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CASEM > High Yield 4 > Flashcards

High Yield 4 Flashcards

1
Q

MOI tib plateau #

A

Axial loading force + varus/ valgus force causing articular shear, depression + malalignment
Pedestrian struck in lower leg, passenger in MVA, fall from height, violent twisting force

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2
Q

Conditions associated w/ tib plateau # + common mechanisms

A

Lateral plateau # + MCL (d/t valgus force)
Medial plateau # + LCL, PCL, medial meniscus (varus force w/ axial load)
Compartment syndrome

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3
Q

Sx + physical of tib plateau #

A

Painful, swollen knee
Inability to wt bear

Physical
Effusion
Decreased active + passive ROM
Tenderness proximal tibia

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4
Q

Ix for tib plateau #

A

XR - AP, lateral, tib plateau view (AP w/ knee in 10 degrees flexion), oblique
MRI or CT

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5
Q

In ?tib plateau #, what sx would make you consider compartment syndrome?

A

Pain not over fracture site
Pain on passive stretch
Paresthesia
Abnormality of pulses
Pressures >30 mm Hg—indication for fasciotomy

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6
Q

DDx for tib plateau #

A

Knee dislocation
Cruciate ligament tears/avulsion
Collateral ligament tears/avulsion
Meniscal tears
Quadriceps tendon rupture
Patellar fracture
Patellar dislocation

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7
Q

Management of tib plateau #

A

Long leg splint
Ice, elevation
Surgery or non operative management
Full extension brace x10 days then hinged knee brace
Non wt bearing x4-6 wks
Repeat XRs q2-3wks
Healing = 12-20 wks

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8
Q

When to refer for surgery in tib plateau #

A

Lateral plateau fracture with:
Articular step off >3 mm
Condylar widening >5 mm
Coronal plane instability

Displaced medial plateau fracture (60% of weight-bearing through medial plateau)
Bicondylar fractures
Fracture dislocations, vascular injuries, and compartment syndrome

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9
Q

Sx of patella/ quadriceps tendinopathy

A

Anterior knee pain worse w/ jumping or running or prolonged knee flexion
Progressive

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10
Q

RF for patella/ quadriceps tendinopathy

A

Running or jumping sports (volleyball, basketball, soccer, track + field)
Poor flexibility of quads + hamstrings
Use of fluoroquinolone abx within 90 days
Underlying CTD

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11
Q

Physical for patella + quadriceps tendinopathy

A

Patellar tendinitis: localized tenderness at the patellar tendon origin (inferior pole of the patella), patellar tendon midportion, and/or patellar tendon insertion (tibial tubercle)
Quadriceps tendinitis: localized tenderness at the quadriceps tendon midportion and/or quadriceps tendon insertion (superior pole of the patella)
Both: pain reproduced with extension of the knee versus resistance and/or with maximal stretching of the quadriceps
Both: poor flexibility of the quadriceps and hamstrings

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12
Q

DDx for patella/ quadriceps tendinopathy

A

Patellofemoral pain syndrome
Hoffa disease (fat pad impingement)
Osgood-Schlatter disease
Sinding-Larsen-Johansson syndrome
Chondromalacia patella/patellofemoral osteoarthritis
Osteochondral lesions
Patellar subluxation/dislocation
Patellar stress fracture
Patellar tendon rupture (partial or complete)
Quadriceps tendon rupture (partial or complete)
Lumbar radiculitis/radiculopathy involving the L3 and/or L4 nerve roots

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13
Q

Management of patella/ quadriceps tendinopathy

A

Relative rest, ice, NSAIDs, topical nitro patch
Patella tendon strap

Stretching + strengthening”
quadriceps, mainly single leg squats with a slow negative phase

Percutaneous intervention if failed conservative rx x6mo
Needle tenotomy
Platelet-rich plasma (PRP)
Prolotherapy
Tendon scraping or hydrodissection, separating the peritenon/fat pad from the tendon, disrupting the neovessels and nerves
Shock wave therapy

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14
Q

MOI patella / Quadriceps tendon rupture

A

Rapid, eccentric contraction w/ knee in partial flexion + foot planted
Landing from a jump, falls.
Patella tendon ruptures are usually complete

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15
Q

RF patella / Quadriceps tendon rupture

A

More common in males
Patellar tendon rupture typically < 40 years
Quad tendon typically > 40 years
Quad tendon rupture is more common than patellar tendon rupture
Corticosteroid in tendon
SLE, RA
DM
Obesity
Hx of tendinosis
Fluoroquinolones
High jump, basketball, wt lifting
Previous TKR, ACL reconstruction using patella graft

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16
Q

Sx of patella / Quadriceps tendon rupture

A

Pop
Immediate disabling pain
Unable to wt bear or straighten knee
Acute onset swelling

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17
Q

Physical for patella / Quadriceps tendon rupture

A

Audible crepitus
Often unable to weight bear
Often large hemarthrosis and bruising
Unable to do a straight leg raise or maintain a passively extended knee
Patella alta (patella is superiorly displaced) in complete patellar tendon rupture
Patella baja (patella is inferiorly displaced) in complete quadriceps tendon rupture
Palpable defect (may be masked by swelling acutely or by scar tissue in delayed evaluation)
Tenderness to palpation over patellar poles, retinaculum, or tibial tuberosity
Absence of/altered patellar tendon reflex
Altered gait if able to bear weight
Quadriceps atrophy (in chronic cases)

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18
Q

Ix for patella / Quadriceps tendon rupture

A

US usually used
MRI is gold standard

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19
Q

DDx for patella / Quadriceps tendon rupture

A

Fracture
Muscular strain (grade I or II)
Patellar subluxation/dislocation
Meniscal or ligamentous pathologies
Osgood-Schlatter disease
Sinding-Larsen-Johansson syndrome (inferior patella pain d/t repeated stress on growth plate)

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20
Q

Management of patella / Quadriceps tendon rupture

A

Immobilize w/ straight leg splint, ice, elevation
Refer to ortho
Incomplete - can be treated non operatively
Immobilization and protected ambulation for 6 wk, followed by a hinged brace allowing active extension in situ until pain resolves

Surgery is indicated for:
complete ruptures
incomplete ruptures failing to respond to nonoperative treatment
Ideally within 2 wks

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21
Q

Rehab for patella / Quadriceps tendon rupture

A

Immobilise x6 wks - during this time, work on active flexion + passive extension exercises
6 wk onward: straight-leg raise exercises
8 wk onward: stationary biking and water running
3 mo onward: progressive quadriceps exercises
4 mo onward: jogging
9 mo onward: jumping and contact sports permitted
Comprehensive physical therapy program should be completed before return to athletics

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22
Q

Complications of patella / Quadriceps tendon rupture

A

Loss of flexion is common after quadriceps tendon rupture.
Extensor mechanism weakness
Postoperative infection
Degenerative change at the patellofemoral joint

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23
Q

What is a Bakers cyst, and what are the types?

A

Cystic enlargement of the gastrocnemius-semimembranosus bursa, located on the medial side of the popliteal fossa between the medial head of the gastrocnemius and the semimembranosus tendon:

Primary cysts arise with no communication into the joint (more common in children).

Secondary cysts are associated with communication between the bursa and joint capsule (more common in the adult population)

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24
Q

RF for bakers cyst

A

Trauma
Intra-articular knee pathology (meniscal tears, OA, RA, ACL tear)

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25
Q

Sx of bakers cyst

A

Usually asymptomatic
Posterior knee pain, swelling, palpable mass, knee stiffness
Can have leg swelling, calf pain

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26
Q

Physical of bakers cyst

A

Palpable medial popliteal mass
Examine in full extension + 90 degrees flexion

Foucher sign
Tense cyst with knee in extension softens or decreases in size with knee flexion
Change in findings related to knee position helps to differentiate popliteal cyst from solid masses

Homans sign
Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight
Indicates DVT but can be positive in Baker’s cyst

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27
Q

Ix for bakers cyst

A

US or MRI

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28
Q

Management of bakers cyst

A

Manage underlying joint pathology
May not need treatment of cyst if asymptomatic

If symptomatic w/o vascular or neurogenic compression:
Rehab to maintain knee flexibility
Direct cyst aspiration + steroid inj

If conservative x6 wks does not work or if vascular or neurogenic compression, refer for surgery

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29
Q

Complications of bakers cyst

A

Cyst rupture or dissection
Enlarged cyst may compress adjacent vein, resulting in pseudothrombophlebitis or thrombophlebitis with symptoms of leg swelling and erythema.
Compression of tibial nerve may result in neuropathy, plantar foot numbness, or gastrocnemius atrophy.
Compression of popliteal artery may lead to limb claudication or ischemia.
Compartment syndrome may result from cyst rupture, which requires emergent management.

