Lower Extremity Flashcards
(136 cards)
1
Q
What are some questions to ask during history taking of the LE?
A
Muscle or joint pain? Reduced range of motion? Muscle weakness? Any joint redness/swelling? Numbness or tingling? Concern for peripheral vascular disease?
2
Q
What is ligamentum teres?
A
Ligament to the head of the femur that carries artery to the head of the femur.
3
Q
Anterior knee tendons:
A
Quadriceps tendon – sup. to pat.
Patellar tendon – inf. to pat.
4
Q
Medial knee tendons:
A
Pes Anserinus – 3 tend.; tibial slope
Semi-membranosis & -tendinosis
5
Q
Posterior knee tendons:
A
Med & Lat hds of gastroc
6
Q
Lateral knee tendons:
A
ITB – at Gurdy’s tub.
Biceps femoris – fib hd
7
Q
Shape of the medial meniscus.
A
C-shaped.
8
Q
Shape of the lateral meniscus.
A
O-shaped.
9
Q
ACL:
A
Function: stops anterior translation of tibia on femur Orientation of fibers: Anterior medial bundle Posterior lateral bundle MOI: Hyperextension Rotation w change of direction Jump stop w/wt posterior Intercondylar notch
10
Q
ACL surgeries:
A
Difficult to mimic fiber orientation Gold standard: BPTB graft Hamstring graft Achilles’ tendon graft Allograft (cadaver BPTB) versus autograft (yours)
11
Q
PCL:
A
Function – stops posterior translation of tibia on femur
MOI – falling forward on bent knee; direct blow to ant. tibia w/ ft not fixed
Surgery – rare, even with 3˚ tear
12
Q
MCL knee:
A
Commonly injured
MOI – valgus force
Surgery – maybe w/3˚
13
Q
LCL knee:
A
Less commonly injured.
MOI: varum force.
Surgery: super rare.
14
Q
Ankle Syndesmosis injury:
A
Ankle injury
Btwn tibia & fibula
Ant/post tibiofibular ligaments.
15
Q
Talocrural joint:
A
Ankle. Btwn tibia & talus modified hinge closed-packed=dorsiflexion resting is 10°
16
Q
Subtalar joint:
A
Ankle joint.
Btwn talus & calcaneous
synovial joint
Get chondral defects here at times
17
Q
List the three arches of the foot.
A
Longitudinal arch: Area of plantar fascia. Transverse arch: Under ball of foot. Lateral arch: Btwn head of 5th and calcaneous.
18
Q
Spine Examination Inspection.
A
Ask patient to stand up with his/her back toward you.
Note patient’s posture with his/her feet together & arms at sides.
Is head erect?
Are shoulders & pelvis level?
Inspect from the side.
Evaluate spinal curvature.
Assess cervical & lumbar concavity & thoracic convexity.
19
Q
What is valgum?
A
Inward rotation.
20
Q
What is varum?
A
Outward rotation.
21
Q
Where is the SI joint?
A
45 degrees from the iliac crest at L4.
22
Q
ROM of the spine (thoracic & lumbar)
A
Flexion (Look for scoliosis)
Extension
Lateral bending
Rotation – in seated position
23
Q
Describe flexion of the spine.
A
Bend forward & touch toes.
Evaluate for scoliosis.
May palpate along the spinous processes during this maneuver.
24
Q
Describe extension of the spine.
A
Stabilize the patient.
Bend backwards.
25
Describe lateral bending of the spine.
Stabilize the patient.
Lean to each side as far as possible.
“Like you’re picking up a suitcase”
26
Describe rotation of the spine.
Should be seated.
Stabilize the patient.
Rotate the trunk posteriorly.
27
Describe female athlete triad.
Poor nutrition.
Amenorrhea.
Osteoporosis.
28
Describe amenorrhea.
Females don't have their first period till after 16 years old.
29
What is dowager's hump?
Informal term for kyphosis.
30
Scoliosis evaluation.
Inspect from several angles and with patient bending forward.
“Dextroscoliosis” – curve is convex (toward) the right.
“Levoscoliosis” - curve is convex (toward) to the left.
May see falsely apparent leg length “discrepancy”, with “shortening” on the concave side.
31
Hip extension. ROM.
If done with patient on exam table, it is best if patient is lying prone (face down) or on one side.
