Lower limb Flashcards
What is the clinical presentation of piriformis syndrome?
- •= 6-10% of sciatica cases
- = Peak 30 -40 years old
- = Female > male 6:1
- = Genetic (variations)
- •Pain in buttock radiating down leg
- = Low tolerance to sitting
- = Worse for walking /squatting / hip IR
- = Cyclists / Drivers
- = Bed rest (positional)
WHat is the the clinical presentation of spondylolisthesis?
- = 5-7%caucasion populations
- = 40% Eskimos!!!
- = 90% L5
- = Old or young people
- = Female > male
=RISK FACTORS
- = activities with repetitive extension and flexion eg Gymnasts, rowers, dead lifts
History
- = 30% patients will be asymptomatic
- = LBP , thigh pain +/- leg pain
- = Pain improves with Lumbar flexion / lying down
What is the clinical presentation of groin sprain
- •Groin strain = tear / stretch of adductor muscles. Usually adductor longus (62%) cases.
- •Overstretching or forceful abduction of thigh in activity
- •Sudden changes in direction while running / quick stopping and starting
- •Approx 2.5 % sports injuries (esp hockey, football, karate)
- •Older athletes due to decreased elasticity
- •Medial thigh pain better with rest
- •Sudden severe pain in the groin
- •If chronic diffuse and dull ache
What is the clinical presentation of greater trochanteric syndrome?
(differentiate between Hip OA and GTPS)
- •Females 40 > 60 years old
- •Abnormal hip biomechanics are hypothesised to predispose to the development of gluteal tendinopathies. Compressive forces cause impingement of the gluteal tendons and bursa onto the greater troch by the ITB.
- •Diagnosis delay can worsen prognosis
- •Commonly mistaken for Hip OA, referred pain from the lumbar spine
- •Always ask about putting shoes /socks on to differentiate GTPS from OA. (GTPS will not be painful)
- •Direct palpation of trochanter is reliable for GTPS
- •Pain after 30 seconds on a single leg stance is also reliable.
Red flags for the lower limb
-
Neoplastic
- Relatively uncommon around the knee.
- Most commonly secondary cancer from breast, lung, kidney, thyroid and prostate
-
Infection
- Staphylococcal or Haemophilus influenza
-
Inflammatory
- Spondyloarthropathies
- Gout
- Juvenile arthritis
Other conditions of the lower limb?
•Children and Adolescents
- •Patella subluxation
- •Osgood Schlatter
- •Patella tendonitis
- •Referred pain from SCFE
- •Osteochondritis dessicans
•Adults
- •PFPS
- •Medial Plica Syndrome
- •Pes Anserine bursitis
- •Ligamentous sprains
- •Meniscal injuries
- •Inflammatory arthropathy
•Older adults
- •OA
- •Pseudogout / gout
- •Popliteal cysts
Common conditions of the knee
Ligament sprain
- ACL serious and disabling = chronic instability +/- DJD. (sudden change in direction , int tibial rotation on fixed knee such as pivoting)
- PCL Minimal disability (hyperextension injury or direct blow to tibia on a flexed knee )
- Medial collateral (direct valgus force to knee, external tibial rotation injury)
- Lateral Collateral ( direct varus force to the knee)
traumatic synovitis
Osteoarthritis
Patellofemoral syndrome
Bursitis
What is the clinical presentation of patellofemoral syndrome
Patellofemoral syndrome
The most common overuse injury of the knee
No specific history or trauma
+/- biomechanical factors
Teenagers with faulty knee mechanisms or 50 -70 year olds with DJD
What is the common presentation of osteoarthritis
Common cause of knee pain in elderly pt
Stiffness first thing in am and after resting
Gradual onset swelling
A grating or scraping noise when bending knee
Decreased ROM that improves with movement
Serious disorders of the knee
- 1.Acute cruciate ligament tear
- 2.Vascular disorders a. DVT b. thrombophlebitis
- 3.Neoplasia
- 4.Infections
- 5.Rheumatoid arthritis
- 6.Juvenile arthritis
- 7.Rheumatic fever
Common conditions for leg pain
- Musculotendinous injury
- Exercise-related pain (tendon strains, such as Achilles tendon damage, compartment syndromes)
- Muscle injuries (hamstring strains, calf strain, shin splints)
- Overuse injuries
- •Radicular pain
- •Especially L5 and S1 nerve roots (could be NO LBP just leg pain)
- •Also remember referred pain patterns from facet joints and the SIJ etc (non radicular)
- •Osteoarthritis
What is the clinical presentation of Achilles tendinopathy?
