All right, so let's talk about MSK lower extremities. If you've listened to any of my podcasts, you know I don't go over every single boring detail. I'm going to focus on the things that always come up on the exams, the things you really need to know, the high old stuff. So I may not go over every single condition for lower extremity, but I will focus on the ones that seem to come up on exams. So let's ahead and get started with MSK lower extremity. As always, thank you so much
for the really nice comments to support. I really do appreciate it, so thank you. Let's go ahead and get started. We'll start with the hip and then we'll work our way on down. So hip fracture mechanism of injury young patients, this is going to be major trauma, So motor vehicle collisions. Hip fractures not a common occurrence in young patients unless there's a serious trauma or some sort of pathologic condition. So normally in younger patients you're looking for
some kind of major trauma. Old patients osteoporosis in falls. Proximately ninety percent of hip fractures and older patients are going to occur just from a simple fall from a standing position. So in young patients think high impact injury like MBA. Older adults think low impact like a fall from standing position due to bone loss scene in this age range, particularly in women due to their higher rates of osteoporosis. So there's a few different types of hip fractures depending on the
location involved. Femoral neck, introcanic fractures, trokin fractures. Really, I think there's only one you should commit to memory, and that's the femoral neck fractures because of the risks associated with this type. So formoral neck fractures a vascular necrosis. So if themoral neck fractures, you need to know this type is associated with one of the highest risks of a vascular necrosis. The blood
supply to the femoral neck is pretty poor. It's similar to the scafhoid bone that we'll talk about in the risk So any trauma to this area like a fracture, can lead to a disruption in the tenuous blood blood supply and can lead to complications like a vascular necrosis, which is just death of the tissue the bone due to insufficient blood supply. So remember increased risk of a vascular necrosis with formoral neck fractures compared to other type of hip fractures. Now,
in physical exam, this is important. You're going to see a shortened, externally rotated lower extremity, so most hip fractures will prevent present with the lay being externally rotated and shortened. This is important because with a hip dislocation it's usually going to be the opposite. So most cases with hip dislocations, you'll see internal rotation and external rotation with the fracture, so internal with dislocation most
of the time, and external with a fracture. The way that you can remember that is because fracture very conveniently has an E in it but not an eye, and then dislocation has an eye in it but not an E. So remember internal rotation for dislocation because that as an eye in the word, external rotation for fracture because it has an E in the word but not I. And these little things will help you get the answer right in vignette,
so sometimes you'll look in just for those little details. Treatment is surgical in most cases, or IF, which stands for open reduction with internal fixation versuing another versus another option, which would be Arthur PLASTI don't focus too much on treatment. It's not gonna it's not really high yield with most of the MSK likely not going to be what your tests it on. So talking about hip dislocations, really three things you need to focus on for dislocations. So first,
large forced trauma is going to be the most common cause. So large force trauma, motor vehicle accidents, pedestrians struck by automobiles, they're going to be your most common causes of hip dislocations can also be associated with high energy impact sports American football, rugby, skiing, snowboarding, gymnastics, But focus on your large force trauma like an MVA. Posterior dislocation is going to be your most common almost always posterior eighty to ninety percent, so you have posterior
anterior dislocation. Posterior is way more common. That's the one you need to memorize. Ninety percent of the cases are going to be a posterior dislocation. AKA that's what you're going to be tested on. So that's what you need to know. Now for the physical exam, shortened internally rotated lower extremity like I talked about before, So majority of time patients will present with a shortened
internally rotated lower extremity. That's because this is the classic presentation of a posterior dislocation, which we know by far is the most common type ninety percent of the time. So this will be the presentation you're going to see shortened internally rotated. Anterior dislocations will have exterior rotation, but who cares. Don't memorize that that's very rare. If you see a hypt dislocation, be thinking internal rotation again. The way you remember that is because dislocation has an eye,
not an e, so internal rotation. Fracture has an e not an eye, so external rotation. Remember that treatment again not high yield, pretty straightforward reduced the dislocation. This can be done either closed under sedation or open with surgical reduction. And again, this is something that needs to be done or I guess I didn't mention it, but it needs to be done urgently because the longer the dislocation proceeds without intervention, the higher the risk of complications that
