6- Knee & Lower Leg Flashcards
List 4 functions of the meniscus
- Increased stability to the femorotibial articulation
- Distribute axial load
- Absorb shock
- Lubrication & nourishment to the knee joint.
Cuccurollo 4th Edition Chapter 4 MSK pg226-231
Four Compartment of the Leg 🔑🔑 MOCK
ANTERIOR COMPARTMENT
- Deep peroneal nerve
- Ankle dorsiflexors and foot invertors:
- Tibialis anterior (TA; deep peroneal nerve: L4, L5)
- Extensor hallucis longus (deep peroneal nerve: L4, L5) great toe extensor
- Ankle dorsiflexors and foot evertors:
- Extensor digitorum longus (deep peroneal nerve: L4, L5) toe extensor
- Peroneus tertius (deep peroneal nerve: L4, L5)
LATERAL COMPARTMENT
- Common peroneal nerve (superficial and deep)
- Foot evertors and weak plantar flexors
- Peroneus brevis (superficial peroneal nerve: L5, S1)
- Peroneus longus (superficial peroneal nerve: L5, S1)
POSTERIOR COMPARTMENT
- Deep posterior compartment → plantar flexor
- Tibial nerve
- Gastrocnemius (tibial nerve, L5, S1, S2)
- Soleus (tibial nerve, L5, S1, S2)
- Plantaris (tibial nerve, L5, S1, S2)
- Superficial posterior compartment
- Sural nerve
- Popliteus (tibial nerve, L5, S1, S2) internal rotation of the leg on the femur
- Tibialis posterior (tibial nerve, L5, S1, S2) inversion and plantar flexor
- Flexor digitorum longus (tibial nerve, L5, S1, S2) flexion lateral four toes, inversion, plantar flexor
- Flexor hallucis longus (tibialis nerve, S2, S3)
Cuccurollo 4th Edition Chapter 4 MSK pg247
Knee pain after squat. Examination (2) & Management. 🔑🔑
MENISCAL INJURIES
Mechanism
- Shearing forces from loading and rotational forces on the knee: occur with tibial rotation while the knee is partially flexed during weight bearing (closed kinetic chain)
Medial meniscal injuries
- Common in sports such as football, basketball, and soccer
Lateral meniscal injuries
- Occur during squatting
- Full flexion with rotation is the usual mechanism (e.g., wrestling).
OA “Degenerative tears”
- They usually occur in patients >40 years old
- Impingement episodes may be minimal
Presentation
- Obstructive meniscal tears may cause true locking
- Posterior horn tears of the medial meniscus is more common
Examination
- Effusion will limit flexion (meniscal fragment impingement)
- Partial Squat / Thessaly test
- Medial / Lateral joint line tenderness
- McMurray’s tests
- Apley’s grind
Imaging
- MRI is the gold standard in diagnosing meniscal tears
- Asymptomatic, degenerative meniscal tears are found in up to 60% over age 50.
Treatment
- Physiotherapy for non-obstructive meniscal injuries
- Surgical resection for obstructive meniscal injuries
- Inner two-thirds: meniscus is resected, weight bearing as tolerated in 1 to 2 days
- Outer third: meniscus is repaired & nonweight bearing for 4 to 6 weeks.
Cuccurollo 4th Edition Chapter 4 MSK pg236-237
https://radiopaedia.org/articles/meniscal-tear
https://www.orthobullets.com/knee-and-sports/3005/meniscal-injury
Soccer player twisted knee and injured. He felt a “pop” 🔑🔑 OSCE Dr. Jamal
Function of ACL
Mechanism of Injury
Examination
When to refer for surgical treatment?
When can he resume playing?
ACL INJURIES
Anatomy of ACL
- Lateral femoral condyle → anterior, inferior, and medial → medial tibial eminence
- Lax in flexion and tighter in extension.
Function of ACL
- Limit anterior tibial translation (main)
- Limit posterior translation of the femur
- Limit hyperextension of the knee.
- Limits internal rotation of the femur
- Absorbs force from posterior menisci.
