leg pain and venous problems Flashcards
what are s&s of an achilles rupture?
sudden ,severe calf pain
load popping sound
unable to weight bare
swelling and bruising in the calf or heel
+ve calf squeeze test
what is the imaging of choice for a suspected achilles rupture?
ultrasound
what is the cause of chronic venous insufficiency?
malfunction of the valves in the veins creating increased venous pressure
what are risk factors for chronic venous insufficiency?
age
family history
female
history of DVT
obesity
pregnancy
sitting or standing for prolonged periods
tall height
what are s&s of chronic venous insufficiency?
dull aching, heaviness or cramping in legs (also during the night)
itching and tingling
pain worse with standing, better with elevation of legs
skin colour changes
varicose veins
thickening and hardening of skin around the area
varicose ulcers
what are varicose veins?
abnormally dilated superficial veins
what are s&s of varicose veins?
achy or heavy legs
itchiness of the skin over the veins
restless legs
swelling of legs
what is a compartment syndrome?
ischaemia or reduced blood flow of the leg compartments, can be acute or chronic
what are s&s of acute compartments syndrome?
severe, increasing leg pain
redness, warmth and swelling of the compartment
weakness or paralysis of the foot
sensory changes in calf and foot
painful stretching of the compartment
–> surgical emergency! irreversible neuro deficits if not treated
what is the cause of chronic compartment syndrome?
increase in intra-compartmental pressure from increased blood flow in the muscles during physical activity causing muscle tissue swelling and the pressure induces vascular insufficiency
what are s&s of chronic compartment syndrome?
abnormal tight fascia compresses arteries & nerves, causing local and distal ischaemic symptoms:
- cramping in leg
- weakness and sensory loss in leg due to deep peroneal nerve compression
- artery compression leading to foot cyanosis
- diminished pulse
- post exercise muscle contracture
what is deep vein thrombosis (DVT)?
thromboembolism affecting the deep veins causing venous insufficiency
what are s&s of DVT?
50% is asymptomatic
deep, aching, constant pain within the calves
swelling, redness, warmth over calf
tender to touch
what is virchow’s triad?
3 factors that predispose a person to develop vascular thrombosis:
1. blood stasis in vein: immobility, surgery or long flights
2. hyper-coagulability: smoking, cancer, oral contraceptive pill, clotting disorders
3. damage to the intima of veins: previous DVT, venous surgery
what are the most common investigations for DVT?
CPTA: computed tomographic angiogram
D-dimer blood test (detects fragments of the breakdown products of a blood clot)
duplex ultrasound
magnetic resonance venography
contrast venography
what is the management for DVT?
urgent hospital referral
treatment: heparin, then oral anticoagulants
what is peripheral arterial disease (PAD)?
arterial insufficiency causing ischaemia in the lower limb
what are the risk factors for PAD?
diabetes
history of cardiovascular disease
hypercholesterolaemia
> 60 years
what are s&s of PAD?
calf cramping and pain after walking a set distance (intermittent claudication)
pain is relieved by rest
pain occurs faster with uphill walking
pain relieved by lowering leg out of bed
paleness, bleu, cold, loss of hair on leg
ulceration/gangrene of lower leg and foot
weak or absent pulses
bruit may be heard when auscultating the femoral arteries or aorta
when is beurger’s test positive?
> 90°: normal
15-30° for 30-60 seconds cause pallor: ischaemic leg
<20°: severe ischaemia
what is the diagnostic test for PAD?
ABPI: ankle brachial pressure index
ratio of systolic BP at ankle and arm provides a measure of blood flow at ankle
>0.9: normal
0.6-0.9: claudication
0.3-0.6: resting pain
<0.3: impending gangrene
what is the treatment for PAD?
self help: stop smoking, exercise, lose weight, eat healthy, foot care
medical treatment: antiplatelet agents (aspirin); statin for cholesterol, ACE inhibitors, etc.
surgery: angioplasty, bypass surgery or amputation
what is a diabetic neuropathy?
polyneuropathy affecting the longest nerves first (most common in type II diabetic patients)
what are s&s of diabetic neuropathy?
