CLINICAL CARE OF THE LOWER EXTREMITY MUSCULOSKELETAL SYSTEM

Question 1

What Dx / Tx
Thought to be secondary to a reaction of the periosteum in response to increased stress, as seen in runners
– Must be differentiated from a tibial stress fracture
Clinical Symptoms
(1) Gradual onset of pain with prolonged walking or running activity
(2) Pain is localized to the distal third of the medial tibia
(3) Patient may have increased training intensity, pace or distance
Physical Exam
(1) Visual
–(a) Unremarkable, possible pes planus
–(b) Evaluate for any biomechanical deficiencies
(2) Palpation
–(a) Tenderness along posterior medial crest of tibia in the middle to distal third of the leg
3) ROM = Unremarkable
(4) Muscle Test = Pain with resisted plantar flexion
(5) Neurovascular = Unremarkable
(6) Special Test = None

Answer 1

Shin Splints
Treatment
(1) NSAIDS
(2) Ice
(3) Light Duty-Activity modification
(4) Gradual pain free return to running
(5) Weight lose if needed
(6) Proper running shoes

Question 2

Shin splints not healing with conservative management should be further investigated with what?

Answer 2

plain films and/or MRI or bone scan

Question 3

Clinical Symptoms

-Occur in many athletes, but especially runners, who ramp up mileage too quickly
(1) Initially symptoms very similar to shin splints
–(a) However pain becomes more focal and time course to recovery much longer
(2) Gradual increase in pain related to physical activity
–(a) May increase over course of weeks to months
–(b) Pain worsens and begins to hurt at rest
(3) Clues in the history that are concerning :
–(a) Pain at rest
–(b) Pain that suddenly increases in intensity around site of more mild symptoms
Physical Exam
(1) Visual
–(a) Unremarkable, possible pes planus
–(b) Evaluate for any biomechanical deficiencies
(2) Palpation = Point tenderness in the tibia
(3) ROM = Unremarkable
(4) Muscle Test = Pain with resisted plantar flexion
(5) Neurovascular = Unremarkable
(6) Special Test = None

Answer 3

Suspected Tibial Stress Fracture
OBTAIN FILMS FOR DX
Treatment
(1) Rest/duty modification
(2) Weight bearing modification and training
(3) NSAID/Tylenol/ice for pain
(4) Expect duty modification for roughly 12 weeks
–(a) “Cross training” for runners who develop stress fracture
—–1) Cycling, swimming or other low/no impact cardiovascular fitness modalities

Question 4

True/ False

Imaging is not needed to make diagnosis for Tibial Stress Fracture

Answer 4

False

Question 5

What should be on the differential of every patient with shin pain

Answer 5

Tibial Stress Fracture

Question 6

Muscles of the lower leg are divided into four compartments by what?

Answer 6

fibrous septa

Question 7

_______is characterized by an elevation of intra-compartmental pressure to a degree that compromises blood flow to the involved muscles and nerves

Answer 7

Compartment syndrome

Question 8

_________ can be acute resulting from crushing injury, muscle
strains or closed fracture

Answer 8

Compartment Syndrome

Question 9

What issue?

(1) Chronic in nature and followed by exercise
(2) Associated with prolonged walking or running with gradual onset of pain symptoms
(3) Do not experience pain at rest
(4) Anterior compartment is most commonly involved

Answer 9

Exertional compartment syndrome

Question 10

Clinical Symptoms
(1) Severe leg pain out of proportion to apparent injury
(2) Persistent deep ache or burning pain
(3) Parasthesias
(4) Symptoms progress over few hours
Physical Exam
(1) Seven “P’s”
–(a) Pain
–(b) Pallor
–(c) Parasthesias
–(d) Paresis
–(e) Poikilothermia
–(f) Pressure
–(g) Pulselessness
(2) Visual = Tense shiny skin that may be pale
(3) Palpation = Tenderness, tense compartment and possible coolness to affected compartment
(4) ROM = Increased pain with passive stretching of muscle in the involved compartment
(5) Muscle Test = Muscle weakness to muscles that are in or run through involved compartment
(6) Neurovascular = Decreased sensation and pulses in and distal to involved compartment
(7) Special Test =None

