LOWER EXTREMITY DISORDERS Flashcards
sciatic nerve = runs from
L4 - S3
- articular & muscular
- sensation
- external rotation & posterior thigh, foot
femoral nerve =
L2 - L4
anterior thigh compartment
lateral femoral cutaneous nerve =
L3 - L4
sensory
blood supply of the hip
Femoral Artery
⦁ Profunda femoris
⦁ Circumflex
Artery of the ligamentum teres
⦁ Posterior division of the obturator artery
⦁ Femoral head
AVN = AVASCULAR NECROSIS
- Interruption of vascular supply to the femoral head
- Causes
⦁ fracture
⦁ dislocation
⦁ SCFE
⦁ steroids
⦁ ETOH
⦁ Perthes
⦁ Coagulopathy
⦁ Sickle cell - AVN = commonly bilateral
- Prognosis: 70-80% of cases collapse - femoral head dies - by 3 years
- TREATMENT
⦁ early - anticoags, bisphosphonates, decompression, treat the cause
⦁ later = surgery - decompression vs total hip vs arthrodesis
xray, then do MRI and bone scan for AVN
HIP BURSAE
- between bone and surrounding soft tissue
o Trochanteric - between greater trochanter & IT band
o Ischial - between ischial tuberosity & gluteus muscles
o Iliopsoas - between lesser trochanter and iliopsoas tendon
- pain & snapping in groin and anterior hip with hip flexion and crunches
PT is a runner and was a dancer
ILIOPSOAS BURSITIS / TENDINOSIS
- inflammation of the bursa or inflammation of the tendon
- HX & PE
- consider XRAY or MRI to rule out other diagnoses
- TX = relative rest, stretch, consider NSAIDS. PT
consider injection or surgical referral if not improving with conservative treatment
FAdAxl
acetabular labrum tear
- hip pain with deep click
- catching sensation; feels stiff
- worse with deep flexion & rising from seated position
- decreased ROM
ACETABULAR LABRAL TEAR
HX & PE
- Pain with FAdAxL = hip flexion, adduction, and axial load
- imaging: (xrays negative) = MRI arthrogram (inject dye into joint
TREATMENT = PT to maximize ROM and strength
- can do steroid injection or surgery if needed
DIAGNOSIS OF ACETABULAR LABRAL TEAR
MRI ARTHROGRAM - see dye spill through with tear
-Ober Test
tightness of the IT band
- left lateral hip pain
- gradual onset
- no trauma or previous hx
- painful to lay on left side
TROCHANTERIC BURSITIS
HX & PE
- point tender over lateral thigh
- pain with Ober test (determines any tightness of the IT band)
- **Hx Key = de-conditioned; significant increase in activity
Treatment = Ice, NSAIDS, PT (stretch IT band & strengthen hip muscles); steroid injection
- progressive right hip & groin pain
- associated decreased ROM
- no trauma, no other joint complaints
OSTEOARTHRITIS OF THE HIP
HX & PE
- xrays - weight bearing
TREATMENT = PT, APAP > NSAIDS, hip injection (US guided) - steroid. Surgical referral if disabling. Can use APAP & NSAIDS together as long as no CI
- 13 y/o female gymnast with increasing groin pain over last 2 months
- hurts to jump, run, stretch and land
- increased pain with increased activity
- no acute trauma
PUBIC RAMUS STRESS FRACTURE
- *Point tender left superior pubic ramus
- non-tender adductors, normal hip exam
- Xray (negative) - so do bone scan or MRI
Treatment = relative rest, non-painful activity, slow increase
STRESS FRACTURES
- stress fractures can occur anywhere
- commonly occur in feet, ankles, tibia, fibula, patella, femur, and/or others (ribs)
- can be a sign of an underlying problem in addition to overuse (ie: estrogen deficiency, hormonal abnormalities, nutritional deficiencies, or metabolic disorders)
won’t see on xray - need MRI or bone scan
- have gradual onset of pain with activity
HISTORY
- increased intensity / duration of activity
- change in footwear
- change in surface
initial xrays often negative; negative studies = bone scan, MRI
key to treatment = pain free ambulation / activity
initial xrays often negative; negative studies = bone scan, MRI
key to treatment = pain free ambulation / activity
- if fracture is on the inferior side = continue with non-painful activity, gradual return
- if fracture is on superior side = ortho referral!!! - high risk for complete fracture
- address causation - diet, activity level, maturity
- chronic right groin pain after increased training in past month
- worse with right footed kicking and resisted adduction
- pain & stiffness gradually loosen up
- pain with resisted adduction**
ADDUCTOR TENDINOPATHY
- TTP medial groin at tendon insertion
TREATMENT = relative rest, ice strengthening - PT
hockey = think of
athletic pubalgia - sport’s hernia
dilated superficial ring of inguinal canal
hockey player with left groin pain; worse with skating & hip motion. no specific trauma
ATHLETIC PUBALGIA / SPORTS HERNIA
- not a true hernia
- pain in hernia region without palpable hernia
- injury to conjoined tendon, internal oblique, external oblique, transversalis fascia, inguinal ligament, etc.