can happen with dislocations, like a vascular necrosis. Moving on to slipped capital flemoral epiphysis. So this is a weakness in the proximal flemoral growth plate that leads to displacement of the capital fmoral epiphysis. So to put this simply, the fmoral head is slipping off of the flemoral neck. Sometimes it's described as ice cream falling off of a cone, because if you look at an X ray, that's actually what it looks like. Risk factors A few things that
you need to know. Obesity, this is the single grace risk factor. More than sixty percent of patients with this condition measured greater than or equal to the ninetieth percentile in weight. Males are much more prevalent in mail is proximately a one point five to one male to female ratio. The age range you're going to see this in twelve years and girls thirteen point five years. In
boys, that's going to be the peak age. So the mean age of presentation twelve years and girls thirteen point five years and boys, and this is because this is when they're experiencing a peak in growth related to puberty. So these risk factors are going to give you a really good idea of what type of patient you're going to be looking for in the vignette, so they're always going to give you the most common patient demographic, So they're not going to
give you a seven year old, skinny female. The patient the vignette for slip cap is going to be a male. It's going to be obese, and he's going to be in the age range around twelve to thirteen years old. Remember these little details, they're going to help you in the vignettes. Clinical manifestations painful limp, So the two most common manifestations to see in patients
are going to be pain and altered gait, so a painful limp. The classic complaint will be a child complaining of dole aching pain and the hip growing possible even in the knee with no preceding trauma. So be careful because fifteen round fifteen percent of patients, the only complaint they're going to have is isolated thigh or knee pain and not necessarily the hip. And that's because the involvement of the medial optat or nerve which runs along the medial thigh from the knee
up through the hip. So they may just have a knee pain, so be aware of that too. This is a condition of the hip, but they may present with knee pain diagnosis X ray. The diagnosis of slipcap is usually made just with Plaine radiographs. Classic appearance will reveal a posterior displacement of the flemoral epiphysis. If they give you a picture on the X ray,
it's going to look like ice cream slipping off of a cone. Remember that that's the classic way to describe this on X ray, ice cream slipping off of a cone, the flemoral heads sliding off of the neck. They're not going to say ice cream slipping off of a cone, but you need to create that visual so if you see it, you'll know what it is.
Treatment. This is going to be operative stabilization pinning, so these patients need to be non weight bearing referred to an orthopedic surgeon where the treatment is going to be surgical pinning. So that's gold standard for slip cap. A single cannulated screw place in the center of the epiphosis to keep the ice cream from falling off of the cone. All right. Moving on to a similar disease that can always be very confusing to get these two mixed up. Leg calvay
perthes disease. So this is idiopathic osteo necrosis or a vascular necrosis of the hip, so the blood supply to the head of the femur gets disrupted and this can lead to death or necrosis of the tissue. There's some theories proposed mechanisms, but normally we don't know why this happens five to eight years old, so it can be seen in children between the ages of three to twelve, but the peak incidence is going to be between five and eight, so
look for that age rangel on your vignette. More common in males, even more so than when we talked about in slip cap so one to four male to female ratio, so very high incidents in males. Clinical manifestations painless LIMP. This is something a little bit of a little controversial, so painless limp. So they absolutely may have pain in this condition, but I'm generalizing this for the sake of the ex am and in saying painless limp, it's not
so clear cut in real life. But normally this disease has this insidious onset, may start with little to no pain, oftentimes just hip stiffness. Loss of internal rotation. Eventually does progress and they'll develop some discomfort, usually after activity, but the pain, if it's present, is usually mild. It can also also be referred to the thigh or knee. Most exam questions are going to present this to you as a painless limp or maybe a limp with
mild pain. This is what helps differentiate it from slip cap, which normally almost always has a painful limp. So again, this isn't one hundred percent nothing is in medicine. Lake Calvey can be painful, slip cap can be pain less. But for the exam it's best to remember Lake Calve as pain less and slipped cap as painful. And if you ever forget which one has
a painful limp, which one has a painless limp? Painless, pain less with an L, painful with an F, remember pain less with an L only Lake Calve prothest disease has an L anywhere in the beginning of leg I'm talking about the first letters, but it doesn't have an F in any of the first letters, So painless with an L remember Lake Calvey and the first letters has an L in it, but it doesn't have in the first letters. Painful with an F only slip Capital for moral epiphysis has an F.
