Lecture 7- Knee Flashcards
(108 cards)
1
Q
Function of the posterior cruciate ligament?
A
Posterior cruciate prevent forward movement of the femur on the tibia
2
Q
Function of the collateral ligaments?
A
The collateral ligaments provide medial and lateral knee stability
MCL is extra capsular (its deep layer attaches to the joint margins and the medial meniscus)
LCL: narrow strong cord easily palpated (stabilizes the knee in a one stance)
3
Q
What are the dynamic stabilisers of the knee?
A
Hamstrings
Quadriceps
4
Q
What are the static stabilisers of the knee?
A
Osseous anatomy
Menisci
Primary restraints: ACL, PCL
Secondary restraints: MCL, LCL, capsule
5
Q
What is the Q angle?
A
This angle is a measure of external tibial rotation and it is the angle between: line drawn from the ASIS to the centre of the patella
and a line from the centre of the patella to the tibial tubercle
- Females ≤ 16
6
Q
Joint effusion of the knee, what could the injury be, according to the effusion?
A
Immediate effusion 0-2hrs -ACL rupture -Patellar dislocation -Major chondral lesion Delayed effusion 6-24hrs -meniscus -small chondral lesion No effusion -MCL sprain (superficial)
7
Q
When do we x-Ray a knee? –Ottawa rule
A
Age 55 years or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex to 90° Inability to bear weight
8
Q
Blood supply to the menisci?
A
Crucial to meniscal healing
Geniculate arteries (branch of the popliteal artery)
Outer 10-30% of peripheral medial meniscus
Outer 10-25% of peripheral lateral meniscus
Most of the menisci are avascular (synovial fluid via diffusion)
30% of the peripheral medial meniscus 25% of the peripheral lateral meniscus
9
Q
Nerve supply to the menisci?
A
Tibial, Obturator and Femoral nerve
10
Q
What are the functions of the menisci?
A
Shock absorption and stress distribution across the joint Improve joint congruency & static stability
Limit extremes of flexion and extension
Prevent hyperextension and protect the joint margins Provide nutrition and lubrication to the articular cartilage
11
Q
Meniscal injuries
A
- male predominance
- in older individuals: tears due to degeneration and is more horizontal
- in young individuals: twisting impact to the knee (e.g. Soccer) with associated valgus or varus tears (bucket-handle tear)
12
Q
What is the O’Donoghue triad?
A
-MCL
-ACL
-MM
More often involves the lateral meniscus
13
Q
What are most common meniscal Injury?
A
Meniscal injuries take the form of tears, most frequently:
-Anterior horn
- Posterior horn
- Bucket handle
14
Q
When should you refer your patient with a knee injury?
A
- Locked knee (bucket-handle tear)
- Uncertain diagnosis
- Conservative care is unsuccessful
15
Q
How do you assess acute meniscal tears?
A
Joint effusion and joint line tenderness (lateral or medial)
-Quadriceps wasting
-(+) McMurray Test (lateral/medial)
- (+) Apleys test
- (+) Thessaly test
16
Q
Treatment for a meniscal tear?
