Clinical challenges of the leg

1
Clinical challenges of the leg
2
Part 1 the knee area

• 5 scenarios with extended matching answers.
  Please select the answer which best fits the
  scenario.

3
Scenario 1

• Jane Green, a PE teacher at the local secondary
  school, aged 42, comes to see you complaining
  that her Rt knee has started to let her down. In
  her youth, she represented her county in
  athletics, especially long jump. She stopped aged
  25 due to an injury. She has recently joined a
  ladys netball team, and wonders if this has
  caused her knee problem. There is no knee
  swelling or tenderness on examination of the knee.

4
Whish is the most likely diagnosis?

• A osteoarthritis knee
• B Osgood Schlatters disease
• C - Anterior Cruciate ligament tear
• D Patellar tendonitis
• E meniscal tear
• F Chondromalacia patellae
• G pre-patellar bursitis
• H Partially dislocated knee cap

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Answer Q1 ACL tear

• An ACL tear is most often a sports-related
  injury.
• ACL tears can also occur during rough play, mover
  vehicle collisions, falls, and work-related
  injuries.
• About 80 of sports-related ACL tears are
  "non-contact" injuries. This means that the
  injury occurs without the contact of another
  athlete, such as a tackle in football.
• Most often ACL tears occur when pivoting or
  landing from a jump. The knee gives-out from
  under the athlete when the ACL is torn.
• Female athletes are known to have a higher risk
  of injuring their anterior cruciate ligament, or
  ACL, while participating in competitive sports.
  Unfortunately, the reasons for this are not
  clearly understood.

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Answer Q1

• Athletes often have particular difficulty once
  they have sustained an ACL injury. Many sports
  require a functioning ACL to perform common
  maneuvers such as cutting, pivoting, and sudden
  turns.
• These high demand sports include football,
  soccer, basketball, and others. Patients may be
  able to function in their normal daily activities
  without a normal ACL, but these high-demand
  sports may prove difficult. Therefore, athletes
  are often faced with the decision to undergo
  surgery in order to return to their previous
  level of competition.

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ACL tear - Rx

• Surgery may be necessary to repair the tear

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Scenario 2

• Richard Simms, aged 37, comes to see you with a
  knee problem. He has recently been starting to
  play a bit of football in the back garden with
  his 4 year old son, and has started to get some
  pain and occasional swelling in his Lt knee. He
  used to play a lot of football in his youth, but
  gave up when he got married 8 years ago. He has
  also noticed that his knee sometimes locks so
  that he is unable to straighten it.

9
Whish is the most likely diagnosis?

• A osteoarthritis knee
• B Osgood Schlatters disease
• C - Anterior Cruciate ligament tear
• D Patellar tendonitis
• E meniscal tear
• F Chondromalacia patellae
• G pre-patellar bursitis
• H Partially dislocated knee cap

10
Causes of meniscal tears

• The two most common causes of a meniscus tear are
  due to traumatic injury (often seen in athletes)
  and degenerative processes (seen in older
  patients who have more brittle cartilage).
• The most common mechanism of a traumatic meniscus
  tear occurs when the knee joint is bent and the
  knee is then twisted.

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Signs / symptoms of meniscal tear

• Knee pain
• Swelling of the knee
• Tenderness when pressing on the meniscus
• Popping or clicking within the knee
• Limited motion of the knee joint

12
Meniscal tears

• Individuals who experience a meniscus tear
  usually experience pain and swelling as their
  primary symptoms.
• Another common complaint is joint locking, or the
  inability to completely straighten the joint.
  This is due to a piece of the torn cartilage
  physically impinging the joint mechanism of the
  knee.

13
More complex injuries

• It is not uncommon for the meniscus tear to occur
  along with injuries to the anterior cruciate
  ligament (ACL) and the medial collateral ligament
  (MCL)-these three problems occurring together are
  known as the "unhappy triad," which is seen in
  sports such as football when the player is hit on
  the outside of the knee.