In the first letters of the words, so that helps you remember. For moral epiphysis slip cap. For moorl epiphysis is painful, doesn't have an L anywhere in the first letters. Hopefully that wasn't too confusing, and hopefully I explain that right. But that's how I used to remember it. If I ever forgot which had the painless, which had the painful, that's how I remember. Look at the first letters. Is there an L, then it's
painless. If there's an F, it's painful. Treatment observation. In most cases, the treatment for Lake Helve prothestases is conservative non weight bearing physical therapy. Around sixty to seventy percent of hips effected are going to heal spontaneously without any functional impairment. So surgery is an option, but it's not as common and it's mostly reserved for older children, generally over eight, whereas your younger
patients typically won't benefit from surgery. So Lake Calves slip Cap, they have a lot of similarities, and sometimes it's hard to differentiate the two on an exam question. And you will get a question probably about one of these on your exams. So let's go again over the key differences. So slip cap generally going to be older children like twelve to thirteen years old, lake calve younger children around five to eight slipcap generally painfull lake calva for the sake of
the exam, remember it it's pain lisp. And then finally, slip cap surgery will commonly be the treatment of choice, where lake calve will more commonly just be observation. So those two remember, don't get those mixed up, because that can be an easy question. You can get right if you can remember the little differences between the two. Okay osgod Schlaughter disease. This is an injury caused by repetitive strain and chronic evulsion of the pophesis of the tibial
tubercle. So in younger children, the tibial tuberosity where the boteler tendant attaches to it hasn't ossified yet, which basically just means it hasn't completely turned a
bone, so it's still contains some cartilage, so it's weaker. So when kids who are active play a lot of sports jumping and kicking, squatting, that Beateeller ligament is constantly pulling on the attachment side of the tibial tubercle, and eventually this causes separation of the patellar tendon from the tibial tubercle and some
trauma and inflammation. Eventually, the area as it begins to heal, a callus is formed and it leads to this tibial tubercle becoming more pronounced and generally that's what we see on X ray role when we palpay it on our physical
exam. This elevation of the tivial tuberosity as far as the age range thirteen to fourteen year old boy during a growth spurt can be seen in ages ranging from nine to fourteen, but it's more common in boys than the thirteen to fourteen year old age range, as this is a common time for a growth spurt. It could also be seen in girls, but it's not as common. So in the vignette, again, be looking for a boy in their
early teens. On exam, you're looking for or clinical manifestations. You're looking for anterior knee pain which is exacerbated by activity, so kneeling, running, jumping, squatting. I think basketball, as most vignettes are going to mention a young male playing basketball that presents with anterior knee pain on physical exam pronoun pronounced tender tibule, tubercle. So remember all that calous formation is causing this area to become more pronounced. And then as far as treatment, it's really
just gonna be conservative. So it's typically a benign and self limited condition, and conservative measures are going to be the mainstay of therapy, so And says physical therapy self limited condition symptoms generally resolve as the growth plays ossified. It's rare to require surgery. Okay, so you're gonna get an exampt question. It's gonna be a young kid, it's gonna be hip or knee paying exacerbated by sports, and the answer choices you're gonna have lake Helva, slipcap,
Osgat schlatter trust may have been there. You're gonna have no idea which one is, which, which one affects the hip, which one affects the knee. So this is the mnemonic I had, and it's it's dumb, but it helped me remember enough about Osgat Schlatter that I could remember the little bit about it that I needed to differentiate from slipcap and the other ones. So
Ozgat Schlatter is the one that evolves the knee. It's usually worth worse with squatting, So I used to remember instead of osgod schlatter disease, You're gonna remember Osgood's squatter denise. So squatter because the pain is usually worth worse with like squatting, kneeling sometimes jumping, and denise because it's a condition of the knee, the potellar ligament, and the tibial tubercle. These dumb things are gonna help Sabi on an examp. So remember Osgod osgod schlaughter disease. Remember
Osgod's squattered in knees. All right, so let's talk about some more nice stuff. Of all of the Loric's extremity MSK questions, the majority are going to be about the knee. So let's start with one of the biggest ones in that's interior cruciate ligament injury. So the ACL is the most commonly injured knee ligament, and the majority of a CL tears are going to occur from athletic injury. So the type of injury you're looking for is a non contact
pivoting injury most common cause. So the typical mechanism for an ACL injury involves running or jumping athlete who suddenly stops and changes directions like they're cutting. They pivot or the land in a way which involves rotation and valgus stress of the knee and the tibia slides anteriorly on the femur and pop goes the a CL
history, pop and swell. So the way this will be described on a vignette, of course, in real life, is the patient felt a pop in their knee at the time of the injury and then had a cute swelling after which is hemarthrosis which led to the swelling. Up to seventy seven percent of patients presenting with a cute traumatic knee hemarthrosis will have an ACL injury. So remember pop, then sudden swelling, pop and swell for the ACL.