Mechanism of Injury
- Noncontact injuries (most common)
- Pivot and sudden deceleration: tibia translates anteriorly while knee is in slight flexion and valgus
- Forceful knee hyperextension
- Contact injuries
- Blow to the lateral aspect of the knee: Contact injuries → ACL + meniscal tears
Terrible Triad → Valgus force to a flexed and rotated knee
- Injury to the ACL
- MCL
- Medial meniscus
Presentation
- Severe effusion in for 2 to 12 hours +/- hemarthrosis
- Posterior lateral joint line pain
- Feelings of instability preventing return to sport
- Difficulty weightbearing
- Neurovascular injury → Peroneal nerve
Examination
- Effusion
- Anterior Drawer (influenced by muscle guarding i.e. hamstring)
- Lachman Test (influenced by muscle guarding i.e. hamstring)
- Pivot Shift Test
Imaging
- MRI 97% sensitivity and 100% specificity
- Arthroscopy
Surgical Referral
- Indicated: instability, sport or job requiring stable knee, multiple injury (tribble triad)
- No Indicated: partial tear, complete tear with stability, sedentary lifestyle
ER - POLICE - MIS
💡 Grade l & ll Lachman <5mm or 5-10 mm translation
- Education
- Sports-specific exercises after 6 to 12 weeks.
- Protection & Orthosis
- Initially partial weight bearing
- ICE & compression
- Aggressive cryotherapy (ice)
- Loading (Stretch, ROM, Aerobic, ST, Proprioception/Balance, Plyometric & Sport)
- Emphasize early full passive extension
- Strength
- Increasing hamstring strength to decrease quadriceps dominance ratio
- Isometric or Eccentric quadriceps exercises
- Isometric hamstring exercises
- Core and gluteal strengthening
- Emphasize closed chain (foot planted) exercises: squats or leg-press
- Avoid isokinetic quadricep strengthening (15-30°) during early rehab
- Open chain quadriceps strengthening
- Proprioceptive training
- Neuromuscular training/plyometrics (jump training)
💡 Grade lll Lachman > 10mm translation
- Education
- Complete rehabilitation in 6 months to 12 months
- Exercises from 0 degrees and 45 degrees flexion are avoided the first 3 to 6 months
- Protection & Orthosis
- Lenox hill derotation orthosis
- ICE & modalities
- Loading
- ROM first 2 weeks → Progress to closed chain kinetics
- Strength hamstring and quadriceps
- Proprioceptive training
- Surgical reconstruction
Return To Play
- Patient should pass series of functional tests that replicate sport-specific activities
- Full painless ROM
- Pain free weight bearing
- Strength is 80% compared to sound limb to avoid muscle imbalance
- Various single- and double- leg hopping and jumping
Rehab Time Frame
- 1st Month: Passive ROM → Partial weight bearing with crutch walking
- 2nd Month: Full weight bearing → Partial ROM exercises
- 3rd Month: Full ROM exercises +/- Running and strength exercises
Cuccurollo 4th Edition Chapter 4 MSK pg237-238
PMR Secrets 3rd Edition Chapter 47 Kne pg385
https://www.orthobullets.com/knee-and-sports/3008/acl-tear
Dr. Ali Note
PCL injury. Mechanism, Examination & Management 🔑🔑
PCL INJURY
Anatomy
- Medial femoral condyle → posterior, inferior, and lateral → posterior tibial plateau.
- Lax in extension and tighter in flexion.
Function
- Limit posterior tibial translation (main)
- PCL pulls the femur posteriorly
- Absorbs force from patellofemoral joint
Mechanism
- Tibia is forced backward in relation to the femur causing injury to the PCL.
- Hyperflexion is a common mechanism of PCL injury
Examination
- Posterior drawer test
- Sag tests
Management:
- Controversy over surgical repair of an otherwise isolated PCL tear
- Passive mobilization with progressive weight bearing and quadriceps strengthening
Cuccurollo 4th Edition Chapter 4 MSK pg238-239
Posterior knee pain downhill activities.
Most likely diagnosis, Origin & Insertion, 3 Actions, 1 shoe modification.
POPLITEUS TENDONITIS
Anatomy
- lateral femoral condyle and inserts into the triangular area in the posterior tibia.
Action
- Unlocking the knee by laterally rotating the femur.
