Lower Extremity Injuries Corinne Gratson, M.S., PA-C

1. Lower Extremity InjuriesCorinne Gratson, M.S., PA-C

2. Hip/Pelvis Injuries • Hip made up from head of femur (“ball”) & acetabulum (“socket”) of pelvis • Muscles: -Flexors (Iliopsoas, sartorius, rectus femoris) -Extensors (Glute Max, hamstrings) -Abductors (Glute Med, glute min) -ADDuctors (gracilis, pectineus, adductor longus, adductor brevis, adductor magnus)

3. Hip/Pelvis • Nerves: -Femoral (hip flexors) -Obturator (ADDuctors) -Superior Gluteal (Abductors) • Ligaments: -Sacroiliac (sacrum to ilium) -Sacrotuberous (sacrum to ischial tuberosity) -Sacrospinous (sacrum to ischial spine)

4. Ortho Evaluation • Inspection • Palpation • Bony & soft tissue • ROM • Active, passive, resistive • Strength – resistive ROM • Neuro/vascular • Special tests

5. Hip/Pelvis • Always check ABOVE & BELOW joint of injury (so this would mean what?) • Standing Inspection -check iliac crest heights (asymmetry = poss. leg length discrepancy) -look for muscle atrophy • Gait Inspection -Observe for asymmetry R/L -Antalgic Gait – shortened stride, decreased stance phase on affected leg -Trendelenburg Limp – look for pelvic tilt during stance phase (+ sign when pt. leans toward affected side)

6. Hip/Pelvis • Supine Inspection -Leg Length Discrepancy (anyone know how?) -Compare AROM/PROM Flex: 110-120º Ext: 10-15 ABD: 45-50 ADD: 20-30 Int Rot: 15-45 Ext Rot: 40-65

7. Hip/Pelvis • Osteoarthritis S/Sx: pain in AM, stiffness, deep groin pain; pain w/hip flexion & int. rot.; pt. presents w/decreased AROM/PROM XR: Joint space narrowing, osteophytes Tx: NSAIDs, PT, eventually will need hip replacement

9. Hip/Pelvis • Greater Trochanteric Bursitis S/Sx: lateral hip pain, tender to palpation @ greater trochanter, pain w/resisted hip ABduction Tx: Ice, NSAIDs, Steroid Injection

11. Hip/Pelvis • Buttock/Posterior Hip Pain -Indicates lumbar spine abnormality until proven otherwise -Radicular pain produced by deep palpation of sciatic n. differentiates sciatica from intra-articular abnormality -Test: pt. in lateral decubitus, flex hip & knee to 90º, palpate n. midway b/t greater troch & ischium

12. Hip/Pelvis • Labral Tears/Femoroacetabular Impingement -Young, athletic pt’s -Groin pain during/after activity -Impingement is premature and improper collision or impact between the head and/or neck of the femur and the acetabulum = PAIN -Reproduce: hip flexion w/internal rotation -XR may be normal -MRI confirms -R/O Inguinal Hernia

13. Hip • Femoral Avascular Necrosis -Osteonecrosis, death of femoral head -Legg-Calve’-Perthes Disease in peds

14. Hip

15. Hip • AVN: Bimodal (20-40) (6-10), equal male/female; approx 2.5% of THA’s due to AVN • Risk Factors: femoral neck fx, steroid use, EtOH, sickle cell, clotting abnl., “bends”, ionizing radiation, pancreatitis, gout; genetics-poss. relation to clotting disorder w/protein S deficiency

16. Hip • AVN S/Sx: Pain in hip w/out prior trauma, groin pain; usually vague pain 4-6 months prior to eval; pain w/Int. Rot. of hip PE: Groin pain w/ROM (int. rot.); limps; normal neuro exam; combo of H&P Dx: XR (look for crescent), MRI Tx: All eventually need surgery (core decompression, osteotomy, vascularized fibular graft, nonvasc. Bone graft, THA; PT/OT

17. Hip • Special Tests • Faber (Patrick’s): Flex, ABD, ER; (+) hip or SI jt. pain • SI Joint Compression/Distraction: Supine (compression), supine/side lying (distraction); (+) pain • Gaenslen’s: Supine @ edge of table, near leg over edge, opposite leg in flexion; apply pressure to near leg; (+) pain in ipsilateral SI joint • Trendelenburg: Pt stands on one leg, WB leg is involved leg; the PSIS or iliac crest on the same side as the leg lifted will drop in relation to the contralateral side; weak glute med on WB leg

