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CHI309 - Chiropractic skills and Principles 2 > Lecture 7- Knee > Flashcards

Lecture 7- Knee Flashcards

1
Q

Function of the posterior cruciate ligament?

A

Posterior cruciate prevent forward movement of the femur on the tibia

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2
Q

Function of the collateral ligaments?

A

The collateral ligaments provide medial and lateral knee stability
MCL is extra capsular (its deep layer attaches to the joint margins and the medial meniscus)
LCL: narrow strong cord easily palpated (stabilizes the knee in a one stance)

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3
Q

What are the dynamic stabilisers of the knee?

A

Hamstrings

Quadriceps

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4
Q

What are the static stabilisers of the knee?

A

Osseous anatomy
Menisci
Primary restraints: ACL, PCL
Secondary restraints: MCL, LCL, capsule

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5
Q

What is the Q angle?

A

This angle is a measure of external tibial rotation and it is the angle between: line drawn from the ASIS to the centre of the patella
and a line from the centre of the patella to the tibial tubercle
- Females ≤ 16

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6
Q

Joint effusion of the knee, what could the injury be, according to the effusion?

A 
Immediate effusion 0-2hrs
-ACL rupture
-Patellar dislocation 
-Major chondral lesion
Delayed effusion 6-24hrs
-meniscus
-small chondral lesion 
No effusion
-MCL sprain (superficial)
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7
Q

When do we x-Ray a knee? –Ottawa rule

A 
Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex to 90°
Inability to bear weight
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8
Q

Blood supply to the menisci?

A

Crucial to meniscal healing
Geniculate arteries (branch of the popliteal artery)
Outer 10-30% of peripheral medial meniscus
Outer 10-25% of peripheral lateral meniscus
Most of the menisci are avascular (synovial fluid via diffusion)
30% of the peripheral medial meniscus 25% of the peripheral lateral meniscus

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9
Q

Nerve supply to the menisci?

A

Tibial, Obturator and Femoral nerve

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10
Q

What are the functions of the menisci?

A

Shock absorption and stress distribution across the joint Improve joint congruency & static stability
Limit extremes of flexion and extension
Prevent hyperextension and protect the joint margins Provide nutrition and lubrication to the articular cartilage

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11
Q

Meniscal injuries

A
  • male predominance
  • in older individuals: tears due to degeneration and is more horizontal
  • in young individuals: twisting impact to the knee (e.g. Soccer) with associated valgus or varus tears (bucket-handle tear)
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12
Q

What is the O’Donoghue triad?

A

-MCL
-ACL
-MM
More often involves the lateral meniscus

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13
Q

What are most common meniscal Injury?

A

Meniscal injuries take the form of tears, most frequently:
-Anterior horn

  • Posterior horn
  • Bucket handle
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14
Q

When should you refer your patient with a knee injury?

A
  1. Locked knee (bucket-handle tear)
  2. Uncertain diagnosis
  3. Conservative care is unsuccessful
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15
Q

How do you assess acute meniscal tears?

A

Joint effusion and joint line tenderness (lateral or medial)
-Quadriceps wasting
-(+) McMurray Test (lateral/medial)

  • (+) Apleys test
  • (+) Thessaly test
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16
Q

Treatment for a meniscal tear?

A

Conservative treatment
RICE
ROM
Muscle strengthening exercises
Avoid twisting on a weight bearing flexed knee
Surgical treatment usually for younger patient and is proportional to the lesion location

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17
Q

OSTEOCHONDRITIS DISSECANS

A

Disorder of one or more ossification centers, characterized by sequential degeneration or aseptic necrosis and recalcification often inducing early OA
Traditionally divided into:
-juvenile (open physes)
-adult (closed physes)
Most common sites:
-knee
-elbow
-ankle
Often heal on its own especially if the child is still growing
-10-20 yrs most common
- male more common
- bilateral involvement in 30-40% of cases
- implication in juveniles if not diagnosed properly = OA
- differential diagnosis: acute traumatic osteochondral fractures and sometimes meniscal injuries
- causes 50% of loose bodies in the knee

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18
Q

Possible Aetiologies of OSTEOCHONDRITIS DISSECANS

A 
Trauma
Vascular causes/ischemia
Skeletal maturation (accessory centers of ossification)
Genetic conditions
Metabolic factors
Hereditary factors 
Anatomic variation
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19
Q

