Musculoskeletal Conditions Flashcards

1
Q

Achilles tendinopathy (management)

A

Management:
● Supportive footwear and rest.
● Referral to physiotherapist or exercise physiologist for stretching and strengthening exercises (if symptoms
have not settled with 1-2 weeks of rest)

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2
Q

AC joint injury - dislocation/subluxation (mechanism, examination, grades, treatment)

A

Mechanism: Direct trauma to the superior or lateral aspect of the shoulder with the arm adducted.
Examination:
● Passive cross-body adduction (pain = positive)
● AC Paxinos shear test (one handed)
● AC shear test
○ Force applied posterior acromion and mid-clavicle
Grades: I partial, II complete tear, III complete tear with the coracoclavicular affected.
Treatment: Analgesia, St John’s high sling, mobilisation exercise when able.
● For Grade III compression, bandage with padding at pressure points.

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3
Q

AC joint injury - osteoarthritis (RF, presentation, examination, diagnostic test, management)

A

Risk factors: builders, sportspeople
Presentation: night pain
Examination: full ROM but pain on full elevation
Diagnostic test: Bell-van Riet.
Management: rest, support, analgesia; +/- intra-articular injections for resistant or severe cases.

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4
Q

44M, mathematics teacher, presents with an acutely painful right shoulder 3 hours after falling off his son’s
skateboard directly onto his shoulder. Unable to abduct and is in a significant amount of pain. No step-wise deformity.
Nil previous injuries.
(3 immediate management steps, timeframe for basketball, examination findings for clearance)

A

List 3 immediate management steps that you initiate today.
● Apply a broad-arm sling
● Analgesia - paracetamol 1g PO QID PRN
● Apply ice to the shoulder
Mark is keen to return to basketball. Within what timeframe can he safely return?
● 2-6 weeks
List 3 physical examination findings you would look for to confirm that Mark is ready to return to basketball.
● No pain to palpate at the acromio-clavicular joint
● No pain on abduction of the shoulder
● Full range of motion through the shoulder joint
● Ability to bear weight through the shoulder joint on outstretched hand without pain

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5
Q

ACL rupture (significance, mechanism, clinical features, management)

A

Significance: serious and disabling injury that may result in chronic instability.
Mechanism: sudden change in direction, marked valgus force (direct).
Clinical features: history of pain and ‘giving way’ of the knee.
Management: conservative management (physiotherapy), surgical (if conservative fails or due to occupation).

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6
Q

Acute blue finger syndrome/blue toe syndrome (presentation, prognosis, cause)

A

Presentation: sudden onset of pain and cyanosis.
Prognosis: lasts 2-3 days, can recur one or more times per year.
Cause: unknown (? emboli).

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7
Q

Adhesive capsulitis (prognosis, causes, phases, examination, diagnosis, management)

A

Prognosis: self-limiting that can last 2-3 years.
Causes: idiopathic, diabetes, trauma.
Phases:
● Initial: painful, lasting 2-9 months
● Intermediate: stiff, lasting 4-12 months
● Recovery: pain improving, lastis 5-24 months
Examination: severe global passive movement loss in all planes
Diagnosis: clinical.
Management: symptomatic.
● Initial: paracetamol 1g PO 4-6 hourly +/- ibuprofen 400mg PO TDS PRN +/- prednisolone 30mg PO daily for
three weeks then wean.
○ AVOID USE OF NSAID AND PREDNISOLONE CONCURRENTLY
● Intermediate and recovery: arthrographic distension (hydrodilation) may provide sustained relief and improve
function.
● Refer refractory for surgical evaluation.

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8
Q
Anterior ankle (anterior tibialis) tendinopathy
(epidemiology, cause, presentation, examination, management)
A

Epidemiology: > 45 years, cyclists, runners (uphill), soccer players, hikers.
Cause: chronic overuse (dorsiflexion).
Presentation: insidious pain, swelling along the course of the tendon, difficulty walking.
Examination: pain on resisted ankle dorsiflexion, weakness compared to the other side.
Management: rest, structural support, physical therapy (inc eccentric strength exercises).

