Transcript Lower_Extremity_Soft_Tissue_Disorders

Overview
 Hip
 Trochanteric bursitis
 Iliotibial band syndrome
 Piriformis syndrome
 Meralgia paresthetica
 Knee
 Ankle & Foot
Quick Quiz
 How many bursae are located at the greater
trochanter?
 Three
 What gender is more affected by trochanteric bursitis?
 Female
Trochanteric Bursitis
 Most common cause of pain at the hip
 3 bursae: gluteus maximus most important
 Deep aching pain +/- burning sensation
 Lateral hip and thigh
 Worse with walking/climbing stairs
 15% have a limp
Trochanteric Bursitis
Trochanteric Bursitis
 More common in women
 Precipitators: local trauma, leg length discrepancies,
jogging
 Weeks to months
 Rest, NSAIDs, CS injection, surgery
 Failure to improve may be secondary to iliotibial
band syndrome
Trochanteric Bursitis
Quick Quiz
 What is the name of the this test used to diagnose
iliotibial band syndrome?
 Ober’s test
Iliotibial Band Syndrome
 Fascia connecting the ilium w/ the lateral tibia
 Repetitive flexion and extension of the hip
 Runners (“camber running”)
 Local tenderness at lateral femoral condyle
 Positive Ober’s test
 Reduce mileage, CS injection
Iliotibial Band Syndrome
Iliotibial Band Syndrome
Piriformis Syndrome
 History of traumatic injury to the sacroiliac and gluteal
region
 Pain in the region of the SI joint, greater sciatic notch,
and piriformis muscle
 Worse with lifting or stooping
 Palpable, sausage-like swelling of the muscle
 Irritation of sciatic nerve
Piriformis Syndrome
 Pace and Nagle sign
 Enlargement on MRI or CT scan
 Treatment includes:
 Rectal muscle massage
 Local CS injection
 Initiate piriformis muscle stretching
Piriformis Syndrome
Quick Quiz
 Name 3 common causes of meralgia paresthetica.
 Obesity, pregnancy, trauma, surgical injury, tight-
fitting clothes, and DM
Meralgia Paresthetica
 Entrapment syndrome - lateral femoral
cutaneous nerve
 Occurs primarily in adults
 Lateral aspect of inguinal ligament, medial to
anterior superior iliac spine
 Belts, tight fitting clothes, obesity, pregnancy,
diabetes, ascites, trauma/ surgery
 Burning pain/dysesthesia of anterolateral portion
of the thigh
Meralgia Paresthetica
Meralgia Paresthetica
 Smaller area of sensory deficit is common
 DDX: L2/L3 radiculopathy, spinal stenosis
 Treatment:
 Weight reduction
 Eliminate occupational trauma
 CS injection
 NSAIDs
 Neurolysis
 Epidural CS injection
 Ice
Overview
 Hip
 Knee
 Prepatellar bursitis
 Infrapatellar bursitis
 Anserine bursitis
 Pellegrini-Stieda disease
 Popliteal cyst
 Ankle & Foot
Quick Quiz
 According to Secrets, how do you differentiate
prepatellar bursitis from knee arthritis?
 Acute inflammatory arthritis results in loss of full
extension, whereas prepatellar bursitis pain is
increased with flexion. Thus, if an inflamed knee
demonstrates full extension w/out pain and a
negative bulge sign, the disease is likely extraarticular.
Prepatellar Bursitis
Prepatellar Bursitis
 Recurrent trauma
 Erythematous, well-circumscribed, fluctuance
over front of patella
 Trauma, gout, infection
 Aspiration
 Rest, avoidance of kneeling, NSAIDs
 Septic bursitis: rest, serial aspirations,
parenteral and then oral abx
 Surgery if no improvement
Prepatellar Bursitis
Infrapatellar Bursitis/Tendonitis
 “Parson’s knee”
 Overuse, trauma, infection, gout
 Pain at midpoint of patella tendon
 Same treatment as prepatellar bursitis
Quick Quiz
 The pes anserinus (“goose foot”) is the anatomic
location of the conjoined tendon of which muscles?
