Lower Extremity Flashcards
Where is true “hip” pain seen?
In the groin (near the joint socket)
What is femoroacetabular impingement?
Bone overgrowth or abnormality in bone development (like tearing of the labrum or destruction of the articular cartilage leading to osteoarthritis)
Types of femoroacetabular impingement
Pincer (acetabular involvement)
Cam (femoral head involvement)
Combo
Clinical presentation of femoracetabular impingement
Groin pain and/or lateral hip pain
Pain might be sharp/stabbing or deep/dull ache
Pain worse with turning, twisting, standing, squatting
Tests for femoracetabular impingement
FADIR or FABER
FADIR impingement test
Knee/hip flexion with ADduction and Internal Rotation of the hip
FABER/Patricks/Figure Four
Flexion, ABduction, External Rotation of hip
Ipsilateral pain in the front is hip pathology
Contralateral pain in back is SI joint dysfunction
When would you use an MRI for a femoroacetabular impingement?
If there is clicking or catching
Tx for femoracetabular impingment
Decrease aggravating activities, NSAIDS, pt
What is a common precursor for a labral tear of the hip?
Femoroacetabular impingement
Clinical presentation of labral tear
Dull/sharp groin pain, often radiates
Catching/clicking that may cause the pain
Gold standard for imaging of labral tear
MR arthrogram (want to be able to see fluid densities with a fluid injection)
When do you let a labral tear heal on its own?
If inside the cup of the labrum and it is not rubbing/clicking
What is snapping hip syndrome?
Snapping or popping sensation in the hip with walking, getting up from a chair or swinging the leg
Cause of snapping hip syndrome
Muscle or tendon sliding over a bony prominence, which can lead to bursitis
External snapping hip syndrome
IT band over the greater trochanter (can see it while swinging the leg)
Internal snapping hip syndrome
Iliopsoas tendon over iliopectineal eminence or femoral head (anterior groin popping)
Who is at increased risk of snapping hip syndrome?
Adolescents, athletes with repetitive hip flexion, dancers
Clinical presentation of snapping hip syndrome
Snapping/popping sensation
Pseudosubluxation (sensation of hip subluxation or dislocation)
Difficulty with stairs, running, arising from seated (internal) etc
Physical exam for external snapping hip syndrome
Passive internal/external rotation of hip while laying on side
Physical exam for internal snapping hip syndrome
Flex, abduct and externally rotate hip (FABER) then extend hip
Tx for snapping hip syndrome
NSAIDs, avoidance, corticosteroid injection, PT
What is the most common cause of lateral hip pain in adults?
Greater trochanteric pain syndrome (previously trochanteric bursitis)
What is greater trochanteric pain syndrome?
Repetitive overload tendinopathy (glut med and min) with hip abduction and pelvic instability
Clinical presentation of greater trochantetic pain syndrome
Lateral hip pain with localized pain to greater trochanter, pain increased with pressure over trochanter
Physical exam for greater trochanteric pain syndrome
TTP over greater trochanter, pain with resisted abduction, Trendelenburg sign due to pain not weakness
Terrible/Unhappy triad or Triad of O’Donoghue
ACL, MCL, medial meniscus
Most common MOI for MCL sprain
Knee flexion + foot planted AND lateral impact causing valgus stress and rotation
MOI for LCL sprain
Tibial internal rotation and medial impact
What is the most important structure for stability of the knee?
ACL
What does the ACL do?
Prevent anterior translation and rotation of the tibia
MOI for ACL injury
Noncontact: quick position change with cutting/pivoting (lateral bend)
Contact: direct blow causing hyperextension or valgus deformity with lateral impact
Why is an ACL injury more common in females?
Quad dominance during deceleration, increased valgus stress with pivoting or deceleration, decreased proprioception, decreased intercondylar notch width, estrogen
History for ACL injury
Feeling or hearing a pop, immediate pain and swelling, report feeling of instability
Specialized tests for ACL injury
Lachman, anterior drawer or pivot shift
Gold standard for diagnosis of ACL injury
MRI
What does the PCL do?
Prevents posterior translation and external rotation of the tibia (largest and strongest ligament of the knee)
MOI for PCL injury
High energy trauma: MVA
Low energy trauma: sports (mostly soccer)
Clinical presentation of PCL injury
Generalized knee pain and a feeling of something not being right, presentation varies based on MOI
Specialized tests for PCL injury
Posterior drawer sign and posterior sag sign
What is a meniscus?