Specific Location of OSTEOCHONDRITIS DISSECANS

A 
Lesions involve both bone and cartilage, most commonly:
-femoral condyles: 
Medial 85%
Lateral 10%
-posterior patella surface (5%)
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20
Q

Clinical presentation of OSTEOCHONDRITIS DISSECANS

A
  • Initially
    Vague symptoms, poorly localized knee pain; stiffness with or after activities; and occasional swelling
    Catching, grinding, locking more associated with late stage (loose body)
  • Later presentation
    Knee pain; worse with activity; relieve with rest
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21
Q

Anterior cruciate ligament injuries risk factors

A

Risk factors result of a combination of:
• Female gender
• Decreased notch width
• Increased BMI
• Generalized joint laxity

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22
Q

Anterior cruciate ligament injuries

A

• The ACL resist anterior tibial glide and the most common MOI is a non contact mechanisms (+ 70%) involving deceleration with pivoting/twisting or landing in near extension.
• Most often occurs in combination with MCL tears, meniscal, or articular cartilage
• Most frequent cause of haemarthrosis in the knee
• ACL and OA (Neuman et al. 2008)

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23
Q

Clinical evaluation of a patient with a Anterior cruciate ligament injury?

A

• Painful joint line palpation
• Decrease ROM
• Anterior Drawer test
• Pivot shift test
• Lachman’s test
X-Ray may reveal a “segond”

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24
Q

Treatment for a Anterior cruciate ligament injury?

A

Non surgical approach brings satisfaction to a vast majority of patients
• Surgical repair is advocated according to:
• Patient age
• The degree of instability
• Meniscal involvement
• Associated knee injuries
• Patient preferences and occupation

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25
Q

Function of the Posterior cruciate ligament?

A

PCL is thought to be the primary stabiliser of the knee
• Seldom injured in isolation (LCL and Popliteus muscle)
• Likely to be under reported
Primary function is to prevent
• posterior translation and
• External rotation of the tibia
Injury much less common that for ACL

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26
Q

Causes of a Posterior cruciate ligament injury?

A

Injury most often occurs when a force is applied to the anterior tibia when the knee is flexed (eg dashboard injury in MVA)
Hyperextension and rotational or varus/valgus stress mechanisms also may be responsible for PCL tears.

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27
Q

Clinical presentation of a patient with Posterior cruciate ligament injury?

A
  • Typical pop not always present
    • Posterior knee pain
    • Pain and haemarthrosis much less than for ACL
  • Posterior tibial sag is visible
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28
Q

Clinical evaluation of a patient with Posterior cruciate ligament injury?

A
  • The posterior drawer test
  • The dial test (300 and 900)
  • The posterior sag test
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29
Q

Treatment of a patient with Posterior cruciate ligament injury?

A

• Non surgical treatment is advocated even in a grade III on less the patient is unresponsive and the pain is debilitating.
• Spontaneous healing occurs in more then 2/3 of PCL ruptures after 3 – 12 months
• Surgical reconstruction is recommended in combined injuries (PCL, ACL, avulsion fractures)

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30
Q

Medial collateral ligament injury

A
  • MCL is the most commonly injured ligament in the knee
    • Estimated to be around 24 per 100 000 and is quite higher
    in athletic individual
    • Twice prevalent in male – female
    • Injury ranges from sprain to tear (usually minor unless associated with other ligamentous injury)
    • MOI – valgus force; external tibial rotation
  • Semimembranosus muscle, pes anserine muscles, and vastus medialis provide dynamic stability – why does this matter?
    • MCL tear = Superficial fiber
    • The posterior fibers = rotational force and valgus in the last degrees of knee extension
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31
Q

Clinical evaluation of a patient with Posterolateral knee injuries?

A
  • Evaluation must include both varus and rotational laxity at different degree of flexion
    • The dial test (normal 5.50 of rotation) (300 and 900)
    • if more then 100 of laxity
      • Varus stress test (00 and 300)
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32
Q

Myofascial pain disorders syndrome: ANTERIOR AND ANTEROMEDIAL KNEE PAIN- what muscles

A

• Rectus femoris
• Vastus medialis (especially anteromedial)
• Sartorius, Gracilis (especially anteromedial)
• Adductors longus and brevis (especially anteromedial)

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33
Q

Myofascial pain disorders syndrome: INFEROMEDIAL KNEE PAIN- what muscle?