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30
Q

DDx of bakers cysts

A

Deep vein thrombosis (DVT)
Popliteal artery aneurysm
Solid tumors (lipoma, sarcoma, etc.)
Other cystic structures (ganglion cyst, meniscal cyst, myxoid tumors)

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31
Q

RF + MOI for PCL tear

A

Contact sports (football, soccer, skiing, wrestling)

MOI
Dashboard injury in MVA (Posteriorly directed force to anterior proximal tibia in flexed knee)

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32
Q

Sx of acute vs chronic PCL tear

A

Acute:
Pain in posterior knee
Pain w/ kneeling
Feeling of instability
Rapid onset swelling

Chronic:
Vague anterior knee pain
Pain with or inability to descend inclines/stairs, deceleration, or running at full stride

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33
Q

Physical for PCL tear

A

Perform neurovascular exam before other provocative tests
If combined with an ACL injury, assume vascular injury, perform ankle-brachial index, and, if low stat, referral to vascular surgeon
Posterior drawer test positive
Posterior sag positive

Quadriceps active test positive
Perform with the patient supine and knee flexed at 90 degrees and hip flexed at 45 degrees.
Examiner stabilizes the foot, and the patient attempts to extend the knee while the examiner applies a counter force against the ankle.
Patient also may be asked to activate quadriceps by sliding foot down the table.
In a PCL-deficient knee, the posteriorly subluxed tibia will translate anteriorly with quadriceps activated.

Dynamic posterior shift test:
Patient is supine with knee and hip flexed at 90 degrees.
Examiner slowly extends knee.
With a PCL tear, there will be “clunk” near full extension when the posteriorly subluxed tibia is reduced.

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34
Q

Ix for PCL tear

A

XR: AP, lateral, sunrise, tunnel, oblique + stress views
Stress XRs (lateral XR with knee flexed + posteriorly directed force applied to proximal tibia): 8mm or more posterior tibial translation is indicative of complete PCL tear
MRI gold standard

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35
Q

DDx for PCL tear

A

​​ACL tear
Tibial or fibular fracture
Medial or lateral collateral ligament tear
Meniscal derangement
Posterolateral corner injury
Knee and/or patella dislocation

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36
Q

Management of PCL tear

A

Acute
Ice, compression, elevation, immobilization (partial wt bearing, full extension for grade 3 lesions)
Refer to ortho
Non operative indications:
Isolated grade 1 + 2 tears
RTP 2-4wks w/ knee brace

PT
Multiphase with time-specific and objective finding–related phases
Progressive weight-bearing
Quadriceps strengthening
Immobilization initially, with progressive addition of flexion until full range of motion (ROM) achieved
Functional PCL brace may be useful but not proven effective

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37
Q

Indications for surgery in PCL tear

A

Associated bony avulsion fractures.
Multiple ligament injuries.
Persistent pain in grade 3 lesions.
Chronic symptomatic instability with activities of daily living or with sports.
Acute grade 3 injury in young, active patient

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38
Q

Complications of surgical vs non surgical care of PCL tear

A

Nonoperative:
Chronic PCL laxity
Progressive medial compartment and patellofemoral degenerative changes
Increased risk of meniscal tears, articular cartilage injury with chronic PCL insufficiency

Operative:
Most common: residual laxity
Iatrogenic neurovascular injury (especially of the popliteal artery)
Loss of motion
Infection
Medial femoral condyle osteonecrosis
Anterior knee pain
Painful hardware

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39
Q

RF for Patellar subluxation + dislocation

A

Prior history of subluxed or dislocated patella
Recurrence rate 15–50% after initial dislocation
Adolescent females
Patella alta (“high-riding patella”)
Excessive genu valgum
Weak vastus medialis
Excessive tibial torsion
Family history of patellar instability
Trochlear dysplasia
Lateralized tibial tuberosity
Weak hip abductor and external rotator muscles
Risk factors associated with developmental dysplasia (firstborn girl, high birth weight, deliver by cesarean section, breech delivery)

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40
Q

Sx of Patellar subluxation + dislocation

A

Severe pain, pop
Consider subluxation if hx consistent w/ dislocation but pain resolved

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41
Q

Physical for Patellar subluxation + dislocation

A

Immediately after dislocation, may show patella dislocated laterally and prominence medially due to uncovered medial femoral condyle
Obvious effusion
Tenderness most apparent over the medial edge of patella and lateral femoral condyle
Limited range of motion with knee in extended position
Fear of redislocation when knee is flexed
Positive apprehension sign with movement of patella laterally
Check anterior cruciate ligament (ACL) and meniscus, as up to 12% of patellar dislocations have associated major ligamentous or meniscal injury.
“J” sign: Seated patient straightens the knee; the patella moves outward instead of straight upward.

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42
Q

Ix for Patellar subluxation + dislocation

A

XR
MRI

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43
Q

Management of Patellar subluxation + dislocation (acute)

A

Reduce (may need conscious sedation): leg in extension w/ hip flexed (reduces tension of quad tendon), apply Gentle pressure on patella directed lateral to medial
Postreduction XRs
RICE
Knee immobilization x2-3 wk
Wt bearing as tolerated after 1 wk
Aspiration if hemarthrosis present to reduce pain - check for fat globules (would help dx osteochondral #)

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44
Q

When to refer to ortho for Patellar subluxation + dislocation

A

Osteochondral fracture
Recurrent patellar dislocations despite adequate rehabilitation, especially in younger patients (<14 yr old), in whom recurrence rates can reach 60%
Evidence of joint locking
High-risk athlete participates in activities involving pivoting and is at increased risk of recurrent patellar dislocation

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45
Q

PT, type of brace + RTP for Patellar subluxation + dislocation

A

PT
Isometric quadriceps exercises are begun as soon as possible, although it is often difficult and painful for the athlete to produce a contraction that involves the vastus medialis.
Active range of motion exercises (closed chain) are started at 1 wk and physical therapy consultation given for quadriceps and lateral hip strengthening

Bracing
Knee immobilizer or hinged brace is used for ambulation until 100 degrees of painless flexion is present, there is no effusion, and a normal heel-to-toe gait is possible.
Immobilizer or hinged brace ultimately is replaced with a neoprene sleeve with a lateral buttress until normal, painless activities of daily living are possible.

RTP
There should be evidence of adequate healing (absence of sensations of instability, lack of effusion, and absence of pain on patellofemoral compression) and adequate function (able to perform rotational movements such as pivoting, cutting, and twisting without evidence of instability) for return to sports
Athlete may need McConnell taping or patellar stabilizing braces to accomplish this.

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46
Q

What is a knee dislocation?

A

Complete disruption of tibiofemoral articulation

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47
Q

Types of knee dislocation with associated MOI + other injuries

A

Dislocation is described as the displacement of the tibia relative to the femur
Anterior dislocation (40%):
Hyperextension of the knee of at least 30 degrees
Rupture of the posterior capsule followed by the PCL

Posterior dislocation (33%):
Direct blow to the anterior tibia with the knee flexed at 90 degrees (“dashboard” injury or falling onto flexed knee)
ACL is usually spared.

Medial dislocation (4%):
Varus stress causing tear to ACL, PCL, and LCL; highest risk of posterolateral corner (PLC) damage and thus the highest risk of irreducible dislocation
Associated with tibial plateau fracture

Lateral dislocation (18%):
Valgus stress causing tear to ACL, PCL, and MCL
Associated with tibial plateau fracture

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48
Q

Complications of knee dislocation

A

Popliteal artery injury (64% of dislocations) - only 6 hr window to prevent permanent ischemic damage
Fibular nerve injury (50% of dislocations)
Characterized by hypesthesia of anterolateral leg and dorsum of foot, weakness of ankle dorsiflexion

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49
Q

RF for knee dislocation

A

More common in young males
Morbid obesity
Contact or high velocity sports

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50
Q

Sx of knee dislocation

A

Pop
Knee pain and instability
Often unable to weight bear

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51
Q

Physical for knee dislocation

A

Difficulty weightbearing
If knee dislocation has not spontaneously reduced, deformity is obvious (and should present to the ED). Most (especially the lower energy sporting injuries) reduce spontaneously
Dimple sign: dimple of the medial skin and soft tissues
Pucker sign: Puckering of skin results from its attachment to the invaginated capsule
A key sign is extensive bruising of either medial or lateral knee, which is from a hemarthrosis that has leaked out from a torn joint capsule
If high impact injury + multiple ligaments unstable, suspected relocated knee dislocation

Vascular exam:
By palpation, Doppler, ankle-brachial pressure indexes, and distal perfusion
Dorsalis pedia, posterior tibialis, popliteal
Popliteal thrill or expanding pulsatile hematoma
Signs of distal ischemia: pallor, paresthesias, pain, paralysis, unequal temperature
If peripheral pulses are normal initially, it is essential to do serial, frequent exams with documentation of pulses