14
Rx of meniscal tears

• Surgery may be required to remove
  arthroscopically bits of torn meniscus and
  debris, or repair of the torn meniscus

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Scenario 3

• Harry Thomas, aged 14, has had pains in his legs,
  just below the knees, intermittently for a few
  months. They have become worse recently, and are
  affecting his ability to play football for the
  school team. His parents are very concerned there
  is something serious wrong.

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Whish is the most likely diagnosis?

• A osteoarthritis knee
• B Osgood Schlatters disease
• C - Anterior Cruciate ligament tear
• D Patellar tendonitis
• E meniscal tear
• F Chondromalacia patellae
• G pre-patellar bursitis
• H Partially dislocated knee cap

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Osgood Schlatter disease

• Osgood-Schlatter disease is a common condition in
  children often referred to as growing pains of
  the knees.
• Osgood-Schlatter disease is the result of rapid
  growth and pulling of the tendons around the
  growth plate of the knee in adolescents.
• The large quadriceps muscle of the front of the
  thigh attaches to a bump over the front of the
  shin bone. When this large muscle contracts, it
  pulls on this tendon.
• Over time, repetitive pulling, combined with the
  growth taking place in the bone, causes
  irritation of the growth plate.
• Osgood-Schlatter is most common in active
  adolescents.

18
Rx options

• Rest. - This injury needs rest if it is to heal
  properly.Only doing as much exercise as it will
  allow without causing pain.Weight bearing
  exercise will make it worse. Keep sessions few
  and high quality rather than training every day.
   
• Apply icetherapy to the knee regularly throughout
  the day to reduce pain and inflammation and
  particularly following activity or sport. Ice
  should be applied at least three times a day for
  10 to 15 minutes. Ice massage with an ice cube is
  a convenient way to apply cold therapy to a
  specific area such as the patella tendon.
• Gently stretch the quad muscles if comfortable to
  do so.
• Use a knee support or knee strap to help reduce
  the tension on the knee.

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Scenario 4

• Gary Brooks, aged 55, took early retirement from
  the Police Force 3 years ago, and now does some
  voluntary work part-time maintaining the gardens
  of Stratton House. He has recently had a lot of
  pain in his Rt knee, and is finding it difficult
  to kneel on it to plant the autumn bedding plants
  in the borders. His knee feels swollen and tender.

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Whish is the most likely diagnosis?

• A osteoarthritis knee
• B Osgood Schlatters disease
• C - Anterior Cruciate ligament tear
• D Patellar tendonitis
• E meniscal tear
• F Chondromalacia patellae
• G pre-patellar bursitis
• H Partially dislocated knee cap

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Prepatellar bursitis

• Prepatellar bursitis, or Housemaid's Knee
  Syndrome, is a condition of swelling and
  inflammation over the front of the knee.
• This is commonly seen in patients who kneel for
  extended periods, such as carpet layers and
  gardeners.

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Rx

• The management of prepatellar bursitis depends on
  its aetiology.
• When considering management, cases need to be
  separated into septic and non-septic bursitis.
• According to one study, patients with septic
  bursitis usually presented earlier and had more
  pain, erythema, warmth and tenderness and some
  had mild fever (37.5C maximum recorded).
• Clinical features alone could not identify all
  the septic cases, so a low threshold is needed
  for performing, or referring for, aspiration.

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Non septic bursitis

• Conservative treatment
• Rest, Ice, Patient education about the condition
  and its aetiology.
• A thick foam cushion, or knee pads, to kneel on
  can help prevent recurrence. Occupational therapy
  referral may be helpful.
• Physiotherapy referral may be helpful if there is
  reduced range of movement in the knee joint. A
  stick or cane may be needed to aid walking.
• Medical treatment
• Aspiration of the prepatellar bursa and injection
  of a corticosteroid infection must be excluded
  prior to this. Complications should be discussed
  with the patient, including infection,
  subcutaneous atrophy, bleeding and patellar
  tendon rupture. Hydrocortisone may be used.
• Non-steroidal anti-inflammatory drugs
  (NSAIDs),these can be used for mild-to-moderate
  pain and to reduce inflammation
• Surgical treatment This may be needed if
  prepatellar bursitis is chronic or recurrent.
• Arthroscopic bursectomy this can be performed
  under local anaesthetic on an outpatient basis.
  The cosmetic effect is better than open
  bursectomy.
• Open bursectomy the traditional open surgical
  approach of excising the bursa.

