Musculoskeletal Disorders of the Lower Extremities.

Oloff LM, ed. Philadelphia, PA 19106-3399, WB Saunders Co, 1994, hardback, 757 pp, illus, $125.

This work was created in order to present in a logical progression a vast amount of information for foot specialists on a multitude of systemic diseases that manifest in the lower extremities, as well as those conditions that are peculiar to the foot and ankle, and to focus on information that would interest the clinician. Its target audience is pediatric medical and surgical specialists and those who are actively involved in the management of foot and ankle disorders.

Forty-five chapters are divided into seven sections covering basic science, clinical features of articular disease, musculoskeletal manifestations of systemic disease, radiological evaluation, medical management, surgical management, and chronic pain syndromes.

The section on basic science covers topics including articular anatomy and histology, inflammatory reactions, biomechanics, wound healing, and the physiology and repair of bone and cartilage. Although the chapter on inflammatory reactions offers a great deal of biochemical detail that is beyond the scope of knowledge of physical therapists, the chapter on the treatment of nonhealing wounds is both very informative and clinically meaningful, and includes an algorithm for their evaluation and treatment. other chapters within this section offer in-depth, yet understandable, treatment of subject matter. Indeed, the biomechanics chapter is of particular worth to physical therapists because it includes detailed descriptions of pathological gait with emphasis on the ankle, subtalar, and midtarsal joints. Kinetic closed-chain concepts are set forth in discussions of how muscular deficits affect gait and how orthoses influence joint mechanics. Biomechanical concepts are presented in later chapters as well, such as the chapter on central metatarsophalangeal joint arthrosis that contains an encompassing discussion of foot biomechanics and functional anatomy, and this text offers greater detail than most kinesiology texts.

The section on clinical features of a host of articular diseases offers extensive detail on pathologies, including rheumatoid arthritis, connective tissue disease, crystalline deposition disease, septic arthritis, vascular manifestations of systemic disease, and spondyloarthropathies. Here again, the focus is on presenting as much clinical detail as possible. This is especially shown in the chapter on rheumatoid arthritis, which addresses spinal column degeneration, and upper cervical degeneration and its sequelae. Manifestations of these diseases with respect to gait are also addressed. A chapter on athletic injuries covers common foot injuries, their etiologies, diferential diagnosis, grading systems, and treatment stages, and provides for more than a sufficient working knowledge of conditions commonly seen in physical therapy clinics. The author also touches upon the role of orthotics in the management of these conditions.

Within the section on musculoskeletal manifestations of systemic diseases, a unique chapter on the diabetic foot differs from other texts that cover neuropathy, ulceration, and infection, and instead focuses on diabetic musculoskeletal lesions, including diabetic osteolysis, generalized osteopenia, limited joint mobility, and fascial disorders. A chapter on HIV infection and AIDS reviews neurological, vascular, dermatologic, and musculoskeletal manifestations of this disease but only briefly relates this to the lower extremity.

The heavy medical emphasis of this work is clearly illustrated in the sections on radiographic evaluation and medical management. The former section reviews imaging techniques and principles, crosssectional imaging, and contrast radiography. The latter section contains chapters on pharmacologic management of inflammatory disease and on the use of glucocorticoids in the management of rheumatic disorders. Although appropriate for their target audience, these sections are clearly beyond the scope of knowledge of physical therapists and makes for very tedious reading. A chapter detailing rehabilitation principles for the patient with arthritis, which is oddly placed within the medical management section, reviews basic evaluation techniques and therapeutic modalities, and contains no new information for the novice or experienced therapist. Passing references to physical therapy are contained within the text, but no rehabilitative detail is offered.

The section on surgical management of foot disorders offers a great deal of operative detail for tendon transfers, fusions, joint implants, and arthroplasties for a multitude of conditions. Variations of surgical procedure are sometimes presented and often include the author's own techniques of choice. Follow-up studies on surgical outcomes are sometimes presented. An interesting chapter on ankle arthroscopy defines the goals and limits of this procedure and outlines conditions that are amenable to this type of intervention.

A final section on chronic pain begins with a chapter on the physiology of pain and related theories. Within this section lie enlightening chapters on the treatment of peripheral nerve entrapment and compartment syndromes. These chapters are notable for their discussion of surgical goals, operative technique, and clinical manifestations of each condition.

This work is generally written in a consistent didactic style, and numerous authors contributed chapters within their field of expertise. The text is abundantly illustrated with charts, graphs, photographs, scans, roentgenograms, and drawings that complement the text; some of the illustrations are labeled. The photographic detail is especially valuable in sections that discuss surgical detail. References are both abundant and timely and are logically placed to support salient points.

This work was meant to serve as a definitive text on foot disorders. Due to its heavy medical orientation and narrow focus on the foot, however, this work is of little value to physical therapists in general practice. Only therapists with a special interest in foot disorders and who seek extensive medical information will find this text a useful reference.

Eugene Pavone, PT Rockland Physical Therapy Service Spring Valley, NY

Mr Pavone works at Rockland Physical Therapy Service treating orthopedic and sports-related cases. He also performs functional capaci assessments for the work hardening program.