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9
Q

Baker’s cyst (pathophysiology, RF, Ix, presentation)

A

Pathophysiology: herniation of a chronic knee effusion between the heads of the gastrocnemius muscles.
Risk factors: OA, RA, internal derangement of the knee.
Investigation: indicated as there is likely intra-articular pathology.
Presentation: pain and swelling in the calf (similar to DVT).

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10
Q

Biceps tendon rupture (epidemiology, cause, presentation, examination, treatment)

A

Epidemiology: elderly
Cause: spontaneous, or after lifting or falling on outstretched hand
Presentation: preceding tearing or snapping sensation, pain and difficulty moving shoulder
Examination: bruised upper arm, rolled up lump on flexion of elbow.
Treatment: conservative in elderly, surgical considered in younger population.

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11
Q

Calcaneal apophysitis (epidemiology, location, treatment)

A

AKA: Sever disorder
Epidemiology: boy, 7-15 years.
Pain: heel at insertion of tendon achilles.
Treatment: shoes with slightly raised heels, calf stretching exercises. Restriction of strenuous sporting activity for 12
weeks then review.

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12
Q

Calcific tendinopathy (presentation, Ix, DDx, Mx)

A

Presentation:
● Pain similar to that experienced by patients with rotator cuff tendinopathy or shoulder impingement
● Gradual pain, top or lateral aspect of the shoulder
● Increased pain at night, inability to lay on affected shoulder
Investigation: Plain XR and ultrasound.
Differentials: rotator cuff tear, cervical radiculopathy, acromioclavicular OA, biceps tendinopathy, glenohumeral OA,
frozen shoulder.
Management:
● Conservative management with NSAIDs, corticosteroid injection (methylprednisolone 20 to 40mg) and
physical therapy.

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13
Q

Carpal tunnel syndrome (causes, management)

A

Causes: idiopathic, acromegaly, diabetes, hypothyroidism, multiple myeloma, occupational, Paget disease,
pregnancy (2nd-3rd trimester), premenstrual oedema, rheumatoid arthritis, tophi gout.
Management: ** diuretics have no role
● Treatment of underlying condition
● NSAID (do no use in pregnancy)
● Corticosteroid injection
● Splinting and elevation at night
● Surgical referral if progressive with motor deficits

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14
Q

Charcot neuropathy (risk factor, cause, pathophysiology, differentials, examination, treatment)

A

Risk factor: diabetes.
Cause: multifactorial (neuropathy, vasculopathy, metabolic abnormality of bone).
Pathophysiology: small muscle wasting, decreased sensation, maldistribution of weight bearing.
Differentials: septic arthritis, cellulitis, gout, osteoarthritis, idiopathic inflammatory diseases, osteomyelitis, and
complex regional pain syndrome.
Examination:
● Active phase - redness with intense oedema.
● Chronic (most common) - slow progressing with insidious swelling over months or years.
Treatment: individualised with MDT approach.
1. Offloading of foot until resolution of swelling
2. Podiatry and orthotics

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15
Q

Chilblains (erythema pernio)

precautions, treatment

A

Precautions: rule out Raynaud, protect from trauma, do not rub or massage area, do not apply heat or ice.
Treatment:
● Physical - elevate affected part, warm gradually
● Drug - betamethasone 0.05% BD
● Other - nifedipine SR 30 mg PO daily.

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16
Q

Chronic compartment syndrome

cause, RF, alleviation, aggravation, management

A

Cause: repetitive loading or exertional activities.
Risk factors: competitive athletes (long-distance runners, basketball, skiers, soccer).
Alleviation: rest.
Aggravated: exertional activity resumed.
Management: conservative for 2-3 months (NSAIDs, reducing activities, stretching), fasciotomy.

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17
Q

De Quervain tendonitis (mechanism, examination, diagnostic signs)

A

Mechanism: work-induced of the first dorsal extensor compartment.
Examination: pain at and proximal to wrist on radial border, pain during pinch grasp, pain on movement of thumb and
wrist.
Triad of diagnostic signs:
● Tenderness to palpate over and just proximal to radial styloid
● Firm tender localised swelling in the area of the radial styloid
● Positive Finkelstein sign (hand in fist, movement of wrist in ulnar direction)

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18
Q

Dupuytren’s contracture (pathophysiology, presentation, RF, Mx)

A

Pathophysiology: fibrous hyperplasia of palmar fascia.
Presentation: discomfort and dysfunction.
Risk factors: smoking, ETOH, liver cirrhosis, COPD, diabetes, heavy manual labour.
Management: corticosteroid injection (if rapidly growing), surgery (for severe deformity).

