Lower extremity Flashcards
ROM of spine
- Flexion
- Extension
- Lateral bending
- Rotation (seated position)
Dextroscoliosis
Curve is convex (toward) the right
Levoscoliosis
Curve is convex (toward) the left
Straight leg raise (SLR)
- Tests for impingement of spinal nn/ sciatic n
- Elevate leg, dorsiflex foot
- Pain into ipsilateral leg = + = lumbosacral radiculopathy
- Pain in contralateral leg = + crossed SLR
Seated SLR
- Pt has hands on table
- Extend leg
- Watch for pt to “flip back”
FAbEr test
- F = flexion, A = abduction, E = external rotation
- Supine figure 4
- Checks SI joint dysfunction
- Checks adductors
Slump test
- Seated
- Slump
- Tuck chin
- Knee extension
- Dorsiflexion
- Checks sciatica or a herniated disc
Antalgic gait
- Limp adopted to avoid pain on weight-bearing structures
- Short stance phase
- Trendelenburg lurch
Trendelenburg sign
- Identifies weak hip abductor on side that is bearing weight
- If contralateral hip drops = +
Hip scour test
- Acetabular labrum
- Apply axial load to femur as you rotate hip internally & externally
Ober’s test
- IT band
- Tibial IR & hip ABD & extension
- Then lower leg to table
- If leg will not lower = +
Noble’s test
- IT band
- Pt supine, palpate IT band & passively flex & extend knee
- subjective test for pain
Thomas test
- Iliopsoas (B)
- If femur raises off table = +
OR - Rectus femoris (A)
- Unable to have 90˚ flexion of knee = +
Ottawa knee rules
- 55 or older
- Isolated tenderness at patella
- Tenderness at fibular head
- Unable to flex knee to 90
- Unable to bear weight immediately after & ER for 4 steps
- If any above are + = X-ray needed
Baker’s cyst
- Synovial fluid cyst in popliteal region
- Palpable as fluctuant fullness
- May be painful (can leak –> calf swelling)
- Best to palpate w/ knee extended
Popliteal artery aneurysm
- Due to atherosclerotic vascular disease
- Male > female
- Usually > 65yo
- Bilateral >50%
- Best to palpate w/ knee extended
- Most common aneurysm of peripheral vascular system
Popliteal artery aneurysm dx
Pulsatile swelling behind knee
Meniscal tears s/s & tx
- Pain/swelling at joint line
- Max swelling is seen day after injury
- May report popping, clicking, locking
- “Feel like knee is going to give out”
- Surgery (repair or menisectomy)
Meniscal tear MOI
Weight bearing w/ rotation
Patellar dislocations MOI
- Knee flexed btwn 20-45˚ w/ valgus load
- Then max contraction of quads
- Will almost always go laterally
Patellar fractures MOI
- Direct blow/force
- Extremely painful (unable to SLR)
Chondromalacia patellae
- Degenerative process –> softening of articular surface of patella
- More frequent in women
Chondromalacia patellae MOI
- Overuse w/ poor tracking
- Large Q-angle
Q-angle
- Women have greater Q-angles
- Normal = <15˚
Patellar tendonitis MOI
- “Jumper’s knee”
- Overuse w/ heavy quad loads & poor quad flex
Patellar tendonitis s/s
- Increased pain w/ activity
- Increased pain w/ resisted knee extension
- Aches after exercise
- Swelling
- Tenderness at inferior pole
- Risk of tendon rupture
MCL sprains MOI
- Most frequently injured ligament in knee
- Blow to lateral side of knee forcing valgus
MCL s/s
- Pain
- Mild to moderate swelling exterior to joint
- Discoloration
- Point tenderness along length
- Valgus instability
- May feel “pop”
LCL sprains MOI
Foot planted, medial side impact/varus force
LCL s/s
- Pain
- Lateral knee swelling
- Ecchymosis
- Point tenderness over length of LCL
- Varus instability
- May feel “pop” w/ complete rupture
ACL sprain MOI
Twisting maneuver during weight bearing
- Hyperextension
- Rotation w/ change of direction
- Jump stop w/ weight posterior
ACL fxn
Stops anterior translation of tibia on femur
ACL sprain s/s
- Immediate pain & feeling of instability
- Audible “pop”
- Joint effusion & loss of motion within 24hrs
- Unwilling to bear weight
- Sense of instability w/ weight bearing
PCL sprains MOI
Direct force against anterior tibia, driving it posteriorly
PCL s/s
- Pain
- Joint effusion
- Limited range of motion into full flexion & extension
- May have audible “pop”
Unhappy triad
Sprain of:
- MCL
- ACL
- Medial meniscus
- Receives lateral blow to knee w/ foot fixed
- Combo of valgus force
- Rotation of leg –> stress on medial collateral ligament 1st
Iliotibial band MOI
Overuse w/ tight TFL & gluteus maximus
Iliotibial s/s
- Pain over lateral epicondyle
- Pain going downstairs *
- Pain when leg is swinging forward during gait
Iliotibial tx
- Stretch gluteus maximus & TFL
- Arch supports
Popliteus tendonitis MOI
Overuse injury if hamstrings get tired & popliteus has to carry more than its regular load
Popliteus tendonitis s/s
- Pain w/ resisted knee flexion
- Pain w/ palpation
Knee bulge sign/ Sweep test
- Testing for knee effusion
- With leg straight, “milk” knee joint fluid down 1 side & up other - observe for bulge
Ballottement of patella
- Testing for knee effusion
- Apply downward pressure from above the knee to milk fluid down
- Push patella into the joint space, feel for fluid / boggy sensation
Osgood-Schlatter’s disease MOI
- Repetitive traction on tibial tuberosity apophysis via patella tendon & quads
- Young athletes
Osgood-Sclatter’s disease s/s, what actions aggravate it?