-Extend thigh posteriorly.
-Ask patient to push down with leg against your hands.
Can be performed more easily with patient standing
32
Hip flexion. ROM.
Patient supine.
Can be done with leg straight or with knee flexed.
Perform strength testing with patient sitting.
33
Hip abduction. ROM.
| Hip adduction. ROM.
Passively (you move patient's leg).
Patient supine.
Grasp ankle & abduct extended leg.
Grasp ankle & move leg medially across the body
34
Internal rotation of the hip. ROM.
```
Passively (you move patient's leg).
Patient supine.
Flex the leg to 90° at hip & knee.
Hold knee with one hand.
Grasp ankle with other.
Swing ankle laterally.
```
35
External rotation of the hip. ROM.
Passively (you move patient's leg).
Follow same directions as used to assess internal rotation, except swing the ankle medially.
36
Lower extremity exam
Strength testing – hip flexion
ROM - knee
Ask patient to move to sitting position.
1. Hip flexion against resistance
2. Knee flexion & extension, then flexion & extension against resistance
- Flexion – “Don’t let me pull your foot/feet away from the table”.
- Extension – “Push my hand(s) way from the table with your legs.
37
Hip scour test.
Apply axial pressure with a passively bent knee and laterally and medially rotate the hip to score it.
38
Ober's test.
(roll over on your side). IT band. Tibial IR and hip ABD and extension. Then lower leg to the table. Positive test is if leg will not lower.
39
Noble's test.
IT band. patient is supine, palpate IT band and passively flex and extend knee. Subjective for the pain.
40
Thomas test.
```
iliopsoas (B). Positive is if femur raises off table. or… On back with single leg to chest. If opposite knee can get to 90 degrees, then it is iliopsoas. if knee is extended, then tight rectus femoris.
Rectus femorus (A). Positive if unable to have 90 degree flexion of the knee.
```
41
Straight leg raise. SLR.
| Purpose.
Testing for impingement of spinal nerves or “sciatica” or lumbosacral radicular pain:
Sciatica:
-Pain, numbness, or tingling in the leg – caused by injury to or pressure on lumbar nerves L3-L5, sacral nerves S1-3 or compression of the sciatic nerve itself.
Radiculopathy:
-Sciatica caused by injury/pressure on a particular nerve root (e.g. L4), is considered a radiculopathy (e.g. lumbar radiculopathy); another term – lumbosacral radiculopathy.
Weakness is a red flag.
42
Slump test.
Tests for sciatica.
| Have the patient sit up tall, then slump and hold their head down to their chest. Then lift leg and dorsal flex.
43
L4 nerve root damage.
Motor weakness: extension of quadriceps.
Screening exam: square and rise.
Reflexes: knee jerk diminished.
44
L5 nerve root damage.
Motor weakness: dorsiflexion of great toe and foot.
Screening exam: heel walking.
Reflexes: none reliable.
45
S1 nerve root damage.
Motor weakness: Plantar flexion of great toe and foot.
Screening exam: walking on toes.
Reflexes: ankles jerk diminished.
46
Straight leg raise (SLR).
| Demonstrate.
Elevate leg, dorsiflex foot.
Pain into ipsilateral leg is a positive test – suggests a lumbosacral radiculopathy.
-Assess degree of elevation at which pain occurs (e.g. 60 degrees) – “Positive SLR – pain down to mid-calf with elevation of leg to 600”
Pain in the contralateral leg is a positive crossed SLR
Tightness / discomfort in the buttocks or hamstring is not a positive test.
Two parts, lift the leg passively until they have pain, then back off and dorsal flex the foot to see if they have pain.
47
Seated SLR test (flip sign).
-Patient seated with his/her hands on table.
-Extend leg.
-Watch for pt to “flip back” when leg extended.
Positive for leaning back. Refer for more tests.
48
Faber test.
Supine “figure 4” and push the knee and opposite hip:
-Assesses SI Joint Dysfunction.
-Assesses Adductors.
If the hip cannot go laterally, then be concerned about the tightness of the hip muscles. When the patient says that hurts, ask them where.
49
Antalgic gait.
Limp adopted to avoid pain on weight-bearing structures, characterized by a very short stance phase
Patient remains on painful leg for as short a time as possible
“Limp” / Trendelenburg lurch.
No dorsal flexion.
