Orthopedic Pathology 300 (Lower Extremity Pathologies) Flashcards
Hip Dislocation
Normal adult hip one of the most stable joints in body
Ball and socket joint
Stability depends on shape of articulating surfaces
Severe violence required to dislocate a hip
TYPES of hip dislocation
Posterior dislocation
Anterior dislocation
Central dislocation
Posterior dislocation (hip)
most common,
can be associated with fracture,
present shortened and internally rotated
MOI
E.g.
leg flexed – posterior force hits knee and drives femur backward out of AF socket
I.e.
sitting in a car (without seatbelt?)
Anterior dislocation (hip)
least common,
can be associated with fracture,
will present externally rotated
note posterior/anterior dislocation vs glide/slide
posterior glide
= flexion, IR
anterior glide
= extension, ER
Central dislocation (hip)
due to severe blow to lateral hip;
ALWAYS associated with FRACTURE
treatment hip dislocaiton
Emergency
Surgery
Casting
hip dislocation complications
Avascular necrosis
Severe post-traumatic DJD
recall which other bone (dislocation?) carried risk of avascular necrosis?
scaphoid mainly
also lunate
trochanteric bursitis
Bursa
Between gluteus max and trochanter
also b/w gluterus medius and GT
(also minimus)
three trochanteric bursae
Trochanteric Bursa of Gluteus Maximus Muscle
Trochanteric Bursae of Gluteus Medius Muscle
Trochanteric Bursa of Gluteus Minimus Muscle
which aspect of hip affected? (trochanteric bursitis)
Affects the lateral aspect of the hip
which demographic affected?
Middle age/older
WOMEN > men
trochanteric bursitis causes
Poor stretching and warm up
Occupations: cashiers, wallpaper hangers
Bucket seats and tight fitting chairs
Overuse
Post surgery
Direct trauma
Lying on one side for extended periods of time
Ice skaters/dancers
trochanteric bursitis – SSx
Difficulty walking
Walk with limp
Aching over trochanter
Walking with legs apart helps discomfort (?)
Radiating pain
Worse with climbing stairs and getting out of a car
trochanteric bursitis – Tx
US
Acupuncture
NSAIDs
Stretching/Strengthening
Massage
Ice / Hydrotherapy
Iliotibial Band Syndrome (ITBS)
what are the two types
IT Band Contracture
IT band Friction Syndrome
which ITBS is more common
IT band Friction Syndrome
IT Band contracture
Contracture or thickening of IT band
The thickening alters biomechanics of the knee and hip with compensation occurring in the SI joint or ankle
May be TrPs in TFL or glut max.
ITB contracture – what movements common?
APT
& Internal hip rotation (?)
IT band Friction Syndrome
Inflammation and pain where the iliotibial band crosses the lateral femoral condyle
causes of ITBS
Overuse of flexion of knee and hip
Prolonged repetitive hip and knee flexion
—> Running or cycling
Postural imbalance
—> Anterior pelvic tilt or hyperlordosis
Prolonged wheelchair/bedrest
Weakness in hip abductors and lateral rotators.
*** NOT ENOUGH STRETCHING? (TFL/ITB contracture?)
shortened TFL
“A shortened TFL can lead to an anterior tilt of the pelvis and/or medial rotation of the femur”
ITBS pain
Pain
Gradual onset and worse with activity
Along lateral thigh (IT band contracture)
Lateral aspect of knee (IT band friction syndrome)
what kind of pain with ITB contracture
Along lateral thigh (IT band contracture)
what kind of pain with ITB friction syndrome
Lateral aspect of knee (IT band friction syndrome)
where is inflammation? (ITBS)
Inflammation at lateral femoral condyle
where HT/TrP (ITBS)
TFL, gluteals, hip flexors
what about lower back Sx (ITBS)
L-spine and SI joint symptoms
what other condition can it go hand in hand with?
Trochanteric bursitis
ITBS – Tx
Activity modification
—> Decrease training, rest
Hydrotherapy/cryotherapy
Modalities
—> Ultrasound, cold laser, shockwave therapy
Soft tissue/massage
Stretching/strengthening
Corticosteroid injections
Surgery
—> Rarely performed
Knee Pathologies
..
Bursitis (types in/around knee)
Prepatellar Bursitis**
Aka gardeners
Suprapatellar Bursitis (FYI)
Aka chambermaids
Infrapatellar Bursitis Bursitis (FYI)
Aka preachers
WHY?