That little rhyme there, pop and swell for the ACL physical exam Lockman test the most sensitive exam test. Therefore, this is the one you should commit to memory. You do this test with the knee and thirty degrees reflection, stabilize the distal femur with one hand while pulling the proximal tibia anteriorly towards you with the other hand, and attacked. ACL is going to limit the anterior
translation how far the tibia will go. If this isn't the case, there's increased anterior translation compared to the unaffected knee, patient likely has an ACL tear. The way that you're going to remember Lachman is the most sensitive exam test for an ACL tear is that the first three letters in Lockman are ACL rearranged, So Lackman Lockman LAC is ACL rearrange. So you'll always know if you see a Lockman test, look at those first three letters ACL rearranged. This
is your most sensitive exam test for AL tears. Of course, imaging, I'm not going to really go into this for most of these because it's going to be repetitive, But like most extremity injuries, you start with an X ray to rule upon the abnormalities, do an MRI to make the actual diagnosis of the tear. Treatment is going to be individualized to each patient. Most
active, younger patients and athletes are going to opt for surgical reconstruction. Older patients may go the conservative route with physical therapy, so conservative or surgical repair. Two things that memorize for an ACL tear the pop and swell. For the ACL, that pop felt in the knee, followed by him arthrosis causing the swelling. And remember your Lockman tests best physical exam test Lockman LAC. First three letters are ACL rearranged. Moving on to post tior cruciate ligament injury.
Very little to know here. This isn't a very high y old topic. It's rare to see this as an isolated injury. Isolated PCL injuries, they're just very uncommon. It's usually going to be in combination with other multiligament trauma to the knee, so the mechanism is usually going to be a direct blow to the proximal tibia with a flex knee like a dashboard injury. So the main cause of a PCL injury is a high energy trauma, most often
involving motor vehicle collisions. Second most common would be sporting related activities, but focus on your motor vehicle accident direct blow to the proximal tibia with a flex knee when it hits the dashboard. As far as the test, posterior drawer tests. So there's a few different physical exam maneuvers for a PCL tear, but posterior drawer tests is generally considered the most accurate maneuver for diagnosing PCL and
injury. AKA, that's the one you should know. So knee at ninety degrees of flexion, Wrap both hands around the patient's proximal tibia normally sitting on the foot to keep the leg fixated. Then apply a posteriorly directed force to the proximal tibia so you push back on the tibia with the knee flexed. Increased posterioria displacement compared with the uninvolved leg suggest tear of the PCL m riot A confirm of course, treatment's going to be conservative or surgical, conservative like
rest ice itself. Nothing specific to know here, and it's really surprising how well some individuals can do with this type of injury. They did a study and two percent of all college football players presenting for the exam prior to the NFL Draft had an asymptomatic PCL terror, So they were playing football with this terror. They had no idea, So conservative verse surgical, depending on the patient. Nothing high yield to memorize there, all right, moving on to
medial collateral ligament injury. Just a couple of things to commit to memory for MCL and LCL injuries will go over both of those. So medial collateral ligament injuries are caused by a valgus force to the lateral aspect of the knee. So really two mechanisms of injury will see with an MCL injury, either from direct valgus stress from a blow to the lateral aspect of the knee, or via an indirect stress like if the foot gets caught on the floor when the
athletes trying to change direction quickly. The key is the valgus stress. Whatever the cause, something caused the need to be pushed inward valgus stress. That's what you need to remember. How positive valgus stress test. The diagnosis of an MCL injury is often made clinically based upon the history, clinical presentation, and exam findings, and the physical exam tests you need to know as a valgus stress tests. You do this with the knee at both thirty degrees reflection
and zero degrees of extension. You apply valgus stress and you look for laxity of the joint. You feel how much the medial joint line widens. Okay, so the only thing I would remember for your medial collateral ligament injury is valgus you have to remember valgus force, valgus stress. This is associated with MCL injuries. How do you remember what valgus is? How do you remember what it's associated with? So this is how you remember it. This is
how you associated with MCL. MCL. Valgus has the word gus in it, So when you seek gus and valgus, I want you to think of Gusto as in Muccio gusto muccio, because Mucco starts with an M, so that helps you remember MCL and gusto from the valgus. Muccio gusto in English means nice to meet you, and this helps you remember the knee is being pushed inward from lateral force, and the knee is are getting closer together and meeting together. It's a ridiculous way to remember it, but I never forgot
