Foot, Ankle and Knee
Sonali Iyer, MD
Objectives
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Background
Anatomy
History
Physical Examination
Radiology and Laboratory
Case Studies
The Foot
Midfoot
Hindfoot
Forefoot
The Foot
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26 bones
– Plus 2 sesamoid bones under great toe for weight bearing and balance
33 joints
– Medial longitudinal arch
– Calcaneous, talus, navicular, first 3 cuneforms, first 3 metatarsals
– Strengthened by calcaneonavicular (Spring) ligament
Lateral longitudinal arch
– Calcaneous, cuboid, 4th and 5th metatarsals
– Weight bearing
Transverse arches
– Weight bearing and springing off with foot
Dorsiflexion
– Most stable position
Plantarflexion
– Ligaments less taut
– Joint more vulnerable to injury
Extensor tendons
Peroneus tertius
Peroneus longus
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4 distinct bones
– tibia, fibula, talus and calcaneus.
3 joints
– Talocrural Joint: hinge joint formed by the fibula and tibula enclosing on the talus. Allows
dorsiflexion and plantarflexion.
– Inferior tibiofibular Joint: This is strong joint between the lower surfaces of the tibia and
fibula. This is supported by the inferior tibiofibular ligament.
– Subtalar Joint: joint comprises of the talus and calcaneus. Provides shock absorption,
inversion and eversion.
2 main groups of ligaments
– Lateral Collateral Ligament:
• Prevents excessive inversion. It is considerably weaker than the larger medial
ligament and thus prone to sprains. Made up of 3 individual bands:
• Anterior talofibular ligament (AFTL): passes from the fibula to the front of the talus
bone.
• Calcaneofibular ligament (CFL)- connects the calcaneus and the fibula
• Posterior talofibular Ligament (PTFL)- passes from the back of the fibula to the rear
surface of the calcaneus.
– Medial Collateral Ligament:
• Also known as the deltoid ligament spreads out in a fan shape to cover the distal end
of the tibia and the inner surfaces of the talus, navicular, and calcaneus.
Physical Exam
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Upright
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Supine
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Standing look at shoes, wear patterns, symmetry, muscle wasting, erythema, scarring, arch height, toe
position, knees, general posture, single leg heel raise
Walking normally, heels, toes,
Weight bearing dorsiflexion and calf length
Neurological (web space between the 1st, 2nd toes deep peroneal nerve)
Vascular (dorsalis pedis, posterior tibial pulses, capillary refill great toe, edema, color)
Palpate collateral ligaments, joint lines (ant and post), TDH, peroneals, plantar fascia, sustentaculum tali,
navicular, base of 5thmet, dome of talus, individual bones
Active and passive ROM (ankle, subtalar, transverse tarsal, midtarsal, tarsometatarsal, forefoot, toes)
Resisted muscle tests
Special tests eg posterior impingement, syndesmotic ligaments, anterior drawer
Prone
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Achilles tendon
Stress tests for ATFL and Syndesmosis
When to image
The combined Ottawa ankle and foot rules have a sensitivity of 97.8% and a specificity of 31.5%,
giving a negative likelihood ratio of 0.07; this will yield a post-test probability of about 1% for fracture
of the ankle if test results are negative (not requiring x ray)
Treatment
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Change shoes
OTC arch supports and insoles, pads
Custom Orthotics
Calf stretching/toe rises
Activity modification (swimming/biking)
Weight loss
Night splints/boots/casts
Treatment Options
• Physical therapy
– Ultrasound
– Interferential stimulation
• Contrast soaks (10 mins warm, 30 secs ice
cold, repeat x2, end with cold)
• NSAIDS
• Injections
Forefoot Problems
• Women far outnumber men because of shoe
choices. Shoe modification is the first line of
treatment for:
– Bunions
– Neuromas
– Metatarsalgia
– Sesamoiditis
• Stress fractures
• Over- pronation
Over-Pronation
• Many foot problems are
due to excessive
pronation (flat feet):
– Plantar fasciitis
– Achilles and posterior
tibial tendinitis
– Sesamoiditis
– Bunions
– Sinus tarsi and tarsal
tunnel syndromes
– Metatarsalgia
1st MTP Arthritis
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Hallux rigidus or limitus
1st MTP can be swollen
Spur can be seen dorsal on the xray.