- Limits anterior translation of the femur (With the ACL)
Presentation
- Running downhill causes forward femoral displacement, stressing popliteus tendon
- Lateral knee pain with downhill activities and with excessive pronation
- Pain with legs in figure of four or cross-legged position
Examination
- Tenderness anterior to the fibular collateral ligament and LCL
ER - POLICE - MS
- EDUCATION: Avoid downhill running until symptoms resolve
- ORTHOSIS: Medial arch supports or medial heel wedges
- ICE & Compression
- NSAIDs
Cuccurollo 4th Edition Chapter 4 MSK pg245
Knee pain during football match. Examination (2) & Management.
MCL TEARS
- Impact force to the lateral knee
- Sustained valgus force
LCL TEARS
- Impact force to the medial knee
- Sustained varus force
Examination
- Ligaments
- Ecchymosis and lateral joint soft tissue swelling
- Tenderness
- Instability on valgus/varys stress testing is present
- Isolated injury → Instability in slight flexion of 30 degrees
- Combined injury → Instability in full extension
- Dial test
- Increased tibial external rotation > 10° compared to other side at 30° knee flexion
- Neurovascular
- Common peroneal nerve injuries may occur with LCL/PLC injury
ER - POLICE - MS
- Education
- Grade I: 5 mm of motion → Return to play at 5-7 days
- Grade Il: 5 to 10 mm → return to play at 2-4 weeks
- Grade Ill: >10 mm, complete tear, no firm endpoint → return to play at 4-8 weeks
- Return to sport expected in 6-8 weeks
- Protection: Knee brace with dial lock or hinge.
- Loading: Strengthening and stability exercises
- ICE, Compress & Modalities: acute injury
- Medications: NSAIDs in acute phase
- Surgery: Reconstruction/repair for grade lll
Cuccurollo 4th Edition Chapter 4 MSK pg239
https://www.orthobullets.com/knee-and-sports/3010/mcl-knee-injuries
https://www.orthobullets.com/knee-and-sports/3011/lcl-injury-of-the-knee
Pain over the lateral femoral condyle. Worsen by walking or jogging. Symptoms improve with running. List 2 tests to do & Management.
ITB SYNDROME
- ITB slides over the lateral femoral condyle
- Pain with knee flexion and extension
- Pain after excessive running, cycling or hiking
Causes
- Inflexibility of the ITB
- Adductor/abductor muscle imbalances
Tests
- Ober test
- Noble’s test
ER - POLICE - MS
- Education: Load management
- Orthosis: Foot overpronation (flat foot)
- Loading
- Stretching the ITB, hip flexors, and gluteus maximus
- Strengthening the hip abductors, gluteus maximus, and TFL
- Mediation: Injection at the lateral femoral condyle
Cuccurollo 4th Edition Chapter 4 MSK pg239-240
List 10 Potential secondary causes of osteoarthritis (OA). 🔑🔑
SPINE
- Paget’s disease.
WRIST & HAND
- Rheumatoid arthritis.
- Acromegaly (GH effects on cartilage/bone).
- Ehlers-Danlos syndrome.
- Marfan syndrome.
HIP
- Legg calve perthes disease (avascular necrosis).
- Acetabular dysplasia.
- SCFE.
KNEE
- Septic joint.
- Gout.
- CPPD (pseudogout).
- Hemochromatosis.
- Ligament tear (eg ACL for knee).
- Meniscal tear.
ANKLE & FOOT
- Neuropathic (charcot) arthropathy (DM, syringomyelia, myelomeningocele, SCI, etc).
What are the general principles of rehabilitation of arthritis of the knee? 🔑🔑 MOCK
- Non-weight-bearing strengthening exercises should be emphasized, particularly with emphasis on the quadriceps.
- Exercise load should increase each week, and maintenance of cardiovascular conditioning is a must-even before a total joint replacement.
- Hydrotherapy provides the appropriate environment in which osteoarthritic patients can exercise at intensities that improve strength and mobility.
- Activities of daily living and transfer/ambulatory evaluation are essential and should include evaluation for assistive devices, including raised toilet seats, shower grab bars, reachers, and ambulatory aids to maximize independence and ensure safety in the home environment.