it. So as soon as you see valgus, think Muccio Gusto m and mucho Gusto helps to remember mc L injury. Nice to meet because the knees are being pushed in and meeting together. Treatment is going to be very low yield, conservative or surgical. Nothing to bother memorizing talk about lateral collateral ligament injury the opposite, so this occurs due to a sudden various force to the
knee as opposed to valgus. So these are among the least common knee injuries, but they can occur when the knee joint is struck from the inside, so various stress, and it's really rare to have this as an isolated injury. It's much more common in combination with other other injuries, so positive varus stress tests. So either do this at both thirty degrees offlection and zero degrees
a full extension while applying various stress. So remember MCL has a positive valgus test because muccio gusto knees are meaning together mucho gusto ns to meet you. And then when we have LCL injuries by method of exclusion, it's the exact opposite, so varus legs being pushed outward LCL positive virus stress test. I also used to remember that leaky pipes rust because of rust and va russ leaky helps me remember the l and LCL, so hopefully one of those stick,
whether it's mucho gusto or leaky pipes rust in LCL with virus stress. So remember that remember your test for those. Let's move on to miniscal injury. So cute miniscal tears most often are going to be from twisting injury. So the tears typically happen when a person quickly changes direction while rotating or twisting the knee when the foot is planted. In older adults, we can see chronic
degenerative tears and these can occur with minimal twisting or stress. In some cases no trauma at all, but in general though, be thinking some sort of twisting of the leg in the vignette. As far as the manifestations, I want you to remember pop lock and drop like poplock and drop it, So when you think of miniscal tears, remember pop lock and drop as the most
common clinical manifestation. So patients with untreated miniscal tears are going to complain of the knee popping locking where they can't fully extend the knee, and then sometimes the knee will even give out where they drop because the knee just gave way. So remember miniscal tears pop lock and drop it. They're also going to have joint line tenderness on the exam, So on exam, joint line tenderness
is really the most sensitive physical exam finding. It's nonspecific though, so the physical exam test you should know about as it's the most commonly tested on is known as the McMurray test. So the McMurray test is a test of repeated passive flection and extension of the knee. Place your fingers at the joint line while you're performing the test, and you're feeling for a painful pop or click in the knee indicating a likely miniscal tear. Just an fyi in case you
don't know that. I do have a YouTube channel where I have like pictures of all these things and it's a lot easier to go along with the explanations if you have time to look at the videos, just to get a better idea, because it's hard to explain these physical exam tests. There is other tests with this type of injury. There's the apple, the thessaly, they're
not as commonly used or tested on. I'd focus on the McMurray tests as that's the one you need to do, you'll likely need to do in an osci and the one you'll get tested on this is you can remember McMurray test is associated with meniscal tears, So Murray is obviously a man's name, and meniscle when you broke, when you break down the words a miniscle as men is called, so menace call men is called, and men is called murray. So as soon as you see miniscal tear and a question, hopefully your
head thinks men is called? What are men called? They're called murray. That helps you remember the McMurray tests. So men is called murray as a miniscal tear as you use the McMurray test. All right, Moving on to the tibiofamoral dislocation, the knee dislocation. This is a potentially limb threatening injury. Dislocations of the tibiophomoral joint of the knee are true surgical emergencies. They
have a high rate of neurovascular injury. And if there's a populateal artery injury caused from the dislocation that goes unrecognized about eight hours after the majority of patients are going to require amputation of the leg. So this is a really serious injury. It's normally going to occur from high energy trauma, so relatively rare injury, but when it does takes place, it's certainly going to be a serious high energy trauma like a motor vehicle accident, fall from very high up
complications. These are the main things that you need to know about tibio from oral dislocations. First one poplteal artery. This is the most dangerous complication following a tibial from oral dislocation. Delaying diagnosis and repair can lead to amputation like I talked about before, So what we do to avoid missing this diagnosis is after the dislocation is reduced, we assess the distal and the poplteeal pulses. This can be done with an echo break index of betside ultrasound if available.