A
Conservative treatment
RICE
ROM
Muscle strengthening exercises
Avoid twisting on a weight bearing flexed knee
Surgical treatment usually for younger patient and is proportional to the lesion location
17
Q
OSTEOCHONDRITIS DISSECANS
A
Disorder of one or more ossification centers, characterized by sequential degeneration or aseptic necrosis and recalcification often inducing early OA
Traditionally divided into:
-juvenile (open physes)
-adult (closed physes)
Most common sites:
-knee
-elbow
-ankle
Often heal on its own especially if the child is still growing
-10-20 yrs most common
- male more common
- bilateral involvement in 30-40% of cases
- implication in juveniles if not diagnosed properly = OA
- differential diagnosis: acute traumatic osteochondral fractures and sometimes meniscal injuries
- causes 50% of loose bodies in the knee
18
Q
Possible Aetiologies of OSTEOCHONDRITIS DISSECANS
A
Trauma Vascular causes/ischemia Skeletal maturation (accessory centers of ossification) Genetic conditions Metabolic factors Hereditary factors Anatomic variation
19
Q
Specific Location of OSTEOCHONDRITIS DISSECANS
A
Lesions involve both bone and cartilage, most commonly: -femoral condyles: Medial 85% Lateral 10% -posterior patella surface (5%)
20
Q
Clinical presentation of OSTEOCHONDRITIS DISSECANS
A
- Initially
Vague symptoms, poorly localized knee pain; stiffness with or after activities; and occasional swelling
Catching, grinding, locking more associated with late stage (loose body) - Later presentation
Knee pain; worse with activity; relieve with rest
21
Q
Anterior cruciate ligament injuries risk factors
A
Risk factors result of a combination of:
• Female gender
• Decreased notch width
• Increased BMI
• Generalized joint laxity
22
Q
Anterior cruciate ligament injuries
A
• The ACL resist anterior tibial glide and the most common MOI is a non contact mechanisms (+ 70%) involving deceleration with pivoting/twisting or landing in near extension.
• Most often occurs in combination with MCL tears, meniscal, or articular cartilage
• Most frequent cause of haemarthrosis in the knee
• ACL and OA (Neuman et al. 2008)
23
Q
Clinical evaluation of a patient with a Anterior cruciate ligament injury?
A
• Painful joint line palpation
• Decrease ROM
• Anterior Drawer test
• Pivot shift test
• Lachman’s test
X-Ray may reveal a “segond”
24
Q
Treatment for a Anterior cruciate ligament injury?
A
Non surgical approach brings satisfaction to a vast majority of patients
• Surgical repair is advocated according to:
• Patient age
• The degree of instability
• Meniscal involvement
• Associated knee injuries
• Patient preferences and occupation
25
Function of the Posterior cruciate ligament?
PCL is thought to be the primary stabiliser of the knee
• Seldom injured in isolation (LCL and Popliteus muscle)
• Likely to be under reported
Primary function is to prevent
• posterior translation and
• External rotation of the tibia
Injury much less common that for ACL
26
Causes of a Posterior cruciate ligament injury?
Injury most often occurs when a force is applied to the anterior tibia when the knee is flexed (eg dashboard injury in MVA)
Hyperextension and rotational or varus/valgus stress mechanisms also may be responsible for PCL tears.
27
Clinical presentation of a patient with Posterior cruciate ligament injury?
* Typical pop not always present
• Posterior knee pain
• Pain and haemarthrosis much less than for ACL
* Posterior tibial sag is visible
28
Clinical evaluation of a patient with Posterior cruciate ligament injury?
* The posterior drawer test
* The dial test (300 and 900)
* The posterior sag test
29
Treatment of a patient with Posterior cruciate ligament injury?
• Non surgical treatment is advocated even in a grade III on less the patient is unresponsive and the pain is debilitating.
• Spontaneous healing occurs in more then 2/3 of PCL ruptures after 3 – 12 months
• Surgical reconstruction is recommended in combined injuries (PCL, ACL, avulsion fractures)
30
Medial collateral ligament injury
* MCL is the most commonly injured ligament in the knee
• Estimated to be around 24 per 100 000 and is quite higher
in athletic individual
• Twice prevalent in male – female
• Injury ranges from sprain to tear (usually minor unless associated with other ligamentous injury)
• MOI – valgus force; external tibial rotation
* Semimembranosus muscle, pes anserine muscles, and vastus medialis provide dynamic stability – why does this matter?
• MCL tear = Superficial fiber
• The posterior fibers = rotational force and valgus in the last degrees of knee extension
31
Clinical evaluation of a patient with Posterolateral knee injuries?
* Evaluation must include both varus and rotational laxity at different degree of flexion
• The dial test (normal 5.50 of rotation) (300 and 900)
* + if more then 100 of laxity
• Varus stress test (00 and 300)
32
Myofascial pain disorders syndrome: ANTERIOR AND ANTEROMEDIAL KNEE PAIN- what muscles
• Rectus femoris
• Vastus medialis (especially anteromedial)
• Sartorius, Gracilis (especially anteromedial)
• Adductors longus and brevis (especially anteromedial)
33
Myofascial pain disorders syndrome: INFEROMEDIAL KNEE PAIN- what muscle?
