1. Lower Limb Periarthritis
I. Salehi A.
Lower Limb Periarthritis
Iraj Salehi Abari MD.,
Internist
Rheumatologist

2. In the name of God

3. Periarthritis of hip region:
Trochanteric Bursitis
Ischial Bursitis (weaver’s buttom)
Coccygeal Bursitis

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Approach to joint pain

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Approach to joint pain

6. Periarthritis of hip region:
Psoas tendinitis
Adductor tendinitis
Retractile capsulitis of hip
Trigger hip
Snapping hip syndrome
Meralgia paresthetica

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Approach to joint pain

10. I. Salehi A.
Approach to joint pain

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12. Periarthritis of knee region:
Prepatellar Bursitis
Housemaid’s knee
Infrapatellar Bursitis
Parson’s knee
Anserine Bursitis
Patellar tendinitis
Jumper’s knee

13. Periarthritis of knee region:
Baker’s Cyst:
G/S bursa
Foucher’s sign
Iliotibial tract syndrome
Runner’s knee
Lateral knee tender point (2cm proximal)

14. Periarthritis of knee region:
Pellgrini-Stida disease
MCL calcification
Plica syndrome
Osgood-Schlater
Meniscal tearing:
Mc-Mury maneuver
Apley grind maneuver
Thessaly test

15. Periarthritis of knee region:
ACL injury:
Luchman test (20)
Anterior drawer test (90; 3mm)
PCL injury:
Posterior sag sign
Posterior drawer test
LCL injury:
Varus stress test
MCL injury:
Valgus stress test

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20. Foot: Foot region: Variations in forefoot and toe length:
Forefoot, Midfoot, Hindfoot
Variations in forefoot and toe length:
Greek, Square, Egyptian
Medial longitudinal arch:
Slightly above the floor: Nl
Absent arch: Flatfoot
High arch: Pes cavus

21. Foot: Various deformities of the toes: Hindfoot position: Cock-up toe
Mallet toe
Hammer toe
Hindfoot position:
Valgus angle of 0-6: Nl
Valgus angle > 6: Pes valgus
Varus angle: Pes varus

22. Forefoot region: Bones of: Joints of: Bursas Of:
Metatarsal, Phalangeal
Joints of:
MTPs, PIPs, DIPs
Bursas Of:
Bunion, Bunionette

23. Midfoot region: Bones of: Joints of: Cuboid Navicular
Cuneiform (3 number)
Joints of:
Calcaneocuboid
Talonavicular
Intertarsal

24. Hindfoot region: Bones of: Joints of: Ligaments: Bursa:
Talus, Calcaneus
Joints of:
Tibio-fibulo-talar, Subtalar (Talocalcaneal)
Ligaments:
Medial: Deltoid
Lateral: Ant. & Post. Talofibular, Calcaneofibular
Bursa:
Malleolus (int., ext.), Retroachilles, Retrocalcaneal, Subcalcaneal

25. Periarthritis of foot region:
Ankle Sprain
Foot Bursitis:
Retrocalcaneal B.(Deep)
Retroachilles B.(Superficial)
Malleolus B.
Internal
External
Bunion B.
Bunionette B.(Tailor bunion)

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29. Periarthritis of foot region:
Achilles tendinitis
Haglund’s deformity
Plantar fasciitis (Calcaneal spur):
Calcaneal Jump Sign
Tarsal tunnel syndrome(TTS)
Morton neuroma: Mulder sign
Sesamoiditis
Corn

30. Plantar Fasciitis (Introduction):
Plantar pain of calcaneus
One of the most common causes of foot pain in adults
F/M ratio = 2/1
Age: 40 – 60, in runners: younger age
Up to 1/3: Bilateral
An inflammation of plantar fascia

31. Plantar Fasciitis (Etiology):
Local mechanical condition:
Obesity
Prolonged standing and walking
High-impact aerobic exercise
Systemic inflammatory condition:
Spondyloarthritis
Rheumatoid arthritis
Gouty arthritis

32. Plantar Fasciitis (Clinical features):
Plantar pain of calcaneus:
Severe on first walking after non-weight-bearing
Worse by prolonged standing or walking
Plantar tenderness of calcaneus:
Positive Calcaneal jump sign
Whole Plantar fascia pain and tenderness:
Increased by dorsiflexing the toes

33. Plantar Fasciitis (Evaluation):
Plain X-Rays of foot for all patients
R/O occult bony pathology, tumor, fracture
CBC, ESR, HLA-B27, RF, Uric acid, Ca/P, Alk Ph
If we suspect to a systemic condition
MRI of plantar surface of foot
If there is whole plantar fascia tenderness

34. Plantar Fasciitis (treatment):
Conservative: 80% in one year
Correction of Life Style
Health recommendation
Shoe and slipper
Heel cups and arch supports
Stretching exercises
NSAIDs, Local glucocorticoids injection
Orthotics, Night splints, Cast
Shock wave therapy
Surgery

35. Morton Neuroma (Introduction):
One of the most forefoot pain syndrome
Perineural fibrosis of the interdigital nerves
Plantar burning pain of forefoot, with associated painful paresthesias into the affected two toes

36. Morton Neuroma (Clinical features):
Plantar burning pain of forefoot, with associated painful paresthesias into the affected two toes
Nerves between:
3rd & 4th toes: most common
2rd & 3th toes: uncommon
4rd & 5th toes: rare
Feeling of walk with a stone in shoe

37. Morton Neuroma (Clinical features):
Worsening of pain with prolonged standing or walking
Worsening of pain by improperly fitted or padded shoes
Wearing of tight, narrow-toed shoes:
Bunion
Bunionette
Hammer toe
Morton neuroma

38. Morton Neuroma (Clinical features):
Antalgic gait
Mulder Click test (Morton test)
Gaenslen Maneuver
Digital nerve stretch test
DDx with Metatarsalgia