- •Chronic overuse injury
- Tendon has 10x body weight passing through it with activity
Injury = repeated load over time >ability of the tendon to withstand and heal repetitive microtrauma
- •Tendon blood supply is poor especially distally
- •Very common injury
- •Middle aged adults male > female
•Risk Factors
- •>age / overuse / poor conditioning / high arched feet / > pronation / > activity / < recovery / change of surface / < flexibility /
History = post heel pain / sharp initially / recently changed training level / better with rest
Clinical presentation of Mortons Neuroma
•Mechanically induced nerve irritation = fibrosis and nerve degeneration of the digital nerve.
- •Usually between 2nd and 3rd or 4th and 5th metatarsal heads.
•Aggravated by increased compression of the foot. (high heeled shoes) then add the compression of the normal gait cycle = Morton’s neuroma!
- •Fairly common and occurs at any age
History = gradual onset of pain on plantar surface of forefoot
- = Feels like walking on a marble
- = Moves from an ache to a sharp burning pain with numbness
- = Agg with squeeze of foot
- = Rel by rest , massage , removal of compression
CLinical presentation of Gastroc strain
- •Tearing/damage to the medial head of the gastroc at or above the musculotendinous Jcn.
- •Usually follows a rapid eccentric load in activities like tennis, aerobics ,soccer, basketball
- •Common injury / usually 35 – 50 years old / Male > female
- •Risk Factors = Prior calf strain / lack of warm up / weekend warrior / > age / > weight
- History = POP / local calf pain radiating to knee o ankle / pain with ankle ROM / +/-
Serious disorders of the leg?
- Neoplasia
- Fairly uncommon
- Consider if past history of breast, lung or kidney cancer
- Infection
- Uncommon.
- Consider Osteomyelitis or septic arthritis
- Vascular conditions
- Intermittent claudication
- DVT
- Thrombophlebitis
- Varicose veins (uncomplicated)
Other conditions for leg pain
HIP Osteoarthritis when it presents as Knee pain.
Osgood –Schlatter disorder
Spinal canal stenosis
Early Herpes Zoster
Greater Trochanter pain disorders
Nerve entrapments (lateral cutaneous n , common peroneal nerve, posterior tibial nerve)
SIJ
Peripheral neuropathy
common conditions of foot pain
Foot strain
Sprained ankle
Tibialis Posterior tendinopathy
Great toe
osteoarthritis
Skin Conditions
Plantar fasciitis
Achilles tendinopathy
What are the causes of chin splins?
a.Tibialis anterior strain
- TA, EHL EDL overuse
- Pain anterolateral aspect leg
- Pain with heel strike, down hill running and over striding
b.Medial tibial stress syndrome
- TP, FHL ,FDL +/- soleus strain
- Pain with toe off
c. repetitive micro trauma
Clinical presentation for chin splints
- Typically 18 – 50 year olds
- Female > male
Poor foot or ankle biomechanics
gradual onset
poor footwear / poor shock absorption
ant shin dull and achy pain
Hard running surfaces
recent change or start of the activity
Muscle weakness/muscle imbalances
pain at the start of workout – eases - pain
leg length discrepancies
pain to palpate
Tibial torsions
improves with rest/stretching
Examination findings chin splints
- No visible signs
- Pain on palpation
- Ankle ROM may be normal
- Ankle ROM may have mild decrease due to pain on stretching damaged tissue.