• Pes Anserine
34
Myofascial pain disorders syndrome: LATERAL KNEE PAIN- what muscle
• Vastus Lateralis
35
Myofascial pain disorders syndrome: POSTERIOR KNEE PAIN- what muscles?
* Gastrocnemius & soleus
• Hamstrings (esp Biceps Femoris)
* Popliteus
36
Iliotibial band syndrome
Is essentially a tendonitis and a common cause of lateral knee pain especially in cyclists and runners (repetitive knee flexion/extension)
• During flexion, ITB moves posteriorly along lateral femoral condyle
• TFL hypertonicity most likely cause
37
Iliotibial band syndrome- clinical presentation
* Lateral knee pain, may radiate
• Worse running DOWNHILL or lengthening their stride
* Most patients experience pain only during activities*
38
Iliotibial band syndrome- risk factors
• Preexisting iliotibial band tightness
• High weekly mileage
• Time spent walking or running on a track
• Interval training
• Muscular weakness of knee extensors and flexors and hip abductors
39
Iliotibial band syndrome- clinical evaluation
* Tenderness over the lateral femoral condyle
* Noble test
• Pain can be elicited with active flexion-extension of the knee within the first 30° while the thumb presses over the epicondyle and ITB
• Standing on the affected leg in a 300 flexed position
* Crepitus may be felt
• Ober test
40
Acute knee dislocation
* Usually at least ACL and PCL torn entirely (primary constraints of the knee)
* Hard signs of vascular injury such as distal ischaemia often present
• Assessment of pulses is NB if you encounter these
• Surgical intervention with adequate rehabilitation is essential!
41
Anterior knee pain
Represent the most common knee complaints and is often multifactorial
• Patellarabnormalitiesorinstability
• Chondral and osteochondral damage
• Muscle imbalance
• Must include a complete evaluation of the lower limb (from hip to toes)
• Morecommoninwomen2x
42
Connective / soft tissue source of pain, what is the condition
Fat pad syndrome*
ITB friction syndrome*
Plica syndrome
Quadriceps and patella tendonitis
43
Articular cartilage source of pain, what is the condition?
Degeneration (OA)*
| Chondromalacia Patella
44
Intra-articular source of pain, what is the condition?
Loose bodies
| Meniscal flaps
45
Systemic pathology as a source of pain, what is the condition?
Inflammatory arthritis
46
Patellofemoral Pain Syndrome
Anterior or retro patella pain with running, jumping, squatting and stair climbing in the absence of any pathological condition
47
Patellofemoral Pain Syndrome: epidemiology
* 25 – 40% of knee problems in athletes
• 25% general population
• Hard to diagnoses (poor understanding of the condition)
* Female : Male ratio is 2:1
• Common in runners (19 – 46%)
• If untreated it will go unresolved for years
• Littre evidence linking PFPS and PF arthritis
48
Diagnosis testing for Patellofemoral Pain Syndrome
1. Anterior knee pain with quadriceps contraction (patellofemoral grind test)
2. Pain during squatting and
3. Pain on palpation of the posteromedial or lateral border of the patella
49
Patellofemoral Pain Syndrome treatment?
Conservative care
• Taping (modify patellar tracking)
• Patellarbraces
• Foot orthotics
• Muscle rehabilitation (hip muscles, trunk stability, quadriceps, hamstrings)
50
Patellar tendonitis
Tendonitis is a common cause of anterior knee pain
• Quadriceps or patellar (also known as Jumper’s knee) tendonitis
• Hamstrings too as a cause of posterior knee pain
51
Jumper’s knee
Repetitive loading of the extensor mechanism of the knee – kicking, jumping
• Painlocatedattheinferiorpoleofthepatella
• Usually presents as an ache after activity, easing with rest
• Somelocalswellingmaybepalpable
• Giving way or weakness is not uncommon
• Prevalence is highest among volleyball player...