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19
Q

Erythromelalgia (trigger, presentation, cause, management)

A

Trigger: heat and exercise.
Presentation: redness, burning sensation and swelling of the hands
Cause: primary or secondary (diabetes, haematological disorders, connective tissue disease)
Management: aspirin.

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20
Q

Femoroacetabular impingement (key point, mechanism, types, treatment)

A

Key point: radiological findings have poor correlation to symptoms.
Mechanism: abnormal contact between the proximal femur and the acetabulum.
Types:
● Pincer - over covered acetabulum
● Cam - aspherical femoral head
Treatment: no proven effective treatment

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21
Q

Flexor hallucis longus tendonitis (epidemiology, examination, diagnosis, management)

A

Epidemiology: ballet dancers, jumping.
Examination: Pain on resisting great toe flexion when the foot is held in plantar flexion. If ruptured = unable to flex the
big toe.
Diagnosis: clinical.
Management: conservative; complete tear = surgical.

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22
Q

Glenoid labrum tear (key points, SLAP)

A

Key points
● Glenoid labrum is a ring of fibrous tissue attached to the rim of the glenoid.
● Injuries are divided into SLAP (superior labrum anterior to posterior) or non-SLAP + stable or unstable.

SLAP
● Risk factors: overhead throwing athletes and laborers with overhead throwing activities.
● Cause: forceful eccentric traction exerted on the biceps tendon, chronic stress placed on labrum when the
shoulder is forcefully abducted and externally rotated.
● History: anterior shoulder pain, clicking of the shoulder.
● Examination: O’Brien, Crank and Speed test.
● Investigation: MRI most specific.

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23
Q

Greater trochanteric pain syndrome (cause, ddx, mx)

A

Cause: gluteus medius and/or minimus tendons +/- bursal pathology.
Differential: referred pain along L2 and L3 dermatomes.
Management:
● Initial - exercises to improve tensile strength and analgesia
● Severe - local corticosteroid injection at point of maximal tenderness

24
Q

Hamstring injuries - risk factors

A

Risk factors:
● Inadequate warming up poor stretching
● Muscle weakness or imbalance in the muscle strength within the hamstring muscles
● Muscle weakness or imbalance between hamstrings and quadriceps
● Poor footwear

25
Q

Iliotibial band syndrome (presentation, mechanism, aggravating factors)

A

Clinical presentation: lateral aspect of knee (typical), hip pain over greater trochanter (some).
Mechanism: repeated knee flexion to or through a 30 degree angle.
Aggravating factors: physical activity (most intense at heel-strike).

26
Q

Infrapatellar bursitis

A

AKA Clergyman’s knee

Same as prepatellar bursitis

27
Q

Lateral epicondylitis (signs, diagnosis, prognosis, management)

A

Signs:
● Localised tenderness over lateral epicondyle (anteriorly)
● Pain of passive stretching wrist
● Pain on resisted extension write and third finger
● Normal elbow movement
Diagnosis: clinical.
Prognosis: self-resolving within a year for most.
Management:
● NSAID
● Local corticosteroid injection (intermediate relief 6-12 weeks)
● Exercise (progressive loading, stretching and strengthening)

28
Q

Lumbar disc herniation (prognosis, assessment, symptoms and signs per nerve route, investigation, management)

A
Prognosis:
● 80% recover within 2 weeks
● 95% recover within a year
Assessment:
● Positive straight leg raise has high sensitivity for nerve root involvement
Nerve root involvement:
L3-4 
- Reduced knee extension
- Reduced anterior and lateral thigh sensation 
- Reduced or absent knee jerk 
L5
- Reduced dorsiflexion
- Reduced dorsum foot sensation 
- Reduced or absent ankle reflex
S1
- Reduced plantar flexion of ankle 
- Reduced lateral aspect of foot sensation 
- Reduced or absent ankle jerk 

Investigation: not indicated unless there are severe or progressive neurological deficits.

Management: conservative, corticosteroid injection, surgical (severe or progressive neurological deficits).