- SURGICAL REFERRAL
PIRIFORMIS STRAIN VS SYNDROME
STRAIN = NO SCIATICA
SYNDROME = SCIATICA
PIRIFORMIS STRAIN / SYNDROME
Piriformis muscle lies over sciatic nerve
buttock & lower back pain -
- left buttock pain; retired professional soccer player
- insidious onset
- painful to sit, pain increases after running
- previous back aches, but no specific trauma
- points to left lower back & buttocks
- some radiation to hamstrings
- no numbness, no red flags
PE = normal gait & appearance. TTP left upper/outer buttocks. painful resisted external rotation and painful passive internal rotation. normal sensory and strength
Piriformis strain = no sciatica
Piriformis syndrome = sciatica
TREATMENT = rule out other things. NSAIDS, stretch/strengthen. PT
femur fractures = think _______
if young = think ________
think DVT
if young = think AVN
femur fractures
- head / neck
- Etiology: fall (arrhythmia, osteoporosis, pathologic, seizures, stroke)
- functional status
- exam = rule out other injuries
⦁ shortened external rotation
⦁ internal rotation = pain in hip and groin
Treatment = Pins, ORIF (open reduction, internal fixation)
- think DVT
- if young = think AVN
Treatment of femur fractures - head / trochanter
⦁ internal fixation (screws) - in head / trochanter
⦁ hip compression screw - in head / trochanter & femur
⦁ Hemi-arthroplasty - hip replacement without replacing the acetabulum
⦁ Total hip replacement
femur fracture - shaft = worried about
compartment syndrome
shaft femur fracture
- high forces involved
- lots of bleeding - vascular injury
- treatment = SURGICAL REFERRAL
- worried about compartment syndrome
75% of compartment syndrome cases are caused by
fractures
COMPARTMENT SYNDROME
- 75% caused by FRACTURES***
- other causes = crush, envenomation, immobilization, constrictive dressing, infection, burns, tourniquets
- CECS (chronic exertion compartment syndrome)
get compression of soft tissues first, then vessels, nerves
- compression of veins before arteries due to pressure inside them
TREATMENT = release pressure
most common hip dislocation
posterior
HIP DISLOCATION
- high energy trauma - MVA
- younger patients
o Anterior
- 10-15%
- dashboard with thigh abducted
- leg is externally rotated
o Posterior dislocation = most common
- leg is internally rotated
TREATMENT = reduction ASAP (concerned about AVN, and sciatic injury)
- also keep in mind that there may be a concomitant injury - another fracture / dislocation
if leg is externally rotated
anterior hip dislocation
if leg is internally rotated
posterior hip dislocation
hip dislocation = worried about
AVN & sciatic injury
may also be concomitant injuries - fx/dislocations
KNEE INJURY HISTORICAL CLUES
⦁ noncontact injury with a “pop” = ACL tear
⦁ contact injury with a “pop” = MCL, LCL tear, meniscus tear, or fracture
⦁ acute swelling = ACL tear, PCL tear, fracture, knee dislocation, patellar dislocation
⦁ lateral blow to the knee = MCL tear
⦁ medial blow to the knee = LCL tear
⦁ knee “gave out” or “buckled” = ACL tear, patellar dislocation
⦁ Fall onto a flexed knee or dashboard injury = PCL
flat feet
pes planus
genu varus vs genu valgus
genu varus = knees apart, feet together (bow legged)
genus valgus = knees together, feet apart (knock knees)
popliteal fossa bulges
- popliteal artery aneurysm
- Baker’s cyst
- popliteal thrombophlebitis
knee exam MUST include
hip ROM
PATELLOFEMORAL SYNDROME (PFS)
- idiopathic softening / fissuring of patellar articular cartillage
- MC seen in runners**
- *have anterior knee pain “behind” or around the patella
- worse with knee hyperflexion (prolonged sitting), jumping or climbing
DIAGNOSIS = APPREHENSION SIGN - apply pressure to medial & lateral patella - painful!