From prolonged kneeling or recurrent trauma to ant. knee
Pain and swelling and restricted ROM
Patellofemoral pain syndrome
aka patellofemoral syndrome, patellofemoral tracking syndrome
General term used for pain around patellofemoral joint
Usually refers to anterior knee pain.
patellofemoral syndrome (general term for Sx when more specific pathology not determined) – diagnosis of exclusion
Does not include…
a) Patellar Tendinopathy
b) or Chondromalacia Patellae
patellofemoral syndrome – feature
Problem with patellofemoral contact and/or tracking of the patella in the femoral groove
Mechanism is not fully understood
chondromalacia patella
the breakdown of cartilage on the underside of the kneecap (patella).
When the kneecap rubs against the thigh bone, it hurts and swells.
It is common among runners and other athletes and has been given the nickname “runner’s knee.”
malacia
Malacia is abnormal softening of a biological tissue, most often cartilage.
The word is derived from Greek μαλακός, malakos = soft.
patellar tendinitis – aka
jumper’s knee
patellar tendinitis vs tendinopathy
tendinopathy includes either tendinitis or tendinosis
patellofemoral pain syndrome —> contributing factors
Abnormal biomechanics
Increased internal tibial or femoral rotation.
Increased foot pronation (collapsed arch?)
tracking of patella vs PF pain syndrome (contributing factor)
Abnormal shape, tracking and stability of patella
E.g.
—> Patella alta
PF pain syndrome other contributing factors
Tight muscles/stuctures
—> Vastus lateralus, ITB, lateral retinaculum
—> Rectus femoris, hamstrings
Weak muscles
—> VMO, glut med, piriformis
Knee injury
—> Patellar subluxation/dislocation,
—> knee surgery
Knee stress/overuse
It places excessive lateral force on the patella and can also externally rotate the tibia, upsetting the balance of the PF mechanism.
This can lead to excessive lateral tracking of the patella.
Weak muscles
—> VMO
Tight muscles/stuctures
—> Vastus lateralus
PF pain syndrome – clinical manifestation
Anterior knee pain
Crepitus
Grating/grinding sensation
Swelling
Atrophy
quads
DJD
PF pain syndrome – when pain worse
Typically worsens with:
Sitting for long periods of time (Movie Theatre Sign)
Walking up and down stairs
Squatting/kneeling
Cinema Sign (also known as Theatre sign, Movie-goers sign, Movie sign)
Pain during prolonged sitting is sometimes termed the “movie sign” or “theatre sign” because individuals might experience pain while sitting to watch a film
PF pain syndrome – Tx
NSAIDs
Braces/Taping
Manual Therapy
–> Massage
–> Mobilization
Orthotics
Strengthening
–> VMO, quads, hip
Proprioceptive training
Surgery (uncommon)
–> Lateral release
Chondromalacia Patella (associated condition)
Softening of the cartilage of the patella
Can be asymptomatic
Thought to be secondary to patellar tracking issues
Leg, Ankle and Foot Pathologies
..
Shin Splints
Defined as “pain and discomfort in the leg from repetitive activity on hard surfaces, or due to forceable, excessive use of the foot flexors”
shin splints aka
Aka medial tibial stress syndrome
shin splints – why poorly defined?
Poorly defined; sometimes grouped together as …
periostitis,
tibialis posterior tendonitis,
tibial stress fractures
and compartment syndrome
shin splints causes
Overuse
Overtraining
—> increase in distance, intensity and duration
Running on hard or uneven surfaces
Poor footwear
Poor shock absorption or support
shin splints — risk factors
Poor biomechanics:
—> Excessive pronation (collapsed arch?)
—> unequal leg length
Overweight
shin splints – clinical presentation
Most commonly the pain is on the posteromedial border of the tibia.
Usually middle or lower tibia
Often bilateral
Similar to tendonitis, where it initially gets better with “warm up”, but as condition progresses pain will be present through exercise and continue during activities of daily living.
shin splints – foot movement?
Excessive foot pronation is often present
shin splint – if untreated?
If untreated, it may progress to a stress fracture
shint splint – tx
Rest; 2-6 weeks
Avoid running or standing long periods
Ice, NSAIDs
Gradual return to activity/training
Low impact, cross-training
Stretching/strengthening
Massage, chiro, physio
New shoes/orthotics
Surgery (rare)
compartment syndrome
A critical pressure increase within a confined compartmental space
Most commonly occurs in the anterior leg compartment
Can also occur in many areas of the body, including foot, thigh, forearm, hand, gluteal area.
two types of compartment syndrome
Two types:
Acute
and
Chronic (aka, chronic exertional compartment syndrome, CECS)
compartment syndrome – MOI
Connective tissue that forms compartment is rigid, therefore any swelling or bleeding that occurs can increase intra-compartmental pressure.
Increased pressure will cause the vessels to be compressed leading to decreased blood flow and ischemia.