• Patellar tendon rupture is a rare occurrence
Evaluation of patellar alignment is essential
52
Jumper's knee treatment?
Treatment is very similar as for lateral epicondylitis
• Progression of the condition leads to tendinopathy and in some cases calcific deposition within the tendon
53
Quadriceps Tendonitis
Same as for patellar tendonitis in presentation, with pain at the proximal pole of the patella
Common MOI extensor overload but a shorter lever therefore not as vulnerable at the PT
Most NB component of Rx = QUAD STRETCHING!!
54
The Blazina stages
Patellar tendinopathy can be classified according to onset and relation to activity
• PhaseI- Painonlyafterpracticeorgame
• Phase II - Pain during practice but does not interfere
with participation
• Phase III - Pain during and after practice and interferes with participation
• Phase IV - Complete tendon disruption
55
Plica Syndrome
Plica are synovial embryonic remnant that initially divided the knee into 3 compartments. By the third or fourth month of fetal life, the membranes are resorbed, and the knee becomes a single chamber.
Four types of which mediopatellar plica is usually the only to be symptomatic
56
Mediopatellar Plica Syndrome
Usually a combination of anatomical variance and either direct trauma or repetitive microtrauma
Inflammation progresses to hypertrophic changes and therefore a
symptoms develops
57
Mediopatellar Plica Syndrome: clinical presentation
Difficult to differentiate from other knee pathology
Aggravation of symptoms by activity, such as climbing stairs, squatting, or sitting
Pseudolocking and catching
Occasional giving way
Clicking or high pitched snapping
Anterior or anteromedial knee pain
58
Fat Pad Impingement Syndrome
```
Anterior knee pain caused by hemorrhage, inflammation, fibrosis and/or degeneration of the anterior knee fat pad(s)
3 main fat pads
- anterior supra patellar
- infrapatellar
- posterior supra patellar
```
59
Fat Pad Impingement Syndrome: aetiology
• Repeated microtrauma,
• Major trauma, or other
• Patellofemoral conditions
60
Patellar dislocation
• Acute, traumatic dislocation following direct contact or sudden change indirection when the tibia is stabilised (weight-bearing)
• Knee “gives way” at the time due to quadriceps inhibition due to pain
• Severe pain, rapid swelling and difficulty with any knee flexion
• Obvious dislocation of the patella is visible
• Most often the dislocation is lateral
61
In patient with indirect trauma patellar dislocation
• Hypermobile patella
• Patellaalto
• Shallow trochlear groove
• Systemic collagen tissue disorder (Marfan)
62
How to prevent another patellar dislocation?
• BracingORTAPING*duringactivities
• Quadriceps strengthening & flexibility
• Hamstring flexibility to prevent counteraction of their antagonists (quads)
• Address footwear and refer for orthotic evaluation if necessary
Patient with first time dislocation will likely have cartilage damage (95%)
63
Knee bursitis
Bursitis around the knee usually occurs in the
• Prepatellar (housemaid knee)***
• Pesanserine
Often occurs secondary to
• Directtrauma
• Injections
• Repetitive overuse
64
Chondromalacia Patella
Loss of cartilage in the trochlear groove and retro patella surface
Found in 50% of patient with OA of the knee
Can be asymptomatic
Caused by:
Patellofemoral laxity
Recurrent dislocation
Malalignment
65
Chondromalacia Patella clinical presentation
- anterior knee pain, often aching, can be sharp
- exacerbated by stair climbing or when rising from a seated position or kneeling
- may not be present with activity such as running or walking on level surfaces
- morning stiffness, crepitus may be present
66
Chondromalacia Patella clinical evaluation
Palpation of the lateral and medial patellar facet
| X-Ray: skyline view
67
Osgood-Schlatter disease
Traction apophysitis of the proximal tibial tubercle and occurs in active pre adolescents / adolescents
Repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle (MOI same as for tendonitis)
68
Osgood-Schlatter disease progresses too?