TREATMENT = NSAIDS, rest, rehab
ex: 12 y/o - nonspecific anterior knee pain; worse with activities such as running/squatting/jumping. May have some swelling. No injury. Occasional popping
⦁ Patellofemoral Grind = put pressure on superior patella as patient fires quads
⦁ Patellar Apprehension test - apply medial forces to patella - forcing it laterally
Diagnosis = look for muscle imbalance, flexibility issues, feet and alignment
TX = NICER = NSAIDS, ice, compression, elevation, rest
- patellar stabilizing brace
- PT
TEST FOR PFS
APPREHENSION TEST
MC knee ligament injury
ACL
ACL TEAR
***MC knee ligament injury; 70% sports related
MOA = non-contact pivoting injury (deceleration, hyperextension, internal rotation)
“pop” & swelling –> hemarthrosis
knee buckling
MC in women
- inability to bear weight
PE = Lachman’s test (have ACL laxity) = most sensitive test
TX = therapy vs surgery (depends on patient)
ex: 18 y/o female BB player - preparing for layup, ends up on floor holding her knee, screaming in pain. felt a “pop” - unable to continue. Instability & increased stiffness
PE = Valgus for MCL, Varus for LCL = Bohler Test
TX = NICER, brace, pain free activity, time (2-8 weeks, take 1 year for full maturation of scar in a complete tear)
PCL TEAR
- MC associated with dashboard injuries - anterior force to proximal tibia with knees flexed
- or direct blow injury or fall on a flexed knee
- usually associated with other ligamentous injuries
Anterior bruising
Large effusion
PE = Pivot Shift test, Posterior drawer test TX = PT, bracing, occasionally surgery
**Sag sign = same position as anterior drawer - thumb slides medial to patella into tibial condyle. if lacking condyle = positive sag sign
Posterior drawer = posterior pressure on tibia; positive if posterior translation of tibia
tests for meniscal injuries
McMurray test
Apley test
MENISCAL TEAR
- MOI = degenerative (squatting, twisting, compression, or trauma with femur rotation)
- Medial = 3x more common than lateral - because of bony attachments
Locking
Popping
Giving way
Effusion after activities
***MCMURRAY’S SIGN - pop or click when tibia is externally and internally rotated
Apley Compression Test = pt prone - knee bent up in air, compress down and rotate
TREATMENT = NSAIDS, partial weight bearing until ortho follow up; arthroscopy
ex: steps off ladder onto uneven ground; knee twisted - immediate medial pain. Swelling. Now has trouble squatting, kneeling, climbing
TESTS = full flexion, joint line tenderness, McMurray, Apley’s compression test, Bounce test, Duck walk
CHRONIC PATELLAR TENDINOPATHY
NOT an inflammatory condition. not due to inflammation - so NSAIDS only help with pain. Steroid injections can decrease pain short term.
- may be a red flag to other associated factors: nutrition, malalignments, muscle problems, training errors, medications (fluoroquinolones, doxy, steroids), systemic dz (psoriasis, SLE, hyperthyroid, DM)
- TREATMENT = rest, d/c painful activities. avoid immobilization if possible, as too much rest is bad (results in poorly aligned collagen & healing)
- progress through passive & active ROM
PATELLAR TENDONITIS / TENDINOSIS / TENDINOPATHY
- Jumper’s Knee
- Affects participants in “explosive” sports involving quick movements
⦁ Basketball players are most commonly affected
⦁ Commonly in hikers/ backpackers on hills and unpredictable terrain
Causes
⦁ Excessive activity - Especially a rapid increase in frequency/intensity of training
⦁ Improper mechanics of training
⦁ Excessive weight on person with a weight bearing exercise lifestyle
TREATMENT = ice, NSAIDS, PT, orthotics
SEPTIC ARTHRITIS VS SEPTIC BURSITIS
- bursitis = red & angry looking. Area of fluctuance. Knee moves pretty well. DON’T aspirate the joint through the cellulitis
- septic joint doesn’t look red, just swollen. Very tender, and any motion causes severe pain
knee injections
THERAPEUTIC INJECTIONS
- steroid delivery for OA and other non-infectious inflammatory arthritides (gout)
- delivery of viscosupplementation
GLUCOSAMINE & HYALURONATE INJECTIONS
- studies show a weak benefit in pain relief with glucosamine +/- chondroitin, but no harm except $
- studies have not supported the benefit of multiple hyaluronate injections over a single steroid injection, however, they have shown pain relief
best approach for steroid injections (knee)
SUPERIOR ANTEROLATERAL
FIBULAR SHAFT FRACTURE
- treatment is based on patient’s comfort (splint, cast, walking boot). complete healing - 6-8 wks
- referral ⦁ comminuted ⦁ significantly displaced ⦁ associated tibial fracture ⦁ neurovascular injury
- be sure to evaluate syndesmosis appropriately***
MC tibial plateau fracture
lateral
knee pain imaging
- if arthritis or fracture or you are going to refer =
⦁ standing AP of both knees, both laterals, and Merchant / sunrise view
⦁ for arthritis = get standing 30 degree AP too
HIP FLEXION MUSCLES
⦁ anterior muscles ⦁ iliopsoas ⦁ rectus femoris ⦁ sartorius ⦁ pectineus
HIP EXTENSION MUSCLES
⦁ posterior muscles
⦁ gluteus maximus
⦁ hamstrings
⦁ adductor magnus
FAdAxL test
labral injury
flexion
adduction
axial load
FAbER
SI joint
Flexion
Abduction
External Rotation
FAIR
Piriformis
Flexion
Adduction
Internal Rotation
FAdIR
FAI
flexion
Adduction
internal rotation
