Download Common Lower Extremity Problems

Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
This lecture will review the more common injuries and pathologies of the upper extremity.
It is meant as on overview of this topic to support and review your current knowledge-base.
Each section will review the anatomy, history and physical findings, then review specific
problems of each joint.
The Hip
A. Anatomy
1. Bone
• Femur
• Acetabulum of the pelvis
• Physes in pediatric patients
2. Soft tissue
• Labrum
3. Bursa
• Greater trochanteric bursa
• Ischial bursa
4. Muscle
• Hip flexors: iliopsoas, rectus
femoris and sartorius
• Adductors: adductor brevis/longus/maximus
• Abductors: Gluteus medius/minimus and Tensor fascia lata.
• External rotators: Gluteus maximus, Obturators and piriformis.
5. Nerve
• Sciatic n.
• Lateral femoral cutaneous n.
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
I. Specific Injuries
A. Hip strain- muscles have been pulled, stretched. The most common injuries about the hip and
groin in athletes.
Hx- sudden onset of pain at site of specific tendon. Especially prevalent early in seaon.
PE- tender to palpation at site of muscle pull. Often at the musculotendinous junction. + swelling
and ecchymosis.
Dx- H&P; Xrays only helpful if avulsion fx
Rx- initial treatment aimed at reduction of local hemorrhage and edema. RICE, NSAID’s, PT as
needed. Return to sports when pain-free.
B. Hip contusion. Can happen at muscle belly or at sites of bony protuberances. Can lead to
hematome at this site. Subacute complication is Myositis Ossificans. Injury to the ASIS or iliac
crest is considered a “hip pointer.”
Hx- direct contact to site of the hip.
PE- tender to palpation site of contusion; + ecchymosis;
Dx- xrays usually negative. If myosisitis ossificans, will see heterotopic calcification after at
least 3 wks.
Rx- RICE, NSAID’s; PT with modalities especially useful with myositis ossificans. If you are
assisting on the field, consider immobilizing (such as with ACE wrap) with muscle in full
stretch. Also, can be prevented if football player wears hip protectors- this actually does not
always happen.
C. Hip bursitis- most common greater trochanteric, also consider ischial bursitis. Inflammation
of the bursa.
Hx- repetitive contact, compression of the bursa (ie: sleeping on one side preferentially)
PE- point tender bursa (eg: lateral hip if greater trochanteric bursa, buttocks if ischial bursa).
Dx- H&P; xrays rarely needed.
Rx- RICE, NSAID’s; modalities prn. Consider steroid injection if these do not help. Surgical
removal of bursa not generally required, but can occur if failure of above treatment to improve
pain.
D. Piriformis syndrome
The piriformis syndrome is somewhat controversial in that its diagnosis and treatment
have not been well defined in the literature. This syndrome may represent up to 5% of the cases
of patients with "sciatic" type pain. Often considered a diagnosis of exclusion. ? Is this the same
as wallet neuritis?
Anatomy- the piriformis muscle is located underneath the gluteal musculature, but on top of the
sciatic nerve. If this muscle is hypertrophied or in spasm, it may impinge upon the sciatic nerve
and produce Hx and PE factors consistent with irritated nerve root.
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
Hx and PE- Variable. Sitting may exacerbate pain, especially after long trips. In addition, there
may be pain with resisted external rotation or passive internal rotation of the hip (AKA Freiberg's
sign). There usually is pain to deep palpation of
the sciatic notch. While sensory changes may
occur in this syndrome, motor weakness is
typically not present.
Rx- Treatment is as above. In this case I would
consider muscle relaxers in acute pain. Also,
rigorous flexibility program specifically
addressing the piriformis will help. Physical
therapy modalities (include stretch and spray
techniques) has been described. Some authors
suggest piriformis muscle injection with local
anesthetic. Surgery is reserved for recalcitrant
cases that do not improve with nonsurgical
treatment.
E. Hip Dislocation
Mechanism- tends to occur with direct collision in skiing or contact sports. More common than
fractures in children, most often affects early adolescents. Most (85-95%) are posterior.
Hx- acute onset of pain
PE- In posterior dislocation, the leg will be held in flexion, adduction, and internal rotation;
ipsilateral knee and neuro exam to evaluate sciatic nerve are important
Dx- xray/CT before and after reduction
Rx--requires emergency reduction.If no associated fractures, treatment generally crutches with
partial weightbearing for 6-8 weeks. Slowly increase ROM and strength after this.
Complication- 10 to 20% incidence of avascular necrosis is the major complication. Greater
risk if delayed reduction, severe injury, greater than five years old
F. Meralgia paresthetica- entrapment of the lateral femoral cutaneous nerve. May be associated
with trauma (thigh contusion as above). Mechanism may be compression vs stretching/traction
injury.
Hx- symptoms range from dysesthesia or anesthesia in the distribution of the lateral femoral
cutaneous nerve (anterolateral thigh close to the ASIS/iliac crest). There may be a burning
sensation.
PE- may be normal to decreased sensation in the area of the lateral femoral cutaneous nerve.
May also see decreased hair loss in this area. Tenderness to deep palpation can be demonstrated
as well.
Dx- H&P, xrays and MRI not particularly helpful. Sometimes local injection with topical
anesthetic helps confirm diagnosis.
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
Rx- Many cases resolve spontaneously or with nonsurgical measures (ice, NSAID’s and
PT/modalities). Rarely surgical REFERRAL may be necessary for decompression if continued
symptoms.
G. The Pediatric Hip
1. Slipped Capital Femoral Epiphysis (SCFE)
This term is a misnomer. Actually the epiphysis is held in place by the acetabulum ligaments,
while the proximal metaphysis is displaced Inferior displacement of the femoral capital epiphysis
in relation to the proximal metaphysis. Etiology usually unknown. An inherent weakness of the
proximal growth plate is the most plausible explanation.
Epidemiology :
o 3:1 male to female ratio
o Especially in adolescence (peak 11-15 yrs old), with hormonal factors playing a role.
o Higher prevalence in African Americans
o 20-40 % of cases are bilateral within 1 year
o Patients usually heavier, taller and older than LCP.
o Pain worse in SCFE; severe limp.
PE- Clinical findings:
o Typically overweight (greater than 95 percentile for weight)
o Hip pain, may even radiate into the knee.
o Flexion contracture in external rotation
o Decreased ranges of motion
o Short limb; gait disturbances.
o Positive Trendelenburg
Dx- Radiologic findings:
o Postero-medial slip of the epiphysis
o Positive Klein's line: a line drawn along the superior or anterior femoral neck. Normally
the epiphysis should intersect this line. In SCFE, the epiphysis is flush with the line or
even below it.
o Widened growth plate
o Flattened proximal femoral epiphysis
o Blurred metaphyseal margin
Rx- all patients should be REFERRED to orthopedics. Prevention of progression of slip and
avoidance of complications of avascular necrosis are the goals. Hip spica casting vs surgical
pin/screw.
2. Legg-Calve-Perthes Disease
LCP is an idiopathic avascular necrosis of the femoral head. The disease has variable
presentation.80% of the cases occur between the ages of 4 and 9 years (average = 6 yrs). There is
a boy:girl of 4:1. This process is usually unilateral. Pathophysiology = interrupted blood supply
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
of the growing femoral epiphysis.
Hx- Initially pain free, this condition often presents as a limp after activity. The limp usually
worsens, and eventually the patient may complain of pain in the hip, groin, inner thigh, or
occasionally the knee. + h/o trauma.
PE- there may be reduced range of motion. Pain with extreme internal rotation or abduction.
Dx- xray findings include five stages: cessation of growth of capital epiphysis, subchondral
fracture, resorption of bone and reossification (healed) stage.
Rx: initially directed to pain control (NSAID’s), ROM, activity modification. A recent
prospective cohort study demonstrated no difference between nonsurgical (spica cast or exercise
program) vs surgical intervention. A subgroup analysis indicated that surgery was best suited for
patients who presented with disease later (after 8 yrs of age). Bracing not helpful.
3. Apophysis injuries in children with open growth centers (apophysitis or avulsion fx)growth plate at site of tendon insertion. Hip has many growth centers. Similar to tibial tubercle or
calcaneus. This results from the same mechanism as the muscle strain as above.
•
•
•
•
•
Generally occurs with acute forceful contraction of muscle; usually without trauma.
Mostly treated nonsurgically; excellent outcomes, no functional limitations.
The ability of the apophysis to resist tension is weakest at time of its appearance.
Therefore have a high index of suspicion with hip pain in a 12-16 year old.
Rx initially with rest and anti-inflammatories, then gradual increase in ROM,
strengthening. Return to work/play when sx tolerance.
Note REFER if wide displacement of fx fragment or if continued sxs after reasonable
attempt at nonsurgical Rx. Few data are available to help with the decision of
nonsurgical vs surgical treatment.