29
Q

Medial collateral ligament rupture (mechanism, features, examination, management)

A

Mechanism: external tibial rotation, direct valgus force to knee (direct).
Clinical features: aggravated by twisting or valgus stress.
Examination: focal tenderness at the distal iliotibial band.
Management: conservative with early limited motion brace if isolated injury. Followed by knee rehabilitation.

30
Q

Meniscal tears (key points, cause, clinical features)

A
Key points:
● Medial more likely than lateral
● Twisting knee injury is a common cause
Cause: injury or degenerative
Clinical features: joint line pain, locking, swelling, loss of movement, pain worse with activity
31
Q

Meralgia paresthesia (cause, RF, presentation, treatment)

A

Cause: entrapment of lateral femoral cutaneous nerve of the thigh under the lateral end of the inguinal ligament.
Risk factor: obesity, pregnancy, ascites, local trama.
Presentation: burning pain with associated numbness and tingling to lateral thigh (does not cross midline).
Treatment: treat cause, corticosteroid injection, surgical release (if refractory).

32
Q

Monoarthritis (major cause, examination, investigation)

A
Major causes:
● Osteoarthritis
● Lyme disease
● Infection
● Trauma
● Systemic rheumatic disease
Examination: ? effusion
Investigation: if cause of effusion is uncertain then joint aspiration is strongly recommended
33
Q

Morton neuroma (pathophysiology, cause, diagnosis, features, history, examination, investigation, treatment)

A

Pathophysiology: fibrous enlargement of an interdigital nerve.
Cause: overuse and inappropriate footwear.
Diagnosis: clinical.
Clinical features: <50 years, women, third and fourth metatarsal heads (common), severe burning pain.
History: worse on weight-bearing, aggravated wearing tight shoes, relieved by taking off shoes and squeezing
forefoot.
Examination: clicking sensation (Mulder’s sign), possible tenderness.
Investigation: ultrasound, MRI (can look like a neuroma).
Treatment: loose shoes, sponge rubber metatarsal pad, surgical excision, corticosteroid injection.

34
Q

Olecranon bursitis (mechanisms, management)

A

Mechanisms: prolonged pressure, overuse or strenuous activity, crystal induced arthropathy, inflammatory arthritis.
Management:
● Initial - needle aspiration of fluid, ibuprofen 400mg TDS PRN, firm compressing arthrosis.
● Chronic - surgical removal.

35
Q

Osgood-schlatter (pathophysiology, prognosis, diagnosis, investigation, management)

A

Pathophysiology: tibial tuberosity avulsion.

Prognosis: benign and self-limiting.

Diagnosis: clinical.

Investigation: XR not required unless atypical presentation.
Management: Aim to relieve discomfort.
● Ice after sporting activities
● NSAIDs PRN
● Continue sports participation if tolerated
● Quadriceps strengthening
● Modify activities that cause pain

Patient case: adolescent, pain worse when playing netball or climbing stairs, tender over tibial tubercle.

36
Q

Osteitis pubis (definition, RF, presentation, diagnosis, examination, radiological findings)

A

Definition: idiopathic, inflammatory disease involving the pubic symphysis and surrounding structures.
Risk factors: athletes, rheumatological conditions, pregnancy, pelvic trauma/surgery.
Presentation: insidious onset of pelvic pain with nil systemic symptoms.
Diagnosis: clinical.
Examination: tenderness over the pubic symphysis or pain with resisted adductor testing.
Radiological findings: subchondral erosive change, joint irregularity and sclerosis of the pubic symphysis.

37
Q

Patellar tendinopathy (cause, clinical features, examination, management)

A

AKA Jumper’s knee
Cause: repetitive jumping
Clinical features: pain localised to below the knee
Examination: localised tenderness at the inferior pole of the patella with the patella tilted +/- localised swelling
Management: conservative treatment
● Referral to physiotherapist for exercise-based rehabilitation
● Modified footwear and a patella tendon strap
● Chronic cases may require surgery

38
Q

Patellofemoral syndrome (cause, RF, epidemiology, history, examination, management, gold standard)

A

AKA: chondromalacia patellae.
Cause: overuse of the knee.
Risk factors: female, obesity, weak quadriceps, certain activities (running, jogging, cycling).
Epidemiology: female 13-15 with faulty knee mechanism, people 50-70 with OA of patellofemoral joint.
History: no specific history of trauma.
Clinical features: pain walking down slopes or stairs.
Examination: crepitation during flexion, pain on compression of patella onto the femur (Perkin’s test).
Gold standard: MRI (but not necessary in most cases).
Management: conservative with graduated lower limb exercise.

