Lower limb pathologies 2

Question 1

meniscus

Answer 1

medial and lateral, situated between femoral condyle and tibial plateau, meniscofemoral lig- humphrey and wrisberg lig, medial meniscus is more commonly injured due to less mobile- MCL and joint capsule

Question 2

meniscus vascularization

Answer 2

fully vascularized at birth, the blood vessels in the meniscus recede during maturity. in adulthood the red red region contains the overwhelming majority of blood vessels. outer region- vascularized, red-white region- displays both properties of red and white, white white region- none vascularized

Question 3

meniscus pathology- tears

Answer 3

meniscus lesions most common intra-articular knee injury, medial injured more frequently 5:1 ratio, 815 meniscal tears occur posteriorly, often associated with ACL tears- 60%, can get degenerative meniscal tear

Question 4

meniscus pathology- mechanisms of injury

Answer 4

usually involves components of flexion and rotational forces under compression, e.g. twisting, squatting or cutting manoeuvres, on assessment- joint line tenderness or effusion, 95% cases picked up on MRI

Question 5

meniscal injury classification- vertical longitudinal tear

Answer 5

between fibres on outside of meniscus, the biomechanics of knee is not always disrupted and may be asymptomatic

Question 6

meniscal injury classification- vertical radial tears

Answer 6

AKA tear- tear cause unstable mechanics and leads to locking, disrupts fibres on outside, this effects meniscus able to absorb, effects white-white region- not able to recover- may need surgery. to remove meniscus- leads to onset of degeneration

Question 7

meniscal injury classification- horizontal tears

Answer 7

split meniscus into upper and lower part, can exit without clinical symptoms, usually mechanically stable, may rise to flap tear

Question 8

meniscal injury classification-oblique

Answer 8

give rise to flaps that are mechanically unstable, associated with mechanical symptoms requires surgery to prevent flap getting caught during knee flexion

Question 9

meniscal injury classification-complex/ degenerative

Answer 9

associated with 2 or more types of tears, most common in elderly and associated with OA in knee

Question 10

meniscal injury- treatment

Answer 10

historically- treated with surgery with part of the menisci being removed- discovered that this results in degenerative OA
currently- try treat conservatively, surgery is trying to repair meniscus instead of removing it

Question 11

cruciate ligament injuries

Answer 11

ACL>PCL- due to fact ACL is more at risk of injury, due to fact PCL has thinner fibre bundles and smaller attachment, ACL most commonly injured 15-25 playing sport, women>men

Question 12

what are ACL and PCL injuries associated with

Answer 12

ACL- meniscal tears, articular cartilage damage, MCL injury, bone bruising, PCL- associated with posterolateral corner injuries

Question 13

ACL injuries

Answer 13

intra-articular, extra synovial structure, good vascularity, anteromedial- restrains anterior tibial translation greater than 45° knee flexion and posterolateral- restrains tibia in full extensions- 2 bands, partial tears progress to complete tears with a higher rate of meniscus and cartilage injuries

Question 14

what happens when ACL is ruptured

Answer 14

bleed from ligaments- hemarthrosis leads to severe swelling a few hours after onset

Question 15

PCL- mechanisms of injury

Answer 15

posterior force to proximal tibia, if combined with a rotation force injury- P-L complex, may occur due to a heavy impact- car crash

Question 16

PCL-signs and symptoms

Answer 16

mild to moderate injuries, positive posterior draw test, often asymptomatic or may have vague symptoms of pain in posterior knee, pain on kneeling

Question 17

medial stablising structures

Answer 17

static- superficial and deep MCL, posterior oblique lig,
dynamic- semimembranosus, quads, pes anserine
majority of athletes with MCL injuries will achieve pre-injury activity level with non-operative treatment

Question 18

why is damage to lateral knee rare

Answer 18

as they are more mobile- not connected to LCL or capsule, injuries are connected with combined cruciate tears, and damage to medial stabilizers of knee

Question 19

lateral stabilizing structures

Answer 19

anterolateral- capsule and iliotibial tract, posterolateral- biceps femoris, popliteus tendon, lateral head of gastroc

