Belmatt Healthcare Training www.belmatt.co.uk 0207 692 8709 [email protected]
Minor Injuries Course
Clinical Approaches to the Lower Limb
Contents:
Hip Clinical Hip Anatomy
Clinical Hip Assessment
Clinical Case Studies of the Hip
Knee Clinical Knee Anatomy
Clinical Knee Assessment
Clinical Case Studies of the Knee
Ankle and Foot Clinical Ankle and Foot Anatomy
Clinical Ankle and Foot Assessment
Clinical Case Studies of the Ankle and Foot
2 Clinical Hip:
Acetabulum • Lunate surface o Load shifts from periphery to centre of lunate surface under increasing load. • Acetabular labrum
Ilium • Anterior, posterior, and inferior gluteal lines o Which muscles attach between the anterior, posterior and inferior gluteal lines?
Which gluteal muscles are responsible for internal rotation? External rotation?
How does gluteus medius contribute to both internal and external rotation?
Pubis • Pubic symphysis • Symphysis mobility during walking o Vertically 2.6mm o Sagittally (Anterior/posterior) 1.3mm o In pregnancy the pubic symphysis width increases 2- 3mm (a total gap of 9mm- similar to a newborn) § Length and height of stride shortens due to this change. § Foot inversion can occur if pelvic loosening causes pain.
Ischium • Ischial tuberosity o What muscles attach to this tuberosity?
Femur • Head o Why is the hip joint is least stable when both flexed and adducted?
• Neck o Most common fracture site in the elderly.
• Greater and lesser trochanters Greater
3 o Anterior border § Gluteus minimus § Action: o Lateral border § Gluteus medius § Action: o Posterior border § Obturator internus/externus, superior/inferior gemelli § Action: Lesser o Psoas major, iliacus o Action:
Ligaments • Iliofemoral ligament (Y-Shaped) o Tensile strength > 350kg o Is twisted during standing. This helps maintain erect posture without need for muscular activity. o This tension also helps keep femoral head pressed into the acetabulum. o Hip flexion: ligament tension reduced, hip mobility increased.
• Pubofemoral ligament o Limits extension and lateral rotation of the hip.
• Ischiofemoral ligament o Limits extension and medial rotation of the hip.
• Joint Capsule o Thin and loosely attached posteroinferiorly.
Musculature
Image:https://upload.wikimedia.org/wikipedia/commons/5/55/Posterior_Hip_Muscles
4 Gluteal Compartment: - Abduction, external, internal rotation • Gluteus maximus • Gluteus medius • Gluteus minimus • Piriformis
- Small external rotators • Superior and Inferior Gemelli • Obturator internus tendon • Quadratus femoris
Posterior Thigh Compartment - Thigh Extension, Knee Flexion, Leg Rotation • Semitendinosus and Semimembranosus • Biceps femoris •
Medial Thigh Compartment - Adduction • Adductor longus and Adductor Brevis • Pectineus • Gracilis
- Adduction, flexion, extension • Adductor magnus
Anterior Thigh Compartment - Hip and Knee flexion • Iliopsoas • Sartorius • Tensor fasciae latae Rectus femoris
https://web.duke.edu/anatomy/Lab14/Lab14.html
5 Clinical Hip Assessments:
Gait analysis: Trendelenburg gait Antalgic gait
Functional Tests: Standing Lift foot onto 20 cm step and return (hip flexion-extension) 0 reps nonfunctional, 1-2 reps functionally poor, 3-4 reps functionally fair, 5+ reps functional Sit in chair and return to standing (hip extension-flexion). 0 reps nonfunctional, 1-2 reps functionally poor, 3-4 reps functionally fair, 5+ reps functional Walk sideways 6m (hip adduction/abduction). 0m nonfunctional, 1-3m one way functionally poor, 3-6m one way functionally fair, 6-8m one way functional. Test leg off floor (patient may hold for balance) and internal rotate non-weight bearing hip. 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-12 reps functional Test leg off floor (patient may hold for balance) and externally rotate. 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-12 reps functional
Special Tests: FABER (Flexion, Abduction, and External Rotation) • Supine patient, test leg has foot on top of the knee of opposite leg • Test leg knee lowered toward table. • Negative test indicated by test leg’s knee falling to the table, positive test indicated by test leg’s knee remaining above opposite straight leg. • Positive indicates hip joint problems, iliopsoas spasm, SI joint issues.
