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W7 Flashcards

1
Q

Leg pain Several potential underlying pathologies:

A
  • Bone stress
  • Vascular insufficiency
  • Inflammation
  • increase intracompartmental pressure
  • Nerve entrapment
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2
Q

bone stress

A

normal remodeing
accelerated remodeling
stress reaction G1,2,3
stress fracture G4
fracture + complete

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3
Q

Medial Tibial Stress Syndrome MTSS “shin splints”

A
  • Inflammatory, traction phenomena on medial aspect of tibia
  • Tibialis posterior
  • Soleus
  • Flexor digitorum longus
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4
Q

Medial Tibial Stress Syndrome MTSS incidence

A

4-35%

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5
Q

2 primary proposed pathomechanics of MTSS

A
  • Tibial bending
  • Soft-tissue traction
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6
Q

MTSS – Risk factors

A
  • Increased hip external rotation
    • particularly in males
  • Prior use of orthotics
  • Fewer years of running experience
  • Female gender
  • Previous history of MTSS
  • Increased body mass index
  • Navicular drop and especially if > 10 mm
  • Increased ankle plantarflexion ROM
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7
Q

Demographics of MTSS

A
  • Females more susceptible
  • BMI
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8
Q

MISS areas and descrition

A
  • DIFFUSE along medial tibial border (usually middle to distal 1/3)
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9
Q

MTSS behavior

A
  • Usually ‘warms up’ with activity
  • Worse next day, post exercise
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10
Q

History of MTSS

A
  • Gradual onset
  • Predisposing factors: training errors
  • Prior history of orthotics, prior history of MTSS
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11
Q

Patient Reported Outcome Measure of MTSS

A

Medial Tibial Stress Syndrome Score (4 point score)
* Addresses pain at rest, pain while performing ADL, limitations in sporting activities, pain while performing
sporting activities

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12
Q

AROM/PROM/ MTSS

A
  • Decreased hip internal rotation
  • Increased hip external rotation
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13
Q

Palpation of MTSS

A

VERY IMPORTANT
Diffuse tenderness on palpation of tibia (usually middle to distal 1/3)

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14
Q

Tibial Stress Fracture (#)

A
  • Common cause of leg pain in athletes,
    especially impact, e.g. running
  • 90% affect posteromedial aspect
  • Most common site junction between middle
    ⅓ & distal ⅓
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15
Q

incidence of Tibial Stress Fracture (#)

A

3-5% but as high as 20% in
some populations, i.e. runners, military

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16
Q

Tibial Stress Fracture (#) Area & description

A
  • Localised leg pain (usually posteromedial border, mid-distal 1/3)
  • Acute or sharp
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17
Q

Tibial Stress Fracture (#) behaviour

A
  • Constant am-pm &/or increasing over time
  • Aggravated by exercise especially impact
  • May be at-rest or night pain
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18
Q

Tibial Stress Fracture (#) History

A
  • Gradual onset
  • Often recent increase in training (intensity, distance etc.)
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19
Q

Tibial Stress Fracture (#) – observation

A
  • May observe possible predisposing factors
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20
Q

Tibial Stress Fracture (#) – palpation

A

LOCALISED tenderness on palpation of
tibia

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21
Q

Tibial Stress Fracture (#) – special test

A
  • Positive Hop Test
  • Exacerbated by vibration - tuning fork
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22
Q

Chronic Exertional Compartment Syndrome (CECS)

A

increase pressure within a closed fibroosseous space
reduces blood flow and tissue perfusion
ischemic pain damages tissues

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23
Q

CECS area and description

A
  • Ache, “tightness” or “bursting” sensation
  • Anterolateral (anterior compartment), posteromedial (deep posterior compartment)
  • Sometimes paraesthesia or motor weakness (most common with lateral compartment)
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24
Q

