Lower Leg MDT Flashcards
The following describes what injury:
- Formerly known as medial tibial stress syndrome
- Thought to be secondary to a reaction of the periosteum in response to increased stress, as seen in runners
- Must be differentiated from a tibial stress fracture
Shin Splints
Pt presents with:
- Gradual onset of pain with prolonged walking or running activity
- Pain is localized to the distal third of the medial tibia
- Patient may have increased training intensity, pace or distance
Shin splints
Pt PE:
- Tenderness along posterior medial crest of tibia in the middle to distal third of the leg
- Pain with resisted plantar flexion
- possible pes planus
Shin splints
How do you differentiate between shin splints and stress fracture
Plain film radiographs
Treatment of Shin splints
- NSAIDS
- Ice
- Light Duty-Activity modification
- Gradual pain free return to running
- Weight lose if needed
- Proper running shoes
What sx differentiates shin splints from tibial stress fracture?
Pain at rest
Treatment of Tibial Stress Fracture
- Rest/duty modification
- Weight bearing modification and training
- NSAID/Tylenol/ice for pain
- Expect duty modification for roughly 12 weeks
What divides muscles of the lower leg into 4 compartments?
Fibrous septa
The following describes what injury:
- elevation of intra-compartmental pressure to a degree that compromises blood flow to the involved muscles and nerves
- can be acute resulting from crushing injury, muscle strains or closed fracture
- Inflammation raises pressure in the compartment
Compartment syndrome
Pt presents with:
- Severe leg pain out of proportion to apparent injury
- Persistent deep ache or burning pain
- Parasthesias
- Symptoms progress over few hours
Compartment syndrome
The 7 P’s of compartment syndrome
Pain
Pallor
Parasthesias
Paresis
Poikilothermia
Pressure
Pulselessness
What of the 7 P’s is the most common indicator of compartment syndrome?
Pain and parasthesias
Pt PE:
- Tense shiny skin that may be pale
- Tenderness, tense compartment and possible coolness to affected compartment
- Increased pain with passive stretching of muscle in the involved compartment
- Muscle weakness to muscles that are in or run through involved compartment
- Decreased sensation and pulses in and distal to involved compartment
Compartment syndrome
Treatment of Acute compartment syndrome
- MEDEVAC
- requires fasciotomy
How should patient with acute compartment syndrome be prepped for transport
- Remove any tight fitting items around the extremity
Including splints, dressings, etc - Place limb in neutral position
- Not elevated or lowered
- Analgesics and supplemental oxygen
Treatment of chronic exertional compartment syndrome
- rest from aggravating activities
- Rest
- NSAIDS
- May require surgery
What is contraindicated for CECS because of its constricting properties?
Ice is considered contraindicated because of it’s constricting properties
The following are a risk for what injury:
- Athletes
- Age (30-40 year olds)
- Male gender
- Obesity
- Running mechanics issues
- Misalignment, footwear, leg length discrepancy
- Fluoroquinolone antibiotic use associated
- Rheumatologic diseases
Achilles tendon rupture
Pt presents with:
- Sensation of being struck violently in back of ankle
- Possible “pop” followed by acute onset of pain
- Pain is not always felt in rupture
- Reports of up to 1/3 of patients are pain free at time of rupture
Achilles Tendon rupture
What position should a patient with Achilles tendon rupture be examined in?
prone position, feet hanging off end of table
Pt PE:
- Ecchymosis, edema, foot malalignment
- Possible impaired plantarflexion
- Positive thompson test
Achilles tendon rupture
What special test will be positive for achilles tendon rupture
Thompson test
What is the gold standard imaging for achilles tendon rupture
MRI
Can use US
Pitfalls in missing Achilles tendon rupture
- Patient able to plantar flex their foot
- Patient is able to walk
- Tendon is not painful
- Examiner cannot palpate a defect in the Achilles tendon
Treatment of Achilles Tendon Rupture
- Light duty
- Ice
- NSAID
- Consider Achilles tendon support
Heel lift
Elastic bandage
Taping
-Physical Therapy
If available will give exercises and provide support as above
The following describes what injury:
- Injury to these joints can occur as a result of significant trauma or from an indirect mechanism, as may occur in athletics or as a result of tripping
- The critical injury involves the second tarsometatarsal joint
Lisfranc Fracture
Pt presents with:
- Patients often report a sprain
- Pain is localized to the dorsum of the midfoot
- The swelling may be relatively mild
Lisfranc fracture
Pt PE:
- Ecchymosis in the plantar arch
- Edema in the tarsometatarsal joint
- Maximum tenderness and swelling over the tarsometatarsal joint rather than the ankle ligaments
- Pain to the tarsometatarsal region with all resisted ankle motions
Lisfranc fracture
How do you confirm a Lisfranc fracture
Plain film radiographs
CT or MRI if unclear
Treatment of Lisfranc fracture
- MEDEVAC
- Orthopedic consult
- Nondisplaced injuries are treated with 6-8 weeks of non weight bearing cast immobilization
- Fractures or dislocations that are displaced require surgery
- Non-weight bearing (NWTB)
- Analgesics
What is the most common ankle sprain
Inversion injury
Majority of ankle sprains involve which ligament only?
Anterior talofibular ligament (ATFL
Stronger force ankle sprain can also damage which ligament?
