Lecture 9 - Lower Limb Soft Tissue And Bone Disorders

Question 1

Dysplasia of the hip: Pathophysiology

Answer 1

• during childbirth
• abnormality in size, shape, orientation or organization of the femoral head or acetabulum

RISK FACTORS: breech, female, Family Hx, Firstborne

Question 2

Dysplasia of the hip: assessment

Answer 2

• ortolani and barlow maneuvers
• Galeazzi sign
• Hip abduction range

Question 3

Dysplasia of the hip: management

Answer 3

• subluxation often corrects spontaneously
• if subluxation persists: Pavlik harness
• if dislocation persists: closed reduction and Hip Spica casting

Question 4

Perthe’s disease pathophysiology

Answer 4

• osteochondrosis of capital epiphysis of femoral head: disruption of blood supplu
• cessatin of endochondral ossification
• Vascular invasion of cartilage
• necrosis of marrow space and trabecular bone

Question 5

Perthe’s disease: Assessment

Answer 5

• low grade ache, male 4-10 yo
• Limited abduction and internal rotation upon physical exam
• XRAY: increased density and flattening of femoral capital epiphysis

Question 6

Perthe’s disease: Management

Answer 6

Rest

• exercise for range of motion
• Brace
• surgery

Question 7

Avascular necrosis of the femoral head: pathophysiology

Answer 7

• damage to deep branch of medial femoral circumflex artery leading to necrosis of femoral head
• follows femoral fracture in high energy trauma
• can have non traumatic causes: anything that compromises blood supply in artery

Question 8

Avascular necrosis of the femoral head: clinical assessment

Answer 8

• history of hip pain progressively worse over time
• located in groin, proximal thigh, buttock
• aggravates with weight bearing and eases with rest
• antalgic gait
• passive movement elicits pain
• limitation in motion in capsular pattern
• MRI

Question 9

Avascular necrosis of the femoral head: management

Answer 9

• if non traumatic: non-weight bearing activities, alter risk factors
• older patient: hip replacement
• younger patient: reconstructive procedure

Question 10

Osgood Schlatter’s syndrome (aka: traction apophysitis)

Answer 10

• apophysis biomechanically weak during growth spurt: at danger in young athletes
• resultant traction causes irritation, inflammation, microtrauma
• Osgood Shlatters: tibial tuberosity
• Sinding Larsen Johansson: inferior angle of patella

Question 11

What is an apophysis

Answer 11

Secondary ossification centre, attachment of tendons

Question 12

Osgood Schlatters: clinical presentation

Answer 12

• in very active younf children aged 10-15 during growth spurt
• more often boys cause growth spurt later
• often unilateral
• inflammed, swollen and tender on palpation
• child may have poor lower limb alignment

Question 13

Osgood Schlatters management

Answer 13

PRICEM

• gentle strecth of rectus femoris
• orthotics
• patellar tendon taping

Question 14

Patellofemoral dislocation

Answer 14

• Patella moves laterally
• Predisposing factor: femoral anteversion, genu valgum, increased Q angle, Patella alta, ligament laxity, muscle weakness

Question 15

Patellofemoral dislocation assessment

Answer 15

Physical exam: tenderness over medial patella, patellar apprehension test

Question 16

Patellofemoral dislocation: management

Answer 16

• relocate and assess for fracture
• conservative
• surgery sometimes required

Question 17

Patellofemoral pain syndrome

Answer 17

• 12-35 years
• activity dependent
• aching pain
• cause unknown

Contributing factors: abnormal biomechanics, tight structured, muscle imbalance, training/load

Question 18

Patelofemoral pain syndrome diagnosis

Answer 18

• history : area of pain, aggrevating activities, crepitus
• Physical: alignment abnormalities, single leg step down (less pain if glide patella medially), isometric muscle test
• no imaging required

Question 19

Management of Patellofemoral pain syndrome

Answer 19

Rest

• McConnell taping: increased activation of vastus medialis
• Address control and strength issues
• stretch tight structures
• orthotics
• NSAIDS in acute phase only

Question 20

Achilles tendinosis

Answer 20

A degenerative mucoid condition characterised by an increase in ground substance and vascular tissue and an absence of inflammatory markers

Question 21

Achilles tendinosis presentation

Answer 21

• pain localised to tendon
• gradual onset
• pain aggravated during or after activities
• pain can disappear after warm up and return when cooling down

Question 22

Stage 1: reactive tendinopathy

Answer 22

• acute tensile stress or compressive overload
• tendon cells activated and proliferate
• proteoglycans produced
• tendon thickening
• short term reduction in stress

Question 23

Stage 2 tendinopathies: tendon dysrepair

Answer 23

• worsening pathology with greater matrix breakdown
• tendon cells more prominant
• myofibroblasts appear
• increased production of proteoglycans and collagen
• collagen separation and disruption of matrix
• growth of vessels and nerves

Question 24

Stage 3 tendinopathies: degenerative

Answer 24

• end stage of disease
• matrix and cell changes progress
• apoptosis
• large areas of disorganised matrix, little collagen, vessels

Question 25

Pain in tendinopathy

Answer 25

Up to 65% of degenerative tendons which rupture were pain free Where does pain originate: - biochemical substances - neurovascular in growth

Question 26

Management of stage 1 early stage 2 tendinopathy

Answer 26

PHARMACOLOGY - tenocyte inhibitor - affrecan inhibitor PHYSICAL - load management

Question 27

Late stage 2 or stage 3 tendinopathy management

Answer 27

PHARMACOLOGY - prolotherapy - aprotinin - sclerosing therapy - glyceryl trinitrate PHYSICAL - exercise with eccentric component - Shock wave therapy, friction, ultrasound

Question 28

Exercises for tendinopathies: effect

Answer 28

- increased collagen production in affected tendon - improve tendon structure - reduce tendon vessels - reduce pain

Question 29

Achilles tendinosis prsentation

Answer 29

- common in sports involving running and jumping - tenderness and thickening in mid portion of achilles - crepitus or nodules - pain on heel rise test

Question 30

Management of achilles tendinosis

Answer 30

Eccentric exercise protocol by Alfredson and cook

Question 31

Plantar heel pain pathophysiology

Answer 31

Overuse of plantar ffascia at attachment of calcaneus - collagen disarray in ABSENCE of inflammatory cells - RISK FACTORS: pes planus/cavus, sports, excessive load

Question 32

Plantar heel pain assessment

Answer 32

- pain with 1st step am, prolonged standing or running | - palation of medial calcaneal tuberosity is the definitive objective sign

Question 33

Plantar heel pain: management

Answer 33

- offload the platar fascia: activity modification - NSAIDS - stretching - self massage - strengthening exercise - taping - corticosteroid injection