Also of course palpating. If there's signs of vascular compromise, these patients need emergency surgery console to keep them from losing the leg. And then also you may have an injury of the pernial nerves. So focus on the poploteal artery, but also be aware that the proneal nerve is injured in about twenty three percent of patients with need dislocations. Main takeaway with need dislocations, assess for vascular compromise, don't miss a popliteal arter injury. Moving on to Patello famral
syndrome antior knee pain. This is what you're looking for in the vignette, antior knee pain with Patelo famorl syndrome. So it's an overuse disorder that involves the Patelo for moral region and it will present as antiior knee pain around or behind the patello. Who you're looking for in the vignette is going to be runners and women in the vignette. It will be a female runner. That's your demographic. That's who's going to be in the vignette. That's who this
is seen most commonly. And sometimes this is even called runners knee I used to remember this because the name instead of being Patello for moral syndrome, I remembered it as Patello female run syndrome. So just help me remember. If I see a vignette it's a female and she's a runner, I should be thinking of Patello from female run syndrome aka Patello for Moorl syndrome. So remember Patelo female run syndrome. You'll remember female runner. That's who's likely going to
be in the vignette. Treatment is conservative and says rest et cetera. Takeaway, female runner antior knee pain. That's what you need to know for this now, eliot tibial band syndrome. This is going to sound very similar to Patello fhamoral syndrome. The main difference is the location of the pain and this is the second most common cause of knee pain due to overuse, patelophamoral being the first lateral knee pain in this case instead of anterior, so overuse injury
of the lateral knee. The pain develops where the iliotibial band runs a clock across the lateral famoral epicondo runners, you're going to see the sin so again primarily seen in runners, can also be seen in cyclists basically any athlete undergoing exercises with repetitive knee flection and extension. But primarily runners will be what you're looking from the vignette. Not so much of a predilection though for females as
we saw in patelo femoral syndrome aka patello female run syndrome. Remember it that way. Treatment conservative and SAIDs, rests, etc. There's some physical exam tests for this. The noble the overtest i don't think they're worth the time memorizing. Way more high yield things for you to focus on. For msk SO Patelo famoral syndrome, iliotibial band syndrome, very similar treatment similar usually the vinet vinet, they're going to be a runner. Main thing to focus on
to differentiate is where the pain is. Patelo formoral syndrome, antior pain. Remember that's where the patela is. So do you remember it's patela patelo, So you remember it's the patella. Patella is obviously in the anterior side of the name. That's where the pain is. And then iliotibial band syndrome pain is going to be lateral. That's the main takeaway to differentiate these two.
Otherwise it's very little to no moving on to an ankle sprain, So, lateral ankle sprains are going to be your most common inversion of the plantar flexed foot. That's going to be the most common mechanism of injury in an ankle sprain. Medial ankle sprains are actually very rare. They're not going to give you that. Remember, they're going to give you the common stuff. That's
where you're going to be tested on. So it's going to be a lateral ankle sprain that's involved in seventy to ninety percent of all sports related ankle sprains. And the ligament that's most commonly going to be injured in the vignette is going to be the anterior talo fibular ligament. This is the injury the ligament injuring the majority of ankle sprains, seventy three percent of ankle sprains. No, this one. There's obviously other ggaments that can be injured, but this
is the one you need to commit to memory. It's the one that I was asked. This is the one that you're going to be asked, and remember. The way that you can remember this is anterior taalofibular ligament is sometimes referred to as the ATF ligament, and ATF in your mind is going to stand for always tears first, because it's the most likely ligament to tear in an ankle sprains. Remember anterior taalofibular ligament aka the ATF ligament, always tears
first. Let's talk about the Ottawa Ankle rules. So the Ottawa Ankle Rules, they're very sensitive for excluding ankle fractures and determining whether or not you need X rays of the ankle or the midfoot ninety six to ninety nine sensitive. They're really just very common sense. Basically, it states if you can walk after the injury or you're basically, if you can walk after the injury and you're not tender in the ankle or the midfoot, it's probably a sprain and
you don't need X rays. The specific guidelines are as followed. So if you're unable to bear weight both immediately after the injury and for four steps in the office or the ear plus you have tenderness at the posterior edge or the tip of the lateral or medial malleolis, you need an ankle X ray.
And then the other one is if you're unable to bear weight both immediately after the injury and for four steps in the office or the er plus you have tenderness at the base of the fifth metatarsal or the navicular, you need a foot X ray. If you don't present with those things, you probably don't need an X ray and it's a sprain. Nothing to know for the treatment of a sprain, it's just ice elevation end sets ankle X rays. If you get a question, it's likely going to be about the interior tail of
fib ligament. So remember only one thing about ankle sprains. Remember atf ligament always tears. First, let's talk about ankle achilles tendin rupture. Two things that I would know for achilles tendin rupture risk factors floral quinolans SOW. Fluoroquinolones can put patients at an increased risk for tendin rupture. Is it common? No? In Actually a large case study was only seen in twelve patients per one hundred thousand. But just because something isn't common in real life doesn't mean
it's not a common exam question. And this one's one of the favorites for examp questions. So I would just know that another common cause is going to be a sports related injury. Over eighty percent of ruptures occurred during recreational sports, particularly stopping ghost sports as like tennis, basketball, softball. But for the exam focus on some history of fluoroquinolone use. No needs to focus on the clinical menifestations. They're pretty common sense. Basically, they're gonna have a
pop in some severe pain in the posterior ankle. What you should know though, is the Thompson tests, so definitely be familiar with the Thompson tests. To do this, the patient lies prone with their feet dangling off the table. You squeeze the calf the gastro acnemius muscle, and then you watch for a plant our flection of the foot. The absence of plant our flection is going to mark a positive test and it will be indicative of a rupture.
