High Yield 4 Flashcards

Question

Sx of bakers cyst

Answer 1

Usually asymptomatic Posterior knee pain, swelling, palpable mass, knee stiffness Can have leg swelling, calf pain

Answer 2

Palpable medial popliteal mass Examine in full extension + 90 degrees flexion Foucher sign Tense cyst with knee in extension softens or decreases in size with knee flexion Change in findings related to knee position helps to differentiate popliteal cyst from solid masses Homans sign Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight Indicates DVT but can be positive in Baker’s cyst

Answer 3

Manage underlying joint pathology May not need treatment of cyst if asymptomatic If symptomatic w/o vascular or neurogenic compression: Rehab to maintain knee flexibility Direct cyst aspiration + steroid inj If conservative x6 wks does not work or if vascular or neurogenic compression, refer for surgery

Answer 4

Cyst rupture or dissection Enlarged cyst may compress adjacent vein, resulting in pseudothrombophlebitis or thrombophlebitis with symptoms of leg swelling and erythema. Compression of tibial nerve may result in neuropathy, plantar foot numbness, or gastrocnemius atrophy. Compression of popliteal artery may lead to limb claudication or ischemia. Compartment syndrome may result from cyst rupture, which requires emergent management.

Answer 5

Deep vein thrombosis (DVT) Popliteal artery aneurysm Solid tumors (lipoma, sarcoma, etc.) Other cystic structures (ganglion cyst, meniscal cyst, myxoid tumors)

Answer 6

Contact sports (football, soccer, skiing, wrestling) MOI Dashboard injury in MVA (Posteriorly directed force to anterior proximal tibia in flexed knee)

Answer 7

Acute: Pain in posterior knee Pain w/ kneeling Feeling of instability Rapid onset swelling Chronic: Vague anterior knee pain Pain with or inability to descend inclines/stairs, deceleration, or running at full stride

Answer 8

Perform neurovascular exam before other provocative tests If combined with an ACL injury, assume vascular injury, perform ankle-brachial index, and, if low stat, referral to vascular surgeon Posterior drawer test positive Posterior sag positive Quadriceps active test positive Perform with the patient supine and knee flexed at 90 degrees and hip flexed at 45 degrees. Examiner stabilizes the foot, and the patient attempts to extend the knee while the examiner applies a counter force against the ankle. Patient also may be asked to activate quadriceps by sliding foot down the table. In a PCL-deficient knee, the posteriorly subluxed tibia will translate anteriorly with quadriceps activated. Dynamic posterior shift test: Patient is supine with knee and hip flexed at 90 degrees. Examiner slowly extends knee. With a PCL tear, there will be “clunk” near full extension when the posteriorly subluxed tibia is reduced.

Answer 9

XR: AP, lateral, sunrise, tunnel, oblique + stress views Stress XRs (lateral XR with knee flexed + posteriorly directed force applied to proximal tibia): 8mm or more posterior tibial translation is indicative of complete PCL tear MRI gold standard

Answer 10

ACL tear Tibial or fibular fracture Medial or lateral collateral ligament tear Meniscal derangement Posterolateral corner injury Knee and/or patella dislocation

Answer 11

Acute Ice, compression, elevation, immobilization (partial wt bearing, full extension for grade 3 lesions) Refer to ortho Non operative indications: Isolated grade 1 + 2 tears RTP 2-4wks w/ knee brace PT Multiphase with time-specific and objective finding–related phases Progressive weight-bearing Quadriceps strengthening Immobilization initially, with progressive addition of flexion until full range of motion (ROM) achieved Functional PCL brace may be useful but not proven effective

Answer 12

Associated bony avulsion fractures. Multiple ligament injuries. Persistent pain in grade 3 lesions. Chronic symptomatic instability with activities of daily living or with sports. Acute grade 3 injury in young, active patient

Answer 13

Nonoperative: Chronic PCL laxity Progressive medial compartment and patellofemoral degenerative changes Increased risk of meniscal tears, articular cartilage injury with chronic PCL insufficiency Operative: Most common: residual laxity Iatrogenic neurovascular injury (especially of the popliteal artery) Loss of motion Infection Medial femoral condyle osteonecrosis Anterior knee pain Painful hardware

Answer 14

Prior history of subluxed or dislocated patella Recurrence rate 15–50% after initial dislocation Adolescent females Patella alta (“high-riding patella”) Excessive genu valgum Weak vastus medialis Excessive tibial torsion Family history of patellar instability Trochlear dysplasia Lateralized tibial tuberosity Weak hip abductor and external rotator muscles Risk factors associated with developmental dysplasia (firstborn girl, high birth weight, deliver by cesarean section, breech delivery)

Answer 15

Severe pain, pop Consider subluxation if hx consistent w/ dislocation but pain resolved

Answer 16

Immediately after dislocation, may show patella dislocated laterally and prominence medially due to uncovered medial femoral condyle Obvious effusion Tenderness most apparent over the medial edge of patella and lateral femoral condyle Limited range of motion with knee in extended position Fear of redislocation when knee is flexed Positive apprehension sign with movement of patella laterally Check anterior cruciate ligament (ACL) and meniscus, as up to 12% of patellar dislocations have associated major ligamentous or meniscal injury. “J” sign: Seated patient straightens the knee; the patella moves outward instead of straight upward.

Answer 17

Reduce (may need conscious sedation): leg in extension w/ hip flexed (reduces tension of quad tendon), apply Gentle pressure on patella directed lateral to medial Postreduction XRs RICE Knee immobilization x2-3 wk Wt bearing as tolerated after 1 wk Aspiration if hemarthrosis present to reduce pain - check for fat globules (would help dx osteochondral #)

Answer 18

Osteochondral fracture Recurrent patellar dislocations despite adequate rehabilitation, especially in younger patients (<14 yr old), in whom recurrence rates can reach 60% Evidence of joint locking High-risk athlete participates in activities involving pivoting and is at increased risk of recurrent patellar dislocation

Answer 19

PT Isometric quadriceps exercises immediately Active range of motion exercises at 1 wk quadriceps and lateral hip strengthening Bracing Hinged brace is used for ambulation until 100 degrees of painless flexion is present, there is no effusion, and a normal heel-to-toe gait is possible. Then neoprene sleeve until normal, painless activities of daily living are possible. RTP There should be evidence of adequate healing (absence of sensations of instability, lack of effusion, and absence of pain on patellofemoral compression) and adequate function (able to perform rotational movements such as pivoting, cutting, and twisting without evidence of instability) for return to sports Athlete may need McConnell taping or patellar stabilizing braces to accomplish this.