39
Q

Peroneal nerve entrapment (symptoms, examination, treatment)

A

Symptoms: pain in lateral shin area and dorsum of the foot.
Examination: sensory disturbance (dorsum of foot), weakness of eversion and dorsiflexion (foot drop).
Treatment: shoe wedging or other orthotics to maintain eversion, neurolysis (most effective treatment).

40
Q

Pes anserinus pain syndrome (presentation, location, RF, imaging, ddx, treatment)

A

AKA anserine bursitis.
Presentation: localised swelling, with or without fluctuation, and little pain. ** If acute, pain, swelling and redness may
be present.
Location: medial over upper medial tibia.
Risk factors: knee OA, obesity, female, knee misalignment and diabetes.
Imaging: not required but generally used to rule out underlying OA.
DDx: bursal gout and/or septic arthritis.
Treatment: weight-reduction program, quadriceps strengthening exercises, and use of an analgesic and/or short-term
NSAIDs. If resistant, consider corticosteroid injection.

41
Q

Piezogenic papules (key feature, pathophysiology, management)

A

Key feature: multiple soft, round, compressible, smooth, skin-coloured papules (0.2 to 1.2 cm).

Pathophysiology: herniations of fat.

Management: weight reduction, felt padding and cushion/crepe soled shoes

42
Q

Plantar fasciitis (buzzwords, history, diagnosis, managemet)

A

Key words: pain on the plantar aspect of the heel on the medial side (~5cm from the posterior end of the heel),
radiates to the sole.
History: pain under the heel, first steps out of bed, relieved by walking, increasing towards the end of the day, worse
after sitting.
Diagnosis: clinical. ** Heel spurs are common incidental findings on XR
Management:
1. Avoid walking in flat shoes or barefoot
2. Stretching and strengthening of calf muscles and fascia
3. Use of heel cup or cushion
4. Ice massage after aggravating activity that cannot be avoided or modified

43
Q

Polymyositis and dermatomyositis (buzzwords, features, diagnosis, treatment)

A

Buzzwords: weakness + joint and muscle pain + violaceous facial rash (dermatomyositis)
Main feature: symmetrical muscle weakness and wasting involving proximal muscles.
Diagnosis: serum CK, biopsies, electromyography.
Treatment: corticosteroids and cytotoxic drugs. Early referral.

44
Q

Prepatellar bursitis (presentation, cause, ddx, management)

A

AKA: housemaid/coal miner/carpet layer knee
Presentation: painful, tender swelling over the patella
Cause: repetitive low-grade trauma (e.g. frequent kneeling).
DDx: gout, septic arthritis.
Management:
● Mild = RICE (avoid traumatic compression), NSAIDs
● Severe or refractory = aspiration MCS, consider hospital referral (? septic arthritis), consider corticosteroid
injection (inflammatory), drain fluid if persistent

45
Q

Principles of NSAIDs in MSK

A

● Consider fish oil, paracetamol and topical NSAIDs to reduce the need for oral NSAIDs
● Assess benefit-risk profile for each patient
○ Avoid in active peptic ulcer disease or GI bleeding
○ Avoid in eGFR <30 or long-term use in eGFR 30-60
○ Avoid in cirrhosis, established or high risk CVD, planning pregnancy (can lower fertility)
● Minimum effect dose for shortest time possible
● Do not use more than one NSAID at a time (apart from low dose aspirin)
● Do not use concurrently with corticosteroids
● Consider co-prescribing PPI and testing for H.pylori
● Do not continue if there is no benefit or treatment is harmful

46
Q

Pulled elbow

A

AKA: radial head subluxation

Examination:
● Not using affected limb
● Elbow in extension and the forearm in pronation
● Distressed only on elbow movement
● No swelling, deformity or bruising of the elbow or wrist
● On palpation tenderness is usually absent
● Marked resistance and pain with supination of the forearm

Diagnosis: Clinical

Investigation: If a differential is suspected

Treatment:

