OverviewHip

Trochanteric bursitisIliotibial band syndromePiriformis syndromeMeralgia paresthetica

KneeAnkle & Foot

Quick QuizHow many bursae are located at the greater

trochanter?Three

What gender is more affected by trochanteric bursitis?Female

Trochanteric BursitisMost common cause of pain at the hip3 bursae: gluteus maximus most importantDeep aching pain +/- burning sensationLateral hip and thighWorse with walking/climbing stairs 15% have a limp

Trochanteric Bursitis

Trochanteric BursitisMore common in womenPrecipitators: local trauma, leg length discrepancies,

joggingWeeks to monthsRest, NSAIDs, CS injection, surgeryFailure to improve may be secondary to iliotibial

band syndrome

Trochanteric Bursitis

Quick QuizWhat is the name of the this test used to

diagnose iliotibial band syndrome?

Ober’s test

Iliotibial Band SyndromeFascia connecting the ilium w/ the lateral tibiaRepetitive flexion and extension of the hipRunners (“camber running”)Local tenderness at lateral femoral condylePositive Ober’s testReduce mileage, CS injection

Iliotibial Band SyndromeIliotibial Band Syndrome

Iliotibial Band SyndromeIliotibial Band Syndrome

Piriformis SyndromeHistory of traumatic injury to the sacroiliac

and gluteal regionPain in the region of the SI joint, greater

sciatic notch, and piriformis muscleWorse with lifting or stoopingPalpable, sausage-like swelling of the muscleIrritation of sciatic nerve

Piriformis SyndromePace and Nagle signEnlargement on MRI or CT scanTreatment includes:

Rectal muscle massageLocal CS injectionInitiate piriformis muscle stretching

Piriformis Syndrome

Quick QuizName 3 common causes of meralgia

paresthetica.

Obesity, pregnancy, trauma, surgical injury, tight-fitting clothes, and DM

Meralgia ParestheticaEntrapment syndrome - lateral femoral

cutaneous nerveOccurs primarily in adultsLateral aspect of inguinal ligament, medial to

anterior superior iliac spine Belts, tight fitting clothes, obesity, pregnancy,

diabetes, ascites, trauma/ surgeryBurning pain/dysesthesia of anterolateral portion

of the thigh

Meralgia ParestheticaMeralgia Paresthetica

Meralgia ParestheticaSmaller area of sensory deficit is commonDDX: L2/L3 radiculopathy, spinal stenosisTreatment:

Weight reductionEliminate occupational traumaCS injectionNSAIDsNeurolysisEpidural CS injectionIce

OverviewHipKnee

Prepatellar bursitisInfrapatellar bursitisAnserine bursitisPellegrini-Stieda diseasePopliteal cyst

Ankle & Foot

Quick QuizAccording to Secrets, how do you

differentiate prepatellar bursitis from knee arthritis?

Acute inflammatory arthritis results in loss of full extension, whereas prepatellar bursitis pain is increased with flexion. Thus, if an inflamed knee demonstrates full extension w/out pain and a negative bulge sign, the disease is likely extra-articular.

Prepatellar BursitisPrepatellar Bursitis

Prepatellar BursitisRecurrent traumaErythematous, well-circumscribed, fluctuance

over front of patellaTrauma, gout, infectionAspirationRest, avoidance of kneeling, NSAIDsSeptic bursitis: rest, serial aspirations,

parenteral and then oral abxSurgery if no improvement

Prepatellar Bursitis

Infrapatellar Bursitis/Tendonitis“Parson’s knee”Overuse, trauma, infection, goutPain at midpoint of patella tendonSame treatment as prepatellar bursitis

The pes anserinus (“goose foot”) is the anatomic location of the conjoined tendon of which muscles?

Sartorius, gracilis, & semitendinosus

Quick Quiz

Anserine BursitisMedial aspect of knee

Deep to insertion of “pes anserinus”Superficial to medial collateral ligament

Pain with climbing stairsRest, NSAIDs, CS injection

Anserine Bursitis

Pellegrini-Stieda DiseaseFollows an injury to the MCLMost asymptomaticPain over femoral insertion siteX-rays: calcification of the insertion of MCLCalcification of hematomaSelf limitedRest, NSAIDs, CS injection

Pellegrini-Stieda Disease

Popliteal CystsAny age (child to adult)Communication between knee joint and

gastrocnemius-semimembranosus bursa at medial head of gastrocnemius tendon

“Pain and swelling at the back of the knee”Palpation at the back of the knee on extensionAdult association with RA, OA

