This document discusses disorders of the lower limbs, including causes such as congenital defects, inflammation, degeneration, trauma, and infection. It covers disorders grouped by age and then focuses on specific conditions of the hip and knee. For the hip, it describes diseases such as developmental dysplasia of the hip, Perthes disease, femoroacetabular impingement, bursitis, and osteoarthritis. For the knee, it discusses genu valgum/varum and performs assessments of range of motion, ligaments, and special tests for conditions like osteoarthritis.

1. Disorders of lower limbDisorders of lower limb

2. Causes :Causes :
►Congenital.Congenital.
►Inflammatory.Inflammatory.
►Degenerative.Degenerative.
►Neurogenic.Neurogenic.
►Traumatic.Traumatic.
►Infective.Infective.
►Idiopathic.Idiopathic.

3. Age groupsAge groups
►Newborn and InfantsNewborn and Infants
►ChildrenChildren
►AdolescentsAdolescents
►Adults middle ageAdults middle age
►Adults > 50Adults > 50

4. 1) Hip Pathologies1) Hip Pathologies

5. ChildrenChildren

6. AdultsAdults
►Tendinitis – ilIopsoas , adductor strainTendinitis – ilIopsoas , adductor strain
►FAIFAI
►Trochanteric bursitisTrochanteric bursitis
►Stress fracturesStress fractures
►Early osteoarthritisEarly osteoarthritis
►AVNAVN

7. AdultsAdults
►Established OAEstablished OA
►Inflammatory OAInflammatory OA
►Fragility fracturesFragility fractures
►MetastasisMetastasis
►InfectionInfection

8. DDHDDH
►Breech presentationBreech presentation
►Ist born femaleIst born female
►Family historyFamily history

9. DDHDDH

10. DDHDDH

11. DDHDDH

12. Septic arthritisSeptic arthritis

13. PerthesPerthes
► B> GB> G
► Pain Hip orPain Hip or
referred painreferred pain
in the kneein the knee
► LimpingLimping
► Limited internalLimited internal
rotationrotation

14. SUFESUFE
►Pain and limpingPain and limping
►Hx of recent injuryHx of recent injury
►M>FM>F
►12-15 Yrs12-15 Yrs
►Flexion results inFlexion results in
Ext rotation of the hipExt rotation of the hip

15. FAIFAI

16. BursitisBursitis
► Localised pain over theLocalised pain over the
G. TrochanterG. Trochanter

17. Stress fractureStress fracture

18. OAOA
►Pain, poorly localisedPain, poorly localised
►StiffnessStiffness
►Lose rotation firstLose rotation first

19. AVNAVN
►Alcohol and steroidsAlcohol and steroids
►Xrays may be normalXrays may be normal

20. METASTASISMETASTASIS
► Hx of Primary CaHx of Primary Ca
(thyroid, breast,lung(thyroid, breast,lung
kidneys, prostate)kidneys, prostate)
► Unrelenting painUnrelenting pain
► Multiple myelomaMultiple myeloma
► ChondrosarcomaChondrosarcoma

21. 2) The knee2) The knee

22. GENU VALGUS & GENUGENU VALGUS & GENU
VARUSVARUS

24. CausesCauses
►Lateral ligament laxityLateral ligament laxity
►Blount’s diseaseBlount’s disease
►Congenital pseudoarthrosis of tibiaCongenital pseudoarthrosis of tibia
►Coxa varaCoxa vara

25. In ligamentous laxity notelat.Widening
Of knee joints
In Blount angulation at med.tib
metaphysis

26. InIn coxa vara ,angulation at the neckcoxa vara ,angulation at the neck
shaft levelshaft level
In cong. Pseudarthrosis of tibia,the
angulation is in the distal ⅓

27. ►Gait:Gait: intoeing, lateral thrust-the fibular headintoeing, lateral thrust-the fibular head
and upper tibia shift laterally in Blount due toand upper tibia shift laterally in Blount due to
laxity and incompetence of the lat. Collat. Lig.laxity and incompetence of the lat. Collat. Lig.
►StabilityStability
►SymmetrySymmetry
►Level of fibular head,Level of fibular head, normally at thenormally at the
level of the upper tibial growth plate, while it islevel of the upper tibial growth plate, while it is
proximal in Blount, cong.longitudinal dificiencyproximal in Blount, cong.longitudinal dificiency
of the tibia and achondroplasiaof the tibia and achondroplasia

28. X-rayX-ray
► 3 years and older3 years and older
► Getting worseGetting worse
► Abnormal site ofAbnormal site of
angulationangulation
► Large physis andLarge physis and
epiphysisepiphysis
► History –History – taruma, infection,taruma, infection,
possible metal intoxication(lead orpossible metal intoxication(lead or
floride)floride)
Metaphysial/diaphysial
angle ≥ 18°

