LL MSK Pathologies Flashcards
Pathology of GTPS
Compressive forces cause impingement of bursa and glute tendons onto the greater trochanter by the ITB
Compression increased by weak hip adductors - hip joint ABD causes overstretching of ITB leading to compression and lateral pelvic tilt to contralateral side
Prevalence ACL sprains/tears
- ACL tear > common than PCL because ACL more vulnerable - has thinner fibre bundles and smaller attachment
- ACL most commonly injured in 15-25 age group participating in pivoting sports;
- Women > men
- Other structures are commonly involved in ACL tears: Meniscal tears, Articular cartilage damage, MCL injury, Bone bruising, (O’Donaghue unhappy triad = sprain injury thought to most likely injure the 3 structures: ACL, L meniscus, MCL)
Define Greater Trochanteric Pain Syndrome (GTPS)
Attributable (caused) to tendinopathy of gluteus medius and/or minimus +/- bursal pathology.
GTPS is a common cause of lateral hip pain
Prevalence of Ankle LCL sprains
More common than deltoid ligt sprain
Usually after traumatic event/acute presentation - occurs due to an inversion type injury
Common in teens-40s
Management of Posterior Tibial Tendon Dysfunction
- Rest
- Orthotics (conservative)
- Rehab
- Surgery but not recommended for elderly, obese patients as not necessary; young adult athletes may require surgical opinion
Treatment outcome: can be poor if not treated correctly.
Types of Apohysitis
Osgood Schlatter Disease = Apophysitis occurring at tibial tubercle
Sinding-Larsen-Johansson Syndrome = Apophysitis occurring at patella tendon attachment at apex of patella
Sever’s Disease = Apophysitis occurring at Achille’s tendon attachment on the middle facet of the calcaneus
Meniscal Anatomy
Menisci situated between corresponding femoral condyle and tibial plataeu Meniscofemoral ligaments (Humphrey and Wrisberg), attach the meniscus to the femur. The menisci are attached to each other via the transverse ligament. The horn attachments connect the tibial plateau to the meniscus. Lateral meniscus is more mobile than the medial meniscus as there is no attachment to the LCL or joint capsule Medial meniscus is more commonly injured because it is attached to the medial joint capsule and deeper fibres of MCL and therefore less mobile
General factors influencing PFP (AKP)
Split into two categories and assess for both; if structural
look at what we can do. Obviously can’t treat structural except with orthoses but can alter functional problems. Think of training errors
Functional:
Muscle length/strength
Stability
Proprioception
Structural:
Bony alignment
Patella shape
Trochlear shape
Foot position
Management of Meniscal Injuries
Previous sole treatment involved surgically removing meniscal tears. However, discovered this results in the gradual development of osteoarthritis of the knee OR those already w/ OA = it is associated w/ increased risk of progression of OA of the knee
Hence, the current management strategies in repairing meniscus-related lesions is to maintain the tissue intact whenever possible by conservative treatment
Causes of AVN of femur
The femoral head receives its blood supply through the neck of femur. Fractures across this zone may cause a loss of this supply leading to tissue death; Femoral neck # -> AVN to femur
Trauma causes - # femoral neck, # dislocated hip, surgery around hip
Non-trauma causes (affects both hips bilaterally)- prolonged use of corticosteroids (management of asthma), XS alcohol
Risk factors of Plantar Fasciitis
Obesity/overweight
Flatfoot
High arch
Reduced dorsiflexion
DM
RA - connective (soft) tissue disease hence effecting soft tissues
Prevalence of AKP
More common in adolescence (teens); may be seen in older ages
What are the lateral supporting structures of the knee
Anterolateral stabilisation = LCL, ITB, Joint capsule
Posterolateral stabilisation = Popliteal, biceps femoris, lateral head gastrocnemius tendons + various other structures
Pathology of Meniscal Injuries
Usually involves components of flexion and rotational forces under compression e.g. twisting, squatting or cutting manoeuvres (football).
