Assessment & Treatment of Common Lower Extremity Issues in ...
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Assessment & Treatment of Common Lower Extremity
Issues in Primary CareLaurel Short, DNP, FNP-C
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Disclosure
I have no current affiliation or financial interest with any grantor or commercial interests that may have direct interest in the subject matter of the CE Program.
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Here’s what we’ll cover
• Review key components of a comprehensive musculoskeletal exam
• Describe an organized approach to exam techniques
• Identify history questions used to assess patients presenting with problems for the lower extremity
• Identify functional anatomy with clinical significance for the lower limb
• Discuss pharmacologic and non-pharmacologic treatment options for common lower limb conditions
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Lower Limb
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Hip
Pelvic Girdle: 3 joints
Hip joint
Sacroiliac joint
Pubic symphysis
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Diagnosing Hip Pain:Often Challenging
• BACK PAIN
• GLUTEAL PAIN
• LATERAL HIP PAIN
• ANTERIOR HIP PAIN
• GROIN PAIN
• LEG PAIN OR TINGLING
• SCIATICA
• WEAKNESS
• GAIT DIFFICULTY
• SPASM
Common Chief Complaints
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Diagnostic TestingWill the test change your treatment plan?
• X-ray
•MRI
• EMG (especially if numbness/tingling, weakness)
• http://www.abemexam.org/Verify-Certification/ABEM-Directory
• Consider visceral causes
• Always assess for lumbar spine symptoms
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Observation example: Different approaches for hip replacement
incisions
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Hip
• Key point: Identify if pain is from hip joint, a surrounding area, or lumbar spine
• Assess anterior, lateral, and posterior hip
• Good lumbar spine exam
• Special tests: Stinchfield (resisted flexion with extended knee), Faber, Gaenslon, Ober
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Common Hip Diagnoses
• Osteoarthritis
• Trochanteric bursitis (Greater trochanteric pain syndrome)
• Hip flexor tendinosis, Psoas tendinosis
• Sacroiliac Joint Dysfunction/Pain
• Piriformis Syndrome
• Meralgia Paresthetica
• Lumbar Spine etiology
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Meralgia Paresthetica
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Trochanteric Pain Syndrome
Key Point: Often a secondary issue/symptom of gluteal weakness, gait
abnormality, and/or iliotibial band syndrome
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Piriformis Syndrome
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Trendelenburg Sign
Testing the STANDING leg
Dropping the opposite side indicates gluteal
weakness
+ For Right gluteal weakness
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Knee
• Largest joint in the body
• Modified hinge joint
• Greatest range of motion is flexion
• More exposed joint, therefore higher risk of injury
• Is pain intra-articular or extra-articular?
• Meniscal tear testing (McMurray, Apley)
• Ligament stability testing:
Anterior and posterior cruciate ligaments (Anterior & Posterior Drawer, Lachman)
Medial and lateral collateral ligaments (Varus/Valgus test)
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Knee X-ray Views: Include Weight Bearing
& Sunrise View
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Common Knee Diagnoses
• Osteoarthritis
• Effusion (secondary to trauma or OA)
• Tendinosis: Patellar, Quadriceps
• Pes Anserine Bursitis
• Iliotibial band syndrome
• Patellofemoral syndrome (aka “runner’s knee”)
• Ligament strain or tear
• Meniscal tear
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Managing knee pain can be integral for
patient quality of life!
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Peroneal Neuropathy
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P.R.I.C.E. NSAID
Hinged Brace (OA)
Physical Therapy
Aspiration,
Injection
Knee Treatment
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Foot/Ankle
• Foot and ankle are focal points of support for the body to weight bear and ambulate
• Heel and toe pads act as shock absorbers for walking and activity
• Complex joints allow for balance on variable terrain
• Morton’s Neuroma: Squeeze test- usually between 3rd and 4th metatarsal heads
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Common Foot & Ankle Diagnoses
• Achilles Tendinosis (complete rupture less common)
• Gastroc strain
• Peroneal and Posterior Tibial tendinosis
• Ankle Sprain- ATF, CF, PTF
• Anterior Tibial Stress Syndrome (Shin splints)
• Plantar Fasciitis
• Morton’s Neuroma
• Metatarsalgia
• Hallux Valgus
• Pes Planus
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Foot and Ankle
• Include inspection of shoes
• Sensation
• Proprioception
• Arches
• Add visual of foot
Deformed Joint Pes Planus
Charcot Joint
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Injury may effect all 3! ATF, PTF, CFL (CFL least common)
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Plantar fasciitis
Tenderness over the medial tuberosity of the
calcaneus, tightness with dorsiflexion
Assess for gastric tightness, arches
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Metatarsalgia & Morton’s Neuroma
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Foot Fractures
May occur with low impact/no trauma
Assess for swelling
Key: Pain with percussion?
