Lower Extremity Flashcards
1
Q
Dextroscoliosis
A
- Inspect from several angles and with patient bending forward
- curve is convex (toward) the right
2
Q
Levoscoliosis
A
- Inspect from several angles and with patient bending forward
- curve is convex (toward) to the left
3
Q
What could you see as a result from Dextroscoliosis/Levoscoliosis
A
May see falsely apparent leg length “discrepancy”, with “shortening” on the concave side
4
Q
Sciatica
A
Pain, numbness, or tingling in the leg – caused by injury to or pressure on lumbar nerves L3-L5, sacral nerves S1-3 or compression of the sciatic nerve itself
Weakness is a red flag
5
Q
Radiculopathy
A
Sciatica caused by injury/pressure on a particular nerve root (e.g. L4), is considered a radiculopathy (e.g. lumbar radiculopathy); another term – lumbosacral radiculopathy
Weakness is a red flag
6
Q
How do you Tests for impingement of spinal nerves / sciatic nerve?
A
-Straight leg raise (SLR)
- Elevate leg, dorsiflex foot Pain into ipsilateral leg is a positive test – suggests a lumbosacral radiculopathy
- Assess degree of elevation at which pain occurs (e.g. 60 degrees) – “Positive SLR – pain down to mid-calf with elevation of leg to 600”
- Pain in the contralateral leg is a positive crossed SLR
- Tightness / discomfort in the buttocks or hamstring is not a positive test
7
Q
Describe the Seated SLR test (“flip sign”)
A
- Patient seated with his/her hands on table
- Extend leg
- Watch for pt to “flip back” when leg extended
8
Q
Valgus/valgum
A
Inward
9
Q
Varum
A
bowed out
10
Q
FAbER Test
A
- Flex –> Abduct –> Externally Rotate
- Assesses SI Joint Dysfunction
- Assesses Adductors
11
Q
Antalgic gait
A
- Limp adopted to avoid pain on weight-bearing structures, characterized by a very short stance phase
- Patient remains on painful leg for as short a time as possible
- “Limp” / Trendelenburg lurch –> No dorseflexion
12
Q
Describe a normal plum ling
A
neck, AC joint, hip, and knee aligned when you look at a person from the side
13
Q
Trendelenburg sign
A
- Identifies weak hip abductor muscles on side that is bearing weight (side we are testing)
- If contralateral hip (not bearing weight) drops, the hip abductors on the weight bearing side are weak
14
Q
Ottawa Knee Rules Level 1
A
- Helps determine if patient needs to get an xray or not
- Age >55
- Isolated tenderness at the patella
- Tenderness at the fibular head
- unable to flex knee at 90 degrees
- UNAble to bear weight immediately after the ER for 4 steps
15
Q
Baker’s cyst (popliteal cyst)
A
- A synovial fluid cyst located in the popliteal space
- Palpable as fluctuant fullness
- May be painful &/or, if they leak, result in calf swelling
- Best to palpate with knee extended
16
Q
Popliteal artery aneurysm
A
- Usually due to atherosclerotic vascular disease
- Males»_space;females
- Usually > 65 years old
- The most common aneurysm of the peripheral vascular system
- Bilateral > 50% of the time
- Diagnosis: pulsatile swelling behind the knee
- Best to palpate with knee extended
17
Q
Meniscal Tears
A
- Wight bearing with rotation
- Pain / Swelling localized at joint line.
- Won’t see much swelling – why?
- -> Depends on the location of the tear… if you tear at an a-vascular zone… no swelling … needs surgery (gets chopped out)… increases your risk for osteo-arthritis
- -> Outer zone –> vascular zona … it will get sewn down and it will heel itself “Buckethandle tear”
- Maximum amount of swelling is frequently seen the day after injury.