CECS behaviour

A
  • Absence of pain at rest (dissipates within minutes of rest, ache may persist 30mins)
  • Increasing pain & tightness with exercise (10 15mins)
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25
CECS history
Typically, gradual onset (but can be acute)
26
CECS – Physical examination
* Unremarkable at rest * With exertion, TOP within muscle compartment * Muscle tightness * May be visible muscle bulging/herniation * May have ↓ peripheral pulse * Predisposing factors e.g. pes cavus, excessive pronation * Intracompartmental pressure testing
27
Periosteal contusion
* “Bone bruise” * Direct blow by hard object e.g. kicked by opponents’ boot * Severe pain at time of injury, usually settles quickly * Persistent pain may occur due to haematoma formation under periosteum * Local tenderness & bony swelling
28
Acute fracture of tibia/fibula. Patient interview
* Hx of trauma – direct blow or landing from jump with twisted foot
29
Acute fracture of tibia/fibula- Physical examination
* Inability to weight bear if fracture displaced * Fractures of tibia are often compound & visible through damaged skin * Fractures of fibula may be isolated & can exhibit tenderness on palpation only
30
Nerve Entrapment ( Leg pain – Less common causes)
* Peroneal nerve in lateral compartment * Deep peroneal nerve in anterior compartment * History of trauma or impingement e.g. tight brace/cast * Sensory changes, motor changes
31
what is nerve entrapment confirmed with what test
* Confirmed with nerve conduction studies
32
Leg pain – NOT TO BE MISSED! TUMORS
* Night pain (woken at night with pain) * Chronic pain, worsening over time * Most likely younger age group (11- 29y/o) * Loss of appetite * Weight loss * Malaise
33
Leg pain – NOT TO BE MISSED! INFECTIONS
E.g. osteomyelitis, cellulitis * Fever * Redness
34
Calf Pain – causes aeitology
* Common in middle-age (over 40y/o) * Medial head most common site of injury * Most commonly at musculotendinous junction
35
Calf muscle strain- common calf pain areas and descripton
* Sharp stabbing pain * ‘tearing’ sensation at time of injury
36
Calf muscle strain History common calf pain
* MOI: Typically, with acceleration from a stationary position with ankle in dorsiflexion or when lunging forward
37
38
Calf muscle strain physical exam common calf pain
* Palpable defect, tenderness on palpation * Pain with active PF, unilateral calf raise, hop * Loss of DF ROM
39
Gastrocnemius, Plantaris or Soleus?
* Tenderness on palpation is deep to gastrocnemius * Use knee flexion to differentiate pain on contraction & stretch
40
Calf pain – Common Causes muscle cramp
* Most common site in body for muscle cramps * Painful involuntary contractions * During or immediately after exercise * <60secs duration * Current theory = fatigue related
41
Calf pain – Common Causes muscle DOMS
* 24-48 hours after unaccustomed high-intensity exercise * Excessive eccentric muscle contractions
42
Calf pain – Common Causes muscle contusion
* History of direct blow to muscle by blunt external force (e.g. collision with player or object) * Swelling & bleeding
43
Leg & calf pain – Less common causes Referred pain from spine
* Distribution/pattern of pain (refer to week 2 neuro lectures) * Poorly localised * Pain/stiffness in low back area * Aggravating positions/ movements that relate to low back * AROM lumbar spine
44
Calf pain - less common causes Vascular Entrapment
* Popliteal artery entrapment * Pain worse with exertion, especially active ankle PF * Pulses may be diminished with active PF / post-exercise * Differential Dx compartment syndrome * Can be present at rest * Typically develop & dissipate more quickly * Confirmed by Doppler ultrasound
45
Calf pain – NOT TO BE MISSED! Deep vein thrombosis (DVT)- need to be reffered on
* Constant calf pain * Tenderness * Increased temperature * Diffuse swelling * Wells’ clinical prediction rule (>3 major points) * Confirmed by Doppler scan & venography
46
major indication for DVT must be reffered on
* Recent paralysis or immobilisation (e.g. plaster) * Bedridden >3 days +/- surgery within 4 weeks * Localised tenderness * Calf swollen * Family Hx * Cancer Rx (ongoing or within 6 months)
47
Risk Factors Deep vein thrombosis (DVT)
