The
lower limb- Examination
- Hip pain
- Pain in kneeThe lower limb
- Ankle pain
- Foot
- Heel pain
- Orthoses
- Supports
- Splints
- Gait
Examination
Principles:
- Inspection
- Palpation
- Feel for heat from between joints with back of hand
- Press only enough to blanch thumbnail
- Range of movement: passive
- Function
Use GALS
- Wrist piano key sign on ulnar styloid
- Subluxation of wrist results in reduced grip Loss of extension means that patient can't get up off the floor. Movements 20deg lat 30deg med 70deg flexion 50deg extension
Hand Square hand with OA 1CMCJ because 1MC drops
Leg length
- Supine: measure ASIS to lateral malleolus
- Supine: put malleoli together and bend knee
- Sitting: square in chair
Anserine bursa: medial upper tibia (insertion of strap muscles).
Crepitus patellofemoral compartment: contract quads with hand over patella.
Look at
- knees
- hips
- back
- feet
- Foot should have 30 deg plantar flexion and 15 deg dorsiflexion
- Subtalar joint: inversion should be twice eversion
- Forefoot: pronation out supination in
- footwear
Hip pain
- Upper lumbar referral
- SI referral
- OA: early sclerosis on X-ray. ROM reduced, esp. internal rotation. Lying prone, there should be 80-90deg of rotation - compare both sides.
- RA and ank spond
- Transient synovitis
- 0-5 CDH
- 5-10 Perthes
- 10-15 Adolescent coxa vara (slipped upper femoral epiphysis)
- Osteomalacia leading to psuedomyopathy
- Bursitis - psoas ischial (pain in lower buttock on sitting) trochanteric
- Osteitis pubis: athletes. Stress exerted by adductor muscles. Stress # femoral neck: long distance athletes.
- ?Gilmore's groin: tenderness/dilation of superficial inguinal ring with cough impulse. Athletes. Rx surgery.
- Quadriceps haematoma: athletes.
Pain in knee
- Arthritides
- Chondromalacia patellae: patellofemoral pain reproduced by stair climbing or sitting for a while with knee flexed at 90deg. Lig sprains
- Baker's cyst (popliteal bursitis). Popliteal cysts in children resolve spontaneously.
- Internal derangement Osgood-Schlatters
- Panniclitis (tender fat pads)
- Osteochondritis
- Prepatellar bursitis
- Referred pain
- Iliotibial band friction syndrome: athletes. Iliotibial tract: lie on side, flex knee. Knees will not come together because of tight band.
- Plicae: ?surgical removal. Patellar tendinitis: proximal tendon swollen on MRI.
- Patellar maltracking: OA with valgus deformity - increase n Q angle
- Medial tibial stress syndrome: athletes. Pain at periosteal attachment on lower medial third of tibia.
- Shin splints: anterior compartment syndrome.
- Gastrocnemius muscle tear: Thompson test.
Ankle pain
In RA often due to tenosynovitis rather than arthritis. Sprains: normally invert (supinate) foot when walking. Sprain may lead to pronation of foot with calcaneal eversion when walking resulting in tibialis posterior tendinitis.
Foot
| Forefoot | MT PP TP | Surgery only useful if hindfoot and midfoot are OK. | |
| Midfoot | Navicular cunieform cuboid | In RA, navicular/cunieform can drop. | |
| Hindfoot | talus calcaneus | Ankle flexion/extension Subtalar inversion/eversion: problems result in over-pronation which leads to wear in middle of heel because of abnormal heel strike. |
Foot pain
- Mechanical
- Metatarsal bursitis: usually 1MT head, throbbing pain.
- Mortons metatarsalgia (interdigital neuroma: usually proximal part of plantar digital N. Pain on walking, often 3rd and 4th toe. Toe deformities, splaying of forefoot, Mulders click and pain on compressing MT heads.)
