JC Lau 2002

Differential Diagnosis II Mid-term

ANKLE SPRAIN PRESENTATION
CASE I 20 year old male sustained an ankle injury. He has had multiple ankle injuries to both
ankles over the last few years. He is very active and in addition to playing basketball and soccer,
he also is a snowboarder. He injured his ankle snowboarding (Dorsiflexion, inversion injury)
IF THE INJURY IS ACUTE (2 Days) AND THERE IS SIGNIFICANT SWELLING:
HISTORY
Looking for Instability
1. Mechanism

If they fell forward on their board, they will do a DORSIFLEXION/INVERSION sprain

Due to boot holding foot in Dorsiflexion yet still allowing foot to rotate inside.
2. Lots of swelling

Indicative of LOTS of injury

Will throw off a lot of tests because fluid acts almost like a "splint"
3. Ottowa Guidelines

Inability to bear weight after injury OR during examination

Pin point pain Bony tenderness (specific areas of bony tenderness)

a.
Malleoli
b.
Navicular
c.
Cuboid
d.
5th MT head
EXAMINATION
X-ray - 3 views you must take (if no finding, wait 2 weeks and reshoot films)
1. A P Ankle
2. Lateral Ankle
3. Mortise view
Will reveal a Talar Dome Fracture OR Osteochondritis Dessicans of the ankle
Mortise view is taken A-P with 20 internal rotation
4. 2 Additional Views
a. Mortise Inversion Tilt
b. Mortise Eversion Tilt
Take two lines (one at the top of Talus, one at bottom of Tibia)
This angle is the Talar Tilt, should NOT be > 10
Positive Talar Tilt findings
If angle is open, patient has TORN the Calcaneofibular ligament, Anterior Talofibular
ligament
Must also look for tearing of the Interosseous Membrane and Tibiofibular
ligament
If X-ray is NEGATIVE:
1. Drawer Test
2. Talus Rock test
3. Inversion Stress test
4. Pin point tenderness

JC Lau 2002

Tests for Interossesous tear

1. Squeeze test / External compression test

Pain elicited with test due to further separation of Interosseous tear!!

2. External Rotation test - BEST test to use!!

Patient is seated with ankle in neutral position

Then PASSIVELY Externally rotate the ankle

POSITIVE FINDING: Looking for end-range pain
3. Squeeze / Dorsiflexion test

Pain or limitation with PASSIVE Dorsiflexion

Then squeeze
POSITIVE FINDING: There will then be an Increase in Dorsiflexion and/or Decrease in pain
Results of Interossesous tear
Calcification (Syndosmosis)
Diagnosis
1. Snowboarder's fracture

Lateral process of the Talus is fractured

May see on Lateral Film or A P (with internal or external rotation)

Possibly even an Oblique Film

2. Mechanism of Snowboarder's Fracture = Dorsiflexion and Inversion
PATIENT JUST INURED HIS ANKLE AT A SPORTING EVENT THAT YOU ARE THE DOCTOR
FOR. YOU ARE PRESENT TO EXAM THE ANKLE WITHIN 30 MINUTES PRIOR TO ANY
SIGNIFICANT SWELLING. WHAT IS YOUR APPROACH?
EXAMINATION in order
1. Ottawa Guidelines
2. Look for deformity
3. Check Neurovascular status
4. Person is able to bear weight

If all of these check out, ok to proceed to Orthopedic tests

Orthopedic Tests:
1. Drawer test
2. Inversion / Eversion Stress test
Only do this if Anterior Drawer is positive
This is because there is a sequence of injury (Anterior Talofibular must rupture before
Calcaneofibular ligament tears)
TREATMENT:
1. Adjustment of ankle
a. Once Ottawa rules and Anterior Drawer test are clear (fracture is ruled out and ligaments
are checked)
Talus
(1) Adjust Talus in OPPOSITE position of injury
(2) In case of Snowboarder, put ankle in Plantarflexion and Eversion
(3) In Inversion sprain patient, put ankle in Dorsiflexion and Eversion

JC Lau 2002

Calcaneus adjustment
(1) Do this one first

GOAL of Adjustments: to separate the Talus from the Tibia!!

2. Rehabilitation
a. Have patient walk ASAP!!
b. Taping
Stimulates propioceptive receptors and causes a quicker reaction of the Peroneals!!
Must leave room for swelling to occur (or else it will cause a lot of pain in the patient)
c.

Exercise
If you exercise the WELL ankle, patient gets a 30% stimulus to the affected ankle!!
Thus exercising one side helps the other!!

HE INJURED HIS ANKLE 2 MONTHS AGO BUT STILL HAS SOME PAIN AND A LITTLE
SWELLING. HE COMPLAINS OF SOME SNAPPING AT THE LATERAL ANKLE AND FEELS
HIS ANKLE GIVE OUT OCCASIONALLY.
1. Differentials / Causes of Ankle pain after a typical ankle injury
a. Tearing of Lateral Retinalum
Allows Peroneals to "snap"
Patient could also have just stretched out the Retinaculum really bad previously
b. Tearing of Bifurcate ligament
Palpable if you go from Cuboid and go in a little bit
Positive Sign is Cuboid goes in and out a lot
c.

Ligament impingement - torn ligament gets stuck in these possible spots:

Fascicle of Inferior Tibiofibular Ligament
Sinus Tarsi - ligament in there called the Interosseous ligament that can do this

Prevention program for Ankle Sprains:

1. Muscle strengthening
a. Tibialis anterior
Must work eccentrically
b. Adductors
c. Peroneals
2.

Propioceptive training
a. Balance boards
b. Wobble boards
Goal is to increase reaction time to sudden change in terrain
NO WAY to beat sudden change without visual cue (can increase reaction time if we see it
coming)

Other Ligaments that get damaged by Inversion Sprain:

1. Interosseous TaloCalcaneal Ligament
Inside Sinus Tarsi
Diagnosed with MRI
Can get entrapped
2. Bifurcate Ligament
3. Distal portion Tibiofibular ligament

JC Lau 2002

If this gets torn, often becomes unstable

Ankle Sprains
1. General Notes
Inversion / Plantarflexion is MOST COMMON
a. INVERSION SPRAIN: Sequence of Tearing (from front to back)
Anterior Talofibular
Calcaneofibular
Posterior Talofibular (this will only tear if SEVERE!)
b. EVERSION SPRAIN:
Deltoid Ligament rarely torn!
2. Evaluation
a. Palpate for bony tenderness (for fracture)
b. Anterior Drawer test
c. Tilt Test
d. Ottawa Rules
Inability to bear weight after injury or at time of evaluation
Tenderness at specific bony areas (Malleoli, Navicular, Cuboid, Head of 5 th MT)
Must take X-ray if ANY of these are found!!
Grading of Ligament Injury (Ankle swelling changes these rules for the Ankle!)
Sprained Anterior Talofibular ligament
No more than 25%
Grade 1
NOT LOOSE!!
Grade 2

Full rupture of the Anterior Talofibular ligament

Others are ok
LOOSE!