Neuro exam:
Sensory: anterolateral lag, dorsum of foot, first web space
Motor: ankle dorsiflexion, eversion

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52
Q

DDx for knee dislocation

A

Tibial plateau fracture
Supracondylar femoral fracture
Isolated fibular nerve injury
ACL injury/rupture

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53
Q

Ix for knee dislocation

A

CBC, Cr, INR
XR to r/o # but may be normal
ABI
Systolic BP x4 limbs w/ Doppler probe
Highest pressure from dorsal pedal pulse or posterior tibial pulse / highest brachial BP
If asymmetric pulses or ABI <0.9, perform angiography
MRI

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54
Q

Treatment for knee dislocation

A

Support ABCs
Splint in 20 degrees flexion to prevent traction or compression of the PA
Get to hospital ASAP + contact ortho immediately - plan to reduce in ED
In ED:
Reduce to reduce pressure on neurovascular structures
If pucker or dimple sign present, suspect posterolateral dislocation which is irreducible - consider immediate open reduction in ED
Refer to ortho +/- vascular
Admit for serial ABI + pulse exams x48 hrs
Rehab:
Goal of 90 degrees knee flexion 6 wk postoperatively and 120 degrees at 12 wk
No return to full activity or sports before 9 mo

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55
Q

Complications of knee dislocation

A

Amputation
Compartment syndrome
Neurovascular deficit
Chronic pain
Stiffness
Instability

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56
Q

RF for PFPS

A

Recent increase in training
Increased running, squats, lunges
Patella hyper or hypomobility
Malalignment
Valgus/ varus deformity
Common in young teens
Specialisation of single sport leads to higher incidence

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57
Q

Sx of PFPS

A

Diffuse anterior knee pain
Associated w/ squatting, running, stairs, prolonged sitting
Persists for years
Pain on knee straightening

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58
Q

Physical for PFPS

A

Crepitus/ grinding
Anterior knee pain during squatting
Tenderness on patella edges

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59
Q

DDx for PFPS

A

Patellar or quadriceps tendinopathy
Patellofemoral osteoarthritis
Patellar instability with subluxation or dislocation
Osteochondral defect of the trochlear or patellar surface
Osteochondritis dissecans
Iliotibial band syndrome
Infrapatellar fat pad inflammation or impingement
Synovial plica
Retinacular strain
Osgood-Schlatter apophysitis (proximal anterior tibia)
Sinding-Larsen-Johansson apophysitis (inferior patellar pole)
Referred pain from the hip, often affecting the anterior distal thigh and knee

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60
Q

Management of PFPS

A

Rx
Foot orthotics/ supportive shoes
Ice, compression, elevation for acute pain control
Taping (McConnell)
PT

Activity modification recommendations + home exercises
Reduce aggravating activity (running, squatting)
Encourage other activities (swimming, cycling)
Combined hip + knee exercises preferred
Isometric quadriceps strengthening (push knee into floor with leg straight)
Straight leg lift from floor slowly
IT band stretches
Hamstring stretches
Hip adductor strengthening by squeezing ball between legs
Calf stretch

RTP
If patient has PFP during, immediately following, or the day after exercising:
Decrease activity. Avoid strength training exercises such as full squats and lunges.
Consider alternate activities, such as an elliptical trainer, bicycling, or swimming.
Runners who need to maintain running-specific conditioning, use a floatation belt for pool running.
Sx usually resolve within 4 wks

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61
Q

MOI meniscal injury

A

Twisting, shearing or compressive force
Usually twisting through a flexed, planted knee

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62
Q

RF for meniscal injury

A

Male gender
Abnormal mechanical axis
Playing soccer or rugby
Ligament deficiency
Degenerative joint disease
Discoid meniscus
Poor quadriceps control
Waiting >12 mo between ACL tear and reconstruction surgery is a risk factor for medial meniscus tear

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63
Q

Conditions commonly associated w/ meniscal injury

A

ACL
Tib plateau #

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64
Q

Sx of meniscal injury

A

Pain with walking, stairs, squatting, kneeling, prolonged sitting
Onset after plant + pivot action
Slow onset swelling
Catching, locking, clicking
Giving way

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65
Q

Exam of meniscal injury

A

Locked knee (bucket handle tear, ligament tear or loose body)
Effusion + joint line tenderness
McMurray positive
Thessaly positive

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66
Q

Ix for meniscal injury

A

XR wt bearing (AP, lat, skyline, tunnel)
MRI

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67
Q

DDx for meniscal injury

A

Synovitis
Intra-articular loose body
Articular cartilage defect (OCD)
Ligamentous injury, particularly ACL and/or MCL
Patellar subluxation/dislocation
Degenerative joint disease
PFPS
Tibial plateau fracture

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68
Q

Management of meniscal injury

A

Initial: RICE
Surgery or
Non op (For small central tears or degenerative tears) - steroid shot, PT

Then:
Lower weight bearing activities (bike, swim)
Avoid plant/ pivot/ twist activities
PT addressing balance, quadriceps, and hamstring strength

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69
Q

When to refer for surgery in meniscal injury

A

Locked knee
Younger patients with vertical longitudinal tears in periphery of meniscus
Locking symptoms, flap tears, and bucket-handle tears.
Associated cruciate ligament injury, osteochondral defect, loose bodies, or fracture.
Nonurgent referrals include tears treated nonoperatively but that continue to cause pain or disability

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70
Q

Complications of meniscal injury

A

Injury to peroneal nerve possible with lateral meniscus repair
Injury to infrapatellar branch of saphenous nerve possible with medial meniscus repair
Repair could fail, resulting in repeat arthroscopy.
Infection

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71
Q

Types of knee “locking”

A

“True locking” - mechanical block, usually extension blocked, caused by meniscus tear or loose body - sometimes a wiggle can unlock it
“Pseudo locking” - pain/ muscle contracture “locks” - can be in flexion or extension, d/t swelling, inflammation, patella maltracking, plica syndrome
Acutely locked knee is an orthopedic emergency

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72
Q

What is Osgood Schlatter’s?

A

Apophysitis (inflammation of growth plate (apophysis)) of tibial tuberosity at attachment to patellar tendon
Overuse injury

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73
Q

RF for Osgood Schlatter’s

A

Ages of growth spurts (girls 8-13 y/o, boys 12-15 y/o)
Males
Running + jumping sports
Excessive kneeling
Overweight

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74
Q

Sx of Osgood Schlatter’s

A

Anterior knee pain
Often bilateral
Worse w/ activity (running, jumping, kneeling), improves w/ rest
Chronic, insidious, fluctuant swelling

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75
Q

Physical for Osgood Schlatter’s

A

Tender tibial tuberosity
Prominent tibial tubercle
Able to maintain full symmetric knee extension w/ SLR
If inable to do this, highly suggestive of tibial tubercle avulsion #
Pain w/ resisted knee extension, active or passive knee flexion

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76
Q

DDx for Osgood Schlatter’s

A

​​Patellar tendonitis
Sinding-Larsen-Johansson syndrome
Tibial tubercle avulsion fracture
Tibial plateau fracture
Patellar fracture
Osteochondritis dissecans
Patellofemoral syndrome
Pes anserine bursitis
Patellar tendon rupture
Patellar subluxation
Chondromalacia patellae
Hoffa disease (infrapatellar fat pad impingement)
Osteomyelitis
Tumor

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77
Q

Management of Osgood Schlatter’s

A

Relative rest
Activity as tolerated if sx resolve within 24hrs
NSAIDs
Ice after exercise
Lasts 6-18mo, self limiting (will resolve when growth plate closes)
Stretch quads + hamstrings + strengthen quads
If conservative treatment failed, consider surgical excision of enlarged tibial tubercle

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78
Q

Sx of medial tibial stress syndrome

A

Chronic, insidious, progressive
Posteromedial border of the middle to distal ⅔ of tibia
Early in course: Pain occurs during activity rather than at onset:
Sometimes relieved as activity continues
Often worse with toe-off
Often aches after rest which is in contrast to chronic exertional compartment syndrome where pain is relieved quickly by rest
Late in course: pain through full duration of activity:
Pain and aching continue after cessation of inciting activity.

