Differential diagnosis with interventions of lower extremity | Musculoskeletal system

Hip conditions

Avascular necrosis
- Etiologies that result in impaired or loss of blood supply to femoral head

Symptoms
- Loss of range of motion in hip flexion, internal rotation, and abduction
- Pain in groin and/or thigh
- Tenderness with palpation at hip joint
- Antalgic gait
Diagnosis
- Clinical presentation
- X-ray
- Bone scans
- CT or MRI imaging
Medical management
- Surgical intervention for revascularization
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
Physical therapy management
- Joint protection
- Functional mobility training
- Improve joint mechanics and mobility
- Improve strength/coordination

Trochanteric bursitis
- Inflammation of deep trochanteric bursa due to direct injury, irritation by iliotibial band, or repetitive microtrauma
  - Can be associated with rheumatoid arthritis

Symptoms
- Sharp or dull ache on the outside of the hip
- Pain that radiates down the upper thigh
- Pain that worsens with activities that involve the hip, such as walking, running, or climbing stairs
- Tenderness at lateral hip
Diagnosis
- Clinical presentation
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Management of rheumatoid arthritis as indicated
Physical therapy management
- Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing

Iliotibial band tightness
- Tight iliotibial band, abnormal gait pattern
  - Can lead to trochanteric bursitis

Symptoms
- Pain that worsens with activity, especially running, cycling, or going up and down stairs
- Severe pain when bending your knee
- Swelling on the outside of the knee
- Tenderness to the touch on the outside of the knee
Diagnosis
- Clinical presentation
  - Special tests- Ober’s and Noble’s tests
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Treatment of trochanteric bursitis as appropriate
Physical therapy management
- Gait training- appropriate running shoes, orthotics may be prescribed
- Reduction of pain/inflammation
- Soft tissue and manual techniques
- Joint mobility and functional training

Coxa vara and coxa valga
- Caused by defect in ossification (formation) of femoral head; can also be a result of avascular necrosis due to septic arthritis
  - Coxa vara- angle of femoral neck <115 degrees
  - Coxa valga- angle of femoral neck >125 degrees

Symptoms
- Coxa vara
  - Leg length discrepancy
  - Pain in the hip and/or leg
  - Stiffness with abduction
  - Prominent greater trochanter
  - Limited hip mobility
- Coxa valga
  - Increased anterior pelvic tilt
Diagnosis
- Clinical presentation
- X-ray
Medical management
- Surgery if angle is >60 degrees from normal value
- Assistive devices as indicated
Physical therapy management
- Improve joint mobility and mechanics
- Use of orthotics for leg length discrepancy
- Use of muscle energy techniques to correct pelvis tilt

Piriformis syndrome
- Tightness or spasm of piriformis can result in compression of sciatic nerve
  - Tightness can be a result of repetitive movement of piriformis or overuse
  - Compression of sciatic nerve can cause radiation of pain down leg

Symptoms
- Restriction in internal rotation
- Pain with palpation of piriformis muscle
- Referred pain to down posterior leg
- Weakness of external rotation
Diagnosis
- Clinical presentation
  - Special test- piriformis test
  - Rule out lumbar spine involvement
- Electrodiagnostics of sciatic nerve
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
Physical therapy management
- Pain management and reduction of pain from posterior leg to only piriformis (centralization of pain)
- Muscle mobility and strengthening
- Muscle balance restoration
- Correction of biomechanical faults with orthoses

Knee conditions

Ligament sprains
- Can involve one (single plane) or multiple (rotary instability) ligaments of the knee
  - Anterior cruciate ligament
  - Posterior cruciate ligament
  - Medial collateral ligament
  - Lateral collateral ligament
- Classification of sprains
  - First degree: minimal instability of knee joint; ligament stretched but not torn
  - Second degree: minimal- moderate instability of knee joint; ligament is partially torn
  - Third degree: extreme instability; ligament is completely torn and ruptured

Symptoms
- First degree: minimal pain and swelling
- Second degree: moderate pain, swelling, tenderness to joint, and joint laxity noted with certain movements
- Third degree: significant pain, swelling, and instability due to complete tear
Diagnosis
- Clinical presentation
  - Special tests based on ligament injury
    - Anterior cruciate ligament - Lachman, anterior drawer
    - Posterior cruciate ligament- posterior drawer test
      - Medial collateral ligament- valgus knee test
      - Lateral collateral ligament - varus knee test
  - MRI
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Surgery indicated if functional instability present- can be for grade two or three sprains
Physical therapy management
- If surgery performed, interventions will be based on protocols post-surgery
- Reduction of pain and inflammation
- Functional training
- Joint mobility

