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OverviewHip
Trochanteric bursitisIliotibial band syndromePiriformis syndromeMeralgia paresthetica
KneeAnkle & Foot
Quick QuizHow many bursae are located at the greater
trochanter?Three
What gender is more affected by trochanteric bursitis?Female
Trochanteric BursitisMost common cause of pain at the hip3 bursae: gluteus maximus most importantDeep aching pain +/- burning sensationLateral hip and thighWorse with walking/climbing stairs 15% have a limp
Trochanteric Bursitis
Trochanteric BursitisMore common in womenPrecipitators: local trauma, leg length discrepancies,
joggingWeeks to monthsRest, NSAIDs, CS injection, surgeryFailure to improve may be secondary to iliotibial
band syndrome
Trochanteric Bursitis
Quick QuizWhat is the name of the this test used to
diagnose iliotibial band syndrome?
Ober’s test
Iliotibial Band SyndromeFascia connecting the ilium w/ the lateral tibiaRepetitive flexion and extension of the hipRunners (“camber running”)Local tenderness at lateral femoral condylePositive Ober’s testReduce mileage, CS injection
Iliotibial Band SyndromeIliotibial Band Syndrome
Iliotibial Band SyndromeIliotibial Band Syndrome
Piriformis SyndromeHistory of traumatic injury to the sacroiliac
and gluteal regionPain in the region of the SI joint, greater
sciatic notch, and piriformis muscleWorse with lifting or stoopingPalpable, sausage-like swelling of the muscleIrritation of sciatic nerve
Piriformis SyndromePace and Nagle signEnlargement on MRI or CT scanTreatment includes:
Rectal muscle massageLocal CS injectionInitiate piriformis muscle stretching
Piriformis Syndrome
Quick QuizName 3 common causes of meralgia
paresthetica.
Obesity, pregnancy, trauma, surgical injury, tight-fitting clothes, and DM
Meralgia ParestheticaEntrapment syndrome - lateral femoral
cutaneous nerveOccurs primarily in adultsLateral aspect of inguinal ligament, medial to
anterior superior iliac spine Belts, tight fitting clothes, obesity, pregnancy,
diabetes, ascites, trauma/ surgeryBurning pain/dysesthesia of anterolateral portion
of the thigh
Meralgia ParestheticaMeralgia Paresthetica
Meralgia ParestheticaSmaller area of sensory deficit is commonDDX: L2/L3 radiculopathy, spinal stenosisTreatment:
Weight reductionEliminate occupational traumaCS injectionNSAIDsNeurolysisEpidural CS injectionIce
OverviewHipKnee
Prepatellar bursitisInfrapatellar bursitisAnserine bursitisPellegrini-Stieda diseasePopliteal cyst
Ankle & Foot
Quick QuizAccording to Secrets, how do you
differentiate prepatellar bursitis from knee arthritis?
Acute inflammatory arthritis results in loss of full extension, whereas prepatellar bursitis pain is increased with flexion. Thus, if an inflamed knee demonstrates full extension w/out pain and a negative bulge sign, the disease is likely extra-articular.
Prepatellar BursitisPrepatellar Bursitis
Prepatellar BursitisRecurrent traumaErythematous, well-circumscribed, fluctuance
over front of patellaTrauma, gout, infectionAspirationRest, avoidance of kneeling, NSAIDsSeptic bursitis: rest, serial aspirations,
parenteral and then oral abxSurgery if no improvement
Prepatellar Bursitis
Infrapatellar Bursitis/Tendonitis“Parson’s knee”Overuse, trauma, infection, goutPain at midpoint of patella tendonSame treatment as prepatellar bursitis
The pes anserinus (“goose foot”) is the anatomic location of the conjoined tendon of which muscles?
