LE Conditions | Transes

LE Conditions

Traction apophysitis secondary to forceful mm

contracture
Pelvic conditions
There is chipping of part of the bone
Sartorius = ASIS
DUVERNEY’s Fx
Rectus Femoris = AIIS
Hamstrings = Ischial Tuberosity
Abdominal mm = Iliac Crest
Rectus Abdominis = Superior corner of pubic
symphysis
Lesser Trochanter = Iliopsoas
Bleeding: MC complication of pelvic fx; may cause
damage to the internal organs:
Urethra
Urinary Bladder

OSTEITIS PUBIS In ammation of the symphysis pubis

M > F; Common in athletes (gymnasts, horseback
riders)

Self-limiting

Isolated Iliac wing fx

Cause:

Stable fx
Childbirth/Pregnancy = ⬆ Relaxin hormone
(Relaxes the symphysis pubis to allow the pelvis to expand
MALGAIGNE’s Fx for childbirth)
Hyperactivity of the adductors

Overuse

S/Sx:

X-ray: Moth Eaten appearance

Double vertical fx; anterior + posterior pelvic ring

Unstable Fx

AVULSION FX

Tight adductors = LOM Abductors

(+) Dull aching pain to sharp stabbing pain

“Groin Burning Pain”

Mx:

Stretching
Rest
Pool activities (CI: Frog kick like in breastroke d/t
widening of pubis)

Symphysis pubis Caused by any condition that leads to one having lax
dysfunction ligaments such as osteitis pubis

(+) Pain while going down a curb/stairs

*Cause/s:

Overactive Adductors

Underactive abductors

Weak Spinal Stabilizing mm

Diastasis Rupture of the ligaments in the pubic area

symphysis pubis

1 PTRP, MD
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 LE Conditions | Transes

MULTIPLE Malignant bone cancer that started in the bone SLIPPED CAPITAL FEMORAL LEGG-CALVE-PERTHES DISEASE
marrow
EPIPHYSIS
MYELOMA MC site of Metastasis (where it can spread):
Innominate bone (1st: Ilium; 2nd: Pubis; 3rd:
Ischium)

Overproduction of abnormal plasma cells (myeloid

cells)

Myeloid cells makes immune cells and if it’s

abnormal it attacks it’s own immune system

S/Sx:

(+) Nocturnal, nagging pain

X-ray: mickey mouse lesion (Punched out
appearance)

Weakness & multiple fractures

HIP POINTER Contusion d/t direct trauma to the ASIS

(speci cally the iliac crest)

INJURY (+) Bruise

Downward slippage of Avascular necrosis of

Tenderness @ the ASIS femoral head from the femoral head in children

growth plate Average: 7 y.o

INNOMINATE LLD d/t mm imbalance MC hip disorder in Chandler’s Disease:

Special Test
adolescence (10 - 16
SYNDROME y.o)

Avascular necrosis of
Supine-To-Sit Test femoral in adults
Rare condition

Idiopathic condition

M>F
Common cause is from
fractures from falls or
trauma for Chandler’s
disease

M > F

(+) Sagging rope sign

Characteristics Tall and obese Short and thin children

Pain (+) Pain in lateral hip

(+) Pain in groin and thigh area

Pain may radiate to the Pain may radiate to the knee

knee

Gait (+) Trendelenburg/Wadding (+) Psoatic Gait (FADER)

Gait

LOM ABIR
ABIR
(Upon presentation: Hip
exed + ER)

Anterior Code: ALSUP (Anterior Longer Supine)

Innominate Supine: A ected leg is LONGER in supine

Syndrome
Sitting: A ected leg is shorter in supine

Posterior Code: PSUP (Posterior Shorter Supine)