Apophysis
Muscle attachments
Iliac crest
•
•
•
•
Tensor fascia lata
Gluteus medius
Transverse abdominis
Internal/external obliques
12-15 years
Anterior superior iliac spine (ASIS)
•
Sartorius
13-15 years
Ischial tuberosity
•
Hamstrings
14-16 years
Lesser trochanter
•
Iliopsoas
8-12 years
Greater trochanter
•
•
Gluteus medius, minimis
Obturator
AAFP Board Review 2006
Age at 1st appearance
4 years
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
H. Fractures of the head and neck of the femur
Classification system as described by Collona:
1. Transphyseal separations
Similar to Salter I, through physeal plate
least common in children consider pathologic lesions
Rx: reduction and internal fixation
Complication- possible AVN in >65%
2. Transcervical Fractures of the femoral neck
Most common (45-50%)
Rx: reduction and internal fixation
Complication- AVN in 40%
3. Cervicotrochanteric fractures
Second most common (35%)
Rx: reduction and internal fixation
Complication- AVN in 25%
4. Intertrochanteric fractures
12% of fractures
Rx: closed reduction and traction and hip spica cast
5. Subtrochanteric Hip fxs
1-2 centimeters below the lesser trochanter
If < 10 y/o, treat with closed reduction and traction
Hx- Usually with a fall. Older women do not have reaction times to break fall with her hand,
land directly onto greater trochanter of the hip with resultant fx. Hip fracture is associated with a
higher incidence of osteoporosis. Female>>Male predominance.
PE- shortened limb in external rotation. Assess neurovascular compromise.
Dx- should obtain plain films, usually diagnostic.
Rx- analgesia, immobilization, REFER to ortho for surgery. Do not forget Rx for osteoporosis
including bisphosphonates (unless contraindication), calcium and vitamin D. Also must
anticoagulate due to high incidence of DVT with this fx/surgery. Post-op rehab should include
balance training, falls prevention.
HIP REFERENCES
Anderson K, Strickland S, Warren R. Hip and groin injuries in athletes. Am J Sport Med. 29(4): 521-33, 2001.
Herring JA, Kim HT, Browne R. Legg-Calve-Perthes Disease: prospective multicenter study of the effect of
treatment on outcome. J Bone Joint Surg. 86A(10):2121-34, 2004.
Ivins G. Meralgia paresthetica: the elusive diagnosis. Ann Surg. 232(2): 281-86, 2000.
Loder RT, Aronsson DD, Dobbs MB, et al. Slipped capital femoral epiphysis. J Bone Joint Surg. 82A(8):1170-88,
2000.
Ulkar B, Yildiz Y, Kunduracioglu B. Meralgia paresthetica: a long-standing, performance limiting cause of anterior
thigh pain in a soccer player. Am J Sport Med. 31(5): 787-9, 2003.
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
I. The KNEE
A. Anatomy and Biomechanics
from DeLee, Drez, Orthopedic Sports Medicine, 1994
•
BONES
1. Femur- The trochlear
groove of the femur is the
"valley" within which, the
patella glides. The lateral
femoral condyle in most
patients is higher and wider
than the medial femoral
condyle. The articular
cartilage lining the femur is
considerably less than that of
the patella. The femur
transmits forces from the lower leg to the pelvis and L-spine
and facilitates ambulation.
2. Patella- One of the largest sesamoid bones of the body. It
is located within the quadriceps/patellar tendon. There are
facets on the posterior surface of the patella (in contact with
the femur): medial, lateral and odd.
3. Tibia- serves as the distal-most attachment of the extensor
mechanism. The patellar tendon inserts onto the tibial
tubercle (site of the apophysis in developing skeletons).
•
SOFT TISSUE
1. Quadriceps- the quadriceps musculature allows knee extension.
•
•
•
•
Vastus lateralis
Vastus medialis oblique (VMO)
Vastus intermedius
Rectus femoris
2. Quadriceps and patellar tendons-provide superior and inferior
stabilizing forces to the patella.
3. Medial and lateral retinacula- primary stabilizers on either side of the
patella.
4. Patellofemoral ligaments- other major soft tissue restraints to
mobility of the patella.
5. Bursae- multiple bursae, especially the prepatellar bursa. Acute
inflammation may lead to anterior knee pain.
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
6. The hamstring muscles cause flexion of the knee and assist with flexion of the hip. They insert
medial and lateral knee and contribute small amount to the stability of the knee to varus and
valgus stress.
Note- the vastus lateralis and rectus femoris muscles tend to build up preferentially. The result is
a relatively weaker vastus medialis obliqus (VMO). This allows for lateralization and tilting of
the patella. The patella may not sit nicely in the femoral groove, but may ride
on top of the lateral femoral condyle, increasing wear-and-tear. Concomitantly,
the vector analysis of forces created by the quadriceps and patellar tendons
reveals that the mean resultant vector is posteriorly directed (through the patella
and femoral condyles). In fact, the greatest force occurs with the knee flexed to
70-90°. This posteriorly-directed force is magnified if the hamstrings are tight.
The above biomechanical factors cause the patella and femur to "grind"
together, increasing wear-and-tear, pain, inflammation. The exact etiology for
pain in patellofemoral pain syndromes is not known. It is believed to be a
combination of mechanical and biochemical factors.
•
LIGAMENTS
1. ACL is the primary restraint to anterior directed force of the tibia relative to the femur.
Secondary restraints to anterior translation include MCL, LCL, iliotibial band and capsule. In
fact, in pts with a torn ACL, the MCL provides significant contribution to anterior translation
restraint. In addition, ACL provides secondary restraint for valgus stress.
2. MCL is the primary restraint to valgus stress. It is also a secondary restraint to anterior
translation. MCL originates from the medial femoral condyle and inserts distal to the tibial
plateau. There are superficial and deep components. The superficial component is extra-articular.
The deep component is more intra-articular and adherent to the medial meniscus. This explains
why there exists the terrible triad: ACL tear, MCL tear and medial meniscus tear.
3. PCL is larger and stronger than the ACL. It is the primary restraint to posterior translation of
the tibia relative to the femur. Secondary support to posterior motion is contributed by the LCL,
posterolateral capsule (especially with full extension).
4. LCL primary restraint to varus translation. ACL/PCL are secondary restraints to varus stress.
•
MENISCUS
The meniscus is a hydrated fibrocartilage The fetal menisci have vasculature throughout the
entire width of the meniscus. By nine months, the inner one third will be avascular. By
adulthood, only the thicker periphery will be vascular (10-30%).
Functions of the meniscus
o
o
o
Joint congruity: the menisci increase the contact area between the femur and tibia
Load transmission: The forces acting at the surface of the meniscus are distributed to a larger
surface area on the femoral condyles. "Shock transmitters."
Joint lubrication
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
o
Joint stability- The meniscus provide some support to the overall stability of the knee. Therefore,
meniscal tears may present as instability sxs (buckling or giving way).
1. Medial meniscus: the medial meniscus is semilunar in shape, narrow anteriorly and
broadening posteriorly. The
medial meniscus is closely
adherent to the deep portion of the
MCL, a fact that reflects clinical
relevance in combination injuries.
2. Lateral meniscus nearly
circular and covers a larger
portion of the lateral plateau. The
width is fairly uniform throughout.
B. History
• Localization of pain or
symptomsLocation of Pain
•
Differential Diagnosis
Anterior
•
•
•
•
•
•
Patellofemoral arthralgia (PFA)
Patellar/quadriceps tendinitis
Osgood-Schlatter disease
Sinding-Larsen-Johansson disease
Degenerative joint disease (OA)
OCD
Medial
•
•
•
•
MCL sprain
Medial meniscus tear
Pes anserine bursitis/tendinitis
OA
Lateral
•
•
•
LCL sprain
Lateral meniscus tear
Iliotibial band syndrome
Posterior
•
•
•
•
Meniscal tears in the posterior horns
PCL tear
Baker's cyst
Popliteus tendinitis
Mechanism of Injury- pivot injury may cause dislocated patella, ACL tear or meniscus
tear. Direct blow may cause fractures or MCL/LCL/PCL sprains (depending upon the
AAFP Board Review 2006
Common Lower Extremity Problems
•
•
•
•
•
•
•
•
•
•
•
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
direction of the force).
Presence of effusion- large effusions point toward ligamentous and meniscal pathology.
Timing of effusion- ACL tear usually first 4-12 hrs; meniscus by 12-36 hrs.
Locking? Determine true from pseudo-locking. True locking causes knee to become
incapable of further flexion and extension. Pseudo-locking involves clicks and clunks as
the patella moves within the femoral groove.
Instability- the sensation of knee giving way, buckling or shifting (again, determine true
from pseudo-buckling). True buckling should cause the pt to fall to the ground. This
implies ligamentous or meniscal damage. Pseudobuckling (caused by weakness of
quadriceps) occurs when the pt does not fall to the ground, and often relates to pathology
of the patella or articular cartilage (OA).
Acute vs ChronicRecent treatment- RICE, NSAID's, PT.
PMHx/PSHx- include diagnoses, meds. Some poorly controlled medical conditions may
inhibit healing potential (DM, hypothyroidism, renal insufficiency).D. Physical Exam
Inspection- deformity, effusion, ecchymoses, erythema, muscle asymmetry (atrophy) and
Quadriceps angle.
a. Q (quadriceps) angle- measure of genu valgus (knock-kneed). The angle created by
two lines: one drawn from the middle of the patella to the tibial tubercle, and the
other line from the middle of the patella to the ASIS of the iliac crest. Normal in
males is < 10° , females < 15°. Patients with high Q angles are at increased risk for
patellofemoral conditions.
b. Lateralizing and tilting of patella may indicate patellar source for pain.
Palpation
a. Anterior- patella, patellar tendon, quadriceps tendon, joint line, tibial tubercle.
b. Medial- patellar retinaculum, MCL (origin and insertion), meniscus, pes anserine
tendons, pes anserine bursa, medial femoral condyle, medial facet of the patella.
c. Lateral- patellar retinaculum, LCL, lateral meniscus, iliotibial band (inserts at
Gerdy's tubercle), lateral femoral condyle.
d. Posterior- hamstring tendons, posterior joint line (posterior horns of the meniscus,
popliteal fossa (neurovascular structures, Baker's cyst).
