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Clinic - Common Conditions Overview > Knee, Leg, Ankle & Foot > Flashcards

Knee, Leg, Ankle & Foot Flashcards

1
Q

Describe the presentation of DVT in the lower limb

A
  • unilateral severe cramping pain in calf
  • unilateral oedema, heaviness, fatigue
  • discolouration of skin
  • warmth over area
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2
Q

What are 3 PROMs that can be used in lower limb pain?

A

KOOS (knee injury and osteoarthritis outcome score)
LEFS (lower extremity functional scale)
FADI (foot and ankle disability index)

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3
Q

Describe the condition of patella subluxation including pathology, mechanism, risk factors, presentation and treatment

A

Pathology:
- dislocation of patella out of trochlear groove of femoral condyle, usually a lateral shift caused by damage to the medial patellofemoral ligament

Mechanism:
- valgus stress, IR of femur on fixed foot, trauma

Risk factors:
- females (Q angle), repetitive activity involving LL loading, imbalance between strong vastus lateralis and weak vastus medialis, pes planus, knee valgus, pivoting on planted foot

Presentation:

  • acute onset
  • sense of popping out on onset
  • swelling with bruising
  • knee instability
  • knee locking
  • patella hypermobility
  • pain on palpation of patella
  • laxity knee valgus

Treatment:

  • return to activity 6-8 weeks
  • high recurrence
  • immobilize for 6 weeks
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4
Q

Which meniscus is more commonly injured in the knee and why?

A

Medial - less mobile and resists more pressure during weight bearing

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5
Q

What is the terrible triad?

A

Medial meniscal tear
MCL sprain
ACL sprain

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6
Q

Describe the presentation of a meniscal tear including pathology, mechanism, risk factors, presentation, findings and prognosis

A

Pathology:
- partial or total tear of meniscus (medial or lateral)

Mechanism:

  • acute: twisting on a semi-flexed knee and fixed foot, excessive anterior translation of femur on tibia (ie: heavy squat)
  • chronic: degenerative tear assoc w/ OA

Presentation:

  • lateral or medial knee pain
  • crepitus and catching, locking, popping with ROM
  • agg by flexing and loading knee, hyperfleixon of knee, kneeling, rotation of femur over tibia

Findings:

  • pain with medial / lateral gapping (medial gapping suggests lateral meniscus tear and vice versa)
  • pain on palpation of joint line

Tests:

  • Stork
  • McMurray’s
  • Thessaly
  • Apley Grind

Prognosis:

  • requires surgery if SSX impacting QOL
  • recovery from surgery 3-4 months
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7
Q

What is the typical mechanism of injury for a meniscal tear?

A
  • twisting on a semi flexed knee and planted foot

- anterior translation of femur on tibia (ie: heavy squat)

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8
Q

Describe the condition of gout including pathology, risk factors, presentation and prognosis

A

Pathology:
- formation of monosodium urate crystals in joint space (typically toes, fingers, elbow, knee and ankle) causes arthritis to develop; hard crystal nodules (tophi) can develop in joints and cause permanent deformities

Risk factors:
- male, age, diabetes, obesity, alcohol, HTN, fatigue, purines, stress

Presentation:

  • localized intense joint pain and swelling
  • recurrent and episodic

Prognosis:

  • episodes resolve in days - 2 weeks but are typically recurrent
  • pharma to reduce inflammation
  • medical clearance needed for hands on treatment
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9
Q

Describe the typical mechanism of injury for an ACL and PCL sprain

A

ACL:

  • usually non-traumatic
  • a cut and plant injury (sudden change in direction / speed over a planted foot)
  • rapid deceleration / jump landing on a planted foot

PCL:

  • usually traumatic blow to anterior tibia on a flexed knee
  • MVA or contact sports (hyperflexion on a fixed foot)
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10
Q

Describe the presentation of an ACL sprain / terrible triad

A

Pathology:

  • sprain typically a cut-and plant injury or a rapid deceleration / jump landing (ACL only)
  • lateral blow to knee on a fixed foot (terrible triad)

Presentation:

  • acute traumatic onset with an audible pop
  • severe knee pain
  • immediate oedema and sense of instability

Findings:

  • oedema
  • joint laxity
  • decreased knee ROM
  • increased medial gapping (terrible triad)

Tests - ACL only:

  • Anterior Drawer
  • Lachmans

Tests - terrible triad:

  • medial / valgus stress test
  • stork test

Prognosis:

  • ACL: recovery and return to activity in 3 months (high recurrence)
  • terrible triad: typically requires surgery, return to activity 6-9 months
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11
Q

Describe the presentation of a PCL sprain

A

Mechanism:
- usually a traumatic blow to anterior tibia or causing hyperextension of knee

Presentation:

  • mild retropatellar / medial knee pain
  • agg by weight bearing in a semi flexed position (climbing stairs, squatting)
  • instability walking on uneven surfaces
  • oedema, decreased ROM, knee instability

Tests:
- posterior drawer

Prognosis:
- good (return to activity 2-4 weeks)

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12
Q

Describe the condition of Osgood Schlatter including pathology, presentation, findings and prognosis

A

Pathology:
- repeated tension on growth plate of upper tibia from quadriceps causes inflammation of patellar ligament at tibial tuberosity

Risk factors:
- young adolescents, active in high volume sports (running, jumping), inadequate flexibility in quadriceps / hamstrings

Presentation:

  • insidious onset pain at tibial tuberosity becoming severe and constant
  • worse with activity and better with rest

Findings:
- pain with palpation of quadriceps, tibial tuberosity and resisted isometric extension

Prognosis:
- self limiting (only affects adolecents during growth phase)

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13
Q

Describe the condition of patellar tendinopathy including pathology, mechanism, presentation, findings and prognosis

A

Pathology:
- repetitive microtrauma to patellar tendon causes disrepair and degeneration of tendon

Risk factors:
- repetitive loading of patellar tendon (running, jumping)

Presentation:

  • pain over inferior patella agg by quadriceps activity (running, jumping, walking, squatting, prolonged sitting)
  • completely absent at rest

Findings:

  • pain with squat and resisted isometric extension
  • pain on palpation of tibial tuberosity

Prognosis:
- recovery 2-9 months

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14
Q

Which bursa can become inflamed in the knee and what is the typical mechanism of injury?

A

Pes anserine bursitis - typically caused by overuse of pes anserine mm (assoc with repetitive abduction and flexion, knee valgus, pes planus)

Pre-patellar bursitis - typically caused by repetitive or prolonged kneeling

Popliteal cyst / Baker’s cyst - burs abetween medial head of gastrocs and oblique popliteal ligament in popliteal fossa, typically secondary to underlying inflammation (OA, sprain, meniscal tear)

Prognosis:
- typically self limiting within 2-7 days

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15
Q

Describe the condition of ITB friction syndrome including pathology, risk factors, presentation, findings and prognosis

A

Pathology:
- repetitive motion of knee flexion and extension causes friction between ITB and lateral femoral epicondyle (ITB moves from anterior to epicondyle in extension to posterior in flexion)

Risk factors:
- repetitive knee flexion / extension, weak hip abductors, cross stance gait

Presentation:

  • lateral knee pain (burning, sharp)
  • agg by knee flexion / extension, palpation over lateral femoral condyle, palpation of ITB
  • oedema
  • audible snapping with flexion and extension

Prognosis:
- recovery within 2 weeks to 2 months if underlying biomechanics and load addressed

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16
Q

Describe the condition of medial plica syndrome

A

Pathology:
- inflammation of medial plica (runs parallel to medial patella)

Mechanism:
- overuse injury, repetitive knee flexion and extension, chronic patellar maltracking or internal knee derangements (meniscal tear, OA)

Presentation:

  • proximo-medial knee pain
  • agg by activity, rapid extension / flexion of knee
  • catching / locking in knee and crepitus with flexion / extension
  • sense of knee instability

Findings:

  • painful arc (30-60 deg knee flexion)
  • pain on palpation of medial femoral condyle

Prognosis:

  • 6-8 weeks recovery conservatively
  • improve patellofemoral alignment (can brace if needed)
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17
Q

Describe the condition of patellofemoral pain syndrome including pathology, risk factors, presentation, and prognosis

A

Pathology:

  • umbrella term for pain arising from patellofemoral joint or adjacent soft tissues
  • usually involves misalignment of patella

Risk factors:
- knee hyperextension, knee valgus or varus, pes planus or cavus, increased Q angle, tighteness in ITB, hamstrings, gastrocs

Presentation:

  • insidious onset anterior knee pain
  • agg by activity, prolonged sitting, kneeling, high heels

Findings:
- variable depending on nature of pathology

Prognosis:
- full recovery possible when underlying biomechanics addressed

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18
Q

Which signs indicate peripheral ischaemia (peripheral vascular or peripheral arterial disease)?