Answer 20

Complete disruption of tibiofemoral articulation

Answer 21

Dislocation is described as the displacement of the tibia relative to the femur Anterior dislocation (40%): Hyperextension of the knee of at least 30 degrees Rupture of the posterior capsule followed by the PCL Posterior dislocation (33%): Direct blow to the anterior tibia with the knee flexed at 90 degrees (“dashboard” injury or falling onto flexed knee) ACL is usually spared. Medial dislocation (4%): Varus stress causing tear to ACL, PCL, and LCL; highest risk of posterolateral corner (PLC) damage and thus the highest risk of irreducible dislocation Associated with tibial plateau fracture Lateral dislocation (18%): Valgus stress causing tear to ACL, PCL, and MCL Associated with tibial plateau fracture

Answer 22

Popliteal artery injury (64% of dislocations) - only 6 hr window to prevent permanent ischemic damage Fibular nerve injury (50% of dislocations) Characterized by hypesthesia of anterolateral leg and dorsum of foot, weakness of ankle dorsiflexion

Answer 23

More common in young males Morbid obesity Contact or high velocity sports

Answer 24

Pop Knee pain and instability Often unable to weight bear

Answer 25

Difficulty weightbearing If knee dislocation has not spontaneously reduced, deformity is obvious (and should present to the ED). Most (especially the lower energy sporting injuries) reduce spontaneously Dimple sign: dimple of the medial skin and soft tissues Pucker sign: Puckering of skin results from its attachment to the invaginated capsule A key sign is extensive bruising of either medial or lateral knee, which is from a hemarthrosis that has leaked out from a torn joint capsule If high impact injury + multiple ligaments unstable, suspected relocated knee dislocation Vascular exam: By palpation, Doppler, ankle-brachial pressure indexes, and distal perfusion Dorsalis pedia, posterior tibialis, popliteal Popliteal thrill or expanding pulsatile hematoma Signs of distal ischemia: pallor, paresthesias, pain, paralysis, unequal temperature If peripheral pulses are normal initially, it is essential to do serial, frequent exams with documentation of pulses Neuro exam: Sensory: anterolateral lag, dorsum of foot, first web space Motor: ankle dorsiflexion, eversion

Answer 26

Tibial plateau fracture Supracondylar femoral fracture Isolated fibular nerve injury ACL injury/rupture

Answer 27

CBC, Cr, INR XR to r/o # but may be normal ABI Systolic BP x4 limbs w/ Doppler probe Highest pressure from dorsal pedal pulse or posterior tibial pulse / highest brachial BP If asymmetric pulses or ABI <0.9, perform angiography MRI

Answer 28

Support ABCs Splint in 20 degrees flexion to prevent traction or compression of the PA Get to hospital ASAP + contact ortho immediately - plan to reduce in ED In ED: Reduce to reduce pressure on neurovascular structures If pucker or dimple sign present, suspect posterolateral dislocation which is irreducible - consider immediate open reduction in ED Refer to ortho +/- vascular Admit for serial ABI + pulse exams x48 hrs Rehab: Goal of 90 degrees knee flexion 6 wk postoperatively and 120 degrees at 12 wk No return to full activity or sports before 9 mo

Answer 29

Amputation Compartment syndrome Neurovascular deficit Chronic pain Stiffness Instability

Answer 30

Recent increase in training Increased running, squats, lunges Patella hyper or hypomobility Malalignment Valgus/ varus deformity Common in young teens Specialisation of single sport leads to higher incidence

Answer 31

Diffuse anterior knee pain Associated w/ squatting, running, stairs, prolonged sitting Persists for years Pain on knee straightening

Answer 32

Crepitus/ grinding Anterior knee pain during squatting Tenderness on patella edges

Answer 33

Patellar or quadriceps tendinopathy Patellofemoral osteoarthritis Patellar instability with subluxation or dislocation Osteochondral defect of the trochlear or patellar surface Osteochondritis dissecans Iliotibial band syndrome Infrapatellar fat pad inflammation or impingement Synovial plica Retinacular strain Osgood-Schlatter apophysitis (proximal anterior tibia) Sinding-Larsen-Johansson apophysitis (inferior patellar pole) Referred pain from the hip, often affecting the anterior distal thigh and knee

Answer 34

Rx Foot orthotics/ supportive shoes Ice, compression, elevation for acute pain control Taping (McConnell) PT Activity modification recommendations + home exercises Reduce aggravating activity (running, squatting) Encourage other activities (swimming, cycling) Combined hip + knee exercises preferred Isometric quadriceps strengthening (push knee into floor with leg straight) Straight leg lift from floor slowly IT band stretches Hamstring stretches Hip adductor strengthening by squeezing ball between legs Calf stretch RTP If patient has PFP during, immediately following, or the day after exercising: Decrease activity. Avoid strength training exercises such as full squats and lunges. Consider alternate activities, such as an elliptical trainer, bicycling, or swimming. Runners who need to maintain running-specific conditioning, use a floatation belt for pool running. Sx usually resolve within 4 wks

Answer 35

Twisting, shearing or compressive force Usually twisting through a flexed, planted knee

Answer 36

Male gender Abnormal mechanical axis Playing soccer or rugby Ligament deficiency Degenerative joint disease Discoid meniscus Poor quadriceps control Waiting >12 mo between ACL tear and reconstruction surgery is a risk factor for medial meniscus tear

Answer 37

ACL Tib plateau #

Answer 38

Pain with walking, stairs, squatting, kneeling, prolonged sitting Onset after plant + pivot action Slow onset swelling Catching, locking, clicking Giving way

Answer 39

Locked knee (bucket handle tear, ligament tear or loose body) Effusion + joint line tenderness McMurray positive Thessaly positive

Answer 40

XR wt bearing (AP, lat, skyline, tunnel) MRI

Answer 41

Synovitis Intra-articular loose body Articular cartilage defect (OCD) Ligamentous injury, particularly ACL and/or MCL Patellar subluxation/dislocation Degenerative joint disease PFPS Tibial plateau fracture

