Ch 10 MDT Lower Extremity Flashcards
Secondary to a reaction of the periosteum in response to increased stress, as seen in runners
Shin Splints
Gradual onset of pain with prolonged walking or running activity
Pain is localized to distal third of the medial tibia
Patient may have increased training, intensity, pace, or distance
Shin Splints
Physical Exam:
- Visal: Unremarkable
- Tenderness along posterior medial crest of tibia
- ROM: Unremarkable
- Pain with resisted plantar flexion
Shin Splints
Diagnostics for Shin Splints
Radiographs if concerned for stress fracture
Treatment for Shin Splints
NSAIDs
Ice
Light duty
Gradual pain free return to running
Weight loss
Proper running shoes
Shin splints not healing with conservative management should be further investigated with:
Plain films/MRI
Should be on the differential of every patient with shin pain
Suspected Tibial Stress Fracture
Symptoms similar to shin splints
Pain becomes more focal and time course to recovery is much longer
May increase over the course of weeks or months
Pain worsens and begins to hurt AT REST
Suspected Tibial Stress Fracture
Unremarkable visual exam
Point tenderness in the tibia
ROM is unremarkable
Pain with resisted plantar flexion
Patient complains they have PAIN AT REST
Suspected Tibial Stress Fracture
Diagnostics for Suspected Tibial Stress Fracture
Plain film X-ray
MRI/CT/Bone scan is better to detect stress fractures
Treatment for Suspected Tibial Stress Fracture
Duty modification for 12 weeks
NSAID/Tylenol
RICE
Cross training for runners (cycling/swimming)
Elevation of intra-compartmental pressure to a degree that compromises blood flow to the involved muscles and nerves
Compartment Syndrome
Muscles of the lower leg are divided into ____ compartments by fibrous septa
Four
Acute Compartment Syndrome can result from:
Crush injury
Muscle strain
Closed fracture
Type of Compartment Syndrome:
- Chronic in nature and followed by exercise
- Associated with prolonged walking or running with gradual onset of pain
- Do not experience pain at rest
- Anterior compartment is most commonly involved
Exertional compartment syndrome
Severe leg pain out of proportion to apparent injury
-Deep ache or burning
Symptoms progress over few hours
Pain, pallor, parasthesias, paresis, poikothermia, pressure, pulselessness
Pale, Shiny skin
Compartment Syndrome
Diagnostics tests for Compartment Syndrome
During Surgery
Intercompartmental pressure monitoring for chronic exertional Compartment Syndrome
Treatment for Compartment Syndrome
Fasciotomy
- Prior to transport: Remove tight fitting items, place limb in neutral position
- Analgesics and Supplemental O2
Largest tendon in the body
Achilles
Achilles Tendon Rupture
___ per 100,000 general population
5-10
Achilles Tendon Rupture occurs in ___% of competitive athletes
8.3%
__% of military recruits develop Achilles tendinopathy
6.8%
What muscles converge to form the Achilles tendon?
Gastrocnemius and Soleus
Achilles inserts posteriorly on the:
Calcaneus
Risk factors for Achilles Tendon Rupture
Athletes
Age 30-40 y/o
Male
Obesity
Running mechanic issues
Fluoroquinolone antibiotic use
Rheumatologic disease
Sensation of being struck violently in back of ankle
-“Pop”
Ecchymosis, edema, foot malalignment
ROM/Strength: Impaired plantarflexion
Positive Thompson test
Achilles Tendon Rupture
Exam Achilles Tendon Rupture patient in what position?
Prone, feet hanging off table
Diagnostics for Achilles Tendon Rupture
MRI (Gold Standard)
U/S
Treatment for Achilles Tendon Rupture
Light duty
Ice
NSAID
Achilles tendon support
Physical therapy
Complete tear: Ortho Consult in 1-2 Days
Ligament that connects Talus and anterior fibula
Anterior talofibular ligament (ATFL)
Ligament that connects Talus and posterior fibular
Posterior talofibular ligament (PTFL)
Ligament that connects calcaneus and fibula
Calcaneofibular ligament (CFL)
Majority of ankle sprains involve _____ only
ATFL
Results from “high ankle sprain”
Disruption of interosseous membrane
Eversion injury with dorsiflexion
Results in medial ankle sprain
Syndesmosis injury
Eversion injury
Repeat ankle injury is almost ____ times as likely as primary injury
Five
Ankle sprain
Edema is measured with what method?