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79
Q

RF for medial tibial stress syndrome

A

Female sex
Higher body weight
Navicular drop (an indicator of excessive pronation)
Prior running injury
Limited external/internal rotation of hip
Limited ankle range of motion (ROM)
Higher body mass index (BMI)
Overall poor conditioning
Limited core strength

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80
Q

Physical for medial tibial stress syndrome

A

Tenderness to palpation along the middle to distal 2/3 of the tibia, along the posteromedial border
Diffuse posteromedial pain with palpation is most sensitive finding
Shoe exam shoes overpronation wear pattern, excessive wear of shoes
r/o stress # by hopping on one foot, vibration

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81
Q

Ix for medial tibial stress syndrome

A

XR + possibly bone scan to r/o stress fracture

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82
Q

DDx for medial tibial stress syndrome

A

Stress fracture
Compartment syndrome
Muscular strain
Nerve entrapment
Fascial defects
Popliteal artery entrapment syndrome

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83
Q

Management of medial tibial stress syndrome

A

Rx
Correct biomechanics, well cushioned shoe
Ice, NSAIDs
Complete rest ideally then cross training with pain-free activities
Stretching and strengthening
Physiotherapy - shockwave therapy
Taping

Activity modification recommendations + home exercises
Target-specific stretching and strengthening exercises
Core strengthening
Towel calf stretches
Tracing alphabet with toes
Alternate heel/toe walking

84
Q

Prevention of medial tibial stress syndrome in future

A

Shock-absorbing insoles: most promising in studies
Pronation control insoles if navicular drop
Replacing running shoes after 300 miles/ 6mo wear
Gradually increasing running programs
Increase rest days
Cross training w/ non wt bearing activity

85
Q

Sx of DOMs + physical findings

A

Hx
Delayed onset muscle soreness - muscle pain after training sensation. Typically starts 12 hrs after exercise, peaks at 24-48 hrs, stops after 5 days

Physical
Painful muscles, swelling, increased muscle girth, reduced passive stretch, reduced muscle strength

86
Q

Prevention of DOMs

A

regularly participating in exercise that causes symptoms, warming up correctly, stretching + massage

87
Q

Sx of heat cramp

A

Often a prodrome “cramp prone state” when muscle feels tight or painful. Cramps usually involve muscles which cross 2 joints (like calf, hamstrings or quads)
Painful, involuntary contractions of muscles
Commonly calf, quads + abdomen

Tense, tender, involuntary contraction of muscle belly

88
Q

DDx for heat cramp

A

Gastroc/ soleus strain or tear
DVT
Popliteal artery entrapment
Referred pain from lumbar spine

89
Q

Management of heat cramp

A

Rest
Oral rehydration + electrolyte replacement - IV if unable to tolerate by mouth
Passive stretching
Massage
Ice

90
Q

Prevention of heat cramp

A

Training should be similar to match/ game intensity + duration
Passive stretching during play
Acclimatise to heat
Appropriate clothing
Hydration

91
Q

What is the physiology that occurs in athletes when they acclimatise to hotter climates?

A

Increased blood volume and venous tone, earlier onset of sweating, more sweat volume, more diluted sweat

92
Q

What is ITB friction syndrome?

A

Overuse tendinopathy that occurs from compression of the iliotibial band (ITB) against the lateral femoral epicondyle

93
Q

Sx of ITB friction syndrome

A

Pain is especially sharp after foot strike in the gait cycle, usually at ~30 degrees of knee flexion
Lateral knee pain - sharp or burning
Pain is not present when the patient starts exercising but begins at a predictable time or distance within the workout.
Symptoms that subside shortly after the workout but return with the next workout
Pain worse with downhill running, stride lengthening, or sitting for long periods of time with a flexed knee
Involvement in sports that require continuous running or repetitive knee flexion (i.e., bicycling)

94
Q

RF for ITB friction syndrome

A

Training factors: higher weekly mileage, downhill running, disproportionate running on a track in the same direction
Increased peak hip adduction (possibly owing to significant weakness of the hip abductors of one limb as compared with the other) and increased knee internal rotation during stance phase, with running

95
Q

Physical for ITB friction syndrome

A

May notice local tenderness and swelling as well as crepitation, snapping, or pitting edema over the distal ITB where it passes over the lateral femoral epicondyle, and there may be pain or paresthesia along the length of the band

Positive Ober test
Position the patient on the unaffected side with the involved knee in 90 degrees of flexion. The leg is abducted at the hip, and the examiner then grasps the ankle and extends leg, allowing the knee to return to an adducted position. A person with ITB tightness will remain abducted

Positive Noble compression test:
With the patient on his or her side with the affected knee up and flexed at 90 degrees, apply pressure on the ITB at the lateral femoral epicondyle and extend the knee. A positive test occurs when pain occurs as the knee approaches 30 degrees of flexion

Leg length discrepancy can cause tightening of ITB

96
Q

DDx for ITB friction syndrome

A

​​Patellofemoral syndrome
Degenerative joint disease
Lateral meniscal damage or pathology
Lateral collateral ligament sprain
Superior tibiofibular joint sprain
Popliteal or biceps femoris tendinopathy
Peroneal nerve injury
Gout and other metabolic arthropathy
Referred pain

97
Q

Management + RTP for ITB friction syndrome

A

Rest, avoid aggravating activities
Ice, NSAIDs
PT - hip + core strengthening + stretching, foam roller
Gait training - increasing gait width, reducing hip adduction changing from heel strike to forefoot landing, and avoiding excess pronation
Can consider steroids but this increases risk of ITB rupture
Surgery for ITB release if no improvement w/ conservative therapy
RTP when sx have 100% improved - going back too early will cause significant delay
Usually 6 wks

98
Q

Sx of chronic compartment syndrome

A

Usually lateral, diffuse leg pain
Often bilateral
Fullness, cramp-like, tightness type pain
Aggravated w/ impact activities
No pain at rest but pain w/ activity, usually specific amount of exertion every time
Resolves <30 mins after stopping activity
Associated w/ paresthesias + foot drop
Change in activity/ training intensity may have provoked sx

99
Q

RF for chronic compartment syndrome

A

Rapid increase in repetitive activity
Participation in high-risk sport activities
Significant musculature of the lower extremity
Diabetes mellitus

100
Q

Physical for chronic compartment syndrome

A

Normal exam at rest

Examine postexertion
Pain may become present
Muscle/facial tightness may be palpable
Neurovascular abnormalities may become present
Passive stretching of the muscles in the affected compartment may also cause pain.

101
Q

Ix for chronic compartment syndrome

A

Needle manometry is gold standard
Pre + post exercise compartment pressures

102
Q

DDx for chronic compartment syndrome

A

Acute compartment syndrome
Stress fracture
Medial tibial stress syndrome
Fascial hernia
Tendonitis
Popliteal artery entrapment syndrome
Peripheral nerve entrapment
Peripheral vascular disease
Referred pain (L4)
Exertional DVT

103
Q

Management + RTP for chronic compartment syndrome

A

Conservative measures: stretch, soft tissue therapy (friction massage), correct biomechanics (rarely successful), forefoot training
Definitive management: fasciotomy, 80-90% success rate
Recurrence rate 20-30%
RTP 8-12 wks

104
Q

Criteria for diagnosis of compartment syndrome based on compartment pressures

A

(1) preexercise/rest pressure of greater than 15 mmHg
(2) 1-minute postexercise pressure of greater than 30 mmHg
(3) 5-minute postexercise pressure of greater than 20 mmHg.
(4) Post-Exercise elevated pressure despite 15 minutes rest

105
Q

MOI, physical findings + management of acute compartment syndrome

A

Usually associated w/ # or crush injury

Physical
Pain out of proportion to physical exam
Pain w/ passive stretching
Neurovascular abnormalities at rest

Management
Immediate consult for ortho surg
Emergency fasciotomy
Complications
Muscle necrosis

106
Q

Sx of DVT

A

Can be asymptomatic
Swelling, pain, discoloration
PE sx can be first sign (SOB, CP, cough, hemoptysis)

107
Q

Physical for DVT

A

Well criteria for DVT
Swelling >1cm compared to opposite leg
Palpable cord
Warmth
Superficial venous dilation
Homans sign - passive dorsiflexion of ankle elicits pain in calf

108
Q

Ix for DVT

A

D dimer if low risk, if high risk + neg D dimer then do further imaging

Bilateral duplex US
CBC, PT as a baseline
?PE
do CT angiography or V/Q scan

ECG - S wave in lead I, Q wave in lead III, inverted T wave in lead III (S1Q3T3)

109
Q

DDx for DVT

A

Superficial thrombophlebitis
Cellulitis
Torn muscles and ligaments
Ruptured Baker cyst
Bilateral edema (seen with heart, kidney, or liver disease) is rarely caused by DVT.
Prior DVT and postphlebitic syndrome
Arterial insufficiency
Arthritis
Lymphangitis
Extrinsic compression of iliac vein secondary to tumor, hematoma, or abscess
Hematoma
Lymphedema
Neurogenic pain
Prolonged immobilization or limb paralysis
Stress fractures or other bony lesions
Varicose veins