A
  • acute pain in limb aggravated by exertion
  • diminished peripheral pulse and temperature
  • pallor / cyanosis
  • urgent medical referral (caused by embolism, thrombosis or atherosclerosis)
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19
Q

Which signs indicate a complete Achilles rupture?

A
  • acute onset severe pain easing to a dull ache
  • difficulty walking and plantarflexing
  • oedema
  • palpable mass in calf
20
Q

What are the spinal nerve roots that supply the obturator, femoral and sciatic nerves?

A

Obturator and femoral L2-4

Sciatic nerve L4-S3

21
Q

What are the 5 Ottawa Rules for diagnostic imaging of the knee after a traumatic onset?

A
  • 55 or older
  • tenderness at fibula head
  • tenderness of patella
  • unable to flex to 90 deg
  • unable to weight bear 4 steps
22
Q

Which nerve roots does the patella reflex test?

A

L3-4

23
Q

Which nerve roots does the tibialis posterior and Achilles reflex test?

A

Tibialis posterior L4-5

Achilles S1-2

24
Q

What are the 4 most common conditions causing pain in the medial knee?

A

Medial meniscus tear
MCL sprain
Pes anserine bursitis
Arthritis

25
Q

What are the 4 most common conditions causing centralized pain over the patella?

A

Patellofemoral pain syndrome
Patella maltracking
Bursitis
Arthritis

26
Q

What are the 2 most common conditions that can cause lateral knee pain?

A

ITB syndrome

LCL sprain

27
Q

What are the 4 most common conditions that can cause pain inferior to the patella?

A

Osgood Schlatter (adolescent)
Jumpers knee (adults)
Patellofemoral instability
Osteochondritis dissecans

28
Q

What are 2 PROMs that can be used to evaluate ankle and foot pain?

A

FADI (foot and ankle disability index)

LEFS (lower extremity functional scale)

29
Q

Which spinal nerve roots can refer pain or radicular symptoms to the foot and ankle?

A

L5-S2

30
Q

Describe the presentation of an Achilles rupture

A
  • acute onset severe pain easing to a dull ache
  • may be a sense of popping or snapping with onset
  • may have a palpable mass in calf
  • decreased strength plantarflexion / gait
  • decreased or absent Achilles reflex
  • oedema / bruising
31
Q

Describe the presentation of compartment syndrome

A
  • caused by increased pressure within the compartment of the leg (usually secondary to fracture)
  • deep aching, burning or cramping pain and sensation of tightness/ pressure
  • can be acute pain or related to exertion
  • oedema
  • numbness / paraesthesia
  • pallor
  • diminished pulses
  • paralysis

(medical emergency)

32
Q

Describe the condition of achilles tendinopathy including mechanism, risk factors, presentation, findings and prognosis

A

Mechanism:
- overuse injury caused by repetitive overuse and compression (less common is blunt trauma)

Risk factors:
- running, jumping, sudden increase in volume, decreased calf strength or flexibility, pes planus

Presentation:

  • dull aching pain localized to Achilles tendon
  • insidious onset
  • worst in morning with first steps, improves with movement
  • oedema, tendon thickening
  • calf atrophy in chronic or severe cases

Findings:

  • decreased ROM dorsiflexion
  • decreased strength plantarflexion
  • pain with plantar and dorsiflexion, palpation of tendon

Prognosis:

  • 2-9 months full recovery
  • SSX reduction 5-6 weeks
33
Q

Describe the condition of calf strain including mechanism, risk factors, presentation, findings and diagnosis

A

Mechanism: sudden acceleration or eccentric overstretch

Risk factors:
- sudden increase in volume, sports requiring sudden acceleration and changes in direction, obesity

Presentation:

  • acute onset sharp and stabbing localized calf pain
  • oedema / bruising with onset
  • agg by: ankle movements esp. plantarflexion, stretching calves, walking

Findings:

  • pain / oedema of calf
  • pain with ankle movements esp. plantarflexion
  • pain with bilateral calf raise
  • decreased dorsiflexion ROM
  • positive Thomson’s test

Prognosis:
- return to activity 2-3 months

34
Q

What are the 3 types of ankle sprain, the most common sprain and the most common ligaments sprained, and the typical mechanisms of injury?