ROM/Flexibility- include hamstring flexibility.
Special Tests for Ligamentous abnormalities
a. Patellar apprehension test- patient supine: examiner provides lateral distraction to the
patella; positive test is apprehension that the patella will dislocate.
b. Patellar grind/compression test- patient supine: active, isometric contraction of the
quads by patient with posteriorly directed force placed on the patella by examiner.
Positive test is reproduction of the patients pain with this maneuver.
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
c. Note any leg length discrepancy. As well, must document hamstring flexibility.
d. Valgus/varus stress tests: tests MCL/LCL, respectively. Test @ 0° and 30° of flexion:
instability (opening) during valgus stress with the knee in complete extension
demonstrates both and MCL and ACL tears.
e. Lachman's test for ACL. Knee in 30°of flexion. Outside hand stabilizes the femur,
inside hand around the tibia at the tibial tubercle. An anteriorly-directed force is applied.
Assess for translation (in mm) and endpoint (good, fair, poor). This is the most accurate
exam maneuver for ACL tears acutely. False negative tests occur when hamstring spasm
with tense effusion, bucket-handle tears of meniscus. False positive test with PCL tear.
f. Anterior/posterior drawer tests- for ACL and PCL, respectively. The knee is flexed
to 90°, hip at 45° with feet flat on exam table; examiner may sit on foot, apply an
anteriorly or posteriorly-directed force. Maintain thumbs at joint line. Assess for
translation and quality of endpoint. The anterior drawer is generally not as helpful as the
Lachman and pivot shift tests for ACL integrity. In addition, it requires more motion to an
acutely injured knee. The posterior drawer test, on the other hand, is the most helpful
test for PCL integrity.
g. Pivot shift test- for
ACL integrity. Start
with knee straight and
an examining hand
under heel of foot. Turn
the foot into internal
rotation with one hand,
place a valgus-directed
force at the knee with
the other hand. At the
same time, bring the
knee from extension to
flexion. A palpable
clunk appreciated at
30° of flexion at the joint line represents the tibia reducing on the femur in ACL-deficient
knee. This may be quite uncomfortable for the acutely injured patient. It requires
significant relaxation on the part of the patient, and they probably won't let you do it a
second time (so get it right the first time!). This is the most accurate test for chronic tear
of the ACL (> 6 months).
h. McMurray test- positive test indicated by a palpable or audible clunk. Pain is not
diagnostic. This test performed by palpating bilateral joint lines with the pt supine. The
examiner produces internal/external tibial rotation while flexing the knee. The examiner
then extends the knee while simultaneously, the examiner produces a valgus or varusAAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
directed force.
The value of this and other clinical exam tests has been questioned. The positive
predictive value approximates 85%, for audible/palpable click. The positive
predictive value is higher in the medial meniscus than the lateral meniscus.
i. Apley's distraction test- patient lying prone, knee flexed to 90°, examiner stabilizes
posterior femur in one hand and distracts the foot upward. At the same time, the foot
should be rotated internally and externally. Reproduction of patients pain may indicate
MCL/LCL sprain or tear. A variation to this is Apley's compression test. Performed
similarly to the distraction test, the examiner produces a compression force from the heel
directed into the exam table. Again, reproduction of pain with internal/external rotation of
the foot is a positive test. This may indicate possible meniscal pathology.
Note: in patients with open growth plates, positive Lachman's test, valgus/varus tests may
actually represent opening of tibial or femoral growth plate fracture.
Grading system for most ligament sprains/tears:
Grade
Histology/Translation
1
Fibers stretched, no laxity
2
Few fibers torn, some laxity
3
Many fibers torn, much laxity
Endpoint
Good
Fair
Poor, soft
D. Diagnosis
1. The Use of Arthrocentesis
Arthrocentesis hemarthrosis usually indicates ACL tear (75-80% of all acute
hemarthroses = an ACL tear). Other pathology presenting as hemarthrosis includes patellar
dislocation and a peripheral meniscus tear. Serial exams may be more helpful.
2. Plain radiographsMy usual knee series for acute trauma includes AP, lateral and Merchant (sunrise) views. Some
authors include oblique views (X2). I do not believe these views help in the diagnosis of most
acute knee injuries. The patient is exposed to more radiation and they add to the cost of
diagnosis. Occasionally, you may visualize patellar fractures more readily with the oblique
views.
3. MRI
MRI can effectively and accurately diagnose ligamentous abnormalities of the knee. Cost of this
test ranges from $600-1200. The issue, however, is whether MRI can contribute to or change the
treatment of these internal derangements of the knee. A number of articles have demonstrated
that MRI is better than "diagnostic" arthroscopy in evaluating knee injuries and assisting with
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
treatment options. But only a few studies to date have compared the ability of MRI to the ability
of clinical examination (history, physical exam and xrays). In these studies, clinical exam was
found to be as good as MRI in evaluating knee derangements and assisting with their treatment.
The reported overall sensitivity and specificity of MRI in the diagnosis of internal
derangements of the knee are 88% and 94%, respectively. In general, the MRI does much better
with diagnosis of ligament injuries, and does fairly well with meniscal tears. These results are
very institution and radiologist specific. More physicians are incorporating serial exams over a
short period of time, radiographs and response to physical therapy in the evaluation of knee
injuries.
E. Specific Injuries and Treatment
1. Anterior Knee Pain Disorders- there is no consensus on the definition or classification of
anterior knee pain, making literature comparisons difficult.
a. Patellofemoral arthralgia (PFA)- AKA patellofemoral dysfunction, patellofemoral pain
syndrome, chondromalacia patella....
Hxo Pain in the anterior, peripatellar areas
o Pain with prolonged sitting ("movie theater sign"), driving distances
o Pain with stairs
o A subset will have symptoms of instability, pseudolocking and quad weakness (patellar
subluxation/dislocation).
PEo Pain with palpation of medial facet,+ patellar compression, ↑ Q angle,
o Inspection - "Grasshopper eyes," patella alta (high-riding patella), genu valgus, high Q angle.
Usually little or no effusion.
o Palpation- Peripatellar pain, pain to palpation of the medial facet of the patella.
o Range of motion- normal
o Special tests- + patellar compression/grind, + hamstring tightness, VMO atrophy. Normal
ligament/meniscus exams.
Dx- Xrays can demonstrate patella alta (high riding patella), assess for other causes of anterior knee
pain (patellar fx, OCD) and joint space narrowing, spurs (arthritis). The lateral view may also
demonstrate fragmentation of the apophysis at the tibial tubercle. Tangential (sunrise) view
can assess for patellofemoral joint space and lateralization/tilt of the patella, as well as spurs.
Rx- Paramount in treatment of patellofemoral disorders is the strengthening of the VMO and the
improved flexibility of the hamstrings.
o
o
o
o
o
PRICES
NSAID's or analgesics
Bracing- include lateral support (donut or "U") with patellar cutout
VMO strengthening
Hamstring flexibility
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
b. Patellar subluxation and dislocation
Hx- acute traumatic dislocation occurs mostly with flexion and concomitant pivot. Acute,
immediate swelling (possibly hemarthrosis). Inability to continue play, work, etc. The
dislocation usually relocates with the first knee extension. Therefore, swift and accurate
diagnosis requires a high index of suspicion.
PE- acute swelling, pain to palpation throughout: inferiorly (patellar tendon), superiorly (quad
tendon), medially (medial retinaculum), and laterally
(lateral femoral condyle). + patellar + apprehension test
(apprehension if examiner directs the patellar laterally).
See figure at right.
Dx- xray can demonstrate patella lateral to the trochlear
groove. If patella relocated, effusion may be only
radiographic clue to dislocation. Look for small avulsion
fx on medial patella on the sunrise view (pathognomonic for dislocation).
Rx- knee extension immobilizer for ~ 4 weeks. Start early isometric quad contraction exercises
(quad setting) to improve muscular function and decrease intra-articular effusion. At 4 weeks,
start quad exercises. Progress activity with bracing (patellar support). Return to sport when full,
painless ROM, normal strength.
c. Patellar tendon rupture, Quad tendon rupture-may be the end-stage of inflamed
extensor mechanism
Hx- acute onset of pain, sudden "pop," with or without significant force, + recent steroid
injections
PE- inability to actively extend the knee or greatly decreased strength, ecchymosis, effusion;
defect or lack of palpable tendons; patella alta (patellar tendon rupture) or patella baja (quad
tendon rupture)
Xray- Normal or: avulsions, patella alta/baja, as above
Rx- REFER to ortho. Full patellar tendon rupture and all quad tendon ruptures should undergo
early surgical reattachment. Partial patellar tendon rupture = extension immobilizer for 4-6
weeks, gradual increased ROM, PRE's with bracing.
d. Patellar tendinitis, Quadriceps tendinitis, Osgood-Schlatter disease, Sinding-LarsenJohansson syndrome
Hx- insidious onset anterior knee pain, especially with overuse (jumping, running, etc.). Note:
Osgood-Schlatter disease and Sinding-Larsen-Johansson syndrome are common in the patient
undergoing a growth spurt (ie: 11-15 yrs old).
PE- point tender on tendon or tibial tubercle (Osgood-Schlatter Disease). Also, may see
deformity or bony irregularity with Osgood-Schlatter disease (tibial tubercle) and SindingLarsen-Johansson syndrome (inferior pole of the patella). Tightness of the hamstring, quadriceps
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
and heel cord musculature.