Grade 3

Full rupture of Anterior Talofibular and Calceneofibular ligaments

Posterior Talofibular can or cannot be ruptured

3. Treatment
a. Taping
1. Open Gibney Taping
Has horse shoe and stirrups WITHOUT being closed off
2. Air Stirrup
3. Prophylactic taping
For Chronic sprain prevention
b. Crutches
Used for 2nd and 3rd degree tears
c. Adjusting
Talus
Calcaneus do first
Only after patient has been cleared by Ottawa rules and Anterior Drawer test

JC Lau 2002
d. Muscle Strengthening
Peroneals
Tibialis Anterior
Hip Abductors
Strengthening of EVERTORS and DORSIFLEXORS will help prevent injury!
X-ray Findings:
1. Avulsion Fractures (Jones Fracture)
a. Must compare the X-ray to 2 Ossification centers
Smooth lines = 2 Ossification
Jagged line with wide space = Avulsion Fracture
Often see little pieces of bone on X-ray (Avulsion)
2. Avulsion Sites:
a. Base of 5th MT
Due to pull of Peroneus Brevis
b. Inferior tip of Fibula (Lateral Malleolus)
FLAT FEET PRESENTATION
Case I - pg. 17 (to see how to test for flatfeet)
A 25-year-old runner has been told that he has flatfeet. He is wondering if you think he does and
what can be done about it.
1. Non-weight bearing position, is there an arch?
1. Tarsal Coalition
Connection between Calcaneus and Talus and Navicular that
should not be there (connective tissue bridge)

Must take an X-ray

Flat Foot
CT Scan or MRI
2. Tibialis Posterior Rupture
Rheumatoid Arthritis predisposes to this
1. Normally
Even if a person a flat footed, there should be an arch
NORMAL
(There is an arch)

2. Exception
CHILDREN!
This is because when baby is in-utero, there is a period of time
that takes bones to "DE-ROTATE"
Feet are turned (baby fetal position) once baby bears
weight, bones will rotate into normal position
This does not occur in some people Tarsal Coalition

If Arch is present

NOT flat footed

JC Lau 2002

1. Is Medial Arch present/sufficient?

Can you get a finger underneath
If Arch is NOT present

2. Evaluate patient PRONE, examine relationship between forefoot

and hindfoot
a. Evaluate Forefoot Varus/Valgus
b. Evaulate Hindfoot Varus/Valgus
Valgus = eversion

MOST COMMON:
1. Hindfoot Varus
Have a lot to move when heel strike occurs to get to pronation
It is the "rate" that the patient has to pronate that causes the problem patient will have
a tendency to OVER-PRONATE!!!
Hindfoot Varus will look supinated statistically, but will behave opposite during motion
(OVER-pronates!!)
2. Forefoot Valgus
With Forefoot Valgus, when patient bears weight 4th and 5th digits will not be touching
SubTalar joint must supinate to get 4th and 5th digits down to the ground!! Thus
Hindfoot must be Varus to allow for Forefoot Valgus to be able to bear weight!!
Orthodics
1. Hindfoot Varus
Medial post would be placed on heel to prevent pronation!
2. Forefoot Valgus
Lateral Forefoot post to eliminate need for Hindfoot Varus!
In Utero causes of Flat Foot
1. IN-UTERO environment causes
It has caused bony malposition that CANNOT be exercised or adjusted away!!
2. Sustentaculum Tali Agenesis- KNOW!!
If this doesn't form in an infant, it will not hold Talus up and it will be allowed to drop!
Also, if Calcaneus EVERTS, Talus will be allowed to SLIP OFF of the Sustentaculum
Tali!
Muscle and Ligaments that Stabilize the Medial Arch (TOM DICK & HARRY)
1. Flexor Hallicus Longus
Most important!!
2. Flexor Digitorum
3. Tibialis Posterior
Rheumatoid Arthritis is the MOST COMMON reason patients rupture Flexor Hallicis
Longus or Tibialis Posterior!!
Tight Achilles tendon will INVERT ankle because it attaches medially on Calcaneus! This
may help compensate for Pronation!!
Foot will look flat in the NON-weight bearing position!!
Orthotic
1. Unilateral Pronator
Need an orthodic to PREVENT torsion of Tibia and Hip
2. Bilateral Pronator

JC Lau 2002

NO need use orthodic UNLESS they are experiencing symptoms!

Shoe Recommendations
1. Shoes Parts
1. Heel Counter
The higher the heel counter, the more cushion BUT more
predisposition to Inversion sprain!!
Upper
Person who sprains ankle easy should have a small heel counter
Upper part of shoe
2. Vamp - where laces go
3. Toe Box
1. Insole
2. Midsole
a. Usually made of:
EVA (for cushion)
Polyurethene (for durability)
"Dual Density" is a combination of the two.
Most shoes have this combo!!
Sole of Shoe

b. Often add AIR or GEL that is encapsulated

Sometimes with a plastic bar
This extends the life of the shoe!!
c.

FLEXIBILITY SHOULD BE AT THE METATARSALS NOT THE

MIDFOOT(middle of shoe)!!
If it bends at Mid-foot, it will predispose person to Plantarfascitis!!!

3. Outsole
2. Lasts = the MOLD of the shoe
a. Straight Last
b. Semi-curved Last
c. Curved Last
3. Lasts that holds Upper to Sole of shoe
a. Slip last stitched
b. Board Last - glued together
Made of cardboardish material
c. Combination last

JC Lau 2002

Front is slip-lasted
Back is Board-lasted

Shoe Recommendations
Motion Control Shoe
Board lasted
Straight Last
Pronator

Normal / Mild
Pronator

Supinator

Because you want a very firm Heel Counter.