Hypertrophy of the tibial tubercle
Avulsion of the tibial tubercle
Enlarged, and tender to palpation
69
Rheumatoid arthritis
A chronic systemic inflammatory autoimmune disease of unknown aetiology
An external trigger (eg, infection or trauma) triggers it, leading to:
Synovial hypertrophy and chronic joint inflammation
Theorized to be inheritable
70
RA IN THE KNEE
- RA most commonly affects smaller joints (wrist and hand) although knee presentation in common in the juvenile form which often affects one joint at a time
- acute swelling , erythema and pain, limited weight bearing, often present with a limp
71
RA IN THE KNEE : clinical presentation
RA affects larger joints later in the presentation
The characteristic presentation is “symmetric” not only from a stand point of left to right but also from medial to lateral
72
Osteoarthritis: epidemiology
Osteoarthritis is the most common disease of joints in adults around
the world, and OA of the knee affect close to 6% in adults
Females > males
Prevalence of Knee OA is around 40% ≥ 70 74 year olds
X-ray findings are not well correlated with clinical signs only 15% have associated symptoms
Primary OA occurs as a degenerative process of ageing
Secondary OA is usually due to trauma or Repetative loading
73
Clinical evaluation and treatment of OA of the knee
Observed deformity in late OA
Mild effusion often present
Hypertrophied joint margins
Tenderness on palpation along medial joint line and MCL in earlier OA
74
Baker’s cyst
Essentially a ganglion at the posterior knee- a synovial herniation, most commonly medially
Occurs when normal fluid from the knee overflows under pressure through a weak spot in the capsule known as the popliteal recess
75
Bakers cyst: clinical presentation
Posterior knee pain or mechanical symptoms such as catching and accompanied by a feeling of fullness in the popliteal fossa
76
Causes of Hyperpronation
• Obesity, hip abductor weakness, Genu valgum
• Short Achilles tendon, high heels
• Tight shoes, weak toes flexor
CAN RESULT IN...
• Plantar fasciitis
• Forefoot changed
(Metatarsalgia, Hallux valgus)
77
Acute and chronic Compartment syndrome
– Raised intracompartmental pressures possibly induced by muscle swelling or increased osmoHc pressure~>blood flow impairment ~>pain
– Patients typically experience pain and swelling and may also have sensory deficits or paresthesias, and motor loss or weakness
– ACS is a medical emergency and can affect any compartment
– CCS lower extremiHes
– Younger individual +++
78
Causes of compartment syndrome
1. Vasculartrauma
2. Fractures
3. Crushinjuries
4. Anticoagulation therapy
5. Tight casts and splint
79
Shin splints
• Accounts for an esHmated 10% to 20% of all injuries in runners and up to 60% of all overuse injuries of the leg
• Common causes:
– MedialTibialStressSyndrome(MTSS)
– Tibial Stress Fracture
– ChronicCompartmentSyndrome
80
Medial Tibial stress syndrome
– Maladaptive remodeling process of bone as a reaction to stresses on the Tibia (loading – external or myofascial)
– Maladaptation process:
• Porous bone formation micro fissures eventually stress fracture
– MTSS is a spectrum of pathology ranging from initial periostitis to bony changes (above) to stress fracture
– Flexor digitorum longus (++) and SOLEUS (++++) are major contributors
81
Medial Hbial stress syndrome: presentation
– Diffuse pain along the middle and distal thirds of the posteromedial Tibia
– Typically runners or jumping activities
– Initial stage* - pain at the beginning of activity, may resolve as the activity continues, and then recurs after the activity ceases OR occurs only at the end of the the activity
• In the early stages, the pain usually resolves with several minutes' rest
82
Tibial stress fracture
– Diffuse pain at the posteromedial margin of the Tibia
– May begin insidiously and intensify with further training, eventually persisting throughout the day and even at night
One specific fracture type:
• Anterior cortex fractures - fracture of anterior cortex of the midshaft (poor blood supply and morphological bowing of the Tibia)
