Consolidation

• Achilles tendinopathy

  Condition characterised by Achilles pain, gradual increase in pain and severity, and impact on function
• Signs and symptoms of Achilles tendinopathy

  • Achilles pain
  • Increase in pain and severity and impact on function are typically gradual
  • Minor symptoms (pain or stiffness) upon WB after prolonged rest or sleep (morning stiffness or arising pain) or pain upon commencing walking or running that improves after a few minutes
  • As severity progresses, symptoms are reported for several hours or even days following bouts of activity
• Most patient recall a change in loading activity coinciding with pain onset

  Relative tendon overload is the main trigger
• Midportion achilles tendinopathy

  Recent change in tendon loading (increasing distance, speed, frequency, with insufficient recovery between loading periods), increase in high energy storage activities like jumping and landing, and changes in footwear or training surface
• Insertional achilles tendinopathy

  Increased pain with increased DF ROM
• Treatment plan for Achilles tendinopathy

  1. Education and advice (activity modification, pain monitoring)

  2. Exercise program (Midportion: Repeated and, initially, pain-provoking exercise, Combination of eccentric/concentric movements, Staged loading program with particular attention to avoiding DF for Insertional)
• Conditions to exclude for Achilles pain

  • Midportion achilles tendinopathy
  • Insertional achilles tendinopathy
  • Plantaris tendon involvement
  • Flexor hallucis longus and tibialis posterior tendinopathy
  • Posterior ankle joint impingement
  • Achilles tendon rupture
  • Referred pain from neural structures and L/S
  • Sever's disease
• Lateral ankle sprain

  Condition characterised by immediate pain, swelling, and sometimes a "popping" sound during injury, tenderness and pain at the lateral ankle, swelling and bruising around the ATFL/CFL, pain increases with activity and decreases with rest and elevation, instability and limited ROM
• Mechanism of lateral ankle sprain

  Plantar flexion and inversion
• Treatment plan for lateral ankle sprain

  1. Initial treatment (PEACE and LOVE protocol, resting ankle for 72 hours followed by gradual activity, NSAIDs for analgesia, early WB with support, and compression with braces)

  2. Exercise program (Restore full ROM, muscle conditioning / strength, proprioception, functional exercise)
• Conditions to exclude for acute ankle injury

  • Lateral ankle sprain (ATFL, CFL, PFL)
  • Medial ligament injury
  • Fractures
  • Dislocated ankle
  • Syndesmosis injury
• Plantar fasciopathy

  Condition characterised by sharp pain and tenderness at plantar medial aspect of the heel on first walking in the morning and after a period of rest that gets better after walking for a while, pain worsens at the end of day and with impact activities, gastrocnemius tightness associated with DF stiffness of the ankle and plantar fascia injury
• Mechanism of plantar fasciopathy

  Training load error / increase in load, excessive foot pronation, reduced DF possibly the most important risk factor for chronic PF, intrinsic risk factors include age, gender, body weight, heel spurs, nerve entrapment, systemic disease, biomechanical dysfunction, and genetics, extrinsic risk factors include footwear, sport, lifestyle, foot/ankle/leg deformities, and occupation
• Treatment plan for plantar fasciopathy

  1. Advice and education (activity modification, pain monitoring)

  2. Treatment can include taping (low dye taping/augmented low dye taping) for excessive foot pronation

  3. Exercise program (Heavy slow loading + shoe inserts, calf and LL strength as well as cross training via interval bike training, sports specific rehab like plyos)
• Conditions to exclude for rearfoot and inferior heel pain

  • Plantar fasciopathy (fasciitis)
  • Fat pad contusion (heel pain)
  • Calcaneal stress fracture
  • Tarsal tunnel syndrome
  • Spondyloarthropathies (inflammatory rheumatic diseases)
  • Osteoid osteoma (neoplasia)
• Patellofemoral pain syndrome

  Condition characterised by tenderness around the kneecap, patellar maltracking is possible, insidious onset of poorly defined pain (anterior retropatellar pain/peripatellar pain), worsening of pain in loading positions (particularly flexion)
• Mechanism of patellofemoral pain syndrome

  Excessive loading or varied and rapid increases to physical activity which the knee cannot cope with contribute to pain, female sex are more likely to develop PFP, local factors (knee extension or quad strength, hypomobility and maltracking of patella, different shape/size patellas, patella alta), proximal factors (reduced hip abd/add/er/ir/ext strength reduced er/ir, wasting of quads), distal factors (prolonged or increased foot pronation)
• Treatment plan for patellofemoral pain syndrome

  Integrated approach (exercise, taping, foot orthoses, bracing), education and advice (load vs capacity, pain monitoring, hip + knee strengthening slightly superior to knee strengthening alone, address psychological features), exercise program (address pain and stiffness, improve strength and function of hip and thigh muscles, movement control/coordination/balance exercises, gait retraining, functional activity retraining)
• Conditions to exclude for anterior knee pain

  • Chonrornalacia Patalle
  • Hoffa's pad syndrome
  • Iliotibial band friction syndrome
  • Patellar tendinopathy
  • Knee OA
  • Meniscus tears
  • Popliteal cyst (Baker's Cyst)
  • ACL or PCL injury
  • Referred pain from the hip or lumbar spine
• Patellar tendinopathy

