MSK - LOWER EXTREMITY DISORDERS:

HIP DISORDERS:
DISORDER: WHAT IS IT/LOOK LIKE? WHAT DO WE DO ABOUT IT: KEY TAKEAWAYS/TESTS:

FRACTURES & DISLOCATIONS (BONY CONDITIONS):

Pelvic Fracture: MOI = HIGH energy trauma Can be LIFE THREATENING****

(MVA) (hemodynamic instability)

HIGH MORTALITY RATE! (esp in

men, elderly & those in shock)

Pelvic Rami MOI = LOW impact trauma Eval = pelvis, spine, ABD, hips &
Fracture: in ELDERLY that has a broad NV
MORE COMMON presentation
AP pelvis (hip series) BUT CT
MORE SENSITIVE***

PC, PT, WBAT, ortho f/u

HIP FRACTURES: MOI = fall or trauma (high Eval = ER & ABD hip with a MOST COMMON cause of elevated
BADD NEWS for impact in young) = WOMEN SHORT leg (looks like CAPTAIN mortality in ELDERLY**
elderly with osteoporosis & MORGAN with hip to the side) Prevention is KEY = osteoporosis,
ELDERLY calcium, vit D, increase WBE
AP pelvis & true lat of hip & femur
Groin pain, unable to HIP FRACTURE
ambulate, pain radiating to ORTHO REF = SURG within 1-2 EXTERNALLY ROTATED
knee days

Worry about = avascular necrosis

Opposites ↕ (femoral neck)

Hip Dislocation: MOI = head of femur pushed REDUCE ASAP (sedation) MOST COMMON = POSTERIOR**
POST to acetabulum with - Allis Maneuver (most common)
knee flexed (think knees - Captain Morgan HIP DISLOCATION
hitting dashboard in MV) INTERNALLY ROTATED

SHORT extrem, ADD & IR

(OPPOSITE of hip fracture)!! Hip series = Judet View (wanna
see acetabulum)
After reduction = CT

Worry about = sciatic nerve***

(foot drop, numbness dorsal foot)

Hip Osteoarthritis: MOI = wearing away of Eval = abnormal gait (learn toward Think of a poor grandpa that can’t
articular cartilage from age affected side) even put his socks on & walks funny
& overuse PASSIVE IR/ER at 90 -> PAIN