Innominate Supine: A ected leg is SHORTER

Syndrome
Sitting: A ected leg is LONGER

ISCHIOGLUTEAL in ammation of the bursa in the ischiogluteal area

Other name: Code (By The Way) =

BURSITIS
Boatman’s Bottom
Tailor’s Bottom
Weaver’s Bottom
Cause

Prolonged sitting on a hard surface

Direct trauma to the buttocks

2 PTRP, MD
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 LE Conditions | Transes

Management Surgical Fixation w/ Pins + Orthosis: AB + IR: Keeps the II: 6-12 wks

Screws femoral head inside the hip

socket

Fragmentation Deterioration of the femoral head

Toronto = Positions the leg

Stage (+) Crescent Sign = thin, radiolucent line
in ABIR
beneath joint surface; sign of coxa plana
( attening of the femoral head)

Trilateral = ABIR

III. 2-3 Yrs

Reossification/ (+) Coxa Magna = Abnormally large femoral

remodeling/ head

revascularizati (+) Coxa Breva = Short, broad neck

*Scottish-Rite = FAB

on stage (+) Bird’s Beak

Iv: healing

Hip dislocations

CONGENITAL

Congenital Hip D/L D/L at birth

WALDENSTROM STAGES (STAGES OF LCPD) Special Test: Ortolani’s Test

1-2 wks

Congenital Hip is intact at birth but is dislocatable

I: Initial/ Dislocatable Hip

ST: Barlow’s test
avascular/ Quiet Phase; Worst Stage

necrosis stage (+) Sagging Rope Sign Congenital Intact @ birth, but subluxable

Subluxable Hip
Partial hip D/L d/t lax ligaments

Teratologic Hip D/L Fixed hip D/L prenatally

Arthrogryposis Multiplex Congenita: Infant is seen

w/ multiple joint fractures and contractures w/c may
lead to hip D/L as well

Acetabular Absent cotyloid ligament (acetabular labrum)

Dysplasia
(+) Shallow Hip Socket
Mx: VIP w/ Pillow (orthoses)

Von Rosen = FAB

Ilfeld = FAB

*Pavlik Harness = FABER (most stable

position of the hip)

Frejka Pillow

ACQUIRED

3 PTRP, MD
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 LE Conditions | Transes

Acquired Hip D/L D/t trauma

MOI:

Young: MVA (Dashboard Injury)

Neck-Shaft Angle
@ birth: 150 - 160°

Adult: 120 - 135°

N: 125°
Geria: Falls (impaired balance and
proprioception)
P — Pronated Foot P — Posterior Pelvic Tilt
Direction of D/L: Posterior
I — IR Hip I — Ipsilateral leg is longer
Mx Mx:

Total Hip Arthroplasty (MC incision: S — Shorter leg E — ER Hip

Posterolateral approach)
A — Anterior Pelvic Tilt S — Supinated Foot
Cemented Cementless
Elderly Young + active Decreased Neck-Shaft Angle Increased NSA, >125°
Polymethyl population
<125°
Methacrylate (PMMA)
Porous coating

WB as tolerated — as WB is limited until 3

early as <24 hours
mos (as early as 6
CI: US — d/t uneven wks)
ANTEVERSION RETROVERSION
heating

To Avoid After THA Anterolateral Approach Posterolateral Approach

H = Hip exion beyond Hip exion Beyond

90
90

A = Adduction
Hip extension, ADD,
ER beyond neutral

IR = Internal Rotation
Combined motion
of FABER

If the G. Med is
incised, avoid hip
abduction

Golden Rules No hip exion beyond 90

Do not cross the leg beyond neutral (put pillow in b/

n)

NO twisting in either sitting or standing

Angle of Torsion
@ birth: 30°

Adult: 8 - 15°

N: 15°
COXA VARA VS COXA VALGA
Special test: Ryder’s/ Craig’s Test

COXA VARA COXA VALGA

(+) W-Sitting/ TV Sitting

Code: PISA Code: PIES

Increased anteversion

Med. Knee pain

Increased Angle Decreased Angle

Internal Rot. Of Hip ER of the hip

Internal Tibial Torsion External Tibial Torsion

4 PTRP, MD
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 LE Conditions | Transes

Sprinting — Excessive hip exion + knee extension

In-Toeing Out-toeing
Palpate the ischial tuberosity to con rm (sa origin nya)

