Disorders of Lower Limb

Disorders of lower Disorders of lower limblimb

Causes :Causes :►Congenital. Congenital. ► Inflammatory.Inflammatory.►Degenerative.Degenerative.►Neurogenic.Neurogenic.►Traumatic.Traumatic.► Infective.Infective.► Idiopathic.Idiopathic.

Age groupsAge groups

►Newborn and InfantsNewborn and Infants►ChildrenChildren►AdolescentsAdolescents►Adults middle ageAdults middle age►Adults > 50Adults > 50

1) Hip Pathologies1) Hip Pathologies

Children Children

Adults Adults

►Tendinitis – ilIopsoas , adductor strainTendinitis – ilIopsoas , adductor strain►FAIFAI►Trochanteric bursitis Trochanteric bursitis ►Stress fracturesStress fractures►Early osteoarthritisEarly osteoarthritis►AVNAVN

AdultsAdults

►Established OAEstablished OA► Inflammatory OAInflammatory OA►Fragility fracturesFragility fractures►Metastasis Metastasis ► Infection Infection

DDHDDH►Breech presentationBreech presentation► Ist born femaleIst born female►Family historyFamily history

DDHDDH

DDHDDH

DDHDDH

Septic arthritisSeptic arthritis

PerthesPerthes► B> GB> G► Pain Hip or Pain Hip or

referred pain referred pain in the kneein the knee

► LimpingLimping► Limited internal Limited internal

rotationrotation

SUFESUFE►Pain and limpingPain and limping►Hx of recent injuryHx of recent injury►M>FM>F►12-15 Yrs12-15 Yrs►Flexion results in Flexion results in Ext rotation of the hipExt rotation of the hip

FAIFAI

Bursitis Bursitis ► Localised pain over Localised pain over

the G. Trochanterthe G. Trochanter

Stress fractureStress fracture

OAOA►Pain, poorly localisedPain, poorly localised►StiffnessStiffness►Lose rotation firstLose rotation first

AVNAVN►Alcohol and steroidsAlcohol and steroids►Xrays may be normalXrays may be normal

METASTASISMETASTASIS►Hx of Primary Ca Hx of Primary Ca

(thyroid, breast,lung (thyroid, breast,lung kidneys, prostate)kidneys, prostate)

► Unrelenting painUnrelenting pain

►Multiple myelomaMultiple myeloma► Chondrosarcoma Chondrosarcoma

2) The knee2) The knee

GENU VALGUS & GENU GENU VALGUS & GENU VARUSVARUS

CausesCauses►Lateral ligament laxityLateral ligament laxity►Blount’s diseaseBlount’s disease►Congenital pseudoarthrosis of tibiaCongenital pseudoarthrosis of tibia►Coxa varaCoxa vara

In ligamentous laxity notelat.Widening Of knee joints

In Blount angulation at med.tib metaphysis

InIn coxa vara ,angulation at the coxa vara ,angulation at the neck shaft levelneck shaft level

In cong. Pseudarthrosis of tibia,the angulation is in the distal ⅓

►Gait:Gait: intoeing, lateral thrust-the fibular intoeing, lateral thrust-the fibular head and upper tibia shift laterally in Blount head and upper tibia shift laterally in Blount due to laxity and incompetence of the lat. due to laxity and incompetence of the lat. Collat. Lig.Collat. Lig.

►StabilityStability►SymmetrySymmetry►Level of fibular head, Level of fibular head, normally at the normally at the

level of the upper tibial growth plate, while it level of the upper tibial growth plate, while it is proximal in Blount, cong.longitudinal is proximal in Blount, cong.longitudinal dificiency of the tibia and achondroplasiadificiency of the tibia and achondroplasia

X-rayX-ray► 3 years and older 3 years and older ►Getting worseGetting worse► Abnormal site of Abnormal site of

angulationangulation► Large physis and Large physis and

epiphysisepiphysis►History – History – taruma, taruma,

infection, possible metal infection, possible metal intoxication(lead or floride)intoxication(lead or floride)

Metaphysial/diaphysial angle ≥ 18°

FindingFinding

►Metaphysis, Metaphysis, thick and thick and frayed in rickets frayed in rickets

► InIn physiologic physiologic genu varum genu varum no no intrinsic bone disease, intrinsic bone disease, gentle curve, medial gentle curve, medial cortices thickening, cortices thickening, horizontal joint lines of the horizontal joint lines of the knee & ankle are tilted knee & ankle are tilted mediallymedially

Knock Knees / Genu Knock Knees / Genu ValgumValgum

► Legs are bowed Legs are bowed inwards in the inwards in the standing position. standing position. Bowing occurs at Bowing occurs at or around the or around the knee. On standing knee. On standing with knees with knees together, the feet together, the feet are far apart.are far apart.

