CMS II: Ortho - Lower Extremity

What does a POSITIVE Ober test indicate?

tight TFL or ITB

- will be unable to keep their leg lowered

What does a POSITIVE Homan's test indicate?

positive if patient experiences pain

- indicates possible DVT

What is a POSITIVE Thompson test?

positive if the ankle does NOT plantarflex

- indicates a torn Achille's tendon

What causes ITB syndrome?

occurs when the iliotibial band becomes irritated and rubs on the lateral femoral epicondyle

- results from repetitive flexion/extension

What type of pain will a patient with ITB syndrome present with?

pain in the ANTEROLATERAL aspect of the knee

- most painful when the heel strikes the floor while walking

- can be asymptomatic with rest

What non-surgical options are recommended for treatment of ITB syndrome?

PT

NSAIDs

RICE

Activity modification

If not responsive → corticosteroid injection

What is compartment syndrome? What is the most common cause and compartment involved?

occurs when there is an increase in intracompartmental pressures that could compromise blood flow

- m/c after a tibial fracture

- m/c in the anterior compartment

What is considered a NORMAL intracompartmental pressure?

<10 mmHg

What is considered a DANGEROUS intracompartmental pressure?

>40mmHg

*significant when >30mmHg

What are the 6 P's associated with compartment syndrome?

SEVERE leg Pain

Paresthesia

Pallor

Paralysis

Pulselessness

Poikilothermia

If a patient presents with compartment syndrome with paresthesias in the foot/dorsal region, what compartment is most likely involved?

anterior/lateral

If a patient presents with compartment syndrome with paresthesias in the plantar region, what compartment is most likely involved?

posterior

If a patient presents with compartment syndrome with pain with passive EHL stretching, what compartment is most likely involved?

anterior

If a patient presents with compartment syndrome with pain with passive FHL stretching, what compartment is most likely involved?

posterior

If a patient presents with compartment syndrome with pain with passive dorsiflexion of the ankle, what compartment is most likely involved?

superior

If a patient presents with compartment syndrome with pain with passive inversion of foot, what compartment is most likely involved?

lateral

What type of compartment syndrome is considered an EMERGENCY? What is the 1st line treatment?

ACUTE - will require a fasciotomy

What type of compartment syndrome occurs persistently due to intense exercise and subsides with d/c of activity?

chronic/exertional compartment syndrome

What type of tendonitis will present with pain at the insertion point on the SUPERIOR pole of the patella?

quadriceps tendonitis

What type of tendonitis will present with pain at the insertion point on the INFERIOR pole of the patella?

patellar tendonitis

In YOUNGER patients with patellar/quadriceps tendinitis, what is the m/c cause?

jumping/kicking (overuse/overload)

"jumper's knee"

What is a hallmark symptom of patellar/quadriceps tendinitis?

anterior knee pain

- noted after exercise, prolonged sitting, squatting and sitting

What is involved in the non-surgical treatment of patellar/quadriceps tendinitis?

Rest

Knee immobilizer

NSAIDs

Analgesic creams

Heat/ice

Steroid injections

PT

What is the most common gastrocnemius tear?

acute strain or rupture of the medial head of the muscle

Who most commonly suffers from a gastrocnemius tear?

athletes >30 y/o

What type of pain is common with a gastrocnemius tear?

Pulling/tearing sensation in the calf

Pain is proximal + medial

What treatment options are recommended for a gastrocnemius tear?

NSAIDs

RICE

Calf sleeve or compression hose

CAM boot/tall pneumatic walker

Gentle PT

**surgery is rare and reserved for very severe cases

What are TWO terms used to describe a BENIGN synovial cyst on the knee?

Baker cyst

Popliteal cyst

Can a popliteal cyst produce pain?

Yes - pain can be mistaken for DVT

- if it ruptures, it can result in severe calf pain (m/c in elderly)

Is aspiration of a popliteal cyst recommended?

NO - only provides transient relief (not worth it)

What is a contusion?

an injury to bone or soft tissue due to DIRECT blunt trauma

- presents as a PAINFUL "bruise" due to rupture of capillaries

T/F. Disability from a contusion is MINOR, but it can be very painful.

TRUE - if there is excessive swelling, it could lead to compartment syndrome

What is the m/c site for a contusion?

thigh

What can occur as a complication of contusions?

myositis ossificans traumatica

- leads to formation of bone in soft tissue/muscle

What is recommended in the treatment of contusions?

Minor analgesics

RICE

PT

Surgical excision - if ossification is present

What is medial tibia stress syndrome? How will it present?

shin splints - inflammation of the tibial periosteum due to repetitive muscle contractions

- will present with gradual onset of pain in the ANTEROMEDIAL aspect of the distal leg

Shin splints is associated with what?

running on a hard + uneven surface and FLAT feet (planus)

Treatment for shin splints is _______.

conservative

- rest/ice/massage/NSAIDs/PT

What type of fracture results from a hairline or microscopic break in the bone?

stress fracture

Which type of LE stress fracture has the worst prognosis?

anterior tibial stress fracture

What diagnostic test can CONFIRM presence of a stress fracture?

MRI (exception to soft tissue rule)

*XR might not show injury for up to 3 weeks

When should surgery for a stress fracture be considered?

no response to conservative treatment (rest, splints, cast, etc)

What are 70% of amputations as a result of (3)?

DM

Severe infection

PVD

What is the BEST type of amputation to have if needed?

BKA - below the knee amputation (transtibial)

What complication occurs in 55-85% of amputees? How can it be treated?

phantom limb sensation on the missing limb

- treatment includes: nerve medications, TENS unit and pain management

What is Virchow's triad?

SHE

- venous Stasis

- Hyper-coagulability

- Endothelial injury

*presence of triad increases risk for DVT

DVT can most commonly cause what pulmonary condition?

pulmonary embolism

- will present with dyspnea, chest pain and hemoptysis

What is a hallmark symptom of a DVT?

unilateral swelling of the calf or thigh

*can occur +/- pain

What is the GOLD STANDARD to confirm a DVT?

venography

T/F. A duplex U/S can be useful for diagnosing proximal clot formation.

TRUE

What is the GOLD STANDARD to confirm a PE?

pulmonary angiography

A patient with a score of >2 on the Wells probability score is at an increased for what?

a DVT

T/F. A patient with risk factors for a DVT/PE should receive prophylactic treatment.

TRUE

- can prescribed enoxaparin, warfarin, xarelto

_________ is discomfort in the legs with either a neurogenic or vascular cause.

claudication

Neurogenic claudication is associated with what? How will it present?

spinal stenosis

Will present with pain that begins in the buttocks and radiates to the legs while walking (proximal to distal)

- does NOT immediately stop with rest from walking

Vascular claudication is associated with what? How will it present?

peripheral vascular disease which causes compromise blood flow with walking

Will present with pain w/ activity that is relieved with rest

- progresses from distal to proximal

For vascular claudication, what PE findings can also present with symptoms of pain? (3)

diminished/absent pulses

Pallor

ABI <0.9