PAIN SYNDROMES OF LOWER EXTREMITY

BABAK ASHRAFNEJAD MD.

Meralgia paresthetica

� An entrapment neuropathy due to compression of lateral femoral cutaneous nerve by inguinal ligament.

� Burning pain , numbness and dysesthesis in distribution of LFCN.

� Worsening the symptoms by sitting , squatting or wearing wide belts.

� PH.EX : tenderness of LFCN at ASIS , tinel sign , sensory deficit.

� Diagnosis : EMG , Xray , CBC , ESR , ANA , MRI.

� Diff. Diag : lumbar radiculopathy , trochanteric bursitis , diabetic femoral neuropathy , double crush synd.

� Treatment : 1. short course coservative therapy (NSAIDS). 2. Peripheral nerve block at 1 inch medial to ASIS and 1 inch inferior to inguinal ligament as fanlike manner ( 5-7 ml of LA and steroid )

FEMORAL NEUROPATHY

� An uncommon pain producing condition.

� Pain , numbness and paresthesias in anterior thigh and midcalf with weakness of quadriceps. Sensory abnormalities may be mild or absent.

� Pain radiating from the groin into the anterior thigh , usually worse at night and at rest , which subsides over days and weeks followed by painless weakness of quadriceps.

� Ethiology : iliac hemorrhage , iliac abscess , abdominal aortic aneurysms , trauma , stretch , compression , idiopathic , space occupying lesions , DM , pregnancy and delivery , iatrogenic (hysterectomy) , hip arthroplasty , neural blockade and tourniquet uses , laparoscopy , renal transplantation , lithotomy positions , inguinal and femoral herniorrhaphies.

� Diag : EMG , CT , MRI , US

FEMORAL NEUROPATHY

� Treatment : exploration of the nerve should be undertaken if complete distribution of nerve , unintentional suturing or stapling of nerve is suspected. Anti neuropathic drugs , Nerve block , physical therapy.

SAPHENOUS NEUROPATHY

� Etiology : thigh (laceration , arterial surgery , compression , entrapment ) , knee ( surgery , external compression ) , lower leg ( surgery , vein cannulation ) , infrapatellar ( compression , arthroscopy ) , entrapment in the sartorius tendon.

� Tenderness at course of nerve , pain at medial aspect of knee and radiate downward to the medial of foot.

� Diag : EMG , SSEP , CT , MRI.

� Treatment : surgical correction of any lesions , NSAIDS , anti neuropathic drugs ,

OBTURATOR NEUROPATHY

� Pain and weakness of adductor musculatures.

� Hip unstability , leg weakness , paresthesias , lateral movement and extension of leg may increase the pain , sensory deficit in medial thigh.

� Etiology : pelvic fractures , direct penetrating injuries , pelvic malignancies , endometriosis , hip arthroplasty , obturator hernia , nerve entrapment , lithotomy position , pregnancy and labor , pelvic hemorrhage , nerve pulsy at newborn.

� Diag : EMG , CT , MRI , US

� Treatment : surgery , anti neuropathic drugs.

Knee pain

� Painful conditions of knee

� bone or joint pathology : fractures , tumors , instability , arthritis , osteophytes , infections , hemarthrosis , osgood schlatter disease , chronoc dislocation of patella .

� Periarthicular pathology : bursitis , tendinitis , muscle strain and sprain , infections.

� Systemic disease : rheumatoid arthritis , collagen vascular disease , reiter synd , gout.

� SMP : causalgia , RSD.

� Referral pain : lumbar plexopathy , radiculopathy , spondylosis , fibromyalgia , myofascial pain , inguinal hernia , entrapment neuropathy , intrapelvic and retroperitoneal tumors.

BURSITIS SYNDROMES OF KNEE

� Suprapatellar bursitis : extends superiorly from beneath the patella under quadriceps.

� Pain at the anterior of knee above the patella radiate into the distal anterior thigh.

� Tenderness at anterior knee just above patella.

� Passive flexion as well as active resisted extension reproduces the pain.

� Boggy feeling palpation at knee.

� Diagnosis : Xray , MRI , EMG , CBC , ESR.

� Treatment : NSAIDS , knee brace , injection , physical therapy

BURSITIS SYNDROMES OF KNEE

� Prepatellar bursitis : lies between the subcutaneous tissues and patella .

� Pain and swelling in the anterior knee over the patella that radiates superiorly and inferiorly.

� Diagnosis : Xray , MRI , EMG , CBC , ESR.

� Treatment : NSAIDS , brace , injection , physical therapy.

� Superficial infrapatellar bursitis : lies between the subcutaneous tissues and upper part of ligamentum patellae. The deep infrapatellar bursa lies between the ligamentum patellea and tibia.

