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Leg Flashcards

(51 cards)

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1
Q

What is tibial stress syndrome?

A
  • commonly called shin splints and presents with leg pain at the distal 2/3rds of the tibia
  • an overuse syndrome with a continuum of sequential pathological progression from: tendinopathy, myositis and/or periostitis -> compartment syndrome, periosteal avulsion fracture or tibial stress fracture
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2
Q

What are the two primary types of tibial stress syndrome? What is the 3rd, less common type?

A
  • medial (posterior) tibial stress syndrome
  • anterior tibial stress syndrome

Less common:
- lateral tibial stress syndrome

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3
Q

What anatomy is associated with medial (posterior) tibial stress syndrome?

A

Tibialis posterior tendon

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4
Q

What anatomy is associated with anterior tibial stress syndrome?

A

Tibialis anterior muscle

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5
Q

What anatomy is associated with lateral tibial stress syndrome?

A

Peroneus/fibular is longus and brevis

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6
Q

What is the epidemiology of tibial stress syndrome?

A
  • F>M (2-4 times more likely)
  • runners, especial without sufficient rest
  • increased BMI
  • over pronation
  • increased hip rotation
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7
Q

If tibial stress syndrome is due to strain/tendinopathy, what are the findings?

A
  • diffuse pain with palpation and activity/muscle contraction
  • pain may reduce with warm up
  • rest is palliative
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8
Q

What are the symptoms of medial (posterior) tibial stress syndrome?

A
  • exercise related diffuse pain and tenderness along lower 1/3rd of posteriomedial tibial crest
  • bumpy tibial crest
  • classic tendinous strain symptoms including pain with stretch and contraction, tendon tenderness
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9
Q

What are the symptoms of anterior tibial stress syndrome?

A
  • symptoms of myositis including weakness, swelling, pain/tenderness and warmth over tibialis anterior
  • stretch and contraction reproduce pain
  • may have associated periostitis or periosteal avulsion fracture
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10
Q

The etiology for tibial stress fracture and tibial stress syndromes is the same, so what key findings from the history would make you lean towards fracture as your Dx?

A
  • deep, sharp, point tenderness with minimal radiation
  • pain with activity AND rest
  • night pain
  • localized swelling without pulse change
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11
Q

What is the gold standard for detecting a fracture?

A

Bone scan

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12
Q

What ancillary tests can be used to screen for tibial fracture, although they have limited use?

A

Tuning fork and US

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13
Q

What is the recovery time, prognosis for tibial stress fracture?

A

3 weeks

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14
Q

What are the key DDXs to rule out before diagnosing tibial stress syndrome?

A
  • stress fracture
  • muscle hernia
  • exertional compartment syndrome
  • radiculopathy and peripheral nerve entrapment
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15
Q

What is the early treatment for tibial stress syndrome?

A
  • POLICE (complete rest for 7 days and ice massage, taping)
  • use alternative activities for 2-3 weeks (cross training, etc.)
  • CMT and STM
  • isometric exercises
  • shoe, surface, orthoses change
  • NSAIDs with cryotherapy
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16
Q

What is the late treatment for tibial stress syndrome?

A
  • increase warm up and cool downs
  • isometric and isotonic exercises
  • graded return to offending activity (running, jumping)
  • CMT and STM
  • gait analysis and orthotic counseling
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17
Q

What is the prognosis for tibial stress syndrome?

A
  • improve quickly (within 2 weeks) with rest

* if compliant patient is not better in 2 weeks, need x-rays/bone scan to rule out stress fracture

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18
Q

What are the two types of compartment syndrome?

A
  • chronic exertional

- acute

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19
Q

95% of chronic exertional compartment syndrome occur in what age group, gender and anatomical area?

A

Lower leg (R 2 times more than L) in 26-28 year old males

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20
Q

Acute compartment syndrome occurs most commonly in what age group, gender and anatomical area?

A

Males under 35

Most cases are in leg or forearm but can occur in foot, thigh and gluteal region

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21
Q

What is a compartment syndrome?

Study These Flashcards
A
  • loss of circulation (claudication) due to unyielding size of osteoma social compartment and increasing soft tissue pressure/fluid accumulation.

Claudication > ischemia > necrosis

22
Q

Chronic exertional compartment syndrome more commonly affects what compartment and is caused by what kind of activity?

Study These Flashcards
A

More common in posterior compartment and caused by endurance sports with high impact such as running

23
Q

Acute compartment syndrome more commonly affects what compartment and is caused by what kind of activity?

Study These Flashcards
A

More common in anterior compartment and caused by contact sports such as martial arts

24
Q

What are some risk factors for developing compartment syndrome other than activity (running, martial arts, etc.)?