29. FindingFinding
► Metaphysis,Metaphysis, thick andthick and
frayed in ricketsfrayed in rickets
► InIn physiologic genuphysiologic genu
varumvarum no intrinsic boneno intrinsic bone
disease, gentle curve, medialdisease, gentle curve, medial
cortices thickening, horizontalcortices thickening, horizontal
joint lines of the knee & anklejoint lines of the knee & ankle
are tilted mediallyare tilted medially

30. Knock Knees / Genu ValgumKnock Knees / Genu Valgum
► Legs are bowedLegs are bowed
inwards in theinwards in the
standing position.standing position.
Bowing occurs at orBowing occurs at or
around the knee. Onaround the knee. On
standing with kneesstanding with knees
together, the feettogether, the feet
are far apart.are far apart.

31. 31
Normal Knee – Anterior,Normal Knee – Anterior,
ExtendedExtended

32. 32
Surface Anatomy - Anterior, Extended*Surface Anatomy - Anterior, Extended*
Patella
Hollow
Indented

33. 33
Normal Knee – Anterior, FlexedNormal Knee – Anterior, Flexed

34. 34
Surface Anatomy - Anterior, FlexedSurface Anatomy - Anterior, Flexed
Head
Of
Fibula
Patella
Tibial
Tuberosity

35. 35
Palpation – Anterior*Palpation – Anterior*
Patella:
Lateral and Medial Patellar Facets
Superior
And
Inferior
Patellar Facets
Patellar Tendon**
Lateral Fat Pad
Medial Fat
Pat

36. 36
Surface Anatomy - MedialSurface Anatomy - Medial
Medial
Femoral
Condyle
Patella
Joint
Line
Medial
Tibial
Condyle
Tibial
Tuberosit
y

37. 37
Palpation - MedialPalpation - Medial
Medial Collateral Ligament (MCL)*
Pes anserine
bursa**
Medial joint
line

38. 38
Surface Anatomy – LateralSurface Anatomy – Lateral
Patella
Head
Of
Fibula
Tibial
Tuberosity
Quadriceps

39. 39
Palpation – Lateral*Palpation – Lateral*
Lateral joint
line
Lateral Collateral
Ligament (LCL)**

40. 40
Palpation - PosteriorPalpation - Posterior
► Popliteal fossa*Popliteal fossa*
► Abnormal bulgesAbnormal bulges
 Popliteal artery aneurysmPopliteal artery aneurysm
 Popliteal thrombophlebitisPopliteal thrombophlebitis
 Baker’s cystBaker’s cyst

41. 41
Range Of Motion TestingRange Of Motion Testing
► ExtensionExtension FlexionFlexion
00ºº 135º135º
► Describe loss of degrees of extensionDescribe loss of degrees of extension
► Example:Example: “lacks 5 degrees of“lacks 5 degrees of
extension”extension”
► Locking* =Locking* = patient unable to fully extend orpatient unable to fully extend or
flex knee due to a mechanical blockage in theflex knee due to a mechanical blockage in the
knee (i.e., loose body, bucket-handleknee (i.e., loose body, bucket-handle
meniscus tear)meniscus tear)

42. 42
Special Tests – Anterior Knee PainSpecial Tests – Anterior Knee Pain
► Patellar apprehension test*Patellar apprehension test*
► Patellofemoral grind test**Patellofemoral grind test**
Starting
position
Push patella
laterally

43. 43
Special Tests - LigamentsSpecial Tests - Ligaments
► AssessAssess
stability of 4stability of 4
knee ligamentsknee ligaments
via appliedvia applied
stresses*stresses*
Anterior Cruciate
Posterior
Cruciate
Lateral Collateral
Medial Collateral

44. 44
Stress Testing of LigamentsStress Testing of Ligaments
► Use a standard exam routineUse a standard exam routine
 Direct, gentle pressureDirect, gentle pressure
 No sudden forcesNo sudden forces
► Abnormal testAbnormal test
1.1. Excessive motion = laxityExcessive motion = laxity
What is NORMAL motion?*What is NORMAL motion?*
2.2. Soft/mushy end point**Soft/mushy end point**

45. 45
Collateral LigamentCollateral Ligament
AssessmentAssessment
Patient and Examiner
Position*

46. 46
Valgus Stress Test for MCL*Valgus Stress Test for MCL*
Note Direction Of Forces

47. 47
Varus Stress Test for LCL*Varus Stress Test for LCL*
Note direction of
forces

48. 48
Anterior Drawer Test for ACLAnterior Drawer Test for ACL
►Physician Position & Movements*Physician Position & Movements*
►Patient PositionPatient Position
Note direction of
forces

49. OsteoarthritisOsteoarthritis

50. Osteoarthritis (OA)Osteoarthritis (OA)
► OA is theOA is the most common formmost common form
of arthritis and the mostof arthritis and the most
common joint diseasecommon joint disease
► Over 10 million AmericansOver 10 million Americans
suffer from OA of the kneesuffer from OA of the knee
alonealone
► Most of the people who haveMost of the people who have
OA are older than age 45, andOA are older than age 45, and
women are more commonlywomen are more commonly
affected than men.affected than men.
► OA most often occurs at theOA most often occurs at the
ends of the fingers, thumbs,ends of the fingers, thumbs,
neck, lower back, knees, andneck, lower back, knees, and
hips.hips.

