improved with a wide variety of rehabilitative interventions aimed at the whole person and not just at the affected structure. The aims of rehabilitation are to manage pain, increase mobility and improve activity.43e49 Appropriate education and self-management, support services and social services as well as braces, aids and devices can prevent injuries or minimise tissue damage. In the acute phase there is clear evidence that PRICE (Protection, Rest, Ice, Compression, Elevation) can limit tissue damage, pain and loss of function. Immobilisation might prevent further tissue damage and pain. Function can be improved by
148 K. E. Dreinho¨fer et al
Table 7. Summary of the level of evidence from selected and appraised guidelines, systematic reviews and major clinical studies for rehabilitative interventions on the target outcomes. Rehabilitation interventions
Aims of intervention Function/structure
Activity & participation
Tissue damage
Symptom pain
Ib þ
Ib þ
Ib þ
þ þ þ þ þ þ
Ib þ Ib þ
III þ
III þ
PRICE (Protection, Rest, Ice, Compression, Elevation) Joint mobilisation Joint-specific exercises Joint immobilisation Physical fitness Braces, aids and devices Support services, social interventions Education & self management
Ib III Ib III
þ þ þ þ
III þ
Ib Ib Ib III Ib III
III þ Ib þ III þ
Ia e IV, grading of evidence; Nature of effect: þ, positive; 0, evidence of no effect; , negative effect. #, inconsistent findings; IE, inadequate evidence.
a multi-disciplinary approach including joint mobilisation and specific exercises, education and support services as well as improved physical fitness. Recommendations for rehabilitative interventions To prevent trauma, the main recommendation is to maintain a level of physical fitness (see Table 7). Appropriate education and self-management (training in sports, driving lessons in traffic, education on the job) will decrease the number of accidents. To reduce the impact of trauma-related tissue damage and pain protection (braces, aids and devices) are helpful. In the early phase of trauma-related tissue damage and pain immobilisation and rest, ice, compression and elevation is of importance to limit the extent of the damage. In the later phase joint mobilisation, specific exercises and muscle techniques play an important role for protection from further tissue damage due to contractions, muscle weakness and lost proprioception. Functional limitations will be reduced and will allow for appropriate activity and participation. A multi-disciplinary approach to rehabilitation is recommended e.g. so that the patient can return to sport with the ability to enjoy it and prevent further injuries. Health system intervention In trauma, a key aspect that impacts on the outcome of a trauma incident is the structure and resourcing of the local health system. Early and appropriate treatment is the key factor in all of the different areas of injuries.50e52 In sports injuries, RICE (rest, ice, compression and elevation) prevents further tissue damage and allows fast recovery. In repetitive occupational injuries, early intervention can reduce the risk of chronicity. In life-threatening major trauma, appropriate medical treatment (intubation, oxygenation, stabilisation of fractures, fluid restitution) at the scene of the accident improves the chances for survival and long-term functional outcome. All three of the interventions mentioned above require appropriate education and training of the relevant people for early diagnosis and treatment: namely the
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trainers and physiotherapists in sport, superiors in the workplace and the general public for all kinds of accidents. This includes contacting the rescue services promptly in cases of major trauma so that expertise can be provided at the scene of the accident.
Practice points Sports and occupational injuries are a common cause of lower limb pain. The whole working population should be considered to be at risk for occupational musculoskeletal injuries, particularly those exposed to repetitive movements, high force, awkward joint posture, direct pressure, vibration, prolonged constrained posture or psychological factors such as psychological demand, stress, etc. The whole population that participates in physical activity or sport is at risk for sports injuries, particularly those who are physically unfit if they try to do too much, too quickly. As are participants in contact sports, with the wrong body type for the sport, or where the level of expertise and experience differs or where the rules of the sport are not observed. In the rehabilitation phase the risk for a new injury is increased. To prevent occupational injuries risk factors need to be identified and the workplace and organisation of work need to be adapted accordingly, supported by laws. In the early trauma phase accurate diagnosis and treatment including pain management are crucial. Partial work restriction and short-term immobilisation need to be considered, but early return to work is crucial. Based on an understanding of the mechanism of injury, future injuries can be prevent by considering adaptations in the workplace, by transferring the patient to another job or a by a distinct job modification. In addition, participation in accident awareness and prevention campaigns might be beneficial. This includes a multi-disciplinary approach to educate participants on: the importance of physical and psychological fitness the skills and techniques required by the particular work the nutritional requirements of the sports events correct clothing and protective equipment obeying the rules To prevent sports injuries it is important to maintain physical fitness, to be trained to use the correct technique under adequate supervision and in appropriate facilities. In addition the wearing of protective equipment and obeying the rules are key elements of the prevention strategy. In the early phase of a sports injury, the first step is to immediately remove the player from the field to prevent further injury. First treatment includes RICE (rest, ice, compression and elevation) and non-steroidal anti-inflammatory drugs (NSAIDs). An early, correct diagnosis has to be based on a competent clinical examination with, if indicated, imaging, and is crucial for prognosis.
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Operative reconstruction of the tendons, capsule and ligaments needs to be considered, as well as operative or non-operative stabilisation of fractures. A multi-disciplinary approach to the care of athletes should involve the coach, physiotherapist, physician, physiologist, psychologist, nutritionist, podiatrist and biomechanics specialist. In the late phase, prompt and adequate rehabilitation is necessary, in order to correct any predisposing problems. Before returning to practise, the individual must be pain free and have the muscle strength and skill required by the sport. Based on an understanding of the rules, the physiological stresses and the possible mechanisms for injury, adaptations to both training and technique need to be considered.
Research agenda Population-based studies and well designed prospective cohort studies are necessary to identify the true burden of occupational and sports injuries. More controlled trials are necessary to extend the already existing knowledge with regard to the aetiology, prevention and treatment of occupational and sports injuries of the lower extremities. When studying the effectiveness of prevention and treatment efforts, special emphasis should be given to a clear description of the characteristics of the disorder and study population and also to the content of the interventions.
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