Download Chapter 12: The Peripheral Vascular System

Chapter 12: The Peripheral Vascular System
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Injury to vascular endothelial cells can provoke thrombus
formation, atheromas, and the vascular lesions of
hypertension
An atheroma begins in the intima as lipid-filled foam
cells, then fatty streaks.
Complex atheromas are thickened asymmetric plaques
that narrow the lumen, reducing blood flow, and weaken
the underlying media. They have a soft lipid core and a
fibrous cap of smooth muscle cells and a collagen-rich
matrix. Plaque rupture may precede thrombosis.
Atherosclerosis can cause symptomatic limb ischemia
with exertion; distinguish this from spinal stenosis, which
produces leg pain with exertion that may be reduced by
leaning forward (stretching the spinal cord in the
narrowed vertebral canal) and less readily relieved by rest
Hair loss over the anterior tibiae occurs with decreased
arterial perfursion. “Dry” or brown-black ulcers from
gangrene may ensue
Only about 10% of patients have the classic triad of leg
pain with exertion that stops with rest. The low symptom
rate may reflect functional declines in walking, even
though PAD is present or progressing.
Symptom location suggests the site suggests the site of
arterial ischemia:
~ Buttock, hip – aortoiliac
~ Erectile dysfunction – iliac-pudendal
~ Thigh – common femoral or aortoiliac
~ Upper Calf – superficial femoral
~ Lower calf – popliteal
~ Foot – tibial or peroneal
Abdominal pain, “food fear,” and weight loss suggest
intestinal ischemia of the celiac or superior or inferior
mesenteric arteries
Prevalence of abdominal aortic aneurysms in first-degree
relatives is 15% to 28%
Lymphedema of the arm and hand may follow axillary
node dissection and radiation therapy
Prominent veins in an edematous arm suggest venous
obstruction
In Raynaud’s disease, wrist pulses are typically normal,
but spasm of more distal arteries causes episodes of
sharply demarcated pallor of the fingers
Note that if an artery is widely dilated, it is aneurismal
Bounding carotid, radia, and femoral pulses in aortic
insufficiency; asymmetric diminished pulses in arterial
occlusion from atherosclerosis or embolism
An enlarged epitrochlear node may arise local or distal
infection or may be associated with generalized
lymphadenopathy
Lymphadenopathy refers to enlargement of thenodes,
with or without tenderness. Try to distinguish between
local and generalized lymphadenopathy, respectively, by
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finding either (1) a causative lesion in the drainage area or
(2) enlarged nodes in at least two other non-contiguous
lymph node regions
A diminished or absent pulse indicates partial or complete
occlusion proximally; for example, at the aortic or iliac
level, all pulses distal to the occlusion are typically
affected
Chronic aterial occlusion, usually from atherosclerosis,
causes intermittent claudication
An exaggerated, widened femoral pulse suggest a femoral
aneurysm, a pathologic dilatation of the artery
An exaggerated, widened popliteal pulse suggests an
aneurysm of the popliteal artery.
Popliteal and femoral aneurysms are not common
They are usually caused by atherosclerosis and occur
primarily in men older than 50 years
Atheroslerosis (arteriosclerosis obliterans) most
commonly obstructs arterial circulation in the thigh.
The femoral pulse is then normal, the popliteal decreased
or absent
The doralis pedis artery may be congenitally absent or
may branch higher in the ankle. Search for a pulse more
laterally
Decreased or absent pedal pulses (assuming a warm
environment) with normal femoral and popliteal pulses
suggest occlusive disease in the lower popliteal artery or
its branches-often seen in diabetes mellitus
Sudden arterial occlusion from embolism or thrombosis
causes pain and numbness or tingling.