Think about osteoporosis
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“Universal” Conservative Treatment
• NSAIDs- oral and/or topical
• Ice/HEAT
• Physical Therapy and Home Exercises
• Cortisone injection
• PRP and newer therapies (?)
• Refer if significant weakness, neurologic findings, or lack of progress with 2-3 months of rehab
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SHOULDER EXAM: No atrophy. Normal strength of rotator cuff and shoulder girdle. Special tests are negative.
Range of Motion: Pain with Internal Rotation, External Rotation, Abduction. Painful arc of motion 80-120 degrees (supraspinatus/impingement).
Special Tests: Positive impingement testing.
ELBOW EXAM: No atrophy, no effusion, redness or warmth. ROM is pain-free and within functional limits, normal strength. Inspection/Palpation:
Tenderness at: lateral epicondyle.
Special Tests: Positive resisted middle finger extension, resisted supination.
WRIST/HAND EXAM: No swelling, redness or warmth. No skin breakdown or nail abnormalities. No palmar or dorsal atrophy. Range of motion is pain free and within functional limits, normal strength.
Inspection: thenar atrophy.
Special Tests: Positive Phalen's, Tinel's, Median nerve compression.
HIP EXAM: No atrophy.Inspection/Palpation:
Tenderness at: trochanteric bursa, piriformis, SI joint.
Special Tests: Negative FABER's, Stinchfield's (resisted hip flexion).
KNEE EXAM: No atrophy, no effusion, redness or warmth. ROM is pain-free and within functional limits, normal strength. Good ligamentous stability.
ANKLE/FOOT EXAM: No swelling, redness or warmth. No skin breakdown or gross deformity. No atrophy. Range of motion is pain free and within functional limits, normal strength. Special tests are negative.
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Thorough Exam PT/OT
Modify Activity NSAID/Ice/Injection
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Challenge Yourself, Practice These Skills, &
Achieve Confidence with MSK Issues!
• Functional Anatomy
• Good Exam
• Partner with the Patient
• Reassess
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ReferencesAkhtar S, Bradley MJ, Quinton DN, Burke FD. Management and referral for trigger finger/thumb. BMJ 2005, 331:30-3.
Brown, K.,L. & Merrill, E. (2015). Musculoskeletal management matters: principles of assessment and triage for the nurse practitioner. The Journal for Nurse Practitioners, 11(10), 929-939. http://dx.doi.org/10.1016/j.nurpra.2015.08.036
Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Annual Incidence of Common Musculoskeletal Procedures and Treatment. http://www.aaos.org/research/stats/CommonProceduresTreatments-March2014.pdf Published March 2014. Accessed [09/01/2017].
Hoppenfeld, S., & Hutton, R. (1976). Physical examination of the spine and extremities. New York: Appleton-Century-Crofts.
Musculoskeletal Medicine. PM&R Knowledge Now. Retrieved on 09/01/2017 from https://now.aapmr.org/category/musculoskeletal-medicine/
Sallis, R. (n.d.) Examination skills of the musculoskeletal system. American Academy of Family Physicians. Retrieved on 09/01/2017 from http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/education/fellowship/sportsmedfellow/Documents/MS%20exam.pdf
Sarwark, J. F., & Carl, R. L. (2010). Essentials of musculoskeletal care. Rosemont, IL: American Academy of Orthopaedic Surgeons.
Silva MB, Skare TL.(2012). Musuloskeletal disorders in diabetes mellitus. Rev Bras Rheumatoly, 52(4), 594-609.