Lower Limb Flashcards
Anterior compartment of lower leg
Tbialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius
Deep peroneal nerve
Anterior tibial artery
Lateral compartment of lower leg
Peroneus brevis, peroneus longus
Superficial peroneal nerve
Peroneal (perforating) arteries
Deep posterior compartment of lower leg
Tibialis posterior, flexor digitorum longus, flexor hallucis longus, popliteus
Tibial nerve
Posterior tibial artery
Superficial posterior compartment of lower leg
Gastrocnemius, soleus, plantaris
Cutaneuous nerves only e.g. sural
Night pain
Wakes you up at night
ask for systemic symptoms that indicate autoimmune diseases or cancer
Tinnel’s sign
Light palpation on nerve reproduces symptoms of pins and needles/ tingling => irritated nerve
Foot dorsiflexion
10-15
Tibialis ant, EDL, EHL, peroneals
Foot plantarflexion
45-55
Gastroc, soleus, tib posterior, FDL, FHL
Foot inversion
30-40
Tibialis posterior
Foot eversion
15-25
Peroneals
Foot pronation
15-30
Eversion + Abduction + Dorsiflexion
Foot supination
45-60
Inversion + Adduction + Plantar flexion
Over pronation (i.e. flat foot) causes
flattening of long arch movement mid-tarsal joints rotation of tibia functional q angle of knee load on tibialis posterior
Isotope bone scan (IBS)
Radioactive isotome -> inject Technetium-99 polyphosphonate Triphasic bone scan - 0 mins: isotope angiogram - 2 mins: blood pool - 2 hr: delayed
Looking for hotspots
Stress fracture
Acute onset due to repetitive microtrauma
Imbalance between deposition/resorption
Low BMD
Fatigue of shock absorbing muscles
Point tenderness O/E
Crescendo night pain
Immediate pain on running
Training conditions - hard surface, increased intensity
Plain radiograph => callus at 2-3wks
IBS
Rest for 6-9wks until pain free
immobilise if severe
phased RTS
Internal fixation if not healing
Medial Tibial Stress Syndrome (Shin splints)
Cause unknown - theories of traction periostitis or tibial bending
lasts hrs to d
Typically within first 2 wks of new season
Aching during/after exercise
Able to exercise through pain
O/E Posterio-medial tenderness on distal third of tibia
RF: INTRINSIC - endocrine, bone geometry, biomech, nutritional; EXTRINSIC - surface, training error, footwear
Ix - XR, IBS, MRI
Rx - RICE for 7-10d, aerobic NWB fitness, podiatry for assessment
Prevent - gradual increased training, good dorsiflexion, flexibility pre-season, footwear, training surface, diet
Chronic Compartment Syndrome
Increased pressure within a closed compartment due to inelastic fascia; caused by increased muscle volume due to continuous exercising
Compromised circulation and tissues
Starts within a few mins of exercise and stops after rest
Stops them from continuing
Associated numbness and weakness
Ix
Intra-compartmental pressure studies; insert cather in muscle and exercise for 5 min
Normal <10mmHg; Significant >30mmHg
Physio, orthotics, NSAIDS
Superficial fasciotomy
Tibialis Anterior/ EDL/ EHL Tendinopathy
Overuse injury of dorsiflexors
Downhil running, tight shoelaces
TA => pain on resisted dorsiflexion
EDL => pain on resisted toe extension
EHL => pain on resisted halux extension
RICE, Rehab, injection
Tibialis Posterior/ FDL/ FHL Tendinopathy
Overuse of plantarflexors
Ballet dancers
Tom, Dick and nervous Harry
TP => post-medial calf -> medial melleolus -> navicular tuberosity ; pain on resisted inversion
FHL => Pain on resisted toe flexion
RICE, eccentrics, injection
Popliteal artery entrapment syndrome
Claudication during exercise by head of gastrocnemius or thick fibrous band
Similar Sx to CCS
Tib posterior pulse disappears when acutely plantarflexed
Doppler, Arteriogram
Surgery
Nerve entrapment
Superficial peroneal nerve (lateral compartment)
Pain and paraesthesia
Tinnel’s sign
Nerve conduction studies
steroid injection, surgical release
Fascial hernia
Anterior compartment defect