Answer 10

Compartment Syndrome
Treatment
1) Acute compartment syndrome is a medical emergency and requires fasciotomy by surgeon
(2) Prior to transport:
--(a) Remove any tight fitting items around the extremity
--(b) Including splints, dressings, etc.
(3) Place limb in neutral position
--(a) Not elevated or lowered
(4) Analgesics and supplemental oxygen

Question 11

Exertional compartment syndrome Treatment

Answer 11

(a) Rest from aggravating activities
(b) NSAIDS
(c) May require surgery
(d) Ice is considered contraindicated because of its constricting properties

Question 12

What Tendon?
Largest tendon in the body
Gastrocnemius and Soleus muscles converge to form this

Answer 12

Achilles tendon

Question 13

Theses are risk factors for what?

(1) Athletes
(2) Age (30-40 year olds)
(3) Male gender
(4) Obesity
(5) Running mechanics issues
- -(a) Misalignment, footwear, leg length discrepancy
(6) Fluoroquinolone antibiotic use associated
(7) Rheumatologic diseases

Answer 13

Achilles Tendon Rupture

Question 14

Sensation of being struck violently in back of ankle
(1) Possible “pop” followed by acute onset of pain
–a) Pain is not always felt
Physical Exam
(1) Exam patient in prone position, feet hanging off end of table
(2) Visual: Ecchymosis, edema, foot malalignment
(3) Palpation: Palpate tendon along its tract
–(a) Note thickening or defect
–(b) Note the areas of tenderness relate to pathology
(4) ROM: Possible impaired plantarflexion
–(a) Do not rely on this for diagnosis
(5) Strength: Plantarflexion may or may not be impaired
(6) Neurovascular: Check status. No impairment is typical
(7) Special Test: Thompson test is an excellent test
–(a) Still, negative Thompson test can miss about 10% of ruptures

Answer 14

Achilles Tendon Rupture.
Treatment
(1) Light duty
(2) Ice
(3) NSAID
(4) Consider Achilles tendon support
--(a) Heel lift
--(b) Elastic bandage
--(c) Taping
(5) Physical therapy
--(a) If available will give exercises and provide support as above

Question 15

Referral Decisions Achellies Tendon Rupture

(1) All complete tears require ortho consult
- -(a) Medevac for______
- -(b) If complete should be seen by ortho within ___ days
(2) Partial tear or tendinopathy that does not improve require ___ consult

Answer 15

a) complete tear
b) 1-2
(2) ortho consult

Question 16

Lateral ankle ligaments

1. _____ :Connects Talus and anterior fibula
2. _____ : Connects talus and posterior fibular
3. _____: Connects calcaneus and fibula

Answer 16

1. ATFL
2. PTFL
3. CFL

Question 17

What type of injury?

(1) Results in medial ankle sprain
(2) Syndesmosis injury

Answer 17

Eversion injury

Question 18

What type of injury?

(1) Results in lateral ankle sprain
- (a) Majority of ankle sprains involve ATFL only
- (b) Stronger forces can also lead to damage of CFL

Answer 18

Inversion injury

Question 19

What injury?