A

• Pes Anserine

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34
Q

Myofascial pain disorders syndrome: LATERAL KNEE PAIN- what muscle

A

• Vastus Lateralis

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35
Q

Myofascial pain disorders syndrome: POSTERIOR KNEE PAIN- what muscles?

A
  • Gastrocnemius & soleus
    • Hamstrings (esp Biceps Femoris)
  • Popliteus
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36
Q

Iliotibial band syndrome

A

Is essentially a tendonitis and a common cause of lateral knee pain especially in cyclists and runners (repetitive knee flexion/extension)
• During flexion, ITB moves posteriorly along lateral femoral condyle
• TFL hypertonicity most likely cause

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37
Q

Iliotibial band syndrome- clinical presentation

A
  • Lateral knee pain, may radiate
    • Worse running DOWNHILL or lengthening their stride
  • Most patients experience pain only during activities*
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38
Q

Iliotibial band syndrome- risk factors

A

• Preexisting iliotibial band tightness
• High weekly mileage
• Time spent walking or running on a track
• Interval training
• Muscular weakness of knee extensors and flexors and hip abductors

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39
Q

Iliotibial band syndrome- clinical evaluation

A
  • Tenderness over the lateral femoral condyle
  • Noble test
    • Pain can be elicited with active flexion-extension of the knee within the first 30° while the thumb presses over the epicondyle and ITB
    • Standing on the affected leg in a 300 flexed position
  • Crepitus may be felt
    • Ober test
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40
Q

Acute knee dislocation

A
  • Usually at least ACL and PCL torn entirely (primary constraints of the knee)
  • Hard signs of vascular injury such as distal ischaemia often present
    • Assessment of pulses is NB if you encounter these
    • Surgical intervention with adequate rehabilitation is essential!
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41
Q

Anterior knee pain

A

Represent the most common knee complaints and is often multifactorial
• Patellarabnormalitiesorinstability
• Chondral and osteochondral damage
• Muscle imbalance
• Must include a complete evaluation of the lower limb (from hip to toes)
• Morecommoninwomen2x

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42
Q

Connective / soft tissue source of pain, what is the condition

A

Fat pad syndrome*
ITB friction syndrome*
Plica syndrome
Quadriceps and patella tendonitis

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43
Q

Articular cartilage source of pain, what is the condition?

A

Degeneration (OA)*

Chondromalacia Patella

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44
Q

Intra-articular source of pain, what is the condition?

A

Loose bodies

Meniscal flaps

45
Q

Systemic pathology as a source of pain, what is the condition?

A

Inflammatory arthritis

46
Q

Patellofemoral Pain Syndrome

A

Anterior or retro patella pain with running, jumping, squatting and stair climbing in the absence of any pathological condition

47
Q

Patellofemoral Pain Syndrome: epidemiology

A
  • 25 – 40% of knee problems in athletes
    • 25% general population
    • Hard to diagnoses (poor understanding of the condition)
  • Female : Male ratio is 2:1
    • Common in runners (19 – 46%)
    • If untreated it will go unresolved for years
    • Littre evidence linking PFPS and PF arthritis
48
Q

Diagnosis testing for Patellofemoral Pain Syndrome

A
  1. Anterior knee pain with quadriceps contraction (patellofemoral grind test)
  2. Pain during squatting and
  3. Pain on palpation of the posteromedial or lateral border of the patella
49
Q

Patellofemoral Pain Syndrome treatment?

A

Conservative care
• Taping (modify patellar tracking)
• Patellarbraces
• Foot orthotics
• Muscle rehabilitation (hip muscles, trunk stability, quadriceps, hamstrings)

50
Q

Patellar tendonitis

A

Tendonitis is a common cause of anterior knee pain
• Quadriceps or patellar (also known as Jumper’s knee) tendonitis
• Hamstrings too as a cause of posterior knee pain

51
Q

Jumper’s knee

A

Repetitive loading of the extensor mechanism of the knee – kicking, jumping
• Painlocatedattheinferiorpoleofthepatella
• Usually presents as an ache after activity, easing with rest
• Somelocalswellingmaybepalpable
• Giving way or weakness is not uncommon
• Prevalence is highest among volleyball player…
• Patellar tendon rupture is a rare occurrence
Evaluation of patellar alignment is essential

52
Q

Jumper’s knee treatment?

