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Injuries in Sport > Lower Limb > Flashcards

Lower Limb Flashcards

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1
Q

Anterior compartment of lower leg

A

Tbialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius
Deep peroneal nerve
Anterior tibial artery

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2
Q

Lateral compartment of lower leg

A

Peroneus brevis, peroneus longus
Superficial peroneal nerve
Peroneal (perforating) arteries

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3
Q

Deep posterior compartment of lower leg

A

Tibialis posterior, flexor digitorum longus, flexor hallucis longus, popliteus
Tibial nerve
Posterior tibial artery

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4
Q

Superficial posterior compartment of lower leg

A

Gastrocnemius, soleus, plantaris

Cutaneuous nerves only e.g. sural

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5
Q

Night pain

A

Wakes you up at night

ask for systemic symptoms that indicate autoimmune diseases or cancer

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6
Q

Tinnel’s sign

A

Light palpation on nerve reproduces symptoms of pins and needles/ tingling => irritated nerve

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7
Q

Foot dorsiflexion

A

10-15

Tibialis ant, EDL, EHL, peroneals

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8
Q

Foot plantarflexion

A

45-55

Gastroc, soleus, tib posterior, FDL, FHL

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9
Q

Foot inversion

A

30-40

Tibialis posterior

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10
Q

Foot eversion

A

15-25

Peroneals

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11
Q

Foot pronation

A

15-30

Eversion + Abduction + Dorsiflexion

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12
Q

Foot supination

A

45-60

Inversion + Adduction + Plantar flexion

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13
Q

Over pronation (i.e. flat foot) causes

A 
flattening of long arch
movement mid-tarsal joints
rotation of tibia
functional q angle of knee
load on tibialis posterior
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14
Q

Isotope bone scan (IBS)

A 
Radioactive isotome -> inject Technetium-99 polyphosphonate
Triphasic bone scan 
- 0 mins: isotope angiogram
- 2 mins: blood pool
- 2 hr: delayed

Looking for hotspots

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15
Q

Stress fracture

A

Acute onset due to repetitive microtrauma
Imbalance between deposition/resorption
Low BMD
Fatigue of shock absorbing muscles

Point tenderness O/E
Crescendo night pain
Immediate pain on running
Training conditions - hard surface, increased intensity

Plain radiograph => callus at 2-3wks
IBS

Rest for 6-9wks until pain free
immobilise if severe
phased RTS
Internal fixation if not healing

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16
Q

Medial Tibial Stress Syndrome (Shin splints)

A

Cause unknown - theories of traction periostitis or tibial bending

lasts hrs to d
Typically within first 2 wks of new season
Aching during/after exercise
Able to exercise through pain
O/E Posterio-medial tenderness on distal third of tibia

RF: INTRINSIC - endocrine, bone geometry, biomech, nutritional; EXTRINSIC - surface, training error, footwear

Ix - XR, IBS, MRI

Rx - RICE for 7-10d, aerobic NWB fitness, podiatry for assessment

Prevent - gradual increased training, good dorsiflexion, flexibility pre-season, footwear, training surface, diet

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17
Q

Chronic Compartment Syndrome

A

Increased pressure within a closed compartment due to inelastic fascia; caused by increased muscle volume due to continuous exercising
Compromised circulation and tissues

Starts within a few mins of exercise and stops after rest
Stops them from continuing
Associated numbness and weakness

Ix
Intra-compartmental pressure studies; insert cather in muscle and exercise for 5 min
Normal <10mmHg; Significant >30mmHg

Physio, orthotics, NSAIDS
Superficial fasciotomy

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18
Q

Tibialis Anterior/ EDL/ EHL Tendinopathy

A

Overuse injury of dorsiflexors
Downhil running, tight shoelaces

TA => pain on resisted dorsiflexion
EDL => pain on resisted toe extension
EHL => pain on resisted halux extension