This is an important test because other indicators of an Achille tendon rupture they're not always accurate. For instance, asking somebody just to plant our flex the foot, it's not always accurate to assist and diagnosis because you can actually plant our flex your foot using accessory muscles like the tibialis posterior. So always from the Thompson tests and a suspect Achilles tendon rupture, squeeze the calf, that's what you're going to be asked. Diagnosis of a rupture can be made solely by
the clinical exam. You can get an MRI or even an ultrasound to confirm, but the treatment can range from splinting all the way to surgical repair. It's not important know the two things Chilles tend in rupture, remember your fluoroquinolone use and know the Thompson test. Plant or fasciitis. Very little to know here, So this is chronic overuse that leads to micro tears and inflammation in
the origin of the plant or fascia. So they're gonna have heal pain that's worse with their first few steps in the morning or after a period of inactivity. This is what you're looking for in the vignette. They'll have some heal pain when they first wake up in the morning. It's normally how it's going to be presented. This is mainly a clinical diagnosis. X rays would really just to be able to rule out some differentials like maybe a calcaneal stress fracture,
but nothing really to know for imaging or lab tests. Treatment is conservative stretching exercises for the plant or fascia, calf muscle, silicone heelshoe inserts and sets. You can even use corticosteroid injections. Very little to know there. Interdigital Morton's neuroma. This is a compressive neuropathy of the interdigital nerve that leads
to plantar four foot pain. So basically something is squeezing on the foot, causing the metatarsos to squeeze together and put pressure on the nerve between the two structures, which leads to proliferation and a benign growth of the nerve tissue. This can lead to numbness, burning, et cetera on the foot like those parascesaes. Who you're looking for in the vignette, women with tight fitting shoes, women wearing high heels in the vignette. This will absolutely be a female
as they're approximately five times more likely than males to develop more neuroma. They may mention something about wearing shoes that are too tight, wearing high heels. High heels cause overpronation of the foot, and that's one of the risk factors. And then tight shoes are also associated with this condition. While you're looking for in the description of the pain is burning pain most common in the third
inner metatarso space. So patient with the neuroma will most commonly be complaining of this burning pain in the third inner metatarso space between the third and the fourth distal metatarsals. It's a clinical diagnosis. For the most part. You can use ultrasound actually visualize the neuroma, but it's usually not necessary and nothing really to know if for a treatment, it's mainly conservative metatarsal support, padded shoe,
insert specialized orthopedic shoes. So two things that I would focus on to identify it in the vignette. It's going to be a woman in the vignette, and the pain will likely be in the third in a metatarsal space. I used to remember this because the M in Morton, Sonoma, if you turn if you turn an M to the side, it's a three and then helps remember the third intermetatarsal space will be the most common area for the burning pain. If you turn an M upside down, that's a W and it
helps you remember this is most common in women. The other thing that I used to remember too is if you turn it. If you turn an M upside down, it kind of looks like the heels in high heels. I don't know, Maybe that one makes no sense to you better with the visuals on YouTube, but that's the main things that I that I remember so more in Sonoma. Turn that M to the side, it's a three. Third intermetatarsal space most common. Turn the M upside down, that's a W.
Remember it's most common in women. Moving on to Jones fracture. Jones fracture is a fracture of the fifth metatarso specifically, a fracture of the proximal diaphysis at the junction of the metaphysis and diaphysis. You can remember Jones fracture is a fracture of the fifth metatarsal because Jones has five letters. And then there's something called pseudo Jones fracture, so you may hear of this. Pseudo Jones fracture terminology isn't being used as often, but if you hear it, it's
the same thing. It's a fracture of the fifth metatarsal, but it's just a little bit more proximal. In this case, it's the fracture of the base or the tuberocity of the fifth metatarsal. I used to remember that because I would remember Jones is a fracture of the fifth metatarsal. Pseudo Jones adds a p there and just helps him remember. It's a little bit more proximal at the base of the tuberocity the base or the tuberosity of the fifth metatarsal.