FADDIR(Flexion, Adduction, and Internal Rotation) • Tests for anterior-superior impingement syndrome, anterior labral tear, iliopsoas tendinitis. • Supine patient, hip placed into full flexion, lateral rotation, and full abduction to start. • Hip then extended with internal rotation and adduction. • Positive test produces pain, symptom reproduction with or without a click or apprehension Trendelenburg Sign • Assesses hip stability and hip abductor stabilisation. • Patient stands on one limbIf pelvis on opposite side rises, negative test. • If pelvis on opposite side drops, positive test. • Positive test indicated weak gluteus medius or unstable hip.
6 Hip Peripheral Nerve Neuropathy: Nerve: Sciatic (L4-S3) Muscle Weakness: - If injured in pelvis or upper femur area, hamstrings and all muscles below the knee can be affected. Results in a high steppage gait with inability to stand on heel or toes. Sensory Alteration: Entire foot except instep and medial malleolus. Mechanism of Injury: Can be injured anywhere along its path from the lumbosacral spine down the back of the leg to the knee. Is the most commonly injured nerve in the hip region.
Nerve: Femoral (L2-4) Muscle Weakness: Patient not able to flex the thigh on the trunk or extend the knee. Deep tendon knee reflex lost. Sensory Alteration: medial aspect of distal thigh and medial aspect of leg and foot (saphenous nerve). Mechanism of Injury: Not commonly injured, though childbirth, anterior femoral dislocation, or hernia surgery, stripping of varicose veins, hip surgery, or fractures may cause.
Nerve: Obturator Nerve (L2-4) Muscle Weakness: Weak adduction, knee flexion and hip lateral rotation. Sensory Alteration: Small, involving a small area in the middle medial part of the thigh, although complaints of pain from pubic symphysis to medial aspect of knee are common. Mechanism of Injury: May be compressed as it leaves the pelvis or injured by pelvic or hip surgery, pregnancy, fractures, or tumors, and is a cause of pain in athletes.
http://www.onhealth.com/content/1/bursitis_hip_knee_joint
7 A 24 year old man presented with a one week history of right posterior thigh pain following a football injury at the weekend. He reports that he felt severe pain and a ‘twange/pop’ sensation after kicking a ball. He reports no swelling but has noticed a small bruise in the centre of the posterior thigh. He describes that symptoms are worse with activity and in the mornings he notices the muscles are tight but ease with gentle movement and stretches.
1. Which muscles are involved? 2. Why does it hurt more during knee extension? 3. What would you do next?
A 72-year-old female, was brought to the emergency room by her son-in-law after falling in her bathtub. She fell upon entering the bathtub when her right leg slipped out from under her; she landed on her right hip. There was no trauma to her head, nor does she complain of right or left wrist pain. However, she reports severe pain in the right hip and upper thigh, and was unable to get up after her fall. She presents with a shortened and externally rotated right leg. 1. What is the diagnosis? 2. What do you do next? 3. Which muscles cause this clinical presentation?
A 36-year-old male patient presented with insidious onset of progressive anterior right hip and groin pain of 7 years' duration.
1. What do you do next? 2. What special tests might you do to assess impingement? 3. If femoroacetabular impingement is diagnosed, what options exist for the patient?
8 Clinical Knee Anatomy: • Distal femur: o Femoral condyles § Medial vs. Lateral o Patellar surface § Patellofemoral pain syndrome o Femoral epicondyles
• Meniscus o Why are tears of the medial meniscus more common than tears of the lateral meniscus?
• Tibia: o Tibial condyles o Tibial plateau o Intercondylar eminence o Tibial tuberosity
• Patella: o Articular surface o Patellar ligament vs. Quadriceps tendon
Patellar Apprehension Test
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(http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/lateral%20patellar %20apprehension.htm)
• Genu Varum and Genu Valgum o Genu varum (bowleg) is characteristic in certain conditions such as rickets. Excessive pressure is taken by the medial side of the knee joint in this condition. o Genu valgum (knock knee) is normal in children under the age of six. Excessive pressure is taken by the lateral side of the knee joint in this condition o If either of these conditions are not corrected in the adult, they can lead to the development of osteoarthritis.
Ligaments • Anterior cruciate ligament o Restraint to anterior tibial displacement.
• Posterior cruciate ligament o Restraint to posterior tibial displacement.
