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Differential Diagnosis MSK > LE > Flashcards

LE Flashcards

1
Q

Injury to ATF, CF, PTF 2* to inversion with PF
- rich blood supply = significant swelling within 2 hr
- TTP over involved ligaments, ecchymosis that drains distally
- varying levels of instability (grade 1-3)
- (+) talar tilt & anterior drawer (presence of dimple just inferior to tip of lateral malleolus)
- (-) radiograph for fx but stress film may show increase joint space
- arthrography is accurate only within 24 hrs

A

Lateral ankle sprain

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2
Q

injury to anterior &/or posterior inferior tibiofibular ligament 2* hyperdorsiflexion & eversion
- (+) squeeze & ER test
- Pain & swelling over ligament/interosseous membrane
- Oblique radiograph may show abnormal widening of joint space
- recovery time = 5 + (0.97 x cm from ankle joint that squeeze test is positive) +- 3 days
- r/u fx

A

syndesmotic sprain

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3
Q

Overuse syndrome of flexor halliucis longus & flexor digitorum longus
- callus under 2nd >3rd>4th MT head & medial distal hallux
- pain & soreness over distal 1/3-2/3 of posterior-medial shin & posterior-medial malleolus
- hypermobile 1st metatarsal
- may be associated with a high arch that results in increase pronation with increase stress on tibialis posterior to decelerate foot
- pain with resisted inversion & PF
- pain with stretching into DF & eversion
- (-) radiograph

A

shin splints/posterior AKA medial Tibial stress syndrome

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4
Q

overuse synrome of tibialis anterior, ext hallucis longus & ext digitorum longus attributed to running on unconditioned legs, soft tissue imbalance, alignment abnormalities, low arch, excessive pronation to accommodate rearfoot varus
- pain & TTP @ anterior tibialis
- pain with resisted DF and inversion
- pain wtih stretching into PF and eversion
-callus formation under 2nd MT head & medial distal hallux
- tight gastroc/soleus muscle
- soreness with heel walking & running downhill (increase in eccentric control)
- (-) radiograph

A

Shin splints/anterior

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5
Q

Can be acute 2* fx, crush injury, burns, or prolonged limb compression; can be a chronic progression of shin splints resulting in loss of microcirculation in shin muscle; occurs within 30 minutes of exercise & improved with rest; males>females, R>L
Beware: back pressure can compromise blood flow & immediate referral may be needed (ice do not compress)
- 5 P’s = paresthesia (toes), paresis (dropfoot), pain (anterior tibia), pallor, pulseless
- skin feels warm & firm
- cramping, pain, & tightness
- most reliable sign is sensory deficit at dorsum of foot in 1st interdigital celft
- ischemia of EHL
- pulses are normal until the end & then surgery is needed within 4-6 hours to prevent muscle necrosis & nerve damage
- increase soft tissue pressures via fluid accumulation
- normal compartment pressure <10 mm Hg
- 20 mm Hg is compromised capillary blood flow
- 30 mm Hg results in ischemic necrosis

A

compartment syndrome

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6
Q

structurally 3 anatomical sites where tendon passes through tunnel/passage with acute angulation that can result in irritation & decreased vascularization 2* to trauma, inversion sprains, or direct blow
- subluxing tendon = snapping while everting in DF; subluxation more common in young athletes 2* to forceful DF of inverted foot with peroneals contracting
- swelling & ecchymosis inferior to lateral malleolus
- radiograph may show avulsion of peroneal retinaculum

A

Peroneal tendonitis

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7
Q

<30 yo, injury is 2* direct blow to gastroc or forceful contraction; >30 yo, injury is 2* to degeneration (higher incidence in people with type O blood)
- snap/pop associated with injury
- palpable gap in tendon (hatchet sign) is examined early
- cannot walk on toes, swelling (within 1-2 hr) & ecchymosis
- (+) thompson & matles test

A

achilles tendon rupture

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8
Q

inflammatory condition caused by poor biomechanics or overuse
- TTP & crepitus @ medial ankle
- pain with passive pronation
- pain with active inversion (supination) & PF