Xrays- most often, normal. May see calcification at one of the poles of the patella. May also see
fragmentation or avulsion fracture at the tibial tubercle.
Rx- RICE, NSAID’s, PT. A Chopat strap may be used to provide comfort. This may also be
accomplished with taping or other braces.
2. Ligamentous injuries
a. ACL tears- complete vs partial
Natural History- ACL contributes significant stability to the knee. ACL provides primary
stability to anterior motion and secondary role in preventing valgus stress and rotatory instability.
Acute ACL tears associated with some other injury 67% of time (MCL tears, meniscal tears,
osteochondral fractures).
Hx- Mechanism usually planted foot with pivot or hyperextension. Knee effusions usually early,
first 4-12 hours. Usually cannot continue working, playing. Pt may describe a significant "pop."
Pts may also experience shifting, buckling episodes resulting in falls.
PE- ⇓'d ROM, effusion (+ hemarthrosis), + Lachman's/Anterior drawer/Pivot shift tests.
Absolute pt relaxation is key to accurate ligamentous assessment. Also, consider serial exams for
improved diagnostic acumen. With decreased swelling, increased ROM, the exam will yield
more information.
Note:The Lachman test is the most accurate assessment of the acutely injured ACL.
Dx- Xray with effusion, + lateral capsular sign on AP ("Segond fracture") at the lateral tibial
plateau. Typical segond fragment is 10 x 2 mm located up to 10 mm from the lateral joint line.
Also, ? depression > 2 mm on the lateral femoral condyle.
Arthrocentesis should be reserved for tense or painful effusions, ? of infectious or
metabolic disease. The use of serial exams can give good diagnostic information without the
invasiveness and risk of this procedure.
Rxo Most active people require surgical reconstruction to decrease shifting (instability)
episodes, further trauma to supporting structures. Results of simple repair (suture of the two
ends) has been disappointing. Indications for surgery include recurrent shifting episodes and
effusions, combined injuries (ACL, meniscus). Historically, surgeons have been less inclined
to reconstruct pts over 40 yrs. Surgical candidacy now depends more upon physiologic age
than chronological age. Goal is to supply normal function and stability. Surgery cannot
duplicate the natural structure and function of intact ACL.
o A special consideration is the care of ACL-deficient adolescent. Early physeal fracture
data indicated that altered growth patterns occurred when fractures crossed the growth plates
(Salter III-VI). The concern was that during reconstructive surgery, placing a screw across a
growth plate may alter growth response. Subsequent data has not supported these theories,
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
however. Currently, younger children with wide-open physes, nonoperative approach may be
more appropriate. However, in children nearing closure of growth plates (roughly 15yrs and
older), more surgeons are treating with intra-articular reconstruction.
o Timing of ACL surgery is important. Most authors agree, surgical reconstruction is
associated with a higher rate of arthrofibrosis in those pts undergoing surgery during the
acute, inflammatory stage (effusion, hemarthrosis). A common waiting period of three
weeks after injury is considered a reasonable wait.
There is no indication that reconstruction does anything to
alter a patient's risk for accelerated osteoarthritis down the
road.
o Nonsurgical approach with rigorous rehab (especially hamstrings and gastrocnemius) is
another option. This may be a better option for an older active person who is willing to
modify his or her activity, or if supporting structures are not damaged. Functional knee
bracing will not prevent further shifting of the tibia.
b. MCL tearsHx- Mechanism = valgus stress (a lineman falling on the outside of another lineman's leg).
Patient c/o medial knee pain, pain that may be along the joint line. Possibly small effusion, but
not like the large effusion seen with ACL. They may have difficulty with weight-bearing,
depending on the grade of injury.
PE- Tender to palpation MCL anywhere along the length of the ligament (origin to insertion).
Usually not a large intra-articular effusion. May see localized edema along the length of the
ligament. Pain, pain, pain (+) opening with valgus stress with knee at 30° of knee flexion. If
opening at full extension, then concomitant ACL tear. Apley's distraction test will produce pain
at MCL (Apley's compression test negative).
Dx- H&P, plain films help r/o acute bony pathology. Remember in young pt (with open growth
plates) "opening" with valgus stress may indicate physeal injury and not MCL tear.
Rx- most MCL tears treated nonoperatively. Early functional ROM exercises combined with
support for valgus stress at the knee (lateral hinged knee brace) are the mainstays of treatment for
MCL tears. After the pt obtains 90° of flexion, resistive exercises can begin, strengthening the
quads and hamstrings. Note that few authors suggest cast or extension brace immobilization,
even for isolated grade 3 (full-thickness) tears. Histologic scar formation occurs whether
immobilization or early functional rehab is the mode of treatment. The early rehab knees,
however, demonstrate fibroblasts and connective tissue that is oriented in a more functional way.
However, grade 3 MCL tears may have concomitant ACL or meniscal tear; then treatment is
consistent with individual treatment plans of these injuries.
Natural Hx- interestingly enough, unlike long-term follow-up of ACL and meniscus tears
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
(regardless of specific treatment), follow-up of MCL tears has not demonstrated significant
degenerative changes/symptoms up to 10 years7,8, 11.
c. PCL tears: isolated vs combined
Hx- Mechanism = sports-related and motor vehicle accidents are the most common causes of
injury. In athletics, a fall on a flexed (~ 90°) with the foot plantarflexed is the most common
mechanism for PCL injuries. In MVA's, direct force applied to the tibial tubercle by the
dashboard creates a PCL injury.
PE- effusion (smaller than ACL). + Posterior drawer + posterior sag sign, + quadriceps active
test. The exam may demonstrate a false positive Lachman and anterior drawer tests.
Rx- isolated, complete PCL injuries do well nonoperatively. PCL tears that are combined with
meniscal tears or other associated injuries are generally treated operatively. Again, goal is to
decrease instability and improve function. The ability of surgery to decrease risk of degenerative
process over the years has not been demonstrated.
d. LCL tears-much less common.
Hx-Mechanism = varus stress. Rare isolated LCL. Look for ACL, PCL tears.
PE- + varus stress test (with or without laxity). + effusion. May have associated ITB and
popliteus tendon injuries.
Dx- xrays will r/o bony abnormalities if appropriate.
Rx- grade 1 and 2 injuries usually treated nonsurgically. PRICES, functional bracing and rehab
are the mainstays of treatment. Isolated grade 3 tears of the LCL may be treated as above. If
associated injuries (ACL, PCL, meniscus), better treated surgically per the specific injury.
3. Meniscal Tears
Most meniscal tears are medial 70-90%. Meniscal injuries account for 45-50% of acute
hemarthrosis in adolescents (as opposed to adults where 75% of acute hemarthroses represent
ACL tears). Assess for concomitant ACL tears (associated ≈ 15-35%). Meniscal tears may be
acute or degenerative.
Hx- recurrent effusions, locking or sensation of giving way.
PE•
Decreased ROM (especially extension). May represent a tear that flips up and blocks full
extension, AKA "locked knee."
•
Joint line tenderness- posterior joint line tenderness more sensitive for meniscal injury
than anterior. Anterior joint line tenderness may reflect anterior knee pain syndromes,
etc.
N.B. When palpating joint line, internal tibial rotation renders the lateral meniscus more
palpable, external tibial rotation renders the medial meniscus more palpable.
AAFP Board Review 2006
Common Lower Extremity Problems
•
•
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
McMurray's test produces a palpable (audible) clunk. This test attempts to catch a
meniscal flap in between the tibia and femur.
Apley's compression test for meniscal pathology = positive for pain. Pt prone. Knee
flexed to 90°. The examiner produces a compression force directed toward the exam
table. Pain may indicate a meniscal tear. The distraction test may stretch the collateral
ligaments and create pain. This may help
distinguish MCL vs meniscus injury.
Dx
Hx of recurrent effusions, instability; PE of +
McMurray's, Apley's compression tests
Xrays- more useful for ruling out other causes of
pain, locking or effusion. DDx = loose bodies,
OCD, OA, ligament tears.
MRI- useful in confirming diagnosis; its utility
improves if the reason for the MRI is to assess if
associated injuries that may change the course of
treatment (ACL, PCL, etc.). There are a significant number of changes on MRI in
totally asymptomatic individuals, however!
Types of tears
I.
Longitudinal
II.
Horizontal
III.
Oblique
IV.
Radial
Rx
•
•
•
•
•
Nonoperative
Acute rehab- ROM, Quad setting (isometric contraction of the quadriceps- no
flexion/extension of the knee)
Subacute rehab- ROM, resistance exercises
Bracing- early mobilization with hinged knee brace when tolerable
Continue with functional drills, sport-specific drills, etc.
Current data demonstrate symptomatic/clinical healing in about six weeks for many pts
(especially younger athletes). Therefore, if continued Sxs at this time REFER to ortho
Operative- note there is no literature support that arthroscopic partial menisectomy
decreases the likelihood of degenerative arthritis at a later date. This fact has supported
increased attempts at nonoperative treatment. I tend to recommend surgery for failed
nonoperative treatment (≈ 6 weeks), continued pain or extension block, recurrent
effusions, loose body Sxs. In addition, if there are associated injuries (ACL/PCL) I would
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
be more likely to recommend surgery.
1. Partial menisectomy
2. Meniscal repair- attempt at suturing the torn pieces together. More applicable in
younger patients with smaller tears, especially in the periphery.
N.B. Rates of meniscal retear or failure to heal following meniscal repair range from 5% to 30%
in the literature.