Similar Sx to CCS
Detectable swelling on standing/exercising -> disappears on lying
Subcutaneous fasciotomy
Knee - Per Anserinus (aka goose foot)
Sartorius, gracilis, semitendinosus
Lateral knee (superficial to deep)
ITB
Patella retinaculum
LCL and joint capuse
Medial knee (superficial to deep)
Sartorius
Superficial MCL
Deep MCL and joint capsule
Back of the knee
PCL
Popliteus
Menisci
Function of popliteus
Unlocks tibia relative to the femur in flexion
MCL origin and Inserion
Origin - behind medial epicondyle
Insertion - 1cm below joint line
Questions to ask about knee pain
VAS
Constant or related to activity
Anterior, stair climbing, prolonged sitting => PFP
Twisting/rotating => meniscal
Questions to ask about knee instability
Pivoting/ twisting => ACL
Linear instability - stairs/ level ground => quads weakness
Side to side instability => PCL
Mechanical symptoms of knee
Locking/ clicking/ snapping => bucket handle meniscal tear; loose body
Other questions - knee
treatment to date benefits of previous treatment athletic hx PMH Occupational Hx
Knee examination
Inspection
Palpation
ROM and strength
Patella - tilt, apprehension, translation, crepitus, j-sign, q angle
Meniscus - McMurray’s, Apley’s, Thessaly’s
Ligamentous stability - anterior and posterior drawer, Lachman’s, Pivot-shift, quads active, varus/valgus, dial test, external rotation
Gait
Joint borders
Nerves and vessels
J-sign
patella flips out laterally on flexion
Zones of meniscal blood supply
Red red zone – very vascular – will heal more easily
Red white zone – medium blood supply
White white zone – inner avascular
Double PCL sign
Pathognomic of a bucket handle meniscal tear
Management of Meniscal tear
Non-operative
- <5mm stable peripheral tear
- Degenerative tears
- Associated ligamentous instabilities
- Medically unfit
Surgically treated either by removal of the meniscus via arthroscopy, or using sutures
Articular Lesions
Types
- Partial thickness chondral lesions; avascular
- Full thickness defects; potential to feel with fibrocartilage (type 1 collagen)
- Traumatic vs insidious
Accelerate degenerative wear and loose body formation in joint capsule
structural abnormality in patella and joint
Ix
MRI with gadolinium
Other: AP XR, CT, PA XR in 45dg flexion
Articular Lesions: Grades
Grade 0 - Normal bone
Grade 1 - 75% (soft cartilage and swelling)
Grade 2 - 50% (partial thickness defect with fissures)
Grade 3 - 25% (fissuring to subchondral bone)
Grade 4 - Down to subchondral bone
Articular Lesions Management
Treatment for G3/4 after failed non-op
Avoid in obesity, inflammatory conditions, malalignment, meniscal defects, degenerative changes
Best options: ACI and OCD, OATS
Microfracture
Osteochondral Autograft Transplantation (OATS)
ACI and Osteochondral allograft (OCD) transplantation
Microfracture
For defects <4cm2 in patients <35yo Creates a bigger defect and puncture holes to cause the bone to bleed and fill the defect with clot which will over time become fibrocartilage to relieve the pain Immediate post-op ROM on CPM instituted TWB for 6-8 weeks Return to sport after 4-9 months
Osteochondral Autograft Transplantation (OATS)
For younger patients with more demand on their knees
Allograft; lateral trochlear ridge taken from patient or cadaveric meniscus
NWB for 3 weeks
Full ROM immediately
4/12 return to sport
ACI and Osteochondral Allograft transplantation
Autologous chondrocyte transplantation
Good results in larger defects
Better for patellofemoral joint
OCD has better results with non-op in pts with open growth plates
Immediate CPM
NBW until ROM and quads strength restored
FBW usually by 10-12/52
Possible off-loading brace use
Progressive walking programme from 12-32/52 (elliptical, swimming, cycling)
Jogging/aerobics 9-12/12
High impact sport at 12-18/12
ACL Tear Treatment
Graft harvest from patella
Early ROM exercises!