The limb distal to the occlusion becomes cold, pale, and
pulseless. Emergency treatment is required. If collateral
circulation is good, only numbness and coolness may
result
Coldness, especially when unilateral or associated with
other signs, suggests arterial insufficiency from
inadequate arterial circulation
Edema causes swelling that may obscure the veins,
tendons, and bony prominences
Conditions such as muscular atrophy can also cause
different circumferences in the legs
In deep venous thrombosis, the extent of edema suggests
the location of the occlusion: the popliteal vein when the
lower leg or the ankle is swollen; the iliofemoral veins
when the entire leg is swollen
Venous distention suggests a venous cause of edema
A painful, pale swollen leg, together with tenderness in
the groin over the femoral vein, suggests deep iliofemoral
vein, suggests deep iliofemoral thrombosis. Only half of
patients with deep venous thrombosis in the calf have
tenderness and cords deep in the calf. Calf tenderness is
nonspecific and may be present without thrombosis
Local swelling, redness, warmth, and a subcutaneous cord
suggest superficial thrombophlebitis
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Brownish discoloration or ulcers just above the malleolus
suggest chronic venous insufficiency
Thickened brawny skin suggests lymphedema and
advanced venous insufficiency
Varicose veins are dilated and tortuous. Their walls may
feel somewhat thickened
Aterial occlusive disease is much less common in the
arms than in the legs.
Absent or diminished pulses at the wrist are found in
acute embolic occlusion and in Buerger’s disease , or
thromboangiitis obliterans
Extending the hand fully may cause pallor and a falsely
positive Allen Test
Persisiting pallor of an Allen test indicates occlusion of
the ulnar artery or its distal branches
Marked pallor on elevation suggests arterial insufficiency
The foot above is still pale, and the veins are just starting
to fill- signs of arterial insufficiency
Persisting rubor on dependency suggests arterial
insufficiency
When veins are incompetent, dependent rubor and the
timing of color return and venous filling are not reliable
tests of arterial insuffiency
Rapid filling of the superficial veins while the saphenous
vein is occluded indicates incompetent valves in the
communicating veins.
Blood flows quickly in a retrograde direction from the
deep to the saphenous system
Sudden additional filling of superficial veins after release
of compression indicates incompetent valves in the
saphenous vein
When both steps are abnormal, the test is positive-positive
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Chapter 16: The Musculoskeletal System
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Articular disease typically involves swelling and
tenderness of the entire joint and limits both active and
passive range of motion
Extra-articular disease typically involves selected regions
of the joint and types of movement
Approximately 85% of patients have idiopathic low back
pain without a precise underlying cause (this term is
preferred to “sprain” or “strain”)
For midline back pain, assess for musculoligamentous
injury, disc herniation, vertebral collapse, spinal cord
metastases, or rarely epidural abscess.
For pain off the midline, assess for sacroiliitis,
trochanteric bursitis, sciatica, or hip arthritis
Radicular gluteal and posterior leg pain in the S1
distribution in sciatica that increases with cough or
Valsalva
Leg pain that resolves with rest and/or lumbar forward
flexion in spinal stenosis
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Consider cauda equine syndrome from S2-4 midline disc
or tumor if bowel or bladder dysfunction (usually urinary
retention and overflow incontinence)
In cases of low back pain plus a red flag, there is a 10%
probabiliry of serious systemic disease
Radicular pain from spinal nerve compression, most
commonly C7 followed by C6
Unlike low back pain, usually from foraminal
impingement from degenerative joint changes (70% to
75%) rather than disc herniation (20% to 25%)
Pain in one joint suggests trauma, monoarticular arthritis,
possible tendinitis, or bursitis.
Lateral hip pain near the greater trochanter suggests
trochanteric bursitis
Migratory pattern of spread in rheumatic fever or
gonococcal arthritis; progressive additive pattern with
symmetric involvement in rheumatoid arthritis
Extra-articular pain in inflammation of bursae (burtsitis),
tendons (tendinitis), or tendon sheaths (tenosynovitis);
also sprains from stretching or tearing of ligaments
Severe pain of rapid onset in a red, swollen joint in acute
septic arthritis or gout. In children consider osteomyelitis
in bone contiguous to a joint
Fever, chills, warmth, redness in septic arthritis; also
consider gout or possible rheumatic fever
Pain, swelling, loss of active and passive motion,
“locking,” deformity in articular joint pain;
Loss of active but not passive motion, tenderness outside
the joint, absence of deformity often in nonarticular pain
Stiffness and limited motion after inactivity, sometimes
called gelling, in degenerative joint disease but usually
lasts only a few minutes or more in rheumatoid arthritis
and other inflammatory arthritides
Stiffness also with fibromyalgia and polymyalgia
rheumatic (PMR)
Generalized symptoms are common in rheumatoid
arthritis, systemic lupus erythematosus (SLE), PMR, and
other inflammatory arthritides.