- May report popping, clicking, locking (gets in the intercondilar notch)
- May report “feels like knee is going to give out” – very specific complaint to meniscal injury
- Surgery – repair or menisectomy
18
Q
Patellar dislocations
A
- knee flexed between 20-45˚ w/valgus load – then max contraction of quads
- Will almost always go laterally
19
Q
Describe the Slump Test
A
- Seated –> Slump –> tuck chin –> extend knee –> Dorsiflex
- For sciatica or herniated disk
20
Q
Patellar fractures
A
- Significant direct blow/force
- not common in athletics
- extremely painful – unable to SLR
21
Q
Chondromalacia patellae
A
- degenerative process that results in a softening (degeneration) of the articular surface (hyaline cartilage) of the patella
- MOI – overuse w/poor tracking
- Commonly large Q-angle
- The more knock-kneed you are, the greater the Q-angle.
- Women naturally have greater Q-angles (wider hips for child-bearing).
- Thus, women experience chondromalacia patella more frequently than men.
- Normal = <15°
22
Q
Patellar Tendonitis
A
“Jumper’s knee”
- MOI – overuse w/heavy quad loads & poor quad flex.
- S/S - Pain increased with activity, aches after exercise, possible swelling, pt tenderness at inf pole, increased pain with resisted knee extension
- Risk of tendon rupture!
23
Q
MCL Sprains MOI and S/S
A
- Most frequently injured lig in the knee
- MOI: Blow to lateral side of the knee forcing valgus
- S/S: pain, mild to mod swelling exterior to jt, discoloration, and point tenderness along length, valgus instability, may report feeling a “pop”
24
Q
LCL Sprains MOI and S/S
A
- MOI: Foot planted, medial side impact/varus force
- S/S: pain, lateral knee swelling, ecchymosis, point tenderness over the length of the LCL, varus instability, may feel “pop” with complete rupture
25
Anterior Cruciate Ligament Sprains
- MOI: A twisting maneuver during weight bearing – such as changing directions or landing from a jump while twisting
- Forced hyperextension
- Landing w/bent knee with center of gravity too far posterior – ex: skiing in deep powder
- A direct blow to the back of the tibia that drives the tibia forward (very rare!)
- S/S: Immediate pain & feeling of instability
- Audible “pop”
- Joint effusion and loss of motion usually result within 24 hours
- Athlete will be unwilling to bear weight or will have a sense of significant instability with weight bearing
26
ACL Tear Test
Lachman’s Test
27
PCL Sprains MOI and S/S
- MOI: injured by a direct force against the ant. tibia, driving it posteriorly
- S/S: pain, joint effusion, and limited range of motion into full flexion & extension, may have audible “pop”
- Athletes who have good quadriceps and hamstring muscle strength may not complain of a feeling of instability with weight bearing. So this type of injury is sometimes missed.
28
Describe the Hip Scour Test
- Tests Acetabular Labrum
| - Apply axial load and "grind" the Femur into the acetabulum to try to catch a part of the torn labrum
29
Ober's Test
- Tests the IT band
- Roll over to your side --> knee flexion --> Tibal IR --> hip ABD --> extension --> Drop Leg to table
- Positive test is if leg will not lower to the table
30
Noble's Test
- Tests the IT band
- Patient is supine, palpate IT band and passively flex and extend knee
- Subjective ---> "do you feel pain when I do this?"
31
Thomas Test
-Laying on back kind of in fetal position with legs hanging off the table ... as he drops one leg down it should just droop down... UNLESS
- Illiopsoas (B)
- Positive is if femur raises off table
or
- Rectus femoris (A)
- Positive if unable to have 90 degree flexion of the knee
32
Unhappy Triad”
- Sprain of the MCL, ACL, and tear of the medial meniscus.
- Athlete receives a lateral blow to the knee with the foot fixed. Combination of valgus force and rotation of the leg places stress on the medial collateral ligament first.
33
Antiversion of the hip
-Femoral head has to rotate anteriorly for the toes to face forward
"pigeon foot"
34
Retroversion of the hip
Femoral head has to rotate posteriorly for the toes to face forward
"Cartoon feet" AKA "duck foot"
35
Clarks test
To test for antiversion or retroversion of the hip
- Feel for the greater trocanter
- Take a gonio___ measurement
- 8-15 degrees is acceptable = Neutral
- Outside of the range = anti/retroversion... look it up
36
What is effusion?