Subtalar Pronation Subtalar Supination Rectus Femoris

Strained d/t forceful kicking

Squinting Patelle grasshopper’s Eye Patella/Frog’s

Eye Patella Adductor Longus
Forced Abduction

COXA SALTANS MUSCLE CONTUSION

“Snapping Hip Syndrome
Hematoma d/t direct trauma to the muscle

INTERNAL SNAPPING HIP EXTERNAL SNAPPING HIP MC contused mm: Quads (Rectus Femoris) — “Charley Horse”

HO VS MO

HO MO

Heterotrophic Ossi cation Myositis Ossi cation

Abnormal bone growth in Abnormal bone growth in

the joint the muslce

Cause Prolonged immobilization Trauma/contusion

MC Sites CVA - Shoulder

Brachialis (Biceps)

TBI — “
Quads
SCI — Hip

Burns — Post Elbow

S/Sx Pain
Pain

Tight iliopsoas and iliofemoral Tight ITB

ligament Hard end-feel

Palpable mass

Hallmark Sign: LOM

Flexion contracture
Hits your iliopectineal eminence/ Hits the greater trochanter of Increased Alkaline
hip capsule femur Phosphatase (controls
the rate of ossi cation)
INTRACAPSULAR SNAPPING HIP
Mx Early Mobilization
Gentle active ROM
Loose bodies secondary to trauma/arthritis Frequent stretching exercises

Contraindicated:

MERALGIA PARESTHETICA Passive stretching

Impingement of the lateral Massage

femoral cutaneous n of the thigh
@ the inguinal ligament
Imaging Bone Scan

S/Sx:
X-ray — for later stage
(+) Pain and tingling
Medicine Disodium Etidronate
sensation anterolateral
thigh

Causes:

Pregnancy

Tight jeans and belt

“PULLED” MUSCLE

Overstretched mm

“Muscle Strain”

Cause:

Overused, fatigues,
underconditioned mm

Hamstrings: Commonly
strained mm in the body

Ex: Long head of

hamstrings — Hurdles/

5 PTRP, MD
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 LE Conditions | Transes

Kn Conditions 2. Super cial Infrapatellar Bursitis

Other Names:

Differential Diagnosis for: ANTERIOR KNEE PAIN

Nun’s knee

1. Osgood Schlatter Disease Vicar’s Knee

Results from bers of the patellar tendon pulling small bits of Clergyman’s Knee

immature bone from the tibial tuberosity

M > F; Adolescents
3. Pes Anserine Bursitis
- Boys — 10-15 y.o
SGT a ected

- Girls — 8-13 y.o.

(+) Pain @ inferomedial tibia

S/sx:

(+) Pain on Tibial Tuberosity 4. Popliteal Bursitis

(+) Pain w/ forceful contraction of patellar tendon against “Baker’s Cyst”

tubercle (active knee extension or resisted knee exion)

Nerve involved: Tibial N.
Localized heat and tenderness

Dx: Palpate tenderness at the tibial tubercle; bony bump

Ligamentous Injuries

2. Patellar Tendinitis MCL vs LCL

Jumper’s Knee”

Overuse Syndrome
MCL LCL
Insertional tendinopathy

MOI Excessive valgus force Excessive varus force

S/sx:

• (+) Di culty descending stairs

A ected Unhappy Triad of
Patellar Tendon Tear — high riding of patella (Patella Alta)
O’Donoghue:

- MCL

• (+) Movement of patella during knee extension

- ACL

Quads Tendon Tear — low riding of patella (Patella Baja) - Med. Meniscus

Palpation Position px in Figure of 4

3. Sinding Larsen Johanson Disease
Lesion @ inferior pole of patella
Pellegrini Steida —
calci cation of MCL

4. Osteochondritis Dissecans
focal lesion @ lateral aspect of medial condyle
Acl vs PCL
Is a disorder of one or more ossi cation sites with localized
subchondral necrosis by recalci cation