Deep groin pain, painful WB Hip series = joint space

narrowing, sclerosis,
osteophytes

Conservative tx = WL, PC,

NSAIDs, etc
- only surgery if young or severe

Avascular Necrosis: MOI = death of cellular Eval = decreased ROM, IR, hip CRESCENT SIGN = subchondral
elements of bone (blood flexion & ABDuction radiolucency
supply issue) - usually femur
MRI = gold standard**
Initially ASYMP, but groin pain
will radiate to ipsilateral ORTHO REF, stop drugs, avoid
buttock, med thigh, or knee WB for weeks, & SURG
- or can be abrupt onset of
pain (worse with WB & night)
 MSK - LOWER EXTREMITY DISORDERS:
Slipped Cap OVERWEIGHT MALE
Femoral Epiphysis ADOLESCENTS*** (12-13)
(SCFE):
Displacement of femoral
epiphysis from metaphysis
- Hip, groin, thigh or
knee PAIN with LIMP
- Presents like a hip
fracture
Opposites ↕
Legg-Calve-Perthes Idiopathic osteonecrosis &
Disease collapse of femoral head
(blood supply issue)
4-6 YR OLD MALES, SGA
Diffuse aching pain in groin,
med thigh or knee &
abnormal gait that worsens
Developmental Common in infants (esp
Dysplasia of Hip SWADDLED)* shallow &
(DDH): poorly developed
acetabulum
Mild instability to dislocated
hip
SOFT TISSUE CONDITIONS OF THE HIP:
Femoral Acetabular Abnormal morph of joint ->
Impingement (FAI): friction of fem head,
acetabulum & labrum (early
OA if it tears)
Anterior hip or groin pain
Cam type = extra bone on
fem head/neck (Pistol Grip
Deformity)
Pincer type = acetabulum too
big for fem head
Acetabular Labral Impingement of cartilage from
Tears: femoral neck when hip
FLEX/IR - THINK DANCERS,
ICE SKATERS, GYMNASTS
Anterior hip/groin pain,
Eval = waddling gait with limp & Ice cream falling of a cone*****
short steps (mild to severe)
Hip series = bilat
AP = widening of physis,
deformity of femoral neck &
KLEIN’s Line* (epiphysis falls at
or below)
MRI = detect early stages
Worry ab AVN
NWB with crutches til ORTHO
REF will probs need SURG
Eval = waddling gait, dragging leg,
out-toeing & rest in hip flexion or
ADDuction with PAIN at IR or hip
ABDuction
Hip series - repeat
TX = CONTROVERSIAL b/c will
self limit in 4 yrs but obv want to
relieve pain & maintain femoral
head shape & position in joint
Eval = decreased ABD of hip, ORTOLANI = hip abducted “clunk”
unilat flat buttock assym thigh as femoral head enters acetabulum
folds, late crawling, walking & limp (POP OUT)
GALEAZZI SIGN = height of BARLOW = hip adducted “clunk” as
affected side is shorter femoral head enters acetabulum
(POP IN)
US = under 6 months
AP pelvis & frog leg lat (4.5- 6
months)
Tx depends on age:
- infants (under 6 mo) = ortho ref &
pavlik harness
- infants (above 6 mo) = ortho ref
& closed red with hip spica casting
- older than 18 months = SURG
Hip series = look for CAM lesion, Windshield wiper test = pain with
OA & hip dysplasia (passive IR/ER with hip 90 deg)
MR = check for labral tears (early
OA)
Anatomy is just messed up (could be
SURG from SCFE, LCPD, trauma)
- cam = shave extra bone
- pincer = resect overhanging rim
of acetabulum
**BUT be careful b/c risk of AVN
Hip series or MR but Young = trauma
Arthroscopy = GOLD standard Elderly = degenerative
Conserv tx (10-12 wks) = act mod,
NSAIDs, injections
 MSK - LOWER EXTREMITY DISORDERS:
catching, locking & sometimes
butt pain
Transient Synovitis: Inflammation of lining of hip
joint - immune resp to viral
or bacterial infection (MOST
COMMON in 3-6 YR MALES)
Hip pain, refusal to WB
unilat
Trochanteric Inflammation = bursal sac
Bursitis: overlying greater trochanter in
FEMALE RUNNERS
Low back pain, IT band
tenderness, obesity & lateral
hip pain (worse before bed)
Muscle Strains: Direct trauma or
overstretching, strong muscle
activation causing muscle
tears
MOI = forced ABDuction
Pain with hip ADDuction &
flexion
Piriformis Irritation or compression of
Syndrome: sciatic nerve (as it passes
through piriformis) - 40 YR
OLD WOMEN
MOI = anatomy or trauma (fat
wallet syndrome)
Pain or paresthesia in groin,
pelvis, deep buttock &
hamstrings (worsens with
climbing stairs & squatting)
THIGH / FEMUR DISORDERS:
DISORDER: WHAT IS IT/LOOK LIKE?
FRACTURES & DISLOCATIONS (BONY CONDITIONS):
Femur Fractures: Due to trauma or low-energy
injuries in elderly,
osteoporosis or bone cancer
Not improving = SURG -
debridement of deformity or repair
of labrum
Eval = well-appearing, hip flexed, Think = little boy that had strep, URI
ABDucted & ER or GI infection within past 2 weeks
with hip pain
Hip series = norm
US = visual effusion
MRI = effusion & r/o others
Labs will be normal but u may do a
synovial fluid analysis to r/o