Swelling IN the joint space
-Edema is swelling OUTSIDE of the joint space
37
Iliotibial Band
- Origin - Tensor fascia latae M. & 2/3 glut max M.
- Insertion - Gurdy’s tubercle
- MOI: overuse w/tight TFL and glut max
- S/S: Pain over lateral epicondyle; Pain going DOWN stairs; Pain when leg is swinging forward during gait
- Treatment: Must stretch glut max and TFL; Arch supports commonly help
38
Popliteus Tendonitis
- MOI: Overuse injury if hamstrings get tired and popliteus has to carry more than its regular load in knee flexion
- S/S: nothing unique; pain w/resisted knee flexion; pain w/palpation
39
Osgood-Schlatter's Disease
- MOI: repetitive traction on the tibial tuberosity apophysis via the patellar tendon and quadriceps group
- Occurs in young athletes when the growth plate of the tibial tuberosity is still fluid
- S/S: aggravated by running, jumping, or kneeling in youth athletes; pain & swelling around tuberosity
40
Sinding-Larsen-Johansson Disease
- resembles Osgood-Schlatter's disease except that the pathology involves the proximal rather than the distal end of the patellar tendon
- caused by repetitive traction forces on the inferior pole of the patella
41
Peroneal nerve contusion
- nerve passes just below the proximal head of the fibula, where it lies subcutaneously
- localized pain from the contusion and a radiating pain to the anterior lateral leg musculature and dorsum (back) of the foot
42
Prepatellar bursitis
-most commonly injured, direct trauma, large amounts of fluid between skin and patella; looks like golf ball hanging
43
Infrapatellar bursitis
-result of repetitive kneeling or repeated trauma over the distal patellar tendon.
44
Suprapatellar bursitis
-fills whole knee jt capsule – common after ACL tear
45
Pes Anserinus bursitis
-related to cycling or running, constant friction or external blow
46
Baker’s Cyst
- Posterior aspect of knee
- Often palpable (red arrow)
- Common after ACLr
- Painful with *full* extension and *full* flexion
- Surgical if necessary for pain relief
- Playable as tolerated
47
Plica or ‘Medial Shelf’
- Plica is an unusual fold of the synovium
- MOI: Plica gets pinched under the patella if the quads fatigue and can’t pull it out of the way soon enough before the patella compresses
- S/S: pain, popping, snapping, or just aching at rest under medial edge of patella
48
Fat Pad Impingement or Bruise
- MOI: bottom of the patella pinches, or impinges on, the fat pad on top of the tibia
- S/S: will report a sensation of pinching, bruise feeling in full extension
49
Sweep Test
- Testing for knee effusion (fluid accumulation around the joint usu. assoc. with trauma or overuse)
- With leg straight, “milk” knee joint fluid down one side & up the other - observe for bulge
50
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
51
Genu valgus
“knock knees”
52
Genu varus
“bow legs”
53
Valgus stress test
- Testing for medial collateral ligament (MCL) laxity &/or pain
- With leg slightly flexed, stabilize the knee & abduct the distal leg
- Note any ligament laxity or pain
54
Varus stress test
- Testing for lateral collateral ligament laxity &/or pain
- Like valgus stress test, except adduct the distal leg
- Note any ligament laxity or pain
55
Lachman’s test
- Testing for ACL tear
- Patient’s knee is flexed ~ 15-20º
- You stabilize thigh with one hand, with other hand, pull upper tibia forward
- Compare sides
- More sensitive sign of ACL tear than drawer test
56
Anterior drawer sign
- Testing for anterior cruciate ligament tear (ACL tear)
- Patient’s knee is flexed 90º; foot & hips stable
- Pull upper tibia forward assessing for excessive forward movement
- Compare sides
57
Posterior drawer sign