ACL PCL
Test: Wilson’s Test

Cause: Repetitive microtrauma resulting in ischemia Nd disruption “Stoutest Ligament”

of the subchondral growth

S/sx:
MOI - Hyperextension of knee
- Hyper exion

- Excessive ant. Translation - Excessive post. Translation

Activity-related pain
of tibia of tibia

Swelling
- Dashboard Injury

Giving way
- Goalkeeper’s Injury

- Fall on knee w/ PF
Pain increase in passive knee extension and tibial IR

Relief with tibial ER

S/sx - (+) Audible pop
- (+) Di culty extending knee

Mx:
- (+) Buckling of knee -
(quads weakness)
Nonoperative Mx for Stable Lesions

• Activity modi cation

Special Tests (+) Lachman Test (+) Posterior Sag Sign

• Protected weight-bearing
(+) Posterior Drawer Test
• Immobilization for 4-6 wks
Reconstruction ACL Reconstruction:

Arthroscopic Procedures
1. Patellar-Tendon
• Fixate lesion
Bone Graft

• Debride tissues from the defect

-

• Implant tissues to stimulate healing

2. Semitendinosus
Gracilis Graft

5. Ho a’s Disease - clinically

Impingement of infrapatellar fat pad
recommended

Management (+) Strengthen Hamstrings &

Bursitis Quads

1. Pre-Patellar Bursitis Isoms > Concentric >

Isotonic > eccentric
“Housemaid’s Knee”

Activities:

• Gardening
Knee oa
• Carpet laying

MC Site of OA: Knee

• Wrestling

6 PTRP, MD
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 LE Conditions | Transes

Most debilitating condition for elderly population

• Knee pain ➡ improper weight-bearing distribution ➡ (+)
Weight-bearing condition — d/t wear-and-tear
medial knee pain

S/sx:
Assessment:
• ⬇ Joint space — collapsed medial side
• ⬆ Anteversion

• (+) Bony Spurs

• ⬆ Q-angle

• (+) Genu Varum deformity

• Subtalar pronation

Management:

• External Tibial Torsion

• Pain Relievers: Acetaminophen

• Subluxation

• Orthosis:

• VMO Dysplasia

CARS UBC — gives genu valgus force to correct genu

varum

• Anterior Pelvic Tilt

Lateral Heel wedge

• (+) Grinding or clicking knees when extended

• Tai Chi

• Steroids — last resort

Deformities

Genu varum

⬇ Q-angle

Normal: 18-19 mos

• Bow Leg

Genu valgum

⬆ Q-angle

Normal: 3-4 y.o.

• “Knocked Knees”

Normal Valgus Angle: 6o — reached by 6 y.o.

Genu recurvatum

Excessive hyperextension of the leg

“Saber Leg”

Causes:

• Weakness or paralysis of Knee extension

• Polio

• Spastic Knee Extensors

Chondromalacia patella

Lesion @ articulating surface of patella

S/sx:

• (+) Pain

Sitting

Squatting

Stair Descend

(+) Cinema Sign/Theater Sign

Special Tests:

(+) Waldron Special Test

(+) Clark’s Special Test

Stages of Chondromalacia Patella

I — Swelling

II — Fissuring

III — Deformed Surface

IV — Lesion at the Femoral Cartilage

Malalignment syndrome

“Miserable Malalignment Syndrome”

Improper alignment of leg

7 PTRP, MD

 LE Conditions | Transes

management:
Leg, Ankle, F t Conditions • Stretching

• Night splint

Blount’s disease • Corticosteroid

• Surgery

Growth arrest @ medial side of tibia

Pes …
Stress fracture
Pes Planus “Flat Foot Deformity”