Mid-sole is "built up" thus is the HEAVIEST shoe!!
Pronator cannot be diagnosed just from LATERAL shoe wear!
Diagnostic sign is bulge on medial aspect of shoe from pronation!!

Stability Shoe
Semi-curved last
Combination last
Cushion Shoe
Curved last
Slip last
1. LIGHTEST of all shoes!!
Slip last has no board
Curved last has less Mid-sole!

LAST PRONATOR CASE - 7 year old female with flat feet. What should she do?
3 Indicators for Orthotic Recommendation in a child:
1. Overweight kid
2. Unilateral problem
3. No Arch is seen when NON-weight bearing
ONLY in these conditions because their arch have not formed fully!
FOOT NUMBNESS
Case Study - 25-year female
A 25 year old female runner and bicyclist complains of numbness on the bottom of her right foot.
It is worse when she wears her shoes. She does have a history of ankle sprains on the involved
side.
Possible Diagnoses:
1. Nerve Damage Posterior Tibial Nerve
2. Mortons Neuroma
3. Tarsal Tunnel Syndrome
Muscle Actions:
Dorsiflexion - L4/5
1.
Plantarflexion - S1/2
2.
Inversion - L5
3.
Eversion - L5/S1
4.
Nerve Damage from:

JC Lau 2002

Stretch

1. Ankle Sprain
Only if it was an Eversion/Dorsiflexion injury
This would stretch the Tarsal Tunnel
2. Pronation - stretches medial ankle
1. Tight shoes
2. Scar Tissue
3. Bone spurs

Compression

4. Soft tissue tumors

Neuromas - directly off of the nerve
Lipoma
Ganglions
5. Fracture

Local Concern
1. Surgery at knee
That cuts the Saphenous Nerve
Morton's Neuroma - pp. 32
1. Interdigital Neuritis - must D/Dx from this!
Transverse Ligament that spans the Metatarsals
When weight bearing, the arch is flattened and stretches the Ligament
This puts pressure on the Interdigital nerve
2. Mortons Neuroma
a. General Information:
Benign nerve tumor of Digital nerve between the Metatarsals
Entrapment or irritation of Digital Plantar nerve
b. Location
MOST COMMON between 3rd /4th toe, may occur between 2nd /3rd toe (often a
palpable mass is found between these digits)
c.

Signs and Symptoms (Tumor signs/symptoms tend to wax and wane

Pain OR Numbness and tingling
Provocative
Made worse by DORSIFLEXION or TRANSVERSE
COMPRESSION
Palliative

PLANTARFLEXION of the MTP joint may relieve the symptoms

d. Tests
1. Dorsiflexion of toes and ankle
This will stretch the nerve and make symptoms worse
2. Palpate for nodule (pea-sized) and press on nodule!
See if symptoms get worse!
3. Transverse compression NON specific!
4. Plantarflexion of MTP joint
Will relieve symptoms
e. Treatment: 3 Step approach (When one fails, move on to next step)

JC Lau 2002
1. Orthodics
To correct pronation/supination
Direct padding to cushion Neuroma
2. Local injection of Corticosteroid
3. Surgical excision of Neuroma
SCIATIC NERVE
Tibial Nerve

Posterior Tibial

Medial & Lateral Plantar

Common Peroneal

Sural

Deep Peroneal

Superficial Peroneal

More MOTOR
(only sensory to middle of digits 1 and 2)

Medial Calcaneal nerve

Tarsal Tunnel Syndrome
1. General Information
Posterior Tibial Nerve entrapped or compressed in Tarsal Tunnel!!
Insidious onset of numbness/tingling across bottom of foot WITHOUT LOW BACK PAIN!!
(If low back pain is present, you are thinking mainly of S1-2)
2. Causes
a. Flexor Retinaculum compresses Tunnel from:
From scar tissue (tightens Retinaculum)
Tightened/stretched from Pronation (would cause a transient signs and symptoms
while walking only)
b. Hyperpronation
Collapses the arch and stretches the nerve
Also tightens the Flexor Retinaculum
c. Stretch / Compression of Tarsal Tunnel contents
d. Systemic Illness
e. Swelling
f.

Ganglion cysts
No adjustment or soft tissue work will make this go away
Requires excision usually

g. Tumor Growth
h. Subluxation - These possibly cause stretch and compression of the nerve
Calcaneus
Talus
3. Testing
a. Dorsiflexion and Eversion
Stretches the nerve because the nerve is behind the Medial Malleolus

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b. Compression of Tarsal Tunnel
By Flexor Retinaculum
Can compress only the Lateral or Medial Plantar Nerve if you compress on nerve
after it bifurcates
c. Tinel's Sign
Tap or compression
d. Neurological Testing
Rarely positive!
Sensory findings are more common than motor findings
4. Treatment:
a. Trial of Orthodics and/or Foot Adjustments
b. Podiatric Referral
If due to Ganglion or other pathology

Case 2
A 40 year old male patient complains of numbness on the TOP PART of his FOOT. It seems to
be worse when he wears his shoes.
1. Causes
a. Deep and Superficial Peroneal Nerves
Either up at Common Peroneal nerve (L5)
b. Shoes too tight
Compressing the nerves
c. Internal Compression - Talar Osteophyte
d. Footballer's Ankle (Europe)
Soccer injury from kicking ball in Plantarflexed position
Affects the Deep Peroneal nerve under the Flexor Retinaculum
e. Anterior Talus Subluxation
Case 3
A 55 year old male complains of pain, numbness and tingling down the lateral leg to the foot. He
thinks that stepping up to curbs is more difficult then before he had the pain.
Causes:
1. Sural Nerve injury
a. Plantarflexion/Inversion sprain
Most commonly injured this way
2. Coffin Foot
Occurs when you sleep at night with ankles crossed on top of each other
Causes compression of Sural nerve and numbness
3. Diabetes
4. Nerve Root Involvement
5. Anomalies of Bone Development

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a. Tarsal Coalition
When 2 bones that are supposed to separate DO NOT!
Failure to separate!
D/DX is when there is NO ARCH in NON-WEIGHT BEARING POSITION!!
(Normally, arch should re-appear in the Neutral foot!)