Limited MTP extension (compare to other
foot), pain is during the toe-off phase of
walking.
• Tx with stiff soled shoes, NSAIDs
Differential diagnosis of foot arthritis
Interdigital Neuroma
• Perineural fibrosis secondary
to repetitive irritation
• 90% are in the third
interspace; rest in 2nd
• Feels like walking on a pebble.
Feels better out of shoes.
• + squeeze test.
– Pain is between metatarsal
heads.
• Treatment:
– wide shoes, MT pads/cut-outs,
inject.
– Surgery if neuroma >5mm
Stress Fracture
• Pain directly over a
metatarsal, usually more
proximal than MT heads.
• Change in activities,
worse with wt bearing
• Initial xray often normal.
Bone scan positive early.
• Tx with modified activity,
stiff soled shoe or
boot/cast, time.
Diagnostic Algorithm for Forefoot Pain
Midfoot Problems
• Dorsal midfoot pain occurs secondary to
arthritis. Bony prominence=‘bossing’
– XR and/or bone scan will show changes.
– Treatment
• stiff soled shoes, firm arch support, NSAIDs, activity
modification.
• Plantar midfoot pain is rare.
– plantar fasciitis or fibromatosis.
Hindfoot Problems
• Plantar fasciitis is the most common.
– Pain is plantar/medial.
• Heel pad pain is usually a ‘stone bruise’ or due
to atrophy of the fat pad.
• Posterior tibial tendon dysfunction is the most
overlooked problem of the foot.
Plantar Fasciits
• Pain with arising,
especially first AM steps
• Almost always at plantarmedial origin.
• Inflammation and chronic
degeneration.
• Worse with obesity,
overpronation.
• Not due to spurs
• Treatment:
– Arch support, elevate heel.
– NO barefeet, flat shoes
– NSAIDs, injections, PT for
ultrasound.
Plantar Heel Pain
• Can be traumatic (stone bruise) or common in
elderly as fat pad atrophies.
• Add a pad, like gel heel cushions.
Posterior Tibial Tendinitis (PTT)
• Most missed problem of the
foot.
• Pain/aching between navicular
and medial malleolus. Looks
swollen
• Injury, inflammatory synovitis,
degenerative rupture.
• Resembles flatfeet. Heel
should invert with rising on
toes. Pain along post tib
tendon
• Treatment:
– arch supports, slight heel.
NSAIDs and PT for u/s.
– Surgery
Causes of Chronic Ankle Pain
• Posterior Ankle Impingement
– Pain with plantar flexion
• Flexor Hallucis Longus Tendonitis (Dancer’s Tendonitis)
– Posteromedial ankle pain, weakness of the big toe
• Posterior Tibial Tendon Dysfunction
• Noninsertional Achilles Tendinopathy
– Pain in the morning and with activity.
• Retrocalcaneal Bursitis/ Insertional Achilles Tendinopathy
– Pain at medial and lateral insertion site of the achilles tendon
• Osteochondral lesions of the talar dome
– Fracture of the talar dome cartilage and subchondral bone
causing ankle joint instability
Ankle Sprain
• Sprains account for 25% of all
sports-related injuries and 75% of
all ankle injuries
• Lateral ankle ligaments are the
most commonly injured
• > 40% of sprains can case chronic
problems like pain, instability, loss
of function
• Usual mechanism is combination
of plantarflexion and inversion of
foot
• Treatment: PRICE with physical
therapy and occasional need for
surgery. Pain medication
Anterior talofibular ligament (ATFL)
Calcaneofibular ligamen (CFL)
Achilles Rupture Treatment
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“Snap” in heel with pain, which may
subside quickly
Risk factors: male, age >40, DM, HTN,
antibiotic/ steroid use.
Treatment controversial; Refer to
Ortho
Surgical: better for young, active
– Lower rate of re-rupture
– Higher wound complications
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Casting: better for old, less active
– Up to 40% re-rupture
– Lower cost and wound complications
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Exam:
– Thompson Test positive, gap in tendon
– Ultrasound sensitive for tear
Tarsal Tunnel Syndrome
• Post Tib nerve is
entrapped near med
malleolus.
– Plantar tingling/
burning as opposed to
pain/ swelling of PTT.
• Entire foot not involved
as with diabetes.
• + Tinel test; can be
loss of PP sensation,
can be toe clawing.
• Tx:
– arch support if
overpronated.
