Common Pathologies lower limb Flashcards
Aim of physio intervention
differential diagnosis, determine appropriateness of physio/ other assessments (X-rays, scans, blood tests)/ interventions (injections/ surgery), to rehabilitate LL dysfunction conservatively
diagnosis and management
understand who gets it (typical patient), understand disease aetiology, understand typical presentation, understand why aetiology causes presentation, understand management
different groups of LL pathologies
tendinopathies (gluteal, achilleas, plantar fascia, rupture), OA (hip>knee»ankle), joint disorders (FAI, meniscal tears), sprains (ACL/PCL, MCL/LCL, ankle- LLS=ATFL, CFL), adolescents (OGS. SLJ)
LL MSK disorders- vascular, bone, muscle/tendon
Vascular= Venous (DVT) or arterial, bone= stress fracture or fracture, muscle/tendon= tendinopathies or muscle strains
LL MSK disorders- neural and joint
neural= entrapment, peripheral, spinal joint= degenerative, inflammatory, traumatic
what causes insertional tendinopathy
due to calcaneal compression
typical GTPS patients and subjective
female/ postmenopausal/ increased BMI/ comorbidities
subjective= diffuse pain, sleep disturbance, standing on one leg, walking, hills/stairs
gluteal tendinopathy treatment
reduce compression, increase strength, increase functional strength and control. increase resilience to compression
physio main treatment for GTPS
education, load management, self- management strategies, strengthening exercises targeted to hip abductors
activity modification
reduce external loading- volume, intensity, frequency, duration, heel raises
MTU- functions as a shock absorber and spring- good
good muscle coordination, increased energy efficiency, greater elastic recoil- less hear production- -0tentional to improve or protect from tendinopathy
MTU- functions as a shock absorber and spring- bad
poor muscle coordination (ineffective function)- reduced energy efficiency and greater amplitude of tendon strain or greater cumulative load- greater energy absorption (More heat)- potential to trigger cellular response and tendinopathy
neuromuscular demanding exercise programme- achilleas (step up)
work away from patient preferred speed/ tempo, ensure full DF, stop movement at different positions, make patient aware of tremor- aim to smooth this, add external load early, different knee flexion angles, movement straight up (not leaning forward), change limb alignment
what happens with OA
breakdown of articular cartilage, fibrillation, fissures, gross ulcerations, disappearance of articular surface, osteophyte formation, thickening of subchondral bone, synovial membrane changes
clinical features of LL OA
high levels of activity (early OA), hip pain on movement/ walking, pain around joint, loss of ROM (on PROM R>P), antalgic or trendelenburg gait
treatment for OA
depends on severity of condition:
mobilisations for pain and stiffness, strengthening and ROM exercises, lifestyle/weight loss, surgery where pain and stiffness are severe= TJR or compartment replacement
what muscle groups are commonly injured
hamstrings>calf>groin>quads
groin strain- muscles and causes
muscles- adductors, iliopsoas, rectus femoris
cause- inflammation from overuse muscle/tendon direct trauma/biomechanics, inflammation/ pain on movement or contraction= loss of function/ weakness, visible/ palpable defect
hamstring strain rehab
POLICE, early load, length of muscle (ROM/ stretch), strengthen, pain relief if needed
collateral ligament injury- mechanisms of injury
usually varus/valgus contract force (i.e.direct blow to the knee can also occur as a result of a varus or valgus blow to the foot, MCl most commonly injured structure in knee> common than LCL, characteristic instability caused by MCL/ LCL injury is opening of medial/lateral joint space
signs and symptoms of lig injury
any age group but often early adulthood, focal joint pain, +/- h/o clicking/ popping, giving way, locking, swelling developing (24+ hours for extra articular lig, <24 for intra articular), positive test
ACL- MOI
injury on external rotation, usually sudden deceleration and change of direction with fixed foot or hyperextension injury, often combined with valgus strain of MCL and medial meniscus
ACL- signs and symptoms
knee buckles, unable to stand, immediate swelling- haemarthrosis (within 2 hours), inability to resume sport, locking/ loss of extension, positive lachmans test
PCL- MOI and S+S
MOI- posterior force to proximal tibia, if combined with rotational force injury to P-L complex
S+S= mild to mod swelling, positive posterior draw test, often asymptomatic, pain on kneeling
postero-lateral complex- structures involved
ITB/LCL/Popliteus/acurate ligament/ posterior horn lat meniscus/ lat coronary ligament/ posterior lat joint capsule/ bicep fem tendon
postero-lateral complex- injury
rare but disabling and need specialist referral, associated with ACL/PCL injuries, poor outcome
postero-lateral complex- mechanisms
