Select Disorders of the Lower Leg-104 SLIDES--KEY FOR THE FINAL Flashcards
Musculotendinous Conditions–Anterior and Medial Tibial Stress Syndromes
__________– inflammatory reaction involving the connective tissues of the leg (deep or crural fascia) at its insertion into the inside (medial) or front (anterior) aspect of the tibia
“Shin Splints” (vague, non-specific)
Periosteal reaction
Musculotendinous Conditions–Anterior and Medial Tibial Stress Syndromes
Classic Presentation
May exhibit both ATSS and MTSS in same extremity
• Pain with activity & stretching the involved structure; relieved by rest
DDX:
– Often increased uptake focally in area of stress fracture
– Uptake in patients with shin splints syndrome is less localized and is usually _______ involving the posteromedial tibia cortex
longitudinal
Musculotendinous Conditions–Anterior and Medial Tibial Stress Syndromes
Management
• PHASE 1: Decrease Inflammation – Rest from activity – Ice – Calf wrap, brace – Fit for orthotics (if applicable) – Nutritional support for inflammation control
PHASE 2: Rehabilitation – Continue to decrease inflammation with modalities – Cross friction – ST modalities – CMT to foot, leg – Stretch
PHASE3:Functional Improvement
– Advanced exercise from Phase 2
– Plyometrics
– Taping
Return to Full Activity
General Management Considerations
1• Replacing old shoes with new ones with better shock absorption
2• Temporary support with taping or medial heel wedge
3• Consider ________ if shin splints are recurrent
Know
orthotics
Vascular Conditions X 5
1–Varicose Veins
The thickened, twisting or dilated parts of the vein are called “\_\_\_\_\_\_\_\_” • Affects ~15% of men • Affects ~30% of women • Common areas include: – Calf – Foot – Inside thigh – Groin
Pathophysiology
• With age, veins can lose _______, lose ability to comply with venous pressure
• Valves become WEAK, allowing the blood to POOL!
• Pooling leads to _________ and elongation / twisting
• Valves may separate due to widening of the veins
– May also be due to other causes of increased pressure, damage or trauma to valves, thrombophlebitis
Symptoms may include: – Leg cramps – Ache – Throbbing – Heavy feeling in legs – Fatigue – May itch around vein – May be worse with: • Menses • Dependency (prolonged sitting or standing)
varicosities
elasticity
enlargement
** Varicose veins usually improve within 3 months after delivery
Management • Rest periods during activity • Compression hosiery – squeeze veins to stop excess blood from flowing backward • Walking or other light exercise • Leg elevation • Weight loss • Avoid wearing tight clothing • Avoid long periods of standing/sitting
Sclerotherapy
– Small and medium sized varicosities are injected with a solution that scars and closes the vein
Lasersurgery
– Small varicosities and spider veins are blasted with laser light to slowly close them
Management
• Catheter Ablation
– Catheter tip is inserted into large varicosities, heated and then pulled out, destroying the vein by causing it to collapse and seal shut
Stripping– Removes long veins through several small incisions
Vascular Conditions x 5
2—Deep Vein Thrombosis (DVT)
• Blood clot in a deep vein
80% in deep veins of calf
• Can be spontaneous or effort induced
• MC in individuals > 40 years old
Interferes with circulation
– Partial or complete blockage leads to pooling
– Pooling leads to chronic swelling and pain
–Pooling, chronic swelling and pain lead to
vessel/valve damage = _______ ________
Signs & Symptoms Include: • \_\_\_\_\_\_\_\_\_\_\_ edema – Most specific symptom!!! • UNILATERAL leg pain (50%) • UNILATERAL leg tenderness (75%) • UNILATERAL warmth • UNILATERAL changes in skin color • May be asymptomatic!!!!!!! (50%)
Effort Induced
• Abrupt onset of sharp calf pain
Spontaneous
• Gradual onset of calf pain (57%), edema (28%)
venous hypertension
Unilateral
Risks Include:
• Prolonged standing, sitting bed rest, immobilization
– Even long plane or car trips
• Recent fracture, surgery or trauma
– Especially hip, knee or gynecological surgery
• Medications
– such as estrogen and birth control pills
• Smoking
• Obesity
• Pregnancy or childbirth – within the last 6 months
• History of polycythemia vera
– Blood disorder: bone marrow makes too many red blood cells
Diagnosis***Refer for Dopplar Ultrasonography (m/c)
**Venography (gold standard)
Standard Treatment:
• Heparin(IV):Continued until warfirin takes effect. Warfirin(PO):takes several days to become fully effective; then taken for ~ 6 months
Vascular Conditions x 5
3–Superficial Thrombophlebitis
Most often associated with components of
_______ _______:
1. Intimal damage (can result from trauma, infection or inflammation)
2. Blood stasis
3. Changes in blood constituents (presumably causing changes in coagulability)
• Most often affects the superficial veins in the legs but may also affect superficial veins in the groin
•Canals ooccur anywhere medical interventions occur – arm or neck (external jugular vein) from intravenous
catheters
• Distinguishing venous thrombosis (_____) from venous phlebitis (___________) can be challenging
Symptoms
• Rapidly developing localized pain and swelling
• Overlying skin becomes red,_______ and exquisitely tender
• Vein feels like a HARD cord under the skin and may feel hard along its entire length
Virchow Triad
clot
inflammation
warm
1--Superficial Thrombophlebitis • INFLAMMATION • Involves a sudden acute reaction • Embolism is RARE --More common in female patients & those over 60 yoa
Vs
2–Deep Vein Thrombosis
• Non-inflammatory circulatory blockage
• Often chronic blockage but may be due to sudden trauma
• Embolism may occur
• Compression of surrounding muscles may lead to thrombus detachment
–Not associated with superficial varicosities
Vascular Conditions x 5
4—Peripheral Vascular Disease (PVD, PAD) AKA Arterial Vascular Disease
• Insufficient tissue perfusion caused by existing ___________
• Many people live daily with PVD
• Has the potential to cause loss of LIMB or even loss of LIFE!!