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Septic bursitis

• Aspiration this should be performed to confirm
  septic bursitis as detailed in the investigations
  above. Guidance on diagnosis can be obtained
  rapidly from the aspirated fluid white cell count
  whilst waiting for culture results. Care must be
  taken here because, if the knee joint is opened,
  septic arthritis will ensue.
• Antibiotic therapy if septic bursitis is
  suspected and whilst waiting for confirmatory
  culture results, start antibiotics. Intravenous
  antibiotics should be used if the patient is
  systemically unwell. Cephalosporins or
  penicillinase resistant penicillins (eg
  augmentin), or a combination of penicillin V and
  flucloxacillin may be prescribed but may need to
  get advice from local microbiologist.
• Incision and drainage if symptoms of septic
  bursitis have not improved significantly within
  36-48 hours of antibiotic treatment, incision and
  drainage is usually performed.

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Scenario 5

• Jodie Fletcher, aged 17, comes in about her knee
  pain. She has just started sixth form college,
  and is getting pain in her left knee, especially
  when she goes up and down stairs. She hasnt had
  these problems until now. She wonders if it is
  related to the fact that the college is on 4
  floors, and due to the high number of students,
  most use the stairs rather than the lifts. She
  did had an injury to her Lt knee when she fell
  off a wall at the age of 5 years.

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Whish is the most likely diagnosis?

• A osteoarthritis knee
• B Osgood Schlatters disease
• C - Anterior Cruciate ligament tear
• D Patellar tendonitis
• E meniscal tear
• F Chondromalacia patellae
• G pre-patellar bursitis
• H Partially dislocated knee cap

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Chondromalacia patellae

• The most common disorder of the kneecap area is
  known as chondromalacia, often called Runner's
  Knee.
• Chondromalacia occurs because of irritation of
  the cartilage on the undersurface of the kneecap.

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Chondromalacia patellae

• Chondromalacia patella is the softening and
  breakdown of the tissue (cartilage) that lines
  the underside of the kneecap (patella).
• It is a common cause of anterior knee pain.
• Chondromalacia of the patella occurs in
  adolescents and young adults.
• The condition is more common in females. It can
  be related to the abnormal position of the knee.

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Problems begin when the kneecap does not move
properly and rubs against the lower part of the
thigh bone. This may occur because

• The kneecap is in an abnormal position (also
  called poor alignment of the patellofemoral
  joint)
• There is tightness or weakness of the muscles on
  the front and back of the thigh
• The patient is doing too much activity that
  places extra stress on the kneecap (such as
  running, jumping or twisting, skiing, or playing
  soccer)
• The patient has flat feet

30
Chondromalacia patellae

• Chondromalacia of the patella can also be a sign
  of arthritis of the kneecap, which is usually
  seen in older people.
• People who have previously had a dislocation,
  fracture, or other injury to the kneecap are more
  likely to develop chondromalacia.

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Symptoms of chondromalacia patellae

• A grating or grinding sensation when the knee is
  flexed (moved so that the ankle is brought closer
  to the back of the thigh)
• Knee pain in the front of the knee that occurs
  when getting up after sitting for a long period
  of time
• Knee pain that worsens with use of stairs or
  getting out of a chair
• Knee tenderness

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Signs and tests

• On physical examination
• The knee may be tender and mildly swollen, and
  the kneecap may not be perfectly lined up with
  the femur.
• When the knee is flexed, there may be a grinding
  sensation below the kneecap.
• Pressing the kneecap when the knee is
  straightening out may be painful.
• X-rays are usually normal, although a specific
  x-ray view of the kneecap may show signs of
  arthritis or tilting.