septic arthritis (esp if kid has
fever & ill)
Self limiting - the kid will be fine in
3-4 days but just reassure mom &
give NSAIDs to control pain & tell
her to F/U for radiograph in 6
weeks to check for AVN
Tenderness on palpation along
greater trochanteric bursa
(JUMPing)
Clinical diagnosis* but can do a hip
series to r/o OA, bony abnormality
NSAIDS, IT band stretching, PT &
cortisone injections
Tenderness over muscle belly Very common & common cause of
groin pain
Rest, activity mod, NSAIDs, ice, Hip adductors & flexors (most
PT (if persists 4-6 weeks -> ortho) common) = pulled groin
Can linger for months
Eval = pain with hip flexion & “Sausage-shaped” mass in buttock
passive IR & restricted ADDuction (feeling tight piriformis)
Imaging to r/o others & EMG to r/o
lumbar radiculopathy
Rest, NSAIDs, muscle relaxers,
PT, surg if fail
WHAT DO WE DO ABOUT IT: KEY TAKEAWAYS/TESTS:
Image hip, fever, & knee to r/o Significant hematoma & blood loss -
dislocation, intra-articular STABILIZE for life threatening
extension, fracture conditions
 MSK - LOWER EXTREMITY DISORDERS:
Mid-Shaft Fractures: High energy trauma -> torsion
stress causes spiral fracture
that extends into metaphyseal
area
Deformity & severe pain
(assoc with hemodynamic
instability)
SOFT TISSUE CONDITIONS OF THIGH & FEMUR:
Quadriceps Compression of the muscle &
Contusions: soft tissue against the femur
-> myofiber & capillary rupture
-> hematoma = inhibits
movement
MOI = direct trauma to ant
thigh (football, lacrosse)
Pain, swelling, decreased
knee motion & bruising
Quadriceps Tendon Rupture of extensor
Rupture: mechanism of knee in people
OVER 40 (usually prev
trauma)
MOI = direct blow or sudden
forceful quads contraction
with knee bent & foot fixed
(eccentric contraction of
muscle)
Severe pain, “pop”, swelling
Hamstring Strain: Strain of biceps femoris (knee
flexor/hip extensor) ELDERLY
MOI = forced extension of
knee or directional change
Pain in back of thigh & POP
after injury
Meralgia Entrapment of lateral femoral
Paresthesia: cutaneous nerve in inguinal
canal (L2-L3) 30-40 YR OLD
MALE baseball players,
gymnastics, soccer, body
building
Pain, paresthesia or
numbness to anterolat thigh
KNEE DISORDERS:
DISORDER: WHAT IS IT/LOOK LIKE?
Admission & ortho consult
(reduction)
Eval for sciatic nerve damage &
superficial temporal artery & vein
Hip series, femur series, knee
series
STABILIZE for life threatening
conditions, admission & ORTHO
REF, traction before surgery
Eval = abnormal gait, swelling, Most common = anterior & lateral
tenderness, decreased knee ROM thigh regions
Femur series after 2 weeks Complications:
- compartment syndrome - rare
Immobilize knee in 120 degrees - myositis ossificans = abnormal
for 24 hrs, ice, compression, deposit of calcium post trauma
NSAIDs, ROM/PT
Eval = antalgic gait, tenderness, BIG DEAL!!!
palpable defect in quads tendon,
limited flexion, can’t straighten
leg***
Femur / Knee series = bony
avulsion or PATELLA BAJA
Compression, knee immobilizer,
NSAIDs, ice, NWB
Partial thickness = long leg
cylinder cast
Full thickness = surg
Exam = stiff-legged gait, High risk of recurrence**
tenderness, painful resisted knee
flexion & hip extension
Femur series + AP series (check if
ischial tuberosity avulsion)
MRI if edema or hemorrhage
Ice, compression, crutches, PT*
Exam = POS tinsel sign at ASIS Sports & TIGHT pants
- do a lumbar spine exam*
Clinical dx
Resolves but can do activity mod,
weight loss, NSAIDs, PT same shit
as the others
WHAT DO WE DO ABOUT IT: KEY TAKEAWAYS/TESTS:
 MSK - LOWER EXTREMITY DISORDERS:
BONY CONDITIONS OF THE KNEE:
Patellar Fracture: Transverse fracture most
common - can disrupt
extensor mech of knee
MOI = direct blow or forceful
contraction of quads (FALL,
KNEE ON DASHBOARD)
Tibial Plateau Direct trauma, fall, or high
Fracture: energy injury - MIDDLE AGED
FEMALES (LATERAL MOST
COMMON)
Swelling, pain, decreased
ROM
Osgood-Schlatter OVERUSE = repetitive strain
Disease (OSD): on quads -> injury to TIB
TUB -> avulsion at
Osgood-Squatter bone-tendon junction
D’Knees
Pain at TIB TUB (intermittent
for mo-yrs), activities worsen
pain & localized pain inf to
patella
Osteoarthritis: Pain with loading joint
(walking, running, kneeling) &
extreme ROM, buckling
sensation
Patellar Instability: Partial or complete
displacement of patella
relative to trochlea (patella no
contact w/femur in ext) ->
patella alta
MOI = plant & cut (soccer
players), direct force of med
aspect of patella when knee
flexed
Feels like knee cap slipped or
goes out -> ant knee pain
Knee Joint Displacement of tibia relative
