Ankle + knee pain Flashcards
ligament stretched or torn
-don’t hear or feel a “pop” but swollen
sprain
tendon or muscle stretched or torn
- tender, tight muscle
strain
lateral (fibula) ligaments of ankle joint (ant to post)
#1 anterior talofibular ligament (most susceptible to acute injury) #2 calcaneal fibular ligament posterior talofibular ligament peroneus longus brevis tendons
medial (tibia) ligaments of ankle joint
deltoid ligament
primary plantar flexor
achilles tendon: attaches at posterior portion of calcaneus
primary everters of ankle
inferior to lateral malleolus: peroneus brevis (attaches to distal 5th metatarsal, can cause avulsion fracture) peroneus longus
primary inverter of ankle
posterior tibialis tendon: inferior to medial malleolus
high ankle sprain ligaments
anterior tibiofibular ligament
posterior tibiofibular ligament
syndesmosis: sheet of interosseous membrane
ankle injury grades
grade I: minimal swelling + pain, ATFL stretch, no instability, able to bear weight with some pain
grade II: partial tear of ATFL, stretched CFL, > pain + swelling, mild-mod joint instability, lots pain with weight bearing, loss of ROM
grade III: complete tear of ATFL and CFL, partial tear of PTFL, > joint instability, can’t bear weight, loss of function
most common ankle injury
forced inversion with ankle in plantar flexion (tear anterior talofibular ligament)
causes of tendinosis (usually chronic ankle pain, d/t overuse causing inflammation, partial tendon rupture)
achilles tendon
peroneal tendon
posterior tibialis tendon
cause of achilles tendon rupture
jumping sports
steroid injection complication
FQ antibiotics
hemarthrosis think
hemophilia
knee pain + limp, think
hip disorder:
legg-perthes
slipped capital femoral epiphysis
ankle/knee pain + poor response to treatment
malignancy
bony swelling + ankle/knee pain
tumor
fever + ankle/knee pain
osteomyelitis
septic arthritis
if “snap” or “pop” felt
ligament rupture
inability to bear weight after injury think
fracture (not sprain)
PE for joint
ROM strength palpation stability gait
ottowa ankle rules to determine need for xray with ACUTE ankle injury: sensitive for ankle and midfoot fractures
must be > 6yo
pain in malleolar or midfoot zone and one of following:
bony tenderness at posterior edge or tip of either malleoli
bony tenderness over navicular(medial)
bony tenderness at base of 5th metatarsal (lateral)
inability to bear weight both immediately and in ED (4 steps)
if negative: probably not a fracture
talar tilt test
lateral ankle pain
anterior talofibular + calcaneofibular ligament
grasp each side of foot at talus and apply varus stress (bow out)
+ if asymmetric ROM between ankles
anterior drawer test
lateral ankle pain
anterior talofibular ligament
grasp calcaneus and try to slide heel forward
+ if at least 3 mm difference between ankles
squeeze test
anterior/lateral ankle pain
compress tibia and fibula above midpoint of calf
+ pain: syndesmosis sprain (high ankle)
cotton test/rocker test
anterior/lateral ankle pain
like talar tilt test - mediolateral force applied and any ROM > 3 mm is abnormal
eversion + dorsiflexion trauma (rare) causes
medial ankle pain:
deltoid ligament sprain (very strong)
often associated with fracture or posterior tibialis tendon injury
medial ankle pain think
deltoid liagment
posterior ankle pain think
achilles tendon:
crepitus, tenderness, swelling, gap
thompson (mildcalf compression) test
assess if achilles tendon is intact lie prone with feet over edge of table squeeze gastrocnemius and soleus normal: plantar flexion positive: no foot movement (complete or near complete rupture of tendon)
if ankle bone pain at night, bone pain without injury, or don’t respond to tx get
xray
imaging for achilles tendinosis or achilles tendon rupture
no gold standard: U/S or MRI (good if young athlete - help with prognosis)
early mobilization of ankle sprain
more likely to return to sport vs brace improve functioning reduce pain + swelling return sooner less instability
lace up brace for ankle sprain
less likely to cause disabling swelling vs semirigid brace
semirigid brace for ankle sprain
return sooner vs elastic bandage
prevent ankle sprain during high risk sport if previous grade II or III tear
PT for ankle sprain