Consider EMG.
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85-year-old man with polymyalgia rheumatica on prednisone. He sees his urologist
who prescribed enoxacin (two 200-mg tablets twice a day) for a UTI. Later he
develops pain in both calves radiating to the heels. The patient noted mild swelling
in the lower extremities. On examination a week later he had difficulty walking
because of pain in his lower legs.
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He later presented to the ED with mild, nonpitting edema of the left calf and ankle,
and pain on plantar flexion. Homan sign negative.
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The patient was diagnosed with a muscle strain and discharged with a prescription
for 100 mg of celecoxib twice per day for pain and 20 mg of furosemide per day for
edema.
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Two weeks later, he was re-evaluated in the ED for severe left leg pain, increased
edema, erythema, and warmth extending to the knee, with posterior leg
tenderness on palpation.
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What is the diagnosis?
1. DVT
2. Muscle sprain
3. Achilles tendon rupture
• 51 year old female presents with heel pain that
she has had for several months. It is worse in the
morning, particularly with her first step.
– Probable diagnosis?
– Clinical tests to confirm diagnosis?
• What is the probable diagnosis?
A. Tarsal tunnel syndrome
B. Peripheral neuropathy
C. Calcaneal stress fractures
D. Heel fat pad atrophy
E. Plantar fasciitis
• Which clinical finding(s) would confirm the diagnosis?
A. Tenderness and a positive Tinel sign (pain and radiation
of nerve pain in the distribution of the nerve) when the
nerve is tapped with the index finger over the site of
nerve compression.
B. Numbness or pain is in a non-anatomical distribution
C. Positive ‘squeeze test’ involves medial and lateral
compression of the calcaneus.
D. Pain improves by wearing shoes with a supportive sole
and avoiding bare feet walking.
E. Tenderness over the medial tubercle of the calcaneus
which worsens with dorsiflexion of the toes
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A 20-year-old man was thrown from a sled. His
body weight fell on his left foot, which was
folded beneath him.. Standard AP and lateral
XRs revealed no fracture. The foot was placed
in slight plantar flexion and immobilized with a
soft cast.
After three days, still unable to bear weight,
the patient was reevaluated at a student health
clinic. His left foot remained edematous, and
ecchymosis was noted laterally. The soft cast
was removed, and an elastic wrap was applied.
Seven days after the injury, the patient was
evaluated in a sports medicine clinic. He is still
unable to bear weight and has an expanding
hematoma on his foot and worsening pain.
Palpation elicited only minimal tenderness on
the plantar surface, with the tenderness
limited to the region of the second and third
tarsometatarsal joints.
What is the diagnosis?
Lisfranc Injuries
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The Lisfranc ligament is a large band of plantar collagenous tissue that spans the articulation
of the medial cuneiform and the second metatarsal base. The bony architecture of this joint,
specifically the "keystone" wedging of the second metatarsal into the cuneiform, forms the
focal point that supports the entire tarsometatarsal articulation. This anatomy establishes a
"weak link" that, with stress, is prone to injury.
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TARSOMETATARSAL fracture dislocation (Lisfranc injuries) is an infrequent but serious injury
which is difficult to diagnose.
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These injuries have the potential to cause chronic disability, with the development of posttraumatic midfoot arthritis if the diagnosis is delayed or the injury is not treated
appropriately.
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Diagnosis
– A high index of suspicion is required in any injury to the midfoot in which there is gross
swelling and pain that causes difficulty in weight bearing. There is usually a history of a direct
crush injury or an indirect twisting injury to the midfoot.
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Physical examination
– Marked swelling of the foot . Localized ecchymosis beneath the medial arch.
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Imaging
– If clinical suspicion is high and the plain XR do not provide a positive diagnosis, an MRI scan is
required.
