LE Flashcards by Shea Frady

Injury to ATF, CF, PTF 2* to inversion with PF
- rich blood supply = significant swelling within 2 hr
- TTP over involved ligaments, ecchymosis that drains distally
- varying levels of instability (grade 1-3)
- (+) talar tilt & anterior drawer (presence of dimple just inferior to tip of lateral malleolus)
- (-) radiograph for fx but stress film may show increase joint space
- arthrography is accurate only within 24 hrs

Lateral ankle sprain

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injury to anterior &/or posterior inferior tibiofibular ligament 2* hyperdorsiflexion & eversion
- (+) squeeze & ER test
- Pain & swelling over ligament/interosseous membrane
- Oblique radiograph may show abnormal widening of joint space
- recovery time = 5 + (0.97 x cm from ankle joint that squeeze test is positive) +- 3 days
- r/u fx

syndesmotic sprain

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Overuse syndrome of flexor halliucis longus & flexor digitorum longus
- callus under 2nd >3rd>4th MT head & medial distal hallux
- pain & soreness over distal 1/3-2/3 of posterior-medial shin & posterior-medial malleolus
- hypermobile 1st metatarsal
- may be associated with a high arch that results in increase pronation with increase stress on tibialis posterior to decelerate foot
- pain with resisted inversion & PF
- pain with stretching into DF & eversion
- (-) radiograph

shin splints/posterior AKA medial Tibial stress syndrome

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overuse synrome of tibialis anterior, ext hallucis longus & ext digitorum longus attributed to running on unconditioned legs, soft tissue imbalance, alignment abnormalities, low arch, excessive pronation to accommodate rearfoot varus
- pain & TTP @ anterior tibialis
- pain with resisted DF and inversion
- pain wtih stretching into PF and eversion
-callus formation under 2nd MT head & medial distal hallux
- tight gastroc/soleus muscle
- soreness with heel walking & running downhill (increase in eccentric control)
- (-) radiograph

Shin splints/anterior

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Can be acute 2* fx, crush injury, burns, or prolonged limb compression; can be a chronic progression of shin splints resulting in loss of microcirculation in shin muscle; occurs within 30 minutes of exercise & improved with rest; males>females, R>L
Beware: back pressure can compromise blood flow & immediate referral may be needed (ice do not compress)
- 5 P’s = paresthesia (toes), paresis (dropfoot), pain (anterior tibia), pallor, pulseless
- skin feels warm & firm
- cramping, pain, & tightness
- most reliable sign is sensory deficit at dorsum of foot in 1st interdigital celft
- ischemia of EHL
- pulses are normal until the end & then surgery is needed within 4-6 hours to prevent muscle necrosis & nerve damage
- increase soft tissue pressures via fluid accumulation
- normal compartment pressure <10 mm Hg
- 20 mm Hg is compromised capillary blood flow
- 30 mm Hg results in ischemic necrosis

compartment syndrome

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structurally 3 anatomical sites where tendon passes through tunnel/passage with acute angulation that can result in irritation & decreased vascularization 2* to trauma, inversion sprains, or direct blow
- subluxing tendon = snapping while everting in DF; subluxation more common in young athletes 2* to forceful DF of inverted foot with peroneals contracting
- swelling & ecchymosis inferior to lateral malleolus
- radiograph may show avulsion of peroneal retinaculum

Peroneal tendonitis

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<30 yo, injury is 2* direct blow to gastroc or forceful contraction; >30 yo, injury is 2* to degeneration (higher incidence in people with type O blood)
- snap/pop associated with injury
- palpable gap in tendon (hatchet sign) is examined early
- cannot walk on toes, swelling (within 1-2 hr) & ecchymosis
- (+) thompson & matles test

achilles tendon rupture

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inflammatory condition caused by poor biomechanics or overuse
- TTP & crepitus @ medial ankle
- pain with passive pronation
- pain with active inversion (supination) & PF