BL burning/tingling in feet
BL paraesthesia in a glove and stocking distribution
pain worse at night
unsteadiness which is worse at night
what is medial tibial stress syndrome?
inflammation of tendinous (fascial) attachments to bone (deep posterior or anterior compartments) caused by repetitive or overuse strain
what are s&s of medial tibial stress syndrome?
dull ache during and/or after activity in posterior knee/calf
stiffness
ttp over periostitis
pain during passive stretching and strength testing of the muscle
limp/abnormal gait with medial ankle pronation
what are risk factors for developing medial tibial stress syndrome?
sudden increase in activity
hyper-pronation
running on hard surfaces
inflexible footwear
what is the piriformis syndrome?
compression of the sciatic nerve due to hypertonicity, spasm or triggerpoints within the piriformis muscle
what are s&s of piriformis syndrome?
pain and parasthesia in buttock/trochanter
pain radiates into posterolateral thigh
unable to lie on affected side
+ve bonnet test
+ve piriformis stretch test
which nerve is compressed in meralgia paraesthetica?
lateral femoral cutaneous nerve is compressed by the inguinal ligament, close to the ASIS
what are the s&s of meralgia paraesthetica?
pain/ paraesthesia over the anterolateral thigh (tennis racket shape)
+ve tinel’s around 1 cm medial to the ASIS
what is the management for meralgia paraesthetica?
rest from exacerbating activities
mobilisation of the affected tissue
lose weight
stop wearing tight clothing
what structures are entrapped in the medial tarsal tunnel syndrome?
the tibial nerve is entrapped between the medial malleolus and the calcaneus
what is the most common cause of medial tarsal tunnel syndrome?
tibialis posterior tenosynovitis due to trauma or overuse in dorsiflexion
what are s&s of medial tarsal tunnel syndrome?
pain/paraesthesia over the lateral aspect and sole of the foot
pain in the distal leg
+ve tinel’s over the tarsal tunnel
+ve SLR with dorsiflexion and eversion
what is the medial plantar nerve syndrome (aka jogger’s foot)?
entrapment of the medial plantar nerve between the navicular and the abductor hallucis
what are s&s of medial plantar nerve syndrome?
pain around the navicular bone and medial arch
pain is worse with running
what is the most common site for the common peroneal nerve to be entrapped?
the fibular head
what are the most common causes for peroneal nerve entrapment?
blunt trauma
tight casts
crossed legs
repetitive inversion or pronation in runners
what are s&s for common peroneal nerve entrapment?
foot drop (weakness in ankle dorsiflexion)
weakness in foot eversion
+ve tinel’s over the head of the fibula
+ve SLR with plantar flexion and inversion
what is the most common cause of superficial peroneal entrapment?
inversion sprain of ankle
what are s&s of superficial peroneal entrapment?
paraesthesia over the anterolateral shin and dorsum of foot
weakness of foot eversion
+ve SLR with plantar flexion and inversion
what is the most common site for a stress fracture?
tibia
what are the s&s of a tibial stress fracture?
pain/ache over the tibia
pain worse with activity and better with rest
what is the management for a stress fracture?
rest for 6-10 weeks
graduate return to play
what is a tennis leg?
rupture of the medial gastrocnemius at junction where the achilles merges with the muscle
what are the most common s&s of a tennis leg?
sudden sharp pain in the calf (feels like being hit on the back of the leg)
unable to put heel on the ground (walks on tiptoes)
localised ttp or hardness of the muscle
painful passive dorsiflexion and resisted plantar flexion
bruising over the site or rupture
what is the management for tennis leg?
RICE
firm elastic bandage from toes to below the knee
gentle stretching and massage
commence mobilisation 48 hrs after rest with active exercise
what is the most common cause of tibialis anterior tenosynovitis?
overuse during downhill running
what are s&s of tibialis anterior tenosynovitis?
pain, redness and warmth over the tibialis anterior tendon (distal to the tibia)
pain on passive plantarflexion and resisted dorsiflexion
what is the management for tibialis anterior tenosynovitis?
RICE
cross-friction
ultrasound
