Leg pain Flashcards
MC nerve root causing leg pain
L5 and S1 nerve roots
Chronic ischaemia due to arterial occlusion can
manifest as :
intermittent claudication or rest pain in
the foot due to small vessel disease
varicose veins can certainly cause a dull aching ‘heaviness’ and cramping, and can lead to _____
painful ulceration
The most common cause of leg pain in children is _______
soreness and muscular strains due to trauma or unaccustomed exercise.
So-called _________, or idiopathic leg pain, is
thought to be responsible for up to 20% of leg pain in
children
‘growing pains’
Pain location of growing pains
The pains are typically intermittent and
symmetrical and deep in the legs, usually in the
anterior thighs or calves
Main consideartions for leg pain in the elderly
The older the patient, the more likely it is that arterial
disease with intermittent claudication and neurogenic
claudication due to spinal canal stenosis will develop
_______ is usually contraindicated for radicular sciatica
Conventional spinal manipulation
Referred pain in the leg can arise from disorders
of the _____ or ______
SIJs or from spondylogenic disorders
__________ is that which
originates from any of the components of the vertebrae
(spondyles), including joints, the intervertebral disc,
ligaments and muscle attachments
Non-radicular or spondylogenic pain
This causes typically a dull ache in the buttock
but it can be referred to the iliac fossa, groin or
posterior aspects of the thighs
Sacroiliac dysfunction
This is the commonest lower limb entrapment and
is due to the lateral femoral cutaneous nerve of the
thigh being trapped under the lateral end of the
inguinal ligament, 1 cm medial to the ASIS.
Meralgia paraesthetica
DDx for Meralgia paraesthetica
• L2 or L3 nerve root pain (L2 causes buttock pain
also)
• Femoral neuropathy (extends medial to midline)
The _________nerve can
be entrapped where it winds around the neck of the
fibula or as it divides and passes through the origin of
the peroneus longus muscle 2.5 cm below the neck of
the fibula.
common peroneal (lateral popliteal)
Pain location of peroneal nerve palsy
Pain in the lateral shin area and dorsum of the
foot
This is an entrapment neuropathy of the posterior
tibial nerve in the tarsal tunnel beneath the flexor
retinaculum on the medial side of the ankle. The
Tarsal tunnel syndrome
SSx of Tarsal tunnel syndrome
A burning or tingling pain in the toes and sole of
the foot, occasionally the heel.
Retrograde radiation to calf, perhaps as high as
the buttock
Test for Tarsal tunnel syndrome
Tinel test (finger or reflex hammer tap over
nerve below and behind medial malleolus) may
be positive
Mx of Tarsal tunnel syndrome
- Relief of abnormal foot posture with orthotics
- Corticosteroid injection into tunnel
- Decompression surgery if other measures fail
The commonest site of acute occlusion is the _____
common femoral artery
Ominous sign of acute limb ischemia
Paralysis (paresis or weakness) and muscle compartment
pain or tenderness is a most important and
ominous sign
acute limb ischemia
If the foot becomes dusky purple and fails to blanch on pressure, ________ has occurred
irreversible necrosis
What artery is being tested?
Palpate deeply just below the inguinal ligament, midway between the ASIS and the symphysis pubis. If absent or diminished, palpate over abdomen for aortic aneurysm
Femoral artery.
What artery?
Palpate, with curved fingers,
just behind and below the tip of the medial malleolus
of the ankle.
Posterior tibial artery
What artery?
Feel at the proximal end of the first metatarsal space just lateral to the extensor tendon of the big toe.
Dorsalis pedis artery.
pitting oedema is tested by ________
pressing firmly with your thumb for at least
5 seconds over the dorsum of each foot, behind each
medial malleolus and over the shins.
What test?
Raise both legs to about 60 ° for about 1 minute, when
maximal pallor of the feet will develop. Then get the
patient to sit up on the couch and hang both legs
down.
Postural colour changes (Buerger test)
What is a positive Buerger test?
A positive Buerger test is pallor on elevation and rubor on dependency and indicates severe chronic ischaemia
What is the golden rule for Tx of ALI
Occlusion is usually reversible if treated within 4 hours (i.e. limb salvage). It is often irreversible if treated after 6 hours (i.e. limb amputation).