Posterior tibialis tendonitis

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Occurs in 8-18 yo male > female 2* rapid growth with stress on epiphysis with jumping or athletic events
- TTP with mediolateral compression of calcaneus
- decreased DF from pain; pain with stairs
- radiographs may not be helpful
- responds well to heel lift (healing takes months)

Sever Syndrome (achilles apophysitis)

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Vascular watershed is 4.5 cm above tendon insertion & vulnerable to ischemia 2* running hills (up = stretch; down = eccentric stress), poor footwear, excess pronation (increase rotational forces); occurs mostly in males 30-50 yo

Achilles tendonitis/tendinosis

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RA, poor fitting footwear, flatfeet
- pain, swelling, great toe valgus > 15*
- decreased ROM of great toe & hammertoe of 2nd toe
- R/O RA

Hallux Valgus (bunion)

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Extreme hyperextension of great toe in CKC position resulting in sprain of plantar capsule & LCL of 1st MTP
- pain with toe extension
- impairment of push-off, antalgic gait
-ecchymosis & swelling of 1st MTP joint
- R/O sesamoid & MT fx

turf toe

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May be associated with osteochrondritis (child) or DJD, gout, or RA (adult)
- decreased DF of 1st MTP joint
- pain & swelling on dorsal aspect of 1st MTP
- difficulty walking up stairs & uphill
- LE ER to clear foot during gait
- radiograph confirms dorsal osteophyte & decreases joint space

Hallux Rigidus

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continuous with gastroc/soleus muscle complex; subject to inflammation 2* repetitive stress, poorly cushioned footwear, hard surfaces, increased pronation, obesity
- morning pain that decreases with activity, nodules palpable over proximal-medial border of plantar fascia
- pain with DF and toe ext
- decreased DF from tight gastroc/soleus muscle complex
- weak foot intrinsics
- sensation & reflexes WNL
- (-) EMG; radiograph may show calcaneal spur, but no correlation exists between bone spur and pain of plantar fasciitis

Plantar fasciitis

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sitting with legs crossed, compression during surgery, presence of a fabella, tight ski boots or hockey skates, treatment of nerve during strong inversion and PF contraction
- compromised ankle stability can increase risk of sprains
- local pain & ecchymosis at the site of external trauma
- footdrop, decreased eversion & DF
- partial sensory loss
- test = pain with walking on medial borders of foot
- MRI, EMG/NCV may be helpful

Common peroneal nerve palsy

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thickening of interdigital nerve (25-50 yo, female>male) 2* high-heel shoes, excessive pronation, high arch, lateral compression of forefoot, increased weight
- throbbing/burning into plantar aspect of 3rd & 4th MT heads; feels like a pebble is in the shoe
- callus under involved rays
- increased pain with weight bearing
- (+) morton test
- weak instrinsic muscles
- EMG = unreliable
- r/o stress fx (contrast MRI)

Morton neuroma

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compression of contents of tarsal tunnel (posterior tibial nerve & artery, tibialis posterior, FDL, FHL) may be 2* trauma, weight gain, excessive pronation, or inflammation
- sharp pain into medial/plantar aspect of foot & 1st MTP
- burning, night pain, swelling
- increased pain with walking & passive DF or eversion
- motor weakness & intrinsic atrophy difficult to detect
- DTRs & ROM = WNL
- (+) tinel sign just below & behind medial malleolus
- abnormal EMG; r/o diabetic neuropathy & neuroma

