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.