• May be acutely compounded by either emboli or thrombi
• With acute limb ischemia,can be lifethreatening
– May require emergency intervention to minimize morbidity (incidence of ill health) and mortality (death)
–Results in damage to the liming of the vessels = __________ ___________
—Atherosclerotic process may gradually progress to complete OCCLUSION of medium and large arteries
Symptoms Include:
• Pain, cramping and/or muscle weakness with activity (___________)
• Symptoms relieved by rest: intermittent
• Symptoms often occur with specific amount of activity (i.e. walking 5 blocks)
• Time it takes to get relief is consistent
Examination Findings Include:
• Auscultation for bruit
• Peripheral pulses diminished or ABSENT
• Skin may be: COOL, thin, SHINY, atrophic, pale on elevation / red on dependency
Advanced Imaging
• Doppler Untrasonography
• Arteriogram
atherosclerosis
atherosclerotic plaques
claudication
*****Vascular vs. Neurogenic Claudication
VASCULAR Claudication
• Involves STENOSIS of peripheral vessels compromising the blood supply to the muscles
• Most evident with INCREASED demand as occurs with walking
VS
NEUROGENIC Claudication
• Secondary to spinal stenosis
• Compression of nerves and/or blood supply to nerves causing leg symptoms
• In general, related to POSTURE!!
Vascular Conditions x 5
5—-A–ACUTE Compartment Syndrome
1–* Medical Emergency *!!!!!
• Pressure in compartment(due to blood clot or other fluid, fracture etc.) exceeds blood pressure and capillaries collapse
— Irreversible ______ _______and muscle _______ occur within hours
• Failure to intervene can lead to paralysis,loss of limb, even death
Causes
• INTERNAL increase in compartment volume or external restriction of the lower extremity compartment
Symptoms
• SEVERE pain (with or w/t mvmt) out of proportion to examination
• The traditional 5 P’s MAY be present:
pain, paraesthesia, pallor, poikilothermia, pulselessness
– But, NOT diagnostic of compartment syndrome
– w/ exception of pain and paraesthesia, these traditional signs are not clinically reliable
– Manifest only in the late stages
nerve injury
necrosis
***Fasciotomy: Decompression of anterior and lateral compartments of leg
5-B—–CHRONIC Compartment Syndrome
Common Clinical Presentation
• Symptoms present ONLY with activity
– Tend to subside within 1hr of terminating the
activity
• May have Hx of sudden increase in activity
• May have deep cramping pain, numbness or
• Muscle may feel tight or “full”
• Often occurs __________
• Similar to _____________, the pain may be reproducible at a specific exercise distance or time interval
Common Examination Findings——
• Passive stretching INCREASE pain
• Palpable tenderness over compartment immediately after activity
• Neurological exam may be positive immediately after activity
• SLIT CATHETER used to measure pressure – 1minute before exercise
– 1min. and 5min. after exercise
bilaterally
claudication
5–C—–DEEP Posterior Compartment
• Pain in posteriomedial distal 1/3 of tibia
• Sensory changes of foot and toes
– _________ nerve
• WEAK toe FLEXION and ankle INVERSION
• Pain with passive __________
• POSTERIOR tibial pulse may be diminished or absent
Tibial
dorsiflexion
5–D—SUPERFICIAL Posterior Compartment
POSTERIOR middle 1/3 leg pain (gastroc pain) • Sensory changes to lateral foot – \_\_\_\_\_\_\_ nerve • Weakness during \_\_\_\_\_\_\_\_\_\_\_ flexion • Passive DORSIFLEXION may cause pain • Normal pulses
Sural
plantar
5—E—Anterior Compartment
Pain at anterior shin
• Sensory changes between 1st & 2nd toes
– _____ __________ nerve
• Weak toe EXTENSION and ankle DOSIFLEXION
• Pain on passive ________ _________
• Diminished or ABSENT dorsalis pedis pulse
Deep peroneal
plantar flexion
Lateral Compartment
Pain in lateral leg • Sensory changes at dorsum of foot – \_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ nerve • Weak ankle \_\_\_\_\_\_\_\_\_ • Pain on passive plantar flexion and inversion • Normal pulse
Superficial peroneal
eversion
Osseous Conditions—-Stress Fracture: 2 Theories
Theory #1
• During initial increase in exercise,__________ activity lags behind _________ activity by a few weeks resulting in a period during which bone is more susceptible to injury
• Stress from repetitive use results in micro
fractures that consolidate into stress fractures
osteoblastic
osteoclastic
Osseous Conditions—-Stress Fracture: 2 Theories
Theory #2
• Strong and repetitive ________ ________ on bone at the insertion point of muscles results in focal bending stresses beyond the ability of the bone to tolerate
loading stress
