Knee, Ankle, and Foot Pathology

Question 1

osgood schlatter disease

Answer 1

repetitive pulling of patellar tendon over tibial tubercle –> pain and swelling

adolescents age 10-15

anterior over tibial tubercle

gradually worsens

prominence of tibial tubercle w/ mild effusion, local tenderness, warmth

jumping, sports

tx: nsaids, quads and hams stretching and strengthening; avoid activities that cause pain; ice

usually resolves within a year or so w/ conservative treatment, surgery rarely indicated

Question 2

peroneal compression

Answer 2

common peroneal nerve entrapment

most common peripheral nerve injury in LE

can be injured at any level down thigh and into leg, but usually at fibular head

habitual leg crossing, compression against bed railing or hard mattress, prolonged immobility

Question 3

patellofemoral syndrome

defn and causes

Answer 3

poor tracking of patella over femoral condyles –> grinding

d/t wear and tear, overuse, overload, muscular/biomechanical problems

runners

Question 4

patellofemoral syndrome

clinical presentation and PE

Answer 4

gradual onset of anterior knee pain d/t repetitive movement

dull, aching, possible swelling, clicking

worse with stairs, walking, running, extended sitting, standing from seated

weak quads (vastus medialis atrophy), offset patella, swollen knee

limited knee flexion d/t pain

crepitus, lateral patellar tenderness on passive or active movement

special testing: tracking of patella over femoral groove on knee flexion and extension; patella grind

XR may be normal or misaligned

Question 5

patellofemoral syndrome

tx and prognosis

Answer 5

RICE

bracing and taping for patellar alignment

quads (esp vastus medialis) stretch and strengthen

surgery last resort

Question 6

knee OA

Answer 6

gradual cartilage wear and tear

repetitive trauma over 15-20 years

pain intermittent –> constant

stiffness esp after inactivity

worse with weight-bearing

limp, limited flexion and extension, pain at end of ROM, joint line tenderness, crepitus

risk factors: obesity, trauma, knee instability

XR: osteophytes, sclerosis, non-uniform joint space narrowing

Question 7

Answer 7

knee OA

Question 8

Answer 8

patellofemoral syndrome

Question 9

meniscal tear

defn and causes

Answer 9

foot plant on twisted knee

usually basketball, football, skiing, aging d/t degeneration

Question 10

meniscal tear

dx: clinical presentation and PE

Answer 10

acute injury –> mild swelling and pain >24h

tears d/t chronic degeneration = gradual worsening over time

mild to moderate, dull, aching

with twisting or bending –> worse, sharp

popping, clicking, catching, joint effusion

possible vastus medialis atrophy

limited extension, full flexion d/t pain and catching

joint line effusion and tenderness

special testing: mcmurray test = knee flexion, internal or external rotation w/ valgus or varus stress –> clicking or pain

definitive: MRI

Question 11

Answer 11

meniscal tear (medial)

note fluid in substance of meniscus

Question 12

meniscal tear

tx and prognosis

Answer 12

nsaids

RICE, activity restriction, crutches if needed

quad and hamstring strengthening

consider surgery if locking or concurrent ACL tear

prognosis depends on extent of injury, may predispose to accelerated degeneration

Question 13

mcmurray’s test

Answer 13

meniscal tears, mcl, lcl

valgus and varus stress with knee flexion –> clicking or pain

Question 14

knee ligment tear

defn and causes

Answer 14

ACL = most common

high-impact jumping, twisting, lateral impact while foot is planted

basketball, ski, football

“pop” + immediate swelling

PCL: impact to tibia when knee is bent, e.g. dashboard MVA

LCL: excessive varus movement

MCL: excessive valgus movement

Question 15

“unhappy triad”

Answer 15

MCL + ACL + meniscus tear

“blown knee”

lateral impact + foot planted = football, rugby, motocross …

Question 16

knee ligament tear

dx: clinical presentation and PE

Answer 16

immediate sharp, severe pain after high-impact twisting, often with “pop”

“giving out”

gradually lessens to dull ache

worse with climbing, jumping running

bruising, effusion, tenderness

limited flexion and extension

special testing: Lachman and Anterior Drawer for ACL; posterior drawer for PCL; valgus and varus stretch for LCL and MCL

definitive: MRI

Question 17

lachman’s test

Answer 17

ACL tear

knee at 15 degree flexion

pull shin anteriorly while putting back-pressure on thigh

no movement = good

laxity = ACL tear

Question 18

anterior and posterior drawer test

Answer 18

anterior: ACL tear
posterior: PCL tear

lay on table, knees bent 90 degrees, pull tibia anteriorly (ACL) and push back (PCL)

no movement = good

laxity and pain = tear

Question 19

Answer 19

ACL tear

note disruption of ACL integrity

Question 20

knee ligament tear

tx and prognosis

Answer 20

nsaids

RICE, hard braces

PT: proprioception, ROM, quad+ham strengthening for knee stability

consider surgical reconstruction for young adults, athletes, or severe instability

PCL, MCL, LCL: good px; usually responds well to conservative tx

ACL: fair px; if not treated early at risk for prolonged instability, accelerated joint degeneration