- Aggravated by running, jumping, or kneeling
- Pain & swelling around tuberosity
Sinding-Larsen-Johansson disease
- Resembles Osgood-Schlatter’s disease except involves proximal rather than distal end of the patellar tendon
- Caused by repetitive traction forces on the inferior pole of the patella
Peroneal nerve contusion
- Nerve passes below proximal head of the fibula, where it lies subcutaneously
- Localized pain from the contusion & radiating pain to anterior lateral leg musculature & dorsum of foot
Prepatellar bursa
- Most commonly injured
- Direct trauma
- Fluid btwn skin & patella
- Looks like golf ball hanging
Infrapatellar bursa
Result of repetitive kneeling or repeated trauma over the distal patellar tendon
Suprapatellar bursa
- Fills whole knee joint capsule
- Common after ACL tear
Pes anserinus bursa
- Related to cycling or running
- Constant friction or external blow
Plica or “Medial Shelf” MOI
- Plica: unusual fold of synovium
- Plica gets pinched under patella if the quads fatigue & can’t pull it out of the way soon enough before patella compresses
Plica s/s
- Pain
- Popping
- Snapping
- Aching at rest under medial edge of patella
Fat pad impingement MOI
Bottom of the patella pinches, or impinges on, the fat pad on top of the tibia
Fat pad impingement s/s
- Sensation of pinching
- Bruise feeling in full extension
Genu valgus vs genu varus
Valgus = knock knees Varus = bow legs
Valgus stress test
- Testing for medial collateral ligament (MCL) laxity &/or pain
- W/ leg slightly flexed, stabilize knee laterally & abduct distal leg
- Note any ligament laxity or pain
Varus stress test
- Testing for lateral collateral ligament laxity &/or pain
- W/ leg slightly flexed, stabilize knee medially, & adduct distal leg
- Note any ligament laxity or pain
Lachman’s test
- Testing for ACL tear
- Knee is flexed 15-20º
- Stabilize thigh w/ 1 hand, pull upper tibia forward w/ other hand
- Compare sides
Anterior drawer test
- Testing for ACL tear
- Knee is flexed 90º; foot & hips stable
- Pull upper tibia forward assessing for excessive forward movement
- Compare sides
Posterior drawer test
- Testing for PCL tear
- Similar to anterior drawer sign, except tibia is pushed back (rather than pulled forward)
- Excessive laxity suggest PCL tear
McMurray’s test
Testing for meniscal tear
McMurray’s test - medial meniscal tear
To test for medical meniscal tear:
- Flex knee, place thumb & index finger on joint space
- Rotate foot laterally & extend leg
- Palpable click or pain at joint line = medial meniscal tear
McMurray’s test - lateral meniscal tear
To test for lateral meniscal tear:
- Same procedure done except – rotate foot medially, & extend leg
- Palpable click or pain at joint line = lateral meniscal tear
Calf pain w/ dorsiflexion suggests what?
DVT
Which test is used to assess for achilles rupture?
Thompson’s test
Which test is used to assess for DVT?
Homan’s sign
What does a compression test assess?
Fx
Lymphedema
Blockage of the lymph vessels that drain fluid from tissues throughout the body
LE stasis dermatitis
- Chronic venous insufficiency w/ incompetent valves & higher pressure in capillary bed
- Tissue damaged & inflamed
- “Brawny,” non-pitting edema
Sx of venous insufficiency (varicose vv)
- Dull ache or pressure sensation after prolonged standing; relieved w/ elevation
- Dependent ankle edema
- Ankle ulcerations
- SF thrombosis / thrombophlebitis
Signs of peripheral artery insufficiency
- Dependent rubor
- Pallor w/ raised extremity )
- Hair loss on leg/foot
- Atrophic skin; nail changes
- Ulcers
- Necrosis/gangrene
Consequences of peripheral artery insufficiency
- Gangrene
- Amputation
Pes cavus
- Rigid foot, High Arch/instep
- Plantar soft tissues shortened
- Leads to claw toes
- Difficult to absorb shock
Pes planus
Flat, mobile foot
Pes planus MOI
- Congenital
- Trauma
- Muscle weakness
2 types of pes planus
- Rigid or congenital
- Rare
- Calcaneous in valgus & midtarsal in pronation
- Visible in NWB position - Flexible or acquired
- Due to tibial torsion or subtalar jt. dysfunction
- Apparent in WB position, but arch re-appears on tiptoes
Claw toes
Hyperextension of MP jt. & flexion of PIP & DIPs
What are claw toes associated w/ ?