High fever and chills suggest an infectious cause
Joint pain and systemic disorders
~ A butterfly rash on the cheeks- Systemic lupus
erythematosus
~ The scaly rash and pitted nails of psoriasis –
psoriatic arthritis
~ A few papules, pustules, or vesicles on reddened
bases, located on the distal extremities – Gonococcal
arthritis
~ An expanding erythematous patch early in an
illness – Lyme disease
~ Hives- Serum sickness, drug reaction
~ Erosions or scale on the penis and crusted, scaling
paules on the soles and palms- Reiter’s syndrome,
which also includes arthritis, urethritis, and uveitis
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~ The maculopapular rash of rubella- arthritis of
rubella
~ Clubbing of the fingernails – Hypertrophic
osteoarthropathy
~ Red, burning, and itchy eyes (conjunctivitis) –
Reiter’s syndrome, Behcet’s syndrome
~ Preceding sore throat – Acute rheumatic fever or
gonococcal arthritis
~ Diarrhea, abdominal pain, cramping – Arthritis
with ulcerative colitis, regional enteritis, scleroderma
~ Symptoms of urethritis – Reiter’s syndrome or
possibly gonococcal arthritis
~ Mental status change, facial or other weakness, stiff
neck – Lyme disease with central nervous system
involvement
Acute involvement of only one joint suggests trauma,
septic arthritis, gout
Rheumatoid arthritis typically involves several joints,
symmetrically distributed
Dupuytren’s contracture bowlegs or knock-knees
Subcutaneous nodules in rheumatoid arthritis or
rheumatic fever; effusions in trauma; crepitus over
inflamed joints, in osteoarthritis, or inflamed tendon
sheaths
Decreased range of motion in arthritis, inflammation of
tissues around a joint, fibrosis in or around a joint, or
bony fixation (ankylosis).
Ligamentous laxity of the ACL in knee trauma
Muscle atrophy or weakness in rheumatoid arthritis
Palpable bogginess or doughtiness of the synovial
membrane indicates synovial membrane indicates
synovitis, which is often accompanied by effusion.
Palpable joint fluid in effusion, tenderness over the
tendon sheaths in tendinitis
Warmth- arthritis, tendinitis, bursitis, osteomyelitis
Tenderness and warmth over a thickened synovium
suggest arthritis or infection
Redness over a tender joint suggests septic or gouty
arthritis, or possibly rheumatoid arthritis
Facial asymmetry associated with TMJ syndrome
Typical features of TMJ are unilateral chronic pain with
chewing, jaw clenching, or teeth grinding, often
associated with stress (may also present as headache)
Pain with chewing also in trigeminal neuralgia, temporal
arteritis
Swelling, tenderness, and decreased range of motion in
inflammation or arthritis
Dislocation of the TMJ may be seen in trauma
Palpable crepitus or clicking in poor occlusion, meniscus
injury, or synovial swelling from trauma
Pain and tenderness on palpation in TMJ syndrome
Scoliosis may cause elevation of one shoulder
With anterior dislocation of the shoulder, the rounded
lateral aspect of the shoulder appears flattened
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Atrophy of supraspinatus and infraspinatus over posterior
scapula with increased prominence of scapular spine
within 2 to 3 weeks of rotator cuff tear
A significant amount of synovial fluid is needed before
the joint capsule appears distended
Localized tenderness arises from subacromial or
subdeltoid bursitis, degenerative changes, or calcific
deposits in the rotator cuff
Swelling of the supraspinatus suggests a bursal tear that
communicates with the articular cavity
Tenderness over the “SITS” muscle insertions and
inability to lift the arm above the shoulder level are seen
in sprains, and tendon rupture of the rotator cuff, most
commonly the supraspinatous
Tenderness and effusion suggest synovitis of the
glenohumeral joint.