prevents subsequent sprains
acute grade I ankle sprain tx
RICE symptomatically
early mobilization: bear weight as tolerated
NSAID or acetaminophen for pain
acute grade II ankle sprain tx
RICE for 2-3 days
NSAIDS
immobilization in lace up splint 2-7 days, crutches
acute grade III ankle sprain tx
same as grade II - but longer recovery
immobilization in air-stirrup splint or below knee cast for up to 3 mo
PT afterward
if still functionally impaired or separation of tibia and fibular: need surgery
syndesmosis sprain tx
body weight can increase stress, pain, instability
removable splint or casting to allow for progressive weight bearing as tolerated
passive ROM - esp dorsiflexion within week of injury
if avulsion fragment > 2mm
immobilize in cast or splint and refer to surgeon
avulsion of peroneus brevis on 5th metatarsal head
heals without treatment
immobilize until weight bearing tolerated
refer to surgeon if
fracture of base of 5th metatarsal (jones fracture)
proximal 2nd, 3rd, 4th (Lis Franc)
growth plate (salter-harris fracture)
treatment of achilles tendinosis
rest, ice, heel lifts
rehab of gastroc and soleus: stretching, ROM, then strength
NSAIDS
treatment of achilles tendon rupture or if very active with achilles tendinosis
surgery (prevent re-rupture)
all patients with ankle injuries should undergo
rehab
knee joint
patella
tibia
femur
primary stabilizers of knee
ACL (insertion), PCL, MCL, LCL
menisci
joint capsule
medial and lateral retinacula attach to patella
knee actions
during flexion: forward translation, internal rotation of tibia
extension: rearward translation, external rotation
ACL role
prevent anterior movement of tibia on femur
helps MCL stabilize knee during lateral stress when knee is flexed
menisci role
stabilize knee during pivoting
popliteus m. role
attached to lateral meniscus
prevents lateral meniscus from sliding forward and getting crushed during flexion
locks knee in full extension and unlocks
flexed knee hits dashboard in MVA
PCL injury
causes of anterior knee pain: pain climbing up/down stairs, squatting, pronged sitting, snap/pop/click/catching of knee
patellar tendonitis
patellofemoral dysfunction
chondromalacia patellae
sudden swelling of knee
hemarthrosis (most commonly associated with ACL tear, osteochondral fracture in 10%)
hear or feel pop think
ACL tear
knee gets “stuck” during ROM
meniscus injury or loose joint body (cartilage)
stiffness with inactivity - improves after few minutes (vs RA), pain with weight bearing activity
DJD
lachman test
ACL Tear
knee flexed at 20-30 deg
stabilize femur, other hand on proximal tibia - try to slide tibia forward
+ if: >3 mm difference or no endpoint
posterior drawer test
PCL tear
flex knee to 90 degrees and push tibia posterior
-do this before lachman test to ensure integrity
posterolateral or posteromedial pain at extreme of flexion or extension is a
meniscal injury
anterior joint line tenderness and pain with squatting suggests
chondromalacia
McMurray test
meniscal damage
medial meniscus: extension + valgus + internal rotation
lateral: extension + varus + external rotation
+ if: palpable click, pain
MCL or LCL test
varus or vagus stress
determine laxity
pathophys of anterior knee pain
quadricep atrophy
crepitus with manipulation of patella
patellar apprehension test
patellar compression test
anterior knee pain
press inferiorly on superior patella: pain
hold patella and contract quad: pain
ottawa knee rules if 18 yo or older to determine if acute knee injury has fracture
get xray if any of following: >55yo tenderness at head of fibula isolated patella tenderness inability to flex to 90 deg inability to bear weight immediately and in ED
confirmatory test for meniscal tear
MRI
refer for additional evaluation or surgery if:
hemarthrosis ACL or meniscal tear third degree collateral ligament injuries severe functional impairment poor response to conservative tx
treatment of knee pain
exercise
treatment of ACL
immobilization and then, surgery
treatment of meniscus tear
protected weight bearing + PT
if continues, surgery
treatment of DJD
glucosamine
CS injections
NOT NSAIDS - not inflammatory (unless acute flare)
treatment of collateral ligament tear
knee immobilizer, crutches until can tolerate walking
-focal area of bony tenderness
fracture