Answer 42

Initial: RICE Surgery or Non op (For small central tears or degenerative tears) - steroid shot, PT Then: Lower weight bearing activities (bike, swim) Avoid plant/ pivot/ twist activities PT addressing balance, quadriceps, and hamstring strength RTP 6-12wks

Answer 43

Locked knee Younger patients with vertical longitudinal tears in periphery of meniscus Locking symptoms, flap tears, and bucket-handle tears. Associated cruciate ligament injury, osteochondral defect, loose bodies, or fracture. Nonurgent referrals include tears treated nonoperatively but that continue to cause pain or disability

Answer 44

Injury to peroneal nerve possible with lateral meniscus repair Injury to infrapatellar branch of saphenous nerve possible with medial meniscus repair Repair could fail, resulting in repeat arthroscopy. Infection

Answer 45

“True locking” - mechanical block, usually extension blocked, caused by meniscus tear or loose body - sometimes a wiggle can unlock it “Pseudo locking” - pain/ muscle contracture “locks” - can be in flexion or extension, d/t swelling, inflammation, patella maltracking, plica syndrome Acutely locked knee is an orthopedic emergency

Answer 46

Apophysitis (inflammation of growth plate (apophysis)) of tibial tuberosity at attachment to patellar tendon Overuse injury

Answer 47

Ages of growth spurts (girls 8-13 y/o, boys 12-15 y/o) Males Running + jumping sports Excessive kneeling Overweight

Answer 48

Anterior knee pain Often bilateral Worse w/ activity (running, jumping, kneeling), improves w/ rest Chronic, insidious, fluctuant swelling

Answer 49

Tender tibial tuberosity Prominent tibial tubercle Able to maintain full symmetric knee extension w/ SLR If inable to do this, highly suggestive of tibial tubercle avulsion # Pain w/ resisted knee extension, active or passive knee flexion

Answer 50

Patellar tendonitis Sinding-Larsen-Johansson syndrome Tibial tubercle avulsion fracture Tibial plateau fracture Patellar fracture Osteochondritis dissecans Patellofemoral syndrome Pes anserine bursitis Patellar tendon rupture Patellar subluxation Chondromalacia patellae Hoffa disease (infrapatellar fat pad impingement) Osteomyelitis Tumor

Answer 51

Relative rest Activity as tolerated if sx resolve within 24hrs NSAIDs Ice after exercise Lasts 6-18mo, self limiting (will resolve when growth plate closes) Stretch quads + hamstrings + strengthen quads If conservative treatment failed, consider surgical excision of enlarged tibial tubercle

Answer 52

Chronic, insidious, progressive Medial distal ⅔ of tibia Pain w/ activity, can improve as activity continues, can be painful at rest too

Answer 53

Female sex Higher body weight Navicular drop (an indicator of excessive pronation) Prior running injury Limited external/internal rotation of hip Limited ankle range of motion (ROM) Higher body mass index (BMI) Overall poor conditioning Limited core strength

Answer 54

Tenderness to palpation along the middle to distal 2/3 of the tibia, along the posteromedial border Diffuse posteromedial pain with palpation is most sensitive finding Shoe exam shoes overpronation wear pattern, excessive wear of shoes r/o stress # by hopping on one foot, vibration

Answer 55

XR + possibly bone scan to r/o stress fracture

Answer 56

Stress fracture Compartment syndrome Muscular strain Nerve entrapment Fascial defects Popliteal artery entrapment syndrome

Answer 57

Rx Correct biomechanics, well cushioned shoe Ice, NSAIDs Complete rest ideally then cross training with pain-free activities Stretching and strengthening Physiotherapy - shockwave therapy Taping Activity modification recommendations + home exercises Target-specific stretching and strengthening exercises Core strengthening Towel calf stretches Tracing alphabet with toes Alternate heel/toe walking

Answer 58

Shock-absorbing insoles: most promising in studies Pronation control insoles if navicular drop Replacing running shoes after 300 miles/ 6mo wear Gradually increasing running programs Increase rest days Cross training w/ non wt bearing activity

Answer 59

Hx Delayed onset muscle soreness - muscle pain after training sensation. Typically starts 12 hrs after exercise, peaks at 24-48 hrs, stops after 5 days Physical Painful muscles, swelling, increased muscle girth, reduced passive stretch, reduced muscle strength

Answer 60

regularly participating in exercise that causes symptoms, warming up correctly, stretching + massage

Answer 61

Often a prodrome “cramp prone state” when muscle feels tight or painful. Cramps usually involve muscles which cross 2 joints (like calf, hamstrings or quads) Painful, involuntary contractions of muscles Commonly calf, quads + abdomen Tense, tender, involuntary contraction of muscle belly

Answer 62

Gastroc/ soleus strain or tear DVT Popliteal artery entrapment Referred pain from lumbar spine

Answer 63

Rest Oral rehydration + electrolyte replacement - IV if unable to tolerate by mouth Passive stretching Massage Ice

Answer 64

Training should be similar to match/ game intensity + duration Passive stretching during play Acclimatise to heat Appropriate clothing Hydration

Answer 65

Increased blood volume and venous tone, earlier onset of sweating, more sweat volume, more diluted sweat

Answer 66

Overuse tendinopathy that occurs from compression of the iliotibial band (ITB) against the lateral femoral epicondyle

Answer 67

Pain is especially sharp after foot strike in the gait cycle, usually at ~30 degrees of knee flexion Lateral knee pain - sharp or burning Pain is not present when the patient starts exercising but begins at a predictable time or distance within the workout. Symptoms that subside shortly after the workout but return with the next workout Pain worse with downhill running, stride lengthening, or sitting for long periods of time with a flexed knee Involvement in sports that require continuous running or repetitive knee flexion (i.e., bicycling)

Answer 68

Training factors: higher weekly mileage, downhill running, disproportionate running on a track in the same direction Increased peak hip adduction (possibly owing to significant weakness of the hip abductors of one limb as compared with the other) and increased knee internal rotation during stance phase, with running