� Pain and swelling in the anterior knee over the patella that radiates superiorly and inferiorly.

� Diagnosis : Xray , EMG , MRI

� Treatment : NSAIDS , brace , injection , physical therapy.

BURSITIS SYNDROMES OF KNEE

� Pes anserine bursitis : lies beneath the pes anserine tendon (insertional tendon of sartorius , gracilis and semitendinous to medial side of tibia )

� pain over the medial knee that increses with passive valgus and external rotation.

� Diagnosis : Xray , MRI , EMG.

� Treatment : NSAIDS , injection , physical therapy.

BAKER’S CYST OF THE KNEE

� Common cause of knee pain

� abnormal accumulation of synovial fluid in the medial aspect of the popliteal fossa.

� The sac communicates with the knee joint with a one way valve effect causing gradual expansion.

� Fullness feeling behind the knee (lump sign).

� Squatting and walking worsen the pain.

� Constant and aching pain.

� Cyst may ruptured spontaneously.

� Diagnosis :Xray , CBC , ESR , ANA , RF , MRI .

� Treatment : elastic bandage , NSAIDS , injection , surgery.

QUADRICEPS EXPANSION SYNDROME

� Overuse or misuse of knee causes strain and cacific tendinitis of quadriceps.

� Expansions : 4 muscle tendon consists of vastus lateralis , vastus intermedius , vastus medialis and rectus femoris expands around the patella called expansions.

� Pain over the superior pole of patella ,specially on medial side thet worsen with activity and with aching characteristic.

� Tenderness under superior edge of patella .

� Active resisted extension of knee will reproduces the pain.

� Diagnosis : Xray , CBC , ESR , ANA , MRI.

� Treatment : combination of NSAIDS and physical therapy , injection of expansion.

ANKLE AND FOOT PAIN

� Articular : RA , OA , gout , hallux valgus

� periarticular : RA nodules , tophi plantar faciitis , achilles tendinitis , bursitis.

� Osseous : fractures , sesamoiditis , neoplasm , infection.

� Neurologic : tarsal tunnel syndrome , morton neuroma , peripheral neuropathy , radiculopathy.

� Vascular : atherosclerosis , buerger disease , raynaud phenomenon.

� Referral : knee , RSD.

ACHILLES TENDON PAIN

� Achilles tendinitis

� Etiology : microtrauma , trauma , tophi , RA nodules.

� Symptoms : activity related pain , swelling , tenderness , crepitus over the tendon 2-6 cm from its insertion. Passive dorsiflexion worsen the pain.

� Diagnosis : US , MRI

� Treatment : rest , weight reduction , shoe modification , NSAIDS , physical therapy , splint , injection , surgury.

� Achilles tendon rupture

� Etiology : forced ankle dorsiflexion in 30-50 y/o men with previous pathology.

� Symptoms : sudden pain , swelling , ecchymosis , tenderness , palpable gap over the tendon

ACHILLES TENDON PAIN

� Diagnosis : thompson calf squeeze test , US , MRI

� Treatment : repair surgery , immobilization with cast.

� Subtendinous bursitis :

� etiology : RA , SA

� symptoms : worse in beginning of activity and diminishes as activity continues , tenderness and errythema on posterior of heel and tendon insertion

� treatment : rest , physical therapy , NSAIDS , surgury.

� Subcutaneous calcaneal bursitis

MORTON NEUROMA

� Etiology : metatarsalgia ( pain in metatarsal head or MTP joints) , chronic foot strain , repetitive trauma , neuropathy of interdigital nerve (between 3and 4) as neuroma.

� Symptoms : paroxysmal lancinating , burning or neuralgic pain at affected interdigital cleft

� treatment : metatarsal pad , weight reduction , shoe modification , injection , surgery

HEEL SPUR PAIN AND PLANTAR FASCIITIS

� Plantar fascia is a longitudinal fibrous tissue with its origin at medial tubercle of calcaneous , transverses the foot dividing into 5 bands at midfoot , attaches to the proximal phalanx . A normal fascia a dorsoplantar thickness of 3 mm and increases in fasciitis to 15mm.

� Symptoms : more common in women at midaged , skin of heel is thicker , commonly unilateral , risk factors (obesity , poorly fitting shoes , walking and running , prolonged standing , heel spur , tarsal tunnel syndrome)

� diagnosis : pain is worse on awakening at morning and decreases through the day and get worse toward the end of day. Localized tenderness on palpation of anteromedial aspect of heel .dorsiflexion is limited , Xray , isotope scan , MRI.

� Treatment : it is self limited condition.heel pads , shoes modification ,

HEEL SPUR AND PLANTAR FASCIITIS

� NSAIDS , physical therapy , night splint , injection , surgery