RESTRICTED ROM
1. Active ROM Restricted - see if movement pattern is restricted
a. Testing:
Muscle Tendon problem = pain
Nerve root problem = painless
Peripheral nerve problem
2. Passive ROM Restriction - Non-contractile tissues
If patient is PASSIVE Restricted, most likely they will be ACTIVELY Restricted as well.
Can have Active restriction without Passive restriction, but not Passive without Active!!
Causes of PROM Restriction:
a. Capsular Tightness
b. Muscle Tendon Tightness
c.

Obstruction - most commonly BONE

Usually fracture if traumatic, or an Accesory bone/Bone spur if Non-traumatic

d. Intra-Articular
Joint swelling
Mechanical obstruction (joint mice)
Testing for PROM Restriction:
1. Post-Isometric Relaxation testing - e.g. ITB stretch that can go farther after an
Isometric contraction
a. If it increases
Capsular tightness
Muscle Tendon Tightness
b. ANYTHING INSIDE JOINT WILL NOT INCREASE ROM WITH THIS PROCEDURE
Joint swelling, joint mice, subluxation...etc
Ankle Examples:
1. Joint swelling - ankle sprain

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2. Joint mice - Osteochondritis Dessicans
3. Posterior Tightness
Gastroc
Soleus
Plantaris
4. Soft tissue problems only block movement in one direction
5. Intra-articular problems block movement in ALL directions
Os Trigone - accessory bone (in posterior part of leg, blocking plantarflexion)
Stidus process

HEEL PAIN pp. 58

Case 1
25 year old female marathon runner complains of pain on the bottom of her RIGHT HEEL. The
pain is felt primarily on weight bearing and is helped only slightly with a padded insert.
Possible Diagnosis
1. Fat Pad Syndrome too young
2. Stress Fracture
Highly more likely in female due to Estrogen levels linked to Bone Density
Emotional or physical stress can throw off menstrual cycles as well as low body fat
Thus, must ask patient what her menstrual status is!!
Diagnostic Tests:
1. Lateral X-ray of Calcaneus
2. Bone Scan
Is the definitive tool if there was a negative X-ray
3. Plantar Fascitis
Usually radiates towards Medial Arch
Very unlikely for Plantar Fascitis to be just localized at the heel
a. General Information
Pain is felt along the INSIDE and BOTTOM of foot often sharp and burning!
Pain goes all the way across the Medial arch (to the front of foot)
b. Causes:
May be due to PRONATION or SUPINATION
c.

Signs and Symptoms: WORST in the early morning when stepping out of bed
1. Pain worse with DORSIFLEXION of 1st Toe
2. Pain worse when coupled with Ankle Dorsiflexion

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If NO pain is elicited with Dorsiflexion of 1st toe, Dorsiflex the Ankle

Will get a sharp, lightening-like pain across foot!

3. Heel Spur
Tension from Plantar Fascia will cause Heel Spur to develop
Is NOT the cause of Plantar Fascitis NOR the cause of pain!!
Pain is due to the tension of the Plantar Fascia!!
d. Treatment:
1. Podiatrist
Orthotics 1st
Cortisone Injections if pain persists (breaks down tissue can lead to Plantar
Fascia ripping)
2. Chiropractic care
Low dye taping
Gradual stretching
Orthotics
ART/MRT

Case 2
59 year old male patient complains of HEEL PAIN. The pain remains local to his heel and is felt
onl upon weightbearing. He has worked in a factory for 25 years that has hard concrete floors
and as a manager he has spent quite a bit of time walking the floors.
Possible Diagnosis
1. Fat Pad Syndrome - Most likely diagnosis
a. Is there a firm heel counter in her shoe?
Allows Calcaneal fat pad to spread at heel strike
LOOSE, poorly fitting
Heel Counter
Permits increased transmission of impact to heel
Maintains the compactness of fat pad
FIRM, well fitting
Heel Counter
Buffers the force of impact
b. General Information
Fat pad degenerates with aging and therefore is more common in elderly!
Must differentiate between Plantar Fascitis
c. Evaluation
1. Tenderness is decreased with:
a. Squeeze test
Squeeze heel and poke on center of heel see if pain goes away
Dont squeeze and then poke to see if pain is increased
b. Increased padding at heel
2. Pain is at MIDDLE of Heel
If pain is at Medial Heel, it is indicative of Plantar Fascitis (because Plantar
Fascia originates off of the medial heel)
3. D/DX from Fat Pad Syndrome and Plantar Fascitis:
Fat Pad Syndrome
Plantar Fascitis
Pain at MIDDLE of Heel
Pain at Medial Heel

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Pat Pad Syndrome feels better with

TIGHT FITTING SHOES
Squeezing fat pad around heel will
decrease tenderness

Very unlikely that pain is just localized

at the Heel!!!
Squeezing fat pad makes no difference

d. Treatment
1. Tuli Cups
Mimics Fat Pad cushion
2. Firm Heel Counter
2. Stress Fracture
Highly more likely in female due to Estrogen levels linked to Bone Density
Emotional or physical stress can throw off menstrual cycles as well as low body fat
Thus, must ask patient what her menstrual status is!!
Diagnostic Tests:
1. Lateral X-ray of Calcaneus
2. Bone Scan
Is the definitive tool if there was a negative X-ray
3. Bone Bruise
Fat pad didn't act to cushion well enough
Will show a positive Squeeze test as well
4. Plantar Fascitis
Not likely due to localized pain
5. Psoriatic Arthritis
Look for skin lesions
Behind ear, extensors surfaces
Look for localized spots
Tests for Sero-negative Arthritides:
HLA-B27
ANA
C-Reactive proteins
(ALL are non-specific)
6. Reiter's Syndrome
7. Anklyosing Spondylitis
Case 3
25 year old male complains of pain at the bottom of his LEFT HEEL. He has not performed any
unusual activities and is not involved in any sports or exercise routine. He also has noticed some
SI pain that tends to flair up occasionally.
Possible Diagnosis
1. Reiter's Syndrome
2. Ankylosing Spondylitis
3. Psoriatic Arthritis
ALL involve the SIJ to some degree in some people
ALL involve HEEL to some degree in some

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ALL involve SPINE to some degree in some

Possible that adjustment could aggravate the condition
Would want to tell patient to take some anti-inflammatories to prevent excessive
inflammation and aggravation of joints