4. Osteoarthritis
OA is one of the most common disorders requiring medical attention in a family physician’s
office. In men, the predominant joint is the knee, with the first MTP and DIP joints affecting
women. Radiographic evidence of OA can be seen in up to 40 million Americans.
Approximately 25 million will actually experience symptoms or dysfunction. Reports of
prevalence range from 65-85% of patients over the age of 65 years will be affected by OA.
Multiple risk factors for OA have been proposed. The lack of prospective, well-controlled human
studies, however, make definitive assessment of risk difficult. Proposed risk factors include:
•
Age
•
•
•
Previous injury/internal derangement
Obesity
Gender - women may demonstrate a higher prevalence of OA.
OA is generally divided into two categories: primary (idiopathic) or secondary. Secondary OA
is caused by previous trauma/internal derangement of the joint, metabolic disorder or deposition
diseases.
The question of whether exercise (such as jogging, etc.) increases the risk of OA of the knees,
hips and lumbar spine has not been fully answered. While anecdotal and retrospective studies
imply an associated risk, the available prospective, controlled human studies do not support this.
There does appear to be an increased risk of OA in joints with prior injury (fx), internal
derangement (ligament or meniscus injury) or biomechanical abnormalities.
Clinical presentation: Osteoarthritis (OA) is a slowly progressive degeneration of the articular
cartilage of the body. At the same time, hypertrophy of the underlying bone may contribute to
irregularities such as subchondral sclerosis and osteophytes. The arthropathy is typically devoid
of inflammation, though adjacent synovitis may exist.
Hx- Common symptoms include pain, brief (< 30 minutes) duration of stiffness with disuse,
clicking and grinding, and occasional swelling.
PE- may yield biomechanical changes (genu varum), minimal-to-no effusions, disuse atrophy of
surrounding musculature (especially the knee), crepitus and decreased range of motion. There
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
may also be diffuse tenderness to palpation of the individual joint.
Prognosis: OA is considered a progressive arthropathy. The rapidity of this progression,
however, is highly variable. Progression is not guaranteed, and radiographic regression has even
been demonstrated in some patients. This arthropathy is characterized by various
histopathologic and radiographic changes as previously described. In addition, biochemicallyinduced accelerated remodeling occurs with the release of various growth factors from cells in
the bone, cartilage, platelets and lymphocytes. In fact, some of the growth factors are utilized in
research as markers for disease. Their usefulness in clinical medicine is limited at present.
Dx: H&P; recall that severity of symptoms does NOT correlate well with radiographic findings.
a. Radiographic evidence of OA includes:
•
Subchondral sclerosis and cysts
•
Osteophyte formation
•
Narrowing of joint space
•
Deformity and malalignment
b. Lab testing is helpful more in ruling out other differential diagnoses rather than
specifically diagnosing OA. The complete blood count (CBC), chemistry profile and
urinalysis are usually normal. Markers for inflammation (ESR, C-reactive protein) are
usually normal, though may be slightly elevated during the acute phase of erosive OA.
Rheumatoid factor and antinuclear antibody titers are normal.
c. Arthrocentesis-occasionally, small intra-articular effusions may be present. If the
diagnosis is still in question, a joint aspiration may be considered. Synovial fluid analysis
may demonstrate clear-to-yellow color, few WBC’s (< 300/µL) [< 25% neutrophils],
culture is negative and fluid glucose is
roughly equal to serum.
Because of the chronicity and risks from comorbid conditions in this age group,
Rx: Mainstays of treatment include
pharmacologic and nonpharmacologic measures. nonpharmacologic measures may be more
important than pharmacologic interventions.
Nonpharmacologic management
•
Weight reduction techniques - a loss of just 5 kg may significantly decrease symptoms.
This is paramount in the overall health and function of patients.
•
Aerobic conditioning (low impact)
•
Joint specific rehabilitation (including, range of motion, stretching and strengthening
exercises).
•
Thermal and cryotherapy
AAFP Board Review 2006
Common Lower Extremity Problems
•
•
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
Emotional and social support
Physical support (braces, canes, walkers). Also, since many of these patients have severe
varus deformity, shoe inserts (lateral heel and sole wedges) may correct biomechanical
abnormalities that greatly contribute to symptoms.
Pharmacologic management
•
Acetaminophen- should be drug of first choice. It has a good safety profile and
increasing support for efficacy in noninflammatory pain.
NSAID’s- use lowest effective dose. Consider pulse therapy, drug holidays, etc.
•
Significant risk for gastric, renal and hepatic toxicity with long-term use.
Nonacetylated salicylates- (such as salsalate and choline-magnesium-trisalicylate) often
•
overlooked but provide good analgesia. In addition, these medications do not inhibit
prostaglandins that are protective to gastric mucosa.
Opiates- may be a short-term alternative for severe pain. Keep in mind that they may be
•
sedating and increase the risk for falls.
Corticosteroids- intra-articular injections may offer modest benefit and should be used
•
sparingly. Optimal dosing and frequency are not known, but many authors suggest no
more than 2-3 injections per weightbearing joints per year.
Hyalgan/Synvisc- intra-articular injection of hyaluronic acid derivatives. Multiple
•
injections (Hyalgan = 1 q week x 5; Synvisc = 1 q week x 3) of these substances may
improve pain and function. ? May temporize the pt’s need for surgical procedures
(debridement, total knee replacement, etc.). Most studies with significant placebo effect.
Surgical Management
•
Indications for surgery- consider surgery when ADL's are affected, pain is severe and
recalcitrant, medical management has been maximized.
KNEE REFERENCES
BenGal S, Lowe J, Mann G, et al. The role of the knee brace in prevention of anterior knee pain. AJSM. 25(1):11822, 1997.
Cannon WD Jr., Vittori JM: The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed
knees versus stable knees. Am. J. Sports med 20:176-181, 1992
Cutbill JW, Ladly KO, Bray RC, et al. Anterior knee pain- a review. CJSM. 7(1):40-5, 1997
DeLee JC, Drez D: Orthopaedic sports medicine principles and practices. Vol. 1 & 2, W. B. Saunders Co., 1994.
Galanty HL, Matthews C. Anterior knee pain in adolescents. CJSM. 4(3):176-81, 1994.
Gelb HJ, Glasgow SG, Sapega AA, et al. Clinical value and cost-effectiveness of magnetic resonance imaging in the management
of knee disorders. Am J Sport Med. 24(1):99-103, 1996.
Jackson DW, Jennings LD, Maywood RM, et al. Magnetic resonance imaging of the knee. Am J Sports Med. 16: 28-38, 1988.
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
Karlsson J, Thomee R, Sward L. 11-yr follow-up of patellofemoral pain syndrome. CJSM. 6(1):22-6, 1996.
Lundberg M, Messner K. Partial medial collateral ligament ruptures. Am J Sports Med. 24(2):1603, 1996.
Messner K, Lundberg M. Ten yr prognosis of isolated and combined medial collateral ligament ruptures. Am J Sports Med.
25(1): 2-6, 1997.
Parker AW, Drez D, Cooper JL. Anterior cruciate ligament injuries in patients with open physes. Am J Sports Med. 22(1):44-7,
1994.
Reider B, Sathy MR, Talkington J, et al. Treatment of isolated medial collateral ligament injuries in athletes with early functional
rehabilitation. Am J Sports Med. 22(4):470-7, 1993.
Rose NE, Gold SM. A comparison of accuracy between clinical examination and MR imaging in the diagnosis of meniscal and
anterior cruciate ligament tears. Arthroscopy. 12(4): 398-405, 1996.
Ruffin MT, Kiningham RB. Anterior knee pain- the challenge of patellofemoral syndrome. AFP. 47(1):185-94, 1993.
Stanitski CL. Anterior knee pain syndromes in the adolescent. JBJS. 75A(9):1407-16, 1993.
Tria AJ, Palumbo RC, Alicea JA. Conservative care for patellofemoral pain. Ortho Clinics of NA. 23(4):545-53, 1992.
The LEG
Differential diagnosis of leg pain in the athlete includes medial tibial stress syndrome, stress
fracture of the tibia and chronic exertional compartment syndrome. We will discuss these below.
1. Medial tibial stress syndrome (MTSS)- AKA shin splints, periostitis. Neither of these terms
ideal. Muscular cause of leg pain, especially as it inserts into bone.
Hx- pain anterior and medial tibia over fairly diffuse area. Especially early in the season when
athlete is less well trained. Pain usually occurs at the beginning of the workout, that improves
with continued exercise. Especially common in runners and jumpers (basketball, volleyball,
etc).Pain is relieved with rest, with no evidence of night pain.
PE- tender to palpation over diffuse one third of the posteromedial tibia. No ecchymosis,
palpable nodules.
Dx- usually thru H&P, but should obtain xrays to help rule out stress fx of the tibia. Consider
bone scan vs MRI if still have not ruled out stress fx.
Rx- aggressive stretching program; appropriate off-season work-out. NSAID’s, RICE. Crosstraining may be useful.
2. Tibial stress fracture- generally considered to be overuse syndrome of the bone.
Pathophysiology is repetitive loading causing microtrauma. Represents a continuum of
pathology from stress reaction demonstrated only on special testing (bone scan, MRI) to frank
fracture line visible on plain films. High index of suspicion is required. Most stress fractures are
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
located within the lower extremity, especially the metatarsals and the tibia.