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Rx

• Temporarily resting the knee and taking
  nonsteroidal anti-inflammatory drugs (NSAIDs may
  help the pain
• Physical therapy, especially quadriceps
  strengthening and hamstring stretching, may be
  helpful. Stronger muscles will help hold the
  kneecap in the correct position.
• If needed, weight loss may be helpful.
• Changing exercise may help
• Avoiding running straight down hills walking
  down instead.
• Bicycle or swim, instead of running.
• Reduce the amount of exercise taken.
• Run on a smooth, soft surface such as a track,
  rather than on cement.
• Other techniques areSpecial shoe inserts and
  support devices (orthotics) may help people with
  flat feet.Taping to realign the kneecap may help
  prevent problems, good quality running shoes etc.

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Part 2 disorders around the hip area
35
Disorders around the hip

• Trochanteric Bursitis/Pain syndrome
• Ischial bursitis
• Ilio-psoas bursitis
• Pyriformis syndrome
• Sacro-iliac dysfunction
• OA hip
• Meraligia paraesthetica
• Slipped upper femoral epiphysis
• Referred from Lumbar spine
• Ilio-inguinal nerve entrapment

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Question 1

• A 48 year old lady comes to see you limping with
  pain in the left hip. It came on after a car
  journey in her sons 2-seater sports car, is
  painful on rising from sitting, after walking for
  a while and to lie on it for any length of time.
• What is the single most likely diagnosis?

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Disorders around the hip

• Trochanteric Bursitis/Pain syndrome
• Ischial bursitis
• Ilio-psoas bursitis
• Pyriformis syndrome
• Sacro-iliac dysfunction
• OA hip
• Meraligia paraesthetica
• Slipped upper femoral epiphysis
• Referred from Lumbar spine
• Ilio-inguinal nerve entrapment

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Question 2

• Mr Farah, 34yrs, is a keen runner but has
  recently been training on sand to save stress on
  his knees. He is having increasing pain in the
  back of the hip when getting out of bed, when
  lying on that side and when pushing the leg back
  in a stride. He finds your waiting room chairs
  uncomfortable to sit on.
• What is the single most likely diagnosis?

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Disorders around the hip

• Trochanteric Bursitis/Pain syndrome
• Ischial bursitis
• Ilio-psoas bursitis
• Pyriformis syndrome
• Sacro-iliac dysfunction
• OA hip
• Meraligia paraesthetica
• Slipped upper femoral epiphysis
• Referred from Lumbar spine
• Ilio-inguinal nerve entrapment

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Question 3

• Mr Henry, a highly paid accountant, with a
  healthy-looking wallet in his back pocket has
  been inspired by the olympics to take up exercise
  and has majored on cycling and rowing at the gym.
  He is now getting not only pain deep in the back
  of the right hip , but after walking for a while
  it spreads to his posterior thigh and calf with
  some tingling in his sole. He has no back pain
  and you are surprised to find his Pace test is
  positive on examination.
• What is the most likely diagnosis?

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Disorders around the hip

• Trochanteric Bursitis/Pain syndrome
• Ischial bursitis
• Ilio-psoas bursitis
• Pyriformis syndrome
• Sacro-iliac dysfunction
• OA hip
• Meraligia paraesthetica
• Slipped upper femoral epiphysis
• Referred from Lumbar spine
• Ilio-inguinal nerve entrapment

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Question 4

• Claudette, 54 yrs, has come back to see you for
  the results of her ultrasound scan of the left
  groin (which have excluded a recurrence of her
  repaired hernia) walking in partially stooped
  over to the left. She had noted a swelling and
  sharp pain there and the anterior hip and
  anterior/medial thigh which is now pretty
  constant and it is worse when she actively flexes
  or passively extends the hip. The pain used to
  occur only after walking for a bit. The site of
  her hernia repair has become numb/ tingling. You
  find her Ludloff sign is definitely positive.
• What is the most likely diagnosis?