Popliteal CystsDifferential diagnosis:

DVT, thrombophlebitisPopliteal artery aneurysmGangliaNerve sheath tumorsSarcoma

Popliteal CystsUS, CT, MRITreatment in children is conservative: spontaneous

resolutionTreatment in adults is aimed at underlying pathologyKnee arthrocentesis and CS injection

Popliteal Cysts

Subgastrocnemius bursa and Baker's cyst in 58-year-old man are seen on sagittal T2-weighted MR images (TR/TE, 4,500/99). Image in more lateral position than A shows fluid in Baker's cyst (BC), superficially in relation to medial gastrocnemius tendon (g), and also between capsule (arrowheads) and gastrocnemius tendon in subgastrocnemius bursa (s).

OverviewHipKneeAnkle & Foot

Achilles tendinitis/bursitisPlantar fasciitisTarsal tunnel syndromeMorton’s neuroma

Achilles TendinitisPain, swelling, tenderness +/- crepitus near

insertion siteThickening and irregularity of the tissues

surrounding the tendon; +/- palpable nodulePain increased with passive dorsiflexion Repetitive trauma, microscopic tears due to

excess use of calf muscles; bad footwear

Achilles TendinitisSpondyloarthropathies, gout, RA, familial

hypercholesterolemiaUS, MRIRest, avoidance of provocative activties, shoe

modification, heel raise, NSAIDS, heat, splint (plantar flexion)

CS injections are discouraged

Achilles TendinitisAchilles Tendinitis

Quick QuizWhat is the name of the following physical

exam test that is used to test for an Achilles tendon rupture?

The Thompson Test

Achilles BursitisRA, Psoriatic arthritis, AS, Reiter’s, gout, traumaOveruse: ballet dancers, runners; tight shoesPain at posterior heel, painful dorsiflexionLocal swelling with “bulge” on medial and lateral

aspects of tendonRest, activity modification, moist heat, heel

elevation, NSAIDS

Quick QuizWhat name is given to the following exam

finding, which may be confused with a RA nodule?

“Pump bumps”

Achilles Bursitis

Plantar FasciitisRepetitive microtraumaPain often worse after period of restLocalized tenderness at anteromedial surface of

calcaneusObese, middle-age, elderlyChange in shoe-wear, change in walking

surface, enthesopathyWeight reduction, rest, hot soaks, NSAIDS, heel

cup, CS injection

Plantar Fasciitis

Plantar Fasciitis

Tarsal Tunnel SyndromeEntrapment neuropathy of posterior tibial nerveTarsal tunnel: fibro-osseus canal

flexor retinaculumvascular structurestendons of flexor hallucis longus, flex

digitorum longus

Tarsal Tunnel Syndrome

Tarsal Tunnel SyndromeBone deformities, pressure from casts, RA,

diabetes, ganglia, synovial cysts, flexor tenosynovitisParesthesias & pain in toes, sole, heel, may travel to

calf +/- relief with walking, pain worse at night

Tarsal Tunnel SyndromeTenderness with palpation of nerve posterior to

medial malleolusVasomotor changesElectrodiagnostic studiesCS injection, NSAIDs, orthotics, surgical

decompression

Morton’s Interdigital NeuromaEntrapment neuropathy of interdigital plantar nerve3rd & 4th metatarsal heads > 2nd & 3rdChronic irritation neuromaTransverse tarsal ligament

Morton’s Interdigital Morton’s Interdigital NeuromaNeuroma

Quick QuizCompression of a Morton’s neuroma can

cause the “neuromatous” mass to slip, producing a palpable click. What is the eponym given to this click?

Mulder’s Click

Morton’s Interdigital NeuromaUnilateral, mid-age womenLancinating, burning, neuralgic pain radiating

from web space to toesTight shoes, hard surfaces, prolonged standing

exacerbate painTenderness over interspace between metatarsal

bones, +/- tender noduleProper footwear, metatarsal pads, CS injection,

surgery

Shin SplintsMedial tibial stress syndromeRepetitive running on hard surfaces or repetitive

forcible foot dorsiflexionMedial tibial pain at beginning of exercisePain may become persistent3-6 cm tender area on postero-medial, distal

tibiaBone scan: posteromedial tibial cortex uptake

Shin Splints

Questions?