Tarsal tunnel

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Repetitive high-impact sports or direct trauma
- impairment of push-off, antalgic gait, swollen 1st MTP
- TTP, pain with passive DF of MTP
- (+) radiograph & MRI
- r/o turf toe, bipartite sesamoid

sesamoiditis

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repetitive stress, occurs approximately 3 weeks after increased training; 2nd MT is most common
Beware: of eating disorders with repetitive stress fx
- point tenderness & swelling
- deep nagging & night pain
- ROM WNL
- (+) metatarsal load & bump
- bone scan & MRI detect earlier than radiograph
- therapeutic US in continuous mode will increase pain to aid in DX
- r/o DVT

stress fracture

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hypertrophic osteoarthropathy of midfoot in clients with IDDM
- progressive bone & muscle weakness
- decreased sensation but minimal pain
- profound unilateral swelling
- increase skin temp (local); erythema
- radiograph looks like osteomyelitis (bone fragments present)

Charcot foot

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bacterial infection usually related to skin trauma but skin break may not be evident; not contagious
- pain, swelling, warmth
- chills, fever, weakness
- advancing erythema with reddish streaks
- helpful to outline reddened area with a sharpie permanent marker to monitor status

cellulitis

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risk factors: immobility, surgery, fx, trauma, oral contraceptives, CHF, CA, DM, pregnancy, type A blood
- leg pain & tenderness
- increased circumference >1.2 cm
- lower leg warmth & firm to palpation
- (+) homans sign
- wells score > or equal to 3

DVT

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injury results from varus stress resulting in overstretching or tearing the lateral ligament of the knee
- warm & swollen lateral knee
- TTP @ knee joint line (palpate in figure 4 position)
- ROM may not be effected
- (+) varus stress test
- confirmed with MRI or arthrogram with contrast
- (-) radiograph, but needed to r/o avulsion or epiphyseal plate injury; varus stress film may show increase joint gapping

LCL sprain

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mechanical irritation
- prepatella = common in sport = falling on knee or maintaining quadruped position
- infrapatella = clergyman bursitis = kneeling
- Pes anserinus = prevalent in long-distance running or middle-aged woman with OA of knee
- localized radiating het
- localized egg-shaped swelling
- radiating pain 2-4 cm below involved bursa
- crepitus
- discomfort with AROM & PROM
- diagnosis confirmed with MRI

bursitis of knee

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defect in posterior capsule that is influenced by chronic irritation or meniscus tear - golf ball sized swelling at semimembranosus tendon or medial gastroc muscle belly; best palpated in full knee extension - stiff & tender with limited knee ROM - MRI may be helpful, r/o DVT or tumor

Baker's cyst

repetitive stress & excessive friction 2* tight ITB, pronation with IR of tibia, genu varum, cycling with cleat in IR - proximal Px: hip syndrome - distal Px: runner's knee - pain with downhill running - pain @ 30* of knee flexion in WB results in ambulating stifflegged to avoid flexion - TTP over lateral femoral condyle - (+) ober, noble, and renne test - (-) radiograph - need to r/o trochanteric bursitis & osteochrondritis - MRI & US may confirm dx

ITB Friction Syndrome

results from overuse, downhill running, activities with sudden stops - posterior lateral knee pain at the end of a workout or running downhill (just posterior to LCL) - crepitus over tendon - discomfort sitting with legs crossed & with resisted flexion from full extension - MRI may be helpful; need to r/o ITB, biceps tendonitis

Popliteus Tendonitis

Injury results from direct trauma or a significant increase in unaccustomed activity (presence of medial plica is more common than lateral plica) - pain over medial femoral condyle; palpable cords along medial condyle, pain at superomedial joint line - clicking/snapping, locking, "giving away" - pain @ end range flexion - false (+) McMurray (pseudolocking) - (+) slutter, plica, theatre sign, & bowstring - need to r/o patellofemoral tracking px - radiograph is not helpful, MRI is only noninvasive procedure that shows plica - arthroscopy may reveal avascular fibrotic edge of the plica

Plica syndrome

patella tendonitis (common in skeletally immature) 2* traction overuse injury such as jumping, kicking, running, or microtrauma - TTP at patella tendon insertion & pain with resisted knee extension - localized crepitus & swelling - increase in dynamic Q-angle - r/o osgood-schlatter, SLJ, & bursitis - confirmed via MRI