Closed chain exercises emphasised in early rehab
Delay sports for 6-9 months
PCL Tear Treatment
Isolated tear not treated
brace for 4wks
rehab
return to running soon
only 3rd degree tear needs surgical rx
PCL tear + another ligament tear => reconstruct both
post-reconstruction brace for 6-12 wks
MCL Tear Treatment
Grade 1 &2 repair themselves with hinged brace for 6 wks
Closed chain exercises, jogging and treadmill start once contralateral quad strength is 80%
RTS once 80% max speed achieved
Grade 3 requires surgery if when in full extension knees moves excessively in valgus
Combined injury in 80%
Tibial sided tears require acute surgical repair
Stener lesions occur with avulsion fracture and will not heal without repair
LCL Injury
Dial test
- Prone at extension – externally rotate the legs – if asymmetry => LCL tear
- Prone at 90 degrees flexion – externally rotate the legs – if asymmetry => PCL and LCL tear
Patellar tendonitis
Jumping athletes Repetitive, forceful eccentric contraction 80-90% RTS Physiotherapy = only treatment Surgery has poor outcome
Patellar instability
Caused by increased Q angle, i.e. valgus
Young females
Repaired by moving tibial tuberosity through osteotomy or MPFL reconstruction
Sinus Tarsi Syndrome
Pain and instability following supinatory ankle sprain
Conical cavity between anterior and posterior talo-calcaneal joint; base lies over antero-lateral ankle
contains ligamnt and nerves
Clinical diagnosis
MRI for confirmation
Rx
Stapling
Injection
Cuboid Syndrome
Acute or chronic
Following inversion injury
Common in over-pronated, hypermobile, pes cavus
Predisposing factors - Increase mechanical advantage of peroneus longus running under cuboid, over-corrected foot orthoses, poor footwear
Pain during activity on unever surface
Dull ache in 5th ray
Swollen foot, bruised
Severe => Limping, difficulty WB
MRI, Dynamic CT, XR, Vitamin D
RICE, Brace, Manipulation and taping, injection, orthotics, surgery
Plantar Fasciitis injection
Steroid injection
Risk - potential fascial rupture and fat pad atrophy
Achilles Tendinopathy
Common in primary care
Majority self-limiting in early phases
Debilitating with significant socio-economic impact
> 10% persistence of Sx and fail to respond to Rx
Surgery when persistence of >6month
Mid-portion Achilles Tendinopathy
Aetiology unclear
- training errors
- overuse stresses
- lack of flexibility
Intrinsic factors - tendon vascularity, GS dysfunction, age, sex, weight, height, pes cavus, lateral ankle joint instability
Extrinsic - change in training method, poor technique, previous injury, footwear, surface
Little or no inflammation
Degeneration - loss of collagen structure, scarring, cysts
Neo-vascularisation > neo-nerves; REDUCE NEO-VASCULARISATION REDUCE PAIN
immobilisation ineffective
Tendinopathy spectrum
Reactive - non-inflammatory proliferative response in the cell and matrix
Dysrepair - Matrix breakdown and disorganisation
Degenerative - Progression of both matrix and cell changes, cell death/ apoptosis
Tendinopathy Management
Prevention - sensible training programme Early medical attention Rest from aggravating exercise Modify activity Deep friction massage Gentle static stretch Eccentric strengthening of gastoc-soleus muscle Foot orthoses Control of Sx HVIGI ESWT Regenerative medicine surgery
Achilles tendinopathy treatment options
Sclerosant dry needling GTN ESWT Regenerative medicine - PRP/ Autologous blood, stem cell, tenocyte implantation Electro-coagulation Radiofrequency Corticosteroid HVIGI
10 days post HVIGI
High volume image guided injection - 40ml normal saline + 9ml 0.5% Marcaine + 20mg Depomedrone; injected under USS guidance betwen anterior aspect of tendon and Kager’s fat pad
- 3 days relative rest. Avoid high impact, rushing around and stairs.