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Treatment
– Displaced fractures require surgery
– Nondisplaced fractures can be treated with NWB in a cast x6wks then a walking boot x6week
Knee
Background
• Frequent knee pain affects approximately 25%
of adults, limits function and mobility, and
impairs quality of life
• Knee pain is the 10th most common reason for
outpatient visits
• Osteoarthritis is the most common cause of
knee pain in people aged 50 years or older
History
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Patient age
Current symptoms and duration
Pain with or after activity/changes in activity
Catching/locking (“mechanical”) or Instability
Stairs, squats, “theater sign”
Exacerbating and relieving factors
What treatment already tried (Rest, NSAIDs,
brace, …)
• Prior knee injury or surgery
• PMH
Knee Pain Diagnosis based on Location
Location
Differential
Anterior (2nd
most
common)
Patellofemoral syndrome
Patellar dislocation
Dashboard Knee
Patellofemoral OA
Patella alta
Knee effusion
Prepatellar bursitis
Infrapatellar bursitis
Jumper’s knee/ Patellar tendonitis
Hemarthrosis
Cruciate ligament injuries
Medial (most
common)
- Medial
joint line
pain
- Medial
tibial
plateau
pain
OA
Medial Collateral ligament injury
Medial Meniscus tear
Tibial plateau fracture
Inflammatory arthritis
Septic arthritis
Anserine bursitis
Posterior
Knee effusion
Baker’s cyst
Lateral
Lateral compartment OA
Lateral collateral ligament injury
Iliotibial band syndrome
Lateral Meniscus tear
Referred
Knee Examination
(6-step Msk exam)
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Inspection
Palpation
Range of Motion
Strength
Neurovascular (rare)
Special Tests
Knee Examination
• Inspection
– Alignment of lower extremities
• Varus, valgus, recurvatum
– Patellar position and motion (j curve deformity)
– Inspection for asymmetries
• Swelling, torsion, inability to extend knee
• Atrophy
Knee Examination
• Palpate for effusion and
warmth
• Palpate for tenderness
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Tibial tubercle
Quadriceps tendons
Retropatellar tenderness
Joint line
Ligaments (MCL/LCL)
Bursa (incl. pes anserine)
• ROM
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Flexion: 130°/135°
Extension: 0° to -10°
Internal Rotation: 10°
External Rotation: 10°
• Strength
– Hamstrings
– Quads: squat, duck
walk
Knee Examination
• Special Tests (ligaments)
– Valgus and Varus Stress Tests (r/o)
(MCL/LCL)
– Lachman’s (r/o), Pivot shift test (r/i)
& Anterior Drawer (r/i) (ACL)
– Posterior Drawer & Posterior Sag
Test (PCL)
– Postero-lateral corner
– Patellar apprehension/stability (r/o
+r/i)- stability
– Flexibility
– Joint line tenderness (r/o),
McMurray’s (r/o), Thessaly (r/o)
(Meniscus)
•
http://ahn.mnsu.edu/athletictraining/s
pata/kneemodule/specialtests.html
MCL Stability
LCL Stability
Apply Valgus or Medial Stress
Apply Varus or Lateral Stress
ACL stability
PCL stability
Posterior drawer
Lachman Test
Thesslay test
Knee Injury: Diagnostic Accuracy of Physical
Examination Maneuvers and Clinical Findings
Sensitivity
(%)
Specificity
(%)
61
87
48
97
93
87
52
97
76
29
Anterior cruciate ligament (ACL) injury
• Most are non-contact
injury, 2° to
deceleration forces or
hyperextension
• Planted foot & sharply
rotating
• If 2° to contact, may
have associated injury
(MCL, meniscus)
Anterior cruciate ligament (ACL) injury
• Risk of injury 2 – 8 times ↑ in women
• ~250,000 injuries/year in general population
• Gender difference not clear
– Joint laxity, limb alignment
– Neuromuscular activation
Anterior cruciate ligament (ACL) injury
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Hx:
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Hearing or feeling a “pop” & knee gives way
Significant swelling quickly (< 1 hours)
Unstable
↓ range of motion
Achy, sharp pain with movement
PE:
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Large effusion, ↓ ROM
Difficult to bear weight
Positive anterior drawer
Positive Lachman’s
Imaging:
– X-ray always
– MRI
Anterior cruciate ligament (ACL) injury
• Treatment:
– RICE
– Hinged knee brace
– Crutches
– Pain medication
– ROM/Rehabilitation
– Avoid most activities (stationary bike o.k.)