Question 21

compartment syndrome

defn and causes

Answer 21

limb and life threatening: necrosis, permanent fx impairment, rhabdo(–> kidney failure)

perfusion pressure < tissue pressure in closed space eg muscles, nerves, vessels surrounded by tight fascia

d/t extreme swelling or bleeding

trauma, tigh casts, etc.

usually acute

may be chronic in cases of repeated low-intensity trauma

Question 22

compartment syndrome

dx: clinical presentation and PE

Answer 22

6 “P’s” - pain (out of proportion), paresthesia, paralysis, pallor (+/-), pulselessness, pressure

severe pain and pressure esp. following an injury

consider in any case of severe pain following injury esp when significant swelling present

nothing relieves pain

pain on passive muscle stretching is an early clinical indicator

palpation: may be warm or cold. when severe, feels tense or hard

Question 23

compartment syndrome

tx and prognosis

Answer 23

fasciotomy

IV hydration

O2 administration d/t hypoxic limb, hyperbaric is best

elevation is contraindicated (decreases arterial flow –> worse ischemia)

good prognosis if fasciotomy w/in 6 hours, necrosis will occur after that (w/ compromise to life and limb)

Question 24

metatarsal frx

Answer 24

most common: 5th metatarsal frx at base of bone (nearest tarsal)

forceful INversion

pain and tendernaess at base of 5th metatarsal +/- swelling, bruising, addtl injuries

high risk of delayed healing and nonunion

nondisplaced –> conservative tx (e.g. boot)

if displaced or non-union, surgery

Question 25

malleolar frx

Answer 25

lateral malleolar (fibular) is most common frx of distal fibula direct trauma or twisting usually accompanied by medial ligament injuries or another frx joint widening indicates ruptured ligament local tenderness, inability to bear weight

Question 26

MTP joint pain

Answer 26

metatarsal-phalangeal pain, most often of 1st and 2nd MTP joints d/t abnormal mechanics e.g. flatfoot (pes planus), high arch (pes cavus), overpronation, poor muscle balance d/t tight gastrocs and dorsiflexors, improper footwear worse w/ weight-bearing, walking, running, etc. +/- swelling, redness, tenderness at 1st and 2nd MTP DD: OA, gout, RA, interdigital neuritis tx: RICE, nsaids, good footwear, correction of foot mechanics, corticosteriods if severe, surgery if refractory

Question 27

ankle sprain defn and causes

Answer 27

inversion, eversion, twisting planted foot most common: lateral sprain d/t eversion = anterior talofibular ligament (ATFL)

Question 28

ankle sprain dx: clinical presentation and PE

Answer 28

diffuse initially then localized to medial or lateral w/ reduced swelling initial sharp pang --\> constant deep aching worse w/ weight-bearing or ROM bruising if severe limited active and passive ROM DDx: medial or lateral malleolar frx, 5th metatarsal frx, midfoot frx; palpate all for bony tenderness, deformity, or crepitus. XR can r/o.

Question 29

ankle sprain tx and prognosis

Answer 29

RICE + bracing PT (rehab) if severe, consider surgery (e.g. high-level athletes, chronic instability) severe lateral, medial, and high ankle sprains may take 4-6 weeks to fully recover, mild sprains usually much more quickly

Question 30

plantar fasciitis

Answer 30

pain d/t inflammation along plantar fascia esp at insertion on heel or arch most common cause of heel pain repetitive trauma, poor mechanics, poor footwear, overpronation, flat feet, prolonged standing or weight bearing gradual onset, usually after change in amount or intensity of running or walking, change in footwear, change of surface burning feeling usually accompanies tight achilles point tenderness at medial process of calcaneous, tight plantar fascia common complication: heel spurs

Question 31

achilles tendon rupture

Answer 31

torn tendon usually 4-5 cm proximal to calcaneous, where blood supply is weakest sudden strain or direct blow to contracted tendon acute, sharp pain inability to ambulate obvious swelling, possible bruising often a palpable defect special testing: Thompson test: lying prone with knee passively flexed or standing/kneeling on chair, squeeze calf. no plantarflexion = rupture. tx: casting +/- surgery good prognosis but usually some loss of ROM

Question 32

thompson test

Answer 32

achille's tendon rupture lie prone or stand while kneeling on chair squeeze gastroc plantar flexion = normal no plantarflexion = achille's tendon rupture

Question 33

tarsal tunnel syndrome

Answer 33

entrapment of tibial nerve as it moves under retinaculum of tarsal tunnel (posterior to medial malleolus)

Question 34

Tinel's test

Answer 34

tapping over affected nerve to reproduce sx e.g. tapping over median nerve in carpal tunnel, ulnar nerve in cubital tunnel, or tibial nerve in tarsal tunnel

Question 35

medial tibial stress syndrome

Answer 35

aka shin splints overuse/repetitive stress --\> repetitive pulling of muscle on periosteum --\> microtears in muscle and bone pain with activity posterior tibialis, flexor digitorum, soleus, tibialis anterior insertions could progress to stress frx (felt at rest) RICE + nsaids ddx stress frx, compartment syndrome