A

Posterior tibialis tendonitis

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9
Q

Occurs in 8-18 yo male > female 2* rapid growth with stress on epiphysis with jumping or athletic events
- TTP with mediolateral compression of calcaneus
- decreased DF from pain; pain with stairs
- radiographs may not be helpful
- responds well to heel lift (healing takes months)

A

Sever Syndrome (achilles apophysitis)

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10
Q

Vascular watershed is 4.5 cm above tendon insertion & vulnerable to ischemia 2* running hills (up = stretch; down = eccentric stress), poor footwear, excess pronation (increase rotational forces); occurs mostly in males 30-50 yo

A

Achilles tendonitis/tendinosis

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11
Q

RA, poor fitting footwear, flatfeet
- pain, swelling, great toe valgus > 15*
- decreased ROM of great toe & hammertoe of 2nd toe
- R/O RA

A

Hallux Valgus (bunion)

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11
Q

Extreme hyperextension of great toe in CKC position resulting in sprain of plantar capsule & LCL of 1st MTP
- pain with toe extension
- impairment of push-off, antalgic gait
-ecchymosis & swelling of 1st MTP joint
- R/O sesamoid & MT fx

A

turf toe

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12
Q

May be associated with osteochrondritis (child) or DJD, gout, or RA (adult)
- decreased DF of 1st MTP joint
- pain & swelling on dorsal aspect of 1st MTP
- difficulty walking up stairs & uphill
- LE ER to clear foot during gait
- radiograph confirms dorsal osteophyte & decreases joint space

A

Hallux Rigidus

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12
Q

continuous with gastroc/soleus muscle complex; subject to inflammation 2* repetitive stress, poorly cushioned footwear, hard surfaces, increased pronation, obesity
- morning pain that decreases with activity, nodules palpable over proximal-medial border of plantar fascia
- pain with DF and toe ext
- decreased DF from tight gastroc/soleus muscle complex
- weak foot intrinsics
- sensation & reflexes WNL
- (-) EMG; radiograph may show calcaneal spur, but no correlation exists between bone spur and pain of plantar fasciitis

A

Plantar fasciitis

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13
Q

sitting with legs crossed, compression during surgery, presence of a fabella, tight ski boots or hockey skates, treatment of nerve during strong inversion and PF contraction
- compromised ankle stability can increase risk of sprains
- local pain & ecchymosis at the site of external trauma
- footdrop, decreased eversion & DF
- partial sensory loss
- test = pain with walking on medial borders of foot
- MRI, EMG/NCV may be helpful

A

Common peroneal nerve palsy

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14
Q

thickening of interdigital nerve (25-50 yo, female>male) 2* high-heel shoes, excessive pronation, high arch, lateral compression of forefoot, increased weight
- throbbing/burning into plantar aspect of 3rd & 4th MT heads; feels like a pebble is in the shoe
- callus under involved rays
- increased pain with weight bearing
- (+) morton test
- weak instrinsic muscles
- EMG = unreliable
- r/o stress fx (contrast MRI)

A

Morton neuroma

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15
Q

compression of contents of tarsal tunnel (posterior tibial nerve & artery, tibialis posterior, FDL, FHL) may be 2* trauma, weight gain, excessive pronation, or inflammation
- sharp pain into medial/plantar aspect of foot & 1st MTP
- burning, night pain, swelling
- increased pain with walking & passive DF or eversion
- motor weakness & intrinsic atrophy difficult to detect
- DTRs & ROM = WNL
- (+) tinel sign just below & behind medial malleolus
- abnormal EMG; r/o diabetic neuropathy & neuroma

A

Tarsal tunnel

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16
Q

Repetitive high-impact sports or direct trauma
- impairment of push-off, antalgic gait, swollen 1st MTP
- TTP, pain with passive DF of MTP
- (+) radiograph & MRI
- r/o turf toe, bipartite sesamoid

A

sesamoiditis

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17
Q

repetitive stress, occurs approximately 3 weeks after increased training; 2nd MT is most common
Beware: of eating disorders with repetitive stress fx
- point tenderness & swelling
- deep nagging & night pain
- ROM WNL
- (+) metatarsal load & bump
- bone scan & MRI detect earlier than radiograph
- therapeutic US in continuous mode will increase pain to aid in DX
- r/o DVT

