Fankle and leg D/D

According to the west point ankle sprain grading system, where is tenderness in a grade 1 sprain?

ATFL

According to the west point ankle sprain grading system, where is tenderness in a grade 2 sprain?

ATFL, CFL

According to the west point ankle sprain grading system, where is tenderness in a grade 3 sprain?

ATFL, CFL and PTFL

Slight and local edema and ecchymosis is indicative of what ankle sprain grade?

Grade 1

Moderate and local edema and ecchymosis is indicative of what ankle sprain grade?

Grade 2

Significant and diffuse edema and ecchymosis is indicative of what ankle sprain grade?

Grade 3

WB ability of a grade 1 ankle sprain?

Full or partial WB

WB ability of a grade 2 ankle sprain?

Difficult without crutches

WB ability of a grade 3 ankle sprain?

Impossible without significant pain

Ligament damage of a grade 1 ankle sprain?

Stretched ligament

Ligament damage of a grade 2 ankle sprain?

Partial tear

Ligament damage of a grade 3 ankle sprain?

Complete tear

Instability of a grade 1 ankle sprain?

None

Instability of a grade 2 ankle sprain?

None or slight

Instability of a grade 3 ankle sprain?

Definite

When does the Ottawa ankle rules warrant an ankle radiograph?

Pain in the malleolar region with any of these:

• bone tenderness at post ed of distal 6cm or tip of either malleoli

• Instability to WB for at least 4 steps immediately after injury at the time of eval

When does the Ottawa ankle rules warrant a foot radiograph?

If there is pain in the midfoot region with any of these:

• tender navicular bone

• tender at base of the fifth metatarsal

What is Patellofemoral syndrome (Runner’s Knee)?

• What would you observe

• What special test would be (+)

Generally 20—50yr

MOI: trauma, tight ITB/glute max/TFL

Worse after sitting for long periods (Movie goer sign), end range flexion painful

Clarke test (+)

What is Patellar tendinopathy (Jumper’s Knee)?

• What would you observe

• What special test would be (+)

Generally 15—30yr, inflammation of patellar tendon

MOI: gradual, repeated eccentric overload during deceleration activities

Pain increases with squatting and jumping, end range knee flexion painful

Single leg hop test (+); high step up test (+)

What is Prepatellar bursitis?

• What would you observe

• What special test would be (+)

Generally 15—50yr, inflammation of bursa due to recurrent minor trauma of anterior knee

MOI: direct trauma to anterior aspect of knee

Pain increases with kneeling; local, fluctuating swelling

What is Osgood Schlatter disease?

• What would you observe

• What special test would be (+)

Generally 8—13yr in female; 10—15yr in male

Sudden onset; traction apophysitis of tibial tubercule

Visible lump over site, anterior knee pain with running, jumping, squatting, kneeling, knee impact

Knee extension against resistance increases symptoms

What is an ACL injury?

• What would you observe

• What special test would be (+)

Generally 15—45yr

MOI: can be from contact or non—contact,

• contact: lateral blow → valgus forces to knee resulting in ACL/MCL/medial meniscus injury

• non contact: tibia ER on planted foot

Immediate swelling, popping sound, instability, symptoms increase with WB, pain at end ranges

(+) Lachman’s, (+) Pivot Shift, (+) Anterior drawer

What is Sinding—Larsen—Johansson syndrome?

• What would you observe

• What special test would be (+)

Traction epophysitis at inferior pole of patella (superior to the osgood schlatter site)

Pain with activities like cycling, athletics, resisted knee extension

(+) X ray finding fragmentation or irregular calcification

What is a PCL injury?

• What would you observe

• What special test would be (+)

Forceful blow to anterior tibia with a flexed knee, dashboard or falling onto flexed knee

• hyperflexion

Popping sound, pain in posterior aspect of the knee joint which worsens with kneeling

(+) posterior sag, (+) posterior drawer

What ST would be (+) with MCL or LCL injury?

Collateral ligament instability test

What is ITB friction syndrome?

• What would you observe

• What special test would be (+)

Generally 25—55yr

MOI: overuse

Pain with repetitive movements, climbing or descending stairs; diffuse lateral knee pain, localized at lateral femoral condyle

(+) Ober’s, (+) Noble compression, (+) Renne

What is Plantar Fasciitis?