110
Q

Management of DVT

A

If provoked, anticoagulation x3mo

If unprovoked 1st time, indefinite anticoagulation if low risk bleeding, if high risk bleeding then 3mo
Rivaroxaban 15mg PO BID x3 wks then 20mg PO daily
Apixaban 10mg PO BID x7 days then 5mg PO BID daily

Refrain from training x1mo
Compression stockings x9mo

111
Q

Rehab + RTP for DVT

A

Light ambulation after 24hrs of anticoagulation
Weeks 1 to 3: reintroduction to activities of daily living
Week 4: begins engaging in non–weight-bearing activities (e.g., swimming)
Week 5: progresses to nonimpact-loading exercises (e.g., cycling)
Week 6: begins impact-loading exercises (e.g., running)
Week 6+: A gradual transition to sport-specific protocols as well as an increase in the duration and intensity of training may be initiated
No contact sports while on anticoagulation

112
Q

Prevention of DVT

A

Avoid prolonged immobility.
Hydrate adequately.
Consider compression stockings when immobilized.
Caution when using birth control; use low-estrogen pills when possible.
Prophylaxis for hospitalized patients
When travelling:
Hourly walking breaks
Loose clothing
Avoid crossing legs

113
Q

RF for DVT

A

Immobilisation (trauma, long flights, post op)
Pregnancy
Malignancy
Smoking
Steroids
Dehydration
Increased age
Antiphospholipid syndrome
Estrogen therapy
Fam hx
Obesity
Trauma
Clotting disorder (factor V leiden, antithrombin deficiency, protein C or S deficiency)

114
Q

MOI hamstring strain

A

Excessive load during an eccentric contraction, such as with running or jumping
​​Usual mechanism of injury occurs in the later part of the swing phase as the hamstrings rapidly change from eccentrically working to decelerate knee extension to concentrically becoming an extensor of the hip

115
Q

RF for hamstring strain

A

Strength imbalances, flexibility, core strength, lumbopelvic position, and fatigue
Prev hx of hamstring injury

116
Q

Sx of hamstring strain

A

Usually acute: sudden onset posterior thigh pain
Chronic presents w/ tightness

117
Q

Physical for hamstring strain

A

A “stiff-legged” gait may occur as patient tries to avoid hip flexion with knee extension.
Position patient prone and inspect for swelling and/or ecchymosis.
Palpate the entire length of each hamstring muscle going from common origin on ischial tuberosity moving distally until insertion on fibular head (BF), medial femur (SM), and medial tibia (ST)

118
Q

DDx for hamstring strain

A

Direct hamstring injury, including muscle laceration or contusion (common direct mechanism for injury as opposed to indirect strain mechanism)
Posterior lateral corner knee injury, meniscal injury, or popliteal cyst formation or rupture
Pelvic or proximal femoral stress fracture
Piriformis syndrome, gluteus medius injury, or adductor strain
Pain radiating from the lumbar back, sacroiliac joint, or hip

119
Q

Management of hamstring strain

A

Acute
Goals: control pain, swelling, hemorrhage, and muscle fiber adhesion; work toward restoration of normal gait
Protection, rest, ice, compression, and elevation (PRICE)

Subacute/ rehab
Advance activity as tolerated
Core strength
Lumbar stability
Nordic hamstring exercises

RTP
When pain free - can be weeks to months

Surgery
Consider in severe proximal or distal injuries

120
Q

Prevention of hamstring strain

A

Nordic hamstring exercises

121
Q

What makes up the hamstring?

A

Biceps femoris
Semiteninosus
Semimembranosus

122
Q

RF + MOI for proximal hamstring tendon rupture

A

RF
Sprinters, water skiers

Mechanism
Forceful knee extension while hip joint is in flexion

123
Q

Sx + physical for proximal hamstring tendon rupture

A

Pain and bruising in posterior thigh

Stiff leg gait (they don’t want to stretch hamstring by flexing hip, or activate it by flexing knee)
Bruising
Often can palpate retracted muscle
Weakness and pain with resisted knee extension

124
Q

Ix for proximal hamstring tendon rupture

A

X-rays to look for avulsed bony fragment, US or MRI to confirm

125
Q

Management of proximal hamstring tendon rupture

A

Operative repair suggested for complete proximal avulsions, or 2 tendon involvement in young, active individuals if there is retraction. Suggest: obtain imaging and refer above semi-urgently.

126
Q

What is a Lisfranc injury?

A

Lisfranc ligament is between medial cunieform + 2nd MT
An injury to the ligament complex that stabilizes the mifdoot. The Lisfranc ligament attaches the medial cuneiform to the base of the 2nd MT. There is a spectrum of injuries from mild sprains to dislocations. There may only be soft-tissue involvement, or there may be fracture-dislocations.

127
Q

MOI Lisfranc injury

A

Hindfoot placed in a fixed position with forefoot forcefully abducted in sports such as equestrian and windsurfing produces lateral displacement of the metatarsals with associated fracture of 2nd metatarsal base.
An axially applied force to a plantarflexed foot (tiptoe position) causing disruption of the dorsal ligament complex
A force applied to the heel and the axis of the foot with the toes fixed in plantar position
Typical sport injury example: Imagine a player’s foot is in a position like they are about to do a sprint: ankle is in plantar flexion and toes are dorsiflexed. Their foot is slightly rotated, like they are going to take off at an angle. Then, another player falls on their heel causing an axial load +/- abduction force.
Crush injury
MVA

128
Q

RF + commonly associated conditions w/ Lisfranc injury

A

RF
Males

Commonly associated conditions
Cuneiform and cuboid fracture dislocations
Compartment syndrome of the foot

129
Q

Sx + physical for Lisfranc injury

A

Midfoot or diffuse pain
Swelling

Physical
Often have difficulty weight bearing, particularly walking on tip toes
Midfoot swelling
Plantar ecchymosis is classic
Tenderness over tarsal-metatarsal joint
Gap sign between 1st + 2nd metatarsals
Passive pronation and supination of forefoot can cause pain or you can stabilize the hindfoot and passively abduct and pronate the forefoot
Palpate tarsal metatarsal joints
Pain w/ stress of midfoot
Chronic - instability causes flattening of arch

130
Q

Ix for Lisfranc injury

A

XRs (AP, internal oblique, lateral) - wt bearing increases sensitivity
widened interval between 1st + 2nd MTS
increased displacement between the medial cuneiform and 2nd MT base
Increased interval between the medial and intermediate cuneiforms

CT good for subtle injuries
MRI good for ligament

131
Q

DDx for Lisfranc injury

A

Lisfranc fracture dislocation
Tarsometatarsal sprain
Metatarsal fracture
Cuboid fracture
Cuneiform fracture

132
Q

Management of Lisfranc injury

A

Grade 1
If pain with weightbearing and ligament stress tests and swelling, suggest immobilization and non-weightbearing
Immobilization in short walker boot with protected weight-bearing for 2 wk and then reexamination:
If tenderness has resolved and no evidence of diastasis on repeat imaging, weight-bearing as tolerated in boot
Weight-bearing out of boot after 6 wk
No high-impact activity for first 3 to 4 mo after injury
Single leg hop test pain free before activity

Injuries beyond grade 1, particularly any injuries with displacement on x-ray or evidence of dynamic instability
Refer to surgeon, non wt bearing
ORIF

133
Q

Complications of Lisfranc injury

A

Compartment syndrome
Post traumatic arthritis
Progressive foot deformity + functional impairment

134
Q

Sx of achilles tendinopathy

A

Pain in posterior calf + heel
Initially subsides w/ use but returns w/ continued use
Morning stiffness
Weakness
Intermittent swelling

135
Q

Physical of achilles tendinopathy

A

Worn shoes
Pain and stiffness 2 to 6 cm above Achilles tendon insertion
Pain with running, especially sprinting
Tenderness over the distal Achilles tendon (2 to 6 cm above the insertion):
Tenderness near insertion suggests insertional Achilles tendinopathy (enthesopathy) or bursitis.
Thickening of distal Achilles tendon in chronic cases
Tenderness with resisted plantar flexion
Weakness with repetitive single leg heel raises
Crepitus with ankle motion
Negative Simmonds-Thompson test: Compression of the calf will cause normal passive plantar flexion of the foot:
A positive test (absence of plantar flexion with calf compression) suggests complete Achilles tendon rupture.
Decreased ankle dorsiflexion (from tight heel cord)

136
Q

RF of achilles tendinopathy

A

Training errors: recent increase in distance, intensity, or length of activity
Worn and/or old shoes
Inflexibility, especially tight heel cords
Higher body mass index (BMI)
Hypertension
Diabetes
Hypothyroidism
Older patients: decreased tensile strength and increased stiffness of tendon
Malalignment of the leg (excessive genu valgum, external tibial torsion) or ankle/foot (pes planus)

Medications:
Fluoroquinolones: Recent use of these antibiotics has been associated with increased risk for Achilles tendinopathy and rupture.
Glucocorticoids
Aromatase inhibitors
Statins have been theorized to cause tendinopathy and have been shown in some animal models.