Question 20

damage to patellar tendon

Answer 20

patella tendon rupture- patella moves up- inability to extend the knee

Question 21

what are apophysitis

Answer 21

this is a normal developmental outgrowth of a bone, which fuses lateral in adult development, they are found where major tendons and ligaments attach a bone, the tibial tubercle apophysis for example, insertion patella tendon
patient between 12-16 athletes

Question 22

when does apophysitis become a problem

Answer 22

during adolescent bony growth exceeds the ability of the muscle tendon unit to stretch efficiently- decrease flexibility and increased tendon across apophysis, during adult bone is ossified- no problem, excessive and repetitive traction in adolescence can result in micro trauma and chronic irritation leads to thickening and pain at apophysis

Question 23

osgood disease and sinding-larson-johanson syndrome, severs disease

Answer 23

osgood disease- tibial tubercle (kicking action), sinding- larson- johansons syndrome- superior poll of patella- quads tendon
sever’s disease- achilles tendon (runners and jumpers)

Question 24

patella femoral joint pain/ anterior knee pain

Answer 24

indicates no individual structure can be isolated for pain, could be caused by tightness of muscles in front or behind knee- altered biomechanics at PF joint, altered alignment, could be due to high or low riding patella

Question 25

patella femoral joint pain/ anterior knee pain- causes and symptoms

Answer 25

adolescent people generally, can be older, triggered by overuse
symptoms- aching in front of knee, aggravated by deep flexion- going up stairs rest relieves symptoms

Question 26

ankle lateral ligament

Answer 26

usually after a traumatic event/ acute presentation
pain and tenderness, swelling/bruising, muscle spasm, inability to bear weight-may indicate fracture present
ATFL- most commonly injured, more severe CFL, or may effect all

Question 27

ankle lateral ligament- Ottawa ankle rules

Answer 27

look for pain on distal end of fibula and posterior edge, and 2-3 inches above medial malleolus, pain on weight bearing, indicates need for X-ray of ankle, pain on navicular of 5th MT and inability to weight bear- check for fracture- X-ray

Question 28

ankle lateral ligament- how to diagnose and treatment

Answer 28

diagnose- anterior draw test- lateral lig, instability, talar tilt- CFL,
treatment- reduce swelling, proprioception exercises, strengthening of evertors, reduce likelihood of recurrence

Question 29

plantar fasciitis

Answer 29

common sports injury or sedentary population, pain affecting the heel, worse in the morning and after weight bearing all day, pain usually centred around medial calcaneal tubercle but affect central heel and into achilles

Question 30

plantar fasciitis- diagnosis and rusk factors

Answer 30

often misdiagnosed as sinus tarsi injury
test- palpation with twisting motion to MCT will cause and pain
risk factors- obese, flat foot or high arch, reduce DF

Question 31

Joint fractures- 5th MT

Answer 31

fracture at base of 5th MT, patient and clinician often don’t release fracture has occurred- may damage ligs, affects base of 5th MT maybe peroneal swelling often misdiagnosed as insertional tendinosis, can indicate Vit D deficiency

Question 32

joint fractures- treatment

Answer 32

usually repairs with immobilisation but sometimes requires surgical fix if union does not occur, recovery 4-16 weeks depending on intervention
surgery needed for meta-diaphyseal fracture but not for metaphyseal fracture

Question 33

posterior tibial tendon dysfunction/ rupture- presentation and risk factors

Answer 33

presentation- occurs in obese, middle aged females with up to 10% cases, pain on posterior medial malleolus extending to navicular lowered media larch- flat foot
risk factors- diabetes, hypertension, obesity, previous surgery, foot/ankle trauma, and steroid use is found in up to 60% cases

Question 34

posterior tibial tendon dysfunction/ rupture- test and treatment

Answer 34

test- tiptoe single phase support- normal- as they step up heel turn inwards as they go onto tiptoes- high foot varus, if rupture for dysfunctional- heel bone wont turn inwards
treatment- rest- orthotics- rehab- surgery not common- treatment outcome can be poor if not treated correctly