4. Anatomical Short Leg

Possible that short leg would cause more weight to be forced on long leg side
Case 4
10 year old male patient complains of RIGHT HEEL PAIN. He noticed this after landing from
jumping off a fence. The onset was about one month ago and the pain has not gone away.
Possible Diagnoses:
1. Sever's - Osteochondrosis
a. Anatomical variant
Even though Kid comes in from heel pain after landing, must factor in all the normal
anatomic variants
b. Epiphyseal problem with Calcaneus (similar to an Osgood Schlatter's of the HEEL)
Disruption of the growth area
Developmental thing that people grow out of
c. Normal variant
Looks like a fracture but is a normal variant!
2. Bone Bruise
3. Stress Fracture
4. Full Fracture
Looking for a Salter Harris (1 - 5)
Looking for a grade 5 due to compression!
Will see some slippage or fractures!
Tests:
a. Point tenderness
b. Squeeze test
c. Lateral and A-P X-ray
Whiter bone = Bone necrosis
Possibility of kid having Avascular Necrosis
Radiolucent line = Fracture
Nutrient canal = looks like a line that is perpendicular line to the Growth plate
Case 5
29 year old male runner complains of posterior heel pain (around the posterior structures). The
pain is worse while running, however, when he rests or sits for a period of 30 minutes or longer,
he notices a sharp increase in pain and a perception of stiffness when he stands up and initially
upon walking. The pain and stiffness tends to work itself out after he walks for a minute or so.
Possible Diagnoses:
1. Achilles Tendonitis - pg. 59-61
a. General Information
1 or 2 Strain of Tendon
Area most affected is 2 cm proximal to the Calcaneal insertion

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Area is surrounded by a Peri-tendon

Most common with runners and jumpers

Can lose up to 75% of Achilles tendon fibers and STILL FUNCTION OK!!!
The danger with the Achilles is that person can operate with 25% of fibers and feel
fine
It will only take a slight jar to cause full rupture of this thin band
Thus this is why we can have partial rupture without bad symptoms and then
experience a sudden rupture!!!
Two Types of Achilles Tendonitis:
1. Substance Tendonitis
In the substance of the tendon (not at the insertion point)
2. Insertion Tendonitis
Located AT the insertion site
Will lead to local inflammation, causing Retrocalcaneal Bursitis later
b. Causes
1. Shock absorption
2. Hyperpronation
3. Cavus foot
4. Muscles tendon attaching to Calcaneus are Eccentrically weak!
Leads to CHRONIC Achilles tendon injuries
Patient is very painful when he gets up from sitting. Stiff!!
Chronic Tendonitis with overlap of Retrocalcaneal Bursiitis
Osteoarthritis if older person
c. Evaluation
1. Palpation
If tender at insertion or a couple of inches above insertion
2. Swelling
Palpable defects may be found with impending rupture (often visible)
3. Diagnostic Ultrasound or MRI
For suspected partial ruptures
4. Check for tightness of Triceps Surae group (Prescribe stretching what is tight!)
a. Do with knee FLEXED
Testing Soleus primarily (taking Gastroc out of it)
Not much improvement with knee FLEXED, mainly Soleus is tight!!
b. Do with knee EXTENDED:
Testing ALL of the Triceps Surae group
Not much improvement with knee FLEXED, mainly Gastroc is tight!!
5. Thompson test
For acute ruptures
d. D/DX from Retrocalcaneal Bursitis BOTH OCCUR IN THE SAME SPOT!
1. Wearing Shoes:
Achilles Tendonitis

Retrocalcaneal Bursitis

Makes it feel better

Gives support

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Makes it WORSE!
More friction on the inflamed Bursa!

JC Lau 2002
Treatment
1. Conservative Care
a. Rest
b. Ice
c. Modify activity
d. Stretch portion of Triceps Surae that is tight (from testing)
e. Plaster casting into PLANTARFLEXION
Allows connective tissue to heal (by reducing stress on tendon)
HIGH RATE of re-tear if patient is active
f.

Eccentrically shorten/strengthen Achilles Tendon

Shorten with Heel Lift (relieves tension off of tendon)
Elastic Taping
Eccentrically train Triceps Surae
Eccentrically train Triceps Surae
Train on a small 2 X 4 (to adjust depth)
Do 2 feet first with body weight
Move on to using a step
Lower with gravity 1st. If that does not elicit discomfort
by the 3rd set, hold onto some weights.
PROTOCOL:
1. Go up fast into Plantarflexion
2. Lower slowly
3. Do 3 sets of 10 (3rd set should hurt a little bit)
1st set = non-painful
2nd set = non-painful
3rd set = slightly painful
NOTES:
* If you do all three sets and none of them hurt, the therapy
is not effective!!
Do over 6 - 7 days, every 2 days you increase the speed!!
Can do this daily.
Ice BEFORE and AFTER the exercise
* This can apply to all muscles with tendon problems!!
* This has been tested and PROVEN to work!!
*ONLY INCREASE WEIGHT!!! NEVER REPS or SETS!!!!

2. Surgical Re-attachment (for full rupture, this is usually required)

Strong
LOW RATE of re-tear
For active patients!!
2. Retrocalcaneal Bursitis
a. General Information
Irritation of the Bursa directly behind the Achilles tendon (just proximal to the insertion
into the Calcaneus)
Found POSTERIOR to the Calcaneus but ANTERIOR to the Achilles Tendon (that is
why tenderness here could be either Tendonitis or Bursitis)
b. Causes:
Most often found in Runners
Due to repetitive rubbing from the TOP of Heel Counter

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May proceed to the development of a osseous deformity called Haglunds Deformity

(extra bone formation from irritation of the Bursa) p. 15 of notes

c. Evaluation
1. Tenderness on palpation AROUND the tendon, not on the tendon
Must examine shoes to see:
If they have adequate padding
If they rub on the heels excessively
If they are in a constant position of slight plantarflexion where heel rubs on shoe
d. Treatment
1. Pad the area
To dissipate forces
With thick mole skin behind the Calcaneus
2. Taping
Same as Achilles Tendonitis taping
3. Pulsed Ultrasound

Case 6
25 year old female runner complains of pain at the back of her LEFT HEEL. In addition, whe
notices a swelling that seems to be persistent and becoming more solid to the touch.
Possible Diagnoses:
1. Chronic Retrocalcaneal Bursitis
Become more solid and less likely to dissipate
2. Hagland's Deformity (A.K.A's: Runner's bump, Pump bump)
Bone spur at the Achilles Insertion
Extra bone formation from irritation of the Retrocalcaneal Bursa
Has tendency to push against the shoe and cause irritation
Not good to surgically remove because that is the insertion for the Achilles.
Will need to re-attach tendon if you remove it!
3. Bone bruise
Very localized tenderness
Usually see in younger patients
If during acute conditions
4. Chronically
More likely due to Pinching by shoes

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TIBIAL BONE TUMORS

Tumor
Osteosarcoma

Malignant

Location
Diaphysis
Proximal Metaphysis

Ewing's Sarcoma

Diaphysis

If you think Tibial pain is due to tumor, most commonly the tumor is Malignant!
Tumor
Benign

1.
2.
3.
4.