A

Treatment is very similar as for lateral epicondylitis
• Progression of the condition leads to tendinopathy and in some cases calcific deposition within the tendon

53
Q

Quadriceps Tendonitis

A

Same as for patellar tendonitis in presentation, with pain at the proximal pole of the patella
Common MOI extensor overload but a shorter lever therefore not as vulnerable at the PT
Most NB component of Rx = QUAD STRETCHING!!

54
Q

The Blazina stages

A

Patellar tendinopathy can be classified according to onset and relation to activity
• PhaseI- Painonlyafterpracticeorgame
• Phase II - Pain during practice but does not interfere
with participation
• Phase III - Pain during and after practice and interferes with participation
• Phase IV - Complete tendon disruption

55
Q

Plica Syndrome

A

Plica are synovial embryonic remnant that initially divided the knee into 3 compartments. By the third or fourth month of fetal life, the membranes are resorbed, and the knee becomes a single chamber.
Four types of which mediopatellar plica is usually the only to be symptomatic

56
Q

Mediopatellar Plica Syndrome

A

Usually a combination of anatomical variance and either direct trauma or repetitive microtrauma
Inflammation progresses to hypertrophic changes and therefore a
symptoms develops

57
Q

Mediopatellar Plica Syndrome: clinical presentation

A

Difficult to differentiate from other knee pathology
Aggravation of symptoms by activity, such as climbing stairs, squatting, or sitting
Pseudolocking and catching
Occasional giving way
Clicking or high pitched snapping
Anterior or anteromedial knee pain

58
Q

Fat Pad Impingement Syndrome

A 
Anterior knee pain caused by hemorrhage, inflammation, fibrosis and/or degeneration of the anterior knee fat pad(s)
3 main fat pads
- anterior supra patellar
- infrapatellar
- posterior supra patellar
59
Q

Fat Pad Impingement Syndrome: aetiology

A

• Repeated microtrauma,
• Major trauma, or other
• Patellofemoral conditions

60
Q

Patellar dislocation

A

• Acute, traumatic dislocation following direct contact or sudden change indirection when the tibia is stabilised (weight-bearing)
• Knee “gives way” at the time due to quadriceps inhibition due to pain
• Severe pain, rapid swelling and difficulty with any knee flexion
• Obvious dislocation of the patella is visible
• Most often the dislocation is lateral

61
Q

In patient with indirect trauma patellar dislocation

A

• Hypermobile patella
• Patellaalto
• Shallow trochlear groove
• Systemic collagen tissue disorder (Marfan)

62
Q

How to prevent another patellar dislocation?

A

• BracingORTAPING*duringactivities
• Quadriceps strengthening & flexibility
• Hamstring flexibility to prevent counteraction of their antagonists (quads)
• Address footwear and refer for orthotic evaluation if necessary
Patient with first time dislocation will likely have cartilage damage (95%)

63
Q

Knee bursitis

A

Bursitis around the knee usually occurs in the
• Prepatellar (housemaid knee)***
• Pesanserine
Often occurs secondary to
• Directtrauma
• Injections
• Repetitive overuse

64
Q

Chondromalacia Patella

A

Loss of cartilage in the trochlear groove and retro patella surface
Found in 50% of patient with OA of the knee
Can be asymptomatic
Caused by:
Patellofemoral laxity
Recurrent dislocation
Malalignment

65
Q

Chondromalacia Patella clinical presentation

A
  • anterior knee pain, often aching, can be sharp
  • exacerbated by stair climbing or when rising from a seated position or kneeling
  • may not be present with activity such as running or walking on level surfaces
  • morning stiffness, crepitus may be present
66
Q

Chondromalacia Patella clinical evaluation

A

Palpation of the lateral and medial patellar facet

X-Ray: skyline view

67
Q

Osgood-Schlatter disease

A

Traction apophysitis of the proximal tibial tubercle and occurs in active pre adolescents / adolescents
Repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle (MOI same as for tendonitis)

68
Q

Osgood-Schlatter disease progresses too?