Jumper's knee

result of aging, poor biomechanics, or repetitive trauma - joint line crepitus - decreased terminal knee extension 2* edema (quad inhibition) - decreased stance time during gait - "gelling" phenomenon = increased viscosity synovial fluid 2* inflammation - stiffness with immobility - radiograph = decreased joint space, spurs, osteophytes

DJD

softening of patella articular cartilage 2* poor biomechanical alignment, tracking, &/or weak hip ER - anterior knee pain; pain with stairs; crepitus - VMO atrophy; weak hip ER & ABD - increase knee valgus, increase dynamic Q-angle - (+) theatre, clarke & fairbank apprehension - confirmed via MRI

Chondromalacia (patellofemoral syndrome) PFS

lesions of subchondral bone of insidious onset, trauma, or pre-exisitng abnormalities of epiphyses: most common in 10-18 yo; male >female - knee effusion - crepitus with knee flexion/extension - poorly localized knee pain - antalgic gait - (+) wilson test - may have TTP over medial femoral condyle with knee flexion - radiograph may not help; need MRI or bone scan

Osteochrondritis Dissecans

Ossification between rather than within strained muscle fibers resulting from direct trauma - decreased knee ROM - weakness of involved muscle - TTP, swelling, & hyperemia - confirmed with radiograph after 2-3 wks; earlier than with MRI

Heterotopic Ossification

Calcification in a muscle due to trauma, painful hematomas develop rapidly & calcification occurs in 2-3 wks; may be neurogenic after SCI or TBI - warm & TTP over involved site - decreased knee ROM - pain with contraction of involved muscle - confirmed with radiograph after 2-3 wks; faster than MRI

Myositis Ossificans

Results from traction force on proximal patella tendon 2* chronic extensor overload; 10-14 yo male - anterior knee pain & TTP at distal pole of patella with knee extension - antalgic gait - decreased knee ROM - radiograph (lateral view) = fragmentation of inferior patella pole

Sinding-Larsen Johansson

Tibial apophysitis that may occur from growth of femur resulting in avulsion of proximal tibial physis; may have genetic predisposition; 8-15 yo male>female - intermittent aching pain at tibial tubercle & distal patellar tendon - enlarged tibial tuberosity - tight quads & hamstrings resulting in decreased AROM - effusion results in knee extensor lag - (+) ely test - (+) radiograph for avulsion of tibial tuberosity (lateral view) - r/u avascular necrosis

Osgood-Schlatter Syndrome

Prediposing factors include, excessive tibial ER, pronation, patella alta; tight lateral retinaculum, weak hip ER, small medial patella facet; most common in adolescent girls with genu valgum (increased Q-angle & femoral rotation) - effusion shuts down VMO - (+) patella tilt & patella apprehension - tenderness along medial patella border - sitting @ 90/90, patella points lateral and superior (grasshopper eyes) - client c/o knee giving away or clicking when cutting away from affected leg - increased Q-angle - radiograph may reveal osteochondral fragments or fx; multiple views are needed to evaluate articular surfaces

Patella subluxation

results from direct trauma - pain & "dome" effusion - palpable defect - unable to extend knee - (+) ottawa knee rules - confirmed with radiograph

Patella fracture

Injured via rotatory forces while WB or knee hyperextension; medial femoral/lateral tibial rotation injures medial meniscus & lateral femoral/medial tibial rotation injures lateral meniscus - common types of tears: children = longitudinal & peripheral tear; teenagers = bucket handle tear - (-) varus/valgus stress test - pain @ end range flexion/extension WB - gradual swelling over 1-3 days; ecchymosis - joint line tenderness - (+) McMurray, Apley, Thessaly, KKU, Steinmann - anterior horn locks in extension, posterior in flexion, medial in 10-30* of flexion, lateral >70* of flexion - radiograph may r/o fx,tumor, osseous loose bodies - MRI may reveal pseudotear; confirm with arthrogram using contrast