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Normal Knee – Anterior, Normal Knee – Anterior, ExtendedExtended

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Surface Anatomy - Anterior, Surface Anatomy - Anterior, Extended* Extended*

Patella

Hollow

Indented

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Normal Knee – Anterior, FlexedNormal Knee – Anterior, Flexed

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Surface Anatomy - Anterior, FlexedSurface Anatomy - Anterior, Flexed

Head OfFibula

Patella

TibialTuberosity

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Palpation – Anterior*Palpation – Anterior*Patella:

Lateral and Medial Patellar Facets

Superior AndInferior Patellar Facets

Patellar Tendon**

Lateral Fat PadMedial Fat Pat

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Surface Anatomy - MedialSurface Anatomy - Medial

Medial FemoralCondyle

Patella

JointLine

MedialTibial Condyle

TibialTuberosity

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Palpation - MedialPalpation - MedialMedial Collateral Ligament (MCL)*

Pes anserine bursa**

Medial joint line

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Surface Anatomy – LateralSurface Anatomy – LateralPatella

Head OfFibula

TibialTuberosity

Quadriceps

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Palpation – Lateral*Palpation – Lateral*

Lateral joint line

Lateral Collateral Ligament (LCL)**

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Palpation - PosteriorPalpation - Posterior► Popliteal fossa*Popliteal fossa*

► Abnormal bulgesAbnormal bulges Popliteal artery aneurysmPopliteal artery aneurysm Popliteal thrombophlebitisPopliteal thrombophlebitis Baker’s cystBaker’s cyst

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Range Of Motion TestingRange Of Motion Testing► Extension Extension FlexionFlexion

00º º 135º 135º

► Describe loss of degrees of extensionDescribe loss of degrees of extension► Example: Example: “lacks 5 degrees of “lacks 5 degrees of

extension”extension”

► Locking* = Locking* = patient unable to fully extend patient unable to fully extend or flex knee due to a mechanical blockage or flex knee due to a mechanical blockage in the knee (i.e., loose body, bucket-in the knee (i.e., loose body, bucket-handle meniscus tear)handle meniscus tear)

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Special Tests – Anterior Knee Special Tests – Anterior Knee PainPain

►Patellar apprehension test*Patellar apprehension test*

►Patellofemoral grind test**Patellofemoral grind test**

Starting position

Push patella laterally

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Special Tests - LigamentsSpecial Tests - Ligaments

► Assess Assess stability of 4 stability of 4 knee knee ligaments via ligaments via applied applied stresses*stresses*

Anterior Cruciate PosteriorCruciate

Lateral CollateralMedial Collateral

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Stress Testing of LigamentsStress Testing of Ligaments► Use a standard exam routineUse a standard exam routine

Direct, gentle pressureDirect, gentle pressure No sudden forcesNo sudden forces

► Abnormal test Abnormal test 1.1. Excessive motion = laxityExcessive motion = laxity

What is NORMAL motion?*What is NORMAL motion?*

2.2. Soft/mushy end point**Soft/mushy end point**

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Collateral Ligament Collateral Ligament AssessmentAssessment

Patient and Examiner Position*

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Valgus Stress Test for MCL*Valgus Stress Test for MCL*

Note Direction Of Forces

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Varus Stress Test for LCL*Varus Stress Test for LCL*

Note direction of forces

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Anterior Drawer Test for ACLAnterior Drawer Test for ACL►Physician Position & Movements*Physician Position & Movements*►Patient PositionPatient Position

Note direction of forces

OsteoarthritisOsteoarthritis

Osteoarthritis (OA)Osteoarthritis (OA)►OA is the OA is the most common form most common form

of arthritis and the most of arthritis and the most common joint diseasecommon joint disease

►Over 10 million Americans Over 10 million Americans suffer from OA of the knee suffer from OA of the knee alonealone

►Most of the people who have Most of the people who have OA are older than age 45, OA are older than age 45, and women are more and women are more commonly affected than men.commonly affected than men.

►OA most often occurs at the OA most often occurs at the ends of the fingers, thumbs, ends of the fingers, thumbs, neck, lower back, knees, and neck, lower back, knees, and hips.hips.

