Lower Limb Injury.indd

 

NOTES

LOWER LIMB INJURY

▪ Injury to ligaments, tendons, bony

structures of lower extremities

CAUSES

▪ Trauma, sport

PATHOLOGY & CAUSES

▪ Pain, swelling in affected region/joint

SIGNS & SYMPTOMS

DIAGNOSTIC IMAGING

▪ Imaging to confi rm

OTHER DIAGNOSTICS

▪ History: traumatic event, risk factors review

▪ Physical examination: especially

provocative (eponymous) musculoskeletal

joint evaluation

DIAGNOSIS

MEDICATIONS

Acute

▪ Analgesics (NSAIDs)

SURGERY

Therapeutic

▪ Surgical intervention (depending on

disability, desire to return to sport/

demanding activity)

OTHER INTERVENTIONS

Acute

▪ Rest, ice

TREATMENT

GENERALLY, WHAT IS IT?

666 OSMOSIS.ORG

Figure 115.1 A positive Simmond’s test (left)

in an individual with a ruptured achilles’

tendon

osms.it/achilles-tendon-rupture

ACHILLES TENDON RUPTURE

▪ Acute, complete disruption of achilles

tendon

▫ Commonly traumatic, but can be

iatrogenic

CAUSES

▪ Recreational Sports: > 80% of achilles

tendon ruptures

▫ Increased activity, shear stress on

achilles, direct trauma to tendon

▫ Sudden, forced dorsifl exion of ankle

outside normal range of motion

RISK FACTORS

▪ Age: 30–40 years old

▪ Biologically-male individuals

▪ Obesity

▪ Fluoroquinolone use: unknown mechanism

▪ Systemic corticosteroid use

COMPLICATIONS

▪ Re-injury: 10% of individuals with rupture

have history of previous rupture

PATHOLOGY & CAUSES

▪ Ankle pain

▪ Poor ambulation

SIGNS & SYMPTOMS

OTHER DIAGNOSTICS

Physical inspection

▪ History: sudden, painful pop in lower leg;

inability to walk; pain immediately after

injury

▪ Calf muscles

▫ Soft, lumped together toward knee

DIAGNOSIS

▪ Proximal achilles

▫ Likewise collected proximally

Physical examination maneuvers

▪ Calf squeeze test (Simmonds/Thompson

test)

▫ Squeezing calf of affected leg does

not elicit plantar fl exion (very high

sensitivity, specifi city)

▪ Palpable gap test

▫ Posterior leg palpation at level of achilles

to palpate gap in tendon

▪ Knee fl exion test (Matles test)

▫ Individual is prone with knees fl exed at

90° → observe angle of ankle

▫ Ruptured achilles → acute angle

(unopposed dorsifl exion of foot by

grativity)

OSMOSIS.ORG

 Chapter 115 Lower Limb Injury

667

Figure 115.2 A ruptured achilles tendon prior

to surgical repair.

MEDICATIONS

Acute

▪ Analgesics (NSAIDs/acetaminophen)

SURGERY

Curative

▪ Orthopedic tendon repair

OTHER INTERVENTIONS

Acute

▪ Rest, ice

TREATMENT

osms.it/ACL-injury

ANTERIOR CRUCIATE LIGAMENT

INJURY

▪ Damage/complete tear of anterior cruciate

ligament (ACL) in knee; common in

deceleration injuries

CAUSES

▪ Common mechanism: twisting knee after

planting foot

▫ Typically, non-contact injury

▫ Common athletic injury

RISK FACTORS

▪ Biologically-female individuals

▪ Valgus knee angulation

▪ ↑ traction ability of fi eld of play

▫ Wet surfaces: rotation/shift of

gravity results in slipping, rather than

biomechanical injury to body

PATHOLOGY & CAUSES COMPLICATIONS

▪ Segond fracture: avulsion fracture of lateral

aspect of tibial plateau; occurs in most ACL

tears

▪ Immediate pain

▪ May have popping sensation/sound at time

of injury

▪ Immediate knee swelling → hemarthrosis

▫ Diagnostic maneuvers should be

performed immediately after injury for

clearest results

▪ Post-injury

▫ Knee may “give out” when walking/

standing

SIGNS & SYMPTOMS

668 OSMOSIS.ORG

Figure 115.3 An MRI scan of the knee

demonstrating partial disruption of the

anterior cruciate ligament.