Meniscus injuries
- Combination of flexion, compression, and rotary forces on knee casing abnormal stress to knee

Symptoms
- Pain increases with twisting or weight-bearing activities.
- A sensation of the knee giving way or locking up, especially when squatting, standing up, or turning.
- A feeling that the knee is not stable or may give out.
Diagnosis
- Clinical presentation
  - Special tests- McMurray, Apley, Thessaly
- MRI
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Surgery may be indicated
Physical therapy management
- Reduction of pain and inflammation
- Functional training
- Joint mobility

Patellafemoral pain syndrome
- Dysfunction of knee due to trauma, muscle imbalance/tightness, improper loading of joints

Symptoms
- Pain in the front of the knee, around or behind the kneecap
- Pain when going up or down stairs
- Pain when squatting or kneeling
- Pain after prolonged sitting with bent knees
- A grinding or catching sensation in the knee
Diagnosis
- Clinical presentation- description of pain when increased load to patellar such as stair climbing or squatting
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
Physical therapy management
- Reduction of pain and inflammation
- Taping, mobilization of patellar
- Functional training
- Biofeedback for vastus medialis
- Prescription of orthotics as appropriate

Patellar tendinopathy
- Degeneration of patellar tendon due to overload and/or jumping related activities
  - Can be related to patellofemoral pain syndrome

Symptoms
- Pain that’s worse with activity, such as running, jumping, or walking
- Pain that’s worse when going downhill or descending stairs
- Pain that’s worse when bending or straightening your leg
- Pain that’s worse when sitting for long periods or using stairs
- Tenderness on the front of the knee
- Tenderness behind the lower part of the kneecap
Diagnosis
- Clinical presentation
  - Abnormal patella position
    - Patella alta- patella tracks superiorly
    - Patella baja- patella tracks inferiorly
  - X-ray
Medical management
- Re-alignment of patella if subluxation has occurred
Physical therapy management
- Improve lower extremity strength- specifically quadriceps and hamstrings
- Functional training
- Joint mobility
- Patella taping or bracing

Conditions of lower leg

Acute compartment syndrome
- Increased compartment pressure of lower leg (specifically- anterior, lateral, and posterior areas)
  - Commonly caused by direct trauma or fracture

Symptoms (six P’s)
- Pain to lower leg
- Palpable tenderness to lower leg
- Paresthesia to lower leg - specifically to deep peroneal nerve
- Paresis to lower leg- specifically to deep peroneal nerve
- Pallor to lower leg
- Pulselessness to dorsal pedal artery
Diagnosis
- Clinical presentation
Medical management
- Medial emergency- immediate fasciotomy is indicated to relieve pressure and decrease the likelihood of prolonged neurovascular compromise
Physical therapy management
- Post-operatively physical therapy to ensure return to normal function

Chronic exertional compartment syndrome
- Increased compartment pressure of lower leg (specifically- anterior, lateral, and posterior areas) causing a restriction in blood flow
  - Develops gradually over a period of time due to repetitive movements and exertional activities
  - Typically occurring in only one compartment of lower leg

Symptoms
- Pain
- Numbness and tingling
- Weakness
- Swelling
- Tightness
- Foot drop
Diagnosis
- Clinical presentation
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
Physical therapy management
- Functional training, proprioceptive training
- Decrease exacerbating activity
- May require use of orthoses

Stress fractures
- Microfractures to the tibia or fibula due to overuse (repetitive micro-traumas to the tibia or fibula)
  - Commonly due to poor alignment of lower extremity when performing activity, deconditioning, or improper training

Symptoms
- Dull, aching pain that gradually worsens with activity
- Mild swelling may occur around the fracture site
- Affected area may feel weak or unstable
- Difficult to put weight on the injured area
- Pain may be more severe at night or when resting
Diagnosis
- Clinical presentation
- X-ray
- MRI
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
Physical therapy management
- Initially decreased exacerbating activity
- Correction of malalignment and biomechanical issues
- Strengthening and coordination activities