43
Disorders around the hip

• Trochanteric Bursitis/Pain syndrome
• Ischial bursitis
• Ilio-psoas bursitis
• Pyriformis syndrome
• Sacro-iliac dysfunction
• OA hip
• Meraligia paraesthetica
• Slipped upper femoral epiphysis
• Referred from Lumbar spine
• Ilio-inguinal nerve entrapment

44
Question 5

• Colin, 41 yrs, has had a limp for as long as he
  can remember. He had a lot of knee pain as a
  teenager after a rugby injury, and has always
  walked with this foot in external rotation. He
  has come back to see you in your trainers absence
  with the results of an X ray showing significant
  abnormality of the left hip and quite gross
  arthritis, but a normal right side.
• What is the most likely primary diagnosis?

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Trochanteric Bursitis

• Bursa irritated between the femoral trochanteric
  process and the gluteus medius/iliotibial tract
• Trauma/ hip surgery/ repetitive movement/
  spontaneous
• Point tenderness over gt. Trochanter
• FemaleMale 41. Incidence 2/1000 in primary
  care
• Pain on rising from sitting
• painful to lie on
• Rx- injection/ NSAID/ Physio

46
The below are avoided best by core stability
exercises ( physio)(1)

• It is important to isolate the exact muscles for
  the desired effect. If the whole tummy is tensed
  up the stability muscles do not strengthen up
  well.
• It is only necessary to tense the muscles up to
  about 25-30 of their maximum capacity to get the
  best effect. So trying very hard when doing these
  exercises is not helpful.
• All the exercises are held for 10 seconds each
  time and done 10 times each - a total of 100
  seconds. Three times a day is enough initially.
• Exercise One
• Lie on your front in a relaxed position. Tighten
  up the pelvic floor as if you are trying to stop
  yourself passing water, then imagine there is
  something hot under your tummy and try and draw
  it to your backbone. Do not tense up the chest or
  lift your hips off the surface. Once you have
  this, remember to keep breathing normally, not
  fast or particularly deep breaths.

47
core stability exercises ( physio)(2)

• Hold for ten seconds then relax. Give yourself a
  short time to recover then repeat the process
  until you have done it ten times. You will find
  that when you breathe the muscles will tend to
  slacken, and when you tighten the muscles youll
  stop breathing. Work steadily until you can do
  both easily at the same time.
• Exercise Two
• You may need guidance from a physical therapist
  to do these correctly
• Lie on your back with your knees bent. Gently
  tense up the pelvic floor again as this usually
  tenses up the correct muscles in the abdomen. You
  can add a gentle drawing down of the tummy button
  towards the spine. Breathe normally as before and
  hold for ten seconds each time.
• Exercise Two - first progression. Tense up the
  muscles as in exercise two. Hold the muscles
  tense and your pelvis stable while you let one
  bent leg gently out to one side a short way and
  back. Repeat with other. Five each.

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core stability exercises ( physio)(3)

• Exercise Two - second progression. Hold as in the
  previous exercise, then lift one foot an inch off
  the floor only, and hold. Try and allow no
  movement apart from the small leg lift. Five each
  leg.
• Exercise Two - third progression. Tense up the
  muscles and hold. Bend the left leg up towards
  the chest, reach out with the right arm and
  gently push against the left thigh, holding 10
  seconds. Alternate for five each leg.
• Standing and sitting
• By now you should be able to tense the correct
  muscles in standing and sitting and may not need
  to lie down to practice them anymore. You can
  also tense them up when doing stressful
  activities such as lifting a suitcase or whatever
  the particularly difficult movement is for you.
  Do them many times every day for the greatest
  benefit.
• If you want to go to an exercise class which will
  help this problem, then Pilates is the best
  choice.