Answer 69

May notice local tenderness and swelling as well as crepitation, snapping, or pitting edema over the distal ITB where it passes over the lateral femoral epicondyle, and there may be pain or paresthesia along the length of the band Positive Ober test Position the patient on the unaffected side with the involved knee in 90 degrees of flexion. The leg is abducted at the hip, and the examiner then grasps the ankle and extends leg, allowing the knee to return to an adducted position. A person with ITB tightness will remain abducted Positive Noble compression test: With the patient on his or her side with the affected knee up and flexed at 90 degrees, apply pressure on the ITB at the lateral femoral epicondyle and extend the knee. A positive test occurs when pain occurs as the knee approaches 30 degrees of flexion Leg length discrepancy can cause tightening of ITB

Answer 70

Patellofemoral syndrome Degenerative joint disease Lateral meniscal damage or pathology Lateral collateral ligament sprain Superior tibiofibular joint sprain Popliteal or biceps femoris tendinopathy Peroneal nerve injury Gout and other metabolic arthropathy Referred pain

Answer 71

Rest, avoid aggravating activities Ice, NSAIDs PT - hip + core strengthening + stretching, foam roller Gait training - increasing gait width, reducing hip adduction changing from heel strike to forefoot landing, and avoiding excess pronation Can consider steroids but this increases risk of ITB rupture Surgery for ITB release if no improvement w/ conservative therapy RTP when sx have 100% improved - going back too early will cause significant delay Usually 6 wks

Answer 72

Usually lateral, diffuse leg pain Often bilateral Fullness, cramp-like, tightness type pain Aggravated w/ impact activities No pain at rest but pain w/ activity, usually specific amount of exertion every time Resolves <30 mins after stopping activity Associated w/ paresthesias + foot drop Change in activity/ training intensity may have provoked sx

Answer 73

Rapid increase in repetitive activity Participation in high-risk sport activities Significant musculature of the lower extremity Diabetes mellitus

Answer 74

Normal exam at rest Examine postexertion Pain may become present Muscle/facial tightness may be palpable Neurovascular abnormalities may become present Passive stretching of the muscles in the affected compartment may also cause pain.

Answer 75

Needle manometry is gold standard Pre + post exercise compartment pressures

Answer 76

Acute compartment syndrome Stress fracture Medial tibial stress syndrome Fascial hernia Tendonitis Popliteal artery entrapment syndrome Peripheral nerve entrapment Peripheral vascular disease Referred pain (L4) Exertional DVT

Answer 77

Conservative measures: stretch, soft tissue therapy (friction massage), correct biomechanics (rarely successful), forefoot training Definitive management: fasciotomy, 80-90% success rate Recurrence rate 20-30% RTP 8-12 wks

Answer 78

(1) preexercise/rest pressure of greater than 15 mmHg (2) 1-minute postexercise pressure of greater than 30 mmHg (3) 5-minute postexercise pressure of greater than 20 mmHg. (4) Post-Exercise elevated pressure despite 15 minutes rest

Answer 79

Usually associated w/ # or crush injury Physical Pain out of proportion to physical exam Pain w/ passive stretching Neurovascular abnormalities at rest Management Immediate consult for ortho surg Emergency fasciotomy Complications Muscle necrosis

Answer 80

Can be asymptomatic Swelling, pain, discoloration PE sx can be first sign (SOB, CP, cough, hemoptysis)

Answer 81

Well criteria for DVT Swelling >1cm compared to opposite leg Palpable cord Warmth Superficial venous dilation Homans sign - passive dorsiflexion of ankle elicits pain in calf

Answer 82

D dimer if low risk, if high risk + neg D dimer then do further imaging Bilateral duplex US CBC, PT as a baseline ?PE do CT angiography or V/Q scan ECG - S wave in lead I, Q wave in lead III, inverted T wave in lead III (S1Q3T3)

Answer 83

Superficial thrombophlebitis Cellulitis Torn muscles and ligaments Ruptured Baker cyst Bilateral edema (seen with heart, kidney, or liver disease) is rarely caused by DVT. Prior DVT and postphlebitic syndrome Arterial insufficiency Arthritis Lymphangitis Extrinsic compression of iliac vein secondary to tumor, hematoma, or abscess Hematoma Lymphedema Neurogenic pain Prolonged immobilization or limb paralysis Stress fractures or other bony lesions Varicose veins

Answer 84

If provoked, anticoagulation x3mo If unprovoked 1st time, indefinite anticoagulation if low risk bleeding, if high risk bleeding then 3mo Rivaroxaban 15mg PO BID x3 wks then 20mg PO daily Apixaban 10mg PO BID x7 days then 5mg PO BID daily Refrain from training x1mo Compression stockings x9mo

Answer 85

Light ambulation after 24hrs of anticoagulation Weeks 1 to 3: reintroduction to activities of daily living Week 4: begins engaging in non–weight-bearing activities (e.g., swimming) Week 5: progresses to nonimpact-loading exercises (e.g., cycling) Week 6: begins impact-loading exercises (e.g., running) Week 6+: A gradual transition to sport-specific protocols as well as an increase in the duration and intensity of training may be initiated No contact sports while on anticoagulation

Answer 86

Avoid prolonged immobility. Hydrate adequately. Consider compression stockings when immobilized. Caution when using birth control; use low-estrogen pills when possible. Prophylaxis for hospitalized patients When travelling: Hourly walking breaks Loose clothing Avoid crossing legs

Answer 87

Immobilisation (trauma, long flights, post op) Pregnancy Malignancy Smoking Steroids Dehydration Increased age Antiphospholipid syndrome Estrogen therapy Fam hx Obesity Trauma Clotting disorder (factor V leiden, antithrombin deficiency, protein C or S deficiency)

Answer 88

Excessive load during an eccentric contraction, such as with running or jumping Usual mechanism of injury occurs in the later part of the swing phase as the hamstrings rapidly change from eccentrically working to decelerate knee extension to concentrically becoming an extensor of the hip

Answer 89

Strength imbalances, flexibility, core strength, lumbopelvic position, and fatigue Prev hx of hamstring injury

Answer 90

Usually acute: sudden onset posterior thigh pain Chronic presents w/ tightness

Answer 91

A “stiff-legged” gait may occur as patient tries to avoid hip flexion with knee extension. Position patient prone and inspect for swelling and/or ecchymosis. Palpate the entire length of each hamstring muscle going from common origin on ischial tuberosity moving distally until insertion on fibular head (BF), medial femur (SM), and medial tibia (ST)