– Surgery (in most cases)
• Prognosis:
– Usually an isolated injury
– Post-op: 8-12 months until full activity
• Referral:
– Almost all young, athletic patients will
prefer surgical reconstruction
– ?Increased risk of DJD if not treated
– Can still get DJD if reconstructed
Meniscal Tear
• Absorbs shock, distributes
load, stabilizes joint
• Thick at periphery → thin
centrally
• Causes:
Sudden twisting/
hyperflexion
– Young athletes
• Simple movements /
degenerative tears
– Older knee
Lateral
Medial
Meniscal Tear
• Hx:
– Clicking, catching or locking
– Worse with activity
– Tends to be sharp pain at
joint line
– Effusion
• PE:
– mild-moderate effusion
– pain with full flexion
– tender at joint line
– + McMurray’s
• Imaging:
– MRI
Meniscal Tear
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Treatment:
– RICE
– Surgical repair or excision
(arthroscopic)
– Crutches
– NSAIDs
– Knee sleeve
– Asymptomatic tears do not
require treatment
Prognosis:
– Results of surgical
repair/excision are very good
– Return to full activities 2-4
months after surgery; tends to
be quicker for athletes
When to refer:
– Most symptomatic meniscal
injuries require surgery
Medial Collateral ligament (MCL) Injury
• Important in resisting
valgus movement
• Common in contact
sports, i.e. football,
soccer
• Hit on outside of knee
while foot planted
• Associated injuries
common, depending
on severity
Medial Collateral ligament (MCL) Injury
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Hx:
– Immediate pain over medial knee
– Worse with flexion/extension of knee
– Pain may be constant or present with
movement only
– Knee feels ‘unstable’
– Soft tissue swelling, bruising
PE:
– no effusion
– medial swelling
– pain with flexion
– tender over medial femoral condyle,
proximal tibia
– Valgus stress at 0° & 30° → PAIN,
possible laxity
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Imaging:
– obtain radiographs to r/o fracture
– MRI if other structures involved or if
unsure of diagnosis
Medial Collateral ligament (MCL) Injury
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Treatment: Grade I→no laxity @ 0°or 30°
Grade II→no laxity @ 0°,but lax @ 30°
– RICE
– Hinged-knee brace (Grade II)
– Crutches
– Aggressive rehabilitation
– NSAIDs
Treatment: Grade III → lax @ 0° & 30°
– Same as above
– Consider Orthopedic referral
Prognosis:
– Grade I -- 10 days
– Grade II -- 3-4 weeks
– Grade III -- 6-8 weeks
When to refer:
– Other ligamentous injuries (surgical)
– Severe MCL injury
– Not progressing as expected
Features that should prompt an xray after
acute knee injury include:
1. Unable to bear
weight
2. Can’t flex >90d
3. Patella TTP
4. Fibular head TTP
5. Age <18 or >55
6. All of the above
A 70-year-old male dairy farmer is evaluated
for 1-year history of pain in the left knee that
worsens with activity and improves with rest.
On exam, vital signs are normal. There is a
small left knee effusion, but no erythema or
warmth. Range of motion is limited and
elicits pain. Extension of this joint is limited to
approximately 10 degrees, but flexion is
nearly full. The remainder of the
musculoskeletal examination is normal.
The ESR is 15 mm/h. A standing radiograph of
the left knee is taken.
Which of the following is the most likely
diagnosis?
1.
2.
3.
4.
Avascular necrosis
Osteoarthritis
Rheumatoid Arthritis
Torn Medical Meniscus
From: Osteoarthritis
Ann Intern Med. 2007;147(3):ITC8-1. doi:10.7326/0003-4819-147-3-200708070-01008
Copyright © American College of Physicians. All rights reserved.