Mx of ALI
- Intravenous heparin (immediately) 5000 U
* Emergency embolectomy (ideally within 4 hours):
Sx of ALI
• Stenting of vessels (a good modern option)—discuss
this with an interventional cardiovascular physician
• Arterial bypass if acute thrombosis in chronically
diseased artery
Mx of irreversible ALI
Amputation (early) if irreversible ischaemic changes
ALI prevention
Lifetime anticoagulation with warfarin will be
required
_______caused by gradual arterial
occlusion can manifest as intermittent claudication,
rest pain in the foot, or overt tissue loss—ulceration,
gangrene
Chronic ischaemia
_______is a pain or tightness
in the muscle on exercise (Latin claudicare, to limp),
relieved by rest
Intermittent claudication
________ is a constant severe
burning-type pain or discomfort in the forefoot at
rest, typically occurring at night when the blood flow
slows down.
Rest pain
Determine the level of obstruction
• Pain in the buttock, thigh and calf, especially
when walking up hills and stairs
• Persistent fatigue over whole lower limb
• Impotence is possible (Leriche syndrome)
Proximal obstruction (e.g. aortoiliac)
Obstruction in the thigh
Determine the level of osbtruction
•____________ (the commonest) causes
pain in the calf (e.g. 200–500 m), depending on
collateral circulation
• ___________ → claudication at about 100 m
•___________ → claudication at 40–50 m
Superficial femoral
profunda femoris
multiple segment involvement
affects small arteries, causes rest
pain and cyanosis (claudication uncommon)
Buerger disease
The presence of_________implies an immediate threat to limb viability.
rest pain
In CLI,
Why do doppler?
measure resting ankle systolic BP; determine ankle/brachial index; normal value 0.9–1.1
Gold standard for dx of CLI
Angiography: the gold standard, reserved for
proposed intervention
What to do in CLI if need surgery is needed?
Arteriography
Drug TX for CLI
Drug therapy: aspirin 150 mg daily.
What has no value in CLI Tx
Drug therapy: aspirin 150 mg daily.
Prognosis of CLI
About one-third progress, while the rest regress
or don’t change. 5
When to refer to a vascular surgeon?
- ‘Unstable’ claudication of recent onset; deteriorating
- Severe claudication—unable to maintain lifestyle
- Rest pain
- ‘Tissue loss’ in feet
What surgical procedure?
__________—for localised iliac stenosis
endarterectomy
What procedure?
This angioplasty is performed with a special intra-arterial balloon catheter for localised limited occlusions. An alternative to the balloon is laser angioplasty
Percutaneous transluminal dilation
________ are dilated, tortuous and elongated
superficial veins in the lower extremity
Varicose veins
Why are varicose veins dilated?
1
2
The veins are dilated because of incompetence
of the valves in the superficial veins or in the
communicating or perforating veins between the
deep and superficial systems
Risk factors for varicose veins
Female sex Family history Pregnancy Multiparity Age Occupation Diet (low fibre)
Dilated superficial veins, which can mimic varicose
veins, may be caused by extrinsic compression of
the veins by a_____ or _________
pelvic or intra-abdominal tumour
Uncommon causes of superficial veins
Uncommonly, but importantly, superficial veins
dilate as they become collaterals following previous
DVT, especially if the ilio-femoral segment is involved.
When do varicose veins become painful?
Pain is a feature where there are incompetent perforating
veins running from the posterior tibial vein to the
surface through the soleus muscle
Cx of varicose veins
Superficial thrombophlebitis Skin ‘eczema’ (10%) Skin ulceration (20%) Bleeding Calcification Marjolin ulcer (squamous cell carcinoma
This helps determine long saphenous vein incompetence.
A marked dilated long saphenous vein in the fossa ovalis (saphena varix) will confirm incompetence. It disappears when the patient lies down
Venous groin cough impulse
A doubly positive __________is
when the veins fill rapidly before the pressure is
released and then with a ‘rush’ when released. This
indicates coexisting incompetent perforators and
long saphenous vein
Trendelenburg test
A similar test to the Trendelenburg test is performed with the pressure (tourniquet or finger) being applied over the
short saphenous vein just below the popliteal fossa
Short saphenous vein incompetence test.