If the margins of the capsule and synovial membrane are
palpable, a moderate to large effusion is present.
Minimal degrees of synovitis at the glenohumeral joint
cannot be detected on palpation
Restricted range of motion in bursitis, capsulitis, rotator
cuff tears or sprains, or tendinitis
Age 60 years or older and a positive dropped-arm test are
the individual findings mostlikely to identify a rotator cuff
tear, with likelihood rations (LRs) of 3.2 and 5.0,
respectively. The combined findings of supraspinatus
weakness, and a positive impingement sign increase the
likelihood of a tear to 48.0; when all thee are absent, the
LR fails to 0.02, virtually ruling out the diagnosis
Localized tenderness or pain with adduction suggests
inflammation or arthritis of the acromioclavicular joint.
But sensitivity and specificity of tenderness is -95% and
10%; of adduction, -80% and 50%
Difficulty with these motions suggests rotator cuff
disorder
Pain during this maneuver(Neer’s impingement signprevent scapular motion with pt. arm above their head) is
a positive test indication possible rotator cuff tear
Pain during this maneuver(Hawkin’s impingement signshoulder and elbow at 90degrees palm facing down-rotate
arm inward with hand on rotator) is a positive test
indicating possible rotator cuff tear
Weakness during this maneuver(supraspinatus strength“empty can test”- elevate arms 90degree and invert arms
in)is a positive test indication possible rotator cuff tear
Weakness during this maneuver(infraspinatus strengthelbows at 90degree rotate in) a positive test indicating
possible rotator cuff tear or bicipital tendinitis
Pain during this maneuver(forearm supination- elbow
90degree provide resistance to pt supination) is a positive
test indication inflammation of the long head of the biceps
tendon and possible rotator cuff tear
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(“Drop-arm” sign) If the patient cannot hold the arm fully
abducted at shoulder level, the test is positive, indicating a
rotator cuff tear
Swelling over the olecranon process in olecran bursitis;
inflammation or synovial fluid in arthritis
Tenderness distal to the Epicondyle in lateral
epicondylitis (tennis elbow) and less commonly in medial
epicondylitis (pitcher’s or golfer’s elbow)
The olecranon is displaced posteriorly in posterior
dislocation of the elbow and supracondylar fracture
Full elbow extension makes intra-articular effusion or
hemarthrosis unlikely
Guarded movement suggests injury
Poor finger alignment is seen in flexor tendon damage
Diffuse swelling in arthritis or infections
Local swelling from cystic ganglion
In osteoarthritis, Heberden’s nodes at the DIP joints,
Bouchard’s nodes at the PIP joints
In rheumatoid arthritis, symmetric deformity in the PIP,
MCP, and wrist joints, with ulnar deviation
Thenar atrophy in median nerve compression from carpal
tunnel syndrome; hypothenar atrophy in ulnar nerve
compression
Flexion contractures in the ring, 5th, and 3rd fingers, or
Dupuytren’s contractures, arise from thickening of the
palmar fascia
Tenderness over the distal radius in Colles’ fracture
Any tenderness or bony step-offs are suspicious for
fracture
Swelling and/or tenderness suggests rheumatoid arthritis
if bilateral and of several weeks’ duration
Tenderness over the extensor and abductor tendons of the
thumb at the radial styloid in de Quervain’s tenosynovitis
and gonococcal tenosynovitis
Tenderness over the “snuffbox” in scaphoid fracture, the
most common injury of the carpal bones
Poor blood supply puts the scaphoid bone at risk for
avascular necrosis
Synovitis in the MCPs is painful with this pressure- a
point to remember when shaking hands
The MCPs are often boddy or tender in rheumatoid
arthritis (but rarely involved in osteoarthritis)
Pain with compression also in posttraumatic arthritis
PIP changes seen in rheumatoid arthritis, Bouchard’s
nodes in osteoarthritis
Pain at the base of the thumb in the first carpormetacarpal
arthritis
Hard dorsolateral nodules on the DIP joints, or
Heberden’s nodes, common in osteo arthritis; DIP joint
involvement in psoriatic arthritis
Tenderness and swelling in tenosynovitis, or
inflammation of the tendon sheaths
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De Quervain’s tenosynovitis over the extensor and
abductor tendons of the thumb as they cross the radial