50
Trendelenburg sign.
Identifies weak hip abductor muscles on side that is bearing weight (side we are testing).
If contralateral hip (not bearing weight) drops, the hip abductors on the weight bearing side are weak.
51
Angle of torsion hip.
Antiversion: neck of femur is slightly rotated posteriorly (pigeon toes, dislocate out the front).
52
Retroverted hip.
neck of the femur points backwards. (duck foot). backward dislocation.
53
Clarks test.
( if concerned about antiversion). Find greater trochanter by having patient in prone position, bend knee and rotate hip back and forth to see where the greater trochanter is. That is the neutral. Then measure it to see how many degrees it is from normal. 8-15 degrees is acceptable, outside is not good.
54
Inspection of the knee.
Inspect the skin & subcutaneous tissue over muscle and joints for the following:
-Color Incl. skin & nail beds
-Skin folds
-Swelling (edema)
-Masses
Effusion is in the joint space. Edema is not in the joint space.
55
Palpation of the knee.
Palpate landmarks:
- Patella
- Patellar tendon
- Medial & lateral epicondyles
- Medial & lateral condyles of tibia
- Tibial tuberosity
56
Palpation of the popliteal fossa.
Palpate for pulse (cysts or aneurysm)
Popliteal pulse
-Knee should be flexed
-May need to press deeply
57
Ottawa Knee Rules
Help to make a decision if you need to X-ray or not.
Age greater than 55.
Isolated tenderness at the patella (no other bony tenderness).
Tenderness at the fibular head.
Unable to flex knee to 90.
Unable to bear weight immediately after and in ER for 4 steps (limping counts).
-Any one of these positive with an appropriate MOI, the patient should get X-ray.
58
Baker's Cyst (popliteal cyst).
A synovial fluid cyst located in the popliteal space.
Palpable as fluctuant fullness.
May be painful &/or, if they leak, result in calf swelling.
Best to palpate with knee extended.
Synovial sack pops out the back of the knee.
59
Popliteal Artery Aneurysm.
Usually due to atherosclerotic vascular disease.
Males >>females.
Usually > 65 years old.
The most common aneurysm of the peripheral vascular system.
Bilateral > 50% of the time.
Diagnosis: pulsatile swelling behind the knee.
Best to palpate with knee extended.
60
Meniscal Tears.
MOI – wt brg w/rotation.
S/S:
-Pain / Swelling localized at jt line.
-Won’t see much swelling – why?
-Maximum amount of swelling is frequently seen the day after injury.
-May report popping, clicking, locking
-May report “feels like knee is going to give out” – very specific complaint to meniscal injury
-Surgery – repair or menisectomy
If tear is at an avascular zone: then little pain but lots of popping and clicking.
If vascular zone: it is sewed down.
61
Buckethandle tear.
Locks the knee into place.
| Tear in meniscus.
62
Patellar dislocations:
MOI - knee flexed between 20-45˚ w/valgus load – then max contraction of quads
Will almost always go laterally.
63
Patellar Fractures:
MOI - significant direct blow/force.
Not common in athletics.
Extremely painful – unable to SLR.
64
Chondromalacia Patellae.
Degenerative process that results in a softening (degeneration) of the articular surface (hyaline cartilage) of the patella. Weakening of the bone under the patella.
MOI – overuse w/poor tracking.
.Commonly large Q-angle.
65
Patella tracking syndrome.
When the patella doesn't track within the patellar groove.
66
Q-Angle.
The more knock-kneed you are, the greater the Q-angle.
Women naturally have greater Q-angles (wider hips for child-bearing).
Thus, women experience chondromalacia patella more frequently than men.
Normal = <15°
67
Patellar Tendonitis.
“Jumper’s knee”
MOI – overuse w/heavy quad loads & poor quad flex.
S/S - Pain increased with activity, aches after exercise, possible swelling, pt tenderness at inf pole, increased pain with resisted knee extension.
Risk of tendon rupture!
Patellar tendinopathy.
Distal end is Osgood-Schlatter.
Proximal end near patella: Sinding-Larson-Johansson.
68
MCL sprain.
Most frequently injured lig in the knee.
MOI: Blow to lateral side of the knee forcing valgus.
S/S: pain, mild to mod swelling exterior to jt, discoloration, and point tenderness along length, valgus instability, may report feeling a “pop”.