direct blow to antero-medial tibia in an extended knee, fall onto a flexed knee, non-contact hyperextension
S +S of postero-lat injury
pain in the postero-lateral corner, personal nerve symptoms, associated ligament pathology, positive posterolateral drawer
S + S of meniscal tears
H/O loaded twisting/ squatting, catching, locking, acute block to extension, effusion developing over 24 hours, joint line tenderness, +ve clinical tests= McMurray’s/ Apley’s/ Joint line tenderness
Patella-femoral disorders
patella femoral pain syndrome, Mal-tracking, dislocation, chondromalacia patella, patella tendinosis, prepatellar bursitis
PFPS
pain at front of knee, worsened by prolonged sitting/ stair climbing or activities involved in bending, usually related to excessive mechanical loading/ chemical irritation of nerve endings
PFPS- contributing factor
patella malalignment- abnormal biomechanics, muscle imbalance, overuse, direct trauma
P/F dislocation / subluxation
dislocation- patella slipped out and had to be manually relocated, subluxation- patella slipped out and spontaneously relocated
S+S= localised tenderness around medial extensor retinaculum+ lateral knee pain, haemarthrosis,
PFJ disorders- functional and structural
functional- muscle length/ strength, stability, proprioception
structural- bony alignment, patella shape, trochlear shae, foot position
PFD treatment
pain/CMP/maltracking- patella mobilisation/ tape/ exercise
dislocation- reduction, tendon transposition, quadriceps strengthening
meniscal management- depends on
clinical evaluation, associated lesions, type/location and extent of tear
meniscal management- arthroscopic management
partial meniscectomy- preserve peripheral rim+ remove loose unstable fragment= increases incidence of degenerative changes, meniscal repair= poor success, rehab programme- depending on surgery
meniscal management- conservative treatment
10% of patients with partial thick or short radial tears requires surgery after 4 years, mobilisations, exercise- quads and proprioception
ligament rehab
unlikely to be isolated, consider Rx of other structures, rehab +/- reconstruction, functional bracing
MCL- aggressive conservative rehab 4-6 weeks return to sport, PCL or LCL= if isolated (unusual) then conservative, not isolated= surgery
lateral ligament strain diagnosis- demographic and 24hr aggs
demographic- common teens to 40’s
24 hr: Aggs- walking or running over uneven ground, turning sharply, landing on inverted ankle
lateral ligament strain diagnosis- symptoms and HPC
symptoms- pain+SWELLING local esp. ATFL
HPC- traumatic= specific injury involving ankle inversion, sudden onset, can be recurrent
lateral ligament strain diagnosis- SQ and SH and assessment
SQ- giving way, swelling- onset or recurrent, walking over uneven ground
SH- sport involving rotation
assessment= ROM, lig tests, muscle strength tests, rehab target deficits
lateral ligament strain diagnosis- management (functional vs Immobilisation)
functional treatment (ankle exercises + external support) and proprioception immobilisation= more effective in shor and long term than immobilisation (decreased swelling, increased stability)
plantar fasciitis- demographic and 24 hour aggs
demo- late 50’s, obese women, athletes (long distance runnings)
24 hour= first few steps am, or after prolonged rest, running/dancing/jumping/prolonged standing/walking
plantar fasciitis- subjective
symptom location- medial origin of medial band of plantar fascia, HPC- gradual onset over weeks/months, may be associated with traumatic incident
FSH- sport or job that involves weight bearing
SQ= P+Ns or Numbness
plantar fasciitis- management- taping
medial arch support for the overpronated foot, correction of calcaneal valgus, effectiveness unknown,
plantar fasciitis- management exericses
stretching of PF, hamstrings and calfs= improved with stretching alone, strengthening of tibialis posterior, intrinsics may be beneficial but lack of evidence
perthes
AVN of femoral head, self limiting with revascularization occurring within 2-4 years, femoral head may remain deformed resulting in OA, most common in 6 year old males, want to reduce weight bearing and see if femoral head regrows
LL disorder treatments
tendons= modify load, strengthen, progress, RTP
joint/OA- modify load/ ROM/ Strengthen/ progressive function
ligaments= modify load/ ROM/ balance/ strength/ neuromuscular control
fractures and joint replacement- ROM/ strengthen/ rehab function
what do locking, swelling, subjective assessment at knee
locking= meniscus injury (tear can lead to flaps that can catch), swelling- constant? temp, how long? activity induced? knee giving away/locking- how many times over a period of time? painful?
what is the unhappy triad an dhow to differentiate between them?
meniscus, ACL, LCL
meniscus= locking, ACL- giving way/ popping/ immediate swelling, MCL- pain and swelling medially
test for PFJ pain
stairs and squats- anything where flex and ext under load