1) Results in “high ankle sprain”
(2) Disruption of the interosseous membrane (Tib-Fib

Answer 19

Eversion injury with Dorsiflexion

Question 20

What Dx/Tx
Injury post Inversion, Eversion or Eversion with dorsiflexion of the ankle.
Physical Exam
(1) Visual = Note Swelling, Ecchymosis and Wt bearing status
–1) Edema is measured with figure of 8 method
(2) Palpation
–(a) Entire fibula, distal tibia, foot, and Achilles tendon
–(b) TTP over ATFL, CFL or PTFL (anterior to posterior)
–(c) Check areas required for the Ottawa Ankle Rules
—–1) Posterior edge/tip of lateral malleolus
—–2) Posterior edge/tip of medial malleolus
—–3) Base of fifth metatarsal (Navicular bone)
(3) Muscle Test = Eversion and inversion may be limited by pain
(4) Neurovascular = Unremarkable
(5) Special Test
–(a) Positive Anterior Drawer- ATFL
—–1) Limited in the acute setting because of edema
—–2) More reliable in follow up visit
(6) Positive Talar Tilt- CFL
(7) Positive tib/fib squeeze( syndesmosis sprain)

Answer 20

Ankle Sprain
Treatment
(1) RICE
(2) NSAIDS
(3) Light Duty-activity modification
(4) Pain free calf stretching and ankle strengthening
(5) Bracing as needed

Question 21

True/False

Prolonged bracing will lead to poor proprioception

Answer 21

True

Question 22

Diagnostic Tests ankle sprain

(1) Risk stratification for obtaining plain films via _______ Rules
- -(a) Using these rules helps to decrease the number of plain films ordered for sprains
- —1) Still not 100% effective at “ruling out” a fracture
- —2) Catches about 98% of fractures
- —3) 2% of fractures missed
- -(b) ________ supersedes Ottawa Ankle Rules
(2) MRI for patients without relief after __-__ weeks

Answer 22

1) Ottawa Ankle
b) Clinical judgement
2) 6-8

Question 23

Referral Decisions ankle sprain

(1) Fractures foot or ankle
(2) Tears or subluxation peroneal tendons
(3) Nerve injury
(4) Chronic instability or recurrent sprains
(5) Failure to improve in 6 wks with appropriate treatment esp. OCD talar dome
(6) Syndesmosis sprains require non-weight bearing ambulation and possible surgical fixation
(7) If conservative management has not reduced symptoms in 6 weeks then orthopedic evaluation may be warranted

Answer 23

MEDEVAC SEE YAH!! NORMAL CEPHALIC AY TRAUMATIC

Question 24

What Dx/Tx
Clinical Symptoms
(1) Patients often report a sprain
(2) Pain is localized to the dorsum of the midfoot
(3) The swelling may be relatively mild
Physical Exam
(1) Visual
–(a) Ecchymosis in the plantar arch
–(b) Edema in the tarsometatarsal joint
(2) Palpation
–(a) Maximum tenderness and swelling over the tarsometatarsal joint rather than the ankle ligaments
(3) ROM = Unremarkable
(4) Muscle Test = Pain to the tarsometatarsal region with all resisted ankle motions
(5) Neurovascular = Unremarkable
(6) Special Test
–(a) During examination, stabilize the hindfoot (calcaneus) with one hand and rotate and/or abduct the forefoot with the other hand
–(b) This maneuver produces severe pain with a Lisfranc injury but only minimal pain with an ankle sprain

Answer 24

Lisfranc Fracture 
Treatment
(1) Ortho consult
(2) Non displaced injuries are treated with 6-8 weeks of non-weight bearing cast immobilization
(3) Fractures or dislocations that are displaced require surgery
(4) Non-weight bearing (NWTB)
(5) Analgesics
(6) MEDEVAC

Question 25

Referral Decisions Lisfranc Fracture

(1) Because these injuries are frequently missed, they warrant a low threshold for further evaluation and diagnostic testing
(2) Even a minimally displaced fracture dislocation requires _______
(3) Any possibility of _______ syndrome requires immediate surgical evaluation

Answer 25

2) surgical reduction

3) compartment

Question 26

Diagnostic Tests Lisfrank fx

(1) Radiographs (are/are not) needed for diagnosis
(2) When the AP radiograph shows that the ______ metatarsal base has shifted laterally, even by only a few millimeters, a Lisfranc fracture dislocation has occurred
(3) If confusion still exists, ______ is helpful in confirming the diagnosis