A

Hypertrophy of the tibial tubercle
Avulsion of the tibial tubercle
Enlarged, and tender to palpation

69
Q

Rheumatoid arthritis

A

A chronic systemic inflammatory autoimmune disease of unknown aetiology
An external trigger (eg, infection or trauma) triggers it, leading to:
Synovial hypertrophy and chronic joint inflammation
Theorized to be inheritable

70
Q

RA IN THE KNEE

A
  • RA most commonly affects smaller joints (wrist and hand) although knee presentation in common in the juvenile form which often affects one joint at a time
  • acute swelling , erythema and pain, limited weight bearing, often present with a limp
71
Q

RA IN THE KNEE : clinical presentation

A

RA affects larger joints later in the presentation
The characteristic presentation is “symmetric” not only from a stand point of left to right but also from medial to lateral

72
Q

Osteoarthritis: epidemiology

A

Osteoarthritis is the most common disease of joints in adults around
the world, and OA of the knee affect close to 6% in adults
Females > males
Prevalence of Knee OA is around 40% ≥ 70 74 year olds
X-ray findings are not well correlated with clinical signs only 15% have associated symptoms
Primary OA occurs as a degenerative process of ageing
Secondary OA is usually due to trauma or Repetative loading

73
Q

Clinical evaluation and treatment of OA of the knee

A

Observed deformity in late OA
Mild effusion often present
Hypertrophied joint margins
Tenderness on palpation along medial joint line and MCL in earlier OA

74
Q

Baker’s cyst

A

Essentially a ganglion at the posterior knee- a synovial herniation, most commonly medially
Occurs when normal fluid from the knee overflows under pressure through a weak spot in the capsule known as the popliteal recess

75
Q

Bakers cyst: clinical presentation

A

Posterior knee pain or mechanical symptoms such as catching and accompanied by a feeling of fullness in the popliteal fossa

76
Q

Causes of Hyperpronation

A

• Obesity, hip abductor weakness, Genu valgum
• Short Achilles tendon, high heels
• Tight shoes, weak toes flexor
CAN RESULT IN…
• Plantar fasciitis
• Forefoot changed
(Metatarsalgia, Hallux valgus)

77
Q

Acute and chronic Compartment syndrome

A

– Raised intracompartmental pressures possibly induced by muscle swelling or increased osmoHc pressure~>blood flow impairment ~>pain
– Patients typically experience pain and swelling and may also have sensory deficits or paresthesias, and motor loss or weakness
– ACS is a medical emergency and can affect any compartment
– CCS lower extremiHes
– Younger individual +++

78
Q

Causes of compartment syndrome

A
  1. Vasculartrauma
  2. Fractures
  3. Crushinjuries
  4. Anticoagulation therapy
  5. Tight casts and splint
79
Q

Shin splints

A

• Accounts for an esHmated 10% to 20% of all injuries in runners and up to 60% of all overuse injuries of the leg
• Common causes:
– MedialTibialStressSyndrome(MTSS)
– Tibial Stress Fracture
– ChronicCompartmentSyndrome

80
Q

Medial Tibial stress syndrome

A

– Maladaptive remodeling process of bone as a reaction to stresses on the Tibia (loading – external or myofascial)
– Maladaptation process:
• Porous bone formation micro fissures eventually stress fracture
– MTSS is a spectrum of pathology ranging from initial periostitis to bony changes (above) to stress fracture
– Flexor digitorum longus (++) and SOLEUS (++++) are major contributors

81
Q

Medial Hbial stress syndrome: presentation

A

– Diffuse pain along the middle and distal thirds of the posteromedial Tibia
– Typically runners or jumping activities
– Initial stage* - pain at the beginning of activity, may resolve as the activity continues, and then recurs after the activity ceases OR occurs only at the end of the the activity
• In the early stages, the pain usually resolves with several minutes’ rest

82
Q

Tibial stress fracture

A

– Diffuse pain at the posteromedial margin of the Tibia
– May begin insidiously and intensify with further training, eventually persisting throughout the day and even at night
One specific fracture type:
• Anterior cortex fractures - fracture of anterior cortex of the midshaft (poor blood supply and morphological bowing of the Tibia)