OAOAOA is a disease of joints that affects all of the weight-bearing components of the joint:

•Articular cartilage•Menisci•Bone

OAOANodal osteoarthritis Note bony enlargement of distal and proximal interphalangeal joints (Heberden's nodes and Bouchard's nodes, respectively).

AgeAge► Age is the strongest risk factor for OA. Although OA can start in Age is the strongest risk factor for OA. Although OA can start in

young adulthood, if you are over 45 years old, you are at higher risk.young adulthood, if you are over 45 years old, you are at higher risk.

Female genderFemale gender► In general, arthritis occurs more frequently in women than in men. In general, arthritis occurs more frequently in women than in men.

Before age 45, OA occurs more frequently in men; after age 45, OA Before age 45, OA occurs more frequently in men; after age 45, OA is more common in women. OA of the hand is particularly common is more common in women. OA of the hand is particularly common among women. among women.

Joint alignmentJoint alignment► People with joints that move or fit together incorrectly, such as bow People with joints that move or fit together incorrectly, such as bow

legs, a dislocated hip, or double-jointedness, are more likely to legs, a dislocated hip, or double-jointedness, are more likely to develop OA in those joints. develop OA in those joints.

OA – Risk Factors

Hereditary gene defectHereditary gene defect► A defect in one of theA defect in one of the genes responsible for the cartilage genes responsible for the cartilage

component collagen can cause deterioration of cartilage. component collagen can cause deterioration of cartilage.

Joint injury or overuse caused by physical labor or Joint injury or overuse caused by physical labor or sportssports

► Traumatic injury (ex. Ligament or meniscal tears) to the knee Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for developing OA in these joints. or hip increases your risk for developing OA in these joints. Joints that are used repeatedly in certain jobs may be more Joints that are used repeatedly in certain jobs may be more likely to develop OA because of injury or overuse. likely to develop OA because of injury or overuse.

ObesityObesity

► Being overweight during midlife or the later years is among Being overweight during midlife or the later years is among the strongest risk factors for OA of the knee. the strongest risk factors for OA of the knee.

OA – Risk Factors

Osteoarthritis (OA) - Osteoarthritis (OA) - DefinitionDefinition

Osteoarthritis may result from wear and tear on the joint

•The normal cartilage lining is gradually worn away and the underlying bone is exposed.

Osteoarthritis (OA) - Osteoarthritis (OA) - DefinitionDefinition•The repair mechanisms of tissue absorption and

synthesis get out of balance and result in osteophyte formation (bone spurs) and bone cysts

A case of the, “Which came first? The chicken or the egg?”

Asymmetrical joint space narrowing from loss of articular cartilage

The medial (inside) part of the knee is most commonly affected by osteoarthritis. 

OA – Radiographic Diagnosis

OA – Radiographic Diagnosis•Asymmetrical joint space narrowing

•Periarticular sclerosis

•Osteophytes

•Sub-chrondral bone cysts

OA – Arthroscopic Diagnosis

Normal Articular Cartilage

Ostearthritic degenerated cartilage with exposed subchondral bone

Arthroscopy allows earlier diagnosis by demonstrating the more subtle cartilage changes that are not visible on x-ray

•OA is a condition which progresses slowly over a period of many years and cannot be cured•Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition

•Functional treatment goals:•Limit pain•Increase range of motion•Increase muscle strength

OA – Disease Management

OA – Non-operative Treatments

•Pain medications•Physical therapy•Walking aids•Shock absorption•Re-alignment through orthotics•Limit strain to affected areas

•Osteoarthritis usually affects the inside half (medial compartment) of the knee more often than the outside (lateral compartment).

•This can lead to the lower extremity becoming slightly bowlegged, or in medical terms, a genu varum deformity

Proximal Tibial Osteotomy

Proximal Tibial Osteotomy•In the procedure to realign the angles, a wedge of bone is removed from the lateral side of the upper tibia.

•A staple or plate and screws are used to hold the bone in place until it heals.

•This converts the extremity from being bow-legged to knock-kneed.

•The Proximal Tibial Osteotomy buys some time before ultimately needing to perform a total knee replacement. The operation probably lasts for 5-7 years if successful.

3) The foot3) The foot

Case1 varus deformityCase1 varus deformity

Case 2 calcaneus deformityCase 2 calcaneus deformity

Case 3 equinus deformityCase 3 equinus deformity

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