•
Progressive disorder of the joints causedby gradual loss of cartilage and resulting in t
he development of bony spurs and cysts at the margins of the joints and into the
subchondral bone
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Primary OA
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results from abnormal stresses on weight
bearing joints or normal stresses operating on weakened joints
– Occurs in the elderly
– Affects the lower cervical and lumbar spine, acromioclavicular joint, 1st carpometacarpal joint,
PIP, DIP, hips, knees, 1st MTP
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Secondary OA
– Affects joints not typically affected by primary OA
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Wrist, elbow, MCP, ankle, 2nd-5th MTP
Trauma
inflammatory arthritis- RA, infection
Neuropathies- Diabetes, Avascular necrosis
metabolic disorder
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Hemochromatosis
Calcium pyrophosphate deposits (CPPD)
Hypothyroidism
Hyperparathyroidism
Hypophosphatasia
Hypomagnesemia
Acromegaly
– Hereditary
Osteoarthritis
• Nonpharmacologic
Treatment:
– Nonpainful aerobic activity
– Weight loss
– Physical Therapy
• Improve ROM, increase
strength
– Bracing
– Accupuncture
– Surgery
• Pharmacologic Treatment:
– APAP
– Supplements
• Glucosamine and Chondroitin
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NSAIDs, COX-2’s
Tramadol
Viscosupplementation
Intrarticular Steroids
Glucosamine in Knee OA
• Controversial
• May provide modest
pain reduction
– Differences in results
between preparations
(G. sulfate more
effective)
• May preserve joint
space
– 1500 mg/day
Intra-articular Corticosteroids
• Intra-articular
Corticosteroids
– Beneficial in KNEE
– Short-duration benefits: 24 weeks
• Intra-articular
Viscusopplements
– Effective in knee and hip
Delayed effect (1-3 weeks)
– Long duration (6 months)
– One-time injection
(SynviscOne)
• Weekly injections 3-5x for
others
– May delay need for joint
replacement
Surgery
• Arthroscopy
• Joint
replacement
• Cartilage
transplantation
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31 year old female, L knee pain
Recreational runner
Localizes pain to front of knee
No trauma, insidious onset
Localizes pain “around kneecap”
Worse with stairs
Worse after prolonged sitting
Knee occasionally “gives out”
Key Questions
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Mechanism of Injury?
Acute or Chronic?
Where is the pain?
Mechanical Symptoms?
(Locking, popping,
catching?)
Associated instability?
Swelling?
Previous injuries or
surgeries?
What makes it worse?
What makes it better?
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Insidious Onset
Chronic
Anterior knee
gives out
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None
None
None
Running, Stairs
Multiple days of rest
Physical Exam
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Inspection: mild genu valgus
Palpation: TTP lateral > medial patellar facets
ROM: full w/o pain
Strength: normal
Neurovascular: normal
Special Tests:
– + patellar grind
– Decreased patellar glide
– Inflexible hamstrings (Popliteal angle)
Case 3 – Plain Films
Lateral
AP
Case 3 – Plain Films
Sunrise
Tunnel
What’s your diagnosis?
1.
2.
3.
4.
Patellar tendinopathy
Patellar instability
Patellofemoral syndrome
Plica syndrome
Patellofemoral Syndrome (Runner’s
Knee)
• Diagnosis in nearly 25% of all knee injuries
• Most common diagnosis made in runners
• Most common diagnosis in primary care
sports medicine clinics
Patellofemoral Syndrome
Clinical symptoms
• Diffuse anterior knee pain
• Worsened by patellofemoral loading– stairs,
prolonged sitting, squatting
• “Theater sign”
• May occasionally give out
• Symptoms frequently bilateral
• Swelling generally absent
• Usually no trauma hx, rare hx direct blow
patella
Patellofemoral Syndrome
Physical exam
• Pain reproduced by direct pressure over patella and
rocking in femoral groove
– Patellar grind test
• Patellar glide (retinacular flexibility)
• Vastus medialis oblique atrophy?
• Patellar tracking—lateral movement of patella near
full knee extension
• Relative weakness in hip abductors/external
rotators
Patellofemoral Syndrome
• Treatment:
– Relative rest for 1-3months;
non-painful aerobics
– Physical Therapy
• Improve Quad/Hamstring
flexibility
• Quad, Hip abductor
strengthening
• Core strengthening
– Patellar stabilization
brace/taping
– Foot orthotics
– Surgery (last-ditch effort)
– Weight loss
• 34 yo training for 1st marathon
• Atraumatic onset of R lateral knee pain 1 week
ago after 10 mile run
• Sharp burning pain
• Better with rest, returns with running
Key Questions
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Mechanism of Injury?
Acute or Chronic?
Where is the pain?
Mechanical Symptoms?
(Locking, popping,
catching?)
Associated instability?
Swelling?
Previous injuries or
surgeries?
What makes it worse?
What makes it better?
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Insidious Onset
Acute
Lateral knee
gives out
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None
None
None
Running
Multiple days of rest
Physical Exam
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Inspection: normal
Palpation: TTP over lateral femoral condyle
ROM: full
Strength: normal
Neurovascular: normal
Special tests:
– + Noble test
– Tight on Ober test
Ober test
Noble test
What’s your diagnosis?
1.
2.
3.
4.
