Knee, Ankle, and Foot Pathology Flashcards
osgood schlatter disease
repetitive pulling of patellar tendon over tibial tubercle –> pain and swelling
adolescents age 10-15
anterior over tibial tubercle
gradually worsens
prominence of tibial tubercle w/ mild effusion, local tenderness, warmth
jumping, sports
tx: nsaids, quads and hams stretching and strengthening; avoid activities that cause pain; ice
usually resolves within a year or so w/ conservative treatment, surgery rarely indicated
peroneal compression
common peroneal nerve entrapment
most common peripheral nerve injury in LE
can be injured at any level down thigh and into leg, but usually at fibular head
habitual leg crossing, compression against bed railing or hard mattress, prolonged immobility
patellofemoral syndrome
defn and causes
poor tracking of patella over femoral condyles –> grinding
d/t wear and tear, overuse, overload, muscular/biomechanical problems
runners
patellofemoral syndrome
clinical presentation and PE
gradual onset of anterior knee pain d/t repetitive movement
dull, aching, possible swelling, clicking
worse with stairs, walking, running, extended sitting, standing from seated
weak quads (vastus medialis atrophy), offset patella, swollen knee
limited knee flexion d/t pain
crepitus, lateral patellar tenderness on passive or active movement
special testing: tracking of patella over femoral groove on knee flexion and extension; patella grind
XR may be normal or misaligned
patellofemoral syndrome
tx and prognosis
RICE
bracing and taping for patellar alignment
quads (esp vastus medialis) stretch and strengthen
surgery last resort
knee OA
gradual cartilage wear and tear
repetitive trauma over 15-20 years
pain intermittent –> constant
stiffness esp after inactivity
worse with weight-bearing
limp, limited flexion and extension, pain at end of ROM, joint line tenderness, crepitus
risk factors: obesity, trauma, knee instability
XR: osteophytes, sclerosis, non-uniform joint space narrowing
knee OA
patellofemoral syndrome
meniscal tear
defn and causes
foot plant on twisted knee
usually basketball, football, skiing, aging d/t degeneration
meniscal tear
dx: clinical presentation and PE
acute injury –> mild swelling and pain >24h
tears d/t chronic degeneration = gradual worsening over time
mild to moderate, dull, aching
with twisting or bending –> worse, sharp
popping, clicking, catching, joint effusion
possible vastus medialis atrophy
limited extension, full flexion d/t pain and catching
joint line effusion and tenderness
special testing: mcmurray test = knee flexion, internal or external rotation w/ valgus or varus stress –> clicking or pain
definitive: MRI
meniscal tear (medial)
note fluid in substance of meniscus
meniscal tear
tx and prognosis
nsaids
RICE, activity restriction, crutches if needed
quad and hamstring strengthening
consider surgery if locking or concurrent ACL tear
prognosis depends on extent of injury, may predispose to accelerated degeneration
mcmurray’s test
meniscal tears, mcl, lcl
valgus and varus stress with knee flexion –> clicking or pain
knee ligment tear
defn and causes
ACL = most common
high-impact jumping, twisting, lateral impact while foot is planted
basketball, ski, football
“pop” + immediate swelling
PCL: impact to tibia when knee is bent, e.g. dashboard MVA
LCL: excessive varus movement
MCL: excessive valgus movement
“unhappy triad”
MCL + ACL + meniscus tear
“blown knee”
lateral impact + foot planted = football, rugby, motocross …
knee ligament tear
dx: clinical presentation and PE
immediate sharp, severe pain after high-impact twisting, often with “pop”
“giving out”
gradually lessens to dull ache
worse with climbing, jumping running
bruising, effusion, tenderness
limited flexion and extension
special testing: Lachman and Anterior Drawer for ACL; posterior drawer for PCL; valgus and varus stretch for LCL and MCL
definitive: MRI
lachman’s test
ACL tear
knee at 15 degree flexion
pull shin anteriorly while putting back-pressure on thigh
no movement = good
laxity = ACL tear
anterior and posterior drawer test
anterior: ACL tear
posterior: PCL tear
lay on table, knees bent 90 degrees, pull tibia anteriorly (ACL) and push back (PCL)
no movement = good
laxity and pain = tear
ACL tear
note disruption of ACL integrity
knee ligament tear
tx and prognosis
nsaids
RICE, hard braces
PT: proprioception, ROM, quad+ham strengthening for knee stability
consider surgical reconstruction for young adults, athletes, or severe instability
PCL, MCL, LCL: good px; usually responds well to conservative tx
ACL: fair px; if not treated early at risk for prolonged instability, accelerated joint degeneration
compartment syndrome
defn and causes
limb and life threatening: necrosis, permanent fx impairment, rhabdo(–> kidney failure)
perfusion pressure < tissue pressure in closed space eg muscles, nerves, vessels surrounded by tight fascia
d/t extreme swelling or bleeding
trauma, tigh casts, etc.