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Hip Adductor Strains

• groin pain is the most common finding.
• quadriceps strain, adductor tendonitis are the
  most common
• Tenderness to palpation
• Rest, physio /- NSAID

50
Less commonly.
Ilio-psoas bursitis and Tendonitis

• Iliacus
• Ilio-psoas
• are essentially identical in terms of
  presentation and management. due to their close
  proximity.

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- Bursitis

• associated with hip pathology (eg, rheumatoid
  arthritis, osteoarthritis)
• recreational injury (eg, running).
• anteromedial side of the thigh to the knee pain
• extension, adduction, and internal rotation of
  the hip ? pain
• pain worsens slowly over weeks or months
• Tenderness may occur anteriorly below the middle
  of the inguinal ligament and lateral to the
  femoral artery.
• Occasionally, a palpable mass
• Retroperitoneal extension (groin and pelvic
  complications)

52
Tendonitis

• Acute trauma and overuse resulting from
  repetitive hip flexion.
• insidious onset (36 months) of anterior hip or
  groin pain extends towards the knee
• Aggravating activity with resolution soon
  thereafter?pain all the time
• Reports of an audible snap or click in the hip or
  groin
• hip may be held in slight flexion and external
  rotation
• shortened stride length and anterior pelvic tilt
• femoral triangle and lesser trochanter tender
• Sitting, knee extended and subsequent elevation
  of the heel on the affected side. Pain (Ludloff
  sign) iliopsoas is the sole hip flexor activated
  in this position.
• snapping hip sign affected hip in a flexed,
  abducted, and externally rotated, then passively
  move the hip into extension
• Treatment - Rest, physio /- NSAID

53
Ischial Bursitis

• See diagram
• Sitting on hard surfaces/ Cycling
• Palpable tender point deep in buttock
• Pressure relief/ NSAID/ Physio/ Injection/
  Attention to aggravating seating

54
Piriformis syndrome

• Uncommon
• Posterior hip pain may extend to L5 and S1
  neuritis sx
• Worse on lifting affected leg when lying on the
  contralateral thigh (Paces test resisted ext
  rotation/ abduction)
• Point tenderness (lateral border of sacrum gt
  trochanter
• Physio/ stretches and correction of gait

55
Sacro-iliac dysfunction

• Worse with age
• Osteoarthritis, During pregnancy, some other
  problem which alters the normal walking pattern,
  inflammatory arthritides, infection (rare)
• worse with standing and walking and improved when
  lying down.
• Pain may also be present in the groin and thighs
• Tender over SI ligaments

• Differential Ligament strains, A/S (rare) and
  infection (staph. rare)
• Rx physio, analgesics/ nsaid/ injection

56
OA hip

• 50 unless congenital deformity/ avasc necrosis
• Stiffness as well as pain
• Referral of pain to knee but no further
• Tender to internally rotate first
• Pain is predictor of need for intervention esp.
  disturbed sleep
• Differential capsulitis as well as the above
• Cycle of inflammation-cartilage loss-bony
  growth(osteophytes)-stiffness and pain
• Family history
• Rx analgesics (pulses of NSAID), injection
  (specialist), resurfacing, replacement
• Keep walking

57
Slipped Upper Femoral Epiphysis

• BoysgtGirls (31)
• 10-14 years
• 30 bilat
• Leg held in flex/ lateral rotation
• Obesity and delayed puberty
• Knee pain only in some
• X-ray confirms

58
Acetabular Labral Tear

• Degenerative/ inflammatory arthritis
• after twisting injury when weight-bearing/
  repetitive injury.
• Pain in anterior hip or groin. Stiffness locking,
  clicking or catching sensation in hip limited
  range of motion in your hip joint
• Sometimes no pain symptoms

Diagnosis arthroscopy or MRI Rest, physio,
analgesia and arthroscopic rx if persists more
than 4/12
59
Stress Fracture

• Femoral Neck
• Up to 1.5 athletes (new recruits/ poor training)
• Females more common - osteoporosis
• Deep hip pain worse at all extremes of passive
  movement
• Worsens progressively ? avascular necrosis