RICE, Rehab, injection

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19
Q

Tibialis Posterior/ FDL/ FHL Tendinopathy

A

Overuse of plantarflexors
Ballet dancers
Tom, Dick and nervous Harry

TP => post-medial calf -> medial melleolus -> navicular tuberosity ; pain on resisted inversion
FHL => Pain on resisted toe flexion

RICE, eccentrics, injection

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20
Q

Popliteal artery entrapment syndrome

A

Claudication during exercise by head of gastrocnemius or thick fibrous band
Similar Sx to CCS
Tib posterior pulse disappears when acutely plantarflexed

Doppler, Arteriogram

Surgery

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21
Q

Nerve entrapment

A

Superficial peroneal nerve (lateral compartment)
Pain and paraesthesia
Tinnel’s sign

Nerve conduction studies

steroid injection, surgical release

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22
Q

Fascial hernia

A

Anterior compartment defect

Similar Sx to CCS
Detectable swelling on standing/exercising -> disappears on lying

Subcutaneous fasciotomy

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23
Q

Knee - Per Anserinus (aka goose foot)

A

Sartorius, gracilis, semitendinosus

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24
Q

Lateral knee (superficial to deep)

A

ITB
Patella retinaculum
LCL and joint capuse

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25
Medial knee (superficial to deep)
Sartorius Superficial MCL Deep MCL and joint capsule
26
Back of the knee
PCL Popliteus Menisci
27
Function of popliteus
Unlocks tibia relative to the femur in flexion
28
MCL origin and Inserion
Origin - behind medial epicondyle | Insertion - 1cm below joint line
29
Questions to ask about knee pain
VAS Constant or related to activity Anterior, stair climbing, prolonged sitting => PFP Twisting/rotating => meniscal
30
Questions to ask about knee instability
Pivoting/ twisting => ACL Linear instability - stairs/ level ground => quads weakness Side to side instability => PCL
31
Mechanical symptoms of knee
Locking/ clicking/ snapping => bucket handle meniscal tear; loose body
32
Other questions - knee
``` treatment to date benefits of previous treatment athletic hx PMH Occupational Hx ```
33
Knee examination
Inspection Palpation ROM and strength Patella - tilt, apprehension, translation, crepitus, j-sign, q angle Meniscus - McMurray's, Apley's, Thessaly's Ligamentous stability - anterior and posterior drawer, Lachman's, Pivot-shift, quads active, varus/valgus, dial test, external rotation Gait Joint borders Nerves and vessels
34
J-sign
patella flips out laterally on flexion
35
Zones of meniscal blood supply
Red red zone – very vascular – will heal more easily Red white zone – medium blood supply White white zone – inner  avascular
36
Double PCL sign
Pathognomic of a bucket handle meniscal tear
37
Management of Meniscal tear
Non-operative - <5mm stable peripheral tear - Degenerative tears - Associated ligamentous instabilities - Medically unfit Surgically treated either by removal of the meniscus via arthroscopy, or using sutures
38
Articular Lesions
Types - Partial thickness chondral lesions; avascular - Full thickness defects; potential to feel with fibrocartilage (type 1 collagen) - Traumatic vs insidious Accelerate degenerative wear and loose body formation in joint capsule structural abnormality in patella and joint Ix MRI with gadolinium Other: AP XR, CT, PA XR in 45dg flexion
39
Articular Lesions: Grades
Grade 0 - Normal bone Grade 1 - 75% (soft cartilage and swelling) Grade 2 - 50% (partial thickness defect with fissures) Grade 3 - 25% (fissuring to subchondral bone) Grade 4 - Down to subchondral bone
40
Articular Lesions Management
Treatment for G3/4 after failed non-op Avoid in obesity, inflammatory conditions, malalignment, meniscal defects, degenerative changes Best options: ACI and OCD, OATS Microfracture Osteochondral Autograft Transplantation (OATS) ACI and Osteochondral allograft (OCD) transplantation