MEDICATIONS

Acute

▪ NSAIDs

SURGERY

▪ Complete ACL tears

▪ Reconstruction with neighboring patellar

ligament/semitendinosus tendon

▪ Eligibility: severity of symptoms, individual’s

future athletic ambitions

▪ Majority of individuals elect for surgical

repair

▪ Increased risk of osteoarthritis

OTHER INTERVENTIONS

▪ Rehabilitation: intensive physical therapy

Acute

▪ Rest, ice, compression of injured knee

TREATMENT

DIAGNOSTIC IMAGING

X-ray

▪ Rule out fractures (nondiagnostic for

ligament tears)

MRI

▪ Preferred modality to evaluate ligament

integrity

▪ Very high sensitivity, specifi city

Knee arthroscopy

OTHER DIAGNOSTICS

Physical inspection

▪ History: pivot sign (knee buckling

phenomenon, especially at heel strike

phase of walking cycle)

▫ Tibia’s ability to travel anteriorly (without

intact ACL) when knee is fl exed at

0–30°→ snaps back around 40°+ of

fl exion

▫ Underlying this phenomenon: role of

iliotibial band in knee extension, fl exion

at different degrees of knee position

Physical examination maneuvers

▪ Anterior drawer test

▫ Supine individual: affected leg fl exes

90°, foot rests on end of bed →

examiner sits on foot of affected leg (to

stabilize) → grasps around proximal

tibia with both hands → pulls anteriorly

on tibia → observes anterior movement

level

▫ Normal laxity: < 1cm/0.4in anterior tibial

subluxation; negative test, likely intact

ACL

▫ ↑ Laxity: > 1cm/0.4in; positive test, likely

torn ACL

▪ Lachman test

▫ Supine individual: knee fl exed around

20° → examiner fl exes knee → grasps

around proximal tibia with one hand

while stabilizing ipsilateral thigh with

other hand → pulls anteriorly on tibia →

observes anterior movement level

DIAGNOSIS ▫ Similar endpoints to anterior drawer test

▫ Best sensitivity (85%), specifi city (94%)

compared to other diagnostic tests

OSMOSIS.ORG

 Chapter 115 Lower Limb Injury

669

osms.it/IT-band-syndrome

ILIOTIBIAL BAND SYNDROME

▪ Painful overuse injury: fi brous band of

tissue connects muscles of proximal lower

extremity to lateral tibia

▪ Common injury for runners

CAUSES

▪ Iliotibial band (ITB): involved in knee

fl exion (at < 30°), knee extension at

terminal extension (near 0° fl exion); very

active in heavy activity → overuse causes

infl ammation

▪ Greatest tension across ITB occurs at 30°

▫ Runners: position of 30° at foot strike →

repeat → infl ammation, injury

▫ Cyclists: position of 30° at down-pedal

position → repeat → infl ammation,

injury

RISK FACTORS

Intrinsic

▪ Weak hip abductors/fl exors

▪ Gastrocnemius, soleus infl exibilty

▪ Leg length discrepancy

Extrinsic

▪ Sudden training distance/intensity increase

▪ Running: overstriding, foot eversion (poorly

fi tted/raised shoes)

▪ Cold weather exercise

PATHOLOGY & CAUSES

Knee pain

▪ Sharp/burning, worse during exercise at

knee fl exion of 30°

▪ Beyond exercise, pain may ache more/be

deeper

▪ Location: lateral femoral epicondyle (LPE)

SIGNS & SYMPTOMS

OTHER DIAGNOSTICS

Physical inspection

▪ History: Running/cycling with indolent

course of lateral knee pain with training

Physical examination maneuvers

▪ Noble compression test (examiner attempts

to recreate pain experienced during

training)

▫ Individual lays in decubitus position

with affected leg above unaffected →

examiner puts one thumb proximal to

LPE with pressure → examiner uses

other hand to passively move affected

about the knee from 0–60° fl exion →

pain → positive test

▪ Ober test

▫ Individual lies on uninvolved side →

fl exes hip, knee 90° → knee placed in 5°

fl exion angle → examiner fully abducts

lower extremity being tested → allows

force of gravity to adduct extremity until

hip cannot adduct any further

▪ Palpation of knee (check for no effusion)

▫ Rule out meniscal injury (lateral knee

pain, ⊕ effusion)

DIAGNOSIS

MEDICATIONS

Acute

▪ Analgesics (NSAIDs/acetaminophen)

SURGERY

▪ ITB release: individuals who have failed

long-term physical therapy program

OTHER INTERVENTIONS

▪ Exercise adjustment

▫ Address extrinsic risk factors

TREATMENT

670 OSMOSIS.ORG

Figure 115.4 An MRI scan in the coronal

plane of the right knee of individual

complaining of iliotibial band syndrome

symptoms. The band is infl ammed with

surrouding edema close to its point of

insertion.