Hx- pain usually starts after workouts. As time continues, the pain starts to progress into the end
of the workout, then finally preventing further exercise. Night pain is possible. Risk factors
include nutritional abnormalities, eating disorders, menstrual irregularities. Also often associated
recent change in training regimen (increased mileage, change in running surface, new running
shoes, etc.
PE- usually point tender in a more localized region on the tibia. Occurs more on the proximal
tibia. + palpable nodules representing periosteal reaction/callus formation. Some authors discuss
the occurrence of pain with use of a tuning fork or ultrasound on the tibia. The vibration may
elicit pain at the site of fx.
Dx- H&P, high index of suspicion; plain films may demonstrate haziness on the anterior tibial
cortex, or a linear lucency called the “dreaded black line” as the process continues to develop.
Changes on plain films may not be evident until up to 2-3 weeks. Bone scan or MRI may help
demonstrate early stress fractures, not apparent on plain xray. However, plain films should
usually be obtained first. The MRI is especially helpful in distinguishing between MTSS and
stress fx.
Rx- relative rest, NSAID’s, splinting prn for 2-4 weeks is a common approach. Correct
modifiable risk factors (nutritional, menstrual abnormalities, etc.). Maintain aerobic
cardiovascular fitness. Cross-training may help. Gradually increase intensity of workout
(increasing no more than 10%/week). Specific treatment s are quite variable, however..
Individualize to patient symptoms and function.
REFER to ortho if continued pain despite above
treatment.
3. Chronic exertional compartment
syndrome (CECS): the lower limb has four
compartments that house the muscles and
neurovascular structures. Each compartment
contains the artery, vein and major nerve for the
muscles in the compartment. With exercise,
there can be a compression of these structures,
especially the nerve, with resultant pain,
paresthesias and dysesthesias. Etiology
unknown.
Compartments:
Anterior- deep peroneal nerve* most common
Lateral- superficial peroneal nerve
Posterior, superficial- sural nerve
Posterior, deep- tibial nerve
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
Hx- tightness, pain, paresthesias in particular compartment area with specific duration of
exercise. The pain subsides with cessation of activity. Can be bilateral. Males = Females.
Runners, especially.
PE- examine after exercise of sufficient intensity and duration to evoke sxs. May demonstrate
diffuse palpable tenderness. In extreme cases, the muscle may herniate thru fascia and palpate a
fullness or “mass.”
Dx- H&P; Xrays negative. Again, if questions, rule out stress fx as above. The hallmark
diagnostic tool to confirm CECS is measurement of compartment pressures. This is measured
with a hand-held device with a slit catheter. There is some disagreement in what constitutes
normal vs abnormal pressures. Test athlete pre and post-exercise. If pressures are elevated after
exertion, the diagnosis is confirmed. CESC is diagnosed with pressures:
¾
¾
¾
Pre-exercise > 15 mm Hg
1 minute post-exercise > 30 mm Hg
5-minute post-exercise > 20 mm Hg
Rx- Relative rest and activity modification may help some patients. If continued sx more than 3
months and if suspicion for CECS, REFER to ortho for fasciotomy for Sx relief.
LEG REFERENCES
Edwards PH, Wright ML, Hartman JF, et al. A practical approach for the differential diagnosis of chronic leg pain in
the athlete. Am J Sports Med. 33(8):1241-49, 2005.
Korkola M, Amendolda A. Exercise-induced leg pain. Phys and Sport Med. 29(6):235-42, 2001.
Monteleone GP. Stress fractures in the athlete. Ortho Clin of N Am. 26(3):423-32, 1995.
The FOOT and ANKLE
I.
Anatomy
Bones: Tibia, fibula, talus, calcaneus, tarsal navicular, cuboid, cuneiforms (3).
Lateral:
LigamentsAnterior talofibular (ATFL), calcaneofibular (CFL),
posterior talofibular (PTFL).
Muscle/tendonPeroneus longus/brevis, eversion
Medial
LigamentsDeltoid (superficial and deep).
Muscle/tendonPosterior tibialis, plantarflexion/inversion
Toe flexors, plantarflexion
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
Anterior:
LigamentsAnterior tibiofibular
Muscle/tendonToe extensors, dorsiflexion
Anterior tibialis, dorsiflexion/inversion
Posterior:
LigamentsPosterior tibiofibular
Muscle/tendonAchilles (gastroc/soleus unit), plantarflexion
Note: Medially, the names of tendons are easily remembered by the mnemonic "Tom, Dick AN’
Harry" = posterior Tibialis, flexor Digitorum longus, posterior tibial Artery and Nerve, flexor
Hallucis longus.
from DeLee and Drez, Orthopedic Sports Medicine, 1994
B.
•
•
•
•
•
C.
History
Mechanism of injury (inversion 85-90%, eversion 10-15%, dorsi/plantarflexion).
Weight-bearing, continued playing/working?
Occupation- return to sport/work issues
PMHx- rheumatoid disorders, peptic ulcer disease, diabetes (longer healing), prior
ankle sprain.
Medications- anti-inflammatories (OTC and prescription), anticoagulants, etc.
Physical Exam
1.
Inspection- ecchymosis and edema are gravity-dependent. Therefore, their
location does not help direct where pathology exists. In addition, amount of
edema not particularly helpful in determining soft tissue vs bony pathology.
2.
Palpation- good knowledge of anatomy improves diagnostic acumen.
3.
Range of Motion (ROM)
Dorsiflexion (0-20Ε)
Anterior tibialis, Toe extensors (hallucis longus, digitorum longus).
Plantarflexion (0-50Ε)
Gastroc/soleus unit, Posterior tibialis, Toe flexors (hallucis longus
and digitorum longus).
AAFP Board Review 2006
Common Lower Extremity Problems
Gaetano P. Monteleone, Jr., M.D.
Director, Division of Sports Medicine
Dept. of Family Medicine
West Virginia University School of Medicine
[email protected]
Inversion (0-35Ε): Anterior tibialis
Eversion (0-15Ε): Peroneus longus and brevis
4.
Special Tests
a. Anterior Drawer- measure translation (in mm) .
Examiner stabilizes tibia with one hand and applies an
anteriorly directed force on the heel with the other
hand. Some motion is normal. Increasing amounts of
motion indicates increasing laxity of the lateral ankle
ligaments (ATFL, CFL, PTFL).
b. Talar Tilt- measure opening (in degrees). Compare to the
unaffected side. Relaxation is key!
c. Side-to-side (Cotton test)- helpful in
assessing syndesmosis complex sprains. The
syndesmosis complex is comprised of the anterior and
tibiofibular ligaments, and the interosseus membrane.
Sprains in this region are also known as the high ankle sprain.
•
Side-to-side (Cotton) test- place examining
hand under the plantar aspect of the
foot/ankle, with your thumb under one
malleolus and your middle finger under the
other malleolus. Place a medial and lateraldirected force (not inversion/eversion stress
as in the talar tilt test) on the ankle. Assess if
translation and assess quality of endpoint.
There may be a few mm of motion with a
syndesmosis sprain. An alternative to this is
to passively externally rotate the foot. Pain
with this maneuver will occur in a
syndesmosis sprain (= External Rotation
test).
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
•
d. Proximal squeeze testProximal squeeze test- examiner squeezes mid-shaft of tibia/fibula. Pain in the
syndesmosis area may indicate a syndesmosis (high) sprain.
e. Neurovascular assessment
D.
Radiology
1. Routine Xray series = AP, lateral and mortise (ankle in 20Ε internal
rotation). Incidence of clinically significant fracture in < 15% of all ankle
xrays. Stress xrays have been recommended by some authors. This is
accomplished by using the telos apparatus. Good clinical exam and
appropriate follow-up is just as helpful with diagnosis but with less
discomfort to the patient.
2. Ottawa Ankle Rules- Since the incidence of clinically significant fx of
the ankle is low, then most of the xrays are not needed or helpful. The
high volume of these ankle xrays contributes significantly to the burden on
society. However, legal concerns contribute to the over-utilization of these
tests in the urgent care arena. Recently, more studies evaluated utility of
ankle xrays, attempting to elucidate where ankle xrays would be more
useful:
Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography
in acute ankle injuries. JAMA. 269(9):1127-32, 1993.
•
•
•
A two-stage nonrandomized, prospective cohort assessing the
effectiveness of the Ottawa Decision Rules as a screening tool to diagnose
ankle fractures.
The Ottawa Decision Rules = obtain ankle xray if any of the following:
Age > 55 yrs
Inability to weight-bear immediately post injury and in ER (4 steps)
Bone pain at posterior of either malleoli
Ottawa rules as a screening test for ankle fractures demonstrated a sensitivity of
100% and a specificity of 40%. Positive and negative predictive values were 18
and 100%, respectively. In establishing criteria to assist with when to order xrays
for supposed fractures, diagnosticians wish to have as high sensitivity and
negative predictive values as possible (not miss any fractures, and feel
comfortable that a negative xray truly represents no fracture). This appears to
have been accomplished with the Ottawa ankle rules. If used appropriately, the
authors predict a decrease of xray utilization for ankle injuries by about 30%.
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
3. Adjunctive Tests
a. CT- useful in a few situations. Helpful in delineating fractures of the foot and
ankle, estimating the depth of the posterior lateral malleolus in patients with
suspected peroneus tendon subluxation. Its utility has been decreased with the
advent of MRI.
b. MRI- useful in evaluating most ankle injuries, if physical exam equivocal.
Consider MRI if this test will change your treatment. Better assessment of
tendons, etc. No radiation exposure to patients, but costly (~ $ 800-1000).
E.