Answer 92

Direct hamstring injury, including muscle laceration or contusion (common direct mechanism for injury as opposed to indirect strain mechanism) Posterior lateral corner knee injury, meniscal injury, or popliteal cyst formation or rupture Pelvic or proximal femoral stress fracture Piriformis syndrome, gluteus medius injury, or adductor strain Pain radiating from the lumbar back, sacroiliac joint, or hip

Answer 93

Acute Goals: control pain, swelling, hemorrhage, and muscle fiber adhesion; work toward restoration of normal gait Protection, rest, ice, compression, and elevation (PRICE) Subacute/ rehab Advance activity as tolerated Core strength Lumbar stability Nordic hamstring exercises RTP When pain free - can be weeks to months Surgery Consider in severe proximal or distal injuries

Answer 94

Nordic hamstring exercises

Answer 95

Biceps femoris Semitendinosus Semimembranosus

Answer 96

RF Sprinters, water skiers Mechanism Forceful knee extension while hip joint is in flexion

Answer 97

Pain and bruising in posterior thigh Stiff leg gait (they don't want to stretch hamstring by flexing hip, or activate it by flexing knee) Bruising Often can palpate retracted muscle Weakness and pain with resisted knee flexion

Answer 98

X-rays to look for avulsed bony fragment, US or MRI to confirm

Answer 99

Operative repair suggested for complete proximal avulsions, or 2 tendon involvement in young, active individuals if there is retraction. Suggest: obtain imaging and refer above semi-urgently.

Answer 100

Spectrum of injuries from sprain to dislocation Lisfranc complex is 1st, 2nd + 3rd metatarsal base, cunieforms + cuboid bone + ligaments Lisfranc ligament is between medial cunieform + 2nd MT

Answer 101

Direct trauma (heavy object dropped on dorsum of midfoot or crush injury) Indirect: (twisting force on a plantar-flexed foot) eg football or soccer player is tackled while their foot is caught or planted) Step-off injuries: Missing a step or misjudging a landing, causing the forefoot to rotate while the midfoot remains fixed

Answer 102

RF Males Commonly associated conditions Cuneiform and cuboid fracture dislocations Compartment syndrome of the foot

Answer 103

Midfoot or diffuse pain Swelling Physical Pain w/ wt bearing, pain on tip toes Midfoot swelling Plantar ecchymosis is classic Tenderness over tarsal-metatarsal joint Passive pronation and supination of forefoot can cause pain Pain w/ stress of midfoot Chronic - instability causes flattening of arch

Answer 104

XRs (AP, internal oblique, lateral) - wt bearing increases sensitivity widened interval between 1st + 2nd MTS increased displacement between the medial cuneiform and 2nd MT base Increased interval between the medial and intermediate cuneiforms CT good for subtle injuries MRI good for ligament

Answer 105

Lisfranc fracture dislocation Tarsometatarsal sprain Metatarsal fracture Cuboid fracture Cuneiform fracture

Answer 106

Grade 1 Immobilization in short walker boot with protected weight-bearing x2 wks Then short boot w/ wt bearing as tolerated x4 wks Walking without boots at 6 wks No high-impact activity for first 3 to 4 mo after injury Single leg hop test pain free before activity Injuries beyond grade 1, particularly any injuries with displacement on x-ray or evidence of dynamic instability Refer to surgeon, non wt bearing ORIF

Answer 107

Compartment syndrome Post traumatic arthritis Progressive foot deformity + functional impairment

Answer 108

Pain in posterior calf + heel Initially subsides w/ use but returns w/ continued use Morning stiffness Weakness Intermittent swelling

Answer 109

Worn shoes Pain and stiffness 2 to 6 cm above Achilles tendon insertion Pain with running, especially sprinting Tenderness over the distal Achilles tendon (2 to 6 cm above the insertion): Tenderness near insertion suggests insertional Achilles tendinopathy (enthesopathy) or bursitis. Thickening of distal Achilles tendon in chronic cases Tenderness with resisted plantar flexion Weakness with repetitive single leg heel raises Crepitus with ankle motion Negative Simmonds-Thompson test: Compression of the calf will cause normal passive plantar flexion of the foot: A positive test (absence of plantar flexion with calf compression) suggests complete Achilles tendon rupture. Decreased ankle dorsiflexion (from tight heel cord)

Answer 110

Training errors: recent increase in distance, intensity, or length of activity Worn and/or old shoes Inflexibility, especially tight heel cords Higher body mass index (BMI) Hypertension Diabetes Hypothyroidism Older patients: decreased tensile strength and increased stiffness of tendon Malalignment of the leg (excessive genu valgum, external tibial torsion) or ankle/foot (pes planus) Medications: Fluoroquinolones: Recent use of these antibiotics has been associated with increased risk for Achilles tendinopathy and rupture. Glucocorticoids Aromatase inhibitors Statins have been theorized to cause tendinopathy and have been shown in some animal models.

Answer 111

Retrocalcaneal bursitis Superficial Achilles bursitis Calcaneal apophysitis (Sever condition) in adolescents Haglund deformity: prominent superior tuberosity of calcaneus Achilles tendon rupture Gastrocsoleus tear Plantaris tendinopathy Overuse myositis Chronic exertional compartment syndrome Os trigonum irritation or posterior ankle impingement syndrome Vascular/neurogenic claudication Deep venous thrombosis Hematoma Infection

Answer 112

Relative rest Consider 7-10 days immobilisation w/ walking boot if sx severe Ice after activity Heel lifts short term Night splints for severe/ refractory sx Properly fitted shoes Stretching Strengthening - gastrocnemius and soleus strengthening program with emphasis on eccentric exercises NSAIDs Nitroglycerin patch ¼ patch (1.25mg/ 24hr) can be applied to tendon, replaced q24hr until sx subside PRP Surgery Debridement If sx persist >6mo w/ conservative treatment Gradual RTA No more than 10% increase per week

Answer 113

Laceration Pushing off with the weight-bearing forefoot while extending the knee, such as with sprint starts and the push off in basketball Sudden, unexpected dorsiflexion of the ankle, as when the foot slips in a hole Violent dorsiflexion of a plantarflexed foot, as with a fall from a height

Answer 114

Feeling of being kicked in back of heel Pop + pain in ankle Pain in heel Pain w/ wt bearing