- Testing for posterior cruciate ligament tear (PCL tear)
- Similar to anterior drawer sign, except tibia is pushed back (rather than pulled forward)
- Excessive laxity suggest PCL tear
58
McMurray’s test
- Testing for meniscal tear
- Flex knee, place thumb & index finger on joint space
- To test for medical meniscal tear
- Rotate foot laterally and extend leg
- Palpable click or pain at joint line indicates medial meniscal tear
- To test for lateral meniscal tear
- Same procedure done except – rotate foot medially, and extend leg
- Palpable click or pain at joint line indicates lateral meniscal tear
NOW THERE IS A NEW TEST... thessaly's test
59
Palpation – for pitting edema
-Press downward with thumb for a few seconds, observe for indentation:
-Indicate how high edema rises up leg
-Dorsum of foot
-Behind medial malleolus
-Pretibial (shins)
-Grade from 0 to 4+ edema
“2+ pitting edema to mid-calf”
60
Posterior tibial pulse
Behind and slightly below medial malleolus
61
Dorsalis pedis pulse
Dorsum of the foot Over 1st-2nd metatarsals
62
Grade the amplitude of the pulse:
```
0 Absent, unable to palpate
1+ Diminished, weaker than expected
2+ Brisk, normal
3+ Increased
4+ Bounding
```
63
Ottawa Ankle Rules
See picture
64
Ankle sprain vs Strain
Sprain – tear or stretch of a ligament (bone to bone)
Strain – tear of stretch of a tendon / muscle structure (tendon is muscle to bone)
65
Anterior drawer sign
- Testing for anterior talofibular ligament tear
- Stabilize the distal tibia
- Grasp & pull calcaneus forward assessing for excessive forward movement
66
Anterior tibialis tendonitis
- Tends to be more acute
| - Isolate to confirm with MMT
67
Achilles’ tendonosis
- Tends to be more chronic
- Obvious swelling
- Long rehab w/ many set-backs
- Risk of rupture – age group?
68
Achilles’ Rupture
- MOI – big bang!; usually age related; “weekend warrior”
- Surgery
- Suture mop ends together = LOTS of scar tissue!
- Long, slow rehab
69
Neuropathic ulcer
-Commonly assoc. with diabetes
70
"Pes planus”
Flat foot
71
Inversion Sprains
- Most common MOI:
- Plantarflexion with hindfoot inversion
- 1st degree = ATF lig torn, little laxity, pain
- 2nd degree = ATF lig torn & some CF lig damage, clear laxity but end pt, pain
- 3rd degree = all three lateral ligs torn, laxity w/no end pt, pain, unable to bear weight
72
Eversion Sprains
- MOI: Land in plantar-flexion and rotation into eversion
| - If excessive eversion may fracture the fibula (lateral Malleolus)
73
Syndesmosis Sprains
- MOI: Plantarflexion with hindfoot inversion and rotation of talus in mortise
- Damage to ATF lig, CF lig, distal tib-fib lig (ant &/or post)
- Often referred to as a HIGH ANKLE SPRAIN
-Takes longer to heal because every time the individual steps, the tib-fib lig is stressed
74
Plantar Fascitis:
- MOI: overuse; acute or chronic
- S/S: Pain most severe when first getting out of bed in the morning
- Pain generally diminishes during activity & increases when activity stops
- Pt tender at the origin on the ant./medial calcaneous & distally to mid-fascia
-Predisposing factors: excessive pronation, obesity, abnormally high arch (pes cavus)
75
Different types of Plantar Fascitis:
1) Tarsal Tunnel Syndrome
- Use Ankle DF with Foot Eversion
2) Tinel's Sign
- Sever Disease (calcaneal apophysitis)
- If patient is 13 years old or younger
- Indicated if pain elicited when squeezing heel
3) Heel Spur
- get x-ray to confirm
76
Turf Toe
-MOI: sprain of 1st MP jt from hyperextension
S/S: moderate pain in ball of foot under the big toe with gait
- Swelling and signif pt tenderness on inferior jt
- Incr pain w/toe extension
Treatment:
- Turf toe tape
- Steel inserts – very helpful!
