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At the heart of general practice since 1960

Practical lowdown on... Problems with lower limbs

Acute knee injury

•The Ottawa Knee Rule reduces the need for an X-ray after acute knee injury by 26 per cent. It is as reliable in children as in adults. Patients with major trauma are not suitable candidates for the use of the rule.

•The economic impact of adopting this approach could be a cost saving to the NHS of nearly £2m.

•The rule states that a knee X-ray series is only required for knee injury patients with any of these findings:

– age 55 or older

– isolated tenderness of the patella (that is, no bone tenderness of the knee other than the patella)

– tenderness at the head of the fibula

– inability to flex to 90°

– inability to bear weight both immediately and when examined (they should be able to take four steps – that is, take their weight on each leg twice even if they limp)

If there is no fracture

•Mobilise as soon as pain permits

•Encourage quadriceps exercises (see box right)

•Provide suitable analgesia

Anterior knee pain

Where there is a past history of injury

•Refer to the next fracture clinic if pain and effusion have persisted for more than two weeks.

•If no grounds for immediate referral, arrange an X-ray. Request AP, lateral and skyline views.

•If the X-ray is abnormal, refer to the next fracture clinic. This applies whether

the fracture is of the patella or a flake of bone from an osteochondral fracture.

•If the X-ray is normal, refer to orthopaedic outpatients if there is a good history of patella dislocation or the patella is unstable on examination.

•If neither of these applies, give advice (see over) and review after eight weeks. Most young patients with anterior knee pain will have improved spontaneously in that time.

Where there is no history of injury

•Examine for gross abnormalities which might warrant immediate attention.

•Reassure the patient if it is Osgood-Schlatter disease. Otherwise advise as below.

Patients still in pain after eight weeks (with or without a history of injury)

•Arrange an X-ray, if not already done.

•If abnormal, refer to outpatients for assessment.

•If normal, refer for physiotherapy. If still no progress, refer to outpatients for assessment. Advise the patient that it may mean specialist physiotherapy or a brace rather than surgery.

General advice for patellofemoral pain

•Avoid provoking activities (such as stairs, walking up and down hills, the breaststroke kick, skiing, cycling, exercise bikes and high-impact aerobics).

•Recommend quads exercises (see box on page 55) and hamstring stretching exercises. There is some evidence that exercise may reduce anterior knee pain.

•Recommend simple analgesics. NSAIDs may reduce pain in the short term but not after three months.

•Recommend a support bandage.

Steroid injections at the knee

Consider injections for:

•anserine bursitis

• the knee joint

• the medial ligament of the knee.

Protection

Recommend impact-cushioning soles.

Acute ankle injury

The Ottawa Ankle Rule reduces the need for X-rays following ankle injury by 30 to 40 per cent (see box below).

Note that the rule is very good at identifying patients who do not need an X-ray (high sensitivity). It is poor at identifying those who have a fracture (low specificity).

An ankle X-ray is required if there is any pain in the malleolar zone and:

•there is bone tenderness at the posterior edge or tip of the lateral malleolus; or

•there is bone tenderness at the posterior edge of the medial malleolus; or

•the patient is unable to bear weight both at injury and when seen.

A foot X-ray is required if there is pain in the midfoot zone and:

•there is bone tenderness at the navicular; or

•there is bone tenderness at the base of the fifth metatarsal; or

•the patient is unable to weight-bear both at injury and when seen.

The immediate treatment of an ankle sprain (as for any injured joint or limb) is rest, ice, compression, elevation (RICE). Of these, compression appears to be the most important and, with elevation, must be maintained for at least 48 hours. Ice should be applied no more than 20 minutes at a time, three times a day and the skin should be separated from the ice by a wet towel. It is an approach based on experience rather than evidence.

Analgesia, support with mobilisation, immobilisation and surgical repair are all used in inversion injuries of the ankle. There is no robust evidence to guide the clinician in their use, although the use of support and early mobilisation seems to result in faster recovery and better long-term outcomes.

Rehabilitation after ankle injuries

Recommend active mobilisation to restore proprioception. This can be achieved by regular exercises.

•Imagine writing the alphabet with the foot, first capitals then lower-case letters.

•Balance on the injured leg while moving the free leg forward and backward and side to side; initially with eyes open then with eyes shut.

•Use a wobble board.

Heel pain

Plantar fasciitis

Characteristics

Isolated plantar heel pain on initiation of weight-bearing either in the morning on rising or after a period of sitting. The pain tends to decrease after a while but increases as time on the feet increases.

•Examine to confirm heel pain and to check the range of movements. There may be associated tightness of the Achilles tendon.

•Do not X-ray. The presence of a calcaneal spur does not alter treatment.

•Advise the patient about weight reduction, if appropriate, and the use of cushioned shoes.

•Give analgesics. There is no evidence that NSAIDs are more effective than simple analgesics.

•Advise the patient about stretching exercises (plantar fascia and Achilles tendon),

although there is no evidence of effectiveness.

•Refer to a podiatrist if there is no improvement after six weeks.

The benefit of steroid injection is likely to be temporary, if any, and not worth the

possible harms. There is evidence of

benefit from shock wave application if it is available.

Plantar stretching for plantar fasciitis

•Sit with the affected foot crossed over the other knee.

•Grasp the toes and pull towards the shin until the plantar fascia is stretched.