137
Q

DDx of achilles tendinopathy

A

Retrocalcaneal bursitis
Superficial Achilles bursitis
Calcaneal apophysitis (Sever condition) in adolescents
Haglund deformity: prominent superior tuberosity of calcaneus
Achilles tendon rupture
Gastrocsoleus tear
Plantaris tendinopathy
Overuse myositis
Chronic exertional compartment syndrome
Os trigonum irritation or posterior ankle impingement syndrome
Vascular/neurogenic claudication
Deep venous thrombosis
Hematoma
Infection

138
Q

Management of achilles tendinopathy

A

Relative rest
Consider 7-10 days immobilisation w/ walking boot if sx severe
Ice after activity
Heel lifts short term
Night splints for severe/ refractory sx
Properly fitted shoes
Stretching
Strengthening - gastrocnemius and soleus strengthening program with emphasis on eccentric exercises
NSAIDs
Nitroglycerin patch
¼ patch (1.25mg/ 24hr) can be applied to tendon, replaced q24hr until sx subside
PRP

Surgery
Debridement
If sx persist >6mo w/ conservative treatment

Gradual RTA
No more than 10% increase per week

139
Q

MOI achilles tendon rupture

A

Laceration
Pushing off with the weight-bearing forefoot while extending the knee, such as with sprint starts and the push off in basketball
Sudden, unexpected dorsiflexion of the ankle, as when the foot slips in a hole
Violent dorsiflexion of a plantarflexed foot, as with a fall from a height

140
Q

Sx of achilles tendon rupture

A

Feeling of being kicked in back of heel
Pop + pain in ankle
Pain in heel
Pain w/ wt bearing

141
Q

Physical for achilles tendon rupture

A

Swelling and/ or ecchymosis
Able to walk but not on toes
May still be able to plantar flex but reduced strength
Increased passive dorsiflexion
Unable to do single leg calf raise
Compare resting posture of feet
Positive Thompson test
Palpate for gap

142
Q

DDx for achilles tendon rupture

A

​​Achilles tendinitis
Ankle sprain
Peritendinitis
Retrocalcaneal bursitis
Superficial Achilles bursitis
Periostitis
Plantar tendon rupture
Calcaneal avulsion
Gastroc, soleus or plantaris tear

143
Q

Management of achilles tendon rupture, details, pros vs cons of surgery vs nonoperative

A

RICE
Both surgical and nonsurgical treatment will require an initial period of about 6 weeks of casting or special braces. The cast may be changed at 2- to 4-week intervals to slowly stretch the tendon back to its normal length. Casting may be combined with early movement (1-3 weeks) to improve overall strength and flexibility.

Surgery
Open or percutaneous repair
Lower rate of re-rupture but higher rate of complications
Risks: anesthesia, infection, skin breakdown, scarring, bleeding, accidental nerve injury, blood clots
Posterior splint or short-leg cast is placed in gravity equinus for 10-14 days to reduce tension on the incision
With each cast change, the ankle is gradually dorsiflexed, with a neutral position being reached at approximately 4 weeks postsurgery.
4 wks post op: begin weight bearing on the leg.
At 6 weeks postsurgery, the cast is discontinued, and the patient is referred to physical therapy.

Non-operative
Higher rate of rerupture (up to 40%), although this is less w/ early mobilisation, but power reduced compared to surgical management
Suitable for elderly, less active patients, poor surgical candidates
0 to 2 wk: equinus cast in 15 to 20 degrees plantar flexion and non–weight-bearing with crutches
2 to 6 wk: removable controlled ankle motion (CAM) boot with 1- to 2-inch heel lift. Partial weight-bearing with crutches progressing to full weight-bearing as tolerated (WBAT) by week 4. Boot should be removed for active unrestricted plantar flexion and dorsiflexion to neutral.
6 to 8 wk: full weight-bearing in the boot. Decrease heel lift by 25% each week. Start resisted plantar flexion exercises with resistance bands, gentle dorsiflexion stretching with belt.
8 to 12 wk: Discontinue boot 1 wk after ambulation with no heel lift; physical therapist to guide patient through strengthening, range of motion, and proprioception
16 wk: Start run–walk program, and continue strengthening.
6 mo: Return to full activity.

144
Q

RF for achilles tendon rupture

A

Men >40
Recreational sports
advancing age
Tendinopathy
cortisone injection
systemic corticosteroids
Fluoroquinolones
previous history of tear (esp if managed conservatively as higher risk of re-rupture)
CTD
Immobilization
Obesity

145
Q

What are the bones in the hind, mid and forefoot?

A

The hindfoot includes the calcaneus and talus.
The midfoot includes the navicular, cuboid, and cuneiform bones.
The forefoot includes the metatarsals and phalanges

146
Q

Physical for metatarsal #

A

Point-tenderness directly over the metatarsal
Mild swelling, bruising
Graduated activity from calf raises to hopping to jogging -> does it reproduce pain?
Single leg hop
Fulcrum test

147
Q

Imaging for metatarsal #

A

XR - periosteal reaction to visible # line
CT - To visualise cortical #s in bones
Bone scan - Good at detecting increased bony remodelling, but this is not specific to stress #s. Uptake also remains for a long time so not as useful for ongoing monitoring
MRI - Periosteal or bone marrow edema

148
Q

DDx for metatarsal #

A

MTP joint synovitis: inflammation of the joint rather than stress reaction in the bone itself. Bone scan will show distal uptake around MTP joint. MRI is diagnostic. Claw toe may also cause synovitis with plantar displacement of metatarsal head or a metatarsal stress reaction.
MTP capsular strain and/or chip fracture of 1st metatarsal head (turf toe)
Lisfranc sprain/fracture: injury to the 2nd MTC articulation. Any pain at the proximal 2nd metatarsal in association with a twisting injury in plantar flexion should raise concern for this injury.
Midfoot sprain: injury to MTC ligamentous structures
Forefoot mass (ganglion or tumor)
Metatarsalgia
Morton Neuroma
Freiberg infarction: osteonecrosis of 2nd metatarsal head; more common in adolescent athletes with unilateral (usually) pain in 2nd metatarsal head

149
Q

RF for stress #

A

> 10 EtOH per week, RED-S, female, low vit D levels, smoking, running >25mi weekly, sudden increase in activity
Intrinsic RF: females, amenorrhea >6mo, low BMD, restricted ROM, RED-S, ED, low vit D
Extrinisic RF: increase in training intensity, duration or frequency, hard surfaces, change in footwear, extremes in age, past hx of stress #

150
Q

Management of metatarsal stress #

A

Reduced loading, relative rest, management of contributing factors (optimising bone health, correcting biomechanical errors, using S+C coach, correcting footwear)
Consider exogen
Adjunctive therapies: pulsed US, orthoses, braces, surgery
Calcium 2000mg daily, vit D 1000 units daily, r/o RED-S
Recovery = 12 wks

151
Q

What is a Dancers # + what is management?

A

spiral # of 5th metatarsal
Usually non surgical w/ fracture brace or cast shoe
Wt bearing as tolerated

152
Q

What are the common sites of stress #?

A

tibia, navicular, fibula, metatarsals, calcaneus

153
Q

MOI lateral ankle sprain

A

Inversion + plantarflexion
Ligaments are injured in sequential pattern
ATFL then CFL then PTFL

154
Q

RF for lateral ankle sprain

A

Athletes (especially those involved in sports with jumping near other players and quick “cutting” motions, i.e., basketball, soccer, football)
Dancers
Congenital tarsal coalition (allows less “give” in the foot and results in more stress to ankle)
Prior ankle injury (Previously injured or stretched ligaments provide less overall stability.)

155
Q

Sx + physical for lateral ankle sprain

A

Audible pop
Rapid swelling, pain, inability to walk

Physical
Ecchymosis
Swelling
Tenderness to palpate
Anterior drawer:
Tests stability of ATFL; performed by holding the distal tibia and pulling the heel forward. Increased laxity relative to the opposite side indicates a tear of the ATFL. The anterior drawer test in the ankle has poor sensitivity and specificity.
Inversion tilt:
tests stability of CFL; performed by holding the distal tibia and moving the foot from a neutral position to an inversion position. Increased laxity compared with opposite side indicates a tear of the CFL.

