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Injuries in Sport > Lower Limb > Flashcards

Lower Limb Flashcards

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1
Q

Anterior compartment of lower leg

A

Tbialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius
Deep peroneal nerve
Anterior tibial artery

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2
Q

Lateral compartment of lower leg

A

Peroneus brevis, peroneus longus
Superficial peroneal nerve
Peroneal (perforating) arteries

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3
Q

Deep posterior compartment of lower leg

A

Tibialis posterior, flexor digitorum longus, flexor hallucis longus, popliteus
Tibial nerve
Posterior tibial artery

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4
Q

Superficial posterior compartment of lower leg

A

Gastrocnemius, soleus, plantaris

Cutaneuous nerves only e.g. sural

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5
Q

Night pain

A

Wakes you up at night

ask for systemic symptoms that indicate autoimmune diseases or cancer

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6
Q

Tinnel’s sign

A

Light palpation on nerve reproduces symptoms of pins and needles/ tingling => irritated nerve

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7
Q

Foot dorsiflexion

A

10-15

Tibialis ant, EDL, EHL, peroneals

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8
Q

Foot plantarflexion

A

45-55

Gastroc, soleus, tib posterior, FDL, FHL

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9
Q

Foot inversion

A

30-40

Tibialis posterior

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10
Q

Foot eversion

A

15-25

Peroneals

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11
Q

Foot pronation

A

15-30

Eversion + Abduction + Dorsiflexion

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12
Q

Foot supination

A

45-60

Inversion + Adduction + Plantar flexion

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13
Q

Over pronation (i.e. flat foot) causes

A 
flattening of long arch
movement mid-tarsal joints
rotation of tibia
functional q angle of knee
load on tibialis posterior
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14
Q

Isotope bone scan (IBS)

A 
Radioactive isotome -> inject Technetium-99 polyphosphonate
Triphasic bone scan 
- 0 mins: isotope angiogram
- 2 mins: blood pool
- 2 hr: delayed

Looking for hotspots

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15
Q

Stress fracture

A

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

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16
Q

Medial Tibial Stress Syndrome (Shin splints)

A

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

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17
Q

Chronic Compartment Syndrome

A

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

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18
Q

Tibialis Anterior/ EDL/ EHL Tendinopathy

A

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

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19
Q

Tibialis Posterior/ FDL/ FHL Tendinopathy

A

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

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20
Q

Popliteal artery entrapment syndrome

A

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

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21
Q

Nerve entrapment

A

Superficial peroneal nerve (lateral compartment)
Pain and paraesthesia
Tinnel’s sign

Nerve conduction studies

steroid injection, surgical release

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22
Q

Fascial hernia

A

Anterior compartment defect

Similar Sx to CCS
Detectable swelling on standing/exercising -> disappears on lying

Subcutaneous fasciotomy

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23
Q

Knee - Per Anserinus (aka goose foot)

A

Sartorius, gracilis, semitendinosus

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24
Q

Lateral knee (superficial to deep)

A

ITB
Patella retinaculum
LCL and joint capuse

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25
Q

Medial knee (superficial to deep)

A

Sartorius
Superficial MCL
Deep MCL and joint capsule

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26
Q

Back of the knee

A

PCL
Popliteus
Menisci

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27
Q

Function of popliteus

A

Unlocks tibia relative to the femur in flexion

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28
Q

MCL origin and Inserion

A

Origin - behind medial epicondyle

Insertion - 1cm below joint line

29
Q

Questions to ask about knee pain

A

VAS
Constant or related to activity
Anterior, stair climbing, prolonged sitting => PFP
Twisting/rotating => meniscal

30
Q

Questions to ask about knee instability

A

Pivoting/ twisting => ACL
Linear instability - stairs/ level ground => quads weakness
Side to side instability => PCL

31
Q

Mechanical symptoms of knee

A

Locking/ clicking/ snapping => bucket handle meniscal tear; loose body

32
Q

Other questions - knee

A 
treatment to date
benefits of previous treatment
athletic hx
PMH
Occupational Hx
33
Q

Knee examination

A

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

34
Q

J-sign

A

patella flips out laterally on flexion

35
Q

Zones of meniscal blood supply

A

Red red zone – very vascular – will heal more easily
Red white zone – medium blood supply
White white zone – inner  avascular

36
Q

Double PCL sign

A

Pathognomic of a bucket handle meniscal tear

37
Q

Management of Meniscal tear

A

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

38
Q

Articular Lesions

A

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

39
Q

Articular Lesions: Grades

A

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

40
Q

Articular Lesions Management

A

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

41
Q

Microfracture

A 
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
42
Q

Osteochondral Autograft Transplantation (OATS)

A

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

43
Q

ACI and Osteochondral Allograft transplantation

A

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

44
Q

ACL Tear Treatment

A

Graft harvest from patella

Early ROM exercises!
Closed chain exercises emphasised in early rehab
Delay sports for 6-9 months

45
Q

PCL Tear Treatment

A

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

46
Q

MCL Tear Treatment

A

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

47
Q

LCL Injury

A

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
48
Q

Patellar tendonitis

A 
Jumping athletes
Repetitive, forceful eccentric contraction
80-90% RTS
Physiotherapy = only treatment
Surgery has poor outcome
49
Q

Patellar instability

A

Caused by increased Q angle, i.e. valgus
Young females
Repaired by moving tibial tuberosity through osteotomy or MPFL reconstruction

50
Q

Sinus Tarsi Syndrome

A

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

51
Q

Cuboid Syndrome

A

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

52
Q

Plantar Fasciitis injection

A

Steroid injection

Risk - potential fascial rupture and fat pad atrophy

53
Q

Achilles Tendinopathy

A

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

54
Q

Mid-portion Achilles Tendinopathy

A

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

55
Q

Tendinopathy spectrum

A

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

56
Q

Tendinopathy Management

A 
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
57
Q

Achilles tendinopathy treatment options

A 
Sclerosant
dry needling
GTN
ESWT
Regenerative medicine - PRP/ Autologous blood, stem cell, tenocyte implantation
Electro-coagulation
Radiofrequency
Corticosteroid
HVIGI
58
Q

10 days post HVIGI

A

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.
59
Q

Crisp-Padhiar Syndrome

A

Trauma
Presence of Os naviculare
Tibialis posterior tendinopathy and dysfunction
Acquired flatfoot
Os naviculare synchondrosis
Anomalous tibialis posterior attachment of Os naviculare

60
Q

Osteoarthritis of the foot

A

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

61
Q

OA Classification

A

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

62
Q

OA Treatment

A

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

63
Q

Freiberg’s Disease/Infraction

A

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

64
Q

Smillie classification (Freiberg’s disease)

A

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

65
Q

Ainhum

A

Painful constriction of usually 5th toe

Resulting in autoamputation

66
Q

Loa loa filariasis

A

Infection Loa Loa (worm)
Hard soft tissue mass behind achilles tendon; superficial

XR - linear pearl-like calcification

Surgical removal

67
Q

Adnexal tumour of hallux

A

Rare

XR - multiple enchondroma
Malignant mixed chondroid syringoma

68
Q

Morton’s neuroma

A

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

Injuries in Sport (13 decks)

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