41
Microfracture
``` For defects <4cm2 in patients <35yo Creates a bigger defect and puncture holes to cause the bone to bleed and fill the defect with clot which will over time become fibrocartilage to relieve the pain Immediate post-op ROM on CPM instituted TWB for 6-8 weeks Return to sport after 4-9 months ```
42
Osteochondral Autograft Transplantation (OATS)
For younger patients with more demand on their knees Allograft; lateral trochlear ridge taken from patient or cadaveric meniscus NWB for 3 weeks Full ROM immediately 4/12 return to sport
43
ACI and Osteochondral Allograft transplantation
Autologous chondrocyte transplantation Good results in larger defects Better for patellofemoral joint OCD has better results with non-op in pts with open growth plates Immediate CPM NBW until ROM and quads strength restored FBW usually by 10-12/52 Possible off-loading brace use Progressive walking programme from 12-32/52 (elliptical, swimming, cycling) Jogging/aerobics 9-12/12 High impact sport at 12-18/12
44
ACL Tear Treatment
Graft harvest from patella Early ROM exercises! Closed chain exercises emphasised in early rehab Delay sports for 6-9 months
45
PCL Tear Treatment
Isolated tear not treated brace for 4wks rehab return to running soon only 3rd degree tear needs surgical rx PCL tear + another ligament tear => reconstruct both post-reconstruction brace for 6-12 wks
46
MCL Tear Treatment
Grade 1 &2 repair themselves with hinged brace for 6 wks Closed chain exercises, jogging and treadmill start once contralateral quad strength is 80% RTS once 80% max speed achieved Grade 3 requires surgery if when in full extension knees moves excessively in valgus Combined injury in 80% Tibial sided tears require acute surgical repair Stener lesions occur with avulsion fracture and will not heal without repair
47
LCL Injury
Dial test - Prone at extension – externally rotate the legs – if asymmetry => LCL tear - Prone at 90 degrees flexion – externally rotate the legs – if asymmetry => PCL and LCL tear
48
Patellar tendonitis
``` Jumping athletes Repetitive, forceful eccentric contraction 80-90% RTS Physiotherapy = only treatment Surgery has poor outcome ```
49
Patellar instability
Caused by increased Q angle, i.e. valgus Young females Repaired by moving tibial tuberosity through osteotomy or MPFL reconstruction
50
Sinus Tarsi Syndrome
Pain and instability following supinatory ankle sprain Conical cavity between anterior and posterior talo-calcaneal joint; base lies over antero-lateral ankle contains ligamnt and nerves Clinical diagnosis MRI for confirmation Rx Stapling Injection
51
Cuboid Syndrome
Acute or chronic Following inversion injury Common in over-pronated, hypermobile, pes cavus Predisposing factors - Increase mechanical advantage of peroneus longus running under cuboid, over-corrected foot orthoses, poor footwear Pain during activity on unever surface Dull ache in 5th ray Swollen foot, bruised Severe => Limping, difficulty WB MRI, Dynamic CT, XR, Vitamin D RICE, Brace, Manipulation and taping, injection, orthotics, surgery
52
Plantar Fasciitis injection
Steroid injection | Risk - potential fascial rupture and fat pad atrophy
53
Achilles Tendinopathy
Common in primary care Majority self-limiting in early phases Debilitating with significant socio-economic impact >10% persistence of Sx and fail to respond to Rx Surgery when persistence of >6month
54
Mid-portion Achilles Tendinopathy
Aetiology unclear - training errors - overuse stresses - lack of flexibility Intrinsic factors - tendon vascularity, GS dysfunction, age, sex, weight, height, pes cavus, lateral ankle joint instability Extrinsic - change in training method, poor technique, previous injury, footwear, surface Little or no inflammation Degeneration - loss of collagen structure, scarring, cysts Neo-vascularisation > neo-nerves; REDUCE NEO-VASCULARISATION REDUCE PAIN immobilisation ineffective
55
Tendinopathy spectrum