  Condition commonly affecting younger athletes and men, characterised by pain localised in the tendon (inferior pole of the patella or distal patella tendon) and load-related pain with a dose-response component, pain free at rest, and in a few cases, pain can decrease with loading ("warm up phenomenon"), but often increased the day after, quad atrophy, reduced lower limb muscle strength and flexibility, excessive foot pronation
• Mechanism of patellar tendinopathy

  When intensity, frequency, and volume of patellar tendon loading exceeds capacity to recovery and adapt appropriately (i.e. doing too much too soon), loss of function related to mechanical loading, load-related pain with a dose-response component
• Treatment plan for patellar tendinopathy

  1. Education and advice (activity modification, pain monitoring, discuss realistic rehabilitation time frames, address wrong beliefs about pain, passive treatments are low value care)

  2. Exercise program (ISOs, isotonics, energy storage and release)
• Conditions to exclude for anterior knee pain

  • Patellofemoral pain
  • Patellar tendinopathy
  • Patellofemoral instability
  • Quadriceps tendinopathy
  • Fat pad impingement
  • Osgood-Schlatter lesion in adolescents
  • Referred pain from the hip
  • Osteochondritis dissecans
  • Slipped capital femoral epiphysis
  • Tumour (especially in the young)
• Exercise program


  1. ISOs (quad isometrics in isolation and calf isometrics)

  2. Isotonics (green light or up to 5/10 pain, double leg squat, low/high step up, calf raises)

  3. Energy storage and release (green light up to 3/10 pain, jumping/landing, cutting)

  4. RTS
• Common and less common problems that need to be excluded

  • Common causes of anterior knee pain: patellofemoral pain, patellar tendinopathy
  • Less common causes: patellofemoral instability, quadriceps tendinopathy, fat pad impingement, Osgood-Schlatter lesion in adolescents
  • Not to be missed: referred pain from the hip, osteochondritis dissecans, slipped capital femoral epiphysis, tumour (especially in the young)
• Infrapatellar fat pad / fat pad impingement

  • Swelling around patellar tendon
  • Pain and tenderness around inferior pole of the patellar tendon
  • Limited ROM
  • Painful EOR knee extension
  • Pain with movements close to EOR flexion once fat pad is swollen (fat pad cannot glide down into trochlear groove)
  • Aggravation during full extension and dynamic extension
  • Pain exacerbated by both flexion and extension manoeuvres
  • Pain during prolonged standing and going up/downstairs
• Infrapatellar fat pad / fat pad impingement presents after forceful extension manoeuvre
• Infrapatellar fat pad / fat pad impingement has increased risk in young women and in jumping sports as well as with ligamentous laxity
• Treatment plan for infrapatellar fat pad / fat pad impingement

  1. Reduce inflammation via activity modification, limit active/passive extension, fat pad deload tape and extension block taping, heel raise into a more flexed position, and ice

  2. Rehabilitation targeting movement patterns and posture, and muscular retraining (starting out of knee extension and progress through to RTS)
• Meniscus injury


  • Major complaint of knee pain, swelling and knee locking which is when the patient is unable to straighten the leg fully
  • This can be accompanied by a clicking feeling
  • 3 or more of the following: Tenderness at one point over the medial joint line, Pain in the area of the medial joint line during hyperextension of the knee joint, Pain in the area of the medial joint line during hyperflexion of the knee joint, Pain during external rotation of the foot and the lower leg when the knee is flexed at different angles around 70–90°, Weakened or hypotrophied quadriceps muscle
• Meniscus injury commonly occurs in contact sports
• The most common mechanism of meniscus injury is a twisting injury with the foot anchored on the ground; this rotational force is often caused by another player's body
• Knee valgus force (with or without rotation) resulting in injury to the medial collateral ligament, frequently accompanied by injury to the posteriomedial capsule, medial meniscus, and anterior cruciate ("terrible triad")
• Hyperextension leading to anterior cruciate injuries, often associated with meniscus tears
• 60-75% of cases of anterior cruciate ligament injury are accompanied by medial meniscus injury
• Injury to the medial meniscus is about 5 times more common than injury to the lateral meniscus
• Treatment plan for medial meniscal injuries

  Conservative management is warranted for non-displaced or degenerative tears; however, if this fails surgical intervention may be required
• Common and less common problems that need to be excluded

  • Common causes of acute knee pain: medial meniscus tear, MCL sprain, ACL sprain (rupture), lateral meniscus tear, articular cartilage injury, PCL sprain, patellar dislocation
  • Less common causes: patellar tendon rupture, quadriceps tendon rupture, acute patellofemoral contusion, LCL sprain
  • Not to be missed: fracture of tibial plateau, avulsion fracture of tibial spine
• MRI can predict those patients with early OA and a meniscus tear that can benefit from surgery
• Femoroacetabular impingement

  • Moderate to marked hip or groin pain related to certain movements or positions
  • Pain reported in the thigh, back or buttock
  • Stiffness
  • Restricted hip ROM
  • Clicking and/or catching
  • Locking or giving way
  • Decreased ability to perform activities of daily living and sports
  • Pain exacerbates into EOR hip flexion
  • Positive FADDIR test
  • Reproduction of pain with hip flexion
  • Pain ascending and descending stairs