Osteoid Osteoma
Giant Cell Tumor
Fibrous Dysplasia
Osteochondroma

LOWER LEG DISORDERS

Case #1
A 22 year female patient complains of right lower leg pain. She noticed this during running AND
at rest. It has gradually worsened over the last three weeks. She runs 10 miles, 3 5 X week.
Tibial Stress Fracture pp. 87 - 88
1. General Information
a. Medial Tibial Stress Syndrome
Early stage of Tibial Stress Fracture
b. Account for half of all stress fractures in athletes
c. Loser's Lines are signs of healed stress fractures
2. Occurs when Osteolytic activity outweighs Osteoblastic activity
a. Corticosteroid overuse
b. Osteoporosis with age
c. Inactivity / sedentary lifestyle
d. Female Triad
Overly active
Low Body Fat: ed body fat leads to ed Estrogen leading to ed Bone Density
(Hypothalamic feedback)
Amenorrhea
3. Site based on Activity:
a. Runners
More likely to have DISTAL and MIDDLE 1/3 Tibial Fractures
b. Dancers

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JC Lau 2002

More often have MIDDLE 1/3

May progress to full fracture called The Dreaded Black Line radiographically

c. Military Recruits
Have more PROXIMAL Fractures
4. Evaluation (Continuous Ultrasound doesnt work to locate Stress Fracture!)
a. X-ray
Cant see on X-ray until it heals and a Callus forms
Healing of Stress fractures take a minimum of 2 - 3 weeks to occur
b. Bone Scan GOLD STANDARD!
Radioactive dye injected into the bloodstream
Metabolically active areas will have more uptake of the dye (require more blood)
Problem is that in an adolescent, there are many areas that have INCREASED blood
supply (growing bones) Thus, look to see if it is UNILATERAL!!
5. Treatment
a. NOT Casted!
Heals well if you STOP the stress on the bone!
b. Non-Athletes
Restriction of impact
c. Athletes
Decrease activity / stress (can exercise in a pool)
Increased Calcium intake
d. Air Stirrups
May decrease healing time
Case #2
A 29 year old male runner complains of right POSTERIOR LOWER LEG pain. The pain is worse
while running, however, when he rests for a period of 20 30 minutes, he notices a dramatic
decrease in pain. The pain seems to appear about 10 14 minutes into his run. He has tried
stretching before and after his runs, however, this did not seem to have an effect.
1. Compartment Syndrome - pg 90
a. Four Compartments of Lower Leg:

Anterior

Deep Posterior

Tibialis Anterior
Extensor Digitorum Longus
Tibial Artery and Vein
Deep Peroneal Nerve
Tibialis Posterior
Flexor Digitorum Longus
Flexor Hallicis Longus
Posterior Tibial Artery and Vein

Superficial Posterior
Lateral

Triceps Surae

Peroneus Longus and Brevis

Superficial Peroneal nerve

b. Cause:

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Increased pressure in compartment may be acute from blood buildup or chronic due
to exercise
ACUTE

CHRONIC

Buildup of BLOOD/FLUID
Not common
EXERCISE:
Blood going into muscle causing swelling
Fascia cant adapt to the swelling (cant expand)
This causes compression increases pressure!!
Increased pressure will eventually damage the
muscle!!!

c. Signs / Symptoms:
1. Fine walking or light run
2. Continuous running increases pressure
Causes pain
Pain gradually gets better upon cessation of running (takes 20 30 minutes)
d. Evaluation
1. Slit Catheter Measurement
Stick needles into leg while you exercise
Measures compartment pressure 3 times:
a. Pre-exercise
b. During exercise
c. Post-exercise
POSITIVE FINDINGS:
Higher pressure at activity in patient with Compartment Syndrome
Takes longer for pressure to return to baseline after exercise
May not even get back to normal pressure
e. Treatment
1. Deep ART/MRT 1st
Do Conservative trial for several weeks
2. Fasciotomy
3. Fascietomy
1. Deep Vein Thrombosis
a. Causes:
Minor local trauma feels like a deep ache in the msucle
Prolonged sitting
Immobilization
Birth control pills increases the coagulability
b. Fatal if:
Danger is risk of Pulmonary Embolism
Embolus to LUNG Pulmonary infarction DEATH!!
c. Signs / Symptoms
Pain felt in isolated portion of calf muscles
Onset is usually sudden without prior warning (especially if they are older)

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JC Lau 2002
d. Evaluation
1. Homan's test - PASSIVELY Dorsiflex the ankle (Not a valuable test!)
a. Specific to a hospital setting
Where patients were bed ridden
If they tested positive, they knew it couldnt be muscular because they were
bed-ridden
b. Outside of hospital
It would not D/DX from a muscle strain
May be able to differentiate if you do a resisted muscle test along with
Homans
2. Doppler-Ultrasound = Required to Diagnose
e. Treatment
1. IV Warfarin / Coumadin
For 3 - 6 months
Prolonged use will increase chance of bleeding out!
Contraindicated to adjust due to risk of Subarachnoid bleeding post adjustment
(documented!)
2. Later go to Oral medications
2. Tennis Leg
a. Mechanism of Injury
Occurs with sudden EXTENSION of knee with foot dorsiflexed
Tearing of MEDIAL HEAD of Gastroc
If person is walking, it eliminates this as a Diagnosis!!
b. Signs / Symptoms
Sudden, sharp pain felt at Upper medial calf
Pain worse with PLANTARFLEXION
c.