156
Q

Ottawa ankle rules

A

XR needed if pain in malleolar zone and:
bone tenderness at posterior edge of lateral malleolus OR
bone tenderness at posterior edge of medial malleolus OR
inability to wt bear immediately + in ED

157
Q

DDx for lateral ankle sprain

A

Tibia fracture (shaft, malleolus, etc.)
Pilon fracture
Fibula fracture (malleolus, Maisonneuve)
Avulsion fracture
Osteochondral defect in talar dome/tibial plafond
Anterior ankle impingement
Os trigonum syndrome
Talus fracture
Calcaneal fracture
Peroneal subluxation
Bimalleolar/trimalleolar fracture

158
Q

Management of lateral ankle sprain

A

RICE, NSAIDS, increase weight bearing as tolerated, crutches prn
Phase 1 consists of RICE protocols to improve pain and swelling (often weeks 1 to 2).
Phase 2 consists of progressive range of motion exercises to improve motion and decrease swelling. Patients should continue to use a protective brace when walking to prevent further injury. Patients should be working toward full weight-bearing during this stage (weeks 2 to 4).
Phase 3 begins more aggressive strengthening and rehabilitation exercises. Specifically, patients should work on proprioception and endurance. This can be a formalized physical therapy program as needed (weeks 4 to 6).
Consider taping & bracing
Consider surgical referral for anatomical reconstruction of Gr III sprain after 6 weeks of conservative management

159
Q

Complications of lateral ankle sprain

A

Stiffness from prolonged immobilization
Recurrent instability
Osteochondral defects
Chronic regional pain syndromes

160
Q

Describe the lateral ankle ligaments

A

Anterior talofibular ligament (ATFL): passes from the tip of the fibula to the lateral talar neck; taut in plantar flexion; injured most commonly
Calcaneofibular ligament (CFL): passes inferior and posterior from the tip of the fibula to the lateral calcaneus; usually injured with the ATFL
Posterior talofibular ligament (PTFL): passes posteriorly from the fibula to the talus; injured less often

161
Q

What ligament is injured in a medial ankle sprain?

A

Deltoid

162
Q

RF medial ankle sprain

A

Previous ankle sprain
High-risk sports, including football, basketball, and long jumping
Valgus-flat foot deformity
Low arch of the foot (i.e., pes planus)
Dysfunction of the spring ligament
Dysfunction of the posterior tibialis
Extreme fatigue of peroneus (fibularis) longus muscle

163
Q

MOI medial ankle sprain

A

Off-balanced, pronated foot landing, which leads to forced external rotation, abduction, and eversion
Supination and excessive external rotation of the ankle

164
Q

Sx + physical for medial ankle sprain

A

Medial ankle pain
Swelling + ecchymosis

Physical
Tenderness over deltoid
A check of posterior tibial tendon function with resisted inversion.
A check of extensor hallucis longus tendon function with resisted extension of the great toe.
A check of range of motion of the ankle joint.
A check of flexor hallucis longus tendon function with resisted flexion of the great toe.
An eversion stress test determines the stability of the deltoid ligament; this is done with passive eversion of the ankle
An anterior drawer test may evaluate anterior and medial subluxation with deltoid ligament injury

165
Q

DDx for medial ankle sprain

A

Syndesmosis tear or sprain
Posterior tibial tendon tear or subluxation
Flexor hallucis longus tendon tear or sprain
Distal tibia fracture
Osteochondral fracture of the talar dome
Fracture of the calcaneus
Fracture of the lateral process of the talus
Medial ankle sprain with associated proximal fibular fracture (Maisonneuve fracture

166
Q

Management medial ankle sprain

A

PRICE
Aircast boot, limit wt bearing
​​
Grade I sprain:
functional rehabilitation and possibly a splint or a brace, with the recognition that return to sports generally is more delayed (3 to 6 wk) than with a lateral sprain (1 to 3 wk)

Grade II sprain
same as grade 1, but in addition, may need a short period prior of immobilization in posterior splint or walking boot (3 to 4 wk)

Grade III sprain
Treatment is controversial; requires immobilization (6 to 8 wk) or may need operative repair
Refer for surgery if:
Significant instability
Grade 3 injury

167
Q

Rehab for medial ankle sprain

A

The exercises should begin as soon as the initial pain and swelling have subsided sufficiently to allow the patient to perform simple exercises and should continue until the patient has returned to pain-free activity
Achilles tendon stretch
Foot circles
Alphabet exercises: Although leg is stable, patient should use the great toe and foot to “write” the letters of the alphabet in the air.
Isometric and isotonic plantar flexion, dorsiflexion, inversion, eversion, and toe curls
Marble pickups (using toes)
Heel walks
Toe walks
Circular wobble board
Walking on different surfaces
Walk–jog, jog–run

168
Q

What is a Jones #?

A

base of 5th metatarsal at metaphyseal-diaphyseal junction

169
Q

Management of Jones #

A

Rx
RICE
Immobilisation w/ aircast + crutches
NSAIDs
Consider Exogen
Calcium + vit D

Non operative treatment
should be reserved only for acute #, minimally displaced, is < 3 months old, and no evidence of non-union
up to 2/3 of these fractures should heal
non-wt-bearing cast for 6-8 wks is necessary for healing

Surgery
RTP quicker
More reliable rehab
Intramedullary screw fixation, may need bone grafting
Immobilised in cast x2 wks

170
Q

Sx + physical for navicular #

A

Insidious onset, poorly localised midfoot ache
Pain radiates along medial arch dorsally
Improves w/ rest

Physical
Localised tenderness at “N spot” - proximal dorsal navicular
Minimal swelling

171
Q

Management of navicular #

A

Non wt bearing w/ cast or removable brace x8 wks
Activity modification recommendations + home exercises
Mobilise stiff ankle, subtalar, midtarsal joints + calf
Recovery - 4mo

172
Q

Rehab/ FU for navicular #

A

Reexamine patient every 2 to 3 wk to ensure adequate recovery.
First 2 wk following cast removal: activities of daily living, swimming, water running
Second 2 wk: Assess “N” spot; if nontender, then 5-min jogging on grass every other day. Gradually increase to 10 min per session.
Third 2 wk: Assess “N” spot; if nontender, then faster running for short distances, that is, 50 m on alternate days; gradual speed increase
Fourth 2 wk: Assess “N” spot; if nontender, then gradual return to full training over several weeks. Average time to return to sport is 5 to 6 mo from diagnosis.

173
Q

RF for navicular #

A

Training errors: number, frequency, intensity, and duration of strain cycles
Impact attenuation: muscle fatigue, training surfaces, footwear
Gait mechanics: foot type, lower extremity alignment, altered gait
Bone health: nutrition, genetics, hormones, bone disease
Sprinting, jumping, hurdling
Ballet

174
Q

Ottawa foot rules

A

XR needed if pain in midfoot zone and:
bone tenderness at base of 5th metatarsal OR
bone tenderness at navicular OR
inability to wt bear immediately + in ED

175
Q

What is a syndesmosis injury?

A

Injury to 3 ligaments - anterior tibiofibular ligament (ATFL), interossseous ligament (IOL), posterior tibiofibular ligament (PTFL)

176
Q

MOI syndesmosis injury

A

Sudden, forced external rotation + hyperdorsiflexion of ankle
Soccer (player tackling ball), football (player prone, has foot stepped on, leading to forceful external rotation), and skiing (slalom skiers, catch ski on gate)

177
Q

RF syndesmosis injury

A

Collision sports are at higher risk:
Football
Rugby
Lacrosse

Sports that immobilize the foot in a high ankle shoe or boot:
Hockey
Slalom skiing; catching inner ski on gate
Wrestling

Sports played on turf (e.g., soccer)

178
Q

Sx syndesmosis injury

A

Usually report inversion mechanism
“Regular” ankle sprain that isn’t improving
Pain usually between anterior distal tibia and fibula and also posteromedially at ankle joint.
Pain can be persistent on weight-bearing or an unusually long period of recovery after the initial injury.
Pain is also worse with pushing off or with external rotation.

