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)
What is the mechanism of action for ACL
Abduction and internal rotation of the hip, external rotation of the knee.
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 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