Osteoarthritis
Meniscal tear
Iliotibial band syndrome
LCL sprain
Iliotibial Band Syndrome
• Treatment:
– Physical Therapy
• Specific ITB stretches
• Hip abductor strengthening
• Core strengthening (Gluteus
Medius)
– Slow return to activity
– Extrinsic factors: shoes,
running surface, training
errors
– NO running until pain free
with stairs
– Next start with light run,
stopping when stiff or tight
– Stretch after run
– Post-run ice for 20 minutes
A 24-year-old woman is evaluated for a 2-week history of persistent pain and swelling in the right
foot and knee and the left heel. One month ago, she developed an episode of conjunctivitis that
resolved spontaneously. She also had an episode of severe diarrhea 2 months ago while traveling
to Central America that was successfully treated with a 3-day course of ciprofloxacin and
loperamide. She has not had other infections of the gastrointestinal or genitourinary tract, rash,
or oral ulcerations. Her weight has been stable, and she has not had abdominal pain, blood in the
stool, or changes in her bowel habits. She has had only one sexual partner 6 years ago. She
otherwise feels well, has no other medical problems, and takes no medications other than
acetaminophen for joint pain.
On physical examination, vital signs, including temperature, are normal. Cutaneous examination,
including the nails and oral mucosa, is normal. There is no evidence of conjunctivitis or iritis.
Musculoskeletal examination reveals swelling, warmth, and tenderness of the right knee and
ankle. There is tenderness to palpation at the insertion site of the left Achilles tendon.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Enteropathic arthritis
Psoriatic arthritis
Reactive arthritis
Rheumatoid arthritis
A 52-year-old woman is evaluated for a 4-day history of swelling and pain of the left
ankle. She has a 6-year history of Crohn disease associated with joint involvement of
the knees and ankles which is controlled on infliximab and azathioprine. Her last
disease flare was 2 years ago and was treated with a slow prednisone taper.
On exam, T38 °C (100.5 °F), HR 88/min, and RR is 18/min. The left ankle is warm and
swollen, and passive range of motion of this joint elicits pain. The knees are mildly
tender to palpation bilaterally and without effusions, warmth, or erythema. Range of
motion of the knees elicits crepitus bilaterally. The remainder of the musculoskeletal
examination is normal.
Arthrocentesis of the left ankle is performed and yields 3 mL of cloudy yellow fluid.
The synovial fluid leukocyte count is 75,000/µL (92% neutrophils). Polarized light
microscopy of the fluid shows no crystals, and Gram stain is negative. Culture results
are pending.
Which of the following is the most likely diagnosis?
1. Avascular necrosis of the ankle
2. Crohn disease arthropathy
3. Crystal-induced arthritis
4. Septic arthritis
Causes of septic arthritis
Bacterial
Clinical clues
Gram positive
•Staph aureus
•Coag neg staph species
•
Healthy adults, skin breakdown, previously damaged joint (eg, rheumatoid
arthritis), prosthetic joint
•Non-group A Strept species
•
Healthy adults, splenic dysfunction
Gram negative
•E.coli
•Pseudomonas
•Haemophilus
•Neisseria gonorrheoeae
•
Immune compromised hosts, gastrointestinal infection
•
Healthy adults (particularly young, sexually active), associated tenosynovitis,
vesicular pustules, late complement deficiency, negative synovial fluid culture and
gram stain
Mycobacterium
• Tuberculosis
•Marinum
•
Immune compromised hosts, recent travel to or residence in an endemic area
•
Exposure to ticks, antecedent rash, knee joint involvement
Mycoplasma hominis
•
Immune compromised hosts with prior urinary tract manipulation
Fungal
Sporothrix schenckii
Histoplasma
Cryptococccus
Blastomcyes
Candida
Aspergillus
Coccidioides
•
Immune compromised hosts
Viral
Parvovirus B19
Hepatitis B
Hepatitis C
Rubella
HIV
Spirochete
•Borrelia burgdorefi
Parallel
Perpendicular
Gout
• disease that occurs in response to the
presence of monosodium urate (MSU) crystals
in joints, bones, and soft tissues.
