Semimembranosus bursitis

1
Semimembranosus bursitis

• The semimembranosus bursa lies between the
  semimembranosus muscle and the medial head of
  gastrocnemius. This bursa my become enlarged and
  present as a painless lump in the medial part of
  the popliteal fossa.
• Overuse/ training
• On examination lump is fluctuant, it cannot be
  pushed into the joint. The knee joint is normal.
• Rest/ NSAID/Physio/ Injection/ Excision.

2
Pain Around the Knee
3
Sinding Larsen's disease
Osgood-Schlatter's disease
Traction apophysitis - repeated avulsion of the
apophysis into which part of the patellar tendon
is inserted. Occurs at pubertal growth spurt
quadriceps has enlarged but the apophysis has not
yet fused to the tibia. Pain, tenderness and
lump over tibial tubercle. Pain after activity
Rest, NSAID, rarely POP, even rarer excision of
spicule of bone

• This is a traction osteochondritis of the lower
  pole of patella.
• Pain over the inferior border of the patella is
  the presenting complaint.
• The disease is similar to Osgood-Schlatter's
  disease but occurs 1-2 years earlier.

4
Plica/ medial shelf syndrome.

• Patient indicating painful area of knee

The inferomedial quadrant is usually the most
painful region. This area is highlighted by
several X's in this figure. A painful taut band
of tissue that emanates from the central portion
of the medial patella may often be palpated (3
o'clock position on the figure).
5
Plica/ medial shelf syndrome.
Secondary to injury or overuse Otherwise normal
structure (remnant of embryonic development),
significant source of anterior knee pain
Discrete trauma or repeated microtrauma ?
inflammatory process normal plica hypertrophies
into a truly pathological structure
Symptoms aggravated by activity or prolonged
standing, squatting, sitting, and stair climbing.
Quadriceps extension exercises (short arc) /
NSAID/ Arthroscopic resection
6
Ilio-tibial band syndrome

• Mostly younger athletes and mostly at lateral
  aspect of knee but can ovely the hip
• Female preponderance
• Pain on crossing leg/ standing with legs crossed
• Extends from lateral hip to lateral knee
• RX exercises and stretches/ acupuncture/analgesi
  cs/injection

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Knee minimum set

• Look while walking! (history)
• Age
• Squat (sometime)
• Feel
• Temp
• Joint lines
• Soft tissue
• Fluid
• Ligaments
• Feet (hips)

8
http//www.allaboutarthritis.com/video/animation/a
nkle_move_MMG.swf
9
Foot woes - 1

• Toes
• Hallux rigidus / hallux valgus with bunion
• Mortons thingeymajig
• Forefoot
• Metatarsalgia look and squeeze
• Stress fracture
• Mid foot
• Arches!
• This image http//www.allaboutarthritis.com/video/
  animation/ankle_move_MMG.swf

10
Foot woes - 2

• Mid foot (cont)
• Posterior tibial tendon
• Tarsal Tunnel
• Soft tissue gout?
• Hind foot
• Plantar fasciitis
• bursa

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Retro-calcaneal/ Achilles tendon bursitis
Achilles tendon bursitis is a common foot pain in
athletes, particularly runners. It can often be
mistaken for Achilles tendinitis or can also
occur in conjunction with Achilles tendinitis
(Haglunds Syndrome)

• Pain at the back of the heels especially when
  running uphill or on soft surfaces.
• Tenderness/ swelling/ redness at back of heel/
  spongy resistance
• Change of or tight-fitting shoes
• Overuse
• Haglunds deformity

RICE/ NSAID/ PHYSIO/ FOOTWEAR/ INJECTION/ SURGERY
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Tibialis posterior tendon dysfunction

• Seen in conjunction with over-pronation of the
  foot - about 70 of patients with this condition
  are females who are overweight, and have previous
  underlying problems of overpronation
• This increases forces on this muscle and the
  tendon becomes irritated, especially as it skirts
  around the medial malleolus, resulting in pain,
  inflammation and swelling (Stages 1 and 2)
• pain in the sole of the foot, around the ankle
  and up the leg. Over time the tendon will
  degenerate and may ultimately rupture - if this
  occurs then arch will collapse (stages 3 and 4)
  and present as a talo-navicular bulge on the
  medial aspect..

13
Tibialis posterior tendon dysfunction
Visible T. P. tendon behind Med. Malleolus
Tendon failed with resultant pronation and
prominent talo-navicular, with foot pain
14
Tibialis posterior tendon dysfunction

• .and laterally, when viewed behind as 'too many
  toes.

• Single-limb heel rise. Patient with posterior
  tibial tendon dysfunction is unable to rise up on
  the toes because of an inability to invert the
  hindfoot.

15
Tibialis posterior tendon dysfunction

• In stage 1 aggressive orthotic correction, rest
  and NSAID / surgical decompression
• In stage 2 may need also a special plaster boot
  or brace. Or operative Tendon of flex. digitorum
  is shortened and attached to navicular/ distal
  broken portion of PT tendon. Combined with
  calcaneal osteotomy? disappointing results
• Stages 3 and 4 Fusion of various joints

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Ottawa Rules
An ankle x-ray is required only if there is any
pain in malleolar zone and any of these
findings bone tenderness at A or B inability to
weight bear both immediately and at consultation.
A foot x-ray is required if there is any pain in
the midfoot zone and any of these findings bone
tenderness at C or D inability to weight bear
both immediately and at consultation.