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LE Diff Dx

Clin Med Lower Extremity Diff Dx

QuestionAnswer
Standing Exam--Standing Squat Clearing of lumbar, pelvic, hip, knee, foot, ankle
Standing Exam-- Vertical Compression Rise up on balls of feet & quickly & vigorously hit down on heels; Assessed status of WB structures
Neuro Screening L4-5 Deep Peroneal N; Toe walking S1-2 Tibial/Superficial Peroneal N; Quads L2-4 (best tested unilaterally)
What the difference with looking at rotation in sitting? Hips taken out, so it's pure spinal movement
Lumbar HNP Develops over time; Fissure in annulus; Pain 2ndary to chemical irritation; N/T from compression
Where is lumbar HNP most common? L4-5/L5-S1
S/sx of HNP Unilateral radicular s/sx (increased with sitting, walking, standing, coughing, sneezing); Difficulty finding a comfortable position
Physical Exam- HNP Shoulders shifte opposite of pelvis; avoid flexion/dural tensioning; Bilateral (+) leg raise testing; Neuro findings
Diff Dx of HNP-- Cauda Equina Sx, Demyelinating conidions, Extraspinal n entrapment, Hip/knee arthritis Perianal numbness, urinary overflow, reduced anal sphincter tone, bilateral; Clonus; Abdominal/pelvic mass; Decreased IR of hip, knee deformity/effusion
Diff Dx HNP-- LFCN; Spinal stenosis; Thoracic cord compressin; Troch bursitis; Vascular insufficiency Sensory only; Older population; Clonus/spasticity/high sensory pattern/abdominal reflexes; No tension, pain down lateral thigh/leg, exquisite tenderness; Absent pulses, claudicating, trophic changes
Lumbar Spinal Stenosis Neurogenic claudication; Narrowing of spinal canal; affected as much as 30% population >60 yo (only some have s/sx)
S/sx lumbar spinal stenosis Radicular (uni or bilateral w or wo back pain); progress prox->distal; standing/walking aggravate, sitting relieves; stooping over/leaning relieves
Physical exam Lumbar Spinal Stenosis Propriocaption may be impaired; Sensory/reflex changes; Bowel/bladder s/sx
Diff Dx Lumbar Spinal Stenosis Abdominal aortical aneurysm (mass); Arterial insufficiency (recovery after rest; absent pulses); Diabetes (non-segmental n/t; skin changes); Folic acid/B12 deficiency; Infection (temp elevation & elevated ESR, IVD narrowing); Tumor (night pn, patchy neuro
What is spondylolisthesis? Anterior slippage of one vertebra on the one below; Pars defect
Clinical s/sx spondylolisthesis back pain that may radiate; normally more irritated by extension
Physical Exam- Spondylolisthesis Step off; Hamstring spasm
Diff Dx- Spondylolisthesis IV disc injury (no step-off; nod efect on radiograph); IV discitis (elevated ESR & fever); Osteoid osteoma (night pn; bone scan; pain relief w ASA); SC tumor (sensory; UMN s/sx); Tethered SC (pain; HS tightness; UMN s/sx)
OA of the Hip loss of articular cartilage; Primary (idiopathic) or 2ndary (childhood hip disease)
S/sx Hip OA Gradual onset anterior thigh/groin pn; Perceived only in knee at times; Pain with activity- gradually increases in freq/intensity; Decreasing ROM/gait abnormality (capsular pattern- abd is always 2nd)
Physical exam- Hip OA Earliest sign = loss of IR; Global changes in ROM; Gait abnormality
Hip OA Diff Dx Degen lumbar disc disease (normal ROM); LFCN (sens, normal ROM); HNP (sens/ref changes); Inflam arthritis (RA; Lupus; ankyl spondy); Osteonecrosis fem head (radiograph); Troch burs (local tender; norm ROM); Pelvis/spine tumor (back/PM pn, normal ROM)
What can cause "snapping" in snapping hip? ITB over GT; Iliopsoas over pectineal eminence; Intra-articular tears of the labrum
S/sx Snapping Hip--IT Band Pain with rising; Lying on affected side; With walking/hip rotation; PM pain
S/sx Snapping Hip-- Iliopsoas Felt in groin as hip extends from flexed position
S/sx Snapping Hip-- Intra-articular More disabling
Snapping Hip Physical Exam ITB sublux recreated w/ hip rotatoin w/ hip in abd; Iliopsoas palpated while extending hip from flexion; Intra-articular w/ restricted IR or shortening of limb
Diff Dx-- Snapping Hip Hip OA (limited ROM); Osteochondral loose body (pain w/ hip motion); Osteonecrosis (groin pain); Acetabular labrum tear (pain/instability w/ hip motion; C-sign)
LFCN Syndrome Nerve entrapment; Pain, burning, hypoesthesia over lateral thigh (not below knee); only SENSORY
Potential causes of LFCN Obesity; compression from belt/clothing; Scar tissue from surgery; Trauma
S/sx LFCN Dysesthesia anterolateral thigh; "electric jab" w/ hip extension
Physical exam LFCN Pressure over nerve; No MMT or reflex changes
Diff Dx- LFCN Diabetes/peirpheral neuropathy (foot numbness); Hip arthritis (limited IR; limp); Abd tumor (mass; wt loss); Lumbar disc herniation (motor/sensory changes); Troch burs (local tenderness; stiffness with rising)
Claudication LE discomfort that is associated with activity; Vascular or neurogenic origin. Neuro assoc w/ spinal stenosis (ischemia to cauda equina); Vascular (peripheral vascular disease, compromised blood flow w/ walking)
S/sx Claudication Vague pain that begins in butt, spreads down leg; may develop paresthesias & dysesthesias
