2Scope Painful hips. Painful thighs. Pain in the knee. Shin problems. Ankle problems.Foot problems.
3Painful Hips Remember pain from the spine. Age related conditions. We will exclude trauma.SLE and gout very rare.Septic arthritis: they are very ill!Problems with protheses.We will exclude today.
4Hip Examination Observe gait. Check where the pain really is. With them lying down gently roll limb back and forth. If this is sore = serious hip pathology.A simple test for a normal hip joint is putting the foot on the opposite knee while lying on back.Flex hip to 90° (normal) flex knee to 90° and test for internal (30°) and external (45°) rotation.Abduction is normally tested lying supine 60°.Adduction, ditto 30°.
5Painful Hips Osteoarthritis. Rheumatoid arthritis. Palindromic arthritis.Transient symptoms, may have restriction of movement, xrays normal.Over 60% eventually get seropositive rheumatoid or SLE.Psoriatic arthropathy.All of these “true” arthritis produce pain more anteriorly than laterally, and often cause radiation to the knee
6Painful Hips Avascular necrosis. Trochanteric bursitis. Severe pain, relatively short history. Commoner in SLE, steroids etc.Trochanteric bursitis.Often worse when lying on affected side.Passive hip movements should be full and pain free.Point tenderness.Lateral pain.
7Painful Thighs Few localised problems. Usually referred pain from hip or back.
8Knee Pain Excluding trauma! Normal range of movement: Flexion 140°.Extension straight!Valgus = knock knees.Varus = bow legged.Remember foot arch collapse and hip problems as common causes of knee pain.
9Knee Examination Look for valgus and varus. Look at the knees while standing – makes swelling more obvious and Baker’s cysts visible.Lie them down, ? Swelling – palpate. Aspirate if erythema for crystals.The anserine bursa is about 4cm medial to the tibial tuberosity.
10Knee Problems Pre-patella bursitis. Patellar tendonitis. Infrapatellar bursitis.These three can be managed with NSAID’s, steroid injection and gentle exercises.
14Shin Problems“Shin splints” over use causing a periostitis of the tibia.Pacing activity.Physiotherapy advice.Shin pain common in plantar arch collapse.Anterior leg tendonitis.
15The Ankle Dorsiflexion – anterior tibialis (mainly). Plantar flexion – gastrocnemius and soleus muscles (fuse to form the achilles tendon).Tibiotalar joint and talocalcaneal joint.Look at the back with the patient standing for achilles inflammation, valgus and varus.
16The AnklePlantar arch if going onto tip toe restores the arch then the flat foot is usually benign.? Swelling.? Erythema.
17Ankle and Foot Problems Plantar arch collapse.Causes pain in the toes, ankle, anterior tibial region, heel and knee (especially around the anserine bursa).Worse after walking and at the end of the day.Custom fitted arch supports are often made and not worn as the arch collapse has usually come on gradually and the support redistributes the weight. They need slow “weaning”.NSAID’s useless.
18Ankle and Foot Problems Plantar fasciitis.Heel pain, worst on wakening or in the morning.Plantar arch collapse predisposes.Spurs are irrelevant – they are secondary to the fasciitis.Sorbothane heel supports.Steroid injection.NSAID’s useless.
19Ankle and Foot Problems Stress fractures.Sudden onset of pain and swelling.Common in people with arch collapse.Much commoner in women.Often resolve spontaneously.Hard clinically to distinguish from gout.
20Ankle and Foot Problems Metatarsalgia.Transverse arch collapse.Neuromas.Wider shoes.Flat shoes.Arch supports.Steroid injection between the metatarsal heads.Surgery if all else fails.
21Ankle and Foot Problems Ankle anterior tendonitis.Commonly either in inflammatory arthritis or overuse.Pain during active dorsiflexion.
22Ankle and Foot Problems Achilles tendonitis.Pain on active plantar flexion against resistance worse than passive movement.Treatment for achilles and anterior tendonitis.Simple stretching exercises.NSAID’s.No steroid injection – danger of rupture.Arch supports if needed.Pacing of activity.