69
LCL sprain.
MOI: Foot planted, medial side impact/varus force.
S/S: pain, lateral knee swelling, ecchymosis, point tenderness over the length of the LCL, varus instability, may feel “pop” with complete rupture.
70
ACL sprain.
MOI:
A twisting maneuver during weight bearing – such as changing directions or landing from a jump while twisting.
Forced hyperextension.
Landing w/bent knee with center of gravity too far posterior – ex: skiing in deep powder.
A direct blow to the back of the tibia that drives the tibia forward (very rare!).
S/S:
Immediate pain & feeling of instability.
Audible “pop”.
Joint effusion and loss of motion usually result within 24 hours.
Athlete will be unwilling to bear weight or will have a sense of significant instability with weight bearing.
Lachman's test.
71
PCL Sprains.
MOI: injured by a direct force against the ant. tibia, driving it posteriorly.
S/S: pain, joint effusion, and limited range of motion into full flexion & extension, may have audible “pop”.
Athletes who have good quadriceps and hamstring muscle strength may not complain of a feeling of instability with weight bearing. So this type of injury is sometimes missed.
Posterior drawer test.
72
Unhappy Triad.
Sprain of the MCL, ACL, and tear of the medial meniscus.
Athlete receives a lateral blow to the knee with the foot fixed. Combination of valgus force and rotation of the leg places stress on the medial collateral ligament first.
73
Iliotibial band.
Origin - Tensor fascia latae M. & 2/3 glut max M.
Insertion - Gurdy’s tubercle.
MOI: overuse w/tight TFL and glut max.
S/S: Pain over lateral epicondyle; Pain going DOWN stairs; Pain when leg is swinging forward during gait.
Treatment: Must stretch glut max and TFL; Arch supports commonly help.
74
Popliteus Tendonitis.
MOI: Overuse injury if hamstrings get tired and popliteus has to carry more than its regular load in knee flexion.
S/S: nothing unique; pain w/resisted knee flexion; pain w/palpation.
75
Osgood-Schlatter's Disease.
MOI: repetitive traction on the tibial tuberosity apophysis via the patellar tendon and quadriceps group.
Occurs in young athletes when the growth plate of the tibial tuberosity is still fluid.
S/S: aggravated by running, jumping, or kneeling in youth athletes; pain & swelling around tuberosity.
76
Sliding-Larsen-Johansson Disease.
Resembles Osgood-Schlatter's disease except that the pathology involves the proximal rather than the distal end of the patellar tendon.
Caused by repetitive traction forces on the inferior pole of the patella.
77
Peroneal nerve contusion.
Nerve passes just below the proximal head of the fibula, where it lies subcutaneously.
Localized pain from the contusion and a radiating pain to the anterior lateral leg musculature and dorsum (back) of the foot.
78
Prepatellar bursitis.
Most commonly injured, direct trauma, large amounts of fluid between skin and patella; looks like golf ball hanging.
79
Infrapatellar bursitis.
Result of repetitive kneeling or repeated trauma over the distal patellar tendon.
80
Suprapatellar Bursitis.
Fills whole knee jt capsule – common after ACL tear.
81
Pes Anserinus Bursitis.
Related to cycling or running, constant friction or external blow.
82
Baker's Cyst.
```
Posterior aspect of knee
Often palpable (red arrow).
Common after ACLr.
Painful with full extension and full flexion.
Surgical if necessary for pain relief.
Playable as tolerated.
```
83
Plica or 'Medial Shelf'
Plica is an unusual fold of the synovial capsule that wasn't reabsorbed as a baby.
MOI: Plica gets pinched under the patella if the quads fatigue and can’t pull it out of the way soon enough before the patella compresses.
S/S: pain, popping, snapping, or just aching at rest under medial edge of patella.
84
Fat Pad Impingement or Bruise.
MOI: bottom of the patella pinches, or impinges on, the fat pad on top of the tibia.
S/S: will report a sensation of pinching, bruise feeling in full extension.
85
Bulge sign/Sweep test.
Testing for knee effusion
(fluid accumulation around the joint usu. assoc. with trauma or overuse).
With leg straight, “milk” knee joint fluid down one side & up the other - observe for bulge.
86
Ballottement of patella.
Testing for knee effusion.