osms.it/meniscus-tear

MENISCUS TEAR

▪ Injury to fi brocartilage (medial/lateral) knee

pads (provide cushion, increase stability at

tibiofemoral articulation interface)

CAUSES

▪ Pathophysiology: planted foot → twisting

force at knee → compressional, rotational,

shear stress placed on meniscus → tear

▫ Medial meniscus tears > lateral

meniscus tears

▫ Medial meniscus fi rmly attached to

medial collateral ligament (MCL) → ↓

mobility of medial meniscus → ↓ force

required to tear fi brocartilage

▫ Poor blood supply to meniscus via

geniculate arteries → poor healing/

PATHOLOGY & CAUSES

▫ Correct leg length discrepancy with

insole lift

▪ Physical therapy

▫ Address strength of hip abduction/

fl exion, calf infl exibility

Acute

▪ Rest, ice

regenerative capability post injury

Young, healthy athletes

▪ Forceful, sudden, decelerating movement

while changing direction

Elderly

▪ Chronic injury requires less torsional force

at knee

RISK FACTORS

▪ Soccer, basketball, American football

COMPLICATIONS

▪ Osteoarthritis

OSMOSIS.ORG

 Chapter 115 Lower Limb Injury

671

▪ Pain at time of injury

▪ Swelling within 24 hours

▪ Clicking/crepitus with walking/knee

extension

▪ Inability to fully extend/lock knee: occurs

in anterior meniscus tears > posterior

meniscus tears

SIGNS & SYMPTOMS

DIAGNOSTIC IMAGING

X-ray

▪ Non-diagnostic; commonly performed to

rule out knee fracture

MRI

▪ Most sensitive imaging modality for

detecting tears

▫ Medial meniscus: very high sensitivity,

specifi city

▫ Lateral meniscus: high sensitivity, very

high specifi city

▪ Indicated for surgical evaluation

▫ Prevalence of MRI-positive meniscal

tears in asymptomatic population

increases with age

OTHER DIAGNOSTICS

Physical inspection

▪ Joint line tenderness (at tibial-femoral

interface) because synovial capsule/

collateral ligament accompanies injury; less

sensitive/specifi c fi nding

▪ Joint effusion likely present

Physical examination maneuvers

▪ McMurray test: tests medial, lateral

meniscus

▫ Individual is supine with affected knee

fully fl exed → examiner grasps heel

with one hand, around tibial prominence

with other hand → exerts rotational

force while extending leg → evaluates

pain/click/palpable crepitus

▫ External rotation → medial meniscus

moves under femoral condyle

DIAGNOSIS

▫ Internal rotation → lateral meniscus

moves under femoral condyle

▫ Sensitivity (wide range), specifi city

(high–very high), ⊕ likelihood ratio (LR)

(4.0), ⊝ LR (0.6)

▪ Apley grinding test: tests medial meniscus

▫ Individual lays in prone position →

examiner fl exes affected knee to 90° →

rotates foot laterally → while stabilizing

thigh/femur (with examiner’s knee),

exerts downward force on tibia

▫ Pain: likely medial meniscal tear

▪ Thessaly test: tests medial, lateral meniscus

▫ Individual stands only on affected leg

while holding onto examiner for stability

→ fl exes knee to 20° → rotates knee,

body externally/internally

▫ Pain/locking/clicking: positive test

▪ Childress duck-waddle test: tests posterior

horn of medial/lateral meniscus

▫ Reserved for athletes fi t to complete

maneuver

▫ Individual squats, walks forward in

squatting position → knees are fl exed

fully → waddling steps exert posterior

pressure on knee

▫ Pain/clicking: positive test

Figure 115.5 An arthroscopic view of a torn

medial meniscus.