Neurogenic Claudication S/sx Proximal->Distal; Exacerbated down incline; Sitting/lying down decreases
Vascular Claudication S/sx Distal->Proximal; Resolution of s/sx with cessation of activity
Tests for Neurogenic Claudication May not display abnormal physical findings at rest; Reflex/myotomal changes may devleop following activity; Radiographs or MRI
Tests for Vascular Claudication Diminished/absent pulses below waist; Redness/pallor changes with elevation; Doppler studies/arteriography
Diff Dx-- Claudication Chronic compartment sx (athletic; pain during/post activity); L3-4 HNP (dimished reflex; numbness); Meniscal tear (traumatic hx, popping/locking/catching); Osteonecrosis of femur/tibia (>50; Women; Prolonged steroid use)
Compartment Syndrome- 4 compartments Anterior- EHL (most frequently affected); Lateral-Peroneals; Superficial Posterior-Dorsiflexion; Deep Posterior- FHL
What is acute compartment syndrome? Increase in compartment pressure that decreases blood supply; following any condition that can cause significant swelling
What is chronic compartment syndrome? Exertional increase in compartment pressure; Exercise-induced increase in tissue pressure >40 mmHg
Presentation- Compartment Syndrome Leg pain, occasionally paresthesias radiating into foot
S/sx Acute Compartment Syndrome Severe leg pain more than what would be expected; Paresthesias/numbness
S/sx Chronic Compartment Syndrome Prolonged walking/running; Pressure returns to <10 mmHg when resting & gradually resolves within 30'; No pain at rest
Presentation Compartment syndrome Passive stretching exacerbates; decreased sensation of involved nn; paralysis & loss of dorsalis pedis pulse
Acute Compartment Syndrome Presentation Marked swelling, tenseness, tenderness of involved compartment
Chronic Compartment Diff Dx Shin splints- tender along tibia; Stress fx- pain at rest; radiographic findings
Acute Compartment Syndrome Diff Dx Contusion- low compartment pressure
Chronic Compartment Syndrome Presentation Most asymptomatic at rest; Swollen & tense with tenderness to palpation when exercising
IT Band Syndrome Distal ITB rubs against lateral femoral condyle; ITB sits anterior when knee extended & posterior when knee flexed >30 deg; Anterolateral knee pain increased with running/cycling (downhill, most intense at heel strike); audible pop; asymptomatic at rest
Diff Dx IT Band Syndrome HS strain; LCL sprain (increased mvmt with varus stress test); Meniscal injury (jt line tenderness; mechanical s/sx; (+) McMurray's test)
Chronic Lateral Ankle Pain is common following what? Inversion Ankle injury
Chronic Lateral Ankle Pain Ssx Giving way/repeated sprains; Asymptomatic periods; Bone, cartilage or tendon lesions often report constant, dull pain over involved area
Exam of chronic lateral ankle pain Ask pt to ID painful area with 1 finger; assess swelling, ROM, stress testing, sensation
Diff Dx- Lateral Ankle Sprain- Lateral Gutter Syndrome Anterolateral impingement syndrome; Chronic scar tissue in gutter; Tenderness along anterolateral ankle; No pain at rest; Tenderness/swelling noted ATF/lateral gutter
What makes up the lateral gutter of the ankle Lateral- Fibula; Medial- Talus; Superior- Tibia
Diff Dx- Lateral Ankle pain- Chronic ankle/subtalar instability Giving way/wkness; inability to return to prior level of fxn; assess proprioception; ligament stress tests
Diff Dx- Lateral Ankle pain- Nerve Injury Direct blow, stretch, entrapment, transection of superficial peroneal or sural nn; Diffuse, dull, achy pain over lateral ankle (burning, tingling, radiating pain; + Tinel sign; Exam L4, L5, S1 to rule out proximal lesion)
Diff Dx- Chronic Lateral Ankle pain - Peroneal tenosynovitis/peroneal subluxation Peroneus brevis most commonly affected by a tear; chronic retromalleolar pain, swelling, tenderness
What is the most common cause of heel pain in adults? Plantar Fasciitis
Etiology of plantar fasciitis Degenerative tear of part of fascial origin from alcaneus following by tendinosis-type rxn; women 2x more than men; NOT associated with particular foot type; common on overwt people; insidious onset
S/sx Plantar Fasciitis Focal pain/tenderness directly over medial calcaneal tub; most intense pain when rising from resting; exacerbated with prolonged standing/walking; 50% have heel spur (not cause of pain)
Diff Dx- plantar fasciitis Plantar fascia rupture; calcaneal stress fx; calcaneal tumor; fat pad atrophy; sciatica; seronegative spondyloarthrophathy; tarsal tunnel sx
Tarsal Tunnel Sx Compression neuropathy of tibial n or branches posteiror to medial malleolus; mostly unknown etiology
S/sx Tarsal Tunnel Sx Diffuse, poorly localized pn along medial ankle/into arch (worse post walking/exercise); tender over tarsal tunnel; + Tinel; Decreased sensation on plantar aspect; EMG may reveal entrapment
Diff Dx- Tarsal Tunnel CRPS (discoloration; skin/temp changes); Diabetic neuropathy (hx; bilateral;stocking); HNP (leg/thigh): Peripheral neuropathy (stocking); PTT dysfxn (pain assoc with pes planus)
Created by: Jenica Moore Jenica Moore on 2012-05-05



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