Apply downward pressure from above the knee to milk fluid down.
Push patella into the joint space, feel for fluid / boggy sensation.
Does it float back up when you push it down.
87
Genu Varum.
| Genu Varus.
Bow legs.
88
Genu Valgum.
| Genu Valgus.
Knock knees.
89
Valgus stress test knee.
Testing for medial collateral ligament (MCL) laxity &/or pain.
With leg slightly flexed, stabilize the knee & abduct the distal leg.
Note any ligament laxity or pain.
90
Varus stress test knee.
Testing for lateral collateral ligament laxity &/or pain.
Like valgus stress test, except adduct the distal leg
Note any ligament laxity or pain.
91
Lachman's test knee.
Testing for ACL tear.
Patient’s knee is flexed ~ 15-20º.
You stabilize thigh with one hand, with other hand, pull upper tibia forward.
Compare sides.
More sensitive sign of ACL tear than drawer test.
92
Anterior drawer sign knee.
Testing for anterior cruciate ligament tear (ACL tear).
Patient’s knee is flexed 90º; foot & hips stable.
Pull upper tibia forward assessing for excessive forward movement.
Compare sides.
93
Posterior drawer sign knee.
Testing for posterior cruciate ligament tear (PCL tear).
Similar to anterior drawer sign, except tibia is pushed back (rather than pulled forward).
Excessive laxity suggest PCL tear.
94
McMurray's test knee.
Testing for meniscal tear.
Flex knee, place thumb & index finger on joint space.
To test for medical meniscal tear:
-Rotate foot laterally and extend leg.
-Palpable click or pain at joint line indicates medial meniscal tear.
To test for lateral meniscal tear:
Same procedure done except – rotate foot medially, and extend leg.
Palpable click or pain at joint line indicates lateral meniscal tear.
95
Thesssaly test knee.
Twisting on a fixed knee that is weight bearing. Hearing or feeling popping.
96
Lower extremity palpation.
```
Palpate all lower extremity bones, joints, & surrounding muscles for the following:
-Muscle tone
-Edema
-Warmth
-Crepitus
-Tenderness
-Palpate known tender areas last.
Palpate calf:
-Tenderness
-Swelling
-Palpate for firm “cord” suggestive of thrombosed vein (blood clot)
Palpate ankle and foot:
-Achilles tendon.
-Medial and lateral malleoli.
-Heel, calcaneus, plantar fascia.
-Heads of the five metatarsals.
-Metatarsophalangeal joints.
```
97
Inspection of ankle and foot.
Deformities.
Nodules or other masses.
Swelling.
Callus: (Skin thickening found on the bottom of foot - generally superficial & doesn't usu. cause pain).
Corns: (Usu. found on top of toes – specially shaped callus of dead skin; smaller than calluses but deeper & painful).
98
Palpation for pitting edema.
```
Press downward with thumb for a few seconds, observe for indentation:
Indicate how high edema rises up leg:
-Dorsum of foot
-Behind medial malleolus
-Pretibial (shins)
Grade from 0 to 4+ edema:
“2+ pitting edema to mid-calf”
```
99
Palpation for pedal pulses.
```
Posterior tibial pulse:
-Behind and slightly below medial malleolus.
Dorsalis pedis pulse:
-Dorsum of the foot.
-Over 1st-2nd metatarsals.
```
100
Grading of pulses.
```
Grade the amplitude of the pulse:
0 Absent, unable to palpate
1+ Diminished, weaker than expected
2+ Brisk, normal
3+ Increased
4+ Bounding
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101
ROM Ankle and foot. .
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Dorsiflexion
Plantarflexion
Inversion
Eversion.
Flexion of toes.
Extension of toes.
```
102
Strength testing ankle.
Patient still seated.
Dorsiflexion:
-Place your hand on top of patient’s foot
-“Bend your foot up against my resistance”
Plantar flexion:
-Place your hand under patient’s foot
-“Push down against my hand, like your foot’s on the accelerator”.
103
Ottawa Ankle Rules.
An ankle X-ray series is required only if there is any pain in malleolar zone and any of these findings:
-Bone tenderness posterior edge or tip of lateral malleolus.
-Bone tenderness posterior edge or tip of medial malleolus.
-Inability to bear weight both immediately and in ER.