Specific Injuries
1. Ligament Injuries (Sprains)
a. Lateral Ligament Complex Sprain (ATFL, CFL, PTFL)
• Constitutes 85-90% of all ankle sprains. Mechanism= inversion. Pain, ecchymosis
and edema. Keep in mind the possibility of concomitant tendon or physis injury.
• Grading System- Note: ATFL tears first; then the CFL; finally the PTFL tears.
There are a number of ankle sprain grading systems out there. I use one that is a little
more objective, utilizing the anterior drawer test and the talar tilt test abnormalities to
grade severity of ankle sprain. These grading systems are guidelines. Individualize
each case. Let signs and symptoms be your guide to return to activity. One grading
system is as below:
1
Mild
2
Moderate
3
Severe
Few fibers
stretched/torn; minimal
edema; no laxity
More fibers torn
(ATFL, ?CFL);
moderate ecchymosis
and edema; mild laxity
Severe ecchymosis and
edema; moderate-tosevere laxity
Anterior drawer -
Anterior drawer
5-15 mm
Talar tilt
10-20 o
Anterior drawer
> 15 mm
Talar tilt > 20o
from Birrer RB, Bordelon RL, Sammarco GJ. Ankle: don't dismiss a sprain. Patient Care. 26(4):6-28, 1992.
•
Treatment:
P.R.I.C.E.S.Protection (crutches, etc.); also Pain meds
Rest (relative)
Ice
Compression
Elevation
Support- (taping, braces); also Strengthening/Stretching exercises.
AAFP Board Review 2006
Talar tilt 0-10 o
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
• Pharmacology: all NSAID's are similar. If one class does not work, try a
different class. Remember, it may take up to 7-10 days to obtain a full
anti-inflammatory effect.Use narcotics sparingly.
• Exercise (ROM, Strengthening, Proprioceptive, Aerobic)- mobilization
is paramount to more rapid and effective return to work/sport. Let sxs be
guide to progression of rehab and activities regardless of severity of grade
of ankle sprain.
• ? Cast- reserve for some grade 3. Also can use pneumatic fracture walker
boot. The advantage of a fracture walker boot is the pt may take foot out
of boot and do cryotherapy, ROM and gentle strengthening exercises (to
decrease inflammation and atrophy, etc.).
• Specific Treatment and Natural History
Grade 1 injuries will usually respond to appropriate treatment within 7-10
days. Grade 2 injuries may also be treated with functional rehabilitation,
with subsequent disability lasting − 12 to 15 days.
Grade 3 injuries may take 4 wks (or more) for return.
My usual treatment regimen is as below: Remember, MOBILIZATION!
Grade
Rehab Program
1
Brace 1-2 weeks, then with activity prn; ROM as soon as pain allows; then strengthening and
proprioception exercises as soon as pt tolerates. Key is appropriate follow up!
2
Brace 2-4 weeks; Exercises as above.
3
Pneumatic walker boot for up to 4-6 weeks, then brace with activity. Exercises as above.
Consider casting especially with concomitant fractures. Recovery may take 3 months or more.
• Prevention
™ Proper strength and flexibility
™ Ankle taping, bracing and high-top shoes decrease the incidence and severity of
lateral ankle sprains. Studies indicate, however, that braces are more effective than
taping because the effect of taping decreases during the game. The effects of braces
continue the end of the game.
b. Medial (Deltoid) Ligament Complex sprain
More rare, only 5-10% of all ankle sprains. Mechanism = eversion.
Hx- h/o eversion injury, pain on medial ankle.
PE- pain medial ankle; + ecchymosis. Also, palpate the proximal fibula. The force may
be transmitted more proximally to the proximal fibula causing a Maisonneuve's
fracture.
Dx- xrays as needed. Consider xray of proximal fibula if tender to palpation.
Rx- For isolated injuries, similar to lateral complex. Expect longer rehab until 100% than
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
lateral sprains. Consider utilizing a fracture walker boot for comfort. Progress to
ankle stirrup brace as tolerated, esp. with work/sport.
Syndesmosis sprains (tibiofibular, or "high" ankle sprain)
The distal tibiofibular joint is held together by the anterior and posterior
tibiofibular ligaments. The interosseus membrane rounds out the syndesmosis
complex. It is important to note that the anterior portion of the talar dome is wider
than the posterior portion. Therefore, it makes sense that a hyperdorsiflexion
injury could force the tibia and the fibula apart. Partial tear typically involves just
the anterior tibiofibular ligament. Full tears include the posterior tib-fib ligament
and the interosseus membrane. It is rare to have a full syndesmosis sprain without
a concomitant fracture!
Hx- Mech = Eversion with external rotation of the foot, or dorsiflexion injury.
This injury is the typical ankle sprain that just does not get better. There may be
continued swelling months after the initial injury. Initial xrays may be read as
"normal," but closer evaluation may show typical abnormalities.
PE- Continued swelling, not particularly limited to the lateral complex. Point
tender to palpation of the anterior tibiofibular ligament area. May have a + sideto-side test, as well as a + proximal squeeze test.
Dx- Many syndesmosis sprains (especially partial tears) will have normal xrays.
However, the "classic" radiographic criteria for dx of syndesmosis sprain include
widened or asymmetrical mortise.
Rx• Partial tear- nonsurgical treatment is the mainstay. In acute injury, place in a
fracture walker boot (ski boot) x 4-6wks. Expect a more protracted course
than routine inversion sprain. Include ROM and theraband strengthening
exercises as soon as tolerated. After fracture walker boot, treat with P.T.
• Full syndesmosis tear (wide mortise) involves significant instability; may be
associated with fracture. For this reason, REFER to ortho for surgical screw
fixation.
•
•
2. Bony Abnormalities of the Ankle
a. Fibular fractures- note, especially with eversion injuries.
Fibular shaft fx- often secondary to direct trauma to lateral calf (ie: helmet to
calf during a tackle. Treated with aircast stirrup brace vs. cast immobilization
depending upon severity of injury. Return to sport by 4-8 weeks. Consider
Maisonneuve's fx as below.
Distal fibular fx: many classification systems. The Weber classification is as
follows. Weber A = below the mortise, B = at the mortise (joint line), C = above
the joint line. Weber C fx are usually associated with syndesmotic injuries.
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
Current data do not demonstrate improved outcome with surgery of isolated
lateral malleolus fractures without significant displacement. A number of studies
demonstrate good results from nonsurgical treatment of these fractures with up to
3 mm of displacement. In patients with fractures with greater than 3 mm of
displacement or angulation, consider referral.
• Maisonneuve's fx (proximal fibular fx associated with medial malleolus
fracture/injury to the syndesmosis): In this injury, the medial malleolus fractures,
with extension up through the interosseus membrane and out the proximal fibula.
Do not assume a medial malleolus fracture is isolated. If you see this fracture,
examine the proximal fibula. Consider xray of the knee if any questions. Whether
this is treated with nonsurgical vs surgical options relates to whether the mortise
has widened ( > 4 mm clear space!). See below in medial malleolous fractures.
•
•
b. Medial malleolar (tibial) fractures
Often occur anteromedial lip.
Isolated medial malleolar fractures may be treated nonoperatively and operatively,
depending on severity, instability, etc. Small avulsion fx may be treated with air
stirrup vs pneumatic walker boot depending on pts pain. If bimalleolar fracture,
appropriate referral for more definitive treatment is helpful. Also, if posterior tibia
fx, usually indicates significant injury. Consider the possibility of trimalleolar fx
and Maisonneuve fracture (above). Again, orthopedic referral is appropriate.
3. Tendon and Soft Tissue Injuries
a. Anterior tibialis tendinitis- pain with resisted inversion/dorsiflexion and passive
plantarflexion/inversion. Rx with NSAID's, ice, rehab, theraband exercises.
b. Posterior tibialis tendinitis- pain with resisted and pain with passive
dorsiflexion/eversion. Rx with NSAID's, ice, rehab, theraband exercises.
c. Peroneus tendinitis/subluxation (with or without tendon tears)
Peroneal tendons pass posteriorly to the lateral malleolus. They are situated in a
groove in the posterior lateral malleolus and are held in place by the retinaculum. The
groove is concave in most people, helping to nestle the tendons securely. In cadaveric
studies, however, 11% of grooves were flat and 7% were convex. The common inversion
sprain may also tear the retinacula, resulting in instability (subluxation) of the peroneus
tendons. Continued motion/rubbing of the tendon on the posterior portion of the
malleolus can cause tendinitis or peroneus tears.
Hx- pain in the posterior portion of the ankle, behind the lateral malleolus. Pain
with active eversion maneuvers. Patient may also experience a sensation of
"popping" at the ankle. This may be painful. A sense of giving way or instability
may be described. This may encourage the clinician to falsely diagnose lateral
ligament instability. Common in basketball, ballet, volleyball. In the chronic form
of subluxation, the pt will almost always relate a prior inversion ankle sprain.
PE- Tender to palpation of peroneus tendons (posterior to the lateral malleolus);
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
there may be localized edema, acutely. Many examiners will falsely associate
posterior lateral malleolus pain as tear of the posterior talofibular ligament in the
lateral ankle ligament complex. Recall that an isolated PTFL sprain is rare; in
typical inversion ankle sprain, ATFL goes first, then CFL, then PTFL tears
(implying a grade 3 ankle sprain!). Must have high clinical suspicion to
demonstrate subluxation on exam.