- Differential diagnosis with seasmoiditis or fracture
77
Fracture to the base of the 5th metatarsal
-MOI: inversion moment commonly combined with landing from a jump
S/S: Very pt tender at head of 5th
- Bone may even feel mobile
- Cannot bear wt on that foot
- Pain w/resisted eversion
Treatment:
-Refer on crutches for x-rays
78
Lisfranc Injury:
- Injury to any side of the 2nd metat head articulations; dislocations or fracture
- MOI – varied; signif impact from something
- S/S – painful wt bearing – inability to go into terminal stance of gait; pt tender in dorsal apex of mid-foot around head of 2nd metat
- Treatment – refer immediately for x-rays
79
Different types of foot pathologies (Part 1)
1) Spring Ligament Sprain
2) Heel Contusion
= Fat Pad Contusion
3) Morton’s Neuroma:
- compression of a nerve bundle betwn the metatarsal heads in ball of foot; most commonly betwn 3-4 or 2-3;
- MOI - shoes with narrow toe box
- S/S - tingling, burning, pain in the ball of their foot AND DISTALLY into assoc toes.
- Treatment – ditch the tight shoes permanently; may place felt pad directly under neuroma
80
Different types of foot pathologies (Part 2)
1) Blisters
2) Bunion- inflammation and thickening of the bursa of the MTP joint of the big toe – with valgus deformity
3) Metatarsalgia
- Pain and tenderness under the metatarsal heads
- Unable to progress through terminal stance during walking because cannot load forefoot
81
Describe type of toe pathologies (Part 3)
1) Claw Toes
- Hyperextension of MP jt. and flexion of PIP & DIPs
- Assoc. with pes cavus, fallen metatarsal arch, or problems with intrinsic musculature
2) Hammer Toes
- Extension contracture at MP jt. Flexion contracture at PIP, DIP may be in any position
- Can be congenital, poor fitting shoes, hallux valgus or muscular imbalance
82
Describe Pes Cavas
- Rigid foot, High Arch
- Plantar soft tissues are shortened
- Often leads to claw toes
- Difficult to absorb shock
83
Describe Pes Planus
- Flat, mobile foot
- MOI: Congenital, trauma, muscle weakness
- All infants have flat feet until ~ 2 y.o.
Two types:
1) Rigid or congenital: Rare
- Calcaneous in valgus & midtarsal in pronation
- Visible in NWB position
2) Flexible or acquired
- Due to tibial torsion or subtalar jt. dysfunction
- Apparent in WB position, but if stand on tiptoes, arch re-appears
84
Pes cavus
High Instep
85
Signs of peripheral artery insufficiency
- Palpation: Pulses Femoral, popliteal, posterior tibial, dorsalis pedis
- Skin temperature: Cool
- Capillary refill: Delayed (> 2 sec)
-Auscultation for bruits: Abdominal aorta, Femoral & popliteal arteries
86
Venous insufficiency [varicose veins (varicosities) ]
-Dilated, tortuous superficial veins - result from defective structure & function of the valves of the saphenous system
Symptoms include:
- Dull ache or pressure sensation after prolonged standing; relieved with elevation
- Dependent ankle edema may develop
- Ankle ulcerations may develop
- Superficial thrombosis / thrombophlebitis may occur
- Support hose if prolonged sitting --> Flight to Australia
87
Stasis dermatitis
- Due to chronic venous insufficiency with incompetent valves & higher pressure in capillary bed.
- Tissue is damaged & inflamed
- “Brawny,” non-pitting edema
88
Lymphedema
-Results from blockage of the lymph vessels that drain fluid from tissues throughout the body (& transport immune cells to where they’re needed)
89
Homan’s sign
- Testing for deep venous thrombosis
- In a patient with calf pain, tenderness, &/or swelling
- Passivel dorsiflex the foot
- Calf pain with dorsiflexion suggests DVT
- Questionable reliability & validity.
- Calf pain may be due to some other cause
- Negative test does NOT rule out DVT
90
Evaluation of ???? IDK
Specific Structure Tests:
- Homan’s Sign (DVT)
- Thompson’s Test (Achilles’ rupture)
- Compression Test (fx)
91
Describe thessaly's test
- Its to evaluate Medial and lateral menisci
- Person will hold on to something (on both sides)
- They will swivel at the knee
- Now bend the knee and swivel
- ****WEIGHT BEARING****