—> Causing pain, nerve damage and possible tissue death
muscle and nerve anoxia
—> muscle and nerve necrosis
—> ?
leaky basement membranes
—> transudate (edema)
acute compartment syndrome
Most commonly due to trauma
—> E.g. Tibial fracture
—> Rarely will it be due to overuse or progress from CECS1,5
acute compartment syndrome — clinical presentation
Severe pain
Skin is taut and shiny from swelling
Paresthesia/anesthesia may be present from nerve compression
acute compartment syndrome – Dx
Intra-compartmental pressure monitoring
—> with needle?
Acute compartment syndrome – Tx
Emergency fasciotomy
Best results within 6 hours. If later than 12 hours, high likelihood of long-term disability/amputation
Usually will release all four compartments
Wound may be left open for up to 5 days post surgery to allow swelling to decrease.
Chronic Exertional Compartment Syndrome
Etiology:
Exercise induced/overuse
—> Overtraining, poor technique, impact
—> During strenuous exercise, there can be a 20% increase in muscle weight and volume d/t to blood flow and edema
Chronic Exertional Compartment Syndrome
—> predisposing factors
/ risk factors
Anatomical configuration
Muscle imbalances
Improper footwear
Chronic Exertional Compartment Syndrome
—> clinical presentation
Achy/cramping pain and swelling over the compartment area
May have paresthesia/anaesthesia over compartment and foot
Pain will come on at the same time, distance and intensity of exercise
what happens to pain (CECS)
Pain will continue and worsen through activity, but will subside with rest
The pressure may remain high in the compartment for more than 20 minutes post exercise
CECS – muscle herniation (?)
Muscle herniations may be palpated
—> May only be apparent after exercise
CECS –> Dx
Intra-compartmental monitoring
—> Can be done before, during and after exercising
CECS – Tx
Rest (4-8 weeks)
Activity modification
Massage/physio/chiro
Orthotics
Stretching/strengthening
Surgery; Fasciotomy
—> Non-operative treatments are generally unsuccessful (???)
Achilles Tendinitis
Common overuse injury
Can be seen in athletes, recreational athletes and inactive individuals
Pain due to microtears and inflammation
Develops at mid point of tendon
Achille’s Tendinitis – causes
Overuse
—> Stop and go sports
Running on hills or hard surface
Direct trauma
Poor stretching
Tight and/or weak calf muscles
—> Ballet dancers, high heels
Worn out shoes or footwear that inhibits movement
Over pronation syndrome (collapsed arch?)
Poor biomechanics
Achille’s tendinitis – clinical manifestation
Pain is usually located at mid-tendon
—> Can also be at bone/tendon junction
Redness and swelling over tendon
—> Tendon can appear and feel thicker
Crepitus with touching or moving tendon
Morning pain
Pain when pushing off during walking
Pain with raising toes
Muscle atrophy
—> chronic
Can lead to rupture if not treated
what can happen if achille’s tendinitis not treated ??
Can lead to rupture if not treated
note risk factor
WEAK CALVES
achille’s tendinitis – Tx
Rest
Activity modification
Isometric and eccentric loading exercises
Calf stretches
Massage
Joint mobilization/manipulation
Night splint
Orthotics
—> Overpronation
Steroid injections
Modalities
—> Shockwave, cold laser, ultrasound
Surgery
—> rare
Achille’s tendon rupture
Can be a partial rupture or full rupture
Largest tendon in the body
Most commonly ruptured tendon
AT rupture why
Sudden overstretch of the tendon
Forceful dorsiflexion
Fall
AT rupture – Dx
Ultrasound
MRI
AT rupture – Tx
Surgery
Casted
Plantar Fasciitis
Overuse condition of resulting in inflammation of the plantar fascia
m/c cause of foot pain in athletes
Overuse and stress on the plantar fascia cause tissue fatigue and microtearing
MOST COMMON CAUSE OF FOOT PAIN
plantar fasciitis
plantar fascia
Attaches to calcaneal tuberosity (medial),MTP joints and flexor tendon sheaths
plantar fascia function
Functions as a passive bowstring during … (??), which shortens and raises the medial longitudinal arch
Windlass mechanism; adds stability to a loaded foot with minimal muscle activity.
windlass mechanism
TOE DORSIFLEXION = CALCANEUS moves ANTERIOR
—> ACCENTUATES ARCH
plantar fasciitis – WHICH DEMOGRAPHIC ?
Occurs at any age, but most commonly experienced in middle age.