usually acute
may be chronic in cases of repeated low-intensity trauma
compartment syndrome
dx: clinical presentation and PE
6 “P’s” - pain (out of proportion), paresthesia, paralysis, pallor (+/-), pulselessness, pressure
severe pain and pressure esp. following an injury
consider in any case of severe pain following injury esp when significant swelling present
nothing relieves pain
pain on passive muscle stretching is an early clinical indicator
palpation: may be warm or cold. when severe, feels tense or hard
compartment syndrome
tx and prognosis
fasciotomy
IV hydration
O2 administration d/t hypoxic limb, hyperbaric is best
elevation is contraindicated (decreases arterial flow –> worse ischemia)
good prognosis if fasciotomy w/in 6 hours, necrosis will occur after that (w/ compromise to life and limb)
metatarsal frx
most common: 5th metatarsal frx at base of bone (nearest tarsal)
forceful INversion
pain and tendernaess at base of 5th metatarsal +/- swelling, bruising, addtl injuries
high risk of delayed healing and nonunion
nondisplaced –> conservative tx (e.g. boot)
if displaced or non-union, surgery
malleolar frx
lateral malleolar (fibular) is most common
frx of distal fibula
direct trauma or twisting
usually accompanied by medial ligament injuries or another frx
joint widening indicates ruptured ligament
local tenderness, inability to bear weight
MTP joint pain
metatarsal-phalangeal pain, most often of 1st and 2nd MTP joints
d/t abnormal mechanics e.g. flatfoot (pes planus), high arch (pes cavus), overpronation, poor muscle balance d/t tight gastrocs and dorsiflexors, improper footwear
worse w/ weight-bearing, walking, running, etc.
+/- swelling, redness, tenderness at 1st and 2nd MTP
DD: OA, gout, RA, interdigital neuritis
tx: RICE, nsaids, good footwear, correction of foot mechanics, corticosteriods if severe, surgery if refractory
ankle sprain
defn and causes
inversion, eversion, twisting planted foot
most common: lateral sprain d/t eversion = anterior talofibular ligament (ATFL)
ankle sprain
dx: clinical presentation and PE
diffuse initially then localized to medial or lateral w/ reduced swelling
initial sharp pang –> constant deep aching
worse w/ weight-bearing or ROM
bruising if severe
limited active and passive ROM
DDx: medial or lateral malleolar frx, 5th metatarsal frx, midfoot frx; palpate all for bony tenderness, deformity, or crepitus. XR can r/o.
ankle sprain
tx and prognosis
RICE + bracing
PT (rehab)
if severe, consider surgery (e.g. high-level athletes, chronic instability)
severe lateral, medial, and high ankle sprains may take 4-6 weeks to fully recover, mild sprains usually much more quickly
plantar fasciitis
pain d/t inflammation along plantar fascia esp at insertion on heel or arch
most common cause of heel pain
repetitive trauma, poor mechanics, poor footwear, overpronation, flat feet, prolonged standing or weight bearing
gradual onset, usually after change in amount or intensity of running or walking, change in footwear, change of surface
burning feeling
usually accompanies tight achilles
point tenderness at medial process of calcaneous, tight plantar fascia
common complication: heel spurs
achilles tendon rupture
torn tendon usually 4-5 cm proximal to calcaneous, where blood supply is weakest
sudden strain or direct blow to contracted tendon
acute, sharp pain
inability to ambulate
obvious swelling, possible bruising
often a palpable defect
special testing: Thompson test: lying prone with knee passively flexed or standing/kneeling on chair, squeeze calf. no plantarflexion = rupture.
tx: casting +/- surgery
good prognosis but usually some loss of ROM
thompson test
achille’s tendon rupture
lie prone or stand while kneeling on chair
squeeze gastroc
plantar flexion = normal
no plantarflexion = achille’s tendon rupture
tarsal tunnel syndrome
entrapment of tibial nerve as it moves under retinaculum of tarsal tunnel (posterior to medial malleolus)
Tinel’s test
tapping over affected nerve to reproduce sx
e.g. tapping over median nerve in carpal tunnel, ulnar nerve in cubital tunnel, or tibial nerve in tarsal tunnel
medial tibial stress syndrome
aka shin splints
overuse/repetitive stress –> repetitive pulling of muscle on periosteum –> microtears in muscle and bone
pain with activity
posterior tibialis, flexor digitorum, soleus, tibialis anterior insertions
could progress to stress frx (felt at rest)
RICE + nsaids
ddx stress frx, compartment syndrome