A

stress fracture

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18
Q

hypertrophic osteoarthropathy of midfoot in clients with IDDM
- progressive bone & muscle weakness
- decreased sensation but minimal pain
- profound unilateral swelling
- increase skin temp (local); erythema
- radiograph looks like osteomyelitis (bone fragments present)

A

Charcot foot

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19
Q

bacterial infection usually related to skin trauma but skin break may not be evident; not contagious
- pain, swelling, warmth
- chills, fever, weakness
- advancing erythema with reddish streaks
- helpful to outline reddened area with a sharpie permanent marker to monitor status

A

cellulitis

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20
Q

risk factors: immobility, surgery, fx, trauma, oral contraceptives, CHF, CA, DM, pregnancy, type A blood
- leg pain & tenderness
- increased circumference >1.2 cm
- lower leg warmth & firm to palpation
- (+) homans sign
- wells score > or equal to 3

A

DVT

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21
Q

injury results from varus stress resulting in overstretching or tearing the lateral ligament of the knee
- warm & swollen lateral knee
- TTP @ knee joint line (palpate in figure 4 position)
- ROM may not be effected
- (+) varus stress test
- confirmed with MRI or arthrogram with contrast
- (-) radiograph, but needed to r/o avulsion or epiphyseal plate injury; varus stress film may show increase joint gapping

A

LCL sprain

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22
Q

mechanical irritation
- prepatella = common in sport = falling on knee or maintaining quadruped position
- infrapatella = clergyman bursitis = kneeling
- Pes anserinus = prevalent in long-distance running or middle-aged woman with OA of knee
- localized radiating het
- localized egg-shaped swelling
- radiating pain 2-4 cm below involved bursa
- crepitus
- discomfort with AROM & PROM
- diagnosis confirmed with MRI

A

bursitis of knee

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23
Q

defect in posterior capsule that is influenced by chronic irritation or meniscus tear
- golf ball sized swelling at semimembranosus tendon or medial gastroc muscle belly; best palpated in full knee extension
- stiff & tender with limited knee ROM
- MRI may be helpful, r/o DVT or tumor

A

Baker’s cyst

24
Q

repetitive stress & excessive friction 2* tight ITB, pronation with IR of tibia, genu varum, cycling with cleat in IR
- proximal Px: hip syndrome
- distal Px: runner’s knee
- pain with downhill running
- pain @ 30* of knee flexion in WB results in ambulating stifflegged to avoid flexion
- TTP over lateral femoral condyle
- (+) ober, noble, and renne test
- (-) radiograph
- need to r/o trochanteric bursitis & osteochrondritis
- MRI & US may confirm dx

A

ITB Friction Syndrome

25
Q

results from overuse, downhill running, activities with sudden stops
- posterior lateral knee pain at the end of a workout or running downhill (just posterior to LCL)
- crepitus over tendon
- discomfort sitting with legs crossed & with resisted flexion from full extension
- MRI may be helpful; need to r/o ITB, biceps tendonitis

A

Popliteus Tendonitis

26
Q

Injury results from direct trauma or a significant increase in unaccustomed activity (presence of medial plica is more common than lateral plica)
- pain over medial femoral condyle; palpable cords along medial condyle, pain at superomedial joint line
- clicking/snapping, locking, “giving away”
- pain @ end range flexion
- false (+) McMurray (pseudolocking)
- (+) slutter, plica, theatre sign, & bowstring
- need to r/o patellofemoral tracking px
- radiograph is not helpful, MRI is only noninvasive procedure that shows plica
- arthroscopy may reveal avascular fibrotic edge of the plica

A

Plica syndrome

27
Q

patella tendonitis (common in skeletally immature) 2* traction overuse injury such as jumping, kicking, running, or microtrauma
- TTP at patella tendon insertion & pain with resisted knee extension
- localized crepitus & swelling
- increase in dynamic Q-angle
- r/o osgood-schlatter, SLJ, & bursitis
- confirmed via MRI