PMR Secrets 3rd Edition Chapter 47 Kne pg388
What are contraindications for intra-articular steroid injections? 🔑🔑 OSCE
- Reluctant patient or no informed consent given
- Children younger than 18 years of age
- Recent fracture site
- Prosthetic joint
- Hypersensitivity or allergy to any of the drugs used
- Sepsis – local or systemic
Injection Techniques in Musculoskeletal Medicine 5th Edition pg121
Provide three musculoskeletal (MSK) complications of corticosteroids. 🔑🔑
- Muscle: Steroid myopathy.
- Tendon: Tendon rupture
- Joint: Steroid arthropathy
- Bone: Osteoporosis & Osteonecrosis
Ref: Primer on the rheumatic diseases. Table 46-3; Delisa pg 1750; Braddom pg 521.
Name 10 complications of corticosteroid – general question including injection and systemic.
SKIN
- Subcutaneous fat atrophy
- Skin depigmentation (4%) - Resolution 6 to 24 months later
- Delayed soft tissue healing - Consider appropriate timing of return to activity
NERVE
- Nerve damage or transient paresis of an extremity
- Complex regional pain syndrome
VESSELS
- Bleeding or bruising → Apply firm pressure
MUSCLE
- Steroid myopathy
TENDON
- Tendon rupture and atrophy - Interval between injections to a minimum of 3 months - Rest from provocative activity for 6 to 8 weeks - Avoid bilateral tendon injection.
JOINT
- Flare of pain (2 to 10%) - Resolve within 12-24 hours
- Sepsis 1 in 17,000 for joint injection and 1 in 162,000 for soft tissue injection - Less in prepackaged corticosteroid in a sterile syringe
BONE
- Steroid arthropathy - Interval between injections to a minimum of 3 months
- Osteonecrosis/AVN.
STEROID
- Facial flushing (5%) → last 1 to 2 days
- Cataracts
- Raise systolic blood pressure
- Impaired diabetic control → Rise up to a week, increased by multiple doses
- Suppression of the hypothalamic-pituitary axis (Cushing Syndrome) - Clinical syndrome 10–14 days after injection - Moon face, Buffalo hump, Acne-like eruptions, Flushing, Palpitations, Tremors, Dyspnoea, Weight gain, 5–8 kg, Disturbed menstruation - Spontaneous resolution at 3 months (one injection) and 6 months (two injections)
- Peptic ulcer disease
ALLERGIC REACTION
- Anaphylaxis
Injection Techniques in Musculoskeletal Medicine 5th Edition Chapter 2
The stability of the patella is dependent upon three main characteristics
- SHAPE: Proper contour of the patella
-
GROOVE: Depth of the intercondylar groove
- Lateral lip of the patellar surface of the femur acts to prevent subluxation.
- MUSCLE: Adequate muscular control
Cuccurollo 4th Edition Chapter 4 MSK pg240
List 4 Patellar malpositions 🔑🔑
💡 Insall-Salvati Index: Normal values range from 0.8 to 1.2
- Patella Alta:
- High-riding, laterally shifted patella
- Vastus lateralis tightness and relative medial weakness
- Patella Baja
- Low patella
- Quadriceps rupture.
- Squinting patella
- Patellar internal rotation
- Frog’s eye patella
- Patellar external rotation
Patella Subluxation, 8 Predisposing factors, 3 Xray Views.