60
Referred pain from lumbar spine

• Common
• Quality of pain (Kelgren) referred versus
  radiculitis/ radiculopathy (L5 lateral, S1
  posterior, L1 and 2 anterior)
• Some association with back pain
• Usually, like OA, worse after sitting/ lying.
  Referral below knee
• Usually no neurology
• Examination FROM hip, No point tenderness

61
Nerve Entrapment

• Pain/ Paraesthesiae/ hyperaesthesia/ numbness
• Anterior Obturator Nerve ( medial groin/ anterior
  leg with some assoc weakness of jumping on
  exercise stretches and physio
• Ilio-inguinal ( operations and tears of lower
  abdo muscles ? inguinal and supro-pubic sx)
• Genito-femoral (sx below ing canal and on
  anterior aspect of hip)
• Lateral Femoral Cutaneous (Meralgia
  Paraesthetica)
• As well as physio, NSAID, local injections and
  anti-neuropathic meds OK

62
Medical Causes to bear in mind

• BONE Sacro-iliac joint instability,
  osteomyelitis, pelvic stress fracture, metastases
• INGUINAL Lymphadenopathy, aneurysm, hernia (
  inguinal or femoral)
• GENITALTesticular cancer, epididymitis,
  varicocoele
• ABDOMINAL Appendix, prostatitis, ovarian tumour

63
Story

• Onset
• Sudden Muscular, labral tear, capsular strain,
  SUFE,
• Gradual OA, Bursitis, tendonitis
• Site
• Anterior OA, Adductor strain, Ilio-psoas(bursa
  and tendon), labral tear, nerve entrapment
• Posterior Sacro-iliac, Piriformis, Lumbar
  referal
• Lateral Nerve entrapment, OA, Trochanteric
  bursa, lumbar referal
• Radiation
• Knee Around Hip or back
• Below knee Back (remember referred and
  radicul-itis/-opathy)
• Sensory / Motor sx
• Nerve entrapment, radicular involvement
  neuralgic pain
• Type of Pain
• Non-mechanical (medical causes)
• Mechanical all the others
• Etc

64
Examine

• Gait watch carefully flexed (?), antalgic
• Passive/ Active movement flex, extend, abduct,
  adduct and rotate
• Remember 90 degree flexion and internal rotation
  pain with capsulits, OA, SUFE, labral tear etc
• Lateral, anterior and posterior palpation
• Turn patient on side and think of the back too.
• If any suspicion check the neuro.
• If it doesnt add up remember referred,
  entrapment, radicular and medical causes

65
Pain around the hip
Always be prepared to reconsider or re-examine.
66
Part3 disorders of the foot and ankle area
67
Which are common causes of ankle pain at 1)
front outside aspect 2) back inside aspect 3)
back outside aspect?

• a) Tarsal Tunnel Syndrome
• b) Subtalar Disease
• c) Sinus Tarsi syndrome
• d) Sural nerve trapping
• e) Peroneal tendon dysfunction
• f) Tibialis posterior tendon dysfunction

68
Which of the following cause pain below the heel

• a) Achilles tendonitis
• b) Atrophy of fat pad
• c) Retrocalcaneal bursitis
• d) Plantar fasciitis

69
Simmonds Test True or false

• a) Is used to diagnose Achilles tendon rupture
• b) Is done with the patient standing upright
• c) The calf of the non-affected leg is squeezed
• d) If the tendon is in tact the foot will
  dorsiflex

70
For reactive arthritis of the ankle following
chlamydial infection, what is the recommended
treatment?

• a) Colchicine
• b) NSAIDs and Fluconazole
• c) NSAIDs and Doxycylcine
• d)Oral prednisolone
• e) Steroid injection

71
39 yr female, progressive pain left heel 3/52
since started running, under plantar aspect of
heel, worst in the morning easing with
activity?a)Sinus Tarsi Syndromeb)Plantar
Fasciitisc)Goutd)Achilles tendonitis