Peroneus subluxation exam: Patient actively everts ankle while the examiner resists this
action. Some authors describe the examiner adding dorsiflexion and plantarflexion to this
resisted action. A palpable subluxation of the tendon will be appreciated. This may be
difficult to appreciate! Keep trying!
Dx- xrays not usually helpful in the diagnosis except to r/o other injuries. Some
surgeons advocate CT scan for depth of groove on posterior aspect of the fibula.
This is more helpful for intra-operative management, than for nonoperative
treatment. Others advocate MR-arthrogram to evaluate for longitudinal tendon
tears. These may best be reserved for cases that do not respond to nonsurgical
treatment.
Rx- Treatment for this entity is controversial. Nonsurgical options should be
explored first.
• If this is an acute injury, consider nonweight-bearing cast for up to 6
wks.
• Post-cast treatment includes muscle-specific physical therapy.
Modalities to decrease local inflammation and fibrosis may be helpful.
• Surgery is reserved for recalcitrant pain and instability.
d. Achilles tendinitis- tendon from the gastrocnemius and soleus muscles.
Hx- especially with repetitive plantarflexion (volleyball, ballet, soccer). Overuse injury.
Poor warm-up, flexibility.
PE- tender to palpation, pain with resisted plantarflexion and passive dorsiflexion. +
palpable thickening of the tendon (compare to other side).
Dx- H&P. Xrays to r/o other abnormalities, not helpful in specific dx of achilles
tendinitis.
Rx- PRICES, NSAID's, heel lifts to unload the tendon tension. Chronic cases may
require physical therapy with modalities (phonophoresis, ultrasound, etc.). Difficult cases
may require immobilization with fracture walker boot or cast. Walker boot has the
advantage of concurrent cryotherapy/physical therapy without increasing the risk of
tendon atrophy. Complication includes tendon rupture, partial tear.
e. Retrocalcaneal bursitis- inflamed bursa at the insertion of the achilles into the
calcaneus. May actually represent a partial tear of the achilles. Treatment as above.
Also, add padding and avoidance of mechanical irritation. Avoid steroid injections in
this area due to risk of tendon rupture.
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
f. Achilles rupture: usually occurs at musculotendinous junction. Pt feels like "hot
poker" in posterior ankle or as if their feet were kicked out from underneath them. PE
demonstrates swelling, ecchymosis and + Thompson's test:
Pt prone with feet hanging off exam table. Intact tendon results in plantarflexion of the ankle when
examiner squeezes calf muscles. A positive Thompson test results in no motion at the ankle with calf
squeeze. This indicates a complete tear of the tendon.
Rx- Referral to orthopedics is appropriate. While controversy exists regarding surgery
vs nonsurgery, I tend to encourage surgical treatment.
g. Plantar fasciitis (PF)- the plantar aponeurosis makes up the soft tissue support of the
longitudinal arch. It originates from the medial calcaneal tuberosity and this is where
most pts will describe pain.
Hx- insidious onset of heel pain especially upon awakening and after a long day.
PE- tender to palpation medial calcaneal tuberosity, pain with passive stretch of the
plantar fascia. + foot pronation, + tight achilles tendon.
Dx- H&P. Xrays not helpful. May demonstrate heel spur. 50% of all pts with spur are
asymptomatic! Spur is not the cause of pain in PF.
Rx- NSAID's, Ice, stretching exercises of the plantar fascia and achilles, bottle rolls. Heel
pads may help, correction of biomechanical abnormalities may be required (orthotics).
Recalcitrant cases may require posterior leg night splints (specifics of duration of
splinting, angle of splint not clear). Cautious use of steroid injections has been described.
Steroids may cause heel fat pad atrophy and cause heel pain for another reason! Surgery
for continued sxs, despite above therapies.
•
•
4. Bone injuries to the Foot
Fractures at the Base of 5th MetatarsalAcute, traumatic = Jone's fx. Jone's fracture is a transverse fx ~ 1.5 cm distal to the
tubercle. It extends into the
4,5-intermetatarsal articulation.
High rate of delayed and nonunion. Treatment = short leg
non-weightbearing cast
immobilization. May take 6-8
weeks to heal. If continued
pain at 12 weeks, refer for
screw fixation. For athletes,
consider screw fixation
immediately, return to play
with incision healing.
Avulsion fx of the 5th
metatarsal- fx caused by
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
contraction of the peroneus brevis tendon. This fx does not involve the same risk for
delayed/nonunion as with the Jone's fx. This fx has an excellent prognosis for healing.
Rx as for ankle sprain. May need post-op shoe (hard-soled shoe for sx support).
d. Fractures of the Metatarsals- may be stress or acute/traumatic fx. PE = point
tenderness along affected ray, + edema, ecchymoses. Treatment = unless major
displacement or angulation, OK for post op shoe or short leg walking cast with good
arch support. Duration 4-6 weeks, depending upon localized tenderness.
e. Fractures of the Phalanges- often occur with direct trauma. Pain with limited
motion. PE with ecchymosis, edema and tender to palpation.+ deformity. Dx- plain
xrays. Will accept fair amount of angulation and displacement. Consider REFERRAL
to orthopedics if large intra-articular fx. Otherwise most pts do well with post op shoe
to decrease motion, and some do well with just
buddy taping to comfort.
5. Miscellaneous Problems with the Foot
a. Hallux Valgus (bunion): lateral (toward the fibula)
angulation of the 1st MTP.
Hx- may see pain around the 1st MTP initially, then
characteristic deformity. Usually bilateral.
PE- tender to palpation 1st MTP; erythema later in
process, with subluxation of the proximal phalanx on
the metatarsal head.
Dx- xrays demonstrating hallux valgus angle > 10o is
diagnostic. With time subluxation prox phalanx.
Rx- RICE, NSAID’s; modification of activity and
shoewear (wider toe box). REFER to ortho if continued pain despite this as symptoms
dictate.
b. Morton’s neuroma: described by
Morton in 1876. Term a misnomer.
Pathology is scar formation around the
interdigital nerve.
Hx- pain, paresthesias, dysesthesias in
foot, especially the 3/4 interspace (most
common) and 2/3 interspace. Pain usually
dull and throbbing and relieved by rest.
PE- tender to palpation; pain with lateral
compression of the forefoot.
Dx- H&P; xrays can rule out other causes
of forefoot pain.
AAFP Board Review 2006
Common Lower Extremity Problems
AAFP Board Review Greensboro, NC 5/2006
Guy Monteleone, M.D.
Director, Division of Sports Medicine
Dept of Family Medicine
West Virginia University School of Medicine
[email protected]
Rx- NSAID’s, wider shoe toe box; consider steroid injection to decrease inflammation
(acutely) and reduce scar formation (this effect may take up to 3 months). REFER to
ortho if continued pain after this.
c. Turf toe: sprain of the 1st MTP joint capsule (grouping of ligaments around the joint).
Usually occurs with hyperdorsiflexion of the 1st MTP. This injury more common with
more flexible athletic shoes and advent of turf for sporting events. Grades 1-3 as in other
ligament sprains.
Hx- hyperextension at the 1st MTP. Especially in football, rugby and soccer.
PE- tender to palpation 1st MTP, ecchymosis grade 2 or 3, may see instability at the joint
for grade 3.
Dx- Xrays often negative. May see avulsion fx.
Rx- May take time to heal. Grade 2 up to 2 wks, grade 3 up to 6 weeks. RICE, NSAID’s,
tape or splint hallux to prevent hyperexetension at the joint. If continued pain and sxs
after this REFER to ortho for consideration of surgical Rx. If associated dislocation of
MTP joint, REFER to ortho.
FOOT AND ANKLE REFERENCES
Birrer RB, Bordelon RL, Sammarco GJ. Ankle: don't dismiss a sprain. Patient Care. 26(4):6-28, 1992.
Eiff MP, Smith AT. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med. 22(1):83-8, 1994
Hamilton WG, Geppert MJ, Pain in the posterior aspect of the ankle in dancers. J Bone Joint Surg. 78A(10): 1491-1500, 1996.
Loomer R, Fisher C, Smith L, et al. Osteochondral lesions to the talus. Am J Sports Med. 21(1): 13-9, 1993.
Liu SH, Jason WJ. Lateral ankle sprains and instability problems. Clinics in Sports Med. 13(4):793-809, 1994.
Liu SH, Nuccion SL, Finerman G. Diagnosis of anterolateral ankle impingement. Am J Sports Med. 25(3):389-93, 1997.
Mason RB, Henderson IJ. Traumatic peroneal tendon instability. Am J Sports Med. 24(5):652-8, 1996.
Miller C, et al. Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med. 23(5):746-50, 1995.
Niemi WJ, Savidakis J, DeJesus JM. Peroneal subluxation: a comprehensive review of the literature with case presentations. J Foot Ankle
Surg. 36(2):141-5, 1997.
Rubin A, Sallis R. Evaluation and diagnosis of ankle injuries. AFP. 54(5):1609-18, 1996.
Tandeter HB, Shvartzman P. Acute ankle injuries- clinical decision rules for radiographs. AFP. 55(8): 2721-8, 1997.
Verhagen E, van der Beek A, Twisk J, et al. The effect of a proprioceptive balance board training program for the prevention of ankle sprains:
a prospective controlled trial. Am J Sports Med 32: 1385-1393, 2004
Wester JU, Jensen IE, RasmussenF, et al. Osteochondral lesions of the talar dome in children. Acta Orthop Scand. 65(1):110-2, 1994.
Wexler RK. The injured ankle. AFP. 57(3):474-80, 1998.
AAFP Board Review 2006