* Older age * Period of immobilisation * Surgery * Trauma * Stroke * Pregnancy and post-partum * Use of oral contraceptives or hormone replacement therapy * Obesity * A previous DVT
48
Acute ankle injuries Lateral ligament injuries MOI
– INV suggests lateral ligs, EVN suggests medial ligs – Compressive forces consider osteochondral injury – Sometimes audible snap/crack/tear
49
Acute ankle injuries Lateral ligament injuries onset
– Able to WB immediately suggests sprain – Unable to WB suspect #
50
Acute ankle injuries Lateral ligament injuries locatsion
* Pain/Swelling/Bruising * Gives indication of ligament involved
51
Acute ankle injuries Lateral ligament sprains- ATFL MOI
* PF & INV * First ligament to tear – torn in 97% of cases
52
Acute ankle injuries Lateral ligament sprains- ATFL physical exam
* Localised pain (antero-lateral) * Localised swelling (antero-lateral) * Figure of 8 Test with measuring tape * +ve anterior drawer (Fig 41.3f) * ∆ ROM, strength and balance
53
Acute ankle injuries Lateral ligament sprain: CFL (calcanofibula)
* Usually in conjunction with ATFL * Isolated rupture rare (3% of inversion injuries)
54
Acute ankle injuries Lateral ligament sprain: CFL physica exam
* Localised pain (lateral, below lateral malleolus) * Localised swelling (lateral, below lateral malleolus) * +ve talar tilt test (INV) * ∆ ROM, strength and balance
55
Acute ankle injuries Lateral ligament sprain: PTFL
* Last ligament to tear * Complete tear of ATFL, CFL & PTFL rare & results in dislocation of ankle joint * Isolated rupture of PTFL rare
56
Acute ankle injuries AITFL (anterior inferior talofibular) MOI
* hyper-DF force OR * ER with axial load
57
Acute ankle injuries AITFL (anterior inferior talofibular) physical exam
* Swelling above T/C joint * Pain with WB DF (reduced with compression of malleoli together) * ER Stress Test * Dorsiflexion compression test * ∆ ROM, strength and balance * Confirmed with imaging
58
ottowa ankle rules
Ankle x-ray only if: Pain in malleolar region and any 1 of: * Bone tenderness at side of posterior edge of lateral maleolus or posterior edge of medial maleolus * Inability to WB immediately & at clinical exam for 4 steps
59
ottowa foot rules
Foot x-ray only if: Pain in midfoot zone and any 1 of: * Bone tenderness at base of 5th metatarsa or navicular * Inability to WB immediately & at clinical exam for 4 steps
60
less common Acute ankle injuries Osteochondral lesions talar dome
* Usually when compressive component to injury e.g. landing from jump * Usually on superomedial talar dome * May not be evident on initial x-ray * Often Dx following unremitting ankle aching post ankle sprain treatment
61
Acute ankle injuries Osteochondral lesions talar dome Patient interview
* Usually 4-6wks on * Progressing well thendevelops increasing pain, stiffness, swelling, catching/locking common
62
Acute ankle injuries Osteochondral lesions talar dome physical exam
* Reduced ROM * Palpation with foot PF 45 degrees to expose talar dome * Confirm with MRI or bone scan + CT
63
Less common Acute ankle injuries Medial ligament sprain
* Less common as medial ligament stronger
64
Less common Acute ankle injuries Medial ligament sprain MOI
* forced eversion
65
Less common Acute ankle injuries Medial ligament sprain physica exam
* pain on medial palpation & swelling * Talar tilt test (EVN) * ∆ROM, strength and balance
66
less common Acute ankle injuries Fractures – talus & calcaneus
* Lateral talar process * Inability to WB long periods * Swelling & bruising over lateral aspect ankle * TOP immediately anterior & inferior to lateral malleolus * Posterior talar process * Anterior calcaneal process * TOP just anterior to opening of sinus tarsi
67
Fractures – talus & calcaneus MOI
MOI forced PF
68
less common Acute ankle injuries Tendon rupture/dislocation - Peroneals MOI
Forced passive DF * Peroneal retinaculum ripped off lateral malleolus * Subluxation & relocation with PF * TOP peroneal tendons * +ve peroneal subluxation test in PF
69
not to be missed casued of ankle pain
Complex regional pain syndrome type 1 (post-injury) Greenstick fractures (children) Syndesmosis injury Tarsal coalition (may come to light as a result of an ankle sprain)
70
common causes Medial ankle pain Tendinopathy – Tibialis posterior history