Where are the sites where it is difficult to identify incompetence
medial aspect of the
leg, posterior to the medial border of the tibia
_____________studies will accurately localise sites of incompetence and determine the state of the functionally important deep venous system.
Venous duplex ultrasound
How to Tx varicose veins
• Keep off legs as much as possible.
• Sit with legs on a footstool.
• Use supportive stockings or tights (apply in
morning before standing out of bed).
• Avoid scratching itching skin over veins.
What Tx regimen?
It is ideal for smaller, isolated veins, particularly
below the knee joint.
Compression sclerotherapy
This is the best treatment when a clear
association exists between symptoms and
obvious varicose veins (i.e. long saphenous vein
incompetence
Surgical ligation and stripping
T or F
Surgery for varicose veins may relieve
heavy, aching legs
F (does not relieve)
• Usually occurs in superficial varicose veins
• Presents as a tender, reddened subcutaneous
cord in leg
• Usually localised oedema
Superficial thrombophlebitis
When is there a risk of DVT in superficial thrombophlebitis?
there is extension above the level of the
knee when there is a risk of pulmonary embolism
This rare but life-threatening condition is when an
extensive clot obstructs the iliofemoral veins so
completely that subcutaneous oedema and blanching
occurs.
Iliofemoral thrombophlebitis (phlegmasia dolens)
Initial presentation of Iliofemoral thrombophlebitis
This initially causes a painful ‘milky white
leg’, previously termed phlegmasia alba dolens
Cx of Iliofemoral thrombophlebitis
may develop ‘shock’,
gangrene and pulmonary embolus.
Mc etiologies of Cellulitis and erysipelas
Streptococcus pyogenes (commonest) and Staphylococcus aureus.
Tx of S. pyogenes
If S. pyogenes confirmed:
phenoxymethylpenicillin 500 mg(o) 6 hourly for 10 days
Doubtful of Dx of S. pyogenes? How to Tx
If organism doubtful:
flu/dicloxacillin 500 mg (o) 6 hourly for 7–10 days
Tx of severe, life threatenong S. aureus
Severe, may be life-threatening: flucloxacillin/dicloxacillin 2 g IV 6 hourly for 7–10 days
T or F
Always X-ray the legs (including hips) of a patient
complaining of unusual deep leg pain, especially
a child.
T
Pain that does not fluctuate in intensity with
movement, activity or posture has ____ or ______ cause
an inflammatory
or neoplastic cause
Hip disorders such as _____ and _______can present as pain in the knee
(usually medial aspect).
osteoarthritis and slipped
femoral epiphysis
Avoidance of amputation with acute lower limb
ischaemia depends on early recognition which is __________
(surgery
within 4 hours—too late if over 6 hours).
Common presentation of knee problems
pain, stiffness, swelling, clicking and
locking
Excessive strains across the knee, such as a _________are more likely to cause ligament
injuries, while twisting injuries tend to cause
_________
valgus producing force,
meniscal tears
It should be suspected with a history of either a valgus strain or a sudden pivoting of the knee, often associated
with a cracking or popping sensation.
It is often associated with the rapid onset of haemarthrosis or inability to walk or weight-bear.
A ruptured anterior cruciate ligament (ACL)
A rapid onset of painful knee swelling (minutes
to 1–4 hours) after injury indicates________
blood in the
joint—haemarthrosis
Swelling over 1–2 days after injury indicates
synovial fluid—______
traumatic synovitis
Any collateral ligament repair should be undertaken
early but, if associated with ACL injuries, early
surgery may result in ________
knee stiffness
Consider_________ in the
prepubertal child (especially a boy aged 10–14)
presenting with knee
Osgood–Schlatter disorder (OSD)
The condition known as _______ is the
commonest type of knee pain and accounts for
at least 11% of sports-related musculoskeletal
problems.
anterior knee pain
Prime cause of anterior knee pain
The prime cause of this is patellofemoral
dysfunction pain. It is a benign condition with a
good prognosis.