A

Inversion sprain (most common)

  • ATFL (most commonly sprained), CFL (2nd most common), PTFL (rarely sprained)
  • mechanism of injury forceful supination of ankle

Eversion sprain

  • deltoid ligament sprain
  • mechanism of injury forceful pronation

High ankle / syndesmosis sprain:

  • sprain of syndesmotic ligs and/or interosseous membrane between distal tibia and fibula
  • mechanism of injury: combined ER of leg and dorsiflexion of ankle
35
Q

Describe the presentation, findings and prognosis for an inversion ankle sprain

A

Presentation:

  • aching throbbing pain in ankle esp. over lateral ankle
  • traumatic onset, may have had a sense of giving way
  • oedema / bruising
  • pain agg. by weight bearing, ankle movements, palpation

Tests:

  • positive Anterior Drawer (ATFL sprain)
  • positive Talar Tilt (CFL sprain)
  • positive Posterior Drawer (PTFL sprain)

Prognosis:

  • return to activity 4-6 weeks
  • requires bracing / splinting
  • high risk of chronic ankle instability and recurrence, needs prolonged rehab and potentially bracing with activity in future
36
Q

Which tests can be used in a case of ankle sprain?

A 
Anterior Drawer (ATFL sprain)
Talar Tilt (CFL sprain)
Posterior Drawer (PTFL sprain)
Squeeze Test (high ankle sprain)
37
Q

Describe the condition of shin splints including the types of shin splints, mechanism and pathology, findings and prognosis

A

Definition:

  • umbrella term for exercise induced anterior leg pain
  • tibialis anterior strain: overuse of anterior compartment of leg, causes pain over anterolateral leg agg. by heel stride and downhill running
  • medial tibial stress syndrome: overuse of deep posterior leg mm, pain over anterior shin agg. by toe off

Mechanism and pathology:
- overuse of anterior and/or deep posterior leg muscles causing pain over anterior shin

Risk factors:
- incorrect biomechanics, hard surfaces, poor footwear, sudden increase in volume

Presentation:

  • insidious onset dull and aching anterior shin pain
  • typically pain at start of activity that eases during movement
  • agg. by activity, stretching

Findings:

  • variable and vague
  • pain on palpation of anterior and/or deep posterior leg compartment
  • pain with heel strike (tibialis anterior strain)
  • pain with toe off (medial tibial stress syndrome)

Prognosis:
- full recovery once biomechanics and loading are addressed

38
Q

What are the differences between the two main types of shin splints?

A

Tibialis anterior strain:

  • overuse of anterior leg mm
  • pain agg. by heel strike, downhill running

Medial tibial stress syndrome:

  • overuse of deep posterior leg mm
  • pain agg. by toe off
39
Q

Describe the condition of stress fractures including pathology and mechanism, risk factors, presentation, findings and prognosis

A

Pathology:
- chronic microtrauma caused to bones (most common tibia, 2nd most common 2nd MET and navicular)

Mechanism and risk factors:

  • overuse injury with repetitive loading (running, jumping etc)
  • risk factors: obesity, female, osteoperosis, corticosteroids, poor biomechanics, sudden increase in volume, inadequate rest

Presentation:

  • localized bone pain
  • dull at rest and sharp with weight bearing
  • insidious onset becoming constant

Prognosis:

  • variable depending on severity and location of fracture
  • mild: return to activity 6-8 weeks
  • chronic or severe: return to activity 3-8 months
40
Q

Describe the condition of tibialis posterior tendinopathy including pathology, mechanism and risk factors, presentation and findings, and prognosis

A

Pathology:

  • inflammation of tibialis posterior tendon, can progress to degeneration and cause a fixed pes planus
  • inadequate strength in tib post causes collapse of the medial longitudinal arch of the foot and acquired pes planus

Risk factors:
- pes planus, overpronation of foot in gait, age, obesity, previous trauma

Presentation and findings:

  • pain in medial foot and behind medial malleolus
  • agg. by prolonged weight bearing
  • pes planus
  • decreased ROM subtalar (inversion / eversion)
  • difficulty or inabiity to perform unilateral heel raise

Prognosis:

  • full recovery for early cases that have not progressed to degeneration
  • SSX reduction 5-6 weeks
  • recovery 2-9 months
41
Q

Describe the condition of plantar fasciopathy including mechanism, pathology, risk factors, presentation, findings and prognosis

A

Pathology:
- chronic micro trauma of plantar fascia, can cause chronic degeneration and formation of bone spurs within plantar fascia or at attachment to medial heel