* overuse – running, walking * Acute injury rare
71
common causes Medial ankle pain Tendinopathy – Tibialis posterior general health
* Can be secondary to RA / seronegative arthropathy
72
common causes Medial ankle pain Tendinopathy – Tibialis posterior physical exam
* TOP posteromedial to malleolus to insertion navicular tubercle * Excessive pronation * Pain resisted inversion
73
common causes Medial ankle pain Tendinopathy – Flexor hallucis longus history
* overuse e.g. toe flexion in dancers, jumpers, PF in dancers, footballers * Shoes too big (grip with toes) * Often associated with posterior impingement of the ankle
74
common causes Medial ankle pain Tendinopathy – Flexor hallucis longus physical exam
* Pain with resisted toe flexion * Pain on toe-off in gait
75
less common Medial ankle pain Tarsal tunnel syndrome
* Entrapment of posterior tibial nerve in tarsal tunnel (where nerve winds around medial malleolus) * 50% idiopathic * other result of trauma * Overuse e.g. excessive pronation
76
less common Medial ankle pain Tarsal tunnel syndrome pt interview
* Poorly defined burning, tingling or numbness on plantar aspect of foot & toes * Pain aggravated by activity * Pain relieved with rest * Can be worse at night
77
less common Medial ankle pain Tarsal tunnel syndrome physical exam
*Tenderness over tarsal tunnel *Tinel’s sign +ve and reproduces symptoms *Altered sensation along arch of foot (differentiate from dermatome) *Swelling/thickening may be present at medial ankle or heel *Ganglion or cyst may be palpable *Confirmed with nerve conduction studies
78
less common Medial ankle pain Referred pain from spine
* Distribution/pattern of pain (Neuro lecture) * Poorly localised * Pain/stiffness in back * Aggravating positions/ movements that relate to low back * AROM lumbar spine
79
NOT TO BE MISSED Medial ankle pain Navicular stress fracture
* History overuse * Persistent pain * TOP * Worsens with activity
80
NOT TO BE MISSED Medial ankle pain Complications of acute ankle injuries
* Persistent pain / problem * Hx ankle injury
81
NOT TO BE MISSED Medial ankle pain Complex regional pain syndrome type 1
* Burning pain * Pain felt worse than may be expected * Stiffness * Changes to skin/hair/nails of limb * Temperature changes
82
common causes Lateral ankle pain Tendinopathy - Peroneals pt interview
* Hx Inversion ankle sprain * Hx overuse e.g. excessive eversion (cambered surface), excessive loading (dancing, basketball, volleyball)
83
common causes Lateral ankle pain Tendinopathy - Peroneals physical exam
* Excessive pronation * TOP peroneal tendons * May be swelling * Pain with resisted eversion
84
85
less common Lateral ankle pain Recurrent subluxation/dislocation of peroneal tendons
* Hx ankle injury * Complains of flicking/pop
86
less common Lateral ankle pain Stress fracture of the talus
* Hx overuse * Worsens with increasing activity
87
less common Lateral ankle pain * Superior tibiofibular joint
Distribution
88
less common Lateral ankle pain Anterolateral impingement
Hx repeated minor ankle sprains * Pain at anterior aspect lateral malleolus * Intermittent catching sensation * TOP anteroinferior border fibula * End ROM DF +/- combined eversion painful
89
common causes Anterior ankle pain – Anterior Impingement
* Soft tissue or bony tissue trapped between tibia & talus during DF * May be due to chronic ankle pain or after ankle sprain * Common in footballers, ballet dancers, gymnasts
90
common causes Anterior ankle pain – Anterior Impingement pt interview
* Anterior ankle pain, vague discomfort * Pain sharper & more localised over time * Aggravated by DF * Later stage = stiffness
91
common causes Anterior ankle pain – Anterior Impingement
* Tenderness anterior T/C joint * Exostoses (bone spur) may be palpable * DF restricted and pain * Anterior impingement test * Confirmed with x-ray
92
common causes poserior ankle pain Achilles tendinopathy - midportion
* Collagen degeneration (disarray & separation) * Absent inflammatory cells * Increased mucoid ground substance * Increased cells and vascular spaces +/-neovascularization
93
common causes poserior ankle pain Achilles tendinopathy - midportion pt interview
