1
Q
What are joints of the lower limb you would assess?
A
- Spine
- Hips
- Knee
- Ankle
- Foot
2
Q
What is cauda equina syndrome?
A
- The spinal cord ends near the first lumbar vertebrae, cauda equina are a bundle of nerves below the spinal cord.
- Contains the nerve roots from L1-L5 and S1-5
3
Q
what is the longest, widest nerve in the body?
A
- The sciatic nerve
- Herniated / slipped disc can cause sciatic nerve pain.
4
Q
Name the dermatones:
A
Cervical c1-7
Thoracic T1-12
Lumbar L1-5
Sacral S1-2
5
Q
Pain timeframe classification:
A
Acute :<6 weeks
Subacute: 6-12 weeks
Chronic: >12 weeks
6
Q
HX
A
- SOCRATES
- Ask about occupation
- Ask if they have been doing any heavy lifting/gym
- Steroid use- may weaken the bone
- Ask about cancer- possible metastasis
- Have they been managing the pain?
7
Q
Spine examination:
A
look:
- Posture
- spinal curvature- scoliosis, kyphosis- red flag if it’s new onset and they have not been diagnosed
Examination
- Palpate the spine for any tenderness or sweades
Movement:
- Flexion
- Extension
- Rotation ask pt to sit down so not uncomfortable
8
Q
Sciatica
A
- inflammation of the sciatic nerve
- Result of irritation, not injury
- Tell pt to keep moving as this can help with recovery
- scaitica should be unilateral if it’s bilateral, it’s a red flag!
9
Q
Disc problems
A
- full herniation is uncommon
- slight bulging of the disc can occur from occupation, sitting for prolonged periods of time.
- 90% of sciatica are due to a herniated disc
10
Q
symptoms of sciatica
A
- shooting pain down the leg
- feels like a stabbing pain
- Unilateral pain that radiates down the knee to the foot/toes
- pain is more severe than back pain
- numbness and parathesia (altered sensation) is a concern.
11
Q
cauda equina s&s:
A
- saddle anaesthesia - numbness
- recent onset of bladder dysfunction
- incontinence
- sexual dysfunction
12
Q
spinal stenosis
A
- Narrowing of the passage where the spinal cord runs.
-pressure in the narrow nerves can cause pain when walking - Causes: osteoarthritis, Cushing syndrome, ankylosing spondylitis, pagers disease, hyperparathyroidism
13
Q
Cancer
A
red flag when they have sudden onset of back pain when they have cancer.
14
Q
Infection
A
- HIV
- Immmunosuppression
- Corticoid steroid use
- Tb
- IV drug use
- referred pain- pylenonephritis
15
Q
Back pain risk factors:
A
- Age 25-45
- Male
- Previous back pain
- Obesity
- Pregnancy
- Smoking
- stress/depression
- Lifting heavy @ work
16
Q
Back pain management:
A
- Don’t take in unless red flag is present
- Avoid bed rest, tell them to stay active
- Drug therapy- continuous not when required
- exercise & rehabilitation
Give prevention advice: - weight loss, cessation of smoking, regular sleep, good mental health
17
Q
Red flags for back pain:
A
TUNAFISH
Trauma
Unexplained weight loss-cancer
Neurological symptoms
Age: <20 or >50
Fever
IV drug use- infection risk
Steroid use
HX of cancer
18
Q
The hip
A
- ball and socket joint
- joint above is the spline & below is the knee
- looking for sweades
- look for symmetry of the legs- any shortening?
-expose hips, front , back and sides
-assess distal sensation and circulation - Any muscle wastage?
- look at their gait- trendelenburg gait is the result of a defective hip abductor so, there is a drop of pelvis when lifting leg opposite weak gluteus medius.
- antalgic gait- hurty foot walk
19
Q
Hip assessment:
A
Look:
- SWEADES
- Assess pts face for grimace
Feel:
- bursa?- fluid filled sac- may become inflamed and get bursitis. - May occur from trauma or lying on their hip for a long time. ( common site is greater trochanter)
Movement:
- Flexion
- abduction
- internal & external rotation
20
Q
Common hip complaints:
A
- NOF
- Osteoarthiritis
- Regerred pain from the lumbar spine
- bursitis
- Quadriceps/ hamstring tear
21
Q
Knee
A
- Fibula head
- Patella
- Lateral condole
- Medial condole ( bony prominence)
- Tibial tuberosity
- Joint space
4 ligaments:
1. Anterior cruciate ligament
2. Posterior cruciate ligament
3. Fibular/ lateral collateral ligament (lcl)
4. Tibial/medial collateral ligament (mcl)
-meniscus- cushion
Muscles: - quadriceps & hamstring
22
Q
Knee assessment:
A
- gain a HX
- look
- SWEADES
- any neurovascular compromise?- any pallor, cyanosis?
Ask about previous surgeries/injuries? - any knee locking?
- pain; when does it occur, does it improve after activity?
23
Q
How can you test for effusion/ fluid of the knee?
A
Perform the ballottement test
Patella tap test
24
Q
Movement of the knee
A
- straight leg raise
- Flexion
- Extension
-Any hyperflexion?- get them supine and ask them to push their knees into the bed, if they have hyperflexion, their heels will come off the bed! - perform active , passive and resisted rom.- unless pain on passive, don’t perform resisted
25
Knee trauma
- Fractures: Patella, fibular head, tibial process
- Bakers cyst- often found behind the knee/popiteal fossa (fluid)
- Ligament damage
- Patella dislocation
- Bursitis
26
How to test for an acl injury?