styloid
Condition that impair range of motion include arthritis,
tenosynovitis, Dupuytren’s contracture
Onset of carpal tunnel syndrome often related to repetitive
motion with wrists flexed (as in key board use, mailsorting), pregnancy, rheumatoid arthritis, diabetes,
hypothyroidism
Thenar atrophy may also be present
Decreased sensation in the median nerve distribution in
carpal tunnel syndrome
Decreased grip strength is a positive test for weakness of
the finger flexors and/ or intrinsic muscles of the hand
Wrist pain and grip weakness in de Quervanin’s
tensynovitis
Decreased grip strength in arthritis, carpal tunnel
syndrome, epicondylitis, and cervical radiculopathy
Pain during this maneuver identifies de Quervain’s
tenosynovitis from inflammation of the abductor pollicis
longus and extensor pollicis brevis tendons and tendon
sheaths
Weakness on thumb abduction is a positive test- the
abductor pollicis longus is innervated only but the median
nerve
Weak thumb abduction, hand symptom diagrams, and
decreased sensation roughly double the likelihood of
carpal tunnel disease
Aching and numbness in the median nerve distribution is
a positive test
Numbness and tingling in the median nerve distribution
within 60 seconds is a positive test
Tinel’s and Phalen’s signs do not reliably predict positive
electrodiagnosis of carpal tunnel disease
Impaired hand movement in arthritis, trigger finger,
Dupuytren’s contracture
Neck stiffness signals arthritis, muscle strain, or other
underlying pathology that should be pursued
Lateral deviation and rotation of the head suggest
torticollis, from contraction of the sternocleidomastoid
muscle
Tenderness of the spinous processes suggests fracture or
dislocation if preceded by trauma, underlying infection, or
arthritis
Tenderness of the facet joints in arthritis, especially btw
C5 and C6
Step-offs in spondylolisthesis, or forward slippage of one
vertebra, which may compress the spinal cord
Vertebral tenderness is suspicious for fracture or infection
Tendernessover the sacroiliac joint in sacroliitis
Ankylosing spondylitis may produce sacroiliac tenderness
Pain on percussion may arise from osteoporosis,
infection, or malignancy
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Increased thoracic kyphosis occurs with aging. In children
a correctable structural deformity should be pursued
In scoliosis, there is lateral and rotator curvature of the
spine to bring the head back to midline
Scoliosis often becomes evident during adolescence,
before symptoms appear
Unequal shoulder heights seen in scoliosis; Sprengel’s
deformity of the scapula (from the attachment of an extra
bone or band btw the upper scapula and C7); In
“winging” of the scapula (from loss of innervation of the
serratus anterior muscle by the long thoracic nerve); and
in contra-lateral weakness of the trapezius
Unequal heights of the iliac crests, or pelvic tilt, suggest
unequal lengths of the legs and disappear when a block is
placed under the short leg and foot
Scoliosis and hip abduction or adduction may also cause a
pelvic tilt
“Listing” of the trunk to one side is seen with a herniated
lumbar disc
Birthmarks, port-wine stains, hairy patches, and lipomas
often overlie bony defects such as spina bifida
Café-au-lait spots (discolored patches of skin), skin tags,
and fibrous tumors in neurofibromatosis
Spasm(paravertebral muscles) occurs in degenerative and
inflammatory processes of muscles, prolonged contraction
from abnormal posture, or anxiety
Sciatic nerve tenderness suggests a herniated disc or mass
lesion impinging on the contributing nerve root
Herniated intervertebral discs, most common at L5-S1 or
L4-L5, may produce tenderness of the spinous processes,
the intervertebral joints, the paravertebral muscles, the
sacrosciatic notch, and the sciatic nerve
Rheumatoid arthritis may also cause tenderness of the
intervertebral joints
Remember that tenderness in the costovertebral angles
may signify kidney infection rather than a
musculoskeletal problem
Limitations in range of motion can arise from stiffness
from arthritis, pain from trauma, or muscle spasm such as
torticollis
It is important to assess any complaints or findings of
neck, shoulder, or arm pain or numbness for possible
cervical cord or nerve root compression
Tenderness at C1-C2 in rheumatoid arthritis suggests
