Hip, Knee, Ankle and Foot problems

Question 1

What mechanism most often causes an ACL rupture?

Answer 1

Forward momentum, leg fixed plus/minus rotation

Foot rigid on the ground with knee flexed (e.g. landing after a jump)

Question 2

How is an ACL tear diagnosed?

Answer 2

Clinical: history of trauma, effusion and pain
Decreased range of movement
Positive anterior draw test
MRI or arthroscopy

Question 3

Describe the management options for cruciate ligament tears

Answer 3

Rest
Physiotherapy
Immobilisation if needed
May need to be surgically repaired, particularly if the patient is an athlete

Question 4

What are the potential complications of cruciate ligament tears?

Answer 4

Chronic instability

Osteoarthritis of the knee

Question 5

What mechanism most often causes PCL tears?

Answer 5

Knee flexed, tibia forced posteriorly; common after road traffic collisions

Question 6

How is a PCL tear diagnosed?

Answer 6

History of trauma
Inability to weight bear; knee gives way
Positive posterior draw test
MRI or arthroscopy

Question 7

Name five problems that can develop in the hindfoot

Answer 7

Achilles tendonitis/tendinosis
Plantar fasciitis
Ankle osteoarthritis
Tibialis posterior dysfunction
Cavovarus foot

Question 8

Name six problems that can develop in the forefoot

Answer 8

Hallux valgus
Hallux rigidus
Lesser toe deformities
Morton’s neuroma
Metatarsalgia
Rheumatoid Forefoot

Question 9

Name three problems that can develop in the midfoot

Answer 9

Ganglia
Osteoarthritis
Plantar fibromatosis

Question 10

Which organism is most commonly responsible for septic arthritis?

Answer 10

Staphylococcus aureus (especially MRSA)

Question 11

How does septic arthritis present?

Answer 11

Swollen, painful joint (usually unilateral)
Fever, rigors
Bacteraemia causes vomiting and hypotension etc

Question 12

Describe the approach to treating septic arthritis

Answer 12

1) empirical IV antibiotics e.g. flucloxacillin (should cover staph and strep)
2) move on to specific antibiotics (still IV) once the culture/sensitivity results are available

Question 13

How is trochanteric bursitis treated?

Answer 13

Steroid injections

Question 14

What type of knee deformity is usually seen in OA of the knee?

Answer 14

Varus deformity (due to OA of the medial compartment)

Question 15

Describe the aetiology of septic arthritis (of the knee)

Answer 15

Penetrating injuries
Spread from osteomyelitis of the adjacent bone
Systemic infection (bacteraemia, commonly gonorrhoea)
Iatrogenic

Question 16

What is the function of the menisci of the knee?

Answer 16

To convert downward force to lateral force on the knee

This reduces force on the articular cartilage

Question 17

Describe the presentation of meniscal tears

Answer 17

May be acute pain (“painful squelch”) but often the inital trauma goes unnoticed
Inability to fully extend the knee
May be effusion (slow onset swelling)
Pain on weight bearing

Question 18

Describe the management options for meniscal tears

Answer 18

Arthroscopy:

• excision of fragment
• meniscal repair
• meniscal transplantation/graft

Question 19

What is a bunion?

Answer 19

Development and subsequent inflammation/swelling of a bursa on the first metatarsal head (due to lateral subluxation of the first MTP joint)

Question 20

Describe the operative and non-operative management options for hallux valgus

Answer 20

Non-operative
 - footwear modification
 - orthotics
 - analgesia
Operative
 - 1st metatarsal osteotomy
 - soft tissue realignment
 - bunion excision

Question 21

Describe the clinical features associated with hallux valgus

Answer 21

Deformity (including bunions)
Metatarsalgia
OA of the first MTP joint
Symptoms from footwear

Question 22

What is hallux rigidus?

Answer 22

Osteoarthritis of the big toe, usually the first MTP joint

Question 23

What is Morton’s neuroma?

Answer 23

A.k.a interdigit neuralgia

Irritation and thickening of the interdigital nerve, in the 3rd or 2nd web space

Question 24

What causes Morton’s neuroma?

Answer 24

Chronic, repetitive trauma to the ball of the foot, e.g. wearing high heels

Question 25

How is Morton’s neuroma diagnosed?

Answer 25

Clinical features: pain/discomfort (+ paraesthesia) in the ball of the foot
Mulder’s click on examination

Question 26

What are the treatment options for Morton’s neuroma?

Answer 26

Modification of footwear
Steroid Injections
Surgical excision

Question 27

Describe the presenting features of plantar fasciitis

Answer 27

Heel pain; tenderness over the insertion of the plantar fascia on the calcaneus

• worse in the morning
• worse on weight-bearing after rest

Question 28

What are the treatment options for plantar fasciitis?

Answer 28

Rest, change training schedule
Analgesia (NSAIDs) and ice
Orthotics (heel pads)
Physiotherapy
Weight loss
Night splinting/immobilisation
Local corticosteroid injections
Local analgesia injections

Question 29

What degenerative changes occur in plantar fasciitis?

Answer 29

Changes in the plantar fascia:

• fibroblast hypertrophy
• absence of inflammatory cells
• disorganised/dysfunctional collagen
• avascularity