RECURRENT PATELLAR SUBLUXATION
- Knee tends to buckle after a subluxation
- Patella will often reset at 25-degree to 30-degree flexion
Xray Views
- AP view: assess patellar position over the sulcus
- Lateral view : assess patellar height and is done at 45-degree knee flexion
- Sunrise (tunnel) view: assess patellofemoral articulation and femoral condyle
Cuccurollo 4th Edition Chapter 4 MSK pg240-241
Anterior knee pain with running, cycling and getting from seated position. Diagnosis, Predisposing Factors, PEx, Imaging, Management 🔑🔑 Dr. Jamal
PATELLOFEMORAL PAIN SYNDROME (PFPS)
- Runner’s knee or biker’s knee
- Repeated microtrauma, leading to peripatellar synovitis
Presentation
- Anterior knee pain of acute or insidious onset, worsen with repetitive flexion
- Crepitus and effusion may be present
- Pain with squatting or descending stairs
- Pain with prolonged sitting or on arising after sitting (theater sign)
Predisposing Factors
- Training Errors
- Equipments: Bicycle fit, Recent change in equipment
- Program: Training distance and intensity (training volume), overtraining
- Patella Malpositions or Maltracking
- Increased Q angle
- Femoral anteversion
- Genu valgum
- External tibial torsion
- Pronated feet
- Patella Alta, Baja, Squint, Frog
- Increased Q angle
- Muscle Imbalance
- Tight hip flexors, abductors, hamstrings
- Weak quadriceps and hip abduction
- Recurrent patellar subluxation
Examination
💡 Examination in the last 30-degree extension is important → Beyond will be normal
- Inspection: Quadricep muscle atrophy, Patella malposition
- Measurement: ROM to r/o tightness, Increase Q Angel, Limb Length Discrepancy
- Functional Test: One Leg Squat → Evaluation proprioception & abductors strength
- Palpation: Crepitus
- Special Tests
- Patellar Instability → Apprehension test
- Patella Articulation → Clarke’s Sign (Patellar Grind Test)
- Chondromalacia Patella → Compression
- Hamstring tightness → Straight Leg test
- Hip abductors tightness → Ober & Nobel Compression Test
- Hip flexors tightness → Thomas Test
Imaging
- AP: patellar position over the sulcus
- Lateral: patellar height and is done at 45-degree knee flexion and full extension.
- Sunrise: patellofemoral articulation and femoral condyle height
ER - POLICE - MS
-
Education & Control Risk Factors
- Proper bicycle fit: Minimizing hyperflexion
- Reduce aggravating activities (climbing, jumping, squatting) or activity modification
- Inactive patients → start baseline exercises with progression
-
Protection & Orthosis
- Knee Taping
- Proprioceptive feedback
- Balance contractile forces between the vastus lateralis and medialis.
- Knee Brace
- Provides proprioceptive feedback
- May prevent reinjury
- Allow the patient to resume activity.
- Correct pronation or supination of foot
- Knee Taping
-
ICE & Modalities
- Ice 10 to 15 minutes four to six times per day is used in the acute phase
-
Optimal Loading
- Stretching: Hamstrings, ITB, adductors, and vastus lateralis
- ROM: -
- Aerobic: -
- Strength:
- Quadriceps (isometric & isotonic), start from short arc 0-45 flexion
- Hip flexors (straight leg raise)
- Core strengthening
- Proprioceptive / Balance : Sport specific & Correct mechanics
-
Medications
- Oral NSAIDs
-
Surgical
- Conservative measures fail after 4 to 6 months
- An obvious surgical lesion exists
- Lateral release of the knee capsule and retinaculum
- Patellar realignment
- Patellar tendon transfer
- Patellectomy
Cuccurollo 4th Edition Chapter 4 MSK pg241-242
Female 15-35 highly active with symptoms of aching behind the patella, recurrent effusion of the knee, knee instability and crepitus. History of anterior knee pain, which is exacerbated by running, stair climbing, squatting, kneeling, or changing from a sitting to a standing position Diagnosis, name 2 tests & 4 predisposing factors.
CHONDROMALACIA PATELLA
- Diagnosis is clinical with a history of anterior knee pain made worse with squatting, prolonged sitting or ascending stairs
- Pain on patellar compression in knee extension.
Arthroscopy
- Softening of the patellar articular cartilage followed by cartilage degeneration.
Presentation
- Diffuse pain in the peripatellar or retropatellar area of the knee (major symptom)
- Insidious onset and typically vague in nature
- Aggravated by specific daily activities including
- Climbing or descending stairs
- Prolonged sitting with knee bent (known as theatre pain)
- Squatting or kneeling
Predisposing factors
- Same as Patellofemoral Pain Syndrome
- Also infection, trauma, or autoimmune processes.