A

Jumper’s knee

28
Q

result of aging, poor biomechanics, or repetitive trauma
- joint line crepitus
- decreased terminal knee extension 2* edema (quad inhibition)
- decreased stance time during gait
- “gelling” phenomenon = increased viscosity synovial fluid 2* inflammation
- stiffness with immobility
- radiograph = decreased joint space, spurs, osteophytes

A

DJD

29
Q

softening of patella articular cartilage 2* poor biomechanical alignment, tracking, &/or weak hip ER
- anterior knee pain; pain with stairs; crepitus
- VMO atrophy; weak hip ER & ABD
- increase knee valgus, increase dynamic Q-angle
- (+) theatre, clarke & fairbank apprehension
- confirmed via MRI

A

Chondromalacia (patellofemoral syndrome) PFS

30
Q

lesions of subchondral bone of insidious onset, trauma, or pre-exisitng abnormalities of epiphyses: most common in 10-18 yo; male >female
- knee effusion
- crepitus with knee flexion/extension
- poorly localized knee pain
- antalgic gait
- (+) wilson test
- may have TTP over medial femoral condyle with knee flexion
- radiograph may not help; need MRI or bone scan

A

Osteochrondritis Dissecans

31
Q

Ossification between rather than within strained muscle fibers resulting from direct trauma
- decreased knee ROM
- weakness of involved muscle
- TTP, swelling, & hyperemia
- confirmed with radiograph after 2-3 wks; earlier than with MRI

A

Heterotopic Ossification

32
Q

Calcification in a muscle due to trauma, painful hematomas develop rapidly & calcification occurs in 2-3 wks; may be neurogenic after SCI or TBI
- warm & TTP over involved site
- decreased knee ROM
- pain with contraction of involved muscle
- confirmed with radiograph after 2-3 wks; faster than MRI

A

Myositis Ossificans

33
Q

Results from traction force on proximal patella tendon 2* chronic extensor overload; 10-14 yo male
- anterior knee pain & TTP at distal pole of patella with knee extension
- antalgic gait
- decreased knee ROM
- radiograph (lateral view) = fragmentation of inferior patella pole

A

Sinding-Larsen Johansson

34
Q

Tibial apophysitis that may occur from growth of femur resulting in avulsion of proximal tibial physis; may have genetic predisposition; 8-15 yo male>female
- intermittent aching pain at tibial tubercle & distal patellar tendon
- enlarged tibial tuberosity
- tight quads & hamstrings resulting in decreased AROM
- effusion results in knee extensor lag
- (+) ely test
- (+) radiograph for avulsion of tibial tuberosity (lateral view)
- r/u avascular necrosis

A

Osgood-Schlatter Syndrome

35
Q

Prediposing factors include, excessive tibial ER, pronation, patella alta; tight lateral retinaculum, weak hip ER, small medial patella facet; most common in adolescent girls with genu valgum (increased Q-angle & femoral rotation)
- effusion shuts down VMO
- (+) patella tilt & patella apprehension
- tenderness along medial patella border
- sitting @ 90/90, patella points lateral and superior (grasshopper eyes)
- client c/o knee giving away or clicking when cutting away from affected leg
- increased Q-angle
- radiograph may reveal osteochondral fragments or fx; multiple views are needed to evaluate articular surfaces

A

Patella subluxation

36
Q

results from direct trauma
- pain & “dome” effusion
- palpable defect
- unable to extend knee
- (+) ottawa knee rules
- confirmed with radiograph

A

Patella fracture

37
Q

Injured via rotatory forces while WB or knee hyperextension; medial femoral/lateral tibial rotation injures medial meniscus & lateral femoral/medial tibial rotation injures lateral meniscus
- common types of tears: children = longitudinal & peripheral tear; teenagers = bucket handle tear
- (-) varus/valgus stress test
- pain @ end range flexion/extension WB
- gradual swelling over 1-3 days; ecchymosis
- joint line tenderness
- (+) McMurray, Apley, Thessaly, KKU, Steinmann
- anterior horn locks in extension, posterior in flexion, medial in 10-30* of flexion, lateral >70* of flexion
- radiograph may r/o fx,tumor, osseous loose bodies
- MRI may reveal pseudotear; confirm with arthrogram using contrast