Answer 115

Swelling and/ or ecchymosis Able to walk but not on toes May still be able to plantar flex but reduced strength Increased passive dorsiflexion Unable to do single leg calf raise Compare resting posture of feet Positive Thompson test Palpate for gap

Answer 116

Achilles tendinitis Ankle sprain Peritendinitis Retrocalcaneal bursitis Superficial Achilles bursitis Periostitis Plantar tendon rupture Calcaneal avulsion Gastroc, soleus or plantaris tear

Answer 117

RICE Surgery Open or percutaneous repair Lower rate of re-rupture but higher rate of complications Risks: anesthesia, infection, skin breakdown, scarring, bleeding, accidental nerve injury, blood clots Non-operative Higher rate of rerupture (up to 40%), although this is less w/ early mobilisation, but power reduced compared to surgical management Suitable for elderly, less active patients, poor surgical candidates

Answer 118

Men >40 Recreational sports advancing age Tendinopathy cortisone injection systemic corticosteroids Fluoroquinolones previous history of tear (esp if managed conservatively as higher risk of re-rupture) CTD Immobilization Obesity

Answer 119

The hindfoot includes the calcaneus and talus. The midfoot includes the navicular, cuboid, and cuneiform bones. The forefoot includes the metatarsals and phalanges

Answer 120

Point-tenderness directly over the metatarsal Mild swelling, bruising Graduated activity from calf raises to hopping to jogging -> does it reproduce pain? Single leg hop Fulcrum test

Answer 121

XR - periosteal reaction to visible # line CT - To visualise cortical #s in bones Bone scan - Good at detecting increased bony remodelling, but this is not specific to stress #s. Uptake also remains for a long time so not as useful for ongoing monitoring MRI - Periosteal or bone marrow edema

Answer 122

MTP joint synovitis: inflammation of the joint rather than stress reaction in the bone itself. Bone scan will show distal uptake around MTP joint. MRI is diagnostic. Claw toe may also cause synovitis with plantar displacement of metatarsal head or a metatarsal stress reaction. MTP capsular strain and/or chip fracture of 1st metatarsal head (turf toe) Lisfranc sprain/fracture: injury to the 2nd MTC articulation. Any pain at the proximal 2nd metatarsal in association with a twisting injury in plantar flexion should raise concern for this injury. Midfoot sprain: injury to MTC ligamentous structures Forefoot mass (ganglion or tumor) Metatarsalgia Morton Neuroma Freiberg infarction: osteonecrosis of 2nd metatarsal head; more common in adolescent athletes with unilateral (usually) pain in 2nd metatarsal head

Answer 123

>10 EtOH per week, RED-S, female, low vit D levels, smoking, running >25mi weekly, sudden increase in activity Intrinsic RF: females, amenorrhea >6mo, low BMD, restricted ROM, RED-S, ED, low vit D Extrinisic RF: increase in training intensity, duration or frequency, hard surfaces, change in footwear, extremes in age, past hx of stress #

Answer 124

Reduced loading, relative rest, management of contributing factors (optimising bone health, correcting biomechanical errors, using S+C coach, correcting footwear) Consider exogen Adjunctive therapies: pulsed US, orthoses, braces, surgery Calcium 2000mg daily, vit D 1000 units daily, r/o RED-S Recovery = 12 wks

Answer 125

spiral # of 5th metatarsal Usually non surgical w/ fracture brace or cast shoe Wt bearing as tolerated

Answer 126

tibia, navicular, fibula, metatarsals, calcaneus

Answer 127

Inversion + plantarflexion Ligaments are injured in sequential pattern ATFL then CFL then PTFL

Answer 128

Athletes (especially those involved in sports with jumping near other players and quick “cutting” motions, i.e., basketball, soccer, football) Dancers Congenital tarsal coalition (allows less “give” in the foot and results in more stress to ankle) Prior ankle injury (Previously injured or stretched ligaments provide less overall stability.)

Answer 129

Audible pop Rapid swelling, pain, inability to walk Physical Ecchymosis Swelling Tenderness to palpate Anterior drawer: Tests stability of ATFL; performed by holding the distal tibia and pulling the heel forward. Increased laxity relative to the opposite side indicates a tear of the ATFL. The anterior drawer test in the ankle has poor sensitivity and specificity. Inversion tilt: tests stability of CFL; performed by holding the distal tibia and moving the foot from a neutral position to an inversion position. Increased laxity compared with opposite side indicates a tear of the CFL.

Answer 130

XR needed if pain in malleolar zone and: bone tenderness at posterior edge of lateral malleolus OR bone tenderness at posterior edge of medial malleolus OR inability to wt bear immediately + in ED

Answer 131

Tibia fracture (shaft, malleolus, etc.) Pilon fracture Fibula fracture (malleolus, Maisonneuve) Avulsion fracture Osteochondral defect in talar dome/tibial plafond Anterior ankle impingement Os trigonum syndrome Talus fracture Calcaneal fracture Peroneal subluxation Bimalleolar/trimalleolar fracture

Answer 132

RICE, NSAIDS, increase weight bearing as tolerated, bracing/ taping, crutches prn Consider surgical referral for anatomical reconstruction of Gr III sprain after 6 weeks of conservative management

Answer 133

Stiffness from prolonged immobilization Recurrent instability Osteochondral defects Chronic regional pain syndromes

Answer 134

Anterior talofibular ligament (ATFL): passes from the tip of the fibula to the lateral talar neck; taut in plantar flexion; injured most commonly Calcaneofibular ligament (CFL): passes inferior and posterior from the tip of the fibula to the lateral calcaneus; usually injured with the ATFL Posterior talofibular ligament (PTFL): passes posteriorly from the fibula to the talus; injured less often

Answer 135

Previous ankle sprain High-risk sports, including football, basketball, and long jumping Valgus-flat foot deformity Low arch of the foot (i.e., pes planus) Dysfunction of the spring ligament Dysfunction of the posterior tibialis Extreme fatigue of peroneus (fibularis) longus muscle

Answer 136

Off-balanced, pronated foot landing, which leads to forced external rotation, abduction, and eversion Supination and excessive external rotation of the ankle