Antalgic gait or sometimes can’t
walk, joint effusion, tenderness on
patella, decreased ROM
Knee series & Merchant views
Knee immobilizer & NWB Bipartite patellae = normal variant
Non-displaced = cylinder cast with bilat smooth edges, “smooth like
Surg only for open or disrupt of a rock that went through a cement
extensors truck” (incidental finding)
NWB or antalgic gait, joint line Very common to have a lateral
tenderness meniscus tear with this***or a
**assess ligaments & NV Segond Fracture (ACL tear)
Knee series but CT, MRI is easier
to see occult fractures
ORTHO consult, knee immobilizer,
NWB, pain control can need surg
Prominence & tenderness of tib Think 8-15 yr old playing sports
tub, antalgic gait, AROM = pain, with ANT knee pain - growth spurts
resisted extension of knee
EXAMINE THE HIP!!!
Knee series = separation of tib tub
with new bone formed underneath
Reassure -> activity mod, NSAIDs,
quad stretching, patellar strap
Antalgic gait, tenderness, pos Medial compartment usually
meniscus tests, reduced ROM
3 view knee WB = narrowed joint
space, subchondral sclerosis,
osteophytes, cystic changes
Incurable = (damage to articular
cartilage)
- Weight loss, activity mod,
therapeutic exercise,
meds, just helping sx
- Surg = joint replacement
but complications
APPREHENSION TEST = pain & LATERAL = most common
involuntary guarding
Knee series & merchant view
Reduce if dislocation & reduce
pain & swelling, PT, basically
wanna AVOID OPERATING**
TRUE ORTHO EMERG**** - CAN
 MSK - LOWER EXTREMITY DISORDERS:
Dislocation: to femur - due to ligamentous
disruption damage & soft
tissue injury (high velocity
injuries = MVA, falls,
athletics)
Ant = high energy hyperext
(MOST COMMON)
Post = med/lat or rotary
(BADDDDDDDD!!!!!)
SOFT TISSUE CONDITIONS OF THE KNEE:
Anterior Cruciate Common injury in SPORTS
Ligament (ACL): MOI = valgus blow to the knee
POP & SWELL for or sudden change in
the ACL direction (jumping, pivoting,
& deceleration) - PLANT &
TWiST
Pain, instability moving side to
side or going down stairs,
POPPING & INTERMITTENT
UNHAPPY TRIAD = SWELLING or weakness
ACL + MCL +
Meniscus Tear
Posterior Cruciate Less common - DIRECT blow
Ligament (PCL): to knee causing tibia to
translate post to femur
(DASHBOARD INJURY***),
landing on person’s foot
Knee instability, clicking or
locking sensation, pain,
effusions & weakness
Medial Collateral Trauma with a VALGUS force
Ligament (MCL): applied to a planted and firm
MCL TEAR = knee joint or non-traumatic as
VALGUS STRESS concurrent ACL injury
MUCHO GUSTO
VALGUS
Knee pain, instability, knee
“giving out”, popping &
clicking
Lateral Collateral Traumatic forces applied to
Ligament: inside of knee with the knee
LCL TEAR = VARUS planted on the ground
STRESS (VARUS force)
LEAKY PIPES RUST Lateral knee pain, knee
VARUS buckling with hyperextension
Visual deformity & effusion
Knee series
CONCERN = POPLITEAL
ARTERY (most important - norm
pulse), common peroneal nerve
(decreased sens to lat foot & 1st
dorsal web space, dorsiflex &
eversion) & tibial nerve
(decreased sens to post leg & foot)
& ACL/PCL injuries
Reduction = longitudinal traction
to affected knee (NVE after**)
ABI needs to be checked***
SURG = EMERG then MRI &
delayed lig reconstruct
Eval = acute effusion & stiffness of
knee, limited ROM, joint line
tenderness
MRI*** & Knee series r/o fractures
& check for segond fracture
ORTHO REF
Sprain = pain & swelling control,
functional brace & PT
Complete tear = reconstruction
(but early degen & instability) or
conservative with PT
Eval = Effusion, tenderness to
palp, decreased ROM
MRI*** & knee series r/o fractures
Knee immob, WBAT, PC, PT
MOST require SURG due to MOI
then intense PT & extended
bracing
Ecchymosis, edema, effusion,
tenderness to palp, AROM &
PROM decreased
MRI**** & knee series r/o fractures
Immob, NSAIDS
Grade 1 & 2 = PWB with brace, PT
Grade 3 = SURG
Bruising, swelling, effusion,
popping & clicking, tenderness,
decreased AROM & PROM
MRI*** & knee series
Immob, WBAT, NSAIDs,
branching, PT, limit activity
LEAD TO AMPUTATION
Complications:
- NV injury, knee instability, stiffness,
compartment syndrome, DJD
LACHMAN TEST = excessive
anterior translation of the tibia
compared to other side (30 degrees)
(ACL rearranged)
ANT DRAWER TEST = excessive
anterior translation of tibia (90
degrees)
PIVOT SHIFT TEST = subluxation at
20-40 degrees knee flexion (rotary
laxity)
POST DRAWER TEST = excessive
posterior translation of tibia
compared to other
POST SAG TEST = sag or drop back
of the tibial tubercle compared to
other
VALGUS STRESS TEST =