Meniscus Tear

Injury results from dashboard blow to anterior shin with knee flexed @ 90* or falling on knee with foot PF - minimal swelling; ecchymosis may appear days later - tenderness in popliteal fossa & pain with kneeling - client may be able to continue to play - (+) posterior drawer, posterior lachman, & sag/dropback/godfrey - (-) radiograph (except for avulsion); MRI is study of choice - bloody arthrocentesis

PCL Sprain

Injury results from twisting while changing directions, deceleration with valgus & ER, hyperextension of the knee with foot PF - audible pop, immediate swelling (<2 hr) - intense pain at posterior lateral tibia - unstable in WB - (+) anterior drawer, lachman, & pivot shift - KT1000 anterior displacement >5mm - (-) radiograph (except for avulsion); MRI study of choice - Bloody arthrocentesis

ACL Sprain

injury results from valgus stress resulting in overstretching the medial ligament of the knee - flexion limited to 90* & knee extension lag present - if deep fibers are torn, knee joint rapidly fills with blood - (+) valgus stress test - TTP @ knee joint line (possible palpable defect) - confirmed with MRI or arthrogram with contrast - (-) radiograph but needed to r/o avulsion or epiphyseal plate injury; valgus stress film may show increased joint gapping

MCL Sprain

Damage to fibrocartilage via repetitive hip ER or external rotatory force to hip while hyperextended & hyperabducted; highly associated with hip dysplasia; anterior hip pain correlated to weak gluteals & abdominals 2* to excessive anterior femoral translation - pain with prolonged sitting, getting in/out of car, putting on shoes/socks, & twisting activities - increased anterior hip pain with hyperext & ER - pain with resisted SLR (anterior lesion) - often associated with weak gluteals - decreased hip ROM; clicking/catching from flexion to extension - (+) FABER, impingement, scour, & labral tests - screen for osteoid osteoma & testicular CA - MRI with contrast

Hip Labral tear

Can result from direct trauma to iliac crest or ASIS resulting in contusion - TTP @ iliac crest/ASIA - pain with resisted hip flexion & stretching into hip extension - pain with ambulation & hip abduction - screen for McBurney's point & rebound tenderness - (-) radiograph; need to r/o fx & avulsion

Hip pointer

Calcium deposits approx. 2-4 wks after thigh contusion - localized pain - limited knee flexion - palpation of calcific mass

Myositis Ossificans

Systemic disorder with bilateral WB symtpoms - aching pain during WB > groin, medial thigh, & distal knee; loss of movement & function 2* pain - trendenlenburg - (+) thomas, ely, & FABER - radiograph = bilateral head; joint space narrowing; migration of femoral head into acetabulum

Usually occurs >55 yo in male > female (3:2) - aching pain during WB > groin, medial thigh, and knee - loss of movement & function (+) FABER & trendenlenburg - radiograph reveals narrow joint space, spurring & osteophytes; can r/o fx & necrosis

DJD of hip

Etiology unknown; recent virus, URI, ear infection, or bronchitis, female 2-4x more than males; 3-10 yo - medial thigh/groin pain with movement (infant = pain with diaper change) - child splints in hip flexion, slight abd, and ER - awakes with a limp - hip abd restricted by pain - (+) log roll test - possible with low-grade fever - r/o septic hip, slipped capital femoral epiphysis, & Legg-Calve-Perthes

Transient Synovitis (Toxic Synovitis Phantom Hip Disease)

Gradual onset with Hx of endurance tasks Beware: eating disorders, amenorrhea, & osteoporosis - groin pain with activity - TTP @ greater trochanter - (+) FABER test - may need CT or MRI if radiograph is inconclusive - need r/o trochanteric bursitis & osteoid osteoma

