LOWER LIMB INJURIES

Clinical symptoms: One should suspect a spinal element to the presentation in most patients, particularly those with the following signs.

Clinical Symptoms ● See algorithm

● Associated low back, buttock or pos- terior thigh pain

● Lower limb paraesthesia, related to exercise ● Atypical symptoms ● Positive straight leg raise (Fig.6a) ● Positive slump (Fig.6b)

● Pain relieved quickly on lumbar flexion

● Loss of peripheral muscle control due to painless weakness ● Poor lumbo-pelvic stability

Box 1: Clinical symptoms indicative of spinal involvement in leg pain

Examination (to include) ● Active movements ● Neurological examination ● Straight leg raise (Fig.6a) ● Slump test (Fig.6b) ● Spinal palpation

Straight leg raise test A straight leg raise test is carried out with the subject lying supine. The practitioner stabilises the pelvis with one hand while raising one leg, with the knee straight, by the heel (Fig.6a). The test is positive if it reproduces the tingling/paraesthesia/pain or unilateral loss of range of movement. The foot angulation can be varied to bias the attention towards particular peripher- al nerves.

Slump test The patient sits unsupported on the side of the couch. The thighs must be support- ed by the couch and knees flexed to 90 degrees.

The patient should be asked to

flex their chin to their chest, the therapist then places overpressure onto the patient’s shoulders until pain is repro- duced or resistance encountered (Fig.6b). The patient can then move their foot into various positions to bias attention

Figure 6a: Straight leg raise test

towards particular peripheral nerves. Neck flexion is released once symptoms are encountered to assess if this release in tension alters the reproduced symptoms.

Investigation ● X-ray for bone lesion eg. Pars lesion ● MRI to assess disc patency, and other soft tissue and bone lesions ● EMG if impaired neural conduction is suspected ● Bloods if systemic disease suspected

Management: Management is by expert manipulative therapy with the possibility of epidural or spinal surgery in the most resistant cases. Acupuncture may be a useful adjunct. Biomechanical interven- tion may be required especially if leg length discrepancy is a contributory fac- tor.

7. TIBIALIS POSTERIOR TENDINITIS This condition involves the tibialis poste- rior tendon as it passes around the medi- al malleolus which it uses as a pulley to divert into the foot (Fig.8a). Around the malleolus it is subjected to torsional as well as longitudinal forces. The tendon

Figure 6b: Slump test

can become inflamed, degenerative, develop a tenosynovitis, rupture or suffer microtears. Differential diagnosis includes tarsal tunnel syndrome, tarsal coalition, pump bumps, bursitis and flexor hallucis longus tendinitis.

Clinical symptoms ● Pain on push off, hopping or landing ● Pain during or after exercise ● Morning stiffness ● Pain posterior or medial to the malleo- lus along the length of the tendon ● Swelling ● Crepitus

Examination ● Palpation ● Static resisted contractions ● Stretch positions of soleus, flexor hal- lucis longus, tibialis posterior, and flexor digitorum longus ● Ability to supinate from a pronated position ● Compare pain and inhibition between active hallux plantarflexion (flexor hallu- cis longus) and resisted supination from a pronated position (tibialis posterior)

Figure 7a: Superior view of a prolapsed interverte- bral disc (PID)

Figure 7b: MRI of PID SportEX 31