A foot X-ray series is required only if there is any pain in mid foot zone and any of these findings:
-Bone tenderness at base of 5th metatarsal.
-Bone tenderness at navicular.
-Inability to bear weight both immediately and in ER.
104
Difference between ankle sprain and strain.
Sprain – tear or stretch of a ligament (bone to bone).
| Strain – tear or stretch of a tendon / muscle structure (tendon is muscle to bone).
105
Anterior drawer sign ankle.
Testing for anterior talofibular ligament tear.
Stabilize the distal tibia.
Grasp & pull calcaneus forward assessing for excessive forward movement.
106
Syndesmosis joint
Between tibia and fibula. Injured means there is space between the two bones when there should not be space.
107
Anterior tibialis tendonitis.
- Tends to be more acute
| - Isolate to confirm with MMT
108
Achilles' tendonosis.
- Tends to be more chronic
- Obvious swelling
- Long rehab w/ many set-backs
- Risk of rupture – age group?
109
Achilles' Rupture.
MOI – big bang!; usually age related; “weekend warrior”
| Surgery: Suture mop ends together = LOTS of scar tissue! Long, slow rehab.
110
Neuropathic Ulcer.
Lower leg and foot abnormality.
| Commonly associated with diabetes.
111
Foot Pathology.
| Pes Planus.
Flat mobil foot.
Lose the spring ligament makes you lose the longitudinal arch.
MOI: Congenital, trauma, muscle weakness.
All infants have flat feet until ~ 2 y.o.
Two types:
-Rigid or congenital
--Rare
--Calcaneous in valgus & midtarsal in pronation
--Visible in NWB position
-Flexible or acquired
--Due to tibial torsion or subtalar jt. dysfunction
--Apparent in WB position, but if stand on tiptoes, arch re-appears.
112
Ankle Pathology.
| Inversion Sprains.
Most common MOI:
-Plantarflexion with hindfoot inversion.
1st degree = ATF lig torn, little laxity, pain.
2nd degree = ATF lig torn & some CF lig damage, clear laxity but end pt, pain.
3rd degree = all three lateral ligs torn, laxity w/no end pt, pain, unable to bear weight.
113
Ankle Pathology.
| Eversion Sprains.
MOI: Land in plantar-flexion and rotation into eversion.
If excessive eversion may fracture the fibula (lateral Malleolus).
Deltoid ligament.
114
Ankle Pathology.
| Syndesmosis Sprains.
MOI:
-Plantarflexion with hindfoot inversion and rotation of talus in mortise.
-Damage to ATF lig, CF lig, distal tib-fib lig (ant &/or post).
-Often referred to as a HIGH ANKLE SPRAIN.
Takes longer to heal because every time the individual steps, the tib-fib lig is stressed.
115
Foot Pathology.
| Plantar fasciitis.
```
MOI: overuse; acute or chronic
S/S:
-Pain most severe when first getting out of bed in the morning.
-Pain generally diminishes during activity & increases when activity stops.
-Pt tender at the origin on the ant./medial calcaneous & distally to mid-fascia.
Predisposing factors:
-excessive pronation.
-obesity.
-abnormally high arch (pes cavus).
Differential Diagnosis:
Tarsal Tunnel Syndrome:
-Use Ankle DF with Foot Eversion.
-Tinel's Sign.
Sever Disease (calcanea apophysitis):
-If patient is 13 years old or younger.
-Indicated if pain elicited when squeezing heel.
Heel Spur:
-get x-ray to confirm.
```
116
Foot Pathology.
| Turf Toe.
MOI: sprain of 1st MP jt from hyperextension.
S/S:
-moderate pain in ball of foot under the big toe with gait.
-Swelling and signif pt tenderness on inferior jt.
-Incr pain w/toe extension.
Treatment:
-Turf toe tape.
-Steel inserts – very helpful!
Differential diagnosis with seasmoiditis or fracture.
117
Foot Pathology.
| Fracture to the base of the 5th metatarsal.
```
MOI: inversion moment commonly combined with landing from a jump.
S/S:
-Very pt tender at head of 5th.
-Bone may even feel mobile.
-Cannot bear wt on that foot.
-Pain w/resisted eversion.
Treatment:
-Refer on crutches for x-rays.
```
118
Foot Pathology.
| Lisfranc Injury.
Injury to any side of the 2nd metat head articulations; dislocations or fracture.