A

Meniscus Tear

38
Q

Injury results from dashboard blow to anterior shin with knee flexed @ 90* or falling on knee with foot PF
- minimal swelling; ecchymosis may appear days later
- tenderness in popliteal fossa & pain with kneeling
- client may be able to continue to play
- (+) posterior drawer, posterior lachman, & sag/dropback/godfrey
- (-) radiograph (except for avulsion); MRI is study of choice
- bloody arthrocentesis

A

PCL Sprain

39
Q

Injury results from twisting while changing directions, deceleration with valgus & ER, hyperextension of the knee with foot PF
- audible pop, immediate swelling (<2 hr)
- intense pain at posterior lateral tibia
- unstable in WB
- (+) anterior drawer, lachman, & pivot shift
- KT1000 anterior displacement >5mm
- (-) radiograph (except for avulsion); MRI study of choice
- Bloody arthrocentesis

A

ACL Sprain

40
Q

injury results from valgus stress resulting in overstretching the medial ligament of the knee
- flexion limited to 90* & knee extension lag present
- if deep fibers are torn, knee joint rapidly fills with blood
- (+) valgus stress test
- TTP @ knee joint line (possible palpable defect)
- confirmed with MRI or arthrogram with contrast
- (-) radiograph but needed to r/o avulsion or epiphyseal plate injury; valgus stress film may show increased joint gapping

A

MCL Sprain

41
Q

Damage to fibrocartilage via repetitive hip ER or external rotatory force to hip while hyperextended & hyperabducted; highly associated with hip dysplasia; anterior hip pain correlated to weak gluteals & abdominals 2* to excessive anterior femoral translation
- pain with prolonged sitting, getting in/out of car, putting on shoes/socks, & twisting activities
- increased anterior hip pain with hyperext & ER
- pain with resisted SLR (anterior lesion)
- often associated with weak gluteals
- decreased hip ROM; clicking/catching from flexion to extension
- (+) FABER, impingement, scour, & labral tests
- screen for osteoid osteoma & testicular CA
- MRI with contrast

A

Hip Labral tear

42
Q

Can result from direct trauma to iliac crest or ASIS resulting in contusion
- TTP @ iliac crest/ASIA
- pain with resisted hip flexion & stretching into hip extension
- pain with ambulation & hip abduction
- screen for McBurney’s point & rebound tenderness
- (-) radiograph; need to r/o fx & avulsion

A

Hip pointer

43
Q

Calcium deposits approx. 2-4 wks after thigh contusion
- localized pain
- limited knee flexion
- palpation of calcific mass

A

Myositis Ossificans

44
Q

Systemic disorder with bilateral WB symtpoms
- aching pain during WB > groin, medial thigh, & distal knee; loss of movement & function 2* pain
- trendenlenburg
- (+) thomas, ely, & FABER
- radiograph = bilateral head; joint space narrowing; migration of femoral head into acetabulum

A

RA

45
Q

Usually occurs >55 yo in male > female (3:2)
- aching pain during WB > groin, medial thigh, and knee
- loss of movement & function
(+) FABER & trendenlenburg
- radiograph reveals narrow joint space, spurring & osteophytes; can r/o fx & necrosis

A

DJD of hip

46
Q

Etiology unknown; recent virus, URI, ear infection, or bronchitis, female 2-4x more than males; 3-10 yo
- medial thigh/groin pain with movement (infant = pain with diaper change)
- child splints in hip flexion, slight abd, and ER
- awakes with a limp
- hip abd restricted by pain
- (+) log roll test
- possible with low-grade fever
- r/o septic hip, slipped capital femoral epiphysis, & Legg-Calve-Perthes

A

Transient Synovitis (Toxic Synovitis Phantom Hip Disease)

47
Q

Gradual onset with Hx of endurance tasks
Beware: eating disorders, amenorrhea, & osteoporosis
- groin pain with activity
- TTP @ greater trochanter
- (+) FABER test
- may need CT or MRI if radiograph is inconclusive
- need r/o trochanteric bursitis & osteoid osteoma

A

Femoral neck stress fracture

48
Q

Pelvic fx 2* strenuous muscle contraction in skeletally immature child
- TTP & weakness with resisted muscle contraction @ ASIS, AIIS, PSIS, PIIS - depending on muscle involved
- (+) radiograph for avulsion