672 OSMOSIS.ORG

SURGERY

▪ Arthroscopic/open surgery

▪ Meniscectomy/repair determined by

amount of viable tissue intraoperatively,

individual’s timetable to return to sport/

activity

▫ Meniscectomy: faster timetable to

return to baseline activity; long-term ↑

osteoarthritis risk

TREATMENT

osms.it/patellar-tendon-rupture

PATELLAR TENDON RUPTURE

▪ Sudden, forced quadriceps contraction

against fl exed knee, fi xed foot

CAUSES

▪ Most common in individuals < 40 years old

involved in heavy training regimens/sport

▫ Landing from high jump, making sudden

changes in direction at high speed

▪ Traumatic injury (non-athletic): foot/leg is

stuck as individual falls backward

▫ Body weight falls backward → large

eccentric force on fi xed leg → force

transmitted to patellar tendon → rupture

▫ Knee typically fully fl exed when injury

occurs → exposes tendon to most stress

RISK FACTORS

▪ Recent glucocorticoid injection

▪ Sports with explosive jumping: basketball,

weightlifting

▪ Heavy training hours: > 20 per week

▪ Biologically-male individuals

COMPLICATIONS

▪ Tibial tuberosity avulsion fracture

▪ Patellar fracture/avulsion

PATHOLOGY & CAUSES

▪ Painful, popping sensation

▪ Immediate swelling

▪ Antalgic gait: inability to bear weight on

affected leg

SIGNS & SYMPTOMS

DIAGNOSTIC IMAGING

Bedside Ultrasound

▪ Assists bedside diagnosis

X-ray

▪ Evaluation of patellar positioning, potential

fracture/avulsion complication

MRI

▪ Reserved for unusual presentations:

constitutional signs that raise suspicion of

tumor

OTHER DIAGNOSTICS

Physical inspection

▪ Observation: upward shift of patella

(pathognomonic); swelling distal to patella

▪ Strength: inability to maintain straight leg,

raise leg against gravity while supine

DIAGNOSIS

OTHER INTERVENTIONS

▪ Rest: crutches for severe pain, avoidance of

positions/activities that exacerbate pain

▪ If knee commonly gives out: patellar

restraining brace; sign of poor quadriceps

strength

▪ Physical therapy

Acute

▪ Rest, ice

OSMOSIS.ORG

 Chapter 115 Lower Limb Injury

673

Figure 115.6 An MRI scan of the knee in

the sagittal plane demonstrating a patellar

tendon rupture

SURGERY

▪ Recommended within one week of injury

for improved outcomes

OTHER INTERVENTIONS

▪ Post-operative physical rehabilitation

TREATMENT

osms.it/patellofemoral-pain-syndrome

PATELLOFEMORAL PAIN

SYNDROME

▪ Common overuse disorder

▪ Anterior knee pain that cannot be attributed

to intra-articular (meniscus)/peripatellar

(patellar tendinopathy) pathology

CAUSES

▪ Multifactorial pathophysiology

Intrinsic, anatomical factors

▪ Leg length discrepancy

▪ Abnormal foot morphology

▪ Hamstring infl exibility

▪ Abnormal patellar mobility

▪ Hallux valgus

Extrinsic, athletic factors

▪ Exercise overload

PATHOLOGY & CAUSES RISK FACTORS

▪ Biologically-female individuals (2:1)

▪ Active individuals; teens–20s

▪ Amount of training (ex. distance run)

correlates with incidence of disease

▪ Anterior knee pain

▫ Worsened with training, knee extension,

especially with squatting, running

exercises

▫ May occur with prolonged sitting

▫ May be present for years

▪ Knee occasionally buckles/gives way

▪ Knee clicks/grinds: most evident when

climbing stairs

SIGNS & SYMPTOMS

674 OSMOSIS.ORG

OTHER DIAGNOSTICS

Physical inspection

▪ History

▫ Absence of traumatic inciting event

▫ Achy/sharp knee pain: typically below

patella

▪ Leg length discrepancy > 1cm/0.4in → poor

biomechanics when running → predisposes

individual to knee injury

▫ < 0.5cm/0.2in leg length discrepancy is

common → no increased risk of injury

Physical examination maneuvers

▪ Palpation

▫ Nontender patella, patellar tendon,

quadriceps tendon

▪ Tests

▫ Squatting: most individuals experience

pain

▫ Patellar glide with extended knee:

examiner moves patella laterally

▫ Lateral movement ↑ ¾ patellar width

abnormal

DIAGNOSIS

MEDICATIONS

Acute

▪ NSAIDs (naproxen): short-term use (2–3

weeks) recommended

OTHER INTERVENTIONS

▪ Lower extremity muscle strengthening

▪ Stretching: especially hamstrings

▪ Patellar bracing/taping

Acute

▪ Pain control: avoidance of painful exercise

(stair/hill running); substitution of less

stressful exercise (stationary bike exercises)

TREATMENT

osms.it/sprained-ankle

SPRAINED ANKLE

▪ Common ankle injury from foot hypereversion/inversion

TYPES

Lateral ankle sprain

▪ Most common

▪ Inversion of plantar-fl exed foot → stretches

ankle’s lateral ligament complex

▪ Lateral ligament: anterior talofi bular

ligament (ATFL), calcaneofi bular ligament,

posterior talofi bular ligament

PATHOLOGY & CAUSES Medial ankle sprain

▪ Infrequent injury

▪ Eversion of foot to medial deltoid ligament

complex

▪ Ligament strong enough that medial

malleolus fracture is more common than

ligament sprain

Syndesmotic sprain

▪ AKA high ankle sprain

▪ Injury to interosseous membrane between

tibia, fi bula

▫ Foot is dorsifl exed/ankle eversion

▪ Higher rate of injury in contact sports

(American football)