18. Hip Fractures

19. Hip Fractures • Femoral Head Fx – rare, associated w/dislocations

20. Hip Fractures • Femoral Neck Fxs – typically older adults, high risk of AVN depending upon fx location (increased w/displacement of fx)

22. Hip Fractures • Trochanteric Fx- greater troch = avulsion @ glute med insertion • Lesser troch = pathologic vs avulsion of iliopsoas

23. Hip Fractures • Intertrochanteric Fxs – generally in elderly, osteoporotic

24. Hip Fractures • Subtrochanteric- bimodal: 20-40 y/o (high energy trauma) & >60 y/o (falls, osteoporosis

25. Hip • Slipped Capital Femoral Epiphysis • Disorder of hips, adolescents/preadolescents • Femoral head displaced relative to femur • Femoral head remains in acetabulum • Outward rotation of lower femur & leg, limp • 80% occur during growth phase: boys (10-16y/o), girls (10-14y/o); males > females • Obese, AA males

26. Hip • Slipped Capital Femoral Epiphysis • Etiology: multifactorial, weakened growth plate (physis) w/higher than normal stresses on it • Endocrine factors (hypothyroidism, pituitary, hypogonadal secretions, renal probs

27. Hip • Slipped Capital Femoral Epiphysis • S/Sx: pain (acute/chronic) in groin, thigh, knee • Descreased internal rotation of hip; noted external rotation of hip • Limp • Trendelenburg gait • Pain greatest with internal rotation, flexion, ABduction • Xrays: AP/Lat…check lateral (more pronounced); frog leg = gold standard

28. Hip • Slipped Capital Femoral Epiphysis • Tx: NWB until stabilized, surgery, PT (may partial weightbear if slip is stable)

31. Knee • Anatomy: bones, menisci, muscles, nerves • 3 Compartments: medial, lateral, patellofemoral • Bones: Tibia, Femur, Patella (helps knee ext) • Menisci: Medial/Lateral; fibrocartilage; joint lubrication, nutrition, load distribution

32. Knee • Ligaments/Tendons: 1) Patellar tendon- distal quad, inserts on tibial tuberosity 2) ACL- origin is postermedial lateral femoral condyle; attachment tibia’s ant. Intercondylar spine (prevents anterior displacement of tib on femur 3) PCL- origin is anterolateral medial femoral condyle; inserts on post. Intercondylar spine (prevents post. Displacement of tib on femur during flexion) 4) MCL- Medial femoral condyle to medial tibial plateau & medial meniscus (stablizes against VALGUS loads) 5) LCL- Lateral femoral condyle to fibular head (stabilizes against VARUS loads)

33. Knee

34. Knee • Muscles: Quads (extensors): rectus femoris, vastus lateralis/intermedius/medialis Hamstrings (flexors): biceps femoris, semimembranosus, semitend., gracilis • Nerves: Femoral: innervates quads Sciatic: bypasses knee posteriorly w/popliteal vessels Common Peroneal: major branch of sciatic, travels laterally around fibular neck

35. Knee • Always compare joints __________! (fill in the blank!) • Assess for referred pain from spine and/or hip • ROM: normal = 0-155º • Inspect: erythema, effusion, skin abrasion; muscle atrophy; standing varus/valgus alignment (females 7º valgus, males 5º); assess gait (antalgic)

36. Knee • Special Tests • Anterior Drawer/Posterior Drawer (tests stability of ACL/PCL, respectively) • Lachman’s (specific for ACL) • McMurray’s (tests for meniscal tears) • Varus/Valgus Stress (tests LCL/MCL respectively) • Apley’s Compression/Distraction (tests menisci & capsule)

37. Knee

38. Knee • Meniscal Injuries: -pt. c/o episodic painful “mechanical symptoms” like popping, locking, giving way -focal tenderness to palpation @ affected jt. line (best appreciated w/knee @ 90º) -McMurray test; Apley compression/distraction test -Only imaging to see meniscal tear = MRI -Definitive tx. = knee arthroscopy (scope), PT -Menisci are more avscular in nature (esp. toward center)