Answer 26

1) Are
2) second
3) CT or MRI

Question 27

Bunion creates _____ which is a lateral deviation of the great toe at MTP joint

Answer 27

hallux valgus

Question 28

What dx/tx
Clinical symptoms
(1) Pain and swelling, aggravated by shoe wear, are the principal complaints
(2) The Great toe pronates with resulting callus on the medial aspect
Physical Exam
(1) Visual
–(a) Valgus stress at the MTP with hypertrophic changes over joint
–(b) A hypertrophic bursa is evident over the medial eminence of the first metatarsal
–(c) The great toe is pronated (rotated inward) with subsequent callus on its medial aspect
(2) Palpation = Tenderness over the joint
(3) ROM
–(a) Normal MTP motion
–(b) MTP valgus greater than 15 degrees
(4) Muscle Test = Unremarkable
(5) Neurovascular
–(a) Numbness or tingling over the medial aspect of the great toe can result
(6) Special Test = None

Answer 28

Bunion / Halx Valgus
Treatment
(1) The initial treatment is patient education and shoe wear modifications
(2) Light Duty
(3) Ice

Question 29

Patient education and shoe wear modifications Halx valgus

• (a) Shoes should have adequate width at the forefront and should be constructed of soft uppers, with no thick stitching over the ____ eminence
• (b) An ______ or a shoe repair professional can stretch the shoe directly over the bunion
• (c) _____ place undue pressure on the forefoot and bunion prominence and should be avoided

Answer 29

a) medial eminence
b) orthotist
c) High heels

Question 30

Diagnostic Tests Bunion / Halx Valgus

(1) The severity of a bunion deformity is graded by measuring forefoot angles on ________ radiograph of the foot
(2) The normal hallux valgus angle is < __°, and a normal intermetatarsal (IM) angle is < 10°

Answer 30

1) weightbearing AP

2) 15 degrees

Question 31

Morton neuroma is not a true neuroma but rather a ______ of the common digital nerve as it passes between the metatarsal heads

(1) The condition is most common between the ____ and _____ toes (third web space)
(2) Less common between other digits

Answer 31

perineural fibrosis

1) third and fourth

Question 32

What Dx/Tx
Clinical Symptoms
(1) Plantar pain in the forefoot is the most common presenting symptom
(2) Dysesthesias into the affected two toes or burning plantar pain that is aggravated by activity is common
(3) Occasionally, patients report numbness in the adjacent toes of the involved web space
(4) Night pain is rare
(5) Many patients state that they feel as though they are “walking on a marble” or that there is “a wrinkle in my socks”
(6) Removing the shoe and rubbing the ball of the foot often obtain relief
(7) Wearing high-heeled or tight, restrictive shoes aggravate symptoms
Physical Exam
(1) Visual = Unremarkable unless plantar calluses are present
(2) Palpation
–(a) Isolated pain on the plantar aspect of the web space is consistent with an intermetatarsal neuroma
(3) ROM = Unremarkable
(4) Muscle Test = Unremarkable
(5) Neurovascular = Possible decreased sensation of the digital nerve
(6) Special Test = Positive metatarsal squeeze test
–1) Apply upward pressure between adjacent metatarsal heads and then compress the metatarsals from side to side with the free hand
–2) The upward pressure places the neuroma between the metatarsal heads, allowing it to be compressed during side-to-side compression

Answer 32

Morton Neuroma
Treatment
(a) Patients should be advised to wear a low-heeled, soft-soled shoe with a wide toe box
(b) Metatarsal pads
–1) Takes pressure off of the metatarsal heads

Question 33

______ is a long fibrous band like tissue that arises from the medial tuberosity of the calcaneus and extends to the proximal phalanges

Answer 33

Plantar fascia

Question 34

What is the most common cause of heal pain in adults?