OSMOSIS.ORG

 Chapter 115 Lower Limb Injury

675

▪ Pain over lateral/medial ankle (depending

on eversion/inversion mechanism)

▪ Swelling hours after inciting event

▪ Inability to ambulate

SIGNS & SYMPTOMS

DIAGNOSTIC IMAGING

X-ray

▪ Evaluate for malleolar, distal fi bular, talar

dome fracture, syndesmotic separation

complication

OTHER DIAGNOSTICS

Physical inspection

▪ History

▫ Mechanism of foot inversion/eversion

▫ Prior ankle injuries

▫ Ability to walk after injury: correlates

with fracture complication

▪ Observation: swelling/ecchymosis

Physical examination maneuvers

▪ Palpation

▫ Fibula, distal tibia: syndesmotic injury

▫ Foot: lateral, medial surface for

evaluation of medial, lateral ligament

complex pain

▫ Thompson test: rule out achilles

pathology

▪ Maneuvers of passive inversion/eversion

(replicate pain)

▫ Squeeze test (syndesmotic evaluation):

examiner compresses fi bular against

tibia at level of mid-calf → pain in region

of ATFL → likely syndesmotic sprain

▫ External rotation stress test

(syndesmotic evaluation): examiner

stabilizes leg proximal to ankle →

grasps plantar aspect of foot →

externally rotated → pain in region of

ATFL → likely syndesmotic sprain

DIAGNOSIS

▪ Higher rate of chronic ankle sprains →

recurrent ankle sprains → ossifi cation of

interosseous membrane

▫ Anterior drawer test (ATFL integrity

test): individual places affected foot in

neutral position (slightly plantar-fl exed,

inverted) → examiner stabilizes lower

leg with one hand → grasps heel with

other while foot rests on examiner’s

anterior arm → anterior pull of foot →

↑ laxity of joint (vs. unaffected foot) →

likely lateral sprain, ATFL instability

▫ Talar tilt test (calcaneofi bular integrity

test): individual places affected foot in

neutral position → examiner grasps foot

→ passive inverts at ankle → ↑ inversion

of ankle (vs. unaffected side) → likely

lateral sprain, calcaneofi bular instability

MEDICATIONS

Acute

▪ NSAIDs

SURGERY

▪ Reserved for ligament rupture in setting of

chronic ankle instability

OTHER INTERVENTIONS

▪ Rehabilitation: physical therapy

Acute

▪ Rest: limit weight bearing, use crutches if

individual is unable to bear weight

▪ Ice

▪ Early application of compressive wrapping

→ ↓ swelling

▪ Elevation of ankle → ↓ swelling

TREATMENT

676 OSMOSIS.ORG

osms.it/unhappy-triad

UNHAPPY TRIAD

▪ Severe knee injury, typically after trauma,

that results in trio of ACL, medial collateral

ligament (MCL), lateral meniscus tears

CAUSES

▪ During contact sports, forceful blow to

posterolateral aspect of knee, with planted

foot (lower body tackle from behind in

rugby/American football)

▪ Pathophysiology: posterior force tears ACL

→ abnormal ↑ anterior glide of tibia relative

to femur → medial rotation of tibia → tear

of MCL with shearing force → further knee

instability → increased rotational force →

lateral meniscal tear

COMPLICATIONS

▪ Osteoarthritis

PATHOLOGY & CAUSES

▪ Pain

▪ Hemarthrosis

▪ Popping/multiple pops

SIGNS & SYMPTOMS

OTHER DIAGNOSTICS

Physical examination maneuvers

▪ ACL maneuvers

▫ Anterior drawer test

▫ Lachman test

▪ MCL maneuvers

▫ Examiner stabilizes affected leg with

one hand → exerts valgus stress on

lateral aspect of knee → pain and ↑

laxity → likely MCL tear

▪ Lateral meniscus maneuvers

▫ McMurray testing

DIAGNOSIS

MEDICATIONS

Acute

▪ NSAIDs

SURGERY

▪ ACL repair: athletes/ individuals who desire

return to play/demanding activity

▪ Lateral meniscus repair vs. meniscectomy

OTHER INTERVENTIONS

Acute

▪ Rest

▪ Ice

▪ Elevation/compression → ↓ swelling

▪ Knee brace: ACL, MCL recovery