•Hold each stretch for a count of 10 and

repeat 10 times, three times a day, for eight weeks.

Achilles tendonopathy

Characteristics

An insidious onset leading to chronic posterior heel pain and swelling. The pain is worse with activity and pressure from shoes. There may be swelling medially and laterally to the insertion of the Achilles tendon.

There is insufficient evidence to determine which treatment is most appropriate. However, the following are commonly tried:

•open-backed footwear

•stretching exercises to lengthen the Achilles tendon

•simple analgesia: the condition is not one of inflammation and there is no reason to prefer an NSAID.

Achilles tendon rupture

There may be a history of a sharp snap felt in the tendon on exertion or on injury such as slipping off a ladder.

Up to 20 per cent of Achilles tendon ruptures are missed.

•Consider rupture in those with an acute history (as above) and all those who have a longer-standing Achilles swelling or ankle injury that is slow to resolve.

•Diagnose rupture by lying the patient face down with the feet over the end of the couch. Squeeze the calf firmly. If the tendon is intact this will cause plantar flexion of the foot. If the tendon is ruptured there will be, at most, a small flicker of the foot (Thompson's test).

•Refer any patient with a suspected rupture to be seen within 24 hours.

Problems with feet

Bunions

Although a percentage of bunions are inherited by an autosomal dominant gene this is of variable penetrance and not a reason for early referral or assessment.

•Examine to exclude heel valgus deformity and flatfoot and refer to a podiatrist if either is found. Orthoses may help reduce pain. While awaiting the appointment, teach the patient calf and foot exercises.

•Refer only those whose lives are severely affected by the bunion. They should be aware that:

– after the operation they will not be able to wear a shoe for eight weeks; and

– recovery of function will take at least six months.

Hallux rigidus

•Advise the patient to wear a shoe with a rigid sole or to insert a rigid insole into the shoe.

•Refer if pain is interfering with work or sleep. Advise the patient that surgery is similar to bunion surgery, as is the recovery time.

Metatarsalgia

Examine for a high arch and the presence of corns or calluses beneath the metatarsal heads.

•Refer to a podiatrist.

•Advise the patient to wear a metatarsal pad on the foot (just behind the site of the pain) or an adhesive pad inserted into the shoe to relieve the pressure on the metatarsal heads.

•Refer those not responding and patients with severe lancinating pain radiating

down the cleft between two toes (Morton's neuroma).

Steroid injections in soft tissue lesions

Benefits

The poor quality of many studies means that evidence of long-term benefit is lacking. However, it is used because clinical experience demonstrates at least short-term relief, for which there is evidence.

Harms

The following are found in injections of the shoulder and similar figures will apply to

injections in other sites:

•infection in one in 14,000-50,000 injections

•tendon rupture in less than 1 per cent

•local scarring in less than 1 per cent.

Discuss with the patient the benefits and harms and familiarise yourself with the common techniques.

Indications

•Intensive use of other approaches for at least two months has failed; or

•Rehabilitation is inhibited by symptoms.

Good practice

•Obtain the patient's consent.

•Check that you can define the local

anatomy.

•Select the finest needle that will reach the lesion.

•Clean your hands and the patient's skin.

•Use a no-touch technique.

•Use short- or medium-acting corticosteroid preparations in most cases, with local anaesthetic.

•Injection should be peritendinous; avoid injection into tendon substance.

•Minimum interval between injections should be six weeks.

•Use a maximum of three injections at one site.

•Soluble preparations may be useful in those patients who have had a local reaction to a previous injection that was an aqueous suspension.

•Record details of the injection.

•Do not repeat if two injections do not provide at least four weeks' relief.

Post-injection advice

Warn the patient of early post-injection

local anaesthesia and to avoid initial overuse. Advise resting for at least two weeks after injection and avoid heavy loading for six weeks. The patient should inform the doctor if there is any suggestion of infection or other serious adverse event.

Contraindications to steroid injection in soft tissue lesions

•If pain relief and anti-inflammatory

effects can be achieved by other methods

•Local or systemic infection

•Coagulopathy

•Tendon tear

•Young patients.

This is an extract from Practical General Practice 5e, ISBN 07506 8867X, Elsevier Ltd, April 2006, price £47.99. To order your copy please go to www.elsevierhealth.com or phone Elsevier customer services on 01865 474000.

Practical General Practice 5e is compiled by Alex Khot, a GP in East Sussex, and Andrew Polmear, a retired GP and former senior research fellow at the University of Sussex

Knee exercises

Stretching the hamstrings

•Stand up with the affected leg slightly

in front.

•Place both palms over the knee cap

and push towards the ground. Keep this position for 30 seconds.

•Repeat four times. As time goes on,

try to increase the stretch by pointing

your toes upwards.

Strengthening the quadriceps

•Lying down on your back, lift the

leg with the knee straight to a position about 45° off the horizontal.

•Hold this position for a count of 10 seconds.

•Lower the leg and rest.

•Repeat 10 times. As time goes

on, build up to doing three sets of 10 repetitions.

Heel pain

Guideline

Thomas JL, Christensen JC, Kravitz SR et al. The diagnosis and treatment of heel pain; clinical

practice guideline. Journal of Foot and Ankle Surgery 2001; 40: 329-340. Online:

www.acfas.org.

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