Mechanism:

  • chronic overuse injury caused by repetitive loading / overstretching of plantar fascia
  • typically caused by poor foot biomechanics (pes planus) or weakness of foot arch mm (tibialis post and ant, intrinsic foot mm)

Risk factors:
- pes planus, sudden increase in volume, hard surfaces, poor shoes, obesity

Presentation:

  • pain in anterior medial heel and over medial longitudinal foot arch
  • pain worst with first steps in the morning that improves with activity
  • insidious onset becoming constant

Findings:

  • pes planus
  • pain and decreased ROM dorsiflexion
  • pain over medial tuberosity of calcaneus
  • positive Windlass test

Prognosis:

  • 90% successfully treated conservatively with full recovery 6-12 months
  • deload, improve foot mechanics / orthotics, gradual return to activity
42
Q

What is Morton’s neuroma?

A

Pathology:
- entrapment and traction of common plantar digital nerves causes thickening of neural tissue around nerves

Risk factors:
- high heels, high impact repetitive sports, calf tightness

Presentation:

  • sharp, burning, nerve pain at ball of foot
  • sensation of standing on a pebble

Findings:

  • plantar webspace pain and/or paraesthesia / numbness
  • pain with pressure over metatarsal heads and compression of medial arch
  • Tinels (plantar surface)

Prognosis:
- early cases can be resolved but a high rate of chronicity and recurrence

43
Q

Describe the condition of meralgia paresthetica

A

Pathology:
- compression of lateral femoral cutaneous nerve under inguinal ligament or by external compression (seat belts, tight clothes etc)

Presentation

  • nerve pain over anterolateral thigh
  • may have numbness, coldness
  • agg. by standing or walkin and relieved by sitting (decreases tension in inguinal ligament)

Findings:
- hyperalgesia in anterolateral thigh
(if motor SSX: consider an L2 radiculopathy as a more likely DD)

Prognosis:
- SSX reduction 2-8 weeks when compression resolved

44
Q

Describe the condition of common peroneal nerve entrapment

A

Mechanism:
- common peroneal nerve winds around neck of fibula and is vulnerable to compression / damage

Risk factors:
- knee trauma, compression caused by tight boots or pants or sitting with legs crossed

Presentation:

  • pain, paraesthesia and anaesthesia over anterior and lateral leg and foot
  • foot drop (paralysis of ankle and foot extensors) and foot inversion (paralysis of fibularis mm)

Findings:

  • Tinels (fibular head)
  • SLR (with ankle in plantarflexion and inversion)

Prognosis:
- 3-6 months; can be months to years if Wallerian degeneration has occurred

45
Q

Describe the condition of tarsal tunnel syndrome

A

Pathology:
- compression of posterior tibial nerve or terminal branches (medial / lateral plantar nerves) under the tarsal tunnel posterior to medial malleolus

Risk factors:
- ankle trauma, heel varus or valgus, obesity, pregnancy, diabetes, tendinopathy

Presentation:

  • pain, paraesthesia over medial ankle and plantar foot
  • pain agg. by eversion and dorsiflexion, prolonged walking
  • sensory deficit in plantar foot
  • pain on palpation over tarsal tunnel
  • positive Tinels (tarsal tunnel)

Prognosis:
3-6 months (up to years if Wallerian degeneration has occurred)

46
Q

Describe the 2 types of peripheral nerve entrapment affecting the leg and foot, the nerves that are affected, and the presentation of each

A

Common peroneal nerve entrapment:

  • neuropathy occurs as common peroneal nerve winds around fibula head (can be caused by knee trauma, compression caused by tight boots, crossing legs etc)
  • affects sensory supply of anterolateral leg and foot
  • affects motor supply of fibularis mm (causes inversion) and ankle and foot extensors (causes foot drop)

Posterior Tibial Nerve / Tarsal Tunnel Syndrome:

  • compression of posterior tibial nerve in tarsal tunnel posterior to medial malleolus
  • sensory of medial ankle and plantar foot
  • motor of toe abduction and flexion
47
Q

Which 3 nerves provide cutaneous supply to the foot and ankle?

A

Femoral (medial leg, medial ankle, medial foot)

Common peroneal (lateral leg, lateral ankle, plantar foot including plantar surface digits 1-5)

Tibial (posterolateral leg, dorsal foot including dorsal surface digits 1-5)

Clinic - Common Conditions Overview (26 decks)

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