• Medial (tibial) collateral ligament o Resists valgus o Stronger than LCL (LCL reinforced by iliotibial band).
• Lateral (fibular) collateral ligament o Primary restraint to varus load. o More mobile than MCL
• If a force applied against the knee when the foot cannot move, ligament injuries are likely. • Tearing of the medial collateral ligament may also tear the medial meniscus due to their firm attachment. This often results from twisting the knee whilst flexed.
10 • Additionally, an “unhappy triad” may occur when the anterior cruciate ligament is also ruptured. What specific movements cause the unhappy triad?
. Muscles: Anterior Compartment - primarily extension of the knee
• Tensor fasciae latae o Lateral knee stabilisation.
• Vastus lateralis
• Vastus intermedius
• Vastus medialis
• Linea aspera
- Quadriceps: o Predominate at all times during knee motion. o Generate most of the muscle force on the knee.
Posterior Compartment - Primarily knee flexion • Biceps femoris
• Semitendinosus and Semimembranosus • Plantaris
• Popliteus
Medial Compartment • Gracilis
• Sartorius
Pes Anserinus (“goose’s foot”) o The insertion of Sartorius, gracilis, and semitendinosus. o Irritation of the underlying bursa from overuse or injury can cause inflammation.
11 Clinical Knee Assessment: Ottawa Knee Rules: - Xrays are only required if the following are present: o Isolated bony tenderness of the patella o Bony tenderness of fibula head o Patient cannot flex knee to 900 o Patient cannot weight bear (4 steps) after injury or in A&E.
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Common Mechanisms of injury: Varus/valgus contact without rotation Injured structures: Collateral ligament, epiphyseal fracture, patellar dislocation Varus/valgus contact with rotation Injured structures: Collateral and cruciate ligaments, patellar dislocation, meniscus tear
13 Hyperextension Injured structures: ACL, PCL, posterior capsule
Hyperflexion Injured structures: Meniscus (posterior horn), ACL Forced internal rotation Injured structures: Lateral meniscus Forced external rotation Injured structures: Medial meniscus, MCL, ACL
Genu valgum Possible correlated motions: Pes planus Excessive subtalar pronation Lateral patellar subluxation Excessive hip adduction Ipsilateral hip excessive internal rotation Lumbar spine contralateral rotation Possible compensatory motions: Forefoot varus, excessive subtalar supination (allow lateral heel to contact ground), in-toeing (decrease lateral pelvic sway during gait), ipsilateral pelvic lateral rotation. Genu varum Possible correlated motions: Excessive lateral angulation of the tibia in the frontal plane; tibial varum. Medial tibial torsion, ipsilateral hip lateral rotation. Excessive hip abduction Possible compensatory motions: forefoot valgus, excessive subtalar pronation to allow the medial heel to contact the ground, ipsilateral pelvic medial rotation.
I Genu Valgum II Genu Valgum (http://www.orthoseek.com/articles/img/bowl1.gif)
14 Specific tests: Joint line tenderness (meniscal pathology) Childress sign (duck squat- meniscus) Anterior/Posterior drawer tests Lachman’s test McMurray test (no longer recommended) Low sensitivity, reliabilty, and pain.
Knee muscles and Referred Pain:
Tensor fasciae latae: Lateral aspect of thigh Sartorius: Over course of muscle Quadriceps: Anterior thigh, patella, lateral thigh, and knee (vastus lateralis) Adductor Longus/Brevis Superior anterolateral thigh, anterior thigh, proximal to patella and sometimes down anteriomedial leg. Gracilis Medial thigh (midportion) Semimembranosus/semitendinosus Ischial tuberosity, posterior thigh, posteromedial calf Biceps femoris Posterior knee up posterior thigh Gastrocnemius Posterior knee, posterolateral calf, posteromedial calf to foot instep
15 Posterior Leg with Ligaments and Muscles
16 Artist Image : Anterior Leg and Dorsum of foot
17 Clinical Case Studies:
A 17 year old male football player presents by stating that his knee feels unstable. He says during his last game, he twisted to challenge a player, and felt a ‘pop’ in his knee.
1. What soft tissues could be affected? 2. How would you test for each soft tissue? 3. Would you order an Xray?
A 10 year old boy presents to you with anterior knee pain that gets worse with exercise. 1. Describe your assessment. 2. Do you order an Xray? 3. What do you do next?