possible risk for subluxation and high cervical cord
compression
Deformity of the thorax on forward bending in scoliosis
To measure flexion of the spine, mark the spine at the
lumbosacral junction, then 10 cm above and 5 cm below
this point. A 4 cm increase btw the two upped marks is
normal; the distance btw the lower two marks should be
unchanged
Persistence of lumber lordosis suggests muscle spasm or
ankylosing spondylitis
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Decreased spinal mobility in osteoarthritis, and
ankylosing spondylitis among other condtions
Underlying cord or nerve root compression should be
considered
Note that arthritis or infection in the hip, rectum, or pelvis
may cause symptoms in the lumbar spine
Most problems of gait appear during the weight-bearing
stance phase
A wide base suggests cerebellar disease or foot problems
Hip dislocation, arthritis, or abductor, weakness can cause
the pelvis to drop on the opposite side, producing a
waddling gait
Lack of knee flexion interrupts the smooth pattern of gait
Loss of lordosis may reflect paravertebral spasm;excess
lordosis suggests a flexion deformity of the hip
Changes in leg length are seen in abduction or adduction
deformities and scoliosis
Leg shortening and external rotation suggest hip fracture
Bulges along the ligament may suggest an inguinal hernia
or, on occasion, an aneurysm
Enlarged lymph nodes suggest infection in the lower
extremity or pelvis
Tenderness in the groin area may be from synovitis of the
hip joint, bursitis, or possibly psoas abscess
Focal tenderness over the trochanter in trochanteric
bursitis
Tenderness over the posterolateral surface of the greater
trochanter in localized tendinitis or muscle spasm from
referred hip pain
Tenderness in ischiogluteal bursitis of “weaver’s bottom”because of the adjacent sciatic nerve, this may mimic
sciatica
In flexion deformity of the hip, as the opposite hip is
flexed (with the thigh against the chest), the affected hip
does not allow full leg extension, and the affected thigh
appears flexed
Flexion deformity may be masked by an increase, rather
than flattening, in lumber lordosis and an anterior pelvic
tilt
Restricted abduction is common in hip osteoarthritis
Restrictions of internal and external rotation are sensitive
indicators of hip disease such as arthritis
Stumbling or pushing the knee into extension with the
hand during heel strike suggests quadriceps weakness
Bowlegs (genu varum) and knock-knees (genu valgum)
are common
Flexion contracture (inability to extend fully) in limb
paralysis
Swelling over the patella suggests prepatellar bursitis
Swelling over the tibial tubercle suggests infrapatellar
More medial- anserine bursitis
Osteoarthritis if tender bony ridges along the joint
margins, genu varum deformity, and stiffness 30 minutes
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or less (likelihood ratios: 11.8, 3.4, and 3.0) Crepitus may
also be present
Meniscus teat with tenderness after trauma more common
in medial meniscus
MCL(medial collateral ligament) tenderness after injury
suspicious for an MCL tear
LCL injuries less frequent
Tenderness over the tendon or inability to extend the leg
suggest a partial or complete tear of the patellar tendon
Pain and crepitus suggests roughening of the patellar
undersurface that articulates with the femur. Similar pain
may occur with climbing stairs or getting up from a chair
Pain with compression and with patellar movement
during quadriceps contraction suggests chondromalacia,
or degenerative patella (the patellofemoral syndrome)
Swelling above and adjacent to the patella suggest
synovial thickening of effusion in the knee joint
Thickening, bogginess, or warmth in these areas indicate
synovitis or non-tender effusions from osteoarthritis
Prepatellar bursitis (“housemaid’s knee) from excessive
kneeling
Anserine bursitis from running, valgus knee deformity,
fibromyalgias, osteoarthritis
A popliteal of the gastrocnemius semimembranosus bursa
A fluid wave or bulge on the medial side btw the patella
and the femur is considered a positive buldge sign
consistent with an effusion
When the knee joint contains a large effusion,
suprapatellar compression ejects fluid into the spaces
adjacent to the patella
A palpable fluid wave signifies a positive “balloon sign.”