Study These Flashcards
A
  • large muscle mass

- anticoagulant use

25
Compartment syndrome can be a sequellae to what other condition?
Shin splints/tibial stress syndrome
26
Compartment syndrome can be associated with what other comorbidities?
- muscle hypertrophy - muscle and CT anomalies - fascial herniations - venous hypertension
27
What is the classic presentation of chronic exertional compartment syndrome?
- diffuse pain with digital palpation and muscle contraction/activity (need to rule out tibial stress syndrome) - gradual onset of severe cramping with throbbing/pulsation quality (need to rule out DVT) - onset after predictable time or distance of activity (need to rule out intermittent claudication/central canal stenosis) - rest is rapidly palliative (need to rule out intermittent claudication/central canal stenosis)
28
What is the pathophysiology of chronic compartment syndrome?
- activity elevates compartment pressure 3-4 times - ischemia occurs due to compression of capillaries and arterioles, affecting muscles and nerves. NOTE: pulses still present - can lead to acute compartment syndrome through a self perpetuating cycle of increased edema and increased pressure
29
What are the typical exam findings for chronic exertional compartment syndrome?
- no obvious swelling or erythema - painful AROM - painful PROM at end range stretch - tender to very light palpation - painful muscle weakness possible (may need repetitive muscle testing to elicit this) - normal neuro
30
What is the treatment for chronic exertional compartment syndrome?
Similar to the tibial stress syndrome - rest - ice - eliminate extrinsic factors - change training techniques - ID and treat intrinsic/biomechanical factors - light therapeutic massage distal to proximal
31
What is the prognosis for chronic exertional compartment syndrome?
- may need referral to MD if 6 weeks of failed treatment | - diagnosis confirmed by measuring compartment pressure and then surgical fasciotomy along with major lifestyle changes
32
What is acute compartment syndrome?
Serious ischemia due to excessively high compartment pressure from pooling of exudates and/or blood MEDICAL EMERGENCY
33
What are some common causes of acute compartment syndrome?
- trauma without fracture (crush, contusion/blunt, inversion sprain, contact sports - concomitant fracture (tibia, radius) - insect or snack bite - Prolonged compression - Post surgery - History of confirmed fascial herniation
34
What is the classic presentation of acute compartment syndrome?
- increased/worsening pain, disproportionate to the trauma or injury - throbbing, pulsating, cramping quality - visible edema with ecchymosis - palpatory tenderness - pain with toe wiggling and muscle stretching - painful muscle weakness
35
What are some comorbidities for acute compartment syndrome?
- fracture | - hemorrhage (hemophilia or vascular occlusion)
36
What are the typical exam findings for acute compartment syndrome?
- overt swelling and erythema - painful AROM/PROM - very light palpatory tenderness - painful muscle weakness with single isometric test - neuro is positive for 6 Ps in “stocking distribution”
37
What are the 6 Ps that are positive on neuro exam with acute compartment syndrome?
- pain - paresthesia - paresis - paralysis - pallor - pulseless (although rarely)
38
What is the treatment for acute compartment syndrome?
- EMERGENT REFERRAL, because there is risk of rapid and irreversible damage within 2-4 hours of onset - surgical decompression (fasciotomy) - ice for pain - do not compress or elevate
39
How would acute cellulitis of the leg present?
- hot and red (mimicking DVT)
40
What is acute cellulitis?
Spreading infection of the subcutaneous dermis (strep or staph)
41
What is thrombophlebitis?
- Aggregated platelets, due to endothelial damage, causing inflammatory changes to the vessel wall, destroys valves and thrombus formation - blood flow can be restored through recanalization - or complications can occur: chronic pain insufficiency, pulmonary embolism, host thrombotic syndrome
42
Thrombus formation is most typical in the veins of the leg. Which ones?
- posterior tibial v. = distal DVT (less common) | - popliteal v. = proximal DVT (80% of cases, higher risk of embolus)
43
Why is DVT an urgent referral?
- there is a high risk of pulmonary embolism which has a high mortality rate
44
What are some things from the history that could indicate risk for DVT?
- prolonged bed rest - extended sitting - long air travel - knee surgery
45
What is the typical presentation of DVT?
often asymptomatic until embolism occurs but could present with unilateral leg symptoms: - swelling - pitting edema - erythema - local tenderness - palpable “hard cord” from dilated superficial veins - leg may feel colder
46
What are the possible DDxs for DVT?
- rupture popliteal cyst - cellulitis - severe tendonitis/strains - lymphadema - primary varicosities
47
What is the Well’s decision making tool?
Clinical prediction guide for determining DVT probability
48
What diagnostic tests are needed for DVT?
- d-dimer | - ultrasound
49
What is the treatment for DVT?
- anticoagulants - early ambulation - thrombus removal - stockings to prevent post-thrombotic syndrome
50
What is post thrombotic syndrome?
long term sequels of DVT that includes: - pain - swelling - varicosities - pigmentation and skin changes - possible ulceration
51
What is the treatment for post-thrombotic syndrome?
- elevation | - gradual compression stocking use

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