increased laxity compared to other
side (NOT PAIN)
- grade 1 = pain without lax at 0 or 30
- grade 2 = pain & lax at 30, stable 0
- grade 3 = pain & lax at 0 & 30
UNHAPPY TRIAD = ACL + MCL +
Meniscus Tear
Varus Stress Test = increased lax
compared to the contralateral (NOT
PAIN)
Usually non-surg unless assoc
injuries
 MSK - LOWER EXTREMITY DISORDERS:
Cartilage Injuries Non-contact hyperextension,
(Meniscus Tears): twisting or locking injuries
POP, LOCK & DROP
Joint line knee pain,
LOCKING, POPPING,
intermittent swelling & knee
“GIVING OUT”
Patellar Tendon Most common at tendon-bone
Rupture: junction at distal pole of
patella - UNDER 40,
ATHLETES
MOI = sudden eccentric
contraction of quads with a
flexed knee (attempting to
take off from a long jump)
POP with sudden pain &
swelling in the front of the
knee, & tearing sensation
Patellar Tendonitis Chronic inflammation of
(Jumper’s Knee): patellar tendon at either pole
of patella or tib tub (MOST
COMMON = DISTAL POLE)
- overuse (mechanical
overloading - jumping &
landing
Initially dull, aching pain after
jumping or running &
becomes worse
Patellofemoral Pain Spectrum of disorders =
Disorders: chondromalacia patella
(softening of cartilage),
Patellofemalerun patellofemoral arthralgia, &
syndrome instability - RUNNERS, 20 YR
OLD FEMALES, BILAT,
OVERWEIGHT
ANTERIOR KNEE PAIN with
bending movements (up &
down hills or stairs), unstable,
sitting for a prolonged time
(Theater sign)
Prepatellar Bursitis ASEPTIC = enlarged tender &
(Housemaid’s warm due to overuse or
Knee): repetitive trauma - bursa
inflamed (kneeling on hard
surfaces or direct trauma -
CARPENTERS)
- mild pain ^ swelling,
Bucket-handle = central portion of McMURRAYs TEST = pain, locking,
tear gets caught in intercondylar catching sensation when stressing
notch (MOST COMMON CAUSE affected component (Men is called
OF LOCKING) Murray)
Effusion, antalgic gait, joint
tenderness
MRI***
Bucket handle = MOST
COMMON INDICATION FOR
KNEE SURG UNHAPPY TRIAD = ACL + MCL +
Meniscus Tear
Repair = long healing in young
Partial = quick healing
Unable to WB, swelling, Risks = hx patellar tendinopathy,
ecchymosis, PATELLA ALTA, corticosteroids, diabetes, renal failure
tenderness to palp, unable to hold
leg in extension
Knee series = r/o avulsion & see Can be assoc with avulsion fracture
patellar position of inferior pole of patella
MRI ***= partial vs. complete tear
Partial = cylinder cast or brace
locked in ext, PT
Complete = SURG & PT
Swelling, antalgic gait, point UNILAT MC in MALES - basketball,
tenderness to palp, pain with volleyball, runners, high jump
active knee extension
RISK for TENDON RUPTURE
Patellar tendon strap, NSAIDs,
activity mods, PT
If child = eval for hip path, MC REASON FOR ANT KNEE PAIN
swelling, effusion, check gait, VISITS
tenderness to palp, crepitus
PATELLAR GRIND TEST =
Knee series & merchant view & reproduction of pain or grinding
MRI if acute (eval for cartilage
fracture & defect)
Weight loss, NSAIDS, activity
mod, neoprene sleeves or patellar
supports, quad strengthening
Aseptic = rest, ice, kneepad,
aspiration if concern about sepsis
or gout
Septic = aspirate fluid for gram
stain, cell count, culture***
- antibiotics to cover staph & strep
 MSK - LOWER EXTREMITY DISORDERS:
tenderness to palp
SEPTIC = CONCERNING**
(warm, tender, red), bacterial
spread from skin or local
cellulitis, fever (STAPH
AUREUS, staph epidermidis,
strep)
ANKLE / LOWER LEG DISORDERS:
DISORDER: WHAT IS IT/LOOK LIKE?
FRACTURES & DISLOCATIONS (BONY CONDITIONS):
Tibial Shaft Direct trauma or indirect with
Fracture: rotary & compressive forces
(falling, skiing)
Ankle Fractures: Pattern depends on force,
position of foot and ankle at
TOI
Swelling, tenderness to palp,
some can and can’t WB
Lateral Malleolar Mild avulsion due to inversion
Fractures: injuries to displaced fractures
with disruption of ankle
mortise
Medial Malleolar Usually an avulsion type injury
Fractures: - eversion or ER injuries
assoc with injuries to deltoid
ligament
Posterior Malleolar Avulsion of posterior
Fractures: tibiofibular ligament
Bimalleolar (Lateral Severe pronation, ABDuction,
or Medial)Fractures: & ER force causing a
shearing of lateral malleolus &
avulses the medial malleolus
Trimalleolar (Lateral, ABDuction, severe ER
Medial, or Posterior) rotation force that is so strong
Fractures: it moves the talus posteriorly
to shear off the posterior
aspect of the tibia
Tibial Plafond Fracture of articular surface of
- ADMIT for sepsis, ext
surrounding cellulitis, failure outpt
tx, suspected joint involvement,