If patient describes pain during these movements look for in an assessment:
Joint line tenderness
Joint effusion - swelling
Define Jones #
Fracture to the base of the 5th metatarsal
Polzer Classification = split into 2: Metaphyseal Fracture, Meta-diaphyseal Fracture
Lawrence and Botte classification = split into 3 = Zone 1 (Tuberosity Avulsion #), Zone 2 (Jones #), Zone 3 (Diaphyseal stress #)
Stress # for female athletes
Female athletes developing Relative Energy Deficiency Syndrome (REDS)/ Female Athlete Triad
Risk factors: in teens-20s, High levels of exercise and eating insufficient nutrients to accommodate exercise levels, increasing risk of lowering BMD thus greater risk of stress #
Signs: Low body fat, menstrual cycle stopped/dysfunctional, Previous #, high levels of exercise
Risk factors of Hip Impingement
Repetitive hip motion
High levels sports
Pediatric diseases (slipped/# epiphyseal (growth) plate)
Femoral neck #
Previous hip surgery
MOI of PCL strains/tears
MOI =Posterior force to the proximal tibia.
If combined with a rotational force injury to P-L complex can occur
Mainly from car accidents - knee hits dashboard resulting in neck of femur # and/or subluxation of the hip joint; PCL rupture/strain tends to be overlooked due to the more severe injuries
Pathology of Patella tendinosis
Alterations to Tendon cell population – increased number of tenocytes, increased tenoctye metabolism, increased immature tenocytes, increased rates of apoptosis, immunoactive cells.
Disorganisation of collagen, reduction type I collagen, disorganised areas with higher concentrations of immature collagen bundles (increased type III).
Ground substance changes– PG and GAG content alters, increased H2O, chemical alterations – substance P, Glutamate and lactate.
Neovascularization – influx of blood vessels into the anterior surface and mid substance this is associated with various nerve fibres ingrowing into the tendon
Define Avascular Necrosis (AVN)
AVN is condition in which there is loss of blood supply to the bone. Bone is living tissue, hence loss of blood supply, means bone death. If bone death progresses, leads to bone collapse
Prevalence of Avulsion Injuries
May not be able to surgically repair tendons that have avulsion injuries for a prolonged period
More common in adolescents involved in sports because the tendons are stronger than apophyses (where tendon attached to bone) - because in adolescents bone have yet to fully ossify
Clinical Presentation of AKP
Complaint of ‘deep ache in front of knee’ ○ Aggs = when patellofemoral joint lowered; deep knee flexion
○ Eases = with rest
○ localised tenderness around medial extensor retinaculum + lateral knee pain
○ haemarthrosis
recurrent dislocation likely: 15-44%
Pain is the main symptom all patients experience; syndrome indicates presence of other common conditions: Tightening of muscles anterior/posterior to knee causing a change to knee biomechanics, creating pain.
Altered alignment
Superior/inferior migrated patella
Direct trauma
Overuse - jogging/overweight
HPC: Dislocation: patella slipped out and had to be manually relocated
Subluxation: patella slipped out and spontaneously relocated
Clinical presentation of patient with GTPS
Age 40-60
Female - more common due to biomechanics - females have larger pelvic width w/ greater prominence of trochanters, which is associated w/ greater stretching of ITB as it passes over greater trochanter
Post-menopause
Lower femoral neck shaft angle - increases compression of gluteus medius tendon over greater trochanter
Increased BMI
Systemic factors?
Explain Pincer-type FAI
Result of excess acetabular coverage of the femoral head.
Over coverage can be either:
□ Global (coxa profunda) - due to deepened acetabulum
OR
□ Focal anteriorly (acetabular retroversion) - due to altered orientation of acetabulum
Results in abutment of the femoral head neck junction against the acetabular rim pressing upon the labrum, in turn causing damage to articular cartilage (chondral injuries)
Picked up on AP viewing (radiographic imaging) looking at lateral center edge angle = x>40o
Prevalence of Meniscal Injuries
Meniscus lesions most common intra-articular knee injury - injuries inside knee joint capsule
Most common in athletic young patients - sports-related injuries take >1/3 of all cases
Old adults meniscal tear may be caused by degeneration of the joint - may come about by a gradual or sudden onset
Medial injured more frequently 5:1 ratio to lateral
81% meniscal tears are located posteriorly.