Answer 137

Medial ankle pain Swelling + ecchymosis Physical Tenderness over deltoid A check of posterior tibial tendon function with resisted inversion. A check of extensor hallucis longus tendon function with resisted extension of the great toe. A check of range of motion of the ankle joint. A check of flexor hallucis longus tendon function with resisted flexion of the great toe. An eversion stress test determines the stability of the deltoid ligament; this is done with passive eversion of the ankle An anterior drawer test may evaluate anterior and medial subluxation with deltoid ligament injury

Answer 138

Syndesmosis tear or sprain Posterior tibial tendon tear or subluxation Flexor hallucis longus tendon tear or sprain Distal tibia fracture Osteochondral fracture of the talar dome Fracture of the calcaneus Fracture of the lateral process of the talus Medial ankle sprain with associated proximal fibular fracture (Maisonneuve fracture

Answer 139

PRICE Aircast boot, limit wt bearing Grade I sprain: functional rehabilitation and possibly a splint or a brace, with the recognition that return to sports generally is more delayed (3 to 6 wk) than with a lateral sprain (1 to 3 wk) Grade II sprain same as grade 1, but in addition, may need a short period prior of immobilization in posterior splint or walking boot (3 to 4 wk) Grade III sprain Treatment is controversial; requires immobilization (6 to 8 wk) or may need operative repair Refer for surgery if: Significant instability Grade 3 injury

Answer 140

The exercises should begin as soon as the initial pain and swelling have subsided sufficiently to allow the patient to perform simple exercises and should continue until the patient has returned to pain-free activity Achilles tendon stretch Foot circles Alphabet exercises: Although leg is stable, patient should use the great toe and foot to “write” the letters of the alphabet in the air. Isometric and isotonic plantar flexion, dorsiflexion, inversion, eversion, and toe curls Marble pickups (using toes) Heel walks Toe walks Circular wobble board Walking on different surfaces Walk–jog, jog–run

Answer 141

base of 5th metatarsal at metaphyseal-diaphyseal junction

Answer 142

Rx RICE Immobilisation w/ aircast + crutches x6-8wks NSAIDs Consider Exogen Calcium + vit D Surgery if displaced, not responding to conservative management RTP quicker More reliable rehab Intramedullary screw fixation, may need bone grafting Immobilised in cast x2 wks

Answer 143

Insidious onset, poorly localised midfoot ache Pain radiates along medial arch dorsally Improves w/ rest Physical Localised tenderness at “N spot” - proximal dorsal navicular Minimal swelling

Answer 144

Non wt bearing w/ cast or removable brace x8 wks Mobilise stiff ankle, subtalar, midtarsal joints + calf Recovery - 4mo

Answer 145

Cast x8 wks Reexamine patient every 2 to 3 wk to ensure adequate recovery. 8-10 wks: activities of daily living, swimming, water running 10-12 wks: Assess “N” spot; if nontender, then 5-min jogging on grass every other day. Gradually increase to 10 min per session. 12-14 wks: Assess “N” spot; if nontender, then faster running for short distances, that is, 50 m on alternate days; gradual speed increase 14-16 wks: Assess “N” spot; if nontender, then gradual return to full training over several weeks. Average time to return to sport is 5 to 6 mo from diagnosis.

Answer 146

Training errors: number, frequency, intensity, and duration of strain cycles Impact attenuation: muscle fatigue, training surfaces, footwear Gait mechanics: foot type, lower extremity alignment, altered gait Bone health: nutrition, genetics, hormones, bone disease Sprinting, jumping, hurdling Ballet

Answer 147

XR needed if pain in midfoot zone and: bone tenderness at base of 5th metatarsal OR bone tenderness at navicular OR inability to wt bear immediately + in ED

Answer 148

Injury to: anterior inferior tibiofibular ligament (AITFL) posterior inferior tibiofibular ligament (PITFL) interossseous ligament (IOL) interosseous membrane (IOM)

Answer 149

Sudden, forced external rotation + hyperdorsiflexion of ankle Soccer (player tackling ball), football (player prone, has foot stepped on, leading to forceful external rotation), and skiing (slalom skiers, catch ski on gate)

Answer 150

Collision sports are at higher risk: Football Rugby Lacrosse Sports that immobilize the foot in a high ankle shoe or boot: Hockey Slalom skiing; catching inner ski on gate Wrestling Sports played on turf (e.g., soccer)

Answer 151

Usually report inversion mechanism “Regular” ankle sprain that isn’t improving Pain usually between anterior distal tibia and fibula and also posteromedially at ankle joint. Pain can be persistent on weight-bearing or an unusually long period of recovery after the initial injury. Pain is also worse with pushing off or with external rotation.

Answer 152

Dorsiflex + plantarflex talus to find joint line Palpation over syndesmosis is painful Usually minimal swelling Squeeze test at mid calf causes pain at ankle External rotation test: distal lower leg is stabilized with ankle in neutral position while mediolateral force/external rotation of the foot is performed; positive test noted by pain and/or increased rotation relative to unaffected side Push-off test: Push off/heel raise on affected side may be weak or absent. Fibular translation (drawer) test: pain or increased translation of fibula from anterior to posterior or loss of firm end point relative to uninjured side Stabilization test: Distal syndesmosis is stabilized with athletic tape and assess if symptoms are decreased with running and jumping. Cotton test: increased translation or pain with translation of talus from medial to lateral (may indicate deltoid ligament tear) Crossed-leg test: pain at syndesmosis with gentle pressure exerted on the medial side of the knee while resting the midtibia of affected leg on uninjured knee

Answer 153

XR normally fibular overlaps tibia - can see widening of this Stress view for XRs (dorsiflexion then external rotation) MRI

Answer 154

PER ankle fracture (Weber C) SER ankle fracture (Weber B) Fracture of the proximal fibula (Maisonneuve) Ossification of the syndesmosis Calcification of the syndesmosis Deltoid ligament tear Talar dome fracture

Answer 155

NSAIDs, ice, rest, elevation, compression Non wt bearing in cast/ boot x2 wks Then high ankle brace + ROM exercises, then progress to strengthening RTP 6 to 8 wk

Answer 156

Refer for surgery (screw fixation) Non wt bearing cast x6 wks

Answer 157

Insidious + progressive pain in inferior heel Can be bilateral Worse in AM with first few steps Lessens w/ gradually increased activity Worsens w/ prolonged standing or inactivity