- No neuro SSX
- No Vascular SSx
- No special tests except to exclude other things
treatment for chin splints
- •AVOID repetitive lower extremity stress for 1-2 weeks
- •Lower training intensity
- •Stretch +/- ice massage
- •?? NSAIDs
- •Physical Therapy Dry needling
- •MFR Friction massage
- •Trigger point ant or post muscles Assess up the lower limb chain
- •Cool pool exercises Consider aides to correct abnormalities (orthotics)
Serious conditions not to be missed for the foot
- VASCULAR (small vessels)
- Ischaemic pain
- Acute arterial obstruction
- Atherosclerosis
- SEVERE INFECTIONS
- NEUROPATHY
- Peripheral neuropathy
- I.e. diabetes
- RA
- RUPTURES (Achilles)
Other less common conditions for the foot
Gout
Morton’s neuroma
Tarsal tunnel syndrome
Chillblains
Stress fractures
Osteochondritis
What are the x-ray vies of the knee?
- AP
- Lateral
- Skyline
- Intercondylar
When do you use a knee MRI
eniscal and ligament tear/rupture.
Clinical presentation of patellar bursitis?
- Common in excessive kneeling, a direct trauma/landing or in bacterial
- infection
- • Commonly known as ‘carpet layers knee’
- • Symptoms
- Obvious swelling
- Pain on knee ROM
- Red, hot, swollen, systemic
- symptoms (if infection)
What is the treatment for patellar bursitis?
Activity modification
NSAIDs or higher dose anti inflammatories
• Aspiration
What is the mechanism of action for ACL
Abduction and internal rotation of the hip, external rotation of the knee.
What is the management for ACL?
Often does not happen in isolation MCL and medial meniscus injuries common in conjunction.
- • Patients with chondral damage often have poorer outcomes following ACL repair surgery.
- Current best practice management for most patients is surgical intervention – graft (hamstring/patella) and repair.
- • Return to sport is usually 12 months following surgical intervention with the appropriate rehab
What is the clinical presentation of meniscal tear?
- Most common mechanism is twisting injury with the foot planted on the ground
- Varied pain levels, sometimes no initial symptoms – pain tends to increase over 24 hours
Clinical Examination
- • Joint line tenderness
- • Usually with knee flexed at 45-90 Joint effusion
- Pain Usually on hyperflexion, squatting
- • Restricted ROM
- • Due to ‘flap’ or the joint effusion
What is the management for meniscal tear?
Conservative Vs Surgical
Conservative management
- strength training and
- changes to biomechanical compensations,
- gait retraining,
- proprioception
What are the ligament knee test
Anterior draw test: ACL
Lachman’s test: ACL
Posterior Draw test: PCL
Valgus Stress test at 0 & 25 degrees: MCL
Varus Stress test at 0 & 25 degrees: LCL
What test to use for a meniscal injury
Thessaly : dancing pose
clinical presentation Achilles tendinopathy
Increased tendon load
Midportion tendinopathy
tight calves
reduced knee flexor strength
increased dorsiflexion ROM
Assessment for achiles tendinopathy?
Single leg heel raise or hop
weight-bearing tendon by doing knee to wall
ultrasound
What is the management of an inversion sprain
- Ottawa rules negative: move within pain range
- Initial action: decrease swelling increase ROM
- biomechanical compensations – Lx, hips, pelvis
- Proprioceptive exercises
- Accessory mobilisation of the ankle, subtalar and midtarsal joints
What is the treatment for plantar fascitis
Risk factors
- • High BMI
- • Inc load??
- Training volume
- Standing prolong periods
- Dec ankle and hammy flexibility
- • (the evidence is sketchy)
Treatment and management
- Needs to be multifaceted
- Minimise agg factor
- • Footwear
- • Taping
- Midfoot, gastroc, foot intrinsic strengthening
- Dry needling
What is the treatment for medial tibial stress syndrome?
Risk factors
- • Biomechanics: Poor or excessive pronantion
- Overload Tib post, FDL and soleus esp when poor ankle flexibility
- High levels PF
- Increase in load
- Poor footwear
TTT & Management
- Load management
- K-Tape
- Ankle mobilization