  1. Apply pressure over the radial head
  2. Fully pronate forearm and then flex the elbow
47
Q

Rotator cuff tears

A

If two of the three tests are positive in a patient over 60 then there is 98% chance of rotator cuff tear
● Supraspinatus weakness
● Weakness in external rotation
● Impingement (in external or internal rotation or both)

48
Q

Rotator cuff tendinopathy (diagnostic pointers, causes, diagnosis, examination)

A

Diagnostic pointers: impingement signs, weakness external rotation, weakness supraspinatus.
Causes: inflammation (tendonitis), tear in tendon (degeneration), calcification, amyloidosis or impingement under the
acromion.
Diagnosis: clinical.
Examination:
● “Empty can” - gold standard for supraspinatus function.

49
Q

Shoulder impingement syndrome (key points, presentation, useful tests)

A

Key points
● Refers to a spectrum of clinical findings
● Important to distinguish from a rotator cuff tear (weakness, older patients, positive drop arm sign with
weakness on external rotation) and adhesive capsulitis (restricted active and passive glenohumeral motion)
Presentation: Pain with overhead activity.
Useful tests: Neer and Hawkins Kennedy impingement tests.

50
Q

Spinal canal stenosis (cause, presentation, alleviating factors, investigations, management)

A

** rule out cauda equina (bilateral lower limb weakness, reduced sensation in saddle area, urinary retention,
bowel incontinence)
Common cause: degenerative changes at the facet joint and intervertebral discs causing spondylolisthesis.
Presentation: older, back pain with radiculopathy +/- neurogenic claudication.
Alleviating factor: flexion by sitting or leaning on shopping carts.
Investigations: MRI (best)
Management:
● Conservative (physical therapy and exercise)
● Corticosteroid injection (nil evidence of benefit)
● Surgical (for severe and progressive neurological deficits)

51
Q

Spondylolisthesis (definition, aggravating factors, examination, diagnosis, management)

A

Definition: slippage of vertebral body over another.
Aggravating factors: standing, walking and exercise.
Examination findings: increased lumbar lordosis, tender prominent spinous process of ‘slipped’ vertebrae, limited
flexion, hamstring tightness or spasm.
Diagnosis: clinic but lateral XR (standing) can confirm.
Management: strict flexion exercise for 3 months, avoidance of hyperextension of spine.

52
Q

Tarsal tunnel syndrome (pathophysiology, triggers, signs and symptoms, examination, treatment)

A

Pathophysiology: entrapment of the posterior tibial nerve in the tarsal tunnel beneath flexor retinaculum on medial
side of ankle.
Triggers: dislocation, fracture, tenosynovitis.
Signs and symptoms: burning or tingling of toes and sole of foot, retrograde radiation to calf.
Examination: Tinel test, tourniquet above ankle
Treatment: orthotics, corticosteroid injection, decompression surgery (if others fail)

53
Q

Tibialis posterior tendonitis (epidemiology, features, management)

A

Epidemiology: middle-aged females, ballet dancers.
Clinical features:
● Weakness medial ankle and foot
● Pain on standing on toes, resisted active inversion and stretching into eversion
Examination: ‘too many toes sign’, incomplete inversion, difficulty performing heel raise, pes planus (over time)
Management: Conservative, takes 12-24 months to resolve.
● Orthotic correction (semi-rigid to support arch)
● Exercises under physiotherapist guidance
● Remedial massage

54
Q

45M, recent 10km hike, pain in the medial side of ankle with weakness or first 3 toes. O/E tender of the posteromedial aspect of medial malleolus. Pain worse on resisted active inversion and standing on toes.

What is the likely diagnosis?

A

Tibialis posterior tendonitis

55
Q

Torn ‘monkey muscle’ (pathophysiology, features, management)

A

Pathophysiology: rupture of medial head of gastrocnemius at the musculotendinous junction.
Epidemiology: tennis and squash players who play infrequently or are unfit.

Clinical features: unable to put heel to ground.

Management:

  1. RICE for 48 hours
  2. Ice pack immediately for 20 mins then every 2 hours when awake
  3. Firm elastic bandage from toes to below knee
  4. Raised heel on shoes
  5. Mobilisation after 48 hours rest
  6. Physiotherapy for gentle stretching massage then restricted exercise