immunocompromised
WHAT DO WE DO ABOUT IT: KEY TAKEAWAYS/TESTS:
Check joint above & below - MOST COMMONLY INVOLVED IN
pain, swelling, deformity, NVE**** OPEN FRACTURES
Tib/Fib series Frequently occurs with fibular
injuries, compartment syndrome
Long leg splint with knee in 10-15
flexion & ankle at 90
EMERGENT ORTHO CONSULT
& HOSPITALIZED for NVE & PC
Need to CHECK KNEE & Assoc with ligament & syndesmosis
FOOT*** injuries, skin wounds, dislocations &
foot fractures
Ankle series +/- stress view, CT to
help surgical plan
Padded post splint & clamshell
with NWB, elevation above heart &
PC
- stable = short leg cast & PT
- unstable = ORIF
Point tenderness, swelling, MC portion of ankle injured due to
difficulty ambulating excessive inversion stress
CAM boot or short leg cast
Minimally displaced = cast or CAM
boot
Displaced = ORIF
Same tx as above Rare isolated injuries
Unstable = allow talus to sublux or
dislocate
Controversial tx = most fix
Unstable = allow talus to sublux or
dislocate
Usually SURG
Ankle series & CT while Likely post-traumatic issues = early
 MSK - LOWER EXTREMITY DISORDERS:
(Pilon) Fracture: distal tibia (from foot driving
talus up) = HIGH ENERGY
35-45 YR old MALES
Maisonneuve Fracture of prox fibula, medial
Fracture: malleolus & rupture of deltoid
ligament (worry about
syndesmosis - TORN)
- strong ER force to foot is
cause (athletics)
Toddler Fracture: Spiral or oblique fracture of
lower ⅓ of tibial shaft
(TODDLERS = 9 months to 3
YRS) - due to torsion of lower
leg
Refusal to WB
Ankle Dislocations: Displacement of talus & foot
from tibia
MOI = axial load to foot in
plantar flexion w/ eversion or
inversion (sports, MVC,
elderly falls)
Ankle Sprain: Inversion (lateral) = most
common
Eversion = high sprains
Pain, swelling, bruising &
painful WB
Inversion (Lateral) ATFL & CF ligaments
Ankle Sprain:
MOI = turning of ankle during
a fall or landing on irreg
surface (rolling an ankle)
Lateral ankle pain, swelling
& “pop”
Eversion (“high”) Syndesmotic injury = ATFL &
Ankle Sprain: med deltoid ligament
MOI = foot turned out or ER &
everted or hyperdorsiflexion
injury
Severe, prolonged pain along
anterior ankle (worsens
w/WB)
SOFT TISSUE INJURIES:
splinted** onset arthritis, stiffness
Tx = reduce # fragments & align
joint back up & usually admitted for
just pain Control, long leg splint
PALPATE prox fibula in any ankle
injury***
Ankle series & tib/fib series
ORTHO ref = SURG ASAP
Worry about peroneal nerve injury
Eval = tenderness to palpation Think little kid getting his leg caught
along lower tib on a slide at playground
BUT keep child abuse in back of
Ankle series or tib/fib series mind (2nd most common NAT)
Long leg splint, PC, re-eval in a
week & short leg walking cast (3
weeks)
Ankle series Posterior & lateral dislocation =
MOST COMMON
REDUCE = sedation 50% are OPEN
Then reassess NV, and
well-padded post splint with a
clam-shell**
ORTHO red = probs will need surg
Ankle series to r/o fracture (if MOST COMMON sports injury in
necessary) & MRI if pt fails outpatient clinic
conserv tx
Consider damage to lower leg -
ligaments & tendons, 5th
metatarsal
Eval = tenderness to palp over ligs Most common Ankle Sprain***
ATF Ligament = Always Tears First
Ankle series to r/o fracture
ANT DRAWER TEST (ATFL) =
Splinting (ankle brace), ice, WBAT, increased translation when compared
PT or home exercise to other side
strengthening exercises
SUBTALAR TILT TEST (CF) =
Complication = chronic instability increased translation compared to
other side
Eval = tenderness to palp over EXTERNAL ROTATION STRESS
ATFL (check prox tibia to r/o TEST (syndesmotic injury) =
Maisonneuve injury) reproduction of pain
Ankle series & ER stress view
(Mortise view = check loss of
normal overlap between tibia &
fibula)** & asymmetry in joint
space around tibiotalar joint =
disrupt of syndesmosis & MRI
Conserv = NWB in cast or brace
 MSK - LOWER EXTREMITY DISORDERS:
Achilles Tendon Rupture 2-6 cm above
Rupture: tendon’s attachment to
calcaneus
MOI = force of gastroc
suddenly applied to
dorsiflexed foot
Hear or feeling of a POP &
sudden pain & weakness
pushing off floor (feels like got
kicked in heel by a horse)
Ankle series = eval for bony
avulsion at calcaneus
& US to visualize tendon injury
Casting & surgery eventually
Think of an out of shape dad trying to
play football on thanksgiving
(weekend warriors)
- steroid or chronic oral corticosteroid
use
- fluoroquinolone use (common
exam question - know this is a
risk***)
- overweight
THOMPSON TEST = foot will not
plantarflex when calf squeezed
(gastroc)