* Generally ‘warms up’ with activity * Hx Relative tendon overload** * Single episode * Over time * Predisposing factors
94
common causes poserior ankle pain Achilles tendinopathy - midportion physical exam
* +/- pain with resisted PF * TOP along tendon +/- thickening * Crepitus (moreso if synovitis)
95
common causes poserior ankle pain Achilles tendinopathy - midportion intrinsic factors
* Central adiposity in males * Peripheral adiposity in females * Increased BMI * Hypercholesterolaemia * Diabetes mellitus (type I & II) * Previous injury * Genetic predisposition (collagen) * Older age → may relate to cumulative load
96
common causes poserior ankle pain Achilles tendinopathy - midportion extrinsic factors
* Recent change in tendon load e.g. distance, speed, frequency, insufficient recovery * Activities involving high energy storage e.g. jumping & landing
97
common causes Posterior ankle pain Achilles tendinopathy – insertional +/- retrocalcaneal bursitis pt interview
* Hx excessive DF * Aggravated by DF
98
common causes Posterior ankle pain Achilles tendinopathy – insertional +/- retrocalcaneal bursitis physical exam
* Soft tissue swelling either side of tendon if bursitis present
99
different tests for midportion tendinopathy and Achilles tendinopathy – insertional +/- retrocalcaneal bursitis
* Hop on toes (tensile)- midportion * Hop-lunge to DF (compression +tensile)- bursitis
100
less common posterior ankle pain Flexor hallucis longus and tibialis
Hx overuse TOP tendon Pain with resisted contraction
101
not to be missed poserior ankle pain lumbar spine
Distribution
102
less common Posterior ankle pain Posterior impingement
* Impingement of posterior talus by adjacent aspect of posterior tibia in extremes of PF * Common in ballet dancers, gymnasts, cricket bowlers, footballers * May be secondary to PF/INV sprain * Posterior pain, especially in extreme PF * Posterior impingement test (forced passive PF)
103
not to be missed Posterior ankle pain – Achilles tendon rupture pt interview
* Hx Acute incident / trauma * 30-40 y/o male>female * “hit/kicked in the back of the leg” * Audible snap or tear
104
not to be missed Posterior ankle pain – Achilles tendon rupture physical exam
* Obvious limp * ROM/function may be preserved by other muscles * Unable to walk on toes * Palpable gap approx 3-6cm proximal to calcaneal insertion * Strength PF reduced * +ve Thompson’s test * In prone foot hangs straight down (not slight PF)
105
not to be missed Posterior ankle pain Sever’s Disease
* Children & Adolescents * Calcaneal (traction) apophysitis * Achilles insertion tractions on calcaneal growth-plate Presents with * Activity related pain * Local pain, tenderness & swelling at the insertion of achilles tendon * Tight calf and restricted DF
106
common Rearfoot pain Plantar heel pain pt interview
* Onset= Gradual, insidious * Pain= inferior medial aspect of heel * Behaviour= Worse a.m. “first step pain” → also if sitting/inactive for a while then first get up * Initially improves with activity * Ache post-activity * Progression= as condition becomes more severe pain with WB, worsens with activity, NWB pain
107
common Rearfoot pain Plantar heel pain physical exam
* Acute tenderness medial tuberosity of calcaneus +/- along plantar fascia * +ve Windlass (Jack’s) test * Passive DF first MTP joint +/- palpation provokes pain
108
common Rearfoot pain Plantar heel pain * Predisposing factors
* ↓ ankle DF * High BMI * Acute increase in running/WB volume
109
common Rearfoot pain Fat pad contusion what is the fat paf composed of, function
* Fat pad composed of elastic fibrous tissue separating closely packed fat cells * Acts as shock absorber * Protects calcaneus at heel strike
110
common Rearfoot pain Fat pad contusion causes
* Fall onto heel from height * Occasionally chronic due to excessive heel strike with poor cushioning
111
common Rearfoot pain Fat pad contusion pt interview
* Marked inferior-lateral heel pain * Increase with WB * Especially heel contact * Hx traumatic event (usually)
112
common Rearfoot pain Fat pad contusion physica exam
* Tenderness posteroinferior lateral heel * May be redness * MRI: oedematous changes
113
less common Rear-foot pain Calcaneal Stress #