A

Apophysitis

49
Q

Injury results from violent muscle contraction
- may hear “pop”
- TTP @ apophysis
- (+) thomas and ely test
- CT or MRI if radiograph is inconclusive
- r/o slipped capital femoral epiphysis

A

Avulsion Fracture

50
Q

Idiopathic osteonecrosis of capital femoral epiphysis; associated with (+) fam hx @ breech birth; onset occurs over 1-3 months in 4-13 yo; occurs unilaterally; males>females
- hip or groin pain (antalgic gait)
- (+) trendenlenburg & log roll
- decreased ROM (IR & abd & ext); >15* hip flexion contracture
- leg-length inequality; thigh atrophy
- bone scan and MRI needed for early detection, radiographs may appear normal for several weeks, 1st sign (approx 4 wks) is radiolucent crescent image parallel to superior rim of femoral head
- need to r/o JRA & hip inflammation

A

Legg-Calve- Perthes Syndrome

51
Q

Imbalance of growth & hormones that weakens epiphyseal plate; may be 2* weight gain; occurs 10-18 yo; male 2x>females
- gradual onset of unilateral hip, thigh, and knee pain
- decreased hip IR; hip positioned in ER
- quadriceps atrophy
- antalgic gait and decreased limb length
- AP radiograph needed to identify widening of physis & decreased height of epiphysis; lateral view = epiphyseal displacement
- need to r/o muscle strain, avulsion & endocrine disorder

A

Slipped Capital Femoral Epipysis

52
Q

May result from breech birth, trauma, or when hip is in a weakened state after THR
- (+) ortolani, barlow & radiograph
- cogenital
- shortened limb, positioned in flexion & abd
- posterior traumatic (MVA)
- groin & lateral hip pain
- shortened limb
- positioned in flexion, abd, & IR
- anterior traumatic (forced abduction)
- groin pain & tenderness
- anterior/superior = hip extension & ER
- anterior/inferior = hip in flexion, abd, ER

A

Hip dislocation

53
Q

Benign tumor found in long bones; etiology unknown
- vague hip pain @ night
- increased pain with activity and decreased with aspirin
- decreased ROM & quad atrophy
- may be apparent on radiograph but confirmed by MRI or CT
- need to r/o trochanteric bursitis, femoral neck fx

A

Osteoid Osteoma

54
Q

Men 18-24 yo with unknown etiology should be screened
- enlarged inguinal lymph nodes
- enlarged/heavy scrotum

A

Testicular Cancer

55
Q

biomechanical or overuse problem; repetitive inside kicks in soccer result in forceful adduction and compression of bursa; contusions
- deep, aching, diffuse pain from greater trochanter to distal lateral thigh & groin
- TTP on ITB & pain when rolling on hip when sleeping
- ROM = WNL except abduction may be limited due to pain
- no snapping but palpable crepitus may be present
- (+) ober & patrick/FABER
- (-) radiograph (needed to r/o femoral neck stress fx)
- MRI & US may confirm

A

Greater Trochanteric Bursitis

56
Q

Irritation & inflammation 2* overuse or unaccustomed activity
- pain in medial groin/thigh with hip flexion & ext
- audible snapping when moving from hip flex to ext
- screen for McBurneys point & rebound tenderness
- (-) radiograph; need to r/o avulsion fx
- confirmed by MRI and US

A

Ilipsoas Bursitis/Tendonitis

57
Q

Occasional marble-sized lump along the path of the inguinal ligament
- pain with exertion, cough
- radiating pain into groin, ipsilateral thigh, flank, & lower abdomen
- pain with cutting, turning, striding out
- (+) pubic arthralgia test

A

Pubic Arthralgia (AKA sports hernia)

58
Q

May result from muscle contraction, trauma, prolonged sitting
- dull ache in buttocks
- pain increase sitting & walking & decreased in supine
- pain with resisted hip ER & passive IR with adduction
- (-) radiograph needed to r/o stress fx; MRI needed to r/o spine pathology (LS root lesion, spinal stenosis, SI problem)

A

Piriformis Syndrome

59
Q
A

Differential Diagnosis MSK (2 decks)

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