Femoral neck stress fracture

Pelvic fx 2* strenuous muscle contraction in skeletally immature child - TTP & weakness with resisted muscle contraction @ ASIS, AIIS, PSIS, PIIS - depending on muscle involved - (+) radiograph for avulsion

Apophysitis

Injury results from violent muscle contraction - may hear "pop" - TTP @ apophysis - (+) thomas and ely test - CT or MRI if radiograph is inconclusive - r/o slipped capital femoral epiphysis

Avulsion Fracture

Idiopathic osteonecrosis of capital femoral epiphysis; associated with (+) fam hx @ breech birth; onset occurs over 1-3 months in 4-13 yo; occurs unilaterally; males>females - hip or groin pain (antalgic gait) - (+) trendenlenburg & log roll - decreased ROM (IR & abd & ext); >15* hip flexion contracture - leg-length inequality; thigh atrophy - bone scan and MRI needed for early detection, radiographs may appear normal for several weeks, 1st sign (approx 4 wks) is radiolucent crescent image parallel to superior rim of femoral head - need to r/o JRA & hip inflammation

Legg-Calve- Perthes Syndrome

Imbalance of growth & hormones that weakens epiphyseal plate; may be 2* weight gain; occurs 10-18 yo; male 2x>females - gradual onset of unilateral hip, thigh, and knee pain - decreased hip IR; hip positioned in ER - quadriceps atrophy - antalgic gait and decreased limb length - AP radiograph needed to identify widening of physis & decreased height of epiphysis; lateral view = epiphyseal displacement - need to r/o muscle strain, avulsion & endocrine disorder

Slipped Capital Femoral Epipysis

May result from breech birth, trauma, or when hip is in a weakened state after THR - (+) ortolani, barlow & radiograph - cogenital - shortened limb, positioned in flexion & abd - posterior traumatic (MVA) - groin & lateral hip pain - shortened limb - positioned in flexion, abd, & IR - anterior traumatic (forced abduction) - groin pain & tenderness - anterior/superior = hip extension & ER - anterior/inferior = hip in flexion, abd, ER

Hip dislocation

Benign tumor found in long bones; etiology unknown - vague hip pain @ night - increased pain with activity and decreased with aspirin - decreased ROM & quad atrophy - may be apparent on radiograph but confirmed by MRI or CT - need to r/o trochanteric bursitis, femoral neck fx

Osteoid Osteoma

Men 18-24 yo with unknown etiology should be screened - enlarged inguinal lymph nodes - enlarged/heavy scrotum

Testicular Cancer

biomechanical or overuse problem; repetitive inside kicks in soccer result in forceful adduction and compression of bursa; contusions - deep, aching, diffuse pain from greater trochanter to distal lateral thigh & groin - TTP on ITB & pain when rolling on hip when sleeping - ROM = WNL except abduction may be limited due to pain - no snapping but palpable crepitus may be present - (+) ober & patrick/FABER - (-) radiograph (needed to r/o femoral neck stress fx) - MRI & US may confirm

Greater Trochanteric Bursitis

Irritation & inflammation 2* overuse or unaccustomed activity - pain in medial groin/thigh with hip flexion & ext - audible snapping when moving from hip flex to ext - screen for McBurneys point & rebound tenderness - (-) radiograph; need to r/o avulsion fx - confirmed by MRI and US

Ilipsoas Bursitis/Tendonitis

Occasional marble-sized lump along the path of the inguinal ligament - pain with exertion, cough - radiating pain into groin, ipsilateral thigh, flank, & lower abdomen - pain with cutting, turning, striding out - (+) pubic arthralgia test

Pubic Arthralgia (AKA sports hernia)

May result from muscle contraction, trauma, prolonged sitting - dull ache in buttocks - pain increase sitting & walking & decreased in supine - pain with resisted hip ER & passive IR with adduction - (-) radiograph needed to r/o stress fx; MRI needed to r/o spine pathology (LS root lesion, spinal stenosis, SI problem)

Piriformis Syndrome

LE Flashcards

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