Disorders of lower limb
Causes :
► Congenital.
► Inflammatory.
► Degenerative.
► Neurogenic.
► Traumatic.
► Infective.
► Idiopathic.
Age groups
► Newborn and Infants
► Children
► Adolescents
► Adults middle age
► Adults > 50
1) Hip Pathologies
Children
Adults
► Tendinitis – ilIopsoas , adductor strain
► FAI
► Trochanteric bursitis
► Stress fractures
► Early osteoarthritis
► AVN
Adults
► Established OA
► Inflammatory OA
► Fragility fractures
► Metastasis
► Infection
DDH
► Breech presentation
► Ist born female
► Family history
DDH
DDH
DDH
Septic arthritis
Perthes
► B> G
► Pain Hip or
referred pain
in the knee
► Limping
► Limited internal
rotation
SUFE
► Pain and limping
► Hx of recent injury
► M>F
► 12-15 Yrs
►Flexion results in
Ext rotation of the hip
FA
I
Bursitis
► Localisedpain over the
G. Trochanter
Stress fracture
OA
► Pain, poorly localised
► Stiffness
► Lose rotation first
AVN
► Alcoholand steroids
► Xrays may be normal
METASTASIS
► Hx of Primary Ca ► Multiple
myeloma
(thyroid, breast,lung ► Chondrosarcoma
kidneys, prostate)
► Unrelenting pain
2) The knee
GENU VALGUS &
GENU VARUS
Causes
► Lateralligament laxity
► Blount’s disease
► Congenital pseudoarthrosis of tibia
► Coxa vara
In ligamentous laxity notelat.Widening In Blount angulation at med.tib
Of knee joints metaphysis
In cong. Pseudarthrosis of tibia,the In coxa vara ,angulation at the neck
angulation is in the distal ⅓ shaft level
►Gait: intoeing, lateral thrust-the fibular head
and upper tibia shift laterally in Blount due to
laxity and incompetence of the lat. Collat. Lig.
► Stability
► Symmetry
►Level of fibular head, normally at the
level of the upper tibial growth plate, while it is
proximal in Blount, cong.longitudinal dificiency
of the tibia and achondroplasia
X-ray
►3 years and older
► Getting worse
► Abnormal site of
angulation
► Large physis and
epiphysis
► History – taruma, infection,
possible metal intoxication(lead or
floride)
Metaphysial/diaphysial
angle ≥ 18°
Findin
g
► Metaphysis, thick and
frayed in rickets
► In physiologic genu
varum no intrinsic bone
disease, gentle curve, medial
cortices thickening, horizontal
joint lines of the knee & ankle
are tilted medially
Knock Knees / Genu Valgum
► Legs are bowed
inwards in the
standing position.
Bowing occurs at or
around the knee. On
standing with knees
together, the feet are
far apart.
Normal Knee –
Anterior,
Extended
31
Surface Anatomy - Anterior, Extended*
Patella
Indented
Hollow
32
Normal Knee – Anterior, Flexed
33
Surface Anatomy - Anterior, Flexed
Patella
Tibial
Tuberosity
Head
Of
Fibula
34
Palpation – Anterior*
Patella:
Lateral and Medial Patellar Facets
Superior
And
Inferior
Patellar
Facets
Medial Fat
Lateral Fat Pad Pat
Patellar Tendon**
35
Surface Anatomy - Medial
Tibial Patella
Tuberosit
y Medial
Joint Femoral
Line
Condyle
Medial
Tibial
Condyle
36
Palpation - Medial
Medial Collateral Ligament (MCL)*
Pes anserine
bursa**
Medial joint
line
37
Surface Anatomy – Lateral
Patella
Quadriceps
Tibial
Tuberosity
Head
Of
Fibula
38
Palpation – Lateral*
Lateral Collateral
Ligament
(LCL)** Lateral joint
line
39
Palpation - Posterior
► Popliteal fossa*
► Abnormal bulges Popliteal
▪ artery aneurysm Popliteal
▪ thrombophlebitis
▪ Baker’s cyst
40
Range Of Motion Testing
► Extension Flexion
0º 135º
► Describe loss of degrees of extension
► Example: “lacks 5 degrees of
extension”
► Locking* = patient unable to fully extend or
flex knee due to a mechanical blockage in the
knee (i.e., loose body, bucket-handle meniscus
tear)
41
Special Tests – Anterior Knee Pain
► Patellar apprehension
test*
Starting Push patella
laterally
positio
n
► Patellofemoral grind
test** 42
Special Tests - Ligaments
Posterior
Anterior Cruciate Cruciate
► Assess stability
of 4 knee
ligaments via
applied
stresses*
Medial Collateral
Lateral Collateral
43
Stress Testing of Ligaments
► Use a standard exam routine
▪ Direct, gentle pressure
▪ No sudden forces
► Abnormal test
1. Excessive motion = laxity
What is NORMAL motion?*
2. Soft/mushy end point**
44
Collateral Ligament
Assessment
Patient and
Examiner
Position*
45
Valgus Stress Test for MCL*
Note Direction Of
Forces
46
Varus Stress Test for LCL*
Note direction
of forces 47
Anterior Drawer Test for ACL
► Physician Position & Movements*
► Patient Position
Note direction
of forces 48
Osteoarthritis
Osteoarthritis (OA)
► OA is the most common form
of arthritis and the most
common joint disease
► Over 10 million Americans
suffer from OA of the knee
alone
► Most of the people who have OA
are older than age 45, and
women are more commonly
affected than men.