A 72 year old woman notes that her left knee has recently begun to swell. She has had pain in the medial aspect of the knee for several years but only recently did she notice fullness around the knee. She fell several weeks ago and supposes that the fall may have caused the buildup of fluid. The knee hurts her all day long but feels worse going down stairs, especially early in the morning and late in the day. She finds paracetamol helpful, but the pain relief is not adequate for her to be fully active.
1. Describe your assessment. 2. Do you order an Xray? 3. What do you do next?
How are the structures of the foot and leg affected by wearing high-heeled shoes or boots? What surface anatomical structures would you expect to change when a person puts on this type of footwear?
On the death of her husband, a 50yr old female decided to earn her living by becoming an office cleaner. Part of her work involved scrubbing a flight of stone steps. After 3 weeks she noticed a painful swelling in front of the lower part of the left knee. What is the diagnosis?
You arrive at an accident scene and find a young gentleman lying on the group. He states he was knocked by a car and is now unable to stand. On examination ABC intact. However, you note that his left leg is shortened and externally rotated. What is the possible diagnosis?
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Artist Image : Anterior Leg with Ligaments, Muscles
19 Clinical Ankle and Foot Anatomy: Tibia • Medial malleolus
Fibula:
Tarsals: • Talus • Calcaneus o Forms the “heel” of the foot and consequently receives the ground reaction forces during the heel strike portion of initial contact. • Navicular • Cuboid • Medial, middle and lateral cuneiform • Metatarsals and phalanges
Image : Anterior Ankle http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/image_artic le_collections/anatomy_
20 Joints:
https://www.slideshare.net/AkramJaffar/anatomy-of-the-ankle-and-joints-of-foot
The Ankle (Talocrural Joint) The ankle joint is a synovial hinge joint and is formed between the distal tibia, distal fibula and the talus.
Ankle Movements • Dorsiflexion: 10-20o • Plantarflexion: 40-55o - These movements allow forward progression during locomotion.
Ligamentous Support of Talocrural Joint. - Approximately 90% of all ankle sprains are supination injuries.
Lateral Ligaments - Resist supination
• Anterior talofibular ligament o Resists ankle inversion during plantar flexion o Most commonly sprained
• Calcaneofibular o Resists ankle inversion during dorsiflexion o Second most commonly sprained ankle ligament
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Medial Ligaments • Deltoid o Resist pronation
Syndesmotic Ligaments - Maintain stability between distal fibula and tibia.
• Anterior tibiofibular • Posterior tibiofibular • Transverse tibiofibular ligament • Interosseous membrane
Parts of the foot - The foot can be divided into hindfoot, midfoot, and forefoot.
Hindfoot • Comprises the talus and calcaneus • Includes the subtalar joint • Includes heel pad o U-shaped and consists of vertical fat-filled columns reinforced by elastic transverse and diagonal fibres to produce a honeycomb effect. o Designed to absorb shock. o ~ 11,610 heel impacts per mile of walking. Subtalar Joint - Includes the talus and calcaneus bones.
Subtalar Movements: • Equal amounts of inversion/eversion o To assess, grasp calcaneus and rock it side to side • Equal amounts of abduction/adduction • Limited dorsi/plantar flexion • Subtalar movement never occurs in isolation to midfoot motion.
Midfoot • Comprises cuboid, navicular, and cuneiform bones. • No significant dislocation of metatarsals or cuneiforms can occur unless bone is broken. o Fractures through or around 2nd metatarsal base are most common causes of mid tarsal movement. o Movements: • Hindfoot movement never occurs in isolation to midfoot motion.
Intertarsal Joints - Are closely congruent and exhibit minimal movement amongst each other. • Cuneonavicular joint
22 o Plantar calcaneonavicular (Spring) ligament § Helps to maintain medial longitudinal arch of the foot. § Bears the major portion of body weight by supporting the head of the talus. § Disruption of this ligament contributes to talar vertical tilt and hindfoot valgus.
• Cuneocuboid joint o Calcaneocuboid ligaments § Maintain the arch of the foot § Short Plantar and Long Plantar Ligaments
Tarsometatarsal (Lisfranc) Joints - Intrinsically stable due to an arch-like configuration. • 2nd metatarsal joint rigidity is the central structure of the medial longitudinal arch. o It provides a rigid lever for push-off in late stance. • Motion of 1st, 4th, and 5th joints greater than 2nd and 3rd. o 1st tarsometatarsal joint ~10o plantar flexion.
