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.