179
Q

Physical for syndesmosis injury

A

Dorsiflex + plantarflex talus to find joint line
Palpation over syndesmosis is painful
Usually minimal swelling
Squeeze test at mid calf causes pain at ankle
External rotation test: distal lower leg is stabilized with ankle in neutral position while mediolateral force/external rotation of the foot is performed; positive test noted by pain and/or increased rotation relative to unaffected side
Push-off test: Push off/heel raise on affected side may be weak or absent.
Fibular translation (drawer) test: pain or increased translation of fibula from anterior to posterior or loss of firm end point relative to uninjured side
Stabilization test: Distal syndesmosis is stabilized with athletic tape and assess if symptoms are decreased with running and jumping.
Cotton test: increased translation or pain with translation of talus from medial to lateral (may indicate deltoid ligament tear)
Crossed-leg test: pain at syndesmosis with gentle pressure exerted on the medial side of the knee while resting the midtibia of affected leg on uninjured knee

180
Q

Ix for syndesmosis injury

A

XR
normally fibular overlaps tibia - can see widening of this
Stress view for XRs (dorsiflexion then external rotation)
MRI

181
Q

DDx for syndesmosis injury

A

PER ankle fracture (Weber C)
SER ankle fracture (Weber B)
Fracture of the proximal fibula (Maisonneuve)
Ossification of the syndesmosis
Calcification of the syndesmosis
Deltoid ligament tear
Talar dome fracture

182
Q

Management of syndesmosis injury w/o #

A

Phase I is to limit inflammatory response and protect the joint, usually with nonsteroidal anti-inflammatory drugs (NSAIDs) and short-term (10 days to 2 wk) non–weight-bearing protection in a cast, boot, or brace with crutches. Include protection, rest, ice, compression, and elevation and modalities to minimize edema.
Phase II is typically restoration of range of motion and normalization of gait pattern. In this phase, high ankle braces (DonJoy Velocity and others) may facilitate rehabilitation.
Phase III progression once patient can ambulate and hop without dysfunction. Progress to agility drills, plyometrics, sports-specific tasks, and strengthening.
Return to play is challenging and is typically based on a functional testing evaluation and physical examination; usually 6 to 8 wk
Patient may return to play with demonstration of tasks such as backward pedaling, vertical hopping, or running in figure-8 pattern.

183
Q

Management of syndesmosis injury with fracture

A

Refer for surgery (screw fixation)
Non wt bearing cast x6 wks

184
Q

Sx of plantar fasciitis

A

Insidious + progressive pain in inferior heel
Can be bilateral
Worse in AM with first few steps
Lessens w/ gradually increased activity
Worsens w/ prolonged standing or inactivity

185
Q

Physical for plantar fasciitis

A

Tenderness localized to anteromedial aspect of the heel with palpation
Tight Achilles heel cord
Pes planus or pes cavus foot deformity
Passive range of motion: hypermobility of subtalar joint, midtarsal joint, and first ray
Pain with passive dorsiflexion of toes

186
Q

DDx for plantar fasciitis

A

Skeletal:
Calcaneal stress fracture
Bone contusion
Subtalar arthritis
Inflammatory arthropathies
Infections (osteomyelitis/subtalar pyarthrosis)
Neoplasm

Soft tissue:
Intrinsic muscle strain (abductor hallucis, flexor digitorum brevis, quadratus plantae)
Plantar fibromatosis
Plantar fascia rupture
Achilles tendinitis
Posterior tibial tendinitis
Retrocalcaneal bursitis
Fat pad atrophy

Neurologic:
Entrapment of branches of the posterior tibial nerve usually at or after passage through the posterior tarsal tunnel: medial plantar nerve, lateral plantar nerve, or medial calcaneal nerve
Radicular symptoms of L4–S1 (sciatic nerve)
Abductor digiti quinti nerve entrapment
Peripheral neuropathy

187
Q

Management of plantar fasciitis

A

Avoid aggravating activity
Avoid barefoot walking + flat shoes
Stretching in morning + throughout day
High load eccentric strength training
RICE
NSAIDs
Taping foot (arch taping)
Comfortable shoes
Night splint - toes in extension, ankle at 90 degrees
Extremes - orthotics, steroids, surgery

188
Q

RF for plantar fasciitis

A

Excessive torsion and hyperpronation with poor supporting footwear
Poor shock dissipation with cavus foot
Hindfoot valgus with pronation deformity
Limited ankle dorsiflexion
Varus knee alignment in runners
Obesity and prolonged standing on hard surfaces
Spiked athletic shoes

189
Q

What is a hallux valgus?

A

Hallux valgus (HV) refers to a subluxation of the 1st metatarsophalangeal (MTP) joint with lateral or valgus deviation of the great toe and medial or varus deviation of the 1st metatarsal, leading to a bony prominence at the medial aspect of the joint (medial eminence or bunion

190
Q

RF for hallux valgus

A

Fam hx
Constrictive footwear
Females

191
Q

Sx + physical for hallux valgus

A

Pain over medial MTP prominence

Physical
Assess severity standing + non wt bearing
Check alignment of arch + hindfoot

192
Q

Management of hallux valgus

A

Wider toe box footwear
Shoes w/ flexible stitching over medial eminence
Medial longitudinal arch support
Surgery if above failed (osteotomy, MTP fusion if severe)
Complications of surgery::
Stiffness
Decreased ROM
Bunion may persist

193
Q

What is a hammer, claw + mallet toe?

A

Mallet toe is a flexion deformity at the distal interphalangeal (DIP) joint.
Hammer toe is a flexion deformity affecting the proximal interphalangeal (PIP) joint. Concomitant extension at the MTP joint may be present.
Claw toe is a flexion deformity affecting the PIP and DIP joints. Concomitant extension at the MTP joint is always present.

194
Q

RF for hammer/ claw/ mallet toe

A

Increasing age
Constrictive footwear
Neuromuscular disorders (peripheral neuropathy, muscular dystrophy, stroke, CP)
Obesity

195
Q

Management of hammer/ claw/ mallet toe

A

Shoes - wider toe box, flat/ low feel
Orthotics

Pressure relief methods:
Toe sleeves, typically with foam padding to relieve pressure over the dorsal toe
Toe crests relieve pressure at the tip of the toes.
Metatarsal pads relieve pressure under the metatarsal heads.
Rocker bottom sole can help reduce forefoot pressure during gait

Surgery may be indicated if non operative treatment is unsuccessful
Botox if clawing is d/t spasticity

196
Q

What is Morton’s neuroma?

A

An inflammatory fibrosing process of the interdigital nerve of the foot, characterized by pain on the plantar surface of the foot
Most commonly occurs between the heads of the 3rd and 4th metatarsals, although may also involve the 2nd or 4th intermetatarsal spaces

197
Q

RF Morton’s neuroma

A

Females
Kickboxers, ballet dancers, runner

198
Q

Sx of Morton’s neuroma

A

​​Intermittent, episodic pain, usually on the plantar surface of the foot between the 3rd and 4th metatarsals
Forefoot pain radiating to the affected interspace and toes
Numbness or paresthesias in the toes and interdigital space are common
Pain on weight-bearing, exacerbated with exercise, and relieved with rest

199
Q

Physical of Morton’s neuroma

A

Tenderness to palpation on the plantar surface of the foot, usually between the 3rd and 4th metatarsals
Mulder click: palpable click after compressing the metatarsal heads while palpating the digital interspace on plantar aspect of foot

200
Q

DDx for Morton’s neuroma

A

Metatarsalgia
Metatarsal stress fracture
Ganglion cyst
Neuropathies (diabetic, alcoholic, toxic, nutritional)
Intermetatarsal bursitis
Freiberg disease (metatarsal avascular necrosis)

201
Q

Management of Morton’s neuroma

A

Decreased pressure on metatarsal heads
Wide toe box shoes
Metatarsal pad

Avoid repetitive toe dorsiflexion
NSAIDs
Steroid inj
Surgical excision of neuroma is indicated if conservative therapy fails

202
Q

MOI + RF turf toe (1st MTP sprain)

A

MOI
Forced hyperextension of 1st MTP causing a sprain

RF
Artificial turf and playing surfaces
Athlete’s experience and years of sports participation
Athlete’s position while playing sport
Athlete’s weight, where higher forces are transmitted with increased weight
Flattening of the 1st MTP
Football players (defensive and offensive running backs, wide receivers, linemen)
Foot pronation
Hallux degenerative joint disease
Increased ankle dorsiflexion
Increased friction between athletic shoe and turf
Increased toe box flexibility and decreased number of cleats in the shoe
Prior 1st MTP joint injury
Pes planus

203
Q

Sx 1st MTP sprain

A

Pain w/ wt bearing
Pain w/ ROM
Pain w/ applied pressure to MTP during running or jumping (toeing off)
Swelling

204
Q

Physical for 1st MTP sprain

A
205
Q

DDx for 1st MTP sprain

A

Gout
Plantar plate rupture
1st distal metatarsal or proximal phalangeal fracture
Osteoarthritis of 1st MTP (hallux rigidus)
Sesamoiditis
Sesamoid stress fracture

206
Q

Management of 1st MTP sprain

A

Grade 1
Ice, NSAIDs, elevation
Toe spica taping which restricted excessive dorsiflexion
Gentle ROM exercises from day 5
Grade 2
As grade 1 but include orthotics
Explosive, push off activities should be restricted until pain free, usually x2 wks
Grade 3
As grade 2 but restriction of activity likely up to 8 wks

CASEM (14 decks)

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