Hindfoot (Subtalar)-Midfoot (Transverse Tarsal) Relationship • Subtalar pronation/supination give flexibility to transverse tarsal joint. • Subtalar eversion: both longitudinal and oblique axes are parallel. o This allows a ‘loose packed’ condition for the transverse tarsal joint which allows motion. • Subtalar inversion: locks the transverse tarsal joint. o This provides rigidity in the midfoot. o Transverse tarsal joint is in a “closed packed” position.
Forefoot • Comprises metatarsals and phalanges • Ability to move independently of hindfoot allows forefoot to adapt to variable terrain.
Metatarsophalangeal (MTP) Joints • Joints between metatarsals and proximal phalanges • Stabilised by ligaments o Medial and Lateral collateral ligament o 4 Transverse metatarsal ligaments § Narrow bands which run across and connect the metatarsal heads.
Interphalangeal Joints • Hallux has a single interphalangeal joint. • 2nd-5th toes have both proximal (PIP) and distal interphalangeal (DIP) joints. • Flexion is generally greater than extension. • PIP has slightly greater range of motion than DIP.
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Foot Arches • Medial Longitudinal Arch Components o Main characteristic is its elasticity. o Weakest part is talonavicular joint, though the plantar calcaneonavicular (spring) ligament reinforces. o Calcaneonavicular (spring) ligament blends with deltoid ligament and is supported inferiorly by tibialis posterior tendon. o Plantar aponeurosis also supports the medial longitudinal arch.
o Three most important contributors to arch stability § Plantar Fascia § Long/Short Plantar ligaments § Calcaneonavicular (spring) ligament
• Lateral Longitudinal Components o Principle joint is calcaneocuboid joint. This joint is able to lock and allow limited movement. o Reinforced by short and long plantar ligaments.
Muscle Control of Ankle Posterior Compartment - Primarily plantar flexion
• Gastrocnemius
• Soleus
- Soleus and gastrocnemius both contribute to the calcaneal tendon (Achilles tendon) and through it attach ro the calcaneus.
• Plantaris o Absent in 10-20% of people. o Similar in form and function to palmaris longus
• Flexor digitorum longus
• Flexor hallucis longus
• Tibialis posterior o Medial ankle stabilisation.
24 https://web.duke.edu/anatomy/Lab14/Lab14.html
Lateral Compartment This is the smallest of the muscular compartments of the leg and contains two muscles: • Fibularis (peroneus) longus
• Fibularis (peroneus) brevis
Anterior Compartment - primarily dorsi flexion • Tibialis anterior
• Extensor digitorum longus
• Extensor hallucis longus
• Fibularis (peroneus) tertius
Muscle Control of the Foot • Extensor digitorum brevis
• Extensor hallucis brevis
• Plantar aponeurosis
25 https://web.duke.edu/anatomy/Lab14/Lab14.html
Initial Contact During Running o Hindfoot running § Initial ground contact occurs at the hindfoot § Similar kinematic pattern to normal walking.
o Midfoot running § Initial contact occurs at heel and forefoot simulteaneously. § Decreased ankle dorsiflexion. § Toes extended
o Forefoot running § No heel strike § Ankle plantarflexed and toes extended § Foot slightly inverted (supinated) § Contact occurs on lateral aspect just posterior to metatarsal heads. § Ankle dorsiflexes and heel comes in contact prior to mid-stance. § After heel contacts ground, normal kinematic pattern.
• Foot experiences 275% body weight during running
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Clinical Foot and Ankle Assessment:
Ottawa foot and ankle rules Xrays only obtained for the following: - Bone tenderness is present over the lateral or medial malleolus. - If patient is unable to weight bear for 4 steps both immediately post- injury and in A&E.
Do not order Xrays for the following: - Patients younger than 15 or older than 60 - Intoxicated patients - Multiple painful injuries - Pregnancy - Head injury - Or diminished sensation due to neurologic deficit. - Patients who exhibit laxity of the ATFL without other clinical findings.
Common Mechanisms of injury (malalignment): Rearfoot varus (calcaneal varus) Possible correlated motions: Tibial, femoral and pelvic lateral rotation Possible compensatory motions: Excessive internal rotation, hallux valgus, plantar flexed first ray, functional forefoot valgus, prolonged midtarsal pronation. Rearfoot valgus(calcaneal valgus) Possible correlated motions: Tibial, femoral and pelvic internal rotation, hallux valgus. Possible compensatory motions: Excessive external rotation, functional forefoot varus.