- Trauma & chronic foot pain
- Arthritis
- Sausage toe (dactylitis) in psoriatic arthropathy and reiter's syndrome
- Osteochondritis (MT heads or navicular)
- Freiburgs infraction: teenagers, increased sporting activity. Limp and MTPJ pain. Rest & immobilise: can need surgery if deformity develops.
- Vascular
- Neurological
- Neuropathies
- Tarsal tunnel syndrome (post tibial N compression: burning on sole of foot in dermatome served by medial plantar N)
Hallux limitus
1MTPJ should bend 60deg at push-off phase. Sesamoids move forward to increase functional length.
- Inflamed joint
- Restricted movement when weightbearing
- Poor quality of motion Ostophytic lipping
- Sesamoid pain and dysfunction
- Long 1MT
Causes
- Joint disease
- Sesamoid function
- Mechanical: reduced movement of 1MTPJ with problems in hindfoot. Restoring hindfoot position by orthosis can restore function.
Management
- Leather rigid-sole shoe
- Toe spring
- Surgery
- Decompression osteotomy
- Kellers
- Fusion Replacement
Bunions
IM angle between 1 and 2MT
- 10deg normal
- 15deg mod deformity
- 20deg severe deformity
Considerations for surgery
- Age
- Degree of deformity
- Sesamoid function
- Length and position of metatarsals
- Joint disease
- Bone density
- Patient wishes
Cause
- Footwear
- Heredity
- Joint disease
- Mechanical
- 1st ray instability
- STJ pronation
Management
- Footwear
- Orthoses
- Surgery
- Bunionectomy
- Osteotomy (IM angle)
- Fusion
- Arthroplasty (Kellers)
Heel pain
- Within heel
- Pagets
- Arthritis of subtalar joint
- Calcaneal disease
- Beneath heel
- Plantar fasciitis: heel padding x2 (sorbithane) and look at footwear.
- Soft tissue
- Painful heel cushions (athletes)
- Calcification
- Referred pain from S1
- Behind heel
- Plantar calcaneal bursitis (policeman's heel)
- Increased activity or wt gain
- Direct pressure or sideways compression causes pain
- Achilles tendinitis: Rx heel lift and stretching.
- Achilles bursitis
- Subcutaneous
- Retrocalcaneal
- Ruptured achilles tendon
- Apophysitis of calcaneum (Sever's disease)
- Adolescents
- Gradual onset dull ache exacerbated by jumping
- Rx rest or perhaps heel lift
- Plantar calcaneal bursitis (policeman's heel)
Orthoses
- Control weight-bearing
- Re-establish base for muscle function
- Pronation/supination ratio
Insoles
- Medial longitudinal arch supports
- Flat feet
- Lateral plantar nerve compression P
- revent subtalar valgus subluxation
- Metatarsal domes
- May need larger shoes
- Mechanical/metatarsophalyngeal joint problems
- Heel insoles
- Traumatic heel pain
- May need hole cut out over tender area
Modified shoes
- Shoe raises for unequal leg lengths more than 1cm
- Depth shoe to accommodate insoles
- Bespoke shoe
Supports
- Collars
- Corsets
- Polythene jackets for mechanical causes of respiratory dysfunction
- Epicondylitis clasp
Splints
- Resting (night)
- Working
- Serial for reducing contractures
Functions of a splint
- Stabilise joint
- Immobilise to reduce pain and inflammation P
- ut limb in best functional position
- Protect joint to improve confidence
- Prevent/reduce deformity
Sports injuries Mostly overuse/muscular. Rest overuse injures but keep damaged muscles mobile.
Gait
Walking heel strike phase foot pronates which makes foot flatter Toe-off phase 1MTPJ: pelvis lifts to allow swing through.
Trendelenberg gait: no pelvis tilt so spine must curve. pelvis or hip problem e.g. OA hip. Antalgic gait: pain so less time weightbearing on that side. Reflux inhibition of quadriceps results in pseudoparalysis or pseudo giving way.