Calcaneofibular ligament (CFL)
What is a less common ankle sprain
Eversion
Eversion with dorsiflexion injury leads to what kind of ankle sprain?
High ankle sprain
Ottawa ankle rules
- Posterior edge/tip of lateral malleolus
- Posterior edge/tip of medial malleolus
- Base of fifth metatarsal
- Navicular bone
Treatment of ankle sprain
- RICE
- NSAIDS
- Light Duty-activity modification
- Pain free calf stretching and ankle strengthening
- Bracing as needed
Prolonged bracing will lead to poor proprioception
The following describes what injury:
- lateral deviation of the great toe at the MTP Joint
- Much more common in females (10:1)
Bunion (hallux valgus)
Pt presents with:
- Pain and swelling, aggravated by shoe wear, are the principal complaints
- The Great toe pronates with resulting callus on the medial aspect
Bunion
Pt PE:
- Valgus stress at the MTP with hypertrophic changes over joint
- A hypertrophic bursa is evident over the medial eminence of the first metatarsal
- The great toe is pronated (rotated inward) with subsequent callus on its medial aspect
- Tenderness over the joint
- MTP valgus greater than 15 degrees
- Numbness or tingling over the medial aspect of the great toe can result
Bunion
Normal hallux valgus angle and normal intermetatarsal angle
hallux valgus: <15 degrees
intermetatarsal angle: <10 degrees
Treatment of Bunion
- The initial treatment is patient education and shoe wear modifications
- Shoes should have adequate width at the forefront and should be constructed of soft uppers, with no thick stitching over the medial eminence
- An orthotist or a shoe repair professional can stretch the shoe directly over the bunion
- High heels place undue pressure on the forefoot and bunion prominence and should be avoided
- Light Duty
- Ice
If bunion conservative treatment fails, what should be done
Surgical correction
The following describes what injury:
- not a true neuroma but rather a perineural fibrosis of the common digital nerve as it passes between the metatarsal heads
- The condition is most common between the third and fourth toes (third web space)
- Less common between other digits
Morton Neuroma
Pt presents with:
- Plantar pain in the forefoot is the most common presenting symptom
- Dysesthesias into the affected two toes or burning plantar pain that is aggravated by activity is common
- Occasionally, patients report numbness in the adjacent toes of the involved web space
- Night pain is rare
- Many patients state that they feel as though they are “walking on a marble” or that there is “a wrinkle in my socks”
- Removing the shoe and rubbing the ball of the foot often obtain relief
- Wearing high-heeled or tight, restrictive shoes aggravate symptoms
Morton Neuroma
Pt PE:
- Isolated pain on the plantar aspect of the web space is consistent with an intermetatarsal neuroma
- Possible decreased sensation of the digital nerve
Morton Neuroma
What special test will be positive for morton neuroma
Positive metatarsal squeeze test
Treatment of Morton Neuroma
- Patients should be advised to wear a low-heeled, soft-soled shoe with a wide toe box
- Metatarsal pads
- Takes pressure off of the metatarsal heads
The following describes what injury:
- Most common cause of heal pain in adults
- Due to degeneration of the plantar fascia
- Occurs twice as much is woman as in men
- More common in over weight patients
Plantar Fasciitis
Pt presents with:
- The pain is often most severe on awakening or when rising from a resting position because the first few steps stretch the plantar fascia
- Prolonged standing and walking also increases the pain; sitting typically relieves symptoms
- Focal Pain directly over the medial calcaneal tuberosity and 1-2 cm distally along the plantar fascia
Plantar Fasciitis
Pt PE:
- TTP directly over the plantar medial calcaneal tuberosity and 1 to 2 cm distally along the plantar fascia
- Use heavy palpation while dorsiflexing toes with other hand
Plantar Fasciitis
Treatment of Plantar Fasciitis
’- NSAIDS
- Ice massage
- Light duty to include activity modification
- OTC heel pads
- Night splints may be helpful
Pt presents with:
- “pump bump” that is irritated by shoe wear
- Start-up pain
- Pain after activity
- Antalgic gait
Posterior heel pain
Pt PE:
- Calcaneal prominence may be present with associated edema
- Superficial bursa may be present (pump bump)
- Tenderness may be noted over the heel or directly on the Achilles tendon
- Dorsiflexion may be limited by pain
Posterior heel pain
Treatment of Posterior Heel Pain
- Light duty- activity modification
- Heel lift or open back shoes
- Ice massage
- Achilles stretch
- Casting for 6 weeks in extreme cases
The following describes what injury:
- Hyperextension injury of the first metatarsal
- Coined because of the increased incidence of hyperextension injury associated with playing on artificial turf
Turf Toe
Pt presents with:
- Patients usually report swelling, tenderness, and limited motion of the first MP joint
- A grade 1 sprain is a stretch injury of the capsule
- Athlete usually able to participate in sports with mild symptoms
- Other more severe injuries may result in edema of the first MTP joint
Turf Toe
Pt PE:
- Edema and ecchymosis with more severe injuries
- Antalgic gait
- Tenderness over the MTP
- Passive flexion and extension of the great toe is painful
Turf Toe
Treatment of Turf toe
- RICE
- NSAIDS
- Stiff shoe inserts
- Severe injury requires protective weight bearing or immobilization for 1-2 weeks and with 4-6 week period of rest from sports