Figure 8
Ankle sprain
Check areas required for the Ottawa ankle rules:
Posterior edge/tip of Lateral Malleolus
Posterior edge/tip of Medial Malleolus
Base of fifth metatarsal (Navicular bone)
Swelling, ecchymosis of ankle
Eversion/Inversion limited due to pain
Positive Anterior Drawer = ATFL
Positive Talar Tilt = CFL
Positive tib/fib squeeze (syndesmosis sprain)
Ankle Sprain
Ottawa Ankle Rules catches __% of fractures
98%
Ankle sprain
MRI for patients without relief after ___ weeks
6-8
Treatment for Ankle Sprain
RICE
NSAIDs
Light duty
Pain free stretching/strengthening
Brace
Critical injury involves the second tarsometatarsal joint
Second metatarsal “keys” into a slot in the cuneiforms and is the stabilizing apex for the other tarsometatarsal joints
Lisfranc Fracture
Patients report a sprain
Pain is localized to the dorsum of the midfoot
Swelling may be relatively mild
Ecchymosis in plantar arch
Edema in the tarsometatarsal joint
Maximum tenderness and swelling over the tarsometatarsal joint rather than ankle ligaments
Lisfranc Fracture
Special test to differentiate Lisfranc Fracture from an ankle sprain
Stabilize the calcaneus with one hand and rotate and/or abduct the forefoot with the other hand
Diagnostics for Lisfranc Fracture
Radiographs
When AP radiographs shows _____________, even by only a few millimeters, a Lisfranc Fracture has occurred
Second metatarsal base has shifted laterally
Treatment for Non-displaced Lisfranc Fracture
Ortho consult
6-8 weeks in non-weight bearing cast immobilization
Analgesics
Treatment for displaced Lisfranc Fracture
Ortho consult
SURGERY
Analgesics
Creates hallux valgus with lateral deviation of the great toe at the MTP Joint
Prominence of the medial aspect of the first metatarsal head
Bunion
Bunions are much more common in females at a ratio of:
10:1
Pain and swelling, aggravated by shoe wear
Great toe pronates with resulting callus on the medial aspect
Bunion
Valgus stress at the MTP joint of the great toe
Hypertrophic bursa
Great toe is pronated (rotated inward)
Tenderness over joint
MTP valgus greater than 15 degrees
Bunion
The severity of a bunion deformity is graded by measuring:
Forefoot angles on weight-bearing AP radiographs of the foot
Normal hallux valgus angle is ___
Normal intermetatarsal angle is ____
< 15 degrees
< 10 degrees
Treatment for Bunion
Patient education and shoe modification
Light duty
Ice
Perineural fibrosis of the common digital nerve as it passes between the metatarsal heads
Most common between the third and fourth toes (third web space)
Morton neuroma
Most common symptom of Morton neuroma
Plantar pain in the forefoot
Plantar pain of forefoot
Dysesthesias or burning plantar pain that is aggravated by activity
Numbness in the adjacent toes
“Walking on a marble” or “Wrinkle in my socks”
Morton neuroma
Positive Special tests for Morton neuroma
Metatarsal squeeze test
Diagnostic tests for Morton neuroma
Diagnosed clinically
MRI/US if diagnosis is unclear
Treatment for Morton neuroma
Wear low-healed, soft-soled shoe with a wide toe box
Metatarsal pads (take pressure off of the metatarsal heads)
Long fibrous band like tissue that arises from the medial tuberosity of the calcaneus and extends to the proximal phalanges
Plantar fascia
Most common cause of heal pain in adults
Due to degeneration
Occurs twice as much in woman as in men
More common in over weight patients
Plantar Fasciitis
Pain is most severe on awakening or when rising from a resting position
Prolonged standing and walking increases pain
Focal pain directly over the medial calcaneal tuberosity and 1-2 cm distally along the plantar fascia
Plantar Fasciitis
Diagnosis for Plantar Fasciitis
Clinically
Pain in the inferior heel that is worse when starting to walk plus finding of local point tenderness
Treatment for Plantar Fasciitis
NSAIDs
Ice massage
Light duty
OTC heel pads
Night splints
Plantar Fasciitis
Surgical release should be considered only after _____ months of intense non-operative management
6-12 months
Pain in the posterior heel may originate from one or more of the following structures:
Achilles Tendinosis
Retrocalcaneal bursitis
Haglund syndrome
Pre-Achilles bursitis
“Pump bump” that is irritated by shoe wear
Start-up pain in heel
Pain after activity
Antalgic gait
Posterior heel pain
Calcaneal prominence may be present with edema
Superficial bursa (pump bump)
Tenderness over heel or Achilles tendon
Dorsiflexion limited
Positive Thompson test
Posterior heel pain
Diagnostic tests for posterior heel pain
Clinically diagnosed
- Lateral radiographs may show calcification
- Prominent posterosuperior process of the calcaneus
Treatment for Posterior heel pain
Light duty
Heel lift or open back shoes
Ice massage
Achilles stretch
Casting for 6 weeks in extreme cases
Hyperextension injury of the first metatarsal
Turf Toe
Swelling, tenderness, and limited motion of first MP joint
Turf Toe
Diagnostic tests for Turf Toe
Radiographs are useful for ruling out fractures
Bone scan or MRI when diagnosis is in question
Treatment for Turf Toe
RICE
NSAIDs
Stiff shoe inserts
Treatment for severe Turf Toe
Immobilization for 1-2 weeks and 4-6 week period of rest from sports