39. Knee • Meniscal Injuries: BEFORE AFTER

40. Knee • Ligament Injuries (ACL): -Associated w/sports (FB, hockey, BBall, lacrosse, gymnastics, wrestling, Vball) -4-6 times higher in females (hormones weaken ligaments; common in pregnancy) -Increased risk w/elevated Q angle, notch stenosis, narrow ACL -Typically non-contact (decelerating/changing direction/landing from a jump) -Contact (clipping – direct blow to knee w/valgus load & external rotation of tibia)

41. Knee • ACL S/Sx: Immediate pain, audible “pop”; swelling within a few hours (hemarthrosis); feeling of instability, difficult weightbearing PE: ALWAYS COMPARE ????; mod-severe effusion, knee ext. may be limited by pain/spasm/effusion; (+) Lachman’s, (+) Pivot shift; (+/-) Ant Drawer (least reliable due to poss. PCL injury as well) Imaging: XR knee (look for tibial spine avulsion fx, lateral capsule avulsion fx); MRI (Image of Choice!) accuracy up to 95% Tx: RICE, splint, crutches; nonop + PT/OT (if elderly); nonop + PT/OT (if skeletally immature); ligament reconstruction; early ROM/early weight bearing post-op

42. Knee • PCL Injury: • young adults, males > females; uncommon • MVA, collision sports, hyperextension injury to knee • Direct blow to anterior tibia w/knee flexed & foot plantar flexed • Hyperflexion without a blow • Be aware of possible popliteal artery injuries

43. Knee • PCL Injury: Grade I: Tibial plateau is anterior to femoral condyles Grade II: Tibial plateau is level w/femoral condyles Grade III: Tibial plateau is posterior to femoral condyles

44. Knee • PCL Injury: S/Sx: Knee pain/swelling after injury w/gradual improvement; minimal instability (climbing stairs); recurrent effusion; posterior knee pain; knee recurvatum (late finding) PE: (+) Posterior Drawer; (+) Posterior Sag XR: Plain XR r/o fx; MRI (Test of Choice!) Tx: Partial/WBAT; nonop initially (except for high grade knee dislocations); knee immobilizer/crutches; early ROM & strengthening; PT Surgery – Grade 3 PCL injury, posterolateral corner injuries, assoc. ligamentous injuries, knee gives way, pain

45. Knee • PCL Injury:

46. Knee • MCL: • Direct blow to lateral knee; valgus load to knee • Contact sports, falls • S/Sx: pain medial knee, poss. effusion, can be assoc. w/ACL tear, meniscal tear • PE: (+) pain and/or laxity @ 0º & 30º valgus stress (if + at 0º, most likely ACL + MCL) • XR: r/o fx; MRI • Tx: RICE, hinged knee brace, WBAT, PT; rarely surgical (unless chronic pain, instability)

47. Knee • LCL: • Similar to that of MCL; just pain/laxity w/varus stress @ knee; can palpate the LCL in most pt’s when they are in “Figure 4” position • Tx same as MCL

48. Knee • Chondromalacia • Softening & deterioration of cartilage underside of patella; exact cause unknown • Stage 1: swelling, softening of articular cartilage • Stage 2: fissuring of softened articular cartilage • Stage 3: deformation of surface of articular cartilage caused by fragmentation • S/Sx: pain anterior knee w/walking, running, ascending stairs, squatting; recurrent swelling around kneecap, grating/grinding sensation w/flex & ext of knee • Tx: Conservative 1st (avoid activities, isometrics, NSAIDs, neoprene knee sleeve; Surgery (change insertion of Vast. Medialis, shave/smooth patella; last resort: remove patella

49. Knee • Osgood-Schlatter Disease • Peds population (Jumper’s knee –adults), very common, self-limiting; young athletes (dancers, bball, vball) • Causes: repetitive jumping, repetitive leg extension exercises, limb malalignment; i.e. recurrent microtrauma from overuse

50. Knee • OSD: • S/Sx: dull, aching pain over patellar tendon; exacerbated by active/resisted knee extension • PE: tenderness over inferior pole of patella; may also have tenderness over tibial tubercle; quads/hamstrings/hip flexor tightness • XR: AP/Lat knee r/o other pathologic processes; US/MRI help to identify cases of mucoid degen. • Tx: Rest (not immobilized), gradual return to activity (start w/low impact, i.e. swim, bike, etc.), ICE, PT for stretch/strengthening • **No corticosteroids*** risk of patellar tendon rupture