C-shaped cartilage that increases contact area for articulation
Increases joint stability, facilitates lubrication and shock absorption
When does a meniscus injury occur?
Due to excessive rotational force of femur on tibia
Clinical presentation of meniscus injury
Joint line pain, inability to full extend knee (locking or catching)
Specialized test for meniscus injury
McMurrays (Medial is Bolander- out laterally, Lateral is bermingham-rotate in), Apley’s compression/distraction
Treatment based on grade of knee sprain
I (mild stretch): RICE, WB as tolerated
II (partial tear): RICE, brace, crutches, PT, maybe surgery
III (complete tear): surgical repair, crutches, brace, aggressive PT
Clinical presentation of patellofemoral pain syndrome (Runners knee)
Anterior pain under the patella (involves retinaculum), positive theater/car ride sign
Usually see crepitus, popping, feelings of instability
Specialized tests for patellofemoral pain syndrome
Patellar glide and patellar apprehension test
What is a baker’s cyst?
Accumulation of joint fluid in the popliteal fossa
What is patellar tendonitis?
Patellar tendon inflammation from repetitive trauma
Steroid injection is not recommended because it is near the insertion site and there is risk for rupture
Clinical presentation of ilitotibial syndrome
Gradual onset of localized pain at the insertion point of the IT band
Initially sharp/burning pain during activity that may develop into a constant deep ache
Overuse
What is knee bursitis and where is it most commonly seen?
Inflammatory disorder of the bursa (thin walled sac lined with synovial fluid)
Prepatellar and pes anserine are most common (there is also suprapatellar and infrapatellar tho)
Presents with pain, swelling and tenderness
What is osteochondritis dissecans?
Idipathic osteonecrosis of subchondral bone (10-20 yo)
What is the process of osteochondritis dissecans?
Trauma Focal hypovascularity Necrosis Chondromalacia Articular fragment *Each step is a different grade
Reason for osteochondritis in the elbow
Chronic valgus stress or micro trauma with compression attributed to overhead activities (commonly affecting capitellum)
Reason for osteochondritis in the knee
Repetitive axial loading (valgus/varus stress)
Most commonly lateral portion of medial femoral condyle
Clinical presentationof osteochondritis dessicans
Gradual onset of poorly localized deep pain (elbow seen laterally), elbow tends to have decreased ROM
Popping, locking or catching in advanced disease
Importance of imaging in osteochondritis dessicans
See flattening of articular surface (crater) which is usually when a provider first thinks about this disease as a diagnosis
What are the pathologies causing anterior knee pain?
Quads/patellar tendons, patellofemoral pain syndrome, bursitis, patellar fracture/dislocation, Osgood-Schlatters
What are the pathologies causing medial knee pain?
MCL, medial meniscus, pes anserine bursitis
What are the pathologies causing lateral knee pain?
LCL, IT band syndrome, lateral meniscus
What are the pathologies causing posterior knee pain?
Baker’s cyst, DVT
What is the most common ankle sprain and what is the MOI?
Lateral ligament complex (mostly anterior talofibular ligament, but also included calcaneofibular ligament and posterior talofibular ligament )
Inversion injury with plantar flexion
Test: anterior drawer
What occurs in a medial ankle sprain?
Eversion injury of deltoid ligament complex
What occurs in a syndesmotic/ high ankle sprain and what is the MOI?
Usually involves anterior/posterior tibiofibular and transverse tibiofibular ligaments and the interosseus membrane
Dorsiflexed/rotational ankle injury
Test: squeeze test
What is the function of the Achilles Tendon?
Plantarflexion
What is the associated disease in kids of the achilles tendon?
Calcaneal apophysitis (Sever’s disease)
Clinical presentation of tendinopathy associated with achilles tendon
Recent increase in training, burning pain increased with activity
Clinical presentation of rupture of achilles tendon
Sudden pivoting or rapid acceleration with a sensation of a violent hit or pop
Specialized test for achilles tendon
Thompson test
What is important to remember for immobilization for an achilles tendon rupture
Splint them in a continued plantar flexed position to allow for correct healing
Clinical presentation of plantar fasciitis
Pain with onset of walking (first step in the morning)
Most common on plantar aspect of heel
What do you want to rule out with plantar fasciitis presentation?
S1 radiculopathy (weakness with dorsiflexion of great toe)