► OA most often occurs at the
ends of the fingers, thumbs,
neck, lower back, knees, and
hips.
OA
OA is a disease of
joints that affects all
of the weight-bearing
components of the
joint:
•Articular
cartilage
•Menisci
•Bone
OA
Nodal osteoarthritis
Note bony
enlargement of distal
and proximal
interphalangeal
joints (Heberden's
nodes and
Bouchard's nodes,
respectively).
OA – Risk Factors
Ag
e
► Age is the sttrrongest risk ffacttor for OA. Although OA can sttart in young adulthood, if you
are over 45 years
old, you are at higher risk.
Female gender
► IIn general, arthritis occurs more frequently in women than in men. Before age 45, OA occurs
more ffrrequently in men; afftter age 45, OA is more common in women. OA of the hand
is parttiicularly common among women.
OA – Risk Factors
Heredittarry gene defect
► A deffect in one of tthe genes responsible ffor the carttiilage component collagen can cause
detteriorattiion of cartilage.
Joint injury or overruse caused by physical labor or sports
► Traumatic injury (ex. Ligament or meniscal tears) tto the knee or hip increases your risk
ffor developing OA in tthese joints. Jointts that are used repeattedly in certtain jobs may be more
likely to develop OA because of injury or overuse.
► Being overweight during midlife or tthe latter years is among the strongest risk factors ffor OA
Osteoarthritis (OA) - Definition
Osteoarthritis may result from wear and tear
on the joint
• The normal
cartilage lining
is gradually
worn away and
the underlying
bone is
exposed.
Osteoarthritis (OA) - Definition
•The repair mechanisms of tissue absorption and
synthesis get out of balance and result in
osteophyte formation (bone spurs) and bone
cysts
A case of the, “Which
came first? The
chicken or the egg?”
OA – Radiographic Diagnosis
Asymmetrical joint space narrowing from loss
of articular cartilage
The medial (inside) part of the knee is most commonly affected by osteoarthritis.
OA – Radiographic Diagnosis
•Asymmetrical
joint space
narrowing
•Periarticular
sclerosis
•Osteophytes
•Sub-chrondral
bone cysts
OA – Arthroscopic Diagnosis
Arthroscopy allows earlier
diagnosis by demonstrating the
more subtle cartilage changes
that are not visible on x-ray
Normal Articular Cartilage
Ostearthritic degenerated cartilage
with exposed subchondral bone
OA – Disease Management
•OA is a condition which progresses slowly over a
period of many years and cannot be cured
•Treatment is directed at decreasing the symptoms of
the condition, and slowing the progress of the
condition
•Functional treatment goals:
•Limit pain
•Increase range of motion
•Increase muscle strength
OA – Non-operative Treatments
•Pain medications
•Physical therapy
•Walking aids
•Shock absorption
•Re-alignment through
orthotics
•Limit strain to affected
areas
Proximal Tibial Osteotomy
•Osteoarthritis usually
affects the inside half
(medial compartment) of
the knee more often
than the outside (lateral
compartment).
•This can lead to the lower
extremity becoming
slightly bowlegged, or in
medical terms, a genu
varum deformity
Proximal Tibial Osteotomy
•In the procedure to realign the
angles, a wedge of bone is
removed from the lateral side
of the upper tibia.
•A staple or plate and screws
are used to hold the bone in
place until it heals.
•This converts the extremity
from being bow-legged to
knock-kneed.
•The Proximal Tibial Osteotomy buys some time before ultimately
needing to perform a total knee replacement. The operation
probably lasts for 5-7 years if successful.
3) The foot
Case1 varus deformity
Case 2 calcaneus deformity
Case 3 equinus deformity
Thank you