So that's Jones fracture. Not too much to know there either. And then Finally moving on to Liz Franc or a Tarso metatarsal injury. This is an injury in which the metatarsal bones are displaced from the tarsis. So the Liz Franc ligament consists of religaments that run from the second metatarsal to the medial
cuneiform. So when you have a Tarso metatarsal fracture or other trauma in this area, it can lead to a disruption between the medial cuneiform and the base of the second metatarsal, which can lead to widening between the first and the second metatarsal basis. Because when because the second metatarsal, when it fractures, it loses its anchor that holds it in a place, which is the List Franc ligaments what spreads apart, look for something called a flex sign. This
is pathnemonic for a Liz Franc injury. So a flex sign is when there's an evulsion fracture at the origin or the insertion point of the List Franc ligament, So either at the medial cuneiform or the base of the second metatarsal, or the List Franc ligament transverses. Oftentimes you'll see a bony fragment in this first intermetatarsal space or this finding path indemonic for list Franc injury because you know the anchor of the liszt Franc ligament has been fractured off, so either at
the origin or the insertion point of the ligament surgical intervention. So these can be treated concern patively with a cast and immobilization. But the problem is even
relatively minor injuries to the tarso metatarsal joint can lead to severe disability. So whereas some of their other injuries can be treated with supportive measures, Lizz Frank injury, more often than not it's going to be surgical repair because if it's not treated properly, diagnosis his mystic can lead to osteoarthritis and long term disability. All right, So those are the main things that I think you need to know for the lower extremities. Let's move on to five quick questions and
we will wrap it up. Question one, twenty seven year old Mail presents to the office with pain and swelling of his left knee. He was playing soccer with friends and he was running. He stopped short to change directions and felt a pop in his left knee, followed by pain and swelling. A Lockman test is performed, which demonstrates increased anterior translation of the tibia compared to the uninjured leg with no distinct endpoint. What type of injury to this patient
likely sustained? You should know this one. That's your anterior cruciate ligament. So first the history of a pop in the knee followed by immediate swelling. That hemarthrosis a common presentation for an ACL tear. Up to seventy seven percent of patients with humor throsis after an injury of the knee have an a CL tear. When you have that positive Lockman test as well, we know that's a sensitive test for an ACL tear. Remember that because the first three letters
of Lackman or a CL rearrange all signs point to an ACL tear. We have the pop and swell, and then we also have the Lockman test ACL first three letters. We know this is an interior cruciate ligament injury. Question two. A fourteen year old boy presents the office complaining of interior knee pain. He says the pain is most severe when he plays basketball or squats down on exam. You know to pronounced tender tabule tubercle. What is the main
state treatment for the likely diagnosis in this patient? So that is going to be conservative and says ice rest elevation. So this is og Schlatter disease. We have a fourteen year old boy fits the demographics already as an osgit Schlatter's most common in males nine to fourteen years of age range, peak incidence in boys thirteen to fourteen years when they're going through the growth spurt, paying exacerbated by squatting, jumping, et cetera, when he's playing sports. All very
typical. And then an exam the announced tender tibio tubercle seals of the deal. As we know this is an injury caused by repetitive strain and chronic revulsion of the hypothesis of the tibio tubercle. Mainstay of treatment for osgod Schlatter disease is conservative with n sets, etc. Surgical repair is rare. Remember osgod schlaughter disease remember instead Osgood's squatter denees. Remember it's exacerbated by activity like squatting,
and Denise helps you remember it's an issue of the knee. Question three, what is the most common ligament to injure in an ankle sprain, So that of course is going to be your anterior taalo fibular ligament, your atf ligament. Remember atf ligament ATF in your mind stands for always tears first, because this is the ligament in the ankle most likely to tear in an ankle
sprain. Question four, which test is performed as part of the physical exam and is suspected Achilles tend rupture, then involves squeezing the gastro acnemius muscle and watching for plant our flection of the foot. That is going to be your Thompson test. So squeeze the calf and look to see if the foot plant reflection plant or flexes. If not, this is a positive test indicating a
likely Achilles ten rupture. Question five last question. A thirty one year old Mail was playing football with friends when one of his friends landed on the lateral aspect of his right knee in an attempt to tackle him. Immediately felt a tearing sensation, which was followed by severe pain. A Valgus stress test is performed, which displays pain and laxity at approximately thirty degrees offlection. What structure of the need, did this patient likely injured? So that is going to
be the medial collateral ligament. So we have a patient with lateral trauma to the knee and a positive Valgus stress test, So an MCL injury would be the most common structure to be injured in the setting of this type of trauma and confirmed with the positive Valgus stress test. Again, if you forget which test is positive with which ligament, remember MCL is tested with the Valgus stress
test valgus. Think of mucho gusto. Mucho starts with an M. That helps you remember MCL Gusto for valgus, And remember mucho gusto means nice to meet you. And that's because the Valgus force from these is being pushed inward, meeting at the middle. All right, So that is everything that I think you need to know if your lower extremities. Thank you so much for listening, and good luck on your pants, your pantry, your ears, and good luck in PA school.