The hip joint is mainly innervated by________ hence
pain is referred from the groin down the front
and medial aspects of the thigh to the knee
L3,
It is not uncommon for children with a
slipped upper femoral epiphysis to present with a
_______
limp and knee pain
Patients with disc lesions may notice that
__________ hurts the knee,
whereas walking does not because of the L3 innervation
sitting, coughing or straining
L3 nerve root pressure from an L2–3 disc prolapse
(uncommon) and L4 nerve root pain will cause
_________
anteromedial knee pain
L5 reference from an L4–5
disc prolapse can cause _______
anterolateral knee pain,
S1 reference from an L5–S1 prolapse can cause pain
at the_______
back of the knee
A UK study highlighted the fact that the commonest
causes of knee pain are ______ and ______due to overstress of the knee or other minor trauma
simple ligamentous strains
and bruises
Low-grade trauma of repeated overuse, such as
frequent kneeling, may cause ___________
known variously as ‘housemaid’s knee’ or ‘carpet
layer’s knee’.
prepatellar bursitis
________ is referred to as ‘clergyman’s knee
Infrapatellar bursitis
The most common overuse problem of the knee
is the________________(often
previously referred to as chondromalacia patellae).
patellofemoral joint pain syndrome
MC mets to the knees
The commonest neoplasias are secondaries from the
breast, lung, kidney, thyroid and prostate
Septic arthritis from blood-borne infection can be of the primary type in children, where the infection is either ______, _______ and _______ in adults.
staphylococcal or due to Haemophilus influenzae, or gonococcal arthritis
________ should be kept in
mind with a fleeting polyarthritis that involves the
knees and then affects other joints
Rheumatic fever
Red flag pointers for knee pain
- Acute swelling with or without trauma
- Acute or acute on chronic erythema
- Systemic features (e.g. fever) in absence of trauma
- Unexplained chronic, persistent pain
A ruptured_______ will cause severe pain
behind the knee and can be confused with deep
venous thrombosis
Baker cyst
The sudden onset of painful swelling (usually within
60 minutes) is typical of________
haemarthrosis
Causes of hemarthrosis?
Torn cruciate ligaments, esp. ACL
Capsular tears with collateral ligament tears
Peripheral meniscal tears
Dislocation or subluxation of patella
Osteochondral fractures
Bleeding disorders (e.g. haemophilia), anticoagulants
Causes of recurrent pain and swelling
• patellofemoral pain syndrome • osteochondritis dissecans • degenerative joint disease including degenerative meniscus tears • arthritides
________ usually means a sudden inability to extend
the knee fully (occurs at 10–45 ° , average 30 ° ) but
ability to flex fully
Locking
Causes of true locking
• torn meniscus (bucket handle) • loose body (e.g. bony fragment from osteochondritis dissecans) • torn ACL (remnant) • flap of articular cartilage • avulsed anterior tibial spine • dislocated patella • synovial osteochondromatosis
Causes of pseudolocking
- patellofemoral disorders
- first or second degree medial ligament tear
- strain of ACL
- gross effusion
- pain and spasm of hamstrings
_________ of the knee implies that the patient
feels that something is ‘getting in the way of joint
movement’ but not locking
‘Catching’
_________ may be due to an abnormality such as
patellofemoral maltracking or subluxation, a loose
intra-articular body or a torn meniscus, but can
occur in normal joints when people climb stairs or
squat
Clicking
Causes of anterior knee pain
- patellofemoral syndrome
- osteoarthritis of the knee
- patellar tendonopathy
- osteonecrosis
Common causes of lateral knee
- osteoarthritis of lateral compartment of knee
- lesions of the lateral meniscus
- patellofemoral syndrome
What ligaments are affected by these tests
Adduction (varus) and abduction (valgus) stresses of the tibia on the femur are applied in full extension and then at 30 ° flexion with the leg over the side of the couch
What indicates damage in the ligament test
firmness indicates stability, ‘mushiness’ indicates damage
Stability of the ACL can be tested with the_______
anterior drawer test
What test?
The tibia is pulled forwards off the femur and in
the presence of a cruciate ligament injury there will
be increased gliding of the tibia on the femur
anterior drawer test
In the presence of ______ injury, the increased
external rotation of the tibia against the femur may
add to the positive drawer sign
medial ligament
What test?