Examination
- Quadricep muscle atrophy
- Limb malaligment
- Dial test → tibial torsion
- Craig Test → femoral torsion
- Patellar maltracking
- Apprehension test
- Compression test
- Clark test
Education & Control Risk Factors
- Proper bicycle fit: Minimizing hyperflexion, Adjust saddle & rotation of the cleats
- Reduce aggravating activities (climbing, jumping, squatting)
- Inactive patients → start baseline exercises with progression
Protection & Orthosis
- Knee Taping
- Proprioceptive feedback
- Balance contractile forces between the vastus lateralis and medialis.
- Knee Brace
- Provides proprioceptive feedback
- May prevent reinjury
- Allow the patient to resume activity.
- Correct pronation or supination of foot
ICE & Modalities
- Ice 10 to 15 minutes four to six times per day is used in the acute phase
- Pain modalities: Cold modalities
Optimal Loading
- Stretching: Hamstrings, ITB, adductors, and vastus lateralis
- Strengthening: Quadriceps (isometric & isotonic), start from short arc 0-45 flexion
- Strengthening: Hip flexors (straight leg raise)
- Proprioceptive exercises
- Correct mechanics
Medications
- Oral NSAIDs
Surgical
- Conservative measures fail after 4 to 6 months
- Arthroscopic debridement
- Patellar realignment surgery
- An obvious surgical lesion exists
Cuccurollo 4th Edition Chapter 4 MSK pg243
https://www.orthobullets.com/knee-and-sports/3022/idiopathic-chondromalacia-patellae
Activity-related anterior knee pain specially on high impact exercises. Give 4 advices
PATELLAR TENDONITIS (JUMPER’S KNEE)
- Overuse syndrome of the patellofemoral extensor unit.
Predispoding Factors
- Repetitive, high quadriceps loading: jumping, squatting, kneeling, and climbing stairs.
- Repetitive, forceful, eccentric contraction of the extensor mechanism leading to degenerative, rather than inflammatory, micro-tears.
- Poor quadriceps and hamstring flexibility or tendinopathy
Presentation
- Pain on high impact activity, such as jumping.
- Pain may diminish during exercise and become more apparent afterward.
- Pain in inferior pole of the patella.
Examination
- Tenderness on palpation over the patellar tendon
- Bassett sign
- Tenderness to palpation at distal pole of patella in full extension
- No tenderness to palpation at distal pole of patella in full flexion (patellar tendon taut)
ER - POLICE - MS
Education & Control Risk Factors
- Proper bicycle fit: Minimizing hyperflexion, Adjust saddle & rotation of the cleats
- Reduce aggravating activities (climbing, jumping, squatting)
- Inactive patients → start baseline exercises with progression
Protection & Orthosis
- Knee Taping
- Proprioceptive feedback
- Balance contractile forces between the vastus lateralis and medialis.
- Knee Brace
- Provides proprioceptive feedback
- May prevent reinjury
- Allow the patient to resume activity.
- Correct pronation or supination of foot
ICE & Modalities
- Ice 10 to 15 minutes four to six times per day is used in the acute phase
- Pain modalities: Cold modalities
Optimal Loading
- Stretching: Hamstrings, ITB, adductors, and vastus lateralis
- Strengthening: Quadriceps (isometric & isotonic), start from short arc 0-45 flexion
- Strengthening: Hip flexors (straight leg raise)
- Proprioceptive exercises
- Correct mechanics
Medications
- Oral NSAIDs
Cuccurollo 4th Edition Chapter 4 MSK pg244
Spot diagnosis.
Traction aphophysitis of the insertion of patellar tendon on tibial tuberosity
Activity related knee pain → Relative rest and gradual resumption of activities
PMR Secrets 3rd Edition Chapter 47 Kne pg381
Medial shin pain, improve during exercise and flare up after exercise. 🔑🔑
MEDIAL TIBIAL STRESS SYNDROME (MTSS)
- Most common exercise-induced leg pain, known as “Shin Splint”
Mechanism
- Overuse or repetitive-stress injury
- Chronic traction on the periosteum at the periosteal–fascial junction
- Excessive use of the foot flexors, as in jumping
Presentation
- Pain may improve with exercise but worsens after the completion of the activity and can last until the next morning. (opposite to exertion compartment syndrome)
- Pain along the posteromedial border of the tibia.
