Week 8 - physical examination of the leg

Question 1

leg pain

Answer 1

→ Several potential underlying pathologies:
o Bone stress
o Vascular insufficiency
o Inflammation
o Increased intracompartmental pressure.
o Nerve entrapment.

Question 2

bone stress

Answer 2

→ Pathology continuum
o Normal remodelling
o Accelerated remodelling.
o Stress reaction – grade 1
o Stress reaction – grade 2
o Stress reaction – grade 3
o Stress fracture – grade 4.
o Fracture + complete (at end of continuum)

Question 3

MTSS

Answer 3

medial tibial stress syndrome

→ Inflammatory, traction phenomena on medial aspect of tibia.
o Tibialis posterior
o Soleus
o Flexor digitiform longus all become tight and are causing stress when they contract.
→ Incidence – 4-35% of population.

→ Incidence – 4-35% of population.
→ 2 primary proposed Patho mechanics
o Tibial bending.
o Soft-tissue traction.

Question 4

risk factors for MTSS

Answer 4

→ Risk factors:
o Increased hip external rotation
o Prior use of orthotics
o Fewer years of running experience
o Female gender
o Previous history of MTSS
o Increased body mass index
o Navicular drop and especially if less than 10mm.
o Increased ankle plantarflexion ROM.

Question 5

patient interview for MTSS

Answer 5

o Demographics – female susceptible, BMI.
o Area and description – diffuse along medial tibia border (usually middle to distal 1/3).
o Behaviour – usually warms up with activity, worse the next day, post exercise.
o History – gradual onset, predisposing factors (training errors), prior history of orthotics prior history of MTSS.
o Patient reported outcome measure – medial tibial stress syndrome score (4 point score), addresses pain at rest, pain while performing ADL, limitations in sporting activities, pain while performing sporting activity.

Question 6

phys exam for MTSS

Answer 6

o Observations – look for navicular drop and notice BMI.
o AROM/PROM hip – decreased hip internal rotation or increased hip external rotation.
o Palpation – diffuse tenderness on palpation of tibia (usually middle to distal 1/3).
o Imaging bone scan may show diffuse area of uptake along medial boarder, MRI shows diffuse oedema and periosteal thickening.

Question 7

tibial stress fracture patient interview

Answer 7

o Area and description – localised leg pain) usually posterior medial boarder, mid distal 1/3).
o Acute or sharp pain.
o Behaviour – constant am to pm, increasing pain over time, aggravated by exercise or impact may be at rest or night pain.
o History – gradual onset, often recent increase in training.

Question 8

physical exam for tibial stress fracture

Answer 8

o Observations – may observe possible predisposing factors – pes cavus/planus, leg length discrepancy, calf bulk asymmetry, expecting localised pain.
o Palpation – localised tenderness of palpation of tibia, hot to touch, look red, play dough (leaves imprint).
o Special test – positive hip test, exacerbated by vibration (using tuning fork)
o Body chart + TOP + SL hop pain – very strong likelihood of stress.
o Imaging – bone scan and MRI (right) showing tibial stress fracture in the presence of bone marrow oedema. Note – bone scans are not specific in terms of bone architecture.

Question 9

tibial stress fracture

Answer 9

fill

Question 10

chronic exertional compartment syndrome

Answer 10

o Observations – may observe possible predisposing factors – pes cavus/planus, leg length discrepancy, calf bulk asymmetry, expecting localised pain.
o Palpation – localised tenderness of palpation of tibia, hot to touch, look red, play dough (leaves imprint).
o Special test – positive hip test, exacerbated by vibration (using tuning fork)
o Body chart + TOP + SL hop pain – very strong likelihood of stress.
o Imaging – bone scan and MRI (right) showing tibial stress fracture in the presence of bone marrow oedema. Note – bone scans are not specific in terms of bone architecture.

Question 11

patient interview for CECS

Answer 11

o Area and description – ache, “tightness,” or “bursting” sensation, anterolateral (anterior compartment), posteromedial (deep posterior compartment), sometimes paraesthesia or motor weakness (most common with lateral compartment) due to pressure on nerves.
o Behaviour – absence of pain at rest (dissipates within minutes of rest, ache may persist 30mins), increasing pain and tightness with exercise (10-15mins).
o History – typically, gradual onset but can be acute.

Question 12

physical exam CECS

Answer 12

o Unremarkable at rest.
o With exertion, TOP within muscle compartment.
o Muscle tightness,
o May be visible muscle bulging/herniation.
o May have decreased peripheral pulse.
o Predisposing factors (e.g., pes cavus, excessive pronation).
o Intracompartment pressure testing.

Question 13

CECS common causes

Answer 13

→ Common causes:
o Periosteal contusion
 Bone bruise
 Direct blow by hard object (kicked by opponent boot).
 Severe pain at time of injury, usually settles quickly.
 Persistent pain may occur due to haematoma formation under periosteum.
 Local tenderness and bony swelling.
o Acute fracture of tibia/fibula
 Patient interview – Hx of trauma, direct blow or landing from jump with twisted foot.

Question 14

leg pain causes

Answer 14

→ Not to be missed: tumours
o osteosarcoma and osteoid osteoma.
o Infection (osteomyelitis, cellulitis)
o Acute compartment syndrome
o Chronic transition to acute compartment syndrome
o Chronic ankle injuries and Maisonneuve fracture.
o DVT

→ Rare and unusual
o Syphilis
o Sickle cell anaemia
o Hyperparathyroidism
o Sarcoidosis
o Rickets
o Paget’s disease
o Erythema nodosum

Question 15

calf pain

Answer 15

calf strain

Question 16

patient interview for calf strain

Answer 16

o Area and description – sharp stabbing pain, tearing sensation at time of injury.
o History = MOI – typically with acceleration from a stationary position with ankle in dorsiflexion or when lunging forward.

Question 17

physical exam for calf strain

Answer 17

palpable defect, tenderness on palpation, pain with active PF, unilateral calf raises, hop, loss of DF ROM. Chronic strain may occur as an overuse injury or following inadequate rehab of acute injury.

Question 18

location and differential diagnosis

Answer 18

tenderness on palpation is deep to gastrocnemius.
o Use knee flexion to differentiate soleus form gastrocs.

Question 19

common causes and differential diagnosis for calf strain

Answer 19

o Muscle cramp - most common site in body for muscle cramps, painful involuntary contractions, during or immediately after exercise, less than 60 seconds duration, current theory – fatigue related.
o DOMS – 24-48hrs after unaccustomed high-intensity exercise, excessive eccentric muscle contractions.
o Contusion – history of direct blow to muscle by blunt external force (collision, with player or object).
o Swelling and bleeding.

Question 20

less common causes calf strain

Answer 20

o Superficial posterior compartment syndrome
o Deep posterior compartment syndrome
o Referred pain.
 Check lumbar spine and adjacent areas.
 Myofascial structures
 Superior Tibiofibular joint.
 Knee (PCL,

 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.