CLINICAL CARE OF THE LOWER EXTREMITY MUSCULOSKELETAL SYSTEM Flashcards
1
Q
What is thought to be secondary to a reaction of the periosteum in response to increased stress, as seen in runners?
A
Shin splints
2
Q
True or False
Shin splints must be differentiated from a tibial stress fracture
A
True
3
Q
A patient presents with a history of gradual onset of pain with prolonged walking or running that is localized to the distal third of the medial tibia, what is the most likely diagnosis?
A
Shin splints
4
Q
Patients with what will have tenderness along the posterior medial crest of the tibia in the middle to distal third of the leg?
A
Shin splints
5
Q
True or False
Patients with shin splints with have pain with resisted plantar flexion
A
True
6
Q
What is the treatment for stress fractures?
A
- NSAIDS
- Ice
- LLD activity mod
- Gradual return to pain free running
- Weight loss if needed
- Proper running shoes
7
Q
Shin splints not responding to conservative management should be further investigated with plain films and/or ____ or bone scan
A
MRI
8
Q
What should be a differential diagnosis for any patient with shin pain?
A
Tibial stress fractures
9
Q
Typically tibial stress fractures occur in runners who do what?
A
Ramp up mileage to quickly
10
Q
What presents very similarly to shin splints but becomes more focal and recovery time is much longer?
A
Tibial stress fractures
11
Q
What are some clues that a patient presenting with shin splints may have a tibial stress fracture?
A
- Pain at rest
2. Pain that suddenly increases in intensity around site of more mild symptoms
12
Q
Patients with what will have point tenderness in the tibia upon palpation?
A
Tibial stress fracture
13
Q
True or False
All patients with a suspected tibial stress fracture need imaging to confirm the diagnosis
A
True
14
Q
True or False
All patients with suspected stress fractures require X-rays but a negative X-ray cannot rule out a stress fracture
A
True
15
Q
What imaging is better at detecting stress fractures of the tibia?
A
MRI/CT
*MRI is mostly used
16
Q
What is the treatment for a tibial stress fracture?
A
- Rest/duty mod
- Weight bearing modification and training
- NSAID/Tylenol/ice
- Duty mod for roughly 12 weeks
17
Q
Muscles of the lower legs are divided into four compartments by what?
A
Fibrous septa
18
Q
What is characterized by an elevation of intra-compartmental pressure to a degree that compromises blood flow to the involved muscles and nerves?
A
Compartment syndrome
19
Q
What syndrome can be acute resulting from crushing injury, muscle strains, or closed fractures?
A
Acute compartment syndrome
20
Q
What raises pressure in the fibrous septa?
A
Inflammation
21
Q
What form of compartment syndrome is chronic in nature and followed by exercise; usually associated with prolonged walking or running with gradual onset of pain symptoms?
A
Exertional compartment syndrome
22
Q
The following symptoms are associated with what?
- Severe leg pain out of proportion to apparent injury
- Persistent deep ache or burning pain
- Paresthesias
- Symptoms progress over few hours
A
Compartment syndrome
23
Q
What are the Seven “P’s” when concerned for compartment syndrome?
A
- Pain
- Pallor
- Parasthesias
- Paresis
- Poikilothermia
- Pressure
- Pulselessness
24
Q
True or False
Compartment syndrome
Measurement of compartment pressures are not required for diagnosis but are often done by surgical team
A
True
25
True or False
Acute compartment syndrome is a medical emergency and requires a fasciotomy by a surgeon
True
26
What is the treatment for chronic exertional compartment syndrome?
1. Rest from aggravating activities
2. NSAIDS
3. Possible surgery
4. Ice is contraindicated
27
True or False
Achilles tendinopathy is common
True
28
How many cases of Achilles tendinopathy happen per 100,000 cases in the general population?
5-10
29
Achilles tendinopathy is more common amongst who?
Athletes
30
Achilles tendinopathy occurs in what percentage of competitive athletes?
8.3%
31
What percentage of military recruits develop Achilles tendinopathy?
6.8%
32
What is the largest tendon in the body?
Achilles tendon
33
The gastrocnemius and soleus muscles converge to form the what?
Achilles tendon
34
What tendon inserts posteriorly on the calcaneus?
Achilles
35
These are all risk factors for what?
1. athletes
2. age (30-40)
3. males
4. obesity
5. running mechanic issues
6. fluoroquinolone antibiotic use
7. rheumatologic disease
Achilles tendon rupture
36
What special test should be used for a possible Achilles tendon rupture?
Thompson test
** can still miss about 10% of ruptures**
37
If an Achilles tendon rupture is suspected what is the gold standard imaging to be used to confirm the diagnosis?
MRI
UT is an alternative
38
What is the treatment for an Achilles tendon rupture?