- Anterior cruciate ligament tear
- Lachman’s test
- A PCL test should be performed first to rule it out
- Have the pt lying supine and bring their knee to 30 degrees of flexion and fixate the femur with outer hand (hold thigh firmly stretched).
- Externally rotate the tibia slightly and translate the tibia anteriorly.
- The test is positive if the anterior translation of the tibia is 3mm greater than the uninjured leg.
27
How to test for a pcl injury?
- To assess for a posterior cruciate ligament tear, perform the posterior drawer test for pcl.
- Have pt lying supine and ask them flex hip to 45 and knees to 90 degrees.
- Fixate position by slightly sitting on foot.
- Palpate the joint line and push the tibia posteriorly in an explosive movement.
- Test is positive if tibia translates posteriorly more than 6mm.
28
How can you assess for fluid in the knee?
- Perform the patella tap/ Ballottement test
- Stroke hand downwards until you reach the patella pouch, 3cm from the patella.
- With your other hand, place 2cm bellow the patella and apply downwards pressure using both hands.
- Using the hand on top, tap the patella and see if it floats which suggests there’s fluid inside.
29
How to assess the medial & lateral collateral ligament:
- Perform the Valgus & Varus stress test
- Valgus stress test for Medial lateral collateral ligament injuries:
. Have pt lying supine with 30 degrees of knee flexion. Secure the ankle with inner hand and place the outer hand around the knee. Push medially against the knee and laterally against the ankle. ( PUSH INWARDS)
- Varus stress test for the Lateral collateral ligament
. Have pt lying supine with knees at 30 degree flexion. Grab the ankle with outer hand, position yourself so you’re in between the pts legs at the edge of the bed with leg being tested dangling off. Push knee outwards and look for laxity (abnormal displacement).
30
How to test for a meniscus tear:
- Apleys grind test- not v reliable
- Mcmurrays/ teardrop test:
. Have pt lying supine with knee fully flexed, rotate the tibia medially and extend and flex the knee a few times.
+ the test is positive if pt exhibits pain, knee clicking or locking.
31
What is the patella apprehension test?
- It assesses for laxity of the tendon
- Move the patella to one side as if it will dislocate and the pt may try to stop you or bring their knee down to stop the displacement.
32
Calves
- Look for swelling
- Look at the Achilles- rupture is common in runners!
-Simmons and Thompson test: essentially the same, squeezing the calf muscle.
. The foot should move when the calves are squeezed but someone with an Achilles rupture will not move.
33
OTTAWA KNEE RULES:
- An x ray is indicated if:
- Pt is <12 or >55 with a knee injury
- Pt is unable to weight bear immediately for more than 4 steps
- If they have an isolated patella tenderness
- Tenderness at the Fibular head
- Inability to flex their knee to 90 degrees
* Pittsburg decision tool is similar
34
Hemarthrosis:
- Bleeding into a joint
- Often due to trauma, sudden swelling
- Red flag as the blood will rot down the meniscus
- Sudden onset of trauma, hot to touch- Red flag!
35
Meniscus
- Horse C shoe shaped inside cartilage inside the knee
- Act as a cushion and important for knee stability
- Job is to help with articulation
- Joint locking and knee giving way is a sign of meniscus tear!!
36
Ankle
- Tarsals, metatarsals and phalanges
- Bottom of the fibula forms the lateral malleolus
- The medial malleolus is formed by the bottom of the tibia.
- The lateral malleolus is formed by the bottom of the fibula.
- Calcaneous- heel bone
- Navicular- pedal pulse site
- Base of 5th metatarsal- widest part of the foot
37
Ligaments of the ankle:
Lateral view:
- Posterior talofibular ligament
- calcenofibular ligament
- Anterior talofibular ligament
* If you evert (inwards) your ankle, you’re damaging the lateral view
Medial view:
- Deltoid ligament
* If you invert your ankle, you’re damaging the medial ligaments
38
Look, feel, move
LOOK:
- Expose the ankle and look at the front, back and sides for sweades, scars from previous surgery. Symmetry of the foot, look at gait- hiphitch?.
FEEL:
- Temperature, pedal pulse, cap refill, distal sensation, oedema?
MOVE:
- Dorsal flexion- pointing toes towards you
- Plantar flexion- pointing toes away from you
- Inversion and Eversion- inverting is rolling your ankles!
- Flexion and extension of the toes
39
Ankle landmarks to palpate:
- Medial & Lateral mallleolus - up to 6cm upwards: Deltoid lig, Ant talofibular lig, Post talofibular lig, Calcanofibular lig
- Navicular bone
- Maetatarsal heads
- Base of 5th metatarsal- little toe
- Achilles tendon
40
OTTAWA ANKLE RULES:
- Bony tenderness at Lateral or Medial malleolus- up to 6cm upwards- Ankle x ray
- Tenderness at base of 5th metatarsal- foot x ray
- Tenderness at Navicular- foot x ray
- Unable to weight bear more than 4 steps
PMMH
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Decks in class (12)
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