Ankle and foot conditions

Ligament sprains
- Classification of sprains
  - Grade 1
    - A mild sprain where the ligament is stretched or slightly torn
    - Symptoms include minor swelling, tenderness, and bruising
    - Recovery time is usually 1–3 weeks
  - Grade 2
    - A moderate sprain where the ligament is partially torn
Symptoms include swelling, bruising, pain, and difficulty walking
Recovery time is usually 3–6 weeks * Grade 3
A severe sprain where the ligament is completely torn
Symptoms include severe pain, swelling, bruising, and instability
Recovery time can be several months

Symptoms
- See specific grade for symptoms associated
Diagnosis
- Clinical presentation
  - Special tests: Anterior drawer, talar tilt
- X-ray
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Grade 2- immobilization device may be recommended
- Grade 3 sprains typically will need surgical intervention
Physical therapy management
- Grade 1- conservative management of rest, ice, compression, and elevation acutely; then functional mobility training
- Grade 2 and 3:
  - Functional mobility training
  - Biomechanical fault re-alignment
  - Joint protection and mobility
  - Post-surgical protocols if surgery indicated

Achilles tendinopathy
- Chronic inflammation of the Achilles tendon due to overuse, age, rheumatoid arthritis, or gout

Symptoms
- Pain, typically located in the back of the heel or just above it
- Tenderness and stiffness in the Achilles tendon
- Swelling and redness around the tendon
- Pain that worsens with activity and improves with rest
Diagnosis
- Clinical presentation
  - Special tests- Thompson’s test
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Corticosteroids
- Management of rheumatoid arthritis or gout
Physical therapy management
- Determine the phase (acute vs subacute vs chronic) and make appropriate selection of interventions based on phase of healing

Tarsal tunnel syndrome
- Entrapment of posterior tibial nerve within tarsal tunnel
  - Overuse injury due to tendonitis of posterior tibialis

Symptoms
- Numbness and tingling in the sole of the foot, arch, or toes.
- Burning or shooting pain may radiate from the ankle to the foot or calf
- Foot drop
- Swelling or redness
- Pain that improves with rest
Diagnosis
- Clinical presentation
  - Special test- Tinel’s sign
- Electrodiagnostic testing
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Surgical intervention if conservative management not effective
Physical therapy management
- Joint mobility
- Functional exercise training
- Orthoses
- Neurotension stretching

Foot deformities
- Pes cavus- hollow or flat foot
  - Due to genetics or biomechanical faults
- Equinus- plantarflexed foot
  - Can be due to genetics, bone deformity, neurological conditions

Symptoms
- Observation of foot as noted above
Diagnosis
- Clinical presentation and observation
Medical management
- Management of underlying causes as appropriate
Physical therapy management
- Improved biomechanical alignment
- Orthoses as appropriate
- Joint mobility
- Patient education

Charcot- Marie tooth disease
- Progressive disorder causing peroneal muscular atrophy and peroneal nerves- causing motor and sensory deficits
  - Genetic disorder
  - Begins in lower legs but can progress to forearm and hands
- Symptoms
  - Foot and leg weakness
  - Foot abnormalities: High arches, hammertoes, and flat feet
  - Numbness, tingling, and burning sensations in lower leg
  - Muscle atrophy in the feet and legs
  - Clumsiness and difficulty with fine motor skills

Diagnosis
- Clinical presentation
- Electrodiagnostic exam
- Genetic testing
Medical management
- Acetaminophen or non-steroidal inflammatory (NSAIDs)
- Surgical correction of joint abnormalities as deemed appropriate
Physical therapy management
- Progressive disorder with no cure so physical therapy interventions are centered around patient education, skin assessments for possible development of wounds, contraction prevention/management, and functional mobility assessment/training

Foot deformities
- Rearfoot varus
  - inversion of calcaneus when subtalar joint in neutral
- Rearfoot valgus
  - ** eversion of calcaneus when subtalar joint in neutral**
- Forefoot varus
  - inversion of forefoot when subtalar in neutral
- Forefoot valgus
  - eversion of forefoot when subtalar in neutral

Diagnosis of foot deformities
- Clinical presentation and observation
Symptoms
- Abnormalities in gait due to uneven levers
Medical management
- None indicated
Physical therapy management
- Improving foot alignment
- Orthoses as appropriate
- Strengthening as appropriate