83
Q

Deep vein thrombosis

A

– Venous thromboembolism (VTE)
– Either occult or following prolonged immobilizaHon (eg. surgery) and usually resolves spontaneously without complicaHon
– However, death from DVT- associated massive pulmonary embolism (PE) is not uncommon
– Most common presentaHon:
• Homan’s sign: calf pain on dorsiflexion of the foot
• A palpable tender venous segment / mass in the calf
– May have associated erythema, warmth and oedema

84
Q

Myofascial pain syndrome

A

– Tibialis Anterior – medial Hbia
– No other real culprits for “shin” pain
• Local Tp’s in extensor digitorum / hallicus
may contribute to local pain / discomfort

85
Q

Achilles tendonitis

A

Presentation:
– Paratenonitis
• Localized/burning pain during or following activity
• Later - onset of pain may occur earlier during activity, with decreased activity level, or even at rest
– Tendinosis
• Usually asymptomatic
• Patient may complain of a sensation of fullness or note a nodule in the back of the leg

86
Q

Achilles tendonitis: aetiologies and treatment

A

Generally an overuse injury in the conditioned athlete,or presents in the unconditoned patient taking up a new activity (eg. running)
– HYPERPRONATION is a common underlying risk factor; SUPINATION being less problematic
Treatment options:
• Eccentric strengthening of gastroc/soleus complex
• Stretching once inflammation sexled
• Heel raises

87
Q

Tendon rupture

A

• Achilles tendon rupture
– Typically a middle-aged recreational athlete who continues a youthful passion for a vigorous sport
– Male : Female 10:1
– Rapid eccentric loading of the Achilles tendon eg. landing a jump
• Gastrocnemius tear (calf “rupture”)
– Usually due to sudden, forceful contraction – eg. acceleration or repetitive forces eg. running uphill

88
Q

Common peroneal nerve entrapment

A

CPN courses around the fibular neck and passes through the peroneus Longus muscle
Causes:
• Frequent crossing of the legs
• Fibular fractures
• Direct trauma to the knee
Presentation:
• Foot “drop” – weak extension, “slapping” gait
• Sensory deficit

89
Q

Ankle sprain

A

• Most commonly sprained ankle ligament is the ATFL, followed by the CFL, then PTFL
Presentation
• Swelling usually lateral but may be diffuse
• Ecchymosis frequently found laterally, but it may sexle into the lateral or medial heel

90
Q

Ankle sprain: provocative tests

A

• Anterior drawer usually positive but may be masked in early stages due to severe swelling
• Neurologic examination may be necessary in severe sprains as peroneal nerve and Tibial nerve injuries may occur

91
Q

Ankle sprain: possibility of fracture

A

• Distal fibular fracture can occur with severe EVERSION sprains
• Local tenderness, severe swelling laterally and persistent pain are indicators
• Oxawa ankle rules need to be considered
– Chronic, recurrent instability:
• A frequent cause of ongoing pain and recurrent sprain

92
Q

Synovial Impingement at the Ankle

A

A relatively common cause of ongoing pain following ankle inversion sprain – Causes
• synovitis,
• Fibrotic scar tissue &
• Periosteal new bone may develop
– Occurs anteriorly or posteriorly
– Exacerbated by passive dorsi or plantar flexion
– Arthroscopic surgery is most common treatment
– Ankle impingement sign*

93
Q

Posterior Tibial Tendinopathy

A

– Main insertion for the PTT is on the medial navicular
– Hyperpronation may result in PTT tendon becomes overstretched
– It is usually an overuse injury
– Medial ankle pain behind the medial malleolus
– Swelling and tenderness
– Resisted inversion elicit pain and relaHve weakness

94
Q

Peroneal Tendon Subluxation

A

– Snapping/popping of peroneal or fibularis tendons over distal fibula
– Usually reduces spontaneously
– Lateral ankle pain behind the lateral malleolus
– Local swelling and tenderness
– Symptoms elicited with resisted eversion
– Causes:
• Congenital loose retinaculum or shallow groove
• Traumatic retinacular tear such as following inversion sprain

95
Q

Tarsal Tunnel Syndrome

A

Entrapment of 6bial nerve or its branches as it passes posterior to medial malleolus under the flexor retinaculum (tarsal tunnel)
Causes:
– Idiopathic – 50%
– Excessive pronaHon
– Compressive footwear (seen with ski boots)
Tarsal tunnel syndrome is primarily a clinical diagnosis

