Lower Limb
Orthopaedic Medicine
www.bradfordvts.co.uk
Scope
• Painful hips.
• Painful thighs.
• Pain in the knee.
• Shin problems.
• Ankle problems.
• Foot problems.
Painful Hips
• Remember pain from
the spine.
• Age related conditions.
– We will exclude trauma.
• SLE and gout very rare.
• Septic arthritis: they
are very ill!
• Problems with
protheses.
– We will exclude today.
Hip Examination
• Observe gait.
• Check where the pain really is.
• With them lying down gently roll limb back and
forth. If this is sore = serious hip pathology.
• A simple test for a normal hip joint is putting
the foot on the opposite knee while lying on
back.
• Flex hip to 90° (normal) flex knee to 90° and
test for internal (30°) and external (45°)
rotation.
• Abduction is normally tested lying supine 60°.
• Adduction, ditto 30°.
Painful Hips
• Osteoarthritis.
• Rheumatoid arthritis.
• Palindromic arthritis.
– Transient symptoms, may have restriction of
movement, xrays normal.
– Over 60% eventually get seropositive
rheumatoid or SLE.
• Psoriatic arthropathy.
– All of these “true” arthritis produce pain
more anteriorly than laterally, and often
cause radiation to the knee
Painful Hips
• Avascular necrosis.
– Severe pain, relatively short history.
Commoner in SLE, steroids etc.
• Trochanteric bursitis.
– Often worse when lying on affected side.
– Passive hip movements should be full
and pain free.
– Point tenderness.
– Lateral pain.
Painful Thighs
• Few localised problems.
• Usually referred pain from hip or back.
Knee Pain
Excluding trauma!
• Normal range of movement:
– Flexion 140°.
– Extension straight!
• Valgus = knock knees.
• Varus = bow legged.
• Remember foot arch collapse and hip
problems as common causes of knee pain.
Knee Examination
• Look for valgus and varus.
• Look at the knees while standing –
makes swelling more obvious and
Baker’s cysts visible.
• Lie them down, ? Swelling – palpate.
Aspirate if erythema for crystals.
• The anserine bursa is about 4cm
medial to the tibial tuberosity.
Knee Problems
• Pre-patella bursitis.
• Patellar tendonitis.
• Infrapatellar bursitis.
– These three can be managed with
NSAID’s, steroid injection and gentle
exercises.
Knee Problems
• Anserine bursitis.
– Hamstring stretching.
– Plantar arch supports.
– NSAID’s.
– Steroid injection useless.
Knee Problems
• Patellofemoral syndrome.
– Nebulous diagnosis?
– Time and pacing of activity.
– ?Static quads.
• Fat pad entrapment syndrome.
– Pacing of activity.
– Steroid injection.
Knee Problems
• Tracking disorders.
– Decent exercises.
– ?Static quads.
– Avoid surgery!
• Osgood-Schlatters.
– Time and pacing activity.
– Avoid surgical referral.
Shin Problems
• “Shin splints” over use causing a
periostitis of the tibia.
– Pacing activity.
– Physiotherapy advice.
• Shin pain common in plantar
arch collapse.
• Anterior leg tendonitis.
The Ankle
• Dorsiflexion – anterior tibialis (mainly).
• Plantar flexion – gastrocnemius and
soleus muscles (fuse to form the achilles
tendon).
• Tibiotalar joint and talocalcaneal joint.
• Look at the back with the patient
standing for achilles inflammation, valgus
and varus.
The Ankle
• Plantar arch if going onto tip toe
restores the arch then the flat foot is
usually benign.
• ? Swelling.
• ? Erythema.
Ankle and Foot Problems
• Plantar arch collapse.
– Causes pain in the toes, ankle, anterior tibial
region, heel and knee (especially around the
anserine bursa).
– Worse after walking and at the end of the day.
– Custom fitted arch supports are often made
and not worn as the arch collapse has usually
come on gradually and the support
redistributes the weight. They need slow
“weaning”.
– NSAID’s useless.
Ankle and Foot Problems
• Plantar fasciitis.
– Heel pain, worst on wakening or in the
morning.
– Plantar arch collapse predisposes.
– Spurs are irrelevant – they are secondary
to the fasciitis.
– Sorbothane heel supports.
– Steroid injection.
– NSAID’s useless.
Ankle and Foot Problems
• Stress fractures.
– Sudden onset of pain and swelling.
– Common in people with arch
collapse.
– Much commoner in women.
– Often resolve spontaneously.
– Hard clinically to distinguish from
gout.
Ankle and Foot Problems
• Metatarsalgia.
– Transverse arch collapse.
– Neuromas.
– Wider shoes.
– Flat shoes.
– Arch supports.
– Steroid injection between the metatarsal
heads.
– Surgery if all else fails.
Ankle and Foot Problems
• Ankle anterior tendonitis.
– Commonly either in inflammatory
arthritis or overuse.
– Pain during active dorsiflexion.
Ankle and Foot Problems
• Achilles tendonitis.
– Pain on active plantar flexion against
resistance worse than passive movement.
• Treatment for achilles and anterior
tendonitis.
– Simple stretching exercises.
– NSAID’s.
– No steroid injection – danger of rupture.
– Arch supports if needed.
– Pacing of activity.