- Tenderness on palpation along the medial tibial border
Predisposing Factors
- Training Error
- Inappropriate warm-up
- Training errors: Rapid increase in training volume “too much, too fast”
- Surface
- Repetitive running on hard uneven surfaces
- Equipments
- Inappropriate footwear
- Recent change in footwear.
- Biomechanics
- Hyperpronation.
Imaging
- MRI will help rule out a stress fracture
ER - POLICE - MS
Education & Risk Factors “Training Error”
- Overtraining → Relative rest
- Decreasing the volume of the inciting activity or avoidance of the activity entirely
- Return to activity should be gradual, 50% of intensity and distance.
- Soft, level surfaces should be used initially.
- Avoid increasing training regimens “too much, too fast”
- Avoid extensive running on hard or uneven surfaces.
Protection & Orthosis
- Crutch walking is indicated if pain persisted during walking
- Orthotics: over pronation or forefoot varus.
Optimal Loading
- Stretching
ICE & Modalities
- Icing 15 minutes 4-6 times daily
Surgery
- Fasciotomy of the posteromedial fascia (rarely needed)
Cuccurollo 4th Edition Chapter 4 MSK pg250
Spot diagnosis. Predisposing Factor 🔑🔑 , Management & Return To Play
STRESS FRACTURES
- Microfractures develop, and with continued overuse are not compensated by normal boney growth and turnover
- As a result they can coalesce and propagate through the bone to become a symptomatic stress fracture.
Presentation
- Night pain
- Pain worsens with increased activity.
- Pain localized to the fracture site.
Predisposing Factor
- Low bone mineral density (BMD)
- Females with late onset of menses
- Individuals with low body weight (<75% ideal body weight)
- Poor nutrition correlates with lower calcium intake
- Tobacco and excessive alcohol use
- Female athlete triad
- Biomechanics conditions
- Overpronation (genu valgum and a wide gait)
- Leg length discrepancies
- Muscle imbalances
- Lack of flexibility
- Poor conditioning
- Training errors
- Rapid increase in training volume “too much, too fast”
- Running on hard surfaces
- Using worn-out shoes
Examination
- Tenderness localized to the fracture site
- Swelling and redness (DDx Shin Splints, Chronic Exertional Compartment Syndrome)
Imaging
- Xray
- Stress fractures may not be seen for 2 to 3 weeks
- Periosteal thickening appears first, followed by cortical lucency
- MRI is the most sensitive and specific (first choice of test)
ER - POLICE - MS
Education “Return to Sport”
- Relative rest
- Substitute running with low impact exercises like cycling and swimming
- Impact activity start at low intensity for short periods (10–15 minutes)
- After at least 1 to 2 weeks of pain-free normal ambulation
Protection
- Crutch walking in case of antalgic gait for 7 to 10 days
- Shoe modification
- Medial arch support for hyperpronation
- Good cushion to decrease impact force
Optimal Loading
- Muscle strengthening and stretching
Medications
- Calcium intake should be 1,500 mg daily with 400 to 800 IU of vitamin D.
Cuccurollo 4th Edition Chapter 4 MSK pg251-252
Leg pain during exercise and complain of bulging in his right leg. Diagnosis, Complications, Examination, Investigations, Management.
CHRONIC EXERTIONAL COMPARTMENT SYNDROME (CECS)
- Chronically raised intracompartmental pressure.
Presentation
- Pain can be neuropathic or ischemic
- Pain increase with exercise (opposite to medial tibial stress syndrome)
- Pain diminish with rest (opposite to medial tibial stress syndrome)
- It may persist if the exercise session was particularly demanding.
Differentials
- Tibial stress fractures
- Periostitis
Examination / Complications
- On palpation, the compartment may be firm tender
- Fascial hernias may be palpable
- Nerve impingement
- Anterior (deep peroneal nerve)
- Ankle dorsiflexion weakness
- Numbness over the first web space of the dorsum of the foot
- Lateral (superficial peroneal nerve)
- Foot eversion weakness
- Numbness of the dorsal foot and anterolateral distal shin
- Posterior (tibial nerve)
- Weakness with plantar flexion and numbness of the plantar foot
- Anterior (deep peroneal nerve)
- Tissue ischemia (distal pulses diminished)
Investigations
- Plain films, CT, bone scan, and MRI help to investigate other sources of leg pain
- Manometric technique
- Pressures are measured pre and post exercise, positive test is delay in return to pre exercise pressure levels of 6 to 30 minutes.