- 3 days eccentric loading (Alfredsson or modified).
- 3 days start sports or activity specific functional loading.
- 10th day – start RTS specific rehabilitation programme.
- Full training at 2-3 weeks depending on symptoms.
- Repeat HVIGI only if still painful or AT reoccurs.
Crisp-Padhiar Syndrome
Trauma
Presence of Os naviculare
Tibialis posterior tendinopathy and dysfunction
Acquired flatfoot
Os naviculare synchondrosis
Anomalous tibialis posterior attachment of Os naviculare
Osteoarthritis of the foot
Cartilage deteriorates + Osteophytes + Altered joint mechanics
Pain, stiffness, swelling
Big toes - common cause of forefoot pain
Men
XR - Osteophyte, joint space narrowing, sclerosis, joint irregularities and bone cysts
OA Classification
Radiographic classification
GRADE 0: Dorsiflexion 40-60° , Normal radiography , No pain.
GRADE 1 - Dorsi 30-40, Mild to mod osteophytes formation, good joint preservation
GRADE 2 - Dorsi 10-30, Moderate osteophyte formation, joint space narrowing, subchondral sclerosis
GRADE 3 - Dorsi <10, Marked osteophyte formation, loss of visible joint space, with or without subchondral cyst formation, constant to severe pain at extremeties
GRADE 4: Stiff joint, Severe changes with loose bodies and osteochondritis dissecans
OA Treatment
CONSERVATIVE
NSAIDS. Glucosamine with chondroitin. Vitamins & Minerals.
Foot orthoses. Shoe modification (rocker). Modification of activity.
Physiotherapy.
MUA/Image guided injection – LA + Steroid, Ostenil mini, prolotherapy.
SURGERY
Cheilectomy
Dorsiflexion phalangeal osteotomy (Kessel-Bonney)
Metatarsal Osteotomy (Waterman’s decompression) Arthroplasty (Keller’s)
Arthrodesis - favoured procedures
Hemi-implants
Total joint replacement
Freiberg’s Disease/Infraction
Infraction and fracture of metatarsal head
F>M 4:1
Pts 13-18yo
Common in 2nd and 3rd metatarsals; common with long second metatarsal
Disruption in blood supply due to micro-trauma or osteonecrosis and stress overloading > collapse of the 2nd metatarsal head
Smillie classification (Freiberg’s disease)
Stage 1 - Subchondral fracture visible only on MRI
Stage 2 - Dorsal collapse of articular surface on plain radiographs
Stage 3 - Collapse of dorsal MT head, with plantar articular portion intact
Stage 4 - Collapse of entire MT head, joint space narrowing
Stage 5 - Severe arthritic changes and joint space obliteration
Ainhum
Painful constriction of usually 5th toe
Resulting in autoamputation
Loa loa filariasis
Infection Loa Loa (worm)
Hard soft tissue mass behind achilles tendon; superficial
XR - linear pearl-like calcification
Surgical removal
Adnexal tumour of hallux
Rare
XR - multiple enchondroma
Malignant mixed chondroid syringoma
Morton’s neuroma
benign fibrotic thickening of a plantar interdigital nerve
Irritation of nerve
degenerative process
Compression or entrapment of the nerve.
Stretching of the nerve.
Nerve ischaemia.
Avoid shoes with thin soles, high heels, or a constricting toe box.
Metatarsal pad
+/- NSAIDs