MOI – varied; signif impact from something.
S/S – painful wt bearing – inability to go into terminal stance of gait; pt tender in dorsal apex of mid-foot around head of 2nd metat.
Treatment – refer immediately for x-rays.
If any question, do a weight bearing X-ray bilaterally.
119
Foot Pathology.
| Morton's Neuroma.
Compression of a nerve bundle betwn the metatarsal heads in ball of foot;
most commonly betwn 3-4 or 2-3;
MOI - shoes with narrow toe box.
S/S - tingling, burning, pain in the ball of their foot AND DISTALLY into assoc toes.
Treatment – ditch the tight shoes permanently; may place felt pad directly under neuroma.
120
Foot Pathology.
| Bunion.
Inflammation and thickening of the bursa of the MTP joint of the big toe – with valgus deformity.
121
Foot Pathology.
| Metatarsalgia.
Pain and tenderness under the metatarsal heads.
| Unable to progress through terminal stance during walking because cannot load forefoot.
122
Foot Pathology.
| Claw Toes.
Hyperextension of MP jt. and flexion of PIP & DIPs.
| Assoc. with pes cavus, fallen metatarsal arch, or problems with intrinsic musculature.
123
Foot Pathology.
| Hammer Toes.
Extension contracture at MP jt. Flexion contracture at PIP, DIP may be in any position.
Can be congenital, poor fitting shoes, hallux valgus or muscular imbalance.
124
Foot Pathology.
| Pes Cavus.
Rigid foot, High Arch.
Plantar soft tissues are shortened.
Often leads to claw toes.
Difficult to absorb shock.
125
Lower extremity signs of peripheral artery insufficiency upon inspection.
```
Dependent rubor
Pallor with raised extremity (may also have pain)
Hair loss on leg/foot
Atrophic skin; nail changes
Ulcers
Necrosis/gangrene
```
126
Lower extremity signs of peripheral artery insufficiency upon palpation.
-Pulses:Femoral, popliteal, posterior tibial, dorsalis pedis.
-Skin temperature: Cool
-Capillary refill: Delayed (> 2 sec)
Auscultation for bruits:
-Abdominal aorta
-Femoral & popliteal arteries.
127
```
Lower extremity venous insufficiency.
Varicose veins (varicosities).
```
Dilated, tortuous superficial veins - result from defective structure & function of the valves of the saphenous system
Symptoms include:
-Dull ache or pressure sensation after prolonged standing; relieved with elevation.
-Dependent ankle edema may develop.
-Ankle ulcerations may develop.
-Superficial thrombosis / thrombophlebitis may occur.
Support hose if prolonged sitting.
128
Stasis dermatitis.
Due to chronic venous insufficiency with incompetent valves & higher pressure in capillary bed.
Tissue is damaged & inflamed.
“Brawny,” non-pitting edema.
129
Lymphedema (lymphatic obstruction).
Results from blockage of the lymph vessels that drain fluid from tissues throughout the body (& transport immune cells to where they’re needed).
130
Homan's Sign.
Testing for deep venous thrombosis.
In a patient with calf pain, tenderness, &/or swelling.
Passivel dorsiflex the foot
Calf pain with dorsiflexion suggests DVT.
Questionable reliability & validity.
-Calf pain may be due to some other cause.
-Negative test does not rule out DVT.
131
Thompson's Test.
Achilles' rupture.
| Squeeze calf muscles will cause plantar flexion if the tendon is not ruptured.
132
Slump test.
```
Slump Test
Seated
Slump
Tuck Chin
Knee Extension
Dorsiflexion.
Alternative to the straight leg.
```
133
Hip scour test.
Hip Scour Test
Acetabular Labrum
Apply axial load to femur as you rotate hip in internal and external rotation with varying degrees of hip flexion
134
Ober's Test.
```
Ober’s Test
IT Band
Tibial IR and hip ABD and extension
Then lower leg to table.
Positive test is if leg will not lower.
```
135
Noble's Test.
Noble’s Test
IT Band
Patient is supine, palpate IT band and passively flex and extend the knee.
Subjective test for pain.
136
Thomas test.
```
Thomas Test
Iliopsoas (B)
Positive is if femur raises off table or
Rectus Femoris (A)
Positive is unable to have 90 degree flexion of the knee
```