The patient lies on the couch and the flexed knee is rotated (internally and externally) in varying degrees of abduction as it is straightened into extension. A hand over the affected knee feels for ‘clunking’ or tenderness
McMurray test.
What test?
At 15–20° flexion,
attempt to push the patella laterally and note the
patient’s reaction.
Patella apprehension test
If the Q angle is >15 ° in men and >19 ° in women
there is a predisposition to____ and ______
patellofemoral pain and instability.
________ excellent for diagnosing cartilage and
menisci disorders and ligament damage;
the investigation of choice for internal
‘derangement
MRI:
What dxtic:
_________ good for assessment of patellar
tendon, soft tissue mass, fluid collection,
Baker cyst and bursae
ultrasound:
When is CT useful in knee conditions?
useful for complex fractures of tibial
plateau and patellofemoral joint special
dysfunction
A painful knee during the first decade of life (0–10
years) in non-athletes is an uncommon presenting
symptom, but_____ and ______ have to be considered
suppurative infection and juvenile
chronic arthritis
__________which is often seen around
4–6 years, may predispose to abnormal biomechanical
stresses, which contribute to overuse-type injuries if
the child is involved in sport
genu valgum,
Pain in the knee presents most frequently in the second
decade and is most often due to the _______
patellofemoral
syndrome
In children in their 20s, An important problem is subluxation of the patella, typically found in teenage girls. It is caused by _____________without complete dislocation of the patella
maltracking of the patellofemoral mechanism
OSD is common in pre-pubertal adolescent boys
but can occur in those aged_____
10–16 years
__________ is a traction
apophysitis resulting from repetitive traction stresses
at the insertion of the patellar tendon into the tibial
tubercle, which is vulnerable to repeated traction in
early adolescence
Osgood–Schlatter disorder (OSD)
SSx of OSD
• Localised pain in region of tibial tubercle during
and after activity
• Aggravated by kneeling down and going up and
downstairs
Pain character of OSD
Pain reproduced by attempts to straighten flexed
knee against resistance
T or F, in OSD
Corticosteroid injections should be avoided
T
T or F, in OSD
Plaster cast immobilisation should also be avoided
T
This commonly occurs in adolescent boys aged 5–15
years whereby a segment of articular cartilage of the
femoral condyle (85%) undergoes necrosis and may
eventually separate to form an intra-articular loose
body
Osteochondritis dissecans: juvenile form
Osteoarthritis is the most common cause and
excellent results are now being obtained using ____________ in those severely affected
total knee replacement
________typically a disorder of the elderly with
about 50% of the population having evidence of
involvement of the knee by the ninth decade.
Most cases remain asymptomatic but patients (usually
aged 60 or older) can present with an acutely hot, red,
swollen joint resembling septic arthritis.
Chondrocalcinosis of knee
pseudogout
Possible associated DO of Chondrocalcinosis of knee
pseudogout
haemochromatosis, hyperparathyroidism or
diabetes mellitus
Tx of pseudogout
The treatment is similar to acute
gout although colchicine is less effective. Acute
episodes respond well to NSAIDs or intra-articular
corticosteroid injection.
Spontaneous osteonecrosis of the knee (SONK) is
more common after the age of 60, especially in females;
it can occur in either the _____ and ______
femoral (more commonly)
or tibial condyles
The sudden onset of pain in the knee, with a normal joint
X-ray, is diagnostic of _______
osteonecrosis
Surgical Mx of osteonecrosis
Surgery in the form of subchondral drilling may be
required for persistent pain in the early stage
The adult form occurs more often in males and may
be the result of cysts of osteoarthritis fracturing into
the joint
Osteochondritis dissecans:
adult form
This common complaint is usually a result of a
pedunculated fibrous lump in the prepatellar bursa,
often secondary to trauma, such as falls onto the knee.
The knee ‘mouse
T or F
The medial meniscus is three times more likely to
be torn than the lateral
T
Suspect these injuries when
there is a history of injury with a twisting movement
with the foot firmly fixed on the ground
Meniscal tears
What are the signs of Parrot beak tear of lateral meniscus:?