96
Q

Tarsal tunnel syndrome: clinical presentation

A

– Vague plantar foot pain
– Paresthesia, numbness and atrophy of the intrinsic foot muscles as the condition progresses
– Pain usually aggravated by activity and relieved by rest
– Tenderness on palpation of the medial malleolus region
– + Tinel’s sign
– DDX

97
Q

Plantar fasciitis

A
  • Excessive femoral anteversion; lateral tibial torsion
  • Leg length discrepancy (short leg)
    • Hyperpronation
    • Inappropriate footwear*
    • Muscle tightness (tending to hyper-pronation)**
    • Obesity
    • Overtraining
98
Q

Plantar fasciitis clinical presentation

A

– “Heel pain” upon weight bearing - typically worse in the morning with the first steps
• Often worse in stomach sleepers
– Pain gradually improves with activity though returns with prolonged weight-bearing
Also associated with arthritic conditions and Diabetes (weakness of intrinsic foot muscles and predisposition to inflammation)
Examination findings:
– Point tenderness on the medial calcaneal tuberosity
– Pain may be exacerbated by passive dorsiflexion or active plantar flexion
– Pain may be exacerbated by forced passive dorsiflexion of the great toe (Windlass test)

99
Q

Other DDX for Plantar fasciitis

A

Heel Spurs
– Occur at the Achilles tendon or plantar fascia insertions
– MicrotraumaHc or associated with underlying arthritis
– Can be asymptomatic
Fat Pad Syndrome
– Inflammation of the heel fat pad
– Trauma (acute or repetitive)
• Obesity
• Footwear

100
Q

Metatarsalgia

A

Pain over the metatarsal heads without any other obvious diagnosis
– Second metatarsal head is most frequently involved – with hyperpronation, the forces on the foot move medially, and the second metatarsal may assume an excessively large percentage of the force.
General treatment recommendations include:
• Strengthening the plantar muscles
• Footwear with low heels and wide toe boxes
• Orthotics if required

101
Q

Metatarsal Stress Fracture causes

A
  • Excessive alcohol consumption
    • Excessive or sudden increase in physical activity with limited rest periods
  • Female sex (esp if amenorrhea)
    • Vitamin D deficiency
    • Distance running - > 40km/week increases risk
    • Smoking
102
Q

Hallux valgus

A

Lateral deviation on of the hallux (toward other toes)
• Leads to bunion formation (tender medial bony prominence)
– Hyperpronation leading to excessive force on the first ray most common cause
– High heels producing a downward and medial force on the talus and/or a Tight Achilles tendon has also been implicated
– Narrow footwear

103
Q

Hallux rigidus

A

Osteoarthrosis of 1st MTP joint
– Narrowed joint space
– Hypertrophy and Osteophytosis
– Associated dorsal or dorsomedial bunion formation
– Limits ROM
– often extension (DF)
• What is the implication of that – on gait?
– On the plantar fascia?

104
Q

Turf toe

A

1st MTP joint sprain
– Typically secondary hyperextension while forefoot fixed in weight bearing
– Potential joint capsular stretching or tearing

105
Q

Interdigital (Morton’s neuroma) neuralgia

A

Perineural fibrosis of the common digital nerve
– Most frequently between the 3rd and 4th metatarsals, with neuropathic pain* to the associated toes
– Often intermixent with asymptomatic episodes in between
– Patients someHmes feel a “marble”
Causes:
– Abnormal foot posture (planus or cavus)
– Footwear with narrow toe box

106
Q

Interdigital (Morton’s neuroma) neuralgia: orthopaedic tests

A
  1. Anterior drawer test: (Predominantly ATFL)
    – Adding inversion tests more lateral ligaments
  2. Forefoot compression test (Compression across metatarsals)
    Reproduction of symptoms in Morton’s Neuroma
  3. Tinel sign (sensitive but not specific)
  4. Triple compression stress test (tarsal tunnel)
107
Q

Specific Intervention for Plantar Fasciitis

A
  • RICE
  • corticosteriods
  • muscle stretching
  • Ultrasounds
108
Q

Function of the anterior cruciate ligament?

A

Anterior cruciate prevent forward displacement of the tibia and controls rotational movement of the tibia

CHI309 - Chiropractic skills and Principles 2 (7 decks)

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