 Sartorius, gracilis, & semitendinosus
Anserine Bursitis
 Medial aspect of knee
 Deep to insertion of “pes anserinus”
 Superficial to medial collateral ligament
 Pain with climbing stairs
 Rest, NSAIDs, CS injection
Anserine Bursitis
Pellegrini-Stieda Disease
 Follows an injury to the MCL
 Most asymptomatic
 Pain over femoral insertion site
 X-rays: calcification of the insertion of MCL
 Calcification of hematoma
 Self limited
 Rest, NSAIDs, CS injection
Pellegrini-Stieda Disease
Popliteal Cysts
 Any age (child to adult)
 Communication between knee joint and
gastrocnemius-semimembranosus bursa at
medial head of gastrocnemius tendon
 “Pain and swelling at the back of the knee”
 Palpation at the back of the knee on extension
 Adult association with RA, OA
Popliteal Cysts
 Differential diagnosis:
 DVT, thrombophlebitis
 Popliteal artery aneurysm
 Ganglia
 Nerve sheath tumors
 Sarcoma
Popliteal Cysts
 US, CT, MRI
 Treatment in children is conservative: spontaneous
resolution
 Treatment in adults is aimed at underlying pathology
 Knee arthrocentesis and CS injection
Popliteal Cysts
Subgastrocnemius bursa and Baker's cyst in 58-year-old man
are seen on sagittal T2-weighted MR images (TR/TE,
4,500/99). Image in more lateral position than A shows fluid in
Baker's cyst (BC), superficially in relation to medial
gastrocnemius tendon (g), and also between capsule
(arrowheads) and gastrocnemius tendon in subgastrocnemius
bursa (s).
Overview
 Hip
 Knee
 Ankle & Foot
 Achilles tendinitis/bursitis
 Plantar fasciitis
 Tarsal tunnel syndrome
 Morton’s neuroma
Achilles Tendinitis
 Pain, swelling, tenderness +/- crepitus near
insertion site
 Thickening and irregularity of the tissues
surrounding the tendon; +/- palpable nodule
 Pain increased with passive dorsiflexion
 Repetitive trauma, microscopic tears due to
excess use of calf muscles; bad footwear
Achilles Tendinitis
 Spondyloarthropathies, gout, RA, familial
hypercholesterolemia
 US, MRI
 Rest, avoidance of provocative activties, shoe
modification, heel raise, NSAIDS, heat, splint
(plantar flexion)
 CS injections are discouraged
Achilles Tendinitis
Quick Quiz
 What is the name of the following physical exam test
that is used to test for an Achilles tendon rupture?
 The Thompson Test
Achilles Bursitis
 RA, Psoriatic arthritis, AS, Reiter’s, gout, trauma
 Overuse: ballet dancers, runners; tight shoes
 Pain at posterior heel, painful dorsiflexion
 Local swelling with “bulge” on medial and lateral
aspects of tendon
 Rest, activity modification, moist heat, heel
elevation, NSAIDS
Quick Quiz
 What name is given to the following exam finding,
which may be confused with a RA nodule?
 “Pump bumps”
Achilles Bursitis
Plantar Fasciitis
 Repetitive microtrauma
 Pain often worse after period of rest
 Localized tenderness at anteromedial surface of
calcaneus
 Obese, middle-age, elderly
 Change in shoe-wear, change in walking surface,
enthesopathy
 Weight reduction, rest, hot soaks, NSAIDS, heel
cup, CS injection
Plantar Fasciitis
Plantar Fasciitis
Tarsal Tunnel Syndrome
 Entrapment neuropathy of posterior tibial nerve
 Tarsal tunnel: fibro-osseus canal
 flexor retinaculum
 vascular structures
 tendons of flexor hallucis longus, flex
digitorum longus
Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome
 Bone deformities, pressure from casts, RA, diabetes,
ganglia, synovial cysts, flexor tenosynovitis
 Paresthesias & pain in toes, sole, heel, may travel to
calf
 +/- relief with walking, pain worse at night
Tarsal Tunnel Syndrome
 Tenderness with palpation of nerve posterior to
medial malleolus
 Vasomotor changes
 Electrodiagnostic studies
 CS injection, NSAIDs, orthotics, surgical
decompression
Morton’s Interdigital Neuroma
 Entrapment neuropathy of interdigital plantar nerve
 3rd & 4th metatarsal heads > 2nd & 3rd
 Chronic irritation  neuroma
 Transverse tarsal ligament
Morton’s Interdigital Neuroma
Quick Quiz
 Compression of a Morton’s neuroma can cause the
“neuromatous” mass to slip, producing a palpable
click. What is the eponym given to this click?
 Mulder’s Click
Morton’s Interdigital Neuroma
 Unilateral, mid-age women
 Lancinating, burning, neuralgic pain radiating
from web space to toes
 Tight shoes, hard surfaces, prolonged standing
exacerbate pain
 Tenderness over interspace between metatarsal
bones, +/- tender nodule
 Proper footwear, metatarsal pads, CS injection,
surgery
Shin Splints
 Medial tibial stress syndrome
 Repetitive running on hard surfaces or repetitive
forcible foot dorsiflexion
 Medial tibial pain at beginning of exercise
 Pain may become persistent
 3-6 cm tender area on postero-medial, distal tibia
 Bone scan: posteromedial tibial cortex uptake
Shin Splints
Questions?