Medial Tibial Stress Tibial periostitis = due to
Syndrome (Shin chronic excessive stress at
Splints): bone-muscle junction
FEMALES - running on
different terrain & poor
footwear
Eval = antalgic gait & swelling &
tenderness to palp along middle ⅕
of posteromedial border of tibia
**PAIN with PASSIVE plantar
flexion & eversion
MRI

Bilat anterior leg pain (worse Activity mod, NSAIDs, better

during activity then gets better sneakers
but eventually progresses)

Compartment Increased pressure of Acute or chronic EMERGENCY!!!!

Syndrome: muscular compartments that
causes muscle necrosis & NV
damage

ACUTE Younger HIGH energy =
Compartment - MALES under 35 yrs with
Syndrome: tibial fracture
- soft tissue injury with
bleeding disorder or anticoags
5 P’s: ****
PAIN, Paresthesia, Pallor,
Pulselessness, Paralysis
Eval = pain with passive motion &
swelling of extremity
Measure compartment
pressure**
TX ASAP = ADMIT & URGENT
ORTHO REF (immed remove any
restrictive casts or dressing &
elevate limb to reduce swelling)
Fasciotomy = slicing through
fascia to relieve pressure on
muscle & nerves (leave skin open)
EMERGENCY!!!!
Occur after TRAUMA (fractures,
severe swelling or crush injuries)
complications= muscle necrosis,
perm damage & amputations
PREVENTION is KEY!!! = splint
(don’t ever immediately cast a
fracture), loose wraps, elevate, ice &
patient education***

Chronic (Exertional) Results from muscle
Compartment hypertrophy in compartment
Syndrome: (swelling with athletic
exertion) - RUNNERs,
MILITARY
Lower leg - most common
aching pain & cramping with
exercise
Normal before exercise & foot drop
after running
Measure compartment pressures
before & after exercise & bone
scan/MRI
Tx = activity mods, pain ct, refer to
ortho

FOOT DISORDERS:
DISORDER: WHAT IS IT/LOOK LIKE? WHAT DO WE DO ABOUT IT: KEY TAKEAWAYS/TESTS:

FOOT FRACTURES & DISLOCATIONS (BONY CONDITIONS):

Calcaneus Intra (75%) or extra articular Eval = antalgic gait, unable to WB, Most frequently fractured tarsal bone
 MSK - LOWER EXTREMITY DISORDERS:
Fractures:
MOI = Axial load drives talus
into calcaneus (falls or high
velocity injury)
Severe pain, unable to WB,
swelling
Lisfranc Injuries Spectrum = sprains, fractures,
(Tarsometatarsal dislocations
Injury):
MOI = rotational force & axial
load on hyperflexed foot or
crush injuries (MVC,
basketball)
Mild pain, difficulty WB (can’t
run on toes)
5th Metatarsal Joint between prox 4th & 5th
Fractures: metatarsal
- tuberosity fracture
- jones fracture
- diaphyseal stress fracture
Tuberosity Fracture Occurs PROXIMAL to
(Pseudo-Jones): articulation of 4th & 5th
metatarsals
MOI = forced inversion with
foot in plantar flexion
(peroneal tendons & plantar
aponeurosis)
Jones Fracture: Acute fracture at junction off
the diaphysis & metaphysis
(5th metatarsal - jones has 5
letters)
MOI = laterally directed force
on the forefoot that disrupts
the plantar flexed foot
Diaphyseal Stress Occurs just distal to
Fracture: ligamentous attachment of
bone & extends 1.5 cm into
diaphysis
- strenuous activity (dancers,
runners)
Stress (March) Incomplete fracture due to
Fracture: overuse or high impact
ecchymosis on plantar foot,
tenderness to palp on calcaneus Complications = 50% intra-articular
fractures
Foot series & CT - compartment syndrome of foot
- arthritis with stiffness
Immobilization in bulky, dressing - nonunion, chronic pain
with post splint, pain control, NWB
with case for 6-8 weeks & surg if
necessary
Eval = swelling & tenderness Easily missed diagnosis
along dorsal midfoot & bruising on
mid foot or plantar aspect Complications:
- Post-trauma degenerative
Foot series (WEIGHT changes
BEARING**) - Complex regional pain
- widening btwn 1st & 2nd syndrome
metatarsal bases - Symptomatic implants req
- Fleck sign = fleck fracture near removal
base of 2nd metatarsal or med
cuneiform
Tx depends on degree of instability
- none = restore integ of TMT lig
(NWB in CAM boot)
- widening = surgical red, fix or
arthrodesis
- fracture/displ/disloc/compart
syndrome = URGENT ORTHO ref
Tenderness to palpation, HISTORY is key = acute fractures
ecchymosis & swelling (tuberosity & jones) & insidious pain
onset (diaphyseal stress fracture)
Foot series
Immobilize in short leg/post splint,
NWB with crutches, ice, ortho ref
CAM boot with WB 4-6 weeks Most common fracture at base of 5th
metatarsal fracture
CONCERN of disrupted blood
supply - affect healing
Controversial = surg with screw &
casting OR casting
Symptoms days before
presentation
Screw fixation due to high rate of
nonunions or conserv tx of NWB
Eval = discrete tenderness to 2nd metatarsal = most common
palpation
 MSK - LOWER EXTREMITY DISORDERS:
Fatigue fracture (FEMALES, military, runners,
high arch)
Insidious onset of aching pain
with ambulation or exercise
FRACTURES & DISLOCATIONS (BONY CONDITIONS):
Hallux Valgus: Deformity of 1st MTP joint -
prox phalanx deviates laterally
relative to 1st metatarsal -
poorly fitted, pointed shoes,
FEMALES
Joint prominence of 1st
metatarsal head after certain
shoes -> pain over medial
eminence, redness & swollen
SOFT TISSUE CONDITIONS OF THE FOOT:
Pes Cavus - “High Abnormal arch - decrease in
Arch”: plantar WB area (assoc with
clawing of tops)
Pes Planus - “Flat Progressive deformity due to
Foot”: collapse of medial longitudinal
arch - forefoot abduction &
hindfoot valgus
Arch pain, med ankle, heel,
pretibial pain
Posterior TIbial Progressive degenerative
Dysfunction (PTTD): condition in which tendon
becomes thick, swollen,
tender & inflamed -> causes
flat foot deformity & medial
arch pain (60 YR OLD
WOMEN)
Progressively worsening foot
pain with activity (STAIRS)
Sever Disease Traction apophysitis of growth
(Calcaneal center of calcaneus at
Apophysitis): insertion of achilles tendon
BOYS 8-12 (gymnastics,
soccer, martial arts) -
improper footwear
Pain at heel (worsens with
activity)
Plantar Fasciitis: Repetitive microtrauma &
overuse (prolonged walking &
standing, pes cavus, planus,
achilles tightness, obesity)
Foot series, bone scan & MRI
Pain control, ortho, post splint,
surgery if active person (due to
risk of displacement or nonunion)
Eval = swelling or calculus on med
aspect, deformity & tenderness to
palp
Foot series
Tx = conserv (wider shoes, spacer
btwn 1st & 2nd toes) or surg
Eval = atrophy of calf muscles Careful hx (residual clubfoot,
while pt standing post-traumatic, neuromusc disorders)
WB foot & ankle series
Tx = softer soled shoe, orthotics,
or surg
Gait analysis, “too many toes Common in kids as arch develops
sign” (see lesser toes when Most common cause is posterior
standing behind pt & Single heel tibial tendon dysfunction
Raise
WB foot series & MRI later on
Conserv tx (orthotics) or surgery if
pain persists
Normal arch WB, but flatten with Too Many Toes Sign = when
standing, swelling medially, standing behind pt, can see lesser
tenderness, pain with resisted toes (due to hyperpronation)
ankle plantar flexion & inversion
Single Heel Raise = have pt lift feet
WB ankle & foot series, & MRI at off ground -> if cannot perform or
later stages med ankle pain -> post tibial tendon
is weak or inflamed
CAM boot, arch support, NSAIDS,
PT or SURG if pain persists
Eval = point tenderness, swelling Calcaneal Squeeze Test = pain
at post calcaneus when pressing forcefully on lat & med
heel
Foot series (only if pain persists)
REASSURANCE*, activity mods,
heel cups, avoid barefoot walking,
Eval = tenderness of med Most common cause of heel pain
calcaneal tubercle & along plantar
fascia (pain with passive Complication = plantar fascia rupture
dorsiflexion of big toe)
 MSK - LOWER EXTREMITY DISORDERS:

Sharp, stabbing pain along clinical diagnosis** but can do Foot

plantar aspect of heel or foot
(severe in morning or
standing after rest)
series - WB if unclear
Conserv = avoid high impact,
stretching achilles & plantar fascia,
night splint, orthotics

Neuropathic Joint destruction from loss or
(Charcot) diminution of proprioception,
Arthropathy: pain & temp perception
Will see on boards (assoc with diabetic
neuropathy)
Swelling, redness & pain
Radiograph = osteolysis and
destruction of joints with sublux,
fragment of bone & sclerosis (arch
collapse)
PREVENT deformity, wounds &
amputation (tx primary disease),
assist w/WB)
“ROCKER BOTTOM FOOT”
Risks = periph neuropathy, trauma,
nephropathy
HIGH RISK PTS = diabetic control
sugars, freq foot exams, proper
shoes

Tarsal Tunnel Compressive or traction
Syndrome: neuropathy of post tibial nerve
(as it passes post to med
malleolus)
Cyst or lipoma in tarsal tunnel
(most common), trauma,
venous varicosities ->
paresthesia or burning
Eval = thickening, swelling, Ill-defined, burning, tingling pain
fullness (mild tenderness), + Tinel in plantar aspect of foot with POS
Sign, decreased sensation tinel sign
EMG-NCS = Sensory Nerve
Conduction velocity to confirm Dx
Conserv - surg (remove
cyst/lipoma)

Interdigital (Morton) Enlargement of 3rd
Neuroma: common digital branch of
medial plantar nerve (benign
M = looks like high growth from fibrous covering
heels & turn it of nerves) - 40-60 YR OLD
WOMEN wearing tight HIGH
ろ - M to side HEELS
3rd intermetatarsal
space Shooting pain with numbness
or burning pain in 3rd
W = MC in women interspace (worsens with
WB, tight shoes)
Eval = palpable 3rd interspace Feels like walking with a pebble in
causes pain to radiate into toes shoe
(palpable mass)
- Mulder Click = snapping Good prognosis but can develop a
sensation with squeezing forefoot true neuroma if nerve is
transected
Foot series to r/o bony conditions
Conserv tx = wide shoes,
metatarsal pads, NSAIDs
Surg = excise growth or
decompress nerve