* 2nd most common tarsal stress fracture * Either upper posterior margin or adjacent to medial tuberosity * Especially military (marching), runners, ballet dancers, jumping athletes
114
less common Rear-foot pain Calcaneal Stress # pt interview
* Insidious onset heel pain * Aggravated by weight bearing
115
less common Rear-foot pain Calcaneal Stress # physical exam
* Localised tenderness * Pain reproduced by squeezing posterior aspect of calcaneus from both sides simultaneously
116
common causes Mid-foot pain Navicular stress fracture
* Common stress fracture in athletes esp. sprinting, jumping, hurdles
117
common causes Mid-foot pain Navicular stress fracture pt interview
* Hx overuse / repetition * Spike in training load most common cause * Insidious onset * Poorly localised midfoot ache +/- radiate along arch or dorsum * Improves with rest
118
common causes Mid-foot pain Navicular stress fracture physical exam
“N spot” – proximal dorsal surface of navicular tender with stress fracture
119
Mid-foot pain A common midtarsal joint sprain… Bifurcate ligament:
* “Low ankle sprain” * Hx traumatic event / ankle sprain mechanism * Mid-foot lesion therefore lateral midfoot pain & swelling * Swelling over EDB not ATFL * -ve Anterior Drawer * Pain with midfoot inversion, PF, Add
120
common cause Mid-foot pain Lisfranc joint sprain- connects tarsals to metatarsals
* Spectrum of injury – sprain, tear, displacement * Tarsometatarsal joints Not common in general population but 2nd most common foot injury in athletes
121
common causes Forefoot pain Stress fracture: metatarsals (neck, base)
* 2 nd most common stress fracture of all * Insidious onset * Hx overuse / repetition * Hx training error * Aggravated by weight bearing * Gastroc fatigue (increased forefoot loading) * Of the MTs, 2nd MT most common * Pronating foot * Morton’s foot (long 2nd ray- tarsal)
122
common causes Forefoot pain Metatarsal fractures
* 5 th MT most common * Often avulsion injury from acute ankle sprain (zone 1) * Hx acute MOI * Difficulty weight-bearing * Tenderness on palpation
123
common causes- Forefoot pain MTP joint synovitis“Metatarsalgia”
* Synovium of MTP joints becomes painful due to prolonged excessive pressure * Pes cavus * Excessive pronation * Clawing, hammer toes * Tight extensor tendons - Pain aggravated by forefoot weight-bearing * Gradual onset pain * Local tenderness on palpation * Passive forced flexion of toe aggravate pain * + Met. Squeeze
124
common causes Forefoot pain First MTP joint sprain- turf toe MOI, symptoms, aggs
* MOI forced hyperextension of first MTP joint * Localised pain, swelling at first MTP joint * Aggravated by weight bearing * Pain with passive movement first MTP joint
125
common causes Forefoot pain Hallux Limitus (Rigidus)
* Restriction in DF of hallux a 1 st MTP joint * Due to exostoses or OA of joint * 60°DF required for gait
126
common causes Forefoot pain Hallux Limitus (Rigidus) causes
* Trauma * Excessive pronation * Repetitive WB DF 1st MTP * RA * Hypomobile 1st ray/ metatarsal
127
common causes Forefoot pain Hallux Limitus pt interview
* Pain over 1st MTP * Deep ache * Aggravated by walking esp. high heels
128
common causes Forefoot pain Hallux Limitus physical examination
* Shoe sole wear under 2nd MTP joint * Tenderness 1st MTP joint * Palpable dorsal exostoses * Limited 1st MTP joint DF
129
common causes Forefoot pain Hallux Valgus (Bunion)
* A static subluxation of 1st MTP joint * Valgus/lateral deviation of great toe * Bony exostoses develop * Often overlying bursitis * Affects 23% of adults 18-65 years
130
common causes Forefoot pain Hallux Valgus (Bunion) Predisposing factors:
* Constricting footwear * Excessive pronation * Increased length 1st MT
131
common causes Forefoot pain Morton’s Neuroma
* Swelling of nerve & scar tissue arising from compression of interdigital nerve * Usually between 3rd & 4th MTs
132
common causes Forefoot pain Morton’s neuroma: planterflexion inversion
* Pain radiating into toes * Associated pins & needles, numbness * Pain increased by forefoot WB * Aggravated by narrow footwear
133
common causes Forefoot pain Morton’s neuroma: planterflexion eversion
* Localised tenderness * May be associated excessive pronation * + Met. Squeeze

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