Treatment:
1. Temporary heel lift
Do heel lift in both legs to eliminate uneven stresses
Mild Strain

Full Rupture

2. Crutch walking
To shorten the Gastrocnemius to allow healing
3. Taping
1. Long leg cast with use of Crutches
If more serious
For several weeks
Keeps foot in Dorsiflexion position

1. Shin Splints pp. 84 87

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JC Lau 2002

1. Muscles Involved
Tibialis Anterior and Extensors of toes and ankle

Anterior Shin Splints

(Lateral)

2. Causes:
Running/walking on hard surface
Poor shock absorption from shoes (shoes worn down)
If you strike down hard on foot
3. Treatment Goals
Have to work eccentrically to CONTROL Lowering of
foot to ground

Posterior Shin Splints

(Medial)

1. Muscles Involved
Tibialis Posterior and Flexors of toes and ankle
2. Causes:
Usually due to Hyperpronation!
If you accelerate through mid-stance TOO QUICKLY!!

ACUTE CARE
1. Ice
2. Support with Elastic tape
Applied in a spiral pattern, upward pattern toward area of tenderness
To apply compression towards the Periosteal tension
Can also use Elastic Stocking (with Velcro straps)
3. Orthotics
Especially helpful for Posterior Shin splints
4. Shock absorbent shoes
Anterior Shin Splints require this
5. Increase Dietary Calcium
D/DX Shin Splints from Compartment Syndrome
1. Onset of Pain - Biggest difference between Shin Splints and Compartment Syndrome is
onset of pain
a. Compartment Syndrome
Hits you 10 15 minutes into the run
Compartment Syndrome will only have pain during activity
b. Shin splints
Hurts right away, feels better later in run
Shin splints will have pain in between activity
SNAPPING/POPPING HIP PRESENTATIONS
Case 1
A 25 year old female dancer complains of snapping and popping with some discomfort in the
RIGHT GROIN area. It seems to be worse with circumduction maneuvers
1. Snapping Hip Syndrome p. 177
a. General information
Snap without pain = Tendon snap
Snap with pain = Tendon snapping over a Bursa!
SNAPPING / CLICKING IN HIP:

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1. Psoas Tendon, snaps over:

a. Lesser Trochanter
b. Iliopectineal eminence
Anteriorly

Laterally
Posteriorly

2. Symphysis Pubis
a. Due to instability from:
Post partum
Trauma
1. Iliotibial Band
a. Snaps over Greater Trochanter
1. Biceps Femoris Tendon
Snaps over the Ischial Tuberosity

Causes of Hip Snapping or Clicking

1. Suction effect
2. Subluxation
3. Osteochondral Loose Body
Case 2
A 45 year old female patient complains of snapping of the outer hip area and some discomfort
with walking felt at the same location as the snapping. The hip also seems to pop sometimes
when walking.
1. Subtrochanteric Bursitis
a. A.K.A
Ski-runners Hip
Found also in Ballet Dancers
b. General information
Usually gradual onset (proportional to the degree of activity)
Severe bouts may occur between exercise
Often present when first arising in the morning
2 Bursa involved:
1. Subgluteus Medius bursa
2. Subgluteus Maximus bursa
c. Signs / Symptoms
1. Well localized LATERAL HIP pain
2. Usually with only a minor degree of limp
3. May cause pain radiating to the LOW BACK, the LATERAL THIGH and KNEE (not
common)
4. Tenderness and swelling over the Greater Trochanter
d. Cause:
Repetitive activity can be a major cause n younger population due to friction over
Bursa causing it to become inflamed
Anything that leads to altered hip mechanics
e. Evaluation
1. Ask if painful
Adventitial Bursa form anywhere of ABNORMAL FRICTION!
Ask if painful: To identify if Bursa is involved!
If Bursa is involved, it will be painful!!!

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JC Lau 2002
2. Location of pain
To ID tendon that is snapping over the Bursa
f.

Treatment
1. Strengthen muscle of tendon if TOO LAX
2. Adjust areas
To prevent abnormal stress/biomechanics

Other Hip Bursitis

Subtrochanteric
Bursitis

Iliopectineal &
Iliopsoas
Bursitis

Ischial Bursitis

Subgluteus Medius bursa

Subgluteus Maximus bursa
Iliopsoas Bursa
1. Causes:
Tight Hip Flexors coupled with repetitive activity
2. Signs / Symptoms:
Anterior tenderness at hip, 1 2 cm below middle 1/3 of
Inguinal Ligament)
1. Causes
Direct blow
Acute or Chronic Trauma
a. From prolonged sitting on hard surfaces
b. Horseback riding
2. Symptoms
Extension of knee, which rotates the Ischial Tuberosity away
from the sitting surface
Local tenderness over Ischial Tuberosity

Case 3
A 15 year old hurdler had an injury while in practice and felt a pop on the inner part of his UPPER
THIGH. He now has pain and some weakness, even with walking.
Adductor Strain
1. General Information
a. Most often found in:
High jumps or hurdlers
Sprinting
Ice Hockey
Water Skiing
Football

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JC Lau 2002
b. Occurs most often at Myofascial Junction of Adductor Magnus
Due to sudden contraction of the Adductors from a stretched position of HIP
ABDUCTION or FLEXION
2. Signs / Symptoms
a. Reports a sudden pulling sensation in the groin that was incapacitating
b. Difficulty in bearing weight
c. Very painful
d. Severe injury may affect the Symphysis Pubis
3. Evaluation
a. Discrete tenderness at
Adductor Muscle group
Pubic attachment
b. Resisted Adduction
Sharply increases the pain or discomfort
4. Treatment
a. Figure 8 Supportive Taping
More angle so it pulls inwards!
b. Gentle stretching
c. Slow return to activity
Because it will take a long time to heal
Minimal stretching to avoid over-tearing
Stretching is required however to prevent healing in a shortened position
Case 4
A 25 year old bicyclist complains that he has snapping in the BUTTOCKS area everytime he
extends his LEG
1. Snapping Hip Syndrome
1. Biceps Femoris Tendon
Posteriorly
Snaps over the Ischial Tuberosity
Causes of Hip Snapping or Clicking
1. Suction effect
2. Subluxation
3. Osteochondral Loose Body

PAINFUL LIMP PRESENTATIONS

Hip Disorders based on age: pg. 171
0 - 3.5 years old

Congenital Hip Dislocation / Dysplasia

28

Avascular Necrosis

10 14

Slipped Femoral Epiphysis

14 25

Apophyseal injury (Apophysitis)

Avascular Necrosis
Synovitis
Rheumatoid Arthritis

20 40

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JC Lau 2002

Causes of Hip Disorders:

Trauma

Insidious

1.
2.
3.
1.
2.
3.

