Lower%20Limb

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Lower Limb

• Orthopaedic Medicine
• www.bradfordvts.co.uk

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Scope

• Painful hips.
• Painful thighs.
• Pain in the knee.
• Shin problems.
• Ankle problems.
• Foot problems.

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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.

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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.

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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

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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.

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Painful Thighs

• Few localised problems.
• Usually referred pain from hip or back.

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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.

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Knee Examination

• Look for valgus and varus.
• Look at the knees while standing makes swelling
  more obvious and Bakers cysts visible.
• Lie them down, ? Swelling palpate. Aspirate if
  erythema for crystals.
• The anserine bursa is about 4cm medial to the
  tibial tuberosity.

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Knee Problems

• Pre-patella bursitis.
• Patellar tendonitis.
• Infrapatellar bursitis.
• These three can be managed with NSAIDs, steroid
  injection and gentle exercises.

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Knee Problems

• Anserine bursitis.
• Hamstring stretching.
• Plantar arch supports.
• NSAIDs.
• Steroid injection useless.

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Knee Problems

• Patellofemoral syndrome.
• Nebulous diagnosis?
• Time and pacing of activity.
• ?Static quads.
• Fat pad entrapment syndrome.
• Pacing of activity.
• Steroid injection.

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Knee Problems

• Tracking disorders.
• Decent exercises.
• ?Static quads.
• Avoid surgery!
• Osgood-Schlatters.
• Time and pacing activity.
• Avoid surgical referral.

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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.

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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.

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The Ankle

• Plantar arch if going onto tip toe restores the
  arch then the flat foot is usually benign.
• ? Swelling.
• ? Erythema.

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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.
• NSAIDs useless.

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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.
• NSAIDs useless.

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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.

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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.

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Ankle and Foot Problems

• Ankle anterior tendonitis.
• Commonly either in inflammatory arthritis or
  overuse.
• Pain during active dorsiflexion.

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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.
• NSAIDs.
• No steroid injection danger of rupture.
• Arch supports if needed.
• Pacing of activity.