Sartorius, gracilis, & semitendinosus
Quick Quiz
Anserine BursitisMedial aspect of knee
Deep to insertion of “pes anserinus”Superficial to medial collateral ligament
Pain with climbing stairsRest, NSAIDs, CS injection
Anserine Bursitis
Pellegrini-Stieda DiseaseFollows an injury to the MCLMost asymptomaticPain over femoral insertion siteX-rays: calcification of the insertion of MCLCalcification of hematomaSelf limitedRest, NSAIDs, CS injection
Pellegrini-Stieda Disease
Popliteal CystsAny age (child to adult)Communication between knee joint and
gastrocnemius-semimembranosus bursa at medial head of gastrocnemius tendon
“Pain and swelling at the back of the knee”Palpation at the back of the knee on extensionAdult association with RA, OA
Popliteal CystsDifferential diagnosis:
DVT, thrombophlebitisPopliteal artery aneurysmGangliaNerve sheath tumorsSarcoma
Popliteal CystsUS, CT, MRITreatment in children is conservative: spontaneous
resolutionTreatment in adults is aimed at underlying pathologyKnee arthrocentesis and CS injection
Popliteal Cysts
Subgastrocnemius bursa and Baker's cyst in 58-year-old man are seen on sagittal T2-weighted MR images (TR/TE, 4,500/99). Image in more lateral position than A shows fluid in Baker's cyst (BC), superficially in relation to medial gastrocnemius tendon (g), and also between capsule (arrowheads) and gastrocnemius tendon in subgastrocnemius bursa (s).
OverviewHipKneeAnkle & Foot
Achilles tendinitis/bursitisPlantar fasciitisTarsal tunnel syndromeMorton’s neuroma
Achilles TendinitisPain, swelling, tenderness +/- crepitus near
insertion siteThickening and irregularity of the tissues
surrounding the tendon; +/- palpable nodulePain increased with passive dorsiflexion Repetitive trauma, microscopic tears due to
excess use of calf muscles; bad footwear
Achilles TendinitisSpondyloarthropathies, gout, RA, familial
hypercholesterolemiaUS, MRIRest, avoidance of provocative activties, shoe
modification, heel raise, NSAIDS, heat, splint (plantar flexion)
CS injections are discouraged
Achilles TendinitisAchilles Tendinitis
Quick QuizWhat is the name of the following physical
exam test that is used to test for an Achilles tendon rupture?
The Thompson Test
Achilles BursitisRA, Psoriatic arthritis, AS, Reiter’s, gout, traumaOveruse: ballet dancers, runners; tight shoesPain at posterior heel, painful dorsiflexionLocal swelling with “bulge” on medial and lateral
aspects of tendonRest, activity modification, moist heat, heel
elevation, NSAIDS
Quick QuizWhat name is given to the following exam
finding, which may be confused with a RA nodule?
“Pump bumps”
Achilles Bursitis
Plantar FasciitisRepetitive microtraumaPain often worse after period of restLocalized tenderness at anteromedial surface of
calcaneusObese, middle-age, elderlyChange in shoe-wear, change in walking
surface, enthesopathyWeight reduction, rest, hot soaks, NSAIDS, heel
cup, CS injection
Plantar Fasciitis
Plantar Fasciitis
Tarsal Tunnel SyndromeEntrapment neuropathy of posterior tibial nerveTarsal tunnel: fibro-osseus canal
flexor retinaculumvascular structurestendons of flexor hallucis longus, flex
digitorum longus
Tarsal Tunnel Syndrome
Tarsal Tunnel SyndromeBone deformities, pressure from casts, RA,
diabetes, ganglia, synovial cysts, flexor tenosynovitisParesthesias & pain in toes, sole, heel, may travel to
calf +/- relief with walking, pain worse at night
Tarsal Tunnel SyndromeTenderness with palpation of nerve posterior to
medial malleolusVasomotor changesElectrodiagnostic studiesCS injection, NSAIDs, orthotics, surgical
decompression
Morton’s Interdigital NeuromaEntrapment neuropathy of interdigital plantar nerve3rd & 4th metatarsal heads > 2nd & 3rdChronic irritation neuromaTransverse tarsal ligament
Morton’s Interdigital Morton’s Interdigital NeuromaNeuroma
Quick QuizCompression of a Morton’s neuroma can
cause the “neuromatous” mass to slip, producing a palpable click. What is the eponym given to this click?
Mulder’s Click
Morton’s Interdigital NeuromaUnilateral, mid-age womenLancinating, burning, neuralgic pain radiating
from web space to toesTight shoes, hard surfaces, prolonged standing
exacerbate painTenderness over interspace between metatarsal
bones, +/- tender noduleProper footwear, metatarsal pads, CS injection,
surgery
Shin SplintsMedial tibial stress syndromeRepetitive running on hard surfaces or repetitive
forcible foot dorsiflexionMedial tibial pain at beginning of exercisePain may become persistent3-6 cm tender area on postero-medial, distal
tibiaBone scan: posteromedial tibial cortex uptake
Shin Splints
Questions?