- Pes cavus
- Fallen metatarsal arch
- Problems w/ intrinsic musculature
Hammer toes
- Extension contracture at MP jt.
- Flexion contracture at PIP
- DIP (any position)
Causes of hammer toes
- Congenital
- Poor fitting shoes
- Hallux valgus
- Muscular imbalance
Bunion
Inflammation & thickening of the bursa of the MTP joint of the big toe – w/ valgus deformity
Metatarsalgia
- Pain & tenderness under metatarsal heads
- Unable to progress through terminal stance during walking bc cannot load forefoot
Morton’s neuroma
- Compression of a nerve bundle btwn metatarsal heads in ball of foot
- Commonly btwn 3-4 or 2-3
Morton’s neuroma MOI
Shoes w/ narrow toe box
Morton’s neuroma s/s
- Tingling
- Burning
- Pain in the ball of foot AND DISTALLY into assoc toes
Morton’s neuroma tx
- Ditch tight shoes permanently
- Place felt pad directly under neuroma
Lisfranc injury
- Injury to any side of the 2nd metat head
- Dislocations or fx
Lisfranc s/s
- Painful wt bearing, inability to go into terminal stance of gait
- Tender in dorsal apex of mid-foot around head of 2nd metat
Lisfranc MOI
Significant impact
Lisfranc tx
Refer immediately for x-rays
Fx to base of 5th MT MOI
Inversion combined w/ landing from a jump
Fx to base of 5th MT s/s
- Tender at head of 5th
- Bone may even feel mobile
- Cannot bear wt on foot
- Pain w/resisted eversion
Tx for fx at base of 5th MT
Refer on crutches for x-ray
Turf toe MOI
Sprain of 1st MP jt from hyperextension
Turf toe s/s
- Moderate pain in ball of foot under big toe w/ gait
- Swelling & tenderness on inferior jt
- Incr pain w/toe extension
Tx of turf toe
- Tape
- Steel inserts
DDx of turf toe
Seasmoiditis or fx
Plantar fascitis MOI
Overuse, acute or chronic
Plantar fascitis s/s
- Pain most severe when 1st getting out of bed
- Pain diminishes during activity & increases when activity stops
- Tender at origin on the ant./medial calcaneous & distally to mid-fascia
Predisposing factors for plantar fascitis
- Excessive pronation
- Obesity
- Abnormally high arch
DDx for plantar fascitis
- Tarsal tunnel syndrome (Tinel’s sign)
- Sever disease (pain when squeezing heel, 13yo or younger)
- Heel spur
Inversion sprains MOI
Plantarflexion w/ hindfoot inversion
Types of inversion sprains
- 1st degree = ATF lig torn, little laxity, pain
- 2nd degree = ATF lig torn & some CF lig damage, clear laxity w/ end pt, pain
- 3rd degree = all 3 lateral ligs torn, laxity w/ no end pt, pain, unable to bear weight
Eversion sprains MOI
Land in plantar-flexion & rotation into eversion
Excessive eversion can cause fx of what?
Fibula
Syndesmosis sprain MOI
- Plantarflexion w/ hindfoot inversion & rotation of talus in mortise
- Damage to ATF lig, CF lig, distal tib-fib lig (ant &/or post) *HIGH ANKLE SPRAIN
Why do syndesmosis sprains take longer to heal?
Bc every time he/she steps, the tib-fib lig is stressed
What kind of ulcer is commonly associated w/ diabetes?
Neuropathic
Achilles Rupture MOI
- Big bang!
- Age related
- “weekend warrior”
Tx of achilles rupture
Surgery
- Suture ends together = LOTS of scar tissue!
- Long, slow rehab
Anterior tibialis tendonitis
- More acute
- Isolate to confirm w/ MMT
Achilles tendonitis
- More chronic
- Obvious swelling
- Long rehab w/ many set-backs
Difference btwn sprain & strain
Sprain = ligament Strain = tendon
Pulse grading (amplitude)
0 Absent, unable to palpate 1+ Diminished, weaker than expected 2+ Brisk, normal 3+ Increased 4+ Bounding
Callus
- Skin thickening found on bottom of foot
- Generally SF & doesn’t cause pain
Corns
- Found on top of toes
- Specially shaped callus of dead skin
- Smaller than calluses but deeper & painful
Anterior drawer sign
- Testing for anterior talofibular ligament tear
- Stabilize distal tibia
- Grasp & pull calcaneus forward assessing for excessive forward movement