83
Deep vein thrombosis
– Venous thromboembolism (VTE)
– Either occult or following prolonged immobilizaHon (eg. surgery) and usually resolves spontaneously without complicaHon
– However, death from DVT- associated massive pulmonary embolism (PE) is not uncommon
– Most common presentaHon:
• Homan’s sign: calf pain on dorsiflexion of the foot
• A palpable tender venous segment / mass in the calf
– May have associated erythema, warmth and oedema
84
Myofascial pain syndrome
– Tibialis Anterior – medial Hbia
– No other real culprits for “shin” pain
• Local Tp’s in extensor digitorum / hallicus
may contribute to local pain / discomfort
85
Achilles tendonitis
Presentation:
– Paratenonitis
• Localized/burning pain during or following activity
• Later - onset of pain may occur earlier during activity, with decreased activity level, or even at rest
– Tendinosis
• Usually asymptomatic
• Patient may complain of a sensation of fullness or note a nodule in the back of the leg
86
Achilles tendonitis: aetiologies and treatment
Generally an overuse injury in the conditioned athlete,or presents in the unconditoned patient taking up a new activity (eg. running)
– HYPERPRONATION is a common underlying risk factor; SUPINATION being less problematic
Treatment options:
• Eccentric strengthening of gastroc/soleus complex
• Stretching once inflammation sexled
• Heel raises
87
Tendon rupture
• Achilles tendon rupture
– Typically a middle-aged recreational athlete who continues a youthful passion for a vigorous sport
– Male : Female 10:1
– Rapid eccentric loading of the Achilles tendon eg. landing a jump
• Gastrocnemius tear (calf “rupture”)
– Usually due to sudden, forceful contraction – eg. acceleration or repetitive forces eg. running uphill
88
Common peroneal nerve entrapment
CPN courses around the fibular neck and passes through the peroneus Longus muscle
Causes:
• Frequent crossing of the legs
• Fibular fractures
• Direct trauma to the knee
Presentation:
• Foot “drop” – weak extension, “slapping” gait
• Sensory deficit
89
Ankle sprain
• Most commonly sprained ankle ligament is the ATFL, followed by the CFL, then PTFL
Presentation
• Swelling usually lateral but may be diffuse
• Ecchymosis frequently found laterally, but it may sexle into the lateral or medial heel
90
Ankle sprain: provocative tests
• Anterior drawer usually positive but may be masked in early stages due to severe swelling
• Neurologic examination may be necessary in severe sprains as peroneal nerve and Tibial nerve injuries may occur
91
Ankle sprain: possibility of fracture
• Distal fibular fracture can occur with severe EVERSION sprains
• Local tenderness, severe swelling laterally and persistent pain are indicators
• Oxawa ankle rules need to be considered
– Chronic, recurrent instability:
• A frequent cause of ongoing pain and recurrent sprain
92
Synovial Impingement at the Ankle
A relatively common cause of ongoing pain following ankle inversion sprain – Causes
• synovitis,
• Fibrotic scar tissue &
• Periosteal new bone may develop
– Occurs anteriorly or posteriorly
– Exacerbated by passive dorsi or plantar flexion
– Arthroscopic surgery is most common treatment
– Ankle impingement sign*
93
Posterior Tibial Tendinopathy
– Main insertion for the PTT is on the medial navicular
– Hyperpronation may result in PTT tendon becomes overstretched
– It is usually an overuse injury
– Medial ankle pain behind the medial malleolus
– Swelling and tenderness
– Resisted inversion elicit pain and relaHve weakness
94
Peroneal Tendon Subluxation
– Snapping/popping of peroneal or fibularis tendons over distal fibula
– Usually reduces spontaneously
– Lateral ankle pain behind the lateral malleolus
– Local swelling and tenderness
– Symptoms elicited with resisted eversion
– Causes:
• Congenital loose retinaculum or shallow groove
• Traumatic retinacular tear such as following inversion sprain
95
Tarsal Tunnel Syndrome
Entrapment of 6bial nerve or its branches as it passes posterior to medial malleolus under the flexor retinaculum (tarsal tunnel)