Answer 34

Plantar Fasciitis

Question 35

Clinical Symptoms
(1) The pain is often most severe on awakening or when rising from a resting position because the first few steps stretch the plantar fascia
(2) Prolonged standing and walking also increases the pain; sitting typically relieves symptoms
(3) Focal Pain directly over the medial calcaneal tuberosity and 1-2 cm distally along the plantar fascia
Physical Exam
(1) TTP directly over the plantar medial calcaneal tuberosity and 1 to 2 cm distally along the plantar fascia
–(a) Use heavy palpation while dorsiflexing toes with other hand
(2) ROM = Normal
(3) Muscle Test = Normal
(4) Neurovascular = Unremarkable
(5) Special Test = None

Answer 35

Plantar Fasciitis.
Treatment
(1) NSAIDS
(a) Ice massage
(b) Light duty to include activity modification
(c) OTC heel pads
(d) Night splints may be helpful

Question 36

Referral Decisions Plantar Fasciitis

(1) Patients whose symptoms do not respond to ____treatment need further evaluation
(2) Surgical release should be considered only after __ to __ months of intense nonoperative management

Answer 36

1) non-operative

2) 6 to 12

Question 37

What dx / tx
Clinical Symptoms
(1) “Pump bump” that is irritated by shoe wear
(2) Start-up pain
(3) Pain after activity
(4) Antalgic gait
Physical Exam
(1) Visual
–(a) Calcaneal prominence may be present with associated edema
–(b) Superficial bursa may be present(pump bump)
(2) Palpation
–(a) Tenderness may be noted over the heel or directly on the Achilles tendon
(3) ROM = Dorsiflexion may be limited by pain
(4) Muscle Test = Normal
(5) Neurovascular = Unremarkable
(6) Special Test = Positive Thompson test for Achilles tendon rupture

Answer 37

posterior heel pain
Treatment
(1) Light duty- activity modification
(2) Heel lift or open back shoes
(3) Ice massage
(4) Achilles stretch
(5) Casting for 6 weeks in extreme cases

Question 38

Pain in the posterior heel may originate from one or more of the following structures:

(1) Insertion of the Achilles tendon at the calcaneus = ____
(2) Retrocalcaneal bursa =
(3) Prominent process of the calcaneus impinging on the retrocalcaneal bursae and/or Achilles tendon = ____
(4) Inflammation of the bursa between the skin and the Achilles tendon = ____

Answer 38

1 (Achilles tendinosis)
2 (retrocalcaneal bursitis)
3 (haglund syndrome)
4 (pre-achilles bursitis)

Question 39

Posterior heel pain

Orthopedic consultation if failure to respond to nonsurgical treatment or suspect partial or full _____ rupture

Answer 39

Achilles tendon

Question 40

What Dx / Tx
Hyperextension injury of the first metatarsal
-Increased incidence of hyperextension injury associated with playing on artificial turf
-Patients usually report swelling, tenderness, and limited motion of the first MP joint
Physical Exam
(1) Visual
–(a) Sometimes normal
–(b) Edema and ecchymosis with more severe injuries
–(c) Antalgic gait
(2) Palpation = Tenderness over the MTP
(3) ROM = Passive flexion and extension of the great toe is painful
(4) Muscle Test = May be limited by pain
(5) Neurovascular = Unremarkable
(6) Special Test = N/a

Answer 40

Turf Toe
Treatment
(1) RICE
(2) NSAIDS
(3) Stiff shoe inserts
(4) Severe injury requires protective weight bearing or immobilization for 1-2 weeks and with 4-6 week period of rest from sports

Question 41

turf toe
Severe injury requires protective weight bearing or immobilization for __-__ weeks and with __-__ week period of rest from sports

Answer 41

1-2 immobilization

4-6 rest from sports

Question 42

Turf toe Referral Decisions

(1) ______ fractures can require open reduction or excision
(2) Urgent surgical intervention is necessary for an ______ Dislocation
(3) ______ lesions or loose bodies also require further evaluation

Answer 42

1) Intra-articular
2) irreducible dislocation
3) Osteochondral