• It may result in an acute arthritis and a chronic
arthropathy (tophaceous gout)
Risk factor for Hyperuricemia and Gout
Comorbidities
Demographics
• Advanced age
• Male
• Postmenopausal women
•
•
•
•
•
•
Lifestyle
Commonly Used Medications
•
•
•
•
Diuretics
Low-dose aspirin (eg, <325 mg)
Cyclosporine
Niacin
Hypertension
Cardiovascular disease
Chronic kidney disease
Diabetes mellitus
Dyslipidemia
Metabolic syndrome
•
•
•
•
Obesity (high BMI)
Diet rich in meat and seafood
High alcohol intake
Frequent consumption of
high-fructose corn syrup
DIAGNOSING GOUT
• Hx & P.E.
– Abrupt onset of severe pain, swelling, and tenderness that reaches its
maximum within just 6–12 hours, especially with overlying erythema,
is suggestive of crystal inflammation though not specific for gout
– Monoarticular in ~90% of initial presentations; ~50% are podagra
– Reduced mobility in affected joint
• Synovial fluid analysis
• Not Serum Urate
– Not reliable
– May be normal with flares
– May be high with joint Sx from other causes
Acute Flare Med Choices
• NSAIDS
– Interaction with warfarin
– Contraindicated in:
•
•
•
• Colchicine
–
–
–
–
Renal disease
PUD
GI bleeders
Not as effective “late” in flare
Drug interaction : Statins, Macrolides, Cyclosporine
Contraindicated in dialysis pt.s
Cautious use in : renal or liver dysfunction; active infection, age > 70
• Corticosteroids
– Worse glycemic control
– May need to use mod-high doses
• Low-dose colchicine had similar efficacy to
high-dose colchicine with lower adverse effect
profile
• Colchicine now has FDA-approved dosing
based on creatinine clearance
– CrCl 30-80 ml/min = 0.6mg daily
– CrCl <30 ml/min = 0.3mg daily
– HD = 0.6mg twice weekly (not dialyzable)
Terkeltaub, RA., et al. Arthritis Rheum 2010.
99
TREATMENT GOALS
• Rapidly end acute flares
Protect against future flares
Reduce chance of crystal inflammation
• Prevent disease progression
Lower serum urate to deplete total body urate pool
Correct metabolic cause
PROTECTION VS. FUTURE FLARES
• Colchicine : 0.5-1.0 mg/day
• Low-dose NSAIDS
• Both decrease freq &
severity of flares
• Prevent flares with start of
urate-lowering RX
Best with 6 mos of
concommitant RX
• Won’t stop destructive
aspects of gout
Recommendations From the 2012 American College of Rheumatology
Guidelines for Management of Gout
• ACR recommends a comprehensive treatment plan for the management of gout, including both
nonpharmacologic and pharmacologic approaches1,2
• Patient education including diet and lifestyle modifications is recommended along with the
following pharmacologic approaches for the management of gout1,2
Acute Gout Flares
• Treat an acute gout
flare with
pharmacologic
therapy (NSAIDs,
corticosteroids, or
colchicine) within
24 hours of onset2
Gout Flare Prophylaxis
• For gout attack prophylaxis,
initiate low-dose colchicine or lowdose NSAIDs when initiating uratelowering therapy (ULT)2
• Anti-inflammatory prophylaxis
should be continued from
initiation of ULT for the greater of2:
•
At least 6 months, or
•
Following achievement of
target serum urate, for
3 months in patients without
or 6 months in patients with
tophi on physical exam
Chronic Gout Management
• When initiating ULT, begin
anti-inflammatory gout flare
prophylaxis1
• Initiate first-line ULT, febuxostat
or allopurinol, or if at least one of
these is contraindicated or not
tolerated, probenecid can be used
to treat to sUA target of <6 mg/dL1
• sUA should be monitored
regularly (every 2-5 weeks) during
ULT titration, then every 6 months
once target sUA is achieved1
Rheumatoid Arthritis
• The prevalence of rheumatoid arthritis in most Caucasian
populations approaches 1% among adults 18 and over and
increases with age, approaching 2% and 5% in men and
women, respectively, by age 65
• The incidence also increases with age, peaking between the
4th and 6th decades
• The annual incidence for all adults has been estimated at 67
per 100,000
Rheumatoid Arthritis
• Description
–
–
–
–
–
–
–
Morning stiffness
Arthritis of 3 or more joints
Arthritis of hand joints
Symmetric arthritis
Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes
• A person shall be said to have
rheumatoid arthritis if he or
she has satisfied 4 of 7
criteria, with criteria 1-4
present for at least 6 weeks