No history of trauma

Spontaneous forefoot pain, radiating into the contiguous sides of the third and fourth toes, and typically made worse when the patient wears tight shoes, suggests a plantar (Morton's) neuroma. Neuromata rarely affect other interdigital clefts.

Acute onset of pain and swelling, as in other joints, should prompt consideration of gout, infection and other acute inflammatory arthropathies. A history of insidious onset of pain in the foot, associated with stiffness or

Subluxed patella

Meniscal

Supra Patellar Swelling

Tear of anterior cruciate ligament

Fluid in suprapatellar pouch Effusion with meniscal tear haemarihrosis with cruciate ligament tear

Tear of medial collateral ligament

Fig. 8.20 S Non-traumatic lesions about the knee. IB Traumatic lesions about the knee.

Tear of anterior cruciate ligament

Subluxed patella

Fluid in suprapatellar pouch Effusion with meniscal tear haemarihrosis with cruciate ligament tear

Meniscal

Tear of medial collateral ligament swelling, which is worse ufler inactivity and shows diurnal variation, may be due to rheumatoid arthritis or other inflammatory conditions. The forefoot is more commonly affected than the hindfoot. In more established cases, the metatarsal heads become prominent and the patient may report a sensation of walking on pebbles or broken glass.

The complaint of deformity of the great toe, either with or without pain on walking, is typical of hallux valgus. The pain is usually experienced over a soft tissue bunion overlying the exposed head of the first metatarsal, which can be associated with episodes of redness and swelling. Patients often have difficulty in obtaining suitable footwear. It is a very common problem and there is a family history of the disorder in two-thirds of patients. It is important to establish whether the toe is painful or not, because cosmetic treatment of deformity alone is not justified.

Pain under the heel on weight bearing, usually well localised to the medial tubercle of the calcaneum, may be due to plantar fasciitis. This may be a feature of seronegative spondyloarthropathies. Diffuse heel pain may also be a consequence of increased activity and poor footwear (e.g. jogger's or policeman's heel).

ANATOMY OF THE LOWER LIMB The hip

As the hip is a ball and socket joint, flexion, extension, abduction, adduction, rotation and the combined movement of circumduction are all possible. The actual range changes through life, as does the posture of the joint. As age increases, the first movements to decrease are extension and internal rotation, followed by abduction. The femoral and obturator nerves supply sensory branches to the hip joint and knee joint, explaining the frequency of referred pain from the hip to the knee.

Hip abductor function may be deficient or absent following congenital or acquired dislocation of the hip, fracture of the neck of the femur, paralysis (as in poliomyelitis) or painful inhibition of function in arthritis. When the normal subject stands on one leg. the glutei contract, so that the opposite side of the pelvis is tilted up slightly: this mechanism allows the opposite leg to clear the ground while walking. If the glutei are deficient, the opposite side of the pelvis will tilt downwards and balance can only be maintained by leaning sideways to shift the centre of gravity over the affected hip (Trendelenburg's sign. Fig. 8.251. When walking, this causes the patient to dip or lurch towards the affected side. This can be corrected by the use of a stick in the opposite hand. Willi bilateral abductor impairment, the trunk leans from side to side, producing a characteristic rolling gait.

The knee

The main landmarks of the knee are illustrated in Figure 8,21. The patella and the tibial tubercle can be readily palpated

Suprapatellar pouch

Patella

Medial meniscus

Medial collateral ligament

Tibial tubercle

Tibia

Suprapatellar Pouch
Fig. 8,21 Surface anatomy of the knee.

KEY POINTS

• Establish the site and distribution of pain and associated symptoms.

• Pain in the knee may be referred from the hip.

• The speed of onset of swelling after knee injury is of diagnostic help:

- slow (6-24 hours) suggests avascular aetiology, e.g. meniscal tear

- fast (within 1 hour) suggests vascuiar aetiology, e.g. cruciate ligament rupture.

• Increased hindfoot pain on uneven ground suggests subtalar joint pathology.

• Document functional difficulties; but remember that the ability to weight bear does not exclude an impacted fracture at the hip.

Ligament Injury Hip Trunk Flexion

Tibia with I he patellar tendon between these two structures. With the knee in flexion, ihe wide anterior joint line can be felt readily at the lateral and medial sides of the patellar tendon. The examiner can then palpate the femoral condyle above and the tibial plateau below, allowing the joint line to be defined and traced anteroposterior!^ Sites of tenderness can be related to (he joint line.

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