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LE Diff Dx
Clin Med Lower Extremity Diff Dx
| Question | Answer |
|---|---|
| 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) |
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