Lower limb pathologies 2 Flashcards
meniscus
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
meniscus vascularization
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
meniscus pathology- tears
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
meniscus pathology- mechanisms of injury
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
meniscal injury classification- vertical longitudinal tear
between fibres on outside of meniscus, the biomechanics of knee is not always disrupted and may be asymptomatic
meniscal injury classification- vertical radial tears
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
meniscal injury classification- horizontal tears
split meniscus into upper and lower part, can exit without clinical symptoms, usually mechanically stable, may rise to flap tear
meniscal injury classification-oblique
give rise to flaps that are mechanically unstable, associated with mechanical symptoms requires surgery to prevent flap getting caught during knee flexion
meniscal injury classification-complex/ degenerative
associated with 2 or more types of tears, most common in elderly and associated with OA in knee
meniscal injury- treatment
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
cruciate ligament injuries
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
what are ACL and PCL injuries associated with
ACL- meniscal tears, articular cartilage damage, MCL injury, bone bruising, PCL- associated with posterolateral corner injuries
ACL injuries
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
what happens when ACL is ruptured
bleed from ligaments- hemarthrosis leads to severe swelling a few hours after onset
PCL- mechanisms of injury
posterior force to proximal tibia, if combined with a rotation force injury- P-L complex, may occur due to a heavy impact- car crash
PCL-signs and symptoms
mild to moderate injuries, positive posterior draw test, often asymptomatic or may have vague symptoms of pain in posterior knee, pain on kneeling
medial stablising structures
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
why is damage to lateral knee rare
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
lateral stabilizing structures
anterolateral- capsule and iliotibial tract, posterolateral- biceps femoris, popliteus tendon, lateral head of gastroc
damage to patellar tendon
patella tendon rupture- patella moves up- inability to extend the knee
what are apophysitis
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
when does apophysitis become a problem
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
osgood disease and sinding-larson-johanson syndrome, severs disease
osgood disease- tibial tubercle (kicking action), sinding- larson- johansons syndrome- superior poll of patella- quads tendon
sever’s disease- achilles tendon (runners and jumpers)
patella femoral joint pain/ anterior knee pain
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
patella femoral joint pain/ anterior knee pain- causes and symptoms
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
ankle lateral ligament
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
ankle lateral ligament- Ottawa ankle rules
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
ankle lateral ligament- how to diagnose and treatment
diagnose- anterior draw test- lateral lig, instability, talar tilt- CFL,
treatment- reduce swelling, proprioception exercises, strengthening of evertors, reduce likelihood of recurrence
plantar fasciitis
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
plantar fasciitis- diagnosis and rusk factors
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
Joint fractures- 5th MT
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
joint fractures- treatment
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
posterior tibial tendon dysfunction/ rupture- presentation and risk factors
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
posterior tibial tendon dysfunction/ rupture- test and treatment
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