Answer 158

Tenderness localized to anteromedial aspect of the heel with palpation Tight Achilles heel cord Pes planus or pes cavus foot deformity Passive range of motion: hypermobility of subtalar joint, midtarsal joint, and first ray Pain with passive dorsiflexion of toes

Answer 159

Skeletal: Calcaneal stress fracture Bone contusion Subtalar arthritis Inflammatory arthropathies Infections (osteomyelitis/subtalar pyarthrosis) Neoplasm Soft tissue: Intrinsic muscle strain (abductor hallucis, flexor digitorum brevis, quadratus plantae) Plantar fibromatosis Plantar fascia rupture Achilles tendinitis Posterior tibial tendinitis Retrocalcaneal bursitis Fat pad atrophy Neurologic: Entrapment of branches of the posterior tibial nerve usually at or after passage through the posterior tarsal tunnel: medial plantar nerve, lateral plantar nerve, or medial calcaneal nerve Radicular symptoms of L4–S1 (sciatic nerve) Abductor digiti quinti nerve entrapment Peripheral neuropathy

Answer 160

Avoid aggravating activity Avoid barefoot walking + flat shoes Stretching in morning + throughout day High load eccentric strength training RICE NSAIDs Taping foot (arch taping) Comfortable shoes Night splint - toes in extension, ankle at 90 degrees Extremes - orthotics, steroids, surgery

Answer 161

Excessive torsion and hyperpronation with poor supporting footwear Poor shock dissipation with cavus foot Hindfoot valgus with pronation deformity Limited ankle dorsiflexion Varus knee alignment in runners Obesity and prolonged standing on hard surfaces Spiked athletic shoes

Answer 162

Hallux valgus (HV) refers to a subluxation of the 1st metatarsophalangeal (MTP) joint with lateral or valgus deviation of the great toe and medial or varus deviation of the 1st metatarsal, leading to a bony prominence at the medial aspect of the joint (medial eminence or bunion

Answer 163

Fam hx Constrictive footwear Females

Answer 164

Pain over medial MTP prominence Physical Assess severity standing + non wt bearing Check alignment of arch + hindfoot

Answer 165

Wider toe box footwear Shoes w/ flexible stitching over medial eminence Medial longitudinal arch support Surgery if above failed (osteotomy, MTP fusion if severe) Complications of surgery:: Stiffness Decreased ROM Bunion may persist

Answer 166

Mallet toe is a flexion deformity at the distal interphalangeal (DIP) joint. Hammer toe is a flexion deformity affecting the proximal interphalangeal (PIP) joint. Concomitant extension at the MTP joint may be present. Claw toe is a flexion deformity affecting the PIP and DIP joints. Concomitant extension at the MTP joint is always present.

Answer 167

Increasing age Constrictive footwear Neuromuscular disorders (peripheral neuropathy, muscular dystrophy, stroke, CP) Obesity

Answer 168

Shoes - wider toe box, flat/ low feel Orthotics Pressure relief methods: Toe sleeves, typically with foam padding to relieve pressure over the dorsal toe Toe crests relieve pressure at the tip of the toes. Metatarsal pads relieve pressure under the metatarsal heads. Rocker bottom sole can help reduce forefoot pressure during gait Surgery may be indicated if non operative treatment is unsuccessful Botox if clawing is d/t spasticity

Answer 169

An inflammatory fibrosing process of the interdigital nerve of the foot, characterized by pain on the plantar surface of the foot Most commonly occurs between the heads of the 3rd and 4th metatarsals, although may also involve the 2nd or 4th intermetatarsal spaces

Answer 170

Females Kickboxers, ballet dancers, runner

Answer 171

Intermittent, episodic pain, usually on the plantar surface of the foot between the 3rd and 4th metatarsals Forefoot pain radiating to the affected interspace and toes Numbness or paresthesias in the toes and interdigital space are common Pain on weight-bearing, exacerbated with exercise, and relieved with rest

Answer 172

Tenderness to palpation on the plantar surface of the foot, usually between the 3rd and 4th metatarsals Mulder click: compress metatarsals together laterally, pain or click in between metatarsals is positive finding

Answer 173

Metatarsalgia Metatarsal stress fracture Ganglion cyst Neuropathies (diabetic, alcoholic, toxic, nutritional) Intermetatarsal bursitis Freiberg disease (metatarsal avascular necrosis)

Answer 174

Decreased pressure on metatarsal heads Wide toe box shoes Metatarsal pad Avoid repetitive toe dorsiflexion NSAIDs Steroid inj Surgical excision of neuroma is indicated if conservative therapy fails

Answer 175

1st MTP sprain MOI Forced hyperextension of 1st MTP causing a sprain RF Artificial turf and playing surfaces Athlete’s experience and years of sports participation Athlete’s position while playing sport Athlete’s weight, where higher forces are transmitted with increased weight Flattening of the 1st MTP Football players (defensive and offensive running backs, wide receivers, linemen) Foot pronation Hallux degenerative joint disease Increased ankle dorsiflexion Increased friction between athletic shoe and turf Increased toe box flexibility and decreased number of cleats in the shoe Prior 1st MTP joint injury Pes planus

Answer 176

Pain w/ wt bearing Pain w/ ROM Pain w/ applied pressure to MTP during running or jumping (toeing off) Swelling

Answer 177

Gout Plantar plate rupture 1st distal metatarsal or proximal phalangeal fracture Osteoarthritis of 1st MTP (hallux rigidus) Sesamoiditis Sesamoid stress fracture

Answer 178

Grade 1 Ice, NSAIDs, elevation Toe taping to restrict excessive dorsiflexion Gentle ROM exercises from day 5 Grade 2 As grade 1 but include orthotics Explosive, push off activities should be restricted until pain free, usually x2 wks Grade 3 As grade 2 but restriction of activity likely up to 8 wks

Answer 179

Fowler Kennedy 0-2wks: aircast boot, 2cm heel lift, NWB w. crutches 2-6wks: aircast boot w/ 2cm heel lift, protected wt bearing w/ crutches. Active ROM. Knee + hip exercises as appropriate, hydrotherapy 6-8 wks: aircast boot, d/c heel lift, WBAT. Dorsiflexion stretching, graduated resistance exercises, gait training 8-12 wks: wean off boot, progress ROM, strength + proprioception >12 wks: increase dynamic WB exercise, plyometric training, sports specific training