Fracture
Sprain
Strain
Overuse
Infection
Tumor

PAINFUL LIMP CASE STUDIES:

Case 1
A 25 year old FEMALE runner (approximately 3.5 hours / week) complains of groin pain and is
starting to limp due to the pain. The onset was gradual. She does not remember any single
event that "strained" her hip
1. Stress fracture (at Femoral neck) pg 181
a. General Information
Found more with jogging and aerobics
She is at the right age and runs enough to get it
b. Types of Hip Stress Fractures:
1. Superior Transverse Type (Tension)
Considered unstable
May need pinning
2. Inferior Type (Compression)
c. Causes:
1. Overuse
2. Osteoporosis or Poor bone status
Amennorheic patients
High level athlete
Low body fat
d. Signs and Symptoms:
1. Groin pain and Inguinal pain
87% report this!
From a stress fracture at the Femoral neck
May not be visible on X-ray
2. Discomfort at the extremes of Hip rotation
Heel percussion is not a good test in this case
e. Evaluation
1. History:
a. Diet - intake of Calcium
b. Menses
2. X-ray
Stress fracture at Femoral neck may not be visible on x-ray unless there is Callus
formation
Takes 3 - 4 weeks to develop
3. Bone Scan
Definitive Dx!!

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JC Lau 2002
f.

Treatment
1. Bed - rest
For severe cases
2. Non-weight bearing with crutches
For less severe cases
3. Pool walking
For Rehabilitation

2. Adductor Strain
Another possible diagnosis
DX with Resistive Muscle test for Adductors
Case 2
A 45 year old female patient complains of pain in her HIP that is getting strong enough that she
notices limping. She DID NOT fall on the HIP. She says the pain is deep and bothers her
sometimes at night.
1. Osteoarthritic Hip
a. Signs / Symptoms
Pain is worse on weightbearing
Patient demonstrates an ABductor lurch or quick step off pattern (quickly step off of
painful side)
As ROM is lost, a shuffling gait is seen
b. General Information
ROM is lost in a sequence with rotation first affected (Internal first), followed by
FLEXION and ABDUCTION later
Pre-risk fractors for OA/DJD:
1. Congenital hip dysplasia
2. Congenital hip dislocation
3. Legg Calve Perthes
4. Slipped Epiphysis
c. Evaluation
1. Radiographic evidence:
Pseudocysts
Asymmetrical joint space loss
Sclerosis / Osteophytes
2. Radiographically, there are several caveats
Early articular cartilage damage NOT VISIBLE!
Osteophytes do not necessarily mean DJD/OA
Weight bearing films are required! (to determine the degree of joint space loss)
d. Treatment, the key to long term success is:
Toning of the hip musculature and Stretching contractures
Example would be DJD in KNEE:
1. General Knee exercises
To increase muscle tone
If you develop muscle tone around knee, it will decrease pain and inflammation
(even without Osseous changes)

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JC Lau 2002
2. Lateral Heel Lift
If there is a decrease in Medial Joint space
3. Posterior Tibial Adjustment
2. Paget's Disease
10 - 15% of elderly patients
May be asymptomatic
Possibly due to a slow virus
3. Tumor
Pain waking at night
History of cancer
Cachexia
Case 3
Parents of a 10 year old boy have noticed that their son is starting to limp. he has not
complained of hip pain, however, he has told them that his knee hurts
1. Legg-Calve-Perthes - pg 187
a. General Information
Avascular necrosis that is Idiopathic!
Avascualr necrosis of Femoral head with associated subchondral fracture (Idiopathic)
Usually Avascular necrosis is due to Trauma or Slipped Capital Epiphysis, but in this
case, it is idiopathic in nature
b. Signs and Symptoms
When kid has knee pain, always check the hip
1. Chronic limp
With minimal pain
Made worse with activity
2. Pain refers to knee
Kids with knee pain MUST have hips evaluated!!
May be flexion/adduction contracture
c. Evaluation
1. X-ray
Later stages seen
When Avascular necrosis occurs, bone death occurs
Bone will grow again, but it is weaker "Mushroom shape"
Deforms
2. M.R.I
Best seen with this method
d. Treatment
1. Bracing
2. Surgery
Avoiding trauma to hip is the main treatment goal
Try to take stress off hip to prevent acceleration of disease
2. Transient Synovitis of Hip

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JC Lau 2002

See next case

Case 4
A 12 year old boy who is 5' 10" complains of a sudden onset of hip pain that is bad enough that
he is not able bear weight on the involved side:
1. Slipped Capital Epiphysis p. 184
a. General information
Progressive or sudden POSTERIOR/INFERIOR slippage of the Femoral Epiphysis
Occurs between ages of 8 - 12
20 - 25% occurs bilateral
2 Types:
1. Sudden - traumatic induced
50%
2. Progressive (without any trauma)
50%
Will be able to walk on it for awhile

2 Body types will be evident:

1. Tall, rapidly growing adolescent
2. Frohlic Syndrome
Too many female hormones
Gynecomastia

b. Evaluation
1. PASSIVE FLEXION of HIP
Tends to Externally rotate
2. Radiographic evidence - A-P and Frog leg views required
a. A - P view
Inferior slippage is seen on A to P
b. Frog leg Lateral for Hip
Will show Posterior slippage
Most of the displacement is seen Postierorly, thus Frog leg is best!
c. Treatment:
1. Surgical consult
Minimal slippage is often "Pinned"
2. DO NOT ADJUST!
If you try to adjust it back in, you WILL CAUSE Avascular necrosis!
Must pin it back
2. Transient Synovitits of the Hip - pg. 179
a. General information
Caused by trauma:
1. Fall
2. Direct blow
Infective
Usually TRANSIENT
However, prolonged course may indicate impending Legg-Calve-Perthes
b. Signs / Symptoms
Severe pain in Hip and Groin
Inability to bear weight
c. Evaluation
1. Bone Scan

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JC Lau 2002
2. CT Scan
Bone scan and CT may help diagnose, but main way is looking for signs of
infection
3. LOOK FOR SIGNS OF INFECTION!
Big distinction between this and other hip disorders is that you are looking for
signs of infection!
Unable to bear weight, recent infection, fever..etc
d. Treatment
Must be aspirated
Treated with IV Antibiotics

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