— pain in the lateral joint line — pain radiating up and down the thigh — pain worse with activity — a palpable and visible lump when the knee is examined at 45°
How to manage Parrot beak tear of lateral meniscus:?
_________ offers relief.
The peripheral meniscus is vascular and can be
repaired within________weeks of injury
Arthroscopic partial meniscectomy
6–12
Sx of Cleavage tear of medial meniscus
— pain in medial joint line
— pain aggravated by slight twisting of the joint
— pain provoked by patient lying on the side
and pulling the knees together
— pain worse with activity
Mx of medial meniscus tear
Arthroscopic meniscectomy is appropriate
treatment, but some do settle with a trial of
physiotherapy
Possible mechanisms of Anterior cruciate ligament rupture?
1
2
3
• Sudden change in direction with leg in momentum
• Internal tibial rotation on a flexed knee
(commonest) (e.g. during pivoting)
• Marked valgus force (e.g. a rugby tackle)
What is the ‘unhappy triad’
ruptured ACL, medial meniscus tear and medial collateral ligament tear.
This is a very serious and disabling injury that may
result in chronic instability. Chronic instability can
result in degenerative joint changes if not dealt with
Anterior cruciate ligament rupture
DDx of Anterior cruciate ligament rupture
subluxed or dislocated
patella
What are the tests for subluxed or dislocated patella? 1 2 3
— anterior drawer: negative or positive
— pivot shift test: positive (only if instability)
— Lachman test: lacking an end point
What test?
This test is emphasised because it is a sensitive and
reliable test for the integrity of the ACL. It is an
anterior draw test with the knee at 15–20 ° of flexion.
At 90 ° of flexion, the draw may be negative but the
anterior cruciate torn.
The Lachman test
Functional instability due to anterior cruciate
deficiency is best elicited with the _________
This is more difficult to perform than the Lachman
test.
pivot shift test.
This is an important test for anterolateral rotatory
instability. It is positive when anterior cruciate injuries
are sufficient to produce a functional instability.
Pivot shift test
Sx Mx of ACL tears
This usually involves reconstruction of the ligament using patellar or preferably hamstring tendons
How to MX ACL injury with a significant medial
ligament injury
The presence of an ACL injury with a significant medial
ligament injury will necessitate reconstructive surgery
but this is probably best delayed for some weeks as the
subsequent incidence of knee stiffness is high.
Mechanisms of PCL injury
- Direct blow to the anterior tibia in flexed knee
- Severe hyperextension injury
- Ligament fatigue plus extra stress on knee
Mx of PCL injury
• Usually managed conservatively with
immobilisation and protection for 6 weeks
• Graduated weight-bearing and exercises
__________calcification in haematoma at
upper (femoral) origin of MCL
Pellegrini–
Stieda syndrome—
Mx of MCL rupture
If an isolated injury, this common injury responds
to conservative treatment with early limited motion
bracing to prevent opening of the medial joint line.
Always think of an _________ in a young boy
with severe bone pain in a leg (especially at night)
that responds nicely to aspirin or paracetamol or
other NSAID
osteoid osteoma
If a patient presents with a history of an audible
‘pop’ or ‘crack’ in the knee with an immediate
effusion (in association with trauma) he or she has
an _________ until proved otherwise
ACL tear
Haemarthrosis following an injury should be
regarded as an ________ until proved
otherwise
anterior cruciate tear
The ‘movie theatre’ sign, whereby the patient seeks
an aisle seat to stretch the knee, is usually due to
__________
patellofemoral pain syndrome
The ‘bed’ sign, when pain is experienced when the
knees touch while in bed, is suggestive of a _______
medial
meniscal cleavage tear
A__________(medial pain on full squatting)
indicates a tear of the posterior horn of the medial
meniscus.
positive squat test
________ should not be performed on the
young athlete with an acute knee injury
Joint aspiration
If an older female patient presents with the sudden
onset of severe knee pain think of _____
osteonecrosis.
Reserve intra-articular corticosteroid injections
for inflammatory conditions such as ______
rheumatoid
arthritis or a crystal arthropathy:
When not give IA injections?
inflammation is acute and diffuse or in the early stages of injury