Occurs more commonly in athletic populations and accounts for 8-10% of all running related injuries
plantar fasciitis – ETIOLOGY
over-pronation and over-supination
May be caused by over pronation or supination:
Pronation causes a stretching effect and leads to a repetitive tension overload
Supination causes a poor dissipation of forces. The rigidity of the foot leads to more shock absorption into the plantar fascia, which would normally be dissipated through the leg
plantar fasciitis – RISK FACTORS
Overuse
—> Overtraining, poor technique (running/dancing)
Poor biomechanics/muscle imbalances
—> Pronation/supination, hip mechanics (int/ext rotation)
Impact/weight bearing activities
—> Prolonged standing, running on hard surface
Improper foot wear
Weight gain
plantar fasciitis –> SSX / clinical presentaiton
Sharp heel pain
Often worse with getting out of bed in the morning
Can be unilateral or bilateral
Symptoms range from mild to severe
Limited dorsiflexion and tight calcaneal tendon
Worse with stair climbing and activity
Heel spur
what can heel pain do? (plantar fasciitis)
Can radiate along bottom of inside of foot
Pain can be reproduced with palpation of medal calcaneal tuberosity or extension of 1st digit (toe)
heel spur (plantar fasciitis)
Seen in up to 50% of patients
Not an indication of severity
Not causative for plantar fasciitis, but the reaction to chronic fascial tension
plantar fasciitis – Tx
NSAIDs
Rest
Corticosteroid injections
Orthotics
Taping (athletic or kinesio)
Ankle mobilization
Correcting imbalances
Stretching/strengthening
Massage/physio/chiro
Night splints
Surgery
—> Plantar fasciotomy w/ or w/o heel spur removal
when surgery (plantar fascitiis)
Surgery should be considered a last resort as 95% of patients respond to conservative care
—> Other sources reports 70-90%
—> More than 80% of patients improve within 12 months regardless of type of care
Calcaneal Spurs (HEEL SPURS)
Bony outgrowth that forms on calcaneus
—> Can be on the back of the heel or under the sole
HEEL SPURS — WHY
May result from continuous pulling on attachment sites
—> Back of heel: calcaneal tendon
—>Under the sole: plantar fascia
May be associated with plantar fasciitis or calcaneal tendonitis, but not considered to be the pain generator.
May be found in 10 to 27% of asymptomatic individuals
varus/valgus types in FOOT
Hindfoot varus – inversion of calcaneus
Hindfoot valgus – eversion of calcaneus
Forefoot varus – inversion of forefoot on the hindfoot at the midtarsal joint
Forefoot valgus – eversion of forefoot on hindfoot at midtarsal joint
Pes Planus
AKA pes planovagus, flat feet, pronation of feet, fallen arches
Decreased, flattened medial longitudinal arch leads to sole of foot coming into complete contact with ground
Pronated hindfoot
Unilateral or bilateral
Common
functional vs structural Pes Planus
Functional
—> Due to ligamentous laxity and muscle weakness
—> Reversible; arch can be recreated
Structural
—> Due to bony malformation
—> Irreversible; arch can’t be recreated
pes planus causes
Hypermobility
Poor biomechanics
Shortened or weak muscles
Congenital
Poor posture
Nerve lesions/trauma
Footwear
Pregnancy; weight gain
pes planus – SSx / clinical manifestations
Flattened medial arch
Pain (maybe)
Weak muscles
Trigger points
Other conditions (knee, hip, ankle, SI, etc.)
pes planus – Tx
Orthotics
Surgery
Massage, chiropractic
Strengthening/stretching
Exercises/modify ADLs
Mobilization
Proper arch support
Weight loss
Pes Cavus
Aka claw foot
Increased arches
Toes appear clawed
Forefoot will drop below rearfoot when non-weight bearing
pes cavus – causes
Possible normal variant
Hereditary
Neurological (MD)
pes cavus – Sx
Calluses
Unable to properly fit shoes
Stiffness and immobility
Inversion ankle sprains (think of fibularis longus)
Pressure sores
Pain (maybe)
pes cavus – tx
Depends on severity
Foot orthotics
Pads
surgery
Hallux valgus
Aka hallux abducto valgus (HAV)
Valgus orientation of big toe
Most commonly associated with medial deviation of 1st MT and bunion at 1st MTP joint
Symptoms can include pain, redness, swelling and drift of other digits
Can be due to poor footwear, injuries, neuromuscular problems
Always progressive
Treatment – surgery, orthotics, relief of pressure
toe pathologies
..
Hammer toe
MTP hyper extension, PIP flexion and DIP hyperextension
Claw toe
MTP hyperextension and PIP & DIP flexion
Mallet toe
Mallet toe – DIP flexion
toe deformities – clinical manifestations
Pressure
Pain
Corns
Calluses
Altered biomechanics
Tight tendons, ligaments
toe deformities – etiology
Muscle imbalances
Arthritis
Genetics
Shoes
toe deformities – Tx
Proper shoes/splints
Gel toe shields/caps
Surgery