Reactive - non-inflammatory proliferative response in the cell and matrix Dysrepair - Matrix breakdown and disorganisation Degenerative - Progression of both matrix and cell changes, cell death/ apoptosis
56
Tendinopathy Management
``` Prevention - sensible training programme Early medical attention Rest from aggravating exercise Modify activity Deep friction massage Gentle static stretch Eccentric strengthening of gastoc-soleus muscle Foot orthoses Control of Sx HVIGI ESWT Regenerative medicine surgery ```
57
Achilles tendinopathy treatment options
``` Sclerosant dry needling GTN ESWT Regenerative medicine - PRP/ Autologous blood, stem cell, tenocyte implantation Electro-coagulation Radiofrequency Corticosteroid HVIGI ```
58
10 days post HVIGI
High volume image guided injection - 40ml normal saline + 9ml 0.5% Marcaine + 20mg Depomedrone; injected under USS guidance betwen anterior aspect of tendon and Kager's fat pad - 3 days relative rest. Avoid high impact, rushing around and stairs. - 3 days eccentric loading (Alfredsson or modified). - 3 days start sports or activity specific functional loading. - 10th day – start RTS specific rehabilitation programme. - Full training at 2-3 weeks depending on symptoms. - Repeat HVIGI only if still painful or AT reoccurs.
59
Crisp-Padhiar Syndrome
Trauma Presence of Os naviculare Tibialis posterior tendinopathy and dysfunction Acquired flatfoot Os naviculare synchondrosis Anomalous tibialis posterior attachment of Os naviculare
60
Osteoarthritis of the foot
Cartilage deteriorates + Osteophytes + Altered joint mechanics Pain, stiffness, swelling Big toes - common cause of forefoot pain Men XR - Osteophyte, joint space narrowing, sclerosis, joint irregularities and bone cysts
61
OA Classification
Radiographic classification GRADE 0: Dorsiflexion 40-60° , Normal radiography , No pain. GRADE 1 - Dorsi 30-40, Mild to mod osteophytes formation, good joint preservation GRADE 2 - Dorsi 10-30, Moderate osteophyte formation, joint space narrowing, subchondral sclerosis GRADE 3 - Dorsi <10, Marked osteophyte formation, loss of visible joint space, with or without subchondral cyst formation, constant to severe pain at extremeties GRADE 4: Stiff joint, Severe changes with loose bodies and osteochondritis dissecans
62
OA Treatment
CONSERVATIVE NSAIDS. Glucosamine with chondroitin. Vitamins & Minerals. Foot orthoses. Shoe modification (rocker). Modification of activity. Physiotherapy. MUA/Image guided injection – LA + Steroid, Ostenil mini, prolotherapy. SURGERY Cheilectomy Dorsiflexion phalangeal osteotomy (Kessel-Bonney) Metatarsal Osteotomy (Waterman’s decompression) Arthroplasty (Keller’s) Arthrodesis - favoured procedures Hemi-implants Total joint replacement
63
Freiberg's Disease/Infraction
Infraction and fracture of metatarsal head F>M 4:1 Pts 13-18yo Common in 2nd and 3rd metatarsals; common with long second metatarsal Disruption in blood supply due to micro-trauma or osteonecrosis and stress overloading > collapse of the 2nd metatarsal head
64
Smillie classification (Freiberg's disease)
Stage 1 - Subchondral fracture visible only on MRI Stage 2 - Dorsal collapse of articular surface on plain radiographs Stage 3 - Collapse of dorsal MT head, with plantar articular portion intact Stage 4 - Collapse of entire MT head, joint space narrowing Stage 5 - Severe arthritic changes and joint space obliteration
65
Ainhum
Painful constriction of usually 5th toe | Resulting in autoamputation
66
Loa loa filariasis
Infection Loa Loa (worm) Hard soft tissue mass behind achilles tendon; superficial XR - linear pearl-like calcification Surgical removal
67
Adnexal tumour of hallux
Rare XR - multiple enchondroma Malignant mixed chondroid syringoma
68
Morton's neuroma
benign fibrotic thickening of a plantar interdigital nerve Irritation of nerve degenerative process Compression or entrapment of the nerve. Stretching of the nerve. Nerve ischaemia. Avoid shoes with thin soles, high heels, or a constricting toe box. Metatarsal pad +/- NSAIDs

Injuries in Sport (13 decks)

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