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http://www.steenwyk.com/pronsup.htm
Hallux valgus Possible correlated motions: Forefoot valgus, Subtalar pronation and related rotation Possible compensatory motions: Excessive tibial/femoral/pelvic lateral rotation, ipsilateral lumbar spine rotation.
Passive Assessment: Plantar flexion, dorsiflexion (extension)- talocrural joint Supination, pronation- subtalar joint Abduction/adduction- midtarsal joint Flexion/extension- toes Abduction/adduction-toes
Active Assessment: Squatting (both ankles dorsiflex symmetrically) Standing on toes (both ankles plantar flex symetrically) Squatting and bouncing at end of squat Standing on one foot at a time Going up and down stairs Walking on toes Running straight ahead Jumping Jumping and going into full squat Functional Tests: Standing on one leg Dorsiflex toes 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-15 reps functional Plantar flex
28 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-15 reps functional Lift lateral aspect of foot off ground 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-15 reps functional Lift medial aspect of foot off ground 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-15 reps functional Seated Pull small towel up under toes or pick up and release small object 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-15 reps functional Lift toes off ground (toe extension) 0 reps nonfunctional, 1-4 reps functionally poor, 5-9 reps functionally fair, 10-15 reps functional
Special Tests: Anterior Drawer test of ankle (ligamentous instability): Primarily tests for anterior talofibular ligament injuries. Supine patient with foot relaxed. Tibia and fibular stabilised with patient’s foot in 200 plantar flexion. Talus moved forward. Sometimes a dimple appears over the ATFL area if pain and muscle spasm are minimal.
Foot and Ankle Peripheral Nerve Neuropathy
Nerve: Deep Peroneal/Fibular (L4-S2) Muscle Weakness: Tibialis anterior, extensor digitorum longus/brevis, extensor hallucis longus Sensory Alteration: Triangular area bewteen 1st-2nd toes
Nerve: Superficial Peroneal/Fibular(L4-S2)
29 Muscle Weakness: Peroneus (fibularis) longus/brevis Sensory Alteration: Lateral aspect of dorsum of foot
Nerve: Tibial (L4-S3) Muscle Weakness: Gastrocnemius, soleus, plantaris, tibialis posterior, Flexor digitorum longus, flexor hallucis longus, foot intrinsic muscles Sensory Alteration: Sole of foot except medial border, plantar surface of toes
Plantar Fasciitis vs Tarsal Tunnel Syndrome Plantar fasciitis Cause: overuse Pain: Plantar aspect of foot, anterior calcaneus. Worse with walking/running, and in the morning Full ROM of passive and active movements Normal resisted isometric movements No sensory deficits Normal reflexes Tarsal tunnel syndrome Cause: trauma, space occupying lesion, inflammation, inversion, pronation, valgus deformity. Pain: Medial heel and medial longitudinal arch, worse with standing, walking and at night. Full active ROM Pain on passive pronation Weakness of foot intrinsics upon resisted isometric movements No sensory deficits Normal reflexes
30 Clinical Case Studies:
A 28 year old female presented with pain in both lower legs on the inside of her shinbones radiating approx. 6 inches above her ankle. She was training for her first half marathon. She explained how when she first set out on a run her legs would be fine but after only five minutes the pain became so severe that she had to stop and walk home.
1. What passive movements would make her symptoms worse? 2. What muscles are associated with those movements? 3. Do you order an Xray? 4. What do you do for the patient?
A 63 year old male presented with a ‘turned ankle.’ He mentions that he was running and lost his balance and turned his ankle. He felt a searing pain in the outer surface of his right ankle. He has swelling, and bruising about the ankle but has been treating himself with R.I.C.E. since the incident.
1. Which two ligaments are likely involved? 2. How would you test each of the ligaments? 3. Do you order an Xray? 4. What treatment is given for the patient?
A 42 year old female presents with continual pain upon walking in any shoes other than her sandals. When she wears shoes she finds moderate pain about the base of her big toe. As she works in a hospital environment she is worried about how this affects her ability to continue her job.
1. Which joint is likely affected? What is the diagnosis? 2. Do you order an Xray? 3. What tests might you do? 4. What treatment options may be available?
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