A returning fluid wave into the suprapatellar pouch
confirms an effusion
Palpable fluid returning into the pouch further confirms
the presence of a large effusion
A palpable patellar click with compression may also
occur, but yields more false positives
A defect in the muscles with tenderness and swelling in a
ruptured Achilles tendon; tenderness and thickening of
the tendon above the calcaneus, sometimes with a
protuberant posterolateral bony process of the calcaneus
in Achilles tendinitis
Absence of plantar flexion is a positive test indicating
rupture of the Achilles tendon
Sudden severe pain “like a gunshot wound,” an
Ecchymosis from the calf into the heel, and a flat-footed
gait with absence of “toe-off” may also be present
Crepitus with flexion and extension in osteoarthritis
A click or pop along the medial joint with valgus stress,
external rotation, and leg extension suggests a probable
tear of the posterior portion of the medial meniscus. The
tear may displace meniscal tissue, causing “locking” on
full knee extension
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A McMurray sign and locking make a medialmeniscus
tear 8.2 and 3.2 times more likely
(Abduction)Pain or a gap in the medial joint line points to
ligamentous laxity and a partial tear of the medial
collateral ligament. Most injuries are on the medial side
(Adducion) Pain or a gap in the lateral joint line points to
ligamentous laxity and a partial tear of the lateral
collateral ligament
(Anterior Drawer Sign- slides from supine knee up) A
few degrees of forward movement are normal if equally
present on the opposite side
A forward jerk showing the contours of the upper tibia is
a positive anterior drawer sign, making an ACL tear 11.5
times more likely
(Lachman Test) Significant forward excursion indicates
an ACL tear (likelihood increases 17.0 if positive test)
(Posterior Drawer sign) isolated PCL tears are rare
Localized tenderness of the ankle joint in arthritis,
ligamentous injury, or infection of the ankle
Rheumatoid nodules; tenderness in Achilles tendinitis,
bursitis, or partial tear from trauma
Bone spurs may be present on the calcneus
Focal heel pain on palpation of the plantar fascia suggests
plantar fascilitis; seen in prolonged standing or hellstrike
exercise, also in rheumatoid arthritis, gout
After trauma, inability to bear weight after4 steps and
tenderness over the posterior aspects of either malleolus,
especially the medial malleolus, is suspicious for ankle
fracture (Ottowa ankle rule)
Tenderness on compression of the metatarsophalangeal
joints is an early sign of rheumatoid arthritis
Acute inflammation of the first metatarsophalangeal joint
in gout
Pain and tenderness at the metatarsals is called
metatarsalgia, in trauma, arthritis, vascular compromise
Pain of the ankle(tibiotalar) joint during movements of
the ankle and the foot helps to localize possible arthritis
An arthritic joint is frequently painful when moved in any
direction, wheras a ligamentous sprain produces maximal
pain when the ligament is stretched. For example, in a
common form of sprained ankle, inversion and plantar
flexion of the foot cause pain, whereas eversion and
plantar flexion are relatively pain free
Unequal leg length may explain a scoliosis
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