• What would you observe

• What special test would be (+)

20—60yr

MOI: gradual with no known cause

Painful sole of foot under heel in WB; worse in the morning; flattened arches observed

Passive great toe extension painful; plantar aspect of heel tender upon palpation

(+) Windlass

What is Achilles tendinitis?

• What would you observe

• What special test would be (+)

20—40yr

MOI: overuse

Jumping, running increases symptoms on posterior ankle

Active and passive DF is painful and limited; extended knee limits passive DF

What is gastrocnemius strain?

• What would you observe

• What special test would be (+)

20—40yr

MOI: sudden overload

Pain in upper calf, increases with heel raises; antalgic gait, painful active/passive DF and resisted PF

What is Posterior tibialis tendinitis?

• What would you observe

• What special test would be (+)

20—40yr

MOI: overuse with a flat, pronated foot

Pain at medial ankle throughout tendon, swelling over medial ankle, PF and eversion painful, resisted inversion with PF foot painful

What is Anterior tibialis tendinitis?

• What would you observe

• What special test would be (+)

15—45yr

MOI: overuse

Symptoms increases with repetitive DF, passive PF painful - inversion worsens, resisted DF painful

What is Medial tibial stress syndrome (shin splints)?

• What would you observe

• What special test would be (+)

15—30yr

MOI: overuse

Pain on anterior or posteromedial lower leg, active PF + inversion painful, resisted PF and eversion painful

What is anterior compartment syndrome?

• What would you observe

• What special test would be (+)

Ischemic condition of the leg

MOI: trauma, muscle hypertrophy, fx

Severe cramping, diffuse pain, tightness; pain decreases with rest and increases with activity

6Ps: pain + pallor + paresis + paresthesia + pulselessness + palpable tenderness → acute surgery

What is Morton’s Neuroma?

• What would you observe

• What special test would be (+)

40—60yr

MOI: gradual with unknown cause

WB increases symptoms on sole of foot, pronated foot or flattened arch can be observed, passive toe extension painful

What is tarsal tunnel syndrome?

• What would you observe

• What special test would be (+)

25—50yr

MOI: post traumatic

What is a metatarsal stress fracture?

• What would you observe

• What special test would be (+)

15—45yr

MOI: overuse

Tender over site and worsens with WB on forefoot

Palpation, US, tuning fork, bone scan, MRI and CT

What is Midfoot sprain?

• What would you observe

• What special test would be (+)

15-40yr

MOI: high impact landing with a foot twist when in a fixed position

Toe walking increases symptoms on midfoot, pain in passive midfoot movement

Lateral and anterior—posterior radiographs

What is Sever’s disease (Calcaneal apophysitis)?

• What would you observe

• What special test would be (+)

8—13yr

Traction apophysitis at the achilles tendon insertion

MOI: foot pronation, tight gastroc—soleus, jumping and landing from a height

Limited DF and stiffness, pain over posteroinferior heel, increases in WB, improves with rest

(+) Squeeze test, Xray

Orientation of forefoot?

Forefoot varus; inversion

Orientation of forefoot?

Forefoot valgus; eversion

What is osteogenesis imperfecta? (OI)

A congenital disorder of type I collagen synthesis that affects all connective tissues in the body.

• osteoporosis

• Fxs

• bowing of long bones

• spinal deformities

• mm weakness

• ligamentous laxity

• blue sclera in the eyes

• orthodontal issues

• hearing loss

• cardiopulmonary abnormalities

What does this describe:

15—50yr pt

Gradual onset of symptoms

Inflamed patellar tendon, tender over site

Pain with passive end range knee flexion

Pain worsens with squatting, jumping

Patellar tendinitis (Jumper’s Knee)

What does this describe:

8—15yr pt

Traction apophysitis of the tibial tubercule

Pain with running, jumping and squatting

Pain worsens with resisted knee extension

Osgood—Schlatter’s Disease

What is piriformis syndrome?

Entrapment of the sciatic N by the piriformis muscle as it passes through the sciatic notch

What causes piriformis syndrome?

Trauma to hip/buttock

Piriformis m hypertrophy

Sitting for prolonged periods

What are symptoms of piriformis syndrome?

Restriction in ROM of hip adduction and IR

Tender with palpation

Pain in buttocks worsened with hip movements

Pain radiating into posterior thigh

How do you treat piriformis syndrome?

short term rest, usage of muscle relaxers and NSAIDs

Stretching of the piriformis muscle, ROM exercises, deep tissue massage