Causes:
– Idiopathic – 50%
– Excessive pronaHon
– Compressive footwear (seen with ski boots)
Tarsal tunnel syndrome is primarily a clinical diagnosis
96
Tarsal tunnel syndrome: clinical presentation
– Vague plantar foot pain
– Paresthesia, numbness and atrophy of the intrinsic foot muscles as the condition progresses
– Pain usually aggravated by activity and relieved by rest
– Tenderness on palpation of the medial malleolus region
– + Tinel’s sign
– DDX
97
Plantar fasciitis
* Excessive femoral anteversion; lateral tibial torsion
* Leg length discrepancy (short leg)
• Hyperpronation
• Inappropriate footwear*
• Muscle tightness (tending to hyper-pronation)**
• Obesity
• Overtraining
98
Plantar fasciitis clinical presentation
– “Heel pain” upon weight bearing - typically worse in the morning with the first steps
• Often worse in stomach sleepers
– Pain gradually improves with activity though returns with prolonged weight-bearing
Also associated with arthritic conditions and Diabetes (weakness of intrinsic foot muscles and predisposition to inflammation)
Examination findings:
– Point tenderness on the medial calcaneal tuberosity
– Pain may be exacerbated by passive dorsiflexion or active plantar flexion
– Pain may be exacerbated by forced passive dorsiflexion of the great toe (Windlass test)
99
Other DDX for Plantar fasciitis
Heel Spurs
– Occur at the Achilles tendon or plantar fascia insertions
– MicrotraumaHc or associated with underlying arthritis
– Can be asymptomatic
Fat Pad Syndrome
– Inflammation of the heel fat pad
– Trauma (acute or repetitive)
• Obesity
• Footwear
100
Metatarsalgia
Pain over the metatarsal heads without any other obvious diagnosis
– Second metatarsal head is most frequently involved – with hyperpronation, the forces on the foot move medially, and the second metatarsal may assume an excessively large percentage of the force.
General treatment recommendations include:
• Strengthening the plantar muscles
• Footwear with low heels and wide toe boxes
• Orthotics if required
101
Metatarsal Stress Fracture causes
* Excessive alcohol consumption
• Excessive or sudden increase in physical activity with limited rest periods
* Female sex (esp if amenorrhea)
• Vitamin D deficiency
• Distance running - > 40km/week increases risk
• Smoking
102
Hallux valgus
Lateral deviation on of the hallux (toward other toes)
• Leads to bunion formation (tender medial bony prominence)
– Hyperpronation leading to excessive force on the first ray most common cause
– High heels producing a downward and medial force on the talus and/or a Tight Achilles tendon has also been implicated
– Narrow footwear
103
Hallux rigidus
Osteoarthrosis of 1st MTP joint
– Narrowed joint space
– Hypertrophy and Osteophytosis
– Associated dorsal or dorsomedial bunion formation
– Limits ROM
– often extension (DF)
• What is the implication of that – on gait?
– On the plantar fascia?
104
Turf toe
1st MTP joint sprain
– Typically secondary hyperextension while forefoot fixed in weight bearing
– Potential joint capsular stretching or tearing
105
Interdigital (Morton’s neuroma) neuralgia
Perineural fibrosis of the common digital nerve
– Most frequently between the 3rd and 4th metatarsals, with neuropathic pain* to the associated toes
– Often intermixent with asymptomatic episodes in between
– Patients someHmes feel a “marble”
Causes:
– Abnormal foot posture (planus or cavus)
– Footwear with narrow toe box
106
Interdigital (Morton’s neuroma) neuralgia: orthopaedic tests
1. Anterior drawer test: (Predominantly ATFL)
– Adding inversion tests more lateral ligaments
2. Forefoot compression test (Compression across metatarsals)
Reproduction of symptoms in Morton’s Neuroma
3. Tinel sign (sensitive but not specific)
4. Triple compression stress test (tarsal tunnel)
107
Specific Intervention for Plantar Fasciitis
- RICE
- corticosteriods
- muscle stretching
- Ultrasounds
108
Function of the anterior cruciate ligament?
Anterior cruciate prevent forward displacement of the tibia and controls rotational movement of the tibia