1. LLD
2. Ice
3. NSAIDS
4. Achilles tendon support
a. heel lift
b. elastic bandage
c. taping
5. PT
39
True or False
All complete tears of the Achilles tendon require an ortho consult and a MEDEVAC
True
40
What ankle ligament connects the Talus and anterior fibula?
Anterior talofibular ligament (ATFL)
41
What ankle ligament connects the talus and posterior fibula?
Posterior talofibular ligament (PTFL)
42
What ankle ligament connects the calcaneus and fibula?
Calcaneofibular ligament (CFL)
43
What is the large, strong, and less commonly injured medial ankle ligament?
Deltoid ligament
44
What injury of the ankle is most common?
Inversion
45
Inversion ankle injuries result is what kind of ankle sprain?
Lateral ankle sprain
46
The majority of ankle sprains involve what lateral ankle ligament?
ATFL
47
What kind of ankle injury results in a medial ankle sprain?
Eversion
**less common**
48
What ankle injury results in a "high ankle sprain", a disruption of the interosseous membrane?
Eversion injury with dorsiflexion
49
Repeat ankle injuries are how many more times likely as the primary injury?
five times
50
How is edema measured with ankle injuries?
Figure of 8 method
51
True or False
With ankle sprains you should palpate the entire fibula, distal tibia, foot, and Achilles tendon
True
52
For ankle sprains you should use what rules?
Ottawa ankle rules
53
What special test should be done for an ankle sprain?
1. Anterior Drawer - ATFL
2. Talar Tilt - CFL
3. Tib/fib squeeze
54
Ottawa ankle rules help catch about what percentage of fractures?
98%
55
An MRI should be ordered for a patient with an ankle sprain if they have no relief after how many weeks?
6-8
56
What is the treatment for an ankle sprain?
1. RICE
2. NSAIDS
3. LLD/activity mod
4. Pain free calf stretching and strengthening
5. Bracing as needed
57
The critical injury of a Lisfranc fracture involves the second what?
tarsometatarsal joint
58
True or False
Lisfranc fracture
The second metatarsal "keys" into a slot in the cuneiforms and is the stabilizing apex for the other tarsometatarsal joints
True
59
These are symptoms associated with what fracture?
1. Patients often report a sprain
2. pain is localized to the dorsum of the midfoot
3. swelling may be relatively mild
Lisfranc fracture
60
Patients with what will have maximum tenderness to palpation and swelling over the tarsometatarsal joint rather than the ankle ligaments?
Lisfranc fracture
61
This is a special test associated with what?
During examination, stabilize the hindfoot (calcaneus) with one hand and rotate
and/or abduct the forefoot with the other hand
Lisfranc fracture
This maneuver produces severe pain with a Lisfranc injury but only minimal
pain with an ankle sprain
62
AP radiographs that show that the second metatarsal base has shifted laterally, even by only a few millimeters, what kind of fracture has occurred?
Lisfranc
63
True or False
Lisfranc fractures
If there is confusion about the diagnosis, a CT or MRI is helpful in confirmation
True
64
What is the treatment for a Lisfranc fracture?
1. Ortho consult
2. Non displaced injuries are treated with 6-8 weeks of non-weight bearing cast
immobilization
3. Fractures or dislocations that are displaced require surgery
4. Non-weight bearing (NWTB)
5. Analgesics
6. MEDEVAC
65
True or False
Even a minimally displaced Lisfranc fracture requires surgical reduction
True
66
What creates hallux valgus, which is lateral deviation of the great toe at the MTP joint?
Bunion
67
What may lead to prominence of the medial aspect of the first metatarsal head (bunion)?
Hallux valgus
68
Are bunions more common in men or women?
Women 10:1
69
Pain and swelling, aggravated by shoe wear are the principal complaints of what?
Bunions
70
The great toe pronates with resulting callous on the medial aspect in what?
Bunion
71
You will see the following in visual exam of what?
1. Valgus stress at the MTP with hypertrophic changes over joint
2. A hypertrophic bursa is evident over the medial eminence of the first metatarsal
3. The great toe is pronated (rotated inward) with subsequent callus on its medial aspect
Bunion
72
True or False
The severity of a bunion deformity is graded by measuring forefoot angles on weightbearing AP radiographs of the foot
True
73
True or False
Bunion
The normal hallux valgus angle is < 15°, and a normal intermetatarsal (IM) angle is <10°
True
74
What is the initial treatment for a bunion?
1. PT education and shoe wear modifications
2. LLD
3. Ice
75
True or False
Bunion
Patients with persistent pain may benefit from surgical correction
True
76
What neuroma is not a true neuroma but rather a perineural fibrosis of the common digital nerve as it passes between the metatarsal heads?