- Slit/wick catheter technique
Management
- Fasciotomy
Cuccurollo 4th Edition Chapter 4 MSK pg248
Patient discharged on cast and after 2 hours came pain, paresthesias, and paralysis (3 Ps). Diagnosis, Mechanism, Management 🔑🔑
ACUTE COMPARTMENT SYNDROME (ACS)
💡 Muscle necrosis may develop in 4 to 8 hours → surgical emergency
- Intracompartmental tissue pressure acutely becomes elevated and produces a secondary elevation in venous pressure that obstructs venous outflow
- Volkmann’s ischemic necrosis
- Tissue necrosis can develop with secondary muscle paralysis, muscle contractures, and sensory impairment
- It results in claw hand or foot caused by contractures of the ischemic muscle.
Causes
- Trauma in association with fractures of the long bones of the leg or forearm.
- After prolonged limb compression (e.g., following severe drug or alcohol intoxication or poor positioning during surgery).
- Certain animal bites
- Vascular disease
- Thrombosis
- Conditions that decrease serum osmolarity
- Ischemia-reperfusion injury
- s/p revascularization procedures
Presentation
- Sensory hypesthesia distal to the involved compartment
- Pain, paresthesias, and paralysis (3 Ps).
- Extreme pain on stretching the long muscles passing through a compartment
- Pulses can be normal in ACS because the intracompartmental pressure rarely exceeds systolic or mean arterial pressure levels.
Management
- Remove cast or dressing if present
- Measure compartment pressure
- Manometric techniques
- Slit catheter technique
- Diastolic pressure minus the intracompartmental pressure is ≤20 mmHg.
- Surgical fasciotomy (risk of muscle necrosis and nerve damage.)
Cuccurollo 4th Edition Chapter 4 MSK pg49
Muay thai player with chronic leg pain.
MYOSITIS OSSIFICANS
- Heterotopic ossification within muscle from encapsulated blood secondary to a hematoma.
- Repeated trauma to that area of muscle
- Nerve impingement symptoms may occur
Imaging
- Calcific flocculations can develop within 14 days.
- Ossification can be seen between 2 and 3 weeks
- US can be helpful for office or bedside diagnosis of a hematoma and myositis ossificans
ER - POLICE - MS
Control Risk Factors / Protection
- Avoid repeated trauma
Optimal Loading
- ROM exercises to avoid contracture
- Strengthening of the involved muscles
ICE & Modalities
- Radiation therapy
- Avoid US, heat, massage
Surgery
- Nerve entrapment, decreased ROM, or loss of function
- Delayed until the lesion matures at 10 to 12 months
Cuccurollo 4th Edition Chapter 4 MSK pg225-226
Spot diagnosis, complication, Investigation, 2 other locations, examination 🔑🔑
OSTEOCHONDRITIS DISSECANS (OCD)
- Etiology remains unclear, no clear evidence
- Fragmentation of articular cartilage with subchondral bone
- Repetitive stresses to subchondral bone (trauma) that disrupt blood supply to that area of bone (vascular insult) → localized area of AVN → formation of dead subchondral bone covered with articular hyaline cartilage → piece may detach from the rest of the bone, entering the joint space as a loose body.
Presentation
- Joint pain and irritation, synovial effusion, and a buckling sensation
- Joint locking indicates of loose body
Complication
- Early degenerative joint disease (early OA)
Xray
- MRI will better define the lesion area.
Locations of OCD
- Distal humerus
- Elbow
- Distal femur (most common)
- Patella
- Talar dome 🔑🔑
Examination
- Medial femoral condyle: knee flexed 90 degrees with pressure directed medial to the inferior pole of the patella
Management
- Knee must be placed at rest and protected from weight bearing
- Surgical excision
- Healing does not occur
- Fragment becomes detached
Cuccurollo 4th Edition Chapter 4 MSK pg244-245
Coxa Varus and Valgus
Coxa vara hip deformity whereby the angle between the femoral head-neck span and the shaft is reduced to less than 120 degrees. Coxa valga refers to an increase in this angle.