Often associated with ACL tears (60% of cases)
Most patients do not require a MRI scan - if they do = 95% cases picked up; 5% not picked up
Define Patellofemoral Joint Pain
AKA Anterior Knee Pain (AKP) - Umbrella term to cover pain over the anterior of the knee joint
Indicates no distinction can be made to a specific structure
PFJ disorders:
○ Patella femoral pain syndrome ○ Mal-tracking ○ Dislocation ○ Chondromalacia patella
○ Patella tendinosis
○ Prepatellar bursitis
Clinical presentation of ankle LCL sprains
PC:
Pain/tenderness, swelling local to lat ligt. Esp. ATFL and/or bruising - in more mod-severe cases (ATFL>CFL>PTFL)
Aggravated - Walking or running over uneven ground, Turning sharply, Landing on inverted ankle
Severe/Moderate tears Grade II-III pain on WB, walking and most movements of the ankle
HPC/Previous episodes:
Traumatic = specific injury involving ankle inversion (MOI)
Sudden onset
Can be recurrent
SQs:
Giving way
Swelling- onset or recurrent
Walking over uneven ground
SH:
Sport involving rotation/turning eg. football, rugby, hockey!
Special tests: Anterior drawer test = ATFL injury
Talar tilt test = CFL injury (+ve)
Muscle spasm
Inability bear weight - may indicate # present
Ottawa ankle rules - used to determine if a X-ray is necessary:
Look for pain on weight-bearing at the distal end of fibula and posterior edge of L malleolus and likewise pain on distal 2-3” tibia just proximal to M malleolus
Look for pain on navicular and 5th MT and inability to weight-bear
Site of symptoms may not be diagnostic – multitude of other injuries such as peroneal tendon strains, neural irritation, OCDs, syndesmotic ligament tears, osteochondral lesions of the talus, occult stress fractures, synovitis, adhesions, intra-articular loose bodies, chronic instability, anterolateral impingement, and peroneal tendon pathology
Signs of Hip Dysplasia in infants
limping when first walking or one hip is less flexible when changing baby
Prevalence of PCL strains/tears
Up to 60% of PCL tears have associated posterolateral complex injuries
PCL tears account for up to 40% of ligament injuries in acute haemarthrosis
Meniscal injury with PCL injury is uncommon
Types of Hip Impingement
CAM-type Femoral Acetabulum Impingement (FAI)
Pincer-type Femoral Acetabulum Impingement (FAI)
Mixed FAI - some patients exhibit both impingements
Symptoms of Hip Impingement
Sitting cross legged is difficult or painful
Difficulties putting socks and shoes (52%)
Unable to sit for period of time (23%)
Slight or more severe limp (65%)
Adductor related symptoms
Walking long distance painful and pain doesn’t disappear straight away with rest
Significant pain after sports activities
> 40% buttock / low back pain
4 radiographic stages of maturation of apophysis
- Cartilaginous (0-11 years)
- Apophyseal (11-14 years)
- Epiphyseal (14-18 years), during which the epiphysis and apophysis coalesce
- Bony (> 18 years)
Difference in signs of quadriceps tendon and patella tendon ruptures
Patella tendon rupture also seen by patella gliding more superior than normal
Define Hip Dyplasia
Hip socket (acetabulum) does not cover femoral head fully causing hip joint to be partially/completely dislocated
Pathology of Hip Impingement
• Pathophysiology of FAI is unclear - brought by bony deformities from birth/developmentally acquired through overuse, causing repetitive abutment and wear of articular cartilage (chondral injuries)
Explain CAM-type FAI
Caused by an irregular osseous prominence of the proximal femoral neck or head-neck junction.
Cam impingement can become symptomatic in physically active young males (athletes)
Bony protrusion located at the anterosuperior aspect of the femoral head-neck junction
Picked up on Dunn view (radiographic imaging) looking at alpha angle = 90o flexion & 20o ABD
Risk factors of babies acquiring Hip Dysplasia
Born in breech position; foot deformities
Prevalence of Jones #
Patient (and clinician) often don’t realise fracture has occurred
May have sprained ankle - pain at LCL but also # 5th MT w/out knowing
Affects base of 5th MT, maybe peroneal swelling, often misdiagnosed as insertional tendinitis.
Can indicate vitamin D deficiency
Pathology of ACL sprains/tears
Intra-articular (good blood supply); extrasynovial structure.
Proximal part has greater vascularity.
Comprised of 2 bundles = Anteromedial (AMB); posterolateral (PLB).
○ AMB restrains anterior tibia translation at > 45 of knee flexion
○ PLB shown to be more important restrain toward full extension.
Substantial number of partial tears (difficult to diagnose) progress to complete tears with a higher rate of meniscal and cartilage injuries
ACL rupture = bleeding occurs (hemarthrosis) - large swelling, typically a couple hours from onset
