Image Challenge: Hip, Foot and Ankle UCSF Primary Care Sports Medicine Conference 2018 Carlin Senter, MD Associate Professor UCSF Primary Care Sports Medicine 12/13/2018 Anthony Luke, MD, MPH Professor The 3 hip ROM tests in order are: A. B. Extension, flexion, adduction C. Extension, flexion, abduction D. Flexion, abduction, adduction Name the 3 hip ROM tests the in order in E. Flexion, adduction, abduction which they are performed here: F. Flexion, external rotation, internal rotation Flexion, internal rotation, external rotation 1 71% 1% Extension, flexion, adduc... 0% 6% Extension, flexion, abduc... 3% Hip passive range of motion Flexion, abduction, addu... 19% Flexion, adduction, abdu... Flexion, external rotation,... Flexion, internal rotation,... Flexion normal 120° http://www.youtube.com/watch?v=5LNYdJIrWYo External normalrotation 40-60° Internal normalrotation 30- 40° Hip passive range of motion: internal and external rotation What is the most likely diagnosis? A. B. Trochanteric bursitis C. Iliotibial band tendinitis 21 y/o soccer player has groin pain with this D. Hip flexor tendinitis maneuver. What is the most likely diagnosis? E. Femoroacetabular impingement Sacroiliac joint dysfunction 2 82% 2% 9% Trochanteric bursitis Iliotibial band tendinitis 2% Hip flexor tendinitis FADIR 4% Femoroacetabular imp... Sacroiliac joint dysfunction . Flexion . Adduction . Internal . Rotation http://www.aafp.org/afp/2009/1215/p1429.html Please focus on L hip. What x-ray findings do you NOT see? 4 radiographic hallmarks of osteoarthritis 1. Joint space narrowing 2. Subchondral sclerosis What x-ray findings of the L hip are seen? 3. Subchondral cysts 4. Osteophytes A. B. Joint space narrowing C. Subchondral sclerosis D. Subchondral cysts E. Osteophytes Femoral neck fracture 3 Which muscle is weak in this runner? 87% 7% Joint space narrowing 0% 6% Subchondral sclerosis Subchondral cysts 0% Osteophytes Femoral neck fracture Which Muscle is weak in this runner? A. B. Gluteus Minimus C. Gluteus Medius D. Piriformis E. Quadratus Lumborum F. Hamstring Rectus abdominis 78% What will this patient have difficulty doing? A. 8% B. Wearing running shoes C. Swimming Gluteus Minimus D. Going on her toes Gluteus Medius 1% E. Curling her toes 4% Piriformis F. Taking her shoes off 6% Case: What will this patient have difficulty doing ? Quadratus Lumborum Feeling her little toe 4% Hamstring Rectus abdominis 77% 15% 4 Wearing running shoes 0% Swimming 4% Going on her toes Curling her toes 0% 3% Taking her shoes off Feeling her little toe PT Dysfunction Presentation . Usually women > 40 y.o. Weakness with inversion . “ . Too many toes sign Unable to plantarflex – Single limb heel rise test ” Looseness on this Exam is Consistent with Injury to ? A. B. High tibial fibular ligament C. Anterior Talofibular ligament D. Calcaneal Fibular ligament E. Posterior Talofibular ligament Spring Ligament 80% 2% High tibial fibular ligament Anterior Talofibular liga... What is the difference between these two7% R knee x-rays taken days apart onCalcane athel Fibular lsameigament 11% Posterior Talofibular lig... patient? 1% Spring Ligament 1. 2. 1. Ankle Ligaments Lateral Collateral Complex . Anterior talofibular lig. Calcaneofibular lig. MedialPosterior Ligament talofibular Complex lig. Deltoid ligament Superficial and deep ligaments 5 The difference between the 2 radiographs: A. B. Non weight-bearing versus weight-bearing C. Extended versus flexed D. AP versus lateral AP versus sunrise view 0% Non weight-bearing vers.. 0% Extended versus flexed 0% AP versus lateral 0% AP versus sunrise view 10 Weight-bearing radiographs increase sensitivity for joint space narrowing 3 views for knee pain - Weight bearing flexed PA (aka notch view) - Lateral of affected side - Sunrise or merchant view What is the diagnosis? FW B XR What is the diagnosis? . A. 66 y/o woman B. Glenohumeral joint osteoarthritis Presented to urgent care with sudden severe R shoulder pain C. Frozen shoulder . that developed a few days after doing extensive yard work D. Calcific tendinitis ROM limited to 10 degrees forward flexion, 10 degrees abduction. E. Gout . Unable to tolerate strength testing of shoulder due to F. Polymyalgia rheumatic excruciting pain Fibromyalgia 6 0% Glenohumeral joint oste... 0% Frozen shoulder Calcific tendinitis of the shoulder 0% Calcific tendinitis 0% . Calcium deposit in rotator cuff tendon, most commonly Gout 0% supraspinatus at its insertion on greater tuberosity of Polymyalgia rheumatic 0% . humerus Fibromyalgia Can cause severe shoulder pain, causing patient to go to 10 . emergency room . Can be asymptomatic, incidentally found on radiographs . Diagnosed by radiograph or ultrasound Tx (not a lot of evidence for any of following) - - Rest, ice, NSAIDs, Physical therapy Subacromial corticosteroid injection - deposition Extracorporeal shock-wave therapy (Bannuru RR et al. Annals - Internal Medicine, 2014) Arthroscopic debridement if above does not resolve symptoms can dissolve calcium Case: What nerve is involved here? Winged scapula . Long thoracic nerve = pure motor . nerve Injury muscle . obvious on a wall pushup Causes paralysis of serratus anterior What nerve is involved here? - Brachial neuritis (Parsonagewinged scapula turner) most - Trauma or compression . - A. UsuallyStretch resolves or traction over 1-3 years . B. Superficial branch of the radial nerve Physical therapy to maintain range of motion, strengthen around the injury C. Axillary nerve UpToDate “Overview of upper extremity peripheral nerve syndromes” accessed 7/15/17. D. Suprascapular nerve E. Long thoracic nerve F. Musculocutaneous nerve Ulnar nerve 7 0% Superficial branch of the... 0% Axillary nerve 0% Suprascapular nerve 0% Long thoracic nerve 0% Musculocutaneous nerve 0% Ulnar nerve 29 10 Have a great evening! See you tomorrow.