MC: Distal 1/3 of tibia — hypovascular malunion

Collapse of MLA d/t laxity of spring ligament

Cause: Repetitive stress from walking, running

• Commonly seen in pxs w/ Down
X-ray: (+) Black Dreaded Line syndrome
Orthosis:
• Scaphoid pad

Anterior compartment syndrome • Thomas heel

• UCBL — for Down syndrome pxs

Increased pressure @ anterior compartment

Pes Cavus “Hollow foot”, “High Arch Foot”

Cause:

Associated w/ Charcot Marie Tooth Disease

• Edema
(+) High arched foot + Clawed toes

• Hypertrophy
Management:
A ected: • ⬆ Toe box

• DF muscles
• Medial arch cushion
• Ant. Tibial Artery

Talipes Equinovarus “Clubfoot”

• Deep Peroneal Nerve

• Adducted

S/sx: • Inverted

• Pain
• Plantar exion

• Paresthesia
Condition: seen in pxs c spina bi da
• Pulselessness
Management:

• Pallor
• Dennis-Brown Splint

• Serial casting

• Paralysis: (+) Foot drop

• Rocker bottom

Shin splint
TOE CONDITIONS
“Medial Tibial Stress Syndrome”

D/t overload of tibialis posterior mm

Hallux valgus
Common in runners (toe runners)

Deformity: >15o
• N: <15o

Achilles tendinitis Cause:

• Pointed shoes

Is an insertional tendinopathy

S/sx:

S/sx:
• (+) 1st MTP bunion

• (+) Di culty ascending stairs

• Metatarsus. Adductus

• Midportion of achilles tendon - weak point

Special Test:
• (+) Thompson Test
Hallux rigidus

Osteophyte formation at the dorsum of 1st MTP

Sever’s disease vs haglund’s deformity S/sx:

• Di culty in push-o

Sever’s Disease Haglund’s Deformity • Apropulsive gait: (-) Push-o

- avulsion fx of calcaneus via achilles - posterior prominence at the

tendon calcaneus
Gout
- (+) Pump bump

- Causes:

Accumulation of monosodium uric crystals — tophi

• High-heels

• Winter boots M > F

Laboratory ndings:
• ⬆ Uric acid

Plantar fascitis Types:

In ammation of plantar aponeurosis (shock absorber of the foot)

Causes:
• Prolonged walking or standing

• Obesity

• Ill lled/ at shoes

S/sx:
• Medial heel pain

• First step pain

• Tight gastrocnemius

8 PTRP, MD
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 LE Conditions | Transes

• Gonagra — Knee
Wagner 4 - Partial Gangrene
• Podagra — Toes

• Cheiragra — Wrist
Wagner 5 - Entire Foot gangrene
Medication:
• Colchicine

• Allopurinol

Dancer tendinitis vs turf toe

A. Dancer Tendinitis

- in ammation of FHL tendon d/t overuse

- Common in: ballerinas

B. Turf toe

- rupture of FHL tendon

- Hyperextension injury

- Common in: Football players

Morton’s neuroma A

• A

“Interdigital Neuritis”

A ected: 3rd interdigital nerve

S/sx:
• (+) Pain b/n 3rd and 4th digit

Special test:

• Mulder’s Sign — (+) Palpable click

Metatarsalgia

Pain at the MMT heads

Orthosis:
• MTT bar or pad

Toe deformities

Deformity Claw Toes Hamer Toes Mallet Toes

MTP / / N

PIP Flex Flex N

DIP Flex / Flex

Diabetic foot

Charcot’s Neuropathy — decreased sensation at the foot secondary

to decreased blood supply vasa nervorum

Semmes-Weinstein Mono lament

Mono lament Force Indication

4.17 1g Normal Sensation

5.7 10g Loss of protective

sensation

6.10 5g Severely insensate foot;

prone to ulceration

Wagner Classi cation

Wagner I Super cial

Wagner 2 - Exposure of bones, muscle tendons

Wagner 3 - Osteomyelitis

- Abscess formation by Staph Aureus

9 PTRP, MD
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