51. OAOA
OA is a disease of
joints that affects all
of the weight-bearing
components of the
joint:
•Articular
cartilage
•Menisci
•Bone

52. OAOA
Nodal osteoarthritis
Note bony
enlargement of distal
and proximal
interphalangeal
joints (Heberden's
nodes and
Bouchard's nodes,
respectively).

53. AgeAge
► Age is the strongest risk factor for OA. Although OA can start in young adulthood, if you are over 45 yearsAge is the strongest risk factor for OA. Although OA can start in young adulthood, if you are over 45 years
old, you are at higher risk.old, you are at higher risk.
Female genderFemale gender
► In general, arthritis occurs more frequently in women than in men. Before age 45, OA occurs moreIn general, arthritis occurs more frequently in women than in men. Before age 45, OA occurs more
frequently in men; after age 45, OA is more common in women. OA of the hand is particularly commonfrequently in men; after age 45, OA is more common in women. OA of the hand is particularly common
among women.among women.
Joint alignmentJoint alignment
OA – Risk Factors

54. Hereditary gene defectHereditary gene defect
► A defect in one of theA defect in one of the genes responsible for the cartilage component collagen can cause deterioration ofgenes responsible for the cartilage component collagen can cause deterioration of
cartilage.cartilage.
Joint injury or overuse caused by physical labor or sportsJoint injury or overuse caused by physical labor or sports
► Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for developing OATraumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for developing OA
in these joints. Joints that are used repeatedly in certain jobs may be more likely to develop OA because ofin these joints. Joints that are used repeatedly in certain jobs may be more likely to develop OA because of
injury or overuse.injury or overuse.
ObesityObesity
► Being overweight during midlife or the later years is among the strongest risk factors for OA of the knee.Being overweight during midlife or the later years is among the strongest risk factors for OA of the knee.
OA – Risk Factors

55. Osteoarthritis (OA) - DefinitionOsteoarthritis (OA) - Definition
Osteoarthritis may result from wear and tear
on the joint
•The normal
cartilage lining
is gradually
worn away and
the underlying
bone is
exposed.

56. Osteoarthritis (OA) - DefinitionOsteoarthritis (OA) - Definition
•The repair mechanisms of tissue absorption and
synthesis get out of balance and result in
osteophyte formation (bone spurs) and bone cysts
A case of the, “Which
came first? The
chicken or the egg?”

57. Asymmetrical joint space narrowing from loss of
articular cartilage
The medial (inside) part of the knee is most commonly affected by osteoarthritis.
OA – Radiographic Diagnosis

58. OA – Radiographic Diagnosis
•Asymmetrical
joint space
narrowing
•Periarticular
sclerosis
•Osteophytes
•Sub-chrondral
bone cysts

59. OA – Arthroscopic Diagnosis
Normal Articular Cartilage
Ostearthritic degenerated cartilage
with exposed subchondral bone
Arthroscopy allows earlier
diagnosis by demonstrating the
more subtle cartilage changes
that are not visible on x-ray

60. •OA is a condition which progresses slowly over a
period of many years and cannot be cured
•Treatment is directed at decreasing the symptoms of
the condition, and slowing the progress of the
condition
•Functional treatment goals:
•Limit pain
•Increase range of motion
•Increase muscle strength
OA – Disease Management

61. OA – Non-operative Treatments
•Pain medications
•Physical therapy
•Walking aids
•Shock absorption
•Re-alignment through
orthotics
•Limit strain to affected
areas

62. •Osteoarthritis usually
affects the inside half
(medial compartment) of
the knee more often than
the outside (lateral
compartment).
•This can lead to the lower
extremity becoming
slightly bowlegged, or in
medical terms, a genu
varum deformity
Proximal Tibial Osteotomy

63. Proximal Tibial Osteotomy
•In the procedure to realign the
angles, a wedge of bone is
removed from the lateral side
of the upper tibia.
•A staple or plate and screws
are used to hold the bone in
place until it heals.
•This converts the extremity
from being bow-legged to
knock-kneed.
•The Proximal Tibial Osteotomy buys some time before ultimately
needing to perform a total knee replacement. The operation
probably lasts for 5-7 years if successful.

64. 3) The foot3) The foot

65. Case1 varus deformityCase1 varus deformity

69. Case 2 calcaneus deformityCase 2 calcaneus deformity

72. Case 3 equinus deformityCase 3 equinus deformity

76. Thank youThank you