Morton Neuroma
77
What condition is most common between the third and fourth toes (third web space)?
Morton neuroma
78
Plantar pain in the forefoot is the most common presenting symptom in what?
Morton Neuroma
79
Dysesthesias into the affected two toes or burning plantar pain that is aggravated by activity is common in what? Patients also report numbness in the adjacent toes of the involved web space.
Morton neuroma
80
Many patients with what state they feel as though they are "walking on a marble" or that there is a "wrinkle in my socks", removing the shoe and rubbing the ball of the foot often help obtain relief?
Morton neuroma
81
True or False
Isolated pain on the plantar aspect of the web space is consistent with an intermetatarsal neuroma
True
82
What special test is indicated with a Morton Neuroma?
Metatarsal squeeze test
Apply upward pressure between adjacent metatarsal heads and then compress
the metatarsals from side to side with the free hand
The upward pressure places the neuroma between the metatarsal heads, allowing it to be compressed during side-to-side compression
83
What is the treatment for a Morton Neuroma?
1. Low heeled, soft soled shoe with a wide toe box
| 2. Metatarsal pads
84
What is a long fibrous band like tissue that arises from the medial tuberosity of the calcaneus and extends to the proximal phalanges?
Plantar fascia
85
What provides support to the foot and toes by tightening thus elevating the longitudinal arch, inversion of the hindfoot and external rotation?
Plantar fascia
86
What is the most common cause of heel pain in adults due to the degeneration of the plantar fascia, occurring twice as much in woman as in men, and is more common in over weight patients?
Plantar fasciitis
87
The following are clinical symptoms associated with what?
1. Pain is often most severe on awakening, or when rising from a resting position because the first few steps irritate the foot
2. Prolonged standing and walking also increase the pain; sitting relieves symptoms
3. Focal pain directly over the medial calcaneal tuberosity and 1-2 cm distally along the plantar fascia
Plantar fasciitis
88
True or False
Patients with plantar fasciitis will be TTP directly over the plantar medial calcaneal tuberosity and 1-2 cm distally along the plantar fascia
True
89
What is the treatment for plantar fasciitis?
1. NSAIDS
2. Ice massage
3. LLD/activity mod
4. OTC heel pads
5. Night splints may be helpful
90
True or False
Plantar fasciitis
Patients whose symptoms do not respond to non-operative treatment need further evaluation, Surgical release should be considered only after 6 to 12 months of intense nonoperative management
True
91
The following structures may be associated with pain originating from where?
1. Insertion of the Achilles tendon at the calcaneus (Achilles tendinosis)
2. Retrocalcaneal bursa (retrocalcaneal bursitis)
3. Prominent process of the calcaneus impinging on the retrocalcaneal bursae and/or Achilles tendon (haglund syndrome)
4. Inflammation of the bursa between the skin and the Achilles tendon (pre-achilles bursitis)
Posterior Heel pain
92
The following clinical symptoms are associated with what?
1. "pump bump"
2. Start up pain
3. Pain after activity
4. Antalgic gait
Posterior heel pain
93
A calcaneal prominence may be present with associated edema and superficial bursa may be present (pump bump) in what?
Posterior heel pain
94
True or False
You may have a positive thompson test for Achilles tendon rupture in a patient with posterior heel pain
True
95
True or False
Posterior heel pain
Lateral radiographs of the heel may show calcification of the Achilles tendon and spur formation, a prominent posterosuperior process of the calcaneus also may be present
True
96
What is the treatment for posterior heel pain?
1. LLD/ activity mod
2. Heel lift or open back shoes
3. Ice massage
4. Achilles stretch
5. Casting for 6 weeks in extreme cases
97
What is known as a hyperextension injury of the first metatarsal?
Turf toe
98
True or False
Turf toe is called such because of the increased incidence of hyperextension injury associated with playing on artificial turf
True
99
Patients with what usually report swelling, tenderness, and limited motion of the first MP joint?
Turf toe
100
True or False
Turf toe
Radiographs are useful to detect associated avulsion fractures, evaluate joint congruity, and rule out preexisting arthritic changes and when the diagnosis is in question, a bone scan or MRI can help exclude other possibilities such as sesamoid or metatarsal fractures
True
101
What is the treatment of turf toe?
1. RICE
2. NSAIDS
3. Stiff shoe inserts
4. Severe injury requires protective weight bearing or immobilization for 1-2 weeks and with 4-6 week period of rest from sports
102
True or False
Turf toe
Intra-articular fractures can require open reduction or excision
True
103
True or False
Turf toe
Urgent surgical intervention is necessary for an irreducible dislocation
True
104
True or False
Turf toe
Osteochondral lesions or loose bodies also require further evaluation
True
